Canadian Anaesthetists Research Articles

Guidelines to the Practice of Anesthesia - Revised Edition 2020.

OverviewThe Guidelines to the Practice of Anesthesia Revised Edition 2020 (the Guidelines) were prepared by the Canadian Anesthesiologists’ Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2020 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgement in determining the proper course of action for any patient’s circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.Electronic supplementary materialThe online version of this article (10.1007/s12630-019-01507-4) contains supplementary material, which is available to authorized users.

Representation of women amongst speakers at the Canadian Anesthesiologists' Society annual meeting: a retrospective analysis from 2007 to 2019.

Despite an increase in the proportion of women entering the field of anesthesiology, women remain underrepresented in academic and leadership positions. Speaking at national and international conferences is an important component of academic visibility and promotion. To date, the gender representation of speakers at the Canadian Anesthesiologists' Society (CAS) annual meeting has not been examined. We conducted a retrospective analysis of the representation of women amongst speakers at the CAS annual meeting between 2007 and 2019, inclusively. We also examined the representation of women in different subspecialty subject area symposia at each CAS annual meeting, and the gender composition of meeting symposia panels (i.e., groups of two or more speakers in a session) at the meeting. Overall, 28.5% (358/1,256) of speaker slots included women, similar to their representation in Canadian clinical anesthesiology over the study period (26.7%), and increasing significantly over the study period. Women were more highly represented as obstetric anesthesia speakers at the CAS annual meetings, with lower representation in cardiothoracic anesthesia, transplant anesthesia, and critical care symposia. Of the 311 meeting symposia, 146 (46%) were composed of all men speakers. The representation of women speakers at the CAS annual meeting was similar to the representation of women in the anesthesiology workforce in Canada over the study period. Gender representation varied widely by subspecialty symposia, subject area, and women were absent from nearly half of all symposia at the CAS annual meetings, which are potential areas of future investigation and intervention.

In Memoriam: Brian Kavanagh, 1962 to 2019

In Memoriam: Brian Kavanagh, 1962 to 2019

Practice advisory on the bleeding risks for peripheral nerve and interfascial plane blockade: evidence review and expert consensus.

The risk of bleeding complications during regional anesthesia procedures is a significant patient safety consideration. Nevertheless, existing literature provides limited guidance on the stratification of bleeding risk for peripheral nerve and newly described interfascial plane blocks. Our objective was to produce an evidence-based consensus advisory that classifies bleeding risks in patients undergoing regional peripheral nerve and interfascial plane block procedures. This advisory is intended to facilitate clinical decision-making in conjunction with national or local guidelines and to guide consideration for appropriate alterations to anticoagulation regimens before specific regional anesthesia procedures. In pursuit of this goal, the Regional Anesthesia and Acute Pain Section of the Canadian Anesthesiologists Society (CAS) assembled a panel of seven Canadian experts to classify the risk of bleeding complications associated with regional peripheral nerve and interfascial plane blocks. At the 75th annual meeting of the CAS in June 2018, the panel's expert opinion was finalized and the published literature was quantified within an organized framework. All common peripheral nerve and interfascial plane blocks were categorized into "low risk", "intermediate risk", and "high risk" based on the literature evidence, bleeding risk scores, and consensus opinion (in that order of priority). Clinical data is often limited, so readers of this consensus report should be reminded that these recommendations are mostly based on expert consensus. Hence, this advisory should not to be defined as a standard of care but rather serve as a resource for clinicians assessing the risk and benefits of regional anesthesia in management of their patients.

Improving Access to Safe Anesthetic Care in Rural and Remote Communities in Affluent Countries.

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.

Investigation into spinal anesthetic failure with hyperbaric bupivacaine: the role of cold exposure on bupivacaine degradation.

