Publications by authors named "Richard D Urman"

465 Publications

Design of Clinical Trials Evaluating Sedation in Critically Ill Adults Undergoing Mechanical Ventilation: Recommendations From Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) Recommendation III.

Crit Care Med 2021 Apr 28. Epub 2021 Apr 28.

1 Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY. 2 University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. 3School of Health Sciences, University of London, London, United Kingdom. 4 School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia. 5 Center of Healthy Aging, Self-Management, and Complex Care, The Ohio State University, College of Nursing, Columbus, OH. 6 Clear Consults, LLC, Hayward, WI. 7 Leslie Dan Faculty of Pharmacy, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada. 8 Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD. 9 Departments of Anesthesiology and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI. 10 School of Pharmacy, Northeastern University, Boston, MA 11 Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA. 12 Department of Anesthesia, University of Iowa, Iowa City, IA. 13 Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY. 14 Department of Anesthesiology, University of Utah, Salt Lake City, UT. 15 Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia. 16 Intensive Care Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. 17 Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA. 18 Department of Medicine, Tufts University School of Medicine, Maine Medical Center, Portland, ME. 9 Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. 20 Division of Anesthesiology and CCM, Hadassah Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel. 21 Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT. 22 Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT. 23 Department of Medicine, Section of Pulmonary and Critical Care, The University of Chicago, Chicago, IL. 24 Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. 25 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD. 26 Department of Anesthesiology and the Critical Illness, Vanderbilt University Medical Center, Nashville, TN. 27 Department of Critical Care Services, Maine Medical Center, Portland, ME. 28 Department of Outcomes Research, Cleveland Clinic, Cleveland, OH. 29 Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA. 30 Monash Health School of Clinical Sciences - Department of Intensive Care Medicine - Critical Care Research, Melbourne, VIC, Australia. 31 Department of Anesthesiology and Operative Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Charité Mitte & Campus Virchow-Klinikum, Berlin, Germany. 32 Department of Anesthesiology, Columbia University Medical Center, New York, NY. 33 Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL. 34 Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Objectives: Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators.

Design: A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process.

Participants: Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process.

Measurements And Main Results: The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization.

Conclusions: These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.
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http://dx.doi.org/10.1097/CCM.0000000000005049DOI Listing
April 2021

Surgical Complications Requiring Intervention in Open versus Minimally Invasive Radical Prostatectomy.

Urol Int 2021 Apr 26:1-5. Epub 2021 Apr 26.

Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Introduction: Injuries to surrounding structures during radical prostatectomy (RP) are rare but serious complications. However, it remains unknown if injuries to intestines, rectum, or vascular structures occur at different rates depending on the surgical approach.

Methods: We compared the frequency of these outcomes in open RP (ORP) and minimally invasive RP (MIS-RP) using the national American College of Surgeons National Surgical Quality Improvement Program database (2012-2017). Along with important metrics of clinical and surgical outcomes, patients were identified as undergoing surgical repair of small or large bowel, vascular structures, or hernias based on Current Procedural Terminology codes.

Results: In our propensity matched analysis, a total of 13,044 patients were captured. Bowel injury occurred more frequently in ORP than in MIS-RP (0.89 vs. 0.26%, p < 0.01). By intestinal segment, rectal and large bowel injuries were more common in ORP than MIS-RP (0.41 vs. 0.11% and 0.31 vs. 0.05%, both p < 0.01). However, there was no statistically significant difference between the groups for small bowel injury (0.17 vs. 0.11%, p = 0.39). Vascular injury was more common in MIS-RP (0.18 vs. 0.08%, p = 0.08). Hernias requiring repair were only identified in the MIS-RP group (0.12%).

Conclusion: When considering surgical approach, rectal and large bowel injuries were more common in ORP, while vascular injuries and hernia repair were more common in MIS-RP. Our findings can be used in counseling patients and identifying risk factors and strategies to reduce these complications.
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http://dx.doi.org/10.1159/000515618DOI Listing
April 2021

Efficacy of an Online Curriculum for Perioperative Goals of Care and Code Status Discussions: A Randomized Controlled Trial.

Anesth Analg 2021 Apr 22. Epub 2021 Apr 22.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

Background: Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature.

Methods: In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa.

Results: Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group.

Conclusions: Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.
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http://dx.doi.org/10.1213/ANE.0000000000005548DOI Listing
April 2021

Is sugammadex superior to neostigmine in reversing rocuronium-induced neuromuscular blockade?

