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

Purpose: Although health research in Canada is primarily conducted in academic hospitals, most patients receive their care in community hospitals. The benefits of increasing research capacity in community hospitals include improved study recruitment, increased generalizability of results, broader patient access to novel therapies, better patient outcomes, enhanced staff satisfaction, and improved organizational efficiency. Nevertheless, building research programs in community hospitals remains challenging because of a lack of support and expertise. To address this gap, we developed a toolkit to help community hospital professionals build and sustain their community hospital research programs.

Source: The toolkit was developed by the Canadian Community Intensive Care Unit Research Network (CCIRNet), a group of clinician-researchers and research staff from community hospitals across Canada who have experience building community hospital research programs. Feedback from a concurrent qualitative study of Canadian community critical care professionals informed the toolkit's design.

Principal findings: The CCIRNet toolkit outlines five stages of community hospital clinical research program development: 1) building a research team and gaining support, 2) developing a new research program, 3) choosing a first research study, 4) getting the study up and running, and 5) sustaining a research program. Feedback from qualitative interviews emphasized the need for a step-by-step approach, frequently asked questions, and essential resources. Accordingly, each stage is structured in a question-and-answer format and includes relevant resources for each section.

Conclusion: The CCIRNet toolkit is a practical resource for establishing research programs in community hospitals. The toolkit may increase research participation and support clinical research capacity building in community hospitals.

Purpose: The aim of this project was to collect data on the delivery of anesthesia in Canada. Specifically, our goal was to increase knowledge by identifying provider demographics and different models of anesthesia delivery, and to explore relationships among specialist anesthesiologists (SAs) and family practice anesthetists (FPAs) with a focus on mentoring.

Methods: An online questionnaire was circulated to SAs and FPAs holding membership with the Canadian Anesthesiologists' Society or the Society of Rural Physicians of Canada. A total of 274/2,578 individuals completed the survey (170 SAs and 104 FPAs), providing a response rate of 10.6%. The survey included questions about demographics, anesthesia training, anesthesia resources, models of care, and mentoring relationships.

Results: Three major themes emerged from the data: 1) FPAs and rural operating rooms are underused resources as 65% (64/98) of FPAs reported having capacity to increase their individual volume of anesthesia services and 41% (40/98) thought capacity existed within their hospital to increase the volume of surgery; 2) 20 hospitals employed a mixed model of anesthesia care whereby SAs and FPAs worked collectively within the same site; providers working within this model reported high levels of satisfaction and independence; 3) most SAs and FPAs perceived a benefit to mentoring and were interested in participating in a mentoring program.

Conclusion: This survey shows perceived capacity to expand surgical services in rural areas, a precedent for a mixed SA-FPA model of anesthesia delivery at the same site, and desire for anesthesia providers to engage in mentoring. Such options should be considered to strengthen the physician-led anesthesiology profession in Canada.

Purpose: The impact of postoperative dexmedetomidine sedation on outcomes following cardiac surgery remains controversial. We sought to compare postoperative sedation techniques with dexmedetomidine vs propofol infusions on postoperative recovery outcomes following cardiac surgery to assess whether dexmedetomidine is associated with longer time to achieve recovery milestones.

Methods: In this historical cohort study, we abstracted the electronic medical records of a convenience sample of cardiac surgery patients either receiving dexmedetomidine (0.5-1.5 µg·kg^-1·hr^-1) or propofol (5-80 µg·kg^-1·min^-1) infusions for postoperative sedation. The study period included time periods where the standard postoperative sedation practice included dexmedetomidine (March 2019-January 2022) or propofol (January 2022-June 2022) infusions. Measured outcomes for both groups included time to tracheal extubation and intensive care unit and hospital length of stay.

Results: Two thousand and sixty-five patients receiving dexmedetomidine and 510 patients receiving propofol were included. Postoperative sedation after cardiac surgery with dexmedetomidine was associated with a 1.8-hr longer time to tracheal extubation than propofol (98.3% confidence interval, 1.5 to 2.1; P < 0.001).

Conclusions: Dexmedetomidine administration for postoperative sedation in a convenience sample of over 2,000 cardiac surgery patients was associated with a longer time to tracheal extubation than propofol.

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.