Mentor: Karin Trujillo Program: General Surgery Type: Original Research Background: Minimally invasive video-assisted thoracoscopic surgery (VATS) is the standard of care for early-stage lung cancers. Thoracic epidural analgesia (TEA) is the gold standard for postoperative analgesia, although the associated sympathetic blockade can elicit hypotension requiring intervention. Liposomal bupivacaine intercostal nerve blockade (ICNB) has been utilized as a viable alternative with fewer side effects including hypotension. However, its impact on the frequency of interventions is not known. Our objective was identifying the incidence of postoperative hypotension and quantify the interventions between ICNB and TEA in patients undergoing VATS lobectomy for malignancy. Methods: Patients who underwent VATS lobectomy for malignancy at a single institution between 2018–2021 were reviewed. Those with a history of chronic opioid use, previous thoracic surgery, history of atrial fibrillation, and congestive heart failure were excluded. The primary outcome was episodes of clinically significant hypotension (systolic blood pressure <90mmHg) requiring intervention. Results: A total of 155 patients were identified, 110 (71%) receiving TEA and 45 (29%) receiving ICNB. There were no demographic differences between the groups. Overall, 30% of patients in the TEA group had at least one clinically significant episode requiring intervention compared to 9% for ICNB (p=0.005). The most common interventions are shown in Table 1. There was no difference in average oral morphine milligram equivalents between the groups, although patients in the ICNB group utilized more non-opioid adjuncts. Conclusion: Hypotension requiring intervention that is associated with thoracic epidurals should warrant consideration of local anesthetic blockade to streamline postoperative management and utilize fewer hospital resources for equivalent postoperative analgesia.

Introduction: A systematic analysis of clinical trials was performed in order to assess the effectiveness and risks of bilateral renal denervation (RDN) in patients with chronic heart failure with reduced ejection fraction (HFrEF). Methods: A systematic review was conducted of all clinical trials exploring the effectiveness of RDN in patients with HF who had reduced (<50%) EF. Primary outcomes were NYHA class, 6-min walk test, N-terminal pro-Btype natriuretic peptide (NT-proBNP) levels, left ventricular ejection fraction (LVEF) and other cardiac parameters including left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic diameter (LVEDD), and left atrium diameter (LAD). Secondary outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), glomerular filtration rate (GFR), and creatinine. Results: Seven studies were included in this analysis. From baseline to 6 months after RDN, the pooled mean NYHA class was decreased (mean difference [MD], -0.9; 95% confidence interval [CI], -1.6 to -0.2; P = 0.018), the mean 6-min walk test was increased (MD, 79.5 m; 95% CI, 26.9 to 132.1; P = 0.003), and the average NT-proBNP level was decreased (MD, -520.6 pg/mL; 95% CI, -1128.4 to 87.2; P = 0.093). Bilateral RDN increased the LVEF (MD, 5.7%; 95% CI, 1.6 to 9.6; P = 0.004), decreased the LVESD (MD, -0.4 cm; 95% CI, -0.5 to -0.2; P < 0.001), decreased the LVEDD (MD, -0.5 cm; 95% CI, -0.6 to -0.3; P < 0.001), and decreased the LAD (MD, -0.4 cm; 95% CI, -0.8 to 0; P = 0.045). In addition, RDN significantly decreased systolic BP (MD, -9.4 mmHg; 95% CI, -16.3 to -2.4; P = 0.008) and diastolic BP (MD, -4.9 mmHg; 95% CI, -9.5 to -0.4; P = 0.033), and decreased HR (MD, -4.5 bpm; 95% CI, -8.2to -0.9; P = 0.015). RDN did not significantly change GFR (MD, 7.9; 95% CI, -5.0 to 20.8; P = 0.230), or serum creatinine levels (MD, -7.2; 95% CI, -23.7 to 9.4; P = 0.397). Conclusion: Bilateral RDN appears safe and well-tolerated in patients with HF. RDN improved the signs and symptoms of HF and slightly decreased systolic and diastolic BP without affecting renal function in the clinical trials performed to date.

