Τhe minimum fascia–tumor distance (MFTD) criterion is more feasible for benign tumors than for malignant tumors for the localization of parotid tumors. For benign parotid tumors, US is enough to guide operations.

The Diagnostic Performance of Ultrasonography and Computed Tomography in Differentiating Superficial from Deep Lobe Parotid Tumors

Ping‐Chia Cheng  Chih‐Ming Chang  Chun‐Chieh Huang  Wu‐Chia Lo  Tsung‐Wei Huang  Po‐Wen Cheng Li‐Jen Liao

First published: 12 January 2019 https://doi.org/10.1111/coa.13289

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/coa.13289

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Abstract

Objectives

To validate and compare ultrasound (US) versus computed tomography (CT) criteria in the localization of superficial/deep lobe tumors of the parotid gland.

Design and Setting

This was a retrospective study of diagnostic tests performed from January 2008 to June 2017.

Participants

We included adult patients who were referred for a neck ultrasonography examination due to parotid tumors, and who subsequently underwent parotid surgery.

Main outcome measures

We assessed the location of parotid tumors, comparing the minimum fascia–tumor distance (MFTD) criterion on an US with eight CT criteria. We analyzed receiver operating characteristic (ROC) curves of the MFTD for malignant, benign, and all parotid tumors, and compared the accuracy, sensitivity, and specificity of the optimal MFTD with those of CT anatomical criteria.

Results

A total of 166 parotid tumors were included. The mean (SD) MFTD in superficial lobe tumors was significantly shorter than that of deep lobe tumors (1.2 [0.7] vs 2.8 [1.9] mm, effect size: 1.84; 95% CI, 1.27 to 2.41). The areas under the ROC curve were 0.63 for malignant tumors and 0.88 for benign tumors. The optimal MFTD cut point was 2.4 mm for the 154 benign parotid tumors and the accuracy, sensitivity, and specificity were 90%, 80% and 91%, respectively. For the 136 benign parotid tumors that underwent CT examination, three criteria had an accuracy of over 90% (FNline, tMasseter and Conn's arc), but the sensitivities were all below 50%.

Conclusions

MFTD is more feasible for benign tumors than for malignant tumors for the localization of parotid tumors. For benign parotid tumors, US is enough to guide operations.

Diagnostic Error, the Internet, and Collaboration in Global Health

In high-income countries, 5% of adults suffer from diagnostic error each year in the outpatient setting. Of these, over half of these errors have "the potential for severe harm." This is thought to be an underestimate in high-income countries, and the rate of diagnostic errors in low income countries may be much higher.^[1] In the United States, "Postmortem examination research spanning decades has shown that diagnostic errors contribute to approximately 10 percent of patient deaths, and medical record reviews suggest that they account for 6 to 17 percent of adverse events in hospitals."^[2]

In the case report, "Empirical treatment of tuberculosis: TB or not TB?" Webb et al describe a 38 year-old woman in India who presented with cough, and malaise. CT of her chest revealed findings suggestive of interstitial TB. Despite being sputum negative, she was treated empirically for TB due to its high prevalence and the possibility of sputum negative TB (as high as 50% of all newly diagnosed TB annually). She slowly developed greater malaise, jaundice and abdominal pain. Her husband was unable to work as he frequently presented her to medical care for diagnosis. Finally, a community health worker uploaded the patient's care records (de-identified and with patient consent) to an open access database to stimulate discussion among clinicians and increase the number of her care team. The patient traveled to a hospital that one of the clinicians staffed in order to undergo an in-person examination, where she was diagnosed with drug-induced liver injury and improved with supportive care.

Access to medical care remains a problem in much of the world. Poorly-qualified practitioners are particularly an issue in rural areas. Delays in diagnosis and incorrect diagnosis can lead to substantial patient harm. Some of the techniques for improving diagnosis have included facilitating more effective teamwork, enhancing health care professional education, and ensuring that health information technology supports patients and healthcare professionals in the diagnostic process. The internet has a substantial role to play in the future, especially in difficult to access or underserved areas. This case report introduced a new "collaborative initiative headed by Dr. Rakesh Biswas… to encourage discourse among his medical colleagues regarding challenging cases they may face."^[3] Another promising project is the app "Human Diagnosis Project," which allows providers to enhance diagnostic capabilities and collaborate around the world on difficult cases.^[4] Access to the internet and a way to protect patient identity would be substantial barriers to further development of this technology, as would the language barriers inherent in any system used in multiple states and countries. However this technology could be promising to break down barriers to health care for the underserved, and seems to fit well with currently in place community health workers.

