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Szamos K, Balla B, Pálóczi B, Enyedi A, Sessler DI, Fülesdi B, Végh T. One-lung ventilation with fixed and variable tidal volumes on oxygenation and pulmonary outcomes: A randomized trial. J Clin Anesth 2024; 95:111465. [PMID: 38581926 DOI: 10.1016/j.jclinane.2024.111465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 03/22/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE Test the hypothesis that one-lung ventilation with variable tidal volume improves intraoperative oxygenation and reduces postoperative pulmonary complications after lung resection. BACKGROUND Constant tidal volume and respiratory rate ventilation can lead to atelectasis. Animal and human ARDS studies indicate that oxygenation improves with variable tidal volumes. Since one-lung ventilation shares characteristics with ARDS, we tested the hypothesis that one-lung ventilation with variable tidal volume improves intraoperative oxygenation and reduces postoperative pulmonary complications after lung resection. DESIGN Randomized trial. SETTING Operating rooms and a post-anesthesia care unit. PATIENTS Adults having elective open or video-assisted thoracoscopic lung resection surgery with general anesthesia were randomly assigned to intraoperative ventilation with fixed (n = 70) or with variable (n = 70) tidal volumes. INTERVENTIONS Patients assigned to fixed ventilation had a tidal volume of 6 ml/kgPBW, whereas those assigned to variable ventilation had tidal volumes ranging from 6 ml/kg PBW ± 33% which varied randomly at 5-min intervals. MEASUREMENTS The primary outcome was intraoperative oxygenation; secondary outcomes were postoperative pulmonary complications, mortality within 90 days of surgery, heart rate, and SpO2/FiO2 ratio. RESULTS Data from 128 patients were analyzed with 65 assigned to fixed-tidal volume ventilation and 63 to variable-tidal volume ventilation. The time-weighted average PaO2 during one-lung ventilation was 176 (86) mmHg in patients ventilated with fixed-tidal volume and 147 (72) mmHg in the patients ventilated with variable-tidal volume, a difference that was statistically significant (p < 0.01) but less than our pre-defined clinically meaningful threshold of 50 mmHg. At least one composite complication occurred in 11 (17%) of patients ventilated with variable-tidal volume and in 17 (26%) of patients assigned to fixed-tidal volume ventilation, with a relative risk of 0.67 (95% CI 0.34-1.31, p = 0.24). Atelectasis in the ventilated lung was less common with variable-tidal volumes (4.7%) than fixed-tidal volumes (20%) in the initial three postoperative days, with a relative risk of 0.24 (95% CI 0.01-0.8, p = 0.02), but there were no significant late postoperative differences. No other secondary outcomes were both statistically significant and clinically meaningful. CONCLUSION One-lung ventilation with variable tidal volume does not meaningfully improve intraoperative oxygenation, and does not reduce postoperative pulmonary complications.
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Affiliation(s)
- Katalin Szamos
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Boglárka Balla
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Balázs Pálóczi
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Attila Enyedi
- University of Debrecen, Institute of Surgery, Department of Thoracic Surgery, Debrecen, Hungary
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Béla Fülesdi
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary; Outcomes Research Consortium, Cleveland, OH, USA
| | - Tamás Végh
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary; Outcomes Research Consortium, Cleveland, OH, USA.
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Alfirevic A, Almonacid-Cardenas F, Yalcin EK, Shah K, Kelava M, Sessler DI, Turan A. Blood bupivacaine concentrations after pecto-serratus and serratus anterior plane injections of plain and liposomal bupivacaine in robotically-assisted mitral valve surgery: Sub-study of a randomized trial. J Clin Anesth 2024; 95:111470. [PMID: 38604047 DOI: 10.1016/j.jclinane.2024.111470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/06/2024] [Accepted: 04/07/2024] [Indexed: 04/13/2024]
Abstract
STUDY OBJECTIVE To investigate the timing of peak blood concentrations and potential toxicity when using a combination of plain and liposomal bupivacaine for thoracic fascial plane blocks. DESIGN Pharmacokinetic analysis. SETTING Operating room. PATIENTS Eighteen adult patients undergoing robotically-assisted mitral valve surgery. INTERVENTIONS Ultrasound-guided pecto-serratus and serratus anterior plane blocks using a mixture of 0.5% bupivacaine HCl up to 2.5 mg/kg and liposomal bupivacaine up to 266 mg. MEASUREMENTS Arterial plasma bupivacaine concentration. MAIN RESULTS Samples from 13 participants were analyzed. There was substantial inter-patient variability in plasma concentrations. A geometric mean maximum bupivacaine concentration was 1492 ng/ml (range 660 to 4650 ng/ml) at median time of 30 min after injection. In 4/13 (31%) patients, plasma bupivacaine concentrations exceeded our predefined 2000 ng/ml toxic threshold. A second much smaller peak was observed about 32 h after the injection. No obvious signs of local anesthetic toxicity were observed. CONCLUSIONS Combined injection of plain and liposomal bupivacaine for pecto-serratus/serratus anterior plane blocks produced a biphasic pattern, with the highest arterial plasma concentrations observed within 30 min. Maximum concentrations exceeded the potential toxic threshold in nearly a third of patients, but without clinical evidence of toxicity. Clinicians should not assume that routine combinations of plain and liposomal bupivacaine for thoracic fascial plane blocks are inherently safe.
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Affiliation(s)
- Andrej Alfirevic
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
| | | | - Esra Kutlu Yalcin
- Division of Multi-specialty Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Karan Shah
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Marta Kelava
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA; Division of Multi-specialty Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
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Thomsen KK, Sessler DI, Krause L, Hoppe P, Opitz B, Kessler T, Chindris V, Bergholz A, Flick M, Kouz K, Zöllner C, Schulte-Uentrop L, Saugel B. Processed electroencephalography-guided general anesthesia and norepinephrine requirements: A randomized trial in patients having vascular surgery. J Clin Anesth 2024; 95:111459. [PMID: 38599161 DOI: 10.1016/j.jclinane.2024.111459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024]
Abstract
STUDY OBJECTIVE Processed electroencephalography (pEEG) may help clinicians optimize depth of general anesthesia. Avoiding excessive depth of anesthesia may reduce intraoperative hypotension and the need for vasopressors. We tested the hypothesis that pEEG-guided - compared to non-pEEG-guided - general anesthesia reduces the amount of norepinephrine needed to keep intraoperative mean arterial pressure above 65 mmHg in patients having vascular surgery. DESIGN Randomized controlled clinical trial. SETTING University Medical Center Hamburg-Eppendorf, Hamburg, Germany. PATIENTS 110 patients having vascular surgery. INTERVENTIONS pEEG-guided general anesthesia. MEASUREMENTS Our primary endpoint was the average norepinephrine infusion rate from the beginning of induction of anesthesia until the end of surgery. MAIN RESULT 96 patients were analyzed. The mean ± standard deviation average norepinephrine infusion rate was 0.08 ± 0.04 μg kg-1 min-1 in patients assigned to pEEG-guided and 0.12 ± 0.09 μg kg-1 min-1 in patients assigned to non-pEEG-guided general anesthesia (mean difference 0.04 μg kg-1 min-1, 95% confidence interval 0.01 to 0.07 μg kg-1 min-1, p = 0.004). Patients assigned to pEEG-guided versus non-pEEG-guided general anesthesia, had a median time-weighted minimum alveolar concentration of 0.7 (0.6, 0.8) versus 0.8 (0.7, 0.8) (p = 0.006) and a median percentage of time Patient State Index was <25 of 12 (1, 41) % versus 23 (3, 49) % (p = 0.279). CONCLUSION pEEG-guided - compared to non-pEEG-guided - general anesthesia reduced the amount of norepinephrine needed to keep mean arterial pressure above 65 mmHg by about a third in patients having vascular surgery. Whether reduced intraoperative norepinephrine requirements resulting from pEEG-guided general anesthesia translate into improved patient-centered outcomes remains to be determined in larger trials.
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Affiliation(s)
- Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Daniel I Sessler
- OutcomesResearch Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Opitz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till Kessler
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Viorel Chindris
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; OutcomesResearch Consortium, Cleveland, OH, USA
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leonie Schulte-Uentrop
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; OutcomesResearch Consortium, Cleveland, OH, USA
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Rössler J, Shah K, Medellin S, Turan A, Ruetzler K, Singh M, Sessler DI, Maheshwari K. Development and validation of delirium prediction models for noncardiac surgery patients. J Clin Anesth 2024; 93:111319. [PMID: 37984177 DOI: 10.1016/j.jclinane.2023.111319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 11/05/2023] [Indexed: 11/22/2023]
Abstract
STUDY OBJECTIVE Postoperative delirium is associated with morbidity and mortality, and its incidence varies widely. Using known predisposing and precipitating factors, we sought to develop postoperative delirium prediction models for noncardiac surgical patients. DESIGN Retrospective prediction model study. SETTING Major quaternary medical center. PATIENTS Our January 2016 to June 2020 training dataset included 51,677 patients of whom 2795 patients had delirium. Our July 2020 to January 2022 validation dataset included 14,438 patients of whom 912 patients had delirium. INTERVENTIONS None. MEASUREMENTS We trained and validated two static prediction models and one dynamic delirium prediction model. For the static models, we used random survival forests and traditional Cox proportional hazard models to predict postoperative delirium from preoperative variables, or from a combination of preoperative and intraoperative variables. We also used landmark modeling to dynamically predict postoperative delirium using preoperative, intraoperative, and postoperative variables before onset of delirium. MAIN RESULTS In the validation analyses, the static random forest model had a c-statistic of 0.81 (95% CI: 0.79, 0.82) and a Brier score of 0.04 with preoperative variables only, and a c-statistic of 0.86 (95% CI: 0.84, 0.87) and a Brier score of 0.04 when preoperative and intraoperative variables were combined. The corresponding Cox models had similar discrimination metrics with slightly better calibration. The dynamic model - using all available data, i.e., preoperative, intraoperative and postoperative data - had an overall c-index of 0.84 (95% CI: 0.83, 0.85). CONCLUSIONS Using preoperative and intraoperative variables, simple static models performed as well as a dynamic delirium prediction model that also included postoperative variables. Baseline predisposing factors thus appear to contribute far more to delirium after noncardiac surgery than intraoperative or postoperative variables. Improved postoperative data capture may help improve delirium prediction and should be evaluated in future studies.
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Affiliation(s)
- Julian Rössler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Karan Shah
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, OH, USA
| | - Sara Medellin
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Mriganka Singh
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, USA; Center on Innovation-Long Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
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Ruetzler K, Bustamante S, Schmidt MT, Almonacid-Cardenas F, Duncan A, Bauer A, Turan A, Skubas NJ, Sessler DI. Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial. JAMA 2024; 331:1279-1286. [PMID: 38497992 PMCID: PMC10949146 DOI: 10.1001/jama.2024.0762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/18/2024] [Indexed: 03/19/2024]
Abstract
Importance Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear. Objective To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy. Design, Setting, and Participants Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat. Interventions Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt. Main Outcomes and Measures The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries. Results Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of -3.7% (95% CI, -4.4% to -3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]). Conclusion and Relevance In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures. Trial Registration ClinicalTrials.gov Identifier: NCT04701762.
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Affiliation(s)
- Kurt Ruetzler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
- Division of Multi-Specialty Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Sergio Bustamante
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Marc T. Schmidt
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | | | - Andra Duncan
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Andrew Bauer
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
- Division of Multi-Specialty Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Nikolaos J. Skubas
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I. Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
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Sessler DI, Turan A. Journal policy on large language generative models. J Clin Anesth 2024:111450. [PMID: 38614941 DOI: 10.1016/j.jclinane.2024.111450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/17/2024] [Indexed: 04/15/2024]
Affiliation(s)
- Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, USA.
| | - Alparslan Turan
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, USA
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Sessler DI. Trends in academic publishing. J Clin Anesth 2024:111455. [PMID: 38599936 DOI: 10.1016/j.jclinane.2024.111455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, USA.
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Sessler DI. The Gathering Storm: The 2023 Rovenstine Lecture. Anesthesiology 2024:139990. [PMID: 38569091 DOI: 10.1097/aln.0000000000004965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Anesthesiologists are currently in demand and highly compensated. What appears to be a great success from our perspective is considered problematic from every other healthcare perspective. Consequently, there are powerful healthcare forces seeking to improve anesthesia access and reduce service cost. They will try to impose solutions that may radically change operative anesthesia. The Rovenstine lecture, delivered on World Anesthesia Day 2023, identified substantial challenges our specialty faces and discusses solutions that might be forced on us. It also presented opportunities in perioperative care.
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Affiliation(s)
- Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
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Araujo-Duran J, Kopac O, Montalvo Campana M, Bakal O, Sessler DI, Hofstra RL, Shah K, Turan A, Ayad S. Virtual Reality Distraction for Reducing Acute Postoperative Pain After Hip Arthroplasty: A Randomized Trial. Anesth Analg 2024; 138:751-759. [PMID: 37678233 PMCID: PMC10909914 DOI: 10.1213/ane.0000000000006642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Relaxation and distraction provided by virtual reality presentations might be analgesic and reduce the need for opioid analgesia. We tested the hypothesis that a virtual reality program (AppliedVR) decreases acute postoperative pain and opioid requirements in patients recovering from hip arthroplasty. We also evaluated whether virtual reality distraction improves patient mobility and reduces the need for antiemetics. METHODS We evaluated 106 adults who were recovering from elective primary total hip arthroplasty. Participating patients were randomized to 2- to 8-minute-long 3-dimensional immersive virtual reality relaxation and distraction video presentations (eg, guided breathing exercises, games, mindfulness) or to 2-dimensional presentations of nature short films (eg, forest wildlife) with neutral music that was chosen to be neither overly relaxing nor distracting, presented through identical headsets. Our primary outcome was pain after virtual reality or sham video presentations, adjusted for pretreatment scores. Secondary outcomes included total opioid consumption, pain scores obtained per routine by nurse staff, perception of video system usability, and pain 1 week after hospital discharge. RESULTS Fifty-two patients were randomized to virtual reality distraction and relaxation, and 54 were assigned to 2-dimensional sham presentations. Virtual reality presentations were not found to affect pain scores before and after presentations, with an estimated difference in means (virtual reality minus sham video) of -0.1 points (95% confidence interval [CI], -0.5 to 0.2; P = .391) on a 0 to 10 scale, with 10 being the worst. The mean (standard error [SE]) after-intervention pain score was estimated to be 3.4 (0.3) in the virtual reality group and 3.5 (0.2) in the reference group. Virtual reality treatment was not found to affect postoperative opioid consumption in morphine milligram equivalents, with an estimated ratio of geometric means (virtual reality/sham video) of 1.2 (95% CI, 0.6-2.1; P = .608). Virtual reality presentations were not found to reduce pain scores collected every 4 hours by nursing staff, with an estimated difference in means of 0.1 points (95% CI, -0.9 to 0.7; P = .768). CONCLUSIONS We did not observe statistically significant or clinically meaningful reductions in average pain scores or opioid consumption. As used in our trial, virtual reality did not reduce acute postoperative pain.
