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. 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

A 76-year-old woman with myxomatous changes of the mitral valve and severe mitral regurgitation underwent an elective mitral valve repair and coronary artery bypass grafting. The intraoperative course was complicated by an inferior vena cava tear and coagulopathy requiring return to the operating room on postoperative day 1 to rule out a surgical cause of ongoing bleeding. A transthoracic echocardiogram (TTE) was performed on postoperative day 6 (Video 1). An 88-year-old-man with severe aortic valve stenosis and atrial fibrillation had his anticoagulation discontinued after recurrent episodes of lower GI bleeding. He had a cardiac CT scan performed as part of a preoperative transcatheter aortic valve implantation (TAVI) workup. There were concerning findings on the CT scan, which prompted admission to hospital and a subsequent TTE (Video 2). Question: Based on the presented TTE clips, where is the abnormality in each clip located, and what is the most likely differential diagnosis? Answer: Patient 1: TTE demonstrated a possible mobile mass in the left atrium (LA), likely originating from the right upper pulmonary vein. This was further investigated with a cardiac CT scan (Fig 1), which revealed bilateral moderate-sized pleural effusions and atelectasis, but no evidence of a LA or pulmonary vein thrombus. Patient 2: The CT scan revealed a lobulated filling defect within the LA extending to the LA appendage and measuring 5.2 cm × 2.7 cm (Fig 2). Subsequent TTE demonstrated a mobile LA mass located in the inferior-posterior portion of the LA and extending into the LA appendage, consistent with an LA thrombus. The absence of LA and LA appendage filling defect on cardiac CT scan (Fig 1) ruled out an intracardiac thrombus such that the suspicious finding seen on TTE was most likely consistent with an imaging artifact. No further investigation or treatment was required. Anticoagulation was initiated, and the patient (who remained asymptomatic) was discharged home with a follow-up TTE scheduled in 1 month’s time. Artifacts are common and an inherent limitation of US-based diagnostic modalities such as echocardiography, often resulting in apparent distortions of normal anatomy, as exemplified herein (patient 1). Practitioners must understand how artifacts are generated and, most importantly, how to proceed when faced with a potential artifact. Misinterpreting artifacts as pathologic entities can lead to inappropriate patient interventions, and misreading pathologic findings as artifacts can prevent initiation of proper and timely management. Common imaging artifacts and their respective mechanisms have been previously described1Bertrand P.B. Levine R.A. Isselbacher E.M. Vandervoort P.M. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis.J Am Soc Echocardiogr. 2016; 29: 381-391Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 2Le H.T. Hangiandreou N. Timmerman R. et al.Imaging artifacts in echocardiography.Anesth Analg. 2016; 122: 633-646Crossref PubMed Scopus (23) Google Scholar, 3Quien M.M. Saric M. Ultrasound imaging artifacts: how to recognize them and how to avoid them.Echocardiography. 2018; 35: 1388-1401Crossref PubMed Scopus (26) Google Scholar and can be broadly classified into two categories: (1) those arising from violating built-in assumptions within the US imaging system and (2) those arising from interference from external devices. Side-lobe and beam-width artifacts are generated when the assumption that echoes are only generated from reflectors within the main US beam is violated.3Quien M.M. Saric M. Ultrasound imaging artifacts: how to recognize them and how to avoid them.Echocardiography. 2018; 35: 1388-1401Crossref PubMed Scopus (26) Google Scholar A US beam has an hourglass appearance as it travels from the transducer. The beam remains the same width until it narrows toward the focal zone and then increasingly diverges beyond the focal zone1Bertrand P.B. Levine R.A. Isselbacher E.M. Vandervoort P.M. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis.J Am Soc Echocardiogr. 