Background: Many diagnostic and interventional procedures are performed in bronchoscopy suites in high-risk patients. Minor impairment in respiratory muscle function caused by incomplete reversal of neuromuscular block can contribute to postoperative pulmonary complications (PPCs). We assessed whether there are fewer serious PPCs after diagnostic or therapeutic bronchoscopy when neuromuscular block is reversed with sugammadex rather than neostigmine. Methods: This is a retrospective cohort study for bronchoscopy under general anaesthesia with the use of neuromuscular blockers between July 2016 and June 2022. The primary outcome was a composite of PPCs. The secondary outcome was hypoxaemia. We used inverse probability of treatment weighting (IPTW) to adjust for confounding, fitting weighted outcome regression models to evaluate the association between the treatment and outcomes. Results: We analysed 8557 bronchoscopies across 6123 patients for the primary analysis. Adequate balance was achieved on all potential confounders after IPTW. The unweighted PPC incidence was 85/3830 (2.2%) for sugammadex and 93/4727 (2.0%) for neostigmine. The weighted PPC incidence was 2.7% for sugammadex and 1.9% for neostigmine. Sugammadex was associated with higher odds of experiencing the primary outcome of PPCs (odds ratio [OR]: 1.44; 95% confidence interval [CI]: 1.02-2.05; P=0.038), but not the secondary outcome of hypoxaemia (OR: 0.98; 95% CI: 0.81-1.20; P=0.878). Conclusions: Sugammadex was associated with a higher risk of PPCs than neostigmine. However, the absolute difference observed (0.8%) might not be clinically meaningful. Randomised trials are needed to more accurately determine the effect of neuromuscular block reversal agent selection on respiratory complications.

BACKGROUND:Both intraoperative hypotension and excessive fluid administration can lead to detrimental perioperative complications. However, how much fluid is considered excessive and how is intraoperative hypotension related to major postoperative complications? METHODS:We conducted a single-center retrospective cohort study in 6243 patients undergoing complex spine surgery at the Cleveland Clinic Foundation between 2012 and 2022 and studied the relationship between intraoperative net fluid administration and intraoperative hypotension with major postoperative complications. The primary outcome was a collapsed composite of postoperative complications including acute kidney injury (AKI), myocardial infarction (MI), stroke, and intensive care unit (ICU) admissions. Secondary outcomes were in-hospital postoperative pulmonary complications, surgical site infections (SSI), and mortality. RESULTS:The study consisted of 6998 complex spinal surgery cases from 6243 patients. The median net fluid administration was 2100 mL (Interquartile range: 1450 to 3020 mL), and we found a change point in net fluid administration of 1865 mL (95% Confidence Interval: 1228 to 4710 mL). The odds ratio of developing postoperative complications for every 500 mL increase in net fluid administration was 1.16 (95% confidence interval [CI], 1.11-1.21; P < .0001) above and 0.87 (95% CI, 0.77-0.98; P = .026) below the change point. The odds ratio of developing postoperative pulmonary complications was 1.12 (95% CI, 1.07-1.18; P < .0001) for every 500 mL increase in net fluid administration.Intraoperative hypotension was detected in 2052 complex spine surgeries (29%). The odds ratio of developing any postoperative complication was 1.57 (95% CI, 1.37-1.80; P < .0001) and 1.30 (95% CI, 1.04-1.61; P = .019) for postoperative pulmonary complications. CONCLUSIONS:We discovered a change point in net fluid administration of 1,865mL. Above this change point, higher net fluid administration is associated with increased odds of developing postoperative complications. Intraoperative hypotension in complex spine surgeries was associated with increased postoperative complications.

