Jesse M. Ehrenfeld

Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study

Objective To determine whether use of intermediate acting neuromuscular blocking agents during general anesthesia increases the incidence of postoperative respiratory complications. Design Prospective, propensity score matched cohort study. Setting General teaching hospital in Boston, Massachusetts, United States, 2006-10. Participants 18 579 surgical patients who received intermediate acting neuromuscular blocking agents during surgery were matched by propensity score to 18 579 reference patients who did not receive such agents. Main outcome measures The main outcome measures were oxygen desaturation after extubation (hemoglobin oxygen saturation <90% with a decrease in oxygen saturation after extubation of >3%) and reintubations requiring unplanned admission to an intensive care unit within seven days of surgery. We also evaluated effects on these outcome variables of qualitative monitoring of neuromuscular transmission (train-of-four ratio) and reversal of neuromuscular blockade with neostigmine to prevent residual postoperative neuromuscular blockade. Results The use of intermediate acting neuromuscular blocking agents was associated with an increased risk of postoperative desaturation less than 90% after extubation (odds ratio 1.36, 95% confidence interval 1.23 to 1.51) and reintubation requiring unplanned admission to an intensive care unit (1.40, 1.09 to 1.80). Qualitative monitoring of neuromuscular transmission did not decrease this risk and neostigmine reversal increased the risk of postoperative desaturation less than 90% (1.32, 1.20 to 1.46) and reintubation (1.76, 1.38 to 2.26). Conclusion The use of intermediate acting neuromuscular blocking agents during anesthesia was associated with an increased risk of clinically meaningful respiratory complications. Our data suggest that the strategies used in our trial to prevent residual postoperative neuromuscular blockade should be revisited.

Utility of the surgical apgar score: Validation in 4119 patients

OBJECTIVES To confirm the utility of a 10-point Surgical Apgar Score to rate surgical outcomes in a large cohort of patients. DESIGN Using electronic intraoperative records, we calculated Surgical Apgar Scores during a period of 2 years (July 1, 2003, through June 30, 2005). SETTING Major academic medical center. PATIENTS Systematic sample of 4119 general and vascular surgery patients enrolled in the National Surgical Quality Improvement Program surgical outcomes database at a major academic medical center. MAIN OUTCOME MEASURES Incidence of major postoperative complications and/or death within 30 days of surgery. RESULTS Of 1441 patients with scores of 9 to 10, 72 (5.0%) developed major complications within 30 days, including 2 deaths (0.1%). By comparison, among 128 patients with scores of 4 or less, 72 developed major complications (56.3%; relative risk, 11.3; 95% confidence interval, 8.6-14.8; P < .001), of whom 25 died (19.5%; relative risk, 140.7; 95% confidence interval, 33.7-587.4; P < .001). The 3-variable score achieves C statistics of 0.73 for major complications and 0.81 for deaths. CONCLUSIONS The Surgical Apgar Score provides a simple, immediate, objective means of measuring and communicating patient outcomes in surgery, using data routinely available in any setting. The score can be effective in identifying patients at higher- and lower-than-average likelihood of major complications and/or death after surgery and may be useful for evaluating interventions to prevent poor outcomes.

Real-Time Checking of Electronic Anesthesia Records for Documentation Errors and Automatically Text Messaging Clinicians Improves Quality of Documentation

INTRODUCTION:The quality of electronic anesthesia documentation is important for downstream communication and to demonstrate appropriate diligence to care. Documentation quality will also impact the success of reimbursement contracts that require timely and complete documentation of specific interventions. We implemented a system to improve completeness of clinical documentation and evaluated the results over time. METHODS:We used custom software to continuously scan for missing clinical documentation during anesthesia. We used patient allergies as a test case, taking advantage of a unique requirement in our system that allergies be manually entered into the electronic record. If no allergy information was entered within 15 min of the “start of anesthesia care” event, a one-time prompt was sent via pager to the person performing the anesthetic. We tabulated the daily fraction of cases missing allergy data for the 6 mo before activating the alert system. We then obtained the same data for the subsequent 9 mo. We tested for systematic performance changes using statistical process control methodologies. RESULTS:Before initiating the alert system, the fraction of charts without an allergy comment was slightly more than 30%. This decreased to about 8% after initiating the alerts, and was significantly different from baseline within 5 days. Improvement lasted for the duration of the trial. Paging was suspended on nights, weekends, and holidays, yet weekend documentation performance also improved, indicating that weekday reminders had far-reaching effects. DISCUSSION:Electronic anesthesia documentation performance can be rapidly managed and improved by using an automatic process monitoring and alerting system.

