[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Canadian physicians are faced with an increasing frequency of drug shortages. We hypothesized that drug shortages have a clinical impact on anesthesia care in Canada. METHODS: We conducted a self-administered survey of anesthesiologists in Canada using the membership list of the Canadian Anesthesiologists' Society. For survey development, we identified key domains, including types of drug shortages, impact on the ability of anesthesia practitioners to provide general anesthesia care, and impact on patient outcomes. We undertook assessments of face validity, clinical sensibility, and content validity. Respondents were surveyed from January-April 2012. RESULTS: Completed valid questionnaires were submitted by 1,187 respondents (61.4%), and 779 (65.7%) of respondents described a shortage of one or more anesthesia or critical care drugs. Changes in anesthesia practice resulting from drug shortages were common; 586 (49%) respondents thought they had given an inferior anesthetic, and 361 (30%) reported administering medications with which they were unfamiliar. Respondents also reported that drug shortages were, at times, responsible for changes in the conduct of patient care, with 28 (2.4%) noting cancellation or postponement of surgery and 92 (7.8%) witnessing a drug error. One hundred sixty-five (13.9%) respondents regarded drug shortages as having prolonged recovery from anesthesia, and 124 (10.5%) viewed drug shortages as resulting in an increased number of postoperative complications, such as postoperative nausea and vomiting. INTERPRETATION: Drug shortages are common in anesthetic practice in Canada. This state of affairs may have a negative effect on how anesthesiologists practice anesthesia and may be associated with adverse patient outcomes.
Canadian Anaesthetists? Society Journal 04/2013; 60(6). DOI:10.1007/s12630-013-9920-z · 2.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evidence suggests that statins reduce cardiovascular complications in patients undergoing noncardiac surgery, although questions remain regarding the mechanism of benefit and the preferred dosing strategy. In this trial, we evaluated the perioperative effects on C-reactive protein (CRP) that resulted from starting atorvastatin within seven days of noncardiac surgery. The objective was to identify anti-inflammatory effects of atorvastatin prior to conducting a large randomized trial with clinical end points.
In a single centre, parallel group, placebo-controlled trial, sixty high cardiac risk participants over age 45 yr undergoing noncardiac surgery were assigned randomly to one of three groups to receive atorvastatin 80 mg (A) and/or placebo (P). Group AA (n = 26) received atorvastatin seven days before surgery, the day of surgery, and for seven days post surgery. Group PA (n = 17) received placebo seven days before surgery, atorvastatin on the day of surgery, and atorvastatin for seven days post surgery. Group PP (n = 17) received placebo at all times. All participants, health care professionals, research assistants, and outcome adjudicators were masked to treatment allocation. Analyses were by intention to treat. The primary outcome was the C-reactive protein level at 48 hr.
Fifty-six participants completed the 30-day follow-up. The mean (standard deviation) changes in CRP levels from baseline at 48 hr in Groups AA, PA, and PP were 141.0 (72.4), 153.5 (42.2), and 111.2 (84.6), respectively. The mean differences (95% confidence interval) at 48 hr for AA vs PA, AA vs PP, and PA vs PP were: -20.1 (-81.2 to 41.1), 22.7 (-31.7 to 77.2), and 42.8 (-20.0 to 105.7), respectively, adjusting for baseline CRP, type of procedure, presence of coronary artery disease, use of medications, and for multiple comparisons using Tukey's method.
Administration of atorvastatin, initiated within seven days preoperatively, was not associated with clinically significant reductions in CRP levels.
Canadian Anaesthetists? Society Journal 04/2012; 59(6):527-37. DOI:10.1007/s12630-012-9702-z · 2.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the safety and efficiency of a protocol for glycemic control in intensive care unit (ICU) patients with neurovascular or head injury.
Two cohorts of 50 consecutive patients admitted to the ICU with an admission diagnosis of neurovascular or head injury before and after protocol implementation were evaluated. All patients in the interventional cohort received insulin using a standardized intravenous insulin infusion protocol targeting blood glucose levels of 7-9 mmol/l. Efficiency (time to reach and time within target range), safety (hypoglycemia), and nursing compliance (protocol violations) were evaluated.
