Cardiac arrest in the OR: How are our ACLS skills?

Purpose

While advanced cardiac life support (ACLS) training is widely available, it is not mandatory for all anaesthetists, We hypothesised that adherence to ACLS guidelines during resuscitation of ventricular fibrillation (VFib) as assessed in a simulator environment would be poor by anaesthetists not trained in ACLS compared wrth those who had received training,

Methods

With approval by the ethics review board, 89 subjects participated in the study. The simulation system consisted of a computer controlled mannequin with lifelike qualities set in a mock operating room. Each subject was given a test scenario that contained several standard anaesthetic problems. A VFib cardiac arrest occurred after approximately one hour into the simulation. A perfect score (score = A) defined complete compliance with the ACLS guidelines, whereas minor deviations (score = B) included changes in energy levels, drug doses or treatment order. The failure to discontinue the anaesthetic, defibrillate or administer epinephrine were considered major deviations (score = C).

Results

Eight subjects followed the ACLS guidelines (9%, score = A), while 27 subjects showed minor (30%, score = B) and 54 subjects major deviations (61 %, score = C). Sixty-two of the 89 participants (70%) had taken the ACLS course and achieved higher scores than did anaesthetists without such training (P < 0.05). Forty-two participants (47%) did not discontinue the anaesthetic, 10(11%) never gave epinephrine and 5 (6%) never used the defibrillator.

Conclusion

Adherence to ACLS guidelines was poor. A greater proportion of subjects wrthout previous ACLS training had deviations from protocol than did subjects who had received training. We need to consider ways to ensure that anaesthetists obtain and retain resuscitation skills according to ACLS guidelines.     

Education of basic/advanced life support and emergency medicine for anesthesiologists: a survey of chairpersons at university department and newly board certified anesthesiologists]

To determine how the education of basic life support (BLS)/advanced cardiac life support (ACLS) and emergency medicine for anesthesiologists is conducted, we performed a survey of chairpersons at university departments and newly board certified anesthesiologists in 1999. Basic and advanced life support courses for residents were provided in more than half of the anesthesiology departments that responded to this survey. However, approximately only 10% of the respondents had regular BLS/ACLS courses for residents. On the other hand, more than 80% of respondents considered a rotation in emergency medicine desirable as a part of anesthesia training. To improve the resuscitation skills of anesthesiologists, an urgent need to establish regular BLS/ALS courses and educational programs in emergency medicine in anesthesia training does exist.     

Anesthesia advanced circulatory life support

Purpose

The constellation of advanced cardiac life support (ACLS) events, such as gas embolism, local anesthetic overdose, and spinal bradycardia, in the perioperative setting differs from events in the pre-hospital arena. As a result, modification of traditional ACLS protocols allows for more specific etiology-based resuscitation.

Principal findings

Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient??s comorbidities and coexisting anesthetic or surgically related pathophysiology. When the health care provider identifies the probable cause of arrest, the practitioner has the ability to initiate medical management rapidly.

Conclusions

Recommendations for management must be predicated on expert opinion and physiological understanding rather than on the standards currently being used in the generation of ACLS protocols in the community. Adapting ACLS algorithms and considering the differential diagnoses of these perioperative events may prevent cardiac arrest.     

Drug shortages in Canadian anesthesia: a national survey

Background

Canadian physicians are faced with an increasing frequency of drug shortages. We hypothesized that drug shortages have a clinical impact on anesthesia care in Canada.

Methods

We conducted a self-administered survey of anesthesiologists in Canada using the membership list of the Canadian Anesthesiologists’ Society. For survey development, we identified key domains, including types of drug shortages, impact on the ability of anesthesia practitioners to provide general anesthesia care, and impact on patient outcomes. We undertook assessments of face validity, clinical sensibility, and content validity. Respondents were surveyed from January-April 2012.

