Cognitive Aids for the Management of Thoracic Anesthesia Emergencies: Consensus Guidelines on Behalf of a Canadian Thoracic Taskforce.

A cognitive aid is a tool used to help people accurately and efficiently perform actions. Similarly themed cognitive aids may be collated into a manual to provide relevant information for a specific context (eg, operating room emergencies). Expert content and design are paramount to facilitate the utility of a cognitive aid, especially during a crisis when accessible memory may be limited and distractions may impair task completion. A cognitive aid does not represent a rigid approach to problem-solving or a replacement for decision-making. Successful cognitive aid implementation requires dedicated training, access, and culture integration. Here the authors present a set of evidence-based cognitive aids for thoracic anesthesia emergencies developed by a Canadian thoracic taskforce.

Trauma Surveillance and Registry Development in Mozambique: Results of a 1-Year Study and the First Phase of National Implementation.

BACKGROUND: Mozambique has had no policy-driven trauma system and no hospital-based trauma registries, and injury was not a public health priority. In other low-income countries, trauma system implementation and trauma registries have helped to reduce mortality from injury by up to 35%. In 2014, we introduced a trauma registry in four hospitals in Maputo serving 18,000 patients yearly. The project has since expanded nationally. This study summarizes the challenges, results, and lessons learned from this large national undertaking. METHODS: Between October 2014-September 2015, we implemented a trauma registry at four hospitals in Maputo. In October 2015, the project began to be expanded nationally. Physicians and allied health professionals at each hospital were trained to implement the registry, and each identified and trained data collectors. We conducted semi-structured interviews with the key stakeholders of this project to identify the challenges, results, and creative solutions implemented for the success of this project. RESULTS: Most participants identified the importance of having a trauma registry and its usefulness in identifying gaps in trauma care. The registry identified that less than 5% of injured patients arrived by ambulance, which served as evidence for the need for a prehospital system, which the Ministry of Health had already begun implementing. Participants also highlighted how the registry has allowed for a structured clinical approach to patients, ensuring that severely injured patients are identified early. Challenges reported included the high rates of missing data, the difficulty in establishing a streamlined flow of trauma patients within each hospital, and the bureaucratic challenges faced when attempting to improve capacity for trauma care at each hospital by introducing a trauma bay and new technologies. Participants identified the need to improve data completeness, to disseminate the results of the project nationally and internationally, to improve inter-divisional cooperation, and to continue educating health providers on the importance of registries. Participants also identified political instabilities in the region as a potential source of challenge in expanding the project nationally; they also identified the lack of uniform resource allocation and low personnel in many areas, especially rural, as a major burden that would need to be overcome. CONCLUSION: Introduction of a trauma registry system in Mozambique is feasible and necessary. Initial findings provide insight into the nature of traumas seen in Maputo hospitals, but also underscore future challenges, especially in minimizing missing data, utilizing data to develop evidence-based trauma prevention policies, and ensuring the sustainability of these efforts by ensuring continued governmental support, education, and resource allocation. Many of these measures are being undertaken.

Deployment of second-generation resuscitative endovascular balloon occlusion of the aorta for unresponsive hypotension in a polytrauma patient

Summary: Noncompressible hemorrhagic control remains one of the most challenging areas in damage control medicine and continues to be a leading cause of preventable death. For decades, emergency thoracotomy or laparotomy and aortic cross clamping have remained the gold standard intervention. Recently, there has been a movement toward less invasive techniques for noncompressible hemorrhagic control, such as resuscitative endovascular balloon occlusion of the aorta (REBOA). The REBOA technique involves inflation of an endovascular balloon within the abdominal aorta proximal to the vascular injury to temporarily inhibit bleeding. Although the literature is robust on this new technique, skepticism remains about whether REBOA is superior to aortic cross clamping, as it has been associated with complications including organ and limb ischemia, limb amputation, femoral aneurysm, and thrombosis.

Intermittent use of resuscitative endovascular balloon occlusion of the aorta in penetrating gunshot wound of the lower extremity

Summary: The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in penetrating injuries is an emerging adjunct in the civilian trauma surgeon's toolbox for the management of traumatic hemorrhagic shock. Furthermore, within the Canadian civilian context, little has been reported with regard to its use as an assisted damage-control measure in vascular reconstruction of the lower extremity. We report a case of penetrating gunshot injury of the lower extremity where the preoperative deployment of REBOA had a remarkable positive impact in the resuscitation phase and the intraoperative control of blood loss. A description of the procedure and the advantage gained from REBOA are discussed.

