Canadian Journal of Anesthesia/Journal canadien d anesthésie

Clinkard, David; Buckley, Norman; Diatchenko, Luda; Ghasemlou, Nader

doi: 10.1007/s12630-024-02837-8pmid: 39285126

Hanouz, Jean-Luc; Lefrançois, Valentin; Boutros, Mariam; Fiant, Anne Lise; Simonet, Thérèse; Buléon, Clément

doi: 10.1007/s12630-024-02815-0pmid: 39147992

PurposeThe modified Mallampati classification is part of the preoperative airway risk assessment. Inconsistency in the way it is examined may contribute to heterogeneity in its diagnostic performance. The best visible Mallampati score could reduce interobserver heterogeneity but its diagnostic characteristics remain unknown.MethodsDuring preoperative anesthesia consultation of adult patients with a senior anesthesiologist, we compared the modified Mallampati classification score vs the best visible Mallampati score using cervical extension, tongue in, and phonation. The primary outcome was the diagnostic characteristic of the modified Mallampati classification score vs the best visible Mallampati score as predictors of difficult orotracheal intubation (more than two direct laryngoscopies or need for an alternate device). We performed a multivariable analysis to identify independent predictors of difficult orotracheal intubation in the tested cohort.ResultsDifficult orotracheal intubation occurred in 77/3,243 (2.4%) patients. A best visible Mallampati score was obtained in 1,596 (49.2%) patients. Sensitivity and specificity of the modified Mallampati classification score for predicting difficult orotracheal intubation were 0.56 (95% confidence interval [CI], 0.44 to 0.66) and 0.69 (95% CI, 0.68 to 0.71), respectively. By comparison, the best visible Mallampati score was less sensitive (difference, −0.30; 95% CI, −0.19 to −0.30; P < 0.001) but more specific (difference, 0.24; 95% CI, 0.22 to −0.25; P < 0.001). In patients with difficult orotracheal intubation, 53% were incorrectly reclassified as low risk by the best visible Mallampati score.ConclusionCompared with the modified Mallampati classification score, the best visible Mallampati score decreased sensitivity for predicting difficult orotracheal intubation and falsely classified half of the patients with difficult orotracheal intubation. Taking the risks associated with difficult airways into account, our findings indicate that a careful examination of the modified Mallampati classification is required during the global preoperative airway examination.Study registrationClinicalTrials.gov (NCT02788253); 9 February 2016.

Boonstra, Linda; Carvalho, Jose C. A.; Turner, William; Downey, Kristi; Ye, Xiang Y.; Thomas, Jackie; Balki, Mrinalini

doi: 10.1007/s12630-024-02828-9pmid: 39300008

PurposeThe purpose of our study was to determine the minimum effective dose of oxytocin maintenance infusion required to maintain adequate uterine tone in 90% of patients (ED90) after administration of the initial bolus at elective Cesarean delivery (CD) under spinal anesthesia.MethodsWe conducted a prospective, double-blind dose-finding study with biased coin up-down design. Immediately after delivery, a 1-IU oxytocin bolus was administered, followed by a maintenance infusion. The obstetrician assessed the uterine tone by palpation as satisfactory or unsatisfactory. In case of unsatisfactory response, the dose for the next patient was increased by 2 IU·hr−1. For satisfactory response, the dose for the next patient was either decreased by 2 IU·hr−1 with a probability of 1/9, or remained unchanged. The primary outcome was a satisfactory uterine tone from five minutes after delivery until discharge from postanesthesia care unit. The secondary outcomes were blood loss, need for additional uterotonics, and side effects.ResultsWe analyzed data for 40 patients. The ED90 of oxytocin maintenance infusion was 4.5 IU·hr−1 (95% confidence interval, 3.3 to 5.5) based on the isotonic regression estimator. The median [interquartile range] blood loss was 861 [553–1,181] mL; 18% received additional uterotonics, and 38% developed hypotension post delivery.ConclusionBased on the results of this dose-finding study, we recommend a maintenance infusion rate of 4.5 IU·hr−1 following an oxytocin bolus of 1 IU for adequate uterine tone in pregnant patients undergoing elective CDs. This infusion rate is four-fold lower than that required without an initial bolus.Study registrationClinicalTrials.gov (NCT04946006); first submitted 25 June 2021.

