Monitored Anesthesia Care Research Articles

Conscious sedation by sedation-trained interventionalists versus anesthesia providers in patients with acute ischemic stroke undergoing endovascular thrombectomy: A propensity score-matched analysis.

The appropriate choice of perioperative sedation during endovascular thrombectomy for ischemic stroke is unknown. Few studies have evaluated the role of nursing-administered conscious sedation supervised by a trained interventionalist. To compare the safety and efficacy of endovascular thrombectomy for ischemic stroke performed with nursing-administered conscious sedation supervised by a trained interventionalist with monitored anesthesia care supervised by an anesthesiologist. A retrospective review of a prospectively collected stroke registry was performed. The primary outcome was functional independence at 90 days, defined as a modified Rankin score of 0-2. Propensity score matching was performed to control for known confounders including patient comorbidities, access type, and direct-to-suite transfers. A total of 355 patients underwent endovascular thrombectomy for large vessel occlusion between 2018 and 2022. Thirty five patients were excluded as they arrived at the endovascular suite intubated. Three hundred and twenty patients were included in our study, 155 who underwent endovascular thrombectomy with nursing-administered conscious sedation and 165 who underwent endovascular thrombectomy with monitored anesthesia care. After propensity score matching, there were 111 patients in each group. There was no difference in modified Rankin score 0-2 at 90 days (26.1% vs 35.1%, p = 0.190). Patients undergoing monitored anesthesia care received significantly more vasoactive medications (23.4% vs 49.5%, p < 0.001) and had a lower intraoperative minimum systolic blood pressure (134 vs 123 mmHg, p < 0.046). There was no difference in procedural efficacy, safety, intubation rates, and postoperative complications. Perioperative sedation with nursing-administered conscious sedation may be safe and effective in patients undergoing endovascular thrombectomy for ischemic stroke.

A retrospective comparative study of anesthesia with remimazolam and remifentanil versus dexmedetomidine and remifentanil for transcatheter aortic valve replacement

Remimazolam, an ultrashort-acting benzodiazepine, allows for rapid and reliable arousal. Rapid awakening using remimazolam may be beneficial in transcatheter aortic valve replacement (TAVR), as it allows rapid detection of neurologic deficits. The purpose of this study was to compare arousal time and outcomes between monitored anesthesia care (MAC) with remimazolam and remifentanil and conventional MAC with dexmedetomidine, propofol, and remifentanil. This study was a single center retrospective study. All TAVR cases performed under MAC (MAC-TAVR) at our institution between 2019 and 2021 were included. Patients were classified by anesthesia method into remimazolam and dexmedetomidine groups. Among 258 MAC-TAVR patients, 253 were enrolled. After propensity score matching, 76 patients were assigned to each group. The time from end of drug-administration to arousal [20.0 (16.0, 24.0) min vs. 38.5 (30.0, 56.3) min, p < 0.0001] and the time from attempted-arousal to arousal [1.0 (1.0, 1.0) min vs. 12.5 (3.0, 26.8) min, p < 0.0001] were significantly shorter in the remimazolam group. There was no significant difference in the length of ICU stay [2.0 (2.0, 2.0) days vs. 2.0 (2.0, 2.0) days, p = 0.157] and postoperative hospital stay [6.0 (4.0, 9.0) days vs. 5.0 (4.0, 8.0) days, p = 0.262].Trial registration: Clinical trial number: R03-123, Registry URL: https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000051635Registration number: UMIN000045195, Principal investigator's name: Atsuhiro Kitaura,Date of registration: 20 August 2021.

