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

Purpose: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is increasingly being used in patients with respiratory failure. The goal of this study was to characterize postdischarge psychological and functional outcomes of this patient population.

Methods: We conducted a historical cohort study of survivors who required VV-ECMO during the COVID-19 pandemic. Using telephone interviews, we assessed the following domains: disability (using the World Health Organization Disability Schedule [WHODAS 2.0] and modified Rankin Scale [mRS]), health-related quality of life (using the European Quality of Life 5 Dimensions 5 Level tool), cognition (using the telephone Montreal Cognitive Assessment tool), depression (using the Patient Health Questionnaire-9), and posttraumatic stress disorder symptoms (using the Impact of Event Scale-6). We used descriptive statistics to analyze our results.

Results: Twenty-six participants with a median [interquartile range (IQR)] age of 47 [42-59] yr and 6 (23%) of whom were female were evaluated at a median [IQR] of 22 [17-23] months after ECMO separation. Twenty-two (85%) had a diagnosis of COVID-19. The median [IQR] WHODAS 2.0 score was 26 [15-30] with the highest degree of disability in the mobility and participation domains. Of the 24 participants who were employed full-time, 12 (50%) were able to work in the same capacity. Of the 25 respondents who were living independently at baseline, 22 (88%) maintained complete independence for their activities of daily living (mRS < 3), one (4%) described persistent functional limitations (mRS = 3), and two (8%) required constant care (mRS = 4 or 5). Thirteen (52%) and nine (38%) reported at least moderate pain or anxiety, respectively. Ten (40%) and seven (28%) participants screened positive for symptoms of depression or posttraumatic stress disorder, respectively.

Conclusions: Patients who required VV-ECMO experienced significant functional disability, pain, cognitive challenges, mental health problems, and lower quality of life approximately two years after discharge.

Purpose: Pain management after cardiac surgery is imperative, as inadequate analgesia can increase the risk of myocardial ischemia, thromboembolism, and pulmonary complications. Nonsteroidal anti-inflammatory drugs (NSAIDs) are an important component of multimodal analgesia, but their use in the postoperative cardiac surgery population is controversial owing to concerns of acute kidney injury (AKI), thrombotic events, and bleeding. We aimed to evaluate the rate of AKI, major adverse cardiovascular events (MACE), and major bleeding in patients receiving NSAIDs early after cardiac surgery.

Methods: We conducted a single-centre historical cohort study, which included adult patients who underwent cardiac surgery with sternotomy or thoracotomy between 1 October 2020 and 30 September 2022 and received nonselective NSAIDs postoperatively. The primary outcome was the proportion of patients who developed AKI, MACE, or major bleeding within 7 days of the NSAID exposure during their hospitalization. We used machine learning to identify risk factors associated with adverse events. We assessed pain reduction by analyzing differences in pain scores, opioid use, and supplemental oxygen requirements.

Results: We included 431 patients in this study. After NSAID administration, 12% experienced AKI, 1% had MACE, and 3% developed major bleeding. Risk factors for AKI included older age; shorter height; a history of stroke; low preoperative estimated glomerular filtration rate (eGFR) and hemoglobin level; high preoperative platelet count, international normalized ratio, and blood urea nitrogen level; and reduced eGFR and platelet count before NSAID exposure.

Conclusion: In patients who received nonselective NSAIDs early after cardiac surgery, the rate of AKI was lower than reported in literature, likely due to selection bias. Baseline renal function emerged as the most important factor, with low preoperative eGFR being the strongest predictor of AKI following NSAID administration.

Purpose: The ideal sedative should have a rapid onset, short duration, and quick and predictable recovery. Despite the increasing use of the recently developed sedative remimazolam for intraoperative sedation, there is a paucity of research on its comparative recovery profile. Our aim was to compare the recovery profiles of intraoperative sedation with propofol, dexmedetomidine, and remimazolam in patients undergoing surgery under regional anesthesia.

Methods: We included 119 patients scheduled to undergo upper limb surgery under brachial plexus blockade in a randomized controlled trial. We randomized patients to receiving intraoperative sedation with propofol, dexmedetomidine, or remimazolam. The primary outcome was the recovery time (from the completion of infusion to attaining a Modified Observer's Assessment of Alertness and Sedation score of 5). As secondary outcomes, we assessed other recovery profiles, including length of stay, quality of recovery, and the Aldrete score.

Results: The mean (95% confidence interval [CI]) recovery time was 19 min (95% CI, 16 to 22) for patients in the dexmedetomidine group, 17 min (95% CI, 15 to 19) for the remimazolam group, and 12 min (95% CI, 10 to 13) for the propofol group (P < 0.001). Post hoc analysis revealed that the recovery time in the remimazolam group was longer compared to that in the propofol group (mean difference, 5 min; 95% CI, 3 to 8; Bonferroni adjusted P < 0.001). We found no significant differences among the three groups in the recovery-related secondary outcomes (all P > 0.05).

Conclusions: Patients in the propofol group exhibited the most rapid recovery time from intraoperative sedation under regional anesthesia, followed by those in the remimazolam and dexmedetomidine groups. We found no differences in the recovery-related secondary outcomes.

Study registration: ClinicalTrials.gov ( NCT05688345 ); first submitted 30 December 2022.

