Introduction: Virtual care has recently gained momentum yet remains underutilized for preoperative assessment. We applied implementation science methodology to the development of a virtual preoperative assessment pathway. Methods: We conducted a two-phase formative evaluation of a multidisciplinary virtual preoperative assessment. In phase 1, we conducted semi-structured interviews with patients, family members, health care providers, and decision makers to explore their experiences and perceptions of virtual care and preoperative assessment. We performed thematic analysis using the Promoting Action on Research Implementation in Health Services (PARIHS) framework to identify factors influencing the implementation of virtual preoperative assessments. In phase 2, evidence-based strategies from the Expert Recommendations for Implementing Change (ERIC) were matched to PARIHS themes and rated for importance and feasibility by stakeholders using Go-Zone analysis. Results: Forty stakeholders were interviewed, including 12 patients or family members, 18 health care providers, and 10 decision makers. Eight themes and 49 subthemes were identified to focus the implementation of virtual preoperative assessment. Twelve implementation strategies were judged to be most important and feasible by stakeholders: develop a formal implementation blueprint, identify early adopters, identify and prepare champions, involve patients and family members, conduct local consensus discussions, build a coalition, develop educational materials, distribute educational materials, prepare patients to be active participants, revise professional roles, re-examine the implementation, and stage implementation scaleup. Discussion: We identified 12 evidence-based strategies to guide the implementation of virtual multidisciplinary preoperative assessments. Our findings can be used to guide implementation of this care innovation in other settings.

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Background: Canadian specialty training programs are expected to deliver curriculum content and assess competencies related to the CanMEDS Scholar role. We evaluated our residency research program and benchmarked it against national norms for quality improvement purposes. Methods: In 2021, we reviewed departmental curriculum documents and surveyed current and recently graduated residents. We applied a logic model framework to assess if our program’s inputs, activities, and outputs addressed the relevant CanMeds Scholar competencies. We then descriptively benchmarked our results against a 2021 environmental scan of Canadian anesthesiology resident research programs. Results: Local program content was successfully mapped to competencies. The local survey response rate was 40/55 (73%). In benchmarking, our program excelled in providing milestone-related assessments, research funding, administrative, supervisory, and methodologic support, and requiring a literature review, proposal presentation, and local abstract submission as output. Acceptable activities to meet research requirements vary greatly among programs. Balancing competing clinical and research responsibilities was a frequently reported challenge. Conclusions: The logic model framework was easily applied and demonstrated our program benchmarked well against national norms. National level dialogue is needed to develop specific, consistent scholar role activities and competency assessments to bridge the gap between expected outcome standards and education practice.

Purpose Airway evaluation is a fundamental component of the preanesthetic examination. Virtual care has increased during the COVID-19 pandemic. We aimed to assess the reliability of a virtual preanesthetic airway evaluation compared with a traditional in-person airway evaluation. Methods This prospective observational study compared the inter-rater agreement of an in-person airway evaluation performed by a consultant anesthesiologist with a virtual airway evaluation (VAE) performed by consultant anesthesiologists and medical students. The airway evaluation was completed using a comprehensive airway evaluation and scoring tool. The primary outcome was the inter-rater agreement of total scores between in-person anesthesiologist airway evaluations and the VAEs of both the anesthesiologists and medical students, assessed using Cohen's Kappa (CK). Secondary outcomes included the inter-rater agreement for each airway evaluation component between the in-person anesthesiologists and both the anesthesiologist and medical student VAEs, assessed using prevalence-adjusted and bias-adjusted Kappa. Results One hundred out of 111 participants completed all three evaluations. The in-person anesthesiologist airway evaluations had fair and good levels of agreement of total scores with the VAEs of the anesthesiologists (CK, 0.21; 97.5% confidence interval [CI], 0.07 to 0.34) and the medical students (CK, 0.74; 97.5% CI, 0.62 to 0.86), respectively. One participant was reported to have a difficult intubation. Conclusion Virtual airway evaluations performed by anesthesiologists and medical students had fair and good inter-rater agreement, respectively, with in-person anesthesiologist airway evaluations. Further study with a focus on patients with difficult airways is required to define the predictive value of VAEs regarding difficult intubations.

