Showing papers in "Canadian Journal of Anaesthesia-journal Canadien D Anesthesie in 2019"

Anesthetic technique and cancer outcomes: a meta-analysis of total intravenous versus volatile anesthesia

Abstract: Cancer-related mortality, a leading cause of death worldwide, is often the result of metastatic disease recurrence. Anesthetic techniques have varying effects on innate and cellular immunity, activation of adrenergic-inflammatory pathways, and activation of cancer-promoting cellular signaling pathways; these effects may translate into an influence of anesthetic technique on long-term cancer outcomes. To further analyze the effects of propofol (intravenous) and volatile (inhalational gas) anesthesia on cancer recurrence and survival, we undertook a systematic review with meta-analysis. Databases were searched up to 14 November 2018. Comparative studies examining the effect of inhalational volatile anesthesia and propofol-based total intravenous anesthesia (TIVA) on cancer outcomes were included. The Newcastle Ottawa Scale (NOS) was used to assess methodological quality and bias. Reported hazard ratios (HRs) were pooled and 95% confidence intervals (CIs) calculated. Ten studies were included; six studies examined the effect of anesthetic agent type on recurrence-free survival following breast, esophageal, and non-small cell lung cancer (n = 7,866). The use of TIVA was associated with improved recurrence-free survival in all cancer types (pooled HR, 0.78; 95% CI, 0.65 to 0.94; P < 0.01). Eight studies (n = 18,778) explored the effect of anesthetic agent type on overall survival, with TIVA use associated with improved overall survival (pooled HR, 0.76; 95% CI, 0.63 to 0.92; P < 0.01). This meta-analysis suggests that propofol-TIVA use may be associated with improved recurrence-free survival and overall survival in patients having cancer surgery. This is especially evident where major cancer surgery was undertaken. Nevertheless, given the inherent limitations of studies included in this meta-analysis these findings necessitate prospective randomized trials to guide clinical practice. PROSPERO (CRD42018081478); registered 8 October, 2018.

Anatomical evaluation of the extent of spread in the erector spinae plane block: a cadaveric study

Abstract: The erector spinae plane (ESP) block is an interfascial analgesic technique first described as an alternative for pain control at the thoracic level. The objective of this observational study was to determine the anatomical spread of dye following a T7 ESP block in a cadaveric model. An ultrasound-guided ESP block was performed in four fresh human cadavers using an in-plane approach with a linear probe in a longitudinal orientation and a puncture in a craniocaudal direction. Twenty millilitres of an iodinated contrast/methylene blue solution was injected deep to the erector spinae muscle at the distal end of the T7 transverse process bilaterally in two of the specimens, and unilaterally in the other two (six ESP blocks in total). Subsequently, the specimens were subjected to a multi-slice computed tomography (CT) scan with three-dimensional reconstruction. Two of the specimens were dissected to evaluate the distribution of the contrast solution, and a sectional study was performed in the other two. In the six samples, evaluated by CT scan and anatomical dissection, a craniocaudal spread of the dye was observed in the dorsal region from T1–T11 with lateral extension towards the costotransverse region. No diffusion of contrast solution or dye to the anterior region (paravertebral space) was observed by CT scan or dissection. The results suggest that the ESP block reaches a wide range of the posterior rami of spinal nerves without diffusion into the paravertebral space or involvement of the anterior rami.

Efficacy and safety of erythropoietin and iron therapy to reduce red blood cell transfusion in surgical patients: a systematic review and meta-analysis

Abstract: Iron restricted anemia is prevalent in surgical patients and is associated with an increased risk of allogeneic red blood cell (RBC) transfusion and adverse events. Treatment of anemia includes oral and intravenous iron and erythropoiesis stimulating agents (ESAs). More recent studies have focused on the use of intravenous iron as the primary approach to treating anemia. Nevertheless, the optimal treatment strategy for anemia remains to be established. Our primary objective was to evaluate the efficacy and safety of ESA and iron therapy relative to iron therapy alone in reducing RBC transfusion in surgical patients. We searched the Cochrane Library, MEDLINE, EMBASE, and ClinicalTrials.gov from inception to May 2018. We included randomized-controlled trials in which adult surgical patients received an ESA and iron, vs iron alone, prior to cardiac and non-cardiac surgery. Our primary outcome was RBC transfusion rate. Secondary outcomes included hemoglobin concentration (post-treatment and postoperatively), number of RBC units transfused, mortality, stroke, myocardial infarction (MI), renal dysfunction, pulmonary embolism (PE), and deep vein thrombosis (DVT). In total, 25 studies (4,719 participants) were included. Erythropoiesis stimulating agents and iron therapy reduced RBC transfusion relative to iron therapy (relative risk [RR] 0.57; 95% confidence interval [CI], 0.46 to 0.71) without any change in mortality (RR 1.31; 95% CI, 0.80 to 2.16), stroke (RR 1.91; 95% CI, 0.63 to 5.76), MI (RR 1.12; 95% CI, 0.50 to 2.50), renal dysfunction (RR 0.96; 95% CI, 0.72 to 1.26), PE (RR 0.92; 95% CI, 0.15 to 5.83), or DVT (RR 1.48; 95% CI, 0.95 to 2.31). Administration of ESA and iron therapy reduced the risk for RBC transfusion compared with iron therapy alone in patients undergoing cardiac and non-cardiac surgery. Nevertheless, publication bias and heterogeneity reduces the confidence of the finding. Although the analysis was probably under-powered for some outcomes, no difference in the incidence of serious adverse events was observed with ESA and iron compared with iron alone. Further large prospective trials are required to confirm these findings.

Erector spinae plane catheter for neonatal thoracotomy: a potentially safer alternative to a thoracic epidural.

