University of Ottawa … · University of Ottawa Department of Anesthesiology. Evaluate and discuss the design and executionof randomized clinical trials, systematic reviews, database

University of Ottawa Annual Gary Johnson Anesthesiology Research Day May 10th, 2013

POSTGRADUATE PROGRAM:

YEAR 2013

ANNUAL GARY JOHNSON ANESTHESIOLOGY RESEARCH DAY

Friday, May 10, 2013

0730 Hours – 1200 Hours

The Ottawa Hospital- Civic Campus Amphitheater

1053 Carling Ave, Ottawa, Ontario

EVENING PROGRAM:

THE UNIVERSITY OF OTTAWA DEPARTMENT OF ANESTHESIOLOGY

ANNUAL DINNER

& AWARDS CEREMONY

Friday May 10, 2013

Reception 1800 Hours Dinner 1900 Hours

The Canadian War Museum

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ACKNOWLEDGEMENTS: Welcome to all of you! We are most grateful to the administrative and support staff for having so carefully attended to the many details to make this day possible. A new venue adds to these challenges. We appreciate the time and commitment of the research nurses and associates of the University Department and the CHEO Research Institute, who provided invaluable assistance towards the successful completion of many of the projects you will hear about today. For the members of the Department of Anesthesiology who supervised individual students, residents and fellows throughout the process, they are to be especially thanked. We very much appreciate the willingness and cooperation of our colleagues who have implemented research protocols on patients under their care. Finally, a whole hearted “THANK YOU!” to Dr. Homer Yang, our esteemed out-going Chair, for his visionary leadership and enthusiastic support for all research-related activity in the Department. We wish you the very best in your future endeavours. The Department of Anesthesiology gratefully acknowledges the support of all our corporate sponsors. The IT Department of The Ottawa Hospital – Civic Campus has provided technical and audiovisual support for the day. MEETING CHAIR: Dr. Kimmo Murto, Assistant Professor, Research Committee Member Department of Anesthesiology, University of Ottawa ADJUDICATORS:

Dr. Ben Sohmer Assistant Professor Department of Anesthesiology, HI University of Ottawa

Dr. Sherissa Microys Assistant Professor Department of Anesthesiology, TOH University of Ottawa

Dr. Jan M. Davis Visiting Professor Professor of Anesthesia, Faculty of Medicine & Adjunct Professor of Psychology, Faculty of Arts University of Calgary

CORPORATE SPONSORS

AbbVie Blue Zone Covidien

Fresenius Kabi G.E.

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RESEARCH DAY OBJECTIVES: A) Resident/Fellow Presentations

To provide an academic forum for residents and fellows in the Department of Anesthesiology to present the results of randomized clinical trials, prospective observational studies, case reports or retrospective chart audits in which they have participated during the course of their postgraduate training.

Following this activity, participants will be able to do the following:

Discuss results of anesthesia and perioperative medicine related clinical, education and

bench research that has been performed by residents and fellows affiliated with the University of Ottawa Department of Anesthesiology.

Evaluate and discuss the design and execution of randomized clinical trials, systematic reviews, database analyses, quality improvement projects and retrospective chart reviews.

Review the merits of basic statistical tests as they apply to the areas of research mentioned above.

B) Key Note Speaker – Dr. Jan Davies – “Investigations as a Safety Tool: 1993-2013” Recall 7 safety-related events of 1983 Describe the progression from person-centred to systemic view of safety-related

investigations Name 10 lessons learned/principles for safety-related investigations List 5 human factors related features of the PowerPoint presentation

PLANNING COMMITTEE: Dr. Kimmo Murto Dr. Greg Bryson Dr. Homer Yang Dr. Vern Naik Dr. Louise Sun Lynne McHardy Jennifer Borup

PLANNED DISCUSSION PERIODS: Each podium presentation will consist of a formal 10-minute talk, followed by a 5-minute question and answer period. Each poster presentation will consist of a 3-minute summary, followed by a 5-minute question and answer period. The address of the Visiting Professor will be concluded by a 10-minute discussion period.

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ACCREDITATION: This event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification program of the Royal College of Physicians and Surgeons of Canada. This program has been reviewed and approved by the University of Ottawa, Office of Continuing Medical Education for 3.25 CME Section 1 credits. PLEASE NOTE: In order to receive your Certificate of Attendance, you will be required to fill in a Research Day “Course Evaluation Form”. Your response will remain anonymous.

