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Mizubuti GB, Ho AMH, Silva LMD, Phelan R. Perioperative management of patients on glucagon-like peptide-1 receptor agonists. Curr Opin Anaesthesiol 2024; 37:323-333. [PMID: 38390914 DOI: 10.1097/aco.0000000000001348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW To summarize the mechanism of action, clinical outcomes, and perioperative implications of glucagon-like peptide-1 receptor agonists (GLP-1-RAs). Specifically, this review focuses on the available literature surrounding complications (primarily, bronchoaspiration) and current recommendations, as well as knowledge gaps and future research directions on the perioperative management of GLP-1-RAs. RECENT FINDINGS GLP-1-RAs are known to delay gastric emptying. Accordingly, recent case reports and retrospective observational studies, while anecdotal, suggest that the perioperative use of GLP-1-RAs may increase the risk of bronchoaspiration despite fasting intervals that comply with (and often exceed) current guidelines. As a result, guidelines and safety bulletins have been published by several Anesthesiology Societies. SUMMARY While rapidly emerging evidence suggests that perioperative GLP-1-RAs use is associated with delayed gastric emptying and increased risk of bronchoaspiration (particularly in patients undergoing general anesthesia and/or deep sedation), high-quality studies are needed to provide definitive answers with respect to the safety and duration of preoperative drug cessation, and optimal fasting intervals according to the specific GLP-1-RA agent, the dose/duration of administration, and patient-specific factors. Meanwhile, clinicians must be aware of the potential risks associated with the perioperative use of GLP-1-RAs and follow the recommendations put forth by their respective Anesthesiology Societies.
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Affiliation(s)
- Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Leopoldo Muniz da Silva
- Department of Anesthesiology, São Luiz Hospital - Rede D'Or - CMA, Rua Alceu de Campos Rodrigues, São Paulo, SP, Brazil
| | - Rachel Phelan
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
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Mizubuti GB, Maxwell S, Shatenko S, Braund H, Phelan R, Ho AMH, Dalgarno N, Hobbs H, Szulewski A, Haji F, Arellano R. Competencies for proficiency in basic point-of-care ultrasound in anesthesiology: national expert recommendations using Delphi methodology. Can J Anaesth 2024:10.1007/s12630-024-02746-w. [PMID: 38632162 DOI: 10.1007/s12630-024-02746-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/27/2024] [Accepted: 01/30/2024] [Indexed: 04/19/2024] Open
Abstract
PURPOSE Point-of-care ultrasound (POCUS) allows for rapid bedside assessment and guidance of patient care. Recently, POCUS was included as a mandatory component of Canadian anesthesiology training; however, there is no national consensus regarding the competencies to guide curriculum development. We therefore aimed to define national residency competencies for basic perioperative POCUS proficiency. METHODS We adopted a Delphi process to delineate relevant POCUS competencies whereby we circulated an online survey to academic anesthesiologists identified as POCUS leads/experts (n = 25) at all 17 Canadian anesthesiology residency programs. After reviewing a list of competencies derived from the Royal College of Physicians and Surgeons of Canada's National Curriculum, we asked participants to accept, refine, delete, or add competencies. Three rounds were completed between 2022 and 2023. We discarded items with < 50% agreement, revised those with 50-79% agreement based upon feedback provided, and maintained unrevised those items with ≥ 80% agreement. RESULTS We initially identified and circulated (Round 1) 74 competencies across 19 clinical domains (e.g., basics of ultrasound [equipment, nomenclature, clinical governance, physics]; cardiac [left ventricle, right ventricle, valve assessment, pericardial effusion, intravascular volume status] and lung ultrasound anatomy, image acquisition, and image interpretation; and clinical applications [monitoring and serial assessments, persistent hypotension, respiratory distress, cardiac arrest]). After three Delphi rounds (and 100% response rate maintained), panellists ultimately agreed upon 75 competencies. CONCLUSION Through national expert consensus, this study identified POCUS competencies suitable for curriculum development and assessment in perioperative anesthesiology. Next steps include designing and piloting a POCUS curriculum and assessment tool(s) based upon these nationally defined competencies.
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Affiliation(s)
- Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada.
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Kingston General Hospital Site, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Sarah Maxwell
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Sergiy Shatenko
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Heather Braund
- Faculty of Health Sciences, Office of Professional Development and Educational Scholarship, Queen's University, Kingston, ON, Canada
| | - Rachel Phelan
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Nancy Dalgarno
- Faculty of Health Sciences, Office of Professional Development and Educational Scholarship, Queen's University, Kingston, ON, Canada
| | - Hailey Hobbs
- Department of Critical Care Medicine, POCUS Fellowship Program Director, Queen's University, Kingston, ON, Canada
| | - Adam Szulewski
- Departments of Emergency Medicine and Psychology, Educational Scholarship Lead & Resuscitation and Reanimation Medicine Fellowship Program Director, Queen's University, Kingston, ON, Canada
| | - Faizal Haji
- Division of Neurosurgery, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Ramiro Arellano
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
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van Zyl T, Ho AMH, Klar G, Haley C, Ho AK, Vasily S, Mizubuti GB. Analgesia for rib fractures: a narrative review. Can J Anaesth 2024; 71:535-547. [PMID: 38459368 DOI: 10.1007/s12630-024-02725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/11/2023] [Accepted: 12/27/2023] [Indexed: 03/10/2024] Open
Abstract
PURPOSE Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach. SOURCE Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts. PRINCIPAL FINDINGS Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities. CONCLUSION Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).
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Affiliation(s)
- Theunis van Zyl
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Christopher Haley
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Adrienne K Ho
- Department of Public Health Sciences (Epidemiology), School of Medicine, Queen's University, Kingston, ON, Canada
| | - Susan Vasily
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology & Perioperative Medicine, Queen's University, Kingston General Hospital, Victory 2 Wing, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
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Ho AMH, Klar G, Chung AD, Mizubuti GB. Sizing double-lumen tubes by direct measurement of the mainstem bronchus. Braz J Anesthesiol 2024; 74:844481. [PMID: 38320690 PMCID: PMC10876600 DOI: 10.1016/j.bjane.2024.844481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 12/19/2023] [Indexed: 02/16/2024]
Affiliation(s)
- Anthony M-H Ho
- Queen's University, Kingston Health Sciences Centre, Department of Anesthesiology and Perioperative Medicine, Kingston, Ontario, Canada
| | - Gregory Klar
- Queen's University, Kingston Health Sciences Centre, Department of Anesthesiology and Perioperative Medicine, Kingston, Ontario, Canada
| | - Andrew D Chung
- Queen's University, Kingston Health Sciences Centre, Department of Radiology, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- Queen's University, Kingston Health Sciences Centre, Department of Anesthesiology and Perioperative Medicine, Kingston, Ontario, Canada.
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Ho AMH, Sehgal A, Leitch J, Saha T, Mizubuti GB. Comment on: The fragility index of randomized controlled trials in pediatric anesthesiology. Can J Anaesth 2024; 71:163-164. [PMID: 37989936 DOI: 10.1007/s12630-023-02658-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 09/28/2023] [Accepted: 09/28/2023] [Indexed: 11/23/2023] Open
Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Anupam Sehgal
- Department of Pediatrics, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Jordan Leitch
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada.
