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

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.

Purpose: The use of a quantitative neuromuscular monitor is strongly recommended by many anesthesiology societies. While most monitors are used at the hand to record responses at the adductor pollicis muscle, this site may be unavailable. We sought to compare simultaneous quantitative neuromuscular measurements obtained at the adductor pollicis (hand) and flexor hallucis brevis (foot) muscles.

Methods: We preoperatively enrolled consenting patients in a prospective cohort study, and their attending anesthesiologists managed intraoperative neuromuscular block at their discretion. The anesthesiologists placed one set of electromyography electrodes over the ulnar nerve/adductor pollicis muscle and another over the posterior tibial nerve/flexor hallucis brevis muscle. During the onset of neuromuscular blockade, simultaneous measurements were obtained every 20 sec until the train-of-four (TOF) count reached 0. At the conclusion of the operation, sugammadex recovery data were recorded every 20 sec until a TOF ratio ≥ 0.9 was achieved.

Results: Of the 103 enrolled patients, 81 had simultaneous measurements during the onset of neuromuscular blockade at the hand and foot sites. The mean paired difference between the onset times at the two sites was 31 sec (95% confidence interval [CI], 5 to 56; P = 0.02). The mean paired difference between the offset times at the two sites was -3 sec (95% CI, -56 to 50; P = 0.26).

Conclusions: While quantitative neuromuscular monitoring at the flexor hallucis brevis (foot) muscle showed some statistical differences in onset time and a recovery compared with monitoring at the adductor pollicis muscle (hand), these differences are of unclear clinical significance.

Purpose: Cardiac surgery-associated acute kidney injury (AKI) is linked to poor outcomes. An observational study from Copenhagen, Denmark identified perioperative red blood cell (RBC) transfusion as a modifiable risk factor for AKI, with a dose-dependent relationship between the number of RBC units transfused and the occurrence and severity of AKI. We aimed to externally validate those findings in a larger population.

Methods: We conducted a retrospective observational study of adult patients undergoing nonemergent on-pump cardiac surgery at Toronto General Hospital (Toronto, ON, Canada) between 2016 and 2021. Acute kidney injury was classified using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Data were analyzed using inverse probability weighted logistic regression.

Results: Among 5,204 patients, 798 developed AKI, with 77% classified as stage 1, 11% as stage 2, and 12% as stage 3. Patients with AKI were older, had lower preoperative hemoglobin levels and estimated glomerular filtration rates, longer cardiopulmonary bypass duration, and lower intraoperative hemoglobin levels. Red blood cells were administered to 37% of patients, with 14% receiving plasma and 32% platelets. Only RBC transfusion, alone or combined with other blood products, was significantly associated with AKI. The transfusion of 1-2 RBC units increased the probability of stage 1 AKI by 4% and stage 2-3 AKI by 2% compared with patients not receiving RBCs. The risk was especially pronounced with the transfusion of > 2 units of RBCs, which raised the probability of stage 1 AKI by 12% and stage 2-3 AKI by 9%.

Conclusions: This study confirms previous findings that RBC transfusion is associated with postoperative AKI in cardiac surgery patients. The association was strongest among patients who received > 2 units of RBCs. Prospective studies are needed to determine the optimal strategies for transfusion in these patients and evaluate potential alternatives.