David R. Jobes

Do Regulations Limiting Residents’ Work Hours Affect Patient Mortality?

AbstractOBJECTIVE: To conduct a statewide analysis of the effect of New York’s regulations, limiting internal medicine and family practice residents’ work hours, on patient mortality.n DESIGN: Retrospective study of inpatient discharge files for 1988 (before the regulations) and 1991 (after the regulations).n SETTING AND PATIENTS: Adult patients discharged from New York teaching hospitals (170,214) and nonteaching hospitals (143,455) with a principal diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia, for the years 1988 and 1991 (periods before and after Code 405 regulations went into law). Patients from nonteaching hospitals served as controls.n MEASUREMENT: In-hospital mortality.n RESULTS: Combined unadjusted mortality for congestive heart failure, acute myocardial infarction, and pneumonia patients declined between 1988 and 1991 in both teaching (14.1% to 13.0%; P=.0001) and nonteaching hospitals (14.0% to 12.5%; P=.0001). Adjusted mortality also declined between 1988 and 1991 in both teaching (odds ratio [OR], death 1991/1988, 0.868; 95% confidence interval [CI], 0.843 to 0.894; P=.0001) and nonteaching hospitals (OR, death 1991/1988, 0.853; 95% CI, 0.826 to 0.881; P=.0001). This beneficial trend toward lower mortality over time was nearly identical between teaching and nonteaching hospitals (P=.4348).n CONCLUSION: New York’s mandated limitations on residents’ work hours do not appear to have positively or negatively affected in-hospital mortality from congestive heart failure, acute myocardial infarction, or pneumonia in teaching hospitals.

Early tracheal extubation in adults undergoing single-lung transplantation for chronic obstructive pulmonary disease: pilot evaluation of perioperative outcome

The objective of this pilot study was to evaluate the safety and success of early tracheal extubation (ETE) as compared to delayed tracheal extubation (DTE) in single-lung transplantation (SLT) for chronic obstructive pulmonary disease (COPD). This retrospective observational study was undertaken at a university hospital. Fifty-seven adult patients who underwent SLT for COPD (1998-2003) were enrolled. The study cohort was divided into an ETE subgroup (tracheal extubation in the operating room) or a DTE subgroup (tracheal extubation in the intensive care unit). There were no significant differences in perioperative outcomes between subgroups (in-hospital mortality; length of stay; prolonged mechanical ventilation; primary graft dysfunction; pneumonia; atrial fibrillation; renal dysfunction; and, sepsis). The anesthetic technique associated with ETE in SLT for COPD was characterized by limited systemic anesthetics and perioperative thoracic epidural analgesia. Appropriate ETE in SLT for COPD is not only safe but also results in equivalent perioperative outcome when compared to the traditional technique of DTE. Future studies should be powered to examine whether ETE reduces native lung complications such as hyperinflation, pneumonia and pneumothorax.

Ultrasound-guided Catheterization of the Internal Jugular Vein

In Reply:—We thank Dr. Eikermann et al. for their interest in our article and their suggestions for conducting randomized controlled studies to determine the optimal time after an upper respiratory infection (URI) for providing anesthesia and to characterize the optimal technique for airway management. First, we would like to emphasize that the work that claims the use of a laryngeal mask airway (LMA) as an alternative to tracheal intubation in children with recent URI was completed in a randomized controlled study that included 41 children in each group. Although the incidence of laryngospasm was 10% with the LMA (twice higher than with an endotracheal tube), this did not reach statistical significance because of the low number of children involved. To our knowledge, our study is the first to report a large number of children with a recent URI and to provide some evidence that despite the use of an LMA, the incidence of respiratory complications remains high. However, we agree with the authors that multiple attempts to insert the LMA are often associated in clinical practice with difficult anatomical conditions or light or inadequate anesthesia and are independent of the presence of an URI. However, if laryngospasm were an epiphenomenon, one would observe the higher incidence of complications at insertion, which was not the case in our study because the higher odds ratio for laryngospasm was observed intraoperatively and even in the postoperative care unit. Furthermore, multiple attempts to insert the LMA were only found in the univariate analysis for all respiratory complications, whereas URI was almost the only factor that remained in the multivariate analysis, which further confirms that a recent URI is a risk factor for the occurrence of perioperative respiratory complications with the use of an LMA. The second point raised by the authors on the time delay after a recent URI before proceeding with anesthesia is of interest. Although we agree that we cannot provide strong evidence that anesthesiologists should consider at least a 2-week interval, we still believe that the absence of evidence does not translate into the evidence of absence. Please note that the underlying pathophysiologic mechanisms involved in the occurrence of respiratory complications after insertion of an LMA are completely different than those observed in the case of an endotracheal tube. The nonadrenergic, noncholinergic autonomic nervous system is primarily involved with the LMA stimulating the sensory nerves (C fibers), whereas the cholinergic system is the main pathway that is activated by the insertion of an endotracheal tube. This explains in part why the incidence of bronchospasm is negligible in the presence of an LMA. Furthermore, we disagree with the authors that there was no “control group” per se because fever can be present independently of a URI and cough is the second most common symptom in childhood (10–20% of preschool children), not necessarily associated with a recent URI. We based our definition of URI on the parents’ statements because parental confirmation of the presence of a cold has already been identified as a predicting factor for the occurrence of adverse events during anesthesia. Therefore, we believe that our categorization into two groups precludes the possibility of mixing URIs of different severities. We finally agree with the authors that URI dilemma remains an issue. Please note that there is no evidence in the literature that waiting several weeks after an URI will decrease the incidence of respiratory complications. Although we agree that a randomized controlled study may definitely add some evidence to our statement, we would like to point out that prospective observational studies produce invaluable information about perioperative morbidity in pediatric anesthesia. We are aware that such studies include many confounding factors that were, however, closely examined in our study by integrating different models in the multivariate analysis. Therefore, we believe that our results are of great importance in designing for the future randomized control studies to confirm our findings without integrating these confounding factors.

Prolonged Mechanical Ventilation After Aortic Arch Repair Requiring Deep Hypothermic Circulatory Arrest: Incidence, Effect on Outcome, and Clinical Predictors

Objective: To delineate the incidence, outcome impact, and clinical predictors of prolonged mechanical ventila- tion (PMV) after adult aortic arch repair requiring deep hypothermic circulatory arrest (AAR-DHCA) Aims: (1) To determine the incidence of PMV after AAR-DHCA. (2) To determine whether PMV after AAR-DHCA is a multivariate predictor for mortality or length of stay in the intensive care unit. (3) To determine multivariate predictors for PMV after AAR-DHCA. (4) To determine whether aprotinin influences PMV after AAR-DHCA. Study Design: Retrospective and observational. Prolonged mechanical ventilation was defined as mechanical ventilation via an endotracheal tube for longer than 72 hours. Study Setting: Single large university hospital. Participants: All adults undergoing AAR-DHCA in 2000 and 2001. Main Results: Cohort size was 144. Antifibrinolytic exposure was 100%: aprotinin 66% and aminocaproic acid 34%. The incidence of AF was 21.5 %. PMV did not independently predict for mortality or prolonged stay in the intensive care unit. The multivariate predictors for PMV were chronic obstructive pulmonary disease, stroke, and infection. In multivariate analysis, aprotinin exposure has no significant association with PMV. Conclusions: PMV after AAR-DHCA is common, but does not independently predict mortality or ICU stay. The risk of PMV after AAR-DHCA increases with preexisting chronic obstructive pulmonary disease, stroke and infection. Pe- rioperative intervention should focus on protection against stroke and infection.