Journal-related Activities and Other Special Activities at the 2016 American Society of Anesthesiologists Annual Meeting
2016; Lippincott Williams & Wilkins; Volume: 125; Issue: 4 Linguagem: Inglês
10.1097/aln.0000000000001281
ISSN1528-1175
AutoresCharles D. Collard, Deborah J. Culley, Shiroh Isono, Jerrold H. Levy, Michael J. Avram,
Tópico(s)Venous Thromboembolism Diagnosis and Management
ResumoSunday, October 23, 1:10 pm to 3:10 pm, McCormick Place, W375bThis year Anesthesiology will sponsor four sessions at the Annual Meeting of the American Society of Anesthesiologists (ASA).Daniel I. Sessler, M.D., Cleveland Clinic, Cleveland, Ohio; and Paul S. Myles, M.B.B.S., M.P.H., M.D., F.F.A.R.C.S.I., F.A.N.Z.C.A., Monash University, Melbourne, Victoria, Australia.Anesthesiology is sponsoring its second Major Trials Session at the 2016 Annual Meeting of the ASA. The session will provide a high-profile, large audience forum for initial presentation of major randomized clinical trial results. It is designed for substantial trials, usually randomized and blinded, with a clinically important primary outcome. Articles selected for the Trials Session will be simultaneously published in the journal and have a press release.Sunday, October 23, 2016, 9:00 am to 12:00 pm, McCormick Place, W375cThe 2016 Journal Symposium titled “Coagulation 2016: New Drugs and New Data” addresses managing bleeding and coagulopathy in a perioperative setting. It will feature the following moderator and speakers.Michael J. Avram, Ph.D., Northwestern University Feinberg School of Medicine, Chicago, Illinois.1. Critical Quality of Clot StructureAlisa S. Wolberg, Ph.D., F.A.H.A., University of North Carolina at Chapel Hill, Chapel Hill, North Carolina2. Anticoagulation Management for Surgery and Regional AnesthesiaMarc Samama, M.D., Ph.D., F.C.C.P., Cochin and Hotel-Dieu University Hospitals, Paris, France3. Managing New Anticoagulants: Purified and Recombinant Strategies for Prevention and Treatment of BleedingJerrold H. Levy, M.D., Duke University, Durham, North CarolinaIn a perioperative setting, managing bleeding and coagulopathy are critical for clinicians. Perioperative bleeding is due to multiple causes, including fibrinolysis, activation of inflammatory pathways, consumption of coagulation factors, dilutional changes, and other factors. Additionally, an increasingly frequent cause of bleeding is the perioperative use of anticoagulation and antiplatelet agents that until recently have no well-established reversal methods. New direct-acting oral anticoagulants are frequently utilized for management of both venous thromboembolic prophylaxis and therapy, as well as stroke prevention in patients with atrial fibrillation. As a result, new data and therapeutic approaches have emerged for understanding critical aspects of clot formation for hemostasis, management of perioperative anticoagulation especially for regional anesthesia, and specific antidotes for the novel anticoagulants. Three experts will introduce these topics for the first 90 min of the symposium, with 25-min presentations and 5-min discussions. The speakers will discuss three different considerations from the basic science of clot structure, to new data and guidelines about managing perioperative anticoagulation, and novel considerations for the use of recombinant and purified therapeutic approaches to reverse anticoagulation and treating bleeding and coagulopathy.These lectures will be followed by oral presentations of 12 abstracts, summarized below, that were selected for their relevance to the symposium topic. The full text for each abstract can be found at the ASA abstract Web site.“Anticoagulation Based on Heparin Dose–Response Technique Fails to Predict Heparin Bolus Dose Requirement during Cardiac Surgery” by Junko Ichikawa, M.D., Takahito Marubuchi, M.D., Tetsu Mori, M.D., Mitsuharu Kodaka, M.D., Makiko Komori, M.D., Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan. The accuracy of Hepcon Heparin Management System Plus–based heparin administration in achieving target activated clotting time (ACT) and desired heparin concentration was evaluated prospectively in 86 patients undergoing cardiac surgery with cardiopulmonary bypass. Blood samples for baseline ACT, predicted heparin dose–response (HDR), and predicted heparin concentration were obtained after induction of anesthesia. A kaolin ACT of 450 s was a target value for the HDR on the Hepcon Heparin Management System, and unfractionated heparin was administered based on the estimated dose. Kaolin ACT was measured 3 min later. There was wide variation in the heparin concentrations required to reach target ACT, which was achieved in 31.4% of patients. Correlation between calculated and measured HDR was poor, although the predicted heparin concentration was strongly correlated with the measured concentration.