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

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.

Purpose: We sought to evaluate the efficacy of intravenous dexamethasone in reducing rebound pain post-orthopedic wrist and hand surgery, administered prior to supraclavicular brachial plexus blockade.

Methods: We conducted a randomized placebo-controlled trial on 56 patients scheduled for elective wrist and hand surgery under supraclavicular brachial plexus blockade. We randomized participants into either a control group, receiving 0.9% of intravenous saline, or a dexamethasone group, receiving 0.11 mg·kg^-1 of intravenous dexamethasone. The primary outcome was the difference in pain scores before vs after block resolution. Secondary outcomes included the incidence of rebound pain, pain scores, cumulative opioid consumption, patient satisfaction with postoperative analgesia, and block-related complications in the first 24 hr postoperatively.

Results: The mean (standard deviation [SD]) pain score difference was significantly larger in the control group (7.3 [1.9]) compared with the dexamethasone group (4.7 [2.1]), with a mean difference between groups of 2.6 (95% confidence interval, 1.5 to 3.7; P < 0.001). The incidence of rebound pain was also significantly higher in the control group (79% vs 32%; P < 0.001). The cumulative opioid consumption in 24 hr was greater in the control group than in the dexamethasone group (median [interquartile range (IQR)], 72 [54-97] mg vs 25 [14-60] mg; P < 0.001). We found no significant differences in postoperative complications.

Conclusions: Preoperative administration of 0.11 mg·kg^-1 intravenous dexamethasone significantly reduced rebound pain within 24 hr after wrist and hand surgery under supraclavicular brachial plexus blockade. The results of our trial support the use of intravenous dexamethasone as an effective method for managing postoperative pain for wrist and hand surgery under supraclavicular brachial plexus blockade.

Study registration: www.CRIS.nih.go.kr ( KCT0007208 ); first submitted 5 April 2022.