Department of Anesthesia

ANNUAL GARY JOHNSON ANESTHESIOLOGY RESEARCH DAY PROGRAM

0730 - 0800 Continental Breakfast (Theatre Hall 201-202, Ottawa Conference and Event Centre, 200 Coventry Rd, Ottawa, ON)

OPENING REMARKS

0800 - 0805 Dennis Reid, MB,ChB, D.Obst.RCOG, FRCA, FRCPC Professor of Anesthesiology, University of Ottawa 0805 - 0810 Colin McCartney, MBChB, PhD, FRCA, FCARCSI, FRCPC Professor and Chair of Anesthesiology 0810 - 0815 Gregory Bryson, MD, MSc, FRCPC Chair, Gary Johnson Research Day Planning Committee SESSION ONE: PODIUM PRESENTATIONS 0815 - 0830 Understanding Barriers and Facilitators to Intraoperative Temperature Management Using the TDF-2 Karim Mohamed, MD (PGY2) 0830 - 0845 Intrathecal Drug Delivery Systems for Cancer Pain: An Evidence-Based Analysis Tim Oliveira, MD (PGY4) 0845 - 0900 3d Tee Analysis of Coaptation Surface Area in A Porcine Model Of Aortic Insufficiency Marie-Eve Chamberland, MD (Fellow) 0900 - 0915 Factor Xiii (Fxiii) Inhibitor: Systematic Review of Case Reports & Case Series Kira Tone, MD (PGY3) 0915- 0930 Survival and Quality of Life in Survivors of Prolonged Critical Illness Following Cardiac Surgery: Is the Effort Worthwhile? Alyssa Nikolla, (MS) SESSION TWO: BULLET PRESENTATIONS 0930 - 0935 The Impact Of Transversus Abdominis Plane Blocks On Length Of Stay Following Elective Abdominal Surgery Kathryn Wheeler, MD (PGY2) 0935 - 0940 Performance Assessment of Staff Anesthesiologists: A Post-Implementation Physician Survey Kathryn Wheeler, MD (PGY2)

0940 - 0945 Neuro-Monitoring Alerts and New Neurologic Deficits in Pediatric Spine Fusion Surgery Kamyar Ghaffari, MD (Research Assistant) 0945 – 0950 Investigating caregiver burden of cardiac surgical patients. Oliver Gervais, (MS) 0950 - 0955 Dexmedetomidine Use to Limit Hypertensive Crises During Pheochromocytoma Resection Amir Bouzari, MD (PGY4) 0955 - 1000 Major complications and perioperative factors associated to spinal fusion surgery in children. A quality assurance study. Karoll Rodelo Ceballos, MD (PGY3) 1000 - 1005 Unilateral Transversus Abdominis Plane Block (Tap) Catheter for the Treatment of Abdominal Wall Pain in Pregnancy: A Case Report Elizabeth Miller, MD (PGY3) 1005 - 1010 Does Contextual Interference Improve Basic Life Support Skills Retention? A Randomized Controlled Trial Purnima Rao, MD (Fellow) 1010 – 1015 Bed Bracket Failures: Problem Analysis and Quality Improvement Initiative Kelvin Kwan, MD (PGY3) 1015 - 1020 Percutaneous Balloon Occlusion of HeartWare™ Cannula after Complete Drive Wire Transection Matthew McFarling, MD (Fellow) 1020 - 1040 COFFEE SESSION THREE: VISITING PROFESSOR’S PRESENTATION 1040 - 1125 Venous Return, autonomic nervous system and the brain Alain Deschamps, MD, PhD

Objectives: 1. Identify research in anesthesia and perioperative medicine related clinical (RCTs, chart audits and case reports/series), education and bench research that has been performed by residents and fellows affiliated with the University of Ottawa Department of Anesthesiology. 2. Appraise the design and execution of randomized clinical trials, quality improvement projects and medical education initiatives. 3. Evaluate basic descriptive and inferential statistics as they apply to the areas of research mentioned above.

1125 - 1140 Questions 1140 - 1145 Wrap up 1145 - 1205 Resident Photo 1800 Awards Dinner (Adam Room, The Fairmont Château Laurier, 1 Rideau St, Ottawa, ON)

SESSION 1 (10 Minute Podium Presentations)

Understanding barriers and facilitators to intraoperative temperature management using the TDF-2 Boet S., Mohamed K., Baron J., Patey A., Bryson G., Koudieh D., Brehaut J., Grimshaw J.

Abstract

Background: Intraoperative hypothermia is associated with a range of adverse health outcomes including surgical site infections, cardiac events, blood loss, increased length of stay, mortality, and patient thermal discomfort.1-3 Although safe and effective warming techniques exist to prevent hypothermia, between 20-50% of patients are hypothermic at the end of surgery.4 We aimed to identify barriers and facilitators to these behaviours in order to better inform an intervention to improve perioperative temperature management.

Methods: After REB approval, fifteen staff anesthesiologists at The Ottawa Hospital were interviewed. The interview guide was based on the Theoretical Domains Framework (TDF-2).5 Relevant domains were identified by the frequencies of beliefs, content, and influence on the performance of the target behaviour.