Abstract: A three-week-old 4-kg neonate required thoracotomy for excision of the right lower lobe to remove a large congenital cystic adenomatoid malformation. An erector spinae plane block (ESPB) was used for postoperative analgesia and was performed in the lateral position (after the surgeon had marked the incision site). An 18G 50-mm Tuohy needle (Pajunk, Geisinger, Germany) was inserted at approximately T6, and the erector spinae plane was hydro-dissected with saline under ultrasound guidance extending two vertebral spaces above and below the injection site (panels A and B in the figure); this was followed by placement of a 20G SonoLong catheter (Pajunk, Geisinger, Germany). Following completion of the surgery, the catheter was bolus with local anesthetic under ultrasound guidance, again confirming that it spread at least two segments craniocaudally above and below the incision and chest tube site (panel C). In addition to administration of oral acetaminophen 12.5 mg kg every six hours, ropivacaine 0.1% (0.25 mg kg hr) was infused via the ESPB catheter. The patient thus had excellent analgesia for the first 48 hr postoperatively and required only a single dose of morphine (0.1 mg kg) on the day of surgery. The chest tube and ESPB catheter were removed on the second postoperative day without incident, and the patient was discharged on postoperative day 3. Thoracotomy is associated with significant postoperative pain. Opioid-based analgesia has proved difficult, particularly due to the associated respiratory depression when used in neonates. Conversely, untreated pain results in inadequate ventilation, thereby increasing pulmonary morbidity. A traditional regional anesthesia approach for post-thoracotomy pain relies on a thoracic epidural. In children, the shorter distance from skin to the dura implies a significant risk to the spinal cord during epidural needle insertion. A potentially safer approach to the thoracic epidural space is via a caudally threaded epidural. However, recent studies suggest high rates of catheter migration in small children. The paravertebral block maintains a significant risk of damage to surrounding structures (e.g., spinal nerves, pneumothorax). Erector spinae plane block is a relatively new block used to provide chest wall analgesia and has thus far displayed an excellent safety profile. Erector spinae plane block affords an excellent margin of safety because of its more superficial depth and greater distance from important structures (e.g., spinal cord, pleura). Coagulopathy should be a lesser contraindication given that the needle placement is a significant distance from the spinal cord and epidural venous plexus, a common source of epidural hematoma formation seen with thoracic epidural and paravertebral approaches. The potential risk of a pneumothorax from an ESPB is additionally offset, specifically during thoracotomy, by the intentional surgical exploration of the lung and planned chest tube insertion. Thus, the ESPB is a potentially reliable, safe alternative to epidural and paravertebral catheters and should be considered for chest wall surgery, particularly in neonates. A. C. Adler, MS, MD, FAAP, FASE (&) Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA e-mail: adamcadler@gmail.com; axadler@texaschildrens.org

Interprofessional communication in the operating room: a narrative review to advance research and practice.

Abstract: Communication failures are often at the root of adverse events for surgical patients; however, evidence to inform best communication practice in the operating room is relatively limited. This narrative review outlines the importance of interprofessional communication for surgical patient safety, maps its barriers and facilitators, and highlights key strategies for enhancing communication quality in the operating room. Based on this review, a research agenda to inform best practices in interprofessional operating room communication is suggested. The non-systematic literature search included searches of relevant databases (Medline (via OVID), PubMed, Scopus, and EMBASE, PsycINFO, CINAHL), relevant grey literature sources (e.g., patient safety institute websites), and reference lists of selected articles. Effective interprofessional communication plays a critical role in the operating room, but faces many challenges at the individual, team, environmental, and organizational level. Factors that support effective communication are less documented than barriers, but include team integration, flattened hierarchies, and structure/standardization. Checklists, safety briefings, and teamwork/communication training are the most common techniques used to improve communication in the operating room. Of all communication techniques, closed-loop communication may be the most practical and inexpensive strategy. The perioperative community should be encouraged to implement existing effective solutions to improve communication and investigate creative solutions to identified barriers. Improved methods of data collection are needed to enhance evidence quality, increase understanding of communication barriers and facilitators, and identify the best strategy to advance practice.

Guidelines to the Practice of Anesthesia – Revised Edition 2019

Abstract: The Guidelines to the Practice of Anesthesia Revised Edition 2019 (the Guidelines) were prepared by the Canadian Anesthesiologists’ Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2019 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgement in determining the proper course of action for any patient’s circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

Intraoperative use of dexmedetomidine for the prevention of emergence agitation and postoperative delirium in thoracic surgery: a randomized-controlled trial.

Abstract: We investigated whether preventive use of dexmedetomidine during surgery was effective for reducing emergence agitation and postoperative delirium. In this double-blind randomized-controlled trial, 143 patients undergoing thoracoscopic lung resection surgery were randomly assigned to the dexmedetomidine-sevoflurane (DEX-Sevo, n = 73) or sevoflurane (Sevo, n = 70) groups. Dexmedetomidine or saline administration was started after inducing anesthesia and continued until the end of surgery at a fixed dose (0.5 µg·kg−1·hr−1). The primary endpoint was the incidence of delirium up until the end of postoperative day 3. Emergence agitation and postoperative delirium were measured with the Riker sedation agitation scale and the confusion assessment method, respectively. The secondary endpoints were serum cytokine and catecholamine levels. The DEX-Sevo group showed less frequent emergence agitation than the Sevo group (13% vs 35%, respectively; relative risk, 0.38; 95% confidence interval [CI], 0.18 to 0.79; P = 0.011) but the incidence of delirium after discharge from the postanesthesia care unit was not different (25% vs 25%, DEX-Sevo vs Sevo). Both pro- and anti-inflammatory cytokines were lower in the DEX-Sevo group than in the Sevo group. Nevertheless, the interleukin (IL)6/IL10 ratio (median difference, 5.8; 95% CI,1.8 to 10.0; P = 0.012) and IL8/IL10 ratio (median difference, 0.8; 95% CI, 0.2 to 1.3; P = 0.007) were higher in the DEX-Sevo group than in the Sevo group, indicating a pro-inflammatory cytokine balance in the DEX-Sevo group. Norepinephrine and epinephrine levels were lower in the DEX-Sevo group than in the Sevo group (both, P < 0.001). Intraoperative dexmedetomidine reduced emergence agitation but not postoperative delirium in patients undergoing thoracic surgery. Dexmedetomidine seemed to affect emergence agitation through catecholamines, but not through an anti-inflammatory action. Trial registration Clinical Research Information Service (KCT 0001877); registered 7 April, 2016.

