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Ben-Arie E, Mayer PK, Lottering BJ, Ho WC, Lee YC, Kao PY. Acupuncture reduces mechanical ventilation time in critically ill patients: A systematic review and meta-analysis of randomized control trials. Explore (NY) 2024; 20:477-492. [PMID: 38065826 DOI: 10.1016/j.explore.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 06/16/2024]
Abstract
BACKGROUND Mechanical Ventilation (MV) is an essential life support machine, frequently utilized in an Intensive Care Unit (ICU). Recently, a growing number of clinical trials have investigated the effect of acupuncture treatment on MV outcomes. OBJECTIVES This study investigated the safety and efficacy of acupuncture treatment for critically ill patients under MV. METHODS In this systematic review and meta-analysis of randomized controlled trials, the efficacy of acupuncture related interventions was compared to routine ICU treatments, and sham/control acupuncture as control interventions applied to ICU patients undergoing MV. The databases of PubMed, Cochrane Library, and Web of Science were extensively searched in the month of April 2022. The primary outcome measurements were defined as total MV time, ICU length of stay, and mortality. The Cochrane Collaboration risk of bias tool was employed to analyze the severity of bias. The meta-analysis was conducted using Review Manager 5.3 software. The quality of evidence was evaluated according to the GRADE approach. RESULTS A total of 10 clinical trials were included in this investigation. When comparing the performance of acupuncture-related interventions to that of the reported control interventions, the results of the meta-analysis revealed a significant reduction in the total number of MV days as well as the duration of ICU length of stay following acupuncture treatment (MD -2.06 [-3.33, -0.79] P = 0.001, I2 = 55 %, MD-1.26 [-2.00, -0.53] P = 0.0008, I2 = 77 %, respectively). A reduction in the total mortality was similarly observed (RR = 0.67 [0.47, 0.94] P = 0.02, I2 = 0 %). CONCLUSION This systematic review and meta-analysis identified a noteworthy reduction in the total MV days, time spent in the ICU, as well as the total mortality following acupuncture related interventions. However, the small sample size, risk of bias and existing heterogeneity should be taken into consideration. The results of this study are promising and further investigations in this field are warranted.
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Affiliation(s)
- Eyal Ben-Arie
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung 40402, Taiwan
| | - Peter Karl Mayer
- International Master Program in Acupuncture, College of Chinese Medicine, China Medical University, Taichung 40402, Taiwan; Department of Chinese Medicine, China Medical University Hospital, Taichung 40402, Taiwan
| | - Bernice Jeanne Lottering
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung 40402, Taiwan
| | - Wen-Chao Ho
- Department of Public Health, China Medical University, Taichung 40402, Taiwan
| | - Yu-Chen Lee
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung 40402, Taiwan; Department of Acupuncture, China Medical University Hospital, Taichung 40402, Taiwan; Chinese Medicine Research Center, China Medical University, Taichung 40402, Taiwan.
| | - Pei-Yu Kao
- Surgical Intensive Care Unit, China Medical University Hospital, Taichung 40402, Taiwan; Division of Thoracic Surgery, Department of Surgery, China Medical University Hospital, Taichung 40402, Taiwan; Institute of Traditional Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan.