J Clin Anesth 2021 Apr 16:110288. Epub 2021 Apr 16.

Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, United States of America; Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, United States of America.

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http://dx.doi.org/10.1016/j.jclinane.2021.110288DOI Listing
April 2021

Frequency and Temporal Distribution of Postoperative Respiratory Depressive Events.

Anesth Analg 2021 05;132(5):1206-1214

From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.

Background: The frequency and temporal distribution of postoperative respiratory depression (RD) events are not completely understood. This study determined the temporal distribution and frequency of RD episodes in postsurgical patients continuously monitored by bedside capnography and pulse oximetry.

Methods: This was a post hoc study of a subset of postsurgical patients enrolled in The PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial from 2 sites in the United States. These patients had undergone continuous bedside monitoring on general care wards. These data were adjudicated for potential RD episodes. The number of RD episodes per patient and the time of each RD episode were determined. The first RD episode experienced by a patient was classified as an "initial" episode, and the initial and all subsequent RD episodes experienced by a patient were classified as "all" episodes. A PRODIGY risk score was calculated.

Results: Data analyzed from 250 patients contained 2539 RD episodes in 155 (62.0%, 95% confidence interval, 55.7-68.0) patients with median 2 [0-8], range of 0-545 RD episodes per patient, with a PRODIGY risk score distribution of 100 (40.0%) low, 79 (31.6%) intermediate, 70 (28.0%) high (missing data from 1 patient). Median time to the initial RD episode was 8.8 [5.1-18.0] hours postoperatively. There was a peak occurrence of initial RD events between 14:00 and 20:00 on the day of surgery, and these were associated with a large number of subsequent events in the same timeframe. The peak time of all RD episodes occurred from 02:00 to 06:00. Patients with high PRODIGY risk scores had higher incidence and greater number of RD episodes per patient (P < .001, overall comparisons between groups for both incidence [χ2] and number of episodes [Kruskal-Wallis test]).

Conclusions: Continuous monitoring of surgical patients demonstrates that RD episodes are common, and risk increases with higher PRODIGY scores. In this patient cohort, the rate of initial RD episodes peaked in the afternoon to early evening, while peak rate of all RD episodes occurred in early morning. Further, among patients with RD episodes, the number of episodes increased with higher PRODIGY scores.
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http://dx.doi.org/10.1213/ANE.0000000000005478DOI Listing
May 2021

Structural Heart Issues in Dextrocardia: Situs Type Matters.

Ochsner J 2021 ;21(1):111-114

Department of Anesthesiology, Louisiana State University Health-Shreveport, Shreveport, LA.

Patients who are diagnosed with dextrocardia, a rare congenital heart condition in which the heart points toward the right side of the chest, need their specific situs classification (eg, solitus, inversus, ambiguus) ascertained to optimize their care and outcomes. In this report, we discuss the perioperative anesthetic management of a patient presenting with dextrocardia. A 44-year-old African American female with a history of hypertension, hyperlipidemia, gastroesophageal reflux disease, and diabetes mellitus type 2 was admitted for shortness of breath, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. The patient had been diagnosed with dextrocardia in 2003 at an outside hospital and was asymptomatic prior to this presentation. Chest x-ray revealed bilateral perihilar vascular congestion with bibasilar atelectasis and suspected small bilateral pleural effusions consistent with new-onset congestive heart failure. Preoperative 2-dimensional transthoracic echocardiography revealed an ostium secundum-type atrial septal defect (ASD) with mild left-to-right atrial shunting. The patient's ASD was repaired using a pericardial patch. The anesthetic management of patients presenting with dextrocardia is complex. Preoperative cardiac transthoracic echocardiography can identify cardiac lesions or aberrant anatomy associated with dextrocardia. Proper placement of electrocardiogram electrodes is necessary to avoid false-positive results for perioperative ischemia. Central line access must be adjusted to anatomic variations. Clinicians should have high suspicion for associated pulmonary hypertension and should limit sedatives preoperatively to minimize the cardiovascular effects of hypoxia and/or hypercarbia on the pulmonary vasculature. Finally, high clinical suspicion for respiratory complications should be maintained, as dextrocardia has been associated with respiratory complications secondary to primary ciliary dyskinesia in approximately 25% of patients.
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http://dx.doi.org/10.31486/toj.19.0119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993426PMC
January 2021

A prediction model for delirium after cardiac surgery: Another step towards prevention?