A systematic review of technology-based preoperative preparation interventions for child and parent anxiety

Abstract: The purpose of this systematic review was to examine the effect of technology-based preoperative preparation interventions on children’s and parents’ anxiety. PsycINFO, Cochrane, Science Direct, Taylor and Francis, and Pubmed MEDLINE databases were searched. Studies were restricted to those reporting on technology-based preoperative preparation interventions for pediatric patients (0–18 yr old) receiving elective surgery under general anesthesia. Thirty-eight studies that provided level II or level III evidence were included (33 randomized-controlled trials and five non-randomized-controlled studies). Of the 38 studies, preoperative anxiety (measured by various indices of anxiety) was significantly reduced in children and parents in 25 and 11 studies, respectively. For children, tablet and handheld devices with interactive components were the most encouraging strategies. Video preparation alone may provide sufficient information to manage preoperative anxiety in parents. The available literature is extremely heterogeneous and limits the ability to make definitive conclusions about the efficacy of technology-based preoperative preparation interventions. The available literature suggests that, for children, tablet and handheld devices with interactive capacity may represent a viable option to address preoperative anxiety. The findings are more mixed for parents, with video preparation a possible option. Execution of well-designed, methodologically sound studies is required to facilitate a better understanding of the efficacy of technology-based preoperative preparation.

Carfentanil: a narrative review of its pharmacology and public health concerns.

Abstract: Carfentanil is a synthetic fentanyl analogue approved for veterinary use. It is a mu-opioid receptor agonist with an estimated analgesic potency approximately 10,000 times that of morphine and 20-30 times that of fentanyl, based on animal studies. Since 2016, an increasing number of reports describe detection of carfentanil in the illicit drug supply. Little is known about the pharmacology of carfentanil in humans. Its high potency and presumed high lipophilicity, large volume of distribution, and potential active metabolites have raised concerns about the management of people exposed to carfentanil as well as the safety of first responders. Exposed individuals exhibit features of an opioid toxidrome and respond to opioid antagonists such as naloxone, although empiric dose requirements are unknown and very high doses may be required. Rare reports of suspected accidental poisoning of first responders have not been analytically confirmed and are unlikely to represent true poisoning. General occupational hygiene measures, including regular decontamination with soap and water, basic personal protective equipment (nitrile gloves, N95 mask, and eye goggles), and ready access to naloxone are generally sufficient in most circumstances.

The perioperative patient on buprenorphine: a systematic review of perioperative management strategies and patient outcomes

Abstract: An increasing number of patients with opioid use disorder (OUD) are treated with opioid agonist-antagonists such as buprenorphine/naloxone. Perioperative management of patients on buprenorphine/naloxone is inconsistent and remains a controversial topic with mismanagement posing a significant risk to the long-term health of these patients. We performed a systematic literature search involving Medline, Medline In-Process, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsycINFO, Web of Science (Clarivate), Scopus (Elsevier), CINAHL (EbscoHosst), and PubMed (NLM). Eighteen studies were included in the final sample, including one controlled study and four observational studies . Neither the controlled study nor the observational studies assessed addiction treatment retention, harm reduction, or long-term mortality rates as primary or secondary outcomes. Of the observational studies, authors showed equivalent peri- and postoperative pain control among buprenorphine continued patients. All but one authors described adequate analgesia among the case reports in which buprenorphine ≤ 16 mg sublingually (SL) daily was continued during the perioperative period. Long-term harm reduction was not reported with only three case reports including any long-term abstinence or relapse rates. The current understanding of the risks and benefits of continuing or stopping buprenorphine perioperatively is limited by a lack of high-quality evidence. Observational studies and case reports indicate no evidence against continuing buprenorphine perioperatively, especially when the dose is < 16 mg SL daily. In patients with significant potential for relapse, such as those with a recent history of OUD, the discontinuation of buprenorphine should have a strong rationale supported by patient and surgical preferences. Future studies require standardized reporting of median doses, details on the route of delivery, dosing schedules and any dosing changes, and rates of addiction relapse, including long-term morbidity and mortality where possible.

The future is now-it's time to rethink the application of the Global Warming Potential to anesthesia.

Abstract: All volatile anesthetic agents are fluorocarbons and variably potent greenhouse gases (GHG). As a chlorofluorocarbon (CFC), isoflurane also has ozone depleting potential (as does nitrous oxide [N2O]), while sevoflurane and desflurane, being hydrofluorocarbons (HFC), do not. The global emission of HFCs increased 128% from 1990 to 2005 and is projected by 2030 to increase a further 336% compared with 2005 emissions. The Montreal Protocol is an international treaty agreed upon in 1987 with the primary goal to protect the ozone layer and to reverse the ozone hole over Antarctica. While it is being heralded as a major multinational success, since it has led to the phase-out of CFCs and a subsequent slow recovery of the ozone layer, it has led to an increased use of HFCs, which are also very potent GHGs. The 2016 Kigali amendment to the Montreal Protocol further aims to phasedown those HFCs with a high potential for contributing to global warming. Unfortunately, the field of anesthesia finds itself in a unique position where the release of its CFCs and HFCs has actually increased over time. What makes inhalational anesthetics potent GHGs?

Correlation between incremental remifentanil doses and the Nociception Level (NOL) index response after intraoperative noxious stimuli.

