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Avijit Sharma,1 Feng Dai,2 Lanya Tseng,1 Philip R Effraim,1 Bin Zhou,2 Robert B Schonberger,1 Jinlei Li1 1Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA; 2Yale Center for Analytical Sciences, Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USACorrespondence: Jinlei Li, Department of Anesthesiology, Yale University School of Medicine, 20 York Street, New Haven, CT, 06510, USA, Tel +1 917 601 6828, Fax +1 203 785 6664, Email jinlei.li@yale.eduPurpose: Glucocorticoids are commonly used as regional anesthesia adjuvants to improve blockade quality and duration. There are limited data in the literature regarding the potential systemic effects and safety of perineural glucocorticoids. This study examines the effects of perineural glucocorticoids on serum glucose, potassium, and white blood cell count (WBC) in the immediate postoperative period after primary total hip arthroplasty (THA).Patients and Methods: A retrospective cohort study was carried out at a tertiary academic medical center utilizing electronic health records of 210 patients who underwent THA, for which patients received either a periarticular local anesthetic injection alone (PAI, N=132) or additional peripheral nerve blocks (PNB, N=78) containing 10 mg dexamethasone and 80 mg methylprednisolone acetate (PAI+PNB). The primary outcome was change in serum glucose from a preoperative baseline on postoperative days (POD) 1, 2, and 3. Secondary outcomes included changes in WBC and serum potassium.Results: The change in serum glucose from baseline was found to be significantly higher in the PAI+PNB group compared to the PAI group on POD 1 (mean difference 19.87 mg/dL, 95% CI [12.42, 27.32]; P< 0.001) and POD 2 (mean difference 17.5 mg/dL, 95% CI [9.66, 25.44], P< 0.001). No significant difference was found on POD 3 (mean difference − 8.18 mg/dL, 95% CI [− 19.07, 2.70], P=0.14). Statistically significant but clinically insignificant differences were detected in serum potassium in the PAI+PNB group compared to the PAI group on POD1 (mean difference 0.16 mEq/L, 95% CI [0.02, 0.30], P=0.03) and WBC on POD 2 (mean difference 3.18 × 1000/mm3, 95% CI [2.14, 4.22], P< 0.001).Conclusion: Patients who underwent THA and received PAI+PNB with glucocorticoid adjuvants demonstrated higher elevations in serum glucose for the first two PODs compared to patients who received PAI alone. These differences resolved by a third POD and are likely to be of no clinical significance.Keywords: perineural glucocorticoid, perineural dexamethasone, perineural methylprednisolone acetate, total Hip arthroplasty, fascia plane block, serum glucose

The coronavirus disease 2019 (COVID-19) pandemic has revealed that even the best-resourced hospitals may lack sufficient ventilators to support patients under surge conditions. During a pandemic or mass trauma, an affordable, low-maintenance, off-the-shelf device that would allow health care teams to rapidly expand their ventilator capacity could prove lifesaving, but only if it can be safely integrated into a complex and rapidly changing clinical environment. Here, we define an approach to safe ventilator sharing that prioritizes predictable and independent care of patients sharing a ventilator. Subsequently, we detail the design and testing of a ventilator-splitting circuit that follows this approach and describe our clinical experience with this circuit during the COVID-19 pandemic. This circuit was able to provide individualized and titratable ventilatory support with individualized positive end-expiratory pressure (PEEP) to 2 critically ill patients at the same time, while insulating each patient from changes in the other's condition. We share insights from our experience using this technology in the intensive care unit and outline recommendations for future clinical applications.

Objective To examine whether supraphysiological oxygen administration during surgery is associated with lower or higher postoperative kidney, heart, and lung injury. Design Observational cohort study. Setting 42 medical centers across the United States participating in the Multicenter Perioperative Outcomes Group data registry. Participants Adult patients undergoing surgical procedures ≥120 minutes’ duration with general anesthesia and endotracheal intubation who were admitted to hospital after surgery between January 2016 and November 2018. Intervention Supraphysiological oxygen administration, defined as the area under the curve of the fraction of inspired oxygen above air (21%) during minutes when the hemoglobin oxygen saturation was greater than 92%. Main outcomes Primary endpoints were acute kidney injury defined using Kidney Disease Improving Global Outcomes criteria, myocardial injury defined as serum troponin >0.04 ng/mL within 72 hours of surgery, and lung injury defined using international classification of diseases hospital discharge diagnosis codes. Results The cohort comprised 350 647 patients with median age 59 years (interquartile range 46-69 years), 180 546 women (51.5%), and median duration of surgery 205 minutes (interquartile range 158-279 minutes). Acute kidney injury was diagnosed in 19 207 of 297 554 patients (6.5%), myocardial injury in 8972 of 320 527 (2.8%), and lung injury in 13 789 of 312 161 (4.4%). The median fraction of inspired oxygen was 54.0% (interquartile range 47.5%-60.0%), and the area under the curve of supraphysiological inspired oxygen was 7951% min (5870-11 107% min), equivalent to an 80% fraction of inspired oxygen throughout a 135 minute procedure, for example. After accounting for baseline covariates and other potential confounding variables, increased oxygen exposure was associated with a higher risk of acute kidney injury, myocardial injury, and lung injury. Patients at the 75th centile for the area under the curve of the fraction of inspired oxygen had 26% greater odds of acute kidney injury (95% confidence interval 22% to 30%), 12% greater odds of myocardial injury (7% to 17%), and 14% greater odds of lung injury (12% to 16%) compared with patients at the 25th centile. Sensitivity analyses evaluating alternative definitions of the exposure, restricting the cohort, and conducting an instrumental variable analysis confirmed these observations. Conclusions Increased supraphysiological oxygen administration during surgery was associated with a higher incidence of kidney, myocardial, and lung injury. Residual confounding of these associations cannot be excluded. Trial registration Open Science Framework osf.io/cfd2m

