Publications by authors named "Rodney A Gabriel"

168 Publications

The Influence of Hospital Urbanicity on Mortality in Patients With Acute Respiratory Failure: A National Cohort Retrospective Analysis.

Respir Care 2021 Sep 21. Epub 2021 Sep 21.

Department of Anesthesiology, University of California, San Diego, La Jolla, California.

Background: The primary objective of this study was to employ a national database to evaluate the association of hospital urbanicity, urban versus rural, on mortality and length of hospital stay in patients hospitalized with acute respiratory failure.

Methods: We used the 2014 National Inpatient Sample database to evaluate the association of hospital urbanicity with (1) mortality and (2) prolonged hospital stay, defined as ≥ 75th percentile of the study population. We conducted a mixed-effects logistic regression analysis adjusting for sociodemographic variables and medical comorbidities. The random effect was hospital identification number (a unique value assigned in the NIS database for a specific institution). The odds ratio (OR), 95% CI, and values were reported for each independent variable.

Results: The odds of inpatient mortality were significantly higher among urban teaching (OR 1.39, 95% CI 1.39-1.66, < .001) and urban nonteaching hospitals (OR = 1.39, 95% CI 1.26-1.52, < .001) compared to rural hospitals. The odds of prolonged hospital stay were significantly higher among urban teaching (OR = 1.82, 95% CI 1.66-2.0, < .001) and urban nonteaching compared to rural hospitals (OR = 1.50, 95% CI 1.36-1.65, < .001).

Conclusions: This study supports the current body of literature that there are significant differences in patient populations among hospital type. Differences in health outcomes among different types of hospitals should be considered when designing policies to address health equity as these are unique populations with specific needs.
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http://dx.doi.org/10.4187/respcare.09003DOI Listing
September 2021

Recommendations for developing clinical care protocols during pandemics: From theory and practice.

Best Pract Res Clin Anaesthesiol 2021 Oct 27;35(3):461-475. Epub 2021 Feb 27.

Division of Regional Anesthesia, Clinical Director of Anesthesiology, Koman Outpatient Pavilion, Associate Professor of Anesthesiology, Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA. Electronic address:

In 2019, a novel coronavirus called the severe acute respiratory syndrome coronavirus 2 led to the outbreak of the coronavirus disease 2019, which was deemed a pandemic by the World Health Organization in March 2020. Owing to the accelerated rate of mortality and utilization of hospital resources, health care systems had to adapt to these major changes. This affected patient care across all disciplines and specifically within the perioperative services. In this review, we discuss the strategies and pitfalls of how perioperative services in a large academic medical center responded to the initial onset of a pandemic, adjustments made to airway management and anesthesia specialty services - including critical care medicine, obstetric anesthesiology, and cardiac anesthesiology - and strategies for reopening surgical caseload during the pandemic.
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http://dx.doi.org/10.1016/j.bpa.2021.02.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7912357PMC
October 2021

Class 3 obesity is not associated with same-day admission in obese patients undergoing parathyroidectomy.

J Clin Anesth 2021 Jul 28;75:110472. Epub 2021 Jul 28.

Department of Anesthesiology, Division of Perioperative Informatics, University of California, San Diego (9500 Gilman Dr), La Jolla, CA 92093, USA; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego (9500 Gilman Dr), La Jolla, CA 92093, USA. Electronic address:

Importance: Rising rates of obesity and outpatient performance of parathyroidectomies are making it increasingly crucial to investigate the association of obesity with post-operative complications.

Objective: To determine whether Class 3 obesity is associated with increased same-day admission compared to lower obesity classes following outpatient parathyroidectomy.

Design: Retrospective cohort study.

Setting: Outpatient surgery.

Patients: 12,973 patients ≥18 years old who underwent outpatient parathyroidectomy between 2014 and 2016, per the American College of Surgeons National Surgical Quality Improvement Program registry.

Interventions: Primary exposure variable: body mass index (BMI), with patients assigned to one of six cohorts.

Measurements: Primary outcome measure: same-day admission. Secondary outcome measure: 30-day readmission. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI).

Main Results: There was a final sample size of 12,973 adult patients who underwent parathyroidectomy from 2014 to 2016. The admission rate for BMI ≥30 and < 40 kg/m (reference cohort) was 42.6%. The admission rates for Class 3 obesity categories were 46.2%, 56.2%, and 52.6% for those in the BMI range of ≥40 kg/m and < 50 kg/m, ≥50 kg/m and < 60 kg/m, and ≥ 60 kg/m, respectively. On multivariable logistic regression, there were no difference in the odds of 30-day hospital admission or readmission rate with any of the BMI cohorts when compared to the reference group.

Conclusions: There is no significant difference in rates of same-day admission or 30-day readmission between any Class 3 (BMI ≥40 kg/m) obesity cohort and the Class 1 and 2 (BMI ≥30 and < 40 kg/m) reference cohort following outpatient parathyroidectomy. This corroborates the notion that BMI classes cannot be used in a vacuum to determine eligibility for outpatient parathyroidectomy - a concept that can guide safe and cost-effective institutional practices.
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http://dx.doi.org/10.1016/j.jclinane.2021.110472DOI Listing
July 2021

Cryoablation of an Inguinal Angiomyomatous Hamartoma: A Case Report.

A A Pract 2021 Jun 24;15(7):e01492. Epub 2021 Jun 24.

From the Department of Anesthesiology, Division of Pain Medicine.

Angiomyomatous hamartomas are mixed-tissue benign lymphatic tumors that typically occur in the inguinal or axillary lymph nodes. These lesions may cause local lymphedema and painful compression neuralgias. Ultrasound-guided percutaneous cryoablation is an interventional technique that has been shown to provide sustained pain relief for peripheral neuropathies and neuralgias. Previously, our group published a case report of a patient with an inguinal angiomyomatous hamartoma causing a compression neuralgia, whose pain was temporarily alleviated after blockade of the femoral branch of the genitofemoral nerve. We present a follow-up case report describing this patient's sustained pain relief after cryoablation therapy.
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http://dx.doi.org/10.1213/XAA.0000000000001492DOI Listing
June 2021

Serratus anterior plane versus paravertebral nerve blocks for postoperative analgesia after non-mastectomy breast surgery: a randomized controlled non-inferiority trial.