Monitored Anesthesia Care in Tympanoplasty a Comparative Study of Pentazocine Phenargan Combination versus Pentazocine Dexmedetomidine

The objective of this study was to compare the effectiveness and safety of two different drug combinations used for monitored anesthesia care (MAC) in tympanoplasty procedures. The first combination consisted of pentazocine and phenergan, while the second combination included pentazocine and dexmedetomidine. A prospective, randomized controlled trial was conducted on patients scheduled for tympanoplasty surgery. A total of 100 patients were randomly assigned to either the pentazocine-phenergan group or the pentazocine-dexmedetomidine group. The primary outcome measured included the level of sedation achieved, pain scores during surgery, and the incidence of adverse events such as respiratory depression, nausea, vomiting, bradycardia and hypotention. The results showed that the pentazocine-dexmedetomidine combination achieved a higher sedation score and lower pain scores compared to the pentazocine-phenergan combination. Sedation score in Group PP mean RSS of 1.928571429, while Group PD had a higher mean RSS score of 3.142857143 also VAS scores in Group PP mean VAS sore of 4.542857143, and Group PD had mean VAS score of 3.285714286. However, higher incidences of adverse events were noted in Group PD compared with Group PP. In conclusion, this comparative study suggests that the pentazocine-dexmedetomidine combination may offer superior sedative effects and better analgesia compared to the pentazocine-phenergan combination during tympanoplasty with manageable adverse effects.

Anesthésie locale sous contrôle d’un anesthésiste pour l’enclouage des fractures du fémur proximal

IntroductionProximal femur fractures have high rates of morbidity, mortality, and perioperative complications. Limiting anesthesia, especially in the elderly population, is a priority from a medical perspective. The goal of the current study is to present a technique of using local anesthetic with monitored anesthesia care (MAC) for the fixation of intertrochanteric (IT) femur fractures with cephalomedullary nailing (CMN), provide early clinical results in a small series of patients, and evaluate the safety, efficiency, and anesthetic efficacy of our technique. HypothesisThe use of only local anesthetic with MAC for the fixation of IT fractures is safe and leads to decreased operative times when compared to spinal and general anesthesia. Materials and methodsPatients undergoing cephalomedullary nailing (CMN) with a long nail for intertrochanteric (IT) femur fractures by a single surgeon from January 2020 to June 2021 were identified retrospectively from a prospectively-collected patient registry. Patient demographics, operative time, length of hospital stay, perioperative medication use, and complications were collected. Analysis of variance, Chi-squared, linear regression, and two-sampled t-tests were performed to analyze potential differences between the local anesthesia group and the general or spinal anesthesia group. ResultsThirty-seven patients were identified. Eleven patients underwent CMN using local anesthesia with MAC, 11 using spinal anesthesia, and 15 using general anesthesia. The local anesthesia group demonstrated significantly lower operating room times and anesthesia induction to incision time compared to other anesthesia techniques. The local anesthesia group also trended towards less need for vasopressors during surgery and less postoperative delirium. No differences were identified in intraoperative narcotic use, complications, patient mortality, or hospital readmissions. ConclusionsLocal anesthesia with MAC for the treatment of IT fractures with CMN was associated with decreased operating room times and had similar complication rates including blood transfusions, readmissions, and mortalities, when compared to spinal and general anesthesia. Level of evidenceIII, therapeutic.

S1264 Gastric Per-Oral Pyloromyotomy With Monitored Anesthesia Care Is Safe and Practicable: A Pilot Study

S1264 Gastric Per-Oral Pyloromyotomy With Monitored Anesthesia Care Is Safe and Practicable: A Pilot Study

Comparison of the Quality of Recovery-15 score in patients undergoing oncoplastic breast-conserving surgery under monitored anesthesia care versus general anesthesia: a prospective quality improvement study.

