Relationship Between Newly Established Perioperative DNR Status and Perioperative Outcomes in the Elderly Population: A NSQIP Database Analysis

Background: Health care practitioners have developed complex algorithms to numerically calculate surgical risk. We examined the association between the initiation of a new do-not-resuscitate (DNR) status during hospitalization and postoperative outcomes, including mortality. We hypothesized that new DNR status would be associated with similar complication rates, even though mortality rates may be higher. Methods: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Research File. Two cohorts were defined by the presence of a new DNR status during the hospitalization that was not present on hospital admission. Multivariable logistic regression was used to control for differences between the DNR and non-DNR cohorts. The primary outcome was 30-day mortality. Secondary outcomes included rates of postoperative complications, including returning to the operating room, reintubation, failure to wean from ventilation, surgical site infections, dehiscence, pneumonia, acute kidney injury, renal failure, stroke, cardiac arrest, acute myocardial infarction, transfusion requirements, sepsis, urinary tract infections, venous thromboembolisms, total number of complications for each patient, and hospital length of stay. Results: In our geriatric population with a newly established DNR status, the mortality rate was 39.29%, significantly greater than the non-DNR population after multivariable regression. Secondary outcomes also occurred at an increased rate in the DNR cohort including surgical site infections (8.29% vs 4.04%), pneumonia (18% vs 2.26%), renal insufficiency (2.43% vs 0.35%), acute renal failure (5% vs 0.19%), stroke (3% vs 0.36%), acute myocardial infarction (6.29% vs 0.95%), and cardiac arrest (5.86% vs 0.51%). Conclusions: The initiation of a new DNR status during hospitalization is associated with a significantly higher burden of both morbidity and mortality. This contrasts with prior studies that did not show an increased rate of adverse outcomes and suggests that a new DNR status in postoperative patients may reflect a consequence of adverse postoperative events. The informed consent process in older patients at risk for adverse outcomes after surgery should include discussions regarding goals of care and acceptable risk.

Racial and socioeconomic disparities in kyphoplasty among the Medicare population

INTRODUCTION

Kyphoplasty is a minimally invasive treatment for chronic refractory pain secondary to spinal compression fracture. This study investigates racial and socioeconomic disparities in kyphoplasty among the Medicare population.

MATERIALS AND METHODS

This study utilized data from the Medicare Limited Data Sets (LDS), a CMS administrative claims database. Patients aged 18 and older with ICD code consistent with spinal pathology and compression fractures were included. Outcome was defined as kyphoplasty by race and socioeconomic status (SES) with low SES defined by dual enrollment in Medicare/Medicaid.

RESULTS

There was a total of 215,502 patients gathered from CMS data, and 717 (0.33%) of these patients underwent kyphoplasty during the study period. Of these patients, 458 (63.8%) were female, the average age was 76.5 years old, 655 (91.3%) were White, 20 (2.7%) were Black, 9 (1.3%) were Hispanic, and 98 (13.7%) were Medicare/Medicaid dual eligible. White patients (32,317/157,177 [20.6%]) were less likely to be dual enrollment eligible in Medicare and Medicaid than Black (5407/13,522 [39.9%]), Hispanic (2833/3675 [77.1%]), Asian (2087/3312 [63.0%]), or North American Native patients (778/1578 [49.1%]). Multivariate regression (MVR) analysis was performed and showed that Blacks were less likely than Whites to have a kyphoplasty performed (OR 0.46 [95% CI: 0.29-0.72], p-value <0.001). Although Hispanics (OR 0.95 [0.49-1.86]), North American Native (OR 0.82 [0.3-2.19]), and unknown race had a decreased odd of undergoing kyphoplasty, it was not statistically significant.

CONCLUSION

Our study showed after adjustment for pertinent comorbidities, Medicare/Medicaid dual-eligible patients and Black patients were significantly less likely to receive kyphoplasty than White patients with Medicare.

Utilization of Regional Anesthesia in the Electrophysiology Lab: A Narrative Review

PURPOSE OF REVIEW

The electrophysiology lab is an important source of growth of anesthetic volume as the indications and evidence for catheter ablations and various cardiac implantable electronic devices improve. Paired with this increase in volume is an increasing number of patients with substantial comorbid conditions presenting for their EP procedures. For these patients, the interaction between their comorbidities and traditional anesthesia practices may create the risk of hemodynamic instability, cardiovascular or respiratory complications, and potential need for prolonged post-operative monitoring negatively impacting length of hospital stay.

RECENT FINDINGS

Regional anesthetic techniques, including pectoralis, serratus, and erector spinae plane blocks, offer options for both regional analgesia and surgical anesthesia for a variety of EP procedures. Existing case reports and extrapolations from other areas support these techniques as viable, safe, and effective components of an anesthetic plan. In this article, we will review the development and challenges of various EP procedures and how different regional anesthetic techniques can function as a component of the anesthesia plan.

A machine learning approach to predicting early and late postoperative reintubation

Accurate estimation of surgical risks is important for informing the process of shared decision making and informed consent. Postoperative reintubation (POR) is a severe complication that is associated with postoperative morbidity. Previous studies have divided POR into early POR (within 72 h of surgery) and late POR (within 30 days of surgery). Using data provided by American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP), machine learning classification models (logistic regression, random forest classification, and gradient boosting classification) were utilized to develop scoring systems for the prediction of combined, early, and late POR. The risk factors included in each scoring system were narrowed down from a set of 37 pre and perioperative factors. The scoring systems developed from the logistic regression models demonstrated strong performance in terms of both accuracy and discrimination across the different POR outcomes (Average Brier score, 0.172; Average c-statistic, 0.852). These results were only marginally worse than prediction using the full set of risk variables (Average Brier score, 0.145; Average c-statistic, 0.870). While more work needs to be done to identify clinically relevant differences between the early and late POR outcomes, the scoring systems provided here can be used by surgeons and patients to improve the quality of care overall.

Regional Anesthesia for Lobectomy and Risk of Pulmonary Complications: A National Safety Quality Improvement Program Propensity-Matching Analysis

OBJECTIVE

To determine whether general anesthesia (GA) in conjunction with regional anesthetic (RA) techniques are associated with favorable pulmonary outcomes versus GA alone among patients undergoing lobectomy by either video-assisted thoracoscopic surgery (VATS) or open thoracotomy.

DESIGN

A retrospective cohort (2014-2017).

SETTING

The American College of Surgeons National Surgical Quality Improvement Program.

PARTICIPANTS

Adult patients undergoing lobectomy by either VATS or open thoracotomy.

INTERVENTIONS

Two groups of patients were identified based on the use of GA alone or GA in conjunction with RA (RA+GA) techniques (either neuraxial or peripheral nerve blocks). Both groups were propensity-matched based on pulmonary risk factors. The authors' primary outcome was composite postoperative pulmonary complication (PPC), including pneumonia, reintubation, and failure to wean from the ventilator.

