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American Society of Anesthesiologists (ASA): Annual Meeting (Anesthesiology 2015)
Ultrasound bests auscultation for ETT positioning
SAN DIEGO – Assessment of the trachea and pleura via point-of-care ultrasound is superior to auscultation in determining the exact location of the endotracheal tube, a randomized, single-center study found.
“It’s been reported that about 20% of the time the endotracheal tube is malpositioned,” study author Dr. Davinder S. Ramsingh said in an interview at the annual meeting of the American Society of Anesthesiologists. “Most of the time (the tube) is too deep, which can lead to severe complications.”
In a double-blinded, randomized study, Dr. Ramsingh and his associates assessed the accuracy of auscultation vs. point-of-care ultrasound in verifying the correct position of the endotracheal tube (ETT). They enrolled 42 adults who required general anesthesia with ETT and randomized them to right main bronchus, left main bronchus, or tracheal intubation, followed by fiber optically–guided visualization to place the ETT. Next, an anesthesiologist blinded to the ETT exact location used auscultation to assess the location of the ETT, while another anesthesiologist blinded to the ETT exact location used point-of-care ultrasound to assess the location of the ETT. The ultrasound exam consisted of assessing tracheal dilation via standard cuff inflation with air and evaluation of pleural lung sliding, explained Dr. Ramsingh of the department of anesthesiology and perioperative care at the University of California, Irvine.
Dr. Ramsingh reported that in differentiating tracheal versus bronchial intubations, auscultation demonstrated a sensitivity of 66% and a specificity of 59%, while ultrasound demonstrated a sensitivity of 93% and a specificity of 96%. Chi-square comparison showed a statistically significant improvement with ultrasound (P = .0005), while inter-observer agreement of the ultrasound findings was 100%.
Limitations of the study, he said, include the fact that “we don’t know the incidence of malpositioned endotracheal tubes in the operating room and that this study was evaluating patients undergoing elective surgical procedures.”
The researchers reported having no financial disclosures.
SAN DIEGO – Assessment of the trachea and pleura via point-of-care ultrasound is superior to auscultation in determining the exact location of the endotracheal tube, a randomized, single-center study found.
“It’s been reported that about 20% of the time the endotracheal tube is malpositioned,” study author Dr. Davinder S. Ramsingh said in an interview at the annual meeting of the American Society of Anesthesiologists. “Most of the time (the tube) is too deep, which can lead to severe complications.”
In a double-blinded, randomized study, Dr. Ramsingh and his associates assessed the accuracy of auscultation vs. point-of-care ultrasound in verifying the correct position of the endotracheal tube (ETT). They enrolled 42 adults who required general anesthesia with ETT and randomized them to right main bronchus, left main bronchus, or tracheal intubation, followed by fiber optically–guided visualization to place the ETT. Next, an anesthesiologist blinded to the ETT exact location used auscultation to assess the location of the ETT, while another anesthesiologist blinded to the ETT exact location used point-of-care ultrasound to assess the location of the ETT. The ultrasound exam consisted of assessing tracheal dilation via standard cuff inflation with air and evaluation of pleural lung sliding, explained Dr. Ramsingh of the department of anesthesiology and perioperative care at the University of California, Irvine.
Dr. Ramsingh reported that in differentiating tracheal versus bronchial intubations, auscultation demonstrated a sensitivity of 66% and a specificity of 59%, while ultrasound demonstrated a sensitivity of 93% and a specificity of 96%. Chi-square comparison showed a statistically significant improvement with ultrasound (P = .0005), while inter-observer agreement of the ultrasound findings was 100%.
Limitations of the study, he said, include the fact that “we don’t know the incidence of malpositioned endotracheal tubes in the operating room and that this study was evaluating patients undergoing elective surgical procedures.”
The researchers reported having no financial disclosures.
SAN DIEGO – Assessment of the trachea and pleura via point-of-care ultrasound is superior to auscultation in determining the exact location of the endotracheal tube, a randomized, single-center study found.
“It’s been reported that about 20% of the time the endotracheal tube is malpositioned,” study author Dr. Davinder S. Ramsingh said in an interview at the annual meeting of the American Society of Anesthesiologists. “Most of the time (the tube) is too deep, which can lead to severe complications.”
In a double-blinded, randomized study, Dr. Ramsingh and his associates assessed the accuracy of auscultation vs. point-of-care ultrasound in verifying the correct position of the endotracheal tube (ETT). They enrolled 42 adults who required general anesthesia with ETT and randomized them to right main bronchus, left main bronchus, or tracheal intubation, followed by fiber optically–guided visualization to place the ETT. Next, an anesthesiologist blinded to the ETT exact location used auscultation to assess the location of the ETT, while another anesthesiologist blinded to the ETT exact location used point-of-care ultrasound to assess the location of the ETT. The ultrasound exam consisted of assessing tracheal dilation via standard cuff inflation with air and evaluation of pleural lung sliding, explained Dr. Ramsingh of the department of anesthesiology and perioperative care at the University of California, Irvine.
Dr. Ramsingh reported that in differentiating tracheal versus bronchial intubations, auscultation demonstrated a sensitivity of 66% and a specificity of 59%, while ultrasound demonstrated a sensitivity of 93% and a specificity of 96%. Chi-square comparison showed a statistically significant improvement with ultrasound (P = .0005), while inter-observer agreement of the ultrasound findings was 100%.
Limitations of the study, he said, include the fact that “we don’t know the incidence of malpositioned endotracheal tubes in the operating room and that this study was evaluating patients undergoing elective surgical procedures.”
The researchers reported having no financial disclosures.
AT THE ASA ANNUAL MEETING
Key clinical point: Using point-of-care ultrasound was superior to auscultation in determining the exact location of the endotracheal tube.
Major finding: In differentiating tracheal versus bronchial intubations, auscultation demonstrated a sensitivity of 66% and a specificity of 59%, while ultrasound demonstrated a sensitivity of 93% and a specificity of 96%.
Data source: An randomized study of 42 adults who required general anesthesia with ETT.
Disclosures: The researchers reported having no financial disclosures.
Residents’ Forum: Docs not at par on post-call days
SAN DIEGO – If you feel sleepy and out of sorts on a post-call day, compared with a normal work-day, you’re not alone.
Anesthesiology faculty reported significant increases in feeling irritable, jittery, and sleepy, along with significant decreases in feeling confident, energetic, and talkative following an on-call period, according to a study presented at the annual meeting of the American Society of Anesthesiologists.
To date, most studies of partial sleep deprivation in health care settings have focused on residents and interns, and less on medical faculty, said lead study author Dr. Haleh Saadat of the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, Ohio. “Our call is 17 hours, from 3 p.m. to 7 a.m.; but the call period at most hospitals is 24 hours, and even longer at some private practices,” she said in an interview.
To examine the effects of partial sleep deprivation on reaction time, simple cognitive skills, and mood status in 21 anesthesiologists, Dr. Saadat and her associates obtained verbal consent from the study participants and measured reaction time, mood states, and eight subjective behavioral characteristics at two different time points: between 6:30 a.m. and 8 a.m. on a regular noncall day of work, and between 6:30 a.m. and 8 a.m. after an overnight call (a shift that runs from 3 p.m. to 7 a.m.). The behavioral characteristics included feeling alert, energetic, anxious, confident, irritable, jittery/nervous, sleepy, and talkative, and the researchers used paired t-tests to compare variable means between regular sleep days and post-call days.
Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = .047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than .001).
Of the 21 anesthesiologists, 19 completed all simple cognitive task questions at both time points and reported significant increases in several of these parameters on post-call days, compared with normal work-days.
Post-call observations found participants feeling more irritable, confident, energetic, sleepy (P less than .001), feeling more jittery (P = .003), and feeling less talkative (P less than .001) than on normal work–days.
Coping strategies used to address their sleep deprivation were measured as well, with “most of our subjects using problem solving, followed by seeking social support and avoidance,” Dr. Saadat noted. “People who used avoidance had greater declines in reaction time on post–call days, compared with the rest of the study participants. It didn’t matter whether you were male, female, younger, or older.”
Dr. Saadat called for additional studies to evaluate the neurocognitive impact of partial sleep deprivation on physicians’ on-call duties.
“I would like to see if we can replicate the results in bigger centers,” she said. “If this is what is happening, we may need to pay more attention to faculty’s work hours in both academic and private practice settings – not only among anesthesiologists, but also in other specialties. These observations require a closer look at the potential implications for patients’ and professionals’ safety.”
The researchers reported no financial disclosures.
As a surgical resident, I have experienced firsthand the “drunk-tired” phenomenon, and to be honest, I do not believe it to be such a rare occurrence. “Drunk-tired” may be eloquently defined as being so tired you start behaving like you’re drunk, without actually consuming any alcohol of course.
The first manuscript relating fatigue amongst shift workers to performance impairment was published in 1996 by Dawson et al. demonstrating that moderate levels of fatigue actually produce more impairment than being legally intoxicated (Nature 1997;388:235). It didn’t take much of a leap to translate these observations to health care workers who work long hours, do shift work, and are on-call at times for more than 24 hours at a time. Recently, at the annual meeting of the American Society of Anesthesiologists in San Diego, Dr. Haleh Saadat from Ohio presented her study on the effects of partial sleep deprivation in staff anaesthesiologists leading to significantly decreased reaction times, cognitive skills, and mood disturbances on post-call days, compared with normal work days. No surprise there, as this is in line with what Dawson and his colleagues published nearly two decades ago. This study can certainly be translated to medical students, residents, fellows and staff from the breadth of specialties in medicine. In my opinion, what’s the point? I can already foresee what these studies are going to demonstrate, namely a clean sweep of all forms of cognitive and motor impairments when a subject is sleep deprived. The question becomes how we are translating all of this information into action that changes the lives of health care professionals and more importantly improves patient safety. Understandably, this is a loaded question and I am simply too exhausted to wrap my head around it.