Hyperbaric bupivacaine (0.75% in dextrose) is used for spinal obstetric anesthesia. Occasional clusters of anesthetic failures occur in this setting, not readily attributable to clinical factors. We hypothesized that cold temperature exposure is related to bupivacaine instability. An electronic survey was distributed to Canadian anesthesiologists to determine consistencies in spinal anesthesia practice, and to invite submission of failed bupivacaine samples for analysis. Another survey for hospital pharmacists focused on bupivacaine logistics. Ultraviolet (UV) spectrometry, differential scanning calorimetry, and high performance liquid chromatography were used to evaluate the effect of temperature on bupivacaine chemical stability. Mass spectrometry (MS) was used to observe bupivacaine and dextrose degradation in laboratory samples of hyperbaric 0.75% bupivacaine in dextrose. Hyperbaric bupivacaine that failed to produce adequate anesthesia in labour and delivery patients was subject to tandem MS/MS analysis on commonly observed ions to look for ion patterns consistent with bupivacaine degradation products and to compare with laboratory samples subjected to cold temperatures. Canadian obstetric anesthesiologists report similar practices and use hyperbaric bupivacaine for spinal anesthesia. Pharmacists surveyed indicated facility storage at room temperature but variable temperatures during shipping. No standard procedure for failure reporting was identified. Analysis of bupivacaine showed a slight decrease in bupivacaine concentration or UV spectral changes after incubation at temperatures ≤ 4°C. Mass spectrometric analysis of hyperbaric bupivacaine from failed spinal anesthesia cases showed complex and inconsistent patterns of ion formation, and different from the ion patterns observed for cooled vs uncooled bupivacaine solutions. Temperature-related changes were noted for dextrose in cooled samples in which dextrose-related ions were formed. Canadian clinical practice and handling of hyperbaric bupivacaine is consistent. Most respondents indicated an interest in a formal reporting and collection process. Cold exposure did not degrade bupivacaine. A complex and possibly inconsistent reaction involving dextrose was identified that requires further analysis of a larger sample size to elucidate the mechanisms.

Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial

In laboratory animals, exposure to most general anaesthetics leads to neurotoxicity manifested by neuronal cell death and abnormal behaviour and cognition. Some large human cohort studies have shown an association between general anaesthesia at a young age and subsequent neurodevelopmental deficits, but these studies are prone to bias. Others have found no evidence for an association. We aimed to establish whether general anaesthesia in early infancy affects neurodevelopmental outcomes. In this international, assessor-masked, equivalence, randomised, controlled trial conducted at 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand, we recruited infants of less than 60 weeks' postmenstrual age who were born at more than 26 weeks' gestation and were undergoing inguinal herniorrhaphy, without previous exposure to general anaesthesia or risk factors for neurological injury. Patients were randomly assigned (1:1) by use of a web-based randomisation service to receive either awake-regional anaesthetic or sevoflurane-based general anaesthetic. Anaesthetists were aware of group allocation, but individuals administering the neurodevelopmental assessments were not. Parents were informed of their infants group allocation upon request, but were told to mask this information from assessors. The primary outcome measure was full-scale intelligence quotient (FSIQ) on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III), at 5 years of age. The primary analysis was done on a per-protocol basis, adjusted for gestational age at birth and country, with multiple imputation used to account for missing data. An intention-to-treat analysis was also done. A difference in means of 5 points was predefined as the clinical equivalence margin. This completed trial is registered with ANZCTR, number ACTRN12606000441516, and ClinicalTrials.gov, number NCT00756600. Between Feb 9, 2007, and Jan 31, 2013, 4023 infants were screened and 722 were randomly allocated: 363 (50%) to the awake-regional anaesthesia group and 359 (50%) to the general anaesthesia group. There were 74 protocol violations in the awake-regional anaesthesia group and two in the general anaesthesia group. Primary outcome data for the per-protocol analysis were obtained from 205 children in the awake-regional anaesthesia group and 242 in the general anaesthesia group. The median duration of general anaesthesia was 54 min (IQR 41-70). The mean FSIQ score was 99·08 (SD 18·35) in the awake-regional anaesthesia group and 98·97 (19·66) in the general anaesthesia group, with a difference in means (awake-regional anaesthesia minus general anaesthesia) of 0·23 (95% CI -2·59 to 3·06), providing strong evidence of equivalence. The results of the intention-to-treat analysis were similar to those of the per-protocol analysis. Slightly less than 1 h of general anaesthesia in early infancy does not alter neurodevelopmental outcome at age 5 years compared with awake-regional anaesthesia in a predominantly male study population. US National Institutes of Health, US Food and Drug Administration, Thrasher Research Fund, Australian National Health and Medical Research Council, Health Technologies Assessment-National Institute for Health Research (UK), Australian and New Zealand College of Anaesthetists, Murdoch Children's Research Institute, Canadian Institutes of Health Research, Canadian Anesthesiologists Society, Pfizer Canada, Italian Ministry of Health, Fonds NutsOhra, UK Clinical Research Network, Perth Children's Hospital Foundation, the Stan Perron Charitable Trust, and the Callahan Estate.

Perceptions of Perioperative Stroke Among Chinese Anesthesiologists: Starting a Long March to Eliminate This Underappreciated Complication.

