Amanda J. Naylor

Postoperative Hypoxemia Is Common and Persistent: A Prospective Blinded Observational Study.

BACKGROUND:The incidence, severity, and duration of postoperative oxygen desaturation in the general surgical population are poorly characterized. We therefore used continuous pulse oximetry to quantify arterial oxygen saturation (SpO2) in a cross-section of patients having noncardiac surgery. METHODS:Oxygen saturation, blinded to clinicians, was recorded at 1-minute intervals in patients >45 years old for up to 48 hours after noncardiac surgery in 1250 patients from Cleveland Clinic Main Campus and 250 patients from the Juravinski Hospital. We determined (1) the cumulative minutes of raw minute-by-minute values below various hypoxemic thresholds; and (2) the contiguous duration of kernel-smoothed (sliding window) values below various hypoxemic thresholds. Finally, we compared our blinded continuous values with saturations recorded during routine nursing care. RESULTS:Eight hundred thirty-three patients had sufficient data for analyses. Twenty-one percent had ≥10 min/h with raw SpO2 values <90% averaged over the entire recording duration; 8% averaged ≥20 min/h <90%; and 8% averaged ≥5 min/h <85%. Prolonged hypoxemic episodes were common, with 37% of patients having at least 1 (smoothed) SpO2 <90% for an hour or more; 11% experienced at least 1 episode lasting ≥6 hours; and 3% had saturations <80% for at least 30 minutes. Clinical hypoxemia, according to nursing records, measured only in Cleveland Clinic patients (n = 594), occurred in 5% of the monitored patients. The nurses missed 90% of smoothed hypoxemic episodes in which saturation was <90% for at least one hour. CONCLUSIONS:Hypoxemia was common and prolonged in hospitalized patients recovering from noncardiac surgery. The SpO2 values recorded in medical records seriously underestimated the severity of postoperative hypoxemia.

C-MAC compared with direct laryngoscopy for intubation in patients with cervical spine immobilization: A manikin trial

Introduction The aim of this study was to compare C‐MAC videolaryngoscopy with direct laryngoscopy for intubation in simulated cervical spine immobilization conditions. Methods The study was designed as a prospective randomized crossover manikin trial. 70 paramedics with < 5 years of medical experience participated in the study. The paramedics attempted to intubate manikins in 3 airway scenarios: normal airway without cervical immobilization (Scenario A); manual inline cervical immobilization (Scenario B); cervical immobilization using cervical extraction collar (Scenario C). Results Scenario A: Nearly all participants performed successful intubations with both MAC and C‐MAC on the first attempt (95.7% MAC vs. 100% C‐MAC), with similar intubation times (16.5 s MAC vs. 18 s C‐MAC). Scenario B: The results with C‐MAC were significantly better than those with MAC (p < 0.05) for the time of intubation (23 s MAC vs. 19 s C‐MAC), success of the first intubation attempt (88.6% MAC vs. 100% C‐MAC), Cormack‐Lehane grade, POGO score, severity of dental compression, device difficulty score, and preferred airway device. Scenario C: The results with C‐MAC were significantly better than those with MAC (p < 0.05) for all the analysed variables: success of the first attempt (51.4% MAC vs. 100% C‐MAC), overall success rate, intubation time (27 s MAC vs. 20.5 s C‐MAC), Cormack‐Lehane grade, POGO score, dental compression, device difficulty score and the preferred airway device. Conclusion The C‐MAC videolaryngoscope is an excellent alternative to the MAC laryngoscope for intubating manikins with cervical spine immobilization.

Long-Acting Patient-Controlled Opioids Are Not Associated With More Postoperative Hypoxemia Than Short-Acting Patient-Controlled Opioids After Noncardiac Surgery: A Cohort Analysis.

BACKGROUND:Opioids can contribute to postoperative desaturation. Short-acting opioids, titrated to need, may cause less desaturation than longer-acting opioids. We thus tested the primary hypothesis that long-acting patient-controlled intravenous opioids are associated with more hypoxemia (defined as an integrated area under a postoperative oxyhemoglobin saturation of 95%) than short-acting opioids. METHODS:This analysis was a substudy of VISION, a prospective cohort study focused on perioperative cardiovascular events (NCT00512109). After excluding for predefined criteria, 191 patients were included in our final analysis, with 75 (39%) patients being given fentanyl (short-acting opioid group) and 116 (61%) patients being given morphine and/or hydromorphone (long-acting opioid group). The difference in the median areas under a postoperative oxyhemoglobin saturation of 95% between short-acting and long-acting opioids was compared using multivariable median quantile regression. RESULTS:The short-acting opioid median area under a postoperative oxyhemoglobin saturation of 95% per hour was 1.08 (q1, q3: 0.62, 2.26) %-h, whereas the long-acting opioid median was 1.28 (0.50, 2.23) %-h. No significant association was detected between long-acting and short-acting opioids and median area under a postoperative oxyhemoglobin saturation of 95% per hour (P = .66) with estimated change in the medians of −0.14 (95% CI, −0.75, 0.47) %-h for the patients given long-acting versus short-acting IV patient-controlled analgesia opioids. CONCLUSIONS:Long-acting patient-controlled opioids were not associated with the increased hypoxemia during the first 2 postoperative days.

