Association between obstructive sleep apnea and atrial fibrillation and delirium after cardiac surgery. Sub-analysis of DECADE trial

BACKGROUND

Atrial fibrillation and delirium are common complications after cardiac surgery. Both are associated with increased Intensive Care Unit (ICU) and hospital length of stay, functional decline, 30-day mortality and increase in health care costs. Obstructive Sleep Apnea (OSA) induces deleterious effects in the cardiovascular and nervous systems. We hypothesized that adult patients with preoperative OSA have a higher incidence of postoperative atrial fibrillation and delirium than patients without OSA, after cardiac surgery.

METHODS

Sub-analysis of the DECADE trial at Cleveland Clinic hospitals. Our exposure was OSA, defined by STOP-BANG questionnaire score higher than 5 and/or a preoperative diagnosis of OSA. The primary outcome was atrial fibrillation, defined by clinician diagnosis or documented arrhythmia. The secondary outcome was delirium assessed twice during the initial five postoperative days using the Confusion Assessment Method for ICU. We assessed the association between OSA, and atrial fibrillation and delirium using a logistic regression model adjusted for confounders using inverse probability of treatment weighting.

RESULTS

590 patients were included in the final analysis. 133 were diagnosed with OSA and 457 had no OSA. Satisfactory balance between groups for most confounders (absolute standardized difference < 0.10) was achieved after weighting. The atrial fibrillation incidence was 37% (n = 49) in the patients with OSA and 33% (n = 150) in the non-OSA patients. OSA was not associated with atrial fibrillation with an estimated odds ratio of 1.22 (95% CI: 0.75,1.99;p = 0.416). The delirium incidence was 17% (n = 22) in patients with OSA and 15% (n = 67) in the non-OSA patients. OSA was not associated with delirium with an estimated odds ratio of 0.93 (95% CI: 0.51,1.69;p = 0.800).

CONCLUSION

In adult patients having cardiac surgery, OSA is not associated with a higher incidence of postoperative atrial fibrillation and delirium. These results suggest different prominent factors rather than OSA affect the incidence of these postoperative outcomes.

Evaluation and Management of Pulmonary Hypertension in Noncardiac Surgery: A Scientific Statement From the American Heart Association

Pulmonary hypertension, defined as an elevation in blood pressure in the pulmonary arteries, is associated with an increased risk of death. The prevalence of pulmonary hypertension is increasing, with an aging population, a rising prevalence of heart and lung disease, and improved pulmonary hypertension survival with targeted therapies. Patients with pulmonary hypertension frequently require noncardiac surgery, although pulmonary hypertension is associated with excess perioperative morbidity and death. This scientific statement provides guidance on the evaluation and management of pulmonary hypertension in patients undergoing noncardiac surgery. We advocate for a multistep process focused on (1) classification of pulmonary hypertension group to define the underlying pathology; (2) preoperative risk assessment that will guide surgical decision-making; (3) pulmonary hypertension optimization before surgery to reduce perioperative risk; (4) intraoperative management of pulmonary hypertension to avoid right ventricular dysfunction and to maintain cardiac output; and (5) postoperative management of pulmonary hypertension to ensure recovery from surgery. Last, this scientific statement highlights the paucity of evidence to support perioperative pulmonary hypertension management and identifies areas of uncertainty and opportunities for future investigation.

Perioperative strategies to reduce risk of myocardial injury after non-cardiac surgery (MINS): A narrative review

