Showing papers in "Canadian Journal of Anaesthesia-journal Canadien D Anesthesie in 2011"

A systematic review of intravenous ketamine for postoperative analgesia

Abstract: Purpose Perioperative intravenous ketamine may be a useful addition in pain management regimens. Previous systematic reviews have included all methods of ketamine administration, and heterogeneity between studies has been substantial. This study addresses this issue by narrowing the inclusion criteria, using a random effects model, and performing subgroup analysis to determine the specific types of patients, surgery, and clinical indications which may benefit from perioperative ketamine administration.

Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials.

Abstract: Various strategies have been proposed for postoperative pain control. Among those, intravenous lidocaine infusion (IVLI) has gained in interest. However, its clinical benefit remains unclear. This systematic review is an evaluation of the analgesic efficacy and safety of IVLI during general anesthesia. A systematic search was performed using MEDLINE, EMBASE, Cochrane, and SCOPUS databases, likewise, grey literature. The review included all randomized controlled trials that used a placebo or any comparator and evaluated IVLI during general anesthesia for any type of surgery. Primary outcomes were pain control and opioid requirement. Secondary outcomes were mortality, length of stay, ileus recovery time, nausea/vomiting, and adverse events. Random effects models were used and heterogeneity was assessed using the I2 index. From 5,472 citations retrieved, 29 studies involving a total of 1,754 patients met eligibility. At six hours postoperatively, intravenous lidocaine infusion reduced pain at rest (weighted mean difference [WMD] −8.70, 95% confidence intervals [CI] −16.19 to −1.21), during cough (WMD −11.19, 95% CI −17.73 to −4.65), and during movement (WMD −9.56, 95% CI −17.31 to −1.80). Intravenous lidocaine infusion also reduced opioid requirement (morphine) (WMD −8.44 mg, 95% CI −11.32 to −5.56), time to first flatus (WMD −7.62 hr, 95% CI −10.78 to −4.45), time to first feces (WMD −10.71 hr, 95% CI −16.14 to −5.28), nausea/vomiting (risk ratios = 0.71, 95% CI 0.57-0.90), and hospital length of stay (WMD −0.17 days, 95% CI −0.41 to 0.07). Abdominal surgery was strongly associated with benefit. For the 12 studies that systematically screened adverse events, the incidence of cardiac and neurologic adverse events was comparable. Eight studies observed toxic plasma levels. Perioperative IVLI reduced postoperative pain and opioid requirement, as well as ileus recovery time, hospital length of stay, and nausea/vomiting. Intravenous lidocaine infusion was effective mainly in abdominal surgery populations. Considering that toxic levels were detected and that adverse events were not systematically screened for in most studies, dose and safety of IVLI should be established before recommending its use.

Easily adoptable total joint arthroplasty program allows discharge home in two days

Abstract: Purpose A safe efficient care pathway is needed to address the increasing need for arthroplasty surgery in Canada Our primary objective was to determine whether a fast-track model of care can reduce length of hospital stay following total hip and knee arthroplasty while maintaining patient safety and satisfaction

Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL.

Abstract: Interscalene brachial plexus block (interscalene block) complications usually depend on the dose administered. The objective of this study was to determine whether ultrasound-guided interscalene block with a 5-mL dose of 0.75% ropivacaine would have sufficient analgesic efficacy after shoulder arthroscopic surgery when compared with a 10-mL dose. Patients undergoing arthroscopic rotator cuff repair surgery (n = 60) were assigned randomly to one of two groups receiving 5 mL (Group 5) or 10 mL (Group 10) of 0.75% ropivacaine. Ultrasound-guided interscalene block was performed using the in-plane technique, and general anesthesia was administered. Time to first analgesic request was recorded, and the following issues were assessed in the postanesthesia care unit at six, 12, 24, and 48 hr postoperatively: postoperative pain as determined by a visual analogue scale (VAS), patient satisfaction, hemidiaphragmatic paralysis, other block-related complications, and postoperative nausea and vomiting (PONV). There was no significant difference between groups in time to first analgesic requirement (median [interquartile range] for Group 5: 16 [12-48] hr, Group 10: 18 [12-48] hr; P = 0.907). The postoperative pain VAS score was similar in both groups. The incidence of hemidiaphragmatic paralysis on postoperative chest x-ray was 33% in Group 5 and 60% in Group 10 (P = 0.035). However, the incidences of other block-related complications, PONV, and patient satisfaction were not significantly different between groups. Interscalene block performed under ultrasound guidance with 0.75% ropivacaine 5 mL showed analgesic efficacy similar to that with 0.75% ropivacaine 10 mL, but with a lower incidence of hemidiaphragmatic paralysis.

