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

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.

Purpose: We aimed to investigate the correlation between the duration of low Bispectral Index™ (BIS™) values and 1-year mortality in older patients, particularly in those with different comorbidities.

Methods: We conducted a retrospective cohort study of 5,927 older patients (≥ 65 yr of age) who underwent elective noncardiac surgery under general anesthesia with BIS monitoring between February 2015 and February 2022. We used univariable and multivariable Cox proportional hazard models to explore the associations between the cumulative duration of BIS values < 40 and postoperative 1-year mortality. We performed exploratory subgroup and interaction analyses to investigate whether any association with outcome differed in patients with multimorbidity as assessed by the Charlson comorbidity index (CCI).

Results: We included 5,927 patients undergoing elective noncardiac surgery, with a mean (standard deviation [SD]) age of 71 (5) yr. Among them, 2,234 (38%) patients with multimorbidity had a CCI ≥ 3, and 3,693 (62%) had CCI < 3. Postoperatively, 588/5,927 (10%) patients died within 1 year. After adjusting for covariates, multivariable Cox proportional hazard analysis showed that the cumulative duration of BIS < 40 was not significantly associated with 1-year mortality (adjusted hazard ratio, 1.07; 95% confidence interval [CI], 0.99 to 1.15; P = 0.08); this association remained stable among patients with multimorbidity (adjusted hazard ratio, 1.06; 95% CI, 0.96 to 1.16).

Conclusions: In this retrospective cohort study of 5,927 older patients, the cumulative duration of BIS < 40 was not significantly associated with 1-year mortality, especially in patients with multimorbidity.

Purpose: Climate change is increasingly recognized as an emergency, particularly within the health care sector. Reducing nitrous oxide (N₂O) usage is critical for mitigating anesthesia-related greenhouse gas emissions, a significant environmental threat. We aimed to evaluate the effectiveness of implementing quality improvement (QI) strategies to reduce the carbon footprint in anesthesia practice at two quaternary hospitals in São Paulo, Brazil, São Luiz Anália Franco Hospital and and São Luiz Itaim Hospital. We aimed to lower N₂O use in inhalational anesthesia, targeting a 75% reduction in carbon footprint over 16 weeks.

Methods: Through a QI initiative, we restricted N₂O usage to inhalational induction in pediatric anesthesia only. Employing quality and safety tools, we implemented educational strategies to limit N₂O application and minimize waste from the central anesthesia workstation pipeline. We calculated greenhouse gas emissions as carbon dioxide equivalents (CO₂e), monitored adverse events, and tracked sedative agents use both before and after the interventions.

Results: From January to August 2024, our project encompassed 30,217 anesthetics over 32 weeks. Among these, 6,806 involved inhalational anesthesia, with 624 (9%) involving N₂O. In adult patients, baseline data over 16 weeks prior to the intervention showed an average N₂O usage rate of 11%, which decreased significantly to 2% postintervention (P < 0.001). In pediatric patients, N₂O usage dropped from 62% to 46% following the intervention (P < 0.001). The emissions per anesthetic using N₂O declined from 132 kg (lower control limit [LCL], 98 kg; upper control limit [UCL], 167 kg) to 23 kg (LCL, 9 kg; UCL, 38 kg) following our interventions.

Conclusions: By optimizing N₂O usage through educational and judicious interventions, our QI initiative achieved a 82.5% postintervention reduction in anesthesia-related institutional CO₂e. Moreover, we fostered a significant cultural shift, enhancing accountability for health care initiatives aimed at environmental protection.

Purpose: Anesthesia contributes up to 25% of operating room (OR) waste. We sought to conduct a quality improvement project to initiate soft plastic recycling, aiming to recycle 1,000 g per day of soft plastic.

Methods: In this single-centre, anesthesiology resident-led quality improvement initiative in British Columbia, Canada, we started a soft plastics recycling collection program in a single operating room (OR) and expanded it to 12 ORs through a series of Plan-Do-Study-Act cycles. The outcome measure was the daily weight of soft plastics recycled. We tracked the number of mistakes as a balancing measure. We collected data eight months after the conclusion of the project to assess sustained changes. We visualized data with Shewhart control charts.

Results: One OR resulted in a mean (standard deviation [SD]) of 194 (157) g of soft plastics collected daily. Once we expanded to all ORs, a mean (SD) of 1,524 (708) g of waste was collected daily. A mean (SD) of 1,284 (613) g was recycled daily during the eight-month follow-up. There was a median [interquartile range (IQR)] of 0 [0-2] mistakes per day with only one OR, which increased to a median [IQR] of 2 [1-4] mistakes per day upon expansion, and remained low at eight months, with a median [IQR] of 1 [0-3] mistake per day. E-mail reminders and signage improved the error rate.

