Publications by authors named "Jean Wong"

104 Publications

Predictive Performance of Oximetry to Detect Sleep Apnea in Patients Taking Opioids.

Anesth Analg 2021 May 5. Epub 2021 May 5.

From the Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: Long-term use of opioids for treatment of chronic pain is associated with significant risks including worsening unrecognized or untreated sleep apnea that may increase morbidity and mortality. Overnight oximetry has been validated for predicting sleep apnea in surgical and sleep clinic patients. The objective of the study was to assess the predictive accuracy of oxygen desaturation index (ODI 4%) from home overnight oximetry when compared to apnea hypopnea index (AHI) from polysomnography for predicting sleep apnea in patients taking opioids for chronic pain.

Methods: This was a planned post hoc analysis of a prospective cohort study conducted at 5 pain clinics. Patient characteristics and daily morphine milligram equivalent (MME) dose were recorded. All consented patients underwent home overnight oximetry (PULSOX-300i, Konica Minolta Sensing, Inc, Osaka, Japan) and in-laboratory polysomnography. The predictive performance of ODI 4% from oximetry was assessed against AHI from polysomnography.

Results: Among 332 consented patients, 181 with polysomnography and overnight oximetry data were analyzed. The mean age and body mass index of 181 patients were 52 ± 13 years and 29 ± 6 kg/m2, respectively, with 40% men. The area under the receiver operating curve for ODI to predict moderate-to-severe sleep apnea (AHI ≥15 events/h) and severe sleep apnea (AHI ≥30 events/h) was 0.82 (95% confidence interval [CI], 0.75-0.88) and 0.87 (95% CI, 0.80-0.94). ODI ≥5 events/h had a sensitivity of 85% (95% CI, 74-92) and specificity of 57% (95% CI, 52-61) to predict moderate-to-severe sleep apnea. ODI ≥15 events/h had a sensitivity of 71% (95% CI, 55-83) and specificity of 88% (95% CI, 84-91) to predict severe sleep apnea.

Conclusions: Overnight home oximetry has a high predictive performance in predicting moderate-to-severe and severe sleep apnea in patients on opioids for chronic pain. It is a useful additional tool for health care providers for the screening of sleep apnea in this high-risk group.
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http://dx.doi.org/10.1213/ANE.0000000000005545DOI Listing
May 2021

Effects of comprehensive geriatric care models on postoperative outcomes in geriatric surgical patients: a systematic review and meta-analysis.

BMC Anesthesiol 2021 Apr 22;21(1):127. Epub 2021 Apr 22.

Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T2S8, Canada.

Background: The elderly population is highly susceptible to develop post-operative complications after major surgeries. It is not clear whether the comprehensive geriatric care models are effective in reducing adverse events. The objective of this systematic review and meta-analysis is to determine whether the comprehensive geriatric care models improved clinical outcomes, particularly in decreasing the prevalence of delirium and length of hospital stay (LOS) in elderly surgical patients.

Method: We searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Emcare Nursing, Web of Science, Scopus, CINAHL, ClinicalTrials. Gov, and ICTRP between 2009 to January 23, 2020. We included studies on geriatric care models in elderly patients (≥60 years) undergoing elective, non-cardiac high-risk surgery. The outcomes were the prevalence of delirium, LOS, rates of 30-days readmission, and 30-days mortality. We used the Cochrane Review Manager Version 5.3. to estimate the pooled Odds Ratio (OR) and Mean Difference (MD) using random effect model analysis.

Results: Eleven studies were included with 2672 patients [Randomized Controlled Trials (RCTs): 4; Non-Randomized Controlled Trials (Non-RCTs): 7]. Data pooled from six studies showed that there was no significant difference in the prevalence of delirium between the intervention and control groups: 13.8% vs 15.9% (OR: 0.76; 95% CI: 0.30-1.96; p = 0.57). Similarly, there were no significant differences in the LOS (MD: -0.55; 95% CI: - 2.28, 1.18; p = 0.53), 30-day readmission (12.1% vs. 14.3%; OR: 1.09; 95% CI: 0.67-1.77; p = 0.73), and 30-day mortality (3.2% vs. 2.1%; OR: 1.34; 95% CI: 0.66-2.69; p = 0.42). The quality of evidence was very low.

Conclusions: The geriatric care models involved pre-operative comprehensive geriatric assessment, and intervention tools to address cognition, frailty, and functional status. In non-cardiac high-risk surgeries, these care models did not show any significant difference in the prevalence of delirium, LOS, 30-days readmission rates, and 30-day mortality in geriatric patients. Further RCTs are warranted to evaluate these models on the postoperative outcomes.

Trial Registration: PROSPERO registration number - CRD42020181779 .
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http://dx.doi.org/10.1186/s12871-021-01337-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061210PMC
April 2021

Correction to: Interventions to reduce medication errors in anesthesia: a systematic review.

Can J Anaesth 2021 Apr 21. Epub 2021 Apr 21.

Niagara Health, St. Catharines, ON, Canada.

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http://dx.doi.org/10.1007/s12630-021-01994-4DOI Listing
April 2021

Obesity and Obesity Hypoventilation, Sleep Hypoventilation, and Postoperative Respiratory Failure.

Anesth Analg 2021 05;132(5):1265-1273

Department of Medicine, University of Chicago, Chicago, Illinois.

Obesity hypoventilation syndrome (OHS) is considered as a diagnosis in obese patients (body mass index [BMI] ≥30 kg/m2) who also have sleep-disordered breathing and awake diurnal hypercapnia in the absence of other causes of hypoventilation. Patients with OHS have a higher burden of medical comorbidities as compared to those with obstructive sleep apnea (OSA). This places patients with OHS at higher risk for adverse postoperative events. Obese patients and those with OSA undergoing elective noncardiac surgery are not routinely screened for OHS. Screening for OHS would require additional preoperative evaluation of morbidly obese patients with severe OSA and suspicion of hypoventilation or resting hypoxemia. Cautious selection of the type of anesthesia, use of apneic oxygenation with high-flow nasal cannula during laryngoscopy, better monitoring in the postanesthesia care unit (PACU) can help minimize adverse perioperative events. Among other risk-reduction strategies are proper patient positioning, especially during intubation and extubation, multimodal analgesia, and cautious use of postoperative supplemental oxygen.
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http://dx.doi.org/10.1213/ANE.0000000000005352DOI Listing
May 2021

Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey.

Anesth Analg 2021 05;132(5):1223-1230

From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.