The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium.

BACKGROUND:In this study, we sought to determine the frequency and outcomes of epidural hematomas after epidural catheterization. METHODS:Eleven centers participating in the Multicenter Perioperative Outcomes Group used electronic anesthesia information systems and quality assurance databases to identify patients who had epidural catheters inserted for either obstetrical or surgical indications. From this cohort, patients undergoing laminectomy for the evacuation of hematoma within 6 weeks of epidural placement were identified. RESULTS:Seven of 62,450 patients undergoing perioperative epidural catheterizations developed hematoma requiring surgical evacuation. The event rate was 11.2 × 10−5 (95% confidence interval [CI], 4.5 × 10−5 to 23.1 × 10−5). Four of the 7 had anticoagulation/antiplatelet therapy that deviated from American Society of Regional Anesthesia guidelines. None of 79,837 obstetric patients with epidural catheterizations developed hematoma (upper limit of the 95% CI, 4.6 × 10−5). The hematoma rate in obstetric epidural catheterizations was significantly lower than in perioperative epidural catheterizations (P = 0.003). CONCLUSIONS:In this series, the 95% CI for the frequency of epidural hematoma requiring laminectomy after epidural catheter placement for perioperative anesthesia/analgesia was 1 event per 22,189 placements to 1 event per 4330 placements. Risk was significantly lower in obstetric epidurals.

Variability in practice and factors predictive of total crystalloid administration during abdominal surgery: retrospective two-centre analysis

BACKGROUND Variation in clinical practice in the perioperative environment and intensive care unit is a major challenge facing modern medicine. The objective of the present study was to analyse intraoperative crystalloid administration practices at two academic medical centres in the USA. METHODS We extracted clinical data from patients undergoing intra-abdominal procedures performed at UC Irvine (UCI) and Vanderbilt University (VU) Medical Centres. Limiting data to uncomplicated elective surgery with minimal blood loss, we quantified variability in fluid administration within individual providers, between providers, and between types of procedures using a corrected coefficient of variation (cCOV). Regression was performed using a general linear model to determine factors most predictive of fluid administration. RESULTS For provider analysis and model building, 1327 UCI and 4585 VU patients were used. The average corrected crystalloid infusion rate across all providers at both institutions was 7.1 (sd 4.9) ml kg(-1) h(-1), an overall cCOV of 70%. Individual providers ranged from 2.3 (sd 3.7) to 14 (sd 10) ml kg(-1) h(-1). The final regression model strongly favoured personnel as predictors over other patient predictors. CONCLUSIONS Wide variability in crystalloid administration was observed both within and between individual anaesthesia providers, which might contribute to variability in surgical outcomes.

Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial

Rationale: Saline is the intravenous fluid most commonly administered to critically ill adults, but it may be associated with acute kidney injury and death. Whether use of balanced crystalloids rather than saline affects patient outcomes remains unknown. Objectives: To pilot a cluster‐randomized, multiple‐crossover trial using software tools within the electronic health record to compare saline to balanced crystalloids. Methods: This was a cluster‐randomized, multiple‐crossover trial among 974 adults admitted to a tertiary medical intensive care unit from February 3, 2015 to May 31, 2015. The intravenous crystalloid used in the unit alternated monthly between saline (0.9% sodium chloride) and balanced crystalloids (lactated Ringers solution or Plasma‐Lyte A). Enrollment, fluid delivery, and data collection were performed using software tools within the electronic health record. The primary outcome was the difference between study groups in the proportion of isotonic crystalloid administered that was saline. The secondary outcome was major adverse kidney events within 30 days (MAKE30), a composite of death, dialysis, or persistent renal dysfunction. Measurements and Main Results: Patients assigned to saline (n = 454) and balanced crystalloids (n = 520) were similar at baseline and received similar volumes of crystalloid by 30 days (median [interquartile range]: 1,424 ml [500‐3,377] vs. 1,617 ml [500‐3,628]; P = 0.40). Saline made up a larger proportion of the isotonic crystalloid given in the saline group than in the balanced crystalloid group (91% vs. 21%; P < 0.001). MAKE30 did not differ between groups (24.7% vs. 24.6%; P = 0.98). Conclusions: An electronic health record‐embedded, cluster‐randomized, multiple‐crossover trial comparing saline with balanced crystalloids can produce well‐balanced study groups and separation in crystalloid receipt. Clinical trial registered with www.clinicaltrials.gov (NCT 02345486).