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Affiliation(s)
| | | | | | - Omer Bakal
- From the Department of Outcomes Research
| | | | | | - Karan Shah
- Department of Quantitative Health Sciences
| | - Alparslan Turan
- From the Department of Outcomes Research
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Sabry Ayad
- From the Department of Outcomes Research
- Department of Regional Practice, Anesthesiology Institute, Cleveland Clinic/Fairview Hospital, Cleveland, Ohio
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Chhabada S, Skinner C, Kopac O, Castro P, Mascha EJ, Wang D, Gama de Abreu M, Turan A, Sessler DI, Ruetzler K. Association Between Age- and Sex-Specific Body Mass Index Percentile and Multiple Intubation Attempts: A Retrospective Cohort Analysis. Anesth Analg 2024; 138:821-828. [PMID: 36920865 DOI: 10.1213/ane.0000000000006400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Obesity distorts airways and slightly complicates intubations in adults, but whether obesity complicates pediatric intubations remains unclear. We, therefore, tested the primary hypothesis that increasing age- and sex-specific body mass index (BMI) percentile is associated with difficult intubation, defined as >1 intubation attempt. METHODS We conducted a retrospective analysis of pediatric patients between 2 and 18 years of age who had noncardiac surgery with oral endotracheal intubation. We assessed the association between BMI percentile and difficult intubation, defined as >1 intubation attempt, using a confounder-adjusted multivariable logistic regression model. Secondarily, we assessed whether the main association depended on preoperative substantial airway abnormality status or age group. RESULTS A total of 9339 patients were included in the analysis. Median [quartiles] age- and sex-specific BMI percentile was 70 [33, 93], and 492 (5.3%) patients had difficult intubation. There was no apparent association between age- and sex-specific BMI percentile and difficult intubation. The estimated odds ratio (OR) for having difficult intubation for a 10-unit increase in BMI percentile was 0.98 (95% confidence interval [CI], 0.95-1.005) and was consistent across the 3 age groups of early childhood, middle childhood, and early adolescence (interaction P = .53). Patients with preoperative substantial airway abnormalities had lower odds of difficult intubation per 10-unit increase in BMI percentile, with OR (95% CI) of 0.83 (0.70-0.98), P = .01. CONCLUSIONS Age- and sex-specific BMI percentile was not associated with difficult intubation in children between 2 and 18 years of age. As in adults, obesity in children does not much complicate intubation.
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Affiliation(s)
| | - Chelsea Skinner
- General Anesthesiology Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Pilar Castro
- From the Departments of Pediatric and Congenital Cardiac Anesthesia
| | - Edward J Mascha
- Outcomes Research
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dong Wang
- Outcomes Research
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marcelo Gama de Abreu
- Outcomes Research
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- Outcomes Research
- General Anesthesiology Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Kurt Ruetzler
- Outcomes Research
- General Anesthesiology Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Jiang Y, Xie Y, Fang P, Shang Z, Chen L, Zhou J, Yang C, Zhu W, Hao X, Ding J, Yin P, Wang Z, Cao M, Zhang Y, Tan Q, Cheng D, Kong S, Lu X, Liu X, Sessler DI. Cognitive Training for Reduction of Delirium in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e247361. [PMID: 38652478 PMCID: PMC11040409 DOI: 10.1001/jamanetworkopen.2024.7361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/20/2024] [Indexed: 04/25/2024] Open
Abstract
IMPORTANCE Postoperative delirium is a common and impactful neuropsychiatric complication in patients undergoing coronary artery bypass grafting surgery. Cognitive training may enhance cognitive reserve, thereby reducing postoperative delirium. OBJECTIVE To determine whether preoperative cognitive training reduces the incidence of delirium in patients undergoing coronary artery bypass grafting. DESIGN, SETTING, and PARTICIPANTS This prospective, single-blind, randomized clinical trial was conducted at 3 university teaching hospitals in southeastern China with enrollment between April 2022 and May 2023. Eligible participants included those scheduled for elective coronary artery bypass grafting who consented and enrolled at least 10 days before surgery. INTERVENTIONS Participating patients were randomly assigned 1:1, stratified by site, to either routine care or cognitive training, which included substantial practice with online tasks designed to enhance cognitive functions including memory, imagination, reasoning, reaction time, attention, and processing speed. MAIN OUTCOMES AND MEASURES The primary outcome was occurrence of delirium during postoperative days 1 to 7 or until hospital discharge, diagnosed using the Confusion Assessment Method or the Confusion Assessment Method for Intensive Care Units. Secondary outcomes were postoperative cognitive dysfunction, delirium characteristics, and all-cause mortality within 30 days following the operation. RESULTS A total of 218 patients were randomized and 208 (median [IQR] age, 66 [58-70] years; 64 female [30.8%] and 144 male [69.2%]) were included in final analysis, with 102 randomized to cognitive training and 106 randomized to routine care. Of all participants, 95 (45.7%) had only a primary school education and 54 (26.0%) had finished high school. In the cognitive training group, 28 participants (27.5%) developed delirium compared with 46 participants (43.4%) randomized to routine care. Those receiving cognitive training were 57% less likely to develop delirium compared with those receiving routine care (adjusted odds ratio [aOR] 0.43; 95% CI, 0.23-0.77; P = .007). Significant differences were observed in the incidence of severe delirium (aOR, 0.46; 95% CI, 0.25-0.82; P = .01), median (IQR) duration of delirium (0 [0-1] days for cognitive training vs 0 [0-2] days for routine care; P = .008), and median (IQR) number of delirium-positive days (0 [0-1] days for cognitive training vs 0 [0-2] days for routine care; P = .007). No other secondary outcomes differed significantly. CONCLUSIONS AND RELEVANCE In this randomized trial of 208 patients undergoing coronary artery bypass grafting, preoperative cognitive training reduced the incidence of postoperative delirium. However, our primary analysis was based on fewer than 75 events and should therefore be considered exploratory and a basis for future larger trials. Trial Registration Chinese Clinical Trial Registry Identifier: ChiCTR2200058243.
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Affiliation(s)
- Yu Jiang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Yanhu Xie
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Panpan Fang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Zixiang Shang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Lihai Chen
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jifang Zhou
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Chao Yang
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Wenjie Zhu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Xixi Hao
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Jianming Ding
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Panpan Yin
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Zan Wang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Mengyuan Cao
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Yu Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Qilian Tan
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Dan Cheng
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Siyu Kong
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Xianfu Lu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Xuesheng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Daniel I. Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
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Davies SJ, Sessler DI, Jian Z, Fleming NW, Mythen M, Maheshwari K, Veelo DP, Vlaar AP, Settels J, Scheeren T, van der Ster B, Sander M, Cannesson M, Hatib F. Comparison of differences in cohort (forwards) and case control (backwards) methodological approaches for validation of the Hypotension Prediction Index. Anesthesiology 2024:139987. [PMID: 38557791 DOI: 10.1097/aln.0000000000004989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND The Hypotension Prediction Index (the index) software is a machine learning algorithm that detects physiological changes that may lead to hypotension. The original validation used a case control (backwards) analysis that has been suggested to be biased. We therefore conducted a cohort (forwards) analysis and compared this to the original validation technique. METHODS We conducted a retrospective analysis of data from previously reported studies. All data were analysed identically with 2 different methodologies and receiver operating characteristic curves (ROC) constructed. Both backwards and forwards analyses were performed to examine differences in area under the ROC for HPI and other haemodynamic variables to predict a MAP < 65mmHg for at least 1 minute 5, 10 and 15 minutes in advance. RESULTS Two thousand and twenty-two patients were included in the analysis, yielding 4,152,124 measurements taken at 20 second intervals. The area-under-the-curve for the index predicting hypotension analysed by backward and forward methodologies respectively was 0.957 (95% CI, 0.947-0.964) vs 0.923 (95% CI, 0.912-0.933) 5 minutes in advance, 0.933 (95% CI, 0.924-0.942) vs 0.923 (95% CI, 0.911-0.933) 10 minutes in advance , and 0.929 (95% CI, 0.918-0.938) vs. 0.926 (95% CI, 0.914-0.937) 15 minutes in advance. No other variable had an area-under-the-curve > 0.7 except for MAP. Area-under-the-curve using forward analysis for MAP predicting hypotension 5, 10, and 15 minutes in advance was 0.932 (95% CI, 0.920-0.940), 0.929 (95% CI, 0.918-0.938), and 0.932 (95% CI, 0.921-0.940). The R 2 for the variation in the index due to MAP was 0.77. CONCLUSION Using an updated methodology, we found the utility of the HPI index to predict future hypotensive events is high, with an area under the receiver-operating-characteristics curve similar to that of the original validation method.
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Affiliation(s)
- Simon J Davies
- Department of Anaesthesia, Critical Care and Perioperative Medicine, York and Scarborough Teaching Hospitals NHS foundation Trust, York, UK
- Centre for Health and Population Science, Hull York Medical School, York, UK
| | | | | | | | - Monty Mythen
- Edwards Lifesciences, Irvine, California, USA
- UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK
| | | | - Denise P Veelo
- Departments of Anaesthesia and Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Alexander Pj Vlaar
- Departments of Anaesthesia and Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jos Settels
- Edwards Lifesciences, Irvine, California, USA
| | - Thomas Scheeren
- Edwards Lifesciences, Irvine, California, USA
- Department of Anesthesiology, University Medical Centre Groningen, The Netherlands
| | - Bjp van der Ster
- Departments of Anaesthesia and Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
- ErasmusMc, Rotterdam, The Netherlands
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Giessen, Germany
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, UCLA, California, USA
| | - Feras Hatib
- Edwards Lifesciences, Irvine, California, USA
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Paredes S, Harb A, Rössler J, Nikoo MZ, Ruetzler K, Turan A, Pu X, Sessler DI. Metformin Use in Type 2 Diabetics and Delirium After Noncardiac Surgery: A Retrospective Cohort Analysis. Anesth Analg 2024:00000539-990000000-00800. [PMID: 38517762 DOI: 10.1213/ane.0000000000006863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The cause of postoperative delirium is unknown, but it is thought to result at least in part from inflammation. Metformin, besides its hypoglycemic properties, demonstrates anti-inflammatory effects systemically and in the brain. We tested the primary hypothesis that chronic metformin use in adults with type 2 diabetes is associated with less delirium during the first 5 days after major noncardiac surgery. Secondary outcomes were a composite of serious complications (myocardial infarction, cardiac arrest, stage 2-3 acute kidney injury [AKI], and mortality) and time to discharge alive. METHODS We considered adults with type 2 diabetes who did or did not routinely use metformin daily and had noncardiac surgery. Delirium was assessed by Confusion Assessment Method for Intensive Care Unit (CAM-ICU) or brief Confusion Assessment Method (bCAM) for 5 postoperative days. Postoperative AKI was defined by Kidney Disease Improving Global Guidelines. Logistic regression and generalized estimating equation models accounted for within-patient correlation across multiple surgeries and explored the association between metformin use and postoperative delirium and complications. Inverse propensity score weighting and propensity score calibration (PSC) adjusted for confounding variables. RESULTS No significant difference was observed in the incidence of postoperative delirium between the 2 groups, with 260 of 4744 cases (5.5%) among metformin users and 502 of 5918 cases (8.5%) cases in nonmetformin users, for an odds ratio of 0.88 (95% confidence interval [CI], 0.73-1.05; P = .155), number-needed-to-expose = 118 patients. Similarly, there were fewer composite complications in metformin users (3.3%) than in nonusers (11.7%); However, the common-effect odds ratio of 0.67 was not statistically significant (97.5% CI, 0.39-1.17; P = .106). Discharge from the hospital was significantly faster in patients who took metformin (3 [interquartile range, IQR, 1-5] days for metformin users and 3 [IQR, 2-6] days for nonmetformin users), with a hazard ratio of 1.07 for early discharge, and tight CIs (1.01-1.13). CONCLUSIONS Chronic metformin use was associated with slightly and nonsignificantly less delirium. However, patients who used metformin had clinically meaningfully fewer major complications, mostly stage 2 to 3 kidney injury. While not statistically significant, the reduction was substantial and warrants further investigation because there is currently no effective preventive measure for perioperative renal injury. Benefit would be especially meaningful if it could be produced by acute perioperative treatment. Finally, metformin was associated with faster hospital discharge, although not by a clinically meaningful amount.
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Affiliation(s)
- Stephania Paredes
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Ayoub Harb
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, Ohio
| | - Julian Rössler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Kurt Ruetzler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Xuan Pu
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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14
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Li K, Wang J, Sessler DI. Continuous ward monitoring and intensive postoperative management. Chin Med J (Engl) 2024; 137:631-632. [PMID: 38384165 PMCID: PMC10950178 DOI: 10.1097/cm9.0000000000002997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Indexed: 02/23/2024] Open
Affiliation(s)
- Kai Li
- Department of Anesthesiology, China-Japan Union Hospital, Jilin University, Changchun, Jilin 130031, China
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Jiayi Wang
- Outcomes Research Consortium, Cleveland, Ohio 44195, USA
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Daniel I. Sessler
- Department of Anesthesiology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 201999, China
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio 44195, USA
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15
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Ilfeld BM, Smith CR, Turan A, Mariano ER, Miller ME, Fisher RL, Trescot AM, Cohen SP, Eisenach JC, Sessler DI, Prologo JD, Mascha EJ, Liu L, Gabriel RA. Smallest Clinically Meaningful Improvement in Amputation-Related Pain and Brief Pain Inventory Scores as Defined by Patient Reports of Global Improvement After Cryoneurolysis: a Retrospective Analysis of a Randomized, Controlled Clinical Trial. Anesth Analg 2024:00000539-990000000-00707. [PMID: 38478876 DOI: 10.1213/ane.0000000000006833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND The smallest meaningful improvement in pain scores (minimal clinically important difference [MCID]) after an analgesic intervention is essential information when both interpreting published data and designing a clinical trial. However, limited information is available for patients with chronic pain conditions, and what is published is derived from studies involving pharmacologic and psychological interventions. We here calculate these values based on data collected from 144 participants of a previously published multicenter clinical trial investigating the effects of a single treatment with percutaneous cryoneurolysis. METHODS In the original trial, we enrolled patients with a lower-limb amputation and established phantom pain. Each received a single-injection femoral and sciatic nerve block with lidocaine and was subsequently randomized to receive either ultrasound-guided percutaneous cryoneurolysis or sham treatment at these same locations. Investigators, participants, and clinical staff were masked to treatment group assignment with the exception of the treating physician performing the cryoneurolysis, who had no subsequent participant interaction. At both baseline and 4 months (primary end point), participants rated their phantom limb pain based on a numeric rating scale (NRS) and their interference of pain on physical and emotional functioning as measured with the Brief Pain Inventory's interference subscale. They subsequently qualitatively defined the change using the 7-point ordinal Patient Global Impression of Change (PGIC). The smallest clinically meaningful improvements in phantom limb pain and Brief Pain Inventory scores were calculated using an anchor-based method based on the PGIC. RESULTS The median (interquartile range [IQR]) phantom pain NRS (0-10) improvements at 4 months considered small, medium, and large were 1 [1-1], 3 [3-4], and 4 [3-6], respectively. The median improvements in the Brief Pain Inventory interference subscale (0-70) associated with a small, medium, and large analgesic changes were 16 [6-18], 24 [22-31], and 34 [22-46]. The proportions of patients that experienced PGIC ≥5 were 33% and 36% in the active and placebo groups, respectively. The relative risk of a patient experiencing PGIC ≥5 in the active group compared to the sham group with 95% confidence interval was 0.9 (0.6-1.4), P = .667. CONCLUSIONS Amputees with phantom limb pain treated with percutaneous cryoneurolysis rate analgesic improvements as clinically meaningful similar to pharmacologic treatments, although their MCID for the Brief Pain Inventory was somewhat larger than previously published values. This information on patient-defined clinically meaningful improvements will facilitate interpretation of available studies and guide future trial design.