J Clin Anesth 2021 Mar 23:110238. Epub 2021 Mar 23.

Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, United States of America.

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http://dx.doi.org/10.1016/j.jclinane.2021.110238DOI Listing
March 2021

Regional Anesthesia Abdominal Blocks and Local Infiltration After Cesarean Delivery: Review of Current Evidence.

Curr Pain Headache Rep 2021 Mar 24;25(5):28. Epub 2021 Mar 24.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA.

Purpose Of Review: In this review, we discuss surgical infiltration and various abdominal wall blocks, including transversus abdominis plane (TAP) block and quadratus lumborum blocks, and review the literature on the evidence behind these approaches and analgesia for cesarean delivery (CD).

Recent Findings: Adequate pain management in the parturient following CD is important to facilitate early ambulation and neonatal care while also improving patient satisfaction and decreasing hospital length of stay. Neuraxial opioids have been a mainstay for postoperative analgesia; however, this option may not be available for patients undergoing emergency CD and have contraindications to neuraxial approaches, refusing an epidural or spinal, or with technical difficulties for neuraxial placement. In such cases, alternative options include a fascial plane block or surgical wound infiltration. The use of regional blocks or surgical wound infiltration is especially recommended in the parturient who does not receive neuraxial opioids for CD. Adequate postoperative analgesia following CD is an important component of the overall care of the parturient as it helps facilitate early mobilization and improve patient satisfaction. In conclusion, the use of abdominal fascial plane blocks or surgical wound infiltration is recommended in the parturient who does not receive neuraxial opioids for CD.
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http://dx.doi.org/10.1007/s11916-021-00945-4DOI Listing
March 2021

Preoperative Management of Surgical Patients Using Dietary Supplements: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

Mayo Clin Proc 2021 May 16;96(5):1342-1355. Epub 2021 Mar 16.

Division of General Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN.

The widespread use of complementary products poses a challenge to clinicians in the perioperative period and may increase perioperative risk. Because dietary supplements are regulated differently from traditional pharmaceuticals and guidance is often lacking, the Society for Perioperative Assessment and Quality Improvement convened a group of experts to review available literature and create a set of consensus recommendations for the perioperative management of these supplements. Using a modified Delphi method, the authors developed recommendations for perioperative management of 83 dietary supplements. We have made our recommendations to discontinue or continue a dietary supplement based on the principle that without a demonstrated benefit, or with a demonstrated lack of harm, there is little downside in temporarily discontinuing an herbal supplement before surgery. Discussion with patients in the preoperative visit is a crucial time to educate patients as well as gather vital information. Patients should be specifically asked about use of dietary supplements and cannabinoids, as many will not volunteer this information. The preoperative clinic visit provides the best opportunity to educate patients about the perioperative management of various supplements as this visit is typically scheduled at least 2 weeks before the planned procedure.
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http://dx.doi.org/10.1016/j.mayocp.2020.08.016DOI Listing
May 2021

Receptor and Molecular Targets for the Development of Novel Opioid and Non-Opioid Analgesic Therapies.

Pain Physician 2021 Mar;24(2):153-163

Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital/Harvard, Boston, MA; Department of Anesthesiology, LSU School of Medicine, New Orleans, LA.

Background: Although conventional pain relief therapeutics have centered around mu-opioid agonists, these drugs are limited by adverse side effects, including respiratory depression and addiction potential. The ongoing opioid epidemic has galvanized research into novel analgesic therapies with more favorable profiles. New pharmacologic agents have been developed to target neuronal pathways involved in pain sensation. Certain receptors have been recognized to mediate nociceptive transmission, central sensitization, and the development of chronic pain states.

Objectives: We conducted a literature review to identify potential targets for novel analgesic therapies.

Study Design: This study is a narrative review of potential analgesic targets. We characterize their antinociceptive mechanisms of action and evaluate their therapeutic potential.

Methods: A systemized search of available literature on novel analgesics was performed. A search was performed through the PubMed database to identify articles with key words of "novel analgesics," "novel non-opioid analgesics," "novel pain targets," and "non-opioid analgesics." Potential drug classes were identified and researched through corresponding keywords, with an emphasis on publications from 2018 to 2020. Older articles were included if frequently referenced by current literature.