2016; 29: 381-391Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar,3Quien M.M. Saric M. Ultrasound imaging artifacts: how to recognize them and how to avoid them.Echocardiography. 2018; 35: 1388-1401Crossref PubMed Scopus (26) Google Scholar (Fig 3). However, echogenic objects that reside where the beam diverges can be interpreted as originating from the focal zone, creating a beam-width artifact. Similarly, a side-lobe artifact is produced when the small amount of energy emitted from the side of the beam hits a strong reflector within these side lobes and is interpreted as originating from the central beam.3Quien M.M. Saric M. Ultrasound imaging artifacts: how to recognize them and how to avoid them.Echocardiography. 2018; 35: 1388-1401Crossref PubMed Scopus (26) Google Scholar In practice, echocardiographic beam-width and side-lobe artifacts are commonly produced from highly reflective annular or prosthetic interfaces and can be mistaken for thrombi or vegetations.1Bertrand P.B. Levine R.A. Isselbacher E.M. Vandervoort P.M. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis.J Am Soc Echocardiogr. 2016; 29: 381-391Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar,4Kyavar M. Sadeghpour A. Alizadehasl A. Salehi N. Thrombosis on implanted device for atrial septal defect closure or echocardiographic beam width artifact? A diagnostic enigma.Int J Cardiovasc Imaging. 2012; 28: 1851-1852Crossref PubMed Scopus (5) Google Scholar Prior reports have demonstrated that beam-width artifacts have created the appearance of a strong reflector within the LA, which can be mistaken for migration of a pulmonary artery catheter or pacemaker lead into the LA.5Skubas N. Brown N.I. Mishra R. Diagnostic dilemma: a pacemaker lead inside the left atrium or an echocardiographic beam width artifact?.Anesth Analg. 2006; 102: 1043-1044Crossref PubMed Scopus (9) Google Scholar In the case of patient 1, we speculate that the observed artifact resulted from an interaction between the pleural effusion and the atelectatic lung, as follows: a pleural effusion appears as an anechoic space on US, and the atelectatic lung becomes comparatively hyperechoic and acts as a strong reflector located outside of the US beam focal zone, which in turn is picked up by the weak US beam side lobe and interpreted as occurring within the main US beam over the LA. Accordingly, Karabinis et al6Karabinis A. Saranteas T. Karakitsos D. et al.The ‘cardiac-lung mass’ artifact: an echocardiographic sign of lung atelectasis and/or pleural effusion.Crit Care. 2008; 12: R122Crossref PubMed Scopus (18) Google Scholar described a “cardiac-lung mass” artifact that serves as an example of how cardiac artifacts are generated from the interaction between the US beam and adjacent parenchymal lung disease.6Karabinis A. Saranteas T. Karakitsos D. et al.The ‘cardiac-lung mass’ artifact: an echocardiographic sign of lung atelectasis and/or pleural effusion.Crit Care. 2008; 12: R122Crossref PubMed Scopus (18) Google Scholar These investigators reported on an intracardiac artifact only visible in apical views in 17 of 205 patients with atelectasis or pleural effusions (11 within left cardiac chamber; 6 within right cardiac chamber). In all cases, atelectasis or pleural effusions were located adjacent to the heart, and in some cases the cardiac artifact displayed respiratory variation on M-mode. The artifact resolved with resolution of lung pathology. The authors speculate this cardiac-lung mass artifact is attributable to beam-width or mirror image artifact generated by abnormalities in the lung parenchyma.6Karabinis A. Saranteas T. Karakitsos D. et al.The ‘cardiac-lung mass’ artifact: an echocardiographic sign of lung atelectasis and/or pleural effusion.Crit Care. 2008; 12: R122Crossref PubMed Scopus (18) Google Scholar The artifact in patient 1 resided in the LA by the right upper pulmonary vein. The “cardiac-mass lung artifact” described by Karabinis et al6Karabinis A. Saranteas T. Karakitsos D. et al.The ‘cardiac-lung mass’ artifact: an echocardiographic sign of lung atelectasis and/or pleural effusion.Crit Care. 2008; 12: R122Crossref PubMed Scopus (18) Google Scholar appeared as an echogenic structure at the level of the mitral valve with a less echogenic, mobile