Abstract: The Pain Monitoring Device (PMD) monitor (Medasense Biometrics Ltd., Ramat Gan, Israel) uses the Nociception Level (NOL) index, a multiple parameter-derived index that has recently shown a good sensitivity and specificity to detect noxious stimuli. The aim of this study was to assess the latest version of the device (PMD200TM) on variations of the NOL response after standardized tetanic stimuli to study the correlation between remifentanil doses and NOL. Data from 26 patients undergoing midline laparotomy and receiving a desflurane-remifentanil-based anesthetic coupled with low thoracic epidural analgesia were analyzed. A standardized tetanic stimulus was applied to the forearm of the patients at different remifentanil infusion rates. The primary aim was to evaluate the correlation between post-tetanic stimulation NOL values from the PMD200 and remifentanil doses. The NOL index variations after experimental and clinical stimuli were also compared with heart rate (HR), mean arterial pressure (MAP), and Bispectral Index™ (BIS). A correlation between post-tetanic stimulation NOL values and remifentanil doses was found (r = −0.56; 95% confidence interval [CI], −0.70 to −0.44; P < 0.001). The NOL discriminated noxious from non-noxious states with the maximal Youden’s index value of the NOL receiver operating characteristic (ROC) curve showing a specificity of 88% (95% CI, 69.0 to 100) and sensitivity of 79.1% (95% CI, 56.2 to 95.5). The area under the NOL ROC curve (AUC, 0.9; 95% CI, 0.84 to 0.95) was significantly different from the other variables (P < 0.001 vs HR; P < 0.001 vs MAP; P < 0.001 vs BIS). The NOL value after noxious stimulus decreased with incremental remifentanil doses, showing a significant inverse correlation between the NOL index and opioid doses. The sensitivity and specificity of NOL to discriminate between noxious and non-noxious stimuli suggests its interesting potential as a monitor of nociception intensity during anesthesia. www.clinicaltrials.gov (NCT 02884778); 27 July, 2016.

Practice advisory on the bleeding risks for peripheral nerve and interfascial plane blockade: evidence review and expert consensus

Abstract: The risk of bleeding complications during regional anesthesia procedures is a significant patient safety consideration. Nevertheless, existing literature provides limited guidance on the stratification of bleeding risk for peripheral nerve and newly described interfascial plane blocks. Our objective was to produce an evidence-based consensus advisory that classifies bleeding risks in patients undergoing regional peripheral nerve and interfascial plane block procedures. This advisory is intended to facilitate clinical decision-making in conjunction with national or local guidelines and to guide consideration for appropriate alterations to anticoagulation regimens before specific regional anesthesia procedures. In pursuit of this goal, the Regional Anesthesia and Acute Pain Section of the Canadian Anesthesiologists Society (CAS) assembled a panel of seven Canadian experts to classify the risk of bleeding complications associated with regional peripheral nerve and interfascial plane blocks. At the 75th annual meeting of the CAS in June 2018, the panel's expert opinion was finalized and the published literature was quantified within an organized framework. All common peripheral nerve and interfascial plane blocks were categorized into "low risk", "intermediate risk", and "high risk" based on the literature evidence, bleeding risk scores, and consensus opinion (in that order of priority). Clinical data is often limited, so readers of this consensus report should be reminded that these recommendations are mostly based on expert consensus. Hence, this advisory should not to be defined as a standard of care but rather serve as a resource for clinicians assessing the risk and benefits of regional anesthesia in management of their patients.

Perioperative dexmedetomidine reduces delirium in elderly patients after non-cardiac surgery: a systematic review and meta-analysis of randomized-controlled trials

Abstract: Delirium is a frequent postoperative complication in elderly patients after non-cardiac surgery. We performed this updated meta-analysis to ascertain more precisely the efficacy of dexmedetomidine (DEX) on the incidence of postoperative delirium (POD) in elderly patients after non-cardiac surgery. We searched PubMed, EMBASE, the Cochrane Library, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) from inception until February 24, 2019. In this meta-analysis, we included randomized-controlled trials comparing the effect of DEX vs normal saline (NS) or other anesthetic drugs on POD incidence in elderly (either ≥ 60 or ≥ 65 yr old) patients undergoing non-cardiac surgery. We performed subgroup analyses of the DEX dosing strategy (starting time, dose, and duration of administration, with or without loading dose) and the strategy of various control drugs. A random-effects model was used for all analyses. We included 11 studies involving 2,890 patients in our meta-analysis. The pooled results of these studies revealed that DEX significantly reduced the incidence of POD (relative risk [RR], 0.47; 95% confidence interval [CI], 0.38 to 0.58; P < 0.001) compared with the control group. Meanwhile, the incidences of hypotension (RR, 1.20; 95% CI, 1.04 to 1.39; P = 0.01) and bradycardia (RR, 1.33; 95% CI, 1.08 to 1.63; P = 0.007) were increased in the DEX group. Subgroup analyses revealed a decrease in POD incidence when DEX was administered intraoperatively (RR, 0.43; 95% CI, 0.33 to 0.57; P < 0.001) and postoperatively (RR, 0.38; 95% CI, 0.27 to 0.54; P < 0.001) with a loading dose (RR, 0.49; 95% CI, 0.36 to 0.69; P < 0.001) compared with NS (RR, 0.49; 95% CI, 0.37 to 0.64; P < 0.001) and other anesthetic drugs (RR, 0.40; 95% CI, 0.26 to 0.60; P < 0.001). There were significant differences in the time to extubation (standardized mean difference, -0.60; 95% CI, -1.17 to -0.03; P = 0.04) and the length of hospital stay (mean difference, -0.50 days; 95% CI, -0.97 to -0.03; P = 0.04). The amount of data for the duration of mechanical ventilation and length of intensive care unit stay were insufficient to perform a meta-analysis. Perioperative dexmedetomidine reduces the incidence of POD in elderly patients after non-cardiac surgery, but this comes at the cost of an increased incidence of hypotension and bradycardia.

