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Objective Despite advances in health care and ample resources, post-partum hemorrhage (PPH) rates are increasing in high income countries. Although guidelines recommend therapeutic uterotonics, timing of administration is open to judgement and most often based on (inherently inaccurate) visual estimates of blood loss. With severe hemorrhage, every minute of delay can have significant consequences. Our objective was to examine the timing of uterotonic administration and its impact upon maternal outcomes. We hypothesized that increased time to uterotonic administration following the identification of PPH, would be associated with a greater decline in hemoglobin (Hb) and higher odds of hypotension and transfusion. Methods We reviewed all cases of PPH that occurred at an academic centre between June 2015 and September 2017. All cases of primary PPH (i.e., those declared within 24 h of delivery with estimated blood loss [EBL] >500 mL for vaginal and >1000 mL for cesarean deliveries) were analyzed. Patient records were excluded if they were missing information regarding time of PPH declaration, uterotonic administration, and/or Hb measures, or if a pre-existing medical condition could have contributed to PPH. Results Of 4397 births, there were 259 (5.9%) cases of primary PPH, of which 128 were included in this analysis. For these patients, each 5-minute delay in uterotonic treatment was associated with 26% higher odds of hypotension following delivery of any type. For vaginal deliveries (n = 86), each 5-minute delay was associated with 31% and 34% higher odds of hypotension and transfusion, respectively. Conclusion In this study, delay in administration of therapeutic uterotonics was associated with a higher incidence of hypotension and transfusion in primary PPH patients.

Postoperative analgesia following total knee arthroplasty (TKA) often includes intrathecal opioids, periarticular injection (PAI) of local anesthetic, systemic multimodal analgesia, and/or peripheral nerve blockade. The adductor canal block (ACB) provides analgesia without muscle weakness and magnesium sulphate (MgSO4) may extend its duration. The purpose of this trial was to compare the duration and quality of early post-TKA analgesia in patients receiving postoperative ACB (± MgSO4) in addition to standard care. Elective TKA patients were randomized to: 1) sham ACB, 2) ropivacaine ACB, or 3) ropivacaine ACB with added MgSO4. All received spinal anesthesia with intrathecal morphine, intraoperative PAI, and multimodal systemic analgesia. Patients and assessors remained blinded to allocation. Anesthesiologists knew whether patients had received sham or ACB but were blinded to MgSO4. The primary outcome was time to first analgesic (via patient-controlled analgesia [PCA] with iv morphine) following ACB. Secondary outcomes were morphine consumption, side effects, visual analogue scale pain scores, satisfaction until 24 hr postoperatively, and length of stay. Of 130 patients, 121 were included. Nine were excluded post randomization: four were protocol violations, three did not meet inclusion criteria, and two had severe pain requiring open label blockade. There were no differences in the median [interquartile range] time to first PCA request: sham, 310 min [165–550]; ropivacaine ACB, 298 min [120–776]; and ropivacaine ACB with MgSO4, 270 min [113–780] (P = 0.96). Similarly, we detected no differences in resting pain, opioid consumption, length of stay, or associated side effects until 24 hr postoperatively. We found no analgesic benefit of a postoperative ACB, with or without added MgSO4, in TKA patients undergoing spinal anesthesia and receiving intrathecal morphine, an intraoperative PAI, and multimodal systemic analgesia. www.clinicaltrials.gov (NCT02581683); registered 21 October 2015.

Anesthetic management for anterior mediastinal mass resection is often challenging. The main concern being that the tumor might, on reduction in muscle tone, cause circulatory and/or airway collapse. In the setting of pregnancy, the expected physiologic changes (eg, increased oxygen demand, decreased functional residual capacity, and aortocaval compression) may further increase the risks. The objective of this report is to present a challenging case of a pregnant woman undergoing an anterior mediastinal mass resection with the additional rare requirement for one-lung anesthesia, and to describe the perioperative considerations and the plan executed to ensure a successful outcome. A 30-year-old pregnant (23 weeks) patient with a large anterior mediastinal mass and evidence of significant cardiovascular and tracheobronchial compression presented for thymectomy requiring one-lung ventilation. Anesthesia consisted of preoperative preparation, thoughtful selection of vascular access sites, preservation of spontaneous ventilation until sternotomy was accomplished, use of bronchial blocker and readily reversible pharmacologic agents, availability of backup airway and oxygenation plans, standby high-frequency ventilation, and anticipation of postoperative respiratory difficulties. Surgical considerations included the possibility of extracorporeal membrane oxygenation and the need for lifting the thymoma to relieve the compression of the mediastinum. A methodical and multidisciplinary plan is described to mitigate the risk of cardiorespiratory collapse in the setting of anterior mediastinal mass resection. Backup measures in case of catastrophe, as well as careful consideration of the physiologic changes of pregnancy, must be taken into account.

