This Month in Anesthesiology

Although in-hospital opioid intake before discharge is a reliable predictor of opioid intake after discharge, opioid prescriptions after surgery are often driven by local practice conventions. The hypothesis that a best practice alert based on recorded in-hospital opioid intake will reduce the quantity of opioids prescribed to surgical patients at discharge was tested in a cluster randomized multiple crossover trial that included 21,689 patients over a 48-week period during which a state-wide opioid education and awareness campaign was in place. Four hospitals were randomized to alternate between active and inactive alert conditions for four 8-week periods, each separated by a 4-week washout interval. During active alert periods, an alert was displayed when the opioid prescription exceeded that recommended based on in-hospital opioid intake. The median (interquartile range) opioid dose prescribed at discharge was 75 (0 to 225) oral morphine milligram equivalents when the alert was active and 100 (0 to 225) oral morphine milligram equivalents when it was inactive. The ratio of geometric means (active alert/inactive alert) for opioids prescribed at discharge was 0.95 (95% CI, 0.80 to 1.13). See the accompanying Editorial on page 119.Frailty is a state of vulnerability to adverse health outcomes resulting from accumulation of multidimensional age- and disease-related deficits. The association of preoperative frailty with adverse postoperative patient outcomes is well established. This retrospective population-based cohort study sought to identify postoperative healthcare costs attributable to preoperative frailty. A validated, multidimensional frailty index was used to identify older patients (at least 66 yr old) with and without preoperative frailty having elective, major noncardiac surgery between 2012 and 2018. Validated health system cost ascertainment methods were used to estimate the total perioperative costs (expressed in 2018 Canadian dollars) attributable to frailty in the year after their operations. Of 171,576 older patients, 23,219 (13.5%) were identified with preoperative frailty. After adjustment for confounders, the ratio of means for costs at 1 yr in patients with frailty compared to those without was 1.53 (95% CI, 1.51 to 1.56), which was equivalent to an absolute mean adjusted cost difference of $11,828 (95% CI, $11,805 to $11,850) attributable to the presence of preoperative frailty.Inotropes may improve a patient’s hemodynamics or oxygen delivery to end organs during cardiac surgery, but they also expose patients to potentially severe unintended consequences and are associated with 1- to 3-day prolongations of hospital and intensive care unit lengths of stay, all of which contribute to variable practice patterns. This retrospective, multilevel, observational cohort study tested the hypothesis that potentially meaningful variation in inotrope use occurs at the clinician and institution levels, and that characteristics influencing the likelihood a patient will receive intraoperative inotropes spans multiple perioperative data types. Inclusion criteria were met by 51,085 nonemergent cardiac surgeries with cardiopulmonary bypass between 2014 and 2019 across 611 anesthesiologists and 29 hospitals. Of the included cases, 27,033 patients (52.9%) received intraoperative inotropes. Within the adjusted model, 35.1% of the variation in inotrope use was attributable to the institution, 9.2% to the anesthesiologist, and 55.6% to the patient. The adjusted median odds ratio for a patient receiving inotropes was 1.73 for two randomly selected clinicians and 3.55 for two randomly selected institutions.Platelets are typically stored at 20° to 24°C for 5 to 7 days (room temperature platelets). After 5 days of room temperature storage, pathogen-reduced room temperature platelets can be stored at 1° to 6°C for up to an additional 9 days (delayed cold-stored platelets). The hypothesis that use of delayed cold-stored platelets in cardiac surgery would be associated with decreased postoperative platelet count increments but similar transfusion and clinical outcomes compared to room temperature–stored platelets was tested in a retrospective study of 713 adults who underwent elective cardiac surgery with intraoperative administration of at least 1 unit of platelets. Room temperature platelets were administered in 529 cases and delayed cold-stored platelets in 184 cases. The adjusted odds ratio (95% CI) of allogeneic transfusion in the first 24 h postoperatively for patients receiving delayed cold-stored platelets intraoperatively compared to those receiving room temperature platelets was 1.65 (1.13 to 2.39). Posttransfusion platelet counts were modestly lower in the delayed cold-stored platelets group without an increased rate of reoperation for bleeding or higher chest tube output.Mechanomyography measures