Guidelines to the Practice of Anesthesia-Revised Edition 2024.

OVERVIEW: The Guidelines to the Practice of Anesthesia-Revised Edition 2024 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia-Revised Edition 2024 supersede all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

RéSUMé: Le Guide d'exercice de l'anesthésie, version révisée 2024 (le Guide), a été préparé par la Société canadienne des anesthésiologistes (SCA), qui se réserve le droit de décider des termes de sa publication et de sa diffusion. Le Guide est soumis à révision et des versions mises à jour sont publiées chaque année. Le Guide d'exercice de l'anesthésie, version révisée 2024, remplace toutes les versions précédemment publiées de ce document. Bien que la SCA incite les anesthésiologistes du Canada à se conformer à son guide d'exercice pour assurer une grande qualité des soins dispensés aux patient·es, elle ne peut garantir les résultats d'une intervention spécifique. Les anesthésiologistes doivent exercer leur jugement professionnel pour déterminer la méthode d'intervention la mieux adaptée à l'état de leur patient·e. La SCA n'accepte aucune responsabilité ou imputabilité de quelque nature que ce soit découlant d'erreurs ou d'omissions ou de l'utilisation des renseignements contenus dans son Guide d'exercice de l'anesthésie.

Training Anesthesiology Residents to Care for the Traumatically Injured in the United States.

Training and education for trauma anesthesiology have been predicated on 2 primary pathways: learning through peripheral "complex, massive transfusion cases"-an assumption that is flawed due to the unique demands, skills, and knowledge of trauma anesthesiology-or learning through experiential education, which is also incomplete due to its unpredictable and variable exposure. Residents may receive training from senior physicians who may not maintain a trauma-focused continuing medical education. Further compounding the issue is the lack of fellowship-trained clinicians and standardized curricula. The American Board of Anesthesiology (ABA) provides a section for trauma education in its Initial Certification in Anesthesiology Content Outline. However, many trauma-related topics also fall under other subspecialties, and the outline excludes "nontechnical" skills. This article focuses on the training of anesthesiology residents and proposes a tier-based approach to teaching the ABA outline by including lectures, simulation, problem-based learning discussions, and case-based discussions that are proctored in conducive environments by knowledgeable facilitators.

The incidence of awake tracheal intubation in anesthetic practice is decreasing: a historical cohort study of the years 2014-2020 at a single tertiary care institution.

PURPOSE: Awake tracheal intubation (ATI) is recommended in airway management guidelines when significant difficulty is predicted with airway management. Use of the technique may be declining, which may have implications for patient safety or for skills acquisition and maintenance. This historical cohort database study sought to determine if the use of ATI was decreasing in our adult tertiary care center. METHODS: With institutional research ethics board approval, we queried our anesthesia information management system for cases with ATI descriptors for each year from 2014 to 2020. Records of the retrieved cases were independently reviewed by all three authors to verify they met inclusion criteria for the ATI cohort prior to analysis for the primary outcome. Secondary outcome measures included airway device and route used for ATI, first attempt and ultimate success rates, and reported adverse issues recorded in cases of failed ATI or those requiring more than one attempt. RESULTS: A total of 692 cases of ATI were identified between 2014 and 2020. There was a statistically significant decrease in yearly ATIs over the seven-year study period (Chi square goodness of fit, P < 0.001), with ATI use decreasing by about 50%. First attempt success was significantly greater with use of flexible bronchoscopy vs video laryngoscopy to facilitate ATI (84% vs 60%; P < 0.001), while there was no difference in first attempt success with the oral vs nasal route (82% vs 82%; P = 1.0). CONCLUSION: In this single-center historical cohort study, the use of ATI decreased significantly from 2014 to 2020. Whether this decrease will result in morbidity or mortality related to airway management is currently unclear. Regardless, it has implications for training opportunities and maintenance of competence in performing the procedure.

