Anesthesia & Analgesia

Time-Out and Distraction: Performing Checklists After the Plane Has Taken Off No abstract available

Ventilator Mode Does Not Influence Blood Loss or Transfusion Requirements During Major Spine Surgery: A Retrospective Study BACKGROUND: Blood loss during adult spinal deformity surgery is multifactorial. Anesthetic-related factors, such as mode of mechanical ventilation, may contribute to intraoperative blood loss. The aim of this study was to determine the influence of ventilator mode and ventilator parameters on intraoperative blood loss and transfusion requirements in patients undergoing prone position spine surgery. METHODS: This single-center retrospective study examined electronic medical records of patients ≥18 years of age who underwent elective prone position spine surgery between May 2015 and June 2016. Associations between ventilator mode and ventilator parameters with intraoperative estimated blood loss (EBL), packed red blood cells (PRBCs), fresh-frozen plasma (FFP), cryoprecipitate and platelet transfusions, and subfascial drain output were examined using multiple linear regression models controlling for age, sex, American Society of Anesthesiologist (ASA) physical status score, body mass index (BMI), preoperative blood coagulation parameters and laboratory values, operative levels, cage constructs, osteotomies, transforaminal lumbar interbody fusions, laminectomies, reoperation, spine surgery invasiveness index, and operative time. In a secondary analysis, EBL, blood product transfusions, and postoperative drain output were compared between pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV) propensity score–matched cohorts. RESULTS: Nine hundred forty-six records were reviewed, and 822 were included in the analysis. After adjusting for confounding, no statistically significant associations were observed between mode of ventilation and intraoperative EBL (estimate, −1.77; 95% confidence interval [CI], −248.23 to 244.68; P = .99) or blood product transfusions (PRBC: estimate, −9.34; 95% CI, −154.08 to 135.40; P = .90; FFP: estimate, −2.60; 95% CI, −58.73 to 53.52; P = .93; cryoprecipitate: estimate, −13.81; 95% CI, −70.33 to 42.71; P = .63; platelets: −7.43; 95% CI, −38.84 to 23.98; P = .64). After propensity score matching (n = 27 per group), no significant differences were observed in EBL (mean difference, 525 mL; 95% CI, −15 to 1065; P = .056) or blood transfusions (PRBC: mean difference, 208 mL; 95% CI, −23 to 439; P = .077; FFP (mean difference, 34 mL; 95% CI, −17 to 84; P = .19); cryoprecipitate (mean difference, 55 mL; 95% CI, −24 to 133; P = .17); or platelets (mean difference, 26 mL; 95% CI, −12 to 64; P = .18) between PCV and VCV groups. CONCLUSIONS: In prone position spine surgery, neither mode of mechanical ventilation nor airway pressure is associated with intraoperative blood loss or need for allogeneic transfusion. Use of modern ventilation strategies using lung protective techniques may mitigate differences in blood loss previously observed between PCV and VCV modes. Accepted for publication May 30, 2019. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Lauren K. Dunn, MD, PhD, Department of Anesthesiology, University of Virginia, PO Box 800710, Charlottesville, VA 22908. Address e-mail to lak3r@virginia.edu. © 2019 International Anesthesia Research Society

Delaying Elective Surgery in Geriatric Patients: An Opportunity for Preoperative Optimization Deciding whether to pursue elective surgery is a complex process for older adults. Comprehensive geriatric assessment (CGA) can help refine estimates of benefits and risks, at times leading to a delay of surgery to optimize surgical readiness. We describe a cohort of geriatric patients who were evaluated in anticipation of elective abdominal surgery and whose procedures were delayed for any reason. Themes behind the reasons for delay are described, and a holistic framework to guide preoperative discussion is suggested. Accepted for publication June 12, 2019. Funding: This study received the Specialty Care Education Center of Excellence Grant from the Office of Academic Affiliations of the US Veterans Health Administration. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Serena P. Wong, DO, Division of Geriatrics, Department of Medicine, Duke University Medical Center, DUMC Box 3003, Durham, NC 27710. Address e-mail to serena.wong@duke.edu. © 2019 International Anesthesia Research Society