Anesthetic management of patients with an anterior mediastinal mass: continuing professional development.

Abstract: Purpose Many cases have been reported of hemodynamic and airway collapse induced by general anesthesia in patients with an anterior mediastinal mass We examined the literature for predictors of perioperative risk, guidelines for preoperative investigations, and strategies for management of the patient with a mediastinal mass

GABA(A) receptors as molecular targets of general anesthetics: identification of binding sites provides clues to allosteric modulation.

Abstract: Purpose The purpose of this review is to summarize current knowledge of detailed biochemical evidence for the role of γ-aminobutyric acid type A receptors (GABAA–Rs) in the mechanisms of general anesthesia.

Anesthetic Sites and Allosteric Mechanisms of Action on Cys-loop Ligand-gated Ion Channels

Abstract: Purpose The Cys-loop ligand-gated ion channel superfamily is a major group of neurotransmitter-activated receptors in the central and peripheral nervous system. The superfamily includes inhibitory receptors stimulated by γ-aminobutyric acid (GABA) and glycine and excitatory receptors stimulated by acetylcholine and serotonin. The first part of this review presents current evidence on the location of the anesthetic binding sites on these channels and the mechanism by which binding to these sites alters their function. The second part of the review addresses the basis for this selectivity, and the third part describes the predictive power of a quantitative allosteric model showing the actions of etomidate on γ-aminobutyric acid type A receptors (GABAARs).

Sleep and general anesthesia.

Abstract: The mechanisms through which general anesthetics cause reversible loss of consciousness are characterized poorly. In this review, we examine the evidence that anesthetic-induced loss of consciousness may be caused by actions on the neuronal pathways that produce natural sleep. It is clear that many general anesthetics produce effects in the brain (detected on electroencephalogram recordings) that are similar to those seen during non-rapid eye movement non-(REM) sleep. Gamma aminobutyric acid (GABA)ergic hypnogenic neurons are thought to be critical for generating non-REM sleep through their inhibitory projections to wake-active regions of the brain. The postsynaptic GABAA receptor is a major molecular target of many anesthetics and thus may be a point of convergence between natural sleep and anesthesia. Furthermore, we also present growing evidence in this review that modulating wake-active neurotransmitter (e.g., acetylcholine, histamine) release can impact on anesthesia, supporting the idea that this point of convergence is at the level of the brain arousal systems. While it is clear that general anesthetics can have effects at various points in the sleep-wake circuitry, it remains to be seen which points are true anesthetic targets. It will be challenging to separate non-specific effects on baseline arousal from a causal mechanism. Sophisticated experimental approaches are necessary to address basic mechanisms of sleep and anesthesia and should advance our understanding in both of these fields.

Brief review: Anesthetic neurotoxicity in the elderly, cognitive dysfunction and Alzheimer’s disease

Abstract: Purpose Postoperative cognitive decline in the elderly has emerged as a major health concern. In addition, there is a growing interest in the potential relationship between general anesthetic exposure and the onset and progression of Alzheimer’s disease (AD). The available evidence of a possible association between anesthesia, surgery, and long-term cognitive effects, including AD, deserves consideration. In this review, we summarize the evidence for anesthesia-induced neurotoxicity in the elderly, while highlighting the limitations of existing data, and we put the literature into perspective for the clinician.

Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial.

Abstract: Background We have always been searching for the ideal local anesthetic for outpatient spinal anesthesia. Lidocaine has been associated with a high incidence of transient neurological symptoms, and bupivacaine produces sensory and motor blocks of long duration. Preservative-free 2-chloroprocaine (2-CP) seems to be a promising alternative, being a short-acting agent of increasing popularity in recent years. This study was designed to compare 2-CP with bupivacaine for spinal anesthesia in an elective ambulatory setting.