Background: Patients with chronic kidney disease who require maintenance dialysis suffer excess morbidity and mortality for reasons that are not clearly elucidated. There are few targets for intervention to improve their outcomes. The authors hypothesized that perioperative hypotension is more common in patients receiving dialysis. Methodology: A retrospective cohort study was conducted of adult patients who had inpatient noncardiac surgery lasting greater than 2 h with general anesthesia between January 2012 and December 2021 at the Cleveland Clinic (Cleveland, Ohio). Using International Classification of Diseases codes and dialysis documentation in the electronic medical record, was derived age, American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status, surgery type, and propensity score (predicting dialysis dependence) matched groups of patients (1) with dialysis-dependent chronic kidney disease, (2) with nondialysis chronic kidney disease, and (3) without kidney disease. The primary outcomes were total area under the curve of mean arterial pressure (MAP) less than 65 mmHg during the surgery and postoperative MAP less than 70 mmHg during 48 h after surgery. Results: Three 1:1:1 matched groups of 1,886 patients (total, 5,658 patients) from an overall cohort of 123,761 were derived. Cases with dialysis-dependent kidney disease had a greater intraoperative area under the curve of MAP less than 65 mmHg (difference in medians, 18.4 mmHg-min 98.75% CI, 11.3 to 25.6; P < 0.001) when compared to patients who had nondialysis kidney disease and when compared to patients without kidney disease (difference in medians, 15.5 mmHg-min; 98.75% CI, 6.6 to 24.4; P < 0.001). Patients receiving preoperative dialysis were also more likely to have postoperative MAP less than 70 mmHg compared to patients with nondialysis kidney disease (rate ratio, 1.52; 98.75% CI, 1.48 to 1.57; P < 0.0001) and compared to patients without kidney disease (rate ratio, 1.43; 98.75% CI, 1.38 to 1.47; P < 0.0001). Conclusions: Perioperative hypotension is more severe and common among patients who undergo chronic maintenance dialysis compared to similar patients without dialysis dependence. The management of hemodynamics in this population comes with unique considerations that warrant further systematic evaluation.

BACKGROUND:Superior Vena Cava (SVC) diameter and collapsibility index, dynamic measures of fluid responsiveness, have been successfully utilized as echocardiographic indices for fluid responsiveness in ventilated septic patients. Whether these measurements are correlated with Central Venous Pressure (CVP) measurements in liver transplant patients is unknown. We sought to assess the correlation of maximum and minimum SVC diameter and SVC collapsibility index measurements obtained intraoperatively by Transesophageal Echocardiography (TEE) with those of simultaneously recorded CVP measurements obtained through a right atrial port of a pulmonary artery catheter. The secondary aim of the study was to assess the correlation between SVC measurements and simultaneously obtained thermodilution cardiac index measurements. METHODS:Single center prospective observational trial of patients with end stage liver disease undergoing liver transplantation in an academic tertiary care center. RESULTS:The minimum SVC exhibited a mild significant correlation with CVP as did the maximum SVC. The correlation between the SVC collapsibility index and CVP was not significantly different from zero. In our secondary analysis, the correlation between minimum SVC diameter and cardiac index was determined to be weak but non-zero as was the correlation between the maximum SVC diameter and cardiac index. The correlation between SVC collapsibility index and cardiac index was not different from zero. CONCLUSION:While statistically significant, the weak clinical correlation of intraoperative SVC measurements obtained by TEE make them unsuitable as a replacement for central venous pressure or thermodilution cardiac index measurements in liver transplant recipients.

OBJECTIVES:Perioperative coagulation management in liver transplantation recipients is challenging. Viscoelastic testing with rotational thromboelastography (TEG) can help quantify hemostatic profiles. The current work aimed to investigate whether the etiology of end-stage liver disease, pretransplant disease severity, or pretransplant thrombotic or bleeding complications are associated with specific TEG patterns. DESIGN:Retrospective cohort study. SETTING:Single quaternary care hospital. PARTICIPANTS:A total of 1,078 adult liver transplant patients. INTERVENTIONS:The primary exposure was the etiology of end-stage liver disease classified as either intrinsic or nonintrinsic (eg, biliary obstruction or cardiovascular). Secondary exposures were patients' preoperative Model for End-Stage Liver Disease (MELD) score, Child-Pugh class, presence of major preoperative thrombotic complications, and major bleeding complications. MEASUREMENTS AND MAIN RESULTS:Patients with intrinsic liver disease (84%) showed higher odds of hypocoagulable (odds ratio [OR]: 3.70, 95% confidence interval [CI]: 1.94-7.07, p < 0.0001) and mixed TEG patterns (OR: 4.59, 95% CI: 2.07-10.16, p = 0.0002) compared with those with nonintrinsic disease. Increasing MELD scores correlated with higher odds of hypocoagulable (OR: 1.14, 95% CI: 1.08-1.19, p < 0.0001) and mixed TEG patterns (OR: 1.08, 95% CI: 1.03-1.14, p = 0.0036). Child-Pugh class C was associated with higher odds of hypocoagulable (OR: 8.55, 95% CI: 3.26-22.42, p < 0.0001) and mixed patterns (OR: 12.48, 95% CI: 3.89-40.03, p < 0.0001). Major preoperative thrombotic complications were not associated with specific TEG patterns, although an interaction with liver disease severity was observed. CONCLUSIONS:Liver transplantation candidates with intrinsic liver disease tend to exhibit hypocoagulable TEG patterns, while nonintrinsic disease is associated with hypercoagulability. Increasing end-stage liver disease severity, as evidenced by increasing MELD scores and higher Child-Pugh classification, was also associated with hypocoagulable TEG patterns.