Reg Anesth Pain Med 2021 Sep 22;46(9):773-778. Epub 2021 Jun 22.

Department of Anesthesiology, Division of Regional Anesthesia, University of California San Diego, La Jolla, California, USA.

Background: Paravertebral and serratus plane blocks are both used to treat pain following breast surgery. However, it remains unknown if the newer serratus block provides comparable analgesia to the decades-old paravertebral technique.

Methods: Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection serratus or paravertebral block in a subject-masked fashion (ropivacaine 0.5%; 20 mL unilateral; 16 mL/side bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room with serratus blocks (measurement: Numeric Rating Scale), and (2) opioid consumption would be non-inferior with serratus blocks in the operating and recovery rooms. In order to claim that serratus blocks are non-inferior to paravertebral blocks, both hypotheses must be at least non-inferior.

Results: Within the recovery room, pain scores for participants with serratus blocks (n=49) had a median (IQR) of 4.0 (0-5.5) vs 0 (0-3.0) for those with paravertebral blocks (n=51): 0.95% CI -3.00 to -0.00; p=0.001. However, the difference in morphine equivalents did not reach statistical significance for superiority with the serratus group consuming 14 mg (10-19) vs 10 mg (10-16) for the paravertebral group: 95% CI -4.50 to 0.00, p=0.123. Since the 95% CI lower limit of -4.5 was less than our prespecified margin of -2.0, we failed to conclude non-inferiority of the serratus block with regard to opioid consumption.

Conclusions: Serratus blocks provided inferior analgesia compared with paravertebral blocks. Without a dramatic improvement in safety profile for serratus blocks, it appears that paravertebral blocks are superior to serratus blocks for postoperative analgesia after non-mastectomy breast surgery.

Trial Registration Number: NCT03860974.
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http://dx.doi.org/10.1136/rapm-2021-102785DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8380889PMC
September 2021

National trends in nonoperating room anesthesia: procedures, facilities, and patient characteristics.

Curr Opin Anaesthesiol 2021 Aug;34(4):464-469

Department of Anesthesiology, University of California, San Diego, La Jolla, California, USA.

Purpose Of Review: Nonoperating room anesthesia (NORA) continues to increase in popularity and scope. This article reviews current and new trends in NORA, trends in anesthesia management in nonoperating room settings, and the evolving debates surrounding these trends.

Recent Findings: National data suggests that NORA cases will continue to rise relative to operating room (OR) anesthesia and there will continue to be a shift towards performing more interventional procedures outside of the OR. These trends have important implications for the safety of interventional procedures as they become increasingly more complex and patients continue to be older and more frail. In order for anesthesia providers and proceduralists to be prepared for this future, rigorous standards must be set for safe anesthetic care outside of the OR.Although the overall association between NORA and patient morbidity and mortality remains unclear, focused studies point toward trends specific to each non-OR procedure type. Given increasing patient and procedure complexity, anesthesiology teams may see a larger role in the interventional suite. However, the ideal setting and placement of anesthesia staff for interventional procedures remain controversial. Also, the impact of COVID-19 on the growth and utilization of non-OR anesthesia remains unclear, and it remains to be seen how the pandemic will influence the delivery of NORA procedures in postpandemic settings.

Summary: NORA is a rapidly growing field of anesthesia. Continuing discussions of complication rates and mortality in different subspecialty areas will determine the need for anesthesia care and quality improvement efforts in each setting. As new noninvasive procedures are developed, new data will continue to shape debates surrounding anesthesia care outside of the operating room.
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http://dx.doi.org/10.1097/ACO.0000000000001022DOI Listing
August 2021

Frameworks for trainee education in the nonoperating room setting.

Curr Opin Anaesthesiol 2021 Aug;34(4):470-475

Department of Anesthesiology.

Purpose Of Review: As the volume and types of procedures requiring anesthesiologist involvement in the nonoperating room anesthesia (NORA) setting continue to grow, it is important to create a formal curriculum and clearly define educational goals.

Recent Findings: A NORA rotation should be accompanied by a dedicated curriculum that should include topics such as education objectives, information about different interventional procedures, anesthesia techniques and equipment, and safety principles. NORA environment may be unfamiliar to anesthesia residents. The trainees must also learn the principles of efficiency, rapid recovery from anesthesia, and timely room turnover. Resident education in NORA should be an essential component of their training. The goals and objectives of the NORA educational experience should include not only developing the clinical knowledge necessary to implement the specific type of anesthetic desired for each procedure, but also the practical knowledge of care coordination needed to safely and efficiently work in the NORA setting.

Summary: As educators, we must foster and grow a resident's resilience by continually challenging them with new clinical scenarios and giving them appropriate autonomy to take risks and move outside of their comfort zone. Residents should understand that exposure to such unique and demanding environment can be transformative.
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http://dx.doi.org/10.1097/ACO.0000000000001023DOI Listing
August 2021

The expanding role of chronic pain interventions in multimodal perioperative pain management: a narrative review.

Postgrad Med 2021 Jun 8:1-9. Epub 2021 Jun 8.

Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System; Palo Alto, California, USA.

Surgery is a risk factor for chronic pain and long-term opioid use. As perioperative pain management continues to evolve, treatment modalities traditionally used for chronic pain therapy may provide additional benefit to patients undergoing surgery. Interventions such as radiofrequency ablation, cryoneurolysis, and neuromodulation may potentially be used in conjunction with acute pain procedures such as nerve blocks and multimodal analgesia. Pharmacological agents associated with chronic pain medicine, including gabapentinoids, ketamine, and selective serotonin reuptake inhibitors, may be useful adjuncts in perioperative pain management when indicated. There may also be a role for acupuncture, music therapy, and other integrative medicine therapies. A transitional pain service can help coordinate outpatient care with inpatient perioperative pain management and promote a more personalized and comprehensive approach that can improve postoperative outcomes.
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http://dx.doi.org/10.1080/00325481.2021.1935281DOI Listing
June 2021

Should there be a body mass index eligibility cutoff for elective airway cases in an ambulatory surgery center? A retrospective analysis of adult patients undergoing outpatient tonsillectomy.

