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Barboi C, Stapelfeldt WH. Mortality following noncardiac surgery assessed by the Saint Louis University Score (SLUScore) for hypotension: a retrospective observational cohort study. Br J Anaesth 2024; 133:33-41. [PMID: 38702236 PMCID: PMC11213987 DOI: 10.1016/j.bja.2024.03.039] [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: 10/11/2023] [Revised: 03/07/2024] [Accepted: 03/13/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND The Saint Louis University Score (SLUScore) was developed to quantify intraoperative blood pressure trajectories and their associated risk for adverse outcomes. This study examines the prevalence and severity of intraoperative hypotension described by the SLUScore and its relationship with 30-day mortality in surgical subtypes. METHODS This retrospective analysis of perioperative data included surgical cases performed between January 1, 2010, and December 31, 2020. The SLUScore is calculated from cumulative time-periods for which the mean arterial pressure is below a range of hypotensive thresholds. After calculating the SLUScore for each surgical procedure, we quantified the prevalence and severity of intraoperative hypotension for each surgical procedure and the association between intraoperative hypotension and 30-day mortality. We used binary logistic regression to quantify the potential contribution of intraoperative hypotension to mortality. RESULTS We analysed 490 982 cases (57.7% female; mean age 57 yr); 33.2% of cases had a SLUScore>0, a median SLUScore of 13 (inter-quartile range [IQR] 7-21), with 1.19% average mortality. The SLUScore was associated with mortality in 12/14 surgical groups. The increases in the odds ratio for death within 30 days of surgery per SLUScore increment were: all surgery types 3.5% (95% confidence interval [95% CI] 3.2-3.9); abdominal/transplant surgery 6% (95% CI 1.5-10.7); thoracic surgery1.5% (95% CI 1-3.3); vascular surgery 3.01% (95% CI 1.9-4.05); spine/neurosurgery 1.1% (95% CI 0.1-2.1); orthopaedic surgery 1.4% (95% CI 0.7-2.2); gynaecological surgery 6.3% (95% CI 2.5-10.1); genitourinary surgery 4.84% (95% CI 3.5-6.15); gastrointestinal surgery 5.2% (95% CI 3.9-6.4); gastroendoscopy 5.5% (95% CI 4.4-6.7); general surgery 6.3% (95% CI 5.5-7.1); ear, nose, and throat surgery 1.6% (95% CI 0-3.27); and cardiac electrophysiology (including pacemaker procedures) 6.6% (95% CI 1.1-12.4). CONCLUSIONS The SLUScore was independently, but variably, associated with 30-day mortality after noncardiac surgery.
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Affiliation(s)
- Cristina Barboi
- Indiana University School of Medicine, Department of Anesthesiology, Indianapolis, IN, USA.
| | - Wolf H Stapelfeldt
- Indiana University School of Medicine, Department of Anesthesiology, Indianapolis, IN, USA; Richard L. Roudebush VA Medical Centre, Department of Anesthesiology, Indianapolis, IN, USA
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Viswanathan VK, Subramanian S, Mounasamy V, Sambandam S. What are the predisposing factors for periprosthetic fractures following total hip arthroplasty? - a National Inpatient Sample-based study. Arch Orthop Trauma Surg 2024; 144:2803-2810. [PMID: 38661998 DOI: 10.1007/s00402-024-05343-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION With a progressive rise in the number of total hip arthroplasties (THA) over the past decades, the proportion of patients sustaining peri-prosthetic fractures (PPF) has been substantially increasing. In this context, the need for clearly understanding the factors predisposing patients to PPF following THA and the impact of these adverse complications on the overall healthcare burden cannot be understated. MATERIALS AND METHODS Based upon the Nationwide Inpatient Sample (NIS) database, the patients who underwent THA in the United States between 2016 and2019 (with ICD-10 CMP code) were identified. The patients were divided into 2 groups; group A - patients who sustained PPF and group B - those who did not. The information about the patients' demographic profile, medical comorbidities; and hospital admission (including length of stay and expenditure incurred) were analysed; and compared between the 2 groups. RESULTS Overall, 367,890 patients underwent THA, among whom 4,425 (1.2%) sustained PPF (group A). The remaining patients were classified under group B (363,465 patients). On the basis of multi-variate analysis (MVA), there was a significantly greater proportion of females, elderly patients, and emergent admissions (p < 0.001) in group A. The length of hospital stay, expenditure incurred and mortality were also significantly higher (p = 0.001) in group A. Based on MVA, Down's syndrome (odd's ratio 3.15, p = 0.01), H/O colostomy (odd's ratio 2.09, p = 0.008), liver cirrhosis (odd's ratio 2.01, p < 0.001), Parkinson's disease (odd's ratio 1.49, p = 0.004), morbid obesity (odd's ratio 1.44, p < 0.001), super obesity (odd's ratio 1.49, p = 0.03), and H/O CABG (coronary artery bypass graft; odd's ratio 1.21, p = 0.03) demonstrated significant association with PPF (group A). CONCLUSION Patients with PPF require higher rates of emergent admission, longer hospital stay and greater admission-related expenditure. Female sex, advanced age, morbid or super obesity, and presence of medical comorbidities (such as Down's syndrome, cirrhosis, Parkinson's disease, previous colostomy, and previous CABG) significantly enhance the risk of PPF after THA. These medical conditions must be kept in clinicians' minds and close follow-up needs to be implemented in such situations so as to mitigate these complications.
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Affiliation(s)
| | | | - Varatharaj Mounasamy
- Department of Orthopedics, University of Texas Southwestern, Dallas VAMC, Dallas, Texas, US
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Diaddigo SE, Lavalley MN, Truong AY, Otterburn DM. Catastrophic complications following microvascular free tissue transfer: A 10-year review of NSQIP data. J Plast Reconstr Aesthet Surg 2024; 93:42-50. [PMID: 38640554 DOI: 10.1016/j.bjps.2024.02.058] [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: 10/03/2023] [Revised: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION There is an absence of literature regarding the risks of catastrophic medical outcomes (CMOs) such as stroke, cardiac arrest, and pulmonary embolism in microvascular free tissue transfer. This study aims to determine the CMO and mortality rates, as well as risk factors, associated with microvascular reconstruction of the head and neck, extremity, and breast. METHODS This study uses data from the American College of Surgeons National Surgical Quality Improvement Program. Cases of microvascular free tissue transfer from 2012 to 2021 were analyzed to assess the 30-day rates of CMOs, including death, as well as associated risk factors. RESULTS Of the 22,839 included patients, 785 (3.44%) experienced 1043 CMOs, including 99 (0.43%) deaths. Pulmonary complications of prolonged respiratory failure and pulmonary embolism were the most common. Independent risk factors included age, male sex, underweight status, longer operation times, American Society of Anesthesiologists (ASA) class of III or above, wound classification other than clean, and underlying conditions such as diabetes, hypertension, chronic obstructive pulmonary disorder, dyspnea, metastatic cancer, and ventilator dependence. CMOs were associated with an average 10-day delay in hospital discharge. Multivariate regression analysis revealed that head and neck reconstructions were associated with increased risk of CMO (OR 4.96; p < 0.0001). CONCLUSION This is the largest study to examine CMOs following microvascular free tissue transfer. Compared to previous literature spanning the period between 2006 and 2011, we observed a decreased rate of CMOs but a slight increase in 30-day mortality. Our data provide updated and comprehensive criteria for risk stratification and patient counseling. The modifiable risk factors reported in our study should be considered in elective, non-urgent cases of microvascular reconstruction.
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Affiliation(s)
- Sarah E Diaddigo
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - Myles N Lavalley
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - Albert Y Truong
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - David M Otterburn
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA.
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Rowland BA, Motamedi V, Michard F, Saha AK, Khanna AK. Impact of continuous and wireless monitoring of vital signs on clinical outcomes: a propensity-matched observational study of surgical ward patients. Br J Anaesth 2024; 132:519-527. [PMID: 38135523 DOI: 10.1016/j.bja.2023.11.040] [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: 07/04/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Continuous and wireless vital sign monitoring is superior to intermittent monitoring in detecting vital sign abnormalities; however, the impact on clinical outcomes has not been established. METHODS We performed a propensity-matched analysis of data describing patients admitted to general surgical wards between January 2018 and December 2019 at a single, tertiary medical centre in the USA. The primary outcome was a composite of in-hospital mortality or ICU transfer during hospitalisation. Secondary outcomes were the odds of individual components of the primary outcome, and heart failure, myocardial infarction, acute kidney injury, and rapid response team activations. Data are presented as odds ratios (ORs) with 95% confidence intervals (CIs) and n (%). RESULTS We initially screened a population of 34,636 patients (mean age 58.3 (Range 18-101) yr, 16,456 (47.5%) women. After propensity matching, intermittent monitoring (n=12 345) was associated with increased risk of a composite of mortality or ICU admission (OR 3.42, 95% CI 3.19-3.67; P<0.001), and heart failure (OR 1.48, 95% CI 1.21-1.81; P<0.001), myocardial infarction (OR 3.87, 95% CI 2.71-5.71; P<0.001), and acute kidney injury (OR 1.32, 95% CI 1.09-1.57; P<0.001) compared with continuous wireless monitoring (n=7955). The odds of rapid response team intervention were similar in both groups (OR 0.86, 95% CI 0.79-1.06; P=0.726). CONCLUSIONS Patients who received continuous ward monitoring were less likely to die or be admitted to ICU than those who received intermittent monitoring. These findings should be confirmed in prospective randomised trials.
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Affiliation(s)
- Bradley A Rowland
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Vida Motamedi
- Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Anesthesiology, Vanderbilt School of Medicine, Nashville, TN, USA
| | | | - Amit K Saha
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA.
