Expiratory Central Airway Collapse and Dynamic Hyperinflation During Peroral Endoscopic Myotomy: A Case Report.

In tracheobronchomalacia, the structural weakening of the airway results in altered ventilatory mechanics. This case report describes a patient with known tracheobronchomalacia who experienced expiratory central airway collapse and dynamic pulmonary hyperinflation during peroral endoscopic myotomy (POEM) to treat symptomatic achalasia. We discuss the physiological considerations and potential complications of a POEM procedure with superimposed tracheobronchomalacia and present perioperative strategies for the prevention and management of this potentially deleterious combination. Although tracheobronchomalacia was a known condition in our patient, it is likely an underdiagnosed condition that may first present intraoperatively.

Identifying intraoperative events in a simulated laparotomy video: a multinational study of inattentional blindness among anesthesiologists.

PURPOSE: Medical errors may be occasionally explained by inattentional blindness (IB), i.e., failing to notice an event/object that is in plain sight. We aimed to determine whether age/experience, restfulness/fatigue, and previous exposure to simulation education may affect IB in the anesthetic/surgical setting. METHODS: In this multicentre/multinational study, a convenience sample of 280 anesthesiologists watched an attention-demanding video of a simulated trauma patient undergoing laparotomy and (independently/anonymously) recorded the abnormalities they noticed. The video contained four expected/common abnormalities (hypotension, tachycardia, hypoxia, hypothermia) and two prominently displayed unexpected/rare events (patient's head movement, leaky central venous line). We analyzed the participants' ability to notice the expected/unexpected events (primary outcome) and the proportion of expected/unexpected events according to age group and prior exposure to simulation education (secondary outcomes). RESULTS: Anesthesiologists across all ages noticed fewer unexpected/rare events than expected/common ones. Overall, younger anesthesiologists missed fewer common events than older participants did (P = 0.02). There was no consistent association between age and perception of unexpected/rare events (P = 0.28), although the youngest cohort (< 30 yr) outperformed the other age groups. Prior simulation education did not affect the proportion of misses for the unexpected/rare events but was associated with fewer misses for the expected/common events. Self-perceived restfulness did not impact perception of events. CONCLUSION: Anesthesiologists noticed fewer unexpected/rare clinical events than expected/common ones in an attention-demanding video of a simulated trauma patient, in keeping with IB. Prior simulation training was associated with an improved ability to notice anticipated/expected events, but did not reduce IB. Our findings may have implications for understanding medical mishaps, and efforts to improve situational awareness, especially in acute perioperative and critical care settings.

RéSUMé: OBJECTIF: Les erreurs médicales peuvent parfois s'expliquer par la cécité d'inattention, soit le fait de ne pas remarquer un événement/objet qui est à la vue de tous et toutes. Notre objectif était de déterminer si l'âge/l'expérience, le repos/la fatigue et l'exposition antérieure à l'enseignement par simulation pouvaient affecter la cécité d'inattention dans le cadre de l'anesthésie/chirurgie. MéTHODE: Dans cette étude multicentrique/multinationale, un échantillon de convenance de 280 anesthésiologistes ont visionné une vidéo exigeant l'attention portant sur un patient de trauma simulé bénéficiant d'une laparotomie et ont enregistré (de manière indépendante/anonyme) les anomalies qu'ils et elles ont remarquées. La vidéo contenait quatre anomalies attendues/courantes (hypotension, tachycardie, hypoxie, hypothermie) et deux événements inattendus/rares bien en vue (mouvement de la tête du patient, fuite du cathéter veineux central). Nous avons analysé la capacité des participant·es à remarquer les événements attendus/inattendus (critère d'évaluation principal) et la proportion d'événements attendus/inattendus selon le groupe d'âge et l'exposition antérieure à l'enseignement par simulation (critères d'évaluation secondaires). RéSULTATS: Les anesthésiologistes de tous âges ont remarqué moins d'événements inattendus/rares que d'événements attendus/courants. Globalement, les anesthésiologistes plus jeunes ont manqué moins d'événements courants que leurs congénères plus âgé·es (P = 0,02). Il n'y avait pas d'association constante entre l'âge et la perception d'événements inattendus ou rares (P = 0,28), bien que la cohorte la plus jeune (< 30 ans) ait surpassé les autres groupes d'âge. La formation antérieure par simulation n'a pas eu d'incidence sur la proportion d'inobservation des événements inattendus ou rares, mais a été associée à moins de cécité d'inattention envers les événements attendus ou courants. Le repos perçu n'a pas eu d'impact sur la perception des événements. CONCLUSION: Les anesthésiologistes ont remarqué moins d'événements cliniques inattendus/rares que d'événements attendus/courants dans une vidéo exigeant l'attention portant sur la simulation d'un patient traumatisé, ce qui s'inscrit dans la cécité d'inattention. La formation préalable par simulation était associée à une meilleure capacité à remarquer les événements anticipés/attendus, mais ne réduisait pas la cécité d'inattention. Nos résultats peuvent avoir des implications pour la compréhension des accidents médicaux et les efforts visant à améliorer la conscience situationnelle, en particulier dans les contextes de soins périopératoires aigus et de soins intensifs.