STUDY OBJECTIVE:In the United States, alcohol use disorder adversely affects 5.6% of all adults. Excessive alcohol consumption adversely affects organ functions critical for adaptation to stress induced by surgery. Colorectal resection is one of the most common major surgeries in patients at risk for alcohol use disorder. The objective of this study was to assess the impact of alcohol use disorder on hospital outcomes after colectomy using a population-based discharge database. SETTING:Population-based discharge database. PATIENTS:The Premier Healthcare Database was queried for the 603,730 adult patients who underwent colectomy from 2016 to 2019. INTERVENTIONS:None. MEASUREMENTS:Multiple logistic regressions estimated the associations between in-hospital mortality, length of stay, and hospitalization cost with alcohol use disorder as the primary predictor, adjusting for other substance use disorders, psychotic disorders, depression, other Elixhauser comorbidities, age, payor, race, gender, non-elective surgery, and other unbalanced variables. MAIN RESULTS:A discharge code for alcohol use disorder was identified in 2.9% of colectomy patients and the overall in-hospital mortality rate in all sampled colectomy patients was 1.4%. Alcohol use disorder was associated with a significantly increased risk of in-hospital mortality after adjusting for other factors (AOR 1.36, 95% CI 1.24-1.48, p < 0.0001). Alcohol use disorder was also significantly associated with long length of stay (AOR 1.45, 95% CI 1.39-1.52, p < 0.0001) and high hospitalization costs (AOR 1.63, 95% CI 1.56-1.70, p < 0.0001). CONCLUSIONS:Alcohol use disorder is associated with an increased risk of in-hospital mortality in patients undergoing colectomy, one of the most common major surgeries. Future research should examine if enhanced efforts to identify patients with alcohol use disorder could enable anesthesiologists to provide worthwhile perioperative interventions for this high-risk population.

Bartels, Karsten MD, PhD, MBA*,†,‡; Lobato, Robert L. MD, MS*; Bradley, Cathy J. PhD§ Author Information

Objectives: To compare postoperative nausea and vomiting (PONV) prophylaxis treatment and outcomes based on patients’ sex, using a retrospective cohort. The setting was the operating room and post-anesthesia care unit of a tertiary care university medical center. Patients: A total of 678 adult male and female patients with American Society of Anesthesiologist (ASA) scores of 1–4 underwent surgery with general anesthesia. All patients received preoperative PONV risk assessment. PONV prophylaxis was administered at the discretion of the anesthesia care team members with guidance from a computerized decision support system. Measurements: Adequacy of prophylaxis was retrospectively determined based on individual patient risk factors and the observed treatment received, compared with guideline-based prophylaxis recommendations. Patient outcome was measured by diagnosis of PONV in recovery. Results: Comparing patients who received fewer than the guideline-recommended number of prophylactic antiemetics by sex, 94.6% were female and 5.4% were males (p < 0.001). Patients who received fewer than guideline-recommended number of antiemetics had significantly higher rates of nausea or vomiting in the post-anesthesia care unit (30.4% vs 17.5%, p < 0.001). Conclusion: This retrospective cohort study shows that female patients receiving general anesthesia are disproportionately affected by failure to adhere to PONV prevention guidelines.

OBJECTIVETo test the hypothesis that obstructive sleep apnea (OSA) is a risk factor for development of postoperative atrial fibrillation (POAF) after cardiac surgery.DESIGNRetrospective analysis.SETTINGSingle-center university hospital.PARTICIPANTSFive hundred forty-five patients in sinus rhythm preoperatively undergoing coronary artery bypass grafting (CABG), aortic valve replacement, mitral valve replacement/repair, or combined valve/CABG surgery from January 2008 to April 2011.INTERVENTIONSRetrospective review of medical records.MEASUREMENTS AND MAIN RESULTSPostoperative atrial fibrillation was defined as atrial fibrillation requiring therapeutic intervention. Of 545 cardiac surgical patients, 226 (41%) patients developed POAF. The risk was higher in 72 OSA patients than 473 patients without OSA (67% v 38%, adjusted hazard ratio 1.83 [95% CI: 1.30-2.58], p<0.001). Of the 32 OSA patients who used home positive airway pressure (PAP) therapy, 18 (56%) developed POAF compared with 29 of 38 (76%) patients who did not use PAP at home (unadjusted hazard ratio 0.63 [95% CI: 0.35-1.15], p = 0.13).CONCLUSIONOSA is significantly associated with POAF in cardiac surgery patients. Further investigation is needed to determine whether or not use of positive airway pressure in OSA patients reduces the risk of POAF.

