Predictors for time to awake in patients undergoing awake craniotomies

OBJECTIVE Awake craniotomies are often characterized by alternating asleep-awake-asleep periods. Preceding the awake phase, patients are weaned from anesthesia and mechanical ventilation. Although clinicians aim to minimize the time to awake for patient safety and operating room efficiency, in some patients, the time to awake exceeds 20 minutes. The goal of this study was to determine the average time to awake and the factors associated with prolonged time to awake (> 20 minutes) in patients undergoing awake craniotomy. METHODS Records of patients who underwent awake craniotomy between 2003 and 2020 were evaluated. Time to awake was defined as the time between discontinuation of propofol and remifentanil infusion and the time of extubation. Patient and perioperative characteristics were explored as predictors for time to awake using logistic regression analyses. RESULTS Data of 307 patients were analyzed. The median (IQR) time to awake was 13 (10–20) minutes and exceeded 20 minutes in 17% (95% CI 13%–21%) of the patients. In both univariate and multivariable analyses, increased age, nonsmoker status, and American Society of Anesthesiologists (ASA) class III versus II were associated with a time to awake exceeding 20 minutes. BMI, as well as the use of alcohol, drugs, dexamethasone, or antiepileptic agents, was not significantly associated with the time to awake. CONCLUSIONS While most patients undergoing awake craniotomy are awake within a reasonable time frame after discontinuation of propofol and remifentanil infusion, time to awake exceeded 20 minutes in 17% of the patients. Increasing age, nonsmoker status, and higher ASA classification were found to be associated with a prolonged time to awake.

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Risk Factors and Indications for 30-Day Readmission After Primary Surgery for Epithelial Ovarian Cancer

International Journal of Gynecological Cancer ◽

10.1097/igc.0000000000000339 ◽

2015 ◽

Vol 25 (2) ◽

pp. 193-202 ◽

Cited By ~ 10

Author(s):

Mariam AlHilli ◽

Carrie Langstraat ◽

Christine Tran ◽

Janice Martin ◽

Amy Weaver ◽

...

Keyword(s):

Risk Factors ◽

Ovarian Cancer ◽

Postoperative Complications ◽

Epithelial Ovarian Cancer ◽

Odds Ratio ◽

Residual Disease ◽

Factors Associated ◽

Primary Surgery ◽

American Society ◽

American Society Of Anesthesiologists

BackgroundTo identify patients at risk for postoperative morbidities, we evaluated indications and factors associated with 30-day readmission after epithelial ovarian cancer surgery.MethodsPatients undergoing primary surgery for epithelial ovarian cancer between January 2, 2003, and December 29, 2008, were evaluated. Univariable and multivariable logistic regression models were fit to identify factors associated with 30-day readmission. A parsimonious multivariable model was identified using backward and stepwise variable selection.ResultsIn total, 324 (60.2%) patients were stage III and 91 (16.9%) were stage IV. Of all 538 eligible patients, 104 (19.3%) were readmitted within 30 days. Cytoreduction to no residual disease was achieved in 300 (55.8%) patients, and 167 (31.0%) had measurable disease (≤1 cm residual disease). The most common indications for readmission were surgical site infection (SSI; 21.2%), pleural effusion/ascites management (14.4%), and thromboembolic events (12.5%). Multivariate analysis identified American Society of Anesthesiologists score of 3 or higher (odds ratio, 1.85; 95% confidence interval, 1.18–2.89;P= 0.007), ascites [1.76 (1.11–2.81);P= 0.02], and postoperative complications during initial admission [grade 3–5 vs none, 2.47 (1.19–5.16); grade 1 vs none, 2.19 (0.98–4.85); grade 2 vs none, 1.28 (0.74–2.21);P= 0.048] to be independently associated with 30-day readmission (c-index = 0.625). Chronic obstructive pulmonary disease was the sole predictor of readmission for SSI (odds ratio, 3.92; 95% confidence interval, 1.07–4.33;P= 0.04).ConclusionsClinically significant risk factors for 30-day readmission include American Society of Anesthesiologists score of 3 or higher, ascites and postoperative complications at initial admission. The SSI and pleural effusions/ascites are common indications for readmission. Systems can be developed to predict patients needing outpatient management, improve care, and reduce costs.