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Affiliation(s)
- Brian M Ilfeld
- From the Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Cameron R Smith
- Department of Anesthesiology, University of Florida, Gainesville, Florida; ‡Departments of General Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- Department of Anesthesiology, Perioperative and Pain Medicine, Palo Alto Veterans Health System, Palo Alto, California
| | - Edward R Mariano
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Matthew E Miller
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, California
| | - Rick L Fisher
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, California
| | | | - Steven P Cohen
- Department of Anesthesiology, Johns Hopkins University, Baltimore, Maryland
| | - James C Eisenach
- Department of Anesthesiology, Wake Forest Medical Center, Winston-Salem, North Carolina
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Edward J Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Liu Liu
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Rodney A Gabriel
- From the Department of Anesthesiology, University of California San Diego, San Diego, California
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16
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Zakaria L, Sessler DI, Shaw AD, Spiess BD. Treatment-Effect Heterogeneity in Hemodynamic Responses to Hydroxocobalamin. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00173-3. [PMID: 38584047 DOI: 10.1053/j.jvca.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Luai Zakaria
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH; Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH; Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH.
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH
| | - Bruce D Spiess
- Department of Cardiothoracic Anesthesiology, University of Florida, Gainesville, FL; HemoSonics, LLC, Durham, NC
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17
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Vail EA, Feng R, Sieber F, Carson JL, Ellenberg SS, Magaziner J, Dillane D, Marcantonio ER, Sessler DI, Ayad S, Stone T, Papp S, Donegan D, Mehta S, Schwenk ES, Marshall M, Jaffe JD, Luke C, Sharma B, Azim S, Hymes R, Chin KJ, Sheppard R, Perlman B, Sappenfield J, Hauck E, Tierney A, Horan AD, Neuman MD. Long-term Outcomes with Spinal versus General Anesthesia for Hip Fracture Surgery: A Randomized Trial. Anesthesiology 2024; 140:375-386. [PMID: 37831596 DOI: 10.1097/aln.0000000000004807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
BACKGROUND The effects of spinal versus general anesthesia on long-term outcomes have not been well studied. This study tested the hypothesis that spinal anesthesia is associated with better long-term survival and functional recovery than general anesthesia. METHODS A prespecified analysis was conducted of long-term outcomes of a completed randomized superiority trial that compared spinal anesthesia versus general anesthesia for hip fracture repair. Participants included previously ambulatory patients 50 yr of age or older at 46 U.S. and Canadian hospitals. Patients were randomized 1:1 to spinal or general anesthesia, stratified by sex, fracture type, and study site. Outcome assessors and investigators involved in the data analysis were masked to the treatment arm. Outcomes included survival at up to 365 days after randomization (primary); recovery of ambulation among 365-day survivors; and composite endpoints for death or new inability to ambulate and death or new nursing home residence at 365 days. Patients were included in the analysis as randomized. RESULTS A total of 1,600 patients were enrolled between February 12, 2016, and February 18, 2021; 795 were assigned to spinal anesthesia, and 805 were assigned to general anesthesia. Among 1,599 patients who underwent surgery, vital status information at or beyond the final study interview (conducted at approximately 365 days after randomization) was available for 1,427 (89.2%). Survival did not differ by treatment arm; at 365 days after randomization, there were 98 deaths in patients assigned to spinal anesthesia versus 92 deaths in patients assigned to general anesthesia (hazard ratio, 1.08; 95% CI, 0.81 to 1.44, P = 0.59). Recovery of ambulation among patients who survived a year did not differ by type of anesthesia (adjusted odds ratio for spinal vs. general, 0.87; 95% CI, 0.67 to 1.14; P = 0.31). Other outcomes did not differ by treatment arm. CONCLUSIONS Long-term outcomes were similar with spinal versus general anesthesia. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rui Feng
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Frederick Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jeffrey L Carson
- Division of General Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Derek Dillane
- Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Trevor Stone
- Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven Papp
- Division of Orthopedics, Ottawa Hospital Civic Campus, Ottawa, Ontario, Canada
| | - Derek Donegan
- Department of Orthopedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Samir Mehta
- Department of Orthopedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mitchell Marshall
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York
| | - J Douglas Jaffe
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Charles Luke
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Balram Sharma
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Syed Azim
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York
| | - Robert Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Ki-Jinn Chin
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Richard Sheppard
- Department of Anesthesiology, Hartford Hospital, Hartford, Connecticut
| | | | - Joshua Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Ellen Hauck
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Ann Tierney
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Annamarie D Horan
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
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Cata JP, Sessler DI. Lost in Translation: Failure of Preclinical Studies to Accurately Predict the Effect of Regional Analgesia on Cancer Recurrence. Anesthesiology 2024; 140:361-374. [PMID: 38170786 DOI: 10.1097/aln.0000000000004823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The major goal of translational research is to evaluate the efficacy and effectiveness of treatments and interventions that have emerged from exhaustive preclinical evidence. In 2007, a major clinical trial was started to investigate the impact of paravertebral analgesia on breast cancer recurrence. The trial was based on preclinical evidence demonstrating that spinal anesthesia suppressed metastatic dissemination by inhibiting surgical stress, boosting the immunological response, avoiding volatile anesthetics, and reducing opioid use. However, that trial and three more recent randomized trials with a total of 4,770 patients demonstrate that regional analgesia does not improve survival outcomes after breast, lung, and abdominal cancers. An obvious question is why there was an almost complete disconnect between the copious preclinical investigations suggesting benefit and robust clinical trials showing no benefit? The answer is complex but may result from preclinical research being mechanistically driven and based on reductionist models. Both basic scientists and clinical investigators underestimated the limitations of various preclinical models, leading to the apparently incorrect hypothesis that regional anesthesia reduces cancer recurrence. This article reviews factors that contributed to the discordance between the laboratory science, suggesting that regional analgesia might reduce cancer recurrence and clinical trials showing that it does not-and what can be learned from the disconnect.
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Affiliation(s)
- Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas-MD Anderson Cancer Center, Houston, Texas
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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Affiliation(s)
- Daniel I Sessler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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20
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Anusic N, Sessler DI. Innovative designs for trials informing the care of cardiac surgical patients: part I. Curr Opin Anaesthesiol 2024; 37:42-48. [PMID: 38085861 DOI: 10.1097/aco.0000000000001335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW Randomized clinical trials, now commonplace and regarded as top-tier evidence, are actually a recent development. The first randomized trial took place in 1948, just six decades ago. As anticipated from a relatively young field, rapid progress continues in response to an ever-increasing number of medical questions that demand answers. We examine evolving methodologies in cardiac anesthesia clinical trials, focusing on the transition towards larger sample sizes, increasing use of pragmatic trial designs, and the innovative adoption of real-time automated enrollment and randomization. We highlight how these changes enhance the reliability and feasibility of clinical trials. RECENT FINDINGS Recent understanding in clinical trial methodology acknowledges the importance of large sample sizes, which increase the reliability of findings. As illustrated by P value fragility, small trials can mislead despite statistical significance. Pragmatic trials have gained prominence, offering real-world insights into the effectiveness of various treatments. Additionally, the use of real-time automated enrollment and randomization, particularly in situations where obtaining prior consent is impractical, is an important methodological advance. SUMMARY The landscape of cardiac anesthesia clinical trials is rapidly evolving, with a clear trend towards large sample sizes and innovative approaches to enrollment. Recent developments enhance the quality and applicability of research findings, thus providing robust guidance to clinicians.
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Affiliation(s)
- Nikola Anusic
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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Li S, Liu M, Yang J, Yan X, Wu Y, Zhang L, Zeng M, Zhou D, Peng Y, Sessler DI. Intravenous tranexamic acid for intracerebral meningioma resections: A randomized, parallel-group, non-inferiority trial. J Clin Anesth 2024; 92:111285. [PMID: 37857168 DOI: 10.1016/j.jclinane.2023.111285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/14/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023]
Abstract
STUDY OBJECTIVES Tranexamic acid (TXA) is an antifibrinolytic that is widely used to reduce surgical bleeding. However, TXA occasionally causes seizures and the risk might be especially great after neurosurgery. We therefore tested the hypothesis that TXA does not meaningfully increase the risk of postoperative seizures within 7 days after intracranial tumor resections. DESIGN Randomized, double-blind, placebo-controlled, non-inferiority trial. SETTING Beijing Tiantan Hospital, Capital Medical University. PATIENTS 600 patients undergoing supratentorial meningioma resection were included from October 2020 to August 2022. INTERVENTIONS Patients were randomly assigned to a single dose of 20 mg/kg of TXA after induction (n = 300) or to the same volume of normal saline (n = 300). MEASUREMENT The primary outcome was postoperative seizures occurring within 7 days after surgery, analyzed in both the intention-to-treat and per-protocol populations. Non-inferiority was defined by an upper limit of the 95% confidence interval for the absolute difference being <5.5%. Secondary outcomes included incidence of non-epileptic complication within 7 days, changes in hemoglobin concentration, estimated intraoperative blood loss. Post hoc analyses included the types and timing of seizures, oozing assessment, and a sensitivity analysis for the primary outcome in patients with pathologic diagnosis of meningioma. MAIN RESULTS All 600 enrolled patients adhered to the protocol and completed the follow-up for the primary outcome. Postoperative seizures occurred in 11 of 300 (3.7%) of patients randomized to normal saline and 13 of 300 (4.3%) patients assigned to tranexamic acid (mean risk difference, 0.7%; 1-sided 97.5% CI, -∞ to 4.3%; P = 0.001 for noninferiority). No significant differences were observed in any secondary outcome. Post hoc analysis indicated similar amounts of oozing, calculated blood loss, recurrent seizures, and timing of seizures. CONCLUSION Among patients having supratentorial meningioma resection, a single intraoperative dose of TXA did not significantly reduce bleeding and was non-inferior with respect to postoperative seizures after surgery. REGISTRY INFORMATION This trial was registered at clinicaltrials.gov (NCT04595786) on October 22, 2020, by Dr.Yuming Peng.
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Affiliation(s)
- Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Jingchao Yang
- Department of Anesthesiology, Cancer Hospital, Chinses Academy of Medical Sciences, Beijing, PR China
| | - Xiang Yan
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
| | - Yaru Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Liyong Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Dabiao Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; Outcome Research Consortium, Cleveland, OH, USA.
| | - Daniel I Sessler
- Outcome Research Consortium, Cleveland, OH, USA; Department of Outcome Research, Cleveland Clinic, Cleveland, OH, USA.
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Wang J, Lin F, Zeng M, Liu M, Zheng M, Ren Y, Li S, Yang X, Chen Y, Chen X, Sessler DI, Peng Y. Intraoperative blood pressure and cardiac complications after aneurysmal subarachnoid hemorrhage: a retrospective cohort study. Int J Surg 2024; 110:965-973. [PMID: 38016131 PMCID: PMC10871595 DOI: 10.1097/js9.0000000000000928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 11/08/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Previous studies report that intraoperative hypotension worsens outcomes after aneurysmal subarachnoid hemorrhage (aSAH). However, the hypotensive harm threshold for major adverse cardiovascular events (MACE) remains unclear. METHODS The authors included aSAH patients who had general anesthesia for aneurysmal clipping/coiling. MACE were defined by a composite of acute myocardial injury, acute myocardial infarction, and other cardiovascular complications identified by electrocardiogram and echocardiography. The authors initially used logistic regression and change-point analysis based on the second derivative to identify mean arterial pressure (MAP) of 75 mmHg as the harm threshold. Thereafter, our major exposure was MAP below 75 mmHg characterized by area, duration, and time-weighted average. The area below 75 mmHg represents the severity and duration of exposure and was defined as the sum of all areas below a specified threshold using the trapezoid rule. Time-weighted average MAP was derived by dividing area below the threshold by the duration of anesthesia. All analyses were adjusted for baseline risk factors including age greater than 70 years, female sex, severity of intracerebral hemorrhage, history of cardiovascular disease, and preoperative elevated myocardial enzymes. RESULTS Among 1029 patients enrolled, 254 (25%) developed postoperative MACE. Patients who experienced MACE were slightly older (59±11 vs. 54±11 years), were slightly more often women (69 vs. 58%), and had a higher prevalence of cardiovascular history (65 vs. 47%). Adjusted cardiovascular risk increased nearly linearly over the entire range of observed MAP. However, there was a slight inflexion at MAP of 75 mmHg. MACE was significantly associated with area [adjusted odds ratios (aOR) 1.004 per 10 mmHg.min, 95% CI: 1.001-1.007, P =0.002), duration (aOR 1.031 per 10 min, 95% CI: 1.009-1.054, P =0.006), and time-weighted average (aOR 3.516 per 10 mmHg, 95% CI: 1.818-6.801, P <0.001) of MAP less than 75 mmHg. CONCLUSIONS Lower blood pressures were associated with cardiovascular complications over the entire observed range, but worsened when MAP was less than 75 mmHg. Pending trial data to establish causality, it may be prudent to keep MAP above 75 mmHg in patients having surgical aSAH repairs to reduce the risk of MACE.
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Affiliation(s)
- Juan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Maoyao Zheng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yue Ren
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xiaodong Yang
- Institute of Computing Technology, Chinese Academy of Sciences, Beijing, People’s Republic of China
| | - Yiqiang Chen
- Institute of Computing Technology, Chinese Academy of Sciences, Beijing, People’s Republic of China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Daniel I. Sessler
- Department of Outcome Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Outcome Research Consortium, Cleveland, Ohio, USA
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23
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Anusic N, Sessler DI. Innovative designs for trials informing the care of cardiac surgical patients: Part II. Curr Opin Anaesthesiol 2024; 37:49-54. [PMID: 38085856 DOI: 10.1097/aco.0000000000001334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW This review examines advances in clinical trial methodologies relevant to cardiac anesthesia. It focuses on innovative approaches, including factorial randomization, composite outcomes, and cluster randomized trials, which enhance the efficiency, practical relevance, and generalizability of trial outcomes. RECENT FINDINGS Factorial randomization is becoming popular because the approach allows investigators to simultaneously evaluate two or more interventions. Furthermore, factorial designs can evaluate interactions among treatments which is highly relevant information that cannot be obtained from separate trials. Composite outcomes are also increasingly utilized, combining multiple individual outcomes into a single measure, which increases statistical power and can better represent relevant physiology. Designing valid composites requires careful consideration of component outcome severity and incidence. Cluster randomized trials, including stepped wedge and multiple crossover designs, address the challenges of group-level effects and shared environments. SUMMARY The evolution of clinical trial designs is marked by a shift towards methodologies that enhance efficiency and provide more nuanced insights into treatment effects. These include factorial designs for simultaneous intervention assessment, composite outcomes for comprehensive physiological representation, and cluster trials for group-level effect analysis. Such advancements are shaping the future of clinical research, making it more relevant, efficient, and broadly applicable.
