Authorsâ reply to the letter to the editor by Sabour

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/147224/1/ejp1345.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/147224/2/ejp1345_am.pd

An observational study of end-tidal carbon dioxide trends in general anesthesia

PURPOSE: Despite growing evidence supporting the potential benefits of higher end-tidal carbon dioxide (ETCO METHODS: This retrospective, observational, multicentre study included 317,445 adult patients who received general anesthesia for non-cardiothoracic procedures between January 2008 and September 2016. The primary outcome was a time-weighted average area-under-the-curve (TWA-AUC) for four ETCO RESULTS: Both TWA-AUC and median ETCO CONCLUSIONS: Between 2008 and 2016, intraoperative ETC

Adherence to Analgesics for Cancer Pain: A Comparative Study of African Americans and Whites Using an Electronic Monitoring Device

Despite well-documented disparities in cancer pain outcomes among African Americans, surprisingly little research exists on adherence to analgesia for cancer pain in this group. We compared analgesic adherence for cancer-related pain over a 3-month period between African Americans and whites using the Medication Event Monitoring System (MEMS). Patients (N = 207) were recruited from outpatient medical oncology clinics of an academic medical center in Philadelphia (≥18 years of age, diagnosed with solid tumors or multiple myeloma, with cancer-related pain, and at least 1 prescription of oral around-the-clock analgesic). African Americans reported significantly greater cancer pain (P \u3c .001), were less likely than whites to have a prescription of long-acting opioids (P \u3c .001), and were more likely to have a negative Pain Management Index (P \u3c .001). There were considerable differences between African Americans and whites in the overall MEMS dose adherence, ie, percentage of the total number of prescribed doses that were taken (53% vs 74%, P \u3c .001). On subanalysis, analgesic adherence rates for African Americans ranged from 34% (for weak opioids) to 63% (for long-acting opioids). Unique predictors of analgesic adherence varied by race; income levels, analgesic side effects, and fear of distracting providers predicted analgesic adherence for African Americans but not for whites. Perspective: Despite evidence of disparities in cancer pain outcomes among African Americans, surprisingly little research exists on African Americans\u27 adherence to analgesia for cancer pain. This prospective study uses objective measures to compare adherence to prescribed pain medications between African American and white patients with cancer pain

Cerebrovascular Disease and Perioperative Neurologic Vulnerability: A Prospective Cohort Study

Background: Stroke is a devastating perioperative complication without effective methods for prevention or diagnosis. The objective of this study was to analyze evidence-based strategies for detecting cerebrovascular vulnerability and injury in a high-risk cohort of non-cardiac surgery patients.Methods: This was a single-center, prospective cohort study. Fifty patients undergoing non-cardiac surgery were recruited −25 with known cerebrovascular disease and 25 matched controls. Neurologic vulnerability was measured with intraoperative cerebral oximetry as the primary outcome. Perioperative neurocognitive testing and serum biomarker analysis (S-100β, neuron specific enolase, glial fibrillary acid protein, and matrix metalloproteinase-9) were measured as secondary outcomes.Results: Cerebral desaturation events (an oximetry decrease ≥20% from baseline or <50% absolute value for ≥3 min) occurred in 7/24 (29%) cerebrovascular disease patients and 2/24 (8.3%) controls (relative risk 3.5, 95% CI 0.81–15.2; P = 0.094). Cognitive function trends were similar in both groups, though overall scores (range: 1,500–7,197) were ~1 standard deviation lower in cerebrovascular patients across the entire perioperative period (−1,049 [95% CI −1,662, −436], P < 0.001). No significant serum biomarker differences were found between groups over time. One control patient experienced intraoperative hypoxic-ischemic injury, but no robust biomarker or oximetry changes were observed.Conclusions: Cerebrovascular disease patients did not demonstrate dramatic differences in cerebral oximetry, cognitive trajectory, or molecular biomarkers compared to controls. Moreover, a catastrophic hypoxic-ischemic event was neither predicted nor detected by any strategy tested. These findings support the need for novel research into cerebrovascular risk and vulnerability

Retrospective observational evaluation of postoperative oxygen saturation levels and associated postoperative respiratory complications and hospital resource utilization.