RéSUMé: OBJECTIF: L'intubation trachéale éveillée (ITE) est recommandée dans les lignes directrices de prise en charge des voies aériennes lorsque des difficultés significatives sont anticipées dans la prise en charge des voies aériennes. L'utilisation de cette technique pourrait être en déclin, ce qui pourrait avoir des répercussions sur la sécurité des patients ou sur l'acquisition et le maintien des compétences. Cette étude de cohorte historique visait à déterminer si l'utilisation de l'ITE était en diminution dans notre centre de soins tertiaires pour adultes. MéTHODE: Après avoir obtenu l'approbation du comité d'éthique de la recherche de notre institution, nous avons extrait les données des patients ayant des descripteurs d'ITE de 2014 à 2020 à partir de notre système de gestion de l'information en anesthésie. Les données des dossiers de ces patients ont été examinées de manière indépendante par les trois auteurs afin de vérifier s'ils répondaient aux critères d'inclusion de la cohorte ITE avant l'analyse du critère d'évaluation principal. Les critères d'évaluation secondaires comprenaient le dispositif d'intubation et la voie d'accès utilisés pour l'ITE, les taux de réussite de la première tentative et de la réussite finale, et les problèmes indésirables signalés enregistrés dans les cas d'échec de l'ITE ou ceux nécessitant plus d'une tentative. RéSULTATS: Au total, 692 cas d'ITE ont été identifiés entre 2014 et 2020. Il y a eu une diminution annuelle statistiquement significative des ITE au cours de la période d'étude de sept ans (test d'adéquation du Chi carré, P < 0,001), l'utilisation de l'ITE diminuant d'environ 50 %. Le succès de l'intubation à la première tentative a été significativement plus important avec l'utilisation de la bronchoscopie flexible en comparaison à la vidéolaryngoscopie pour faciliter l'ITE (84 % vs 60 %; P < 0,001), bien qu'aucune différence n'ait été observée dans le succès de la première tentative par voie orale en comparaison à nasale (82 % versus 82 %; P = 1,0). CONCLUSION: Dans cette étude de cohorte historique monocentrique, l'utilisation de l'intubation trachéale éveillée a diminué de manière significative de 2014 à 2020. Il n'est pas clair si cette diminution entraînera une morbidité ou une mortalité liée à la prise en charge des voies aériennes. Quoi qu'il en soit, cela a des implications pour la formation et le maintien des compétences dans l'exécution de la procédure.

Guidelines to the Practice of Anesthesia: Revised Edition 2023.

OVERVIEW: The Guidelines to the Practice of Anesthesia Revised Edition 2023 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2023 supersede all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgment in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

RéSUMé: Le Guide d'exercice de l'anesthésie, version révisée 2023 (le Guide), a été préparé par la Société canadienne des anesthésiologistes (SCA), qui se réserve le droit de décider des termes de sa publication et de sa diffusion. Le Guide est soumis à révision et des versions mises à jour sont publiées chaque année. Le Guide d'exercice de l'anesthésie, version révisée 2023, remplace toutes les versions précédemment publiées de ce document. Bien que la SCA incite les anesthésiologistes du Canada à se conformer à son guide d'exercice pour assurer une grande qualité des soins dispensés aux patients, elle ne peut garantir les résultats d'une intervention spécifique. Les anesthésiologistes doivent exercer leur jugement professionnel pour déterminer la méthode d'intervention la mieux adaptée à l'état de leur patient. La SCA n'accepte aucune responsabilité ou imputabilité de quelque nature que ce soit découlant d'erreurs ou d'omissions ou de l'utilisation des renseignements contenus dans son Guide d'exercice de l'anesthésie.

Guidelines to the Practice of Anesthesia - Revised Edition 2022.

OVERVIEW: The Guidelines to the Practice of Anesthesia Revised Edition 2022 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2022 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

RéSUMé: Le Guide d'exercice de l'anesthésie, version révisée 2022 (le Guide), a été préparé par la Société canadienne des anesthésiologistes (SCA), qui se réserve le droit de décider des termes de sa publication et de sa diffusion. Le Guide est soumis à révision et des versions mises à jour sont publiées chaque année. Le Guide d'exercice de l'anesthésie, version révisée 2022, remplace toutes les versions précédemment publiées de ce document. Bien que la SCA incite les anesthésiologistes du Canada à se conformer à son guide d'exercice pour assurer une grande qualité des soins dispensés aux patients, elle ne peut garantir les résultats d'une intervention spécifique. Les anesthésiologistes doivent exercer leur jugement professionnel pour déterminer la méthode d'intervention la mieux adaptée à l'état de leur patient. La SCA n'accepte aucune responsabilité ou imputabilité de quelque nature que ce soit découlant d'erreurs ou d'omissions ou de l'utilisation des renseignements contenus dans son Guide d'exercice de l'anesthésie.

