BACKGROUND:Trauma outcome prediction models have traditionally relied upon patient injury and physiologic data (eg, Trauma and Injury Severity Score [TRISS]) without accounting for comorbidities. We sought to prospectively evaluate the role of the American Society of Anesthesiologists physical status (ASA-PS) score and the National Surgical Quality Improvement Program Surgical Risk-Calculator (NSQIP-SRC), which are measurements of comorbidities, in the prediction of trauma outcomes, hypothesizing that they will improve the predictive ability for mortality, hospital length of stay (LOS), and complications compared to TRISS alone in trauma patients undergoing surgery within 24 hours. METHODS:A prospective, observational multicenter study (9/2018-2/2020) of trauma patients ≥18 years undergoing operation within 24 hours of admission was performed. Multiple logistic regression was used to create models predicting mortality utilizing the variables within TRISS, ASA-PS, and NSQIP-SRC, respectively. Linear regression was used to create models predicting LOS and negative binomial regression to create models predicting complications. RESULTS:From 4 level I trauma centers, 1213 patients were included. The Brier Score for each model predicting mortality was found to improve accuracy in the following order: 0.0370 for ASA-PS, 0.0355 for NSQIP-SRC, 0.0301 for TRISS, 0.0291 for TRISS+ASA-PS, and 0.0234 for TRISS+NSQIP-SRC. However, when comparing TRISS alone to TRISS+ASA-PS ( P = .082) and TRISS+NSQIP-SRC ( P = .394), there was no significant improvement in mortality prediction. NSQIP-SRC more accurately predicted both LOS and complications compared to TRISS and ASA-PS. CONCLUSIONS:TRISS predicts mortality better than ASA-PS and NSQIP-SRC in trauma patients undergoing surgery within 24 hours. The TRISS mortality predictive ability is not improved when combined with ASA-PS or NSQIP-SRC. However, NSQIP-SRC was the most accurate predictor of LOS and complications.

A multicenter prospective observational study finds NSQIP-SRC to have superior predicative ability compared to TRISS and ASA-PS when evaluating mortality, length of stay, and complications in elderly operative trauma patients. Supplemental digital content is available in the text. BACKGROUND The Trauma and Injury Severity Score (TRISS) uses anatomical and physiologic variables to predict mortality. Elderly (65 years or older) trauma patients have increased mortality and morbidity for a given TRISS, in part because of functional status and comorbidities. These factors are incorporated into the American Society of Anesthesiologists Physical Status (ASA-PS) and National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC). We hypothesized scoring tools using comorbidities and functional status to be superior at predicting mortality, hospital length of stay (LOS), and complications in elderly trauma patients undergoing operation. METHODS Four level I trauma centers prospectively collected data on elderly trauma patients undergoing surgery within 24 hours of admission. Using logistic regression, five scoring models were compared: ASA-PS, NSQIP-SRC, TRISS, TRISS–ASA-PS, and TRISS–NSQIP-SRC. Brier scores and area under the receiver operator characteristics curve were calculated to compare mortality prediction. Adjusted R2 and root mean squared error were used to compare LOS and predictive ability for number of complications. RESULTS From 122 subjects, 9 (7.4%) died, and the average LOS was 12.9 days (range, 1–110 days). National Surgical Quality Improvement Program Surgical Risk Calculator was superior to ASA-PS and TRISS at predicting mortality (area under the receiver operator characteristics curve, 0.978 vs. 0.768 vs. 0.903; p = 0.007). Furthermore, NSQIP-SRC was more accurate predicting LOS (R2, 25.9% vs. 13.3% vs. 20.5%) and complications (R2, 34.0% vs. 22.6% vs. 29.4%) compared with TRISS and ASA-PS. Adding TRISS to NSQIP-SRC improved predictive ability compared with NSQIP-SRC alone for complications (R2, 35.5% vs. 34.0%; p = 0.046). However, adding ASA-PS or TRISS to NSQIP-SRC did not improve the predictive ability for mortality or LOS. CONCLUSION The NSQIP-SRC, which includes comorbidities and functional status, had superior ability to predict mortality, LOS, and complications compared with TRISS alone in elderly trauma patients undergoing surgery. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III

