Defining major surgical complications using administrative data in Ontario: a validation study.

BACKGROUND: Although surgical complications are often included as an outcome of surgical research conducted using administrative data, little validation work has been performed. We sought to evaluate the diagnostic performance of an algorithm designed to capture major surgical complications using health administrative data. METHODS: This retrospective study included patients who underwent high-risk elective general surgery at a single institution in Ontario, Canada, from Sept. 1, 2016, to Sept. 1, 2017. Patients were identified for inclusion using the local operative database. Medical records were reviewed by trained clinicians to abstract postoperative complications. Data were linked to administrative data holdings, and a series of code-based algorithms were applied to capture a composite indicator of major surgical complications. We used sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy to evaluate the performance of our administrative data algorithm, as compared with data abstracted from the institutional charting system. RESULTS: The study included a total of 270 patients. According to the data from the chart audit, 55% of patients experienced at least 1 major surgical complication. Overall sensitivity, specificity, PPV, NPV and accuracy for the composite outcome was 72%, 80%, 82%, 70% and 76%, respectively. Diagnostic performance was poor for several of the individual complications. CONCLUSION: Our results showed that administrative data holdings can be used to capture a composite indicator of major surgical complications with adequate sensitivity and specificity. Additional work is required to identify suitable algorithms for several specific complications.

Effect of High-Dose Selenium on Postoperative Organ Dysfunction and Mortality in Cardiac Surgery Patients: The SUSTAIN CSX Randomized Clinical Trial.

Importance: Selenium contributes to antioxidative, anti-inflammatory, and immunomodulatory pathways, which may improve outcomes in patients at high risk of organ dysfunctions after cardiac surgery. Objective: To assess the ability of high-dose intravenous sodium selenite treatment to reduce postoperative organ dysfunction and mortality in cardiac surgery patients. Design, Setting, and Participants: This multicenter, randomized, double-blind, placebo-controlled trial took place at 23 sites in Germany and Canada from January 2015 to January 2021. Adult cardiac surgery patients with a European System for Cardiac Operative Risk Evaluation II score-predicted mortality of 5% or more or planned combined surgical procedures were randomized. Interventions: Patients were randomly assigned (1:1) by a web-based system to receive either perioperative intravenous high-dose selenium supplementation of 2000 µg/L of sodium selenite prior to cardiopulmonary bypass, 2000 µg/L immediately postoperatively, and 1000 µg/L each day in intensive care for a maximum of 10 days or placebo. Main Outcomes and Measures: The primary end point was a composite of the numbers of days alive and free from organ dysfunction during the first 30 days following cardiac surgery. Results: A total of 1416 adult cardiac surgery patients were analyzed (mean [SD] age, 68.2 [10.4] years; 1043 [74.8%] male). The median (IQR) predicted 30-day mortality by European System for Cardiac Operative Risk Evaluation II score was 8.7% (5.6%-14.9%), and most patients had combined coronary revascularization and valvular procedures. Selenium did not increase the number of persistent organ dysfunction-free and alive days over the first 30 postoperative days (median [IQR], 29 [28-30] vs 29 [28-30]; P = .45). The 30-day mortality rates were 4.2% in the selenium and 5.0% in the placebo group (odds ratio, 0.82; 95% CI, 0.50-1.36; P = .44). Safety outcomes did not differ between the groups. Conclusions and Relevance: In high-risk cardiac surgery patients, perioperative administration of high-dose intravenous sodium selenite did not reduce morbidity or mortality. The present data do not support the routine perioperative use of selenium for patients undergoing cardiac surgery. Trial Registration: ClinicalTrials.gov Identifier: NCT02002247.

Minimum protamine dose required to neutralize heparin in cardiac surgery: a single-centre, prospective, observational cohort study.

PURPOSE: Excess protamine contributes to coagulopathy following cardiopulmonary bypass (CPB) and may increase blood loss and transfusion requirements. The primary aim of this study was to find the least amount of protamine necessary to neutralize residual heparin following CPB using the gold standard assays of anti-IIa and anti-Xa activity. Secondary objectives were to evaluate whether the post-CPB activated clotting time could be used as a surrogate marker for quantifying heparin neutralization. METHODS: Twenty-eight consecutive patients undergoing elective cardiac surgery were enrolled. Protamine administration was standardized through an infusion pump at 25 mg·min-1. Blood samples were withdrawn prior to and following administration of 150, 200, 250, and 300 mg protamine and analyzed for activated clotting time and anti-IIa and -Xa activity. RESULTS: Following a mean (standard deviation) cumulative heparin dose of 67,700 (19,400) units and a CPB duration of 113 (71) min, protamine requirements varied widely. Eight out of 25 (32%) patients showed complete neutralization of anti-IIa and -Xa activity at the first sampling point (150 mg protamine; protamine:heparin ratio, 0.3 [0.1]). A protamine:heparin ratio of 0.5 (0.2) was sufficient for heparin neutralization in > 90% of patients. After CPB, a low to mid-range activated clotting time correlated well with anti-IIa and -Xa activity. CONCLUSIONS: The protamine:heparin ratio required to neutralize residual unfractionated heparin (UFH) following CPB is variable. A protamine:heparin ratio of 0.3 was sufficient to neutralize UFH in some patients, while a ratio of 0.5 is sufficient to neutralize both residual anti-IIa and -Xa activity in most patients. Larger studies are necessary to confirm these findings and evaluate their clinical implications. STUDY REGISTRATION: ClinicalTrials.gov (NCT03787641); registered 26 December 2018.