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Postdischarge antibiotic use for prophylaxis following spinal fusion

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.117 ◽

2020 ◽

Vol 41 (7) ◽

pp. 789-798

Author(s):

David K. Warren ◽

Katelin B. Nickel ◽

Jennifer H. Han ◽

Pam Tolomeo ◽

Christopher J. Hostler ◽

...

Keyword(s):

Spinal Fusion ◽

Linear Models ◽

Prophylactic Antibiotic ◽

Antibiotic Use ◽

Prophylactic Antibiotics ◽

Factors Associated ◽

American Society ◽

American Society Of Anesthesiologists ◽

Surgical Admission ◽

Significant Factors

AbstractObjective:Despite recommendations to discontinue prophylactic antibiotics after incision closure or <24 hours after surgery, prophylactic antibiotics are continued after discharge by some clinicians. The objective of this study was to determine the prevalence and factors associated with postdischarge prophylactic antibiotic use after spinal fusion.Design:Multicenter retrospective cohort study.Patients:This study included patients aged ≥18 years undergoing spinal fusion or refusion between July 2011 and June 2015 at 3 sites. Patients with an infection during the surgical admission were excluded.Methods:Prophylactic antibiotics were identified at discharge. Factors associated with postdischarge prophylactic antibiotic use were identified using hierarchical generalized linear models.Results:In total, 8,652 spinal fusion admissions were included. Antibiotics were prescribed at discharge in 289 admissions (3.3%). The most commonly prescribed antibiotics were trimethoprim/sulfamethoxazole (22.1%), cephalexin (18.8%), and ciprofloxacin (17.1%). Adjusted for study site, significant factors associated with prophylactic discharge antibiotics included American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 1.31; 95% CI, 1.00–1.70), lymphoma (OR, 2.57; 95% CI, 1.11–5.98), solid tumor (OR, 3.63; 95% CI, 1.62–8.14), morbid obesity (OR, 1.64; 95% CI, 1.09–2.47), paralysis (OR, 2.38; 95% CI, 1.30–4.37), hematoma/seroma (OR, 2.93; 95% CI, 1.17–7.33), thoracic surgery (OR, 1.39; 95% CI, 1.01–1.93), longer length of stay, and intraoperative antibiotics.Conclusions:Postdischarge prophylactic antibiotics were uncommon after spinal fusion. Patient and perioperative factors were associated with continuation of prophylactic antibiotics after hospital discharge.

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Analysis of factors affecting reversal of Hartmann’s procedure and post-reversal complications

Scientific Reports ◽

10.1038/s41598-020-73791-w ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Jae Hyun Kang ◽

Byung Mo Kang ◽

Sang Nam Yoon ◽

Jeong Yeon Kim ◽

Jun Ho Park ◽

...

Keyword(s):

Medical Records ◽

Elective Surgery ◽

Multivariable Analysis ◽

Colorectal Disease ◽

Hartmann’S Procedure ◽

Class Iii ◽

Factors Affecting ◽

Hartmann's Procedure ◽

American Society ◽

American Society Of Anesthesiologists

Abstract Although Hartmann’s procedure (HP) is commonly used as emergency treatment for colorectal disease, the reversal of HP (HR) is infrequently performed. The aims were to evaluate the rate of HR and determine the factors predictive of achieving HR. We retrospectively reviewed the medical records of patients who underwent HP between January 2007 and June 2019 at six Hallym University-affiliated hospitals. Multivariable analysis was performed to identify which factors were independently associated with HR. In the study period, 437 patients underwent HP, and 127 (29.0%) subsequently underwent HR. Of these, 46 (35.9%) patients experienced post-HR complications. In multivariable analysis, an interval between HP and HR of > 6 months was associated with the only lower rate of post-HR complications. Multivariate analysis showed that HR was less likely in patients aged > 70 years, those with American Society of Anesthesiologists (ASA) class III or IV, elective surgery, those experiencing more than two HP-related complications, and those with a malignancy (an indication for HP). One-third of the patients underwent HR. Age > 70 years, ASA class III or IV, elective surgery, more than two HP-related complications, and malignancy were associated with a non-HR rate.

