Tharusan Thevathasan Eikermann Research Laboratory

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Intraoperative neuromuscular blocking agent administration and hospital readmission Tharusan Thevathasan Eikermann Research Laboratory Critical Care Division Massachusetts General Hospital Harvard Medical School In close collaboration with: Schneider Lab (Rehabilitation) Berger Lab (Surgery) Houle Lab (Biostatistics)

Conflicts of Interest Dr. Eikermann: Merck funding Equity stake at Calabash Bioscience Inc. Buzen philanthropic funding The remaining contributors declared no financial or ethical conflicts of interest.

Background High prevalence of hospital readmissions continues to be a challenge for the healthcare system, with implications for the quality of patient care and excess financial costs (> $52 billion in the USA in 2013). CMS now publicly report 30-day readmission data and have implemented financial penalties towards hospitals with excess 30-day readmissions. Anesthesiologists use different strategies to optimize surgical relaxation: neuraxial anesthesia, inhalational anesthetics, opioids, neuromuscular blocking agents (NMBA). NMBA dose is associated with an increased risk of postoperative respiratory complications. American Hospital Association. TrendWatch 2011; Barrett et al. Agency for Healthcare Research and Quality (US) 2015; Fingar et al. Agency for Healthcare Research and Quality (US) 2015; Centers for Medicare & Medicaid Services. Readmission Reduction Program (HRRP); Eikermann et al. Anesthesiology 2015

Methods Study population Consecutively enrolled cohort of 13,122 adult patients who underwent abdominal surgery under general anesthesia at MGH between 01/2007 and 08/2014 Exposure Quintiles of intraoperatively administered NMBA ED95 dose Primary outcome 30-day hospital readmission Secondary outcomes Hospital length of stay, hospital costs Statistical method A priori defined multivariable logistic and negative binomial regression models adjusted for 22 confounders: Underlying and acute patient characteristics and demographics Age, gender, BMI, Charlson comorbidity index, ASA physical status, admission source Procedural complexity and duration Work RVU, procedural risk quantification index, duration of surgery, neuraxial anesthesia, emergency case Intraoperative respiratory and hemodynamic parameters MAC, PEEP, plateau pressure, FiO2, blood pressure Intraoperatively administered drugs Opioids, vasopressors, NMBA reversal agent, colloid and crystalloid fluids, PRBC units NMBA pharmaco-kinetics Type (benzylisoquinoline vs. steroid-type), potency (low vs. high)

Results – Outcomes P for trend: z=13.03, p<0.001

Results – Sensitivity Analyses Dose-dependent relationship between NMBA dose and readmision was reproduced in sub-cohorts: Ambulatory surgical procedures: OR 2.61 [95% CI 1.11-6.17] for 5th vs. 1st NMBA dose quintile NMBA dose quintile Short and long surgical duration Low and high ASA physical status Low and high Charlson comorbidity status Abdominal surgical subtypes (e.g. liver resection, gastrectomy, colorectal resection, lap. cholecystectomy, hernia repair) After adjusting for major respiratory complications After inclusion of patients who died in the hospital

Conclusion Dose-dependent relationship between intraoperative NMBA dose and increased risk of 30-day hospital readmission after abdominal surgery, an effect that is modified in patients undergoing ambulatory surgical procedures. This study is the first to test the association between intraoperative neuromuscular blocking agent administration and the risk of 30-day hospital readmission in patients undergoing abdominal surgery.

Acknowledgement Matthias Eikermann MD PhD Jeffrey C. Schneider MD Ross D. Zafonte DO David L. Berger MD Randall S. Glidden MD Shirley Shih MD Kyan C. Safavi MD Sara M. Burns MS Anne M. Que MS Stephanie D. Grabitz cand med