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ANNUAL GARY JOHNSON ANESTHESIOLOGY RESEARCH DAY PROGRAM

0730 - 0815 Continental Breakfast, Exhibits (Amphitheatre Lobby, TOH, Civic Campus)

0815 - 0830 Opening Remarks Kimmo Murto, MD Chair, Gary Johnson Research Day Planning Committee SESSION ONE: PODIUM PRESENTATIONS: 0830 - 0845 Association of Positive Airway Pressure Device Treated Obstructive Sleep Apnea and 30 Day Post-Operative Mortality and Healthcare Resource Use: A Population Based Study Daniel McIsaac, MD (PGY4) 0845 – 0900 Early Morbidity and Mortality Associated with Thoracic Endovascular Aortic Repair (TEVAR) at a Tertiary Care Centre Graeme Bishop, MD (Fellow) 0900 - 0915 Efficacy of Metoprolol in Preventing Cardiovascular Complications and All-Cause Mortality in Emergent Surgeries Louise Sun, MD (PGY5) 0915 - 0930 Anesthesia for Awake Brain Port Surgery Al Faraidy, Mona, MD (Fellow) 0930 – 0945 Celocoxib for Pediatric Adenotonsillectomy: A Randomized Controlled Double Blinded Study Colleen Daly, MD (PGY1) 0945 - 1000 Influence of a Hysterectomy Enhanced Recovery (HER) Protocol on Recovery and Hospital Discharge Time Compared to a Traditional Anesthetic Regimen Elizabeth Miller, MD (PGY1) 1000 - 1030 COFFEE (Amphitheatre Lobby) SESSION TWO: POSTER PRESENTATIONS: 1030-1038 The Impact of Simulation-Based Crisis Resource Management Training: A Systemic Review Lillia Fung, MD (PGY3)

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1038 – 1046 Regional Anaesethetic Experience of Final Year Trainees Ian Ewington, MD (Fellow) 1046 – 1054 Perioperative Care of Elderly Ambulatory Surgery Patients in the USA Daniel McIsaac, MD (PGY4) 1054 – 1102 Multimodal Analgesia with Lidocaine for Acute Pain –

A Retrospective Study Qutaiba Amir Tawfic, MD (Fellow) 1102 – 1110 Pre-Admission Unit Quality Assurance Project: Comorbidities in Elective Surgical Patients – Agreement between Self-Report and Chart Review Jennifer Wilson, MD (PGY2) 1110 - 1118 Association between Early Tracheostomy and Mortality Following Major Cardiac Surgery: A Propensity-Matched

Analysis Louise Sun, MD (PGY5) SESSION THREE: VISITING PROFESSOR’S PRESENTATION: 1120 - 1205 Investigations as a Safety Tool: 1983-2013 Jan Davies, MSc, MD, FRCPC 1205 - 1215 Questions 1215 - 1220 Wrap up 1220 Residents Photographs (Front steps Civic Campus) 1800 - 2200 ANNUAL DINNER AND AWARDS CEREMONY (Canadian War Museum)

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Title: Association of Positive Airway Pressure Device Treated Obstructive Sleep Apnea and 30 Day Post-Operative Mortality and Healthcare Resource Use: A Population Based Study Authors: Daniel McIsaac, Gregory L. Bryson, Andrea Gershon, Duminda N. Wijeysundera, Neal Badner, Carl van Walraven Introduction: Obstructive sleep apnea (OSA) is associated with adverse post-operative cardiopulmonary events in small studies that do not capture post-discharge outcomes. We undertook a population-based cohort study to measure the association of OSA with 30-day post-operative mortality (primary outcome) and healthcare resource use (secondary outcomes). Methods: Ontario residents aged 40 years and older having elective non-cardiac surgery in 2002-2012 was identified using linked healthcare administrative data. We defined 3 exposure groups: “Treated OSA” (polysomnogram (PSG) >6 months prior to surgery receiving a PAP device), “No treated OSA” (PSG >6 months prior to surgery, no PAP), “No PSG” (did not undergo PSG). The data sources accurately capture PSG, PAP use, demographics, surgery, healthcare resource utilization and mortality. The association between OSA status and 30-day mortality and healthcare resource utilization (ICU admission, mechanical ventilation, LOS, hospital readmission) was measured using multivariable regression. Results: Of the 268 271 subjects, 14 027 (5.2%) had a PSG at least 6 months prior to their operation. PAP was used by 2050 (14.6% of PSG studied, 0.76% of total cohort). Treated OSA was not associated with increased adjusted odds of 30-day mortality, having lower adjusted odds of mortality than the No PSG group. OSA was associated with increased adjusted odds of post-operative ICU admission, but not mechanical ventilation. Discussion: People treated with PAP or who required prior PSG testing had no increased risk of mortality. OSA patients were more likely to be admitted to ICU; this could reflect monitoring protocols or clinical decision making based on a diagnosis of OSA.

