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King CR, Gregory S, Fritz BA, Budelier TP, Ben Abdallah A, Kronzer A, Helsten DL, Torres B, McKinnon S, Goswami S, Mehta D, Higo O, Kerby P, Henrichs B, Wildes TS, Politi MC, Abraham J, Avidan MS, Kannampallil T. An Intraoperative Telemedicine Program to Improve Perioperative Quality Measures: The ACTFAST-3 Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2332517. [PMID: 37738052 PMCID: PMC10517374 DOI: 10.1001/jamanetworkopen.2023.32517] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/30/2023] [Indexed: 09/23/2023] Open
Abstract
Importance Telemedicine for clinical decision support has been adopted in many health care settings, but its utility in improving intraoperative care has not been assessed. Objective To pilot the implementation of a real-time intraoperative telemedicine decision support program and evaluate whether it reduces postoperative hypothermia and hyperglycemia as well as other quality of care measures. Design, Setting, and Participants This single-center pilot randomized clinical trial (Anesthesiology Control Tower-Feedback Alerts to Supplement Treatments [ACTFAST-3]) was conducted from April 3, 2017, to June 30, 2019, at a large academic medical center in the US. A total of 26 254 adult surgical patients were randomized to receive either usual intraoperative care (control group; n = 12 980) or usual care augmented by telemedicine decision support (intervention group; n = 13 274). Data were initially analyzed from April 22 to May 19, 2021, with updates in November 2022 and February 2023. Intervention Patients received either usual care (medical direction from the anesthesia care team) or intraoperative anesthesia care monitored and augmented by decision support from the Anesthesiology Control Tower (ACT), a real-time, live telemedicine intervention. The ACT incorporated remote monitoring of operating rooms by a team of anesthesia clinicians with customized analysis software. The ACT reviewed alerts and electronic health record data to inform recommendations to operating room clinicians. Main Outcomes and Measures The primary outcomes were avoidance of postoperative hypothermia (defined as the proportion of patients with a final recorded intraoperative core temperature >36 °C) and hyperglycemia (defined as the proportion of patients with diabetes who had a blood glucose level ≤180 mg/dL on arrival to the postanesthesia recovery area). Secondary outcomes included intraoperative hypotension, temperature monitoring, timely antibiotic redosing, intraoperative glucose evaluation and management, neuromuscular blockade documentation, ventilator management, and volatile anesthetic overuse. Results Among 26 254 participants, 13 393 (51.0%) were female and 20 169 (76.8%) were White, with a median (IQR) age of 60 (47-69) years. There was no treatment effect on avoidance of hyperglycemia (7445 of 8676 patients [85.8%] in the intervention group vs 7559 of 8815 [85.8%] in the control group; rate ratio [RR], 1.00; 95% CI, 0.99-1.01) or hypothermia (7602 of 11 447 patients [66.4%] in the intervention group vs 7783 of 11 672 [66.7.%] in the control group; RR, 1.00; 95% CI, 0.97-1.02). Intraoperative glucose measurement was more common among patients with diabetes in the intervention group (RR, 1.07; 95% CI, 1.01-1.15), but other secondary outcomes were not significantly different. Conclusions and Relevance In this randomized clinical trial, anesthesia care quality measures did not differ between groups, with high confidence in the findings. These results suggest that the intervention did not affect the targeted care practices. Further streamlining of clinical decision support and workflows may help the intraoperative telemedicine program achieve improvement in targeted clinical measures. Trial Registration ClinicalTrials.gov Identifier: NCT02830126.
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Affiliation(s)
- Christopher R. King
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Stephen Gregory
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Daniel L. Helsten
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Brian Torres
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sherry McKinnon
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Shreya Goswami
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Divya Mehta
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Omokhaye Higo
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Paul Kerby
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bernadette Henrichs
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Troy S. Wildes
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha
| | - Mary C. Politi
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
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Lou SS, Dewey MM, Bollini ML, Harford DR, Ingold C, Wildes TS, Stevens TW, Martin JL, Grossman BJ, Kangrga I. Reducing perioperative red blood cell unit issue orders, returns, and waste using failure modes and effects analysis. Transfusion 2023; 63:755-762. [PMID: 36752098 PMCID: PMC10089960 DOI: 10.1111/trf.17275] [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: 09/01/2022] [Revised: 11/07/2022] [Accepted: 01/13/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Surgical transfusion has an outsized impact on hospital-based transfusion services, leading to blood product waste and unnecessary costs. The objective of this study was to design and implement a streamlined, reliable process for perioperative blood issue ordering and delivery to reduce waste. STUDY DESIGN AND METHODS To address the high rates of surgical blood issue requests and red blood cell (RBC) unit waste at a large academic medical center, a failure modes and effects analysis was used to systematically examine perioperative blood management practices. Based on identified failure modes (e.g., miscommunication, knowledge gaps), a multi-component action plan was devised involving process changes, education, electronic clinical decision support, audit, and feedback. Changes in RBC unit issue requests, returns, waste, labor, and cost were measured pre- and post-intervention. RESULTS The number of perioperative RBC unit issue requests decreased from 358 per month (SD 24) pre-intervention to 282 per month (SD 16) post-intervention (p < .001), resulting in an estimated savings of 8.9 h per month in blood bank staff labor. The issue-to-transfusion ratio decreased from 2.7 to 2.1 (p < .001). Perioperative RBC unit waste decreased from 4.5% of units issued pre-intervention to 0.8% of units issued post-intervention (p < .001), saving an estimated $148,543 in RBC unit acquisition costs and $546,093 in overhead costs per year. DISCUSSION Our intervention, designed based on a structured failure modes analysis, achieved sustained reductions in perioperative RBC unit issue orders, returns, and waste, with associated benefits for blood conservation and transfusion program costs.
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Affiliation(s)
- Sunny S. Lou
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Megan M. Dewey
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Mara L. Bollini
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Derek R. Harford
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Cindy Ingold
- Transfusion Services, Barnes-Jewish Hospital, St Louis, MO
| | - Troy S. Wildes
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
- Currently at University of Nebraska Medical Center, Omaha, NE
| | - Tracey W. Stevens
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | | | - Brenda J. Grossman
- Transfusion Services, Barnes-Jewish Hospital, St Louis, MO
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, MO
| | - Ivan Kangrga
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
- Perioperative Services, Barnes-Jewish Hospital, St Louis, MO
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Guay CS, Kafashan M, Huels ER, Jiang Y, Beyoglu B, Spencer JW, Geczi K, Apakama G, Ju YES, Wildes TS, Avidan MS, Palanca BJA. Postoperative Delirium Severity and Recovery Correlate With Electroencephalogram Spectral Features. Anesth Analg 2023; 136:140-151. [PMID: 36130079 PMCID: PMC9653519 DOI: 10.1213/ane.0000000000006075] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND Delirium is an acute syndrome characterized by inattention, disorganized thinking, and an altered level of consciousness. A reliable biomarker for tracking delirium does not exist, but oscillations in the electroencephalogram (EEG) could address this need. We evaluated whether the frequencies of EEG oscillations are associated with delirium onset, severity, and recovery in the postoperative period. METHODS Twenty-six adults enrolled in the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES; ClinicalTrials.gov NCT02241655) study underwent major surgery requiring general anesthesia, and provided longitudinal postoperative EEG recordings for this prespecified substudy. The presence and severity of delirium were evaluated with the confusion assessment method (CAM) or the CAM-intensive care unit. EEG data obtained during awake eyes-open and eyes-closed states yielded relative power in the delta (1-4 Hz), theta (4-8 Hz), and alpha (8-13 Hz) bands. Discriminability for delirium presence was evaluated with c-statistics. To account for correlation among repeated measures within patients, mixed-effects models were generated to assess relationships between: (1) delirium severity and EEG relative power (ordinal), and (2) EEG relative power and time (linear). Slopes of ordinal and linear mixed-effects models are reported as the change in delirium severity score/change in EEG relative power, and the change in EEG relative power/time (days), respectively. Bonferroni correction was applied to confidence intervals (CIs) to account for multiple comparisons. RESULTS Occipital alpha relative power during eyes-closed states offered moderate discriminability (c-statistic, 0.75; 98% CI, 0.58-0.87), varying inversely with delirium severity (slope, -0.67; 98% CI, -1.36 to -0.01; P = .01) and with severity of inattention (slope, -1.44; 98% CI, -2.30 to -0.58; P = .002). Occipital theta relative power during eyes-open states correlated directly with severity of delirium (slope, 1.28; 98% CI, 0.12-2.44; P = .007), inattention (slope, 2.00; 98% CI, 0.48-3.54; P = .01), and disorganized thinking (slope, 3.15; 98% CI, 0.66-5.65; P = .01). Corresponding frontal EEG measures recapitulated these relationships to varying degrees. Severity of altered level of consciousness correlated with frontal theta relative power during eyes-open states (slope, 11.52; 98% CI, 6.33-16.71; P < .001). Frontal theta relative power during eyes-open states correlated inversely with time (slope, -0.05; 98% CI, -0.12 to -0.04; P = .002). CONCLUSIONS Presence, severity, and core features of postoperative delirium covary with spectral features of the EEG. The cost and accessibility of EEG facilitate the translation of these findings to future mechanistic and interventional trials.