the isometric force generated by the thumb in response to ulnar nerve stimulation directly. It is the gold standard research technique for quantitative assessment of depth of neuromuscular blockade, but mechanomyography systems are no longer commercially available. The hypothesis that the train-of-four ratios recorded by an archival mechanomyograph would be equivalent to those of a modern laboratory-built mechanomyograph was tested by comparing the train-of-four ratios measured by the two instruments in the contralateral arms of eight anesthetized patients during the onset and recovery from rocuronium neuromuscular blockade. Seven hundred sixty-seven paired train-of-four ratio data points were collected with the archival and new mechanomyography systems. The new laboratory-built mechanomyograph and the archival mechanomyograph obtained essentially interchangeable train-of-four ratio measurements, providing reassurance of comparability of past and future studies performed with these modern mechanomyography systems.Epinephrine is administered after severe refractory hypotension or cardiac arrest to restore circulation and organ perfusion by augmenting systemic arterial blood pressure. The hypothesis that intravenously administered epinephrine induces significant microvascular but not macrovascular constriction in the brain, increasing in severity after repetitive dosing and in the aged brain, eventually leading to impaired cerebral microvascular oxygen delivery and tissue hypoxia was tested using an in vivo multimodal imaging approach in healthy young and aged male mice. Epinephrine produced immediate vasoconstriction throughout the cerebral microvasculature that persisted beyond the elevated arterial blood pressure and initial enhancement of cerebral blood flow. Microvascular constriction in the aged brain was less prominent and slower to recover than in the young brain. Intravascular hemoglobin desaturation was observed in both cerebral arteries and veins with a paradoxical increase in brain tissue oxygenation that persisted after the epinephrine-induced systemic blood pressure increase. Brain tissue hyperoxia was more pronounced and long-lasting in aged mice than in young mice.Recombinant activated factor VIIa (rFVIIa) was approved by the Food and Drug Administration in 1999 for the prevention and treatment of bleeding in patients with hemophilia A or B, factor VII deficiency, and Glanzmann’s thrombasthenia. It has been widely used off-label to control excessive cardiac surgical bleeding. Five randomized controlled trials of its use in adult cardiac surgical patients reported decreased mechanical ventilation time, chest tube drainage, and allogeneic transfusions in rFVIIa groups without an increase in adverse events, including thromboembolic events. A meta-analysis of 35 randomized placebo-controlled trials, only three of which were in cardiac surgery patients, reported increased arterial thromboembolic events after rFVIIa administration, tempering enthusiasm for its use in cardiac surgical patients. Most early reports of rFVIIa administration for cardiac surgical bleeding were based on administering the recommended hemophilia dose (90 mcg/kg) for intractable bleeding. This Clinical Focus Review concludes that administering less than 20 mcg/kg for cardiac surgical bleeding appears to achieve hemostasis without an increase in thromboembolic events and notes that recent reports advocate “gentle and early” very-low-dose rFVIIa administration rather than high-dose salvage therapy.Comparative effectiveness research helps patients, clinicians, and policy makers make decisions that can improve health and health care at both individual and population levels. This Review Article provides stakeholders with information that can facilitate interpretation of research on the comparative effectiveness of spinal versus general anesthesia in older adults undergoing hip fracture surgery, elective knee and hip arthroplasty, and lower-extremity vascular repair. It first reviews methodologic considerations for observational studies and randomized controlled trials. It then provides an overview of available evidence from randomized controlled trials and selected observational studies on the effect of spinal versus general anesthesia across a range of outcomes and on the effectiveness of co-administration of intraoperative sedation and peripheral nerve block with spinal anesthesia. It concludes that evidence from the randomized hip fracture surgery and elective knee and hip arthroplasty trials does not provide strong evidence of superior effectiveness of either technique for improving outcomes on average, but trial data from small samples and quasi-experimental lower-extremity vascular surgery studies offer preliminary evidence to suggest some reductions in complications with spinal anesthesia.

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