Probiotics in hospitalized adult patients: a systematic review of economic evaluations Can. J. Anesth. (IF 3.374) Pub Date : 2019-11-12 Vincent I. Lau, Bram Rochwerg, Feng Xie, Jennie Johnstone, John Basmaji, Jana Balakumaran, Alla Iansavichene, Deborah J. Cook
Abstract Purpose Probiotics may prevent healthcare-associated infections, such as ventilator-associated pneumonia, Clostridioides difficile-associated diarrhea, and other adverse outcomes. Despite their potential benefits, there are no summative data examining the cost-effectiveness of probiotics in hospitalized patients. This systematic review summarized studies evaluating the economic impact of using probiotics in hospitalized adult patients. Methods We searched MEDLINE, EMBASE, CENTRAL, ACP Journal Club, and other EBM reviews (inception to January 31, 2019) for health economics evaluations examining the use of probiotics in hospitalized adults. Independently and in duplicate, we extracted data study characteristics, risk of bias, effectiveness and total costs (medications, diagnostics/procedures, devices, personnel, hospital) associated with healthcare-associated infections (ventilator-associated pneumonia, Clostridioides difficile-associated diarrhea and antibiotic-associated diarrhea). We used Grading of Recommendations Assessment, Development and Evaluation methods to assess certainty in the overall cost-effectiveness evidence. Results Of 721 citations identified, we included seven studies. For the clinical outcomes of interest, there was one randomized-controlled trial (RCT)-based health economic evaluation, and six model-based health economic evaluations. Probiotics showed favourable cost-effectiveness in six of seven (86%) economic evaluations. Three of the seven studies were manufacturer-supported, all which suggested cost-effectiveness. Certainty of cost-effectiveness evidence was very low because of risk of bias, imprecision, and inconsistency. Conclusion Probiotics may be an economically attractive intervention for preventing ventilator-associated pneumonia, Clostridioides difficile-associated diarrhea, and antibiotic-associated diarrhea in hospitalized adult patients. Nevertheless, certainty about their cost-effectiveness evidence is very low. Future RCTs examining probiotics should incorporate cost data to inform bedside practice, clinical guidelines, and healthcare policy. Trial registration: PROSPERO CRD42019129929; Registered 25 April, 2019.
Association of intensive care unit occupancy during admission and inpatient mortality: a retrospective cohort study Can. J. Anesth. (IF 3.374) Pub Date : 2019-09-16 Nicholas A. Fergusson, Steve Ahkioon, Mahesh Nagarajan, Eric Park, Yichuan Ding, Najib Ayas, Vinay K. Dhingra, Dean R. Chittock, Donald E. G. Griesdale
Abstract Purpose There is conflicting evidence regarding the influence of intensive care unit (ICU) occupancy at the time of admission on important patient outcomes such as mortality. The objective of this analysis was to characterize the association between ICU occupancy at the time of ICU admission and subsequent mortality. Methods This single-centre, retrospective cohort study included all patients admitted to the ICU at the Vancouver General Hospital between 4 January 2010 and 8 October 2017. Intensive care unit occupancy was defined as the number of ICU bed hours utilized in a day divided by the total amount of ICU bed hours available for that day. We constructed mixed-effects logistic regression models controlling for relevant covariates to assess the impact of admission occupancy quintiles on total inpatient (ICU and ward) and early (72-hr) ICU mortality. Results This analysis included 10,365 ICU admissions by 8,562 unique patients. Compared with ICU admissions in the median occupancy quintile, admissions in the highest and second highest occupancy quintile were associated with a significant increase in the odds of inpatient mortality (highest: odds ratio [OR], 1.33; 95% confidence interval [CI], 1.12 to 1.59; P value < 0.001; second highest: OR, 1.21; 95% CI, 1.02 to 1.44; P value < 0.03). No association between admission occupancy and 72-hr ICU mortality was observed. Conclusions Admission to the ICU on days of high occupancy was associated with increased inpatient mortality, but not with increased 72-hr ICU mortality. Capacity strain on the ICU may result in significant negative consequences for patients, but further research is needed to fully characterize the complex effects of capacity strain.
