1. IMPACT OF VOLUME OF EXPERIENCE ON OFF-PUMP VERSUS ON-PUMP CORONARY ARTERY BYPASS GRAFTING
Benedetto U, Lau C, Caputo M, et al. Comparison of outcomes for off-pump versus on-pump coronary artery bypass grafting in low-volume and high-volume centers and by low-volume and high-volume surgeons. Am J Cardiol. 2018. 121:552–557.
Controversy remains regarding the superiority of off-pump (OPCAB) over on-pump (ONCAB) coronary bypass grafting (CABG). It has been speculated that hospital and surgeon experience with OPCAB may play a role. This retrospective analysis of data on >2 million patients undergoing CABG from the National (Nationwide) Inpatient Sample supports this hypothesis, of whom, about 550,000 underwent OPCAB, and 1.5 million underwent ONCAB. Overall hospital mortality was equal, between OPCAB and ONCAB. However, in cases involving ≥2 grafts, OPCAB was associated with increased mortality in low-volume hospitals (<29 per year; odds ratio [OR] of 1.32) and with low-volume surgeons (<19 per year; OR of 1.26), but decreased mortality in high-volume hospitals (>165 per year; OR of 0.82) and high-volume surgeons (≥48 per year; OR of 0.63). In cases involving 1 graft, OPCAB was not associated with increased mortality in low-volume hospitals or surgeons, but it was associated with decreased mortality in high-volume hospitals and surgeons.
2. SINGLE-VISIT PEDIATRIC AMBULATORY SURGERY
Olson JK, Deming LA, King DR, et al. Single visit surgery for pediatric ambulatory surgical procedures: a satisfaction and cost analysis. J Pediatr Surg. 2017.
This single-center prospective cohort study compared 90 patients undergoing single-visit ambulatory surgery (SVS) in an ambulatory surgery center with matched patients undergoing conventional surgery (CS). Eligible patients underwent mainly repairs of umbilical hernias (41%) and inguinal hernias (~38%) or excision of soft tissue lesions (18%), were >1 month old (mean age = 5 years), and had no known comorbidities. SVS included a 1-hour clinic visit in the morning followed by the operation within 3 hours. Postoperative family surveys revealed similar rates of satisfaction (98% of SVS, and 93% of CS), but 41% of CS families would have chosen SVS, while none of the SVS families would have chosen CS if offered. Estimated cost savings was about $188. Cancellation rate was higher in the SVS group (~20% vs 12%) but not statistically significant (likely due to the small sample size). Whether the latter offsets the benefits of less family disruption and cost remains to be resolved.
3. BILATERAL RECTUS SHEATH BLOCK FOR LAPAROSCOPIC APPENDECTOMY
Maloney C, Kallis M, El-Shafy IA, et al. Ultrasound-guided bilateral rectus sheath block vs conventional local analgesia in single port laparoscopic appendectomy for children with nonperforated appendicitis. J Pediatr Surg. 2018;53:431–436.
This single-center, retrospective observational study compared the use of preincisional ultrasound-guided (USG) bilateral rectus sheath block (BRSB; 136 patients) to conventional local anesthetic infiltration (139 patients), based on availability of anesthesiologists to perform the BRSB, for single transumbilical incision laparoscopic appendectomy for nonperforated appendicitis in children (mean age ~11.5 years). Patients receiving BRSB required fewer opioids during their hospital stay (0.11 vs 0.29 mg/kg); 18% vs 0% did not require any opioid, and furthermore had lower initial (0.4 vs 2.4) and sustained mean (1.3 vs 1.8) postoperative pain scores. Performance of the BRSB added an average of about 6.7 minutes to anesthetic time. The effects of BRSB on postdischarge pain remain to be evaluated.
