Neira, VM - Using Simulation To Assess How Anesthesia Residents Prepare For A Disclosure Meeting

Can J Anesth/J Can Anesth (2014) 61:S1–S165
DOI 10.1007/s12630-014-0239-1
33101 - RANDOMIZED PROSPECTIVE TRIAL COMPARING TWO SUPRAGLOTTIC AIRWAY

DEVICES: I-GEL™ AND LMA- SUPREME™ IN PARALYZED PATIENTS
Author(s)
François Donati
Anesthesiology
Université de Montréal, Hôpital Maisonneuve-Rosemont
Role: Presenting Author
Louis-Pierre Poulin
Anesthesiology
Université de Montréal
Role: Primary Author
Co-Author(s)
Nikola Joly - Anesthesiology, Université de Montréal, Centre Hospitalier Universitaire de Montréal
(CHUM), Division hôpital Saint-Luc
Issam Tanoubi - Anesthesiology, Université de Montréal, Hôpital Maisonneuve-Rosemont
Pierre Drolet - Anesthesiology, Université de Montréal, Hôpital Maisonneuve-Rosemont
Introduction: Many features can influence the choice of a supraglottic airway device (SAD) such as
the ease of insertion, adequate ventilation pressures and lack of adverse effects. The goal of this
randomized prospective trial was to evaluate the performance of the I-gel™ and the LMA-Supreme™.
Methods: One hundred adult patients (ASA I-III) scheduled to undergo elective surgery under general
anesthesia were randomized either to an I-gel™ (n=50) or an LMA-Supreme™ (n=50). The primary
objective was to compare ventilation pressures. Secondary objectives included time and number of
trials needed to introduce the device, adverse effects and repositioning. Endoscopic view of the glottic
aperture and position of the drain tubes with regard to the oesophagus were also evaluated.
Results: Both devices were inserted successfully in 46 (92%) patients in both groups. There was no
significant difference in the leak pressure (I-gel™: 23 + 7 vs. LMA-Supreme™: 21 + 8 cmH2O; P =
0.14) or peak inspiratory pressure between both devices. Insertion time was shorter with the I-gel™
than with the LMA-Supreme™ (19 ± 7 vs. 27 ± 17 s; P = 0.003). The vocal cords were completely
visualized more often through the I-gel™ (70%) than through the LMA-Supreme™ (50%) (P = 0.007).
Oesophageal mucosa was easily visualized through the drain port in all patients but four, two in each
group. There was no difference between groups regarding peroperative or postoperative
complications. Postoperative patient discomfort was generally mild and comparable for both devices.
Conclusion: Both the LMA-Supreme™ and the I-gel™ offer similar performance for positive pressure
ventilation during general anesthesia. The I-gel™ was associated with a faster insertion time and
better fiberscopic visualization of the glottis, suggesting a more optimal alignment between the SAD
and ventilatory stuctures.
Registered clinical trial: Clinicaltrials.gov reference number NCT01001078
References:
Anaesthesia. 66(6):481-7. 2011
Anaesthesia. 65(12): 1173-9. 2010
Anaesth and Intensive Care. 38(6): 1018-22. 2010
BMC Anesthesiology. 12:18. 2012
British Journal of Anaesthesia. 109 (6): 996–1004. 2012
Anesth Analg. 114(1): 152-6. 2012
© Canadian Anesthesiologists’ Society 2014 13

S2 Abstracts
13
Abstracts S3
33356 - A MOBILE DEVICE APPLICATION: CALCULATIONS TO MANAGE OBESE PATIENTS
Author(s)
John H P. Friesen
Anesthesia and Perioperative Medicine
University of Manitoba
Role: Primary & Presenting Author
Introduction: Mobile devices, including smart phones and tablets, are ubiquitous in the operating
room and they have become essential point of care anesthesia equipment(1,2). They are also
increasingly important as educational tools (3). Following is a description of a mobile application that
performs and documents calculations used in the safe anesthetic management of obese patients(4). It
demonstrates an approach to the design of a useful, safe, and reliable cognitive aid.
Methods: Clinically important formulas were chosen from three areas of interest: weight scalars,
blood volumes, and risk for obstructive sleep apnea. Mathematical functions were coded in
JavaScript, and the user interface was written using CSS and active HTML5. The display was
optimized for use on smart phones and tablets. To create an app suitable for installation on mobile
devices, the program was then compiled using Adobe PhoneGap Build.
Results: The Figure is a screenshot of the Blood Volumes display screen. The “Menu” and “Input”
buttons navigate to the application’s menu screen and data input form respectively. Touching the
“Info” button displays information about the formulas and lists relevant references. Patient data
required for the calculations are shown beneath the navigation bar, and below that the calculated
values are displayed. The Weight Scalars screen uses a similar layout with identical navigation
buttons. The OSA Risk screen presents an interactive Stop-Bang questionnaire, again with an “Info”
button to show references and discussion.
Discussion: Obesity is a common and challenging perioperative problem(5). It lends itself to the use
of a cognitive aid because of the quantitative and mathematical nature of many of its effects on
anesthetic technique and safety. A point of care app can improve patient safety and promote
efficiency by eliminating the need to estimate several different quantities for each patient. The app
can perform all the computations with a single button press, and the output will then remain available
for the duration of the case. To be useful, an app must provide evidence of accuracy and reliability(6).
In this case, references to the medical literature are given for each formula or score. Primary sources
document the original descriptions. Selected secondary sources provide an entry to the literature and
facilitate critical appraisal of the available evidence. The app described here demonstrates a number
of calculations used in the anesthetic management of obese patients. It is clinically useful for patient
management in the operating room, and is also designed to act as a learning tool for students and
residents.
References:
1. Anaesthesia. 2011 66: 630-1
2. Postgrad Med J 2013 doi:10.1136/postgradmedj-2013-131930
3. Best Pract Res Clin Anaesthesiol 2012 26: 33-53
4. www.bigsleep.altervista.org
5. Can J Anesth 2012 59: 974-96
6. J Physician Assist Educ 2013 24: 38-40
13
S4 Abstracts
33770 - A RANDOMIZED TRIAL OF AMITRIPTYLINE VERSUS GABAPENTIN FOR

NEUROPATHIC PAIN IN CHILDREN
Author(s)
Stephen C. Brown, MD FRCPC
The Hospital For Sick Children
Co-Author(s)
Khush Amaria, PhD - Division of Adolescent Medicine, The Hospital for Sick Children
Fiona Campbell, MD FRCA - Dept of Anesthesia and Pain Medicine, The Hospital for Sick Children
Bradley Johnston, PhD - Dept of Anesthesia and Pain Medicine, The Hospital for Sick Children
Patricia McGrath, PhD - Dept of Anesthesia and Pain Medicine, Pain Innovations Inc
Introduction: Treatment of neuropathic pain and complex regional pain syndrome requires a
multimodal approach of pharmacologic, physical, and psychological therapies. While amitriptyline and
gabapentin are our front line drugs for treating neuropathic pain, no studies have yet compared them
directly to determine which drug might be better for relieving pain, disability and sleep
disturbances(1,2).Our primary study objective was to compare the efficacy of gabapentin and
amitriptyline for treating neuropathic pain in children in a randomized controlled trial (RCT).
Secondary objectives were to evaluate changes in children’s disability and sleep.
Methods: REB ethical approval was obtained prior to study initiation and patient consent/ascent was
obtained prior to commencemnt of each drug trial. Eligible participants ranged from 8 to 17 years of
age. Diagnosis of neuropathic pain (pre 2011 NP classification) was made at The Hospital for Sick
Children’s Chronic Pain Clinic. Electrocardiograms were performed on all patients prior to study to
rule out conduction abnormalities. Patients were prescribed a regimen of pharmacologic, physical,
and psychological therapy. Patients received either gabapentin (300 mg tid) or amitriptyline (10 mg
qhs) with capsules matched for size and dosing regimen matched with appropriate placebos for a 6-
week, triple-blind (patient, physician, data analyst) RCT. Patients completed weekly interviews to
obtain outcomes and attended an in-hospital interview at 6 weeks. Primary outcome was a change in
usual (i.e., past week) pain intensity from baseline to 6-weeks as measured by an 11-point Colored
Analog Scale (3).
Results: Thirty-four patients (82% female) were randomized to amitriptyline or gabapentin. Two
patients allocated to the amitriptyline group were ineligible due to a contraindicated condition
identified at start of trial. Three participants were discontinued from gabapentin and amitriptyline
groups (2 and 1, respectively) due to adverse events deemed unrelated to study medications. The
primary analysis was based on 29 patients having completed the study. Mean pain intensity at
baseline was comparable for 2 groups: 6.5±1.4 for amitriptyline and 5.3±2.6 for gabapentin. At the
end of the 6-week trial, mean usual pain intensity was 5.0±3.0 for amitriptyline (a difference of -1.5
from baseline) and 3.3±2.4 for gabapentin (a difference of -2.0 from baseline). Usual pain scores did
not differ significantly between groups (p > .05, independent sample t-tests).
Discussion: Based on our data, our standard dose of amitriptyline and gabapentin are effective in
reducing usual pain intensity ratings in a 6 week trial for children and adolescents with neuropathic
pain.
References:
1. Dworkin et al (2010). Recommendations for the pharmacological management of neuropathic pain:
an overview and literature update. Mayo Clinic Proceedings, Mar;85(3 Suppl):S3-14.
2. IASP (2010) Pharmacological Management of Neuropathic Pain. Pain Clinical Updates, Vol. XVIII,
Issue 9.
3. McGrath PA, Seifert CE, Speechley KN, Booth JC, Stitt L, Gibson MC. A new analogue scale for
assessing children’s pain: an initial validation study. Pain. 1996; 46:435-443.
13
Abstracts S5
33877 - ULTRASONOGRAPHY FOR URGENT VISUALIZATION OF SPINAL CANAL ANATOMY
Author(s)
Muhammad Ajmal, MBBS, DA
Dept. of Anesthesia, Coombe Women and Infants University Hospital, Dublin, Ireland
Disclosure:
Co-Author(s)
John Loughrey, FFARCSI – Dept. of Anesthesia, Rotunda Hospital, Dublin, Ireland
Introduction: This is something the experts may disagree upon whether reassuring sonoanatomy of
1, 2
the spinal canal is enough to warrant epidural placement when a patient gives a history of spinal
3
canal problem such as spina bifida occulta in an acute care setting? Spina bifida occulta although is
not a contraindication for epidural placement but enhances the risk of inadvertent dural puncture or
neurological injury in case of a tethered spinal cord. In this case report we highlight the role of
ultrasonographic images to facilitate decision making for epidural placement in an obstetric acute care
setting where a woman provided a history of spina bifida occulta.
Case description: A 33-year-old primigravida requested analgesia for her labor pains. Her labor was
anticipated to be highly painful and prolonged. Augmentation of labor with oxytocin was planned.
There were no clinical abnormalities present, but based on a lumbosacral radiograph taken 10-year
prior, the patient had provided a history of spina bifida occulta during her antenatal visit. Although an
anesthesia-clinic appointment was scheduled for assessment, she missed that appointment and now
presented in labor to the labor ward. At this stage, an urgent radiological assessment of her vertebral
canal was not possible. Remifentanil patient-controlled-analgesia (PCA) could have been available
but given the parturient’s characteristics, epidural analgesia was the best choice of treatment for her.
After discussing the case and having obtained written informed-consent, an ultrasonographic
assessment of her lumbosacral vertebral canal was performed. The sonoanatomy in “paramedian
sagittal oblique” plane showing lumbar vertebral arches and in “transverse median” plane showing
thecal sac (1& 2 in Fig. A) was essentially normal. The depth of epidural space from the intended
skin puncture point at L4 – L 5,measured using ultrasonography, was 3.95 cm. An epidural catheter
was placed at L4-L5 using 18 G Tuohy needle; the loss of resistance was encountered at 4 cm from
skin and 5 cm of the catheter was left in the epidural space. The epidural analgesia was effective and
did not cause any adverse consequences. Two months later, the only abnormality involved prominent
degenerative changes at L5-S1 with a moderate-sized broad-based disc bulge that was abutting the
thecal sac centrally [1, Fig. B]. A follow-up magnetic resonance imaging (MRI) [Fig. B] revealed
lumbosacral transitional anatomy (lumbarization of S1) and no spina bifida occulta.
Discussion: MRI is the gold standard to assess spinal canal anatomy. However, in this parturient in
the acute care setting and with radiologically unassessed spinal canal problem, the bed-side
assessment of lumbosacral sonoanatomy reassured anesthesiologist to a great extent. Measuring
the depth of epidural space during pre-procedure scanning further enhanced the confidence of the
anesthesiologist.This discourse promoted the use of epidural analgesia instead of choosing
4-6
Remifentanil PCA as an alternate analgesia-technique .
References:
1. Anesthesiology 2011; 114: 1459-85
2. BMJ 2013; 346: f1720
3. Anaesthesia 1988; 43: 867-69
4. Anaesthesia 2013; 68: 283-87
5. Anaesthesia 2012; 67: 538-40
6. Anaesthesia 2013; 68: 231-35
13
S6 Abstracts
13
Abstracts S7
36359 - CEREBRAL OXIMETRY FOR CESAREAN DELIVERY IN A CASE OF MOYAMOYA

DISEASE
Author(s)
Muhammad Ajmal, MBBS, DA
Anesthesia
Dept. of Anesthesia, Coombe Women and Infants University Hospital, Dublin, Ireland
Co-Author(s)
Patrick Thornton, FCAI - Dept. of Anesthesia, Rotunda Hospital, Dublin, Ireland
Introduction: Abnormalities in intracranial blood vessels predispose Moyamoya disease patients to

1
frequent ischemic and hemorrhagic strokes . Hemodynamic instability and the vascular response to
anesthesia further increase this risk. We report cerebral oxygen saturation (rSO2) observations using
non-invasive near infrared spectroscopic (NIRS) cerebral oximetry during a cesarean delivery (CD)
under combined spinal epidural (CSE) anesthesia in a Moyamoya case.
Case description: A 30-yr old, pre-obese [BMI 27.3] G1P0 woman diagnosed with Moyamoya
disease at the age of 11 years was scheduled for an elective CD at 37 weeks gestation. The patient
had suffered from ischemic and hemorrhagic strokes in the past. She had been epileptic since the
diagnosis of Moyamoya and experienced frequent headaches during pregnancy due to her disease.
The specific monitoring used during her CD involved invasive blood pressure recording and
noninvasive NIRS cerebral oximetry. A low-dose intrathecal injection of 8 mg of heavy bupivacaine
using CSE was sufficient to achieve an optimum block. The minor hemodynamic instability was
treated with boluses of phenylephrine. An intravenous bolus of 5 i.u. oxytocin at a volume of 5 ml was
injected over the span of one minute immediately following the delivery. Her rSO2 remained normal
[60-75%] and was relatively higher after the delivery [See fig. below]. She remained comfortable and
calm during the procedure and did not suffer from any complication due to her Moyamoya disease.
Discussion: The clinical cerebral monitoring was supplemented by continuous rSO2 measurements
using NIRS. This noninvasive cerebral oximetry measures the rSO2 in brain tissue in the area of
2
interest and is an indirect measure of the cerebral perfusion in that area . The normal range of rSO2 is
60-75%. NIRS cerebral oximetry is frequently used in procedures such as carotid endarterectomy and
cardiopulmonary bypass surgeries but its use in obstetrical anesthesia is less common. NIRS has
3
been used in a Moyamoya parturient previously, however only for a portion of the cesarean delivery .
We began measuring the patient’s rSO2 as soon as she arrived in the operating room. We applied
cerebral oximeter over the frontal lobes of our patient because she had suffered from frontal lobe
infarctions in the past. The increase in rSO2which was observed following delivery and administration
of oxytocin was observed with no changes in the hemodynamics of the patient. We postulate that it
may be as a result of vasodilatory effects of oxytocin on the cerebral circulation [See Fig.
below]. Oxytocin leads to dilatation or constriction in a myriad of blood vessels. It has a vasopressin-
like weak vasoconstrictive effect, and some reports suggest that it may reduce cerebral blood
4 5
flow (CBF), although other articles suggest an increase in CBF in experimental animals . The rSO2
6
monitoring in obstetric anesthesia is currently scarce . We propose that rSO2 should be monitored in
Moyamoya patients undergoing anesthesia, particularly when oxytocin is administered.
References:
1. N Engl J Med 2009; 360: 1226-1237
2. Curr Opin in Anaesthesiol 2010; 23: 576-581
3. Br J Anaesth 1996; 77: 550-552
4. Regul Pept.1996 62: 37-39
5. J Neurosurg 1992; 77: 424-431
6. Can J Anesth 1994; 41: 79-80
13
S8 Abstracts
13
Abstracts S9
36942 - ABDOMINAL COMPARTMENT SYNDROME IN A SEVEN YEAR OLD MALE TRAUMA

VICTIM
Author(s)
Cameron Goldie, M.D.
Caleb Zelenietz, M.D.

Department of Anesthesia and Perioperative Medicine
Introduction: Abdominal compartment syndrome (ACS) is a life threatening entity in critically ill
patients. Over the past decade there has been increasing awareness of ACS in trauma patients after
1,2
resuscitation . ACS in adults is defined as a sustained intra abdominal pressure (IAP) greater than
1
20 mm Hg that is associated with new organ dysfunction or failure . In children, ACS is defined as "a
sustained IAP greater than 10 mm Hg with new or worsening organ dysfunction that can be attributed
1
to elevated IAP" . The normal range of IAP in critically ill children is 4-10 mm Hg. ACS has multiple
1
risk factors, including major trauma, shock and resuscitation . The World Society of the Abdominal
Compartment Syndrome published definitions, diagnosis and treatment recommendations in 2013.
They propose an algorithmic approach to the management of ACS that weakly recommends (grade
2D) decompressive laparotomy in adults suffering from ACS, along with treating the underlying
etiology and optimizing the perfusion of intra-abdominal organs. Specific paediatric recommendations
for the treatment of ACS include the use of decompressive laparotomy, paracentesis for fluid removal,
negative pressure wound therapy to facilitate abdominal closure and attempted avoidance of a
1,3
positive cumulative fluid balance in at risk patients . The incidence of ACS after trauma and the
frequency of leaving the abdomen open after trauma laparotomy may be declining due to the
4
decreased amount of crystalloid resuscitation .
Discussion: Consent for this case report was obtained within the guidelines of our local ethics review
board. We describe the case of a 30 kg seven year old male, with no past medical history. He injured
his right leg by sliding into a functioning grain auger on a farm in a rural area. Nearly 6 hours later, he
underwent emergent above-knee amputation (AKA) at our tertiary care paediatric hospital. In total, he
received 100 mL/kg of intravenous fluids (IVF) prior to surgery, 30 mL/kg of red blood cells and 73
mL/kg of crystaliod. Hemodynamics worsened at the conclusion of the AKA in spite of repeated IVF
boluses. Intra-abdominal hemorrhage was suspected based upon multiple clinical findings and the
general surgery service was consulted intra-operatively. Laparotomy was performed in the context of
unstable hemodynamics. No intra-abdominal pathology was identified. Hemodynamics improved
once the laparotomy was performed. In total, he received 50 mL/kg of red blood cells, 50 mL/kg of
crystalloid, and 17 mL/kg of volulyte IVF intra-operatively. Post-operative intravesicular pressures
were 13 - 14 mmHg, but end organ function was preserved, so no further action was taken.
Conclusions: Abdominal compartment syndrome is a life threatening condition often associated with
critical illness. Prompt diagnosis and treatment is necessary to avoid its sequelae.
References:
1) Intensive Care Med 2013 39:1190–1206
2) J Trauma (2003) 54:848 –861
3) Surg Clin N Am 2012 92:207–220
4) J Trauma Acute Care Surg 2014 epub ahead of print
13
S10 Abstracts
36987 - VALIDATING PATIENT SELF-REPORT TOOL IN PREOPERATIVE TRIAGE
Author(s)
Jeremy Russell Neufeld, BSc, MD
Anesthesiology
The Ottawa Hospital
Co-Author(s)
Jennifer Wilson, MD - Anesthesiology, The Ottawa Hospital
Sylvain Gagne, MD, FRCPC - Anesthesiology, The Ottawa Hospital
Homer Yang, MD, FRCPC - Anesthesiology, The Ottawa Hospital
Monica Taljaard, PhD - Clinical Epidemiology Program, Ottawa Hospital Research Institute
Mary-Lou Crossan, BA, Medical Laboratory Technologist - Laboratory Medicine, The Ottawa Hospital
Introduction: Preoperative screening tools relying on patient self-reported comorbidities are being
1, 2, 3, 4
used in many institutions to help streamline pre-anesthetic care . With multi-disciplinary input, we
designed a questionnaire that, in another study, was shown to have a high level of agreement
between patient self-reported comorbidities and those reported by anesthesiologists. Our study aims
to validate the ability of this tool to appropriately triage patients into one of three pre-op assessment
streams so that it can be used to better allocate resources in the Pre Anesthetic Unit (PAU).
Methods: After obtaining local ethics board approval, 895 patients coming for elective non-cardiac
surgery in June-December 2013 were selected as a convenience sample for our prospective
observational study. Inclusion criteria were: 18 years of age or older, elective non-cardiac surgery not
deemed to be high risk, and reading and writing competency in one of the official languages. Based
on 57 possible comorbidities on the completed tool the patients were triaged into nursing telephone,
nursing visit in person or anesthesiologist consult, which was deemed the highest level of
assessment. This information was recorded on Form 1. Form 2 was placed in the patient chart for the
anesthesiologist performing the anesthetic to provide their triage opinion and rationale prior to the
induction of anesthesia. We calculated the rates of upgraded and downgraded visits, as well as the
sensitivity and specificity of the questionnaire in correctly classifying patients requiring anesthesia
consult, together with 95% confidence intervals (CI).
Results: Of the 895 screened patients, 16 did not meet the inclusion criteria. 114 anesthesiologists
participated, including 90 staff and 24 residents. Of the Form1-Form2 pairs, 385 (43.8%) were
complete; 487 (55.4%) had a blank or missing Form 2; 6 (0.68%) were missing Form 1; and 1 surgery
was cancelled. The results are recorded in Table 1. No adverse events or critical incidents were
reported in any of the patients that anesthesiologists recommended be upgraded or downgraded. The
sensitivity of the questionnaire in identifying patients who require anesthesia consult was 89.9% (95%
CI 85.7%-94.1%) and the specificity was 79.0% (95% CI 73.2%-84.9%).
Discussion: This study demonstrated that our tool can be used to help triage patients coming for
elective non-cardiac surgery into the appropriate assessment stream. In particular, it can identify
patients who require anesthesia consult with high probability (90%) and rule out those who do not
(nearly 80%). In the majority of cases the anesthesiologist agreed with the tool triage classification.
Common reasons for upgrade were difficult airway and uncontrolled respiratory disease. Downgrades
were most frequently suggested for patients presenting with well controlled chronic disease (i.e.
diabetes). This information will help guide future improvement of our tool and improve the efficiency of
the PAU.
References:
1. Can J Anaesth. 1998; 45:87–92
2. Journal of Arthroplasty. 2012; 27(10):1750-1756
3. Anaesthesia & Intensive Care. 2012; 40(2):297-304
13
Abstracts S11
4. Anaesthesia. 2003; 58 (9), pp. 874-877

13
S12 Abstracts
36990 - PERIOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY AS AN ADJUNCT TO

ANGIOGRAPHY DURING THE DEPLOYMENT OF AN ENDOVASCULAR AORTIC GRAFT
THROUGH AN EMBOLISED TRANSCATHETER TRANSAPICAL AORTIC VALVE IMPLANT
Author(s)
Marie-Jo Plamondon, MDCM FRCPC
Anesthesiology
University of Ottawa
Co-Author(s)
Sudhir Nagpal, MD FRCSC FACS - Surgery, Division of Vascular Surgery, University of Ottawa
Mireille Méthot, MD FRCSC - Surgery, Division of Vascular Surgery, University of Ottawa
Jordan Hudson, MD FRCPC MPH - Anesthesiology, University of Ottawa
An 83 year-old woman with significant comorbidities underwent an elective TAVI (transapical aortic
valve implant) procedure due to severe aortic stenosis. The procedure was complicated by
embolisation of the new prosthetic valve into the aorta. Initially, the valve was positioned too high
above the annulus, and was deemed unstable with moderate paravalvular leaks. As the left
ventricular apex was being closed, the valve embolised into the ascending aorta. There was then
severe transvalvular and paravalvular regurgitation. At that point the cardiac team proceeded to the
cardiac operating room for an emergent aortic valve replacement. The embolised valve migrated into
the descending aorta, becoming lodged just below the diaphragm and 3cm above the celiac artery.
The valvular leaflets remained closed and were facing the direction of the blood flow causing
significant stenosis of the descending aorta, but paravalvular flow remained. Within 24 hours it was
decided to bring the patient to the main operating room for urgent repair of the descending thoracic
aorta.
She was transported to the main OR (intubated, on Milrinone and Norepinephrine). The
transesophageal echocardiography (TEE) examination revealed an embolised #23 Edwards Sapien
XT valve with the 3 leaflets closed facing the aortic blood flow (Figure 1a). A small jet of blood was
visible around the valve mainly on its posterior left side. TEE became a useful adjunct to angiography
for accurate visualization of the guide wires within the valve. It was difficult to confirm with certainty
the position of the wires solely based on angiography. After deployment of the first Palmaz stent, TEE
demonstrated that the leaflets were still partially closed. A second Palmaz stent was deployed just 1-
2mm below the prosthetic valve but encompassing its lower edge. At that point TEE was used to
confirm that no residual closed leaflets could be seen. Once the deployment completed, flow within
the new lumen was assessed by both angiography and TEE and was found to be adequate (Figure
1b).
This case report illustrates how important TEE can be as an adjunct monitor in complex endovascular
cases. As reported by Swaminathan & al., “transesophageal echocardiography has been found to be
a valuable imaging tool for guiding placement of the endograft, detecting leaks around the endograft,
(1)
and supplementing information derived from angiography during endograft deployment” . TEE is
(2)
useful for guidewire positioning. Rocchi et al have developed an algorithm into which stent
implantation procedures can be altered based on the transesophageal echocardiography results. With
growing evidence of superiority of transesophageal echocardiography in comparison with
(3)
angiography, it has become common practice in our institution to use TEE in addition to
angiography for monitoring in complex endovascular cases.
References:
1. The importance of intraoperative transesophageal echocardiography in endovascular repair of
thoracic aortic aneurysms. Swaminathan M, Lineberger CK, McCann RL, Mathew JP.Anesth
Analg. 2003 Dec;97(6):1566-72.
2. Transesophageal echocardiography-guided algorithm for stent-graft implantation in aortic
dissection. Rocchi G, Lofiego C, Biagini E, Piva T, Bracchetti G, Lovato L, Parlapiano M, Ferlito
M, Rapezzi C, Branzi A, Fattori R. J Vasc Surg. 2004 Nov;40(5):880-5.
3. How to guide stent-graft implantation in type B aortic dissection? Comparison of angiography,
transesophageal echocardiography, and intravascular ultrasound. Koschyk DH, Nienaber CA,
Knap M, Hofmann T, Kodolitsch YV, Skriabina V, Ismail M, Franzen O, Rehders TC, Dieckmann
C, Lund G, Reichenspurner H, Meinertz T. Circulation. 2005 Aug 30;112(9 Suppl):I260-4.
13
Abstracts S13
13
S14 Abstracts
36993 - POSTOPERATIVE OUTCOME OF PATIENTS WITH KNOWN OBSTRUCTIVE SLEEP