Whether regional anesthesia procedures should be performed in heavily sedated/anesthetized adults remains controversial. One of the purported advantages of performing regional nerve blocks in conversant patients is early warning against major nerve injury and, arguably, early detection of local anesthetic systemic toxicity. A 60-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) underwent a clavicle fracture repair under general anesthesia. Intraoperative transesophageal echocardiography revealed dynamic left ventricular outflow track obstruction and systolic anterior motion of the posterior mitral valve leaflet. In part based on such echo findings, he received an ultrasound-guided interscalene plus a superficial cervical plexus block for postoperative analgesia prior to emergence from general anesthesia. Given the lack of robust data on the safety of ultrasound-guided regional techniques in heavily sedated/anesthetized adults, we use the example of echographic evidence of significant HOCM to argue for a pragmatic and individualized approach when faced with unusual situations in which the pros of such an approach may outweigh the cons – in this case for performing an interscalene block on an anesthetized adult.

BackgroundVenous thromboembolism (VTE) is a major cause of perioperative morbimortality. Despite significant efforts to advance evidence-based practice, prevention rates remain inadequate in many centres.ObjectiveTo evaluate the effectiveness of different strategies aimed at improving adherence to adequate VTE prophylaxis in surgical patients at high risk of VTE.MethodBefore and after intervention study conducted at a tertiary hospital. Adherence to adequate VTE prophylaxis was compared according to three strategies consecutively implemented from January 2019 to December 2020. A dedicated hospitalist physician alone (strategy A) or in conjunction with a nurse (strategy B) overlooked the postoperative period to ensure adherence and correct inadequacies. Finally, a multidisciplinary team approach (strategy C) focused on promoting adequate VTE prophylaxis across multiple stages of care—from the operating room (ie, preoperative team-based checklist) to collaboration with clinical pharmacists in the postoperative period—was implemented.ResultsWe analysed 2074 surgical patients: 783 from January to June 2019 (strategy A), 669 from July 2019 to May 2020 (strategy B), and 622 from June to December 2020 (strategy C). VTE prophylaxis adherence rates for strategies (A), (B) and (C) were (median (25th–75th percentile)) 43.29% (31.82–51.69), 50% (42.57–55.80) and 92.31% (91.38–93.51), respectively (pA=B). There was a significant reduction in non-compliance on all analysed criteria (risk stratification (A (25.5%), B (22%), C (6%)), medical documentation (A (68%), B (55.2%) C (9%)) and medical prescription (A (51.85%), B (48%), C (6.10%)) after implementation of strategy C (pConclusionPerioperative VTE prophylaxis strategies that relied exclusively on physicians and/or nurses were associated with suboptimal execution and prevention. A multidisciplinary team-based approach that covers multiple stages of patient care significantly increased adherence to adequate VTE prophylaxis in surgical patients at high risk of developing perioperative VTE.

Rib fractures are a common complication of trauma and a marker of internal injuries and can carry a high mortality rate. Advanced age, multiple rib fractures, flail chest, and concomitant injuries are poor prognostic risk factors. Fractured ribs and chest drains are painful which can lead to

Modern massive transfusion protocols call for early plasma and platelets to patients presenting with hemorrhagic shock. The packed red blood cell (PRBC):plasma:platelet ratio generally ranges from 1:1:1 to 3:1:1, but the ideal ratio remains controversial. We aimed to determine the effects of different resuscitation strategies and blood product ratios on hematocrit, platelet and fibrinogen concentrations (FC) during resuscitation. Assuming: pre-insult blood volume 5 L; hematocrit 0.4, FC = 100%, platelet count 400 × 109/L; predetermined constant values for each blood product unit (volume, hematocrit, FC, platelet number); and transfusion rate to maintain euvolemia, we simulated different resuscitation strategies using a computer-based hemorrhage model. When crystalloids are administered to restore an acute 30% blood loss, the initial hematocrit, platelets and FC are adequate, and remain physiologic when further resuscitation is carried out with 1:1:1. Higher transfusion ratios increase the hematocrit at the expense of proportional drops in FC and platelets. When crystalloids and PRBCs (1500 mL) are administered to restore an acute 60% blood loss, the FC drops to 39%. Further resuscitation with 1:1:1 (but not with 2:1:1 or 3:1:1) increases the FC while maintaining the hematocrit and platelets within physiologic range. When blood products (1–3:1:1) are administered to restore an acute 60% blood loss, the initial hematocrit, platelets and FC are at adequate levels, but remain within physiologic range only when 1:1:1 (but not 2:1:1 or 3:1:1) is implemented for further resuscitation. Notably, platelet concentration consistently drops in all simulated scenarios reaching dangerously low levels particularly with high blood loss/transfusion rates and with higher transfusion ratios. The FC does not always drop by the same proportion with higher ratios probably because it is based on plasma concentration and is thus “cushioned” by the reduction in plasma volume as the hematocrit rises with higher transfusion ratios. In summary, computer simulation suggests that in non-severe shock hemorrhage, the differences between 1-3:1:1 transfusion ratios during initial resuscitation may be small. In severe shock, however, 1:1:1 results in the most physiologic hematocrit, FC and platelet concentration and is, therefore, desirable.

