Showing papers in "Canadian Journal of Anaesthesia-journal Canadien D Anesthesie in 2020"

Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients

Abstract: A global health emergency has been declared by the World Health Organization as the 2019-nCoV outbreak spreads across the world, with confirmed patients in Canada. Patients infected with 2019-nCoV are at risk for developing respiratory failure and requiring admission to critical care units. While providing optimal treatment for these patients, careful execution of infection control measures is necessary to prevent nosocomial transmission to other patients and to healthcare workers providing care. Although the exact mechanisms of transmission are currently unclear, human-to-human transmission can occur, and the risk of airborne spread during aerosol-generating medical procedures remains a concern in specific circumstances. This paper summarizes important considerations regarding patient screening, environmental controls, personal protective equipment, resuscitation measures (including intubation), and critical care unit operations planning as we prepare for the possibility of new imported cases or local outbreaks of 2019-nCoV. Although understanding of the 2019-nCoV virus is evolving, lessons learned from prior infectious disease challenges such as Severe Acute Respiratory Syndrome will hopefully improve our state of readiness regardless of the number of cases we eventually manage in Canada.

Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore.

Abstract: The coronavirus disease 2019 (COVID-19) outbreak has been designated a public health emergency of international concern. To prepare for a pandemic, hospitals need a strategy to manage their space, staff, and supplies so that optimum care is provided to patients. In addition, infection prevention measures need to be implemented to reduce in-hospital transmission. In the operating room, these preparations involve multiple stakeholders and can present a significant challenge. Here, we describe the outbreak response measures of the anesthetic department staffing the largest (1,700-bed) academic tertiary level acute care hospital in Singapore (Singapore General Hospital) and a smaller regional hospital (Sengkang General Hospital). These include engineering controls such as identification and preparation of an isolation operating room, administrative measures such as modification of workflow and processes, introduction of personal protective equipment for staff, and formulation of clinical guidelines for anesthetic management. Simulation was valuable in evaluating the feasibility of new operating room set-ups or workflow. We also discuss how the hierarchy of controls can be used as a framework to plan the necessary measures during each phase of a pandemic, and review the evidence for the measures taken. These containment measures are necessary to optimize the quality of care provided to COVID-19 patients and to reduce the risk of viral transmission to other patients or healthcare workers.

What we do when a COVID-19 patient needs an operation: operating room preparation and guidance.

Abstract: To the Editor, We read with interest the recent review in the Journal by Wax and Christian on coronavirus disease 2019 (COVID-19). The first case of COVID-19 in Singapore was confirmed on 23 January 2020. In the week of February 13–19, the World Health Organization reported that Singapore had more cases of COVID-19 than any other country outside of mainland China. We wish to share the protocol that we use in our hospital in preparing an operating room (OR) for confirmed or suspected COVID-19 patients coming for surgery. An OR with a negative pressure environment located at a corner of the operating complex, and with a separate access, is designated for all confirmed (or suspected) COVID-19 cases. The OR actually consists of five interconnected rooms, of which only the ante room and anesthesia induction rooms have negative atmospheric pressures. The OR proper, preparation, and scrub rooms all have positive pressures (eFig. 1 in the Electronic Supplementary Material [ESM]). Understanding the airflow within the OR is crucial to minimizing the risk of infection. The same OR and the same anesthesia machine will only be used for COVID-19 cases for the duration of the epidemic. An additional heat and moisture exchanger (HME) filter is placed on the expiratory limb of the circuit. Both HME filters and the soda lime are changed after each case. The anesthetic drug trolley is kept in the induction room. Before the start of each operation, the anesthesiologist puts all the drugs and equipment required for the procedure onto a tray to avoid handling of the drug trolley during the case. Nevertheless, if there is a need for additional drugs, hand hygiene and glove changing are performed before entering the induction room and handling the drug trolley. A fully stocked airway trolley is also placed in the induction room. As far as possible, disposable airway equipment is used. The airway should be secured using the method with the highest chance of first-time success to avoid repeated instrumentation of the airway, including using a video-laryngoscope. Equipment in limited supply, such as bispectral index monitors or infusion pumps, may be requested but need to be thoroughly wiped down after use. The Figure details the roles and responsibilities of each OR team member. Hospital security is responsible for clearing the route from the ward or intensive care unit (ICU) to the OR, including the elevators. The transfer from the ward to the OR will be done by the ward nurses in full personal protective equipment (PPE) including a wellfitting N95 mask, goggles or face shield, splash-resistant gown, and boot covers. For patients coming from the ICU, a dedicated transport ventilator is used. To avoid aerosolization, the gas flow is turned off and the endotracheal tube clamped with forceps during switching Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12630-020-01617-4) contains supplementary material, which is available to authorized users.

Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients

Abstract: To assess the management and safety of epidural or general anesthesia for Cesarean delivery in parturients with coronavirus disease (COVID-19) and their newborns, and to evaluate the standardized procedures for protecting medical staff. We retrospectively reviewed the cases of parturients diagnosed with severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection disease (COVID-19). Their epidemiologic history, chest computed tomography scans, laboratory measurements, and SARS-CoV-2 nucleic acid positivity were evaluated. We also recorded the patients’ demographic and clinical characteristics, anesthesia and surgery-related data, maternal and neonatal complications, as well as the health status of the involved medical staff. The clinical characteristics of 17 pregnant women infected with SARS-CoV-2 were similar to those previously reported in non-pregnant adult patients. All of the 17 patients underwent Cesarean delivery with anesthesia performed according to standardized anesthesia/surgery procedures. Fourteen of the patients underwent continuous epidural anesthesia with 12 experiencing significant intraoperative hypotension. Three patients received general anesthesia with tracheal intubation because emergency surgery was needed. Three of the parturients are still recovering from their Cesarean delivery and are receiving in-hospital treatment for COVID-19. Three neonates were born prematurely. There were no deaths or serious neonatal asphyxia events. All neonatal SARS-CoV-2 nucleic acid tests were negative. No medical staff were infected throughout the patient care period. Both epidural and general anesthesia were safely used for Cesarean delivery in the parturients with COVID-19. Nevertheless, the incidence of hypotension during epidural anesthesia appeared excessive. Proper patient transfer, medical staff access procedures, and effective biosafety precautions are important to protect medical staff from COVID-19.

Practical considerations for performing regional anesthesia: lessons learned from the COVID-19 pandemic

Abstract: Coronavirus disease (COVID-19) was declared a pandemic by the World Health Organization on 11 March 2020 because of its rapid worldwide spread. In the operating room, as part of hospital outbreak response measures, anesthesiologists are required to have heightened precautions and tailor anesthetic practices to individual patients. In particular, by minimizing the many aerosol-generating procedures performed during general anesthesia, anesthesiologists can reduce exposure to patients' respiratory secretions and the risk of perioperative viral transmission to healthcare workers and other patients. To avoid any airway manipulation, regional anesthesia should be considered whenever surgery is planned for a suspect or confirmed COVID-19 patient or any patient who poses an infection risk. Regional anesthesia has benefits of preservation of respiratory function, avoidance of aerosolization and hence viral transmission. This article explores the practical considerations and recommended measures for performing regional anesthesia in this group of patients, focusing on control measures geared towards ensuring patient and staff safety, equipment protection, and infection prevention. By doing so, we hope to address an issue that may have downstream implications in the way we practice infection control in anesthesia, with particular relevance to this new era of emerging infectious diseases and novel pathogens. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not the first, and certainly will not be the last novel virus that will lead to worldwide outbreaks. Having a well thought out regional anesthesia plan to manage these patients in this new normal will ensure the best possible outcome for both the patient and the perioperative management team.

Personal protective equipment (PPE) for both anesthesiologists and other airway managers: principles and practice during the COVID-19 pandemic

Abstract: Healthcare providers are facing a coronavirus disease pandemic. This pandemic may last for many months, stressing the Canadian healthcare system in a way that has not previously been seen. Keeping healthcare providers safe, healthy, and available to work throughout this pandemic is critical. The consistent use of appropriate personal protective equipment (PPE) will help assure its availability and healthcare provider safety. The purpose of this communique is to give both anesthesiologists and other front-line healthcare providers a framework from which to understand the principles and practices surrounding PPE decision-making. We propose three types of PPE including: 1) PPE for droplet and contact precautions, 2) PPE for general airborne, droplet, and contact precautions, and 3) PPE for those performing or assisting with high-risk aerosol-generating medical procedures.

High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission.

Abstract: We conducted two World Health Organization-commissioned reviews to inform use of high-flow nasal cannula (HFNC) in patients with coronavirus disease (COVID-19). We synthesized the evidence regarding efficacy and safety (review 1), as well as risks of droplet dispersion, aerosol generation, and associated transmission (review 2) of viral products. Literature searches were performed in Ovid MEDLINE, Embase, Web of Science, Chinese databases, and medRxiv. Review 1: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy (COT) in critically ill patients with acute hypoxemic respiratory failure. Review 2: we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection transmission associated with HFNC. For both reviews, paired reviewers independently conducted screening, data extraction, and risk of bias assessment. We evaluated certainty of evidence using GRADE methodology. No eligible studies included COVID-19 patients. Review 1: 12 RCTs (n = 1,989 patients) provided low-certainty evidence that HFNC may reduce invasive ventilation (relative risk [RR], 0.85; 95% confidence interval [CI], 0.74 to 0.99) and escalation of oxygen therapy (RR, 0.71; 95% CI, 0.51 to 0.98) in patients with respiratory failure. Results provided no support for differences in mortality (moderate certainty), or in-hospital or intensive care length of stay (moderate and low certainty, respectively). Review 2: four studies evaluating droplet dispersion and three evaluating aerosol generation and dispersion provided very low certainty evidence. Two simulation studies and a crossover study showed mixed findings regarding the effect of HFNC on droplet dispersion. Although two simulation studies reported no associated increase in aerosol dispersion, one reported that higher flow rates were associated with increased regions of aerosol density. High-flow nasal cannula may reduce the need for invasive ventilation and escalation of therapy compared with COT in COVID-19 patients with acute hypoxemic respiratory failure. This benefit must be balanced against the unknown risk of airborne transmission.

Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for COVID-19.

Abstract: Protection of frontline HCPs is paramount. However, PPE is a limited resource and often requires providers to be adaptive and resourceful in a crisis. The inexpensive and simple method of using clear drapes during extubation (and possibly intubation) of COVID-19 patients may be considered by frontline HCPs and infection control specialists as an additional precaution. Modifications of the clear plastics can be adapted for surgical procedures that may be AGMPs.

The impact of high-flow nasal cannula (HFNC) on coughing distance: implications on its use during the novel coronavirus disease outbreak.

Abstract: To the Editor, Novel coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 threatens healthcare resources throughout the world. This is particularly true for the patients who develop moderate to severe respiratory failure and require oxygen supplementation devices such as high-flow nasal cannula (HFNC). The HFNC uses humidification to allow the delivery of up to 100% oxygen at flow rates of up to 60 L min; however, there is a concern this may aerosolize respiratory tract pathogens. The World Health Organization (WHO) released interim guidance on the management of severe respiratory infection when COVID-19 is suspected. Using evidence from several recently published studies, WHO guidance proffers that HFNC do not create wide-spread dispersion of exhaled air and therefore should be associated with low risk of transmission of respiratory viruses. This document also recommends wearing a standard medical face mask if the healthcare worker is within 2 m of the patient and there is a physical bed separation of at least 1 m. We carried out an experiment to simulate a patient coughing while using HFNC to assess the maximum distance of droplet dispersion. Formal ethics approval was waived by the Office of Human Research Protection Programme, National Healthcare Group, Singapore. The authors (n = 5), with no history of lung disease, participated. All gargled 10 mL of diluted red then blue food dye. They were then seated with their mouths approximately 1.30 m from the floor, inhaled to vital capacity, and coughed with an open mouth. Each participant coughed twice and the furthest distance that a visible food dye droplet travelled on the ground was measured. The process was repeated while wearing a wellfitting HFNC (2004F7015 High/Low Blender, Bio-Med USA and Optiflo, Fisher Paykel Healthcare New Zealand) at 60 L min flow. We showed that in these healthy volunteers, coughgenerated droplets spread to a mean (standard deviation) distance of 2.48 (1.03) m at baseline and 2.91 (1.09) m with HFNC. A maximum cough distance of 4.50 m was reported when using HFNC (Table). Hui et al. used a simulator model and a smoke-laser illumination technique to investigate the dispersion of droplets amplified by HFNC. They showed that when HFNC flow rates were increased from 10–60 L min, non-cough exhaled air distances (in the forward direction) increased from 6.5 to 17.2 cm, and up to 62 cm (in the lateral direction). It is uncertain if such short distances are accurate in patients who are coughing. Leung et al. found no evidence of increased surrounding surface contamination when using HFNC in patients with gram negative bacterial pneumonia. Nevertheless, extrapolating findings from patients with bacterial pneumonia to those N.-H. W. Loh, MBBS (&) Y. Tan, MBBS A. Y. H. Tan, MBBS Department of Anaesthesia, National University Hospital, Singapore, Singapore e-mail: will.loh@nus.edu.sg

Patient self-proning with high-flow nasal cannula improves oxygenation in COVID-19 pneumonia.