RéSUMé: OBJECTIF: L'excès de protamine contribue à la coagulopathie après la circulation extracorporelle (CEC) et peut augmenter les pertes de sang et les besoins transfusionnels. L'objectif principal de cette étude était de déterminer la quantité minimale de protamine nécessaire pour neutraliser l'héparine résiduelle post-CEC en utilisant les tests de référence de l'activité anti-IIa et anti-Xa. Les objectifs secondaires consistaient à évaluer si le temps de coagulation activé post-CEC pouvait être utilisé comme marqueur de substitution pour quantifier la neutralisation de l'héparine. MéTHODE: Vingt-huit patients consécutifs bénéficiant d'une chirurgie cardiaque non urgente ont été recrutés. L'administration de protamine par une pompe à perfusion à 25 mg·min-1 a été normalisée. Des échantillons de sang ont été prélevés avant et après l'administration de 150, 200, 250 et 300 mg de protamine et analysés pour déterminer le temps de coagulation activé et l'activité anti-IIa et -Xa. RéSULTATS: Après une dose cumulative moyenne (écart type) d'héparine de 67 700 (19 400) unités et une durée de CEC moyenne de 113 (71) min, les besoins en protamine variaient considérablement. Huit patients sur 25 (32 %) ont affiché une neutralisation complète de l'activité anti-IIa et -Xa au premier point de prélèvement (150 mg de protamine; rapport protamine : héparine, 0,3 [0,1]). Un rapport protamine/héparine de 0,5 (0,2) était suffisant pour la neutralisation de l'héparine chez > 90 % des patients. Après la CEC, un temps de coagulation activé bas à moyen était bien corrélé avec l'activité anti-IIa et -Xa. CONCLUSION: Le rapport protamine : héparine nécessaire pour neutraliser l'héparine non fractionnée (HNF) résiduelle suivant une CEC est variable. Un rapport protamine : héparine de 0,3 était suffisant pour neutraliser l'HNF chez certains patients, tandis qu'un rapport de 0,5 est suffisant pour neutraliser à la fois l'activité résiduelle des anti-IIa et celle des anti-Xa chez la plupart des patients. Des études plus vastes sont nécessaires pour confirmer ces résultats et évaluer leurs implications cliniques. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT03787641); enregistrée le 26 décembre 2018.

Patient Sex and Postoperative Outcomes after Inpatient Intraabdominal Surgery: A Population-based Retrospective Cohort Study.

BACKGROUND: Intraabdominal surgeries are frequently performed procedures that lead to a high volume of unplanned readmissions and postoperative complications. Patient sex may be a determinant of adverse outcomes in this population, possibly due to differences in biology or care delivery, but it is understudied. The authors hypothesized that there would be no association between patient sex and the risk of postoperative adverse outcomes in intraabdominal surgery. METHODS: This retrospective, population-based cohort study involved adult inpatients aged 18 yr or older who underwent intraabdominal surgeries in Ontario, Canada, between April 2009 and March 2016. The authors studied the association of patient sex on the primary composite outcome of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. Inverse probability of exposure weighting based on propensity scores (computed using demographic characteristics such as rural residence status and median neighborhood income quintile, common comorbidities, and surgery- and hospital-specific characteristics) was used to estimate the adjusted association of sex on outcomes. RESULTS: The cohort included 215,846 patients (52.3% female). The primary outcome was observed in 24,712 (21.9%) females and 25,486 (24.7%) males (unadjusted risk difference, 2.8% [95% CI, 2.5 to 3.2%]; P < 0.001). After adjustment, the association between the male sex and the primary outcome was not statistically significant (adjusted risk difference, -0.2% [95% CI, -0.5 to 0.2%]; P = 0.378). CONCLUSIONS: In a large population of intraabdominal surgical patients, there was no differential risk between sexes in the composite outcome of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days.

Association Between Handover of Anesthesiology Care and 1-Year Mortality Among Adults Undergoing Cardiac Surgery.

Importance: Handovers of anesthesia care from one anesthesiologist to another is an important intraoperative event. Despite its association with adverse events after noncardiac surgery, its impact in the context of cardiac surgery remains unclear. Objective: To compare the outcomes of patients who were exposed to anesthesia handover vs those who were unexposed to anesthesia handover during cardiac surgery. Design, Setting, and Participants: This retrospective cohort study in Ontario, Canada, included Ontario residents who were 18 years or older and had undergone coronary artery bypass grafting or aortic, mitral, tricuspid valve, or thoracic aorta surgical procedures between 2008 and 2019. Exclusion criteria were non-Ontario residency status and other concomitant procedures. Statistical analysis was conducted from April 2021 to June 2021, and data collection occurred between November 2020 to January 2021. Exposures: Complete handover of anesthesia care, where the case is completed by the replacement anesthesiologist. Main Outcomes and Measures: The coprimary outcomes were mortality within 30 days and 1 year after surgery. Secondary outcomes were patient-defined adverse cardiac and noncardiac events (PACE), intensive care unit (ICU), and hospital lengths of stay (LOS). Inverse probability of treatment weighting based on the propensity score was used to estimate adjusted effect measures. Mortality was assessed using a Cox proportional hazard model, PACE using a cause-specific hazard model with death as a competing risk, and LOS using Poisson regression. Results: Of the 102 156 patients in the cohort, 25 207 (24.7%) were women; the mean (SD) age was 66.4 (10.8) years; and 72 843 of surgical procedures (71.3%) were performed in teaching hospitals. Handover occurred in 1926 patients (1.9%) and was associated with higher risks of 30-day mortality (hazard ratio [HR], 1.89; 95% CI, 1.41-2.54) and 1-year mortality (HR, 1.66; 95% CI, 1.31-2.12), as well as longer ICU (risk ratio [RR], 1.43; 95% CI, 1.22-1.68) and hospital (RR, 1.17; 95% CI, 1.06-1.28) LOS. There was no statistically significant association between handover and PACE (30 days: HR 1.09; 95% CI, 0.79-1.49; 1 year: HR 0.89; 95% CI, 0.70-1.13). Conclusions and Relevance: Handover of anesthesia care during cardiac surgical procedures was associated with higher 30-day and 1-year mortality rates and increased health care resource use. Further research is needed to evaluate and systematically improve the handover process qualitatively.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient.