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Affiliation(s)
- Nikola Anusic
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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24
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Roshanov PS, Chan MTV, Borges FK, Conen D, Wang CY, Xavier D, Berwanger O, Marcucci M, Sessler DI, Szczeklik W, Spence J, Alonso-Coello P, Fernández C, Pearse RM, Malaga G, Garg AX, Srinathan SK, Jacka MJ, Tandon V, McGillion M, Popova E, Sigamani A, Abraham V, Biccard BM, Villar JC, Chow CK, Polanczyk CA, Tiboni M, Whitlock R, Ackland GL, Panju M, Lamy A, Sapsford R, Williams C, Wu WKK, Cortés OL, MacNeil SD, Patel A, Belley-Côté EP, Ofori S, McIntyre WF, Leong DP, Heels-Ansdell D, Gregus K, Devereaux PJ. One-year Outcomes after Discharge from Noncardiac Surgery and Association between Predischarge Complications and Death after Discharge: Analysis of the VISION Prospective Cohort Study. Anesthesiology 2024; 140:8-24. [PMID: 37713506 DOI: 10.1097/aln.0000000000004763] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
BACKGROUND In previous analyses, myocardial injury after noncardiac surgery, major bleeding, and sepsis were independently associated with most deaths in the 30 days after noncardiac surgery, but most of these deaths occurred during the index hospitalization for surgery. The authors set out to describe outcomes after discharge from hospital up to 1 yr after inpatient noncardiac surgery and associations between predischarge complications and postdischarge death up to 1 yr after surgery. METHODS This study was an analysis of patients discharged after inpatient noncardiac surgery in a large international prospective cohort study across 28 centers from 2007 to 2013 of patients aged 45 yr or older followed to 1 yr after surgery. The study estimated (1) the cumulative postdischarge incidence of death and other outcomes up to a year after surgery and (2) the adjusted time-varying associations between postdischarge death and predischarge complications including myocardial injury after noncardiac surgery, major bleeding, sepsis, infection without sepsis, stroke, congestive heart failure, clinically important atrial fibrillation or flutter, amputation, venous thromboembolism, and acute kidney injury managed with dialysis. RESULTS Among 38,898 patients discharged after surgery, the cumulative 1-yr incidence was 5.8% (95% CI, 5.5 to 6.0%) for all-cause death and 24.7% (95% CI, 24.2 to 25.1%) for all-cause hospital readmission. Predischarge complications were associated with 33.7% (95% CI, 27.2 to 40.2%) of deaths up to 30 days after discharge and 15.0% (95% CI, 12.0 to 17.9%) up to 1 yr. Most of the association with death was due to myocardial injury after noncardiac surgery (15.6% [95% CI, 9.3 to 21.9%] of deaths within 30 days, 6.4% [95% CI, 4.1 to 8.7%] within 1 yr), major bleeding (15.0% [95% CI, 8.3 to 21.7%] within 30 days, 4.7% [95% CI, 2.2 to 7.2%] within 1 yr), and sepsis (5.4% [95% CI, 2.2 to 8.6%] within 30 days, 2.1% [95% CI, 1.0 to 3.1%] within 1 yr). CONCLUSIONS One in 18 patients 45 yr old or older discharged after inpatient noncardiac surgery died within 1 yr, and one quarter were readmitted to the hospital. The risk of death associated with predischarge perioperative complications persists for weeks to months after discharge. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Pavel S Roshanov
- Department of Medicine, Western University, London, Canada; Population Health Research Institute, Hamilton, Canada
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong, Hong Kong
| | - Flavia K Borges
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - David Conen
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - C Y Wang
- Honorary Professor; Department of Anesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | - Denis Xavier
- St. John's Medical College Hospital, Bangalore, India
| | - Otavio Berwanger
- George Institute for Global Health, London, United Kingdom; Imperial College London, London, United Kingdom
| | - Maura Marcucci
- Clinical Epidemiology and Research Centre (CERC), Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Milan, Italy; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jessica Spence
- Anesthesia and Critical Care, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Hospital Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red (CIBER) de Epidemiología y Salud Pública, Madrid, Spain
| | - Carmen Fernández
- Department of Anesthesiology and Intensive Care Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rupert M Pearse
- Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom
| | - German Malaga
- Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Amit X Garg
- Department of Medicine, University of Western Ontario, London, Canada
| | | | - Michael J Jacka
- Department of Critical Care and Anesthesia, University of Alberta, Edmonton, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Michael McGillion
- School of Nursing, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Ekaterine Popova
- IIB Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain; Centro Cochrane Iberoamericano, Barcelona, Spain
| | - Alben Sigamani
- Numen Health, Bangalore, India; Narayana Hrudayalaya Health City Bangalore, Bangalore, India
| | - Valsa Abraham
- Christian Medical College and Hospital Ludhiana, Ludhiana, India
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, South Africa
| | | | - Clara K Chow
- Westmead Applied Research Centre, University of Sydney, Sydney, Australia; Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Carísi A Polanczyk
- Graduate Program in Epidemiology and Cardiovascular Science, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Institute for Health Technology Assessment, Porto Alegre, Rio Grande do Sul, Brazil
| | - Maria Tiboni
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Richard Whitlock
- Department of Surgery, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Gareth L Ackland
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Mohamed Panju
- Department of Medicine, McMaster University, Hamilton, Canada
| | - André Lamy
- Department of Surgery, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Robert Sapsford
- Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Colin Williams
- Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - William Ka Kei Wu
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, New Territories, Hong Kong
| | - Olga L Cortés
- Research Department and Nursing Department, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá DC, Colombia
| | - S Danielle MacNeil
- Schulich School of Medicine and Dentistry, Western University, London, Canada; Otolaryngology-Head & Neck Surgery, London Health Sciences Centre, London, Canada
| | - Ameen Patel
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Emilie P Belley-Côté
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Sandra Ofori
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - William F McIntyre
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Darryl P Leong
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | | | - P J Devereaux
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
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25
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Sessler DI. Nuanced Interpretation of Research Results. Anesthesiology 2023; 139:730-733. [PMID: 37934105 DOI: 10.1097/aln.0000000000004753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Affiliation(s)
- Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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26
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Shimada T, Pu X, Kutlu Yalcin E, Cohen B, Bravo M, Mascha EJ, Sessler DI, Turan A. Association between postoperative hypotension and acute kidney injury after noncardiac surgery: a historical cohort analysis. Can J Anaesth 2023; 70:1892-1900. [PMID: 37919627 DOI: 10.1007/s12630-023-02601-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/16/2023] [Accepted: 05/21/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE The extent to which postoperative hypotension contributes to renal injury remains unclear, much less what the harm thresholds might be. We therefore tested the primary hypothesis that there is an absolute hypotensive arterial pressure threshold for acute kidney injury during the initial seven days after noncardiac surgery. METHODS We conducted a single-centre historical cohort analysis of adults who had noncardiac surgery and had creatinine recorded preoperatively and postoperatively. Our exposure was the lowest postoperative mean arterial pressure, defined as the average of the three lowest postoperative pressure measurements. Our primary analysis was the association between the lowest mean arterial pressure and acute kidney injury, defined according to Kidney Disease: Improving Global Outcomes initiative criteria. Our analysis was adjusted for potentially relevant confounding factors including intraoperative hypotension. RESULTS Among 64,349 patients analyzed, 2,812 (4.4%) patients had postoperative acute kidney injury. Each 5-mm Hg decrease in the lowest mean arterial pressure was associated with a 28% (97.5% confidence interval [CI], 23 to 32; P < 0.001) increase in the odds of acute kidney injury for lowest mean arterial pressures < 80 mm Hg. Higher lowest pressures were not associated with acute kidney injury (odds ratio, 1.08; 97.5% CI, 0.99 to 1.17; P = 0.04) for each 5-mm Hg decrease in the lowest mean arterial pressure. CONCLUSION Postoperative hypotension, defined as the lowest postoperative mean arterial pressure < 80 mm Hg, was associated with acute kidney injury after noncardiac surgery. A prospective trial will be required to determine whether the observed association is causal and thus amenable to modification.
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Affiliation(s)
- Tetsuya Shimada
- Department of Anesthesiology, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan
- Department of Anesthesiology, National Defense Medical College, Tokorozawa, Saitama, Japan
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Xuan Pu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Esra Kutlu Yalcin
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Barak Cohen
- Outcomes Research Consortium, Cleveland, OH, USA
- Division of Anesthesia, Intensive Care and Pain, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Mauro Bravo
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Edward J Mascha
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
- Department of Outcomes Research, Cleveland Clinic, 9500 Euclid Ave. - L1-407, Cleveland, OH, 44195, USA.
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27
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Conen D, Ke Wang M, Popova E, Chan MTV, Landoni G, Cata JP, Reimer C, McLean SR, Srinathan SK, Reyes JCT, Grande AM, Tallada AG, Sessler DI, Fleischmann E, Kabon B, Voltolini L, Cruz P, Maziak DE, Gutiérrez-Soriano L, McIntyre WF, Tandon V, Martínez-Téllez E, Guerra-Londono JJ, DuMerton D, Wong RHL, McGuire AL, Kidane B, Roux DP, Shargall Y, Wells JR, Ofori SN, Vincent J, Xu L, Li Z, Eikelboom JW, Jolly SS, Healey JS, Devereaux PJ. Effect of colchicine on perioperative atrial fibrillation and myocardial injury after non-cardiac surgery in patients undergoing major thoracic surgery (COP-AF): an international randomised trial. Lancet 2023; 402:1627-1635. [PMID: 37640035 DOI: 10.1016/s0140-6736(23)01689-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/06/2023] [Accepted: 08/11/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Higher levels of inflammatory biomarkers are associated with an increased risk of perioperative atrial fibrillation and myocardial injury after non-cardiac surgery (MINS). Colchicine is an anti-inflammatory drug that might reduce the incidence of these complications. METHODS COP-AF was a randomised trial conducted at 45 sites in 11 countries. Patients aged 55 years or older and undergoing major non-cardiac thoracic surgery were randomly assigned (1:1) to receive oral colchicine 0·5 mg twice daily or matching placebo, starting within 4 h before surgery and continuing for 10 days. Randomisation was done with use of a computerised, web-based system, and was stratified by centre. Health-care providers, patients, data collectors, and adjudicators were masked to treatment assignment. The coprimary outcomes were clinically important perioperative atrial fibrillation and MINS during 14 days of follow-up. The main safety outcomes were a composite of sepsis or infection, and non-infectious diarrhoea. The intention-to-treat principle was used for all analyses. This trial is registered with ClinicalTrials.gov, NCT03310125. FINDINGS Between Feb 14, 2018, and June 27, 2023, we enrolled 3209 patients (mean age 68 years [SD 7], 1656 [51·6%] male). Clinically important atrial fibrillation occurred in 103 (6·4%) of 1608 patients assigned to colchicine, and 120 (7·5%) of 1601 patients assigned to placebo (hazard ratio [HR] 0·85, 95% CI 0·65 to 1·10; absolute risk reduction [ARR] 1·1%, 95% CI -0·7 to 2·8; p=0·22). MINS occurred in 295 (18·3%) patients assigned to colchicine and 325 (20·3%) patients assigned to placebo (HR 0·89, 0·76 to 1·05; ARR 2·0%, -0·8 to 4·7; p=0·16). The composite outcome of sepsis or infection occurred in 103 (6·4%) patients in the colchicine group and 83 (5·2%) patients in the placebo group (HR 1·24, 0·93-1·66). Non-infectious diarrhoea was more common in the colchicine group (134 [8·3%] events) than the placebo group (38 [2·4%]; HR 3·64, 2·54-5·22). INTERPRETATION In patients undergoing major non-cardiac thoracic surgery, administration of colchicine did not significantly reduce the incidence of clinically important atrial fibrillation or MINS but increased the risk of mostly benign non-infectious diarrhoea. FUNDING Canadian Institutes of Health Research, Accelerating Clinical Trials Consortium, Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario, Population Health Research Institute, Hamilton Health Sciences, Division of Cardiology at McMaster University, Canada; Hanela Foundation, Switzerland; and General Research Fund, Research Grants Council, Hong Kong.
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Affiliation(s)
- David Conen
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Michael Ke Wang
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ekaterine Popova
- Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain; Centro Cochrane Iberoamericano, Barcelona, Spain
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute University San Raffaele, Milan, Italy
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cara Reimer
- Department of Anesthesiology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Sean R McLean
- Vancouver Acute Department of Anesthesia and Perioperative Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | | | | | | | | | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Luca Voltolini
- Thoracic Surgery Unit, University Hospital Careggi, Florence, Italy
| | - Patrícia Cruz
- Service of Anesthesiology and Reanimation, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Donna E Maziak
- Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Laura Gutiérrez-Soriano
- Anesthesiology Department, Anesthesiology Research Group, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - William F McIntyre
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Juan Jose Guerra-Londono
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Anna L McGuire
- Division of Thoracic Surgery, Vancouver General Hospital, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Biniam Kidane
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | | | - Yaron Shargall
- Division of Thoracic Surgery, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Sandra N Ofori
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Lizhen Xu
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zhuoru Li
- Population Health Research Institute, Hamilton, ON, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Pappas MA, Auerbach AD, Kattan MW, Blackstone EH, Rothberg MB, Sessler DI. Consequences of preoperative cardiac stress testing-A cohort study. J Clin Anesth 2023; 90:111158. [PMID: 37418830 PMCID: PMC10530324 DOI: 10.1016/j.jclinane.2023.111158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE To understand the consequences of functional cardiac stress testing among patients considering noncardiac nonophthalmologic surgery. DESIGN A retrospective cohort study of 118,552 patients who made 159,795 visits to a dedicated preoperative risk assessment and optimization clinic between 2008 and 2018. SETTING A large integrated health system. PATIENTS Patients who visited a dedicated preoperative risk assessment and optimization clinic before noncardiac nonophthalmologic surgery. MEASUREMENTS To assess changes to care delivered, we measured the probability of completing additional cardiac testing, cardiac surgery, or noncardiac surgery. To assess outcomes, we measured time-to-mortality and total one-year mortality. MAIN RESULTS In causal inference models, preoperative stress testing was associated with increased likelihood of coronary angiography (relative risk: 8.6, 95% CI 6.1-12.1), increased likelihood of percutaneous coronary intervention (RR: 4.1, 95% CI: 1.8-9.2), increased likelihood of cardiac surgery (RR: 6.8, 95% CI 4.9-9.4), decreased likelihood of noncardiac surgery (RR: 0.77, 95% CI 0.75-0.79), and delayed noncardiac surgery for patients completing noncardiac surgery (mean 28.3 days, 95% CI: 23.1-33.6). The base rate of downstream cardiac testing was low, and absolute risk increases were small. Stress testing was associated with higher mortality in unadjusted analysis but was not associated with mortality in causal inference analyses. CONCLUSIONS Preoperative cardiac stress testing likely induces coronary angiography and cardiac interventions while decreasing use of noncardiac surgery and delaying surgery for patients who ultimately proceed to noncardiac surgery. Despite changes to processes of care, our results do not support a causal relationship between stress testing and postoperative mortality. Analyses of care cascades should consider care that is avoided or substituted in addition to care that is induced.