Abstract: To the Editor, A high-flow nasal cannula (HFNC) is commonly used in the management of hypoxic respiratory failure, and is associated with more ventilator-free days and lower mortality compared with standard oxygen therapy or noninvasive ventilation. Nevertheless, its use in coronavirus disease 2019 (COVID-19) patients is complicated by the increased risk of particle dispersion (especially with coughing), potential depletion of oxygen supplies, and concerns that it is unlikely to change the natural course of viral pneumonia. These factors have resulted in calls to forgo its use in favour of earlier intubation. While these concerns are valid, they may have unintended consequences during the current pandemic. Hospital policies directing earlier intubation of COVID-19 patients will accelerate consumption of intensive care unit (ICU) resources including ventilators, sedative medications, and human resources. Lastly, creating a lower barrier to intubation and ICU admission obscures the true severity of the disease and distorts pandemic modeling. Emerging evidence suggests that COVID-19 patients develop atypical acute respiratory distress syndrome (ARDS) with relatively preserved lung mechanics despite severe hypoxemia due to shunt fraction. It is additionally known that prone positioning can improve oxygenation and reduce shunt fraction. For patients without increased work of breathing, we propose that HFNC can meet the oxygen demands while allowing patients to manage their body position independently through self-proning. Concerns related to additional HFNC-mediated aerosol generation can be mitigated through any or all of the following: a surgical mask placed on the patient to limit particle dispersal, enhanced personal protective equipment for staff, patient cohorting, and negative pressure environments. We recently used this strategy to treat a 68-yr-old COVID-19 patient (who provided written consent for this report). The patient presented with bilateral opacities suggestive of pneumonia that rapidly worsened after two days of admission (Figure A). He was placed in a negative pressure room, HFNC was applied (initially at 60 Lpm and 90% oxygen), and the patient was instructed to self-prone via telephone by lying with his chest down for as long as possible (Figure B). He was also provided with pillows to arrange for his self-comfort and it was explained that this was done to improve his oxygen levels. Total proning time was approximately 16–18 hr each day (including 8–10 hr while asleep at night), and was interrupted for meals and short breaks for physiotherapy. While the patient never complained of severe dyspnea, he did say that he felt better while prone. Proning resulted in cyclical improvements in his oxygenation (Figure C). During his treatment, the patient developed nasal congestion and blood clots in posterior nasal passages that resulted in worsening oxygenation. Despite a shorter proning duration than is typical in ventilated patients, the observed physiologic effects of proning on oxygenation were clearly apparent and reproducible. During his stay, our patient maintained oral nutrition, communicated with his family via cellphone, and participated in self-directed physiotherapy. As the nurse conveyed instructions to the patient by phone and the patient self-proned, the direct nursing and respiratory therapist care were actually less than would be expected for an intubated patient requiring proning. The patient was M. Slessarev, MD (&) J. Cheng, MD M. Ondrejicka, MD R. Arntfield, MD Division of Critical Care Medicine, Department of Medicine, Western University, London, ON, Canada e-mail: marat.slessarev@lhsc.on.ca

Asymptomatic carriage and transmission of SARS-CoV-2: What do we know?

Abstract: Risk to healthcare workers treating asymptomatic patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the operating room depends on multiple factors. This review examines the evidence for asymptomatic or pre-symptomatic carriage of SARS-CoV-2, the risk of transmission from asymptomatic patients, and the specific risks associated with aerosol-generating procedures. Protective measures, such as minimization of aerosols and use of personal protective equipment in the setting of treating asymptomatic patients, are also reviewed. We examined the published literature as well as Societal guidelines. There is evidence that a proportion of those infected with SARS-CoV-2 have detectable viral loads prior to exhibiting symptoms, or without ever developing symptoms. The degree of risk of transmission from asymptomatic patients to healthcare providers will depend on the prevalence of disease in the population, which is difficult to assess without widespread population screening. Aerosol-generating procedures increase the odds of viral transmission from infected symptomatic patients to healthcare providers, but transmission from asymptomatic patients has not been reported. Techniques to minimize aerosolization and appropriate personal protective equipment may help reduce the risk to healthcare workers in the operating room. Some societal guidelines recommend the use of airborne precautions during aerosol-generating procedures on asymptomatic patients during the coronavirus disease pandemic, although evidence supporting this practice is limited. Viral transmission from patients exhibiting no symptoms in the operating room is plausible and efforts to reduce risk to healthcare providers include reducing aerosolization and wearing appropriate personal protective equipment, the feasibility of which will vary based on geographic risk and equipment availability.

Simulation as a tool for assessing and evolving your current personal protective equipment: lessons learned during the coronavirus disease (COVID-19) pandemic.

