431 A Perioperative Systems Design to Improve Intraoperative Glucose Monitoring Is Associated with a Reduction in Surgical Site Infections in a Diabetic Patient Population
Although periodic intraoperative blood sugar measurement may be appropriate in both diabetic patients and patients receiving insulin, it is often not measured. The effect of a perioperative glucose monitoring alert on diabetic patient outcomes was determined by comparing the outcomes of diabetic patients/patients with impaired glucose management in a preintervention cohort of 3,994 patients who underwent surgery before implementation of the alert system in July 2011 and a postintervention cohort of 11,901 patients who underwent surgery after implementation of the alert system. The rate of intraoperative glucose monitoring rose from 61.6 to 87.3% after the intervention. Hyperglycemia on postanesthesia care unit entry fell from 11.0 to 7.2% after the intervention while the rate of hypoglycemia was unchanged. The unadjusted surgical site infection rate fell from 1.5 to 1.0% after implementation of the alert system. See the accompanying Editorial View onpage 369.
409 Risk Factors and Clinical Outcomes Associated with Perioperative Transfusion-associated Circulatory Overload
To clarify risk factors for perioperative transfusion-associated circulatory overload (TACO) and improve understanding of its effect on clinical outcomes, a case–control study was conducted in patients who underwent noncardiac surgery, including 163 patients with evidence of TACO and up to five matched complication-free transfused controls (n = 726). There were significant relationships in the final multivariable model between TACO and increasing intravenous nonsanguineous fluid volume, blood product type (plasma and mixed blood products), emergency surgery, chronic kidney disease, left ventricular dysfunction, and preoperative β-blocker use. Patients who developed TACO had more need for postoperative mechanical ventilation (73.0 vs. 33.2%). In the TACO cohort, intensive care unit length of stay increased from 6.5 to 11.1 days and hospital length of stay increased from 5 to 12 days. Both short and long-term survival decreased in patients who experienced TACO (hazard ratio = 2.1). See the accompanying Editorial View onpage 363.
461 “Opt out” and Access to Anesthesia Care for Elective and Urgent Surgeries among U.S. Medicare Beneficiaries
In 2001, the United States Centers for Medicare and Medicaid Services issued a rule allowing states to “opt out” of the requirement that nurse anesthetists be supervised by a physician, the intent of which was to increase access to care. Medicare administrative claims data for 1,142,815 cases were used to determine the effect of “opt out” on access to anesthesia care using patient travel distances as a measure of access. Overall, “opt out” was not associated with an increase in access as measured by either the percentage of patients who avoided travel outside their home zip code or the travel distances. In addition, “opt out” had no effect on the use of anesthesia for patients undergoing colonoscopy/sigmoidoscopy, esophagogastroduodenoscopy, or cataract surgery. No effect was observed on travel distances for patients for whom “opt out” might have larger effects.
441 Does a Platelet Transfusion Independently Affect Bleeding and Adverse Outcomes in Cardiac Surgery?
The hypothesis that a single early platelet transfusion in patients undergoing cardiac surgery, in the absence of concomitant red blood cell or plasma transfusion, is associated with fewer bleeding complications and more adverse events was tested in 169 patients who received one transfusion between 1997 and 2013 and 507 propensity score matched control patients who did not receive a transfusion. Patients who received a platelet transfusion experienced less blood loss but required postoperative vasoactive medication, prolonged mechanical ventilation, prolonged intensive care unit stay, and transfusion of red blood cells, fresh frozen plasma, or platelets in the intensive care unit more often than did patients who did not receive platelets. Most of these observed associations were not strong. Early platelet transfusion was not associated with serious adverse outcomes like reinterventions for bleeding, thromboembolic complications, organ failure, or in-hospital mortality.
534 Influence of Ethanol on Oxycodone-induced Respiratory Depression: A Dose-escalating Study in Young and Elderly Individuals
Many visits to the emergency department because of misuse or abuse of legally prescribed opioids involve concomitant ethanol consumption, suggesting opioid-induced respiratory depression may be exacerbated by simultaneous ethanol intake. In a three-way sequential crossover ethanol dose-escalation study (0, 0.5, or 1.0 g/l breath concentration) conducted in 12 young and 12 older opioid naive volunteers, oxycodone alone (oral 20 mg immediate release) significantly reduced baseline minute ventilation, the slope of the hypercapnic ventilatory response curve, and minute ventilation at an end-tidal Pco2 of 55 mmHg. Baseline minute ventilation and minute ventilation at an end-tidal Pco2 of 55 mmHg were further impaired by the concomitant administration of ethanol, independent of dose. Older subjects were especially likely to have repeated apneic events produced by the ethanol–oxycodone combination, resulting in frequent episodes of oxygen desaturation.
482 Paradoxical Emergence: Administration of Subanesthetic Ketamine during Isoflurane Anesthesia Induces Burst Suppression but Accelerates Recovery
Ketamine anesthesia shares certain traits with rapid eye movement sleep, which is characterized by increased cortical activity and cholinergic tone and may prepare the brain for wakefulness. The hypothesis that administration of a subanesthetic dose of ketamine during isoflurane anesthesia would increase both cholinergic tone in the prefrontal cortex and high-frequency cortical activity and accelerate emergence once isoflurane was discontinued was tested in 20 adult male rats randomly assigned to receive either a saline control or ketamine injection. A single intraperitoneal injection of ketamine during isoflurane anesthesia both deepened the anesthetic state and facilitated recovery. It caused a significant increase in burst suppression ratio during isoflurane anesthesia and a significant reduction in emergence time once isoflurane was discontinued, with significant increases in both high-frequency cortical activation and acetylcholine release from the prefrontal cortex during the recovery period. See the accompanying Editorial View onpage 371.
376 Practice Guidelines for Preoperative Fasting and the Use of Pharma cologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures (Practice Parameters)
These Practice Guidelines update “Practice Guidelines for Perioperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration, An Updated Report” adopted by the American Society of Anesthesiologists in 2010 and published in 2011. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. The Guidelines include recommendations for preoperative assessment to identify patient conditions that may be associated with the risk of perioperative aspiration and preoperative fasting of clear liquids, breast milk, infant formula, as well as solids and nonhuman milk. It also includes recommendations for preoperative use of gastrointestinal stimulants (i.e., metoclopramide), blockers of gastric acid secretion (histamine-2 receptor antagonists and proton pump inhibitors), antacids, antiemetics, and anticholinergic agents (i.e., glycopyrrolate).
547 Perioperative Hyperglycemia Management: An Update (Clinical Concepts and Commentary)
The stress of anesthesia and surgery alters the finely regulated balance between hepatic glucose production and glucose utilization in peripheral tissues, potentially leading to hyperglycemia. Perioperative hyperglycemia is reported to occur in 20 to 40% of patients undergoing general surgery and approximately 80% of patients after cardiac surgery. Studies in both general and cardiac surgery patients as well as in intensive care unit patients have reported a clear association between patient hyperglycemia (blood glucose more than 180 mg/dl) and adverse clinical outcomes, including surgical site infections, delayed wound healing, and increased length of stay. Treating elevated blood glucose has been reported to decrease morbidity. In addition to discussing these and related issues, the present Clinical Concepts and Commentary makes treatment recommendations for preoperative, intraoperative, and postoperative glycemic management. It also discusses perioperative glucose monitoring, including the limitations of point-of-care testing.