As life expectancy increases, more patients ≥65 years undergo general anesthesia. Anesthetic agents may contribute to postoperative cognitive dysfunction, and incidence may differ with anesthetic agents or intraoperative anesthesia depth. Responses to anesthetic adjuvants vary among elderly patients. Processed electroencephalography guidance of anesthetic may better ensure equivalent cerebral suppression. This study investigates postoperative cognitive dysfunction differences in elderly patients given desflurane or sevoflurane using processed electroencephalography guidance.IRB approved, randomized trial enrolled consenting patients ≥65 years scheduled for elective surgery requiring general anesthesia ≥120 minute duration. After written informed consent, patients were randomly assigned to sevoflurane or desflurane. No perioperative benzodiazepines were administered. Cognitive impairment was measured by an investigator blinded to group assignment using mini-Mental Status Examination (MMSE) at baseline; 1, 6, and 24 hours after the end of anesthesia. Mean arterial pressure was maintained within 20% of baseline. Anesthetic dose was adjusted to maintain moderate general anesthesia per processed electroencephalograpy (Patient State Index 25 to 50). The primary outcome measure was intergroup difference in MMSE change 1 hour after anesthesia (median; 95% confidence interval).110 patients consented; 26 were not included for analysis (no general anesthesia; withdrew consent; baseline MMSE abnormality; inability to perform postoperative MMSE; data capture failure); 47 sevoflurane and 37 desflurane were analyzed. There were no significant differences in patient characteristics; intraoperative mean blood pressure (desflurane 86.4; 81.3 to 89.6 versus sevoflurane 82.5; 80.2 to 86.1 mmHg; p = 0.42) or Patient State Index (desflurane 41.9; 39.0 to 44.0 versus sevoflurane 41.0; 37.5 to 44.0; p = 0.60) despite a lower MAC fraction in desflurane (0.82; 0.77 to 0.86) versus sevoflurane (0.96; 0.91 to 1.03; p < 0.001). MMSE decreased 1 hour after anesthesia (p < 0.001). The decrease at one hour was larger in sevoflurane (−2.5; −3.3 to −1.8) than desflurane (−1.3; −2.2 to −0.5; p = 0.03). MMSE returned to baseline by 6 hours after anesthesia.ConclusionsFor elderly patients in whom depth of anesthesia is maintained in the moderate range, both desflurane and sevoflurane are associated with transient decreases in cognitive function as measured by MMSE after anesthesia, with clinically insignificant differences between them in this setting.Trial registryClinicalTrials.gov NCT01199913

Objective To evaluate the predictive utility of the Hospital Frailty Risk Score (HFRS), a stratification tool based on the ICD-10 ( International Classification of Disease, Tenth Revision), and other risk factors for 30-day readmissions and mortality in a nationally representative cohort. Study Design Retrospective database review. Setting Nationwide Readmissions Database (2017). Methods Patients with head and neck cancer who underwent major surgical procedures were identified from the 2017 Nationwide Readmissions Database, representing 116 medical centers nationwide. Bivariate and multivariable logistic regression methods were used to identify factors associated with unplanned 30-day readmission, 30-day readmission mortality, and increased length of hospital stay. Results A total of 14,420 patients underwent major head and neck cancer surgery. Unplanned readmission occurred in 11% of patients. The most common reasons for unplanned readmission were procedural complications (26.5%), sepsis (7.3%), and respiratory failure (3.9%). Elevated frailty index (HFRS ≥5) was identified in 22% of patients. Frailty was associated with higher 30-day readmission rates (18.0% vs 9.5%, P < .01), which held on multivariate modeling (odds ratio [OR], 1.59 [95% CI, 1.37-1.85]). Frail patients spent more days in the hospital (8.2 vs 6.8, P = .02) and incurred more charges across hospital stays ($275,000 vs $188,000, P < .01). Patients >75 years old (OR, 1.26 [1.03-1.55]) and patients with electrolyte abnormalities (OR, 1.25 [1.07-1.46] were significantly more likely to be readmitted. Conclusion In this head and neck cancer surgical population, HFRS significantly predicted unplanned readmission. HFRS is a potential risk stratification tool and should be compared with other methods and explored in other cancer populations. Beyond the challenge of identifying at-risk patients, future work should explore potential interventions aimed at mitigating readmission.

The administration of dextrose during emergence from anesthesia was not associated with a difference in the incidence of PONV exceeding 20% or in the severity of PONV in the first 2 hours after anesthesia. The relationship between PONV and the optimal dose and timing of IV dextrose administration remains unclear and may warrant further study.

BACKGROUND:The Acute Pain Service (APS) was initially introduced to optimize multimodal postoperative pain control. The aim of this study was to evaluate the association between the implementation of an APS and postoperative pain management and outcomes for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).METHODS:In this propensity-matched retrospective cohort study, we performed a before–after study without a concurrent control group. Outcomes were compared among patients undergoing CRS-HIPEC when APS was implemented versus historical controls (non-APS). The primary objective was to determine if there was a decrease in median total opioid consumption during postoperative days 0–3 among patients managed by the APS. Secondary outcomes included opioid consumption on each postoperative day (0–6), time to ambulation, time to solid intake, and hospital length of stay.RESULTS:After exclusion, there were a total of 122 patients, of which 51 and 71 were in the APS and non-APS cohort, respectively. Between propensity-matched groups, the median (quartiles) total opioid consumption during postoperative days 0–3 was 27.5 mg intravenous morphine equivalents (MEQs) (7.6–106.3 mg MEQs) versus 144.0 mg MEQs (68.9–238.3 mg MEQs), respectively. The median difference was 80.8 mg MEQs (95% confidence interval, 46.1–124.0; P < .0001). There were statistically significant decreases in time to ambulation and time to solid diet intake in the APS cohort.CONCLUSIONS:After implementing the APS, CRS-HIPEC patients had decreased opioid consumption by >50%, as well as shorter time to ambulation and time to solid intake. Implementation of an APS may improve outcomes in CRS-HIPEC patients.

Supplemental Digital Content is available in the text.Published ahead of print February 1, 2016