Appraising and highlighting gaps among prophylactic intervention studies for reducing the incidence of postoperative nausea and vomiting in children: a systematic review.

OBJECTIVES: Postoperative nausea and vomiting (PONV) is a leading perioperative morbidity outcome following general anaesthesia. This systematic review aims to identify, appraise and summarise the evidence synthesis studies of prophylactic interventions that reduce the incidence of paediatric PONV, thereby highlighting knowledge gaps and avenues of future research. DESIGN: Systematic review using the AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews 2) tool and the ROBIS (Risk Of Bias In Systematic reviews) tool. DATA SOURCES: Seven major databases, including MEDLINE and EMBASE, from inception to 23 September 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Evidence synthesis studies of only randomised controlled trials that explored prophylactic interventions for PONV in children undergoing general anaesthesia. DATA EXTRACTION AND SYNTHESIS: Following screening process by two reviewers, data were extracted from all eligible studies, including demographic parameters and details of interventions. Eligible studies were categorised into 'pharmacological' and 'non-pharmacological' groups and high-risk surgical groups of 'strabismus' and 'tonsillectomy' for qualitative synthesis. RESULTS: There were 20 evidence synthesis reviews (17 meta-analyses, 2 systematic reviews, 1 network meta-analysis): 14 investigated pharmacological PONV prophylaxis in children, 5 investigated non-pharmacological interventions, 1 studied both pharmacological and non-pharmacological interventions. Monotherapy pharmacological prophylaxis agents, for example, dexamethasone (relative risk (RR) 0.49, 95% CI 0.41 to 0.58), 5-hydroxytryptamine (5-HT3) antagonists (OR 0.12, 95% CI 0.07 to 0.20) and α2-adrenoreceptor agonists (dexmedetomidine: RR 0.33, 95% CI 0.21 to 0.54), are more effective than placebo. A combination of pharmacological agents provided superior efficacy to monotherapy, particularly dexamethasone and 5-HT3 antagonists (RR 0.21, 95% credible interval 0.15 to 0.28). Acustimulation practice was consistently favourable in preventing PONV compared with placebo (RR 0.36, 95% CI 0.25 to 0.52). CONCLUSION: Monotherapy pharmacological prophylaxis is more effective than placebo in reducing the incidence of paediatric PONV, with the efficacy increased further by using combination pharmacotherapy. Further research must compare multiple treatment arms of pharmacological and non-pharmacological prophylaxes for PONV to identify the optimal multimodal prophylaxis regimen. PROSPERO REGISTRATION NUMBER: CRD42021236698.

Perioperative clinical practice recommendations for pediatric tonsillectomy: a systematic review.

PURPOSE: Tonsillectomy is one of the most common surgical procedures performed in children. Since most clinical practice guidelines (CPGs) are designed to support surgical decisions, none are specifically designed for the perioperative management of children undergoing tonsillectomy. We aimed to identify and analyze the existing CPGs with recommendations for the perioperative management of children undergoing tonsillectomy by conducting a systematic review. SOURCE: We searched Embase, MEDLINE, MEDLINE ePub Ahead of Print, and CINAHL for relevant articles published from inception to 3 August 2022. The inclusion criteria were: 1) CPG of perioperative recommendations for tonsillectomy under general anesthesia in children, 2) CPG that include at least one evidence-based recommendation, 3) peer-reviewed CPG published in English after 2000. We extracted data on baseline characteristics of each CPG and general recommendations for perioperative interventions or complications. PRINCIPAL FINDINGS: Out of five eligible CPGs, AGREE II and REX confirmed that two CPGs were high quality while only one of the two was recommended for implementation without modifications. Most of the recommendations were for pain management. Acetaminophen was the only medication recommended in all five CPG. Except for the oldest CPG, the CPG all supported of the use of nonsteroidal anti-inflammatory drugs and steroids as a pain adjunct. CONCLUSIONS: Acetaminophen, nonsteroidal anti-inflammatory drugs, and steroids are recommended in the perioperative management of pediatric tonsillectomy. Future CPG should further clarify the safe use of opioids based on severity of obstructive sleep apnea and in the context of opioid-sparing techniques, such as dexmedetomidine, high-dose dexamethasone, and gabapentinoids. STUDY REGISTRATION: PROSPERO (CRD42021253374); first submitted 18 June 2021.

