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POSTGRADUATE PROGRAM:

YEAR 2010

ANNUAL GARY JOHNSON ANESTHESIOLOGY RESEARCH DAY

Friday, May 14, 2010 0730 Hours – 1500 Hours

University of Ottawa Faculty of Medicine Amphitheater “A”

451 Smyth Road, Ottawa, Ontario

EVENING PROGRAM:

THE UNIVERSITY OF OTTAWA DEPARTMENT OF ANESTHESIOLOGY

ANNUAL DINNER &

AWARDS CEREMONY

Friday May 14, 2010 Reception 1800 Hours

Dinner 1900 Hours The National Art Centre

Panorama Room

University of Ottawa Annual Gary Johnson Anesthesiology Research Day May 14th, 2010

ACKNOWLEDGEMENTS: We are most grateful to the administrative and support staff, for having so carefully attended to the many details to make this day possible. In addition, the research nurses and research associates of the University Department provided invaluable assistance both directly, and indirectly, towards successful completion of many of the projects which will be presented this year. Also, the members of the Department of Anesthesiology who supervised individual residents throughout the process are to be especially thanked. Finally, we very much appreciate the willingness and cooperation of our colleagues who have implemented research protocols on patients under their care. The Department of Anesthesiology gratefully acknowledges the support of all our corporate sponsors. The University of Ottawa Medical School 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. Patti Murphy Assistant Professor Department of Anesthesiology, TOH University of Ottawa

Dr. Alan Chaput Assistant Professor Department of Anesthesiology, TOH University of Ottawa

Dr. Jerrold Lerman Visiting Professor Professor of Anesthesia University of Buffalo & University of Rochester, N.Y.

CORPORATE SPONSORS Carestream

Covidien Hospira

Leo Pharma Inc. Merck Canada Inc.

Paladin Labs Sonosite Canada Inc.

Thank you to Abbott for sponsoring the coffee break

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RESEARCH DAY OBJECTIVES: A) Resident/Fellow Presentations

To provide an academic forum for residents in the Department of Anesthesia 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:

Illustrate and describe to residents and anesthesiologists how to design, perform,

analyze and present basic science studies, clinical trials, case reports and quality improvement studies.

Identify clinically relevant problems in anesthesiology. Critically appraise experimental design, and examine data that addresses the

experimental question. Evaluate the relevance of the findings to the practice of anesthesiology and formulate

insightful questions to challenge the presenters. B) Key Note Speaker – Dr. Jerrold Lerman “Invigorating Clinical Research in Anesthesia” To identify the educational requirements, infrastructure and personal commitments needed to develop and sustain a career in anesthesia research. To review clinical anesthesia research: what makes poor studies so poor. To explore the impact of research on clinical care. PLANNING COMMITTEE: Dr. Kimmo Murto Dr. Howard Nathan Dr. Homer Yang Lynne McHardy Jennifer Borup PLANNED DISCUSSION PERIODS: Each research presentation will consist of a formal 10 minute talk, followed by a 5 minute period for questions and answers. The address of the Visiting Professor will be concluded by a 10-minute discussion period.

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ACCREDITATION: This program 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 and has been approved for up to 5 Section 1 Credits.

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ANNUAL GARY JOHNSON ANESTHESIOLOGY RESEARCH DAY PROGRAM

0730 – 0800 Continental Breakfast, Exhibits (Atrium, Roger Guindon Hall,

University of Ottawa, 451 Smyth Road)

0800 – 0815 Opening Remarks Kimmo Murto, MD Chair, Gary Johnson Research Day Planning Committee SESSION ONE: 0815 - 0830 Does Delay in Vasopressor Administration in Septic Shock Patients

Affect Mortality? Vance Beck, MD (PGY4) 0830 - 0845 Anesthesia Machine Check Survey. Nicole Hale, MD (PGY5) 0845 - 0900 Perioperative Care of Cardiac Rhythm Management Devices. Ozgur Sinan Demir, MD (PGY4) 0900 - 0915 Long-term Functional Recovery after Coma due to Stroke,

Encephalopathy or Seizures after Cardiac Surgery measured by the Glasgow Outcome Scale. Extended: The Long-GOSE Coma Study.

Shona Nair, MD (PGY5) 0915 - 0930 Impact of Standard Reporting Guidelines on the Accuracy and

Transparency of Published Randomized Controlled Trials in Anesthesiology.

Louise Sun, MD (PGY2) 0930 – 0945 Safety of Cell Therapy with Mesenchymal Stromal Cells (MSCs):

A Systematic Review Manoj Lalu, MD (PGY2) 0945 - 1030 COFFEE AND EXHIBITS SESSION TWO: 1030 - 1045 Factors Predicting Blood Loss and Transfusion in Pediatric Patients

Undergoing Spinal Fusion Surgery. Karolinah Lukitto, MD (PGY4)

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1045 -1100 Urgent Replacement of a Mechanical Mitral Prosthesis in an

Anticoagulated Patient with Bombay Red Blood Cell Phenotype. Travis Nairn, MD (PGY4) 1100 – 1115 Opiate Tolerant Patients: Prevalence, Recognition, and Management among Surgical Patients at The Ottawa Hospital Robert Sikorski, MD (PGY4) 1115 -1130 Clopidogrel and General Surgery: How Bad could it be? Ali Namazie, MD (PGY5) 1130 - 1215 Invigorating Clinical Research in Anesthesia Jerrold Lerman, MD, FRCPC (Visiting Professor) Professor, Department of Anesthesia, University of Buffalo & University of Buffalo, Rochester, N.Y. 1215 Residents Photographs (Front Stairs Medical School) 1215 - 1315 LUNCHEON (Royal Room, TOH, General Campus) SESSION THREE: 1315 – 1330 Consent for Labour Epidural Analgesia: A Survey of Resident Practice. Wesley Edwards, MD (Fellow) 1330 - 1345 Outpatient Management of the Patient with Obstructive Sleep Apnea. Claudia Gomez, MD (Fellow) 1345 -1400 Continuous Epidural Analgesia in a Patient with Severe Pain Associated with Calciphylaxis. Kelly Shinkaruk, MD (Fellow) 1400 - 1415 The Role of Ketamine and Lignocaine Infusion in Postoperative Pain Management for Major Liver Resection – A Pilot Project. Debashis Roy, MD (Fellow) 1415 -1430 Risk-Adjusted Analysis of Anesthesia Care Delivery at The

Ottawa Heart Institute. Diem Tran, MD (Fellow) 1430 - 1445 Association of Postoperative Myocardial Ischemia Identified by