Table 1. Multivariable adjusted associations with OSA as reference exposure

No PSG (n=254244)

Treated OSA (n=2050)

No treated OSA (n=11977)

Incidence (%) Incidence (%) Adj-OR (95%CI) Incidence (%)

Adj-OR (95% CI)

Death 6421 (2.53) 17 (0.83) 0.53(0.32,0.86) 204 (1.70) 0.79(0.68,0.92)

Readmission 13456 (5.29) 92 (4.49) 0.95(0.77,1.18) 705 (5.89) 1.17(1.08,1.27) ICU admission 31555 (12.41) 242 (11.80) 1.57(1.35,1.83) 1643 (13.72) 1.41(1.33,1.50) Mechanical ventilation* 13413 (11.93) 156 (11.36) 0.93(0.79,1.11) 856 (11.66) 0.89(0.82,0.97)

Mean/median

(SD) Mean/Median

(SD) Difference (P-value)

Mean/median (SD)

Difference (P-value)

Length of stay 6.84/5 (6.46) 5.58/4 (4.61) -0.22 (0.08) 6.11/5 (5.76) 0.14 (0.006) *Mechanical ventilation available from 2008-2012 only. “No PSG” (n=112413), “OSA” (n=1373), “No OSA” (n=7342).

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Title: Early Morbidity and Mortality Associated with Thoracic Endovascular Aortic Repair (TEVAR) at a Tertiary Care Centre Authors: Graeme Bishop and Ashraf Fayad Introduction: Thoracic endovascular aortic repair (TEVAR) is associated with a lower incidence of morbidity and mortality compared to the traditional open approach.1 As such; TEVAR is being performed on patients who were once declined intervention. Our study aims to identify early morbidity and mortality to ensure patient selection remains appropriate. Methods: After ethics approval, a historical cohort study of patients who underwent TEVAR from July 2007-12 at our institution was conducted. The electronic record was used to identify the outcomes reported in Table 1, as well as complications related to CSF drainage. Results: A total of 82 patients were identified with an average age of 66 +/- 15 years. 56 were male and 26 were female. Emergency procedures represented 37% of our cohort. The indication was aneurysm in 61%, type B dissection in 21%, trauma in 9%, and aortic ulcer in 7%. Repeat aortic surgery accounted for 41% of patients and 20% underwent hybrid procedures. 75% had CSF drains placed with no major complications noted. Early mortality and major morbidity are displayed in Table 1. Table 1. 30-day Morbidity and Mortality Outcome Incidence (%) Incidence from Literature (%)2,3,4

Mortality 7.3 6-13 MI 17.1 2-6 Permanent SCI 8.5 0-13 Transient SCI 2.4 0-5 Stroke 6.1 2-8 Renal Failure 2.4 3-4 Discussion: Our in-hospital rates of major morbidity and mortality are largely in-line with other academic centres. Notably, our rate of MI was higher than most published rates. The reason is unclear, but differing definitions of MI, variances in post operative surveillance, and patient selection may contribute. All but two of our cases of MI occurred in urgent/emergent or hybrid/repeat procedures. This may indicate a need for enhanced perioperative cardiac care of these high-risk groups. References: 1 J Am Coll Card. 2010 55(10):986-1001 2 Circulation 2011;123:2938-2945 3 Vasc and Endovasc Surg. 2007;41(3):186–91 4 Semin Cardio Vasc Anes. 2012;15(4):123–40.

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Title: Efficacy of Metoprolol in Preventing Cardiovascular Complications and All-Cause Mortality in Emergent Surgeries

Authors: Louise Sun, Homer Yang, George Wells, Philip J. Devereaux, Gordon Guyatt, Salim Yusuf, Kate Leslie

