RESUMEN
BACKGROUND: Intrathecal morphine is frequently administered after cesarean delivery to provide pain relief lasting up to 24 h. An enhanced recovery after cesarean pathways reduces the amount of postoperative opioids needed. The ideal dose of intrathecal morphine when combined with a pathway has not been determined. METHODS: This was a non-inferiority trial in 72 healthy women undergoing a scheduled cesarean delivery. Women were randomized to receive either 50 mcg, 150 mcg, or 250 mcg of intrathecal morphine during spinal anesthesia, with a standardized postoperative enhanced recovery pathway. The time to request supplemental opioids was the primary outcome. Secondary outcomes included pain scores, side effects, and quality of recovery at 24 h. RESULTS: The duration of analgesia with 50 mcg of morphine (median 24.5 h [IQR: 3.5-34.4]) was inferior to 150 mcg (29.4 h [24.5-72]), and both doses were inferior to 250 mcg (32 h [30.5-72]). Women who received 50 mcg morphine had higher pain scores than the other doses, received more supplemental opioids, and had lower quality recovery scores. The secondary outcomes between 150 mcg and 250 mcg were similar. Side effects were similar among all groups. 63% of women who received 250 mcg remained opioid-free at 72 h, compared to 150 mcg (52%) and 50 mcg (30%). CONCLUSIONS: The duration of analgesia using intrathecal morphine with an enhanced recovery pathway was longer with 250 mcg than with lower doses, and side effects were similar. 50 mcg provided inferior pain relief over 24 h. More than half of our patients avoided additional opioids for up to 72 h with either 150 mcg or 250 mcg doses. REGISTRATION: Clinical trial number NCT05069012.
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Analgesia Epidural , Morfina , Femenino , Humanos , Embarazo , Analgésicos Opioides , Método Doble Ciego , Manejo del Dolor , Dolor Postoperatorio/tratamiento farmacológicoRESUMEN
Anesthesiologists are critical members of the multidisciplinary team managing patients with suspected placenta accreta spectrum (PAS). Preoperatively, anesthesiologists provide predelivery consultation for patients with suspected PAS where anesthetic modality and invasive monitor placement is discussed. Additionally, anesthesiologists carefully assess patient and surgical risk factors to choose an anesthetic plan and to prepare for massive intraoperative hemorrhage. Postoperatively, the obstetric anesthesiologist hold unique skills to assist with postoperative pain management for cesarean hysterectomy. We review the unique aspects of peripartum care for patients with PAS who undergo cesarean hysterectomy and explain why these responsibilities are critical for achieving successful outcomes for patients with PAS. KEY POINTS: · Anesthesiologists are critical members of the multidisciplinary team planning for patients with suspected placenta accreta spectrum.. · Intraoperative preparation for massive hemorrhage is a key component of anesthetic care for patients with PAS.. · Obstetric anesthesiologists have a unique skill set to manage postpartum pain and postoperative disposition for patients with PAS who undergo cesarean hysterectomy..
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Anestesia , Placenta Accreta , Embarazo , Femenino , Humanos , Placenta Accreta/cirugía , Cesárea/efectos adversos , Pérdida de Sangre Quirúrgica , Histerectomía/efectos adversos , Estudios Retrospectivos , PlacentaRESUMEN
Placenta accreta spectrum (PAS) disorder is a potentially life-threatening condition that can occur during pregnancy. PAS puts pregnant individuals at a very high risk of major blood loss, hysterectomy, and intensive care unit admission. These patients should receive care in a center with multidisciplinary experience and expertise in managing PAS disorder. Obstetric anesthesiologists play vital roles in the peripartum care of pregnant patients with suspected PAS. As well as providing high-quality anesthesia care, obstetric anesthesiologists coordinate peridelivery care, drive transfusion-related decision making, and oversee postpartum analgesia. However, there are a number of key knowledge gaps related to the anesthesia care of these patients. For example, limited data are available describing optimal anesthesia staffing models for scheduled and unscheduled delivery. Evidence and consensus are lacking on the ideal surgical location for delivery; primary mode of anesthesia for cesarean delivery; preoperative blood ordering; use of pharmacological adjuncts for hemorrhage management, such as tranexamic acid and fibrinogen concentrate; neuraxial blocks and abdominal wall blocks for postoperative analgesia; and the preferred location for postpartum care. It is also unclear how anesthesia-related decision making and interventions impact physical and mental health outcomes. High-quality international multicenter studies are needed to fill these knowledge gaps and advance the anesthesia care of patients with PAS.
