Blood pressure fragmentation as a new measure of blood pressure variability: association with predictors of cardiac surgery outcomes.

Background: Fluctuations in beat-to-beat blood pressure variability (BPV) encode untapped information of clinical utility. A need exists for developing new methods to quantify the dynamical properties of these fluctuations beyond their mean and variance. Objectives: Introduction of a new beat-to-beat BPV measure, termed blood pressure fragmentation (BPF), and testing of whether increased preoperative BPF is associated with (i) older age; (ii) higher cardiac surgical risk, assessed using the Society of Thoracic Surgeons' (STS) Risk of Morbidity and Mortality index and the European System for Cardiac Operative Risk Evaluation Score (EuroSCORE II); and (iii) longer ICU length of stay (LOS) following cardiac surgery. The secondary objective was to use standard BPV measures, specifically, mean, SD, coefficient of variation (CV), average real variability (ARV), as well a short-term scaling index, the detrended fluctuation analysis (DFA) ⍺1 exponent, in the same type of analyses to compare the results with those obtained using BPF. Methods: Consecutive sample of 497 adult patients (72% male; age, median [inter-quartile range]: 67 [59-75] years) undergoing cardiac surgery with cardiopulmonary bypass. Fragmentation, standard BPV and DFA ⍺1 measures were derived from preoperative systolic blood pressure (SBP) time series obtained from radial artery recordings. Results: Increased preoperative systolic BPF was associated with older age, higher STS Risk of Morbidity and Mortality and EuroSCORE II values, and longer ICU LOS in all models. Specifically, a one-SD increase in systolic BPF (9%) was associated with a 26% (13%-40%) higher likelihood of longer ICU LOS (>2 days). Among the other measures, only ARV and DFA ⍺1 tended to be associated with longer ICU LOS. However, the associations did not reach significance in the most adjusted models. Conclusion: Preoperative BPF was significantly associated with preoperative predictors of cardiac surgical outcomes as well as with ICU LOS. Our findings encourage future studies of preoperative BPF for assessment of health status and risk stratification of surgical and non-surgical patients.

Preoperative Treatment of Severe Diabetes Mellitus and Hypertension Mitigates Healthcare Disparities and Prevents Adverse Postoperative Discharge to a Nursing Home.

OBJECTIVE: To evaluate whether patients of Black race are at higher risk of adverse postoperative discharge to a nursing home, and if a higher prevalence of severe diabetes mellitus and hypertension are contributing. BACKGROUND: It is unclear whether a patient's race predicts adverse discharge to a nursing home after surgery, and if preexisting diseases are contributing. METHODS: A total of 368,360 adults undergoing surgery between 2007 and 2020 across 2 academic healthcare networks in New England were included. Patients of self-identified Black or White race were compared. The primary outcome was postoperative discharge to a nursing facility. Mediation analysis was used to examine the impact of preexisting severe diabetes mellitus and hypertension on the primary association. RESULTS: In all, 10.3% (38,010/368,360) of patients were Black and 26,434 (7.2%) patients were discharged to a nursing home. Black patients were at increased risk of postoperative discharge to a nursing facility (adjusted absolute risk difference: 1.9%; 95% confidence interval: 1.6%-2.2%; P <0.001). A higher prevalence of preexisting severe diabetes mellitus and hypertension in Black patients mediated 30.2% and 15.6% of this association. Preoperative medication-based treatment adherent to guidelines in patients with severe diabetes mellitus or hypertension mitigated the primary association ( P -for-interaction <0.001). The same pattern of effect mitigation by pharmacotherapy was observed for the endpoint 30-day readmission. CONCLUSIONS: Black race was associated with postoperative discharge to a nursing facility compared to White race. Optimized preoperative assessment and treatment of diabetes mellitus and hypertension improves surgical outcomes and provides an opportunity to the surgeon to help eliminate healthcare disparities.

Intraoperative Hypotension and Acute Kidney Injury, Stroke, and Mortality during and outside Cardiopulmonary Bypass: A Retrospective Observational Cohort Study.