Microcirculatory response during on-pump versus off-pump coronary artery bypass graft surgery.

OBJECTIVES: The use of cardiopulmonary bypass (CPB) during coronary artery bypass graft surgery (CABG) is associated with a systemic inflammatory response, resulting in altered microcirculation. The aim of this study was to evaluate whether beating heart surgery can preserve the microcirculation. METHODS: Sublingual microcirculation was characterized by a Sidestream Darkfield Imaging Microscope during off-pump (OPCABG) and on-pump (ONCABG) surgery. Microcirculatory parameters were evaluated during eight precise perioperative time points. RESULTS: The quality of the microcirculation decreased during early ONCABG. OPCABG resulted in a significantly better microcirculation compared to ONCABG for three of six parameters during surgery. However, by the end of surgery and postoperatively, the microcirculatory parameters were no different between the groups. CONCLUSIONS: While the results do not show a marked preservation of the microcirculation during and after OPCABG compared to ONCABG, they coincide with the body temperature fluctuations of each group during and after surgery. Our work suggests that active warming could impact the microcirculation parameters.

Epidural analgesia and postoperative orthostatic haemodynamic changes: observational study.

CONTEXT: In thoracic and abdominal surgery, epidural analgesia provides excellent pain relief, but associated postural hypotension can delay mobilisation. OBJECTIVES: To assess postoperative orthostatic haemodynamic changes in patients receiving epidural analgesia after major surgery. DESIGN: Prospective observational study. Physiological intervention. SETTINGS: Montreal General Hospital tertiary teaching hospital. PATIENTS OR OTHER PARTICIPANTS: Patients scheduled for thoracic or abdominal surgery with thoracic epidural analgesia using a mixture of bupivacaine 0.1% and fentanyl 3 µg ml(-1). INTERVENTION(S): Arterial blood pressure and heart rate were measured in supine, sitting and standing position before surgery and daily for the first 3 postoperative days. MAIN OUTCOME MEASURE: Orthostatic hypotension, defined as a drop in SBP of more than 20  mmHg during the orthostatic tests, was investigated as a predictor of inability to mobilise during the postoperative period. RESULTS: One hundred and sixty-one patients were enrolled in the study. Hypotension was detected in 59 (37%) of the patients on postoperative day 1, 20 (12%) on day 2 and four (2.5%) on day 3. On day 1, 43% of the patients walked, 39% only sat and 17% were bedridden. Supine SBP less than 90  mmHg, haemodynamic changes during the orthostatic tests, dizziness or nausea, did not predict inability to walk. Only blood loss more than 500  ml and supine mean BP less than 70  mmHg were negative predictors of mobilisation on day 1. CONCLUSION: Epidural analgesia is associated with arterial hypotension in the postoperative period. However, haemodynamic assessment does not predict inability to walk after thoracic and abdominal surgery. Early mobilisation should be tried irrespective of BP or orthostatic changes in postoperative patients with epidural analgesia.

Factors associated with bicycle helmet use and proper fit: a cross-sectional survey of Montreal cyclists during the COVID-19 pandemic.

OBJECTIVES: With increased bicycle use during the COVID-19 pandemic and growing availability of bicycle-sharing programs in Montreal, we hypothesize helmet use has decreased. The aim of this study was to evaluate helmet use and proper fit among Montreal cyclists during the pandemic relative to historical data. METHODS: Nine observers collected data on bike type, gender, helmet use, and ethnicity using the iHelmet© app at 18 locations across the island of Montreal from June to September 2021. Proper helmet wear was assessed at one busy location. Multiple logistic regression was used to identify factors associated with helmet wear and results were compared to a historical study. RESULTS: Of the 2200 cyclists observed, 1109 (50.4%) wore a helmet. Males (OR = 0.78, 95%CI = 0.65-0.95), young adults (OR = 0.65, 95%CI = 0.51-0.84), visible minorities (OR = 0.38, 95%CI = 0.28-0.53), and bike-share users (OR = 0.21, 95%CI = 0.15-0.28) were less likely to be wearing a helmet, whereas children (OR = 3.92, 95%CI = 2.17-7.08) and cyclists using racing bicycles (OR = 3.84, 95%CI = 2.62-5.62) were more likely to be wearing a helmet. The majority (139/213; 65.3%) of assessed cyclists wore properly fitting helmets. Children had the lowest odds of having a properly fitted helmet (OR = 0.13, 95%CI = 0.04-0.41). Compared to 2011, helmet use during the pandemic increased significantly (1109/2200 (50.4%) vs. 2192/4789 (45.8%); p = 0.032). CONCLUSION: Helmet use among Montreal cyclists was associated with age, gender, ethnicity, and type of bicycle. Children were least likely to have a properly fitted helmet. The recent increase in popularity of cycling and expansion of bicycle-sharing programs reinforce the need for bicycle helmet awareness initiatives, legislation, and funding prioritization.