Contribution of sedative-hypnotic agents to delirium via modulation of the sleep pathway.

Abstract: Purpose To review the mechanisms of sedative-hypnotic action with respect to the risk of delirium imparted by drugs that act on γ-amino-butyric-acid type A receptors or α2 adrenoceptors.

Brief review: Supplementing oxygen through an airway exchange catheter: efficacy, complications, and recommendations

Abstract: An airway exchange catheter (AEC) may be employed as a conduit for endotracheal tube placement and for oxygen insufflation or jet ventilation via its lumen. The recent barotrauma-related death of a young healthy patient receiving oxygen insufflated through an AEC prompted the Chief Coroner of Ontario to seek guidelines regarding their use. A literature search was undertaken using a number of search strategies to investigate both the efficacy and complications associated with supplying oxygen through an AEC. No studies were found comparing either oxygen insufflation or jet-ventilation through an AEC to any standard forms of oxygen therapy. The only case series found using AEC jet ventilation reported that 11% of patients sustained pulmonary barotrauma. Thirteen case reports documented jet ventilation as being associated with pneumothorax, pneumomediastinum, pneumoperitoneum, cardiovascular collapse, and death. In three case series (totalling 76 adults and 20 children) using only oxygen insufflation, no complications were reported. Jet ventilation through an AEC may be associated with a significant risk of barotrauma. Oxygen insufflation appears to be associated with a lower risk, but it is not risk-free. The authors caution against the use of an AEC to administer oxygen failing the proven benefit of its use over the use of standard oxygen therapies. Should a patient decompensate with an AEC in situ, tracheal re-intubation is the key management strategy. Supplemental oxygen can be provided using standard techniques prior to tracheal intubation or between attempts. Under emergency circumstances, oxygen insufflation or manual ventilation through an AEC may be considered provided vigilance for barotrauma is maintained and re-intubation is not delayed.

Meta-analysis of desflurane and propofol average times and variability in times to extubation and following commands

Abstract: Purpose We performed a meta-analysis to compare the operating room recovery time of desflurane with that of propofol.

High-dose dexmedetomidine increases the opioid-free interval and decreases opioid requirement after tonsillectomy in children.

Abstract: Purpose Dexmedetomidine, a selective α2 adrenoreceptor agonist, has analgesic and sedative properties, minimal impact on respiratory parameters, and reportedly decreases analgesic requirements after surgery. Given its pharmacodynamic profile, dexmedetomidine might have a role for postoperative pain control in children undergoing tonsillectomy. In this study, we hypothesized that dexmedetomidine would delay and decrease opioid requirements after tonsillectomy.

The intercristal line determined by palpation is not a reliable anatomical landmark for neuraxial anesthesia

Abstract: Purpose The radiological intercristal line (Tuffier’s line) usually intersects the spine at the L4-L5 interspace The intercristal line determined by palpation may be used erroneously as a surrogate for the true radiological Tuffier’s line We studied term pregnant women to establish the level at which a transverse line connecting the superior aspects of the iliac crests, as determined by palpation, intersects the lumbar spine, as assessed by ultrasound

Anesthetic management of patients with Brugada syndrome: a case series and literature review.

Abstract: Purpose To review the anesthetic management and perioperative outcomes of patients diagnosed with Brugada syndrome (BrS) who were treated at a single centre and to compare those results with a comprehensive review of the existing literature.

A prospective cohort study evaluating associations among delirium, postoperative cognitive dysfunction, and apolipoprotein E genotype following open aortic repair.

