Faculty Bibliography

STUDY OBJECTIVE/OBJECTIVE:Obesity is a growing worldwide epidemic, and obese patients undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI pathway (HBP) for patients with a body mass index (BMI) of 40 or greater undergoing planned robotic hysterectomy. Our primary outcome was rate of all-cause perioperative complications in patients undergoing surgery with the utilization of the HBP. DESIGN/METHODS:A retrospective cohort study. SETTING/METHODS:An academic teaching hospital. PATIENTS/METHODS:) undergoing robotic hysterectomy. INTERVENTIONS/METHODS:The HBP was developed by a multidisciplinary team and was instituted January 1, 2016 as a quality improvement project. Morbidly obese patients undergoing robotic hysterectomy after this date were compared to consecutive historic controls. MEASUREMENTS AND MAIN RESULTS/RESULTS:Seventy-two patients underwent robotic hysterectomies on the HBP and were compared to 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of HBP, there has been a decrease in anesthesia time (-57.0 min; p=.001), total operating room time (-47.0 min; p=.020), lower estimated blood loss (median 150 cc [IQR 100-200] vs 200 cc [IQR 100-300]; p=.002), and overnight hospital admissions (33.3% vs 63.6%; p < 0.001). There were fewer all-cause complications seen in HBP (19.4% vs 37.9%; p=.023) and infectious complications (8.3% vs 33.3%; p=.001) and no increase in readmission rates (p=.400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio [OR] 0.353; p=.010) after controlling for covariate (total time in OR). CONCLUSION/CONCLUSIONS:HBP is a feasible method of optimizing outcome for morbidly obese patients undergoing major gynecologic surgery. Initiation of HBP can lead to decreased all-cause complications and overnight hospital admissions without increasing readmission rates.

BACKGROUND:Patients undergoing multilevel spine surgery are at risk for delayed extubation. OBJECTIVE:To evaluate the impact of type and volume of intraoperative fluids administered during multilevel thoracic and/or lumbar spine surgery on postoperative extubation status. METHODS:Retrospective evaluation of medical records of patients ≥ 18 yr undergoing ≥ 4 levels of thoracic and/or lumbar spine fusions was performed. Patients were organized according to postoperative extubation status: immediate (IMEX; in OR/PACU) or delayed (DEX; outside OR/PACU). Propensity score matched (PSM) analysis was performed to compare IMEX and DEX groups. Volume, proportion, and ratios of intraoperative fluids administered were evaluated for the associated impact on extubation status. RESULTS:A total of 246 patients (198 IMEX, 48 DEX) were included. PSM analysis demonstrated that increased administration of non-cell saver blood products (NCSB) and increased ratio of crystalloid: colloids infused were independently associated with delayed extubation. With increasing EBL, IMEX had a proportionate reduction in crystalloid infusion (R = -0.5, P < .001), while the proportion of crystalloids infused remained relatively unchanged for DEX (R = -0.27; P = .06). Twenty-six percent of patients receiving crystalloid: colloid ratio > 3:1 had DEX compared to none of those receiving crystalloid: colloid ratio ≤ 3:1 (P = .009). DEX had greater cardiac and pulmonary complications, surgical site infections and prolonged intensive care unit and hospital stay (P < .05). CONCLUSION/CONCLUSIONS:PSM analysis of patients undergoing multilevel thoracic and/or lumbar spine fusion demonstrated that increased administration of crystalloid to colloid ratio is independently associated with delayed extubation. With increasing EBL, a proportionate reduction of crystalloids facilitates early extubation.

Objective: Obesity is a significant risk factor for perioperative morbidity and mortality. Outcomes can be improved with standardized protocols including preventive measures and specialized surgical equipment and personnel. We sought to evaluate the outcomes of a surgical safety protocol for all patients with a body mass index (BMI) of >=40 undergoing planned gynecologic surgery.
Method(s): The high BMI pathway (HBP) was developed by a multidisciplinary team of gynecologic oncologists (GO), anesthesiologists, and ancillary surgical and nursing staff based on the most current recommendations from the literature and instituted as a quality improvement project. It was implemented for all morbidly obese patients undergoing planned surgery by a GO. Patients who underwent robotic hysterectomies (RH) on the HBP from 2016 to 2018 were compared with consecutive historical controls who had RHs from 2014 to 2015 prior to HBP implementation. Standard two-sided statistical analyses were performed.
Result(s): Of the 80 patients who successfully completed surgery on the HBP, 55 patients (68.8%) underwent RH and were included in this analysis. These patients were compared to 48 historical controls prior to HBP initiation. There were no significant differences in patient factors or perioperative times between pre- and post-HBP groups (Table 1). Since implementing HBP, there were fewer anesthesia-related complications (ARC) in HBP patients after RH compared to pre-HBP patients (0.0% vs 12.5%, P = 0.02). Among the control patients with ARC, two had respiratory distress requiring pharmacologic intervention, two had increased postoperative nausea and vomiting, and two had intractable postoperative pain. There was also an increase in same-day discharges among patients who underwent RH (65.5% vs 41.7%, P = 0.03), but no difference in hospital readmission rates. There were no differences in intraoperative and 30-day postoperative complications.
Conclusion(s): A HBP to improve perioperative safety for morbidly obese patients undergoing RH resulted in fewer ARCs and increased rates of same-day discharge without increasing perioperative times or intraoperative and postoperative complications. [Figure presented]
Copyright