Background Functional mitral regurgitation (FMR) is common in patients with myocardial infarction or dilated cardiomyopathy, and portends a poor prognosis despite guideline-directed medical therapy (GDMT). Surgical or transcatheter mitral repair for FMR from recent randomized clinical trials showed disappointing or conflicting results. Aims To provide an update on the role of surgical repair in the management of FMR. Materials and methods A literature search was conducted utilizing PubMed, Ovid, Web of Science, Embase, and Cochrane Library. The search terms included secondary/FMR, ischemic mitral regurgitation, mitral repair, mitral replacement, mitral annuloplasty, transcatheter mitral repair, and percutaneous mitral repair. Randomized clinical trials over the past decade were the particular focus of the current review. Results Recent data underlined the complexity and poor prognosis of FMR. GDMT and cardiac resynchronization, when indicated, should always be applied. Accurate assessment of the interplay between ventricular geometry and mitral valve function is essential to differentiate proportionate FMR from the disproportionate subgroup, which could be helpful in selecting appropriate transcatheter intervention strategies. Surgical repair, most commonly performed with an undersized ring annuloplasty, remains controversial. Adjunctive valvular or subvalvular repair techniques are evolving and may produce improved results in selected FMR patients. Conclusion FMR resulted from complex valve-ventricular interaction and remodeling. Distinguishing proportionate FMR from disproportionate FMR is important in exploring their underlying mechanisms and to guide medical treatment with surgical or transcatheter interventions. Further studies are warranted to confirm the clinical benefit of appropriate surgical repair in selected FMR patients.

BackgroundOrotracheal intubation (OTI) can result in aerosolisation leading to an increased risk of infection for healthcare providers, a key concern during the COVID-19 pandemic.ObjectiveThis study aimed to evaluate the OTI time and success rate of two aerosol-mitigating strategies under direct laryngoscopy and videolaryngoscopy performed by anaesthesiologists, intensive care physicians and emergency physicians who were voluntarily recruited for OTI in an airway simulation model.MethodologyThe outcomes were successful OTI, degree of airway visualisation and time required for OTI. Not using a stylet during OTI reduced the success rate among non-anaesthesiologists and increased the time required for intubation, regardless of the laryngoscopy device used.ResultsSuccess rates were similar among physicians from different specialties during OTI using videolaryngoscopy with a stylet. The time required for successful OTI by intensive care and emergency physicians using videolaryngoscopy with a stylet was longer compared with anaesthesiologists using the same technique. Videolaryngoscopy increased the time required for OTI among intensive care physicians compared with direct laryngoscopy. The aerosol-mitigating strategy under direct laryngoscopy with stylet did not increase the time required for intubation, nor did it interfere with OTI success, regardless of the specialty of the performing physician.ConclusionsThe use of a stylet within the endotracheal tube, especially for non-anaesthesiologists, had an impact on OTI success rates and decreased procedural time.

We describe 4 cases in which patients with coagulopathies, an absolute contraindication to epidural/paravertebral blocks, received an erector spinae plane block to manage severe thoracic pain with respiratory impairment. Intubation was avoided in 2 cases, and weaning from the ventilator was facilitated in 2 cases. Ultrasound-guided erector spinae plane block is simple to perform, has a low risk profile, and provides an excellent analgesic alternative.

> Misunderstanding is generally simpler than true understanding, and hence has more potential for popularity. —Raheel Farooq (writer) In an Australian study, the most common mishap with endotracheal tube (ETT) placement was inadvertent endobronchial intubation (ETT placed too deep), more so than oesophageal intubation, accounting for nearly half of all the ETT-related incident reports.1 In the prehospital setting in a German study, emergency physicians inadvertently intubated the right mainstem bronchus in 6.7% of their intubations.2 In patients intubated by an emergency physician or anaesthesiologist in a German emergency department, the incidence of right mainstem intubation was 7%.3 In that study, the ETT tip was within 2 cm of the carina in another 13% of patients.3 When an ETT tip is that close to the carina, events such as head flexion can move the ETT up to 3.1 cm (mean 1.9 cm) toward the carina from the neutral position.4 Furthermore, rostral displacement of the carina because of Trendelenburg positioning (to treat hypotension, to cannulate a central vein or during surgery) or pneumoperitoneum for laparoscopy can result in right mainstem bronchial intubation. The margin of safety is correspondingly small in small patients. Mainstem intubation could trigger bronchospasm, cause hypoxaemia due to a massive shunt and atelectasis, and the increased inspiratory pressure may result in barotrauma and even haemodynamic disturbances. In complex cases (eg, major trauma), it can complicate diagnosis and management of life-threatening injuries. Endobronchial intubation accounts for 2% of adverse respiratory claims in adults and 4% in children in the American Society of Anesthesiologists’ Closed Claims Database.5 Inadvertent mainstem intubation is therefore an important discussion topic with learners rotating through anaesthesia, emergency medicine, critical care and surgery. Spanning over 3 decades of our careers, we must have asked hundreds of residents and students in and from …

Introduction and objectives Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids. Methods Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR). Results Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03-0.28]), and (P2) (PR = 0.42%; 95% CI [0.20-0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20-29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22-8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p< 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p< 0.05). Conclusion MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.

