Showing papers in "Survey of Anesthesiology in 2015"

Management of Sickle Cell Disease Summary of the 2014 Evidence-Based Report by Expert Panel Members

Abstract: Importance Sickle cell disease (SCD) is a life-threatening genetic disorder affecting nearly 100 000 individuals in the United States and is associated with many acute and chronic complications requiring immediate medical attention. Two disease-modifying therapies, hydroxyurea and long-term blood transfusions, are available but underused. Objective To support and expand the number of health professionals able and willing to provide care for persons with SCD. Evidence Review Databases of MEDLINE (including in-process and other nonindexed citations), EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, TOXLINE, and Scopus were searched using prespecified search terms and keywords to identify randomized clinical trials, nonrandomized intervention studies, and observational studies. Literature searches of English-language publications from 1980 with updates through April 1, 2014, addressed key questions developed by the expert panel members and methodologists. Findings Strong recommendations for preventive services include daily oral prophylactic penicillin up to the age of 5 years, annual transcranial Doppler examinations from the ages of 2 to 16 years in those with sickle cell anemia, and long-term transfusion therapy to prevent stroke in those children with abnormal transcranial Doppler velocity (≥200 cm/s). Strong recommendations addressing acute complications include rapid initiation of opioids for treatment of severe pain associated with a vasoocclusive crisis, and use of incentive spirometry in patients hospitalized for a vasoocclusive crisis. Strong recommendations for chronic complications include use of analgesics and physical therapy for treatment of avascular necrosis, and use of angiotensin-converting enzyme inhibitor therapy for microalbuminuria in adults with SCD. Strong recommendations for children and adults with proliferative sickle cell retinopathy include referral to expert specialists for consideration of laser photocoagulation and for echocardiography to evaluate signs of pulmonary hypertension. Hydroxyurea therapy is strongly recommended for adults with 3 or more severe vasoocclusive crises during any 12-month period, with SCD pain or chronic anemia interfering with daily activities, or with severe or recurrent episodes of acute chest syndrome. A recommendation of moderate strength suggests offering treatment with hydroxyurea without regard to the presence of symptoms for infants, children, and adolescents. In persons with sickle cell anemia, preoperative transfusion therapy to increase hemoglobin levels to 10 g/dL is strongly recommended with a moderate strength recommendation to maintain sickle hemoglobin levels of less than 30% prior to the next transfusion during long-term transfusion therapy. A strong recommendation to assess iron overload is accompanied by a moderate strength recommendation to begin iron chelation therapy when indicated. Conclusions and Relevance Hydroxyurea and transfusion therapy are strongly recommended for many individuals with SCD. Many other recommendations are based on quality of evidence that is less than high due to the paucity of clinical trials regarding screening, management, and monitoring for individuals with SCD.

Postoperative Opioid-induced Respiratory Depression: A Closed Claims Analysis

Abstract: Background:Postoperative opioid-induced respiratory depression (RD) is a significant cause of death and brain damage in the perioperative period. The authors examined anesthesia closed malpractice claims associated with RD to determine whether patterns of injuries could guide preventative strategies

Predictors of Persistent Pain After Total Knee Arthroplasty: A Systematic Review and Meta-analysis

Abstract: Background Several studies have identified clinical, psychosocial, patient characteristic, and perioperative variables that are associated with persistent postsurgical pain; however, the relative effect of these variables has yet to be quantified The aim of the study was to provide a systematic review and meta-analysis of predictor variables associated with persistent pain after total knee arthroplasty (TKA) Methods Included studies were required to measure predictor variables prior to or at the time of surgery, include a pain outcome measure at least 3 months post-TKA, and include a statistical analysis of the effect of the predictor variable(s) on the outcome measure Counts were undertaken of the number of times each predictor was analysed and the number of times it was found to have a significant relationship with persistent pain Separate meta-analyses were performed to determine the effect size of each predictor on persistent pain Outcomes from studies implementing uni- and multivariable statistical models were analysed separately Results Thirty-two studies involving almost 30 000 patients were included in the review Preoperative pain was the predictor that most commonly demonstrated a significant relationship with persistent pain across uni- and multivariable analyses In the meta-analyses of data from univariate models, the largest effect sizes were found for: other pain sites, catastrophizing, and depression For data from multivariate models, significant effects were evident for: catastrophizing, preoperative pain, mental health, and comorbidities Conclusions Catastrophizing, mental health, preoperative knee pain, and pain at other sites are the strongest independent predictors of persistent pain after TKA