Our planet is in the midst of an environmental crisis. Government and international agencies such as the Intergovernmental Panel on Climate Change urge radical and transformative change at every level of how we conduct our personal and professional lives. The health care industry contributes to climate change. According to a study from the University of Chicago, the health care sector accounts for 8% of the United States' total greenhouse gas emissions. In an effort to understand the current state of environmental practice, attitudes, and knowledge among anesthesiologists in the United States, we conducted a survey of American anesthesiologists regarding environmental sustainability. The environmental survey was sent out by e-mail to a random sampling of 5200 members of the American Society of Anesthesiologists. This process was repeated a second time. A total of 2189 anesthesiologists of 5200 responded to the survey, a 42% response rate. Of the survey respondents, 80.1% (confidence interval, 78.2%-81.9%) were interested in recycling. Respondents reported recycling in 27.7% of operating rooms where they work. The majority of respondents (67%; confidence interval, 64%-69%) reported there was insufficient information on how to recycle intraoperatively. Respondents supported sustainability practices such as reprocessing equipment, using prefilled syringes, and donating unused equipment and supplies. The affirmative response rate was 48.4% for reprocessing equipment, 56.6% for using prefilled syringes, and 65.1% for donating equipment and supplies to medical missions. Questions about hospital-wide organization of sustainability programs elicited many "I don't know" responses. Eighteen percent of responders indicated the presence of a sustainability or "green" task force. A total of 12.6% of responders indicated the presence of a mandate from hospital leadership to promote sustainability programs. Two important conclusions drawn from the survey data are a lack of hospital-wide organization of sustainability programs and a belief among survey responders that they lack adequate information on recycling and sustainability.

STUDY DESIGN: This is a prospective, randomized, double-blinded comparison of tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and placebo used intraoperatively in patients with adult spinal deformity. OBJECTIVE: The purpose of this study was to provide high-quality evidence regarding the comparative efficacies of TXA, EACA, and placebo in reducing blood loss and transfusion requirements in patients undergoing posterior spinal fusion surgery. SUMMARY OF BACKGROUND DATA: Spine deformity surgery usually involves substantial blood loss. The antifibrinolytics TXA and EACA have been shown to improve hemostasis in large blood loss surgical procedures. METHODS: Fifty-one patients undergoing posterior spinal fusion of at least 5 levels for correction of adult spinal deformity were randomized to 1 of 3 treatment groups. Primary outcome measures included intraoperative estimated blood loss, total loss, (estimated blood loss + postoperative blood loss), and transfusion rates. RESULTS: Patients received TXA (n = 19), EACA (n = 19), or placebo (n = 13) in the operating room (mean ages: 60, 47, and 43 yr, respectively); TXA patients were significantly older and had larger estimated blood volumes than both other groups. Total losses were significantly reduced for EACA versus control, and there was a demonstrable but nonsignificant trend toward reduced intraoperative blood loss in both antifibrinolytic arms versus control. EACA had significant reductions in postoperative blood transfusions versus TXA. CONCLUSION: The findings in this study support the use of antifibrinolytics to reduce blood loss in posterior adult spinal deformity surgery. LEVEL OF EVIDENCE: 1.