“Report on 5-Yr Experience with Obstetric Hemorrhage Protocol” by Cathleen Peterson-Layne, M.D., Ph.D., Nicole R. Guinn, M.D., Evelyn Lockhart, M.D., Holly Ann Muir, M.D., Duke University Hospital, Durham, North Carolina; University of New Mexico, Albuquerque, New Mexico. Quality improvement data collected from the time of implementation of an obstetric hemorrhage protocol (OHP) to present (2010 to 2015) were reviewed. The OHP was activated 121 times in a setting of approximately 16,000 deliveries in that time. The introduction of tranexamic acid (TXA) and fibrinogen concentrate to the OHP addressed the inhibition of fibrinolysis and rapid treatment of hypofibrinogenemia. Point-of-care coagulation testing allowed for detection of coagulopathy, facilitating goal-directed therapy. Interval analysis after process improvement changes suggests that they led to improved hemorrhage management as measured by reduced erythrocyte transfusion. Indicators of severe maternal morbidity associated with maternal hemorrhage, intensive care unit (ICU) admission, or transfusion of four or more blood products were also reduced.“Aminocaproic Acid Is Associated with Decreased Cognition Early after Cardiac Surgery Compared to Tranexamic Acid” by Yinghui Low, M.D., Mary Cooter, Ph.D., Niccolo Terrando, Ph.D., Miles Berger, M.D., Mihai V. Podgoreanu, M.D., Mark Stafford-Smith, M.D., Mark F. Newman, M.D., Joseph P. Mathew, M.D., Rebecca Y. Klinger, M.D., Duke University Hospital, Durham, North Carolina; University of California - San Francisco, San Francisco, California; Duke University Medical Center, Durham, North Carolina. The antifibrinolytic drugs TXA and epsilon-aminocaproic acid (EACA) are used to reduce blood loss and transfusion requirements in cardiac surgery. The hypothesis that there would be a difference in postoperative cognitive dysfunction (POCD) after cardiac surgery between patients who received TXA and those who received EACA was tested in a cohort of 155 patients, 69 of whom received TXA and 86 of whom received EACA. POCD was defined as a decline from baseline of greater than or equal to 1 SD in one or more of the five cognitive domains. After propensity score adjustment, multivariate analysis demonstrated a higher 6-week POCD in patients who received EACA (59.3%) than in those who received TXA (46.4%; odds ratio [OR], 3.28; 95% CI, 1.48 to 7.62).“The Effect of Remote Ischemic Preconditioning on Platelets and Coagulation in Healthy Volunteers” by Nathan J. Clendenen, M.D., M.S., Denis V. Snegovskikh, M.D., Trevor M. Banack, M.D., Yale University, New Haven, Connecticut; Yale University, Wallingford, Connecticut. Remote ischemic preconditioning (RIPC) aims to reduce injury to vital organs by inducing ischemia in a limb before a systemic ischemic insult. Because platelets may play a role in transferring a signal from the ischemic limb to distant tissues, a study was conducted in four healthy volunteers to identify platelet markers of RIPC after two and four cycles of blood pressure cuff inflation to 200 mmHg for 5 min and release for 5 min. RIPC induced mild platelet activation measured by P-selectin expression, changed surface expression of CXCR4 by 20% after two cycles, progressively reduced the percent of monocytes aggregated with platelets, decreased clot formation time, and increased maximum lysis measured by rotational thromboelastometry (ROTEM).