Pharmacologic methods to minimise coughing during extubation in the era of COVID-19.

BACKGROUND/AIM: Given the current severe acute respiratory syndrome coronavirus 2 pandemic, coughing at the time of extubation is at risk of creating aerosolisation. This may place health care workers at risk of nosocomial infection during the perioperative period. This study aims to summarise the current pharmacologic methods to minimise cough at the time of extubation, and to determine whether some strategies could be more beneficial than others. METHODS: This is a summary of systematic reviews. A comprehensive search through MEDLINE was performed. Thirty-three publications were screened for eligibility. Only the manuscripts discussing pharmacologic methods to minimise coughing on extubation were included in this review. FINDINGS: Many pharmacological agents have been proposed to decrease the incidence of cough at the time of extubation. Of these, intravenous administration of dexmedetomidine (relative risk 0.4; 95% CI: 0.4-0.5) or remifentanil (RR 0.4; 95% CI: 0.4-0.5) seems to have the largest effect to reduce cough on extubation. CONCLUSION: The available data in the current literature is sparse. Yet, dexmedetomidine and remifentanil seem to be the most efficient agents to decrease the incidence of emergence coughing.

'A pain in the buttock': A case report of gluteal compartment syndrome after robotic partial nephrectomy.

Acute compartment syndrome is a surgical emergency that, if unrecognised, leads to tissue and muscle ischaemia, necrosis, multi-organ failure and even death. Gluteal compartment syndrome is a rare type of compartment syndrome that typically occurs as a sequela of trauma, and its presentation may be difficult to recognise. We describe a case of a patient who developed gluteal compartment syndrome following a prolonged renal surgery in lateral decubitus position. Our case report aims to raise clinicians' awareness to consideration of this rare syndrome in patients presenting with lower extremity or back pain after prolonged surgery.

Single-dose premedication enhances multimodal analgesia after knee arthroplasty.

BACKGROUND: With the current trend to reduce postoperative opioid use to enhance recovery and address perioperative opioid addiction concerns, the challenge of managing pain after total knee arthroplasty has increased. This study examined the effect of adding a preoperative medication regime to a multimodal postoperative analgesia protocol that included regional anaesthesia. MATERIALS AND METHODS: Sixty patients undergoing elective first-time unilateral knee arthroplasty received celecoxib 100mg, gabapentin 600mg and dexamethasone 10mg po one hour before skin incision. They were compared to a sequential retrospective cohort of 49 patients. All patients routinely received acetaminophen 650mg po q6h, ibuprofen 400mg po q8h, patient-controlled opioid analgesia and continuous adductor canal blocks postoperatively. Pain scores and opioid consumption were recorded at 4, 8, 12, 24 and 48h. RESULTS: Pain scores and cumulative opioid use were statistically and clinically significantly reduced at all time points up to 48h. CONCLUSIONS: Combining preoperative oral celecoxib, gabapentin and dexamethasone had a clinically significantly effect in reducing pain scores and opioid use for at least 48h. Most of this effect is probably due to dexamethasone.

Incidence of Venous Thromboembolism in Adults Receiving Extracorporeal Membrane Oxygenation: A Systematic Review.

Extracorporeal membrane oxygenation (ECMO) has become an increasingly used tool for cardiorespiratory support. Thrombosis is a well-recognized complication of ECMO, yet the burden of disease remains unclear. We undertook a systematic review to investigate the incidence of venous thromboembolism (VTE) during ECMO or soon after decannulation, in patients screened for VTE. We retrieved all studies that evaluated VTE incidence in ECMO patients in EMBASE, MEDLINE, Web of Science, and Cochrane Library from inception to April 2, 2021. Studies reporting incidence of VTE diagnosed on systematic screening tests during ECMO or within 7 days of decannulation in adult patients were included. A total of 18 studies were included in the systematic review. These studies screened a total of 1095 ECMO patients. Most studies screened for cannula-associated deep vein thrombosis (CaDVT) after decannulation. The overall incidence of DVT was 52.8% (95% CI, 49.8-55.8%). Incidence of DVT was 53.5% (95% CI, 50.0-57.0%) for venovenous ECMO vs. 34.0% (95% CI, 26.5-42.2%) for venoarterial ECMO. No studies screened for pulmonary embolism. Our systematic review found a very high incidence of DVT among patients treated with ECMO. Routine screening for DVT after decannulation for all ECMO patients may be warranted.