A dreaded complication of internal jugular vein (IJV) cannulation is common carotid artery (CCA) puncture/cannulation, which has decreased, but not been eliminated, with ultrasound (US) guidance.1 Typically, with the head/neck in midline position, the IJV lies mostly lateral to the CCA.2 When the head is turned to the contralateral side for IJV cannulation, the IJV moves anteriorly and medially such that a considerable percentage of it now …

Background In patients with remarkably enlarged cardiac chambers and history of implantation of older types of mitral valve prosthesis, the considerations for reoperative tricuspid valve surgery are not limited to the risks of sternal reentry but also include the dilemma of whether to carry out prophylactic replacement of the normal functioning but outdated prosthesis or leave it in situ. Methods We reviewed our surgical strategy and postoperative 5-year follow-up findings in two patients who underwent redo tricuspid surgery 3 to 4 decades after mechanical mitral valve replacement. Both patients presented with significant symptoms of progressive right heart failure due to severe tricuspid regurgitation, despite optimal medical therapy. Results We found the beating-heart approach to be an effective and safe method for redo tricuspid surgery. Both first-generation mitral mechanical prostheses were not replaced and have remained well functional upon the patients’ postoperative 5-year follow-up, respectively. Conclusion For patients with normal functioning first-generation mechanical mitral prostheses, whether to prophylactically replace the prosthesis should be based on an individualized risk-benefit analysis.

Background: Selective neonatal left mainstem bronchial intubation to treat right lung disease is typically achieved with elaborate maneuvers, instrumentation and devices. This is often attributed to bronchial geometry which favors right mainstem entry of an endotracheal tube deliberately advanced beyond the carina. Case summary: A neonate with severe bullous emphysema affecting the right lung required urgent non-ventilation of that lung. We achieved left mainstem bronchial intubation by turning the endotracheal tube 180° such that the Murphy's eye faced the left instead of the right, and simulated a left-handed intubation by slightly orientating the endotracheal tube such that its concavity faced the left instead of the right as in a conventional right-handed intubation. Conclusion: Urgent intubation of the left mainstem bronchus with an endotracheal tube can be easily achieved by recognizing that it is the position of the endotracheal tube tip and the direction of its concavity that are the chief determinants of which bronchus an endotracheal tube goes when advanced. This is important in critically ill neonates as the margin of safety and time window are small, and the absence of double-lumen tubes. Use of fiberoptic bronchoscope and blockers should be reserved as backup plans. Resumo: Justificativa: A intubação seletiva neonatal do brônquio principal esquerdo para tratar a doença pulmonar direita é tipicamente realizada com elaboradas manobras, instrumentação e dispositivos. Isso é frequentemente atribuído à geometria brônquica que favorece a entrada principal direita de um tubo endotraqueal (TET) deliberadamente avançado para além da carina. Resumo do caso: Recém-nascido com enfisema bolhoso grave afetando o pulmão direito que precisou com urgência da não ventilação desse pulmão. Conseguimos a intubação brônquica esquerda fazendo uma rotação de 180° do TET, de forma que o olho de Murphy ficasse voltada para a esquerda e não para a direita, e simulamos uma intubação à esquerda orientando ligeiramente o TET, de modo que sua concavidade virasse para a esquerda em vez de para a direita, como em uma intubação convencional à direita. Conclusão: A intubação urgente do brônquio principal esquerdo com um TET pode ser facilmente obtida reconhecendo-se que é a posição da ponta do TET e a direção de sua concavidade que determinam para qual brônquio o TET irá quando avançado. Isso é importante em neonatos criticamente doentes diante da margem de segurança e janela de tempo pequenas e na ausência de tubos de duplo lúmen. O uso de broncofibroscópio e bloqueadores deve ser considerado como planos de segurança. Keywords: Bullous emphysema, Endobronchial intubation, Neonate, Palavras-chave: Enfisema bolhoso, Intubação endobrônquica, Recém-nascido

Outside of anesthesia, lumbar puncture (LP) is commonly performed for diagnostic and therapeutic purposes. Patients with leukemia and lymphoma need multiple LPs for diagnosis and intrathecal chemotherapy. Thrombocytopenia, sometimes complicated by coagulopathy, is frequently present in this patient

