Publications by authors named "Anoushka Afonso"

25 Publications

  • Page 1 of 1

Intraoperative haemodynamics and postoperative intensive care unit admission in older patients with cancer.

J Perioper Pract 2021 Jun 16:17504589211012351. Epub 2021 Jun 16.

Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA.

Purpose: Research on the impact of various intraoperative haemodynamic variables on the incidence of postoperative ICU admission among older patients with cancer is limited. In this study, the relationship between intraoperative haemodynamic status and postoperative intensive care unit admission among older patients with cancer is explored.

Methods: Patients aged ≥75 who underwent elective oncologic surgery lasting ≥120min were analysed. Chi-squared and t-tests were used to assess the associations between intraoperative variables with postoperative intensive care unit admission. Multivariable regressions were used to analyse potential predict risk factors for postoperative intensive care unit admission.

Results: Out of 994 patients, 48 (4.8%) were admitted to the intensive care unit within 30 days following surgery. Intensive care unit admission was associated with the presence of ≥4 comorbid conditions, intraoperative blood loss ≥100mL, and intraoperative tachycardia and hypertensive urgency. On multivariable analysis, operation time ≥240min (Odds Ratio [OR] = 2.29, p = 0.01), and each minute spent with intraoperative hypertensive urgency (OR = 1.06, p = 0.01) or tachycardia (OR = 1.01, p = 0.002) were associated with postoperative intensive care unit admission.

Conclusion: Intraoperative hypertensive urgency and tachycardia were associated with postoperative intensive care unit admission in older patients undergoing cancer surgery.
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http://dx.doi.org/10.1177/17504589211012351DOI Listing
June 2021

Sentinel lymph node biopsy in patients with endometrial cancer and an indocyanine green or iodinated contrast reaction - A proposed management algorithm.

Gynecol Oncol 2021 Aug 13;162(2):262-267. Epub 2021 May 13.

Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA. Electronic address:

Objective: To describe the incidence of adverse reactions to indocyanine green (ICG) administered during sentinel lymph node (SLN) biopsy for endometrial cancer, and to propose an ICG management algorithm for these patients.

Methods: All patients who underwent surgery for endometrial cancer with SLN biopsy using ICG from 1/2017 to 8/2020 were identified using a single-institution prospective database. Surgical adverse events (SAEs) related to the procedure were identified. A review of the literature was performed.

Results: In all, 1414 patients met inclusion criteria and were evaluated. Sixty-seven (4.7%) patients had a history of either an iodine or contrast allergy. No patients had a history of documented ICG allergy. Among patients with an iodine or contrast allergy, 65 (97%) received a corticosteroid with or without diphenhydramine prior to ICG administration. One hundred five patients (7.4%) experienced 116 SAEs. Among these patients, 3 experienced potentially allergic SAEs possibly related to ICG administration. After thorough chart review, however, the likelihood these SAEs were due to ICG appeared low. No patients experienced an anaphylactic response after ICG admission.

Conclusion: There were no anaphylactic reactions to ICG intracervical administration during 1414 consecutive SLN biopsies, including in patients with a documented iodine or contrast allergy. Intracervical injection of ICG is safe, and premedication using corticosteroids with or without diphenhydramine prior to SLN biopsy is a reasonable strategy in patients with iodinated contrast allergy.
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http://dx.doi.org/10.1016/j.ygyno.2021.05.009DOI Listing
August 2021

Perioperative Inpatient Opioid Consumption Following Autologous Free-Flap Breast Reconstruction Patients: An Examination of Risk and Patient-Reported Outcomes.

Ann Surg Oncol 2021 May 6. Epub 2021 May 6.

Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Background: The response to the unprecedented opioid crisis in the US has increased focus on multimodal pain regimens and enhanced recovery after surgery (ERAS) pathways to reduce opioid use. This study aimed to define patient and system-level factors related to perioperative consumption of opioids in autologous free-flap breast reconstruction.

Methods: We conducted a retrospective study to identify patients who underwent autologous breast reconstruction between 2010 and 2016. A multivariate linear regression model was developed to assess patient and system-level factors influencing opioid consumption. Opioid consumption was then dichotomized as total postoperative opioid consumption above (high) and below (low) the 50th percentile to afford more in-depth interpretation of the regression analysis. Secondary outcome analyses examined postoperative complications and health-related quality-of-life outcomes using the BREAST-Q.

Results: Overall, 601 patients were included in the analysis. Unilateral reconstruction, lower body mass index, older age, and administration of ketorolac and liposomal bupivacaine were associated with lower postoperative opioid consumption. In contrast, history of psychiatric diagnoses was associated with higher postoperative opioid consumption. There was no difference in the rates of postoperative complications when comparing the groups, although patients who had lower postoperative opioid consumption had higher BREAST-Q physical well-being scores.

Conclusion: System-level components of ERAS pathways may reduce opioid use following autologous breast reconstruction, but surgical and patient factors may increase opioid requirements in certain patients. ERAS programs including liposomal bupivacaine and ketorolac should be established on a system level in conjunction with continued focus on individualized care, particularly for patients at risk for high opioid consumption.
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http://dx.doi.org/10.1245/s10434-021-10023-zDOI Listing
May 2021

Goal-directed fluid therapy in autologous breast reconstruction results in less fluid and more vasopressor administration without outcome compromise.