Myocardial injury is a frequent complication of surgical patients after having non-cardiac surgery that is strongly associated with perioperative mortality. While intraoperative anesthesia-related deaths are exceedingly rare, about 1% of patients undergoing non-cardiac surgery die within the first 30 postoperative days. Given the number of surgeries performed annually, death following surgery is the second leading cause of death in the United States. Myocardial injury after non-cardiac surgery (MINS) is defined as an elevation in troponin concentrations within 30 days postoperatively. Although typically asymptomatic, patients with MINS suffer myocardial damage and have a 10% risk of death within 30 days after surgery and excess risks of mortality that persist during the first postoperative year. Many factors for the development of MINS are non-modifiable, such as preexistent coronary artery disease. Preventive measures, systematic approaches to surveillance and treatment standards are still lacking, however many factors are modifiable and should be considered in clinical practice: the importance of hemodynamic control, adequate oxygen supply, metabolic homeostasis, the use of perioperative medications such as statins, anti-thrombotic agents, beta-blockers, or anti-inflammatory agents, as well as some evidence regarding the choice of sedative and analgesic for anesthesia are discussed. Also, as age and complexity in comorbidities of the surgical patient population increase, there is an urgent need to identify patients at risk for MINS and develop prevention and treatment strategies. In this review, we provide an overview of current screening standards and promising preventive options in the perioperative setting and address knowledge gaps requiring further investigation.

Hypoventilation in the PACU is associated with hypoventilation in the surgical ward: Post-hoc analysis of a randomized clinical trial

OBJECTIVE

To evaluate the association between early postoperative hypoventilation in the last hour of the post-anesthesia care unit (PACU) stay and hypoventilation during the rest of the first 48 postoperative hours in the surgical ward.

DESIGN

Sub-analysis of a clinical trial.

SETTING

PACU and surgical wards of a single medical center.

PATIENTS

Adults having abdominal surgery under general anesthesia.

INTERVENTIONS

Monitoring with a respiratory volume monitor from admission to PACU until the earlier of 48 h after surgery or discharge.

MEASUREMENTS

The exposure was having at least one low minute-ventilation (MV) event during the last hour of PACU stay, defined as MV lower than 40% the predicted value lasting at least 1 min. The primary outcome was low MV events lasting at least 2 min during the rest of the first 48 postoperative hours, while in the surgical ward. The secondary outcome was the rate of low MV events per monitored hour.

MAIN RESULTS

Data of 292 patients were analyzed, of which 20 (6.8%) patients had a low MV event in PACU. Low MV events in the surgical ward were found in 81 (28%) patients. All patients who had low MV events in PACU had events again in the ward, while 61/272 (22%) had an event in the ward but not in PACU. The incidence rate of low MV events per hour was 24 (95% CI: 13, 46) among patients having an event in the PACU, and 2 (1, 4) among those who did not.

CONCLUSIONS

In adults recovering from abdominal surgery, events of hypoventilation during the first postoperative hour are associated with similar events during the rest of the first 48 postoperative hours, with positive predictive value approaching 100%. Sixty-one patients had ward hypoventilation that was not preceded by hypoventilation in PACU.

Regional anesthesia for thoracic surgery: a narrative review of indications and clinical considerations

Background and Objective

Surgical procedures involving incisions of the chest wall regularly pose challenges for intra- and postoperative analgesia. For many decades, opioids have been widely administered to target both, acute and subsequent chronic incisional pain. Opioids are potent and highly addictive drugs that can provide sufficient pain relief, but simultaneously cause unwanted effects ranging from nausea, vomiting and constipation to respiratory depression, sedation and even death. Multimodal analgesia consists of the administration of two or more medications or analgesia techniques that act by different mechanisms for providing analgesia. Thus, multimodal analgesia aims to improve pain relief while reducing opioid requirements and opioid-related side effects. Regional anesthesia techniques are an important component of this approach.

Methods

For this narrative review, authors summarized currently used regional anesthesia techniques and performed an extensive literature search to summarize specific current evidence. For this, related articles from January 1985 to March 2022 were taken from PubMed, Web of Science, Embase and Cochrane Library databases. Terms such as "pectoral nerve blocks", "serratus plane block", "erector spinae plane block" belonging to blocks used in thoracic surgery were searched in different combinations.

Key Content and Findings

Potential advantages of regional anesthesia as part of multimodal analgesia regiments are reduced surgical stress response, improved analgesia, reduced opioid consumption, reduced risk of postoperative nausea and vomiting, and early mobilization. Potential disadvantages include the possibility of bleeding related to regional anesthesia procedure (particularly epidural hematoma), dural puncture with subsequent dural headache, systemic hypotension, urine retention, allergic reactions, local anesthetic toxicity, injuries to organs including pneumothorax, and a relatively high failure especially with continuous techniques.