Abstract: Patients undergoing major vascular surgery are at high risk of postoperative delirium and postoperative cognitive dysfunction (POCD). Apolipoprotein E (APOE) is involved in central acetylcholine synthesis, and patients bearing the e4 genotype (APOE-e4) are at increased risk of both vascular dementia and peripheral vascular disease. The purpose of this study was to evaluate the associations among delirium, POCD, and APOE-e4 in patients undergoing open aortic repair. Following Research Ethics Board approval and written informed consent, we recruited a cohort of patients ≥ 60 yr of age undergoing open aortic repair. Apolipoprotein E genotyping and a battery of nine neuropsychometric (NP) tests were performed prior to surgery. Delirium was assessed on postoperative days two, four, and discharge using the Confusion Assessment Method. Neuropsychometric testing was repeated at discharge and again three months following surgery. A group of non-surgical patients was used to adjust NP scores using reliable change index methodology. Logistic regression was used to evaluate independent predictors of both delirium and POCD. Eighty-eight patients underwent surgery, 78 completed NP testing on discharge, and sixty-nine completed NP testing at three months. Delirium was noted in 36% of patients after surgery, while POCD was noted in 62% at discharge and 6% at three months. Delirium predicted POCD at discharge (odds ratio 2.86; 95% confidence intervals 0.99 to 8.27) but not at three months. Apolipoprotein E-e4 genotype was not associated with either delirium or POCD following adjustment for covariates. Both delirium and POCD are common following open aortic repair; however, the APOE genotype did not predict either condition. This trial has been registered with ClinicalTrials.gov (NCT00911677).

Recurarization after sugammadex reversal in an obese patient.

Abstract: We report a case that involved immediate postoperative respiratory failure necessitating tracheal intubation, which was possibly related to recurarization after sugammadex reversal A 54-yr-old woman weighing 115-kg was scheduled for laparoscopic repair of abdominal dehiscence under general anesthesia Muscle relaxation was induced and maintained with rocuronium (170 mg iv total dose) At the end of the 170-min procedure, two twitches were visualized after supramaximal train-of-four (TOF) stimulation at the adductor pollicis muscle, and the patient’s central core temperature was 356°C Sugammadex 200 mg iv (174 mg·kg−1) was administered With the patient fully awake, a TOF ratio 09 was obtained five minutes later The tracheal tube was then removed, and the patient was transferred to the postanesthesia care unit Ten minutes later, the patient presented respiratory failure necessitating tracheal intubation and sedation with propofol One TOF response only was visualized at the adductor pollicis muscle Another dose of sugammadex 200 mg iv was administered Forty-five minutes later, the patient was fully awake and her trachea was extubated after repeated measures of the TOF ratio (≥ 09) at the adductor pollicis muscle The patient fully recovered without sequelae, further complication, or prolonged hospital stay Shortly after tracheal extubation, an obese patient experienced respiratory failure necessitating tracheal intubation and an additional dose of sugammadex This occurred despite initial reversal of neuromuscular blockade with an appropriate dose of sugammadex 2 mg·kg−1 iv given at two responses to TOF stimulation

Cerebral oximetry desaturation during shoulder surgery performed in a sitting position under regional anesthesia.

Abstract: Purpose Hypotension in the sitting position may reduce cerebral perfusion and oxygenation. We prospectively determined the incidence of cerebral oximetry (rSO2) desaturation in seated patients undergoing ambulatory shoulder arthroscopy.

Physician professional behaviour affects outcomes: A framework for teaching professionalism during anesthesia residency

Abstract: In this review, we examine the association between physician professional behaviour and indicators measuring patient outcomes and satisfaction with care as well the potential for complaints, discipline, and litigation against physicians. We also review issues related to the structured teaching of professionalism to anesthesia residents, including resident evaluation. A search of the OVID Medline and PubMed databases was carried out using keywords relevant to the topics under consideration. Program directors of Canadian anesthesiology training programs were also surveyed to assess the current state of professionalism training and evaluation in their programs. Unprofessional behaviour is frequently manifested in practice by medical students, residents, and physicians, and it is associated with personality characteristics that are evident early in training. There is a correlation between unprofessional physician behaviours and patient dissatisfaction, complaints, and lawsuits as well as adverse outcomes of care. Physician health and workplace relationships are negatively impacted by such behaviours. Canadian program directors recognize the need to approach the teaching of professionalism in an organized fashion during physician training. A framework is provided for defining behavioural expectations, and mechanisms are offered for teaching and evaluating behaviours and responding to individuals with behaviours that persistently breach defined expectations. There is a need to define explicitly not only the expectations for behaviour but also the processes by which the behaviours will be assessed and documented. In addition, emphasis is placed on the nature, order, and magnitude of the responses to behaviours that do not meet expectations.