Off-Pump Versus On-Pump Coronary-Artery Bypass Grafting in Elderly Patients

Abstract: *Herzund Gefäb-Klinik, Bad Neustadt, Bad Neustadt; †Herzund Diabeteszentrum,BadOeynhausen, BadOeyhausen; ‡HerzzentrumDresden, Dresden; §Universitäts-Klinik Jena, Jena; ║Universitätsklinik Giessen, Giessen; ¶Robert Bosch Krankenhaus Stuttgart, Stuttgart; #Herzzentrum Universität Leipzig, Leipzig; **Universitätsklinik Hamburg-Eppendorf and ††Albertinen-Krankenhaus, Hamburg; ‡‡Klinikum für Herzchirugie Karlsruhe, Karlsruhe; §§Universität Bochen, Bochen; and║║Universitätsklinik Regensburg, Regensburg, Germany. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/SA.0000000000000105

Serious Complications Related to Obstetric Anesthesia: The Serious Complication Repository Project of the Society for Obstetric Anesthesia and Perinatology

Abstract: Background Because of the lack of large obstetric anesthesia databases, the incidences of serious complications related to obstetric anesthesia remain unknown. The Society for Obstetric Anesthesia and Perinatology developed the Serious Complication Repository Project to establish the incidence of serious complications related to obstetric anesthesia and to identify risk factors associated with each. Methods Serious complications were defined by the Society for Obstetric Anesthesia and Perinatology Research Committee which also coordinated the study. Thirty institutions participated in the approximately 5-yr study period. Data were collected as part of institutional quality assurance and sent to the central project coordinator quarterly. Results Data were captured on more than 257,000 anesthetics, including 5,000 general anesthetics for cesarean delivery. There were 157 total serious complications reported, 85 of which were anesthesia related. High neuraxial block, respiratory arrest in labor and delivery, and unrecognized spinal catheter were the most frequent complications encountered. A serious complication occurs in approximately 1:3,000 (1:2,443 to 1:3,782) obstetric anesthetics. Conclusions The Serious Complication Repository Project establishes the incidence of serious complications in obstetric anesthesia. Because serious complications related to obstetric anesthesia are rare, there were too few complications in each category to identify risk factors associated with each. However, because many of these complications can lead to catastrophic outcomes, it is recommended that the anesthesia provider remains vigilant and be prepared to rapidly diagnose and treat any complication.

Bariatric Surgery Complications Before vs After Implementation of a National Policy Restricting Coverage to Centers of Excellence

Abstract: fore; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n=179) vs hospitals without the COE designation (n=519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17]). Conclusions and Relevance Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.

Measurement of Disability-Free Survival After Surgery

Abstract: Background:Survival and freedom from disability are arguably the most important patient-centered outcomes after surgery, but it is unclear how postoperative disability should be measured. The authors thus evaluated the World Health Organization Disability Assessment Schedule 2.0 in a surgical popula

Dying With Dignity in the Intensive Care Unit

Abstract: It is not uncommon for patients to have an expected death in an ICU. This review covers issues related to the end of life in the absence of discordance between the patient's family and caregivers.

Acute and Perioperative Care of the Burn-Injured Patient

Abstract: Care of burn-injured patients requires knowledge of the pathophysiologic changes affecting virtually all organs from the onset of injury until wounds are healed. Massive airway and/or lung edema can occur rapidly and unpredictably after burn and/or inhalation injury. Hemodynamics in the early phase of severe burn injury is characterized by a reduction in cardiac output and increased systemic and pulmonary vascular resistance. Approximately 2 to 5 days after major burn injury, a hyperdynamic and hypermetabolic state develops. Electrical burns result in morbidity much higher than expected based on burn size alone. Formulae for fluid resuscitation should serve only as guideline; fluids should be titrated to physiologic endpoints. Burn injury is associated basal and procedural pain requiring higher than normal opioid and sedative doses. Operating room concerns for the burn-injured patient include airway abnormalities, impaired lung function, vascular access, deceptively large and rapid blood loss, hypothermia, and altered pharmacology.