structure projecting toward the LA. The addition of M-mode in the patient would have improved temporal resolution and potentially displayed respiratory variation similar to that demonstrated by Karabinis et al6Karabinis A. Saranteas T. Karakitsos D. et al.The ‘cardiac-lung mass’ artifact: an echocardiographic sign of lung atelectasis and/or pleural effusion.Crit Care. 2008; 12: R122Crossref PubMed Scopus (18) Google Scholar if indeed the observed artifact was originating from adjacent lung parenchymal disease. Application of color Doppler also may have revealed flow through the artifact that would not be seen with a true mass. Differentiating artifacts from true anatomy can be challenging, but various strategies have been described. An important concept that holds true to all types of artifacts is to image the same structure through different acoustic windows and with different angles because artifacts are not typically reproducible in multiple echocardiographic planes.2Le H.T. Hangiandreou N. Timmerman R. et al.Imaging artifacts in echocardiography.Anesth Analg. 2016; 122: 633-646Crossref PubMed Scopus (23) Google Scholar, 3Quien M.M. Saric M. Ultrasound imaging artifacts: how to recognize them and how to avoid them.Echocardiography. 2018; 35: 1388-1401Crossref PubMed Scopus (26) Google Scholar, 4Kyavar M. Sadeghpour A. Alizadehasl A. Salehi N. Thrombosis on implanted device for atrial septal defect closure or echocardiographic beam width artifact? A diagnostic enigma.Int J Cardiovasc Imaging. 2012; 28: 1851-1852Crossref PubMed Scopus (5) Google Scholar, 5Skubas N. Brown N.I. Mishra R. Diagnostic dilemma: a pacemaker lead inside the left atrium or an echocardiographic beam width artifact?.Anesth Analg. 2006; 102: 1043-1044Crossref PubMed Scopus (9) Google Scholar Artifacts also do not respect normal anatomic boundaries.7Markan S. Haider N. Novalija J. Iqbal Z. Gandhi S.D. Pagel P.S. A mobile threadlike structure in the left atrium: cor triatriatum, artifact, or thrombus?.J Cardiothorac Vasc Anesth. 2009; 23: 566-568Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Minimizing the gain settings may help decrease strong reflections from weaker lobes, thereby reducing side-lobe artifacts,3Quien M.M. Saric M. Ultrasound imaging artifacts: how to recognize them and how to avoid them.Echocardiography. 2018; 35: 1388-1401Crossref PubMed Scopus (26) Google Scholar,5Skubas N. Brown N.I. Mishra R. Diagnostic dilemma: a pacemaker lead inside the left atrium or an echocardiographic beam width artifact?.Anesth Analg. 2006; 102: 1043-1044Crossref PubMed Scopus (9) Google Scholar which also can be mitigated with tissue harmonic imaging through improvement of image contrast.2Le H.T. Hangiandreou N. Timmerman R. et al.Imaging artifacts in echocardiography.Anesth Analg. 2016; 122: 633-646Crossref PubMed Scopus (23) Google Scholar, 3Quien M.M. Saric M. Ultrasound imaging artifacts: how to recognize them and how to avoid them.Echocardiography. 2018; 35: 1388-1401Crossref PubMed Scopus (26) Google Scholar, 4Kyavar M. Sadeghpour A. Alizadehasl A. Salehi N. Thrombosis on implanted device for atrial septal defect closure or echocardiographic beam width artifact? A diagnostic enigma.Int J Cardiovasc Imaging. 2012; 28: 1851-1852Crossref PubMed Scopus (5) Google Scholar Color Doppler is also useful,1Bertrand P.B. Levine R.A. Isselbacher E.M. Vandervoort P.M. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis.J Am Soc Echocardiogr. 2016; 29: 381-391Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar because flow can be seen through the artifact but not through a true mass. Beam-width artifacts can be minimized with adjustment of the focal zone.1Bertrand P.B. Levine R.A. Isselbacher E.M. Vandervoort P.M. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis.J Am Soc Echocardiogr. 2016; 29: 381-391Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar Finally, when in doubt, one should pursue additional imaging modalities3Quien M.M. Saric M. Ultrasound imaging artifacts: how to recognize them and how to avoid them.Echocardiography. 2018; 35: 1388-1401Crossref PubMed Scopus (26) Google Scholar, 4Kyavar M. Sadeghpour A. Alizadehasl A. Salehi N. Thrombosis on implanted device for atrial septal defect closure or echocardiographic beam width artifact? A diagnostic enigma.Int J Cardiovasc Imaging. 