INTRODUCTION:The clinical importance of postoperative episodic hypoxemia is still unclear, and therefore largely under-studied. As a result, there is limited understanding of its relationship with early postoperative respiratory complications (PRC, defined as intubation within three days of surgery) and hospital resource utilization. MATERIALS AND METHODS:This single center study was performed using a retrospective observational design. We described population based definitions of desaturation from continuous SpO2 monitoring data captured in the post anesthesia care unit (PACU), namely median SpO2 in PACU, duration of desaturation below median, nadir desaturation, and length of oxygen therapy relative to PACU duration. These measures were evaluated against the occurrence of early PRC in logistic regression models. Measures that were independently associated with early PRC were accepted as the primary study exposures. Stratified logistic regression models were planned if significant interaction occurred with high risk surgical procedures. Models were adjusted by including several patient conditions, procedural, and anesthesia risk factors. Propensity matching on desaturation occurrence was planned to evaluate the relationship with postoperative resource utilization. RESULTS:Among 125,740 patients included in the univariate analyses, 351 patients (0.3%) developed early PRC. Nadir desaturation 60 min) to 3.04 (>90 min); p<0.001] were identified as independent predictors of early PRC occurrence. A modest interaction was observed between desaturation and higher surgical risk. Propensity matching for postoperative oxygen requirement was performed in 37,354 matched patients. Matched analysis demonstrated significant increase in day of surgery charges, respiratory charges, total charges, hospital length of stay, reintubation and use of invasive or non-invasive ventilatory support. CONCLUSIONS:In summary, we report that prolonged PACU oxygen therapy and nadir desaturation <89% in PACU as captured in a retrospective database are independently associated with early PRC. This study describes resource implications of PACU desaturation in a large academic medical center in North America

Retrospective observational evaluation of postoperative oxygen saturation levels and associated postoperative respiratory complications and hospital resource utilization

Introduction: The clinical importance of postoperative episodic hypoxemia is still unclear, and therefore largely under-studied. As a result, there is limited understanding of its relationship with early postoperative respiratory complications (PRC, defined as intubation within three days of surgery) and hospital resource utilization. Materials and methods This single center study was performed using a retrospective observational design. We described population based definitions of desaturation from continuous SpO2 monitoring data captured in the post anesthesia care unit (PACU), namely median SpO2 in PACU, duration of desaturation below median, nadir desaturation, and length of oxygen therapy relative to PACU duration. These measures were evaluated against the occurrence of early PRC in logistic regression models. Measures that were independently associated with early PRC were accepted as the primary study exposures. Stratified logistic regression models were planned if significant interaction occurred with high risk surgical procedures. Models were adjusted by including several patient conditions, procedural, and anesthesia risk factors. Propensity matching on desaturation occurrence was planned to evaluate the relationship with postoperative resource utilization. Results: Among 125,740 patients included in the univariate analyses, 351 patients (0.3%) developed early PRC. Nadir desaturation 60 min) to 3.04 (>90 min); p<0.001] were identified as independent predictors of early PRC occurrence. A modest interaction was observed between desaturation and higher surgical risk. Propensity matching for postoperative oxygen requirement was performed in 37,354 matched patients. Matched analysis demonstrated significant increase in day of surgery charges, respiratory charges, total charges, hospital length of stay, reintubation and use of invasive or non-invasive ventilatory support. Conclusions: In summary, we report that prolonged PACU oxygen therapy and nadir desaturation <89% in PACU as captured in a retrospective database are independently associated with early PRC. This study describes resource implications of PACU desaturation in a large academic medical center in North America

Outlying End-Tidal Carbon Dioxide During General Anesthesia Is Associated With Postoperative Pulmonary Complications: A Multicenter Retrospective Observational Study From US Hospitals Between 2010 and 2017

BACKGROUND: Postoperative pulmonary complications (PPCs) occur in up to 33% of patients who undergo noncardiothoracic surgery. Emerging evidence suggests that permissive hypercapnia may reduce the risk of lung injury. We hypothesized that higher intraoperative end-tidal carbon dioxide (Etco2) concentrations would be associated with a decreased risk of PPCs. METHODS: This retrospective, observational, multicenter study included patients undergoing general anesthesia for noncardiothoracic procedures (January 2010-December 2017). The primary outcome was PPC within 30 postoperative days. Secondary outcomes were PPC within 1 week, postoperative length of stay, and inhospital 30-day mortality. The association between these outcomes, median Etco2, and 4 time-weighted average area-under-the-curve (TWA-AUC) thresholds (45 mm Hg) was explored using a multivariable mixed-effect model and by plotting associated risks. RESULTS: Among 143,769 cases across 11 hospitals, 10,276 (7.1%) experienced a PPC. When compared to a baseline median Etco2 of 35 to 40 mm Hg, a median Etco2 >40 mm Hg was associated with an increase in PPCs within 30 days (median Etco2, 40-45 mm Hg; adjusted OR, 1.16 [99% confidence interval {CI}, 1.00-1.33]; P value = .008 and median Etco2, >45 mm Hg; OR, 1.64 [99% CI, 1.33-2.02]; P value 45 mm Hg (ie, a positive TWA-AUC >45 mm Hg) was also associated with PPCs (OR, 1.24 [95% CI, 1.17-1.31]; P 45 mm Hg) were associated with PPCs within 30 days. The lowest PPC incidence was found in patients with an Etco2 of 35 to 38 mm Hg. Prospective studies are needed to clarify the relationship between postoperative PPCs and intraoperative Etco2

Secondary outcomes on matched dataset.

<p>Secondary outcomes on matched dataset.</p

Unmatched and matched univariates.

<p>Unmatched and matched univariates.</p

Independent predictors of early postoperative tracheal intubation–Higher surgical risk.

<p>Independent predictors of early postoperative tracheal intubation–Higher surgical risk.</p