RéSUMé: OBJECTIF: L'amygdalectomie est l'une des interventions chirurgicales les plus courantes pratiquées chez les enfants. Étant donné que la plupart des lignes directrices de pratique clinique sont conçues pour soutenir les décisions chirurgicales, aucune n'est spécifiquement conçue pour la prise en charge périopératoire des enfants bénéficiant d'une amygdalectomie. Notre objectif était d'identifier et d'analyser les lignes directrices de pratique clinique existantes comportant des recommandations pour la prise en charge périopératoire des enfants bénéficiant d'une amygdalectomie en réalisant une revue systématique. SOURCES: Nous avons recherché des articles pertinents dans Embase, MEDLINE, MEDLINE ePub Ahead of Print et CINAHL, publiés depuis la création de ces bases de données jusqu'au 3 août 2022. Les critères d'inclusion étaient les suivants : 1) lignes directrices de pratique clinique comportant des recommandations périopératoires pour l'amygdalectomie sous anesthésie générale chez les enfants, 2) lignes directrices de pratique clinique incluant au moins une recommandation fondée sur des données probantes, et 3) lignes directrices de pratique clinique évaluées par des pairs et publiées en anglais après 2000. Nous avons extrait des données sur les caractéristiques de base de chacune des lignes directrices de pratique clinique et des recommandations générales pour les interventions périopératoires ou les complications. CONSTATATIONS PRINCIPALES: Sur les cinq lignes directrices de pratique clinique admissibles, AGREE II et REX ont confirmé que deux lignes directrices de pratique clinique étaient de haute qualité, tandis qu'une seule des deux a été recommandée pour une mise en œuvre sans modifications. La plupart des recommandations portaient sur la prise en charge de la douleur. L'acétaminophène était le seul médicament recommandé dans les cinq lignes directrices de pratique clinique. À l'exception des lignes directrices de pratique clinique les plus anciennes, les autres ont toutes soutenu l'utilisation d'agents anti-inflammatoires non stéroïdiens et de stéroïdes comme adjuvants pour la douleur. CONCLUSION: L'acétaminophène, les agents anti-inflammatoires non stéroïdiens et les stéroïdes sont recommandés pour la prise en charge périopératoire de l'amygdalectomie pédiatrique. À l'avenir, les lignes directrices de pratique clinique devraient clarifier davantage l'utilisation sécuritaire des opioïdes en fonction de la gravité de l'apnée obstructive du sommeil et dans le contexte des techniques d'épargne des opioïdes, telles que la dexmédétomidine, la dexaméthasone à forte dose et les gabapentinoïdes. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021253374); soumise pour la première fois le 18 juin 2021.

Prophylaxis for pediatric postoperative nausea and vomiting: a scoping review of clinical trials.

PURPOSE: Postoperative nausea and vomiting (PONV) is common in pediatric patients undergoing general anesthesia, and clinicians seek prophylactic interventions to prevent its ill effects on patients as well as its ramifications on perioperative care. We sought to assess the body of evidence around prophylactic strategies, both pharmacologic and nonpharmacologic, targeting pediatric PONV. SOURCE: We searched MEDLINE, MEDLINE ePubs Ahead of Print and In-Process Citations, Embase Classic+Embase, the Cochrane Database of Systematic Reviews, Cochrane CENTRAL (via the Ovid platform), Scopus (Elsevier), Web of Science (Clarivate Analytics), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, and the International Standard Randomized Controlled Trial Number Registry, from their inception to 23 September 2022. PRINCIPAL FINDINGS: Of 188 clinical trials, 157 (83%) investigated pharmacologic interventions, 25 (13%) investigated nonpharmacologic interventions, and six (3%) investigated mixed pharmacologic and nonpharmacologic interventions. The most common surgeries investigated for pediatric PONV were strabismus surgery (68 trials, 36%) and tonsillectomy or tympanoplasty (45 trials, 23%). Of four measurement tools used to assess PONV in the included trials, the most common was clinical judgement (170 trials, 90%). CONCLUSION: The majority of data in pediatric PONV prophylaxis is based on pharmacologic interventions, with a paucity of research in nonpharmacologic or mixed interventions. Assessing and documenting PONV using tools such as the Baxter Animated Retching Faces Scale or PONV numeric scoring system may help standardize pediatric PONV prophylaxis research moving forward. Furthermore, concurrently assessing pain and adverse effects associated with PONV might further inform our understanding of this complex clinical entity.