Association of intraoperative dexmedetomidine use with postoperative hypotension in unilateral hip and knee arthroplasties: a historical cohort study.

PURPOSE: Dexmedetomidine is frequently used as a sedative agent for orthopedic surgery patients undergoing total hip or knee arthroplasty. Although the benefits of dexmedetomidine are well described in the literature, there is also potential for harm, especially regarding the hemodynamic effects of dexmedetomidine in the postoperative setting. METHODS: This historical cohort study included all primary unilateral total hip or knee arthroplasties conducted from April 2017 to February 2020 in a single, university-affiliated, tertiary care centre (Jewish General Hospital, Montreal, QC, Canada). We used multivariable logistic regression to analyze the predictors for postoperative hypotension, defined as a systolic blood pressure < 90 mm Hg or any systolic blood pressure while on a vasopressor infusion in the postanesthesia care unit. Models were validated using calibration and discrimination with bootstrapping technique. RESULTS: One thousand five hundred and eighty-eight patients were included in this study. Postoperative hypotension occurred in 413 (26%) patients. Statistically significant predictors for postoperative hypotension included female sex (adjusted odds ratio [aOR], 3.24; 95% confidence interval [CI], 2.29 to 4.58), a history of transient ischemic attack or cerebrovascular accident (aOR, 1.97; 95% CI, 1.04 to 3.72), and intraoperative dexmedetomidine use (aOR, 2.61; 95% CI, 1.99 to 3.42). Moreover, the risk of postoperative hypotension was approximately two times higher than baseline, with a total intraoperative dexmedetomidine dose above 50 µg (relative risk, 1.99; 95% CI, 1.63 to 2.44; P < 0.001). A higher preoperative systolic blood pressure (aOR, 0.98; 95% CI, 0.97 to 0.99) was a protective factor for postoperative hypotension. CONCLUSION: In this historical cohort study, dexmedetomidine was a strong risk factor for postoperative hypotension in total hip or knee arthroplasty patients. Dexmedetomidine, and particularly at high cumulative doses above 50 µg, should be administered judiciously in high-risk surgical patients to minimize the risk of postoperative hypotension.

RéSUMé: OBJECTIF: La dexmédétomidine est fréquemment utilisée comme agent sédatif pour les patients en chirurgie orthopédique bénéficiant d'une arthroplastie totale de la hanche ou du genou. Bien que les avantages de la dexmédétomidine soient bien décrits dans la littérature, il existe également un potentiel de préjudice, en particulier en ce qui touche aux effets hémodynamiques de la dexmédétomidine dans un contexte postopératoire. MéTHODE: Cette étude de cohorte historique comprenait toutes les arthroplasties totales unilatérales primaires de la hanche ou du genou réalisées entre avril 2017 et février 2020 dans un seul centre de soins tertiaires universitaire (Hôpital général juif, Montréal, QC, Canada). Nous avons utilisé la régression logistique multivariable pour analyser les prédicteurs d'hypotension postopératoire, définie comme une tension artérielle systolique < 90 mmHg ou toute tension artérielle systolique pendant une perfusion de vasopresseurs en salle de réveil. Les modèles ont été validés à l'aide de l'étalonnage et de la discrimination avec une technique d'auto-amorçage. RéSULTATS: Mille cinq cent quatre-vingt-huit patients ont été inclus dans cette étude. Une hypotension postopératoire est survenue chez 413 (26 %) patients. Les prédicteurs statistiquement significatifs d'une hypotension postopératoire comprenaient le sexe féminin (rapport de cotes ajusté [RCA], 3,24; intervalle de confiance [IC] à 95 %, 2,29 à 4,58), des antécédents d'accident ischémique transitoire ou d'accident vasculaire cérébral (RCA, 1,97; IC 95 %, 1,04 à 3,72) et l'utilisation peropératoire de dexmédétomidine (RCA, 2,61; IC 95 %, 1,99 à 3,42). De plus, le risque d'hypotension postopératoire était environ deux fois plus élevé que la valeur initiale, avec une dose peropératoire totale de dexmédétomidine supérieure à 50 µg (risque relatif, 1,99; IC 95 %, 1,63 à 2,44; P < 0,001). Une tension artérielle systolique préopératoire plus élevée (RCA, 0,98; IC 95 %, 0,97 à 0,99) était un facteur protecteur contre l'hypotension postopératoire. CONCLUSION: Dans cette étude de cohorte historique, la dexmédétomidine était un facteur de risque important d'hypotension postopératoire chez les patients bénéficiant d'une arthroplastie totale de la hanche ou du genou. La dexmédétomidine, et en particulier à des doses cumulatives élevées supérieures à 50 µg, devrait être administrée judicieusement chez les patients chirurgicaux à haut risque afin de minimiser le risque d'hypotension postopératoire.