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Analysis of urgent/emergent conversions from monitored anesthesia care to general anesthesia with airway instrumentation

BMC Anesthesiology ◽

10.1186/s12871-021-01403-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Sang Kim ◽

Brian A. Chang ◽

Amreen Rahman ◽

Hung-Mo Lin ◽

Samuel DeMaria ◽

...

Keyword(s):

Risk Factors ◽

General Anesthesia ◽

Mount Sinai Hospital ◽

Anesthesia Care ◽

Monitored Anesthesia Care ◽

Surgical Specialty ◽

Factors Associated ◽

Physical Status Classification ◽

American Society ◽

American Society Of Anesthesiologists

Abstract Background Monitored Anesthesia Care (MAC) is an anesthetic service involving the titration of sedatives/analgesics to achieve varying levels of sedation while avoiding general anesthesia (GA) and airway instrumentation. The goal of our study was to determine the overall incidence of conversion from MAC to general anesthesia with airway instrumentation and elucidate reasons and risk factors for conversion. Methods In this retrospective observational study, all non-obstetric adult patients who received MAC from July 2002 to July 2015 at Mount Sinai Hospital were electronically screened for inclusion via a clinical database. Patient, procedure, anesthetic, and practitioner data were all collected and analyzed to generate descriptive analyses. Subsequent univariate and multivariate analyses were used to identify specific risk factors associated with conversion to GA. Results Overall, 0.50% (1097/219,061) of MAC cases were converted to GA. Approximately half of conversions were due to the patient’s “intolerance” of MAC (with or without failed regional anesthesia), while the other half were due to physiologic derangements. Body mass index, male sex, American Society of Anesthesiologists Physical Status Classification, anesthesia team composition, and surgical specialty were all associated with risk of conversion to GA. Conclusions This is one of the first and largest retrospective studies aimed at identifying reasons and risk factors associated with the conversion of MAC to GA. These findings may be used to help better anticipate or prevent these events.

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Surgeon and Type of Anesthesia Predict Variability in Surgical Procedure Times

Anesthesiology ◽

10.1097/00000542-200005000-00036 ◽

2000 ◽

Vol 92 (5) ◽

pp. 1454-1466 ◽

Cited By ~ 139

Author(s):

David P. Strum ◽

Allan R. Sampson ◽

Jerrold H. May ◽

Luis G. Vargas

Keyword(s):

Surgical Procedure ◽

Healthcare Delivery ◽

Surgical Time ◽

Data Set ◽

Risk Class ◽

Factors Associated ◽

Surgical Scheduling ◽

Large Teaching Hospital ◽

American Society ◽

American Society Of Anesthesiologists

Background Variability in surgical procedure times increases the cost of healthcare delivery by increasing both the underutilization and overutilization of expensive surgical resources. To reduce variability in surgical procedure times, we must identify and study its sources. Methods Our data set consisted of all surgeries performed over a 7-yr period at a large teaching hospital, resulting in 46,322 surgical cases. To study factors associated with variability in surgical procedure times, data mining techniques were used to segment and focus the data so that the analyses would be both technically and intellectually feasible. The data were subdivided into 40 representative segments of manageable size and variability based on headers adopted from the common procedural terminology classification. Each data segment was then analyzed using a main-effects linear model to identify and quantify specific sources of variability in surgical procedure times. Results The single most important source of variability in surgical procedure times was surgeon effect. Type of anesthesia, age, gender, and American Society of Anesthesiologists risk class were additional sources of variability. Intrinsic case-specific variability, unexplained by any of the preceding factors, was found to be highest for shorter surgeries relative to longer procedures. Variability in procedure times among surgeons was a multiplicative function (proportionate to time) of surgical time and total procedure time, such that as procedure times increased, variability in surgeons' surgical time increased proportionately. Conclusions Surgeon-specific variability should be considered when building scheduling heuristics for longer surgeries. Results concerning variability in surgical procedure times due to factors such as type of anesthesia, age, gender, and American Society of Anesthesiologists risk class may be extrapolated to scheduling in other institutions, although specifics on individual surgeons may not. This research identifies factors associated with variability in surgical procedure times, knowledge of which may ultimately be used to improve surgical scheduling and operating room utilization.