2012; 28: 1851-1852Crossref PubMed Scopus (5) Google Scholar, 5Skubas N. Brown N.I. Mishra R. Diagnostic dilemma: a pacemaker lead inside the left atrium or an echocardiographic beam width artifact?.Anesth Analg. 2006; 102: 1043-1044Crossref PubMed Scopus (9) Google Scholar,7Markan S. Haider N. Novalija J. Iqbal Z. Gandhi S.D. Pagel P.S. A mobile threadlike structure in the left atrium: cor triatriatum, artifact, or thrombus?.J Cardiothorac Vasc Anesth. 2009; 23: 566-568Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar (as was done in patient 1) to ensure no true pathologic abnormality is present that may jeopardize appropriate management (such as the real thrombus noted in patient 2). Video 3 highlights additional TTE images taken in patient 1 and patient 2 in an attempt to differentiate artifact from a true mass. See also the Narration Video for a detailed explanation of Videos 1-3. 1.Artifacts are produced when built-in assumptions within the US imaging system/equipment are violated or when there is external interference with the US beam. Recognizing how artifacts are generated can help avoid misdiagnosis and unnecessary testing.2.US artifacts are rarely visible in multiple acoustic planes and do not respect anatomic boundaries. Side-lobe and beam-width artifacts can be reduced or recognized by using tissue harmonic imaging, reducing gain, applying color Doppler, or adjusting the focal zone.3.Additional imaging modalities may be required to differentiate artifact from true anatomic or pathologic structures.4.Atelectasis associated with pleural effusions adjacent to cardiac structures are strong reflectors and can cause side-lobe or beam-width artifacts that may be misinterpreted as intracardiac masses. None declared. Author contributions: S. M. was involved in obtaining ethics approval, drafting and revising the manuscript, and approving the final version for publication. G. B. M. helped by drafting and critically revising the manuscript and approving the final version for publication. P. D. was involved in the care of the patients and helped by drafting and critically revising the manuscript and approving the final version for publication. R. A. helped by drafting and critically revising the manuscript and approving the final version for publication. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: Videos for this case are available under "Supplementary Data." eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlYTI0ZGJkN2RmOGExOTg1NzQ1YzNhNjZhYzhjM2NiMSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg4Mzg5NTQ4fQ.PyAmZbASw6FlXTwVCWzGxv9ZHkE1oP8mqm6PRI3lokR_qd6jhnMiYjtl7Tv3QnSz19w504ZhzLmYe3wGsrTZ0z1aqw1YWWMbEeorvwDmOlebnBxnBSZyfIAMskNk11KBd3K9_Xf-7TfGAj2_M78suitxCMuqG7esRenMVwYU8lKEop1sN9_tblfpWAqLJVKJGHzlWjpqVeRnwBH_gvMv73plEEbQxN6ZF_2sgjXCNh_CW7Jl6fi_vpR57Jx2VXMqQCPThgi4P9-xt50H-i6VsAOrhtc9JMuD0U7n3DhGHMgjlMIpPK3CQ9BhCc886zmXTXG4PAQhc6_5RHdbpudceQ Download .mp4 (13.39 MB) Help with .mp4 files Video 1Transthoracic echocardiogram apical four-chamber view of a 76-year-old woman on postoperative day 6 after a mitral valve repair and coronary artery bypass grafteyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlNjNlMWY1NzhiZTg1OGJlY2RiNjNhZDIyNjkzNGMzZiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg4Mzg5NTQ4fQ.ZLBn4Dl7MOIZJ3zEBBa-WkFtSMkcDpSNBHIMhJAdzkbZCxeezrkp8rY0kyy2JbtKidcVqoshTzIGlZfcFjw7IsGVXuS_AbJV3VE8ySh3Ts-DDglfTJBQnxRe-70PntXVOKaVlRU-5jRisw0sSIB4rBzdar52WP0DYYCDMBIaWHqLgOP7zWLHxU_3SZZxw1P3zKDDNu1iq7JGvQyWtlUhKmCJjOSmCYpq4H6C1qqriKheoKChG0NdaRv3FiRsin3STJfjcKzFJJZHMTGMIqxtIO0b6UELYBIe1803jmsJ2UjMIysypRZsdeMOAsNNa_jmQcTprCoB03LOgUmNzJpF3A Download .mp4 (13.35 MB) Help with .mp4 files Video 2Transthoracic echocardiogram apical four-chamber view of an 88-year-old man with aortic stenosis taken during the preoperative workup for a transcatheter aortic valve implantation (TAVI)eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmOTA0Y2ZlYTY1NDYwZjllNWJjMjkyMTI3MmE3YzY1OSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg4Mzg5NTQ4fQ.gnxWpJATnjRO73S1RHkUuzftZ2xks-ZFAF5iN7brctn71F93OggZyxq2a1Peo68iAkN65f9ZNyFsEtF9Lw12bHINSoDv-siMyQtsTEMqcDcqkDZtE_ZIHSn7JRYpcN6D8YKYe6GJwIUk6Vjkj5_bNDLkNoPnqNvmVNe8eR-APjNiSgMpjVUMkfIRVMl_eg25l1olPxbC4vvRiX-3Gytcn8q76QVcCy2YZSQ2E1aGm_lb_jKvi1HekthIuQEedd4q-Km94FyqqA2B01cBEXkjbG6TEmvvLjDS6YcrAuuHXHyDoRXQOGam5w03zEiR-I2ty9xY8-fHmWixrgZUci9qdg Download .mp4 (77.17 MB) Help with .mp4 files Video 3The apical four-chamber TTE of the patient after the mitral valve repair reveals an echogenic structure in the LA, which may be a potential mass. Zooming in and focusing over the LA provides an increased resolution of this potential structure. The differential diagnosis includes whether this represents a true structure vs an artifact. The addition of color flow Doppler can be useful because color flow may move through an artifact but would not move through a true mass. Imaging through multiple acoustic windows is also useful because artifacts are not typically reproducible in multiple echocardiographic planes. Unfortunately, obtaining satisfactory acoustic windows can be a challenge, especially in postoperative patients, given the presence of surgical bandages and chest tubes, which can limit the acoustic windows, as is seen in this limited parasternal long axis view. However, note is made of a left-sided pleural effusion in the far field. As the probe is rotated, the parasternal short axis view of the left ventricle is obtained. Again, a pleural effusion can be seen in the far field as an anechoic space. Note the hyperechoic structure in the far field, likely representing atelectatic lung. We hypothesize that this hyperechoic tissue was picked up by the weak side lobe of the US beam in the apical four-chamber and appears as the hyperechoic mass seen within the LA. The apical four-chamber TTE of patient 2 demonstrates an echogenic mass in the LA, which appears to move with each cardiac systole. Echocardiographic contrast was used in this patient, which helps with visualization of the endocardial borders. There is potentially a filling defect seen in the LA from the presence of the clot. LA = left atrium; TTE = transthoracic echocardiogrameyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjNjYyNWU0MmI0ZjhkZmQ2MjI1Y2JjMGYwYjFjZTJmMSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg4Mzg5NTQ4fQ.hVz9kt-l7chB44nZRhWmDNj34XqGbLX37lMb-7uHmiRLbURK6MD9WMzODRqN3TmKe61wuB0tu51EGRUxQhoeDVrNtzWAZIQizjX0lKdBE3xpwiKRZAv6-cTzOIcaWcu-WqtkybzduZax4wei_4aroWqOYE0u0kP0SfOdng_Y8dgMWA3gtzfA3nr9TInCmlz5QEOwRejaDz9iD14cCAr2GoNkO_UiFtOk1jJJrwC8FP7ofQmAhSsMV5KgAwlNl69vvBTKMaGH3kqDRM1g2DxbA8Zw2K0BozSTsGqQ7pAz4fmjbNu2vlszWjXS3yUZFlt471hu_B31KkbG0pW5T462aQ Download .mp4 (74.41 MB) Help with .mp4 files Video 4

Assessment and management of postoperative pain after hospital discharge is very challenging. We conducted a systematic review to synthesize available evidence on the prevalence of moderate-to-severe postoperative pain within the first 1 to 14 days after hospital discharge. The previously published protocol for this review was registered in PROSPERO. MEDLINE and EMBASE databases were searched until November 2020. We included observational postsurgical pain studies in the posthospital discharge setting. The primary outcome for the review was the proportion of study participants with moderate-to-severe postoperative pain (eg, pain score of 4 or more on a 10-point Numerical Rating Scale) within the first 1 to 14 days after hospital discharge. This review included 27 eligible studies involving a total of 22,108 participants having undergone a wide variety of surgical procedures. The 27 studies included ambulatory surgeries (n = 19), inpatient surgeries (n = 1), both ambulatory and inpatient surgeries (n = 4), or was not specified (n = 3). Meta-analyses of combinable studies provided estimates of pooled prevalence rates of moderate-to-severe postoperative pain ranging from 31% 1 day after discharge to 58% 1 to 2 weeks after discharge. These findings suggest that moderate-to-severe postoperative pain is a common occurrence after hospital discharge and highlight the importance of future efforts to more effectively evaluate, prevent, and treat postsurgical pain in patients discharged from the hospital.

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).