High-flow nasal oxygen as first-line therapy for COVID-19-associated hypoxemic respiratory failure: a single-centre historical cohort study.

PURPOSE: The optimal noninvasive modality for oxygenation support in COVID-19-associated hypoxemic respiratory failure and its association with healthcare worker infection remain uncertain. We report here our experience using high-flow nasal oxygen (HFNO) as the primary support mode for patients with COVID-19 in our institution. METHODS: We conducted a single-centre historical cohort study of all COVID-19 patients treated with HFNO for at least two hours in our university-affiliated and intensivist-staffed intensive care unit (Jewish General Hospital, Montreal, QC, Canada) between 27 August 2020 and 30 April 2021. We report their clinical characteristics and outcomes. Healthcare workers in our unit cared for these patients in single negative pressure rooms wearing KN95 or fit-tested N95 masks; they underwent mandatory symptomatic screening for COVID-19 infection, as well as a period of asymptomatic screening. RESULTS: One hundred and forty-two patients were analysed, with a median [interquartile range (IQR)] age of 66 [59-73] yr; 71% were male. Patients had a median [IQR] Sequential Organ Failure Assessment Score of 3 [2-3], median [IQR] oxygen saturation by pulse oximetry/fraction of inspired oxygen ratio of 120 [94-164], and a median [IQR] 4C score (a COVID-19-specific mortality score) of 12 [10-14]. Endotracheal intubation occurred in 48/142 (34%) patients, and overall hospital mortality was 16%. Barotrauma occurred in 21/142 (15%) patients. Among 27 symptomatic and 139 asymptomatic screening tests, there were no cases of HFNO-related COVID-19 transmission to healthcare workers. CONCLUSION: Our experience indicates that HFNO is an effective first-line therapy for hypoxemic respiratory failure in COVID-19 patients, and can be safely used without significant discernable infection risk to healthcare workers.

RéSUMé: OBJECTIF: La modalité non invasive optimale pour le soutien en oxygène lors d'insuffisance respiratoire hypoxémique liée à la COVID-19 et son association avec l'infection des travailleurs de la santé restent incertaines. Nous rapportons ici notre expérience avec l'utilisation de canules nasales à haut débit (CNHD) comme principale modalité de soutien pour les patients atteints de COVID-19 dans notre établissement. MéTHODE: Nous avons mené une étude de cohorte historique monocentrique de tous les patients atteints de COVID-19 traités par CNHD pendant au moins deux heures dans notre unité de soins intensifs affiliée à l'université et dotée d'intensivistes (Hôpital général juif, Montréal, QC, Canada) entre le 27 août 2020 et le 30 avril 2021. Nous rapportons leurs caractéristiques cliniques et leurs résultats. Les travailleurs de la santé de notre unité ont soigné ces patients dans des chambres individuelles à pression négative en portant des masques KN95 ou N95 ajustés; ils ont subi un dépistage symptomatique obligatoire de l'infection à la COVID-19, ainsi qu'un dépistage en période asymptomatique. RéSULTATS: Cent quarante-deux patients ont été analysés, avec un âge médian [écart interquartile (ÉIQ)] de 66 [59-73] ans; 71 % étaient des hommes. Les patients avaient un score SOFA (Sequential Organ Failure Assessment) médian [ÉIQ] de 3 [2, 3], un ratio médian [ÉIQ] de saturation en oxygène par oxymétrie de pouls/fraction d'oxygène inspiré de 120 [94-164], et un score 4C (un score de mortalité spécifique à la COVID-19) médian [ÉIQ] de 12 [10­14]. Dans l'ensemble, 48/142 patients (34 %) ont reçu une intubation endotrachéale, et la mortalité hospitalière globale était de 16 %. Un barotraumatisme est survenu chez 21/142 (15 %) patients. Parmi les 27 tests de dépistage symptomatiques et 139 tests asymptomatiques, aucun cas de transmission de COVID-19 liée aux CNHD aux travailleurs de la santé n'a été observé. CONCLUSION: Notre expérience indique que les CNHD constituent un traitement de première intention efficace pour l'insuffisance respiratoire hypoxémique chez les patients atteints de COVID-19 qui peut être utilisé en toute sécurité, sans risque d'infection significatif discernable pour les travailleurs de la santé.