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Anestesia , Placenta Accreta , Hemorragia Posparto , Anestesia/efectos adversos , Transfusión Sanguínea , Cesárea , Femenino , Humanos , Histerectomía , Placenta Accreta/diagnóstico , Placenta Accreta/cirugía , Embarazo , Estudios RetrospectivosRESUMEN
OBJECTIVE: To describe global geographic variations in the diagnosis and management of placenta accreta spectrum (PAS). METHODS: An international cross-sectional study was conducted among PAS experts practicing at medical institutions in member states of the United Nations. Survey questions focused on diagnostic evaluation and management strategies for PAS. RESULTS: A total of 134 centers participated. Participating centers represented each of the United Nations' designated regions. Of those, 118 (88%) reported practicing in a medium-volume or high-volume center. First-trimester PAS screen was reported in 35 (26.1%) centers. Respondents consistently implement guideline-supported care practices, including utilization of ultrasound as the primary diagnostic modality (134, 100%) and implementation of multidisciplinary care teams (115, 85.8%). Less than 10% of respondents reported routinely managing PAS without hysterectomy; these centers were predominantly located in Europe and Africa. Antepartum management and availability of mental health support for PAS patients varied widely. CONCLUSION: Worldwide, there is a strong adherence to PAS care guidelines; however, regional variations do exist. Comparing variations in care to outcomes will provide insight into the clinically significant practice variability.
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Placenta Accreta , Estudios Transversales , Femenino , Humanos , Histerectomía , Grupo de Atención al Paciente , Placenta Accreta/diagnóstico por imagen , Placenta Accreta/terapia , Embarazo , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
BACKGROUND: Preparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe factors which influenced rapid cycle implementation of a novel comprehensive checklist for the perioperative care of the COVID-19 parturient. METHODS: Within our labour and delivery unit, implementation of a novel checklist for the COVID-19 parturient requiring perioperative care was accomplished through rapid cycling, debriefing and on-site walkthroughs. Post-implementation, consistent use of the checklist was reported for all obstetric COVID-19 perioperative cases (100% workflow checklist utilization). Retrospective analysis of the factors influencing implementation was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR). RESULTS: Analysis of factors influencing implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting, and characteristic of individuals (external pressures, baseline culture, and personal attributes) were perceived to act as early barriers. Constructs such as communication culture and learning climate, shifted in influence over time. CONCLUSION: We describe the influential factors of implementing a novel comprehensive obstetric workflow for care of the COVID-19 perioperative parturient during the first surge of the pandemic using the CFIR framework. Early workflow adoption was facilitated primarily by two domains, namely thoughtful innovation design and careful implementation planning in the setting of a long-standing culture of improvement. Factors initially assessed as barriers such as communication, culture and learning climate, transitioned into facilitators once a perceived benefit was experienced by healthcare teams. These results provide important information for the implementation of rapid change during a time of crisis.
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COVID-19 , SARS-CoV-2 , Lista de Verificación , Humanos , Investigación Cualitativa , Estudios RetrospectivosRESUMEN
BACKGROUND: Care of the pregnant patient during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic presents many challenges, including creating parallel workflows for infected and noninfected patients, minimizing waste of materials, and ensuring that clinicians can seamlessly transition between types of anesthesia. The exponential community spread of disease limited the time for development and training. METHODS: The goals of our workflow and process development were to maximize safety for staff and patients, minimize the risk of contamination, and reduce the waste of unused supplies and materials. We used a cyclical improvement system and the plus/delta debriefing method to rapidly develop workflows consisting of sequential checklists and procedure-specific packs. RESULTS: We designed independent workflows for labor analgesia, neuraxial anesthesia for cesarean delivery, conversion of labor analgesia to cesarean anesthesia, and general anesthesia. In addition, we created procedure-specific material packs to optimize supplies and prevent wastage. Finally, we generated sequential checklists to allow staff to perform standard operating procedures without extensive training. CONCLUSIONS: Collectively, these workflows and tools allowed our staff to urgently care for patients in high-risk situations without prior experience. Over time, we refined the workflows using a cyclical improvement system. We present our checklists and workflows as well as the system we used for their development, so that others may use them to their benefit.