APNEA
Author(s)
Eugene KH. Choo, MD
Anesthesiology
Co-Author(s)
Claudia Gomez, MD - Anesthesiology, The Ottawa Hospital
Gregory L. Bryson, FRCPC, MSc - Anesthesiology, The Ottawa Hospital
Introduction: The ASA Clinical Practice guidelines on the perioperative management of patients with
obstructive sleep apnea (OSA) suggest that patients with OSA are at high risk of perioperative apneic
events and recommend they be monitored until they are no longer at risk (1). Guidance regarding
duration of monitoring and use of constant positive airway pressure (CPAP) is vague. In June 2003,
our institution introduced a protocol for the post-operative care of patients with diagnosed OSA.
Patients diagnosed with OSA were monitored for a four-hour period following surgery. Those treated
with CPAP were discharged to unmonitored wards, including those prescribed neuraxial opioids, if
monitoring was uneventful. Patients non-compliant, or unable to use CPAP and those experiencing
respiratory events during the monitored interval remained in a monitored setting overnight. The aim
of this study was to document the outcomes of inpatients managed under this protocol.
Methods: Ethics board approval was obtained for this retrospective cohort study. Database analysts
identified all patients who underwent elective inpatient surgery between 2003.07.01 and 2012.03.31
who had previously undergone polysomnogram (PSG) testing at our institution. Records for airway
surgery and procedures involving the surgical treatment for OSA were excluded. PSG reports were
reviewed and OSA severity documented. In-hospital mortality and hospital length of stay were
abstracted from administrative records. Inpatient records were reviewed manually to document
patient, surgical and anesthetic characteristics. The use of high-dependency units (HDU), calls to the
ICU outreach (RACE) team, post-operative complications, and compliance with CPAP was also
recorded.
Rate of in-hospital mortality and number of RACE calls between patients with PSG confirmed and
absent OSA was estimated using the method of penalized likelihood (Firth's method). For planned
and unplanned HDU admission, standard multivariable logistic regression analysis was used.
Results: A total of 1586 subjects were included in the final analysis. 662 subjects (41.7%) did not
have OSA based on PSG testing; leaving 924 (58.3%) with PSG confirmed OSA. Of the subjects with
OSA, 281 subjects (17.7%) had mild OSA, 233 (14.7%) had moderate OSA, 335 (21.1%) had severe
OSA and 75 (4.7%) had OSA of unknown severity. There were no significant differences in in-
hospital mortality (OR 0.78, 95% CI 0.06 to 9.6), unplanned HDU admission (OR 1.05, 95% CI 0.56 -
1.99), or RACE team calls (OR 1.19, 95% CI 0.57 to 2.6) among those with OSA. Length hospital stay
(HR 1.06, 95% CI 0.98 to 1.14) was similar in those with and without OSA. Planned HDU admissions
for overnight monitoring (OR 1.88, 95% CI 1.35 to 2.6) were significantly more frequent in those with
OSA.
Discussion: Patients with known sleep apnea undergoing inpatient surgery, managed under our
institutional OSA protocol, did not experience an increased rate of mortality, morbidity, or
unanticipated use of critical care resources.
References:
1. Anesthesiology 2013 120: 00-00 (ahead of print)
13
Abstracts S15
37002 - MALIGNANT HYPERTHERMIA (MH) TESTING IN PROBANDS WITHOUT MH-REACTION
Author(s)
Sheila Riazi, MSc, MD
Anesthesia
University Health Network
Co-Author(s)
Carly Sterling - Anesthesia, University Health Network
Henry Rosenberg, MD - Anesthesia, Saint Barnabas Medical Center, Livingstone, New Jersey, United
States
Natalia Kraeva, PhD - Anesthesia, University health network
Introduction: Malignant hyperthermia (MH) is characterized by an adverse reaction to volatile

anesthetic, and /or succinylcholine. Typically, following an adverse anesthetic reaction or positive
1
family history, patients will undergo caffeine-halothane contracture (CHCT) and/ or genetic testing.
However, sometimes patients with no individual or family history of anesthetic reaction are referred for
MH testing due to a variety of reasons. The objective of our study was to investigate reasons for
referrals in non-anesthetic cases, and assess their phenotype.
Methods: Following institutional research ethics board approval, all the CHCT-tested probands at our
center were identified. Patients with anesthetic reactions were excluded. Reasons for referrals,
baseline CK, genetics results, histopathology were analyzed and compared between patients with
positive and negative CHCT results. Response to dantrolene among patients with positive CHCT was
also assessed. Wilcoxon rank sums test, and fisher’s exact test were used for numerical, and
categorical parameters, respectively.
Results: Between 1992-2012, 152 referred probands from total of 525 were identified with no
anesthetic reaction. Among these, 104 (68.4%) had positive CHCT. Reasons for referrals included
unexplained high creatine kinase-CK (N=77, 50.6%), post viral chronic fatigue (N=63, 41.4%), post-
exercise rhabdomyolysis (N=12, 7.9%), and heat stroke (N=1, 0.6%). Fifty-nine patients with high CK
(76.6%), and thirty -six patients with post-viral chronic fatigue (57.1%) had positive CHCT based on
the standardized North American CHCT test protocol. The viral illness included influenza, Epstein-
Barr, and cytomegalovirus. The fatigue was defined as muscle pain, weakness, and cramps,
interfering with functional ability, lasted more than three months after the onset of viral illness. Mean
CK levels (IU/L) were significantly higher in the group with positive CHCT (687.5 vs 321.3, p=0.013).
Thirty-eight (36.5%) patients, all belonging to positive CHCT group, had abnormal histomorphology,
including 9 patients with central core (CCD), and multi-minicores. Of all patients with positive CHCT,
only 3 carried causative mutations in Ryanodine receptor-I (RYR-I). Two of these were referred for
unexplained high CK, and one was referred for exercise-induced rhabdomyolysis. Forty patients with
positive CHCT (38.4%) were given oral dantrolene, in which 30 (75.0%) responded with improvement
of musculoskeletal symptoms, and reduction in CK, half of these patients were referred for post-viral
fatigue symptoms
Discussion: MH susceptibility as confirmed by the caffeine halothane contracture test may

predispose patients to a variety of non anesthetic induced muscle abnormalities. The results support
the contention that MH maybe more than an anesthetic disorder but should be interpreted in the
context of the limitations of the sensitivity of the CHCT.
References:
1- Glahn KP, Ellis FR, Halsall PJ, Müller CR, Snoeck MM, Urwyler A, Wappler F. European Malignant
Hyperthermia Group. Recognizing and managing a malignant hyperthermia crisis: guidelines from the
European Malignant Hyperthermia Group. Br J Anaesth. 2010 Oct;105(4):417-20.
13
S16 Abstracts
13
Abstracts S17
37035 - INDIVIDUALIZED BLOOD MANAGEMENT IN CARDIAC SURGERY USING A POINT-OF-

CARE BASED TRANSFUSION ALGORITHM
Author(s)
Debashis Roy
Resident
Department of Anesthesiology
University of Toronto
Co-Author(s)
Tarik Timoumi, MD - Anesthesiology, Université Paris Diderot-Paris
Cielo Bingley, RN - ONTraC, University of Toronto
Rafiq Kanji, MBChB - Medical Student, Keele University
Stuart McCluskey, MD - Anesthesiology, University of Toronto
Rita Selby, MD - Department of Laboratory Medicine & Pathobiology, University of Toronto
Vivek Rao, MD - Department of Cardiac Surgery, University of Toronto
Keyvan Karkouti, MD - Department of Anesthesiology, University of Toronto
Introduction: Coagulopathy leading to excessive blood loss, blood product transfusion, and adverse
1,2
outcomes is a major complication of cardiac surgery with cardiopulmonary bypass. Current
management of coagulopathic bleeding relies on conventional coagulation testing that have long
3
turnaround times and are not able to detect important coagulation defects such as fibrinolysis,
4
platelet dysfunction, or specific factor deficiencies. These shortcomings hamper management,
forcing clinicians to delay therapy until the results become available or resort to empiric therapy based
on their clinical judgment. These strategies are inefficient and potentially harmful because they can
lead to underuse of blood products in some patients, leading to excessive blood loss and possibly re-
2,5
exploration, and to overuse of blood products in others. Individualized blood management using a
transfusion algorithm that employs point-of-care coagulation tests may alleviate these problems.
Methods: An integrated transfusion algorithm (Figure) that employed viscoelastic (ROTEM) and
aggregometric (Platelet Works) point-of-care tests, as well as an objective measure of blood loss, was
incorporated into routine practice at our hospital on January 2013. Following REB approval, we
retrospectively compared the transfusion and clinical outcomes of patients operated from January to
July 2013 (post-algorithm) to those operated on during 2012 (pre-algorithm), using multivariable
Poisson regression (with robust confidence limits) to adjust for baseline differences.
Results: Patients had similar characteristics pre- and post-algorithm. Incorporation of this algorithm
into routine practice was associated with a significant (P < 0.0001) reduction in blood transfusion
rates. Red blood cell transfusions decreased by 12% (from 52% pre-algorithm to 40% post-algorithm),
platelet transfusions decreased by 15% (from 34% to 19%), and plasma transfusions decreased by
21% (from 34% to 13%). Post-algorithm, there was also significant improvement in clinical outcome
such as re-exploration rate (P-0.001), major blood loss (P<0.0001), refractory coagulopathy (P-0.002)
and acute kidney injury (P-0.008). Nadir and discharge hemoglobin concentrations were similar,
suggesting that reduced transfusions were not due to a more restrictive transfusion strategy.
Conclusion: Individualized blood management using transfusion algorithm that employs point-of-care
coagulation tests can reduce transfusions and improve outcomes. Whether these results are
generalizable to other centres, however, needs to be determined.
References:
1. Scand Cardiovasc J. 2012; 46: 194-202
2. Transfusion. 2008; 48: 2S-30S
3. Thromb Haemost. 2009; 101(2):394-401.
4. Br J Anaesth. 2012; 108(1):36-41
5. Br J Anaesth 2004; 92: 178-86
13
S18 Abstracts
13
Abstracts S19
37047 - SIMULATION AND THE MAINTENANCE OF COMPETENCE IN THE ANESTHESIOLOGY

– A SYSTEMATIC REVIEW
Author(s)
Purva Kristina. Khanduja, MBChB FRCA FRCPC MEd(c)
Department of Anesthesia
Mount Sinai Hospital
Co-Author(s)
M. Dylan Bould , MBChB MEd - Department of Anesthesia, University of Ottawa
Viren Naik, MD MEd - Department of Anesthesia, University of Ottawa
Emily Hladkowicz, BA - The Ottawa Hospital Research Institure, The Ottawa Hospital Research
Institute
Sylvain Boet, MD MbChb - Department of Anesthesia, University of Ottawa
Introduction: In an era of growing public demand for the provision of high quality care and
accountability, guidelines for continuing medical education are under constant review. The primary
objective of our systematic review was to determine whether simulation-based education (SBE), in
isolation or combined with alternative educational strategies, is an effective learning strategy
independent practitioners in anesthesiology relative to Kirkpatrick’s model of educational outcomes.
Our secondary goal was to describe the current use of simulation-based performance assessment.
Methods: A systematic search of online databases (MEDLINE, EMBASE, PubMed, CENTRAL, and
st
CDSR) was conducted to include studies published from 1948 (MEDLINE) until January 31 , 2013.
All original research describing SBE for attending anesthesiologists was considered eligible for
inclusion. Data analysis and extraction was carried out independently by two authors with further
review by a third author in cases of disagreement until consensus was reached. For simulation-based
performance assessment, tool characteristics and sources of validity evidence were collated.
Results: Of 1963 studies screened, 22 studies met inclusion criteria. Only 8 studies recruited
independent practicing anesthesiologists as their sole target group highlighting that this population
remains understudied.
Fifteen studies described the effectiveness of SBE (see table 2).
With the exception of studies employing survey-based methodology, the effectiveness of SBE was
evaluated in the simulated setting in 8 instances.
Over two thirds of studies identified reported a positive effect on learning. All surveys describing the
learner’s reaction and self-perceived impact on subsequent clinical practice reported high satisfaction
scores with associated improved preparedness and/or performance.
Seven studies reported the psychometric properties of simulation-based performance assessment as
their sole objective. These predominantly recruited Anesthesiologists as a convenience sample to
establish discriminative validity and concentrated on a single aspect of validity evidence.
Conclusions: Anesthesiologists perceive simulation as a positive experience with self-reported

impact on performance in a wide variety of clinical settings. Limited evidence suggests that SBE is
associated with improved learning both immediately and in the longer-term when compared to no
other intervention.
Few studies compared participation in SBE with other educational strategies. This limits our ability to
comment on the effectiveness of simulation when compared to alternative, non-simulation-based
CME activities.
Although simulation-based assessment appears to discriminate between experienced and
inexperienced practitioners, none of the studies identified specifically examined different aspects of
construct validity or performance standards for experienced practitioners.
Future research in this area should focus on the optimal modality and frequency of exposure, quality
of assessment tools and the impact of simulation-based educational interventions beyond the
individual towards improved patient safety.
13
S20 Abstracts
References:
(1) Gallagher CJ, Tan JM. The current status of simulation in the maintenance of certification in
anesthesia. Int Anesthesiol Clin 2010;48(3):83-99.
(2) Bashook PG, Parboosingh J. Recertification and the maintenance of competence. BMJ
1998;316(7130):545-548.
(3) McGaghie WC, Siddall VJ, Mazmanian PE, Myers J. Lessons for continuing medical education
from simulation research in undergraduate and graduate medical education: effectiveness of
continuing medical education: American College of Chest Physicians Evidence-Based Educational
Guidelines. Chest 2009;135(3 Suppl):62S-68S.
(4) Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of
high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach
2005;27(1):10-28.
13
Abstracts S21
37079 - VALIDATION OF A PREOPERATIVE SELF-REPORT COMORBIDITY QUESTIONNAIRE
Author(s)
Jennifer LC. Wilson, MD
Homer Yang, MD, CCFP, FRCPC

The Ottawa Hospital
Co-Author(s)
Jeremy Neufeld, MD - Department of Anesthesiology, University of Ottawa
Sylvain Gagne, MD, FRCPC - Department of Anesthesiology, The Ottawa Hospital
Barbara Crawford-Newton, RN, BScN, MA, CNCC(C) - Pre-Admission Unit, The Ottawa Hospital
Jeremy Grimshaw, MBChB, PhD, FRCGP, FCAHS - Department of Medicine, Ottawa Hospital
Research Institute
Introduction: Growing resource limitations coupled with an ongoing increase in medically complex
patients requires a cost-effective Pre-Admission Unit (PAU) process to ensure health care
sustainability. Recently, a self-reported health history questionnaire was implemented at our
institution as a required preoperative component for all elective non-cardiac surgery patients. The
questionnaire aims to accurately capture patient comorbidity and assist in triaging patients to the most
appropriate PAU assessor (RN versus MD). Evidence regarding the validity of self-reported patient
1, 2, 3
comorbidity is limited . The objective of our study was to determine the concordance between 40
self-reported patient comorbidity responses on this questionnaire, and the PAU Anesthesiologist’s
assessment as recorded in the medical record.
Methods: In November of 2012, 1741 patients underwent elective surgeries at our

institution. Following local ethics committee approval, a representative sample of 450 cases were
selected to review, using computer-generated random numbers. To be eligible for review, patients
had to be: 18 years of age or older; attending their first PAU visit; require an elective surgical
procedure; and, be competent to read and write in an official language. On the questionnaire, patients
were required to report the presence or absence of 40 comorbidities. To measure agreement, where
neither the patient nor physician report was considered the gold standard, we calculated overall
agreement and kappa statistics.
Results: The sample consisted of 196 males (44%), mean age 56.6 (SD 16.2 years), mean BMI 33
(SD 8), and mean of 3 (SD 2) comorbidities. The most frequent surgical specialties included were:
orthopedics, general, urology, gynecology, otolaryngology, vascular and neurosurgery. Kappa values
measuring agreement between self-report and physician assessment ranged from 0.09 to 1.00
(median 0.79), and were classified as "almost perfect", "substantial", "moderate", "fair", or "slight",
4
based on standard cutpoints defined in the literature . Table 1 summarizes the results for all
comorbidities considered. We found substantial or better agreement on 27 of the 40
comorbidities. Overall, the kappa for the entire questionnaire was 0.73, representing substantial
agreement.
Discussion: The results of this study indicate that our self-reported health history questionnaire has
acceptable agreement with most physician-defined conditions. Agreement was particularly strong for
diseases that are well defined, such as organ transplantation and implantable cardiac rhythm devices,
or severe diseases that require ongoing care like chronic renal failure requiring necessitating dialysis.
The use of this questionnaire represents an efficient and cost-effective way to accurately capture
patient comorbidities prior to their PAU visits. Future study is required to evaluate the appropriateness
of using this patient questionnaire to triage patients to the most appropriate PAU assessor.
13
S22 Abstracts
References:
1. J Arthroplasty 2012 27:1750-1756
2. Arthritis Rheum 2003 49:156-63
3. Neuroepidemiology 2010 35:83-90
4. Biometrics 1977 33:159-174
Table 1. Summary of agreement between self-report and physician assessment. *indicates perfect
agreement.
Agreement (Kappa) Total Comorbidities

(n=40)
Almost perfect (0.81-1.00) 18 Dialysis*, Pacemaker or ICD*, Artificial heart valve*,
Organ transplant*, Recent pneumonia*, HIV
positive*, Diabetic, Autoimmune problem, Sleep
apnea machine, Shortness of breath causing recent
hospital admission, Use of a blood thinner, Heart
problem, Refusal of blood products, History of blood
clots, Obstructive sleep apnea, Disease affecting
muscle or nerves, Kidney problem, Aneurysm
Substantial (0.61-0.80) 9 High blood pressure, Seizure, Stroke, Thyroid
problem, Previous radiation, Asthma, Personal
history of problems with anesthetics, Use of
recreational drugs, chronic bronchitis or emphysema
Moderate (0.41-0.60) 8 Chronic pain, Arthritis, History of a bleeding problem,
Memory problem, Alcohol use, Family history of
problems with anesthetics, Liver problems, Unable to
climb 2 flights of stairs
Fair (0.21-0.40) 4 Difficultly laying flat for 30 min, Current cold, chest
infection or fever, History of extreme confusion after
an operation, History of difficulty placing a breathing
tube
Slight (0-0.20) 1 History of fainting
13
Abstracts S23
37258 - PERIOPERATIVE OUTCOMES OF HIGH SPINAL ANESTHESIA FOR CARDIAC

SURGERY
Author(s)
Daniela Goldie
Anesthesia
Co-Author(s)
Stephen Kowalski, MD, FRCPC, Associate Professor - Department of Anesthesia, University of
Manitoba
Hilary P. Grocott, MD, FRCPC, FASE, Professor of Anesthesia and Surgery - Department of
Anesthesia, University of Manitoba
Trevor W.R. Lee, MD, FRCPC, Associate Professor - Department of Anesthesia, University of
Manitoba
Doug Maguire, MD, FRCPC, Associate Professor - Department of Anesthesia, University of Manitoba
Introduction: The surgical stress response, which causes increased secretion of catabolic hormones
and catecholamines as well as the release of inflammatory cytokines, has been the focus of a number
of preventive perioperative strategies. The stress response, that clinically manifests in tachycardia,
hypertension, arrhythmias, increased myocardial oxygen consumption, hypercoagulability and
impaired immune function, has been implicated in a number of adverse perioperative outcomes (1).
High spinal anesthesia (HSA) for cardiac surgery has previously been shown to blunt the surgical
stress response (2). Although a previous retrospective observational study demonstrated that HSA
was associated with a shorter time to extubation, decreased post-operative morphine requirements
and a trend towards shorter intensive care (ICU) and hospital length of stay (LOS) (3), its overall
relationship to patient outcomes is not clear. The purpose of this study is to investigate if the use of
HSA is associated with a reduction in adverse perioperative outcomes.
Methods: Following Institutional research ethics board approval, we conducted a retrospective chart
review to identify patients having had cardiac surgery under spinal anesthesia at our institution from
December 2003 until December 2010. The HSA group was compared to a control group of patients
whom were matched according to age, sex, procedure, surgeon and date of surgery. The primary
outcome was a composite of major morbidity including death, stroke and re-operation for bleeding.
Secondary outcomes include factors such as time to extubation, ICU and hospital LOS, post-
operative delirium and twenty-four hour analgesic requirements. Data was analyzed using Chi-Square
or Fishers’ Exact Test, Student T test and conditional logistic regression.
Results: Three hundred and six patients were studied (n=153 HSA group; n=153 controls). The HSA
and control groups had similar demographics except more patients in the HSA group had a
preoperative diagnosis of COPD (18 versus 9%, p=0.02). Intraoperatively, the groups were similar
with no significant differences in type of surgery performed, cardiopulmonary bypass time, aortic cross
clamp time, intraoperative hemoglobin, or glucose levels. The HSA group had significantly less
intraoperative administration of opioids (p=0.0001), ketamine (p=0.01) and insulin (21 versus 42%,
p=0.0001). Postoperatively, the HSA group was extubated in the operating room more frequently (78
versus 48%, p=0.0001), had less nausea and vomiting (12 versus 43%, p=0.0001), required less
morphine and acetaminophen use (p=0.0001), and trended towards fewer postoperative transfusions
(p=0.10). However, there were no significant between group differences in the composite primary
outcome (Odds Ratio 1.50, 95% Confidence Interval 0.72-3.11), ICU LOS (p =0.80), or hospital LOS
(p =0.60).
Discussion: Although the use of high spinal anesthesia for cardiac surgery reduced the requirements
for postoperative analgesia, suggesting an improvement in patient quality of recovery, it did not
appear to reduce the overall incidence of major adverse outcomes nor impact hospital LOS. These
benefits need to be balanced with the risk of neuraxial hematoma formation.
References:
1. Dynamics 2007 18: 14-20
2. Anesthesiology 2003 98: 499-510
3. Dynamics 2009 20: 18-24
13
S24 Abstracts
13
Abstracts S25
37354 - OBSTRUCTIVE SLEEP APNEA AND 30-DAY POSTOPERATIVE MORTALITY
Author(s)
Daniel I. McIsaac, MD, MPH
Co-Author(s)
Andrea Gershon, MD, MSc, FRCPC - Respiratory Program, Institute for Clinical Evaluative Sciences
Gregory Bryson, MD, MSc, FRCPC - Anesthesiology, The Ottawa Hospital
Duminda Wijeysundera, MD, PhD, FRCPC - Anesthesiology, University of Toronto
Neal Badner, MD, FRCPC - Anesthesiology, University of British Columbia
Carl van Walraven, MD, MSc, FRCPC - Epidemiology and Community Medicine, University of Ottawa
Introduction: Obstructive sleep apnea (OSA) is associated with adverse postoperative