Gender differences in career satisfaction, moral distress, and incivility: a national, cross-sectional survey of Canadian critical care physicians

Abstract: In a national cross-sectional survey, we aimed to i) characterize work profile, workload, and income, ii) evaluate work satisfaction, work-life integration, burnout, incivility, mentorship, and promotion, iii) gauge future physician resource requirements, and iv) assess for differences by gender and specialty (adult vs pediatric). We developed, tested, and administered an electronic questionnaire. We analyzed 265 fully and 18 partially completed questionnaires. Respondents were predominantly men (192; 72.5%) and adult intensivists (229; 87.7%). Most intensivists (226/272; 83.1%) were somewhat satisfied or strongly satisfied with their career. Over one third of respondents felt that their daily intensive care unit (ICU) clinical work (113/270; 41.9%), yearly non-ICU clinical work (86/248; 34.7%), administrative work (101/264; 38.3%), and in-house call coverage (78/198; 39.4%) were somewhat high or very high. Nearly half (129/273; 47.3%) felt that their work schedule did not leave enough time for personal/family life. Twenty-seven percent (74/272) of respondents were experiencing at least one symptom of burnout when surveyed and 171/272 (63%) experienced burnout symptoms more than once a month. Ten percent planned to retire in the next five years and 17-20% retired each five-year interval thereafter. Compared with men, women felt that their work schedule left significantly less time for personal/family life (χ2 [4] = 11.36, P < 0.05, odds ratio [OR] = 0.55), experienced more frequent and severe burnout symptoms (F [1,120.91] = 8.04, P < 0.01, OR = 2.0; F [1,112.80] = 4.91, P < 0.05, OR = 1.9), and more incivility in their division (χ2 [1] = 13.73, P < 0.001, OR = 2.8), hospital (χ2 [1] = 8.11, P < 0.01, OR = 2.2), and university (χ2 [1] = 4.91, P < 0.05, OR = 2.3). Although most intensivists were satisfied with their careers, many were dissatisfied with their workload, experienced work-life integration challenges, and acknowledged burnout symptoms. Women intensivists were significantly less satisfied with their careers, experienced greater work-life integration challenges, more frequent and severe burnout symptoms, and greater incivility.

Cervical erector spinae plane block catheter using a thoracic approach: an alternative to brachial plexus blockade for forequarter amputation.

Abstract: To the Editor, We read with interest the recent report outlining the utilization of an erector spinae plane block (ESPB) for chronic shoulder pain. The reporting of clinical outcomes and the identification of contrast spread to the cervical spine nerve roots with an ESPB inspired us to use one in managing a patient who required analgesia of the brachial plexus and anterior thoracic distribution. An 81-yr-old female (consenting to this report) with congestive heart failure and a history of breast cancer presented with a painful recurrent radiation-induced sarcoma of the left proximal humerus. The patient initially decided to forego further treatment because of anticipated debilitating pain and instead to seek an end-oflife care. After discussion with the surgical team, the patient elected to undergo forequarter amputation intended to optimize palliative pain control, but also had a reasonable possibility for a cure. In the preoperative area, we placed a left ultrasound-guided ESPB catheter (Flexblock, Arrow, Teleflex , Morrisville, NC, USA) using an in-plane approach at the T5 transverse process. After saline hydrodissection of the fascial plane deep to the erector spinae muscle, the catheter was threaded 10 cm past the cephalad-oriented needle tip into the space. We injected 10 mL 0.5% ropivacaine through the catheter with complete relief of her shoulder pain 30 min prior to the induction of general anesthesia. Her complex five-hour surgery included removal of the left arm, scapula and clavicle. During the procedure, the catheter tip could be palpated by the surgeon at approximately the C5 and C6 level. Intraoperatively, the patient received ketamine 20 mg, methadone 5 mg, and fentanyl 250 lg. At the end of surgery, the patient was extubated and transferred to the intensive care unit. She reported a pain score of 0 and the ESPB catheter was started with a continuous ropivacaine infusion 0.2% at 5 mL hr with a 5-mL demand every 30 min. On postoperative day (POD) 1, she was in good spirits and tolerated a full diet without any pain. She was transferred later that day to an acute care bed, started on oral oxycodone 5 mg (only as needed), and continued her ESPB catheter infusion. In the first 48 hr, the patient only received bolused ESPB local anesthetic for breakthrough pain and did not require any oxycodone. On POD 3, the infusion was then switched to an automatic 5 mL bolus every hour with a further 5 mL demand bolus every 30 min for breakthrough pain as well as a regularly scheduled oxycodone 5 mg dose every eight hours. On POD 4, the ESPB catheter was removed and the patient’s pain remained well controlled with oxycodone. The patient was discharged on POD 5. During a follow-up visit a month later, she stated that she has been feeling ‘‘optimistic’’ and had well-controlled pain using only acetaminophen and gabapentin. She has had no evidence of local recurrence or metastasis. This novel description of a cervical ESPB catheter being advanced into a cervical location from the thoracic region supports the utilization of ESPB as an alternative to the brachial plexus catheter for complex upper extremity procedures. This case also illustrates the impact of a regional analgesia-based regimen as an important B. C. H. Tsui, MD, MSc (&) T. J. Caruso, MD J. L. Horn, MD Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, USA e-mail: bantsui@stanford.edu

A national survey on attitudes and barriers on recycling and environmental sustainability efforts among Canadian anesthesiologists: an opportunity for knowledge translation.

Abstract: Anesthesia-related activities produce 25% of all operating room (OR) waste and contribute to environmental pollution and climate change. The aim of this study was to document Canadian anesthesiologists’ current practice, attitudes towards, and perceived barriers regarding recycling of OR waste and environmental sustainability efforts. With Research Ethics Board approval, members of the Canadian Anesthesiologists’ Society (CAS) completed an online survey consisting of 25 questions assessing current environmentally sustainable practices in anesthesiology and gaps, barriers, and interest in gaining further knowledge on this topic. Four hundred and twenty-six of 2,695 (16%) CAS members responded to the questionnaire. Despite a willingness to recycle at work among most anesthesiologists (393/403, 97.5%), only 122/403 (30.2%) did so. Other sustainability efforts in Canadian ORs included donating unused medical equipment and supplies to medical missions (198/400, 49.5%) and evening shut-off of anesthesia machines and other OR equipment (185/400, 46.3%). Reported barriers to recycling in the OR included a lack of support from hospital/OR leadership (254/400, 63.5%) and inadequate information/education (251/400, 62.8%). Only 122/389 (31.4%) of respondents were aware of any efforts to expand sustainability programs at their institutions but 273/395 (69.1%) of respondents indicated an interest in obtaining further education on the topic. Canadian anesthesiologists appear ready to incorporate environmental sustainability in their practice but indicate that significant barriers exist. Our study highlights the need for further educational programs and implementation strategies.