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Servicio de Anestesia en Hospital/organización & administración , Anestesia Obstétrica , COVID-19/prevención & control , Lista de Verificación , Atención a la Salud/organización & administración , Control de Infecciones/organización & administración , Flujo de Trabajo , COVID-19/transmisión , Vías Clínicas/organización & administración , Femenino , Humanos , Embarazo , Mejoramiento de la Calidad/organización & administración , Indicadores de Calidad de la Atención de Salud/organización & administraciónRESUMEN
Transthoracic echocardiographic evaluation of the right ventricle is more difficult than the left ventricle and has not been well characterised in the parturient during delivery. As a preliminary investigation, our goal was to use bedside transthoracic echocardiography to evaluate right ventricular myocardial function before and after caesarean delivery. Term parturients undergoing caesarean delivery under spinal anaesthesia were enrolled. Echocardiography was performed pre- and postoperatively. Assessment of myocardial function included longitudinal myocardial strain using 2D-speckle tracking for both ventricles, and fractional area change for the right ventricle. Troponin-T, creatine kinase-muscle/brain and brain natriuretic peptide were measured pre- and postoperatively. One hundred patients were enrolled; 98 completed the study. Adequate images from both timepoints (pre- and postoperatively) were obtained in 85 patients for left ventricle assessment, and 66 for the right ventricle. Right ventricular fractional area change (mean (standard deviation)) (24.9% (8.9%) to 24.9% (9.2%); P = 0.99) and strain (-19.7% (6.8%) to -18.1% (6.5%); P = 0.08) measurements suggested mild baseline dysfunction and did not change after delivery. Left ventricular strain values were normal and unchanged after delivery (-23.8% (7.4%) to -24.3% (6.7%); P = 0.51). One patient had elevated troponin-T and demonstrated worse biventricular function. Elevation of brain natriuretic peptide (n=7) was associated with mildly decreased left ventricular strain, but creatine kinase-muscle/brain (n=4) was not associated with consistent changes in cardiac function. Further investigations into peripartum right ventricular function are required to validate the findings in this preliminary study. Findings of baseline mild right ventricular dysfunction and functional changes associated with troponin-T and brain natriuretic peptide warrant rigorous investigation.
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Cesárea , Ventrículos Cardíacos , Disfunción Ventricular Derecha , Ecocardiografía , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Embarazo , Disfunción Ventricular Derecha/diagnóstico , Función Ventricular DerechaRESUMEN
PURPOSE OF REVIEW: Post dural puncture headache (PDPH) is a relatively common complication which may occur in the setting of inadvertent dural puncture (DP) during labor epidural analgesia and during intentional DP during spinal anesthetic placement or diagnostic lumbar puncture. Few publications have established the long-term safety of an epidural blood patch (EBP) for the treatment of a PDPH. RECENT FINDINGS: The aim of this pilot study was to examine the association of chronic low back pain (LBP) in patients who experienced a PDPH following labor analgesia and were treated with an EBP. A total of 146 patients were contacted and completed a survey questionnaire via telephone. The EBP group was found to be more likely to have chronic LBP (percentage difference 20% [95% CI 6-33%], RR 2.6 [95% CI 1.3-5.2]) and also LBP < 6 (percentage difference 24% [95% CI 9- 37%], RR 2.3 [95% CI 1.3-4.1]). There were no significant differences in the severity and descriptive qualities of pain between the EBP and non-EBP groups. Our findings suggest that PDPH treated with an EBP is associated with an increased prevalence of subsequent low back pain in parturients. The findings of this pilot study should spur further prospective research into identifying potential associations between DP, EBP, and chronic low back pain.