Background: Postoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half-life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil-based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil-based total intravenous anesthesia. Methods: Forty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil-based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient-controlled analgesia pump. Self-reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery. Results: The mean difference between the sufentanil and control groups regarding morphine consumption in the post-anesthetic care unit and at 12, 24 and 48 h after surgery were −7.2 mg (95%CI: −12.5 to −2.1, p

Prophylactic administration of a vasopressor to mitigate the hypotensive effect of propofol (and/or other co-induction agents) during sedation/anesthesia immediately prior to tracheal intubation in frail patients in the intensive care unit and emergency and operating rooms appears to be not an uncommon practice. We submit that this practice is unnecessary and potentially harmful. Despite restoring the blood pressure, phenylephrine, for instance, may have an additive or synergistic effect with propofol in reducing the cardiac output and, ultimately, organ perfusion. Airway instrumentation often leads to sympathetic activation and hypertension (thereby increasing myocardial oxygen consumption) which may be exacerbated by an arbitrary prophylactic dose of phenylephrine. Finally, in spite of the well-recognized need to reduce dosages of propofol in frail patients, excessive doses are commonly given, leading to hypotension. We herein discuss each of these points and suggest alternative techniques to promote a stable induction in frail patients.

Background and objectives: Focused Cardiac Ultrasound (FoCUS) has proven instrumental in guiding anesthesiologists’ clinical decision-making process. Training residents to perform and interpret FoCUS is both feasible and effective. However, the degree of knowledge retention after FoCUS training remains a subject of debate. We sought to provide a description of our 4-week FoCUS curriculum, and to assess the knowledge retention among anesthesia residents at 6 months after FoCUS rotation. Methods: A prospective analysis involving eleven senior anesthesia residents was carried out. At end of FoCUS Rotation (EOR) participants completed a questionnaire (evaluating the number of scans completed and residents’ self-rated knowledge and comfort level with FoCUS), and a multiple-choice FoCUS exam comprised of written- and video-based questions. Six months later, participants completed a follow-up questionnaire and a similar exam. Self-rated knowledge and exam scores were compared at EOR and after 6 months. Spearman correlations were conducted to test the relationship between number of scans completed and exam scores, perceived knowledge and exam scores, and number of scans and perceived knowledge. Results: Mean exam scores (out of 50) were 44.1 at EOR and 43 at the 6-month follow-up. Residents had significantly higher perceived knowledge (out of 10) at EOR (8.0) than at the 6-month follow-up (5.5), p = 0.003. At the EOR, all trainees felt comfortable using FoCUS, and at 6 months 10/11 still felt comfortable. All the trainees had used FoCUS in their clinical practice after EOR, and the most cited reason for not using FoCUS more frequently was the lack of perceived clinical need. A strong and statistically significant (rho = 0.804, p = 0.005) correlation between number of scans completed during the FoCUS rotation and 6-month follow-up perceived knowledge was observed. Conclusion: Four weeks of intensive FoCUS training results in adequate knowledge acquisition and 6-month knowledge retention. Resumo: Justificativa e objetivos: A ultrassonografia cardíaca no local de atendimento (USCLA) provou ser importante para orientar o processo de tomada de decisão clínica dos anestesiologistas. Treinar os residentes para fazer e interpretar uma USCLA é viável e eficaz. No entanto, o grau de retenção do conhecimento após o treinamento permanece um assunto de debate. Procuramos fornecer uma descrição do currículo de quatro semanas do treinamento de USCLA e avaliar a retenção do conhecimento entre os residentes de anestesia seis meses após a rotação em USCLA. Métodos: Uma análise prospectiva foi realizada com 11 residentes seniores de anestesia. Ao final da rotação em USCLA, os participantes preencheram um questionário (avaliando o número de exames ultrassonográficos concluídos, o conhecimento adquirido e o nível de conforto dos residentes com a USCLA) e fizeram um exame de múltipla escolha para USCLA, composto por perguntas escritas e baseadas em vídeo. Seis meses depois, os participantes preencheram um questionário de acompanhamento e um exame similar. A autoavaliação do conhecimento e os escores do exame foram comparados no final da rotação e após seis meses. Correlações de Spearman foram usadas para testar a relação entre o número de exames concluídos e os escores dos exames, o conhecimento percebido, os escores dos exames, o número de exames e o conhecimento percebido. Resultados: Os escores médios dos exames (50) foram: 44,1 no final da rotação e 43 após seis meses. Os residentes tiveram conhecimento percebido significativamente maior (10) no final da rotação (8,0) que após seis meses (5,5), p = 0,003. No final da rotação, todos os residentes se sentiram confortáveis usando o aparelho de USCLA e, aos seis meses, 10/11 ainda se sentiam confortáveis. Todos os residentes haviam usado o USCLA em sua prática clínica após o final da rotação e a razão mais citada para não usar o USCLA com mais frequência foi a falta de necessidade clínica percebida. Uma correlação forte e estatisticamente significativa (rho = 0,804, p = 0,005) foi observada entre o número de exames realizados durante a rotação em USCLA e o conhecimento percebido em seis meses de seguimento. Conclusão: Quatro semanas de treinamento intensivo de USCLA resultaram em aquisição e retenção adequadas do conhecimento por seis meses. Keywords: POCUS, FoCUS, Knowledge retention, Education, Anesthesia, Palavras-chave: POCUS, USCLA, Retenção de conhecimento, Educação, Anestesia