Abstract: To the Editor, We believe that protection of the well-being of healthcare providers while maintaining a workforce sufficient to respond to the coronavirus disease (COVID19) are fundamental to pandemic planning. In this letter, we describe how our hospital used low-fidelity airway simulation to assess and evolve the personal protective equipment (PPE) used for airway management of patients with COVID-19. We have now had 47 healthcare workers processed through the COVID-19 airway simulation scenario. During the first day of the simulation, we used our facility’s recommended PPE comprising a ‘‘yellow gown’’ (Eden Textile micro fibre isolation gown, Edmonton, AB, Canada), a N95 respirator, a visor integrated into a surgical mask, and non-sterile nitrile gloves (Figure A). When the practitioners changed the simple face mask to allow bagmask ventilation during the induction of anesthesia, a patient cough was simulated. We did this by using Glo Germ powder (Marlatek, Inc., Brockville, ON, Canada), a product designed to identify the simulated spread of microorganisms, which was brushed as powder onto the mannequin (contact) and forcefully expelled from the airway mannequin’s naris using a MAD Nasal intranasal mucosal atomization device (Teleflex, Morrisville, NC, USA) (droplet). Spread of the simulated nasal secretions was visualized with ultraviolet light. This technique revealed that the reusable yellow gowns were permeable to liquid; six out of the six first participants had visible soilage on their scrubs beneath their gowns. During the fifth simulation, an airway assistant wearing a disposable Association for the Advancement of Medical Instrumentation (AAMI) level-3 surgical gown (Sirus sterile nonreinforced surgical gown; Medline, Chicago, IL, USA) showed no contamination of scrubs beneath the gown. It also came to our attention that there was a significant amount of contamination on the practitioner’s neck, on the base of their wrist, as well as on their lower pants and shoes. While skin contamination is not a method of transmission for the severe acute respiratory syndrome coronavirus-2 responsible for causing COVID-19, these areas of soilage increase the risk for self-contamination (e.g., during doffing) via mucous membranes. We approached our institution’s Infection Control and Prevention Group with the findings of these first six participants; they indicated that the supplied yellow gowns lose their permeability protection after 25 washes. We have since upgraded our PPE to disposable surgical gowns or coveralls (Kleenguard A60; Kimberly-Clark, Roswell, GA, USA) of at least an AAMI level-3 protection consistent with US Food and Drug Administration recommendations for moderate to highly invasive procedures. We have also included neck protection in the form of either a coverall, or if a surgical gown is worn, S. L. Lockhart, MD, FRCPC (&) Department of Anesthesiology, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada e-mail: slockhart@providencehealth.bc.ca

A magnetic resonance imaging study of local anesthetic spread in patients receiving an erector spinae plane block

Abstract: Despite the popularity of the erector spinae plane (ESP) block, both the mechanism of the block and the extent of injectate spread is unclear. This study used magnetic resonance imaging (MRI) to evaluate the spread of local anesthetic injectate following ESP blocks in six patients with pain. Six patients received a left-sided ultrasound-guided ESP block at the T10 level. The injectate contained 29.7 mL of 0.25% bupivacaine and 0.3 mL of gadolinium in the first patient, with an additional 5 mL (50 mg) of triamcinolone in the subsequent five patients. Sensory block to pinprick and cold as well as pain score (with 0 indicating no pain and 10 being maximum pain) were assessed 20 and 30 min respectively following the ESP block. MRI was performed one hour after the block. The injectate spread into the intercostal space and neural foramina in all six patients, but the extent of cephalocaudal spread was variable, with a median [interquartile range] spread of 9 [5–11] and 3 [2–6] levels for the intercostal space and neural foramina, respectively. The injectate also spread extensively within the erector spinae muscles. Spread to the epidural space was seen in two patients. Sensory block was achieved in both ventral and dorsal dermatomes in all patients, though the extent was variable. Our study showed that the ESP block injectate consistently spread to the erector spinae muscles, neural foramina, and intercostal space. It was associated with sensory changes and pain relief in the dorsal and ventral thoracic and abdominal walls. Nevertheless, the extent of spread to the neural foramina and intercostal space, and the sensory block itself, was highly variable.

Guidelines to the Practice of Anesthesia - Revised Edition 2020.

Abstract: The Guidelines to the Practice of Anesthesia Revised Edition 2020 (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 2020 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.

Reasons for article retraction in anesthesiology: a comprehensive analysis.

Abstract: Increasing awareness of scientific misconduct has prompted various fields of medicine, including orthopedic surgery, neurosurgery, and dentistry to characterize the reasons for article retraction. The purpose of this review was to evaluate the reasons for and the rate of article retraction in the field of anesthesia within the last 30 years. Based on a reproducible search strategy, two independent reviewers searched MEDLINE, EMBASE, and the Retraction Watch website to identify retracted anesthesiology articles. Extracted data included: author names, year of publication, year of the retracted article, journal name, journal five-year impact factor, research type (clinical, basic science, or review), reason for article retraction, number of citations, and presence of a watermark indicating article retraction. Three hundred and fifty articles were included for data extraction. Reasons for article retraction could be grouped into six broad categories. The most common reason for retraction was fraud (data fabrication or manipulation), which accounted for nearly half (49.4%) of all retractions, followed by lack of appropriate ethical approval (28%). Other reasons for retraction included publication issues (e.g., duplicate publications), plagiarism, and studies with methodologic or other non-fraud data issues. Four authors were associated with most of the retracted articles (59%). The majority (69%) of publications utilized a watermark on the original article to indicate that the article was retracted. Journal Citation Reports journal impact factors ranged from 0.9 to 48.1 (median [interquartile range (IQR)], 3.6 [2.5–4.0]), and the most cited article was referenced 197 times (median [IQR], 13 [5–26]). Most retracted articles (66%) were cited at least once by other journal articles after having been withdrawn. Most retracted articles in anesthesiology literature were retracted because of research misconduct. Limited information is available in the retraction notices, unless explicitly stated, so it is challenging to distinguish between an honest error and research misconduct. Therefore, a standardized reporting process with structured retraction notices is desired.