J Plast Reconstr Aesthet Surg 2021 Feb 4. Epub 2021 Feb 4.

Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States. Electronic address:

Objective: Aggressive or restricted perioperative fluid management has been shown to increase complications in patients undergoing microsurgery. Goal-directed fluid therapy (GDFT) aims to administer fluid, vasoactive agents, and inotropes according to each patient's hemodynamic indices. This study assesses GDFT impact on perioperative outcomes of autologous breast reconstruction (ABR) patients, as there remains a gap in management understanding. We hypothesize that GDFT will have lower fluid administration and equivocal outcomes compared to patients not on GDFT.

Methods: A single-center retrospective review was conducted on ABR patients from January 2010-April 2017. An enhanced recovery after surgery (ERAS) using GDFT was implemented in April 2015. With GDFT, patients were administered intraoperative fluids and vasoactive agents according to hemodynamic indices. Patients prior to April 2015 were included in the pre-ERAS cohort. Primary outcomes included the amount and rate of fluid delivery, urine output (UOP), vasopressor administration, major (i.e., flap failure) and minor (i.e., seroma) complications, and length of stay (LOS).

Results: Overall, 777 patients underwent ABR (ERAS: 312 and pre-ERAS: 465). ERAS patients received significantly less total fluid volume (ERAS median: 3750 mL [IQR: 3000-4500 mL]; pre-ERAS median: 5000 mL [IQR 4000-6400 mL]; and p<0.001), had lower UOP, were more likely to receive vasopressor agents (47% vs 35% and p<0.001), and had lower LOS (ERAS: 4 days [4-5]; pre-ERAS: 5 [4-6]; and p<0.001) as compared to pre-ERAS patients. Complications did not differ between cohorts.

Conclusions: GDFT, as part of ERAS, and the prudent use of vasopressors were found to be safe and did not increase morbidity in ABR patients. GDFT provides individualized perioperative care to the ABR patient.
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http://dx.doi.org/10.1016/j.bjps.2021.01.017DOI Listing
February 2021

Burnout Rate and Risk Factors among Anesthesiologists in the United States.

Anesthesiology 2021 05;134(5):683-696

Background: Physician burnout, widespread across medicine, is linked to poorer physician quality of life and reduced quality of care. Data on prevalence of and risk factors for burnout among anesthesiologists are limited. The objective of the current study was to improve understanding of burnout in anesthesiologists, identify workplace and personal factors associated with burnout among anesthesiologists, and quantify their strength of association.

Methods: During March 2020, the authors surveyed member anesthesiologists of the American Society of Anesthesiologists. Burnout was assessed using the Maslach Burnout Inventory Human Services Survey. Additional survey questions queried workplace and personal factors. The primary research question was to assess rates of high risk for burnout (scores of at least 27 on the emotional exhaustion subscale and/or at least 10 on the depersonalization subscale of the Maslach Burnout Inventory Human Services Survey) and burnout syndrome (demonstrating all three burnout dimensions, consistent with the World Health Organization definition). The secondary research question was to identify associated risk factors.

Results: Of 28,677 anesthesiologists contacted, 13.6% (3,898) completed the survey; 59.2% (2,307 of 3,898) were at high risk of burnout, and 13.8% (539 of 3,898) met criteria for burnout syndrome. On multivariable analysis, perceived lack of support at work (odds ratio, 6.7; 95% CI, 5.3 to 8.5); working greater than or equal to 40 h/week (odds ratio, 2.22; 95% CI, 1.80 to 2.75); lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex, and asexual status (odds ratio, 2.21; 95% CI, 1.35 to 3.63); and perceived staffing shortages (odds ratio, 2.06; 95% CI, 1.76 to 2.42) were independently associated with high risk for burnout. Perceived lack of support at work (odds ratio, 10.0; 95% CI, 5.4 to 18.3) and home (odds ratio, 2.13; 95% CI, 1.69 to 2.69) were most strongly associated with burnout syndrome.

Conclusions: The prevalence of burnout among anesthesiologists is high, with workplace factors weighing heavily. The authors identified risk factors for burnout, especially perceived support in the workplace, where focused interventions may be effective in reducing burnout.

Editor’s Perspective:
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http://dx.doi.org/10.1097/ALN.0000000000003722DOI Listing
May 2021

Trends in Peripheral Nerve Block Usage in Mastectomy and Lumpectomy: Analysis of a National Database From 2010 to 2018.

Anesth Analg 2021 07;133(1):32-40

From the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.

Background: Compared to general anesthesia, regional anesthesia confers several benefits including improved pain control and decreased postoperative opioid consumption. While the benefits of peripheral nerve blocks (PNB) have been well studied, there are little epidemiological data on PNB usage in mastectomy and lumpectomy procedures. The primary objective of our study was to assess national trends of the annual proportion of PNB use in breast surgery from 2010 to 2018. We also identified factors associated with PNB use for breast surgery.