Results: Preliminary results suggest participants were aware of adverse health outcomes related to hypothermia (Beliefs about consequences) and practice guidelines (Knowledge). However, there was discrepancy in the temperature threshold used to define hypothermia (Knowledge). Patient- and surgery-related factors informed temperature management during surgery (Memory, attention and decision-making). Most participants intended to maintain normothermia (Intention) but agreed their level of control was limited (Beliefs about capabilities). Factors influencing control were availability of warming equipment (Environmental context and resources) and behaviours of the operating room team (Social influence). Temperature management did not always involve temperature monitoring, as temperature probe measurements were felt to be inaccurate (Environmental context and resources).

Conclusions: Identifying beliefs that drive intraoperative temperature management by anesthesiologists will help inform an intervention to reduce the incidence of inadvertent intraoperative hypothermia and associated adverse health outcomes.

1. Mangram AJ, et al. American Journal of Infection Control. 1999;27(2):97-134. 2. Kirkland KB, et al. Infect Control Hosp Epidemiol. Nov 1999;20(11):725-730. 3. Poulsen KB, et al. Epidemiol Infect. Oct 1994;113(2):283-295. 4. Kurz A. Best Practice & Research Clinical Anaesthesiology. 2008;22(1):39-62. 5. Cane J, et al.Implement Sci. 2012;7(1):37.

Title

Intrathecal Drug Delivery Systems for Cancer Pain: An Evidence-Based Analysis

Authors

T Oliveira1, CE Smyth1, MT Ansari2, N Ahmadzai2, K Coyle3, S Alisic1, M Sheppard1, T Sandhu1, D Coyle4 1 Department of Anesthesiology, University of Ottawa, Ottawa, Ontario, Canada 2 Ottawa Evidence-based Practice Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada 3 Health Economics Research Group, Brunel University London, Uxbridge, Middlesex, United Kingdom 4 Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada

Purpose

Even with expert medical management, 10-30% of cancer patients receiving conventional pain therapy have persistent pain.1 We aimed to investigate the benefits, harms, and cost-effectiveness of intrathecal drug delivery systems (IDDS) compared with current standards of care for adult patients with chronic pain due to malignant conditions.

Methods

This study did not require REB approval. Using a methodological approach to literature search, this systematic review conformed to the Cochrane Collaboration’s methods and followed an a priori protocol. Two reviewers screened records and assessed study validity. To assess evidence quality, we used the Cochrane risk of bias tool for RCTs and the Phillips checklist for economic studies.

Results

A total of 470 abstracts for the benefits/harms search were retrieved with 3 selected for analysis. The cost-effective search yielded 425 abstracts with 1 for analysis. Low quality evidence demonstrated that compared to conventional management alone, IDDS with conventional management reduced overall drug toxicity by 29% (95% CI, 6.93 to 51.07) over 12 weeks, as measured by the National Cancer Institute common toxicity criteria.2 No significant reduction in pain scores was observed (5% with 95% CI, -3.13 to 13.13). Weak economic evidence from suggested that IDDS are initially more expensive than conventional pain therapy, but can be more cost-effective than oral therapy if administered for seven months or longer.3

Conclusions

There was inadequate evidence to establish the benefit, harm, or cost-effectiveness of IDDS compared with current standards of care and further evidence is needed in this area.

References

(1) Smyth CE, Jarvis V, Poulin P. Can J Anesth 2014;61(2):141-53. (2) Smith TJ, Staats PS, Deer T, Stearns LJ, Rauch RL, Boortz-Marx RL, et al. J Clin Oncol. 2002 Oct 1;20(19):4040-9. (3) Brogan SE, Winter NB, Abiodun A, Safarpour R. Pain Med. 2013 Apr;14(4):478-86.

3D TEE ANALYSIS OF COAPTATION SURFACE AREA IN A PORCINE MODEL OF AORTIC INSUFFICIENCY Chamberland, M-E.*, Al-Atassi, T.#, Boodhwani, M.#, Labrosse, M.α, Toeg, H.#, Sohmer, B.* Divisions of Cardiac Anesthesiology* and Cardiac Surgery#, University of Ottawa Heart Institute, and Departement Of Mechanical Engineering α, University of Ottawa PURPOSE: Surgeons require increasingly detailed information for aortic valve (AV) repair techniques. We utilized a porcine model of aortic insufficiency (AI) in a left heart simulator (LHS) incorporating finite element (FE) modeling, and structural analysis using 3D echocardiography. We hypothesized that coaptation surface area (CoapSA) would decrease progressively as an AV becomes more insufficient. METHODS: Porcine aortic roots were analyzed on a LHS before (n=8) and after intervention (n = 8) which consisted of implantation of patches at the sinotubular junction (STJ) to enlarge it. Regurgitant and left ventricular stroke volumes were calculated from the LHS. 3D TEE images of the root were obtained to assess CoapSA while effective regurgitant area (ERA) was obtained from the FE model. RESULTS: The intervention group had a significant increase in STJ diameter by a mean of 14±1 mm, representing a 55±4% increase from baseline. CoapSA was significantly lower in the intervention group (1.03±0.11 cm2 vs. 1.80±0.08 cm2, p < 0.001). There was a linear correlation between increase in STJ/VAJ ratio and a decrease in CoapSA (Figure 1A), as well as an increase in AI as assessed by regurgitant fraction (Figure 1B). These findings were consistent with the results from the FE model (Figure 1C). CONCLUSION: In LHS and FE models of AI, STJ dilatation results in a predictable decrease in CoapSA. CoapSA is consistently reproducible and is now validated in LHS and FE models of AI. Measuring CoapSA may provide novel insights into mechanisms of AI and may have a predictive value for AV repair. REFERENCE: Sohmer B, Hudson C, Atherstone J, Lambert AS, Labrosse M, Boodhwani M. Measuring aortic valve coaptation surface area using three-dimensional transesophageal echocardiography. Can J Anesth. 2013; 60:24-31