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Affiliation(s)
- Matthew A Pappas
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, United States of America; Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America.
| | - Andrew D Auerbach
- Department of Hospital Medicine, University of California, San Francisco, CA, United States of America
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Eugene H Blackstone
- Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Michael B Rothberg
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, United States of America
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, United States of America; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
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Pappas MA, Auerbach AD, Kattan MW, Blackstone EH, Rothberg MB, Sessler DI. Diagnostic and prognostic value of cardiac stress testing before major noncardiac surgery-A cohort study. J Clin Anesth 2023; 90:111193. [PMID: 37441833 PMCID: PMC10529226 DOI: 10.1016/j.jclinane.2023.111193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/16/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE To assess the incremental contribution of preoperative stress test results toward a diagnosis of obstructive coronary artery disease (CAD), prediction of mortality, or prediction of perioperative myocardial infarction in patients considering noncardiac, nonophthalmologic surgery. DESIGN, SETTING, PARTICIPANTS A retrospective cohort study of visits to a preoperative risk assessment and optimization clinic in a large health system between 2008 and 2018. MEASUREMENTS To assess diagnostic information of preoperative stress testing, we used the Begg and Greenes method to calculate test characteristics adjusted for referral bias, with a gold standard of angiography. To assess prognostic information, we first created multiply-imputed logistic regression models to predict 90-day mortality and perioperative myocardial infarction (MI), starting with two tools commonly used to assess perioperative cardiac risk, Revised Cardiac Risk Index (RCRI) and Myocardial Infarction or Cardiac Arrest (MICA). We then added stress test results and compared the discrimination for models with and without stress test results. MAIN RESULTS Among 136,935 visits by patients without an existing diagnosis of CAD, the decision to obtain preoperative stress testing identified around 4.0% of likely new diagnoses. Stress testing increased the likelihood of CAD (likelihood ratio: 1.31), but for over 99% of patients, stress testing should not change a decision on whether to proceed to angiography. In 117,445 visits with subsequent noncardiac surgery, stress test results failed to improve predictions of either perioperative MI or 90-day mortality. Reweighting the models and adding hemoglobin improved the prediction of both outcomes. CONCLUSIONS Cardiac stress testing before noncardiac, nonophthalmologic surgery does not improve predictions of either perioperative mortality or myocardial infarction. Very few patients considering noncardiac, nonophthalmologic surgery have a pretest probability of CAD in a range where stress testing could usefully select patients for angiography. Better use of existing patient data could improve predictions of perioperative adverse events without additional patient testing.
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Affiliation(s)
- Matthew A Pappas
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, United States of America; Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America.
| | - Andrew D Auerbach
- Department of Hospital Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Eugene H Blackstone
- Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Michael B Rothberg
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, United States of America
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, United States of America; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
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Alfirevic A, Sessler DI, Pu X, Turan A. Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair. Response to Br J Anaesth 2023; 131:e126-7. Br J Anaesth 2023; 131:e155-e156. [PMID: 37690944 DOI: 10.1016/j.bja.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Affiliation(s)
- Andrej Alfirevic
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Xuan Pu
- 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 Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
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Rivas E, López-Baamonde M, Sanahuja J, Del Rio E, Ramis T, Recasens A, López A, Arias M, Kampakis S, Lauteslager T, Awara O, Mascha EJ, Soriano A, Badía JR, Castro P, Sessler DI. Early detection of deterioration in COVID-19 patients by continuous ward respiratory rate monitoring: a pilot prospective cohort study. Front Med (Lausanne) 2023; 10:1243050. [PMID: 38020176 PMCID: PMC10645134 DOI: 10.3389/fmed.2023.1243050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Background Tachypnea is among the earliest signs of pulmonary decompensation. Contactless continuous respiratory rate monitoring might be useful in isolated COVID-19 patients admitted in wards. We therefore aimed to determine whether continuous monitoring of respiratory patterns in hospitalized patients with COVID-19 predicts subsequent need for increased respiratory support. Methods Single-center pilot prospective cohort study in COVID-19 patients who were cared for in routine wards. COVID-19 patients who had at least one escalation of pulmonary management were matched to three non-escalated patients. Contactless respiratory monitoring was instituted after patients enrolled, and continued for 15 days unless hospital discharge, initiation of invasive mechanical ventilation, or death occurred. Clinicians were blinded to respiratory rate data from the continuous monitor. The exposures were respiratory features over rolling periods of 30 min, 24 h, and 72 h before respiratory care escalation. The primary outcome was a subsequent escalation in ventilatory support beyond a Venturi mask. Results Among 125 included patients, 13 exhibited at least one escalation and were each matched to three non-escalated patients. A total of 28 escalation events were matched to 84 non-escalation episodes. The 30-min mean respiratory rate in escalated patients was 23 breaths per minute (bpm) ranging from 13 to 40 bpm, similar to the 22 bpm in non-escalated patients, although with less variability (range 14 to 31 bpm). However, higher respiratory rate variability, especially skewness over 1 day, was associated with higher incidence of escalation events. Our overall model, based on continuous data, had a moderate accuracy with an AUC 0.81 (95%CI: 0.73, 0.88) and a good specificity 0.93 (95%CI: 0.87, 0.99). Conclusion Our pilot observational study suggests that respiratory rate variability as detected with continuous monitoring is associated with subsequent care escalation during the following 24 h. Continuous respiratory monitoring thus appears to be a valuable increment over intermittent monitoring. Strengths and limitations Our study was the initial evaluation of Circadia contactless respiratory monitoring in COVID-19 patients who are at special risk of pulmonary deterioration. The major limitation is that the analysis was largely post hoc and thus needs to be confirmed in an out-of-sample population.
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Affiliation(s)
- Eva Rivas
- Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, United States
| | - Manuel López-Baamonde
- Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Josep Sanahuja
- Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Elena Del Rio
- Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Tomeu Ramis
- Department of Anesthesiology and Critical Care, Hosptial Universitary Son Espases, Mallorca, Spain
| | - Anna Recasens
- Department of Anesthesiology, Hospital del Mar. Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio López
- Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Marilyn Arias
- Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | | | | | - Osama Awara
- Circadia Technologies, Ltd., London, United Kingdom
| | - Edward J. Mascha
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, United States
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Alex Soriano
- Department of Infectious Disease, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, CIBERINF, Barcelona, Spain
| | - Joan Ramon Badía
- Department of Pneumology, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Daniel I. Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, United States
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de Jonge SW, Hulskes RH, Zokaei Nikoo M, Weenink RP, Meyhoff CS, Leslie K, Myles P, Forbes A, Greif R, Akca O, Kurz A, Sessler DI, Martin J, Dijkgraaf MG, Pryor K, Belda FJ, Ferrando C, Gurman GM, Scifres CM, McKenna DS, Chan MT, Thibon P, Mellin-Olsen J, Allegranzi B, Boermeester M, Hollmann MW. Benefits and harms of perioperative high fraction inspired oxygen for surgical site infection prevention: a protocol for a systematic review and meta-analysis of individual patient data of randomised controlled trials. BMJ Open 2023; 13:e067243. [PMID: 37899157 PMCID: PMC10619062 DOI: 10.1136/bmjopen-2022-067243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 07/27/2023] [Indexed: 10/31/2023] Open
Abstract
INTRODUCTION The use of high fraction of inspired oxygen (FiO2) intraoperatively for the prevention of surgical site infection (SSI) remains controversial. Promising results of early randomised controlled trials (RCT) have been replicated with varying success and subsequent meta-analysis are equivocal. Recent advancements in perioperative care, including the increased use of laparoscopic surgery and pneumoperitoneum and shifts in fluid and temperature management, can affect peripheral oxygen delivery and may explain the inconsistency in reproducibility. However, the published data provides insufficient detail on the participant level to test these hypotheses. The purpose of this individual participant data meta-analysis is to assess the described benefits and harms of intraoperative high FiO2compared with regular (0.21-0.40) FiO2 and its potential effect modifiers. METHODS AND ANALYSIS Two reviewers will search medical databases and online trial registries, including MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and WHO regional databases, for randomised and quasi-RCT comparing the effect of intraoperative high FiO2 (0.60-1.00) to regular FiO2 (0.21-0.40) on SSI within 90 days after surgery in adult patients. Secondary outcome will be all-cause mortality within the longest available follow-up. Investigators of the identified trials will be invited to collaborate. Data will be analysed with the one-step approach using the generalised linear mixed model framework and the statistical model appropriate for the type of outcome being analysed (logistic and cox regression, respectively), with a random treatment effect term to account for the clustering of patients within studies. The bias will be assessed using the Cochrane risk-of-bias tool for randomised trials V.2 and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation methodology. Prespecified subgroup analyses include use of mechanical ventilation, nitrous oxide, preoperative antibiotic prophylaxis, temperature (<35°C), fluid supplementation (<15 mL/kg/hour) and procedure duration (>2.5 hour). ETHICS AND DISSEMINATION Ethics approval is not required. Investigators will deidentify individual participant data before it is shared. The results will be submitted to a peer-review journal. PROSPERO REGISTRATION NUMBER CRD42018090261.
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Affiliation(s)
- Stijn W de Jonge
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Rick H Hulskes
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Robert P Weenink
- Department of Anaesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Kate Leslie
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Paul Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Andrew Forbes
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ozan Akca
- Department of Anaesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Andrea Kurz
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anaesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anaesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Janet Martin
- Department of Anaesthesiology and Perioperative Medicine, and Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Marcel Gw Dijkgraaf
- Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Kane Pryor
- Department of Anaesthesiology, Weil Medical College of Cornell University, New York City, New York, USA
| | - F Javier Belda
- Department of Surgery, Hospital Clinico Universitario de Valencia, Valencia, Valenciana, Spain
- Department of Anaesthesia and Critical Care, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Carlos Ferrando
- Department of Anaesthesiology and Critical Care, Hospital Clínic de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Gabriel M Gurman
- Department of Anaesthesiology and Critical Care Medicine, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Christina M Scifres
- Department of Obstetrics and Gynaecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - David S McKenna
- Department of Obstetrics and Gynaecology, Wright State University and Miami Valley Hospital, Dayton, Ohio, USA
| | - Matthew Tv Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Pascal Thibon
- Centre d'appui pour la Prévention des Infections Associées aux Soins, CPias Normandie, Centre Hospitalo-Universitaire, Caen, Normandy, France
| | | | | | - Marja Boermeester
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
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Hale J, Xu J, Wang D, Rodriguez-Patarroyo F, Bakal O, Kopac O, Yamak Altinpulluk E, Onal O, Brooker JE, Cruz M, Maurtua M, Agudelo-Jimenez R, Sessler DI, Turan A. Nitrous oxide for the treatment of complex regional pain syndrome: a randomized blinded trial. Reg Anesth Pain Med 2023:rapm-2023-104537. [PMID: 37898481 PMCID: PMC11055939 DOI: 10.1136/rapm-2023-104537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/02/2023] [Indexed: 10/30/2023]
Abstract
INTRODUCTION Complex Regional Pain Syndrome (CRPS) is a debilitating neuropathic condition often refractory to conventional treatments. N-methyl-D-aspartate (NMDA) receptor antagonists have a well-established role in the development and modulation of chronic neuropathic pain. Nitrous oxide is widely used and generally safe anesthetic gas with NMDA receptor antagonist activity. We therefore tested the hypothesis that brief periods of nitrous oxide exposure reduce pain in patients with CRPS. METHODS Patients with a diagnosis of CRPS were randomized to either 2 hours of nitrous oxide exposure on three alternating days (Nitrous Oxide) versus a placebo air/oxygen mixture (Air-Oxygen). Our primary outcome was patient-reported pain scores at 1 week and 1 month. Secondary and exploratory outcomes were physical and mental health (PRMOIS-29 v2 survey), specific neuropathic pain symptoms (McGill short-form questionnaire), and opioid consumption. RESULTS 44 patients participated in the study; 20 were randomized to Nitrous Oxide and 24 were assigned to Air-Oxygen. Pain scores did not differ significantly, with the estimated difference in means (Nitrous Oxide-Air-Oxygen) of -0.57 (95% CI: -1.42 to 0.28) points, p=0.19. There were also no differences detected in secondary outcomes, with the estimated difference in mean Z-scores for physical health (Nitrous Oxide-Air-Oxygen) of 0.13 (95% CI: -0.16 to 0.43), mental health 0.087 (95% CI: -0.31 to 0.48), and Patient Global Impression of Change score -0.7 (95% CI: -1.85 to 0.46). CONCLUSIONS Compared with air/oxygen, 2 hours of nitrous oxide/oxygen exposure for three sessions did not provide meaningful therapeutic potential for patients with chronic CRPS. Our results do not support using nitrous oxide for the treatment of CRPS.
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Affiliation(s)
- Jason Hale
- Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jijun Xu
- Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dong Wang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Omer Bakal
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Orkun Kopac
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Ozkan Onal
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesiology and Reanimation, Selcuk Universitesi, Konya, Turkey
| | - Jack E Brooker
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Miguel Cruz
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marco Maurtua
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ruben Agudelo-Jimenez
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
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Khanna AK, O'Connell NS, Ahuja S, Saha AK, Harris L, Cusson BD, Faris A, Huffman CS, Vallabhajosyula S, Clark CJ, Segal S, Wells BJ, Kirkendall ES, Sessler DI. Incidence, severity and detection of blood pressure and heart rate perturbations in postoperative ward patients after noncardiac surgery. J Clin Anesth 2023; 89:111159. [PMID: 37295123 DOI: 10.1016/j.jclinane.2023.111159] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/22/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023]
Abstract
STUDY OBJECTIVE We sought to determine changes in continuous mean and systolic blood pressure and heart rate in a cohort of non-cardiac surgical patients recovering on the postoperative ward. Furthermore, we estimated the proportion of vital signs changes that would remain undetected with intermittent vital signs checks. DESIGN Retrospective cohort. SETTING Post-operative general ward. PATIENTS 14,623 adults recovering from non-cardiac surgical procedures. INTERVENTIONS & MEASUREMENTS Using a wireless, noninvasive monitor, we recorded postoperative blood pressure and heart rate at 15-s intervals and encouraged nursing intervention as clinically indicated. MAIN RESULTS 7% of our cohort of 14,623 patients spent >15 sustained minutes with a MAP <65 mmHg, and 23% had MAP <75 mmHg for 15 sustained minutes. Hypertension was more common, with 67% of patients spending at least 60 sustained minutes with MAP >110 mmHg. Systolic pressures <90 mmHg were present for 15 sustained minutes in about a fifth of all patients, and 40% of patients had pressures >160 mmHg sustained for 30 min. 40% of patients were tachycardic with heart rates >100 beats/min for at least continuous 15 min and 15% of patients were bradycardic at a threshold of <50 beats/min for 5 sustained minutes. Conventional vital sign assessments at 4-h intervals would have missed 54% of mean pressure episodes <65 mmHg sustained >15 min, 20% of episodes of mean pressures >130 mmHg sustained >30 min, 36% of episodes of heart rate > 120 beats/min sustained <10 min, and 68% of episodes of heart rate sustained <40 beats per minute for >3 min. CONCLUSIONS Substantial hemodynamic disturbances persisted despite implementing continuous portable ward monitoring coupled with nursing alarms and interventions. A significant proportion of these changes would have gone undetected using traditional intermittent monitoring. Better understanding of effective responses to alarms and appropriate interventions on hospital wards remains necessary.