Iron supplementation for patients undergoing cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: Iron supplementation has been evaluated in several randomized controlled trials (RCTs) for its potential to increase baseline hemoglobin and decrease red blood cell transfusion during cardiac surgery. This study's main objective was to evaluate the current evidence for iron administration in cardiac surgery patients. METHODS: We searched MEDLINE, EMBASE, CENTRAL, Web of Science databases, and Google Scholar from inception to 19 November 2020 for RCTs evaluating perioperative iron administration in adult patients undergoing cardiac surgery. The RCTs were assessed using a risk of bias assessment and the quality of evidence was assessed using the grading of recommendations, assessments, development, and evaluations. RESULTS: We reviewed 1,767 citations, and five studies (n = 554) met the inclusion criteria. The use of iron showed no statistical difference in incidence of transfusion (risk ratio, 0.86; 95% confidence interval, 0.65 to 1.13). Trial sequential analysis suggested an optimal information size of 1,132 participants, which the accrued information size did not reach. CONCLUSION: The current literature does not support or refute the routine use of iron therapy in cardiac surgery patients. TRIAL REGISTRATION: PROSPERO (CRD42020161927); registered 19 December 2019.

RéSUMé: OBJECTIF: La supplémentation en fer a été évaluée dans plusieurs études randomisées contrôlées (ERC) pour son potentiel à augmenter l'hémoglobine de base et à diminuer la transfusion d'érythrocytes pendant la chirurgie cardiaque. L'objectif principal de cette étude était d'évaluer les données probantes actuelles soutenant l'administration de fer chez les patients de chirurgie cardiaque. MéTHODE: Nous avons effectué des recherches dans les bases de données MEDLINE, EMBASE, CENTRAL, Web of Science et Google Scholar de leur création jusqu'au 19 novembre 2020 pour en extraire les ERC évaluant l'administration périopératoire de fer chez les patients adultes bénéficiant d'une chirurgie cardiaque. Les ERC ont été évaluées à l'aide d'une évaluation du risque de biais et la qualité des données probantes a été évaluée à l'aide du système de notation GRADE. RéSULTATS: Nous avons examiné 1767 citations et cinq études (n = 554) répondaient aux critères d'inclusion. L'administration de fer n'a montré aucune différence statistique dans l'incidence des transfusions (risque relatif, 0,86; intervalle de confiance à 95 %, 0,65 à 1,13). Selon l'analyse séquentielle des études, la taille d'information optimale serait de 1132 participants, une taille que l'information accumulée n'a pas atteint. CONCLUSION: La littérature actuelle ne soutient ni ne réfute l'utilisation systématique d'une thérapie à base de fer chez les patients de chirurgie cardiaque. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42020161927); enregistrée le 19 décembre 2019.

Comparison of hospitalized patients with COVID-19 who did and did not live in residential care facilities in Montréal: a retrospective case series.

BACKGROUND: As in other jurisdictions, the demographics of people infected with SARS-CoV-2 changed in Quebec over the course of the first COVID-19 pandemic wave, and affected those living in residential care facilities (RCFs) disproportionately. We evaluated the association between clinical characteristics and outcomes of hospitalized patients with COVID-19, comparing those did or did not live in RCFs. METHODS: We conducted a retrospective case series of all consecutive adults (≥ 18 yr) admitted to the Jewish General Hospital in Montréal with laboratory-confirmed SARS-CoV-2 infection from Mar. 4 to June 30, 2020, with in-hospital follow-up until Aug. 6, 2020. We collected patient demographics, comorbidities and outcomes (i.e., admission to the intensive care unit, mechanical ventilation and death) from medical and laboratory records and compared patients who did or did not live in public and private RCFs. We evaluated factors associated with the risk of in-hospital death with a Cox proportional hazard model. RESULTS: In total, 656 patients were hospitalized between March and June 2020, including 303 patients who lived in RCFs and 353 patients who did not. The mean age was 72.9 (standard deviation 18.3) years (range 21 to 106 yr); 349 (53.2%) were female and 118 (18.0%) were admitted to the intensive care unit. The overall mortality rate was 23.8% (156/656), but was higher among patients living in RCFs (36.6% [111/303]) compared with those not living in RCFs (12.7% [45/353]). Increased risk of death was associated with age 80 years and older (hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.35-4.24), male sex (HR 1.74, 95% CI 1.25-2.41), the presence of 4 or more comorbidities (HR 2.01, 95% CI 1.18-3.42) and living in an RCF (HR 1.62, 95% CI 1.09-2.39). INTERPRETATION: During the first wave of the COVID-19 epidemic in Montréal, more than one-third of RCF residents hospitalized with SARS-CoV-2 infection died during hospitalization. Policies and practices that prevent future outbreaks of SARS-CoV-2 infection in this setting must be implemented to prevent high mortality in this vulnerable population.