Results

Completed valid questionnaires were submitted by 1,187 respondents (61.4%), and 779 (65.7%) of respondents described a shortage of one or more anesthesia or critical care drugs. Changes in anesthesia practice resulting from drug shortages were common; 586 (49%) respondents thought they had given an inferior anesthetic, and 361 (30%) reported administering medications with which they were unfamiliar. Respondents also reported that drug shortages were, at times, responsible for changes in the conduct of patient care, with 28 (2.4%) noting cancellation or postponement of surgery and 92 (7.8%) witnessing a drug error. One hundred sixty-five (13.9%) respondents regarded drug shortages as having prolonged recovery from anesthesia, and 124 (10.5%) viewed drug shortages as resulting in an increased number of postoperative complications, such as postoperative nausea and vomiting.

Interpretation

Drug shortages are common in anesthetic practice in Canada. This state of affairs may have a negative effect on how anesthesiologists practice anesthesia and may be associated with adverse patient outcomes.     

Illinois dental anesthesia and sedation survey for 2006

This is a 10-year follow-up survey of a 1996 study of all dentists in Illinois holding a permit to administer sedation or general anesthesia. The survey describes the scope of sedation and anesthesia services provided in dental offices in Illinois. A mail survey was sent to 471 dentists who were registered with the department of professional regulation to administer sedation or general anesthesia. Classification by specialty area of practice showed: 63% (84% in 1996) are oral and maxillofacial surgeons, 20% (11% in 1996) general dentists, 6% (5% in 1996) periodontists, 9% (0% in 1996) pediatric dentists, 1% (less than 1% in 1996) dentist anesthesiologists. Advanced cardiovascular life support (ACLS) training was reported by 90% (85% in 1996) of the respondents. The total number of sedations and general anesthetics administered for the year was 115,940. Two mortalities and two cases of long-term morbidity were reported for the 10-year period. Respondents reported that 30 patients required transfer to a hospital but suffered no long-term morbidity. Other practice characteristics were detailed.     

Perioperative Cardiac Arrests in Children between 1988 and 2005 at a Tertiary Referral Center: A Study of 92,881 Patients

Background: The objective of this study was to determine the incidence and outcome of perioperative cardiac arrest (CA) in children younger than 18 yr undergoing anesthesia for noncardiac and cardiac procedures at a tertiary care center.

Methods: After institutional review board approval (Mayo Clinic, Rochester, Minnesota), all patients younger than 18 yr who had perioperative CA between November 1, 1988, and June 30, 2005, were identified. Perioperative CA was defined as a need for cardiopulmonary resuscitation or death during anesthesia care. A cardiac procedure was defined as a surgical procedure involving the heart or great vessels requiring an incision.

Results: A total of 92,881 anesthetics were administered during the study period, of which 4,242 (5%) were for the repair of congenital heart malformations. The incidence of perioperative CA during noncardiac procedures was 2.9 per 10,000, and the incidence during cardiac procedures was 127 per 10,000. The incidence of perioperative CA attributable to anesthesia was 0.65 per 10,000 anesthetics, representing 7.5% of the 80 perioperative CAs. Both CA incidence and mortality were highest among neonates (0-30 days of life) undergoing cardiac procedures (incidence: 435 per 10,000; mortality: 389 per 10,000). Regardless of procedure type, most patients who experienced perioperative CA (88%) had congenital heart disease.     

Under “real world” conditions, desflurane increases drug cost without speeding discharge after short ambulatory anesthesia compared to isoflurane