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Viswanathan VK, Subramanian S, Jones H, Mounasamy V, Sambandam S. Patient disposition after discharge following primary total hip arthroplasty: home versus skilled nursing facility-a study based on national inpatient sample database. Arch Orthop Trauma Surg 2024; 144:937-945. [PMID: 37819436 DOI: 10.1007/s00402-023-05081-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/17/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION In view of the shortened length of hospital stay following THA, an increasing proportion of patients have required transfer to "extended-care" (ECF) or "skilled nursing" facilities (SNF) over the past years. As a result, the expenditure related to postoperative care facility has been acknowledged as a crucial component of total economic burden associated with THA. In this context, the clinical and demographic factors leading to the need for transfer of patients to SNF following primary THA need to be clearly understood. METHODS The NIS database was utilised to identify the patients, who underwent primary THA between 2016 and 2019. The patients were then grouped under two categories: group A-patients who required post-THA transfer to SNF; and group B-those who were discharged home. The details regarding patients' demographic profile, medical comorbidities and complication profile during the perioperative period were recorded; and compared between groups A and B. RESULTS Based on the database, 368,431 patients underwent primary THA between 2016 and 2019; among whom, 67,498 (18.3%) were transferred to SNF (group A) following the surgery. Among the various comorbidities evaluated [on multivariate analysis (MVA)], uncomplicated DM (OR 1.45; p < 0.001), CKD (OR 1.47; p < 0.001), cirrhosis (OR 1.83; p < 0.001), Parkinson's disease (OR 3.94; p < 0.001), previous H/O dialysis (OR 2.84; p < 0.001), colostomy (OR 2.03; p < 0.001) or organ transplant (OR 1.42; p < 0.001); morbid obesity (OR 1.72; p < 0.001), cocaine abuse (OR 1.76; p < 0.001); and legal blindness (OR 2.58; p < 0.001) were associated with significantly greater need for post-THA transfer to SNF. Among the systemic complications reviewed (on MVA), pneumonia (odds ratio 3.2; p < 0.001), DVT (odds ratio 2.58; p < 0.001), higher need for blood transfusions (odds ratio 2.55; p < 0.001), ARF (odds ratio 2.32; p < 0.001), MI (odds ratio 2.2; p < 0.001), anaemia (odds ratio 1.65; p = 0.002) and PE (odds ratio 1.56; p < 0.001) significantly raised the probability of need for higher discharge destinations. In addition, prosthesis-related local complications such as prosthetic dislocation (OR 1.59; p < 0.001), fracture (OR 2.64; p < 0.001) or early peri-prosthetic infection (PPI; OR 1.71; p = 0.01) also necessitated specialised facilities of care following THA. CONCLUSION We could observe that 0.2% of patients required transfer to SNF following primary THA. Comorbidities such as Parkinson's disease, previous H/O dialysis, legal blindness and H/O colostomy had the highest odds of necessitating patient disposition to SNF. The occurrence of one or more systemic complications including pneumonia, DVT, ARF, MI, PE, and blood loss anaemia (or need for blood transfusion) or local prosthesis-related complications (dislocation, fracture or infections) substantially increased the chances of requiring transfer to a specialised care facility.
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Affiliation(s)
| | | | - Hunter Jones
- University of Texas Southwestern, Dallas, TX, USA
| | - Varatharaj Mounasamy
- Department of Orthopedics, University of Texas Southwestern, Dallas VAMC, Dallas, TX, USA
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Stahlschmidt A, Passos SC, Dornelles DD, Polanczyk C, Gutierrez CS, Minuzzi RR, Castro SMJ, Stefani LC. Troponin elevation as a marker of short deterioration and one-year death in a high-risk surgical patient cohort in a low and middle income country setting: a postoperative approach to increase surveillance. Can J Anaesth 2023; 70:1776-1788. [PMID: 37853279 DOI: 10.1007/s12630-023-02558-4] [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: 10/18/2022] [Revised: 04/02/2023] [Accepted: 04/28/2023] [Indexed: 10/20/2023] Open
Abstract
PURPOSE Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate the clinical outcomes of a cohort of high-risk surgical patients according to high-sensitivity troponin T (hsTnT) in an LMIC setting. METHODS We conducted a prospective cohort study of 442 high-risk patients undergoing noncardiac surgery at a Brazilian hospital between February 2019 and March 2020. High-sensitivity troponin T levels were measured preoperatively, 24 hr, and 48 hr after surgery and stratified into three groups: normal (< 20 ng·L-1); minor elevation (20-65 ng·L-1); and major elevation (> 65 ng·L-1). We performed survival analysis to determine the association between myocardial injury and one-year mortality. We described medical interventions and evaluated unplanned intensive care unit (ICU) admission and complications using multivariable models. RESULTS Postoperative myocardial injury occurred in 45% of patients. Overall, 30-day mortality was 8%. Thirty-day and one-year mortality were higher in patients with hsTnT ≥ 20 ng·L-1. One-year mortality was 18% in the unaltered troponin group vs 31% and 41% for minor and major elevation groups, respectively. Multivariable analysis of one-year survival showed a hazard ratio (HR) of 1.94 (95% confidence interval [CI], 1.22 to 3.09) for the minor elevation group and a HR of 2.73 (95% CI, 1.67 to 4.45) for the troponin > 65 ng·L-1 group. Patients with altered troponin had more unplanned ICU admissions (13% vs 5%) and more complications (78% vs 48%). CONCLUSION This study supports evidence that hsTnT is an important prognostic marker and a strong predictor of all-cause mortality after surgery. Troponin measurement in high-risk surgical patients could potentially be used as tool to scale-up care in LMIC settings. STUDY REGISTRATION ClinicalTrials.gov (NCT04187664); first submitted 5 December 2019.
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Affiliation(s)
- Adriene Stahlschmidt
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Sávio C Passos
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Debora D Dornelles
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carisi Polanczyk
- Cardiology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Claudia S Gutierrez
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Rosangela R Minuzzi
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Stela M J Castro
- Department of Statistics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Luciana C Stefani
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035-903, Brazil.
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Al-Hajj S, El-Hussein M, von Schreeb J, Hamieh C, Ahmad N, Souaiby N. Multicenter assessment of impairments and disabilities associated with Beirut blast injuries: a retrospective review of hospital medical records. Trauma Surg Acute Care Open 2023; 8:e001103. [PMID: 37810766 PMCID: PMC10551996 DOI: 10.1136/tsaco-2023-001103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 08/25/2023] [Indexed: 10/10/2023] Open
Abstract
Objectives This study aims to describe the injury patterns of the Beirut blast victims and assess hospitals' disaster management and preparedness during the 2020 Beirut port blast. Methods A cross-sectional retrospective multicenter study was conducted in two stages. Data were collected on blast victims presented to participating hospitals from August 4 till August 8, using three designed questionnaires. Stage 1 included all blast patients' records and stage 2 examined a subset of inpatient and outpatient records. Binary logistic regression was performed to assess the factors associated with death and disability for blast patients. Results A total of 3278 records were collected, 83% were treated at emergency departments and 17% were admitted to hospitals. Among those, 61 deaths and 35 long-term disabilities were reported. Extremity operations (63%) were mostly performed. Outpatients (n=410) had a mean age of 40±17.01 years and 40% sustained lacerations (40%). 10% of those patients sustained neurological complications and mental problems, and 8% had eye complications. Inpatients (n=282) had a mean age of 49±20.7 years and a mean length of hospital stay of 6±10.7 days. Secondary (37%) and tertiary (25%) blast injuries were predominant. 49% sustained extremity injuries and 19% head/face injuries. 11 inpatient deaths and 20 long-term disabilities were reported. Death was significantly associated with tertiary concussion and crush syndrome (p<0.05). Of the 16 hospitals, 13 implemented disaster plans (87%), and 14 performed a triage with a mean time of 0.96±0.67 hours. One hospital (6%) performed psychological evaluations, without follow-up. Conclusion Beirut blast victims suffered deaths and disabilities associated with their injuries. They predominantly sustained lacerations caused by shattered glass. Tertiary injuries were associated with death. Triage, disaster plans, and hospital preparedness should be effectively implemented to enhance patients' clinical outcomes. Level of evidence Prognostic and epidemiological/Level III.
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Affiliation(s)
- Samar Al-Hajj
- Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
| | | | - Johan von Schreeb
- Department of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institute, Stockholm, Stockholm, Sweden
| | | | - Nesrine Ahmad
- Middle East and North Africa Program for Advanced Injury Research, American University of Beirut, Beirut, Lebanon
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Viswanathan VK, Aggarwal VA, Subramanian S, Mounasamy V, Sambandam S. What enhances the in-hospital mortality following total hip arthroplasty? A national inpatient sample-based study. Arch Orthop Trauma Surg 2023; 143:6423-6430. [PMID: 36976373 DOI: 10.1007/s00402-023-04850-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/18/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE With prolonged life expectancy and advancements in prosthetic designs, the proportion of patients belonging to diverse age groups undergoing total hip arthroplasty (THA) has progressively increased. In this context, the details regarding risk factors associated with mortality after THA, and its prevalence need to be clearly understood. This study sought to identify the possible co-morbidities associated with post-THA mortality. METHODS Based on Nationwide Inpatient Sample (NIS) database, patients undergoing THA from 2016 to 2019 (using ICD-10CMP) were identified. The included cohort was stratified into two groups: "early mortality" and "no mortality" groups. The data regarding patients' demographics, co-morbidities, and associated complications were compared between the groups. RESULTS Overall, 337,249 patients underwent THA, among whom, 332 (0.1%) died during their hospital admission ("early mortality" group). The remaining patients were included under "no mortality" group (336,917 patients). There was significantly higher mortality in the patients, who underwent emergent THA (as compared with elective THA: odd's ratio 0.075; p < 0.001). Based on multivariate analysis, presence of liver cirrhosis, chronic kidney disease (CKD) and previous history of organ transplant increased the odds of mortality {odds ratio [Exp (B)]} after THA by 4.66- (p < 0.001), 2.37-fold (p < 0.001) and 1.91-fold (p = 0.04), respectively. Among post-THA complications, acute renal failure (ARF), pulmonary embolism (PE), pneumonia, myocardial infarction (MI), and prosthetic dislocation increased the odds of post-THA mortality by 20.64-fold (p < 0.001), 19.35-fold (p < 0.001), 8.21-fold (p < 0.001), 2.71-fold (p = 0.05) and 2.54-fold (p < 0.001), respectively. CONCLUSION THA is a safe surgery with low mortality rate during early post-operative period. Cirrhosis, CKD, and previous history of organ transplant were the most common co-morbidities associated with post-THA mortality. Among post-operative complications, ARF, PE, pneumonia, MI, and prosthetic dislocation substantially enhanced the odds of post-THA mortality.