Pulmonary embolism is the third leading cause of cardiovascular death. Novel percutaneous catheter-based thrombectomy techniques are rapidly becoming popular in high-risk pulmonary embolism - especially in the presence of contraindications to thrombolysis. The interventional nature of these procedures and the risk of sudden cardiorespiratory compromise requires the presence of an anesthesiologist. Facilitating catheter-based thrombectomy can be challenging since qualifying patients are often critically ill. The purpose of this narrative review is to provide guidance to anesthesiologists for the assessment and management of patients having catheter-based thrombectomy for acute pulmonary embolism. First, available techniques for catheter-based thrombectomy are reviewed. Then, we discuss definitions and application of common risk stratification tools for pulmonary embolism, and how to assess patients prior to the procedure. An adjudication of risks and benefits of anesthetic strategies for catheter-based thrombectomy follows. Specifically, we give guidance and rationale for use monitored anesthesia care and general anesthesia for these procedures. For both, we review strategies for assessing and mitigating hemodynamic perturbations and right ventricular dysfunction, ranging from basic monitoring to advanced inodilator therapy. Finally, considerations for management of right ventricular failure with mechanical circulatory support are discussed.

PURPOSE OF REVIEW:The brain is the command center of the rest of the body organs. The normal multiorgan talks between the brain and the rest of the body organs are essential for the normal body homeostasis. In the presence of brain injury, the disturbed talks between the brain and the rest of body organs will result in several pathological conditions. The aim of this review is to present the most recent findings for the pathological conditions that would result from the impaired multiorgan talks in the presence of brain injury.RECENT FINDINGS:The brain injury such as in acute ischemic stroke, subarachnoid hemorrhage and traumatic brain injury will result in cascade of pathological talks between the brain and the rest of body organs. These pathological talks could result in pathological conditions such as cardiomyopathy, acute lung and kidney injuries, impaired liver functions, and impaired gut barrier permeability as well.SUMMARY:Better understanding of the pathological conditions that could result from the impaired multiorgan talks in the presence of brain injury will open the doors for precise targeted therapies in the future for myriad of pathological conditions.

BACKGROUND:To test whether higher intraoperative PEEP levels and/or higher TV levels are associated with higher incidence of postoperative AKI within the first postoperative week, in adult patients having orthopedic surgeries under general anesthesia. METHODS:We conducted a sub analysis of a non-randomized alternating intervention cross over study performed in patients undergoing orthopedic surgery under general anesthesia at Cleveland Clinic, Cleveland, OH. We included four different combinations of PEEP (5 or 8 cm H2 O) and TV (6 or 10 mL/kg of PBW) that alternated each week in the six orthopedic operating rooms. Our primary outcome was postoperative AKI defined by the KDIGO criteria with baseline creatinine as the closest preoperative value to the time of surgery obtained within 30 days and postoperative value as the highest creatinine value within 7 days after surgery. Secondary outcome was the maximum postoperative in-hospital creatinine level within seven postoperative days. MAIN RESULTS:A total of 1933 patients were included in the analysis. The incidence of AKI was 6.8% in the study population and similar in high TV versus low TV group and high PEEP versus low PEEP group. Neither TV nor PEEP significantly impacted AKI incidence. The estimated odds ratio of AKI comparing TV = 6 mL/kg to TV = 10 mL/kg was 0.96 (97.5% CI: 0.63, 1.46; p = .811); while the estimated odds ratio of AKI comparing PEEP = 5cm H2 O to PEEP = 8cm H2 O was 0.92 (97.5% CI: 0.60, 1.39; p = .623). No interaction was found between TV and PEEP on AKI. Additionally, neither TV nor PEEP had a significant effect on the seven postoperative day creatinine levels. CONCLUSION:Higher levels of PEEP or TV during mechanical ventilation in adult patients undergoing orthopedic surgeries under general anesthesia do not increase the odds of developing postoperative AKI within the narrow limits studied.