Continuous ECG Monitoring with Ischemic Events. Hesham Talab, MD (Fellow) 1800 – 2200 ANNUAL DINNER AND AWARDS CEREMONY (National Arts Centre, Panorama Room)

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TITLE: Does Delay in Vasopressor Administration in Septic Shock Patients affect Mortality? AUTHORS: Vance Beck, Anand Kumar, Greg Bryson INTRODUCTION: Early management with fluid and antibiotic treatment has been shown to reduce the mortality in patients with septic shock (1,2). This study examined whether early directed treatment with vasopressor medication would similarly improve survival rates in patients with septic shock. METHODS: This project received approval from its local research ethics board. 8,640 adult patients with septic shock from 24 intensive care units in Canada and the United States, time to vasopressor administration were collected retrospectively. Initial incident of hypotension was considered the onset of septic shock when a) hypotension persisted despite fluid therapy (> 2L of saline or equivalent) or b) hypotension that only transiently improved with fluid therapy. Hypotension was defined as a mean blood pressure of < 65 mm Hg, a systolic blood pressure of < 90 mm Hg, or a decrease in systolic pressure of 40 mm Hg from the patient’s baseline, consistent with the 1991 Society of Critical Care Medicine/American College of Chest Physicians consensus statement on Sepsis Definitions. Time intervals to treatment were divided into ten similar, comparably-sized groups based on the distribution of cases in the cohort sample. For comparison purposes of demographic, medical and treatment characteristics, two categories were created, with one group representing ‘early treatment’ and the other ‘delayed treatment’. RESULTS: The main outcome was survival to hospital discharge. In total, all of the 8640 patients met the definition of septic shock and received vasopressor treatment. Median time to vasopressor administration of the entire cohort was 2.92 hours. Demographic characteristics, medical comorbidities, illness severity, infection and treatment characteristics were similar in those treated before or after the median time to vasopressors. The overall mortality rate was 47%. Interval between presentation and vasopressor treatment and its association with mortality is shown in Figure 1. DISCUSSION: Among patients admitted to a critical care unit diagnosed with hypotension we observed no trend tampered outcomes with earlier administration of vasopressors. Multivariable analysis will be undertaken to determine the independent predictors of mortality in this population. Key Words: sepsis, vasopressin; delayed; early; mortality; vasopressor; mortality REFERENCES:

1. Rivers et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med (2001) vol. 345 (19) pp. 1368-77

2. Kumar, A., et al., Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med, 2006. 34(6): p. 1589-96.

3. Bone, R.C., et al., Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest, 1992. 101(6): p. 1644-55.

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TITLE: Anesthesia Machine Check Survey AUTHOR: Nicole Hale INTRODUCTION: Each year the Canadian Anesthesiologists’ Society (CAS) publishes updated guidelines on pre-anesthetic checklist. Failure to check anesthesia equipment prior to use can lead to patient injury or “near misses.”1,2 A previous report in 1981 stated that as many as a third of anesthetics are performed without a proper pre-anesthesia machine check.3 In 1993 a pre-use anesthesia apparatus checkout recommendation (AACR) was developed in the United states and endorsed by the Food and Drug Administration(FDA).4 Despite the wide acceptance of the AACR a paper in 1996 reported 40.9% of 22 anesthesia providers missed more than 50% of planted faults when using the 1993 FDA Anesthesia Apparatus Checkout Recommendations.5 A simulator based study performed in Canada in 2000 suggested that improvement was needed when compared to national and international standards.6 Similarly, preliminary results of a web based Anesthesia Machine Pre-use Check Survey by Lampotang et al. showed that there continues to be an opportunity for improvement. 7 The objective of this project was to assess the current trends at our institution with regards to a pre-anesthetic machine checklist. METHODS: Ethics was sought from the Ottawa Hospital Research Ethics Board and deemed not required. An anonymous web based survey was developed based on the CAS guidelines. Participants answered questions (check boxes and free text) about pre-anesthesia machine check. Data was collected with SSL encryption into a database for further analysis. The web survey is ongoing. RESULTS: Will be presented at the Gary Johnson Research day. REFERENCES 1. Anesthesiology 60:34-42, 1984 2. Anesthesia Patient Safety Foundation 23(1), 2008 3. Anaesthesia 36:933-36, 1981 4. Anesthesia Apparatus Checkout Recommendations, 1993 5. American Association of Nurse Anesthetists Journal 64(3):277-82, 1996 6. Canadian Journal of Anesthesia 47:974, 2000 7. Anesthesiology 103:A1195, 2005 8. European Journal of Anesthesia 24:1050-1056, 2007

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TITLE: Perioperative Care of Cardiac Rhythm Management Devices AUTHORS: Sinan Demir, Gregory Bryson INTRODUCTION: The ACC/AHA Guidelines state “If a patient is pacemaker dependent, the device should be reprogrammed to an asynchronous mode during surgery (VOO or DOO)…implantable cardioverter defibrillator devices (ICD) should have their tachyarrhythmia treatment algorithms programmed off before surgery.”1 Similarly, the ASA advises “conventional pacing function of a cardiac rhythm management device (CRMD) should be altered by changing to an asynchronous pacing mode in pacemaker-dependent patients and suspending special algorithms, including rate-adaptive functions…In addition, an ICD’s antitachyarrhythmia functions should be suspended.”2 In November 2007, The Ottawa Hospital implemented a fax referral system to streamline communication with our rhythm device clinic and decrease referrals of patients not dependent on their rhythm CRMD. The purpose of this quality assurance review is to document the volume of such referrals, their perioperative management, and the outcomes of surgical patients with a CRMD. METHODS: Following Research Ethics Board approval a retrospective chart review was conducted on all patients referred to the Rhythm Device Clinic at the University of Ottawa Heart Institute in preparation for elective surgery. All records from 2007.11.07 to 2009.09.01 were eligible. Subjects were identified from a clinic log of consultation requests. A single reviewer (SD) reviewed consultation reports and perioperative records to determine management of the CRMD and perioperative outcomes. Data are described as median (IQR) and number (%). RESULTS: A total of 58 referals to the Rhythm Device Clinic were made over the 22 month study period. During this interval a total of 13,887 elctive surgeries were performed for a referral rate of 0.4%. Five charts could not be located in health records leaving records fo 32 pacemakers and 21 ICD for review. The leading indication for CRMD therapy was complete heart block (11, 33%) and ischemic cardiomyopathy (13, 62%) for pacemakers and ICDs, respectively. Referral intervals and outcomes are described in Table 1. TABLE 1Clinical characteristics and outcomes. Pacemaker