BMJ Case Reports invites authors to submit global health case reports that describe the need for accurate and timely diagnosis. These cases could focus on:

• Deleterious effects of delayed or missed diagnoses
• Interventions which overcome the barriers to diagnosis
• Ways in which current tools are adapted to difficult situations to ensure safe, timely care

Manuscripts may be submitted by students, physicians, nurses and allied health professionals to BMJ Case Reports at www.bmjcasereports.com. For more information, review our guidance on how to write a global health case report and look through our online collection

To read more about difficult diagnoses, specifically TB, at BMJ Case Reports please review:

• Extrapulmonary tuberculosis: a debilitating and often neglected public health problem
• Multidrug-resistant tuberculosis in rural China: lack of public awareness, unaffordable costs and poor clinical management
• Delays in diagnosis and treatment of extrapulmonary tuberculosis in Guatemala

To read more about diagnostic error and tools to overcome, please review:

^[1]Diagnostic  Errors: Technical  Series on Safer Primary  Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO

^[2] National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. National Academies Press; 2016 Jan 29.

^[3]Debashish A. Evidence-based care: 38 year old woman suffering from TB with Jaundice seeking medical experts help, 2017. http://bit.ly/2MdJ0UI. (accessed 11 Jan 2019).

^[4] Human Diagnosis Project [Internet]. https://www.humandx.org/ Accessed on 11 Jan 2019.

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Separating Acute Rheumatic Fever from Nonrheumatic Streptococcal Myocarditis

Introduction. Streptococcal pharyngitis has been historically complicated with systemic involvement manifesting as acute rheumatic fever, which is a serious condition that can lead to permanent damage to heart valves. A recent association between streptococcal pharyngitis and nonrheumatic heart disease is emerging in literature. We present a case of nonrheumatic streptococcal myocarditis diagnosed using cardiac MRI. Case Presentation. A 25-year-old male, presented with complaints of sore throat, nonproductive cough, fever, pleuritic chest pain, and progressive dyspnea for four days. The patient had elevated troponins at presentation of 0.47 (ng/L) that peaked at 4.0 (ng/L). ECG showed sinus rhythm and ST elevations in leads V2, V3, V4, and V5. NT-Pro-BNP was 1740. Transthoracic echocardiogram (TTE) showed reduced ejection fraction (EF) of 37% and global hypokinesis. The rapid strep test was positive for group A streptococcus and C-reactive protein was elevated at 161. Cardiac MRI demonstrated an EF of 53% and edema in the anterior wall without delayed gadolinium enhancement. Cardiac catheterization showed normal coronaries. Discussion. According to modified Jones criteria, the patient did not meet the full major or minor criteria to be diagnosed with acute rheumatic fever. The course of the nonrheumatic myocarditis is favorable and includes a full recovery of cardiac function, no involvement of cardiac valves, or long-term use of antibiotics. Conclusion. It is crucial to make a separate distinction between acute rheumatic fever and nonrheumatic myocarditis because this will have huge implications on management and long-term use of antibiotics. Cardiac imaging modalities can aid in distinction between the two disease entities.

http://bit.ly/2Fvrjzt

Leukocytoclastic vasculitis with purpura and renal failure induced by the anti-epidermal growth factor receptor antibody panitumumab: a case report

Panitumumab is the first human combinatorial antibody for the treatment of metastatic colorectal carcinoma. Dermatologic toxicity of all grades occurs in more than 90% of patients. However, there are few repor...

http://bit.ly/2sD7oGx

Perioperative Dextrose Infusion and Postoperative Nausea and Vomiting: A Meta-analysis of Randomized Trials