RéSUMé: OBJECTIF: Avec la popularité grandissante du vélo durant la pandémie COVID-19 et l'expansion du vélopartage à Montréal, nous croyons que le port du casque a diminué. L'objectif de cette étude était d'évaluer l'utilisation du casque et le port adéquat parmi les cyclistes montréalais et de comparer nos résultats avec des données historiques. MéTHODE: Neuf observateurs, stationnés à 18 emplacements, ont recueilli les informations suivantes en utilisant l'application mobile iHelmet© : type de vélo, sexe, origine ethnique et port du casque. Le port adéquat du casque a été observé à un endroit. L'association de chaque variable avec le port et le port adéquat a été fait par régression multivariable et comparé à des données historiques. RéSULTATS: Des 2 200 cyclistes observés, 1 109 (50,4 %) portaient un casque. Les enfants (OR = 3,92, IC95% = 2,17­7,08) et les cyclistes de performance (OR = 3,84, IC95% = 2,62­5,62) portaient le casque plus fréquemment tandis que les hommes (OR = 0,78, IC95% = 0,65­0,95), les jeunes adultes (OR = 0,65, IC95% = 0,51­0,84), les minorités visibles (OR = 0,38, IC95% = 0,28­0,53), et les utilisateurs de vélopartage (OR = 0,21, IC95% = 0,15­0,28) le portaient moins. La majorité (139/213; 65,3 %) des casques étaient portés adéquatement. Les enfants étaient plus à risque de porter un casque mal ajusté (OR = 0,13, IC95% = 0,04­0,41). L'utilisation d'un casque chez les cyclistes montréalais a augmenté significativement depuis 2011 (1 109/2 200 (50,4 %) c. 2 192/4 789 (45,8 %); p = 0,032). CONCLUSION: Le port du casque à vélo à Montréal est associé à l'âge, le sexe, l'origine ethnique et le type de vélo. Les enfants sont plus à risque de mal porter un casque. Des stratégies de promotion ainsi que la législation peuvent favoriser des comportements sécuritaires à vélo.

Post-conditioning: promising answers and more questions.

Volatile anesthetic agents have been used for decades in the peri-operative setting. Data from the past 15 years have shown that pre-injury administration of volatile anesthetic can decrease the impact of ischemia-reperfusion injury on the heart, brain, and kidney. Recent data demonstrated that volatile agents administered shortly after injury can decrease the ischemia-reperfusion injury. Several questions need to be answered to optimize this therapeutic target, but this is a promising era of secondary injury mitigation.

Bilateral Cardiac Sympathectomy and Extrapericardial Coil Implantation for the Management of Electrical Storm.

We present a novel multidisciplinary approach for the treatment of electrical storm combining bilateral cardiac sympathectomy, extrapericardial coil insertion, and implantable cardioverter defibrillator upgrade in a patient with nonischemic cardiomyopathy and ventricular arrhythmias refractory to conventional therapies. (Level of Difficulty: Advanced.).

Regional anesthesia for carotid surgery: less intraoperative hypotension and vasopressor requirement.