Conclusions

This narrative review summarizes regional anesthetic techniques, specific indications, and clinical considerations for patients undergoing thoracic surgery, with evidence from studies performed. However, there is a need for more studies comparing new block methods with standard methods so that clinical applications can increase patient satisfaction.

Mild acute kidney injury after pediatric surgery is not-associated with long-term renal dysfunction: A retrospective cohort study

BACKGROUND AND STUDY OBJECTIVE

Acute kidney injury (AKI) is a sudden deterioration in renal function and is common in pediatric patients undergoing cardiac and non-cardiac surgery. Few studies have investigated the association of postoperative AKI with kidney dysfunction seen long-term and other adverse outcomes in pediatric patients. The study aimed to determine the association between postoperative AKI (mild AKI vs. no AKI and mild AKI vs. moderate-severe AKI) and chronic kidney dysfunction (CKD) seen long-term in pediatric patients undergoing cardiac and non-cardiac major surgery.

DESIGN

Restrospective, cohort study.

SETTING

Tertiary care hospital.

PATIENTS

This retrospective cohort study included patients aged 2-18 years who underwent cardiac and non-cardiac major surgery lasting >2 h at the Cleveland Clinic Main Campus between June 2005 and December 2020.

MEASUREMENTS

Postoperative AKI and CKD seen in long-term were defined and staged according to the Kidney Disease: Improving Global Outcomes criteria.

MAIN RESULTS

Among 10,597 children who had cardiac and non-cardiac major surgery, 1,302 were eligible. A total of 682 patients were excluded for missing variables and baseline kidney dysfunction and 620 patients were included. The mean age was 11 years, and 307 (49.5%) were female. Postoperative mild AKI was detected in 5.8% of the patients, while moderate-severe AKI was detected in 2.4%. There was no significant difference in CKD seen in long-term between patients with and without postoperative AKI, p = 0.83. The CKD seen in long-term developed in 27.7% of patients with postoperative mild AKI and 33.3% of patients with postoperative moderate and severe AKI. Patients without postoperative AKI had an estimated 1.09 times higher odds of having CKD seen in long-term compared with patients who have postoperative mild AKI (odds ratio [95% CI] 1.09 [0.48,2.52]).

CONCLUSION

In contrast to adult patients, the authors did not find any association between postoperative AKI and CKD seen in long-term in pediatric patients.

Association between body mass index and difficult intubation with a double lumen tube: A retrospective cohort study

STUDY OBJECTIVE

Obesity, defined by the World Health Organization as body mass index (BMI) ≥ 30.0 kg/m², is associated with adverse outcomes and challenges during surgery. Difficulties during endotracheal intubation, occur in 3-8% of procedures and are among the principal causes of anesthetic-related morbidity and mortality. Endotracheal intubation can be challenging in obese patients due to an array of anatomic and physiologic factors. Double lumen tubes (DLTs), the most commonly used airway technique to facilitate anatomic isolation of the lungs for one lung ventilation. However, DLTs can be difficult to properly position and are also more likely to cause airway injuries and bleeding when compared to conventional single lumen tubes. We investigated the association between BMI and difficult tracheal DLT intubation.

DESIGN

Retrospective cohort study.

SETTING

Operating room.

PATIENTS

We analyzed electronic records of adults having cardiac and thoracic surgery requiring general anesthesia and endotracheal intubation with DLT at the Cleveland Clinic between 2008 and 2021.

MEASUREMENTS

BMI, preoperative airway abnormalities and difficult intubation, defined as more than one intubation attempt, was assessed using multivariable logistic regression.

MAIN RESULTS

Among 8641 analyzed anesthetics requiring DLT, 1459 (17%) were difficult intubations. After adjusting for confounders, each 5 kg/m² increase in BMI was associated with a marginal increase of difficult intubation, odds ratio (OR) 1.06 (95% Confidence Interval [CI]: 1.002, 1.11; P = 0.040). Difficult intubation was not associated with airway abnormalities, estimated OR 0.85 (95% CI: 0.62, 1.17; P = 0.321). There was no interaction between known airway abnormalities and BMI (P = 0.894).