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Epidemiology and risk factors associated with surgical site infection following surgery on thoracic aorta

Epidemiology and Infection ◽

10.1017/s0950268818001930 ◽

2018 ◽

Vol 146 (14) ◽

pp. 1841-1844

Author(s):

K. Morikane

Keyword(s):

Risk Factors ◽

Surgical Site Infection ◽

Thoracic Aorta ◽

Artery Bypass ◽

Univariate Analysis ◽

National Database ◽

Site Infection ◽

Factors Associated ◽

American Society ◽

American Society Of Anesthesiologists

AbstractSurgical site infection (SSI) following cardiovascular surgery has been well documented, possibly owing to its highly invasive nature, but SSI following surgery on the thoracic aorta has not. This study aimed to describe the epidemiology and assess risk factors associated with the latter in Japan using a national database for SSI. Data on surgery on thoracic aorta performed between 2012 and 2014 were extracted from the Japan Nosocomial Infections Surveillance (JANIS) database. Risk factors were assessed initially by univariate analysis, and then entered into a logistic regression model for final evaluation. The cumulative incidence of SSI was 4.1% (146/3538) and staphylococci were the most frequent pathogens isolated. Factors such as the duration of operation, emergency surgery and male gender were significantly associated with SSI. These findings differ from previous studies on open heart and coronary artery bypass surgery, in which the American Society of Anesthesiologists (ASA) score was significantly associated with SSI, but gender was not. This study suggests that risk stratification in the JANIS system might be improved by incorporating additionally identified factors for risk adjustment, when comparing the incidence of SSI between hospitals.

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Parastomal Hernia Repair Outcomes: A Nine-Year Experience

The American Surgeon ◽

10.1177/000313481908500734 ◽

2019 ◽

Vol 85 (7) ◽

pp. 738-741

Author(s):

You Wei Lin ◽

Patrick Keller ◽

Daniel L. Davenport ◽

Margaret A. Plymale ◽

Crystal F. Totten ◽

...

Keyword(s):

Class Iii ◽

Free Survival ◽

Patient Demographics ◽

Institutional Review ◽

European Hernia Society ◽

Parastomal Hernia Repair ◽

Patient Groups ◽

American Society ◽

American Society Of Anesthesiologists ◽

Prospective Database

Parastomal hernias (PHs) frequently complicate enterostomy creation. Decision for PH repair (PHR) is driven by patient symptoms due to the frequency of complications and recurrences. The European Hernia Society (EHS) PH classification is based on the PH defect size and the presence/ absence of concomitant incisional hernia. The aim of this study was to evaluate PHR outcomes based on EHS classification. An Institutional Review Board–approved retrospective review of a prospective database between 2009 and 2017 was performed. Patient demographics, enterostomy type, EHS classification, operative technique, and clinical outcomes (postoperative complications, 30-day readmission, and PH recurrence) were obtained. Cases were analyzed by EHS classifications I and II (SmallPH) versus III and IV (LargePH). Sixty-two patients underwent PHR (35: SmallPH, 27: LargePH). Patient groups (SmallPH vs LargePH) were similar based on American Society of Anesthesiologists Class III and obesity. Hernia recurrence was seen in 26 per cent of repairs with no difference between groups. The median recurrence-free survival was 3.9 years. There was no difference in superficial SSI, deep SSI, nonwound complications, or readmission between SmallPH and LargePH. Both small and large PHs experience similar outcomes after repair. Strategies to improve outcomes should be developed and implemented universally across all EHS PH classes.

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What should be the preferred choice of hemiarthroplasty technique in American Society of Anesthesiologists (ASA) class III patients with femoral neck fractures? Cemented or cementless

Injury ◽

10.1016/j.injury.2015.05.019 ◽

2015 ◽

Vol 46 (8) ◽

pp. 1567-1570 ◽

Cited By ~ 7

Author(s):

Hakan Cicek ◽

Fırat Seyfettinoglu ◽

Kasım Kilicarslan ◽

Hasan Ulas Ogur ◽

Levent Öztürk ◽

...

