2020 in review

Central MessageThis review highlights the articles on perioperative care that garnered greatest interest over course of year. This Although year 2020 will be remembered for viral pandemic so pervasively impacted our lives, it also featured a number published considerable in Journal's readership. As such, this year-in-review straddles broad spectrum critical topics. Four exemplar articles, summarized below, range content from efficacy extracorporeal support patients with out-of-hospital cardiac arrests to elucidation optimal intensive staffing strategies.1Yannopoulos D. Bartos J. Raveendran G. Walser E. Connett Murray T.A. et al.Advanced reperfusion strategies arrest and refractory ventricular fibrillation (ARREST): phase 2, single-centre, open-label, randomised controlled trial.Lancet. 2020; 396: 1807-1816Abstract Full Text PDF PubMed Scopus (79) Google Scholar,2Huard P. Kalavrouziotis Lipes Simon M. Tardif M.A. Blackburn S. al.Does full-time presence an intensivist lead better outcomes surgical unit?.J Thorac Cardiovasc Surg. 159: 1363-1375.e7Abstract (7) Scholar The ongoing, unrelenting opioid epidemic continues direct much-warranted attention novel means preventing dependence, we are reminded wanton devastation addiction.3Clement K.C. Canner J.K. Lawton J.S. Whitman G.J.R. Grant M.C. Sussman M.S. Predictors new persistent use after coronary artery bypass grafting.J 160: 954-963.e4Abstract (14) In same vein, promotion early extubation prevention delirium underscores importance maintaining neurologic integrity context delivery.4Muller Moran H.R. Maguire Kowalski Jacobsohn Mackenzie al.Association earlier postoperative March 29, 2019; ([Epub ahead print])PubMed recognition impact dependence United States role cardiothoracic surgeons mitigation epidemic, Journal work Clement colleagues.3Clement authors observed approximately 8% undergoing graft surgery developed use. Multivariable analysis identified female sex, anxiety, tobacco use, prior substance abuse, chronic obstructive pulmonary disease, living southern States, increased amount prescribed opioids as each independently associated resulted further downstream healthcare utilization, indicated by readmission rates emergency department encounters. challenges misuse considerable, findings provide important relevant message despite limitations inherent Truven Health Marketscan Database. For instance, database captures neither surgery-specific variables nor provider- level prescribing practices. Nevertheless, authors' corroborate results recent studies field collectively highlight risk following providers targets reducing volume at discharge.5Brescia A.A. Waljee J.F. Hu H.M. Englesbe M.J. Brummett C.M. Lagisetty P.A. al.Impact surgery.Ann 108: 1107-1113Abstract (29) Scholar,6Holst K.A. Dearani J.A. Schaff H.V. Hanson K.T. Thiels C.A. Erdman M.K. al.What drives prescriptions surgery: practice or patient?.Ann 110: 1201-1208Abstract (6) Enhanced recovery post–cardiac may offer opportunity reduce inpatient which turn translate postdischarge reduction.7Williams J.B. McConnell Allender J.E. Woltz Kane K. Smith P.K. al.One-year first US-based enhanced (ERAS Cardiac) program.J 157: 1881-1888Abstract (81) Conscientious prescription practices along pain management education without sacrificing patient satisfaction. study adds understanding implications active surgery. Each team is encouraged heed colleagues, well other who have endorsed multimodal excessive patients. ARREST (advanced fibrillation) Trial sui generis comparing membrane oxygenation (ECMO)-facilitated resuscitation standard advanced life (ACLS) treatment (OHCA).1Yannopoulos single-center, randomized control trial performed North America, ECMO-related provided 43% (6 14) survival rate, compared 7% (1 15) ACLS. addition, there was significantly improved rate ECMO group 6-month follow-up. Patients sustain OHCA historically poor survival, most time-sensitive emergency. Survival diminished even when combined prolonged cardiopulmonary resuscitation. Out-of-hospital responsible significant proportion morbidity mortality globally, estimated 350,000 deaths annually alone.1Yannopoulos aging population increasing prevailing obesity across all age groups portend burden future. Approximately 60% 80% present shockable rhythm, typically fibrillation.1Yannopoulos Almost undergo more than 40 minutes eventually die, mainly consequence comorbid disease makes any resuscitative efforts useless. Hospitalization complicated consequent physical deconditioning unit (ICU) length stay, averaging up 21 days. Reassuringly, however, functional assessment scores tend improve 6 months. ECMO-facilitated achieved multiple goals cohort: perfusion, support, facilitated treatment, served bridge face multiorgan injury. Early implementation facilitates adjunctive therapies, such angiography. promising, nevertheless casts doubt applicability systems. cost provision high owing specialist nature resource intensity