Considerations for Integration of Perioperative Electronic Health Records Across Institutions for Research and Quality Improvement: The Approach Taken by the Multicenter Perioperative Outcomes Group.

Use of the electronic health record (EHR) has become a routine part of perioperative care in the United States. Secondary use of EHR data includes research, quality, and educational initiatives. Fundamental to secondary use is a framework to ensure fidelity, transparency, and completeness of the source data.

Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER): A Multicenter Matched Cohort Analysis.

Background: Five percent of adult patients undergoing noncardiac inpatient surgery experience a major pulmonary complication. The authors hypothesized that the choice of neuromuscular blockade reversal (neostigmine vs. sugammadex) may be associated with a lower incidence of major pulmonary complications.

Intraoperative glycemic control in patients undergoing Orthotopic liver transplant: a single center prospective randomized study.

Background: Perioperative hyperglycemia is associated with poor outcomes yet evidence to guide intraoperative goals and treatment modalities during non-cardiac surgery are lacking. End-stage liver disease is associated with altered glucose homeostasis; patients undergoing liver transplantation display huge fluctuations in blood glucose (BG) and represent a population of great interest. Here, we conduct a randomized trial to compare the effects of strict versus conventional glycemic control during orthotopic liver transplant (OLT).

Preoperative Risk and the Association between Hypotension and Postoperative Acute Kidney Injury.

Background: Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown.

An observational study of end-tidal carbon dioxide trends in general anesthesia.

Purpose: Despite growing evidence supporting the potential benefits of higher end-tidal carbon dioxide (ETCO) levels in surgical patients, there is still insufficient data to formulate guidelines for ideal intraoperative ETCO targets. As it is unclear which intraoperative ETCO levels are currently used and whether these levels have changed over time, we investigated the practice pattern using the Multicenter Perioperative Outcomes Group database.

Methods: This retrospective, observational, multicentre study included 317,445 adult patients who received general anesthesia for non-cardiothoracic procedures between January 2008 and September 2016.

Airway Management and Clinical Outcomes in External Laryngeal Trauma: A Case Series.

External laryngeal trauma is a rare but potentially fatal event that presents several management challenges. This retrospective observational case series conducted at a level-1 trauma center over a 12-year period consists of 62 cases of acute external laryngeal trauma. Patient demographics, mode and mechanisms of injury, presenting signs and symptoms, initial imaging results, airway management, time to surgical management, and 6-month outcomes including airway status, deglutition status, and voice quality were investigated.

Intraoperative hyperglycemia is independently associated with infectious complications after non-cardiac surgery.

Background: Perioperative hyperglycemia and its associated increase in morbidity and mortality have been well studied in the critical care and cardiac surgery literature. However, there is little data regarding the impact of intraoperative hyperglycemia on post-operative infectious complications in non-cardiac surgery.

Methods: All National Surgery Quality Improvement Program patients undergoing general, vascular, and urological surgery at our tertiary care center were reviewed.

Propofol Drug Shortage Associated With Worse Postoperative Nausea and Vomiting Outcomes Despite a Mitigation Strategy.

Drug shortages negatively affect patient care and outcomes. Postoperative nausea and vomiting (PONV) can be mitigated using risk assessment and prophylaxis. A 2012 propofol shortage provided an opportunity to study the impact of using prophylactic antiemetics and changing the technique from a propofol infusion to inhaled agents in an ambulatory surgery setting.

Impact of a Novel Multiparameter Decision Support System on Intraoperative Processes of Care and Postoperative Outcomes.

Background: The authors hypothesized that a multiparameter intraoperative decision support system with real-time visualizations may improve processes of care and outcomes.

Methods: Electronic health record data were retrospectively compared over a 6-yr period across three groups: experimental cases, in which the decision support system was used for 75% or more of the case at sole discretion of the providers; parallel controls (system used 74% or less); and historical controls before system implementation. Inclusion criteria were adults under general anesthesia, advanced medical disease, case duration of 60 min or longer, and length of stay of two days or more.

Management of 1-Lung Ventilation-Variation and Trends in Clinical Practice: A Report From the Multicenter Perioperative Outcomes Group.

Background: Lung-protective ventilation (LPV) has been demonstrated to improve clinical outcomes in surgical patients. There are very limited data on the current use of LPV for patients undergoing 1-lung ventilation (1LV) despite evidence that 1LV may be a particularly important setting for its use. In this multicenter study, we report trends in ventilation practice for patients undergoing 1LV.

Influence of non-invasive blood pressure measurement intervals on the occurrence of intra-operative hypotension.

The American Society of Anesthesiologists Standards for Basic Monitoring recommends blood pressure (BP) measurement every 5 min. Research has shown distractions or technical factors can cause prolonged measurement intervals exceeding 5 min. We investigated the relationship between prolonged non-invasive BP (NIBP) measurement interval and the incidence of hypotension, detected post-interval.

Postoperative Respiratory Complications in Patients at Risk for Obstructive Sleep Apnea: A Single-Institution Cohort Study.

Background: Obstructive sleep apnea (OSA) is a prevalent condition that is associated with early postoperative respiratory complications (PRCs). As the majority of patients with OSA are undiagnosed, preoperative screening remains the most efficient method to identify suspected OSA.