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Analgesia Epidural/efectos adversos , Analgesia Obstétrica/efectos adversos , Parche de Sangre Epidural/efectos adversos , Dolor Crónico/epidemiología , Dolor de la Región Lumbar/epidemiología , Cefalea Pospunción de la Duramadre/terapia , Adulto , Estudios de Casos y Controles , Femenino , Humanos , Proyectos Piloto , Cefalea Pospunción de la Duramadre/complicacionesRESUMEN
Purpose of Review: Post dural puncture headache (PDPH) is a known and relatively common complication which may occur in the setting of patients undergoing lumbar punctures (LP) for diagnostic or therapeutic purposes, and is commonly treated with an epidural blood patch (EBP). There have been few publications regarding the long-term safety of EBP for the treatment of PDPH. Recent Findings: The aim of this pilot study was to examine any association of chronic low back pain (LBP) in patients who experienced a PDPH following a LP, and were treated with an EBP. A total of 49 patients were contacted and completed a survey questionnaire via telephone. There was no increased risk of chronic LBP in the dural puncture group receiving EBP (percentage difference 1% [95% CI -25% - 26%], RR: 0.98 [95% CI 0.49 - 1.99]) compared to the dural puncture group not receiving EBP. There were no significant differences in the severity and descriptive qualities of pain between the EBP and non-EBP groups. Both groups had higher prevalence of back pain compared to baseline. Summary: Our findings suggest that dural puncture patients undergoing EBP do not experience low back pain with increased frequency compared to dural puncture patients not undergoing EBP. Higher prevalence of LBP compared to baseline and compared to general population was seen in both groups. However, this pilot study is limited by a small sample size and no definitive conclusion can be drawn from this observation. The findings of this study should spur further prospective research into identifying potential associations between LP, EBP and chronic low back pain.
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Dolor de la Región Lumbar , Cefalea Pospunción de la Duramadre , Parche de Sangre Epidural , Humanos , Dolor de la Región Lumbar/etiología , Proyectos Piloto , Cefalea Pospunción de la Duramadre/epidemiología , Cefalea Pospunción de la Duramadre/etiología , Cefalea Pospunción de la Duramadre/terapia , Punción Espinal/efectos adversosAsunto(s)
Hipoxia/etiología , Postura/fisiología , Trastornos Puerperales/etiología , Apnea Obstructiva del Sueño/etiología , Cesárea/efectos adversos , Parto Obstétrico/métodos , Femenino , Humanos , Hipoxia/prevención & control , Posicionamiento del Paciente/efectos adversos , Posicionamiento del Paciente/métodos , Complicaciones Posoperatorias/prevención & control , Trastornos Puerperales/prevención & control , Método Simple Ciego , Apnea Obstructiva del Sueño/prevención & control , Posición Supina/fisiologíaRESUMEN
The molecular mechanisms underlying seizure susceptibility in preeclampsia are unknown. We hypothesized that altered expression of distinct proteins in the cerebrospinal fluid (CSF) may reflect pathophysiological changes in the central nervous system that contribute to the neurological manifestations of severe preeclampsia. We obtained CSF samples from 13 patients with preeclampsia and 14 control patients during spinal anesthesia before delivery and analyzed them by SOMAscan, an aptamer-based proteomics platform for alterations in 1310 protein levels. Ingenuity Pathway Analysis was conducted to highlight relationships between preeclampsia-specific proteins found to be significantly altered. For 2 of the target proteins, we validated the difference in CSF concentrations by ELISA. SOMAscan revealed 82 proteins, whose expression levels were significantly different (P<0.05) in CSF from patients with preeclampsia versus controls. Principal component analysis achieved perfect separation of the preeclampsia and control groups in 2 dimensions. The differentially expressed proteins converge around 4 signaling molecules: TGF-ß (transforming growth factor-ß), VEGFA (vascular endothelial growth factor A), angiotensinogen, and IL-6 (interleukin-6). Within the TGF-ß pathway, upregulation of activin A (301.6±47.4 versus 151.6±20.5 pg/mL; P=0.0074) and follistatin-related gene (5129±347 versus 3016±188 pg/mL; P<0.0001) in preeclampsia was confirmed by ELISA. In summary, signaling pathways important for vascular remodeling, inflammation, and neuronal growth, signaling, and electrophysiology were well represented among the proteins found to be altered in CSF in patients with preeclampsia.