BACKGROUND: In cardiac surgery, the association between hypotension during specific intraoperative phases or vasopressor-inotropes with adverse outcomes remains unclear. This study's hypothesis was that intraoperative hypotension duration throughout the surgery or when separated into hypotension during and outside cardiopulmonary bypass may be associated with postoperative major adverse events. METHODS: This retrospective observational cohort study included data for adults who had cardiac surgery between 2008 and 2016 in a tertiary hospital. Intraoperative hypotension was defined as mean arterial pressure of less than 65 mmHg. The total duration of hypotension was divided into three categories based on the fraction of overall hypotension duration that occurred during cardiopulmonary bypass (more than 80%, 80 to 60%, and less than 60%). The primary outcome was a composite of stroke, acute kidney injury, or mortality during the index hospitalization. The association with the composite outcome was evaluated for duration of hypotension during the entire surgery, outside cardiopulmonary bypass, and during cardiopulmonary bypass and the fraction of hypotension during cardiopulmonary bypass adjusting for vasopressor-inotrope dose, milrinone dose, patient, and surgical factors. RESULTS: The composite outcome occurred in 256 (5.1%) of 4,984 included patient records; 66 (1.3%) patients suffered stroke, 125 (2.5%) had acute kidney injury, and 109 (2.2%) died. The primary outcome was associated with total duration of hypotension (adjusted odds ratio, 1.05; 95% CI, 1.02 to 1.08; P = 0.032), hypotension outside cardiopulmonary bypass (adjusted odds ratio, 1.06; 95% CI, 1.03 to 1.10; P = 0.001) per 10-min exposure to mean arterial pressure of less than 65 mmHg, and fraction of hypotension duration during cardiopulmonary bypass of less than 60% (reference greater than 80%; adjusted odds ratio, 1.67; 95% CI, 1.10 to 2.60; P = 0.019) but not with each 10-min period hypotension during cardiopulmonary bypass (adjusted odds ratio, 1.04; 95% CI, 0.99 to 1.09; P = 0.118), fraction of hypotension during cardiopulmonary bypass of 60 to 80% (adjusted odds ratio, 1.45; 95% CI, 0.97 to 2.23; P = 0.082), or total vasopressor-inotrope dose (adjusted odds ratio, 1.00; 95% CI, 1.00 to 1.00; P = 0.247). CONCLUSIONS: This study confirms previous single-center findings that intraoperative hypotension throughout cardiac surgery is associated with an increased risk of acute kidney injury, mortality, or stroke.

Perioperative Multimodal General Anesthesia Focusing on Specific CNS Targets in Patients Undergoing Cardiac Surgeries: The Pathfinder Feasibility Trial.

Multimodal general anesthesia (MMGA) is a strategy that utilizes the well-known neuroanatomy and neurophysiology of nociception and arousal control in designing a rational and clinical practical paradigm to regulate the levels of unconsciousness and antinociception during general anesthesia while mitigating side effects of any individual anesthetic. We sought to test the feasibility of implementing MMGA for seniors undergoing cardiac surgery, a high-risk cohort for hemodynamic instability, delirium, and post-operative cognitive dysfunction. Twenty patients aged 60 or older undergoing on-pump coronary artery bypass graft (CABG) surgery or combined CABG/valve surgeries were enrolled in this non-randomized prospective observational feasibility trial, wherein we developed MMGA specifically for cardiac surgeries. Antinociception was achieved by a combination of intravenous remifentanil, ketamine, dexmedetomidine, and magnesium together with bupivacaine administered as a pecto-intercostal fascial block. Unconsciousness was achieved by using electroencephalogram (EEG)-guided administration of propofol along with the sedative effects of the antinociceptive agents. EEG-guided MMGA anesthesia was safe and feasible for cardiac surgeries, and exploratory analyses found hemodynamic stability and vasopressor usage comparable to a previously collected cohort. Intraoperative EEG suppression events and postoperative delirium were found to be rare. We report successful use of a total intravenous anesthesia (TIVA)-based MMGA strategy for cardiac surgery and establish safety and feasibility for studying MMGA in a full clinical trial. Clinical Trial Number: www.clinicaltrials.gov; identifier NCT04016740 (https://clinicaltrials.gov/ct2/show/NCT04016740).

Cognition and Pain: A Review.