PURPOSE: Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. SOURCE: Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS: Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

RéSUMé: OBJECTIF: Depuis la dernière publication des lignes directrices du Canadian Airway Focus Group (CAFG) en 2013, la littérature sur la prise en charge des voies aériennes s'est considérablement étoffée. Le CAFG s'est donc réuni à nouveau pour examiner la littérature et mettre à jour ses recommandations de pratique. Ce premier article de deux traite de la prise en charge des voies aériennes difficiles chez un patient inconscient. SOURCES: Des sujets de recherche ont été assignés aux membres du Canadian Airway Focus Group, qui compte des médecins anesthésistes, urgentologues et intensivistes. Les recherches ont été menées dans les bases de données Medline, EMBASE, Cochrane Central Register of Controlled Trials et CINAHL. Les résultats ont été présentés au groupe et discutés lors de vidéoconférences toutes les deux semaines entre avril 2018 et juillet 2020. Les recommandations du CAFG sont fondées sur les meilleures données probantes publiées. Si les données probantes de haute qualité manquaient, les énoncés se fondent alors sur le consensus du groupe. CONSTATATIONS ET RECOMMANDATIONS CLéS: La plupart des études comparant la vidéolaryngoscopie à la laryngoscopie directe indiquent un taux de réussite plus élevé à la première tentative et globalement avec la vidéolaryngoscopie, ainsi que des taux de complication inférieurs. Ainsi, les ressources le permettant, le CAFG recommande dorénavant l'utilisation de vidéolaryngoscopes avec le type de lame convenablement sélectionné pour faciliter toutes les intubations trachéales. En cas d'échec de la première tentative d'intubation trachéale ou d'échec de positionnement du dispositif supraglottique (DSG), d'autres tentatives peuvent être entreprises tant que la ventilation et l'oxygénation du patient le permettent. Néanmoins, le nombre total de tentatives devrait être limité, à trois ou moins, avant de déclarer un échec et de considérer les options de « stratégie de retrait ¼. En cas d'échec de l'intubation, les options de stratégie de retrait chez un patient toujours oxygéné comprennent l'éveil (si possible), la temporisation avec un DSG, une dernière tentative d'intubation trachéale à l'aide d'une technique différente, ou une cricothyroïdotomie. L'échec de l'intubation trachéale, de la ventilation au masque facial et de la ventilation via un DSG accompagné d'une hypoxémie présente ou imminente, définit une urgence « impossible de ventiler, impossible d'oxygéner ¼. Le bloc neuromusculaire doit alors être confirmé ou mis en place, et une tentative finale de ventilation au masque, de positionnement du DSG ou d'intubation trachéale avec une lame de vidéolaryngoscopie hyper-angulée peut être réalisée, si cette approche n'a pas encore été essayée. Si la ventilation demeure impossible, une cricothyroïdotomie d'urgence devrait être réalisée sans délai utilisant une technique de scalpel-bougie-tube (chez le patient adulte). Le CAFG recommande à toutes les institutions de désigner une personne comme « leader des voies aériennes ¼ afin d'assister à la mise en place de protocoles pour les voies aériennes difficiles, d'assurer une formation et un équipement adéquats et d'aider aux examens de la qualité en rapport avec les voies aériennes.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway.

PURPOSE: Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. SOURCE: Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS: Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient's tolerance for withdrawal of airway support and whether re-intubation might be difficult.

RéSUMé: OBJECTIF: Depuis la dernière publication des lignes directrices du Canadian Airway Focus Group (CAFG) en 2013, la littérature sur la prise en charge des voies aériennes s'est considérablement étoffée. Le CAFG s'est donc réuni à nouveau pour examiner la littérature et mettre à jour ses recommandations de pratique. Ce deuxième article traite de l'évaluation des voies aériennes, de la prise de décision et de la mise en œuvre sécuritaire d'une stratégie de prise en charge des voies aériennes lorsque des difficultés sont anticipées. SOURCES: Des sujets de recherche ont été assignés aux membres du Canadian Airway Focus Group, qui compte des médecins anesthésistes, urgentologues et intensivistes. Les recherches ont été réalisées dans les bases de données Medline, EMBASE, Cochrane Central Register of Controlled Trials et CINAHL. Les résultats ont été présentés au groupe et discutés lors de vidéoconférences toutes les deux semaines entre avril 2018 et juillet 2020. Les recommandations du CAFG sont fondées sur les meilleures données probantes publiées. Si les données probantes de haute qualité manquaient, les énoncés se fondent alors sur le consensus du groupe. CONSTATATIONS ET RECOMMANDATIONS CLéS: Avant d'amorcer la prise en charge des voies aériennes, une stratégie documentée devrait être formulée pour chaque patient, en fonction de l'évaluation de ses voies aériennes. L'examen au chevet devrait rechercher les prédicteurs de difficultés pour la ventilation au masque, l'intubation trachéale utilisant la vidéolaryngoscopie ou la laryngoscopie directe, l'utilisation d'un dispositif supraglottique, ainsi que pour la cricothyroïdotomie d'urgence. La physiologie du patient et ses problématiques contextuelles devraient également être évaluées. Les difficultés anticipées devraient inciter à prendre des décisions éclairées sur la façon la plus sécuritaire de procéder à la prise en charge des voies aériennes. L'intubation trachéale éveillée peut procurer une marge de sécurité supplémentaire lorsqu'on s'attend à ce que la vidéolaryngoscopie ou la laryngoscopie directe soient impossibles, lorsqu'on prévoit des difficultés pour plus d'un mode de prise en charge des voies aériennes (p. ex., intubation trachéale et ventilation au masque), ou lorsque la difficulté prévue coïncide avec des problèmes physiologiques ou contextuels importants. En cas de choix de prise en charge des voies respiratoires du patient après induction de l'anesthésie générale malgré les difficultés prévues, les directives à l'équipe devraient inclure les déclencheurs pour passer d'une technique à l'autre, l'aide d'experts disponibles et l'équipement requis disponible. Des difficultés imprévues lors de la prise en charge des voies aériennes peuvent toujours survenir, de sorte que la personne responsable de la prise en charge des voies aériennes devrait avoir une stratégie pour chaque patient, et l'établissement doit rendre facilement disponible le matériel pour la prise en charge des voies aériennes difficiles. L'extubation trachéale du patient à risque doit également être soigneusement planifiée, y compris l'évaluation de la tolérance du patient lors du retrait du dispositif de soutien des voies aériennes et d'une ré-intubation potentiellement difficile.