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Affiliation(s)
| | | | - Surabhi Subramanian
- Pediatric Radiology, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Varatharaj Mounasamy
- Department of Orthopedics, University of Texas Southwestern, Dallas VAMC, Dallas, TX, USA
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9
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Degu S, Kejela S, Zeleke HT. Perioperative mortality of emergency and elective surgical patients in a low-income country: a single institution experience. Perioper Med (Lond) 2023; 12:49. [PMID: 37715264 PMCID: PMC10504717 DOI: 10.1186/s13741-023-00341-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/12/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND The perioperative mortality rate is an indicator of access to safe anesthesia and surgery. Studies showed higher perioperative mortality rates among low- and middle-income countries. But the specific causes and factors contributing to perioperative death have not been adequately studied in the Ethiopian context. METHODS This is a retrospective institutional study of the largest academic medical center in Ethiopia. Data of all patients who were admitted to surgical wards or intensive care and underwent surgical interventions were evaluated for perioperative mortality rate determination. All mortality cases were then evaluated in depth. RESULTS Of the 3295 patients evaluated, a total of 148 patients (4.5%) died within 30 days of surgery. By the 7th postoperative day, 69.5% of the perioperative mortality had already occurred. Septic shock contributed to 54.2% of deaths. Emergency surgery patients had more than a twofold higher mortality rate than elective surgery patients (p value < 0.001) and had a 2.6-fold higher rate of dying within 7 days of surgery (p value of 0.02). Patients with ASA performance status of 3 or more had a 1.7-fold higher rate of death within 72 h of surgery (p value of 0.015). CONCLUSION More than two thirds of patients died within 7 postoperative days. More emergency patients died than elective counterparts, and emergency cases had a higher rate of dying within 7 days of surgery. Poor ASA performance score was associated with earlier postoperative death. Further prospective multi-institutional studies are warranted to elucidate the factors that contribute to higher postoperative mortality in low-income country patients.
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Affiliation(s)
- Samrawit Degu
- Department of Surgery, Lancet Biherawi General Hospital, Addis Ababa, Ethiopia
| | - Segni Kejela
- Department of Surgery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
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Garcia BN, Tyser A, Roca H, Kazmers NH. Patient-Reported Outcome Measurement and Minimal Clinically Important Difference for Hand Surgeons. J Am Acad Orthop Surg 2023:00124635-990000000-00743. [PMID: 37418325 DOI: 10.5435/jaaos-d-23-00318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/05/2023] [Indexed: 07/09/2023] Open
Abstract
Patient-reported outcome measurement (PROM) tools are used to evaluate health status and response to treatment and have been integral in the effort to improve the quality of care provided. Patient reported outcomes (PROs) have garnered additional attention since becoming a priority of the National Institutes of Health in the early part of this century, and their use in both clinical practice and research has subsequently increased. In the upper extremity, a variety of PRO instruments exist that can assist physicians in their ability to track and/or prognosticate outcomes, make comparisons between treatments as well as strengthen research methodologies, and help determine the value of care. A more complete interpretation of the clinical significance of patient-reported outcome measurements is informed by parameters such as minimal clinically important difference, substantial clinical benefit and patient acceptable symptom state.
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Affiliation(s)
- Brittany N Garcia
- From the Department of Orthopaedics, University of Utah, Salt Lake City, UT
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Saputra PBT, Jannah AR, Rofananda IF, Al-Farabi MJ, Wungu CDK, Susilo H, Alsagaff MY, Gusnanto A, Oktaviono YH. Clinical characteristics, management, and outcomes of pulmonary valve myxoma: systematic review of published case reports. World J Surg Oncol 2023; 21:99. [PMID: 36941612 PMCID: PMC10026419 DOI: 10.1186/s12957-023-02984-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/13/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Cardiac myxoma is the most common type of primary cardiac tumor, with the majority located in the atrial wall. The tumor is attached to valvular structures in a few cases, of which the pulmonary valve is the least affected. Pulmonary valve myxoma may have different clinical manifestations from the more common cardiac myxomas because of its vital position. A misdiagnosis of these types of cardiac myxoma may be detrimental to the care and well-being of patients. Therefore, this systematic review aims to define the clinical characteristics of pulmonary valve myxoma and how this differs from a more common cardiac myxoma. METHODS Employed literature was obtained from PubMed, ScienceDirect, Scopus, Springer, and ProQuest without a publication year limit on August 23, 2022. The keyword was "pulmonary valve myxoma." Inclusion criteria were as follows: (1) case report or series, (2) available individual patient data, and (3) myxoma that is attached to pulmonary valve structures with no evidence of metastasis. Non-English language or nonhuman subject studies were excluded. Johanna Briggs Institute checklists were used for the risk of bias assessment. Data are presented descriptively. RESULTS This review included 9 case reports from 2237 articles. All cases show a low risk of bias. Pulmonary valve myxoma is dominated by males (5:4), and the patient's median age is 57 years with a bimodal distribution in pediatric and geriatric populations. The clinical manifestation of pulmonary valve myxoma is often unspecified or asymptomatic. However, systolic murmur in the pulmonary valve area is heard in 67% of cases. Echocardiography remains the diagnostic modality of choice in the majority of cases. Tumor attached to the pulmonary cusps or annulus and extended to adjacent tissues in all cases. Therefore, valve replacement or adjacent tissue reconstructions are required in 77% of cases. The recurrence and mortality are considerably high, with 33% and 22% cases, respectively. CONCLUSIONS Pulmonary valve myxoma is more common in males with a bimodal age distribution, and its outcomes seem worse than usual cardiac myxomas. Increasing awareness of its clinical symptoms, early diagnosis, and complete myxoma resection before the presence of congestive heart failure symptoms are important in achieving excellent outcomes. A firm embolization blockade is needed to prevent myxoma recurrence.
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Affiliation(s)
- Pandit Bagus Tri Saputra
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | | | | | - Makhyan Jibril Al-Farabi
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Citrawati Dyah Kencono Wungu
- Department of Physiology and Medical Biochemistry, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.
- Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia.
| | - Hendri Susilo
- Department of Cardiology and Vascular Medicine, Universitas Airlangga Hospital, Surabaya, Indonesia.
| | - Mochamad Yusuf Alsagaff
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
- Department of Cardiology and Vascular Medicine, Universitas Airlangga Hospital, Surabaya, Indonesia
| | | | - Yudi Her Oktaviono
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
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12
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Huepenbecker SP, Fu S, Sun CC, Zhao H, Primm KM, Giordano SH, Meyer LA. Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis. Ann Surg Oncol 2023; 30:1508-1519. [PMID: 36310311 PMCID: PMC10466211 DOI: 10.1245/s10434-022-12663-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/28/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND The association between Medicaid expansion and postoperative mortality after surgery for gynecologic cancer is unknown. Our objective was to compare 30- and 90-day postoperative mortality after gynecologic cancer surgery before and after 2014 in states that did and did not expand Medicaid. METHODS We searched the National Cancer Database for women aged 40-64 years old between 2010 and 2016 who underwent surgery for a primary gynecologic malignancy. We used pre/post and quasi-experimental difference-in-difference (DID) multivariable logistic regressions to evaluate mortality pre-2014 (2010-2013) and post-2014 (2014-2016) for states that did and did not expand Medicaid in January 2014. We completed univariable logistic regressions for covariates of interest. RESULTS Among 169,731 women, 30-day postoperative mortality in expansion states after 2014 significantly decreased for endometrial cancer (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26-0.67) and ovarian cancer (OR 0.67, 95% CI 0.46-0.99) and increased for cervical cancer (OR 3.82, 95% CI 1.12-13.01). Compared with non-expansion states, expansion states had improved 30-day postoperative mortality for endometrial cancer after 2014 (DID OR 0.54, 95% CI 0.31-0.96). Univariable analysis demonstrated improved 30-day postoperative mortality for Black women with endometrial cancer in expansion states (DID OR 0.22, 95% CI 0.05-0.95). There was improved 90-day postoperative mortality for endometrial cancer in expansion states (OR 0.66, 95% CI 0.50-0.85), and improved 90-day postoperative mortality for Midwestern women with ovarian cancer in expansion states on univariable analysis (DID OR 0.48, 95% CI 0.26-0.91). CONCLUSIONS State Medicaid legislation was associated with improved postoperative survival in women with endometrial cancer and subgroups of women with endometrial and ovarian cancer.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Becton, Dickinson and Company, Franklin Lakes, NJ, USA
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristin M Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA.
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13
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Madsen HJ, Henderson WG, Bronsert MR, Dyas AR, Colborn KL, Lambert-Kerzner A, Meguid RA. Associations Between Preoperative Risk, Postoperative Complications, and 30-Day Mortality. World J Surg 2022; 46:2365-2376. [PMID: 35778512 DOI: 10.1007/s00268-022-06638-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Comorbidities and postoperative complications increase mortality, making early recognition and management critical. It is useful to understand how they are associated with one another. This study assesses associations between comorbidities, complications, and mortality. METHODS We calculated associations between comorbidities, complications, and 30-day mortality using the 2012-2018 ACS-NSQIP database. We examined the association between mortality and number of complications which complications were most associated with mortality. RESULTS 5,777,108 patients were included. 30-day mortality was 0.95%. For most comorbidities or postoperative complications, patients with these had higher mortality than patients without. Having ≥ 1 complication increased mortality risk by 32.5-fold (6.5% vs. 0.2%). Mortality rate significantly increased with increasing number of complications, particularly after two or more complications. Bleeding and sepsis were associated with the most deaths. CONCLUSION The 30-day mortality rate was < 1% but was 32-fold higher in patients with complications and increased rapidly for patients with ≥ 2 complications. Bleeding and sepsis were the most prominent complications associated with mortality.
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Affiliation(s)
- Helen J Madsen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA. .,Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Dyas
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kathryn L Colborn
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Anne Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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14
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Fecho K, Ahalt SC, Knowles M, Krishnamurthy A, Leigh M, Morton K, Pfaff E, Wang M, Yi H. Leveraging Open Electronic Health Record Data and Environmental Exposures Data to Derive Insights Into Rare Pulmonary Disease. Front Artif Intell 2022; 5:918888. [PMID: 35837616 PMCID: PMC9274244 DOI: 10.3389/frai.2022.918888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
Research on rare diseases has received increasing attention, in part due to the realized profitability of orphan drugs. Biomedical informatics holds promise in accelerating translational research on rare disease, yet challenges remain, including the lack of diagnostic codes for rare diseases and privacy concerns that prevent research access to electronic health records when few patients exist. The Integrated Clinical and Environmental Exposures Service (ICEES) provides regulatory-compliant open access to electronic health record data that have been integrated with environmental exposures data, as well as analytic tools to explore the integrated data. We describe a proof-of-concept application of ICEES to examine demographics, clinical characteristics, environmental exposures, and health outcomes among a cohort of patients enriched for phenotypes associated with cystic fibrosis (CF), idiopathic bronchiectasis (IB), and primary ciliary dyskinesia (PCD). We then focus on a subset of patients with CF, leveraging the availability of a diagnostic code for CF and serving as a benchmark for our development work. We use ICEES to examine select demographics, co-diagnoses, and environmental exposures that may contribute to poor health outcomes among patients with CF, defined as emergency department or inpatient visits for respiratory issues. We replicate current understanding of the pathogenesis and clinical manifestations of CF by identifying co-diagnoses of asthma, chronic nasal congestion, cough, middle ear disease, and pneumonia as factors that differentiate patients with poor health outcomes from those with better health outcomes. We conclude by discussing our preliminary findings in relation to other published work, the strengths and limitations of our approach, and our future directions.