Background: Sleep disorders affect up to 25% of the general population and are associated with increased risk of adverse perioperative events. The key sleep medicine topics that are most important for the practice of anesthesiology have not been well-defined. The objective of this study was to determine the high-priority sleep medicine topics that should be included in the education of anesthesia residents based on the insight of experts in the fields of anesthesia and sleep medicine.

Methods: We conducted a prospective cross-sectional survey of experts in the fields of sleep medicine and anesthesia based on the Delphi technique to establish consensus on the sleep medicine topics that should be incorporated into anesthesia residency curricula. Consensus for inclusion of a topic was defined as >80% of all experts selecting "agree" or "strongly agree" on a 5-point Likert scale. Responses to the survey questions were analyzed with descriptive statistical methods and presented as percentages or weighted mean values with standard deviations (SD) for Likert scale data.

Results: The topics that were found to have 100% agreement among experts were the influence of opioids and anesthetics on control of breathing and upper airway obstruction; potential interactions of wake-promoting/hypnotic medications with anesthetic agents; effects of sleep and anesthesia on upper airway patency; and anesthetic management of sleep apnea. Less than 80% agreement was found for topics on the anesthetic implications of other sleep disorders and future pathways in sleep medicine and anesthesia.

Conclusions: We identify key topics of sleep medicine that can be included in the future design of anesthesia residency training curricula.
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http://dx.doi.org/10.1213/ANE.0000000000005446DOI Listing
May 2021

Interventions to reduce medication errors in anesthesia: a systematic review.

Can J Anaesth 2021 Mar 11. Epub 2021 Mar 11.

Niagara Health, St. Catharines, ON, Canada.

Background: The objective of this study was to provide a synthesis of the interventions designed to reduce medication errors in anesthetized patients.

Methods: We electronically searched major databases using index and free-text keywords related to anesthesia and medication errors. We included cohort studies exploring interventions to reduce anesthetic medication errors in both adult and pediatric patients. The risk of bias for each study was assessed using the Newcastle-Ottawa Scale.

Results: One thousand five-hundred and fifty-eight titles or abstracts were screened, and 56 full-text studies were assessed for eligibility; eight studies were included in the final analysis. Case reports and retrospective studies were excluded. The quality of most studies (n = 6) was graded as "low". There were three categories of interventions: I) multimodal interventions (6 studies, n = 900,170 medication administrations) showed a reduction in rates of errors of 21-35% per administration and 37-41% per anesthetic; II) improved labels (1 study, n = 55,426 medication administrations) resulted in a 37% reduction in rates of errors per anesthetic; and III) the effect of education was assessed in one study and showed no effect.

Conclusion: Multimodal interventions and improved labelling reduce medication errors in anesthetized patients.
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http://dx.doi.org/10.1007/s12630-021-01959-7DOI Listing
March 2021

Treatment for patients with sleep apnea on opioids for chronic pain: results of the OpSafe trial.

J Clin Sleep Med 2021 Apr;17(4):819-824

Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Study Objectives: Approximately 20% of North Americans are afflicted with chronic pain with 3% being opioid users. The objective was to determine whether patients on opioids for chronic pain with newly diagnosed sleep apnea attended sleep clinic review and followed treatment recommendations.

Methods: The study was a post hoc analysis from a multicenter perspective cohort study. Inclusion criteria included adults taking opioid medications for chronic pain for >3 months. Demographic data and daily opioid dose were collected. Sleep apnea was diagnosed via level 1 polysomnography. Patients who attended sleep clinic review were grouped based on the types of treatment they received.

Results: A total of 204 patients completed polysomnography and 58.8% were diagnosed to have sleep apnea (apnea-hypopnea index ≥5 events/h). Of those with sleep apnea, 58% were recommended to have an evaluation by a sleep physician. Body mass index and age were 29.5 ± 6 kg/m² and 56 ± 12 years, respectively. Of those with newly diagnosed sleep apnea, 25% received treatment, with the majority being treated with positive airway pressure therapy, whereas the rest received positional therapy and opioids/sedative reduction. The adherence rate of positive airway pressure therapy was 55% at 1 year. Over 50% of participants on opioids for chronic pain with newly diagnosed sleep apnea declined attendance for sleep clinic review or treatment.

Conclusions: There was a high refusal rate to attend clinic for treatment. Adherence to positive airway pressure therapy was low at 55%. This sheds light on the high rate of treatment nonadherence and the need for further research.

Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: Opioid Safety Program in Pain Clinics (Op-Safe); URL: https://www.clinicaltrials.gov/ct2/show/NCT02513836; Identifier: NCT02513836.
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http://dx.doi.org/10.5664/jcsm.9064DOI Listing
April 2021

Sleep-disordered breathing in patients on opioids for chronic pain.

Reg Anesth Pain Med 2020 Oct 14;45(10):826-830. Epub 2020 Sep 14.

Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada

The past two decades has seen a substantial rise in the use of opioids for chronic pain, along with opioid-related mortality and adverse effects. A contributor to opioid-associated mortality is the high prevalence of moderate/severe sleep-disordered breathing, including central sleep apnea and obstructive sleep apnea, in patients with chronic pain. Although evidence-based treatments are available for sleep-disordered breathing, patients are not frequently assessed for sleep-disordered breathing in pain clinics. To aid healthcare providers in this area of clinical uncertainty, we present evidence on the interaction between opioids and sleep-disordered breathing, and the prevalence and predictive factors for sleep-disordered breathing in patients on opioids for chronic pain. We provide recommendations on how to evaluate patients on opioids for risk of moderate/severe sleep-disordered breathing in clinical care, which could lead to earlier use of therapeutic interventions for opioid-associated sleep-disordered breathing, such as opioid cessation or positive airway pressure therapy. This would improve quality of life and well-being of patients with chronic pain.
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http://dx.doi.org/10.1136/rapm-2020-101540DOI Listing
October 2020

The Effectiveness of High-Flow Nasal Oxygen During the Intraoperative Period: A Systematic Review and Meta-analysis.

Anesth Analg 2020 10;131(4):1102-1110

Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: High-flow nasal oxygen (HFNO) is increasingly being used in intensive care units for management of hypoxemia and respiratory failure. However, the effectiveness of HFNO for preventing hypoxemia in the intraoperative period is unclear. The purpose of this systematic review was to compare patient oxygenation and end-tidal CO2 (EtCO2), between HFNO and conventional oxygenation, during the intraoperative period in surgical patients.

Methods: Standard databases were searched from inception to February 2020. Studies involving intraoperative use of HFNO with 1 of the 4 outcomes: (1) oxygen (O2) desaturation, (2) minimum O2 saturation, (3) safe apnea time, or (4) EtCO2 were included. Intraoperative period was divided into 2 phases: at induction with general anesthesia and during surgical procedure under sedation without tracheal intubation.