Legend x = control ● = intervention

FACTOR XIII (FXIII) INHIBITOR: SYSTEMATIC REVIEW OF CASE REPORTS & CASE SERIES Kira J Tone, Tyler E James, Dean A Fergusson, Jason Tay, Marc T Avey, Shaun Kilty, Alan Tinmouth, Manoj M Lalu Introduction Factor XIII (FXIII) supports clot stabilization and wound healing. Acquired FXIII deficiency due to autoantibodies causes bleeding despite normal routine coagulation tests. Given the rarity of this disease, large clinical studies to inform clinical practice are not feasible. We therefore performed a systematic review of case reports/series to determine: “In hospitalized and/or perioperative patients what are management and treatment strategies for FXIII acquired inhibitor?” Methods MEDLINE, Embase, and Web of Science were systematically searched (07/2014). Two reviewers performed article screening and data extraction independently. Completeness of reporting was evaluated using elements from the CARE guidelines1. PROSPERO registration: 42014006279 Results 1082 citations were reviewed with 36 case reports and 3 case series meeting eligibility criteria (66 patients total; 18 perioperative, 48 medical; Table 1). At presentation 51 patients (77%) had intramuscular/subcutaneous bleeding and 38 patients (58%) had external/surgical bleeding. Clinical improvement in bleeding occurred in patients receiving FXIII concentrate (11/17 patients), cryoprecipitate (4/8), and plasma (2/6). Inhibitor reduction occurred in patients who received rituximab (5/5 patients), plasma exchange (1/1), exchange transfusion (1/1), IVIG (1/1), steroid (10/14), or cyclophosphamide (8/12). Concurrent initiation of multiple therapies made independent association to outcomes difficult to establish. 56 patients (85%) had reported outcomes, of which 64% relapsed and/or died. Completeness of reporting varied widely for specific CARE items. Least reported items included informed consent and a title containing the words ‘case report’. Discussion This systematic review provides the most complete overview of FXIII acquired inhibitor to date. Despite multimodal therapy, this disease has significant morbidity and mortality for patients. References 1. Gagnier et al. 2014. The CAse REport Guidelines: consensus - based clinical case report guideline Development. Journal of Clinical Epidemiology 67 (2014) 46-51.

Table 1. Characteristics, treatments and outcomes of patients with Factor XIII acquired inhibitor Medical Perioperative Combined Total Number of Studies 19 Case Reports

2 Case Series 17 Case Reports

1 Case Series 36 Case Reports

3 Case Series Participants (total) 48 18 66 Age (Mean (Range)) 63.3 (20-87) 57.5 (9-82) 61.3 (9-87) Gender (Male:Female) 21:19 8:10 29:29 Reported Presenting Symptoms

External Bleeding (total) 10 11 21 Hematoma (IntraMuscular/SubCutaneous) 38 13 51 Hematoma (Thoracoabdominal/ Intracerebral Hemorrhage /Retroperitoneal)

8 2 10

Surgical Bleeding 3 14 17 Airway Compromise 0 1 1 Anemia 12 6 18

Reported Past Medical History: Risk Factors

Amiodarone 0 1 1 Ciprofloxacin 0 1 1 Isoniazid 4 2 6 Practolol 1 0 1 Procainamide 1 1 2 Autoimmune Disease 8 4 12 Cancer 3 0 3 Inflammatory Bowel Disease 2 1 3 Liver Disease 5 0 5 Myeloproliferative & Myelodysplastic Disease

0 1 1

Sepsis 0 1 1 Systemic Lupus Erythematosus 6 2 8

Interventions Any Intervention Reported 47/48 18/18 65/66 Red Blood Cells 9 10 19 Plasma 8 11 19 Cryoprecipitate 4 4 8 Whole Blood 5 1 6 Factor XIII 26 9 35 Tranexamic Acid 4 1 5 ɛ-aminocaproic acid 1 3 4 Steroids 28 8 36 Rituximab 7 4 11 Cyclophosphamide 21 6 27 Immunoadsorption 2 1 3 Plasmapheresis 5 4 9 Plasma Exchange 0 3 3 Immunoglobulin 3 2 5 Discontinuededication of Risk 6 6 12 Perioperative Prophylactic Treatment - 5 -

Outcome Any Outcome Reported 38 18 56 Relapses 11 11 22 Spontaneous Resolution 1 0 1 Partial Resolution 7 9 13 Complete Resolution 22 4 11 Death 9 5 12