The COVID-19 pandemic prompted the rapid uptake of Virtual Care (VC). Positive patient outcomes with VC are previously reported but little is known about the experiences of patients and providers using VC during the pandemic. We aimed to describe patient and primary care provider experiences, satisfaction, perceptions, and attitudes to VC during the COVID-19 pandemic that might explain adoption of VC across the continuum of care and inform sustained uptake. We conducted a sequential explanatory mixed methods study using online surveys and virtual interviews with a convenience sample of primary care providers and patients in a Canadian province (July – December 2020). Eligible participants included patients and primary care providers using VC during the COVID-19 pandemic. Survey responses and interviews were analyzed using descriptive statistics and thematic analysis, respectively. Overall satisfaction was compared using the Mann-Whitney U test. Eighty-five patients and 94 primary care providers responded to the surveys. Patients reported higher overall satisfaction with VC than primary care providers (median [interquartile range]: 4.4 [4.0-4.7] and 3.7 [3.4-3.9] p < 0.001). Ten patients and 11 primary care providers were interviewed. Both groups strongly appreciated VC’s increased access and convenience, identified the lack of compensation as a pre-pandemic barrier to providing VC, and reported willingness to continue VC post-COVID-19 pandemic. The COVID-19 pandemic provided an opportunity for patients and primary care providers to rapidly adopt VC with high satisfaction. Patients and primary care providers viewed VC positively due to its convenience and accessibility; both intend to continue using VC post-pandemic. Experience Framework This article is associated with the Staff & Provider Engagement lens of The Beryl Institute Experience Framework (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens.

Endotracheal intubation is a common lifesaving procedure. An in situ endotracheal tube (ETT) must be secured in position to avoid displacement and potentially life-threatening complications. Adhesive tapes form the most common intraoperative ETT stabilization methods. Limited published data are available to guide the clinical decision regarding ETT taping method. We performed an interventional study aiming to establish which of many commonly employed ETT tape/supplementary adhesive methods provides the most resistance to ETT distraction. An experiment was undertaken to measure the force required to distract an ETT secured to a live dermal model with 24 different ETT securing methods comprising six types of tape alone and in combination with one of three supplementary adhesives. The primary measurement was the peak force (Newtons) required to distract a secured ETT 3 cm. A total of 1,164 measurements were made. The mean force required to distract the ETT ranged from 7.8 to 21.8 Newtons. The combination of Cloth Adhesive™ + Mastisol® had the greatest observed mean distraction force, as well as the greatest estimated lower and upper confidence limits. There are significant differences in force required to distract an ETT based on taping methods.

