Risk of cardiac events after elective versus urgent or emergent noncardiac surgery: Implications for quality measurement and improvement.

INTRODUCTION: Patient populations differ for elective vs urgent and emergent surgery. The effect of this difference on surgical outcome is not well understood and may be important for improving surgical safety. Our primary hypothesis was that there is an association of surgical acuity with risk of postoperative cardiac events. Secondarily, we examined elective vs urgent and emergent patients separately to understand patient characteristics that are associated with postoperative cardiac events. METHODS: We performed a retrospective cohort study of patients ≥65 years undergoing noncardiac elective or urgent/emergent surgery. Logistic regression estimated the association of surgical acuity with a postoperative cardiac event, which was defined as myocardial infarction or cardiac arrest within 30 days of surgery. For the secondary analysis, we modeled the outcome after stratifying by acuity. RESULTS: The study included 161,177 patients with 1014 cardiac events. The unadjusted risk of a postoperative cardiac event was 3.2 per 1000 among elective patients and 28.7 per 1000 among urgent and emergent patients (adjusted odds ratio 4.10, 95% confidence interval 3.56-4.72). After adjustment, increased age, higher baseline cardiac risk, peripheral vascular disease, hypertension, worse American Society of Anesthesiologist (ASA) physical classification, and longer operative time were associated with a postoperative cardiac event. Higher baseline cardiac risk was more strongly associated with postoperative cardiac events in elective patients. In contrast, worse ASA physical classification was more strongly associated with postoperative cardiac events in urgent and emergent patients. Black patients had higher odds of a postoperative cardiac event only in urgent and emergent patients compared to White patients. CONCLUSIONS: Quality measurement and improvement to address postoperative cardiac risk should consider patients based on surgical acuity.

Emotion regulation difficulties are associated with nightmares and suicide attempts in an adult psychiatric inpatient sample.

Although many studies have examined potential moderators of the relation between nightmares and suicide, few have examined emotion regulation, particularly utilizing severe populations such as psychiatric inpatients. The present study sought to investigate whether emotion regulation difficulties are associated with nightmares and suicide attempts in an inpatient sample. We included 2,683 psychiatric inpatients ranging from 18 to 81 years (M = 34.35, SD = 14.70). Nightmare frequency, emotion regulation difficulties, and their interaction predicted previous suicide attempts. Limitations include the homogeneity and cross-sectional nature of the sample. Suggestions for future study are discussed.

The reliability and clinical utility of ICD-11 schizoaffective disorder: A field trial.

A major goal for the revision of the International Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10) is to increase the clinical utility of the diagnostic system. Schizoaffective disorder has a history of poor diagnostic reliability due to the similarities and overlap in symptoms that it shares with other disorders, especially primary psychotic and mood disorders. The present study was part of the case-controlled field trials for ICD-11 and examines how the proposed changes for schizoaffective disorder may improve differential diagnosis and diagnostic accuracy. Clinicians from around the globe (n = 873) were provided with either ICD-10 or ICD-11 diagnostic guidelines and asked to apply them to case vignettes comparing schizoaffective disorder to schizophrenia and mood disorders with psychotic symptoms. Participants were asked to respond to follow-up diagnostic questions to determine which components of the diagnostic guidelines affected diagnostic accuracy. Overall, clinicians showed small improvements in accurately diagnosing vignettes using ICD-11 over ICD-10. Results suggest the discrepancy in diagnosing schizoaffective disorder is related primarily to the presence of mood symptoms and discrepancies about whether those symptoms are more consistent with schizoaffective disorder or a mood disorder diagnosis. Continuing to identify ways to more accurately capture this symptom picture will be important in the future as well as systematic efforts to educate clinicians about differential diagnosis.

Establishing an Acute Pain Service in Private Practice and Updates on Regional Anesthesia Billing.

Acute pain management is an expanding perioperative specialty and there is a renewed focus on implementing and developing an acute pain service (APS) in nonacademic hospitals (ie, "private practice"). An anesthesiologist-led APS can improve patient care by decreasing perioperative morbidity and potentially reducing the risk of chronic postsurgical pain syndromes. Elements of a successful APS include multidisciplinary collaboration to develop perioperative pain protocols, education of health care providers and patients, and regular evaluation of patient safety and quality of care metrics. Standardization of regional anesthesia procedures and billing practices can promote consistent outcomes and efficiency.

Sleep Disturbance, Activities of Daily Living, and Depressive Symptoms among Older Adults.

