mariano big data nwac 2015
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What “BIG DATA” Can Do for What “BIG DATA” Can Do for Regional AnesthesiologistsRegional Anesthesiologists
What “BIG DATA” Can Do for What “BIG DATA” Can Do for Regional AnesthesiologistsRegional Anesthesiologists
Edward R. Mariano, M.D., Edward R. Mariano, M.D., M.A.S.M.A.S.
Associate Professor of AnesthesiologyAssociate Professor of AnesthesiologyStanford University School of MedicineStanford University School of Medicine
Chief, Anesthesiology and Perioperative Chief, Anesthesiology and Perioperative CareCare
Veterans Affairs Palo Alto Health Care Veterans Affairs Palo Alto Health Care SystemSystem
Edward R. Mariano, M.D., Edward R. Mariano, M.D., M.A.S.M.A.S.
Associate Professor of AnesthesiologyAssociate Professor of AnesthesiologyStanford University School of MedicineStanford University School of Medicine
Chief, Anesthesiology and Perioperative Chief, Anesthesiology and Perioperative CareCare
Veterans Affairs Palo Alto Health Care Veterans Affairs Palo Alto Health Care SystemSystem
@EMARIANOMD@EMARIANOMD
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Financial DisclosuresFinancial DisclosuresFinancial DisclosuresFinancial Disclosures Halyard (formerly I-Flow), B Braun – Halyard (formerly I-Flow), B Braun –
Unrestricted educational program Unrestricted educational program funding paid to my institutionfunding paid to my institution
The contents of the following The contents of the following presentation are solely the presentation are solely the responsibility of the speaker without responsibility of the speaker without input from any of the above input from any of the above companies.companies.
Halyard (formerly I-Flow), B Braun – Halyard (formerly I-Flow), B Braun – Unrestricted educational program Unrestricted educational program funding paid to my institutionfunding paid to my institution
The contents of the following The contents of the following presentation are solely the presentation are solely the responsibility of the speaker without responsibility of the speaker without input from any of the above input from any of the above companies.companies.
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
How Do We Study Rare How Do We Study Rare Outcomes?Outcomes?
How Do We Study Rare How Do We Study Rare Outcomes?Outcomes?
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Private DatabasesPrivate DatabasesPrivate DatabasesPrivate Databases
Premier Perspective database Premier Perspective database (Charlotte, NC, USA)(Charlotte, NC, USA)
382, 236 382, 236 patients in approx 400 US patients in approx 400 US acute care hospitals over 4 yearsacute care hospitals over 4 years
Premier Perspective database Premier Perspective database (Charlotte, NC, USA)(Charlotte, NC, USA)
382, 236 382, 236 patients in approx 400 US patients in approx 400 US acute care hospitals over 4 yearsacute care hospitals over 4 years
Memtsoudis SG, et al. Anesth Memtsoudis SG, et al. Anesth 2013;118:10462013;118:1046
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
American College of American College of SurgeonsSurgeons
American College of American College of SurgeonsSurgeons
Started in the Veterans Health Started in the Veterans Health Administration in the 1980sAdministration in the 1980s
Adopted and expanded by the American Adopted and expanded by the American College of Surgeons into NSQIPCollege of Surgeons into NSQIP
Started in the Veterans Health Started in the Veterans Health Administration in the 1980sAdministration in the 1980s
Adopted and expanded by the American Adopted and expanded by the American College of Surgeons into NSQIPCollege of Surgeons into NSQIP
Schechter MA, et al. Surgery Schechter MA, et al. Surgery 2012;152:3092012;152:309
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Prospective RegistriesProspective RegistriesProspective RegistriesProspective Registries