Purpose: We aimed to evaluate the effects of intravenous dexmedetomidine (DEX) on perioperative opioid requirements, and secondarily on perioperative respiratory adverse events (PRAE), emergence delirium (ED), and postoperative nausea and vomiting in pediatric patients undergoing tonsillectomy.

Methods: We conducted a systematic review with meta-analysis, searching seven databases up to 7 May 2024. We included randomized controlled trials of patients aged 18 yr or younger undergoing tonsillectomy, comparing intravenous DEX and opioids with opioids. Our primary outcome was perioperative opioid requirements, expressed as oral morphine equivalents (OME). The secondary outcomes included the incidences of perioperative respiratory adverse events (PRAE), emergence delirium (ED), and postoperative nausea and vomiting (PONV), We used the Cochrane Risk of Bias 2 tool and assessed the certainty of the evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). We used a pairwise random effects model to compute the risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs) of the effects of DEX on each outcome. To explore dose-dependent effects of DEX, we used a random effects meta-regression model.

Results: We included 16 trials in our systematic review, of which we analyzed 7 for opioid requirements, 4 for PRAE, 3 for ED, and 12 for PONV. Dexmedetomidine was associated with lower perioperative opioid requirements (MD, -0.25 mg·kg^-1 OME; 95% CI, -0.36 to -0.13; moderate certainty), equivalent to a 40% relative reduction of perioperative OME, and a lower likelihood of ED (RR, 0.24; 95% CI, 0.08 to 0.71; moderate certainty). Despite DEX not having a dose-dependent effect on OME, the RR of ED decreased 87% for each 0.5 µg·kg^-1 increment in DEX dose. Dexmedetomidine did not reduce the incidence of sustained or severe cough as a part of PRAE, but it reduced PONV (RR, 0.48; 95% CI, 0.35 to 0.66; I² = 0%; low certainty).

Conclusion: Dexmedetomidine may improve the perioperative course of children undergoing tonsillectomy by decreasing perioperative opioid requirements and dose-dependently lowering the incidence of ED. Limitations of the present systematic review with meta-analysis include an inconsistent definition of PRAE in trials and heterogeneity due to variability of observed effect sizes.

Study registration: PROSPERO ( CRD42023392579 ); first submitted 1 July 2023.

Purpose: Cardiac arrest can cause hypoxic-ischemic injury and result in both spinal cord injury and death determination by neurologic criteria (DNC). The presence and severity of hypoxic-ischemic spinal cord injury (HISCI) impacts neuro-prognostication, rehabilitation, and may confound DNC evaluation in patients by interfering with motor responses and respiratory muscle function in apnea testing. We describe five children with postarrest HISCI detected on magnetic resonance imaging (MRI) and supplement our observations with a literature review.

Clinical features: Postarrest HISCI was identified in five consecutive pediatric cases of prolonged cardiac arrest and hypoxic-ischemic brain injury in a single centre. All patients had cardiopulmonary resuscitation for > 30 min and resultant severe hypoxic-ischemic brain injury. Spinal MRI indications were loss of rectal tone (n = 3), focal deficit (n = 1), and practice change related to recent cases (n = 1). A rapid review of the literature yielded case reports, case series, and retrospective reviews describing 90 patients (81 adults; nine pediatric) with postarrest HISCI. Ischemia distribution was variable, most frequently reported at the cervical and thoracic levels, although some patients had ischemia of the entire cord. Paraplegia was the most common deficit among survivors. There were no reports of HISCI in patients who underwent assessment for DNC.

Conclusions: This case series and rapid literature review highlights that both adults and children may be at risk of HISCI after prolonged cardiac arrest. Our findings suggest that further research should focus on determining the incidence and sequelae of HISCI after resuscitated cardiac arrest, as well as evaluating its potential impact on DNC practice and neuro-prognostication.

Purpose: Spinal cord stimulation (SCS) is a surgical intervention for patients with neuropathic pain refractory to medical management. There are limited data on its outcomes from Canadian centres. We aimed to describe the indications, patient- and procedure-related characteristics, and outcomes of patients who underwent SCS implantation at a Canadian tertiary centre.

Methods: We conducted a retrospective cohort study of patients who underwent SCS at St. Michael's Hospital (Toronto, ON, Canada) between 1 January 2020 and 31 July 2023. We collected data on patient demographics, analgesic use, type of SCS trial (percutaneous vs tunneled), indication, antibiotic use during and after surgery, and complications.

Results: We included 100 patients with a mean (standard deviation) age of 62 (14) yr. Indications included chronic pain after spinal surgery (n = 44), chronic back pain (no prior spine surgery) (n = 22), complex regional pain syndrome (n = 6), spinal stenosis (n = 4), and visceral pain (n = 4). Complications included implantable pulse generator-associated pain (47%), lead migration (14%), lead fracture (9%), surgical site infection (2%), and cerebrospinal fluid leak (6%). Almost all patients were on pharmacotherapy for pain relief at baseline (n = 96) and agents included opioids, nonsteroidal anti-inflammatory drugs, anticonvulsants, and antidepressants.

Conclusions: In this cohort of patients who underwent SCS implantation at a Canadian tertiary centre, infection and lead migration rates were consistent with global estimates (3.8% and up to 27%, respectively); nevertheless, we observed high rates of dural puncture compared with an expected incidence of 0.48%.