Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis of randomised controlled trials and observational studies.

BACKGROUND: Benzodiazepine use is associated with delirium, and guidelines recommend avoiding them in older and critically ill patients. Their perioperative use remains common because of perceived benefits. METHODS: We searched CENTRAL, MEDLINE, CINAHL, PsycInfo, and Web of Science from inception to June 2021. Pairs of reviewers identified randomised controlled trials and prospective observational studies comparing perioperative use of benzodiazepines with other agents or placebo in patients undergoing surgery. Two reviewers independently abstracted data, which we combined using a random-effects model. Our primary outcomes were delirium, intraoperative awareness, and mortality. RESULTS: We included 34 randomised controlled trials (n=4354) and nine observational studies (n=3309). Observational studies were considered separately. Perioperative benzodiazepines did not increase the risk of delirium (n=1352; risk ratio [RR] 1.43; 95% confidence interval [CI]: 0.9-2.27; I2=72%; P=0.13; very low-quality evidence). Use of benzodiazepines instead of dexmedetomidine did, however, increase the risk of delirium (five studies; n=429; RR 1.83; 95% CI: 1.24-2.72; I2=13%; P=0.002). Perioperative benzodiazepine use decreased the risk of intraoperative awareness (n=2245; RR 0.26; 95% CI: 0.12-0.58; I2=35%; P=0.001; very low-quality evidence). When considering non-events, perioperative benzodiazepine use increased the probability of not having intraoperative awareness (RR 1.07; 95% CI: 1.01-1.13; I2=98%; P=0.03; very low-quality evidence). Mortality was reported by one randomised controlled trial (n=800; RR 0.90; 95% CI: 0.20-3.1; P=0.80; very low quality). CONCLUSIONS: In this systematic review and meta-analysis, perioperative benzodiazepine use did not increase postoperative delirium and decreased intraoperative awareness. Previously observed relationships of benzodiazepine use with delirium could be explained by comparisons with dexmedetomidine. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42019128144.

An innovative approach to identifying learning needs for intrinsic CanMEDS roles in continuing professional development.

CONTEXT: The CanMEDS framework promotes the development of competencies required to be an effective physician. However, it is still not well understood how to apply such frameworks to CPD contexts, particularly with respect to intrinsic competencies. OBJECTIVE: This study explores whether physician narratives around challenging cases would provide information regarding learning needs that could help guide the development of CPD activities for intrinsic CanMEDS competencies. METHODS: We surveyed medical and surgical specialists from Southern Ontario using an online survey. To assess perceived needs, participants were asked, 'Describe three CPD topic you would like to learn about in the next 12 months'. To identify learning needs that may have arisen from problems encountered in practice, participants were asked, 'Describe three challenging situations encountered in the past 12 months.' Responses to the two open-ended questions were analyzed using thematic content analysis. RESULTS: Responses were received from 411 physicians, resulting in 226 intrinsic CanMEDS codes for perceived learning needs and 210 intrinsic codes for challenges encountered in practices. Discrepancies in the frequency of intrinsic roles were observed between the two questions. Specifically, Leader (28%), Scholar (43%), and Professional (16%) roles were frequently described perceived learning needs, as opposed to challenges in practice (Leader: 3%; Scholar: 2%; and Professional: 8%. Conversely, Communicator 39%, Health Advocate 39%, and to a lesser extent Collaborator 11%) roles were frequently described in narratives surrounding challenges in practice, but appeared in <10% of descriptions of perceived learning needs (Communicator: 4%; Health Advocate 6%; Collaborator: 3%). CONCLUSION: The present study provides insight into potential learning needs associated with intrinsic CanMEDS competencies. Discrepancies in the frequency of intrinsic CanMEDS roles coded for perceived learning needs and challenges encountered in practice may provide insight into the selection and design of CPD activities.

Recipient factors associated with having a potential living donor for liver transplantation.

Because of a persistent discrepancy between the demand for liver transplantation (LT) and the supply of deceased donor organs, there is an interest in increasing living donation rates at centers trained in this method of transplantation. We examined a large socioeconomically heterogeneous cohort of patients listed for LT to identify recipient factors associated with living donation. We retrospectively reviewed 491 consecutive patients who were listed for LT at our center over a 24-month period. Demographic, medical, and socioeconomic data were extracted from electronic records and compared between those who had a potential living donor (LD) volunteer for assessment and those who did not; 245 patients (50%) had at least 1 potential LD volunteer for assessment. Multivariate logistic regression analysis identified that patients with a LD were more likely to have Child-Pugh C disease (odds ratio [OR], 2.44; P = 0.02), and less likely to be older (OR, 0.96; P = 0.002), single (OR, 0.34; P = 0.006), divorced (OR, 0.53; P = 0.03), immigrants (OR, 0.38; P = 0.049), or from the lowest income quintile (OR, 0.44; P = 0.02). In conclusion, this analysis has identified several factors associated with access to living donation. More research is warranted to define and overcome barriers to living donor liver transplantation through targeted interventions in underrepresented populations.