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Affiliation(s)
- Karamarie Fecho
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stanley C. Ahalt
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Michael Knowles
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Ashok Krishnamurthy
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Margaret Leigh
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Emily Pfaff
- North Carolina Clinical and Translational Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Max Wang
- CoVar Applied Technologies, Durham, NC, United States
| | - Hong Yi
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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15
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Fecho K, Ahalt SC, Appold S, Arunachalam S, Pfaff E, Stillwell L, Valencia A, Xu H, Peden DB. Development and Application of an Open Tool for Sharing and Analyzing Integrated Clinical and Environmental Exposures Data: Asthma Use Case. JMIR Form Res 2022; 6:e32357. [PMID: 35363149 PMCID: PMC9015759 DOI: 10.2196/32357] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The Integrated Clinical and Environmental Exposures Service (ICEES) serves as an open-source, disease-agnostic, regulatory-compliant framework and approach for openly exposing and exploring clinical data that have been integrated at the patient level with a variety of environmental exposures data. ICEES is equipped with tools to support basic statistical exploration of the integrated data in a completely open manner. OBJECTIVE This study aims to further develop and apply ICEES as a novel tool for openly exposing and exploring integrated clinical and environmental data. We focus on an asthma use case. METHODS We queried the ICEES open application programming interface (OpenAPI) using a functionality that supports chi-square tests between feature variables and a primary outcome measure, with a Bonferroni correction for multiple comparisons (α=.001). We focused on 2 primary outcomes that are indicative of asthma exacerbations: annual emergency department (ED) or inpatient visits for respiratory issues; and annual prescriptions for prednisone. RESULTS Of the 157,410 patients within the asthma cohort, 26,332 (16.73%) had 1 or more annual ED or inpatient visits for respiratory issues, and 17,056 (10.84%) had 1 or more annual prescriptions for prednisone. We found that close proximity to a major roadway or highway, exposure to high levels of particulate matter ≤2.5 μm (PM2.5) or ozone, female sex, Caucasian race, low residential density, lack of health insurance, and low household income were significantly associated with asthma exacerbations (P<.001). Asthma exacerbations did not vary by rural versus urban residence. Moreover, the results were largely consistent across outcome measures. CONCLUSIONS Our results demonstrate that the open-source ICEES can be used to replicate and extend published findings on factors that influence asthma exacerbations. As a disease-agnostic, open-source approach for integrating, exposing, and exploring patient-level clinical and environmental exposures data, we believe that ICEES will have broad adoption by other institutions and application in environmental health and other biomedical fields.
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Affiliation(s)
- Karamarie Fecho
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stanley C Ahalt
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stephen Appold
- Kenan-Flagler Business School, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Saravanan Arunachalam
- Institute for the Environment, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Emily Pfaff
- North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lisa Stillwell
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alejandro Valencia
- Institute for the Environment, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Hao Xu
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - David B Peden
- North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Allergy & Immunology, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Center for Environmental Medicine, Asthma and Lung Biology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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16
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Ninety-Day and In-hospital Mortalities After Gastrointestinal and Hepatopancreatic Biliary Surgery—a Case Series Analysis. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03286-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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17
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Goudra B. American Board of Anesthesiology and Accountability (or lack of): What the rest of the world can learn? Saudi J Anaesth 2022; 16:1-3. [PMID: 35261580 PMCID: PMC8846227 DOI: 10.4103/sja.sja_499_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/04/2021] [Accepted: 07/04/2021] [Indexed: 11/09/2022] Open
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18
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Sessler DI. Anaesthesia's legacy: carpe diem. Br J Anaesth 2021; 128:413-415. [PMID: 34949440 DOI: 10.1016/j.bja.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Abstract
Intraoperative mortality is now rare. In contrast, 30-day postoperative mortality remains common, with most deaths occurring during the initial hospitalisation. The legacy of anaesthesiology will be determined by our success in dealing with postoperative mortality, which is currently the major problem in perioperative medicine. Carpe diem!
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Affiliation(s)
- Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
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19
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Saab R, Wu BP, Rivas E, Chiu A, Lozovoskiy S, Ma C, Yang D, Turan A, Sessler DI. Failure to detect ward hypoxaemia and hypotension: contributions of insufficient assessment frequency and patient arousal during nursing assessments. Br J Anaesth 2021; 127:760-768. [PMID: 34301400 DOI: 10.1016/j.bja.2021.06.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/05/2021] [Accepted: 06/03/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Postoperative hypotension and hypoxaemia are common and often unrecognised. With intermittent nursing vital signs, hypotensive or hypoxaemic episodes might be missed because they occur between scheduled measurements, or because the process of taking vital signs arouses patients and temporarily improves arterial blood pressure and ventilation. We therefore estimated the fraction of desaturation and hypotension episodes that did not overlap nursing assessments and would therefore usually be missed. We also evaluated the effect of taking vital signs on blood pressure and oxygen saturation. METHODS We estimated the fraction of desaturated episodes (arterial oxygen saturation <90% for at least 90% of the time within 30 continuous minutes) and hypotensive episodes (MAP <70 mm Hg for 15 continuous minutes) that did not overlap nursing assessments in patients recovering from noncardiac surgery. We also evaluated changes over time before and after nursing visits. RESULTS Among 782 patients, we identified 878 hypotensive episodes and 2893 desaturation episodes, of which 79% of the hypotensive episodes and 82% of the desaturation episodes did not occur within 10 min of a nursing assessment and would therefore usually be missed. Mean BP and oxygen saturation did not improve by clinically meaningful amounts during nursing vital sign assessments. CONCLUSIONS Hypotensive and desaturation episodes are mostly missed because vital sign assessments on surgical wards are sparse, rather than being falsely negative because the assessment process itself increases blood pressure and oxygen saturation. Continuous vital sign monitoring will detect more disturbances, potentially giving clinicians time to intervene before critical events occur.
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Affiliation(s)
- Remie Saab
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Bernie P Wu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Eva Rivas
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Anesthesia, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Andrew Chiu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Sofia Lozovoskiy
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Chao Ma
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Dongsheng Yang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
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20
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Khanna AK, Shaw AD, Stapelfeldt WH, Boero IJ, Chen Q, Stevens M, Gregory A, Smischney NJ. Postoperative Hypotension and Adverse Clinical Outcomes in Patients Without Intraoperative Hypotension, After Noncardiac Surgery. Anesth Analg 2021; 132:1410-1420. [PMID: 33626028 DOI: 10.1213/ane.0000000000005374] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative hypotension (POH) is associated with major adverse events. However, little is known about the association of blood pressure thresholds and outcomes in postoperative patients without intraoperative hypotension (IOH) on the general-care ward. We evaluated the association of POH with major adverse cardiac or cerebrovascular events (MACCE) in patients without IOH. METHODS This retrospective analysis included 67,968 noncardiac patient-procedures (2008-2017) for patients discharged to the ward with postoperative mean arterial pressure (MAP) readings, managed for ≥48 hours postsurgery, with no evidence of IOH. The primary outcome was 30-day MACCE evaluated by postoperative MAP thresholds: ≤75, ≤65, and ≤55 mm Hg (POH defined as a single measurement below threshold). Secondary outcomes included all-cause mortality (30-/90-day), 30-day acute myocardial infarction, 30-day acute ischemic stroke, 30-day readmission, 7-day acute kidney injury, and 30-day readmission. Associations between POH and adverse events were also evaluated in a cohort (#2) of 16,034 patient-procedures with IOH (intraoperative MAP ≤65 mm Hg). RESULTS In patients without IOH, exposure to POH was not associated with MACCE at any investigated MAP threshold (P < .016 was considered significant: ≤75 mm Hg, hazard ratio [HR] 1.18 [98.4% confidence interval {CI} 0.99-1.39], P = .023; ≤65 mm Hg, HR 1.18 [0.99-1.41], P = .028; ≤55 mm Hg, HR 1.23 [0.90-1.71], P = .121); however, associations were observed at all MAP thresholds for secondary outcomes of acute kidney injury and 30-day readmission, for 30-/90-day mortality for MAP ≤65 mm Hg, and 90-day mortality for MAP ≤55 mm Hg, compared to those without POH. No associations were detected between POH and secondary outcomes of acute ischemic stroke or acute myocardial infarction at any MAP threshold. No interaction between POH and IOH was found when we evaluated the association of POH on outcomes in the data set including all patients, regardless of IOH status (P values for interaction terms nonsignificant). When the interaction term was utilized, the association between POH without IOH and MACCE was significant for MAP ≤75 mm Hg (HR 1.20 [1.01-1.41]) and MAP ≤65 mm Hg (HR 1.21 [1.02-1.45]), but not MAP ≤55 mm Hg. Cohort #2 (POH with IOH) showed largely similar results for MACCE: not significant for MAP ≤75 and ≤65 mm Hg, but significant for MAP ≤55 mm Hg (HR 1.53 [1.05-2.22], P = .006). CONCLUSIONS POH in patients without IOH was not associated with MACCE at any MAP investigated. No interaction was identified between POH and IOH. Large prospective randomized trials are necessary to develop better evidence and inform clinicians the value of postoperative blood pressure management.