PURPOSE: To compare the measured "real world" perioperative drug cost and recovery associated with desflurane- and isoflurane-based anesthesia in short (less than one hour) ambulatory surgery. METHODS: We conducted a prospective, randomized, blinded trial with patients undergoing arthroscopic meniscectomy under general anesthesia. Following iv induction, patients received either isoflurane (group I; n = 25) or desflurane (group D; n = 20) for maintenance. The primary outcome variable was total perioperative drug cost per patient in Canadian dollars. Secondary outcome variables included volatile agent consumption and cost, adjuvant anesthetic and postanesthesia care unit (PACU) drug cost, readiness for PACU discharge, and incidence of adverse events. RESULTS: Total perioperative drug cost per patient was 14.58 +/- 6.83 Canadian dollars (mean +/- standard deviation) for group I, and 21.47 +/- 5.18 Canadian dollars for group D (P < 0.001). Isoflurane consumption per patient was 6.0 +/- 3.0 mL compared to 18.6 +/- 7.7 mL for desflurane (P < 0.0001); corresponding costs were 0.83 +/- 0.42 Canadian dollars vs 7.61 +/- 3.15 Canadian dollars (P < 0.0001). There were no differences in adjuvant anesthetic or PACU drug cost. All but one patient from each group were deemed ready for PACU discharge at 15 min postoperatively (Aldrete score >or= 9). One patient in group D experienced postoperative nausea. No other adverse events were noted. CONCLUSIONS: Measured total perioperative drug cost for a short ambulatory procedure (less than one hour) under general anesthesia was higher when desflurane rather than isoflurane was used for maintenance, essentially due to volatile agent cost. Desflurane use did not translate into faster PACU discharge under "real world" conditions.     

Anesthesiologists in North Carolina: a survey reflecting emerging subspecialization

This North Carolina case study addresses the migration of anesthesiologists into subspecialty, clinical areas of anesthesiology over a 4-year period (1984 to 1987). Three hundred fourteen members of the North Carolina Society of Anesthesiologists (NCSA) were surveyed using a one-page questionnaire. The response rate was 93.6%. The questionnaire elicited data to characterize the magnitude of change in anesthesiologist manpower, to assess emerging subspecialization, to describe the flux of anesthesiologists entering and leaving practice, and to detail evolving modes of practice. Results indicated a net increase in manpower averaging 8.8% per year in academic programs, whereas clinical community practitioners increased physician positions at a rate three times the former (27% increase per year). Of 184 anesthesiologists recruited to North Carolina over 4 years, 75 different residency programs were represented; 48% of new anesthesiologists were from southern educational programs and 44% entered practice with fellowships (i.e., postgraduate year 4 to 5). The principal fellowship was cardiac (33%). Subspecialty areas were represented in all 53 reporting clinical practices. The principal practice mode emerging was hospital-based, same day surgery (85%) followed by pediatric anesthesia (81%), perioperative pain management (68%), obstetric anesthesia (63%), and an anesthesia "clinic" (54%). Respondents expected additional practice options over the next 3 years with anesthesia for ambulatory diagnostic and therapeutic modalities projected to emerge at the fastest rate. In conclusion, anesthesiologists in North Carolina seem to be filling unmet needs in obstetric and cardiac anesthesia, critical care, ambulatory surgery, and pain therapy units. These observations may represent a vignette of the national scene.     

Perioperative blood pressure control: a prospective survey of patient management in cardiac surgery

OBJECTIVE: To conduct a survey of current cardiac anesthetic practice in Europe and the United States, as a first step toward establishing guidelines for the management of perioperative hypertension. DESIGN: Prospective, multicenter study. SETTING: University hospitals. PARTICIPANTS: Unselected patients (n = 1,930) requiring cardiac surgery. INTERVENTIONS: Data extending from the preoperative evaluation to 120 hours or more after surgery were collected from all patients. MEASUREMENTS AND MAIN RESULTS: Only the data from patients undergoing coronary artery bypass surgery, valve surgery, or combined procedures were analyzed, leaving a final total of 1,660 patients from the original 1,930. Of these, 88% were treated at least once perioperatively to lower arterial blood pressure. Deepening of anesthesia was the most commonly used antihypertensive measure (68%), regardless of the ongoing anesthetic regimen, and was usually combined with vasodilator therapy, most frequently nitroglycerin (53%) or sodium nitroprusside (28%). Reported perioperative mean arterial pressure (MAP) was 15 to 20 mmHg lower than MAP before anesthesia induction, regardless of the use of antihypertensive therapy. The MAP at which antihypertensive treatment was initiated varied markedly among the various phases of surgery and showed no clear correlation with preoperative MAP. CONCLUSIONS: The results of this survey show that current anesthetic practice tries to prevent perioperative hypertension wherever possible during cardiac surgery. Blood pressure measurements taken before surgery have little influence on the development of hypertension intraoperatively, and the main determinants of perioperative blood pressure control and the need for therapeutic intervention are factors arising from the surgical procedure itself, such as aortic cross-clamping and activation of adrenergic mechanisms.     