Background: An increasing number of patients with congenital heart disease are surviving to adulthood. Consensus guidelines and expert opinion suggest that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population. Methods: By using the Nationwide Inpatient Sample database (years 2002 through 2009), the authors compared patients with adult congenital heart disease (ACHD) who underwent noncardiac surgery with a non-ACHD comparison cohort matched on age, sex, race, year, elective or urgent or emergency procedure, van Walraven comborbidity score, and primary procedure code. Mortality and morbidity were compared between the two cohorts. Results: A study cohort consisting of 10,004 ACHD patients was compared with a matched comparison cohort of 37,581 patients. Inpatient mortality was greater in the ACHD cohort (407 of 10,004 [4.1%] vs. 1,355 of 37,581 [3.6%]; unadjusted odds ratio, 1.13; P = 0.031; adjusted odds ratio, 1.29; P < 0.001). The composite endpoint of perioperative morbidity was also more commonly observed in the ACHD cohort (2,145 of 10.004 [21.4%] vs. 6,003 of 37,581 [16.0%]; odds ratio, 1.44; P < 0.001). ACHD patients comprised an increasing proportion of all noncardiac surgical admissions over the study period (P value for trend is <0.001), and noncardiac surgery represented an increasing proportion of all ACHD admissions (P value for trend is <0.001). Conclusions: Compared with a matched control cohort, ACHD patients undergoing noncardiac surgery experienced increased perioperative morbidity and mortality. Within the limitations of a retrospective analysis of a large administrative dataset, this finding demonstrates that this is a vulnerable population and suggests that better efforts are needed to understand and improve the perioperative care they receive.

OBJECTIVES Recent analyses establish that heart transplantation is increasing among adults with congenital heart disease (ACHD), but the effects of pretransplant mechanical circulatory support (MCS) on perioperative and post-transplant outcomes have not been examined in the ACHD population. METHODS Scientific Registry of Transplant Recipients data on all adult heart transplants from September 1987 to September 2012 (n = 47 160) were classified based on primary diagnosis codes as CHD or non-CHD and MCS or non-MCS. Demographic, procedural, outcome and survival variables were compared between MCS and non-MCS ACHD patient groups. RESULTS MCS was used in 83 (6.8%) ACHD patients compared with 8625 (18.8%) patients without CHD (P < 0.001). MCS as a fraction of ACHD transplants increased over time (P = 0.002). MCS patients spent more time on the wait list, had a higher baseline serum creatinine and were more likely to be male, status 1A, hospitalized, in the ICU and/or on a ventilator prior to transplant. However, MCS patients experienced equivalent short-term survival (30-day mortality = 10.8% in MCS vs 13.5% in non-MCS, P = 0.62) and overall survival by Kaplan-Meier analysis (P = 0.57). MCS patients had a longer post-transplant length of stay and were more likely to be transfused, but otherwise had no significant differences in adverse outcomes. CONCLUSIONS MCS is less commonly used in adult CHD patients compared with all patients undergoing heart transplant, but has been increasing over time. Within the ACHD population, patients with MCS have a higher risk profile, but except for increased transfusion rate and longer length of stay, do not experience less favourable post-transplant outcomes.

