Kim Turner

The Recite Study: A Canadian Prospective, Multicenter Study of the Incidence and Severity of Residual Neuromuscular Blockade

BACKGROUND:Postoperative residual neuromuscular blockade (NMB), defined as a train-of-four (TOF) ratio of <0.9, is an established risk factor for critical postoperative respiratory events and increased morbidity. At present, little is known about the occurrence of residual NMB in Canada. The RECITE (Residual Curarization and its Incidence at Tracheal Extubation) study was a prospective observational study at 8 hospitals in Canada investigating the incidence and severity of residual NMB. METHODS:Adult patients undergoing open or laparoscopic abdominal surgery expected to last <4 hours, ASA physical status I–III, and scheduled for general anesthesia with at least 1 dose of a nondepolarizing neuromuscular blocking agent for endotracheal intubation or maintenance of neuromuscular relaxation were enrolled in the study. Neuromuscular function was assessed using acceleromyography with the TOF-Watch® SX. All reported TOF ratios were normalized to the baseline values. The attending anesthesiologist and all other observers were blinded to the TOF ratio (T4/T1) results. The primary and secondary objectives were to determine the incidence and severity of residual NMB (TOF ratio <0.9) just before tracheal extubation and at arrival at the postanesthesia care unit (PACU). RESULTS:Three hundred and two participants were enrolled. Data were available for 241 patients at tracheal extubation and for 207 patients at PACU arrival. Rocuronium was the NMB agent used in 99% of cases. Neostigmine was used for reversal of NMB in 73.9% and 72.0% of patients with TE and PACU data, respectively. The incidence of residual NMB was 63.5% (95% confidence interval, 57.4%–69.6%) at tracheal extubation and 56.5% (95% confidence interval, 49.8%–63.3%) at arrival at the PACU. In an exploratory analysis, no statistically significant differences were observed in the incidence of residual NMB according to gender, age, body mass index, ASA physical status, type of surgery, or comorbidities (all P > 0.13). CONCLUSIONS:Residual paralysis is common at tracheal extubation and PACU arrival, despite qualitative neuromuscular monitoring and the use of neostigmine. More effective detection and management of NMB is needed to reduce the risks associated with residual NMB.

Perioperative management of patients with obstructive sleep apnea: a survey of Canadian anesthesiologists

IntroductionObstructive sleep apnea (OSA) may increase the incidence of postoperative complications when undiagnosed. The purpose of this study was to evaluate the perspectives of Canadian anesthesiologists regarding the perioperative management of patients with diagnosed or suspected OSA.MethodsThis study was conducted as a survey of Canadian anesthesiologists using a self-administered scenario-based questionnaire. We initially mailed the survey questionnaire and then mailed it again to non-respondents six weeks later. Subsequently, we e-mailed the online version of our survey to active members of the Canadian Anesthesiologists’ Society.ResultsThe response rates were 35% and 26% for the postal and online modes of administration, respectively. About 50% of the respondents relied on clinical suspicion rather than on a systematic screening to identify patients who may have undiagnosed OSA preoperatively. Forty-seven percent of all respondents either did not know of any institutional policy to guide their perioperative management of patients with OSA or reported an absence of an institutional policy. Fifteen percent of the respondents would discharge diagnosed OSA inpatients with compliant use of continuous positive airway pressure (CPAP) to the ward without monitoring. Nevertheless, a more conservative approach was observed for CPAP non-compliant inpatients. We indeed observed that more than 40% of respondents would send an ambulatory OSA patient home, while another 60% would favour hospital admission.ConclusionsThe majority of anesthesiologists continue to rely on clinical suspicion alone to identify OSA. Moreover, the lack of institutional policy is concerning. A concerted effort to develop an evidence-based guideline may be the next step to assist institutions.RésuméIntroductionL’apnée obstructive du sommeil (AOS), si elle n’est pas dépistée, peut augmenter l’incidence de complications postopératoires. L’objectif de cette étude était d’évaluer les perspectives des anesthésiologistes canadiens quant à la prise en charge périopératoire des patients atteints d’AOS reconnue ou soupçonnée.MéthodeCette étude a été réalisée sous forme de sondage auprès des anesthésiologistes canadiens à l’aide d’un questionnaire auto-administré basé sur des scénarios cliniques. Nous avons envoyé le questionnaire par la poste, puis l’avons renvoyé six semaines plus tard aux personnes n’ayant pas répondu. Par la suite, nous avons envoyé une version en ligne par courriel aux membres actifs de la Société canadienne des anesthésiologistes.RésultatsLes taux de réponse étaient de 35 % et 26 % aux questionnaires envoyés par la poste et par courriel, respectivement. Environ 50 % des répondants affirment se fonder sur une suspicion clinique plutôt que sur un dépistage méthodique pour identifier les patients potentiellement atteints d’AOS non diagnostiquée en période préopératoire. En tout, 47 % des répondants ne savaient pas s’il existait une quelconque politique institutionnelle orientant leur prise en charge périopératoire des patients atteints d’AOS ou rapportaient l’absence d’une telle politique institutionnelle. Quinze pour cent des répondants transfèreraient à l’étage des patients hospitalisés souffrant d’AOS diagnostiquée avec une prescription générale pour leur dispositif de ventilation à pression positive continue (CPAP) et n’installeraient pas de monitorage. Toutefois, une approche plus conservatrice a été observée en matière de prise en charge des patients hospitalisés qui hésitent à utiliser un CPAP. En effet, nous avons observé que plus de 40 % des répondants donneraient le congé à un patient atteint d’AOS en clinique d’un jour, alors que 60 % favoriseraient une admission à l’hôpital.ConclusionLa majorité des anesthésiologistes continuent de s’appuyer sur leur seule suspicion clinique pour identifier l’AOS. De plus, l’absence de politique institutionnelle est préoccupante. Un effort concerté visant à mettre au point une recommandation fondée sur des données probantes devrait constituer la prochaine étape pour soutenir les institutions.