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Degani Costa LH, Yepes Pereira B, Queiros Castro I, Werneck H, Mizubuti GB, Falcão LFDR. Impact of COVID-19 pandemic on surgical activity in the Brazilian private healthcare system. PLoS One 2023; 18:e0289032. [PMID: 38096262 PMCID: PMC10720996 DOI: 10.1371/journal.pone.0289032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 07/07/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Surgical volume was drastically reduced in many countries due to challenges imposed by the COVID-19 pandemic. OBJECTIVES We sought to estimate the number of cancelled surgical and diagnostic procedures within the Brazilian private healthcare system between 2020 and 2021 over the course of the COVID-19 pandemic, and to project the procedural backlog generated for specific elective and time-sensitive surgeries, and diagnostic procedures. METHODS Data were systematically extracted from the Brazilian national regulatory agency for the private healthcare system and included (i) quarterly and annual surgical and diagnostic volume, and (ii) the number of private health insurance beneficiaries between January 2016 and June 2021. Based on pre-pandemic data we estimated the expected number of surgical and diagnostic procedures that failed to be performed between 2020 and 2021. RESULTS The average quarterly surgical and diagnostic procedures declined by 29.5% in 2020 and by 21.5% in 2021 compared to 2019. In 2020, such reduction reflected a lower number of diagnostic procedures under anesthesia (-35.1%), as well as elective (-14.7%), time-sensitive (-18.8%), and urgent (-4.6%) surgeries. In the first half of 2021, though the surgical and diagnostic procedures increased compared to 2020, they remained significantly below their historical average. The estimated backlogs were 134.385,64 for total surgical procedures, 2.634,64 for bariatric surgery and arthroplasty revision (elective surgeries), 2.845,61 for oncologic (time-sensitive) surgeries, and 304.193,99 for diagnostic procedures, requiring 1.7, 15.9, and 6.8 years, respectively, to make up for such backlogs. CONCLUSION There was a major decline on the number of surgical and diagnostic procedures due to the COVID-19 pandemic. Despite a slight recovery of elective surgeries throughout the pandemic, many time-sensitive surgeries and diagnostic procedures were cancelled, with potential medium- to long-term consequences to patients and the system as a whole.
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Affiliation(s)
- Luiza Helena Degani Costa
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
- Centro Universitário São Camilo, São Paulo, São Paulo, Brazil
| | - Barbara Yepes Pereira
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | | | - Heitor Werneck
- Agência Nacional de Saúde Suplementar, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Glenio B. Mizubuti
- Kingston Health Sciences Center, Queen’s University, Kingston, Ontario, Canada
| | - Luiz Fernando dos Reis Falcão
- Centro Universitário São Camilo, São Paulo, São Paulo, Brazil
- Universidade Federal de São Paulo – Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, São Paulo, Brazil
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Mizubuti GB, Ho AMH, Klar G, van Zyl T, Patterson L, Davidson T, Hong X, Beyea JA. Near complete dynamic/ball-valve airway obstruction by a laryngeal cyst. Can J Anaesth 2023; 70:2002-2003. [PMID: 37752380 DOI: 10.1007/s12630-023-02577-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 09/28/2023] Open
Affiliation(s)
- Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada.
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Theunis van Zyl
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Lindsey Patterson
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Taryn Davidson
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Xinyuan Hong
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Jason A Beyea
- Otolaryngology/Head & Neck Surgery, Department of Surgery, Queen's University, Kingston, ON, Canada
- Institute for Clinical Evaluative Sciences (IC/ES), Queen's University, Kingston, ON, Canada
- Kingston Ear Institute, Kingston, ON, Canada
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Mizubuti GB, Ho AMH, Phelan R, DuMerton D, Shelley J, Vowotor E, Xiong J, Smethurst B, McMullen M, Hopman WM, Martou G, Edmunds RW, Tanzola R. Dobutamine and Goal-Directed Fluid Therapy for Improving Tissue Oxygenation in Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction Surgery: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e48576. [PMID: 37991835 DOI: 10.2196/48576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 10/13/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Breast reconstruction is an integral part of breast cancer care. There are 2 main types of breast reconstruction: alloplastic (using implants) and autologous (using the patient's own tissue). The latter creates a more natural breast mound and avoids the long-term need for surgical revision-more often associated with implant-based surgery. The deep inferior epigastric perforator (DIEP) flap is considered the gold standard approach in autologous breast reconstruction. However, complications do occur with DIEP flap surgery and can stem from poor flap tissue perfusion/oxygenation. Hence, the development of strategies to enhance flap perfusion (eg, goal-directed perioperative fluid therapy) is essential. Current perioperative fluid therapy is traditionally guided by subjective criteria, which leads to wide variations in clinical practice. OBJECTIVE The main objective of this trial is to determine whether the use of minimally invasive cardiac output (CO) monitoring for guiding intravenous fluid administration, combined with low-dose dobutamine infusion (via a treatment algorithm), will increase tissue oxygenation in patients undergoing DIEP flap surgery. METHODS With appropriate institutional ethics board and Health Canada approval, patients undergoing DIEP flap surgery are randomly assigned to receive CO monitoring for the guidance of intraoperative fluid therapy in addition to a low-dose dobutamine infusion (which potentially improves flap oxygenation) versus the current standard of care. The primary outcome is tissue oxygenation measured via near-infrared spectroscopy at the perfusion zone furthest from the perforator vessels 45 minutes after vascular reanastomosis of the DIEP flap. Low dose (2.5 μg/kg/hr) dobutamine infusion continues for up to 4 hours postoperatively, provided there are no associated complications (ie, persistent tachycardia). Flap oxygenation, hemodynamic parameters, and any medication-associated side effects/complications are monitored for up to 48 hours postoperatively. Complications, rehospitalizations, and patient satisfaction are also collected until 30 days postoperatively. RESULTS Funding and regulatory approvals were obtained in 2019, but the study recruitment was interrupted by the COVID-19 pandemic. As of October 4, 2023, 34 participants have been recruited. Because of the significant delays associated with the pandemic, the expected completion date was extended. We expect the study to be completed and ready for potential news release (as appropriate) and publication by July 2024. No patients have suffered any adverse effects/complications from participating in this study, and none have been lost to follow-up. CONCLUSIONS CO-directed fluid therapy in combination with a low-dose dobutamine infusion via a treatment algorithm has the potential to improve DIEP flap tissue oxygenation and reduce complications following DIEP flap breast reconstruction surgery. However, given that the investigators remain blinded to group randomization, no comment can be made regarding the efficacy of this intervention for improving tissue oxygenation at this time. Nevertheless, no patients have been withdrawn for safety concerns thus far, and compliance remains high. TRIAL REGISTRATION Clinicaltrials.gov NCT04020172; https://clinicaltrials.gov/study/NCT04020172.
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Affiliation(s)
- Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Rachel Phelan
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Deborah DuMerton
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jessica Shelley
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Elorm Vowotor
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Jessica Xiong
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
| | - Bethany Smethurst
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
| | - Michael McMullen
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Wilma M Hopman
- Kingston Health Sciences Centre, Kingston General Health Research Institute, Kingston, ON, Canada
| | - Glykeria Martou
- Division of Plastic Surgery, Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Robert Wesley Edmunds
- Division of Plastic Surgery, Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Robert Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
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Cohen JC, Ho AMH, O'Reilly HD, Mizubuti GB. Separate circuit nasal cannulae for end-tidal CO 2 monitoring may lead to hypoxia in patients with unilateral nasal airway obstruction. Braz J Anesthesiol 2023; 73:699-700. [PMID: 37433403 PMCID: PMC10533956 DOI: 10.1016/j.bjane.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/09/2023] [Accepted: 07/03/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Jared C Cohen
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Ontario, Canada
| | - Anthony M-H Ho
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Ontario, Canada
| | - Heather D O'Reilly
- Children's Hospital of Eastern Ontario, Department of Anesthesiology and Pain Medicine, Ottawa, Ontario, Canada
| | - Glenio B Mizubuti
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Ontario, Canada.
