Continuation of chronic gabapentinoid medications into the postoperative period is associated with the increased use of naloxone to reverse over-sedation or respiratory depression. Such patients requiring this therapy warrant high levels of postoperative monitoring.

BACKGROUND: Preoperative anemia is common in cardiac surgery, yet there were limited data describing the role of sex in the associations between anemia and clinical outcomes. Understanding these relationships may guide preoperative optimization efforts. METHODS: This is an observational cohort study of adults undergoing isolated coronary artery bypass grafting or single- or double-valve surgery from 2008 to 2018 at a large tertiary medical center. Multivariable regression assessed the associations between preoperative hemoglobin concentrations and a primary outcome of postoperative acute kidney injury (AKI) and secondary outcomes of perioperative red blood cell (RBC) transfusion, reoperation, vascular complications (ie, stroke, pulmonary embolism, and myocardial infarction), and hospital length of stay (LOS). Each outcome was a single regression model, using interaction terms to assess sex-specific associations between hemoglobin and outcome. RESULTS: A total of 4117 patients were included (57% men). Linear splines with sex-specific knots (13 g/dL in women and 14 g/dL in men) provided the best overall fit for preoperative hemoglobin and outcome relationships. In women, each 1 g/dL decrease in hemoglobin <13 g/dL was associated with increased odds of AKI (odds ratio = 1.49; 95% confidence interval [CI], [1.23-1.81]; P < .001), and there was no significant association between hemoglobin per 1 g/dL >13 g/dL and AKI (0.90 [0.56-1.45]; P = .67). The association between hemoglobin and AKI in men did not meet statistical significance (1.10 [0.99-1.22]; P = .076, per 1 g/dL decrease <14 g/dL; 1.00 [0.79-1.26]; P = .98 for hemoglobin per 1 g/dL >14 g/dL). In women, lower preoperative hemoglobin (per 1 g/dL decrease <13 g/dL) was associated with increased odds of RBC transfusion (2.90 [2.33-3.60]; P < .001), reoperation (1.27 [1.11-1.45]; P < .001) and a longer hospital LOS (multiplicative increase in geometric mean 1.05 [1.03-1.07]; P < .001). In men, preoperative hemoglobin (per 1 g/dL decrease <14 g/dL) was associated with increased odds of perioperative RBCs (2.56 [2.27-2.88]; P < .001) and longer hospital LOS (multiplicative increase in geometric mean 1.02 [1.01-1.04] days; P < .001) but not reoperation (0.94 [0.85-1.04]; P = .256). Preoperative hemoglobin per 1 g/dL >13 g/dL in women and 14 g/dL in men were associated with lower odds of RBCs transfusion (0.57 [0.47-0.69]; P < .001 and 0.74 [0.60-0.91]; P = .005, respectively). CONCLUSIONS: Preoperative anemia was associated with inferior clinical outcomes after cardiac surgery. The associations between hemoglobin and outcomes were distinct for women and men, with different spline knot points identified (13 and 14 g/dL, respectively). Clinicians should consider data-driven approaches to determine preoperative hemoglobin values associated with increasing risk for adverse perioperative outcomes across sexes.

Background: Fluid resuscitation has become the cornerstone of early septic shock management, but the optimal fluid rate is still not well studied. The goal of this investigation is to examine the relationship between fluid resuscitation rate and septic shock resolution. Method: We retrospectively studied adult (≥ 18 years) patients with septic shock, defined based on sepsis III definition, from January 1, 2006, through May 31, 2018, in the medical intensive care unit (MICU) of Mayo Clinic Rochester. The fluid resuscitation time was defined as the time required to infuse the initial fluid bolus of 30 ml/kg, based on the recommendations of the 2016 surviving sepsis campaign. The cohort was divided into four groups based on the average fluid rate (group 1 ≥ 0.5, group 2 0.25-0.49, group 3 0.17-0.24, and group 4 < 0.17 ml/kg/min). The primary outcome was the time to shock reversal. Multivariable regression analyses were conducted to account for potential confounders. Result: A total of 1052 patients met eligibility criteria and were included in the analysis. The time-to-shock reversal was significantly different among the groups (P < .001). Patients in group 1 who received fluid resuscitation at a faster rate had a shorter time to shock reversal (HR = 0.78; 95% CI 0.66-0.91; P = .01) when compared with group 4 with a median (IQR) time-to-shock reversal of 1.7 (1.5, 2.0) vs. 2.8 (2.6, 3.3) days, respectively. Using 0.25 ml/kg/min as cutoff, the higher fluid infusion rate was associated with a shorter time to shock reversal (HR = 1.22; 95% CI 1.06-1.41; P = .004) and with decreased odds of 28-day mortality (HR = 0.71; 95% CI 0.60-0.85; P < .001). Conclusion: In septic shock patients, initial fluid resuscitation rate of 0.25-0.50 ml/kg/min (i.e., completion of the initial 30 ml/kg IV fluid resuscitation within the first 2 h), may be associated with early shock reversal and lower 28-day mortality compared with slower rates of infusion.In this study, we assess the impact of the initial fluid replacement rate on the outcome of patients with septic shock managed based on Surviving Sepsis Campaign (SSC) guidelines. We found among septic shock patients the minimum initial fluid resuscitation rate of 0.25-0.50 ml/kg/min (i.e., completion of the initial 30 ml/kg IV fluid resuscitation within the first 2 h) is associated with a shorter time to shock reversal and improved patient outcome.

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Purpose: To ascertain postoperative nausea and vomiting (PONV) rates in adult patients after strabismus operations and assess causes for prolonged post-anesthesia recovery. Methods: This was a retrospective observational study of consecutive adult patients who underwent strabismus operations at one institution from January 1, 2010, to May 31, 2017. The anesthetic records were abstracted and PONV rates were ascertained. On the basis of the cohort's 75th percentile of anesthesia recovery duration, patients were categorized into goal recovery (lower three quartiles) and prolonged recovery (upper quartile). Multivariable logistic regression analyses were performed to assess associations between clinical characteristics and prolonged recovery. Results: A total of 794 adult patients who underwent strabismus surgery were identified. PONV was present in 31 (3.9%) patients. The median (interquartile range) post-anesthesia recovery was 45 minutes (range: 33 to 63 minutes). Prolonged recovery was associated with long-term benzodiazepine use (odds ratio [OR]: 3.07; 95% CI [confidence interval]: 1.23 to 7.80; P = .02). Patients with prolonged recovery had higher rates of PONV (15 [7.2%] vs 16 [2.7%], P = .007), oversedation (107 [51.4%] vs 226 [38.6%], P = .001), and postoperative analgesic administration (138 [66.4%] vs 222 [37.9%], P < .001). Inverse associations were found between desflurane and oversedation (OR: 0.63; 95% CI: 0.45 to 0.86; P = .004) and between acetaminophen administration and postoperative analgesic administration (OR: 0.57; 95% CI: 0.38 to 0.86; P = .007). Conclusions: Adult patients undergoing general anesthesia for strabismus surgery had a low PONV rate. However, the presence of PONV was associated with delayed recovery room discharge. Other factors associated with prolonged Phase I recovery were long-term benzodiazepine use and longer operations, which likely resulted in an increased need for anesthetic agents and therefore more intense postoperative sedation. [ J Pediatr Ophthalmol Strabismus . 2019;56(3):151–156.]