Laughing and Crying About Anesthesia: A Memoir of Risk and Safety

A memoir can be defined as an account of something noteworthy or a narrative composed from personal experience. Dr. Zeitlin easily fulfills these definitions in his memoir. He is a storyteller who describes his personal accounts as ‘‘like a braided cord. Each thread has to be considered and then carefully wound into the core.’’ Dr. Zeitlin writes in a charming and frequently humorous manner that is often self-deprecating, sometimes poignant, and occasionally caustic. He never loses site of his central theme, namely, the progression toward the reduction of risk and enhancement of patient safety he has witnessed during his career as an anesthesiologist. Dr. Zeitlin’s personal narrative begins with his life as an intern and his introduction to anesthesia while caring for patients with polio during the time when the first respiratory intensive care units were being developed. Having made anesthesia his career choice, he humorously relates the start of his initial interview with the esteemed Sir Robert Macintosh by describing how Sir Robert emerged naked, dripping wet from a shower, and searching for his towel. Dr. Zeitlin recounts his brusque introduction to independent administration of anesthesia, including his inability to sleep the night before. He humbly recalls the following day when he administered his first anesthetic for a gynecological procedure. During the procedure, the patient freed her legs from the stirrups and curled them around the operating surgeon causing him to cry out, ‘‘She’s asphyxiating me!’’ This outburst was quickly followed by an inquiry as to the whereabouts of Dr. Zeitlin’s supervisor. Dr. Zeitlin writes of events and individuals he encountered throughout his training in England as well as during his career in private and academic institutions within England and the United States until his retirement. He skillfully weaves many of the important developments and events in anesthesia into his many personal vignettes and reminiscences; these include the actual discovery of anesthesia, the Chloroform Commissions, and the formulation of guidelines and standards, to name but a few. All are described with the backdrop of reduced risk and improved patient safety. Dr. Zeitlin includes portrayals of many of the personalities he encountered on both sides of the ether screen, those individuals who populated his life within the context of evolving tolerance for, shall we say, eccentric or perhaps even abusive behaviour during his training and professional practice on both sides of the Atlantic. Dr. Zeitlin’s touching recollection, now 42 years later, of the death of a 19-yr-old woman who suffered cardiac arrest during an elective procedure illustrates not only our perioperative concern for protecting our patients from harm but also the personal emotional repercussions we experience following the death of a patient. This particular chapter entitled ‘‘What went wrong?’’ evolves into a discussion of Dr. Zeitlin’s involvement many years later in the American Society of Anesthesiologists Closed Claims Project. He concludes this chapter with his caustic description of the haggling of the lawyers and culminates with his simple statement, ‘‘I still feel guilty because a young woman died’’. The patient had ultimately died of sepsis. In the preface, Dr. Zeitlin states that he wrote this book for ‘‘the interested non-medical reader’’. In my view, this book would appeal to any individual who is interested in the history of our profession and is looking to gain insight Dr. Zeitlin is generously donating a portion of his book royalties to the Foundation for Anesthesia Education and Research (FAER).

Ketorolac does not increase perioperative bleeding: a meta-analysis of randomized controlled trials.

Ketorolac Does Not Increase Perioperative Bleeding: A Meta-Analysis of Randomized Controlled Trials Sir: D the assurance of a well-designed and rigorous meta-analysis showing no increased overall risk of perioperative surgical bleeding with ketorolac, we would echo and emphasize the authors’ caveat that one be selective in its use as determined by the type of procedure and patient risk. We recently published the experience at our center with the use of ketorolac in reduction mammaplasty, demonstrating a significant increase in surgical bleeding complications in patients treated with this agent.1 Admittedly, our study design lacked the precision of a randomized and blinded trial, but the data are compelling enough to arguably preclude one even being attempted. We feel that ketorolac should not be used in outpatient and short-stay surgical procedures where there is extensive surgical undermining in subcutaneous and prefascial tissue planes where large bleeding surfaces obscured by subcutaneous fat are created. Notwithstanding the obvious opioidsparing benefit of ketorolac in these settings, we have stopped the routine use of this agent for reduction mammaplasty and abdominoplasty procedures. However, the authors have convincingly demonstrated a wide array of surgical settings in plastic surgery where ketorolac remains a useful therapeutic adjunct for postoperative analgesia. DOI: 10.1097/PRS.0000000000001046

