Publications by authors named "Timothy E Miller"

75 Publications

Duke University Medical Center Perioperative Diabetes Management Program.

Clin Diabetes 2021 Apr;39(2):208-214

Duke University Medical Center, Durham, NC.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of . The following article describes a project at an academic tertiary-care medical center aimed at identifying surgical patients with uncontrolled diabetes early in the preoperative process to improve their perioperative glycemic control and surgical outcomes.
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http://dx.doi.org/10.2337/cd20-0029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061555PMC
April 2021

Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative.

Nat Rev Nephrol 2021 09 11;17(9):605-618. Epub 2021 May 11.

Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.

Postoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research.
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http://dx.doi.org/10.1038/s41581-021-00418-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8367817PMC
September 2021

Assisted Fluid Management Software Guidance for Intraoperative Fluid Administration.

Anesthesiology 2021 08;135(2):273-283

Background: Excessive or inadequate fluid administration causes complications, but despite this, fluid administration during noncardiac surgery is highly variable. Goal-directed management helps optimize the amount and timing of fluid administration; however, implementation is difficult because algorithms are complex. The authors therefore tested the performance of the Acumen Assisted Fluid Management software (Edwards Lifesciences, USA), which is designed to guide optimal intravenous fluid administration during surgery.

Methods: In this multicenter, prospective, single-arm cohort evaluation, the authors enrolled 330 adults scheduled for moderate- to high-risk noncardiac surgery that required arterial catheter insertion and mechanical ventilation. Clinicians chose a fluid strategy based on a desired 10%, 15%, or 20% increase in stroke volume (SV) in response to a fluid bolus. Dedicated fluid management software prompted "test" or "recommended" boluses, and clinicians were free to initiate a "user" bolus of 100 to 500 ml of crystalloid or colloid. Clinicians were free to accept or decline the software prompts. The authors primarily compared the fraction of software-recommended boluses that produced suitable increases in SV to a 30% reference rate. On an exploratory basis, we compared responses to software-recommended and clinician-initiated boluses.

Results: Four hundred twenty-four of 479 (89%) software-recommended fluid boluses and 508 of 592 (86%) clinician-initiated fluid boluses were analyzed per protocol. Of those, 66% (95% CI, 62 to 70%) of delivered fluid boluses recommended by the software resulted in desired increases in SV, compared with the 30% reference rate, whereas only 41% (95% CI, 38 to 44%) of clinician-initiated boluses did (P < 0.0001). The mean ± SD increase in SV after boluses recommended by the software was 14.2 ± 13.9% versus 8.3 ± 12.1% (P < 0.0001) for those initiated by clinicians.

Conclusions: Fluid boluses recommended by the software resulted in desired SV increases more often, and with greater absolute SV increase, than clinician-initiated boluses. Automated assessment of fluid responsiveness may help clinicians optimize intraoperative fluid management during noncardiac surgery.

Editor’s Perspective:
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http://dx.doi.org/10.1097/ALN.0000000000003790DOI Listing
August 2021

Association between perioperative fluid management and patient outcomes: a multicentre retrospective study.

Br J Anaesth 2021 Mar 13;126(3):720-729. Epub 2020 Dec 13.

Department of Critical Care Medicine, Orlando Regional Medical Center, Orlando, FL, USA. Electronic address:

Background: Postoperative complications increase hospital length of stay and patient mortality. Optimal perioperative fluid management should decrease patient complications. This study examined associations between fluid volume and noncardiac surgery patient outcomes within a large multicentre US surgical cohort.

Methods: Adults undergoing noncardiac procedures from January 1, 2012 to December 31, 2017, with a postoperative length of stay ≥24 h, were extracted from a large US electronic health record database. Patients were segmented into quintiles based on recorded perioperative fluid volumes with Quintile 3 (Q3) serving as the reference. The primary outcome was defined as a composite of any complications during the surgical admission and a postoperative length of stay ≥7 days. Secondary outcomes included in-hospital mortality, respiratory complications, and acute kidney injury.

