Objectives: 
1. We aim to characterize IPR nationally through a retrospective review of the National Surgical Quality Improvement Program participant user file (NSQIP PUF).
2.Identify risk factors for IPR including analysis of procedure type and preoperative characteristics.https://jdc.jefferson.edu/patientsafetyposters/1041/thumbnail.jp

Bauer, MD, Tyler M.

Cowan, MD, Scott W.

Goldhammer, MD, Jordan E.

Johnson, MD, Adam P.

Kelz, MD, Rachel R.

Wirtalla, MD, Chris

English

Objectives: 
1. We aim to characterize IPR nationally through a retrospective review of the National Surgical Quality Improvement Program participant user file (NSQIP PUF).
2.Identify risk factors for IPR including analysis of procedure type and preoperative characteristics.http://jdc.jefferson.edu/patientsafetyposters/1041/thumbnail.jp

Name not available

Preventing Isolated Perioperative Reintubation: Who is at highest risk?

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsHouse Staff Quality Improvement and PatientSafety Posters GME Quality and Safety5-31-2017Preventing Isolated Perioperative Reintubation:Who is at highest risk?Tyler M. Bauer, MDThomas Jefferson University, tyler.bauer@jefferson.eduAdam P. Johnson, MDThomas Jefferson University, adam.johnson@jefferson.eduChris Wirtalla, MDUniversity of PennsylvaniaJordan E. Goldhammer, MDThomas Jefferson University, Jordan.Goldhammer@jefferson.eduRachel R. Kelz, MDUniversity of PennsylvaniaSee next page for additional authorsFollow this and additional works at: http://jdc.jefferson.edu/patientsafetypostersPart of the Medicine and Health Sciences CommonsLet us know how access to this document benefits youThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inHouse Staff Quality Improvement and Patient Safety Posters by an authorized administrator of the Jefferson Digital Commons. For more information,please contact: JeffersonDigitalCommons@jefferson.edu.Recommended CitationBauer, MD, Tyler M.; Johnson, MD, Adam P.; Wirtalla, MD, Chris; Goldhammer, MD, Jordan E.; Kelz, MD, Rachel R.; and Cowan,MD, Scott W., "Preventing Isolated Perioperative Reintubation: Who is at highest risk?" (2017). House Staff Quality Improvement andPatient Safety Posters. Poster 67.http://jdc.jefferson.edu/patientsafetyposters/67AuthorsTyler M. Bauer, MD; Adam P. Johnson, MD; Chris Wirtalla, MD; Jordan E. Goldhammer, MD; Rachel R.Kelz, MD; and Scott W. Cowan, MDThis poster is available at Jefferson Digital Commons: http://jdc.jefferson.edu/patientsafetyposters/67Background • Postoperative respiratory complications occur in 1.03% of surgery patients with an average costs of $62,704 per patient, per event.1,2  • Post-operative respiratory failure is often secondary to a concurrent severe complication, such as cardiac arrest, sepsis, pneumonia, aspiration, or pulmonary embolism.3 • Isolated perioperative reintubation (IPR), defined as unplanned intubation in the first 24 hours of surgery without concurrent complications, has not been well characterized in the literature. • IPR likely occurs due to one or a combination of the following3,4:  • Opioid overdose • Over-sedation • Residual paralysis • Fluid overload.  • IPR represents a rare but possibly preventable cause for respiratory failure in the immediate postoperative period.        Objectives  1. We aim to characterize IPR nationally through a retrospective review of the National Surgical Quality Improvement Program participant user file (NSQIP PUF).  2. Identify risk factors for IPR including analysis of procedure type and preoperative characteristics. • Chi-squared analysis identified 22 patient covariates and 18 CPT procedure groups that were associated with IPR (p<0.1) and included in the multivariable analysis.  • Multivariable logistic regression analysis identified 12 patient factors and 8 operation types significantly associated with an elevated likelihood of IPR (p<0.05).  Next Steps • Perform institutional review of IPR events and compare to national trends and benchmarks.  This will allow us to better understand: • Interplay and overlap of underlying etiologies. • Cost an average IPR event. • Combining the identified risk factors with physiologic parameters during emergence from anesthesia to help develop a high risk pulmonary pathway in the immediate perioperative period. • Traditionally, neostigmine has been used to promote anesthesia reversal in high risk patients • New, novel neuromuscular blockade reversal agents have demonstrated more effective at reversing the neuromuscular blockade than neostigmine, albeit at a higher price. • As the price for neostigmine rises, and becomes more comparable to these new agents, it may become beneficial to treat high risk groups, such as the ones identified in our study, with the newer agents. • Develop and validate robust anesthesia and surgery outcomes. • Many outcomes require appropriate patient selection, pre-operative optimization, and intra-operative management by anesthesia. • Outcomes such as IPR require close coordination and collaboration between anesthesia and surgery. • Sharing and benchmarking outcomes like these may help to promote collaboration for improved outcomes in these two specialties References 1. Dimick JB, Chen SL, Taheri P a, et al. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J. Am. Coll. Surg. 2004;199:531–7. doi:10.1016/j.jamcollsurg.2004.05.276. 2. Alvarez MP, Samayoa-Mendez AX, Naglak MC, et al. Risk Factors for Postoperative Unplanned Intubation: Analysis of a National Database. Am. Surg. 2015;81:820–825.  3. Milgrom DP, Njoku VC, Fecher AM, et al. Unplanned intubation: when and why does this deadly complication occur? Surgery 2013;154:376–83. doi:10.1016/j.surg.2013.05.006. 4. Craft J. Patient-controlled analgesia: Is it worth the painful prescribing process? Proc. Bayl. Univ. Med. Cent. 2010;23:434–438.  Preventing Isolated Perioperative Reintubation:  Who is at highest risk?   Tyler M. Bauer1, Adam P. Johnson1, Chris Wirtalla2, Jordan E. Goldhammer3, Rachel R. Kelz2, and Scott W. Cowan1   1Department of Surgery, Thomas Jefferson University Hospital; 2Department of Surgery, University of Pennsylvania; 3Department of Anesthesia, Thomas Jefferson University Hospital Results Methods • The 2014 NSQIP PUF was queried for all observations. • Study and event exclusions were applied as below (Figure 1A and B) • Procedures were grouped by Current procedural terminology (CPT) code, as recommended in the NSQIP appendix B file. • IPR was analyzed with known risk factors and procedure grouping using chi square analysis (p < 0.001) • Multivariable logistic regression Analysis was used to analyze for independent risk factors (p < 0.05) • Inclusion into the multivariable analysis was based on a chi square p value < 0.1.  Limitations • Retrospective review of registry data is limited to data collected by the registry and may not have generalizability outside of participants in the ACS NSQIP patient registry. • Since there is no explicit variable for IPR, it was inferred by exclusions.  Further chart review at an institutional level may be necessary to validate the application of the se exclusions for this purpose. Discussion • We identified a national IPR of 0.1% in all eligible patients.  • Ten procedures demonstrate a higher than average likelihood of IPR, and two, spine and knee arthroplasty, demonstrate a lower likelihood. • TKA and Spine Surgeries had a odds ratio of < 0.01 (protective). We believe this was due to a low amount of onboard anesthetics and enhanced operative management of anesthesia with somatosensory evoked potentials  respectively. • Further chart review and prospective analysis may be required to understand the mechanism for increased likelihood of IPR in other general and vascular procedures. • Many of the patient comorbidities overlap with risk factors for  931 POD 0 UI 625 Isolated POD 0 UI 5 Neurologic (CVA) day 0, 1, or 2 74 SIRS/Sepsis day 0, 1, or 2 25 Pneumonia day 0, 1, or 2 109 Cardiac (MI/Cardiac arrest) day 0, 1, or 2 88 Vent Dependence at any time 5 Pulmonary Embolism day 0, 1, or 2 750,937 Cases in 2014 PUF 706,209 Cases included in analysis 2,750 On ventilator pre-op 36,833 SIRS/Sepsis pre-op 1,736 SSI Pre-op 1,398 Pneumonia pre-op 73,778 Not under general anesthesia Figure 1A: Study Exclusions  Figure 1B: Event Exclusions  IPR Covariate OR P>|z| 95% CI Preoperative risk factor Age (>60 years) 1.44 <0.001 1.2 - 1.72 Current smoker 1.25 0.023 1.03 - 1.51 Report of dyspnea (rest and moderate) 1.76 <0.001 1.41 - 2.19 Ascites (in prev 30days) 2.22 0.039 1.04 - 4.74 COPD (Severe) 1.88 <0.001 1.49 - 2.37 CHF(in prev 30 days) 1.89 0.002 1.27 - 2.81 HTN 1.44 <0.001 1.19 - 1.75 Transfusion preoperatively in last 72 hours 2.87 <0.001 1.94 - 4.26 Wound classification (>/= 2) 1.32 0.007 1.08 - 1.62 ASA classification (>/= 3) 3.10 <0.001 2.44 - 3.93 Operative time (>3 hours) 1.65 <0.001 1.38 - 1.99 African American 1.34 0.013 1.06 - 1.7 Procedure Colectomy 1.45 0.009 1.1 - 1.92 Esophagectomy 3.79 <0.001 1.95 - 7.36 CAS 7.92 0.041 1.08 - 57.89 EVAR 2.37 <0.001 1.5 - 3.73 Aorticoilliac (open) 2.36 0.001 1.4 - 3.98 Spine 0.62 0.046 0.39 - 0.99 Nephrectomy 1.74 0.026 1.07 - 2.84 Cystectomy 2.07 0.039 1.04 - 4.12 TKA 0.31 0.010 0.13 - 0.75 Hip Fracture 1.79 0.020 1.1 - 2.93 

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Preventing Isolated Perioperative Reintubation: Who is at highest risk?

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