Background: Complex spine surgery predisposes patients to substantial levels of blood loss, which can increase the risk of surgical morbidity and mortality. Case Description: A 29-year-old achondroplastic male required thoracolumbar deformity correction. However, he refused potential allogeneic blood transfusions for religious reasons. He, therefore, underwent pre-operative autologous blood donation and consented to the use of the intraoperative cell salvage device. Immediately prior to the incision, he underwent acute normovolemic hemodilution. Throughout the case, we additionally utilized meticulous hemostasis. Postoperatively, he was supplemented with iron and erythropoietin and recovered well. When he required a revision procedure 3 months later, similar strategies were successfully employed. Conclusion: Numerous strategies exist pre-operatively, intraoperatively, and post-operatively to optimize blood loss management for patients who refuse blood transfusions but warrant major spinal deformity surgery.

BACKGROUND:Cocaine has a short biological half-life, but inactive urine metabolites may be detectable for a week following use. It is unclear if patients who test positive for cocaine but have a normal electrocardiogram and vital signs have a greater percentage of hemodynamic events intraoperatively. METHODS:A total of 328 patients with a history of cocaine use who were scheduled for elective noncardiac surgery under general anesthesia were enrolled. Patients were categorized into cocaine-positive versus cocaine-negative groups based on the results of their urine cocaine toxicology test. The primary aim of this study was to evaluate whether asymptomatic cocaine-positive patients had similar percentages of intraoperative hemodynamic events, defined as (1) a mean arterial blood pressure (MAP) of <65 or >105 mm Hg and (2) a heart rate (HR) of <50 or >100 beats per minute (bpm) compared to cocaine-negative patients. The study was powered to assess if the 2 groups had an equivalent mean percent of intraoperative hemodynamic events within specific limits using an equivalence test of means consisting of 2 one-sided tests. RESULTS:The cocaine-positive group had a blood pressure (BP) that was outside the set limits 19.4% (standard deviation [SD] 17.7%) of the time versus 23.1% (SD 17.7%) in the cocaine-negative group (95% confidence interval [CI], 0.5-7.0). The cocaine-positive group had a HR outside the set limits 9.6% (SD 16.2%) of the time versus 8.2% (SD 14.9%) in the cocaine-negative group (95% CI, 4.3-1.5). Adjusted for age, sex, body mass index (BMI), smoking status, and the presence of comorbid hypertension, renal disease, and psychiatric illness, the cocaine-positive and cocaine-negative patients were similar within a 7.5% margin of equivalence for MAP data (β coefficient = 2%, P = .003, CI, 2-6) and within a 5% margin of equivalence for HR data (β coefficient = 0.2%, P < .001, CI, 4-3). CONCLUSIONS:Asymptomatic cocaine-positive patients undergoing elective noncardiac surgery under general anesthesia have similar percentages of intraoperative hemodynamic events compared to cocaine-negative patients.

Drug dosing in obese patients has been a challenge because the change in weight can be a source of errors, both of underdosing and overdosing the patient, with serious ramifications. Different scalars are used to calculate drug dosing—total body weight, lean body weight, ideal body weight, and so on. Some drugs should be dosed on total body weight and others on ideal body weight. This chapter elaborates on dosing in common classes of drugs used in anaesthesia as well as the pharmacological principles applied to achieve therapeutic aims of administration.

PURPOSE:Etomidate and ketamine are hemodynamically stable induction agents often used to sedate critically ill patients during emergency endotracheal intubation. In 2015, quality improvement data from our hospital suggested a survival benefit at Day 7 from avoidance of etomidate in critically ill patients during emergency intubation. In this clinical trial, we hypothesized that randomization to ketamine instead of etomidate would be associated with Day 7 survival after emergency endotracheal intubation.METHODS:A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at one high-volume medical center in the United States. 801 critically ill patients requiring emergency intubation were randomly assigned 1:1 by computer-generated, pre-randomized sealed envelopes to receive etomidate (0.2-0.3 mg/kg, n = 400) or ketamine (1-2 mg/kg, n = 401) for sedation prior to intubation. The pre-specified primary endpoint of the trial was Day 7 survival. Secondary endpoints included Day 28 survival.RESULTS:Of the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%, difference - 7.8, 95% confidence interval - 13, - 2.4, p = 0.005). Day 28 survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%, difference - 2.7, 95% confidence interval - 9.3, 3.9, p = 0.294).CONCLUSION:While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.

