Multi-Institutional Analysis of Outcomes in Supraglottic Jet Ventilation with a Team-Based Approach.

OBJECTIVES/HYPOTHESIS: To evaluate the safety and complications of endoscopic airway surgery using supraglottic jet ventilation with a team-based approach. STUDY DESIGN: Retrospective cohort study. METHODS: Subjects at two academic institutions diagnosed with laryngotracheal stenosis who underwent endoscopic airway surgery with jet ventilation between January 2008 and December 2018 were identified. Patient characteristics (age, gender, race, follow-up duration) and comorbidities were extracted from the electronic health record. Records were reviewed for treatment approach, intraoperative data, and complications (intraoperative, acute postoperative, and delayed postoperative). RESULTS: Eight hundred and ninety-four patient encounters from 371 patients were identified. Intraoperative complications (unplanned tracheotomy, profound or severe hypoxic events, barotrauma, laryngospasm) occurred in fewer than 1% of patient encounters. Acute postoperative complications (postoperative recovery unit [PACU] rapid response, PACU intubation, return to the emergency department [ED] within 24 hours of surgery) were rare, occurring in fewer than 3% of patient encounters. Delayed postoperative complications (return to the ED or admission for respiratory complaints within 30 days of surgery) occurred in fewer than 1% of patient encounters. Diabetes mellitus, active smoking, and history of previous tracheotomy were independently associated with intraoperative, acute, and delayed complications. CONCLUSIONS: Employing a team-based approach, jet ventilation during endoscopic airway surgery demonstrates a low rate of complications and provides for safe and successful surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2292-2297, 2021.

Comparison of a simplified nasal continuous positive airways pressure device with nasal cannula in obese patients undergoing colonoscopy during deep sedation: A randomised clinical trial.

BACKGROUND: Continuous positive airways pressure (CPAP) with a CPAP machine and mask has been shown to be more effective at minimising hypoxaemia than other devices under deep sedation. However, the efficacy of a new and simple CPAP device for spontaneously breathing obese patients during colonoscopy is unknown. OBJECTIVE: We hypothesised that oxygenation and ventilation in obese patients under deep sedation during colonoscopy using CPAP via a new nasal mask (SuperNO2VA) would be better than routine care with oxygen supplementation via a nasal cannula. DESIGN: Randomised study. SETTING: Single-centre, June 2017 to October 2017. PATIENTS: A total of 174 patients were enrolled and randomly assigned to Mask group or Control group. Thirty-eight patients were excluded and data from 136 patients underwent final analysis. INTERVENTION: Patients in the Mask group were provided with nasal CPAP (10 cmH2O) at an oxygen flow rate of 15 l min. In the Control group, patients were given oxygen via a nasal cannula at a flow rate of 5 l min. MAIN OUTCOME MEASURES: The primary outcome was elapsed time from anaesthesia induction to the first airway intervention. RESULTS: The elapsed time from anaesthesia induction to the first airway intervention was 19 ±â€Š10 min in the Mask group (n=63) vs. 10 ±â€Š12 min in the Control group (n=73, P < 0.001). In all, 87.5% (56/64) of patients achieved the target CPAP value. More patients in the Control group (63%) received airway intervention than in the Mask group (22%) (P < 0.001). Hypoxaemia (pulse oximeter oxygen saturation, SpO2 < 90%) occurred more frequently in the Control group (22%) than in the Mask group (5%) (P = 0.004). Minute ventilationPostinduction/minute ventilationBaseline and minute ventilationProcedure-end/minute ventilationBaseline was lower in the Control group than in the Mask group (P = 0.007 and 0.001, respectively). CONCLUSION: Application of a nasal mask at a target CPAP of 10 cmH2O improves ventilation and decreases the frequency and severity of hypoxaemia. TRIAL REGISTRATION: NCT03139448, registered at ClinicalTrials.gov.

Surgical Apgar score is associated with myocardial injury after noncardiac surgery.