Results: Eight randomized controlled trials (RCTs; 4 induction, 4 procedure, 2314 patients) were included for systematic review and meta-analyses. We found the risk of intraoperative O2 desaturation was lower in HFNO versus conventional oxygenation control group; at induction with an odds ratio (OR; 95% confidence interval [CI]) of 0.06 (0.01-0.59, P = .02), and during procedure, OR (95% CI) of 0.09 (0.05-0.18; P < .001). The minimum O2 saturation was higher in HFNO versus conventional oxygenation; at induction by a mean difference (MD) (95% CI) of 5.1% (3.3-6.9; P < .001), and during procedure, by a MD (95% CI) of 4.0% (1.8-6.2; P < .001). Safe apnea time at induction was longer in HFNO versus conventional oxygenation by a MD (95% CI) of 33.4 seconds (16.8-50.1; P < .001). EtCO2 at induction was not significantly different between HFNO and conventional oxygenation groups.

Conclusions: This systematic review and meta-analysis show that, in the intraoperative setting, HFNO compared to conventional oxygenation reduces the risk of O2 desaturation, increases minimum O2 saturation, and safe apnea time. HFNO should be considered for anesthesia induction and during surgical procedures under sedation without tracheal intubation in patients at higher risk of hypoxemia.
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http://dx.doi.org/10.1213/ANE.0000000000005073DOI Listing
October 2020

Concomitant benzodiazepine and opioids decrease sleep apnoea risk in chronic pain patients.

ERJ Open Res 2020 Jul 25;6(3). Epub 2020 Aug 25.

Dept of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, ON, Canada.

Background: The concurrent use of sedating centrally acting drugs and opioids by chronic pain patients occurs routinely despite concerns of negative impacts on respiration during sleep. The effects of centrally acting drugs and opioids on sleep apnoea have not been well characterised. The objective of this study was to assess the effect of concomitant centrally acting drugs and opioids on the prevalence and severity of sleep apnoea in chronic pain patients.

Methods: We conducted a prospective cohort study at five chronic pain clinics. Each participant underwent an in-laboratory polysomnography and daily morphine milligram equivalents were calculated. Participants were grouped into centrally acting drugs and opioid users sole opioid users.

Results: Of the 332 consented participants, 204 underwent polysomnography and 120 (58.8%) had sleep apnoea (72% obstructive, 20% central, and 8% indeterminate sleep apnoea). Overall, 35% (71 of 204) were taking opioids alone, and 65% (133 of 204) were taking centrally acting drugs and opioids. There was a 69% decrease in the odds of having sleep apnoea (apnoea-hypopnoea index ≥5 events·h) in participants taking benzodiazepine/opioids sole opioid users (OR 0.31, 95% CI:0.12-0.80, p=0.015). Additionally, concomitant benzodiazepine/opioids sole opioid use was associated with a decrease in respiratory arousal index scores (p=0.03). Mean overnight was approximately 1% lower in the concomitant benzodiazepine/opioids group sole opioid users (93.1±2.5 94.4±2.1%, p=0.01).

Conclusion: In chronic pain patients on opioids, administration of certain benzodiazepine sedatives induced a mild respiratory depression but paradoxically reduced sleep apnoea risk and severity by increasing the respiratory arousal threshold.
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http://dx.doi.org/10.1183/23120541.00093-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7445118PMC
July 2020

Risk of major cardiovascular and cerebrovascular complications after elective surgery in patients with sleep-disordered breathing: A retrospective cohort analysis.

Eur J Anaesthesiol 2020 Aug;37(8):688-695

From the Department of Anesthesia, Toronto Western Hospital, University Health Network (RC, CS, TM, JW, FC), Department of Anesthesia, University of Toronto (RC, CS, JW, FC), Centre for Sleep Health and Research, Toronto General Hospital, Toronto, Ontario, Canada (CMR) and Section of Pulmonary and Critical Care, Sleep Disorders Center, University of Chicago, Chicago, Illinois, USA (BM).

Background: There is limited and conflicting data on whether sleep-disordered breathing (SDB) is associated with postoperative major cardiovascular and cerebrovascular events (MACCE), and mortality.

Objectives: To determine whether SDB is associated with increased risks of MACCE, mortality and length of hospital stay.

Design: Retrospective cohort analysis from the Nationwide Inpatient Sample.

Setting: Adults who underwent elective abdominal, orthopaedic, prostatic, gynaecological, thoracic, transplant, vascular or cardiac surgery in the United States of America between 2011 and 2014.

Patients: The study cohort included 1813 974 surgical patients, of whom 185 615 (10.2%) had SDB. Emergency or urgent surgical procedures were excluded.

Main Outcome Measures: The incidences of MACCE, respiratory and vascular complications, in-hospital mortality and mean length of hospital stay were stratified by SDB. Linear and logistic regression models were constructed to determine the independent association between SDB and outcomes of interest.

Results: The incidences of MACCE [25.3 vs. 19.8%, odds ratio (OR) 1.20, P < 0.001] and respiratory complications (11.75 vs. 8.0%, OR 1.43, P < 0.001) were significantly higher in patients with SDB than in those without SDB. SDB was associated with higher rates of atrial fibrillation (14.7 vs. 10.8%, P < 0.001), other arrhythmias (6.0 vs. 5.4%, P < 0.001) and congestive heart failure (9.8 vs. 7.1%, P < 0.001). SDB patients had a lower rate of myocardial infarction (3.1 vs. 3.4%, OR 0.69, P < 0.001), lower mortality (0.6 vs. 1.3%, P < 0.001) and shorter length of hospital stay (4.8 vs. 5.2 days, P < 0.001).

Conclusion: SDB was associated with increased risks of MACCE, and respiratory and vascular complications, but had a lower incidence of in-hospital mortality and shorter length of hospital stay.
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http://dx.doi.org/10.1097/EJA.0000000000001267DOI Listing
August 2020

Liquid Biopsy Serial Monitoring of Treatment Responses and Relapse in Advanced Esophageal Squamous Cell Carcinoma.

Cancers (Basel) 2020 May 26;12(6). Epub 2020 May 26.

Department of Clinical Oncology, University of Hong Kong, Hong Kong, China.