CONCLUSIONS

Difficult intubations with DLT remain common, but BMI is a weak predictor thereof. For example, an increase in BMI from 20 to 40 kg/m² corresponds to an increase in average absolute risk for difficult intubation from 16 to 19%, which probably is not clinically meaningful.

Clinical challenges of glycemic control in the intensive care unit: A narrative review

Glucose control in patient admitted to the intensive care unit has been a topic of much debate over the past 20 years. The harmful effects of uncontrolled hyperglycemia and hypoglycemia in critically ill patients is well established. Although a large clinical trial in 2001 demonstrated significant mortality and morbidity benefits with tight glucose control in this patient population, the results could not be replicated by other investigators. The “Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation” trial in 2009 established that tight glucose control was not only of no benefit, but in fact harmful due to the significant risk of hypoglycemia. The current guidelines suggest a moderate approach with the initiation of intravenous insulin therapy in critically ill patients when the blood glucose level is above 180 mg/dL. The most important factor that underpins glycemic management in intensive care unit patients is the consequent prevention of hypoglycemia. Robust glucose monitoring strategies and insulin protocols need to be implemented in order to achieve this goal.

Chest pain in patients recovering from noncardiac surgery: A retrospective analysis

STUDY OBJECTIVE

Chest pain is relatively common postoperatively. Myocardial infarction (MI) is one cause of chest pain after surgery, but chest pain also results from less severe conditions. Because of its potential severity, chest pain usually prompts the activation of Rapid Response Systems (RRS). While chest pain is a cardinal symptom of myocardial ischemia in the non-surgical setting, the significance and relevance of chest pain after noncardiac surgery remains unclear.

DESIGN

We conducted a retrospective analysis of noncardiac surgical inpatients for whom postoperative chest pain triggered our multidisciplinary RRS.

SETTING

Surgical wards at Cleveland Clinic, Cleveland, OH.

PATIENTS

Postsurgical patients after noncardiac surgery in whom the RSS system was activated for chest pain.

INTERVENTIONS

RRS specified interventions like ECG readings, troponin measurements, transfer to ICU.

MEASUREMENTS

Our primary outcome was MI. Secondary outcomes included the proportion of patients who had an ECG performed, troponin measurements, echocardiography, cardiac catheterization, and were admitted to the Intensive Care Unit (ICU).

MAIN RESULTS

5850 surgical patients experienced postoperative chest pain and triggered an RRS activation between 2009 and 2019. A total of 3110 patients had troponin T measured within 6 h after RRS activation, and 538 of them (17%) had elevated troponin, meeting the Fourth Universal Definition criteria for MI. Additionally, 2 patients had ST-segment elevation infarction (STEMI) without troponin measurement. Among the 540 patients with MI, only 19 (3.5%) were diagnosed with a STEMI by ECG, 388 (72%) had echocardiography, 43 patients (8%) had cardiac catheterization, 8 patients (1.5%) required emergent cardiac surgery, and 424 (79%) were admitted to an ICU.

CONCLUSION

Chest pain is a serious clinical sign, often indicating a postoperative myocardial infarction, and therefore should be taken seriously. Troponin screening should be routinely considered in postsurgical patients who report chest pain.

Honey bee venom re-challenge during specific immunotherapy: prolonged cardio-pulmonary resuscitation allowed survival in a case of near fatal anaphylaxis

BACKGROUND

Specific immunotherapy for patients with honey bee hypersensitivity is commonly applied. Re-challenge with venom is performed to prove protection in individual cases.

CASE PRESENATION

We report a case of near fatal anaphylaxis with asystole for 24 min in a 35-years-old patient with mastocytosis after honey bee sting challenge, despite 5-years of specific immunotherapy. Successful cardio-pulmonary resuscitation was applied for 32 min.

