Obstetric Anesthesiology: An Illustrated Case-Based Approach No abstract available

Cricoid Pressure: Do No Harm, But Do It Correctly No abstract available

Transfusion of Red Blood Cells, Fresh Frozen Plasma, or Platelets Is Associated With Mortality and Infection After Cardiac Surgery in a Dose-Dependent Manner BACKGROUND: It is unclear whether transfusion of platelets or fresh frozen plasma, in addition to red blood cells, is associated with an increased risk of mortality and infection after cardiac surgery. METHODS: Patients who underwent valve surgery and/or coronary artery bypass grafting from January 1, 2011 to June 30, 2017 and September 1, 2013 to June 30, 2017 at 2 centers performing cardiac surgery were included in this retrospective study. After stratifying patients based on propensity score matching, we compared rates of mortality and infection between patients who transfused red blood cells, fresh frozen plasma, or platelets with those who did not receive such transfusions. We also compared outcomes between patients who received any of the 3 blood products and patients who received no transfusions at all. Multivariable logistic regression was used to assess associations between transfusion and outcomes. RESULTS: Of 8238 patients in this study, 109 (1.3%) died, 812 (9.9%) experienced infection, and 4937 (59.9%) received at least 1 type of blood product. Transfusion of any blood type was associated with higher rates of mortality (2.0% vs 0.18%; P < .01) and infection (13.3% vs 4.8%; P < .01). Each of the 3 blood products was independently associated with an increase in mortality per unit transfused (red blood cells, odds ratio 1.18, 95% confidence interval [CI], 1.14–1.22; fresh frozen plasma, odds ratio 1.24, 95% CI, 1.18–1.30; platelets, odds ratio 1.12, 95% CI, 1.07–1.18). Transfusing 3 units of any of the 3 blood products was associated with a dose-dependent increase in the incidence of mortality (odds ratio 1.88, 95% CI, 1.70–2.08) and infection (odds ratio 1.50, 95% CI, 1.43–1.57). CONCLUSIONS: Transfusion of red blood cells, fresh frozen plasma, or platelets is an independent risk factor of mortality and infection, and combination of the 3 blood products is associated with adverse outcomes after cardiac surgery in a dose-dependent manner. Accepted for publication October 3, 2019. Funding: This work was supported by the 1.3.5 Project for Disciplines of Excellence (ZY2016101), West China Hospital of Sichuan University, and the National and Zhejiang Health and Family Planning Commission (2018272998), the Second Affiliated Hospital of Zhejiang University. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Min Yan, MD, PhD, Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, No. 88 Jiefang Rd, Hangzhou, Zhejiang, 330100, China. Address e-mail to zryanmin@zju.edu.cn. © 2019 International Anesthesia Research Society

Patient Blood Management in Cardiac Surgery No abstract available

In Response No abstract available

“Pediatric Anesthetic Neurotoxicity”: Time to Stop! No abstract available

Effect of Oral Carbohydrate Intake During Labor on the Rate of Instrumental Vaginal Delivery: A Multicenter, Randomized Controlled Trial BACKGROUND: Carbohydrate intake during physical exercise improves muscle performance and decreases fatigue. We hypothesized that carbohydrate intake during labor, which is a period of significant physical activity, can decrease the instrumental vaginal delivery rate. METHODS: In a multicenter, prospective, randomized, controlled trial, healthy adult pregnant women presenting with spontaneous labor were assigned to a “Carbohydrate” group (advised to drink 200 mL of apple or grape juice without pulp every 3 hours) or a “Fasting” group (water only). The primary outcome was the instrumental vaginal delivery rate. Secondary outcomes included duration of labor, rate of cesarean delivery, evaluation of maternal hunger, thirst, stress, fatigue, and overall feeling during labor by numeric rating scale (0 worst rating to 10 best rating), rate of vomiting, and hospital length of stay. Statistical analysis was performed on an intention-to-treat basis. The primary outcome was tested with the “Fasting” group as the reference group. The P values for secondary outcomes were adjusted for multiple comparisons. The differences between groups are reported with 99% confidence interval (CI). RESULTS: A total of 3984 women were analyzed (2014 in the Carbohydrate group and 1970 in the Fasting group). There was no difference in the rate of instrumental delivery between the Carbohydrate (21.0%) and the Fasting (22.4%) groups (difference, −1.4%; 99% CI, −4.9 to 2.2). No differences were found between the Carbohydrate and the Fasting groups for the duration of labor (difference, −7 minutes; 99% CI, −25 to 11), the rate of cesarean delivery (difference, −0.3%; 99% CI, −2.4 to 3.0), the rate of vomiting (difference, 2.8%; 99% CI, 0.2–5.7), the degree of self-reported fatigue (difference, 1; 99% CI, 0–2), self-reported hunger (difference, 0; 99% CI, −1 to 1), thirst (difference, 0; 99% CI, −1 to 1), stress (difference, 0; 99% CI, −1 to 1), overall feeling (difference, 0; 99% CI, 0–0), and the length of hospitalization (difference, 0; 99% CI, −1 to 0). CONCLUSIONS: Carbohydrate intake during labor did not modify the rate of instrumental vaginal delivery. Accepted for publication September 25, 2019. Funding: Institutional and/or departmental. The authors declare no conflicts of interest. Clinical trial registration: Clinical trial registered in the European Clinical Trials Database EudraCT: 2007-A00585-49 and NCT 01022697. Reprints will not be available from the authors. Address correspondence to Jean-Luc Hanouz, MD, PhD, Service d’Anesthésie Réanimation (niveau 6), CHU de Caen Normandie, Av Côte de Nacre, 14000 CAEN Cedex, France. Address e-mail to hanouz-jl@chu-caen.fr. © 2019 International Anesthesia Research Society

