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RésuméContexteLa paralysie diaphragmatique unilatérale (PDU) peut potentiellement aggraver les troubles respiratoires du sommeil (TRS). La PDU est associée aux blocs du plexus brachial proximal, tel que les blocs interscalénique et supraclaviculaire. L’impact de la PDU chez les patients atteints de TRS n’est pas connu dans ce contexte. Les objectifs de cette revue exploratoire étaient d’explorer les associations entre la PDU et l’aggravation de la sévérité des TRS, l’oxygénation, et la fonction pulmonaire.MéthodeUne recherche systématique a été mise au point, évaluée par des pairs et appliquée aux bases de données Embase, Medline, CINAHL et Cochrane afin d’inclure les études portant sur des patients adultes (≥ 18 ans) atteints de TRS, où les effets d’une PDU sur la sévérité des TRS, sur l’oxygénation et la fonction pulmonaire étaient examinés.RésultatsSix études (n = 100 patients) portant sur la PDU et les TRS ont été incluses. La population étudiée provenait exclusivement de cliniques de respirologie-sommeil, et ne comptait aucun patient chirurgical. Comparativement au groupe témoin (aucune PDU), la PDU a été associée à un index accru de troubles respiratoires, lesquels étaient les plus prononcés pendant le sommeil paradoxal et en position de décubitus dorsal. Le sommeil en décubitus dorsal et le sommeil paradoxal ont été associés à des événements obstructifs et mixtes (obstructifs et centraux), respectivement. Comparativement au groupe témoin, la PDU a été associée à une saturation en oxygène et à une tension artérielle d’oxygène moyennes et minimales inférieures pendant tous les stades de sommeil et dans toutes les positions. Chez la majorité des patients atteints de PDU, des réductions cliniquement significatives des valeurs du volume expiratoire forcé moyen en une seconde et de la capacité vitale forcée ont été observées, des données compatibles avec une physiologie respiratoire restrictive.ConclusionNous avons observé une association entre la paralysie diaphragmatique unilatérale et une sévérité augmentée des troubles respiratoires du sommeil, particulièrement pendant le sommeil paradoxal et en décubitus dorsal. Malgré l’identification de faiblesses dans la conception des études et d’un manque de données périopératoires, les anesthésiologistes devraient garder à l’esprit cette association lorsqu’ils envisagent un bloc du plexus brachial proximal chez les patients souffrant de TRS.

The erector spinae plane (ESP) block is an emerging regional anesthetic technique with significant potential for clinical benefit. Nevertheless, its exact mechanism(s) of action has been much debated. We reviewed the available literature to explore the possible mechanisms of analgesia for the ESP block. These include neural blockade and central inhibition from direct spread of local anesthetic to the paravertebral or epidural space; analgesia mediated by elevated local anesthetic plasma concentrations due to systemic absorption; immunomodulatory effects of local anesthetics; and an effect mediated through the mechanosensory properties of thoracolumbar fascia. Based on evidence from clinical, human cadaveric, animal, and mechanistic laboratory studies, the most probable primary mechanism is a direct effect of local anesthetic via physical spread and diffusion to neural structures in the fascial plane deep to the erector spinae muscles and adjacent tissue compartments. Biological plausibility of this primary mechanism is confirmed by injectate spread to the ventral rami of spinal nerves (though quite variable) in most studies. There is consistent involvement of dorsal rami; epidural spread is a less commonly observed phenomenon. A systemic effect of local anesthetic is also plausible, but unlikely to be a major contributor to clinical analgesic efficacy. The evidence for significant analgesia due to other proposed mechanisms, such as fascia-mediated analgesia or lymphatic spread, are currently limited and thus remain speculative. Understanding the mechanisms of action could assist clinicians in further investigating and refining ESP block performance, with the ultimate goal of optimizing analgesic efficacy and improving postoperative patient outcomes.

The coronavirus disease 2019 (COVID-19) outbreak has been designated a public health emergency of international concern. To prepare for a pandemic, hospitals need a strategy to manage their space, staff, and supplies so that optimum care is provided to patients. In addition, infection prevention measures need to be implemented to reduce in-hospital transmission. In the operating room, these preparations involve multiple stakeholders and can present a significant challenge. Here, we describe the outbreak response measures of the anesthetic department staffing the largest (1,700-bed) academic tertiary level acute care hospital in Singapore (Singapore General Hospital) and a smaller regional hospital (Sengkang General Hospital). These include engineering controls such as identification and preparation of an isolation operating room, administrative measures such as modification of workflow and processes, introduction of personal protective equipment for staff, and formulation of clinical guidelines for anesthetic management. Simulation was valuable in evaluating the feasibility of new operating room set-ups or workflow. We also discuss how the hierarchy of controls can be used as a framework to plan the necessary measures during each phase of a pandemic, and review the evidence for the measures taken. These containment measures are necessary to optimize the quality of care provided to COVID-19 patients and to reduce the risk of viral transmission to other patients or healthcare workers.