MEASUREMENTS AND MAIN RESULTS

A total of 4,134 VATS (2,067 in GA and 2,067 in RA+GA) and 3,112 thoracotomies (1,556 in GA and 1,556 in RA+GA) were included in the final analysis. Regional anesthetic, as an adjuvant to GA, did not affect the incidence of PPC among patients undergoing lobectomy by VATS (odds ratio [OR] 1.07, 95% CI 0.81-1.43, p = 0.622), as well as in those undergoing lobectomy via thoracotomy (OR 1.19, 95% CI 0.93-1.51, p = 0.174). There was no statistically significant difference between groups in terms of readmission rates, length of stay, and mortality at 30 days.

CONCLUSIONS

The RA techniques were not associated with a lower incidence of pulmonary complications in lobectomy surgery.

Lateral thoracotomy versus sternotomy for left ventricular assist device implantation

PURPOSE OF REVIEW

Traditionally, left ventricular assist devices (LVADs) are implanted via the standard median sternotomy approach. However, a left thoracotomy approach has been purported to offer physiologic benefits. As a result, utilization of the left thoracotomy for LVAD placement is increasing globally, but the benefits of this approach versus sternotomy are still evolving and debatable. This review compares the median sternotomy and thoracotomy approaches for LVAD placement.

RECENT FINDINGS

Recent meta-analyses of LVAD implantation via thoracotomy approach suggest that the thoracotomy approach was associated with a reduced incidence of RVF, bleeding, hospital length of stay (LOS), and mortality [1 ▪▪ ,2 ▪▪ ] . No difference in stroke rates was noted. These results offer support as to the feasibility of a thoracotomy approach for LVAD implantation but also highlight its potential superiority over sternotomy.

SUMMARY

The most recent literature supports the use of lateral thoracotomy for placement of left ventricle assist devices compared to median sternotomy. Long-term outcomes from lateral thoracotomy are still unknown, however, short-term results favor lateral thoracotomy approaches for LVAD implantation. While the conventional median sternotomy approach was the original operative technique of choice for LVAD implantation, lateral thoracotomy is quickly emerging as a potentially superior technique.

Trends in pediatric non-operating room anesthesia: Data from the National Anesthesia Clinical Outcomes Registry

BACKGROUND

Modern pediatric anesthetic encounters occur in operating rooms and non-operating room settings. Most anesthesia providers have cared for children in radiology, endoscopy, and other interventional settings at some point in their training and career. There is an absence of published data on the frequency, timing, and demographics of these pediatric anesthesia encounters.

AIMS

The primary goal of our study is to present data spanning a variety of institutions and practice settings in the United States to define the percentage of non-operating room anesthetic encounters in children. We also set out to characterize the frequency of the most common procedures in the non-operating room setting within the United States.

METHODS

Using the National Anesthesia Clinical Outcomes Registry data from 2015-2019, we analyzed and reported data on current trends in non-operating room anesthesia including patient demographics, encounter setting, procedure type, and the time at which anesthetic encounters occurred.

RESULTS

2 236 788 pediatric anesthetic encounters (patient age <18 y.o.) were analyzed revealing that 22.7% of all pediatric anesthetics occur in non-operating room settings. Patients were more likely to have higher American Society of Anesthesiologists Physical Status classifications in the non-operating room anesthesia group. Gastroenterological suites are the most common setting reported for pediatric non-operating room anesthesia.

CONCLUSIONS

Non-operating room anesthesia in the United States is a prominent segment of pediatric anesthetic practice. Pediatric patients encountered in the non-operating room setting have more comorbidities, though further studies are needed to characterize the implication of this finding.

Regional anesthesia techniques for cardiac surgery: where are we?

PURPOSE OF REVIEW

Inadequate pain relief after cardiac surgery results in decreased patient experience and satisfaction, increased opioid consumption with its associated adverse consequences, and reduced efficiency metrics. To mitigate this, regional analgesic techniques are an increasingly important part of the perioperative cardiac anesthesia care plan. The purpose of this review is to compare current regional anesthesia techniques, and the relative evidence supporting their efficacy and safety in cardiac surgery.

RECENT FINDINGS

Numerous novel plane blocks have been developed in recent years, with evidence of improved pain control after cardiac surgery.

SUMMARY

The current data supports the use of a variety of different regional anesthesia techniques to reduce acute pain after cardiac surgery. However, future randomized trials are needed to quantify and compare the efficacy and safety of different regional techniques for pain control after cardiac surgery.

Percutaneous Decommissioning of a Left Ventricular Assist Device in a Patient With Myocardial Recovery

A 37-year-old man was referred for consideration of percutaneous decommissioning of a left ventricular assist device (LVAD). Following careful hemodynamic monitoring during pump turn-down and temporary outflow graft occlusion, the LVAD was permanently decommissioned by using a vascular plug to induce thrombosis of the outflow graft. (Level of Difficulty: Advanced.)

Prothrombin complex concentrates in cardiac surgery: where are we?

PURPOSE OF REVIEW

Major bleeding in cardiac surgery is commonly encountered, and, until recently, most frequently managed with fresh frozen plasma (FFP). However, a Cochrane review found this practice to be associated with a significant increase in red blood cell (RBC) transfusions and costs. These findings have led to off-label uses of prothrombin complex concentrates (PCCs) in cardiac surgery. The purpose of this review is to compare and contrast the use of FFP and PCC, review the components, limitations and risks of different types of PCCs, and discuss the latest evidence for the use of PCC versus FFP in cardiac surgery.

RECENT FINDINGS

A recent review and meta-analysis suggests that PCC administration in cardiac surgery is more effective than FFP in reducing RBC transfusions and costs.

SUMMARY

The current data supports the use of 4F-PCC instead of FFP as the primary hemostatic agent in cases of major bleeding in cardiac surgery. The use of PCCs is associated with reduced rates of RBC transfusions while maintaining a favorable safety profile. Clear advantages of PCC over FFP include its smaller volume, higher concentration of coagulation factors and shorter acquisition and administration times.

Association Between Early Extubation and Postoperative Reintubation After Elective Cardiac Surgery: A Bi-institutional Study

OBJECTIVE

It is unknown if remaining intubated after cardiac surgery is associated with a decreased risk of postoperative reintubation. The primary objective of this study was to investigate whether there was an association between the timing of extubation and the risk of reintubation after cardiac surgery.

DESIGN

A retrospective, observational study.

SETTING

Two university-affiliated tertiary care centers.

PARTICIPANTS

A total of 9,517 patients undergoing either isolated coronary artery bypass grafting (CABG) or aortic valve replacement (AVR).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 6,609 isolated CABGs and 2,908 isolated AVRs were performed during the study period. Reintubation occurred in 112 patients (1.64%) after CABG and 44 patients (1.5%) after AVR. After multivariate logistic regression analysis, early extubation (within the first 6 postoperative hours) was not associated with a risk of reintubation after CABG (odds ratio [OR] 0.53, 95% CI 0.26-1.06) and AVR (OR 0.52, 95% CI 0.22-1.22). Risk factors for reintubation included increased age in both the CABG (OR per 10-year increase, 1.63; 95% CI 1.28-2.08) and AVR (OR per 10-year increase, 1.50; 95% CI 1.12-2.01) cohorts. Total bypass time, race, and New York Heart Association (NYHA) functional class were not associated with reintubation risk.