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Ho AMH, Nguyen-Do F, Klar G, Mizubuti GB. A simple solution for an underdamped arterial blood pressure tracing. Can J Anaesth 2023; 70:1527-1528. [PMID: 37280455 DOI: 10.1007/s12630-023-02525-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/18/2023] [Accepted: 03/27/2023] [Indexed: 06/08/2023] Open
Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Francis Nguyen-Do
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada.
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Silveira SQ, Nersessian RSF, Abib ADCV, Santos LB, Bellicieri FN, Botelho KK, Lima HDO, Queiroz RMD, Anjos GSD, Fernandes HDS, Mizubuti GB, Vieira JE, da Silva LM. Decreasing inconsistent alarms notifications: a pragmatic clinical trial in a post-anesthesia care unit. Braz J Anesthesiol 2023:S0104-0014(23)00081-7. [PMID: 37562650 DOI: 10.1016/j.bjane.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Alarms alert healthcare professionals of deviations from normal/physiologic status. However, alarm fatigue may occur when their high pitch and diversity overwhelm clinicians, possibly leading to alarms being disabled, paused, and/or ignored. We aimed to determine whether a staff educational program on customizing alarm settings of bedside monitors may decrease inconsistent alarms in the Post-Anesthesia Care Unit (PACU). METHODS This is a prospective, analytic, quantitative, pragmatic, open-label, single-arm study. The outcome was evaluated on PACU admission before (P1) and after (P2) the implementation of the educational program. The heart rate, blood pressure, and oxygen saturation alarms were selected for clinical consistency. RESULTS A total of 260 patients were included and 344 clinical alarms collected, with 270 (78.4%) before (P1), and 74 (21.6%) after (P2) the intervention. Among the 270 alarms in P1, 45.2% were inconsistent (i.e., false alarms), compared to 9.4% of the 74 in P2. Patients with consistent alarms occurred in 30% in the P1 and 27% in the P2 (p = 0.08). Patients with inconsistent alarms occurred in 25.4% in the P1 and in 3.8% in the P2. Ignored consistent alarms were reduced from 21.5% to 2.6% (p = 0.004) in the P2 group. The educational program was a protective factor for the inconsistent clinical alarm (OR = 0.11 [95% CI 0.04-0.3]; p < 0.001) after adjustments for age, gender, and ASA physical status. CONCLUSION Customizing alarm settings on PACU admission proved to be a protective factor against inconsistent alarm notifications of multiparametric monitors.
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Affiliation(s)
- Saullo Queiroz Silveira
- Hospital São Luiz Unidade Itaim, Rede D'Or - Equipe de Anestesia CMA, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | - Rafael Sousa Fava Nersessian
- Hospital São Luiz Unidade Itaim, Rede D'Or - Equipe de Anestesia CMA, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | - Arthur de Campos Vieira Abib
- Hospital São Luiz Unidade Itaim, Rede D'Or - Equipe de Anestesia CMA, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | - Leonardo Barbosa Santos
- Hospital São Luiz Unidade Itaim, Rede D'Or - Equipe de Anestesia CMA, Departamento de Anestesiologia, São Paulo, SP, Brazil; Rede D'Or, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, RJ, Brazil
| | - Fernando Nardy Bellicieri
- Hospital São Luiz Unidade Itaim, Rede D'Or - Equipe de Anestesia CMA, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | - Karen Kato Botelho
- São Luiz Hospital (ITAIM), Rede D'Or, Departamento de Enfermagem, São Paulo, SP, Brazil
| | | | - Renata Mazzoni de Queiroz
- Hospital São Luiz Unidade Itaim, Rede D'Or - Equipe de Anestesia CMA, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | - Gabriel Silva Dos Anjos
- Hospital São Luiz Unidade Itaim, Rede D'Or - Equipe de Anestesia CMA, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | | | - Glenio B Mizubuti
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canada
| | - Joaquim Edson Vieira
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Departamento de Cirurgia, Anestesiologia, São Paulo, SP, Brazil
| | - Leopoldo Muniz da Silva
- Hospital São Luiz Unidade Itaim, Rede D'Or - Equipe de Anestesia CMA, Departamento de Anestesiologia, São Paulo, SP, Brazil; Rede D'Or, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, RJ, Brazil.
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Ho AMH, Mizubuti GB, Klar G. Increasing the success rate of large and small intravenous access. Can J Anaesth 2023; 70:1401-1402. [PMID: 37286746 DOI: 10.1007/s12630-023-02502-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 06/09/2023] Open
Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada.
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
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Maxwell SK, Mizubuti GB, DeJong P, Arellano R. Trick of the Eye or Trick of the Heart? Chest 2023; 163:e237-e240. [PMID: 37164589 DOI: 10.1016/j.chest.2022.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/01/2022] [Accepted: 05/05/2022] [Indexed: 05/12/2023] Open
Affiliation(s)
- Sarah K Maxwell
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Queen's University, Kingston ON, Canada.
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Queen's University, Kingston ON, Canada
| | - Peggy DeJong
- Division of Cardiology, Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston ON, Canada
| | - Ramiro Arellano
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Queen's University, Kingston ON, Canada
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Archibald D, Stambulic T, King M, Ho AMH, Fu M, Lima RME, Lima LHNE, Mizubuti GB. Systemic Heparinization After Neuraxial Anesthesia in Vascular Surgery: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2023; 37:555-560. [PMID: 36609075 DOI: 10.1053/j.jvca.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/21/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The American Society of Regional Anesthesia and Pain Medicine's guidelines recommend a 1-hour interval after neuraxial anesthesia (NA) before systemic heparinization to mitigate the risk of spinal hematoma (SH). The study authors aimed to characterize the time interval between NA and systemic heparinization in vascular surgery patients (primary outcome). The secondary outcomes included the historic incidence of SH, and risk estimation of the SH formation based on available data. Heparin dose, length of surgery, difficulty and/or the number of NA attempts, and patient demographics were recorded. DESIGN A retrospective analysis between April 2012 and April 2022. SETTING A single (academic) center. PARTICIPANTS Vascular surgery patients. INTERVENTIONS Intravenous heparin administration. MEASUREMENTS AND MAIN RESULTS All (N = 311) vascular patients were reviewed, of whom 127 (5 femoral-femoral bypass, 67 femoral-popliteal bypass, and 55 endovascular aneurysm repairs [EVAR]) received NA and were included in the final analysis. Patients receiving general anesthesia alone (N = 184) were excluded. Neuraxial anesthesia included spinal (N = 119), epidural (N = 4), or combined spinal-epidural (N = 4) blocks. The average time between NA and heparin administration was 42.8 ± 22.1 minutes, with 83.7% of patients receiving heparin within 1 hour of NA. The time between NA and heparin administration was 40.4 ± 22.3, 50.1 ± 23.4, and 31.3 ± 12.5 minutes for femoral-femoral bypass, femoral-popliteal bypass, and EVAR, respectively. Heparin was administered after 1 hour of NA in 20% of femoral-femoral bypass, 27% of femoral-popliteal bypass, and 3.9% of EVAR patients. No SHs were reported during the study period. CONCLUSIONS The vast majority of vascular surgery patients at the authors' center received heparin within 1 hour of NA. Further studies are required to assess if their findings are consistent in other vascular surgery settings and/or centers.
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Affiliation(s)
- Dana Archibald
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Thomas Stambulic
- Queen's University School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Morgan King
- Queen's University School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Minnie Fu
- Queen's University School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rodrigo M E Lima
- Department of Anesthesiology, Perioperative, and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lais H N E Lima
- Department of Anesthesiology, Perioperative, and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada.