Competencies for proficiency in basic point-of-care ultrasound in anesthesiology: national expert recommendations using Delphi methodology.

PURPOSE: Point-of-care ultrasound (POCUS) allows for rapid bedside assessment and guidance of patient care. Recently, POCUS was included as a mandatory component of Canadian anesthesiology training; however, there is no national consensus regarding the competencies to guide curriculum development. We therefore aimed to define national residency competencies for basic perioperative POCUS proficiency. METHODS: We adopted a Delphi process to delineate relevant POCUS competencies whereby we circulated an online survey to academic anesthesiologists identified as POCUS leads/experts (n = 25) at all 17 Canadian anesthesiology residency programs. After reviewing a list of competencies derived from the Royal College of Physicians and Surgeons of Canada's National Curriculum, we asked participants to accept, refine, delete, or add competencies. Three rounds were completed between 2022 and 2023. We discarded items with < 50% agreement, revised those with 50-79% agreement based upon feedback provided, and maintained unrevised those items with ≥ 80% agreement. RESULTS: We initially identified and circulated (Round 1) 74 competencies across 19 clinical domains (e.g., basics of ultrasound [equipment, nomenclature, clinical governance, physics]; cardiac [left ventricle, right ventricle, valve assessment, pericardial effusion, intravascular volume status] and lung ultrasound anatomy, image acquisition, and image interpretation; and clinical applications [monitoring and serial assessments, persistent hypotension, respiratory distress, cardiac arrest]). After three Delphi rounds (and 100% response rate maintained), panellists ultimately agreed upon 75 competencies. CONCLUSION: Through national expert consensus, this study identified POCUS competencies suitable for curriculum development and assessment in perioperative anesthesiology. Next steps include designing and piloting a POCUS curriculum and assessment tool(s) based upon these nationally defined competencies.

