Canadian Journal of Anesthesia/Journal canadien d anesthésie

McIsaac, Daniel I.; Berrio-Valencia, Marta; Miller, Elizabeth C.

doi: 10.1007/s12630-024-02718-0pmid: 38485834

Sibai, Jad; Karkouti, Keyvan; McCluskey, Stuart A.

doi: 10.1007/s12630-024-02738-wpmid: 38509436

Mc Donnell, Conor; Li, Casey; Matava, Clyde

doi: 10.1007/s12630-024-02763-9pmid: 38724871

PurposeIn this project, we sought to develop and implement pediatric anesthesia metrics into electronic health records (EHR) in a hospital setting to improve quality and safety of patient care. While there has been an upsurge in metric-driven health care, specific metrics catering to pediatric anesthesia remain lacking despite widespread use of EHR. The rapid proliferation and implementation of EHR presents opportunities to develop and implement metrics appropriate to local patient care, in this case pediatric anesthesia, with the strategic goal of enhancing quality and safety of patient care, while also delivering transparency in reporting of such metrics.Clinical featuresUsing a quasi-nominal consensus group design, we collected requirements from attending anesthesiologists using Agile methodology. Forty-five metrics addressing quality of care (e.g., induction experience, anesthesia delivery, unanticipated events, and postanesthetic care unit stay) and provider performance (e.g., bundle-compliance, collaboration, skills assurance) were developed. Implementation involved integration into the EHR followed by transition from PDF-based feedback to interactive Power BI (Microsoft Corporation, Redmond, WA, USA) dashboards.ConclusionWe introduced and implemented customized pediatric anesthesia metrics within an academic pediatric hospital; however, this framework is easily adaptable across multiple clinical specialties and institutions. In harnessing data-collecting and reporting properties of EHR, the metrics we describe provide insights that facilitate real-time monitoring and foster a culture of continuous learning in line with strategic goals of high-reliability organizations.

Wu, Fei; Smith, Matthew R.; Mueller, Ariel L.; Klapman, Seth A.; Everett, Lucinda L.; Houle, Timothy; Kuo, Braden; Hobai, Ion A.

doi: 10.1007/s12630-024-02719-zpmid: 38485835

PurposeWe aimed to estimate the association of glucagon-like peptide 1 (GLP-1) receptor agonist therapy with the incidence of endoscopically visible gastric contents after preprocedural fasting.MethodsWe reviewed the records of esophagogastroduodenoscopy (EGD) performed at our institution between 2019 and 2023 and determined the presence of residual gastric contents from the procedure notes and saved images. We compared patients taking GLP-1 agonists at the time of the procedure (GLP group, 90 procedures) with patients who started GLP-1 agonist therapy within 1,000 days after undergoing EGD (control, 102 procedures). We excluded emergent procedures without fasting, combined EGD/colonoscopy procedures, and patients with known gastroparesis or previous gastric surgery. We estimated the association between GLP-1 agonist therapy and residual gastric contents with a confounder-adjusted generalized linear mixed effect model.ResultsCompared with controls, the GLP cohort had a higher age, American Society of Anesthesiologists’ Physical Status, and incidence of nausea and diabetes mellitus. Body mass index and fasting duration were comparable between groups. Visible gastric content was documented in 17 procedures in the GLP group (19%) and in five procedures in the control group (5%), with an associated confounder adjusted odds ratio of 5.8 (95% confidence interval, 1.7 to 19.3; P = 0.004). There were five instances of emergent endotracheal intubation in the GLP group vs one case in control and one case of pulmonary aspiration vs none in control.ConclusionsIn fasting patients, GLP-1 agonist therapy was associated with an increased incidence of residual gastric contents, potentially posing an additional risk of periprocedural pulmonary aspiration.

Mizubuti, Glenio B.; Maxwell, Sarah; Shatenko, Sergiy; Braund, Heather; Phelan, Rachel; Ho, Anthony M.-H.; Dalgarno, Nancy; Hobbs, Hailey; Szulewski, Adam; Haji, Faizal; Arellano, Ramiro; ,