Amaral, Sara; Zerriny, Salim; Alrayashi, Walid

doi: 10.1007/s12630-024-02832-zpmid: 39289259

PurposeCharcot–Marie–Tooth (CMT) disease is an inherited neurologic disorder characterized by progressive peripheral neuropathies. The use of peripheral nerve blocks (PNB) in patients with CMT disease has been controversial because of concerns about exacerbating existing neurologic impairments and the “double hit” hypothesis. We aimed to assess the use of PNB in pediatric patients with CMT disease undergoing orthopedic surgery to address the limited data available in the literature on this topic.MethodsIn this retrospective cohort study, we included all pediatric patients with CMT disease scheduled for orthopedic surgery receiving PNB at our centre. All of the patients had preoperative neurologic exams and received one or more ultrasound-guided regional anesthesia techniques. Data extracted included details of anesthesia technique, surgical procedure, opioid consumption, and pain scores during the first three postoperative days. We also reviewed any complications such as neurologic deficits and local anesthetic toxicity. We used descriptive statistics to summarize the findings.ResultsWe included 25 patients, 14 of whom (56%) presented with pre-existing neurologic deficits, primarily in the lower extremities. Postoperative assessments revealed no new neurologic impairments in 24/25 (96%) patients, with only one patient experiencing a nerve injury possibly related to the surgical procedure. Opioid consumption was low in the postanesthesia care unit and on the day of surgery. No additional complications were noted in the first 72 hr after surgery.ConclusionDespite concerns, PNB showed favourable outcomes in a pediatric cohort with CMT disease, with low opioid consumption and pain scores and minimal complications during follow-up. These findings match previous reports of adult patients with CMT disease and suggest that the benefits of PNB may outweigh the perceived risks in pediatric patients with CMT disease.

Dieiev, Vladyslav; Dubrov, Sergii; Díaz-Gómez, José L.; Stevens, Rom A.; Salinas, Pedro; Gudzenko, Vadim; Matolinets, Nataliya; Kravets, Olga; Krishtafor, Daria; Pavlysh, Oleksandr; Cherniaiev, Stepan; Pustavoitau, Aliaksei

doi: 10.1007/s12630-024-02789-zpmid: 38918272

PurposeDespite the potential value of point-of-care ultrasonography (POCUS) in resource-limited environments, it is not widely used in low- and middle-income countries compared with high-income countries. We sought to evaluate the current POCUS practice of Ukrainian anesthesiologists who attended POCUS courses to guide future POCUS training in Ukraine.MethodsWe conducted a 25-question web-based survey. It was distributed to 255 participants of POCUS courses held in Ukraine in 2023. The survey sections described current POCUS practice, perception of POCUS value, POCUS skills self-assessment, and perceived barriers to implementing POCUS in clinical practice.ResultsTwo hundred and forty-four out of 255 course participants completed the survey, representing 214 unique respondents. Those who self-rated their skills identified themselves as either novices or beginners in areas of POCUS knowledge (118/157, 75%), image acquisition (110/158, 70%), image interpretation (117/158, 74%), and integration into clinical decision-making (105/155, 68%). Among all survey responders, 55% (118/214) reported using POCUS for vascular access procedures, 45% (97/214) for trauma assessment, and 44% (93/214) for regional anesthesia. Reported barriers to POCUS implementation included lack of ultrasound devices (101/214, 47%) and lack of trained faculty (112/214, 52%).ConclusionAmong anesthesiologists who participated in POCUS courses in Ukraine, the majority were in early stages of ultrasound practice. Respondents identified POCUS applications not currently practiced and evaluated barriers to POCUS use. Based upon these survey findings, we propose the following measures in Ukraine: 1) developing a standardized national POCUS curriculum; 2) increasing the number of experienced instructors of POCUS; and 3) acquiring ultrasound devices to support clinical applications of POCUS, especially in the Central, Southern, and Eastern regions.

Tworek, Kimberly B.; Ma, Chen-Hsiang; Opgenorth, Dawn; Baig, Nadia; Zampieri, Fernando G.; Basmaji, John; Rochwerg, Bram; Lewis, Kimberley; Kilcommons, Sebastian; Mehta, Sangeeta; Honarmand, Kimia; Stelfox, H. Tom; Wilcox, M. Elizabeth; Kutsogiannis, Demetrios J.; Fiest, Kirsten M.; Karvellas, Constantine J.; Sligl, Wendy; Rewa, Oleksa; Senaratne, Janek; Sharif, Sameer; Bagshaw, Sean M.; Lau, Vincent I.

doi: 10.1007/s12630-024-02800-7pmid: 39042215

PurposeOpioids remain the mainstay of analgesia for critically ill patients, but its exposure is associated with negative effects including persistent use after discharge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be an effective alternative to opioids with fewer adverse effects. We aimed to describe beliefs and attitudes towards the use of NSAIDs in adult intensive care units (ICUs).MethodsOur survey of Canadian ICU physicians was conducted using a web-based platform and distributed through the Canadian Critical Care Society (CCCS) email distribution list. We used previously described survey development methodology including question generation and reduction, pretesting, and clinical sensibility and pilot testing.ResultsWe received 115 completed surveys from 321 CCCS members (36%). Nonsteroidal anti-inflammatory drugs use was most described as “rarely” (59 respondents, 51%) with the primary concern being adverse events (acute kidney injury [108 respondents, 94%] and gastrointestinal bleeding [92 respondents, 80%]). The primary preferred analgesic was acetaminophen (75 respondents, 65%) followed by opioids (40 respondents, 35%). Most respondents (91 respondents, 80%) would be willing to participate in a randomized controlled trial examining NSAID use in critical care.ConclusionsIn our survey, Canadian critical care physicians did not mention commonly using NSAIDs primarily because of concerns about adverse events. Nevertheless, respondents were interested in further studying ketorolac, a commonly used NSAID outside of the ICU, in critically ill patients.

