Canadian Journal of Anesthesia/Journal canadien d'anesthsie

Ke, Janny X. C.; Smith, Mindy A.; Sparrow, Kathryn; West, Nicholas; Yee, May-Sann; Yoo, Kang Mu; Sun, Louise Y.; Beattie, W. Scott; Görges, Matthias; ,

doi: 10.1007/s12630-025-02951-1pmid: 40394406

PurposeThe aim of this study was to develop a consensus list of metrics to measure the quality of care in anesthesia, perioperative care, and acute pain management in Canada.MethodsWe sought to conduct a modified Delphi study involving a multidisciplinary panel of perioperative health care professionals (anesthesiologists, surgeons, nurses, internal medicine and family medicine physicians, and hospital administrators), patients, and caregivers. Participants reviewed a candidate list of metrics synthesized from a previous scoping review and performed three rounds of independent iterative scoring and feedback to achieve consensus. In round 3, we asked participants to identify priority metrics to include in a list of core metrics, and we also asked health care professionals to assess the feasibility of implementing each metric.ResultsThere were 80 participants (49 health care professionals, 22 patients, and 9 caregivers) who completed at least one round of voting, with 56 completing all three rounds. The panel achieved consensus on 87 metrics, of which they deemed 33 to be priority core metrics. The health care professional and patient/caregiver subgroups differed in prioritizing core metrics. Most participants voted airway complications, no residual neuromuscular blockade, difficult airway documentation, complication or critical incident reporting, and complications from pain management the highest priority metrics. Most health care professional participants considered the core metrics to be already measured, currently feasible, or likely feasible by 2025.ConclusionsA multidisciplinary panel developed a list of metrics for measuring the quality of anesthesiology care in Canada. Many metrics require further refinement and validation, and future research is required to guide the measurement techniques and implementation approaches.

Lee, Sandra; Islam, Nehal; Ladha, Karim S.; Bicket, Mark C.; Wijeysundera, Duminda N.

doi: 10.1007/s12630-025-02925-3pmid: 40244359

PurposeHypotension occurs frequently during neuraxial anesthesia and is associated with increased risks of perioperative complications. We sought to conduct a systematic review and meta-analysis of randomized controlled trials that evaluated interventions intended to mitigate exposure to intraoperative hypotension and prevent complications following the administration of neuraxial anesthesia for major nonobstetric noncardiac surgery.SourceWe searched MEDLINE, Embase, PubMed®, and the Cochrane Controlled Register of Trials (database inception to 2 August 2023) for randomized controlled trials (RCTs) that evaluated interventions intended to reduce hypotension during neuraxial anesthesia in major noncardiac nonobstetric surgery, without any restrictions on the comparator type. The outcomes of interest were any measure of intraoperative hypotension (e.g., incidence, duration) and postoperative complications.Principal findingsAmong 33 included RCTs (n = 3,880) evaluating six classes of interventions, interventions that reduced the risk of hypotension included colloid preload (vs crystalloid, risk ratio [RR], 0.48; 95% confidence interval [CI], 0.30 to 0.80; P = 0.004; I2 = 12%; very-low-certainty evidence) and prophylactic ondansetron (vs placebo; RR, 0.64; 95% CI, 0.53 to 0.78; P < 0.001; I2 = 39%; moderate-certainty evidence). Prophylactic ephedrine was also associated with reduced time spent in hypotension. Nevertheless, crystalloid preloading did not reduce risks of hypotensive events compared with no preload (RR, 1.36; 95% CI, 0.96 to 1.92; P = 0.09; I2 = 0%; very-low-certainty evidence). There were no compelling data showing that these interventions reduced the risks of complications.ConclusionsSeveral interventions hold promise for mitigating exposure to hypotension following neuraxial anesthesia, albeit supported by very-low to moderate-certainty evidence. It remains unclear whether these interventions reduce the risks of postoperative complications.Study registrationPROSPERO (https://clinicaltrials.gov/CRD42022336197); first submitted 29 May 2022.