Ultrasound-guided maxillary nerve block: an anatomical study using the suprazygomatic approach Can. J. Anesth. (IF 3.374) Pub Date : 2019-09-23 Gaston Echaniz, Vincent Chan, Jason T. Maynes, Yelda Jozaghi, Anne Agur
Although a maxillary nerve (MN) block reportedly provides satisfactory analgesia for midface surgery and chronic maxillofacial pain syndromes, a safe and reliable MN block technique has not been reported. The goal of this anatomical study was to quantify the various angles and depth of the block needle, as well as to evaluate the impact of volume on the extent of injectate spread that might influence anesthetic coverage and block-related complications.
Disruptive behaviour in the operating room is under-reported: an international survey Can. J. Anesth. (IF 3.374) Pub Date : 2020-01-16 Ian Fast, Alexander Villafranca, Bernadette Henrichs, Kirby Magid, Chris Christodoulou, Eric Jacobsohn
The purpose of this study was to investigate the reporting habits of clinicians who have been exposed to disruptive behaviour in the operating room (OR) and assess their satisfaction with management’s responses to this issue.
Evaluation of hyperoxia-induced hypercapnia in obese patients after cardiac surgery: a randomized crossover comparison of conservative and liberal oxygen administration Can. J. Anesth. (IF 3.374) Pub Date : 2019-10-24 Marie-Hélène Denault, Carolanne Ruel, Mathieu Simon, Pierre-Alexandre Bouchard, Serge Simard, François Lellouche
Recent studies on patients with stable obesity-hypoventilation syndrome have raised concerns about hyperoxia-induced hypercapnia in this population. This study aimed to evaluate whether a higher oxygen saturation target would increase arterial partial pressure of carbon dioxide (PaCO2) in obese patients after coronary artery bypass grafting surgery (CABG).
Risk factors for intraoperative hypoglycemia in children: a retrospective observational cohort study Can. J. Anesth. (IF 3.374) Pub Date : 2019-09-16 Lori Q. Riegger, Aleda M. Leis, Shobha Malviya, Kevin K. Tremper
Abstract Purpose Intraoperative hypoglycemia can result in devastating neurologic injury if not promptly diagnosed and treated. Few studies have defined risk factors for intraoperative hypoglycemia. The authors sought to characterize children with intraoperative hypoglycemia and determine independent risk factors. Methods This retrospective observational single-institution study included all patients < 18 yr of age undergoing an anesthetic from January 1 2012 to December 31 2016. The primary outcome was blood glucose < 3.3 mmol·L−1 (60 mg·dl−1). Data collected included patient characteristics, comorbidities, and intraoperative factors. A multivariable logistic regression model was used to identify independent predictors of intraoperative hypoglycemia. Results Blood glucose was measured in 7,715 of 73,592 cases with 271 (3.5%) having a glucose < 3.3 mmol·L−1 (60 mg·dl−1). Young age, weight for age < 5th percentile, developmental delay, presence of a gastric or jejunal tube, and abdominal surgery were identified as independent predictors for intraoperative hypoglycemia. Eighty percent of hypoglycemia cases occurred in children < three years of age and in children < 15 kg. Conclusion Young age, weight for age < 5th percentile, developmental delay, having a gastric or jejunal tube, and abdominal surgery were independent risk factors for intraoperative hypoglycemia in children. Frequent monitoring of blood glucose and judicious isotonic dextrose administration may be warranted in these children.