So, next time you’re post call, feeling irritable, discoordinated, and inhibited, just remember: you’re as good as drunk and you should probably sleep it off.
Dr. Laura Drudi is the resident medical editor for Vascular Specialist.
As a surgical resident, I have experienced firsthand the “drunk-tired” phenomenon, and to be honest, I do not believe it to be such a rare occurrence. “Drunk-tired” may be eloquently defined as being so tired you start behaving like you’re drunk, without actually consuming any alcohol of course.
The first manuscript relating fatigue amongst shift workers to performance impairment was published in 1996 by Dawson et al. demonstrating that moderate levels of fatigue actually produce more impairment than being legally intoxicated (Nature 1997;388:235). It didn’t take much of a leap to translate these observations to health care workers who work long hours, do shift work, and are on-call at times for more than 24 hours at a time. Recently, at the annual meeting of the American Society of Anesthesiologists in San Diego, Dr. Haleh Saadat from Ohio presented her study on the effects of partial sleep deprivation in staff anaesthesiologists leading to significantly decreased reaction times, cognitive skills, and mood disturbances on post-call days, compared with normal work days. No surprise there, as this is in line with what Dawson and his colleagues published nearly two decades ago. This study can certainly be translated to medical students, residents, fellows and staff from the breadth of specialties in medicine. In my opinion, what’s the point? I can already foresee what these studies are going to demonstrate, namely a clean sweep of all forms of cognitive and motor impairments when a subject is sleep deprived. The question becomes how we are translating all of this information into action that changes the lives of health care professionals and more importantly improves patient safety. Understandably, this is a loaded question and I am simply too exhausted to wrap my head around it.
So, next time you’re post call, feeling irritable, discoordinated, and inhibited, just remember: you’re as good as drunk and you should probably sleep it off.
Dr. Laura Drudi is the resident medical editor for Vascular Specialist.
As a surgical resident, I have experienced firsthand the “drunk-tired” phenomenon, and to be honest, I do not believe it to be such a rare occurrence. “Drunk-tired” may be eloquently defined as being so tired you start behaving like you’re drunk, without actually consuming any alcohol of course.
The first manuscript relating fatigue amongst shift workers to performance impairment was published in 1996 by Dawson et al. demonstrating that moderate levels of fatigue actually produce more impairment than being legally intoxicated (Nature 1997;388:235). It didn’t take much of a leap to translate these observations to health care workers who work long hours, do shift work, and are on-call at times for more than 24 hours at a time. Recently, at the annual meeting of the American Society of Anesthesiologists in San Diego, Dr. Haleh Saadat from Ohio presented her study on the effects of partial sleep deprivation in staff anaesthesiologists leading to significantly decreased reaction times, cognitive skills, and mood disturbances on post-call days, compared with normal work days. No surprise there, as this is in line with what Dawson and his colleagues published nearly two decades ago. This study can certainly be translated to medical students, residents, fellows and staff from the breadth of specialties in medicine. In my opinion, what’s the point? I can already foresee what these studies are going to demonstrate, namely a clean sweep of all forms of cognitive and motor impairments when a subject is sleep deprived. The question becomes how we are translating all of this information into action that changes the lives of health care professionals and more importantly improves patient safety. Understandably, this is a loaded question and I am simply too exhausted to wrap my head around it.
So, next time you’re post call, feeling irritable, discoordinated, and inhibited, just remember: you’re as good as drunk and you should probably sleep it off.
Dr. Laura Drudi is the resident medical editor for Vascular Specialist.
SAN DIEGO – If you feel sleepy and out of sorts on a post-call day, compared with a normal work-day, you’re not alone.
Anesthesiology faculty reported significant increases in feeling irritable, jittery, and sleepy, along with significant decreases in feeling confident, energetic, and talkative following an on-call period, according to a study presented at the annual meeting of the American Society of Anesthesiologists.
To date, most studies of partial sleep deprivation in health care settings have focused on residents and interns, and less on medical faculty, said lead study author Dr. Haleh Saadat of the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, Ohio. “Our call is 17 hours, from 3 p.m. to 7 a.m.; but the call period at most hospitals is 24 hours, and even longer at some private practices,” she said in an interview.
To examine the effects of partial sleep deprivation on reaction time, simple cognitive skills, and mood status in 21 anesthesiologists, Dr. Saadat and her associates obtained verbal consent from the study participants and measured reaction time, mood states, and eight subjective behavioral characteristics at two different time points: between 6:30 a.m. and 8 a.m. on a regular noncall day of work, and between 6:30 a.m. and 8 a.m. after an overnight call (a shift that runs from 3 p.m. to 7 a.m.). The behavioral characteristics included feeling alert, energetic, anxious, confident, irritable, jittery/nervous, sleepy, and talkative, and the researchers used paired t-tests to compare variable means between regular sleep days and post-call days.
Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = .047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than .001).
Of the 21 anesthesiologists, 19 completed all simple cognitive task questions at both time points and reported significant increases in several of these parameters on post-call days, compared with normal work-days.
Post-call observations found participants feeling more irritable, confident, energetic, sleepy (P less than .001), feeling more jittery (P = .003), and feeling less talkative (P less than .001) than on normal work–days.
Coping strategies used to address their sleep deprivation were measured as well, with “most of our subjects using problem solving, followed by seeking social support and avoidance,” Dr. Saadat noted. “People who used avoidance had greater declines in reaction time on post–call days, compared with the rest of the study participants. It didn’t matter whether you were male, female, younger, or older.”
Dr. Saadat called for additional studies to evaluate the neurocognitive impact of partial sleep deprivation on physicians’ on-call duties.
“I would like to see if we can replicate the results in bigger centers,” she said. “If this is what is happening, we may need to pay more attention to faculty’s work hours in both academic and private practice settings – not only among anesthesiologists, but also in other specialties. These observations require a closer look at the potential implications for patients’ and professionals’ safety.”
The researchers reported no financial disclosures.
SAN DIEGO – If you feel sleepy and out of sorts on a post-call day, compared with a normal work-day, you’re not alone.
Anesthesiology faculty reported significant increases in feeling irritable, jittery, and sleepy, along with significant decreases in feeling confident, energetic, and talkative following an on-call period, according to a study presented at the annual meeting of the American Society of Anesthesiologists.
To date, most studies of partial sleep deprivation in health care settings have focused on residents and interns, and less on medical faculty, said lead study author Dr. Haleh Saadat of the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, Ohio. “Our call is 17 hours, from 3 p.m. to 7 a.m.; but the call period at most hospitals is 24 hours, and even longer at some private practices,” she said in an interview.
To examine the effects of partial sleep deprivation on reaction time, simple cognitive skills, and mood status in 21 anesthesiologists, Dr. Saadat and her associates obtained verbal consent from the study participants and measured reaction time, mood states, and eight subjective behavioral characteristics at two different time points: between 6:30 a.m. and 8 a.m. on a regular noncall day of work, and between 6:30 a.m. and 8 a.m. after an overnight call (a shift that runs from 3 p.m. to 7 a.m.). The behavioral characteristics included feeling alert, energetic, anxious, confident, irritable, jittery/nervous, sleepy, and talkative, and the researchers used paired t-tests to compare variable means between regular sleep days and post-call days.
Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = .047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than .001).
Of the 21 anesthesiologists, 19 completed all simple cognitive task questions at both time points and reported significant increases in several of these parameters on post-call days, compared with normal work-days.
Post-call observations found participants feeling more irritable, confident, energetic, sleepy (P less than .001), feeling more jittery (P = .003), and feeling less talkative (P less than .001) than on normal work–days.
Coping strategies used to address their sleep deprivation were measured as well, with “most of our subjects using problem solving, followed by seeking social support and avoidance,” Dr. Saadat noted. “People who used avoidance had greater declines in reaction time on post–call days, compared with the rest of the study participants. It didn’t matter whether you were male, female, younger, or older.”
Dr. Saadat called for additional studies to evaluate the neurocognitive impact of partial sleep deprivation on physicians’ on-call duties.
“I would like to see if we can replicate the results in bigger centers,” she said. “If this is what is happening, we may need to pay more attention to faculty’s work hours in both academic and private practice settings – not only among anesthesiologists, but also in other specialties. These observations require a closer look at the potential implications for patients’ and professionals’ safety.”
The researchers reported no financial disclosures.
Self-reported poor functional status predicts perioperative morbidity
SAN DIEGO – Among patients with pulmonary hypertension presenting for elective surgery, self-reported poor functional status is associated with multiple comorbidities and is independently predictive of longer hospital length of stay, results from an ongoing single-center study suggest.
“Patients with pulmonary hypertension (PHTN) presenting for elective surgery are at significantly higher risk for adverse perioperative outcomes, including increased hospital length of stay, right ventricular failure, cardiac arrhythmia, persistent postoperative hypoxemia, coronary ischemia and death,” researchers led by Dr. Aalap C. Shah wrote in an abstract presented at the at the annual meeting of the American Society of Anesthesiologists. “The diagnosis of PHTN is based on costly echocardiographic examination and right heart catheterization and should be reserved for high-risk patients. No studies have assessed the role of self-reported functional classification on PHTN severity stratification, and few studies have achieved a sufficiently large patient sample size.”
In an effort to evaluate the predictive value of self-reported exercise tolerance on echocardiogram findings, outcomes, and length of stay (LOS) after noncardiac, nonobstetric surgery, the researchers queried the University of Washington database for all PHTN seen in preoperative anesthesia clinic for noncardiac, nonobstetric procedures from April 2007 through September 2013. Inclusion criteria required an echocardiogram less than 1 year prior to the procedure and available patient-reported functional status, which was defined as less than four metabolic equivalents (METS) in exercise testing or four METS or greater. Dr. Shah, formerly a resident in the University of Washington’s department of anesthesiology and pain medicine, and his associates used univariate analyses to compare functional status with echocardiographic findings, complication rates, and length of stay (LOS). At the meeting he presented results from 294 patients evaluated to date: 143 with normal functional status and 151 with poor functional status. Their mean age was 62 years, and 51% of patients were female.