Background There are significant knowledge gaps regarding perioperative outcomes for patients with systemic sclerosis (SSc), a rare immune-mediated disease characterized by cutaneous and organ-based fibrosis. The primary aim of this study was to describe the incidence of various perioperative complications in a single-center population of SSc. Methods 278 SSc patients with 605 unique surgical encounters were identified over a ten-year period (Jan 1, 2010, through Jan 1, 2020). Data collection included airway management, intraoperative adverse events (pulmonary aspiration, cardiac arrest, difficult airway designation), and 30-day postoperative complications (pneumonia, myocardial infarction, atrial fibrillation, congestive heart failure). Results Hypertension (57.9%), pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) (52.5%), interstitial lung disease (ILD) (32.4%), and gastroesophageal reflux disease (82.4%) were common in our study population. Difficult direct laryngoscopy occurred in 10.9% of cases, but the first attempt success rate was high at 93.2%. Video laryngoscopy was used in 24.1% of cases. The most common intraoperative complications were hypotension and bradycardia within 15 minutes of induction (24.3% and 17.5%, respectively), and vasopressor use (34.0%). The in-hospital complication rate was 14.7% while the 30-day postoperative complication rate was 27.6%, with ileus > 3 days (5.6%) and postoperative pneumonia (POP) (5.5%) occurring most often. Microstomia was an independent predictor of difficult airway designation [Adjusted Odds Ratio (ORadj): 3.42, 95% Confidence Interval (CI) = 1.13, 10.31, p = 0.029]. ILD was not associated with 30-day POP (ORadj: 1.41, 95% CI = 0.54, 3.71, p = 0.482). A composite of PH/PAH was an independent predictor for 30-day POP (ORadj: 2.61, 95% CI = 1.08, 6.29, p = 0.033), 30-day CHF diagnosis (ORadj: 4.15, 95% CI = 1.33, 12.94, p = 0.014), and 30-day mortality (ORadj: 3.57, 95% CI = 1.24, 10.28, p = 0.018). Conclusions This study identified perioperative characteristics of patients with SSc. Current knowledge on perioperative outcomes in SSc in the surgical population is predominately based on reports of single case reports or small case series. Our findings suggest that intraoperative and airway complications are similar but postoperative complications are high when compared to known incidences in surgical populations. Secondly, this study demonstrates that composite PAH/PH but not ILD was a strong predictor of POP, CHF and 30-day mortality in this patient population.

Background/objectives Advanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery. Design Retrospective observational study using the Multicenter Perioperative Outcomes Group data set. Setting Thirty-six institutions across the United States. Participants A total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018. Intervention None. Measurements Total induction bolus dose of propofol administered. Results The mean (SD) weight-adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6-65.0), varying from 73.8% among patients aged 65-69 to 45.8% among patients aged 80 and older. Conclusion The present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited.

Ensuring a productive clinical and research workforce requires bringing together physicians and communities to improve health, by strategic targeting of initiatives with clear and significant public health relevance. Within anesthesiology, the traditional perspective of the field’s health impact has focused on providing safe and effective intraoperative care, managing critical illness, and treating acute and chronic pain. However, there are limitations to such a framework for anesthesiology’s public health impact, including the transient nature of acute care episodes such as the intraoperative period and critical illness, and a historical focus on analgesia alone - rather than the complex psychosocial milieu - for pain management. Due to the often episodic nature of anesthesiologists’ interactions with patients, it remains challenging for anesthesiologists to achieve their full potential for broad impact and leadership within increasingly integrated health systems. To unlock this potential, anesthesiologists should cultivate new clinical, research, and administrative roles within the health system - transcending traditional missions, seeking interdepartmental collaborations, and taking measures to elevate anesthesiologists as dynamic and trusted leaders. This special article examines three core themes for how anesthesiologists can enhance their impact within the healthcare system and pursue new collaborative health missions with non-anesthesiologist clinicians, researchers, and administrative leaders. These themes include (i) reframing of traditional anesthesiologist missions towards a broader health system-wide context; (ii) leveraging departmental and institutional support for professional career development; and (iii) strategically prioritizing leadership attributes to enhance system-wide anesthesiologist contributions to improving overall patient health.

Objectives Aberrant automated blood pressure (BP) readings during caesarean delivery may lead to disruptions in monitoring. The present study compared the frequency of aberrant BP readings across two types of commercially available BP monitoring systems in use during caesarean delivery. Methods This was a retrospective observational study using two comparable patient cohorts that resulted from simultaneous introduction of two types of monitors into a single obstetric surgical center in which similar patients were treated for the same surgical procedure by the same set of clinicians during the same year. Our primary hypothesis was that aberrant readings were significantly associated with the type of monitor being used for BP measurement, controlling for a variety of relevant covariates as specified in the analytic plan RESULTS: A total of 1418 cesarean delivery patients met inclusion criteria. Gaps of at least 6 min in machine-captured BP readings occurred in 159 (21.1%) of cases done in the operating room using a Datex-Ohmeda monitor vs. 183 (27.5%) of cases in the operating rooms using Phillips monitors (P = 0.005). In multivariable logistic regression analysis, the relative odds of the occurrence of monitoring gaps was 35% higher in rooms with the Phillips BP monitors as compared to the Datex-Ohmeda monitor while controlling for pre-specified covariates (odds ratio = 1.35, 95% confidence interval = 1.04-1.74, P = 0.02). Conclusion The present analysis suggests that aberrant BP readings for parturients undergoing caesarean delivery are significantly different between the two types of automated BP monitoring systems used in the operating rooms at our institution.

BACKGROUND Automated acquisition of intraoperative patient temperature data by temperature probes leads to the possibility of incurring a number of artifacts related to probe positioning that may impact their utility for observational research. OBJECTIVE We sought to compare the performance of two de-novo algorithms to filter such artifacts. METHODS In this observational retrospective study intraoperative temperature data of adults who received general anesthesia for non-cardiac surgery were extracted from the Multicenter Perioperative Outcomes Group (MPOG) registry. Two algorithms were developed and were then compared to the reference standard of anesthesiologists’ manual artifact detection. Sensitivity and specificity for artifact detection were calculated for each algorithm, as were mean temperatures and Area Under the Curve (AUC) for hypothermia (below 36C) for each patient after artifact removal by each methodology. RESULTS A total of 27,683 temperature readings from 200 anesthetic records were analyzed. The overall agreement among the anesthesiologists was 92.1%. Both the algorithms had high specificity but moderate sensitivity (Specificity- Algorithm 1: 99.02 % vs. Algorithm 2: 99.54%; Sensitivity- Algorithm 1: 49.13% vs. Algorithm 2: 37.72%, F-score- Algorithm 1: 0.65 vs. Algorithm 2: 0.55). The timeX temperature hypothermic Area Under 36.0 degrees and the mean temperature per case after artifact removal were similar between the algorithms and the anesthesiologists. CONCLUSIONS The tested algorithms provide an automated way to filter intraoperative temperature artifacts which closely approximate manual sorting by anesthesiologists.Our study provides evidence demonstrating the efficacy of a highly generalizable artifact reduction algorithm that can be readily employed by observational studies that rely on automated intraoperative data acquisition.