Abstract Objective To determine if virtual care with remote automated monitoring (RAM) technology versus standard care increases days alive at home among adults discharged after non-elective surgery during the covid-19 pandemic. Design Multicentre randomised controlled trial. Setting 8 acute care hospitals in Canada. Participants 905 adults (≥40 years) who resided in areas with mobile phone coverage and were to be discharged from hospital after non-elective surgery were randomised either to virtual care and RAM (n=451) or to standard care (n=454). 903 participants (99.8%) completed the 31 day follow-up. Intervention Participants in the experimental group received a tablet computer and RAM technology that measured blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and body weight. For 30 days the participants took daily biophysical measurements and photographs of their wound and interacted with nurses virtually. Participants in the standard care group received post-hospital discharge management according to the centre’s usual care. Patients, healthcare providers, and data collectors were aware of patients’ group allocations. Outcome adjudicators were blinded to group allocation. Main outcome measures The primary outcome was days alive at home during 31 days of follow-up. The 12 secondary outcomes included acute hospital care, detection and correction of drug errors, and pain at 7, 15, and 30 days after randomisation. Results All 905 participants (mean age 63.1 years) were analysed in the groups to which they were randomised. Days alive at home during 31 days of follow-up were 29.7 in the virtual care group and 29.5 in the standard care group: relative risk 1.01 (95% confidence interval 0.99 to 1.02); absolute difference 0.2% (95% confidence interval −0.5% to 0.9%). 99 participants (22.0%) in the virtual care group and 124 (27.3%) in the standard care group required acute hospital care: relative risk 0.80 (0.64 to 1.01); absolute difference 5.3% (−0.3% to 10.9%). More participants in the virtual care group than standard care group had a drug error detected (134 (29.7%) v 25 (5.5%); absolute difference 24.2%, 19.5% to 28.9%) and a drug error corrected (absolute difference 24.4%, 19.9% to 28.9%). Fewer participants in the virtual care group than standard care group reported pain at 7, 15, and 30 days after randomisation: absolute differences 13.9% (7.4% to 20.4%), 11.9% (5.1% to 18.7%), and 9.6% (2.9% to 16.3%), respectively. Beneficial effects proved substantially larger in centres with a higher rate of care escalation. Conclusion Virtual care with RAM shows promise in improving outcomes important to patients and to optimal health system function. Trial registration ClinicalTrials.gov NCT04344665.

Background: After nonelective (i.e., semiurgent, urgent and emergent) surgeries, patients discharged from hospitals are at risk of readmissions, emergency department visits or death. During the coronavirus disease 2019 (COVID-19) pandemic, we are undertaking the Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM) trial to determine if virtual care with remote automated monitoring (RAM) compared with standard care will increase the number of days adult patients remain alive at home after being discharged following nonelective surgery. Methods: We are conducting a randomized controlled trial in which 900 adults who are being discharged after nonelective surgery from 8 Canadian hospitals are randomly assigned to receive virtual care with RAM or standard care. Outcome adjudicators are masked to group allocations. Patients in the experimental group learn how to use the study’s tablet computer and RAM technology, which will measure their vital signs. For 30 days, patients take daily biophysical measurements and complete a recovery survey. Patients interact with nurses via the cellular modem–enabled tablet, who escalate care to preassigned and available physicians if RAM measurements exceed predetermined thresholds, patients report symptoms, a medication error is identified or the nurses have concerns they cannot resolve. The primary outcome is number of days alive at home during the 30 days after randomization. Interpretation: This trial will inform management of patients after discharge following surgery in the COVID-19 pandemic and offer insights for management of patients who undergo nonelective surgery in a nonpandemic setting. Knowledge dissemination will be supported through an online multimedia resource centre, policy briefs, presentations, peer-reviewed journal publications and media engagement. Trial registration: ClinicalTrials.gov, no. NCT04344665

Introduction Surgical interventions can elicit neuroendocrine responses and sympathovagal imbalance, ultimately affecting cardiac autonomic function. Cardiac complications account for 30% of postoperative complications and are the leading cause of morbidity and mortality following non-cardiac surgery. One cardiovascular parameter, heart rate variability (HRV), has been found to be predictive of postoperative morbidity and mortality. HRV is defined as variation in time intervals between heartbeats and is affected by cardiac autonomic balance. Furthermore, altered HRV has been shown to predict cardiovascular events in non-surgical settings. In multiple studies, experimentally induced pain in healthy humans leads to reduced HRV suggesting a causal relationship. In a different studies, chronic pain has been associated with altered HRV, however, in the setting of clinical pain conditions, it remains unclear how much HRV impairment is due to pain itself versus autonomic changes related to analgesia. We aim to review the available evidence describing the association between postsurgical pain and HRV alterations in the early postoperative period.Methods and analysis We will conduct a scoping review of relevant studies using detailed searches of MEDLINE and EMBASE, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Included studies will involve participants undergoing non-cardiac surgery and investigate outcomes of (1) measures of pain intensity; (2) measures of HRV and (3) statistical assessment of association between #1 and #2. As secondary review outcomes included studies will also be examined for other cardiovascular events and for their attempts to control for analgesic treatment and presurgical HRV differences among treatment groups in the analysis. This work aims to synthesise available evidence to inform future research questions related to postsurgical pain and cardiac complications.Ethics and dissemination Ethics review and approval is not required for this review. The results will be submitted for publication in peer-reviewed journals.

