Daily Anesthesiology Research Analysis

BACKGROUND: Older surgical patients are at risk because of age-related physiologic decline and comorbidities. Some guidelines recommend Bispectral Index (BIS; Medtronic, USA) monitoring to optimize anesthetic depth, but robust evidence supporting improved outcomes is lacking. METHODS: A randomized, multicenter, double-blind trial was conducted across 21 tertiary-care hospitals in China (March 17, 2015, to February 5, 2022). Patients aged 65 yr or older scheduled for elective noncardiac surgery (American Society of Anesthesiologists [ASA] Physical Status I to IV) were randomized 1:1 to BIS-guided or routine anesthetic management. In patients assigned to BIS guidance, hypnotic depth was adjusted to maintain BIS between 40 and 60. Hypnotic depth in patients assigned to routine care per clinical judgment with masked BIS monitors. The primary outcome was 1-yr all-cause mortality. Secondary outcomes included moderate-to-severe complications within 30 days, functional independence, quality of life, the duration of postoperative critical care, the duration of postoperative hospitalization, unplanned intensive care unit admission, and hospital cost. RESULTS: Among 6,982 patients (mean ± SD age, 71 ± 5 yr), BIS values averaged 47 (BIS-guided) versus 46 (routine). One-year mortality was similar in BIS-guided patients (10.2% [356 of 3,485]) and routinely managed patients (10.0% [351 of 3,497]; hazard ratio, 1.02; 95% CI, 0.88 to 1.17; P = 0.812). The incidence of complications within 30 days after surgery were also comparable in each group: 10.4% versus 10.6% (relative risk, 0.99; 95% CI, 0.85 to 1.16; P = 0.938). No significant differences were observed in functional independence or quality of life. CONCLUSIONS: Hypnotic depth, as assessed by BIS, was similar in patients with or without BIS-guided anesthetic titration. Anesthesiologists thus apparently titrate hypnotic depth appropriately even without BIS guidance. Unsurprisingly, outcomes including postoperative 1-yr mortality and 30-day complications were similar in each group.

BACKGROUND: The optimal management of perioperative pain in patients using medications for opioid use disorder (MOUD) is unclear. To motivate and inform efforts to develop evidence-based guidelines for perioperative pain management in these patients, it is important to evaluate whether the prevalence of MOUD use in surgical patients is increasing and to identify which procedures have the highest rate of MOUD use. METHODS: This cohort study analyzed adults 18 to 64 yr undergoing 1 of 1,083 major surgical procedures from 2016 to 2022 from the Merative MarketScan Commercial Database, which includes commercial claims from 22 to 28 million privately insured patients annually. Annual changes in MOUD use from 1 to 180 days before surgery were evaluated using logistic regression models adjusting for patient demographics and comorbidities. For each procedure category, the prevalence of MOUD use among all instances of the procedure during 2016 to 2022 was calculated. RESULTS: Analyses included 8,137,973 surgical admissions for 5,013,213 adults (59.9% female). The adjusted prevalence of MOUD use increased from 55.2 per 100,000 in 2016 to 99.8 per 100,000 in 2022 (adjusted annual change, 16.9 per 100,000 procedures; 95% CI, 14.0 to 19.8). Among 15,701 surgical admissions for patients using MOUD during 2016 to 2022, the most common type of MOUD was buprenorphine (13,193; 84.0%). Procedures with the highest rate of MOUD use were debridement (719.0 per 100,000 procedures), shoulder arthroplasty (579.4 per 100,000 procedures), lower extremity amputation (529.6 per 100,000 procedures), and hip or pelvis open fracture repair (497.6 per 100,000 procedures). CONCLUSIONS: In this cohort study of surgical procedures among privately insured U.S. adults, the prevalence of MOUD use increased between 2016 and 2022, highlighting the importance of developing evidence-based guidelines for perioperative management of these patients. The high rates of MOUD use in common orthopedic procedures suggest that these guidelines may be particularly relevant to the practice of orthopedic surgeons.

BACKGROUND: Socioeconomic deprivation is associated with poor surgical outcomes. We assessed associations between deprivation and postoperative morbidity and mortality in a UK-wide surgical cohort. METHODS: We analysed UK data from the Second Sprint National Anaesthesia Project: Epidemiology of Critical Care provision after Surgery (SNAP-2: EpiCCS), a prospective non-consenting cohort study of adults undergoing elective and emergency inpatient noncardiac surgery. Socioeconomic deprivation was reported using the standardised aggregate scale, Index of Multiple Deprivation (IMD; IMD1: most deprived, IMD5: least deprived). Multivariable mixed effects logistic regression was used to model the association between deprivation and postoperative outcomes, adjusting for potential confounders. RESULTS: Of the 18 901 patients included, those in more deprived groups were younger, had higher disease prevalence, and had greater illness severity. Morbidity, as measured by the Post-Operative Morbidity Survey, was reported in 13.7% at day 7, and in-hospital 30-day mortality was 1.3%. Adjusting for patient characteristics and surgical factors, the odds ratios (ORs) for morbidity at day 7 were 1.26 (95% confidence interval [95% CI]: 1.09-1.47) for IMD2 and 1.32 (95% CI: 1.13-1.53) for IMD1, compared with IMD5. Mortality risk was also higher: OR 1.75 (95% CI: 1.12-1.73) for IMD2 and OR 1.90 (95% CI: 1.22-2.95) for IMD1. However, after adjusting for markers of preoperative physical status and comorbidities, the association between deprivation and outcomes was attenuated. CONCLUSIONS: Socioeconomic deprivation is associated with short-term postoperative morbidity and mortality. This association might relate to poorer baseline fitness among people living in socioeconomically deprived areas, highlighting opportunities for targeted preoperative optimisation.