J Clin Anesth 2021 Sep 24;72:110306. Epub 2021 Apr 24.

Department of Anesthesiology, Pain and Perioperative Medicine, Harvard Medical School/Brigham and Women's Hospital, Boston, MA, USA; Department of Anesthesia Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.

Study Objective: It is unclear what the body mass index (BMI) should be when performing surgery involving the airway at an outpatient surgery facility. The objective of this study was to evaluate the association of Class 3 obesity versus a composite cohort of Class 1 and 2 obesity with same-day hospital admission following outpatient tonsillectomy in adults.

Design: Retrospective cohort study.

Setting: Multi-institutional.

Patients: Patients undergoing outpatient tonsillectomy.

Intervention: None.

Measurements: We used the National Surgical Quality Improvement Program (NSQIP) to analyze association of BMI to same-day admission and 30-day readmission following outpatient tonsillectomy from 2017 to 2019. We looked at six BMI cohorts: 1) ≥30 and < 40 kg/m (reference cohort), 2) ≥20 and < 30 kg/m, 3) <20 kg/m, 4) ≥40 and < 50 kg/m, 5) ≥50 and < 60 kg/m, and 6) ≥60 kg/m. We used multivariable Poisson regression with robust standard errors and controlled for various confounders to calculate risk ratios (RR) and 99% confidence intervals (CI).

Main Results: There were 12,287 patients included in the final analysis, at which 697 (5.7%) and 283 (2.3%) had a same-day admission or 30-day readmission, respectively. On Poisson regression with robust standard errors, the relative risks for BMI ≥40 kg/m and < 50 kg/m, ≥50 kg/m and < 60 kg/m, and ≥ 60 kg/m (BMI ≥30 kg/m and < 40 kg/m was the reference group) were 1.31 (99% CI 1.03-1.65, p = 0.03), 1.99 (99% CI 1.43-2.78, p = 0.002), and 1.80 (99% CI 1.00-3.25, p = 0.07), respectively. Furthermore, Class 3 obesity was not associated with 30-day readmission.

Conclusion: These results contribute data that may help practices - especially freestanding ambulatory surgery centers - decide appropriate BMI cutoffs for surgery involving the airway. Whether this is considered clinically significant enough to rule out eligibility will differ from practice-to-practice and will depend on surgical volume, resources available and financial interests.
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http://dx.doi.org/10.1016/j.jclinane.2021.110306DOI Listing
September 2021

Making a business plan for starting a transitional pain service within the US healthcare system.

Reg Anesth Pain Med 2021 08 20;46(8):727-731. Epub 2021 Apr 20.

Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA.

Chronic pain imposes a tremendous economic burden of up to US$635 billion per year in terms of direct costs (such as the costs of treatment) and indirect costs (such as lost productivity and time away from work). In addition, the initiation of opioids for pain is associated with a more than doubling of pharmacy and all-cause medical costs. The high costs of chronic pain are particularly relevant for anesthesiologists because surgery represents an inciting event that can lead to chronic pain and long-term opioid use. While the presence of risk factors and an individual patient's postoperative pain trajectory may predict who is at high risk for chronic pain and opioid use after surgery, to date, there are few interventions proven to reduce these risks. One promising approach is the transitional pain service. Programs like this attempt to bridge the gap between acute and chronic pain management, provide continuity of care for complicated acute pain patients after discharge from the hospital, and offer interventions for patients who are on abnormal trajectories of pain resolution and/or opioid use. Despite awareness of chronic pain after surgery and the ongoing opioid epidemic, there are few examples of successful transitional pain service implementation in the USA. Key issues and concerns include financial incentives and the required investment from the hospital or healthcare system. We present an economic analysis and discussion of important considerations when developing a business plan for a transitional pain service.
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http://dx.doi.org/10.1136/rapm-2021-102669DOI Listing
August 2021

The Influence of Obesity on Hospital Admission After Outpatient Foot and Ankle Surgery.

J Foot Ankle Surg 2021 Jul-Aug;60(4):738-741. Epub 2021 Mar 6.

Associate Clinical Professor, Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA; Associate Clinical Professor, School of Medicine, University of California, San Diego, La Jolla, CA.

We examined the association of body mass index (BMI) with sociodemographic data, medical comorbidities and hospital admission following ambulatory foot and ankle surgery. We conducted an analysis utilizing data from the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016. Adult patients who underwent ankle surgery defined as ankle arthrodesis, ankle open reduction and internal fixation, and Achilles tendon repair in the outpatient setting. We examined 6 BMI ranges: <20 kg/m underweight, ≥20 to <25 kg/m normal weight, ≥25 to <30 kg/m overweight, ≥30 to <40 kg/m obese, ≥40 kg/mto <50 kg/m severely obese, and ≥50 kg/m extremely obese. The primary outcome was hospital admission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p value of <.05 as statistically significant. Data extraction yielded 13,454 adult patients who underwent ambulatory ankle surgery. We then performed listwise deletion to exclude cases with missing observations. After excluding 5.4% of the data, the final study population included 12,729 patients. The overall rate of hospital admission was in the population was 18.6% (2,377/12,729). The overall rate of postoperative complications was 0.03% (4/12,729). We found no significant association of BMI with hospital admission following multivariable logistic regression. We recommend that BMI alone should not be solely used to exclude patients from having ankle surgery performed in an outpatient setting, especially since this patient group makes up a significant proportion of orthopedic surgery.
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http://dx.doi.org/10.1053/j.jfas.2020.09.019DOI Listing
July 2021

Calibrating predictive model estimates in a distributed network of patient data.

J Biomed Inform 2021 05 1;117:103758. Epub 2021 Apr 1.

UC San Diego Health Department of Biomedical Informatics, University of California San Diego, La Jolla, CA 92093-0728, USA; Division of Health Services Research & Development, VA San Diego Healthcare System, San Diego, CA 92161, USA. Electronic address:

Background: Protecting the privacy of patient data is an important issue. Patient data are typically protected in local health systems, but this makes integration of data from different healthcare systems difficult. To build high-performance predictive models, a large number of samples are needed, and performance measures such as calibration and discrimination are essential. While distributed algorithms for building models and measuring discrimination have been published, distributed algorithms to measure calibration and recalibrate models have not been proposed.