(1) Background: Early predictive markers to track treatment responses are needed for advanced esophageal squamous cell carcinoma (ESCC) patients. We examined the prognostication and risk stratification role of liquid biopsy serial monitoring for this deadly cancer. (2) Methods: Circulating tumor cells (CTCs) and plasma cell-free DNA (cfDNA) were isolated from 60 ESCC patients treated by chemotherapy (CT) at five serial timepoints: baseline (CTC1/cfDNA1), CT pre-cycle III (CTC2/cfDNA2), CT post-cycle IV, end of CT and relapse. (3) Results: In 45/57 ESCC patients with evaluable CTC counts at CT pre-cycle III, positive CTC2 (≥3 CTCs) is independently associated with response at interim reassessment and progression-free survival (PFS) in multivariate analysis. In 42/57 ESCC patients with changes of CTC1/CTC2 and cfDNA1/cfDNA2, patients categorized into four risk groups based on the number of favorable and unfavorable changes of CTC1/CTC2 and cfDNA1/cfDNA2, were independently associated with overall survival (OS) by multivariate analysis. (4) Conclusions: CTC counts at pre-cycle III are independently associated with response at interim reassessment and PFS. Combined changes of CTC counts and cfDNA levels from baseline to pre-cycle III are independently associated with OS. Longitudinal liquid biopsy serial monitoring provides complementary information for prediction and prognosis for CT responses in advanced ESCC.
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http://dx.doi.org/10.3390/cancers12061352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352685PMC
May 2020

Prevalence of Undiagnosed Obstructive Sleep Apnea Among Patients Hospitalized for Cardiovascular Disease and Associated In-Hospital Outcomes: A Scoping Review.

J Clin Med 2020 Apr 2;9(4). Epub 2020 Apr 2.

Department of Anesthesiology and Pain Management, University Health Network, Toronto Western Hospital, Toronto, ON M5T 2S8, Canada.

Background: Obstructive sleep apnea (OSA) is associated with long-term cardiovascular morbidity and is highly prevalent in patients with cardiovascular disease (CVD). The objectives of this scoping review were to determine the prevalence of OSA inpatients hospitalized for CVD and to map the range of in-hospital outcomes associated with OSA.

Methods: We searched MEDLINE(R), Embase, and Cochrane Databases for articles published from 1946-2018. We included studies involving non-surgical adults with OSA or at high risk of OSA who were hospitalized for CVD. The outcomes were considered as in-hospital if they were collected from admission up to 30 days post-discharge from hospital.

Results: After the screening of 4642 articles, 26 studies were included for qualitative synthesis. Eligible studies included patients presenting with acute coronary syndromes (n = 19), congestive heart failure (n = 6), or any cardiovascular disease (n = 1). The pooled prevalence of OSA in cardiac inpatients was 48% (95% CI: 42-53). The in-hospital outcomes reported were mortality (n = 4), length of stay (n = 8), left ventricular ejection fraction (n = 8), peak troponin (n = 7), peak B-type natriuretic peptide (n = 4), and composite cardiovascular complications (n = 2).

Conclusions: OSA is highly prevalent in the cardiac inpatient population. The outcomes reported included mortality, cardiac function, cardiac biomarkers, and resource utilization. There are significant knowledge gaps regarding the effect of treatment and OSA severity on these outcomes. The findings from this review serve to inform further areas of research on the management of OSA among patients with CVD.
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http://dx.doi.org/10.3390/jcm9040989DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230766PMC
April 2020

Prevalence of sleep-disordered breathing in opioid users with chronic pain: a systematic review and meta-analysis.

J Clin Sleep Med 2020 06;16(6):961-969

Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Study Objectives: Opioids have been reported to increase the risk for sleep-disordered breathing (SDB) in patients with noncancer chronic pain on opioid therapy. This study aims to determine the pooled prevalence of SDB in opioid users with chronic pain and compare it with patients with pain:no opioids and no pain:no opioids.

Methods: A literature search of PubMed, Medline, Embase, and Cochrane Central Register of Controlled Trials was conducted. We included all observational studies that reported the prevalence of SDB in patients with chronic pain on long-term opioid therapy (≥3 months). The primary outcome was the pooled prevalence of SDB in opioid users with chronic pain (pain:opioids group) and a comparison with pain:no opioids and no pain:no opioids groups. The meta-analysis was performed using a random-effects model.

Results: After screening 1,404 studies, 9 studies with 3,791 patients were included in the meta-analysis (pain:opioids group, n = 3181 [84%]; pain:no opioids group, n = 359 [9.4%]; no pain:no opioids group, n = 251 [6.6%]). The pooled prevalence of SDB in the pain:opioids, pain:no opioids, and no pain:no opioids groups were 91%, 83%, and 72% in sleep clinics and 63%, 10%, and 75% in pain clinics, respectively. Furthermore, in the pain: opioids group, central sleep apnea prevalence in sleep and pain clinics was 33% and 20%, respectively.

Conclusions: The pooled prevalence of SDB in patients with chronic pain on opioid therapy is not significantly different compared with pain:no opioids and no pain:no opioids groups and varies considerably depending on the site of patient recruitment (ie, sleep vs pain clinics). The prevalence of central sleep apnea is high in sleep and pain clinics in the pain:opioids group. Clinical Trial Registration: Registry: PROSPERO: International prospective register of systematic reviews; Name: Prevalence of sleep disordered breathing, hypoxemia and hypercapnia in patients on oral opioid therapy for chronic pain management; URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018103298; Identifier: CRD42018103298.
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http://dx.doi.org/10.5664/jcsm.8392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849655PMC
June 2020

Abdominal wall closure with prophylactic mesh in colorectal operations.

ANZ J Surg 2020 04 22;90(4):564-568. Epub 2020 Jan 22.

Department of Colorectal Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia.

Background: Prospective studies demonstrate that over one-third of patients undergoing standard suture closure of laparotomy wounds will develop incisional hernias (IHs). Whilst prophylactic mesh has been demonstrated to decrease IH rates in clean laparotomy wounds, mesh has been associated with high rates of seroma formation (>30%), infection (>10%) and pain, discouraging many surgeons from using mesh, especially combined with intestinal surgery. The aim of this study is to review the experience of a single colorectal surgeon who, after noting high IH rates in his own patients, started placing prophylactic mesh routinely in patients judged to be at high risk of IH.

Methods: The records of all patients undergoing bowel resections and ileostomy closure by one surgeon from 2008 to 2018 were independently retrospectively analysed.

Results: Of the 935 procedures identified, 662 patients underwent midline laparotomy with bowel resection and 273 patients underwent closure of loop ileostomy. Mesh was placed prophylactically in 221 (23.6%) of 935 procedures. Comparing the mesh and non-mesh groups, wound infections occurred in nine (4.1%) versus 23 (3.2%) (P = 0.53), seromas occurred in nine (4.1%) versus six (0.8%) (P = 0.003) and chronic pain was noted in 12 (5.4%) versus 17 (2.4%) (P = 0.04). The mean follow-up was 33 months in both the mesh and non-mesh groups. IHs have occurred in three (1.3%) of the mesh group compared to 95 (13.3%) of the non-mesh group procedures (P = 0.0001).