Compared with their counterparts with normal functional status, patients with poor functional status trended toward a higher complication rate at hospital discharge (14.6% vs. 7%, respectively; P = .041) and had a higher cumulative rate of complications (33 vs. 15; P = .035). However, no association between functional status and complications was observed 30 days postoperatively.
Patients with poor functional status had a significantly longer average LOS, compared with patients with normal functional status (7.21 vs. 4.73 days; P = .047). Open surgical approach was also an independent predictor of increased LOS (odds ratio 2.39; P = .005). No significant independent predictors of complications were observed at discharge or 30 days postoperatively.
“Going forward, the goal is to use these data to create a risk stratification algorithm to figure out: Does a patient with good functional status and pulmonary hypertension undergoing toe surgery, for example, really need an echocardiogram before getting surgery?” said Dr. Shah said, who is now an anesthesiology fellow at Boston Children’s Hospital. “Hopefully we can show that using these risk stratification algorithms can decrease the costs and decrease the time to actually getting surgery.”
The researchers reported having no financial disclosures.
SAN DIEGO – Among patients with pulmonary hypertension presenting for elective surgery, self-reported poor functional status is associated with multiple comorbidities and is independently predictive of longer hospital length of stay, results from an ongoing single-center study suggest.
“Patients with pulmonary hypertension (PHTN) presenting for elective surgery are at significantly higher risk for adverse perioperative outcomes, including increased hospital length of stay, right ventricular failure, cardiac arrhythmia, persistent postoperative hypoxemia, coronary ischemia and death,” researchers led by Dr. Aalap C. Shah wrote in an abstract presented at the at the annual meeting of the American Society of Anesthesiologists. “The diagnosis of PHTN is based on costly echocardiographic examination and right heart catheterization and should be reserved for high-risk patients. No studies have assessed the role of self-reported functional classification on PHTN severity stratification, and few studies have achieved a sufficiently large patient sample size.”
In an effort to evaluate the predictive value of self-reported exercise tolerance on echocardiogram findings, outcomes, and length of stay (LOS) after noncardiac, nonobstetric surgery, the researchers queried the University of Washington database for all PHTN seen in preoperative anesthesia clinic for noncardiac, nonobstetric procedures from April 2007 through September 2013. Inclusion criteria required an echocardiogram less than 1 year prior to the procedure and available patient-reported functional status, which was defined as less than four metabolic equivalents (METS) in exercise testing or four METS or greater. Dr. Shah, formerly a resident in the University of Washington’s department of anesthesiology and pain medicine, and his associates used univariate analyses to compare functional status with echocardiographic findings, complication rates, and length of stay (LOS). At the meeting he presented results from 294 patients evaluated to date: 143 with normal functional status and 151 with poor functional status. Their mean age was 62 years, and 51% of patients were female.
Compared with their counterparts with normal functional status, patients with poor functional status trended toward a higher complication rate at hospital discharge (14.6% vs. 7%, respectively; P = .041) and had a higher cumulative rate of complications (33 vs. 15; P = .035). However, no association between functional status and complications was observed 30 days postoperatively.
Patients with poor functional status had a significantly longer average LOS, compared with patients with normal functional status (7.21 vs. 4.73 days; P = .047). Open surgical approach was also an independent predictor of increased LOS (odds ratio 2.39; P = .005). No significant independent predictors of complications were observed at discharge or 30 days postoperatively.
“Going forward, the goal is to use these data to create a risk stratification algorithm to figure out: Does a patient with good functional status and pulmonary hypertension undergoing toe surgery, for example, really need an echocardiogram before getting surgery?” said Dr. Shah said, who is now an anesthesiology fellow at Boston Children’s Hospital. “Hopefully we can show that using these risk stratification algorithms can decrease the costs and decrease the time to actually getting surgery.”
The researchers reported having no financial disclosures.
SAN DIEGO – Among patients with pulmonary hypertension presenting for elective surgery, self-reported poor functional status is associated with multiple comorbidities and is independently predictive of longer hospital length of stay, results from an ongoing single-center study suggest.
“Patients with pulmonary hypertension (PHTN) presenting for elective surgery are at significantly higher risk for adverse perioperative outcomes, including increased hospital length of stay, right ventricular failure, cardiac arrhythmia, persistent postoperative hypoxemia, coronary ischemia and death,” researchers led by Dr. Aalap C. Shah wrote in an abstract presented at the at the annual meeting of the American Society of Anesthesiologists. “The diagnosis of PHTN is based on costly echocardiographic examination and right heart catheterization and should be reserved for high-risk patients. No studies have assessed the role of self-reported functional classification on PHTN severity stratification, and few studies have achieved a sufficiently large patient sample size.”
In an effort to evaluate the predictive value of self-reported exercise tolerance on echocardiogram findings, outcomes, and length of stay (LOS) after noncardiac, nonobstetric surgery, the researchers queried the University of Washington database for all PHTN seen in preoperative anesthesia clinic for noncardiac, nonobstetric procedures from April 2007 through September 2013. Inclusion criteria required an echocardiogram less than 1 year prior to the procedure and available patient-reported functional status, which was defined as less than four metabolic equivalents (METS) in exercise testing or four METS or greater. Dr. Shah, formerly a resident in the University of Washington’s department of anesthesiology and pain medicine, and his associates used univariate analyses to compare functional status with echocardiographic findings, complication rates, and length of stay (LOS). At the meeting he presented results from 294 patients evaluated to date: 143 with normal functional status and 151 with poor functional status. Their mean age was 62 years, and 51% of patients were female.
Compared with their counterparts with normal functional status, patients with poor functional status trended toward a higher complication rate at hospital discharge (14.6% vs. 7%, respectively; P = .041) and had a higher cumulative rate of complications (33 vs. 15; P = .035). However, no association between functional status and complications was observed 30 days postoperatively.
Patients with poor functional status had a significantly longer average LOS, compared with patients with normal functional status (7.21 vs. 4.73 days; P = .047). Open surgical approach was also an independent predictor of increased LOS (odds ratio 2.39; P = .005). No significant independent predictors of complications were observed at discharge or 30 days postoperatively.
“Going forward, the goal is to use these data to create a risk stratification algorithm to figure out: Does a patient with good functional status and pulmonary hypertension undergoing toe surgery, for example, really need an echocardiogram before getting surgery?” said Dr. Shah said, who is now an anesthesiology fellow at Boston Children’s Hospital. “Hopefully we can show that using these risk stratification algorithms can decrease the costs and decrease the time to actually getting surgery.”
The researchers reported having no financial disclosures.
AT THE ASA ANNUAL MEETING
Key clinical point:Poor self-reported exercise tolerance by patients with pulmonary hypertension is associated with multiple comorbidities and increased hospital length of stay.
Major finding: Compared with their counterparts with normal functional status, patients with poor functional status trended toward a higher complication rate at hospital discharge (14.6% vs. 7%, respectively; P = .041) and had a higher cumulative rate of complications (33 vs. 15; P = .035).
Data source: A study 294 PHTN patients seen in preoperative anesthesia clinic at the University of Washington for non-cardiac, nonobstetric procedures from April 2007 through September 2013.
Disclosures: The researchers reported having no financial disclosures.
ASA: Pediatric clinicians over-dispensing opioids, study finds
SAN DIEGO – Pediatric clinicians are dispensing more medicine than needed to treat pain and may be contributing to the epidemic of nonmedical use of prescription opioids, results from a prospective cohort study suggest.
“On the one hand, we have an ethical and more responsibility to treat pain,” Dr. Myron Yaster said in an interview at the annual meeting of the American Society of Anesthesiologists. “I think we’re doing a pretty good job of that. But there’s also a societal issue in what happens to medicines that are left over. That leftover medicine is the most important element in drug addiction. What this study showed is that in the pediatric population, about 60% of what is prescribed is left over.”
As part of a larger ongoing project, Dr. Yaster, professor of pediatric anesthesiology, critical care medicine, and pain management at Johns Hopkins University Hospital, Baltimore, Md., and his associates recruited 433 English-speaking inpatients who were given opioids on discharge from the university’s pediatric hospital. All prescriptions were analyzed by the investigators following discharge for drug, formulation, and amount dispensed. Parents of the patients were interviewed within 2 days of discharge and again up to 2 weeks after discharge to determine if the prescription was filled, to determine pain control on a 4-point Likert scale, how long opioids were used, the amount of medication left at completion of therapy, if patients were given instructions about how to dispose of leftover drug, and if the remaining medications were discarded.
Of the 433 parents, 292 (67%) completed both sets of interviews. The average age of patients was 11 years and their average weight was 44 kg. The majority of patients (89%) were prescribed oxycodone, a liquid formulation 44% of the time. A minority (5%) did not fill their prescriptions, 25% misidentified or did not know the name of their prescription opioid, and patients took opioids for an average of 5 days. “We need to know more about what the prescribers are thinking when they prescribe,” Dr. Yaster said. “Do they actually believe that [patients are] going to take the medicine for 10 days?”
Nearly half of the time (47%), parents rated pain control as “excellent,” followed by “good” (34%), “fair” (10%), or poor (0%). The remaining 9% gave no response. At 2 weeks, an average of 36 opioid tablets and an average of 67 mL of opioid liquid medication remained unused. Overall, patients used only 42% of their prescribed amount.
The researchers also found that 82% of parents were not provided instructions as to what to do with leftover medicine, and only 6% actually did dispose of it. “That means that all that leftover medicine is in people’s medicine cabinets,” Dr. Yaster said. “The study also found that almost half of patients had a teenage sibling. That’s the target population of drug abuse.”