““AURORA” started with practices in AURORA” started with practices in Australia and New Zealand – now Australia and New Zealand – now internationalinternational
Voluntary reportingVoluntary reporting
““AURORA” started with practices in AURORA” started with practices in Australia and New Zealand – now Australia and New Zealand – now internationalinternational
Voluntary reportingVoluntary reporting
Barrington MJ, et al. RAPM 2009;34:534Barrington MJ, et al. RAPM 2009;34:534
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Potential Limitations of Big Potential Limitations of Big DataData
Potential Limitations of Big Potential Limitations of Big DataData
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Potential Limitations of Big Potential Limitations of Big DataData
Potential Limitations of Big Potential Limitations of Big DataData
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Anesthesia Type and Anesthesia Type and MortalityMortality
Anesthesia Type and Anesthesia Type and MortalityMortality
30-day mortality was lower30-day mortality was lower for neuraxial and for neuraxial and neuraxial/GA vs. GA alone for TKAneuraxial/GA vs. GA alone for TKA
Most in-hospital complications were lower for Most in-hospital complications were lower for neuraxial and neuraxial/GA vs. GA aloneneuraxial and neuraxial/GA vs. GA alone
Transfusion requirements lowest for neuraxialTransfusion requirements lowest for neuraxial
30-day mortality was lower30-day mortality was lower for neuraxial and for neuraxial and neuraxial/GA vs. GA alone for TKAneuraxial/GA vs. GA alone for TKA
Most in-hospital complications were lower for Most in-hospital complications were lower for neuraxial and neuraxial/GA vs. GA aloneneuraxial and neuraxial/GA vs. GA alone
Transfusion requirements lowest for neuraxialTransfusion requirements lowest for neuraxial
Memtsoudis SG, et al. Anesth Memtsoudis SG, et al. Anesth 2013;118:10462013;118:1046
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Anesthesia Type and Anesthesia Type and MortalityMortality
Anesthesia Type and Anesthesia Type and MortalityMortality
No difference in 30-day mortality No difference in 30-day mortality between between regional anesthesia and GAregional anesthesia and GA
Regional anesthesia patients are more likely Regional anesthesia patients are more likely to have shorter operative time and next-day to have shorter operative time and next-day dischargedischarge
No difference in 30-day mortality No difference in 30-day mortality between between regional anesthesia and GAregional anesthesia and GA
Regional anesthesia patients are more likely Regional anesthesia patients are more likely to have shorter operative time and next-day to have shorter operative time and next-day dischargedischarge
Schechter MA, et al. Surgery Schechter MA, et al. Surgery 2012;152:3092012;152:309
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Anesthesia Type and Anesthesia Type and MortalityMortality
Anesthesia Type and Anesthesia Type and MortalityMortality
N=6009; N=6009; no difference in 30-day mortality no difference in 30-day mortality based on anesthesia typebased on anesthesia type
Increased pulmonary complications and Increased pulmonary complications and length of stay for GA vs. spinal or local/MAClength of stay for GA vs. spinal or local/MAC
N=6009; N=6009; no difference in 30-day mortality no difference in 30-day mortality based on anesthesia typebased on anesthesia type
Increased pulmonary complications and Increased pulmonary complications and length of stay for GA vs. spinal or local/MAClength of stay for GA vs. spinal or local/MAC
Edwards MS, et al. J Vasc Surg Edwards MS, et al. J Vasc Surg 2011;54:12732011;54:1273
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Analgesia and Cancer Analgesia and Cancer RecurrenceRecurrence