PurposeWe conducted two World Health Organization-commissioned reviews to inform use of high-flow nasal cannula (HFNC) in patients with coronavirus disease (COVID-19). We synthesized the evidence regarding efficacy and safety (review 1), as well as risks of droplet dispersion, aerosol generation, and associated transmission (review 2) of viral products.SourceLiterature searches were performed in Ovid MEDLINE, Embase, Web of Science, Chinese databases, and medRxiv. Review 1: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy (COT) in critically ill patients with acute hypoxemic respiratory failure. Review 2: we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection transmission associated with HFNC. For both reviews, paired reviewers independently conducted screening, data extraction, and risk of bias assessment. We evaluated certainty of evidence using GRADE methodology.Principal findingsNo eligible studies included COVID-19 patients. Review 1: 12 RCTs (n = 1,989 patients) provided low-certainty evidence that HFNC may reduce invasive ventilation (relative risk [RR], 0.85; 95% confidence interval [CI], 0.74 to 0.99) and escalation of oxygen therapy (RR, 0.71; 95% CI, 0.51 to 0.98) in patients with respiratory failure. Results provided no support for differences in mortality (moderate certainty), or in-hospital or intensive care length of stay (moderate and low certainty, respectively). Review 2: four studies evaluating droplet dispersion and three evaluating aerosol generation and dispersion provided very low certainty evidence. Two simulation studies and a crossover study showed mixed findings regarding the effect of HFNC on droplet dispersion. Although two simulation studies reported no associated increase in aerosol dispersion, one reported that higher flow rates were associated with increased regions of aerosol density.ConclusionsHigh-flow nasal cannula may reduce the need for invasive ventilation and escalation of therapy compared with COT in COVID-19 patients with acute hypoxemic respiratory failure. This benefit must be balanced against the unknown risk of airborne transmission.

PurposeCancer-related mortality, a leading cause of death worldwide, is often the result of metastatic disease recurrence. Anesthetic techniques have varying effects on innate and cellular immunity, activation of adrenergic-inflammatory pathways, and activation of cancer-promoting cellular signaling pathways; these effects may translate into an influence of anesthetic technique on long-term cancer outcomes. To further analyze the effects of propofol (intravenous) and volatile (inhalational gas) anesthesia on cancer recurrence and survival, we undertook a systematic review with meta-analysis.SourceDatabases were searched up to 14 November 2018. Comparative studies examining the effect of inhalational volatile anesthesia and propofol-based total intravenous anesthesia (TIVA) on cancer outcomes were included. The Newcastle Ottawa Scale (NOS) was used to assess methodological quality and bias. Reported hazard ratios (HRs) were pooled and 95% confidence intervals (CIs) calculated.Principal findingsTen studies were included; six studies examined the effect of anesthetic agent type on recurrence-free survival following breast, esophageal, and non-small cell lung cancer (n = 7,866). The use of TIVA was associated with improved recurrence-free survival in all cancer types (pooled HR, 0.78; 95% CI, 0.65 to 0.94; P < 0.01). Eight studies (n = 18,778) explored the effect of anesthetic agent type on overall survival, with TIVA use associated with improved overall survival (pooled HR, 0.76; 95% CI, 0.63 to 0.92; P < 0.01).ConclusionThis meta-analysis suggests that propofol-TIVA use may be associated with improved recurrence-free survival and overall survival in patients having cancer surgery. This is especially evident where major cancer surgery was undertaken. Nevertheless, given the inherent limitations of studies included in this meta-analysis these findings necessitate prospective randomized trials to guide clinical practice.Trial registrationPROSPERO (CRD42018081478); registered 8 October, 2018.

This narrative review summarizes the current knowledge on point-of-care ultrasound (POCUS) of gastric contents in order to inform an assessment of aspiration risk and guide anesthetic management at the bedside. An I-AIM framework (Indication, Acquisition, Interpretation, and Medical decision-making) is used to summarize and organize the content areas. This narrative review spans the breadth of the literature on pediatric and adult subjects as well as on special patient populations such as obstetric and severely obese individuals. Areas that need further investigation include the diagnostic accuracy of gastric POCUS from a Bayesian perspective and the impact of POCUS on patient outcomes, healthcare economics, and educational curricula.

Coronavirus disease (COVID-19) was declared a pandemic by the World Health Organization on 11 March 2020 because of its rapid worldwide spread. In the operating room, as part of hospital outbreak response measures, anesthesiologists are required to have heightened precautions and tailor anesthetic practices to individual patients. In particular, by minimizing the many aerosol-generating procedures performed during general anesthesia, anesthesiologists can reduce exposure to patients’ respiratory secretions and the risk of perioperative viral transmission to healthcare workers and other patients. To avoid any airway manipulation, regional anesthesia should be considered whenever surgery is planned for a suspect or confirmed COVID-19 patient or any patient who poses an infection risk. Regional anesthesia has benefits of preservation of respiratory function, avoidance of aerosolization and hence viral transmission. This article explores the practical considerations and recommended measures for performing regional anesthesia in this group of patients, focusing on control measures geared towards ensuring patient and staff safety, equipment protection, and infection prevention. By doing so, we hope to address an issue that may have downstream implications in the way we practice infection control in anesthesia, with particular relevance to this new era of emerging infectious diseases and novel pathogens. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not the first, and certainly will not be the last novel virus that will lead to worldwide outbreaks. Having a well thought out regional anesthesia plan to manage these patients in this new normal will ensure the best possible outcome for both the patient and the perioperative management team.

