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Background: Worldwide, over 14% of individuals hospitalized for psychiatric reasons have readmissions to hospitals within 30 days after discharge. Predicting patients at risk and leveraging accelerated interventions can reduce the rates of early readmission, a negative clinical outcome (i.e., a treatment failure) that affects the quality of life of patient. To implement individualized interventions, it is necessary to predict those individuals at highest risk for 30-day readmission. In this study, our aim was to conduct a data-driven investigation to find the pharmacological factors influencing 30-day all-cause, intra- and interdepartmental readmissions after an index psychiatric admission, using the compendium of prescription data (prescriptome) from electronic medical records (EMR)., Methods: The data scientists in the project received a deidentified database from the Mount Sinai Data Warehouse, which was used to perform all analyses. Data was stored in a secured MySQL database, normalized and indexed using a unique hexadecimal identifier associated with the data for psychiatric illness visits. We used Bayesian logistic regression models to evaluate the association of prescription data with 30-day readmission risk. We constructed individual models and compiled results after adjusting for covariates, including drug exposure, age, and gender. We also performed digital comorbidity survey using EMR data combined with the estimation of shared genetic architecture using genomic annotations to disease phenotypes., Results: Using an automated, data-driven approach, we identified prescription medications, side effects (primary side effects), and drug-drug interaction-induced side effects (secondary side effects) associated with readmission risk in a cohort of 1275 patients using prescriptome analytics. In our study, we identified 28 drugs associated with risk for readmission among psychiatric patients. Based on prescription data, Pravastatin had the highest risk of readmission (OR = 13.10; 95% CI (2.82, 60.8)). We also identified enrichment of primary side effects (n = 4006) and secondary side effects (n = 36) induced by prescription drugs in the subset of readmitted patients (n = 89) compared to the non-readmitted subgroup (n = 1186). Digital comorbidity analyses and shared genetic analyses further reveals that cardiovascular disease and psychiatric conditions are comorbid and share functional gene modules (cardiomyopathy and anxiety disorder: shared genes (n = 37; P = 1.06815E-06))., Conclusions: Large scale prescriptome data is now available from EMRs and accessible for analytics that could improve healthcare outcomes. Such analyses could also drive hypothesis and data-driven research. In this study, we explored the utility of prescriptome data to identify factors driving readmission in a psychiatric cohort. Converging digital health data from EMRs and systems biology investigations reveal a subset of patient populations that have significant comorbidities with cardiovascular diseases are more likely to be readmitted. Further, the genetic architecture of psychiatric illness also suggests overlap with cardiovascular diseases. In summary, assessment of medications, side effects, and drug-drug interactions in a clinical setting as well as genomic information using a data mining approach could help to find factors that could help to lower readmission rates in patients with mental illness.

Background: Low bispectral index (BIS) and low mean arterial pressure (MAP) are associated with worse outcomes after surgery. We tested the hypothesis that a combination of these risk factors, a 'double low', is associated with death and major complications after cardiac surgery., Methods: We used data from 8239 cardiac surgical patients from two US hospitals. The primary outcomes were 30-day mortality and a composite of in-hospital mortality and morbidity. We examined whether patients who had a case-averaged double low, defined as time-weighted average BIS and MAP (calculated over an entire case) below the sample mean but not in the reference group, had increased risk of the primary outcomes compared with patients whose BIS and/or MAP were at or higher than the sample mean. We also examined whether a prolonged cumulative duration of a concurrent double low (simultaneous low MAP and BIS) increased the risk of the primary outcomes., Results: Case-averaged double low was not associated with increased risk of 30-day mortality {odds ratio [OR] 1.73 [95% confidence interval (CI) 0.94-3.18] vs reference; P =0.01} or the composite of in-hospital mortality and morbidity [OR 1.47 (95% CI 0.98-2.20); P =0.01] after correction for multiple outcomes. A prolonged concurrent double low was associated with 30-day mortality [OR 1.06 (95% CI 1.01-1.11) per 10-min increase; P =0.001] and the composite of in-hospital mortality and morbidity [OR 1.04 (95% CI 1.01-1.07), P =0.004]., Conclusions: A prolonged concurrent double low, but not a case-averaged double low, was associated with higher morbidity and mortality after cardiac surgery., (© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Preventable medical errors in the operating room are most often caused by ineffective communication and suboptimal team dynamics. TeamSTEPPS is a government-funded, evidence-based program that provides tools and education to improve teamwork in medicine. The study hospital implemented TeamSTEPPS in the operating room and merged the program with a surgical safety checklist. Audits were performed to collect both quantitative and qualitative information on time out (brief) and debrief conversations, using a standardized audit tool. A total of 1610 audits over 6 months were performed by live auditors. Performance was sustained at desired levels or improved for all qualitative metrics using χ 2 and linear regression analyses. Additionally, the absolute number of wrong site/side/person surgery and unintentionally retained foreign body counts decreased after TeamSTEPPS implementation.