Analgesia and Cancer Analgesia and Cancer RecurrenceRecurrence
Retrospective review of patients with Retrospective review of patients with palpable breast lesions who palpable breast lesions who underwent mastectomy and axillary underwent mastectomy and axillary clearance with PVB catheters x 48h clearance with PVB catheters x 48h vs. opioid IV PCAvs. opioid IV PCA
Primary outcome: metastases or Primary outcome: metastases or cancer recurrence over 2.5-4 year cancer recurrence over 2.5-4 year follow-up (fixed time point)follow-up (fixed time point)
Retrospective review of patients with Retrospective review of patients with palpable breast lesions who palpable breast lesions who underwent mastectomy and axillary underwent mastectomy and axillary clearance with PVB catheters x 48h clearance with PVB catheters x 48h vs. opioid IV PCAvs. opioid IV PCA
Primary outcome: metastases or Primary outcome: metastases or cancer recurrence over 2.5-4 year cancer recurrence over 2.5-4 year follow-up (fixed time point)follow-up (fixed time point)
Exadaktylos AK, et al. Anesth Exadaktylos AK, et al. Anesth 2006;105:6602006;105:660
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Analgesia and Cancer Analgesia and Cancer RecurrenceRecurrence
Analgesia and Cancer Analgesia and Cancer RecurrenceRecurrence
129 patients met inclusion criteria129 patients met inclusion criteria– 50 patients received PVB (2 failures)50 patients received PVB (2 failures)– 79 patients received IV PCA79 patients received IV PCA
No demographic, tumor quality, or No demographic, tumor quality, or therapeutic differences between groupstherapeutic differences between groups
Recurrence/metastasis rates:Recurrence/metastasis rates:– 19/79 (24%) in IV PCA group19/79 (24%) in IV PCA group– 3/50 (6%) in PVB group3/50 (6%) in PVB group– p=0.013p=0.013
129 patients met inclusion criteria129 patients met inclusion criteria– 50 patients received PVB (2 failures)50 patients received PVB (2 failures)– 79 patients received IV PCA79 patients received IV PCA
No demographic, tumor quality, or No demographic, tumor quality, or therapeutic differences between groupstherapeutic differences between groups
Recurrence/metastasis rates:Recurrence/metastasis rates:– 19/79 (24%) in IV PCA group19/79 (24%) in IV PCA group– 3/50 (6%) in PVB group3/50 (6%) in PVB group– p=0.013p=0.013
Exadaktylos AK, et al. Anesth Exadaktylos AK, et al. Anesth 2006;105:6602006;105:660
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Analgesia and Cancer Analgesia and Cancer RecurrenceRecurrence
Analgesia and Cancer Analgesia and Cancer RecurrenceRecurrence
129 patients met inclusion criteria129 patients met inclusion criteria– 50 patients received PVB (2 failures)50 patients received PVB (2 failures)– 79 patients received IV PCA79 patients received IV PCA
No demographic, tumor quality, or No demographic, tumor quality, or therapeutic differences between groupstherapeutic differences between groups
Recurrence/metastasis rates:Recurrence/metastasis rates:– 19/79 (24%) in IV PCA group19/79 (24%) in IV PCA group– 3/50 (6%) in PVB group3/50 (6%) in PVB group– p=0.013p=0.013
129 patients met inclusion criteria129 patients met inclusion criteria– 50 patients received PVB (2 failures)50 patients received PVB (2 failures)– 79 patients received IV PCA79 patients received IV PCA
No demographic, tumor quality, or No demographic, tumor quality, or therapeutic differences between groupstherapeutic differences between groups
Recurrence/metastasis rates:Recurrence/metastasis rates:– 19/79 (24%) in IV PCA group19/79 (24%) in IV PCA group– 3/50 (6%) in PVB group3/50 (6%) in PVB group– p=0.013p=0.013
Exadaktylos AK, et al. Anesth Exadaktylos AK, et al. Anesth 2006;105:6602006;105:660
Mechanism?Preserving immune
competence?Direct effect?
Indirect effect? Both?