Objective: Recalibration models have been shown to improve calibration, but they have not been proposed for data that are distributed in various health systems, or "sites". Our goal is to measure calibration performance and build a global recalibration model using data from multiple health systems, without sharing patient-level data.

Materials And Methods: We developed a distributed smooth isotonic regression recalibration model and extended established calibration measures, such as Hosmer-Lemeshow Tests, Expected Calibration Error, and Maximum Calibration Error in a distributed manner.

Results: Experiments on both simulated and clinical data were conducted, and the recalibration results produced by a traditional (ie, centralized) versus a distributed smooth isotonic regression were compared. The results were exactly the same.

Discussion: Our algorithms demonstrated that calibration can be improved and measured in a distributed manner while protecting data privacy, albeit at some cost in terms of computational efficiency. It also gives researchers who may have too few instances in their own institutions a method to construct robust recalibration models.

Conclusion: Preserving data privacy and improving model calibration are both important to advancing predictive analysis in clinical informatics. The algorithms alleviate the difficulties in model building across sites.
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http://dx.doi.org/10.1016/j.jbi.2021.103758DOI Listing
May 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

Monitored Anesthesia Care Versus General Anesthesia as the Primary Anesthetic for Ankle Amputations.

J Cardiothorac Vasc Anesth 2021 11 5;35(11):3283-3287. Epub 2021 Feb 5.

Department of Anesthesiology, University of California, San Diego, La Jolla, CA; Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA. Electronic address:

Objectives: The authors hypothesized that monitored anesthesia care (MAC)-either by local sedation or regional anesthesia (RA)-compared with general anesthesia (GA), would be associated with lower odds of significant 30-day postoperative complications and mortality in patients undergoing an ankle amputation.

Design: Retrospective cohort study.

Setting: Inpatient.

Participants: The authors used data from patients who underwent ankle amputation from the American College of Surgeons National Surgical Quality Improvement Program registry.

Intervention: RA as primary anesthetic.

Measurements And Main Results: A multivariate logistic regression was used to evaluate the association of primary anesthesia type with the outcomes. The regression analysis included all covariates to test the association of the primary exposure variable (anesthesia type) with each outcome of interest. The odds ratio (OR), with associated 95% confidence interval (CI), was reported for each covariate. There were a total of 3,368 patients undergoing guillotine amputation through the tibia/fibula (n = 2,935) or ankle disarticulation (n = 433). Among these patients, 15.5% (n = 491) received MAC as their primary anesthetic. Among all patients, 11.4% (n = 363) experienced a significant postoperative complication. On multivariate logistic regression, MAC was found to decrease odds of postoperative complications (OR 0.57, 95% CI 0.40-0.82, p = 0.002), but not mortality (OR 1.26, 95% CI 0.87-1.84, p = 0.22).

Conclusion: This study showed that MAC was associated with improved outcomes, as opposed to GA, as the primary anesthetic in ankle amputations.
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http://dx.doi.org/10.1053/j.jvca.2021.01.057DOI Listing
November 2021

The Association of Preoperative Smoking With Postoperative Outcomes in Patients Undergoing Total Hip Arthroplasty.

J Arthroplasty 2021 03 6;36(3):1029-1034. Epub 2020 Oct 6.

Department of Anesthesiology, University of California, San Diego, San Diego, CA; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, San Diego, CA.

Background: Preoperative smoking is an easily modifiable risk factor and has associations with increased postoperative morbidity and mortality. It is important to clarify these risks for specific procedures to provide improved and evidence-based quality of care. The purpose of the present study aims to identify the associations between preoperative smoking and 30-day postoperative outcomes in patients undergoing total hip arthroplasty.

Methods: We used R statistics to conduct a multivariable logistic regression analysis followed by a propensity score matching analysis to explore the association between preoperative smoking and postoperative outcomes.

Results: A final cohort of 67,897 patients who underwent total hip arthroplasty was selected for analysis. After adjusting for potential confounders, the odds of postoperative pulmonary complications (odds ratio [OR], 1.352; 95% confidence interval [95% CI], 1.075-1.700; P = .01), infectious complications (OR, 1.310; 95% CI, 1.094-1.567; P = .003), and extended hospital stay (OR, 1.17; 95% CI, 1.099-1.251; P < .001) were all significantly higher in the smoking population. After propensity matching these cohorts, both infectious complications (P = .017) and extended hospital stays (P = .001) were significantly higher in smoking patients.

Conclusions: After controlling for potential confounding variables, our multivariable regression analysis revealed a significant increase in pulmonary and infectious complications as well as significantly longer hospital stays in our smoking population. When using a propensity score matching analysis, an increase in infectious complications as well as extended hospital stay was observed. Given the concerning prevalence of smoking in the United States, our data provide updated information toward a growing mass of literature supporting smoking cessation before surgical operations.
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http://dx.doi.org/10.1016/j.arth.2020.09.049DOI Listing
March 2021

Speech and Audiology Outcomes After Single-Stage Versus Early 2-Stage Cleft Palate Repair.

Ann Plast Surg 2021 05;86(5S Suppl 3):S360-S366

From the Division of Plastic Surgery, University of California.

Purpose: The timing and management of patients with cleft palates have been controversial. Early soft palate closure at the time of cleft lip repair followed by hard palate closure at a second stage has been hypothesized to improve speech and audiology outcomes. This study compares cleft palate patients who have undergone single-stage versus 2-stage cleft palate repairs and the outcomes on speech and hearing.

Methods: A retrospective chart review identified patients with diagnosis of cleft lip with complete cleft palate who underwent either single or 2-stage repair from 2006 to 2012. Data collected included age at each surgery, necessity of further speech surgery for velopharyngeal insufficiency, frequency of tympanostomy tube placement, presence of hearing loss, and speech assessment data graded per the validated Americleft speech scale.