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Affiliation(s)
- 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.
| | - Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Sanchit Ahuja
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH and Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, 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.
| | - Lynnette Harris
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Bruce D Cusson
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Ann Faris
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Center for Nursing Research, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA.
| | - Carolyn S Huffman
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Center for Nursing Research, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA.
| | - Saraschandra Vallabhajosyula
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Clancy J Clark
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Scott Segal
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Brian J Wells
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Center for Biomedical Informatics, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Eric S Kirkendall
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Center for Healthcare Innovation, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
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Kubulus C, Mahlstedt S, Wagenpfeil G, Sessler DI, Volk T. Chronic pain patients and time to sustained acceptable pain scores after major surgery - A retrospective registry analysis. J Clin Anesth 2023; 89:111152. [PMID: 37244111 DOI: 10.1016/j.jclinane.2023.111152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/04/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
STUDY OBJECTIVE We tested the hypothesis that pre-existing chronic pain is associated with prolonged time to reach sustained acceptable pain scores after major surgery. DESIGN Retrospective study using the German Network for Safety in Regional Anaesthesia and Acute Pain Therapy registry. SETTING Operating rooms and surgical wards. PATIENTS 107,412 patients recovering from major surgery who were cared for by an acute pain service. 3.3% of the treatments were in patients who reported chronic pain with functional or psychological impairment. INTERVENTIONS AND MEASUREMENT We compared time to sustained adequacy of postoperative pain control defined by numeric rating scores <4 at rest and with movement in patients with and without chronic pain using an adjusted cox proportional hazard regression model and Kaplan-Meier analysis. The observation period was censored at 10 days and propensity score matching was used as a sensitivity analysis. MAIN RESULTS Postoperative pain at rest took significantly longer to resolve in patients with chronic pain than in those without (adjusted hazard ratio HR 1.42, 95% CI 1.36-1.49, P < 0.001). Postoperative pain with movement took even longer to resolve in patients with chronic pain (adjusted HR 1.65, 95%CI 1.56-1.75, P < 0.001). CONCLUSIONS Patients with chronic pain sustain more surgical pain than those without, and the pain takes longer to resolve. Clinicians providing postoperative pain management should consider the special needs of chronic pain patients.
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Affiliation(s)
- Christine Kubulus
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany.
| | - Silja Mahlstedt
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Gudrun Wagenpfeil
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Saarland University Faculty of Medicine, Homburg, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
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Ruetzler K, Montalvo M, Rotem OM, Ekrami E, Rössler J, Duran JAA, Dahan A, Gozal Y, Richebe P, Farhang B, Turan A, Sessler DI. Generalizability of nociception level as a measure of intraoperative nociceptive stimulation: A retrospective analysis. Acta Anaesthesiol Scand 2023; 67:1187-1193. [PMID: 37317549 DOI: 10.1111/aas.14286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Nociception-guided intraoperative opioid administration might help reduce postoperative pain. A commonly used and validated nociception monitor system is nociception level (NOL), which provides the nociception index, ranging from 0 to 100, with 0 representing no nociception and 100 representing extreme nociception. We tested the hypothesis that NOL responses are similar in men and women given remifentanil and fentanyl, across various types of anesthesia, as a function of American Society of Anesthesiologists physical status designations, and over a range of ages and body morphologies. METHODS We conducted a retrospective cohort analysis of trial data from eight prospective NOL validation studies. Among 522 noncardiac surgical patients enrolled in these studies, 447 were included in our analysis. We assessed NOL responses to various noxious and non-noxious stimuli. RESULTS The average NOL in response to 315 noxious stimuli was 47 ± 15 (95% CI = 45-49). The average NOL in response to 361 non-noxious stimuli was 10 ± 12 (95% CI = 9-11). NOL responses were similar in men and women, in patients given remifentanil and fentanyl, across various types of anesthesia, as a function of American Society of Anesthesiologists physical status designations, and over a range of ages and body morphologies. CONCLUSION Nociception level appears to provide accurate estimates of intraoperative nociception over a broad range of patients and anesthetic conditions.
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Affiliation(s)
- Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mateo Montalvo
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Elyad Ekrami
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yaacov Gozal
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Medical Center, Jerusalem, Israel
| | - Philippe Richebe
- Département d'Anesthésiologie et Médecine de la Douleur, Université de Montréal, Montréal, Canada
| | - Borzoo Farhang
- University of Vermont Medical Center, Larner College of Medicine, Department of Anesthesiology, Burlington, Vermont, USA
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Fishman G, Ram E, Gorfil D, Kassif Y, David R, Hershko T, Malbrain MLNG, Singer P, Sessler DI. Early detection of oliguric events in critically ill patients in the ICU with a novel continuous urine flow measurement device: results of an initial validation study. J Clin Monit Comput 2023; 37:1341-1349. [PMID: 37027058 PMCID: PMC10080177 DOI: 10.1007/s10877-023-00991-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/26/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVES Urine output is used to evaluate fluid status and is an important marker for acute kidney injury (AKI). Our primary aim was to validate a new automatic urine output monitoring device by comparison to the current practice - the standard urometer. METHODS We conducted a prospective observational study in three ICUs. Urine flow measurements by Serenno Medical Automatic urine output measuring device (Serenno Medical, Yokneam, Israel) were compared to standard urometer readings taken automatically at 5-minutes intervals by a camera, and to hourly urometer readings by the nurses, both over 1 to 7 days. Our primary outcome was the difference between urine flow assessed by the Serenno device and reference camera-derived measurements (Camera). Our secondary outcome was the difference between urine flow assessed by the Serenno device and hourly nursing assessments (Nurse), and detection of oliguria. RESULTS Thirty-seven patients completed the study, with 1,306 h of recording and a median of 25 measurement hours per patient. Bland and Altman analysis comparing the study device to camera measurements demonstrated good agreement, with a bias of -0.4 ml/h and 95% confidence intervals ranging from - 28 to 27ml/h. Concordance was 92%. The correlation between Camera and hourly nursing assessment of urine output was distinctly worse with a bias of 7.2 ml and limits of agreement extending from - 75 to + 107 ml. Severe oliguria (urine output < 0.3 ml/kg/h) lasting 2 h or more was common and observed in 8 (21%) of patients. Among the severe oliguric events lasting more than 3 consecutive hours, 6 (41%) were not detected or documented by the nursing staff. There were no device-related complications. CONCLUSION The Serenno Medical Automatic urine output measuring device required minimal supervision, little ICU nursing staff attention, and is sufficiently accurate and precise. In addition to providing continuous assessments of urine output, it was considerably more accurate than hourly nursing assessments.
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Affiliation(s)
- Guy Fishman
- Department of General Intensive Care, Rabin Medical Center, campus Beilinson, Petah, Tikva, Israel
| | - Eilon Ram
- Department of Cardiac Surgery, Leviev cardiothoracic and vascular center, Sackler School of Medicine, Sheba Medical Center at Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Dan Gorfil
- Cardiothoracic Surgery Department, Rabin Medical Center, campus Beilinson, Petah, Tikva, Israel
| | - Yigal Kassif
- Department of Cardiac Surgery, Leviev cardiothoracic and vascular center, Sackler School of Medicine, Sheba Medical Center at Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Rachel David
- Department of General Intensive Care, Rabin Medical Center, campus Beilinson, Petah, Tikva, Israel
| | - Tzlil Hershko
- Adelson School of Medicine at Ariel University, Samaria, Israel
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Jaczewskiego street 8, Lublin, 20-954, Poland
- International Fluid Academy, Dreef 3, Lovenjoel, 3360, Belgium
| | - Pierre Singer
- Department of General Intensive Care, Rabin Medical Center, campus Beilinson, Petah, Tikva, Israel
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, 9500 Euclid Ave L1-407, Cleveland, OH, 44195, USA
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Coeckelenbergh S, Sessler DI, Doria S, Patricio D, Jaubert L, Huybrechts I, Stefanidis C, Kapessidou P, Tuna T, Engelman E, Barvais L, Perrin L. Nociception level index-guided antinociception versus routine care during remifentanil-propofol anaesthesia for moderate-to-high risk cardiovascular surgery: A randomized trial. Eur J Anaesthesiol 2023; 40:790-793. [PMID: 37497778 DOI: 10.1097/eja.0000000000001892] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Affiliation(s)
- Sean Coeckelenbergh
- From the Department of Anaesthesia and Resuscitation, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (SC, SD, DP, LJ, IH, TT, EE, LB, LP), Department of Anaesthesiology and Intensive Care, Paul Brousse Hospital - Hepatobiliary Centre, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France (SC), Outcomes Research Consortium, Cleveland, OH, United States (SC, DIS), Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States (DIS), Department of Cardiac Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (CS), Department of Anaesthesiology, Saint Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium (PK), EW Data Analysis, Brussels, Belgium (EE)
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Kouz K, Weidemann F, Naebian A, Lohr A, Bergholz A, Thomsen KK, Krause L, Petzoldt M, Moll-Khosrawi P, Sessler DI, Flick M, Saugel B. Continuous Finger-cuff versus Intermittent Oscillometric Arterial Pressure Monitoring and Hypotension during Induction of Anesthesia and Noncardiac Surgery: The DETECT Randomized Trial. Anesthesiology 2023; 139:298-308. [PMID: 37265355 DOI: 10.1097/aln.0000000000004629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Finger-cuff methods allow noninvasive continuous arterial pressure monitoring. This study aimed to determine whether continuous finger-cuff arterial pressure monitoring helps clinicians reduce hypotension within 15 min after starting induction of anesthesia and during noncardiac surgery. Specifically, this study tested the hypotheses that continuous finger-cuff-compared to intermittent oscillometric-arterial pressure monitoring helps clinicians reduce the area under a mean arterial pressure of 65 mmHg within 15 min after starting induction of anesthesia and the time-weighted average mean arterial pressure less than 65 mmHg during noncardiac surgery. METHODS In this single-center trial, 242 noncardiac surgery patients were randomized to unblinded continuous finger-cuff arterial pressure monitoring or to intermittent oscillometric arterial pressure monitoring (with blinded continuous finger-cuff arterial pressure monitoring). The first of two hierarchical primary endpoints was the area under a mean arterial pressure of 65 mmHg within 15 min after starting induction of anesthesia; the second primary endpoint was the time-weighted average mean arterial pressure less than 65 mmHg during surgery. RESULTS Within 15 min after starting induction of anesthesia, the median (interquartile range) area under a mean arterial pressure of 65 mmHg was 7 (0, 24) mmHg × min in 109 patients assigned to continuous finger-cuff monitoring versus 19 (0.3, 60) mmHg × min in 113 patients assigned to intermittent oscillometric monitoring (P = 0.004; estimated location shift: -6 [95% CI: -15 to -0.3] mmHg × min). During surgery, the median (interquartile range) time-weighted average mean arterial pressure less than 65 mmHg was 0.04 (0, 0.27) mmHg in 112 patients assigned to continuous finger-cuff monitoring and 0.40 (0.03, 1.74) mmHg in 115 patients assigned to intermittent oscillometric monitoring (P < 0.001; estimated location shift: -0.17 [95% CI: -0.41 to -0.05] mmHg). CONCLUSIONS Continuous finger-cuff arterial pressure monitoring helps clinicians reduce hypotension within 15 min after starting induction of anesthesia and during noncardiac surgery compared to intermittent oscillometric arterial pressure monitoring. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Weidemann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ashkan Naebian
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anneke Lohr
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Parisa Moll-Khosrawi
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; and Outcomes Research Consortium, Cleveland, Ohio
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Outcomes Research Consortium, Cleveland, Ohio
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O'Brien K, Feng R, Sieber F, Marcantonio ER, Tierney A, Magaziner J, Carson JL, Dillane D, Sessler DI, Menio D, Ayad S, Stone T, Papp S, Schwenk ES, Marshall M, Jaffe JD, Luke C, Sharma B, Azim S, Hymes R, Chin KJ, Sheppard R, Perlman B, Sappenfield J, Hauck E, Hoeft MA, Karlawish J, Mehta S, Donegan DJ, Horan A, Ellenberg SS, Neuman MD. Outcomes with spinal versus general anesthesia for patients with and without preoperative cognitive impairment: Secondary analysis of a randomized clinical trial. Alzheimers Dement 2023; 19:4008-4019. [PMID: 37170754 DOI: 10.1002/alz.13132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/14/2023] [Accepted: 02/25/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION The effect of spinal versus general anesthesia on the risk of postoperative delirium or other outcomes for patients with or without cognitive impairment (including dementia) is unknown. METHODS Post hoc secondary analysis of a multicenter pragmatic trial comparing spinal versus general anesthesia for adults aged 50 years or older undergoing hip fracture surgery. RESULTS Among patients randomized to spinal versus general anesthesia, new or worsened delirium occurred in 100/295 (33.9%) versus 107/283 (37.8%; odds ratio [OR] 0.85; 95% confidence interval [CI] 0.60 to 1.19) among persons with cognitive impairment and 70/432 (16.2%) versus 71/445 (16.0%) among persons without cognitive impairment (OR 1.02; 95% CI 0.71 to 1.47, p = 0.46 for interaction). Delirium severity, in-hospital complications, and 60-day functional recovery did not differ by anesthesia type in patients with or without cognitive impairment. DISCUSSION Anesthesia type is not associated with differences in delirium and functional outcomes among persons with or without cognitive impairment.