Starch or Saline After Cardiac Surgery: A Double-Blinded Randomized Controlled Trial.

BACKGROUND: Despite decades of investigation, the balance of clinical risks and benefits of fluid supplementation with starch remain unresolved. Patient-centered outcomes have not been well explored in a "real-world" trial in cardiac surgery. OBJECTIVE: We sought to compare a starch-based fluid strategy with a saline-based fluid strategy in the cardiac surgery patient. DESIGN: A pragmatic blinded randomized controlled trial comparing starch-based with saline-based fluid strategy. SETTING: A large tertiary academic center in London Ontario between September 2009 and February 2011. PARTICIPANTS: Patients undergoing planned, isolated coronary revascularization. MEASUREMENTS: Serum creatinine and patient weight were measured daily postoperatively. METHODS: Patients were randomized to receive 6% hydroxyethyl starch (Voluven) or saline for perioperative fluid requirements. Fluid administration was not protocolized. Co-primary outcomes were incidence of acute kidney injury (AKI) and maximum postoperative weight gain. Secondary outcomes included bleeding, transfusion, inotropic and ventilator support, and fluid utilization. RESULTS: The study was prematurely terminated due to resource limitations. A total of 69 patients (19% female, mean age = 65) were randomized. Using RIFLE criteria for AKI, "risk" occurred in 12 patients in each group (risk ratio [RR] = 1.0; 95% confidence interval [CI] = 0.5-1.9; P = 1.00), whereas "injury" occurred in 7 of 35 (20%) and 3 of 34 (9%) of patients in the starch and saline groups, respectively (RR = 2.3; 95% CI = 0.6-8.1; P = .31). Maximum weight gain, bleeding and blood product usage, and overall fluid requirement were similar between groups. LIMITATIONS: The study had to be prematurely terminated due to resource limitations which led to a small sample size which was not sufficiently powered to detect a difference in the primary outcomes. CONCLUSIONS: This pragmatic double-blinded randomized controlled trial revealed a number of interesting hypothesis-generating trends and confirmed the feasibility of undertaking a logistically complex trial in a pragmatic fashion.

CONTEXTE: L'équilibre entre les avantages et les risques cliniques d'une supplémentation en fluides à base d'amidon n'est toujours pas établi malgré des décennies d'études. Les résultats des patients subissant une chirurgie cardiaque n'ont pas été explorés suffisamment dans le cadre d'un essai concret. OBJECTIF: Comparer deux stratégies de supplémentation liquidienne, une solution à base d'amidon et une solution saline, chez des patients subissant une chirurgie cardiaque. TYPE D'ÉTUDE: Un essai pragmatique, contrôlé, à répartition aléatoire et mené en double insu comparant deux stratégies de supplémentation liquidienne une solution à base d'amidon et une solution saline. CADRE: Un grand centre universitaire de soins tertiaires de London (Ontario) entre septembre 2009 et février 2011. SUJETS: Des patients subissant une revascularisation coronarienne planifiée et isolée. MESURES: La créatinine sérique et le poids du patient ont été mesurés quotidiennement à la suite de l'intervention. MÉTHODOLOGIE: Les patients ont été répartis aléatoirement pour recevoir du Voluven (solution d'amidon hydroxyéthylé à 6 %) ou une solution saline pour les fluidiques périopératoires. L'administration ne s'est pas faite selon un protocole établi. L'incidence d'insuffisance rénale aiguë (IRA) et un gain pondéral maximal après l'intervention constituaient les deux principaux résultats mesurés. Les résultats secondaires incluaient une hémorragie, l'utilisation de transfusion sanguine, d'inotrope, d'assistance respiratoire et l'administration de fluides. RÉSULTATS: L'étude a été interrompue prématurément par manque de ressources. Les 69 patients (19 % de femmes) répartis aléatoirement avaient en moyenne 65 ans. La classification RIFLE avait permis de détecter un « risque ¼ d'IRA chez 12 patients dans chacun des groupes (RC: 1,0; IC 95 %: 0,5-1,9; p=1,00) et une « insuffisance ¼ chez 7 patients sur 35 (20 %) du groupe « amidon ¼ et 3 patients sur 34 (9 %) du groupe « saline ¼ (RC: 2,3; IC 95 %: 0,6-8,1; p=0,31). Le gain pondéral maximal, le nombre d'hémorragies, l'utilisation de produits sanguins et les besoins liquidiens étaient similaires dans les deux groupes. LIMITES: L'étude a été interrompue prématurément en raison d'un manque de ressources. Par conséquent, le faible échantillon de patients s'avère insuffisamment puissant pour détecter des différences significatives entre les deux groupes. CONCLUSIONS: Cette étude a mis en lumière quelques tendances permettant d'émettre des hypothèses intéressantes. L'étude a également confirmé la possibilité d'entreprendre un essai logistique complexe de manière pragmatique.

Simultaneous en bloc endotracheal tube insertion with GlideScope® Titanium™ video laryngoscope use: a randomized-controlled trial.

PURPOSE: Intubation-associated trauma with the GlideScope is rare, but when it occurs, it is likely due to advancing the endotracheal tube (ETT) blindly between the direct view of the oropharynx and the video view of the glottis. It is also occasionally difficult to advance the ETT to the glottic aperture despite a good view of the glottis on the monitor. One technique to potentially address both issues is to introduce the ETT en bloc with the GlideScope, thus visualizing the ETT tip throughout its entire path. We hypothesized that this en bloc technique could be faster and potentially easier than the standard technique. METHODS: Fifty patients with normal-appearing airways who required orotracheal intubation for elective surgery were randomly allocated to intubation with either the en bloc or the standard (GlideScope-first-then-ETT) technique. A three-dimensional printed clip was utilized to secure the ETT to the GlideScope during en bloc insertion. The primary outcome was time to intubation, defined from mask removal to first end-tidal carbon dioxide detection, recorded by a blinded observer. Secondary outcomes were subjective ease of intubation (100-mm visual analogue scale [VAS], 0 = easy; 100 = difficult), number of intubation attempts/failures, and incidence of oropharyngeal trauma (bleeding). RESULTS: The median [interquartile range (IQR)] intubation time was 36 [31-42] sec with the en bloc technique vs 41 [37-50] sec with the standard technique (difference in medians, 5 sec; 95% confidence interval [CI], 2 to 11; P = 0.008). The median [IQR] ease of intubation VAS was 11 [9-21] mm with the en bloc technique, and 15 [11-24] mm with the standard technique (difference in medians, 4 mm; 95% CI, -2 to 8; P = 0.19). Laryngoscopic grade and number of intubation attempts were similar between the groups; there was no oropharyngeal trauma noted. CONCLUSION: In this study of video laryngoscopy, intubation was slightly faster with the en bloc technique than with the standard GlideScope intubation technique, although the clinical importance of this difference is unknown. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02787629); registered 1 June 2016.