Methods: We identified lumpectomy and mastectomy surgical cases with and without PNB between 2010 and 2018 using the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR). We modeled the nonlinear association between year of procedure and PNB use with segmented mixed-effects logistic regression clustered on facility identifier. The association between PNB use and year of procedure, age, sex, American Society of Anesthesiologists physical status (ASA PS), facility type, facility region, weekday, and tissue expander use was also modeled using mixed-effects logistic regression.

Results: Of the 189,854 surgical cases from 2010 to 2018 that met criteria, 86.2% were lumpectomy cases and 13.8% were mastectomy cases. The proportion of lumpectomy cases with PNB was <0.1% in 2010 and increased each subsequent year to 1.9% in 2018 (trend P < .0001). The proportion of mastectomy cases with PNB was 0.5% in 2010 and 13% in 2018 (trend P < .0001). The year 2014 was the breakpoint selected for segmented regression. Before 2014, the odds of PNB among the mastectomy cases was not significantly different from year to year. After 2014, the odds of PNB increased by 2.24-fold each year (95% confidence interval [CI], 2.00-2.49; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. Similar trends were seen in the lumpectomy cases, where after 2014, the odds of PNB increased by 2.03-fold (95% CI, 1.81-2.27; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. In the mastectomy cohort, year of procedure ≥2014, female sex, facility region, and tissue expander use were associated with higher odds of PNB. For lumpectomy cases, year of procedure ≥2014 and facility region were associated with higher odds of PNB use.

Conclusions: We found increased annual utilization of PNB for mastectomy and lumpectomy since 2010, although absolute prevalence is low. PNB use was associated with year of procedure for both lumpectomy and mastectomy, particularly post-2014.
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http://dx.doi.org/10.1213/ANE.0000000000005368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8205928PMC
July 2021

Survival outcomes of acute normovolemic hemodilution in patients undergoing primary debulking surgery for advanced ovarian cancer: A Memorial Sloan Kettering Cancer Center Team Ovary study.

Gynecol Oncol 2021 01 17;160(1):51-55. Epub 2020 Nov 17.

Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA. Electronic address:

Objective: To describe oncologic outcomes after using acute normovolemic hemodilution (ANH) to reduce requirement for allogenic red blood cell transfusions (ABT) in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer.

Methods: We performed a post-hoc analysis of a recent prospective trial investigating the safety and feasibility of ANH during PDS for advanced ovarian cancer. We report long-term survival outcomes. We compared demographics, clinicopathological characteristics, survival outcomes in this cohort of Stage IIIB-IVB high-grade serous ovarian cancer patients undergoing ANH (ANH group), with a retrospective cohort of all other patients (standard group) undergoing PDS during the same time period (01/2012-04/2017). Standard statistical tests were used.

Results: There were no demographic or clinicopathological differences between ANH (n = 33) and standard groups (n = 360), except for higher median age at diagnosis (57 vs. 62 years, respectively; p = 0.044) and shorter operative time (357 vs. 446 min, respectively; p < 0.001) in the standard group. Cytoreductive outcomes (ANH vs. standard): 0 mm, 69.7 vs. 63.9%; gross residual disease (RD) ≤1 cm, 21.2 vs. 26.9%; >1 cm, 9.1 vs. 9.2% (p = 0.78). RD after PDS was the only independent factor associated with worse progression-free survival (PFS) on multivariable analysis (p < 0.001). Patients with BRCA mutations trended towards improved PFS (p = 0.057). Significant factors for overall survival (OS) on multivariable analysis: preoperative CA125 (p = 0.004), ascites (p = 0.018), RD after PDS (p = 0.04), BRCA mutation status (p < 0.001). After adjustment for potential confounders, ANH was not independently associated with PFS or OS [PFS: HR 0.928 (0.618-1.395); p = 0.721; OS: HR 0.588 (95%CI: 0.317-1.092); p = 0.093].

Conclusions: ANH is an innovative approach in intraoperative management. It was previously proven to decrease need for ABT while maintaining the ability to achieve complete gross resection and associated benefits.
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http://dx.doi.org/10.1016/j.ygyno.2020.10.042DOI Listing
January 2021

Monitoring an Ongoing Enhanced Recovery After Surgery (ERAS) Program: Adherence Improves Clinical Outcomes in a Comparison of Three Thousand Colorectal Cases.

Clin Surg 2020 Aug 10;5. Epub 2020 Aug 10.

Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.

Aim: In 2014, Memorial Sloan Kettering Cancer Center was identified as an outlier for increased length of stay (LOS) after colorectal surgery. We subsequently implemented a comprehensive Enhanced Recovery After Surgery (ERAS) program in January 2016, which is continually monitored to target areas for improvement. The primary aim of this study was to evaluate the impact of a newly established ERAS program in a high-volume colorectal center over time.

Method: This was a retrospective cohort study, comparing 3000 sequential cancer patients who underwent elective colorectal surgery before and after ERAS implementation. Patients were divided into three groups (Pre-, Early, and Late ERAS). Adherence to ERAS process measures and outcomes (LOS, complications, and 30-day readmission) were compared among the three time periods.