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15
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Silveira SQ, da Silva LM, de Campos Vieira Abib A, de Moura DTH, de Moura EGH, Santos LB, Ho AMH, Nersessian RSF, Lima FLM, Silva MV, Mizubuti GB. Relationship between perioperative semaglutide use and residual gastric content: A retrospective analysis of patients undergoing elective upper endoscopy. J Clin Anesth 2023; 87:111091. [PMID: 36870274 DOI: 10.1016/j.jclinane.2023.111091] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/12/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
STUDY OBJECTIVE Semaglutide is a long-acting glucagon-like peptide-1 receptor agonist used for management of type 2 diabetes and/or obesity. To test the hypothesis that perioperative semaglutide use is associated with delayed gastric emptying and increased residual gastric content (RGC) despite adequate preoperative fasting, we compared the RGC of patients who had and had not taken semaglutide prior to elective esophagogastroduodenoscopy. The primary outcome was the presence of increased RGC. DESIGN Single-center retrospective electronic chart review. SETTING Tertiary hospital. PATIENTS Patients undergoing esophagogastroduodenoscopy under deep sedation/general anesthesia between July/2021-March/2022. INTERVENTIONS Patients were divided into two (SG = semaglutide, NSG = non-semaglutide) groups, according to whether they had received semaglutide within 30 days prior to the esophagogastroduodenoscopy. MEASUREMENTS Increased RGC was defined as any amount of solid content, or > 0.8 mL/Kg (measured from the aspiration/suction canister) of fluid content. MAIN RESULTS Of the 886 esophagogastroduodenoscopies performed, 404 (33 in the SG and 371 in the NSG) were included in the final analysis. Increased RGC was observed in 27 (6.7%) patients, being 8 (24.2%) in the SG and 19 (5.1%) in the NSG (p < 0.001). Semaglutide use [5.15 (95%CI 1.92-12.92)] and the presence of preoperative digestive symptoms (nausea/vomiting, dyspepsia, abdominal distension) [3.56 (95%CI 2.2-5.78)] were associated with increased RGC in the propensity weighted analysis. Conversely, a protective [0.25 (95%CI 0.16-0.39)] effect against increased RGC was observed in patients undergoing esophagogastroduodenoscopy combined with colonoscopy. In the SG, the mean time of preoperative semaglutide interruption in patients with and without increased RGC was 10.5 ± 5.5 and 10.2 ± 5.6 days, respectively (p = 0.54). There was no relationship between semaglutide use and the amount/volume of RGC found on esophagogastroduodenoscopy (p = 0.99). Only one case (in the SG) of pulmonary aspiration was reported. CONCLUSIONS Semaglutide was associated with increased RGC in patients undergoing elective esophagogastroduodenoscopy. Digestive symptoms prior to esophagogastroduodenoscopy were also predictive of increased RGC.
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Affiliation(s)
- Saullo Queiroz Silveira
- Department of Anesthesiology, Vila Nova Star Hospital / Rede D'Or - CMA Anesthesia group, São Paulo, SP, Brazil
| | - Leopoldo Muniz da Silva
- Department of Anesthesiology, São Luiz Hospital - ITAIM / Rede D'Or - CMA Anesthesia group, São Paulo, SP, Brazil
| | | | | | | | | | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Rafael Souza Fava Nersessian
- Department of Anesthesiology, São Luiz Hospital - ITAIM / Rede D'Or - CMA Anesthesia group, São Paulo, SP, Brazil
| | - Filipe Lugon Moulin Lima
- Department of Anesthesiology, Vila Nova Star Hospital / Rede D'Or - CMA Anesthesia group, São Paulo, SP, Brazil
| | - Marcela Viana Silva
- Department of Endoscopy, Vila Nova Star Hospital / Rede D'Or - CMA Anesthesia group, São Paulo, SP, Brazil
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada.
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16
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Ho AK, Zamperoni KE, Ho AMH, Mizubuti GB. Introducing the fragility index-A case study using the Term Breech Trial. Birth 2023; 50:11-15. [PMID: 36576726 DOI: 10.1111/birt.12698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/02/2022] [Accepted: 11/21/2022] [Indexed: 12/29/2022]
Abstract
The fragility index (FI) is a sensitivity analysis of the statistically significant result of a clinical study. It is the number of hypothetical changes in the primary event of one of the two cohorts in a 1-to-1 comparative trial to render the statistically significant result non-significant (ie, to alter the P-value from ≤0.05 to >0.05). The FI can be compared with the patient drop-out rates and protocol violations, which, if much higher than the FI, may arguably suggest less robustness/stability of the trial's results. To illustrate the concept, we have chosen the Term Breech Trial (TBT) as a case study. The TBT results favor planned cesarean birth, as opposed to planned vaginal delivery, in the term singleton fetus with breech presentation. Our analysis shows that the FI of the TBT is 21, which is small in comparison to the number (hundreds) of protocol violations present. Some experts have suggested the inclusion of the FI in data analysis and subsequent discussion of clinical trial data. Routine use of such a metric may be valuable in encouraging readers to maintain a healthy degree of skepticism, especially when interpreting trial results which may directly influence clinical practice.
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Affiliation(s)
- Adrienne K Ho
- Department of Public Health Sciences (Epidemiology), Queen's University School of Medicine, Kingston, Ontario, Canada
| | | | - Anthony M H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University School of Medicine, Kingston, Ontario, Canada
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Ho AMH, Klar G, Mizubuti GB. A simple technique for dosing neostigmine and glycopyrrolate in children. Can J Anaesth 2023; 70:282-283. [PMID: 36447091 DOI: 10.1007/s12630-022-02369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/11/2022] [Accepted: 10/03/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
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18
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Klar G, Ho AMH, McMullen M, Stirling D, Mizubuti GB. A simple technique to assess postoperative epidural functionality. J Clin Monit Comput 2022; 36:1903-1906. [PMID: 35616794 DOI: 10.1007/s10877-022-00867-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/20/2022] [Indexed: 11/27/2022]
Abstract
To describe an alternative method of measuring the Epidural Waveform Analysis (EWA), a technique through which anesthesiologists can confirm the position of a needle and/or catheter tip in the epidural space. EWA consists of epidural catheter transduction with a pressure system typically used for invasive arterial blood pressure monitoring which generates a characteristic oscillatory waveform (provided the catheter tip is within the epidural space) in synchrony with the pulsatile epidural circulation. The technique requires a double-male connector, a 3-way stopcock and an arterial pressure extension tubing along with the patient's existing arterial line setup while ensuring a meticulously sterile technique to mitigate the risks of neuraxial infection. The technique described herein has been successfully and routinely applied within our institution to measure EWA with the advantage of being potentially less wasteful. EWA allows anesthesiologists to confirm the correct position of an epidural needle/catheter. We describe a method of successfully measuring EWA while reducing wastefulness.