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Affiliation(s)
- Ashish K Khanna
- From the Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | - Andrew D Shaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta.,Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Wolf H Stapelfeldt
- Department of Anesthesiology & Critical Care Medicine, Saint Louis University, St. Louis, Missouri
| | | | | | | | - Anne Gregory
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta
| | - Nathan J Smischney
- Department of Anesthesiology & Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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21
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Paredes AZ, Hyer JM, Tsilimigras DI, Pawlik TM. Preoperative Medical Referral Prior to Hepatopancreatic Surgery-Is It Worth it? J Gastrointest Surg 2021; 25:954-961. [PMID: 32314229 DOI: 10.1007/s11605-020-04590-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/30/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Many patients who present for complex surgery have underlying medical comorbidities. While surgeons often refer these patients to medical appointments for preoperative "optimization" or "clearance," the actual impact of these visits remains poorly examined. The objective of the current study was to define the potential benefit of preoperative medical appointments on outcomes and costs associated with hepatopancreatic (HP) surgery. METHODS Patients with modifiable comorbidities undergoing HP surgery were identified in the Medicare claims data. The association of preoperative non-surgical visit and postoperative outcomes and expenditures was assessed using inverse propensity treatment weighting analysis and multivariable logistic regression. RESULTS Among the 5574 Medicare beneficiaries who underwent a hepatopancreatic surgery, one in seven patients (n = 830, 14.9%) was "optimized" preoperatively. On multivariable logistic regression analysis, age (OR 1.02; 95% CI 1.01-1.03; p = 0.006) and higher comorbidity burden (OR 1.03; 95% CI 1.01-1.05; p = 0.007) were associated with modest increased odds of being referred in the preoperative period for a non-surgical evaluation; the factor most associated with preoperative non-surgical visit was male patient sex (OR 1.33; 95% CI 1.14-1.56; p < 0.001). After adjustment for competing risk factors and random site effect, patients with an "optimization" visit had 28% lower odds (OR 0.72; 95% CI 0.59-0.86; p < 0.001) of experiencing an operative complication. Additionally, patients who had a non-surgical visit had 13% higher median total expenditures compared with individuals who did not undergo an "optimization" visit (p < 0.05). CONCLUSION In conclusion, roughly one in seven Medicare beneficiaries who underwent HP surgery may have been risk stratified by a non-surgical provider prior to surgery. Preoperative evaluation was associated with modestly lower odds of complications following HP surgery and higher Medicare expenditures. Further research is needed to determine its routine utility as a means to decrease the morbidity surrounding HP surgery.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA.
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22
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Fecho K, Pfaff E, Xu H, Champion J, Cox S, Stillwell L, Peden DB, Bizon C, Krishnamurthy A, Tropsha A, Ahalt SC. A novel approach for exposing and sharing clinical data: the Translator Integrated Clinical and Environmental Exposures Service. J Am Med Inform Assoc 2021; 26:1064-1073. [PMID: 31077269 DOI: 10.1093/jamia/ocz042] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 03/12/2019] [Accepted: 03/25/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE This study aimed to develop a novel, regulatory-compliant approach for openly exposing integrated clinical and environmental exposures data: the Integrated Clinical and Environmental Exposures Service (ICEES). MATERIALS AND METHODS The driving clinical use case for research and development of ICEES was asthma, which is a common disease influenced by hundreds of genes and a plethora of environmental exposures, including exposures to airborne pollutants. We developed a pipeline for integrating clinical data on patients with asthma-like conditions with data on environmental exposures derived from multiple public data sources. The data were integrated at the patient and visit level and used to create de-identified, binned, "integrated feature tables," which were then placed behind an OpenAPI. RESULTS Our preliminary evaluation results demonstrate a relationship between exposure to high levels of particulate matter ≤2.5 µm in diameter (PM2.5) and the frequency of emergency department or inpatient visits for respiratory issues. For example, 16.73% of patients with average daily exposure to PM2.5 >9.62 µg/m3 experienced 2 or more emergency department or inpatient visits for respiratory issues in year 2010 compared with 7.93% of patients with lower exposures (n = 23 093). DISCUSSION The results validated our overall approach for openly exposing and sharing integrated clinical and environmental exposures data. We plan to iteratively refine and expand ICEES by including additional years of data, feature variables, and disease cohorts. CONCLUSIONS We believe that ICEES will serve as a regulatory-compliant model and approach for promoting open access to and sharing of integrated clinical and environmental exposures data.
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Affiliation(s)
- Karamarie Fecho
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Emily Pfaff
- North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hao Xu
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - James Champion
- North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Steve Cox
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lisa Stillwell
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - David B Peden
- North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Allergy, Immunology and Rheumatology, Center for Environmental Medicine, Asthma & Lung Biology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Chris Bizon
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ashok Krishnamurthy
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alexander Tropsha
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stanley C Ahalt
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Aikele N, Burkett J, Conner J. A guide for accommodating wheelchairs in the OR while maintaining safety and quality. Am J Infect Control 2021; 49:75-76. [PMID: 32485275 DOI: 10.1016/j.ajic.2020.05.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 11/28/2022]
Abstract
A paraplegic resident needed appropriate accommodation to complete a surgical residency with implementation of provider wheelchair use in the operating room. Current evidence-based guidelines were reviewed for operating room protocol in conjunction with provisions from the American's with Disabilities Act, to provide a safe and functional environment for operating room staff, the patient, and the resident. Guidelines for equipment use, personal protective equipment, and sterile procedure were combined with the provision that a wheelchair is an extension of its user to draft a protocol for wheelchair use in the operating room. Evidence-based recommendations were successfully coordinated with American's with Disabilities Act provisions to provide a safe operating protocol for the wheelchair-bound surgeon.
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24
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Yes You Can-Cautiously-Infuse Norepinephrine Intraoperatively Through a Peripheral Intravenous Catheter. Anesth Analg 2020; 131:1057-1059. [PMID: 32925323 DOI: 10.1213/ane.0000000000004616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Personalised haemodynamic management targeting baseline cardiac index in high-risk patients undergoing major abdominal surgery: a randomised single-centre clinical trial. Br J Anaesth 2020; 125:122-132. [PMID: 32711724 DOI: 10.1016/j.bja.2020.04.094] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite several clinical trials on haemodynamic therapy, the optimal intraoperative haemodynamic management for high-risk patients undergoing major abdominal surgery remains unclear. We tested the hypothesis that personalised haemodynamic management targeting each individual's baseline cardiac index at rest reduces postoperative morbidity. METHODS In this single-centre trial, 188 high-risk patients undergoing major abdominal surgery were randomised to either routine management or personalised haemodynamic management requiring clinicians to maintain personal baseline cardiac index (determined at rest preoperatively) using an algorithm that guided intraoperative i.v. fluid and/or dobutamine administration. The primary outcome was a composite of major complications (European Perioperative Clinical Outcome definitions) or death within 30 days of surgery. Secondary outcomes included postoperative morbidity (assessed by a postoperative morbidity survey), hospital length of stay, mortality within 90 days of surgery, and neurocognitive function assessed after postoperative Day 3. RESULTS The primary outcome occurred in 29.8% (28/94) of patients in the personalised management group, compared with 55.3% (52/94) of patients in the routine management group (relative risk: 0.54, 95% confidence interval [CI]: 0.38 to 0.77; absolute risk reduction: -25.5%, 95% CI: -39.2% to -11.9%; P<0.001). One patient assigned to the personalised management group, compared with five assigned to the routine management group, died within 30 days after surgery (P=0.097). There were no clinically relevant differences between the two groups for secondary outcomes. CONCLUSIONS In high-risk patients undergoing major abdominal surgery, personalised haemodynamic management reduces a composite outcome of major postoperative complications or death within 30 days after surgery compared with routine care. CLINICAL TRIAL REGISTRATION NCT02834377.
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26
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Ruetzler K, Khanna AK, Sessler DI. Myocardial Injury After Noncardiac Surgery: Preoperative, Intraoperative, and Postoperative Aspects, Implications, and Directions. Anesth Analg 2020; 131:173-186. [PMID: 31880630 DOI: 10.1213/ane.0000000000004567] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Myocardial injury after noncardiac surgery (MINS) differs from myocardial infarction in being defined by troponin elevation apparently from cardiac ischemia with or without signs and symptoms. Such myocardial injury is common, silent, and strongly associated with mortality. MINS is usually asymptomatic and only detected by routine troponin monitoring. There is currently no known safe and effective prophylaxis for perioperative myocardial injury. However, appropriate preoperative screening may help guide proactive postoperative preventative actions. Intraoperative hypotension is associated with myocardial injury, acute kidney injury, and death. Hypotension is common and largely undetected in the postoperative general care floor setting, and independently associated with myocardial injury and mortality. Critical care patients are especially sensitive to hypotension, and the risk appears to be present at blood pressures previously regarded as normal. Tachycardia appears to be less important. Available information suggests that clinicians would be prudent to avoid perioperative hypotension.
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Affiliation(s)
- Kurt Ruetzler
- From the Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Outcomes Research Consortium, Cleveland, Ohio
| | - Ashish K Khanna
- Outcomes Research Consortium, Cleveland, Ohio.,Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, Ohio.,Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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27
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Pre-operative assessment of 30-day mortality risk after major surgery: the role of the quick sequential organ failure assessment: A retrospective observational study. Eur J Anaesthesiol 2020; 36:688-694. [PMID: 30730423 DOI: 10.1097/eja.0000000000000957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The quick Sequential Organ Failure Assessment (qSOFA) is intended for the assessment of the prognosis and risk of sepsis. It may also help predict the mortality risk of nonseptic patients. OBJECTIVE This study investigated the relationship between pre-operative qSOFA scores and 30-day mortality after major surgery. It also evaluated the predictive value of qSOFA scores combined with the American Society of Anesthesiologists (ASA) physical status and Charlson comorbidity index (CCI). DESIGN A retrospective observational study. SETTING Single tertiary academic hospital. PATIENTS Medical records of patients who underwent major surgery (estimated blood loss >500 ml; surgery time >2 h) between January 2010 and December 2017 were examined. MAIN OUTCOME MEASURES The qSOFA score was measured within 24 h before surgery, and its association with 30-day mortality was analysed using multivariable logistic regression. A receiver-operating characteristic curve analysis was used to investigate the predictive power of the pre-operative qSOFA scores combined with the ASA physical status and with CCI. RESULTS A total of 6336 patients were included in the final analysis, and 91 (1.4%) died within 30 days. The multivariable logistic regression analysis including all covariates indicated that 30-day mortality was 2.43-times higher for the score 1 group than for the score 0 group (P = 0.002), and it was 3.54-times higher for the score at least 2 group than for the score 0 group (P < 0.001). The area under the curve (AUC) of the pre-operative qSOFA, ASA physical status and CCI were 0.69, 0.55 and 0.57, respectively. When the pre-operative qSOFA score was combined with the ASA physical status or CCI, the AUCs were 0.73 and 0.72, respectively. CONCLUSION Higher pre-operative qSOFA scores within 24 h of surgery were associated with increased 30-day mortality. Pre-operative qSOFA scores have better predictive value for 30-day mortality when combined with the ASA physical status or CCI.