cardiorespiratory events (1). Existing population based studies of perioperative OSA lack validated
case definitions of OSA exposure status and fail to capture out of hospital outcomes (2,3). To help
understand the perioperative implications of OSA in a larger and more generalizable context, we
undertook a retrospective population-based cohort study to measure the association of OSA treated
with positive airway pressure (PAP) with 30-day mortality and healthcare resource use after non-
cardiac surgery using a validated algorithm to identify OSA exposure.
Methods: Following research ethics approval, we identified all residents of Ontario, aged 40 years
and older, who underwent elective, intermediate to high risk non-cardiac surgery from 2002-2012
using linked health administrative data. A validated algorithm was used to identify cohort members
with PAP treated OSA based on the presence of a preoperative polysomnogram (PSG) followed by
receipt of a PAP device (“Treated OSA” group). Two control groups were identified: those who had a
PSG but did not receive PAP (“No treated OSA”) and those who did not undergo PSG (“No PSG”).
Data sources accurately capture PSG acquisition, PAP devices, demographics, surgery, healthcare
resource utilization and mortality. The association between OSA status and 30-day mortality and
healthcare resource utilization (ICU admission, mechanical ventilation, length of stay (LOS),
readmission, or emergency visits) was measured using multivariable regression adjusting for
demographics, surgery, co-morbidities, income, and previous healthcare utilization.
Results: Of the 333 344 patients identified, 9 193 underwent preoperative PSG (2.8%) and of those
who had a PSG, 1 511 received a PAP device (16%, 0.005% of total). Following multivariable
adjustment, people with PAP treated OSA were no more likely to die within 30 days of surgery than
people who had never had a PSG (odds ratio (OR) 1.00, 95% CI 0.52-1.96) or people who did not
receive a PAP device (OR 1.06, 95% CI 0.76-1.48). People with PAP treated OSA had an increased
odds of admission to ICU and of being mechanically ventilated than either comparator group (OR
1.93, 95% CI 1.63-2.29/OR 1.37, 95% CI 1.04-1.82 vs. “No PSG” (ICU/ventilation); OR 1.25, 95% CI
1.04-1.51/OR 1.37, 95% CI 1.04-1.82 vs. “No treated OSA”), however, there were no differences in
LOS (incidence rate ratio (IRR) 1.00, 95% CI 0.99-1.01), readmission (OR 1.05, 95% CI 0.77-1.42) or
emergency visits (IRR 1.00, 95% CI 0.99-1.01) in the PAP treated OSA group compared to the control
population who never had a PSG.
Discussion: Patients in receipt of PAP therapy for OSA do not experience increased odds of
mortality within 30 days of elective, intermediate to high risk non-cardiac surgery. Increased odds of
ICU admission and mechanical ventilation were observed, but did not result in increased hospital
length of stay of post-discharge resource utilization. Prospective study is needed to assess the
appropriateness and effectiveness of intensive monitoring strategies in patients with PAP treated OSA
in the perioperative period.
References:
1. BJA 2012 109(6): 897-906
2. Anes Analg 2011 112(1): 113-121
3. Chest 2013 144(3): 9093-914
13
S26 Abstracts
37624 - EVALUATION OF RETROMOLAR SPACE SIZE FOR INTUBATION FEASIBILITY
Author(s)
Angela Truong
Anesthesiology & Perioperative Medicine
University of Texas MD Anderson Cancer Center
Dam-Thuy Truong
Anesthesiology & Perioperative Medicine
University of Texas MD Anderson Cancer Center
Co-Author(s)
Juan Cata, M.D. - Anesthesiology & Perioperative Medicine, University of Texas MD Anderson
Cancer Center
Jack Martin, D.D.S. - Oncology Dentistry and Prosthodontics, University of Texas MD Anderson
Cancer Center
Bader Ahmad, D.D.S. - Oncology Dentistry and Prosthodontics, University of Texas MD Anderson
Cancer Center
Introduction: Patients with restricted mouth opening are encountered with increasing frequency,
especially for head and neck surgery. The prevalence of trismus has been reported to be as high as
38% after treatment for head and neck cancers [1]. An airway challenge arises when passage of an
endotracheal tube (ETT) between the teeth is not possible and concomitant contraindications to
nasotracheal intubation are present. We propose using the retromolar space (RMS) as an entry to
perform flexible fiberoptic orotracheal intubation. A prior study of Jordanian subjects has been
performed to correlate mandibular molar space size to third molar eruption [2]. No studies to measure
the dimensions of the RMS to determine the feasibility of retromolar placement of tracheal tubes have
been previously reported. Our objective was to perform a retrospective chart review to determine the
dimensions of the retromolar spaces in a cancer population.
Methods: IRB permission was obtained to review records from January 1, 2011 to January 1, 2012
to identify patients referred to Dental Oncology to measure the dimensions of the RMS using dental
pantomograms. Demographic data: age, ethnicity, gender, height, and weight were collected. Height
of the RMS was measured from the lowest point of the tuberosity to the mandibular alveolar ridge of
the retromolar trigone. Width was measured from the most distal point of the last mandibular molar to
the point of intersection of the anterior border of the ramus with the body of the mandible. Descriptive
statistics were used to summarize both demographic and clinical data including means (with
corresponding standard deviations), medians (with corresponding ranges), and proportions, together
with 95% confidence intervals. Descriptive characteristics were compared with t-test or chi-square
test.
Results: Data from 311 patients (female, n= 121 and male, n= 190) were analyzed. Table 1 shows
the difference between the dimensions of the right RMS compared to the left. Mean dimensions were:
height of 17.87 mm on the right, 18.07 mm on the left, width of 17.48 mm on the right, and 16.51 mm
on the left. Mean width was significantly larger on the right compared to the left (p value < 0.0001).
Of note, 95% of the patients had a width larger than 10 mm, which would allow insertion of a 7.0
mm ETT with an outside diameter of 9.6 mm. Mean thickness of oral mucosa as measured by spiral
CT has been reported to be 2.83 mm [3]. To account for the presence of mucosa, adjusted
dimensions would involve the mean height minus two mucosal thicknesses, giving the right space a
height of 12.21 mm and the left space a height of 12.41 mm. Adjusted widths involve the mean width
minus only one mucosal thickness since the back of the last molar forms the anterior boundary of the
RMS. This gives a mean adjusted width of 14.65 mm for the right and 13.68 mm width for the left
RMS.
Discussion: Hidden behind the last molar, the RMS may seem inaccessible to anesthesia providers.
This study provides information concerning the size of the RMS in 311 cancer patients and shows that
it may readily accommodate commonly used tracheal tubes. We hope this space will gain recognition
13
Abstracts S27
as a viable alternate route for flexible fiberoptic intubation, especially for cancer patients presenting
with severe trismus.
References:
1. Oral Oncol 2004; 40: 879-89
2. Eur J Orthod 2011; 33: 570-76
3. J Periodontol 2011; 82: 829-36
Table 1. Demographics and Retromolar Space Dimensions
13
S28 Abstracts
38109 - QUANTIFYING COMPETENCY – THE DEVELOPMENT AND VALIDATION OF A HAND

MOTION ANALYSIS PROGRAM TO DISCRIMINATE EXPERTS AND NON-EXPERTS DURING
CENTRAL VENOUS LINE CANNULATION
Author(s)
David Clinkard
Queen's University
Co-Author(s)
Matthew Holden, M.Sc - Computer Science, Queen's University
David Messenger, M.D - Emergency Medicine, Queen's University
Tamas Ungi, M.D, PhD - Computer Science, Queen's University
Colleen Davison, PhD - Emergency Medicine, Queen's University
Gabor Fichtinger, PhD - Computer Science, Queen's University
Robert McGraw, M.D - Emergency Medicine, Queen's University
Introduction: Traditionally, technical skills proficiency was assessed by direct observation. While
direct observation and feedback are essential components in technical skills learning they demand
considerable investment of faculty time, and as an assessment tool direct observation is inherently
subjective and has been criticized as unreliable (1). The purpose of this study was to determine if
quantitative electromagnetic motion tracking is feasible, and could discriminated between experts and
non-experts during simulated ultrasound guided insertion of a central venous catheter guidewire.
Methods: 10 resident physicians (FRCP PY1 and 2, CCFP-EM 1) and 10 staff (ICU fellows or
attending physicians) were recruited. Electromagnetic sensor probes were used to capture hand
motion during an ultrasound guided internal jugular cannulation on a standardized manikin. Hand,
ultrasound and needle motion was analyzed for the following metrics: total path length, total time,
translational movements and rotational movements. Subjects were also videotaped and evaluated
using a global rating scale by a blinded expert.
Results: There was a significant difference in almost all examined motion parameters between
experts and non-experts. Experts took 66% less time (50.2 vs. 148.7 sec, p<0.005), and had
significantly less right hand and ultrasound motions (total path, translational and rotational
movements). Left hand path distance was the only parameter that was not significantly different
between groups (experts 2466.9 mm vs. non-experts 4120.8 p=0.08). Concurrent validity of motion
parameters was established by strong correlations (r>0.74) to a previously published, modified global
rating scale.
Discussion: We have demonstrated that electromagnetic hand and instrument motion analysis is
technically feasible for assessing competence in the skills of ultrasound guided insertion of a central
venous catheter guidewire in a simulated setting. In showing that is discriminates between the
performances of non-experts and experts we have provided evidence for construct validity. It also
shows excellent correlation with a modified version of a previously validated global rating scale;
evidence of concurrent validity.
References:
Am. J. Surgery. 2001, 202, 4: 469-480.
13
Abstracts S29
38382 - IMPACT OF TRENDELENBURG POSITION ON RESPIRATORY MECHANICS IN

PEDIATRIC LAPAROSCOPIC SURGERY
Author(s)
Victor M. Neira
Assistant Professor.
Children's Hospital of Eastern Ontario. University of Ottawa
Co-Author(s)
Luis Guerra, Associate Professor - Department of Surgery, Children's Hospital of Eastern Ontario.
Thomas Kovesi, Associate Professor - Department of Pediatrics, Children's Hospital of Eastern
Ontario. University of Ottawa
Maria Campos, Medical Student - N/A, University of Ottawa
Nicholas Barrowman, PhD - Statistics, Children's Hospital of Eastern Ontario Research Institute.
William Splinter, M.D.FRCPC. Associate Professor. - Department of Anesthesiology, Children's
Hospital of Eastern Ontario. University of Ottawa
Introduction: The respiratory effects of the Trendelenburg (head down) position (TDG) during
laparoscopic surgery have been well characterized in adults but not in children. General anesthesia
with neuromuscular relaxation produces a marked decrease in functional residual capacity (FRC) and
lung compliance (LC).(1) Further decrease in FRC and LC occur with the carbon dioxide induced-
pneumoperitoneum (PNP) and the TDG required during laparoscopic procedures.(2) Our aim was to
describe in detail the changes in respiratory mechanics associated with induced pneumoperitoneum
(12 mm Hg pressure) (PNP12) and the Trendelenburg 20° position (TDG20), in pediatric patients
undergoing laparoscopic surgery for abdominal cryptorchidism.
Methods: The 12 enrolled subjects received pressure control ventilation (PCV) with a positive end
expiratory pressure (PEEP) of 5 cm H2O and a peak inspiratory pressure (PIP) of 10-15 cm H2O,
titrated to achieve a tidal volume (VT/kg) of 6-10 ml/kg, and end-tidal carbon dioxide (EtCO2) of 35-40
mm Hg. Adjustments of PIP and respiratory rate (RR) were made to maintain VT/kg within 10% of
baseline and EtCO2 <50 mm Hg. Measurements of VT/kg, weight-adjusted dynamic compliance
(Cdyn/kg), and EtCO2 were recorded at baseline, and after PNP12, the first PIP adjustment (Corr1), at
TDG20, the second PIP adjustment (Corr2), and after deflation and level positioning, and the final PIP
adjustment (Post-deflation corr).
Results: PIP was adjusted for all subjects to maintain VT/kg. VT/kg decreased 42 % after PNP12
(baseline: 9.2 ± 1.3ml/kg; PNP12: 5.3 ± 0.7 ml/kg, p<.001). After Corr1 and then TDG20, VT/kg
decreased another 10% (to 7.4 ±1.2 ml/kg, p<.04). After deflation, it increased to 13 ml/kg, before
being adjusted back to baseline values. Cdyn/kg decreased 43 % after PNP12 (baseline: 0.87 ± 0.21
ml/cmH2O/kg; PNP12: 0.50 ± 0.07 ml/cmH2O/kg, p<.001) and remained below baseline until deflation.
After Corr 1 and TDG20, Cdyn/kg decreased a further 10 % (to 0.51 ± 09 ml/cmH2O/kg, p=.053).
Discussion: PNP12 significantly decreases VT/kg and Cdyn/kg in pediatric patients. The use of
TDG20 produced a minor impact in respiratory mechanics. This study demonstrates that lung
mechanics change significantly during laparoscopic surgery in children, and the need to adjust
ventilator settings to maintain normal gas exchange during laparoscopy when using PCV.
References:
1. Anesthesiol. Clin. North America. 2001;19(1):69-88.
2. Best Pract. Res. Clin. Anaesthesiol. 2010;24(2):227–41.
13
S30 Abstracts
13
Abstracts S31
38413 - EFFET OF OPIOIDS REPLACEMENT BY BETA-BLOCKERS ON POST MASTECTOMY PAIN
Author(s)
Vincent Lecluyse
Anesthesiology
Université de Sherbrooke
Co-Author(s)
Caroline Nadeau - Anesthésie, Université de Sherbrooke
Catherine Boisvert - Anesthésie, Chaleur regional Hospital
Étienne De Medicis - Anesthésie, Université de Sherbrooke
Marie-Hélène Masse - Anesthésie, Université de Sherbrooke
Introduction: Substitution of opioid medication by beta-blockers during laparoscopic cholecystectomy

has been shown to reduce both fentanyl consumption and postoperative nausea in the post-anesthesia
care unit (PACU) [1]. Increasing evidence suggest an association between opioid use and post-operative
chronic pain [2]. There are also laboratory evidences of interaction between opioid and cancer
recurrence [3]. In regards to breast cancer, the intensity of acute postoperative pain is a risk factor for
the development of post-mastectomy pain syndrome. This study was designed to evaluate possible
benefits of opiod-free general anesthesia early in the PACU and on chronicisation of pain in oncological
breast surgery.
Method: This prospective, randomised, double-blinded protocol was designed to compare the effect of
intraoperative fentanyl versus beta-blockers in breast oncological surgery. This abstract represents the
interim analysis of 36 patients. Internal ethics review board approval was obtained. All enrolled patients
received a multimodal co-analgesic regimen consisting of acetaminophen, gabapentin, ketorolac and
ketamine in addition to dexamethasone and ondansetron. Induction was achieved with propofol and
IHQWDQ\OȝJNJIRUWKHFRQWUROJURXS&*Q RUHVPROROPJNJIRUWKHEHWD-blocker group (BB, n =
18) with rocuronium for muscle relaxation. Anesthesia was maintained with sevoflurane in an air/oxygen
mixture. Per-RSHUDWLYHWDFK\FDUGLDDQGK\SHUWHQVLRQZHUHPDQDJHGZLWKWLWUDWHGGRVHVRIIHQWDQ\OȝJ
IV (CG) or metoprolol 2.5 mg IV (BB). Intravenous fentanyl was given as needed in the PACU for both
groups. Phone interviews were conducted up to 6 months after surgery to assess presence of chronic
pain.
Results: Baseline characteristics were similar between the two groups. No significant difference on
postoperative fentanyl use was demonstrated: 4 ȝJ&&YHUVXVȝJ%%P = 0.389).
The occurrence of nausea was also similar (27.8%, CC, versus 16.7%, BB) (P = 0.691). There was no
significant difference in the incidence of perioperarive bradycardia, hypotension and total dose of
ephedrine given between the 2 groups. Chronic pain defined by use of opioid medication 6 months after
surgery was limited to only one patient in the control group (5.6%) (P = 1).
Conclusion: Substitution of fentanyl by beta-blockers for breast cancer surgery in the per-operative
period did not reduce post-operative pain scores, postoperative fentanyl dosage, did not diminish the
occurrence of nausea and did not shorten the time spent in the PACU. Chronic post-mastectomy pain did
not differ between the groups although its incidence was much lower than previously described in the
literature. This interim analysis suggests that opioid-free anesthesia may be an equivalent technique to
traditional anesthesia for this surgical population, although it does not appear to provide any significant
advantage on acute or chronic post-mastectomy pain.
References:
[1] Anesth Analg 2007;105:1255-62.
[2] Pain 2002;100:213-217.
[3] Anesthesiology 2012;116:940-945.
13
S32 Abstracts
38436 - PROFESSIONAL, HEALTH ADVOCATE AND SCHOLAR SIMULATION ASSESSMENT
Author(s)
Victor M. Neira
Assistant Professor
Co-Author(s)
Amy Nakajima, M.D. FRCS - Obstetrics, University of Ottawa
Jocelyne McKenna, M.D. FRCPS Associate Professor - Department of Anesthesiology, University of
Ottawa
Tobias Everett, MBChB FRCA Assistant Professor - Department of Anesthesiology, University of
Toronto
Kathleen Doyle, M.D. FRCPC - Department of Anesthesia and Pain Medicine, University of Alberta
Elaine Ng, M.D. FRCPC - Department of Anesthesiology, University of Toronto
Megan Hayter, BSc M.D. FRCPC - Department of Anesthesiology, University of Toronto
Philipp Mossdorf, M.D. PhD FRCPC - Department of Anesthesiology, University of Ottawa
Nicholas Barrowman, PhD Assistant Professor - Department of Pediatrics, University of Ottawa
Timothy Wood, PhD Assistant Professor - Academy for Innovation in Medical Education, University of
Ottawa
Dylan Bould, MBChB MRCP FRCA Assistant Professor - Department of Anesthesiology, University of
Ottawa
Stanley Hamstra, PhD - Department of Medicine, Anesthesia and Surgery, University of Otawa
Background: In contrast to Medical Expert (ME) and other Intrinsic CanMEDS competencies,
Professional, Health Advocate and Scholar (PHAS) have been difficult to define and assess during
clinical practice and in simulations. (1) Our objective was to collect evidence to support construct
validity of revised Generic Integrated Objective Structured Assessment Tool (GIOSAT) including
content, response process, internal structure, relation to other variables and consequences using
simulated scenarios targeting PHAS competencies.
Methods: Ethics Board approval and informed consent were obtained for a prospective single blind
correlation study. Content: Two simulated scenarios were developed by a panel of experts
highlighting PHAS competencies: Do-not resuscitate (DNR) and Morphine overdose (MOD) with
disclosure.(2)(3) Response process: Four trained raters blinded from residents’ level of training
analyzed video recordings using the GIOSAT. Internal structure was analyzed with generalizability
studies for ME and PHAS scores. Relation with other variables: Primary outcome: correlations
between post-graduate year of residency (PGY) and average PHAS, Intrinsic, Medical Expert and
Total scores. Secondary outcome: correlation between PHAS scores with other Intrinsic, ME and
total GIOSAT scores excluding PHAS.
Results: Twenty one anesthesia residents participated in the study. Generalizability study: Participant
(p) accounted for 20 % of variation component (VC). Scenario (s) and raters (r) did not account for
important VC. However, the interaction between ps and psr accounted for 7 %VC and 17 %VC
respectively. G-coefficient (overall reliability) was .66. Two raters and eleven scenarios using ME and
PHAS are required to obtain a G-coefficient >.8. (Table 1) PGY correlated with PHAS (r=.59, p=.004),
Intrinsic (r= .65, p=.002) and total scores (r=.46, p=.034) but not with ME (r= .26, p=.25). PHAS
scores significantly correlated with other Intrinsic (r=.91, p<.000), ME (r= .7, p<.000) and Total
excluding PHAS (r=.82, p<.0003).
Discussion: Our study demonstrated evidence of construct validity evidence for assessing PHAS
and Intrinsic competencies using clinical simulation with a G-coefficient of .66. Previous studies have
shown limited reliability for assessment of professionalism.(4,5) Results from this study are aligned
with a systematic review focused on reliability of OSCEs, which found overall alpha coefficients of
0.62 and generalizability of 0.49. (6) Reliability increased with the number of stations and assessing
less complex constructs such as medical history of physical examinations. More complex constructs
such as PHAS competencies may need to accept lower reliability. The major limitation of this study is
construct under-representation as we only had two scenarios. Although correlation between PHAS
13
Abstracts S33
scores and PGY was positive, comparison with other scales (such as checklists) would be a good
alternative to support relation with other variables. Future studies with similar methodology may
support construct validity for PHAS competencies at high stakes level using two raters and eleven or
more scenarios.
References:
1. Can. J. Anaesth. [Internet]. 2013 Mar;60(3):280–9.
2. Circulation [Internet]. 2010 ;122(Suppl 3):S665–75. A
3. Can. J. Anaesth. 2006 Jun;53(6):586–90.
4. Am. J. Surg. 2011 ;202(4):433–40.
5. Med. Teach. [Internet]. 2004 ;26(4):366–73.
6. Med. Educ. [Internet]. 2011 ; 45(12):1181–9
13
S34 Abstracts
38515 - DIAGNOSING MURMURS AND DESIGNING LEARNING
Author(s)
Gianni R. Lorello, BSc, MD, MSc(c)
University of Toronto and The Wilson Centre
Co-Author(s)
Maria Mylopoulos, PhD - Department of Pediatrics, The Hospital for Sick Children
Barry Issenberg, MD, FACS - Department of General Internal Medicine, University of Miami
Carol-anne Moulton, MD, MEd, FACS, PhD - Department of Surgery, University of Toronto
Ryan Brydges, PhD - Department of Medicine, University of Toronto and The Wilson Centre
1-4
Introduction: Physical exam skills are declining amongst trainees at all levels, a trend common in
5
specialties with access to technologies like echocardiography. In anesthesiology, a patient’s
perioperative management includes the cardiac exam, and in emergencies, a preoperative
echocardiogram may not be available. Anesthesiologists have distinct considerations for differing
valvular pathologies that influence patient outcomes. Therefore, ensuring that trainees acquire cardiac
auscultation skills is paramount.
With decreasing work hours, simulation-based medical education is an alternative for learning cardiac
auscultation. While many clinicians suggest that direct supervision is essential when teaching clinical
skills, providing a clinician’s time is resource intensive. One way to decrease costs is via self-
regulated learning (SRL).
Engaging in SRL, trainees may benefit from being able to develop and learn from their own learning
approaches. Unlike those who learn with an instructor (have to reconcile the instructor’s teaching
approaches with their own learning approaches), the individualized experiences of SRL trainees’ may
lead to more robust learning outcomes.
Methods: After receiving local ethics approval, we computer randomized first and second year
medical students (n=32) to 2 conditions: (i) SRL, and (ii) one-on-one instructor-regulated learning
(IRL). All participants practiced diagnosing murmurs and underwent 3 video-recorded testing
scenarios including immediate post-test, retention and transfer tests (both 2 weeks later). For all tests,
we assessed participants’ diagnostic accuracy. We documented the students’ sequence of practicing
murmurs as a proxy for understanding their learning approaches. We subsequently performed semi-
structured interviews aimed at clarifying each participant’s learning approaches for learning murmurs
and for general learning, and their awareness of strategies for regulating learning.
Results: There was no significant between-group difference in: (i) time for all 3 sessions, (ii)
diagnostic accuracy on immediate posttest and retention tests [F(1,18)=1.037, p=0.322], and (iii)
diagnostic accuracy on the transfer test (p=0.628). Chi-squared analysis suggests no differences
between instructors’ and students’ approaches to organizing murmur sequences for practice
(p=0.074). Emergent themes from our qualitative work suggest that students use self-testing, start
with familiar concepts, build on prior knowledge, and use confidence as a proxy for learning. Students
express their need to seek social acceptance and exposed to normative pressures.
Discussion: Contrary to clinicians’ expectations, the outcomes did not differ on any test. SRL training
appears to be efficient in that it provides equivalent learning outcomes without the added resource-
intensive support of a clinician. Our interview data suggest that students prefer building on previous
knowledge and normative pressures deter them from asking questions. In an era of increased
physician time demands and decreased trainee work hours, SRL may be a plausible way of teaching
cardiac auscultation skills to trainees.
References:
1. Mangione S, Nieman, L.Z., Gracely, E., et al. The teaching and practice of cardiac auscultation
during internal medicine and cardiology training. A nationwide survey. Annals of internal medicine.
1993;119:47-54.
2. Mangione S. Cardiac auscultatory skills of physicians-in-training. American journal of medical
genetics. 2001;110:210-6.
13
Abstracts S35
3. Mangione SaN, L.Z. Cardiac auscultatory skills of internal medicine and family practice trainees.
JAMA : the journal of the American Medical Association. 1997;278:717-22.
4. Wray NPaF, J.A. Detection and correction of house staff error in physical diagnosis. JAMA : the
journal of the American Medical Association. 1983;249:1035-7.
5. Spencer KT, Anderson AS, Bhargava A, et al. Physician-performed point-of-care echocardiography
using a laptop platform compared with physical examination in the cardiovascular patient. Journal of
the American College of Cardiology. 2001;37:2013-8.
13
S36 Abstracts
38584 - POWER AND CONFLICT: RESIDENTS’ ABILITY TO CHALLENGE AUTHORITY
Author(s)
Zeev Friedman
Associate Professor
Mount Sinai Hospital, University of Toronto
Co-Author(s)
Megan Hayter, Assistant Professor - Department of Anesthesiology, St. Michael’s Hospital, University of
Toronto
Tobias Everett, Assistant Professor - Department of Anesthesiology, The Hospital for Sick Children,
Clyde Matava, Assistant Professor - Department of Anesthesiology, The Hospital for Sick Children,
Laura Noble, B.A, RRT - Department of Anesthesia, Mount Sinai Hospital, University of Toronto
Matthew Dylan Bould, Assistant Professor - Department of Anesthesiology, Children’s Hospital of Eastern
Ontario, University of Ottawa
Introduction: Effective communication is crucial during the management of a life threatening crisis and its
breakdown may pose a severe threat to patient safety. A key dynamic that may contribute to communication
failures is status asymmetry between team members. It may have its most profound effect in teams
consisting of residents and their attending physician. Residents, who in many cases perceive themselves as
1
transient care providers, are reluctant to challenge incorrect decisions made by a superior. We
hypothesized that a strict hierarchical behavior by the attending anesthesiologist would have a negative
effect on residents’ ability to challenge clearly incorrect clinical decisions made during a life threatening
airway crisis.
Methods: After approval from the local research ethics board and written informed consent, anesthesia
residents in post-graduate year 2 were recruited to participate in a videotaped high fidelity simulated
scenario. They were randomized to a group in which the confederate attending anesthesiologist’s
professional behavior was scripted to either recreate a “steep” hierarchy dynamic or an open communication
dynamic. Residents were told that the attending anesthesiologist was also a subject in the study and the real
purpose of the study was not disclosed. This deception was explicitly described in the research ethics
submission. The initial script and scenario were developed and tested during several pilot scenarios. It
included both verbal and nonverbal communication features. The ability to differentiate and identify group
allocation was assessed by an independent video rater during the pilot scenarios as well as at the end of the
study. The scenario allowed residents four opportunities to challenge clearly wrong clinical decisions by their
staff during management of a “can’t intubate can’t ventilate” simulation. Two independent, blinded raters
scored the performances using the modified Advocacy-Inquiry Score (mAIS) and the Ottawa Global Rating
2
Scale (GRS).
Results: Thirty-four second year anesthesia residents completed the study. The maximal mAIS median
across all challenging opportunities and averaged out across raters was 3.5 (2.5, 6.0) in the open group
communication group and 3.0 (1.0, 5.0) in the hierarchical group. The difference in both mAIS and GRS did
not reach a level of significance (p=0.06).
Discussion: The study did not show an effect of a steep hierarchy dynamic professional behavior on
residents’ ability to challenge a wrong decision by their superior. It did however demonstrate residents’
inability to effectively challenge their staff in both groups, resulting in critical communication gaps within the
team, repeated clinical mistakes and deviations from the difficult airway algorithm endangering patients'
safety. Residents are not given the proper tools to efficiently challenge authority during a crisis situation.
This educational gap that affects every resident and attending physician encounter may have significant
implications that need to be addressed through research and possibly changes to the residency program
curriculum.
References:
1. Acad Med 2009; 84:1765-74
2. Br J Anaesth 2013;110:463-71
13
Abstracts S37
13
S38 Abstracts
38672 - PERIOP. MANAGEMENT OF EMERGENCY CABG AND POST-INFARCTION VSR REPAIR
Author(s)
Khalid Hanish, MSc, MRCA, FCAI
Department of anesthesia and perioperative Medicine
Schulich School of Medicine and Dentistry, Western University
Ronit Lavi, MD, FRCPC