Lee, Jiwon; Lee, Jung-Man; Shim, Yon Hee; Cho, Joung Goo; Lee, Jimin; Lim, Jae-Yol; Chang, Chul Ho

doi: 10.1007/s12630-024-02743-zpmid: 38548948

PurposeWe sought to compare three intubation methods using different intubation techniques/tube materials for tube advancement from the nasal cavity into the oral cavity during nasotracheal intubation.MethodsWe conducted a randomized clinical trial with adult patients scheduled to undergo elective surgery requiring nasotracheal intubation for general anesthesia. Participants were randomly allocated to a polyvinyl chloride (PVC) tube group (group P), PVC tube attached to a rubber catheter group (group PR), or velvet-soft PVC tube group (group V). Tracheal intubation was then performed based on group allocation. The primary outcome was the first-attempt success rate of tube advancement into the oral cavity; secondary outcomes included the time required for tube advancement into the oral cavity, total intubation time, and the incidence of epistaxis.ResultsA total of 149 patients were included in the study. The first-attempt success rate in group V (90%) was significantly higher than that in group P (58%) (odds ratio, 6.5; 95% confidence interval [CI], 2.2 to 19.2), but similar to that in group PR (100%). The mean (standard deviation) time required for tube advancement into the oral cavity was significantly shorter in group V (16 [13] sec) than in group PR [40 (10) sec; 95% CI of mean difference, 17 to 30] and group P (26 [16] sec; 95% CI of mean difference, 3 to 16). Total intubation time was longest in group PR. Epistaxis occurred the least in group V.ConclusionsAmong the three intubation techniques/tube materials for nasotracheal intubation, the velvet-soft PVC tube provided the highest first-attempt success rate, most expeditious advancement into the oral cavity, and lowest incidence of epistaxis.Study registrationClinicalTrials.gov (NCT04695444); first submitted 30 December 2020.

Lokon, Aria; Nabecker, Sabine; Colvin, Christhoper; Venn, Stephanie; You-Ten, Kong Eric; Siddiqui, Naveed; Zasso, Fabricio B.

doi: 10.1007/s12630-024-02740-2pmid: 38480633

PurposeThe difficult airway cart is essential for difficult airway management. Recognition of the importance of human factors in critical scenarios promoted the evolution of the difficult airway cart. Limitation to essential equipment, a structured layout, and proper labelling should be observed. We sought to redesign the difficult airway cart accordingly and analyze how perioperative professionals reacted to it.MethodsWe conducted a two-phase prospective qualitative improvement project involving a multidisciplinary team. In phase 1, we reconfigured our difficult airway cart, including developing icons for labelling the drawers and discussing the equipment content. In phase 2, we delivered a multidisciplinary educational program and pre- and postsession questionnaires were administered to the professionals involved and compared.ResultsPhase 1 of the project encompassed 21 participants. We presented the final layout and content of the difficult airway cart. In phase 2, 44 participants responded the presession questionnaires, and 30 participants answered the postsession questionnaires. The results showed that the new design and the implementation program increased the comfort level of professionals involved in a potential airway crisis (presession mean [standard deviation (SD)]: anesthesiologists, 8.0 [1.9]; anesthesia assistants/respiratory therapists [AAs/RTs], 9.3 [0.8]; operating room registered nurses [OR RNs], 6.3 [2.7]; P = 0.001; postsession: anesthesiologists, 8.5 [2.0]; AAs/RTs, 9.6 [0.5]; OR RN, 7.9 [2.0]; P = 0.10). Nevertheless, the improvement was only statistically significant among the OR RNs (presession mean [SD]: 6.3 [2.7]; postsession: 7.9 [2.0]; P = 0.01). Additionally, the program facilitated the recognition of the location of airway equipment in the airway cart (positive responses ranging from 97% to 100%).ConclusionOur quality improvement project successfully designed and implemented a new visual-based difficult airway cart at our institution. We believe this report enables other institutions to reproduce our project.

Won, Dongwook; Kim, Hyerim; Chang, Jee-Eun; Lee, Jung-Man; Kim, Tae Kyong; Kim, Honghyeon; Min, Seong-Won; Hwang, Jin-Young

doi: 10.1007/s12630-024-02741-1pmid: 38507025

PurposeAnesthesiologists can use supraglottic airway devices as a rescue technique for failed intubation even in patients with an increased risk of gastric regurgitation. In this randomized study, we aimed to evaluate the effects of cricoid pressure and paratracheal pressure on placement of the i-gel® (Intersurgical Ltd., Wokingham, Berkshire, UK).MethodsAfter induction of anesthesia in 76 adult patients, we inserted the i-gel under paratracheal or cricoid pressure, and assessed the success rate of i-gel insertion, resistance during insertion, time required for insertion, accuracy of the insertion location, tidal volumes, and peak inspiratory pressure with or without each maneuver after i-gel insertion.ResultsThe overall success rate of insertion was significantly higher under paratracheal pressure than under cricoid pressure (36/38 [95%] vs 27/38 [71%], respectively; difference, 24%; 95% confidence interval [CI], 8 to 40; P = 0.006]. Resistance during insertion was significantly lower under paratracheal pressure than under cricoid pressure (P < 0.001). The time required for insertion was significantly shorter under paratracheal pressure than under cricoid pressure (median [interquartile range], 18 [15–23] sec vs 28 [22–38] sec, respectively; difference in medians, −10; 95% CI, −18 to −4; P < 0.001). Fibreoptic examination of the anatomical alignment of the i-gel in the larynx revealed no significant difference in the accuracy of the insertion location between the two maneuvers (P = 0.31). The differences in tidal volume and peak inspiratory pressure with or without the maneuvers were significantly lower with paratracheal pressure than with cricoid pressure (P = 0.003, respectively).ConclusionsInsertion of the i-gel supraglottic airway was significantly more successful, easier, and faster while applying paratracheal pressure than cricoid pressure.Study registrationClinicalTrials.gov (NCT05377346); first submitted 11 May 2022.