CONCLUSION

This intervention demonstrates, that in anaphylaxis with cardio-vascular arrest, prolonged cardio-pulmonary resuscitation for up to 40 min may be appropriate to overcome the half-life of massively released histamine. Failure of specific immunotherapy was possibly due to sensitization to the allergen Api m10, potentially underrepresented in commercial honey bee venom extracts. Molecular analyses may provide additional clues to the potentially unsuccessful outcome of venom specific immunotherapy, especially in high-risk patients such as mastocytosis.

Tranexamic Acid in Patients Undergoing Noncardiac Surgery

BACKGROUND

Perioperative bleeding is common in patients undergoing noncardiac surgery. Tranexamic acid is an antifibrinolytic drug that may safely decrease such bleeding.

METHODS

We conducted a trial involving patients undergoing noncardiac surgery. Patients were randomly assigned to receive tranexamic acid (1-g intravenous bolus) or placebo at the start and end of surgery (reported here) and, with the use of a partial factorial design, a hypotension-avoidance or hypertension-avoidance strategy (not reported here). The primary efficacy outcome was life-threatening bleeding, major bleeding, or bleeding into a critical organ (composite bleeding outcome) at 30 days. The primary safety outcome was myocardial injury after noncardiac surgery, nonhemorrhagic stroke, peripheral arterial thrombosis, or symptomatic proximal venous thromboembolism (composite cardiovascular outcome) at 30 days. To establish the noninferiority of tranexamic acid to placebo for the composite cardiovascular outcome, the upper boundary of the one-sided 97.5% confidence interval for the hazard ratio had to be below 1.125, and the one-sided P value had to be less than 0.025.

RESULTS

A total of 9535 patients underwent randomization. A composite bleeding outcome event occurred in 433 of 4757 patients (9.1%) in the tranexamic acid group and in 561 of 4778 patients (11.7%) in the placebo group (hazard ratio, 0.76; 95% confidence interval [CI], 0.67 to 0.87; absolute difference, -2.6 percentage points; 95% CI, -3.8 to -1.4; two-sided P<0.001 for superiority). A composite cardiovascular outcome event occurred in 649 of 4581 patients (14.2%) in the tranexamic acid group and in 639 of 4601 patients (13.9%) in the placebo group (hazard ratio, 1.02; 95% CI, 0.92 to 1.14; upper boundary of the one-sided 97.5% CI, 1.14; absolute difference, 0.3 percentage points; 95% CI, -1.1 to 1.7; one-sided P = 0.04 for noninferiority).

CONCLUSIONS

Among patients undergoing noncardiac surgery, the incidence of the composite bleeding outcome was significantly lower with tranexamic acid than with placebo. Although the between-group difference in the composite cardiovascular outcome was small, the noninferiority of tranexamic acid was not established. (Funded by the Canadian Institutes of Health Research and others; POISE-3 ClinicalTrials.gov number, NCT03505723.).

Pro-Con Debate: Prehospital Blood Transfusion-Should It Be Adopted for Civilian Trauma?

Exsanguination is the leading cause of death in severely injured patients; nevertheless, prehospital blood transfusion (PHT) remains a controversial topic. Here, we review the pros and cons of PHT, which is now routine in treatment of military trauma patients in the civilian setting. While PHT may improve survival in those who suffer blunt injury or require prolonged transport from the site of injury, PHT for civilian trauma generally is not supported by high-quality evidence. This article was originally presented as a pro-con debate at the 2020 meeting of the European Society of Anesthesiology and Intensive Care.

Inconsistent Methodology as a Barrier to Meaningful Research Outputs From Studies of Atrial Fibrillation After Cardiac Surgery