CONCLUSION

Reintubation after CABGs and AVRs is a rare event, and advanced age is an independent risk factor. Risk is not increased with early extubation. This temporal association and low overall rate of reintubation suggest the strategies for extubation should be modified in this patient population.

The Association Between Institutional Mortality After Coronary Artery Bypass Grafting at One Year and Mortality Rates at 30 Days

OBJECTIVE

To assess the association between the common quality metric of 30-day mortality and mortality at 60 days, 90 days, and one year after coronary artery bypass grafting.

DESIGN

A retrospective cohort study, with multivariate logistic regression to assess association among mortality outcomes.

SETTING

Hospitals participating in Medicare and reporting data within the Centers for Medicare and Medicaid Services Limited Data Set between April 1, 2016, and March 31, 2017.

PARTICIPANTS

A total of 37,036 patients undergoing surgery at 394 hospitals.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Mortality rates were 1.0%-to-3.1% for the top and bottom quartile of hospitals at 30 days. At one year, the top 25th percentile of hospitals had mortality rates averaging 3.9%; while hospitals below the 75th percentile had mortality rates averaging 7.6%. Twenty-three percent of hospitals in the top quartile at 30 days were no longer in the top quartile at 60 days. At one year, only 48% of hospitals that were in the top quartile at 30 days remained in the top quartile. The correlation between mortality rates at 30 days and the reported points was assessed using Spearman's rho. The R value between mortality at 30 days and mortality at one year was 0.53, which improved to 0.7 and 0.76 at 60 and 90 days.

CONCLUSIONS

Mortality at 30 days correlated poorly with mortality at one year. Hospitals that were high- or low-performing at 30 days frequently were no longer within the same performance group at one year.

Efficacy of an Online Curriculum for Perioperative Goals of Care and Code Status Discussions: A Randomized Controlled Trial

BACKGROUND

Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature.

METHODS

In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa.

RESULTS

Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group.

CONCLUSIONS

Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

Surgical Complications Requiring Intervention in Open versus Minimally Invasive Radical Prostatectomy

INTRODUCTION

Injuries to surrounding structures during radical prostatectomy (RP) are rare but serious complications. However, it remains unknown if injuries to intestines, rectum, or vascular structures occur at different rates depending on the surgical approach.

METHODS

We compared the frequency of these outcomes in open RP (ORP) and minimally invasive RP (MIS-RP) using the national American College of Surgeons National Surgical Quality Improvement Program database (2012-2017). Along with important metrics of clinical and surgical outcomes, patients were identified as undergoing surgical repair of small or large bowel, vascular structures, or hernias based on Current Procedural Terminology codes.

RESULTS

In our propensity matched analysis, a total of 13,044 patients were captured. Bowel injury occurred more frequently in ORP than in MIS-RP (0.89 vs. 0.26%, p < 0.01). By intestinal segment, rectal and large bowel injuries were more common in ORP than MIS-RP (0.41 vs. 0.11% and 0.31 vs. 0.05%, both p < 0.01). However, there was no statistically significant difference between the groups for small bowel injury (0.17 vs. 0.11%, p = 0.39). Vascular injury was more common in MIS-RP (0.18 vs. 0.08%, p = 0.08). Hernias requiring repair were only identified in the MIS-RP group (0.12%).

CONCLUSION

When considering surgical approach, rectal and large bowel injuries were more common in ORP, while vascular injuries and hernia repair were more common in MIS-RP. Our findings can be used in counseling patients and identifying risk factors and strategies to reduce these complications.

Preoperative Cognitive Impairment as a Perioperative Risk Factor in Patients Undergoing Total Knee Arthroplasty

Background:

The study assessed whether pre-existing cognitive impairment (CI) prior to elective total knee arthroplasty (TKA) is associated with worse postoperative outcomes such as delirium, in-hospital medical complications, 30-day mortality, hospital length of stay and non-home discharge.

Methods:

A retrospective database analysis from the NSQIP Geriatric Surgery Pilot Project was used. There was an initial cohort of 6350 patients undergoing elective TKA, 104 patients with CI were propensity score matched to 104 patients without CI.

Results:

Analysis demonstrated a significantly increased incidence of post-operative delirium (POD) in the cohort with pre-op CI (p = < .001), a worsened functional status (p = < .001) and increased nonhome discharge postoperatively compared to the group without CI (p = 0.029). Other post-operative outcomes included 30-day mortality of 0% in both groups, and low rate of complications such as infection (2.88% vs 0.96%), pneumonia (1.92% vs 0%), failure to wean (0.96% vs 0%), and reintubation (0.96% vs 0%). Some other differences between the CI group and non-CI group, although not statistically significant, included increased rate of transfusion (10.58% vs 6.73%), and sepsis (1.92% vs 0%). The length of stay was increased in the non-CI group (4.28% vs 2.32%, p = 0.122).

Conclusion:

CI in patients undergoing TKA is associated with an increased risk of POD, worsened postoperative functional status, and discharge to non-home facility.

Racial and Socioeconomic Disparities in Spinal Cord Stimulation Among the Medicare Population

INTRODUCTION

Spinal cord stimulation (SCS) is used in the treatment of many chronic pain conditions. This study investigates racial and socioeconomic disparities in SCS among Medicare patients with chronic pain.

MATERIALS AND METHODS

Patients over the age of 18 with a primary diagnosis of postlaminectomy syndrome (ICD-10 M96.1) or chronic pain syndrome (ICD-10 G89.4) were identified in the Center for Medicare and Medicaid Services (CMS) Medicare Claims Limited Data Set. We defined our outcome as SCS therapy by race and socioeconomic status. Multivariable logistic regression was used to determine the variables associated with SCS.

RESULTS

We identified 1,244,927 patients treated between 2016 and 2019 with a primary diagnosis of postlaminectomy syndrome (PLS) or chronic pain syndrome (CPS). Of these patients, 59,182 (4.8%) received SCS. Multivariable logistic regression analysis revealed that, compared with White patients, Black (OR [95%CI], 0.62 [0.6-0.65], p < 0.001), Asian (0.66 [0.56-0.76], p < 0.001), Hispanic (0.86 [0.8-0.93], p < 0.001), and North American Native (0.62 [0.56-0.69], p < 0.001) patients were significantly less likely to receive SCS. In addition, patients who were dual-eligible for Medicare and Medicaid were significantly less likely to receive SCS than those eligible for Medicare only (OR = 0.38 [95% CI: 0.37-0.39], p < 0.001).

CONCLUSIONS

This study suggests that racial and socioeconomic disparities exist in SCS among Medicare and Medicaid patients with PLS and CPS. Further work is required to elucidate the complex etiology underlying these findings.