Results: A total of 84 patients were identified and subdivided into groups of single-stage and 2-stage repair. The mean age at the time of single-stage palate repair was 13.3 months. For the 2-stage group, the mean ages were 4.2 and 11.8 months for the soft palate and hard palate repairs, respectively. Comparing the single-stage versus 2-stage palate repairs, there was no significant difference in all speech parameters including hypernasality, hyponasality, nasal air emission, articulation, expressive language, receptive language, speech intelligibility, and speech acceptability for both unilateral and bilateral cleft lip/palate patients. Two-stage repair was associated with increased number of tympanostomy tube placement compared with single-stage repair (relative risk, 1.74; P = 0.009), and the first set of tubes was performed at a statistically significantly younger age, 4.5 months in the 2-stage repair compared with 16.9 months in the single-stage (P = 0.012) with 87.5% performed with first stage of repair. However, there was no difference in the types, degrees of hearing loss, or the presence of at least mild conductive hearing loss at latest follow-up audiograms between the groups.

Conclusions: There was no significant benefit with respect to speech or hearing outcomes between single-stage and 2-stage cleft palate repairs. This advocates for surgeon and family preference in the timing of cleft palate repair.
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http://dx.doi.org/10.1097/SAP.0000000000002747DOI Listing
May 2021

An assessment of perioperative respiratory adverse events and difficult intubation in pediatric patients with Trisomy 21.

Paediatr Anaesth 2021 04 24;31(4):410-418. Epub 2021 Feb 24.

Department of Anesthesiology, University of California, San Diego, CA, USA.

Introduction: Several prior studies have demonstrated an association between trisomy 21 and airway-related anesthetic complications. However, there is a paucity of large clinical studies characterizing the airway challenges associated with trisomy 21. In this analysis, we examine anesthetic-related airway complications in children with trisomy 21 and compare our findings to well-matched controls.

Methods: A chart review of all general anesthetics occurring between 2011 and 2017 at a single pediatric hospital was performed. Children with trisomy 21 were identified. Matched controls were created using a 1:1 propensity score and controlling for patient sex, patient age, surgical specialty, airway management, and anesthetic induction technique. The primary outcomes were the numbers of difficult intubations and perioperative respiratory adverse events. Secondary outcomes included the number of intubation attempts and the Cormack-Lehane grade in each cohort.

Results/data Analysis: A total of 2702 anesthetic records were reviewed. Propensity score matching resulted in adequately matched control groups as indicated by a standard mean difference below 0.2 in each case. Logistic regression analysis between trisomy 21 patients and matched controls demonstrated that the trisomy 21 cohort had a higher incidence of perioperative respiratory adverse events (OR 2.04, 95% CI 1.34-3.09, p = .0008) due largely to a higher incidence of airway obstruction (1.7% vs. 0.2%, p = .0005). The trisomy 21 group had a lower rate of difficult intubation (OR 0.26, 95% CI 0.07-0.91, p = .034). There was no association between trisomy 21 and the number of intubation attempts (RR 0.99, 95% CI 0.88-1.13, p = .92) or Cormack-Lehane grade (RR 0.95, 95% CI 0.87-1.05, p = .35).

Discussion: The trisomy 21 cohort had an increased incidence of perioperative respiratory adverse events compared to matched controls, largely secondary to a higher rate of obstructed ventilation, but without statistically different rates of laryngospasm, bronchospasm, postextubation stridor, or other desaturation events. Our trisomy 21 cohort had a decreased incidence of difficult intubation. There was no association between trisomy 21 and number of attempts required to successfully place an endotracheal tube or a less favorable CL grade.

Conclusions: Compared to matched controls, children with trisomy 21 have a lower incidence of difficult intubation and a higher incidence of perioperative respiratory adverse events, largely due to increased rate of airway obstruction.
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http://dx.doi.org/10.1111/pan.14138DOI Listing
April 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

The Implementation of an Acute Pain Service for Patients Undergoing Open Ventral Hernia Repair with Mesh and Abdominal Wall Reconstruction.

World J Surg 2021 Apr 16;45(4):1102-1108. Epub 2021 Jan 16.

Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA.

Introduction: In this retrospective cohort single-institutional study, we report the outcomes of implementing a standardized protocol of multimodal pain management with thoracic epidural analgesia via the acute pain service (APS) for patients undergoing ventral hernia repair with mesh placement and abdominal wall reconstruction.

Methods: The primary outcome evaluated was postoperative 72-h opioid consumption, measured in intravenous morphine equivalents (MEQ). Secondary outcomes included hospital length of stay (LOS) among other outcomes. The two cohorts were the APS versus non-APS group, in which the former cohort had an APS providing epidural and multimodal analgesia and the latter utilized pain management per surgical team, which mostly consisted of opioid therapy. Using1:1 propensity-score-matched cohorts, Wilcoxon signed-rank test was used to calculate the differences in outcomes. A p < 0.05 was considered statistically significant.

Results: There were 83 patients, wherein 51 (61.4%) were in the APS group. Between matched cohorts, the non-APS cohort's median [quartiles] total opioid consumption during the first three days was 85.6 mg MEQs [58.9, 112.8 mg MEQs]. The APS cohort was 31.7 mg MEQs [16.0, 55.3 mg MEQs] (p < 0.0001). The non-APS hospital LOS median [quartiles] was 5 days [4, 7 days] versus 4 days [4, 5 days] in the APS group (p = 0.01).

Discussion: A dedicated APS was associated with decreased opioid consumption by 75%, as well as a decreased hospital LOS. We report no differences in ICU length of stay, time to oral intake, time to ambulation or time to urinary catheter removal.
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http://dx.doi.org/10.1007/s00268-020-05915-2DOI Listing
April 2021

Acute postoperative pain management with percutaneous peripheral nerve stimulation: the SPRINT neuromodulation system.

Expert Rev Med Devices 2021 Feb 20;18(2):145-150. Epub 2021 Jan 20.

Department of Anesthesiology, University of California, San Diego, United States.

Introduction: Ultrasound-guided percutaneous peripheral nerve stimulation (PNS) may be used to treat acute postoperative pain for various types of surgeries. This modality avoids several limitations of traditional local anesthetic-based peripheral nerve blocks including avoidance of motor blockade and sensory deficits.