An increasing number of patients with congenital heart disease survive to adulthood. Expert opinion suggests that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population. Using the National Surgical Quality Improvement Program database, we identified a cohort of patients aged 18 to 39 years with prior heart surgery who underwent noncardiac surgery between 2005 and 2010. A comparison cohort with no prior cardiovascular surgery was matched on age, sex, race/ethnicity, operation year, American Society of Anesthesiologists physical status, and Current Procedural Terminology code. A study cohort consisting of 1191 patients was compared with a cohort of 5127 patients. Baseline dyspnea, inpatient status at the time of surgery, and a prior operation within 30 days were more common in the study cohort. Postoperative outcomes were less favorable in the study cohort. Observed rates of death, perioperative cardiac arrest, myocardial infarction, stroke, respiratory complications, renal failure, sepsis, venous thromboembolism, perioperative transfusion, and reoperation were significantly higher in the study cohort (P < 0.01 for all). Mean postoperative length of stay was greater in the study cohort (5.8 vs 3.6 days, P < 0.01). Compared with a matched control cohort, young adult patients with a history of prior cardiac surgery experienced significantly greater perioperative morbidity and mortality after noncardiac surgery. A history of prior cardiac surgery represents a marker of substantial perioperative risk in this young population that is not accounted for by the matched variables. These results suggest that adult patients with congenital heart disease are at risk for adverse outcomes and support the need for further registry-based investigations.

OBJECTIVE:To test the hypothesis that including preoperative electrocardiogram (ECG) characteristics with clinical variables significantly improves the new-onset postoperative atrial fibrillation prediction model.DESIGN:Retrospective analysis.SETTING:Single-center university hospital.PARTICIPANTS:Five hundred twenty-six patients, ≥ 18 years of age, who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement/repair, or a combination of valve surgery and coronary artery bypass grafting requiring cardiopulmonary bypass.INTERVENTIONS:Retrospective review of medical records.MEASUREMENTS AND MAIN RESULTS:Baseline characteristics and cardiopulmonary bypass times were collected. Digitally-measured timing and voltages from preoperative electrocardiograms were extracted. Postoperative atrial fibrillation was defined as atrial fibrillation requiring therapeutic intervention. Two hundred eight (39.5%) patients developed postoperative atrial fibrillation. Clinical predictors were age, ejection fraction<55%, history of atrial fibrillation, history of cerebral vascular event, and valvular surgery. Three ECG parameters associated with postoperative atrial fibrillation were observed: Premature atrial contraction, p-wave index, and p-frontal axis. Adding electrocardiogram variables to the prediction model with only clinical predictors significantly improved the area under the receiver operating characteristic curve, from 0.71 to 0.78 (p<0.01). Overall net reclassification improvement was 0.059 (p = 0.09). Among those who developed postoperative atrial fibrillation, the net reclassification improvement was 0.063 (p = 0.03).CONCLUSION:Several p-wave characteristics are independently associated with postoperative atrial fibrillation. Addition of these parameters improves the postoperative atrial fibrillation prediction model.

Background. Do-not-resuscitate (DNR) orders are often active in patients with multiple comorbidities and a short natural life expectancy, but limited information exists as to how often these patients undergo high-risk operations and of the perioperative outcomes in this population. Methods. Using comprehensive inpatient administrative data from the Public Discharge Data file (years 2005 through 2010) of the California Office of Statewide Health Planning and Development, which includes a dedicated variable recording DNR status, we identified cohorts of DNR patients who underwent major cardiac or thoracic operations and compared themto age- and procedure-matched comparison cohorts. The primary study outcome was in-hospital mortality. Results. DNR status was not uncommon in cardiac (n = 2,678, 1.1% of all admissions for cardiac surgery, age 71.6 ± 15.9 years) and thoracic (n = 3,129, 3.7% of all admissions for thoracic surgery, age 73.8 ± 13.6 years) surgical patient populations. Relative to controls, patients who were DNR experienced significantly greater inhospital mortality after cardiac (37.5% vs. 11.2%, p < 0.0001 and thoracic (25.4% vs. 6.4%) operations. DNR status remained an independent predictor of in-hospital mortality onmultivariate analysis after adjustment for baseline and comorbid conditions in both the cardiac (OR 4.78, 95% confidence interval 4.21-5.41, p < 0.0001) and thoracic (OR 6.11, 95% confidence interval 5.37-6.94, p < 0.0001) cohorts. Conclusions. DNR status is associated with worse outcomes of cardiothoracic surgery even when controlling for age, race, insurance status, and serious comorbid disease. DNR status appears to be a marker of substantial perioperative risk, and may warrant substantial consideration when framing discussions of surgical risk and benefit, resource utilization, and biomedical ethics surrounding end-of-life care.