Chest computed tomography images of early coronavirus disease (COVID-19).

Abstract: Severe acute respiratory syndrome-related coronavirus (SARS-CoV-2) has rapidly spread throughout China and as of 8 March 2020 has spread to over 100 countries with 105,000 confirmed cases of coronavirus-related disease (COVID-19). The high infectivity and mortality of COVID-19 makes this a serious public health threat. Recent studies have confirmed that fever, dry cough, and fatigue are the main manifestations. Some patients have other symptoms, such as nasal congestion, runny nose, sore throat, myalgia, and diarrhea. Seriously-ill patients may develop dyspnea and/or hypoxemia one week after the onset of symptoms, and critically-ill patients can quickly progress to acute respiratory distress syndrome, septic shock, severe metabolic acidosis, coagulopathy, and multiple organ dysfunction syndrome. We report a 27-yr-old pregnant woman at 36 weeks gestation who was admitted to the hospital with fever, dry cough, and fatigue as the main manifestations. Her SARSCoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) test was positive and although she developed

Quadratus lumborum block for postoperative analgesia: a systematic review and meta-analysis.

Abstract: The goal of the present systematic review is to determine the efficacy of the quadratus lumborum block (QLB) in providing postoperative analgesia for abdominal wall and hip surgeries when compared with placebo or other analgesic techniques. Electronic databases (Medline, Embase, Cochrane Central, and Scopus) were searched for keywords and controlled vocabulary terms related to QLB from their inception to November 2019. The included studies compared ultrasound-guided single-injection QLB to placebo and other analgesic techniques in adult patients. Forty-two randomized-controlled trials provided the data for this systematic review. Eight studies were assessed as high risk of bias in at least one domain. The included studies had significant heterogeneity with regard to the type of surgery, comparator groups, and outcomes measured; therefore, a limited quantitative analysis was undertaken for the comparison of QLB vs no block or placebo in patients undergoing Cesarean delivery only. For Cesarean delivery, the QLB reduced the opioid use by 24.1 (95% confidence interval, 17.3 to 30.9) mg oral morphine equivalents in the first postoperative 24 hr compared with no block or placebo with no difference in pain scores at rest. For other surgical procedures, the pain scores and opioid use were lower in the QLB group when compared with placebo or no regional anesthesia technique. When compared with other regional anesthetic techniques, the analgesic benefit of QLB was marginal. Quadratus lumborum block provided analgesic benefits compared with placebo for use in the abdominal wall and hip surgery, with only marginal benefits compared with other regional analgesic techniques. The identified studies used different variants of QLB in many different surgery types. These findings and conclusions, therefore, should be considered preliminary. PROSPERO (CRD42018095965); registered 6 June 2018.

Restrictive fluid management strategies and outcomes in liver transplantation: a systematic review

Abstract: Restrictive fluid management strategies have been proposed to reduce complications in liver transplant recipients. We conducted a systematic review to evaluate the effects of restrictive perioperative fluid management strategies, compared with liberal ones, on postoperative outcomes in adult liver transplant recipients. Our primary outcome was acute kidney injury (AKI). Our secondary outcomes were bleeding, mortality, and other postoperative complications. We searched major databases (CINAHL, EMB Reviews, EMBASE, MEDLINE, and the grey literature) from their inception to 10 July 2018 for randomized-controlled trials (RCTs) and observational studies comparing two fluid management strategies (or observational studies reporting two outcomes with available data on fluid volume received) in adult liver transplant recipients. Study selection, data abstraction, and risk of bias assessment were performed by at least two investigators. Data from RCTs were pooled using risk ratios (RR) and mean differences (MD) with random-effect models. We found seven RCTs and 29 observational studies. Based on RCTs, fluid management strategies did not have any effect on AKI, mortality, or any other postoperative complications. Intraoperative RCTs suggested that a restrictive fluid management strategy reduced pulmonary complications (RR, 0.69; 95% confidence interval [CI], 0.47 to 0.99; n = 283; I2 = 27%), duration of mechanical ventilation (MD, -13.04 hr; 95% CI, -22.2 to -3.88; n = 130; I2 = 0%) and blood loss (MD, -1.14 L; 95% CI, -1.72 to -0.57; n = 151; I2 = 0%). Based on low or very low levels of evidence, we did not find any association between restrictive fluid management strategies and AKI, but we observed possible protective effects of intraoperative restrictive fluid management strategies on other outcomes. PROSPERO (CRD42017054970); registered 18 May, 2017.