Effects of neuromuscular block reversal with sugammadex versus neostigmine on postoperative respiratory outcomes after major abdominal surgery: a randomized-controlled trial

Abstract: Postoperative pulmonary complications may be better reduced by reversal of neuromuscular block with sugammadex than by reversal with neostigmine because the incidence of residual block after sugammadex application is lower and diaphragm function is less impaired than after neostigmine administration. The aim of the study was to compare the effect of reversal of neuromuscular block with sugammadex or neostigmine on lung function after major abdominal surgery. One hundred and thirty adults scheduled for major abdominal surgery under combined general and epidural anesthesia were randomly allocated to receive 40 µg of neostigmine or 4 mg·kg−1 of sugammadex to reverse neuromuscular block. Two blinded researchers performed spirometry and lung ultrasound before the surgery, as well as 1 hr and 24 hr postoperatively. Differences in mean changes from baseline were analyzed with repeated measures analysis of variance. Forced vital capacity (FVC) loss one hour after surgery was the main outcome. Secondary outcomes were differences in rate and size of atelectasis one hour and 24 hr after surgery. One hundred twenty-six patients were included in the main analysis. In the neostigmine group (n = 64), mean (95% confidence interval [95% CI]) reduction in FVC after one hour was 0.5 (0.4 to 0.6) L. In the sugammadex group (n = 62), the mean (95% CI) reduction in FVC during the first hour was 0.5 (95% CI, 0.3 to 0.6) L. Thirty-nine percent of patients in the neostigmine group and 29% in the sugammadex group had visible atelectasis. Median [interquartile range (IQR)] atelectasis area was 9.7 [4.7–13.1] cm2 and 6.8 [3.6–12.5] cm2, respectively. We found no differences in pulmonary function in patients reversed with sugammadex or neostigmine in a high-risk population. EudraCT 2014-005156-26; registered 27 May, 2015.

The MacGyver bias and attraction of homemade devices in healthcare.

Abstract: Angus ‘‘Mac’’ MacGyver is arguably one of the most famous fictional characters in modern pop culture. In the original television series (that aired from 1985 to 1992), MacGyver routinely overcame seemingly insoluble problems under time pressure with nothing more than readily available items (e.g., a Swiss Army knife, paper clip, and a chewing gum wrapper), common sense, and scientific acumen. This think-on-your-feet approach has held such a decades-long widespread appeal that ‘‘MacGyver’’ has become part of the modern vernacular, including its entry as a verb into the Oxford English Dictionary: ‘‘To make or repair (an object) in an improvised or inventive manner, making use of whatever items are at hand.’’ There are many healthcare-related examples of ‘‘MacGyvering’’ whereby immediately available equipment is combined or fashioned (in whole or in part) to substitute for equipment that is either unavailable or non-functional. Despite the potential positive aspects to MacGyvering equipment, we would like to suggest that patient-care could still be advanced by conscious understanding of the potential negative aspects as well. Indeed, we would like to propose the term ‘‘MacGyver bias’’ to describe the inherent attraction of our own personal improvised (MacGyvered) devices, with the tendency to hold them in high regard despite the relative absence of evidence for their efficacy. Regardless of geographic location, profession, or specialty, healthcare providers appear to be aficionados of MacGyvered equipment, and workarounds in general. If ‘‘necessity is the mother of invention’’, healthcare may be the birthplace of workarounds. Individuals that write procedures or design equipment are often divorced from the reality of implementing it within the context that it is designed to be used in. Even when testing of equipment and procedures occurs before full clinical introduction, it often occurs in a laboratory setting or under ideal circumstances, and not in clinical, naturalistic settings. Consequently, clinicians are often faced with the need to find new ways to perform the work that are more efficient and better attuned to their work context.

Ultrasound assessment of the inferior vena cava for fluid responsiveness: easy, fun, but unlikely to be helpful.

Abstract: 1) Intravenous fluids are, appropriately, the mainstay of early resuscitation because of their availability, low cost, ease of administration, and potential to improve oxygen delivery; 2) After the very initial stages of resuscitation, critically ill patients consistently have a near 50% probability of being in an FR state, indicating that clinicians are typically operating in a zone of perfect uncertainty; 3) Inadequate fluid administration is generally felt to be harmful; 4) Overzealous fluid administration is associated with increased mortality.

Post-traumatic stress in the postoperative period: current status and future directions

Abstract: This narrative review summarizes the current literature on postoperative traumatic stress, namely post-traumatic stress disorder (PTSD), including defining features, epidemiology, identification of patient and perioperative risk factors, assessment tools, intervention recommendations, and future directions. Postoperative traumatic stress occurs in approximately 20% of patients following surgery, with additionally elevated rates in specific surgical groups. Potential risk factors include the perceived uncontrollable nature of high-risk surgery, psychiatric history, intraoperative awareness, dissociation, surgical complications, medication administration, delirium, and pain. PTSD after surgery may manifest in ways that are distinct from traditional conceptualizations of PTSD. Identification of perioperative risk factors and stress symptoms in the early postoperative period may provide opportunities for intervention. Research on postoperative traumatic stress, including PTSD, is in its infancy. Current evidence shows elevated incidence rates of postoperative traumatic stress, which can worsen overall physical and mental health outcomes. Future research on assessment, prevention, and treatment is warranted.

Representation of female authors in the Canadian Journal of Anesthesia: a retrospective analysis of articles between 1954 and 2017.

Abstract: Females remain under-represented in academic anesthesiology. Our objectives were to investigate gender differences over time in the first and last authors of published articles as well as corresponding citation rates in the Canadian Journal of Anesthesia (CJA). We conducted a cross-sectional, retrospective analysis of first and last authors’ gender from editorials and original articles published in the CJA in a sample of one calendar year of each decade between 1954 to 2017. We analyzed the relationships between author gender, year of publication, article type, and number of citations. Out of 639 articles identified, 542 (85%) were original investigations and 97 (15%) were editorials. Where gender could be confidently identified, the majority (461/571, 81%) of first authors were male. Although there was an increase in the proportion of female first authors over time, this increase was outpaced by the overall increase in female anesthesiologists in Canada. Original articles received more citations and were more likely to have a female first author than editorial articles were. An original article with a female first author resulted in 0.34 (95% confidence interval, 0.28 to 0.39; P < 0.001) more citations per article than a male first author when adjusting for year of publication. Our study shows that, despite a slow increase over time, female authors are under-represented relative to male authors in the CJA and relative to the changing demographics of anesthesiologists in Canada. The reasons for this disparity are multifactorial and further research is needed to identify effective solutions.