Atrial fibrillation after cardiac surgery (AFACS) is a serious postoperative complication. There is significant research interest in this field but also relevant heterogeneity in reported AFACS definitions and approaches used for its identification. Few data exist on the extent of this variation in clinical studies. The authors reviewed the literature since 2001 and included manuscripts reporting outcomes of AFACS in adults. They excluded smaller studies and studies in which patients did not undergo a sternotomy. The documented protocol in each manuscript was analyzed according to six different categories to determine how AFACS was defined, which techniques were used to identify it, and the inclusion and/or exclusion criteria. They also noted when a category was not described in the documented protocol. The authors identified 302 studies, of which 92 were included. Sixty-two percent of studies were randomized controlled trials. There was significant heterogeneity in the manuscripts, including the exclusion of patients with preoperative AF, the definition and duration of AF needed to meet the primary endpoint, the type of screening approach (continuous, episodic, or opportunistic), the duration of monitoring during the study period in days, the diagnosis with predefined electrocardiogram criteria, and the requirement for independent confirmation by study investigators. Furthermore, the definitions of these criteria frequently were not described. Consistent reporting standards for AFACS research are needed to advance scientific progress in the field. The authors here propose pragmatic standards for trial design and reporting standards. These include adequate sample size estimation, a clear definition of the AFACS endpoints, and a protocol for AFACS detection.

Effect of seasons on delirium in postoperative critically ill patients: a retrospective analysis

BACKGROUND AND OBJECTIVES

Postoperative delirium is common in critically ill patients and is known to have several predisposing and precipitating factors. Seasonality affects cognitive function which has a more dysfunctional pattern during winter. We, therefore, aimed to test whether seasonal variation is associated with the occurrence of delirium and hospital Length Of Stay (LOS) in critically ill non-cardiac surgical populations.

METHODS

We conducted a retrospective analysis of adult patients recovering from non-cardiac surgery at the Cleveland Clinic between March 2013 and March 2018 who stayed in Surgical Intensive Care Unit (SICU) for at least 48 hours and had daily Confusion Assessment Method Intensive Care Unit (CAM-ICU) assessments for delirium. The incidence of delirium and LOS were summarized by season and compared using chi-square test and non-parametric tests, respectively. A logistic regression model was used to assess the association between delirium and LOS with seasons, adjusted for potential confounding variables.

RESULTS

Among 2300 patients admitted to SICU after non-cardiac surgeries, 1267 (55%) had postoperative delirium. The incidence of delirium was 55% in spring, 54% in summer, 55% in fall and 57% in winter, which was not significantly different over the four seasons (p = 0.69). The median LOS was 12 days (IQR = [8, 19]) overall. There was a significant difference in LOS across the four seasons (p = 0.018). LOS during summer was 12% longer (95% CI: 1.04, 1.21; p = 0.002) than in winter.

CONCLUSIONS

In adult non-cardiac critically ill surgical patients, the incidence of postoperative delirium is not associated with season. Noticeably, LOS was longer in summer than in winter.

Characteristics and Outcomes of Type 1 versus Type 2 Perioperative Myocardial Infarction After Noncardiac Surgery

BACKGROUND

Perioperative myocardial infarction is frequently attributed to type 2 myocardial infarction, a mismatch in myocardial oxygen supply-demand without unstable coronary artery disease. Our aim was to identify characteristics, management, and outcomes of perioperative type 1 versus type 2 myocardial infarction among surgical inpatients.

METHODS

Adults age ≥45 years hospitalized for noncardiac surgery were identified in the United States. Perioperative myocardial infarction were identified using International Classification of Diseases, 10th revision (ICD-10) codes. Clinical characteristics, invasive myocardial infarction management, mortality, and readmissions were assessed by myocardial infarction subtype.

RESULTS

Among 4,755,382 surgical hospitalizations, we identified 38,975 perioperative myocardial infarctions (0.82%), with type 2 infarction in 42%. Patients with type 2 myocardial infarction were older, more likely to be women, and less likely to have cardiovascular comorbidities compared with type 1 myocardial infarction. Fewer patients with type 2 myocardial infarction underwent invasive management than type 1 myocardial infarction (6.7% vs 28.8%, P < .001). Type 2 myocardial infarction mortality was lower than type 1 myocardial infarction mortality (12.1% vs 17.4%, P < .001; adjusted odds ratio [aOR] 0.51, 95% confidence interval [CI] 0.45-0.59). Invasive management of perioperative myocardial infarction was associated with lower mortality in type 1 (aOR 0.56, 95% CI 0.49-0.74) but not type 2 (aOR 1.19, 95% CI 0.77-1.85) myocardial infarction. Among survivors, there was no difference in 90-day hospital readmission between type 2 and type 1 perioperative myocardial infarction (36.5% vs 36.1%, P = .72).