BACKGROUND: Perioperative IV dextrose infusions have been investigated for their potential to reduce the risk of postoperative nausea and vomiting. In this meta-analysis, we investigated the use of an intraoperative or postoperative infusion of dextrose for the prevention of postoperative nausea and vomiting. METHODS: Our group searched PubMed, Embase, Cochrane library, and Google Scholar for relevant randomized controlled trials examining the use of perioperative IV dextrose for prevention of postoperative nausea and vomiting. The primary outcome was the incidence of postoperative nausea and vomiting (both in the postanesthesia care unit and within the first 24 h of surgery). Secondary outcomes included postoperative antiemetic administration and serum glucose level. RESULTS: Our search yielded a total of 10 randomized controlled trials (n = 987 patients) comparing the use of a perioperative dextrose infusion (n = 465) to control (n = 522). Perioperative dextrose infusion was not associated with a significant reduction in postoperative nausea and vomiting in the postanesthesia care unit (risk ratio = 0.91, 95% CI, 0.73–1.15; P = .44) or within the first 24 h (risk ratio = 0.76, 95% CI, 0.55–1.04; P = .09) of surgery. Although the use of dextrose was associated with a significant reduction in antiemetic administration within the first 24 h (risk ratio = 0.55, 95% CI, 0.45–0.69; P

http://bit.ly/2VYHydd

Impact of Preoperative Erythropoietin on Allogeneic Blood Transfusions in Surgical Patients: Results From a Systematic Review and Meta-analysis

BACKGROUND: Erythropoietic-stimulating agents such as erythropoietin have been used as part of patient blood management programs to reduce or even avoid the use of allogeneic blood transfusions. We review the literature to evaluate the effect of preoperative erythropoietin use on the risk of exposure to perioperative allogeneic blood transfusions. METHODS: The study involved a systematic review and meta-analysis of randomized controlled trials evaluating the use of preoperative erythropoietin. The primary outcome was the reported incidence of allogeneic red blood cell transfusions during inpatient hospitalizations. Secondary outcomes included phase-specific allogeneic red blood cell transfusions (ie, intraoperative, postoperative), intraoperative estimated blood loss, perioperative hemoglobin levels, length of stay, and thromboembolic events. RESULTS: A total of 32 randomized controlled trials (n = 4750 patients) were included, comparing preoperative erythropoietin (n = 2482 patients) to placebo (n = 2268 patients). Preoperative erythropoietin is associated with a significant decrease in incidence of allogeneic blood transfusions among all patients (n = 28 studies; risk ratio, 0.59; 95% CI, 0.47–0.73; P

http://bit.ly/2QQJOQf

Pain Management for Ambulatory Arthroscopic Anterior Cruciate Ligament Reconstruction: Evidence-Based Recommendations From the Society for Ambulatory Anesthesia

Ambulatory arthroscopic anterior cruciate ligament reconstruction is associated with moderate pain, even when nonopioid oral analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs are used. Regional analgesia can supplement nonopioid oral analgesics and reduce postoperative opioid requirements, but the choice of regional analgesia technique for anterior cruciate ligament reconstruction remains controversial. Femoral nerve block, adductor canal block, and local instillation analgesia have all been proposed and are supported by some evidence from randomized controlled trials. Consequently, regional analgesia practice in patients undergoing anterior cruciate ligament reconstruction remains mixed. Published systematic reviews were used to identify the regional analgesia modality that would provide a balance between analgesic efficacy and associated potential risks in the setting of nonopioid multimodal analgesic strategies. Based on the evidence available, local instillation analgesia provides the best balance of analgesic efficacy and associated risks (strong recommendation, moderate level of evidence) when used as a component of multimodal analgesic technique in the first 24 hours after outpatient arthroscopic anterior cruciate ligament reconstruction. In the absence of local instillation analgesia, clinicians might use adductor canal block or femoral nerve block (weak recommendation, weak level of evidence). These recommendations have been endorsed by the Society of Ambulatory Anesthesia and approved by its board of directors. Accepted for publication November 05, 2018. Funding: No external funding was provided from any source. No funding was received from the Society for Ambulatory Anesthesia. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Girish P. Joshi, MBBS, MD, FFARCSI, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390. Address e-mail to girish.joshi@utsouthwestern.edu. © 2019 International Anesthesia Research Society

http://bit.ly/2VYHiuL

Essentials of Anesthesia for Neurotrauma, 1st ed

No abstract available

http://bit.ly/2QSElYS

In Response

No abstract available

http://bit.ly/2VYHc6n

Changes in International Normalized Ratio After Plasma Transfusion in Clinical Settings