OBJECTIVE: Research suggests sleep disturbance plays a role in depression and risk for suicidal behavior (i.e., ideation, attempts, death by suicide). How sleep disturbance affects suicide risk is unclear and one's ability to perform activities of daily living (ADLs) may help explain this relation. This study examined associations between sleep problems, ADLs, and either depressive symptoms or suicide risk among older adults. We hypothesized that ADLs would mediate relations between sleep problems and depressive symptoms and suicide risk. METHOD: Participants (N = 134; age ≥65) were recruited through Amazon's Mechanical Turk. Participants completed questionnaires that assessed insomnia symptoms, nightmares, ADLs, depressive symptoms, and suicidal behaviors. RESULTS: Nightmares were associated with depressive symptoms and suicide risk but not independently associated with ADLs. Insomnia symptoms were associated with depressive symptoms, suicide risk, and ADLs. ADLs mediated the relation between insomnia symptoms and depressive symptoms. The insomnia symptom-suicidal behavior relation and the nightmare-suicidal behavior relation were significantly mediated by a pathway containing ADLs and depressive symptoms. DISCUSSION: ADLs help explain how insomnia symptoms and nightmares confer suicide risk among older adults, either independently or in association with depressive symptoms. CLINICAL IMPLICATIONS: Practitioners should attend to ADL performance when treating older adults with insomnia and depression.

Case Report of Serratus Plane Catheter for Pain Management in a Patient With Multiple Rib Fractures and an Inferior Scapular Fracture.

We placed a superficial serratus anterior plane catheter in an elderly woman with dementia and elevated clotting times who presented with multiple rib fractures after a mechanical fall. She was not a surgical candidate, and treatment consisted of conservative management with physical therapy and pain control. She was not a candidate for a patient-controlled analgesia regimen because of her dementia. Given her elevated international normalized ratio, thoracic epidural and paravertebral analgesia was also contraindicated. We placed an ultrasound-guided serratus anterior plane catheter, allowing titratable continuous infusion in a trauma patient, resulting in excellent analgesia without adverse effects.

Evaluating clinicians' representations of schizoaffective disorder.

BACKGROUND: Schizoaffective disorder (SAD) has routinely exhibited poor diagnostic accuracy and reliability. In addition to phenomenological problems with the definition of SAD, the way in which clinicians represent the symptoms of the disorder could contribute to its poor diagnostic outcomes. PURPOSE: The present study sought to examine clinicians' representations of SAD compared to schizophrenia (SCZ), bipolar disorder with psychotic features (BiPD-PSY), and major depressive disorder with psychotic features (MDD-PSY). METHOD: Participants (N=113) were clinicians recruited via email as part of a larger study. They were randomly assigned to either select symptoms from a predetermined criteria list or freely list features of the disorders based on their own mental representations. RESULTS: Participants' conceptualizations of SAD were not entirely congruent with DSM-5 criteria; they conceptualized it as less psychotic than SCZ and less affective than the two mood disorder tasks. SAD was conceptualized as significantly more depressive than manic. CONCLUSIONS: This study's findings support the notion that clinicians' conceptualizations of SAD are not entirely congruent with its DSM-5 criteria, which could contribute to diagnostic difficulties.

Ultrasound-Guided Genicular Nerve Thermal Radiofrequency Ablation for Chronic Knee Pain.

Osteoarthritis (OA) of the knee is one of the most common joint diseases affecting adults in the United States. For elderly patients with multiple medical comorbidities who do not wish to undergo total knee arthroplasty (TKA), lifestyle modification, pharmacologic management, and injections are the mainstay of therapy. Previously, pain management interventions were limited to intra-articular joint injections and viscosupplementation with hyaluronic acid. Fluoroscopic-guided techniques for radiofrequency ablation (RFA) of the genicular nerves have been previously described and a recent cadaveric study suggests that ultrasound-guided genicular nerve blocks can be performed accurately. We performed an ultrasound-guided radiofrequency ablation of the genicular nerves in 88-year-old woman who had deferred surgical management given her age. Following successful ultrasound guided diagnostic genicular nerve blocks, she proceeded to RFA using the same ultrasound guided technique. The procedure resulted in significant pain relief and improvement in overall function for greater than 6 months. The use of ultrasound provides a relatively rapid and noninvasive method to directly visualize genicular nerves and surrounding vasculature. Our case suggests that, for genicular nerve blockade and RFA, ultrasound may be a useful alternative to fluoroscopy. Not only did the procedure result in significant pain relief that has persisted for greater than 6 months but also more importantly her function status and quality of life were improved.

Quadratus lumborum catheters for breast reconstruction requiring transverse rectus abdominis myocutaneous flaps.

Patients diagnosed with breast cancer may opt to undergo surgical reconstructive flaps at the time of or after mastectomies. These surgeries leave patients with significant postoperative pain and sometimes involve large surgical beds including graft sites from the abdomen to reconstruct the breast. Consequently, multimodal methods of pain management have become highly favored. Quadratus lumborum catheters offer an opioid-sparing technique that can be performed easily and safely. We present a case of a patient who underwent a breast flap reconstruction and had bilateral quadratus lumborum catheters placed for perioperative pain control.

Are Clinicians Better Than Lay Judges at Recalling Case Details? An Evaluation of Expert Memory.