Conclusion: In colorectal operations, prophylactic mesh decreases the risk of IH without prohibitive complications.
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http://dx.doi.org/10.1111/ans.15692DOI Listing
April 2020

Predictive factors for sleep apnoea in patients on opioids for chronic pain.

BMJ Open Respir Res 2019 23;6(1):e000523. Epub 2019 Dec 23.

Sleep Research Laboratory, University Health Network, Toronto Rehabilitation Institute, Toronto, On, Canada.

Background: The risk of death is elevated in patients taking opioids for chronic non-cancer pain. Respiratory depression is the main cause of death due to opioids and sleep apnoea is an important associated risk factor.

Methods: In chronic pain clinics, we assessed the STOP-Bang questionnaire (a screening tool for sleep apnoea; noring, iredness, bserved apnoea, high blood ressure, ody mass index, age, neck circumference and male gender), Epworth Sleepiness Scale, thyromental distance, Mallampati classification, daytime oxyhaemoglobin saturation (SpO) and calculated daily morphine milligram equivalent (MME) approximations for each participant, and performed an inlaboratory polysomnogram. The primary objective was to determine the predictive factors for sleep apnoea in patients on chronic opioid therapy using multivariable logistic regression models.

Results: Of 332 consented participants, 204 underwent polysomnography, and 120 (58.8%) had sleep apnoea (AHI ≥5) (72% obstructive, 20% central and 8% indeterminate sleep apnoea), with a high prevalence of moderate (23.3%) and severe (30.8%) sleep apnoea. The STOP-Bang questionnaire and SpO are predictive factors for sleep apnoea (AHI ≥15) in patients on opioids for chronic pain. For each one-unit increase in the STOP-Bang score, the odds of moderate-to-severe sleep apnoea (AHI ≥15) increased by 70%, and for each 1% SpO decrease the odds increased by 33%. For each 10 mg MME increase, the odds of Central Apnoea Index ≥5 increased by 3%, and for each 1% SpO decrease the odds increased by 45%.

Conclusion: In patients on opioids for chronic pain, the STOP-Bang questionnaire and daytime SpO are predictive factors for sleep apnoea, and MME and daytime SpO are predictive factors for Central Apnoea Index ≥5.

Trial Registration Number: NCT02513836.
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http://dx.doi.org/10.1136/bmjresp-2019-000523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936992PMC
July 2020

Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation.

Anesth Analg 2020 09;131(3):955-968

From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Smokers are at increased risk for surgical complications. Despite the known benefits of smoking cessation, many perioperative health care providers do not routinely provide smoking cessation interventions. The variation in delivery of perioperative smoking cessation interventions may be due to limited high-level evidence for whether smoking cessation interventions used in the general population are effective and feasible in the surgical population, as well as the challenges and barriers to implementation of interventions. Yet smoking is a potentially modifiable risk factor for improving short- and long-term patient outcomes. The purpose of the Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation is to present recommendations based on current scientific evidence in surgical patients. These statements address questions regarding the timing and intensity of interventions, roles of perioperative health care providers, and behavioral and pharmacological interventions. Barriers and strategies to overcome challenges surrounding implementation of interventions and future areas of research are identified. These statements are based on the current state of knowledge and its interpretation by a multidisciplinary group of experts at the time of publication.
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http://dx.doi.org/10.1213/ANE.0000000000004508DOI Listing
September 2020

High-Flow Nasal Oxygen Improves Safe Apnea Time in Morbidly Obese Patients Undergoing General Anesthesia: A Randomized Controlled Trial.

Anesth Analg 2019 10;129(4):1130-1136

From the Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: Morbidly obese patients undergoing general anesthesia are at risk of hypoxemia during anesthesia induction. High-flow nasal oxygenation use during anesthesia induction prolongs safe apnea time in nonobese surgical patients. The primary objective of our study was to compare safe apnea time, between patients given high-flow nasal oxygenation or conventional facemask oxygenation during anesthesia induction, in morbidly obese surgical patients.

Methods: Research ethics board approval was obtained. Elective surgical patients ≥18 years with body mass index ≥40 kg·m were included. Patients with severe comorbidity, gastric reflux disease, known difficult airway, or nasal obstruction were excluded. After obtaining informed consent patients were randomized. In the intervention (high-flow nasal oxygenation) group, preoxygenation was provided by 100% nasal oxygen for 3 minutes at 40 L·minute; in the control group, preoxygenation was delivered using a facemask with 100% oxygen, targeting end-tidal O2 >85%. Anesthesia was induced with propofol, remifentanil, and rocuronium. Bag-mask ventilation was not performed. At 2 minutes after rocuronium, videolaryngoscopy was performed. If the laryngoscopy grade was I or II, laryngoscope was left in place and the study was continued; if grade III or IV was observed, the patient was excluded from the study. During the apnea period, high-flow nasal oxygenation patients received nasal oxygen at 60 L·minute; control group patients received no supplemental oxygen. The primary outcome, safe apnea time, was reached when oxygen saturation measured by pulse oximetry (SpO2) fell to 95% or maximum 6 minutes of apnea. The patient was then intubated. T tests and χ analyses were used to compare groups. P < .05 was considered significant.

Results: Forty patients completed the study. Baseline parameters were comparable between groups. Safe apnea time was significantly longer (261.4 ± 77.7 vs 185.5 ± 52.9 seconds; mean difference [95% CI], 75.9 [33.3-118.5]; P = .001) and the minimum peri-intubation SpO2 was higher (91.0 ± 3.5 vs 88.0 ± 4.8; mean difference [95% CI], 3.1 [0.4-5.7]; P = .026) in the high-flow nasal oxygenation group compared to the control group.

Conclusions: High-flow nasal oxygenation, compared to conventional oxygenation, provided a longer safe apnea time by 76 seconds (40%) and higher minimum SpO2 in morbidly obese patients during anesthesia induction. High-flow oxygenation use should be considered in morbidly obese surgical patients.
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http://dx.doi.org/10.1213/ANE.0000000000003966DOI Listing
October 2019

The prevalence of obstructive sleep apnea in mild cognitive impairment: a systematic review.

BMC Neurol 2019 Aug 15;19(1):195. Epub 2019 Aug 15.

Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst Rd., Toronto, ON, M5T2S8, Canada.