Study objective: This objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus neostigmine results in a decreased number of hypoxic episodes in the early postoperative period in patients undergoing thoracic surgery with single lung ventilation. Design: Single-center, randomized, double-blind, two-arm clinical trial. Setting: Operating room and postanesthesia care unit. Patients: 92 subjects aged >= 18, American Society of Anesthesiologists physical status II-IV, and undergoing a thoracic operation necessitating single lung ventilation. Interventions: Subjects received either 2 mg/kg sugammadex or 50 mu g/kg neostigmine with 8 mu g/kg glycopyrrolate for reversal of moderate neuromuscular blockade. Measurements: For the first 90 min postoperatively, all episodes of hypoxia were recorded. Neuromuscular monitoring was performed with acceleromyography (TOF-Watch (R) SX) and the train of four (TOF) was recorded at 2, 5, 10, and 15 min after administration of the neuromuscular reversal agent. Main results: Subjects who received neostigmine had a median of 1 episode (interquartile range IQR: 0-2.2) of hypoxia versus subjects who received sugammadex who had a median of 0 episodes (IQR: 0-1) (p = 0.009). The mean time to recovery of TOF >= 0.9 was significantly faster with sugammadex at 10 min (95% confidence interval CI: 5-15) compared with neostigmine at 40 min (95% CI: 15-53) (p < 0.001). Conclusions: In thoracic surgical patients necessitating single lung ventilation, sugammadex provides faster reversal of moderate neuromuscular blockade and results in a decreased number of postoperative hypoxic episodes compared with neostigmine.

PurposeTo determine the influence of morbid obesity on the incidence of difficult mask ventilation and difficult intubation.MethodsOver a 6-year period, all tracheal intubations in the operating room of a large tertiary teaching hospital were analyzed. A modified version of the intubation difficulty scale (mIDS) was used to define easy versus difficult intubation, where a score of two or greater was defined as difficult intubation. Difficult mask ventilation was defined as the use of one or more adjuncts to achieve successful mask ventilation.ResultsOf 45,447 analyzed cases, 1893 (4.2%) were classified as difficult intubations. Morbidly obese patients were not more likely to have difficult intubation [Odds Ratio (OR)=1.131, 95% confidence interval (CI): 0.958, 1.334, p=0.146]. Factors that were associated with difficult intubation included patient age>46 years, male sex, Mallampati 3-4, thyromental distance<6cm, and the presence of intact dentition. Of 37,016 cases in which mask ventilation was attempted, 1069 (2.9%) were difficult. Morbidly obese patients were more likely to have difficult mask ventilation (OR=3.785, 95% CI: 3.188, 4.493, p<0.0001). Other factors associated with difficult mask ventilation included patient age>46 years, male sex, Mallampati 3-4, and a history of obstructive sleep apnea. Having intact dentition decreased the likelihood of difficult mask ventilation.ConclusionMorbidly obese patients do not have a higher incidence of difficult intubation compared to non-morbidly obese patients. However, they have a significantly higher incidence of difficult mask ventilation. Other factors that are predictive of both difficult mask ventilation and difficult intubation include age>46 years, male sex, and Mallampati 3-4.

Background Obese patients have a propensity to desaturate during induction of general anesthesia secondary to their reduced functional residual capacity and increased oxygen consumption. Apneic oxygenation can provide supplemental oxygen to the alveoli, even in the absence of ventilation, during attempts to secure the airway. In this study, we hypothesized that oxygen administration through a nasopharyngeal airway and standard nasal cannula during a simulated prolonged laryngoscopy would significantly prolong the safe apneic duration in obese patients. Methods One hundred thirty-five obese patients undergoing non-emergent surgery requiring general anesthesia were randomized to either the control group or to receive apneic oxygenation with air versus oxygen. All patients underwent a standard intravenous induction. For patients randomized to receive apneic oxygenation, a nasopharyngeal airway and standard nasal cannula were inserted. A simulated prolonged laryngoscopy was performed to determine the duration of the safe apneic period, defined as the beginning of laryngoscopy until the peripheral oxygen saturation (SpO(2)) reached 95%. Results The oxygen group had a median safe apneic duration that was 103 s longer than the control group. The lowest mean SpO(2) value during the induction period was 3.8% higher in the oxygen group compared to the control group. Following intubation, patients in the oxygen group had a mean end tidal carbon dioxide (ETCO2) level that was 3.0 mmHg higher than patients in the control group. Conclusions In obese patients, oxygen insufflation at 15 L/min through a nasopharyngeal airway and standard nasal cannula can significantly increase the safe apneic duration during induction of anesthesia.