Background: We tested the hypothesis that an electronic alert for a "double low" of mean arterial pressure less than 75 mmHg and a bispectral index less than 45 reduces the primary outcome of 90-day mortality., Methods: Adults having noncardiac surgery were randomized to receive either intraoperative alerts for double-low events or no alerts. Anesthesiologists were not blinded and not required to alter care based upon the alerts. The primary outcome was all-cause 90-day mortality., Results: Patients (20,239) were randomized over 33 months, and 19,092 were analyzed. After adjusting for age, comorbidities, and perioperative factors, patients with more than 60 min of cumulative double-low time were twice as likely to die (hazard ratio, 1.99; 95% CI, 1.2 to 3.2; P = 0.005). The median number of double-low minutes (quartiles) was only slightly lower in the alert arm: 10 (2 to 30) versus 12 (2 to 34) min. Ninety-day mortality was 135 (1.4%) in the alert arm and 123 (1.3%) in the control arm. The difference in percent mortality was 0.18% (99% CI, -0.25 to 0.61)., Conclusions: Ninety-day mortality was not significantly lower in patients cared for by anesthesiologists who received automated alerts to double-low states. Prolonged cumulative double-low conditions were strongly associated with mortality.

Objective: To design, develop and prototype clinical dashboards to integrate high-frequency health and wellness data streams using interactive and real-time data visualisation and analytics modalities., Materials and Methods: We developed a clinical dashboard development framework called electronic healthcare data visualization (EHDViz) toolkit for generating web-based, real-time clinical dashboards for visualising heterogeneous biomedical, healthcare and wellness data. The EHDViz is an extensible toolkit that uses R packages for data management, normalisation and producing high-quality visualisations over the web using R/Shiny web server architecture. We have developed use cases to illustrate utility of EHDViz in different scenarios of clinical and wellness setting as a visualisation aid for improving healthcare delivery., Results: Using EHDViz, we prototyped clinical dashboards to demonstrate the contextual versatility of EHDViz toolkit. An outpatient cohort was used to visualise population health management tasks (n=14,221), and an inpatient cohort was used to visualise real-time acuity risk in a clinical unit (n=445), and a quantified-self example using wellness data from a fitness activity monitor worn by a single individual was also discussed (n-of-1). The back-end system retrieves relevant data from data source, populates the main panel of the application and integrates user-defined data features in real-time and renders output using modern web browsers. The visualisation elements can be customised using health features, disease names, procedure names or medical codes to populate the visualisations. The source code of EHDViz and various prototypes developed using EHDViz are available in the public domain at http://ehdviz.dudleylab.org., Conclusions: Collaborative data visualisations, wellness trend predictions, risk estimation, proactive acuity status monitoring and knowledge of complex disease indicators are essential components of implementing data-driven precision medicine. As an open-source visualisation framework capable of integrating health assessment, EHDViz aims to be a valuable toolkit for rapid design, development and implementation of scalable clinical data visualisation dashboards., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Arterial blood pressure lability, defined as rapid changes in arterial blood pressure, occurs commonly during anaesthesia. It is believed that hypertensive patients exhibit more lability during surgery and that lability is associated with poorer outcomes. Neither association has been rigorously tested. We hypothesized that hypertensive patients have more blood pressure lability and that increased lability is associated with increased 30 day mortality., Methods: This was a retrospective single-centre study of surgical patients from July 2008 to December 2012. Intraoperative data were extracted from the electronic anaesthesia record. Lability was calculated as the modulus of the percentage change in mean arterial pressure between consecutive 5 min intervals. The number of episodes of lability >10% was tabulated. Multivariate logistic regression was performed to determine the association between lability and 30 day mortality using derivation and validation cohorts., Results: Inclusion criteria were met by 52 919 subjects. Of the derivation cohort, 53% of subjects were hypertensive and 42% used an antihypertensive medication. The median number of episodes of lability >10% was 9 (interquartile range 5-14) per patient. Hypertensive subjects demonstrated more lability than normotensive patients, 10 (5-15) compared with 8 (5-12), P<0.0001. In subjects taking no antihypertensive medication, lability >10% was associated with decreased 30 day mortality, odds ratio (OR) per episode 0.95 [95% confidence interval (CI) 0.92-0.97], P<0.0001. This result was confirmed in the validation cohort, OR 0.96 (95% CI 0.93-0.99), P=0.01, and in hypertensive patients taking no antihypertensive medication, OR 0.96 (95% CI 0.93-0.99), P=0.002. Use of any antihypertensive medication class reduced this effect., Conclusions: Intraoperative arterial blood pressure lability occurs more often in hypertensive patients. Contrary to common belief, increased lability was associated with decreased 30 day mortality., (© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

This article aims to discuss and provide insight into the effects of the increased use and price (from $12.43 to $35.40 in 2014) of intravenous acetaminophen, which has rapidly gained acceptance in the field of perioperative medicine. Overall use and characteristics are described for selected surgeries with absolute use particularly high in orthopedic surgeries associated with substantial costs (up to an additional $160,000 per year per hospital for just orthopedic use). The availability of large-scale data on costs and use of intravenous acetaminophen in the United States will greatly benefit the ongoing discussions on its place in current practice.

The anesthesiologist has been recognized as an integral member of the liver transplant team, and previous studies have demonstrated that inter-anesthesiologist variability can be a driver of outcomes for high-risk patients. We hypothesized that anesthesiologist experience, defined as the number of previous liver transplants performed at our institution, the Icahn School of Medicine at Mount Sinai, would be independently associated with outcomes for liver transplant patients. Eight hundred forty-nine liver transplants performed between January 2003 and January 2013 with a total of 22 anesthesiologists were analyzed. Each transplant was assigned an incremental case number that corresponded to the number of transplants that the attending anesthesiologist had already performed at our institution. Several perioperative covariates were controlled for in the context of a generalized linear mixed effects model to detail the influence of threshold levels of the incremental case number on the primary outcome, 30-day mortality, and a secondary outcome, 30-day graft failure. Sensitivity analyses were conducted to confirm the robustness of these findings. An incremental case number ≤ 5 was associated with a significantly greater risk of 30-day mortality (odds ratio = 2.24, 95% confidence interval = 1.11-4.54, P = 0.025), and there was evidence suggestive of a greater risk of 30-day graft failure (odds ratio = 1.93, 95% confidence interval = 0.95-3.93, P = 0.071). Sensitivity analyses ruled out threats to the validity of these findings, including dropout effects and time trends in the overall performance of the transplantation unit. In conclusion, this study shows that an anesthesiologist's level of experience has a significant effect on outcomes for liver transplant recipients, with increased mortality and possibly graft failure during a provider's first 5 cases. These findings may indicate the need for increased training and supervision for anesthesiologists joining the liver transplant team., (© 2014 American Association for the Study of Liver Diseases.)