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Affiliation(s)
- Ashish K Khanna
- From the Center for Critical Care, Department of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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29
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Factors Associated With Increased Mortality After Isolated Abdominal Aortic Dissection Repair. Ann Vasc Surg 2019; 60:171-177. [DOI: 10.1016/j.avsg.2019.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/17/2019] [Accepted: 03/29/2019] [Indexed: 11/21/2022]
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30
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Freundlich RE, Maile MD, Sferra JJ, Jewell ES, Kheterpal S, Engoren M. Complications Associated With Mortality in the National Surgical Quality Improvement Program Database. Anesth Analg 2019; 127:55-62. [PMID: 29324497 DOI: 10.1213/ane.0000000000002799] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Attributing causes of postoperative mortality is challenging, as death may be multifactorial. A better understanding of complications that occur in patients who die is important, as it allows clinicians to focus on the most impactful complications. We sought to determine the postoperative complications with the strongest independent association with 30-day mortality. METHODS Data were obtained from the 2012-2013 National Surgical Quality Improvement Program Participant Use Data Files. All inpatient or admit day of surgery cases were eligible for inclusion in this study. A multivariable least absolute shrinkage and selection operator regression analysis was used to adjust for patient pre- and intraoperative risk factors for mortality. Attributable mortality was calculated using the population attributable fraction method: the ratio between the odds ratio for mortality and a given complication in the population. Patients were separated into 10 age groups to facilitate analysis of age-related differences in mortality. RESULTS A total of 1,195,825 patients were analyzed, and 9255 deceased within 30 days (0.77%). A complication independently associated with attributable mortality was found in 1887 cases (20%). The most common causes of attributable mortality (attributable deaths per million patients) were bleeding (n = 368), respiratory failure (n = 358), septic shock (n = 170), and renal failure (n = 88). Some complications, such as urinary tract infection and pneumonia, were associated with attributable mortality only in older patients. DISCUSSION Additional resources should be focused on complications associated with the largest attributable mortality, such as respiratory failure and infections. This is particularly important for complications disproportionately impacting younger patients, given their longer life expectancy.
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Affiliation(s)
- Robert E Freundlich
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael D Maile
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Joseph J Sferra
- Department of Surgery, ProMedica Toledo Hospital, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Elizabeth S Jewell
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan.,Department of Anesthesiology, ProMedica Toledo Hospital, Toledo, Ohio
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31
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Novello M, Mandarino FV, Di Saverio S, Gori D, Lugaresi M, Duchi A, Argento F, Cavallari G, Wheeler J, Nardo B. Post-operative outcomes and predictors of mortality after colorectal cancer surgery in the very elderly patients. Heliyon 2019; 5:e02363. [PMID: 31485540 PMCID: PMC6716468 DOI: 10.1016/j.heliyon.2019.e02363] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/18/2019] [Accepted: 08/21/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The frailty of the very elderly patients who undergo surgery for colorectal cancer negatively influences postoperative mortality. This study aimed to identify risk factors for postoperative mortality in octogenarian and nonagenarian patients who underwent surgical treatment for colorectal cancer. METHODS This is a single institution retrospective study. The primary outcomes were risk factors for postoperative mortality. The variables of the octogenarians and nonagenarians were compared by using t-test, chi-square test, and Fisher exact test. A multivariate logistic regression analysis was carried out on the combined cohorts. RESULTS we identified 319 octogenarians and 43 nonagenarians (N = 362) who underwent surgery for colorectal cancer at the Sant'Orsola-Malpighi university hospital in Bologna between 2011 and 2015. The 30-day post-operative mortality was 6% (N = 18) among octogenarians and 21% (N = 9) for the nonagenarians.The groups significantly differed in the type of surgery (elective vs. urgent surgery, p < 0.0001), ASA score (p = 0.0003) and rates of 30-day postoperative mortality (6% vs. 21%, p = 0.0003).In the multivariate analysis ASA > III (OR 2.37, 95% CI [1.43-3.93], p < 0,001), and urgent surgery (OR 2.17, 95% CI [1.17-4.04], p = 0.014) were associated to post-operative mortality. On the contrary, pre-operative albumin≥3.4 g/dL (OR 0.14, 95% CI [0.05-0.52], p = 0.001) was associated with a protective effect on postoperative mortality. CONCLUSIONS In the very elderly affected by colorectal cancer, preoperative nutritional status and pre-existing comorbidities, rather than age itself, should be considered as selection criteria for surgery. Preoperative improvement of nutritional status and ASA risk assessment may be beneficial for stratification of patients and ultimately for optimizing outcomes.
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Affiliation(s)
- Matteo Novello
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Francesco Vito Mandarino
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Salomone Di Saverio
- Department of Surgery, Carlo Alberto Pizzardi Maggiore Hospital, Largo Nigrisoli 2, Bologna, Italy
- Colorectal Unit, Addenbrookes Hospital University of Cambridge, Cambridge, United Kingdom
| | - Davide Gori
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Marialuisa Lugaresi
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Duchi
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Francesca Argento
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Cavallari
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
| | - James Wheeler
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Bruno Nardo
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola- Malpighi Hospital, University of Bologna, Bologna, Italy
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32
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Stefani LC, Gamermann PW, Backof A, Guollo F, Borges RM, Martin A, Caumo W, Felix EA. Perioperative mortality related to anesthesia within 48 h and up to 30 days following surgery: A retrospective cohort study of 11,562 anesthetic procedures. J Clin Anesth 2018; 49:79-86. [DOI: 10.1016/j.jclinane.2018.06.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/02/2018] [Accepted: 06/08/2018] [Indexed: 10/28/2022]
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33
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Tessler MJ, Charland L, Wang NN, Correa JA. The association of time of emergency surgery – day, evening or night – with postoperative 30‐day hospital mortality. Anaesthesia 2018; 73:1368-1371. [DOI: 10.1111/anae.14329] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2018] [Indexed: 12/01/2022]
Affiliation(s)
- M. J. Tessler
- Department of Anesthesia Jewish General Hospital Montreal QC Canada
| | - L. Charland
- Department of Anesthesia Jewish General Hospital Montreal QC Canada
| | - N. N. Wang
- Department of Anesthesia Jewish General Hospital Montreal QC Canada
| | - J. A. Correa
- Department of Mathematics and Statistics McGill University Montreal QC Canada
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Choi JW, Kim DK, Lee SH, Shin HS, Seong BG. Comparison of Safety Profiles between Non-operating Room Anesthesia and Operating Room Anesthesia: a Study of 199,764 Cases at a Korean Tertiary Hospital. J Korean Med Sci 2018; 33:e183. [PMID: 29983691 PMCID: PMC6033099 DOI: 10.3346/jkms.2018.33.e183] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 04/30/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Despite expanding demands for non-operating room anesthesia (NORA) worldwide, studies in this field are scarce. We compared the overall characteristics and the nature of deaths occurring within 48 hours after surgery between NORA and operating room anesthesia (ORA) cases at a Korean tertiary hospital. METHODS We retrospectively analyzed the medical records of patients who underwent surgical procedures under anesthesia services in and outside the operating room from January 2013 to November 2017. All of the mortalities were categorized by principal cause into groups such as patient disease or condition, surgery, anesthesia, and others. RESULTS Overall, 16,383 NORA cases and 183,381 ORA cases were analyzed. Eighty-six deaths were identified. The mortality rate of NORA cases was similar to that of ORA cases (4.9 per 10,000 cases [95% confidence interval (CI), 2.1-9.6] vs. 4.3 per 10,000 cases [95% CI, 3.4-5.3], respectively). Similar to ORA cases, higher American Society of Anesthesiologists physical status and very young age (< 2 years) were significantly associated with mortality in NORA cases. A patient's disease or condition was the most important cause of mortality (65/86, 75.6%), followed by surgery-related causes (16/86, 18.6%). Two cases of anesthesia-related mortality were only identified in the ORA cases, resulting in an overall anesthesia-related mortality of 0.1 per 10,000 cases (95% CI, 0.0-0.4). CONCLUSION Although NORA cases showed an equivalent perioperative mortality rate compared to ORA cases, there may be more room for improving patient safety when considering their favorable characteristics (healthier patients, less invasive and shorter procedures). Trial registry at Clinical Research Information Service, KCT0002719.
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Affiliation(s)
- Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Su Shin
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bong Gyu Seong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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35
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Perioperative myocardial injury and the contribution of hypotension. Intensive Care Med 2018; 44:811-822. [PMID: 29868971 DOI: 10.1007/s00134-018-5224-7] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/10/2018] [Indexed: 02/06/2023]
Abstract
Mortality in the month following surgery is about 1000 times greater than anesthesia-related intraoperative mortality, and myocardial injury appears to be the leading cause. There is currently no known safe prophylaxis for postoperative myocardial injury, but there are strong associations among hypotension and myocardial injury, renal injury, and death. During surgery, the harm threshold is a mean arterial pressure of about 65 mmHg. In critical care units, the threshold appears to be considerably greater, perhaps 90 mmHg. The threshold triggering injury on surgical wards remains unclear but may be in between. Much of the association between hypotension and serious complications surely results from residual confounding, but sparse randomized data suggest that at least some harm can be prevented by intervening to limit hypotension. Reducing hypotension may therefore improve perioperative outcomes.
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An Evidence-Based Opioid-Free Anesthetic Technique to Manage Perioperative and Periprocedural Pain. Ochsner J 2018; 18:121-125. [PMID: 30258291 DOI: 10.31486/toj.17.0072] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background The epidemic of opioid abuse is increasing, and the number of deaths secondary to opioid overdose is also increasing. Recent attention has focused on opioid prescribing and management of chronic pain. However, opioid use in perioperative and periprocedural patients, whether they have chronic pain or exhibit new persistent opioid abuse after a procedure, has received little attention. Methods We present an evidence-based technique that combines subanesthetic infusions of lidocaine and dexmedetomidine supplemented with other intravenous agents and a low dose of inhaled anesthetic. Results Based on evidence of drug action and interaction, an opioid-free anesthetic can be delivered successfully. We present the cases of 2 patients in whom the opioid-free anesthetic technique was used with a successful outcome, adequate pain management, and avoidance of opioid drugs. Conclusion This anesthetic prescription can be useful for opioid-naïve patients as well as for patients with chronic pain that is managed with opioids.