RéSUMé: OBJECTIF: L'échographie ciblée (POCUS) permet une évaluation rapide au chevet des patient·es et l'orientation des soins aux patient·es. Récemment, l'échographie ciblée a été incluse en tant que composante obligatoire de la formation en anesthésiologie au Canada; cependant, il n'y a pas de consensus national sur les compétences qui guideront l'élaboration des programmes d'études. Nous avons donc cherché à définir les compétences à inclure dans les programmes de résidence nationaux pour acquérir des compétences de base en échographie ciblée périopératoire. MéTHODE: Nous avons adopté un processus Delphi pour délimiter les compétences pertinentes en échographie ciblée, processus dans le cadre duquel nous avons fait circuler un sondage en ligne auprès d'anesthésiologistes universitaires identifié·es comme des responsables/expert·es en échographie ciblée (n = 25) dans les 17 programmes canadiens de résidence en anesthésiologie. Après avoir examiné une liste de compétences tirées du programme d'études national du Collège royal des médecins et chirurgiens du Canada, nous avons demandé aux participant·es d'accepter, de peaufiner, de supprimer ou d'ajouter des compétences. Trois rondes ont été complétées entre 2022 et 2023. Nous avons écarté les éléments ayant < 50 % d'accord, révisé ceux avec 50 à 79 % d'accord en fonction des commentaires fournis, et maintenu sans révision les éléments obtenant ≥ 80 % d'accord. RéSULTATS: Nous avons d'abord identifié et diffusé (ronde 1) 74 compétences dans 19 domaines cliniques (p. ex., les bases de l'échographie [équipement, nomenclature, gouvernance clinique, physique]; anatomie échographique cardiaque [ventricule gauche, ventricule droit, évaluation valvulaire, épanchement péricardique, état du volume intravasculaire] et pulmonaire [acquisition et interprétation d'images]; et applications cliniques [surveillance et évaluations en série, hypotension persistante, détresse respiratoire, arrêt cardiaque]). Après trois rondes Delphi (et un taux de réponse de 100 % maintenu), les panélistes se sont finalement mis·es d'accord sur 75 compétences. CONCLUSION: Grâce à un consensus d'expert·es au pays, cette étude a permis d'identifier les compétences en échographie ciblée adaptées à l'élaboration et à l'évaluation de programmes d'études en anesthésiologie périopératoire. Les prochaines étapes comprennent la conception et la mise à l'essai d'un programme d'études et d'outils d'évaluation en échographie ciblée basés sur ces compétences définies à l'échelle nationale.

Analgesia for rib fractures: a narrative review.

PURPOSE: Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach. SOURCE: Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts. PRINCIPAL FINDINGS: Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities. CONCLUSION: Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

RéSUMé: OBJECTIF: Les fractures des côtes sont des blessures courantes et douloureuses souvent associées à une morbidité importante (p. ex., complications respiratoires) et à des taux de mortalité élevés, surtout chez les personnes âgées. La stratification des risques et la mise en œuvre rapide de voies analgésiques à l'aide d'une approche d'analgésie multimodale constituent un critère d'évaluation principal des soins visant à réduire la morbidité et la mortalité associées aux fractures des côtes. Ce compte rendu narratif a pour objectif de décrire les données probantes les plus récentes et les parcours de soins actuellement disponibles, y compris les outils de stratification des risques et les blocs analgésiques pharmacologiques et régionaux fréquemment utilisés dans le cadre de l'approche analgésique multimodale largement recommandée. SOURCES: La littérature disponible a été recherchée à l'aide des bases de données PubMed et Embase pour chaque sujet abordé dans le présent compte rendu et examinée par des expert·es en contenu. CONSTATATIONS PRINCIPALES: Quatre outils de stratification des risques ont été identifiés, le score de l'Étude de la prise en charge des traumatismes contondants de la paroi thoracique (Study of the Management of Blunt Chest Wall Trauma) étant le plus prédictif. Les données probantes actuelles sur les techniques d'analgésie pharmacologiques (c.-à-d. acétaminophène, anti-inflammatoires non stéroïdiens, gabapentinoïdes, kétamine, lidocaïne et dexmédétomidine) et d'analgésie régionale (c.-à-d. analgésie péridurale thoracique, bloc paravertébral thoracique, bloc du plan des muscles érecteurs du rachis et bloc du plan du muscle grand dentelé) ont été examinées, de même que la physiopathologie de la ou des fractures des côtes et de leurs complications associées, y compris l'apparition de douleurs chroniques et d'incapacités. CONCLUSION: Les fractures des côtes continuent d'être un diagnostic grave, avec des taux élevés de mortalité, de développement de douleurs chroniques et d'invalidité. Il a été démontré qu'une approche multidisciplinaire de la prise en charge, combinée à une analgésie appropriée et à l'adhésion aux ensembles et protocoles de soins, réduit la morbidité et la mortalité. La plupart des parcours de soins de stratification des risques identifiés sont peu performants pour prédire la mortalité et les complications après une ou plusieurs fractures de côtes.