Whether changing the institutional practice from general anesthesia (GA) to monitored anesthesia care (MAC) affects postoperative quality of recovery for oncoplastic breast-conserving surgery (BCS) is currently unknown. We designed this quasi-experimental study to evaluate a quality improvement (QI) initiative instituted in Edmonton, AB, Canada. We chose a prospective controlled cohort study design for this QI study, where patients underwent oncoplastic BCS under MAC in one hospital and BCS under GA at another hospital (control). A total of 125 patients undergoing surgery between May 2021 and February 2022 were enrolled. Exclusion criteria were male sex, total mastectomy, or age under 18. All other patients were included. The primary outcome was the change in Quality of Recovery-15 score at 24hr compared with a preoperative baseline. Secondary outcomes included intra- and postoperative time profiles, perioperative analgesic and antiemetic use and length of hospital stay. Statistical analysis included a propensity score analysis to account for confounding variables. Sixty-four patients received GA and 61 MAC. No enrolled patients were lost to follow up but two were excluded secondarily. No patients receiving MAC needed conversion to GA or unplanned airway management. Monitored anesthesia care was associated with superior outcomes for the primary outcome (β/SE[β], 3.31; 99.5% confidence interval, 0.45 to 6.17; P = 0.001) and most secondary outcomes, when accounting for confounding factors. A care transformation initiative for patients undergoing oncoplastic BCS under MAC was associated with a higher quality recovery profile and shorter length of stay without any increase in perioperative or postoperative adverse events.

Intraoperative Stimulation Mapping in Neurosurgery for Anesthesiologists, Part 2: The Anesthetic Considerations

AbstractIntraoperative language and sensorimotor function mapping with direct electrical stimulation allows precise identification of functionally important brain regions. Direct electrical stimulation brain mapping has become the standard of care for the resection of brain lesions near or within eloquent regions with various patient outcome benefits. Intraoperative stimulation mapping (ISM) is commonly performed in an awake patient for language and motor assessments. However, motor mapping under general anesthesia, termed asleep motor mapping, has been increasingly performed over the last two decades for lesions primarily affecting the motor areas of the brain. Both asleep-awake-asleep and monitored anesthesia care have been successfully used for awake craniotomy in modern neuroanesthesia. Each anesthetic agent exerts varying effects on the quality of ISM, especially under general anesthesia. Careful selection of an anesthetic technique is crucial for the successful performance of ISM in both awake and asleep conditions. A comprehensive search was performed on electronic databases such as PubMed, Embase, Cochrane, Scopus, Web of Science, and Google Scholar to identify articles describing anesthesia for awake craniotomy, intraoperative brain mapping, and asleep motor mapping. In the second part of this narrative review, we summarize the effects of different anesthetic regimes and agents on ISM, causes of the failure of awake craniotomy and mapping, and outline the anesthetic considerations for ISM during awake craniotomy and asleep motor mapping.

Outpatient percutaneous image-guided microwave ablation with monitored anesthesia care: An exploratory study

PurposeTo evaluate the feasibility, safety, and periprocedural perception of pain for a combination approach of moderate and deep sedation for image-guided percutaneous microwave ablation of both primary and secondary malignant lesions. MethodsThis was a retrospective study of 33 image-guided percutaneous microwave ablation procedures performed on 33 patients in an outpatient-based interventional radiology center. We used a combination of midazolam, fentanyl, propofol, and/or ketamine to achieve mild to moderate sedation for the procedure, and also to achieve deeper sedation as needed for the ablation portion. ResultsTechnical success was achieved in all image-guided percutaneous microwave ablation procedures. Mean procedural time was 49.4 min. There were no major complications. Intraprocedural pain was absent in all patients. All 33 patients were deemed fit for discharge within 30 min following the procedure. ConclusionThe combination approach of moderate and deep sedation for anesthesia during image-guided percutaneous microwave ablation is an advantageous option. This approach has a strong safety profile, good technical success, short procedure times, low levels of intraprocedural and post-procedural pain, and short recovery from anesthesia.

Analgesic Effects of Magnesium Sulphate as an Adjuvant to Fentanyl for Monitored Anaesthesia Care During Hysteroscopy.