Title: Survival and Quality of Life in Survivors of Prolonged Critical Illness Following Cardiac Surgery: Is the Effort Worthwhile? Authors: Nikolla S1., Bourke M.1, Boodhwani M.2, Dupuis JY1., Cattran C1., Macdonald J1., and McDonald B1. 1Division of Cardiac Anesthesiology and Critical Care Medicine, University of Ottawa Heart Institute 2Division of Cardiac Surgery, University of Ottawa Heart Institute Introduction: The long term outcomes of patients who experience prolonged critical illness post cardiac surgery are unclear. The aim of this study was to assess survival and quality of life (QOL) in patients with prolonged ICU stay (≥10 days) in comparison to a matched control group that experienced an uncomplicated recovery. Methods: The Research Ethics Board at the Ottawa Hospital approved this protocol on May 28, 2014. All patients undergoing major cardiac surgical procedures from Jan 1, 2011 to Dec 31, 2013 were included in this case-control observational study. We excluded patients undergoing heart transplantation, planned LVAD implantation, pulmonary thromboendarterectomy and TAVI procedures due to their unique nature of perioperative decision making and care. Patients with prolonged postoperative ICU LOS were identified from the UOHI perioperative database and those discharged from hospital alive were matched to a control group (ICU stays of < 7 days). QOL measures (SF36) were obtained through mail out and telephone interviews. Vital status was obtained from these interviews and/or clinical records. Results: 245 patients experienced a prolonged ICU stay (median LOS 19 days (IQR 12.6 - 33.6)) ; 27 died in-hospital with 218 alive at hospital discharge. During a mean follow-up time of 21 months, 62 deaths occurred post hospital discharge in the prolonged stay group and there was a highly significant difference (p<0.001) in estimated mean survival time between the prolonged stay and control groups (Figure). There were significant differences between the two groups in QOL measures, predominantly in the physical component scores. Conclusion: While early mortality was high, long term survival was "heartening" with moderate decreases in QOL among survivors. The high resource utilization and human cost of continuing ICU care for many of these prolonged ICU stay patients appears reasonable.

Figure

SESSION 2 (5 Minute Bullet Presentations)

Title: The impact of Transversus Abdominis Plane Blocks on Length of Stay Following Elective Abdominal Surgery Authors: Wheeler K1, Joo J2, Miller E1, McIsaac D1

1Department of Anesthesiology, University of Ottawa 2Department Undergraduate Medical Education, University of Ottawa

Purpose: The purpose of this systematic review and meta-analysis is to determine whether TAP blocks lead to a reduction in LOS following elective abdominal surgery. The results of this study may help to identify the impact of TAP blocks on LOS or highlight the need for further research on resource-related outcomes. Methods: A literature search was performed in the following databases: MEDLINE, PUBMED, CINAHL, EMBASE, Web of Science, CENTRAL, PROSPERO, US Clinical Trials Database, and WHO ICTRP. Given the nature of the study, ethical approval was deemed unnecessary. Risk of bias will be assessed using the Cochrane risk of bias tool for quality assessment of RCTs and the ACORBAT-NSRI and Newcastle-Ottawa Scale for cohort studies. Quality of evidence for each study will be documented using the GRADE approach. Results: Literature search yielded 3,712 articles and 384 registered systematic reviews and clinical control trials. Identification of studies which meet the study inclusion criteria is currently underway. Primary outcomes data (PACU LOS and hospital LOS) will be analyzed separately. Planned sub-group analyses include inpatient vs. outpatient surgery, laparoscopic vs. open and upper vs. lower abdominal procedures, single-shot vs. continuous infusion of local anesthetic, and pre- vs. post-operative block placement. Conclusion: A systematic review protocol was developed and registered with PROSPERO. Knowledge of the effect of TAP block on discharge time may highlight the need for further research on resource-related outcomes and may be beneficial in understanding the role of this intervention in Enhanced Recovery Programmes.

Title: Performance assessment of staff anesthesiologists: a post-implementation physician survey Authors: Wheeler K1, Bryson G1, Boet S1, Pysyk C1, Baxter A1

1Department of Anesthesiology, University of Ottawa Purpose: The use of electronic medical records in the perioperative setting has provided a wealth of clinical data, however the optimal method of packaging such data into formal performance feedback is ill-defined (1). In 2013, our centre provided its anesthesiologists with a table of individualized performance data extracted from the local electronic medical record system. A post-implementation survey was administered to determine user-acceptability of current measures and to highlight areas of potential improvement for future assessments. Methods: Following Research Ethics Board approval an electronic survey was administered to all recipients of a performance assessment as identified by departmental email contact list. Questionnaire items were generated by investigator review of quality indicators in anesthesiology and data elements in the electronic medical record. The survey was pilot tested by five clinical anesthesia fellow volunteers using the Burns Clinical Sensibility tool (2). Eligible participants were sent an email describing the purpose of the study, as well as additional emails containing a copy of the participant’s individual performance assessment and a link to the electronic survey. Three email reminders and a paper version were offered to increase response. Responses are described using numbers (%) and mean (SD). Results: Fifty-eight of 76 (76%) eligible participants responded with 53 complete questionnaires for a completed response rate of 70%. Responses are summarized in Figure 1. Conclusion: Preliminary review of the survey results indicates reasonable user-acceptability of the current performance assessment tool and has identified several areas for future improvement. References: 1. Haller G. Anesthesiology 2009; 110:1158–75 2. Burns KE. CMAJ 2008;179(3):245-52

Neuro-monitoring alerts and new neurologic deficits in pediatric spine fusion surgery

Neira V, Ghaffari K, Bulusu S, Nassef M, Moroz P, Jarvis J, Barrowman N, Splinter W.