Background: Blood pressure derangements are common in orthotopic liver transplantation (OLT), and are potentially associated with adverse outcomes if they are sustained. While this concept is often believed to be true, few have rigorously demonstrated the validity of this claim, especially in likely vulnerable OLT patients., Methods: We retrospectively investigated 827 patients who underwent OLT to determine the magnitude of these hemodynamic associations with adverse outcomes. The median value of the mean arterial pressure (MAP) and the fractional change in the median MAP between subsequent epochs (FCM) were calculated for every 5-minute epoch intraoperatively. Epochs were classified according to prespecified ranges of MAP and fractional changes in MAP (lability) between epochs. Multivariate stepwise logistic regression was used to model associations of risk factors and epochs of intraoperative blood pressure (BP) instability with primary (30-day mortality and/or graft failure) and secondary adverse outcomes., Results: Primary adverse outcomes occurred in 10.9% and 12.2% of patients for 30-day mortality and 30-day graft failure, respectively. Independent hemodynamic predictors for 30-day mortality and graft failure included sustained periods of MAP <50 mmHg and BP lability where the MAP changed >25%. All of these values were statistically significant., Conclusion: Although severe intraoperative hypotension and BP lability during OLT are often observed in current practice as consequences of major surgical manipulations and patient vulnerability, these are likely not benign conditions based on this retrospective analysis. Prospective trials are warranted to investigate the possibility that interventions tailored to avoidance of hypotension and BP lability may improve outcomes.

Pain during hospitalization and dissatisfaction with pain management are common. This project consisted of 4 phases: identifying a pain numeric rating scale (NRS) metric associated with patient satisfaction, identifying independent predictors of maximum NRS, implementing interventions, and evaluating trends in NRS and satisfaction. Maximum NRS was inversely associated with favorable pain satisfaction for both efficacy (n = 4062, χ(2) = 66.2, P < .001) and staff efforts (n = 4067, χ(2) = 30.3, P < .001). Independent predictors of moderate-to-severe maximum NRS were younger age, female sex, longer hospital stay, admitting department, psychoactive medications, and 10 diagnostic codes. After interventions, moderate-to-severe maximum NRS declined by 3.6% per quarter in 2010 compared with 2009. Satisfaction data demonstrated improvements in nursing units meeting goals (5.3% per quarter, r (2) = 0.67) and favorable satisfaction answers (0.36% per quarter, r (2) = 0.31). Moderate-to-severe maximum NRS was an independent predictor of lower likelihood of hospital discharge (likelihood ratio = 0.62; 95% confidence interval = 0.61-0.64). Targeted interventions were associated with improved inpatient pain management.

Objectives: The purpose of this study was to investigate whether patients with an elevated left ventricular mass index undergoing cardiac surgery were more likely to experience postoperative atrial and ventricular arrhythmias., Design: A retrospective analysis., Setting: A single tertiary care university hospital., Participants: One thousand consecutive patients undergoing all types of adult cardiac surgery., Interventions: With institutional review board approval, intraoperative transesophageal echocardiographic images were reviewed by a single reviewer. The left ventricular mass index was calculated using the American Society of Echocardiography-recommended formula. Medical charts were reviewed for the occurrence and type of clinically significant postoperative arrhythmias., Measurements and Results: Of the patients who had an elevated left ventricular mass index, 47.6% (225/473) developed clinically significant postoperative arrhythmias compared with 38.3% (142/371) of patients with a normal left ventricular mass index (odds ratio [OR] = 1.46; 95% confidence interval [CI], 1.11-1.93; p = 0.007). In the multivariate analysis, this finding remained statistically significant, controlling for the effects of age, weight, sex, surgery type, left ventricular function, functional status, left atrial dimensions, and a history of atrial fibrillation (OR = 1.40; 95% CI, 1.03-1.90 per 100-g/m(2) increase in the left ventricular mass index). An increased left ventricular mass index was also an independent predictor of the separate or combined occurrence of atrial or ventricular arrhythmias., Conclusions: An elevated left ventricular mass index was a strong independent predictor of clinically significant postoperative atrial and ventricular arrhythmias after adult cardiac surgery. Although prospective validation is required, targeting patients for arrhythmia prophylaxis therapy may be justified in patients with a left ventricular mass index >188 g/m(2)., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Increased left ventricular mass (LVM) is a well-recognized predictor of cardiovascular morbidity and mortality in epidemiological studies, but its impact on mortality after cardiac surgery is poorly defined. We hypothesized that patients with increased LVM index (LVMI) were more likely to have greater 30 day and 1 yr mortality., Methods: With IRB approval, intraoperative transoesophageal echocardiography images of 844 cardiac surgical patients were reviewed. LVMI was calculated using the American Society of Echocardiography recommended formula. Outcome variables studied were 30 day and 1 yr mortality., Results: Mortality within 30 days occurred in 28 patients (3.3%) and within 1 yr in 91 patients (10.8%). An almost linear relationship was found between increasing LVMI and the risk of mortality within 30 days of cardiac surgery. The odds ratio (OR) of dying within 30 days of surgery was 1.15 (95% confidence interval 1.01-1.31) per 20 g m(-2) increase in LVMI. This finding remained statistically significant in multivariate analysis controlling for the effects of age, weight, gender, surgery type, LV function, and functional status [OR=1.36 (1.11-1.66) per 20 g m(-2) increase]. Increased LVMI was not found to be a statistically significant predictor of 1 yr mortality., Conclusions: Increased LVMI, but not LV systolic function as measured by the fractional area of contraction (FAC) was identified as a strong independent predictor of perioperative mortality after adult cardiac surgery. The relationship between LVMI and risk of 30 day mortality was nearly linear. Furthermore, decreased FAC, and not LVMI, was a strong independent predictor of 1 yr mortality.