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Ranjeva S, Nagebretsky A, Odozynski G, Fernandez-Bustamante A, Frendl G, Gupta RA, Sprung J, Subramaniam B, Ruiz RM, Bartels K, Giquel J, Lee JW, Houle T, Melo MFV. Effects of Intra-operative Cardiopulmonary Variability On Post-operative Pulmonary Complications in Major Non-cardiac Surgery: A Retrospective Cohort Study. J Med Syst 2024; 48:31. [PMID: 38488884 DOI: 10.1007/s10916-024-02050-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/27/2024] [Indexed: 03/17/2024]
Abstract
Intraoperative cardiopulmonary variables are well-known predictors of postoperative pulmonary complications (PPC), traditionally quantified by median values over the duration of surgery. However, it is unknown whether cardiopulmonary instability, or wider intra-operative variability of the same metrics, is distinctly associated with PPC risk and severity. We leveraged a retrospective cohort of adults (n = 1202) undergoing major non-cardiothoracic surgery. We used multivariable logistic regression to evaluate the association of two outcomes (1)moderate-or-severe PPC and (2)any PPC with two sets of exposure variables- (a)variability of cardiopulmonary metrics (inter-quartile range, IQR) and (b)median intraoperative cardiopulmonary metrics. We compared predictive ability (receiver operating curve analysis, ROC) and parsimony (information criteria) of three models evaluating different aspects of the intra-operative cardiopulmonary metrics: Median-based: Median cardiopulmonary metrics alone, Variability-based: IQR of cardiopulmonary metrics alone, and Combined: Medians and IQR. Models controlled for peri-operative/surgical factors, demographics, and comorbidities. PPC occurred in 400(33%) of patients, and 91(8%) experienced moderate-or-severe PPC. Variability in multiple intra-operative cardiopulmonary metrics was independently associated with risk of moderate-or-severe, but not any, PPC. For moderate-or-severe PPC, the best-fit predictive model was the Variability-based model by both information criteria and ROC analysis (area under the curve, AUCVariability-based = 0.74 vs AUCMedian-based = 0.65, p = 0.0015; AUCVariability-based = 0.74 vs AUCCombined = 0.68, p = 0.012). For any PPC, the Median-based model yielded the best fit by information criteria. Predictive accuracy was marginally but not significantly higher for the Combined model (AUCCombined = 0.661) than for the Median-based (AUCMedian-based = 0.657, p = 0.60) or Variability-based (AUCVariability-based = 0.649, p = 0.29) models. Variability of cardiopulmonary metrics, distinct from median intra-operative values, is an important predictor of moderate-or-severe PPC.
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Affiliation(s)
- Sylvia Ranjeva
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA.
| | - Alexander Nagebretsky
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | | | | | - Gyorgy Frendl
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - R Alok Gupta
- Department of Anesthesiology, Northwestern Medicine, Chicago, USA
| | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic, Rochester, USA
| | - Bala Subramaniam
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, USA
| | | | - Karsten Bartels
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, USA
| | - Jadelis Giquel
- Department of Anesthesiology, University of Miami Hospital and Clinics, Miami, USA
| | - Jae-Woo Lee
- Department of Anesthesiology, University of California San Francisco, San Francisco, USA
| | - Timothy Houle
- Department of Anesthesiology, Anesthesia Research Center, Massachusetts General Hospital, Boston, USA
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Wilson MG, Adams CN, Turnbull MD, Falyar CR, Harris EM, Thompson JA, Simmons VC. Improving Certified Registered Nurse Anesthetists' Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol. J Perianesth Nurs 2023; 38:845-850. [PMID: 37589630 DOI: 10.1016/j.jopan.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 08/18/2023]
Abstract
PURPOSE The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements. DESIGN This quality improvement project was conducted using a pre- and postimplementation design. METHODS Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU). FINDINGS Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P = .588), confidence (P = .031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%. CONCLUSIONS Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes.
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Affiliation(s)
- Megan G Wilson
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Cara N Adams
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Matthew D Turnbull
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Christian R Falyar
- Middle Tennesee Acute Surgical Pain Management Fellowship, Middle Tennesee School of Anesthesia, Madison, TN
| | - Erica M Harris
- Duke University Anesthesia Department, Duke University Medical Center, Durham, NC
| | - Julie A Thompson
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Virginia C Simmons
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC.