Remembering David Shephard, MB FRCPC (1930-2011)

Dr. David Shephard, an eloquent and distinguished physician and talented medical writer, died on July 17, 2011 in Thunder Bay Ontario at the age of 81. Without a doubt, Dr. Shephard will be fondly remembered by those with an interest in the history of our profession. He possessed unsurpassed knowledge and dedication to the history of anesthesia, particularly past accomplishments in Canadian Anesthesia. David Arthur Easton Shephard was born on April 4, 1930 in Southsea England. He completed his secondary school education at Marlborough College, Wiltshire, England and studied medicine at the historic St. Thomas’s Hospital Medical School and London University in the United Kingdom. Dr. Shephard then pursued a career in anesthesia initially completing residency training at St. Peter’s Hospital, Chertsey and St. Bartholomew’s Hospital, Rochester, UK. He completed additional residency training in anesthesia in the United States at the esteemed Peter Bent Brigham Hospital in Boston. Dr. Shephard practiced his chosen medical specialty of anesthesia in a multitude of settings, including the Royal Navy and in three countries, the United Kingdom, the United States, and Canada. Dr. Shephard was an accomplished medical writer before becoming a distinguished medical historian. He was appointed editor of Scientific Publications (Biomedical Communications) at the Mayo Clinic and served in that role from 1972 to 1974. He then served as Editor-in-Chief of the important Canadian Medical Association Journal in 1976. He became a Fellow of the American Medical Writers Association and then went on to become its President in 1979. Dr. Shephard’s passion for medical history became his lifelong vocation. He documented the history of a number of medical societies, including The Royal College of Physicians and Surgeons of Canada 1960–1980: The Pursuit of Unity, and the history of the Canadian Anesthesiologists’ Society (CAS) in Watching Closely Those Who Sleep: A History of the Canadian Anaesthetists’ Society, 1943–1993 as part of the 50 anniversary celebrations of the CAS in 1993. Dr. Shephard was the recipient of two Fellowships from the American Society of Anesthesiologists’ Wood Library Museum as well as the Canadian Medical Association’s John B. Nielson Award, which recognized his contribution to the study of the history of medicine. While serving as Archivist for the CAS, Dr. Shephard wrote numerous articles for the Journal regarding the influence of individuals on the advancement of anesthesia practice. In so doing, he ensured that many lives and lifelong contributions to our specialty were documented, highlighted, and K. Turner, MD (&) Departments of Anesthesiology & Perioperative Medicine and Community Health & Epidemiology, Queen’s University, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2V7, Canada e-mail: turnerk@kgh.kari.net

The distinctly Canadian origins of cyclopropane

There was a worldwide quest during the early part of the 20th century to discover an anesthetic agent that could augment or replace the commonly used agents of the time – namely ether, choloroform, and nitrous oxide. Among those pursuing this line of research was Dr. Velyien E. Henderson, Professor of Pharmacology at the University of Toronto, working with Dr. W. Easson Brown, an assistant in the University’s Department of Pharmacology, who was an anesthesiologist at the Toronto General Hospital. Their initial experimentation with propylene had shown promise when the gas was freshly prepared. After storage under pressure in steel tanks, however, its administration induced nausea and cardiac irregularities. Dr. George H. Lucas, a new chemist working with Dr. Henderson, wondered if the toxic contaminant might be cyclopropane, formed when propylene is prepared. Indeed, his analysis of the stored propylene revealed that its isomer, cyclopropane, was also present in the stored tank. In 1928, Dr. Lucas subsequently isolated and purified a sample of cyclopropane, believing it to be a toxic compound. To his great surprise, when the cyclopropane was tested on two kittens in a bell jar, ‘‘the animals went to sleep quietly ... and recovered rapidly’’. After further study, Dr. Brown administered cyclopropane to Dr. Henderson, the first human to receive cyclopropane. Several demonstrations of cyclopropane’s use on other members of the laboratory staff (including Dr. Lucas) soon followed. The Toronto group went on to further Figure ‘‘No. 6 Amplon’’ cylinder (the tradename assigned by the manufacturer E.R. Squibb and Sons) was designed to yield 6 gallons (22.7 L) of cyclopropane administered at a concentration of 12-35%. In a series of 350 cases reported in 1934, Dr. Griffith estimated that he used an average of 1.79 gallons per case at a cost of 50 cents per gallon that, although costly at the time, was considerably less expensive than when the gas was first produced at

Single-dose haloperidol for the prophylaxis of postoperative nausea and vomiting after intrathecal morphine.

2.00 per gallon. (Image courtesy of the RBC Art and Heritage Centre of McGill University Health Centre) K. E. Turner, BScPhm, MSc, MD, FRCPC (&) Department of Anesthesiology & Perioperative Medicine and Public Health Sciences, Medical Lead Health Quality Programs, Queen’s University, Kingston, ON, Canada e-mail: Kim.Turner@kingstonhsc.ca