Dr. Yaster reported having no financial disclosures. One of the study authors was Aaron Hsu, a medical student at Johns Hopkins.
SAN DIEGO – Pediatric clinicians are dispensing more medicine than needed to treat pain and may be contributing to the epidemic of nonmedical use of prescription opioids, results from a prospective cohort study suggest.
“On the one hand, we have an ethical and more responsibility to treat pain,” Dr. Myron Yaster said in an interview at the annual meeting of the American Society of Anesthesiologists. “I think we’re doing a pretty good job of that. But there’s also a societal issue in what happens to medicines that are left over. That leftover medicine is the most important element in drug addiction. What this study showed is that in the pediatric population, about 60% of what is prescribed is left over.”
As part of a larger ongoing project, Dr. Yaster, professor of pediatric anesthesiology, critical care medicine, and pain management at Johns Hopkins University Hospital, Baltimore, Md., and his associates recruited 433 English-speaking inpatients who were given opioids on discharge from the university’s pediatric hospital. All prescriptions were analyzed by the investigators following discharge for drug, formulation, and amount dispensed. Parents of the patients were interviewed within 2 days of discharge and again up to 2 weeks after discharge to determine if the prescription was filled, to determine pain control on a 4-point Likert scale, how long opioids were used, the amount of medication left at completion of therapy, if patients were given instructions about how to dispose of leftover drug, and if the remaining medications were discarded.
Of the 433 parents, 292 (67%) completed both sets of interviews. The average age of patients was 11 years and their average weight was 44 kg. The majority of patients (89%) were prescribed oxycodone, a liquid formulation 44% of the time. A minority (5%) did not fill their prescriptions, 25% misidentified or did not know the name of their prescription opioid, and patients took opioids for an average of 5 days. “We need to know more about what the prescribers are thinking when they prescribe,” Dr. Yaster said. “Do they actually believe that [patients are] going to take the medicine for 10 days?”
Nearly half of the time (47%), parents rated pain control as “excellent,” followed by “good” (34%), “fair” (10%), or poor (0%). The remaining 9% gave no response. At 2 weeks, an average of 36 opioid tablets and an average of 67 mL of opioid liquid medication remained unused. Overall, patients used only 42% of their prescribed amount.
The researchers also found that 82% of parents were not provided instructions as to what to do with leftover medicine, and only 6% actually did dispose of it. “That means that all that leftover medicine is in people’s medicine cabinets,” Dr. Yaster said. “The study also found that almost half of patients had a teenage sibling. That’s the target population of drug abuse.”
Dr. Yaster reported having no financial disclosures. One of the study authors was Aaron Hsu, a medical student at Johns Hopkins.
SAN DIEGO – Pediatric clinicians are dispensing more medicine than needed to treat pain and may be contributing to the epidemic of nonmedical use of prescription opioids, results from a prospective cohort study suggest.
“On the one hand, we have an ethical and more responsibility to treat pain,” Dr. Myron Yaster said in an interview at the annual meeting of the American Society of Anesthesiologists. “I think we’re doing a pretty good job of that. But there’s also a societal issue in what happens to medicines that are left over. That leftover medicine is the most important element in drug addiction. What this study showed is that in the pediatric population, about 60% of what is prescribed is left over.”
As part of a larger ongoing project, Dr. Yaster, professor of pediatric anesthesiology, critical care medicine, and pain management at Johns Hopkins University Hospital, Baltimore, Md., and his associates recruited 433 English-speaking inpatients who were given opioids on discharge from the university’s pediatric hospital. All prescriptions were analyzed by the investigators following discharge for drug, formulation, and amount dispensed. Parents of the patients were interviewed within 2 days of discharge and again up to 2 weeks after discharge to determine if the prescription was filled, to determine pain control on a 4-point Likert scale, how long opioids were used, the amount of medication left at completion of therapy, if patients were given instructions about how to dispose of leftover drug, and if the remaining medications were discarded.
Of the 433 parents, 292 (67%) completed both sets of interviews. The average age of patients was 11 years and their average weight was 44 kg. The majority of patients (89%) were prescribed oxycodone, a liquid formulation 44% of the time. A minority (5%) did not fill their prescriptions, 25% misidentified or did not know the name of their prescription opioid, and patients took opioids for an average of 5 days. “We need to know more about what the prescribers are thinking when they prescribe,” Dr. Yaster said. “Do they actually believe that [patients are] going to take the medicine for 10 days?”
Nearly half of the time (47%), parents rated pain control as “excellent,” followed by “good” (34%), “fair” (10%), or poor (0%). The remaining 9% gave no response. At 2 weeks, an average of 36 opioid tablets and an average of 67 mL of opioid liquid medication remained unused. Overall, patients used only 42% of their prescribed amount.
The researchers also found that 82% of parents were not provided instructions as to what to do with leftover medicine, and only 6% actually did dispose of it. “That means that all that leftover medicine is in people’s medicine cabinets,” Dr. Yaster said. “The study also found that almost half of patients had a teenage sibling. That’s the target population of drug abuse.”
Dr. Yaster reported having no financial disclosures. One of the study authors was Aaron Hsu, a medical student at Johns Hopkins.
AT THE ASA ANNUAL MEETING
Key clinical point: Clinicians dispense more opioids than needed to treat pediatric pain.
Major finding: The majority of patients (89%) were prescribed oxycodone, and overall they used only 42% of the opioids they were prescribed.
Data source: A prospective study based on responses from 292 parents of children who were discharged from a university pediatric hospital with an opioid prescription.
Disclosures: Dr. Yaster reported having no financial disclosures.
Pain a common cause of revisits after same-day surgery
SAN DIEGO – Nearly one-third of pain-related emergency room visits or hospital readmissions following same-day surgery were attributable to inadequate pain management in the peridischarge period, a large single-center analysis demonstrated.
“Pain management in the perioperative period is largely an anesthesiologist responsibility, but maybe it would be helpful if it was a little bit more multispecialty, if we had more communication,” study author Dr. Martha O. Herbst said in an interview at the annual meeting of the American Society of Anesthesiologists.
“There were some patients who came back for pain because they didn’t even receive prescriptions from their surgeon. Maybe a little better communication between the anesthesiologist and the surgeon on how to optimize specific patients and prevent those readmissions for pain would help,” she said.
Inspired by a similar study published in 2002 (J Clin Anesth. 2002;14[5]:349-53), Dr. Herbst, a fourth-year anesthesiology resident at Beaumont Hospital in Royal Oak, Mich., and her associates retrospectively evaluated the number of readmissions or revisits that occurred among 28,647 patients who underwent same-day surgery in the Beaumont Health system in 2012. A total of 1,559 revisits occurred during the study period. Of these, 621 (39.8%) were revisits related to the surgical procedure and 145 (9.3% overall and 23.3% of readmissions) were due to pain.
The researchers then stratified patients into one of six categories for readmission. These included all-cause pain (16%); surgical-related issues such as wound opening or reinfection (21%); medical issues such as exacerbation of chronic obstructive pulmonary disease (43%); bleeding complications such as hematuria, hemodialysis, and surgical site bleeding (6%); adverse medical reactions (2%); and other (12%).
Of the 145 patients who were readmitted for pain from the same-day surgery, 71% were deemed to have no pre-existing risk for readmission while 29% had at least one risk factor for readmission. These included opioid monotherapy during the procedure (11%), history of chronic pain (9%), no pain medication given during the procedure (4%), inadequate doses of analgesics used (3%), and discharge without a prescription for an analgesic (2%).
“There were people who got tiny doses of pain medications after a huge, painful procedure, so that was surprising,” Dr. Herbst said. “Maybe they weren’t optimally managed at the time of surgery.”
The findings, she concluded, underscore the need for a team-based approach to pain management in the same-day surgery population, with discharge planning focused on patient education, expectation management, multimodal analgesia optimization, and pain risk assessment.
The researchers reported having no financial disclosures.
SAN DIEGO – Nearly one-third of pain-related emergency room visits or hospital readmissions following same-day surgery were attributable to inadequate pain management in the peridischarge period, a large single-center analysis demonstrated.
“Pain management in the perioperative period is largely an anesthesiologist responsibility, but maybe it would be helpful if it was a little bit more multispecialty, if we had more communication,” study author Dr. Martha O. Herbst said in an interview at the annual meeting of the American Society of Anesthesiologists.
“There were some patients who came back for pain because they didn’t even receive prescriptions from their surgeon. Maybe a little better communication between the anesthesiologist and the surgeon on how to optimize specific patients and prevent those readmissions for pain would help,” she said.
Inspired by a similar study published in 2002 (J Clin Anesth. 2002;14[5]:349-53), Dr. Herbst, a fourth-year anesthesiology resident at Beaumont Hospital in Royal Oak, Mich., and her associates retrospectively evaluated the number of readmissions or revisits that occurred among 28,647 patients who underwent same-day surgery in the Beaumont Health system in 2012. A total of 1,559 revisits occurred during the study period. Of these, 621 (39.8%) were revisits related to the surgical procedure and 145 (9.3% overall and 23.3% of readmissions) were due to pain.
The researchers then stratified patients into one of six categories for readmission. These included all-cause pain (16%); surgical-related issues such as wound opening or reinfection (21%); medical issues such as exacerbation of chronic obstructive pulmonary disease (43%); bleeding complications such as hematuria, hemodialysis, and surgical site bleeding (6%); adverse medical reactions (2%); and other (12%).
Of the 145 patients who were readmitted for pain from the same-day surgery, 71% were deemed to have no pre-existing risk for readmission while 29% had at least one risk factor for readmission. These included opioid monotherapy during the procedure (11%), history of chronic pain (9%), no pain medication given during the procedure (4%), inadequate doses of analgesics used (3%), and discharge without a prescription for an analgesic (2%).