N=32 ICD N=21

Fax referal to Pacemaker clinic to OR interval. Days(SD)

14 (14) 14(12)

Fax Referal from PAU to reply by pacemaker clinic Interval. Days(SD)

3 (5) 4 (4)

CRMD dependent 9 (28) 21 (100%) Reprogrammed 9 (28) 21 (100%) Intraoperative complications 1 (3) 0 (0) Postoperative complications 0 (0) 2 (10) It is interesting to note that four of nine of pacemaker-dependent patients did not have their devices reprogrammed to an asynchronous mode. The only complication noted, electrocautery-related interference leading to bradycardia, occurred in a patient stated to be pacemaker independent. A magnet was placed over this patient’s CRMD and surgery proceded without complication. A single myocardial infarction and one episode of ventricular tachycardia were noted among ICD patients following surgery. In both cases the ICD’s antitachycardia functions had been reset prior to the event. DISCUSSION: The results of this quality assurance evaluation suggest that the majority of pacemaker patients do not require reprogramming of their CRMDs prior to surgery. Intraoperative conplications were infrequent even among those considered pacemaker dependent. Postoperative complications were relatively frequent among patients with ICDs highlighting the severity of their underlying cardiac condition. A larger multicenter study to determine the neccessity of reprogramming pacemakers prior to elective surgery should be considered. REFERENCES: 1. Fleischmann KE. Circulation. 2009 Nov 24;120(21):2123-51,2. ASA Task Force. Anesthesiology. 2005 Jul;103(1):186-98.

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TITLE: Long-Term Functional Recovery after Coma due to Stroke, Encephalopathy or Seizures After Cardiac Surgery Measured by the Glasgow Outcome Scale Extended – The Long-GOSE Coma Study AUTHORS: Shona Nair, Miguel Bussiére, Michael Bourke, Thierry Mesana, Howard Nathan, Rosendo A. Rodriguez. Supervisor: Rosendo A. Rodriguez INTRODUCTION: A wide spectrum of outcomes is possible in patients who develop coma after cardiac surgery ranging from complete neurologic recovery to death. Our objectives were to prospectively determine the incidence of functional disability after hospital discharge in patients who developed coma longer than 24 hours associated with stroke and/or encephalopathy and/or seizures after cardiac surgery and to determine any association between duration of coma and level of disability. METHODS: Previously, we identified patients who were discharged from hospital after coma duration greater than 24 hrs post cardiac surgery due to stroke, encephalopathy and/or seizures for a two year period ending December 2007. After HREB approval, we prospectively evaluated the functional capacity of these patients using a telephone survey adapted from the Glasgow Outcome Scale Extended (GOSE).1 Functional disability was scored independently by two investigators based on domains related to consciousness, independence (in and outside home), ability to work, social/leisure activities, family and friendships, return to normal life and presence of any physical limitations. Functional recovery was categorized into acceptable (scores ≥7) and unacceptable (scores ≤6). Unacceptable recovery included moderate to severe disabilities, vegetative state or death. RESULTS: Seventy one out of 112 comatose patients were discharged after surgery. Neurologic diagnosis was as follows: stroke (18 patients), encephalopathy (18), stroke and encephalopathy (14) and seizures (4). At the time of the survey (3.5 ±1 year after surgery), 39 patients were alive, 15 had died, 16 lost to follow-up and 1 refused to participate. Acceptable recovery was found in only 28% of patients. Patients with stroke and encephalopathy were more likely to have unacceptable recovery compared to those who had only seizures (78% and 72% compared with 25%; p=0.083). Patients with coma lasting less than 5 days were more likely to have acceptable recovery compared with those whose unconsciousness lasted longer [acceptable recovery: 3 days (95% CI 1,5) versus unacceptable: 6 days (95% CI 5, 8); p=0.007]. CONCLUSIONS: A striking 72% of cardiac surgery patients who are discharged after coma either died or have moderate to severe disabilities. Most functional limitations in patients who are alive are associated with loss of independence, inability to resume social/leisure activities and dysfunctional daily life activities. Patients with coma due to stroke or encephalopathy after surgery are more likely to have unacceptable functional recovery than those with seizures. Prolonged durations of unconsciousness during coma are more likely indicative of long-term moderate to severe disabilities or death. REFERENCES: 1.Wilson JTL, Pettigrew LEL, Teasdale GM. Structured interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale: Guidelines for their use. J Neurotrauma 1998; 15: 573-585.

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TITLE: Impact of Standard Reporting Guidelines on the Accuracy and Transparency of Published Randomized Controlled Trials in Anesthesiology. AUTHORS: Louise Sun, MD; Donald Miller, MD INTRODUCTION: “The randomized controlled trial (RCT) is considered the most valid method of comparing treatments and making inferences regarding cause and effect”[1]. Yet, non-transparent and incomplete reporting of methods and results are common, and potentially misleading to those who seek to apply research findings in their clinical practice. For the purpose of improving RCT reporting quality, the Revised Consolidated Standards for Reporting Randomized Trials (CONSORT) Statement was introduced in 2001 [2].. The purpose of this study was to determine whether there had been an improvement in RCT reporting quality in the Canadian Journal of Anesthesia (CJA) since its endorsement of the CONSORT Statement in 2005. METHODS: As a convenience sample, two CJA volumes, one pre-dating and one three years after the CJA-based endorsement of the CONSORT Statement, were compared. Both authors manually screened all CJA issues published in the years 2004 and 2009 for all RCTs published in the English language. Excluded were observational and cohort studies, systematic reviews, and mislabelled RCTs. A 50 item “Modified CONSORT Checklist” was developed, which incorporated all items from the original 22 item CONSORT with altered weights assigned to each item. A single evaluator (LS) assigned scores for each RCT and compared mean proportion of items reported across 2004 and 2009. Summary data were presented descriptively. RESULTS: Of the 12 issues and 307 articles published in 2004, 27 met the inclusion criteria and were considered valid for analysis. Of the 12 issues and 205 articles published in 2009, 10 were analysed. Mean proportion of reported items improved from 62% (SD 9.4, range = 44.4, 84.0) in 2004 to 85% (SD 5.6, range = 7.8, 93.2) in 2009. There was a notable increase in reporting of 12 of the 50 Modified CONSORT items, whereas the reporting of 10 modified items remained deficient. (Table) DISCUSSION: There was an overall improvement in the quality of RCT reporting since the CJA’s implementation of the CONSORT statement. However, the details of reporting of intention to treat, location where data was collected, dates defining periods of recruitment and follow-up, details of blinding, and evaluation of blinding success remained non-transparent. Our results were consistent with a similar, larger scale study [3]. Of note, we observed a decline in the total number of both published articles and RCTs in 2009, potentially reflecting a combination of increasing rigor of the CJA in accepting RCTs and a recent decline in anesthesia research productivity [4]. TABLE. Specific areas of reporting demonstrating improvement and persistent deficiency