4. RESTRICTIVE VERSUS LIBERAL TRANSFUSION THRESHOLDS IN PERIOPERATIVE VERSUS CRITICALLY ILL PATIENTS
Chong MA, Krishnan R, Cheng D, Martin J. Should transfusion trigger thresholds differ for critical care versus perioperative patients? A meta-analysis of randomized trials. Crit Care Med. 2018;46:252–263.
Chong et al conducted a meta-analysis of 12 randomized trials (RTs) comparing restrictive versus liberal transfusion strategies in critically ill patients and 15 RTs in perioperative patients. Restrictive trigger thresholds were typically defined as hemoglobin levels of 7–8 g/dL and liberal as 9–10 g/dL. They observed that in critically ill patients, restrictive strategies reduced 30-day mortality (OR of 0.82), whereas in perioperative patients, restrictive strategy increased mortality (OR of 1.31). The increased mortality in perioperative patients was not different in cardiac and noncardiac surgery. However, the risk of myocardial infarction was higher with restrictive strategies in noncardiac surgery (OR of 1.66) but not in cardiac surgery. The authors concluded that the benefits and risks of restrictive transfusion strategies may differ in these 2 groups of patients, and that restrictive transfusion strategies are likely beneficial in critically ill patients but may be harmful, especially with lower thresholds in surgical patients.
5. FRAILTY AND MORBIDITY AFTER AMBULATORY GENERAL SURGERY
Seib CD, Rochefort H, Chomsky-Higgins K, et al. Association of patient frailty with increased morbidity after common ambulatory general surgery operations. JAMA Surg. 2018;153:160–168.
In this retrospective observational study, Seib et al assessed the association of the modified frailty index (mFI) score on postoperative morbidity in 140,828 patients >40 years of age (mean age 59) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, who underwent ambulatory 23-hour stays for hernia, breast, thyroid, or parathyroid surgery. A total of 52% had no evidence of frailty, 32.5% had mild frailty (mFI 0.09), 14.9% had intermediate/moderate frailty (mFI 0.18–0.27), and 0.7% had severe/high frailty (MFI ≥0.36). The mean age was higher in those with intermediate (67 years) and high mFIs (71 years). Among all patients, 1.7% experienced postoperative complication, and 0.7% experienced serious complications. Increased mFI was associated with a progressive increase in incidence of complications. The only modifiable covariable associated with decreased risk of serious 30-day complications was anesthesia with local and monitored anesthesia care (OR of 0.66). Thus, frailty adversely affects outcome even after outpatient general surgery, and the type of anesthesia may have an impact.
6. PREHOSPITAL SUPRAGLOTTIC AIRWAYS IN TRAUMA PATIENTS
Hernandez MC, Aho JM, Zielinski MD, Zietlow SP, Kim BD, Morris DS. Definitive airway management after prehospital supraglottic airway insertion: outcomes and a management algorithm for trauma patients. Am J Emerg Med. 2018;36:114–119.
Hernandez et al reviewed definitive airway management (tracheostomy versus endotracheal intubation [ETI]), in 56 adult multitrauma patients (78% men; median age of 36 years) who arrived with a prehospital supraglottic airway (SGA). An SGA had been inserted after failed attempts (median 2) at ETI. Subsequent airway management consisted of tracheostomy in 20 (36%) and ETI in 36 (64%), with equal numbers in the emergency room or operating room. ETI was accomplished with direct laryngoscopy (10), use of bougie (6), GlideScope (9), or with bronchoscopic assistance (11). During definitive airway management, oxygen saturation was lower in those receiving ETI than those receiving tracheostomy (84% vs 92%). An increasing number of attempts of prehospital endotracheal intubation, as well as increased cervical and facial injuries, were associated with the need for surgical tracheostomy. The authors propose an algorithm for definitive airway management in trauma patients arriving with a prehospital SGA.
7. EFFECT OF PROPHYLACTIC HALOPERIDOL ON DELIRIUM AND SURVIVAL IN CRITICALLY ILL PATIENTS
van den Boogaard M, Slooter AJC, Brüggemann RJM, et al. Effect of haloperidol on survival among critically ill adults with a high risk of delirium: the REDUCE randomized clinical trial. JAMA. 2018;319:680–690.