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Affiliation(s)
- Gregory Klar
- Department of Anesthesiology & Perioperative Medicine, Queen's University, Victory 2 Wing, Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology & Perioperative Medicine, Queen's University, Victory 2 Wing, Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Michael McMullen
- Department of Anesthesiology & Perioperative Medicine, Queen's University, Victory 2 Wing, Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Devin Stirling
- Department of Anesthesiology & Perioperative Medicine, Queen's University, Victory 2 Wing, Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology & Perioperative Medicine, Queen's University, Victory 2 Wing, Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
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19
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King M, Stambulic T, Servito M, Mizubuti GB, Payne D, El-Diasty M. Erector spinae plane block as perioperative analgesia for midline sternotomy in cardiac surgery: A systematic review and meta-analysis. J Card Surg 2022; 37:5220-5229. [PMID: 36217996 DOI: 10.1111/jocs.17005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/19/2022] [Accepted: 09/06/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Inadequate analgesia following cardiac surgery increases postoperative complications. Opioid-based analgesia is associated with side effects that may compromise postoperative recovery. Regional anesthetic techniques provide an alternative thereby reducing opioid requirements and potentially enhancing postoperative recovery. The erector spinae plane block has been used in multiple surgical procedures including sternotomy for cardiac surgery. We, therefore, aimed to characterize the impact of this block on post-sternotomy pain and recovery in cardiac surgery patients. METHODS We conducted an electronic search for studies reporting on the use of the erector spinae plane block in adult cardiac surgery via midline sternotomy. Randomized controlled trials, cohort studies, and case-control studies were considered for inclusion. Outcomes of interest included postoperative pain, time-to-extubation, and intensive care unit length of stay. RESULTS In total, 498 citations were identified and five were included in the meta-analysis. The erector spinae plane block did not significantly reduce self-reported postoperative pain scores at 4 h (-2.04; 95% confidence interval [CI] -8.15 to 4.07; p = .29) or 12 h (-0.27; 95% CI -2.48 to 1.94; p = .65) postextubation, intraoperative opioid requirements (-3.07; 95% CI -6.25 to 0.11; p = .05], time-to-extubation (-1.17; 95% CI -2.81 to 0.46; p = .12), or intensive care unit (ICU) length of stay (-4.51; 95% CI -14.23 to 5.22; p = .24). CONCLUSIONS Erector spinae plane block was not associated with significant reduction in postoperative pain, intraoperative opioid requirements, time-to-extubation, and ICU length of stay in patients undergoing cardiac surgery. The paucity of large randomized controlled trials and the high heterogeneity among studies suggest that further studies are required to assess its effectiveness in cardiac surgery patients.
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Affiliation(s)
- Morgan King
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Thomas Stambulic
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Maria Servito
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Darrin Payne
- Division of Cardiac Surgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Mohammad El-Diasty
- Division of Cardiac Surgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada
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20
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Burjorjee J, Phelan R, Hopman WM, Ho AMH, Nanji S, Jalink D, Mizubuti GB. Plasma bupivacaine levels (total and free/unbound) during epidural infusion in liver resection patients: a prospective, observational study. Reg Anesth Pain Med 2022; 47:rapm-2022-103683. [PMID: 36002226 DOI: 10.1136/rapm-2022-103683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/09/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Liver resection patients may be at an increased risk of local anesthetic (LA) toxicity because the liver is essential for metabolizing LA and producing proteins (mainly α1-acid glycoprotein (AAG)) that bind to it and reduce the free (and pharmacologically active/toxic) levels in circulation. The liver resection itself, manipulation during surgery, and pre-existing liver disease may all interfere with normal hepatic protein synthesis and result in an attenuation of the increased AAG (a positive acute-phase protein) that normally occurs postoperatively. The purpose of this study was to determine whether the AAG response is attenuated postoperatively following liver resection and whether patients approach toxicity thresholds with continuous postoperative epidural infusion of bupivacaine. METHODS Prospective, observational study with blood drawn preoperatively, in the postanesthetic care unit, on postoperative day (POD) 2, and prior to discontinuation of epidural analgesia on POD3/POD4. Plasma was analyzed for total and unbound bupivacaine via liquid chromatography-mass spectrometry and AAG via ELISA. Signs/symptoms of local anesthetic systemic toxicity (LAST), pain, and sedation scores were also recorded. RESULTS For the 19 patients completed, total plasma bupivacaine was correlated with total administered, but unbound levels were not associated with the total administered. Unlike non-hepatectomy surgery where unbound LA plasma levels remain stable (or decrease) with continuous postoperative epidural administration, we observed an overall increase. Several patients approached toxicity thresholds and 47% reported at least one symptom of LAST, but no epidurals were discontinued because of LAST. In contrast to the AAG response reported following major non-liver surgery where AAG levels increase twofold, we observed a reduction until POD2 and the magnitude was proportional to resection weight. DISCUSSION Our results are supported by the literature in suggesting that major liver resection patients may be at an increased vulnerability for LAST. Factors such as the extent of liver disease, resection and intraoperative blood loss should be considered when using continuous postoperative epidural infusion of bupivacaine and vigilance should be used in monitoring, for signs/symptoms of LAST, even for those subtle and non-specific. Future research will be required to verify these findings. TRIAL REGISTRATION NUMBER NCT03145805.
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Affiliation(s)
- Jessica Burjorjee
- Department of Anesthesiology and Perioperative Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Rachel Phelan
- Department of Anesthesiology and Perioperative Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Wilma M Hopman
- Kingston General Hospital Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Diederick Jalink
- Department of Surgery, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
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21
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Silveira SQ, da Silva LM, Gomes RF, de Campos Vieira Abib A, Vieira JE, Ho AMH, de Oliveira Lima H, Bellicieri FN, Camire D, Nersessian RSF, Mizubuti GB. An evaluation of the accuracy and self-reported confidence of clinicians in using the ASA-PS Classification System. J Clin Anesth 2022; 79:110794. [DOI: 10.1016/j.jclinane.2022.110794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/19/2022] [Accepted: 03/25/2022] [Indexed: 10/18/2022]
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22
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de Oliveira Lima H, da Silva LM, de Campos Vieira Abib A, Tavares LR, Santos DWDCL, de Araújo ACLF, Moreira LP, Silveira SQ, de Melo Silva Torres V, Simões D, Arellano R, Ho AMH, Mizubuti GB. Coronavirus disease-related in-hospital mortality: a cohort study in a private healthcare network in Brazil. Sci Rep 2022; 12:6371. [PMID: 35430625 PMCID: PMC9012947 DOI: 10.1038/s41598-022-10343-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/31/2022] [Indexed: 02/07/2023] Open
Abstract
COVID-19-related in-hospital mortality has been reported at 30.7–47.3% in Brazil, however studies assessing exclusively private hospitals are lacking. This is important because of significant differences existing between the Brazilian private and public healthcare systems. We aimed to determine the COVID-19-related in-hospital mortality and associated risk factors in a Brazilian private network from March/2020 to March/2021. Data were extracted from institutional database and analyzed using Cox regression model. Length of hospitalization and death-related factors were modeled based on available independent variables. In total, 38,937 COVID-19 patients were hospitalized of whom 3058 (7.8%) died. Admission to the intensive care unit occurred in 62.5% of cases, and 11.5% and 3.8% required mechanical ventilation (MV) and renal replacement therapy (RRT), respectively. In the adjusted model, age ≥ 61 years-old, comorbidities, and the need for MV and/or RRT were significantly associated with increased mortality (p < 0.05). Obesity and hypertension were associated with the need for MV and RRT (p < 0.05).
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23
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Ho AMH, Torbicki E, Winthrop AL, Kolar M, Zalan JE, MacLean G, Mizubuti GB. Caudal catheter placement for repeated epidural morphine doses after neonatal upper abdominal surgery. Anaesth Intensive Care 2022; 50:141-145. [PMID: 35172612 PMCID: PMC8943261 DOI: 10.1177/0310057x211062240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Effective pain control after major surgery in neonates presents many challenges. Parenteral opioids (and co-analgesics) are often used but inadequate analgesia and oversedation are not uncommon. Although continuous thoracic epidural analgesia is highly effective and opioid-sparing, its associated risks and the need for staff with specialised skills and/or neonatal intensive care unit staff buy-in may preclude this option even in many academic centres. We present the case of a six-day-old infant who underwent upper abdominal surgery and received intermittent morphine doses via a tunnelled caudal epidural catheter, which provided satisfactory analgesia and facilitated early extubation.