“There were people who got tiny doses of pain medications after a huge, painful procedure, so that was surprising,” Dr. Herbst said. “Maybe they weren’t optimally managed at the time of surgery.”
The findings, she concluded, underscore the need for a team-based approach to pain management in the same-day surgery population, with discharge planning focused on patient education, expectation management, multimodal analgesia optimization, and pain risk assessment.
The researchers reported having no financial disclosures.
SAN DIEGO – Nearly one-third of pain-related emergency room visits or hospital readmissions following same-day surgery were attributable to inadequate pain management in the peridischarge period, a large single-center analysis demonstrated.
“Pain management in the perioperative period is largely an anesthesiologist responsibility, but maybe it would be helpful if it was a little bit more multispecialty, if we had more communication,” study author Dr. Martha O. Herbst said in an interview at the annual meeting of the American Society of Anesthesiologists.
“There were some patients who came back for pain because they didn’t even receive prescriptions from their surgeon. Maybe a little better communication between the anesthesiologist and the surgeon on how to optimize specific patients and prevent those readmissions for pain would help,” she said.
Inspired by a similar study published in 2002 (J Clin Anesth. 2002;14[5]:349-53), Dr. Herbst, a fourth-year anesthesiology resident at Beaumont Hospital in Royal Oak, Mich., and her associates retrospectively evaluated the number of readmissions or revisits that occurred among 28,647 patients who underwent same-day surgery in the Beaumont Health system in 2012. A total of 1,559 revisits occurred during the study period. Of these, 621 (39.8%) were revisits related to the surgical procedure and 145 (9.3% overall and 23.3% of readmissions) were due to pain.
The researchers then stratified patients into one of six categories for readmission. These included all-cause pain (16%); surgical-related issues such as wound opening or reinfection (21%); medical issues such as exacerbation of chronic obstructive pulmonary disease (43%); bleeding complications such as hematuria, hemodialysis, and surgical site bleeding (6%); adverse medical reactions (2%); and other (12%).
Of the 145 patients who were readmitted for pain from the same-day surgery, 71% were deemed to have no pre-existing risk for readmission while 29% had at least one risk factor for readmission. These included opioid monotherapy during the procedure (11%), history of chronic pain (9%), no pain medication given during the procedure (4%), inadequate doses of analgesics used (3%), and discharge without a prescription for an analgesic (2%).
“There were people who got tiny doses of pain medications after a huge, painful procedure, so that was surprising,” Dr. Herbst said. “Maybe they weren’t optimally managed at the time of surgery.”
The findings, she concluded, underscore the need for a team-based approach to pain management in the same-day surgery population, with discharge planning focused on patient education, expectation management, multimodal analgesia optimization, and pain risk assessment.
The researchers reported having no financial disclosures.
AT THE ASA ANNUAL MEETING
Key clinical point: Among patients who underwent same-day surgery, pain was a significant cause of readmissions or revisits.
Major finding: Of 145 patients who were readmitted for pain following same-day surgery, 71% were deemed to have no pre-existing risk for readmission, while 29% had at least one risk factor for readmission.
Data source: A retrospective evaluation of the number of readmissions or revisits that occurred among 28,647 patients who underwent same-day surgery at a single health system in 2012.
Disclosures: The researchers reported having no financial disclosures.
On post-call day, physicians’ reaction time, simple cognitive tasks suffer
SAN DIEGO – If you feel sleepy and out of sorts on a post-call day, compared with a normal work day, you’re not alone.
Anesthesiology faculty reported significant increases in feeling irritable, jittery, and sleepy, along with significant decreases in feeling confident, energetic, and talkative following an on-call period, according to a study presented at the annual meeting of the American Society of Anesthesiologists.
To date, most studies of partial sleep deprivation in health care settings have focused on residents and interns, and less on medical faculty, said lead study author Dr. Haleh Saadat of the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, Ohio. “Our call is 17 hours, from 3 p.m. to 7 a.m.; but the call period at most hospitals is 24 hours, and even longer at some private practices,” she said in an interview.
To examine the effects of partial sleep deprivation on reaction time, simple cognitive skills , and mood status in 21 anesthesiologists, Dr. Saadat and her associates obtained verbal consent from the study participants and measured reaction time, mood states, and eight subjective behavioral characteristics at two different time points: between 6:30 a.m. and 8 a.m. on a regular noncall day of work, and between 6:30 a.m. and 8 a.m. after an overnight call (a shift that runs from 3 p.m. to 7 a.m.). The behavioral characteristics included feeling alert, energetic, anxious, confident, irritable, jittery/nervous, sleepy, and talkative, and the researchers used paired t-tests to compare variable means between regular sleep days and post-call days.
Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = 0.047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than 0.001).
Of the 21 anesthesiologists, 19 completed all simple cognitive task questions at both time points and reported significant increases in several of these parameters on post-call days, compared with normal work days.
Post-call observations found participants feeling more irritable, confident, energetic, sleepy (P less than .001), feeling more jittery (P = .003), and feeling less talkative (P less than .001) than on normal work days.
Coping strategies used to address their sleep deprivation were measured as well, with “most of our subjects using problem solving, followed by seeking social support and avoidance,” Dr. Saadat noted. “People who used avoidance had greater declines in reaction time on post-call days, compared with the rest of the study participants. It didn’t matter whether you were male, female, younger, or older.”
Dr. Saadat called for additional studies to evaluate the neurocognitive impact of partial sleep deprivation on physicians’ on-call duties.
“I would like to see if we can replicate the results in bigger centers,” she said. “If this is what is happening, we may need to pay more attention to faculty’s work hours in both academic and private practice settings – not only among anesthesiologists, but also in other specialties. These observations require a closer look at the potential implications for patients’ and professionals’ safety.”
The researchers reported no financial disclosures.
SAN DIEGO – If you feel sleepy and out of sorts on a post-call day, compared with a normal work day, you’re not alone.
Anesthesiology faculty reported significant increases in feeling irritable, jittery, and sleepy, along with significant decreases in feeling confident, energetic, and talkative following an on-call period, according to a study presented at the annual meeting of the American Society of Anesthesiologists.
To date, most studies of partial sleep deprivation in health care settings have focused on residents and interns, and less on medical faculty, said lead study author Dr. Haleh Saadat of the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, Ohio. “Our call is 17 hours, from 3 p.m. to 7 a.m.; but the call period at most hospitals is 24 hours, and even longer at some private practices,” she said in an interview.
To examine the effects of partial sleep deprivation on reaction time, simple cognitive skills , and mood status in 21 anesthesiologists, Dr. Saadat and her associates obtained verbal consent from the study participants and measured reaction time, mood states, and eight subjective behavioral characteristics at two different time points: between 6:30 a.m. and 8 a.m. on a regular noncall day of work, and between 6:30 a.m. and 8 a.m. after an overnight call (a shift that runs from 3 p.m. to 7 a.m.). The behavioral characteristics included feeling alert, energetic, anxious, confident, irritable, jittery/nervous, sleepy, and talkative, and the researchers used paired t-tests to compare variable means between regular sleep days and post-call days.
Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = 0.047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than 0.001).
Of the 21 anesthesiologists, 19 completed all simple cognitive task questions at both time points and reported significant increases in several of these parameters on post-call days, compared with normal work days.
Post-call observations found participants feeling more irritable, confident, energetic, sleepy (P less than .001), feeling more jittery (P = .003), and feeling less talkative (P less than .001) than on normal work days.
Coping strategies used to address their sleep deprivation were measured as well, with “most of our subjects using problem solving, followed by seeking social support and avoidance,” Dr. Saadat noted. “People who used avoidance had greater declines in reaction time on post-call days, compared with the rest of the study participants. It didn’t matter whether you were male, female, younger, or older.”
Dr. Saadat called for additional studies to evaluate the neurocognitive impact of partial sleep deprivation on physicians’ on-call duties.
“I would like to see if we can replicate the results in bigger centers,” she said. “If this is what is happening, we may need to pay more attention to faculty’s work hours in both academic and private practice settings – not only among anesthesiologists, but also in other specialties. These observations require a closer look at the potential implications for patients’ and professionals’ safety.”
The researchers reported no financial disclosures.
SAN DIEGO – If you feel sleepy and out of sorts on a post-call day, compared with a normal work day, you’re not alone.
Anesthesiology faculty reported significant increases in feeling irritable, jittery, and sleepy, along with significant decreases in feeling confident, energetic, and talkative following an on-call period, according to a study presented at the annual meeting of the American Society of Anesthesiologists.
To date, most studies of partial sleep deprivation in health care settings have focused on residents and interns, and less on medical faculty, said lead study author Dr. Haleh Saadat of the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, Ohio. “Our call is 17 hours, from 3 p.m. to 7 a.m.; but the call period at most hospitals is 24 hours, and even longer at some private practices,” she said in an interview.
To examine the effects of partial sleep deprivation on reaction time, simple cognitive skills , and mood status in 21 anesthesiologists, Dr. Saadat and her associates obtained verbal consent from the study participants and measured reaction time, mood states, and eight subjective behavioral characteristics at two different time points: between 6:30 a.m. and 8 a.m. on a regular noncall day of work, and between 6:30 a.m. and 8 a.m. after an overnight call (a shift that runs from 3 p.m. to 7 a.m.). The behavioral characteristics included feeling alert, energetic, anxious, confident, irritable, jittery/nervous, sleepy, and talkative, and the researchers used paired t-tests to compare variable means between regular sleep days and post-call days.
Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = 0.047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than 0.001).
Of the 21 anesthesiologists, 19 completed all simple cognitive task questions at both time points and reported significant increases in several of these parameters on post-call days, compared with normal work days.
Post-call observations found participants feeling more irritable, confident, energetic, sleepy (P less than .001), feeling more jittery (P = .003), and feeling less talkative (P less than .001) than on normal work days.
