Journal of Clinical Anesthesia最新文献

Background

The effectiveness of aspirin treatment in septic patients remains a subject of debates.

Objective

To explore the association between aspirin usage and the prognosis of patients with sepsis-induced myocardial injury (SIMI), as well as the timing of aspirin administration.

Methods

Patients with SIMI were screened in the MIMIC-IV database and categorized into aspirin and non-aspirin groups based on their medications during intensive care unit (ICU) stay, and propensity matching analysis (PSM) was subsequently performed to reduce bias at baseline between the groups. The primary outcome was 28-day all-cause mortality. Cox multivariate regression analysis was conducted to evaluate the impact of aspirin on the prognosis of patients with SIMI.

Results

The pre-PSM and post-PSM cohorts included 1170 and 1055 patients, respectively. In the pre-PSM cohort, the aspirin group is older, has a higher proportion of chronic comorbidities, and lower SOFA and SAPS II scores when compared to the non-aspirin group. In the PSM analysis, most of the baseline characterization biases were corrected, and aspirin use was also associated with lower 28-day mortality (hazard ratio [HR] = 0.51, 95 % confidence interval [CI]: 0.42–0.63, P < 0.001), 90-day mortality (HR = 0.58, 95 % CI: 0.49–0.69, P < 0.001) and 1-year mortality (HR = 0.65, 95 % CI: 0.56–0.76, P < 0.001), irrespective of aspirin administration timing. A sensitivity analysis based on the original cohort confirmed the robustness of the findings. Additionally, subsequent subgroup analysis revealed that the use of vasopressin have a significant interaction with aspirin's efficacy.

Conclusion

Aspirin was associated with decreased mortality in SIMI patients, and this beneficial effect persisted regardless of pre-ICU treatment.

Background

When the vast majority (e.g., ≈90%) of a specialty's elective (scheduled) care is ambulatory (i.e., length of stay 0 or 1 night), the administrative, clinical, and economic policy implications are profound. We examined the progressive shift of elective anesthetics in Florida from inpatient to ambulatory, from the first quarter of 2010 through the fourth quarter of 2022. We were particularly interested in the most recent data following the lifting of COVID-19 restrictions on elective surgery in the state.

Methods

This retrospective cohort study included major therapeutic and major diagnostic procedures with >0 American Society of Anesthesiologists base units in the state of Florida inpatient and ambulatory surgery databases. The last 8 quarters of these operating room anesthetic data corresponded to the end of restrictions on elective surgery in Florida due to the COVID-19 pandemic. Our goal was to determine whether the overall mean percentage of cases with 0- or 1-day lengths of stay has reached 90% since the lifting of pandemic restrictions. Numbers of cases over periods of at least four weeks tend to follow normal distributions. Therefore, we analyzed the N = 8 quarters of cases from 2021 to 2022 using Student's t-test. The study was performed when there were N = 8 quarters available from the Florida healthcare databases.

Results

There were overall 22,584,752 surgical cases studied. The percentages of elective anesthetics with length of stay ≤1-day increased progressively from 2010 through 2020. Among the eight successive quarters since the end of pandemic-related elective surgery restrictions, the percentage of elective cases with length of stay 0- or 1 day was stable, averaging 90% (95% two-sided confidence interval 89.4% to 90.3%).

Conclusion

Since the COVID-19 pandemic, the mean quarterly percentage of elective surgery cases with anesthesia in Florida that were ambulatory has been reliably ≈90%. Implications include value in expecting overnight post-anesthesia care unit stay in ambulatory surgery centers and scheduling and sequencing cases based on post-anesthesia care unit capacity. Furthermore, because the vast majority (i.e., ≈90%) of cases would be excluded (i.e., not involve hospital admission for at least 2 midnights), there is a minimal role that risk-adjusted hospital length of stay and mortality can have in evaluating anesthesia department overall quality and economic effectiveness.

Background

Virtual reality (VR) is a novel tool with demonstrated applications within healthcare; however its integration within clinical practice has been slow. Adoption patterns can be evaluated using a technology acceptance model (TAM).

The primary study aim was to use VR TAM to assess factors that influence anesthesiologists' acceptance of VR for preoperative anxiolysis. The secondary aim assessed the model's reliability.

Methods

109 clinical anesthesiologists at Stanford were exposed to a VR application developed as a distraction tool to reduce preoperative patient anxiety. Anesthesiologists were surveyed about their attitudes, beliefs, and behaviors as predictors of their likelihood to clinically use VR. The primary outcome assessed predictive validity using descriptive statistics, construct validity using confirmatory factor analysis, and standardized estimates of model relationships. The secondary outcome assessed reliability with Cronbach's α and composite reliability.