Results: A total of 35 736 patients met the study criteria. There was a U-shaped pattern with highest (Q5) and lowest (Q1) quintiles of fluid volumes having increased odds of complications and a postoperative length of stay ≥7 days (Q5: odds ratio [OR] 1.51 [95% confidence interval {CI}: 1.30-1.74], P<0.001; Q1: OR 1.20 [95% CI: 1.04-1.38], P=0.011) compared with Q3. Patients in Q5 had greater odds of more severe acute kidney injury compared with Q3 (OR 1.52 [95% CI: 1.22-1.90]; P<0.001) and respiratory complications (OR 1.44 [95% CI: 1.17-1.77]; P<0.001).

Conclusions: Both very high and very low perioperative fluid volumes were associated with an increase in complications after noncardiac surgery.
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http://dx.doi.org/10.1016/j.bja.2020.10.031DOI Listing
March 2021

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on the Role of Neuromonitoring in Perioperative Outcomes: Cerebral Near-Infrared Spectroscopy.

Anesth Analg 2020 11;131(5):1444-1455

Departments of Anesthesiology and Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Some neurological complications following surgery have been related to a mismatch in cerebral oxygen supply and demand that may either lead to more subtle changes of brain function or overt complications like stroke or coma. Discovery of a perioperative neurological complication may be outside the treatment window, thereby making prevention an important focus. Early commercial devices used differential spectroscopy to measure relative changes from baseline of 2 chromophores: oxy- and deoxyhemoglobin. It was the introduction of spatially resolved spectroscopy techniques that allowed near-infrared spectroscopy (NIRS)-based cerebral oximetry as we know it today. Modern cerebral oximeters measure the hemoglobin saturation of blood in a specific "optical field" containing arterial, capillary, and venous blood, not tissue oxygenation itself. Multiple cerebral oximeters are commercially available, all of which have technical differences that make them noninterchangeable. The mechanism and meaning of these measurements are likely not widely understood by many practicing physicians. Additionally, as with many clinically used monitors, there is a lack of high-quality evidence on which clinicians can base decisions in their effort to use cerebral oximetry to reduce neurocognitive complications after surgery. Therefore, the Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together an international team of multidisciplinary experts including anesthesiologists, surgeons, and critical care physicians to objectively survey the literature on cerebral oximetry and provide consensus, evidence-based recommendations for its use in accordance with the GRading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature. The group produced the following consensus recommendations: (1) interpreting perioperative cerebral oximetry measurements in the context of a preinduction baseline value; (2) interpreting perioperative cerebral oximetry measurements in the context of the physiologic variables that affect them; (3) using caution in comparing cerebral oximetry values between different manufacturers; (4) using preoperative cerebral oximetry to identify patients at increased risk of adverse outcomes after cardiac surgery; (5) using intraoperative cerebral oximetry indexed to preinduction baseline to identify patients at increased risk of adverse outcomes after cardiac surgery; (6) using cerebral oximetry to identify and guide management of acute cerebral malperfusion during cardiac surgery; (7) using an intraoperative cerebral oximetry-guided interventional algorithm to reduce intensive care unit (ICU) length of stay after cardiac surgery. Additionally, there was agreement that (8) there is insufficient evidence to recommend using intraoperative cerebral oximetry to reduce mortality or organ-specific morbidity after cardiac surgery; (9) there is insufficient evidence to recommend using intraoperative cerebral oximetry to improve outcomes after noncardiac surgery.
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http://dx.doi.org/10.1213/ANE.0000000000005081DOI Listing
November 2020

Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance.

Perioper Med (Lond) 2020 21;9:12. Epub 2020 Apr 21.

6Department of Anesthesiology, Division of General, Vascular and Transplant Anesthesia, Duke University School of Medicine, Duke University Medical Center, Durham, NC USA.

Background: Optimal fluid therapy in the perioperative and critical care settings depends on understanding the underlying cardiovascular physiology and individualizing assessment of the dynamic patient state.

Methods: The Perioperative Quality Initiative (POQI-5) consensus conference brought together an international team of multidisciplinary experts to survey and evaluate the literature on the physiology of volume responsiveness and perioperative fluid management. The group used a modified Delphi method to develop consensus statements applicable to the physiologically based management of intravenous fluid therapy in the perioperative setting.