RéSUMé: OBJECTIF: Les nausées et vomissements postopératoires (NVPO) sont fréquents chez la patientèle pédiatrique bénéficiant d'une anesthésie générale, et les équipes cliniques recherchent des interventions prophylactiques pour prévenir leurs effets néfastes sur les patient·es ainsi que leurs ramifications sur les soins périopératoires. Nous avons cherché à évaluer l'ensemble des données probantes entourant les stratégies prophylactiques pharmacologiques et non pharmacologiques ciblant les NVPO pédiatriques. SOURCES: Nous avons effectué des recherches dans les bases de données MEDLINE, MEDLINE ePubs Ahead of Print and In-Process Citations, Embase Classic+Embase, la base de données des revues systématiques Cochrane, Cochrane CENTRAL (via la plateforme Ovid), Scopus (Elsevier), Web of Science (Clarivate Analytics), ClinicalTrials.gov, le système d'enregistrement international des essais cliniques de l'OMS et le registre international normalisé des numéros d'essais contrôlés randomisés, depuis leur création jusqu'au 23 septembre 2022. CONSTATATIONS PRINCIPALES: Sur 188 études cliniques, 157 (83 %) portaient sur des interventions pharmacologiques, 25 (13 %) sur des interventions non pharmacologiques et six (3 %) sur des interventions pharmacologiques et non pharmacologiques mixtes. Les chirurgies les plus fréquemment étudiées pour les NVPO pédiatriques étaient les chirurgies de strabisme (68 études, 36 %) et les amygdalectomies ou tympanoplasties (45 études, 23 %). Parmi les quatre outils de mesure utilisés pour évaluer les NVPO dans les études incluses, le plus fréquemment utilisé était le jugement clinique (170 études, 90 %). CONCLUSION: La majorité des données sur les prophylaxies pédiatriques pour prévenir les NVPO sont basées sur des interventions pharmacologiques, avec peu de recherche sur les interventions non pharmacologiques ou mixtes. L'évaluation et la documentation des NVPO à l'aide d'outils tels que l'échelle Baxter Animated Retching Faces Scale ou un système de notation numérique des NVPO peuvent aider à normaliser la recherche sur la prophylaxie pédiatrique des NVPO à l'avenir. De plus, l'évaluation simultanée de la douleur et des effets indésirables associés aux NVPO pourrait éclairer davantage notre compréhension de cette entité clinique complexe.

Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial.

BACKGROUND: Tracheal intubation in neonates and infants is a potentially life-saving procedure. Video laryngoscopy has been found to improve first-attempt tracheal intubation success and reduce complications compared with direct laryngoscopy in children younger than 12 months. Supplemental periprocedural oxygen might increase the likelihood of successful first-attempt intubation because of an increase in safe apnoea time. We tested the hypothesis that direct laryngoscopy is not inferior to video laryngoscopy when using standard blades and supplemental oxygen is provided. METHODS: We did a non-inferiority, international, multicentre, single-blinded, randomised controlled trial, in which we randomly assigned neonates and infants aged up to 52 weeks postmenstrual age scheduled for elective tracheal intubation to either direct laryngoscopy or video laryngoscopy (1:1 ratio, randomly assigned using a secure online service) at seven tertiary paediatric hospitals across Australia, Canada, Italy, Switzerland, and the USA. An expected difficult intubation was the main exclusion criteria. Parents and patients were masked to the assigned group of treatment. All infants received supplemental oxygen (1 L/Kg per min) during laryngoscopy until the correct tracheal tube position was confirmed. The primary outcome was the proportion of first-attempt tracheal intubation success, defined as appearance of end-tidal CO2 curve at the anaesthesia monitor, between the two groups in the modified intention-to-treat analysis. A 10% non-inferiority margin between direct laryngoscopy or video laryngoscopy was applied. The trial is registered with ClinicalTrials.gov (NCT04295902) and is now concluded. FINDINGS: Of 599 patients assessed, 250 patients were included between Oct 26, 2020, and March 11, 2022. 244 patients were included in the final modified intention-to-treat analysis. The median postmenstrual age on the day of intubation was 44·0 weeks (IQR 41·0-48·0) in the direct laryngoscopy group and 46·0 weeks (42·0-49·0) in the video laryngoscopy group, 34 (28%) were female in the direct laryngoscopy group and 38 (31%) were female in the video laryngoscopy group. First-attempt tracheal intubation success rate with no desaturation was higher with video laryngoscopy (89·3% [95% CI 83·7 to 94·8]; n=108/121) compared with direct laryngoscopy (78·9% [71·6 to 86·1]; n=97/123), with an adjusted absolute risk difference of 9·5% (0·8 to 18·1; p=0·033). The incidence of adverse events between the two groups was similar (-2·5% [95% CI -9·6 to 4·6]; p=0·490). Post-anaesthesia complications occurred seven times in six patients with no difference between the groups. INTERPRETATION: Video laryngoscopy with standard blades in combination with supplemental oxygen in neonates and infants might increase the success rate of first-attempt tracheal intubation, when compared with direct laryngoscopy with supplemental oxygen. The incidence of hypoxaemia increased with the number of attempts, but was similar between video laryngoscopy and direct laryngoscopy. Video laryngoscopy with oxygen should be considered as the technique of choice when neonates and infants are intubated. FUNDING: Swiss Pediatric Anaesthesia Society, Swiss Society for Anaesthesia and Perioperative Medicine, Foundation for Research in Anaesthesiology and Intensive Care Medicine, Channel 7 Telethon Trust, Stan Perron Charitable Foundation, National Health and Medical Research Council.