Preemptive and Preventive Pain Psychoeducation and Its Potential Application as a Multimodal Perioperative Pain Control Option: A Systematic Review The common treatment for postoperative pain is prescription opioids. Yet, these drugs have limited effect in preventing chronic pain from surgical intervention and have in part contributed to the opioid epidemic. Recently, preemptive analgesia and multimodal analgesia have been proposed with widely gained acceptance in addressing the pain issues. However, both analgesic approaches have been focused on pharmacological means while completely neglecting the psychological aspect. To address this epidemic, we have conducted a systematic review of preoperative educational methods to explore its application as both a preemptive and a preventive psychological approach to decrease postsurgical pain and improve outcome. Preemptive psychoeducation occurs before surgery and would include information about regional or neuraxial analgesia, while preventive psychoeducation occurs throughout the perioperative period. The content and presentation of preemptive psychoeducation can help patients form accurate expectations and address their concerns of surgical outcome, leading to a significant decrease in patients' anxiety levels. By addressing the psychological needs of patients through preoperative education, one can decrease postoperative recovery time and postsurgical acute pain. Reduced postsurgical acute pain results in fewer opioid prescriptions, which theoretically lowers the patient's risk of developing chronic postsurgical pain (CPSP), and potentially offers a novel concept using preemptive pain psychoeducation as a part of multimodal pain management solution to the opioid epidemic. Accepted for publication May 28, 2019. Funding: Departmental/institutional. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Ban C. H. Tsui, MD, FRCPC, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Dr, 3rd Floor, Room H3584, MC 5640, Stanford, CA 94305. Address e-mail to bantsui@stanford.edu. © 2019 International Anesthesia Research Society

In Response No abstract available

Hematologic Challenges in the Critically Ill No abstract available

Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics: A Retrospective Cohort Study BACKGROUND: Increased risks of cerebral venous thrombosis or subdural hematoma, bacterial meningitis, persistent headache, and persistent low back pain are suggested in obstetric patients with postdural puncture headache (PDPH). Acute postpartum pain such as PDPH may also lead to postpartum depression. This study tested the hypothesis that PDPH in obstetric patients is associated with significantly increased postpartum risks of major neurologic and other maternal complications. METHODS: This retrospective cohort study consisted of 1,003,803 women who received neuraxial anesthesia for childbirth in New York State hospitals between January 2005 and September 2014. The primary outcome was the composite of cerebral venous thrombosis and subdural hematoma. The 4 secondary outcomes were bacterial meningitis, depression, headache, and low back pain. PDPH and complications were identified during the delivery hospitalization and up to 1 year postdelivery. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using the inverse probability of treatment weighting approach. RESULTS: Of the women studied, 4808 (0.48%; 95% CI, 0.47–0.49) developed PDPH, including 264 cases (5.2%) identified during a readmission with a median time to readmission of 4 days. The incidence of cerebral venous thrombosis and subdural hematoma was significantly higher in women with PDPH than in women without PDPH (3.12 per 1000 neuraxial or 1:320 vs 0.16 per 1000 or 1:6250, respectively; P < .001). The incidence of the 4 secondary outcomes was also significantly higher in women with PDPH than in women without PDPH. The aORs associated with PDPH were 19.0 (95% CI, 11.2–32.1) for the composite of cerebral venous thrombosis and subdural hematoma, 39.7 (95% CI, 13.6–115.5) for bacterial meningitis, 1.9 (95% CI, 1.4–2.6) for depression, 7.7 (95% CI, 6.5–9.0) for headache, and 4.6 (95% CI, 3.3–6.3) for low back pain. Seventy percent of cerebral venous thrombosis and subdural hematoma were identified during a readmission with a median time to readmission of 5 days. CONCLUSIONS: PDPH is associated with substantially increased postpartum risks of major neurologic and other maternal complications, underscoring the importance of early recognition and treatment of anesthesia-related complications in obstetrics. Accepted for publication June 12, 2019. Funding: J.G. is supported by an R03 from the Agency for Healthcare Research and Quality (1 R03 HS025787-01). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Jean Guglielminotti, MD, PhD, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 W 168th St, PH5-505, New York, NY 10032. Address e-mail to jg3481@cumc.columbia.edu. © 2019 International Anesthesia Research Society