Results: Potential novel analgesic targets include Nav1.7, Nav1.8, CaV2.2, and transient receptor potential vanilloid-1 (TRPV1) cation channel receptors in the peripheral nervous system. Other approaches disrupt the synthesis of pronociceptive signaling molecules such as nitric oxide, prostaglandin E2, and interleukin-6 (IL-6). Within central pain pathways, modification of kappa-opioid, delta-opioid, N-methyl-D-aspartate, and cannabinoid receptors have been investigated in chronic pain and hyperalgesia models. Recent advances in molecular technology have also presented opportunities to modify protein expression or the cellular genome altogether.

Limitations: Several analgesic targets have only demonstrated efficacy in preclinical trials. There are limited data evaluating the long-term safety profiles of therapies further on in development.

Conclusions: We provide an overview of potential analgesic therapies in various stages of development, which may become clinically relevant in the near future. Some drugs such as TRPV1 agonists, anti-IL-6, and anti-nerve growth factor antibodies have demonstrated analgesic effect in specific clinical pain states.
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March 2021

A Dashboard for Tracking Mortality After Cardiac Surgery Using a National Administrative Database.

Cardiol Res 2021 Apr 23;12(2):86-90. Epub 2021 Feb 23.

Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.

Background: Mortality after cardiac surgery is publicly reportable and used as a quality metric by national organizations. However, detailed institutional comparisons are often limited in publicly reported ratings, while publicly reported mortality data are generally limited to 30-day outcomes. Dashboards represent a useful method for aggregating data to identify areas for quality improvement.

Methods: We present the development of a dashboard of cardiac surgery performance using cardiac surgery admissions in a national administrative dataset, allowing institutions to better analyze their clinical outcomes. We identified cardiac surgery admissions in the Medicare Limited Data Sets from April 2016 to March 2017 using diagnosis-related group (DRG) codes for cardiac valve and coronary bypass surgeries.

Results: Using these data, we created a dashboard prototype to enable hospitals to compare their individual performance against state and national benchmarks, by all cardiac surgeries, specific cardiac surgery DRGs and by specific surgeons. Mortality rates are provided at 30, 60 and 90 days post-operatively as well as 1 year. Users can filter results by state, hospital and surgeon, and visualize summary data comparing these filtered results to national metrics. Examples of using the dashboard to examine hospital and individual surgeon mortality are provided.

Conclusions: We demonstrate how this database can be used to compare data between comparator hospitals on local, state and national levels to identify trends in mortality and areas for quality improvement.
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http://dx.doi.org/10.14740/cr1220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935641PMC
April 2021

Racial and Socioeconomic Disparities in Spinal Cord Stimulation Among the Medicare Population.

Neuromodulation 2021 Apr 15;24(3):434-440. Epub 2021 Mar 15.

Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Introduction: Spinal cord stimulation (SCS) is used in the treatment of many chronic pain conditions. This study investigates racial and socioeconomic disparities in SCS among Medicare patients with chronic pain.

Materials And Methods: Patients over the age of 18 with a primary diagnosis of postlaminectomy syndrome (ICD-10 M96.1) or chronic pain syndrome (ICD-10 G89.4) were identified in the Center for Medicare and Medicaid Services (CMS) Medicare Claims Limited Data Set. We defined our outcome as SCS therapy by race and socioeconomic status. Multivariable logistic regression was used to determine the variables associated with SCS.

Results: We identified 1,244,927 patients treated between 2016 and 2019 with a primary diagnosis of postlaminectomy syndrome (PLS) or chronic pain syndrome (CPS). Of these patients, 59,182 (4.8%) received SCS. Multivariable logistic regression analysis revealed that, compared with White patients, Black (OR [95%CI], 0.62 [0.6-0.65], p < 0.001), Asian (0.66 [0.56-0.76], p < 0.001), Hispanic (0.86 [0.8-0.93], p < 0.001), and North American Native (0.62 [0.56-0.69], p < 0.001) patients were significantly less likely to receive SCS. In addition, patients who were dual-eligible for Medicare and Medicaid were significantly less likely to receive SCS than those eligible for Medicare only (OR = 0.38 [95% CI: 0.37-0.39], p < 0.001).

Conclusions: This study suggests that racial and socioeconomic disparities exist in SCS among Medicare and Medicaid patients with PLS and CPS. Further work is required to elucidate the complex etiology underlying these findings.
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http://dx.doi.org/10.1111/ner.13373DOI Listing
April 2021

In Response.