Dexmedetomidine vs. total intravenous anaesthesia in paediatric emergence delirium: A network meta-analysis.

BACKGROUND: Emergence delirium is a common complication in paediatric anaesthesia associated with significant morbidity. Total intravenous anaesthesia (TIVA) and intra-operative dexmedetomidine as an adjuvant to sevoflurane anaesthesia can both reduce the incidence of emergence delirium compared with sevoflurane alone, but no studies have directly compared their relative efficacy. OBJECTIVE: The study objective was to compare the effects of TIVA and dexmedetomidine on the incidence of paediatric emergence delirium. STUDY DESIGN: The current study is a systematic review and network meta-analysis (NMA) of randomised controlled trials. DATA SOURCES: We conducted a systematic search of 12 databases including Medline (Ovid) and Web of Science (Clarivate Analytics) from their respective inception to December 2020. ELIGIBILITY: Inclusion criteria were randomised controlled trials of paediatric patients undergoing general anaesthesia using sevoflurane, sevoflurane with dexmedetomidine or TIVA. Data were extracted by two reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and analysed using NMA methodology. Risk ratios and 95% credible intervals (CrI) were calculated for all outcomes [emergence delirium, postoperative nausea and vomiting (PONV), and time to emergence and extubation]. The protocol was registered with PROSPERO (CRD42018091237). RESULTS: The systematic review returned 66 eligible studies comprising 5257 patients with crude median emergence delirium incidences of 12.8, 9.1 and 40% in the dexmedetomidine with sevoflurane, TIVA and sevoflurane alone groups, respectively. NMA indicated that compared with TIVA, sevoflurane with adjuvant dexmedetomidine decreased the incidence of emergence delirium without statistical difference (risk ratio 0.88, 95% CrI 0.61 to 1.20, low quality of evidence), but resulted in a higher incidence of PONV (risk ratio: 2.3, 95% CrI 1.1 to 5.6, low quality of evidence). CONCLUSION: Clinical judgement, considering the patient's risk factors for the development of clinically significant outcomes such as emergence delirium and PONV, should be used when choosing between TIVA and sevoflurane with adjuvant dexmedetomidine. These findings are limited by the low quality of evidence (conditional recommendation).

Risk prediction models for emergence delirium in paediatric general anaesthesia: a systematic review.

