Mohammed M. Minhaj

CPAP adherence in patients with newly diagnosed obstructive sleep apnea prior to elective surgery.

BACKGROUND Obstructive sleep apnea (OSA) is prevalent in the surgical population, and it has been suggested that preoperative patients should be screened and treated for OSA. However, it remains unclear whether patients diagnosed with OSA in the preoperative period adhere to prescribed CPAP therapy. OBJECTIVE Our aim was to objectively quantify CPAP adherence, investigate predictors of poor CPAP adherence, and to establish an optimal CPAP setting in a cohort of presurgical patients diagnosed with OSA as part of the preoperative work-up. METHODS In a retrospective observational study, we collected data on all adult presurgical patients seen by the Anesthesia Perioperative Medicine Clinic (APMC) who screened positive for OSA on the STOP-Bang questionnaire and underwent an in-laboratory diagnostic polysomnogram (PSG) before surgery. CPAP was offered to patients with moderate or severe OSA. Objective CPAP adherence was recorded during the perioperative period. Factors associated with reduced CPAP adherence were delineated. Patient characteristics were compared between those with STOP-Bang scores of 3-4 and those with higher scores (STOP-Bang score ≥ 5). RESULTS During a 2-year period, 431 patients were referred and 211 patients completed a PSG. CPAP therapy was required in 65% of patients, and the optimal level was 9 ± 2 cm H(2)O. Objective CPAP adherence was available in 75% of patients who received CPAP therapy; median adherence was 2.5 h per night, without any significant difference between the STOP-Bang subgroups. African American race, male gender, and depressive symptomatology were independent predictors of reduced CPAP adherence. Severe OSA was significantly more prevalent in patients with a STOP-Bang score ≥ 5 than those whose score was 3-4 (55.1% versus 34.4%, p = 0.005). However, optimum CPAP pressure levels and adherence to therapy did not differ between the 2 STOP-Bang groups. CONCLUSIONS Adherence to prescribed CPAP therapy during the perioperative period was extremely low. African American race, male gender, and depressive symptoms were independently associated with reduced CPAP usage. Further research is needed to identify and overcome barriers to CPAP acceptance and adherence in the perioperative setting.

Case 13--2014: Management of pulmonary hemorrhage after pulmonary endarterectomy with venovenous extracorporeal membrane oxygenation without systemic anticoagulation.

From the *University of California, San Diego, Thornton Hospital, †University of Chicago, Chicago, IL, ‡University of Pittsburgh, Pittsburgh, PA; and §Duke University Medical Center, Durham, NC. Address reprint requests to Brett Cronin, MD, Dept. of Anesthesiology, University of California, San Diego, Thornton Hospital, 9300 Campus Point Drive #7770, La Jolla, CA 92037. E-mail: bcronin@ ucsd.edu

Transoesophageal echocardiography and central line insertion.

We investigated the potential utility of transoesophageal echocardiography (TOE) in facilitating central venous catheter (CVC) insertion in patients undergoing cardiac surgery. Thirty five patients undergoing elective cardiac surgery and CVC insertion were prospectively included in the observational, single-centre clinical investigation. Following induction of general anaesthesia and tracheal intubation, the TOE probe was inserted and the bicaval view obtained prior to CVC insertion (site at discretion of the anaesthesiologist). Prospectively collected data included site and sequence of CVC insertion attempts, information regarding ease of guidewire insertion, whether or not guidewire was visualized via TOE, and other pertinent information. In 1 patient, the TOE bicaval view could not be readily obtained because of right atrial (RA) distortion. In 31 patients, the TOE bicaval view was obtained and CVC access was successful at the site of first choice (guidewire visualized in all). Three patients had noteworthy CVC insertions. In one, CVC insertion was difficult despite visualization ofguidewire in the RA. In another, multiple guidewire insertions met with substantial resistance and without visualization of guidewire in the RA. One patient was found to have an unanticipated large mobile superior vena cava thrombus that extended into the RA, which changed clinical management by prompting initial CVC insertion into the femoral vein (potentially avoiding morbidity associated with thrombus dislodgement). Our prospective observational clinical study indicates that routine use of TOE during CVC insertion may help avoid potential complications associated with this intervention. If both CVC insertion and TOE are going to be used in the same patient, the benefits of TOE should be maximized by routine visualization of the bicaval view during guidewire insertion.

Relationship between anesthetic depth and venous oxygen saturation during cardiopulmonary bypass.

