BACKGROUND: Hip fractures are a major global health issue with high mortality and morbidity, especially in older adults. One-year mortality post-surgery ranges from 22% to 36%, with many patients never regaining baseline...BACKGROUND: Hip fractures are a major global health issue with high mortality and morbidity, especially in older adults. One-year mortality post-surgery ranges from 22% to 36%, with many patients never regaining baseline mobility. While several predictors of mortality have been identified, their relative contribution to mortality risk within a unified survival prediction framework remains unclear. This study used machine learning to rank key perioperative predictors of mortality following hip fracture surgery. METHODS: Over 11,000 patients from the Australian and New Zealand Hip Fracture Registry were analyzed. Twenty demographic, clinical, and perioperative variables were assessed using a Random Survival Forest (RSF) model. Model performance was evaluated using the concordance index and Brier scores. Permutation-based feature importance ranked predictors according to their contribution to predictive performance for mortality risk. RESULTS: During the follow-up period (median 630 days), 31% of patients died. The RSF model performed well (test C index: 0.7305). The four most important predictors of mortality were American Society of Anesthesiologists (ASA) grade (importance score: 0.051), pre-existing dementia (0.036), age (0.019), and preadmission walking ability (0.016). Other factors like male sex (0.009) and acute hospital stay (0.006) had weaker associations with mortality prediction in this model. CONCLUSIONS: Machine learning identified ASA grade, dementia, age, and mobility as the top predictors of mortality after hip fracture surgery. RSF modeling offered strong performance and better interpretability than traditional methods. These findings support individualized stratification to inform perioperative discussions and goals-of-care planning in this high-risk population.
BACKGROUND: Chronotropic incompetence (CI) is the inability to increase heart rate adequately during exercise to meet metabolic demands and is associated with adverse cardiovascular morbidity and mortality. CI is common...BACKGROUND: Chronotropic incompetence (CI) is the inability to increase heart rate adequately during exercise to meet metabolic demands and is associated with adverse cardiovascular morbidity and mortality. CI is common in the perioperative population and can be diagnosed with preoperative cardiopulmonary exercise testing (CPET). The implications of CI for intraoperative hypotension and treatment with vasopressors are unclear. METHODS: We conducted a single-center retrospective cohort study of patients who underwent CPET before surgery between January 2020 and August 2022. Chronotropic incompetence was defined as chronotropic index of <0.8. The outcomes were the time-weighted average of hypotension and total doses of vasopressors (phenylephrine-equivalent total doses, metaraminol, ephedrine and phenylephrine) in micrograms per kilogram per hour (µg·kg-1·h-1). Hypotension is defined as mean arterial pressure of <65 mm Hg. CPET parameters were compared between groups. T-tests and Mann-Whitney tests were used to compare continuous data, and Fisher's exact tests were used to compare categorical data. Multivariable linear regression analysis and sensitivity analysis were performed. RESULTS: Of 195 patients included, 89 (46%) had CI. There was no difference between time-weighted average of hypotension for the group with no CI and the group with CI (median (IQR) 0.37 (0.21-0.74) vs 0.27 (0.07-0.76) mm Hg, P = .197). There was no difference in phenylephrine-equivalent total doses between the no CI and CI group (46 (11.6-97.3) vs 29.1 (13.2-61.6) µg·kg-1·h-1, P = .139). Those with no CI received higher doses of metaraminol (13.4 (5.82-20.8) vs 7.45 (2.99-14.8) µg·kg-1·h-1, BH-adjusted P = .034). There were no differences in doses of ephedrine (BH-adjusted P = .231) and phenylephrine (BH-adjusted P = .763). The CI group had lower resting heart rates (mean (SD) 88.2 (15.7) vs 80.2 (14.7) beats· min-1, P < .001), peak heart rates (155 (15.1) vs 125 (15.8) beats·min-1 P < .001), peak oxygen consumption (19.1 (5.9) vs 15.4 (3.8) mL·kg-1·min-1, P < .001) and oxygen consumption at the anaerobic threshold (10.6 (2.9) vs 9.4 (2.2) mL·kg-1·min-1 P = .002). CONCLUSIONS: In this surgical cohort, chronotropic competence was neither associated with increased magnitude of hypotension nor with an increase in vasopressor requirements. These findings did not demonstrate an association between CI and intraoperative hypotension and highlight the complex interplay of factors governing perioperative hemodynamics.