Cognition is defined as the brain's ability to acquire, process, store, and retrieve information. Pain has been described as an unpleasant sensory or emotional experience, and for experiencing pain consciously, cognitive processing becomes imperative. Moreover, evaluation of pain strongly depends on cognition as it requires learning and recall of previous experiences. There could be a possible close link between neural systems involved in cognition and pain processing, and studies have reported an association between pain and cognitive impairment. In this narrative review, we explore the available evidence that has investigated cognitive changes associated with pain. We also examine the anatomical, biochemical, and molecular association of pain and neuro-cognition. Additionally, we focus on the cognitive impairment caused by analgesic medications. There is a need to improve our understanding of pathophysiology and cognitive impairment mechanisms associated with chronic pain and its treatment. This area provides a diverse opportunity for grounding future research, aiding institution of timely interventions to prevent chronic pain and associated cognitive decline, ultimately improving patient care.

Impact of frailty in cardiac surgical patients-Assessment, burden, and recommendations.

Elderly patients undergoing cardiac surgery are at an increased risk of adverse postoperative outcomes. Frailty, a state of decreased physiological reserve, is highly prevalent among elderly patients. Despite being associated with adverse surgical outcomes, no universally accepted definition or measurement tool for frailty exists. Moreover, regardless of all the recommendations, a routine perioperative frailty assessment is often ignored. In addition to complications, frailty increases the burden to the healthcare system, which is of particular concern in Southeast Asia due to its socioeconomically disadvantaged and resource limited settings. This narrative review focuses to develop clinical practice plans for perioperative frailty assessment in the context of a cardiac surgical setting.

Pupillometry in perioperative medicine: a narrative review.

PURPOSE: Pupillometry is a technique for objective quantification of nociception that takes into account the central processing of noxious stimuli and its sympathetic response. This narrative review provides an overview of the physiology of the pupil, the principles of pupillometry, and its potential application in the perioperative environment, especially in nociception monitoring and quantifying responses to opioids. SOURCE: Relevant articles, including reports of original investigation, review articles, and meta-analyses were identified from searches of PubMed and Google Scholar databases. Articles that described pupillary physiology and pupillometry, along with original research reports of the application of pupillometry in perioperative and critical care environment were used to synthesize a narrative review. PRINCIPAL FINDINGS: Pupillometry is emerging as an objective measure of nociception, especially in patients under general anesthesia, children, non-verbal patients, and critically ill patients who cannot effectively communicate ongoing pain. Portable automated pupillometers have made accurate quantification of pupillary reflexes, including light reflex and dilatation reflex, possible. This technique has been successfully studied in the perioperative setting for a number of applications, including quantification of nociception, response to analgesia, and assessing efficacy of regional blocks. Pupillary oscillations have shown promise in assessing central opioid effects. Pupillometers can also accurately quantify light reflexes during the neurologic evaluation of critically ill patients. CONCLUSIONS: Pupillometry is an easy to use non-invasive bedside technique to quantify nociception and monitor opioid effects. It has the potential to personalize pain management in perioperative and intensive care unit environments. Additional studies are needed to further understand the utility of pupillometry in this context.

RéSUMé: OBJECTIF: La pupillométrie est une technique de quantification objective de la nociception qui tient compte de l'intégration centrale des stimuli douloureux et de la réponse sympathique de la pupille. Cette revue narrative donne un aperçu de la physiologie de la pupille, des principes de la pupillométrie et de son application potentielle dans le contexte périopératoire, en particulier dans le monitorage de la nociception et la quantification des réponses aux opioïdes. SOURCE: Les articles pertinents, comprenant les comptes rendus de recherche originale, les articles de synthèse et les méta-analyses, ont été identifiés à partir de recherches dans les bases de données PubMed et Google Scholar. Les articles décrivant la physiologie de la pupille et la pupillométrie, ainsi que des comptes rendus de recherche originale portant sur l'application de la pupillométrie dans le contexte périopératoire et des soins intensifs, ont été utilisés pour synthétiser un compte rendu narratif. CONSTATATIONS PRINCIPALES: La pupillométrie est une modalité émergente en tant que mesure objective de la nociception, en particulier chez les patients sous anesthésie générale, les patients pédiatriques, les patients qui ne parlent pas et les patients en état critique qui ne peuvent pas communiquer de façon efficace leur douleur. Les pupillomètres automatisés portatifs ont rendu possible la quantification précise des réflexes pupillaires, y compris du réflexe photomoteur et du réflexe de dilatation. Cette technique a été étudiée avec succès dans le cadre périopératoire pour plusieurs applications, y compris la quantification de la nociception, la réponse à l'analgésie et l'évaluation de l'efficacité des blocs régionaux. Les oscillations pupillaires se sont montrées prometteuses pour l'évaluation des effets centraux des opioïdes. Les pupillomètres peuvent également quantifier avec précision les réflexes photomoteurs lors de l'évaluation neurologique des patients en état critique. CONCLUSION: La pupillométrie est une technique au chevet non invasive facile à utiliser pour quantifier la nociception et surveiller les effets des opioïdes. Cette technique pourrait permettre de personnaliser la prise en charge de la douleur dans les environnements périopératoires et de soins intensifs. D'autres études sont nécessaires pour mieux comprendre l'utilité de la pupillométrie dans ce contexte.