Results

Construct validity and reliability was assessed, where all values established acceptable fit and reliability. Hypothesized predictors of consumer use were evaluated with standardized estimates, looking at perceptions of usefulness, ease of use, and enjoyment in predicting attitudes and intentions toward using and purchasing. Past use and price willing to pay did not predict perceived usefulness. Participants in lower age ranges had higher levels of perceived ease of use than those >55 years.

Conclusion

All confirmatory factor analysis testing for construct validity had good fit. Perceptions of usefulness and enjoyment predicted an anesthesiologist's attitude toward using and intention to purchase, while perceived ease of use predicted perceived usefulness and enjoyment, attitude toward purchasing and using, and intention to use. Past use and price willing to pay did not influence perceptions of usefulness. Lower age predicted greater perceived ease of use. All scales in the model demonstrated acceptable reliability. With good validity and reliability, the VR-TAM model demonstrated factors predictive of anesthesiologist's intentions to integrate VR into clinical settings.

Study objective

A low dynamic driving pressure during mechanical ventilation for general anesthesia has been associated with a lower risk of postoperative respiratory complications (PRC), a key driver of healthcare costs. It is, however, unclear whether maintaining low driving pressure is clinically relevant to measure and contain costs. We hypothesized that a lower dynamic driving pressure is associated with lower costs.

Design

Multicenter retrospective cohort study.

Setting

Two academic healthcare networks in New York and Massachusetts, USA.

Patients

46,715 adult surgical patients undergoing general anesthesia for non-ambulatory (inpatient and same-day admission) surgery between 2016 and 2021.

Interventions

The primary exposure was the median intraoperative dynamic driving pressure.

Measurements

The primary outcome was direct perioperative healthcare-associated costs, which were matched with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP–NIS) to report absolute differences in total costs in United States Dollars (US$). We assessed effect modification by patients' baseline risk of PRC (score for prediction of postoperative respiratory complications [SPORC] ≥ 7) and effect mediation by rates of PRC (including post-extubation saturation < 90%, re-intubation or non-invasive ventilation within 7 days) and other major complications.

Main results

The median intraoperative dynamic driving pressure was 17.2cmH₂O (IQR 14.0–21.3cmH₂O). In adjusted analyses, every 5cmH₂O reduction in dynamic driving pressure was associated with a decrease of −0.7% in direct perioperative healthcare-associated costs (95%CI −1.3 to −0.1%; p = 0.020). When a dynamic driving pressure below 15cmH₂O was maintained, -US$340 lower total perioperative healthcare-associated costs were observed (95%CI −US$546 to −US$132; p = 0.001). This association was limited to patients at high baseline risk of PRC (n = 4059; −US$1755;97.5%CI −US$2495 to −US$986; p < 0.001), where lower risks of PRC and other major complications mediated 10.7% and 7.2% of this association (p < 0.001 and p = 0.015, respectively).

Conclusions

Intraoperative mechanical ventilation targeting low dynamic driving pressures could be a relevant measure to reduce perioperative healthcare-associated costs in high-risk patients.

Objective

As many as half of patients undergoing on-pump cardiac surgery require red blood cell transfusion, emphasizing the need for effective strategies that can reduce this need. We conducted this analysis to assess the effectiveness of Huaxi Integrated Blood Management strategy at our medical center.

Design

Before and after study.

Participants

Patients who underwent on-pump cardiac surgery were included from January 2019 to December 2021. Two cohorts were compared, one before implementation of the strategy (1 January 2019 until 31 May 2020) and one after implementation (1 June 2020 until 31 December 2021).

Measurements

We evaluated temporal trends in blood transfusion, safety, and efficacy of this strategy. Primary outcomes were the incidence and volume of intra- and postoperative blood transfusions of packed red blood cells. Secondary outcomes are intraoperative and postoperative transfusion of other blood products, all-cause mortality during hospitalization, and incidence of new-onset complications.

Main results

Our results demonstrated that this integrated strategy effectively decreased both the perioperative packed red blood cell transfusion volume and incidence for patients who underwent the on-pump cardiac surgery. Following the implementation, the incidence of packed red blood cell transfusions decreased by 8.1% during the intraoperative period and by 12.3% during the postoperative period. The mean volume of such transfusions decreased by 0.28 units during the intraoperative period and by 0.49 units during the postoperative period. Hemoglobin concentrations were significantly higher after implementation, and the maximal mean increase was 4.72 g/l on postoperative day 1. Similar benefit of the strategy was observed across subgroups of patients who underwent different types of surgery.

Conclusions

The Huaxi Integrated Blood Management strategy may be effective at reducing the need for packed red blood cell transfusion and enhancing patient care.