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

Purpose: Our objective was to investigate the temporal trends in baseline characteristics, interventions, and clinical outcomes in patients hospitalized with COVID-19 in Canada over five pandemic waves.

Methods: We conducted a multicentre prospective cohort study enrolling adults and children admitted with COVID-19 from 47 Canadian hospitals. We compared characteristics, interventions, and outcomes of patients across five distinct pandemic waves.

Results: We enrolled 5,285 patients between 2 January 2020 and 8 February 2022. The mean (standard deviation) age was 62.6 (21.0) yr; 41.2% (n = 2,176) were female, and 48% (n = 2,539) required admission to an intensive care unit (ICU), of whom 60.3% (n = 1,530) underwent invasive mechanical ventilation. The proportion of vaccinated patients increased over time. The proportion of vaccinated hospitalized patients progressing to require ICU admission fell over pandemic waves while the proportion of unvaccinated hospitalized patients progressing to require ICU admission did not. Patients were most commonly treated with corticosteroids (48.7%; n = 2,575); use of corticosteroids and other evidence-based treatments increased over time. Hospital mortality was 22.1% (n = 1,166) among all patients, 30.2% (n = 766) among those admitted to an ICU, and 37.9% (n = 580) among those requiring invasive mechanical ventilation. Younger age, absence of chronic cardiac or pulmonary disease, severity of illness at admission, and prior vaccination was associated with a lower mortality; however, pandemic wave itself was not.

Conclusion: Among patients hospitalized in Canada with COVID-19, several clinical factors including prior vaccination were associated with lower mortality, but pandemic wave was not.

Purpose: The use of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) by patients undergoing surgery and procedures requiring anesthesia has become a topic of significant concern for perioperative providers because of the potential increased risk of aspiration resulting from the medication's effect of delaying gastric emptying. There is currently a lack of high-quality data regarding the safety of GLP-1 RAs in patients undergoing surgery, which has led to variations in practice.

Source: We performed an internet search of society-endorsed statements and guidelines related to perioperative management of GLP-1 RAs, focusing on the top 20 countries with the largest anesthesiology societies determined by membership data from the World Federation of Societies of Anesthesiologists. We excluded articles and websites that were not in English.

Principal findings: Our search revealed endorsed statements from fourteen major anesthesiology, endocrinology, and gastroenterology societies. There was considerable variation between societies in the recommendations and guidance for withholding these medications before surgery, the duration of withholding, assessment of the need for avoiding deep sedation or general anesthesia, use of rapid sequence intubation, need for prolonged fasting periods and clear fluid before a nil per os period, recognition of signs and symptoms for aspiration risk, the management of glucose in the perioperative period, and the use of point-of-care ultrasound for risk assessment.

Conclusion: Society-endorsed statements and guidelines provide varying recommendations on the perioperative management of GLP-1 RAs. The insights gained from this comparative analysis may help guide clinical practice, develop institutional practice guidelines, and direct future research efforts.

Purpose: Remimazolam is a recently developed ultra-short-acting benzodiazepine used for anesthesia induction and maintenance. Nevertheless, the effective bolus dose of remimazolam for i-gel^® (Intersurgical Ltd., Wokingham, Berkshire, UK) insertion without the use of neuromuscular blocking agents (NMBAs) has not been well established.

Methods: This study included 25 adult patients scheduled for surgery under general anesthesia who were eligible for i-gel use. Anesthesia was induced with predetermined bolus doses of remimazolam, starting at 0.3 mg·kg^-1 for the first patient, without the use of NMBAs. All patients concurrently received remifentanil using target-controlled infusion (TCI) at a fixed effect-site concentration (Ce) of 3.0 ng·mL^-1. Insertion of the i-gel was attempted 90 sec after remimazolam administration, and insertion conditions were assessed. Subsequent doses of remimazolam were decreased or increased by 0.05 mg·kg^-1, depending on the success or failure of i-gel insertion.

Results: The mean (standard deviation) 50% effective dose (ED₅₀) of a remimazolam bolus for successful i-gel insertion as determined by the modified Dixon's up-and-down method was 0.100 (0.027) mg·kg^-1. The ED₅₀ and ED₉₅ estimated by isotonic regression were 0.111 (83% confidence interval [CI], 0.096 to 0.131) mg·kg^-1 and 0.182 (95% CI, 0.144 to 0.195) mg·kg^-1, respectively. None of the patients required treatment for hypotension or bradycardia during anesthesia induction.

Conclusion: Based on the ED₉₅ of remimazolam bolus dose determined in our study, we recommend using 0.182 mg·kg^-1 of remimazolam in combination with remifentanil TCI at a Ce of 3.0 ng·mL^-1 for successful i-gel insertion without NMBAs in adult patients. This regimen seems effective with a low risk of hemodynamic instability during anesthesia induction.

Study registration: ClinicalTrials.gov ( NCT05298228 ); first submitted 6 March 2022.

Purpose: Medical errors may be occasionally explained by inattentional blindness (IB), i.e., failing to notice an event/object that is in plain sight. We aimed to determine whether age/experience, restfulness/fatigue, and previous exposure to simulation education may affect IB in the anesthetic/surgical setting.

Methods: In this multicentre/multinational study, a convenience sample of 280 anesthesiologists watched an attention-demanding video of a simulated trauma patient undergoing laparotomy and (independently/anonymously) recorded the abnormalities they noticed. The video contained four expected/common abnormalities (hypotension, tachycardia, hypoxia, hypothermia) and two prominently displayed unexpected/rare events (patient's head movement, leaky central venous line). We analyzed the participants' ability to notice the expected/unexpected events (primary outcome) and the proportion of expected/unexpected events according to age group and prior exposure to simulation education (secondary outcomes).

Results: Anesthesiologists across all ages noticed fewer unexpected/rare events than expected/common ones. Overall, younger anesthesiologists missed fewer common events than older participants did (P = 0.02). There was no consistent association between age and perception of unexpected/rare events (P = 0.28), although the youngest cohort (< 30 yr) outperformed the other age groups. Prior simulation education did not affect the proportion of misses for the unexpected/rare events but was associated with fewer misses for the expected/common events. Self-perceived restfulness did not impact perception of events.

Conclusion: Anesthesiologists noticed fewer unexpected/rare clinical events than expected/common ones in an attention-demanding video of a simulated trauma patient, in keeping with IB. Prior simulation training was associated with an improved ability to notice anticipated/expected events, but did not reduce IB. Our findings may have implications for understanding medical mishaps, and efforts to improve situational awareness, especially in acute perioperative and critical care settings.