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Journal: Canadian journal of anaesthesia = Journal canadien d'anesthesie


A global health emergency has been declared by the World Health Organization as the 2019-nCoV outbreak spreads across the world, with confirmed patients in Canada. Patients infected with 2019-nCoV are at risk for developing respiratory failure and requiring admission to critical care units. While providing optimal treatment for these patients, careful execution of infection control measures is necessary to prevent nosocomial transmission to other patients and to healthcare workers providing care. Although the exact mechanisms of transmission are currently unclear, human-to-human transmission can occur, and the risk of airborne spread during aerosol-generating medical procedures remains a concern in specific circumstances. This paper summarizes important considerations regarding patient screening, environmental controls, personal protective equipment, resuscitation measures (including intubation), and critical care unit operations planning as we prepare for the possibility of new imported cases or local outbreaks of 2019-nCoV. Although understanding of the 2019-nCoV virus is evolving, lessons learned from prior infectious disease challenges such as Severe Acute Respiratory Syndrome will hopefully improve our state of readiness regardless of the number of cases we eventually manage in Canada.


BACKGROUND: An adequate airway management plan is essential for patient safety. Recently, new tools have been developed as alternatives to direct laryngoscopy and intubation. Among these, video-laryngoscopy has enjoyed a rapid increase in popularity and is now considered by many as the first-line technique in airway management. This paradigm shift may have an impact on patient safety. PRINCIPAL FINDINGS: Studies show that video-laryngoscopes are associated with better glottic visualization, a higher success rate for difficult airways, and a faster learning curve, resulting in a higher success rate for intubations by novice physicians. Thus, unanticipated difficult intubations may be less frequent if video-laryngoscopy is used as the first-line approach. In addition, on-screen viewing by the operator creates a new dynamic interaction during airway management. The entire operating room team can assess progress in real time, which enhances communication and improves teaching. However, if video-laryngoscopes become standard tools for tracheal intubation, these more costly devices will need to be widely available in all locations where airway management is conducted. Furthermore, algorithms for difficult intubation will require modification, and the question of selecting alternate devices will arise. If the incidence of difficult intubation decreases, the lack of motivation to teach and learn the use of alternative devices might adversely impact patient safety. CONCLUSION: The greater effectiveness of video-laryngoscopes associated with multi-person visualization could enhance overall patient safety during airway management. However, the routine use of video-laryngoscopy also introduces some issues that need to be addressed to avoid potentially dangerous pitfalls.

Concepts: Endotracheal tube, Learning, Airway, Intubation, Alternative rock, Oropharyngeal airway, Paradigm shift, Alternative


BACKGROUND: Interscalene nerve blocks provide adequate analgesia, but there are no objective criteria for early assessment of correct catheter placement. In the present study, pulse oximetry technology was used to evaluate changes in the perfusion index (PI) in both blocked and unblocked arms, and changes in the plethysmographic variability index (PVI) were evaluated once mechanical ventilation was instituted. METHODS: The PI and PVI values were assessed using a Radical-7™ finger pulse oximetry device (Masimo Corp., Irvine, CA, USA) in both arms of 30 orthopedic patients who received an interscalene catheter at least 25 min before induction of general anesthesia. Data were evaluated at baseline, on application of local anesthetics; five, ten, and 15 min after onset of interscalene nerve blocks; after induction of general anesthesia; before and after a 500 mL colloid fluid challenge; and five minutes thereafter. RESULTS: In the 25 patients with successful blocks, the difference between the PI values in the blocked arm and the PI values in the contralateral arm increased within five minutes of the application of the local anesthetics (P < 0.05) and increased progressively until 15 min. After induction of general anesthesia, the PI increased in the unblocked arm while it remained relatively constant in the blocked arm, thus reducing the difference in the PI. A fluid challenge resulted in a decrease in PVI values in both arms. CONCLUSION: The perfusion index increases after successful interscalene nerve blockade and may be used as an indicator for successful block placement in awake patients. The PVI values before and after a fluid challenge can be useful to detect changes in preload, and this can be performed in both blocked and unblocked arms. ( number: NCT 01389011).