Anesth Analg 2021 04;132(4):e61

Department of Anesthesiology, Trident Health System, Charleston, South Carolina.

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http://dx.doi.org/10.1213/ANE.0000000000005415DOI Listing
April 2021

Preoperative Management of Endocrine, Hormonal, and Urologic Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

Mayo Clin Proc 2021 Mar 10. Epub 2021 Mar 10.

Division of General Internal Medicine, Mayo Clinic, Rochester, MN.

Perioperative medical management is challenging due to the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources utilize the recommendations derived from individual studies and do not include a multidisciplinary focus or formal consensus. The Society for Perioperative Assessment and Quality Improvement (SPAQI) identified a lack of authoritative clinical guidance as an opportunity to utilize its multidisciplinary membership to improve evidence-based perioperative care. SPAQI seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this Consensus Statement is to provide practical guidance on the preoperative management of endocrine, hormonal, and urologic medications. A panel of experts with anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialty experience was drawn together and identified the common medications in each of these categories. The authors then utilized a modified Delphi approach to critically review the literature and generate consensus recommendations.
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http://dx.doi.org/10.1016/j.mayocp.2020.10.002DOI Listing
March 2021

Response to: Comment on: Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial.

J Clin Anesth 2021 Mar 10;71:110228. Epub 2021 Mar 10.

Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University Medical Center Goettingen, Germany.

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http://dx.doi.org/10.1016/j.jclinane.2021.110228DOI Listing
March 2021

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization.

World J Surg 2021 May 6;45(5):1272-1290. Epub 2021 Mar 6.

Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.

Background: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.

Methods: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1.

Results: Twelve components of preoperative care were considered. Consensus was reached after three rounds.

Conclusions: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
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http://dx.doi.org/10.1007/s00268-021-05994-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026421PMC
May 2021

Which opioid analgesics are associated with respiratory depression on inpatient wards?

J Clin Anesth 2021 Mar 3:110217. Epub 2021 Mar 3.

Brigham and Women's Hospital, Boston, MA, United States of America.

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http://dx.doi.org/10.1016/j.jclinane.2021.110217DOI Listing
March 2021

Epidural Analgesia in Ventral Hernia Repair: An Analysis of 30-day Outcomes.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):33-47

Jones, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Brovman, MD, Wagenaar, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Whang, MD, Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, New York. Ang, MD, Department of Surgery, Brigham and Women's Hospital, Boston, MA. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Urman, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, Center for Perioperative Research, Brigham and Women's Hospital, Boston, MA.

Background: Ventral hernia repair (VHR) is a common procedure associated with significant postoperative morbidity and prolonged hospital length of stay (LOS). The use of epidural analgesia in VHR has not been widely evaluated.

Purpose: To compare the outcomes of general anesthesia plus epidural analgesia (GA + EA) versus general anesthesia alone (GA) in patients undergoing ventral hernia repair.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify elective cases of VHR. Propensity score-matched analysis was used to compare outcomes in GA vs GA + EA groups. Cases receiving transverse abdominus plane blocks were excluded.

Results: A total of 9697 VHR cases were identified, resulting in two matched cohorts of 521 cases each. LOS was significantly longer in the GA + EA group (5.58 days) vs the GA group (5.20 days, p = 0.008). No other statistically significant differences in 30-day outcomes were observed between the matched cohorts.

Conclusion: Epidural analgesia in VHR is associated with statistically significant, but not clinically significant increase in LOS and may not yield any additional benefit in cases of isolated, elective VHR. Epidural analgesia may not be beneficial in this surgical population. Future studies should focus on alternative modes of analgesia to optimize pain control and outcomes for this procedure.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901129PMC
October 2020

Preoperative Management of Opioid and Nonopioid Analgesics: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

Mayo Clin Proc 2021 May 19;96(5):1325-1341. Epub 2021 Feb 19.

Division of General Internal Medicine, Mayo Clinic, Rochester, MN.