The median time to reach the target blood glucose range was shorter in the interventional cohort than the conventional cohort (5.0 h [0.5-20.5 h] vs. 12.9 h [1.3-90.3 h]; P < 0.001). More time was spent within target range in the interventional cohort than in the conventional cohort (36.4 +/- 16.3% vs. 27.1 +/- 19.0%; P < 0.001). The median prevalence of mild (<4.9 mmol/l) hypoglycemia (0 [0-1.11]% vs. 0.58 [0-2.79]%; P < 0.001) and moderate (<3.9) hypoglycemia (0[0-0.55]% vs. 0 [1-1.25]%; p < 0.001) was significantly lower in the interventional cohort.
The intravenous insulin infusion protocol improved the safety and efficiency of glycemic control for ICU patients with neurovascular or head injury.
Neurocritical Care 09/2009; 12(1):43-9. DOI:10.1007/s12028-009-9275-z · 2.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There are no current standards of care guiding perioperative fluid administration, and clinicians continue to debate restrictive versus liberal fluid administration. We sought to simultaneously evaluate the opinions and practice of surgeons, intensivists and anesthesiologists in a single centre regarding perioperative fluid resuscitation.
A postal survey sent to surgeons, intensivists and anesthesiologists in a single academic health care centre presented case-based scenarios followed by questions on fluid requirements and 5-point Likert scales involving statements about resuscitation. We performed a retrospective chart review to evaluate amount and type of intra-and postoperative (72-h) fluid administration, urine output and postoperative ventilation time in patients undergoing uncomplicated esophagectomy or pneumonectomy.
Seventy-four of 77 respondents (96%) agreed that precise fluid resuscitation diminishes the risk of adverse events. Surgeons overall gave less fluids than anesthesiologists or intensivists and used fewer resuscitation end points to estimate fluid requirements perioperatively. For right hemicolectomies, only 3% of surgeons chose a fluid rate greater than 150 mL/h, compared with 55% of intensivists. We reviewed 49 patients' charts (25 who had pneumonectomies, 24 who had esophagectomies) retrospectively. The coefficient of variation (COV = standard deviation divided by its mean) of fluid administration intraoperatively was 0.56 for pneumonectomy and 0.35 for esophagectomy; postoperatively, the COV was greater than 0.50 for the first 24 hours, but less than 0.50 after 24 hours postoperatively.
The presence of substantial variability of both opinion and practice of perioperative fluid resuscitation in a single centre supports the need for further research to identify objective methods to define perioperative fluid requirements and standards of perioperative resuscitation.
Canadian journal of surgery. Journal canadien de chirurgie 07/2009; 52(3):207-14. · 1.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Crisis resource management (CRM) skills are a set of nonmedical skills required to manage medical emergencies. There is currently no gold standard for evaluation of CRM performance. A prior study examined the use of a global rating scale (GRS) to evaluate CRM performance. This current study compared the use of a GRS and a checklist as formal rating instruments to evaluate CRM performance during simulated emergencies.
First-year and third-year residents participated in two simulator scenarios each. Three raters then evaluated resident performance in CRM using edited video recordings using both a GRS and a checklist. The Ottawa GRS provides a seven-point anchored ordinal scale for performance in five categories of CRM, and an overall performance score. The Ottawa CRM checklist provides 12 items in the five categories of CRM, with a maximum cumulative score of 30 points. Construct validity was measured on the basis of content validity, response process, internal structure, and response to other variables. T-test analysis of Ottawa GRS scores was conducted to examine response to the variable of level of training. Intraclass correlation coefficient (ICC) scores were used to measure inter-rater reliability for both scenarios.
Thirty-two first-year and 28 third-year residents participated in the study. Third-year residents produced higher mean scores for overall CRM performance than first-year residents (P < 0.05), and in all individual categories within the Ottawa GRS (P < 0.05) and the Ottawa CRM checklist (P < 0.05). This difference was noted for both scenarios and for each individual rater (P < 0.05). No statistically significant difference in resident scores was observed between scenarios for both instruments. ICC scores of 0.59 and 0.61 were obtained for Scenarios 1 and 2 with the Ottawa GRS, whereas ICC scores of 0.63 and 0.55 were obtained with the Ottawa CRM checklist. Users indicated a strong preference for the Ottawa GRS given ease of scoring, presence of an overall score, and the potential for formative evaluation.
Construct validity seems to be present when using both the Ottawa GRS and CRM checklist to evaluate CRM performance during simulated emergencies. Data also indicate the presence of moderate inter-rater reliability when using both the Ottawa GRS and CRM checklist.