Department of Anesthesia & Perioperative Medicine
Co-Author(s)
Linrui Guo, FRCSC - Cardiac Surgery , Schulich School of Medicine and Dentistry, Western University
Saad ElGaoud, MRCSI - Cardiac Surgery , Schulich School of Medicine and Dentistry, Western University
Purpose: Describe the perioperative anesthetic management of emergency CABG and post-infarction
ventricular septal rupture repair in an unstable patient.
Clinical Features: Consent was obtained for presentation of this case. A 65 year-old man presented for
emergency CABG and post-infarction ventricular septal rupture for repair. The patient initially presented to a
peripheral hospital with 3 days history of angina and chest pain was found to have posterior STEMI. He
underwent emergency PCI to stent his 100% occluded RCA and a ventriculogram demonstrated a shunt
from LV to RV due to a rupture of the interventricular septum. After 48 hours management at a local
hospital, the patient was transferred to CCU at our institution. On arrival, the patient was in cardiogenic
shock needed IABP and was on heparin infusion, he then on the same day developed upper GI bleeding,
had endoscopy which showed small multiple gastric ulcers, treated with IV PPI. The patient was listed for
surgery the following day; however, at 05:30 am of his planned surgical day, the patient developed VT/VF
cardiac arrest requiring CPR & Defibrillation. To follow resuscitation and stabilization, the patient transferred
to the OR at 06:30 am. Pre induction considerations:
Hemodynamic Instability recent resuscitation with Left to right intra cardiac shunt
Suspected Malignant Hyperthermia trait
Suspected Difficult Intubation
Recent Upper GI Bleed
After an uneventful induction of general anesthesia with low doses of Midazolam, Fentanyl and Propofol,
anaesthesia was maintained using TIVA and fentanyl infusion. Aim was to maintain normal to low SVR,
normal to Low PVR. An ICU ventilator was used for intra-operative ventilation and oxygenation.
Pre CPB TEE: Poor LV function, moderate to severe MR, moderate TR and sever shunt at inferio-septal
wall.
Procedure: CABG X II, two vein grafts to LAD and intermediate, interventricular septal defect was repaired
with Bovine peircardial patch and MV repair with Re-attachment of papillary muscles
Coming of bypass: inotropic support: Epinephrine 2 mcg/min& NorEipnephrine mcg/min/8, single dose of
vasopressin (1 U) and Nitric Oxide @ 12 PPM.
At the end of surgery: patient was on: Epinephrine 2mcg/min, NorEipnephrine 10 mcg/min, Milrinone 0.25
mcg/kg/min, Nitric Oxide 12 PPM and IABP 1:1. PAC information: CI 2.3 and PAP 38/20
Post CPB TEE: Trace shunt at inferio-septal wall, Mild MR, Mild
Post operative Period:
The Patient was transferred to CSRU; during which he had required prolonged period of recovery including:
high inotropic support, ECMO, right ventricular failure, unsuccessful trial of RVAD, prolonged ventilatory
support with tracheostomy, renal replacement Therapy. And prolonged ICU stay of 30 days.
Conclusions: Although our patient survived the incident and his operation, the outcome could have been
worse due to delayed surgical interventions which lead to increased mortality risk from 30% to over 50%.
1 2-6
According to ACCF/AHA 2011 guideline , previous publications and case reports , surgical treatment of
post-infarction ventricular septal rupture should not be delayed.
13
Abstracts S39
References:
1. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery
A Report of the American College of Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines.
Am Coll Cardiol. 2011;58(24):e123-e210. doi:10.1016/j.jacc.2011.08.009
2. Andrew Murday, Optimal management of acute ventricular of septal rupture

Heart 2003 89: 1462-1466
3. Deja M.A., et al. Post infarction ventricular septal defect – can we do better? Eur J Cardiothorac
Surg2000;18 (2):194-201.
4. Prêtre R., et al. Operative results of ‘repair’ of ventricular septal rupture after acute myocardial
infarction. Am J Cardiol 1999; 84:785-788.
5. Cox F.F., et al. Early mortality after surgical repair of post infarction ventricular septal rupture:
importance of rupture location. Ann Thorac Surg 1996; 61:1752-1758.
6. Dalrymple-Hay M.J.R., et al. Post infarction ventricular septal rupture: the Wessex
experience. Semin Thorac Cardiovasc Surg1998; 10(2):111-116.
13
S40 Abstracts
38830 - INTERSPECIALTY CRISIS RESOURCE MANAGEMENT TEAM TRAINING PROGRAM
Author(s)
Milene A. Azzam, MDCM
Anesthesia
McGill University
Co-Author(s)
Rachel Fisher, MDCM, FRCPC - Department of Anesthesia, McGill University
Ilana Bank, MDCM, FRCPC, FAAP - Department of Pediatrics, McGill University
Lily HP Nguyen, MDCM, MSc, FRCSC - Department of Otolaryngology - Head and Neck Surgery,
McGill University
Meredith Young, PhD - Department of Medicine, McGill University
Introduction: Crisis situations in medicine are low frequency, high-stakes events where poor
management can negatively impact patient outcome(1). Anesthesiology has a long history with crisis
resource management (CRM) training, which has demonstrated benefits in clinical practice(2).
Medical crises are often managed by multiple physicians, which may lead to unclear leadership, poor
communication and lack of a shared mental model(3). This differs from traditional CRM training,
where teams often have single physician leadership. The gap between traditional CRM training and
the complexities of interspecialty care in crises (e.g. leadership negotiation, etc.) may be problematic.
To address this gap we developed, implemented and evaluated a simulation-based interspecialty
team CRM training program for senior residents. Here we report a) the details of the program, b) the
current amount of CRM and interspecialty training participants receive, c) reported clinical
experiences in interspecialty crisis situations, and d) perceived benefits of the program.
Method: This study was approved by the Ethics Board at our institution. Senior residents from
anesthesia, otolaryngology (OTL) and pediatric emergency medicine (PEM) participated in a half-day
simulation-based program focusing on interspecialty CRM challenges. An interspecialty team
constructed all training materials to emphasize potential areas of conflict and miscommunication
unique to interspecialty teams. Debriefings following scenarios focused on a) interspecialty-specific
issues (e.g. transfer of leadership, clear intra- vs. inter-specialty communication), and b) development
of a shared mental model, where residents explore other specialties’ management approach and are
able to create a cohesive management strategy. Residents completed a pre-course survey reporting
previous CRM experience (including interspecialty), self-reported clinical experiences in interspecialty
crises, and perceived CRM skill level. In a post-course survey residents reported perceived CRM skill
level (including those relevant to interspecialty context).
Results: 14 anesthesia residents participated, of which 100% reported receiving previous simulation-
based CRM training (compared to 56% (10/18) PEM and OTL residents). Only 31% reported
receiving prior interspecialty training (33% (6/18) OTL and PEM residents). 57% (8/14) of anesthesia
residents reported prior clinical experience in interspecialty crisis contexts (e.g. difficult airway
management in ICU); narrative comments of interspecialty-specific issues encountered frequently
included unclear leadership and poor communication. Participants self-reported significant increases
in CRM skills following course participation (pre= 3.6(.13), post=4.0(.16), on a 5-point
scale)(F(1,143)=17.4,p<0.005).
Conclusion: Anesthesia residents receive CRM training, but little with an interspecialty
focus. Residents report involvement in interspecialty crisis situations in clinical practice, suggesting a
training-to-practice gap. Results support the program continuation, as residents report increases in
CRM skills.
References:
1. Resuscitation 2004 60(1): 51-6
2. Anesthesiology 2010 112(4): 985-92
3. Best Pract Res Clin Anaesthesiol 2011 25(2): 239-49
13
Abstracts S41
38889 - POSTOPERATIVE MYOCARDIAL ISCHEMIA & CARDIAC EVENTS – A META-ANALYSIS
Author(s)
Homer Yang
Professor of Anesthesia
Anesthesia
Co-Author(s)
O AlAtiayh, MD - Anesthesia, University of Ottawa
M Mashaat, MD - Anesthesia, University of Ottawa
H Talab, MD - Anesthesia, University of Toronto
A Chaput, MD - Anesthesia, University of Ottawa
Introduction: Myocardial ischemia in the perioperative period has been associated with
(1)
postoperative cardiac morbidity. The relationship between postoperative myocardial ischemia
(POMI) and postoperative myocardial ischemic outcomes, however, remains controversial. The
current meta-analysis is an update, in view of the number of studies having been published since a
previous meta-analysis. The goal is to determine the association between the postoperative ST
segment changes as detected by continuous ECG monitoring, and cardiac morbidity in patients
undergoing non-cardiac surgery.
Methods: Medline database between 2008 and 2012 was searched, using the terms Anesthesia;
Anesthesia, general; Anesthesia, spinal; Anesthesiology, complications; intraoperative complications;
postoperative complications; postoperative period; surgery; surgical; procedures; operative;
electrocardiography; electrocardiography; ambulatory; ischemia; myocardial ischemia; and myocardial
infarction (MI). Inclusion criteria were prospective observational, RCT evaluating; adult patients
undergoing non-cardiac surgery; ischemia monitoring by continuous electrocardiographic monitoring
(minimum 2 lead) for at least 24 hours. Exclusion criteria were cardiac surgery or cardiac
catheterization; non-English publications. Outcomes analysed were MI, unstable angina, ischemic
pulmonary edema, ischemic ventricular tachyarrhythmia and cardiac death. Studies were evaluated
independently by two researchers and the results were combined with the previous search from 1950
to 2007. Odds ratio (OR) and confidence interval (CI) were calculated using Cochrane Collaboration
Software (Review Manager 12).
Results: Between 2008 and 2012, 1319 studies were identified. Of those, 12 satisfied the pre-defined
criteria. Three had similar patients and related outcomes but it was not possible to verify the data; and
6 had incomplete data. Three additional studies therefore were added to the previous results, with a
total of 3220 patients: 1066 with postoperative ST segment changes and 2154 without. Postoperative
ischemia was associated with ischemic cardiac events in 218 patients, OR 10.92 [6.85, 17.42], in a
random effect model; and OR 12.96 [8.70, 19.31], in a fixed effect model.
Discussion: The present meta-analysis continues to show that in patients undergoing non-cardiac
surgery, early postoperative ST segment changes is an important correlate of adverse cardiac
outcomes. Since 2008, data from several studies from one investigator group was unverifiable and
excluded. Definitions of cardiac events vary significant among studies but the overall effect was
strong in the correlation of postoeprative cardiac outcomes in the presence of postoperative ECG ST
segment changes.
References:
New England Journal of Medicine 1990;323:1781-8.
13
S42 Abstracts
Review: Event rate with postop ischemia

Comparison: 01 Postop ischemia and events
Outcome: 01 Cardiac events (fixed effects)
Study Ischemia No ischemia OR (fixed) Weight OR (fixed)

or sub-category n/N n/N 95% CI % 95% CI
01 Sub-category
Ouyang 1989 8/15 1/9 3.48 9.14 [0.90, 92.40]
Mangano 1990 12/167 3/307 11.69 7.85 [2.18, 28.21]
Mangano 1991 11/42 2/58 7.39 9.94 [2.07, 47.72]
McHugh 1991 2/93 0/15 4.96 0.85 [0.04, 18.50]
Raby 1992 14/35 2/80 4.35 26.00 [5.47, 123.48]
Beattie 1993 5/18 0/37 1.41 30.56 [1.58, 590.33]
Christopherson 1993 7/40 1/60 3.93 12.52 [1.48, 106.18]
Landesberg 1993 11/88 2/63 12.15 4.36 [0.93, 20.40]
Nelson 1993 6/12 0/15 1.34 31.00 [1.51, 634.42]
Berlatzky 1994 7/40 0/85 1.57 38.28 [2.13, 689.16]
Edward 1995 2/26 1/74 2.86 6.08 [0.53, 70.10]
Fleisher 1995 7/37 2/108 4.93 12.37 [2.44, 62.67]
Gannedahl 1995 13/30 0/8 2.61 13.11 [0.69, 247.87]
Hollenberg 1995 0/12 0/12 Not estimable
Bois 1997 11/21 12/93 12.54 7.43 [2.60, 21.20]
Landesberg 1997 17/129 2/276 6.59 20.79 [4.73, 91.49]
Gozal 1998 0/15 0/41 Not estimable
Raby 1999 2/13 0/13 2.45 5.87 [0.25, 135.15]
Scheinin 2000 0/23 0/36 Not estimable
Urban 2000 3/11 1/96 0.89 35.63 [3.31, 383.16]
Landesberg 2001 12/38 0/147 0.84 139.15 [7.99, 2422.00]
Anderson 2004 26/59 0/105 1.20 166.91 [9.90, 2813.44]
Dogan 2008 0/3 0/37 Not estimable
Fayad 2011 3/59 6/253 12.83 2.21 [0.54, 9.09]
Bassuoni 2012 0/40 0/126 Not estimable
Subtotal (95% CI) 1066 2154 100.00 12.96 [8.70, 19.31]
Total events: 179 (Ischemia), 35 (No ischemia)
Test for heterogeneity: Chi² = 22.25, df = 19 (P = 0.27), I² = 14.6%
Test for overall effect: Z = 12.61 (P < 0.00001)
Total (95% CI) 1066 2154 100.00 12.96 [8.70, 19.31]

0.01 0.1 1 10 100

Review: Event rate with postop ischemia Lower event rate Higher event rate
Comparison: 01 Postop ischemia and events
Outcome: 02 Cardiac events (random effects)
Study Ischemia No ischemia OR (random) Weight OR (random)

or sub-category n/N n/N 95% CI % 95% CI
Ouyang 1989 8/15 1/9 3.65 9.14 [0.90, 92.40]

Mangano 1990 12/167 3/307 9.68 7.85 [2.18, 28.21]
Mangano 1991 11/42 2/58 7.09 9.94 [2.07, 47.72]
McHugh 1991 2/93 0/15 2.15 0.85 [0.04, 18.50]
Raby 1992 14/35 2/80 7.17 26.00 [5.47, 123.48]
Beattie 1993 5/18 0/37 2.32 30.56 [1.58, 590.33]
Christopherson 1993 7/40 1/60 4.20 12.52 [1.48, 106.18]
Landesberg 1993 11/88 2/63 7.28 4.36 [0.93, 20.40]
Nelson 1993 6/12 0/15 2.24 31.00 [1.51, 634.42]
Berlatzky 1994 7/40 0/85 2.43 38.28 [2.13, 689.16]
Edward 1995 2/26 1/74 3.31 6.08 [0.53, 70.10]
Fleisher 1995 7/37 2/108 6.71 12.37 [2.44, 62.67]
Gannedahl 1995 13/30 0/8 2.36 13.11 [0.69, 247.87]
Hollenberg 1995 0/12 0/12 Not estimable
Bois 1997 11/21 12/93 12.72 7.43 [2.60, 21.20]
Landesberg 1997 17/129 2/276 7.76 20.79 [4.73, 91.49]
Gozal 1998 0/15 0/41 Not estimable
Raby 1999 2/13 0/13 2.09 5.87 [0.25, 135.15]
Scheinin 2000 0/23 0/36 Not estimable
Urban 2000 3/11 1/96 3.48 35.63 [3.31, 383.16]
Landesberg 2001 12/38 0/147 2.48 139.15 [7.99, 2422.00]
Anderson 2004 26/59 0/105 2.54 166.91 [9.90, 2813.44]
Dogan 2008 0/3 0/37 Not estimable
Fayad 2011 3/59 6/253 8.33 2.21 [0.54, 9.09]
Bassuoni 2012 0/40 0/126 Not estimable
Total (95% CI) 1066 2154 100.00 10.92 [6.85, 17.42]

0.01 0.1 1 10 100

Favours treatment Favours control
13
Abstracts S43
38890 - SUBCUTANEOUS KETAMINE FOR POSTOPERATIVE PAIN MANAGEMENT IN AFRICA
Author(s)
Jon Tuchscherer, M.D.
Anesthesiology
University of Saskatchewan
William McKay, M.D. F.R.C.P.C.

Anesthesiology
Co-Author(s)
Theogene Twagirumugabe, M.D. - Anesthesiology, National University of Rwanda
Introduction: In the developed world, adequate pain control is a normal part of surgical care,
however, this is not the case in sub-Saharan Africa. Ketamine’s role in postoperative analgesia is
1,2
documented, yet its use in developing nations has not been well studied. The purpose of our study
is to determine a subcutaneous (SC) dose of ketamine for use in a future randomized control trial
(RCT) that is both efficacious in reducing postoperative pain scores, and does not result in significant
side effects.
Methods: This study was conducted in a sub-Saharan African nation, and as such, Canadian and
African university research ethics board approval, local hospital research committee approval, and
individual patient consent to conduct and publish the study were obtained. Thirty-one subjects
undergoing major abdominal, orthopedic, or gynecologic surgery were recruited. In addition to
standard postoperative care, subjects received five SC doses of ketamine at scheduled intervals: on
arrival in recovery room, again that evening, then morning and evening on postoperative day one, and
in the morning of postoperative day two. Pain scores were recorded using a zero to ten point
numerical rating scale in the recovery room, and on the mornings of postoperative days one and
two. Patients received 50 mg of ketamine for both the first and second doses, with the subsequent
three doses adjusted according to pain and side effects. We considered a significant reduction in
pain to be a change of 3 or more points on a numerical rating scale within a 24-hour period.
Results: Mean pain scores in the recovery room and on postoperative days 1 and 2 were 9.39, 5.07,
and 2.41, respectively. The overall mean ketamine dose that was efficacious in pain reduction in the
29 patients without side effects was 0.89 mg/kg.
Discussion: Lack of resources including staffing, analgesic drugs, and proper education on pain
control are barriers to the delivery of post-operative pain relief in many sub-Saharan African
nations. Most patients enrolled in our study received 100 mcg of fentanyl in the operating room,
followed by occasional doses of acetaminophen, NSAIDs, or intra-muscular meperidine. The
inclusion of subcutaneous ketamine in addition to all standard analgesic medications resulted in
drastic decreases in patients’ postoperative pain scores (see graph). While some of the decrease in
pain can be attributed to a differing cultural perception of, and reaction to pain, it is likely that
ketamine played a role in improving patient comfort following surgery. As such, we will plan an RCT
for determining the efficacy of subcutaneous ketamine in reducing postoperative pain, using a dose of
1.0 mg/kg twice a day.
References:
1. Laskowski K et al. Can J Anaesth 2011; 58: 911- 923.
2. Batta SK. Anesth Analg 2007; 104: 232
13
S44 Abstracts
13
Abstracts S45
38924 - DIPHTHERIA, O'DWYER, AND THE DIFFICULT PEDIATRIC AIRWAY
Author(s)
Kathryn A. Sparrow, MD
Anesthesia
Memorial University of Newfoundland
Co-Author(s)
Asoka Samarasena, MBBS, FFARCS, FRCPC - Anesthesia, Memorial University of Newfoundland
Jim Connor, PhD - Medical History, Memorial University of Newfoundlan
Sonia Sampson, MD, FRCPC - Anesthesia, Memorial University of Newfoundland
Introduction: Remarkable advances have been made in clinical airway management in recent years.
Although the history of clinical airway management dates back to the portrayal of a tracheotomy
operation in Egyptian tablets over 5,000 years ago,1 it was not until Antonio Brasavola reintroduced
tracheotomy for tonsilar obstruction in 15462, that tracheotomy reappeared as a viable medical
procedure. Intubation did not become regular practice for airway obstruction until Joseph O’Dwyer
introduced his metal tracheal tubes and method for intubation to relieve obstruction caused by
3
diphtheria in 1885. It is important to place O’Dwyer’s discovery in the context of the history of this
infectious disease to better appreciate the value of tracheotomy and tracheal intubation that have
formed the cornerstone to our management of the difficult pediatric airway today. This presentation
will review historical pediatric airway management in diphtheria, the development of O’Dwyer’s
endotracheal tubes, intubation equipment and method, and illustrate similarities to modern airway
management equipment.
Methods: A literature review of historical texts was completed. As this is a historical literature review,
ethics approval was not required.
Results: Until the introduction of an immunization program in the early 1900’s, diphtheria was a major
cause of illness and death in children. The practice of “airway catheterization” was reported in the
4
1700’s. However, it did not become regular practice until Joseph O’Dwyer introduced his metal
tracheal tubes and method for intubation in 1885.3 O’Dwyer presented a design and method to relieve
airway obstruction in patients with diphtheria with a reported increased survival when compared to
tracheotomy.5 This practice changed the way in which airway obstruction was managed, and heralded
a new age of airway innovation. O’Dwyer’s tubes became widely used and saved the lives of
hundreds of children. Prior to his death in 1898, the more effective anti-toxins being developed would
6
largely phase out O’Dwyer’s achievements in diphtheria treatment.
Discussion: Failure to secure the airway has resulted in high morbidity and mortality throughout
history. These deaths have acted as the impetus for further improvements and developments in this
area; much time and invention have resulted in safer and more reliable techniques for placement of
tracheal tubes. The airway devices of the past have helped shape our current armamentarium of
airway devices and approach to reduce the morbidity and mortality associated with airway
management.
References:
1. Intensive Care Med 2008 34: 222-228
2. Laryngoscope 2009 118: 1597-1606
3. Rev Mex Anest 2009 32: S164-167
4. Curr Anaesth Crit Care 1995 6: 54-58
5. Med Rec 1887 32: 557-61
6. Resuscitation 2007 74: 211-214
13
S46 Abstracts
38934 - A SYSTEMATIC REVIEW OF TTE AND TEE IN NON-CARDIAC SURGERY
Author(s)
Amanda Jasudavisius, MD
London Health Sciences Centre
Co-Author(s)
Daniel Bainbridge, MD, FRCPC - Anesthesia and Perioperative Medicine, London Health Sciences
Centre
Ramiro Arellano, MD, FRCPC - Anesthesia and Perioperative Medicine, London Health Sciences
Centre
Background: It is well known that ultrasound is essential in cardiac surgery however the body of
evidence supporting its use in non-cardiac surgery is lacking. Nevertheless, point of care ultrasound
(POC) is an evolving field in anesthesia. While several narrative reviews exist there have been no
systematic reviews to examine the literature and thus guide the development of an evidence based
1, 2
curriculum for anesthesia training purposes . Therefore, we undertook a systematic review to
ascertain common diagnoses made by POC during non-cardiac surgery.
Methods: A systematic review of case series was conducted to evaluate the use of TTE and TEE in
the intraoperative setting for high risk patients or during periods of hemodynamic instability. With the
assistance of a librarian, studies were identified using PubMed, Cochrane, Cinahl, Embase and
reference lists of relevant articles. The search terms included TTE, TEE, perioperative and
ultrasound. The outcome variables analyzed were segmental wall motion abnormalities (SWMAs),
low left ventricular ejection fraction (LVEF), hypovolemia, air embolism, cardiac and aortic thrombus,
pulmonary embolus (PE), aortic valve disease, mitral valve disease, tricuspid valve disease, right
ventricular (RV) failure, pericardial disease and patent foramen ovale. No ethics approval was
required for this study.
Results: Our search found seven studies that met our inclusion criteria. The studies included 279
patients with either Group A: high risk comorbidities (n = 176) or Group B: hemodynamic
compromise/cardiac arrest (n = 103). The most common diagnoses in Group A were low LVEF (40%),
mitral valve disease (22%), RV failure (14%) and SWMAs (12%). In Group B, the most common
diagnoses were low LVEF (24%), RV failure (21%), SWMAs (18%), PE (15%) and hypovolemia
(14%). Other diagnoses occurred less than 5% of the time.
Discussion: Currently there is a limited body of literature that examines the use of POC in non-
cardiac surgery. Regardless, this systematic review suggests that a curriculum designed to teach
intraoperative POC should include common diagnoses such as low LVEF, RV failure, mitral valve
disease, SWMAs, PE and hypovolemia which is based on evidence and not anecdote.
References:
1. Ann of Cardiac Anaesth 2006 9: 108-113
2. J of Cardiovascular Med 2008 9(10): 993-1003
13
Abstracts S47
38974 - ANESTHESIA AND PERIOPERATIVE MEDICINE
Author(s)
Christine M. Pickering
Co-Author(s)
Faisal Siddiqui, MD, FRCPC - Anesthesia, University of Manitoba
Heather McDonald, MD, FRCPC - Anesthesia, University of Manitoba
Stephen Kowalski, MD, FRCPC - Anesthesia, University of Manitoba
Introduction: Anesthesiologists are well suited to care for complex medical patients in the
postoperative setting. In our institution, we have developed the Surgical Special Care Unit (SSCU),
which opened in June 2008. This intermediate care area provides care to medically complex surgical
patients managed by an anesthesiologist. Since the unit has opened, there have been on average,
525 patients admitted per year, with an average length of stay of 4.3 days.
In this study, we looked at the rate of transfer for escalation of care before and after the introduction of
the SSCU. Our hypothesis was that the involvement of an anesthesiologist in the postoperative care
of a surgical patient would reduce the need for escalation of care.
Methods: Local research ethics board approval for this study was obtained. We performed a
retrospective chart review of all patients who had open repair of abdominal aortic aneurysm (AAA) in
our institution for the calendar years of 2007 and 2009. The only difference between these two years
was the introduction of the anesthesia directed care in the SSCU. All AAA patients in 2007 went to an
intermediate care unit with the same monitoring and nurse to patient ratio as the SSCU. There were
no changes in surgical technique or surgeons between 2007 and 2009. We collected information
about the movements of patients through the hospital from the operating room to
discharge. Movements along the expected care pathway were considered forward moves. Any
deviation from the expected care pathway for an increase in acuity of care was considered a
backwards move.
Results: There were 82 patients in the 2007 cohort of AAA patients (56 elective, 25 emergent and 5
endovascular) and 112 in the 2009 cohort (88 elective, 20 emergency and 14 endovascular). There
were 10 deaths in the 2007 group compared to 7 deaths in the 2009 group. This was not statistically
significant with a p-value of 0.1206. Twenty-three patients in the 2007 cohort had multiple
complications and only 17 in the 2009 group. This was statistically significant with a p-value of
0.0324. We saw a total of 221 transfers in the 2007 group 9.5% of these being backward
transfers. In the 2009 group we saw a total number of 344 transfers, 4.9% of these being backward
transfers. This difference was statistically significant with a p-value of 0.0378 and an odds ratio of
2.020 with 95% confidence intervals of 1.041-3.920.
Discussion: In conclusion, since the establishment of our anesthesia run SSCU, we have reduced
the number of backward transfers in a high-risk patient population. We believe this can be attributed
to recognition and treatment of complications earlier in their course, thus reducing admissions to
higher acuity care.
References:
1. Acta Anaesthesiol Scand 2006; 50: 1255-1265
2. Curr Opin Crit Care 2006; 12: 604-608
3. Anesthesiol Clin North America 2000; 18: 495-513
4. Minerva Anestesiol 2001; 67: 252-255
5. Arch Surg 2004; 139: 315-319
6. J Crit Care 2010; 25: 205-213
13
S48 Abstracts
38998 - A RANDOMISED CONTROLLED TRIAL OF EPIDURAL VOLUME EXTENSION DURING A