Coping strategies used to address their sleep deprivation were measured as well, with “most of our subjects using problem solving, followed by seeking social support and avoidance,” Dr. Saadat noted. “People who used avoidance had greater declines in reaction time on post-call days, compared with the rest of the study participants. It didn’t matter whether you were male, female, younger, or older.”
Dr. Saadat called for additional studies to evaluate the neurocognitive impact of partial sleep deprivation on physicians’ on-call duties.
“I would like to see if we can replicate the results in bigger centers,” she said. “If this is what is happening, we may need to pay more attention to faculty’s work hours in both academic and private practice settings – not only among anesthesiologists, but also in other specialties. These observations require a closer look at the potential implications for patients’ and professionals’ safety.”
The researchers reported no financial disclosures.
AT THE ASA ANNUAL MEETING
Key clinical point: Partial sleep deprivation can adversely impact a physician’s performance on a post-call day.
Major finding: Reaction time decreased in all 21 subjects after night call, indicating worse performance (P = .047), while total mood disturbance was significantly higher on post-call days, relative to noncall days (P less than .001).
Data source: A study of 21 anesthesiologists who were queried about the effects of partial sleep deprivation on reaction time, simple cognitive skills, and mood status.
Disclosures: The researchers reported having no financial disclosures.
Study finds inaccurate reporting of pain by back pain sufferers
SAN DIEGO – Patients with chronic low back pain who report pain scores that do not correlate well with their functional activity level are less satisfied with their pain management treatment, a single-center study found.
“Taking into account that the Affordable Healthcare Act is planning to base physician reimbursements on patient satisfaction with provided treatment, it is imperative to educate patients regarding the necessity to accurately report their pain level using a numeric rating scale. We must also identify other parameters in defining our patients’ chronic pain conditions, such a functionality scales and quality of life questionnaires,” Dr. Nebojsa Nick Knezevic said at the annual meeting of the American Society of Anesthesiologists.
“We rely on many different types of scales for pain, including Likert scales, visual analog scales, and numerical pain rating scales,” said Dr. Knezevic, vice chair for research and education at Advocate Illinois Masonic Medical Center, Chicago. “However, there are many reports talking about the subjectivity of these scales. Interpretation of the pain scores can underestimate or overestimate patient conditions, and they may go on to receive treatments that are not indicated.”
In an effort to assess how numeric pain scores reported by patients with chronic low back pain correlate with their functional activity levels and satisfaction with their pain management, Dr. Knezevic and his associates enrolled 100 patients with radicular low back pain and a mean age of 49 years. Overall, 56% were female, and their average duration of low back pain prior to study enrollment was 14 months.
The investigators asked them to complete pain scores on an 11-point numeric rating scale at rest and during movement, as well as the Oswestry Disability Index (ODI) questionnaire. The researchers evaluated the patients 10 times over a 1-year period at the same time points and asked them to grade their satisfaction with pain management on a scale from 1 to 5, where 1 meant completely dissatisfied, 2 meant dissatisfied, 3 meant somewhat satisfied, 4 meant satisfied, and 5 meant completely satisfied. The investigators multiplied the pain scores by 10 to be on the same 0-100 scale as the ODI and compared the values at each visit. Differences between the ODI and pain scores in the range of –10% to +10% were considered normal, while differences between 11% and 30% were considered mild, differences between 31% and 50% were considered moderate, and differences of more than 50% were considered severe.
Dr. Knezevic reported that pain scores at rest correlated well with ODI in 65% of patients, while mild discrepancies were present in 30% of patients, moderate discrepancies in 4%, and severe discrepancies in 1%. On the other hand, pain scores during movement correlated well with ODI in only 39% of patients, while mild discrepancies were present in 42% of patients, moderate discrepancies in 14%, and severe discrepancies in 5%. More than half of patients (58%) reported pain levels during movement that did not correlate with the level of functional activity indicated by their ODI score. However, inconsistencies between male and female pain score reporting at rest and during movement were equal (P = .606 and P = .928, respectively).
The researchers also found that patients who were taking opioids showed greater discrepancy in reporting pain intensity scores, compared with patients using nonopioid analgesics, as well as those who were not taking medications for their low back pain (P = .038).
“Results of this study showed negative correlation between the degree of discrepancy in pain scores and patient satisfaction with pain management treatment,” Dr. Knezevic concluded.
Dr. Knezevic reported having no financial disclosures.
SAN DIEGO – Patients with chronic low back pain who report pain scores that do not correlate well with their functional activity level are less satisfied with their pain management treatment, a single-center study found.
“Taking into account that the Affordable Healthcare Act is planning to base physician reimbursements on patient satisfaction with provided treatment, it is imperative to educate patients regarding the necessity to accurately report their pain level using a numeric rating scale. We must also identify other parameters in defining our patients’ chronic pain conditions, such a functionality scales and quality of life questionnaires,” Dr. Nebojsa Nick Knezevic said at the annual meeting of the American Society of Anesthesiologists.
“We rely on many different types of scales for pain, including Likert scales, visual analog scales, and numerical pain rating scales,” said Dr. Knezevic, vice chair for research and education at Advocate Illinois Masonic Medical Center, Chicago. “However, there are many reports talking about the subjectivity of these scales. Interpretation of the pain scores can underestimate or overestimate patient conditions, and they may go on to receive treatments that are not indicated.”
In an effort to assess how numeric pain scores reported by patients with chronic low back pain correlate with their functional activity levels and satisfaction with their pain management, Dr. Knezevic and his associates enrolled 100 patients with radicular low back pain and a mean age of 49 years. Overall, 56% were female, and their average duration of low back pain prior to study enrollment was 14 months.
The investigators asked them to complete pain scores on an 11-point numeric rating scale at rest and during movement, as well as the Oswestry Disability Index (ODI) questionnaire. The researchers evaluated the patients 10 times over a 1-year period at the same time points and asked them to grade their satisfaction with pain management on a scale from 1 to 5, where 1 meant completely dissatisfied, 2 meant dissatisfied, 3 meant somewhat satisfied, 4 meant satisfied, and 5 meant completely satisfied. The investigators multiplied the pain scores by 10 to be on the same 0-100 scale as the ODI and compared the values at each visit. Differences between the ODI and pain scores in the range of –10% to +10% were considered normal, while differences between 11% and 30% were considered mild, differences between 31% and 50% were considered moderate, and differences of more than 50% were considered severe.
Dr. Knezevic reported that pain scores at rest correlated well with ODI in 65% of patients, while mild discrepancies were present in 30% of patients, moderate discrepancies in 4%, and severe discrepancies in 1%. On the other hand, pain scores during movement correlated well with ODI in only 39% of patients, while mild discrepancies were present in 42% of patients, moderate discrepancies in 14%, and severe discrepancies in 5%. More than half of patients (58%) reported pain levels during movement that did not correlate with the level of functional activity indicated by their ODI score. However, inconsistencies between male and female pain score reporting at rest and during movement were equal (P = .606 and P = .928, respectively).
The researchers also found that patients who were taking opioids showed greater discrepancy in reporting pain intensity scores, compared with patients using nonopioid analgesics, as well as those who were not taking medications for their low back pain (P = .038).
“Results of this study showed negative correlation between the degree of discrepancy in pain scores and patient satisfaction with pain management treatment,” Dr. Knezevic concluded.
Dr. Knezevic reported having no financial disclosures.
SAN DIEGO – Patients with chronic low back pain who report pain scores that do not correlate well with their functional activity level are less satisfied with their pain management treatment, a single-center study found.
“Taking into account that the Affordable Healthcare Act is planning to base physician reimbursements on patient satisfaction with provided treatment, it is imperative to educate patients regarding the necessity to accurately report their pain level using a numeric rating scale. We must also identify other parameters in defining our patients’ chronic pain conditions, such a functionality scales and quality of life questionnaires,” Dr. Nebojsa Nick Knezevic said at the annual meeting of the American Society of Anesthesiologists.
“We rely on many different types of scales for pain, including Likert scales, visual analog scales, and numerical pain rating scales,” said Dr. Knezevic, vice chair for research and education at Advocate Illinois Masonic Medical Center, Chicago. “However, there are many reports talking about the subjectivity of these scales. Interpretation of the pain scores can underestimate or overestimate patient conditions, and they may go on to receive treatments that are not indicated.”
In an effort to assess how numeric pain scores reported by patients with chronic low back pain correlate with their functional activity levels and satisfaction with their pain management, Dr. Knezevic and his associates enrolled 100 patients with radicular low back pain and a mean age of 49 years. Overall, 56% were female, and their average duration of low back pain prior to study enrollment was 14 months.
The investigators asked them to complete pain scores on an 11-point numeric rating scale at rest and during movement, as well as the Oswestry Disability Index (ODI) questionnaire. The researchers evaluated the patients 10 times over a 1-year period at the same time points and asked them to grade their satisfaction with pain management on a scale from 1 to 5, where 1 meant completely dissatisfied, 2 meant dissatisfied, 3 meant somewhat satisfied, 4 meant satisfied, and 5 meant completely satisfied. The investigators multiplied the pain scores by 10 to be on the same 0-100 scale as the ODI and compared the values at each visit. Differences between the ODI and pain scores in the range of –10% to +10% were considered normal, while differences between 11% and 30% were considered mild, differences between 31% and 50% were considered moderate, and differences of more than 50% were considered severe.
Dr. Knezevic reported that pain scores at rest correlated well with ODI in 65% of patients, while mild discrepancies were present in 30% of patients, moderate discrepancies in 4%, and severe discrepancies in 1%. On the other hand, pain scores during movement correlated well with ODI in only 39% of patients, while mild discrepancies were present in 42% of patients, moderate discrepancies in 14%, and severe discrepancies in 5%. More than half of patients (58%) reported pain levels during movement that did not correlate with the level of functional activity indicated by their ODI score. However, inconsistencies between male and female pain score reporting at rest and during movement were equal (P = .606 and P = .928, respectively).