Haloperidol is often used to treat, and sometimes to prevent, delirium in the intensive care unit (ICU). Van den Boogaard et al report this prospective randomized placebo-controlled study (“REDUCE”) of patients (mean age 67 years) receiving haloperidol (2 mg, 3 times per day) or placebo who were admitted to the ICU without delirium, with an anticipated stay of ≥2 days (actual median stay of about 4.5 days). The number of surgical and medical patients was about the same. There was no difference in the primary outcome (28-day survival; 83.3% vs 82.7%), incidence of delirium (33.3% vs 33.0%), or any other secondary outcomes between those receiving haloperidol versus those receiving placebo. These findings do not support the prophylactic use of haloperidol to reduce delirium or to improve survival in ICU patients.
8. BALANCED CRYSTALLOIDS VERSUS SALINE
Self WH, Semler MW, Wanderer JP, et al. Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med. 2018;378:819–828.
Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378:829–839.
Isotonic crystalloids are commonly administered to hospitalized patients. “Normal” saline (0.9%) has a much higher chloride concentration (154 mM/L) than normal plasma (≈100 mM/L), which can cause hyperchloremic metabolic acidosis, with possible renal inflammation and impaired renal perfusion. The clinical significance is debated. “Balanced” crystalloids (eg, lactated Ringer’s or Plasma-Lyte A) contain less chloride (≈100 mM/L). These 2 nonblinded, single-center, prospective randomized studies compared administration of approximately 1000 mL of these 2 solutions in >13,000 noncritically ill patients in the emergency department (Self et al, “SALT-ED” study) with about 2000 mL to >15,000 intensive care patients (Semler et al, “SMART” study). In the emergency room study, there was no difference in the primary outcome (hospital-free days in the first 28 days), but there was a reduced incidence of major adverse kidney events in those receiving balanced crystalloids (4.7% vs 5.6%, OR of 0.82). In the ICU study, the primary outcome (major adverse kidney events within 30 days) was also lower in those receiving balanced crystalloid (14.3% vs 15.4%, OR of 0.91), but with a nonstatistically significant reduced incidence of new renal replacement therapy (2.5% vs 2.9%), persistent renal dysfunction (6.4% vs 6.6%), and hospital mortality 10.3% vs 11.1%).
9. SEXUAL HARASSMENT IN ACADEMIC MEDICINE
Bates CK, Jagsi R, Gordon LK, et al. It is time for zero tolerance for sexual harassment in academic medicine. Acad Med. 2018;93:163–165.
Sexual harassment outside of medicine has received much national attention in recent months, but unfortunately, it is not uncommon in academic (and likely nonacademic) medicine. Bates et al address these concerns by: reviewing the incidence of sexual harassment in vulnerable populations in medicine, including students, residents, and more junior faculty; reviewing the efforts of some professional societies to curb this; and by providing recommendations to address this problem. Sexual harassment ranges from sexist remarks (reported by up to 30%) to requests for sexual favors in exchange for grades or other rewards (reported by 0.2%). Unfortunately, only about 20% of these events are reported by the victims, often due to concern for reprisal, and <40% of these reports are addressed in a way that is helpful to the victim. Several professional societies have created policies to deal with this problem. The authors recommend 6 initial steps that academic medical centers should initiate.
10. SAFETY OF APROTININ DURING ISOLATED CORONARY ARTERY BYPASS SURGERY
Benedetto U, Altman DG, Gerry S, et al. Safety of perioperative aprotinin administration during isolated coronary artery bypass graft surgery: insights from the ART (Arterial Revascularization trial). J Am Heart Assoc. 2018;7.