Discussion: We discussed the clinical and physiological evidence underlying fluid responsiveness and venous capacitance as relevant factors in fluid management and developed consensus statements with clinical implications for a broad group of clinicians involved in intravenous fluid therapy. Two key concepts emerged as follows: (1) The ultimate goal of fluid therapy and hemodynamic management is to support the conditions that enable normal cellular metabolic function in order to produce optimal patient outcomes, and (2) optimal fluid and hemodynamic management is dependent on an understanding of the relationship between pressure, volume, and flow in a dynamic system which is distensible with variable elastance and capacitance properties.
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http://dx.doi.org/10.1186/s13741-020-00142-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7171743PMC
April 2020

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention.

Anesth Analg 2020 06;130(6):1572-1590

Department of Anesthesiology, Duke University Medical Center.

Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.
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http://dx.doi.org/10.1213/ANE.0000000000004641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7379173PMC
June 2020

Focused cardiac ultrasound in preoperative assessment: the perioperative provider's new stethoscope?

Perioper Med (Lond) 2019 22;8:16. Epub 2019 Nov 22.

2Division of General, Vascular, and Transplant, Department of Anesthesiology, Duke University, Durham, NC USA.

Focused cardiac ultrasound (FoCUS)-a simplified, qualitative version of echocardiography-is a well-established tool in the armamentarium of critical care and emergency medicine. This review explores the extent to which FoCUS could also be used to enhance the preoperative physical examination to better utilise resources and identify those who would benefit most from detailed echocardiography prior to surgery. Among the range of pathologies that FoCUS can screen for, the conditions it provides the most utility in the preoperative setting are left ventricular systolic dysfunction (LVSD) and, in certain circumstances, significant aortic stenosis (AS). Thus, FoCUS could help answer two common preoperative diagnostic questions. First, in a patient with high cardiovascular risk who subjectively reports a good functional status, is there evidence of LVSD? Second, does an asymptomatic patient with a systolic murmur have significant aortic stenosis? Importantly, many cardiac pathologies of relevance to perioperative care fall outside the scope of FoCUS, including regional wall motion abnormalities, diastolic dysfunction, left ventricular outflow obstruction, and pulmonary hypertension. Current evidence suggests that after structured training in FoCUS and performance of 20-30 supervised examinations, clinicians can achieve competence in basic cardiac ultrasound image . However, it is not known precisely how many training exams are necessary to achieve competence in FoCUS image . Given the short history of FoCUS use in preoperative evaluation, further research is needed to determine what additional questions FoCUS is suited to answer in the pre-operative setting.
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http://dx.doi.org/10.1186/s13741-019-0129-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6873469PMC
November 2019

Implementation of a Successful Enhanced Recovery after Surgery Program in a Community Hospital.

Cureus 2019 Oct 30;11(10):e6029. Epub 2019 Oct 30.

Anesthesiology, Duke University School of Medicine, Durham, USA.

Background Enhanced recovery after surgery (ERAS) protocols have been shown to be effective at accelerating return to functioning, reducing length of stay, and reducing cost per encounter at major medical centers and health systems across the United States and Europe. Implementation in the community hospital setting has been considered more challenging due to a wide range of factors. This study demonstrates the successful creation of such a program in a community hospital in central North Carolina. Methods Starting in the spring of 2016, an anesthesiology-led, multidisciplinary ERAS team was formed with the purpose of developing an enhanced recovery after major urologic surgery program. A clinical protocol was developed by the team that met quarterly to review metrics. Outcome data were collected by chart review and compared to pre-ERAS values in a retrospective, nonrandomized, consecutive fashion and underwent statistical analysis. Results Overall, a reduction in both average and median length of stay (37% reduction) was observed in the post-ERAS group along with a reduction in 90-day readmission. Statistical analysis confirmed a very strong likelihood (p<.0001) that the ERAS protocol resulted in the observed reduction in the length of stay. Discussion This study demonstrated the feasibility of starting an ERAS program in a community hospital as well as the critical role that anesthesiology leadership can provide. An anesthesiology-led ERAS program offers a solution to some of the challenges faced by community hospitals regarding variable and silo-based care. ERAS pathways aim to implement standardized and coordinated evidence-based care protocols through multidisciplinary teams representing the entirety of the surgical encounter, leading to more consistent and favorable outcomes for patients and hospitals. This model can be applied to many other services in addition to the major urology effort described here.
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http://dx.doi.org/10.7759/cureus.6029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886646PMC
October 2019

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on the Role of Neuromonitoring in Perioperative Outcomes: Electroencephalography.