Diep, Calvin; Jaffe, Rachael; Witiw, Christopher; Daza, Julian F.; Wijeysundera, Duminda N.; Ravi, Bheeshma; Ladha, Karim S.

doi: 10.1007/s12630-025-02960-0pmid: 40355799

PurposePostoperative complications can steer patients away from a typical surgical recovery trajectory and hinder their ability to work and earn income. We aimed to quantify these effects for working-aged adults after elective joint replacement surgery.MethodsWe conducted a population-based cohort study of adults aged 30–63 yr having elective hip or knee arthroplasty using the Canadian Hospitalization and Taxation Database from 2004 to 2019. Our primary exposure was a postoperative complication, defined as a composite of adverse medical events, intensive care unit visit, or rehospitalization within thirty days. Our coprimary outcomes were employment and earnings in the second calendar year after surgery. We matched patients with complications 1:1 to those without complications using a propensity score considering demographic, medical, and financial characteristics. We used probit regression to assess employment after surgery and difference-in-difference ordinary least squares regression for the change in earnings from before to after surgery.ResultsWe included 222,087 adults undergoing an elective hip or knee replacement. In total, 6.3% experienced postoperative complications. In the second year after surgery, 55.1% of patients with complications were working compared with 57.3% of patients without complications (−2.2 percentage points [pp], 95% confidence interval [CI], −3.5 to −1.0). Patients with complications had a CAD 1,782 greater decline in annual earnings from before surgery (95% CI, −2,775 to −789; values inflated to 2023 Canadian dollars) than patients without complications.ConclusionsPostoperative complications resulted in a lower likelihood of employment and lower earnings after elective hip or knee replacement surgery. This may also have broader economic implications.

Jo, Woo-Young; Hong, Chan-Ho; Shin, Kyung Won; Oh, Hyongmin; Park, Hee-Pyoung

doi: 10.1007/s12630-025-02946-ypmid: 40214868

PurposeThe head-elevated position during videolaryngoscopic intubation enables better visualization of the glottis than the head-flat position. We hypothesized that the head-elevated position would result in less cervical spine motion during videolaryngoscopic intubation under manual in-line stabilization.MethodsWe conducted a randomized controlled trial in which we assigned patients undergoing coil embolization for unruptured cerebral aneurysms into the head-elevated (N = 55) or head-flat (N = 54) groups. Manual in-line stabilization was applied to simulate cervical spine immobilization during Macintosh-type videolaryngoscopic intubation. To measure the cervical spine angle, two lateral cervical spine radiographs using the capture method were taken, one before and one during intubation, respectively. The primary outcome was cervical spine motion during intubation (cervical spine angle during intubation − cervical spine angle before intubation) at the occiput–C1 segment. We investigated cervical spine motion at the C1–C2 and C2–C5 segments; intubation performance, such as the success rate at the first attempt, intubation time, and frequency of external laryngeal maneuver; and intubation-associated airway complications (airway bleeding, injury, sore throat, and hoarseness).ResultsThere was significantly less cervical spine motion at the occiput–C1 segment in the head-elevated group than the head-flat group (mean [standard deviation], 8.6° [5.6°] vs 11.4° [5.7°]; mean difference [95% confidence interval], −2.9° [−5.0 to −0.7]; P = 0.009). Cervical spine motion at the C1–C2 and C2–C5 segments, intubation performance, and intubation-associated airway complications did not significantly differ between the groups.ConclusionsThe head-elevated position during Macintosh-type videolaryngoscopic intubation with manual in-line stabilization resulted in less upper cervical spine motion than the head-flat position.Study registrationCRIS.nih.go.kr (KCT0008669); date of registration (approved), 1 August 2023.