Magnesium sulphate (MgSO4) is conventionally used in the treatment of eclampsia, refractive arrhythmias, asthma, etc. In our study, we aimed to study the analgesic effects of MgSO4 as an adjuvant to fentanyl and reduce the intraoperative opioid requirement to decrease their adverse effects. A total of 122 patients scheduled for hysteroscopy were randomly divided into two groups. Patients in the magnesium group (group A) received intravenous MgSO4 50 mg/kg in 100 ml of isotonic saline over 15 minutes before anaesthesia induction and then 15 mg/kg per hour by continuous intravenous infusion. Patients in the control group (group B) received an equal volume of isotonic saline as a placebo. All the patients were induced with fentanyl and propofol. Perioperative haemodynamic monitoring and postoperative assessment of pain were done. Only 18% of the patients in group A required rescue analgesics as compared to 39.3% of patients in group B. The patients receiving MgSO4 displayed lower verbal numeric rating scale scores in the postoperative period. In addition, the intraoperative requirement of fentanyl (101 (21.33) vs. 144 (28.4) µg, mean (SD)) and propofol (121 (13.3) vs. 140 (16.5) mg, mean (SD)) was significantly lower in group A as compared to that in group B. MgSO4, when administered as an adjuvant to opioids, provided effective postoperative analgesia thereby reducing the need for rescue analgesics. It also decreases intraoperative fentanyl consumption and its dose-related side effects.

Etomidate Versus Propofol for Monitored Anesthesia Care During Endoscopic Retrograde Cholangiopancreatography: A Prospective Randomized Controlled Trial.

Background and objectives Propofol-based sedation is one of the most commonly used methods for endoscopic retrograde cholangiopancreatography (ERCP). The commonest complications during ERCP are in the form of adverse cardiopulmonary events as a result of sedation. Etomidate has a more stable cardiovascular and respiratory profile than propofol and has been used forsedation in simple gastrointestinal endoscopy but has not been studied for procedural sedation in ERCP. The objective of the present study was to compare the safety and feasibility of etomidate and propofol for sedation during ERCP procedures. Methods This single-center, randomized trial included 100 American Society of Anesthesiologists (ASA) physical status class I to II patients who were scheduled for ERCP. All patients received midazolam 0.02 mg/kg, lignocaine (2%) 1 mg/kg, and fentanyl 1 µg/kg intravenously, followed by etomidate or propofol according to the group allocation. The primary outcome was to compare the mean arterial pressure (MAP) at various timepoints between the two groups and secondary outcomes were to compare oxygen saturation, induction and recovery times, and adverse events. Transient hypotension was defined as any decrease in MAPbelow 60 mmHg or 20% below the baseline. Transient hypoxia was defined as desaturation (saturation of peripheral oxygen (SpO2) <92%) lasting for more than 10 seconds requiring airway intervention. Results Fifty patients were enrolled in each group (Group E: etomidate and Group P: propofol). Transient hypotension occurred in eight (16%) patients in Group P, and two (4%) patients in Group E (P= 0.045). Baseline MAP was comparable between the two groups but was significantly lower in Group P at three timepoints during the study. Nine (18 %) patients in Group P had a transient hypoxic episode, compared to none in Group E (p= 0.006). The induction and recovery times were similar in the two groups. Conclusions Etomidate offers better hemodynamic and respiratory stability than propofol and can be recommended for use during ERCP in ASA I/II patients.

Comparative analysis of the effect of electromyogram to bispectral index and 95% spectral edge frequency under remimazolam and propofol anesthesia: a prospective, randomized, controlled clinical trial.