Background: Anesthesia information management system workstations in the anesthesia workspace that allow usage of non-record-keeping applications could lead to distraction from patient care. We evaluated whether non-record-keeping usage of the computer workstation was associated with hemodynamic variability and aberrancies., Methods: Auditing data were collected on eight anesthesia information management system workstations and linked to their corresponding electronic anesthesia records to identify which application was active at any given time during the case. For each case, the periods spent using the anesthesia information management system record-keeping module were separated from those spent using non-record-keeping applications. The variability of heart rate and blood pressure were also calculated, as were the incidence of hypotension, hypertension, and tachycardia. Analysis was performed to identify whether non-record-keeping activity was a significant predictor of these hemodynamic outcomes., Results: Data were analyzed for 1,061 cases performed by 171 clinicians. Median (interquartile range) non-record-keeping activity time was 14 (1, 38) min, representing 16 (3, 33)% of a median 80 (39, 143) min of procedure time. Variables associated with greater non-record-keeping activity included attending anesthesiologists working unassisted, longer case duration, lower American Society of Anesthesiologists status, and general anesthesia. Overall, there was no independent association between non-record-keeping workstation use and hemodynamic variability or aberrancies during anesthesia either between cases or within cases., Conclusion: Anesthesia providers spent sizable portions of case time performing non-record-keeping applications on anesthesia information management system workstations. This use, however, was not independently associated with greater hemodynamic variability or aberrancies in patients during maintenance of general anesthesia for predominantly general surgical and gynecologic procedures.

With the increasing use of anaesthesia information management systems (AIMS) there is the opportunity for different institutions to aggregate and share information both nationally and internationally. Potential uses of such aggregated data include outcomes research, benchmarking and improvement in clinical practice and patient safety. However, these goals can only be achieved if data contained in records from different sources are truly comparable and there is semantic inter-operability. This paper describes the development of a standard terminology for anaesthesia and also a Domain Analysis Model and implementation guide to facilitate a standard representation of AIMS records as extensible markup language documents that are compliant with the Health Level 7 Version 3 clinical document architecture. A representation of vital signs that is compliant with the International Standards Organization 11073 standard is also discussed.

Objectives: Optimal brain protection for aortic arch surgery remains unclear. This prospective study examined neurocognitive outcomes in cardiac and thoracic aortic surgical patients, including a small cohort who underwent selective cerebral perfusion., Methods: Fifty-seven adult cardiac and thoracic aortic surgical patients underwent preoperative and postoperative neurocognitive testing. Patients were divided into 3 groups. Group 1 patients underwent procedures with cardiopulmonary bypass alone (n = 24), group 2 patients with cardiopulmonary bypass and hypothermic circulatory arrest (n = 23), and group 3 patients with cardiopulmonary bypass, hypothermic circulatory arrest, and anterograde selective cerebral perfusion (n = 10). Changes in 14 neurocognitive test scores and 6 neurocognitive domain scores (Attention, Speed, Language, Memory, Executive Function, and Motor Function) were evaluated., Results: Multiple regression analyses examining the relationships of cardiopulmonary bypass time, hypothermic circulatory arrest time, and selective cerebral perfusion time with change in cognitive test performance revealed that selective cerebral perfusion time (range, 39-83 minutes) was a significant predictor of decline in performance on memory and language tests. Hypothermic circulatory arrest (range, 14-40 minutes) and cardiopulmonary bypass (range, 70-369 minutes) times were unrelated to decline., Conclusions: Complex thoracic aortic repairs requiring prolonged selective cerebral perfusion were associated with decline in neurocognitive function. It is unclear whether the complexity of the repair necessitating prolonged selective cerebral perfusion or the perfusion technique itself contributed to neurocognitive decline. Prospective multicenter neurocognitive evaluations are necessary to assess the relative merits of current brain protection strategies in thoracic aortic surgery., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Progress has been made in understanding strategic decision making influencing anesthesia groups' operating room business practices. However, there has been little analysis of the remaining gaps in our knowledge. We performed a needs assessment to identify unsolved problems in anesthesia business strategy based on Porter's Five Forces Analysis. The methodology was a narrative literature review. We found little previous investigation for 2 of the 5 forces (threat of new entrants and bargaining power of suppliers), modest understanding for 1 force (threat of substitute products or services), and substantial understanding for 2 forces (bargaining power of customers and jockeying for position among current competitors). Additional research in strategic decisions influencing anesthesia groups should focus on the threat of new entrants, bargaining power of suppliers, and the threat of substitute products or services.