OBJECTIVE:To assess the hypothesis that postoperative survival exhibits heterogeneity associated with the timing of quality metrics.DATA SOURCES:Retrospective observational study using the Nationwide Inpatient Sample from 2005 through 2009.STUDY DESIGN:Survival analysis was performed on all admission records with a procedure code for major cardiac surgery (n = 595,089). The day-by-day hazard function for all-cause in-hospital mortality at 1-day intervals was analyzed using joinpoint regression (a data-driven method of testing for changes in hazard).DATA EXTRACTION METHODS:A comprehensive analysis of a publicly available national administrative database was performed.PRINCIPAL FINDINGS:Statistically significant shifts in the pattern of postoperative mortality occurred at day 6 (95 percent CI = day 5-8) and day 30 (95 percent CI = day 20-35).CONCLUSIONS:While the shift at day 6 plausibly can be attributed to the separation between routine recovery and a complicated postoperative course, the abrupt increase in mortality at day 30 has no clear organic etiology. This analysis raises the possibility that this observed shift may be related to clinician behavior because of the use of 30-day mortality as a quality metric, but further studies will be required to establish causality.

OBJECTIVE:Postcardiopulmonary bypass hemorrhage remains a serious complication of cardiac surgery. Given concerns regarding adverse effects of blood product transfusion and limited efficacy of current antifibrinolytics, procoagulant medications, including recombinant factor VIIa (rFVIIa) and factor eight inhibitor bypass activity (FEIBA), increasingly have been used in managing refractory bleeding. While effective, these medications are associated with thromboembolic complications. This study compared the efficacy and risk of adverse events of rFVIIa and FEIBA in cardiac surgical patients with refractory bleeding.DESIGN:This retrospective study evaluated 168 patients who underwent cardiac surgery and received either FEIBA or rFVIIa to manage postbypass hemorrhage. Demographic, clinical, and outcomes data were collected and statistical analysis performed to compare thromboembolic event rates, relative efficacy, and 30-day mortality following administration of these medications.SETTING:Single university hospital.PARTICIPANTS:Patients undergoing cardiac surgery.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULT:Sixty-one patients received rFVIIa, and 107 received FEIBA. Demographics, surgical procedures, and preoperative anticoagulation were similar between the cohorts; however, the rFVIIa cohort had longer durations of cardiopulmonary bypass (305.1 v 243.8 min, p<0.01). There were no significant differences in the number of thromboembolic events, 30-day mortality, or rates of revision surgery. Neither group demonstrated a clear relationship between dosage and occurrence of thromboembolic events. The rFVIIa cohort received more platelets than the FEIBA cohort (3.13 v 1.67 units, p = 0.01), but transfusion rates of other blood products were similar.CONCLUSIONS:This study suggests that rFVIIa and FEIBA have similar efficacy and adverse event profiles in managing intractable postbypass hemorrhage in cardiac surgical patients. Further prospective studies are required.

We have very little information about the metabolomic changes that mediate neurobehavioral responses, including addiction. It was possible that opioid-induced metabolomic changes in brain could mediate some of the pharmacodynamic effects of opioids. To investigate this, opiate-induced brain metabolomic responses were profiled using a semi-targeted method in C57BL/6 and 129Sv1 mice, which exhibit extreme differences in their tendency to become opiate dependent. Escalating morphine doses(10-40 mg/kg) administered over a 4-day period selectively induced a twofold decrease (p < 0.00005) in adenosine abundance in the brainstem of C57BL/6 mice, which exhibited symptoms of narcotic drug dependence; but did not decrease adenosine abundance in 129Sv1 mice, which do not exhibit symptoms of dependence. Based on this finding, the effect of adenosine on dependence was investigated in genetically engineered mice with alterations in adenosine tone in the brain and in pharmacologic experiments. Morphine withdrawal behaviors were significantly diminished (p < 0.0004) in genetically engineered mice with reduced adenosine tone in the brainstem, and by treatment with an adenosine receptor., (A1) agonist (2-chloro-N6-cyclopentyladenosine, 0.5 mg/kg) or an A(2a) receptor (A(2a)) antagonist (SCH 58261, 1 mg/kg). These results indicate that adenosine homeostasis plays a crucial role in narcotic drug responses. Opiate-induced changes in brain adenosine levels may explain many important neurobehavioral features associated with opiate addiction and withdrawal. (C) 2012 IBRO. Published by Elsevier Ltd. All rights reserved.