Background:During cardiopulmonary bypass, mixed venous oxygen saturation (Svo2) is frequently measured to assess circulatory adequacy. Fluctuations in Svo2 not related to patient movement or inadequate oxygen delivery have been attributed clinically to increased cerebral oxygen consumption due to “light” anesthesia. To evaluate the relationship between anesthetic depth and Svo2, we prospectively measured bispectral index (BIS) and Svo2 values in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods:Adults scheduled for cardiac surgery with cardiopulmonary bypass were recruited for this prospective observational study. During bypass, BIS and Svo2 values were recorded every 5 min. To control for confounding effects of changes in other variables known to affect Svo2, temperature, hematocrit, bypass pump flow, muscle relaxant use, and intravenous and inhaled anesthetic doses were also recorded. Only periods with limited variation in other variables affecting Svo2 were analyzed. The relationship between BIS and Svo2 was evaluated using mixed linear regression. Results:One thousand thirty-four data points were obtained in 41 patients. No overall association between BIS and Svo2 was observed, either in unadjusted analysis or adjusted for covariates. In data points with temperatures less than the median (T < 34.1°C), a significant association between BIS and Svo2 was observed both in unadjusted (&bgr; = −0.32, P = 0.01) and adjusted (&bgr; = −0.27, P = 0.04) analyses. Conclusions:In patients undergoing cardiopulmonary bypass, we found no overall association between BIS and Svo2. A weak but statistically significant association between BIS and Svo2 was observed in patients with temperatures less than 34.1°C. These data suggest that low Svo2 values on bypass are unlikely to be due to light or inadequate anesthesia. The relationship among temperature, BIS and Svo2 deserves further study.

Elongation of chordae tendineae as an adaptive process to reduce mitral regurgitation in functional mitral regurgitation

AIMS In functional mitral regurgitation (FMR), increased leaflet area has been described as a remodelling compensatory mechanism. We hypothesized that chordae tendineae elongation would also occur as part of this remodelling. In this study, the lengths of primary chords and measurements of mitral leaflets and annulus were compared with varying degrees of mitral regurgitation (MR). METHODS AND RESULTS We studied 58 patients who underwent three-dimensional (3D) transoesophageal echocardiography, including 38 with FMR and 20 with normal mitral valves (NL). The FMR group was divided into two subgroups according to two-dimensional vena contracta width (VCW). Three-dimensional datasets from transgastric or mid-oesophageal approach were used to measure primary chordal length, coaptation length, inter-papillary muscle distances, and quantitative 3D measurements of the annulus and leaflets. Leaflet surface area was increased and coaptation length was decreased in FMR compared with NL. While no difference in other 3D measurement of annulus/leaflets was noted between the FMR subgroups, averaged chordal length was shorter in patients with more severe FMR. Chords of the anterior leaflet in FMR with larger VCW were shorter compared with both NL and FMR with smaller VCW. In contrast, the chords of the posterior leaflet were longer in FMR with smaller VCW compared with the other two groups. CONCLUSION Our results suggest the posterior leaflet chords possibly remodel by elongating and contribute to reduced MR and that in a subgroup of FMR patients, the primary chords may remodel by shortening, resulting in augmented MR. This information could be useful in choosing strategy for FMR correction.

Opioid Abuse or Dependence Increases 30-day Readmission Rates after Major Operating Room ProceduresA National Readmissions Database Study

Background: Although opioids remain the standard therapy for the treatment of postoperative pain, the prevalence of opioid misuse is rising. The extent to which opioid abuse or dependence affects readmission rates and healthcare utilization is not fully understood. It was hypothesized that surgical patients with a history of opioid abuse or dependence would have higher readmission rates and healthcare utilization. Methods: A retrospective cohort analysis was performed of patients undergoing major operating room procedures in 2013 and 2014 using the National Readmission Database. Patients with opioid abuse or dependence were identified using International Classification of Diseases codes. The primary outcome was 30-day hospital readmission rate. Secondary outcomes included hospital length of stay and estimated hospital costs. Results: Among the 16,016,842 patients who had a major operating room procedure whose death status was known, 94,903 (0.6%) had diagnoses of opioid abuse or dependence. After adjustment for potential confounders, patients with opioid abuse or dependence had higher 30-day readmission rates (11.1% vs. 9.1%; odds ratio 1.26; 95% CI, 1.22 to 1.30), longer mean hospital length of stay at initial admission (6 vs. 4 days; P < 0.0001), and higher estimated hospital costs during initial admission (

Myocardial performance index in hypertensive disorders of pregnancy: The relationship between blood pressures and angiogenic factors

18,528 vs.