Perioperative care of patients with obstructive sleep apnea — a survey of Canadian anesthesiologists

PURPOSE: At present, there are no guidelines and insufficient evidence to guide the decision-making of anesthesiologists in the perioperative care of patients with obstructive sleep apnea (OSA). The purpose of this study was to examine the current perioperative care provided, and to obtain opinions from anesthesiologists regarding evidence/consensus based guidelines to assist them in providing care to patients with OSA. METHODS: Canadian anesthesiologists were sent a postal questionnaire examining their opinions and perioperative care of patients with OSA. Respondents were asked to indicate the postoperative monitoring they would most likely select for two clinical scenarios, representing administration of a general and regional anesthetic, which was altered to reflect: treatment of OSA; use of postoperative opioids; presence of morbid obesity; and increased severity of OSA. RESULTS: The survey had a response rate of 70% (746/1,063). Sixty-seven percent of respondents provided perioperative care to one to five patients with OSA per month, and 72% reported not having departmental policies for care of OSA patients. Ninety-two percent reported asking patients about OSA preoperatively. There was >or= 75% respondent agreement in two of the five alterations of the general anesthesia case scenario and in none of the alterations of the regional anesthesia case scenario. Eighty-two percent reported that guidelines would assist them in caring for patients with OSA. CONCLUSION: This study demonstrates a variation amongst anesthesiologists in their postoperative monitoring of patients with OSA. The majority surveyed do not have departmental policies, and believed that guidelines would assist them in providing care to patients with OSA.     

Guidelines for cardiac management in noncardiac surgery are poorly implemented in clinical practice: results from a peripheral vascular survey in the Netherlands

BACKGROUND: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery recommend an algorithm for a stepwise approach to preoperative cardiac assessment in vascular surgery patients. The authors' main objective was to determine adherence to the ACC/AHA guidelines on perioperative care in daily clinical practice. METHODS: Between May and December 2004, data on 711 consecutive peripheral vascular surgery patients were collected from 11 hospitals in The Netherlands. This survey was conducted within the infrastructure of the Euro Heart Survey Programme. The authors retrospectively applied the ACC/AHA guideline algorithm to each patient in their data set and subsequently compared observed clinical practice data with these recommendations. RESULTS: Although 185 of the total 711 patients (26%) fulfilled the ACC/AHA guideline criteria to recommend preoperative noninvasive cardiac testing, clinicians had performed testing in only 38 of those cases (21%). Conversely, of the 526 patients for whom noninvasive testing was not recommended, guidelines were followed in 467 patients (89%). Overall, patients who had not been tested, irrespective of guideline recommendation, received less cardioprotective medications, whereas patients who underwent noninvasive testing were significantly more often treated with cardiovascular drugs (beta-blockers 43% vs. 77%, statins 52% vs. 83%, platelet inhibitors 80% vs. 85%, respectively; all P < 0.05). Moreover, the authors did not observe significant differences in cardiovascular medical therapy between patients with a normal test result and patients with an abnormal test result. CONCLUSION: This survey showed poor agreement between ACC/AHA guideline recommendations and daily clinical practice. Only one of each five patients underwent noninvasive testing when recommended. Furthermore, patients who had not undergone testing despite recommendations received as little cardiac management as the low-risk population.     