Neostigmine Versus Sugammadex for Reversal of Neuromuscular Blockade and Effects on Reintubation for Respiratory Failure or Newly Initiated Noninvasive Ventilation: An Interrupted Time Series Design BACKGROUND: Pulmonary complications related to residual neuromuscular blockade lead to morbidity and mortality. Using an interrupted time series design, we tested whether proportions of reintubation for respiratory failure or new noninvasive ventilation were changed after a system-wide transition of the standard reversal agent from neostigmine to sugammadex. METHODS: Adult patients undergoing a procedure with general anesthesia that included pharmacologic reversal of neuromuscular blockade and admission ≥1 night were eligible. Groups were determined by date of surgery: August 15, 2015 to May 10, 2016 (presugammadex), and August 15, 2016 to May 11, 2017 (postsugammadex). The period from May 11, 2016 to August 14, 2016 marked the institutional transition (washout/wash-in) from neostigmine to sugammadex. The primary outcome was defined as a composite of reintubation for respiratory failure or new noninvasive ventilation. Event proportions were parsed into 10-day intervals in each cohort, and trend lines were fitted. Segmented logistic regression models appropriate for an interrupted time series design and adjusting for potential confounders were utilized to evaluate the immediate effect of the implementation of sugammadex and on the difference between preintervention and postintervention slopes of the outcomes. Models containing all parameters (full) and only significant parameters (parsimonious) were fitted and are reported. RESULTS: Of 13,031 screened patients, 7316 patients were included. The composite respiratory outcome occurred in 6.1% of the presugammadex group and 4.2% of the postsugammadex group. Adjusted odds ratio (OR) and 95% confidence intervals (CIs) for the composite respiratory outcome were 0.795 (95% CI, 0.523–1.208) for the immediate effect of intervention, 0.986 (95% CI, 0.959–1.013) for the difference between preintervention and postintervention slopes in the full model, and 0.667 (95% CI, 0.536–0.830) for the immediate effect of the intervention in the parsimonious model. CONCLUSIONS: The system-wide transition of the standard pharmacologic reversal agent from neostigmine to sugammadex was associated with a reduction in the odds of the composite respiratory outcome. This observation is supported by nonsignificant within-group time trends and a significant reduction in intercept/level from presugammadex to postsugammadex in a parsimonious logistic regression model adjusting for covariates. Accepted for publication September 25, 2019. Funding: This work was supported by National Institutes of Health (NIH) award No. K23DA040923 to K.B. The authors declare no conflicts of interest. The content of this report is solely the responsibility of the authors and does not necessarily represent the official views of NIH. NIH had no involvement in study design, collection, analysis, interpretation of data, writing of the report, or the decision to submit the article for publication. Reprints will not be available from the authors. Address correspondence to Karsten Bartels, MD, PhD, University of Colorado, Anschutz Medical Campus, 12401 E 17th Ave, Leprino Office Bldg, 7th Floor, MS B-113, Aurora, CO 80045. Address e-mail to karsten.bartels@ucdenver.edu. © 2019 International Anesthesia Research Society

Analgesic Medication Shortages: Inform Our Patients via a Shared Decision-Making Process No abstract available

Obstructive Sleep Apnea and Ambulatory Surgery: Who Is Truly at Risk? Response to Editorial No abstract available