Background Five percent of adult patients undergoing noncardiac inpatient surgery experience a major pulmonary complication. The authors hypothesized that the choice of neuromuscular blockade reversal (neostigmine vs. sugammadex) may be associated with a lower incidence of major pulmonary complications. Methods Twelve U.S. Multicenter Perioperative Outcomes Group hospitals were included in a multicenter observational matched-cohort study of surgical cases between January 2014 and August 2018. Adult patients undergoing elective inpatient noncardiac surgical procedures with general anesthesia and endotracheal intubation receiving a nondepolarizing neuromuscular blockade agent and reversal were included. Exact matching criteria included institution, sex, age, comorbidities, obesity, surgical procedure type, and neuromuscular blockade agent (rocuronium vs. vecuronium). Other preoperative and intraoperative factors were compared and adjusted in the case of residual imbalance. The composite primary outcome was major postoperative pulmonary complications, defined as pneumonia, respiratory failure, or other pulmonary complications (including pneumonitis; pulmonary congestion; iatrogenic pulmonary embolism, infarction, or pneumothorax). Secondary outcomes focused on the components of pneumonia and respiratory failure. Results Of 30,026 patients receiving sugammadex, 22,856 were matched to 22,856 patients receiving neostigmine. Out of 45,712 patients studied, 1,892 (4.1%) were diagnosed with the composite primary outcome (3.5% sugammadex vs. 4.8% neostigmine). A total of 796 (1.7%) patients had pneumonia (1.3% vs. 2.2%), and 582 (1.3%) respiratory failure (0.8% vs. 1.7%). In multivariable analysis, sugammadex administration was associated with a 30% reduced risk of pulmonary complications (adjusted odds ratio, 0.70; 95% CI, 0.63 to 0.77), 47% reduced risk of pneumonia (adjusted odds ratio, 0.53; 95% CI, 0.44 to 0.62), and 55% reduced risk of respiratory failure (adjusted odds ratio, 0.45; 95% CI, 0.37 to 0.56), compared to neostigmine. Conclusions Among a generalizable cohort of adult patients undergoing inpatient surgery at U.S. hospitals, the use of sugammadex was associated with a clinically and statistically significant lower incidence of major pulmonary complications. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

BACKGROUND/OBJECTIVES: In the context of an aging surgical population, appropriate anesthetic induction dose adjustments for the older adult remain poorly defined. In the present study, we describe the prevalence of excess induction agent dose in reference to Food and Drug Administration (FDA) guidance and seek to investigate the possible association of such excess dose with postinduction hypotension and postoperative acute kidney injury. Study Design A retrospective observational study was conducted in a large tertiary teaching hospital in accordance with our a priori analytic protocol as registered on ClinicalTrials.gov (NCT03699696). For inclusion, patients must have been 65 years or older and received general anesthesia with propofol induction for gynecologic oncology surgery between December 1, 2014 and July 8, 2018. Descriptive variables of the patients, machine-captured perioperative vital signs, induction anesthetic, and vasopressor/inotrope administrations were recorded. MAIN OUTCOME MEASURES: A total of 541 female patients met inclusion criteria. The mean (SD) age of the cohort was 72.20 (5.93). Regarding the primary outcome, 65.43% (354 patients, 95% CI of 61.2%−69.4%) of the cohort received more than the FDA recommended 1–1.5mg/kg induction dose for patients of advanced age undergoing general anesthesia. RESULTS: The percent of patients receiving doses in excess of FDA guidance remained substantial across all age groups but decreased progressively with increasing 5-year age intervals (from 74% among those aged 65–69 to 44% among those aged >80). Excess propofol dose in the present cohort was not associated with our a priori definition of postinduction hypotension. Regarding AKI, among the 30 patients suffering this outcome, it occurred less often in patients who received higher propofol doses (4.2% (9/217) vs. 15.3% (21/138), p

BackgroundDespite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk.MethodsMajor noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline).ResultsAmong 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort.ConclusionsAdult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.Editor’s PerspectiveWhat We Already Know about This TopicWhat This Article Tells Us That Is New

Postoperative pneumonia is one of the most common complications after cardiac surgery, entailing increased patient morbidity, mortality, and health care burden. The primary aim of this study was to assess whether preoperative chlorhexidine mouthwash is associated with reduced postoperative pneumonia after cardiac surgery.A comprehensive systematic search of NLM Pubmed, Embase, Scopus, and Cumulative Index of Nursing and Allied Health was executed to include the studies since inception to June 27, 2017, which assessed the effects of preoperative chlorhexidine gluconate mouthwash on postoperative pneumonia. Studies were identified by 2 independent reviewers, and data were extracted using a predefined protocol. Random effects models were run to obtain risk ratios with 95% confidence intervals. Quality of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation criteria. Postoperative pneumonia after cardiac surgery was the primary outcome of the study.Five studies including a cumulative of 2284 patients were included. A total of 1125 patients received preoperative chlorhexidine. Use of chlorhexidine gluconate was associated with reduced risk of postoperative pneumonia compared with the patients who did not receive it (risk ratio, 0.52; 95% confidence interval, 0.39-0.70; P .001). No adverse effects from chlorhexidine gluconate mouthwash were reported by any of these studies.Among the patients receiving preoperative chlorhexidine mouthwash, the risk of postoperative pneumonia is reduced by approximately one-half; its adoption in preoperative protocols could help improve patient outcomes.

Background The automated acquisition of intraoperative patient temperature data via temperature probes leads to the possibility of producing a number of artifacts related to probe positioning that may impact these probes’ utility for observational research. Objective We sought to compare the performance of two de novo algorithms for filtering such artifacts. Methods In this observational retrospective study, the intraoperative temperature data of adults who received general anesthesia for noncardiac surgery were extracted from the Multicenter Perioperative Outcomes Group registry. Two algorithms were developed and then compared to the reference standard—anesthesiologists’ manual artifact detection process. Algorithm 1 (a slope-based algorithm) was based on the linear curve fit of 3 adjacent temperature data points. Algorithm 2 (an interval-based algorithm) assessed for time gaps between contiguous temperature recordings. Sensitivity and specificity values for artifact detection were calculated for each algorithm, as were mean temperatures and areas under the curve for hypothermia (temperatures below 36 C) for each patient, after artifact removal via each methodology. Results A total of 27,683 temperature readings from 200 anesthetic records were analyzed. The overall agreement among the anesthesiologists was 92.1%. Both algorithms had high specificity but moderate sensitivity (specificity: 99.02% for algorithm 1 vs 99.54% for algorithm 2; sensitivity: 49.13% for algorithm 1 vs 37.72% for algorithm 2; F-score: 0.65 for algorithm 1 vs 0.55 for algorithm 2). The areas under the curve for time × hypothermic temperature and the mean temperatures recorded for each case after artifact removal were similar between the algorithms and the anesthesiologists. Conclusions The tested algorithms provide an automated way to filter intraoperative temperature artifacts that closely approximates manual sorting by anesthesiologists. Our study provides evidence demonstrating the efficacy of highly generalizable artifact reduction algorithms that can be readily used by observational studies that rely on automated intraoperative data acquisition.