Areas Covered: In this review, we discuss the use of SPRINT (SPR Therapeutics, Cleveland, OH) neuromodulation system in the setting of acute postoperative pain management.

Expert Opinion: PNS is a novel modality in regional anesthesia that has much promise in reducing overall opioid use after surgery. Placement of PNS is very similar to that of catheter-based regional anesthesia techniques. Ultrasound is used to guide the percutaneously placed introducer needle in proximity to the target nerve. There are several benefits of PNS over catheter-based approaches, including: 1) avoidance of motor or sensory blockade; 2) no medication bag required to be carried; and 3) electric leads may be kept safely for up to 60 days. While several proof-of-concept studies have been published highlighting its use in various types of surgeries, large high-quality randomized controlled trials are still needed.
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http://dx.doi.org/10.1080/17434440.2021.1877134DOI Listing
February 2021

Clinical Effectiveness of Liposomal Bupivacaine Administered by Infiltration or Peripheral Nerve Block to Treat Postoperative Pain.

Anesthesiology 2021 02;134(2):283-344

The authors provide a comprehensive summary of all randomized, controlled trials (n = 76) involving the clinical administration of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, USA) to control postoperative pain that are currently published. When infiltrated surgically and compared with unencapsulated bupivacaine or ropivacaine, only 11% of trials (4 of 36) reported a clinically relevant and statistically significant improvement in the primary outcome favoring liposomal bupivacaine. Ninety-two percent of trials (11 of 12) suggested a peripheral nerve block with unencapsulated bupivacaine provides superior analgesia to infiltrated liposomal bupivacaine. Results were mixed for the 16 trials comparing liposomal and unencapsulated bupivacaine, both within peripheral nerve blocks. Overall, of the trials deemed at high risk for bias, 84% (16 of 19) reported statistically significant differences for their primary outcome measure(s) compared with only 14% (4 of 28) of those with a low risk of bias. The preponderance of evidence fails to support the routine use of liposomal bupivacaine over standard local anesthetics.
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http://dx.doi.org/10.1097/ALN.0000000000003630DOI Listing
February 2021

Policy and law changes to address healthcare inequities for minority populations during COVID-19.

J Allergy Infect Dis 2020 ;1(3):49-52

Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744000PMC
January 2020

A review of the StimRouter peripheral neuromodulation system for chronic pain management.

Pain Manag 2021 May 9;11(3):227-236. Epub 2020 Dec 9.

Department of Anesthesiology & Pain Medicine, University of California San Diego, San Diego, CA 92037, USA.

The StimRouter peripheral nerve stimulation system created by Bioness, Inc., (CA, USA) is US FDA-approved for the treatment of peripheral mononeuropathy refractory to conservative medical management. StimRouter is a minimally invasive system that utilizes a subcutaneously implanted lead with integrated anchor and electrodes, and an external pulse generator to produce peripheral neuromodulation and achieve pain relief. Multiple published clinical trials reviewed here have shown the StimRouter system to have a high margin of safety, differentiating it from other existing peripheral neuromodulation systems requiring open surgical electrode placement and implantable pulse generators. These studies have also shown the StimRouter system to be efficacious in the treatment of multiple peripheral mononeuropathies; improving patient pain, activity levels and quality of life. StimRouter represents a feasible option for management of chronic peripheral mononeuropathy.
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http://dx.doi.org/10.2217/pmt-2020-0042DOI Listing
May 2021

Predicting Trainee Clinical Success From Performance at Simulated Endotracheal Intubation.

Simul Healthc 2020 Dec 2. Epub 2020 Dec 2.

From the UC San Diego (R.H.H., P.J.S.), VA San Diego Healthcare System, San Diego, CA; Oregon Health Sciences University (V.J.T.), Portland, OR; UC San Diego (B.L., J.H., R.A.G., N.D.), La Jolla, CA; and Columbia University (A.T.D.), New York City, NY.

Introduction: Multiple attempts and failure at endotracheal intubation (ETI) are common for inexperienced practitioners and can cause patient morbidity. A test to predict a provider's likelihood of success at patient ETI could assist decisions about training. This project investigated whether trainees' performance at laryngoscopy on airway mannequins predicted their laryngoscopy outcomes in patients.

Methods: Twenty-one consenting first-year anesthesiology residents, emergency medicine residents, and medical students enrolled in this prospective, observational study. They performed laryngoscopy and ETI with a curved laryngoscope on 4 airway mannequins. Metrics included peak dental force, procedure duration, esophageal intubation, laryngeal view, and first-pass ETI success on the mannequins. Trainee data from 203 patient ETIs were collected over a roughly 2-month period centered around the simulation test. Multivariable logistic regression analyzed the relationship of mannequin metrics, participant experience, and a patient difficult airway score with trainee ETI outcomes in patients.

Results: Median trainee first-pass success rate at patient ETI was 63%, the rate of ETI problems was 16%, and the esophageal intubation rate was 6%. Laryngoscopy peak dental force, first-pass ETI success, and duration on individual mannequins were significant predictors of patient ETI first-pass success. Metrics from 2 of the 4 mannequins predicted ETI problems.

Discussion: Performance metrics from simulated laryngoscopy predicted trainee outcomes during patient ETI. First-pass success and ETI problems affect patient safety and are related to trainee skill. Mannequin laryngoscopy tests could identify trainees who would benefit from additional practice. The metrics could be surrogate end points in research to optimize simulated laryngoscopy training.
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http://dx.doi.org/10.1097/SIH.0000000000000527DOI Listing
December 2020

Efficiency Metrics at an Academic Freestanding Ambulatory Surgery Center: Analysis of the Impact on Scheduled End-Times.

Anesth Analg 2020 Nov 18. Epub 2020 Nov 18.

Department of Anesthesiology.

Background: Understanding the impact of key metrics on operating room (OR) efficiency is important to optimize utilization and reduce costs, particularly in freestanding ambulatory surgery centers. The aim of this study was to assess the association between commonly used efficiency metrics and scheduled end-time accuracy.