Bispectral index (BIS), an index used to monitor the depth of anesthesia, can be interfered with by the electromyogram (EMG) signal. The 95% spectral edge frequency (SEF95) also can reflect the sedation depth. Remimazolam in monitored anesthesia care results in higher BIS values than propofol, though in the same sedation level assessed by Modified Observers Assessment of Alertness and Sedation (MOAA/S). Our study aims to illustrate whether EMG is involved in remimazolam causing higher BIS value than propofol preliminarily and to explore the correlations among BIS, EMG, and SEF95 under propofol and remimazolam anesthesia. Twenty-eight patients were randomly divided into propofol (P) and remimazolam (RM) groups. Patients in the two groups received alfentanil 10 μg/kg, followed by propofol 2 mg/kg and remimazolam 0.15 mg/kg. Blood pressure (BP), heart rate (HR), and oxygen saturation (SpO2) were routinely monitored. The BIS, EMG, and SEF95 were obtained through BIS VISTATM. The primary outcomes were BIS, EMG, and the correlation between BIS and EMG in both groups. Other outcomes were SEF95, the correlation between BIS and SEF95, and the correlation between EMG and SEF95. And all the statistical and comparative analysis between these signals was conducted with SPSS 26.0 and GraphPad Prism 8. BIS values, EMG, and SEF95 were significantly higher in the RM group than in the P group (all p < 0.001). There was a strong positive correlation between BIS and EMG in the RM group (r = 0.416). Nevertheless, the BIS in the P group showed a weak negative correlation with EMG (r = -0.219). Both P (r = 0.787) and RM group (r = 0.559) had a reasonably significant correlation coefficient between BIS and SEF95. SEF95 almost did not correlate with EMG in the RM group (r = 0.101). Bispectral index can be interfered with high EMG intensity under remimazolam anesthesia. However, EMG can hardly affect the accuracy of BIS under propofol anesthesia due to low EMG intensity and a weak negative correlation between EMG and BIS. Moreover, SEF95 may have a great application prospect in predicting the sedation condition of remimazolam.

Anesthetic Choice for Cardiovascular Implantable Electronic Device Placement and Lead Removal: A National Anesthesia Clinical Outcomes Registry Analysis

The authors evaluated the anesthetic approach for cardiovascular implantable electronic device (CIED) placement and transvenous lead removal, hypothesizing that monitored anesthesia care is used more frequently than general anesthesia. A retrospective study. National Anesthesia Clinical Outcomes Registry data. Adult patients who underwent CIED (permanent cardiac pacemaker or implantable cardioverter-defibrillator [ICD]) placement or transvenous lead removal between 2010 and 2021. None. Covariates were selected a priori within multivariate models to assess predictors of anesthetic type. A total of 87,530 patients underwent pacemaker placement, 76,140 had ICD placement, 2,568 had pacemaker transvenous lead removal, and 4,861 had ICD transvenous lead extraction; 51.2%, 45.64%, 16.82%, and 45.64% received monitored anesthesia care, respectively. A 2%, 1% (both p < 0.0001), and 2% (p=0.0003) increase in monitored anesthesia care occurred for each 1-year increase in age for pacemaker placement, ICD placement, and pacemaker transvenous lead removal, respectively. American Society of Anesthesiologists (ASA) physical status ≤III for pacemaker placement, ASA ≥IV for ICD placement, and ASA ≤III for pacemaker transvenous lead removal were 7% (p=0.0013), 5% (p=0.0144), and 27% (p = 0.0247) more likely to receive monitored anesthesia care, respectively. Patients treated in the Northeast were more likely to receive monitored anesthesia care than in the West for all groups analyzed (p < 0.0024). Male patients were 24% less likely to receive monitored anesthesia care for pacemaker transvenous lead removal (p=0.0378). For every additional 10 pacemaker or ICD lead removals performed in a year, a 2% decrease in monitored anesthesia care was evident (p=0.0271, p < 0.0001, respectively). General anesthesia still has a strong presence in the anesthetic management of both CIED placement and transvenous lead removal. Anesthetic choice, however, varies with patient demographics, hospital characteristics, and geographic region.

Randomized controlled trial of procedural sequence for same-day bidirectional endoscopy under monitored anesthesia care (RECoVER Trial)

Randomized controlled trial of procedural sequence for same-day bidirectional endoscopy under monitored anesthesia care (RECoVER Trial)

Surgical Placement of Axillary Impella 5.5 With Regional Anesthesia and Monitored Anesthesia Care

Surgical Placement of Axillary Impella 5.5 With Regional Anesthesia and Monitored Anesthesia Care

Feasibility of ventilator-assisted tubeless anesthesia for video-assisted thoracoscopic surgery.