Machine Learning Models with Preoperative Risk Factors and Intraoperative Hypotension Parameters Predict Mortality After Cardiac Surgery.

OBJECTIVES: Machine learning models used to predict postoperative mortality rarely include intraoperative factors. Several intraoperative factors like hypotension (IOH), vasopressor-inotropes, and cardiopulmonary bypass (CPB) time are significantly associated with postoperative outcomes. The authors explored the ability of machine learning models incorporating intraoperative risk factors to predict mortality after cardiac surgery. DESIGN: Retrospective study. SETTING: Tertiary hospital. PARTICIPANTS: A total of 5,015 adults who underwent cardiac surgery from 2008 to 2016. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The intraoperative phase was divided into the following: (1) CPB, (2) outside CPB, and (3) total surgery for quantifying IOH only. Phase-specific IOH parameters (area under the curve for mean arterial pressure <65 mmHg), vasopressor-inotropes (norepinephrine equivalents), duration, and cross-clamp time, along with preoperative risk factors ,were incorporated into the models. The primary outcome was mortality. The following 5 models were applied to 3 intraoperative phases separately: (1) logistic regression, (2) random forests, (3) neural networks, (4) support vector machines, and (5) extreme gradient boosting (XGB). Mortality was predicted using area under the receiver operating characteristic curve. Of 5,015 patients included, 112 (2.2%) died. XGB model from the outside-CPB phase predicted mortality better with area under the receiver operating characteristic curve, 95% confidence interval (CI): 0.88(0.83-0.94); positive predictive value, 0.10(0.06-0.15); specificity 0.85 (0.83-0.87) and sensitivity 0.75 (0.57-0.90). CONCLUSION: XGB machine learning model from IOH outside the CPB phase seemed to offer a better discrimination, sensitivity, specificity, and positive predictive value compared with other models. Machine learning models incorporating intraoperative adverse factors might offer better predictive ability for risk stratification and triaging of patients after cardiac surgery.

Ultrasound-Guided Pecto-Intercostal Fascial Block for Postoperative Pain Management in Cardiac Surgery: A Prospective, Randomized, Placebo-Controlled Trial.

OBJECTIVE: To explore the effect of pecto-intercostal fascial plane block (PIFB) on postoperative opioid requirements, pain scores, lengths of intensive care unit and hospital stays and incidence of postoperative delirium in cardiac surgical patients. DESIGN: Single- center, prospective, randomized (1:1), quadruple- blinded, placebo-controlled trial. SETTING: Single center, tertiary- care center. PARTICIPANTS: The study comprised 80 adult cardiac surgical patients (age >18 y) requiring median sternotomy. INTERVENTION: Patients were randomly assigned to receive ultrasound-guided PIFB, with either 0.25% bupivacaine or placebo, on postoperative days 0 and 1. MEASUREMENTS AND MAIN RESULTS: Of the 80 patients randomized, the mean age was 65.78 ± 8.73 in the bupivacaine group and 65.70 ± 9.86 in the placebo group (p = 0.573). Patients receiving PIFB with 0.25% bupivacaine showed a statistically significant reduction in visual analog scale scores (4.8 ± 2.7 v 5.1 ± 2.6; p < 0.001), but the 48-hour cumulative opioid requirement computed as morphine milligram equivalents was similar (40.8 ± 22.4 mg v 49.1 ± 26.9 mg; p = 0.14). There was no difference in the incidence of postoperative delirium between the groups evaluated using the 3-minute diagnostic Confusion Assessment Method (3/40 [7.5%] v 5/40 [12.5%] placebo; p = 0.45). CONCLUSION: Patients who received PIFB with bupivacaine showed a decline in cumulative opioid consumption postoperatively, but this difference between the groups was not statistically significant. Low incidence of complications and improvement in visual analog scale pain scores suggested that the PIFB can be performed safely in this population and warrants additional studies with a larger sample size.

