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

Purpose: The aggregate data for successful use of carbetocin in patients at high risk of postpartum hemorrhage is fairly large. Nevertheless, there are scant data evaluating carbetocin in patients with preeclampsia and no established optimal dose. Therefore, we aimed to determine the minimum effective dose (the dose effective in 90% of the studied population [ED₉₀]) of carbetocin to prevent intraoperative uterine atony in patients with preeclampsia undergoing Cesarean delivery.

Methods: We based this nonrandomized triple-blinded dose finding study on biased coin sequential allocation design. We enrolled all consenting nonlabouring parturients aged > 18 yr with singleton pregnancy posted for Cesarean delivery under spinal anesthesia (with and without preeclampsia). Doses of carbetocin included 10 μg, 20 μg, 40 μg, 60 μg, 80 μg, 100 μg, or 120 μg, with 20 μg for the first patient of either group and then successively decided by response to the bolus in the previous patient in the respective group. After a "failed" dose of carbetocin bolus, the subsequent patient in that group received the next highest dose. In the case of a "successful" dose, we decreased it to the lower dose with a probability of 1/9; otherwise, it remained unchanged. The determinant of a successful dose was satisfactory uterine tone at 2 min after carbetocin, along with no need for any additional uterotonic intraoperatively.

Results: The ED₉₀ of carbetocin for patients with and without preeclampsia was 96 µg (95% confidence interval [CI], 59 to 114) vs 68 µg (95% CI, 46 to 76).

Conclusion: The dose requirement of carbetocin to prevent intraoperative uterine atony in patients with preeclampsia is 1.5 times greater than in those without the disease.

Purpose: Hospitals and especially operating rooms are known to have a significant carbon footprint. With health care moving towards patient-centered care, we sought to investigate the perception and attitudes of patients and/or their family members towards health care, anesthesia, and climate change, and its influence on their care choices. We hypothesized that < 30% of our study population were aware of health care's significant contributions to climate change.

Method: Following research ethics board approval and participants' consent, we conducted interviews using a questionnaire that queried participating patients' perceptions on climate change and their knowledge of health care's environmental impact. To determine if such perceptions influenced their care choices, we proposed two different anesthesia care choices with different environmental impacts for a hypothetical surgical scenario. Lastly, we sought to determine participants' interest in further information on the topic. We analyzed the survey responses for associations between participants' perceptions of climate change and on health care's carbon footprint with variables pertaining to participant characteristics, their anesthesia care choices, and interest in further knowledge.

Results: Overall, 320 participants completed the survey, of whom 32% acknowledged health care "greatly contributes to climate change." Nevertheless, perceptions did not translate to care choices as many participants still opted for the choice deemed to have a greater environmental impact (45%). A strong association existed between perception of health care's environmental impact and level of education (P = 0.02).

Conclusion: Public perception of health care's contribution to climate change was poor albeit higher than anticipated. Participants' perceptions of climate change or health care's impact on the environment did not completely translate into choosing a less carbon-intensive anesthesia care modality for their own care. Efforts to inform patients regarding the environmental impact of anesthetic choices may have minimal impact on individual care choices.

Purpose: The vascular endothelium is known to modulate the inflammatory response during surgery. Sevoflurane has been shown to protect against tumor necrosis factor alpha (TNF-α)-induced endothelial dysfunction, but the effects of other anesthetics or combinations with opioids on endothelial response are unclear.

Methods: In this in vitro study, we stimulated human umbilical vein endothelial cells with TNF-α (10 ng·mL^-1) in triplicate in three independent experiments and treated them with sevoflurane (0.8%, 2.0%, and 4.0%), propofol (2, 5, and 10 μg·mL^-1), remifentanil (2, 5, and 10 ng·mL^-1) and fentanyl (0.5, 1.5, and 5 ng·mL^-1) individually and in combinations. We evaluated the expression levels of endothelial adhesion molecules and proinflammatory cytokines using reverse transcription quantitative real-time polymerase chain reaction, Western blotting, and the enzyme-linked immunosorbent assay.