General anesthesia providing one-lung ventilation (OLV) with double-lumen endotracheal intubation has been considered inevitable for thoracic surgery. However, with the recent trend of less invasive surgical technique and enhanced recovery after surgery, tubeless anesthesia has been performed in various thoracic surgeries. The aim of this study was to establish a feasible and safe strategy of ventilator-assisted tubeless anesthesia in video-assisted thoracoscopic surgeries (VATS) based on single-institution experiences. We retrospectively reviewed the medical records of patients who underwent tubeless VATS from November 2019 to December 2021. Perioperative anesthetic and surgical variables as well as complications were reported. Seventeen patients with a median age of 29 and American Society of Anesthesiologists physical status I to II underwent video-assisted pulmonary wedge resection under monitored anesthesia care (MAC) using propofol and remifentanil. Mechanical ventilation was applied in synchronized intermittent mandatory ventilation with pressure support mode through facemask if respiratory support was required. During the operation, none of the patients showed hypoxemia or involuntary movement interfering operation. No patients were converted to general anesthesia or open thoracotomy unintentionally. All patients were discharged on median 2 days postoperatively without complications. Ventilator-assisted tubeless VATS is a feasible and safe option in low-risk patients undergoing video-assisted pulmonary wedge resection.

Dexmedetomidine related apnea and desaturation during awake craniotomy: a case report

Dexmedetomidine (Dex) is regarded as a novel sedative agent since the drug preserves respiration and makes ‘conscious sedation’ possible. This drug is widely used for monitored anesthesia care (MAC). We report a case of apnea and desaturation in awake craniotomy surgery under MAC after loading of Dex with 1 mg/kg over 10 min and discuss possible explanations. We advocate using Dex with a lower loading dose over a prolonged duration and the up-titration of the drug according to the patient’s response particularly in those who are underweight or elderly. Meticulous judgement for possible interactions of Dex with antiepileptics, opioids and other sedative agents is essential during MAC.&#x0D; Abbreviations: BIS- Bispectral Index; Dex- Dexmedetomidine; DBS- Deep Brain Stimulation; MAC- Monitored Anesthesia Care; TCI- Targeted-Controlled Infusion&#x0D; Key words: Dexmedetomidine; Craniotomy; Apnea; Conscious sedation; Balanced anesthesia; Anticonvulsant&#x0D; Citation: Hasyizan HM, Mohd Nazaruddin WHWM, Laila AM, Zamzuri I, Zulfakar MM. Dexmedetomidine related apnea and desaturation during awake craniotomy: a case report. Anaesth. pain intensive care 2023;27(4):609−612; DOI: 10.35975/apic.v27i4.1901&#x0D; Received: May 30, 2022; Reviewed: December 28, 2022; Accepted: May 22, 2023

Intraoperative neurophysiological monitoring and spinal cord stimulator implantation

IntroductionSpinal cord injury (SCI) is one of the most dreaded complications after spinal cord stimulation (SCS) implantation surgery. As a result, intraoperative neurophysiological monitoring (IONM) has been proposed to avoid...

A dual-purpose deep learning model for auscultated lung and tracheal sound analysis based on mixed set training

Many deep learning–based computerized respiratory sound analysis methods have previously been developed. However, these studies focus on either lung sound only or tracheal sound only. The effectiveness of using a lung sound analysis algorithm on tracheal sound and vice versa is rarely reported. Furthermore, no one knows whether using lung and tracheal sounds together in training a deep learning-based respiratory sound analysis model is beneficial. In this study, we first constructed a tracheal sound database, HF_Tracheal_V1, containing 10,448 15-s tracheal sound recordings, 21,741 inhalation labels, 15,858 exhalation labels, and 6414 continuous adventitious sound (CAS) labels collected from 227 participants undergoing a diagnostic/surgical procedure under monitored anesthesia care. HF_Tracheal_V1 and our previously built lung sound database, HF_Lung_V2, were either combined (mixed set), used one after the other (domain adaptation), or used alone to train convolutional neural network bidirectional gate recurrent unit models for inhalation, exhalation, and CAS detection in lung and tracheal sounds. The results revealed that the models trained using lung sound alone performed poorly in tracheal sound analysis and vice versa. However, mixed set training or domain adaptation improved the performance for 1) inhalation and exhalation detection in lung sounds and 2) inhalation, exhalation, and CAS detection in tracheal sounds compared to positive controls (the models trained using lung sound alone and used in lung sound analysis and vice versa). In particular, the model trained on the mixed set had great flexibility to serve two purposes, lung and tracheal sound analyses, at the same time.