Introduction: The Perioperative Ischemic Evaluation (POISE)(1) randomized trial suggested a decrease in major cardiac complications (CVC), and a possible increase in all-cause mortality with administration of metoprolol to non-cardiac surgical patients. We addressed the question of whether these effects might differ by surgical urgency. Methods: REB approval was obtained. Outcomes were CVC and all-cause 30-day mortality. Time to event for each outcome was assessed using a multivariable Cox PH model with respect to treatment (metoprolol versus placebo) and surgical urgency (emergent versus elective). Effect modification was tested using an interaction term of treatment by urgency. Kaplan-Meier curves described time-to-event patterns of outcomes. All analyses were conducted using SAS 9.3. Results: Of 8351 patients, 5 were excluded since case urgency information was unknown; 10.5%(878/8346) were emergent patients. CVC occurred in 10.8% and 5.9% of emergent and elective patients respectively. For emergent patients we found a HR of 0.97(0.65-1.45) associated with metoprolol and for elective patients HR 0.81(0.67-0.98)(interaction p=0.19). Emergent surgery elevated cardiac risk in both metoprolol (HR 2.09[1.52-2.87]) and placebo (HR 1.74[1.28-2.38]) groups. Mortality occurred in 8.4% of emergent and 2.0% of elective cases. For mortality, in emergent patients we found a HR of 1.49 (0.93-2.36) associated with metoprolol and for elective a HR of 1.27(0.92-1.75)(interaction p=0.30). Emergent surgery elevated mortality in both metoprolol (HR 4.61[3.20-6.64]) and placebo (HR 3.93[2.56-6.05]) groups. Discussion: While risk of CVC and death were higher in patients undergoing emergent surgery, we found no evidence of a difference in relative effect of metoprolol in the two populations. Figure. Kaplan-Meier event-free survival curves for CVC by surgical urgency and treatment assignment.

Reference: (1) Lancet. 2008;371(9627):1839-47.

Number at risk:

3736 3571 3530 3515 3506 3500 3494 438 401 397 393 391 390 389

3729 3606 3572 3558 3550 3539 3533 440 407 401 398 395 393 392

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Title: Anesthesia for Awake Brain Port Surgery. Authors: Al Faraidy M, Polis T Introduction: Brain Port system is a new minimally invasive technique to resect brain tumors. We evaluated its use in awake patients using field block and monitored anesthesia care (MAC). Methods: IRB approved retrospective chart review of ten consecutive awake Brain Port procedures. MAC technique was at discretion of attending anesthesiologist. Three patients received remifentanil/propofol infusion, two dexmedetomidine/propofol and five remifentanil/propofol/ketamine infusion. Respiratory rate was monitored using Salter nasal prongs. All patients had Mayfield pin sites and field block infiltrated with 0.25% bupivacaine or 0.5% ropivicaine with epinephrine 1:200,000. Three patients also received ring blocks. Awake neurological testing and quantitative analysis, using EMG and SSEP, were performed. Post operative pain scores were assessed. Results: Mean patient age was 49 years, 50% male and 50% female. Obstructive sleep apnea was present in 20% of patients. 20% had Mallampati class 4 airway. Although transient hypoxia episodes were common, only one patient required temporary insertion of nasal airway. 20% of patients were oversedated or agitated at some point during surgery, but interaction with the surgeon was adequate for neurological assessment. All patients, except one (dexmedetomidine), had good postoperative VAS pain scores 0-3. Patients were discharged home within 48 hours from the procedure.

Hypotension MAP<60mmHg 10 % Hypertension MAP>120mmHg 90 % Tachycardia HR>90 beats/min 40% Bradycardia HR<50 beats/min 40% Hypoxia Saturation <92% 70% Oversedation Ramsay score 5-6 20% Agitation Ramsay score 1 20%

Discussion: Brain Port is a technique offering potentially less brain tissue damage and faster recovery. Our experience with first 10 cases in the world done with field block and MAC is encouraging. All patients had a satisfactory outcome and improved neurological function. Prospective randomized studies should determine the optimal sedation protocol. References:

1. F, Rosa G. Anesthesia for awake neurosurgery. Current Opinion in Anaesthesiology 2009; 22:560-565. 2. Kassam AB, Gardner PA (eds): Principles of endoneurosurgery. In: Endoscopic Approaches to the Skull

Bases. Prog Neurol Surg. Basel, Krager, 2012, vol 26, pp 21-26 3. Jo KW, Shin HJ, Lee JI, et al. Efficacy of endoport- guided endoscopic resection for deep seated brain

lesions. Neurosurg Rev. 2011 Oct;34(4):457-63. 4. Prabhu VC, Bamber NI, Shea JF, Jellish WS. Avoidance and management of trigeminocardiac reflex

complicating awake craniotomy. Clin Neurol Neurosurg, 2008 Dec; 110(10): 1064-7.