Results: Only sevoflurane significantly diminished the messenger ribonucleic acid (mRNA) and protein expression of adhesion molecules in the presence of TNF-α (E-selectin [sevoflurane 0.8%, P < 0.001; 2%, P = 0.03; 4%, P = 0.004], vascular cell adhesion molecule 1 [sevoflurane 0.8%, P < 0.001; 2%, P = 0.002; 4%, P < 0.001], and intercellular adhesion molecule 1 [sevoflurane 0.8%, P = 0.002; 2%, P = 0.007; 4%, P < 0.001]). Additionally, mRNA and protein expression of the proinflammatory cytokines interleukin [IL]-6 and IL-8 decreased after exposure to sevoflurane alone for (IL-6 mRNA: sevoflurane 0.8%, P = 0.004; 4%, P < 0.001; IL-8 mRNA: sevoflurane 4%, P = 0.02; IL-6 protein: sevoflurane 0.8%, P < 0.001; 2%, P = 0.003; 4%, P < 0.001; IL-8 protein: sevoflurane 0.8%, P = 0.03; 2%, P < 0.001; 4%, P = 0.008]). The addition of opioids did not change the expression in either of the adhesion molecules or inflammatory cytokines.

Conclusions: In this exploratory study, sevoflurane inhibited endothelial adhesion molecules and proinflammatory response in vitro, whereas propofol, remifentanil, or fentanyl did not possess the same effect. While the effects in vivo are unknown, these findings might highlight the potential impact of anesthetic choice on modulating the inflammatory response of endothelial cells.

Purpose: Cardiac donation after death determination by circulatory criteria (DCC) can be performed using either direct procurement and perfusion (DPP) or normothermic regional perfusion (NRP). If broadly implemented in Canada, these procedures have the potential to reduce the cardiac transplant wait list. We aimed to evaluate the perspectives of Canadians on cardiac DCC.

Methods: We performed a convergent design mixed methods study involving 21 focus groups and surveys of 109 adults in Canada on the topic of cardiac DCC.

Results: We found that participants were broadly supportive of both cardiac DCC protocols. Principle concerns about DPP included relatively impaired heart quality, while concerns about NRP included the perception that the procedure may be invasive and may not be acceptable to other Canadians, including donor families. Participants who self-identified as second-generation immigrants were concerned about potential lack of support for cardiac DCC, especially NRP, by other Canadians. Participants suggested strategies to increase support for organ donation and cardiac DCC specifically, including mass media campaigns, educational initiatives, encouraging the public to discuss end-of-life wishes with family members, and enlisting primary care providers and community leaders to advance public knowledge and support.

Conclusions: In this mixed methods study of people living in Canada, we found broad support for cardiac DCC. Concerns were primarily related to heart quality in DPP and perceived invasiveness of NRP. Participants identified mass media campaigns, educational material, and engagement of primary care providers and community leaders as strategies to garner support for cardiac DCC.

Purpose: Psychological factors, such as anxiety, depression, and catastrophizing, may increase the risk of chronic postsurgical pain (CPSP) following Cesarean delivery (CD). We sought to evaluate whether postpartum depression (PPD) after CD is associated with CPSP and assess the potential mediating effect of PPD on the relationship between acute severe postoperative pain and CPSP.

Methods: We conducted a secondary analysis of a previous randomized trial. In the original trial, 290 patients undergoing CD in Nepal were randomized to receive either 100 µg of intrathecal morphine or normal saline in addition to their spinal anesthesia with the goal to investigate the relationship between intrathecal morphine use and CPSP development. Eight weeks after CD, we used the Edinburgh Postnatal Depression Scale to identify patients with a provisional diagnosis of PPD (scores ≥ 12). The study outcomes were the occurrence of CPSP at three and six months.

Results: Out of 276 patients analyzed, 20 (7%) experienced PPD. The incidences of CPSP at three and six months were 18% (52/276) and 15% (42/276), respectively. A multivariable model revealed that the odds of experiencing CPSP at three months postpartum were significantly higher in patients with depression (odds ratio [OR], 4.24; 95% confidence interval [CI], 1.53 to 11.7; P = 0.005) than in those without depression. Similarly, PPD was independently associated with an increased incidence of CPSP at six months post CD (OR, 4.05; 95% CI, 1.42 to 11.5; P = 0.009). Causal mediation analysis showed no mediating effect of PPD between acute severe postoperative pain and CPSP.

Conclusions: In this secondary analysis of a previous randomized trial, we found a significant association between PPD and CPSP following CD.