OBJECTIVES: Emergence delirium (ED) occurs in approximately 25% of paediatric general anaesthetics and has significant adverse effects. The goal of the current systematic review was to identify the existing literature investigating performance of predictive models for the development of paediatric ED following general anaesthesia and to determine their usability. DESIGN: Systematic review using the Prediction model study Risk Of Bias Assessment Tool (PROBAST) framework. DATA SOURCES: Medline (Ovid), PubMed, Embase (Ovid), Cochrane Database of Systematic Reviews (Ovid), Cochrane CENTRAL (Ovid), PsycINFO (Ovid), Scopus (Elsevier) and Web of Science (Clarivate Analytics), ClinicalTrials.gov, International Clinical Trials Registry Platform and ProQuest Digital Dissertations and Theses International through 17 November 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: All randomised controlled trials and cohort studies investigating predictive models for the development of ED in children undergoing general anaesthesia. DATA EXTRACTION AND SYNTHESIS: Following title, abstract and full-text screening by two reviewers, data were extracted from all eligible studies, including demographic parameters, details of anaesthetics and performance characteristics of the predictive scores for ED. Evidence quality and predictive score usability were assessed according to the PROBAST framework. RESULTS: The current systematic review yielded 9242 abstracts, of which only one study detailing the development and validation of the Emergence Agitation Risk Scale (EARS) met the inclusion criteria. EARS had good discrimination with c-index of 0.81 (95% CI 0.72 to 0.89). Calibration showed a non-significant Homer-Lemeshow goodness-of-fit test (p=0.97). Although the EARS demonstrated low concern of applicability, the high risk of bias compromised the overall usability of this model. CONCLUSIONS: The current systematic review concluded that EARS has good discrimination performance but low usability to predict ED in a paediatric population. Further research is warranted to develop novel models for the prediction of ED in paediatric anaesthesia. PROSPERO REGISTRATION NUMBER: CRD42019141950.

Pericardial disease as a rare complication of pediatric appendicitis: a systematic literature search.

BACKGROUND: Classic symptoms of acute appendicitis are well known but are uncommon and often misinterpreted in pediatric patients, potentially delaying diagnosis and resulting in rare sequelae. METHODS: We conducted a comprehensive systematic literature search of case reports detailing pericardial disease as a rare complication of pediatric appendicitis through MEDLINE, Embase, and Cochrane Databases. Inclusion criteria was that the patient must be < 18 years old and present with both pericardial disease and appendicitis. RESULTS: Our search yielded 7 cases with an average age of 10.3 ± 3.9 years old. The cases involved cardiac tamponade, pericarditis, and/or pericardial effusion. Five cases were diagnosed with appendicitis before complicated by pericardial disease. Most cases had an infectious component, but a majority had negative pericardial fluid cultures. Pleural effusion and abdominal abscesses were other common complications of pediatric appendicitis. CONCLUSION: Awareness of this uncommon relationship may have prognostic value as this may facilitate appropriate management of pericardial effusions, tamponade, and/or appendicitis.

Anesthesia environmental sustainability programs-a survey of Canadian department chiefs and residency program directors.

INTRODUCTION: Anesthesia-related activities contribute to operating room waste impacting climate change. The aim of this study was to ascertain 1) the current existence and scope of department and education programs concerned with anesthesia "green" practice; and 2) perceived barriers to environmental sustainability efforts among Canadian anesthesia department chiefs and residency program directors. METHODS: Association of Canadian University Departments of Anesthesia-affiliated anesthesiology department chiefs (n = 113) were invited to complete an online survey ascertaining current efforts in, and barriers to, environmentally sustainable anesthesia practice. Similarly, Canadian anesthesiology residency program directors (n = 17) were invited to complete an online survey delineating current educational programs on environmental sustainability and identifying interest in, and barriers to, developing a Canada-wide curriculum. RESULTS: The response rates for department chiefs and program directors were 23% (26/113) and 41% (7/17), respectively. Department chiefs indicated that their departments participate in sustainability efforts such as donating medical equipment (65%) and recycling (58%). Despite interest in environmental sustainability, department chiefs identified inadequate funding (72%), lack of a mandate (64%), and inadequate knowledge (60%) as barriers to implementing environmentally sustainable practices. Only 29% of responding Canadian anesthesiology programs include environmental sustainability in their curriculum. Responding residency program directors believe residents would benefit from more teaching on the topic (86%) but identified barriers including a lack of faculty expertise (100%) and time constraints (71%). Respondents (71%) also indicated an interest in developing a Canadian curriculum on the topic. CONCLUSION: Our results highlight current attitudes, gaps, and barriers to environmentally sustainable anesthesiology practice among departmental and educational leadership. Furthermore, this study identifies potential opportunities to develop cross-Canada collaborative educational programs in this field.