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Cancer Recurrence and Cancer Recurrence and SurvivalSurvival
Cancer Recurrence and Cancer Recurrence and SurvivalSurvival
Myles PS, et al. BMJ 2011;342:d1491Myles PS, et al. BMJ 2011;342:d1491
N=446; long-term follow-up of RCT N=446; long-term follow-up of RCT subjects GA/epidural vs. GA/opioidsubjects GA/epidural vs. GA/opioid
No difference in recurrence-free No difference in recurrence-free survival survival or overall mortalityor overall mortality
N=446; long-term follow-up of RCT N=446; long-term follow-up of RCT subjects GA/epidural vs. GA/opioidsubjects GA/epidural vs. GA/opioid
No difference in recurrence-free No difference in recurrence-free survival survival or overall mortalityor overall mortality
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Cancer Recurrence and Cancer Recurrence and SurvivalSurvival
Cancer Recurrence and Cancer Recurrence and SurvivalSurvival
Myles PS, et al. BMJ 2011;342:d1491Myles PS, et al. BMJ 2011;342:d1491
N=446; long-term follow-up of RCT N=446; long-term follow-up of RCT subjects GA/epidural vs. GA/opioidsubjects GA/epidural vs. GA/opioid
No difference in recurrence-free No difference in recurrence-free survival survival or overall mortalityor overall mortality
N=446; long-term follow-up of RCT N=446; long-term follow-up of RCT subjects GA/epidural vs. GA/opioidsubjects GA/epidural vs. GA/opioid
No difference in recurrence-free No difference in recurrence-free survival survival or overall mortalityor overall mortality
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Cancer Recurrence and Cancer Recurrence and SurvivalSurvival
Cancer Recurrence and Cancer Recurrence and SurvivalSurvival
14 studies met criteria EA±GA vs. GA 14 studies met criteria EA±GA vs. GA (including Cummings study, n=42,151)(including Cummings study, n=42,151)
Improved overall survival with EAImproved overall survival with EA No difference in cancer recurrenceNo difference in cancer recurrence
14 studies met criteria EA±GA vs. GA 14 studies met criteria EA±GA vs. GA (including Cummings study, n=42,151)(including Cummings study, n=42,151)
Improved overall survival with EAImproved overall survival with EA No difference in cancer recurrenceNo difference in cancer recurrence
Chen & Miao. PLOS ONE Chen & Miao. PLOS ONE 2013;8:e565402013;8:e56540
Cummings KC, et al. Anesth Cummings KC, et al. Anesth 2012;116:797 2012;116:797
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Chronic Pain after Breast Chronic Pain after Breast SurgerySurgery
Chronic Pain after Breast Chronic Pain after Breast SurgerySurgery
Survey of 479 women who underwent Survey of 479 women who underwent breast surgery over a 4-year periodbreast surgery over a 4-year period
59% response rate59% response rate Prevalence of pain after >1 year Prevalence of pain after >1 year
postop:postop:– Mastectomy/reconstruction = Mastectomy/reconstruction = 49%49%– Mastectomy alone = Mastectomy alone = 31%31%– Augmentation = Augmentation = 38%38%– Reduction = Reduction = 22%22%
Survey of 479 women who underwent Survey of 479 women who underwent breast surgery over a 4-year periodbreast surgery over a 4-year period
59% response rate59% response rate Prevalence of pain after >1 year Prevalence of pain after >1 year
postop:postop:– Mastectomy/reconstruction = Mastectomy/reconstruction = 49%49%– Mastectomy alone = Mastectomy alone = 31%31%– Augmentation = Augmentation = 38%38%– Reduction = Reduction = 22%22%
Wallace MS, et al. Pain 1996;66:195Wallace MS, et al. Pain 1996;66:195
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Chronic Pain after Breast Chronic Pain after Breast SurgerySurgery
Chronic Pain after Breast Chronic Pain after Breast SurgerySurgery
Meta-analysis: 3 studies assessed this Meta-analysis: 3 studies assessed this outcome (n=167)outcome (n=167)
All PVB-GA vs. GAAll PVB-GA vs. GA At 6 mos, RR=0.16, 95%CI (0.02-1.13)At 6 mos, RR=0.16, 95%CI (0.02-1.13)
– No difference (crosses 1)No difference (crosses 1) At 12 mos, RR=0.61, 95%CI (0.08-4.90)At 12 mos, RR=0.61, 95%CI (0.08-4.90)
– No difference (crosses 1)No difference (crosses 1)
Meta-analysis: 3 studies assessed this Meta-analysis: 3 studies assessed this outcome (n=167)outcome (n=167)
All PVB-GA vs. GAAll PVB-GA vs. GA At 6 mos, RR=0.16, 95%CI (0.02-1.13)At 6 mos, RR=0.16, 95%CI (0.02-1.13)