CONSORT Items that are increasingly reported

% Reported in 2004

% Reported in 2009

CONSORT Items where reporting deficiencies remain

% Reported in

2004

% Reported in 2009

Location(s) where data was collected 9 80 Details of randomization restrictions (e.g. blocking, stratification)

19 40

Specific Hypothesis of study 63 100 Who generated the allocation sequence

19 50

Clearly defined secondary outcomes 26 90 Who enrolled participants 4 30 Explanation of any interim analysis and stopping rules

50 100 Who assigned participants to groups 15 30

Method used to generate random allocation sequence

70 100 How the success of blinding was evaluated

0 10

Allocation sequence implementation method

52 80 Methods for additional analysis (subgroup analysis, adjusted analysis)

22 40

Was allocation sequence concealed until interventions assigned?

37 100 Describe protocol deviations from planned study

22 40

Were participants blinded to group assignment?

33 80 Dates defining periods of recruitment and follow-up

15 60

Flow of participants through each stage 63 100 State whether analysis was by intention to treat

0 30

# participants completing study protocol 30 90 Interpretation of results, taking into account sources of bias and imprecision

52 70

Estimated effect size and precision (e.g. 95% CI) 56 90 Indicating whether subgroup/adjusted analyses were pre-specified or exploratory

67 100

REFERENCES: 1. Altman et al. Ann Intern Med 2001;134:663-694. 2. Tsui, B. Can J Anesth 2006;3:217-21. 3. Moher et al. CMAJ 2004;171:349-350. 4. Greenfield et al. Anesth Analg 2005;100:1759-64 5. Greenfield et al. Anesth Anal 2009;108:191621.

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TITLE: Safety of Cell Therapy with Mesenchymal Stromal Cells (MSCs): A Systematic Review

AUTHORS: M.M. Lalu1, L. McIntyre2, C. Pugliese2, D.J. Stewart3 1Department of Anesthesiology, University of Ottawa, 2 Division of Critical Care Medicine, University of Ottawa, 3Regenerative Medicine Program, Ottawa Hospital Research Institute, and Department of Cell and Molecular Medicine, University of Ottawa, Ottawa, Ontario

INTRODUCTION: Recent preclinical studies suggest that mesenchymal stromal cells (MSCs) may markedly improve outcome from critical illness, specifically septic shock and acute respiratory distress syndrome. Before considering a human clinical trial of MSC immunomodulatory cell therapy for the critically ill we performed a systematic review of all clinical studies to examine the safety of MSCs in adults. We focused on serious adverse events that could affect the cardiovascular, pulmonary, renal, neurological, and hematological systems.

METHODS: Electronic databases were searched from 1950 to 2009 (MEDLINE, EMBASE, Cochrane Central Registry of Controlled Trials); conference proceedings and grey literature were also searched from 2004 to 2009. All prospective clinical trials (randomized controlled trials (RCT), prospective cohort studies, and case series) that examined safety of MSCs in adult populations were identified. Only trials that exclusively used MSCs with no other concomitant experimental therapy were included. No restrictions were placed for language or publication type.

RESULTS: Of the 1885 citations reviewed, 24 studies were included. A total of 652 patients with conditions including ischemic stroke, spinal cord injury, Crohn’s disease, cardiomyopathy, myocardial infarction, graft versus host disease, and healthy volunteers were included. Eleven studies included a control group for comparison (191 MSC treated patients, 250 control) ten were RCTs. No study stopped MSCs administration due to immediate adverse reactions. Of eleven trials with a control group, death was reported in five and was less frequent in the MSC as compared to the control group (7/102 (6.8%) vs. 20/112 (17.8%), p<0.05); four reported arrhythmias which occurred less frequently in the MSC group (3/96 (3.1%) vs. 13/98 (13.2%), p<0.05). Self-limited fever was described in two trials and was more common following intrathecal administration of MSCs versus control (13/22 (59.1%) vs. 0/31 (0.0%), p<0.05). One trial noted more pulmonary edema following intracoronary injection of MSCs as compared to control (3/24 (12.5%) vs. 0/24 (0%), p<0.05). One study noted pinpoint ischemic areas of the brain by computed tomography scan (without neurological deficits) following carotid intraarterial MSC administration. There were no reports of pulmonary hypertension or emboli, hemodynamic instability, hematological issues, or renal insufficiency. Follow-up for the studies ranged from 2 weeks to 30 months. Longer term safety data is currently unavailable.

DISCUSSION: Results from this systematic review suggests that MSC administration appears to be safe based on the available evidence. Longer term follow up studies will help further define the safety profile of MSCs in different patient populations.

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Notes:

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TITLE: Factors Predicting Blood Loss and Transfusion in Pediatric Patients Undergoing Spinal Fusion Surgery. AUTHORS: Neira V, Lukitto K, Kontio K, Moroz P, Jarvis J, Dhanani S, Barrowman N, Corvo A. INTRODUCTION: Spinal fusion surgery in children and adolescents is one of the most complex procedures performed in this population. This extensive and prolonged surgery is associated with hemodynamic instability, bleeding and transfusion, among other complications. Blood loss and transfusion has been associated with morbidity and mortality. The objective of this study was to describe and identify clinical predictors associated with bleeding and transfusions rates in the peri-operative management of pediatric patients undergoing spinal fusion surgery and how they were impacted by blood conservation methods. METHODS: After institutional ethics committee approval, a retrospective chart review was conducted on elective patients (18 years old or younger) who underwent posterior, anterior or combined spinal fusion surgery at a single academic institution (Children’s Hospital of Eastern Ontario) over a period of 13 months (2007-2008). Variables collected included the following: demographics, underlying disorders, laboratory values and perioperative blood conservation techniques. The latter included administered medications, surgical and anesthetic techniques and fluid administration. The main outcome measures of this study were bleeding and blood product transfusion rate. Categoric variables are described using percentages and frequencies; numeric variables as mean, median, standard deviation or range as appropriate. Correlation analysis will be performed to determine association between predictors and outcome variables. RESULTS: Data from 59 patients were collected and analyzed with age ranging from 9-18 years. The M:F ratio was 1:1.5. Further results to be presented at Gary Johnson Research Day. REFERENCES:

1. Motoyama anesthesia for infants and children 2006: 737-69 2. Anesthesiology Clin N Am, 2005; 23: 765-787 3. Eur Spine J (2004) 13 (Suppl. 1): S6–S17 4. Spine, 2002; 27: 2137-2142.