Background: Previous studies have shown that obstructive sleep apnea (OSA) is associated with a higher risk of cognitive impairment or dementia in the elderly, leading to deleterious health effects and decreasing quality of life. This systematic review aims to determine the prevalence of OSA in patients with mild cognitive impairment (MCI) and examine whether an association between OSA and MCI exists.

Methods: We searched Medline, PubMed, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsychINFO, Scopus, the Web of Science, ClinicalTrials.gov and the International Clinical Trials Registry Platform for published and unpublished studies. We included studies in adults with a diagnosis of MCI that reported on the prevalence of OSA. Two independent reviewers performed the abstract and full-text screening, data extraction and the study quality critical appraisal.

Results: Five studies were included in the systematic review. Overall, OSA prevalence rates in patients with MCI varied between 11 and 71% and were influenced by OSA diagnostic methods and patient recruitment locations (community or clinic based). Among studies using the following OSA diagnostic measures- self-report, Home Sleep Apnea Testing, Berlin Questionnaire and polysomnography- the OSA prevalence rates in MCI were 11, 27, 59 and 71%, respectively. In a community-based sample, the prevalence of OSA in patients with and without MCI was 27 and 26%, respectively.

Conclusions: Based on limited evidence, the prevalence of OSA in patients with MCI is 27% and varies based upon OSA diagnostic methods and patient recruitment locations. Our findings provide an important framework for future studies to prospectively investigate the association between OSA and MCI among larger community-based cohorts and implement a standardized approach to diagnose OSA in memory clinics.

Prospero Registration: CRD42018096577.
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http://dx.doi.org/10.1186/s12883-019-1422-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6694482PMC
August 2019

Characterization of respiratory compromise and the potential clinical utility of capnography in the post-anesthesia care unit: a blinded observational trial.

J Clin Monit Comput 2020 Jun 7;34(3):541-551. Epub 2019 Jun 7.

Department of Anesthesiology, University of Arizona Medical Center, Tucson, AZ, USA.

The utility of capnography to detect early respiratory compromise in surgical patients after anesthesia is unclear due to limited prospective data. The purpose of this trial was to determine the frequency and duration of capnography-detected respiratory adverse events in the post-anesthesia care unit (PACU). In this prospective observational trial, 250 consenting patients undergoing elective surgery with general anesthesia were monitored by standard monitoring together with blinded capnography and pulse oximetry monitoring. The capnography notification settings were adjusted to match nursing (Level II) and physician (Level I) alarm thresholds. 163 (95%) patients had a Level II notification and 135 (78%) had a Level I notification during standard monitoring. The most common events detected by the capnography monitor included hypocapnia, apnea, tachypnea, bradypnea and hypoxemia, with silent notification duration for these events ranging from 17 ± 13 to 189 ± 127 s. During standard monitoring, 15 respiratory adverse events were reported, with 8 events occurring when valid blinded/silenced capnography and pulse oximetry data was collected simultaneously. Capnography and the Integrated Pulmonary Index™ algorithm (IPI) detected respiratory adverse events earlier than standard monitoring in 75% and 88% of cases, respectively, with an average early warning time of 8 ± 11 min. Three patients' blinded capnography was unblinded to facilitate clinical care. Respiratory adverse events are frequent in the PACU, and the addition of capnography and IPI to current standard monitoring provides potentially clinically relevant information on respiratory status, including early warning of some respiratory adverse events.Trial registration ClinialTrials.gov Identifier NCT02707003 (https://clinicaltrials.gov/ct2/show/NCT02707003).
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http://dx.doi.org/10.1007/s10877-019-00333-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205778PMC
June 2020

Physical activity in practice: why and how to get GPs moving.

Br J Gen Pract 2019 Jun;69(683):276-277

Nottingham University Hospitals, Nottingham.

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http://dx.doi.org/10.3399/bjgp19X703769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6532792PMC
June 2019

Outcomes of universal germline testing for men with prostate cancer in an Australian tertiary center.

Asia Pac J Clin Oncol 2019 Aug 22;15(4):257-261. Epub 2019 Apr 22.

Kinghorn Cancer Centre, St. Vincent's Hospital, Darlinghurst, NSW, Australia.

Aim: The role of germline testing in prostate cancer is evolving and knowledge of an individual's genetic profile may be used to guide not only an assessment of their familial risk but also have prognostic and therapeutic implications. Although international guidelines have incorporated recommendations for germline testing in prostate cancer, there is little Australian data to guide referrals. The aim of this study is to review the frequency of relevant pathogenic mutations in an Australian center, their associated clinical factors and clinical impact.

Methods: We conducted a single-center retrospective review of men with prostate cancer that undertook prospective germline testing using a targeted next generation sequencing panel.

Results: Results for 100 men were analyzed. Median age at diagnosis was 62 years (range 43-84); 92% had metastatic disease at referral. A pathogenic mutation was confirmed in 9%, a likely pathogenic variant in 2% and a variant of uncertain significance in 15%. Age ≤60 years was associated with an increased risk for a pathogenic germline variant (P = 0.0096). Two of the nine (22%) with pathogenic variants went on to receive targeted treatment.

Conclusions: In this single center study, the incidence of germline mutations in genes associated with DNA-repair was consistent with rates seen previously published international series of men with metastatic disease. A pathogenic variant was only seen in one patient >60 years of age and no man referred solely on the basis of age or high-risk localized disease had a relevant finding.
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http://dx.doi.org/10.1111/ajco.13148DOI Listing
August 2019

Knowledge Gaps in the Perioperative Management of Adults With Narcolepsy: A Call for Further Research.

Anesth Analg 2019 07;129(1):204-211

Division of Pulmonary, Critical Care and Sleep Medicine, Metro Health Medical Center, Case Western Reserve University, Cleveland, Ohio.