Results: Adherence to ERAS metrics significantly increased over time, from a median of 25% Pre-ERAS to 67% Early and 75% Late ERAS ( < 0.0001). Mean LOS decreased from 5.2 days Pre-ERAS to 4.5 Early and 4.0 Late ERAS ( < 0.0001). There were no differences in rates of complications or readmissions, and patients with shorter LOS had lower readmission rates. With ERAS, the readmission rate was 4.4% for patients discharged within 3 days, versus >10% for LOS ≥5 days ( < 0.0001).

Conclusion: Initiation of an ERAS program at a high-volume colorectal center was associated with decreased LOS, without increasing morbidity. Increased ERAS adherence was associated with a further decrease in LOS. Multidisciplinary monitoring to promote protocol adherence is necessary for maintaining a safe and effective ERAS program.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643765PMC
August 2020

Pericardial Effusions in Patients With Cancer: Anesthetic Management and Survival Outcomes.

J Cardiothorac Vasc Anesth 2021 Feb 26;35(2):571-577. Epub 2020 Aug 26.

Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY. Electronic address:

Objectives: The objective of this study was to describe practice patterns of anesthetic management during pericardial window creation.

Design: Retrospective observational cohort study.

Setting: Single tertiary cancer center.

Participants: A total of 150 patients treated for cancer between 2011 and 2015 were included in the study.

Measurements And Main Results: The primary objective was to evaluate anesthetic management in pericardial window creation. Secondary outcomes were 30-day mortality and overall survival after pericardial window creation. Thirty-day mortality was 19.3%, and median survival was 5.84 months. Higher American Society of Anesthesiologists (ASA) physical status of patients was associated with preinduction arterial line placement (51% ASA 3 v 79% ASA 4; p = 0.002) and use of etomidate for anesthetic induction (34% ASA 3 v 60% ASA 4; p = 0.003). However, there was no association between anesthetic management and presence of tamponade in these patients. Cardiac aspirate volume (per 10 mL: odds ratio [OR], 1.02 [95% CI, 1.0-1.04]; p = 0.026) and intraoperative arrhythmia (atrial fibrillation: OR, 6.76 [95% CI, 1.2-37.49]; p = 0.029; sinus tachycardia: OR, 4.59 [95% CI, 1.25-16.90]; p = 0.022) were associated independently with increased 30-day mortality. High initial heart rate (per 10 beats per minute: hazard ratio [HR], 1.18 [95% CI, 1.05-1.33]; p = 0.005) in the operating room and intraoperative sinus tachycardia (HR, 1.86 [95% CI, 1.15-3.03]; p = 0.012) were associated independently with worse overall survival.

Conclusion: Risk of death after pericardial window creation remains high in patients with cancer. Variations in anesthetic management did not affect survival in oncologic patients with pericardial effusions.
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http://dx.doi.org/10.1053/j.jvca.2020.08.049DOI Listing
February 2021

Considerations for Transgender Patients Perioperatively.

Anesthesiol Clin 2020 Jun;38(2):311-326

Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C330F, New York, NY 10065, USA.

With a shift in the cultural, political, and social climate surrounding gender and gender identity, an increase in the acceptance and visibility of transgender individuals is expected. Anesthesiologists are thus more likely to encounter transgender and gender nonconforming patients in the perioperative setting. Anesthesiologists need to acquire an in-depth understanding of the transgender patient's medical and psychosocial needs. A thoughtful approach throughout the entirety of the perioperative period is key to the successful management of the transgender patient. This review provides anesthesiologists with a culturally relevant and evidence-based approach to transgender patients during the preoperative, intraoperative, and postoperative periods.
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http://dx.doi.org/10.1016/j.anclin.2020.01.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197403PMC
June 2020

Prognostic nutritional index (PNI), independent of frailty is associated with six-month postoperative mortality.

J Geriatr Oncol 2020 06 4;11(5):880-884. Epub 2020 Apr 4.

Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, NY, New York, USA. Electronic address:

Introduction: Prognostic Nutritional Index (PNI) is associated with disease and overall survival in patients with cancer. We aimed to assess the relationship between PNI, frailty, and six-month postoperative survival in older patients with cancer.

Methods: In this retrospective study, patients with cancer aged ≥75 who underwent geriatric preoperative evaluation and then proceeded with elective surgery with hospital length of stay of ≥1 day and had six-month follow-up were included. PNI is measured by preoperative [10 × albumin(gr/dl)] + [0.005 × absolute lymphocyte count (per mm)]. Higher PNI is suggestive of better nutritional status. Frailty was assessed by geriatric assessment. PNI among patients with and without each age-related impairment was evaluated. Pearson correlation coefficient was used to assess the correlation between the number of age-related impairments and PNI. Multivariable regression analysis was used to assess the relationship between six-month mortality and PNI.

Results: PNI ranged from 19 to 49 (average 40) among 1025 patients (average age 80). Patients with impairment in Karnofsky Performance Status, falls in the past year, prolonged timed up and go test, limited social activity, significant weight loss, polypharmacy, polycomorbid conditions, depression, and dependent for basic and instrumental activities of daily living had lower PNI than fit patients. The correlation coefficient between PNI and number of aging impairments was -0.28 (p < .001). Each unit increase in PNI was associated with 10% reduction in 6-month mortality (OR = 0.90, p < .001).