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Affiliation(s)
- Christian S Guay
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - MohammadMehdi Kafashan
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Emma R Huels
- Neuroscience Graduate Program
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | | | - Bora Beyoglu
- Baylor Scott and White Research Institute, Plano, Texas
| | | | - Kristin Geczi
- From the Department of Anesthesiology
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Yo-El S Ju
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
- Department of Neurology
- Hope Center for Neurological Disorders
| | | | - Michael S Avidan
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
- Department of Psychiatry
| | - Ben Julian A Palanca
- Department of Psychiatry
- Division of Biology and Biomedical Sciences
- Department of Biomedical Engineering; Washington University School of Medicine in St Louis, St Louis, Missouri
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4
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Fritz BA, King CR, Mickle AM, Wildes TS, Budelier TP, Oberhaus J, Park D, Maybrier HR, Ben Abdallah A, Kronzer A, McKinnon SL, Torres BA, Graetz TJ, Emmert DA, Palanca BJ, Stevens TW, Stark SL, Lenze EJ, Avidan MS. Effect of electroencephalogram-guided anaesthesia administration on 1 yr mortality: 1 yr follow-up of a randomised clinical trial. Br J Anaesth 2021; 127:386-395. [PMID: 34243940 DOI: 10.1016/j.bja.2021.04.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/25/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intraoperative EEG suppression duration has been associated with postoperative delirium and mortality. In a clinical trial testing anaesthesia titration to avoid EEG suppression, the intervention did not decrease the incidence of postoperative delirium, but was associated with reduced 30 day mortality. The present study evaluated whether the EEG-guided anaesthesia intervention continued to be associated with reduced 1 yr mortality. METHODS This manuscript reports 1 yr follow-up of patients from a single-centre RCT, including a post-hoc secondary outcome (1 yr mortality) in addition to pre-specified secondary outcomes. The trial included patients aged 60 yr or older undergoing surgery with general anaesthesia between January 2015 and May 2018. Patients were randomised to receive EEG-guided anaesthesia or usual care. The previously reported primary outcome was postoperative delirium. The outcome of the current study was all-cause 1 yr mortality. RESULTS Of the 1232 patients enrolled, 614 patients were randomised to EEG-guided anaesthesia and 618 patients to usual care. One year mortality was 57/591 (9.6%) in the guided group and 62/601 (10.3%) in the usual-care group. No significant difference in mortality was observed (adjusted absolute risk difference, -0.7%; 99.5% confidence interval, -5.8% to 4.3%; P=0.68). CONCLUSIONS An EEG-guided anaesthesia intervention aiming to decrease duration of EEG suppression during surgery did not significantly decrease 1 yr mortality. These findings, in the context of other studies, do not provide supportive evidence for EEG-guided anaesthesia to prevent intermediate term postoperative death. CLINICAL TRIAL REGISTRATION NCT02241655.
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Affiliation(s)
- Bradley A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Christopher R King
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Angela M Mickle
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Thaddeus P Budelier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Park
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Hannah R Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sherry L McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brian A Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Thomas J Graetz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A Emmert
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ben J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Tracey W Stevens
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Susan L Stark
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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Sindhar S, Kallogjeri D, Wildes TS, Avidan MS, Piccirillo JF. Association of Preoperative Functional Performance With Outcomes After Surgical Treatment of Head and Neck Cancer: A Clinical Severity Staging System. JAMA Otolaryngol Head Neck Surg 2021; 145:1128-1136. [PMID: 31045219 DOI: 10.1001/jamaoto.2019.1035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Patients with head and neck cancers have comorbidities and other constitutional symptoms known to be associated with adverse postoperative outcomes, but the role of functional performance is not well studied. Objective To explore the addition of functional performance to other clinical factors for association with 3 patient outcomes: 30-day unplanned readmission (UR), 90-day medical complications, and overall survival (OS). Design, Setting, and Participants This retrospective cohort study was conducted in a single tertiary care center with patients surgically treated for squamous cell cancer of the lip, oral cavity, pharynx, or larynx from January 2012 to December 2016. All analysis took place between January 2018 and November 2018. Data from 2 registries were analyzed, supplemented with medical record review. Logistic regression analysis was used to explore association of preoperative functional performance with outcomes. Conjunctive consolidation was used to create a useful clinical severity staging system, which included functional performance (estimated from metabolic equivalent [MET] score: <4, light-intensity activities; ≥4 at least moderate-intensity activities); overall comorbidity severity; preoperative weight loss; and TNM tumor staging. Logistic regression was used to assess the prognostic accuracy of the clinical severity staging system for 30-day UR and 90-day complications, and Cox proportional hazard regression for OS. Exposures All patients underwent surgical treatment for head and neck cancer. Main Outcomes and Measures The primary outcomes were 30-day UR and 90-day complications; the secondary outcome was OS. Results For the 657 patients included, the mean (SD) age was 62.0 (11.3) years; 73% were men (n = 477), and 88% were white (n = 580). A total of 75 (11%) had a 30-day UR; 204 (31%) developed a 90-day complication; and 127 (19%) patients died during the observation period. Individually, poor functional performance (<4 METs), high comorbidity burden, preoperative weight loss, and advanced TNM stage were associated with all 3 outcomes; the increased risk for each outcome ranged from 1.5 to 3.0 times the reference range. Using these 4 variables in combination, the 4-category clinical severity staging system demonstrated a strong association between severity stage and all 3 adverse outcomes: 30-day UR (C statistic, 0.63), 90-day complications (C statistic, 0.63), and OS (C statistic, 0.68). Conclusions and Relevance Poor preoperative functional performance, high comorbidity burden, preoperative weight loss, and advanced tumor stage were all associated with worse patient outcomes after head and neck cancer surgery. The model incorporating all 4 of these factors developed in this study may facilitate patient-centered risk assessment and patient-physician shared preoperative decision making.
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Affiliation(s)
- Sampat Sindhar
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis Missouri.,Statistics Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jay F Piccirillo
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis Missouri.,Editor, JAMA Otolaryngology-Head & Neck Surgery
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Smith SK, Nguyen T, Labonte AK, Kafashan M, Hyche O, Guay CS, Wilson E, Chan CW, Luong A, Hickman LB, Fritz BA, Emmert D, Graetz TJ, Melby SJ, Lucey BP, Ju YES, Wildes TS, Avidan MS, Palanca BJA. Protocol for the Prognosticating Delirium Recovery Outcomes Using Wakefulness and Sleep Electroencephalography (P-DROWS-E) study: a prospective observational study of delirium in elderly cardiac surgical patients. BMJ Open 2020; 10:e044295. [PMID: 33318123 PMCID: PMC7737109 DOI: 10.1136/bmjopen-2020-044295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Delirium is a potentially preventable disorder characterised by acute disturbances in attention and cognition with fluctuating severity. Postoperative delirium is associated with prolonged intensive care unit and hospital stay, cognitive decline and mortality. The development of biomarkers for tracking delirium could potentially aid in the early detection, mitigation and assessment of response to interventions. Because sleep disruption has been posited as a contributor to the development of this syndrome, expression of abnormal electroencephalography (EEG) patterns during sleep and wakefulness may be informative. Here we hypothesise that abnormal EEG patterns of sleep and wakefulness may serve as predictive and diagnostic markers for postoperative delirium. Such abnormal EEG patterns would mechanistically link disrupted thalamocortical connectivity to this important clinical syndrome. METHODS AND ANALYSIS P-DROWS-E (Prognosticating Delirium Recovery Outcomes Using Wakefulness and Sleep Electroencephalography) is a 220-patient prospective observational study. Patient eligibility criteria include those who are English-speaking, age 60 years or older and undergoing elective cardiac surgery requiring cardiopulmonary bypass. EEG acquisition will occur 1-2 nights preoperatively, intraoperatively, and up to 7 days postoperatively. Concurrent with EEG recordings, two times per day postoperative Confusion Assessment Method (CAM) evaluations will quantify the presence and severity of delirium. EEG slow wave activity, sleep spindle density and peak frequency of the posterior dominant rhythm will be quantified. Linear mixed-effects models will be used to evaluate the relationships between delirium severity/duration and EEG measures as a function of time. ETHICS AND DISSEMINATION P-DROWS-E is approved by the ethics board at Washington University in St. Louis. Recruitment began in October 2018. Dissemination plans include presentations at scientific conferences, scientific publications and mass media. TRIAL REGISTRATION NUMBER NCT03291626.