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Title: Celecoxib for Pediatric Adenotonsillectomy: A Randomized Controlled Double Blinded Study Authors: Colleen Daly MD, Kimmo Murto MD, Christine Lamontagne MD, Johnna MacCormick MD, Kelly-Ann Ramakko BSc, David Rosen MD, Mary Aglipay BSc and Regis Vaillancourt Pharm D Introduction: Celecoxib is an effective analgesic in adult surgery patients. No comparable pediatric literature exists. Our objective was to determine the effect of a short course of oral celecoxib on pain and functional recovery in pediatric adenotonsillectomy (T&A) patients. Methods: With REB approval 282 children (2-18 yrs) for elective T&A were randomized to either celecoxib (preoperative 6mg/kg and post-operative 3mg/kg BID for five doses) or placebo. Age appropriate diaries documented recovery for postoperative days (PODs) 0-7. Primary outcome averaged once daily scores recording “worst pain in 24 hours” for PODs0-2. Analgesic consumption and adverse events (AEs) were recorded. Baseline QOL and fatigue scores were compared to POD7. CYP2C9 genotype was determined. A mixed model analysis and t-tests were used as indicated. Results: 282 children were randomized and 206 were suitable for intention-to-treat analyses (107 celecoxib 99 placebo). Celecoxib reduced the average ``worst pain`` (100mm scale) over PODs 0-2 by 7 mm (95%CI: 0.3-14, p=0.04) (Figure 1). It reduced pain with swallowing for POD 1 [45 (95%CI: 39-51) vs 53 (95%CI: 47-59), p=0.02]. Total PODs 0-2 acetaminophen consumption (mg/kg±SD) was lower (79±57 vs 97±60, p=0.03) and morphine consumption trended lower (p=0.06) There was no difference in the incidence of AEs, functional recovery or satisfaction. There was minimal difference in tonsil bleeds requiring admission or surgery (4 celecoxib 3 placebo). Discussion: A short course of oral celecoxib after T&A reduced early pain and analgesic consumption. It had no effect on functional recovery. Celecoxib appears to provide some benefit for T&A in children.

Figure1. ``Worst 24 hr pain`` experienced for PODs 0-2 (celecoxib 101 and placebo 94). Celecoxib group experienced significantly less pain at day 0 [49 (95% CI: 42-56) vs 60 (95% CI: 53-67), p=0.02) and day 1 [63 (95% CI: 58-68) vs 72 (95% CI: 67-78), p=0.02)], but not day 2 (p=0.92)

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Title: Influence of a Hysterectomy Enhanced Recovery (HER) Protocol on Recovery and Hospital Discharge Time Compared to a Traditional Anesthetic Regimen Authors: Elizabeth C. Miller, Anne Lui, Alan Chaput, Jonathan Antrobus, Hassan Shenassa. Introduction: The HER protocol, launched in July 2011, is an enhanced recovery protocol for open benign gynecologic surgery, designed to reduce perioperative stress and decrease length of stay. We investigated the effect of the protocol on postoperative day 1 (POD1) discharges and recovery. Methods: Following REB approval, the charts of patients who underwent open benign gynecologic surgery from July 2010-September 2012 (one year before and after the HER protocol launch) were reviewed. Patients were grouped as in Table 1. Run charts were applied to examine the percentage of patients discharged within 24 hr. postoperatively, regardless of anesthetic technique, before and after protocol implementation. Data on operative and discharge dates, anesthetic details and patient medical history were collected. The percentage of 30-day emergency room visits and re-admissions were calculated for each group. Results: (In progress):143 post- HER, and 114 pre-HER charts were reviewed. Emergent cases or patients with chronic pain diagnoses were excluded.50 patients met Group 1 criteria. Chi-squared tests will determine the significance of differences in the median LOS and percentage of discharges on POD1, and the emergency room visits and re-admission rates, between Groups 1 and2. Monthly average LOS, monthly percentage of discharges on POD1, and monthly percentage of emergency room re-visits and readmissions will be determined and run charts will be constructed. Discussion: Compliance with the HER protocol one year after implementation, is variable. Early data suggest that implementation of the protocol may be associated with a meaningful reduction in LOS. Table 1. Criteria defining our study and control groups. Group 1. HER Complaint Patients (study group) Group 2. Standard Anesthetic Care (controls) 1) total intravenous anesthesia, plus:

2) subarachnoid block (SAB) with bupivacaine + epimorph 75-150 µg, plus:

3) transversus abdominal plane (TAP) block, plus:

4) foundational analgesia, and no IV PCA hydromorphone.