There is a lack of guidelines for preoperative dosing of opioid and nonopioid pain medications for surgical patients, which can lead to suboptimal preoperative pain control. The Society for Perioperative Assessment and Quality Improvement identified preoperative dosing of opioid and nonopioid analgesics as an area in which consensus could improve patient care. The aim of this guideline is to provide consensus that will allow perioperative physicians to make optimal recommendations regarding preoperative pain medication dosing. Six categories of pain medications were identified: opioid agonists, opioid antagonists, opioid agonist-antagonists, acetaminophen, muscle relaxants, and triptans/headache medications. We then used a Delphi survey technique to develop consensus recommendations for preoperative dosing of individual medications in each of these groups.
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http://dx.doi.org/10.1016/j.mayocp.2020.06.045DOI Listing
May 2021

Striving for Evidence-Based, Patient-Centered Guidance: The Impetus Behind the Society for Perioperative Assessment and Quality Improvement (SPAQI) Medication Management Consensus Statements.

Mayo Clin Proc 2021 May 19;96(5):1117-1119. Epub 2021 Feb 19.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA.

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http://dx.doi.org/10.1016/j.mayocp.2020.06.022DOI Listing
May 2021

Predicting Postoperative Pain: A Complex Interplay of Multiple Factors.

Anesth Analg 2021 03;132(3):652-655

From the Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1213/ANE.0000000000005200DOI Listing
March 2021

Preoperative Anemia Treatment with Intravenous Iron Therapy in Patients Undergoing Abdominal Surgery: A Systematic Review.

Adv Ther 2021 03 12;38(3):1447-1469. Epub 2021 Feb 12.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Introduction: Preoperative anemia is associated with increased morbidity, mortality, and healthcare costs. As a result of the increased incidence of chronic blood loss and iron deficiency anemia in abdominal surgery patients and its impact on patient outcomes, we systematically evaluated the quality of evidence for preoperative intravenous (IV) administration of iron to patients with anemia undergoing major abdominal surgery with the focus on clinical outcomes.

Methods: In this systematic review, PubMed, Cochrane, The Cumulative Index to Nursing and Allied Health Literature, Web Of Science, and Excerpta Medica Database databases were searched up to 2019 using specific keywords. Inclusion criteria were patients that were over 18 years of age, underwent abdominal surgery, and received an IV iron treatment in the preoperative setting.

Results: The nine studies included in the final systematic review do not provide consistent evidence of a reduced incidence of allogeneic blood transfusions with preoperative IV iron administration. However, IV iron administration did consistently cause a significant increase in hemoglobin levels relative to oral iron therapy or no iron.

Conclusion: Overall, these findings are consistent in that IV iron administration is highly effective at rapidly increasing hemoglobin levels in patients with iron deficiency anemia undergoing major abdominal surgery. Unfortunately, there is currently no evidence of reduced incidence of allogeneic blood transfusions or other enhanced outcomes.
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http://dx.doi.org/10.1007/s12325-021-01628-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932933PMC
March 2021

Costs of Inaccurate Anesthesia Start Time Documentation Within a Health System.

A A Pract 2021 Feb 11;15(2):e01404. Epub 2021 Feb 11.

From the Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and.

Inaccurate anesthesia start time (AST) documentation can result in lost revenue. Using a retrospective analysis, we estimated lost revenue from inaccurate documentation of the AST within a single health care system, including academic and community-based facilities. We used differences in nursing documentation of "in-room" time and AST to calculate lost billable revenue. Of the 282,432 cases included, 25.6% had a documented "in-room" time before the documented AST, resulting in an estimated loss of $703,522 within 30-month study period. Through educational interventions and feedback, anesthesia clinicians have the potential to significantly increase revenue through more accurate documentation of AST.
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http://dx.doi.org/10.1213/XAA.0000000000001404DOI Listing
February 2021

Does an individualized goal-directed therapy based on cerebral oxygen balance benefit high-risk patients undergoing cardiac surgery?

J Clin Anesth 2021 Jun 6;70:110189. Epub 2021 Feb 6.

Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, United States of America; Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, United States of America.

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http://dx.doi.org/10.1016/j.jclinane.2021.110189DOI Listing
June 2021

Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial.

J Clin Anesth 2021 Jun 22;70:110167. Epub 2021 Jan 22.

Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University Medical Center Goettingen, Germany; Outcomes Research Consortium, Cleveland, OH, USA.

Study Objective: Opioid administration for pain in general care floor patients remains common, and can lead to adverse outcomes, including respiratory compromise. The PRODIGY trial found that among ward patients receiving parenteral opioids, 46% experienced ≥1 respiratory depression episode. The objective of this analysis was to evaluate the geographic differences of opioid administration and examine the association between opioid administration characteristics and the occurrence of respiratory depression.