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Affiliation(s)
- S Kendall Smith
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Thomas Nguyen
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Alyssa K Labonte
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - MohammadMehdi Kafashan
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Orlandrea Hyche
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Christian S Guay
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Elizabeth Wilson
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Courtney W Chan
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Anhthi Luong
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - L Brian Hickman
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Daniel Emmert
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Thomas J Graetz
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Spencer J Melby
- Department of Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Brendan P Lucey
- Department of Neurology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Yo-El S Ju
- Department of Neurology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ben J A Palanca
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
- Department of Biomedical Engineering, Washington University in St Louis, Saint Louis, Missouri, USA
- Division of Biology and Biomedical Sciences, Washington University in St Louis, Saint Louis, Missouri, USA
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7
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Budelier TP, King CR, Goswami S, Bansal A, Gregory SH, Wildes TS, Abraham J, McKinnon SL, Cooper A, Kangrga I, Martin JL, Milbrandt M, Evers AS, Avidan MS. Protocol for a proof-of-concept observational study evaluating the potential utility and acceptability of a telemedicine solution for the post-anesthesia care unit. F1000Res 2020; 9:1261. [PMID: 33214879 PMCID: PMC7656276 DOI: 10.12688/f1000research.26794.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction: The post-anesthesia care unit (PACU) is a clinical area designated for patients recovering from invasive procedures. There are typically several geographically dispersed PACUs within hospitals. Patients in the PACU can be unstable and at risk for complications. However, clinician coverage and patient monitoring in PACUs is not well regulated and might be sub-optimal. We hypothesize that a telemedicine center for the PACU can improve key PACU functions. Objectives: The objective of this study is to demonstrate the potential utility and acceptability of a telemedicine center to complement the key functions of the PACU. These include participation in hand-off activities to and from the PACU, detection of physiological derangements, identification of symptoms requiring treatment, recognition of situations requiring emergency medical intervention, and determination of patient readiness for PACU discharge. Methods and analysis: This will be a single center prospective before-and-after proof-of-concept study. Adults (18 years and older) undergoing elective surgery and recovering in two selected PACU bays will be enrolled. During the initial three-month observation phase, clinicians in the telemedicine center will not communicate with clinicians in the PACU, unless there is a specific patient safety concern. During the subsequent three-month interaction phase, clinicians in the telemedicine center will provide structured decision support to PACU clinicians. The primary outcome will be time to PACU discharge readiness determination in the two study phases. The attitudes of key stakeholders towards the telemedicine center will be assessed. Other outcomes will include detection of physiological derangements, complications, adverse symptoms requiring treatments, and emergencies requiring medical intervention. Registration: This trial is registered on clinicaltrials.gov,
NCT04020887 (16
th July 2019).
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Affiliation(s)
- Thaddeus P Budelier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Christopher Ryan King
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Shreya Goswami
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Anchal Bansal
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Stephen H Gregory
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA.,Institute for Informatics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Sherry L McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Amy Cooper
- Department of Perioperative Services, Barnes-Jewish Hospital, St. Louis, MO, 63110, USA
| | - Ivan Kangrga
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jackie L Martin
- Department of Perioperative Services, Barnes-Jewish Hospital, St. Louis, MO, 63110, USA
| | - Melissa Milbrandt
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Alex S Evers
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA.,Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA.,Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
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8
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Gregory SH, King CR, Ben Abdallah A, Kronzer A, Wildes TS. Abnormal preoperative cognitive screening in aged surgical patients: a retrospective cohort analysis. Br J Anaesth 2020; 126:230-237. [PMID: 32943193 DOI: 10.1016/j.bja.2020.08.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/24/2020] [Accepted: 08/09/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Preoperative cognitive dysfunction has been associated with adverse postoperative outcomes. There are limited data characterising the epidemiology of preoperative cognitive dysfunction in older surgical patients. METHODS This retrospective cohort included all patients ≥65 yr old seen at the Washington University preoperative clinic between January 2013 and June 2018. Cognitive screening was performed using the Short-Blessed Test (SBT) and Eight-Item Interview to Differentiate Aging and Dementia (AD8) screen. The primary outcome of abnormal cognitive screening was defined as SBT score ≥5 or AD8 score ≥2. Multivariable logistic regression was used to identify associated factors. RESULTS Overall, 21 666 patients ≥65 yr old completed screening during the study period; 23.5% (n=5099) of cognitive screens were abnormal. Abnormal cognitive screening was associated with increasing age, decreasing BMI, male sex, non-Caucasian race, decreased functional independence, and decreased metabolic functional capacity. Patients with a history of stroke or transient ischaemic attack, chronic obstructive pulmonary disease, diabetes mellitus, hepatic cirrhosis, and heavy alcohol use were also more likely to have an abnormal cognitive screen. Predictive modelling showed no combination of patient factors was able to reliably identify patients who had a <10% probability of abnormal cognitive screening. CONCLUSIONS Routine preoperative cognitive screening of unselected aged surgical patients often revealed deficits consistent with cognitive impairment or dementia. Such deficits were associated with increased age, decreased function, decreased BMI, and several common medical comorbidities. Further research is necessary to characterise the clinical implications of preoperative cognitive dysfunction and identify interventions that may reduce related postoperative complications.
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Affiliation(s)
- Stephen H Gregory
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA.
| | - Christopher R King
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Alex Kronzer
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
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9
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Fritz BA, King CR, Ben Abdallah A, Lin N, Mickle AM, Budelier TP, Oberhaus J, Park D, Maybrier HR, Wildes TS, Avidan MS, Apakama G, Aranake-Chrisinger A, Bolzenius J, Burton J, Cui V, Emmert DA, Goswami S, Graetz TJ, Gupta S, Jordan K, Kronzer A, McKinnon SL, Muench MR, Murphy MR, Palanca BJ, Patel A, Spencer JW, Stevens TW, Strutz P, Tedeschi CM, Torres BA, Trammel ER, Upadhyayula RT, Winter AC, Jacobsohn E, Fong T, Gallagher J, Inouye SK, Schmitt EM, Somerville E, Stark S, Lenze EJ, Melby SJ, Tappenden J. Preoperative Cognitive Abnormality, Intraoperative Electroencephalogram Suppression, and Postoperative Delirium: A Mediation Analysis. Anesthesiology 2020; 132:1458-1468. [PMID: 32032096 DOI: 10.1097/aln.0000000000003181] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Postoperative delirium is a common complication that hinders recovery after surgery. Intraoperative electroencephalogram suppression has been linked to postoperative delirium, but it is unknown if this relationship is causal or if electroencephalogram suppression is merely a marker of underlying cognitive abnormalities. The hypothesis of this study was that intraoperative electroencephalogram suppression mediates a nonzero portion of the effect between preoperative abnormal cognition and postoperative delirium. METHODS This is a prespecified secondary analysis of the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized trial, which enrolled patients age 60 yr or older undergoing surgery with general anesthesia at a single academic medical center between January 2015 and May 2018. Patients were randomized to electroencephalogram-guided anesthesia or usual care. Preoperative abnormal cognition was defined as a composite of previous delirium, Short Blessed Test cognitive score greater than 4 points, or Eight Item Interview to Differentiate Aging and Dementia score greater than 1 point. Duration of intraoperative electroencephalogram suppression was defined as number of minutes with suppression ratio greater than 1%. Postoperative delirium was detected via Confusion Assessment Method or chart review on postoperative days 1 to 5. RESULTS Among 1,113 patients, 430 patients showed evidence of preoperative abnormal cognition. These patients had an increased incidence of postoperative delirium (151 of 430 [35%] vs.123 of 683 [18%], P < 0.001). Of this 17.2% total effect size (99.5% CI, 9.3 to 25.1%), an absolute 2.4% (99.5% CI, 0.6 to 4.8%) was an indirect effect mediated by electroencephalogram suppression, while an absolute 14.8% (99.5% CI, 7.2 to 22.5%) was a direct effect of preoperative abnormal cognition. Randomization to electroencephalogram-guided anesthesia did not change the mediated effect size (P = 0.078 for moderation). CONCLUSIONS A small portion of the total effect of preoperative abnormal cognition on postoperative delirium was mediated by electroencephalogram suppression. Study precision was too low to determine if the intervention changed the mediated effect.