Difficult and failed intubation: Incident rates and maternal, obstetrical, and anesthetic predictors

Abstract: Difficult and failed tracheal intubation may be more common in the obstetrical population. The objective of this study was to determine the incidence of difficult and failed tracheal intubation in a Canadian tertiary care obstetric hospital and to identify predictors. Maternal, perinatal, and anesthetic information on all pregnant women or recently pregnant (up to three days postpartum) women undergoing general anesthesia (GA) from 1984 to 2003 at the Izaac Walton Killam Health Centre (IWK) was abstracted from the Nova Scotia Atlee Perinatal Database, and the information was augmented by chart review. The incidence and predictors of difficult and failed tracheal intubation were determined. Analyses using logistic regression were performed for the complete GA cohort and for the subgroup that had Cesarean delivery under GA. There were 102,587 deliveries of ≥20 weeks gestation in the study population, with 3,107 GAs identified, 2,986 records reviewed, and 2,633 GAs (88%) retained in the complete cohort. Difficult tracheal intubation was encountered in 123 of 2,633 (4.7%) women in the complete cohort and 60 of 1,052 (5.7%) women in the Cesarean delivery subgroup. Only two failed tracheal intubations were identified (0.08%) in the complete cohort, and both occurred during GAs for postpartum tubal ligation. The combined rate of difficult/failed tracheal intubation remained stable over the 20 years reviewed despite decreasing GA rates. Amongst the complete cohort, maternal age ≥35 yr, weight at delivery 90 to 99 kg, and absence of labour predicted increased risks; while weight at delivery 90 to 99 kg and absence of labour amongst the Cesarean delivery subgroup predicted difficult/failed tracheal intubation. Previously accepted risk factors, such as labour, pre-existing medical conditions and obstetrical disorders, did not predict an increased risk of difficult tracheal intubation, while maternal age ≥35 yr, weight 90 to 99 kg, and absence of active labour were found to predict increased risk.

Risk factors for urinary retention after hip or knee replacement: a cohort study.

Abstract: Introduction In 2006, our provincial government initiated a program to reduce wait times for total hip or knee replacements by referring patients to a single tertiary-care centre. This program provided an opportunity to identify risk factors for perioperative complications as part of a continuing quality improvement project. We report the risk of postoperative urinary retention after hip and knee replacements and the risk factors associated with this complication.

Inhibition of learning and memory by general anesthetics

Abstract: Today’s general anesthetics were developed empirically according to their ability to produce memory blockade, analgesia, immobility, and unconsciousness Thus, a major outstanding question remains: How do anesthetics produce their desirable behavioural end points at the molecular level? Understanding the mechanisms underlying memory blockade is of particular importance, because some patients experience the unexpected recall of events during anesthesia while others experience persistent memory deficits in the postoperative period This review provides a brief summary of the acute memory-blocking properties of general anesthetics and the neuronal substrates that most likely contribute to memory loss Studies in human volunteers and laboratory animals have shown that the memory-blocking properties of general anesthetics depend on the specific drug, the dose, the type of memory, and the experimental paradigm, as well as the species and age of the experimental subject The cellular substrates of memory blockade include an increase in neuronal inhibition by γ-aminobutyric acid subtype A receptors, a decrease in excitatory glutamatergic neurotransmission, and alterations in synaptic plasticity Anesthetics target different receptors and brain regions to modify the various forms of memory In the hippocampus, extrasynaptic γ-aminobutyric acid subtype A receptors may play a particularly important role Knowledge regarding the molecular basis of memory blockade may help to address memory disorders associated with the anesthetic state

Anesthetic considerations in mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome: a case series