Standards for preclinical resuscitation--requirements for efficient therapy and scientific analysis. A prospective study using as an example the combined emergency medical service of the Munich administrative district and capital

A standardized treatment protocol is essential for scientific evaluation of parameters influencing the outcome and survival of patients who have suffered cardiac arrest in a non-hospital situation. In addition, a standardized therapy algorithm permits effective, time-saving interaction of all members of the emergency team who work together to perform cardiopulmonary resuscitation (CPR) in any emergency outside the hospital. This paper gives the results obtained in 50 patients in whom on-the-spot resuscitation was performed by a specially trained team [emergency medical team (EMT) + on-scene physician] using an ACLS (advanced cardiac life support) protocol modified from the AHA (American Heart Association) standard. Two different algorithms were used one for ventricular fibrillation (VF) and pulseless ventricular tachycardia and one for asystole and pulseless bradycardia. When indicated, countershocks were first administered at a continuous energy level of 360 J, up to three times one after the other. All patients then received epinephrine intratracheally, 2 mg, immediately after intubation. In the case or persisting asystole a further 2-mg dose of epinephrine and then one 5-mg dose were given i.v. in keeping with the ACLS protocol. In the case of persisting VF or pulseless tachycardia we gave one 100-mg dose of lidocaine i.v. and then performed the next countershock at the same energy level. The time the team members actually needed for the single steps of the ACLS protocol was meticulously documented with the aid of a stop watch.(ABSTRACT TRUNCATED AT 250 WORDS)     

Role of anesthesiologists is the education of cardiopulmonary resuscitation in local hospitals

BACKGROUND: In Japanese local hospitals there are not many persons who can give speedy and exact medical treatment in emergency. We investigated a role of anesthesiologists in the education of cardiopulmonary resuscitation (CPR) in local hospitals. METHODS: A total of 3 doctors and 30 nurses completed the questionnaire about the education of CPR after training of advanced cardiac life support (ACLS) in a local hospital. RESULTS: It showed that all doctors and nurses have had some anxiety about the emergency treatment of patients and could understand the importance of CPR. Moreover, most of them answered that they wanted to learn ACLS more, and that the training of ACLS simulation was the most impressive. CONCLUSIONS: It is important for anesthesiologists to teach ACLS and to promote the spread of ACLS in local hospitals.     

Canadian pediatric anesthesiologists prefer inhalational anesthesia to manage difficult airways: A survey

PURPOSE: To survey Canadian pediatric anesthesiologists to assess practice patterns in managing pediatric patients with difficult airways. METHODS: Canadian pediatric anesthesiologists were invited to complete a web survey. Respondents selected their preferred anesthetic and airway management techniques in six clinical scenarios. The clinical scenarios involved airway management for cases where the difficulty was in visualizing the airway, sharing the airway and accessing a compromised airway. RESULTS: General inhalational anesthesia with spontaneous respiration was the preferred technique for managing difficult intubation especially in infants (90%) and younger children (97%), however, iv anesthesia was chosen for the management of the shared airway in the older child (51%) where there was little concern regarding difficulty of intubation. Most respondents would initially attempt direct laryngoscopy for the two scenarios of anticipated difficult airway (73% and 98%). The laryngeal mask airway is commonly used to guide fibreoptic endoscopy. The potential for complete airway obstruction would encourage respondents to employ a rigid bronchoscope as an alternate technique (17% and 44%). CONCLUSION: Inhalational anesthesia remains the preferred technique for management of the difficult pediatric airway amongst Canadian pediatric anesthesiologists. Intravenous techniques are relatively more commonly chosen in cases where there is a shared airway but little concern regarding difficulty of intubation. In cases of anticipated difficult intubation, direct laryngoscopy remains the technique of choice and fibreoptic laryngoscopy makes a good alternate technique. The use of the laryngeal mask airway was preferred to facilitate fibreoptic intubation.     