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Affiliation(s)
- Bradley A Fritz
- From the Department of Anesthesiology (B.A.F., C.R.K., A.B., A.M.M., T.P.B., J.O., D.P., H.R.M., T.S.W., M.S.A) the Division of Biostatistics (N.L.), Washington University School of Medicine, St. Louis, Missouri the Department of Mathematics and Statistics, Washington University in St. Louis, St. Louis, Missouri (N.L.). Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, University of Manitoba, Winnipeg, Canada Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Medicine, Beth Israel-Deaconess Medical Center, Boston, Massachusetts Department of Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri Department of Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri Department of Surgery, Washington University School of Medicine, St. Louis, Missouri Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Bombardieri AM, Wildes TS, Stevens T, Wolfson M, Steinhorn R, Ben Abdallah A, Sleigh J, Avidan MS. Practical Training of Anesthesia Clinicians in Electroencephalogram-Based Determination of Hypnotic Depth of General Anesthesia. Anesth Analg 2020; 130:777-786. [PMID: 31880629 DOI: 10.1213/ane.0000000000004537] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Electroencephalographic (EEG) brain monitoring during general anesthesia provides information on hypnotic depth. We hypothesized that anesthesia clinicians could be trained rapidly to recognize typical EEG waveforms occurring with volatile-based general anesthesia. METHODS This was a substudy of a trial testing the hypothesis that EEG-guided anesthesia prevents postoperative delirium. The intervention was a 35-minute training session, summarizing typical EEG changes with volatile-based anesthesia. Participants completed a preeducational test, underwent training, and completed a posteducational test. For each question, participants indicated whether the EEG was consistent with (1) wakefulness, (2) non-slow-wave anesthesia, (3) slow-wave anesthesia, or (4) burst suppression. They also indicated whether the processed EEG (pEEG) index was discordant with the EEG waveforms. Four clinicians, experienced in intraoperative EEG interpretation, independently evaluated the EEG waveforms, resolved disagreements, and provided reference answers. Ten questions were assessed in the preeducational test and 9 in the posteducational test. RESULTS There were 71 participants; 13 had previous anesthetic-associated EEG interpretation training. After training, the 58 participants without prior training improved at identifying dominant EEG waveforms (median 60% with interquartile range [IQR], 50%-70% vs 78% with IQR, 67%-89%; difference: 18%; 95% confidence interval [CI], 8-27; P < .001). In contrast, there was no significant improvement following the training for the 13 participants who reported previous training (median 70% with IQR, 60%-80% vs 67% with IQR, 67%-78%; difference: -3%; 95% CI, -18 to 11; P = .88). The difference in the change between the pre- and posteducational session for the previously untrained versus previously trained was statistically significant (difference in medians: 21%; 95% CI, 2-28; P = .005). Clinicians without prior training also improved in identifying discordance between the pEEG index and the EEG waveform (median 60% with IQR, 40%-60% vs median 100% with IQR, 75%-100%; difference: 40%; 95% CI, 30-50; P < .001). Clinicians with prior training showed no significant improvement (median 60% with IQR, 60%-80% vs 75% with IQR, 75%-100%; difference: 15%; 95% CI, -16 to 46; P = .16). Regarding the identification of discordance, the difference in the change between the pre- and posteducational session for the previously untrained versus previously trained was statistically significant (difference in medians: 25%; 95% CI, 5-45; P = .012). CONCLUSIONS A brief training session was associated with improvements in clinicians without prior EEG training in (1) identifying EEG waveforms corresponding to different hypnotic depths and (2) recognizing when the hypnotic depth suggested by the EEG was discordant with the pEEG index.
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Affiliation(s)
- Anna Maria Bombardieri
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Troy S Wildes
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Tracey Stevens
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Maxim Wolfson
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Rachel Steinhorn
- Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Arbi Ben Abdallah
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Jamie Sleigh
- Department of Anesthesiology, Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Michael S Avidan
- From the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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11
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Bombardieri AM, Mathur S, Soares A, Sharma A, Ben Abdallah A, Wildes TS, Avidan MS. Intraoperative Awareness With Recall. Anesth Analg 2019; 129:1291-1297. [DOI: 10.1213/ane.0000000000004358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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12
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Affiliation(s)
- Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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13
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Sadiq F, Kronzer VL, Wildes TS, McKinnon SL, Sharma A, Helsten DL, Scheier LM, Avidan MS, Ben Abdallah A. Frailty Phenotypes and Relations With Surgical Outcomes: A Latent Class Analysis. Anesth Analg 2019; 127:1017-1027. [PMID: 30113393 DOI: 10.1213/ane.0000000000003695] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Frailty is an important concept in the care of older adults although controversy remains regarding its defining features and clinical utility. Both the Fried phenotype and the Rockwood deficit accumulation approaches cast frailty as a "burden" without exploring the relative salience of its cardinal markers and their relevance to the patient. New multifactorial perspectives require a reliable assessment of frailty that can validly predict postoperative health outcomes. METHODS In a retrospective study of 2828 unselected surgical patients, we used item response theory to examine the ability of 32 heterogeneous markers capturing limitations in physical, functional, emotional, and social activity domains to indicate severity of frailty as a latent continuum. Eighteen markers efficiently indicated frailty severity and were then subject to latent class analysis to derive discrete phenotypes. Next, we validated the obtained frailty phenotypes against patient-reported 30-day postoperative outcomes using multivariable logistic regression. Models were adjusted for demographics, comorbidity, type and duration of surgery, and cigarette and alcohol consumption. RESULTS The 18 markers provided psychometric evidence of a single reliable continuum of frailty severity. Latent class analyses produced 3 distinct subtypes, based on patients' endorsement probabilities of the frailty indicators: not frail (49.7%), moderately frail (33.5%), and severely frail (16.7%). Unlike the moderate class, severely frail endorsed emotional health problems in addition to physical burdens and functional limitations. Models adjusting for age, sex, type of anesthesia, and intraoperative factors indicated that severely frail (odds ratio, 1.89; 95% confidence interval, 1.42-2.50) and moderately frail patients (odds ratio, 1.31; 95% confidence interval, 1.03-1.67) both had higher odds of experiencing postoperative complications compared to not frail patients. In a 3-way comparison, a higher proportion of severely frail patients (10.7%) reported poorer quality of life after surgery compared to moderately frail (9.2%) and not frail (8.3%) patients (P < .001). There was no significant difference among these groups in proportions reporting hospital readmission (5.6%, 5.1%, and 3.8%, respectively; P = .067). CONCLUSIONS Self-report frailty items can accurately discern 3 distinct phenotypes differing in composition and their relations with surgical outcomes. Systematically assessing a wider set of domains including limitations in functional, emotional, and social activities can inform clinicians on what precipitates loss of physiological reserve and profoundly influences patients' lives. This information can help guide the current discussion on frailty and add meaningful clinical tools to the surgical practice.