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Beier J, Ahrens E, Rufino M, Patel J, Azimaraghi O, Kumar V, Houle TT, Schaefer MS, Eikermann M, Wongtangman K. The impact of residency training level on early postoperative desaturation: A retrospective multicenter cohort study. J Clin Anesth 2023; 90:111238. [PMID: 37639750 DOI: 10.1016/j.jclinane.2023.111238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE We studied the primary hypothesis that the training level of anesthesiology residents (first clinical anesthesia year, CA1 vs CA2/3 residents) is associated with early postoperative desaturation (oxygen saturation < 90%). We also analyzed the change in the rate (trajectory) of desaturation during the resident's development from CA1 to CA2/3 resident, and its effects on postoperative respiratory complications. DESIGN Retrospective hospital registry study. SETTING Two university-affiliated hospitals networks (MA and NY, USA). PATIENTS 140,818 adults undergoing non-cardiac surgery under general anesthesia and extubation in the operating room by residents (n = 378) between 2005 and 2021. MEASUREMENTS Multivariate logistic and quantile regression were used in the analyses. The secondary outcome was major respiratory complication within 7 days after surgery. MAIN RESULTS In 6.5% and 1.6% of cases, early postoperative desaturation to < 90% and 80% occurred. Compared to CA2/3 residents, CA1 residents had higher odds of experiencing early postoperative desaturation to < 90% and 80% (adjusted odds ratio [ORadj], 1.07; 95%CI 1.03-1.12; p = 0.002, and ORadj 1.10; 95%CI 1.01-1.20; p = 0.037, respectively). The change in postoperative desaturation rate during the transition from CA1 to CA2/3 status varied substantially from ORadj 0.80 (decreased risk) to 1.33 (increased risk). Major respiratory complication did not differ between experience levels (p = 0.52). However, a strong decline in improvement regarding the rate of postoperative desaturation during the transition from CA1 to CA2/3, was paralleled by an increased odds of major respiratory complication for CA2/3 residents (ORadj 1.20; 95%CI 1.02-1.42; p = 0.026, p-for-interaction = 0.056). CONCLUSION Patients treated by CA1 residents have an increased risk of postoperative desaturation. Some residents show an improvement and others a decline in postoperative desaturation rate. Our secondary analysis suggests that there should be more focus on those residents who had a declining performance in postoperative desaturation despite becoming more experienced.
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Affiliation(s)
- Juliane Beier
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michael Rufino
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Jashvin Patel
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Omid Azimaraghi
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Vivek Kumar
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany.
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
| | - Karuna Wongtangman
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Tartler TM, Wachtendorf LJ, Suleiman A, Blank M, Ahrens E, Linhardt FC, Althoff FC, Chen G, Santer P, Nagrebetsky A, Eikermann M, Schaefer MS. The association of intraoperative low driving pressure ventilation and nonhome discharge: a historical cohort study. Can J Anaesth 2023; 70:359-373. [PMID: 36697936 DOI: 10.1007/s12630-022-02378-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/07/2022] [Accepted: 09/21/2022] [Indexed: 01/26/2023] Open
Abstract
PURPOSE To evaluate whether intraoperative ventilation using lower driving pressure decreases the risk of nonhome discharge. METHODS We conducted a historical cohort study of patients aged ≥ 60 yr who were living at home before undergoing elective, noncardiothoracic surgery at two tertiary healthcare networks in Massachusetts between 2007 and 2018. We assessed the association of the median driving pressure during intraoperative mechanical ventilation with nonhome discharge using multivariable logistic regression analysis, adjusted for patient and procedural factors. Contingent on the primary association, we assessed effect modification by patients' baseline risk and mediation by postoperative respiratory failure. RESULTS Of 87,407 included patients, 12,584 (14.4%) experienced nonhome discharge. In adjusted analyses, a lower driving pressure was associated with a lower risk of nonhome discharge (adjusted odds ratio [aOR], 0.88; 95% confidence interval [CI], 0.83 to 0.93, per 10 cm H2O decrease; P < 0.001). This association was magnified in patients with a high baseline risk (aOR, 0.77; 95% CI, 0.73 to 0.81, per 10 cm H2O decrease, P-for-interaction < 0.001). The findings were confirmed in 19,518 patients matched for their baseline respiratory system compliance (aOR, 0.90; 95% CI, 0.81 to 1.00; P = 0.04 for low [< 15 cm H2O] vs high [≥ 15 cm H2O] driving pressures). A lower risk of respiratory failure mediated the association of a low driving pressure with nonhome discharge (20.8%; 95% CI, 15.0 to 56.8; P < 0.001). CONCLUSIONS Intraoperative ventilation maintaining lower driving pressure was associated with a lower risk of nonhome discharge, which can be partially explained by lowered rates of postoperative respiratory failure. Future randomized controlled trials should target driving pressure as a potential intervention to decrease nonhome discharge.
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Affiliation(s)
- Tim M Tartler
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia and Intensive Care, Faculty of Medicine, The University of Jordan, Amman, Jordan
| | - Michael Blank
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Felix C Linhardt
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Friederike C Althoff
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Guanqing Chen
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexander Nagrebetsky
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany.
