Canadian Journal of Anesthesia-Journal Canadien D Anesthesie最新文献

Purpose: Ehlers-Danlos syndromes (EDS) are a group of connective tissue disorders associated with an increased risk of bleeding. We examined the association between point-of-care (POC) testing parameters with bleeding history in a cohort cared for at the GoodHope EDS Clinic at Toronto General Hospital.

Methods: We conducted an exploratory cross-sectional study at the Toronto General Hospital GoodHope EDS Clinic, recruiting adult patients with a diagnosis of EDS from 27 April 2022 to 7 October 2024. Patients provided samples for rotational thromboelastometry (ROTEM) and functional platelet testing (PlateletWorks), and were administered the International Society on Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH-BAT) to calculate the Bleeding Severity Score (BSS). The association between the BSS and POC parameters was examined using descriptive statistics and Spearman correlation analysis.

Results: We recruited 17 patients (hypermobile subtype, n = 10; classical subtype, n = 7). Clinically significant bleeding (BSS ≥ 4 in males; ≥ 6 in females) was reported in the majority (classical group, 86%; hypermobile group, 90%). Nine (53%) patients had major surgery or trauma at a median age of 23 (range, 8-39) yr. There were no significant abnormalities detected using ROTEM. Lower functional platelet percentages were observed in the hypermobile subgroup, with no association with BSS.

Conclusions: Point-of-care functional platelet testing using aggregation in response to an exogenous collagen agonist may detect inherent platelet dysfunction in patients with hypermobile subtype. We did not detect any ROTEM parameter abnormalities that were associated with elevated BSS scores. This supports a multifactorial etiology of bleeding in this patient population.

Purpose: Cardiac complications after noncardiac surgery remain a leading source of postoperative morbidity and mortality. In 2016, the Canadian Cardiovascular Society (CCS) published guidelines that outlined an approach to perioperative cardiac risk assessment for noncardiac surgery, integrating biomarkers. We sought to evaluate the adherence to these guidelines at McGill University Health Centre, a quaternary care hospital in Montreal, QC, Canada.

Methods: We conducted a historical cohort study of all patients undergoing elective noncardiac surgery requiring overnight stay between January 2018 and December 2019. The primary outcome was adherence to preoperative B-type natriuretic peptide (BNP) measurement. Secondary outcomes included adherence to postoperative troponin and electrocardiogram (ECG) acquisition, and 30-day postoperative outcomes.

Results: Among our cohort of 3,623 patients, BNP measurement adherence was 52.4%. Troponin and ECG acquisition adherence was 34.6% and 30.5%, respectively. Patients with an elevated preoperative BNP had higher incidences of 30-day myocardial injury after noncardiac surgery (20.2% vs 4.3%; P < 0.001), myocardial infarction (5.2% vs 0.5%; P < 0.001), mortality (2.5% vs 0.6%; P < 0.001), and to a lesser extent, cardiac arrest and heart failure decompensation. Patients with elevated postoperative troponin levels had higher incidences of 30-day myocardial infarction (20.7% vs 0.0%; P < 0.001), mortality (7.8% vs 0.6%; P < 0.001), and to a lesser extent, cardiac arrest and heart failure decompensation. Elevated BNP and troponin levels were associated with higher physician follow-up rates.

Conclusions: About half of the patients undergoing noncardiac surgery in our cohort underwent BNP screening as recommended by CCS guidelines; troponin and ECG acquisition adherence was even lower. While postoperative cardiac ischemia is associated with increased 30-day morbidity and mortality, more studies exploring physician risk stratification practice and the impact of increased testing on long-term outcomes are needed.

Purpose: Noninvasive positive pressure ventilation (NIV) is a common intervention used to treat acute respiratory failure. Unfortunately, many patients find NIV intolerable, ultimately leading to NIV failure, and the need for escalation to intubation and invasive mechanical ventilation (IMV). Hypothetically, sedation may treat NIV intolerance, thereby preventing the need for IMV. We hypothesized that there may be variability in practice regarding the use of sedation to treat NIV intolerance. Our primary aim was to assess if sedatives are used during NIV, and if so, which agents.

Methods: We created an 18-question survey that addressed demographics, the use of sedatives during NIV, the use of dexmedetomidine specifically, and attitudes and beliefs towards sedative use during NIV. The Hamilton Integrated Research Ethics Board (Hamilton, ON, Canada) approved the survey for global distribution. We used REDCap™ to electronically disseminate the survey in four countries (Australia, Canada, New Zealand, and Saudi Arabia).