Purpose: Intraoperative neuro-monitoring (IONM) is used to detect an impending new neurologic deficit (NND) after pediatric spinal fusion surgery (SFS), our objective was to measure the sensitivity and specificity of IONM.

Methods: Ethics Board approval was obtained for this retrospective chart review of all patients undergoing SFS at a single, academic institution from April 2007 to October 2014. All subjects were less than 21 years old and underwent SFS for correction of scoliosis and/or kyphosis. Exclusion criteria: subjects that did not receive IONM, uninterpretable baseline signals, unavailable data.

Results: Of the potential 318 subjects, 27 were excluded (of note 25 of the excluded subjects were neuromuscular (19 did not have an interpretable baseline signals, 3 did not receive monitoring)). The etiologies of deformities were idiopathic (n=200 (69%)), neuromuscular (n=45 (15%)) and the others (n=46 (17%)).

The incidence of a new neurologic deficit was 3% (n=11). The classifications of deficits were: total spinal (n=2 (18%)), partial spinal (n=6 (55%)), plexopathy (n=2 (18%)) and peripheral nerve (n=1 (9%)), before analysis, this case was excluded because the defect was in the myotome not being monitored by the IONM. The sensitivity and specificity of the evoked potentials are in the table.

Conclusion: Of the modalities studied here, MEPs are the most sensitive modality and adding SSEPs did not improve upon this. Our results are similar to previous studies (1, 2). Low incidence of NNDs and monitoring selected neural structures are limitations in measuring sensitivity more precisely. Baseline signals are often uninterpretable among neuromuscular patients.

Table: Sensitivity and specificity of modalities, individually and combined

Sensitivity

%(95% CI)

Specificity

%(95% CI)

PPV

%

NPV

%

SSEP 28 (7-59) 97 (94-98) 20 97

MEP 88 (52-97) 86 (81-89) 15 99

Both Modalities 78 (39-89) 84 (79-88) 14 99

SSEP: Somato-Sensory Evoked Potential, MEP: Motor Evoked Potential, PPV: Positive Predictive Value, NPV: Negative Predictive Value, CI: confidence interval.

References:

1. Schwartz DM, Auerbach JD, Dormans JP, et al. J Bone Joint Surg Am. 2007;89(11):2440-2449.

2. Vitale MG, Moore DW, Matsumoto H, et al. J Bone Joint Surg Am. 2010;92(1):64-71.

Title: Bed bracket failures: problem analysis and quality improvement initiative. Authors: Kwan, K, Filteau, L, Department of Anesthesiology, The Ottawa Hospital Purpose Bed brackets are devices that are clamped onto the OR bed to secure accessory equipment, such as lithotomy stirrups. PSLS reports of bed bracket failures (brackets falling off) necessitated an investigation into possible causes and strategies to reduce failure rates. Methods OHSN-REB approval was waived. Possible contributing factors were identified by a multidisciplinary team, followed by a survey to OR nurses and attendants at the Civic and General campuses. Findings led to the purchase of new brackets and a new training protocol. A follow-up survey was conducted 3 months post intervention. Odds ratio and confidence interval were calculated using Microsoft Excel. Results The initial survey had 91 responses and the 3-month post intervention survey had 73 responses. As presented in Figure 1, 13% reported receiving training in bracket usage in the initial survey versus 67% post intervention. 33% felt comfortable using the brackets versus 52% post intervention. 29% of respondents had witnessed a bracket failure in the past 3 months versus 22% post intervention. Comparing the 2 surveys, respondents were 2.2 times more likely (Odds ratio 2.2, 95% CI 1.17-4.16) to feel comfortable using the brackets after the training initiative. Conclusion Results suggest that bracket failures are surprisingly frequent. The low comfort level was likely due to low training rates along with a wide variety of non user-friendly brackets in use. The interventions resulted in increased comfort with bed bracket equipment. Site differences suggest that equipment purchases alone are insufficient to improve safety, and education on usage is a key factor.

Title: Investigating caregiver burden of cardiac surgical patients. Authors: Gervais, O., Lamb, L., Tran, D., McDonald, B., Macdonald, J. (University of Ottawa Heart Institute). Purpose: Caregiver burden has been associated with anxiety, depression and health deterioration.1-3 This study aims to determine if there is a difference in caregiver burden between patients who experienced prolonged (>10 days) and short (<7 days) CSICU (cardiac surgical intensive care unit) recovery. It is hypothesized that patients who experienced prolonged CSICU recovery will produce a greater caregiver burden than patients with shorter stays. Methods: Following research ethics approval, a single-centered, retrospective, case control study was conducted with the caregivers of patients who underwent cardiac surgery between January 1st 2011 and December 31st 2013. Each long-stay patient was matched 1:1 to a short-stay patient by age, sex, procedure, and preoperative mortality risk. The caregivers were contacted by telephone and asked the previously validated Zarit Burden Interview (ZBI. Total score /88).