Simulation in healthcare: journal of the Society for Simulation in Healthcare 03/2009; 4(1):6-16. DOI:10.1097/SIH.0b013e3181880472 · 1.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this structured, evidence-based, clinical update was to determine if rapid sequence induction is a safe or effective technique to decrease the risk of aspiration or other complications of airway management.
In June 2006 a structured search of MEDLINE from 1966 to present using OVID software was undertaken with the assistance of a reference librarian. Medical subject headings and text words describing rapid sequence induction or intubation (RSI), crash induction or intubation, cricoid pressure and emergency airway intubation were employed. OVID's therapy (sensitivity) algorithm was used to maximize the detection of randomized trials while excluding non-randomized research. The bibliographies of eligible publications were hand-searched to identify trials not identified in the electronic search.
A total of 184 clinical trials were identified of which 163 were randomized controlled trials (RCTs). Of these clinical trials, 126 evaluated different drug regimens with 114 being RCTs. Only 21 clinical trials evaluated non-pharmacologic aspects of the RSI with 18 RCTs identified. A parallel search found 52 trials evaluating cricoid pressure (outside of the context of an RSI technique) with 44 classified as RCTs. Definitive outcomes such as prevention of aspiration and mortality benefit could not be evaluated from the trials. Likewise, the impact on adverse outcomes of the different components of RSI could not be ascertained.
An absence of evidence from RCTs suggests that the decision to use RSI during management can neither be supported nor discouraged on the basis of quality evidence.
Canadian Journal of Anaesthesia 10/2007; 54(9):748-64. DOI:10.1007/BF03026872 · 2.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Resuscitation of critically ill patients requires medical knowledge, clinical skills, and nonmedical skills, or crisis resource management (CRM) skills. There is currently no gold standard for evaluation of CRM performance. The primary objective was to examine the use of high-fidelity simulation as a medium to evaluate CRM performance. Since no gold standard for measuring performance exists, the secondary objective was the validation of a measuring instrument for CRM performance-the Ottawa Crisis Resource Management Global Rating Scale (or Ottawa GRS).
First- and third-year residents participated in two simulator scenarios, recreating emergencies seen in acute care settings. Three raters then evaluated resident performance using edited video recordings of simulator performance.
A Canadian university tertiary hospital.
: The Ottawa GRS was used, which provides a 7-point Likert scale for performance in five categories of CRM and an overall performance score.
Construct validity was measured on the basis of content validity, response process, internal structure, and response to other variables. One variable measured in this study was the level of training. A t-test analysis of Ottawa GRS scores was conducted to examine response to the variable of level of training. Intraclass correlation coefficient scores were used to measure interrater reliability for both scenarios. Thirty-two first-year and 28 third-year residents participated in the study. Third-year residents produced higher mean scores for overall CRM performance than first-year residents (p < .0001) and in all individual categories within the Ottawa GRS (p = .0019 to p < .0001). This difference was noted for both scenarios and for each individual rater (p = .0061 to p < .0001). No statistically significant difference in resident scores was observed between scenarios. Intraclass correlation coefficient scores of .59 and .61 were obtained for scenarios 1 and 2, respectively.
Data obtained using the Ottawa GRS in measuring CRM performance during high-fidelity simulation scenarios support evidence of construct validity. Data also indicate the presence of acceptable interrater reliability when using the Ottawa GRS.
Critical Care Medicine 08/2006; 34(8):2167-74. DOI:10.1097/01.CCM.0000229877.45125.CC · 6.15 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients who undergo major spinal surgery often require multiple blood transfusions. The antifibrinolytics are medications that can reduce blood-transfusion requirements in cardiac surgery and total knee arthroplasty. The present role of synthetic antifibrinolytics, especially tranexamic acid, in reducing peri-operative blood-transfusion requirements in spine surgery is still unclear. The majority of studies exploring the role of these drugs in spine surgery have limited patient enrollment and report mixed results. The goal of the present review is to discuss the pharmacology of tranexamic acid briefly. A brief synopsis of the studies using the synthetic antifibrinolytics for spine surgery is presented. Finally, the potential risks and the benefits of antifibrinolytics are discussed.
[Show abstract][Hide abstract] ABSTRACT: To determine whether the use of cell salvage reduces the proportion of patients receiving at least one unit of allogeneic packed red blood cells during the perioperative period of an elective vascular surgery.
We identified all relevant articles through the combined use of electronic searches of the MEDLINE and EMBASE databases, the Cochrane library as well as hand searching of all randomized clinical trials and review articles. The electronic search included articles published between 1966 and April 2001. The search included textword searches using "autotransfusion," "cell salvage," "device," or Medical Subject Headings "autologous blood transfusion" or a "randomized controlled trials" filter.