A Dashboard for Tracking Mortality After Cardiac Surgery Using a National Administrative Database

Background

Mortality after cardiac surgery is publicly reportable and used as a quality metric by national organizations. However, detailed institutional comparisons are often limited in publicly reported ratings, while publicly reported mortality data are generally limited to 30-day outcomes. Dashboards represent a useful method for aggregating data to identify areas for quality improvement.

Methods

We present the development of a dashboard of cardiac surgery performance using cardiac surgery admissions in a national administrative dataset, allowing institutions to better analyze their clinical outcomes. We identified cardiac surgery admissions in the Medicare Limited Data Sets from April 2016 to March 2017 using diagnosis-related group (DRG) codes for cardiac valve and coronary bypass surgeries.

Results

Using these data, we created a dashboard prototype to enable hospitals to compare their individual performance against state and national benchmarks, by all cardiac surgeries, specific cardiac surgery DRGs and by specific surgeons. Mortality rates are provided at 30, 60 and 90 days post-operatively as well as 1 year. Users can filter results by state, hospital and surgeon, and visualize summary data comparing these filtered results to national metrics. Examples of using the dashboard to examine hospital and individual surgeon mortality are provided.

Conclusions

We demonstrate how this database can be used to compare data between comparator hospitals on local, state and national levels to identify trends in mortality and areas for quality improvement.

Echocardiographic Assessment of Left Ventricular Assist Device Outflow Velocity During Percutaneous Decommissioning

Left ventricular assist devices (LVADs) have been used as an effective therapeutic option in patients with advanced heart failure, either as a bridge to transplantation or, in some patients, as a bridge to recovery. LVAD withdrawal with ventricular recovery represents the optimal outcome for patients previously implanted with an LVAD. In this E-Challenge, the authors present a case of percutaneous decommissioning of an LVAD, in which TEE provided critical, real-time perioperative evaluation. The authors also review the current perspectives on LVAD decommissioning in terms of patient selection and surgical techniques.

Epidural Analgesia in Ventral Hernia Repair: An Analysis of 30-day Outcomes

BACKGROUND

Ventral hernia repair (VHR) is a common procedure associated with significant postoperative morbidity and prolonged hospital length of stay (LOS). The use of epidural analgesia in VHR has not been widely evaluated.

PURPOSE

To compare the outcomes of general anesthesia plus epidural analgesia (GA + EA) versus general anesthesia alone (GA) in patients undergoing ventral hernia repair.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify elective cases of VHR. Propensity score-matched analysis was used to compare outcomes in GA vs GA + EA groups. Cases receiving transverse abdominus plane blocks were excluded.

RESULTS

A total of 9697 VHR cases were identified, resulting in two matched cohorts of 521 cases each. LOS was significantly longer in the GA + EA group (5.58 days) vs the GA group (5.20 days, p = 0.008). No other statistically significant differences in 30-day outcomes were observed between the matched cohorts.

CONCLUSION

Epidural analgesia in VHR is associated with statistically significant, but not clinically significant increase in LOS and may not yield any additional benefit in cases of isolated, elective VHR. Epidural analgesia may not be beneficial in this surgical population. Future studies should focus on alternative modes of analgesia to optimize pain control and outcomes for this procedure.

The Impact of Preoperative Intravenous Iron Therapy on Perioperative Outcomes in Cardiac Surgery: A Systematic Review

Background

Anemia is common in cardiac surgery affecting 25-40% of patients and associated with increased blood transfusions, morbidity, mortality, and higher hospital costs. Higher rates of stroke, acute renal injury, and total number of adverse postoperative outcomes have also been reported to be associated with preoperative anemia. This systematic review assessed the current evidence for preoperative intravenous iron on major outcomes following cardiac surgery.

Methods

Outcome measures included postoperative hemoglobin, transfusion rates, major adverse events, and mortality. The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and articles were identified using PubMed, Cochrane, CLINAHL, WOS, and EMBASE databases. Articles were included if they compared patients with and without preoperative anemia based on treatment with intravenous iron. Quality was assessed using Cochrane Risk of Bias Tool and Newcastle-Ottawa scale, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

Results

Of the articles reviewed, six met inclusion criteria. These included four randomized double-blind prospective cohort studies, one randomized non-blinded prospective study, and one non-randomized non-blinded prospective study with historical control. Across studies, 1,038 patients were enrolled. Two studies showed higher hemoglobin with iron therapy, and only one study showed significant differences in multiple outcomes such as transfusion and morbidity.

Conclusions

Given the paucity of studies and biases within them, the current evidence for treatment with intravenous iron prior to cardiac surgery is weak. More evidence is needed to support the administration of preoperative intravenous iron in cardiac surgery patients.

The Effect of Anesthesia Type on Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVES

To assess postoperative outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) either under general anesthesia (GA) or monitored anesthesia care (MAC) as the primary anesthetic.

DESIGN

A retrospective, propensity-matched, cohort study, with univariate logistic regression to assess postoperative outcomes.

SETTING

Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

PARTICIPANTS

The study comprised 559 patients who underwent a TAVR procedure under GA or MAC.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

After propensity score matching, there were no significant differences between the two cohorts in age, sex, race, body mass index, functional status, American Society of Anesthesiologists physical status, and other comorbidities. There were no significant differences in 30-day mortality between the two cohorts, or in the number of complications at 30 days. However, hospital length of stay was significantly shorter in the MAC cohort compared with the GA cohort.

CONCLUSIONS

Patients undergoing TAVR under MAC may have similar 30-day mortality and complications, but shorter hospital length of stay, than patients undergoing TAVR under GA.

Preoperative Risk Factors for Nonhome Discharge of Home-Dwelling Geriatric Patients Following Elective Surgery

To identify patient risk factors for nonhome discharge (NHD) for home-dwelling older patients undergoing surgery, we performed a retrospective cohort study of patients aged ≥65 years undergoing elective surgery between 2014 and 2016 using the geriatric research file from the National Surgical Quality Improvement Program (NSQIP). Multivariable logistic regression examined the association between preoperative demographics, comorbidities, and functional status and NHD to determine which factors are most strongly predictive of NHD. Risk of NHD was higher among those of age >85 years, age 75 to 85 years, Black race, with body mass index (BMI) >30, dyspnea with exertion or at rest, partially or totally dependent in activities of daily living (ADLs), preoperative steroid use, preoperative wound infection, use of a mobility aid, fall within 3 months, or living alone at home without support. NHDs were statistically more likely among orthopedic, neurosurgery, or cardiac surgery interventions. Understanding individual patient's risks and setting expectations for likely postoperative course is integral to appropriate preoperative counseling and preoperative optimization.

The Effect of Regional Anesthesia on Outcomes After Minimally Invasive Ivor Lewis Esophagectomy

OBJECTIVE

The objective of the present study was to determine whether regional anesthesia in addition to general anesthesia was associated with improved outcomes compared with general anesthesia alone in minimally invasive Ivor Lewis esophagectomy.