RéSUMé: INTRODUCTION: Les activités liées à l'anesthésie contribuent aux déchets de salle d'opération qui ont un impact sur les changements climatiques. L'objectif de cette étude était d'établir 1) l'existence et la portée des programmes départementaux et de formation s'intéressant à une pratique écoresponsable de l'anesthésie; et 2) les obstacles perçus aux efforts en matière de durabilité environnementale parmi les chefs de départements et les directeurs de programmes de résidence en anesthésie canadiens. MéTHODE: Les chefs des départements d'anesthésiologie affiliés à l'Association canadienne universitaire des départements d'anesthésie (ACUDA) (n = 113) ont été invités à remplir un sondage en ligne afin de déterminer les efforts actuels et les obstacles à une pratique durable de l'anesthésie. Les directeurs de programmes de résidence en anesthésiologie canadiens (n = 17) ont également été invités à remplir un sondage en ligne décrivant les programmes de formation actuels portant sur la durabilité environnementale et identifiant l'intérêt pour et les obstacles à la création d'un cursus s'appliquant à tout le Canada. RéSULTATS: Les taux de réponse des chefs de département et des directeurs de programme étaient de 23 % (26/113) et 41 % (7/17), respectivement. Les chefs de département ont indiqué que leurs départements prenaient part aux efforts de durabilité en faisant don des équipements médicaux (65 %) et en recyclant (58 %). Malgré un intérêt pour la durabilité environnementale, les chefs de département ont fait mention d'un financement inadapté (72 %), de l'absence de mandat (64 %), et d'un manque de connaissances (60 %) en tant qu'obstacles à la mise en place de pratiques durables. Seuls 29 % des programmes d'anesthésiologie canadiens ayant répondu comportaient un volet sur la durabilité environnementale dans leur programme. Les directeurs de programmes de résidence ayant répondu étaient d'avis que les résidents bénéficieraient d'une augmentation de l'enseignement à ce sujet (86 %) mais ont identifié divers obstacles, notamment un manque d'expertise du corps enseignant (100 %) et des contraintes de temps (71 %). Les répondants (71 %) ont également indiqué leur intérêt pour la création d'un cursus canadien à ce sujet. CONCLUSION: Nos résultats résument les attitudes, écueils et obstacles actuels à une pratique durable de l'anesthésiologie parmi les directions des départements et des programmes de formation. En outre, cette étude identifie des occasions potentielles de création de programmes éducatifs collaboratifs pancanadiens dans ce domaine.

Environmentally sustainable perioperative medicine: simple strategies for anesthetic practice.

PURPOSE: This continuing professional development module aims to inform anesthesiologists about the magnitude of healthcare-related waste and its contribution to global warming, as well as providing general strategies to improve environmental sustainability in daily anesthesia practice in a Canadian context. PRINCIPAL CONSIDERATIONS: Global warming is considered to be the biggest global health threat of the 21st century. Healthcare is not only adversely impacted by but also a significant contributor to global warming and environmental degradation. Healthcare provision produces 4.6% of the total national greenhouse gas emissions in Canada, while healthcare waste has increased unabated in recent years, largely because of increased use of disposable medical supplies. Operating rooms are highly energy-intensive and produce up to 33% of total hospital waste. Increasingly, attention in healthcare is being focused on environmental sustainability by exploring evidence-based approaches to more sustainable delivery of healthcare. Key to environmental sustainability research is the life-cycle assessment methodology, which measures the cradle-to-grave impact of products on various environmental outcomes and empowers purchasing departments to make environmentally conscious decisions. By using the "reduce, reuse, recycle" hierarchy of waste reduction, several easily implementable evidence-based strategies are proposed to reduce the environmental footprint of everyday anesthesia practice. These recommendations focus on informed decisions on volatile anesthetic use, reduced drug waste, limited use of single-use devices, and meticulous waste segregation and recycling strategies. CONCLUSIONS: Anesthesiologists have a unique opportunity to be champions of environmental sustainability through evidence-based practices, while simultaneously reaping significant synergistic health, cost, and quality co-benefits.

