Preoperative Anesthesia Virtual Video Consultations in a Preadmission Clinic: Quality Improvement Study.

BACKGROUND: The preadmission clinic (PAC) is crucial in perioperative care, offering evaluations, education, and patient optimization before surgical procedures. During the COVID-19 pandemic, the PAC adapted by implementing telephone visits due to a lack of infrastructure for video consultations. While the pandemic significantly increased the use of virtual care, including video appointments as an alternative to in-person consultations, our PAC had not used video consultations for preoperative assessments. OBJECTIVE: This study aimed to develop, implement, and integrate preoperative video consultations into the PAC workflow. METHODS: A prospective quality improvement project was undertaken using the Plan-Do-Study-Act (PDSA) methodology. The project focused on developing, implementing, and integrating virtual video consultations at London Health Sciences Centre and St. Joseph Health Care (London, Ontario, Canada) in the PAC. Data were systematically collected to monitor the number of patients undergoing video consultations, address patient flow concerns, and increase the percentage of video consultations. Communication between the PAC, surgeon offices, and patients was analyzed for continuous improvement. Technological challenges were addressed, and procedures were streamlined to facilitate video calls on appointment days. RESULTS: The PAC team, which includes professionals from medicine, anesthesia, nursing, pharmacy, occupational therapy, and physiotherapy, offers preoperative evaluation and education to surgical patients, conducting approximately 8000 consultations annually across 3 hospital locations. Following the initial PDSA cycles, the interventions consistently improved the video consultation utilization rate to 17%, indicating positive progress. With the onset of PDSA cycle 3, there was a notable surge to a 29% utilization rate in the early phase. This upward trend continued, culminating in a 38% utilization rate of virtual video consultations in the later stages of the cycle. This heightened level was consistently maintained throughout 2023, highlighting the sustained success of our interventions. CONCLUSIONS: The quality improvement process significantly enhanced the institution's preoperative video consultation workflow. By understanding the complexities within the PAC, strategic interventions were made to integrate video consultations without compromising efficiency, morale, or safety. This project highlights the potential for transformative improvements in health care delivery through the thoughtful integration of virtual care technologies.

Point-of-care lung and cardiac ultrasound (LUCAS) study in hip fracture patients: a prospective cohort study.

PURPOSE: A clinical conflict often presented with hip fracture patients is whether to proceed with timely surgery or delay surgery until a formal echocardiogram is conducted. This study aimed to assess the impact of incorporating point-of-care lung and cardiac ultrasound (LUCAS) scans as part of the preoperative assessment for hip fracture patients. METHODS: We recruited 225 consecutive adult patients booked for urgent hip arthroplasty surgery. A LUCAS scan was performed for each patient. The anesthesiologists were asked to provide their anesthetic plans before and after acknowledging the results of the LUCAS scans. The primary endpoint was a composite outcome of changes to the anesthetic plan. The secondary outcomes included anesthesiologists' opinions of the LUCAS scans. RESULTS: One-hundred-ninety-eight patients were included. The majority of LUCAS findings were not severe. A common abnormal finding was hypovolemia (31%). One-hundred-and-six anesthetic management decisions were changed, with 59 of these changes being an escalation of the anesthetic plan, and 47 of these changes being a de-escalation. Eighty-three percent of anesthesiologists agreed that LUCAS affirmed their anesthetic plans and should be an integral part of the perioperative assessment. CONCLUSION: This study found that LUCAS scans did not significantly alter the anesthetic plan for hip fracture patients. Nevertheless, LUCAS scans can rule out severe cardiopulmonary conditions and allow for both escalation and de-escalation of care. In the setting of early hip surgery, LUCAS presents a viable option in selected patients to address the unmet need to allow for both timely surgery and comprehensive patient evaluation. STUDY REGISTRATION: ClinicalTrials.gov (NCT03275129); registered 8 July 2018.