4,5 Each question was asked twice, regarding their experience 2 months before and after surgery. The caregiver burden scores for patients requiring prolonged and short CSICU recovery were compared using a one-way ANOVA (p<0.05, statistically significant). Results: After 134 phone calls, 52 interviews were completed. 68% of caregivers were female. The mean age of caregivers was 63.41±11.616. The mean ZBI scores obtained from caregivers of short and long stay CSICU patients were 19.55±14.53 and 28.45±17.26 respectively (p=0.205). Conclusion: The caregivers of patients who recovered in CSICU for a short period experienced little or no burden while the caregivers of patients who recovered in CSICU for a prolonged period experienced mild to moderate burden. This difference was not statistically significant. References:

1. Halm MA, Treat-Jacobson D, Lindquist R, Savik K. Correlates of caregiver burden after coronary artery bypass surgery. Nurs Res. 2006;55(6):426-436.

2. Schulz R, Beach SR. Caregiving as a risk factor for mortality: The caregiver health effects study. J Am Med Assoc. 1999;282(23):2215-2219.

3. Davies N. Carers' opinions and emotional responses following cardiac surgery: Cardiac rehabilitation implications for critical care nurses. Intensive & critical care nursing : the official journal of the British Association of Critical Care Nurses. 2000;16(2):66-75.

4. Chou K, Chu H, Tseng C, Lu R. The measurement of caregiver burden. J Med Sci. 2003;23(2):73-82.

5. Hébert R, Bravo G, Girouard D. Fidélité de la traduction française de trois instruments d'évaluation des aidants naturels de maladies déments. Can.J.Aging. 1993;12:324-327.

Dexmedetomidine use to limit hypertensive crises during pheochromocytoma resection

Amir Bouzari MD, Jean Denis Yelle FRCPC, Sanjiv Gupta FRCPC

Purpose:

Hypertensive crises can occur during pheochromocytoma resection. Dexmedetomidine activates α2-receptors causing a dose dependent reduction in catecholamines. Use of dexmedetomidine during pheochromocytoma resection has been reported to improve hemodynamics but the optimal dose range is unclear. We determined the occurrence of sBP > 180 or dBP > 110 mmHg during pheochromocytoma resections where dexmedetomidine doses were predicted to achieve concentrations known to suppress catecholamine levels.

Method:

With REB approval, we conducted a case series analysis of elective laparoscopic pheochromocytoma resections performed by the same surgeon from 2004/01/01 - 2014/10/31 in patients aged 18 - 70 years. Cases were selected where loading doses and maintenance infusions of dexmedetomidine were such that the concentrations predicted by a 3 compartment pharmacokinetic model would be in the range of 0.7 - 3.0 ng/ml. Pathology specimens confirmed the diagnosis of pheochromocytoma. Pre-operative anti-hypertensive use, tumour size, intra-operative anti-hypertensive use and post-operative complications were collected from patient records.

Results:

Five cases were identified where the dose of dexmedetomidine fit the criteria. One patient experienced hypertensive crises.

Conclusion:

Dexmedetomidine may limit hypertensive crises during pheochromocytoma resection. Future work will compare these findings to cases where either lower doses or no dexmedetomidine was used and attempt to refine the optimal dose range.

Pre-Op BP (MAP) Intra-Op Crises Modeled [plasma] (ng/ml)

Dexmedetomidine total dose (mcg/kg DBW*)

Infusion duration (hrs)

Case 1 112/72 (85) N 1.2-1.8 4.0 2 Case 2 100/68 (79) N 1.9-2.1 6.1 2.5 Case 3 104/72 (83) N 0.9-1 2.4 2 Case 4 119/85 (96) N 0.9-1.1 3.1 2 Case 5 139/75 (96) Y 1.6-2.1 7.9 3.5

*DBW = Dosing Body Weight

References:

1. Ebert TJ, et al: The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology 2000; 93:382-394.

2. Dyck JB, et al. Computer-controlled infusion of intravenous dexmedetomidine hydrochloride in adult human volunteers. Anesthesiology 1993; 78:821-828.

Major Complications and Perioperative Factors Associated to Spinal Fusion Surgery in Children.

A quality assurance study.

Rodelo K, Neira V, Ghaffari K, Nassef M, Moroz P, Jarvis J, Barrowman N, Splinter B.

Purpose: The objective is to quantify and describe major complications (MC) and possible perioperative risk factors in spinal fusion surgery (SFS) at CHEO in a quality improving program for benchmarking as well as for planning and developing institutional protocols.

Methods: Ethics Board review was obtained. A retrospective institutional database of cases undergoing SFS at CHEO from April 2007 to October 2014 was performed. Children less than 21 years old were included. Overall MC was defined as a condition that required treatment or intervention and put at risk the safety of the patient. Perioperative factors were chosen based on what others authors have found significant for MC.

Results The study included 318 patients (113 males and 205 females) and their average age was 16.1 +/- 2.3.There were 63.2% idiopathic scoliosis (IS) and 22% neuromuscular scoliosis (NMS). The mean LOS for idiopathic was 5.99 +/-2.1 days and for NMS 14.01 +/- 9.3 days with P<0.001. The mean ICU time was 21.5 +/-9.0 h for idiopathic and for NMS 35.1+/- 32.3 h P<0.001. The mean ICU mechanical ventilation time was 1.04 +/- 4.9 h for IS and 10.6 +/- 25.8 h for NMS P <0.001.The total incidence of MC was 10.9% being the most common neurological 3.3%, cardiovascular 2.2% and pulmonary 1.6%. MC occurred in 48% NMS and 25% IS with P<0.001. The median (IQR) of LOS for MC was 11(8-18.7) and without MC was 6 (5-8) p<0.001. A logistic regression model (univariate) that analyzed factors related to MC are summarized in the table.