Outcomes and clinical practice in patients with COVID-19 admitted to the intensive care unit in Montréal, Canada: a descriptive analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is responsible for millions of infections worldwide, and a substantial number of these patients will be admitted to the intensive care unit (ICU). Our objective was to describe the characteristics, outcomes and management of critically ill patients with COVID-19 pneumonia at a single designated pandemic centre in Montréal, Canada. METHODS: A descriptive analysis was performed on consecutive critically ill patients with COVID-19 pneumonia admitted to the ICU at the Jewish General Hospital, a designated pandemic centre in Montréal, between Mar. 5 and May 21, 2020. Complete follow-up data corresponding to death or discharge from hospital health records were included to Aug. 4, 2020. We summarized baseline characteristics, management and outcomes, including mortality. RESULTS: A total of 106 patients were included in this study. Twenty-one patients (19.8%) died during their hospital stay, and the ICU mortality was 17.0% (18/106); all patients were discharged home or died, except for 4 patients (2 awaiting a rehabilitation bed and 2 awaiting long-term care). Twelve of 65 patients (18.5%) requiring mechanical ventilation died. Prone positioning was used in 29 patients (27.4%), including in 10 patients who were spontaneously breathing; no patient was placed on extracorporeal membrane oxygenation. High-flow nasal cannula was used in 51 patients (48.1%). Acute kidney injury was the most common complication, seen in 20 patients (18.9%), and 12 patients (11.3%) required renal replacement therapy. A total of 53 patients (50.0%) received corticosteroids. INTERPRETATION: Our cohort of critically ill patients with COVID-19 had lower mortality than that previously described in other jurisdictions. These findings may help guide critical care decision-making in similar health care systems in further COVID-19 surges.

Examination of psychological risk factors for chronic pain following cardiac surgery: protocol for a prospective observational study.

INTRODUCTION: Approximately 400 000 Americans and 36 000 Canadians undergo cardiac surgery annually, and up to 56% will develop chronic postsurgical pain (CPSP). The primary aim of this study is to explore the association of pain-related beliefs and gender-based pain expectations on the development of CPSP. Secondary goals are to: (A) explore risk factors for poor functional status and patient-level cost of illness from a societal perspective up to 12 months following cardiac surgery; and (B) determine the impact of CPSP on quality-adjusted life years (QALYs) borne by cardiac surgery, in addition to the incremental cost for one additional QALY gained, among those who develop CPSP compared with those who do not. METHODS AND ANALYSES: In this prospective cohort study, 1250 adults undergoing cardiac surgery, including coronary artery bypass grafting and open-heart procedures, will be recruited over a 3-year period. Putative risk factors for CPSP will be captured prior to surgery, at postoperative day 3 (in hospital) and day 30 (at home). Outcome data will be collected via telephone interview at 6-month and 12-month follow-up. We will employ generalised estimating equations to model the primary (CPSP) and secondary outcomes (function and cost) while adjusting for prespecified model covariates. QALYs will be estimated by converting data from the Short Form-12 (version 2) to a utility score. ETHICS AND DISSEMINATION: This protocol has been approved by the responsible bodies at each of the hospital sites, and study enrolment began May 2015. We will disseminate our results through CardiacPain.Net, a web-based knowledge dissemination platform, presentation at international conferences and publications in scientific journals. TRIAL REGISTRATION NUMBER: NCT01842568.

Intraoperative Pneumothorax Presenting as Abdominal Distention.

A 74-year-old man with a history of lung cancer presented for right upper lobectomy. After induction of anesthesia, it was noted that the abdomen became progressively more distended. Soon afterward, there was a significant decrease in tidal volume. Ultrasonography of the lung showed no sign of pneumothorax at the anterior second intercostal space. However, the roentgenograms showed a massive right-sided pneumothorax and extensive pneumoperitoneum. Both the pneumothorax and the pneumoperitoneum were decompressed in the operating room, and the elective lobectomy proceeded as previously planned. The patient was extubated at the end of the operation, and there were no sequelae postoperatively.