Sheikh, Fatima; Douglas, William; Diao, Yi (David); Correia, Rebecca H.; Gregoris, Rachel; Machon, Christina; Johnston, Neil; Fox-Robichaud, Alison E.; ,

doi: 10.1007/s12630-024-02790-6pmid: 38955983

PurposeWe aimed to identify whether social determinants of health (SDoH) are associated with the development of sepsis and assess the differences between individuals living within systematically disadvantaged neighbourhoods compared with those living outside these neighbourhoods.MethodsWe conducted a single-centre case-control study including 300 randomly selected adult patients (100 patients with sepsis and 200 patients without sepsis) admitted to the emergency department of a large academic tertiary care hospital in Hamilton, ON, Canada. We collected data on demographics and a limited set of SDoH variables, including neighbourhood household income, smoking history, social support, and history of alcohol disorder. We analyzed study data using multivariate logistic regression models.ResultsThe study included 100 patients with sepsis with a median [interquartile range (IQR)] age of 75 [58–84] yr and 200 patients without sepsis with a median [IQR] age of 72 [60–83] yr. Factors significantly associated with sepsis included arrival by ambulance, absence of a family physician, higher Hamilton Early Warning Score, and a recorded history of dyslipidemia. Important SDoH variables, such as individual or household income and race, were not available in the medical chart. In patients with SDoH available in their medical records, no SDoH was significantly associated with sepsis. Nevertheless, compared with their proportion of the Hamilton population, the rate of sepsis cases and sepsis deaths was approximately two times higher among patients living in systematically disadvantaged neighbourhoods.ConclusionsThis study revealed the lack of available SDoH data in electronic health records. Despite no association between the SDoH variables available and sepsis, we found a higher rate of sepsis cases and sepsis deaths among individuals living in systematically disadvantaged neighbourhoods. Including SDoH in electronic health records is crucial to study their effect on the risk of sepsis and to provide equitable care.

O’Grady, Heather K.; Ball, Ian; Berney, Sue; Burns, Karen E. A.; Cook, Deborah J.; Fox-Robichaud, Alison; Herridge, Margaret S.; Karachi, Timothy; Mathur, Sunita; Reid, Julie C.; Rochwerg, Bram; Rollinson, Thomas; Rudkowski, Jill C.; Bosch, Jackie; Turkstra, Lyn S.; Kho, Michelle E.

doi: 10.1007/s12630-024-02838-7pmid: 39317833

PurposePhysical rehabilitation (PR) in the intensive care unit (ICU) may improve outcomes for survivors but clinical trial results have been discordant. We hypothesized that discordant results may reflect treatment heterogeneity received by “usual care” comparator groups in PR studies. Usual-care PR is typically underspecified, which is a barrier to comparing results across treatment studies. The primary objective of the present study was to describe the usual-care PR received by critically ill patients enrolled in the Canadian multicentre Critical Care Cycling to Improve Lower Extremity Strength (CYCLE) pilot randomized controlled trial (RCT) of PR. Other objectives were to help contextualize current research and provide data for international comparison.MethodsIn this secondary analysis of the CYCLE pilot RCT, patients were randomized to in-bed cycling and usual-care PR or usual-care PR alone. Physiotherapists documented usual-care PR including therapy received, type of activity, duration, adverse events and consequences, reasons for no PR, and concurrent relevant medical interventions. We characterized usual care using descriptive statistics at the cohort and patient levels.ResultsAcross seven Canadian centres, 30 patients were randomized to usual-care PR. The median [interquartile range (IQR)] ICU stay was 10 [9–24] days and patients received PR on a median [IQR] of 5 [3–9] days for 23 [17–30] min per day. Eighteen patients (60%) stood, marched, or walked during usual care. Transient adverse events occurred in three patients on 1.5% (3/198) of days and none prompted session termination.ConclusionsIn the usual-care arm of the CYCLE pilot RCT, PR was delivered on half of ICU days and over half of patients stood, marched, or walked. Adverse events during usual-care PR were uncommon.Study registrationClinicalTrials.gov (NCT02377830); first posted 4 March 2015.