Discussion: MC occurs more common in NMS and prolongs LOS. IS requires shorter duration on mechanical ventilation and ICU stay which could be an indicator of less need of ICU care. Combined approaches, NMS, congenital, kyphosis, ASA 3 and blood loss are risks factors that might be associated to MC.

Risk factors (univariate analysis) OR (95% CI) P value

Number of vertebra levels fused 1.049 (0.94- 1.16) 0.349

Combined procedures 16.092 (3.6-70) <0.001

Diagnosis (overall P <0.001)

Idiopathic 1(Ref)

Neuromuscular 6.8(2.8-16.2) <0.001

Congenital 12.8(2.6-62.1) 0.002

Kyphosis 8.0(1.8-35.3) 0.006

Other 1.6(0.33-8) 0.54

Cobb Angle (per 10 degrees) 1.12( 0.94-1.33) 0.21

ASA (Overall P=0.02)

ASA 1 1(ref)

ASA 2 2,4(0.2-21) 0.40

ASA 3 8.9(1.12-70) 0.038

ASA 4 10.5(0.8-130) 0.067

Blood loss (per 1 L) 1.36( 1.16-1.59) <0.001

References:

1.Carreon LY, Puno RM, Lenke LG, et al.. J Bone Joint Surg Am. 2007;89:2427-2432.

2. Zheng F, Cammisa FP, Sandhu HS, Girardi FP, Khan SN. Spine 2002;27(8):818-824.

3. Vaqsuser. SQUIRE guidelines 2008:1-3.

UNILATERAL TRANSVERSUS ABDOMINIS PLANE BLOCK (TAP) CATHETER FOR THE TREATMENT OF ABDOMINAL WALL PAIN IN PREGNANCY: A CASE REPORT

Miller EC1, M.D.; Szeto M2, M.D., F.R.C.P.C; Boet S2, M.D., PhD.

Short title: TAP BLOCK CATHETHERS FOR ABDOMINAL WALL PAIN IN PREGNANCY Affiliations: 1 – Resident in Anesthesiology, University of Ottawa, Department of Anesthesia, The Ottawa Hospital Civic Campus, Room B311, 1053 Carling Avenue, Mail Stop 249,Ottawa, Ontario, Canada, K1Y 4E9 2 – Anesthesiologist, Department of Anesthesia, The Ottawa Hospital, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, Ontario, Canada, K1H 8L6 Funding: This case report publication was funded by the Department of Anesthesiology, The Ottawa Hospital, Ottawa, Canada Competing Interests: None to declare Contributions: E. Miller performed the literature review, and wrote the case report. S. Boet and M. Szeto were involved in the care of the patient, performed the review of the patient medical record and extraction of chart data, and were involved with editing the case report. All authors reviewed the final case report and contributed to the study. Key words: Transversus abdominis plane (TAP) catheters, abdominal wall pain, pregnancy ABSTRACT Purpose: The transversus abdominis plane (TAP) block aims to anesthetize the anterior branches of spinal nerves that innervate the abdominal wall from T6-L11, and are typically used for postoperative analgesia following abdominal surgery2. Several applications of TAP catheters are described in the literature for both acute and chronic abdominal wall pain3-5, but there are no cases to our knowledge of TAP catheters being used during pregnancy. Clinical features: Written patient consent was obtained. We present a case of a twenty-three-year-old primigravid woman admitted to hospital on multiple occasions during her pregnancy for right lower quadrant, “stabbing”, 4 to 8 of 10 abdominal pain, with an unclear diagnosis, and no clear findings on imaging except for prominent ileocolic lymph nodes visualized on magnetic resonance imaging. Despite escalating doses of intravenous opioids, ongoing abdominal pain symptoms persisted. At 34 weeks of gestation, a right-sided TAP block with 0.25% bupivacaine was inserted with ultrasound guidance, and relieved her pain. She was then treated with boluses of 0.5% ropivicaine via a TAP catheter, which led to complete resolution of her pain within three days and discontinuation of all opioid medications. She was discharged home for the remainder of her pregnancy with no recurrence of pain, and had an uneventful cesarian section at term with good outcome. Conclusion: Ultrasound-guided TAP catheters may be used to treat chronic abdominal pain during pregnancy, and may provide an alternative analgesic modality when intravenous opioids are not providing relief or when neuraxial analgesia techniques are not possible or contraindicated.

REFERENCES: 1. Peterson PL, Hilsted KL et al. Bilateral transversus abdominis plane (TAP) block with 24 hours ropivicaine infusion

via TAP catheters: a randomized trial in healthy volunteers. BMC Anesthesiology 2013; 13 (30): available at:[http://www.biomedcentral.com/1471-2253/13/30].

2. Bjerregaard N, Nikolajsen L, et al. Transversus abdominis plane cathether bolus analgesia after major abdominalsurgery. Anesthesiology Research and Practise; 2012.

