Daniel S. Rubin

Perioperative Visual Loss in Spine Fusion Surgery: Ischemic Optic Neuropathy in the United States from 1998 to 2012 in the Nationwide Inpatient Sample

Background:Perioperative ischemic optic neuropathy (ION) causes visual loss in spinal fusion. Previous case–control studies are limited by study size and lack of a random sample. The purpose of this study was to study trends in ION incidence in spinal fusion and risk factors in a large nationwide administrative hospital database. Methods:In the Nationwide Inpatient Sample for 1998 to 2012, procedure codes for posterior thoracic, lumbar, or sacral spine fusion and diagnostic codes for ION were identified. ION was studied over five 3-yr periods (1998 to 2000, 2001 to 2003, 2004 to 2006, 2007 to 2009, and 2010 to 2012). National estimates were obtained using trend weights in a statistical survey procedure. Univariate and Poisson logistic regression assessed trends and risk factors. Results:The nationally estimated volume of thoracic, lumbar, and sacral spinal fusion from 1998 to 2012 was 2,511,073. ION was estimated to develop in 257 patients (1.02/10,000). The incidence rate ratio (IRR) for ION significantly decreased between 1998 and 2012 (IRR, 0.72 per 3 yr; 95% CI, 0.58 to 0.88; P = 0.002). There was no significant change in the incidence of retinal artery occlusion. Factors significantly associated with ION were age (IRR, 1.24 per 10 yr of age; 95% CI, 1.05 to 1.45; P = 0.009), transfusion (IRR, 2.72; 95% CI, 1.38 to 5.37; P = 0.004), and obesity (IRR, 2.49; 95% CI, 1.09 to 5.66; P = 0.030). Female sex was protective (IRR, 0.30; 95% CI, 0.16 to 0.56; P = 0.0002). Conclusions:Perioperative ION in spinal fusion significantly decreased from 1998 to 2012 by about 2.7-fold. Aging, male sex, transfusion, and obesity significantly increased the risk.

Anesthesia for Ambulatory Diagnostic and Therapeutic Radiology Procedures

The radiology suite presents the anesthesia provider with a unique set of challenges such as ionizing radiation, intravascular contrast, magnetic fields, physical separation and barriers from the patient, so-called borrowed space, and the large range of procedures performed. Most of these procedures will continue to be performed without the presence of an anesthesia team but, because of the ever-increasing complexity of the procedures being performed and the increasing comorbidities of patients, the anesthesia provider will likely be called more often to provide care. A thorough understanding of these challenges is essential to providing a safe anesthetic in a difficult environment.

Ischemic Optic Neuropathy in Cardiac Surgery: Incidence and Risk Factors in the United States from the National Inpatient Sample 1998 to 2013.

Background: Ischemic optic neuropathy is the most common form of perioperative visual loss, with highest incidence in cardiac and spinal fusion surgery. To date, potential risk factors have been identified in cardiac surgery by only small, single-institution studies. To determine the preoperative risk factors for ischemic optic neuropathy, the authors used the National Inpatient Sample, a database of inpatient discharges for nonfederal hospitals in the United States. Methods: Adults aged 18 yr or older admitted for coronary artery bypass grafting, heart valve repair or replacement surgery, or left ventricular assist device insertion in National Inpatient Sample from 1998 to 2013 were included. Risk of ischemic optic neuropathy was evaluated by multivariable logistic regression. Results: A total of 5,559,395 discharges met inclusion criteria with 794 (0.014%) cases of ischemic optic neuropathy. The average yearly incidence was 1.43 of 10,000 cardiac procedures, with no change during the study period (P = 0.57). Conditions increasing risk were carotid artery stenosis (odds ratio, 2.70), stroke (odds ratio, 3.43), diabetic retinopathy (odds ratio, 3.83), hypertensive retinopathy (odds ratio, 30.09), macular degeneration (odds ratio, 4.50), glaucoma (odds ratio, 2.68), and cataract (odds ratio, 5.62). Female sex (odds ratio, 0.59) and uncomplicated diabetes mellitus type 2 (odds ratio, 0.51) decreased risk. Conclusions: The incidence of ischemic optic neuropathy in cardiac surgery did not change during the study period. Development of ischemic optic neuropathy after cardiac surgery is associated with carotid artery stenosis, stroke, and degenerative eye conditions.