Abstract: Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome (MELAS) is a rare inherited mitochondrial disorder associated with severe multiorgan pathology and stress-induced episodes of metabolic decompensation and lactic acidosis The purpose of this case series is to review the medical records of patients with MELAS who underwent anesthetic care at the Mayo Clinic to observe their perioperative responses to anesthesia and to assess outcomes From September 1997 to October 2010, nine patients with MELAS were identified who underwent 20 general anesthetics, 12 prior to MELAS diagnosis Debilitating neurologic symptoms involved eight patients, and three patients had substantial cardiac comorbidities The patients tolerated commonly used anesthetics and muscle relaxants, including succinylcholine Lactated Ringer’s solution was used frequently One patient was noted to have elevated postoperative serum lactate, but his serum lactate was chronically elevated Metabolic acidosis was not observed in any patient Hyponatremia and hyperkalemia, sometimes profound, were observed in seven patients, but these abnormalities also occurred at times remote from surgery Two patients developed renal dysfunction following cardiac surgery and abdominal surgery for severe sepsis The MELAS patients developed episodes of hyponatremia and hyperkalemia of variable severity unrelated to the timing of surgery, suggesting these patients are prone to major electrolyte disturbances Given the propensity to develop acid-base disturbances and lactacidemia, it is prudent to review and normalize electrolyte abnormalities and to adjust the anesthetic plan accordingly Fortunately, the limited data suggest that patients with MELAS tolerate commonly used anesthetic drugs well

Oropharyngeal leak pressure with the laryngeal mask airway Supreme™ at different intracuff pressures: a randomized controlled trial

Abstract: A higher oropharyngeal leak pressure (OLP) is a marker of efficacy and safety when using laryngeal mask airway devices. The new disposable laryngeal mask airway (LMA™) Supreme™ has lower OLP compared with the LMA ProSeal™. Increased intracuff pressure of laryngeal mask airway devices may improve OLP but may result in more postoperative pharyngolaryngeal adverse events. This study was designed to compare the OLP of the LMA Supreme at varying intracuff pressures. One hundred and twenty-three patients were divided randomly into three groups. General anesthesia was standardized using a propofol-fentanyl induction and desflurane in air-oxygen for maintenance. Intracuff pressures of the LMA Supreme were adjusted to 80 cm H2O, 60 cm H2O, and 40 cm H2O according to group allocation. The primary outcome was OLP. Secondary outcomes included postoperative pharyngolaryngeal adverse events and the satisfaction scores of patients and anesthesiologists. The OLP was compared amongst groups using analysis of variance with Bonferroni correction. All reported P values are two-sided. The OLP with an intracuff pressure of 80 cm H2O was significantly higher compared with 60 cm H2O and 40 cm H2O (26 [6] vs 20 [6] vs 18 [5] cm H2O, respectively; P < 0.001). The incidence of postoperative pharyngolaryngeal adverse events (P = 0.6), patient satisfaction scores (P = 0.2), and anesthesiologist satisfaction scores (P = 0.8) were comparable amongst the three groups. An intracuff pressure of 80 cm H2O with the LMA Supreme is associated with a higher OLP compared with 60 cm H2O or 40 cm H2O without a greater incidence of postoperative pharyngolaryngeal adverse events. For a superior glottic seal when using the LMA Supreme, we recommend intracuff pressures up to 80 cm H2O.

Ryanodine receptor type 1 gene mutations found in the Canadian malignant hyperthermia population

Abstract: Malignant hyperthermia (MH) is an autosomal dominant pharmacogenetic disorder that is manifested on exposure of susceptible individuals to halogenated anesthetics or succinylcholine. Since MH is associated primarily with mutations in the ryanodine receptor type 1 (RYR1) gene, the purpose of this study was to determine the distribution and frequency of MH causative RyR1 mutations in the Canadian MH susceptible (MHS) population. In this study, we screened a representative cohort of 36 unrelated Canadian MHS individuals for RYR1 mutations by sequencing complete RYR1 transcripts and selected regions of CACNA1S transcripts. We then analyzed the correlation between caffeine-halothane contracture test (CHCT) results and RYR1 genotypes within MH families. Eighty-six percent of patients had at least one RyR1 mutation (31 out of 36), five of which were unrelated individuals who were double-variant carriers. Fifteen of the 27 mutations identified in RYR1 were novel. Eight novel mutations, involving highly conserved amino acid residues, were predicted to be causal. Two of the mutations co-segregated with the MHS phenotype within two large independent families (a total of 79 individuals). Fourteen percent of MHS individuals (five out of 36) carried neither RYR1 nor known CACNA1S mutations. The distribution and frequency of MH causative RyR1 mutations in the Canadian MHS population are close to those of European MHS populations. Novel mutations described in this study will contribute to the worldwide pool of MH-associated mutations in the RYR1 gene, ultimately increasing the value of MH genetic diagnostic testing.