No abstract available

http://bit.ly/2QMP8E9

Systematic Review and Meta-analysis: Sometimes Bigger Is Indeed Better

Clinicians encounter an ever increasing and frequently overwhelming amount of information, even in a narrow scope or area of interest. Given this enormous amount of scientific information published every year, systematic reviews and meta-analyses have become indispensable methods for the evaluation of medical treatments and the delivery of evidence-based best practice. The present basic statistical tutorial thus focuses on the fundamentals of a systematic review and meta-analysis, against the backdrop of practicing evidence-based medicine. Even if properly performed, a single study is no more than tentative evidence, which needs to be confirmed by additional, independent research. A systematic review summarizes the existing, published research on a particular topic, in a well-described, methodical, rigorous, and reproducible (hence "systematic") manner. A systematic review typically includes a greater range of patients than any single study, thus strengthening the external validity or generalizability of its findings and the utility to the clinician seeking to practice evidence-based medicine. A systematic review often forms the basis for a concomitant meta-analysis, in which the results from the identified series of separate studies are aggregated and statistical pooling is performed. This allows for a single best estimate of the effect or association. A conjoint systematic review and meta-analysis can provide an estimate of therapeutic efficacy, prognosis, or diagnostic test accuracy. By aggregating and pooling the data derived from a systemic review, a well-done meta-analysis essentially increases the precision and the certainty of the statistical inference. The resulting single best estimate of effect or association facilitates clinical decision making and practicing evidence-based medicine. A well-designed systematic review and meta-analysis can provide valuable information for researchers, policymakers, and clinicians. However, there are many critical caveats in performing and interpreting them, and thus, like the individual research studies on which they are based, there are many ways in which meta-analyses can yield misleading information. Creators, reviewers, and consumers alike of systematic reviews and meta-analyses would thus be well-served to observe and mitigate their associated caveats and potential pitfalls. Accepted for publication December 10, 2018. Funding: None. The author declares no conflicts of interest. Reprints will not be available from the author. Address correspondence to Thomas R. Vetter, MD, MPH, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Health Discovery Bldg, Room 6.812, 1701 Trinity St, Austin, TX 78712. Address e-mail to thomas.vetter@austin.utexas.edu. © 2019 International Anesthesia Research Society

http://bit.ly/2VWo60U

Continuous Noninvasive Arterial Pressure Monitoring in Obese Patients During Bariatric Surgery: An Evaluation of the Vascular Unloading Technique (Clearsight system)

BACKGROUND: Continuous monitoring of arterial pressure is important in severely obese patients who are at particular risk for cardiovascular complications. Innovative technologies for continuous noninvasive arterial pressure monitoring are now available. In this study, we compared noninvasive arterial pressure measurements using the vascular unloading technique (Clearsight system; Edwards Lifesciences Corp, Irvine, CA) with invasive arterial pressure measurements (radial arterial catheter) in severely obese patients during laparoscopic bariatric surgery. METHODS: In 35 severely obese patients (median body mass index, 47 kg/m2), we simultaneously recorded noninvasive and invasive arterial pressure measurements over a period of 45 minutes. We compared noninvasive (test method) and invasive (reference method) arterial pressure measurements (sampling rate 1 Hz = 1/s) using Bland-Altman analysis (accounting for multiple measurements per subject), 4-quadrant plot/concordance analysis (2-minute interval, 5 mm Hg exclusion zone), and error grid analysis (calculating the proportions of measurements in risk zones A–E with A indicating no risk, B low risk, C moderate risk, D significant risk, and E dangerous risk for the patient due to the risk of wrong clinical interventions because of measurement errors). RESULTS: We observed a mean of the differences (±SD, 95% limits of agreement) between the noninvasively and invasively assessed arterial pressure values of 1.1 mm Hg (±7.4 mm Hg, −13.5 to 15.6 mm Hg) for mean arterial pressure (MAP), 6.8 mm Hg (±10.3 mm Hg, −14.4 to 27.9 mm Hg) for systolic arterial pressure, and 0.8 mm Hg (±6.9 mm Hg, −12.9 to 14.4 mm Hg) for diastolic arterial pressure. The 4-quadrant plot concordance rate (ie, the proportion of arterial pressure measurement pairs showing concordant changes to all changes) was 93% (CI, 89%–96%) for MAP, 93% (CI, 89%–97%) for systolic arterial pressure, and 88% (CI, 84%–92%) for diastolic arterial pressure. Error grid analysis showed that the proportions of measurements in risk zones A–E were 89.5%, 10.0%, 0.5%, 0%, and 0% for MAP and 93.7%, 6.0%, 0.3%, 0%, and 0% for systolic arterial pressure, respectively. CONCLUSIONS: During laparoscopic bariatric surgery, the accuracy and precision of the vascular unloading technique (Clearsight system) was good for MAP and diastolic arterial pressure, but only moderate for systolic arterial pressure according to Bland-Altman analysis. The system showed good trending capabilities. In the error grid analysis, >99% of vascular unloading technique–derived arterial pressure measurements were categorized in no- or low-risk zones. Accepted for publication October 18, 2018. Sebastian A. Haas, MD, and Daniel A. Reuter, MD, are currently affiliated with the Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany. Funding: Edwards Lifesciences Corp (Irvine, CA) provided the technical equipment for the study. Edwards Lifesciences was not involved in the collection of the data, drafting of the manuscript, or the decision to submit the manuscript for publication. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Dorothea E. Rogge, MD, Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. Address e-mail to d.rogge@uke.de. © 2019 International Anesthesia Research Society