PurposeIron restricted anemia is prevalent in surgical patients and is associated with an increased risk of allogeneic red blood cell (RBC) transfusion and adverse events. Treatment of anemia includes oral and intravenous iron and erythropoiesis stimulating agents (ESAs). More recent studies have focused on the use of intravenous iron as the primary approach to treating anemia. Nevertheless, the optimal treatment strategy for anemia remains to be established. Our primary objective was to evaluate the efficacy and safety of ESA and iron therapy relative to iron therapy alone in reducing RBC transfusion in surgical patients.SourceWe searched the Cochrane Library, MEDLINE, EMBASE, and ClinicalTrials.gov from inception to May 2018. We included randomized-controlled trials in which adult surgical patients received an ESA and iron, vs iron alone, prior to cardiac and non-cardiac surgery. Our primary outcome was RBC transfusion rate. Secondary outcomes included hemoglobin concentration (post-treatment and postoperatively), number of RBC units transfused, mortality, stroke, myocardial infarction (MI), renal dysfunction, pulmonary embolism (PE), and deep vein thrombosis (DVT).Principal findingsIn total, 25 studies (4,719 participants) were included. Erythropoiesis stimulating agents and iron therapy reduced RBC transfusion relative to iron therapy (relative risk [RR] 0.57; 95% confidence interval [CI], 0.46 to 0.71) without any change in mortality (RR 1.31; 95% CI, 0.80 to 2.16), stroke (RR 1.91; 95% CI, 0.63 to 5.76), MI (RR 1.12; 95% CI, 0.50 to 2.50), renal dysfunction (RR 0.96; 95% CI, 0.72 to 1.26), PE (RR 0.92; 95% CI, 0.15 to 5.83), or DVT (RR 1.48; 95% CI, 0.95 to 2.31).ConclusionAdministration of ESA and iron therapy reduced the risk for RBC transfusion compared with iron therapy alone in patients undergoing cardiac and non-cardiac surgery. Nevertheless, publication bias and heterogeneity reduces the confidence of the finding. Although the analysis was probably under-powered for some outcomes, no difference in the incidence of serious adverse events was observed with ESA and iron compared with iron alone. Further large prospective trials are required to confirm these findings.

Purpose Simulation-based learning is increasingly used by healthcare professionals as a safe method to learn and practice non-technical skills, such as communication and leadership, required for effective crisis resource management (CRM). This systematic review was conducted to gain a better understanding of the impact of simulation-based CRM teaching on transfer of learning to the workplace and subsequent changes in patient outcomes. Source Studies on CRM, crisis management, crew resource management, teamwork, and simulation published up to September 2012 were searched in MEDLINE ® , EMBASE™, CINAHL, Cochrane Central Register of Controlled Trials, and ERIC. All studies that used simulation-based CRM teaching with outcomes measured at Kirkpatrick Level 3 (transfer of learning to the workplace) or 4 (patient outcome) were included. Studies measuring only learners’ reactions or simple learning (Kirkpatrick Level 1 or 2, respectively) were excluded. Two authors independently reviewed all identified titles and abstracts for eligibility. Principal findings Nine articles were identified as meeting the inclusion criteria. Four studies measured transfer of simulation-based CRM learning into the clinical setting (Kirkpatrick Level 3). In three of these studies, simulation-enhanced CRM training was found significantly more effective than no intervention or didactic teaching. Five studies measured patient outcomes (Kirkpatrick Level 4). Only one of these studies found that simulation-based CRM training made a clearly significant impact on patient mortality. Conclusions Based on a small number of studies, this systematic review found that CRM skills learned at the simulation centre are transferred to clinical settings, and the acquired CRM skills may translate to improved patient outcomes, including a decrease in mortality.

Purpose Burnout has been identified in approximately half of all practicing physicians, including anesthesiologists. In this narrative review, the relationship between burnout, depression, and suicide is explored, with particular attention to the anesthesiologist. Throughout this review, we highlight our professional imperative regarding this epidemic. Source The authors searched the existing English language literature via PubMed from 1986 until present using the search terms physician burnout , depression , and suicide , with particular attention to studies regarding anesthesiologists and strategies to address these problems. Principal findings Burnout and depression have increased among physicians, while the rate of suicide has remained relatively the same. There are many factors associated with burnout and depression as well as many causes. Certain individual factors include sex, amount of social support, and mental health history. Systems factors that play a role in burnout and depression include work compression, demands of electronic health records, production pressure, and lack of control over one’s professional life. Medical license applications include questions that reinforce the stigma of psychological stresses and discourage physicians from seeking appropriate care. Conclusion The concept of physician well-being is multidimensional and includes factors related to each physician as an individual as well as to the working environment. Anesthesiologists must actively engage in self-care. Anesthesiology practices and healthcare organizations should evaluate the balance between demands they place on physicians and the resources provided to sustain an engaged, productive, and satisfied physician workforce. National efforts must be rallied to support physicians seeking help for physical and psychological health problems.