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Proteínas del Líquido Cefalorraquídeo/líquido cefalorraquídeo , Preeclampsia/líquido cefalorraquídeo , Proteómica/métodos , Adulto , Biomarcadores/líquido cefalorraquídeo , Ensayo de Inmunoadsorción Enzimática , Femenino , Humanos , Embarazo , PronósticoRESUMEN
OBJECTIVE: To evaluate whether maintaining a motor-sparing epidural analgesia infusion affects the duration of the second stage of labor in nulliparous parturients compared with a placebo control. METHODS: We conducted a double-blind, randomized, placebo-controlled trial involving nulliparous women with term cephalic singleton pregnancies who requested epidural analgesia. All women received epidural analgesia for the first stage of labor using 0.08% ropivacaine with 0.4 micrograms/mL sufentanil with patient-controlled epidural analgesia. At the onset of the second stage of labor, women were randomized to receive a blinded infusion of the same solution or placebo saline infusion. The primary outcome was the duration of the second stage of labor. A sample size of 200 per group (400 total) was planned to identify at least a 15% difference in duration. RESULTS: Between March 2015 and September 2015, 560 patients were screened and 400 patients (200 in each group) completed the study. Using an intention-to-treat analysis, the duration of the second stage was similar between groups (epidural 52±27 minutes compared with saline 51±25 minutes, P=.52). The spontaneous vaginal delivery rate was also similar (epidural 193 [96.5%] compared with saline 198 [99%], P=.17). Pain scores were similar between groups at each measurement during the second stage. More women who received placebo reported satisfaction scores of 8 or less (epidural 32 [16%] compared with saline 61 [30.5%], P=.001). CONCLUSION: Maintaining the infusion of epidural medication had no effect on the duration of the second stage of labor compared with a placebo infusion. Maternal and neonatal outcomes were similar. A low concentration of epidural local anesthetic does not affect the duration of the second stage of labor. CLINICAL TRIAL REGISTRATION: Chinese Clinical Trial Register, http://www.chictr.org.cn/enindex.aspx, ChiCTR-IOR-15005875.
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Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Analgésicos/administración & dosificación , Dolor de Parto/tratamiento farmacológico , Segundo Periodo del Trabajo de Parto/efectos de los fármacos , Amidas/administración & dosificación , Método Doble Ciego , Femenino , Humanos , Embarazo , Ropivacaína , Sufentanilo/administración & dosificación , Factores de Tiempo , Resultado del TratamientoRESUMEN
This special article presents potentially important trends and issues affecting the field of obstetric anesthesia drawn from publications in 2015. Both maternal mortality and morbidity in the United States have increased in recent years because, in part, of the changing demographics of the childbearing population. Pregnant women are older and have more pre-existing conditions and complex medical histories. Cardiovascular and noncardiovascular medical diseases now account for half of maternal deaths in the United States. Several national and international organizations have developed initiatives promoting optimal obstetric and anesthetic care, including guidelines on the obstetric airway, obstetric cardiac arrest protocols, and obstetric hemorrhage bundles. To deal with the increasing burden of high-risk parturients, the national obstetric organizations have proposed a risk-based classification of delivery centers, termed as Levels of Maternal Care. The goal of this initiative is to funnel more complex obstetric patients toward high-acuity centers where they can receive more effective care. Despite the increasing obstetric complexity, anesthesia-related adverse events and morbidity are decreasing, possibly reflecting an ongoing focus on safe systems of anesthetic care. It is critical that the practice of obstetric anesthesia expand beyond the mere provision of safe analgesia and anesthesia to lead in developing and promoting comprehensive safety systems for obstetrics and team-based coordinated care.