“Effectiveness of Dual Antiplatelet Therapy, Thromboelastograph® with Platelet Mapping and Effect of Therapy Suspension” by Davide Cattano, M.D., Ph.D., Tyrone Burnett, Jr., B.S., Tariq Syed, M.S., Chunyan Cai, Ph.D., The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas. Thrombelastograph® Platelet Mapping (Haemoscope Corp., USA) is a whole blood assay that can potentially determine the efficacy of antiaggregation therapy. This prospective observational study assessed the ability of Thrombelastograph® Platelet Mapping to detect platelet inhibition secondary to dual antiplatelet therapy (APT) before surgery in 239 patients who were receiving or had recently suspended aspirin and clopidogrel therapy. The median time of clopidogrel suspension was 1 day and that of aspirin suspension was 0.5 day. The level of preoperative inhibition of arachidonic acid– and/or ADP-induced platelet aggregation after short-term interruption of APT was low, with decreasing inhibition after longer interruption of therapy. Platelet function commonly recovered at 5 days, and about 30% of patients were not effectively inhibited by clopidogrel.“Coagulation Standards and New Oral Anticoagulants” by Huong-Tram Vu Hoang, M.D., Evan G. Pivalizza, M.D., Davide Cattano, M.D., Anesthesiology, McGovern Medical School UTH Houston, Memorial Hermann TMC Houston, Houston, Texas. New oral anticoagulants are used in the prophylaxis and treatment of venous thrombotic events, as well as stroke and systemic embolism in nonvalvular atrial fibrillation. Routine coagulation data (prothrombin time, partial thromboplastin time [PTT], and thromboelastography) collected for 120 patients taking the new oral anticoagulants rivaroxaban, dabigatran, or apixaban were reviewed to determine their effects on these standard laboratory tests. Rivaroxaban, dabigatran, and apixaban had variable effects on clinical coagulation assays. While the PTT may not be useful in screening in special circumstances and in patients for whom laboratory measurements may be necessary for perioperative anticoagulation management, the prothrombin time was prolonged. Thromboelastography indices of fibrin formation were within the normal range, suggesting that global clot formation was preserved.“Mixing Study in Patients with Activated Prolonged Partial Thromboplastin Time” by Honorio T. Benzon, M.D., Meghan Park, B.A., Paul Lindholm, M.D., Ph.D., Northwestern University Feinberg School of Medicine, Chicago, Illinois. A retrospective study looked at the results of the PTT mixing studies done since January 2010 on 131 patients with prolonged activated PTT but not on any anticoagulant when seen in the preoperative clinic. In a mixing study, the patient’s blood is mixed with normal plasma, and the test is repeated at 1 h. In the presence of prolonged activated PTT, mixing studies identify the presence of deficiencies of clotting factors involved in the intrinsic pathway (correction into the reference normal range) or the presence of an anticoagulant inhibitor (no or very mild correction), with the 1-h result differentiating between immediate and time-dependent inhibitors. Mixing study results were classified into eight categories, and most underwent further workup.“The Utilization of Thromboelastometry to Identify HIT and Hypercoagulable States” by Michelle Shirak, M.D., Gebhard Wagener, M.D., Columbia University Department of Anesthesiology, New York, New York. The ROTEM parameter maximum clot firmness (MCF) can be used to assess the risk of thromboembolic events in noncardiac surgery patients. The ability of parameters of hypercoagulability derived from ROTEM to identify patients with heparin-induced thrombocytopenia and predict thromboembolic complications was tested in a prospective study of 23 postoperative cardiac surgical patients. There was no significant difference in MCF between the 13 patients who developed thromboembolic complications and those who did not. Six patients who were platelet factor 4 positive for heparin-induced thrombocytopenia had longer MCF.“The Hemostatic System in Scoliosis Surgery: Alteration of d-dimer and Fibrinogen Kinetics by Tranexamic Acid” by Ryan P. Pong, M.D., Alicia Edwards, M.B.A., Grete H. Porteous, M.D., Jean-Christopher Leveque, M.D., Rajiv K. Sethi, M.D., Virginia Mason Medical Center, Seattle, Washington. A potential contributor to the coagulopathy seen in scoliosis surgery is the activation of the fibrinolytic system. The hypothesis that the addition of the antifibrinolytic TXA to the perioperative protocol will decrease the fall of fibrinogen and decrease the rise of d-dimer (a product of fibrinolysis) was tested in a retrospective analysis of data from patients who underwent surgery for the treatment of adult de novo scoliosis, nine of whom were cared for before the addition of TXA to the perioperative protocol and 9 of whom were cared for after its addition. Fibrinogen consumption was reduced from 230 ± 130 to 67 ± 102 mg/dl (P = 0.01), and the rise of d-dimer was attenuated from 7.5 ± 6.2 to 2.8 ± 4.4 μg/ml (P = 0.09) with the addition of TXA to the protocol.