STUDY OBJECTIVE: To assess the impact of intraoperative hemodynamics in the development of perioperative myocardial infarction (MI) and myocardial ischemia after noncardiac surgery. DESIGN: Single-center retrospective cohort study of surgical patients from 2007 to 2012. SETTING: Postanesthesia care unit, intensive care unit, and medical-surgical ward at an academic tertiary medical center. PATIENTS: A total of 46,799 adult noncardiac, nonthoracic surgery patients, for which 2290 peak cardiac troponin (cTn) levels were available. MEASUREMENTS: The 10-point Surgical Apgar Score (SAS) was calculated from intraoperative heart rate, blood pressure, and blood loss. Peak troponin (cTn) levels, hospital length of stay, 7- and 30-day postoperative mortality, patient demographics, and prior medical conditions were gathered. Troponin leak was defined as cTn-I 0.6 to 1.5 ng/mL or cTn-T 0.1 to 0.3 ng/mL; perioperative MI criteria were cTn-I greater than 1.5 ng/mL or cTn-T greater than 0.30 ng/mL. MAIN RESULTS: Of 46,799 noncardiac surgical cases, 209 (0.4%) and 192 (0.4%) suffered cTn leak and MI, respectively. Low SAS (0-4) was associated with increased risk of cTn leak and perioperative MI (univariate odds ratio, 2.76 and 2.06; 95% confidence interval, 2.20-3.45 and 1.57-2.70, respectively). In multivariable analysis, Surgical Apgar Score, age 65 years or older, American Society of Anesthesiologists physical status greater than or equal to III, emergency surgery, history of MI or hypertension, prolonged intraoperative tachycardia (heart rate >100 beats/min for >59 minutes), and prolonged hypotension (mean arterial pressure <40 mm Hg for >2 minutes) were independently associated with cTn leak and perioperative MI. CONCLUSIONS: Low SAS scores (0-4) may be associated with cTn elevation after noncardiac surgery. SAS-based risk stratification may guide perioperative cTn surveillance in lieu of routine postoperative screening.

Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices.

BACKGROUND: Despite evidence that use of a checklist during the pre-incision time out improves patient morbidity and mortality, compliance with performing the required elements of the checklist has been low. In an effort to improve compliance, a standardized time out interactive Electronic Checklist System [iECS] was implemented in all hospital operating room (OR) suites at 1 institution. The purpose of this 12-month prospective observational study was to assess whether an iECS in the OR improves and sustains improved surgical team compliance with the pre-incision time out. METHODS: Direct observational analyses of preprocedural time outs were performed on 80 cases 1 month before, and 1 and 9 months after implementation of the iECS, for a total of 240 observed cases. Three observers, who achieved high interrater reliability (kappa = 0.83), recorded a compliance score (yes, 1; no, 0) on each element of the time out. An element was scored as compliant if it was clearly verbalized by the surgical team. RESULTS: Pre-intervention observations indicated that surgical staff verbally communicated the core elements of the time out procedure 49.7 ± 12.9% of the time. After implementation of the iECS, direct observation of 80 surgical cases at 1 and 9 months indicated that surgical staff verbally communicated the core elements of the time out procedure 81.6 ± 11.4% and 85.8 ± 6.8% of the time, respectively, resulting in a statistically significant (P < .0001) increase in time out procedural compliance. CONCLUSION: Implementation of a standardized, iECS can dramatically increase compliance with preprocedural time outs in the OR, an important and necessary step in improving patient outcomes and reducing preventable complications and deaths.

Expansion of the surgical Apgar score across all surgical subspecialties as a means to predict postoperative mortality.

BACKGROUND: A surgical scoring system, akin to the obstetrician's Apgar score, has been developed to assess postoperative risk. To date, evaluation of this scoring system has been limited to general and vascular services. The authors attempt to externally validate and expand the Surgical Apgar Score across a wide breadth of surgical subspecialties. METHODS: Intraoperative data for 123,864 procedures including all surgical subspecialties were collected and associated with Surgical Apgar Scores (created by the summation of point values associated with the lowest mean arterial pressure, lowest heart rate, and estimated blood loss). Patients' death records were matched to the corresponding score, and logistic regression models were created in which mortality within 7, 30, and 90 days was regressed on the Apgar score. RESULTS: Lower Surgical Apgar Scores were associated with an increased risk of death. The magnitude of this association varied by subspecialty. Some subspecialties exhibited higher odds ratios, suggesting that the score is not as useful for them. For most of the subspecialties the association between the Apgar score and mortality decreased as the time since surgery increased, suggesting that predictive ability ceases to be helpful over time. After adjusting for the patient's American Society of Anesthesiologists classification, Apgar scores remained associated with death among most of the subspecialties. CONCLUSION: A previously published methodology for calculating risk among general and vascular surgical patients can be applied across many surgical services to provide an objective means of predicting and communicating patient outcomes in surgery as well as planning potential interventions.

Derivation and validation of Spo2/Fio2 ratio to impute for Pao2/Fio2 ratio in the respiratory component of the Sequential Organ Failure Assessment score.