Postoperative pulmonary complications are a source of morbidity after major surgery. In patients at increased risk of postoperative pulmonary complications we sought to assess the association between neuromuscular blocking agent reversal agent and development of postoperative pulmonary complications.We conducted a retrospective matched cohort study, a secondary analysis of data collected in the prior STRONGER study. Data were obtained from the Multicenter Perioperative Outcomes Group. Included patients were aged 18 yr and older undergoing non-emergency surgery under general anaesthesia with tracheal intubation with neuromuscular block and reversal, who were predicted to be at elevated risk of postoperative pulmonary complications. This risk was defined as American Society of Anesthesiologists Physical Status 3 or 4 in patients undergoing either intrathoracic or intra-abdominal surgery who were either aged80 yr or underwent a procedure lasting2 h. Cohorts were defined by reversal with neostigmine or sugammadex. The primary composite outcome was the occurrence of pneumonia or respiratory failure.After matching by institution, sex, age (within 5 yr), body mass index, anatomic region of surgery, comorbidities, and neuromuscular blocking agent, 3817 matched pairs remained. The primary postoperative pulmonary complications outcome occurred in 224 neostigmine cases vs 100 sugammadex cases (5.9% vs 2.6%, odds ratio 0.41, P0.01). After adjustment for unbalanced covariates, the adjusted odds ratio for the association between sugammadex use and the primary outcome was 0.39 (P0.0001).In a cohort of patients at increased risk for pulmonary complications compared with neostigmine, use of sugammadex was independently associated with reduced risk of subsequent development of pneumonia or respiratory failure.

We aimed to study the association between propofol induction dose (mg/kg) and pre-incision severe hypotension (Mean Arterial Pressure (MAP) ≤ 55 mmHg) among patients ≥65 years of age.Retrospective Observational.40 centers participating in the Multicenter Perioperative Outcomes Group consortium.Patients ≥65 years of age undergoing non-cardiac, non-vascular surgery who received propofol for general anesthetic induction prior to endotracheal intubation between January 2014 and December 2018.None.The primary exposure was total propofol induction dose in mg/kg, and the primary outcome was occurrence of severe hypotension (MAP≤55 mmHg) prior to surgical incision, stratified by non-invasive vs. invasive blood pressure monitoring type.Among 320,585 total patients, 22.6% experienced the outcome of pre-incision severe hypotension (MAP≤55 mmHg). When stratified by blood pressure monitoring type, 20.7% with non-invasive blood pressure measurements, and 35.0% with invasive blood pressure measurements had the outcome. After controlling for a variety of patient and procedural factors, there was a significant independent association between propofol induction dose and pre-incision hypotension (Non-invasive blood pressure cohort odds ratio (OR) 1.10; 95% confidence interval (CI) 1.07 to 1.13; p 0.001; and Invasive blood pressure cohort OR 1.15; 95%CI 1.10 to 1.21; adjusted p 0.001). The association was robust to alternative definitions of the outcome, including less severe hypotension (MAP≤65 mmHg) and blood pressure drop from baseline as a continuous measure. Although no threshold safe induction dose was identified at which hypotension was avoided, an analysis of propofol dose greater or less than 1.5 mg/kg (i.e. the maximum FDA-defined typical induction dose) demonstrated that doses in excess of the FDAs threshold were positively associated with odds of severe hypotension (Non-invasive cohort: OR 1.05; 95% CI 1.02 to 1.08; p 0.001; Invasive cohort: OR 1.11; 95%CI 1.05 to 1.17; adjusted p 0.001).In a multicenter cohort of geriatric surgical patients receiving propofol for general anesthetic induction and endotracheal intubation, severe pre-incision hypotension (MAP ≤55 mmHg) that has previously been associated with postoperative morbidity was common. The dose of propofol used was significantly associated with increased odds of this outcome after controlling for a number of clinically relevant factors. Future studies that are designed to test different approaches to anesthesia induction for reducing severe post induction pre-incision hypotension are warranted.

EDITOR’S PERSPECTIVE What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Background Protective ventilation may improve outcomes after major surgery. However, in the context of one-lung ventilation, such a strategy is incompletely defined. The authors hypothesized that a putative one-lung protective ventilation regimen would be independently associated with decreased odds of pulmonary complications after thoracic surgery. Methods The authors merged Society of Thoracic Surgeons Database and Multicenter Perioperative Outcomes Group intraoperative data for lung resection procedures using one-lung ventilation across five institutions from 2012 to 2016. They defined one-lung protective ventilation as the combination of both median tidal volume 5 ml/kg or lower predicted body weight and positive end-expiratory pressure 5 cm H2O or greater. The primary outcome was a composite of 30-day major postoperative pulmonary complications. Results A total of 3,232 cases were available for analysis. Tidal volumes decreased modestly during the study period (6.7 to 6.0 ml/kg; P < 0.001), and positive end-expiratory pressure increased from 4 to 5 cm H2O (P < 0.001). Despite increasing adoption of a “protective ventilation” strategy (5.7% in 2012 vs. 17.9% in 2016), the prevalence of pulmonary complications did not change significantly (11.4 to 15.7%; P = 0.147). In a propensity score matched cohort (381 matched pairs), protective ventilation (mean tidal volume 6.4 vs. 4.4 ml/kg) was not associated with a reduction in pulmonary complications (adjusted odds ratio, 0.86; 95% CI, 0.56 to 1.32). In an unmatched cohort, the authors were unable to define a specific alternative combination of positive end-expiratory pressure and tidal volume that was associated with decreased risk of pulmonary complications. Conclusions In this multicenter retrospective observational analysis of patients undergoing one-lung ventilation during thoracic surgery, the authors did not detect an independent association between a low tidal volume lung-protective ventilation regimen and a composite of postoperative pulmonary complications. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Objectives: This pilot study sought to assess feasibility of a randomized trial of blood pressure intervention (home blood pressure monitoring vs counseling) in the preoperative clinic and the baseline rates of primary care follow-up after such interventions.Methods: A prospective randomized pilot study was performed at Yale New Haven Hospital Preadmission Testing Clinic. A sample of 100 adults with elevated blood pressure, were recruited during their preadmission visit, and randomized 1:1 to receive brief BP counseling and an educational brochure versus additionally receiving a home BP monitor (HBPM) with a mailed report of their home readings. At 60-day post-surgery telephone follow-up, investigators asked whether participants had primary-care follow-up; had new/adjusted hypertension treatment and felt satisfied with the study.Results: There were 51 patients in the counseling group and 49 in the HBPM group. Of 46 patients in the HBPM group who returned their monitors, 36 (78%) were hypertensive at home. At 60 days post-surgery, 31 (61%) patients in the counseling group and 30 (61%) in the HBPM group were reached by telephone with the remaining followed by EMR. 36 (71%) patients in the counseling group and 36 (73%) in the HBPM group had seen their Primary Care provider. 17 of 36 (47%) in the counseling group and 18 of 31 (58%) in the HBPM group received new or adjusted hypertension medications. 61 participants answered questions regarding their satisfaction with the study with 52 (85%) reporting that they felt moderately to very satisfied. Conclusions: This pilot study suggests that interventional blood pressure trials in the preoperative clinic are feasible, but telephone follow-up leads to significant gaps in outcome ascertainment. Trial Registration: Clinicaltrials.gov, NCT03634813. Registered 16 of August 2018, https://clinicaltrials.gov/ct2/show/NCT03634813