Five randomized controlled trials (RCT) were identified involving cell salvage and vascular surgeries. In infra renal abdominal aortic aneurysm surgery the risk ratio (the risk of receiving at least one unit of allogeneic red cells) was 0.37 [95% confidence intervals (CI) of 0.06 to 2.36]. In elective aorto-femoral bypass surgery the risk ratio was 0.97 (95% CI of 0.66 to 1.42). The pooled risk ratio for cell salvage in vascular surgery was 0.67 (95% CI of 0.35 to 1.28).
Cell salvage, a commonly used technique to recover red cells from the operative field, has been the subject of several studies in vascular surgery. There is insufficient evidence to recommend the routine use of cell salvage in elective abdominal aortic aneurysm and aorto-femoral bypass surgeries. A large RCT would elucidate whether cell salvage is effective as a blood conservation technique.
Canadian Journal of Anaesthesia 06/2004; 51(5):425-31. DOI:10.1007/BF03018303 · 2.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The TRICC trial  demonstrated that a transfusion trigger of 7.0 g/dl and maintenance of hemoglobin concentrations between
7.0 and 9.0 g/dl was at worst equivalent and very likely superior to the more liberal use of red cells. A restrictive strategy
is truly a superior therapy because clinical outcomes are superior, transfusions are decreased by 54% and costs are minimized.
Given conflicting evidence, the optimal transfusion policy for septic patients is not known. The increased demands imposed
by sepsis along with its impairment of the normal adaptive process to anemia would suggest that severely infected patients
should have a more liberal transfusion practice as compared to nonseptic patients. The potential problems with allogeneic
blood products however limits one’s enthusiasm for an aggressive transfusion practice. Thus, the best approach would be to
limit the need to transfuse but to transfuse the best product available if a transfusion is required. We anxiously await the
results of further trials with EPO, different RBC products, and other studies to confirm the results observed in the TRICC
[Show abstract][Hide abstract] ABSTRACT: Patients who undergo infrainguinal revascularization surgery are at increased risk for perioperative thrombotic complications. Aspirin decreases thrombotic events in the nonoperative setting; however, aspirin is often discontinued to avoid perioperative hemorrhagic complications. We used a decision analysis to determine whether aspirin should be discontinued before infrainguinal revascularization surgery. Two strategies were compared: aspirin cessation 2 wk before surgery and aspirin continuation throughout the perioperative period. Clinical events examined included myocardial infarction, thrombotic cerebrovascular accident, hemorrhagic cerebrovascular accident, gastrointestinal hemorrhage, and incisional hemorrhagic complications. Event rates and effect of aspirin were obtained by using MEDLINE. The outcomes were perioperative mortality, life expectancy, and quality-adjusted life expectancy. According to the model, continued aspirin use decreased perioperative mortality rates from 2.78% to 2.05%. Continued aspirin use increased life expectancy from 14.83 to 14.89 yr and increased quality-adjusted life expectancy from 14.72 to 14.79 yr. Aspirin increased the number of hemorrhagic complications by 2.46%, primarily because of an increased incidence of non-life-threatening complications.
[Show abstract][Hide abstract] ABSTRACT: Pediatric patients who undergo posterior spinal fusion surgery to correct scoliosis often require multiple blood transfusions. Tranexamic acid is a synthetic antifibrinolytic drug that reduces transfusion requirements in cardiac surgery and total knee arthroplasty. We evaluated the efficacy of prophylactic tranexamic acid to reduce perioperative blood transfusion requirements in a prospective, double-blinded, placebo control study. Forty patients, 9-18 yr of age, were randomized to either tranexamic acid (initial dose of 10 mg/kg and infusion of 1 mg. kg(-1). h(-1)) or placebo (isotonic saline). Perioperative management was standardized. A uniform transfusion threshold for noncell saved red blood cells was 7.0 g/dL. The total amount of blood transfused in the perioperative period was significantly reduced in the Tranexamic group (P = 0.045). No thrombotic complications were detected in either group. The administration of prophylactic tranexamic acid in patients with scoliosis undergoing posterior spinal fusion surgery has the potential to reduce perioperative blood transfusion requirements. Implications: The administration of prophylactic tranexamic acid in patients with scoliosis who are undergoing posterior spinal fusion surgery has the potential to reduce perioperative blood transfusion requirements.