BACKGROUND: Day-of-surgery cancelations (DOSCs) are common in pediatric care and disproportionately affect socially disadvantaged families. However, disparities in post-cancelation care trajectories, including timeliness...BACKGROUND: Day-of-surgery cancelations (DOSCs) are common in pediatric care and disproportionately affect socially disadvantaged families. However, disparities in post-cancelation care trajectories, including timeliness of rescheduling and risk of repeat cancelation remain poorly characterized. This study evaluated the association between neighborhood opportunity (a composite measure of neighborhood-level resources that support child development, including education, health/environment, and socioeconomic conditions) and outcomes following a DOSC. METHODS: We conducted a retrospective cohort study of children (<18 years) who experienced a DOSC at a tertiary pediatric hospital between January 1, 2017, and June 30, 2024. The primary exposure was neighborhood opportunity, measured using the Child Opportunity Index (COI) 3.0 and categorized into national quintiles. The primary outcome was procedure completion status within 12 months of the original scheduled date (completed/not completed). Time-to-event methods were used to evaluate differences in the rate of procedure completion over time across COI quintiles; with non-completion censored at 12 months. The secondary outcome was additional cancelations (yes/no). Cox proportional hazards models with a time-varying effect for COI (COI × log time) estimated adjusted hazard ratios (HRs) for completion and modified Poisson regression estimated relative risks (RRs) of repeat cancelation. RESULTS: Among 7015 patients who experienced an index DOSC, the median age was 5 (IQR: 3-8) years, and 56.6% (3969/7015) were male. Completion differed across neighborhood opportunity (log-rank P = .02). In time-to-event analyses, no early differences were observed after cancelation; however, disparities emerged over time, with higher completion rates in neighborhoods with less than very high opportunity by 90 days that persisted through 180 days. Repeat cancelations occurred in 8.2% (565/6896) of patients and were more common among children from low (adjusted RR: 1.40, 95% CI, 1.03-1.92) and very low (aRR: 1.51, 95% CI, 1.10-2.07) opportunity neighborhoods. CONCLUSIONS: Neighborhood opportunity was not strongly associated with overall procedure completion within 12 months but was associated with differences in the timing of completion and patterns of repeat cancelation. Children from lower-opportunity neighborhoods were more likely to experience repeat cancelations and delayed early completion. Measuring the timing of completion may represent a novel equity metric for perioperative quality improvement. Interventions such as social risk screening and automated rescheduling may help reduce inequities in post-cancelation care pathways.