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37
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Gabriel RA, A'Court AM, Schmidt UH, Dutton RP, Urman RD. Time of day is not associated with increased rates of mortality in emergency surgery: An analysis of 49,196 surgical procedures. J Clin Anesth 2018; 46:85-90. [DOI: 10.1016/j.jclinane.2018.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/25/2018] [Accepted: 02/01/2018] [Indexed: 12/21/2022]
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Abstract
BACKGROUND Death rates after surgery are increasingly analysed for clinical audit and quality assessment. Many studies commonly provide information only on deaths that occur during hospital stay, known as in-hospital death rates. By using hospital data set linked to death certificate registry, we recorded in- and out-hospital deaths within 30 and 60 post-operative days. METHODS The study included all consecutive surgical procedures (denominator) under general or locoregional anaesthesia in adult patients admitted for elective or non-elective inpatient surgery. Patients undergoing planned day-case surgery or obstetrical procedures were excluded. The primary outcome was 30- and 60-day post-operative mortality rate (numerator) whether before or after discharge. RESULTS The study material consisted of a sample of 36,494 surgical procedures corresponding to 28,202 patients. At 30-day, 384 (crude mortality rate of 1.1%) patients died, 314 (82%) during their hospitalisation and 70 (18%) after discharge. Factors that were associated with in-hospital mortality are ASA scores, emergency, duration of surgery and rate of admission to critical care unit. Within the 30-60 days interval, we recorded 231 supplemental deaths, 103 (45%) after discharge. CONCLUSION In-hospital mortality alone is an incomplete measure of mortality even within 30 days of care. To identify the missing deaths, hospital records need to be linked to data from death certificate. This connection with the national death registry will allow obtaining the rate of in-hospital and out-hospital death.
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Affiliation(s)
- Philippe Dony
- Department of Anaesthesia, University Hospital Centre of Charleroi, Lodelinsart, Belgium
| | - Magali Pirson
- Health Economics, Health Facility Administration and Nursing Science, Free University of Brussels, Brussels, Belgium
| | - Jean G. Boogaerts
- Department of Anaesthesia, University Hospital Centre of Charleroi, Lodelinsart, Belgium
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39
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Gabriel RA, Sztain JF, A'Court AM, Hylton DJ, Waterman RS, Schmidt U. Postoperative mortality and morbidity following non-cardiac surgery in a healthy patient population. J Anesth 2017; 32:112-119. [PMID: 29279996 DOI: 10.1007/s00540-017-2440-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/15/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Perioperative mortality ranges from 0.4% to as high as nearly 12%. Currently, there are no large-scale studies looking specifically at the healthy surgical population alone. The primary objective of this study was to report 30-day mortality and morbidity in healthy patients and define any risk factors. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset, all patients assigned an American Society of Anesthesiologists physical status (ASA PS) classification score of 1 or 2 were included. Further patients were excluded if they had a comorbidity or underwent a procedure not likely to classify them as ASA PS 1 or 2. Multivariable logistic regression was performed to identify predictors of the outcomes, in which odds ratios (OR) and 95% confidence intervals (95% CI) were reported. RESULTS There were 687,552 healthy patients included in the final analysis. Following surgery, 0.7, 7.0, and 0.7 per 1000 persons experienced 30-day mortality, sepsis, and stroke or myocardial infarction, respectively. Healthy patients greater than 80 years of age had the highest odds for mortality (OR 17.7, 95% CI 12.4-25.1, p < 0.001). Case duration was associated with increased mortality, especially in cases greater than or equal to 6 h (OR 3.0, 95% CI 2.0-4.5, p < 0.001). CONCLUSIONS Thirty-day mortality and morbidity is, as expected, lower in the healthy surgical population. Age may be an indication to further risk stratify patients that are ASA PS 1 or 2 to better reflect perioperative risk.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Dr, San Diego, CA, 92103, USA. .,Department of Biomedical Informatics, University of California, San Diego, 9500 Gilman Dr, MC 0881, La Jolla, CA, 92093-0881, USA.
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Dr, San Diego, CA, 92103, USA
| | - Alison M A'Court
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Dr, San Diego, CA, 92103, USA
| | - Diana J Hylton
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Dr, San Diego, CA, 92103, USA
| | - Ruth S Waterman
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Dr, San Diego, CA, 92103, USA
| | - Ulrich Schmidt
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Dr, San Diego, CA, 92103, USA
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Steadman J, Catalani B, Sharp C, Cooper L. Life-threatening perioperative anesthetic complications: major issues surrounding perioperative morbidity and mortality. Trauma Surg Acute Care Open 2017; 2:e000113. [PMID: 29766107 PMCID: PMC5887586 DOI: 10.1136/tsaco-2017-000113] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 11/18/2022] Open
Abstract
Perioperative morbidity and mortality related to anesthesia involves multiple factors. Patient characteristics and comorbidities play a role in many of these events, highlighting the importance of preoperative screening. While optimization of patient comorbidities is not always possible, having data regarding those comorbidities can prove life-saving. Equipment and medication considerations also enter into untoward outcomes such as anesthetic interventions outside of the traditional operating room where resources are sometimes lacking and haste creates errors. Ultimately, when surgeons and anesthesiologists cooperate in patient care, communicating concisely but thoroughly, patients are more likely to do well. The language of surgeons is that of diagnosis requiring a surgical intervention, while anesthesiologists are discussing patient comorbidities impacted by anesthetic medications, positive pressure ventilation, neuraxial techniques, ramifications of patient positioning, effects of opiates and so on. Because all of the considerations combine in determining outcomes, it is incumbent on both surgeons and anesthesiologists to understand those elements leading to severe morbid events as well as death. This review touches on many of the most important factors.
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Affiliation(s)
- Joy Steadman
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Blas Catalani
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christopher Sharp
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lebron Cooper
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Brummett CM, Waljee J, Goesling J, Moser S, Lin P, Englesbe M, Bohnert A, Kheterpal S, Nallamothu BK. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg 2017; 152:e170504. [PMID: 28403427 PMCID: PMC7050825 DOI: 10.1001/jamasurg.2017.0504] [Citation(s) in RCA: 1414] [Impact Index Per Article: 202.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Importance Despite increased focus on reducing opioid prescribing for long-term pain, little is known regarding the incidence and risk factors for persistent opioid use after surgery. Objective To determine the incidence of new persistent opioid use after minor and major surgical procedures. Design, Setting, and Participants Using a nationwide insurance claims data set from 2013 to 2014, we identified US adults aged 18 to 64 years without opioid use in the year prior to surgery (ie, no opioid prescription fulfillments from 12 months to 1 month prior to the procedure). For patients filling a perioperative opioid prescription, we calculated the incidence of persistent opioid use for more than 90 days among opioid-naive patients after both minor surgical procedures (ie, varicose vein removal, laparoscopic cholecystectomy, laparoscopic appendectomy, hemorrhoidectomy, thyroidectomy, transurethral prostate surgery, parathyroidectomy, and carpal tunnel) and major surgical procedures (ie, ventral incisional hernia repair, colectomy, reflux surgery, bariatric surgery, and hysterectomy). We then assessed data for patient-level predictors of persistent opioid use. Main Outcomes and Measures The primary outcome was defined a priori prior to data extraction. The primary outcome was new persistent opioid use, which was defined as an opioid prescription fulfillment between 90 and 180 days after the surgical procedure. Results A total of 36 177 patients met the inclusion criteria, with 29 068 (80.3%) receiving minor surgical procedures and 7109 (19.7%) receiving major procedures. The cohort had a mean (SD) age of 44.6 (11.9) years and was predominately female (23 913 [66.1%]) and white (26 091 [72.1%]). The rates of new persistent opioid use were similar between the 2 groups, ranging from 5.9% to 6.5%. By comparison, the incidence in the nonoperative control cohort was only 0.4%. Risk factors independently associated with new persistent opioid use included preoperative tobacco use (adjusted odds ratio [aOR], 1.35; 95% CI, 1.21-1.49), alcohol and substance abuse disorders (aOR, 1.34; 95% CI, 1.05-1.72), mood disorders (aOR, 1.15; 95% CI, 1.01-1.30), anxiety (aOR, 1.25; 95% CI, 1.10-1.42), and preoperative pain disorders (back pain: aOR, 1.57; 95% CI, 1.42-1.75; neck pain: aOR, 1.22; 95% CI, 1.07-1.39; arthritis: aOR, 1.56; 95% CI, 1.40-1.73; and centralized pain: aOR, 1.39; 95% CI, 1.26-1.54). Conclusions and Relevance New persistent opioid use after surgery is common and is not significantly different between minor and major surgical procedures but rather associated with behavioral and pain disorders. This suggests its use is not due to surgical pain but addressable patient-level predictors. New persistent opioid use represents a common but previously underappreciated surgical complication that warrants increased awareness.
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Affiliation(s)
- Chad M. Brummett
- Department of Anesthesiology, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109
- Institute of Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI 48109
| | - Jennifer Waljee
- Department of Surgery, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109
- Institute of Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI 48109
| | - Jenna Goesling
- Department of Anesthesiology, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109
| | - Stephanie Moser
- Department of Anesthesiology, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109
| | - Paul Lin
- Institute of Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI 48109
| | - Michael Englesbe
- Department of Surgery, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109
- Institute of Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI 48109
| | - Amy Bohnert
- Department of Psychiatry, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109
- Institute of Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI 48109
- Injury Research Center at the University of Michigan Medical School, 2800 Plymouth Road, Suite B10-G080, Ann Arbor, MI 48109
- VA Center for Clinical Management Research, 810 Vermont Avenue, NW Washington DC 20420
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109
- Institute of Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI 48109
| | - Brahmajee K. Nallamothu
- Department of Internal Medicine, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109
- Institute of Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI 48109
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42
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Affiliation(s)
- Jennifer F Waljee
- Department of Surgery, Center for Health Outcomes and Policy, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Justin B Dimick
- Department of Surgery, Center for Health Outcomes and Policy, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Balyan R, Zhang X, Chidambaran V, Martin LJ, Mizuno T, Fukuda T, Vinks AA, Sadhasivam S. OCT1 genetic variants are associated with postoperative morphine-related adverse effects in children. Pharmacogenomics 2017; 18:621-629. [PMID: 28470102 DOI: 10.2217/pgs-2017-0002] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Large interindividual variability in morphine pharmacokinetics (PK) could contribute to variability in morphine analgesia and adverse events. Respiratory depression (RD) and postoperative nausea and vomiting (PONV) are significant adverse drug response of intravenous morphine in the perioperative setting limiting its efficacy in achieving adequate surgical pain relief. OCT1 is a transporter in the liver that transports morphine from the bloodstream into hepatocytes. Earlier we reported association of genetic polymorphisms in OCT1 with morphine PK, and lower morphine clearance in Caucasian children as compared with African-American (AA) children. The aim of this study is to identify the association between common OCT1 genotypes affecting morphine's PK and clinically important postoperative morphine-related adverse outcomes. METHODS After obtaining institutional review board (IRB) approval and informed consents, 311 children ages 6-15 years, American Society of Anesthesiologists' physical status 1 or 2 scheduled for tonsillectomy who received standard anesthetic, surgical and postoperative care were recruited. Clinical data collected included postoperative pain scores, total opioid use, incidence of PONV and RD. Four nonsynonymous SNPs of the OCT1 gene (rs12208357, rs34130495, rs72552763 and rs34059508) in each patient were genotyped using commercially available TaqMan assays. We investigated the genetic association of OCT1 with incidences of postoperative RD and PONV. RESULTS Caucasian and AA children differed significantly in the incidence of obstructive sleep apnea (p < 0.001) and total morphine use (p = 0.028). There were incidences of prolonged post anesthesia care unit stay in 7% of Caucasian children, while no such incidences were observed for AA children (p = 0.05). OCT1 polymorphism rs12208357 was associated with high incidences of PONV and PONV leading to prolonged post anesthesia care unit stay (p < 0.05). A significant association was also found between rs72552763 GAT deletion and high incidence of RD (p = 0.007). CONCLUSION Children with certain OCT1 genotypes are associated with higher risk for RD and PONV following morphine administration leading to prolonged hospital stay. The OCT1 transporters' effects on morphine's PK could explain this association.