After being taken off the market in 2007, the use of aprotinin has been reintroduced without any new clinical safety trials in Europe and Canada. Benedetto et al performed a retrospective study of 536 propensity-matched patients who received aprotinin versus no fibrinolytic during a prospective randomized trial comparing bilateral versus single internal mammary artery grafting for nonemergent, isolated primary coronary artery bypass surgery for multivessel disease. Aprotinin was used in about 27% of the patients enrolled in this study. Use of aprotinin was associated with an increased in-hospital (1.7% vs 0.2%, OR of 9.1) mortality, 5-year mortality (10.6% vs 7.3%, hazard ratio of 1.5), and acute kidney injury (19.0% vs 14.2%, OR of 1.4), when compared with propensity-matched control patients. Interestingly, its use was not associated with a lower incidence of transfusion or reexploration for bleeding. The authors recommend caution in the use of aprotinin until strong evidence of its safety becomes available.
11. DO NOT RESUSCITATE TATTOO
Holt GE, Sarmento B, Kett D, Goodman KW. An unconscious patient with a DNR tattoo. N Engl J Med. 2017;377:2192–2193.
This provocative letter to the editor deserves our attention. It reports on an unconscious patient who presented with a tattoo reading “Do Not Resuscitate” with his signature applied to his anterior chest. The quandary as to the legality of this “document” and whether to honor it—in light of the presence of a previous case report of a patient whose DNR tattoo did not reflect his current wishes—are discussed, including the recommendation of their ethics consultants to honor this tattoo. You may wish to discuss this in your institution, including with risk management and your ethics committee.
12. ASSOCIATION OF APGAR SCORES WITH RISK OF CEREBRAL PALSY AND EPILEPSY
Persson M, Razaz N, Tedroff K, Joseph KS, Cnattingius S. Five and 10 minute Apgar scores and risks of cerebral palsy and epilepsy: population based cohort study in Sweden. BMJ. 2018;360:k207.
In this observational study of more than 1.2 million nonmalformed live, full-term births in Sweden between 1999 and 2012, the relation of Apgar scores to the diagnoses of cerebral palsy (CP) and epilepsy (E) was evaluated. CP was diagnosed in 0.1%, and epilepsy in 0.3%. The hazard ratio for both increased progressively, with a decreased Apgar score at both 5 and 10 minutes, and more notably at 10 minutes, although the effect on epilepsy was less pronounced.
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LoVerde D, Iweala OI, Eginli A, Krishnaswamy G. Chest. 2018;153:528–543.
2. Gabapentin for Chronic Neuropathic Pain
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3. Guideline-Recommended Versus High-Dose Long-term Opioid Therapy for Chronic Noncancer Pain
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4. Prevention of Ventilator-Associated Pneumonia
Álvarez-Lerma F, Palomar-Martínez M, Sánchez-García M, et al. Crit Care Med. 2018;46:181–188.
5. Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment
Fan E, Brodie D, Slutsky AS. JAMA. 2018;319:698–710.
6. Mechanical Ventilation-Induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes
Goligher EC, Dres M, Fan E, et al. Am J Respir Crit Care Med. 2018;197:204–213.
7. Health Care Organizations and Policy Leadership: Perspectives on Nonsmoker-Only Hiring Policies
McDaniel PA, Malone RE. Acad Med. 2018;93:299–305.
8. Diagnosis of Venous Thromboembolism: 20 Years of Progress
Wells PS, Ihaddadene R, Reilly A, Forgie MA. Ann Intern Med. 2018;168:131–140.
9. Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation
Jabre P, Penaloza A, Pinero D, et al. JAMA. 2018;319:779–787.
10. (Physician) Fatigue and Patient Safety
Committee on Patient Safety and Quality Improvement. ACOG Committee Opinion No. 730. Obstet Gynecol. 2018;131:e78–e81.
Name: Eugene A. Hessel II, MD.
Contribution: This author wrote the article.
This manuscript was handled by: Thomas R. Vetter, MD, MPH.