The researchers also found that patients who were taking opioids showed greater discrepancy in reporting pain intensity scores, compared with patients using nonopioid analgesics, as well as those who were not taking medications for their low back pain (P = .038).
“Results of this study showed negative correlation between the degree of discrepancy in pain scores and patient satisfaction with pain management treatment,” Dr. Knezevic concluded.
Dr. Knezevic reported having no financial disclosures.
AT THE ASA ANNUAL MEETING
Key clinical point: Many patients don’t accurately report their level of back pain when using a numeric rating scale.
Major finding: Pain scores at rest correlated well with the Oswestry Disability Index in 65% of patients, while pain scores during movement correlated well with ODI in only 39% of patients.
Data source: A study of 100 patients with radicular low back pain who completed pain scores on an 11-point numeric rating scale at rest and during movement, as well as the ODI, and were followed for 1 year.
Disclosures: The researchers reported having no financial disclosures.
Study eyes liability associated with implantable devices for chronic pain
SAN DIEGO – The maintenance of implantable drug delivery systems for the management of chronic pain was associated with death, permanent brain damage, or permanent neurological injury from granuloma, and was largely associated with substandard care.
Those are key findings from an analysis of data from the Anesthesia Closed Claims Project that were presented by Dr. Dermot R. Fitzgibbon at the annual meeting of the American Society of Anesthesiologists.
“Implantable devices are relatively new in chronic pain management, and have only been available since the early 1990s,” said Dr. Fitzgibbon, professor of anesthesiology and pain medicine at the University of Washington, Seattle. Such devices are considered advanced techniques for refractory chronic pain and include implantable drug delivery systems, spinal cord stimulators, and peripheral nerve stimulators. Previous studies have demonstrated that morbidity and mortality from implantable drug delivery systems (IDDS) and spinal cord stimulators typically occur during implantation or removal of devices or during device maintenance (Neuromodulation. 2012;15[5]:467-82 and Clin J Pain. 2007;23[2]:180-95). The purpose of the current study was to investigate liability associated with implantable devices used to manage chronic pain.
Dr. Fitzgibbon and his associates used the Anesthesia Closed Claims Project Database to identify 970 claims related to chronic pain that have occurred since 1990. A total of 148 of these claims were related to implantable devices, and the majority of them were for surgical procedures (107 [72%] vs. 41 [28%] for IDDS maintenance).
Of the 107 surgical device procedures, 50% were for an IDDS system, followed by spinal cord stimulator (40%), tunneled epidural (7%), and peripheral nerve stimulator (3%). Temporary minor injury occurred in 74% of the surgical device procedures, followed by permanent cord injury (16%), death/permanent brain damage (8%), and other permanent injury (2%). The most common reasons for permanent spinal cord injury were needle or catheter trauma to the cord (7 cases), epidural hematoma (3 cases), and incorrect placement of the stimulator (2 cases). Infections occurred in 25 of the surgical device procedures. Among these 25 claims, 3 resulted in death or severe permanent injury, 7 involved retained parts and sponges, and 5 were cases of epidural abscess – 4 of which were associated with a tunneled epidural catheter.
Of the 41 damaging events that occurred during IDDS maintenance, 44% were temporary minor injuries, while 32% involved death or permanent brain damage from medication administration errors and 24% involved permanent spinal cord injury, primarily from a delay in recognition of granuloma formation at the catheter tip.
The researchers found that maintenance of IDDS, compared with claims related to other surgical devices, were more commonly associated with a risk of death or permanent damage, less commonly resulted in temporary minor injury, were more likely to have care deemed as substandard, and were more commonly associated with payments (P = .001 for all comparisons). The median payment for all claims was $274,000.
The Anesthesia Closed Claims Project is funded by the Anesthesia Quality Institute. Dr. Fitzgibbon reported having no financial disclosures.
SAN DIEGO – The maintenance of implantable drug delivery systems for the management of chronic pain was associated with death, permanent brain damage, or permanent neurological injury from granuloma, and was largely associated with substandard care.
Those are key findings from an analysis of data from the Anesthesia Closed Claims Project that were presented by Dr. Dermot R. Fitzgibbon at the annual meeting of the American Society of Anesthesiologists.
“Implantable devices are relatively new in chronic pain management, and have only been available since the early 1990s,” said Dr. Fitzgibbon, professor of anesthesiology and pain medicine at the University of Washington, Seattle. Such devices are considered advanced techniques for refractory chronic pain and include implantable drug delivery systems, spinal cord stimulators, and peripheral nerve stimulators. Previous studies have demonstrated that morbidity and mortality from implantable drug delivery systems (IDDS) and spinal cord stimulators typically occur during implantation or removal of devices or during device maintenance (Neuromodulation. 2012;15[5]:467-82 and Clin J Pain. 2007;23[2]:180-95). The purpose of the current study was to investigate liability associated with implantable devices used to manage chronic pain.
Dr. Fitzgibbon and his associates used the Anesthesia Closed Claims Project Database to identify 970 claims related to chronic pain that have occurred since 1990. A total of 148 of these claims were related to implantable devices, and the majority of them were for surgical procedures (107 [72%] vs. 41 [28%] for IDDS maintenance).
Of the 107 surgical device procedures, 50% were for an IDDS system, followed by spinal cord stimulator (40%), tunneled epidural (7%), and peripheral nerve stimulator (3%). Temporary minor injury occurred in 74% of the surgical device procedures, followed by permanent cord injury (16%), death/permanent brain damage (8%), and other permanent injury (2%). The most common reasons for permanent spinal cord injury were needle or catheter trauma to the cord (7 cases), epidural hematoma (3 cases), and incorrect placement of the stimulator (2 cases). Infections occurred in 25 of the surgical device procedures. Among these 25 claims, 3 resulted in death or severe permanent injury, 7 involved retained parts and sponges, and 5 were cases of epidural abscess – 4 of which were associated with a tunneled epidural catheter.
Of the 41 damaging events that occurred during IDDS maintenance, 44% were temporary minor injuries, while 32% involved death or permanent brain damage from medication administration errors and 24% involved permanent spinal cord injury, primarily from a delay in recognition of granuloma formation at the catheter tip.
The researchers found that maintenance of IDDS, compared with claims related to other surgical devices, were more commonly associated with a risk of death or permanent damage, less commonly resulted in temporary minor injury, were more likely to have care deemed as substandard, and were more commonly associated with payments (P = .001 for all comparisons). The median payment for all claims was $274,000.
The Anesthesia Closed Claims Project is funded by the Anesthesia Quality Institute. Dr. Fitzgibbon reported having no financial disclosures.
SAN DIEGO – The maintenance of implantable drug delivery systems for the management of chronic pain was associated with death, permanent brain damage, or permanent neurological injury from granuloma, and was largely associated with substandard care.
Those are key findings from an analysis of data from the Anesthesia Closed Claims Project that were presented by Dr. Dermot R. Fitzgibbon at the annual meeting of the American Society of Anesthesiologists.
“Implantable devices are relatively new in chronic pain management, and have only been available since the early 1990s,” said Dr. Fitzgibbon, professor of anesthesiology and pain medicine at the University of Washington, Seattle. Such devices are considered advanced techniques for refractory chronic pain and include implantable drug delivery systems, spinal cord stimulators, and peripheral nerve stimulators. Previous studies have demonstrated that morbidity and mortality from implantable drug delivery systems (IDDS) and spinal cord stimulators typically occur during implantation or removal of devices or during device maintenance (Neuromodulation. 2012;15[5]:467-82 and Clin J Pain. 2007;23[2]:180-95). The purpose of the current study was to investigate liability associated with implantable devices used to manage chronic pain.
Dr. Fitzgibbon and his associates used the Anesthesia Closed Claims Project Database to identify 970 claims related to chronic pain that have occurred since 1990. A total of 148 of these claims were related to implantable devices, and the majority of them were for surgical procedures (107 [72%] vs. 41 [28%] for IDDS maintenance).
Of the 107 surgical device procedures, 50% were for an IDDS system, followed by spinal cord stimulator (40%), tunneled epidural (7%), and peripheral nerve stimulator (3%). Temporary minor injury occurred in 74% of the surgical device procedures, followed by permanent cord injury (16%), death/permanent brain damage (8%), and other permanent injury (2%). The most common reasons for permanent spinal cord injury were needle or catheter trauma to the cord (7 cases), epidural hematoma (3 cases), and incorrect placement of the stimulator (2 cases). Infections occurred in 25 of the surgical device procedures. Among these 25 claims, 3 resulted in death or severe permanent injury, 7 involved retained parts and sponges, and 5 were cases of epidural abscess – 4 of which were associated with a tunneled epidural catheter.
Of the 41 damaging events that occurred during IDDS maintenance, 44% were temporary minor injuries, while 32% involved death or permanent brain damage from medication administration errors and 24% involved permanent spinal cord injury, primarily from a delay in recognition of granuloma formation at the catheter tip.
The researchers found that maintenance of IDDS, compared with claims related to other surgical devices, were more commonly associated with a risk of death or permanent damage, less commonly resulted in temporary minor injury, were more likely to have care deemed as substandard, and were more commonly associated with payments (P = .001 for all comparisons). The median payment for all claims was $274,000.
The Anesthesia Closed Claims Project is funded by the Anesthesia Quality Institute. Dr. Fitzgibbon reported having no financial disclosures.
AT THE ASA ANNUAL MEETING
Key clinical point: Malpractice claims for implantable devices for chronic pain are most often associated with maintenance of implantable drug delivery systems (IDDS) rather than the surgical placement of the devices.
Major finding: Maintenance of IDDS, compared with claims related to other surgical devices, was more commonly associated with a risk of death or permanent damage, less commonly resulted in temporary minor injury, was more likely to have care deemed as substandard, and was more commonly associated with payments (P = .001 for all comparisons).