RéSUMé: OBJECTIF: Ce module de développement professionnel continu a pour objectif de conscientiser les anesthésiologistes quant à l'ampleur du gaspillage et des déchets liés aux soins de santé et leur contribution au réchauffement climatique, ainsi que de proposer des stratégies générales pour améliorer la durabilité environnementale dans la pratique quotidienne de l'anesthésie dans un contexte canadien. CONSIDéRATIONS PRINCIPALES: Le réchauffement climatique est considéré comme la plus importante menace en matière de santé mondiale au XXIe siècle. D'un côté, les soins de santé sont victimes des impacts négatifs du réchauffement climatique et de la dégradation de l'environnement, mais de l'autre, ils y contribuent également de façon significative. La fourniture de soins de santé produit 4,6 % des émissions nationales totales de gaz à effet de serre au Canada, alors que les déchets médicaux ne cessent d'augmenter depuis quelques années ­ augmentation due en grande partie à l'utilisation accrue de matériels médicaux jetables. Les salles d'opération sont particulièrement énergivores et produisent jusqu'à 33 % des déchets hospitaliers totaux. Dans les soins de santé, l'attention se tourne de plus en plus vers la durabilité en explorant des approches fondées sur des données probantes pour une fourniture plus écologique des soins de santé. La méthodologie d'analyse du cycle de vie est un élément crucial de la recherche en durabilité : cette méthodologie mesure l'impact d'un produit, de sa création à son élimination, sur différents résultats environnementaux. Elle permet aux services d'approvisionnement d'être mieux outillés pour prendre des décisions écoresponsables. En s'appuyant sur la hiérarchie des 3 R « réduire, réutiliser, recycler ¼ pour la réduction des déchets, nous proposons plusieurs stratégies fondées sur des données probantes et faciles à mettre en œuvre afin de réduire l'empreinte environnementale de la pratique quotidienne de l'anesthésie. Ces recommandations mettent l'emphase sur des stratégies concernant divers aspects promouvant une plus grande durabilité, soit : la gestion de l'utilisation des anesthésiques volatils, la réduction du gaspillage médicamenteux, l'utilisation restreinte des dispositifs à usage unique, le tri méticuleux des déchets et les stratégies de recyclage. CONCLUSION: Les anesthésiologistes ont une occasion unique de devenir des leaders en durabilité grâce à des pratiques fondées sur des données probantes, tout en récoltant d'importants avantages concomitants et synergiques en matière de santé, de coûts et de qualité.

A national survey on attitudes and barriers on recycling and environmental sustainability efforts among Canadian anesthesiologists: an opportunity for knowledge translation.

BACKGROUND: Anesthesia-related activities produce 25% of all operating room (OR) waste and contribute to environmental pollution and climate change. The aim of this study was to document Canadian anesthesiologists' current practice, attitudes towards, and perceived barriers regarding recycling of OR waste and environmental sustainability efforts. METHODS: With Research Ethics Board approval, members of the Canadian Anesthesiologists' Society (CAS) completed an online survey consisting of 25 questions assessing current environmentally sustainable practices in anesthesiology and gaps, barriers, and interest in gaining further knowledge on this topic. RESULTS: Four hundred and twenty-six of 2,695 (16%) CAS members responded to the questionnaire. Despite a willingness to recycle at work among most anesthesiologists (393/403, 97.5%), only 122/403 (30.2%) did so. Other sustainability efforts in Canadian ORs included donating unused medical equipment and supplies to medical missions (198/400, 49.5%) and evening shut-off of anesthesia machines and other OR equipment (185/400, 46.3%). Reported barriers to recycling in the OR included a lack of support from hospital/OR leadership (254/400, 63.5%) and inadequate information/education (251/400, 62.8%). Only 122/389 (31.4%) of respondents were aware of any efforts to expand sustainability programs at their institutions but 273/395 (69.1%) of respondents indicated an interest in obtaining further education on the topic. CONCLUSION: Canadian anesthesiologists appear ready to incorporate environmental sustainability in their practice but indicate that significant barriers exist. Our study highlights the need for further educational programs and implementation strategies.