1) inhaled general anesthesia, with or without:

2) parenteral opioids, plus IV PCA hydromorphone postoperatively

References:

(1) Toma A, Hopman W. Hysterectomy at a Canadian tertiary care facility: results of a one year retrospective review. BMC Women's Health. 2004;4(1):10.

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Title: The Impact of Simulation-Based Crisis Resource Management Training: A Systematic Review Authors: Lillia Fung, Sylvain Boet, Haytham Qosa, Walter Tavares, Laure Perrier, Andrea Tricco, Scott Reeves, Dylan Bould. Introduction: Skilled crisis resource management (CRM) is vital to the effective management of critical events in healthcare. CRM principals include leadership and followership, communication, teamwork, resource use, and situational awareness1. Simulation-based CRM training is increasingly popular and nnumerous studies have investigated the effects of simulation CRM training on the acquisition of CRM skills, with outcomes ranging from participants response to benefits to patients (Table 1). Still, a knowledge synthesis of the impact of simulation-based CRM training is lacking. This systematic review aims to appraise and summarize the impact of CRM simulation-based training on healthcare providers behavioural changes and patients’ outcomes (Kirkpatrick level 3-4). Table 1. Kirkpatrick (KP) model for learning acquisition2

KP level Explanation 1 – Learner’s reaction Participant’s views on the intervention 2 – Knowledge and skill acquisition Modification of skill/knowledge after intervention 3 – Behavioural change Change in practice at the workplace 4 – Patient outcomes Demonstrated benefit to patients

Methods: A systematic review of Institutional Ethics Board approved trials for CRM simulation-based training was performed. Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and ERIC were searched on September 4, 2012. Search terms included: crisis resource management, crew resource management, teamwork, and simulation. Cohort, case-controlled, or randomized controlled studies with a CRM educational intervention were included. Articles were evaluated for validity and data was extracted by the authors. Results: A total of 7100 abstracts have been identified. After screening 8 and 3 articles with KP level outcomes 3 and 4 were identified, respectively. Primary outcomes measures for these studies are being performed and will be presented at Gary Johnson Day, 2013. Conclusion: This work appraises the impact of simulation-based CRM training and will also contribute to better orientate future research in CRM simulation-based education. References:

1. Clinical Anaesthesiology 25 (2011) 239–249. 2. Kirkpatrick DI, Evaluating Training Programs, 2006.

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Title: Regional Anesthetic Experience of Final Year Trainees Authors: Dr Ian Ewington, Dr Anne Lui, Dr Desiree Persaud Introduction: Over the last few years there has been increasing pressure to restrict hours that trainee doctors work in order to decrease fatigue and increase patient safety.1Regional anaesthesia in particular requires a thorough grounding in order to practice safely and effectively. This in effect means sufficient numbers of blocks must be performed under supervision with appropriate feedback from more experienced physicians. There have been several studies which have examined whether it is possible to define the ‘learning curve’ for regional anaesthetic procedures.2,3Morroset al (2011) suggested that 15 ultrasound guided brachial plexus blocks were necessary before ‘good results’ were obtained. Therefore it is important to clarify the level of confidence and experience of final year trainees with regard to regional anaesthesia particularly in light of changes to training time. Methods: Following ethics approval, the heads of anaesthetic schools in Canada were contacted by email and a request made for participation by sending the link for the web based survey to their final year trainees. Those trainees willing to participate were asked to click on the link which provided information on the survey. The questions were designed to elicit time based regional experience, numbers of blocks performed as well as confidence with managing more advanced regional techniques. Results and Discussion: Pending further collection and analysis prior to Gary Johnson Day.

References: 1. Canadian Association of Internes and Residents. Canadian Patient and Physician Safety and Wellbeing:

Resident Duty Hours. April 2012 2. Morros C, Pérez-Cuenca MD, Sala-Blanch X et al. Ultrasound-guided axillary brachial plexus block: learning

curve and results. Rev EspAnestesiolReanim. 2011; 58(2):74-9 3. Luyet C, Schupfer G, Wipfli M et al.Different Learning Curves for Axillary Brachial Plexus Block:

Ultrasound Guidance versus Nerve StimulationAnesthesiology Research and Practice. 2010; 2010: 1-7

