Absolute Obstetric Anesthesia Review: The Complete Study Guide for Certification and Recertification No abstract available

A Randomized Controlled Trial of Enhanced Recovery After Surgery Versus Standard of Care Recovery for Emergency Cesarean Deliveries at Mbarara Hospital, Uganda BACKGROUND: Enhanced recovery after surgery (ERAS) expedites return to patient baseline and functional status by reducing surgical trauma, stress, and organ dysfunction. Despite the potential benefits of enhanced recovery protocols, limited research has been done in low-resource settings, where 95% of cesarean deliveries are emergent and could possibly benefit from the application of ERAS protocols. METHODS: In a prospective, randomized, single-blind, controlled trial, mothers delivering by emergency cesarean delivery were randomly assigned to either an ERAS or a standard of care (SOC) recovery arm. Patients in the ERAS arm were treated with a modified ERAS protocol that included modified counseling and education, prophylactic antibiotics, antiemetics, normothermia, restrictive fluid administration, and multimodal analgesia. They also received early initiation of mobilization, feeding, and urethral catheter removal. The primary end point was length of hospital stay. The secondary end points were complications and readmission rates. Mean length of stay in the intervention and control arms were compared using t tests. Statistical analyses were performed using STATA version 13 (College Station, TX). RESULTS: A total of 160 patients were enrolled in the study, with 80 randomized to each arm. There was a statistically significant shorter length of stay for the ERAS arm compared to SOC, with a difference of −18.5 hours (P < .001, 95% confidence interval [CI], −23.67, −13.34). The incidence of complications of severe pain and headache was lower in the ERAS arm compared to SOC (P = .001 for both complications). However, pruritus was more common in the ERAS arm compared to SOC (P = .023). CONCLUSIONS: Use of an ERAS protocol for women undergoing emergency cesarean delivery in a low-income setting is feasible and reduces length of hospital stay without generally increasing the complication rate. M. Baluku is currently affiliated with the Department of Anesthesia and Critical Care, Kabale University School of Medicine, Kabale, Uganda. Accepted for publication September 18, 2019. Funding: This research was funded by the Kayanja Fellowship Scholarship, a university grant scheme. The funders did not participate at any stage of the study. The authors declare no conflicts of interest. Trial registration at ClinicalTrials.gov: NCT03518463. Reprints will not be available from the authors. Address correspondence to Moris Baluku, MD, Department of Anesthesia and Critical Care, Kabale University School of Medicine, Kabale, Uganda. Address e-mail to balukumoris16@gmail.com. © 2019 International Anesthesia Research Society

Misinterpretations of α and β No abstract available

Stereoselective Pharmacokinetic Disposition of Ketorolac Following Drug Administration to Periarticular Tissues in Patients No abstract available

Does Weight Matter? Outcomes in Adult Patients on Venovenous Extracorporeal Membrane Oxygenation When Stratified by Obesity Class BACKGROUND: Many believe obesity is associated with higher rates of mortality in the critically ill. The purpose of this retrospective observational study is to evaluate the association between body mass index (BMI) and survival in patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) for acute hypoxic or hypercarbic respiratory failure. METHODS: All of the patients admitted to a dedicated VV ECMO unit were included. Patients <18 years of age, listed for lung transplant, or underweight were excluded. ECMO outcomes, including hospital length of stay and survival to discharge, were analyzed after stratification according to BMI. Multivariate logistic and linear regression techniques were used to assess variables associated with the outcomes of death and length of stay, respectively. RESULTS: One hundred ninety-four patients with a median BMI of 35.7 kg/m2 (33–42 kg/m2) were included. Obese patients were older, had higher creatinine levels, and required higher levels of positive end-expiratory pressure and mean airway pressure at time of cannulation. Survival to discharge in any group did not differ when stratified by BMI classification (P = .36). Multivariable regression did not reveal any association with greater odds of death or longer length of stay when controlling for BMI and other variables. CONCLUSIONS: We did not detect an association between obesity and increased mortality in patients requiring VV ECMO for acute hypoxic or hypercarbic respiratory failure. These data suggest that obesity alone should not exclude candidacy for VV ECMO. Evidence for the “obesity paradox” in this population of VV ECMO patients may be supported by these data. Accepted for publication August 20, 2019. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Samuel M. Galvagno Jr, DO, PhD, FCCM, Department of Anesthesiology, University of Maryland School of Medicine, 22 S Greene St, T3N08, Baltimore, MD 21201. Address e-mail to sgalvagno@som.umaryland.edu. © 2019 International Anesthesia Research Society