Song, Seung Eun; Jung, Ji-Yoon; Jung, Chul-Woo; Park, Jung Yeon; Kim, Won Ho; Yoon, Hyun-Kyu

doi: 10.1007/s12630-025-02952-0pmid: 40281329

PurposeThe aim of this study was to evaluate the first-pass success rate of videolaryngoscopic intubations without a stylet using a Macintosh blade and to identify predictive factors for successful intubation.MethodsWe conducted a prospective observational study of 224 adult patients scheduled for elective videolaryngoscopic intubations using a Macintosh blade. We excluded patients who had cervical spine issues, airway disease, anticipated difficult intubation, or a body mass index > 35 kg·m−2, or who required rapid sequence induction. We initially attempted intubations without a stylet, with laryngeal manipulation on the second attempt if needed, and a stylet added after two failures. We evaluated the first-pass success rate and identified predictive factors using multivariable logistic regression, incorporating demographic, conventional, and ultrasonographic airway parameters. We performed ultrasound examination after induction of general anesthesia. We developed and evaluated a prediction model using receiver operating characteristic curve analysis.ResultsThe first-pass success rate was 80% (180/224), increasing to 96% (215/224) after laryngeal manipulation on the second attempt. Nine patients (4%) required a stylet. Longer sternomental distance (odds ratio [OR], 1.24; 95% confidence interval [CI], 1.01 to 1.53; P = 0.04) and increased thyromental height (OR, 1.14; 95% confidence interval [CI], 1.07 to 1.21; P < 0.001) were associated with first-pass success without a stylet. Limited (OR, 0.39; 95% CI, 0.16 to 1.00; P = 0.049) or severely limited (OR, 0.05; 95% CI, 0.01 to 0.19; P < 0.001) cervical spine movement negatively affected success.ConclusionsRoutine stylet preparation for elective videolaryngoscopic intubations with a Macintosh blade may not be necessary, as only a small percentage of patients required it.

Flick, Moritz; Jannsen, Gyde P.; Krause, Linda; Montomoli, Jonathan; Pollok, Franziska; Moll-Khosrawi, Parisa; Kouz, Karim; Bergholz, Alina; Thomsen, Kristen K.; Hilty, Matthias P.; Ince, Can; Zöllner, Christian; Saugel, Bernd

doi: 10.1007/s12630-025-02941-3pmid: 40355801

PurposeIt remains unknown whether the sublingual microcirculation is impaired during noncardiac surgery. We, therefore, aimed to investigate the sublingual microcirculation in patients undergoing major abdominal surgery. Specifically, we sought to test the primary hypothesis that the sublingual microcirculation is persistently impaired during major abdominal surgery.MethodsIn this prospective observational study, we assessed the sublingual microcirculation using vital microscopy before induction of general anesthesia, at the time of surgical incision, every 20 min during surgery, and on the first postoperative day in 46 patients undergoing major abdominal surgery. The primary endpoint was the area under a proportion of perfused vessels (PPV) of 92% as a measure of the duration and severity of capillary red blood cell flow impairment.ResultsThe median [interquartile range (IQR)] intraoperative area under a PPV of 92% was 71%⋅min [2%⋅min–278%⋅min], and the median [IQR] time-weighted average PPV < 92% was 0.3% [0%–0.9%]. Twelve patients (26%) had an area under a PPV of 92% of 0%⋅min, and five patients (11%) had an area under a PPV of 92% of 400%⋅min or higher. The duration of surgery had no clinically important persistent effect on intraoperative PPV or any other sublingual microcirculation variable. The lowest intraoperative PPV was lower than the PPV at incision (estimated difference, −5.3%; 95% confidence interval, −6.3 to −4.4; P < 0.001).ConclusionsThe area under a PPV of 92% during elective major abdominal surgery was small, indicative of little impairment of sublingual microcirculation. The duration of surgery had no clinically important effect on sublingual microcirculatory variables.