Automated Electronic Health Record-Based Application for Sedation Triage in Routine Colonoscopy.

Nearly all routine endoscopy procedures are performed using moderate sedation (MS) or monitored anesthesia care (MAC). In this article, we describe how we improved decision-making and decreased practitioners' cognitive burden for choosing between MAC and MS by utilizing patient data in an automated application within the electronic health record (EHR). In our practice, we choose between MS or MAC for routine gastrointestinal (GI) procedures according to written anesthesia use guidelines and practitioner preferences. To expedite our decision-making for MS vs MAC, we developed an Excel-based tool from patient demographic characteristics, comorbid conditions, and medication use extracted from the EHR. The data points from Excel were then implemented in the automated application in the EHR to predict the type of sedation for GI procedures. Before use of the new application, nurses spent an average of 4 minutes and gastroenterology practitioners spent 5 minutes reviewing the EHR to determine the appropriate sedation (MS or MAC). After the application was implemented, the use of MS substantially increased. Time spent reviewing the EHR was reduced to 2 minutes. The rate of adverse events for MS (0.5%) vs MAC (0.6%) was comparable and low overall. The EHR-based application, which automates and standardizes determination of sedation type, is a highly beneficial tool that eliminates subjectivity in decision-making, thus allowing for appropriate use of MAC. Complication rates and sedation failure did not increase with use of the application. With the increase in use of MS over MAC, health care costs for the more expensive MAC sedation should also decrease.

Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: a retrospective observational analysis

BackgroundIntraoperative hypotension (IOH) is well-described in the academic setting but not in community practice. IOH is associated with risk of postoperative morbidity and mortality. This is the first report of IOH in the community setting using the IOH measure definition from the Centers for Medicare and Medicaid Services Merit-based Incentive Payment System program. Objectives: To describe the incidence of IOH in the community setting; assess variation in IOH by patient-, procedure-, and facility-level characteristics; and describe variation in risk-adjusted IOH across clinicians.MethodsDesignCross-sectional descriptive analysis of retrospective data from anesthesia records in 2020 and 2021.SettingForty-five facilities affiliated with two large anesthesia providers in the USA.ParticipantsPatients aged 18 years or older having non-emergent, non-cardiac surgery under general, neuraxial, or regional anesthesia. Cases were excluded based on criteria for the IOH measure: baseline mean arterial pressure (MAP) below 65 mmHg prior to anesthesia induction; American Society of Anesthesiologists (ASA) physical status classification of I, V, or VI; monitored anesthesia care only; deliberate induced hypotension; obstetric non-operative procedures; liver or lung transplant; cataract surgery; non-invasive gastrointestinal cases.Main outcomesIOH, using four definitions. Primary definition: binary assessment of whether the case had MAP < 65 mmHg for 15 min or more. Secondary definitions: total number of minutes of MAP < 65 mmHg, total area under MAP of 65 mmHg, time-weighted average MAP < 65 mmHg.ResultsAmong 127,095 non-emergent, non-cardiac cases in community anesthesia settings, 29% had MAP < 65 mmHg for at least 15 min cumulatively, with an overall mean of 12.4 min < 65 mmHg. IOH was slightly more common in patients who were younger, female, and ASA II (versus III or IV); in procedures that were longer and had higher anesthesia base units; and in ambulatory surgery centers. Incidence of IOH varied widely across individual clinicians in both unadjusted and risk-adjusted analyses.ConclusionIntraoperative hypotension is common in community anesthesia practice, including among patients and settings typically considered “low risk.” Variation in incidence across clinicians remains after risk-adjustment, suggesting that IOH is a modifiable risk worth pursuing in quality improvement initiatives.