DESIGN

Retrospective cohort study.

DESIGN

This study examined patients across multiple hospital institutions using the American College of Surgeons National Surgical Quality Improvement Program dataset.

PARTICIPANTS

Patients who underwent minimally invasive Ivor Lewis esophagectomy were identified and grouped according to general plus regional anesthesia versus general anesthesia alone.

MEASUREMENTS AND MAIN RESULTS

Using multivariate logistic regression, outcomes, including 30-day mortality, respiratory complications, infection, blood clots, reintubation, return to the operating room, and length of hospital stay, were examined. Of the 463 patients who underwent minimally invasive Ivor Lewis esophagectomy, 398 met study inclusion criteria. General and regional anesthesia were administered to 108 patients in the study, with the remainder receiving only general anesthesia. Multivariate regression demonstrated no difference in the primary outcome of 30-day mortality (0.93% for regional and general anesthesia, 2.07% for general anesthesia alone [odds ratio 0.49; p = 0.534]). There was no significant difference for any secondary outcome including return to the operating room, failure to wean from the ventilator, reintubation, surgical site infection, pneumonia, renal insufficiency and failure, cardiac arrest, acute myocardial infarction, transfusion, venous thromboembolism, urinary tract infection, length of hospital stay, or total number of complications per patient.

CONCLUSIONS

Despite potential benefits of regional anesthesia for minimally invasive Ivor Lewis esophagectomy, the present study did not show significant differences in any outcomes between regional and general anesthesia versus general anesthesia alone.

Potential Opioid-Related Adverse Drug Events Are Associated With Decreased Revenue in Hip Replacement Surgery in the Older Population

Introduction

Opioid-related adverse drug events (ORADEs) are an increasingly recognized complication associated with the common prescription of opioids after orthopedic surgery. In this study, we attempted to understand how potential ORADEs following hip replacement surgery in older patients affected hospital length of stay, hospital revenue, and their association with specific risk factors and clinically relevant diseases occurring during hospitalization.

Methods

We conducted a retrospective study using the Centers for Medicare and Medicaid Services Administrative Database to analyze Medicare discharges after hip replacement surgery to identify potential ORADEs. The impact of potential ORADEs on mean hospital length of stay (LOS) and hospital revenue was analyzed.

Results

The potential ORADE rate in patients who underwent hip replacement surgery was 8.6%. The mean LOS for discharges with a potential ORADE was 1.41 days longer than that for discharges without an ORADE. The mean hospital revenue per day with a potential ORADE was US$1708 less than without an ORADE. Potential ORADEs were also found to be strongly associated with poor patient outcomes such as pneumonia, septicemia, and shock.

Discussion

Potential ORADEs in hip replacement surgery in older patients are associated with longer hospitalizations, decreased hospital revenue per day, certain patient risk factors, and clinically relevant diseases occurring during hospitalizations. Our finding of an association between potential ORADEs and decreased hospital revenue per day may be attributed to the management of these adverse events, as a patient may need to undergo additional testing, may need additional treatment regimens, and may need a higher level of care.

Conclusion

By reducing the use of opioids and employing a multimodal analgesic approach, we may improve patient care, decrease hospital lengths of stay, and increase hospital revenue.

A Dashboard Prototype for Tracking the Impact of Diabetes on Hospital Readmissions Using a National Administrative Database

Background

Over the past several decades, diabetes mellitus has contributed to a significant disease burden in the general population. Evidence suggests that patients with a coexisting diabetes diagnosis consume more hospital resources, and have higher readmission rates compared to those who do not. Against the backdrop of bundled-payment programs, healthcare systems cannot underestimate the importance of monitoring patient health information at the population level.

Methods

Using the data from the Centers for Medicare and Medicaid Services (CMS) administrative claims database, we created a dashboard prototype to enable hospitals to examine the impact of diabetes on their all-cause readmission rates and financial implications if diabetes was present at the index hospitalization. The technical design involved loading the relevant 10th revision of International Classification of Diseases (ICD-10) codes provided by the medical team and flagging diabetes patients at the claim. These patients were then tagged for readmissions within the same database. The odds ratios were determined based on data from two groups: those with diabetes at index hospitalization which include type 1 only, type 2 only, and type 1 and type 2 diabetes, plus those without diabetes at index hospitalization.

Results

The dashboard presents summary data of diabetes readmissions quality metrics at a national level. Users can visualize summary data of each state and compare odds ratios for readmissions as well as raw hospitalization data at their facility. Dashboard users can also view data classified by a diagnosis-related group (DRG) system. In addition to a “national” data view, for users who inquire about data specific to demographic regions, the DRG view can be further stratified at the state level or county level. At the DRG level, users can view data about the cost per readmissions for all index hospitalization with and without diabetes.

Conclusions

The dashboard prototype offers users a virtual interface which displays visual data for quick interpretation, monitors changes at a population level, and enables administrators to benchmark facility data against local and national trends. This is an important step in using data analytics to drive population level decision making to ultimately improve medical systems.

The Association Between Potential Opioid-Related Adverse Drug Events and Outcomes in Total Knee Arthroplasty: A Retrospective Study

INTRODUCTION

Characterization of the clinical and economic impact of opioid-related adverse drug events (ORADEs) after total knee arthroplasty (TKA) may guide provider and hospital system approach to managing postoperative pain after TKA. Our analysis quantifies the rate of potential ORADEs after TKA, the impact of potential ORADEs on length of stay (LOS) and hospital revenue, as well as their association with specific patient risk factors and comorbid clinical conditions.

METHODS

We conducted a retrospective study using the Centers for Medicare and Medicaid Services administrative database to analyze Medicare discharges involving two knee replacement surgery diagnosis-related groups (DRGs) in order to identify potential ORADEs. The impact of potential ORADEs on mean hospital LOS and hospital revenue was analyzed.

RESULTS

The potential ORADE rate in patients who underwent TKA was 25,523 out of 316,858 records analyzed (8.0%). The mean LOS for patients who experienced a potential ORADE was 1.04 days longer than those without an ORADE. The mean hospital revenue per day with a potential ORADE was $1334 (USD) less than without an ORADE. Potential ORADEs were significantly associated with poor patient outcomes such as pneumonia, septicemia, and shock.

CONCLUSION

Potential ORADEs in TKA are associated with longer hospitalizations, decreased hospital revenue, and poor patient outcomes. Certain risk factors may predispose patients to experiencing an ORADE, and thus perioperative pain management strategies that reduce the frequency of ORADEs particularly in at-risk patients can improve patient satisfaction and increase hospital revenue following TKAs.

A closed claims analysis of vocal cord injuries related to endotracheal intubation between 2004 and 2015

STUDY OBJECTIVE

To provide a contemporary medicolegal analysis of claims brought against anesthesiologists for injuries related to endotracheal intubation.

DESIGN

A retrospective study of closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database between 2004 and 2015.