We conducted a small pilot observational study of the effects of bilateral thoracic paravertebral block (BTPB) as an adjunct to perioperative analgesia in coronary artery bypass surgery patients. The initial ropivacaine dose prior to induction of general anaesthesia was 3 mg/kg, which was followed at the end of the surgery by infusion of ropivacaine 0.25% 0.1 ml/kg/hour on each side (e.g. total 35 mg/hour for a 70 kg person). The BTPB did not eliminate the need for supplemental opioids after CABG in the eight patients studied. Moreover, in spite of boluses that were within the manufacturer's recommendation for epidural and major nerve blocks, and an infusion rate that was only slightly higher than what appeared to be safe for epidural infusion, potentially toxic total plasma ropivacaine concentrations were common. We also could not exclude the possibility that the high ropivacaine concentrations were contributing to postoperative mental state changes in the postoperative period. Also, one patient developed local anaesthetic toxicity after the bilateral paravertebral dose. As a result, the study was terminated early after four days. The question of whether paravertebral block confers benefits in cardiac surgery remains unanswered. However, we believe that the bolus dosage and the injection rate we used for BTPB were both too high, and caution other clinicians against the use of these doses. Future studies on the use of BTPB in cardiac surgery patients should include reduced ropivacaine doses injected over longer periods.

From the *Department of Anesthesiology and Perioperative Medicine, Queen’s University, Kingston, Ontario, Canada; †Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH; and ‡Department of Anaesthesia, The Tweed Hospital, Tweed Heads, Australia. Address reprint requests to Anthony M.-H. Ho, MD, FRCPC, FCCP, Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital, Queen’s University, 76 Stuart Street, Kingston, Ontario, Canada, K7L 2V7. E-mail: hoamh@hotmail.com © 2016 Elsevier Inc. All rights reserved. 1053-0770/2601-0001$36.00/0 http://dx.doi.org/10.1053/j.jvca.2015.04.005

The optimal approach to postoperative analgesia in patients with bilateral diaphragmatic paralysis undergoing abdominal surgery remains unclear. We report a 69-year-old woman with bilateral diaphragmatic paralysis who underwent a laparoscopic hernia repair and an open laparotomy for reversal of a Hartmann procedure under general anesthesia. Postoperative analgesia was provided by intravenous opioid and epidural local anesthetic and opioid, respectively. The patient's trachea was successfully extubated at the end of both surgical procedures. Epidural analgesia was associated with better pain control and shorter intensive care unit stay.

During this COVID-19 pandemic, at increased risk of infection are clinicians involved in aerosol-generating procedures such as endotracheal intubation.1 We herein describe a technique to mitigate aerosolisation. As shown in the figure 1A, the rubber bung of a 20 mL syringe plunger is used to occlude the connector of the endotracheal tube (ETT) figure 1B, preventing aerosolised particles (eg, during coughing) from being directed towards the operator. Once the ETT tip has passed the larynx and its cuff has been inflated to ensure seal, a clamp is applied to the ETT (not shown) prior to removal of the …

Background: Chronic pain is a highly prevalent and complex health problem that is associated with a severe symptom burden, as well as substantial economic and social impact. Many patients with chronic pain still suffer from unrelieved or undertreated pain due to the incomplete efficacy and dose-limiting adverse effects of current therapies. Long-term and high-dose opioid use has considerably increased in the past 20 years despite limited evidence supporting its effectiveness in several chronic pain conditions, and serious concerns have emerged regarding adverse effects and potential misuse. Until recently, the steady increase in opioid prescribing rates has been associated with rising opioid-related mortality and other serious problems, emphasizing the need for better nonopioid therapies. Emerging evidence supports the safe use of magnesium in controlling chronic pain, but its overall efficacy and safety is still unclear. Objective: This paper aims to assess the efficacy and safety of magnesium compared with a placebo for the treatment of chronic noncancer pain. Methods: We will conduct a detailed search on Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE from their inception until the date the searches are run to identify relevant randomized controlled trials. The reference lists of retrieved studies as well as Web-based trial registries will also be searched. We will include randomized double-blind trials comparing magnesium (at any dose, frequency, or route of administration) with placebo using participant-reported pain assessment. Two reviewers will independently evaluate studies for eligibility, extract data, and assess trial quality and potential bias. Risk of bias will be assessed using criteria outlined in the Cochrane Handbook for Systematic Review of Interventions. Primary outcomes for this review will include any validated measure of pain intensity or pain relief. Dichotomous data will be used to calculate the risk ratio and number needed to treat or harm. The quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Results: This protocol is grant-funded and has undergone a peer-review process through the Queen’s University Department of Anesthesiology and Perioperative Medicine Vandewater Endowed Studentship. This project is also supported, in part, by the Chronic Pain Network of the Canadian Institutes of Health Research Strategy for Patient-Oriented Research. The electronic database search strategies are currently being developed and modified. The entire review is expected to be completed by January 1, 2019. Conclusions: The completion of this review is expected to identify available high-quality evidence describing the efficacy and safety of magnesium for the treatment of chronic noncancer pain. International Registered Report Identifier (IRRID): PRR1-10.2196/11654

