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

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.

Purpose: Trauma systems encompass injury prevention, prehospital care, acute care, rehabilitation, and community integration. The proportion of out-of-hospital injury deaths may indicate the effectiveness of trauma systems, particularly in prevention and prehospital care. In the absence of Canadian data, we aimed to estimate this proportion nationally and by province and analyze variations by age, sex, and year.

Methods: We conducted a historical cohort study to analyze aggregate data on hospital discharges and mortality statistics covering injury-related deaths in Canadian provinces and territories from 2017 to 2020. We included deaths from all Canadian provinces and territories except Quebec, for which data on in-hospital deaths were unavailable. We calculated the proportions of out-of-hospital deaths with 95% confidence intervals. We used robust Poisson models to assess provincial variation, adjusting for age, sex, and year for Ontario, Alberta, and British Columbia (the volumes were too low in the other provinces). We conducted subgroup analyses for age group, sex, year, and injury mechanism.

Results: Canada recorded 64,725 injury-related deaths between 2017 and 2020 (32.3% ≥ age 65 yr; 34.5% female), with 48% occurring outside of hospitals globally and 80% in < 65-yr-olds. Proportions of out-of-hospital deaths ranged from 30% in the Atlantic provinces to 58% in Saskatchewan. After adjusting for age, sex, and year, Alberta had a 13% higher risk of out-of-hospital mortality than Ontario (reference standard), while British Columbia had a 26% lower risk. Subgroup analyses revealed variations across age groups, sex, and years.

Conclusions: Half of all injury deaths in Canada between 2017 and 2020 occured outside of hospitals. This proportion varied by province, possibly suggesting differences in the development and maturity of provincial trauma systems. Future studies should strive to identify modifiable determinants of these interprovincial variations to inform public health strategies.

Purpose: In this Continuing Professional Development module, we review the literature on postdural puncture headache (PDPH) in obstetrics. The pathophysiology, risk factors, diagnosis, and outcomes are discussed. We explore the evidence for prevention and treatment options of PDPH in obstetric patients and the importance of the anesthesiologist's role in caring for these patients.

Principal findings: A PDPH is any headache that develops after a dural puncture and is not better accounted for by another diagnosis. Risk factors for PDPH include young age and female sex, which, along with the high rate of neuraxial anesthesia use in the obstetric population, predispose these patients to this complication. A spinal anesthesia technique using a small-gauge pencil-point needle with an experienced operator decreases the risk of PDPH. Individuals with PDPH have an increased risk of major neurologic complications, such as subdural hematoma, cerebral venous sinus thrombosis, and bacterial meningitis. No pharmacological modalities have shown a benefit in preventing or treating PDPH. Epidural blood patch remains the most effective treatment for PDPH and should not be delayed in obstetric patients with severe symptoms.

Conclusions: Postpartum individuals cope with recovering from birth in addition to the demands of caring for a newborn. Often, the addition of a PDPH is incapacitating. Epidural blood patch should not be delayed in patients with early and severe symptoms. All individuals who experience PDPH should be assessed, receive appropriate treatment, and be reviewed by a member of the anesthesia team until symptoms have resolved, with appropriate follow-up instructions before discharge.