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Title: Perioperative Care of Elderly Ambulatory Surgery Patients in the USA Authors: Daniel McIsaac, Gregory L. Bryson Introduction: Age 80 years or older is an independent risk factor for poor outcomes after inpatient surgery; this segment of the population is growing rapidly. The rate of ambulatory surgery in elderly people is high, 432 surgeries per year per 1000 population. Despite growth in both numbers of, and interventions in, this age group, little is known about the trends in care and outcomes in the oldest segment of our ambulatory surgical population. Methods: The National Survey of Ambulatory Surgery (NSAS) provides a nationally representative sample of ambulatory surgery provided in the United States; years 1996 and 2006 were analyzed. All adult knee, shoulder or transurethral surgeries, lumpectomies and laparoscopic cholecystectomies were identified (these are the most common non-ophthalmic/endoscopic ambulatory surgeries in US adults) and categorized by age 80 years or older. Comparing 1996 to 2006, multivariable regression was used to analyze changes in anesthesia care. Outcome data were available for 2006 only; multivariable regression was used to measure the association between age and postoperative outcome. Results: Elderly people were more likely to be cared for in freestanding surgical centers (OR 1.54, p<0.05) and receive general anesthesia (OR 2.34, p<0.05) in 2006 than in 1996. The odds of reporting any complication within 24 hours was higher in elderly people than non-elderly. Overall rates of complications in elderly people were low. Discussion: Despite the association between advanced age and any complication after ambulatory surgery, overall rates were reassuringly low. The need for more robust outcome data on elderly patients is highlighted.

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Title: Multimodal Analgesia with Lidocaine for Acute Pain- A Retrospective Study Authors: Qutaiba Amir Tawfic, Naveen Eipe, John Penning. Introduction: Lidocaine is an amide local anesthetic with a significant analgesic, anti-hyperalgesic and anti-inflammatory properties when used intravenously Methods: This retrospective study included only those patients who received lidocaine infusion for pain between September 2009 and August 2012. Results: In the study period, 102 patients were included in this study. The patients were 52% male with mean age 53 years (±36). The mean weight was 75 kg (range 40-80 kg) .The indications for intravenous lidocaine and durations of lidocaine use are described in Figure 1. History of chronic pain was present in 50%, while only 35.3% of whole patients were chronic opioid users. Bolus dose was used 95% of our patients, with a mean dose of 1.34 mg/Kg (range 0.75- 2.5). The infusion dose was ranging between 0.5-2 mg/kg/hour. Table 1 is showing the duration of lidocaine infusion. Mild side effects and/or signs of toxicity were reported in 10 patients (9.8%) and the infusion was stopped for 8 of them. No serious side effects or toxicity was reported. Conclusion: This quality assurance study reports the safety and indications of intravenous lidocaine by an Acute Pain Service. References: 1-Vigneault L, Turgeon AF, Côté D, et al. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth. 2011;58:22-37. 2-Marret E, Rolin M, Beaussier M, et al. Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery. Br J Surg. 2008 ;95:1331-8.

49%

16.70% 12.70%

6.90% 5.90% 3.40% 4.90% 0%

10%

20%

30%

40%

50%

60%

Fig 1:Indications for IV lidocaine Table 1: The duration of lidocaine infusion Duration of infusion(Days)

No. Of patients

%

<1 3 2.9% 1 18 17.6% 2 41 40.2% 3 34 33.3% 4 6 5.9% Total 102

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http://www.ncbi.nlm.nih.gov/pubmed?term=Vigneault%20L%5BAuthor%5D&cauthor=true&cauthor_uid=21061107

http://www.ncbi.nlm.nih.gov/pubmed?term=Turgeon%20AF%5BAuthor%5D&cauthor=true&cauthor_uid=21061107

http://www.ncbi.nlm.nih.gov/pubmed?term=C%C3%B4t%C3%A9%20D%5BAuthor%5D&cauthor=true&cauthor_uid=21061107

http://www.ncbi.nlm.nih.gov/pubmed?term=CJA%202011%3B58%3A22-37

http://www.ncbi.nlm.nih.gov.libaccess.lib.mcmaster.ca/pubmed?term=Marret%20E%5BAuthor%5D&cauthor=true&cauthor_uid=18844267

http://www.ncbi.nlm.nih.gov.libaccess.lib.mcmaster.ca/pubmed?term=Rolin%20M%5BAuthor%5D&cauthor=true&cauthor_uid=18844267

http://www.ncbi.nlm.nih.gov.libaccess.lib.mcmaster.ca/pubmed?term=Beaussier%20M%5BAuthor%5D&cauthor=true&cauthor_uid=18844267

http://www.ncbi.nlm.nih.gov.libaccess.lib.mcmaster.ca/pubmed/18844267


Title: PAU Quality Assurance Project: Comorbidities in Elective Surgical Patients - Agreement between Self-Report and Chart Review