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TITLE: Urgent Replacement of a Mechanical Mitral Prosthesis in an Anticoagulated Patient with Bombay Red Blood Cell Phenotype AUTHORS: Travis K. Nairn, MD, Antonio Giulivi, MD • Doris Neurath, MBA • Melanie Tokessy, MLT • Ying T. Sia, MD • Marc Ruel, MD • Peter R. H. Wilkes, MD, PhD PURPOSE: Bombay red blood cell phenotype is an extremely rare blood type for which patients can receive only autologous or Bombay phenotype red blood cells. We report a case of urgent repeat sternotomy for replacement of a mechanical mitral prosthesis in a patient with Bombay phenotype anticoagulated with warfarin, to emphasize the transfusion challenges in such patients. CLINICAL FEATURES: A male of Indian descent presented to hospital with New York Heart Association IV symptoms. His medical history revealed previous mitral valve replacement with a mechanical prosthesis in 2005 and Bombay phenotype blood. Preoperative transthoracic echocardiography demonstrated thrombus obstruction of the mitral prosthesis despite anticoagulation with warfarin. Right ventricular systolic pressure was > 100 mm Hg with 3+ tricuspid regurgitation. The patient’s condition was temporized with diuretics, bronchodilators, and bi-level positive airway pressure ventilation while transfusion medicine and cardiac surgery were consulted for urgent surgery. The patient received vitamin K and prothrombin complex concentrate prior to repeat sternotomy and successful mitral prosthesis replacement. After cardiopulmonary bypass, heparinization was corrected with protamine and followed by a second dose of prothrombin complex concentrate and recombinant activated factor VIIa. Postoperatively, the patient received four units of packed red blood cells, two autologous units and two units of Bombay specific red blood cells. Right ventricular pressures stabilized at 40 mm Hg following surgery. The patient recovered following several days of inotropic support with milrinone, diuretics, and bronchodilators. CONCLUSION: Patients with Bombay phenotype red blood cells present as type O, but they are unable to receive red blood cells from any phenotype other than Bombay phenotype. They are able to receive all other blood products, including fresh frozen plasma, cryoprecipitate, platelets, prothrombin complex concentrate, and recombinant activated factor VIIa. Coordination between Canadian Blood Services, transfusion medicine, surgery, and anesthesia is important in managing these patients. REFERENCES: 1. Khan MQ. Bombay blood group: a case report. Pacific Journal of Science and Technology 2009; 10: 333-7. 2. Reid ME, Westhoff CM. Human blood group antigens and antibodies. In: Hoffman R, Furie B, Benz EJ Jr, et al.

(Eds). Hematology: Basic Principles and Practice, 5th ed. Philadelphia: Churchill Livingston; 2008: 2163-78. 3. Bhende YM, Deshpande CK, Bhatia HM, et al. A ‘‘new’’ blood group character related to the ABO system.

Lancet 1952; 1: 903-4. 4. 6. Balgir RS. Identification of a rare blood group, ‘‘Bombay (Oh) phenotype’’, in Bhuyan tribe of Northwestern

Orissa, India. Indian J Hum Gen 2007; 13: 109-13. 5. 8. Plapp CV. ClinLab Navigator’s Essentials of Transfusion Medicine, 1st ed. Charleston: BookSurge

Publishing; 2008. 6. 10. Hrubisko M, Laluha J, Mergancova O, Zakavicova S. New variants in the ABOH blood group system due to

interaction of recessive genes controlling the formation of H antigen in erythrocytes: the ‘Bombay’-like phenotypes OHm, OBHm and OABHm. Vox Sang 1970; 19: 113-22.

7. 12. Franchini M, Capra F, Targher G, Montagnana M, Lippi G. Relationship between ABO blood group and von Willebrand factor levels: from biology to clinical implications. Thromb J 2007; 5: 14.

8. 14. Evans D, Horwich L, McConnell R, Bullen M. Influence of the ABO blood groups and secretor status on bleeding and on perforation of duodenal ulcer. Gut 1968; 9: 319-22.

9. 16. Schricker KT, Neidhardt B, Hacker R, Kail R. Heart surgery in a female patient with blood group Oh (Bombay phenotype) (German). Dtsch Med Wochenschr 1983; 108: 61-3.

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TITLE: Opiate Tolerant Patients: Prevalence, Recognition, and Management among Surgical Patients at The Ottawa Hospital. AUTHORS: Dr. Robert Sikorski, Jen Wilson, Dr. Cathy Smyth, Dr. Howard Nathan INTRODUCTION: Patients taking opiate pain medication on chronic bases may pose a challenge to pain management during the perioperative period. Prevalence of chronic opiate users among the surgical patient population is not known. It is also unknown what proportion of patients taking chronic opiates develop problems associated with pain management during their post operative hospital stay. This preliminary study was designed to provide some basic information about the population of surgical patients at The Ottawa Hospital who are chronic opiate users. METHODS: This study utilized a retrospective chart review of Same Day Admission (SDA) patients at The Ottawa Hospital. For the time period between April 1, 2008 and March 31, 2009 a randomly selected sample of 812 SDA charts was reviewed from the Civic and the General campus of The Ottawa Hospital. Data was collected on complications as well as the prevalence, recognition, and management of patients taking chronic opiates. RESULTS: Results will be presented at the Gary Johnson Research Day.

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TITLE: Clopidogrel and General Surgery: How Bad could it be? AUTHORS: Namazie A., Hudson C., Murto K., Nathan H. INTRODUCTION: The aging population with its associated coronary and peripheral vascular disease and the increased use of percutaneous coronary angiography and drug eluting stents, has resulted in a proliferation of prescriptions for clopidogrel, an anti-platelet agent. The perioperative management of clopidogrel is challenging. One has to weigh the preoperative discontinuation of the drug to reduce bleeding against the possibility of precipitating a devastating vaso-occlusive event. Although significant research in the cardiac surgery literature has been carried out, large studies in the non-cardiac population are lacking. The purpose of this study was to assess whether there was a unified approach, among Ottawa Hospital anesthesiologists, to the management of a patient who presents for semi-urgent elective abdominal surgery and has been prescribed clopidogrel. Also, we were interested in their perceived risk of hemorrhage, whether the patient continued with clopidogrel or not in the perioperative period. METHODS: A survey was sent to all anesthesia staff at the Ottawa Hospital, who regularly provided anesthetics for adult general surgery patients. Questions were directed towards the management of a 65 year old female undergoing a hemicolectomy for colon cancer. The patient had been prescribed clopidogrel. Specifically, the respondents were given examples of various indications for prescribing clopidogrel and they were asked to identify to which of these they would continue the drug in the perioperative period. They were also asked to indicate their perceived risk of morbidity, including hemorrhage, and mortality, with or without the perioperative administration of clopidogrel. In addition, respondent demographics, including years of experience and frequency of encountering such a clinical scenario were collected. RESULTS: Results will be presented at the Gary Johnson Research Day.