SETTING

Closed claims that occurred in any surgical specialty in which the patient was undergoing general anesthesia and anesthesiology was named as the primary responsible service.

PATIENTS

Twenty claims were identified for analysis in 7 surgical specialties. Patient ages ranged from 45 to 76. Data regarding patient comorbidities and case history were obtained when available.

INTERVENTIONS

None.

MEASUREMENTS

Data collected includes patient demographics such as age, outcome severity, alleged complication, plaintiff allegations, contributing factors to the injury, the surgical specialty in which the injury occurred, and the ultimate result of the claim (dismissed/denied/settled).

MAIN RESULTS

Out of 20 claims, settlement payments were made in 10% of claims with a mean payment amount of $7669. Mean patient age was 55.6 years. Within severity of injuries, 65% of claims were classified as "Permanent Minor." The most common contributing factor in claims was "Technical Knowledge/Performance" and the most common plaintiff allegation was "Trauma from endotracheal tube placement." Bilateral vocal cord paralysis, unilateral (left-sided) vocal cord paralysis, and laryngeal nerve injury were the top alleged complications. The surgical specialty in which claims most often resulted was orthopedic surgery.

CONCLUSIONS

Injuries related to endotracheal intubation remain an ongoing challenge to anesthesiologists. Their etiology is often multifactorial and was found in this study to stem most commonly from technical errors and patient co-morbidities. A detailed discussion of risks with patients during the consent process, careful documentation of such discussion, and prompt referral to specialists when needed are critical. Understanding the patterns related to injuries during intubation is essential in order to develop strategies for improved patient safety and outcomes.

Opioid-Related Adverse Events: Incidence and Impact in Patients Undergoing Cardiac Surgery

Purpose. Opioid-related adverse drug events (ORADEs) increase patient length of stay (LOS) and health care costs. However, ORADE rates may be underreported. This study attempts to understand the degree to which ORADEs are underreported in Medicare patients undergoing cardiac surgery. Materials and Methods. The Center for Medicare and Medicaid Services administrative claims database was used to identify ORADEs in 110 158 Medicare beneficiaries who underwent cardiac valve (n = 50 525) or coronary bypass (n = 59 633) surgery between April 2016 and March 2017. The International Classification of Disease (ICD)-10 codes specifically linked to ORADEs were used to identify an actual ORADE rate, while additional ICD codes, clinically associated with butas not specific to adverse drug events were analyzed as potential ORADEs. Length of stay (LOS) and hospital daily revenue were analyzed among patients with or without a potential ORADE. Results. Among patients undergoing valve or bypass surgery, the documented ORADE rate was 0.7% (743/110 158). However, potential ORADEs may have occurred in up to 32.4% (35 658/110 158) of patients. In patients with a potential ORADE, mean LOS was longer (11.4 vs 8.2 days; P < .0001) and mean Medicare revenue/day was lower ($4016 vs $4412; P < .0001). The mean net difference in revenue/day between patients with and without an ORADE varied between $231 and $1145, depending on the Diagnosis-Related Group analyzed. Conclusions. ORADEs are likely underreported following cardiac surgery. ORADEs can be associated with increased LOS and decreased hospital revenue. Understanding the incidence and economic impact of ORADEs may expedite changes to postoperative pain management. Adopting multimodal pain management strategies that reduce exposure to opioids may improve outcomes by reducing complications, side effects, and health care costs.

The Impact of Epidural Analgesia on Perioperative Morbidity or Mortality after Open Abdominal Aortic Aneurysm Repair

BACKGROUND

Epidural analgesia (EA) is frequently used as an adjuvant to general anesthesia (GA) for improved postoperative analgesia and reduced rates of cardiac, pulmonary, and renal complications. However, only a few studies have examined EA-GA specifically during open abdominal aortic aneurysm (AAA) repair. The effects of EA-GA specifically during open AAA repair regarding postoperative outcomes are unknown. This study was performed to evaluate postoperative outcomes in patients undergoing open AAA repair with EA-GA versus GA alone.

METHODS

We performed a retrospective analysis for patients undergoing surgery between January 1, 2014 and December 31, 2016 using the National Surgical Quality Improvement Program (NSQIP) database. Propensity score matching was used to establish cohorts for analysis. Multivariable logistic regression was performed to determine significant perioperative outcomes for each anesthesia type. A total of 2,171 patients underwent open AAA repair in our date range; we excluded emergent and ruptured AAA. A total of 2,145 patients were included in our analysis, of whom 653 patients received EA-GA and 1,492 patients received GA only.

RESULTS

Major postoperative outcomes included mortality, pulmonary cardiac and renal complications, infections, thrombosis, and blood transfusion requirement (including Cell-Saver usage). Additional overall outcomes included hospital length of stay, return to the operating room, and readmission. Patients in EA + GA and GA alone groups were comparable regarding demographics, functional status, and comorbidities. Decreased odds of readmission was observed in EA + GA compared with GA (0.49, 95% CI [0.28-0.86]; P = 0.014); and increased odds of receiving a blood transfusion was observed in those who underwent EA + GA (1.63, 95% CI [1.23-2.14]; P = 0.001). No difference was observed between patients who had an AAA repair with EA + GA versus GA alone with regard to mortality, return to operating room, major pulmonary, cardiac, renal, or infectious complications.

CONCLUSIONS

EA + GA was not associated with decreased mortality or decreased rates of major postoperative pulmonary, cardiac, or renal complications. EA + GA was associated with increased transfusion requirements and decreased rates of hospital readmission.

A contemporary medicolegal analysis of perioperative vision loss from 2007 to 2016

INTRODUCTION

Perioperative vision loss (POVL) is a rare but catastrophic event. Closed claim databases are useful for investigating risk factors of POVL to help guide practices in risk mitigation and risk management strategies.

METHODS

We retrospectively analyzed the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System database for perioperative nerve injuries from when claims were closed between 2007 and 2016. We then extracted, deidentified, and analyzed all the POVL cases.

RESULTS

Of 53 nerve injury claims closed between 2007 and 2016, we found 9 pertaining to POVL. Of these 9 cases, 100% resulted in permanent injury, 76% were associated with spine surgery, 89% of the patients were positioned prone intraoperatively, 67% were noted to have improper or missing documentation, and 56% of the patients claimed they were not informed of the risk of vision loss during preoperative consenting. Four of the 9 cases were settled, with a mean settlement amount of $906,250 (standard deviation, ± $745,647).

CONCLUSIONS

POVL often results in permanent injury with costly burden on the health care system. Risk reduction strategies need to be instituted on the provider and system level, involving a multidisciplinary health care team to develop and execute clinical protocols and patient communication strategies that will help prevent POVL.