Factors Associated With Failure of Spinal Anesthetic: An 8-Year Retrospective Analysis of Patients Undergoing Elective Hip and Knee Joint Arthroplasty.

The primary outcome of this 8-year retrospective review was the failure of spinal anesthetic (SA) in elective hip and knee joint arthroplasty surgery. Of 3542 SAs, a total of 135 failures were identified (3.8%). Factors associated with increased odds of failure were younger age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.05), lower body mass index (BMI; OR, 1.04 [1.01-1.08]), hip arthroplasty (OR, 1.90 [1.28-2.84]) compared to knee arthroplasty, needle insertion at L4-5 (OR, 4.61 [2.02-10.54]) and L5-S1 (OR, 7.66 [2.47-23.7]) compared to L2-3, 22-gauge needle size (OR, 2.17 [1.34-3.52]) compared to 25-gauge needle, and hyperbaric bupivacaine (OR, 1.66 [1.09-2.53]) compared to isobaric bupivacaine.

A deliberately restricted laryngeal view with the GlideScope® video laryngoscope is associated with faster and easier tracheal intubation when compared with a full glottic view: a randomized clinical trial.

INTRODUCTION: During video laryngoscopy (VL) with angulated or hyper-curved blades, it is sometimes difficult to complete tracheal intubation despite a full view of the larynx. When using indirect VL, it has been suggested that it may be preferable to obtain a deliberately restricted view of the larynx to facilitate passage of the endotracheal tube. We used the GlideScope® GVL video laryngoscope (GVL) to test whether deliberately obtaining a restricted view would result in faster and easier tracheal intubation than with a full view of the larynx. METHODS: We recruited 163 elective surgical patients and randomly allocated the participants to one of two groups: Group F, where a full view of the larynx was obtained and held during GVL-facilitated tracheal intubation, and Group R, with a restricted view of the larynx (< 50% of glottic opening visible). Study investigators experienced in indirect VL performed the intubations. The intubations were recorded and the video recordings were subsequently assessed for total time to intubation, ease of intubation using a visual analogue scale (VAS; where 0 = easy and 100 = difficult), first-attempt success rate, and oxygen saturation after intubation. Complications were also assessed. RESULTS: The median [interquartile range (IQR)] time to intubation was faster in Group R than in Group F (27 [22-36] sec vs 36 [27-48] sec, respectively; median difference, 9 sec; 95% confidence interval [CI], 5 to 13; P < 0.001). The median [IQR] VAS rating for ease of intubation was also better in Group R than in Group F (14 [6-42) mm vs 50 mm [17-65], respectively; median difference, 20 mm; 95% CI, 10 to 31; P < 0.001). There was no difference between groups regarding the first-attempt success rate, oxygen saturation immediately after intubation, or complications. CONCLUSIONS: Using the GVL with a deliberately restricted view of the larynx resulted in faster and easier tracheal intubation than with a full view and with no additional complications. Our study suggests that obtaining a full or Cormack-Lehane grade 1 view may not be desirable when using the GVL. This trial was registered at ClinicalTrials.gov: NCT02144207.

The incidence, success rate, and complications of awake tracheal intubation in 1,554 patients over 12 years: an historical cohort study.