Objectives This study sought to assess feasibility of a randomized trial of blood pressure intervention (home blood pressure monitoring vs. counseling) in the preoperative clinic and the baseline rates of primary care follow-up after such interventions. Methods A prospective randomized feasibility study was performed at Yale New Haven Hospital Preadmission Testing Clinic. A sample of 100 adults, with elevated blood pressure, were recruited during their preadmission visit, and randomized 1:1 to receive brief BP counseling and an educational brochure versus additionally receiving a home BP monitor (HBPM) with a mailed report of their home readings. At 60-day post-surgery telephone follow-up, investigators asked whether participants had primary-care follow-up; had new/adjusted hypertension treatment; and felt satisfied with the study. Results There were 51 patients in the counseling group and 49 in the HBPM group. Of 46 patients in the HBPM group who returned their monitors, 36 (78%) were hypertensive at home. At 60 days post-surgery, 31 (61%) patients in the counseling group and 30 (61%) in the HBPM group were reached by telephone with the remaining followed by EHR. Thirty-six (71%) patients in the counseling group and 36 (73%) in the HBPM group had seen their primary care provider. Seventeen of 36 (47%) in the counseling group and 18 of 31 (58%) in the HBPM group received new or adjusted hypertension medications. Sixty-one participants answered questions regarding their satisfaction with the study with 52 (85%) reporting that they felt moderately to very satisfied. Conclusions This feasibility study suggests that interventional blood pressure trials in the preoperative clinic are feasible, but telephone follow-up leads to significant gaps in outcome ascertainment. Trial registration Clinicaltrials.gov, NCT03634813. Registered 16 of August 2018.

BackgroundFierce debate about the health and financial tradeoffs presented by different COVID-19 pandemic mitigation strategies highlights the need for rigorous quantitative evaluation of policy options.ObjectiveTo quantify the economic value of the costs and benefits of a policy of continued limited reopening with social distancing relative to alternative COVID-19 response strategies in the United States.DesignWe estimate the number and value of quality-adjusted life-years (QALY) gained from mortality averted, with a value of $125,000 per QALY, and compare these benefits to the associated costs in terms of plausible effects on US GDP under a policy of continued limited reopening with social distancing relative to a policy of full reopening toward herd immunity. Using the same QALY value assumptions, we further evaluate cost-effectiveness of a return to Shelter-in-Place relative to a policy of limited reopening.SettingUnited StatesMeasurementsQALY and cost as percent of GDP of limited reopening with continued social distancing relative to a strategy of full reopening aimed at achieving herd immunity; a limited reopening “budget” measured in the number of months before this strategy fails to demonstrate cost-effectiveness relative to a full reopening; a shelter-in-place “threshold” measured in the number of lives saved at which a month of sheltering in place demonstrates cost effectiveness relative to the limited reopening strategy.ResultsQALY benefits from mortality averted by continued social distancing and limited reopening relative to a policy of full reopening exceed projected GDP costs if an effective vaccine or therapeutic can be developed within 11.1 months from late May 2020. White House vaccine projections fall within this date, supporting a partial reopening strategy. One month of shelter-in-place restrictions provides QALY benefits from averted mortality that exceed the associated GDP costs relative to limited reopening if the restrictions prevent at least 154,586 additional COVID-19 deaths over the course of the pandemic. Current models of disease progression suggest that limited reopening will not cause this many additional deaths, again supporting a limited reopening strategy.LimitationLimited horizon of COVID-19 mortality projections; infection fatality ratio stable across strategies, ignoring both the potential for ICU overload to increase mortality and the deployment of partially effective therapeutics to decrease mortality; effect on GDP modeled as constant within a given phase of the pandemic; accounts for age and sex distribution of QALYs, but not effect of comorbidities; only considers impact from QALY lost due to mortality and from changes in GDP, excluding numerous other considerations, such as non-fatal COVID-19 morbidity, reduced quality of life caused by prolonged social distancing, or educational regression associated with prolonged school closures and restrictions.ConclusionsA limited reopening to achieve partial mitigation of COVID-19 is cost effective relative to a full reopening if an effective therapeutic or vaccine can be deployed within 11.1 months of late May 2020. One additional month of shelter-in-place restrictions should only be imposed if it saves at least 154,586 lives per month before the development of an effective therapeutic or vaccine relative to limited reopening.FundingThis work was supported in part by grant K01AI119603 from the National Institute of Allergy and Infectious Diseases (NIAID). This work does not necessarily represent the opinions of the NIAID, the NIH, or the United States Government.

OBJECTIVE: Blood pressure (BP) measurement during the pre-surgical assessment has been suggested as a way to improve longitudinal detection and treatment of hypertension. The relationship between blood pressure measured during this assessment and home blood pressure (HBP), a better indicator of hypertension, is unknown. The purpose of the present study was to determine the positive predictive value (PPV) of presurgical blood pressure for predicting elevated HBP. METHODS: We prospectively enrolled 200 patients at a presurgical evaluation clinic with clinic blood pressures ≥130/85mmHg, as measured using a previously-validated automated upper-arm device (Welch Allyn Vital Sign Monitor 6000 Series), to undergo daily HBP monitoring (Omron Model BP742N) between the index clinic visit and their day of surgery. Elevated HBP was defined, per American Heart Association guidelines, as mean systolic HBP≥135mmHg or mean diastolic HBP≥85mmHg. RESULTS: Of the 200 participants, 188 (94%) returned their home blood pressure monitors with valid data. The median number of home blood pressure recordings was 10 (IQR 7–14). Presurgical clinic blood pressure thresholds of 140/90, 150/95, and 160/100mmHg yielded PPVs (95%CI) for elevated HBP of 84.1% (0.78–0.89), 87.5% (0.81–0.92), and 94.6% (0.87–0.99), respectively. In contrast, self-reported blood pressure control, anti-hypertensive treatment, availability of primary care, and preoperative pain scores demonstrated poor agreement with elevated HBP. CONCLUSION: Elevated preoperative clinic blood pressure is highly predictive of longitudinally elevated HBP. BP measurement during pre-surgical assessment may provide a way to improve longitudinal detection and treatment of hypertension.

Objective The types of agents used for monitored anesthesia care (MAC) and their possible differential effects on outcomes have received less study despite increased use over general anesthesia (GA) in transfemoral aortic valve replacements (TAVRs). In this pilot analysis of patients undergoing TAVR using MAC, the authors described the anesthetic agents used and sought to investigate the possible association of anesthetic agent choice with outcomes and the extent to which total weight and time-adjusted doses of anesthetics declined with increasing 10-year age increments. Design Retrospective observational study. Setting Tertiary teaching hospital. Participants Ninety-three participants scheduled to undergo TAVR, with a primary plan of conscious sedation between November 2014 and June 2016, were included. Intervention None. Measurements and Main Results Types of MAC were divided into 4 primary groups, but 2 groups were focused: propofol (n = 39) and dexmedetomidine plus propofol (n = 34). Conversion to GA occurred in 6 participants (6.45%) and was not associated with the type of sedation received. The authors also compared patients who received dexmedetomidine with those who did not in accordance with their a priori analytic plan. There were no associations between the use of dexmedetomidine and postoperative delirium or intensive care unit/hospital length of stay. No significant trends in medication dose adjustments were seen across increasing 10-year age increments. Conclusions A wide breadth of MAC medications is in use among TAVR patients and does not support differences in outcomes. Despite recommendations to reduce anesthetic drug dosing in the elderly, no significant trends in dose reduction with increasing age were noted.