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Naik BI, Kuck K, Saager L, Kheterpal S, Domino KB, Posner KL, Sinha A, Stuart A, Brummett CM, Durieux ME, Vaughn MT, Pace NL. Practice Patterns and Variability in Intraoperative Opioid Utilization: A Report From the Multicenter Perioperative Outcomes Group. Anesth Analg 2021; 134:8-17. [PMID: 34291737 DOI: 10.1213/ane.0000000000005663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Opioids remain the primary mode of analgesia intraoperatively. There are limited data on how patient, procedural, and institutional characteristics influence intraoperative opioid administration. The aim of this retrospective, longitudinal study from 2012 to 2016 was to assess how intraoperative opioid dosing varies by patient and clinical care factors and across multiple institutions over time. METHODS Demographic, surgical procedural, anesthetic technique, and intraoperative analgesia data as putative variables of intraoperative opioid utilization were collected from 10 institutions. Log parenteral morphine equivalents (PME) was modeled in a multivariable linear regression model as a function of 15 covariates: 3 continuous covariates (age, anesthesia duration, year) and 12 factor covariates (peripheral block, neuraxial block, general anesthesia, emergency status, race, sex, remifentanil infusion, major surgery, American Society of Anesthesiologists [ASA] physical status, non-opioid analgesic count, Multicenter Perioperative Outcomes Group [MPOG] institution, surgery category). One interaction (year by MPOG institution) was included in the model. The regression model adjusted simultaneously for all included variables. Comparison of levels within a factor were reported as a ratio of medians with 95% credible intervals (CrI). RESULTS A total of 1,104,324 cases between January 2012 and December 2016 were analyzed. The median (interquartile range) PME and standardized by weight PME per case for the study period were 15 (10-28) mg and 200 (111-347) μg/kg, respectively. As estimated in the multivariable model, there was a sustained decrease in opioid use (mean, 95% CrI) dropping from 152 (151-153) μg/kg in 2012 to 129 (129-130) μg/kg in 2016. The percent of variability in PME due to institution was 25.6% (24.8%-26.5%). Less opioids were prescribed in men (130 [129-130] μg/kg) than women (144 [143-145] μg/kg). The men to women PME ratio was 0.90 (0.89-0.90). There was substantial variability in PME administration among institutions, with the lowest being 80 (79-81) μg/kg and the highest being 186 (184-187) μg/kg; this is a PME ratio of 0.43 (0.42-0.43). CONCLUSIONS We observed a reduction in intraoperative opioid administration over time, with variability in dose ranging between sexes and by procedure type. Furthermore, there was substantial variability in opioid use between institutions even when adjusting for multiple variables.
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Affiliation(s)
- Bhiken I Naik
- From the Department of Anesthesiology and Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kai Kuck
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Leif Saager
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Karen B Domino
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Karen L Posner
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Anik Sinha
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ami Stuart
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Marcel E Durieux
- From the Department of Anesthesiology and Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Michelle T Vaughn
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
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Althoff FC, Xu X, Wachtendorf LJ, Shay D, Patrocinio M, Schaefer MS, Houle TT, Fassbender P, Eikermann M, Wongtangman K. Provider variability in the intraoperative use of neuromuscular blocking agents: a retrospective multicentre cohort study. BMJ Open 2021; 11:e048509. [PMID: 33853808 PMCID: PMC8054197 DOI: 10.1136/bmjopen-2020-048509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess variability in the intraoperative use of non-depolarising neuromuscular blocking agents (NMBAs) across individual anaesthesia providers, surgeons and hospitals. DESIGN Retrospective observational cohort study. SETTING Two major tertiary referral centres, Boston, Massachusetts, USA. PARTICIPANTS 265 537 adult participants undergoing non-cardiac surgery between October 2005 and September 2017. MAIN OUTCOME MEASURES We analysed the variances in NMBA use across 958 anaesthesia and 623 surgical providers, across anaesthesia provider types (anaesthesia residents, certified registered nurse anaesthetists, attendings) and across hospitals using multivariable-adjusted mixed effects logistic regression. Intraclass correlations (ICC) were calculated to further quantify the variability in NMBA use that was unexplained by other covariates. Procedure-specific subgroup analyses were performed. RESULTS NMBAs were used in 183 242 (69%) surgical cases. Variances in NMBA use were significantly higher among individual surgeons than among anaesthesia providers (variance 1.32 (95% CI 1.06 to 1.60) vs 0.24 (95% CI 0.19 to 0.28), p<0.001). Procedure-specific subgroup analysis of hernia repairs, spine surgeries and mastectomies confirmed our findings: the total variance in NMBA use that was unexplained by the covariate model was higher for surgeons versus anaesthesia providers (ICC 37.0% vs 13.0%, 69.7% vs 25.5%, 69.8% vs 19.5%, respectively; p<0.001). Variances in NMBA use were also partially explained by the anaesthesia provider's hospital network (Massachusetts General Hospital: variance 0.35 (95% CI 0.27 to 0.43) vs Beth Israel Deaconess Medical Center: 0.15 (95% CI 0.12 to 0.19); p<0.001). Across provider types, surgeons showed the highest variance, and anaesthesia residents showed the lowest variance in NMBA use. CONCLUSIONS There is wide variability across individual surgeons and anaesthesia providers and institutions in the use of NMBAs, which could not sufficiently be explained by a large number of patient-related and procedure-related characteristics, but may instead be driven by preference. Surgeons may have a stronger influence on a key aspect of anaesthesia management than anticipated.