Conclusion: PNI independent of frailty, age, American Society of Anesthesiologist Performance Scale (ASA-PS), and metastatic disease is associated with six-month postoperative mortality. Future studies should assess the interventions aimed at improving PNI and its impact on surgical outcomes.
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http://dx.doi.org/10.1016/j.jgo.2020.03.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8311543PMC
June 2020

Impact of intraoperative remifentanil on postoperative pain and opioid use in thyroid surgery.

J Surg Oncol 2019 Dec 3;120(8):1456-1461. Epub 2019 Nov 3.

Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.

Background And Objectives: Remifentanil infusion is used as an intraoperative anesthetic for thyroidectomy, but has been associated with acute opioid tolerance and hyperalgesia. A national shortage of remifentanil provided an opportunity to study postoperative pain in patients undergoing thyroidectomy.

Methods: Retrospective review of prospectively collected data from an outpatient surgery center. Primary analysis compared patients treated before and after remifentanil shortage.

Results: Median postoperative opioid consumption was 20 morphine milligram equivalents (MMEs) among those treated in the high-dose period and 15 MMEs in the low-dose period. Remifentanil/weight received was a significant predictor of requiring a postoperative narcotic (P = .006). Total non-remifentanil narcotics administered were equivalent but patients in the low dose period received higher amounts of intraoperative long-acting narcotics.

Conclusions: Remifentanil infusion for thyroid surgery is associated with higher postoperative pain and postoperative narcotics requirement. While a hyperalgesia state is possible, shifting of longer-acting narcotics from intraoperative to postoperatively is also supported.
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http://dx.doi.org/10.1002/jso.25746DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991192PMC
December 2019

Geriatric Assessment, Not ASA Physical Status, Is Associated With 6-Month Postoperative Survival in Patients With Cancer Aged ≥75 Years.

J Natl Compr Canc Netw 2019 06;17(6):687-694

Geriatric Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.

Background: The American Society of Anesthesiologists physical status (ASA PS) classification system is the most common method of assessing preoperative functional status. Comprehensive geriatric assessment (CGA) has been proposed as a supplementary tool for preoperative assessment of older adults. The goal of this study was to assess the correlation between ASA classification and CGA deficits among oncogeriatric patients and to determine the association of each with 6-month survival.

Patients And Methods: Oncogeriatric patients (aged ≥75 years) who underwent preoperative CGA in an outpatient geriatric clinic at a single tertiary comprehensive cancer center were identified. All patients underwent surgery, with a hospital length of stay (LOS) ≥1 day and at least 6 months of follow-up. ASA classifications were obtained from preoperative anesthesiology notes. Preoperative CGA scores ranged from 0 to 13. Six-month survival was assessed using the Social Security Death Index.

Results: In total, 81 of the 980 patients (8.3%) included in the study cohort died within 6 months of surgery. Most patients were classified as ASA PS III (85.4%). The mean number of CGA deficits for patients with PS II was 4.03, PS III was 5.15, and PS IV was 6.95 (P<.001). ASA classification was significantly associated with age, preoperative albumin level, hospital LOS, and 30-day intensive care unit (ICU) admissions. On multivariable analysis, 6-month mortality was associated with number of CGA deficits (odds ratio [OR], 1.14 per each unit increase in CGA score; P=.01), 30-day ICU admissions (OR, 2.77; P=.003), hospital LOS (OR, 1.03; P=.02), and preoperative albumin level (OR, 0.36; P=.004). ASA classification was not associated with 6-month mortality.

Conclusions: Number of CGA deficits was strongly associated with 6-month mortality; ASA classification was not. Preoperative CGA elicits critical information that can be used to enhance the prediction of postoperative outcomes among older patients with cancer.
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http://dx.doi.org/10.6004/jnccn.2018.7277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7373226PMC
June 2019

Development and Evaluation of a New Frailty Index for Older Surgical Patients With Cancer.

JAMA Netw Open 2019 05 3;2(5):e193545. Epub 2019 May 3.

Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.

Importance: Frailty based on the modified Frailty Index is associated with poor postoperative outcomes. However, the index requires high levels of personnel time and effort and often has missing data.

Objective: To evaluate the association of the Memorial Sloan Kettering-Frailty Index (MSK-FI) with established geriatric assessment (GA) and surgical outcomes.

Design, Setting, And Participants: This cohort study included prospectively evaluated patients with cancer 75 years and older who were referred to MSK Geriatrics Service clinics for preoperative evaluation before undergoing surgery requiring hospitalization between February 2015 and September 2017. Patients were comanaged by the Geriatrics Service and Surgery Service in the postoperative period.

Exposures: Impairments identified by GA and comorbid conditions retrieved from submitted International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes within the first 48 hours of hospitalization.

Main Outcomes And Measures: The association of MSK-FI score (which included ICD-9 and ICD-10 codes) with GA impairments (based on clinical interview and examination as well as patient reports) was examined. The associations of MSK-FI score with short-term surgical outcomes (ie, frequency of complications, length of stay, 30-day surgical complications, 30-day intensive care unit admissions, and 30-day readmissions) and 1-year survival, estimated by Kaplan-Meier methods, were determined.