Prolonged use of venoarterial extracorporeal membrane oxygenation (VA ECMO) may be complicated by end-organ dysfunction. Although gaseous microemboli (GME) are thought to damage end organs during cardiopulmonary bypass, patient exposures to GME have not been well characterized during VA ECMO. We therefore performed an observational study of GME in adult VA ECMO patients, with correlation to clinical events during routine patient care. After institutional review board (IRB) approval, we used two Doppler probes to detect GME noninvasively in extracorporeal membrane oxygenation (ECMO) circuits on four patients for 15 hours total while also recording patient care events. We then conducted in vitro trials to compare Doppler signals with gold-standard measurements using an Emboli Detection and Classification EDAC quantifier (Luna Innnovations, Inc. Roanoke, VA) (Terumo Cardiovascular, Ann Arbor, MI) during simulated clinical interventions. Correlations between Doppler and EDAC data were used to estimate GME counts and volumes represented by clinical Doppler data. A total of 503 groups of Doppler peaks representing GME showers were observed, including 194 statistically larger showers during patient care activities containing 92% of total Doppler peaks. Intravenous injections accounted for an estimated 68% of GME and 88% of GME volume, whereas care involving movement accounted for an estimated 6% of GME and 3% of volume. Overall estimated embolic rates of 24,000 GME totaling 4 μl/hr rivals reported GME rates during cardiopulmonary bypass. Numerous GME are present in the postmembrane circuit during VA ECMO, raising concern for effects on microcirculation and organ dysfunction. Strategies to detect and minimize GME may be warranted to limit embolic exposures experienced by VA ECMO patients.

Graphical abstract, Highlights • Papillary fibroadenomas are most commonly associated with aortic valves. • Echogenic artifacts may sometimes be misinterpreted as papillary fibroadenomas. • Confirmation of papillary fibroadenomas with alternative imaging modalities may be helpful.

Key Points Question What are the patterns of intraoperative antibiotic administration across US hospitals with respect to Infectious Diseases Society of America’s guidelines? Findings In this multicenter cohort study comprising 414 851 surgical encounters across 31 institutions, more than one-third of the encounters did not adhere to guidelines. With the exception of timing of antibiotics, all measures of antibiotic administration (choice, dosing, and redosing) had marked nonadherence. Meaning These findings suggest that considerable nonadherence to intraoperative antibiotic administration best practices persists, which may be a contributory factor to stagnant rates of surgical site infections., This multicenter cohort study examines the patterns of adherence to the Infectious Disease Society of America’s guidelines for intraoperative antibiotic administration in US hospitals., Importance Despite widespread adherence to Surgical Care Improvement Project antibiotic measures, prevention of surgical site infections (SSIs) remains a clinical challenge. Several components of perioperative antibiotic prophylaxis guidelines are incompletely monitored and reported within the Surgical Care Improvement Project program. Objectives To describe adherence to each component of perioperative antibiotic prophylaxis guidelines in regard to procedure-specific antibiotic choice, weight-adjusted dosing, and timing of first and subsequent administrations in a nationwide, multicenter cohort of patients undergoing noncardiac surgery. Design, Setting, and Participants This cohort study included adult patients undergoing general, urological, orthopedic, and gynecological surgical procedures involving skin incision between January 1, 2014, and December 31, 2018, across 31 academic and community hospitals identified within the Multicenter Perioperative Outcomes Group registry. Data were analyzed between April 2 and April 21, 2021. Main Outcomes and Measures The primary end point was overall adherence to Infectious Diseases Society of America guidelines, including (1) appropriateness of antibiotic choice, (2) weight-based dose adjustment, (3) timing of administration with respect to surgical incision, and (4) timing of redosing when indicated. Data were analyzed using mixed-effects regression to investigate patient, clinician, and institutional factors associated with guideline adherence. Results In the final cohort of 414 851 encounters across 31 institutions, 51.8% of patients were women, the mean (SD) age was 57.5 (15.7) years, 1.2% of patients were of Hispanic ethnicity, and 10.2% were Black. In this cohort, 148 804 encounters (35.9%) did not adhere to guidelines: 19.7% for antibiotic choice, 17.1% for weight-adjusted dosing, 0.6% for timing of first dose, and 26.8% for redosing. In adjusted analyses, overall nonadherence was associated with emergency surgery (odds ratio [OR], 1.35; 95% CI, 1.29-1.41; P

To investigate the association between self-identified black or African American race and the presence of ambulatory internal medicine follow-up in the year after surgery. Our hypothesis was that among US Veterans who presented for surgery, black or African American race would be associated with a decreased likelihood to receive ambulatory internal medicine follow-up in the year after surgery.Retrospective observational.All US Veterans Affairs hospitals.A total of 236,200 Veterans undergoing surgery between 2006 and 2011 who were discharged within 10 days of surgery and survived the full 1-year exposure period.None.Attendance at an internal medicine follow-up appointment within 1 year after surgery.After controlling for year of surgery, age, age ≥65 years, sex, Hispanic ethnicity, and number of inpatient days, black or African American patients were 11% more likely to lack internal medicine follow-up after surgery (adjusted odds ratio, 1.11; 95% confidence interval, 1.06-1.16). When accounting for geographic region, this difference remained significant at the Bonferoni-corrected P.007 level only in the Midwest United States where black or African American patients were 28% more likely to lack medical follow-up in the year after surgery (odds ratio, 1.28; 95% confidence interval, 1.16-1.42; P.0001).The disparity in ambulatory medical follow-up following surgery among black or African American vs nonblack or non-African American Veterans in the Midwest region deserves further study and may lead to important quality improvement initiatives aimed specifically at this population.

Coronary blood flow can be disrupted during cardiac interventions such as mitral valve surgeries, left atrial appendage ligation, transcatheter aortic valve implantation, and aortic procedures involving reimplantation of coronary buttons. Although difficult to accomplish, coronary imaging using transesophageal echocardiography can be performed by the use of orthogonal imaging with the ability for real-time tilt for angle adjustment. The technique described herein allows imaging of the right coronary artery, left main coronary artery bifurcation, left anterior descending, and circumflex coronary arteries. The imaging is facilitated by acquisition during the delivery of blood cardioplegia. Coronary sinus and great cardiac vein imaging also can be obtained during the delivery of retrograde cardioplegia. Although further studies are needed, this imaging technique may prove useful in procedures where coronary flow disruption is suspected or as an additional parameter to confirm delivery of cardioplegia.