Local Anesthetic Systemic Toxicity in Total Joint Arthroplasty: Incidence and Risk Factors in the United States from the National Inpatient Sample 1998-2013

Background Local anesthetic systemic toxicity (LAST) is a rare and potentially devastating complication of regional anesthesia. Single-institution registries have reported a decreasing incidence, but these results have limited broad applicability. A recent study using a US database found a relatively high incidence of LAST. We used the National Inpatient Sample, a US database of inpatient admissions, to identify the national incidence and associated risk factors for LAST in total joint arthroplasties. Methods In this retrospective study, we studied patients undergoing hip, knee, or shoulder arthroplasty, from 1998 to 2013, with an adjunct peripheral nerve blockade. We used a multivariable logistic regression to identify patient conditions, hospital level variables, and procedure sites associated with LAST. Results A total of 710,327 discharges met inclusion criteria. The average adjusted incidence was 1.04 per 1000 peripheral nerve blocks, with decreasing trend over the 15-year study period (odds ratio [OR], 0.90; P = 0.002). Shoulder arthroplasty (OR, 4.35; P = 0.0001) compared with knee or hip arthroplasty and medium-size (OR, 3.34; P = 0.003) and large-size (OR, 2.40; P = 0.025) hospitals as compared with small hospitals were associated with increased odds of LAST. Conclusions The incidence of LAST nationally in total joint arthroplasty with adjunct nerve blocks is similar to recent estimates from academic centers, with a small decreasing trend through the study period. Despite an overall low incidence rate, practitioners should continue to maintain vigilance for manifestations of LAST, especially as the use of regional anesthesia continues to increase.

Introduction of a Mobile Adverse Event Reporting System Is Associated With Participation in Adverse Event Reporting

Physicians underutilize adverse event reporting systems. Web-based platforms have increased participation; thus, it was hypothesized that a mobile application would increase adverse event reporting. The authors developed a mobile reporting application for iOS and Android operating systems and performed a retrospective review on reporting rates by clinicians in the Department of Anesthesia and Critical Care. Monthly reporting rates were calculated for the intervention year and for the 2 prior years (2013-2016). The Wilcoxon rank sum test and χ2 test were used to evaluate significance. Overall monthly reporting rates for all clinicians were 15.3 ± 7 for the first time period, 17.3 ± 6 for the second time period, and 27.9 ± 7 for the third time period (P = .0035). The majority of reports in the third time period were submitted using the mobile application (193/337, 57%, P = .026). Deployment of a mobile application reduced barriers to adverse event reporting and increased monthly reporting rates for all clinicians.

Perioperative Retinal Artery Occlusion: Incidence and Risk Factors in Spinal Fusion Surgery From the US National Inpatient Sample 1998–2013

Background: Retinal artery occlusion (RAO) is a rare but devastating complication of spinal fusion surgery. We aimed to determine its incidence and associated risk factors. Methods: Hospitalizations involving spinal fusion surgery were identified by searching the National Inpatient Sample, a database of hospital discharges, from 1998 to 2013. RAO cases were identified using ICD-9-CM codes. Using the STROBE guidelines, postulated risk factors were chosen based on literature review and identified using ICD-9-CM codes. Multivariate logistic models with RAO as outcome, and risk factors, race, age, admission, and surgery type evaluated associations. Results: Of an estimated 4,784,275 spine fusions in the United States from 1998 to 2013, there were 363 (CI: 291–460) instances of RAO (0.76/10,000 spine fusions, CI: 0.61–0.96). Incidence ranged from 0.35/10,000 (CI: 0.11–1.73) in 2001–2002 to 1.29 (CI: 0.85–2.08) in 2012–2013, with no significant trend over time (P = 0.39). Most strongly associated with RAO were stroke, unidentified type (odds ratio, OR: 14.33, CI: 4.54–45.28, P < 0.001), diabetic retinopathy (DR) (OR: 7.00, CI: 1.18–41.66, P = 0.032), carotid stenosis (OR: 4.94, CI: 1.22–19.94, P = 0.025), aging (OR for age 71–80 years vs 41–50 years referent: 4.07, CI: 1.69–10.84, P = 0.002), and hyperlipidemia (OR: 2.96, CI: 1.85–4.73, P < 0.001). There was an association between RAO and transforaminal lumbar interbody fusion (OR: 2.95, CI: 1.29–6.75, P = 0.010). RAO was more likely to occur with spinal surgery performed urgently or emergently compared with being done electively (OR: 0.40, CI: 0.23–0.68, P < 0.001). Conclusions: Patient-specific associations with RAO in spinal fusion include aging, carotid stenosis, DR, hyperlipidemia, stroke, and specific types of surgery. DR may serve as an observable biomarker of heightened risk of RAO in patients undergoing spine fusion.