PURPOSE: Awake tracheal intubation is one recommended option to address select situations in the management of a patient with an anticipated difficult airway. A scarcity of data exists on how often awake intubation is performed or whether its use is changing over time, particularly with the increasingly widespread availability of video laryngoscopy. This retrospective database review was undertaken to determine the incidence, success, and complications of awake intubation and the incidence of other tracheal intubation techniques in the operating room over a 12-yr period (2002-2013) at our institution. METHODS: The Anesthesia Information Management System in use at a Canadian tertiary care centre was searched for all awake intubations that occurred during the years 2002-2013. Records were also searched to identify airway methods other than direct laryngoscopy that may have been used after the induction of general anesthesia. Changes in both the incidence of awake intubation and in the use of video laryngoscopy over the 12 years were analyzed using linear regression modelling. RESULTS: Of 146,252 cases performed under general anesthesia with endotracheal intubation, 1,554 intubations (1.06%) were performed awake. There was no significant change in the rate of awake intubation over the studied years (slope -1.4(-4) incidence·year(-1); 95% confidence interval [CI]: -3.0(-4) to 3.0(-5); P = 0.102). The relatively steady rate of awake intubation occurred despite a significant increase in the use of video laryngoscopy over the same time (slope 0.080 incidence·year(-1); 95% CI: 0.076 to 0.083; P < 0.001), particularly from 2009 onwards. Attempted awake intubation failed in 31 (2%) of the cases. Self-reported complications occurred in 15.7% of successful procedures. In addition, in a convenience sample of three years (2011-2013), the rate at which each of 49 attending staff performed awake intubation varied widely from 0-3.4 awake intubations per 100 cases of general anesthesia with endotracheal intubation. CONCLUSIONS: At our tertiary care centre, we did not find a significant change in the use of awake tracheal intubation over the studied years 2002-2013 despite increasing availability and use of video laryngoscopy. It appears that awake tracheal intubation retains an important and consistent role in the management of the difficult airway.

A retrospective analysis of airway management in patients with obstructive sleep apnea and its effects on postanesthesia care unit length of stay.

Obstructive sleep apnea (OSA) is a form of sleep-disordered breathing characterized by periods of partial or complete obstruction of the upper airway during sleep, resulting in oxygen desaturations. Symptoms and risk factors for OSA are of particular importance in the management of OSA patients in the perioperative setting. The present study collected data regarding the intraoperative airway management of OSA patients and their course in the postanesthesia care unit (PACU) over a six-month period. A total of 86 patients underwent general anesthesia, 63 of whom were intubated by direct laryngoscopy. Of these, 43% were classified as a grade 1 view by direct laryngoscopy, 43% were grade 2 and 14% were classified as grade 3. Apnea events or periods of desaturation in the PACU were observed in 27% of cases. Length of stay was significantly longer for cases in which PACU nurses had indicated that OSA had affected the individuals' postoperative course of treatment. Overall, OSA patients had an increased frequency of grade 3 views compared with the general population, and adjuncts were commonly used to help secure the airway in OSA patients. Symptomatic OSA patients placed increased demands on the PACU in terms of length of stay and hospital resources.

L'apnée obstructive du sommeil (AOS) est une forme de trouble respiratoire du sommeil caractérisée par des périodes d'obstruction partielle ou complète des voies respiratoires supérieures pendant le sommeil, qui provoque des désaturations en oxygène. Les symptômes et facteurs de risque d'AOS revêtent une importance particulière pour la prise en charge des patients atteints d'AOS en milieu périopératoire. La présente étude a permis de colliger, sur une période de six mois, des données sur la prise en charge intraopératoire et l'évolution des voies supérieures des patients atteints d'AOS à l'unité de soins posthanesthésique (USPA). Au total, 86 patients ont subi une anesthésie générale. De ce nombre, 63 ont été intubés par laryngoscopie directe, dont 43 % ont obtenu une vue de classe 1, 43 %, une vue de classe 2 et 14 %, une vue de classe 3. Dans 27 % des cas, les chercheurs ont observé des épisodes d'apnée ou de désaturation à l'USPA. La durée d'hospitalisation était beau-coup plus longue dans les cas où, selon les infirmières de l'USPA, l'AOS avait nui à l'évolution postopératoire du traitement. Dans l'ensemble, les patients atteints d'AOS présentaient davantage de vues de classe 3 que la population générale, et il fallait souvent utiliser des accessoires pour sécuriser leurs voies respiratoires. À l'USPA, les patients symptomatiques atteints d'AOS étaient hospitalisés plus longtemps et mobilisaient plus de ressources hospitalières.