Shock is common in critically ill and injured patients. Survival during shock is highly dependent on rapid restoration of tissue oxygenation with therapeutic goals based on cardiac output (CO) optimization. Despite the clinical availability of numerous minimally invasive monitors of CO, limited supporting performance data are available. Following approval of the University of Saskatchewan Animal Research Ethics Board, we assessed the performance and trending ability of PiCCOplus™, FloTrac™, and CardioQ-ODM™ across a range of CO states in pigs. In addition, we assessed the ability of invasive mean arterial blood pressure (iMAP) to follow changes in CO using a periaortic transit-time flow probe as the reference method. Statistical analysis was performed with function-fail, bias and precision, percent error, and linear regression at all flow, low-flow (> 1 standard deviation [SD] below the mean), and high-flow (> 1 SD above the mean) CO conditions. We made a total of 116,957 paired CO measurements. The non-invasive CO monitors often failed to provide a CO value (CardioQ-ODM: 40.6% failed measurements; 99% confidence interval [CI], 38.5 to 42.6; FloTrac: 9.6% failed measurements; 99% CI, 8.7 to 10.5; PiCCOplus: 4.7% failed measurements; 99% CI, 4.5 to 4.9; all comparisons, P < 0.001). The invasive mean arterial pressure provided zero failures, failing less often than any of the tested CO monitors (all comparisons, P < 0.001). The PiCCOplus was most interchangeable with the flow probe at all flow states: PiCCOplus (20% error; 99% CI, 19 to 22), CardioQ-ODM (25% error; 99% CI, 23 to 27), FloTrac (34% error; 99% CI, 32 to 38) (all comparisons, P < 0.001). At low-flow states, CardioQ-ODM (43% error; 99% CI, 32 to 63) and Flotrac (45% error; 99% CI, 33 to 70) had similar interchangeability (P = 0.07), both superior to PiCCOplus (48% error; 99% CI, 42 to 60) (P < 0.001). Regarding CO trending, the CardioQ-ODM (correlation coefficient, 0.82; 99% CI, 0.81 to 0.83) was statistically superior to other monitors including iMAP, but at low flows iMAP (correlation coefficient, 0.58; 99% CI, 0.58 to 0.60) was superior to all minimally invasive CO monitors (all comparisons P < 0.001). None of the minimally invasive monitors of CO performed well at all tested flows. Invasive mean arterial blood pressure most closely tracked CO change at critical flow states.

Postoperative vomiting (POV) in children is frequent. Dextrose-containing intravenous fluids in the perioperative period have shown improvement of POV in adults. Similar studies have not been done in children. The primary purpose was to study the efficacy of intraoperative intravenous dextrose for antiemetic prophylaxis in children undergoing ambulatory surgery. A non-inferiority randomized clinical trial of healthy children (three to nine years old) undergoing ambulatory dental surgery was conducted. The control group received dexamethasone (0.15 mg·kg−1 iv) and ondansetron (0.05 mg·kg−1 iv); the intervention group received dexamethasone (0.15 mg·kg−1 iv) and intravenous 5% dextrose in 0.9% normal saline according to a weight-based maintenance rate. The primary outcome was POV in the postanesthetic care unit (PACU) within two hr after surgery. Secondary outcomes included POV within 24 hr from discharge and unplanned hospital admission. A non-inferiority analysis was conducted on the primary outcome using an absolute risk difference of 7.5% as the non-inferiority margin. Data from 290 patients were analyzed. Demographics and intraoperative anesthetic management were similar between groups. Vomiting in the PACU occurred in 7.6% and 3.5% of the dextrose and ondansetron groups, respectively, with a risk difference of 4.2% (95% confidence interval [CI], -1.0 to 9.5). Given that the upper limit of the 95% CI exceeded our non-inferiority margin, non-inferiority of dextrose compared with ondansetron was not shown. These results do not support the use of intravenous dextrose as a satisfactory alternative to ondansetron to prevent POV in ambulatory pediatric dental surgery patients. www.clinicaltrials.gov (NCT 01912807); registered 18 July 2013.

The harms caused by excessive perioperative intravenous (IV) fluid administration are both well recognized and avoidable. The purpose of this study was to compare the incidence of excess intraoperative fluid administration in pediatric dental surgery patients when either an automated pump-delivery device or a manual gravity-drip device is used. We randomly assigned American Society of Anesthesiologists physical status I and II pediatric dental surgery patients to receive IV fluid via either a manual gravity-drip or automated pump-delivery device. Prior to each case, the attending anesthesiologist determined the target volume of maintenance IV fluid to be administered based on patient weight, estimated fluid deficits, and expected case length. The intraoperative IV fluid delivered was determined at the end of the case by the change in the IV bag weight. The primary outcome was the proportion of procedures that delivered ≥ 10% of the target IV fluid volume. We recruited 105 children aged two to 12 yr (n = 49 in the automated pump-delivery device; n = 53 in the manual gravity-drip device). The proportion of excessive fluid administration was 8/49 (16%) in the automated pump-delivery device group compared with 33/53 (62%) in the gravity-drip group (relative risk of excessive fluid administration, 0.26; 95% confidence interval, 0.13 to 0.51; P < 0.001). Intraoperative fluid administration using an automated pump-delivery device decreased the incidence of excessive IV fluid administration in pediatric dental surgery patients. www.clinicaltrials.gov (NCT03312452); registered 17 October 2017.