– No difference (crosses 1)No difference (crosses 1) At 12 mos, RR=0.61, 95%CI (0.08-4.90)At 12 mos, RR=0.61, 95%CI (0.08-4.90)
– No difference (crosses 1)No difference (crosses 1)
Schnabel A, et al. BJA 2010;105:842Schnabel A, et al. BJA 2010;105:842
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Chronic Pain after Chronic Pain after ThoracotomyThoracotomy
Chronic Pain after Chronic Pain after ThoracotomyThoracotomy
Incidence is approximately Incidence is approximately 50%50%– 3-16% report pain as moderate-severe3-16% report pain as moderate-severe
Heterogeneity in study designsHeterogeneity in study designs Many contributing factors: patients, Many contributing factors: patients,
surgical technique, pre- and postop surgical technique, pre- and postop painpain
To date, To date, no convincing evidenceno convincing evidence that that PVB decreases chronic pain after PVB decreases chronic pain after thoracotomythoracotomy
Incidence is approximately Incidence is approximately 50%50%– 3-16% report pain as moderate-severe3-16% report pain as moderate-severe
Heterogeneity in study designsHeterogeneity in study designs Many contributing factors: patients, Many contributing factors: patients,
surgical technique, pre- and postop surgical technique, pre- and postop painpain
To date, To date, no convincing evidenceno convincing evidence that that PVB decreases chronic pain after PVB decreases chronic pain after thoracotomythoracotomy
Wildgaard & Kehlet. Eur J CTS Wildgaard & Kehlet. Eur J CTS 2009;36:1702009;36:170
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Ultrasound and Patient Ultrasound and Patient SafetySafety
Ultrasound and Patient Ultrasound and Patient SafetySafety
Overall incidence of nerve injury due to Overall incidence of nerve injury due to block=0.4 per 1000 blocks block=0.4 per 1000 blocks
Overall incidence of LAST=0.98 per 1000 Overall incidence of LAST=0.98 per 1000 blocksblocks
No difference with or without ultrasoundNo difference with or without ultrasound
Overall incidence of nerve injury due to Overall incidence of nerve injury due to block=0.4 per 1000 blocks block=0.4 per 1000 blocks
Overall incidence of LAST=0.98 per 1000 Overall incidence of LAST=0.98 per 1000 blocksblocks
No difference with or without ultrasoundNo difference with or without ultrasound
Barrington MJ, et al. RAPM Barrington MJ, et al. RAPM 2009;34:5342009;34:534
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
Ultrasound and Patient Ultrasound and Patient SafetySafety
Ultrasound and Patient Ultrasound and Patient SafetySafety
22 cases of LAST in 25,336 blocks 22 cases of LAST in 25,336 blocks (overall incidence=0.87 per 1000)(overall incidence=0.87 per 1000)
LAST cases: 12/20,401 blocks with US vs. LAST cases: 12/20,401 blocks with US vs. 10/4745 blocks without US (10/4745 blocks without US (p=0.004p=0.004))
22 cases of LAST in 25,336 blocks 22 cases of LAST in 25,336 blocks (overall incidence=0.87 per 1000)(overall incidence=0.87 per 1000)
LAST cases: 12/20,401 blocks with US vs. LAST cases: 12/20,401 blocks with US vs. 10/4745 blocks without US (10/4745 blocks without US (p=0.004p=0.004))
Barrington MJ, et al. RAPM Barrington MJ, et al. RAPM 2013;38:2892013;38:289
Big Data for Regional Big Data for Regional AnesthesiologistsAnesthesiologists
SummarySummarySummarySummary Big data may offer means to study Big data may offer means to study
rare outcomes but has limitationsrare outcomes but has limitations Anesthesia and analgesia choice may Anesthesia and analgesia choice may
affect survivalaffect survival No convincing evidence to date that No convincing evidence to date that
analgesia affects cancer recurrence analgesia affects cancer recurrence or persistent postsurgical painor persistent postsurgical pain
Ultrasound may reduce incidence of Ultrasound may reduce incidence of LASTLAST
Big data may offer means to study Big data may offer means to study rare outcomes but has limitationsrare outcomes but has limitations
Anesthesia and analgesia choice may Anesthesia and analgesia choice may affect survivalaffect survival
No convincing evidence to date that No convincing evidence to date that analgesia affects cancer recurrence analgesia affects cancer recurrence or persistent postsurgical painor persistent postsurgical pain
Ultrasound may reduce incidence of Ultrasound may reduce incidence of LASTLAST