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Affiliation(s)
- Friederike C Althoff
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Xinling Xu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Denys Shay
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Maria Patrocinio
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Philipp Fassbender
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Bochum, Germany
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Karuna Wongtangman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Anesthesiologists' Role in Value-based Perioperative Care and Healthcare Transformation. Anesthesiology 2021; 134:526-540. [PMID: 33630039 DOI: 10.1097/aln.0000000000003717] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Health care is undergoing major transformation with a shift from fee-for-service care to fee-for-value. The advent of new care delivery and payment models is serving as a driver for value-based care. Hospitals, payors, and patients increasingly expect physicians and healthcare systems to improve outcomes and manage costs. The impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical and procedural practices further highlights the urgency and need for anesthesiologists to expand their roles in perioperative care, and to impact system improvement. While there have been substantial advances in anesthesia care, perioperative complications and mortality after surgery remain a key concern. Anesthesiologists are in a unique position to impact perioperative health care through their multitude of interactions and influences on various aspects of the perioperative domain, by using the surgical experience as the first touchpoint to reengage the patient in their own health care. Among the key interventions that are being effectively instituted by anesthesiologists include proactive engagement in preoperative optimization of patients' health; personalization and standardization of care delivery by segmenting patients based upon their complexity and risk; and implementation of best practices that are data-driven and evidence-based and provide structure that allow the patient to return to their optimal state of functional, cognitive, and psychologic health. Through collaborative relationships with other perioperative stakeholders, anesthesiologists can consolidate their role as clinical leaders driving value-based care and healthcare transformation in the best interests of patients.
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Ventilatory frequency during intraoperative mechanical ventilation and postoperative pulmonary complications: a hospital registry study. Br J Anaesth 2020; 125:e130-e139. [PMID: 32223967 DOI: 10.1016/j.bja.2020.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/03/2020] [Accepted: 02/24/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND High ventilatory frequencies increase static lung strain and possibly lung stress by shortening expiratory time, increasing intrathoracic pressure, and causing dynamic hyperinflation. We hypothesised that high intraoperative ventilatory frequencies were associated with postoperative respiratory complications. METHODS In this retrospective hospital registry study, we analysed data from adult non-cardiothoracic surgical cases performed under general anaesthesia with mechanical ventilation at a single centre between 2005 and 2017. We assessed the association between intraoperative ventilatory frequency (categorised into four groups) and postoperative respiratory complications, defined as composite of invasive mechanical ventilation within 7 days after surgery or peripheral oxygen desaturation after extubation, using multivariable logistic regression. In a subgroup, we adjusted analyses for arterial blood gas parameters. RESULTS A total of 102 632 cases were analysed. Intraoperative ventilatory frequencies ranged from a median (inter-quartile range [IQR]) of 8 (8-9) breaths min-1 (Group 1) to 15 (14-18) breaths min-1 (Group 4). High ventilatory frequencies were associated with higher odds of postoperative respiratory complications (adjusted odds ratio=1.26; 95% confidence interval, 1.14-1.38; P<0.001), which was confirmed in a subgroup after adjusting for arterial partial pressure of carbon dioxide and the ratio of arterial oxygen partial pressure to fractional inspired oxygen. We identified considerable variability in the use of high ventilatory frequencies attributable to individual provider preference (ranging from 22% to 88%) and temporal change; however, the association with postoperative respiratory complications remained unaffected. CONCLUSIONS High intraoperative ventilatory frequency was associated with increased risk of postoperative respiratory complications, and increased postoperative healthcare utilisation.