required service. Such high-resource acceptable health systems large private infrastructure where comparatively higher monetary reimbursement. Government-led, social insurance systems, National Service Kingdom, unlikely accommodating costs mortality. demands scarce ICU resources should taken into consideration. builds off previous cohort literature provides insight potential option managing arrest. Despite using only 30 patients, glimpse future ECMO-guided A meta-analysis suggested medical ICUs reduced mortality.8Pronovost P.J. Angus D.C. Dorman T. Robinson Dremsizov T.T. Young T.L. Physician patterns clinical critically ill patients: systematic review.JAMA. 2002; 288: 2151-2162Crossref (1101) Indeed, some contend exert “dose effect,” overnight might outcomes. Randomized reported no incremental benefit ICUs, but these not necessarily apply (CSICUs), given unique acuity complexity cases. Propensity-matched reductions ventilation time, transfusions, complications, CSICU readmissions transition dedicated resident coverage 24/7 house models.9Kumar Zarychanski R. Bell D.D. Manji Zivot Menkis A.H. al.Cardiovascular Research Manitoba Investigator GroupImpact 24-hour in-house intensivists unit.Ann 2009; 88: 1153-1161Abstract (57) Huard colleagues2Huard leveraging dataset 16,454 adult 8-year duration. natural experiment, model transitioned daytime trainees staffing. Using propensity-matched 8348 stratified low-risk (<5%) high-risk (≥5%) EuroSCORE II groups. difference utilization group; nevertheless, ≥5%, change include (2.1% vs 1.4%), (2.3% 3.5%), duration mechanical (5.8 hours 4.3 hours), incidence (1.3% 0.7%), renal replacement therapy 1.7%). regression evaluating temporal trends time changes were model. reintubation (2.6% 1.1%), reflect shorter intubation times, (14.8% 11.8%), may, turn, screening has evolved time. However, acknowledge, their observational, effect unmeasured medical, surgical, confounders cannot excluded. Recent surveys suggest one-half existing CSICUs open-care model, one-third do hours.10Benoit Bagshaw S.M. Norris Zibdawi Chin W.D. Ross D.B. al.Postoperative complications patients.Crit Care Med. 2017; 45: 993-1000Crossref (26) Thus, plausible shared-care intensivists. none aforementioned can fully elucidate underpinning reduction mortality, stands reason continuous specialist, conjunction daily input attending surgeon, allow effective intervention hemodynamic aberrations otherwise arrest.11Arora R.C. Chatterjee Shake J.G. Hirose H. Engelman D.T. Rabin al.Society Thoracic Surgeons Workforce Critical (STS WFCC)Survey contemporary models States.Ann 109: 702-710Abstract (3) Scholar12van Diepen Commentary: evidence 24-7 coverage.J 1380-1381Abstract (1) prospective likely would rigorous compelling including moderate risk. Muller colleagues4Muller intriguing, thought-provoking grafting (CABG) regarding protocol-driven practice, surgery, expeditious restoration physiology.4Muller Their retrospective included 2561 had undergone isolated CABG single institution. evaluated delirium, stratifying within operating room (OR) (0 “early” (1-12 hours) post-CABG, “late” (12-24 post-CABG. final comprised 2223 338 late cohort. commended extubating 36% (920 2561) OR. routinely used standardized data elements confusion methods adjudicate (CAM-ICU), facilitating routine evaluation. CAM-ICU screened events delays extubation. Similarly, major adverse (MAEs) These onset dialysis, pneumonia, sepsis, myocardial infarction, stroke, death, composite outcome events. From perspective, MAE roughly 3- 5-fold later times. Furthermore, markedly Age, history ejection fraction, urgency operative intervention, early/late multivariable logistic analysis. Establishing impetus fast-tracking decreased vast majority patients; undoubtedly, predicated protocol been refined 20 years. variation among providers, common mindset patient-focused approach protocolized clear leads Careful intraoperative explicitly designed facilitate extubation, minimizing narcotic benzodiazepine reliance ketamine propofol induction, maintenance normothermia, blood conservation, transitioning spontaneous breathing soon possible chest closure. checklist. Standardized prospectively, validity accuracy study. single-institution experience, confounding its observational design. sample size in-depth represents one largest experiences OR Delirium 14% long-term disability, cognitive impairment, death. 12 ventilation. fast-track protocols pivotal optimum positive outcome. true regardless procedure complexity, pathways greater consistency minimize unintentional variations quality. An theme evident compendium challenge dogma current collective narrative challenges, traditional mandatory discomfort. There budding algorithms circulatory traditionally abysmal Modifying physician “ultra-fast tracking” break status quo. begin preoperative decision extubate eligible Admittedly, require investigation. just teams best lessons learned during past kick postpandemic era care.