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Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
| | - Emma Torbicki
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
| | | | - Mila Kolar
- Department of Surgery, Queen's University, Kingston, Canada
| | - Julie E Zalan
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
| | - Gillian MacLean
- Department of Pediatrics, Queen's University, Kingston, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
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Ho AMH, Klar G, Mizubuti GB. A simple technique to maintain intraoperative head and neck neutrality. Braz J Anesthesiol 2021; 72:416-417. [PMID: 34848317 PMCID: PMC9373700 DOI: 10.1016/j.bjane.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/31/2021] [Accepted: 11/13/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Anthony M-H Ho
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canada
| | - Gregory Klar
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canada
| | - Glenio B Mizubuti
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canada.
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25
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Knoll W, Phelan R, Hopman WM, Ho AMH, Cenkowski M, Mizubuti GB, Ghasemlou N, Klar G. Retrospective review of time to uterotonic administration and maternal outcomes following post-partum hemorrhage. J Obstet Gynaecol Can 2021; 44:490-495. [PMID: 34844004 DOI: 10.1016/j.jogc.2021.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- William Knoll
- Queen's University School of Medicine, Department of Anesthesiology and Perioperative Medicine, Department of Molecular and Biological Sciences, Queen's University, Botterell Hall, 18 Stuart Street, Kingston ON K7L 3N6 Canada
| | - Rachel Phelan
- Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston ON K7L 2V7 Canada
| | - Wilma M Hopman
- Kingston Health Sciences Research Institute, KGHRI, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
| | - Marta Cenkowski
- Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
| | - Nader Ghasemlou
- Department of Molecular and Biological Sciences, Department of Anesthesiology and Perioperative Medicine, ueen's University, Botterell Hall, 18 Stuart Street, Kingston ON K7L 3N6 Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada.
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da Silva LM, Lima HDO, Ferrer R, Ho AMH, Silveira SQ, Abib ADCV, Bellicieri FN, Camire D, Mittermayer O, Botelho KK, Pla Gil AM, Mizubuti GB. Comparison of strategies for adherence to venous thromboembolism prophylaxis in high-risk surgical patients: a before and after intervention study. BMJ Open Qual 2021; 10:bmjoq-2021-001583. [PMID: 34663589 PMCID: PMC8524289 DOI: 10.1136/bmjoq-2021-001583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/30/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major cause of perioperative morbimortality. Despite significant efforts to advance evidence-based practice, prevention rates remain inadequate in many centres. OBJECTIVE To evaluate the effectiveness of different strategies aimed at improving adherence to adequate VTE prophylaxis in surgical patients at high risk of VTE. METHOD Before 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. RESULTS We 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 (p<0.001; C>A=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 (p<0.05). Additionally, a significant increase in compliance with adequate dosage, dosing interval and scheduling of the prophylactic regimen was observed. CONCLUSION Perioperative 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.
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Affiliation(s)
| | | | - Ricardo Ferrer
- Nursing, São Luiz Hospital-ITAIM/Rede D'Or-CMA, São Paulo, Brazil
| | - Anthony M-H Ho
- Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | | | | | | | - Daenis Camire
- Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Otto Mittermayer
- Anesthesiology, São Luiz Hospital-ITAIM/Rede D'Or-CMA Anaesthesia Team, São Paulo, Brazil
| | | | - Andre Mortari Pla Gil
- Anesthesiology, São Luiz Hospital-ITAIM/Rede D'Or-CMA Anaesthesia Team, São Paulo, Brazil
| | - Glenio B Mizubuti
- Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
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Fleming M, Vautour D, McMullen M, Cofie N, Dalgarno N, Phelan R, Mizubuti GB. Examining the accuracy of residents' self-assessments and faculty assessment behaviours in anesthesiology. Can Med Educ J 2021; 12:17-26. [PMID: 34567302 PMCID: PMC8463238 DOI: 10.36834/cmej.70697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Residents' accurate self-assessment and clinical judgment are essential for optimizing their clinical skills development. Evidence from the medical literature suggests that residents generally do poorly at self-assessing their performance, often due to factors relating to learners' personal backgrounds, cultures, the specific contexts of the learning environment and rater bias or inaccuracies. We evaluated the accuracy of anesthesiology residents' self-assessed Global Entrustment scores and determined whether differences between faculty and resident scores varied by resident seniority, faculty leniency, and/or year of assessment. METHODS We employed variance components modeling techniques and analyzed 329 pairs of faculty and self-assessed entrustment scores among 43 faculty assessors and 15 residents. Using faculty scores as the gold standard, we compared faculty scores with residents' scores (xi(faculty)-xi(resident)), and determined residents' accuracy, including over- and under-confidence. RESULTS The results indicate that residents were respectively over- and under-confident in 10.9% and 54.4% of the assessments but more consistent in their individual self-assessments (rho = 0.70) than faculty assessors. Faculty scores were significantly higher (α = 0.396; z = 4.39; p < 0.001) than residents' self-assessed scores. Being a lenient/dovish (β = 0.121, z = 3.16, p < 0.01) and a neutral (β = 0.137, z = 3.57, p < 0.001) faculty assessor predicted a higher likelihood of resident under-confidence. Senior residents were significantly less likely to be under-confident compared to junior residents (β = -0.182, z =-2.45, p < 0.05). The accuracy of self-assessments did not significantly vary during the two years of the study period. CONCLUSIONS The majority of residents' self-assessments were inaccurate. Our findings may help identify the sources of such inaccuracies.
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Affiliation(s)
- Melinda Fleming
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre
| | - Danika Vautour
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre
| | - Michael McMullen
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre
| | - Nicholas Cofie
- Faculty of Health Sciences, Queens University, Ontario, Canada
| | - Nancy Dalgarno
- Faculty of Health Sciences, Queens University, Ontario, Canada
| | - Rachel Phelan
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre
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Maxwell SK, Mizubuti GB, McMullen M, Heffernan P, Duggan S. A Tale of 2 Tubes for Emergency Management of Airway Obstruction From an Anterior Mediastinal Mass: A Case Report. A A Pract 2021; 14:e01257. [PMID: 32845100 DOI: 10.1213/xaa.0000000000001257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anterior mediastinal masses are challenging. As induction of general anesthesia may result in complete airway obstruction or hemodynamic collapse, maintaining spontaneous ventilation and advancing the endotracheal tube (ETT) distal to the mass are recommended. We discuss the emergency management of an anterior mediastinal mass-induced near-complete airway obstruction at the carina. Despite maintaining spontaneous ventilation, airway obstruction persisted following placement of the ETT proximal to the obstruction. After advancing the ETT into the right mainstem bronchus distal to the mass, hypoxemia persisted, prompting placement of a second ETT into the left mainstem bronchus to overcome the obstruction and provide adequate oxygenation.
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Affiliation(s)
- Sarah K Maxwell
- From the Departments of Anesthesiology and Perioperative Medicine
| | | | - Michael McMullen
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Paul Heffernan
- Critical Care Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Scott Duggan
- From the Departments of Anesthesiology and Perioperative Medicine
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29
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Zoratto D, Phelan R, Hopman WM, Wood GCA, Shyam V, DuMerton D, Shelley J, McQuaide S, Kanee L, Ho AMH, McMullen M, Armstrong M, Mizubuti GB. Adductor canal block with or without added magnesium sulfate following total knee arthroplasty: a multi-arm randomized controlled trial. Can J Anaesth 2021; 68:1028-1037. [PMID: 34041719 DOI: 10.1007/s12630-021-01985-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE 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. METHODS 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. RESULTS 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. CONCLUSION 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. TRIAL REGISTRATION www.clinicaltrials.gov (NCT02581683); registered 21 October 2015.