Objective: The primary purpose of this study was to determine the practicality of long-term, postoperative neurocognitive assessment via remote Internet-based testing in a cohort of patients who had undergone cardiac or thoracic aortic surgery within the previous 6 years. The secondary aim of this study was to examine the relationships among hypothermic circulatory arrest time, cardiopulmonary bypass time, and selective cerebral perfusion time with long-term postoperative neurocognitive function, as assessed by this novel testing method., Methods: Three hundred patients who had undergone cardiac and/or proximal aortic surgery with cardiopulmonary bypass (n = 207), thoracic aortic surgery with hypothermic circulatory arrest (n = 67), or thoracic aortic surgery with hypothermic circulatory arrest and selective cerebral perfusion (n = 26) within the previous 6 years underwent Internet-based neurocognitive assessment., Results: The duration of hypothermic circulatory arrest was negatively associated with processing speed scores and memory scores; arrest duration greater than 21 to 24 minutes was negatively associated with response speed scores. These associations were independent of time since surgery, age at testing, and educational level. Neither cardiopulmonary bypass duration nor selective cerebral perfusion duration was associated with test score results., Conclusions: This study demonstrated the practicality of long-term neurocognitive assessment of patients who have undergone cardiac and thoracic aortic surgery by means of Internet-based computerized testing. Furthermore, there was a negative association between the duration of intraoperative hypothermic circulatory arrest and long-term postoperative neurocognitive function that needs further examination in prospective studies., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Surgical repair of the aortic arch remains technically challenging and is associated with considerable morbidity and mortality. Cerebral oximetry is a noninvasive technology that can monitor the regional oxygen saturation of the frontal cortex. We hypothesized that magnitude and duration of decreased intraoperative regional oxygen saturation was associated with postoperative organ dysfunction. Additionally, we sought to identify regional oxygen saturation threshold values that are predictive of organ dysfunction., Methods: The intraoperative regional oxygen saturation values of 30 patients undergoing aortic arch surgery were recorded and analyzed. Postoperative complications were categorized as "major" and "minor." Severe adverse outcome, extubation time, intensive care unit length of stay, and hospital length of stay data were collected and compared with the integrals of regional oxygen saturation and time (area under the threshold) spent beneath predetermined absolute threshold limits., Results: Twenty subjects underwent hemiarch replacement, and 10 subjects received total aortic arch replacements. There were 30 major and 29 minor complications identified. Sixteen (53.3%) patients had at least 1 major complication. Logistic regression showed statistically significant associations between area under the threshold and severe adverse outcome incidence for regional oxygen saturation thresholds of 60% (P = .038) and 65% (P = .025). Patients who spent more than 30 minutes under the absolute threshold of 60% had an extended hospital stay of 4 days leading to an additional cost of $8300.00., Conclusions: Our findings lend evidence to support the association of decreased perioperative cerebral oxygenation values with poor outcomes after aortic arch surgery., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To investigate the incidence of preanesthesia hypertension, case cancellation for hypertension, and association with postoperative outcomes., Design: Retrospective descriptive, univariate, and multivariate analyses of electronic anesthesia and hospital records., Setting: A large urban academic medical center., Participants: Adult elective surgical patients with preinduction blood pressure (BP) >140/90 mmHg during calendar years 2002 to 2008., Interventions: None., Measurements and Main Results: Preinduction hypertension was present in 21,126 of 209,985 (10%) patients, and the incidence of adverse outcomes (elevated troponin or in-hospital death) was 1.3% overall and 2.8% for the subset of patients with baseline systolic BP >200 mmHg. Independent predictors of adverse outcome included increased baseline systolic BP, intraoperative diastolic BP <85 mmHg, increased intraoperative heart rate, blood transfusion, and anesthetic technique, controlling for standard risk factors. A total of 69 hypertensive patients (0.3%) had surgery cancelled before the induction of anesthesia; 29 of these cancellations occurred among the 1,330 patients with baseline SBP >200 mmHg (2.2%). Among 42 "cancelled" patients who returned for surgery hours to years later, the average preinduction BP was 192/102 mmHg, and adverse cardiovascular outcomes occurred in 4.8%., Conclusions: The increasing severity of preinduction hypertension was an independent risk factor for postoperative myocardial injury/infarction or in-hospital death. Only a small percentage of cases with patients presenting with severe hypertension were cancelled, and the delay of surgery did not result in interval normalization of blood pressure., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objective. Vancomycin is administered widely to patients undergoing cardiac surgery as prophylaxis against resistant Gram-positive sternal wound and venous donor site infections. The purpose of this study was to determine the efficacy of a standardized prebypass and postbypass dosing regimen of vancomycin by assessing plasma concentrations in the immediate postoperative period and postoperative surgical site infections (SSIs). Design. Retrospective cohort study. Setting . Cardiothoracic surgical intensive care unit in a tertiary care academic medical center. Methods. A total of 34 consecutive adult patients who had undergone cardiac surgery with cardiopulmonary bypass (CPB) were analyzed retrospectively. Each patient received 1000 mg of vancomycin administered over 1 hour around the time of induction of anesthesia and 500 mg after discontinuation of CPB. Trough vancomycin levels were sampled in the intensive care unit 12 hours after the last dose given in the operating room. Along with patient characteristics, postoperative readmission rates and SSIs were recorded for 1 year after surgery. Results. The nadir serum vancomycin level before the next dose was 9.3 ± 4.5 µg/mL (mean ± standard deviation). One superficial SSI was noted. Readmission rate for SSIs was 2.94%. Conclusion . Vancomycin concentrations in the serum were greater than the minimum inhibitory concentration for most staphylococci ranging from 4 to 19.3 µg/mL producing acceptable therapeutic serum concentrations and low rate of infectious complications. Thus postbypass dosing is acceptable in vancomycin cardiac surgical prophylaxis.