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Thevathasan T, Copeland CC, Long DR, Patrocínio MD, Friedrich S, Grabitz SD, Kasotakis G, Benjamin J, Ladha K, Sarge T, Eikermann M. The Impact of Postoperative Intensive Care Unit Admission on Postoperative Hospital Length of Stay and Costs: A Prespecified Propensity-Matched Cohort Study. Anesth Analg 2019; 129:753-761. [PMID: 31425217 DOI: 10.1213/ane.0000000000003946] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In this prespecified cohort study, we investigated the influence of postoperative admission to the intensive care unit versus surgical ward on health care utilization among patients undergoing intermediate-risk surgery. METHODS Of adult surgical patients who underwent general anesthesia without an absolute indication for postoperative intensive care unit admission, 3530 patients admitted postoperatively to an intensive care unit were matched to 3530 patients admitted postoperatively to a surgical ward using a propensity score based on 23 important preoperative and intraoperative predictor variables. Postoperative hospital length of stay and hospital costs were defined as primary and secondary end points, respectively. RESULTS Among patients with low propensity for postoperative intensive care unit admission, initial triage to an intensive care unit was associated with increased postoperative length of stay (incidence rate ratio, 1.69 [95% CI, 1.59-1.79]; P < .001) and hospital costs (incidence rate ratio, 1.92 [95% CI, 1.81-2.03]; P < .001). By contrast, postoperative intensive care unit admission of patients with high propensity was associated with decreased postoperative length of stay (incidence rate ratio, 0.90 [95% CI, 0.85-0.95]; P < .001) and costs (incidence rate ratio, 0.92 [95% CI, 0.88-0.97]; P = .001). Decisions regarding postoperative intensive care unit resource utilization were influenced by individual preferences of anesthesiologists and surgeons. CONCLUSIONS In patients with an unclear indication for postoperative critical care, intensive care unit admission may negatively impact postoperative hospital length of stay and costs. Postoperative discharge disposition varies substantially based on anesthesia and surgical provider preferences but should optimally be driven by an objective assessment of a patient's status at the end of surgery.
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Affiliation(s)
- Tharusan Thevathasan
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Curtis C Copeland
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Dustin R Long
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Maria D Patrocínio
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sabine Friedrich
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Stephanie D Grabitz
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - George Kasotakis
- Division of Trauma, Acute Care Surgery & Surgical Critical Care, Boston University School of Medicine, Boston, Massachusetts
| | - John Benjamin
- Department of Anesthesia, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Karim Ladha
- Department of Anesthesia and Pain Medicine, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Todd Sarge
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Matthias Eikermann
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
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Rostin P, Teja BJ, Friedrich S, Shaefi S, Murugappan KR, Ramachandran SK, Houle TT, Eikermann M. The association of early postoperative desaturation in the operating theatre with hospital discharge to a skilled nursing or long-term care facility. Anaesthesia 2019; 74:457-467. [DOI: 10.1111/anae.14517] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2018] [Indexed: 12/17/2022]
Affiliation(s)
- P. Rostin
- Department of Anesthesia, Critical Care, and Pain Medicine; Massachusetts General Hospital and Harvard Medical School; Boston MA USA
- Department of Anaesthesiology and Intensive Care Medicine; University Duisburg-Essen; Essen Germany
| | - B. J. Teja
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - S. Friedrich
- Department of Anesthesia, Critical Care, and Pain Medicine; Massachusetts General Hospital and Harvard Medical School; Boston MA USA
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - S. Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - K. R. Murugappan
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - S. K. Ramachandran
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - T. T. Houle
- Department of Anesthesia, Critical Care, and Pain Medicine; Massachusetts General Hospital and Harvard Medical School; Boston MA USA
| | - M. Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
- Department of Anaesthesiology and Intensive Care Medicine; University Duisburg-Essen; Essen Germany