RéSUMé: OBJECTIF: Les traumatismes associés à l'intubation avec un GlideScope sont rares; quand ils surviennent, ils sont souvent provoqués par l'insertion du tube endotrachéal (TET) en aveugle entre la visualisation directe de l'oropharynx et la visualisation par vidéo de la glotte. Il arrive parfois qu'il soit difficile d'insérer le TET dans l'ouverture glottique malgré une bonne visualisation de la glotte sur le moniteur. Une technique permettant potentiellement de résoudre ces deux problèmes est l'introduction 'en bloc' du TET et du GlideScope, de manière à obtenir une vue de l'extrémité du TET tout au long de son parcours. Nous avons émis l'hypothèse que cette technique en bloc pourrait être à la fois plus rapide et potentiellement plus facile à réaliser que la technique standard. MéTHODE: Cinquante patients présentant des voies aériennes d'apparence normale et nécessitant une intubation orotrachéale pour une chirurgie non urgente ont été randomisés à être intubés soit par une technique en bloc, soit en utilisant la technique standard (GlideScope puis TET). Une pince imprimée en 3D a été utilisée pour attacher le TET au GlideScope pendant l'insertion en bloc. Le critère d'évaluation principal était le temps nécessaire à l'intubation, défini à partir du moment de retrait du masque jusqu'à la première détection de dioxyde de carbone télé-expiratoire, tel que mesuré par un observateur en aveugle. Les critères secondaires comprenaient la facilité subjective d'intubation (sur une échelle visuelle analogique [EVA] de 100 mm, où 0 = facile et 100 = difficile), le nombre de tentatives et d'échecs d'intubation, et l'incidence de lésions oropharyngées (saignement). RéSULTATS: Le temps d'intubation médian [écart interquartile (ÉIQ)] était de 36 [31­42] sec avec la technique en bloc vs 41 [37­50] sec avec la technique standard (différence de moyennes, 5 sec; intervalle de confiance [IC] 95 %, 2 à 11; P = 0,008). La facilité d'intubation médiane [ÉIQ] sur l'EVA était de 11 [9-21] mm avec la technique en bloc, et 15 [11-24] mm avec la technique standard (différence de moyennes, 4 mm; IC 95 %, -2 à 8; P = 0,19). La classification de la laryngoscopie et le nombre de tentatives d'intubation étaient similaires dans les deux groupes; aucun traumatisme oropharyngé n'a été enregistré. CONCLUSION: Dans cette étude vidéolaryngoscopique, l'intubation était légèrement plus rapide lors de l'utilisation de la technique en bloc que lors d'une technique d'intubation standard avec le GlideScope, bien que l'importance clinique de cette différence soit inconnue. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT02787629); enregistrée le 1er juin 2016.

Evolution of Tricuspid Regurgitation After Repair of Degenerative Mitral Regurgitation.

BACKGROUND: The fate of unrepaired tricuspid regurgitation (TR) after mitral valve repair for degenerative mitral regurgitation remains highly debated. The objective of this study was to examine the progress of unrepaired TR after mitral valve repair for degenerative mitral regurgitation, with a particular focus on comparing patients with moderate preoperative TR with those having none or mild preoperative TR. METHODS: Between 2008 and 2018, 183 consecutive patients (mean age, 61 years [SD, 14]) with severe degenerative mitral regurgitation and less-than-severe TR underwent mitral valve repair alone without concomitant TR repair. They were prospectively followed for a median duration of 3.1 years (interquartile range, 1.6-5.5; maximal duration of 9.4 years). RESULTS: At baseline 146 patients (80%) had none or mild TR; 37 patients (20%) had moderate TR. At follow-up 51 patients (30%) had improved TR compared with 28 patients (17%) who had worse TR. At 3 years postoperatively echocardiographic data were available for 82 of 183 patients: 70 (85%) had none or mild TR, 11 (13%) had moderate TR, and 1 (1.2%) had moderate to severe TR. In an exploratory multivariable analysis with limited statistical power, patients with moderate preoperative TR (vs those with none or mild TR) had an association with higher mortality (hazard ratio, 2.8; 95% confidence interval, 0.81-9.4; P = .11). CONCLUSIONS: After mitral valve repair but without concomitant tricuspid valve repair, a number of patients had progression in their TR. There was a signal of harm in patients having moderate preoperative TR in terms of mortality, but this finding is exploratory and requires investigation.

Risk of stroke and other adverse outcomes in patients with perioperative atrial fibrillation 1 year after non-cardiac surgery.