Association Between Intraoperative Hypotension and Postoperative Adverse Outcomes in Patients Undergoing Vascular Surgery - A Retrospective Observational Study.

OBJECTIVE: Intraoperative hypotension (IOH) is associated with adverse outcomes. It could be challenging to define IOH in vascular surgical patients with increased baseline blood pressure (BP). The authors studied the relationship between (1) absolute and relative BP thresholds of IOH, (2) preoperative pulse pressure (PP) and isolated systolic hypertension, and (3) endovascular versus open surgical approach with adverse outcomes in vascular surgical patients. DESIGN: Retrospective observational study. SETTING: Teaching hospital. PATIENTS: A total of 566 vascular surgical patients from 2011 to 2018. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: BP thresholds were as follows: IOH - absolute mean arterial pressure (MAP) <65 mmHg, relative MAP >20% decrease from baseline, preoperative PP hypertension - PP >40 mmHg, isolated systolic hypertension - baseline systolic BP ≥140 mmHg with diastolic BP <90 mmHg. Thresholds were characterized by (1) total duration and (2) area under the curve. Primary outcome was a composite of postoperative in-hospital complications (acute kidney injury, stroke, myocardial infarction, congestive heart failure, and mortality). Forty-six (8.1%) patients had in-hospital complications. Only IOH duration-MAP <65 mmHg (odds ratio 1.01; 95% confidence interval 1.00-1.02; p = 0.004) was significantly associated with outcome. No associations were found with MAP >20% decrease from baseline and preoperative BP. Significant interaction was observed with the surgical approach and outcome (p = 0.031), which was stronger after 60 minutes of IOH in endovascular approach. CONCLUSION: Longer periods of IOH (MAP <65 mmHg for >60 minutes) during endovascular surgery were associated with adverse outcomes. Relative fall in BP from baseline, preoperative isolated systolic, and PP hypertension were not associated with postoperative complications.

Cardiac surgical outcome prediction by blood pressure variability indices Poincaré plot and coefficient of variation: a retrospective study.

BACKGROUND: Recent literature suggests a significant association between blood pressure variability (BPV) and postoperative outcomes after cardiac surgery. However, its outcome prediction ability remains unclear. Current prediction models use static preoperative patient factors. We explored the ability of Poincaré plots and coefficient of variation (CV) by measuring intraoperative BPV in predicting adverse outcomes. METHODS: In this retrospective, observational, cohort study, 3687 adult patients (> 18 years) undergoing cardiac surgery requiring cardio-pulmonary bypass from 2008 to 2014 were included. Blood pressure variability was computed by Poincare plots and CV. Standard descriptors (SD) SD1, SD2 were measured with Poincare plots by ellipse fitting technique. The outcomes analyzed were the 30-day mortality and postoperative renal failure. Logistic regression models adjusted for preoperative and surgical factors were constructed to evaluate the association between BPV parameters and outcomes. C-statistics were used to analyse the predictive ability. RESULTS: Analysis found that, 99 (2.7%) patients died within 30 days and 105 (2.8%) patients suffered from in-hospital renal failure. Logistic regression models including BPV parameters (standard descriptors from Poincare plots and CV) performed poorly in predicting postoperative 30-day mortality and renal failure [Concordance(C)-Statistic around 0.5]. They did not add any significant value to the standard STS risk score [C-statistic: STS alone 0.7, STS + BPV parmeters 0.7]. CONCLUSIONS: In conclusion, BP variability computed from Poincare plots and CV were not predictive of mortality and renal failure in cardiac surgical patients. Patient comorbid conditions and other preoperative factors are still the gold standard for outcome prediction. Future directions include analysis of dynamic parameters such as complexity of physiological signals in identifying high risk patients and tailoring management accordingly.

Comparison of Glycemic Variability Indices: Blood Glucose, Risk Index, and Coefficient of Variation in Predicting Adverse Outcomes for Patients Undergoing Cardiac Surgery.