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Affiliation(s)
- Furqaan Sadiq
- From the Department of Anesthesiology, Institute of Quality Improvement, Research & Informatics (INQUIRI), Washington University School of Medicine, St Louis, Missouri
| | | | - Troy S Wildes
- From the Department of Anesthesiology, Institute of Quality Improvement, Research & Informatics (INQUIRI), Washington University School of Medicine, St Louis, Missouri
| | - Sherry L McKinnon
- From the Department of Anesthesiology, Institute of Quality Improvement, Research & Informatics (INQUIRI), Washington University School of Medicine, St Louis, Missouri
| | - Anshuman Sharma
- From the Department of Anesthesiology, Institute of Quality Improvement, Research & Informatics (INQUIRI), Washington University School of Medicine, St Louis, Missouri
| | - Daniel L Helsten
- From the Department of Anesthesiology, Institute of Quality Improvement, Research & Informatics (INQUIRI), Washington University School of Medicine, St Louis, Missouri
| | | | - Michael S Avidan
- From the Department of Anesthesiology, Institute of Quality Improvement, Research & Informatics (INQUIRI), Washington University School of Medicine, St Louis, Missouri
| | - Arbi Ben Abdallah
- From the Department of Anesthesiology, Institute of Quality Improvement, Research & Informatics (INQUIRI), Washington University School of Medicine, St Louis, Missouri
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14
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Mickle AM, Maybrier HR, Winter AC, McKinnon SL, Torres BA, Lin N, Lenze EJ, Stark S, Muench MR, Jacobsohn E, Inouye SK, Avidan MS, Wildes TS. Achieving Milestones as a Prerequisite for Proceeding With a Clinical Trial. Anesth Analg 2019; 126:1851-1858. [PMID: 29239943 DOI: 10.1213/ane.0000000000002680] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although the National Institutes of Health (NIH) invests $30 billion in research annually, many funded studies fail to generate results that can inform practice. The National Institutes of Health introduced a phased funding mechanism as one potential solution. Study-specific milestones are established for an initial pilot phase. We assess the utility of this phased approach through the ongoing Electroencephalography (EEG) Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) pragmatic clinical trial. The hypothesis of the trial is that EEG guidance of general anesthesia, through prevention of EEG suppression, can decrease postoperative delirium and its downstream negative sequelae. METHODS In collaboration with study stakeholders, we identified critical milestones for the ENGAGES study, with themes common to many clinical trials. These themes include: regulatory tasks; enrollment targets; feasibility and impact of study intervention; primary outcome incidence; measurement reliability of primary outcome; and follow-up. Progress in achieving the milestones was assessed at regular intervals during the pilot phase by ENGAGES investigators, a National Institute on Aging program officer, and a nonpartisan research organization (Westat). RESULTS Regulatory tasks, including institutional review board approval, infrastructure establishment, and trial registration, were completed on schedule. A total of 117 patients were randomized, exceeding the target by 51. The EEG-guided protocol was successfully implemented, and a relevant effect on anesthetic practice was demonstrated (decrease in median age-adjusted minimum alveolar anesthetic concentration from 0.93 to 0.78 [P < .001] and increase in median proportion of zero EEG suppression time from 87% to 94% [P < .01]). Nearly all patients (115 of 117, 98.3%) were assessed for delirium using the Confusion Assessment Method, and the delirium incidence was similar (28.1%; 95% CI, 20%-37%) to the estimate (25%) used for the sample size calculation. Good interrater reliability of delirium assessment was demonstrated (κ = 0.94 [95% CI, 0.86-1]). Finally, 1-month follow-up vital status data were obtained for 96.9% of patients, with 85.7% of patients completing at least 1 survey. CONCLUSIONS With the ENGAGES trial, we demonstrated that key milestones can be identified and progressively assessed during a pilot phase. Success in attaining appropriate milestones hypothetically predicts meaningful completion of a study, and can provide justification for proceeding beyond a pilot phase. The impact of this phased approach on return on investment and scientific yield requires additional study.
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Affiliation(s)
- Angela M Mickle
- From the Washington University School of Medicine, St Louis, Missouri
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15
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Affiliation(s)
- Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Angela M Mickle
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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16
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Wildes TS, Mickle AM, Ben Abdallah A, Maybrier HR, Oberhaus J, Budelier TP, Kronzer A, McKinnon SL, Park D, Torres BA, Graetz TJ, Emmert DA, Palanca BJ, Goswami S, Jordan K, Lin N, Fritz BA, Stevens TW, Jacobsohn E, Schmitt EM, Inouye SK, Stark S, Lenze EJ, Avidan MS. Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial. JAMA 2019; 321:473-483. [PMID: 30721296 PMCID: PMC6439616 DOI: 10.1001/jama.2018.22005] [Citation(s) in RCA: 252] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium. OBJECTIVE To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 1232 adults aged 60 years and older undergoing major surgery and receiving general anesthesia at Barnes-Jewish Hospital in St Louis. Recruitment was from January 2015 to May 2018, with follow-up until July 2018. INTERVENTIONS Patients were randomized 1:1 (stratified by cardiac vs noncardiac surgery and positive vs negative recent fall history) to receive EEG-guided anesthetic administration (n = 614) or usual anesthetic care (n = 618). MAIN OUTCOMES AND MEASURES The primary outcome was incident delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration, EEG suppression, and hypotension. Adverse events included undesirable intraoperative movement, intraoperative awareness with recall, postoperative nausea and vomiting, medical complications, and death. RESULTS Of the 1232 randomized patients (median age, 69 years [range, 60 to 95]; 563 women [45.7%]), 1213 (98.5%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 157 of 604 patients (26.0%) in the guided group and 140 of 609 patients (23.0%) in the usual care group (difference, 3.0% [95% CI, -2.0% to 8.0%]; P = .22). Median end-tidal volatile anesthetic concentration was significantly lower in the guided group than the usual care group (0.69 vs 0.80 minimum alveolar concentration; difference, -0.11 [95% CI, -0.13 to -0.10), and median cumulative time with EEG suppression was significantly less (7 vs 13 minutes; difference, -6.0 [95% CI, -9.9 to -2.1]). There was no significant difference between groups in the median cumulative time with mean arterial pressure below 60 mm Hg (7 vs 7 minutes; difference, 0.0 [95% CI, -1.7 to 1.7]). Undesirable movement occurred in 137 patients (22.3%) in the guided and 95 (15.4%) in the usual care group. No patients reported intraoperative awareness. Postoperative nausea and vomiting was reported in 48 patients (7.8%) in the guided and 55 patients (8.9%) in the usual care group. Serious adverse events were reported in 124 patients (20.2%) in the guided and 130 (21.0%) in the usual care group. Within 30 days of surgery, 4 patients (0.65%) in the guided group and 19 (3.07%) in the usual care group died. CONCLUSIONS AND RELEVANCE Among older adults undergoing major surgery, EEG-guided anesthetic administration, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support the use of EEG-guided anesthetic administration for this indication. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02241655.
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Affiliation(s)
- Troy S. Wildes
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Angela M. Mickle
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Hannah R. Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Sherry L. McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Park
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Brian A. Torres
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Thomas J. Graetz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel A. Emmert
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Ben J. Palanca
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Shreya Goswami
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Katherine Jordan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Nan Lin
- Department of Mathematics, Washington University School of Medicine, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Tracey W. Stevens
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Eric Jacobsohn
- Department of Anesthesiology, University of Manitoba, Winnipeg, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel-Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel-Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Susan Stark
- Department of Occupational Therapy, Washington University School of Medicine, St Louis, Missouri
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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Maybrier HR, King CR, Crawford AE, Mickle AM, Emmert DA, Wildes TS, Avidan MS, Palanca BJA. Early Postoperative Actigraphy Poorly Predicts Hypoactive Delirium. J Clin Sleep Med 2019; 15:79-87. [PMID: 30621829 DOI: 10.5664/jcsm.7576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 09/12/2018] [Indexed: 12/24/2022]
Abstract
STUDY OBJECTIVES Delirium is a postoperative complication accompanied by disturbances in attention, cognition, arousal, and psychomotor activity. Wrist actigraphy has been advocated to study inactivity and inferred sleep patterns during delirium. We hypothesized that altered patterns of motor activity or immobility, reflective of disordered sleep and wakefulness patterns, would serve as predictive markers of hypoactive postoperative delirium. METHODS Eighty-four elderly surgical patients were classified into three groups based on the timing of hypoactive delirium following surgery: intact with no delirium throughout postoperative days (POD) 0-5 (n = 51), delirium during POD 0-1 (n = 24), and delirium during POD 2-5 (n = 13). Delirium was detected on daily Confusion Assessment Method evaluations and chart review. Actigraphy measures were calculated from accelerometry signals acquired on the first postoperative day (POD 0, 16:00-23:00) and night (POD 0, 23:00-POD 1, 06:00). RESULTS Actigraphy metrics showed substantial interpatient variability. Among the three patient groups, only those without delirium showed greater movement during the day compared to night and also fewer minutes of night immobility (P = .03 and P = .02, Wilcoxon rank-sum tests). These patients were poorly discriminated from those with delirium during either POD 0-1 or POD 2-5, using differences in day and night activity (C-statistic, 95% confidence interval [CI]: 0.66 [0.53-0.79] and C-statistic, 95% CI: 0.71 [0.55-0.87], respectively). Inclusion of low-frequency signals improved performance of immobility measures without affecting those based on activity. Cognitively intact patients during POD 0-5 were distinguished from those with delirium during POD 0-1, based on differences in the number of day and night immobile minutes (C-statistic 0.65, 95% CI: [0.53-0.78]). Actigraphy metrics with the strongest association to delirium incidence were not reliably correlated with an increased risk during POD 0-5, when accounting for patient age, sex, intensive care unit admission, and Charlson Comorbidity Index (adjusted odds ratio of 1.7, 95% CI: [1.0-3.0], P = .09, likelihood ratio test). CONCLUSIONS Early postoperative wrist actigraphy metrics that serve as markers of sleep and wakefulness offer limited capacity as sole predictors or markers of hypoactive delirium. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) Study; Identifier: NCT02241655; URL: https://clinicaltrials.gov/ct2/show/NCT02241655.