Observational Study of the Success Rates of Intubation and Failed Intubation Airway Rescue Techniques in 7256 Attempted Intubations of Trauma Patients by Pre-Hospital Physicians

Abstract: Background Effective airway management is a priority in early trauma management. Data on physician pre-hospital tracheal intubation are limited; this study was performed to establish the success rate for tracheal intubation in a physician-led system and examine the management of failed intubation and emergency surgical cricothyroidotomy in pre-hospital trauma patients. Failed intubation rates for anaesthetists and non-anaesthetists were compared. Methods A retrospective database review was conducted to identify trauma patients undergoing pre-hospital advanced airway management between September 1991 and December 2012. The success rate of tracheal intubation and the use and success of rescue techniques were established. Success rates of tracheal intubation by individuals and by speciality were recorded. Results The doctor–paramedic team attended 28 939 patients; 7256 (25.1%) required advanced airway management. A surgical airway was performed immediately, without attempted laryngoscopy, in 46 patients (0.6%). Tracheal intubation was successful in 7158 patients (99.3%). Rescue surgical airways were performed in 42 patients, seven had successful insertion of supraglottic devices, and two patients had supraglottic device insertion and a surgical airway. One patient breathed spontaneously with bag-valve-mask support during transfer. All rescue techniques were successful. Non-anaesthetists performed 4394 intubations and failed to intubate in 41 cases (0.9%); anaesthetists performed 2587 intubations and failed in 11 (0.4%) (P=0.02). Conclusions This is the largest series of physician pre-hospital tracheal intubation; the success rate of 99.3% is consistent with other reported data. All rescue airways were successful. Non-anaesthetists were twice as likely to have to perform a rescue airway intervention than anaesthetists. Surgical airway rates reported here (0.7%) are lower than most other physician-led series (median 3.1%, range 0.1–7.7%).

Analgesic Efficacy of Local Infiltration Analgesia in Hip and Knee Arthroplasty: A Systematic Review

Abstract: In recent years, there has been an increasing interest in local infiltration analgesia (LIA) as a technique to control postoperative pain. We conducted a systematic review of randomized clinical trials investigating LIA for total knee arthroplasty (TKA) and total hip arthroplasty (THA) to evaluate the analgesic efficacy of LIA for early postoperative pain treatment. In addition, the analgesic efficacy of wound catheters and implications for length of hospital stay (LOS) were evaluated. Twenty-seven randomized controlled trials in 756 patients operated on with THA and 888 patients operated on with TKA were selected for inclusion in the review. In THA, no additional analgesic effect of LIA compared with placebo was reported in trials with low risk of bias when a multimodal analgesic regimen was administered perioperatively. Compared with intrathecal morphine and epidural analgesia, LIA was reported to have similar or improved analgesic efficacy. In TKA, most trials reported reduced pain and reduced opioid requirements with LIA compared with a control group treated with placebo/no injection. Compared with femoral nerve block, epidural or intrathecal morphine LIA provided similar or improved analgesia in the early postoperative period but most trials had a high risk of bias due to different systemic analgesia between groups. Overall, the use of wound catheters for postoperative administration of local anaesthetic was not supported in the included trials, and LOS was not related to analgesic efficacy. Despite the many studies of LIA, final interpretation is hindered by methodological insufficiencies in most studies, especially because of differences in use of systemic analgesia between groups. However, LIA provides effective analgesia in the initial postoperative period after TKA in most randomized clinical trials even when combined with multimodal systemic analgesia. In contrast, LIA may have limited additional analgesic efficacy in THA when combined with a multimodal analgesic regimen. Postoperative administration of local anaesthetic in wound catheters did not provide additional analgesia when systemic analgesia was similar and LOS was not related to use of LIA with a fast-track set-up.