There is increasing awareness that sleep disorders may be associated with increased perioperative risk. The Society of Anesthesia and Sleep Medicine created the Narcolepsy Perioperative Task Force: (1) to investigate the current state of knowledge of the perioperative risk for patients with narcolepsy, (2) to determine the viability of developing perioperative guidelines for the management of patients with narcolepsy, and (3) to delineate future research goals and clinically relevant outcomes. The Narcolepsy Perioperative Task Force established that there is evidence for increased perioperative risk in patients with narcolepsy; however, this evidence is sparse and based on case reviews, case series, and retrospective reviews. Mechanistically, there are a number of potential mechanisms by which patients with narcolepsy could be at increased risk for perioperative complications. These include aggravation of the disease itself, dysautonomia, narcolepsy-related medications, anesthesia interactions, and withdrawal of narcolepsy-related medications. At this time, there is inadequate research to develop an expert consensus or guidelines for the perioperative management of patients with narcolepsy. The paucity of available literature highlights the critical need to determine if patients with narcolepsy are at an increased perioperative risk and to establish appropriate research protocols and clearly delineated patient-centered outcomes. There is a real need for collaborative research among sleep medicine specialists, surgeons, anesthesiologists, and perioperative providers. This future research will become the foundation for the development of guidelines, or at a minimum, a better understanding how to optimize the perioperative care of patients with narcolepsy.
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http://dx.doi.org/10.1213/ANE.0000000000004088DOI Listing
July 2019

Pre-operative biomarkers and imaging tests as predictors of post-operative delirium in non-cardiac surgical patients: a systematic review.

BMC Anesthesiol 2019 02 23;19(1):25. Epub 2019 Feb 23.

Department of Anesthesia, Toronto Western Hospital, University Health Network, 2-434 McLaughlin Wing, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.

Background: Post-operative delirium (POD) is a common post-operative complication in elderly individuals and imposes a significant health and financial burden. Identifying predictive biomarkers may help understand the pathophysiology of POD. Our objective is to summarize the evidence of pre-operative biomarkers and imaging tests to predict POD in patients undergoing non-cardiac surgery.

Methods: A systematic search of English language articles in MEDLINE, EMBASE, Cochrane Database, PsychINFO, PubMed and ClinicalTrials. Gov up to January 2018 was performed. Studies that used biomarkers or imaging tests to predict POD and a validated POD assessment tool were included. Animal studies, paediatric, cardiac and intracranial surgery were excluded. Risk of bias was assessed using the Quality In Prognosis Study tool.

Results: Thirty-four prospective cohort studies involving 4424 patients were included. Nineteen studies described serum tests [Interleukin-6, Insulin-like Growth Factor 1, C-Reactive Protein (CRP), cholinesterases, apolipoprotein-E genotype, leptin, hypovitaminosis, hypoalbuminaemia, gamma-amino butyric acid], 10 described cerebral-spinal fluid tests (monoamine precursor, melatonin, acute phase proteins, S100B and neurofibrillary tangles), and 5 described imaging tests. Two studies had high risk of bias due to unclear outcome measurement and study participation. CRP was significantly associated with POD in 5 studies. Other biomarkers were either examined by only a single study or two or more studies with conflicting results.

Conclusion: CRP is the most promising biomarker associated with POD. However, we are still in the early stages in identifying biomarkers and imaging tests that may further understanding of the pathophysiology of POD.
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http://dx.doi.org/10.1186/s12871-019-0693-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6387490PMC
February 2019

Preoperative smoking cessation as part of surgical prehabilitation.

Can J Anaesth 2019 04 3;66(4):476-479. Epub 2019 Jan 3.

Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1007/s12630-018-01283-7DOI Listing
April 2019

Risk factors for opioid-induced respiratory depression in surgical patients: a systematic review and meta-analyses.

BMJ Open 2018 12 14;8(12):e024086. Epub 2018 Dec 14.

Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Objective: This systematic review and meta-analysis aim to evaluate the risk factors associated with postoperative opioid-induced respiratory depression (OIRD).

Design: Systematic review and meta-analysis.

Data Sources: PubMed-MEDLINE, MEDLINE in-process, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PubMed and Clinicaltrials.gov (January 1946 to November 2017).

Eligibility Criteria: The inclusion criteria were: (1) adult patients 18 years or older who were administered opioids after surgery and developed postoperative OIRD (OIRD group); (2) all studies which reported both OIRD events and associated risk factors; (3) all studies with reported data for each risk factor on patients with no OIRD (control group) and (4) published articles in English language.

Data Analysis: We used a random effects inverse variance analysis to evaluate the existing evidence of risk factors associated with OIRD. Newcastle-Ottawa scale scoring system was used to assess quality of study.

Results: Twelve observational studies were included from 8690 citations. The incidence of postoperative OIRD was 5.0 cases per 1000 anaesthetics administered (95% CI: 4.8 to 5.1; total patients: 841 424; OIRD: 4194). Eighty-five per cent of OIRD occurred within the first 24 hours postoperatively. Increased risk for OIRD was associated with pre-existing cardiac disease (OIRD vs control: 42.8% vs 29.6%; OR: 1.7; 95% CI: 1.2 to 2.5; I: 0%; p<0.002), pulmonary disease (OIRD vs control: 17.8% vs 10.3%; OR: 2.2; 95% CI: 1.3 to 3.6; I: 0%; p<0.001) and obstructive sleep apnoea (OIRD vs control: 17.9% vs 16.5%; OR: 1.4; 95% CI: 1.2 to 1.7; I: 31%; p=0.0003). The morphine equivalent daily dose of the postoperative opioids was higher in the OIRD group than in the control; (24.7±14 mg vs 18.9±13.0 mg; mean difference: 2.8; 95% CI: 0.4 to 5.3; I: 98%; p=0.02). There was no significant association between OIRD and age, gender, body mass index or American Society of Anesthesiologists physical status.

Conclusion: Patients with cardiac, respiratory disease and/or obstructive sleep apnoea were at increased risk for OIRD. Patients with postoperative OIRD received higher doses of morphine equivalent daily dose.
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http://dx.doi.org/10.1136/bmjopen-2018-024086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6303633PMC
December 2018

Narcolepsy, Anesthesia, and Sedation: A Survey of the Perioperative Experience of Patients With Narcolepsy.

Anesth Analg 2019 11;129(5):1374-1380

Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Cleveland, Ohio.

Background: Patients with narcolepsy may be at increased perioperative risk due to the interactions among anesthesia, narcolepsy, and narcolepsy medications. This study sought to determine the perioperative experience of narcoleptic patients undergoing anesthesia or sedation, the frequency of perioperative counseling, and self-reported surgical complications.

Methods: A 22-question survey was developed by expert consensus and distributed by the Narcolepsy Network. Recruitment was via the Narcolepsy Network's list-serve and a Facebook link to the survey. One thousand and twenty respondents reported a diagnosis of narcolepsy and 1 or more procedures under anesthesia or sedation. Descriptive, comparative statistics and logistic regression were utilized.

