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

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.

Purpose: We sought to describe the clinical features and outcomes of adult patients with traumatic brain injury in Ontario.

Methods: We carried out a cohort study of adult patients admitted to an intensive care unit (April 2009 to March 2021) with a first episode of traumatic brain injury. To compare the long-term outcome trajectory after traumatic brain injury, we matched patients with traumatic brain injury 1:1 to patients who survived an intensive care unit admission with multisystem trauma but without traumatic brain injury. We measured in-hospital and long-term all-cause mortality; additional endpoints included 1) new psychiatric diagnosis, 2) epilepsy, 3) venous thromboembolic disease, and 4) sepsis. We estimated hazard ratios (HR) with 95% confidence intervals (CI).

Results: Overall, we included 13,283 adult patients with traumatic brain injury. The mean age was 54 yr; 72% of patients were male. The most common pre-existing comorbidities were hypertension (39%) and cardiovascular disease (19%). Median follow-up was 5 years; 17% of patients with traumatic brain injury died during their initial hospital stay, and 16% died during long-term follow-up. Sepsis after hospital discharge occurred in 14% of patients; additional outcomes included new psychiatric diagnosis (7%), epilepsy (4%), and venous thromboembolic disease (2%). Surviving traumatic brain injury was associated with a higher hazard of epilepsy (HR, 2.42; 95% CI, 1.99 to 2.95); the risk of other outcomes was similar or lower when compared with survivors without traumatic brain injury.

Conclusions: Patients with traumatic brain injury have a high risk of in-hospital death. Those who survive the initial hospitalization are at risk of long-term outcomes including new epilepsy.

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.

Purpose: Ambulatory anesthesia for surgical and interventional procedures is increasingly common. In this Continuing Professional Development module, we present a postoperative risk prediction and care model framework for patients with obstructive sleep apnea (OSA) undergoing ambulatory anesthesia.

Principal findings: Ensuring that patients with OSA are safe to be discharged home on the same day as their procedure requires careful consideration of multiple relevant risk factors. Preoperative patient assessment for the prediction of postprocedural complications is based on OSA status and severity, coexisting cardiorespiratory disease severity, the expected physiologic impacts of anesthesia and surgery, and anticipated opioid requirements. Patients with moderate or severe OSA are more likely to be candidates for ambulatory surgery if the planned procedure is peripheral or superficial, is conducted under local or regional anesthesia, and postoperative pain is predominantly managed with nonopioid analgesia. Patients with OSA undergoing sedation may be at an increased postoperative risk if long-acting sedative medications are used and the monitored recovery time is inadequate. Regardless of the procedure, a comprehensive postanesthesia care unit assessment strategy is essential. Patients must be free of postoperative cardiorespiratory indicators of OSA-related complications, have their pain managed with, at most, low-dose oral opioids, and maintain an adequate oxygen saturation while breathing room air. Patients who fail to meet these standards should not be discharged and should stay in a monitored environment overnight.

Conclusions: Obstructive sleep apnea is associated with increased rates of perioperative complications and an increased risk of morbidity and mortality. Perioperative management guidelines and recommendations have been developed for patients with OSA, but higher-quality evidence-based guidance is needed. The framework presented in this Continuing Professional Development module is a practical guide to the daily dilemma practitioners face in safely managing patients with OSA undergoing ambulatory anesthesia.