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Affiliation(s)
- Rajiv Balyan
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Xue Zhang
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Vidya Chidambaran
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Lisa J Martin
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Tsuyoshi Fukuda
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Alexander A Vinks
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Fuller AT, Haglund MM, Lim S, Mukasa J, Muhumuza M, Kiryabwire J, Ssenyonjo H, Smith ER. Pediatric Neurosurgical Outcomes Following a Neurosurgery Health System Intervention at Mulago National Referral Hospital in Uganda. World Neurosurg 2016; 95:309-314. [PMID: 27497624 DOI: 10.1016/j.wneu.2016.07.090] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 07/22/2016] [Accepted: 07/23/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Pediatric neurosurgical cases have been identified as an important target for impacting health disparities in Uganda, with over 50% of the population being less than 15 years of age. The objective of the present study was to evaluate the effects of the Duke-Mulago collaboration on pediatric neurosurgical outcomes in Mulago National Referral Hospital. METHODS We performed retrospective analysis of all pediatric neurosurgical cases who presented at Mulago National Referral Hospital in Kampala, Uganda, to examine overall, preprogram (2005-2007), and postprogram (2008-2013) outcomes. We analyzed mortality, presurgical infections, postsurgical infections, length of stay, types of procedures, and significant predictors of mortality. Data on neurosurgical cases was collected from surgical logbooks, patient charts, and Mulago National Referral Hospital's yearly death registry. RESULTS Of 820 pediatric neurosurgical cases, outcome data were complete for 374 children. Among children who died within 30 days of a surgical procedure, the largest group was less than a year old (45%). Postinitiation of the Duke-Mulago collaboration, we identified an overall increase in procedures, with the greatest increase in cases with complex diagnoses. Although children ages 6-18 years of age were 6.66 times more likely to die than their younger counterparts preprogram, age was no longer a predictive variable postprogram. When comparing pre- and postprogram outcomes, mortality among pediatric patients within 30 days after a neurosurgical procedure increased from 4.3% to 10.0%, mortality after 30 days increased slightly from 4.9% to 5.0%, presurgical infections decreased by 4.6%, and postsurgery infections decreased slightly by 0.7%. CONCLUSIONS Our data show the provision of more complex neurological procedures does not necessitate improved outcomes. Rather, combining these higher-level procedures with essential pre- and postoperative care and continued efforts in health system strengthening for pediatric neurosurgical care throughout Uganda will help to address and decrease the burden throughout the country.
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Affiliation(s)
- Anthony T Fuller
- Duke University Division of Global Neurosurgery and Neuroscience, Durham, North Carolina, USA; Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael M Haglund
- Duke University Division of Global Neurosurgery and Neuroscience, Durham, North Carolina, USA; Duke University School of Medicine, Durham, North Carolina, USA; Duke University Global Health Institute, Durham, North Carolina, USA; Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA; Department of Neurosurgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Stephanie Lim
- Duke University Division of Global Neurosurgery and Neuroscience, Durham, North Carolina, USA; Duke University School of Medicine, Durham, North Carolina, USA
| | - John Mukasa
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael Muhumuza
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Joel Kiryabwire
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Hussein Ssenyonjo
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Emily R Smith
- Duke University Division of Global Neurosurgery and Neuroscience, Durham, North Carolina, USA; Duke University Global Health Institute, Durham, North Carolina, USA.
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Shidara Y, Fujita Y, Fukunaga S, Ikeda K, Uemura M. In-hospital mortality after surgery: a retrospective cohort study in a Japanese university hospital. SPRINGERPLUS 2016; 5:680. [PMID: 27350916 PMCID: PMC4899431 DOI: 10.1186/s40064-016-2279-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 05/05/2016] [Indexed: 11/21/2022]
Abstract
Background The rapidly aging population affects Japan’s health system, which is characterized by equity and full health insurance coverage for the entire population. However, the current outcomes after surgery in tertiary hospitals in Japan are not known. We aimed to gain an overview of postoperative mortality and death in a tertiary university hospital. Methods Using the administrative database of Kawasaki Medical School Hospital, we investigated the pattern of in-hospital mortality and death for patients who underwent surgery under general or regional anesthesia between January 2010 and December 2011. We used a logistic regression model to find pre-operative risk factors associated with in-hospital mortality in this derivation cohort and tested its results in the validation cohort obtained from surgical patients between January 2012 and April 2014. Results Among 8414 admissions for surgery patients aged ≥65 years was 41.0 %, reflecting aged population in Japan. There were 170 deaths in the derivation cohort, resulting in in-hospital mortality of 2.0 %, and in 30-day mortality of 1.0 %, because a half of the death occurred later than 30 days. We identified four independent preoperative risk factors for in-hospital mortality: high-risk surgery [odds ratio (OR) 18.64], moderate-risk surgery (OR 5.00), ASA-PS ≥3 (OR 5.55), and emergency (OR 2.35). A good correlation between actual and calculated mortality based on the derivation cohort was confirmed in the validation cohort. Conclusions This retrospective study of a single university hospital in Japan shows that aged patients in their 70 s is the largest group undergoing surgery, and that the overall in-hospital mortality is similar to that of other countries, but the 30-day mortality is less than that. Risk stratification for in-hospital mortality using preoperative factors was validated.
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Affiliation(s)
- Yo Shidara
- Department of Anesthesiology and ICM, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 7010192 Japan
| | - Yoshihisa Fujita
- Department of Anesthesiology and ICM, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 7010192 Japan ; Department of Anesthesiology, Iwaki Kyoritsu General Hospital, 16 Kusehara, Uchigo Mimaya-machi, Iwaki, Fukushima 973-8555 Japan
| | - Saiko Fukunaga
- Department of Anesthesiology and ICM, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 7010192 Japan
| | - Kae Ikeda
- Department of Anesthesiology and ICM, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 7010192 Japan
| | - Mayumi Uemura
- Department of Anesthesiology and ICM, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 7010192 Japan
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Chidambaran V, Venkatasubramanian R, Zhang X, Martin LJ, Niu J, Mizuno T, Fukuda T, Meller J, Vinks AA, Sadhasivam S. ABCC3 genetic variants are associated with postoperative morphine-induced respiratory depression and morphine pharmacokinetics in children. THE PHARMACOGENOMICS JOURNAL 2016; 17:162-169. [PMID: 26810133 PMCID: PMC4959996 DOI: 10.1038/tpj.2015.98] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 11/04/2015] [Accepted: 11/13/2015] [Indexed: 02/07/2023]
Abstract
Respiratory depression (RD) is a serious side effect of morphine and detrimental to effective analgesia. We reported that variants of the ATP binding cassette gene ABCC3 (facilitates hepatic morphine metabolite efflux) affect morphine metabolite clearance. In this study of 316 children undergoing tonsillectomy, we found significant association between ABCC3 variants and RD leading to prolonged postoperative care unit stay (prolonged RD). Allele A at rs4148412 and allele G at rs729923 caused a 2.36 (95% CI=1.28-4.37, P=0.0061) and 3.7 (95% CI 1.47-9.09, P=0.0050) times increase in odds of prolonged RD, respectively. These clinical associations were supported by increased formation clearance of morphine glucuronides in children with rs4148412 AA and rs4973665 CC genotypes in this cohort, as well as an independent spine surgical cohort of 67 adolescents. This is the first study to report association of ABCC3 variants with opioid-related RD, and morphine metabolite formation (in two independent surgical cohorts).
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Affiliation(s)
- V Chidambaran
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - R Venkatasubramanian
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - X Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - L J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Niu
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - T Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - T Fukuda
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Meller
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Bioinformatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A A Vinks
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Sadhasivam
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
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Predicting In-hospital Postoperative Mortality for the Practitioner: Beyond the Numbers. Anesthesiology 2015; 124:523-5. [PMID: 26629868 DOI: 10.1097/aln.0000000000000973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gottschalk A, Rink B, Smektala R, Piontek A, Ellger B, Gottschalk A. Spinal anesthesia protects against perioperative hyperglycemia in patients undergoing hip arthroplasty. J Clin Anesth 2014; 26:455-60. [DOI: 10.1016/j.jclinane.2014.02.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 01/31/2014] [Accepted: 02/02/2014] [Indexed: 11/27/2022]
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Abstract
Measuring quality assessment in hand surgery remains an underexplored area. However, measuring quality is becoming increasingly transparent and important. Patients now have direct access to hospital and physician metrics and large payers have linked financial incentives to quality metrics. It is critical for hand surgeons to understand the essential elements of quality and its assessment. This article reviews several areas of hand surgery quality assessments including safety, outcomes, satisfaction, and cost.
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Affiliation(s)
- Jennifer F Waljee
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48103, USA
| | - Catherine Curtin
- Department of Surgery, Palo Alto Veterans Hospital, 3801 Miranda Avenue, Palo Alto, CA 94304, USA.
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50
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Abstract
Collaborative quality improvement has demonstrated success in improving quality and reducing health care costs in several state-based examples. Professional societies and payers are keen on identifying the most effective strategies to improve the safety and efficiency of surgical care. This review highlights the development and features of collaborative quality improvement programs, their advantages and examples of successful collaborations for several surgical conditions, and their potential application for surgeons caring for patients with upper extremity trauma and disability.
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Affiliation(s)
- Jennifer F Waljee
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical Center, University of Michigan Health System, 1500 East Medical Center Drive, 2131 Taubman Center, Ann Arbor, MI 48109, USA.
| | - Nancy J O Birkmeyer
- Michigan Bariatric Surgery Collaborative, Center for Healthcare Outcomes and Policy, North Campus Research Complex, 2800 Plymouth Road, B016, Ann Arbor, MI 48109, USA; Department of Surgery, University of Michigan Medical Center, 1500 East Medial Center Drive, Ann Arbor, MI 48109, USA
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