OBJECTIVES: Fluctuations in blood glucose (glycemic variability) increase the risk of adverse outcomes. No universally accepted tool for glycemic variability exists during the perioperative period. The authors compared 2 measures of glycemic variability-(1) coefficient of variation (CV) and (2) the Blood Glucose Risk Index (BGRI)-in predicting adverse outcomes after cardiac surgery. DESIGN: Prospective, observational study. SETTING: Single-center, teaching hospital. PARTICIPANTS: A total of 1,963 adult patients undergoing cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Postoperative blood glucose levels were measured hourly for the first 24 hours and averaged every 4 hours (4, 8, 12, 16, 20, and 24 hours). Glycemic variability was measured by CV and the BGRI. The primary outcome, major adverse events (MAEs), was a predefined composite of postoperative complications (death, reoperation, deep sternal infection, stroke, pneumonia, renal failure, tamponade, and myocardial infarction). Logistic regression models were constructed to evaluate the association. Predictive ability was measured using C-statistics. Major adverse events were seen in 170 (8.7%) patients. Only the fourth quartile of CV showed association (odds ratio [OR] 1.91; 95% confidence interval [CI] [1.19-3.14]; p = 0.01), whereas BGRI was related significantly to MAE (OR 1.20; 95% CI [1.10-1.32]; p < 0.0001). The predictive ability of CV and BGRI increased on adding the standard Society of Thoracic Surgeons (STS) risk index. The C-statistic for STS was 0.68, whereas STS + CV was 0.70 (p = 0.012) and STS + BGRI was 0.70 (p = 0.012). CONCLUSION: Both CV and the BGRI had good predictive ability. The BGRI being a continuous variable could be a preferred measure of glycemic variability in predicting adverse outcomes (cutoff value 2.24) after cardiac surgery.

Preoperative Blood Pressure Complexity Indices as a Marker for Frailty in Patients Undergoing Cardiac Surgery.

OBJECTIVE: Frailty, a state of decreased physiological reserve, increases the risk of adverse outcomes. There is no standard tool for frailty during perioperative period. Autonomic dysfunction, an underlying process in frailty, could result in hemodynamic fluctuations. Complexity, the physiological adaptability of a system can quantify these fluctuations. The authors hypothesized that complexity could be a marker for frailty and explored their relationship in cardiac surgical patients. DESIGN: Prospective, observational study. SETTING: Single-center teaching hospital. PARTICIPANTS: Three hundred and sixty-four adult patients undergoing cardiac surgery. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Preoperative beat-to-beat systolic arterial pressure (SAP) and mean arterial pressure (MAP) time series were obtained. Complexity indices were calculated using multiscale entropy (MSE) analysis. Frailty was assessed from: age >70 years, body mass index <18.5, hematocrit <35%, albumin <3.4 g/dL, and creatinine >2.0 mg/dL. The association between complexity indices and frailty was explored by logistic regression and predictive ability by C-statistics. In total, 190 (52%) patients had frailty. The complexity index (MSEΣ) median (quartile 1, quartile 3) of SAP and MAP time series decreased significantly in frail patients (SAP: 8.32 [7.27, 9.24] v 9.13 [8.00, 9.72], p < 0.001 and MAP: 8.56 [7.56; 9.27] v 9.18 [8.26; 9.83], p < 0.001). MSE Σ demonstrated a fair predictive ability of frailty (C-statistic: SAP 0.62 and MAP 0.64). CONCLUSION: Preoperative BP complexity indices correlate and predict frailty. Impaired autonomic control is the underlying mechanism to explain this finding. A simple automated measure of preoperative BP complexity in the surgeon's office has the potential to reliably assess frailty.

Changes in nonlinear dynamic complexity measures of blood pressure during anesthesia for cardiac surgeries using cardio pulmonary bypass.

Nonlinear complexity measures computed from beat-to-beat arterial BP dynamics have shown associations with standard cardiac surgical risk indices. They reflect the physiological adaptability of a system and has been proposed as dynamical biomarkers of overall health status. We sought to determine the impact of anesthetic induction and cardiopulmonary bypass (CPB) upon the complexity measures computed from perioperative BP time series. In this prospective, observational study, 300 adult patients undergoing cardiac surgery were included. Perioperative period was divided as: (1) Preoperative (PreOp); (2) ORIS-induction to sternotomy; (3) ORSB- sternotomy to CPB; (4) ORposB-post CPB and within 30 min before leaving OR and (5) postoperative phase (PostOp)-initial 30 min in the cardiac surgical intensive care unit. BP waveforms for systolic (SAP), diastolic (DAP), mean arterial pressure (MAP) and pulse pressure (PP) were recorded, and their corresponding complexity index (MSE∑) was calculated. Significant decrease in MSE∑ from Preop to PostOp phases was observed for all BP time series. Maximum fall was seen during post anesthetic induction (ORIS) phase. Mild recovery during the subsequent phases was observed but they never reached the baseline values. In an exploratory analysis, preoperative MSE∑ showed a significant correlation with postoperative length of ICU stay. Blood pressure complexity varies at different time points and is not fixed for a given individual. Preoperative BP Complexity decreased significantly following anesthetic induction and did not recover to baseline until 30 min after surgery. Prevention of this significant fall may offer restoration of MSE∑ throughout surgery. Furthermore, preoperative BP complexity needs to be explored as a predictor of major postoperative adverse events by itself or in addition with the current risk indices.