CONCLUSIONS

Type 2 myocardial infarctions account for approximately 40% of perioperative myocardial infarctions. Patients with type 2 perioperative myocardial infarction are less likely to undergo invasive management and have lower mortality compared with those with type 1 perioperative myocardial infarction.

Naloxegol and Postoperative Urinary Retention: A Randomized Trial

Background: Naloxegol antagonizes peripheral opioid-related side effects without preventing opioid-related analgesia. However, the effect of naloxegol on opioid-induced bladder dysfunction remains unknown. Hypothesis: patients given naloxegol have lower residual bladder urine volume than those given placebo. Methods: 136 patients scheduled for elective hip and knee surgery were randomized to oral naloxegol or placebo given the morning of surgery, and on the first two postoperative mornings. Residual urine volume was measured ultrasonographically within 30 min after voiding once in the morning and once in the afternoon for two postoperative days. Opioid-related Symptom Distress Scale (ORSDS), the need for indwelling urinary catheterization, and quality of recovery (QoR) score were secondary outcomes. Results: 67 were randomized to naloxegol and 64 to placebo. We did not identify a significant effect on urine residual volume, with an estimated ratio of geometric means of 0.9 (0.3, 2.6), p = 0.84. There were no significant differences in ORSDS or QoR. There were 19 (29%) patients assigned to naloxegol who needed indwelling urination catheterization versus 7 (11%) patients in the placebo group, p = 0.012. Conclusions: Our results do not support use of naloxegol for postoperative urinary retention after hip and knee surgery.

Sugammadex Versus Neostigmine for Reversal of Residual Neuromuscular Blocks After Surgery: A Retrospective Cohort Analysis of Postoperative Side Effects

BACKGROUND

Sugammadex and neostigmine given to reverse residual neuromuscular blockade can cause side effects including bradycardia, anaphylaxis, bronchospasm, and even cardiac arrest. We tested the hypothesis that sugammadex is noninferior to neostigmine on a composite of clinically meaningful side effects, or vice versa.

METHODS

We analyzed medical records of patients who had general, cardiothoracic, or pediatric surgery and were given neostigmine or sugammadex from June 2016 to December 2019. Our primary outcome was a collapsed composite of bradycardia, anaphylaxis, bronchospasm, and cardiac arrest occurring between administration of the reversal agent and departure from the operation room. We a priori restricted our analysis to side effects requiring pharmacologic treatment that were therefore presumably clinically meaningful. Sugammadex would be considered noninferior to neostigmine (or vice versa) if the odds ratio for composite of side effects did not exceed 1.2.

RESULTS

Among 89,753 surgeries in 70,690 patients, 16,480 (18%) were given sugammadex and 73,273 (82%) were given neostigmine. The incidence of composite outcome was 3.4% in patients given sugammadex and 3.0% in patients given neostigmine. The most common individual side effect was bradycardia (2.4% in the sugammadex group versus 2.2% neostigmine). Noninferiority was not found, with an estimated odds ratio of 1.21 (sugammadex versus neostigmine; 95% confidence interval [CI], 1.09-1.34; noninferiority P = .57), and neostigmine was superior to sugammadex with an estimated odds ratio of 0.83 (0.74-0.92), 1-side superiority P < .001.

CONCLUSIONS

The composite incidence was less with neostigmine than with sugammadex, but only by 0.4% (a negligible clinical effect). Since 250 patients would need to be given neostigmine rather than sugammadex to avoid 1 episode of a minor complication such as bradycardia or bronchospasm, we conclude that sugammadex and neostigmine are comparably safe.

Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association

Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.

Associations between intraoperative and post-anesthesia care unit hypotension and surgical ward hypotension

STUDY OBJECTIVE

To test whether patients who experience hypotension in the post-anesthesia care unit or during surgery are most likely to experience hypotension on surgical wards.