Authors: Dr. J. Wilson, Dr. J. Neufeld, Dr. H. Yang (PI), Dr. S. Gagne, B. Crawford-Newton, Dr. M. Taljaard, Dr. J. Grimshaw

Introduction: As part of the recent Pre-Admission Unit (PAU) Standardization Project at the Ottawa Hospital, a new ‘pre-op health history patient questionnaire (NUR 71C)’ was implemented as a mandatory component of all new elective surgery bookings. The questionnaire, which was introduced in late 2012, aims to help triage patients to the most appropriate PAU visit type. The purpose of this retrospective cross sectional quality assurance project is to determine the concordance between 43 self-reported patient comorbidity responses on the NUR 71C, and the Anesthesiologist’s assessment according to their PAU visit electronic medical record.

Methods: In November of 2012, 1741 patients underwent elective surgeries at the Ottawa Hospital. Four hundred fifty cases were randomly selected as a convenient sample for review. To be eligible for review patients must have been 18 years of age or older, be attending their first visit with the PAU team, require an elective surgical procedure, and be competent to read and write in one of the two official languages. On the questionnaire, patients reported the presence or absence of 43 comorbidities. Using the Anesthesiologist’s PAU electronic medical record as the gold standard, we calculated sensitivity, specificity, positive and negative predictive value of each self-reported comorbidity. To measure agreement, where neither data source was considered the gold standard, we calculated overall agreement and kappa statistics. Kappas of 0 – 0.20 indicated slight, 0.21 -0.40 indicated fair, 0.41-0.60 indicated moderate, 0.61-0.80 indicated substantial, and 0.81-1.0 indicated almost perfect agreement.

Results and Discussion: to be presented at Gary Johnson Day

References:

1. Gad BV et al. Journal of Arthroplasty. 27(10):1750-1756.e1, 2012 Dec. UI: 22789447 2. Grant C et al. Anaesthesia & Intensive Care. 40(2):297-304, 2012 Mar. UI: 22417025 3. Ahmadian L et alCIN - Computers Informatics Nursing 29 (11), pp. 662-670 UI: 21270635 4. Sangha O et al. Arthritiis Rheum. Apr 15;49(2):156-63.UI: 12687505 5. Horton M et al. Neuroepidemiology. 35(2):83-90, 2010 Aug. UI: 20551692

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Title: Association between Early Tracheostomy and Mortality following Major Cardiac Surgery: A Propensity-Matched Analysis Authors: Louise Sun, Munir Boodhwani, Heather Baer, Bernard McDonald Introduction: Tracheostomy is frequently performed “late” following cardiac surgery to evade the devastating consequences of sternal wound infection (SWI). Although early tracheostomy is associated with improved outcome in the general ICU population, its benefits are unclear in cardiac surgical patients. We investigated whether early tracheostomy is associated with an increased mortality risk post cardiac surgery. Methods: REB approval was obtained for this retrospective study of all patients requiring tracheostomy post cardiac surgery September 1997-October 2010. Early tracheostomy was defined as performed between POD 2-13, and late as between POD 14-30. Primary outcome was all-cause in-hospital mortality. Secondary outcomes were SWI and hospital LOS. Patients were matched based on their propensity to receiving tracheostomy early. Cox proportional hazards analysis compared survival of the time cohorts, stratifying on each matched pair. Survival time was defined as date of tracheostomy until date of death or hospital discharge. Survivors were censored upon discharge. Kaplan-Meier curves described the time-to-event patterns of each time cohort. All analyses were performed using SAS 9.2. Results: Of 413 included patients, 187 had early tracheostomy and 188 late. 109 propensity-matched pairs were made. Mortality occurred in 29.4% of early and 33% of the late group. There was no significant difference in survival between the time cohorts (HR 0.90[0.48-1.70]). Early tracheostomy was associated with lower SWI risk (OR 0.48[0.23-1.0]) and shorter hospital LOS (51[IQR,39-73] versus 59.5[43-83] days, p=0.05). Discussion: While early tracheostomy was associated with decreased SWI risk and hospital LOS; it was not associated with mortality benefit following cardiac surgery. Figure. Kaplan-Meier survival curves for mortality by tracheostomy timing.

Number at risk: 188 130 49 23 11 6 187 138 50 22 9

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