COMBINED SPINAL-EPIDURAL TECHNIQUE FOR LABOUR ANALGESIA
Author(s)
Valerie Zaphiratos
MSc, MD, FRCPC
IWK Health Centre, Halifax, NS & Hôpital Maisonneuve-Rosemont, Montreal, QC
Co-Author(s)
Ronald B George, MD, FRCPC - Women's and Obstetric Anesthesia, IWK Health Centre
Bruce Macaulay, MD, FRCPC - Women's and Obstetric Anesthesia, IWK Health Centre
Prasad Bolleddula, MD, FRCA - Women's and Obstetric Anesthesia, IWK Health Centre
Dolores M McKeen, MD, FRCPC - Women's and Obstetric Anesthesia, IWK Health Centre
Introduction: Combined spinal-epidural (CSE) is a popular method for delivering labour analgesia
due to rapid onset of profound analgesia, minimal motor blockade, and high patient satisfaction.
Epidural volume extension (EVE) involves injection of volume into the epidural space compressing the
dural sac, causing cephalad shift of the cerebral spinal fluid (CSF). Our hypothesis is that EVE with 10
ml of normal saline during CSE will increase the anesthetic sensory block height, decrease pain
scores, decrease pain scores more rapidly, and decrease motor block compared to performing CSE
without EVE.
Methods: An apriori sample size was calculated. With institutional REB approval and written informed
consent, we recruited 54 healthy term labouring nulliparous parturients with cervical dilation < 5 cm.
Intrathecal analgesia consisted of 2 mg bupivacaine and 10 mcg fentanyl. The subjects were
randomly allocated into one of two groups: EVE received 10 ml of normal saline through the Tuohy
needle prior to catheter insertion or NEVE where parturients did not receive EVE. Epidural catheters
were thread 5 cm into the epidural space and a standard continuous epidural infusion was begun
immediately. A blinded researcher assessed sensory dermatome level by blunt pinprick test,
analgesia by numeric rating scale (NRS) 0 to 10, and motor blockade with a m-Bromage score 1 to 6
at 2.5 min intervals. The primary outcome measure was the difference in sensory dermatome level as
determined by non-traumatic pinprick test.
Results: Refer to table 1 for results. A total of 54 parturients were enrolled. There was no significant
difference in demographic criteria. There was no significant difference in peak dermatome levels at 15
min or 30 min between groups. The time to peak dermatome was also not significant between groups.
There was no difference in the minimum pain score, nor the time to minimum pain score between
groups. The number of parturients with a Bromage score less than 6 was less in Group EVE, but this
too was not statistically significant.
Discussion: To our knowledge, this is the first clinical trial to study the effect of EVE for labour
analgesia in parturients. We did not find a significant difference between groups with regards to
sensory dermatome level nor pain scores when using EVE. Although there is a trend toward less
motor block in Group EVE, this was not statistically significant. Our study demonstrates that EVE
does not offer superior analgesia when using a CSE technique for parturients requesting labour
analgesia, but any effect on long-term catheter function was not assessed in this study.
References:
1. Cochrane Database Syst Rev 2012 10: CD003401
2. Anesth Analg 1997 85: 1097-100
3. Br J Anaesth 1992 69: 457-60
4. Reg Anesth Pain Med 1998 23: 92-5
5. Br J Anaesth 2005 95: 500-3
6. Anaesthesia 2011 66: 341-7
13
Abstracts S49
Table 1
Group
Measure No EVE EVE p-value
(n = 28) (n = 26)
Age (years) 27.4 ± 4.4 25.5 ± 3.7 0.0933
BMI (kg/m2) 29.8 ± 3.4 29.3 ± 3.1 0.5899
Cervical dilation at CSE (cm) 3.5 (1, 4) 3.5 (2, 4) 0.9517
Pain score prior to CSE (0 – 10)* 9 (5, 10) 9 (5, 10) 0.5139
Peak dermatome 15 min T6.5 (T4, L4) T6 (T1, L2) 0.2234

Peak dermatome 30 min T6 (T2, L4) T5.5 (T1, L1) 0.7589
Time to peak dermatome (min) 20 (0, 30) 15 (2.5, 30) 0.8266
Minimum pain score (0 – 10) 0 (0, 5) 0 (0, 7) 0.1958
Time to minimum pain (min) 2.5 (0, 25) 2.5 (0, 25) 1.0000
Peak Bromage score (1 – 6) 6 (4, 6) 6 (5, 6) 0.0636
Bromage score < 6 9 (32.1%) 3 (11.5%) 0.1029
Data presented as mean ± SD, median (range), or n (%)
*n = 25 for EVE group for this measure
13
S50 Abstracts
39024 - ULTRASOUND-GUIDED SINGLE INJECTION INFRACLAVICULAR BLOCK VS. ULTRASOUND-

GUIDED DOUBLE INJECTION AXILLARY BLOCK: A NONINFERIORITY RANDOMIZED TRIAL
Author(s)
Ariane Boivin
Anesthesiology
Laval University, CHU de Québec
Co-Author(s)
Marie-Josée Nadeau - Anesthesiology, CHU de Québec, Hôpital de l'Enfant-Jésus
Simon Lévesque - Anesthesiology, CHU de Québec, Hôpital de l'Enfant-Jésus
Nicolas Dion - Anesthesiology, CHU de Québec, Hôpital de l'Enfant-Jésus
Pierre Nicole - Anesthesiology, CHU de Québec, Hôpital de l'Enfant-Jésus
Alexis Turgeon - Anesthesiology, CHU de Québec, Hôpital de l'Enfant-Jésus
Introduction: Single injection ultrasound-guided infraclavicular block is a simple, reliable and effective
1
technique . Recently, a simplified double injection ultrasound-guided axillary block technique has been
2
described with a high success rate . The latter is performed in a superficial and compressible location, with
thus a potentially improved safety profile. However, its effectiveness in comparison to the single injection
infraclavicular block is unknown. We hypothesized that the rate of complete sensory block at 30 minutes
with the double injection ultrasound-guided axillary block is noninferior to the single injection ultrasound-
guided infraclavicular block.
Methods: After local research ethics board approval and informed consent obtained, adults undergoing
distal upper arm surgery were randomized to either group I, ultrasound-guided single injection infraclavicular
block, or group A, ultrasound-guided double injection axillary block. In group A, 25 mL of mepivacaine 1.5%
were injected posteromedial to the axillary artery and 5 mL were injected around the musculocutaneous
nerve upon needle retrieval. In group I, 30 mL of mepivacaine 1.5% were injected posteriorly to the axillary
artery. The primary outcome was the rate of complete sensory block at 30 minutes. Secondary outcomes
were the onset of the block, surgical success rates, performance times and complications. Outcomes were
assessed by an investigator unaware of the technique performed. Considering an average rate of complete
sensory block of 90% with the single injection infraclavicular block and a noninferiority margin of 10%, 224
patients were required, considering an alpha error or 5% (one-sided hypothesis) and a power of 80%.
Results: Both groups of 112 patients each were comparable. At 30 minutes, the rate of complete sensory
block was 91% in group I (90% CI: 86%-94%) compared to 79% in group A (90% CI: 72%-84%); the upper
limit of group A’s confidence interval (84%) is being included in the established noninferiority margin of
10%3. However, the rate of complete sensory block was lower in group A (p<0.01), as well as the onset of
the sensory block (logrank test <0.01). Secondary outcomes are presented in table 1. No complication
related to the regional anesthesia technique was noted.
Discussion: Based on a noninferiority margin defined at 10%, we cannot exclude that the rate of complete
sensory block of the double injection axillary block is ‘noninferior’ to the single injection infraclavicular block.
However, the rate of complete sensory block at 30 minutes is statistically significantly lower with the axillary
block and its onset slower. The ultrasound-guided single injection infraclavicular block seems to be the
preferred technique for upper arm anesthesia. The double injection axillary block remains an acceptable
alternative.
References:
1. Anesth Analg 2009; 109: 668-72.

2. Reg Anesth Pain Med 2012; 37: 248-253.
3. JAMA 2012; 308: 2594-2604.
13
Abstracts S51
Table 1. Characteristics of the blocks

Group I (n=112) Group A (n=112) p
Surgical success, n (%) 104 (93%) 92 (82%) 0,02

Performance time, sec * 200 (157-258) 330 (235-446) <0,01
Paresthesia, n (%) 11 (10%) 16 (14%) 0,32
Vascular puncture, n (%) 2 (2%) 1 (1%) 0,62
* Median and 25-75% interquartile range
13
S52 Abstracts
39026 - SINGLE TIME POINT PHARMACOKINETICS OF ROCURONIUM
Author(s)
Craig J. Railton, BSc, MD, PhD, FRCP(C)
Western University
Co-Author(s)
Rebecca Ashcroft, B.Sc., M.D. - Department of Anesthesia and Perioperative Medicine , Western University
Rommel Tirona, B.Sc., Ph.D. - Pharmacology and Physiology, Western University
Ute Schwarz, M.D., Ph.D. - Division of Clinical Pharmacology, Dept. of Medicine, Western University
Richard Kim, M.D. - Division of Clinical Pharmacology, Dept. of Medicine, Western University
Background: Rocuronium is widely used to provide paralysis for anesthesia. In studies designed to identify
molecular transporters of rocuronium we found neuromuscular stimulation showed poor correlation with
rocuronium plasma concentrations. An inexpensive methodology to estimate Area under the Curve for
rocuronium was developed and is now described.
Methods: Twenty-one adults were studied (10 male and 11 female). Rocuronium dosing was determined by
the anesthesiologist. Blood samples were obtained at 5, 10, 15, 20, 22, 30, 45, 60, 90 and 120 minutes post
administration of rocuronium. The blood samples were analyzed for the plasma rocuronium concentration by
HPLC-MS. Pharmacokinetic data were calculated with the aid spread sheets and statistical software.
Results: The mean age of patients was 50 years (15) with a mean weight of 82 kilograms (16). The mean
dose of rocuronium administered was 51 mg (6). Rocuronium showed best correlation with a two phase
pharmacokinetic model. The following pharmacokinetic parameters were observed: mean AUC0-inf 182424
ng/ml-1 min-1 (57 028); and mean residence time 42 minutes (18). The best correlation of rocuronium
2
concentration with AUC0-inf occurred at 45 minutes post administration (R = 0.89, p <0.0001).
Approximately 96 per cent (2.3) of the rocuronium dose was cleared within two hours, and 7.3 per cent (8.4)
of the dose was found in urine.
Conclusion: Single time point rocuronium plasma concentration can be as a surrogate to estimate the
exposure to rocuronium instead of area under the concentration time curve. Samples taken between 20 and
60 minutes showed the best correlation with AUC. The optimal time for taking samples for all patients is
predicted to be 42 minutes (18).
References:
1. Eur J Clin Pharmacol 2006; 62: 653–9.
2. Ther Durg Monit 2006; 28 (3): 321-5.
Figure 1: A plot of Area under the rocuronium concentration time curve versus rocuronium plasma
concentration for 21 patients (10 male, 11 female)
y = 127.1x + 43290, r2 = 0.89. p 0.0001

400000
Area Under the Curve
300000
(ng/mL*min.)
200000
100000
0
0 500 1000 1500 2000 2500
45 min [Rocuronium]
(ng/mL)
13
Abstracts S53
39028 - SURVIVAL AFTER MASSIVE BLOOD TRANSFUSION DURING LIVER TRANSPLANT
Author(s)
Fatimah D. Alsalah
Anesthesia
LHSC
Achal K. Dhir
Anesthesia
LHSC
Co-Author(s)
Roberto Hernandez, MD - Hepatobiliary surgery, London Health Sciences Centre,
Stephen Morrison, MD, FRCPC - Anesthesia, London Health Sciences
Case report: Patient consent was obtained as per hospital policy. A 39 years old male patient
9
suffering from Hepatitis B cirrhosis (MELD Na 23) with platelet count of 30 x 10 /L, presented for
orthotopic liver transplantation. General anesthesia was induced and invasive monitoring placed as
per our protocol. Pre anhepatic stage was uneventful and he tolerated the vascular clamps without
much hemodynamic instability. One unit of platelet transfusion had been started. About 15 minutes
into the anhepatic phase, Hepatitis B immunoglobulin (HBIG) infusion was started at 2 ml / min. 10
minutes later, he developed sudden and severe hypotension (systolic BP in 30s) and tachycardia
(140/ min). Immediate resuscitation was started including 2-3 min. of CPR for drug circulation and
HBIG infusion stopped immediately. Resuscitation lasted about 10 minutes. Rescue TEE ruled out
massive pulmonary embolism and revealed hyperdynamic but empty heart with no regional wall
motion abnormalities. Severe distention of the small bowel was noticed. Patient became severely
coagulopathic requiring massive blood transfusion. Once adequate volume status was established,
surgeons finished the IVC & portal vein anastomosis and the clamps were released. TEE revealed
frequent showers of air embolism. Patient was kept on vasopressor infusions to maintain acceptable
hemodynamic parameters. Hepatic artery anastomosis was completed but the liver appeared dusky.
Bile duct anastomosis could not be performed due to small bowel distension, abdomen was packed
and he was transferred to ICU. Patient continued to be coagulopathic requiring super massive blood
transfusion. He was taken back to the OR about 8 and 72 hours later for exploration, control of
bleeding and pack removal. Abdominal swelling subsided but he remained coagulopathic. There was
primary non function of the allograft and he was relisted for retransplant. The re-transplantation went
successfully. He was dialysis dependent for three weeks and was recovering well one month after the
first transplant. Patient received a total of 121 units of PRBC's, 91 units of FFP, 22 adult units of
platelets, 10 adult doses of cryoprecipitate and 2 doses of activated factor VIIa.
Discussion: Liver transplantation places significant strain on blood bank services. There is enough
evidence to suggest poor outcome after significant blood transfusion. Highest number of peri-op
1
PRBC's transfused for liver recipient has been reported to be 251 units with no survival after 80 units.
͒HBIG has been shown to be effective in preventing recurrence of hepatitis B after liver
2
transplantation and prolong survival. ͒Severe reactions like anaphylactic or anaphylactoid reactions
3,4
or thromboembolism risk have also been reported . Cause of severe hypotension during anhepatic
phase in our patient could not be ascertained and most probably was multifactorial (Fig). Bleeding
and hypovolemia, reaction to HBIG, air as well as thromboembolic phenomenon contributed to
hemodynamic instability. This case highlights the safety of blood transfusion and successful outcome
after super-massive blood transfusion during liver transplantation.
References
1. Patricia Butler,Blood transfusion in liver transplantation.Transfusion. 1985 ; 25(2): 120–123.
2. Ed Gane New Zealand. Hepatitis B Immunoglobulin Immunoprophylaxis for Hepatitis B: High,
Low, or No Dose? LIVER TRANSPLANTATION 16:S36–S39, 2010.
3. Mikhail Menis. Hyperimmune globulins and same-day thrombotic adverse events as recorded in a
large healthcare database during 2008–2011.Am. J. Hematol. 88:1035–1040
4. FDA drug sheet, hepagam B.
13
S54 Abstracts
13
Abstracts S55
39069 - META-ANALYSES OF INTRATHECAL MORPHINE FOR LUMBAR SPINE SURGERY
Author(s)
Suzanne Lambert
PGY4 Anesthesia Resident
Anesthesiology
McMaster University Hamilton Health Science
Co-Author(s)
Ada Hindle, PGY4 Anesthesia - Anesthesiology, McMaster University Hamilton Health Science
Susan Jo, PGY4 Anesthesia - Anesthsiology, McMaster University Hamilton Health Science
Ji Cheng, MSc Clinical Epidemiology and Biostatistics - Clinical Epidemiology and Biostatistics,
McMaster University Hamilton Health Science
James Paul, Associate clinical professor, research chair and director acute pain service -
Anesthesiology, McMaster University Hamilton Health Sciences
Introduction: Intrathecal morphine has the potential to provide prolonged analgesia following
surgery but this comes at a risk of opioid side effects including the chance of delayed respiratory
depression. Controversy remains as to the optimal dose and indications for intrathecal
morphine. Current limitations in literature include variability in study design, dosing regimens and lack
of outcomes with adequate sample sizes. The purpose of this meta-analysis of randomized controlled
trials was to determine the efficacy of intrathecal morphine in reducing pain scores after lumbar spine
surgery and the resulting incidence of opioid side effects and analgesia related adverse events.
Methods: A literature search of randomized control trials (RCTs) was conducted. The search yielded
greater than 600 citations and a total of 10 trials were selected based on an ‘a priori’ inclusion criteria.
VAS scores were grouped into six-hour time frames. Results were analyzed in terms of low dose (less
than 150 mcg) or high dose (more than 150 mcg) ITM, or combined dose (both less than and more
than 150 mcg). The incidence of side effect profiles related to ITM dosing was also analyzed. Odds
ratios with corresponding confidence intervals were calculated for all outcomes using a random-
effects model.
Results: VAS scores were available for all 10 trials, 520 patients were randomized and data was
available for 453 patients that met our inclusion criteria. Compared to placebo, the pooled results
show that both low and high dose ITM groups had significantly lower VAS scores at 0-6 hours
[Weighted Mean difference (WMD) of -23.18 (95% Confidence Interval (CI) of -37.66 to -8.70)), 6-12
hours [WMD -11.76 (CI -22.92 to -0.60)], and 12-18 hours [WMD -12.04 (CI -20.60 to -
3.49)]. Compared to the control group, the ITM high and low dose groups combined had a
significantly higher incidence of pruritis (Odds Ratio with 95% CI of 3.99 (1.78, 8.91)) as well as a
significantly lower incidence of sedation [OR 0.35 (0.12, 1.00)]. There was no significant difference
between groups regarding nausea, respiratory depression, urinary retention, and post-dural puncture
headache.
Conclusion: The addition of intrathecal morphine provides superior post-operative analgesia up to

18 hours, for lumbar spine surgery. Pruritis is the main side-effect that can be expected regardless of
dosing. Despite concern for increased sedation with intrathecal morphine, our study results indicate
that the incidence is actually reduced when compared to control group.
References:
None cited in Abstract
13
S56 Abstracts
39078 - BLOOD PRESSURE CHANGES DURING CLOSED-LOOP CONTROL OF ANESTHESIA
Author(s)
Nicholas West, MSc
Dept of Anesthesiology, Pharmacology & Therapeutics
University of British Columbia
Co-Author(s)
Klaske van Heusden, PhD - Electrical and Computer Engineering, University of British Columbia
Matthias Görges, PhD - Electrical and Computer Engineering, University of British Columbia
Christian L Petersen, PhD - Anesthesiology, Pharmacology & Therapeutics, University of British
Columbia
Aryannah Umedaly, BSc - Anesthesiology, Pharmacology & Therapeutics, University of British
Columbia
Guy A Dumont, PhD - Electrical and Computer Engineering, University of British Columbia
J Mark Ansermino, FRCPC - Anesthesiology, Pharmacology & Therapeutics, University of British
Columbia
Richard N Merchant, FRCPC - Anesthesiology, Pharmacology & Therapeutics, University of British
Columbia
Introduction: Closed-loop control of anesthesia involves automated administration of anesthetic

agents, according to feedback obtained from a measure of clinical effect, such as a processed EEG
signal [1]. One potential benefit of closed-loop control is improved hemodynamic stability [2]. The
purpose of the present study is to develop a robust controller for automated administration of propofol
and remifentanil both based on EEG feedback. Evaluation of other clinical variables is expected to
yield crucial information regarding the safety and effectiveness of the system. Intraoperative blood
pressure changes may increase postoperative complications [3,4]. Blood pressure may be used to
optimize dosing of analgesic drugs and has been used as a feedback variable in closed-loop systems
[5].
Methods: Following Health Canada authorization, ethical approval and written informed consent,
ASA I-III adults, undergoing surgery requiring general anesthesia, were enrolled in the first phase of
the study, in which propofol was closed-loop controlled and remifentanil was administered by target-
controlled infusion. The NeuroSENSE WAVCNS (NeuroWave Systems, Cleveland Heights, OH)
provided continual feedback for controlling induction and maintenance of propofol anesthesia, using
an initial WAVCNS setpoint of 50. Remifentanil was administered according to an effect-site target
specified by the anesthesiologist in the range 1-12 ng/ml. Adjusting the WAVCNS setpoint and
remifentanil target and administering bolus doses of either drug were permitted.
Results: Data are reported as median (range) for the initial 36 eligible subjects, age 64.5 (38-82)
years and body mass index 27.6 (17.9-35.8) for whom propofol was administered solely in closed-
loop and for whom adequate blood pressure data was available. Induction of anesthesia (WAVCNS
60 for 30 secs) was achieved in 3.9 (2.6-6.3) mins with a propofol dose of 1.5 (0.8-3.1) mg/kg,
culminating in a calculated effect site concentration [6] of 4.5 (2.9-8.9) mg/ml. Propofol and
remifentanil were infused for 95 (9-348) mins. Hypotension was treated in 11 (31%) subjects and
hypertension was treated in 4 (12%) subjects (table 1). Mean arterial pressure dropped from initial
baseline value by 41% (15-64) and tended to vary most widely during the pre-incision phase of
anesthesia (table 1).
Discussion: Intravenous induction and maintenance of anesthesia using a closed-loop system