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Affiliation(s)
- Kyra O'Brien
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rui Feng
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Frederick Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts, USA
| | - Ann Tierney
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Derek Dillane
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Diane Menio
- Center for Advocacy for the Rights and Interests of the Elderly, Philadelphia, Pennsylvania, USA
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Trevor Stone
- Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Steven Papp
- Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa, Canada
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mitchell Marshall
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York, USA
| | - J Douglas Jaffe
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Charles Luke
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Balram Sharma
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Syed Azim
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York, USA
| | - Robert Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Ki-Jinn Chin
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Richard Sheppard
- Department of Anesthesiology, Hartford Hospital, Hartford, Connecticut, USA
| | - Barry Perlman
- Department of Internal Medicine, Peacehealth Medical Group, Springfield, Oregon, USA
| | - Joshua Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ellen Hauck
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Mark A Hoeft
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Jason Karlawish
- Department of Internal Medicine, Division of Geriatric Medicine, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Samir Mehta
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Derek J Donegan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Annamarie Horan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mark D Neuman
- Department of Internal Medicine, Division of Geriatric Medicine, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Ilfeld BM, Khatibi B, Maheshwari K, Madison S, Ali Sakr Esa W, Mariano ER, Kent M, Hanling S, Sessler DI, Eisenach JC, Cohen SP, Mascha E, Li S, Turan A. Patient-centered results from a multicenter study of continuous peripheral nerve blocks and postamputation phantom and residual limb pain: secondary outcomes from a randomized, clinical trial. Reg Anesth Pain Med 2023; 48:471-477. [PMID: 36894197 PMCID: PMC10423523 DOI: 10.1136/rapm-2023-104389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023]
Abstract
INTRODUCTION We previously reported that a 6-day continuous peripheral nerve block reduces established postamputation phantom pain. To provide patients and providers with the information to best inform treatment decisions, here we reanalyze the data and present the results in a more patient-centered format. We also provide information on patient-defined clinically relevant benefits to facilitate evaluation of available studies and guide future trial design. METHODS The original trial enrolled participants with a limb amputation and phantom pain who were randomized to receive a 6-day continuous peripheral nerve block(s) of either ropivacaine (n=71) or saline (n=73) in a double-masked fashion. Here we calculate the percentage of each treatment group that experienced a clinically relevant improvement as defined by previous studies as well as present what the participants of our study defined as small, medium, and large analgesic improvements using the 7-point ordinal Patient Global Impression of Change scale. RESULTS Among patients who were given a 6-day ropivacaine infusion, 57% experienced at least a 2-point improvement on the 11-point numeric rating scale in their average and worst phantom pain 4 weeks postbaseline as compared with 26% (p<0.001) for average and 25% (p<0.001) for worst pain in patients given a placebo infusion. At 4 weeks, the percentage of participants rating their pain as improved was 53% for the active vs 30% for the placebo groups (95% CI 1.7 (1.1, 2.7), p=0.008). For all patients combined, the median (IQR) phantom pain Numeric Rating Scale improvements at 4 weeks considered small, medium, and large were 2 (0-2), 3 (2-5), and 5 (3-7), respectively. The median improvements in the Brief Pain Inventory interference subscale (0-70) associated with small, medium, and large analgesic changes were 8 (1-18), 22 (14-31), and 39 (26-47). CONCLUSIONS Among patients with postamputation phantom pain, a continuous peripheral nerve block more than doubles the chance of a clinically relevant improvement in pain intensity. Amputees with phantom and/or residual limb pain rate analgesic improvements as clinically relevant similarly to other chronic pain etiologies, although their smallest relevant improvement in the Brief Pain Inventory was significantly larger than previously published values. TRIAL REGISTRATION NUMBER NCT01824082.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
- The Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
- The Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Kamal Maheshwari
- The Outcomes Research Consortium, Cleveland, Ohio, USA
- Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sarah Madison
- Department of Anesthesiology, Long Beach VA Medical Center, Long Beach, California, USA
| | - Wael Ali Sakr Esa
- Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford, Palo Alto, California, USA
| | - Michael Kent
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Steven Hanling
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, California, USA
| | - Daniel I Sessler
- The Outcomes Research Consortium, Cleveland, Ohio, USA
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - James C Eisenach
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Steven P Cohen
- Department of Anesthesiology, Johns Hopkins, Baltimore, Maryland, USA
| | - Edward Mascha
- The Outcomes Research Consortium, Cleveland, Ohio, USA
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shuyi Li
- The Outcomes Research Consortium, Cleveland, Ohio, USA
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alparslan Turan
- The Outcomes Research Consortium, Cleveland, Ohio, USA
- Departments of General Anesthesia & Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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Yang LQ, Zhu L, Shi X, Miao CH, Yuan HB, Liu ZQ, Gu WD, Liu F, Hu XX, Shi DP, Duan HW, Wang CY, Weng H, Huang ZL, Li LZ, He ZZ, Li J, Hu YP, Lin L, Pan ST, Xu SH, Tang D, Sessler DI, Liu J, Irwin MG, Yu WF. Postoperative pulmonary complications in older patients undergoing elective surgery with a supraglottic airway device or tracheal intubation. Anaesthesia 2023; 78:953-962. [PMID: 37270923 DOI: 10.1111/anae.16030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 06/06/2023]
Abstract
The two most commonly used airway management techniques during general anaesthesia are supraglottic airway devices and tracheal tubes. In older patients undergoing elective non-cardiothoracic surgery under general anaesthesia with positive pressure ventilation, we hypothesised that a composite measure of in-hospital postoperative pulmonary complications would be less frequent when a supraglottic airway device was used compared with a tracheal tube. We studied patients aged ≥ 70 years in 17 clinical centres. Patients were allocated randomly to airway management with a supraglottic airway device or a tracheal tube. Between August 2016 and April 2020, 2900 patients were studied, of whom 2751 were included in the primary analysis (1387 with supraglottic airway device and 1364 with a tracheal tube). Pre-operatively, 2431 (88.4%) patients were estimated to have a postoperative pulmonary complication risk index of 1-2. Postoperative pulmonary complications, mostly coughing, occurred in 270 of 1387 patients (19.5%) allocated to a supraglottic airway device and 342 of 1364 patients (25.1%) assigned to a tracheal tube (absolute difference -5.6% (95%CI -8.7 to -2.5), risk ratio 0.78 (95%CI 0.67-0.89); p < 0.001). Among otherwise healthy older patients undergoing elective surgery under general anaesthesia with intra-operative positive pressure ventilation of their lungs, there were fewer postoperative pulmonary complications when the airway was managed with a supraglottic airway device compared with a tracheal tube.
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Affiliation(s)
- L Q Yang
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - L Zhu
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - X Shi
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - C H Miao
- Fudan University Shanghai Cancer Center, Shanghai, China
| | - H B Yuan
- Shanghai Changzheng Hospital, Shanghai, China
| | - Z Q Liu
- Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - W D Gu
- Huadong Hospital, Fudan University, Shanghai, China
| | - F Liu
- West China Hospital, Sichuan University, Chengdu, China
| | - X X Hu
- Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - D P Shi
- Jiading District Central Hospital Affiliated Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - H W Duan
- Shanghai Pudong Hospital Fudan University Pudong Medical Center, Shanghai, China
| | - C Y Wang
- Huangpu Branch of Ninth People's Hospital Affiliated to Medical College of Shanghai Jiao Tong University, Shanghai, China
| | - H Weng
- Shanghai Fengxian District Central Hospital, Shanghai, China
| | - Z L Huang
- Ren Ji Hospital (West) affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - L Z Li
- Shanghai Pudong New Area People's Hospital, Shanghai, China
| | - Z Z He
- Ren Ji Hospital (South) affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - J Li
- First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Y P Hu
- The Second Hospital of Wuxi affiliated to Nanjing Medical University, Wuxi, China
| | - L Lin
- The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - S T Pan
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - S H Xu
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - D Tang
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - J Liu
- West China Hospital, Sichuan University, Chengdu, China
| | - M G Irwin
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - W F Yu
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
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Rolfzen ML, Wick A, Mascha EJ, Shah K, Krause M, Fernandez-Bustamante A, Kutner JS, Michael Ho P, Sessler DI, Bartels K. Best Practice Alerts Informed by Inpatient Opioid Intake to Reduce Opioid Prescribing after Surgery (PRIOR): A Cluster Randomized Multiple Crossover Trial. Anesthesiology 2023; 139:186-196. [PMID: 37155372 PMCID: PMC10602614 DOI: 10.1097/aln.0000000000004607] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Overprescription of opioids after surgery remains common. Residual and unnecessarily prescribed opioids can provide a reservoir for nonmedical use. This study therefore tested the hypothesis that a decision-support tool embedded in electronic health records guides clinicians to prescribe fewer opioids at discharge after inpatient surgery. METHODS This study included 21,689 surgical inpatient discharges in a cluster randomized multiple crossover trial from July 2020 to June 2021 in four Colorado hospitals. Hospital-level clusters were randomized to alternating 8-week periods during which an electronic decision-support tool recommended tailored discharge opioid prescriptions based on previous inpatient opioid intake. During active alert periods, the alert was displayed to clinicians when the proposed opioid prescription exceeded recommended amounts. No alerts were displayed during inactive periods. Carryover effects were mitigated by including 4-week washout periods. The primary outcome was oral morphine milligram equivalents prescribed at discharge. Secondary outcomes included combination opioid and nonopioid prescriptions and additional opioid prescriptions until day 28 after discharge. A vigorous state-wide opioid education and awareness campaign was in place during the trial. RESULTS The total postdischarge opioid prescription was a median [quartile 1, quartile 3] of 75 [0, 225] oral morphine milligram equivalents among 11,003 patients discharged when the alerts were active and 100 [0, 225] morphine milligram equivalents in 10,686 patients when the alerts were inactive, with an estimated ratio of geometric means of 0.95 (95% CI, 0.80 to 1.13; P = 0.586). The alert was displayed in 28% (3,074 of 11,003) of the discharges during the active alert period. There was no relationship between the alert and prescribed opioid and nonopioid combination medications or additional opioid prescriptions written after discharge. CONCLUSIONS A decision-support tool incorporated into electronic medical records did not reduce discharge opioid prescribing for postoperative patients in the context of vigorous opioid education and awareness efforts. Opioid prescribing alerts might yet be valuable in other contexts.(Anesthesiology 2023; 139:186-96). EDITOR’S PERSPECTIVE
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Affiliation(s)
- Megan L. Rolfzen
- Department of Anesthesiology, University of Nebraska
Medical Center, Omaha, NE, USA
| | - Abraham Wick
- UCHealth, Pharmacy Analytics Core, Aurora, CO, USA
| | - Edward J. Mascha
- Department of Quantitative Health Sciences, Cleveland
Clinic, Cleveland, OH, USA
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Karan Shah
- Department of Quantitative Health Sciences, Cleveland
Clinic, Cleveland, OH, USA
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Martin Krause
- Department of Anesthesiology, University of California San
Diego, San Diego, CA, USA
| | | | - Jean S. Kutner
- Department of Medicine, University of Colorado School of
Medicine, Aurora, CO, USA
| | - P. Michael Ho
- Department of Medicine, University of Colorado School of
Medicine, Aurora, CO, USA
| | - Daniel I. Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Nebraska
Medical Center, Omaha, NE, USA
- Department of Anesthesiology, University of Colorado School
of Medicine, Aurora, CO, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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Cao SJ, Zhang Y, Zhang YX, Zhao W, Pan LH, Sun XD, Jia Z, Ouyang W, Ye QS, Zhang FX, Guo YQ, Ai YQ, Zhao BJ, Yu JB, Liu ZH, Yin N, Li XY, Ma JH, Li HJ, Wang MR, Sessler DI, Ma D, Wang DX. Long-term survival in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: follow-up of a multicentre randomised trial. Br J Anaesth 2023; 131:266-275. [PMID: 37474242 DOI: 10.1016/j.bja.2023.01.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/21/2022] [Accepted: 01/17/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Experimental evidence indicates that i.v. anaesthesia might reduce cancer recurrence compared with volatile anaesthesia, but clinical information is observational only. We therefore tested the primary hypothesis that propofol-based anaesthesia improves survival over 3 or more years after potentially curative major cancer surgery. METHODS This was a long-term follow-up of a multicentre randomised trial in 14 tertiary hospitals in China. We enrolled 1228 patients aged 65-90 yr who were scheduled for major cancer surgery. They were randomised to either propofol-based i.v. anaesthesia or to sevoflurane-based inhalational anaesthesia. The primary endpoint was overall survival after surgery. Secondary endpoints included recurrence-free and event-free survival. RESULTS Amongst subjects randomised, 1195 (mean age 72 yr; 773 [65%] male) were included in the modified intention-to-treat analysis. At the end of follow-up (median 43 months), there were 188 deaths amongst 598 patients (31%) assigned to propofol-based anaesthesia compared with 175 deaths amongst 597 patients (29%) assigned to sevoflurane-based anaesthesia; adjusted hazard ratio 1.02; 95% confidence interval (CI): 0.83-1.26; P=0.834. Recurrence-free survival was 223/598 (37%) in patients given propofol anaesthesia vs 206/597 (35%) given sevoflurane anaesthesia; adjusted hazard ratio 1.07; 95% CI: 0.89-1.30; P=0.465. Event-free survival was 294/598 (49%) in patients given propofol anaesthesia vs 274/597 (46%) given sevoflurane anaesthesia; adjusted hazard ratio 1.09; 95% CI 0.93 to 1.29; P=0.298. CONCLUSIONS Long-term survival after major cancer surgery was similar with i.v. and volatile anaesthesia. Propofol-based iv. anaesthesia should not be used for cancer surgery with the expectation that it will improve overall or cancer-specific survival. CLINICAL TRIAL REGISTRATIONS ChiCTR-IPR-15006209; NCT02660411.
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Affiliation(s)
- Shuang-Jie Cao
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Yue Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Clinical Research Institute, Shenzhen Peking University-The Hong Kong University of Science & Technology Medical Center, Shenzhen, China
| | - Yu-Xiu Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Wei Zhao
- Department of Anesthesiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ling-Hui Pan
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xu-De Sun
- Department of Anesthesiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Zhen Jia
- Department of Anesthesiology, Affiliated Hospital of Qinghai University, Xining, Qinghai, China
| | - Wen Ouyang
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qing-Shan Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region, China
| | - Fang-Xiang Zhang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Yong-Qing Guo
- Department of Anesthesiology, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Yan-Qiu Ai
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Bin-Jiang Zhao
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jian-Bo Yu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | - Zhi-Heng Liu
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, Guangdong, China
| | - Ning Yin
- Department of Anesthesiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu, China; Department of Anesthesiology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xue-Ying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Jia-Hui Ma
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Hui-Juan Li
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Mei-Rong Wang
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, OH, USA
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK; National Clinical Research Center for Child Health, Hangzhou, China
| | - Dong-Xin Wang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA.