Hyperbilirubinemia is a known risk factor in patients undergoing open heart operations. Infective endocarditis often leads to valvular injury, such as rupture of chordae tendineae or leaflet perforation, which can cause acute heart failure in association with pulmonary hypertension and liver dysfunction. Here we present a patient with massive liver congestion, reflected by extreme hyperbilirubinemia, secondary to acute heart failure following mitral valve endocarditis that was successfully treated by emergency mitral and tricuspid valve repair.

Traditional transfusion guidelines suggest that fresh frozen plasma (FFP) should be given based on laboratory or clinical evidence of coagulopathy or acute loss of 1 blood volume. This approach tends to result in a significant lag time between the first units of erythrocytes and FFP in trauma requiring massive transfusion. In severe trauma, observational studies have found an association between increased survival and aggressive use of FFP and platelets such that FFP:platelet:erythrocyte ratio approaches 1:1:1 to 2 from the first units of erythrocytes given. There are considerable concerns over either approach, and no randomized controlled trials have been published comparing the 2 approaches. Nowadays, trauma clinicans are incorporating the strenghts of both approaches and are no longer treating them as a dichotomy. Specifically, "1:1:1" proponents have devised 1:1:1 activation criteria to minimize unnecessary FFP and platelet transfusion and are prepared to deactivate the protocol as soon as patient is stabilized. Similarly, 1:1:1 skeptics are more mindful of the need to be proactive about trauma coagulopathy and the inherent delays in FFP administration in trauma patients.

Background Efficient airway management is paramount in emergency medicine. Our experience teaching tracheal intubation has consistently identified gaps in the understanding of important issues. Here we discuss the importance of the endotracheal tube (ETT) bevel in airway management. Discussion The ETT bevel orientation is the main determinant of which mainstem bronchus the ETT enters when advanced too distally, despite a common belief that attributes a higher incidence of right mainstem bronchial intubation to the straighter angle sustained by the right mainstem bronchus. Likewise, a bougie- or fiberscope-assisted tracheal intubation can be impeded by the ETT tip hooking onto laryngeal structures; a 90-degree counterclockwise turn of the ETT (such that the bevel is facing posteriorly) prior to advancing it toward the larynx produces a first-pass success rate of 100%. Similarly, a posterior-facing bevel is believed to improve the ease of passage through the back of the nasal cavity when performing nasotracheal intubation. If resistance is met after the ETT tip has reached the laryngeal vicinity, further counterclockwise rotation may change the plane and incident angle of the ETT tip, facilitating passage through the vocal cords. Clockwise twisting of the ETT reduces the incident angle in the sagittal plane, thereby facilitating videolaryngoscopy-assisted tracheal intubation. Finally, a posterior-facing ETT bevel is the least likely to intubate a tracheoesophageal fistula. Conclusions Understanding the implications of the ETT bevel direction may significantly change the efficiency of deliberate endobronchial, nasal, and bougie/fiberscope-, and videolaryngoscope-assisted intubations, and while managing the patient with a tracheoesophageal fistula.

Before-after study designs are effective research tools and in some cases, have changed practice. These designs, however, are inherently susceptible to bias (ie, systematic errors) that are sometimes subtle but can invalidate their conclusions. This overview provides examples of before-after studies relevant to anesthesiologists to illustrate potential sources of bias, including selection/assignment, history, regression to the mean, test-retest, maturation, observer, retrospective, Hawthorne, instrumentation, attrition, and reporting/publication bias. Mitigating strategies include using a control group, blinding, matching before and after cohorts, minimizing the time lag between cohorts, using prospective data collection with consistent measuring/reporting criteria, time series data collection, and/or alternative study designs, when possible. Improved reporting with enforcement of the Enhancing Quality and Transparency of Health Research (EQUATOR) checklists will serve to increase transparency and aid in interpretation. By highlighting the potential types of bias and strategies to improve transparency and mitigate flaws, this overview aims to better equip anesthesiologists in designing and/or critically appraising before-after studies.