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Visiting Professor Lecture Title: Invigorating Clinical Research in Anesthesia Presented by: Jerrold Lerman, MD, FRCPC Summary: The objectives of the lecture are: 1. To understand the educational requirements, infrastructure and personal commitments needed to develop and sustain a career in anesthesia research. 2. To review clinical anesthesia research: what makes poor studies poor? 3. To explore the impact of research on clinical care.

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TITLE: Consent for Labour Epidural Analgesia: A Survey of Resident Practice. AUTHOR: Wesley Edwards INTRODUCTION: Anaesthetists are ethically and legally obliged to obtain consent prior to insertion of an epidural for labour analgesia. At the Ottawa Hospitals maternal education and consent are routinely performed after the onset of labour and just prior to epidural insertion with no routine use of a standardised information card or consent form. This process is dependent on the individual practice of the designated anaesthetist. The objective of this study was to determine the variation in maternal education and epidural consent process based on the routine practice of resident anaesthetists. METHODS: An anonymous written survey was given to anaesthetic residents in years PGY2 to PGY5. The survey was administered on a single day with no forewarning. RESULTS: A total of 28 residents completed the survey. All 28 residents routinely obtained verbal consent with none obtaining written consent. Fifteen residents routinely mention the benefits of epidural analgesia with only 6 routinely ascertaining maternal knowledge and discussing alternative analgesic options. All 28 residents routinely mention post dural puncture headache, infection and nerve root damage during the consent process. Other routinely mentioned risks were epidural failure (27 residents), epidural haematoma (22), hypotension (18), paralysis (17) and back-ache (16). Residents rarely mentioned common side-effects such as motor block (4), itch (2) and urinary retention (1). Serious complications such as inadvertent intravenous injection (7) and total spinal (1) were also not routinely mentioned, with no residents mentioning anaphylaxis or death. Risk quantification was not mentioned routinely by the majority of residents. When risk quantification was mentioned there was a large variation in risk quoted. The largest variation existed for the serious but rare complications. Twenty-four residents felt that a standardised epidural information card would be of assistance during the consent process. DISCUSSION: In obstetric anaesthesia practice there is often a considerable gulf between the legal and ethical necessity of consent and the practicalities of obtaining consent. The legal adequacy of consent requires the disclosure of the nature of the procedure, its gravity, any material risks and any special or unusual risks. Studies show that the majority of women want to be fully informed prior to epidural insertion and written information assists this process. Australian and UK anaesthetists are increasingly using standardised written information to accompany the consent process. The significant variability in routine consent evidenced by this survey would suggest both benefit and support for the introduction of standardised written information to accompany maternal education and consent. REFERENCES:

1. Anaesthesia (2009) 64, 161-164 2. Canadian Journal of Anesthesia (2000) 47:11, 1055-1059 3. International Journal of Obstetric Anaesthesia (2006) 15, 98-103 4. Anaesthesia (2003) 58, 760-764 5. Canadian Journal of Anesthesia (2010) 57, 58-87 6. International Journal of Obstetric Anaesthesia (2004) 13, 30-34 7. Canadian Journal of Anesthesia (2000) 47:11, 1068-1073 8. Canadian Journal of Anesthesia (1997) 44:9, 918-923

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TITLE: Outpatient Management of the Patient with Obstructive Sleep Apnea AUTHORS: Claudia P. Gomez1, Robert Jee2, Sheliza Amarsi2, Josee Blackburn3, Alan Forster3, Monica Taljaard4, Gregory L. Bryson11. Anesthesiology, The Ottawa Hospital, Ottawa, ON, Canada. 2. Anesthesiology, University of Ottawa, Ottawa, ON, Canada. 3. Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, ON, Canada. 4. Methods Center, Ottawa Health Research Institute, Ottawa, ON, Canada. INTRODUCTION: Obstructive sleep apnea (OSA) may be present in approximately 3% of patients presenting for elective general surgery (1). Patients with OSA may be at increased risk of a variety of perioperative cardiovascular and respiratory complications (2). The ASA Practice Guideline suggests that patients with OSA “should not be discharged from the recovery area to an unmonitored setting (i.e., home or unmonitored hospital bed) until they are no longer at risk for postoperative respiratory depression (3).” In many centers this guidance has restricted access to ambulatory surgery for patients with OSA. In June 2003 our institution introduced a policy guiding the perioperative care of the patient with known OSA. Following an uneventful four-hour observation period patients treated with CPAP were discharged home. The purpose of this quality assurance project is to document the outcomes of patients managed under this policy. METHODS: Following research ethics board approval analysts identified all patients undergoing a polysomnogram (PSG) from our electronic health record (EHR). All patients with a previously reported PSG who underwent day surgery from 2003.07.01 to 2009.03.30 were identified. Records for ophthalmological surgery and GI endoscopy were excluded. Patient characteristics, length of stay, mortality, unanticipated admission and readmission to hospital within seven days of discharge were abstracted from admission-discharge records. PSG reports in the EHR were reviewed. Physician grading of PSG defined OSA severity; if absent AASM grading criteria for apnea hypopnea index (AHI) were used (4). Operative reports in the EHR were reviewed to determine site of surgery and anesthetic technique. Data are described using median [IQR] and percentages (95% CI). RESULTS: A total of 1590 records were identified. Forty-three records were excluded for incomplete records leaving 1547 eligible pairs of PSG and operative reports. Only 674 of 1547 PSGs reported a diagnosis of OSA (44 %; 41, 46). Characteristics and outcomes associated with varying degrees of OSA are shown in Table 1. DISCUSSION: Patients managed under our OSA protocol successfully underwent ambulatory surgery with same day discharge. Manual review of paper documentation will be undertaken to evaluate the occurrence of events not severe enough to prompt admission. It is interesting to note that the majority of patients undergoing PSG were found not to have OSA and that daytime somnolence as assessed by the Epworth Sleepiness Scale was a poor indicator of severity of OSA. Clinicians should not use a history of sleep studies or somnolence to diagnose OSA in patients unsure of their diagnosis. REFERENCES: 1. Fidan H. Sleep Breath 2006;10:161–5, 2. Chung SA. Anesth Analg 2008;107:1543–63 3. ASA Task Force. Anesthesiology 2006; 104:1081–93,4. Ruehland WR. Sleep 2009;32(2):150-157 TABLE 1. Patient Characteristics and Outcomes No OSA