Objective To evaluate differences in the inclusion of anesthesiologists in mobile extracorporeal membrane oxygenation (ECMO) teams between North American and European centers. Design A retrospective review of North American versus European mobile ECMO teams. The search terms used to identify relevant articles were the following: “extracorporeal membrane transport,” “mobile ECMO,” and “interhospital transport.” Setting MEDLINE review of articles. Participants None. Interventions None. Results Between 1986 and 2015, 25 articles were published that reported the personnel makeup of mobile ECMO teams in North America and Europe: 6 from North American centers and 19 from European centers. The included articles reported a total of 1,329 cases: 389 (29%) adult-only cohorts and 940 (71%) mixed-age cohorts. Among North American studies, 0 of 6 (0%) reported the presence of an anesthesiologist on the mobile ECMO team in contrast to European studies, in which 10 of 19 (53%) reported the inclusion of an anesthesiologist (Fisher exact p for difference = 0.05). In terms of number of cases, this discrepancy translated to 543 total cases in North America (all without an anesthesiologist) and 499 cases in Europe (37%) including an anesthesiologist on the team (Fisher exact p for difference Conclusions This study demonstrated significant geographic discrepancies in the inclusion of anesthesiologists on mobile ECMO teams, with European centers more likely to incorporate an anesthesiologist into the mobile ECMO process compared with North American centers.

Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality.The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given.Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities.Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Despite guidelines suggesting a 25–50 % reduction in induction doses of intravenous anesthetic agents in the elderly (≥65 years), we hypothesized that practitioners were not sufficiently correcting drug administration for age, contributing to an increased incidence of hypotension in older patients undergoing general anesthesia. We conducted a retrospective, observational study in a tertiary-care academic hospital. The study included 768 female patients undergoing gynecologic surgeries who received propofol-based induction of general anesthesia. Weight-adjusted anesthetic induction dosing, age-associated differences in dosing by ASA-PS (American Society of Anesthesiology—Physical Status), and hemodynamic outcomes between younger (18–64 years, n = 537) and older (≥65 years, n = 231) female patients were analyzed. Older patients received lower doses of propofol and midazolam than younger patients (propofol: 2.037 ± 0.783 vs 2.322 ± 0.834 mg/kg, p

Among a national cohort of surgical patients, the authors analyzed the association between medical follow-up during the first postsurgical year and survival during the second postsurgical year.Retrospective cohort study.US Veterans Hospitals.The study included adults who received surgical care in any Veterans Health Administration facility from 2006 to 2011 who were discharged within 10 days of surgery and who survived for at least 1 year postoperatively.None.The association between the receipt of nonsurgical ambulatory medical care during the first postoperative year and the hazard of death during postsurgical year 2 was measured. Among 236,200 veterans, 93.2% received a nonsurgical medical follow-up visit in postsurgical year 1; of those, 5.1% died during postsurgical year 2. This compares with 9.4% year-2 mortality among patients lacking year-1 medical follow-up (p0.0001). After adjustment for confounders, medical follow-up in postoperative year 1 again was associated with a significantly lower hazard of death in postoperative year 2 (hazard ratio 0.71; 95% confidence interval 0.66-0.78). Sensitivity analyses examining patient subgroups stratified by procedural specialty demonstrated comparable findings. The results were robust under a variety of simulated scenarios of unmeasured confounding.Within a national cohort of US veterans who presented for surgery, those who received nonsurgical ambulatory follow-up during the first postoperative year demonstrated lower all-cause mortality in the subsequent postoperative year than those who did not receive the same type of follow-up care. Interventions focused on postoperative care coordination of outpatient medical follow-up may have the potential to improve long-term postoperative survival.

Modifications in physician billing patterns have been shown to occur in response to payer incentives, but the phenomenon remains largely unexplored in billing for anesthesia services. Within the field of anesthesiology, Medicare's policy not to provide additional reimbursement for higher ASA physical status scores contrasts with the practices of most private payers, and this pattern of reimbursement introduces a change in billing incentives once patients attain Medicare eligibility. We hypothesized that, coincident with the onset of widespread Medicare eligibility at age 65 years, a discontinuity in reported ASA physical status scores would be observed after controlling for the underlying trend of increasing ASA physical status scores with age. This phenomenon would manifest as a pattern of upcoding of ASA physical status scores for patients younger than 65 years that would become less common in patients age 65 years and older.Using data on age, sex, ASA physical status scores, and type of surgery from the National Anesthesia Clinical Outcomes Registry, we used a quasi-experimental regression discontinuity design to analyze whether there was evidence for a discontinuity in reported ASA physical status scores occurring at age 65 years for the nondeferrable anesthesia services accompanying hip, femur, or lower leg fracture repair.A total of 49,850 records were analyzed. In models designed to detect regression discontinuity at 65 years of age, neither the binary variable "age ≥ 65" nor the interaction term of age × age ≥ 65 was a statistically significant predictor of the outcome of ASA physical status score. The statistical inference was unchanged when ASA physical status scores were reclassified as a binary outcome (I-II vs III-V) and when different bandwidths around age 65 years were used. To test the validity of our study design for detecting regression discontinuity, simulations of the occurrence of deliberate upcoding of ASA physical status scores demonstrated the ability to detect deliberate upcoding occurring at rates exceeding 2% of eligible cases of patients younger than 65 years.We found no evidence for a significant discontinuity in the pattern of ASA physical status scores coincident with Medicare eligibility at age 65 years for the nondeferrable conditions of hip, femur, or lower leg fracture repair. Our data do not support the presence of fraudulent ASA physical status scoring among National Anesthesia Clinical Outcomes Registry contributors. If deliberate upcoding of ASA physical status scores is present in our data, the behavior is either too rare or too insensitive to the removal of payer incentives at age 65 years to be evident in the present analysis.

Although statins are highly effective for reducing cardiovascular disease events, prior studies demonstrate their significant underuse in the US population, including among those with known atherosclerotic disease. It is unknown whether this finding applies to the subset of patients who present for outpatient surgery, as such patients would be expected to have recent exposures to healthcare providers during the preoperative referral period. The primary aim of this manuscript was to ascertain the prevalence of statin underuse and associated risk-factors for such underuse among ambulatory surgical patients with documented atherosclerotic cardiovascular disease. This was a retrospective observational study of a random sample of 600 patients ages 40–75 years presenting for ambulatory surgery within a 6-month period in 2016, at one of three ambulatory surgical centers affiliated with a large, tertiary care hospital. Compilation and analysis of data occurred in 2018–2019. Of the 600 subjects, 117 (19.5%) had documented atherosclerotic cardiovascular disease. Within this high-risk group, only 71 (60.7%) carried a prescription for any statin, and only 30 (25.6%) were prescribed a recommended high intensity statin dose for secondary prevention. In a multivariable logistic regression analysis, older age, male sex, and treatment for hypertension were positively associated with statin use. In conclusion, statin underuse among ambulatory surgical patients is common and mirrors what has been observed in non-surgical populations. Future trials are needed to investigate the possible role of surgical teams to promote guideline-based statin therapy, including the role of preoperative screening interventions to impact long term cardiovascular morbidity and mortality.