Efficient implementation of machine learning applications on FPGAs often requires non-linear numerical functions with a non-standard numerical precision that is not readily available from vendor provided standard libraries. While application-specific designs of such functions can result in superior numerical accuracy and area efficiency when compared to ad-hoc composition using vendor-provided primitives, the effort devoted to this challenging task can hardly be portable to other similar applications. In this work, we present an open source generator, NnCore, for floating-point non-linear operator cores built using fixed-point piecewise polynomial segments. The proposed framework takes advantage of properties such as oddness/evenness and intercept-at-origin, often found in the numerical functions commonly used in machine learning applications, and applied an improved segmentation algorithm that specifically handles “outlier” segments, to reduce the required memory size for storing polynomial coefficients. Experimental results show that, at single-precision setting, NnCore generated cores use up to 65% fewer BRAMs, 63% fewer shift-registers, and runs at up to 2.2 χ the clock speed, compare with cores generated from a previous generic function generator. At half-precision, cores can run around 1.2 χ higher clock speed while requiring higher resource usage, or use a comparable number of resource but run at 12% to 45% lower clock speed. The use of HLS C++ as output format allows core integration into modern high-level workflow such as Xilinx SDAccel.

We report a case of severe respiratory distress in a neonate who was not endotracheally intubated soon after esophageal atresia/tracheoesophageal fistula (EA/TEF) repair. In this serious situation, any form of emergency respiratory support or definitive airway management may compromise the esophageal anastomosis and fistula repair. The cause of respiratory distress in the early postoperative period after EA/TEF is multifactorial, and in this case, included symptomatic tracheomalacia, which is commonly associated with EA/TEF.

A 73-year-old man underwent urgent coronary artery bypass grafting after an acute myocardial infarction. An angiogram had revealed multivessel disease with a circumflex artery lesion suspected as the primary culprit. On separation from cardiopulmonary bypass, transesophageal echocardiography revealed a new mobile mass in the aortic root. Cardiopulmonary bypass was reinstituted and a large thrombus emanating from the left coronary ostium was surgically removed. We hypothesize that the thrombus had originated from coronary retrograde extrusion during venous grafting. This case illustrates an unusual source of emboli during coronary artery bypass grafting and emphasizes the importance of perioperative transesophageal echocardiography for the prevention of potentially catastrophic outcomes.

To the Editor, When performing nerve blocks or vascular cannulation under ultrasound (US) guidance, the depth of the target nerve/vessel and/or the defining landmark ( d US cm; [figure 1][1]) is seen on the US screen and noted by the practitioner. This depth serves as a guide for determining the

To determine the dose-dependent effects of testosterone administration on cognition in women with low testosterone levels.71 hysterectomized women with or without oophorectomy with total testosterone31 ng/dl and/or free testosterone3.5 pg/ml received a standardized transdermal estradiol regimen during the 12-week run-in period and were then randomized to receive weekly intramuscular injections of placebo, 3, 6.25, 12.5, or 25 mg testosterone enanthate for 24 weeks. Total testosterone was measured in serum by LC-MS/MS, and free testosterone levels were measured by equilibrium dialysis. Cognitive function was evaluated using a comprehensive battery of standardized neuropsychological tests at baseline and 24 weeks.46 women who had baseline and end-of-treatment cognitive function data constituted the analytic sample. The five groups were similar at baseline. Mean on-treatment nadir total testosterone concentrations were 15, 89, 98, 134, and 234 ng/dl in the placebo, 3, 6.25, 12.5, and 25 mg groups, respectively. No significant changes in spatial ability, verbal fluency, verbal memory, or executive function were observed in any treatment arm compared to placebo even after adjustment for baseline cognitive function, age, and education. Multiple regression analysis did not show any significant relation between changes in testosterone concentrations and change in cognitive function scores.Short-term testosterone administration over a wide range of doses for 24 weeks in women with low testosterone levels was neither associated with improvements nor worsening of cognitive function.

To describe the use of cerebral oximetry to detect a lack of right cerebral perfusion resulting from a malpositioned catheter used for antegrade cerebral perfusion during deep hypothermic circulatory arrest (DHCA). The simple corrective surgical adjustment that followed averted a potentially serious complication.A 57-yr-old male with a type-A aortic dissection undergoing DHCA required antegrade cerebral perfusion for cerebral protection. Catheters were placed accordingly in the left common carotid and brachiocephalic arteries. Whereas frontal cerebral oximetry immediately improved on the left, it did not improve on the right. It was immediately suspected that the tip of the brachiocephalic cannula had advanced into the right subclavian artery, thus depriving the right common carotid artery of blood flow. The problem resolved upon slight withdrawal of the cannula.Vigilance in anesthesia should not stop during DHCA or cardiopulmonary bypass. Cerebral oximetry may provide important information leading to actions that improve brain protection. Vigilances proved important in this case where the cannula tip used for antegrade cerebral perfusion was advanced too far into the right subclavian artery.