Anesthetic Induction Overdose Among Elderly Surgical Patients

老年手术患者麻醉诱导过量

• 批准号: 10092885
• 负责人: ROBERT SCHONBERGER
• 金额: $ 42.9万
• 依托单位: YALE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-04-01 至 2023-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10092885
• 关键词: Acute; Acute Renal Failure with Renal Papillary Necrosis; Adherence; Affect; Age; American; Anesthesia procedures; Anesthesiology; Anesthetics; Antihypertensive Agents; Attention; Blood Pressure; Cardiac; Caring; Characteristics; Clinical; Clinical Data; Complication; Consultations; Data; Databases; Dose; Elderly; Failure; Feedback; Future; Health Care Costs; Healthcare; Hemorrhage; Hospital Costs; Hospital Mortality; Hypotension; Individual; Injury to Kidney; Inpatients; Institution; Intervention; Leadership; Liquid substance; Measures; Medicare; Medicare claim; Morbidity - disease rate; Myocardial Infarction; Operative Surgical Procedures; Outcome; Overdose; Patients; Pattern; Perioperative; Perioperative complication; Polypharmacy; Population; Postoperative Period; Prevalence; Preventive measure; Professional Organizations; Provider; Public Health; Recommendation; Records; Risk; Safety; Sampling; Site; Surgical incisions; System; Testing; Work; aging population; base; comorbidity; data registry; demographics; design; feasibility testing; frailty; health care service utilization; high risk; human old age (65+); improved; member; mortality; older patient; patient population; patient subsets; pressure; primary outcome; secondary outcome; surgery outcome; tool

1 Patients age≥65 account for nearly 40% of annual surgeries, and this proportion will increase as 2 the population ages. These older patients have more perioperative complications - e.g. acute 3 kidney injury (AKI) and myocardial infarction (MI) - and the complication rate increases by 2-4 4 fold after age 80. Anesthesia induction requirements are known to decrease significantly with 5 age. We believe perioperative complications in older surgical patients result in part from 6 a failure among anesthesiologists to follow FDA guidance to reduce induction anesthetic 7 doses for these patients – a population with polypharmacy, frailty, decreased functional 8 reserve, and multiple interacting comorbidities. Severe hypotension (mean arterial 9 pressure<55mmHg) during surgery - even for a few brief minutes - increases risk of AKI by 10 18%, and MI by 30%, highlighting the importance of preventive measures to reduce hypotensive 11 episodes. Our multi-center pilot data indicates that anesthetic induction dose substantially 12 exceeds FDA guidance for many patients age ≥65 and that high induction doses often provoke 13 hypotension among these elderly patients. Hypotension during surgery can have multiple 14 causes, but when provoked by induction anesthetic overdose, it is modifiable. We propose to 15 combine data from the Multicenter Perioperative Outcomes Group (MPOG) database – 16 containing over 9.3 million anesthetic records from 44 centers - with Medicare data to, 1) identify 17 the prevalence of deviation from FDA induction dosing guidance nationwide; 2) test the 18 contribution of anesthetic induction overdose to perioperative complications; and 3) feasibility 19 test a pilot, quality improvement (QI) tool concerning deviation from FDA guidance on induction 20 dosing for the elderly. Among patients age≥65, and separately among those age≥80, our aims 21 are: Aim 1: To measure provider variability and identify outliers in FDA-adherent anesthetic 22 induction practice; Aim 2: Measure the association of anesthetic induction overdose to, a) 23 clinically meaningful hypotension, and b) subsequent postoperative morbidity and mortality; and 24 Aim 3: Develop and feasibility test a QI feedback tool – leveraging an established MPOG 25 platform - focused on deviation from FDA guidance for induction dosing of the elderly. 26 Public Health Significance: Demonstrating patterns of anesthetic overdose in excess of FDA 27 guidance and the consequences of this care failure among vulnerable subsets of patients, we 28 will highlight a clear target – FDA-adherent age-adjustment of anesthesia induction dose - to 29 make healthcare safer for older patients. The proposed analyses will support the testing of an 30 intervention to increase FDA-adherent anesthesia induction dosing for older Americans.

1年龄≥65岁的患者占每年手术的近40%，这一比例将随着年龄的增长而增加。 2、人口老龄化。这些老年患者有更多的围手术期并发症-例如急性 3肾损伤（阿基）和心肌梗死（MI）-并发症发生率增加2-4 80岁后的4倍。已知麻醉诱导要求随着 5岁。我们认为老年外科患者围手术期并发症的部分原因是 6.麻醉师未能遵循FDA指南减少诱导麻醉剂 这些患者接受7剂药物-多药、虚弱、功能降低的人群 8储备，和多种相互作用的合并症。重度低血压（平均动脉 9压力<55 mmHg）-即使是短短几分钟-也会增加阿基的风险， 10 18%，MI 30%，突出了预防措施减少腹泻的重要性。 11集我们的多中心试点数据表明，麻醉诱导剂量 12超过了FDA对许多年龄≥65岁患者的指导，高诱导剂量通常会引起 13例老年患者发生低血压。手术期间的低血压可能会有多个 14个原因，但当诱发麻醉剂过量，它是可以修改的。我们建议 15来自多中心围手术期结局组（MPOG）数据库的联合收割机数据- 16包含来自44个中心的超过930万份麻醉记录-医疗保险数据，1）识别 17全国范围内偏离FDA诱导给药指南的流行率; 2）测试 18麻醉诱导过量对围手术期并发症的贡献;和3）可行性 19测试一个试点，质量改进（QI）工具，涉及与FDA诱导指南的偏离 20岁的老人在年龄≥65岁的患者中，以及分别在年龄≥80岁的患者中，我们的目标是 目的1：测量供应商变异性并识别FDA依从性麻醉剂中的离群值 22诱导实践;目的2：测量麻醉诱导过量与以下因素的相关性：a） 23例有临床意义的低血压，和B）随后的术后发病率和死亡率;和 目标3：开发并可行性测试QI反馈工具-利用已建立的MPOG 25平台-侧重于偏离FDA老年人诱导给药指南。 26公共卫生意义：证明麻醉剂过量超过FDA的模式 27指导和这种护理失败的后果之间的脆弱子集的患者，我们 28将突出一个明确的目标-FDA依从的麻醉诱导剂量的年龄调整-以 29、让老年患者的医疗更安全。拟议的分析将支持对 30干预增加美国老年人的FDA依从麻醉诱导剂量。