Results: In total, 1137 patients (median [interquartile range] age, 80 [77-84] years; 583 [51.2%] women) were included in the study. A higher MSK-FI score was associated with the number of GA impairments (ρ = 0.52; bootstrapped 95% CI, 0.47-0.56). Each 1-point increase in MSK-FI score was associated with longer length of stay (0.58 d; 95% CI, 0.22-0.95; P = .002) and higher odds of intensive care unit admission (odds ratio, 1.28; 95% CI, 1.04-1.58; P = .02). Median (interquartile range) follow-up among survivors was 12.1 (5.6-19.1) months. The MSK-FI score was associated with overall mortality; 12-month risk of death was 5% for a score of 0 and approximately 20% for scores of 4 and higher (nonlinear association, P = .005).

Conclusions And Relevance: In this study, the MSK-FI was associated with the previously validated GA and postoperative outcomes in older patients with cancer and may be a feasible tool for perioperative assessment of older surgical patients with cancer. Future studies should assess the association of MSK-FI score with postoperative care and outcomes of older, frail patients with cancer.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.3545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6512296PMC
May 2019

Enhanced Recovery Programs in Outpatient Surgery.

Anesthesiol Clin 2019 Jun 15;37(2):225-238. Epub 2019 Mar 15.

Department of Anesthesiology & Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, 1133 York Avenue, Suite 312, New York, NY 10065, USA.

Although enhanced recovery pathways were initially implemented in inpatients, their principles are relevant in the ambulatory setting. Opioid minimization and addressing pain and nausea through multimodal analgesia, regional anesthesia, and robust preoperative education programs are integral to the success of ambulatory enhanced recovery programs. Rather than measurements of length of stay as in traditional inpatient programs, the focus of enhanced recovery programs in ambulatory surgery should be on improved quality of recovery, pain management, and early ambulation.
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http://dx.doi.org/10.1016/j.anclin.2019.01.007DOI Listing
June 2019

Organization of Multidisciplinary Cancer Care for the Surgical Patient: Role of Anesthesiologists.

Curr Anesthesiol Rep 2018 Dec 8;8(4):368-374. Epub 2018 Oct 8.

Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY.

Purpose Of Review: The purpose of this review is to describe significant recent trends or developments regarding the role of anesthesiologists in a multidisciplinary team approach to cancer care for the surgical patient. We also discuss our own institutional multidisciplinary approach as a comprehensive cancer center with high surgical volume.

Recent Findings: Beyond the multidisciplinary team meeting concept, and local, institution-specific, or national programs, more formalized concepts and models of perioperative care have evolved. These provide a framework for robust involvement of anesthesiologists in cancer care for the surgical patient, with the goal of allowing for optimal individualized cancer outcomes.

Summary: Because of the wide-ranging nature of their perioperative expertise, anesthesiologists play an important role in multidisciplinary team cancer care for surgical patients. This role has been seen in the recent trends toward clinical models, such as the perioperative surgical home and enhanced recovery programs. Areas for future research include multidisciplinary assessment of the impact of such models on perioperative cancer outcomes through integration of data from national outcomes groups.
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http://dx.doi.org/10.1007/s40140-018-0291-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6294125PMC
December 2018

Perioperative epidural use and survival outcomes in patients undergoing primary debulking surgery for advanced ovarian cancer.

Gynecol Oncol 2018 11 2;151(2):287-293. Epub 2018 Sep 2.

Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America. Electronic address:

Objective: Epidurals are associated with improved outcomes in some solid tumors, presumably due to their effect on surgical stress response. There are limited data on the prognostic significance of epidural anesthesia in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer. We sought to assess the impact of epidural anesthesia on the survival outcomes of patients undergoing PDS for advanced ovarian cancer.

Methods: In this retrospective study, consecutive patients with stage IIIB-IV epithelial ovarian, fallopian tube, or peritoneal carcinoma who underwent PDS at our institution from 01/2005-12/2013 were identified. Progression-free survival (PFS) and overall survival (OS) with regard to epidural use were analyzed.

Results: Of 648 patients, 435 received an epidural and 213 did not. Patients in the former group were more likely to have higher stage disease (stage IV disease, 26% vs. 16%, respectively; P = .005), carcinomatosis (87% vs. 80%, respectively; P = .027), and bulky upper abdominal disease (66% vs. 58%, respectively; P = .046). Complete gross resection was achieved in 48% and 32%, respectively (P < .001). For the epidural vs. non-epidural groups, median PFS was 20.8 months and 13.9 months, respectively (P = .021); median OS was 62.4 months and 41.9 months, respectively (P < .001). After controlling for confounding factors, including residual disease, epidural use was independently associated with a decreased risk of progression (HR = 1.327; 95% CI, 1.066-1.653) and death (HR = 1.588; 95% CI, 1.224-2.06).

Conclusions: Perioperative epidural use was independently associated with improved PFS and OS in these patients. Epidural anesthesia at the time of PDS may be warranted in this setting.
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http://dx.doi.org/10.1016/j.ygyno.2018.08.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6214778PMC
November 2018

Multimodal Analgesia in Breast Surgical Procedures: Technical and Pharmacological Considerations for Liposomal Bupivacaine Use.