Noise in the Operating Room

Abstract: A recently as the 1960s, hospitals were famous for their quiet and serene environment. Noise restrictions were zealously enforced internally by uniformed nurses and externally by street signs around the perimeter declaring “Hospital—Quiet Zone.” Hospitals and especially operating rooms are no longer quiet.1 In 1972, before the introduction of much of the noisy equipment now routinely used during surgical procedures, it was observed that noise levels in operating rooms frequently exceed those of a busy highway.2 The authors labeled noise as the “third pollution” along with air and water pollution. Others have described the noise in critical care areas as equivalent to the cafeteria at noon and only slightly less noisy than in the boiler room. More recent studies have reaffirmed the escalation of the noisy atmosphere of hospitals and operating rooms. Average noise levels commonly are greater than federal limits for occupational noise exposure and frequently exceed those considered a hazard to health. Noise levels of this intensity have wide-spread implications for healthcare workers and their patients. In the following report, we will examine the common sources and possible consequences of excessive operating room noise and suggest some remedies.

Damage Control Surgery in the Era of Damage Control Resuscitation

Abstract: Damage control surgery (DCS) is a concept of abbreviated laparotomy, designed to prioritize short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient. Over the last 10 yr, a new addition to the damage control paradigm has emerged, referred to as damage control resuscitation (DCR). This focuses on initial hypotensive resuscitation and early use of blood products to prevent the lethal triad of acidosis, coagulopathy, and hypothermia. This review aims to present the evidence behind DCR and its current application, and also to present a strategy of overall damage control to include DCR and DCS in conjunction. The use of DCR and DCS have been associated with improved outcomes for the severely injured and wider adoption of these principles where appropriate may allow this trend of improved survival to continue. In particular, DCR may allow borderline patients, who would previously have required DCS, to undergo early definitive surgery as their physiological derangement is corrected earlier.

Diagnostic Value of Histamine and Tryptase Concentrations in Severe Anaphylaxis With Shock or Cardiac Arrest During Anesthesia

Abstract: Background:The diagnosis of acute life-threatening allergic reactions during anesthesia relies on clinical signs, histamine and/or tryptase measurements, and allergic testing. In patients who die after the reaction, skin tests cannot be performed, and the effect of resuscitation manoeuvres on mediat

Difficult Intubation in Obese Patients: Incidence, Risk Factors, and Complications in the Operating Theatre and in Intensive Care Units

Abstract: Background Intubation procedure in obese patients is a challenging issue both in the intensive care unit (ICU) and in the operating theatre (OT). The objectives of the study were (i) to compare the incidence of difficult intubation and (ii) its related complications in obese patients admitted to ICU and OT. Methods We conducted a multicentre prospective observational cohort study in ICU and OT in obese (BMI≥30 kg m −2 ) patients. The primary endpoint was the incidence of difficult intubation. Secondary endpoints were the risk factors for difficult intubation, the use of difficult airway management techniques, and severe life-threatening complications related to intubation (death, cardiac arrest, severe hypoxaemia, severe cardiovascular collapse). Results In cohorts of 1400 and 11 035 consecutive patients intubated in ICU and in the OT, 282 (20%) and 2103 (19%) were obese. In obese patients, the incidence of difficult intubation was twice more frequent in ICU than in the OT (16.3% vs 8.2%, P P =0.04). Severe life-threatening complications were significantly more frequent in ICU than in the OT (41.1% vs 1.9%, relative risk 21.6, 95% confidence interval 15.4–30.3, P Conclusions In obese patients, the incidence of difficult intubation was twice more frequent in ICU than in the OT and severe life-threatening complications related to intubation occurred 20-fold more often in ICU. Clinical trial registration Current controlled trials. Identifier: NCT01532063.

Reliability of the American Society of Anesthesiologists Physical Status Scale in Clinical Practice