Concepts: Anesthesia, Local anesthesia, Catheter, Pulse oximetry, Local anesthetic, Block, Blocking, Masimo


Healthcare providers are facing a coronavirus disease pandemic. This pandemic may last for many months, stressing the Canadian healthcare system in a way that has not previously been seen. Keeping healthcare providers safe, healthy, and available to work throughout this pandemic is critical. The consistent use of appropriate personal protective equipment (PPE) will help assure its availability and healthcare provider safety. The purpose of this communique is to give both anesthesiologists and other front-line healthcare providers a framework from which to understand the principles and practices surrounding PPE decision-making. We propose three types of PPE including: 1) PPE for droplet and contact precautions, 2) PPE for general airborne, droplet, and contact precautions, and 3) PPE for those performing or assisting with high-risk aerosol-generating medical procedures.


PURPOSE: The air-Q® intubating laryngeal airway (ILA) is a supraglottic device (SGD) designed specifically to function as both a primary airway and a bridging device and conduit for fibreoptic intubation in difficult airway scenarios. This observational study evaluated the usability and performance characteristics of pediatric air-Q ILA sizes 1.0, 1.5, 2.0, and 2.5 when used as a primary airway. METHODS: One hundred ten children, American Society of Anesthesiologists physical status I-III and undergoing elective surgery, received a weight-appropriate air-Q ILA following induction of anesthesia. The evaluation criteria included ease of insertion, quality of ventilation, presence of gastric insufflation, oropharyngeal leak pressures (OLPs) and maximum tidal volumes (VT max) in five different head positions, and fibreoptic view of the glottis. RESULTS: For sizes 1.0, 1.5, 2.0, and 2.5, the median [P25,P75] neutral OLPs (cm H2O) were 23.0 [20.0,30.0], 16.5 [15.0,20.8], 14.0 [10.0,17.8], and 14.0 [11.3,16.8], respectively. The median [P25,P75] neutral VT max values (mL·kg(-1)) were 17.4 [14.3,19.7], 20.3 [16.8,25.5], 17.8 [14.5,22.1], and 14.0 [11.6,16.0], respectively. Median [P25,P75] ease of insertion scores (0-10; 0 = easiest ever, 10 = most difficult ever) were 1 [1,2], 2 [2,3], 2 [1,2.8], and 2 [2,3] respectively. Ventilation was adequate in 108/110 cases, and a fibreoptic view of the vocal cords was obtained in 102/110 cases. CONCLUSIONS: The air-Q ILA functions acceptably as a primary SGD in infants and children. The OLPs are lower than published values for the ProSeal laryngeal mask airway (LMA ProSeal™), the current pediatric SGD of choice, but adequate tidal volumes are readily achievable. The fibreoptic views of the glottis portend well for fibreoptic intubation through the device. (This trial was registered at number, NCT00885911).

Concepts: Observational study, Surgery, Anesthesia, Endotracheal tube, Human voice, Intubation, Laryngeal mask airway, Oropharyngeal airway


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.


The goal of the present systematic review is to determine the efficacy of the quadratus lumborum block (QLB) in providing postoperative analgesia for abdominal wall and hip surgeries when compared with placebo or other analgesic techniques.


We analyzed closed civil legal cases in 2007-2016 from the Canadian Medical Protective Association (CMPA) involving specialist anesthesiologists where airway management was the central concern.


We 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.


Risk to healthcare workers treating asymptomatic patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the operating room depends on multiple factors. This review examines the evidence for asymptomatic or pre-symptomatic carriage of SARS-CoV-2, the risk of transmission from asymptomatic patients, and the specific risks associated with aerosol-generating procedures. Protective measures, such as minimization of aerosols and use of personal protective equipment in the setting of treating asymptomatic patients, are also reviewed.