“High- versus Low-dose Tranexamic Acid to Reduce Transfusion Requirements in Pediatric Scoliosis Surgery” by Joshua A. Wetzler, Brian C. Cho, M.D., Stephen L. Freiberg, M.D., Daniel Johnson, B.S., Susan Goobie, M.D., F.R.C.P.C., Nina Nami, M.D., Steven M. Frank, M.D., Johns Hopkins University, Baltimore, Maryland; Boston Children’s Hospital, Boston, Massachusetts. Blood loss and transfusion requirements were quantified for two commonly used TXA dosing regimens in a retrospective analysis of records of 116 pediatric patients who underwent posterior spinal fusion for correction of idiopathic scoliosis. Seventy-two patients received a 10 mg/kg loading dose with a 1 mg kg−1 h−1 maintenance dose (low dose), and 44 patients received a 50 mg/kg loading dose with a 5 mg kg−1 h−1 maintenance dose (high dose). Compared to the low-dose TXA group, the high-dose TXA group had decreased estimated blood loss (695 ± 372 vs. 968 ± 756 ml; P = 0.01) and a decrease in both intraoperative (0.3 ± 0.8 vs. 0.9 ± 1.7 units; P = 0.01) and whole hospitalization (0.4 ± 1.0 vs. 1 ± 1.9 units; P = 0.04) erythrocyte transfusion requirements.“The Use of Low-dose Tranexamic Acid to Reduce Red Blood Cell Transfusion during Complex Multilevel Spine Fusion” by Natalie Moreland, M.D., Louanne M. Carabini, M.D., Ryan J. Vealey, M.D., John Patrick F. Bebawy, M.D., Antoun Koht, M.D., Michael J. Avram, Ph.D. University California at Los Angeles, Los Angeles, California; Northwestern University Feinberg School of Medicine, Chicago, Illinois. The hypothesis that low-dose TXA would reduce intraoperative total erythrocyte transfusion during complex spinal deformity correction was tested in a randomized, double-blind, placebo-controlled trial of low-dose TXA in 61 patients undergoing multilevel spinal fusion. The volume of total erythrocytes (millimeter) transfused was less in the TXA group (placebo group median, 1,460 ml vs. TXA group median, 1,140 mL; median difference, 460 ml; 95% CI, 15 to 914 ml), with a decrease in cell saver transfusion (P = 0.043) and a decrease in PRBC transfusion that did not reach statistical significance. Hemoglobin concentrations measured immediately postoperatively did not differ between groups.“Pathogen-reduced Cryoprecipitate Demonstrates Retention of Fibrinogen, Factor VIII, Factor XIII, and von Willebrand Factor Activity 120 h Post Thaw” by Anne North, Ph.D., Travis Berry, B.A., Jeremy Puckett, B.A., Tovo David, Ph.D., Melissa VonGoetz, M.S., Marc Stern, M.B.A., Melody Holtan, M.B.A., Jessica Hanover, M.D., Nina Mufti, Ph.D., Cerus Corporation, Concord, California. Cryoprecipitate has a shelf life of 4 to 6 h after thawing because of factor VIII instability and concerns over bacterial contamination and growth at room temperature. Preparation of cryoprecipitate from pathogen-reduced prepooled plasma reduces the risk of transfusion-transmissible infections and may allow extended storage of thawed cryoprecipitate at 22°C. Pathogen-reduced cryoprecipitate and control cryoprecipitate were thawed at 37°C and stored at 22°C until sampled aseptically at 0, 6, 24, 48, 72, and 120 h post thaw. Fibrinogen, factor XIII, and von Willebrand factor concentrations in pathogen-reduced cryoprecipitate remained stable over storage, while factor VIII activity declined steadily over storage. Both fibrinogen and factor VIII concentrations met U.S. Code of Federal Regulations, guidelines for single containers of cryoprecipitate.Anesthesiology will sponsor two Best Abstract Sessions this year, one in basic science and another in clinical science. These abstracts were chosen by a panel of editors, who examined the highest scoring abstracts from the ASA subcommittees, choosing those with important scientific and clinical application and novelty. Subsequently, a combination of these editors and appointees from the ASA will choose one abstract