RéSUMé: CONTEXTE: Les activités liées à l'anesthésie produisent 25 % de tous les déchets en salle d'opération et contribuent à la pollution de l'environnement et au changement climatique. Le but de cette étude était de documenter les pratiques actuelles des anesthésiologistes canadiens, leurs attitudes envers le recyclage des déchets de salle d'opération et les efforts pour la protection de l'environnement, ainsi que les obstacles perçus comme s'y opposant. MéTHODES: Après approbation d'un Comité d'éthique de la recherche, les membres de la Société canadienne des anesthésiologistes (SCA) ont pu remplir une enquête en ligne comportant 25 questions évaluant les pratiques actuelles en anesthésiologie pour un environnement durable ses obstacles, ses lacunes, ainsi que l'intérêt à en savoir plus sur ce sujet. RéSULTATS: Quatre cent vingt-six des 2695 membres (16 %) de la SCA ont répondu au questionnaire. Malgré un désir de recyclage dans le cadre du travail chez la plupart des anesthésiologistes (393/403, 97,5 %), seulement 122/403 (30,2 %) le faisaient. D'autres efforts des salles d'opération canadiennes en faveur de la durabilité incluaient le don de l'équipement médical et des fournitures non utilisés à des missions médicales (198/400, 49,5 %) et la fermeture des appareils d'anesthésie et des autres équipements de la salle d'opération le soir (185/400, 46,3 %). Les obstacles au recyclage en salle d'opération qui ont été mentionnés incluaient une absence de soutien de la part du leadership de l'hôpital/de la salle d'opération (254/400, 63,5 %) et une information/éducation insuffisante sur le sujet (251/400, 62,8 %). Seulement 122 des 389 répondants (31,4 %) étaient au courant d'efforts d'extension des programmes en faveur de l'environnement, mais 273/395 (69,1 %) répondants ont manifesté de l'intérêt à obtenir plus de formation sur le sujet. CONCLUSION: Les anesthésiologistes canadiens semblent prêts à incorporer la protection de l'environnement dans leurs pratiques, mais indiquent qu'il existe des obstacles significatifs. Notre étude souligne le besoin de poursuivre les programmes éducatifs et les stratégies de mise en œuvre.

Malignant hyperthermia and the clinical significance of type-1 ryanodine receptor gene (RYR1) variants: proceedings of the 2013 MHAUS Scientific Conference.

The Malignant Hyperthermia Association of the United States and the Department of Anesthesia at the University of Toronto sponsored a Scientific Conference on November 1-2, 2013 in Toronto, ON, Canada. The multidisciplinary group of experts, including clinicians, geneticists, and physiologists involved in research related to malignant hyperthermia (MH), shared new insights into the pathophysiology of diseases linked to the type-1 ryanodine receptor gene (RYR1) as well as the relationship between MH and "awake MH" conditions, such as exertional rhabdomyolysis and exertional heat illness. In addition, the molecular genetics of MH and clinical issues related to the diagnosis and management of disorders linked to RYR1 were presented. The conference also honoured Dr. David H. MacLennan for his contributions to our understanding of the genetics, pathogenesis, and treatment of MH and other RYR1-related myopathies. This report represents a summary of the proceedings of this conference.

Heteroactivation of cytochrome P450 1A1 by teas and tea polyphenols.

We studied 7-ethoxyresorufin deethylase as an index of cytochrome P4501A1 (CYP1A1) activity in liver microsomes from rats pretreated with 3-methylcholanthrene. The enzyme had complex kinetics compatible with a multisite model. At 1 microM substrate, brewed black, green and white teas had complex effects on enzyme activity consisting of activation at low concentrations and inhibition at higher concentrations. Data fit well to a two-site model that allowed us to determine maximal activation (% increase above control), pEC(50) for activation (g ml(-1)) and pIC(50) for inhibition (g ml(-1)). These parameters were 190+/-40, 5.9+/-0.1 and 4.51+/-0.09 for green tea, 350+/-40, 5.43+/-0.05 and 5.43+/-0.05 for black tea and 230+/-80, 5.3+/-0.3 and 4.7+/-0.2 for white tea, respectively. The effects of the brewed teas were mimicked to different degrees by the green tea polyphenols. Maximal activation, pEC(50) (M) and pIC(50) (M) were: (-)-epicatechin, 55+/-9, 5.4+/-0.3, 2+/-1; (-)-epicatechin gallate, 160+/-60, 6.2+/-0.3, 5.28+/-0.06; (-)-epigallocatechin 30+/-10, 6.5+/-0.5, 3.37+/-0.08; and (-)-epigallocatechin gallate 130+/-40, 6.7+/-0.3, 5.0+/-0.1. A crude extract of black tea polyphenols inhibited 7-ethoxyresorufin deethylase, but did not cause enzyme activation consistently. Enzyme activation was dependent upon substrate concentration. Heteroactivation of CYP1A1 may partially explain the lack of agreement between biological and epidemiological evidence of a role for tea in cancer prevention.