Clonidine Does Not Reduce Pain or Opioid Consumption After Noncardiac Surgery.

BACKGROUND: Clonidine is an &agr;2-adrenoceptor agonist, which has analgesic properties. However, the analgesic efficacy of perioperative clonidine remains unclear. We, therefore, tested the hypothesis that clonidine reduces both pain scores and cumulative opioid consumption during the initial 72 hours after noncardiac surgery. METHODS: Six hundred twenty-four patients undergoing elective noncardiac surgery under general and spinal anesthesia were included in this substudy of the PeriOperative ISchemia Evaluation-2 trial. Patients were randomly assigned to 0.2 mg oral clonidine or placebo 2 to 4 hours before surgery, followed by 0.2 mg/d transdermal clonidine patch or placebo patch, which was maintained until 72 hours after surgery. Postoperative pain scores and opioid consumption were assessed for 72 hours after surgery. RESULTS: Clonidine had no effect on opioid consumption compared with placebo, with an estimated ratio of means of 0.98 (95% confidence interval, 0.70–1.38); P = 0.92. Median (Q1, Q3) opioid consumption was 63 (30, 154) mg morphine equivalents in the clonidine group, which was similar to 60 (30, 128) mg morphine equivalents in the placebo group. Furthermore, there was no significant effect on pain scores, with an estimated difference in means of 0.12 (95% confidence interval, −0.02 to 0.26); 11-point scale; P = 0.10. Mean pain scores per patient were 3.6 ± 1.8 for clonidine patients and 3.6 ± 1.8 for placebo patients. CONCLUSIONS: Clonidine does not reduce opioid consumption or pain scores in patients recovering from noncardiac surgery.

The cost-effectiveness of epidural, patient-controlled intravenous opioid analgesia, or transversus abdominis plane infiltration with liposomal bupivacaine for postoperative pain management

STUDY OBJECTIVE Intravenous patient-controlled opioid analgesia (IVPCA), epidural analgesia and transversus abdominis plane (TAP) infiltrations are frequently used postoperative pain management modalities. The aim of this study was to conduct a cost-effectiveness analysis comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively in patients undergoing major lower abdominal surgery. DESIGN Retrospective cost effectiveness analysis. SETTING Operating room. PATIENTS We obtained data on major lower-abdominal surgeries performed under general anesthesia on adult patients between January 2012 and July 2014. INTERVENTIONS A cost-effectiveness analysis was comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively. MEASUREMENTS A decision analytic model was used to estimate the health outcomes for patients undergoing major lower abdominal surgery. The primary outcome was time-weighted pain from 0 to 72 h after surgery, as measured by numerical rating scale pain scores. The analysis was conducted from the perspective of the hospital as the party responsible for most costs related to surgery. MAIN RESULTS From the base case analysis, IVPCA was the optimal strategy regarding cost and effect. TAP with LB, however, was only narrowly dominated, while epidural was clearly dominated. From the sensitivity analysis at willingness-to-pay (WTP) of

Early Resumption of β Blockers Is Associated with Decreased Atrial Fibrillation after Noncardiothoracic and Nonvascular SurgeryA Cohort Analysis

150, IV PCA and TAP infiltration were each the optimal strategy for approximately 50% of the iterations. At WTP of

124: TIMED RESUMPTION OF BETA-BLOCKERS AND THE INCIDENCE OF ATRIAL FIBRILLATION AFTER NONCARDIAC SURGERY.

10,000, epidural was only the optimal strategy in 10% of the iterations. CONCLUSIONS This is the first study in the literature to compare the cost-effectiveness of epidural, IVPCA, and TAP infiltrations with LB. Within reasonable WTP values, there is little differentiation in cost-effectiveness between IVPCA and TAP infiltration with LB. Epidural does not become a cost-effective strategy even at much higher WTP values.

