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

Purpose: Emerging evidence suggests that 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy may be a promising intervention for chronic pain. We designed the Ecstasy for Alleviating Severe Chronic Neuropathic Pain (EASE-Pain) trial, a randomized controlled trial comparing MDMA with an active placebo (methylphenidate) for pain relief. We sought to conduct a prospective preference assessment (PPA) prior to the trial, with the objectives to 1) assess willingness to participate in the trial, 2) identify participants' motivations and concerns to enhance enrolment and acceptability, and 3) compare demographic and health characteristics between willing and nonwilling participants.

Methods: We recruited patients from the St. Michael's Hospital Pain Clinic (Toronto, ON, Canada) from July to August 2024. Each participant completed four PPA phases: 1) a trial description, 2) comprehension assessment, 3) open-ended questions exploring attitudes towards the trial, and 4) a self-administered questionnaire. We analyzed data qualitatively using thematic analysis and quantitatively using t tests and Fisher's exact test.

Results: We enrolled 42 patients, with 76% willing and 24% not willing to participate in the EASE-Pain trial. White/European participants were more likely to be willing than not willing to participate (78% vs 40%; P < 0.001). Motivating factors for participation included pain relief (62%) and seeking alternatives to ineffective treatments (26%). Common concerns included side effects (43%), impacts on comorbidities (19%), and the stigma of MDMA (19%).

Conclusions: The results of this study indicate a strong willingness among patients with chronic pain to participate in the EASE-Pain trial. Primary concerns included side effects and impacts on comorbidities. In response, protocol modifications, including improved patient education on study drug effects, will be implemented.

Purpose: We aimed to investigate the impact that patient-initiated beta-blocker interruption on the morning of surgery has on postoperative adverse outcomes.

Methods: We conducted a historical cohort study of consecutive patients undergoing elective surgical procedures at two hospitals belonging to a single academic institution from 2014 to 2018 in the Canadian province of Ontario. We used electronic medical records to identify the initial cohort and collect patient information, including medication interruption. These data were linked to administrative data holdings, which we used to capture study outcomes, including 30-day and 90-day mortality and a composite outcome representing several adverse events. We used logistic regression to evaluate between-group differences in study outcomes and included a covariate representing propensity for beta-blocker interruption.

Results: The final cohort included 4,971 patients, 22.2% of whom experienced a preoperative beta-blocker interruption. As compared with patients who continued their medication, those with a beta-blocker interruption had significantly decreased odds of 30-day mortality (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.18 to 1.00; P = 0.049) and 90-day mortality (OR, 0.51; 95% CI, 0.28 to 0.90; P = 0.02) in adjusted analyses. Following adjustment, beta-blocker interruption was not significantly associated with any of the secondary outcomes.

Conclusions: Results from this study suggest that preoperative acute beta-blocker interruption is significantly associated with decreased 30-day and 90-day postoperative all-cause mortality. These data challenge the long-held assumption that patients on beta-blockers should continue these medications during the perioperative period and indicate that a proper controlled trial is needed to assess the impact of withholding beta-blockers prior to major surgery.

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.