DESIGN

A prediction study using data from two randomized controlled trials.

SETTING

Operating room, post-anesthesia care unit, and surgical ward.

PATIENTS

550 adult patients having abdominal surgery with ASA physical status I-IV.

INTERVENTIONS

Blood pressure measurement per routine intraoperatively, and with continuous non-invasive monitoring postoperatively.

MEASUREMENTS

The primary predictors were minimum mean arterial pressure (<60, <65, <70 and < 80 mmHg) and minimum systolic blood pressure (<70, <75, <80, <85 mmHg) in the post-anesthesia care unit. The secondary predictors were intraoperative minimum blood pressures with the same thresholds as the primary ones. Our outcome was ward hypotension defined as mean pressure < 70 mmHg or systolic pressure < 85 mmHg. A threshold was considered clinically useful if both sensitivity and specificity exceeded 0.75.

MAIN RESULTS

Minimum mean and systolic pressures in the post-anesthesia care unit similarly predicted ward mean or systolic hypotension, with the areas under the curves near 0.74. The best performing threshold was mean pressure < 80 mmHg in the post-anesthesia care unit which had a sensitivity of 0.41 (95% confidence interval [CI], 0.35, 0.47) and specificity of 0.91 (95% CI, 0.87, 0.94) for ward mean pressure < 70 mmHg and a sensitivity of 0.44 (95% CI, 0.37, 0.51) and specificity of 0.88 (95% CI, 0.84, 0.91) for ward systolic pressure < 85 mmHg. The areas under the curves using intraoperative hypotension to predict ward hypotension were roughly similar at about 0.60, with correspondingly low sensitivity and specificity.

CONCLUSIONS

Intraoperative hypotension poorly predicted ward hypotension. Pressures in the post-anesthesia care unit were more predictive, but the combination of sensitivity and specificity remained poor. Unless far better predictors are identified, all surgical inpatients should be considered at risk for postoperative hypotension.

Perioperative challenges in management of diabetic patients undergoing non-cardiac surgery

Prediabetes and diabetes are important disease processes which have several perioperative implications. About one third of the United States population is considered to have prediabetes. The prevalence in surgical patients is even higher. This is due to the associated micro and macrovascular complications of diabetes that result in the need for subsequent surgical procedures. A careful preoperative evaluation of diabetic patients and patients at risk for prediabetes is essential to reduce perioperative mortality and morbidity. This preoperative evaluation involves an optimization of preoperative comorbidities. It also includes optimization of antidiabetic medication regimens, as the avoidance of unintentional hypoglycemic and hyperglycemic episodes during the perioperative period is crucial. The focus of the perioperative management is to ensure euglycemia and thus improve postoperative outcomes. Therefore, prolonged preoperative fasting should be avoided and close monitoring of blood glucose should be initiated and continued throughout surgery. This can be accomplished with either analysis in blood gas samples, venous phlebotomy or point-of-care testing. Although capillary and arterial whole blood glucose do not meet standard guidelines for glucose testing, they can still be used to guide insulin dosing in the operating room. Intraoperative glycemic control goals may vary slightly in different protocols but overall the guidelines suggest a glucose range in the operating room should be between 140 mg/dL to 180 mg/dL. When hyperglycemia is detected in the operating room, blood glucose management may be initiated with subcutaneous rapid-acting insulin, with intravenous infusion or boluses of regular insulin. Fluid and electrolyte management are other perioperative challenges. Notably diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic state are the two most serious acute metabolic complications of diabetes that must be recognized early and treated.

Cesarean Delivery in the Bronchoscopy Suite in a Patient with an Anterior Mediastinal Mass

Mediastinal masses pose a significant challenge for anesthesiologists due to the risk of cardiorespiratory collapse. Pregnancy in of itself causes multiple detrimental changes to respiratory physiology. We present a case of cesarean delivery performed in the bronchoscopy suite followed by bronchoscopic airway evaluation in a patient at 33 weeks gestation with symptomatic anterior mediastinal mass. We discuss the multidisciplinary approach and anaesthetic management of this complicated case.