Anesth Analg 2020 05;130(5):1278-1291

Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York.

Electroencephalographic (EEG) monitoring to indicate brain state during anesthesia has become widely available. It remains unclear whether EEG-guided anesthesia influences perioperative outcomes. The sixth Perioperative Quality Initiative (POQI-6) brought together an international team of multidisciplinary experts from anesthesiology, biomedical engineering, neurology, and surgery to review the current literature and to develop consensus recommendations on the utility of EEG monitoring during anesthesia. We retrieved a total of 1023 articles addressing the use of EEG monitoring during anesthesia and conducted meta-analyses from 15 trials to determine the effect of EEG-guided anesthesia on the rate of unintentional awareness, postoperative delirium, neurocognitive disorder, and long-term mortality after surgery. After considering current evidence, the working group recommends that EEG monitoring should be considered as part of the vital organ monitors to guide anesthetic management. In addition, we encourage anesthesiologists to be knowledgeable in basic EEG interpretation, such as raw waveform, spectrogram, and processed indices, when using these devices. Current evidence suggests that EEG-guided anesthesia reduces the rate of awareness during total intravenous anesthesia and has similar efficacy in preventing awareness as compared with end-tidal anesthetic gas monitoring. There is, however, insufficient evidence to recommend the use of EEG monitoring for preventing postoperative delirium, neurocognitive disorder, or postoperative mortality.
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http://dx.doi.org/10.1213/ANE.0000000000004502DOI Listing
May 2020

IV Fluids for Major Surgery: Reply.

Anesthesiology 2019 12;131(6):1368-1369

Alfred Hospital and Monash University, Melbourne, Australia (P.S.M.).

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http://dx.doi.org/10.1097/ALN.0000000000003003DOI Listing
December 2019

Impact of an enhanced recovery pathway on length of stay and complications in elective radical cystectomy: a before and after cohort study.

Perioper Med (Lond) 2019 22;8. Epub 2019 Aug 22.

1Division of General, Vascular and Transplant Anesthesia, Duke University, Durham, NC USA.

Background: Enhanced recovery after surgery (ERAS) pathways aim to standardize and integrate perioperative care, incorporating the best available evidence-based practice throughout the perioperative period targeted at attenuating the surgical stress response while optimizing physiologic function, with the goal of facilitating recovery. Radical cystectomy is associated with significant postoperative morbidity, but comprehensive ERAS pathways have not been well studied in this population.

Methods: This is a before and after cohort study of an ERAS pathway for radical cystectomy at a large academic medical center. Following introduction of the ERAS pathway and a wash in period, we prospectively collected data from the next 100 consecutive subjects undergoing radical cystectomy with the ERAS pathway. This cohort was compared to a retrospective cohort of 100 consecutive patients undergoing radical cystectomy with traditional care. The primary outcome was hospital length of stay. Secondary outcomes included perioperative management, time to recovery milestones, complications, and costs.

Results: Implementation of an ERAS pathway for radical cystectomy was associated with reduced hospital length of stay (median LOS 10 days (IQR = 8-18) vs 7 days (IQR = 6-11);  < 0.0001), reduced time to key recovery milestones, including days to first stool (5.83 vs 3.99;  < 0.001) and days to first solid food (9.68 vs 3.2;  < 0.001), reductions in some complications, and a 26.6% reduction in overall costs ( < 0.001).

Conclusions: Our data support the use of an ERAS pathway for radical cystectomy and add to the increasing body of literature supporting enhanced recovery over a wide variety of procedures.

Trial Registration: Not applicable.
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http://dx.doi.org/10.1186/s13741-019-0120-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704620PMC
August 2019

Perioperative fluid management: moving toward more answers than questions-a commentary on the RELIEF study.

Perioper Med (Lond) 2019 15;8. Epub 2019 Jul 15.

2Queen Mary University of London, London, UK.