A demand-based assessment of the Canadian anesthesia workforce — 2002 through 2007

PURPOSE: The number of anesthesia providers required by the Canadian health care system remains controversial. Questions persist regarding both the adequacy of the current supply and what the future demand will be. The purpose of this study was to quantify the number and adequacy of anesthesia providers in 2002, and predict the same for the year 2007. METHODS: All licensed health care facilities potentially employing anesthetic services were identified. On February 1(st), 2002 a questionnaire was mailed to each institution. On April 1(st), a second mailing was sent to non-responders. Those facilities that did not respond to either mailing were contacted by telephone. RESULTS: Responses were obtained from 831 of 891 (93%) health care facilities. Four hundred and twenty-six of the facilities employed anesthetic services. There were 1,610 operating rooms (ORs) in use daily, and 2,134 full-time equivalent (FTE) anesthesia providers were available to the institutions surveyed. Respondents identified an immediate need for 228 additional FTEs. Hospitals with less than five ORs or five FTEs reported higher vacancy rates than hospitals with greater than five ORs or five FTEs (P < 0.0001). Ontario (n = 85) and Quebec (n = 69) had the largest absolute deficits of FTEs and significantly greater odds of vacancies than western provinces (Ontario OR = 1.84, Quebec OR = 2.50). The projected need for 2007 was an additional 560 FTEs. CONCLUSION: This is the first study to survey a national census of "consumers" of anesthetic services: Canadian health care facilities. The results indicate substantial current and worsening future shortages of anesthesia providers in Canada.     

Current perioperative practice in Canadian vascular surgery

Background

The Enhanced Recovery After Surgery (ERAS) Society has set out to improve patient recovery by developing evidence-based perioperative practices. Many institutions and other specialties have begun to apply their principles with great success; however, ERAS principles focus mostly on general surgery, and their applicability to other specialties, such as vascular surgery, is less clear. We sought to investigate the current standard of perioperative care in Canadian vascular surgery by assessing surgeons’ perceptions of evidence supporting ERAS practices, identifying barriers to aligning them and identifying aspects of perioperative care that require research specific to vascular surgery before they could be broadly applied.

Methods

We administered an online survey with 26 questions to all Canadian Society for Vascular Surgery members.

Results

Respondents varied largely in perioperative practice, most notably in the use of nasogastric tubes, Foley catheters and neck drains. Familiarity with supporting evidence was poor. Approximately half (44%) of respondents were not familiar with contrary evidence, while those who were often perceived institutional barriers to change. Finally, one-third (30%) of respondents felt that relevant evidence did not exist to support changing their practice.

Conclusion

The variability of perioperative practice in Canadian vascular surgery is likely due to multiple factors, including a lack of specific evidence. Further research in areas of perioperative vascular care where the current standard of practice varies most greatly may help improve recovery after vascular surgery in Canada over simply adopting existing ERAS principles.     

Point-of-care ultrasonography in Canadian anesthesiology residency programs: a national survey of program directors

Purpose

Point-of-care ultrasonography (POCUS) is a useful tool with multiple perioperative applications relevant to the anesthesiologist. Nevertheless, the full scope of POCUS applications has yet to be formally incorporated into Canadian anesthesiology training. The purpose of this study was to determine the current state of POCUS training in Canadian anesthesiology residency programs.

Methods

We conducted a web-based survey of program directors from Royal College-accredited anesthesiology residency programs across Canada. Respondents were asked about POCUS training and assessment strategies at their institution as well as perceived barriers to POCUS education. We also elicited program directors’ views on the importance of various POCUS applications as well as future direction of POCUS education within Canadian anesthesiology residency programs.

Results

Thirteen of 17 (76%) program directors responded to our survey. All respondents’ residency programs provide some training in POCUS-facilitated vascular access, peripheral nerve blocks, neuraxial techniques, and transthoracic echocardiography. Nevertheless, training varies significantly for the other POCUS applications in our survey. The most frequently quoted teaching method employed is informal bedside teaching, followed by structured expert demonstration, hands-on scanning, and didactic lectures. The most frequently quoted barrier to teaching POCUS is the lack of trained staff. The majority of respondents agreed that competence in POCUS is important for graduating anesthesiology residents, and that POCUS should be incorporated into the National Curriculum for Canadian Anesthesiology Residency.