The fact that doctors have a long tradition of writing medical history to interpret and direct their profession is well established. But readers (particularly modern physician readers) can also understand physician-authored histories as offering commentary and analysis of the world beyond medicine. In this essay, we offer a reading (perhaps a modern one) of J. Marion Sims's 1877 article, 'The Discovery of Anaesthesia' which exemplifies the stance of looking both inward and outward from the medical field. We begin by discussing Sims, including the complicated legacy he left as a physician. Next, we review late 19th-century history with a focus on Reconstruction. Finally, we show how the modern reader can use Sims's article both to trace the first use of ether and nitrous oxide for surgical anaesthesia and to provide a window into the 19th-century medical profession and the post-Civil War period. Through this study, we hope to show how to read both medicine and the world around it in physician histories.

Objectives To test the association among depression symptoms, distressed personality type, and preoperative beta-blocker nonadherence and to estimate the prevalence of untreated major depression in this population. Design Prospective observational study. Setting A veterans hospital. Participants One hundred twenty patients on outpatient beta-blocker therapy presenting for surgery. Interventions The Patient Health Questionnaire (PHQ)-9, the D-Scale-14 (DS14), and Modified Morisky Scale (MMS) questionnaires. Measurements and Main Results Of 99 participants who presented for surgery, the incidence of preoperative nonadherence was 14.1% (95% confidence interval 7%-21%), consistent with prior research. Nonadherence was 9.5% among those with no depression, 27.8% among those with mild depression, and 28.6% among those with moderate-to-severe depression (Cochran-Armitage test for trend p = 0.03). Distressed personality type was found in 35% of the cohort (95% confidence interval 26-45%) and was not associated with beta-blocker nonadherence (Fisher’s exact test, p = 0.24). Among participants with symptoms of major depressive disorder (n = 25, 25.3%), more than half (n = 14, 56%) had no indication of depression listed at their most recent primary care visit. Conclusions Patients with symptoms of depression on chronic beta-blocker therapy are susceptible to medication nonadherence on the day of surgery. Most surgical patients with symptoms of major depression lack a diagnosis of depression. Preoperative depression screening may thus (1) identify a population at increased risk of beta-blocker withdrawal, and (2) identify patients who may benefit from anesthesiologist-initiated referral for this treatable condition.

The difficulty of determining pulselessness via manual palpation in simulated cardiopulmonary resuscitation (CPR) has been well-documented in the literature. Prior studies have suggested that trained medical personnel demonstrate a specificity for the manual diagnoses of pulselessness of only 55%.1 Other research has confirmed the poor diagnostic accuracy of manual pulse checks in a wide spectrum of test subjects - from non-medical personnel to critical care physicians.1–4 These data, along with accumulating evidence for the importance of early, high quality chest compression to improve outcomes from out-of-hospital cardiac arrest, have led the American Heart Association to eliminate pulse checks from their algorithm for bystander CPR. a In this context, the Advanced Cardiac Life Support (ACLS) algorithm for the treatment of Pulseless Electrical Activity (PEA) arrest presents an interesting dilemma, as the very diagnosis of the PEA condition is predicated, by definition, on the finding of pulselessness. Although unnecessary chest compressions during bystander CPR are considered a relatively benign intervention, the failure to promptly diagnose the return of spontaneous circulation during in-hospital PEA Arrest may delay the institution of more targeted and appropriate care modalities. Ambiguity about the presence of spontaneous circulation during resuscitation is among many factors that contributes to the challenging task of “running a code.” Therefore, in order to assess possibilities for improving the detection of the return of spontaneous circulation during in-hospital resuscitation, we conducted a prospective case series (N=8) during which handheld Doppler pulse checks were performed in parallel with standard ACLS procedures during resuscitation of adults with putative PEA arrest or on whom electrocardiogram pads had not yet been placed in an academic tertiary care hospital. The outcomes of interest were: 1) To measure the incidence of Doppler-positive-palpation-negative pulse in patients undergoing resuscitation for putative PEA arrest, and 2) To measure blood pressure in discordant cases of Doppler-positive-palpation-negative putative PEA arrest. This prospective study was approved by the Yale Human Investigation Committee, including a waiver of informed consent. Investigators applied a portable Doppler (Dopplex Pocket Doppler D900 Vascular Ultrasound with 8MHz probe, Huntleigh, United Kingdom) to an available femoral artery during inhospital resuscitation attempts for putative PEA arrest or in situations of unknown cardiac rhythm prior to electrocardiogram lead placement. The Dopplex D900 with associated probes has been deemed by the Food and Drug Administration to be substantially equivalent to other portable ultrasound devices routinely used for blood flow monitoring. While this technology has been in existence for several decades, the sensitivity and specificity of such devices for detecting pulsatile flow during CPR remain unknown. For inclusion in the study, a putative PEA rhythm was defined as an organized rhythm in the absence of a manual pulse, excluding ventricular tachycardia and ventricular fibrillation.b To be included in the case series, subjects also had to meet the following criteria: 1) age > 18 years, 2) ongoing CPR, and 3) availability of a peripheral site for application of a Doppler probe. For included subjects, audible Doppler pulse checks occurred in addition to standard ACLS procedures simultaneously with manual pulse checks. The site of manual pulse checks was not dictated by the research protocol. Doppler pulse checks occurred at an available femoral location that was not being used for the manual pulse check. In the event of a discordant finding of Doppler-positive-palpation-negative pulse, a repeat pulse check and blood pressure measurement were requested, with all management decisions left to the discretion of the code-runner. The cases represent a convenience sample of codes that occurred during times that a study investigator was available to respond. Codes occurred at a tertiary care hospital at which approximately 24 codes are called per month overhead, of which approximately 15% are true cardiac arrests.

The fact that doctors have a long tradition of writing medical history to interpret and direct their profession is well established. But readers (particularly modern physician readers) can also understand physicianauthored histories as offering commentary and analysis of the world beyond medicine. In this essay, we offer a reading (perhaps a modern one) of J. Marion Sims’s 1877 article, ‘The Discovery of Anaesthesia’ which exemplifies the stance of looking both inward and outward from the medical field. We begin by discussing Sims, including the complicated legacy he left as a physician. Next, we review late 19th-century history with a focus on Reconstruction. Finally, we show how the modern reader can use Sims’s article both to trace the first use of ether and nitrous oxide for surgical anaesthesia and to provide a window into the 19thcentury medical profession and the post-Civil War period. Through this study, we hope to show how to read both medicine and the world around it in physician histories.