Explore the vast range of titles available.

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).

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.

IntroductionSurgical 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 analysisWe 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 disseminationEthics review and approval is not required for this review. The results will be submitted for publication in peer-reviewed journals.

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.

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.

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.

In this clinical trial involving patients undergoing high-risk cardiac surgery, aprotinin was somewhat more effective than either aminocaproic acid or tranexamic acid in reducing massive perioperative bleeding but at the expense of a higher rate of death, mainly from cardiac causes. Aprotinin cannot be recommended to control blood loss in this clinical setting. In patients undergoing high-risk cardiac surgery, aprotinin was somewhat more effective than either aminocaproic acid or tranexamic acid in reducing massive perioperative bleeding but at the expense of a higher rate of death, mainly from cardiac causes. Every year an estimated 1 million to 1.25 million patients worldwide undergo cardiac surgery, including high-risk procedures such as repeat coronary-artery bypass grafting (CABG), valve replacements, and combined procedures. 1 High-risk procedures present an increased risk of death, massive bleeding, renal failure, and thrombotic complications, as compared with first-time isolated CABG. 2 – 4 Three antifibrinolytic agents have been used in cardiac surgery to minimize bleeding and reduce the need for transfusion: aprotinin, a naturally occurring serine protease inhibitor, and two lysine analogues, tranexamic acid and aminocaproic acid. 5 In clinical trials, all three drugs have been shown to be effective in reducing the . . .

Purpose 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. Methods High-risk cardiac surgical patients with PH were randomized to receive iMil or placebo after the induction of anesthesia and before CPB. Hemodynamic parameters and RV function were evaluated by means of pulmonary artery catheterization and transesophageal echocardiography. The groups were compared for the primary outcome of the level of difficulty in weaning from CPB. Among the secondary outcomes examined were the reduction in the severity of PH, the incidence of RV failure, and mortality. Results Of the 124 patients randomized, the mean (standard deviation [SD]) EuroSCORE II was 8.0 (2.6), and the baseline mean (SD) systolic pulmonary artery pressure (SPAP) was 53 (9) mmHg. The use of iMil was associated with increases in cardiac output ( P = 0.03) and a reduction in SPAP ( P = 0.04) with no systemic hypotension. Nevertheless, there was no difference in the combined incidence of difficult or complex separation from CPB between the iMil and control groups (30% vs 28%, respectively; absolute difference, 2%; 95% confidence interval [CI], −14 to 18; P = 0.78). There was also no difference in RV failure between the iMil and control groups (15% vs 14%, respectively; difference, 1%; 95% CI, −13 to 12; P = 0.94). Mortality was increased in patients with RV failure vs those without (22% vs 2%, respectively; P < 0.001). Conclusion In high-risk cardiac surgery patients with PH, the prophylactic use of iMil was associated with favourable hemodynamic effects that did not translate into improvement of clinically relevant endpoints. This trial was registered at ClinicalTrials.gov; identifier: NCT00819377.

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. 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. 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). 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. 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. PROSPERO International Prospective Register of Systematic Reviews CRD42020194346; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=194346. PRR1-10.2196/22437.

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% agreement, revised those with 50-79% agreement based upon feedback provided, and maintained unrevised those items with ≥ 80% agreement. 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. 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.