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Anestesia Obstétrica/tendencias , Congresos como Asunto/tendencias , Parto Obstétrico/tendencias , Mortalidad Materna/tendencias , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/métodos , Parto Obstétrico/efectos adversos , Parto Obstétrico/métodos , Femenino , Humanos , Errores Médicos/prevención & control , Errores Médicos/tendencias , Morbilidad , Embarazo , Complicaciones del Embarazo/diagnóstico , Complicaciones del Embarazo/mortalidad , Complicaciones del Embarazo/terapia , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: Understanding of the workflow of perioperative ultrasound (US) examination is an integral component of proficiency. Workflow consists of the practical steps prior to executing an US examination (eg, equipment operation). Whereas other proficiency components (ie, cognitive knowledge and manual dexterity) can be tested, workflow understanding is difficult to define and assess due to its contextual and institution-specific nature. The objective was to define the workflow components of specific perioperative US applications using an iterative process to reach a consensus opinion. DESIGN: Expert consensus, survey study. SETTING: Tertiary university hospital. PARTICIPANTS: This study sought expert consensus among a focus group of 9 members of an anesthesia department with experience in perioperative US. Afterward, 257 anesthesia faculty members from 133 academic centers across the United States were surveyed. INTERVENTIONS: A preliminary list of tasks was designed to establish the expectations of workflow understanding by an anesthesiology resident prior to clinical exposure to perioperative US. This list was modified by a focus group through an iterative process. Afterwards, a survey was sent to faculty members nationwide, and Likert scale ratings for each task were obtained and reviewed during a second round. MEASUREMENTS AND MAIN RESULTS: Consensus among members of the focus group was reached after 2 iterations. 72 participants responded to the nationwide survey (28%), and consensus was reached after the second round (Cronbach's α = 0.99, ICC = 0.99) on a final list of 46 workflow-related tasks. CONCLUSIONS: Specific components of perioperative US workflow were identified. Evaluation of workflow understanding may be combined with cognitive knowledge and manual dexterity testing for assessing proficiency in perioperative US.
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Anestesiología/organización & administración , Atención Perioperativa/normas , Ultrasonografía/normas , Flujo de Trabajo , Anestesiología/educación , Anestesiología/normas , Competencia Clínica , Educación de Postgrado en Medicina/métodos , Grupos Focales , Humanos , Atención Perioperativa/métodos , Análisis y Desempeño de Tareas , Estados UnidosRESUMEN
BACKGROUND: Proficiency in transthoracic echocardiography (TTE) requires an integration of cognitive knowledge and psychomotor skills. Whereas cognitive knowledge can be quantified, psychomotor skills are implied after repetitive task performance. We applied motion analyses to evaluate psychomotor skill acquisition during simulator-based TTE training. METHODS AND RESULTS: During the first month of their fellowship training, 16 cardiology fellows underwent a multimodal TTE training program for 4 weeks (8 sessions). The program consisted of online and live didactics as well as simulator training. Kinematic metrics (path length, time, probe accelerations) were obtained at the start and end of the course for 8 standard TTE views using a simulator. At the end of the course TTE image acquisition skills were tested on human models. After completion of the training program the trainees reported improved self-perceived comfort with TTE imaging. There was also an increase of 8.7% in post-test knowledge scores. There was a reduction in the number of probe accelerations [median decrease 49.5, 95% CI = 29-73, adjusted P < 0.01], total time [median decrease 10.6 s, 95% CI = 6.6-15.5, adjusted P < 0.01] and path length [median decrease 8.8 cm, 95% CI = 2.2-17.7, adjusted P < 0.01] from the start to the end of the course. During evaluation on human models, the trainees were able to obtain all the required TTE views without instructor assistance. CONCLUSION: Simulator-derived motion analyses can be used to objectively quantify acquisition of psychomotor skills during TTE training. Such an approach could be used to assess readiness for clinical practice of TTE.
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Cardiología/educación , Competencia Clínica , Ecocardiografía , Movimiento (Física) , Adulto , Algoritmos , Fenómenos Biomecánicos , Evaluación Educacional , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Maniquíes , Desempeño PsicomotorRESUMEN
BACKGROUND: A gender-neutral threshold aneurysm diameter (AD) of more than 5.5 cm for surgical intervention in abdominal aortic aneurysms (AAA) ignores the fact that women have a smaller baseline AD. We hypothesized that women have a greater AD relative to body surface area (BSA) at the time of surgery and that this worsens outcome. METHODS: The Vascular Study Group of New England database was queried for elective AAA repairs performed from 2003 to 2011 to compare BSA-indexed AD, ie, aortic size index (ASI), between men and women at the time of surgery and the impact of ASI on outcome. RESULTS: Women were older and had higher ASI among both open-repair (n = 1,566) and endovascular repair (n = 2,172) patients (P < .001). Among open-repair patients, mean ASI for men undergoing repair at AD of 5.5 cm (2.75 cm/m²) was used to subdivide women into 2 categories: women with ASI of 2.75 or more were older (P < .001), had a larger aneurysm size (P < .001), and had a higher 1-year mortality (P = .042) than women with ASI less than 2.75. CONCLUSIONS: When indexed to BSA, women have a larger aneurysm size than men at the time of AAA repair.