Perioperative management of patients on glucagon-like peptide-1 receptor agonists.

PURPOSE OF REVIEW: To summarize the mechanism of action, clinical outcomes, and perioperative implications of glucagon-like peptide-1 receptor agonists (GLP-1-RAs). Specifically, this review focuses on the available literature surrounding complications (primarily, bronchoaspiration) and current recommendations, as well as knowledge gaps and future research directions on the perioperative management of GLP-1-RAs. RECENT FINDINGS: GLP-1-RAs are known to delay gastric emptying. Accordingly, recent case reports and retrospective observational studies, while anecdotal, suggest that the perioperative use of GLP-1-RAs may increase the risk of bronchoaspiration despite fasting intervals that comply with (and often exceed) current guidelines. As a result, guidelines and safety bulletins have been published by several Anesthesiology Societies. SUMMARY: While rapidly emerging evidence suggests that perioperative GLP-1-RAs use is associated with delayed gastric emptying and increased risk of bronchoaspiration (particularly in patients undergoing general anesthesia and/or deep sedation), high-quality studies are needed to provide definitive answers with respect to the safety and duration of preoperative drug cessation, and optimal fasting intervals according to the specific GLP-1-RA agent, the dose/duration of administration, and patient-specific factors. Meanwhile, clinicians must be aware of the potential risks associated with the perioperative use of GLP-1-RAs and follow the recommendations put forth by their respective Anesthesiology Societies.

Impact of COVID-19 pandemic on surgical activity in the Brazilian private healthcare system.

INTRODUCTION: Surgical volume was drastically reduced in many countries due to challenges imposed by the COVID-19 pandemic. OBJECTIVES: We sought to estimate the number of cancelled surgical and diagnostic procedures within the Brazilian private healthcare system between 2020 and 2021 over the course of the COVID-19 pandemic, and to project the procedural backlog generated for specific elective and time-sensitive surgeries, and diagnostic procedures. METHODS: Data were systematically extracted from the Brazilian national regulatory agency for the private healthcare system and included (i) quarterly and annual surgical and diagnostic volume, and (ii) the number of private health insurance beneficiaries between January 2016 and June 2021. Based on pre-pandemic data we estimated the expected number of surgical and diagnostic procedures that failed to be performed between 2020 and 2021. RESULTS: The average quarterly surgical and diagnostic procedures declined by 29.5% in 2020 and by 21.5% in 2021 compared to 2019. In 2020, such reduction reflected a lower number of diagnostic procedures under anesthesia (-35.1%), as well as elective (-14.7%), time-sensitive (-18.8%), and urgent (-4.6%) surgeries. In the first half of 2021, though the surgical and diagnostic procedures increased compared to 2020, they remained significantly below their historical average. The estimated backlogs were 134.385,64 for total surgical procedures, 2.634,64 for bariatric surgery and arthroplasty revision (elective surgeries), 2.845,61 for oncologic (time-sensitive) surgeries, and 304.193,99 for diagnostic procedures, requiring 1.7, 15.9, and 6.8 years, respectively, to make up for such backlogs. CONCLUSION: There was a major decline on the number of surgical and diagnostic procedures due to the COVID-19 pandemic. Despite a slight recovery of elective surgeries throughout the pandemic, many time-sensitive surgeries and diagnostic procedures were cancelled, with potential medium- to long-term consequences to patients and the system as a whole.

Dobutamine and Goal-Directed Fluid Therapy for Improving Tissue Oxygenation in Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction Surgery: Protocol for a Randomized Controlled Trial.

