Hospital Stay and Mortality Are Increased in Patients.pdf


Aperçu du fichier PDF hospital-stay-and-mortality-are-increased-in-patients.pdf - page 9/9

Page 1 2 3 4 5 6 7 8 9



Aperçu texte


PERIOPERATIVE MEDICINE

3. Phan TD, Ismail H, Heriot AG, Ho KM: Improving perioperative outcomes: Fluid optimization with the esophageal
Doppler monitor, a metaanalysis and review. J Am Coll Surg
2008; 207:935– 41
4. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF,
Barclay GR, Fleming SC: Intraoperative oesophageal Doppler
guided fluid management shortens postoperative hospital
stay after major bowel surgery. Br J Anaesth 2005; 95:
634 – 42
5. Koch CG, Li L, Duncan AI, Mihaljevic T, Cosgrove DM, Loop
FD, Starr NJ, Blackstone EH: Morbidity and mortality risk
associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care
Med 2006; 34:1608 –16
6. Koch CG, Li L, Duncan AI, Mihaljevic T, Loop FD, Starr NJ,
Blackstone EH: Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg 2006; 81:1650 –7
7. Koch CG, Li L, Sessler DI, Figueroa P, Hoeltge GA, Mihaljevic
T, Blackstone EH: Duration of red-cell storage and complications after cardiac surgery. N Engl J Med 2008; 358:1229 –39
8. Monk TG, Saini V, Weldon BC, Sigl JC: Anesthetic management and one-year mortality after noncardiac surgery. Anesth
Analg 2005; 100:4 –10
9. Punjasawadwong Y, Boonjeungmonkol N, Phongchiewboon
A: Bispectral index for improving anaesthetic delivery and
postoperative recovery. Cochrane Database Syst Rev 2007:
CD003843
10. Leslie K, Myles PS, Forbes A, Chan MT: The effect of bispectral index monitoring on long-term survival in the B-aware
trial. Anesth Analg 2010; 110:816 –22
11. Lindholm ML, Tra¨ff S, Granath F, Greenwald SD, Ekbom A,
Lennmarken C, Sandin RH: Mortality within 2 years after
surgery in relation to low intraoperative bispectral index
values and preexisting malignant disease. Anesth Analg 2009;
108:508 –12
12. Kertai MD, Pal N, Palanca BJ, Lin N, Searleman SA, Zhang L,
Burnside BA, Finkel KJ, Avidan MS, B-Unaware Study Group:
Association of perioperative risk factors and cumulative duration of low bispectral index with intermediate-term
mortality after cardiac surgery in the B-Unaware Trial.
ANESTHESIOLOGY 2010; 112:1116 –27
13. Belden JR, Caplan LR, Pessin MS, Kwan E: Mechanisms and
clinical features of posterior border-zone infarcts. Neurology
1999; 53:1312– 8
14. Chang HS, Hongo K, Nakagawa H: Adverse effects of limited
hypotensive anesthesia on the outcome of patients with
subarachnoid hemorrhage. J Neurosurg 2000; 92:971–5
15. Lienhart A, Auroy Y, Pe´quignot F, Benhamou D, Warszawski
J, Bovet M, Jougla E: Survey of anesthesia-related mortality in
France. ANESTHESIOLOGY 2006; 105:1087–97
16. Nickalls RW, Mapleson WW: Age-related iso-MAC charts for
isoflurane, sevoflurane and desflurane in man. Br J Anaesth
2003; 91:170 – 4
17. Sessler DI, Sigl JC, Manberg PJ, Kelley SD, Schubert A,
Chamoun NG: Broadly applicable risk stratification system
for predicting duration of hospitalization and mortality.
ANESTHESIOLOGY 2010; 113:1026 –37

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.

References
1. Kurz A, Sessler DI, Lenhardt R: Perioperative normothermia
to reduce the incidence of surgical-wound infection and
shorten hospitalization: Study of Wound Infection and Temperature Group. N Engl J Med 1996; 334:1209 –15
2. Noblett SE, Snowden CP, Shenton BK, Horgan AF: Randomized clinical trial assessing the effect of Doppler-optimized
fluid management on outcome after elective colorectal resection. Br J Surg 2006; 93:1069 –76

Anesthesiology 2012; 116:1195–203

1203

Sessler et al.