N = 873 Mild OSA N = 360

Moderate OSA N = 150

Severe OSA N = 164

Male 308 (35%; 32, 39) 211 (59%; 53, 64) 101 (64%; 59, 75) 116 (71%; 63, 78)

GA 620 (78%; 75, 81) 232 (70%; 64, 74) 88 (67%; 58,75) 82 (55%; 46, 63) Epworth 10 [6, 13] 10 [6, 14] 10 [6, 14] 11 [6, 14] AHI 0.4 [0.0, 2.0] 6.5 [4.0, 9.8] 17 [11, 23] 47 [32, 70] RDI 3.0 [1.0, 5.9] 11 [7.3, 16] 25 [18, 30] 54 [40, 77] Nadir SpO2 90 [89, 92] 87 [83, 90] 84 [80, 88] 80 [70, 85] LOS 6 [5,8] 7 [5, 8] 7 [6, 8] 7 [5, 8] Admit 49 (5.6%; 4.2, 7.4) 21 (5.8%; 3.7, 8.9) 12 (8.0%; 4.2, 13.6] 12 (7.3%; 3.8, 12.4) Readmit 0 2 (0.6%; 0.0, 2.0) 0 0

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TITLE: Continuous Epidural Analgesia in a Patient with Severe Pain Associated with Calciphylaxis AUTHORS: Kelly Shinkaruk, MD FRCPC; Cathy Smyth, MD PhD FRCPC; Howard Nathan, MD FRCPC INTRODUCTION: The purpose of this case report is to demonstrate the usefulness of epidural analgesia in managing severe pain associated with calciphylaxis. METHODS: Consent was obtained from the subject of this case report. A 61yr old female presented to our institution’s pain clinic with an advanced case of calciphylaxis with severe bilateral leg ulceration and both nociceptive and neuropathic pain. At that time, the patient rated her pain 8-9/10 on a VAS scale despite oral opioids and co-analgesics including hydromorph contin, gabapentin, nortriptyline, and nabilone. As the leg ulceration progressed, she was admitted to hospital due to sepsis and for initiation of a novel treatment of calciphylaxis (sodium thiosulphate). Despite this, the patient experienced increased pain both at rest and with dressing changes. She received escalating doses of intravenous opioids and ketamine and quickly developed toxicity to these medications including sedation, agitation, and myclonus. Clinically, she showed no significant response to the initial calciphylaxis treatments and deteriorated rapidly. RESULTS: After discussions regarding risks and benefits, the patient and family agreed to receive a continuous lumbar epidural infusion for pain control. An Algoline® catheter was placed at the L2 level under fluoroscopic guidance and tunneled subcutaneously to the patient’s flank. Using patient controlled epidural analgesia infusing bupivicaine 2mg/ml, fentanyl 5mcg/ml, epinephrine 2mcg/ml the VAS score was reduced to 2/10. The patient maintained ambulation but required a Foley catheter. Sodium thiosulphate treatments continued for a total of twelve weeks. Within six weeks of epidural and sodium thiosulphate treatment, the patient showed significant clinical improvement with nearly complete resolution of her leg ulcers. Sleep, appetite and cognition returned to normal. The patient was weaned onto oral opioid medications, the epidural was discontinued, and the patient was discharged home. Over the next two months, follow up appointments revealed excellent progress with minimal residual pain and without recurrence of ulcers. DISCUSSION: Epidural and intrathecal analgesia have many benefits in the cancer pain and vertebral compression fracture populations 1,2,3,4. In addition to optimizing pain control, minimizing opioid side effects, and enhancing quality of life, we propose that epidural analgesia has the additional benefit of improving clinical outcome by decreasing pain-associated stress response. Chronic activation of the stress system profoundly inhibits immune response 5,6 and patients with severe pain and anxiety display a decrease in protection against microbial infections 7. In this case, calciphylaxis, a rare condition causing vasculopathy and severe ulcer-related pain 8,9, shows improved outcome with epidural analgesia as compared with other previously documented modalities including lumbar sympathetic blocks and continuous intravenous opioid and ketamine infusions 10,11. REFERENCES:

1. Anesth Clin 2007; 25:883-898 2. Med Clin N Am 2007; 91:251-270 3. Sem in Onc 2005; 32(2):194-199 4. Pain Med 2004; 5(3):239-247 5. Chin Med J 2006; 119(11):930-938 6. Horm Res 2003; 59:161-179 7. Oral surg, oral med 2001; 91(6):654-658 8. Intl Arch of Med 2009; 2:22 9. Intl J of Derm 2007; 46:231-238 10. Reg Anesth and Pain Med 2000; 25(3):310-312 11. J of Pain and Sympt Manag 2006; 32(2):186-190

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TITLE: Role of Ketamine and Lignocaine Infusion in Postoperative Pain Management for Major Liver Resection –A Pilot Project. AUTHORS: Dr. Debashis Roy, Dr. Achal Dhir. INTRODUCTION: Liver resection involving rooftop incision is a major surgery causing severe post operative pain. Placement of an epidural catheter is controversial in view of deranged coagulation post operatively, after major liver resection. The standard practice in our hospital is to administer intrathecal morphine pre-operatively followed by patient controlled analgesia (PCA). We undertook a pilot project to evaluate the efficacy of intra-operative low dose ketamine and lignocaine infusions on post operative analgesia & opioid consumption in patients undergoing major liver resection. METHODS: After obtaining ethics approval, patients were enrolled in a prospective, non randomised single blinded pilot study comprising twenty adult patients. Patients were divided into 2 groups. Both groups received intrathecal morphine (300 to 400 micrograms) and postoperative hydromorphone PCA. In addition, Group II (intervention) received intraoperative infusions of ketamine (70mcg/kg/hr) and lignocaine (0.33mg/kg/hr). The infusions were stopped approximately 30-45 minute before the completion of surgery. Post-operative hydromorphone consumption (microgram/kg/day) and side effects for the first three days were retrieved from the charts maintained by the APS team, who were blinded to the treatment arm. Statistical calculation was done using unpaired student’s t-test and Fisher’s Exact. RESULTS: No difference in age, weight, height, gender and length of anesthesia were identified between the two groups. Hydromorphone PCA provided adequate analgesia in both the groups but consumption in Group II (67.5±8.7 mcg/kg/day) was less than Group I (78.4±6.6)(p=0.005, unpaired t test). Lower hydromorphone consumption was also observed on post operative day 2 and 3. Sedation scores on post operative day 1 were similar in both groups (p=0.29, Fisher Exact) but on post operative day 2, sedation scores were higher in the control group (p=0.002, Fisher Exact). Post operative nausea and vomiting occurred in 3 patients in group I, and in 1 patient in group II. DISCUSSION: We found that systemic low dose ketamine and lignocaine infusions reduce hydromorphone consumption when administered intraoperatively for major liver resection. The effect continued into post operative days 2 & 3. We were unable to comment on differences in side effects. Studies have shown lignocaine infusion reduce post operative pain, promote a rapid return of bowel function and shorten hospital stay1-3. Low dose ketamine (30-150mcg/kg/hr) has been shown to reduce pain scores, opioid consumption and opioid induced side effect4,5. Our study suggests that lignocaine and ketamine may prevent the induction of central hyperalgesia, in addition to providing analgesia.6 REFERENCES: 1. Anesth Analg. 1998; 86: 235-39. 2. Anesth Analg. 2004; 98: 1050-5. 3. Anesthesiology 2007; 106:11-8. 4. Can J Anaesth 1996; 43: 212–15. 5. Anesthesiology 2003; 98: 1195–205. 6. Pain 2000; 85: 217–24.