Background Pain is one of the most common, feared, and unpleasant symptoms associated with surgery. However, there is a clear gap in patient care after surgical patients are discharged from hospital, resulting in poorly controlled postoperative pain. Inadequate pain management after discharge can have detrimental effects on quality of life and lead to the development of chronic postsurgical pain. The severity of postoperative pain before discharge is well described, but less emphasis has been placed on assessing pain at home after hospital discharge. Objective The objective of this review is to summarize the prevalence of moderate-to-severe postoperative pain within the first 1 to 14 days after hospital discharge. Methods A detailed search of epidemiological studies investigating postoperative pain will be conducted on MEDLINE and EMBASE from their inception until the date the searches are run. The primary outcome will be the proportion of patients reporting moderate-to-severe postoperative pain at rest and with movement within the first 1 to 14 days after hospital discharge. The secondary outcomes will include a comparison of postoperative pain after discharge between patients who underwent ambulatory and inpatient surgery, and adverse outcomes attributable to poor pain control after hospital discharge (eg, readmission to hospital, emergency room or other unplanned medical visits, or a decrease in quality of life). Results The protocol has been registered in PROSPERO (registration number CRD42020194346). The search strategies for MEDLINE and EMBASE have been completed. The final results are expected to be published in May 2021. Conclusions This systematic review is expected to synthesize evidence describing the prevalence of postoperative pain after hospital discharge. Available epidemiological evidence may help inform the magnitude of the problem of postoperative pain at home after hospital discharge. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42020194346; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=194346 International Registered Report Identifier (IRRID) PRR1-10.2196/22437

Point-of-care ultrasound (POCUS) uses ultrasound at the bedside to aid decision-making in acute clinical scenarios. The increased use of ultrasound for regional anesthesia and vascular cannulation, together with more anesthesiologists trained in transesophageal echocardiography have contributed to the widespread use of POCUS in perioperative care. Despite the support of international experts, the practice of POCUS in perioperative care is variable as Canadian guidelines for anesthesiologists do not currently exist. Using a Delphi process of online surveys and a face-to-face national Canadian meeting, we developed a consensus statement for basic POCUS (bPOCUS) performance and training with a group of national experts from all Canadian universities. The group of experts consisted of 55 anesthesiologists from 12 Canadian universities considered local leaders in the field. An initial exploratory online survey of 47 statements was conducted. These statements were derived from previous generic guidelines or consensus conferences, or were based on current literature. Fourteen statements reached full consensus, 19 had 90–100% agreement, and 14 had less than 90% agreement. Eight new statements were proposed during the national meeting, and all statements without full agreement were discussed. A second online survey included 42 modified or new statements. From this second survey, 16 statements obtained full consensus, 39 had very good agreement, and one had good agreement. The final document includes 56 statements that define the scope of practice and necessary training for perioperative bPOCUS. The statements include five bPOCUS domains: cardiac, lung, airway, gastric, and abdomen. The use of bPOCUS is evolving and will play a significant role in perioperative medicine. This consensus statement aims to define a Canadian national standard on which curricula may be based. It also provides a framework to allow further development of bPOCUS in the perioperative setting.

PURPOSE:To examine the effect of discontinuing hydroxyethyl starch (HES) solutions on length of hospital stay, transfusion, risk of death, acute kidney injury (AKI), and dialysis.METHODS:We conducted a historical cohort study of linked administrative and clinical databases in patients undergoing coronary artery bypass surgery (CABG) on cardiopulmonary bypass. We used propensity scores to match patients who did not receive HES (after discontinuation) with patients exposed to HES (before discontinuation) and also controlled for albumin exposure. Hospital length of stay (the primary outcome) was analyzed using Fine-Gray proportional hazard regression, with hospital discharge as the outcome and death as a competing risk. Adverse outcomes were compared between matched patients using conditional logistic regression.RESULTS:We compared 1,085 propensity score-matched pairs (n = 2,170) from a pool of 2,757 patients. Discontinuation of HES was associated with shorter length of hospital stay, as evidenced by an increased probability of discharge (hazard ratio, 1.24; 95% confidence interval [CI], 1.14 to 1.35) and a reduced risk of red blood cell transfusion (odds ratio [OR], 0.68; 95% CI, 0.55 to 0.84), plasma transfusion (OR, 0.48; 95% CI, 0.34 to 0.66), and platelet transfusion (OR, 0.62; 95% CI, 0.44 to 0.87). Discontinuation of HES was not associated with in-hospital mortality (OR, 0.74; 95% CI, 0.36 to 1.54), AKI (OR, 0.84; 95% CI, 0.57 to 1.25), or dialysis (OR, 0.83; 95% CI, 0.25 to 2.73).CONCLUSIONS:For patients undergoing CABG on cardiopulmonary bypass, discontinuation of HES was associated with reduced hospital length of stay and reduced blood product transfusion, without measurable change in renal failure, dialysis rate, or in-hospital mortality. Our results should be interpreted with caution, though we found no evidence of harms associated with discontinuing HES.TRIAL REGISTRATION:www.clinicaltrials.gov (NCT02329158); registered 31 December, 2014.