Background: Deep Brain Stimulation is one of the most performed surgeries in Parkinson disease, which involves stereotactic placement of electrodes within the brain. Electrical stimulation of brain is shown to be arrhythmogenic both experimentally and clinically. We performed a retrospective cohort study to summarize the incidence of adverse cardiovascular events and explore the possible causes.Methods: Adult patients aged 20 - 100 years who received DBS at Cleveland Clinic Main Campus Hospital between 2009 and 2020 were included. Primary analysis included incidence of intraoperative and postoperative bradycardia, hypotension, heart block and cardiac arrest. Logistic regression was used to explore various preoperative factors associated with intraoperative hypotension in a multivariate setting.Results: 646 stage I surgeries were performed on 399 patients, and 1033 stage II surgeries on 622 patients. Intraoperatively, overall incidence of adverse events was 36%. 38% of stage I DBS cases and 33% of stage II cases had intraoperative hypotension. History of hypertension, chronic antiarrhythmic therapy, the year of surgery and anesthetic technique were associated with intraoperative hypotension in stage I cases. Obesity (BMI >30), history of hypertension and kidney diseases, chronic therapy with antiplatelets, calcium channel blockers and diuretics, and anesthetic technique were associated with intraoperative hypotension for stage II cases.Conclusion: Advanced Parkinson disease presents unique perioperative challenges due to underlying autonomic dysfunction. These patients are very prone to hypotension during the intraoperative period as noted in our study. Meticulous preoperative evaluation to identify patients with these risk factors could plausibly prevent hypotension during the perioperative period.

Objective: To investigate the predictors of postoperative mortality in coronavirus disease 2019 (COVID-19)–positive patients. Background: COVID-19–positive patients have more postoperative complications. Studies investigating the risk factors for postoperative mortality in COVID-19–positive patients are limited. Methods: COVID-19–positive patients who underwent surgeries/procedures in Cleveland Clinic between January 2020 and March 2021 were identified retrospectively. The primary outcome was postoperative/procedural 30-day mortality. Secondary outcomes were length of stay, intensive care unit admission, and 30-day readmission. Results: A total of 2543 patients who underwent 3027 surgeries/procedures were included. Total 48.5% of the patients were male. The mean age was 57.8 (18.3) years. A total of 71.2% had at least 1 comorbidity. Total 78.7% of the cases were elective. The median operative time was 94 (47.0–162) minutes and mean length of stay was 6.43 (13.4) days. Postoperative/procedural mortality rate was 4.01%. Increased age [odds ratio (OR): 1.66, 95% CI, 1.4–1.98; P<0.001], being a current smoker [2.76, (1.3–5.82); P=0.008], presence of comorbidity [3.22, (1.03–10.03); P=0.043], emergency [6.35, (3.39–11.89); P<0.001] and urgent versus [1.78, (1.12–2.84); P=0.015] elective surgery, admission through the emergency department [15.97, (2.00–127.31); P=0.009], or inpatient service [32.28, (7.75–134.46); P<0.001] versus outpatients were associated with mortality in the multivariable analysis. Among all specialties, thoracic surgery [3.76, (1.66–8.53); P=0.002] had the highest association with mortality. Total 17.5% of the patients required intensive care unit admission with increased body mass index being a predictor [1.03, (1.01–1.05); P=0.005]. Conclusions: COVID-19–positive patients have higher risk of postintervention mortality. Risk factors should be carefully evaluated before intervention. Further studies are needed to understand the impact of pandemic on long-term surgical/procedural outcomes.

