Canadian Journal of Anesthesia/Journal canadien d'anesthsie

Defoe, Marc; Lam, Wing; Becher, Harald; Lydell, Carmen; Hong, Yongzhe; Sidhu, Surita

doi: 10.1007/s12630-023-02569-1pmid: 37752378

PurposeRight ventricle (RV) assessment is critical during cardiac surgery. Traditional assessment consists of visual estimation and measurement of validated parameters. Cardiac magnetic resonance imaging (cMRI) is the gold standard for RV analysis, and transthoracic three-dimensional (3D) echocardiography is validated against this. We aimed to show that intraoperative 3D transesophageal echocardiography (TEE) RV assessment is feasible and can produce results that correlate with cMRI.MethodsWe recruited cardiac surgery patients who underwent cMRI within the preceding twelve preoperative months. An anesthetic protocol was followed pre-sternotomy and a 3D RV data set was acquired. We used TOMTEC 4D RV-Function to derive RV end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF). We compared these data with the corresponding MRI values.ResultsTwenty-five patients were included. Transesophageal echocardiography EDV and ESV differed from MRI measurements with a mean bias of –53 mL (95% confidence interval [CI], –80 to 26) and –21 mL (95% CI, –34 to –9). Transesophageal echocardiography EF did not differ significantly, with a mean bias of –4% (95% CI, –8 to 1). Results were unchanged after excluding MRIs older than 180 days. Correlation coefficients for EDV, ESV, and EF were r = 0.85, 0.91, and 0.80, respectively. Interclass correlation coefficients for EDV, ESV, and EF were 0.86, 0.89, and 0.96, respectively.ConclusionsIntraoperative TEE RV, EDV, and ESV are underestimated relative to cMRI because of analysis, anesthetic, and ventilation factors. The EF showed a low mean difference, and all values showed strong correlation with MRI. Reproducibility and feasibility were excellent and increased use in clinical practice should be considered.

Khaled, Maram; Youssef, Nayer; Choi, Stephen; Uppal, Vishal; Chui, Jason; Marcucci, Maura; Madden, Kim; Shanthanna, Harsha

doi: 10.1007/s12630-023-02537-9pmid: 37606836

PurposeWe sought to evaluate 1) patient- and anesthesiologist-reported rates of postoperative delirium (POD) risk discussion during preoperative meetings, 2) patients’ and anesthesiologists’ ratings of the importance of POD, and 3) predictors of patient-reported discussion of POD risk during preoperative meetings.MethodsIn this multicentre two-part cross-sectional survey study, patients ≥ 65 yr scheduled to undergo elective noncardiac surgery completed a five-minute survey after preoperative anesthesia consultation. Patients were asked about their perception of POD importance, and whether they discussed or were assessed for POD risk. Anesthesiologists were surveyed using self-administered surveys circulated via institutional email lists. Anesthesiologists were asked about the frequency of POD risk assessment and discussion in older adults, tools used, and perception of POD-screening barriers.ResultsFour hundred and twelve (of 510 approached) patients (50% male; mean age, 73 yr) and 267 anesthesiologists (of 1,205 invited via e-mail) participated in this study conducted in five Canadian hospitals. Postoperative delirium screening and discussion was reported by 88/412 (22%) patients and 229/267 (86%) anesthesiologists. Postoperative delirium was rated as “somewhat–extremely” important by 64% of patients. A previous history of delirium, higher education, the number of daily medications, and longer surgical duration were associated with POD discussion. On average, anesthesiologists rated the importance of POD at 8/10, and 42% ranked “patient risk factors” as the top reason prompting discussion.ConclusionThe combined evaluation of patients’ and anesthesiologists’ perspectives provides valuable information on preoperative POD screening and risk assessment, and highlights areas for improvement in the current practice. Most factors we identified to be associated with higher odds of POD discussion are recognized risk factors of POD.