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Medellin S, Sessler DI. Preventable anesthetic deaths are not the major perioperative problem. Lancet Reg Health West Pac 2023; 37:100821. [PMID: 37693875 PMCID: PMC10485660 DOI: 10.1016/j.lanwpc.2023.100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 05/28/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Sara Medellin
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I. Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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Cao SJ, Zhang Y, Zhang YX, Zhao W, Pan LH, Sun XD, Jia Z, Ouyang W, Ye QS, Zhang FX, Guo YQ, Ai YQ, Zhao BJ, Yu JB, Liu ZH, Yin N, Li XY, Ma JH, Li HJ, Wang MR, Sessler DI, Ma D, Wang DX. Delirium in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: a multicentre randomised trial. Br J Anaesth 2023; 131:253-265. [PMID: 37474241 DOI: 10.1016/j.bja.2023.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Delirium is a common and disturbing postoperative complication that might be ameliorated by propofol-based anaesthesia. We therefore tested the primary hypothesis that there is less delirium after propofol-based than after sevoflurane-based anaesthesia within 7 days of major cancer surgery. METHODS This multicentre randomised trial was conducted in 14 tertiary care hospitals in China. Patients aged 65-90 yr undergoing major cancer surgery were randomised to either propofol-based anaesthesia or to sevoflurane-based anaesthesia. The primary endpoint was the incidence of delirium within 7 postoperative days. RESULTS A total of 1228 subjects were enrolled and randomised, with 1195 subjects included in the modified intention-to-treat analysis (mean age 71 yr; 422 [35%] women); one subject died before delirium assessment. Delirium occurred in 8.4% (50/597) of subjects given propofol-based anaesthesia vs 12.4% (74/597) of subjects given sevoflurane-based anaesthesia (relative risk 0.68 [95% confidence interval {CI}: 0.48-0.95]; P=0.023; adjusted relative risk 0.59 [95% CI: 0.39-0.90]; P=0.014). Delirium reduction mainly occurred on the first day after surgery, with a prevalence of 5.4% (32/597) with propofol anaesthesia vs 10.7% (64/597) with sevoflurane anaesthesia (relative risk 0.50 [95% CI: 0.33-0.75]; P=0.001). Secondary endpoints, including ICU admission, postoperative duration of hospitalisation, major complications within 30 days, cognitive function at 30 days and 3 yr, and safety outcomes, did not differ significantly between groups. CONCLUSIONS Delirium was a third less common after propofol than sevoflurane anaesthesia in older patients having major cancer surgery. Clinicians might therefore reasonably select propofol-based anaesthesia in patients at high risk of postoperative delirium. CLINICAL TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR-IPR-15006209) and ClinicalTrials.gov (NCT02662257).
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Affiliation(s)
- Shuang-Jie Cao
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Yue Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Clinical Research Institute, Shenzhen Peking University-The Hong Kong University of Science and Technology Medical Center, Shenzhen, Guangdong, China
| | - Yu-Xiu Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Wei Zhao
- Department of Anesthesiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ling-Hui Pan
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xu-De Sun
- Department of Anesthesiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Zhen Jia
- Department of Anesthesiology, Affiliated Hospital of Qinghai University, Xining, Qinghai, China
| | - Wen Ouyang
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qing-Shan Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region, China
| | - Fang-Xiang Zhang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Yong-Qing Guo
- Department of Anesthesiology, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Yan-Qiu Ai
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Bin-Jiang Zhao
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jian-Bo Yu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | - Zhi-Heng Liu
- Department of Anesthesiology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, Guangdong, China
| | - Ning Yin
- Department of Anesthesiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, Jiangsu, China; Department of Anesthesiology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xue-Ying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Jia-Hui Ma
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Hui-Juan Li
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Mei-Rong Wang
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, China
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Daqing Ma
- Division of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK; The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Dong-Xin Wang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Outcomes Research Consortium, Cleveland, OH, USA.
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Turan A, Khanna AK, Brooker J, Saha AK, Clark CJ, Samant A, Ozcimen E, Pu X, Ruetzler K, Sessler DI. Association Between Mobilization and Composite Postoperative Complications Following Major Elective Surgery. JAMA Surg 2023; 158:825-830. [PMID: 37256591 PMCID: PMC10233451 DOI: 10.1001/jamasurg.2023.1122] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/21/2023] [Indexed: 06/01/2023]
Abstract
IMPORTANCE Mobilization after surgery is a key component of Enhanced Recovery after Surgery (ERAS) pathways. OBJECTIVE To evaluate the association between mobilization and a collapsed composite of postoperative complications in patients recovering from major elective surgery as well as hospital length of stay, cumulative pain scores, and 30-day readmission rates. DESIGN, SETTING, AND PARTICIPANTS This retrospective observational study conducted at a single quaternary US referral center included patients who had elective surgery between February 2017 and October 2020. Mobilization was assessed over the first 48 postoperative hours with wearable accelerometers, and outcomes were assessed throughout hospitalization. Patients who had elective surgery lasting at least 2 hours followed by at least 48 hours of hospitalization were included. A minimum of 12 hours of continuous accelerometer monitoring was required without missing confounding variables or key data. Among 16 203 potential participants, 8653 who met inclusion criteria were included in the final analysis. Data were analyzed from February 2017 to October 2020. EXPOSURES Amount of mobilization per hour for 48 postoperative hours. OUTCOMES The primary outcome was a composite of myocardial injury, ileus, stroke, venous thromboembolism, pulmonary complications, and all-cause in-hospital mortality. Secondary outcomes included hospital length of stay, cumulative pain scores, and 30-day readmission. RESULTS Of 8653 included patients (mean [SD] age, 57.6 [16.0] years; 4535 [52.4%] female), 633 (7.3%) experienced the primary outcome. Mobilization time was a median (IQR) of 3.9 (1.7-7.8) minutes per monitored hour overall, 3.2 (0.9-7.4) in patients who experienced the primary outcome, and 4.1 (1.8-7.9) in those who did not. There was a significant association between postoperative mobilization and the composite outcome (hazard ratio [HR], 0.75; 95% CI, 0.67-0.84; P < .001) for each 4-minute increase in mobilization. Mobilization was associated with an estimated median reduction in the duration of hospitalization by 0.12 days (95% CI, 0.09-0.15; P < .001) for each 4-minute increase in mobilization. The were no associations between mobilization and pain score or 30-day readmission. CONCLUSIONS AND RELEVANCE In this study, mobilization measured by wearable accelerometers was associated with fewer postoperative complications and shorter hospital length of stay.
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Affiliation(s)
- Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Ashish K. Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- Outcomes Research Consortium, Cleveland, Ohio
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, North Carolina
| | - Jack Brooker
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Amit K. Saha
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, North Carolina
- Department of Anesthesiology, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Clancy J. Clark
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, North Carolina
- Department of Surgery, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Anusha Samant
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, North Carolina
- Department of Anesthesiology, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Xuan Pu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Kurt Ruetzler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
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Lu X, Jiang Q, Qiu Y, Tang W, Sessler DI, Wu J. Aggressive intraoperative warming and postoperative pulmonary complications in elderly patients recovering from esophageal cancer surgery: sub-analysis of a randomized trial. Front Med (Lausanne) 2023; 10:1157392. [PMID: 37521353 PMCID: PMC10375046 DOI: 10.3389/fmed.2023.1157392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/30/2023] [Indexed: 08/01/2023] Open
Abstract
Background Elderly patients having esophagectomies often become hypothermic which may promote complications. We tested the hypothesis that aggressive warming to a core temperature of 37°C reduces postoperative pulmonary complications (PPCs) in elderly patients having esophageal cancer resections. Methods This study was a pre-defined sub-study of a multi-center, parallel group, superiority trial (PROTECT). Patients aged >65 years and having elective radical resection of esophageal cancer in a single center were randomly allocated into either aggressive warming group (target intraoperative core temperatures of 37°C) or routine thermal management group (target intraoperative core temperatures of 35.5°C). The primary endpoint was the incidence of PPCs. Secondary endpoints included duration of chest tube drainage and other postoperative complications. Results A total of 300 patients were included in the primary analysis. PPCs occurred in 27 (18%) of 150 patients in the aggressive warming group and 31 (21%) of 150 patients in the routine thermal management group. The relative risk (RR) of aggressive versus routine thermal management was 0.9 (95% CI: 0.5, 1.4; p = 0.56). The duration of chest drainage in patients assigned to aggressive warming was shorter than that assigned to routine thermal management: 4 (3, 5) days vs. 5 (4, 7) days; hazard ratio (HR) 1.4 [95% CI: 1.1, 1.7]; p = 0.001. Fewer aggressively warmed patients needed chest drainage for more than 5 days: 30/150 (20%) vs. 51/150 (34%); RR:0.6 (95% CI: 0.4, 0.9; p = 0.03). The incidence of other postoperative complications were similar between the two groups. Conclusion Aggressive warming does not reduce the incidence of PPCs in elderly patients receiving esophagectomy. The duration of chest drainage was reduced by aggressive warming. But as a secondary analysis of a planned sub-group study, these results should be considered exploratory. Clinical trial registration https://www.chictr.org.cn/showproj.aspx?proj=37099, ChiCTR1900022257.
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Affiliation(s)
- Xiaofei Lu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Qiliang Jiang
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
- Outcomes Research Consortium, Cleveland, OH, United States
| | - Yuwei Qiu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
- Outcomes Research Consortium, Cleveland, OH, United States
| | - Wei Tang
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Daniel I. Sessler
- Outcomes Research Consortium, Cleveland, OH, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland, OH, United States
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
- Outcomes Research Consortium, Cleveland, OH, United States
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Garg AX, Cuerden M, Cata J, Chan MTV, Devereaux PJ, Fleischmann E, Grande AM, Kabon B, Landoni G, Maziak DE, McLean S, Parikh C, Popova E, Reimer C, Trujillo Reyes JC, Roshanov P, Sessler DI, Srinathan S, Sontrop JM, Gonzalez Tallada A, Wang MK, Wells JR, Conen D. Effect of Colchicine on the Risk of Perioperative Acute Kidney Injury: Clinical Protocol of a Substudy of the Colchicine for the Prevention of Perioperative Atrial Fibrillation Randomized Clinical Trial. Can J Kidney Health Dis 2023; 10:20543581231185427. [PMID: 37457622 PMCID: PMC10338661 DOI: 10.1177/20543581231185427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023] Open
Abstract
Background Inflammation during and after surgery can lead to organ damage including acute kidney injury. Colchicine, an established inexpensive anti-inflammatory medication, may help to protect the organs from pro-inflammatory damage. This protocol describes a kidney substudy of the colchicine for the prevention of perioperative atrial fibrillation (COP-AF) study, which is testing the effect of colchicine versus placebo on the risk of atrial fibrillation and myocardial injury among patients undergoing thoracic surgery. Objective Our kidney substudy of COP-AF will determine whether colchicine reduces the risk of perioperative acute kidney injury compared with a placebo. We will also examine whether colchicine has a larger absolute benefit in patients with pre-existing chronic kidney disease, the most prominent risk factor for acute kidney injury. Design and Setting Randomized, superiority clinical trial conducted in 40 centers in 11 countries from 2018 to 2023. Patients Patients (~3200) aged 55 years and older having major thoracic surgery. Intervention Patients are randomized 1:1 to receive oral colchicine (0.5 mg tablet) or a matching placebo, given twice daily starting 2 to 4 hours before surgery for a total of 10 days. Patients, health care providers, data collectors, and outcome adjudicators will be blinded to the randomized treatment allocation. Methods Serum creatinine concentrations will be measured before surgery and on postoperative days 1, 2, and 3 (or until hospital discharge). The primary outcome of the substudy is perioperative acute kidney injury, defined as an increase (from the prerandomization value) in serum creatinine concentration of either ≥26.5 μmol/L (≥0.3 mg/dL) within 48 hours of surgery or ≥50% within 7 days of surgery. The primary analysis (intention-to-treat) will examine the relative risk of acute kidney injury in patients allocated to receive colchicine versus placebo. We will repeat the primary analysis using alternative definitions of acute kidney injury and examine effect modification by pre-existing chronic kidney disease, defined as a prerandomization estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m2. Limitations The substudy will be underpowered to detect small effects on more severe forms of acute kidney injury treated with dialysis. Results Substudy results will be reported in 2024. Conclusions This substudy will estimate the effect of colchicine on the risk of perioperative acute kidney injury in older adults undergoing major thoracic surgery. Clinical trial registration number NCT03310125.
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Affiliation(s)
| | | | - Juan Cata
- MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | | | | | | | | | - Sean McLean
- Vancouver Acute Department of Anesthesiology, Vancouver General Hospital, BC, Canada
| | - Chirag Parikh
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | | | | | - Pavel Roshanov
- London Health Sciences Centre, ON, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | | | - David Conen
- Population Health Research Institute, Hamilton, ON, Canada
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Nolde JM, Schlaich MP, Sessler DI, Mian A, Corcoran TB, Chow CK, Chan MTV, Borges FK, McGillion MH, Myles PS, Mills NL, Devereaux PJ, Hillis GS. Machine learning to predict myocardial injury and death after non-cardiac surgery. Anaesthesia 2023; 78:853-860. [PMID: 37070957 DOI: 10.1111/anae.16024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 04/19/2023]
Abstract
Myocardial injury due to ischaemia within 30 days of non-cardiac surgery is prognostically relevant. We aimed to determine the discrimination, calibration, accuracy, sensitivity and specificity of single-layer and multiple-layer neural networks for myocardial injury and death within 30 postoperative days. We analysed data from 24,589 participants in the Vascular Events in Non-cardiac Surgery Patients Cohort Evaluation study. Validation was performed on a randomly selected subset of the study population. Discrimination for myocardial injury by single-layer vs. multiple-layer models generated areas (95%CI) under the receiver operating characteristic curve of: 0.70 (0.69-0.72) vs. 0.71 (0.70-0.73) with variables available before surgical referral, p < 0.001; 0.73 (0.72-0.75) vs. 0.75 (0.74-0.76) with additional variables available on admission, but before surgery, p < 0.001; and 0.76 (0.75-0.77) vs. 0.77 (0.76-0.78) with the addition of subsequent variables, p < 0.001. Discrimination for death by single-layer vs. multiple-layer models generated areas (95%CI) under the receiver operating characteristic curve of: 0.71 (0.66-0.76) vs. 0.74 (0.71-0.77) with variables available before surgical referral, p = 0.04; 0.78 (0.73-0.82) vs. 0.83 (0.79-0.86) with additional variables available on admission but before surgery, p = 0.01; and 0.87 (0.83-0.89) vs. 0.87 (0.85-0.90) with the addition of subsequent variables, p = 0.52. The accuracy of the multiple-layer model for myocardial injury and death with all variables was 70% and 89%, respectively.
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Affiliation(s)
- J M Nolde
- Dobney Hypertension Centre, Royal Perth Hospital Research Foundation, Perth, Australia
| | - M P Schlaich
- Dobney Hypertension Centre, Royal Perth Hospital Research Foundation, Perth, Australia
| | - D I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - A Mian
- School of Computer Science and Software Engineering, University of Western Australia, Perth, Australia
| | - T B Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital and Medical School, University of Western Australia and Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - C K Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, and Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - M T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - F K Borges
- McMaster University, Faculty of Health Sciences and Population Health Research Institute, Hamilton, ON, Canada
| | - M H McGillion
- McMaster University, Faculty of Health Sciences and Population Health Research Institute, Hamilton, ON, Canada
| | - P S Myles
- Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - N L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh and Usher Institute, Edinburgh, UK
| | - P J Devereaux
- McMaster University, Faculty of Health Sciences and Population Health Research Institute, Hamilton, ON, Canada
| | - G S Hillis
- Medical School, University of Western Australia and Department of Cardiology, Royal Perth Hospital, Perth, Australia
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