Conclusion

Point-of-care ultrasonography training within Canadian anesthesiology residency programs is highly variable. Given the importance of POCUS abilities and their relevance to modern anesthesia practice, POCUS training and assessment within Canadian anesthesiology residency programs should be formalized.

     

The efficacy and resource utilization of remifentanil and fentanyl in fast-track coronary artery bypass graft surgery: a prospective randomized, double-blinded controlled, multi-center trial

We compared (a) the perioperative complications; (b) times to eligibility for, and actual time of the following: extubation, less intense monitoring, intensive care unit (ICU), and hospital discharge; and (c) resource utilization of nursing ratio for patients receiving either a typical fentanyl/isoflurane/propofol regimen or a remifentanil/isoflurane/propofol regimen for fast-track cardiac anesthesia in 304 adults by using a prospective randomized, double-blinded, double-dummy trial. There were no differences in demographic data, or perioperative mortality and morbidity between the two study groups. The mini-mental status examination at postoperative Days 1 to 3 were similar between the two groups. The eligible and actual times for extubation, less intense monitoring, ICU discharge, and hospital discharge were not significantly different. Further analyses revealed no differences in times for extubation and resource utilization after stratification by preoperative risk scores, age, and country. The nurse/patient ratio was similar between the remifentanil/isoflurane/propofol and fentanyl/isoflu-rane/propofol groups during the initial ICU phase and less intense monitoring phase. Increasing preoperative risk scores and older age (>70 yr) were associated with longer times until extubation (eligible), ICU discharge (eligible and actual), and hospital discharge (eligible and actual). Times until extubation (eligible and actual) and less intense monitoring (eligible) were significantly shorter in Canadian patients than United States' patients. However, there was no difference in hospital length of stay in Canadian and United States' patients. We conclude that both anesthesia techniques permit early and similar times until tracheal extubation, less intense monitoring, ICU and hospital discharge, and reduced resource utilization after coronary artery bypass graft surgery. IMPLICATIONS: An ultra-short opioid technique was compared with a standard fast-track small-dose opioid technique in coronary artery bypass graft patients in a prospective randomized, double-blinded controlled study. The postoperative recovery and resource utilization, including stratification of preoperative risk score, age, and country, were analyzed.     

Cardiac arrest in the operating room requiring prolonged resuscitation

Purpose

Prolonged cardiopulmonary resuscitation (CPR) is often associated with limited success and poor long-term outcomes. The purpose of this report is to present the case of a patient who suffered an unanticipated cardiac arrest in the operating room and survived following a prolonged period of CPR.

Clinical features

A previously healthy 53-yr-old male with inflammatory bowel disease was diagnosed with a perforated bowel and underwent emergency exploratory laparotomy under general anesthesia. Approximately two hours after induction of anesthesia, the patient experienced cardiac arrest, and for 55?min, he underwent CPR and defibrillation according to the Advanced Cardiac Life Support (ACLS) protocols. As the decision to terminate CPR was being considered, a return of spontaneous circulation was detected 56?min after the onset of cardiac arrest. The patient survived with no major organ failure or adverse neurological outcome. No definitive cause of cardiac arrest was diagnosed in the postoperative period. At the follow-up 14?months after the event, the patient had returned to the pre-arrest level of functioning. The results of our literature search showed that no upper limit for the duration of CPR has been defined. Good outcomes after prolonged CPR depend on the patient??s pre-arrest condition and the etiology of the cardiac arrest.

Conclusion

Perioperative cardiac arrests are rare events, and there is little evidence to suggest an upper limit for the duration of resuscitation. Unknown etiologies and the presence of good patient predictors may support the continuation of prolonged CPR with good outcomes.