in each category to receive the Best Abstract award for basic and clinical sciences at the meeting in Chicago, Illinois. Following are summaries of the excellent abstracts that will be presented.Saturday, October 22, 1:15 pm to 3:15 pm, McCormick Place, W476Charles D. Collard, M.D., St. Luke’s Episcopal Hospital and the Texas Heart Institute, Baylor College of Medicine, Houston, Texas; Deborah J. Culley, M.D., Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and Shiroh Isono, Chiba University Graduate School of Medicine, Chiba, Japan“National Impact of Anesthesiology Providers on Outcomes after High-risk Surgery” by S. Kheterpal, M.D., M.B.A., M. Housey, M.S., A. Shanks, Ph.D., Anesthesiology, University of Michigan, Ann Arbor, Michigan. There are no robust analyses of national data spanning a range of procedures evaluating the impact of the anesthesiology provider on surgical outcomes. We hypothesized that a measurable proportion of outcome variation can be attributed to variation in anesthesiology practice and provider across vascular, cardiac, and colorectal surgery. Data were acquired from the Medicare Provider Analysis and Review files, which contain all hospital discharges for Medicare recipient acute care. Using International Classification of Diseases, Ninth Revision, codes, we identified all patients who underwent abdominal aortic aneurysm repair, coronary artery bypass graft (CABG), or colectomy procedures from 2010 to 2013 and linked to part B professional claims to identify the primary surgeon and anesthesiologist using anonymized codes. After adjusting for patient, procedure, hospital, and surgeon covariates, the anesthesiology provider is responsible for approximately 3.1 to 4.5% of mortality/morbidity variation in three common high-risk procedures, similar to a surgeon effect of 4.2 to 5.2%.“Interrelationship of Preoperative Anemia, Postoperative Anemia, Acute Kidney Injury, and Mortality after Coronary Artery Bypass Grafting Surgery” by Patrick J. Nailer, M.D., Manuel Fontes, M.D., Ishwori Dhakal, M.Sc., Jorn A. Karhausen, M.D., Mihai V. Podgoreanu, M.D., Mark Stafford-Smith, M.D., Miklos D. Kertai, M.D., Ph.D., Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina. The relationship between anemia and acute kidney injury (AKI) after CABG surgery has not been clearly defined. The authors used multivariable logistic regression and Cox proportional hazard models to examine the interrelationship between preoperative anemia, postoperative anemia and postoperative AKI, and long-term mortality in 4,217 adult patients who underwent CABG surgery. Preoperative anemia was defined as hemoglobin less than 13 g/dl in men and less than 12 g/dl in women, while postoperative anemia was defined as the median of the lowest in-hospital values measured for the first 10 postoperative days. In the risk-adjusted model for postoperative AKI, preoperative anemia (OR, 1.27; 95% CI, 1.04 to 1.56; P = 0.02), postoperative anemia (OR, 1.38; 95% CI, 1.17 to 1.63; P = 0.0001), and the combination of pre- and postoperative anemia (OR, 1.93; 95% CI, 1.58 to 2.35; P < 0.0001) were associated with an incremental risk of postoperative AKI. Similarly, preoperative anemia (hazard ratio [HR], 1.29; 95% CI, 1.09 to 1.52; P = 0.003) and the combination of pre- and postoperative anemia (HR, 1.23; 95% CI, 1.04 to 1.47; P = 0.02) were significantly associated with long-term mortality in the risk-adjusted Cox model. These data suggest that anemia before and/or after CABG surgery is associated with an incremental risk of postoperative AKI. Furthermore, only preoperative anemia and the combination of pre- and postoperative anemia had a significant relation with long-term mortality after CABG surgery.