AIMS: To determine the 1-year risk of stroke and other adverse outcomes in patients with a new diagnosis of perioperative atrial fibrillation (POAF) after non-cardiac surgery. METHODS AND RESULTS: The PeriOperative ISchemic Evaluation (POISE)-1 trial evaluated the effects of metoprolol vs. placebo in 8351 patients, and POISE-2 compared the effect of aspirin vs. placebo, and clonidine vs. placebo in 10 010 patients. These trials included patients with, or at risk of, cardiovascular disease who were undergoing non-cardiac surgery. For the purpose of this study, we combined the POISE datasets, excluding 244 patients who were in atrial fibrillation (AF) at the time of randomization. Perioperative atrial fibrillation was defined as new AF that occurred within 30 days after surgery. Our primary outcome was the incidence of stroke at 1 year of follow-up; secondary outcomes were mortality and myocardial infarction (MI). We compared outcomes among patients with and without POAF using multivariable adjusted Cox proportional hazards models. Among 18 117 patients (mean age 69 years, 57.4% male), 404 had POAF (2.2%). The stroke incidence 1 year after surgery was 5.58 vs. 1.54 per 100 patient-years in patients with and without POAF, adjusted hazard ratio (aHR) 3.43, 95% confidence interval (CI) 2.00-5.90; P < 0.001. Patients with POAF also had an increased risk of death (incidence 31.37 vs. 9.34; aHR 2.51, 95% CI 2.01-3.14; P < 0.001) and MI (incidence 26.20 vs. 8.23; aHR 5.10, 95% CI 3.91-6.64; P < 0.001). CONCLUSION: Patients with POAF have a significantly increased risk of stroke, MI, and death at 1 year. Intervention studies are needed to evaluate risk reduction strategies in this high-risk population.

Multimodal imaging of aortic annulus and root geometry after valve sparing root reconstruction.

BACKGROUND: Controversy exists regarding the optimal annular stabilization technique following valve sparing aortic root reconstruction (VSRR) with no comprehensive imaging data to evaluate the natural history of aortic root graft geometry, aortic valve competency and patient prognosis post-reconstruction. METHODS: Between 2008-2017, 70 consecutive patients (mean age 56.4±16.4 years, 19.7% females) underwent VSRR. All patients were prospectively evaluated annually with clinical follow-up, echocardiography and CT imaging. Patients were assessed for survival, freedom from reoperation, degree of regurgitation, New York Heart Association (NYHA) status and graft complications and followed up to nine years post-operatively (mean 36±21 months). RESULTS: The largest increase of the aortic annulus diameter observed during the surveillance period was 2.64%±5.4% which occurred between the second and third years of follow-up and the aortic sinuses, sinotubular junction and ascending aorta all remained relatively stable based on annual CT imaging. Echocardiographic data showed far more variability in measurements at each annual post-operative visit with far less precision compared to the CT measurements taken at the same time. Due to the large variability and greater standard deviations, no significant difference was detected between the more precise CT measurements and those from the echocardiogram images. The overall survival rate was 94.3% (66 patients) at one year. Freedom from reoperation was 98.6% (69 patients). Throughout the entire duration of follow-up, aortic insufficiency was identified as 0 in 46 (65.7%), 1+ in 19 (27.1%), 2+ in 4 (5.7%), 3+ in 0 (0%) and 4+ in 1 (1.4%). Mean NYHA status was 1.1±0.3 at most recent follow-up for all patients. CT evidence showed 97.0% (64 patients) freedom from graft complication including: endocarditis, thrombosis, embolism, aneurysm, pseudoaneurysm, dehiscence, dissection and kinking. CONCLUSIONS: The annual imaging data presented here demonstrates stability of the Dacron aortic annuloplasty reconstruction over time, without the need for internal or external annular stabilization. CT imaging proved to be far more reliable than echocardiographic images, however given the stability, annual CT imaging is of little benefit. This is the first prospective study to compare echocardiographic, CT and clinical data following VSRR.

Transversus thoracis muscle plane block in cardiac surgery: a pilot feasibility study.

INTRODUCTION: Cardiac surgery patients often experience significant pain after median sternotomy. The transversus thoracis muscle plane (TTP) block is a newly developed, single-shot nerve block technique that provides analgesia for the anterior chest wall. In this double-blind pilot study, we assessed the feasibility of performing this novel block as an analgesic adjunct. METHODS: All patients aged 18-90 undergoing elective cardiac surgery were randomized to the block or standard care control group on admission to the intensive care unit after surgery. Under ultrasound guidance, patients in the block group received the TTP block with 20 mL of either 0.3% or 0.5% ropivacaine bilaterally, based on weight. The control group did not receive any injections. All blocks were performed by a single anesthesiologist, and data collection was performed by blinded assessors. The primary feasibility outcomes were rate of recruitment, adherence, and adverse events. The rate of recruitment was defined as the ratio of patients giving informed consent to the number of eligible patients who were approached to participate. Secondary outcomes included 12-hour and 24-hour Numeric Rating Scale (NRS) pain scores, 24-hour hydromorphone and acetaminophen requirements, time to extubation, time to first opioid administration, and patient satisfaction (on a yes/no questionnaire) at 24 hours. RESULTS: Twenty patients were approached for this study and 19 were enrolled. Eight patients received the intended intervention in each group. The recruitment rate was 95% of all approached eligible patients, and the adherence rate to treatment group was 94%. There were no block-related adverse events. The mean (SD) NRS pain scores at rest were 3.3 (3.2) in the block group vs 5.6 (3.2) in the control group at 12 hours. At 24 hours, the pain scores were 4.1 (3.9) vs 4.1 (3.3) in the block and control group, respectively. The mean (SD) 24-hour hydromorphone administration was 1.9 (1.1) mg in the block group vs 1.8 (0.9) mg in the control group. DISCUSSION: The TTP block is a novel pain management strategy poststernotomy. The results reveal a high patient recruitment, adherence, and satisfaction rate, and provide some preliminary data supporting safety. TRIAL REGISTRATION NUMBER: NCT03128346.

Early Clinical Outcomes of Hybrid Arch Frozen Elephant Trunk Repair With the Thoraflex Hybrid Graft.