Results: We received 140 responses from active practicing adult intensivists for an approximate response rate of 8%. Most intensivists (88%) reported that they would not administer a sedative to prevent NIV intolerance when a patient is not agitated. Overall, 44% of intensivists rarely or never give a sedative to treat NIV intolerance, 18% prescribe a sedative half the time, and 38% usually or always prescribe a sedative to improve NIV intolerance.

Conclusions: This international survey showed variability and equipoise on beliefs and attitudes regarding the use of sedatives to treat NIV intolerance. This must be considered in the context of a low response rate and may not represent the whole spectrum of opinions. Nevertheless, our findings likely justify the need for comprehensive research to outline the potential benefit and harm of using sedation in critically ill patients receiving NIV who are intolerant.

Purpose: Fibrinogen is widely used in cardiac surgery. Still, reported associations between plasma fibrinogen level and chest tube drainage are weak. The results of trials on fibrinogen supplementation are contradictory. We aimed to investigate how the plasma fibrinogen level relates to severe bleeding and resternotomy for bleeding in patients undergoing on-pump cardiac surgery.

Methods: We conducted an observational post hoc study of 1,386 patients undergoing on-pump cardiac surgery enrolled in the Albumin in Cardiac Surgery (ALBICS) trial. We assessed severe bleeding with the Universal Definition of Perioperative Bleeding classification (UDPB), categorized as "UDPB-low" (classes 0-2) and "UDPB-high" (classes 3-4) and as resternotomy. We measured plasma fibrinogen levels preoperatively and 30 min after protamine administration ("post-cardiopulmonary bypass [CPB]").

Results: The incidences of UDPB-high and resternotomy were 8.1% (112/1,386) and 3.6% (50/1,386). No patient with preoperative a fibrinogen level > 4.7 g·L^-1 (90/1,386; 6.5%) had UDPB-high or resternotomy. After adjustment for hemostatic laboratory values, preoperative fibrinogen predicted UDPB-high (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.60 to 0.98; per standard deviation [SD] [0.9 g·L^-1]) and resternotomy (OR, 0.65; 95% CI, 0.43 to 0.98; per SD [0.9 g·L^-1]). No patient with a post-CPB fibrinogen level > 3.1 g·L^-1 (73/1,386; 5.3%) had UDPB-high or required resternotomy. Post-CPB fibrinogen predicted UDPB-high (OR, 0.51; 95% CI, 0.33 to 0.77; per preoperative SD [0.9 g·L^-1]) and resternotomy (OR, 0.31; 95% CI, 0.16 to 0.62; per preoperative SD [0.9 g·L^-1]).

Conclusion: The preoperative fibrinogen level had borderline and the post-CPB fibrinogen level had strong associations with severe bleeding and resternotomy in patients undergoing on-pump cardiac surgery. Further research is required to delineate whether the observed association represents a cause-and-effect relationship.

Purpose: Traumatic dental injury is a common complication of tracheal intubation. We aimed to compare the incidence of dental contact during laryngoscopy between the conventional technique and a novel technique that maintains head extension using the practitioner's left forearm or elbow to support the patient's forehead.

Methods: We conducted a single-centre randomized crossover trial in 84 adult patients who were scheduled for elective surgery requiring tracheal intubation. Each patient underwent both the novel and conventional laryngoscopy techniques in a randomized sequence. The primary outcome was the incidence of dental contact during direct laryngoscopy. Secondary outcomes included blade-to-tooth distance, angle of head extension, percentage of glottic opening (POGO) score, and POGO scores of 4 or 5.

Results: The novel technique significantly reduced the incidence of dental contact compared with the conventional technique (44/84 [52%] vs 65/84 [77%]; P < 0.001). Additionally, the novel technique achieved a longer blade-to-tooth distance (median difference [interquartile range (IQR)], 0 [0-1] mm; P = 0.001), wider angle of head extension (mean difference, 4.5°; 95% confidence interval, 2.1 to 6.8; P < 0.001), higher POGO score (median difference [IQR], 1 [0-1]; P = 0.003), and higher proportion of POGO scores of 4 or 5 (75/84 [89%] vs 61/84 [73%]; P = 0.01).

Conclusions: Compared with conventional laryngoscopy, a novel laryngoscopy technique that maintains head extension using the practitioner's left forearm or elbow to support the patient's forehead significantly reduced the risk of dental contact, increased the blade-to-tooth distance and the angle of head extension, and provided better glottic visualization. This simple, effective approach can reduce the risk of traumatic dental injury and improve safety during direct laryngoscopy.

Study registration: https://www.

Clinicaltrials: gov ( NCT05495880 ); first submitted 8 August 2022.