A proposed lung ultrasound and phenotypic algorithm for the care of COVID-19 patients with acute respiratory failure

Abstract: Pulmonary complications are the most common clinical manifestations of coronavirus disease (COVID-19). From recent clinical observation, two phenotypes have emerged: a low elastance or L-type and a high elastance or H-type. Clinical presentation, pathophysiology, pulmonary mechanics, radiological and ultrasound findings of these two phenotypes are different. Consequently, the therapeutic approach also varies between the two. We propose a management algorithm that combines the respiratory rate and oxygenation index with bedside lung ultrasound examination and monitoring that could help determine earlier the requirement for intubation and other surveillance of COVID-19 patients with respiratory failure.

Top ten priorities for anesthesia and perioperative research: a report from the Canadian Anesthesia Research Priority Setting Partnership.

Abstract: The purpose of the Canadian Anesthesia Research Priority Setting Partnership (CAR PSP) was to identify a top ten list of shared priorities for research in anesthesia and perioperative care in Canada. We used the methods of the James Lind Alliance to involve patients, caregivers, healthcare professionals, and researchers in determining the research priorities in Canada. In a first survey, participants submitted questions that they want research to answer about anesthesia and perioperative care. We summarized those responses into a longlist of questions. We reviewed the literature to see if any of those questions were already answered. In a second survey, participants chose up to ten questions from the longlist that they thought were most important to be answered with research. From that list, the highest ranking questions were discussed and assigned a final rank at an in-person workshop. A total of 254 participants submitted 574 research suggestions that were then summarized into 49 questions. Those questions were checked against the literature to be sure they were not already adequately addressed, and in a second survey of those 49 questions, participants chose up to 10 that they thought were most important. A total of 233 participants submitted their priorities, which were then used to choose 24 questions for discussion at the final workshop. At the final workshop, 22 participants agreed on a top ten list of priorities. The CAR PSP top ten priorities reflect a wide variety of priorities captured by a broad spectrum of Canadians who receive and provide anesthesia care. The priorities are a tool to initiate and guide patient-oriented research in anesthesia and perioperative care.

Effect of bilateral scalp nerve blocks on postoperative pain and discharge times in patients undergoing supratentorial craniotomy and general anesthesia: a randomized-controlled trial.

Abstract: Post-craniotomy pain is a common clinical issue and its optimal management remains incompletely studied. Utilization of a regional scalp block has the potential advantage of reducing perioperative pain and opioid consumption, thereby facilitating optimal postoperative neurologic assessment. The purpose of this study was to assess the efficacy of regional scalp block on post-craniotomy pain and opioid consumption. We performed a prospective randomized-controlled trial in adults scheduled to undergo elective supratentorial craniotomy under general anesthesia to assess the efficacy of postoperative bilateral scalp block with 0.5% bupivacaine with 1:200,000 epinephrine compared with placebo on postoperative pain and opioid consumption. The primary outcome was the visual analogue scale (VAS) for pain at 24 hr postoperatively. Eighty-nine patients were enrolled (n = 44 in block group; n = 45 in control group). There was no difference in the mean (standard deviation) VAS score at 24 hr postoperatively between the treatment group and the control group [31.2 (21.4) mm vs 23.0 (19.2) mm, respectively; mean difference, 6.6; 95% confidence interval, -2.3, 15.5; P = 0.15]. There was also no significant difference in postoperative opioid consumption. Distribution of individual VAS score and opioid consumption revealed that postoperative pain was highly variable following craniotomy. Time to hospital discharge was not different between treatment and placebo groups. No adverse events associated with scalp block were identified. These data show that bilateral scalp blocks using bupivacaine with epinephrine did not reduce mean postoperative VAS score or overall opioid consumption at 24 hr nor the time-to-discharge from the postanesthesia care unit or from hospital. www.ClinicalTrials.gov, NCT00972790; registered 9 September, 2009.

Understanding burnout and moral distress to build resilience: a qualitative study of an interprofessional intensive care unit team

Abstract: The purpose of this study was to explore personal and organizational factors that contribute to burnout and moral distress in a Canadian academic intensive care unit (ICU) healthcare team. Both of these issues have a significant impact on healthcare providers, their families, and the quality of patient care. These themes will be used to design interventions to build team resilience. This is a qualitative study using focus groups to elicit a better understanding of stakeholder perspectives on burnout and moral distress in the ICU team environment. Thematic analysis of transcripts from focus groups with registered intensive care nurses (RNs), respiratory therapists (RTs), and physicians (MDs) considered causes of burnout and moral distress, its impact, coping strategies, as well as suggestions to build resilience. Six focus groups, each with four to eight participants, were conducted. A total of 35 participants (six MDs, 21 RNs, and eight RTs) represented 43% of the MDs, 18.8% of the RNs, and 20.0% of the RTs. Themes were concordant between the professions and included: 1) organizational issues, 2) exposure to high-intensity situations, and 3) poor team experiences. Participants reported negative impacts on emotional and physical well-being, family dynamics, and patient care. Suggestions to build resilience were categorized into the three main themes: organizational issues, exposure to high intensity situations, and poor team experiences. Intensive care unit team members described their experiences with moral distress and burnout, and suggested ways to build resilience in the workplace. Experiences and suggestions were similar between the interdisciplinary teams.