BACKGROUND: Hybrid aortic arch surgery has evolved to include several technical variations, with most including an off-label use of a conventional thoracic endograft. We describe the early clinical outcomes of the Thoraflex Hybrid graft (Vascutek, Glasgow, Scotland) specifically designed for the treatment of complex arch and proximal descending aortic disease. METHODS: Between January 2014 and April 2017, 40 consecutive patients (66 ± 14 years of age, 45% women) underwent hybrid aortic arch and frozen elephant trunk repair with the multibranched Thoraflex Hybrid graft at 9 Canadian centers. Surgical indications included transverse arch or proximal descending aortic aneurysm in 100%, acute dissection in 10%, chronic dissection in 43%, and acute aortic rupture in 1 patient. Antegrade cerebral perfusion and moderate hypothermia (24.3 ± 1.8°C) were employed in all cases. RESULTS: All 40 device implants were successful. The 30-day or in-hospital mortality was 5%. Stroke and transient neurological deficits occurred in 5% and 3% of patients, respectively. Two (5%) patients experienced transient spinal cord ischemia-there were no instances of permanent paraplegia. Mean follow-up was 550 ± 328 days and late complications included type A aortic dissection in 1 patient, type B dissection in 2 patients, and further distal endografting in 2 patients. Survival at 30 days, 1 year, and 2 years was 95%, 95%, and 90%, respectively. CONCLUSIONS: Hybrid aortic arch and frozen elephant trunk repair with the Thoraflex Hybrid graft appears to be associated with good clinical outcomes, despite being early in the learning curve with this graft. Further investigation with this device is warranted to establish its role within the variations of hybrid arch repair.

Association between known or strongly suspected malignant hyperthermia susceptibility and postoperative outcomes: an observational population-based study.

PURPOSE: Whether current standards of care management for malignant hyperthermia (MH)-susceptible patients result in acceptable postoperative clinical outcomes at a population level is not known. Our objective was to determine if patients with susceptibility to MH experienced similar outcomes as patients without MH susceptibility after surgery under general anesthesia. METHODS: This was a retrospective, population-based cohort study from 1 April 2009 until 31 March 2016 in the Canadian province of Ontario. Participants were adults who underwent common in- or outpatient surgeries under general anesthesia. The exposure studied was either known or strongly suspected MH susceptibility as determined by usage of a specific physician billing code. The primary outcome was a composite of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. Separate analyses were employed, based on whether a patient had in- or outpatient surgery. Inverse probability of exposure weighting based on the propensity score was used to estimate adjusted exposure effects. RESULTS: The cohort included 957,876 patients (583,254 in- and 374,622 outpatients). There were 2,900 (0.3%) patients with a known or strong suspicion of MH susceptibility. For inpatients, the primary outcome occurred in 146,192 (25.1%) of the non-MH-susceptible group and in 337 (20.1%) of the MH-susceptible group (unadjusted risk difference [RD], -5.0%; 95% confidence interval [CI], -6.9 to -3.1%; P < 0.001). In outpatients, the primary outcome occurred in 9,146 (2.4%) of the non-MH-susceptible group and in 32 (2.6%) of the MH-susceptible group (RD, 0.2%; 95% CI, -0.7 to 1.1%; P = 0.72). After adjustment, MH susceptibility was not associated with the primary outcome in either the inpatients (adjusted risk difference [aRD], 1.2%; 95% CI, -1.3 to 3.6%; P = 0.35) or outpatients (aRD, -0.1%; 95% CI -1.0 to 0.9%; P = 0.90). CONCLUSIONS: Among adults in Ontario who underwent common surgeries under general anesthesia from 2009 to 2016, known or strongly suspected MH was not associated with a higher risk of adverse postoperative outcomes. These findings support the current standard of care management for MH-susceptible patients.

RéSUMé: OBJECTIF: Nous ignorons si les normes actuelles de gestion des soins de patients susceptibles d'hyperthermie maligne (HM) aboutissent à des résultats cliniques postopératoires acceptables à l'échelle d'une population. Notre objectif a été de déterminer si des patients présentant une susceptibilité à l'HM présentaient une évolution comparable à celle des patients non connus susceptibles après chirurgie sous anesthésie générale. MéTHODES: Il s'agissait d'une étude de cohorte rétrospective, basée sur une population de la province canadienne de l'Ontario allant du 1er avril 2009 au 31 mars 2016. Les participants étaient des adultes, hospitalisés ou ambulatoires, ayant subi des interventions sous anesthésie générale. L'exposition étudiée était une susceptibilité à l'HM connue ou fortement suspectée, déterminée par l'utilisation d'un code de facturation spécifique des médecins. Le critère d'évaluation principal était un critère composite incluant les décès toutes causes confondues, les réadmissions hospitalières ou les complications postopératoires majeures qui étaient survenus dans un délai de 30 jours postopératoires. Des analyses séparées ont été utilisées, selon que les patients avaient été hospitalisés ou opérés en chirurgie d'un jour. La probabilité inverse de la pondération de l'exposition basée sur le score pour la propension a servi à estimer les effets ajustés de l'exposition. RéSULTATS: La cohorte a inclus 957 876 patients (583 254 patients hospitalisés et 374 622 patients ambulatoires). Parmi eux, 2 900 patients (0,3 %) avaient une susceptibilité à l'HM connue ou fortement suspectée. Pour les patients hospitalisés, le critère d'évaluation principal est survenu chez 146 192 (25,1 %) des patients du groupe non susceptible d'HM et chez 337 (20,1 %) patients du groupe susceptible d'HM (différence de risques [DR] non ajustée : −5,0 %; intervalle de confiance [IC] à 95 % : −6,9 % à −3,1 %; P < 0,001). Pour les patients ambulatoires, le critère d'évaluation principal est survenu chez 9 146 (2,4 %) des patients du groupe non susceptible d'HM et chez 32 (2,6 %) patients du groupe susceptible d'HM (différence de risques [DR] non ajustée : 0,2 %; IC à 95 % : −0,7 % à 1,1 %; P = 0,72). Après ajustement, la susceptibilité à l'HM ne s'est pas avérée associée au critère d'évaluation principal dans le groupe de patients hospitalisés (différence de risques ajustée [DRa], 1,2 %; IC à 95 % : −1,3 % à 3,6 %; P = 0,35) ou dans le groupe de patients ambulatoires (DRa : −0,1 %; IC à 95 % : −1,0 % à 0,9 %; P = 0,90). CONCLUSIONS: Parmi les adultes de la province de l'Ontario ayant subi des interventions chirurgicales usuelles sous anesthésie générale entre 2009 et 2016, l'HM connue ou fortement suspectée n'a pas été associée à un plus grand risque d'évolution postopératoire défavorable. Ces constatations sont en faveur du maintien des normes des soins actuels pour la gestion des patients susceptibles d'HM.