BACKGROUND: The combination of high inspired oxygen fraction (FiO2) and positive-pressure mask ventilation at induction can lead to atelectasis, increasing the risk of perioperative pulmonary complications. Positive end-...BACKGROUND: The combination of high inspired oxygen fraction (FiO2) and positive-pressure mask ventilation at induction can lead to atelectasis, increasing the risk of perioperative pulmonary complications. Positive end-expiratory pressure (PEEP) may reduce atelectasis, but prior studies relied on imaging performed before or after induction rather than during ongoing ventilation. We used electrical impedance tomography (EIT) as a bedside, real-time imaging tool. We hypothesized that higher PEEP levels would improve end-expiratory lung aeration and homogenize ventilation distribution without clinically relevant hemodynamic compromise. METHODS: In this prospective, randomized controlled study, 72 adult patients undergoing elective ophthalmic surgery under general anesthesia were enrolled. The effect of three different PEEP levels (0, 5 and 8 mbar) on the distribution of lung ventilation and hemodynamic parameters during mask ventilation at anesthesia induction with 100% (FiO2) were evaluated. Patients were randomized to ascending or descending PEEP sequences to control for order effects. The primary endpoint was the occurrence and the degree of atelectasis represented by the dorsoventral ventilation gradient at each PEEP level as detected by EIT. Secondary endpoints were changes in end-expiratory lung impedance (EELI) (ratio of EELI gain to EELI loss) and changes in lung compliance (ratio of compliance gain to compliance loss) as surrogate markers for atelectasis formation. Hemodynamic parameters were monitored with noninvasive blood pressure, electrocardiography, and electrical cardiometry. RESULTS: EIT was able to show in real-time that higher PEEP levels significantly improved the mean [SD] dorsoventral ventilation gradient (0.48 [0.21] at 0 mbar vs 0.56 [0.28] at 5 mbar vs 0.63 [0.25] at 8 mbar; p<.001), increased the ratio of gain/loss of the end-expiratory lung impedance of the whole lung (3.1 [4.8] at 0 mbar vs 6.1 [8.1] at 5 mbar (~5.1 cmH2O) vs 10.5 [12.2] at 8 mbar (~8.2 cmH2O); p<.001) and increased the compliance gain/loss ratio of the whole lung (2.7 [9.2] at 0 mbar vs 3.8 [10.3] at 5 mbar vs 4.3 [11.3] at 8 mbar; p=.011), independent of the sequence of PEEP (all data dimensionless). Electrical cardiometry revealed that hemodynamic parameters decreased after induction, but these changes were not associated with specific PEEP levels. CONCLUSIONS: Using real-time bedside EIT our study demonstrates that higher PEEP levels during mask ventilation at anesthesia induction can improve ventilation distribution without adverse hemodynamic effects.
BACKGROUND: Continuous and real-time assessment of cerebral autoregulation can be of important clinical value to individualize blood pressure targets in perioperative settings. There is a high interindividual variability...BACKGROUND: Continuous and real-time assessment of cerebral autoregulation can be of important clinical value to individualize blood pressure targets in perioperative settings. There is a high interindividual variability of the lower (LLA) and upper (ULA) limits of cerebral blood flow autoregulation, and exposure to blood pressure values outside of these limits has been associated with complications. We have developed a novel algorithm for continuous real-time assessment of cerebral autoregulation based on analysis of the dynamic interactions of mean arterial pressure (MAP) and near-infrared spectroscopy cerebral oxygen saturation (Sto2) measurements. The algorithm generates an index, the cerebral autoregulation index (CAI), which characterizes the effectiveness of cerebral autoregulation on a 0 to 100 scale. The aim of this study is to validate the algorithm using data from animals and surgical patients. METHODS: MAP, cerebral Sto2, and cerebral laser-Doppler blood flow (CBF) data were collected as part of an animal study on a piglet model of controlled hypotension. Additionally, simultaneous MAP, cerebral Sto2, and transcranial Doppler cerebral blood flow velocity (CBFV) data were collected on patients in a multicenter prospective observational study during surgery. Individual plots of CBF/CBFV versus MAP were constructed retrospectively for both the animal and human data, and ground truth labels of cerebral autoregulation status were obtained by identifying on these curves the LLA and ULA values. CAI values were generated by postprocessing MAP and cerebral Sto2 data through the algorithm. Receiver operating characteristic (ROC) analysis was then conducted to assess the capability of the algorithm to discriminate impaired autoregulation, where MAP is beyond the individual LLA/ULA limits, from intact autoregulation, where MAP is between LLA and ULA. RESULTS: Seventy-one patients were enrolled in the human study, and the ROC analysis showed an area under the ROC curve (AUC) (95% confidence interval) of 0.92 (0.89-0.94), with a sensitivity and specificity of 0.82 (0.76-0.87) and 0.94 (0.92-0.96), respectively, at the CAI threshold of 45. In addition, 10 female piglets underwent a controlled hypotension protocol where MAP was lowered below the LLA. The ROC analysis showed an AUC of 0.99 (0.98-1.00), with a sensitivity and specificity of 0.95 (0.90-0.99) and 0.96 (0.94-0.98), respectively. CONCLUSIONS: The study demonstrates that the CAI algorithm, using MAP and processed Sto2 signals, is accurate in discriminating states of intact autoregulation from states of impaired autoregulation. This algorithm may allow for personalized cerebral autoregulation-oriented blood pressure management during surgery.