Abstract: Background Previous studies, which relied on hypothetical cases and chart reviews, have questioned the inter-rater reliability of the ASA physical status (ASA-PS) scale We therefore conducted a retrospective cohort study to evaluate its inter-rater reliability and validity in clinical practice Methods The cohort included all adult patients (≥18 yr) who underwent elective non-cardiac surgery at a quaternary-care teaching institution in Toronto, Ontario, Canada, from March 2010 to December 2011 We assessed inter-rater reliability by comparing ASA-PS scores assigned at the preoperative assessment clinic vs the operating theatre We also assessed the validity of the ASA-PS scale by measuring its association with patients' preoperative characteristics and postoperative outcomes Results The cohort included 10 864 patients, of whom 55% were classified as ASA I, 420% as ASA II, 467% as ASA III, and 58% as ASA IV The ASA-PS score had moderate inter-rater reliability (κ 061), with 670% of patients (n=7279) being assigned to the same ASA-PS class in the clinic and operating theatre, and 986% (n=10 712) of paired assessments being within one class of each other The ASA-PS scale was correlated with patients' age (Spearman's ρ, 023), Charlson comorbidity index (ρ=024), revised cardiac risk index (ρ=040), and hospital length of stay (ρ=016) It had moderate ability to predict in-hospital mortality (receiver-operating characteristic curve area 069) and cardiac complications (receiver-operating characteristic curve area 070) Conclusions Consistent with its inherent subjectivity, the ASA-PS scale has moderate inter-rater reliability in clinical practice It also demonstrates validity as a marker of patients' preoperative health status

Comparative Analysis of Outcome Measures Used in Examining Neurodevelopmental Effects of Early Childhood Anesthesia Exposure

Abstract: Use of different outcomes makes interpretation of studies of neurodevelopmental outcomes after childhood anesthesia exposure difficult. The results of three frequently used neurodevelopmental outcomes measures were assessed in 781 children, born from 1989 to 1992, from the Western Australian Pregnancy Cohort (Raine) study, 112 of whom had surgical or diagnostic procedures requiring anesthesia before 3 yr of age. Neuropsychological testing and International Classification of Diseases, 9th Revision, Clinical Modification–coded clinical outcomes identified deficits at age 10 yr in children exposed to anesthesia, whereas academic achievement scores did not, suggesting results of cognition assessment in children with early anesthesia exposure may depend on the outcome measure used. See the accompanying Editorial View on page 1303. (Summary: M.J. Avram. Image: A. Johnson/Vivo Visuals and J.P. Rathmell.)

Perioperative Positive Pressure Ventilation: An Integrated Approach to Improve Pulmonary Care

Abstract: Perioperative Positive Pressure Ventilation: An Integrated Approach to Improve Pulmonary Care Emmanuel Futier;Emmanuel Marret;Samir Jaber; Anesthesiology

Epidural Steroid Injections, Conservative Treatment, or Combination Treatment for Cervical Radicular Pain: A Multicenter, Randomized, Comparative-Effectiveness Study

Abstract: Background:Cervical radicular pain is a major cause of disability. No studies have been published comparing different types of nonsurgical therapy.Methods:A comparative-effectiveness study was performed in 169 patients with cervical radicular pain less than 4 yr in duration. Participants received no

Regional Anaesthesia for Carotid Endarterectomy

Abstract: Summary Regional anaesthesia is a popular choice for patients undergoing carotid endarterectomy (CEA). Neurological function is easily assessed during carotid cross-clamping; haemodynamic control is predictable; and hospital stay is consistently shorter compared with general anaesthesia (GA). Despite these purported benefits, mortality and stroke rates associated with CEA remain around 5% for both regional anaesthesia and GA. Regional anaesthetic techniques for CEA have improved with improved methods of location of peripheral nerves including nerve stimulators and ultrasound together with a modification in the classification of cervical plexus blocks. There have also been improvements in local anaesthetic, sedative, and arterial pressure-controlling drugs in patients undergoing CEA, together with advances in the management of patients who develop neurological deficit after carotid cross-clamping. In the UK, published national guidelines now require the time between the patient's presenting neurological event and definitive treatment to 1 week or less. This has implications for the ability of vascular centres to provide specialized vascular anaesthetists familiar with regional anaesthetic techniques for CEA. Providing effective regional anaesthesia for CEA is an important component in the armamentarium of techniques for the vascular anaesthetist in 2014.

Meta-analysis of the Success of Block Following Combined Spinal-Epidural vs Epidural Analgesia During Labour

Abstract: Observational studies suggest that combined spinal-epidural analgesia (CSE) is associated with more reliable positioning, lower epidural catheter replacement rates, and a lower incidence of unilateral block compared with epidural analgesia. However, evidence from high-quality trials still needs to be assessed systematically. We performed a systematic review that included 10 randomised controlled trials comparing CSE and epidural analgesia in 1722 labouring women in labour. The relative risk of unilateral block was significantly reduced after CSE vs epidural analgesia (0.48, 95% CI 0.24-0.97), but significant between-study heterogeneity was present (I(2) = 69%, p = 0.01). No differences were found for rates of epidural catheter replacement, epidural top-up, and epidural vein cannulation. On the basis of current best evidence, a consistent benefit of CSE over epidural analgesia cannot be demonstrated for the outcomes assessed in our review. A large randomised controlled trial with adequate power is required.