Within the provincial jurisdiction of the singular Saskatchewan Health Authority (SHA), the Department of Anesthesiology's provincial head and research director are responsible for catalyzing provincial anesthesiology research endeavors.There is a need to encourage research in the geographically disperse communities of Saskatchewan, discover research interests and needs, and establish a strategic plan to achieve meaningful research outputs.Inspired by priority setting partnerships (PSP) that enable patients, caregivers, and clinicians to agree on the top ten priorities for future research in anesthesiology, 1,2 our aim was to understand the research priorities of Saskatchewan anesthesiologists, their geographical distribution, and their willingness to conduct and participate in research.Following a University of Saskatchewan research ethics board exemption (14 May 2019), we invited 128 Saskatchewan anesthesiologists and 22 family practice anesthesia (FPA) providers to participate in a confidential online survey (Survey Monkey) using personal email addresses where a preference had been expressed to departmental administrative staff, and SHA

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

BackgroundPositive-pressure ventilation in critically ill patients is commonly administered via a manual resuscitation device or a mechanical ventilator during transport. Our group previously compared delivered ventilation parameters between a self-inflating resuscitator and a flow-inflating resuscitator during simulated in-hospital pediatric transport. However, unequal group access to inline pressure manometry may have biased our results. In this study, we examined the performance of the self-inflating resuscitator and the flow-inflating resuscitator, both equipped with inline manometry, and several mechanical ventilators to deliver prescribed ventilation parameters during simulated pediatric transport. MethodsThirty anesthesia providers were randomized to initial resuscitator device used to hand ventilate a test lung. The resuscitators studied were a Jackson-Rees circuit (flow-inflating resuscitator) or a Laerdal pediatric silicone resuscitator (self-inflating resuscitator), both employing manometers. The scenario was repeated using several mechanical transport ventilators (Hamilton-T1, LTV (R) 1000, and LTV (R) 1200). The primary outcome was the proportion of total breaths delivered within the predefined target PIP/PEEP range (303, 103cm H2O). ResultsThe Hamilton-T1 outperformed the other ventilators for breaths in the recommended range ((2)=2284, df= 2, P<.001) and with no breaths in the unacceptable range ((2)=2333, df=2, P<.001). Hamilton-T1 also outperformed all human providers in proportion of delivered acceptable and unacceptable breaths ((2)=4540, df=3, P<.001 and (2)=639, df=3, P<.001, respectively). Compared with the flow-inflating resuscitator, the self-inflating resuscitator was associated with greater odds of breaths falling outside the recommended range (Odds ratio (95% CI): 1.81 (1.51-2.17)) or unacceptable (Odds ratio (95% CI): 1.63 (1.48-1.81)). ConclusionThis study demonstrates that a majority of breaths delivered by manual resuscitation device fall outside of target range regardless of provider experience or device type. The mechanical ventilator (Hamilton-T1) outperforms the other positive-pressure ventilation methods with respect to delivery of important ventilation parameters. In contrast, 100% of breaths delivered by the LTV 1200 were deemed unacceptable.