Conclusions: We successfully introduced and sustained a soft plastics collection program in our centre's OR suite with the aim to stream it for recycling. Monitoring and education were helpful in growing the program and reducing errors.

Purpose: Nitrous oxide (N₂O) is an ozone-depleting greenhouse gas that lingers in the atmosphere for over a hundred years. Much of the climate impact of medical N₂O is due to systemic central pipeline losses even before it reaches the patients. Health care systems around the world are changing the way it is supplied to decrease wastage to a minimum.

Methods: We conducted a quality improvement project at National University Hospital Singapore with the aim to deactivate the central N₂O piped supply system, substituting it with a portable supply system within the operating room (OR) complex. At the preintervention phase, we gathered N₂O monthly procurement data and evaluated our system and clinical practices. Following this, we carried out three sequential Plan-Do-Study-Act cycles: the first to raise awareness and understanding of N₂O's significant leaks and climate impact, the second to disconnect central piped supply from the anesthesia machines, and the third to fully cease the central piped supply system and transition to using portable cylinder supply in ORs.

Results: We achieved a 96% reduction in N₂O systemic consumption (as estimated using monthly procurement data) and a 66% reduction in the number of general anesthesia cases using N₂O (as captured by snapshot audits). The project will enable annual carbon savings of 307 tonnes of carbon dioxide equivalents (CO₂e) and annual financial savings of CAD 7,620.

Conclusions: This quality improvement project shows that substantial reduction in N₂O systemic consumption in an OR complex is possible through changing the N₂O supply from a central piped supply system to small cylinders directly mounted on anesthesia machines. Next steps would include shifting institutional clinical practice towards using alternatives to N₂O, thereby withdrawing N₂O altogether. This project can be replicated at other centres to collectively reduce the greenhouse gas effect of N₂O in clinical care.

Purpose: Sexual and gender minoritized persons (SGMs) experience inequities, harms, and gaps in care in organ and tissue donation and transplantation (OTDT) systems. The experiences of SGMs navigating OTDT have not been published from their own perspectives.

Methods: We conducted semistructured interviews, transcribed verbatim, and performed a formal qualitative best-fit framework synthesis and inductive thematic analysis with an SGM OTDT patient and caregiver advisory team (N = 12/13) to characterize their self-described experiences.

Results: Emergent themes included: 1) stigma, discriminatory criteria, and inertia to change; 2) OTDT patient and community relations; 3) benefits, strength, and resilience of the SGM community; and 4) SGM priorities and opportunities for improvement. Each theme and its respective subthemes are presented with representative quotes.

Conclusions: Our novel findings detail the ways that SGMs experience OTDT health care, highlighting the harms of discriminatory donor risk assessment criteria and the need for equitable policy revision. Opportunities to enhance inclusive care include institutional acknowledgement of inequities and transparent communication, target training for health care providers, and intersectional SGM and OTDT caregiver support networks.

Purpose: Following liver resection, acute kidney injury (AKI) is a frequent and potentially reversible complication. No predictive model of postoperative AKI following liver resection has assessed the role of oliguria in the postanesthesia care unit (PACU). Our objectives were 1) to estimate the association between PACU oliguria and AKI and to develop and internally validate a predictive model of postoperative AKI using variables available in the PACU and 2) to assess the additive predictive value of PACU urine output.

Methods: We conducted a retrospective cohort study of patients who underwent elective liver resection. Our primary outcome was the occurence of AKI within seven days after surgery. We used two sets of candidate predictors (17 and 11 variables, respectively) to develop a predictive model for postoperative AKI, including PACU urine output. We first calculated risk ratios (RR) with 95% confidence intervals (CIs) for different definitions of PACU oliguria. We then fitted multivariable logistic regression predictive models with a least absolute shrinkage and selection operator and reported optimism-corrected model performance properties.

Results: We included 1,520 patients. Both the incidence of AKI within seven days after surgery and the prevalence of PACU oliguria, defined as a urine output < 0.5 mL·kg^-1·hr^-1, were 11%. PACU oliguria was associated with AKI (RR = 1.74; 95% CI, 1.20 to 2.50). Both predictive models had good discrimination (area under the receiver operating characteristic curves, 0.775 and 0.766, respectively) and excellent calibration. PACU urine output increased models' discrimination.

Conclusion: Oliguria in the PACU was associated with AKI within seven days after surgery. We developed predictive models for 7-day AKI following liver resection that had good performance properties.