Methods: Data from patients who underwent surgery from May 2018 to June 2019 at an academic freestanding ambulatory surgery center was extracted from the medical record. Unique operating room days (ORDs) were analyzed to determine (1) duration of first case delays, (2) turnover times (TOT), and (3) scheduled case duration accuracies. Spearman's correlation coefficients and mixed-effects multivariable linear regression were used to assess the association of each metric with scheduled end-time accuracy.

Results: There were 1378 cases performed over 300 unique ORDs. There were 86 (28.7%) ORDs with a first case delay, mean (standard deviation [SD]) 11.2 minutes (15.1 minutes), range of 2-101 minutes; the overall mean (SD) TOT was 28.1 minutes (19.9 minutes), range of 6-83 minutes; there were 640 (46.4%) TOT >20 minutes; the overall mean (SD) case duration accuracy was -6.6 minutes (30.3 minutes), range of -114 to 176; and there were 389 (28.2%) case duration accuracies ≥30 minutes. The mean (SD) scheduled end-time accuracy was 6.9 minutes (68.3 minutes), range of -173 to 229 minutes; 48 (15.9%) ORDs ended ≥1 hour before scheduled end-time and 56 (18.6%) ORDs ended ≥1 hour after scheduled end-time. The total case duration accuracy was strongly correlated with the scheduled end-time accuracy (r = 0.87, 95% confidence interval [CI], 0.84-0.89, P < .0001), while the total first case delay minutes (r = 0.12, 95% CI, 0.01-0.21, P = .04) and total turnover time (r = -0.16, 95% CI, 0.21-0.05, P = .005) were less relevant. Case duration accuracy had the highest association with the dependent variable (0.95 minutes changed in the difference between actual and schedule end time per minute increase in case duration accuracy, 95% CI, 0.90-0.99, P < .0001), compared to turnover time (estimate = 0.87, 95% CI, 0.75-0.99, P < .0001) and first case delay time (estimate = 0.83, 95% CI, 0.56-1.11, P < .0001).

Conclusions: Standard efficiency metrics are similarly associated with scheduled end-time accuracy, and addressing problems in each is requisite to having an efficient ambulatory surgery center. Pursuing methods to narrow the gap between scheduled and actual case duration may result in a more productive enterprise.
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http://dx.doi.org/10.1213/ANE.0000000000005282DOI Listing
November 2020

The Association of Preoperative Hematocrit With Adverse Events Following Exploratory Laparotomy in Septic Patients: A Retrospective Analysis.

J Intensive Care Med 2020 Oct 21:885066620967925. Epub 2020 Oct 21.

Department of Anesthesiology, 8784University of California, San Diego, La Jolla, CA, USA.

Background: Sepsis continues to be the leading cause of death in intensive care units and surgical patients comprise almost one third of all sepsis patients. Anemia is a modifiable risk factor for worse postoperative outcomes in sepsis patients. Here we aim to evaluate the association of preoperative anemia and postoperative mortality in sepsis patients undergoing exploratory laparotomy.

Methods: The National Surgical Quality Improvement Program registry was used to query for preoperative sepsis patients undergoing exploratory laparotomy between 2014 and 2016. Preoperative hematocrit was stratified into 4 categories: ≥30% to polycythemia, <21%, 21 and less than 30%, and polycythemia. The primary outcome was 30-day mortality. Multivariable logistic regression was used to evaluate the association of preoperative hematocrit with primary and secondary endpoints. The multivariable analysis included preoperative hematocrit, gender, age, BMI, smoking status, functional status, hypertension, steroid use, bleeding disorder, and sepsis. The odds ratio (OR) with associated 95% confidence interval (CI) is reported for all outcomes. A p-value of less than <0.05 was considered statistically significant.

Results: The unadjusted 30-day death rate was the highest for patients with preoperative hematocrit <21% (p < 0.001) compared to the other hematocrit cohorts. The odds of 30-day death was significantly increased for patients with preoperative hematocrit <21% (OR 2.39 95% CI: 1.28-4.49, p = 0.006) and 21-30% (OR 1.35, 95% CI: 1.05 -1.72, p = 0.017) compared to patients with preoperative hematocrit of ≥30% and less than polycythemic ranges (reference cohort).

Conclusion: Preoperative anemia in sepsis patients undergoing surgery can lead to increased mortality, postoperative complications, and length of hospital stay. Diagnosing sepsis early in the hospital course can allow physicians more time to titrate anticoagulation medications and treat preoperative anemia.
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http://dx.doi.org/10.1177/0885066620967925DOI Listing
October 2020

The Performance of an Artificial Neural Network Model in Predicting the Early Distribution Kinetics of Propofol in Morbidly Obese and Lean Subjects.

Anesth Analg 2020 11;131(5):1500-1509

Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.

Background: Induction of anesthesia is a phase characterized by rapid changes in both drug concentration and drug effect. Conventional mammillary compartmental models are limited in their ability to accurately describe the early drug distribution kinetics. Recirculatory models have been used to account for intravascular mixing after drug administration. However, these models themselves may be prone to misspecification. Artificial neural networks offer an advantage in that they are flexible and not limited to a specific structure and, therefore, may be superior in modeling complex nonlinear systems. They have been used successfully in the past to model steady-state or near steady-state kinetics, but never have they been used to model induction-phase kinetics using a high-resolution pharmacokinetic dataset. This study is the first to use an artificial neural network to model early- and late-phase kinetics of a drug.

Methods: Twenty morbidly obese and 10 lean subjects were each administered propofol for induction of anesthesia at a rate of 100 mg/kg/h based on lean body weight and total body weight for obese and lean subjects, respectively. High-resolution plasma samples were collected during the induction phase of anesthesia, with the last sample taken at 16 hours after propofol administration for a total of 47 samples per subject. Traditional mammillary compartment models, recirculatory models, and a gated recurrent unit neural network were constructed to model the propofol pharmacokinetics. Model performance was compared.

Results: A 4-compartment model, a recirculatory model, and a gated recurrent unit neural network were assessed. The final recirculatory model (mean prediction error: 0.348; mean square error: 23.92) and gated recurrent unit neural network that incorporated ensemble learning (mean prediction error: 0.161; mean square error: 20.83) had similar performance. Each of these models overpredicted propofol concentrations during the induction and elimination phases. Both models had superior performance compared to the 4-compartment model (mean prediction error: 0.108; mean square error: 31.61), which suffered from overprediction bias during the first 5 minutes followed by under-prediction bias after 5 minutes.