Personalized pediatric anesthesia and pain management: problem-based review.

Pharmacogenetics, the genetic influence on the interpersonal variability in drug response, has enabled tailored pharmacotherapy and emerging 'personalized medicine.' Although oncology spearheaded the clinical implementation of personalized medicine, other specialties are rapidly catching up. In anesthesia, classical examples of genetically mediated idiosyncratic reactions have been long known (e.g., malignant hyperthermia and prolonged apnea after succinylcholine). The last two decades have witnessed an expanding body of pharmacogenetic evidence in anesthesia. This review highlights some of the prominent pharmacogenetic associations studied in anesthesia and pain management, with special focus on pediatric anesthesia.

The effect of a one-time 15-minute guided meditation (Isha Kriya) on stress and mood disturbances among operating room professionals: a prospective interventional pilot study.

Background: Operating room professionals are exposed to high levels of stress and burnout. Besides affecting the individual, it can compromise patient safety and quality of care as well. Meditation practice is getting recognized for its ability to improve wellness among various populations, including healthcare providers. Methods: Baseline stress levels of perioperative healthcare providers were measured via an online survey using a Perceived Stress Scale (PSS) questionnaire. An in-person meditation workshop was demonstrated during surgical grand rounds and an international anesthesia conference using a 15-minute guided Isha Kriya meditation. The participants were then surveyed for mood changes before and after meditation using a Profile of Mood States (POMS) questionnaire.  Results: Surgeons and anesthesiologists were found to have higher median (interquartile range) Perceived Stress Scores as compared to nurses respectively (17 [12, 20] and 17 [12, 21] vs 14 [9, 19]; P = 0.01). Total mood disturbances were found to be significantly reduced after meditation in both the surgical grand rounds (pre-meditation median [IQR] 99 [85, 112] vs 87 [80, 93] post-meditation; P < 0.0001) and anesthesia conference cohorts (pre-meditation 92 [86, 106] vs 87 [81, 92] post-meditation; P < 0.0001). Conclusions: Isha Kriya, a guided meditation, is easy to learn and takes less than 15 minutes to complete. This meditation technique improves mood changes and negative emotions among operating room professionals and could be used as a potential tool for improving wellness.

Sevoflurane-Based General Anesthesia Induction via Nasopharyngeal Endotracheal Tube Prior to Definitive Airway Control in Pediatric Oral Tumors.

Airway-related tumors in pediatrics are always challenging for anesthesiologists. We present 2 cases of friable, bleeding large tumors in the oral cavity where conventional methods of securing the airway were not possible. Induction of general anesthesia could potentially lead to complete airway collapse and catastrophic obstruction in such cases. Awake fibrotic intubation is limited in pediatric patients. We describe the innovative use of an endotracheal tube inserted blindly as a nasopharyngeal airway guided by end-tidal carbon dioxide trace. This allowed us to bypass the anatomical obstruction and induce anesthesia using sevoflurane in high-flow oxygen. By the described technique, we were able to maintain and assist the spontaneous breathing of the child as well. We also highlight limitations of the use of a conventional nasopharyngeal airway in such situations.

Sevoflurane and thoracic epidural anesthesia for trans-sternal thymectomy in a child with juvenile myasthenia gravis.

Literature on anesthetic management of juvenile myasthenia gravis (JMG) for thymectomy is limited. Recently, use of inhalational agents and total intravenous anesthesia with propofol and remifentanyl has been reported. All these techniques individually or in combination have been tried to avoid the use of muscle relaxant. We report successful use of sevoflurane as sole anesthetic agent for intubation and in combination with thoracic epidural anesthesia for intraoperative anesthetic management in a 5-year-old child with JMG.