Global surgery and the World Health Organization: indispensable partners to achieve triple billion goals

Brian Patrick Kavanagh, MB, BCh, BAO, BSc, MRCP(I), FRCPC

Reassessment of a meta-analysis of intraoperative cerebral oximetry-based management studies

Near-obstructive vallecular cyst

Guest Reviewers

Auricular percutaneous nerve field stimulator device as alternative therapy for Cesarean delivery analgesia: proof of concept

In reply: Reassessment of a meta-analysis of intraoperative cerebral-oximetry-based management studies

Ultrasound-assisted surgical retrieval of the lost femoral trial head during total hip arthroplasty

Perioperative dexmedetomidine reduces delirium in elderly patients after non-cardiac surgery: a systematic review and meta-analysis of randomized-controlled trials Abstract Background Delirium is a frequent postoperative complication in elderly patients after non-cardiac surgery. We performed this updated meta-analysis to ascertain more precisely the efficacy of dexmedetomidine (DEX) on the incidence of postoperative delirium (POD) in elderly patients after non-cardiac surgery. Methods We searched PubMed, EMBASE, the Cochrane Library, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) from inception until February 24, 2019. In this meta-analysis, we included randomized-controlled trials comparing the effect of DEX vs normal saline (NS) or other anesthetic drugs on POD incidence in elderly (either ≥ 60 or ≥ 65 yr old) patients undergoing non-cardiac surgery. We performed subgroup analyses of the DEX dosing strategy (starting time, dose, and duration of administration, with or without loading dose) and the strategy of various control drugs. A random-effects model was used for all analyses. Results We included 11 studies involving 2,890 patients in our meta-analysis. The pooled results of these studies revealed that DEX significantly reduced the incidence of POD (relative risk [RR], 0.47; 95% confidence interval [CI], 0.38 to 0.58; P < 0.001) compared with the control group. Meanwhile, the incidences of hypotension (RR, 1.20; 95% CI, 1.04 to 1.39; P = 0.01) and bradycardia (RR, 1.33; 95% CI, 1.08 to 1.63; P = 0.007) were increased in the DEX group. Subgroup analyses revealed a decrease in POD incidence when DEX was administered intraoperatively (RR, 0.43; 95% CI, 0.33 to 0.57; P < 0.001) and postoperatively (RR, 0.38; 95% CI, 0.27 to 0.54; P < 0.001) with a loading dose (RR, 0.49; 95% CI, 0.36 to 0.69; P < 0.001) compared with NS (RR, 0.49; 95% CI, 0.37 to 0.64; P < 0.001) and other anesthetic drugs (RR, 0.40; 95% CI, 0.26 to 0.60; P < 0.001). There were significant differences in the time to extubation (standardized mean difference, -0.60; 95% CI, -1.17 to -0.03; P = 0.04) and the length of hospital stay (mean difference, -0.50 days; 95% CI, -0.97 to -0.03; P = 0.04). The amount of data for the duration of mechanical ventilation and length of intensive care unit stay were insufficient to perform a meta-analysis. Conclusion Perioperative dexmedetomidine reduces the incidence of POD in elderly patients after non-cardiac surgery, but this comes at the cost of an increased incidence of hypotension and bradycardia.

Simulation-based assessment in anesthesia: an international multicentre validation study Abstract Purpose Simulated clinical events provide a means to evaluate a practitioner’s performance in a standardized manner for all candidates that are tested. We sought to provide evidence for the validity of simulation-based assessment tools in simulated pediatric anesthesia emergencies. Methods Nine centres in two countries recruited subjects to participate in simulated operating room events. Participants ranged in anesthesia experience from junior residents to staff anesthesiologists. Performances were video recorded for review and scored by specially trained, blinded, expert raters. The rating tools consisted of scenario-specific checklists and a global rating scale that allowed the rater to make a judgement about the subject’s performance, and by extension, preparedness for independent practice. The reliability of the tools was classified as “substantial” (intraclass correlation coefficients ranged from 0.84 to 0.96 for the checklists and from 0.85 to 0.94 for the global rating scale). Results Three-hundred and ninety-one simulation encounters were analysed. Senior trainees and staff significantly out-performed junior trainees (P = 0.04 and P < 0.001 respectively). The effect size of grade (junior vs senior trainee vs staff) on performance was classified as “medium” (partial η2 = 0.06). Performance deficits were observed across all grades of anesthesiologist, particularly in two of the scenarios. Conclusions This study supports the validity of our simulation-based anesthesiologist assessment tools in several domains of validity. We also describe some residual challenges regarding the validity of our tools, some notes of caution in terms of the intended consequences of their use, and identify opportunities for further research.