The Association Between Potential Opioid-Related Adverse Drug Events and Outcomes in Colorectal Surgery

Introduction: Major colorectal surgery procedures are complex operations that can result in significant postoperative pain and complications. More evidence is needed to demonstrate how opioid-related adverse drug events (ORADEs) after colorectal surgery can affect hospital length of stay (LOS), hospital revenue, and what their association is with clinical conditions. By understanding the clinical and economic impact of potential ORADEs within colorectal surgery, we hope to further guide approaches to perioperative pain management in an effort to improve patient care and reduce hospital costs. Materials and Methods: We conducted a retrospective study utilizing the Centers for Medicare and Medicaid Services (CMS) Administrative Database to analyze Medicare discharges involving three colorectal surgery diagnosis-related groups (DRGs) to identify potential ORADEs. The impact of potential ORADEs on mean hospital LOS and hospital revenue was analyzed. Results: The potential ORADE rate in patients undergoing colorectal surgery was 23.92%. The mean LOS for discharges with a potential ORADE was 5.35 days longer than without an ORADE. The mean hospital revenue per day with a potential ORADE was $418 less than without an ORADE. Any type of open surgery had a statistically significant higher potential ORADE rate than the matched laparoscopic case (P < .001). Clinical conditions most strongly associated with ORADEs in colorectal surgery included septicemia, pneumonia, shock, and fluid and electrolyte disorders. Conclusion: The incidence of ORADEs in colorectal surgery is high and is associated with longer hospital stays and reduced hospital revenue. Reducing the use of opioids in the perioperative setting, such as using multimodal analgesia strategies, may lead to positive outcomes with shorter hospital stays, increased hospital revenue, and improved patient care.

ABO Blood Group and Transfusions In the Intraoperative and Postoperative Period After LVAD Implantation

OBJECTIVES

To assess whether blood group O patients undergoing left ventricular assist device (LVAD) insertion have higher perioperative transfusion requirements, postoperative chest tube output, and postoperative changes in hematocrit.

DESIGN

Retrospective review of 116 LVAD patients from August 2015 to May 2018.

SETTING

Single-institution, urban academic medical center.

PARTICIPANTS

One hundred sixteen LVAD patients analyzed by blood group: group O (n = 49) versus non-O (n = 67).

INTERVENTIONS

Transfusions in the combined intraoperative and postoperative period at 7 days and 90 days after LVAD implantation, chest tube output in the first 24 hours, and hematocrit change in the first 48 hours postoperatively.

RESULTS

There was no difference between group O and non-O within the univariable analysis for both 7-day and 90-day transfusion rates. Adjusting for covariables, blood type O was not associated with packed red blood cells transfusion after accounting for multiple comparisons (odds ratio 1.33 [1.07-1.66], p = 0.01, where p < 0.005 was considered statistically significant as a Bonferroni correction was performed to control the familywise error rate). Additionally, there was no difference in chest tube output over the first 24 hours (1,129 v 1,057 mL, p = 0.47) or hematocrit change in the first 48 hours postoperatively (3.49 v 4.53%, p = 0.15).

CONCLUSION

O blood group is not a significant predictor of transfusion requirements in the combined intraoperative and postoperative period up to 90 days after LVAD implantation.

A Contemporary Medicolegal Analysis of Injury Related to Peripheral Nerve Blocks

BACKGROUND

Closed malpractice claims can provide insight into low-frequency adverse events in many areas of perioperative and chronic pain care. Over the last decade, there have been changes in surgical and regional anesthetic practice, likely impacting adverse event patterns. Given the wide variability and low frequency of complications associated with peripheral nerve blocks, the study of closed malpractice claims offers an opportunity to examine adverse events, and the patient, technical, and provider factors that led to the claim. Knowledge gained from examination of closed claims has already resulted in multiple improvements in processes of care and patient safety.

OBJECTIVES

An investigation of the factors that contributed to medicolegal claims against anesthesia providers related to peripheral nerve blocks.

STUDY DESIGN

Retrospective analysis.

SETTING

Inpatient and outpatient surgery facilities.

METHODS

The Comparative Benchmarking System database is a medical liability database that contains more than 400,000 malpractice claims from more than 400 academic and community-based institutions accounting for over 30% of malpractice claims in the United States. The present investigation reviewed all (n = 113) available closed malpractice claims related to regional anesthesia (RA) in surgical patients closed between 2006 and 2016, and investigated factors that may have contributed to patient injury, including type of nerve block, type of surgery, nerves injured, resulting neurologic deficits, and potential factors contributing to the injury.

RESULTS

Our data analyzed 62 claims related to RA and showed that most closed claims were classified as permanent minor injuries. The greatest number of claims were for brachial plexus injuries associated with interscalene blocks performed for shoulder or rotator cuff repairs. Femoral and sciatic nerve blocks with resulting lower extremity injuries were the most common nerve blocks resulting in payment. The largest contributing factor to these injuries was noted to be "Technical Knowledge/Performance" of the regionalist followed by "Pre-existing Injury/Radiculopathy." Symptom onset from these claims was most likely to be delayed with the leading initial presenting symptom being paresthesia.

LIMITATIONS

It is difficult to establish cause-effect relationship, and the small sample size limits the ability to detect clinical differences and associations with specific comorbidities or techniques. There was also limited information related to regional anesthetic techniques and medications used that would have helped explore further relationships between the procedure and cause for litigation.

CONCLUSIONS

There remains significant room for risk reduction in regional anesthetic practice. Patterns based on the analysis of closed claims show that interscalene blocks are the most common peripheral nerve block resulting in litigation, even when compared with other blocks involving the brachial plexus. Furthermore, patients with existing nerve injury/radiculopathy may also warrant alternative techniques or greater emphasis during informed consent on the increased risk of injury. As most of the presenting symptoms associated with claims are delayed, an opportunity for improvement in postregional care may be better communication with patients following discharge to discuss their postoperative recovery.

KEY WORDS

Regional, pain, anesthesia, complications, closed claims, liability, nerve, block, injury.

A Contemporary Analysis of Medicolegal Issues in Obstetric Anesthesia Between 2005 and 2015

BACKGROUND

Detailed reviews of closed malpractice claims have provided insights into the most common events resulting in litigation and helped improve anesthesia care. In the past 10 years, there have been multiple safety advancements in the practice of obstetric anesthesia. We investigated the relationship among contributing factors, patient injuries, and legal outcome by analyzing a contemporary cohort of closed malpractice claims where obstetric anesthesiology was the principal defendant.

METHODS

The Controlled Risk Insurance Company (CRICO) is the captive medical liability insurer of the Harvard Medical Institutions that, in collaboration with other insurance companies and health care entities, contributes to the Comparative Benchmark System database for research purposes. We reviewed all (N = 106) closed malpractice cases related to obstetric anesthesia between 2005 and 2015 and compared the following classes of injury: maternal death and brain injury, neonatal death and brain injury, maternal nerve injury, and maternal major and minor injury. In addition, settled claims were compared to the cases that did not receive payment. χ, analysis of variance, Student t test, and Kruskal-Wallis tests were used for comparison between the different classes of injury.