Perioperative fluid and hemodynamic management have been much-debated topics over the last few years. Recently, a number of large trials have been published to help inform this debate. The Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery (RELIEF) study is the largest trial to date of perioperative fluid management. The 3000-patient trial comparing 2 different fluid regimes showed that a restrictive fluid regimen during and up to 24 h after surgery was associated with an increase in acute kidney injury (AKI). This result is at odds with a recent trend to a more restrictive fluid approach during major surgery and suggests that practice may have become too restrictive. A moderately liberal (aiming for 1-2 l positive) or goal-directed approach is therefore recommended.
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http://dx.doi.org/10.1186/s13741-019-0113-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628482PMC
July 2019

Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review.

Curr Med Res Opin 2019 12 21;35(12):2129-2136. Epub 2019 Aug 21.

Vascular and Transplant Anesthesia, Duke University School of Medicine, Durham, NC, USA.

Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the US, with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings. Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid-free/opioid-sparing strategies published in English. In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery, as well as reduced healthcare utilization costs, are also discussed, along with challenges facing the implementation of such strategies. Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA is still in early stages and will require personalization and better management of patient expectations.
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http://dx.doi.org/10.1080/03007995.2019.1646001DOI Listing
December 2019

Paradox of age: older patients receive higher age-adjusted minimum alveolar concentration fractions of volatile anaesthetics yet display higher bispectral index values.

Br J Anaesth 2019 Sep 3;123(3):288-297. Epub 2019 Jul 3.

Anesthesiology Department, Duke University Medical Center, Durham, NC, USA. Electronic address:

Background: Minimum alveolar concentration (MAC) and MAC-awake decrease with age. We hypothesised that, in clinical practice, (i) end-tidal MAC fraction in older patients would decline by less than the predicted age-dependent MAC decrease (i.e. older patients would receive relatively excessive anaesthetic concentrations), and (ii) bispectral index (BIS) values would therefore be lower in older patients.

Methods: We examined the relationship between end-tidal MAC fraction, BIS values, and age in 4699 patients > 30 yr in age at a single centre using unadjusted local regression (locally estimated scatterplot smoothing), Spearman's correlation, stratification, and robust univariable and multivariable linear regression.

Results: The end-tidal MAC fraction in older patients declined by 3.01% per decade (95% confidence interval [CI]: 2.56-3.45; P<0.001), less than the 6.47% MAC decrease per decade that we found in a meta-regression analysis of published studies of age-dependent changes in MAC (P<0.001), and less than the age-dependent decrease in MAC-awake. The BIS values correlated positively with age (ρ=0.15; 95% CI: 0.12-0.17; P<0.001), and inversely with the age-adjusted end-tidal MAC (aaMAC) fraction (ρ= -0.13; 95% CI: -0.16, -0.11; P<0.001).

Conclusions: The age-dependent decline in end-tidal MAC fraction delivered in clinical practice at our institution was less than the age-dependent percentage decrease in MAC and MAC-awake determined from published studies. Despite receiving higher aaMAC fractions, older patients paradoxically showed higher BIS values. This most likely suggests that the BIS algorithm is inaccurate in older adults.
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http://dx.doi.org/10.1016/j.bja.2019.05.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104362PMC
September 2019

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naïve Patients.

Anesth Analg 2019 08;129(2):567-577

Department of Anesthesiology, Vanderbilt, Vanderbilt University School of Medicine and University Medical Center, Nashville, Tennessee.

Surgical care episodes place opioid-naïve patients at risk for transitioning to new persistent postoperative opioid use. With one of the central principles being the application of multimodal pain interventions to reduce the reliance on opioid-based medications, enhanced recovery pathways provide a framework that decreases perioperative opioid use. The fourth Perioperative Quality Initiative brought together a group of international experts representing anesthesiology, surgery, and nursing with the objective of providing consensus recommendations on this important topic. Fourth Perioperative Quality Initiative was a consensus-building conference designed around a modified Delphi process in which the group alternately convened for plenary discussion sessions in between small group discussions. The process included several iterative steps including a literature review of the topics, building consensus around the important questions related to the topic, and sequential steps of content building and refinement until agreement was achieved and a consensus document was produced. During the fourth Perioperative Quality Initiative conference and thereafter as a writing group, reference applicability to the topic was discussed in any area where there was disagreement. For this manuscript, the questions answered included (1) What are the potential strategies for preventing persistent postoperative opioid use? (2) Is opioid-free anesthesia and analgesia feasible and appropriate for routine operations? and (3) Is opioid-free (intraoperative) anesthesia associated with equivalent or superior outcomes compared to an opioid minimization in the perioperative period? We will discuss the relevant literature for each questions, emphasize what we do not know, and prioritize the areas for future research.
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http://dx.doi.org/10.1213/ANE.0000000000004194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261519PMC
August 2019

