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Background: Postoperative delirium is a serious complication of surgery associated with prolonged hospitalisation, long-term cognitive decline, and mortality. This study aimed to determine whether targeting bispectral index (BIS) readings of 50 (light anaesthesia) was associated with a lower incidence of POD than targeting BIS readings of 35 (deep anaesthesia)., Methods: This multicentre randomised clinical trial of 655 at-risk patients undergoing major surgery from eight centres in three countries assessed delirium for 5 days postoperatively using the 3 min confusion assessment method (3D-CAM) or CAM-ICU, and cognitive screening using the Mini-Mental State Examination at baseline and discharge and the Abbreviated Mental Test score (AMTS) at 30 days and 1 yr. Patients were assigned to light or deep anaesthesia. The primary outcome was the presence of postoperative delirium on any of the first 5 postoperative days. Secondary outcomes included mortality at 1 yr, cognitive decline at discharge, cognitive impairment at 30 days and 1 yr, unplanned ICU admission, length of stay, and time in electroencephalographic burst suppression., Results: The incidence of postoperative delirium in the BIS 50 group was 19% and in the BIS 35 group was 28% (odds ratio 0.58 [95% confidence interval: 0.38-0.88]; P=0.010). At 1 yr, those in the BIS 50 group demonstrated significantly better cognitive function than those in the BIS 35 group (9% with AMTS ≤6 vs 20%; P<0.001)., Conclusions: Among patients undergoing major surgery, targeting light anaesthesia reduced the risk of postoperative delirium and cognitive impairment at 1 yr., Clinical Trial Registration: ACTRN12612000632897., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Study Design: A retrospective analysis of patient hospitalization and discharge records., Objective: To examine the association between race and inpatient postoperative complications following lumbar spinal fusion surgery., Summary of Background Data: Racial disparities in healthcare have been demonstrated across a range of surgical procedures. Previous research has identified race as a social determinant of health that impacts outcomes after lumbar spinal fusion surgery. However, these studies are limited in that they are outdated, contain data from a single institution, analyze small limited samples, and report limited outcomes. Our study aims to expand and update the literature examining the association between race and inpatient postoperative complications following lumbar spine surgery., Methods: We analyzed 267,976 patient discharge records for inpatient lumbar spine surgery using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky from 2007 through 2014. We used unadjusted bivariate analysis, adjusted multivariable, and stratified analysis to compare patient demographics, present-on-admission comorbidities, hospital characteristics, and complications by categories of race/ethnicity., Results: Black patients were 8% and 14% more likely than white patients to experience spine surgery specific complications (adjusted odds ratios [aOR]: 1.08, 95% confidence interval [CI]: 1.03-1.13) and general postoperative complications (aOR: 1.14, 95% CI: 1.07-1.20), respectively. Black patients, compared with white patients, also had increased adjusted odds of 30-day readmissions (aOR: 1.13, 95% CI: 1.07-1.20), 90-day readmissions (aOR: 1.07, 95% CI: 1.02-1.13), longer length of stay (LOS) (adjusted Incidence Rate Ratio: 1.15, 95% CI: 1.14-1.16), and higher total charges (adjusted Incidence Rate Ratio: 1.08, 95% CI: 1.07-1.09)., Conclusion: Our findings demonstrate that black patients, as compared with white patients, are more likely to have postoperative complications, longer postoperative lengths of stay, higher total hospital charges, and increased odds of 30- and 90-day readmissions following lumbar spinal fusion surgery., Level of Evidence: 4.

Study Objective: To understand the effect of obstructive sleep apnea on readmission rates and post-operative atrial fibrillation in the cardiac surgical population., Design: Retrospective cohort study., Setting: Administrative database consisting of 2007-2014 data from California, Florida, New York, Kentucky, and Maryland from the State Inpatient Databases, Healthcare Cost and Utilization Project., Patients: A total of 506,604 patients ≥18 years old who underwent coronary artery bypass grafting surgery (CABG) and/or valve surgery were included in the study. After excluding for death during the index hospitalization and missing data, 396,657 patients remained for 30-day readmission analysis., Interventions: None., Measurements: Primary outcomes were unadjusted rates and adjusted odds of 30-day readmission. Secondary outcomes included post-operative atrial fibrillation and readmission diagnoses. Bivariate associations were assessed between OSA status, covariates and potential confounders, and outcomes. Odds ratios (OR) with 95% confidence intervals (CI) were estimated. Statistical significance was assessed at p < 0.05., Main Results: The overall 30-day readmission rate was 17.2%, with a rate of 19.6% vs. 17.1% in the OSA vs. non-OSA group (p < 0.001). Patients with OSA had higher odds of 30-day readmission (OR = 1.08, 95% CI 1.06-1.11) and higher odds of developing post-operative atrial fibrillation (OR = 1.04, 95% CI 1.01-1.08) compared to non-OSA patients. The most common reason for readmission was atrial fibrillation (38.6%), with OSA patients presenting with atrial fibrillation more frequently than their counterparts (41.7% vs. 38.4%, p < 0.001)., Conclusions: Patients with OSA are at increased risk of 30-day readmission and post-operative atrial fibrillation following cardiac surgery compared to those without OSA. Although the importance of OSA is increasingly recognized, it remains a significant risk factor for post-operative readmissions and morbidity. Further research is needed to optimize perioperative management