RESULTS

The largest number of claims, 54.7%, involved maternal nerve injury; 77.6% of these claims did not receive any indemnity payment. Cases involving maternal death or brain injury comprised 15.1% of all cases and were more likely to receive payment, especially in the high range (P = .02). The most common causes of maternal death or brain injury were high neuraxial blocks, embolic events, and failed intubation. Claims for maternal major and minor injury were least likely to receive payment (P = .02) and were most commonly (34.8%) associated with only emotional injury. Compared to the dropped/denied/dismissed claims, settled claims more frequently involved general anesthesia (P = .03), were associated with delays in care (P = .005), and took longer to resolve (3.2 vs 1.3 years; P < .0001).

CONCLUSIONS

Obstetric anesthesia remains an area of significant malpractice liability. Opportunities for practice improvement in the area of severe maternal injury include timely recognition of high neuraxial block, availability of adequate resuscitative resources, and the use of advanced airway management techniques. Anesthesiologists should avoid delays in maternal care, establish clear communication, and follow their institutional policy regarding neonatal resuscitation. Prevention of maternal neurological injury should be directed toward performing neuraxial techniques at the lowest lumbar spine level possible and prevention/recognition of retained neuraxial devices.

Clinical predictors of postoperative delirium, functional status, and mortality in geriatric patients undergoing non-elective surgery for hip fracture

STUDY OBJECTIVE

To identify modifiable preoperative factors that might influence the morbidity and mortality associated with non-elective, inpatient hip fracture surgeries in the geriatric surgical population.

DESIGN

Retrospective database analysis from the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Project.

SETTING

Inpatient, perioperative.

PATIENTS

Geriatric patients undergoing surgery.

INTERVENTIONS

Non-elective hip repair surgery.

MEASUREMENTS

Preoperative demographic, medical, surgical, and anesthetic variables; post-operative rates of delirium, decline in functional status, and 30-day mortality.

MAIN RESULTS

The 1261 patients in this study were predominantly female (74%), white (89%), and non-Hispanic (92%). Ages were distributed across groups from 65 to over 90 years. Most patients were categorized as American Society of Anesthesiologists Physical Status class 3 (64%). General anesthesia (57%) was the most common anesthetic, followed by spinal (38%). Preoperative functional status was recorded in 79% as independent in activities of daily living (ADLs). About one third of patients had baseline dementia. Post-operatively, 42% experienced delirium, and most patients required partial or total assistance with ADLs (72% and 12%, respectively). Reoperation was required in 2.8% of cases. Mortality at 30 days was 5.0%. In the multivariable analysis, risk factors associated with post-operative delirium included dementia and lack of competency to sign consent. In the analysis for postoperative decline in functional status, the major risk factor was a history of falls, while emergently performed surgery was protective. The analysis for mortality at thirty days was under-powered.

CONCLUSIONS

Hip fractures remain a major source of morbidity in geriatric patients. Baseline dementia and inability to sign surgical consent are significant risk factors for adverse outcomes after hip fractures and should be considered in the informed consent process. Data from this study and currently ongoing randomized trials will help guide reductions in morbidity and mortality in this population.

Postoperative Outcomes in Primary Total Knee Arthroplasty Patients With Preexisting Cognitive Impairment: A Systematic Review

INTRODUCTION

To evaluate the body of evidence on the predictive value of preoperative cognitive impairment on in-hospital, short-term, and midterm postoperative outcomes for elderly patients undergoing total knee arthroplasty (TKA).

SIGNIFICANCE

With an aging population, an increasing percentage of the U.S. patient population will be living with cognitive impairment. There is currently no systematic review that assesses postoperative outcomes of patients with mild cognitive impairment (MCI) or preexisting diagnosis of dementia while undergoing elective primary TKA.

RESULTS

A database search between January 1, 1997, and November 1, 2017 in EMBASE, MEDLINE, and PubMed was conducted to identify articles that compared postoperative outcomes after TKA between patients aged 60 years with and without cognitive impairment. Cognitive impairment included preexisting diagnosis of dementia or MCI identified during preoperative assessment. Eligible articles were selected using dual reviewer and third-party arbitrator. The quality of the studies was evaluated using the Newcastle-Ottawa Scale. The strength of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. A total of 6163 abstracts were screened. Only 11 full text articles met inclusion criteria, including 1 case-control, 5 prospective cohort, and 5 retrospective cohort studies. Two studies were of poor quality. Overall, there is moderate strength of evidence for increased risk of postoperative delirium, increased length of stay, and discharge to health-care facility among patients with preoperative MCI or preexisting dementia. The body of evidence is weak for other outcomes of interest including mortality, functionality and complications while in-hospital and in the short- and midterm.

CONCLUSION

This review highlights the need for additional good quality studies to provide more information about MCI and dementia as risk factors in primary TKA.

Optimizing Preoperative Anemia to Improve Patient Outcomes

Anemia is a decrease in red blood cell mass, which hinders oxygen delivery to tissues. Preoperative anemia has been shown to be associated with mortality and morbidity following major surgery. The preoperative care clinic is an ideal place to start screening for anemia and discussing potential interventions in order to optimize patients for surgery. This article (1) reviews the relevant literature and highlights consequences of preoperative anemia in the surgical setting, and (2) suggests strategies for screening and optimizing anemia in the preoperative setting.

The Use of Regional or Local Anesthesia for Carotid Endarterectomies May Reduce Blood Loss and Pulmonary Complications

OBJECTIVE

Over 150,000 carotid endarterectomy (CEA) procedures are performed each year. Perioperative anesthetic management may be complex due to multiple patient and procedure-related risk factors. The authorsaimed to determine whether the use of general anesthesia (GA), when compared with regional anesthesia (RA), would be associated with reduced perioperative morbidity and mortality in patients undergoing a CEA.

DESIGN

Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

SETTING

The authors evaluated patients undergoing a CEA at multiple university- and community-based settings.

PARTICIPANTS

A total of 43,463 patients were identified; 22,845 patients were propensity matched after excluding for missing data.

INTERVENTIONS

The study population was divided into 2 groups: patients undergoing RA or GA. The RA group included regional anesthesia performed by the anesthesiologist or surgeon, monitored anesthesia care, and local infiltration.

METHODS

The primary endpoint was 30-day mortality. Secondary endpoints included surgical site infection, pulmonary complications, return to the operating room, acute kidney injury, cardiac arrest, urinary tract infection, myocardial infarction, thromboembolism, perioperative transfusion, sepsis, and days to discharge.

MEASUREMENTS AND MAIN RESULTS

Younger age, Hispanic ethnicity, body mass index <18.5, dyspnea, chronic obstructive pulmonary disease, and smoking history were associated with receiving GA. Patients with low hematocrit and low platelets were more likely to get RA. There was no mortality difference. GA was associated with a significantly higher rate of perioperative transfusions (p = 0.037) and perioperative pneumonia (p = 0.027).

CONCLUSION

The use of RA over GA in CEA is associated with decreased risk of postoperative pneumonia and a reduced need for perioperative blood transfusions.