Implications of event entry latency on anesthesia information management decision support systems.

BACKGROUND: Decision support systems (DSSs) are being developed to use events entered in anesthesia information management systems (AIMS) for quality of care, compliance, billing, documentation, and management purposes. DSS performance is impacted by latency from the actual time an event occurs to when it is written to the database, as well as how often the database is queried. Such latencies may result in poor DSS recommendations. METHODS: We analyzed approximately 48,000 cases at Hospital A for latency of two DSS prototype events, Surgery Begin and Surgery End. Each latency was measured from 1) the time that the event was recorded in the AIMS database as having taken place to 2) the time when the first DSS query would have been executed after the documentation of that event by the provider. The effects on latency of 1, 5, and 10 min query intervals were determined. Latencies for Surgery Begin and Surgery End were compared with those of Hospital B, where a different AIMS was used. RESULTS: Network delays and the event processing time of the AIMS contributed <1 s and 30 s, respectively, to latency. Average latencies for the two studied events were approximately half of the query interval, the expected value if the events occurred randomly within each interval. However, the longest 5% of latencies exceeded the query interval. This was not due to providers editing the times of the Begin or End Surgery events, as each occurred in only 0.7% of cases. Although the median latencies for the two events were longer at Hospital B than Hospital A by a few minutes, the 90th and 95th percentiles of the latencies were much longer at Hospital B (8–30 min, depending on the query interval and the percentile). CONCLUSIONS: DSS performance is influenced by the timeliness of documentation, the incidence of missing documentation and the query interval. Facilities using a DSS, including electronic whiteboards showing patient status, should assess the latencies of the measured events and critique the influence of the latencies on clinical and managerial decisions.

Balanced Crystalloids versus Saline in Critically Ill Adults

BACKGROUND Comparative clinical effects of balanced crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU). METHODS We conducted a single‐center, pragmatic, multiple‐crossover trial comparing balanced crystalloids (lactated Ringers solution or Plasma‐Lyte A) with saline among adults who were treated with intravenous crystalloids in the emergency department and were subsequently hospitalized outside an ICU. The type of crystalloid that was administered in the emergency department was assigned to each patient on the basis of calendar month, with the entire emergency department crossing over between balanced crystalloids and saline monthly during the 16‐month trial. The primary outcome was hospital‐free days (days alive after discharge before day 28). Secondary outcomes included major adverse kidney events within 30 days — a composite of death from any cause, new renal‐replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) — all censored at hospital discharge or 30 days, whichever occurred first. RESULTS A total of 13,347 patients were enrolled, with a median crystalloid volume administered in the emergency department of 1079 ml and 88.3% of the patients exclusively receiving the assigned crystalloid. The number of hospital‐free days did not differ between the balanced‐crystalloids and saline groups (median, 25 days in each group; adjusted odds ratio with balanced crystalloids, 0.98; 95% confidence interval [CI], 0.92 to 1.04; P=0.41). Balanced crystalloids resulted in a lower incidence of major adverse kidney events within 30 days than saline (4.7% vs. 5.6%; adjusted odds ratio, 0.82; 95% CI, 0.70 to 0.95; P=0.01). CONCLUSIONS Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital‐free days between treatment with balanced crystalloids and treatment with saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SALT‐ED ClinicalTrials.gov number, NCT02614040.)

Patient variables which may predict length of stay and hospital costs in elderly patients with hip fracture.

Objectives: To investigate what factors contribute to increased length of stay (LOS) and increased costs in treatment of elderly patients with hip fractures. Design: Retrospective chart review. Setting: All patients who presented to a large tertiary care center between January 2000 and December 31, 2009. Participants: Charts for all patients older than 60 years who presented with isolated low-energy hip fractures were reviewed. Of the 719 patients identified, 660 were included. Intervention: Patients who underwent operative fixation or hemiarthroplasty secondary to hip fracture were identified using a search of Current Procedural Terminology (CPT) codes search. Main Outcome Measurements: Gender, height, weight, body mass index, length of procedure, American Society of Anesthesiologists (ASA) classification, and medical comorbidities were gathered and compared with LOS and direct daily inpatient hospital cost. Results: No correlation existed between body mass index or specific comorbidities and LOS, but ASA classification was a predictor. For each ASA increase of 1, average LOS increased 2.053 days (P < 0.001). Given total daily cost to the hospital for these patients was

The Surgical Apgar Score in hip and knee arthroplasty

4530, each increase in ASA classification translated to an increase of