http://bit.ly/2QSwScz

Intraoperative Hyperoxia Does Not Reduce Postoperative Pain: Subanalysis of an Alternating Cohort Trial

BACKGROUND: Postoperative pain is common and promotes opioid use. Surgical wounds are hypoxic because normal perfusion is impaired. Local wound ischemia and acidosis promote incisional pain. Some evidence suggests that improving oxygen supply to surgical wounds might reduce pain. We therefore tested the hypothesis that supplemental (80% inspired) intraoperative oxygen reduces postoperative pain and opioid consumption. METHODS: We conducted a post hoc analysis of a large, single-center alternating cohort trial allocating surgical patients having general anesthesia for colorectal surgery to either 30% or 80% intraoperative oxygen concentration in 2-week blocks for a total of 39 months. Irrespective of allocation, patients were given sufficient oxygen to maintain saturation ≥95%. Patients who had regional anesthesia or nerve blocks were excluded. The primary outcome was pain and opioid consumption during the initial 2 postoperative hours, analyzed jointly. The secondary outcome was pain and opioid consumption over the subsequent 24 postoperative hours. Subgroup analyses of the primary outcome were conducted for open versus laparoscopic procedures and for patients with versus without chronic pain. RESULTS: A total of 4702 cases were eligible for analysis: 2415 were assigned to 80% oxygen and 2287 to 30% oxygen. The groups were well balanced on potential confounding factors. Average pain scores and opioid consumption were similar between the groups (mean difference in pain scores, −0.01 [97.5% CI, −0.16 to 0.14; P = .45], median difference in opioid consumption, 0.0 [97.5% CI, 0 to 0] mg morphine equivalents; P = .82). There were also no significant differences in the secondary outcome or subgroup analyses. CONCLUSIONS: Supplemental intraoperative oxygen does not reduce acute postoperative pain or reduce opioid consumption. Accepted for publication November 26, 2018. Funding: This work received internal funding. None of the authors has a personal financial interest in this analysis. B.C. is a recipient of a Fellowship Grant from the American Physicians Fellowship for Medicine in Israel. 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 (http://bit.ly/KegmMq). Trial registration: ClinicalTrials.gov number NCT01777568. Reprints will not be available from the authors. Address correspondence to Alparslan Turan, MD, Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, P77, Cleveland, OH 44195. Address e-mail to TuranA@ccf.org. © 2019 International Anesthesia Research Society