Design: Prospective observational trial.

Setting: 16 general care medical and surgical wards in Asia, Europe, and the United States.

Patients: 1335 patients receiving parenteral opioids.

Interventions: Blinded, alarm-silenced continuous capnography and pulse oximetry monitoring.

Measurements: Opioid-induced respiratory depression, defined as respiratory rate ≤ 5 bpm, SpO ≤ 85%, or ETCO ≤ 15 or ≥ 60 mmHg for ≥3 min; apnea episode lasting >30 s; or any respiratory opioid-related adverse event.

Results: Across all patients, 58% received only long-acting opioids, 16% received only short-acting (<3 h) opioids, and 21% received a combination of short- and long-acting (≥3 h) opioids. The type and median total morphine milligram equivalent (MME) of opioid administered varied significantly by region, with 31.5 (12.5-76.7) MME, 31.0 (6.2-99.0) MME, and 7.2 (1.7-18.7) MME in the United States, Europe, and Asia, respectively (p < 0.001). Considering only postoperative opioids, 54% (N = 119/220) and 45% (N = 347/779) of patients receiving only short-acting opioids or only long-acting opioids experienced ≥1 episode of opioid-induced respiratory depression, respectively. Multivariable analysis identified post-procedure tramadol (OR 0.62, 95% CI 0.424-0.905, p = 0.0133) and post-procedure epidural opioids (OR 0.485, 95% CI 0.322-0.731, p = 0.0005) being associated with a significant reduction in opioid-induced respiratory depression.

Conclusions: Despite varying opioid administration characteristics between Asia, Europe, and the United States, opioid-induced respiratory depression remains a common global problem on general care medical and surgical wards. While the use of post-procedure tramadol or post-procedure epidural opioids may reduce the incidence of respiratory depression, continuous monitoring is also necessary to ensure patient safety when receiving postoperative opioids. REGISTRATION NUMBER: www.clinicaltrials.gov, ID: NCT02811302.
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http://dx.doi.org/10.1016/j.jclinane.2021.110167DOI Listing
June 2021

The impact of regional anesthesia on patient outcomes in open reduction and internal fixation of the ankle.

J Clin Anesth 2021 Jan 21:110165. Epub 2021 Jan 21.

Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, United States of America.

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http://dx.doi.org/10.1016/j.jclinane.2021.110165DOI Listing
January 2021

Artificial Intelligence and a Pandemic: an Analysis of the Potential Uses and Drawbacks.

J Med Syst 2021 Jan 18;45(3):26. Epub 2021 Jan 18.

Department of Anesthesiology, University of California San Diego, 9300 Campus Point Drive MC7770, La Jolla, San Diego, CA, 92037-7770, USA.

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http://dx.doi.org/10.1007/s10916-021-01705-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811949PMC
January 2021

In Response.

Anesth Analg 2021 02;132(2):e31-e33

Harvard Medical School, Brigham and Women's Hospital, Department of Anesthesiology and Perioperative and Pain Medicine, Boston, Massachusetts.

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http://dx.doi.org/10.1213/ANE.0000000000005280DOI Listing
February 2021

Quantitative Sensory Testing to Predict Postoperative Pain.

Curr Pain Headache Rep 2021 Jan 14;25(1). Epub 2021 Jan 14.

Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.

Purpose Of Review: We review the relevance of quantitative sensory testing (QST) in light of acute and chronic postoperative pain and associated challenges.

Recent Findings: Predicting the occurrence of acute and chronic postoperative pain with QST can help identify patients at risk and allows proactive preventive management. Generally, central QST testing, such as temporal summation of pain (TSP) and conditioned pain modulation (CPM), appear to be the most promising modalities for reliable prediction of postoperative pain by QST. Overall, QST testing has the best predictive value in patients undergoing orthopedic procedures. Current evidence underlines the potential of preoperative QST to predict postoperative pain in patients undergoing elective surgery. Implementing QST in routine preoperative screening can help advancing traditional pain therapy toward personalized perioperative pain medicine.
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http://dx.doi.org/10.1007/s11916-020-00920-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808998PMC
January 2021

The role of inspiratory oxygen fraction in postoperative pulmonary complications.

J Clin Anesth 2020 Dec 15:110162. Epub 2020 Dec 15.

Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, United States of America; Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, United States of America.

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http://dx.doi.org/10.1016/j.jclinane.2020.110162DOI Listing
December 2020