BACKGROUND: Antifibrinolytics can reduce intraoperative blood loss. The primary aim of this study was to determine the efficacy of intraoperative tranexamic acid, epsilon-aminocaproic acid, and placebo at reducing perioperative blood loss and the transfusion rate in patients with adolescent idiopathic scoliosis undergoing posterior spinal arthrodesis. METHODS: This is a prospective, randomized, double-blind comparison of tranexamic acid, epsilon-aminocaproic acid, and placebo used intraoperatively in patients with adolescent idiopathic scoliosis. One hundred and twenty-five patients with adolescent idiopathic scoliosis were randomly assigned to the tranexamic acid, epsilon-aminocaproic acid, or control groups. Parameters recorded included estimated blood loss, hematocrit, blood product usage, drain output, and total blood losses. The primary outcomes were intraoperative blood loss and postoperative drainage. Secondary outcomes were transfusion requirements and hematocrit changes both intraoperatively and postoperatively. RESULTS: One hundred and twenty-five patients (ninety-seven female and twenty-eight male, with a mean age of fifteen years) were randomized to receive tranexamic acid (thirty-six patients), epsilon-aminocaproic acid (forty-two patients), or saline solution (forty-seven patients). The groups were similar at baseline, with one exception: the saline solution group had a higher estimated blood volume at baseline than the tranexamic acid group. Both tranexamic acid and epsilon-aminocaproic acid reduced the estimated blood loss per degree and estimated blood loss per pedicle screw. Epsilon-aminocaproic acid, but not tranexamic acid, reduced estimated blood loss and estimated blood loss per level. Tranexamic acid also reduced total blood losses compared with epsilon-aminocaproic acid or saline solution. In an analysis controlling for level, degree, and number of anchors, tranexamic acid reduced drain output and total blood losses. Tranexamic acid or epsilon-aminocaproic acid had a smaller decrease in hematocrit postoperatively. In an analysis controlling for the mean arterial pressure during surgical exposure, tranexamic acid reduced estimated blood loss and total blood losses. Overall, antifibrinolytics (tranexamic acid or epsilon-aminocaproic acid) reduced estimated blood loss, total blood losses, and the decline in hematocrit postoperatively compared with saline solution. There was no difference among the groups with respect to the transfusion rate, duration of surgery, levels fused, or pedicle screws placed. CONCLUSIONS: Tranexamic acid and epsilon-aminocaproic acid reduced operative blood loss but not transfusion rate. Tranexamic acid is more effective at reducing postoperative drainage and total blood losses compared with epsilon-aminocaproic acid. Maintenance of the mean arterial pressure at <75 mm Hg during surgical exposure appears to be critical for maximizing antifibrinolytic benefit. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND CONTEXT: Anti-fibrinolytics have been proven effective in reducing intra-operative blood loss in several settings. However, their value in Adolescent Idiopathic Scoliosis (AIS) remains unclear. No previous study has compared tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and placebo in regards to their ability to limit operative blood loss, post-operative drain output, and transfusion rate. PURPOSE: To determine the efficacy of intra-operative anti-fibrinolytics at reducing peri-operative blood loss and transfusion rate in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion of at least 5 levels. STUDY DESIGN/SETTING: Prospective, double-blind, randomized clinical trial. PATIENT SAMPLE: Patients between the ages of 10-21 with a diagnosis of adolescent idiopathic scoliosis treated with posterior spinal fusion of at least five levels were prospectively enrolled. OUTCOME MEASURES: Primary outcome measures include estimated blood loss, drain output, total blood loss, and transfusion rate. Secondary outcome measures include pre-, intra-, and post-operative hematocrit, duration of surgery, complications, and length of hospital stay. METHODS: This is a prospective, randomized, double-blind comparison of TXA, EACA and placebo used intra-operatively in patients with AIS. 119 AIS patients were randomly assigned to TXA, EACA, or control. TXA was administered at 10 mg/ kg for a loading dose followed by 1 mg/kg-hr, while EACA was given at a 10 fold higher dose. Parameters recorded included estimated blood loss (EBL), pre, intra and post-operative hematocrit, blood product usage, post-operative drain output, and total blood loss. RESULTS: 119 patients were randomized to TXA (n535), EACA (n538), or placebo (n546). There were 93 females and 26 males, average age 15. Most pre-operative characteristics were similar, however saline patients had significantly greater height, weight, and estimated blood volume vs TXA (p<.05). TXA patients had significantly lower hematocrit at anesthesia start vs saline (33.2 vs 35.7, p<.05). There was no difference in transfusion rate, duration of surgery, levels fused, or anchors placed. When controlling for mean arterial pressure (MAP) during exposure, TXA reduced EBL vs saline (p<.05), and reduced total blood loss, total blood loss per anchor, and total blood loss per degree of curve vs saline (p<.05). Additionally, EACA reduced EBL per anchor vs saline in patients with reduced mean exposure MAP (p<.05). Neither TXA nor EACA reduced EBL or total blood loss in patients with mean exposure MAPO75. While total drain output was not reduced for TXA or EACA vs saline, TXA showed reduced drain output per anchor and degree curve (p<.05) compared to saline. CONCLUSIONS: Our results suggest that anti-fibrinolytics safely reduce blood loss in patients with AIS. However, transfusion rates were not impacted. Further, mean arterial pressure during surgical exposure appears to be a critical factor in the efficacy of anti-fibrinolytic action

OBJECTIVE: To examine the efficacy of dexmedetomidine (DEX) as a primary sedative during vascular procedures performed under monitored anesthesia care (MAC). A total of 55 patients were randomized in a 2:2:1 ratio to receive either DEX 1.0 microg/kg load or DEX 0.5 microg/kg load versus midazolam (MDZ) boluses, the current standard of care. This was followed by a maintenance infusion of DEX versus a normal saline infusion for the control group. Midazolam was given in 0.5 mg increments to maintain an equivalent target level of sedation among the 3 study groups. Fentanyl was given in 25 microg increments to treat pain as needed. The percentage of DEX patients not requiring MDZ and the total dose of MDZ and fentanyl were compared to the control. Dexmedetomidine was efficacious as a sole sedative for 50% of patients. The total dose of MDZ and fentanyl was significantly less during the DEX infusions. Patient satisfaction was superior with DEX

We describe the anesthetic management of a morbidly obese patient with obstructive sleep apnea who underwent awake craniotomy. The patient's personal continuous positive airway pressure (CPAP) machine was used to support ventilation intraoperatively. Dexmedetomidine was used as the primary sedative. During cortical mapping, the CPAP was discontinued. The patient was comfortable and able to cooperate with language testing