BACKGROUND: Breast reconstruction is an integral part of breast cancer care. There are 2 main types of breast reconstruction: alloplastic (using implants) and autologous (using the patient's own tissue). The latter creates a more natural breast mound and avoids the long-term need for surgical revision-more often associated with implant-based surgery. The deep inferior epigastric perforator (DIEP) flap is considered the gold standard approach in autologous breast reconstruction. However, complications do occur with DIEP flap surgery and can stem from poor flap tissue perfusion/oxygenation. Hence, the development of strategies to enhance flap perfusion (eg, goal-directed perioperative fluid therapy) is essential. Current perioperative fluid therapy is traditionally guided by subjective criteria, which leads to wide variations in clinical practice. OBJECTIVE: The main objective of this trial is to determine whether the use of minimally invasive cardiac output (CO) monitoring for guiding intravenous fluid administration, combined with low-dose dobutamine infusion (via a treatment algorithm), will increase tissue oxygenation in patients undergoing DIEP flap surgery. METHODS: With appropriate institutional ethics board and Health Canada approval, patients undergoing DIEP flap surgery are randomly assigned to receive CO monitoring for the guidance of intraoperative fluid therapy in addition to a low-dose dobutamine infusion (which potentially improves flap oxygenation) versus the current standard of care. The primary outcome is tissue oxygenation measured via near-infrared spectroscopy at the perfusion zone furthest from the perforator vessels 45 minutes after vascular reanastomosis of the DIEP flap. Low dose (2.5 µg/kg/hr) dobutamine infusion continues for up to 4 hours postoperatively, provided there are no associated complications (ie, persistent tachycardia). Flap oxygenation, hemodynamic parameters, and any medication-associated side effects/complications are monitored for up to 48 hours postoperatively. Complications, rehospitalizations, and patient satisfaction are also collected until 30 days postoperatively. RESULTS: Funding and regulatory approvals were obtained in 2019, but the study recruitment was interrupted by the COVID-19 pandemic. As of October 4, 2023, 34 participants have been recruited. Because of the significant delays associated with the pandemic, the expected completion date was extended. We expect the study to be completed and ready for potential news release (as appropriate) and publication by July 2024. No patients have suffered any adverse effects/complications from participating in this study, and none have been lost to follow-up. CONCLUSIONS: CO-directed fluid therapy in combination with a low-dose dobutamine infusion via a treatment algorithm has the potential to improve DIEP flap tissue oxygenation and reduce complications following DIEP flap breast reconstruction surgery. However, given that the investigators remain blinded to group randomization, no comment can be made regarding the efficacy of this intervention for improving tissue oxygenation at this time. Nevertheless, no patients have been withdrawn for safety concerns thus far, and compliance remains high. TRIAL REGISTRATION: Clinicaltrials.gov NCT04020172; https://clinicaltrials.gov/study/NCT04020172.

Decreasing inconsistent alarms notifications: a pragmatic clinical trial in a post-anesthesia care unit.

BACKGROUND: Alarms alert healthcare professionals of deviations from normal/physiologic status. However, alarm fatigue may occur when their high pitch and diversity overwhelm clinicians, possibly leading to alarms being disabled, paused, and/or ignored. We aimed to determine whether a staff educational program on customizing alarm settings of bedside monitors may decrease inconsistent alarms in the Post-Anesthesia Care Unit (PACU). METHODS: This is a prospective, analytic, quantitative, pragmatic, open-label, single-arm study. The outcome was evaluated on PACU admission before (P1) and after (P2) the implementation of the educational program. The heart rate, blood pressure, and oxygen saturation alarms were selected for clinical consistency. RESULTS: A total of 260 patients were included and 344 clinical alarms collected, with 270 (78.4%) before (P1), and 74 (21.6%) after (P2) the intervention. Among the 270 alarms in P1, 45.2% were inconsistent (i.e., false alarms), compared to 9.4% of the 74 in P2. Patients with consistent alarms occurred in 30% in the P1 and 27% in the P2 (p = 0.08). Patients with inconsistent alarms occurred in 25.4% in the P1 and in 3.8% in the P2. Ignored consistent alarms were reduced from 21.5% to 2.6% (p = 0.004) in the P2 group. The educational program was a protective factor for the inconsistent clinical alarm (OR = 0.11 [95% CI 0.04-0.3]; p < 0.001) after adjustments for age, gender, and ASA physical status. CONCLUSION: Customizing alarm settings on PACU admission proved to be a protective factor against inconsistent alarm notifications of multiparametric monitors.