http://bit.ly/2VUR40W

Quantile Regression and Its Applications: A Primer for Anesthesiologists

Multivariable regression analysis is a powerful statistical tool in biomedical research with numerous applications. While linear regression can be used to model the expected value (ie, mean) of a continuous outcome given the covariates in the model, quantile regression can be used to compare the entire distribution of a continuous response or a specific quantile of the response between groups. The advantage of the quantile regression methodology is that it allows for understanding relationships between variables outside of the conditional mean of the response; it is useful for understanding an outcome at its various quantiles and comparing groups or levels of an exposure on those quantiles. We present quantile regression in a 3-step approach: determining that quantile regression is desired, fitting the quantile regression model, and interpreting the model results. We then apply our quantile regression analysis approach using 2 illustrative examples from the 2015 American College of Surgeons National Surgical Quality Improvement Program Pediatric database, and 1 example utilizing data on duration of sensory block in rats. Accepted for publication December 12, 2018. Funding: None. 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 (http://bit.ly/KegmMq). Reprints will not be available from the authors. Address correspondence to Steven J. Staffa, MS, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115. Address e-mail to steven.staffa@childrens.harvard.edu. © 2019 International Anesthesia Research Society

http://bit.ly/2QRIeNJ

Innovation in Education Research: Creation of an Education Research Core

Within academic medical centers, there is increasing interest among physicians to pursue education as a promotion pathway. Many medical schools and universities offer professional development opportunities for these individuals such as workshops and certificate and advanced degree programs. However, there exists a need for a more personalized support for clinician-educators to be successful in educational scholarship in the health care setting. In 2017, a departmental level educational research community was established within Anesthesiology and Critical Care Medicine at Johns Hopkins University to support faculty, staff, and trainees in creating, completing, and publishing educational scholarship. The research infrastructure includes administrative and institutional review board submission assistance, internal grant support, database management, statistical analysis, and consultation with professional educators. Also, integral to the education core is monthly education lab meetings that allow an opportunity for education researchers to present work in progress, conceive new projects, discuss relevant literature, and cultivate and sustain a community of educational scholars. This innovation in education demonstrates feasibility at a departmental level to successfully support educational research. We have initiated education meetings with a cohort of core education faculty who are interested in an educational promotion track. We present several metrics that can be used to evaluate the effectiveness of the programs similar to this innovation. Accepted for publication November 1, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Deborah A. Schwengel, MD, MEHP, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 1800 Orleans St, Suite 6349H, Baltimore, MD. Address e-mail to Dschwen1@jhmi.edu. © 2019 International Anesthesia Research Society

http://bit.ly/2VUiLHo

Vasopressor Infusion During Prone Spine Surgery and Acute Renal Injury: A Retrospective Cohort Analysis

BACKGROUND: Hypotension is associated with acute kidney injury, but vasopressors used to treat hypotension may also compromise renal function. We therefore tested the hypothesis that vasopressor infusion during complex spine surgery is not associated with impaired renal function. METHODS: In this retrospective cohort analysis, we considered adults who had complex spine surgery between January 2005 and September 2014 at the Cleveland Clinic Main Campus. Our primary outcome was postoperative estimated glomerular filtration rate. Secondarily, we evaluated renal function using Acute Kidney Injury Network criteria. We obtained data for 1814 surgeries, including 689 patients (38%) who were given intraoperative vasopressors infusion for ≥30 minutes and 1125 patients (62%) who were not. Five hundred forty patients with and 540 patients without vasopressor infusions were well matched across 32 potential confounding variables. RESULTS: In matched patients, vasopressor infusions lasted an average of 173 ± 100 minutes (SD) and were given a median dose (1st quintile, 3rd quintile) of 3.4-mg (1.5, 6.7 mg) phenylephrine equivalents. Mean arterial pressure and the amounts of hypotension were similar in each matched group. The postoperative difference in mean estimated glomerular filtration rate in patients with and without vasopressor infusions was only 0.8 mL/min/1.73 m2 (95% CI, −0.6 to 2.2 mL/min/1.73 m2) (P = .28). Intraoperative vasopressor infusion was also not associated with increased odds of augmented acute kidney injury stage. CONCLUSIONS: Clinicians should not avoid typical perioperative doses of vasopressors for fear of promoting kidney injury. Tolerating hypotension to avoid vasopressor use would probably be a poor strategy. Accepted for publication November 13, 2018. Funding: Institutional. 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 (http://bit.ly/KegmMq). Reprints will not be available from the authors. Address correspondence to Daniel I. Sessler, MD, Department of Outcomes Research, Cleveland Clinic, 9500 Euclid Ave, P77, Cleveland, OH 44195. Address e-mail to DS@OR.org. © 2019 International Anesthesia Research Society

http://bit.ly/2QSEhIC