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Molliex S, Passot S, Morel J, Futier E, Lefrant JY, Constantin JM, Le Manach Y, Pereira B. A multicentre observational study on management of general anaesthesia in elderly patients at high-risk of postoperative adverse outcomes. Anaesth Crit Care Pain Med 2018; 38:15-23. [PMID: 29902538 DOI: 10.1016/j.accpm.2018.05.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 05/12/2018] [Accepted: 05/30/2018] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In elderly patients, goal-directed haemodynamic therapy (GDHT), depth of anaesthesia monitoring and lung-protective ventilation have been shown to improve postoperative outcomes. The aim of this study was to evaluate current practices concerning strategies of anaesthesia optimisation in patients aged≥75 years. PATIENTS AND METHODS A multicentre observational study was performed from February to May 2015 in 23 French academic centres. On 30 consecutive days in each centre, patients≥75 years with at least one major comorbidity undergoing elective or emergency procedures (femoral-neck fractures surgery, intraperitoneal abdominal surgery or vascular surgery) were included. Patient characteristics and data related to GHDT, management of hypotension, monitoring of temperature and depth of anaesthesia, lung ventilation, point of care haemoglobin testing were collected. RESULTS In total, 807 patients were included. Only 2% of patients [95% CI: 1-3] received GHDT in full accordance with guidelines. Depth of anaesthesia monitoring was largely performed (53% [95% CI: 50-56]). The multifaceted strategy of lung-protective ventilation combining low tidal volumes (6-8mL/kg), PEEP of 5-8cm cmH2O, and repeated recruitment manoeuvres, was performed in only 4% [95% CI: 3-5] of patients. A centre effect was a major determinant of variation concerning implementation of these strategies. DISCUSSION In patients'≥75 years, strategies of anaesthesia optimisation are not in accordance with eligible guidelines. Implementation of these techniques varies independently of factors related to the patient or the type of surgery and may be dependent on the generated constraints.
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Affiliation(s)
- Serge Molliex
- Department of Anaesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Université Jean-Monnet Saint-Étienne, 42055 Saint-Étienne, France.
| | - Sylvie Passot
- Department of Anaesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Université Jean-Monnet Saint-Étienne, 42055 Saint-Étienne, France.
| | - Jerome Morel
- Department of Anaesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Université Jean-Monnet Saint-Étienne, 42055 Saint-Étienne, France.
| | - Emmanuel Futier
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, Université Clermont-Auvergne, CNRS, Inserm, 63000 Clermont-Ferrand, France.
| | - Jean Yves Lefrant
- Department of Anaesthesiology, Critical Care and Emergency Medicine, Centre Hospitalier Universitaire (CHU) de Nîmes, Université de Montpellier-Nîmes, 30029 Nîmes, France.
| | - Jean Michel Constantin
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, Université Clermont-Auvergne, CNRS, Inserm, 63000 Clermont-Ferrand, France.
| | - Yannick Le Manach
- Departments of Anaesthesia and Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
| | - Bruno Pereira
- Biostatistic Unit, Direction de la Recherche Clinique (DRCI), Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, 63003 Clermont-Ferrand, France.
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O'Reilly-Shah VN, Easton GS, Jabaley CS, Lynde GC. Variable effectiveness of stepwise implementation of nudge-type interventions to improve provider compliance with intraoperative low tidal volume ventilation. BMJ Qual Saf 2018; 27:1008-1018. [PMID: 29776982 DOI: 10.1136/bmjqs-2017-007684] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/13/2018] [Accepted: 04/28/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Identifying mechanisms to improve provider compliance with quality metrics is a common goal across medical disciplines. Nudge interventions are minimally invasive strategies that can influence behavioural changes and are increasingly used within healthcare settings. We hypothesised that nudge interventions may improve provider compliance with lung-protective ventilation (LPV) strategies during general anaesthesia. METHODS We developed an audit and feedback dashboard that included information on both provider-level and department-level compliance with LPV strategies in two academic hospitals, two non-academic hospitals and two academic surgery centres affiliated with a single healthcare system. Dashboards were emailed to providers four times over the course of the 9-month study. Additionally, the default setting on anaesthesia machines for tidal volume was decreased from 700 mL to 400 mL. Data on surgical cases performed between 1 September 2016 and 31 May 2017 were examined for compliance with LPV. The impact of the interventions was assessed via pairwise logistic regression analysis corrected for multiple comparisons. RESULTS A total of 14 793 anaesthesia records were analysed. Absolute compliance rates increased from 59.3% to 87.8%preintervention to postintervention. Introduction of attending physician dashboards resulted in a 41% increase in the odds of compliance (OR 1.41, 95% CI 1.17 to 1.69, p=0.002). Subsequently, the addition of advanced practice provider and resident dashboards lead to an additional 93% increase in the odds of compliance (OR 1.93, 95% CI 1.52 to 2.46, p<0.001). Lastly, modifying ventilator defaults led to a 376% increase in the odds of compliance (OR 3.76, 95% CI 3.1 to 4.57, p<0.001). CONCLUSION Audit and feedback tools in conjunction with default changes improve provider compliance.