Plast Reconstr Surg Glob Open 2017 Sep 15;5(9):e1480. Epub 2017 Sep 15.

Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C.

Enhanced recovery after surgery is a multidisciplinary perioperative clinical pathway that uses evidence-based interventions to improve the patient experience as well as increase satisfaction, reduce costs, mitigate the surgical stress response, accelerate functional recovery, and decrease perioperative complications. One of the most important elements of enhanced recovery pathways is multimodal pain management. Herein, aspects relating to multimodal analgesia following breast surgical procedures are discussed with the understanding that treatment decisions should be individualized and guided by sound clinical judgment. A review of liposomal bupivacaine, a prolonged-release formulation of bupivacaine, in the management of postoperative pain following breast surgical procedures is presented, and technical guidance regarding optimal administration of liposomal bupivacaine is provided.
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http://dx.doi.org/10.1097/GOX.0000000000001480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640354PMC
September 2017

Surgical site infection reduction bundle in patients with gynecologic cancer undergoing colon surgery.

Gynecol Oncol 2017 10 19;147(1):115-119. Epub 2017 Jul 19.

Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States. Electronic address:

Objective: Surgical site infections (SSIs) can lead to substantial morbidity, prolonged hospitalization, increased costs, and death in patients undergoing colorectal procedures. We sought to investigate the effect of using an SSI reduction bundle on the rate of SSIs in gynecologic cancer patients undergoing colon surgery.

Methods: We identified all gynecologic cancer patients who underwent colon resection at our institution from 2014 to 2016, during which time a service-wide SSI reduction bundle was introduced. The intervention included preoperative oral antibiotics with optional mechanical bowel preparation, skin preparation with antibacterial solution, and the use of a separate surgical closing tray. SSI rates were assessed within 30days post-surgery.

Results: Of 233 identified patients, 115 had undergone colon surgery prior to (PRE) and 118 after (POST) the implementation of the intervention. A low anterior resection was the most common colon surgery in both cohorts. The incidence of SSI within 30days of surgery was 43/115 (37%) in the PRE and 14/118 (12%) in the POST cohorts (p≤0.001). Wound dehiscence was noted in 30/115 (26%) and 2/118 (2%) patients, respectively (p≤0.001). In patients whose operation took longer than 360min, 30-day SSI rates were 37% (28/76) and 12% (8/67), respectively (p≤0.001). In patients with an estimated blood loss >500cm, SSI rates were 44% (27/62) and 15% (10/67), respectively (p≤0.001).

Conclusions: The implementation of an SSI reduction bundle was associated with a significant reduction in 30-day SSIs in these patients. The intervention remained effective in patients undergoing longer operations and in those with increased blood loss.
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http://dx.doi.org/10.1016/j.ygyno.2017.07.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605426PMC
October 2017

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

Plast Reconstr Surg 2017 May;139(5):1053-1061

New York, N.Y.

Background: At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center.

Methods: A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption.

Results: In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre-enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre-enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6).

Conclusion: The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000003235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640259PMC
May 2017

Respiratory arrest in patients undergoing arteriovenous graft placement with supraclavicular brachial plexus block: a case series.

J Clin Anesth 2013 Jun 7;25(4):321-3. Epub 2013 May 7.

Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA.

Supraclavicular brachial plexus block is commonly used for upper extremity surgery. Respiratory arrest in three patients with end-stage renal disease after ultrasound-guided supraclavicular brachial plexus block for creation of an arteriovenous graft over a 6-month period is presented. Patients with renal failure may represent a group at particular risk for respiratory failure following supraclavicular brachial plexus block.
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http://dx.doi.org/10.1016/j.jclinane.2012.11.009DOI Listing
June 2013

Measuring determinants of career satisfaction of anesthesiologists: validation of a survey instrument.

J Clin Anesth 2013 Jun 9;25(4):289-95. Epub 2013 May 9.

Department of Anesthesiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.

Study Objective: To measure the parameter of job satisfaction among anesthesiologists.

Design: Survey instrument.

Setting: Academic anesthesiology departments in the United States.

Subjects: 320 anesthesiologists who attended the annual meeting of the ASA in 2009 (95% response rate).

Measurements And Main Results: The anonymous 50-item survey collected information on 26 independent demographic variables and 24 dependent ranked variables of career satisfaction among practicing anesthesiologists. Mean survey scores were calculated for each demographic variable and tested for statistically significant differences by analysis of variance. Questions within each domain that were internally consistent with each other within domains were identified by Cronbach's alpha ≥ 0.7. P-values ≤ 0.05 were considered statistically significant. Cronbach's alpha analysis showed strong internal consistency for 10 dependent outcome questions in the practice factor-related domain (α = 0.72), 6 dependent outcome questions in the peer factor-related domain (α = 0.71), and 8 dependent outcome questions in the personal factor-related domain (α = 0.81). Although age was not a variable, full-time status, early satisfaction within the first 5 years of practice, working with respected peers, and personal choice factors were all significantly associated with anesthesiologist job satisfaction.

