A Brief Conversation with...Roman Dudaryk

by Kevin W. Hatton, MD, FCCM
University of Kentucky College of Medicine

Volume 28 | Issue 3 | Fall 2017

Roman Dudaryk, M.D. is an Associate Professor of Clinical Anesthesiology and Director of Quality Assurance in the Department of Anesthesiology at the University of Miami Miller School of Medicine and Jackson Memorial Hospital.  He is also an invaluable member of the Trauma Anesthesiology Faculty at the Ryder Trauma Center in Miami, FL.

Can you briefly describe your recent research article for our readers?

In this article, we describe the results from our retrospective study of more than 3500 general surgery patients who were admitted to our intensive care unit (ICU) directly from the operating room over a 7-year period.  These patients were retrospectively categorized, based on their intubation status at admission, into one of three groups: extubated (EXT), intubated for medical reasons (MED) or intubated for “discretional postoperative mechanical ventilation” reasons (DPMV) using criteria defined in our research protocol.  From this, we discovered that approximately 16% of patients admitted to our ICU following surgery were in the DPMV cohort, those patients who were still intubated but not, necessarily, for clear (objective or generally-accepted) medical reasons.  We also looked at some factors that may have contributed to this unexpectedly high percentage of DPMV patients, including ASA physical status classification, emergent operation, intraoperative factors and case end times.  From this, we determined that the ASA PS classification and emergency operations were significantly associated with DPMV status in our hospital while surgery end time and difficult airway management were not associated with DPMV status.

That is really interesting…what were you trying to understand better in this research?

For us, it was difficult to understand why some patients came to our ICU still requiring mechanical ventilation after general surgery despite not meeting conventional requirements for postoperative mechanical ventilation, such as hypoxic or hypercarbic respiratory failure, cardiovascular instability, ongoing resuscitation, etc.  We had recognized that there was a frequently vague rationale from our anesthesiology colleagues based, largely, on individual anecdotal experience attributed to “fluid shifts,” fragility of the patient, or less clearly defined reasons.  Therefore, our team wanted to understand what this anecdotal experience constituted in clinical practice.  To that end, the most challenging part of this research was recognizing that this phenomenon, that we termed “discretionary postoperative mechanical ventilation,” was real and represented the collected experience and expertise of trusted anesthesiologists in our hospital.  We believed that once we understood the incidence of DPMV and the associated risk factors, then we could use this information to provide better clinical care for our patients in the ICU, particularly at the times of critical transitions.

Wow…it’s a simple description for an obvious observation…yet novel in concept.  So what were your article’s most important conclusions?

Based on the results of our analysis, we discovered that a significant number of patients admitted to our ICU required mechanical ventilation for discretionary reasons rather than for conventionally-described medical reasons.  In fact, in our study, the majority of patients who were still intubated at ICU admission were in the DPMV cohort (56.4%) compared to the MED cohort.  Further analysis demonstrated that ASA physical status and emergency procedures had significantly more predictive effect than did other intraoperative factors such as duration of operation, type or amount of intraoperative fluid administration, difficulty in airway management or operation end time.

It seems that DPMV is definitely an important contributor to postoperative mechanical ventilation in your hospital.  How might I use this information in my own practice?

Similar to our experience, you, first, have to recognize that DPMV exists and is more than just “laziness” or “inattention” on the part of the anesthesiologists in your hospital.  In fact, the exact opposite is true and the fact that 72% of the surgical patients were admitted to ICU extubated despite the fact that the duration of surgery, the amount of fluids given or the difficult airway status were not associated with postoperative ventilation points to the fact that our anesthesiology faculty and staff put a significant effort behind their attempts to liberate patients from mechanical ventilation before ICU admission.  Anesthesiologists, therefore, have specific reasons for leaving patients intubated after operative procedures, even if they can only give a vague rationale for their decision.  Second, you may want to develop an internal QA/QI process to evaluate DPMV in your hospital.  It is possible that these DPMV represent a conscious or even unconscious “work around” for harmful systems-based processes that exist in your hospital.  Addressing any of these potential problems or processes could provide significant benefit to your patients.  Finally, you should consider ways to highlight the reasons for DPMV between the intraoperative and postoperative care teams.  We believe that this should be a significant focus or highlight in the perioperative handoff process.

In many ways, you may have just described a very important role of the perioperative surgical home (PSH).  How could members of SOCCA apply your methods to evaluate and consider the role of PSH in their practice?

Improving patient outcomes and continuously evaluating these outcomes for patients in the perioperative period are fundamental goals of the PSH concept.  By maintaining the focus of PSH on how perioperative clinicians, including anesthesiologists and anesthesiology critical care specialists, interact to continuously evaluate and improve patient care in the postoperative period, patient care will improve over time.  In this way, anesthesiology critical care specialists work every day to simplify increasingly complex care and to bring value to perioperative patient care.  Similar to our study, PSH requires perioperative clinicians to evaluate their own practices and develop a different mindset about what is really happening with their patients.  To highlight this, postoperative respiratory failure has become one of the key AHRQ reportable quality indicators for hospital performance, also known as PSI-11.  In this context both PSH and the role of Critical Care Anesthesiologists have a tremendous potential to improve the quality of care delivered to surgical patients by decreasing incidence and duration of postoperative mechanical ventilation by highlighting their unique value position, knowledge, and experience when compared to other critical care providers.  At the end of the day, though, it’s a mindset that may provide different (and better) clinical outcomes in an environment of scientific evaluation but will only come with an understanding of administrative and fiscal leaders that these outcomes must be recognized as valuable to the health of our patients.

I want to express my appreciation for taking time to speak with me about your research.  As a final thought, what advice do you have about research for junior faculty and fellows that want to try to answer an important research question?

In anesthesiology, there are a lot of things we do exclusively because of "tradition" and we are largely educated through emulation of our "heroes."  Because of this, “easy” and “obvious” questions are still not yet asked…and definitely not answered.  Junior faculty and fellows should question everything that comes their way, especially at the beginning.  Although it’s hard to believe as a junior faculty or fellow, we all learn with experience and time that very few things are absolute or are absolutely based in evidence.  Much of what we do is very vague and based on low quality evidence; yet these very practices are considered gold standard ideas.  We should all challenge what we do and consider what is really absolute and what is or should be controversial. Question the simplicity and the basic reality of what we do every day.