OBJECTIVE:The study objective was to determine whether significant trends over time have occurred in resource use associated with the use of extracorporeal membrane oxygenation in critically ill adults. METHODS:All adult admissions involving extracorporeal membrane oxygenation were examined by using the Nationwide Inpatient Sample database (years 1998-2009). Trends in volume, outcome, and resource use (including hospital charges, length of stay, and charges per day) were analyzed. RESULTS:An estimated total of 8753 admissions involved extracorporeal membrane oxygenation over the study period. Overall length of stay was 18.3 ± 1.3 days. Total hospital charges averaged $344,009 ± $30,707 per admission, with average charges per day of $40,588 ± $3099. Cumulative national charges for extracorporeal membrane oxygenation admissions increased significantly from $109.0 million in 1998 to $764.7 million in 2009 (P = .0016). Charges per patient and length of stay also increased significantly (P = .0032 and .0321, respectively). The increasing trend in the number of extracorporeal membrane oxygenation admissions during the study period was not statistically significant (P = .19). The post-cardiotomy group had more favorable outcomes and lower resource use. A shift was observed in the relative case-mix of extracorporeal membrane oxygenation admissions over the study period, with a relative decrease in the post-cardiotomy group and increases in the cardiogenic shock, respiratory failure, and lung transplant groups. CONCLUSIONS:These results suggest that dramatic increases in resource use associated with extracorporeal membrane oxygenation are not solely the result of increased volume, but in part are due to a shift toward extracorporeal membrane oxygenation use in patient groups (other than in the post-cardiotomy setting) with greater resource use and worse outcomes.

A 73-YEAR-OLD WOMAN suffered a cardiac arrest in the emergency department waiting room. After prompt resuscitation and admission to the coronary care unit, coronary angiography showed critical stenosis of the left main and left circumflex arteries. An intra-aortic balloon pump was placed, a heparin infusion was initiated, and the patient was brought for urgent coronary artery bypass grafting. Transesophageal echocardiography revealed the unexpected finding of near-systemic right ventricular systolic pressure by tricuspid regurgitation jet velocity on continuous wave Doppler. Midesophageal 4-chamber (Fig 1), midesophageal right ventricular inflow-outflow, and transgastric right ventricular inflow (Fig 2) views revealed a moderate tricuspid regurgitation jet with maximum velocity of 4.88 m/sec, which predicts a right ventricular systolic pressure of at least 95 mmHg above right atrial pressure (Fig 3). There was no evidence of pulmonary stenosis, right ventricular outflow tract obstruction, or atrial or ventricular septal defects. Central venous pressure was measured (by right internal jugular vein catheter) at 10 mmHg. Right atrial size, systolic hepatic vein flow, right ventricular size and function, septal position, and septal motion appeared normal. Direct measurement of pulmonary artery systolic pressure (44 mmHg) did not correlate with the TEE estimate. With the catheter withdrawn into the right ventricle, right ventricular systolic pressure was measured at 42 mmHg. What is the diagnosis? Fig 2Modified transgastric right ventricular inflow view confirming the tricuspid regurgitation jet. LV, left ventricle; RA, right atrium; RV, right ventricle. (Color version of figure is available online.) View Large Image Figure Viewer Download Hi-res image Fig 3Continuous wave Doppler examination of the tricuspid regurgitation jet shows a maximum velocity of 4.88 m/sec, which predicts a right ventricular systolic pressure of at least 95 mmHg above right atrial pressure by the modified Bernoulli equation. (Color version of figure is available online.) View Large Image Figure Viewer Download Hi-res image