Perceptions of Perioperative Stroke Among Chinese Anesthesiologists: Starting a Long March to Eliminate This Underappreciated Complication.

Guidelines to the Practice of Anesthesia - Revised Edition 2019.

The Guidelines to the Practice of Anesthesia Revised Edition 2019 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2019 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

A national survey on attitudes and barriers on recycling and environmental sustainability efforts among Canadian anesthesiologists: an opportunity for knowledge translation.

Anesthesia-related activities produce 25% of all operating room (OR) waste and contribute to environmental pollution and climate change. The aim of this study was to document Canadian anesthesiologists' current practice, attitudes towards, and perceived barriers regarding recycling of OR waste and environmental sustainability efforts. With Research Ethics Board approval, members of the Canadian Anesthesiologists' Society (CAS) completed an online survey consisting of 25 questions assessing current environmentally sustainable practices in anesthesiology and gaps, barriers, and interest in gaining further knowledge on this topic. Four hundred and twenty-six of 2,695 (16%) CAS members responded to the questionnaire. Despite a willingness to recycle at work among most anesthesiologists (393/403, 97.5%), only 122/403 (30.2%) did so. Other sustainability efforts in Canadian ORs included donating unused medical equipment and supplies to medical missions (198/400, 49.5%) and evening shut-off of anesthesia machines and other OR equipment (185/400, 46.3%). Reported barriers to recycling in the OR included a lack of support from hospital/OR leadership (254/400, 63.5%) and inadequate information/education (251/400, 62.8%). Only 122/389 (31.4%) of respondents were aware of any efforts to expand sustainability programs at their institutions but 273/395 (69.1%) of respondents indicated an interest in obtaining further education on the topic. Canadian anesthesiologists appear ready to incorporate environmental sustainability in their practice but indicate that significant barriers exist. Our study highlights the need for further educational programs and implementation strategies.

Anesthesiologist and Emergency Medicine Physician Attitudes and Knowledge Regarding Etomidate for Intubation.

The use of etomidate as an induction agent for critically ill patients is controversial. While its favorable hemodynamic profile is enviable, etomidate has been shown to cause transient adrenal suppression. The clinical consequences of transient adrenal suppression are poorly understood. Anecdotally, some clinicians advocate strongly for etomidate, while others feel it can cause significant harm. To better understand the current clinical environment with respect to single-dose etomidate use in critically ill patients, Canadian anesthesiologists and Canadian emergency medicine (EM) physicians were questioned regarding their opinions, knowledge, and preferences about etomidate use as an induction agent. Invitations to participate with the electronic survey were sent to 100 Canadian EM physicians and 260 Canadian anesthesiologists. The survey had 4 general parts: demographics, familiarity with the current literature, choice of induction agent given various clinical scenarios, and opinions on the controversy. The Pearson γ2 test was used to detect whether significant differences exist between physician groups. Ninety three anesthesiologists and 42 EM physicians responded for response rates of 36% and 42%. There were no self-reported differences in knowledge about etomidate properties between EM physicians and anesthesiologists. There were significant differences in etomidate use between EM physicians and anesthesiologists in general rapid sequence intubation, noncritically ill patients, and those with undifferentiated hypotension. Both EM physicians and anesthesiologists describe the current etomidate controversy as significant and not adequately resolved. There is no significant difference in self-reported etomidate knowledge between anesthesiologists and EM physicians; however, significant practice pattern differences exist with EM physicians using etomidate more often. Broad agreement supports future research to investigate etomidate's impact in critically ill patients.

Seventy-Fifth Anniversary of Canadian Anesthesiologists' Society

Seventy-Fifth Anniversary of Canadian Anesthesiologists' Society

Procedural sedation: a position paper of the Canadian Anesthesiologists' Society.

Procedural sedation: a position paper of the Canadian Anesthesiologists' Society.

The five founders of the Canadian Anesthesiologists' Society.

The five founders of the Canadian Anesthesiologists' Society.

A survey of medication preparation and administration practices among members of the Canadian Anesthesiologists' Society.