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Affiliation(s)
- Hannah R Maybrier
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - C Rya King
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Amanda E Crawford
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Angela M Mickle
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel A Emmert
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri.,Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri.,Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ben Julian A Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri.,Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Abstract
Delirium commonly manifests in the postoperative period as a clinical syndrome resulting from acute brain dysfunction or encephalopathy. Delirium is characterized by acute and often fluctuating changes in attention and cognition. Emergence delirium typically presents and resolves within minutes to hours after termination of general anaesthesia. Postoperative delirium hours to days after an invasive procedure can herald poor outcomes. Easily recognized when patients are hyperactive or agitated, delirium often evades diagnosis as it most frequently presents with hypoactivity and somnolence. EEG offers objective measurements to complement clinical assessment of this complex fluctuating disorder. Although EEG features of delirium in the postoperative period remain incompletely characterized, a shift of EEG power into low frequencies is a typical finding shared among encephalopathies that manifest with delirium. In aggregate, existing data suggest that serial or continuous EEG in the postoperative period facilitates monitoring of delirium development and severity and assists in detecting epileptic aetiologies. Future studies are needed to clarify the precise EEG features that can reliably predict or diagnose delirium in the postoperative period, and to provide mechanistic insights into this pathologically diverse neurological disorder.
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Affiliation(s)
| | | | | | - S Ching
- Department of Electrical and Systems Engineering.,Department of Biomedical Engineering
| | - M S Avidan
- Department of Anesthesiology.,Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine in St Louis, St Louis, MO, USA
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19
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Maybrier HR, Mickle AM, Escallier KE, Lin N, Schmitt EM, Upadhyayula RT, Wildes TS, Mashour GA, Palihnich K, Inouye SK, Avidan MS. Reliability and accuracy of delirium assessments among investigators at multiple international centres. BMJ Open 2018; 8:e023137. [PMID: 30467132 PMCID: PMC6252643 DOI: 10.1136/bmjopen-2018-023137] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Delirium is a common, serious postoperative complication. For clinical studies to generate valid findings, delirium assessments must be standardised and administered accurately by independent researchers. The Confusion Assessment Method (CAM) is a widely used delirium assessment tool. The objective was to determine whether implementing a standardised CAM training protocol for researchers at multiple international sites yields reliable inter-rater assessment and accurate delirium diagnosis. METHODS Patients consented to video recordings of CAM delirium assessments for research purposes. Raters underwent structured training in CAM administration. Training entailed didactic education, role-playing with intensive feedback, apprenticeship with experienced researchers and group discussions of complex cases. Raters independently viewed and scored nine video-recorded CAM interviews. Inter-rater reliability was determined using Fleiss kappa. Accuracy was judged by comparing raters' scores with those of an expert delirium researcher. RESULTS Twenty-seven raters from eight international research centres completed the study and achieved almost perfect agreement for overall delirium diagnosis, kappa=0.88 (95% CI 0.85 to 0.92). Agreement of the four core CAM features ranged from fair to substantial. The sensitivity and specificity for identifying delirium were 72% (95% CI 60% to 81%) and 99% (95% CI 96% to 100%), considering an expert rater's scores as the reference standard (delirious, n=3; non-delirious, n=6). Delirium severity ratings were tightly clustered, with most scores within 5% of the median. CONCLUSION Our results demonstrate that, with appropriate training and ongoing scoring discussions, researchers at multiple sites can reliably detect delirium in postsurgical patients. These results support the premise that methodologically rigorous multi-centre studies can yield standardised and accurate determinations of delirium.
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Affiliation(s)
- Hannah R Maybrier
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Angela M Mickle
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Krisztina E Escallier
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Nan Lin
- Department of Mathematics, Washington University in Saint Louis, St. Louis, Missouri, USA
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Ravi T Upadhyayula
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kerry Palihnich
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Simon Avidan
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
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Gregory S, Murray-Torres TM, Fritz BA, Ben Abdallah A, Helsten DL, Wildes TS, Sharma A, Avidan MS. Study protocol for the Anesthesiology Control Tower-Feedback Alerts to Supplement Treatments (ACTFAST-3) trial: a pilot randomized controlled trial in intraoperative telemedicine. F1000Res 2018; 7:623. [PMID: 30026931 PMCID: PMC6039946 DOI: 10.12688/f1000research.14897.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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] [Accepted: 08/07/2018] [Indexed: 03/17/2024] Open
Abstract
Background: Each year, over 300 million people undergo surgical procedures worldwide. Despite efforts to improve outcomes, postoperative morbidity and mortality are common. Many patients experience complications as a result of either medical error or failure to adhere to established clinical practice guidelines. This protocol describes a clinical trial comparing a telemedicine-based decision support system, the Anesthesiology Control Tower (ACT), with enhanced standard intraoperative care. Methods: This study is a pragmatic, comparative effectiveness trial that will randomize approximately 12,000 adult surgical patients on an operating room (OR) level to a control or to an intervention group. All OR clinicians will have access to decision support software within the OR as a part of enhanced standard intraoperative care. The ACT will monitor patients in both groups and will provide additional support to the clinicians assigned to intervention ORs. Primary outcomes include blood glucose management and temperature management. Secondary outcomes will include surrogate, clinical, and economic outcomes, such as incidence of intraoperative hypotension, postoperative respiratory compromise, acute kidney injury, delirium, and volatile anesthetic utilization. Ethics and dissemination: The ACTFAST-3 study has been approved by the Human Resource Protection Office (HRPO) at Washington University in St. Louis and is registered at clinicaltrials.gov ( NCT02830126). Recruitment for this protocol began in April 2017 and will end in December 2018. Dissemination of the findings of this study will occur via presentations at academic conferences, journal publications, and educational materials.
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Affiliation(s)
- Stephen Gregory
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Teresa M. Murray-Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Daniel L. Helsten
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Troy S. Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Anshuman Sharma
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - ACTFAST Study Group
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
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21
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Gregory S, Murray-Torres TM, Fritz BA, Ben Abdallah A, Helsten DL, Wildes TS, Sharma A, Avidan MS. Study protocol for the Anesthesiology Control Tower-Feedback Alerts to Supplement Treatments (ACTFAST-3) trial: a pilot randomized controlled trial in intraoperative telemedicine. F1000Res 2018; 7:623. [PMID: 30026931 PMCID: PMC6039946 DOI: 10.12688/f1000research.14897.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2018] [Indexed: 01/15/2023] Open
Abstract
Background: Each year, over 300 million people undergo surgical procedures worldwide. Despite efforts to improve outcomes, postoperative morbidity and mortality are common. Many patients experience complications as a result of either medical error or failure to adhere to established clinical practice guidelines. This protocol describes a clinical trial comparing a telemedicine-based decision support system, the Anesthesiology Control Tower (ACT), with enhanced standard intraoperative care. Methods: This study is a pragmatic, comparative effectiveness trial that will randomize approximately 12,000 adult surgical patients on an operating room (OR) level to a control or to an intervention group. All OR clinicians will have access to decision support software within the OR as a part of enhanced standard intraoperative care. The ACT will monitor patients in both groups and will provide additional support to the clinicians assigned to intervention ORs. Primary outcomes include blood glucose management and temperature management. Secondary outcomes will include surrogate, clinical, and economic outcomes, such as incidence of intraoperative hypotension, postoperative respiratory compromise, acute kidney injury, delirium, and volatile anesthetic utilization. Ethics and dissemination: The ACTFAST-3 study has been approved by the Human Resource Protection Office (HRPO) at Washington University in St. Louis and is registered at clinicaltrials.gov ( NCT02830126). Recruitment for this protocol began in April 2017 and will end in December 2018. Dissemination of the findings of this study will occur via presentations at academic conferences, journal publications, and educational materials.
