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

Purpose: The optimal method for monitoring intensive care unit (ICU) performance is unknown. We sought to compare process control charts using standardized mortality ratio (SMR), p-charts, and cumulative sum (CUSUM) charts for detecting increases in risk-adjusted mortality within ICUs.

Methods: Using data from 17 medical-surgical ICUs that included 29,592 patients in Ontario, Canada, we created risk-adjusted p-charts and SMRs on monthly intervals and CUSUM charts. We defined positive signals as any data point that was above the 3-sigma limit (approximating a 99% confidence interval [CI]) on a p-chart, any data point whose 95% CI did not include 1 for the SMR charts, and when a data point exceeded control limits for an odds ratio of 1.5 for CUSUM charts. We simulated increases in mortality of 10%, 30%, and 50% for each ICU to determine the sensitivity of each method. We calculated sensitivity as the number of positive signals divided by the number of ICUs (equal to number of simulated events).

Results: Cumulative sum charts generated 31 signals in 12 different ICUs, while p-charts and SMR agreed in 10 and 6 of these signals, respectively, followed by 21 signals from p-charts across 14 ICUs (agreement in 10 of these signals for both CUSUM and SMR) and 15 signals from SMR charts across eight ICUs (agreement from p-charts and CUSUM in 10 and six signals, respectively). The p-chart had a sensitivity of 88% (95% CI, 73 to 104) for a 50% simulated increase in ICU mortality followed by CUSUM at 71% (95% CI, 49 to 102) and SMR at 59% (95% CI, 35 to 82). Performance with lower simulated increases was poor for all three methods.

Conclusions: P-charts created with risk-adjusted mortality at monthly intervals are potentially useful tools for monitoring ICU performance. Future studies should consider usability testing with ICU leaders and application of these methods to additional clinical domains.

Purpose: We sought to assess the feasibility and estimate the effects on outcomes of a multimodal prehabilitation service implemented as an ancillary surgical service.

Methods: We conducted a pragmatic, nonrandomized feasibility study of surgical prehabilitation. Patients were eligible if they were ≥ 18 yr of age, fluent in English, and referred by a health professional for prehabilitation. Participants received an individualized program of preoperative exercise, nutrition, psychological, and/or smoking cessation support. The primary outcome was operational feasibility, including referral volume, enrolment rate, prehabilitation window, engagement, completion rate, and safety. Secondary outcomes included surgical complications, length of hospital stay, readmission, quality of life, and physical and mental health. Qualitative data related to intervention feasibility and acceptability. We compared intervention participants with patients who were referred for, but declined, prehabilitation.

Results: One hundred and sixteen patients were referred for prehabilitation. The mean age of referred patients was 71 yr and 55% were male. Over 90% of referrals were from surgical oncology, and the most common indication for referral was frailty (46%). Of the 116 referred patients, 83 consented to participate in the study. Patient-reported and objectively measured outcomes improved by a clinically important margin from baseline to presurgery, and returned to presurgery levels by 90 days postoperatively. Qualitative findings suggest that the prehabilitation intervention was well received.

Conclusion: Multimodal surgical prehabilitation is feasible as an integrated clinical service and may be effective for improving physical and psychological outcomes. Further evaluations of clinically integrated prehabilitation programs in Canada are needed to confirm these findings.

Purpose: The combination of acetaminophen with a nonsteroidal anti-inflammatory drug is the cornerstone of perioperative multimodal analgesia. These drugs can be administered intravenously or orally as premedication, consistent with the concept of pre-emptive and preventive analgesia. We aimed to assess the environmental impact of their intravenous and oral administration in a French university hospital.

Methods: We carried out a life cycle assessment to determine the amount of greenhouse gas emissions and depletion of water resources resulting from the oral vs intravenous administration of 1 g acetaminophen and 50 mg ketoprofen. We assessed two schemes of intravenous administration, depending on the use of the same or a different infusion set for each drug.

Results: At our centre, the intravenous administration of both drugs was associated with the emission of 444-556 g CO₂ equivalent (CO₂e), and with 9.8-12.2 L of water waste. The oral administration of both drugs generated 8.36 g of CO₂e emissions and consumed 1.16 L of water. At a national level, the switch from intravenous to oral premedication of the drugs could avoid the emission of 2,900-3,700 tons of CO₂e and the waste of 58,000-74,000 m³ of water each year.