OBJECTIVE: The Sequential Organ Failure Assessment (SOFA) score is validated to measure severity of organ dysfunction in critically ill patients. However, in some practice settings, daily arterial blood gas data required to calculate the respiratory component of the SOFA score are often unavailable. The objectives of this study were to derive Spo2/Fio2 (SF) ratio correlations with the Pao2/Fio2 (PF) ratio to calculate the respiratory parameter of the SOFA score, and to validate the respiratory SOFA obtained using SF ratios against clinical outcomes. PATIENTS AND MEASUREMENTS: We obtained matched measurements of Spo2 and Pao2 from two populations: group 1-patients undergoing general anesthesia and group 2-patients from the acute respiratory distress syndrome network-low-vs. high-tidal volume for the acute respiratory management of acute respiratory distress syndrome database. Using a linear regression model, we first determined SF ratios corresponding to PF ratios of 100, 200, 300, and 400. Second, we evaluated the contribution of positive end-expiratory pressure (PEEP) on the relationship between SF and PF, for patients on PEEP in centimeters of water (cm H2O) of <8, 8-12, and >12. Third, we calculated the SOFA scores in a separate cohort of intensive care unit patients using the derived SF ratios and validated them against clinical outcomes. RESULTS: The total SOFA scores calculated using SF ratios and PF ratios were highly correlated (Spearman's rho 0.85, p < 0.001) in all patients and in the three stratified PEEP categories (<8 cm H2O, Spearman's rho 0.87, p < 0.001; PEEP 8-12 cm H20, Spearman's rho 0.85, p < 0.001; PEEP >12 cm H2O, Spearman's rho 0.85, p < 0.001). The respiratory SOFA scores based on SF ratios and PF ratios correlated similarly with intensive care unit length of stay and ventilator-free days, when validated in a cohort of critically ill patients. CONCLUSION: The total and respiratory SOFA scores obtained with imputed SF values correlate with the corresponding SOFA score using PF ratios. Both the derived and original respiratory SOFA scores similarly predict outcomes.

Improving anesthesiologist performance through profiling and incentives.

STUDY OBJECTIVE: To determine the influence of profiling and incentives on anesthesiologist behavior in relation to several key indicators of performance. DESIGN: Prospective collection and analysis of operational data before and after implementation of a physician profiling, reporting, and incentive program. SETTING: University hospital. MEASUREMENTS: An intervention consisting of two components was studied with the intent of stimulating a high level of performance in relation to a peer group. The first component, a monthly report of physician performance via an individualized performance report, was provided to each physician for each of 6 months. The second component consisted of a financial incentive. For each month in the study, physicians were eligible to receive a variable financial incentive of between $0 and $500 per month depending on individual performance based scoring in relation to each other. Physician performance was tracked in five areas: 1) percentage of first cases of the day in the room at or before the scheduled in-room time, 2) percentage of cases with an anesthesia prep time less than a target, 3) percentage of cases delayed due to waiting for an anesthesiology patient evaluation, 4) percentage of cases delayed during the anesthesiology controlled time, and, 5) percentage of cases delayed due to waiting for the anesthesiology attending. Results were reported to each physician on a monthly basis, by e-mail distribution, of an individualized perioperative efficiency summary report. A monthly financial incentive was awarded to the top performing physicians in the form of a credit to the physician's personal CME/expense account. Also, all physicians received a rank order list of their performance on each indicator at the end of each month. MAIN RESULTS: 31 anesthesiologists, comprising the multispecialty division, and covering all services with the exception of obstetrics, pediatrics, and cardiothoracic anesthesia were tracked for 6 months. Compared to the first month, the percent of first cases of the day in the room at or before the scheduled start time and the percent of cases with an anesthesiology prep time less than target increased significantly (19 +/- 4.6%, vs. 61 +/- 6.5%, 95% CI, p <0.001; and 57 +/- 5.3%, vs. 73 +/- 5.1%, 95% CI, p <0 .001) during the sixth month. The mean number of cases per physician with a delay during anesthesiology controlled time decreased (14.9 +/- 2.9 vs. 3.3 +/- 1, p <0.001), no change occurred in the number of cases with a delay due to waiting for an anesthesiology patient evaluation or number of cases delayed due to waiting for the anesthesiology attending in the sixth month compared with the first month. CONCLUSION: Tracking and rewarding physician performance with monthly profiling and a financial incentive given to the best in a peer group improves anesthesiologist performance in several key areas.