Methods: This retrospective study was performed on patients undergoing anesthesia in a single academic medical center.

Retrospective observational evaluation of postoperative oxygen saturation levels and associated postoperative respiratory complications and hospital resource utilization.

Introduction: The clinical importance of postoperative episodic hypoxemia is still unclear, and therefore largely under-studied. As a result, there is limited understanding of its relationship with early postoperative respiratory complications (PRC, defined as intubation within three days of surgery) and hospital resource utilization.

Materials And Methods: This single center study was performed using a retrospective observational design.

Frequency of inadequate neuromuscular blockade during general anesthesia.

Study Objective: We used electronic health record data to define frequency of inadequate intraoperative neuromuscular blockade (NMB).

Design: Retrospective observational study using electronic health record data.

Setting: Operating room in a tertiary care academic hospital.

Preoperative β-blockade and hypertension in the first hour of functional endoscopic sinus surgery.

Objectives/hypothesis: Local anesthetic with epinephrine is commonly injected into the nasal mucosa during functional endoscopic sinus surgery (FESS). Systemic absorption of epinephrine following local injection may occur, resulting in a mild sympathetic response. This study seeks to determine whether an exaggerated sympathetic response to epinephrine is demonstrated in patients undergoing FESS treated preoperatively with established pharmacologic beta (β) adrenoceptor blockade.

Arterial Pressure Variation in Elective Noncardiac Surgery: Identifying Reference Distributions and Modifying Factors.

Background: Assessment of need for intravascular volume resuscitation remains challenging for anesthesiologists. Dynamic waveform indices, including systolic and pulse pressure variation, are demonstrated as reliable measures of fluid responsiveness for mechanically ventilated patients. Despite widespread use, real-world reference distributions for systolic and pulse pressure variation values have not been established for euvolemic intraoperative patients.

Recognition and Management of Perioperative Stroke in Hospitalized Patients.

We sought to characterize stroke management and outcomes in a postoperative population. By using the electronic medical records, we identified 39 patients suffering perioperative stroke after noncardiac and nonneurosurgical procedures for whom documentation of management and outcomes was available. Thirty-three strokes occurred during admission, whereas 6 occurred after discharge and were recognized upon return to the hospital.

Success of Intubation Rescue Techniques after Failed Direct Laryngoscopy in Adults: A Retrospective Comparative Analysis from the Multicenter Perioperative Outcomes Group.

Background: Multiple attempts at tracheal intubation are associated with mortality, and successful rescue requires a structured plan. However, there remains a paucity of data to guide the choice of intubation rescue technique after failed initial direct laryngoscopy. The authors studied a large perioperative database to determine success rates for commonly used intubation rescue techniques.

Concurrence of Intraoperative Hypotension, Low Minimum Alveolar Concentration, and Low Bispectral Index Is Associated with Postoperative Death.

Background: An intraoperative concurrence of mean arterial pressure less than 75 mmHg, minimum alveolar concentration less than 0.8, and bispectral index less than 45 has been termed a "triple low" state. An association between triple low and postoperative mortality has been reported but was not replicated in a subsequent study.

Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position: A Prospective Interventional Study with a Randomized Comparison of Two Anesthetics.

Background: Beach chair positioning during general anesthesia is associated with cerebral oxygen desaturation. Changes in cerebral oxygenation resulting from the interaction of inspired oxygen fraction (FIO2), end-tidal carbon dioxide (PETCO2), and anesthetic choice have not been fully evaluated in anesthetized patients in the beach chair position.

Methods: This is a prospective interventional within-group study of patients undergoing shoulder surgery in the beach chair position that incorporated a randomized comparison between two anesthetics.

Behavioral Modification of Intraoperative Hyperglycemia Management with a Novel Real-time Audiovisual Monitor.

Background: Hyperglycemia, defined as blood glucose (BG) levels above 200 mg/dl (11.1 mM), is associated with increased postoperative morbidity. Yet, the treatment standard for intraoperative glycemic control is poorly defined for noncardiac surgery.

Psychological sequelae of surgery in a prospective cohort of patients from three intraoperative awareness prevention trials.

Background: Elective surgery can have long-term psychological sequelae, especially for patients who experience intraoperative awareness. However, risk factors, other than awareness, for symptoms of posttraumatic stress disorder (PTSD) after surgery are poorly defined, and practical screening methods have not been applied to a broad population of surgical patients.

Methods: The Psychological Sequelae of Surgery study was a prospective cohort study of patients previously enrolled in the United States and Canada in 3 trials for the prevention of intraoperative awareness.

Intraoperative bispectral index monitoring and time to extubation after cardiac surgery: secondary analysis of a randomized controlled trial.

Background: Fast track recovery is a care process goal after cardiac surgery. Intraoperative anesthetic depth may impact recovery, but the impact of brain monitoring on time to extubation and intensive care unit (ICU) length of stay after cardiac surgery has not been extensively studied. Our goal was to determine if BIS-guided anesthesia improves time to extubation compared to MAC-guided anesthesia in a cardiac surgery population.