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Affiliation(s)
- Dana Zoratto
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2 Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Rachel Phelan
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2 Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Wilma M Hopman
- Kingston General Hospital Research Institute, Kingston Health Sciences Centre, Kingston, ON, Canada.,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Gavin C A Wood
- Department of Surgery, Division of Orthopedic Surgery, Queen's University, Kingston, ON, Canada
| | - Vidur Shyam
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2 Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Deborah DuMerton
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2 Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Jessica Shelley
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2 Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Sheila McQuaide
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2 Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Lauren Kanee
- University of Toronto School of Medicine, Toronto, ON, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2 Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Michael McMullen
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2 Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Mitch Armstrong
- Department of Surgery, Division of Orthopedic Surgery, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Victory 2 Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
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Mizubuti GB, Ho AMH, Jiang A, Klar G. Angiotensin-converting Enzyme Inhibitor-mediated Angioedema. Anesthesiology 2021; 135:340-341. [PMID: 33940592 DOI: 10.1097/aln.0000000000003810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ho AMH, Chung AD, Klar G, Mizubuti GB. Tracheal distortion in achalasia. Can J Anaesth 2021; 68:1077-1079. [PMID: 33751443 DOI: 10.1007/s12630-021-01966-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 02/14/2021] [Accepted: 02/22/2021] [Indexed: 10/22/2022] Open
Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Andrew D Chung
- Department of Radiology, Queen's University, Kingston, ON, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada.
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Ho AK, Ho AMH, Cooksley T, Nguyen G, Erb J, Mizubuti GB. Immune-Related Adverse Events Associated With Immune Checkpoint Inhibitor Therapy. Anesth Analg 2021; 132:374-383. [PMID: 33009134 DOI: 10.1213/ane.0000000000005029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
As part of immune surveillance, killer T lymphocytes search for cancer cells and destroy them. Some cancer cells, however, develop escape mechanisms to evade detection and destruction. One of these mechanisms is the expression of cell surface proteins which allow the cancer cell to bind to proteins on T cells called checkpoints to switch off and effectively evade T-cell-mediated destruction. Immune checkpoint inhibitors (ICIs) are antibodies that block the binding of cancer cell proteins to T-cell checkpoints, preventing the T-cell response from being turned off by cancer cells and enabling killer T cells to attack. In other words, ICIs restore innate antitumor immunity, as opposed to traditional chemotherapies that directly kill cancer cells. Given their relatively excellent risk-benefit ratio when compared to other forms of cancer treatment modalities, ICIs are now becoming ubiquitous and have revolutionized the treatment of many types of cancer. Indeed, the prognosis of some patients is so much improved that the threshold for admission for intensive care should be adjusted accordingly. Nevertheless, by modulating immune checkpoint activity, ICIs can disrupt the intricate homeostasis between inhibition and stimulation of immune response, leading to decreased immune self-tolerance and, ultimately, autoimmune complications. These immune-related adverse events (IRAEs) may virtually affect all body systems. Multiple IRAEs are common and may range from mild to life-threatening. Management requires a multidisciplinary approach and consists mainly of immunosuppression, cessation or postponement of ICI treatment, and supportive therapy, which may require surgical intervention and/or intensive care. We herein review the current literature surrounding IRAEs of interest to anesthesiologists and intensivists. With proper care, fatality (0.3%-1.3%) is rare.
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Affiliation(s)
- Adrienne K Ho
- From the Department of Clinical Oncology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Tim Cooksley
- Department of Acute Medicine and Critical Care, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Giang Nguyen
- Department of Radiology, Queen's University, Kingston, Ontario, Canada
| | - Jason Erb
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
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Mizubuti GB, Camiré D, Ho AMH, Breton S, Klar G. Erector Spinae Plane Block When Neuraxial Analgesia Is Contraindicated by Clotting Abnormalities. Ann Thorac Surg 2021; 112:e245-e247. [PMID: 33549523 DOI: 10.1016/j.athoracsur.2021.01.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Glenio B Mizubuti
- Department of Anesthesiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Daenis Camiré
- Department of Anesthesiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Sophie Breton
- Department of Anesthesiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Gregory Klar
- Department of Anesthesiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada.
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Ho AMH, Klar G, Mizubuti GB. The enduring myth of why a distally placed endotracheal tube always goes into the right mainstem bronchus. Postgrad Med J 2020; 97:409-410. [PMID: 33384339 DOI: 10.1136/postgradmedj-2020-139401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Anthony M-H Ho
- Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Gregory Klar
- Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
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Ho AMH, Pang E, Wan IPW, Yeung E, Wan S, Mizubuti GB. A Pregnant Patient With a Large Anterior Mediastinal Mass for Thymectomy Requiring One-Lung Anesthesia. Semin Cardiothorac Vasc Anesth 2020; 25:34-38. [DOI: 10.1177/1089253220973133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
| | - Etonia Pang
- Prince of Wales Hospital, Shatin NT, Hong Kong SAR
| | | | - Eugene Yeung
- Prince of Wales Hospital, Shatin NT, Hong Kong SAR
| | - Song Wan
- Prince of Wales Hospital, Shatin NT, Hong Kong SAR
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Leitch JK, Ho AMH, Allard R, Mizubuti GB. Postpartum reverse-Takotsubo from pheochromocytoma diagnosed by bedside point-of-care ultrasound: A case report. POCUS J 2020; 5:37-41. [PMID: 36896438 PMCID: PMC9983720 DOI: 10.24908/pocus.v5i2.14432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Point-of-care ultrasound is invaluable in the setting of obstetric anesthesia, where the differential diagnosis for dyspnea, hypoxemia and/or hemodynamic abnormalities is broad. This report describes a previously apparently healthy parturient with an uncomplicated pregnancy at 35-weeks gestation who underwent an emergency cesarean section under general anesthesia due to severe acute abdominal pain and fetal bradycardia. Intraoperatively, she presented with severe hypertension and tachycardia that were difficult to control and associated with ischemic ECG changes. In the immediate postoperative period, she developed retrosternal tightness and dyspnea, and a bedside point-of-care ultrasound scan revealed a grossly dilated and hypokinetic left ventricle, as well as diffuse B-lines throughout all lung fields - consistent with cardiogenic pulmonary edema. She was admitted to the intensive care unit, where she recovered over several days. Pheochromocytoma was subsequently diagnosed, and she eventually underwent uneventful elective adrenalectomy after appropriate endocrine and hemodynamic optimization.
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Affiliation(s)
- Jordan K Leitch
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Queen's University Kingston, ON Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Queen's University Kingston, ON Canada
| | - Rene Allard
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Queen's University Kingston, ON Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Queen's University Kingston, ON Canada
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Johnson F, Ho AMH, Allard R, Mizubuti GB. Relative positions of the right internal jugular vein and the right common carotid artery. Postgrad Med J 2020; 98:e16-e17. [PMID: 37066555 DOI: 10.1136/postgradmedj-2020-138125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/14/2020] [Accepted: 08/15/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Fraser Johnson
- Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
| | - Anthony M-H Ho
- Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
| | - Rene Allard
- Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
| | - Glenio B Mizubuti
- Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
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Leitch JK, Duggan S, Ho AMH, Franklin J, Mizubuti GB. Acute reversible hand ischemia after radial artery cannulation. Can J Anaesth 2020; 67:377-378. [PMID: 31605291 DOI: 10.1007/s12630-019-01502-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 09/23/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jordan K Leitch
- Department of Anesthesiology & Perioperative Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Scott Duggan
- Department of Anesthesiology & Perioperative Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology & Perioperative Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Jason Franklin
- Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology & Perioperative Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada.