Interventional anesthesia and palliative care collaboration to manage cancer pain: a narrative review Can. J. Anesth. (IF 3.374) Pub Date : 2019-09-30 Jenny Lau, David Flamer, Patricia Murphy-Kane
Pain is a common symptom associated with advanced cancer. An estimated 66.4% of people with advanced cancer experience pain from their disease or treatment. Pain management is an essential component of palliative care. Opioids and adjuvant therapies are the mainstay of cancer pain management. Nevertheless, a proportion of patients may experience complex pain that is not responsive to conventional analgesia. Interventional analgesia procedures may be appropriate and necessary to manage complex, cancer-related pain. This narrative review uses a theoretical case to highlight core principles of palliative care and interventional anesthesia, and the importance of collaborative, interdisciplinary care. An overview and discussion of pragmatic considerations of peripheral nervous system interventional analgesic procedures and neuraxial analgesia infusions are provided.
Four early warning scores predict mortality in emergency surgical patients at University Teaching Hospital, Lusaka: a prospective observational study Can. J. Anesth. (IF 3.374) Pub Date : 2019-10-09 Katie Ellen Foy, Janaki Pearson, Laura Kettley, Niharika Lal, Holly Blackwood, M. Dylan Bould
Abstract Purpose The value of early warning scoring systems has been established in high-income countries. There is little evidence for their use in low-resource settings. We aimed to compare existing early warning scores to predict 30-day mortality. Methods University Teaching Hospital is a tertiary center in Lusaka, Zambia. Adult surgical patients, excluding obstetrics, admitted for > 24 hr were included in this prospective observational study. On days 1 to 3 of admission, we collected data on patient demographics, heart rate, blood pressure, oxygen saturation, oxygen administration, temperature, consciousness level, and mobility. Two-, three-, and 30-day mortality were recorded with their associated variables analyzed using area under receiver operating curves (AUROC) for the National Early Warning Score (NEWS); the Modified Early Warning Score (MEWS); a modified Hypotension, Oxygen Saturation, Temperature, ECG, Loss of Independence (mHOTEL) score; and the Tachypnea, Oxygen saturation, Temperature, Alertness, Loss of Independence (TOTAL) score. Results Data were available for 254 patients from March 2017 to July 2017. Eighteen (7.5%) patients died at 30 days. The four early warning scores were found to be predictive of 30-day mortality: MEWS (AUROC, 0.76; 95% confidence interval [CI], 0.63 to 0.88; P < 0.001), NEWS (AUROC 0.805; 95% CI, 0.688 to 0.92; P < 0.001), mHOTEL (AUROC 0.759; 95% CI, 0.63 to 0.89, P < 0.001), and TOTAL (AUROC 0.782; 95% CI, 0.66 to 0.90; P < 0.001). Conclusions We validated four scoring systems in predicting mortality in a Zambian surgical population. Further work is required to assess if implementation of these scoring systems can improve outcomes.
Acceptability of cardiac donation after circulatory determination of death: a survey of the Canadian public Can. J. Anesth. (IF 3.374) Pub Date : 2020-01-02 Kimia Honarmand, Jeanna Parsons Leigh, Claudio M. Martin, Robert Sibbald, Dave Nagpal, Vince Lau, Fran Priestap, Sabe De, John Basmaji, Andrew Healey, Sonny Dhanani, Matthew J. Weiss, Sam Shemie, Ian M. Ball
Cardiac transplantation is a definitive therapy for end-stage heart failure, but demand exceeds supply. Cardiac donation after circulatory determination of death (cardiac DCDD) can be performed using direct procurement and perfusion (DPP), where cardiac activity is restored after heart recovery, or (NRP), where brain blood supply is surgically interrupted, circulation to the thoraco-abdominal organs is restored within the donor’s body, followed by heart recovery. While cardiac DCDD would increase the number of heart donors, uptake of programs has been slowed in part because of ethical concerns within the medical community. These debates have been largely devoid of discussion regarding public perceptions. We conducted a national survey of public perceptions regarding cardiac DCDD.
Transcultural validation of a French version of the Iowa Satisfaction with Anesthesia Scale (ISAS-F) Can. J. Anesth. (IF 3.374) Pub Date : 2020-01-02 Anne-Sophie Falempin, Bruno Pereira, Sophie Gonnu-Levallois, Ingrid de Chazeron, Franklin Dexter, Jean-Étienne Bazin, Christian Dualé
We sought to validate a French translation of the Iowa Satisfaction with Anesthesia Scale (ISAS), a tool to assess the patient’s satisfaction with monitored anesthesia care for surgery. The ISAS tool is particularly pertinent as surgery with monitored anesthesia care is increasingly used in ambulatory surgery settings.