Representation of women on the editorial board of the Canadian Journal of Anesthesia: a retrospective analysis from 1954 to 2018.

Abstract: To the Editor, Editorial board membership is prestigious in academic medicine. The National Academy of Sciences and Institute of Medicine has called for ‘‘reasonable representation of women on editorial boards and in other...leadership positions.’’ Although women represent an increasing proportion of anesthesiologists in Canada, women remain poorly represented in senior leadership positions. We compared the proportion of women on the Canadian Journal of Anesthesia (CJA) editorial board with the proportion of women anesthesiologists in Canada over time. We conducted a retrospective analysis of the gender of the CJA editorial board members since inception (1954) to 2018. Ethical approval was not required as we included publicly available data. We assigned gender as previously described. Editorial board membership was determined by reviewing the journal mastheads of each year. We included the editor-in-chief, deputy editor-in-chief, associate editor(s), statistical editor(s), French language editor, continuing professional development editor, board members, and guest editors. We assigned a ‘‘memberposition’’ to each person on the board in each year. The concurrent proportion of women anesthesiologists in Canada was determined from Canadian Medical Association data. We identified the editorial board in all years except 1983 and 1992 (editorial board not listed), and 2000 (print copy missing). We identified 985 member positions (i.e., members multiplied by the length of their corresponding term in years) and assigned a gender to all but 26 member positions (four individuals), leaving 959 member positions for analysis. A total of 146 people made up 985 member positions of the CJA editorial board: 10% were (14/145) women and 88% (127/145) were men. Women comprised 6% (58/959) of member positions since 1954 (eTable, available as Electronic Supplementary Material). Members spent a median [interquartile range] of 6 [4–9] years on the editorial board, with men spending more time than women (7 [4–9] vs 3 [2–6] years). Since the first woman joined the board in 1996, women accounted for 11% (58/517) of member positions, ranging from a low of 0% (0/27) in 2014 to a high of 19% (5/27) in 2017 (Figure). Women made up 2% (1/58) of deputy/associate editor positions and 6% (6/ 108) of international member positions. The proportion of practicing anesthesiologists in Canada that were women increased from 20% in 1994 to 33% in 2018. The percentage of women anesthesiologists in Canada and Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12630-019-01378-9) contains supplementary material, which is available to authorized users.

Preoperative intravenous dexamethasone prevents tracheal intubation-related sore throat in adult surgical patients: a systematic review and meta-analysis

Abstract: Postoperative sore throat related to tracheal intubation negatively affects patient recovery and satisfaction. Previous reviews suggested that intravenous dexamethasone diminishes postoperative sore throat. Nevertheless, they comprised a small number of studies with inconsistencies in outcome reporting. We performed a systematic review and meta-analysis to assess the efficacy and safety of preoperative intravenous dexamethasone in preventing postoperative sore throat in adult patients. We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to August 24, 2018. We included randomized-controlled trials that assessed the efficacy and safety of intravenous dexamethasone in adult surgical patients who required general anesthesia and endotracheal intubation. Our primary outcomes were the incidence and severity of sore throat at 24 hr after surgery/extubation and adverse events. We pooled the data using a random-effects model. We conducted a trial sequential analysis (TSA) on the incidence of sore throat. We included 15 randomized-controlled trials involving 1,849 patients. In comparison with non-analgesic methods, intravenous dexamethasone was associated with a reduced incidence (risk ratio, 0.62; 95% confidence interval [CI], 0.51 to 0.75) and severity (standardized mean difference, − 1.06; 95% CI, − 1.80 to − 0.33) of postoperative sore throat. Serious adverse events were not associated with intravenous dexamethasone administration in the four studies where this was assessed. The TSA indicated that the evidence regarding the incidence of postoperative sore throat is adequate. Our study indicates that preoperative intravenous administration of dexamethasone alleviates postoperative sore throat more effectively than non-analgesic methods. PROSPERO (CRD42018086697); registered 29 January, 2018.

Making a case for national surgery, obstetric, and anesthesia plans.

Abstract: The United Nations’ 17 sustainable development goals (SDGs) target a wide range of human conditions worldwide, including poverty, equity, development, gender, health, and prosperity. Annually, 16.9 million lives are lost because of surgically amenable conditions, $12.3 trillion of economic productivity will be lost between 2015 and 2030 because of diseases related to surgery, anesthesia, and obstetric (SOA), and 81 million people each year face catastrophic expenditure seeking surgical care. Given that emergency and essential surgery and anesthesia care became part of universal health coverage (UHC) in 2015, and SOA care directly underpins six of the 17 SDGs, a massive movement in global public health is needed to meet the UHC and SDG targets. Efforts must address the entire surgical system, from the community level right through to complex tertiary referral care deploying a trans-professional strategy across all domains of the health system. The human rights and economic arguments for investment in SOA care are clear; there is now a mandate to act.

Potential organ donor identification and system accountability: expert guidance from a Canadian consensus conference.

Abstract: Deceased donation rates in Canada remain below the predicted potential and lag behind leading countries. Missing a potential donor leads to preventable death and disability of transplant candidates and increased healthcare costs. Stakeholders were invited to a national consensus conference on improving deceased organ donor identification and referral (IDR 2) donor IDR 3) enhancing accountability: gaps and solutions; and 4) enhancing accountability: quality/safety organizations. Thirty-seven consensus statements were generated. At the healthcare professional (HCP) level, key statements include: 1) donation be consistently addressed as part of end-of-life care but only after a decision to withdraw life-sustaining treatment; 2) HCP know how and when to identify and refer potential donors; and 3) transplant candidates be informed of local allocation guidelines and performance. At the healthcare system level, key statements include: 1) national adoption of clinical criteria to trigger IDR 2) dedicated resources to match donation activities, including transfer of a potential donor; 3) performance measurement through death audits; 4) reporting and investigation of missed donation opportunities (MDO); 5) recognition of top performers; and 6) missed donor ID&R be considered a preventable and critical safety incident. Our consensus statements establish HCP and healthcare system responsibilities regarding potential organ donor ID&R and include the tracking, reviewing and elimination of MDO through system-wide death audits. Once implemented, these consensus statements will help honour patients’ wishes to donate, improve service to potential transplant recipients, and support HCPs in fulfilling their ethical and legal responsibilitites. Next steps include implementation, assessment of their impact on donation rates, and investigation of new evidence-based targets for system improvement.