Patterns of Opioid Utilization in Pregnancy in a Large Cohort of Commercial Insurance Beneficiaries in the United States

Abstract: Background:There are few data regarding the utilization of opioids during pregnancy. The objective of this study was to define the prevalence and patterns of opioid use in a large cohort of pregnant women who were commercial insurance beneficiaries.Methods:Data for the study were derived from a deid

Interrater Reliability of Qualitative Ultrasound Assessment of Gastric Content in the Third Trimester of Pregnancy

Abstract: Background Pulmonary aspiration of gastric contents in pregnant women undergoing general anaesthesia is one of the most feared complications in obstetric anaesthesia. Bedside gastric ultrasonography is a feasible imaging tool to assess the gastric content. The purpose of this study was to investigate the reliability of qualitative bedside assessment of the gastric content performed by anaesthesiologists on third trimester pregnant women. Methods Pregnant women (≥32 weeks gestational age) were randomized to undergo ultrasound (US) assessments of their stomach in a fasting state (>8 h), or after ingestion of clear fluids only, or solid food. Three anaesthesiologists trained in gastric ultrasonography performed the assessments using a low-frequency curved-array US transducer (5–2 MHz). Primary outcome of the study was the consistency of raters in diagnosing the correct status of the gastric content, which was used to determine the interrater reliability among the three anaesthesiologists. Secondary outcomes were overall proportion of correct and incorrect diagnoses and the specific proportions of correct diagnosis across the three gastric content groups. Results We analysed 32 pregnant women. The interrater reliability displayed a kappa statistic of 0.74 (bias corrected 95% CI: 0.68–0.84). The overall proportion of correct diagnosis was 87.5% (84 of 96). The odds of correct diagnosis for ‘solid contents' were 16.7 times the odds for ‘empty', and 14.3 times for ‘clear fluid'. Conclusions Our results show the consistency of the qualitative US assessment of gastric contents of pregnant women in the third trimester by anaesthesiologists. A kappa of 0.74 suggests substantial agreement in terms of interrater reliability for this diagnostic measurement. Clinical trial registration ClinicalTrials.gov identifier: NCT01564030.

The Evolution of Pain Management in the Critically Ill Trauma Patient: Emerging Concepts From the Global War on Terrorism

Abstract: Background:The evolution of military medical care to manage polytrauma, critically ill-wounded warriors from the greater war on terrorism has been accompanied by significant changes in the diagnosis, management, and modulation of acute and chronic trauma-related pain. A paradigm shift in pain manage

Risk of Invasive Haemophilus influenzae Infection During Pregnancy and Association With Adverse Fetal Outcomes

Abstract: RESULTS In total, 171 women had laboratory-confirmed invasive H influenzae infection, which included 144 (84.2%; 95% CI, 77.9%-89.3%) with unencapsulated, 11 (6.4%; 95% CI, 3.3%-11.2%) with serotype b, and 16 (9.4%; 95% CI, 5.4%-14.7%) with other encapsulated serotypes. Questionnaire response rate was 100%. Overall, 75 of 171 women (43.9%; 95% CI, 36.3%-51.6%) were pregnant at the time of infection, most of whom were previously healthy and presented with unencapsulated H influenzae bacteremia. The incidence rate of invasive unencapsulated H influenzae disease was 17.2 (95% CI, 12.2-24.1; P < .001) times greater among pregnant women (2.98/100 000 woman-years) compared with nonpregnant women (0.17/100 000 woman-years). Unencapsulated H influenzae infection during the first 24 weeks of pregnancy was associated with fetal loss (44/47; 93.6% [95% CI, 82.5%-98.7%]) and extremely premature birth (3/47; 6.4% [95% CI, 1.3%-17.5%]). Unencapsulated H influenzae infection during the second half of pregnancy was associated with premature birth in 8 of 28 cases (28.6%; 95% CI, 13.2%-48.7%) and stillbirth in 2 of 28 cases (7.1%; 95% CI, 0.9%-23.5%). The incidence rate ratio for pregnancy loss was 2.91 (95% CI, 2.13-3.88) for all serotypes of H influenzae and 2.90 (95% CI, 2.11-3.89) for unencapsulated H influenzae compared with the background rate for pregnant women.