of patients with OSA, but these results highlight the importance of this disease on patient outcomes and healthcare costs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To compare in-hospital mortality, postoperative stroke, and combined stroke/mortality in carotid artery stenting (CAS) patients and carotid endarterectomy (CEA) patients., Design: Retrospective observational study using data from the State Inpatient Database, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality., Setting: All coded CAS or CEA hospitalizations from 2007 to 2014 in California, Florida, New York, Kentucky, and Maryland., Participants: A total of 198,120 patients, 18 years of age or older, undergoing CAS or CEA., Interventions: None., Measurements and Main Results: Primary outcomes of the study were unadjusted rates and adjusted odds of in-hospital mortality, postoperative stroke, postoperative cardiovascular complications, and combined stroke/mortality, before and after correcting for confounders, following either CEA or CAS. In multivariate logistic regression analyses, in each successive individual year, CAS was associated with higher odds of in-hospital mortality (odds ratio [OR] ≥1.5 and p < 0.05), postoperative stroke (OR ≥1.4 and p < 0.05), and combined stroke/mortality (OR ≥1.5 and p < 0.05). Similar significant results were obtained when multivariate logistic regression was stratified by symptomatology. Carotid artery stenting was associated with higher odds of cardiovascular complications in 2012 (OR = 1.5, p < 0.05) and lower odds in 2009 (OR = 0.8, p < 0.05)., Conclusion: This study associated carotid stenting, as compared to endarterectomy, with an increased risk of dying and/or stroke. These associations persisted after statistical adjustment for patient demographics, comorbidities, and symptomatology, as well as after post-stratification by patient symptomatology. Despite this study's large, representative sample and well-defined a priori statistical methods, further research into real-world revascularization outcomes with longer-term follow-up is needed to formulate treatment guidelines., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Cerebrospinal-fluid (CSF) drainage is recommended by current guidelines for spinal protection during open and endovascular repairs of thoracic and thoraco-abdominal aortic aneurysms. In the published literature, great variability exists in the rate of CSF-related complications and morbidity. Herein, we perform a systematic review and meta-analysis on the incidence of CSF drainage-related complications, and compare the complication rates between open and endovascular repairs., Methods: The systematic review was conducted according to the Meta-Analysis of Observational Studies in Epidemiology guidelines. Thirty-four studies (4714 patients) were included in the quantitative analysis. The CSF drainage-related complications were categorised as mild, moderate, and severe. Pooled event rates for each complication category were estimated using a random-effect model. Random-effect uni- and multivariable meta-regression analyses were used to assess the effect of aortic-repair approach (open vs endovascular) and the CSF drainage criteria on CSF drainage-related complications., Results: The pooled event rates were 6.5% [95% confidence interval (CI): 4.3-9.8%] for overall complications, 2% (95% CI: 1.1-3.4%) for minor complications, 3.7% (95% CI: 2.5-5.6%) for moderate complications, and 2.5% (95% CI: 1.6-3.8%) for severe complications. The drainage-related-mortality pooled event rate was 0.9% (95% CI: 0.6-1.4%). The uni- and multivariable meta-regression analyses showed no difference in complication rates between the open and endovascular approaches, or between the different CSF drainage protocols., Conclusion: The complication rate for CSF drainage is not negligible. Our results help define a more accurate risk-benefit ratio for CSF drain placement at the time of repair of thoracic and thoraco-abdominal aneurysms., (Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objective: Post-operative delirium is associated with pre-operative cognitive difficulties and diminished functional independence, both of which suggest that brain pathology may be present in affected individuals prior to surgery. Currently, there are few studies that have examined imaging correlates of post-operative delirium. To our knowledge, none have examined the association of delirium with existing structural pathology in pre-operative cancer patients. Here, we present a novel, retrospective strategy to assess pre-operative structural brain pathology and its association with post-operative delirium. Standard of care structural magnetic resonance imaging (MRIs) from a cohort of surgical candidates prior to surgery were analyzed for white matter hyperintensities and cerebral atrophy., Methods: We identified 23 non-small cell lung cancer patients with no evidence of metastases in the brain pre-operatively, through retrospective chart review, who met criteria for post-operative delirium within 4 days of surgery. 24 age- and gender-matched control subjects were identified for comparison to the delirium sample. T1 and fluid-attenuated inversion recovery sequences were collected from standard of care pre-operative MRI screening and assessed for white matter pathology and atrophy., Results: We found significant differences in white matter pathology between groups with the delirium group exhibiting significantly greater white matter pathology than the non-delirium group. Measure of cerebral atrophy demonstrated no significant difference between the delirium and non-delirium group., Conclusions: In this preliminary study utilizing standard of care pre-operative brain MRIs for assessment of structural risk factors to delirium, we found white matter pathology to be a significant risk factor in post-operative delirium. Limitations and implications for further investigation are discussed., (Copyright © 2013 John Wiley & Sons, Ltd.)