Conclusions: Improvements in factors related to job satisfaction among anesthesiologists may lead to higher early and current career satisfaction.
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http://dx.doi.org/10.1016/j.jclinane.2013.01.007DOI Listing
June 2013

Isolated tricuspid valve surgery: predictors of adverse outcome and survival.

Heart Lung Circ 2013 Mar 25;22(3):211-20. Epub 2012 Oct 25.

Anesthesiology and Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, United States.

Background: Isolated tricuspid valve surgery is a rare operation, for which outcomes are not well defined. We describe a single-centre experience with isolated tricuspid surgery, and an analysis of risk factors for adverse outcome and predictors of survival.

Methods: Retrospective analysis of 56 consecutive adult patients undergoing isolated tricuspid valve surgery between November 1998 and November 2010 was performed.

Results: Eight patients died in hospital (early mortality 14.2%). In comparison with tricuspid repair patients, tricuspid replacement patients required more intraoperative red cell blood transfusion (RBC>1 unit: p=0.033), platelet transfusion (p=0.051), and more postoperative ventilator support (p=0.023). Predictors of early (in hospital) mortality include advanced age (p=0.019) higher euroSCORE (p<0.001), transfusion of intraoperative red blood cells (p=0.005), and cryoprecipitate (p=0.014). Twenty-five patients (44.6%) reached the end-point of death. There was no statistical difference in early and late survival rates between repair and replacement groups.

Conclusions: Patients with isolated tricuspid valve surgery continue to be a high-risk group in cardiac surgery with unacceptable operative mortality and limited survival. There were no statistical differences in early and late outcomes between the isolated tricuspid valve repair versus replacement surgery. Timely referral to surgery before the onset of class 3 heart failure, malnutrition, renal dysfunction and age>60 years is recommended.
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http://dx.doi.org/10.1016/j.hlc.2012.09.006DOI Listing
March 2013

Predictive model for postoperative delirium in cardiac surgical patients.

Semin Cardiothorac Vasc Anesth 2010 Sep 20;14(3):212-7. Epub 2010 Jul 20.

Mount Sinai School of Medicine, New York, NY 10029, USA.

Delirium is a common complication following cardiac surgery, and the predictors of delirium remain unclear. The authors performed a prospective observational analysis to develop a predictive model for postoperative delirium using demographic and procedural parameters. A total of 112 adult postoperative cardiac surgical patients were evaluated twice daily for delirium using the Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Model for the ICU (CAM-ICU). The incidence of delirium was 34% (n = 38). Increased age (odds ratio [OR] = 2.5; 95% confidence interval [CI] = 1.6-3.9; P < .0001, per 10 years) and increased duration of surgery (OR = 1.3; 95% CI = 1.1-1.5; P = .0002, per 30 minutes) were independently associated with postoperative delirium. Gender, BMI, diabetes mellitus, preoperative ejection fraction, surgery type, length of cardiopulmonary bypass, intraoperative blood component administration, Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment score, and Charlson Comorbidity Index, were not independently associated with postoperative delirium.
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http://dx.doi.org/10.1177/1089253210374650DOI Listing
September 2010

Solid renal tumor severity in von Hippel Lindau disease is related to germline deletion length and location.

Hum Mutat 2004 Jan;23(1):40-6

Urologic Oncology Branch, National Cancer Institute, Bethesda, Maryland 20892, USA.

von Hippel Lindau disease (VHL) is an autosomal dominant familial cancer syndrome linked to alteration of the VHL tumor suppressor gene. Affected patients are predisposed to develop pheochromocytomas and cystic and solid tumors of the kidney, CNS, pancreas, retina, and epididymis. However, organ involvement varies considerably among families and has been shown to correlate with the underlying germline alteration. Clinically, we observed a paradoxically lower prevalence of renal cell carcinoma (RCC) in patients with complete germline deletion of VHL. To determine if a relationship existed between the type of VHL deletion and disease, we retrospectively evaluated 123 patients from 55 families with large germline VHL deletions, including 42 intragenic partial deletions and 13 complete VHL deletions, by history and radiographic imaging. Each individual and family was scored for cystic or solid involvement of CNS, pancreas, and kidney, and for pheochromocytoma. Germline deletions were mapped using a combination of fluorescent in situ hybridization (FISH) and quantitative Southern and Southern blot analysis. An age-adjusted comparison demonstrated a higher prevalence of RCC in patients with partial germline VHL deletions relative to complete deletions (48.9 vs. 22.6%, p=0.007). This striking phenotypic dichotomy was not seen for cystic renal lesions or for CNS (p=0.22), pancreas (p=0.72), or pheochromocytoma (p=0.34). Deletion mapping revealed that development of RCC had an even greater correlation with retention of HSPC300 (C3orf10), located within the 30-kb region of chromosome 3p, immediately telomeric to VHL (52.3 vs. 18.9%, p <0.001), suggesting the presence of a neighboring gene or genes critical to the development and maintenance of RCC. Careful correlation of genotypic data with objective phenotypic measures will provide further insight into the mechanisms of tumor formation.
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http://dx.doi.org/10.1002/humu.10302DOI Listing
January 2004
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