OBJECTIVE: This study examined the role of expertise in clinicians' memory for case details. Clinicians' diagnostic formulations may afford mechanisms for retaining and retrieving information. METHOD: Experts (N = 41; 47.6% males, 23.8% females; 28.6% did not report gender; age: mean [M] = 54.69) were members of the American Board of Professional Psychologists. Lay judges (N = 156; 25.4% males, 74.1% females; age: M = 18.85) were undergraduates enrolled in general psychology. Three vignettes were presented to each group, creating a 2 (group: expert, lay judge) x 3 (vignettes: simple, complex-coherent, complex-incoherent) mixed factorial design. Recall accuracy for vignette details was the dependent variable. RESULTS: Data analyses used multivariate analyses of variance to detect group differences among multiple continuous variables. Experts recalled more information than lay judges, overall. However, experts also exhibited more false memories for the complex-incoherent case because of their schema-based knowledge. CONCLUSIONS: This study supported clinical expertise as beneficial. Nonetheless, negative influences from experts' schema-based knowledge, as exhibited, could adversely affect clinical practices.

Best multimodal analgesic protocol for total knee arthroplasty.

Total knee arthroplasty is one of the most commonly performed operations in the USA. As with any elective joint surgery, the primary goal includes functional restoration that is not limited by pain. The use of peripheral nerve blocks for patients undergoing knee arthroplasty has resulted in decreased pain scores, improved early ambulation and decreased time to achieve hospital discharge criteria. Concern has been raised over the potential risks of femoral nerve block, and there has been growing support for the adductor canal block. It is the author's opinion that when not contraindicated, intraoperative neuraxial anesthesia combined with a continuous adductor canal block and a multimodal medication regimen for postoperative pain control is the best analgesic protocol for knee arthroplasty.

Management of intra-aortic balloon pumps.

Intra-aortic balloon pumps (IABPs) continue to be the most widely used cardiac support devices with an annual estimate of 200 000 IABPs placed worldwide. IABPs enhance myocardial function by maximizing oxygen supply and minimizing oxygen demand. The use of IABPs is not without risk, with major vascular injury, ischemia, and infection being the most common complications, especially in high-risk patients. While recent studies have questioned the use of IABPs in patients with cardiogenic shock secondary to myocardial infarction, these studies have limitations making it difficult to formulate definitive conclusions. This review will focus on the mechanisms of counterpulsation, the management of IABPs and the evidence supporting this ventricular support therapy.

Comparison of catheter tip migration using flexible and stimulating catheters inserted into the adductor canal in a cadaver model.

Use of adductor canal blocks and catheters for perioperative pain management following total knee arthroplasty is becoming increasingly common. However, the optimal equipment, timing of catheter insertion, and catheter dislodgement rate remain unknown. A previous study has suggested, but not proven, that non-tunneled stimulating catheters may be at increased risk for catheter migration and dislodgement after knee manipulation. We designed this follow-up study to directly compare tip migration of two catheter types after knee range of motion exercises. In a male unembalmed human cadaver, 30 catheter insertion trials were randomly assigned to one of two catheter types: flexible or stimulating. All catheters were inserted using an ultrasound-guided short-axis in-plane technique. Intraoperative knee manipulation similar to that performed during surgery was simulated by five sequential range of motion exercises. A blinded regional anesthesiologist performed caliper measurements on the ultrasound images before and after exercise. Changes in catheter tip to nerve distance (p = 0.547) and catheter length within the adductor canal (p = 0.498) were not different between groups. Therefore, catheter type may not affect the risk of catheter tip migration when placed prior to knee arthroplasty.

Anesthetic evaluation and management of a patient with thoracic endometriosis syndrome presenting for elective surgery.

Thoracic endometriosis syndrome is a relatively uncommon disorder characterized by recurrent pneumothoraces, hemothorax, chest pain, dyspnea, and hemoptysis within 48 to 72 hours of menstruation. A 34 year old, ASA physical status 2 woman with recurrent catamenial pneumothoraces due to thoracic endometriosis syndrome is presented. After treatment with video-assisted thoracoscopic surgery, she underwent successful elective diagnostic abdominal laparoscopy without incident. The presence of parenchymal injury and damage predisposes these patients to ventilator-induced lung injury. Postponement of surgery until the intermenstrual period, with lung protective ventilation, allows patients with this disease to successfully undergo general anesthesia and surgery.

Lung ischemia reperfusion injury: a bench-to-bedside review.

Lung ischemia reperfusion injury (LIRI) is a pathologic process occurring when oxygen supply to the lung has been compromised followed by a period of reperfusion. The disruption of oxygen supply can occur either via limited blood flow or decreased ventilation termed anoxic ischemia and ventilated ischemia, respectively. When reperfusion occurs, blood flow and oxygen are reintroduced to the ischemic lung parenchyma, facilitating a toxic environment through the creation of reactive oxygen species, activation of the immune and coagulation systems, endothelial dysfunction, and apoptotic cell death. This review will focus on the mechanisms of LIRI, the current supportive treatments used, and the many therapies currently under research for prevention and treatment of LIRI.

Anesthetic evaluation and perioperative management in a patient with new onset mediastinal mass syndrome presenting for emergency surgery.

Mediastinal mass syndrome (MMS) is a complex case that poses many challenges to the anesthesiologist. The cornerstone of management focuses on the potential hemodynamic changes associated with this syndrome. We describe the anesthetic management of a patient with a previously undiagnosed mediastinal mass presenting for emergency neurosurgical surgery.