Objective There have been suggestions that patients with subarachnoid hemorrhage (SAH) have a better outcome when treated in high-volume centers. Much of the published literature on the subject is limited by an inability to control for severity of SAH. Methods This is a nationwide retrospective cohort analysis using the Nationwide Inpatient Sample (NIS). The NIS Subarachnoid Severity Scale was used to adjust for severity of SAH in multivariate logistic regression modeling. Results The records of 47 911 414 hospital admissions from the 2006–2011 NIS samples were examined. There were 11 607 patients who met inclusion criteria for the study. Of these, 7787 (67.0%) were treated at a high-volume center compared with 3820 (32.9%) treated at a low-volume center. Patients treated at high-volume centers compared with low-volume centers were more likely to receive endovascular aneurysm control (58.5% vs 51.2%, P = .04), be transferred from another hospital (35.4% vs 19.7%, P < .01), be treated in a teaching facility (97.3% vs 72.9%, P < .01), and have a longer length of stay (14.9 days [interquartile range 10.3–21.7] vs 13.9 days [interquartile range, 8.9–20.1], P < .01). After adjustment for all baseline covariates, including severity of SAH, treatment in a high-volume center was associated with an odds ratio for death of 0.82 (95% confidence interval, 0.72–0.95; P < .01) and a higher odds of a good functional outcome (odds ratio, 1.16; 95% confidence interval, 1.04–1.28; P < .01). Conclusion After adjustment for severity of SAH, treatment in a high-volume center was associated with a lower risk of in-hospital mortality and a higher odds of a good functional outcome.

Supplemental Digital Content is available in the text.

Purpose Clinical equipoise exists with the use of novel reperfusion therapies such as catheter-directed thrombolysis in the management of patients presenting to hospital with high risk pulmonary embolism (PE). Therapeutic options rely on clinical presentation, patient factors, physician preference, and institutional availability. We established a Pulmonary Embolism Response Team (PERT) to provide urgent assessment and multidisciplinary care for patients presenting to our institution with high-risk PE. Methods Data were retrospectively collected from PERT activations between January 2016 and December 2018. Chi square tests were used to determine differences in mortality across the three years of study. Logistic regression was used to evaluate 30-and 90-day mortality and occurrence of major bleeds between those receiving anticoagulation alone (AC) and those receiving advanced reperfusion therapy (ART). Results There were 128 PERT activations over three years, the majority originating from the emergency department. Eighty-five percent of activations were for submassive PE, with 56% of all activations assessed as submassive-high risk. Fifteen patients (12%) presented with massive PE. Advanced reperfusion therapy was used in 29 (23%) patients, of whom 25 (20%) received catheterdirected thrombolysis. There was an increased risk of major bleeding in the ART group compared with in the AC group (odds ratio [OR], 17.9; 95% confidence interval [CI], 4.1 to 125.0; P \ 0.001), but no increased risk of mortality at 30 days (OR, 2.1; 95% CI, 0.4 to 9.1; P = 0.3). The 30-day mortality rate was 7.8%. Conclusion We describe the first Canadian PERT, a multidisciplinary team aimed at providing urgent individualized care for patients with high-risk PE. Further research is necessary to determine whether a PERT improves clinical outcomes.

Purpose of Review Hypoxemia during one-lung ventilation, while decreasing in frequency, persists as an intraoperative challenge for anesthesiologists. Discerning when desaturation and resultant hypoxemia correlates to tissue hypoxia is challenging in the perioperative setting and requires a thorough understanding of the physiology of oxygen delivery and tissue utilization. Recent Findings Oxygen delivery is not directly correlated with peripheral oxygen saturation in patients undergoing one-lung ventilation, emphasizing the importance of hemoglobin concentration and cardiac output in avoiding tissue hypoxia. While healthy humans can tolerate acute hypoxemia without long-term consequences, there is a paucity of evidence from patients undergoing thoracic surgery. Increasingly recognized is the potential harm of hyperoxic states, particularly in the setting of complex patients with comorbid diseases. Summary Anesthesiologists are left to determine an acceptable oxygen saturation nadir that is individualized to the patient and procedure based on an understanding of oxygen supply, demand, and the consequences of interventions.