“Brain Activity Predictive of Arousal during Propofol or Dexmedetomidine Anesthesia: Who’s Going to Wake Up and Why?” by Michael T. Alkire, M.D., Annalotta Scheinin, M.D., Oskari Kantonen, M.D., Jaakko Långsjö, M.D., Kaike Kaisti, M.D., Timo Laitio, M.D., Roosa Kallionpää, M.Sc., Katja Valli, Ph.D., Antti Revonsuo, Ph.D., Harry Scheinin, M.D., Department of Anesthesiology, University of California, Irvine, California. Clinicians are often faced with the challenge of preventing patient movement under “light” general anesthesia. The authors examined neuroimaging data in volunteers receiving dexmedetomidine or propofol anesthesia who subsequently later moved in response to stimulation. The average targeted concentrations for achieving a loss of responsiveness (LOR) were 1.5 ng/ml for dexmedetomidine and 1.87 μg/ml for propofol. Cerebral blood flow using O15-H2O as a tracer was imaged using positron emission tomography on a Siemens high-resolution research tomograph during the LOR. After achieving LOR, subjects were tested for arousal to awakening with loud voice or mild physical stimulation without changing the drug dose. Future arousal to consciousness was predicted in the LOR scans by greater activity (P < 0.001) in the posterior cingulate cortex (Brodmann area 23) for dexmedetomidine, whereas for propofol, it was predicted by increased activity in the medial dorsal thalamus and visual cortical Brodmann area 18. At a more liberal statistical threshold (P < 0.05, uncorrected), a network effect was evident between the two agents that centered on the posterior cingulate cortex and also involved visual areas, thalamus, and Broca area (Brodmann 44) in the left frontal lobe. These data suggest that brain regions responsible for imminent arousal differ depending on which anesthetic is being used, as well as a multiple pathway arousal model that may involve the posterior cingulate, visual cortex, thalamus, and Broca area.“Delayed Detection of Esophageal Intubation in Anesthesia Malpractice Claims” by Marzieh Roza Honardar, M.D., Karen L. Posner, Ph.D., Karen B. Domino, M.D., Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington. In 1991, identification of carbon dioxide in the expired gas to verify endotracheal intubation became an ASA standard of basic anesthetic monitoring. The authors of this study aimed to identify factors associated with delayed detection of esophageal intubation in anesthesia malpractice claims after this change in monitoring standards. The authors analyzed 45 claims for delayed detection of esophageal intubation from the Anesthesia Closed Claims Project Database, and factors associated with delayed detection were abstracted from claim narratives. The authors found that 49% of the cases with delayed detection of esophageal intubation occurred during anesthesia care in the OR or a NORA location with elective cases accounting for 29% and resuscitation for 38%. In 76% of claims, esophageal intubation was recognized during resuscitation and in 13% not until autopsy. In 60% of cases, a quantitative or qualitative carbon dioxide detection device was available at the time of intubation. The most common reasons for delayed detection were associated with carbon dioxide monitoring (73%), such as not using or ignoring end-tidal carbon dioxide or equivocal change in calorimetric carbon dioxide. In 33% of cases, late detection was associated with confusion over differential diagnosis, most often bronchospasm. Cardiac arrest without cardiac output contributed to delayed detection in 13%. Communication problems occurred in 27% of esophageal intubation claims and were more common when the anesthesiologist was called to help in a nonanesthesia location (43%) than during anesthesia care in the OR/NORA (9%; P = 0.017). Nearly, all esophageal intubations with delayed detection resulted in patient death or severe brain damage (96%). Sixty-seven percent resulted in payment made on behalf of the anesthesiologist with a median payment of $665,000 (interquartile range, $236,000 to $1,213,500). The authors conclude that although end-tidal carbon dioxide monitoring has been a standard of care for confirmation of endotracheal tube placement since 1991, carbon dioxide detection issues and differential diagnosis errors contributed to persistence of delayed detection of esophageal intubation in malpractice claims.