Perioperative Quality Initiative consensus statement on postoperative blood pressure, risk and outcomes for elective surgery.

Br J Anaesth 2019 May 2;122(5):575-586. Epub 2019 Mar 2.

Respiratory and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton, NHS Foundation Trust, Southampton, UK.

Background: Postoperative hypotension and hypertension are frequent events associated with increased risk of adverse outcomes. However, proper assessment and management is often poorly understood. As a part of the PeriOperative Quality Improvement (POQI) 3 workgroup meeting, we developed a consensus document addressing this topic. The target population includes adult, non-cardiac surgical patients in the postoperative phase outside of the ICU.

Methods: A modified Delphi technique was used, evaluating papers published in MEDLINE examining postoperative blood pressure monitoring, management, and outcomes. Practice recommendations were developed in line with National Institute for Health and Care Excellence guidelines.

Results: Consensus recommendations were that (i) there is evidence of harm associated with postoperative systolic arterial pressure <90 mm Hg; (ii) for patients with preoperative hypertension, the threshold at which harm occurs may be higher than a systolic arterial pressure of 90 mm Hg; (iii) there is insufficient evidence to precisely define the level of postoperative hypertension above which harm will occur; (iv) a greater frequency of postoperative blood pressure measurement is likely to identify risk of harm and clinical deterioration earlier; and (v) there is evidence of harm from withholding beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors in the postoperative period.

Conclusions: Despite evidence of associations with postoperative hypotension or hypertension with worse postoperative outcome, further research is needed to define the optimal levels at which intervention is beneficial, to identify the best methods and timing of postoperative blood pressure measurement, and to refine the management of long-term antihypertensive treatment in the postoperative phase.
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http://dx.doi.org/10.1016/j.bja.2019.01.019DOI Listing
May 2019

Perioperative Quality Initiative consensus statement on preoperative blood pressure, risk and outcomes for elective surgery.

Br J Anaesth 2019 May 2;122(5):552-562. Epub 2019 Mar 2.

Acute, Critical and Perioperative Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Southampton, UK; Anaesthesia and Critical Care Research Unit, Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK.

Background: A multidisciplinary international working subgroup of the third Perioperative Quality Initiative consensus meeting appraised the evidence on the influence of preoperative arterial blood pressure and community cardiovascular medications on perioperative risk.

Methods: A modified Delphi technique was used, evaluating papers published in MEDLINE on associations between preoperative numerical arterial pressure values or cardiovascular medications and perioperative outcomes. The strength of the recommendations was graded by National Institute for Health and Care Excellence guidelines.

Results: Significant heterogeneity in study design, including arterial pressure measures and perioperative outcomes, hampered the comparison of studies. Nonetheless, consensus recommendations were that (i) preoperative arterial pressure measures may be used to define targets for perioperative management; (ii) elective surgery should not be cancelled based solely upon a preoperative arterial pressure value; (iii) there is insufficient evidence to support lowering arterial pressure in the immediate preoperative period to minimise perioperative risk; and (iv) there is insufficient evidence that any one measure of arterial pressure (systolic, diastolic, mean, or pulse) is better than any other for risk prediction of adverse perioperative events.

Conclusions: Future research should define which preoperative arterial pressure values best correlate with adverse outcomes, and whether modifying arterial pressure in the preoperative setting will change the perioperative morbidity or mortality. Additional research should define optimum strategies for continuation or discontinuation of preoperative cardiovascular medications.
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http://dx.doi.org/10.1016/j.bja.2019.01.018DOI Listing
May 2019

Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery.

Br J Anaesth 2019 May 27;122(5):563-574. Epub 2019 Feb 27.

Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA; Department of Anaesthesia, University College London, London, UK.

Background: Intraoperative mortality is now rare, but death within 30 days of surgery remains surprisingly common. Perioperative myocardial infarction is associated with a remarkably high mortality. There are strong associations between hypotension and myocardial injury, myocardial infarction, renal injury, and death. Perioperative arterial blood pressure management was thus the basis of a Perioperative Quality Initiative consensus-building conference held in London in July 2017.

Methods: The meeting featured a modified Delphi process in which groups addressed various aspects of perioperative arterial pressure.

Results: Three consensus statements on intraoperative blood pressure were established. 1) Intraoperative mean arterial pressures below 60-70 mm Hg are associated with myocardial injury, acute kidney injury, and death. Injury is a function of hypotension severity and duration. 2) For adult non-cardiac surgical patients, there is insufficient evidence to recommend a general upper limit of arterial pressure at which therapy should be initiated, although pressures above 160 mm Hg have been associated with myocardial injury and infarction. 3) During cardiac surgery, intraoperative systolic arterial pressure above 140 mm Hg is associated with increased 30 day mortality. Injury is a function of arterial pressure severity and duration.

Conclusions: There is increasing evidence that even brief durations of systolic arterial pressure <100 mm Hg and mean arterial pressure <60-70 mm Hg are harmful during non-cardiac surgery.
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http://dx.doi.org/10.1016/j.bja.2019.01.013DOI Listing
May 2019

Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine.

Br J Anaesth 2019 May 14;122(5):542-551. Epub 2019 Feb 14.

Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.

Background: Perioperative arterial blood pressure management is a physiologically complex challenge influenced by multiple factors.

Methods: A multidisciplinary, international working subgroup of the Third Perioperative Quality Initiative (POQI) consensus meeting reviewed the (patho)physiology and measurement of arterial pressure as applied to perioperative medicine. We addressed predefined questions by undertaking a modified Delphi analysis, in which primary clinical research and review articles were identified using MEDLINE. Strength of recommendations, where applicable, were graded by National Institute for Health and Care Excellence (NICE) guidelines.

Results: Multiple physiological factors contribute to the perioperative physiological importance of arterial pressure: (i) arterial pressure is the input pressure to organ blood flow, but is not the sole determinant of perfusion pressure; (ii) blood flow is often independent of changes in perfusion pressure because of autoregulatory changes in vascular resistance; (iii) microvascular dysfunction uncouples microvascular blood flow from arterial pressure (haemodynamic incoherence). From a practical clinical perspective, we identified that: (i) ambulatory measurement is the optimal method to establish baseline arterial pressure; (ii) automated and invasive arterial pressure measurements have inherent physiological and technical limitations; (iii) individualised arterial pressure targets may change over time, especially in the perioperative period. There remains a need for research in non-invasive, continuous arterial pressure measurements, macro- and micro-circulatory control, regional perfusion pressure measurement, and the development of sensitive, specific, and continuous measures of cellular function to evaluate blood pressure management in a physiologically coherent manner.

Conclusion: The multivariable, complex physiology contributing to dynamic changes in perioperative arterial pressure may be underappreciated clinically. The frequently unrecognised dissociation between arterial pressure, organ blood flow, and microvascular and cellular function requires further research to develop a more refined, contextualised clinical approach to this routine perioperative measurement.
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http://dx.doi.org/10.1016/j.bja.2019.01.011DOI Listing
May 2019

American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives.

Anesth Analg 2019 08;129(2):543-552

Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.

Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naïve patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use.
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http://dx.doi.org/10.1213/ANE.0000000000003941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6640123PMC
August 2019

Perioperative Fluid Therapy for Major Surgery.

Anesthesiology 2019 05;130(5):825-832

From Duke University School of Medicine, Durham, North Carolina (T.E.M.) Alfred Hospital and Monash University, Melbourne, Australia (P.S.M.).

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http://dx.doi.org/10.1097/ALN.0000000000002603DOI Listing
May 2019

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy.

Anesth Analg 2019 08;129(2):553-566

From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.