Update on Congenital Diaphragmatic Hernia Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH. Accepted for publication June 4, 2019. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Debnath Chatterjee, MD, FAAP, Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, B090, Aurora, CO 80045. Address e-mail to debnath.chatterjee@childrenscolorado.org. © 2019 International Anesthesia Research Society

Bispectral Index During Maintenance of Total Intravenous Anesthesia: Frequency of Out of Recommended Range and Impact of Patients' Characteristics: A Brief Report Little is known about respecting the recommended range of bispectral index (BIS) in practice. This exploratory retrospective analysis of 138 robotic surgical patients having received total intravenous anesthesia shows that BIS was between 40 and 60 during 61.3% ± 25.2% (mean ± standard deviation [SD]) of maintenance, >60 during 3.1% ± 5.5%, and <40 during 35.7% ± 26.9%. Burst suppression was present during 17.8% ± 22.2%. Female sex is associated with increased periods of BIS <40 (P = .002) as is body mass index (BMI) <26 (P = .012). Increased age is associated with increase in burst suppression (P = .005). A larger study is required to confirm the role of patients' factors on the number of periods of low BIS. Accepted for publication May 23, 2019. Funding: This work was supported by grants from Hospital Foch. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Marc Fischler, MD, Department of Anesthesiology, Hospital Foch, 40 Rue Worth, Suresnes, France. Address e-mail to m.fischler@hopital-foch.org. © 2019 International Anesthesia Research Society

Ketamine Administration During Hospitalization Is Not Associated With Posttraumatic Stress Disorder Outcomes in Military Combat Casualties: A Matched Cohort Study BACKGROUND: Ketamine is routinely used within the context of combat casualty care. Despite early concerns that ketamine administration may be associated with elevated risk of posttraumatic stress disorder (PTSD), more recent evidence suggests no relationship. Because PTSD occurs with regular frequency in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Service Members (SMs) and combat-related injuries are associated with higher likelihood of PTSD, it is important to investigate the relationship between ketamine exposure during inpatient medical and surgical care and PTSD symptoms in OIF/OEF SMs. METHODS: Medical record data from OIF/OEF SMs medically evacuated from combat (N = 1158) included demographic characteristics, injury severity, body areas injured, and PTSD Checklist (PCL) scores. The primary analysis assessed the association between ketamine versus nonketamine exposure on positive PTSD screen (logistic regression) and PCL scores (linear regression) after using 1:1 propensity score matching to adjust for available potential confounding variables. Because there were 2 primary outcomes, the binary positive PTSD screen (yes/no) and continuous PCL score, the significance level was set at P ≤ .025. In sensitivity analyses, propensity scores were used to match ketamine to nonketamine records in a 1:4 ratio, as well as to conduct inverse probability treatment weighting (IPTW). Regressions examining the relationship between ketamine exposure and outcomes were repeated for unconditional, 1:4 matching, and IPTW models. RESULTS: In the sample, 107 received ketamine and 1051 did not. In the logistic regression, the probability of a positive PTSD screen was not significantly different between ketamine versus nonketamine patients (odds ratio [OR] = 1.28; 95% confidence interval [CI], 0.48–3.47; P = .62). In the linear regression, PCL scores were not significantly different between ketamine versus nonketamine patients (mean difference = 1.98 [95% CI, −0.99 to 4.96]; P = .19). The results were consistent in the unconditional, 1:4 matching, and IPTW models. CONCLUSIONS: No differences in PTSD screening risk or symptom levels between ketamine exposed and nonexposed were found. Given the small sample size, wide CIs of the effects, and additional confounds inherent to retrospective studies, future studies are needed to examine the complex relationships between ketamine and psychological symptoms. Accepted for publication June 5, 2019. Funding: The present study was funded on a cooperative agreement from the US Army Medical Research and Materiel Command through the Uniformed Services University. The authors declare no conflicts of interest. The opinions and assertions herein are those of the authors and do not necessarily reflect official policy or position of the Uniformed Services University, the Department of Defense, or The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc (HJF). Reprints will not be available from the authors. Address correspondence to Krista B. Highland, PhD, Defense and Veterans Center for Integrative Pain Management, Department of Military & Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD 20852. Address e-mail to khighland@dvcipm.org. © 2019 International Anesthesia Research Society

Alexandros Sfakianakis
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