BACKGROUND:Major depressive disorder (MDD) is a common and debilitating condition that can be challenging to treat. Electroconvulsive therapy (ECT) is currently the therapeutic gold standard for treatment-resistant MDD. We tested our hypothesis that ketamine-based anesthesia for ECT results in superior improvement in treatment-resistant MDD outcomes compared with propofol-based anesthesia.METHODS:Patients with treatment-resistant MDD were enrolled in a randomized clinical trial with assignment to ketamine- or propofol-based anesthesia arms. Using a modified intention-to-treat analysis, we compared the median number of ECT treatments required to achieve a 50% reduction (primary outcome) and a score ≤ 10 (secondary outcome) on the Montgomery-Asberg depression rating scale (MADRS) between anesthesia groups.RESULTS:The study was terminated as significant results were found after the first planned interim analysis with 12 patients in each of the ketamine (intervention) and propofol (control) groups. All ketamine patients achieved at least a 50% MADRS reduction after a median of two ECT treatments whereas ten propofol patients (83%) achieved the same outcome after a median of four ECT treatments. All ketamine patients and seven propofol patients (58%) achieved MDD remission (MADRS ≤ 10). Log rank tests showed that both time-to-50% reduction and remission differed significantly between groups. Adverse events and recovery time were similar between groups.CONCLUSIONS:In this early-terminated small-sized study, ketamine-based anesthesia compared with propofol-based anesthesia provided response and remission after fewer ECT sessions.TRIAL REGISTRATION:www.clinicaltrials.gov (NCT01935115). Registered 4 September 2013.

During resection of a duodenal carcinoid tumor, a 28-year-old morbidly obese woman developed suspected malignant hyperthermia. This hypermetabolic state posed a diagnostic challenge given the similar intraoperative presentation of carcinoid crisis and malignant hyperthermia. The patient's weight posed therapeutic challenges as massive doses and prolonged administration of dantrolene were required that quickly depleted the available supply. Current dantrolene dosing recommendations are based on actual body weight despite a paucity of literature in obese patients. We speculate that the prolonged need for dantrolene redosing was from the continuous release of the volatile anesthetic from the patient's adipose tissue.

Pediatric AnesthesiaVolume 26, Issue 2 p. 221-222 Correspondence Modified pediatric Magill forceps effect on nasal intubation time Farrukh N. Munshey, Farrukh N. Munshey [email protected] Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, CanadaSearch for more papers by this authorJonathan J. Gamble, Jonathan J. Gamble Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, CanadaSearch for more papers by this authorWilliam P. McKay, William P. McKay Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, CanadaSearch for more papers by this author Farrukh N. Munshey, Farrukh N. Munshey [email protected] Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, CanadaSearch for more papers by this authorJonathan J. Gamble, Jonathan J. Gamble Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, CanadaSearch for more papers by this authorWilliam P. McKay, William P. McKay Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, CanadaSearch for more papers by this author First published: 04 January 2016 https://doi.org/10.1111/pan.12823Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Mahan R, Batra Y, Kumar S. Another use of Magill forceps to assist in nasotracheal intubation. Can J Anaesth 2007; 54: 957–958. 10.1007/BF03026808 PubMedGoogle Scholar 2Santillanes G, Gausche-Hill M. Pediatric airway management. Emerg Med Clin North Am 2008; 26: 961–975. 10.1016/j.emc.2008.08.004 PubMedWeb of Science®Google Scholar 3Boedeker BH, Bernhagen MA, Miller DJ et al. Comparison of the Magill forceps and the Boedeker (curved) intubation forceps for removal of a foreign body in a manikin. J Clin Anaesth 2012; 24: 25–27. 10.1016/j.jclinane.2011.04.013 PubMedWeb of Science®Google Scholar 4Sim L, Patel A, Enderby D. Modified Magill's forceps revisited. Anaesthesia 2004; 59: 97. 10.1111/j.1365-2044.2004.03597.x CASPubMedWeb of Science®Google Scholar 5Liberman H. A new intubating forceps. Anaesth Intensive Care 1978; 6: 162–163. 10.1177/0310057X7800600215 CASPubMedWeb of Science®Google Scholar Citing Literature Volume26, Issue2February 2016Pages 221-222 ReferencesRelatedInformation