Recommendations for safe medication injection practices to eliminate the risk of patient-to-patient transmission of blood-borne infections have been in place for many years. The purpose of our study was to evaluate the medication administration practices of Canadian anesthesiologists relative to current safe practice guidelines. An anonymous 17-question online survey was sent to all members of the Canadian Anesthesiologists' Society (CAS) via the membership email list. Data pertaining to respondent demographics, practice characteristics, and medication preparation and administration practices were collected and analyzed descriptively using frequencies and percentages as well as Fisher's exact tests followed by post hoc multiple comparisons. Of the 2,656 CAS members, 546 (21%) responded. The practice of reusing needles (2%) and/or syringes (7%) between patients is reported by only a minority of practitioners; however, sharing a medication vial between more than one patient using new needles and syringes is still widely practiced with 83% doing this sometimes or routinely. The main reasons for sharing medications include the desire to reduce medication waste and the associated costs. Sharing medication vials between multiple patients is common practice in Canada, with new needles and syringes used for each patient. Unfortunately, a small minority of anesthesiologists continue to reuse needles and/or syringes between patients, and this may pose a significant risk of patient-to-patient infection transmission.

The Role of the WFSA in Reaching the Goals of the Lancet Commission on Global Surgery.

The Role of the WFSA in Reaching the Goals of the Lancet Commission on Global Surgery.

Survey of Postoperative Regional Analgesia for Thoracoscopic Surgeries in Canada

To determine the preferences and perceptions regarding analgesic options for video-assisted thoracic surgery (VATS) among thoracic anesthesiologists in Canada. A cross-sectional survey of thoracic anesthesiologists with 30 multiple choice questions was e-mailed through an online survey tool called FluidSurveys was performed to members of the Canadian Anesthesiologists' Society. A nationwide survey. Members of Canadian Anesthesiologists' Society who provide thoracic anesthesia INTERVENTIONS: None. Participant characteristics and outcomes are described using counts and percentages. The frequency of use of each technique for each surgical category is described in percentages and 95% confidence intervals. Based on the responses obtained from individual centers, approximately 469 anesthesiologists provided thoracic care in Canada at the time of the survey. The response rate to the survey was 19% (n = 89). Epidural analgesia was preferred by 93.42% (95% CI 85-98) for open surgeries compared with 41% (30-52) for VATS lobectomies. The difference was statistically significant-52% (37-67). Patient-controlled analgesia was preferred by 27% (19-39) for VATS lobectomies and 46% (35-57) for VATS minor resections. Only 14% preferred paravertebral block for any VATS surgeries. The use of analgesic techniques for VATS surgeries is variable and largely dictated by provider preferences. The majority still prefer epidural analgesia compared with paravertebral catheter (placed either by the anesthesiologist or surgeon). A broadly acceptable choice that is effective, safe, and technically less demanding requires comparative effectiveness studies and more uniform training for physicians.

Benzodiazepine administration during adult cardiac surgery: a survey of current practice among Canadian anesthesiologists working in academic centres.

Benzodiazepines are commonly administered during cardiac surgery because of their limited effect on hemodynamics and presumed role in preventing intraoperative awareness. Recent concerns about an increased risk of delirium with benzodiazepines have resulted in decreased usage in the intensive care unit and in geriatric perioperative practice. Little is known, however, about current benzodiazepine usage in the setting of adult cardiac surgery. We contacted all academic anesthesia departments in Canada to identify practicing attending cardiac anesthesiologists; this group constituted our sampling frame. Information regarding participant demographics, benzodiazepine usage, type, dose, and other administration details were obtained by electronic survey. Responses were analyzed descriptively. The survey was completed by 243/346 (70%) of cardiac anesthesiologists. Eleven percent of respondents do not administer benzodiazepines. Midazolam was the most commonly used benzodiazepine, with a mean (standard deviation) dose of 4.9 (3.8) mg given to an average patient. When respondents were asked the proportion of patients that they gave benzodiazepines, the response was bimodal. The most common considerations that influenced benzodiazepine use were patient age (73%), patient anxiety (63%), history of alcohol/drug/benzodiazepine use (60%), and the presence of risk factors for intraoperative awareness (44%). Benzodiazepine use is common among academic cardiac anesthesiologists in Canada. Nonetheless, heterogeneity exists between individual practices, suggesting clinical equipoise between restrictive and liberal administration of benzodiazepines for cardiac anesthesia. L'administration de benzodiazépines pendant la chirurgie cardiaque chez l'adulte: évaluation de la pratique actuelle des anesthésiologistes canadiens exerçant en milieu universitaire.

Guidelines to the Practice of Anesthesia - Revised Edition 2018.

The Guidelines to the Practice of Anesthesia Revised Edition 2018 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2018 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

History of the crest and motto of the Canadian Anesthesiologists’ Society

History of the crest and motto of the Canadian Anesthesiologists’ Society