Organ donation after cardiac death: donor and recipient outcomes after the first three years of the Ontario experience.

Abstract: Purpose The aim of this study was to explore donor and recipient outcomes from organ donation after cardiac death (DCD) in Ontario and to examine the impact of DCD on deceased donation rates in Ontario since its implementation.

Learning curves of novice anesthesiology residents performing simulated fibreoptic upper airway endoscopy

Abstract: In various medical and surgical specialties, it is essential to acquire fibreoptic upper airway endoscopy skills for successful endotracheal intubation, especially when faced with a difficult airway. The aim of our study was to evaluate the learning curves of residents performing fibreoptic upper airway endoscopy in the simulation environment. Following a standardized video and practice session, 16 residents newly enrolled in the anesthesiology program performed nasal fibreoptic endoscopy of the upper airway (endpoint being the carina) on a high fidelity simulator. Weekly 20-min sessions continued for a period of one month. Each attempt was designated as either a “success” or a “failure” based on the study participant’s ability or inability to visualize the carina in ≤60 sec and with ≤five collisions with the simulated mucosal wall. Proficiency was attained when the downward graphical trend of the cumulative sum (CUSUM) analysis crossed two adjacent boundary lines, i.e., an acceptable failure rate was reached. The residents’ mean number of attempts at fibreoptic airway endoscopy was 47 (9) with a range of 32–64. Time to visualization of the carina was 51 (36) sec. Three classical patterns of CUSUM trends were observed: proficient (n = 7); not proficient with a downward (improvement) trend (n = 3); and not proficient with an upward (worsening) trend (n = 6). The number of attempts at which proficiency was achieved varied from 27 to 58. There is a large variation in the learning curves of residents performing fibreoptic upper airway endoscopy. The training for fibreoptic airway endoscopy should be tailored to the needs of each individual.

Tracheal intubation during chest compressions using Pentax-AWS®, GlideScope®, and Macintosh laryngoscope: a randomized crossover trial using a mannequin

Abstract: Background A randomized crossover trial was conducted to compare the performance of two videolaryngoscopes (Pentax-AWS®, GlideScope®) with the Macintosh laryngoscope for tracheal intubation during continuous chest compressions on a mannequin.

The relationship between Candida species cultured from the respiratory tract and systemic inflammation in critically ill patients with ventilator-associated pneumonia

Abstract: In patients with ventilator-associated pneumonia (VAP), the isolation of Candida species (spp.) in respiratory secretions has been associated with worse outcomes. It is unclear whether Candida colonization is causally related or is a marker of disease severity. The objective of this study was to compare systemic inflammatory markers in patients with a clinical suspicion of VAP with Candida in respiratory tract (RT) cultures vs patients who have bacteria and those with no pathogens. This was a prospective observational study in adults with a clinical suspicion of VAP who were enrolled within 24 hr of intensive care unit (ICU) admission. Patients were divided into four groups according to RT cultures, i.e., bacterial pathogens only, Candida spp. only, culture negative, and a control group with no clinical suspicion of VAP. Clinical outcomes were collected and compared as were systemic inflammatory and coagulation markers, including procalcitonin (PCT), C-reactive protein (CRP) and interleukin (IL)-6. The PCT, CRP, and IL-6 levels were similar in the Candida, bacterial pathogen, and culture negative groups but were significantly increased between the Candida group and the control group (P < 0.05). In the first 28 days, the number of ICU free days was significantly lower in the Candida group compared with the other groups, and mortality at 28 days was greater (Candida 42.9%, bacterial pathogen 25.0%, culture negative 19.8%, control 0.0%; P < 0.05). In patients with a clinical suspicion of VAP, the presence of Candida spp. only in the RT is associated with similar levels of inflammation and worse clinical outcomes compared with patients without Candida in RT secretions.