Objectives: Advanced cardiac life support (ACLS) skills tend to degrade over time. There is mounting evidence that high-fidelity simulation (HFS) is advantageous to teaching ACLS. The aspects of HFS that enhance learning are not entirely clear, but the anxiety generated by a scenario may enhance retention through well-established learning pathways. We sought to determine whether an HFS with added emotional stress could provoke anxiety and, if so, whether or not participants learning ACLS would demonstrate better written and applied knowledge retention 6 months after their initial course., Methods: Twenty-five student volunteers from Year 1 and 2 at Mount Sinai School of Medicine were randomly assigned to a control group or an emotional content (EC) group for a sudden cardiac death management course. All subjects were monitored for heart rate and were assessed using the State-Trait Anxiety Inventory. Control group participants experienced an HFS in which actors were not scripted to add stress, whereas EC group participants were exposed to an emotionally charged environment using the same actors., Results: Participants across the two groups were well matched by resting heart rates, baseline anxiety and prior ACLS knowledge. The EC group participants experienced greater anxiety than controls (mean state anxiety score: 35.0 versus 28.2 [p<0.05]; average heart rate [HR]: 94.6 bpm versus 72.9 bpm [p<0.05]; maximum HR: 120.8 bpm versus 95.3 bpm [p<0.05]). Six months later, written test scores were similar, but the EC group participants achieved higher practical competency examination ('mega code') scores than controls (32.5 versus 25.0; p<0.05). Independent t-tests and Spearman rank coefficients were employed where applicable., Conclusions: Simulation with added emotional stressors led to greater anxiety during ACLS instruction but correlated with enhanced performance of ACLS skills after this course. The quantitative and qualitative values of added stressors need further exploration, but these values represent important variables in simulation-based education., (© Blackwell Publishing Ltd 2010.)

Neurological dysfunction and stroke following cardiac surgery and thoracic surgery requiring hypothermic circulatory arrest is a well-defined problem. The original studies in CABG patients identified risk factors, such as prior stroke and lower educational level. There is older evidence suggesting that higher perfusion pressures during cardiopulmonary bypass are helpful. Hyperthermia during rewarming on cardiopulmonary bypass and postoperative hyperthermia have been associated with adverse cognitive outcomes. Glucose management intraoperatively remains controversial, but most now advocate for moderate glucose control using insulin, if required. The subset of patients having thoracic aortic surgery requiring periods of aortic discontinuity are particularly problematic. A cerebral protection strategy should be determined, and this may include hypothermic circulatory arrest, selective cerebral perfusion, or retrograde cerebral perfusion. All of these techniques have been associated with good surgical outcomes, but there is little information on cognitive outcomes of thoracic aortic surgery.

The N-methyl-D-aspartate (NMDA) glutamate receptor antagonist ketamine may have rapid, albeit transient, antidepressant properties. This study in patients with treatment-resistant major depression (TRD) aimed to (1) replicate the acute efficacy of single-dose intravenous (i.v.) ketamine; (2) test the efficacy of the glutamate-modulating agent riluzole in preventing post-ketamine relapse; and (3) examine whether pretreatment with lamotrigine would attenuate ketamine's psychotomimetic effects and enhance its antidepressant activity. Twenty-six medication-free patients received open-label i.v. ketamine (0.5 mg/kg over 40 min). Two hours prior to infusion, patients were randomized to lamotrigine (300 mg) or placebo. Seventeen patients (65%) met response criterion (50% reduction from baseline on the Montgomery-Asberg Depression Rating Scale) 24 h following ketamine. Lamotrigine failed to attenuate the mild, transient side-effects associated with ketamine and did not enhance its antidepressant effects. Fourteen patients (54%) met response criterion 72 h following ketamine and proceeded to participate in a 32-d, randomized, double-blind, placebo-controlled, flexible-dose continuation trial of riluzole (100-200 mg/d). The main outcome measure was time-to-relapse. An interim analysis found no significant differences in time-to-relapse between riluzole and placebo groups [log-rank chi(2) = 0.17, d.f. = 1, p = 0.68], with 80% of patients relapsing on riluzole vs. 50% on placebo. The trial was thus stopped for futility. This pilot study showed that a sub-anaesthetic dose of i.v. ketamine is well-tolerated in TRD, and may have rapid and sustained antidepressant properties. Riluzole did not prevent relapse in the first month following ketamine. Further investigation of relapse prevention strategies post-ketamine is necessary.