Results: Respondents were mostly women (79.5%) and Caucasian (84.9%), with a mean age of 45 ± 16 years. Most respondents did not receive counseling regarding the possibility of increased sleepiness (70%), cataplexy (90%), or drowsy driving (59%) postanesthesia. More than half of respondents reported adverse events (medication withdrawal symptoms, inadequate pain relief, increased cataplexy). Subjects with cataplexy more frequently reported surgical complications (70% vs 31%; P = .03) and medication withdrawal symptoms (stimulant medications: odds ratio, 3.0 [95% CI, 1.9, 3.06]; P > .001 and antidepressant medications: odds ratio, 6.5 [95% CI, 2.1-19.5]; P = .001). Of the total sample, 18% indicated surgical complications. Undergoing 5 or more separate surgeries or procedures was associated with a 2-fold increase in self-reported complications (odds ratio, 2.2 [95% CI, 1.3-3.4]; P = .001), difficulty waking (odds ratio, 2.1 [95% CI, 1.45-3.06]; P = .001), and inadequate pain relief (odds ratio, 1.77 [95% CI, 1.01-3.13]; P < .05).

Conclusions: Most narcoleptic patients report not receiving counseling regarding potential worsening of narcolepsy symptoms postanesthesia or an increased risk of drowsy driving. Enhanced education of perioperative providers about potential narcolepsy-related issues is essential. Respondents frequently self-report adverse events in the perioperative period. Future studies should clarify the perioperative risk associated with narcolepsy to optimize the care and safety of narcoleptic patients.
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http://dx.doi.org/10.1213/ANE.0000000000003954DOI Listing
November 2019

Preoperative Evaluation: Estimation of Pulmonary Risk Including Obstructive Sleep Apnea Impact.

Anesthesiol Clin 2018 Dec 12;36(4):523-538. Epub 2018 Oct 12.

Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst street, Toronto, Ontario M5T2S8, Canada. Electronic address:

One in 4 deaths occurring within a week of surgery are related to pulmonary complications, making it the second most common serious morbidity after cardiovascular events. The most significant predictors of the postoperative pulmonary complications (PPCs) are American Society of Anesthesiologists physical status, advanced age, dependent functional status, surgical site, and duration of surgery. The overall risk of PPCs can be predicted using scores that incorporate readily available clinical data.
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http://dx.doi.org/10.1016/j.anclin.2018.07.004DOI Listing
December 2018

Sleep Study and Oximetry Parameters for Predicting Postoperative Complications in Patients With OSA.

Chest 2019 04 22;155(4):855-867. Epub 2018 Oct 22.

Department of Anesthesiology, Toronto Western Hospital, University Health Network, Toronto, ON, Canada; Department of Anesthesiology, University of Toronto, Toronto, ON, Canada. Electronic address:

In the surgical setting, OSA is associated with an increased risk of postoperative complications. At present, risk stratification using OSA-associated parameters derived from polysomnography (PSG) or overnight oximetry to predict postoperative complications has not been established. The objective of this narrative review is to evaluate the literature to determine the association between parameters extracted from in-laboratory PSG, portable PSG, or overnight oximetry and postoperative adverse events. We obtained pertinent articles from Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, and Embase (2008 to December 2017). The search included studies with adult patients undergoing surgery who had OSA diagnosed with portable PSG, in-laboratory PSG, or overnight oximetry that reported on specific sleep parameters and at least one adverse outcome. The search was restricted to English-language articles. The search yielded 1,810 articles, of which 21 were included in the review. Preoperative apnea-hypopnea index (AHI) and measurements of nocturnal hypoxemia such as oxygen desaturation index (ODI), cumulative sleep time percentage with oxyhemoglobin saturation (Spo) < 90% (CT90), minimum Spo, mean Spo, and longest apnea duration were associated with postoperative complications. OSA is associated with postoperative complications in the population undergoing surgery. Clinically and statistically significant associations between AHI and postoperative adverse events exists. Complications may be more likely to occur in the category of moderate to severe OSA (AHI ≥ 15). Other parameters from PSG or overnight oximetry such as ODI, CT90, mean and minimal Spo, and longest apnea duration can be associated with postoperative complications and may provide additional value in risk stratification and minimization.
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http://dx.doi.org/10.1016/j.chest.2018.09.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6997937PMC
April 2019

The effect of virtual reality bronchoscopy simulator training on performance of bronchoscopic-guided intubation in patients: A randomised controlled trial.

Eur J Anaesthesiol 2019 03;36(3):227-233

From the Department of Anaesthesia, Toronto Western Hospital, Toronto, Ontario, Canada (DTW, KPS, AN, AO, RP, MS, JW), Department of Anaesthesia, University College, London Hospitals, London, UK (AM), Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (SML), Department of Anaesthesia, John Fawkner Hospital, Coburg, Victoria, Australia (AO) and Department of Anaesthesia, Mount Sinai Hospital, Toronto, Ontario, Canada (EY-T).

Background: The use of a flexible optical bronchoscopic (FOB) for intubation is an essential airway management skill.

Objective(s): Our primary objective was to compare the effects of simulator training (ORSIM high-fidelity simulator) with no simulation training on the performance of FOB intubation in anaesthetised patients.

Design: Randomised controlled trial.

Setting: Single-centre tertiary hospital; trial conducted between April 2015 to May 2016.

Participants: Medical students, anaesthesia assistants and anaesthesia residents with experience of less than five FOB intubations from whom informed consent was obtained.

Intervention: Students, anaesthesia assistants and anaesthesia residents viewed a didactic presentation before performing an initial FOB intubation in an anaesthetised patient. Intubations were recorded and evaluated using the Global Rating Scale (GRS) and checklist scores. Subsequently, participants were randomised to control group (Group CON) and had no simulation training, or to a simulation group (Group SIM) and underwent 60 min of simulation practice. Within a week, participants performed a second FOB intubation and were similarly evaluated.

Main Outcome Measures: Pretraining and posttraining intubation time, GRS and checklist scores.

Results: Baseline characteristics were similar between groups. In Group SIM, there was significant improvement between pre and posttraining GRS [22.9 ± 8.1 vs. 28.2 ± 7.3, mean difference (95% CI) 5.3 (0.3 to 10.3), P = 0.04], and intubation time [177.6 ± 77.6 vs. 119.3 ± 52.2 s, mean difference (95% CI) -58.4 (-100.3 to -16.5) s, P = 0.01]. There was no difference in Group CON, between pre and posttraining intubation time, GRS or checklist.

Conclusion: We conclude, posttraining performance of FOB intubation, as measured by intubation time and GRS, improved in Group SIM, while it was unchanged in the Group CON. The ORSIM simulator may be a useful adjunct in acquiring FOB intubation skills.

Clinical Trial Number And Registry: ClinicalTrials.gov ID: NCT02699242.
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http://dx.doi.org/10.1097/EJA.0000000000000890DOI Listing
March 2019