Data source: An analysis of 970 claims related to chronic pain that have occurred since 1990.
Disclosures: The Anesthesia Closed Claims Project is funded by the Anesthesia Quality Institute. The researchers reported having no financial disclosures.
Frail elders at high mortality risk in the year following surgery
SAN DIEGO – Frail elderly patients face a significantly increased risk of mortality in the year after undergoing major elective noncardiac surgery, a large study from Canada showed.
“The current literature on perioperative frailty clearly shows that being frail before surgery substantially increases your risk of adverse postoperative outcomes,” Dr. Daniel I. McIsaac said in an interview prior to the annual meeting of the American Society of Anesthesiologists, where the study was presented. “In fact, frailty may underlie a lot of the associations between advanced age and adverse postoperative outcomes. Frailty increases in prevalence with increasing age, and as we all know, the population is aging. Therefore, we expect to see an increasing number of frail patients coming for surgery.”
In an effort to determine the risk of 1-year mortality in frail elderly patients having major elective surgery, the researchers used population-based health administrative data in Ontario, to identify 202,811 patients over the age of 65 who had intermediate- to high-risk elective noncardiac surgery between 2002 and 2012. They used the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator and captured all deaths that occurred within 1 year of surgery. Proportional hazards regression models adjusted for age, gender, and socioeconomic status were used to evaluate the impact of frailty on 1-year postoperative mortality.
Of the 202,811 patients, 6,289 (3.1%) were frail, reported Dr. McIsaac of the department of anesthesiology at the University of Ottawa. The 1-year postoperative mortality was 13.6% among frail patients, compared with 4.8% of nonfrail patients, for an adjusted hazard ratio of 2.23. Mortality was higher among frail patients for all types of surgery, compared with their nonfrail counterparts, with the exception of pancreaticoduodenectomy. Frailty had the strongest impact on the risk of mortality after total joint arthroplasty (adjusted hazard ratio of 3.79 for hip replacement and adjusted HR of 2.68 for knee replacement).
The risk of postoperative mortality for frail patients was much higher than for nonfrail patients in the early time period after surgery, especially during the first postoperative week. “Depending on how you control for other variables, a frail patient was 13-35 times more likely to die in the week after surgery than a nonfrail patient of the same age having the same surgery,” said Dr. McIsaac, who is also a staff anesthesiologist at the Ottawa Hospital. “This makes a lot of sense; frail patients are vulnerable to stressors, and surgery puts an enormous physiological stress on even healthy patients. Future work clearly needs to focus [on] addressing this high-risk time in the immediate postoperative period.”
He acknowledged certain limitations of the study, including its reliance on health administrative data and the fact that frailty “is a challenging exposure to study because there are a plethora of instruments that can be used to call someone frail. We used a validated set of frailty-defining diagnoses that have been shown to identify people with multidimensional frailty. That said, you can’t necessarily generalize our findings to patients identified as frail using other instruments.”
The findings, Dr. McIsaac concluded, suggest that clinicians should focus on identifying frail patients prior to surgery, “support them to ensure that they are more likely to derive benefit from surgery than harm, and focus on optimizing their care after surgery to address this early mortality risk.”
The study was funded by departments of anesthesiology at the University of Ottawa and at the Ottawa Hospital. Dr. McIsaac reported having no financial disclosures.
SAN DIEGO – Frail elderly patients face a significantly increased risk of mortality in the year after undergoing major elective noncardiac surgery, a large study from Canada showed.
“The current literature on perioperative frailty clearly shows that being frail before surgery substantially increases your risk of adverse postoperative outcomes,” Dr. Daniel I. McIsaac said in an interview prior to the annual meeting of the American Society of Anesthesiologists, where the study was presented. “In fact, frailty may underlie a lot of the associations between advanced age and adverse postoperative outcomes. Frailty increases in prevalence with increasing age, and as we all know, the population is aging. Therefore, we expect to see an increasing number of frail patients coming for surgery.”
In an effort to determine the risk of 1-year mortality in frail elderly patients having major elective surgery, the researchers used population-based health administrative data in Ontario, to identify 202,811 patients over the age of 65 who had intermediate- to high-risk elective noncardiac surgery between 2002 and 2012. They used the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator and captured all deaths that occurred within 1 year of surgery. Proportional hazards regression models adjusted for age, gender, and socioeconomic status were used to evaluate the impact of frailty on 1-year postoperative mortality.
Of the 202,811 patients, 6,289 (3.1%) were frail, reported Dr. McIsaac of the department of anesthesiology at the University of Ottawa. The 1-year postoperative mortality was 13.6% among frail patients, compared with 4.8% of nonfrail patients, for an adjusted hazard ratio of 2.23. Mortality was higher among frail patients for all types of surgery, compared with their nonfrail counterparts, with the exception of pancreaticoduodenectomy. Frailty had the strongest impact on the risk of mortality after total joint arthroplasty (adjusted hazard ratio of 3.79 for hip replacement and adjusted HR of 2.68 for knee replacement).
The risk of postoperative mortality for frail patients was much higher than for nonfrail patients in the early time period after surgery, especially during the first postoperative week. “Depending on how you control for other variables, a frail patient was 13-35 times more likely to die in the week after surgery than a nonfrail patient of the same age having the same surgery,” said Dr. McIsaac, who is also a staff anesthesiologist at the Ottawa Hospital. “This makes a lot of sense; frail patients are vulnerable to stressors, and surgery puts an enormous physiological stress on even healthy patients. Future work clearly needs to focus [on] addressing this high-risk time in the immediate postoperative period.”
He acknowledged certain limitations of the study, including its reliance on health administrative data and the fact that frailty “is a challenging exposure to study because there are a plethora of instruments that can be used to call someone frail. We used a validated set of frailty-defining diagnoses that have been shown to identify people with multidimensional frailty. That said, you can’t necessarily generalize our findings to patients identified as frail using other instruments.”
The findings, Dr. McIsaac concluded, suggest that clinicians should focus on identifying frail patients prior to surgery, “support them to ensure that they are more likely to derive benefit from surgery than harm, and focus on optimizing their care after surgery to address this early mortality risk.”
The study was funded by departments of anesthesiology at the University of Ottawa and at the Ottawa Hospital. Dr. McIsaac reported having no financial disclosures.
SAN DIEGO – Frail elderly patients face a significantly increased risk of mortality in the year after undergoing major elective noncardiac surgery, a large study from Canada showed.
“The current literature on perioperative frailty clearly shows that being frail before surgery substantially increases your risk of adverse postoperative outcomes,” Dr. Daniel I. McIsaac said in an interview prior to the annual meeting of the American Society of Anesthesiologists, where the study was presented. “In fact, frailty may underlie a lot of the associations between advanced age and adverse postoperative outcomes. Frailty increases in prevalence with increasing age, and as we all know, the population is aging. Therefore, we expect to see an increasing number of frail patients coming for surgery.”
In an effort to determine the risk of 1-year mortality in frail elderly patients having major elective surgery, the researchers used population-based health administrative data in Ontario, to identify 202,811 patients over the age of 65 who had intermediate- to high-risk elective noncardiac surgery between 2002 and 2012. They used the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator and captured all deaths that occurred within 1 year of surgery. Proportional hazards regression models adjusted for age, gender, and socioeconomic status were used to evaluate the impact of frailty on 1-year postoperative mortality.
Of the 202,811 patients, 6,289 (3.1%) were frail, reported Dr. McIsaac of the department of anesthesiology at the University of Ottawa. The 1-year postoperative mortality was 13.6% among frail patients, compared with 4.8% of nonfrail patients, for an adjusted hazard ratio of 2.23. Mortality was higher among frail patients for all types of surgery, compared with their nonfrail counterparts, with the exception of pancreaticoduodenectomy. Frailty had the strongest impact on the risk of mortality after total joint arthroplasty (adjusted hazard ratio of 3.79 for hip replacement and adjusted HR of 2.68 for knee replacement).
The risk of postoperative mortality for frail patients was much higher than for nonfrail patients in the early time period after surgery, especially during the first postoperative week. “Depending on how you control for other variables, a frail patient was 13-35 times more likely to die in the week after surgery than a nonfrail patient of the same age having the same surgery,” said Dr. McIsaac, who is also a staff anesthesiologist at the Ottawa Hospital. “This makes a lot of sense; frail patients are vulnerable to stressors, and surgery puts an enormous physiological stress on even healthy patients. Future work clearly needs to focus [on] addressing this high-risk time in the immediate postoperative period.”
He acknowledged certain limitations of the study, including its reliance on health administrative data and the fact that frailty “is a challenging exposure to study because there are a plethora of instruments that can be used to call someone frail. We used a validated set of frailty-defining diagnoses that have been shown to identify people with multidimensional frailty. That said, you can’t necessarily generalize our findings to patients identified as frail using other instruments.”
The findings, Dr. McIsaac concluded, suggest that clinicians should focus on identifying frail patients prior to surgery, “support them to ensure that they are more likely to derive benefit from surgery than harm, and focus on optimizing their care after surgery to address this early mortality risk.”
The study was funded by departments of anesthesiology at the University of Ottawa and at the Ottawa Hospital. Dr. McIsaac reported having no financial disclosures.
AT THE ASA ANNUAL MEETING
Key clinical point: Frail elderly patients face an increased risk of mortality within 1 year of undergoing noncardiac surgery.
Major finding: The 1-year postoperative mortality was 13.6% among frail patients, compared with 4.8% of nonfrail patients, for an adjusted hazard ratio of 2.23.
Data source: A study of 202,811 patients over the age of 65 years who underwent noncardiac surgery between 2002 and 2012.
Disclosures: The study was funded by departments of anesthesiology at the University of Ottawa and at The Ottawa Hospital. Dr. McIsaac reported having no financial disclosures.