A Matched Cohort Study of Postoperative Outcomes in Obstructive Sleep Apnea: Could Preoperative Diagnosis and Treatment Prevent Complications?

Abstract: BACKGROUND Obstructive sleep apnea (OSA) is associated with increased risk of postoperative complications. The authors investigated whether preoperative diagnosis and prescription of continuous positive airway pressure therapy reduces these risks. METHODS Matched cohort analysis of polysomnography data and Manitoban health administrative data (1987 to 2008). Postoperative outcomes in adult OSA patients up to 5 yr before (undiagnosed OSA, n = 1,571), and any time after (diagnosed OSA, n = 2,640) polysomnography and prescription of continuous positive airway pressure therapy for a new diagnosis of OSA, were compared with controls at low risk of having sleep apnea (n = 16,277). Controls were matched by exact procedure, indication, and approximate date of surgery. Procedures used to treat sleep apnea were excluded. Follow-up was at least 7 postoperative days. Results were reported as odds ratio (95% CI) for OSA or subgroup versus controls. RESULTS In multivariate analyses, the risk of respiratory complications (2.08 [1.35 to 3.19], P < 0.001) was similarly increased for both undiagnosed and diagnosed OSA. The risk of cardiovascular complications, primarily cardiac arrest and shock, was significantly different (P = 0.009) between undiagnosed OSA (2.20 [1.16 to 4.17], P = 0.02) and diagnosed OSA patients (0.75 [0.43 to 1.28], P = 0.29). For both outcomes, OSA severity, type of surgery, age, and other comorbidities were also important risk modifiers. CONCLUSIONS Diagnosis of OSA and prescription of continuous positive airway pressure therapy were associated with a reduction in postoperative cardiovascular complications. Despite limitations in the data, these results could be used to justify and inform large efficacy trials of perioperative continuous positive airway pressure therapy in OSA patients.

Perioperative Auto-titrated Continuous Positive Airway Pressure Treatment in Surgical Patients With Obstructive Sleep Apnea: A Randomized Controlled Trial

Abstract: BACKGROUND Obstructive sleep apnea (OSA) may worsen postoperatively. The objective of this randomized open-label trial is to determine whether perioperative auto-titrated continuous positive airway pressure (APAP) treatment decreases postoperative apnea hypopnea index (AHI) and improves oxygenation in patients with moderate and severe OSA. METHODS The consented patients with AHI of more than 15 events/h on preoperative polysomnography were randomized into the APAP or control group (receiving routine care). The APAP patients received APAP for 2 or 3 preoperative, and 5 postoperative nights. All patients were monitored with oximetry for 7 to 8 nights (N) and underwent polysomnography on postoperative N3. The primary outcome was AHI on the postoperative N3. RESULTS One hundred seventy-seven OSA patients undergoing orthopedic and other surgeries were enrolled (APAP: 87 and control: 90). There was no difference between the two groups in baseline data. One hundred six patients (APAP: 40 and control: 66) did polysomnography on postoperative N3, and 100 patients (APAP: 39 and control: 61) completed the study. The compliance rate of APAP was 45%. The APAP usage was 2.4-4.6 h/night. In the APAP group, AHI decreased from preoperative baseline: 30.1 (22.1, 42.5) events/h (median [25th, 75th percentile]) to 3.0 (1.0, 12.5) events/h on postoperative N3 (P < 0.001), whereas, in the control group, AHI increased from 30.4 (23.2, 41.9) events/h to 31.9 (13.5, 50.2) events/h, P = 0.302. No significant change occurred in the central apnea index. CONCLUSIONS The trial showed the feasibility of perioperative APAP for OSA patients. Perioperative APAP treatment significantly reduced postoperative AHI and improved oxygen saturation in the patients with moderate and severe OSA.