Enhanced recovery pathways have quickly become part of the standard of care for patients undergoing elective surgery, especially in North America and Europe. One of the central tenets of this multidisciplinary approach is the use of multimodal analgesia with opioid-sparing and even opioid-free anesthesia and analgesia. However, the current state is a historically high use of opioids for both appropriate and inappropriate reasons, and patients with chronic opioid use before their surgery represent a common, often difficult-to-manage population for the enhanced recovery providers and health care team at large. Furthermore, limited evidence and few proven successful protocols exist to guide providers caring for these at-risk patients throughout their elective surgical experience. Therefore, the fourth Perioperative Quality Initiative brought together an international team of multidisciplinary experts, including anesthesiologists, nurse anesthetists, surgeons, pain specialists, neurologists, nurses, and other experts with the objective of providing consensus recommendations. Specifically, the goal of this consensus document is to minimize opioid-related complications by providing expert-based consensus recommendations that reflect the strength of the medical evidence regarding: (1) the definition, categorization, and risk stratification of patients receiving opioids before surgery; (2) optimal perioperative treatment strategies for patients receiving preoperative opioids; and (3) optimal discharge and continuity of care management practices for patients receiving opioids preoperatively. The overarching theme of this document is to provide health care providers with guidance to reduce potentially avoidable opioid-related complications including opioid dependence (both physical and behavioral), disability, and death. Enhanced recovery programs attempt to incorporate best practices into pathways of care. By presenting the available evidence for perioperative management of patients on opioids, this consensus panel hopes to encourage further development of pathways specific to this high-risk group to mitigate the often unintentional iatrogenic and untoward effects of opioids and to improve perioperative outcomes.
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http://dx.doi.org/10.1213/ANE.0000000000004018DOI Listing
August 2019

Surgical Prehabilitation: Nutrition and Exercise.

Anesthesiol Clin 2018 Dec;36(4):567-580

Duke University School of Medicine, Duke University Health System, 5th Floor HAFS, DUMC 3094, 2301 Erwin Road, Durham, NC 27710, USA.

Complications after major surgery account for a disproportionate amount of in-hospital morbidity and mortality. Recent efforts have focused on preoperative optimization in an attempt to modify the risk associated with major surgery. Underaddressed, but important, modifiable risk factors are physical fitness and nutritional status. Surgical patients are particularly at risk of 3 related, but distinct, conditions: frailty, sarcopenia, and reduced physical fitness. Exercise-based prehabilitation strategies have shown promise in terms of improving aerobic fitness, although their impact on key clinical perioperative outcome measures have not been fully determined. Preoperative nutritional status also has a strong bearing on perioperative outcome.
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http://dx.doi.org/10.1016/j.anclin.2018.07.013DOI Listing
December 2018

In Response.

Anesth Analg 2018 12;127(6):e105

Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York, Department of Anesthesiology, Virginia Commonwealth University Health System, Richmond, Virginia, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Department of Surgery, Duke University School of Medicine, Durham, North Carolina Department of Surgery, University of Virginia Health System, Charlottesville, Virginia Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina.

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http://dx.doi.org/10.1213/ANE.0000000000003790DOI Listing
December 2018

The rising tide of opioid use and abuse: the role of the anesthesiologist.

Perioper Med (Lond) 2018 3;7:16. Epub 2018 Jul 3.

1Division of General, Vascular and Transplant Anesthesiology, Department of Anesthesiology, Duke University, Box 3094, 2301 Erwin Road, Durham, NC 27710 USA.

Opioid use has risen dramatically in the past three decades. In the USA, opioid overdose has become a leading cause of unintentional death, surpassing motor vehicle accidents. A patient's first exposure to opioids may be during the perioperative period, a time where anesthesiologists have a significant role in pain management. Almost all patients in the USA receive opioids during a surgical encounter. Opioids have many undesirable side effects, including potential for misuse, or opioid use disorder. Anesthesiologists and surgeons employ several methods to decrease unnecessary opioid use, opioid-related adverse events, and side effects in the perioperative period. Multimodal analgesia, enhanced recovery pathways, and regional anesthesia are key tools as we work towards optimal opioid stewardship and the ideal of effective analgesia without undesirable sequelae.
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http://dx.doi.org/10.1186/s13741-018-0097-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6029394PMC
July 2018
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