Topical application of magnesium to prevent intubation-related sore throat in adult surgical patients: a systematic review and meta-analysis.

Abstract: Postoperative sore throat negatively affects patient satisfaction and recovery. We conducted a systematic review and meta-analysis to examine the efficacy of preoperative topical administration of magnesium sulfate in preventing postoperative sore throat in adult patients. We searched Medline, EMBASE, China National Knowledge Infrastructure, and the Cochrane Central Register of Controlled Trials from inception to 6 October, 2018. We included randomized-controlled trials that assessed the efficacy and safety of topical application of magnesium preoperatively in adult patients who underwent endotracheal intubation for general anesthesia. We then pooled the data using a random-effects model and conducted a trial sequential analysis on the incidence of sore throat. Our primary outcome was the incidence of sore throat at 24 hr after surgery/extubation. Our secondary outcomes included the severity of sore throat at 24 hr after surgery/extubation and adverse events. Eleven randomized-controlled trials involving 1,096 patients were included in this study. Topical application of magnesium was associated with reduced incidence of postoperative sore throat (risk ratio, 0.31; 95% confidence interval [CI], 0.21 to 0.45) as well as reduced severity of postoperative sore throat (standardized mean difference, − 2.66; 95% CI, − 3.89 to − 1.43). Three studies reported that significant adverse events were not associated with topical magnesium. The trial sequential analysis suggested that there is adequate evidence supporting the efficacy of topical magnesium in preventing postoperative sore throat. Our study suggests that preoperative topical magnesium can effectively prevent postoperative sore throat. PROSPERO (CRD42018110019); registered 26 September, 2018.

Canadian Pediatric Anesthesia Society statement on clear fluid fasting for elective pediatric anesthesia.

Abstract: To the Editor, The Canadian Pediatric Anesthesia Society (CPAS) Fasting Guidelines Working Group was tasked by the CPAS board of directors to review contemporary fasting guidelines and the relevant perioperative fasting literature. A review of the literature by our group concluded that the current Canadian Anesthesiologists’ Society’s (CAS) fasting guidelines (that recommend a minimum two hours of clear fluid fasting prior to elective procedures) are similar to most fasting guidelines published by other anesthesiology Societies. In addition, we found that the scientific basis for the CAS fasting guidelines is largely rooted in expert opinion with little compelling evidence to support improved outcomes in pediatric patients by following these (or other similar anesthesiology Society’s) fasting guidelines. Furthermore, two recent reports involving large numbers of children failed to show an increase in adverse events when fasting times for clear fluids were shorter than the CAS guidelines recommend. We also found reports of deleterious effects of prolonged fasting (i.e., those in accordance with the CAS fasting guidelines), including patient distress, increased hemodynamic instability, and ketoacidiosis. Accordingly, the CPAS supports (in a statement ratified by the membership at its 2018 annual meeting) fasting guidelines for pediatric patients as follows: Pediatric patients should be encouraged and allowed to ingest clear fluids up to one hour before elective anesthesia or sedation. The CPAS Fasting Guidelines Working Group has also agreed to support the ongoing review and generation of comprehensive fasting guidelines. Nevertheless, until further evidence becomes available, and is reviewed and discussed, the decision was made to alter fasting guidelines pertaining to clear fluids only. A similar fasting guideline is now supported (in jointly published statements by other pediatric anesthesia societies including the Association of Paediatric Anaesthetists of Great Britain and Ireland, The European Society of Pediatric Anesthetists, and L’Association Des Anesthésistes-Réanimateurs Pédiatriques d’Expression Française, who similarly endorsed the guidelines of the Society for Paediatric Anaesthesia in New Zealand and Australia. We recommend that anesthesia groups caring for pediatric patients review their own institutional fasting guidelines and develop policies and provide education which encourages clear fluid intake closer to the time of anesthesia or sedation.

Intravenous lidocaine in the management of chronic peripheral neuropathic pain: a randomized-controlled trial.

Abstract: Neuropathic pain, resulting from injury to the peripheral or central nervous system, is due to upregulation of aberrant sodium channels with neuronal hyperexcitability. Lidocaine blocks these channels and several studies show that intravenous (IV) lidocaine infusion provides significant relief in patients with chronic peripheral neuropathic pain in the short term (for up to six hours). Our objective was to determine if IV lidocaine provides significant pain relief and overall improvement in quality of life in the longer term (for up to four weeks). This single site randomized double-blind, crossover trial compared IV lidocaine infusion (5 mg·kg−1) with active placebo infusion containing diphenhydramine (50 mg) in patients with chronic neuropathic pain of peripheral nerve origin of at least six months duration. The primary outcome was average pain intensity reduction from IV lidocaine relative to placebo at four weeks post-infusion. Secondary outcome measures included parameters of physical function, mood, and overall quality of life. We enrolled 34 subjects in this trial—mostly with painful diabetic neuropathy and post-herpetic neuralgia. There were no significant differences between IV lidocaine and placebo infusions at any time point involving any of the outcome measures. Mean (standard deviation) pain intensity at week 4 for the placebo and lidocaine groups were not different [6.58 (1.97) vs 6.78 (1.56), respectively; between-group difference, 0.17; 95% confidence interval, − 0.50 to 0.84]. We found no significant long-term analgesic or quality of life benefit from IV lidocaine relative to control infusion for chronic peripheral neuropathic pain. clinicaltrials.gov (NCT01669967); registered 22 June, 2012.