Conclusions: A recirculatory model and gated recurrent unit artificial neural network that incorporated ensemble learning both had similar performance and were both superior to a compartmental model in describing our high-resolution pharmacokinetic data of propofol. The potential of neural networks in pharmacokinetic modeling is encouraging but may be limited by the amount of training data available for these models.
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http://dx.doi.org/10.1213/ANE.0000000000004897DOI Listing
November 2020

Patient health status and case complexity of outpatient surgeries at various facility types in the United States: An analysis using the National Anesthesia Clinical Outcomes Registry.

J Clin Anesth 2021 Feb 16;68:110109. Epub 2020 Oct 16.

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

Study Objective: Among the various types of outpatient surgery centers, there are differences in higher American Society of Anesthesiologists Physical Status (ASA PS) scores and surgical complexity among patients who are undergoing surgery. The primary objective of this study was to describe the differences performed at various types of outpatient surgery facilities.

Design: We performed a retrospective analysis of the National Anesthesia Clinical Outcomes Registry (NACOR) data.

Setting: NACOR from 2012 to 2017.

Patients: From 2012 to 2017, there were a total of 13,053,115 outpatient surgeries in the database. After removing cases with unknown facility type, the final study sample was 9,217,336.

Interventions: None.

Measurements: To calculate the probability of either American Society of Anesthesiologists Physical Status (ASA PS) score ≥ 3 or physiologically complex cases (defined as Common Procedural Terminology start-up units ≥8), we performed mixed effects logistic regression for each institution per facility type, controlling for year and using facility identification as the random effect. We present the mean rate of these two classifications as case per 10,000 cases and report the 99.9% confidence interval (CI), to control for multiple comparisons.

Main Results: Among all cases, 5,919,844 (64.2%) were classified as ASA PS 1 or 2 and 254,110 (2.8%) of surgical procedures were considered physiologically complex. The mean rate of cases with ASA PS ≥ 3in the university setting was 2982 per 10,000 cases [99.9% CI 2701-3278 per 10,000 cases]. Large community hospitals had a higher proportion of ASA PS ≥3 patients, medium-sized hospitals had no difference, and all other facility types had a decreased proportion. The mean rate of cases that were physiologically complex in the university setting was 133 per 10,000 cases [99.9% CI 117-151 per 10,000 cases]. Large community hospitals had a higher proportion of physiologically complex cases, medium-sized and small-sized hospitals had no difference, and all other facility types had a decreased proportion.

Conclusions: Freestanding and attached surgery centers exhibited smaller rates of patients that were ASA PS ≥ 3, as well as a decrease in surgically complex cases, when compared to university settings. This suggests that the level of conservativeness for patient and surgery appropriateness for outpatient surgery differs across various facility types.
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http://dx.doi.org/10.1016/j.jclinane.2020.110109DOI Listing
February 2021

A Point-Based Risk Calculator Predicting Mortality in Patients That Developed Postoperative Sepsis.

J Intensive Care Med 2020 Oct 12:885066620960991. Epub 2020 Oct 12.

Department of Anesthesiology, University of California, San Diego, CA, USA.

Background: Predicting the mortality from post-operative sepsis remains a continuing problem. We built a statistical model using national data to predict mortality in patients who developed post-operative sepsis.

Methods: This is a retrospective study using the American College of Surgeons National Quality Surgical Improvement Program database, in which we gathered data from adult patients between 2011 and 2016 who experienced postoperative sepsis. We designed a predictive model using multivariable logistic regression on a training set and validated the model on a separate test set.

Results: There were 128,325 patients included in the final dataset, in which 18,499 (14.4%) died within 30-days of surgery. The model consisted of 10 covariates: American Society of Anesthesiologists Physical Status classification score, preoperative sepsis, age, chronic obstructive pulmonary disease, postoperative myocardial infarction, postoperative stroke, postoperative acute renal failure, transfusion requirement, and infection type. A point-based risk calculator was developed, which had an area under the receiver operating characteristics curve of 0.819 (95% confidence interval 0.814-0.823).

Conclusion: Although further work is needed to confirm and validate our model on external datasets, our scoring system provides a novel way to measure mortality in septic post-operative patients.
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http://dx.doi.org/10.1177/0885066620960991DOI Listing
October 2020

Demographic and Clinical Variables Associated With 30-day Re-Intubation Following Surgical Aortic Valve Replacement.

Respir Care 2021 Feb 15;66(2):248-252. Epub 2020 Sep 15.

Department of Anesthesiology, University of California San Diego, La Jolla, California.

Background: A retrospective study was performed to evaluate factors associated with 30-d re-intubation following surgical aortic valve repair. We hypothesized a significant increase in the odds of re-intubation among patients with preoperative comorbidities.

Methods: The American College of Surgery National Surgical Quality Improvement Program database from 2007 to 2016 was used to evaluate demographic and clinical factors associated with 30-d re-intubation following surgical aortic valve repair. Multivariable logistic regression was used to report factors associated with 30-d re-intubation while controlling for various patient characteristics.

Results: The study population consisted of 5,766 adult subjects who underwent surgical aortic valve repair, of whom 258 (4.47%) were re-intubated within 30 d of surgery. The mean ± SD age was 69 ± 12.98 y, and 3,668 (63.6%) were male. The prevalence of diabetes mellitus, shortness of breath, poor functional status, COPD, congestive heart failure, hypertension, and bleeding disorder was higher among subjects who were re-intubated compared to those who were not ( < .05). Age, severe COPD, congestive heart failure, and bleeding disorder were associated with this outcome.

Conclusions: Age, COPD, congestive heart failure, and bleeding disorder were associated with 30-d re-intubation in this surgical cohort. If surgical aortic valve repair is deemed non-emergent, patients should be optimized preoperatively and receive careful postoperative planning to reduce the risk of postoperative complications.
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http://dx.doi.org/10.4187/respcare.08066DOI Listing
February 2021
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