Hospital Stay and Mortality Are Increased in Patients.pdf

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land Clinic, and few patients managed this way are given
propofol after induction. In addition, most are given only
small amounts of opioid analgesia. Nonetheless, it remains
possible that some of the patients with low MAC fractions of
volatile anesthetic may have been given substantial amounts
of propofol or opioids, rather than being atypically sensitive
to anesthesia. Of course, MAC fraction is but one component of the triple low state, and patients in this study given
mostly intravenous drugs tend to have high BIS and wellsustained MAP (data not shown). Thus, substituting propofol or opioids for volatile anesthetic will not, per se, generate
a triple low state.
We know which patients were given nitrous oxide, but a
limitation of our registry is that nitrous oxide concentration
is not recorded; in addition, a given MAC fraction of nitrous
oxide has less effect on BIS than do volatile anesthetics. Thus,
we made no attempt to include nitrous oxide in our MAC
fraction estimates. However, nitrous oxide was not used in
most cases, and inclusion of nitrous oxide in our statistical
models had only minimal effect on the results.
In summary, the combination of low MAC and low MAP
was a strong and highly statistically significant predictor for
mortality. When combined with low BIS, relative risk adjusted mortality was even greater. Thus, the combination of
low MAC, low MAP, and low BIS, a triple low, is an ominous predictor of excessive hospital length of stay and postoperative mortality. This association is especially concerning
because the threshold and average low values for each state
were well within the range that many anesthesiologists tolerate routinely.
The authors gratefully acknowledge the contributions of Armin
Schubert, M.D. (Chair, Department of Anesthesiology, Ochsner
Health System, New Orleans, Louisiana), and Maged Argalious,
M.D. (Professional Staff, Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio), who conceived and developed the
Cleveland Clinic’s Perioperative Health registry. The authors also
thank Eric K. Christiansen, M.B.A. (Anesthesiology Institute,
Cleveland Clinic), who led extraction of data from the registry.

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Anesthesiology 2012; 116:1195–203


Sessler et al.