Keyword(s):

Femoral Neck ◽

Femoral Neck Fractures ◽

Class Iii ◽

American Society ◽

American Society Of Anesthesiologists

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Prescribing Habits of Providers and Risk Factors for Nonadherence to Opioid Prescribing Guidelines

The American Surgeon ◽

10.1177/0003134820956332 ◽

2020 ◽

pp. 000313482095633

Author(s):

Tommy Ivanics ◽

Hassan Nasser ◽

Pridvi Kandagatla ◽

Shravan Leonard-Murali ◽

Adam Jones ◽

...

Keyword(s):

Risk Factors ◽

Guideline Implementation ◽

Multivariable Analysis ◽

Acute Care Surgery ◽

Factors Associated ◽

Opioid Prescribing ◽

Academic Center ◽

American Society ◽

Care Surgery ◽

American Society Of Anesthesiologists

Background The Michigan Opioid Prescribing Engagement Network introduced guidelines in October 2017 to combat opioid overprescription following various surgical procedures. We sought to evaluate changes in opioid prescribing at our academic center and identify factors associated with nonadherence to recently implemented opioid prescribing guidelines. Methods This retrospective review analyzed opioid prescribing data for appendectomy, cholecystectomy, and hernia repair from January 2015 through September 2017 (pre-guidelines group) and November 2017 through December 2018 (post-guidelines group). October 2017 data were excluded to allow for guideline implementation. Opioid prescribing data were recorded as total morphine equivalents (TMEs). Results Of 1493 cases (903 pre-vs. 590 post-guidelines), the mean TME prescribed significantly decreased post-guidelines (231.9 ± 108.6 vs. 112.7 ± 73.9 mg; P < .01). More providers prescribed within recommended limits post-guidelines (2.8% vs. 44.8%; P < .01). On multivariable analysis, independent risk factors for guideline nonadherence were the American Society of Anesthesiologists class > 2 (adjusted odds ratio [AOR]:1.65, 95% confidence interval[CI] 1.09-2.49; P = .02), general surgery vs. acute care surgery service (AOR 1.89, 95% CI 1.15-3.10; P = .01), oxycodone vs. hydrocodone (AOR:1.90, 95% CI:1.06-3.41; P = .03), and nonphysician provider vs. resident prescriber (AOR:2.10, 95% CI:1.14-3.11; P < .01). Conclusions Opioid prescribing significantly reduced after the adoption of opioid prescribing guidelines at our institution. Numerous factors associated with provider guideline nonadherence may identify actionable targets to minimize opioid overprescribing further.

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Remifentanil Alleviates Propofol-Induced Burst Suppression without Affecting Bispectral Index in Female Patients: A Randomized Controlled Trial

Journal of Clinical Medicine ◽

10.3390/jcm8081186 ◽

2019 ◽

Vol 8 (8) ◽

pp. 1186

Author(s):

Dahye Jung ◽

Sungwon Yang ◽

Min Soo Lee ◽

Yoonki Lee

Keyword(s):

Bispectral Index ◽

Suppression Ratio ◽

Controlled Trial ◽

Burst Suppression ◽

Remifentanil Infusion ◽

Female Patients ◽

Effect Site ◽

Effect Site Concentration ◽

American Society ◽

American Society Of Anesthesiologists

The bispectral index is affected by various factors, such as noxious stimuli and other drugs, such as muscle relaxants. The burst suppression ratio from bispectral index monitoring is correlated with electroencephalographic burst suppression, which is associated with deep anesthesia, metabolic disorders, and brain injury. We assessed patients undergoing total intravenous anesthesia and examined the effects of remifentanil on the bispectral index, burst suppression ratio, and hemodynamic changes immediately after loss of consciousness with propofol. Seventy American Society of Anesthesiologists physical status class I and II Korean female patients scheduled for general anesthesia were administered propofol with an effect-site concentration of 5 μg/mL, using a target-controlled infusion (TCI). After losing consciousness, patients received either saline or remifentanil at an effect-site concentration of 5 ng/mL for 10 min. During this period, we recorded the bispectral index values, including burst suppression ratio, blood pressure, and heart rate. With remifentanil infusion, burst suppression ratios were lower (p < 0.01) but bispectral values were not different. The burst suppression ratio was significantly different at 6, 7, 8, and 10 min after remifentanil infusion (p < 0.05). In female patients with propofol-induced unconsciousness, remifentanil alleviated the burst suppression ratio without affecting the bispectral value.

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