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Ho AMH, Parlow J, Allard R, McMullen M, Mizubuti GB. Interscalene Block in an Anesthetized Adult with Hypertrophic Obstructive Cardiomyopathy Undergoing Clavicle Fracture Reduction. POCUS J 2020; 5:6-9. [PMID: 36895858 PMCID: PMC9979926 DOI: 10.24908/pocus.v5i1.14223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University Kingston, Ontario Canada
| | - Joel Parlow
- Department of Anesthesiology and Perioperative Medicine, Queen's University Kingston, Ontario Canada
| | - Rene Allard
- Department of Anesthesiology and Perioperative Medicine, Queen's University Kingston, Ontario Canada
| | - Michael McMullen
- Department of Anesthesiology and Perioperative Medicine, Queen's University Kingston, Ontario Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University Kingston, Ontario Canada
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Ho AMH, Mizubuti GB. Nasal fiberoptic intubation: what“red out”? Brazilian Journal of Anesthesiology (English Edition) 2020. [PMID: 31812217 PMCID: PMC9373419 DOI: 10.1016/j.bjane.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Anthony M-H Ho
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Glenio B Mizubuti
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá.
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41
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Ho AMH, Dion JM, Takahara G, Mizubuti GB. Estimating the risk of aspiration in gas induction for infantile pyloromyotomy. Paediatr Anaesth 2020; 30:6-8. [PMID: 31863628 DOI: 10.1111/pan.13761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 10/08/2019] [Accepted: 11/02/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Joanna M Dion
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Glen Takahara
- Department of Mathematics and Statistics, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
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42
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Lusty AJ, Hosier GW, Koti M, Chenard S, Mizubuti GB, Jaeger M, Siemens DR. Anesthetic technique and oncological outcomes in urology: A clinical practice review. Urol Oncol 2019; 37:845-852. [DOI: 10.1016/j.urolonc.2019.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/21/2019] [Accepted: 08/12/2019] [Indexed: 12/18/2022]
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Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
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44
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Ho AMH, Chung AD, Mizubuti GB. A hairdresser's painful swollen left leg: artery compresses vein in May-Thurner syndrome. Lancet 2019; 394:e33. [PMID: 31657734 DOI: 10.1016/s0140-6736(19)32311-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/13/2019] [Accepted: 09/10/2019] [Indexed: 11/21/2022]
Affiliation(s)
- Anthony M H Ho
- Department of Anaesthesiology and Perioperative Medicine, Queen's University, Kingston General Hospital, Kingston, ON, Canada
| | - Andrew D Chung
- Department of Radiology, Queen's University, Kingston General Hospital, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anaesthesiology and Perioperative Medicine, Queen's University, Kingston General Hospital, Kingston, ON, Canada.
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45
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Ho AMH, Mizubuti GB. Co-induction with a vasopressor "chaser" to mitigate propofol-induced hypotension when intubating critically ill/frail patients-A questionable practice. J Crit Care 2019; 54:256-260. [PMID: 31630076 DOI: 10.1016/j.jcrc.2019.09.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 08/14/2019] [Accepted: 09/11/2019] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
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Menezes DC, Vidal EIO, Costa CM, Mizubuti GB, Ho AMH, Barros GAM, Fukushima FB. [Sufentanil during anesthetic induction of remifentanil-based total intravenous anesthesia: a randomized controlled trial]. Rev Bras Anestesiol 2019; 69:327-334. [PMID: 31351679 DOI: 10.1016/j.bjan.2018.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 11/26/2018] [Accepted: 12/05/2018] [Indexed: 10/26/2022] Open
Abstract
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 48h after surgery were -7.2mg (95%CI: -12.5 to -2.1, p<0.001), -3.9mg (95%CI: -11.9 to 4.7, p=0.26), -0.6mg (95%CI: (-12.7 to 12.7, p=0.80), and -1.8mg (95%CI: (-11.6 to 15.6, p=0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point. CONCLUSION Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.
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Affiliation(s)
| | - Edison I O Vidal
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Medicina Interna, Botucatu, SP, Brasil
| | - Cesar M Costa
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Medicina Interna, Botucatu, SP, Brasil
| | - Glenio B Mizubuti
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Anthony M H Ho
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Guilherme A M Barros
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brasil
| | - Fernanda B Fukushima
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brasil.
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Ho AMH, Phelan R, Mizubuti GB, Murdoch JAC, Wickett S, Ho AK, Shyam V, Gilron I. Bias in Before-After Studies: Narrative Overview for Anesthesiologists. Anesth Analg 2019; 126:1755-1762. [PMID: 29239959 DOI: 10.1213/ane.0000000000002705] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Anthony M H Ho
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rachel Phelan
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - John A C Murdoch
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sarah Wickett
- Bracken Health Sciences Library, Queen's University, Kingston, Ontario, Canada
| | - Adrienne K Ho
- City Hospital and Queen's Medical Center, Nottingham, United Kingdom
| | - Vidur Shyam
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ian Gilron
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
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48
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Ho AMH, Mizubuti GB, Ho AK, Wan S, Sydor D, Chung DC. Success rate of resuscitation after out-of-hospital cardiac arrest. Hong Kong Med J 2019; 25:254-256. [PMID: 31182676 DOI: 10.12809/hkmj187596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- A M H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Canada
| | - G B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Canada
| | - A K Ho
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - S Wan
- Division of Cardiac Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - D Sydor
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Canada
| | - D C Chung
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
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49
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Menezes DC, Vidal EI, Costa CM, Mizubuti GB, Ho AM, Barros GA, Fukushima FB. [Sufentanil during anesthetic induction of remifentanil-based total intravenous anesthesia: a randomized controlled trial]. Braz J Anesthesiol 2019; 69. [PMID: 31351679 PMCID: PMC9391889 DOI: 10.1016/j.bjane.2019.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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 48h after surgery were -7.2mg (95%CI: -12.5 to -2.1, p<0.001), -3.9mg (95%CI: -11.9 to 4.7, p=0.26), -0.6mg (95%CI: (-12.7 to 12.7, p=0.80), and -1.8mg (95%CI: (-11.6 to 15.6, p=0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point. CONCLUSION Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.
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Affiliation(s)
| | - Edison I.O. Vidal
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Medicina Interna, Botucatu, SP, Brazil
| | - Cesar M. Costa
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Medicina Interna, Botucatu, SP, Brazil
| | - Glenio B. Mizubuti
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canada
| | - Anthony M.H. Ho
- Queen's University, Department of Anesthesiology and Perioperative Medicine, Kingston, Canada
| | - Guilherme A.M. Barros
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brazil
| | - Fernanda B. Fukushima
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brazil,Corresponding author.
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Mizubuti GB, Allard RV, Ho AMH, Wang L, Beesley T, Hopman WM, Egan R, Sydor D, Engen D, Saha T, Tanzola RC. [Knowledge retention after focused cardiac ultrasound training: a prospective cohort pilot study]. Rev Bras Anestesiol 2019; 69:177-183. [PMID: 30665672 DOI: 10.1016/j.bjan.2018.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 09/13/2018] [Accepted: 10/31/2018] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Glenio B Mizubuti
- Queen's University, Kingston General Hospital, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Rene V Allard
- Queen's University, Kingston General Hospital, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Anthony M-H Ho
- Queen's University, Kingston General Hospital, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Louie Wang
- Queen's University, Kingston General Hospital, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | | | - Wilma M Hopman
- Queen's University, Kingston Sciences Centre Research Institute and Public Health Sciences, Kingston, Canadá
| | - Rylan Egan
- Queen's University, Healthcare Quality Graduate Programs, Kingston, Canadá
| | - Devin Sydor
- Queen's University, Kingston General Hospital, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Dale Engen
- Queen's University, Kingston General Hospital, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Tarit Saha
- Queen's University, Kingston General Hospital, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá
| | - Robert C Tanzola
- Queen's University, Kingston General Hospital, Department of Anesthesiology and Perioperative Medicine, Kingston, Canadá.
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