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

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: Accurate hemodynamic monitoring is essential for personalized care in surgical and intensive care unit (ICU) settings, and radial artery catheters are the gold standard. Nevertheless, central-to-peripheral arterial blood pressure gradients (CPAPGs) have been reported in up to 77% of patients, potentially leading to misinformed clinical decisions. Identifying patients at risk of CPAPGs is crucial to adapt monitoring strategies. We aimed to identify the risk factors contributing to CPAPGs and assess their level of consensus in a systematic review of the literature.

Methods: For this systematic review, we searched MEDLINE/PubMed®, Embase, and Cochrane databases (CENTRAL and Database of Systematic Reviews) from inception to 15 July 2024. Studies on adult patients with simultaneous radial and central arterial pressure monitoring were included. We extracted and analyzed risk factors and assessed the consistency of the literature for each.

Results: From 741 retrieved articles, we included 55 studies (N = 5,598) evaluating the presence of CPAPGs during cardiopulmonary bypass, hepatic transplant, ICU stay, and other settings. Overall, 90 unique potential risk factors were evaluated, with 36 showing a statistically significant association with CPAPGs. Complex procedures and smaller radial artery diameter were the most consistent predictors, with both showing significant association with CPAPGs in the 3 studies evaluating them. Vasopressor usage showed statistical significance in half the studies evaluating it, and demographic factors, potentially associated with smaller radial artery diameter, such as older age, shorter stature, and female sex, were also statistically significant risk factors in some studies.

Conclusions: The present systematic review identified numerous risk factors for CPAPGs. In patients with multiple contributing factors, clinicians should consider using more central arterial cannulation to minimize the risk of inaccurate pressure measurements.

Study registration: PROSPERO ( CRD42024561474 ); first submitted 10 July 2024.

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: Oxygen insufflation through the working channel of flexible optical scopes improves oxygenation and visibility during tracheal intubation but potentially causes barotrauma when not pressure-restricted. Pressure limited to 30-40 cm H₂O improves safety. We sought to conduct an in vitro study to develop a setup that delivers oxygen at desired pressures while maintaining sufficient flows to achieve the documented benefits.

Methods: In the present in vitro study, we constructed a setup with equipment readily available in anesthesia locations, allowing regulation of the pressure at which oxygen is delivered at the distal end of the flexible optical scope. Pressure was regulated via the adjustable pressure-limiting valve and measured by immersion in water. We identified which combinations of set flow from the anesthesia machine and set pressure resulted in distal pressures of 10, 15, 30, and 40 cm H₂O, respectively. We measured the resulting flows.

Results: In flexible scopes with a channel diameter ≥ 2 mm, we obtained clinically relevant flows > 3 L·min^-1 at pressure of 30-40 cm H₂O.

Conclusions: Oxygen insufflation through a flexible optical scope at a targeted distal pressure is possible with ubiquitous anesthesia equipment. Scopes with a suction-/working-channel diameter ≥ 2 mm delivered clinically relevant flows > 3 L·min^-1 at a pressure of 30-40 cm H₂O. Thinner scopes delivered lower flows. These findings will guide future studies and the implementation of this setup in clinical practice.

Purpose: Extreme weather events have been increasing in frequency and intensity globally. Surgical patients may be particularly susceptible to the impact of extreme weather on health outcomes and health care delivery. Our primary objective was to synthesize the available evidence on the association between extreme weather events and postoperative adverse outcomes within thirty days after surgery.

Methods: We performed a systematic review of the literature, searching MEDLINE on PubMed®, Embase, CINAHL, Web of Science, and the Cochrane Database of Systematic Reviews for English-language, full-text articles published prior to 30 May 2024. We included studies that involved surgical patients, exposure to an extreme weather event thirty days pre- or postoperatively, and had one or more adverse outcome within thirty days postoperatively. Screening and extraction were performed by two independent reviewers. We also performed thematic analysis to summarize the impact of extreme weather events on postoperative health care delivery.

Results: Our search identified 8,422 articles, of which 4 studies encompassing 117,804 surgical patients qualified for inclusion (3 on heatwave or extreme heat, and 1 on wildfire smoke). Retrospective studies linked temperatures > 40 °C to increased perioperative complications in trauma patients (1 study), temperatures > 30 °C to increased length of hospital stay in patients older than 60 yr (1 study), and wildfire smoke to respiratory complications in pediatric patients with prematurity or respiratory conditions (1 study). Health delivery domains that were affected were patients (3 studies), care processes and infrastructure (2 studies), and capacity (2 studies). The studies were limited by heterogenous definitions of exposure, confounding, and bias.

Conclusions: Our review revealed major research gaps in the impact of extreme weather events on postoperative outcomes and health care delivery. Existing literature is scant and limited by substantial methodologic issues, and further research is urgently required.

Study registration: PROSPERO ( CRD42023435273 ); first submitted 26 June 2023.

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.