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Affiliation(s)
- Stephen Gregory
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Teresa M Murray-Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Daniel L Helsten
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Anshuman Sharma
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
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22
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Fritz BA, Chen Y, Murray-Torres TM, Gregory S, Ben Abdallah A, Kronzer A, McKinnon SL, Budelier T, Helsten DL, Wildes TS, Sharma A, Avidan MS. Using machine learning techniques to develop forecasting algorithms for postoperative complications: protocol for a retrospective study. BMJ Open 2018; 8:e020124. [PMID: 29643160 PMCID: PMC5898287 DOI: 10.1136/bmjopen-2017-020124] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Mortality and morbidity following surgery are pressing public health concerns in the USA. Traditional prediction models for postoperative adverse outcomes demonstrate good discrimination at the population level, but the ability to forecast an individual patient's trajectory in real time remains poor. We propose to apply machine learning techniques to perioperative time-series data to develop algorithms for predicting adverse perioperative outcomes. METHODS AND ANALYSIS This study will include all adult patients who had surgery at our tertiary care hospital over a 4-year period. Patient history, laboratory values, minute-by-minute intraoperative vital signs and medications administered will be extracted from the electronic medical record. Outcomes will include in-hospital mortality, postoperative acute kidney injury and postoperative respiratory failure. Forecasting algorithms for each of these outcomes will be constructed using density-based logistic regression after employing a Nadaraya-Watson kernel density estimator. Time-series variables will be analysed using first and second-order feature extraction, shapelet methods and convolutional neural networks. The algorithms will be validated through measurement of precision and recall. ETHICS AND DISSEMINATION This study has been approved by the Human Research Protection Office at Washington University in St Louis. The successful development of these forecasting algorithms will allow perioperative healthcare clinicians to predict more accurately an individual patient's risk for specific adverse perioperative outcomes in real time. Knowledge of a patient's dynamic risk profile may allow clinicians to make targeted changes in the care plan that will alter the patient's outcome trajectory. This hypothesis will be tested in a future randomised controlled trial.
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Affiliation(s)
- Bradley A Fritz
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Yixin Chen
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, Missouri, USA
| | - Teresa M Murray-Torres
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Stephen Gregory
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Alex Kronzer
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Sherry Lynn McKinnon
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Thaddeus Budelier
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Daniel L Helsten
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Anshuman Sharma
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Michael Simon Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri, USA
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Palanca BJA, Maybrier HR, Mickle AM, Farber NB, Hogan RE, Trammel ER, Spencer JW, Bohnenkamp DD, Wildes TS, Ching S, Lenze E, Basner M, Kelz MB, Avidan MS. Cognitive and Neurophysiological Recovery Following Electroconvulsive Therapy: A Study Protocol. Front Psychiatry 2018; 9:171. [PMID: 29867602 PMCID: PMC5960711 DOI: 10.3389/fpsyt.2018.00171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 04/13/2018] [Indexed: 01/01/2023] Open
Abstract
Electroconvulsive therapy (ECT) employs the elective induction of generalizes seizures as a potent treatment for severe psychiatric illness. As such, ECT provides an opportunity to rigorously study the recovery of consciousness, reconstitution of cognition, and electroencephalographic (EEG) activity following seizures. Fifteen patients with major depressive disorder refractory to pharmacologic therapy will be enrolled (Clinicaltrials.gov, NCT02761330). Adequate seizure duration will be confirmed following right unilateral ECT under etomidate anesthesia. Patients will then undergo randomization for the order in which they will receive three sequential treatments: etomidate + ECT, ketamine + ECT, and ketamine + sham ECT. Sessions will be repeated in the same sequence for a total of six treatments. Before each session, sensorimotor speed, working memory, and executive function will be assessed through a standardized cognitive test battery. After each treatment, the return of purposeful responsiveness to verbal command will be determined. At this point, serial cognitive assessments will begin using the same standardized test battery. The presence of delirium and changes in depression severity will also be ascertained. Sixty-four channel EEG will be acquired throughout baseline, ictal, and postictal epochs. Mixed-effects models will correlate the trajectories of cognitive recovery, clinical outcomes, and EEG metrics over time. This innovative research design will answer whether: (1) time to return of responsiveness will be prolonged with ketamine + ECT compared with ketamine + sham ECT; (2) time of restoration to baseline function in each cognitive domain will take longer after ketamine + ECT than after ketamine + sham ECT; (3) postictal delirium is associated with delayed restoration of baseline function in all cognitive domains; and (4) the sequence of reconstitution of cognitive domains following the three treatments in this study is similar to that occurring after an isoflurane general anesthetic (NCT01911195). Sub-studies will assess the relationships of cognitive recovery to the EEG preceding, concurrent, and following individual ECT sessions. Overall, this study will lead the development of biomarkers for tailoring the cogno-affective recovery of patients undergoing ECT.
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Affiliation(s)
- Ben J A Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St Louis, MO, United States.,Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Hannah R Maybrier
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Angela M Mickle
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Nuri B Farber
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - R Edward Hogan
- Department of Neurology, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Emma R Trammel
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - J Wylie Spencer
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Donald D Bohnenkamp
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - ShiNung Ching
- Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St Louis, MO, United States.,Department of Electrical Systems and Engineering, Washington University, St Louis, MO, United States
| | - Eric Lenze
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Mathias Basner
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Max B Kelz
- Department of Anesthesiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St Louis, MO, United States.,Department of Surgery, Washington University School of Medicine in St. Louis, St Louis, MO, United States
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Kronzer VL, Jerry MR, Ben Abdallah A, Wildes TS, McKinnon SL, Sharma A, Avidan MS. Changes in quality of life after elective surgery: an observational study comparing two measures. Qual Life Res 2017; 26:2093-2102. [PMID: 28357679 DOI: 10.1007/s11136-017-1560-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 03/21/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE Our main objective was to compare the change in a validated quality of life measure to a global assessment measure. The secondary objectives were to estimate the minimum clinically important difference (MCID) and to describe the change in quality of life by surgical specialty. METHODS This prospective cohort study included 7902 adult patients undergoing elective surgery. Changes in the Veterans RAND 12-Item Health Survey (VR-12), composed of a physical component summary (PCS) and a mental component summary (MCS), were calculated using preoperative and postoperative questionnaires. The latter also contained a global assessment question for quality of life. We compared PCS and MCS to the global assessment using descriptive statistics and weighted kappa. MCID was calculated using an anchor-based approach. Analyses were pre-specified and registered (NCT02771964). RESULTS By the change in VR-12 scores, an equal proportion of patients experienced improvement and deterioration in quality of life (28% for PCS, 25% for MCS). In contrast, by the global assessment measure, 61% reported improvement, while only 10% reported deterioration. Agreement with the global assessment was slight for both PCS (kappa = 0.20, 57% matched) and MCS (kappa = 0.10, 54% matched). The MCID for the overall VR-12 score was approximately 2.5 points. Patients undergoing orthopedic surgery showed the most improvement in quality of life measures, while patients undergoing gastrointestinal/hepatobiliary or urologic surgery showed the most deterioration. CONCLUSIONS Subjective global quality of life report does not agree well with a validated quality of life instrument, perhaps due to patient over-optimism.
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Affiliation(s)
- Vanessa L Kronzer
- Department of Anesthesia, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO, 63110, USA
| | - Michelle R Jerry
- Department of Biostatistics, University of Michigan, 534 Canton Street, Canton, MI, 48188, USA
| | - Arbi Ben Abdallah
- Department of Anesthesia, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO, 63110, USA
| | - Troy S Wildes
- Department of Anesthesia, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO, 63110, USA
| | - Sherry L McKinnon
- Department of Anesthesia, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO, 63110, USA
| | - Anshuman Sharma
- Department of Anesthesia, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO, 63110, USA
| | - Michael S Avidan
- Department of Anesthesia, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO, 63110, USA.
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Wildes TS, Avidan MS. The suffering and satisfaction of Schrödinger's cat. Br J Anaesth 2016; 117:691-692. [PMID: 27956667 DOI: 10.1093/bja/aew384] [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: 11/13/2022] Open
Affiliation(s)
- T S Wildes
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 South Euclid Ave, Saint Louis, Missouri, 63110, USA
| | - M S Avidan
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 South Euclid Ave, Saint Louis, Missouri, 63110, USA
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Kronzer VL, Ben Abdallah A, McKinnon SL, Wildes TS, Avidan MS. Ability of preoperative falls to predict postsurgical outcomes in non-selected patients undergoing elective surgery at an academic medical centre: protocol for a prospective cohort study. BMJ Open 2016; 6:e011570. [PMID: 27655260 PMCID: PMC5051422 DOI: 10.1136/bmjopen-2016-011570] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Falls are increasingly recognised for their ability to herald impending health decline. Despite the likely susceptibility of postsurgical patients to falls, a detailed description of postoperative falls in an unselected surgical population has never been performed. One study suggests that preoperative falls may forecast postoperative complications. However, a larger study with non-selected surgical patients and patient-centred outcomes is needed to provide the generalisability and justification necessary to implement preoperative falls assessment into routine clinical practice. The aims of this study are therefore twofold. First, we aim to describe the main features of postoperative falls in a population of unselected surgical patients. Second, we aim to test the hypothesis that a history of falls in the 6 months prior to surgery predicts postoperative falls, poor quality of life, functional dependence, complications and readmission. METHODS AND ANALYSIS To achieve these goals, we study adult patients who underwent elective surgery at our academic medical centre and were recruited to participate in a prospective, survey-based cohort study called Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) (NCT02032030). Patients who reported falling in the 6 months prior to surgery will be considered 'exposed.' The primary outcome of interest is postoperative falls within 30 days of surgery. Secondary outcomes include postoperative functional dependence, quality of life (both physical and mental), in-hospital complications and readmission. Regression models will permit controlling for important confounders. ETHICS AND DISSEMINATION The home institution's Institutional Review Board approved this study (IRB ID number 201505035). The authors will publish the findings, regardless of the results.