Liu, Jingjing; Dong, Sulin; Li, Weiyi; Yu, Xinhua; Huang, Shaoqiang

doi: 10.1007/s12630-023-02564-6pmid: 37715046

PurposeAlthough the Enhanced Recovery After Cesarean Delivery (ERAC) consensus statement provides recommendations for early postoperative drinking and eating, evidence from high-quality clinical research directly addressing parturients is sparse. Our objective was to assess if early oral carbohydrate intake after elective Cesarean delivery improves maternal recovery.MethodsIn this randomized controlled trial, we enrolled parturients undergoing elective Cesarean delivery under spinal anesthesia with tympanic membrane temperatures ≤ 36.5 °C immediately upon arrival at the postanesthesia care unit. Parturients were randomized to either 100 mL of oral complex carbohydrate intake (group CC) or 10 mL of water (group C). The primary outcome was maternal tympanic membrane temperature. Other outcomes included maternal thermal comfort score, degree of shivering, satisfaction, degree of thirst and hunger, and gastric emptying assessed by ultrasonography.ResultsWe included 90 participants in the final analysis. The mean (standard deviation [SD]) maternal body temperature at 120 min after ingestion was 36.7 (0.3) °C in group CC and 36.6 (0.3) °C in group C (difference in means, 0.14 °C; 95% confidence interval, 0.02 to 0.26; P = 0.02). Furthermore, using repeated measure models, the linear trends of temperature changes over time between groups CC and C were significantly different (P = 0.04). The thermal comfort scores at 120 min after ingestion were higher in group CC than in group C (P = 0.02), and the linear trends of shivering score changes over time between groups CC and C also were different (P = 0.003). The mean (SD) visual analogue scale scores for maternal satisfaction were 84 (13) mm in group CC and 47 (20) mm in group C (P < 0.001). Nevertheless, at 90 and 120 min after ingestion, there were no differences between the two groups in the number of participants with a gastric antrum cross-sectional area > 10.3 cm2.ConclusionsEarly oral carbohydrate intake after Cesarean delivery helped to restore maternal body temperature postoperatively and improve maternal satisfaction. Nevertheless, the clinical importance of these finding is unclear, given that most of the differences were small. In addition, there was no delay in maternal gastric emptying after consumption of a complex carbohydrate beverage in the early post-Cesarean period.Study registrationwww.chictr.org.cn (ChiCTR2000031085); first submitted 13 November 2022.

Kim, Yoon Jung; Jung, Chul-Woo; Choi, Seungeun; Kim, Youngwon; Seo, Jeoung-Hwa

doi: 10.1007/s12630-023-02532-0pmid: 37505419

PurposeThe use of smart glasses during ultrasound-guided needle procedures may reduce operators’ head movements but has not been shown to improve procedural performance. Laser guidance has been shown to decrease the time required for ultrasound-guided procedures in phantom models but has not been tested clinically. We hypothesized that adding laser guidance to the use of smart glasses for ultrasound-guided radial artery catheterization using the long axis approach would improve performance by relatively inexperienced users unfamilar with these techniques.MethodsIn an unblinded controlled trial, we enrolled 52 patients requiring radial artery catheterization under anesthesia, randomized into two groups: smart glasses only (SO) (control; N = 26) or smart glasses with laser guidance group (SL) (N = 26). We assessed catheterization time (primary outcome), the number of needle redirections, first-pass success rate, and operator satisfaction (100 = most satisfactory; 0 = unsatisfactory).ResultsComparing the SL with the SO group, catheterization time was shorter (median [interquartile range], 13 [9–20] sec vs 24 [18–46] sec, P < 0.001) and the number of needle redirections was lower (0 [0–1] vs 3 [1–3], P < 0.001) while the first-pass success rate (50% vs 12%, P = 0.007) and operator satisfaction score (85 [76–95] vs 52 [44–74], P < 0.001) were higher.ConclusionLaser guidance improved the performance of ultrasound-guided radial artery catheterization using smart glasses in users inexperienced in the long axis in-plane approach. Nevertheless, it is unclear whether these findings are clinically significant.Study registration dateCRIS.nih.go.kr (KCT0007168); registered 8 April 2022.

Noppens, Ruediger R.; Dar, Farzad Izaddoust; Banik, Sujoy

doi: 10.1007/s12630-023-02563-7pmid: 37697100

PurposeMemsorb™ is a novel device for carbon dioxide (CO2) removal from anesthesia circuits via a semipermeable polymeric membrane. We evaluated the performance of the memsorb device for the removal of CO2 in an Aisys™ CS2 machine and compared it with a standard chemical granulate absorber (CGA) using a high-fidelity lung simulator.MethodsWe used an in vitro lung simulator (DUCt) to control CO2 release by imitating alveolar gas exchange. The ventilator settings were identical for all measurements. The fresh gas flow (FGF) was randomized to either 0.5 L·min−1 or 2 L·min−1, completing three trials for each FGF for either memsorb or CGA. The EtCO2 and FICO2 levels were recorded for 30 min in each setting.ResultsEtCO2 was comparable between the groups with 2 L·min−1 FGF over the observation period. FICO2 was significantly higher in the memsorb group during the trial (2 L·min−1; 3.9 mm Hg; 95% CI, 4.4 to 3.3; P < 0.001). EtCO2 with 0.5 L·min−1 FGF was higher with memsorb than with CGA over the observation period (3.7 mm Hg; 95% CI, 2.7 to 4.7; P = 0.004). With 0.5 L·min−1 FGF, FICO2 was significantly higher in the memsorb group compared with CGA over the whole observation period (6 mm Hg; 95% CI, 6.4 to 5.5; P < 0.001).DiscussionCO2 was successfully removed from the anesthesia circuit. FICO2 was significantly higher with memsorb throughout the observation period. Nevertheless, the clinical impact of these observations remains unclear. Further clinical trials are required to determine the utility of the novel device.