Point-of-care ultrasound (POCUS) is becoming an integral part of anesthesia practice throughout the world. Despite the growing interest in POCUS among trainees and faculty, POCUS training is variable among universities across Canada. This suggests a need for curriculum development and standardization. International guidelines for Emergency Medicine and Critical Care have common frameworks and may be used as a reference to model anesthesia-specific curricula. The Royal College of Anaesthetists of the United Kingdom currently offers the only nationally approved POCUS curriculum for anesthesia and critical care trainees. Most curricula have in common a stepwise approach that consists of foundation of knowledge and skills and competency building through practice. Nevertheless, a significant variety of didactic modalities have been described, and online learning and simulation offer clear advantages. What constitutes the minimum number of studies necessary to achieve competence is still debated as are the most appropriate tools for assessment of POCUS competency.Availability of trained staff anesthesiologists remains a major limitation to curricula implementation in most centres. A National Curriculum should be modeled on the Competency By Design Approach, in line with the CanMEDS 2015 roles, and start with a focus on basic POCUS modalities and applications. Guidance for the training and certification of POCUS among practicing anesthesiologists is lacking.

Inhaled milrinone (iMil) has been used for the treatment of pulmonary hypertension (PH) but its efficacy, safety, and prophylactic effects in facilitating separation from cardiopulmonary bypass (CPB) and preventing right ventricular (RV) dysfunction have not yet been evaluated in a clinical trial. The purpose of this study was to investigate if iMil administered before CPB would be superior to placebo in facilitating separation from CPB.

A 64-year-old woman with a previous liver transplant developed graft failure with biliary complications including a bronchobiliary fistula, which did not respond to preoperative conservative therapy. Liver retransplantation provided definitive therapy for the liver failure and bronchobiliary fistula. We present anesthestic considerations for the intraoperative management of a liver retransplant with one-lung ventilation.

Purpose Point-of-care ultrasound (POCU) is an evolving field in anesthesia. Therefore a systematic review of common diagnoses made by POCU during non-cardiac surgery was conducted. The information obtained from the review may be used to develop POCU curricula for the perioperative setting during non-cardiac surgery. Source A systematic review was conducted for perioperative use of transthoracic /transesophageal echocardiography (TTE/TEE) in high-risk patients or in other patients experiencing periods of hemodynamic instability. The diagnoses included segmental wall motion abnormalities (SWMAs), low left ventricular ejection fraction (LVEF), hypovolemia, air embolism, cardiac/aortic thrombus, pulmonary embolus (PE), aortic valve disease, mitral valve disease, tricuspid valve disease, right ventricular (RV) failure, pericardial disease, and patent foramen ovale. Principal findings Three hundred twenty-one studies were found using our search terms, and thirteen studies were retained that met our inclusion criteria for review. The studies included 968 patients analyzed as either preoperative exams in high-risk patients ( n = 568) or intraoperative exams during times of hemodynamic compromise/cardiac arrest ( n = 400). The most common diagnoses in the preoperative exam group were low ejection fraction (25.4%), aortic valve disease (24.4%), mitral valve disease (20.0%), RV failure (6.6%), and hypovolemia (6.3%). In the intraoperative exam group, the most common diagnoses were hypovolemia (33.2%), low ejection fraction (20.5%), RV failure (13.1%), SWMAs (10.1%), and PE (5.8%). Conclusion In this systematic review examining the use of TTE or TEE in non-cardiac surgery, the most frequent diagnoses were valvulopathy, low LVEF, hypovolemia, PE, SWMAs, and RV failure. This information should be used to inform evidence-based curricula for POCU in anesthesiology.

Recombinant activated factor VII (rFVIIa) is a pro-hemostatic drug that is approved for treatment of bleeding in hemophilia patients, but it is frequently used off-label in non-hemophiliacs. The purpose of this study was to determine if the off-label use of rFVIIa is expanding and whether this poses a net harm to patients.