RéSUMé: OBJECTIF: Une interrogation clinique qui existe souvent avec les patient·es se présentant avec une fracture de hanche est de savoir s'il faut procéder à une intervention chirurgicale rapidement ou retarder la chirurgie jusqu'à ce qu'un échocardiogramme formel soit réalisé. Cette étude visait à évaluer l'impact de l'intégration de l'échographie ciblée pulmonaire et cardiaque (LUCAS, Lung and Cardiac ultrasound) dans le cadre de l'évaluation préopératoire des personnes ayant subi une fracture de la hanche. MéTHODE: Nous avons recruté 225 patient·es adultes consécutif·ves devant bénéficier d'une arthroplastie urgente de la hanche. Une échographie de type LUCAS a été réalisée pour chaque patient·e. On a demandé aux anesthésiologistes de fournir leurs plans anesthésiques avant et après avoir pris connaissance des résultats des échographies de type LUCAS. Le critère d'évaluation principal était un résultat composite des modifications apportées au plan anesthésique. Les critères d'évaluation secondaires comprenaient les opinions des anesthésiologistes sur les échographies de type LUCAS. RéSULTATS: Cent quatre-vingt-dix-huit patient·es ont été inclus·es. La majorité des résultats de l'échographie de type LUCAS n'étaient pas graves. Un résultat anormal courant était l'hypovolémie (31 %). Cent six décisions de prise en charge anesthésique ont été modifiées, 59 de ces changements étant une escalade du plan anesthésique et 47 de ces changements étant une réduction. Quatre-vingt-trois pour cent des anesthésiologistes ont convenu que l'échographie de type LUCAS confirmait leurs plans anesthésiques et devrait faire partie intégrante de l'évaluation périopératoire. CONCLUSION: Cette étude a révélé que les échographies de type LUCAS ne modifiaient pas de manière significative le plan anesthésique pour les patient·es se présentant avec une fracture de hanche. Néanmoins, les échographies de type LUCAS peuvent exclure des affections cardiopulmonaires graves et permettre à la fois d'augmenter ou de réduire les soins périopératoires. Dans le cadre d'une chirurgie précoce de la hanche, l'échographie de type LUCAS présente une option viable chez une patientèle sélectionnée pour répondre à un besoin non satisfait afin de permettre à la fois une chirurgie rapide et une évaluation complète des patient·es. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03275129); enregistrée le 8 juillet 2018.

Medications for the prevention of pruritus in women undergoing cesarean delivery with Intrathecal morphine: A systematic review and bayesian network meta-analysis of randomized controlled trials.

PURPOSE: Intrathecal morphine-induced pruritus can cause significant discomfort in parturients and is refractory to conventional antipruritic treatment. This systematic review and network meta-analysis evaluates the effectiveness of the medications used for prevention of intrathecal (IT) morphine-induced pruritus after cesarean delivery under spinal anesthesia. METHODS: A literature search was conducted from 1946 up to October 2019. We included all randomized controlled trials (RCTs) that compared medications used for prevention of pruritus with a control group in women undergoing cesarean delivery under spinal anesthesia with IT morphine. The primary outcome examined was the incidence of pruritus up to 24 h after cesarean delivery. Dichotomous data were extracted and summarized using odds ratios (OR) and 95% credible intervals (CrI) with Bayesian random effects network meta-analysis model. The GRADE approach was used to evaluate quality of the studies and effect evidence. RESULTS: Of the 26 studies included in the systematic review, 21 studies with a total of 2594 patients were included in the network meta-analysis [prophylaxis, n = 1603 (62%) vs. control, n = 991 (38%)]. These studies investigated seven classes of drugs including serotonin-receptor antagonists, dopamine-receptor antagonists, opioid agonist-antagonists, opioid-receptor antagonists, histamine-receptor antagonists, propofol and celecoxib. The network meta-analysis showed that serotonin-receptor antagonists' prophylaxis [control vs. prophylaxis: 60% vs. 47%; OR (95% CrI): 2.69 (1.43-5.36)] and opioid agonist-antagonists prophylaxis [control vs. prophylaxis: 72% vs. 47%; OR (95% CrI): 4.57 (1.67-12.91)] decreased the incidence of pruritus compared to the control group. Although all included studies were at low risk of bias, the quality of the overall network meta-analysis pooled estimates was low. CONCLUSION: This bayesian network meta-analysis of RCTs demonstrates serotonin-receptor antagonists and opioid agonist-antagonists may prevent pruritus in women undergoing cesarean delivery with intrathecal morphine compared to control group. However, further RCTs of adequate power and clearly defined end points are warranted.

Effect of intrathecal lipophilic opioids on the incidence of shivering in women undergoing cesarean delivery after spinal anesthesia: a systematic review and bayesian network meta- analysis of randomized controlled trials.