Nguyen-Minh, Thi; Hönemann, Christian; Zarbock, Alexander; Rübsam, Marie-Luise

doi: 10.1007/s12630-025-02959-7pmid: 40399737

PurposeDuring general anesthesia, physiologic conditioning of inspired gases is bypassed. Mechanical ventilation with dry and cold gas from the central gas supply may lead to dehydration of the mucus membranes, cilia dysfunction, retention of secretions, and atelectasis. The use of metabolic fresh gas flow improves the conditioning of inspiratory gases but increases water vapour condensation within the breathing system. We sought to investigate the effects of breathing circuit insulation on the conditioning of inspired gases and the condensation of water vapour.MethodsIn this in vitro study, we used a mechanical nonheated, nonhumidified lung model with carbon dioxide (CO2) insufflation. We tested foam, cotton, and polyester insulation (FOI, COI, and PEI) against control (noninsulated regular tubing). We measured temperature, absolute humidity (AH), and water vapour condensation after 120 min. We performed 8 measurements per group (total N = 32) and adjusted P values and confidence intervals (CIs) for multiple testing using Bonferroni–Holm adjustment.ResultsRegarding mean AH, FOI performed better than control. The mean (standard deviation [SD]) differences in AH between control and insulation were −0.63 (0.52) g·m−3 H2O for PEI (adjusted 95% CI, −1.42 to 0.17; P = 0.26), −0.63 (0.74) g·m−3 H2O for COI (adjusted 95% CI, −1.42 to 0.17; P = 0.26), and −1.13 (0.35) g·m−3 H2O for FOI (adjusted 95% CI, −1.92 to −0.33; P < 0.001). The mean temperature was higher in insulated circuits. The mean (SD) difference compared to control was 0.42 (0.28) °C for PEI (adjusted 95% CI, 0.05 to 0.79; P = 0.002), 0.62 (0.26) °C for COI (adjusted 95% CI, 0.25 to 0.99; P < 0.001), and −1.07 (0.14) °C for FOI (adjusted 95% CI, 0.70 to 1.44; P < 0.001). Condensation of water vapour was lower in insulated breathing circuits compared with control.ConclusionFoam-based insulation was the most effective form of insulation of the breathing circuit to increase temperature and AH of inspired gases and to reduce water vapour condensation. Overall, the results of this in vitro study support the principle of breathing circuit insulation as a method for inspired gas conditioning during the use of metabolic flow anesthesia.

Crozier, Mitchell; McVicar, Jason; Lorello, Gianni R.; Mottiar, Miriam; Wilson, C. Ruth; Orser, Beverley A.

doi: 10.1007/s12630-025-02949-9pmid: 40314871

PurposeAccording to an analysis of data from the Canadian Institutes for Health Information (CIHI) National Physician Database, the proportion of female anesthesia physicians is substantially lower than the proportion of female physicians in the total physician population. The goal of this study was to identify trends in female representation in the major subgroups of anesthesia providers, including specialists certified by the Royal College of Physician and Surgeons of Canada (RCPSC), international medical graduates, and family physician anesthetists (FPAs).MethodsWe examined the sex distribution of the existing physician workforce, including anesthesia providers working in urban and rural Canada, using the CIHI National Physician Database (1996–2018). We also examined the sex distribution of physicians entering the workforce using the Canadian Post-MD Education Registry database and calculated descriptive statistics.ResultsThe proportion of female physicians increased steadily over time in all groups; nevertheless, the numbers of female FPAs and rural anesthesia providers continued to lag relative to all Canadian physicians (9.4%, 9.4%, and 26.7%, respectively, in 1996; 18.7%, 21.1%, and 42.1%, respectively, in 2018). Of the graduates from RCPSC training programs in 1996, 28% were female, whereas by 2018, 33.5% of graduates were female.ConclusionsFemale physicians were underrepresented in all subgroups, but the proportions were lowest among FPAs and rural physicians. Given that greater sex diversity in clinical teams is associated with better outcomes, and in light of ongoing workforce shortages, the barriers that prevent female physicians from entering and/or remaining in the anesthesia workforce need to be understood and ameliorated.