BACKGROUND:Monitored anesthesia care (MAC) and general anesthesia (GA) with endotracheal intubation are the 2 most used techniques for patients with acute ischemic stroke (AIS) undergoing endovascular thrombectomy. We aimed to test the hypothesis that increased arterial oxygen concentration during reperfusion period is a mechanism underlying the association between use of GA (versus MAC) and increased risk of in-hospital mortality. METHODS:In this retrospective cohort study, data were collected at the Cleveland Clinic between 2013 and 2018. To assess the potential mediation effect of time-weighted average oxygen saturation (Spo2) in first postoperative 48 hours between the association between GA versus MAC and in-hospital mortality, we assessed the association between anesthesia type and post-operative Spo2 tertiles (exposure-mediator relationship) through a cumulative logistic regression model and assessed the association between Spo2 and in-hospital mortality (mediator-outcome relationship) using logistic regression models. Confounding factors were adjusted for using propensity score methods. Both significant exposure-mediator and significant mediator-outcome relationships are needed to suggest potential mediation effect. RESULTS:Among 358 patients included in the study, 104 (29%) patients received GA and 254 (71%) received MAC, with respective hospital mortality rate of 19% and 5% (unadjusted P value <.001). GA patients were 1.6 (1.2, 2.1) (P < .001) times more likely to have a higher Spo2 tertile as compared to MAC patients. Patients with higher Spo2 tertile had 3.8 (2.1, 6.9) times higher odds of mortality than patients with middle Spo2 tertile, while patients in the lower Spo2 tertile did not have significant higher odds compared to the middle tertile odds ratio (OR) (1.8 [0.9, 3.4]; overall P < .001). The significant exposure-mediator and mediator-outcome relationships suggest that Spo2 may be a mediator of the relationship between anesthetic method and mortality. However, the estimated direct effect of GA versus MAC on mortality (ie, after adjusting for Spo2; OR [95% confidence interval {CI}] of 2.1 [0.9-4.9]) was close to the estimated association ignoring Spo2 (OR [95% CI] of 2.2 [1.0-5.1]), neither statistically significant, suggesting that Spo2 had at most a modest mediator role. CONCLUSIONS:GA was associated with a higher Spo2 compared to MAC among those treated by endovascular thrombectomy for AIS. Spo2 values that were higher than the middle tertile were associated with higher odds of mortality. However, GA was not significantly associated with higher odds of death. Spo2 at most constituted a modest mediator role in explaining the relationship between GA versus MAC and mortality.

There is an ongoing debate about the optimal anesthetic and hemodynamic management of acute stoke patients with large vessel occlusion undergoing endovascular mechanical thrombectomy. Several prospective and retrospective analyses, and randomized controlled trials, attempted to address the challenges of using different anesthetic modalities in acute stroke patients requiring mechanical thrombectomy. We review the advantages and disadvantages of monitored anesthesia care, local anesthesia, conscious sedation, and general anesthesia, along with the relevance of hemodynamic management and perioperative oxygenation status in these complex patients.

Introduction: Postoperative respiratory failure (PRF) contributes significantly to morbidity and mortality. We sought to identify patient characteristics and perioperative risk factors associated with PRF in patients undergoing elective abdominal surgery to improve patient outcomes. Methods: We retrospectively reviewed patients undergoing elective abdominal surgery from 2011 to 2016 at our institution. An experimental group consisting of adult patients with the Patient Safety Indicator 11 diagnosis of PRF was compared with a time-matched control group. Results: Each group consisted of 233 patients. Comorbidities associated with PRF included ascites, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus type II, hypertension, and hypoalbuminemia (P < 0.05). American Society of Anesthesiologists score IV (20.2% versus 3.95%; P < 0.001), operative time (4.13 versus 2.55 h; P < 0.001), laparotomy with open operation (77.7% versus 45.5%; P < 0.001), and net intraoperative fluid balance (3635 versus 2410 mL; P < 0.001) were higher in patients with PRF. On multivariate analysis, age, American Society of Anesthesiologists score, chronic obstructive pulmonary disease, diabetes mellitus type II, laparotomy, and net intraoperative fluid balance maintained significance (P < 0.05). Conclusions: We identified contributing pre- and intra-operative risk factors for PRF undergoing elective abdominal surgery. These findings may help identify those at increased risk for respiratory failure and mitigate complications. (c) 2022 Elsevier Inc. All rights reserved.