Ryan, Molly J.; Lee, Laurie; Drisdelle, Sara; Garros, Daniel; Seabrook, Jamie A.; Curran, Janet; Bretzler, Jacqueline; Slumkoski, Corey; Walls, Martha; Betts, Laura; Burgess, Stacy; Foster, Jennifer R.

doi: 10.1007/s12630-024-02742-0pmid: 38507024

PurposePediatric intensive care units (PICUs) worldwide restricted family presence in response to the COVID-19 pandemic. We aimed to explore the experiences and impact of restricted family presence policies on Canadian PICU clinicians.MethodsWe conducted a qualitative study that followed an interpretive phenomenological design. Participants were PICU clinicians providing direct patient care in Canada during periods of COVID-19-related restricted family presence. We purposively sampled for maximum variation among survey participants who consented to be contacted for further research on the same topic. In-depth interviews were conducted remotely via telephone or video-call, audio-recorded, and transcribed. Interviews were inductively coded and underwent thematic analysis. Proposed themes were member-checked by interviewees.ResultsSixteen PICU clinicians completed interviews. Interviewees practiced across Canada, represented a range of disciplines (eight nurses, two physicians, two respiratory therapists, two child life specialists, two social workers) and years in profession (0–34 years). We identified four themes representing the most meaningful aspects of restricted family presence for participants: 1) balancing infection control and family presence; 2) feeling disempowered by hospital and policy-making hierarchies; 3) empathizing with family trauma; and 4) navigating threats to the therapeutic relationship.ConclusionPediatric intensive care unit clinicians were impacted by restricted family presence policies during the COVID-19 pandemic. These policies contributed to feelings of disempowerment and challenged clinicians’ perceived ability to provide the best family-centred care possible. Frontline expertise should be incorporated into the design and implementation of policies to best support family-centred care in any context and minimize risks of moral distress for PICU clinicians.

Opgenorth, Dawn; Duquette, D’Arcy J.; Tyre, Linda; Auld, Robyn; Crowder, Kim; Gilchrist, Peggy; Young, Paul J.; Bagshaw, Sean M.

doi: 10.1007/s12630-024-02723-3pmid: 38459367

PurposeThe acceptability of waiver of consent for participation in clinical research in intensive care unit (ICU) settings is uncertain. We sought to survey the Canadian public to assess levels of support, comfort, and acceptability for waived consent for low-risk clinical trials.MethodsWe performed a prospective cross-sectional survey of the Canadian public aged 18 yr or older. The survey was conducted by Ipsos between 19 and 23 November 2020. The survey content was derived from a literature review and in consultation with a patient and family partnership committee. The survey focused on attitudes and beliefs on waived consent for participation in low-risk clinical trials in ICU settings. The survey contained 35 items focused on sociodemographics, general health status, participation in medical research, and levels of support and comfort with research and with waived consent. The survey used a case study of a low-risk clinical trial intervention in ICU patients. Analysis was descriptive.ResultsWe included 2,000 participants, 38% of whom reported experience with ICU and 16% with medical research. Participation in medical research was more common among those with postsecondary education, those with chronic disease, and those who were employed in health care. Most (80%) would support a model of waived consent for low-risk clinical trials, citing medical benefits (36%) and low perceived risk (34%). Most (77%) were comfortable with personally participating in a low-risk clinical trial. Most (80%) believed waived consent approaches were acceptable. Half (52%) believed the waived consent process should provide information about the research and include the option of opting out. When asked whether participants should always give full informed consent, regardless of the practicality or level of risk, 74% and 72% agreed, respectively.ConclusionsThere is public support for models of waived consent for participation in low-risk pragmatic clinical trials in ICU settings in Canada; however, this is not universal. This information can inform and guide education, ethics, policy, and legal discussion on consent models.