BACKGROUND: Shivering is a common side effect in women having cesarean delivery (CD) under spinal anesthesia, which can be bothersome to the patient, and it can also interfere with perioperative monitoring. In several studies, the intrathecal (IT) addition of a lipophilic opioid to local anesthetics has been shown to decrease the incidence of shivering. OBJECTIVE: We performed this network meta-analysis to evaluate the effects of intrathecal lipophilic opioids in preventing the incidence of shivering in patients undergoing CD. METHODS: This review was planned according to the PRISMA for Network Meta-Analysis (PRISMA-NMA) guidelines. An English literature search of multiple electronic databases was conducted. We included randomized controlled trials (RCTs) that reported on the incidence of shivering, with study groups receiving either IT fentanyl, sufentanil, or meperidine in women undergoing CD under spinal anesthesia. Quality of the studies was assessed using the modified Oxford scoring system. Using random-effects modeling, dichotomous data were extracted and summarized using odds ratio (OR) with a 95% credible interval (CrI). Statistical analysis was conducted using R studio version 1.0.153 - Inc. RESULTS: Twenty-one studies consisting of 1433 patients (Control group: 590 patients in twenty-one studies; Fentanyl group:199 patients in seven studies; Sufentanil group: 156 patients in five studies; Meperidine group: 488 patients in ten studies) met the inclusion criteria for this systematic review investigating the effect of intrathecal lipophilic opioids in preventing the incidence of shivering in women undergoing cesarean delivery under spinal anesthesia. Methodological validity scores ranged from 3 to 7. The Bayesian mixed network estimate showed the incidence of shivering was significantly lower with IT fentanyl (pooled odds ratio (OR): 0.13; 95% credible interval (CrI): 0.04 to 0.35; P = 0.0004) and IT meperidine (OR: 0.12; 95% CrI: 0.05 to 0.29; P < 0.00001), but not with IT sufentanil (OR: 0.37; 95% CrI: 0.11 to 1.22; P = 0.23). The IT fentanyl group had a significantly lower incidence of intraoperative discomfort [Risk Ratio (RR): 0.19; 95% CI: 0.10-0.35; P < 0.00001], the IT sufentanil group had a significantly higher incidence of pruritus (RR: 6.18; 95% CI: 1.18-32.46; P = 0.03) The IT meperidine group had a significantly lower incidence of intraoperative discomfort (2.7% vs. 13.6%; RR: 0.22; 95% CI: 0.09-0.55; P = 0.001), but there was a significant increase in nausea and vomiting (IT meperidine group vs. Control group: 42.7% vs. 19.4%; RR: 2.56; 95% CI: 1.14-5.75; P = 0.02). Meta-regression analysis based on the opioid dose and quality of the study did not impact the final inference of our result. CONCLUSION: IT fentanyl significantly decreased the incidence of shivering in women undergoing CD under spinal anesthesia without increasing maternal adverse events, confirming that routine use in this patient population is a good choice. IT sufentanil did not decrease the incidence of shivering. IT meperidine decreased the incidence and severity of shivering, but its use was also associated with significant nausea and vomiting.

Oxidative toxicity in neurodegenerative diseases: role of mitochondrial dysfunction and therapeutic strategies.

Besides fluorine, oxygen is the most electronegative element with the highest reduction potential in biological systems. Metabolic pathways in mammalian cells utilize oxygen as the ultimate oxidizing agent to harvest free energy. They are very efficient, but not without risk of generating various oxygen radicals. These cells have good antioxidative defense mechanisms to neutralize these radicals and prevent oxidative stress. However, increased oxidative stress results in oxidative modifications in lipid, protein, and nucleic acids, leading to mitochondrial dysfunction and cell death. Oxidative stress and mitochondrial dysfunction have been implicated in many neurodegenerative disorders including Alzheimer's disease, Parkinson's disease, and stroke-related brain damage. Research has indicated mitochondria play a central role in cell suicide. An increase in oxidative stress causes mitochondrial dysfunction, leading to more production of reactive oxygen species and eventually mitochondrial membrane permeabilization. Once the mitochondria are destabilized, cells are destined to commit suicide. Therefore, antioxidative agents alone are not sufficient to protect neuronal loss in many neurodegenerative diseases. Combinatorial treatment with antioxidative agents could stabilize mitochondria and may be the most suitable strategy to prevent neuronal loss. This review discusses recent work related to oxidative toxicity in the central nervous system and strategies to treat neurodegenerative diseases.