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

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.

Purpose: When a patient requires critical care, the patient and their loved ones embark on a complex and challenging journey through the intensive care unit (ICU). Communication and the development of trusting relationships is an important part of the journey, especially within the paradigm of patient- and family-centred care (PFCC). We sought to expand our understanding of opportunities and threats to communication, trust, and relationship-building throughout the ICU journey from the perspectives of patients, their loved ones, and ICU health care providers.

Methods: We conducted semistructured journey-mapping interviews with 18 participants, including ICU health care providers (n = 10), patients (n = 4), and their loved ones (n = 4). In collaboration with 2 patient partners, we used directed content analysis to identify and understand opportunities and threats.

Results: Using the building blocks of the ICU journey, we identified opportunities and threats that could enhance or disrupt relationships, trust, and communication. Opportunities included actions that the ICU team can take to enhance the journey (e.g., providing predictable, consistent, timely, clear, concise, and digestible information to patients and/or loved ones). Threats included factors inherent to the ICU experience (e.g., patients being unable to communicate, the physical and psychological ICU environment), systemic factors (e.g., limited health human resources), and ineffective communication and/or inaction on the part of the ICU team (e.g., limited consideration for patient and loved ones' decisions, goals, privacy, and/or autonomy).

Conclusions: Opportunities provide actionable steps that can be taken to enhance PFCC, while threats include inaction and factors inherent to the ICU that are more difficult to mitigate.

Purpose: Neutrophil:lymphocyte ratio (NLR), platelet:lymphocyte ratio (PLR), and red cell distribution width (RDW) are values derived from the complete blood count (CBC) that serve as indirect markers of inflammatory states. We aimed to evaluate their ability to predict mortality and intensive care unit (ICU) stay in perioperative adult patients.

Methods: We conducted a single-centre retrospective cohort study of 53,375 perioperative patients (≥ 21 yr) admitted to Singapore General Hospital between 2017 And 2020. We used differentiated blood cell counts acquired at preoperative assessment to obtain NLR, PLR, and RDW. We used multivariable logistic regression models and the area under the receiver operating curve (AUROC) to assess different cut-offs for each of the different inflammatory markers.

Results: The observed 30-day mortality was 0.9% (497/53,375). Among all perioperative patients, 2.2% (1,201/53,375) had an ICU admission > 24 hr. Elevated NLR, PLR, And RDW values were predictive of 30-day mortality and ICU stay > 24 hr on univariable analysis. On multivariable Analysis, the models for 30-day mortality that included a single inflammatory index showed that the index was statistically significant (RDW odds ratio [OR], 2.69; RDW 95% confidence interval [CI], 2.10 to 3.44; model A3 NLR OR, 2.40; model A3 95% CI, 1.89 to 3.06; model A4 PLR OR, 1.91; model A4 95% CI, 1.50 to 2.43). When we included all three inflammatory indices together, RDW (OR, 2.61; 95% CI, 2.04 to 3.33) and NLR (OR, 2.07; 95% CI, 1.58 to 2.72) were statistically significant, and this model had a statistically significantly better AUROC than a model that did not include any inflammatory index.

Conclusion: Elevated inflammatory indices were significantly associated with 30-day mortality and ICU stay of > 24 hr. In multivariable Analysis, they improved the prediction of 30-day mortality risk. Nevertheless, further validation of the use of these indirect inflammatory indices as predictors for the aforementioned outcomes is needed.