Regional anesthesia (RA) is the gold standard of neuromonitoring during carotid endarterectomy (CEA). Recent data show that RA for CEA is associated with fewer postoperative complications. The aim of the present study was to assess hemodynamic stability and vasoactive drug use for CEA performed under RA versus general anesthesia (GA). All patients undergoing CEA from January 2005 to January 2006 were identified from our prospective database. Electronic and paper charts were reviewed. Intraoperative monitoring data were reviewed retrospectively. Hypotension was defined as systolic blood pressure (SBP) <100 mm Hg and deemed prolonged if it lasted more than 10 min. Hypertension was defined as SBP >160 mm Hg. BP variation was defined as the difference between the highest and lowest SBP, and bradycardia as heart rate (HR) below 60. The data were expressed as means +/- standard deviation. Seventy-two consecutive patients underwent CEA: 25 under RA and 47 under GA. There was no difference in preoperative HR and BP. Most patients had symptomatic severe carotid stenosis (80% in RA vs. 85% in GA, nonsignificant). Intraoperatively, RA was associated with less BP variation (60 +/- 27 vs. 78 +/- 22 mm Hg, p = 0.005), bradycardia (5% vs. 63%, p < 0.001), hypotension (20% vs. 70%, p < 0.01), and prolonged hypotension (0% vs. 23%, p = 0.009) and more hypertension (80% vs. 47%, p = 0.007). Vasopressor requirements were less frequent under RA (20% vs. 77%, p < 0.001). There was no significant difference between groups in hypotension or hypertension episodes seen in the postoperative recovery room. RA was associated with less hypotension and less vasopressor used during CEA compared to GA. The improved hemodynamic stability may account for the lower incidence of complications after CEA.

Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm.

BACKGROUND: Percutaneous catheterization is a frequently-used technique to gain access to the central venous circulation. Inadvertent arterial puncture is often without consequence, but can lead to devastating complications if it goes unrecognized and a large-bore dilator or catheter is inserted. The present study reviews our experience with these complications and the literature to determine the safest way to manage catheter-related cervicothoracic arterial injury (CRCAI). METHODS: We retrospectively identified all cases of iatrogenic carotid or subclavian injury following central venous catheterization at three large institutions in Montreal. We reviewed the French and English literature published from 1980 to 2006, in PubMed, and selected studies with the following criteria: arterial misplacement of a large-caliber cannula (>/=7F), adult patients (>18 years old), description of the method for managing arterial trauma, reference population (denominator) to estimate the success rate of the therapeutic option chosen. A consensus panel of vascular surgeons, anesthetists and intensivists reviewed this information and proposed a treatment algorithm. RESULTS: Thirteen patients were treated for CRCAI in participating institutions. Five of them underwent immediate catheter removal and compression, and all had severe complications resulting in major stroke and death in one patient, with the other four undergoing further intervention for a false aneurysm or massive bleeding. The remaining eight patients were treated by immediate open repair (six) or through an endovascular approach (two) for subclavian artery trauma without complications. Five articles met all our inclusion criteria, for a total of 30 patients with iatrogenic arterial cannulation: 17 were treated by immediate catheter removal and direct external pressure; eight (47%) had major complications requiring further interventions; and two died. The remaining 13 patients submitted to immediate surgical exploration, catheter removal and artery repair under direct vision, without any complications (47% vs 0%, P = .004). CONCLUSION: During central venous placement, prevention of arterial puncture and cannulation is essential to minimize serious sequelae. If arterial trauma with a large-caliber catheter occurs, prompt surgical or endovascular treatment seems to be the safest approach. The pull/pressure technique is associated with a significant risk of hematoma, airway obstruction, stroke, and false aneurysm. Endovascular treatment appears to be safe for the management of arterial injuries that are difficult to expose surgically, such as those below or behind the clavicle. After arterial repair, prompt neurological evaluation should be performed, even if it requires postponing elective intervention. Imaging is suggested to exclude arterial complications, especially if arterial trauma site was not examined and repaired.

Subcutaneous cervical and facial emphysema with the use of the Bonfils fiberscope and high-flow oxygen insufflation.

We present a case in which use of the Bonfils retromolar intubation fiberscope resulted in cervical and facial subcutaneous emphysema. The patient was a 75-yr-old woman with Mallampati Grade I airway. The Bonfils retromolar intubation fiberscope was used for teaching purposes. Flow on the oxygen port of the fiberscope was set at 10 L/min. Immediately after insertion of the scope, her whole face and cervical skin showed severe subcutaneous emphysema. The patient was intubated conventionally and the emphysema resolved within 24 h. Subcutaneous emphysema after air insufflation is known from dental procedures with air entering through holes in the teeth. In our case, the oxygen insufflation was sufficient to create emphysema, probably through tiny mucosal lesions.

