Preoperative anesthesiology consult utilization in Ontario - a population-based study.

RATIONALE, AIMS AND OBJECTIVES: Physician consultations are a limited resource. Anesthesiologists provide anaesthesia during surgery and procedures, prepare patients for surgery in preoperative clinics, and provide postoperative care. This study sought to evaluate current consultation usage patterns, with an aim to determine possible opportunities for efficiency. METHOD: A retrospective comprehensive population-based cohort study was performed, evaluating all hospitals in the Canadian province of Ontario from 2002 to 2018. The main outcome measures were American Society of Anesthesiologists (ASA) classification of the patients, and whether the patients underwent surgery within 3 months following the anaesthesia consultation. RESULTS: A cohort of 2,023,499 patients, and a total of 2,920,100 preoperative anaesthesia consultations was obtained. The number of consults per year doubled between 2003 (112,983/year) and 2017 (246,427/year), despite a less than 40% increase in practicing Canadian Anesthesiologists over this same timeframe. Each year, an average of 19.3% of the consults (range: 17.7-20.5%) were for patients that did not progress to having surgery. Of those that did have surgery following the anaesthesia consult, 37.2% were ASA Classification I or II. The most common surgical procedures (percent of total) following anaesthesia consult were: Knee arthroplasty (9.5%), hip arthroplasty (5.8%), cataract extraction (4.1%), repair of muscle of chest/abdomen (3.3%), hysterectomy (2.8%), and cholecystectomy (2.7%). CONCLUSIONS: This study reveals data on utilization and trends over time of preoperative anaesthesia consultations. Potential opportunities for optimization were found, including patients who did not proceed to surgery, and healthier patients undergoing low to moderate risk surgery.

Opioid Prescriptions Following Otologic Surgery: A Population-Based Study.

OBJECTIVE: To examine postoperative opioid-prescribing patterns following otologic surgery. STUDY DESIGN: Retrospective population-based descriptive study. SETTING: All hospitals in the Canadian province of Ontario. METHODS: Of all patients with advanced ear surgery between July 1, 2012, and March 31, 2019, 7 cohorts were constructed: tympanoplasty with or without ossiculoplasty (n = 7812), atticotomy/limited mastoidectomy (n = 1371), mastoidectomy (n = 3717), semicircular canal occlusion (SCO; n = 179), stapedectomy (n = 2735), bone-implanted hearing aid insertion (n = 280), and cochlear implant (n = 2169). Prescriptions filled for narcotics postoperatively were calculated per morphine milligram equivalent (MME) opioid dose. Multivariable regression was used to determine predictors of higher opioid doses. RESULTS: The mean ± SD MMEs prescribed were as follows: tympanoplasty with or without ossiculoplasty, 246.77 ± 1380.78; atticotomy/limited mastoidectomy, 283.32 ± 956.10; mastoidectomy, 280.56 ± 1018.50; SCO, 328.61 ± 1090.86; stapedectomy, 164.64 ± 657.18; bone-implanted hearing aid insertion, 326.11 ± 1054.66; and cochlear implant, 200.87 ± 639.93. SCO (odds ratio [OR], 1.69 [95% CI, 1.16-2.48]) and mastoidectomy (OR, 1.50 [95% CI, 1.36-1.66]) were associated with higher opioid doses than tympanoplasty-ossiculoplasty. Asthma (OR, 1.24 [95% CI, 1.12-1.38]), chronic obstructive pulmonary disease (OR, 1.29 [95% CI, 1.12-1.47]), myocardial infarction (OR, 1.33 [95% CI, 1.05-1.68]), diabetes (OR, 1.22 [95% CI, 1.08-1.39]), and substance-related and addictive disorders (OR, 2.59 [95% CI, 1.67-4.00]) were associated with higher opioid doses prescribed. Overall MME prescribed by year demonstrates a sharp drop from 2017-2018 to 2018-2019. CONCLUSION: This large comprehensive population study provides insight into the prescribing patterns following otologic surgery. The large amounts prescribed and substantial variation require further study to determine barriers that limit good opioid-prescribing stewardship in the postoperative period.