Conclusion: This eco-audit indicates that oral administration of acetaminophen and ketoprofen results in significantly lower carbon emissions and water consumption than intravenous administration. These findings highlight the importance of using the oral route for most patients, limiting intravenous administration for those with specific needs because of higher environmental impact and cost.

Background: Improving survivorship for patients with cancer and frailty is a priority. We aimed to estimate whether exercise prehabilitation improves disease-free survival and return to intended oncologic treatment for older adults with frailty undergoing cancer surgery.

Methods: We conducted a secondary analysis of the oncologic outcomes of a randomized trial of patients ≥ 60 yr of age with frailty undergoing elective cancer surgery. Participants were randomized either to a supported, home-based exercise program plus nutritional guidance or to usual care. Outcomes for this analysis were one-year disease-free survival and return to intended oncologic treatment. We estimated complier average causal effects to account for intervention adherence.

Results: We randomized 204 participants (102 per arm); 182 were included in our modified intention-to-treat population and, of these participants, 171/182 (94%) had complete one-year follow up. In the prehabilitation group, 18/94 (11%) died or experienced cancer recurrence, compared with 19/88 (11%) in the control group (hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.66 to 2.34; P = 0.49). Return to intended oncologic treatment occurred in 24/94 (29%) patients the prehabilitation group vs 20/88 (23%) in the usual care group (HR, 1.53; 95% CI, 0.84 to 2.77; P = 0.16). Complier average causal effects directionally diverged for disease-free survival (HR, 0.91; 95% CI, 0.20 to 4.08; P = 0.90) and increased the point estimate for return to treatment (HR, 2.04; 95% CI, 0.52 to 7.97; P = 0.30), but in both cases the CIs included 1.

Conclusions: Randomization to home-based exercise prehabilitation did not lead to significantly better disease-free survival or earlier return to intended oncologic treatment in older adults with frailty undergoing cancer surgery. Our results could inform future trials powered for more plausible effect sizes, especially for the return to intended oncologic treatment outcome.

Study registration: ClinicalTrials.gov ( NCT02934230 ); first submitted 22 August 2016.

Purpose: To determine the acceptability of the ClearSight™ system (Edwards Lifesciences Corp., Irvine, CA, USA) for continuous blood pressure monitoring during elective cardiac surgery compared with arterial catheterization.

Methods: We enrolled 30 patients undergoing elective cardiac surgery in a prospective observational study. Blood pressure measurements were recorded every 10 sec intraoperatively. We determined agreement based on the Association for the Advancement of Medical Instrumentation (AAMI) recommendations. Statistical analysis included fixed bias (difference of measurements between methods), percentage error (accuracy between ClearSight measurement and expected measurement from arterial line), and interchangeability (ability to substitute ClearSight monitor without effecting overall outcome of analysis). We used a paired samples t test to compare the time required for placing each monitor.

Results: We found fixed bias in the differences between the ClearSight monitor and invasive arterial blood pressure measurement in systolic blood pressure (SBP; mean difference, 8.7; P < 0.001) and diastolic blood pressure (DBP; mean difference, -2.2; P < 0.001), but not in mean arterial pressure (MAP; mean difference, -0.5; P < 0.001). Bland-Altman plots showed that the means of the limits of agreement were greater than 5 mm Hg for SBP, DBP, and MAP. The percentage errors for SBP, DBP, and MAP were lower than the cutoff we calculated from the invasive arterial blood pressure measurements. Average interchangeability rates were 38% for SBP, 50% for DBP, and 50% for MAP. Placement of the ClearSight finger cuff was significantly faster compared with arterial catheterization (mean [standard deviation], 1.7 [0.6] min vs 5.6 [4.1] min; P < 0.001).

Conclusions: In this prospective observational study, we did not find the ClearSight system to be an acceptable substitute for invasive arterial blood pressure measurement in elective cardiac surgery patients according to AAMI guidelines. Nevertheless, based on statistical standards, there is evidence to suggest otherwise.

Study registration: ClinicalTrials.gov ( NCT05825937 ); first submitted 11 April 2023.