Effect of a continuous peripheral nerve block on the inflammatory response in knee arthroplasty.

BACKGROUND AND OBJECTIVES: Experimental nerve block in animals inhibits the inflammatory response. The purpose of this study was to determine to what extent a 48-hour local anesthetic block of all afferent and efferent nerve fibers of the knee area has an impact on postoperative inflammatory response. METHODS: Twelve patients scheduled for primary total knee arthroplasty received spinal anesthesia, and then were randomly allocated to either patient-controlled analgesia with morphine (n = 6) or a combination of continuous lumbar plexus and sciatic nerve blocks (continuous peripheral nerve block; CPNB) with ropivacaine 0.2% for 48 hours. Blood samples were collected before surgery and at 3, 8, 24, and 48 hours after surgical incision to measure plasma glucose, serum insulin and cortisol, C-reactive protein, interleukin-6, and leukocyte count. Pain visual analog scale at rest and on knee flexion were recorded and complications classified. RESULTS: Visual analog scale was lower in the CPNB group at rest and on knee flexion on postoperative days 1 and 2 (P < .05). There were no differences in circulating levels of glucose, insulin, and cortisol. C-reactive protein and leukocyte count were lower in the CPNB group (P < .05). There was a positive correlation between the peak leukocyte count and the inflammatory markers (P < .03). Three patients in the patient-controlled analgesia group and one in the CPNB group had complications requiring conservative management. CONCLUSIONS: Continuous lumbar plexus and sciatic nerve blocks with ropivacaine contribute to the attenuation of the postoperative inflammatory response.

Pharmacokinetic variability of extended interval tobramycin in burn patients.

BACKGROUND: Aminoglycosides are mandatory in the treatment of severe infections in burns. However, their pharmacokinetics are difficult to predict in critically ill patients. Our objective was to describe the pharmacokinetic parameters of high doses of tobramycin administered at extended intervals in severely burned patients. METHODS: We prospectively enrolled 23 burned patients receiving tobramycin in combination therapy for Pseudomonas species infections in a burn ICU over 2 years in a therapeutic drug monitoring program. Trough and post peak tobramycin levels were measured to adjust drug dosage. Pharmacokinetic parameters were derived from two points first order kinetics. RESULTS: Tobramycin peak concentration was 7.4 (3.1-19.6)microg/ml and Cmax/MIC ratio 14.8 (2.8-39.2). Half-life was 6.9 (range 1.8-24.6)h with a distribution volume of 0.4 (0.2-1.0)l/kg. Clearance was 35 (14-121)ml/min and was weakly but significantly correlated with creatinine clearance. CONCLUSION: Tobramycin had a normal clearance, but an increased volume of distribution and a prolonged half-life in burned patients. However, the pharmacokinetic parameters of tobramycin are highly variable in burned patients. These data support extended interval administration and strongly suggest that aminoglycosides should only be used within a structured pharmacokinetic monitoring program.

Additional and repeated computed tomography in interfacility trauma transfers: Room for standardization.

BACKGROUND: Despite the recommendations of the Advanced Trauma Life Support course of the American College of Surgeons, patients undergo computed tomography (CT) in local hospitals before transfer to a trauma center. The problem of repeat CTs caused by technical and protocol issues is ongoing. The objective is to measure the importance of repeat CTs and CTs involving other body regions. METHODS: All secondary transfers to our level 1 facility with CT at the local hospital over 9 years were reviewed. Patients were considered to have had a repeat CT if the same body region or an another body region was scanned as a part of the initial assessment but not for reasons of clinical follow-up. RESULTS: Of 6,292 patients received from local hospitals, 685 (12%) had undergone 1097 CT scans at the local hospitals. Patients being scanned in local hospitals were sicker (injury severity score: 21 vs 13) and required more intensive care unit admissions (38% vs 29%) and more ventilation (32% vs 22%). Thirty-nine percent of CTs were repeated, and 55% of these patients required imaging of another body part. CONCLUSION: Repeat and additional images remain a major issue in trauma transfers. Improvement requires standardization of CT protocols and change in the approach of local hospitals from "finding and requiring need level 1 trauma center" to "not missing any injuries."