Assessment of Fluid Responsiveness in Prone Neurosurgical Patients Undergoing Protective Ventilation: Role of Dynamic Indices, Tidal Volume Challenge, and End-Expiratory Occlusion Test BACKGROUND: In patients in the prone position, the reliability of pulse pressure variation and stroke volume variation (PPV and SVV) and the use of functional hemodynamic tests to predict fluid responsiveness have not previously been established. Perioperatively, in this setting, optimizing fluid management can be challenging, and fluid overload is associated with both intraoperative and postoperative complications. We designed this study to assess the sensitivity and specificity of baseline PPV and SVV, the tidal volume (VT) challenge (VTC) and the end-expiratory occlusion test (EEOT) in predicting fluid responsiveness during elective spinal surgery. METHODS: The study protocol was started during a period of intraoperative hemodynamic stability after prone positioning and before the administration of any vasopressor: (1) at baseline, the controlled ventilation was set at 6 mL/kg of predicted body weight (PBW) (T0); (2) patients underwent the first EEOT (EEOT6) by interrupting the mechanical ventilation for 30 seconds; (3) the ventilation was set again at 6 mL/kg PBW for 1 minute (T1); (4) the VTC was applied by increasing the VT up to 8 mL/kg PBW for 1 minute; (5) the ventilation was kept at 8 mL/kg PBW for 1 minute (T2); (6) a second EEOT (EEOT8) was performed; (7) the VT was reduced back to 6 mL/kg PBW for 1 minute (T3); (8) a fluid challenge of 250 mL of Ringer’s solution was infused over 10 minutes. After each step, a complete set of hemodynamic measurements was recorded. RESULTS: Neither PPV and SVV values recorded at T3 nor the EEOT6 or the EEOT8 predicted fluid responsiveness. The change in PPV after VTC application predicted fluid responsiveness with an area under the curve of 0.96 (95% confidence interval, 0.87–1.00), showing a sensitivity of 95.2% and a specificity of 94.7%, using a cutoff increase of 12.2%. The change in SVV after VTC application predicted fluid responsiveness with an area under the curve 0.96 (95% confidence interval, 0.89–1.00) showing a sensitivity of 95.2% and a specificity of 94.7%, using a cutoff increase of 8.0%. A linear correlation between stroke volume index changes after fluid challenge administration and the changes in PPV and SVV after VTC application was observed (r = 0.71; P < .0001 and r = 0.68; P < .0001, respectively). CONCLUSIONS: In prone elective neurosurgical patients, the baseline values of PPV and SVV and the EEOT fail to predict fluid responsiveness, while the VTC is a very reliable functional hemodynamic test and could be helpful in guiding intraoperative fluid therapy. Accepted for publication September 18, 2019. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Trial registration: ACTRN12618000682246 (registration number at the Australian New Zealand Clinical Trials Registry). Reprints will not be available from the authors. Address correspondence to Antonio Messina, MD, PhD, Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center – IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, Italy. Address e-mail to antonio.messina@humanitas.it. © 2019 International Anesthesia Research Society

A Population-Based Analysis of Intraoperative Cardiac Arrest in the United States BACKGROUND: A new billable code for intraoperative cardiac arrest was introduced with the International Classification of Diseases, Tenth Revision, classification system. Using a national administrative database, we performed a retrospective analysis of intraoperative cardiac arrest in the United States. METHODS: Hospital admissions involving patients ≥18 years of age who underwent operating room procedures in 2016 were identified using the National Inpatient Sample. The primary outcome was the incidence of intraoperative cardiac arrest. Secondary outcomes included total cost of admission, in-hospital mortality, length of stay, and identification of risk factors associated with intraoperative cardiac arrest. Clinical risk factors were evaluated with multivariable logistic regression models using sampling weights and adjustment for clustering by strata. RESULTS: Of 35,675,421 admissions in 2016 in the United States, 9,244,861 admissions were identified in patients ≥18 years of age who underwent at least one operating room procedure. An estimated 5230 hospital admissions involved intraoperative cardiac arrest, yielding an estimated incidence of 5.7 (95% confidence interval [CI], 5.3–6.0) per 10,000 hospital admissions. Admissions involving an intraoperative cardiac arrest had a 35.7% in-hospital mortality, compared with 1.3% for admissions without intraoperative cardiac arrest. Intraoperative cardiac arrest was associated with a 15.44-fold (95% CI, 12.74–18.70; P < .001) increase in the risk-adjusted odds of in-hospital mortality and an additional $13,184 (95% CI, 9600–16,769; P < .001) of total admission costs. Selected factors independently associated with increased risk-adjusted odds of intraoperative cardiac arrest included: black or missing race; cardiac, thoracic, or vascular surgery; congestive heart failure; pulmonary circulation disorders; peripheral vascular disease; end-stage renal disease; and fluid and electrolyte disorders. CONCLUSIONS: In this population-based study of intraoperative cardiac arrest in the United States, admissions involving an intraoperative cardiac arrest were rare but were associated with high in-hospital mortality. M. D. Willingham is currently affiliated with the Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Perioperative Medicine, Washington University in St Louis, St Louis, Missouri. Accepted for publication September 9, 2019. Funding: Support was provided primarily from institutional and/or departmental sources. M.A.F. reports support from a Society of Cardiovascular Anesthesiologists/International Anesthesia Research Society starter grant. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Vikram Fielding-Singh, MD, JD, Department of Anesthesiology & Perioperative Medicine, University of California, Los Angeles, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095. Address e-mail to vfieldingsingh@mednet.ucla.edu. © 2019 International Anesthesia Research Society

Impact of the Addition of Examples to the American Society of Anesthesiologists Physical Status Classification System Examples of comorbidities for the widely used American Society of Anesthesiologists physical status (ASA-PS) classification system were developed and approved in 2014. We conducted a retrospective cohort study of patients with 4 comorbidities included in the examples as warranting a specific minimum ASA-PS class. For each comorbidity subgroup, we used interrupted time-series models to compare ASA-PS underclassification for the periods before (2011–2014) and after (2015–2017) the introduction of examples. Rates of underclassification ranged from 4.8% to 38.7%. We observed no evidence of a significant impact on ASA-PS classification with the introduction of examples in 2014. Accepted for publication September 11, 2019. M. D. Willingham is currently affiliated with the Division of Cardiothoracic Anesthesiology and Perioperative Medicine, Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri. Funding: Institutional and/or departmental. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Vikram Fielding-Singh, MD, JD, Department of Anesthesiology & Perioperative Medicine, University of California, Los Angeles, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095. Address e-mail to vfieldingsingh@mednet.ucla.edu. © 2019 International Anesthesia Research Society

Clinical Examination Skills in the Adult Critically Ill Patient No abstract available