Clinical impact of disinvestment in hydroxyethyl starch for patients undergoing coronary artery bypass surgery: a retrospective observational study.

PURPOSE: To examine the effect of discontinuing hydroxyethyl starch (HES) solutions on length of hospital stay, transfusion, risk of death, acute kidney injury (AKI), and dialysis. METHODS: We conducted a historical cohort study of linked administrative and clinical databases in patients undergoing coronary artery bypass surgery (CABG) on cardiopulmonary bypass. We used propensity scores to match patients who did not receive HES (after discontinuation) with patients exposed to HES (before discontinuation) and also controlled for albumin exposure. Hospital length of stay (the primary outcome) was analyzed using Fine-Gray proportional hazard regression, with hospital discharge as the outcome and death as a competing risk. Adverse outcomes were compared between matched patients using conditional logistic regression. RESULTS: We compared 1,085 propensity score-matched pairs (n = 2,170) from a pool of 2,757 patients. Discontinuation of HES was associated with shorter length of hospital stay, as evidenced by an increased probability of discharge (hazard ratio, 1.24; 95% confidence interval [CI], 1.14 to 1.35) and a reduced risk of red blood cell transfusion (odds ratio [OR], 0.68; 95% CI, 0.55 to 0.84), plasma transfusion (OR, 0.48; 95% CI, 0.34 to 0.66), and platelet transfusion (OR, 0.62; 95% CI, 0.44 to 0.87). Discontinuation of HES was not associated with in-hospital mortality (OR, 0.74; 95% CI, 0.36 to 1.54), AKI (OR, 0.84; 95% CI, 0.57 to 1.25), or dialysis (OR, 0.83; 95% CI, 0.25 to 2.73). CONCLUSIONS: For patients undergoing CABG on cardiopulmonary bypass, discontinuation of HES was associated with reduced hospital length of stay and reduced blood product transfusion, without measurable change in renal failure, dialysis rate, or in-hospital mortality. Our results should be interpreted with caution, though we found no evidence of harms associated with discontinuing HES. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02329158); registered 31 December, 2014.

Reason and Timing for Conversion to Sternotomy in Robotic-Assisted Coronary Artery Bypass Grafting and Patient Outcomes.

OBJECTIVE: Conversion to sternotomy is a primary bailout method for robotically assisted coronary artery bypass grafting procedures. The aims of this study were to identify the primary reasons for conversion from robotically assisted coronary artery bypass grafting to sternotomy and to evaluate the in-hospital outcomes in such patients. METHODS: Prospectively collected data from February 2004 to April 2017 were reviewed for 72 patients (56 men; mean age = 63.8 years) who required conversion to sternotomy during a robotically assisted coronary artery bypass grafting procedure with planned endoscopic left internal thoracic artery harvest and anastomosis to the left anterior descending on the beating heart. RESULTS: The overall rate of conversion was 12.4% (72/581). Conversions occurred either during attempted endoscopic left internal thoracic artery harvest (31.9%), during endoscopic left anterior descending isolation (40.3%), during manual isolation and anastomosis of the left anterior descending (19.4%), or after anastomosis due to unsatisfactory flow (8.3%). Overall, the most common reason for conversion was an intramyocardial left anterior descending (43.1%). The median stay in the intensive care unit was 1 day (range = 0-20) and the median hospital length of stay was 5 days (range = 3-43). In-hospital complications included new atrial fibrillation (16.7%), need for blood transfusion (20.8%), mediastinitis (4.2%), postoperative myocardial infarction (2.8%), exploration for bleeding (2.8%), and 1 in-hospital death. CONCLUSIONS: The reasons for conversion were primarily related to anatomical factors that created difficulties for endoscopic left internal thoracic artery harvesting and left anterior descending identification. Patients who required conversion to sternotomy from robotically assisted coronary artery bypass grafting demonstrated acceptable outcomes and low complication rates.

Association Between Handover of Anesthesia Care and Adverse Postoperative Outcomes Among Patients Undergoing Major Surgery.

Importance: Handing over the care of a patient from one anesthesiologist to another occurs during some surgeries and might increase the risk of adverse outcomes. Objective: To assess whether complete handover of intraoperative anesthesia care is associated with higher likelihood of mortality or major complications compared with no handover of care. Design, Setting, and Participants: A retrospective population-based cohort study (April 1, 2009-March 31, 2015 set in the Canadian province of Ontario) of adult patients aged 18 years and older undergoing major surgeries expected to last at least 2 hours and requiring a hospital stay of at least 1 night. Exposure: Complete intraoperative handover of anesthesia care from one physician anesthesiologist to another compared with no handover of anesthesia care. Main Outcomes and Measures: The primary outcome was a composite of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. Secondary outcomes were the individual components of the primary outcome. Inverse probability of exposure weighting based on the propensity score was used to estimate adjusted exposure effects. Results: Of the 313 066 patients in the cohort, 56% were women; the mean (SD) age was 60 (16) years; 49% of surgeries were performed in academic centers; 72% of surgeries were elective; and the median duration of surgery was 182 minutes (interquartile [IQR] range, 124-255). A total of 5941 (1.9%) patients underwent surgery with complete handover of anesthesia care. The percentage of patients undergoing surgery with a handover of anesthesiology care progressively increased each year of the study, reaching 2.9% in 2015. In the unweighted sample, the primary outcome occurred in 44% of the complete handover group compared with 29% of the no handover group. After adjustment, complete handovers were statistically significantly associated with an increased risk of the primary outcome (adjusted risk difference [aRD], 6.8% [95% CI, 4.5% to 9.1%]; P < .001), all-cause death (aRD, 1.2% [95% CI, 0.5% to 2%]; P = .002), and major complications (aRD, 5.8% [95% CI, 3.6% to 7.9%]; P < .001), but not with hospital readmission within 30 days of surgery (aRD, 1.2% [95% CI, -0.3% to 2.7%]; P = .11). Conclusions and Relevance: Among adults undergoing major surgery, complete handover of intraoperative anesthesia care compared with no handover was associated with a higher risk of adverse postoperative outcomes. These findings may support limiting complete anesthesia handovers.