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Affiliation(s)
| | - George S Easton
- Department of Information Systems and Operations Management, Emory University, Goizueta Business School, Atlanta, Georgia, USA
| | - Craig S Jabaley
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA
| | - Grant C Lynde
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA
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Long D, Lihn A, Friedrich S, Scheffenbichler F, Safavi K, Burns S, Schneider J, Grabitz S, Houle T, Eikermann M. Association between intraoperative opioid administration and 30-day readmission: a pre-specified analysis of registry data from a healthcare network in New England. Br J Anaesth 2018; 120:1090-1102. [DOI: 10.1016/j.bja.2017.12.044] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 12/06/2017] [Accepted: 01/25/2018] [Indexed: 11/17/2022] Open
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Bagchi A, Rudolph MI, Eikermann M. Mechanical ventilation mode and postoperative pulmonary complications - a reply. Anaesthesia 2018; 73:253-254. [PMID: 29333710 DOI: 10.1111/anae.14204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A Bagchi
- Massachusetts General Hospital, Boston, MA, USA
| | - M I Rudolph
- Massachusetts General Hospital, Boston, MA, USA
| | - M Eikermann
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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Bagchi A, Rudolph MI, Ng PY, Timm FP, Long DR, Shaefi S, Ladha K, Vidal Melo MF, Eikermann M. The association of postoperative pulmonary complications in 109,360 patients with pressure-controlled or volume-controlled ventilation. Anaesthesia 2017; 72:1334-1343. [PMID: 28891046 DOI: 10.1111/anae.14039] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2017] [Indexed: 12/20/2022]
Abstract
We thought that the rate of postoperative pulmonary complications might be higher after pressure-controlled ventilation than after volume-controlled ventilation. We analysed peri-operative data recorded for 109,360 adults, whose lungs were mechanically ventilated during surgery at three hospitals in Massachusetts, USA. We used multivariable regression and propensity score matching. Postoperative pulmonary complications were more common after pressure-controlled ventilation, odds ratio (95%CI) 1.29 (1.21-1.37), p < 0.001. Tidal volumes and driving pressures were more varied with pressure-controlled ventilation compared with volume-controlled ventilation: mean (SD) variance from the median 1.61 (1.36) ml.kg-1 vs. 1.23 (1.11) ml.kg-1 , p < 0.001; and 3.91 (3.47) cmH2 O vs. 3.40 (2.69) cmH2 O, p < 0.001. The odds ratio (95%CI) of pulmonary complications after pressure-controlled ventilation compared with volume-controlled ventilation at positive end-expiratory pressures < 5 cmH2 O was 1.40 (1.26-1.55) and 1.20 (1.11-1.31) when ≥ 5 cmH2 O, both p < 0.001, a relative risk ratio of 1.17 (1.03-1.33), p = 0.023. The odds ratio (95%CI) of pulmonary complications after pressure-controlled ventilation compared with volume-controlled ventilation at driving pressures of < 19 cmH2 O was 1.37 (1.27-1.48), p < 0.001, and 1.16 (1.04-1.30) when ≥ 19 cmH2 O, p = 0.011, a relative risk ratio of 1.18 (1.07-1.30), p = 0.016. Our data support volume-controlled ventilation during surgery, particularly for patients more likely to suffer postoperative pulmonary complications.
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Affiliation(s)
- A Bagchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M I Rudolph
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - P Y Ng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - F P Timm
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - D R Long
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - S Shaefi
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - K Ladha
- Department of Anesthesia and Pain Medicine, University of Toronto and Toronto General Hospital, Toronto, ON, Canada
| | - M F Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
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