Background: A single subanesthetic (intravenous) IV dose of ketamine might have rapid but transient antidepressant effects in patients with treatment-resistant depression (TRD). Here we tested the tolerability, safety, and efficacy of repeated-dose open-label IV ketamine (six infusions over 12 days) in 10 medication-free symptomatic patients with TRD who had previously shown a meaningful antidepressant response to a single dose., Methods: On day 1, patients received a 40-min IV infusion of ketamine (.5 mg/kg) in an inpatient setting with continuous vital-sign monitoring. Psychotomimetic effects and adverse events were recorded repeatedly. The primary efficacy measure was change from baseline in the Montgomery-Asberg Depression Rating Scale (MADRS) score. If patients showed a > or =50% reduction in MADRS scores on day 2, they received five additional infusions on an outpatient basis (days 3, 5, 8, 10, and 12). Follow-up visits were conducted twice-weekly for > or =4 weeks or until relapse., Results: Ketamine elicited minimal positive psychotic symptoms. Three patients experienced significant but transient dissociative symptoms. Side effects during and after each ketamine infusion were generally mild. The response criterion was met by nine patients after the first infusion as well as after the sixth infusion. The mean (SD) reduction in MADRS scores after the sixth infusion was 85% (12%). Postketamine, eight of nine patients relapsed, on average, 19 days after the sixth infusion (range 6 days-45 days). One patient remained antidepressant-free with minimal depressive symptoms for >3 months., Conclusions: These pilot findings suggest feasibility of repeated-dose IV ketamine for the acute treatment of TRD.

Background and Objectives: Minimally invasive surgery has been shown to decrease postoperative morbidity and length of stay for several laparoscopic procedures. We sought to retrospectively compare intraoperative surgical and anesthetic parameters, post-anesthetic care unit (PACU) length of stay, and hospital length of stay of patients who underwent robotic-assisted laparoscopic radical prostatectomy (RAP) versus open radical retropubic prostatectomy (ORP)., Methods: A retrospective investigation was performed using a urologic surgery database and an anesthesia electronic medical record. We queried information regarding 106 ORP patients from 2002 through 2007 and 575 RAP patients from 2007 through 2008., Results: Patients in the RAP group compared with ORP patients had reductions in surgical time, anesthesia time, estimated blood loss, crystalloid administration, and PACU and hospital length of stays. Compared with ORP procedures, intraoperative respiratory rates, peak inspiratory pressures, and arterial pressures in RAP procedures were higher; tidal volumes and heart rates were decreased; but end-tidal carbon dioxide concentrations were not different. In the RAP group, intraoperative complications included severe bradycardia, corneal abrasions, and 2 patients required reintubation. Surgically, no rectal perforations were noted, and no operative mortalities occurred., Conclusions: Our data demonstrate the safety and efficacy of RAP due to a combination of surgical and anesthetic factors.

Background: Surgical treatment for aortic arch disease requiring periods of circulatory arrest is associated with a spectrum of neurological sequelae. Cerebral oximetry can non-invasively monitor patients for cerebral ischaemia even during periods of circulatory arrest. We hypothesized that cerebral desaturation during circulatory arrest could be described by a mathematical relationship that is time-dependent., Methods: Cerebral desaturation curves obtained from 36 patients undergoing aortic surgery with deep hypothermic circulatory arrest (DHCA) were used to create a non-linear mixed model. The model assumes that the rate of oxygen decline is greatest at the beginning before steadily transitioning to a constant. Leave-one-out cross-validation and jackknife methods were used to evaluate the validity of the predictive model., Results: The average rate of cerebral desaturation during DHCA can be described as: Sct(o(2))[t]=81.4-(11.53+0.37 x t) (1-0.88 x exp (-0.17 x t)). Higher starting Sct(o(2)) values and taller patient height were also associated with a greater decline rate of Sct(o(2)). Additionally, a predictive model was derived after the functional form of a x log (b+c x delta), where delta is the degree of Sct(o(2)) decline after 15 min of DHCA. The model enables the estimation of a maximal acceptable arrest time before reaching an ischaemic threshold. Validation tests showed that, for the majority, the prediction error is no more than +/-3 min., Conclusions: We were able to create two mathematical models, which can accurately describe the rate of cerebral desaturation during circulatory arrest at 12-15 degrees C as a function of time and predict the length of arrest time until a threshold value is reached.

Introduction: We replaced a nearly fixed-salary academic physician compensation model with a mission-based productivity model with the goal of improving attending anesthesiologist productivity., Methods: The base salary system was stratified according to rank and clinical experience. The supplemental pay structure was linked to electronic patient records and a scheduling database to award points for clinical activity; educational, research, and administrative points systems were constructed in parallel. We analyzed monthly American Society of Anesthesiologist (ASA) unit data for operating room activity and physician compensation from 2000 through mid-2007, excluding the 1-yr implementation period (July 2004-June 2005) for the new model., Results: Comparing 2005-2006 with 2000-2004, quarterly ASA units increased by 14% (P = 0.0001) and quarterly ASA units per full-time equivalent increased by 31% (P < 0.0001), while quarterly ASA units per anesthetizing location decreased by 10% (P = 0.046). Compared with a baseline year (2001), Instructor and Assistant Professor faculty compensation increased more than Associate Professor and Professor faculty (P < 0.001) in both pre- and postimplementation periods. There were larger compensation increases for the postimplementation period compared with preimplementation across faculty rank groupings (P < 0.0001). Academic and educational output was stable., Discussion: Implementing a productivity-based faculty compensation model in an academic department was associated with increased mean supplemental pay with relatively fewer faculty. ASA units per month and ASA units per operating room full-time equivalent increased, and these metrics are the most likely drivers of the increased compensation. This occurred despite a slight decrease in clinical productivity as measured by ASA units per anesthetizing location. Academic and educational output was stable.