maintained hemodynamic stability in the majority of subjects in this population undergoing a wide
variety of procedures. Avoidance of hypotensive episodes, especially at induction of anesthesia, may
require additional tuning of the controller or optimization of the hypnotic/analgesic balance during the
pre-incision period. A randomized trial will be required to compare manual with controlled
administration of anesthesia. Optimized closed-loop control based on an EEG-measured depth of
hypnosis may limit the negative hemodynamic consequences of over- or under-dosing of anesthetic
drugs.
13
Abstracts S57
References:
1. Anesth Analg. 2013 Nov;117(5):1130–8.
2. Anesthesiology. 2001 Jul;95(1):6–17.
3. Anesthesiology. 2007 Dec;107(6):892–902.
4. Can J Anaesth. 2013 Feb;60(2):159–67.
5. Anesthesiology. 2006 Sep;105(3):462–70.
6. Anesthesiology. 1997 Jan;86(1):24–33.
13
S58 Abstracts
39081 - HORNER'S SYNDROME DURING OBSTETRICAL EPIDURAL ANALGESIA: A CASE REPORT
Author(s)
Judith Marois
PGY4 Anesthesiology
Queen's University
Co-Author(s)
Dale Engen, Assistant Professor - Anesthesiology and Perioperative Medicine, Kingston General Hospital
Introduction: Horner’s syndrome, or oculosympathetic palsy, consists of miosis, ptosis, anhydrosis and
conjunctival redness on the affected side. There may also be slight enophthalmos or palpebral fissure
narrowing. It was first reported in 1972 as a rare complication of neuraxial anesthesia including brachial
plexus block and thoracic or lumbar epidural (1). Since then there have been more than 20 case reports of
Horner’s syndrome associated with epidural analgesia. The incidence in obstetrical epidurals is estimated to
be 0.13 – 2.5% (2). In this case report we describe a parturient who developed Horner’s syndrome after
receiving a lumbar epidural for labor analgesia.
Methods: After patient consent and local ethics board approval a retrospective case report via patient
interview and chart review was done.
Results: The patient was a 37 yo G2P0 at 39 weeks 5 days gestation who had a lumbar epidural placed
during her oxytocin induced labor for premature rupture of membranes. It was loaded with 14ml of 0.125%
bupivacaine and an infusion of bupivacaine 0.1%/fentanyl 2mcg/ml was started at 10cc/hour. Approximately
45 minutes after the onset of an effective epidural, her husband (a local Neurologist) noted left sided ptosis,
miosis, conjunctival redness and enophthalmos. This continued for 45 minutes, at which point she was 6cm
dilated. Due to breech presentation, the patient proceeded to an uncomplicated c-section. The epidural
was topped up with 20 cc of 2% lidocaine. The patient had an uneventful recovery, the Horner’s syndrome
resolved while the patient was in the recovery room, approximately 2 hours after it started and she was
discharged home 2 days later.
Discussion: Our patient developed Horner’s syndrome after being loaded with a dilute local anesthetic and
being run at a low infusion rate. This differs from many of the previous case reports where much higher
concentrations and infusion rates were used. As previously reported the oxytocin may have contributed to a
higher sympathetic block. Horner’s syndrome occurs when the sympathetic nervous system is disrupted at
first, second or third order neurons in its path from the hypothalamus to the spinal cord levels
(3). Interestingly, Horner’s symptom is mentioned in the major anesthesia textbooks as a rare complication
of lumbar sympathetic block or subdural block, not from epidural anesthesia. Perhaps the patient’s epidural
was actually subdural, as subdural catheters can go undetected. It is unlikely related to a high block, as the
sensory block was at T7 bilaterally when the Horner’s syndrome was noticed, although sympathetic block
can be higher than the sensory block with epidurals. Overall, this is a rare complication that is important for
trainees to be aware of, as it can signal the need to reassess the parturient for a high block, a subdural
catheter, or rare sinister complications such as carotid artery dissection.
References:
1. NY State J Med. 1972 72: 946-947.
2. Neurology. 1998 51: 1473-1475.
3. Obstet Gynecol Surv. 2011 Feb 66(2): 114-9.
13
Abstracts S59
39083 - RELIABILITY OF EPIDURAL BLOOD PATCH FOR MASSIVE POST SURGICAL CSF LEAK
Author(s)
Maria E. Calvo, MD
Assistant Professor
Anesthesia
McMaster University
Co-Author(s)
Laurie Sellings, PH D. - Anesthesia, University of Toronto
OBJECTIVES:
Report the effectiveness of epidural blood patches as a reliable procedure to correct massive CSF leaks.
Include epidural blood patches in the treatment protocol for failed surgical corrections of epidural tears.
Promote the use of epidural blood patches to avoid further surgical interventions.
METHODS: Patient consent and REB approval was obtained for this presentation. A 66 years old female
underwent L4-L5 bilateral canal enlargement complicated by a dural tear, repair was attempted
intraoperatively; 16 days after the surgery the patient persists with CSF leakage, severe enough to wet the
dressings and flow spontaneously from the surgical site. MRI Stir Images reported massive fluid tracking
towards the skin. Conservative treatment was suggested, because the patient was Asymptomatic. One
month after the surgery the CSF leakage persisted macroscopically. A Fluoroscopically guided epidural
blood patch (1) was performed at the level below the tear L5-S1, radiopaque dye was injected verifying the
edge of the leak and the position of the tip of the 17G Tuohy needle. Autologus blood was injected until the
patient felt pressure (10cc). (2)(3)
RESULTS: Immediately after the injection no free flow of CSF was observed at the surgical wound, the
surgical site was dry and healed 10 days later. Even after a massive CSF leak the patient remain
asymptomatic at all times. Case reports suggest that persistent CSF leaks and post dural puncture
headaches can be succesfully treated with epidural blood patches for months to years following a puncture
(4) or a trauma (3), but little is known about their efficacy in treating dural tears complicating spinal surgery
(5).
DISCUSSION: This case highlights the feasibility and reliability of a fluoroscopically guided EBP in the
treatment of a massive CSF leak on an asymptomatic patient, a month after an intraoperative dural tear.
This procedure can prevent surgical reinterventions and it is consider safer when performed under
fluoroscopic guidance(1), because the anatomy of a surgical tear is different from the post puncture tear or a
post traumatic tear(2,3), the volume used needs to be adjusted to the symptoms of the patient, we use the
sensation of pressure as a guideline to stop the volume injected. It is fundamental to locate the bottom level
of the tear when dealing with large CSF leaks to assure that the blood patch will cover the affected area. We
suggest that EBP should be considered before surgical reinterventions when a persistent CSF leak is
present post surgically and conservative treatment has not been successful. The length of time between the
decision of conservative treatment and EBP should be decided entirely depending on the patients symptoms
and possible complications like infection.
References:
1. Masahiko Kawaguchi, Keiji Hashizume ,Keisuke Watanabe, Satoki Inoue, Hitoshi
Furuya.Fluoroscopically guided epidural blood patch in patients with postdural puncture headache after
spinal and epidural anesthesia. J Anesth(2011) 25:450–453
2. Bobby Mehta, MD, Æ Jordan Tarshis, MD.Repeated large-volume epidural blood patches for the
treatment of spontaneous intracranial hypotension. J Can Anesth (2009) 56:609–613
3. Calvo M, Intracranial hypotension treated after 3 years with Blood Patch, Can J Anesth. CAS 2013
abstract supplement.
4. Bezov D, Ashina S, Lipton R, Headache (2010) 50: 1482-98
5. Mino M, Narita N, Adachi M, Epidural Blood patch for treatment of intracraneal hypotension due to
cerebrospinal fluid leakage after thoraccic spinal surgery. Neurol Surg. 29(9):865-9, 2001 Sep
13
S60 Abstracts
13
Abstracts S61
39088 - AN HYDROXYETHYL STARCH PRIME TO IMPROVE PERFUSION IN CARDIAC SURGERY
Author(s)
Jean-Sébastien Lebon
Anesthesiology
Montreal Heart Institute
Marina Belda
Anesthesiology
Montreal Heart Institute
Co-Author(s)
Eric Laliberté, CPC - Perfusionist, Montreal Heart Institute
Alain Deschamps, FRCPC - Anesthesiology, Montreal Heart Institute
Pierre Couture, FRCPC - Anesthesiology, Montreal Heart Institute
Christian Ayoub, FRCPC - Anesthesiology, Montreal Heart Institute
Antoine Rochon, FRCPC - Anesthesiology, Montreal Heart Institute
Andre Denault, FRCPC - Anesthesiology, Montreal Heart Institute
Jennifer Cogan, FRCPC - Anesthesiology, Montreal Heart Institute
Baqir Qizilbash, FRCPC - Anesthesiology, Montreal Heart Institute
Louis Perreault - Cardiac Surgery, Montreal Heart Institute
Denis Bouchard - Cardiac Surgery, Montreal Heart Institute
Introduction: CPB is associated with a decrease in global perfusion resulting in an increase in serum
lactate. Since composition of priming solution can have an impact on perfusion, we hypothesized that a
priming solution composed of an increasing concentration of hydroxyethyl starch (HES) would result in a
decrease in lactate during CPB.
Material and methods: After approval by the Research and Ethics Committees of our institution,
consent was obtained from patients scheduled for an elective non-complex cardiac surgery. This
prospective, blinded and controlled study randomized patients in three different priming groups: 6% HES
130/0.4 exclusive (HES), HES 500 ml balanced with crystalloid (BAL) or crystalloid exclusive (CRYST).
Plasmalyte was the only crystalloid used in the perioperative period. The total prime volume was
standardized based on patient’s body surface area. Induction of anesthesia, additional fluid
administration and use of vasopressors were decided by the anesthesiologist or intensivist blinded to the
allocation group. The primary end point was the value of immediate postoperative serum lactate as an
estimate of global perfusion during surgery. We also collected data on hemodynamic stability
(vasopressor/inotrope dosage), fluid balance (fluid administration and balance, weight gain) and safety
related to colloids (acute renal failure, blood loss and transfusions and need for renal replacement
therapy (RRT)).
Results: Seventy-six patients were recruited. Baseline characteristics were comparable in the groups.
Postoperative serum lactate level was significantly lower in the HES group but there was no difference
between the CRYST and the BAL groups (Table 1). During CPB, fluid balance was significantly higher in
the CRYST group and no difference was found between the BAL and HES groups. However, fluid
balance in the ICU during the first 24h was significantly lower in the CRYST group and no difference was
found between the BAL and HES group. The use of additional HES and albumin was not significantly
different in ICU. No differences were found for the dosage of vasopressors during surgery and in ICU. No
statistically significant differences were found for blood losses, red blood cell (RBC) or platelet
transfusion, weight gain, ventilation time and max/preop creatinine. However a trend toward a greater
postoperative hemoglobin reduction was noted when HES was used. No patient needed RRT.
Discussion: HES in CPB priming solution improves in a dose-dependent fashion the serum lactate after
CPB. HES also reduces fluid balance during CPB. Even thought the HES group necessitate more fluid in
ICU, the perfusion index, hemodynamyc stability and complication rate were similar to the CRYST group.
In conclusion addition of HES in the CPB prime is an effective strategy to decrease CPB fluid balance
and improve perfusion index during non-complex cardiac surgery.
13
S62 Abstracts
References:
1. Intensive Care Med 1991 17: 320-4.
2. Brit J Anaesth 2013 110: 231-40.
13
Abstracts S63
39089 - A CASE OF TENSION PNEUMOTHORAX PRESENTING AS ABDOMINAL DISTENTION
Author(s)
Stephen Yang M.D., C.M.
Anesthesia
McGill University
Co-Author(s)
Kenneth Kardash M.D. - Anesthesia, McGill University
Christian Sirois M.D. - Thoracic Surgery, McGill University
Introduction: Tension pneumothorax is a life-threatening disease that requires immediate

decompression. Therefore, its diagnosis must be made in a timely fashion. In particular, intraoperative
tension pneumothorax is a rare entity. It classically presents with desaturation, hypotension,
diminished breath sounds on the affected side, distended neck veins and tracheal deviation away
1
from the affected side . However, in our case, the presentation was atypical. The tension
pneumothorax occurred after induction of anesthesia for lung tumor resection. The initial clinical
presentation was marked abdominal distention. The unusual distribution of air invalidated some
traditional aspects of diagnosis and treatment.
Case Description: A 74-year-old male with a history of lung cancer presented for a right upper
lobectomy. After induction of anesthesia, it was noted that the abdomen became progressively more
distended. Soon after, there was a significant decrease in tidal volume. There was no sign of
hemodynamic instability or desaturation. However, the end-tidal CO2 increased to a maximum of 53
mm Hg. The presenting sign of the abdominal distention obscured the etiology of the decrease in
pulmonary compliance. It was unclear whether it is pulmonary or intraabdominal process. Lung
ultrasound showed no sign of pneumothorax at the anterior second intercostal space. We performed
multiple other diagnostic modalities, including gastroscopy and radiography of the chest and
abdomen. The X-rays showed a right-sided pneumothorax and extensive pneumoperitoneum. Both
the pneumothorax and the pneumoperitoneum were decompressed in the operating room, and the
elective lobectomy proceeded as previously planned. The patient was extubated at the end of surgery
and there was no sequela postoperatively.
Discussion: We wanted to report this case to raise awareness of the possibility of atypical
presentation of intraoperative tension pneumothorax. Several clinical features of the case were
striking. Firstly, the presenting sign was abdominal distention, as opposed to the classical
presentation of pulmonary findings. Secondly, ultrasound exam of the anterior chest wall was falsely
negative, which delayed diagnosis. Lastly, there was an absence of hemodynamic instability, which
was false reassuring. This is likely due to the decompression of air into the peritoneum.
Reference:
1. Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think? Emergency medicine journal :
EMJ. Jan 2005;22(1):8-16.
13
S64 Abstracts
39097 - FLUID RESPONSIVENESS WITH END-TIDAL CO2 DURING PASSIVE LEG RAISING
Author(s)
Francis Toupin
Montreal Heart Institute, Université de Montréal
André Y. Denault
Professor
Co-Author(s)
Ariane Clairoux - Department of Anesthesiology, Montreal Heart Institute, Université de Montréal
Alain Deschamps - Department of Anesthesiology, Montreal Heart Institute, Université de Montréal
Jean-Sébastien Lebon - Department of Anesthesiology, Montreal Heart Institute, Université de
Montréal
Yoan Lamarche - Department of Surgery, Montreal Heart Institute, Université de Montréal
Jean Lambert - Department of Social and Preventive Medicine, School of Public Health, Université de
Montréal
Introduction: Assessing fluid responsiveness is an important feature in the management of patients

with hemodynamic instability. Passive leg raising (PLR) is a validated dynamic method to predict fluid
responsiveness, inducing a transient increase in cardiac preload. End-tidal carbon dioxide (ETCO2)
variation correlates tightly with cardiac output variation when alveolar ventilation is kept constant,(1)
assuming constant carbon dioxide production. In this prospective observational study, we tested the
hypothesis that ETCO2 variation can track changes in the cardiac output induced by the PLR
maneuver, predicting fluid responsiveness.(2)
Methods: This study has been approved by the institutional Ethics Committee and patient informed
consent was obtained. Ninety paralysed, mechanically ventilated patients who were going to have a
cardiac or aortic surgery were monitored with a pulmonary artery catheter. A 5-minute PLR maneuver
was performed. Cardiac output measurement by thermodilution was done before and one minute after
PLR initiation. ETCO2 measurement was done during the entire PLR maneuver. Fluid responsiveness
was defined as a 15% increase of the cardiac output and a 5% increase of the ETCO2. Chi-square
tests were used to compare the different variables. A p-value ZDV FRQVLGHUHG VWDWLVWLFDOO\
significant.
Results: PLR induced increase in cardiac output and ETCO2 is strongly associated (Chi-square 16.6,
p < 0.01). There was no difference between the responder and the non-responder as regards to the
global cardiac function assessed by transesophageal echo (Chi-square 0.03, p = 0.83) and central
venous pressure (Chi-square 0.43, p = 0.51).
Conclusion: PLR-induced variation in ETCO2 is a non-invasive and accurate method to assess fluid
responsiveness in paralysed mechanically ventilated patients.
References:
(1) Anesth Analg 2001; 92:306-313.
(2) Int Care Med 2008; 34:659-663.
13
Abstracts S65
39105 - UNDERSTANDING CHRONIC PAIN IN THE EMERGENCY DEPARTMENT
Author(s)
Jennifer Nelli, MD
The Ottawa Hospital
Co-Author(s)
Steven Tremblay, MD - Department of Anesthesiology, The Ottawa Hospital
Patricia Poulin, Ph.D, C.Psych - Department of Psychology, The Ottawa Hospital
Myka Caluyong, BA - Department of Anesthesiology, Research, The Ottawa Hospital
Aaron Zambrana, BA - Department of Anesthesiology, Research, The Ottawa Hospital
Rebecca Small, B.Mus, MA - Department of Anesthesiology, research, The Ottawa Hospital
Yaad Shergill - Department of Anesthesiology, Research, The Ottawa Hospital
Amanda Carson - Department of Anesthesiology, Research, The Ottawa Hospital
Howard Nathan, MD, FRCPC Anesthesiology - Department of Anesthesiology, The Ottawa Hospital
Catherine Smyth, MD, PhD, FRCPC Anesthesiology, Assistant Professor University of Ottawa -
Department of Anesthesiology, The Ottawa Hospital
Introduction: Chronic pain (CP) complaints account for 12-16% of emergency department (ED) visits,
1
with 7% of patients visiting frequently. Increased use of the ED for non-urgent medical conditions
2
such as CP has come to the forefront as ED resources are becoming less accessible. The purpose of
this study was to understand factors leading CP patients to present to the ED.
Methods: This is a prospective, cross-sectional mixed-method study. Surveys and one-on-one

interviews were conducted by medical residents during 30 randomly selected ED shifts between July -
August 2013. Included study participants had: 1) pain as a primary concern for their visit; and 2) pain
lasting greater than 3 months. The following validated surveys were used to assess each patient:
Brief Pain Inventory, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Insomnia
Severity Index-7, Posttraumatic Stress Disorder Checklist-Civilian Version, and Screener and Opioid
Assessment for Patients with Pain. Demographic information was collected. The study protocol was
approved by our institution's research ethics board.
Results: 59 patients met the inclusion criteria. Patients were predominantly women (64.4%),
caucasian (79.9%), and had a family physician (85%). Average patient age was 46.4 years
(SD=16.8). The primary reason for an ED visit was an inability to cope with pain (Table 1). Mental
health problems were common: 61% had moderate to severe depression, 44.1% had moderate or
severe anxiety, 44.1% had posttraumatic stress disorder (PTSD), 45.8% had clinical insomnia, and
42.4% demonstrated opioid misuse. There were no statistically significant differences between males
and females. 79.7% of patients had visited the ED in the previous 12 months for their CP. Patients
were primarily interested in: more effective medications (50.8%), having a health professional explain
the cause of their pain (47.5%) and a Pain Clinic referral (40.7%)
Discussion: Poor coping strategies have been associated with increased pain, depression, disability
3
and poor psychological adjustment. Poor coping strategies may also explain why CP patients seek
help from the ED. We found that the majority of patients were interested in alternative methods to
address their CP. The ED is not the ideal setting for management of complex CP issues.1
Interventions that target CP patients may lead to a better use of resources and improve social and
clinical outcomes. These interventions should target adaptive coping strategies and address the high
levels of depression, anxiety, insomnia and PTSD seen in this group. Understanding these factors
may aid in the implementation of an interdisciplinary pain program to specifically address CP patients
seeking help from the ED.
References:
1. Australas Emerg Nurs J 2013 16: 30-36
2. Am J Emerg Med 2008 26: 255-263
3. Pain 1996 64: 455-462
13
S66 Abstracts
13
Abstracts S67
39116 - MULTICENTERED RANDOMIZED CONTROLLED TRIAL OF INHALED MILRINONE
Author(s)
André Y. Denault
Professor
Co-Author(s)
Jean S. Bussières - Department of Anesthesiology, Institut Universitaire de Cardiologie et de
Pneumologie de Québec
Ramiro Arellano - Department of Anesthesiology, Kingston Hospital, Queens University
Barry Finegan - Department of Anesthesiology, Edmonton Heart Institute, University of Alberta
François Haddad - Department of Cardiology, Stanford University
Anne Q.N. Nguyen - Department of Pharmacology, Université de Montréal
France Varin - Department of Pharmacology, Université de Montréal
Annik Fortier - Department of Public Health, Montreal Health Coordinating Centre
Sylvie Levesque - Department of Public Health, Montreal Health Coordinating Centre
Yanfen Shi - Department of Medicine, Montreal Heart Institute, Université de Montréal
Jean-Claude Tardif - Department of Medicine, Montreal Heart Institute, Université de Montréal
Louis P. Perrault - Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal
Montréal
Introduction: Pulmonary hypertension is a major cause of mortality and morbidity in patients

undergoing valvular and complex heart surgery as it can lead to right ventricular (RV) failure. Inhaled
milrinone (iMil) has been used for the treatment of pulmonary hypertension (1-2) but its safety and
pre-emptive effects in facilitating separation from cardiopulmonary bypass (CPB) and preventing right
ventricular dysfunction have not been studied in patients undergoing high-risk valvular surgery.
Methods: This study has been approved by the institutional Ethics Committee and patient informed
consent was obtained. High-risk cardiac surgical patients with preoperative pulmonary hypertension
were randomized in a double-blind fashion to receive iMil or placebo. The inhalation occurred after the
induction of anesthesia and before surgical incision and CPB. The hemodynamic effects on
ventricular function were evaluated by means of pulmonary artery catheterization and
transesophageal echocardiography. The primary outcome was the level of difficulty in weaning from
CPB.
Results: A total of 124 patients were randomized. There was no baseline difference between the two
groups except for more women and consequently a lower weight mean in the iMil group. The mean
EuroSCORE II was 8.0±2.6 and the baseline average systolic pulmonary artery pressure (PAP) was
59±9 mmHg. The use of iMil was associated with lower diastolic PAP (p=0.0339) and higher mean
systemic to pulmonary arterial pressure ratio (p=0.0113) with no systemic hypotension. However, no
advantage in terms of separation from CPB (easy in 72% in control vs 70% in the iMil group; p=0.240)
and RV failure (15% vs 14%; p=0.941) was observed. Patients in both study groups showed an
increase in mortality with RV failure (22%), compared with those without RV failure (1.9%)
(p=0.0002). Predictors of RV failure were the EuroSCORE II (OR 0.64, 95%CI 0.48-0.86) and RV
systolic area (OR: 0.81, 95% CI 0.70-0.94).
Conclusion: In this high-risk cardiac surgery cohort, the pre-emptive use of inhaled milrinone is
associated with favorable hemodynamic effects which do not translate in improvement of clinically
relevant end-points.
References:
(1) Anesth Analg 2001; 93:1439-1445.
(2) J Thorac Cardiovasc Surg 2005; 130:82-92.
13
S68 Abstracts
39122 - EFFECTIVE VOLUME 90% OF 0.125% BUPIVACAINE-FENTANYL 5 MCG/ML FOR LABOR