Environmentally sustainable perioperative medicine: simple strategies for anesthetic practice

Abstract: This continuing professional development module aims to inform anesthesiologists about the magnitude of healthcare-related waste and its contribution to global warming, as well as providing general strategies to improve environmental sustainability in daily anesthesia practice in a Canadian context. Global warming is considered to be the biggest global health threat of the 21st century. Healthcare is not only adversely impacted by but also a significant contributor to global warming and environmental degradation. Healthcare provision produces 4.6% of the total national greenhouse gas emissions in Canada, while healthcare waste has increased unabated in recent years, largely because of increased use of disposable medical supplies. Operating rooms are highly energy-intensive and produce up to 33% of total hospital waste. Increasingly, attention in healthcare is being focused on environmental sustainability by exploring evidence-based approaches to more sustainable delivery of healthcare. Key to environmental sustainability research is the life-cycle assessment methodology, which measures the cradle-to-grave impact of products on various environmental outcomes and empowers purchasing departments to make environmentally conscious decisions. By using the “reduce, reuse, recycle” hierarchy of waste reduction, several easily implementable evidence-based strategies are proposed to reduce the environmental footprint of everyday anesthesia practice. These recommendations focus on informed decisions on volatile anesthetic use, reduced drug waste, limited use of single-use devices, and meticulous waste segregation and recycling strategies. Anesthesiologists have a unique opportunity to be champions of environmental sustainability through evidence-based practices, while simultaneously reaping significant synergistic health, cost, and quality co-benefits.

Corticosteroids for critically ill COVID-19 patients with cytokine release syndrome: a limited case series.

Abstract: To the Editor, Approximately 5% of coronavirus disease (COVID-19) patients will require admission to an intensive care unit (ICU). Among these patients, the most severe cases may be mediated by a late-onset systemic inflammatory response with cytokine dysregulation referred to as cytokine release syndrome (CRS). Clinically, this results in fever, acute respiratory distress syndrome, multiorgan failure, and/or hemodynamic collapse due to distributive shock. Late-onset severe COVID-19 patients may respond to anti-inflammatory therapy without worsening the initial early viral infection. We describe a case series of 15 COVID-19 patients admitted to ICU who received corticosteroids in the context of CRS. Cytokine release syndrome was identified as worsening hypoxemia or vasoplegia with rising C-reactive protein (CRP) or interleukin-6 levels without alternative clinical explanation. The Research Ethics Board at our local site approved this retrospective case series. The characteristics of these patients are provided in the Table. The median [interquartile range (IQR)] age was 72 [62-74] yr (range, 45-75 yr), and nine of the 15 patients (60%) were male. The indications for steroid administration were hypoxic respiratory failure (67%), vasoplegic shock on multiple vasopressors (20%), or both respiratory and cardiovascular failure (20%). Two nonintubated patients received steroids for impending respiratory failure with increasing inflammatory markers concerning for CRS. The median [IQR] day of steroid administration after symptoms onset was 14 [12–15] days. Nine patients (60%) received methylprednisolone, four patients (27%) received hydrocortisone, and two patients (13%) received dexamethasone. The median [IQR] dose of corticosteroids during the first 24 hr in methylprednisolone equivalents was 160 [83-160] mg. In almost all cases, there was a decrease in vasopressor requirement or an improvement in oxygenation after steroid administration. There was an average fall in CRP of 236 mg L with steroid administration (eFig. 1, available as Electronic Supplementary Material [ESM]). An average increase in the arterial partial pressure of oxygen/fraction of inspired oxygen (i.e., P/F) ratio of 44 was detected 24 hr after steroid administration (eFig. 2, available as ESM). Currently, four patients were discharged home, four patients remained in ICU, four patients were transferred to the medical ward, and three patients are deceased. We present a subset of COVID-19 patients who presented with progressive respiratory failure along with progressive inflammatory biomarkers consistent with severe CRS. We found a significant clinical and biochemical association between corticosteroids and improved surrogate outcomes in late-onset CRS associated with COVID-19. Corticosteroids are indicated to treat CRS occurring from immune or chimeric antigen receptor therapy, but its use in weathering the cytokine storm in viral infection remains controversial, particularly if given early. Other coronaviruses have an inverted ‘‘V’’ distribution of viral shedding, peaking ten days after the Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12630-020-01700-w) contains supplementary material, which is available to authorized users.