Anesthesia Information Management Systems (AIMS) display and archive perioperative physiological data and patient information. Although currently in limited use, the potential benefits of an AIMS with regard to enhancement of patient safety, clinical effectiveness and quality improvement, charge capture and professional fee billing, regulatory compliance, and anesthesia outcomes research are great. The processes and precautions appropriate for AIMS selection, installation, and implementation are complex, however, and have been learned at each site by trial and error. This collaborative effort summarizes essential considerations for successful AIMS implementation, including product evaluation, assessment of information technology needs, resource availability, leadership roles, and training.

Over the past several years office-based procedures with sedation have become increasingly more common. It must be appreciated that not all procedures are well suited for this type of environment. Unacceptable ones would include those associated with significant fluid shifts, post-operative pain, bleeding or procedures of long duration. Since esophagogastroduodenoscopy (EGD) and colonoscopy are relatively non-invasive, of short duration, and not associated with either fluid shifts or significant post-procedure discomfort. In appropriate patients, these procedures are well-suited to office-based practice.

Background: Availability of point-of-care testing (POCT) technology may lead to unnecessary testing and expense without improving outcomes. We tested the hypothesis that frequency of intraoperative blood testing (IBT) would increase in association with installation of POCT devices in our surgical suites., Methods: We performed a retrospective analysis of 38,115 electronic anesthesia records for cases performed in the 1 yr before and 1 yr after POCT installation. For each case, the frequency of IBT was tabulated and the change in frequency of IBT between the study periods was calculated for individual anesthesiologists, for the department as a whole, and for clusters of anesthetizing locations., Results: For the department as a whole, there was no significant change between the before and after study periods in the 13% proportion of cases in which IBT was obtained. For cases in which IBT was used, there was no significant increase in the number of IBTs per case., Conclusions: We found no significant increase in the overall utilization of IBT associated with POCT presence in noncardiothoracic operating rooms.

Free text fields are often used to store clinical drug data in electronic health records. The use of free text facilitates rapid data entry by the clinician. Errors in spelling, abbreviations, and jargon, however, limit the utility of these data. We designed and implemented an algorithm, using open source tools and RxNorm, to extract and normalize drug data stored in free text fields of an anesthesia electronic health record. The algorithm was developed using a training set containing drug data from 49,518 cases, and validated using a validation set containing data from 14,655 cases. Overall sensitivity and specificity for the validation set were 92.2% and 95.7% respectively. The mains sources of error were misspellings and unknown but valid drug names. These preliminary results demonstrate that free text clinical drug data can be efficiently extracted and mapped to a controlled drug nomenclature.

Perioperative myocardial ischemia is the single most important, potentially reversible risk factor for mortality and cardiovascular complications during and after noncardiac surgery. The influence of anesthetic choices and techniques on cardiac risk in noncardiac surgery is difficult to ascertain because of the low incidence of morbid cardiac outcomes in the surgical population as a whole. This article summarizes several areas (eg, perioperative betablockade, glucose management, and perioperative hemodynamics) that have been addressed in well-designed clinical trials.

Study Objective: To characterize the evolution of postoperative nausea and vomiting (PONV) prophylactic drug use., Design: Retrospective data extraction and analysis of electronic anesthesia records., Setting: Anesthesia department of an urban academic medical center., Measurements: 144,134 anesthetics given by 57 attending anesthesiologists were studied. Administered doses of droperidol, ondansetron, dexamethasone, and metoclopramide were tabulated for each year for each practitioner., Main Results: Ondansetron use in the periods before and after the Food and Drug Administration (FDA) warning concerning droperidol was 8% and 35%, respectively. Use of PONV prophylaxis increased for all included patient and anesthetic factors. Among those who used droperidol before the revised FDA warning, 61% stopped using it altogether. Afterwards, 75% (27-100%) of droperidol use was in combination with another agent., Conclusions: We found a significant and sustained decrease in droperidol use after the FDA-mandated labeling revision. We also found a significant increase in ondansetron use--an increase that exceeded the amount needed to substitute for the decreased droperidol use. The changes may be related to multiple factors, including the FDA warning, a trend toward more PONV prophylaxis, and the increasing predominance of serotonin antagonists for this indication.

Background: To reduce the incidence of surgical site infection, preoperative antibiotics should be administered within 60 min before surgical incision. The purpose of this study was to determine whether adding a visual interactive electronic reminder with a message related to antibiotic administration to our anesthesia information management system would increase compliance with prophylactic antibiotic guidelines., Methods: We retrospectively studied electronic anesthesia records of ambulatory and day-of-surgery admission surgical cases in which one of our usual prophylactic antibiotics was administered from June 2004 through December 2005, an interval that includes cases both before and after the February 2005 implementation of the new reminder. Compliance was defined as documented antibiotic administration within 60 min before the surgical procedure starting time. Noncompliant cases were divided into those in which dosing was too early or too late., Results: Compliance for 4987 cases before and 9478 cases after the reminder was implemented increased from 82.4% to 89.1% (P < 0.01). This increase was found both for attending anesthesiologists assisted by a resident or nurse anesthetist (82.9% before vs 89.1% after, P < 0.01) and for attending anesthesiologists working alone (80.1% before vs 89.3% after, P < 0.01). The improvement in compliance was associated with a decrease in the incidence of antibiotics administered too late (i.e., after surgical incision) (15.2% before vs 8.1% after, P < 0.01), but with no significant change in the incidence of antibiotics administered too early (i.e., more than 60 min before skin incision) (2.4% before vs 2.8% after, P = 0.07)., Conclusions: The implementation of a visual interactive electronic reminder regarding administration of preoperative antibiotics in an anesthesia information management system was associated with a sustained increase in compliance with surgical prophylactic antibiotic administration timing guidelines.