EPIDURAL ANALGESIA IN LABOR
Author(s)
Jose Carvalho
Department of Anesthesia and Pain Management and Department of Obstetrics and Gynecology
Floris Klerk
Department of Anesthesia and Pain Management
Co-Author(s)
Cristian Arzola, MD, MSc - Department of Anesthesia and Pain Management, Mount Sinai Hospital,
Xiang Ye, MSc - MIcare Research Center, Mount Sinai Hospital, University of Toronto
Kristi Downey, MSc - Department of Anesthesia and Pain Management, Mount SInai Hospital, UNiversity
of Toronto
Introduction: Practice guidelines for the use of epidural mixtures have changed significantly since the
introduction of the concept of minimum local anesthetic concentration (MLAC) (1). Classic MLAC studies
have established EC50 for various drugs, and clinically useful concentrations – EC90 or EC95 – have
been mathematically derived from those findings. Furthermore, MLAC studies have been performed with
a fixed volume of 20 ml. Epidural anesthesia is known to depend on both the concentration and the
volume of the solution (2). It is fair to assume that each epidural mixture will vary in the minimum volume
required for its efficacy. In 2007 our group set out to explore the concept of effective volume 90%(EV90)
of bupivacaine 0.125%(3). We calculated the EV90 at 13.8 mL (95% CI:12.2-18.3). It remains unknown
how the addition of fentanyl to the bupivacaine solution, and the different test doses preceding the
loading dose, will affect its required volume. The objective of this study is to determine the EV90 of a
loading dose of 0.125% bupivacaine-fentanyl 5mcg/ml, following test doses with 3 ml of either 2%
lidocaine or 0.125% bupivacaine-fentanyl 5mcg/ml.
Methods: REB approval and patient written consent was obtained for this study. 80 patients requesting
epidural analgesia for labor pain are being randomized into two groups: lidocaine test dose or
bupivacaine-fentanyl test dose. The loading dose consists of bupivacaine 0.125% with fentanyl 5mcg/ml.
A double-blind biased coin up-and-down design is being used to determine the EV90 for the two groups.
We include ASAI/II laboring women at term; regular contractions with VNRS > 5 (0-10); cervical dilatation
< 5cm; regular uterine contractions every 3-5 min. After placement of an epidural catheter at L3-4,a test
dose is given with either 3 ml of lidocaine 2% or 3 ml bupivacaine 0.125%-fentanyl 5mcg/ml. After
assessment of the test dose at 3 minutes, the loading volume is given according to the biased coin up-
down method. The initial volume in each group was set at 10 ml. The volume for the subsequent patient
is determined by the response of the previous patient: if the volume fails, the next patient has the volume
increased; if the volume succeeds, the next patient has the volume reduced with a 1/9 chance,
otherwise it remains the same. The in-/decrements are of 2 mL, with minimum and maximum volumes of
DQGPO6XFFHVVLVGHILQHGDV91569156-10) at 20 min after injection of the loading dose.
Hypotension (SBP < 20% from baseline) in combination with nausea, vomiting or fetal bradycardia is
treated with ephedrine 5 mg IV. Secondary outcomes are block characteristics at 20 min (sensory, motor)
and hypotension (SPB <20% from baseline values). The EV90 will be estimated for each of the two
groups using the Dixon and Mood method (4).
th
Results: We started recruitment on the 24 of October 2013. We have approached 50 women and
enrolled 35 of which 3 were excluded (2 protocol violations, 1 failed epidural). With a recruitment rate of
70%, we expect recruitment to be completed by the end of April 2014.
Discussion: This study will determine the EV90 of bupivacaine 0.125% with fentanyl 5mcg/mL to initiate
epidural analgesia in labor, following test doses of either lidocaine 2% or bupivacaine 0.125%.
References:
1) Anesth Analg 1995; 81:833–7; 2) Anesth Analg 2009;108:921-8; 3)SOAP A132, 2007; 4)
Anesthesiology 2007; 107:144-152.
13
Abstracts S69
39133 - TEACHING LUMBAR PUNCTURE USING COMPUTER AUGMENTED REALITY
Author(s)
Melanie Jaeger, MD FRCP
Anesthesiology and Perioperative Medicine
Queen's University
Co-Author(s)
Devin Sydor, MD FRCP - Department of Anesthesiology and Perioperative Medicine, Queen's
University
Zsuzsanna Keri, MD - School of Computing, Queen's University
Tamas Ungi, MD PhD - School of Computing, Queen's University
Parvin Mousavi, PhD - School of Computing, Queen's University
Gabor Fitchtinger, PhD - School of Computing, Queen's University
Introduction: Ultrasound (US) imaging to assist in invasive procedures, such as lumbar puncture
(LP), is increasingly being used to improve procedural success and reduce complications. This
technique may be more useful when the patient has congenital or degenerative spine abnormalities,
or when the bony landmarks are not palpable as in obese patients. The main disadvantage of the
1
ultrasound-guided technique is the long learning curve often required to gain competence. A training
platform for ultrasound guidance, named Perk Tutor, has recently been developed for use as a
2
training aid for various needle insertion procedures . This platform displays the US image overlaying
a 3-dimensional (3-D) image derived from a computed tomography (CT) scan and showing real-time
needle position during the procedure. It also gives feedback to the trainee by computing motion
economy parameters and time spent in each workflow step. Indeed, it has been successful in
3,4
teaching spinal facet joint injection to novices . Perk Tutor is part of the free 3D Slicer software, and
integrates with most available ultrasound machines and position trackers, allowing low-cost replication
at clinical simulation centers. Phantom models are commercially available, and spine models can be
customized with recent 3-D printing technology. We proposed that Perk Tutor would help learners
gain skill in ultrasound image interpretation and needle coordination, thereby enhancing LP success
in challenging cases.
Methods: After obtaining local research ethics board approval and voluntary informed consent, we
recruited 20 anesthesia and surgery residents. They were randomly assigned to either the Perk Tutor
(P) group or the Control (C) group and asked to perform an LP on a lumbar spine part-task
trainer. The trainer was fitted with one of three different custom spine inserts of varying types of
spinal pathology. Group P was trained on model one and two using the 3-D display along with
conventional ultrasound imaging, while Group C had access to only conventional ultrasound imaging.
The groups were then compared using model three and both groups were only allowed the
conventional ultrasound during this phase of the study. We measured success rate, potential tissue
damage (area that the needle swept inside the tissue model), needle path in tissue, and total
procedure time.
Results: Nine out of 10 participants in Group C and all 10 participants in Group P were successful
within the testing time of 10 minutes. Needle trajectory analysis revealed that potential tissue damage
2 2
was significantly lower in the Group P vs Group C (39.7 cm vs. 173.2 cm , p=0.01). Needle path
inside the tissue also trended lower in Group P (233.0 mm vs. 630.0 mm), as did total procedure time
(151s vs. 254s), however these values did not reach statistical significance at our sample size.
Discussion: This pilot study has demonstrated that learning ultrasound-guided lumbar puncture in
pathological spine models may be improved by augmented reality 3-D visualization, and warrants
further study.
References:
1. Am J Phys Med Rehabil 2011 90:860-867.
2. IEEE Trans Biomed Eng. 2012 Dec;59(12):3475-81.
3. Int J Comput Assist Radiol Surg. 2013 Sep;8(5):831-6.
4. Int J Comput Assist Radiol Surg. (In press)
13
S70 Abstracts
13
Abstracts S71
39156 - MEASURING EXPOSURE TO NEGATIVE INTRAOPERATIVE BEHAVIORS
Author(s)
Alexander J. Villafranca, MSc
PhD Candidate
Co-Author(s)
Sandra Robinson, PhD - Sauder School of Business, University of British Columbia
Tom Rodebaugh, PhD. - Psychology, Washington University in St. Louis
George Mashour, MD., PhD. - Anesthesiology, University of Michigan
Michael Avidan, MBBCh - Anesthesiology, Washington University in St. Louis
Eric Jacobsohn, MBCHB - Anesthesiology and Perioperative Medicine, University of Manitoba
Introduction: Negative intraoperative behaviors (NIB), including incivility and bullying, undermine a
culture of operating room (OR) safety (1). Although thought to be common, the predictors of NIB have
not been well studied. Measuring the prevalence and predictors of NIB requires a validated
questionnaire. Our purpose was to develop a validated questionnaire for use with OR workers
(nurses, physicians and technicians).
Methods: Exposure to NIB was taken to be a multidimensional construct, depending on the intended
victims: 1) Not directed to any group (undirected); 2) Directed towards out-group members, i.e. others
in the OR; 3) Directed towards patients; 4) Directed towards in-group members i.e. colleagues; and 5)
Personal exposure. REB approval was obtained. Pretesting involved: 1) Use of the Fry readability
formula to ensure wording was at an acceptable level; 2) Evaluation of individual question relevance
and clarity by 19 OR workers and 3 psychometricians; and 3) "Think aloud trials" with 4
anesthesiologists. Between July-October 2013, the questionnaire was then distributed (online and at
perioperative conferences) to OR workers within the country. Construct factor structure was examined
using exploratory factor analysis. Eigen values (> 1) and cumulative explained variance (> 80%)
determined the number of factors extracted. Extraction was done using principle axis factors.
Interpretability was improved with promax rotation. Internal consistency was examined using
Cronbach's alpha and other statistical methods (Table).
Results: 1088 OR workers within the country completed the questionnaire. Exposure to NIB was best
seen as a construct with 2 dimensions: 1) High-concern transgressions (directed towards self and
witnessing egregious behavior); and Low-concern transgressions (experiencing minor transgressions,
witnessing minor and moderate transgressions, and witnessing undirected behaviors). The scale and
its dimensions showed excellent internal consistency. Deletion of any one question was not found to
improve internal consistency and all questions were therefore retained.
Discussion: We have developed a questionnaire assessing exposure to NIB which employs

appropriate language and has excellent internal consistency and validity. It will enable us to better
study the scope and antecedents of NIB.
References:
1. J Am Coll Surg, 2006. 203(1): p. 96-105.
13
S72 Abstracts
% Variance explained
Inter-item correlation
Kaiser-Meyer-Olkin
Tukey’stest for non-
additivity (p-value)
Highest alpha with

Cronbach's alpha
spherity (p-value)
Bartlett’s test of
(avg, range)
deletion
statistic
# Items
N
Exposure to NIB 108 50 0.995 <0.001 0.995 0.83 (0.08- 99. 0.99 <0.00
7 1) 8 0 1
Factor 1- High- 26 0.998 <0.001 0.998 0.961 (0.75-
concern transgressions 1)
Factor 2- Low- 24 0.997 <0.001 0.997 0.950 (0.74-

concern transgressions 0.99)
13
Abstracts S73
39164 - MEASURING RESPONSES TO NEGATIVE BEHAVIORS IN THE OPERATING ROOM
Author(s)
Alexander J. Villafranca. MSc
PhD Candidate
Co-Author(s)
Sandra Robinson, PhD. - Sauder School of Business, University of British Columbia
Tom Rodebaugh, PhD - Psychology, University of Washington in St. Louis
Pamela Villafranca, Senior Undergraduate student - Conflict resolution studies, University of Winnipeg
Lesia Yasinski, MSA - Nursing Initiatives, Winnipeg Regional Health Authority
Introduction: Negative intraoperative behaviors (NIB) undermine a culture of safety in the operating
room (OR) (1). Adverse consequences to NIB are moderated by behavioral responses of those
exposed to NIB. Currently, there is no model of behavioral responses to NIB, thus the purpose was to
develop and validate one.
Methods: Responses to NIB were conceptualized as falling on a continuum, ranging from responses
aggressively opposing NIB to those enabling NIB. Five questions were developed for each of nine
strategies on this continuum, including: coercing, competing, compromising, collaborating,
ingratiating, being disingenuous, avoiding, acquiescing and promoting. REB approval was obtained.
Pretesting involved: 1) Use of the Fry readability formula to ensure wording was at the appropriate
level; 2) Evaluation of individual question relevance and clarity by 19 OR staff and
3 psychometricians; and 3) "Think aloud trials" with 4 anesthesiologists. The questionnaire was
distributed to OR staff within our country between July-October 2013 (online and at perioperative
conferences). This behavioral response questionnaire was an adjunct to another survey assessing
exposure to NIB. Construct factor structure was examined using exploratory factor analysis. The
number of factors extracted was based on Eigen values (> 1) and cumulative explained variance (>
80%). Extraction was accomplished using the principle axis factor method, and interpretability was
improved with promax rotation. Internal consistency of each extracted dimension was examined using
Cronbach's alpha with and without item deletion, and through item-scale and inter-item correlations.
Results: 776 respondents completed the questionnaire. Behavioral response to NIB was best seen
as a construct with 2 dimensions (see table): 1) Deviance, and 2) Temperance. Deviance consisted of
coercing, strong competing, being disingenuous, ingratiating, and promoting responses. Temperance
consisted in acquiescing, avoiding, collaborating, mild competing, and compromising responses.
Internal consistency for the extracted dimensions was excellent. All questions were retained, as
deletion of any question was not found to appreciably improve internal consistency.
Conclusions: We have developed an appropriately worded, internally consistent and valid

questionnaire measuring responses to NIB. Such a model will be useful to help understand the
potential effect of responses to NIB on patient outcomes, OR staff well-being, and OR economics.
References:
1. J Am Coll Surg, 2006. 203(1): p. 96-105.
13
S74
13
NIB
Deviance
Factor 2-
Factor 1-
Temperance
Responses to
N
726
# Items
Cronbach's alpha
22 0.999
23 0.997
45 0.995
1
1
1
Tukey’stest for non-
<0.00
<0.00
<0.00
additivity (p-value)
Highest alpha with

0.999
0.998
0.995
deletion
Inter-item correlation
1.00)
(avg, range)
0.978 (0.857-
0.95 (0.8-0.99)
0.83 (0.194-1.00)
% Variance explained
99.8
0
Kaiser-Meyer-Olkin
0.99
statistic
1
Bartlett’s test of
<0.00
spherity (p-value)
Abstracts
Abstracts S75
39172 - GOAL DIRECTED FLUID MANAGEMENT IN FREE FLAP RECONSTRUCTIVE SURGERY
Author(s)
Maria Jose Cordero-Rochet
Toronto General, University Health Network
Stuart A. McCluskey, MD, PhD, FRCPC

Department of Anesthesia, University of Toronto
Co-Author(s)
Leonid Minkovich, MD, PhD - Department of Anesthesia and Pain Management, Toronto General
Hospital, University Health Network
Ralph Gilbert, MD - Department of Otolaryngology/Surgical Oncology, Toronto General Hospital,
Introduction: Tumor excision and microsurgical free flap reconstruction (FFR) is a mainstay treatment of
head and neck malignancies. These lengthy and complex surgical procedures are associated with
considerable postoperative morbidity and excessive cyrstalloid administration is known to worsen
outcome (1). The purpose of this study was to determine the effects of goal-directed fluid management
(GDFM) based on continuous SV monitoring on volume and composition of fluids administered during
FFR.
Methods: After the Research Ethics Board approval, and informed consent, 80 consecutive patients
undergoing FFR were enrolled and randomly allocated to the study and control groups. SV was
monitored in both groups using arterial pulse wave analysis (FloTrac/Vigileo™ Edwards Lifesciences,
Irvine, CA) and recorded for postoperative off line analysis. In the study group, a GDFM algorithm was
used to guide fluid administration as follows: after achieving a steady state anesthesia, a Volume
TM
Loading Step-VLS (250 ml of Voluven , Fresenius Kabi, Canada) was administered.If the SV increased
> 10% the patient was considered to be a positive fluid responder. The VLS was repeated until the
increase in SV was < 10%. The SV obtained when the response to intravascular fluid administratoin was
lost was considered the optimized SV. After SV optimization, intravascular volume was maintained with
continuous infusion of 0.5 ml/kg/hr of Ringer’s Lactate. No additional fluid boluses were administered
unless SV decreased by 25% from the optimized SV and the same VLS strategy was repeated as
described above. In the control group, the SV measurements were concealed and not used for clinical
management.
Results: Three patients were lost from the study group after randomization due to failure to complete
the FFR surgery: study group (n = 37), control (n = 40). Demographics, ASA class, type of cancer, type
of free flap, duration of surgery, urinary output and blood loss were similar in the study and control
groups. Intraoperatively, the study group received less cyrstalloid and total fluid but more colloid
(Voluven™). There was no difference in the length of hospital stay or incidence medical or surgical
complications.
Discussion: GDFM significantly decreased the volume of crystalloids, but increased the volume of
colloids administered in the operating room to patients undergoing FFR procedures. As a result, there
was a decrease in the overall fluid gain, but there were no detectable difference in patient outcome.
References:
1. Head and Neck 2010; 32:1345-53.
13
S76 Abstracts
Comparison of types and volume of fluid administration during FFR.
Intraoperative Fluid Study Group Controls

P value
Administration N = 37 N =40
Total volume (ml) 3060 ± 1416 4130 ± 1469 <0.01
Crystalloids (ml) 2178 ± 1045 3836 ± 1072 <0.01
Colloids (ml) 882 ± 371 294 ± 397 <0.01
Fluid balance (ml) 2130 ± 1014 3213 ± 990 <0.01
13
Abstracts S77
39174 - POINT OF CARE INR EVALUATION DURING LIVER TRANSPLANTATION
Author(s)
Hamish S. Mace, MD
Toronto General, University Health Network

Co-Author(s)
Nicholas Lightfoot, MD - Department of Anesthesia and Pain Management, Toronto General Hospital,
Maria Jose Cordero-Rochet, MD - Department of Anesthesia and Pain Management, Toronto General
Introduction: Liver transplantation and the management of the associated coagulopathy may be improved
by point of care (POC) coagulation assessment, as it allows the more contemporaneous analysis of
coagulation. While previous studies have shown a good correlation between POC and laboratory (LAB)
testing at times of stable physiology, the same may not be true during situations of rapid change in
coagulation status such as experienced during cardiac surgery or severe trauma. Before including POC-INR
measurement in a management protocol for liver transplantation, our objective was to determine if the POC-
INR device being considered (Hemochron™ Junior Signature) would provide reliable, and precise
measurements compared to the Laboratory LAB-INR during the three phases of liver transplantation; pre-
anhepatic, anhepatic and neohepatic.
Methods: Following REB approval, a retrospective review was conducted of all patients undergoing
transplantation between July 1 and Dec 31, 2013. Patients receiving POC-INR and LAB-INR assessments in
the pre-anhepatic, anhepatic and neohepatic phases were included. As the POC-INR data was collected as
part of a quality assurance program, the same blood sample was used for both the POC and LAB analysis,
but only the LAB values were used for clinical management. Data was retrieved from the electronic chart,
and the Anesthesia Liver Transplant Database. Statistical analysis was conducted using Microsoft Excel and
SPSS (Statistics 21.0, IBM, Canada,) and included Pearson correlation, linear regression, and Bland-
Altman, and four quadrant concordance plot analyses.
Results: During the study period, 68 liver transplants were performed with 31 meeting the inclusion criteria.
There were no differences between baseline characteristics of the 2 populations. The INR increased during
liver transplantation (Table). POC-INR measurements were within 0.3 of the LAB-INR, 94%, 81% and 71%
of the time in the three phases of transplantation, respectively. The bias (limits of agreement) between
techniques derived from the Bland-Altman analysis was 0.10 ± 0.37, 0.19 ± 0.38 and 0.21 ± 1.14. Pearson
correlation coefficients for point of care versus laboratory INR readings were r = 0.90, r = 0.86 and r = 0.40.
Four quadrant plots showed concordance of 92% between both the pre-anhepatic/anhepatic and the
anhepatic/neohepatic phases.
Conclusion: POC-INR provides a clinically reliable assessment of INR in the pre-anhepatic and anhepatic
phases and may be a useful component of a blood management protocol in liver transplantation. In the
neohepatic phase the POC-INR results should be confirmed by laboratory testing or other POC tests prior to
transfusion related decision making.
References:
N/A
INR in the 3 phases of liver transplantation. Point of Care (POC-INR), Laboratory (LAB-INR)
Pre-anhepatic Anhepatic Neohepatic

POC-INR
1.64 ± 0.42 1.82 ± 0.37 2.22 ± 0.51
(mean ± SD)
POC-INR
1.54 ± 0.42 1.61 ± 0.35 2.01 ± 0.59
(mean ± SD)
13
S78 Abstracts
39175 - MANAGEMENT AND DECISION MAKING SKILLS: PEDIATRIC AIRWAY OBSTRUCTION
Author(s)
Jennifer E. Sainsbury, MBBS MRCP FRCA
Anesthesia, Toronto General Hospital
Co-Author(s)
David Hamilton, MBBS, MRCS, PhD - NIHR Doctoral Research Fellow, Newcastle University
James Moor, MB ChB, FRCS(ORL HNS) - ENT and Head & Neck Surgery, City Hospitals Sunderland
Paul McAndrew, MBBS, FRCA - Anaesthesia, City Hospitals Sunderland
Ashley Orwin, MBBS, FRCA - Anaesthesia, City Hospitals Sunderland
Purpose: An anticipated difficult pediatric airway is challenging and requires meticulous planning. We
present an unusual case of an acutely and severely compromised airway due to tonsillar hypertrophy, and
subsequent management in terms of technical and non-technical skills. Anesthetic non-technical skills
(ANTS) can be equally important in such scenarios and we advocate use of diagrammatic aids to improve
1,2
patient safety.
Clinical Features: Written consent by the patient’s mother was granted for publication. A seven year-old girl
presented to the ED with a 48-hour history of tonsillar swelling and stridor. She was drooling and in
respiratory distress, with friable grade IV tonsillar enlargement preventing nasal patency and concealing the
oropharynx. The floor of mouth was swollen, with a visible airway under 3mm diameter between the tonsils
and tongue. Near-complete airway obstruction was presumed due to acute tonsillitis or Ludwig’s angina.
Two Anesthesiology Staff and an Otolaryngology Staff performed airway assessment; all had regular
exposure to difficult adult airways and pediatric tonsillectomies. Conservative management was disregarded
due to the progressive nature. Surgical management was indicated and anesthesia required. There were no
portents of difficult tracheal intubation pre-morbidly, however the current situation was of concern due to
inability to visualize beyond the tonsils, possible significant lingual tonsil hypertrophy and uncertainty of
ventilation post-induction. The combined anesthetic and surgical team formulated a clear plan for securing
the airway and displayed it prominently as a flow chart in the operating room. The chart aimed to avoid
ambiguity in a stressful situation, providing prompts if the initial plan failed. There is evidence that airway
management has been improved by the use of guidelines, and Allnutt stated that ‘there is no excuse for
3,4
poorly designed procedures when human life is at risk’. Tracheal intubation was successful following the
charted plan involving an intravenous induction with ventilation confirmation, intubation and subsequent
neuromuscular block, allowing surgery to be completed and the girl was later discharged home. Histology of
the tonsillar tissue demonstrated Epstein-Barr virus.
The case we present is unusual due to the acute nature of near-complete upper airway obstruction in a child
with massive tonsillar hypertrophy. Although infectious mononucleosis (IM) is often managed in the out
patient setting, airway obstruction has been reported as high as 1% and can lead to death. Airway
5
compromise secondary to IM can be due to enlargement of tonsillar tissue or oedema of the epiglottis.
Airway management in the acute situation varies hugely from conservative, “hot” tonsillectomy,
6
nasopharyngeal tube, awake bronchoscopic intubation or tracheostomy.
Conclusion: Successful task performance depends on the effective integration of both technical and non-
technical skills. The use of clear diagrams to aid teamwork in such critical situations can be extremely useful
in allowing efficient communication. Technical and non-technical skills can often be considered equally
important in maintaining patient safety.
References:
1. Br J Anaesth 2002 88 (3); 418-29
2. University of Aberdeen & The Scottish Simulation Centre. Anaesthetists’ Non-Technical Skills (ANTS)
Handbook www.abdn.ac.uk/iprc/ants.
3. Ann Fr Anesth 1999; 18: 719–24.
4. Br J Anaesth 1987; 59: 856–64.
5. Ear Nose Throat J 1995; 74(9): 630-8.
6. Anaesthesia 2011; 66: 828-836.
13
Abstracts S79
13
S80 Abstracts
39176 - HYPERKALEMIA AFTER DECEASED DONOR KIDNEY TRANSPLANTATION
Author(s)
Rohan Kothari, BSc
Toronto General Hospital, University Health Network

Co-Author(s)
Hilary Felici, MSc - Department of Anesthesia and Pain Management, Toronto General Hospital,
Olusegun Famure, MSc., MPH, MEd. - Division of Nephrology and the Kidney Transplant Program,
Toronto General Hospital, University Health Network
S. Joseph Kim, MD, PhD - Division of Nephrology and the Kidney Transplant Program, Toronto
General Hospital, University Health Network
Introduction: Delayed Graft Function (DGF), defined as the need for at least one dialysis session
within the first week of kidney transplantation, is associated with increased hospital stay, and reduced
+
graft survival. The indication for DGF is most often postoperative hyperkalemia (PHK, K > 6mEq) or
fluid overload. The objective of this work was to identify modifiable predictors of PHK in order to
reduce the need for dialysis after kidney transplantation.
Methods: Following Research Ethics Board approval, we conducted a retrospective review of 366
consecutive, adult, deceased-donor, kidney transplants at a single institution between August 2007
and December 2012. Data retrieved from the patient's electronic medical records, and in-house
transplant data base included recipient variables (age, gender, BMI, pre-operative dialysis (timing and
modality), etiology of renal failure, co-morbidities, laboratory values), surgical variables (duration of
surgery, intraoperative fluids and transfusions) and donor variables (age, cold ischemic time and
extended criteria donor status). Clinical relevance and univariable analysis (Kruskal-Wallis, p <0.1)
were used to identify variables for inclusion in multivariable logistic regression analysis to identify
independent predictors PHK. Statistical analyses were performed using SAS version 9.3 (SAS
Institute, Cary, NC).
Results: PHK occurred in 29% (n=107) patients and 27% (n=99) patients developed DGF. Recipient
age, sex, BMI, diabetes, preoperative potassium, dialysis modality and timing, intraoperative blood
transfusion, total intraoperative crystalloids, intraoperative NS, intraoperative balanced salt solutions,
and cold ischemic time were included in the logistic regression analysis. Independent predictors of
+
PHK included recipient BMI [OR 1.06, 95% CI 1.01-1.11, p=0.05], preoperative K > 4.6 mEq [OR
1.78, 95% CI 1.03-3.07, p=0.04], and the intraoperative administration of >1500 ml of NS [OR 2.48,
95% CI 1.36-4.45, p<0.01] (c=0.67, Hosmer-Lemeshow p = 0.38). Of those patients that developed
+
PHK, 48% (n=52) were dialyzed postoperatively while 19% (n=48) of patients with a postoperative K
< 6 mEq had DGF.
Conclusion: The administration of intraoperative NS is associated with an increased risk of

hyperkalemia following deceased donor kidney transplantation and use of alternative crystalloid
solutions, titrated to a patient’s fluid requirements should be considered.
References:
N/A
13
Abstracts S81
39178 - LOW-MOLECULAR WEIGHT HEPARIN AND THROMBOELASTOGRAPHY IN

PREGNANCY
Author(s)
Adrienne Carr, MD
Anesthesia
University of Calgary
Co-Author(s)
Lindsay MacKenzie, MD - Anesthesia, University of Calgary
Adrienne Lee, MD, FRCPC - Hematology, University of Calgary
Lorraine Chow, MD, FRCPC - Anesthesia, University of Calgary
Background: Low-molecular weight heparin (LMWH) is often used for either prophylaxis or
treatment of venous thromboembolism (VTE). Anti-Xa assays can be used as a surrogate for LMWH
1
activity, but there is a lack of consistency between bleeding complications and Anti-Xa levels . Due to
the physiologic changes in pregnancy, weight-based dosing may underestimate the dose requirement
of LMWH. TEG is a point-of-care, real-time technique that may be used to monitor the anti-coagulant
effects of LMWH in pregnancy. The aim of this study is to determine if there is a dose-dependent
change in TEG parameters when serial doses of LMWH are added in vitro to whole blood samples
from term pregnant women. The cut-off value for the TEG parameter that can best identify anti-
coagulated samples with the highest negative predictive value (NPV) is also determined.
Methods: Following approval by local ethic board, ASA I or II parturients presenting for elective
caesarean delivery were recruited. Whole blood was collected before delivery and normal saline or
dalteparin were added to yield final concentrations of 0 (control), 0.05U/ml, 0.25 U/ml, 0.5 U/ml, 0.75
U/ml and 1.0 U/ml anti-Xa activity. TEG tracings were obtained for all six samples using the standard
kaolin protocol. TEG parameters obtained include r time, k time, alpha angle and maximum amplitude
(MA). Groups were compared using pairwise comparison procedure (Dunn’s method) and receiver
operating characteristics (ROC) curves were created for TEG parameters.
Results: SDUWXULHQWV ZHUH UHFUXLWHG 6DPSOHV FRQWDLQLQJ 8P/ DQWL-Xa activity were
FRQVLGHUHG³QRUPDO´DQG8P/DQWL-Xa activity were deemed “anti-coagulated”. There was a
statistically significant difference in median TEG r time, k time, alpha angle and MA between normal
8PODQGVDPSOHV8PO3 The ROC curves (Fig 1) for TEG r and k yielded an
AUC of 0.99 and 0.94 respectively, showing that these two parameters were most useful at detecting
the presence of anti-coagulation in whole blood samples. TEG r time showed a dose-dependent
response to increasing LMWH concentrations.
Conclusion: Our pilot study shows that it may be feasible to utilize TEG to detect the presence of
LMWH in maternal whole blood. TEG r time is the most sensitive and specific parameter for detection
of LMWH. From the ROC curve, the r time cut-off of 6.1 min yielded the best combined sensitivity and
specificity. At this value, the NPV for detecting anticoagulated samples was 95%. This can
potentially translate to a point-of-care test that can be used to determine real-time coagulation status
in patients and safety of neuraxial techniques.
References:
1. J Trauma Inj Infect Crit Care, 2009; 66: 1509-1517
13
S82 Abstracts
ROC Curves, k and r, 60 normals
1.0
0.8
0.6
Sensitivity
0.4
TEG r, A = 0.99
0.2 TEG k, A = 0.94
0.0
0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity
13
Abstracts S83
39181 - MANAGEMENT OF LABOUR AND DELIVERY USING MINIMALLY INVASIVE