Association between Performance in a Maintenance of Certification Program and Disciplinary Actions against the Medical Licenses of Anesthesiologists

16,617; P < 0.0001). Length of stay was also higher at readmission (6 days vs. 5 days; P < 0.0001). Readmissions for infection (27.0% vs. 18.9%; P < 0.0001), opioid overdose (1.0% vs. 0.1%; P < 0.0001), and acute pain (1.0% vs. 0.5%; P < 0.0001) were more common in patients with opioid abuse or dependence. Conclusions: Opioid abuse and dependence are associated with increased readmission rates and healthcare utilization after surgery.

Increased Perinatal Morbidity and Mortality Among Asian American and Pacific Islander Women in the United States.

ABSTRACT Objective: To study the association between cardiac function measured by myocardial performance index (MPI), blood pressures and angiogenic factors measured at the time of echocardiography in patients with and without hypertensive disorders of pregnancy (HDP). Methods: We prospectively studied 189 pregnant women and evaluated whether changes in cardiac function observed on echocardiography were correlated with higher blood pressures and whether higher blood pressures were associated with antiangiogenic proteins (soluble fms-like tyrosine kinase, sFlt1; soluble endoglin, sEng). Comprehensive echocardiograms, including measurement of MPI, were performed on all patients. sFlt1 and sEng levels were measured using enzyme-linked immunosorbent assay. Results: Overall, 189 patients were divided into tertiles based on mean arterial pressure (MAP). The MPI was worst in tertile 3 (0.50 ± 0.15) compared to tertile 1 (0.42 ± 0.10), p = 0.0004. sFlt1 (pg/ml) and sEng (ng/ml) were highest in tertile 3 compared to tertile 1: 15055.37 vs. 1623.01 and 33.06 vs. 8.15, respectively, with p-value <0.001. In crude multivariate regression analysis, MAP was positively correlated with MPI (r = 0.32, p < 0.001), GLS (r = 0.54, p < 0.001), sFlt1 (r = 0.60, p < 0.001) and sEng (r = 0.61, p < 0.001). After adjustment for confounders, these relationships persisted between MAP and MPI (r = 0.31, p = 0.0003), GLS (r = 0.46, p < 0.001), sFlt1 (r = 0.56, p < 0.001) and sEng (r = 0.58, p < 0.001). Conclusion: Mean arterial pressure correlates with worsening cardiac function as measured by MPI and serum levels of angiogenic factors. Further studies are needed to evaluate whether a reduction in blood pressure will reverse changes in MPI or reduce levels of angiogenic proteins seen among women with HDP.

Outcomes and mortality in parturient and non-parturient patients with peripartum cardiomyopathy: A national readmission database study

What We Already Know about This Topic Anesthesiology board certification is now time-limited, requiring participation in a program to maintain certification It is unknown how physician performance is associated with participation and performance in this program What This Article Tells Us That Is New The introduction in 2000 of certificates that require participation in a program to maintain certification was not associated with a significant change in the incidence of disciplinary license actions Completing maintenance of certification program requirements in a timely fashion was associated with a lower incidence of license actions Background: In 2000, the American Board of Anesthesiology (Raleigh, North Carolina) began issuing time-limited certificates requiring renewal every 10 yr through a maintenance of certification program. This study investigated the association between performance in this program and disciplinary actions against medical licenses. Methods: The incidence of postcertification prejudicial license actions was compared (1) between anesthesiologists certified between 1994 and 1999 (non–time-limited certificates not requiring maintenance of certification) and those certified between 2000 and 2005 (time-limited certificates requiring maintenance of certification); (2) within the non–time-limited cohort, between those who did and did not voluntarily participate in maintenance of certification; and (3) within the time-limited cohort, between those who did and did not complete maintenance of certification requirements within 10 yr. Results: The cumulative incidence of license actions was 3.8% (587 of 15,486). The incidence did not significantly differ after time-limited certificates were introduced (hazard ratio = 1.15; 95% CI, 0.95 to 1.39; for non–time-limited cohort compared with time-limited cohort). In the non–time-limited cohort, 10% (n = 953) voluntarily participated in maintenance of certification. Maintenance of certification participation was associated with a lower incidence of license actions (hazard ratio = 0.60; 95% CI, 0.38 to 0.94). In the time-limited cohort, 90% (n = 5,329) completed maintenance of certification requirements within 10 yr of certificate issuance. Not completing maintenance of certification requirements (n = 588) was associated with a higher incidence of license actions (hazard ratio = 4.61; 95% CI, 3.27 to 6.51). Conclusions: These findings suggest that meeting maintenance of certification requirements is associated with a lower likelihood of being disciplined by a state licensing agency. The introduction of time-limited certificates in 2000 was not associated with a significant change in the rate of license actions.