Girard, Julie; Zaouter, Cédrick; Moore, Alex; Carrier, François M.; Girard, Martin

doi: 10.1007/s12630-023-02533-zpmid: 37498442

PurposePostoperative pulmonary complications (PPCs) are a common cause of morbidity. Postoperative atelectasis is thought to be a significant risk factor in their development. Recent imaging studies suggest that patients’ extubation may result in similar postoperative atelectasis regardless of the intraoperative mechanical ventilation strategy used. In this pilot trial, we hypothesized that a study investigating the effects of an open lung extubation strategy compared with a conventional one on PPCs would be feasible.MethodsWe conducted a pilot, single-centre, double-blinded randomized controlled trial. Adult patients at moderate to high risk of PPCs and scheduled for elective surgery were eligible. Patients were randomized to an open lung extubation strategy (semirecumbent position, fraction of inspired oxygen [FIO2] 50%, pressure support ventilation, unchanged positive end-expiratory pressure) or to a conventional extubation strategy (dorsal decubitus position, FIO2 100%, manual bag ventilation). The primary feasibility outcome was global protocol adherence while the primary exploratory efficacy outcome was PPCs.ResultsWe randomized 35 patients to the conventional extubation group and 34 to the open lung extubation group. We observed a global protocol adherence of 96% (95% confidence interval, 88 to 99), which was not different between groups. Eight PPCs occurred (two in the conventional extubation group vs six in the open lung extubation group). Less postoperative supplemental oxygen and better lung aeration were observed in the open lung extubation group.ConclusionsIn this single-centre pilot trial, we observed excellent feasibility. A multicentre pilot trial comparing the effect of an open lung extubation strategy with that of a conventional extubation strategy on the occurrence of PPCs is feasible.Study registration dateClinicalTrials.gov (NCT04993001); registered 6 August 2021.

Akinkugbe, Olugbenga; Dhanani, Sonny; Watad, Salmas; Aravind, Prasant D.; Pereira, Myra; Dryden-Palmer, Karen; Alnaji, Fuad; Bell, Chaim; Devine, Luke; Fan, Eddy; Guerguerian, Anne-Marie; Helmers, Andrew; Lavigne, Melanie; Lee, Christie; Maratta, Christina;

Foster, Jennifer R.; Lee, Laurie A.; Seabrook, Jamie A.; Ryan, Molly; Slumkoski, Corey; Walls, Martha; Betts, Laura J.; Burgess, Stacy A.; Moghadam, Neda; Garros, Daniel; ,

doi: 10.1007/s12630-023-02547-7pmid: 37610552

PurposeLimiting family presence runs counter to the family-centred values of Canadian pediatric intensive care units (PICUs). This study explores how implementing and enforcing COVID-19-related restricted family presence (RFP) policies impacted PICU clinicians nationally.MethodsWe conducted a cross-sectional, online, self-administered survey of Canadian PICU clinicians to assess experience and opinions of restrictions, moral distress (Moral Distress Thermometer, range 0–10), and mental health impacts (Impact of Event Scale [IES], range 0–75 and attributable stress [five-point Likert scale]). For analysis, we used descriptive statistics, multivariate regression modelling, and a general inductive approach for free text.ResultsRepresenting 17/19 Canadian PICUs, 368 of 388 respondents (94%) experienced RFP policies and were predominantly female (333/368, 91%), English speaking (338/368, 92%), and nurses (240/368, 65%). The mean (standard deviation [SD]) reported moral distress score was 4.5 (2.4) and was associated with perceived differential impact on families. The mean (SD) total IES score was 29.7 (10.5), suggesting moderate traumatic stress with 56% (176/317) reporting increased/significantly increased stress from restrictions related to separating families, denying access, and concern for family impacts. Incongruence between RFP policies/practices and PICU values was perceived by 66% of respondents (217/330). Most respondents (235/330, 71%) felt their opinions were not valued when implementing policies. Though respondents perceived that restrictions were implemented for the benefit of clinicians (252/332, 76%) and to protect families (236/315, 75%), 57% (188/332) disagreed that their RFP experience was mainly positive.ConclusionPediatric intensive care unit-based RFP rules, largely designed and implemented without bedside clinician input, caused increased psychological burden for clinicians, characterized as moderate moral distress and trauma triggered by perceived impacts on families.

Lu, Justin; Karkouti, Keyvan; Peer, Miki; Englesakis, Marina; Spinella, Philip C.; Apelseth, Torunn O.; Scorer, Thomas G.; Kahr, Walter H. A.; McVey, Mark; Rao, Vivek; Abrahamyan, Lusine; Lieberman, Lani; Mewhort, Holly; Devine, Dana V.; Callum, Jeannie;

Fox, W. Everett; Kleiman, Amanda M.; McNeil, John S.; Blank, Randal S.

doi: 10.1007/s12630-023-02528-wpmid: 37434069