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TITLE: Risk-Adjusted Analysis of Anesthesia Care Delivery at The Ottawa Heart Institute. AUTHORS: Diem T. T. Tran, MD, Jean-Yves Dupuis,MD, Christopher Hudson, MD, Lily Tong,MD, Sandra Vranjes, MD INTRODUCTION: Using risk-adjusted analyses based on CARE score predictions1, this study sought to determine if perioperative mortality at the UOHI is associated with 3 particular aspects of anesthesia care: 1) primary anesthesiologist; 2) training level of who is performing the preoperative assessment; 3) and the fact that anesthesia care was transferred to another anesthesiologist. METHODS: After approval by our Human Research Ethics Board, this quality control study extracted prospectively collected data from our perioperative cardiac surgery database, on 3818 consecutive patients operated between April 1, 2006 and March 31, 2009. Univariate analysis using the Chi-square or Fisher’s exact test (when applicable) was performed to define the association between mortality and the attending anesthesiologist, who performed the preoperative assessment (attending, other staff, fellow or resident) and the staff finishing the case (primary attending versus colleague). The observed mortality associated with each factor was compared with the expected mortality (mean and 95% confidence interval) calculated from the CARE score predictions. Stepwise multiple logistic regression analyses were performed to determine the association between mortality and the three anesthesia-related factors, and the surgeons performing the procedure. P <0.05 was considered statistically significant. RESULTS: The overall mortality rate was 3.2%. There were 13 anesthesiologists practicing at UOHI during the study period. The observed mortality was significantly higher than expected for patients managed by two anesthesiologists: observed 4.3% and 5.9% versus expected 2.7%(CI:1.9-3.4%) and 3.5%(CI:2.7-4.3%), respectively. However, multiple logistic regression analyses including the attending surgeons as a covariate showed that none of the anesthesiologists were a significant risk factor for mortality. Regarding preoperative assessments, 32% were performed by the attending anesthesiologists, 38% by other staff, 17% by fellows and 13% by residents. The lowest mortality was observed in patients assessed by residents (2%) and highest in patients assessed by attending anesthesiologists (4.5%): those rates are in accordance with the expected mortality for both groups: 2.4% (CI:2.0-2.8%) for residents and 4.8%(CI:4.4-5.4%) for the attending. Lastly, 9% of the cases were finished by a second anesthesiologist: those cases had a significantly higher mortality (6.4%), but this was within the limits of the expected mortality (5.4%; 95%CI:4.3-6.5%). CONCULUSION: During the studied time period, perioperative mortality at the UOHI was not associated with any individual attending anesthesiologist, who did the preoperative assessment or the fact that anesthesia care was transferred. This study illustrates how a simple locally developed risk score can be used for risk-adjusted quality control in anesthesia at UOHI. REFERENCE: 1. Dupuis JY, et al Anesthesiology 2001;94:191-204.

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TITLE: Association of Postoperative Myocardial Ischemia Identified by Continuous ECG Monitoring with Ischemic Events

AUTHORS: H. Talab, AJ Chaput, H Yang , University of Ottawa, The Ottawa Hospital INTRODUCTION: Myocardial ischemia in the global perioperative period has been studied (1,2). The relationship between postoperative myocardial ischemia (POMI) and postoperative myocardial ischemic outcomes, however, remains controversial. We present the results of a meta-analysis to determine the relationship between the postoperative ST segment changes as detected by continuous ECG monitoring, and clinically apparent cardiac morbidity in patients undergoing non-cardiac surgery. METHODS: Medline database between 1950 and 2008 was searched, using the terms Anesthesia; Anesthesia, general; Anesthesia, spinal; Anesthesiology, complications; intraoperative complications; postoperative complications; postoperative period; surgery; surgical; procedures; operative; electrocardiography; electrocardiography; ambulatory; ischemia; myocardial ischemia; and myocardial infarction. Studies with the following criteria were included: cohort studies or RCTs; adult patients undergoing non-cardiac surgery; ischemia monitoring by continuous electrocardiographic monitoring (minimum 2 lead) for at least 24 hours. Non-English publications were excluded. Ischemic outcomes analyzed included MI, unstable angina, ischemic pulmonary edema, ischemic ventricular tachyarrhythmia and cardiac death. Studies were evaluated independently by two researchers. Mantel-Haenszel odds ratio and confidence interval were calculated using a random effects model using Review Manager (version 5). RESULTS: Twenty-six studies were included, with a total of 3143 patients. Of these, 1113 patients demonstrated postoperative ST segment changes on continuous Holter, while 2030 patients did not. The odds of having an ischemic event in the presence of post-operative ischemia were 10.26 with a 95% confidence interval of 6.38 - 16.49. DISCUSSION: Previous studies examined the occurrence of myocardial ischemia at various time points during the perioperative continuum. The present meta-analysis shows that in patients undergoing non-cardiac surgery, early postoperative myocardial ischemia (ST segment changes) by itself is an important correlate of adverse cardiac outcomes. REFERENCES:

1. Mangano DT, Browner WS, Hollenberg M, et al. N Engl J Med 1990;323:1781-8. 2. Raby KE, Barry J, Creager MA, et al. JAMA 1992;268:222-

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