Esophageal Atresia/Tracheoesophageal Fistula Repair Complicated by Tracheomalacia: A Case Report of Successful Management of Respiratory Distress Using Caudal Morphine.

We report a case of severe respiratory distress in a neonate who was not endotracheally intubated soon after esophageal atresia/tracheoesophageal fistula (EA/TEF) repair. In this serious situation, any form of emergency respiratory support or definitive airway management may compromise the esophageal anastomosis and fistula repair. The cause of respiratory distress in the early postoperative period after EA/TEF is multifactorial, and in this case, included symptomatic tracheomalacia, which is commonly associated with EA/TEF.

Carbon dioxide monitoring during laparoscopic-assisted bariatric surgery in severely obese patients: transcutaneous versus end-tidal techniques.

Various factors including severe obesity or increases in intra-abdominal pressure during laparoscopy can lead to inaccuracies in end-tidal carbon dioxide (PETCO2) monitoring. The current study prospectively compares ET and transcutaneous (TC) CO2 monitoring in severely obese adolescents and young adults during laparoscopic-assisted bariatric surgery. Carbon dioxide was measured with both ET and TC devices during insufflation and laparoscopic bariatric surgery. The differences between each measure (PETCO2 and TC-CO2) and the PaCO2 were compared using a non-paired t test, Fisher's exact test, and a Bland-Altman analysis. The study cohort included 25 adolescents with a mean body mass index of 50.2 kg/m2 undergoing laparoscopic bariatric surgery. There was no difference in the absolute difference between the TC-CO2 and PaCO2 (3.2±3.0 mmHg) and the absolute difference between the PETCO2 and PaCO2 (3.7±2.5 mmHg). The bias and precision were 0.3 and 4.3 mmHg for TC monitoring versus PaCO2 and 3.2 and 3.2 mmHg for ET monitoring versus PaCO2. In the young severely obese population both TC and PETCO2 monitoring can be used to effectively estimate PaCO2. The correlation of PaCO2 to TC-CO2 is good, and similar to the correlation of PaCO2 to PETCO2. In this population, both of these non-invasive measures of PaCO2 can be used to monitor ventilation and minimize arterial blood gas sampling.

Ventilation during laparoscopic-assisted bariatric surgery: volume-controlled, pressure-controlled or volume-guaranteed pressure-regulated modes.

INTRODUCTION: Managing ventilation and oxygenation during laparoscopic procedures in severely obese patients undergoing weight loss surgery presents many challenges. Pressure-controlled ventilation, volume-guaranteed (PCV-VG) is a dual-control mode of ventilation and an alternative to pressure (PC) or volume (VC) controlled ventilation. PCV-VG features a user-selected tidal volume target, that is auto-regulated and pressure controlled. We hypothesized that PCV-VG ventilation would provide improved oxygenation and ventilation during laparoscopic bariatric surgery with a lower peak inflating pressure (PIP) than either PC or VC ventilation. METHODS: This was a prospective cross-over cohort trial (n = 20). In random sequence each patient received the three modes of ventilation for 20 minutes during the laparoscopic portion of the procedure. For all modes of ventilation the goal tidal volume was 6-8 mL/kg, and the respiratory rate was adjusted to achieve normocarbia. The PIP, exhaled tidal volume, respiratory rate, and oxygen saturation were recorded every five minutes. At the end of 20 minutes, an arterial blood gas was obtained. Data were analyzed using a paired t-test. RESULTS: PCV-VG and PC ventilation both resulted in significantly lower PIP (cmH2O) than VC ventilation (30.5 ± 3.0, 31.6 ± 4.9, and 36.3 ± 3.4 mmHg respectively; p < 0.01 for PCV-VG vs. VC and PC vs. VC). There was no difference in oxygenation (PaO2), ventilation (PaCO2) or hemodynamic variables between the three ventilation modes. CONCLUSIONS: In adolescents and young adults undergoing laparoscopic bariatric surgery, PCV-VG and PC were superior to VC ventilation in their ability to provide ventilation with the lowest PIP.