Pressure support ventilation-pro decreases propofol consumption and improves postoperative oxygenation index compared with pressure-controlled ventilation in children undergoing ambulatory surgery: a randomized controlled trial Can. J. Anesth. (IF 3.374) Pub Date : 2020-01-02 Swapnabharati Moharana, Divya Jain, Neerja Bhardwaj, Komal Gandhi, Sandhya Yaddanapudi, Badal Parikh
Abstract Purpose The PSVPro mode is increasingly being used for surgeries under laryngeal mask airway owing to improved ventilator-patient synchrony and decreased work of breathing. We hypothesized that PSVPro ventilation mode would reduce consumption of anesthetic agents compared with pressure control ventilation (PCV). Methods Seventy children between three and eight years of age undergoing elective lower abdominal and urological surgery were randomized into PCV group (n = 35) or PSVPro group (n = 35). General anesthesia was induced with sevoflurane and a Proseal LMA™ was inserted. Anesthesia was maintained with propofol infusion to maintain the entropy values between 40 and 60. In the PCV mode, the inspiratory pressure was adjusted to obtain an expiratory tidal volume of 8 mL·kg−1 and a respiratory rate of 12–20/min. In the PSVPRO group, the flow trigger was set at 0.4 L·min−1 and pressure support was adjusted to obtain expiratory tidal volume of 8 mL·kg−1. Consumption of anesthetic agent was recorded as the primary outcome. Emergence time and discharge time were recorded as secondary outcomes. Results The PSVPro group showed significant reduction in propofol consumption compared with the PCV group (mean difference, 33.3 µg−1·kg−1·min−1; 95% confidence interval [CI], 24.2 to 42.2). There was decrease in the emergence time in the PSVPro group compared with the PCV group (mean difference, 3.5 min; 95% CI, 2.8 to 4.2) and in time to achieve modified Aldrete score > 9 (mean difference, 3.6 min; 95% CI, 1.9 to 5.2). Conclusion The PSVPro mode decreases propofol consumption and emergence time, and improves oxygenation index in children undergoing ambulatory surgery. Trial registration Clinical Trial Registry of India (CTRI/2017/12/010942); registered 21 December, 2017.
Attitudes of healthcare providers towards cardiac donation after circulatory determination of death: a Canadian nation-wide survey Can. J. Anesth. (IF 3.374) Pub Date : 2020-01-02 Kimia Honarmand, Jeanna Parsons Leigh, John Basmaji, Claudio M. Martin, Robert Sibbald, Dave Nagpal, Vince Lau, Fran Priestap, Sabe De, Andrew Healey, Sonny Dhanani, Matthew J. Weiss, Sam Shemie, Ian M. Ball
The number of patients on cardiac transplant waitlists exceeds the number of available donor organs. Cardiac donation is currently limited to those declared dead by neurologic criteria in all but three countries. Cardiac donation after circulatory determination of death (cardiac DCDD) can be conducted using direct procurement and perfusion (DPP) or normothermic regional perfusion (NRP). Implementation of cardiac DCDD in many countries has been slowed by ethical debates within the donation and transplantation community. We conducted a national survey to determine the perceptions of healthcare providers regarding cardiac DCDD.
Sexual and gender minorities educational content within obstetric anesthesia fellowship programs: a survey Can. J. Anesth. (IF 3.374) Pub Date : 2020-01-02 Hilary MacCormick, Ronald B. George
Improved patient-provider relationships can positively influence patient outcomes. Sexual and gender minorities (SGM) represent a wide variety of marginalized populations. There is an absence of studies examining the inclusion of SGM-related health education within postgraduate training in anesthesia. This study’s objective was to perform an environmental scan of the educational content of North American obstetric anesthesia fellowship programs.