BACKGROUND: Spinal muscular atrophy (SMA) is a genetic disorder resulting in progressive muscle atrophy due to the degradation of motor neurons. There are limited data on anesthesia care for these patients, the incidence...BACKGROUND: Spinal muscular atrophy (SMA) is a genetic disorder resulting in progressive muscle atrophy due to the degradation of motor neurons. There are limited data on anesthesia care for these patients, the incidence of anesthesia-related adverse events, and difficult intubations. The investigators aim to characterize patients with SMA who required anesthetics at a large quaternary pediatric hospital, describe the procedures being performed, report the incidence of severe anesthesia-related adverse events, and determine the incidence of difficult intubations. The investigators hypothesized that lumbar puncture for nusinersen administration would represent the most common procedure for which patients with SMA required anesthesia care. METHODS: A retrospective chart review of anesthetics provided to SMA patients from June 1, 2012, to December 30, 2023. Data obtained included procedures performed, patient characteristics, perioperative care, anesthesia technique, and outcomes. RESULTS: In total, 1804 procedures were performed for 175 patients with SMA. The majority of procedures (1423/1804, 78.9%) were for lumbar puncture for nusinersen administration; 234 of 1804 (13.0%) received general anesthesia with endotracheal tube placement; 22 of 1804 total cases (1.2%) or 22 of 234 (9.4%) of those with endotracheal tube placement met the definition of difficult intubation. There were no statistically significant associations between difficult intubation and SMA type, age, and presence of halo headframe (all P > .05). There were six severe anesthesia-related adverse events (0.33%). Of 1423 total procedures for lumbar punctures for nusinersen administration, 1254 of 1423 (88.1%) were performed with a natural airway (nasal canula, facemask, or home continuous positive airway pressure [CPAP] or biphasic positive airway pressure [BiPAP]) or pre-existing tracheostomy. CONCLUSIONS: Lumbar puncture for nusinersen administration made up the vast majority of procedures for which patients with SMA presented for anesthesia care. The incidence of difficult intubation was 9.4%, and the incidence of anesthesia-related severe adverse events was 0.33%. These results indicate the need to focus research on the perioperative and airway-related risks for this evolving and medically complex population.
BACKGROUND: Pulmonary artery catheters are used widely in cardiac surgery despite conflicting associations with patient outcomes. We evaluated the associations between pulmonary artery catheter use and clinical outcomes...BACKGROUND: Pulmonary artery catheters are used widely in cardiac surgery despite conflicting associations with patient outcomes. We evaluated the associations between pulmonary artery catheter use and clinical outcomes following cardiac surgery using a large cohort of patients treated at a US academic center. METHODS: We performed a retrospective entropy-balanced cohort study of consecutive adults undergoing cardiac surgery from a single tertiary center in Boston, Massachusetts, from 2008 to 2022. We used entropy balancing to achieve exact covariate balance on prespecified baseline characteristics and then estimated the average treatment effect of pulmonary artery catheter use on clinical and mechanistic outcomes. The primary outcome was mortality measured 90 days after surgery. Secondary outcomes were acute kidney injury, hospital and intensive care unit (ICU) length of stay, time in postoperative organ dysfunction measured at 7 days, prolonged inotrope use (>4 hours), significant peak vasopressor requirement (>0.1 μg/kg/min in norepinephrine equivalents), net fluid balance at 24 hours, number of fluid boluses administered, volume of allogeneic red blood cells transfused, and total duration of mechanical ventilation. RESULTS: We included 10,044 patients, of whom 5850 (58.2%) were managed with a pulmonary artery catheter. Pulmonary artery catheter use was not associated with 90-day mortality (risk ratio [RR], 0.966; 95% confidence interval [CI], 0.719-1.30; P =.816) nor in-hospital mortality (RR, 0.921; 95% CI, 0.632-1.34; P =.670). There was no between-group difference in hospital length of stay (median difference [MD], 0.050 days; 95% CI, 0.0477-0.148; P =.269), but patients managed with a pulmonary artery catheter had greater ICU length of stay (MD = 13.1 hours; 95% CI, 9.74-16.4; P <.001). Pulmonary artery catheters were also associated with increased incidence of acute kidney injury (RR, 1.12; 95% CI, 1.07-1.17; P <.001). Patients who received a pulmonary artery catheter were more likely to have prolonged inotrope requirements (RR, 4.13; 95% CI, 3.42-4.98; P <.001), significant vasopressor requirements (RR, 1.37; 95% CI, 1.28-1.46; P <.001), higher positive fluid balances (MD, 566 mL; 95% CI, 453-678; P <.001), higher volumes of allogeneic RBCs transfused (MD, 226 mL; 95% CI, 183-269; P <.001), higher time in postoperative organ dysfunction (MD, 3.96 hours; 95% CI, 3.01-4.90; P <.001), and longer durations of mechanical ventilation (MD, 11.3 hours; 95% CI, 7.33-15.2; P <.001). CONCLUSIONS: In a large entropy-balanced cohort study of adults undergoing cardiac surgery, pulmonary artery catheter use was not associated with mortality, but was linked with a higher treatment intensity and longer ICU stay.
Music therapy is a nonpharmacologic, patient-centered intervention increasingly used in perioperative settings to improve the surgical experience for patients and their families. Despite growing evidence, music therapy's...Music therapy is a nonpharmacologic, patient-centered intervention increasingly used in perioperative settings to improve the surgical experience for patients and their families. Despite growing evidence, music therapy's integration into anesthesia care remains variable, highlighting a need to synthesize the current landscape of music therapy in this clinical context. This scoping review aimed to map the primary characteristics and impacts of live interactive music therapy delivered by a certified music therapist across the perioperative continuum and identify gaps in the literature to guide future research and practice in perioperative settings. Following PRISMA-ScR guidance, database searches were conducted October 2024 to June 2025 using key medical subject headings (MeSH) terms. Inclusion criteria specified (1) live or recorded music therapy delivered by a certified music therapist and (2) intervention timing within 24 hours pre- to 72 hours post-operation. The initial search yielded 2095 articles. After abstract screening, 1049 remained and underwent full-text review. 25 articles met criteria and were included in data extraction. The 25 articles included 1821 patients aged 9-months- to 94-years-old across diverse surgical specialties. Music therapy was delivered preoperatively (n = 17), intraoperatively (n = 8), and postoperatively (n = 15), with inclusion of flexible and protocolized approaches. Pediatric music therapy was more frequently delivered preoperatively, emphasizing play-based, active engagement. Adult music therapy was more evenly distributed across perioperative timepoints, emphasizing introspective, emotion-focused approaches. Selected outcome measures reflected these differences, with pediatric effects captured through behavioral observation (e.g, modified-Yale Perioperative Anxiety Scale [m-YPAS]), whereas adult outcomes relied more heavily on self-reporting (eg, visual analog scale [VAS]). Postoperatively, pediatric and adult music therapy approaches were more aligned across age groups given both used relaxation-based approaches. Perioperative music therapy is a feasible, low-risk adjunct that may complement existing pharmacologic strategies to support anxiety, mood, and pain with minimal interruption to patient care for teams with access to this resource. Limitations including small sample sizes, expectancy effects, inconsistent music therapy intervention reporting, and lack of therapist-contact controls prompt cautious interpretation. Future research should explore intraoperative delivery logistics, dose-response relationships, integration of multimodal outcomes, and anesthesia team perspectives to guide practical integration of music therapy into the anesthesia armamentarium.