Background: Trauma prediction scores such as Revised Trauma Score (RTS) and Trauma and Injury Severity Score (TRISS)) are used to predict mortality, but do not include comorbidities. We analyzed the American Society of Anesthesiologists physical status (ASA PS) for predicting mortality in trauma patients undergoing surgery. Methods: This multicenter, retrospective study compared the mortality predictive ability of ASA PS, RTS, Injury Severity Score (ISS), and TRISS using a complete case analysis with mixed effects logistic regression. Associations with mortality and AROC were calculated for each measure alone and tested for differences using chi-square. Results: Of 3,042 patients, 230 (8%) died. The AROC for mortality for TRISS was 0.938 (95%CI 0.921, 0.954), RTS 0.845 (95%CI 0.815, 0.875), and ASA PS 0.886 (95%CI 0.864, 0.908). ASA PS + TRISS did not improve mortality predictive ability (p = 0.18). Conclusions: ASA PS was a good predictor of mortality in trauma patients, although combined with TRISS it did not improve predictive ability. (C) 2019 Elsevier Inc. All rights reserved.

Study objective: To evaluate the intraoperative hemodynamics and medication requirements of cocaine-positive patients compared to matched cocaine-negative controls. Design: Retrospective cohort study. Setting: Public county hospital. Patients: 821 patients undergoing general anesthesia. Measurements: Incidence of hemodynamic events, defined by a mean arterial pressure of < 65 mmHg or > 105 mmHg or a heart rate of < 50 beats per minute or > 100 beats per minute. Main results: Cocaine-positive patients did not experience a higher incidence of hemodynamic events when compared with matched cocaine-negative patients. Cocaine-positive patients were not more likely to be administered vasopressors intraoperatively but did receive more anti-hypertensive agents. The minimum alveolar concentration of anesthetics used was similar between the two groups. Anesthesia duration, length of stay, and in-hospital mortality did not significantly differ between the two cohorts. Conclusions: Cocaine-positive patients did not demonstrate more intraoperative hemodynamic events or adverse short-term outcomes as compared to matched cocaine-negative controls.

ABSTRACT Biphasic waveform defibrillators permit effective defibrillation of ventricular tachycardia and ventricular fibrillation (VT/VF) at lower energies. Little data is available on trends in th...

Introduction: Intralipid therapy is recommended for patients with local anesthetics like bupivacaine, but it is not advisable for patients with short acting local anesthetic toxicity like lidocaine.

BACKGROUNDUltrasound-guided supraclavicular brachial plexus block (USSB) provides excellent postoperative analgesia after upper extremity surgery. Dexamethasone and clonidine have been added to local anesthetics to enhance and prolong the duration of analgesia.OBJECTIVEThe objective of this randomized prospective study is to evaluate the efficacy of dexamethasone, clonidine, or combination of both as adjuvants to ropivacaine on the duration of USSB for postoperative analgesia.METHODSPatients receiving USSB for postoperative pain control for upper extremity surgery were randomized to one of four groups; ropivacaine 0.5%, ropivacaine 0.5% with 4 mg dexamethasone, ropivacaine 0.5% with 100 mcg clonidine , or ropivacaine 0.5% with 4 mg dexamethasone and 100 mcg clonidine. Pain scores, sensory and motor function were evaluated at post anesthesia care unit (PACU), discharge and at 24 h postoperatively.RESULTSThe duration of sensory and motor blocks was significantly longer in clonidine groups when compared to ropivacaine alone [Sensorial analgesia: ropivacaine alone 13.4±6, Ropivacaine- Clonidine 17.4±6; Ropivacaine-Dexamethasone-Clonidine 18.8±6.2; Motor blocks: Ropivacaine 12±5, Ropivacaine-Clonidine 16.8±5.2, Ropivacaine-Dexamethasone-Clonidine 18.2±5.7]. In clonidine groups, there was significant prolongation of motor and sensory block when compared to ropivacaine group alone.CONCLUSIONThe results demonstrated that clonidine significantly prolongs the duration of ropivacaine effects for the postoperative analgesia in patient underwent upper arm surgeries.