A nomogram for predicting the need for sciatic nerve block after total knee arthroplasty

What We Already Know about This Topic Use of beta (&bgr;) blockers in the perioperative period is associated with reduced incidence of postoperative atrial fibrillation In chronic &bgr;-blocker users, optimal timing for &bgr;-blocker resumption in the postoperative setting is unclear What This Article Tells Us That Is New Resumption of postoperative &bgr;-blocker therapy by the end of postoperative day 1 is associated with reduced incidence of postoperative atrial fibrillation in general surgical patients (noncardiac, nonthoracic, nonvascular surgeries) when compared with patients who resumed &bgr;-blocker therapy after postoperative day 1 There was not a significant difference in incidence of postoperative atrial fibrillation for those patients who postoperatively resumed &bgr;-blocker therapy on the day of surgery versus anytime thereafter Background: Beta (&bgr;) blockers reduce the risk of postoperative atrial fibrillation and should be restarted after surgery, but it remains unclear when best to resume &bgr; blockers postoperatively. The authors thus evaluated the relationship between timing of resumption of &bgr; blockers and atrial fibrillation in patients recovering from noncardiothoracic and nonvascular surgery. Methods: The authors evaluated 8,201 adult &bgr;-blocker users with no previous history of atrial fibrillation who stayed at least two nights after noncardiothoracic and nonvascular surgery as a retrospective observational cohort. After propensity score matching on baseline and intraoperative variables, 1,924 patients who did resume &bgr; blockers by the end of postoperative day 1 were compared with 973 patients who had not resumed by that time on postoperative atrial fibrillation using logistic regression. A secondary matched analysis compared 3,198 patients who resumed &bgr; blockers on the day of surgery with 3,198 who resumed thereafter. Results: Of propensity score–matched patients who resumed &bgr; blockers by end of postoperative day 1, 4.9% (94 of 1,924) developed atrial fibrillation, compared with 7.0% (68 of 973) of those who resumed thereafter (adjusted odds ratio, 0.69; 95% CI, 0.50–0.95; P = 0.026). Patients who resumed &bgr; blockers on day of surgery had an atrial fibrillation incidence of 4.9% versus 5.8% for those who started thereafter (odds ratio, 0.84; 95% CI, 0.67–1.04; P = 0.104). Conclusions: Resuming &bgr; blockers in chronic users by the end of the first postoperative day may be associated with lower odds of in-hospital atrial fibrillation. However, there seems to be little advantage to restarting on the day of surgery itself.

The Association Between Timing of Routine Preoperative Blood Testing and a Composite of 30-Day Postoperative Morbidity and Mortality

Learning Objectives: Post-operative atrial fibrillation (POAF) after non-cardiac surgery remains a rampant problem with incidences ranging from 3-15%. While there is evidence for the protective role of beta blockade in the prevention of POAF after cardiac surgery, the same cannot be said of non-cardiac surgery. Thus, we aimed to assess the relationship between POAF and the timing of resumption of chronically used home beta-blockers in patients recovering from non-cardiac surgery. Methods: With IRB approval, data was obtained for 3,278 adult betablocker users who underwent non-cardiac surgery and stayed at least one night after surgery at Cleveland Clinic main campus (12/7/2012-12/29/2015). Patients who had atrial fibrillation at admission were excluded. We grouped the timing of resumption into 3 clinically-relevant categories: <6, 6-24, and >24 hours. We conducted 3 pairwise comparisons using a multivariable logistic regression, in which 21 potential confounding variables, including demographics, medical conditions, type and duration of surgery, and intraoperative hemodynamic and fluid managements were considered to be included via backward model selection. In sensitivity analysis, matched patients (exactly matched on type of surgery and propensity-score matched on all the other confounders) were compared on POAF using logistic regression adjusting for propensity score. The significance criterion was P < 0.017 (i.e., 0.05/3). Results: The incidence of POAF was 2.6% (32/1,237), 1.2% (20/1,625), and 2.2% (9/416) for patients resuming betablockers within 6, 6-24, and after 24 hours, respectively. No difference on POAF was found among the three timing categories (P = 0.23). The estimated odds ratio of having POAF was 1.65 (98.3% CI: 0.81, 3.37) (<6 vs. 6-24 hours), 1.37 (0.52, 3.61) (<6 vs. >24 hours), and 0.83 (0.30, 2.31) (6-24 vs. >24 hours), respectively. The sensitivity analysis gave consistent results. Conclusions: The timing of resumption of chronically used home beta-blockers is not associated with the incidence of post-operative atrial fibrillation after non-cardiac surgery.