3. Zhong T, Wong KW, et al. Transversus abdominis plane (TAP) catheters inserted under direct vision in the donorsite following free DIEP and MS-TRAM breast reconstruction: a prospective cohort study of 45 patients. Journalof Plastic, Reconstructive & Aesthetic Surgery 2013: 66; 329-36.

4. Farag E, Guirguis MN et al. Continuous transversus abdominis plane block catheters for postoperative paincontrol in renal transplant. J Anesth 2014; available at: [http://link.springer.com/article/10.1007/s00540-014-1855-1].

5. Heil JW, Ilfeld BM et al. Ultrasound-guided transversus abdominis plane catheters and ambulatory perineuralinfusions for outpatient inguinal hernia repair. 2010. Reg Anesth Pain Med 2010; 35: 556-8.

Does contextual interference improve basic life support skills retention? A randomized controlled trial

Rao, P. Department of Innovation in Medical Education, Department of Anesthesiology University of Ottawa

Bould, D. The Children’s Hospital of Eastern Ontario University of Ottawa

Brydges, R. Department of Medicine and The Wilson Centre University of Toronto

Tremblay, L. University of Toronto

Boet, S. Department of Anesthesiology, Department of Innovation in Medical Education University of Ottawa

Purpose: There is poor retention of skills after basic life saving (BLS) training. This leads to delayed or ineffective resuscitation after cardiac arrest and may contribute to poor patient outcome(1). Contextual interference (CI) effect is the improvement in skill retention when skills are practiced repeatedly for short periods of time(2).

The benefits of CI have been demonstrated in verbal and psychomotor learning(3). There are few studies in the healthcare field, none examining resuscitation skills(4).

We will examine laypeople to determine if contextual interference methods, compared to standard BLS teaching, improve retention of BLS skills at three months. We hypothesize that participants trained in BLS using contextual interference techniques will have superior knowledge retention at 3 months.

Methods: An application for REB approval has been submitted. Fifty-six adult laypeople with no previous BLS training will be randomized to a standard BLS (control) or contextual interference (experimental) course.

Primary outcome: Full BLS performance on a 3 month retention test. Secondary outcomes: Time to start chest compressions, chest compression performance, time to defibrillation using AED, percentage of learners who pass the retention test.

The 3 month retention test will be videotaped. Two BLS certified instructors, blinded to group allocation, will review each video.

Anticipated Results and Conclusion: A positive result may lead to changes in course design including BLS, ACLS, ATLS, and NRP. Furthermore improved retention of resuscitation skills has the potential to improve the care of acutely ill patients.

References: 1) Moser DK, Coleman S. Heart Lung 1992;20(4):355-80.2) Magill RA, Hall KC. Hum Move Science 1990;9:241-89.3) Shea JB, Morgan RL. J Exp Psych 1979;5:179-87.4) Brydges R, et al. J Motor Behav 2007;39:40-8.

Title: Percutaneous Balloon Occlusion of HeartWare™ Cannula After Complete Drive Wire Transection McFarling M1, Dick A1, and Sohmer, B1 1University Of Ottawa Heart Institute Purpose: Continuous flow ventricular assist device (VADs) use, as bridge-to-transplant, recovery, or destination therapy is increasing in North America. There is scant literature on management of sudden, out-of-hospital device failure. We present a case of cardiogenic shock following transection of a HeartWare™ LVAD (HeartWare, Framingham, MA) driveline, where balloon occlusion of the outflow cannula1[1], and veno-arterial extracorporeal membrane oxygenation (V-A ECMO) permitted circulatory support. Clinical Features: A patient with ischemic cardiomyopathy presented after complete transection of the driveline. Hemodynamic instability necessitated emergent V-A ECMO support. On institution of circulatory support, systemic flow was inadequate due to low central blood volume. Secondly, retrograde ECMO flow through the stopped LVAD (Fig. 1A) worsened mitral regurgitation, pulmonary hypertension and caused hemorrhage. Percutaneous balloon occlusion (Berenstein 8.5mm/11.5mm balloon occlusion catheter, Boston Scientific, Marlborough, MA) reduced retrograde flow through the VAD, increasing antegrade systemic blood flow and reducing pulmonary venous pressures. Technicians repaired the severed driveline and attempted to restart the device. Conclusion: Stopped continuous flow VADs permit retrograde blood flow[2, 3]. In failed hearts this compromises a significant regurgitant fraction, limiting antegrade systemic flow. Ventricular distension decreases endocardial perfusion, and exacerbates valvular incompetence. Limiting regurgitation is vital when mechanical support is used during device stoppage. Trans-VAD retrograde blood flow is analogous to severe, acute aortic insufficiency. Systemic hypoperfusion, severe functional mitral regurgitation, and pulmonary hemorrhage required non-conventional management. Percutaneous balloon occlusion of the culprit conduit eliminated retrograde flow (Fig. 1B) to permit effective mechanical support; allowing stabilization with reduced pulmonary hemorrhage. References 1. Potapov EV. J Heart Lung Transplant 2011;30:1300–1301. 2. Ando M. J Artif Organs 2001;14:70–73. 3. Kashiyama N. J Artif Organs 2014.