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Affiliation(s)
- Vanessa L Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sherry L McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Kronzer VL, Jerry MR, Ben Abdallah A, Wildes TS, Stark SL, McKinnon SL, Helsten DL, Sharma A, Avidan MS. Preoperative Falls Predict Postoperative Falls, Functional Decline, and Surgical Complications. EBioMedicine 2016; 12:302-308. [PMID: 27599969 PMCID: PMC5078581 DOI: 10.1016/j.ebiom.2016.08.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/21/2016] [Accepted: 08/24/2016] [Indexed: 11/25/2022] Open
Abstract
Background Falls are common and linked to morbidity. Our objectives were to characterize postoperative falls, and determine whether preoperative falls independently predicted postoperative falls (primary outcome), functional dependence, quality of life, complications, and readmission. Methods This prospective cohort study included 7982 unselected patients undergoing elective surgery. Data were collected from the medical record, a baseline survey, and follow-up surveys approximately 30 days and one year after surgery. Results Fall rates (per 100 person-years) peaked at 175 (hospitalization), declined to 140 (30-day survey), and then to 97 (one-year survey). After controlling for confounders, a history of one, two, and ≥ three preoperative falls predicted postoperative falls at 30 days (adjusted odds ratios [aOR] 2.3, 3.6, 5.5) and one year (aOR 2.3, 3.4, 6.9). One, two, and ≥ three falls predicted functional decline at 30 days (aOR 1.2, 2.4, 2.4) and one year (aOR 1.3, 1.5, 3.2), along with in-hospital complications (aOR 1.2, 1.3, 2.0). Fall history predicted adverse outcomes better than commonly-used metrics, but did not predict quality of life deterioration or readmission. Conclusions Falls are common after surgery, and preoperative falls herald postoperative falls and other adverse outcomes. A history of preoperative falls should be routinely ascertained. Postoperative falls are common during hospitalization and after discharge and may be more prevalent in certain specialties. Preoperative falls predict postoperative falls, postoperative functional decline, and in-hospital complications. Ascertaining fall history is practical and informative, and should become routine.
Surgery-related falls occur at a high rate both during hospitalization and after discharge, and they may be especially prevalent in certain surgical specialties. Preoperative falls are the main harbinger of postoperative falls, and also strongly predict postoperative functional decline and complications. Importantly, these findings appear to be true across all ages. Therefore, a history of falls before surgery is a useful tool that should be incorporated into routine preoperative assessment.
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Affiliation(s)
- Vanessa L Kronzer
- Washington University School of Medicine, Department of Anesthesiology, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO 63110, USA.
| | - Michelle R Jerry
- University of Michigan, Department of Biostatistics, 534 Canton Street, Canton, MI 48188, USA.
| | - Arbi Ben Abdallah
- Washington University School of Medicine, Department of Anesthesiology, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO 63110, USA.
| | - Troy S Wildes
- Washington University School of Medicine, Department of Anesthesiology, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO 63110, USA.
| | - Susan L Stark
- Washington University School of Medicine, Program in Occupational Therapy, 4444 Forest Park Avenue, CB 855, Saint Louis, MO 63108, USA.
| | - Sherry L McKinnon
- Washington University School of Medicine, Department of Anesthesiology, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO 63110, USA.
| | - Daniel L Helsten
- Washington University School of Medicine, Department of Anesthesiology, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO 63110, USA.
| | - Anshuman Sharma
- Washington University School of Medicine, Department of Anesthesiology, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO 63110, USA.
| | - Michael S Avidan
- Washington University School of Medicine, Department of Anesthesiology, 660 South Euclid Avenue, Campus Box 8054, Saint Louis, MO 63110, USA.
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Wildes TS, Winter AC, Maybrier HR, Mickle AM, Lenze EJ, Stark S, Lin N, Inouye SK, Schmitt EM, McKinnon SL, Muench MR, Murphy MR, Upadhyayula RT, Fritz BA, Escallier KE, Apakama GP, Emmert DA, Graetz TJ, Stevens TW, Palanca BJ, Hueneke RL, Melby S, Torres B, Leung J, Jacobsohn E, Avidan MS. Protocol for the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) study: a pragmatic, randomised clinical trial. BMJ Open 2016; 6:e011505. [PMID: 27311914 PMCID: PMC4916634 DOI: 10.1136/bmjopen-2016-011505] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Postoperative delirium, arbitrarily defined as occurring within 5 days of surgery, affects up to 50% of patients older than 60 after a major operation. This geriatric syndrome is associated with longer intensive care unit and hospital stay, readmission, persistent cognitive deterioration and mortality. No effective preventive methods have been identified, but preliminary evidence suggests that EEG monitoring during general anaesthesia, by facilitating reduced anaesthetic exposure and EEG suppression, might decrease incident postoperative delirium. This study hypothesises that EEG-guidance of anaesthetic administration prevents postoperative delirium and downstream sequelae, including falls and decreased quality of life. METHODS AND ANALYSIS This is a 1232 patient, block-randomised, double-blinded, comparative effectiveness trial. Patients older than 60, undergoing volatile agent-based general anaesthesia for major surgery, are eligible. Patients are randomised to 1 of 2 anaesthetic approaches. One group receives general anaesthesia with clinicians blinded to EEG monitoring. The other group receives EEG-guidance of anaesthetic agent administration. The outcomes of postoperative delirium (≤5 days), falls at 1 and 12 months and health-related quality of life at 1 and 12 months will be compared between groups. Postoperative delirium is assessed with the confusion assessment method, falls with ProFaNE consensus questions and quality of life with the Veteran's RAND 12-item Health Survey. The intention-to-treat principle will be followed for all analyses. Differences between groups will be presented with 95% CIs and will be considered statistically significant at a two-sided p<0.05. ETHICS AND DISSEMINATION Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) is approved by the ethics board at Washington University. Recruitment began in January 2015. Dissemination plans include presentations at scientific conferences, scientific publications, internet-based educational materials and mass media. TRIAL REGISTRATION NUMBER NCT02241655; Pre-results.
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Affiliation(s)
- T S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - A C Winter
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - H R Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - A M Mickle
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - E J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - S Stark
- Department of Occupational Therapy, Washington University Institute for Public Health, School of Medicine, St. Louis, Missouri, USA
- Department of Neurology, Washington University Institute for Public Health, School of Medicine, St. Louis, Missouri, USA
| | - N Lin
- Department of Mathematics, Biostatistics Division, Washington University in St. Louis, St. Louis, Missouri, USA
| | - S K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - E M Schmitt
- Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - S L McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M R Muench
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M R Murphy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - R T Upadhyayula
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - K E Escallier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - G P Apakama
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - D A Emmert
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - T J Graetz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - T W Stevens
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - R L Hueneke
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - S Melby
- Department of Surgery, Cardiothoracic Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - J Leung
- Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - E Jacobsohn
- Department of Anesthesia, University of Manitoba/Winnipeg Regional Health Authority Anesthesia Program, Winnipeg, Manitoba, Canada
| | - M S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Zhurav L, Wildes TS. Pro: Topical Hypothermia Should Be Used During Deep Hypothermic Circulatory Arrest. J Cardiothorac Vasc Anesth 2012; 26:333-6. [DOI: 10.1053/j.jvca.2011.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Indexed: 11/11/2022]
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Lakshminarasimhachar A, Wildes TS, Pal N, Graetz TJ. Lung transplantation on extracorporeal membrane oxygenation with iatrogenic aortic dissection. J Cardiothorac Vasc Anesth 2011; 25:1121-4. [PMID: 21295998 DOI: 10.1053/j.jvca.2010.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 08/02/2010] [Indexed: 11/11/2022]
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