“Impact of Temperature on Cognition and Brain Connectivity following Hypothermic Surgical Circulatory Arrest” by Rebecca Y. Klinger, M.D., M.S., Jeffrey Browndyke, Ph.D., Tiffany Bisanar, B.S.N., Mary Cooter, M.S., Miles Berger, M.D., Ph.D., Mihai V. Podgoreanu, M.D., Jorn A. Karhausen, M.D., Mark F. Newman, M.D., G. Chad Hughes, M.D., Joseph P. Mathew, M.D., M.B.A., Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina. The optimal temperature for hypothermic circulatory arrest remains unclear. The authors hypothesized that deep hypothermia would reduce postoperative cognitive decline and preserve functional brain network connectivity when compared with high-moderate (HM) hypothermia. Thirty-four patients undergoing hypothermic circulatory arrest for elective proximal aortic reconstructive surgery (ascending aorta + aortic valve or root) with concomitant proximal (hemi-) arch replacement completed a battery of neurocognitive tests at baseline and 4 weeks postoperatively. Fifteen of these patients also underwent resting functional magnetic resonance imaging. Patients were categorized into three groups on the basis of nasopharyngeal temperature at the initiation of circulatory arrest as defined above: deep, low-moderate (LM), and HM. Cognitive function (mean Z score of predefined domains) was compared between the three groups using ANOVA or Kruskal–Wallis tests. Voxel-wise intrinsic connectivity contrast analyses were used to identify group (temperature) × time (pre-/postsurgery) differences in resting-state functional connectivity (RSFC) patterns associated with perioperative cognitive changes, adjusting for baseline cognitive abilities. Statistical significance was established using multiple comparison-corrected cluster-wise topological p-FDR less than 0.05 (peak P < 0.001). In 14 patients treated with deep hypothermia, 10 with LM, and 10 HM, the neurocognitive change score from baseline to 4 weeks was lower in patients subjected to HM hypothermia (global mean Z score: −0.04 ± 0.40 [HM] vs. 0.26 ± 0.21 [deep] and 0.17 ± 0.51 [LM]; P = 0.17], representing an effect size difference of 0.99 between the deep and HM groups. The largest differences were seen in short-term memory (HM: −0.15 ± 0.37 vs. deep: 0.32 ± 0.37 vs. LM: 0.17 ± 0.51; P = 0.04) and executive function (HM: 0.02 ± 0.53 vs. deep: 0.56 ± 0.67 vs. LM: 0.56 ± 1.48; P = 0.03). Group × time comparisons of RSFC change revealed significant gray-matter regional differences in the right parahippocampal, mesial frontal, and posterior cingulate cortices between deep and HM hypothermia groups associated with perioperative short-term memory changes. Short-term memory decline in the HM hypothermia group was associated with perioperative decreases in intrinsic RSFC in the posterior cingulate and mesial frontal cortices and increases in the parahippocampal RSFC. These data suggest that deep hypothermia may be superior to HM hypothermia in mitigating against postoperative cognitive decline and in preserving functional brain connectivity after circulatory arrest for arch surgery.“Early Surgery Confers 1-Yr Mortality Benefit in Hip-Fracture Patients” by Kamal Maheshwari, M.D., Jeffrey A. Planchard, M.D., Jing You, M.S., Wael M. Ali Sakr Esa, M.D., Leif Saager, M.D., Alparslan Turan, M.D., Andrea M. Kurz, M.D., General Anesthesia, Outcomes Research, Anesthesia Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Anesthesia Institute, Cleveland Clinic Foundation, Cleveland, Ohio. Hip fracture is a major cause of morbidity and mortality among older surgical patients and is associated with a 1-yr mortality as high as 33% with or without surgery. Accordingly, there is a debate about the timing of surgery as early surgery may provide a survival benefit. The authors of this study evaluated the relationship between the timing of surgery and 1-yr mortality in 720 patients (more than 65 yr) who underwent hip fracture surgery between March 25, 2005, and February 28, 2015. One-year mortality was derived from the Ohio Death Index, U.S. Social Security Death Index, and PHDS. The authors used a multivariable logistic regression analysis adjusting for baseline clinical status and the surgical factors. Among the 720 patients, 159 patients (22%) died within 1 yr after their surgical procedure. The median time from hospital admission to the start of operation was 30 h. Delaying surgery was significantly associated with increased 1-yr mortality. The estimated OR was 1.05 (95% CI, 1.02 to 1.08) for each increase of 10 h (P = 0.001). These results suggest that mortality is improved with early surgery and that for every 10-h delay from hospital admission to surgery, the 1-yr mortality increased by 5% after adjusting for confounders. On the basis of these results, the authors sug
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