FLOTRACTM SYSTEM IN A PARTURIENT WITH CONGENITALLY CORRECTED
TRANSPOSITION, DEXTROCARDIA AND SYSTEMIC VENTRICULAR DYSFUNCTION
Author(s)
Shalini Dhir, MD, FRCPC
Associate Professor
Western University
Co-Author(s)
Jennifer Racine, MD - Anesthesia & Perioperative Medicine, Western University
Ramesh VedagiriSai, MD, FRCA - Anesthesia & Perioperative Medicine, Western University
Introduction: More women with congenital heart disease now survive to reproductive age due to
advances in modern medicine. Obstetric management is challenging in these complex cases. We
present the anesthetic management of labour and delivery in a woman with congenitally
corrected transposition of great vessels, dextrocardia, systemic ventricular dysfunction and junctional
tachycardia using minimally invasive continuous hemodynamic monitoring and optimisation.
Case report: A 28 year old primigravida presented with a diagnosis of congenitally corrected
transposition of great vessels and dextrocardia. The atrial septal defect had been repaired in
childhood. She had good exercise tolerance, stable vital signs and was followed up by Cardiology
team throughout her pregancy. ECHO showed 50% ejection fraction (EF) and mildly reduced
systemic (morphologic right) ventricle. A multidisciplinary meeting between Obstetrics, Cardiology,
Anaesthesia and Intensive care unit (ICU) team was held to decide on optimal obstetric management.
Induction of labour was planned. Patient consent was obtained for publication.
At 37 weeks she developed palpitations, increasing shortness of breath and peripheral edema.
Repeat ECHO showed moderate ventricular dysfunction with EF 40%, severe systemic
atrioventricular regurgitation and severely enlarged left atrium. Prior to labour induction, an arterial
line was inserted and continuous cardiac output monitoring was performed using arterial pressure
TM
waveform analysis with the FloTrac monitor. Hemodynamic optimization was guided by stroke
volume variation and goal directed fluid therapy. A lumbar epidural was then inserted followed by
rupture of membranes and oxytocin infusion. Fluid balance was closely monitored continuously using
TM nd
FloTrac system. First stage of labour was uneventful and 2 stage was shortened using vacuum
assisted delivery of a healthy baby. She had a second degree tear which was repaired. Post partum
hePRUUKDJHGXHWRXWHULQHDWRQ\ZDVWUHDWHGZLWKȝJ0LVRSURVWROUHFWDOO\DQGLQWUDYHQRXVLQIXVLRQ
of 20 IU of Oxytocin. Estimated blood loss was 800 mL. Cardiac condition was stable apart
from persistent tachycardia throughout labour. Postpartum, she spent 24 hours in ICU with similar
monitoring. Her tachycardia settled spontaneously. She was discharged home on day 4.
Discussion: Patients with congenitally corrected transposition have a thin-walled right ventricle as
the systemic circulatory pump. The stress of increased cardiac output can cause failure,
1
atrioventricular regurgitation and arrhythmias . We used minimally invasive continuous cardiac output
TM
monitoring using FloTrac system, fluid balance optimisation and good maternal pain control to
prevent decompensation and achieve vaginal delivery with a good feto-maternal outcome.
References:
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of moderate to complex congenital
heart disease and the impact of pregnancy. Part I: the transposition complexes. Int J Obstet
Anesth. 2010 Jul;19(3):298-305
13
S84 Abstracts
39184 - NOONAN’S SYNDROME, MICROGNATHIA AND ACUTE RESPIRATORY FAILURE
Author(s)
Andrew Lokoff
School of Medicine, Royal College of Surgeons, Dublin
Introduction: A case describing a patient with Noonan’s Syndrome accompanied by extreme

micrognathia who presented in acute respiratory failure for airway management.
Methods: Institutional approval of the hospital ethics committee was obtained, as was consent from
the family of the patient. The patient was a 28 year old admitted to the hospital with cough,
hemoptysis and frothy sputum. Past medical history included Noonan’s Syndrome, which, in this
patient, included severe micrognathia, short stature and mitral regurgitation. The patient also had a
previous tracheostomy and was known to have subglottic stenosis. Hours after admission, the
patient’s condition deteriorated rapidly such that he was in extreme respiratory distress, with copious
frothy sputum and oxygen saturation of 80% on 100% oxygen by face mask. ENT and Anesthesia
were consulted and the patient was taken to the operating room for airway management. The airway
was topicalized, and the anxious patient was sedated with a plan for an awake, fiberoptic or video
assisted intubation. The fiberoptic approach proved to be impossible given the copious sputum. The
video laryngoscope provided a view of the epiglottis, but the severe micrognathia prevented
simultaneous placement of the endotracheal tube. As the patient further desaturated, a number 3
LMA was easily inserted and a tracheostomy was undertaken under general anesthesia. The largest
tracheostomy tube that could be inserted was a number 4 given the previous tracheostomy. Although
initial ventilation was adequate and the patient transferred to ICU, ventilation became increasingly
difficult and, despite returning to the OR, a larger tube could not be inserted. Unfortunately, the patient
arrested and could not be resuscitated.
Results: Noonan’s Syndrome is autosomal dominant. Penetrance is complete and expressivity

variable. Incidence is 1:1000 to 1:2500 live births. There are no chromosomal abnormalities but a
number of genetic mutations have been identified that are associated with this syndrome. These
patients are of particular concern to anesthesiologists as they may have a high arched palate and
micrognathia. Most patients have cardiovascular abnormalities, the most common of which is
pulmonary stenosis, which may be associated with an ASD. Hypertrophic cardiomyopathy is found in
a minority of patients. Short stature, pectus deformities, scoliosis, cognitive impairment and bleeding
1
abnormalities are other characteristics.
Conclusions; Cases reported in the literature include fiberoptic airway management for elective
2 3
cases , and spinal anesthesia for C Sections. This case is unique in that it combines a difficult
airway of Noonan’s Syndrome and acute respiratory failure. It illustrates the limitation of fiberoptic
intubation in this situation and the difficulty of using a video laryngoscope with severe
micrognathia. Either of these approaches may have been successful in more controlled
circumstances. The LMA proved to be a useful rescue airway.
References:
1, Romano, A, Allanson, J, et al. Noonan Syndrome: Clinical Features, Diagnosis, and Management
Guidelines. pediatrics.aappublications.org 2010; 126: 746-759
2, Bajwa, S, Gupta, S, et al. Anesthetic considerations and difficult airway management in a case of
Noonan syndrome. Saudi J Anaesth 2011; Jul-Sept: 345-347
3, McLure, H, Yentis, S, General Anesthesia for Caesarean Section in a parturient with Noonan’s
Syndrome. Brit J Anaesth 1996; 77: 665
13
Abstracts S85
39185 - THE EFFECT OF ALTERING END-TIDAL CARBON DIOXIDE ON CEREBRAL OXYGENATION

DURING ONE-LUNG VENTILATION
Author(s)
Erika R. Bock, MD
Department of Anesthesiology and Perioperative Medicine
Co-Author(s)
Ryan Amadeo, MD - Department of Anesthesiology and Perioperative Medicine, University of Manitoba
WAC Mutch, MD - Department of Anesthesiology and Perioperative Medicine, University of Manitoba
Introduction: The non-invasive measurement of cerebral oxygen saturation (SctO2) has been previously
described[1,2], and is increasingly used clinically to guide anesthetic management - especially in patients
with potential risk of cerebral injury.Decreases in cerebral oxygen saturation have been shown to be
predictive of increased post-operative neurologic and non-neurologic morbidity in different surgical
populations. [2,3] The goal of the study was to compare a ventilation strategy utilizing two distinct levels of
end-tidal CO2 (ETCO2) to determine its effecton cerebral saturation in patients undergoing thoracic
surgery. This study was undertaken because of previous evidence showed cerebral desaturation during
one-lung ventilation (OLV) (1,2, 4). We hypothesized that ventilation to permissive hypercapnia would result
in fewer episodes of cerebral desaturation.
Methods: In a randomized controlled trial, patients were assigned to two minute-ventilation strategies, both
consistent with the current standard of care. One targeted a low normal ETCO2 (Group 1), defined as 32
mmHg, and the other allowed for an increased ETCO2 (Group 2), defined as 42 mmHg. Continuous
measurement of cerebral oximetry and pulse oximetry were undertaken in both groups.
Results: Approval from the institutional Research Ethics Board was obtained and patients provided consent
for participation in thist study. A total of 34 patients were enrolled in this study, with 17 patients in each
group. All patients were included in the final analysis. Thirty-five percent of patients ventilated to an ETCO2
of 32 mmHg had an episode of cerebral desaturation, defined as a cerebral saturation <65%, whereas no
patients ventilated to an ETCO2 of 42 mmHg had a cerebral desaturation (p< 0.003, Fisher exact test). The
lowest average cerebral saturation recorded in Group 1 patients averaged 68(5)%, whereas in Group 2 this
value was 73(4)%. Within each group, patients reached the ETCO2 target and stayed at the target
value range during the duration of OLV , as did the measured PaCO2. No patients required an increase in
FiO2 during OLV in either group.
Conclusions: The management of one-lung ventilation with a permissive increase in ETCO2 decreased the
incidence of cerebral oxygen desaturation, when compared to maintaining ETCO2in the low normal
range. Thus, permissive hypercapnia may be an easy and presumably safe method to treat intra-operative
cerebral desaturations during thoracic surgery. A lung protective strategy allowing permissive hypercapnia
can therefore be employed without concern for the effects on brain saturation. No cerebral desaturations
occurred when hypercapnia was permitted even using an FiO2 of 0.6 , which allows for further protection
against hyperoxia. Further work needs to be performed to confirm our findings and to determine if our
ventilation strategy results in less postoperative neurologic and non-neurologic morbidity.
References:
1. Hemmerling TM, Bluteau MC, Kazan R, Bracco D (2008) Significant decrease of cerebral oxygen
saturation during single-lung ventilation measured using absolute oximetry. Br J Anaesth 101: 870-875.
2. Kazan R, Bracco D, Hemmerling TM (2009) Reduced cerebral oxygen saturation measured by absolute
cerebral oximetry during thoracic surgery correlates with postoperative complications. Br J Anaesth 103:
811-816.
3. Casati A, Fanelli G, Pietropaoli P, Proietti R, Tufano R, Danelli G, Fierro G, De CG, Servillo G (2005)
Continuous monitoring of cerebral oxygen saturation in elderly patients undergoing major abdominal
surgery minimizes brain exposure to potential hypoxia. Anesth Analg 101: 740-7, table
4. Brinkman R, Amadeo RJJ, Funk, DJ, Girling LG, Grocott HP, Mutch WAC. (2013) Cerebral oxygen
desaturation during one-lung ventilation: correlation with hemodynamic variables. CJA 60: 660-666.
5. Mutch WAC, Patel SR, Shahidi AM, Kulasekara SI, Fisher JA, Duffin J, Hudson C. (2013) Cerebral
oxygen saturation: Graded Response to Carbon Dioxide and Isoxia and Graded Response to Oxygen
with Isocapnia. PLOSOne 8 (2): e57881
13
S86 Abstracts
13
Abstracts S87
39193 - BLOOD TRANSFUSION IN AORTIC VALVE REPLACEMENTS WITH ENDOCARDITIS

SUBMISSION TYPE: PRESENTATION
Author(s)
Hannah Dahn
Department of Anesthesia, Division of Cardiac Surgery
Dalhousie University
Co-Author(s)
Karen Buth - Division of Cardiac Surgery, Dalhousie University
JF Legare - Division of Cardiac Surgery, Dalhousie University
Heather Mingo - Pain Therapy and Perioperative Medicine, Dalhousie University
Blaine Kent - Department of Anesthesia, Dalhousie University
Matthias Scheffler - Department of Anesthesia, Dalhousie University
Background: Accurately predicting patients’ blood requirements preoperatively is crucial to ensure

that appropriate blood products are ordered and that blood saving techniques are used when
indicated (1). Past literature has identified underlying endocarditis as a potential predictor of blood
requirements (2). However, it was not clearly determined if the predictive nature of endocarditis was
due to the more complex surgery or to the underlying inflammatory process, which has been shown to
have detrimental effects on blood coagulation (3). This study will investigate what factors of
endocarditis, if any, are predictive of perioperative or postoperative blood transfusion in aortic valve
replacements (AVR).
Methods: After REB approval, data was obtained from a center-specific database as well as chart
review. 662 consecutive AVR cases (isolated AVR, AVR plus root repair/replacement or AVR plus
pericardial patch, excluding AVR for aortic dissection) with aortic insufficiency of 3 or higher since
1995 were analyzed. Cases of remote endocarditis were excluded. Univariate analysis was performed
XVLQJ)LVKHU¶VH[DFWWHVWDQGȤWHVWWRLGHQWLI\YDULDEOHVWKDWPD\EH DVVRFLDWHGZLWKWUDQVIXVLRQRI
any allogenic blood product (pRBC, FFP, platelets, or cryoprecipitate). A multivariate logistic
regression was generated to identify independent predictors of perioperative blood transfusion. In-
hospital mortality was also examined univariately.
Results:The two groups vary significantly on several variables (Table 1). Unadjusted transfusion
rates in patients with no endocarditis, treated endocarditis and active endocarditis (microorganisms
found at time of surgery) were 32%, 60% and 79% (p< 0.001), respectively. Independent predictors of
any transfusion were urgent/emergent surgery (OR=2.845; 95% CI = 1.285-6.299), moderate-severe
preoperative anemia (OR = 11.629; 95% CI = 5.687-23.779), preoperative renal failure (OR = 3.836;
95% CI= 1.595-9.226), BMI 70 (OR = 2.935; 95% CI = 1.585-5.434) and non-isolated AVR (OR =
3.589; 95% CI = 2.162-5.956). Endocarditis was not an independent predictor of transfusion (OR =
0.748; 95% CI = 0.35-1.601). Unadjusted in-hospital mortality in patients with and without endocarditis
was 7.6% and 2.1% (p<0.01), respectively.
Discussion: Aortic valve endocarditis is not independently associated with allogenic blood
transfusion in AVR. Unadjusted transfusion rates are higher in patients with endocarditis. This
appears to be due to the higher prevalence of many independent predictors of blood transfusion
within the endocarditis group.
References:
1) Ann Thorac Surg 2007;83(5 Suppl):S27-86.
2) J Cardiothorac Vasc Anesth 2011;25(1):36-41.
3) Thromb Res 2012;129(3):290-295.
13
S88 Abstracts
13
Abstracts S89
39194 - CANADIAN SURVEY OF NEGATIVE INTRAOPERATIVE BEHAVIORS
Author(s)
Alexander J. Villafranca, MSc
PhD Candidate
Co-Author(s)
Bonnie McLeod, MN - executive committee, International Federation of Perioperative Nurses
Amy Young, MD - Anesthesiology, University of Michigan
Pamela Villafranca, Senior undergraduate student - Conflict resolution studies, University of Winnipeg
Eric Jacobsohn, MBCHB - Anesthesiology and perioperative medicine, University of Manitoba
Introduction: Negative behaviors (NIB) by healthcare workers, which include verbal abuse and
obstructionism, have detrimental effects on teamwork and may affect patient safety. In addition, the
behavioral responses of those subjected to negative behaviors may themselves have consequences
to staff and patient safety. Although negative behaviors in the larger medical profession have been
shown to be ubiquitous, the national prevalence of negative intraoperative behaviours (NIB) has not
been established. Similarly, the systematic evaluation of behavioral responses is lacking.
Methods: Following REB approval, a questionnaire assessing exposure to NIB was distributed to
Canadian OR staff (online and at perioperative conferences). The option to complete a second
questionnaire assessing behavioral responses to NIB was also offered. Exposure to NIB was
quantified using 4 measures: personal exposure, witnessing , self-labeling as being bullied, and self-
labeling as a being subjected to incivility. To facilitate classification, these measures were
dichotomized at frequency cutoffs of interest. Responses to NIB were split into 9 categories: coercing,
competing, compromising, collaborating, ingratiating, being disingenuous, avoiding, acquiescing and
promoting. Response frequency scores of were compared using Friedman's test, with Wilcoxon
signed rank tests and Bonferroni correction for post hoc analysis.
Results: 1088 and 776 respondents completed the exposure and response questionnaires,
respectively. In past year, 64.5% (95% CI 59.6-69.2%) reported being the target of at least 1 NIB, with
9.8% (95% CI 8.0-11.7 %) being a target every few days. Similarly, 31.1% (95% CI 28.3-33.8%)
identified themselves as being victims of bullying at least once in the past year, and 64.0% (95% CI
61.1-66.9%) identified themselves as having been treated with incivility. 89.5% (95% CI 84.5-94.5%)
witnessed at least 1 NIB in the past year, while 25.4% (95% CI 22.7-28.1%) witnessed NIB daily.
The frequency scores of the 9 response strategies differed significantly (p <0.001). Post hoc testing
revealed a number of specific inter-response differences, including the significantly higher average
frequency scores for "acquiescing" compared to all other response types (p<0.001). Examples of
acquiescing behavior are shown in figure 1.
Discussion: Experiencing and witnessing NIB appear to be prevalent in Canada. The most common
response to NIB was "Acquiescing". This is concerning, as such responses may exacerbate the
negative effects of these behaviors by decreasing communication, teamwork and potentially
undermining clinical decision making. As a voluntary survey, prevalence overestimation may have
occurred due to self-selection. The survey is currently being expanded to other English-speaking
countries. Once completed, multivariate analysis will be undertaken allowing us to better understand
predictors and responses to these behaviors.
References:
N/A
13
S90 Abstracts
13
Abstracts S91
39196 - EARLY ENDOTRACHAL TUBE INSERTION WITH GLIDESCOPE USE: A RCT
Author(s)
Jason Fridfinnson, MD
University of Western Ontario
Co-Author(s)
Fiorenzo Cusano, MD - Anesthesiology and Perioperative Medicine, University of Western Ontario
Timothy Turkstra, MD, FRCPC - Anesthesiology and Perioperative Medicine, University of Western
Ontario
Introduction: The GlideScope videolaryngoscope is routinely used worldwide for tracheal

intubation. It is occasionally difficult to advance the endotracheal tube (ETT) into the trachea despite
a good view of the glottis.1,2 One technique that may be utilized when difficulty is encountered is to
introduce the ETT into the pharynx prior to GlideScope insertion. When the GlideScope is
subsequently introduced, the ETT tip is often positioned right at the glottic aperture, facilitating
intubation. This randomized, single blinded trial assessed whether this ETT-first technique could
improve routine (elective) orotracheal intubation with the GlideScope.
Methods: This study was approved by the ethics review board and all participants provided written
informed consent to participate. 160 elective patients with normal-appearing airways who required
orotracheal intubation were randomly allocated to intubation using the ETT-first technique or the
standard technique. The operators were experienced clinicians. The primary outcome was time to
intubation. Secondary outcomes included subjective ease of intubation (10 cm visual analog scale
[VAS] — Easy = 0, Difficult = 10), number of attempts/failures, incidence of oropharyngeal trauma,
and incidence of post-operative sore throat or vocal changes.
Results: Baseline demographics were similar between the two groups. Mean time to intubation (TTI)
was 48.2 (SD 17.1) seconds with the ETT-first technique versus 51.5 (SD 21.8) seconds with the
standard GlideScope-first technique (P = 0.30). The median ease of intubation using the VAS was
13.3 [IQR 5.3-21] with the ETT-first technique, and 13.5 [interquartile range 5.6-29.5] with the
GlideScope-first technique, (p = 0.10).
Discussion: In this study of experienced clinicians, no significant difference was observed in the time
to intubation whether the endotracheal tube or GlideScope was inserted into the oropharynx first.
There was no significant difference between the groups for number of intubation attempts, incidence
of oropharyngeal bleeding, laryngoscopic grade, sore throat, vocal changes or perceived ease of
intubation. Amongst the subset of more challenging intubations, a trend was observed for both easier
and faster performance with the ETT-first technique (See the upper 50% portion of the curves in
Figure). This could suggest additional study would be beneficial.
References:
1) Sun et al. Br J Anaesth. 2005 Mar;94(3):381-4.
2) Cooper et al. Can J Anaesth. 2005 Feb;52(2):191-8.
13
S92 Abstracts
13
Abstracts S93
39197 - PERIOPERATIVE INTRA-ABDOMINAL PRESSURES IN CARDIAC SURGERY
Author(s)
Nathan Scott Ludwig, MD BSc
Anesthesia & Perioperative Medicine
Fraser Alexander Bebbington, MD BSc

Anesthesia & Perioperative Medicine
Ronit Lavi, MD FRCPC

Background: Intra-abdominal hypertension (IAH), a sustained intra-abdominal pressure (IAP) of

greater than 12 mmHg is an important contributor to the morbidity and mortality of critically ill patients.
1,2
Therefore, it is recommended by the World Society of Abdominal Compartment Syndrome to
1,2
regularly measure IAP in critical ill patients who display risk factors for IAH. There is limited data
3,4,5
regarding IAH in patients undergoing cardiac surgery. The aim of this study was to identify
predisposing factors for IAH and characterize changes in IAP during and after cardiac surgery.
Methods: Local ethics committee approval was obtained. 50 patients undergoing elective on pump
cardiac surgery were recruited and informed consent was obtained. Intra-abdominal pressures were
measured using a Foley catheter according to standards set out by the World Society of Abdominal
1
Compartment Syndrome. Measurements were taken at 5 time points: post induction, on arrival to
cardiac ICU, 2 hrs post arrival to cardiac ICU, post op day 1 and post op day 2. At each time point a
set of vitals was taken including blood pressure, heart rate, and urine output. Other data collected for
analysis included demographic, anthropometric, co-morbid conditions, medications, surgical data, and
laboratory values obtained during the perioperative period. Patients’ clinical and procedural
characteristics were correlated with IAP measurements.
Results: Between July 2012 and August 2013, 50 patients (41 men and 9 women) were recruited.
The average age was 65. Thirty three (66%) of patients has at least one reading of increased IAP.
Increased BMI, obstructive sleep apnea, and use of ACE inhibitors were positively associated with
increased IAP (p<0.05). A higher protamine dose was also associated with increased IAP.
Cerebrovascular disease as well as intraoperative vasopressor and inotrope use were associated with
decreased IAP. Other intraoperative variables including surgical duration, bypass time, cross clamp
time, and fluid administration were not associated with increased IAP. There was no association
between IAP and post operative variables including blood transfusion, ICU length of stay, and percent
change in hemoglobin, hematocrit or creatinine from baseline.
Conclusion: A large proportion of patients undergoing cardiac surgery have increased IAP during the
perioperative period. Contributing factors to increased IAP should be assessed and measurement of
IAP during cardiac surgery should be considered.
References:
1) Intensive Care Med. 2013; 39 (7):1190-1206.
2) J Emerg Trauma Shock. 2011; 4(2): 279-91.
3) Appl Cardiopulm Pathophysiol. 2008; 12: 3-12.
4) Interact CardioVasc and Thorac Surg. 2013;17(4):644-51.
5) Intraoperative intra-abdominal pressures in cardiac surgery. Abstract: Canadian Anesthesiologists’
Society, Québec, june 2012
13
S94 Abstracts
IAP Elevated At Any Time

No (N=17) Yes (n=33) P Value
Gender – Male 13 (76.5%) 27 (81.8%) .717
Age – Mean (sd) 65.5 (10.2) 65.5 (8.7) .995
BMI- Mean (sd) 27.0 (4.6) 32.0 (7.0) .011*
Beta Blocker 10 (58.8%) 24 (72.7%) .318
Calcium Channel Blocker 5 (29.4%) 15 (45.5%) .273
ACE I 5 (29.4%) 21 (63.6%) .022
ARB 8 (47.1%) 7 (21.2%) .059
Diuretic 7 (41.2%) 13 (39.4%) .903
Statin 11 (64.7%) 27 (81.8%) .294
Nitrates 7 (41.2%) 16 (48.5%) .623
PPI 1 (5.9%) 9 (27.3%) .134
Diabetes 5 (29.4%) 15 (45.5%) .273
HTN 14 (82.4%) 27 (81.8%) >.999
Prior MI 6 (35.3%) 16 (48.5%) .373
Smoker 10 (58.8%) 17 (51.5%) .623
OSA 0 (0.0%) 9 (27.3%) .020*
CHF 2 (11.8%) 7 (21.2%) .699
Arrhythmia 2 (11.8%) 8 (24.2%) .461
Cerebrovascular Disease 6 (35.3%) 3 (9.1%) .047*
PVD 3 (17.7%) 3 (9.1%) .396
COPD 1 (5.9%) 3 (9.1%) >.999
Procedure .311
CABG 12 (70.6%) 24 (72.7%)
AVR 0 (0.0%) 4 (12.1%)
CABG + AVR 2 (11.8%) 3 (9.1%)
TV REPAIR 1 (5.9%) 0 (0.0%)
AVR MVR 0 (0.0%) 1 (3.0%)
MVR 2 (11.8%) 1 (3.0%)
OR Vasopressor/Iontrope Use 17 (100.0%) 15 (45.5%) <.001*
Epinephrine 7 (41.2%) 11 (33.3%) .584
Norepinephrine 4 (23.5%) 1 (3.0%) .040 *
Phenylephrine 11 (64.7%) 12 (36.4%) .057
Ephedrine 5 (29.4%) 3 (9.1%) .102
Milrinone 3 (17.7%) 4 (12.1%) .677
Blood Products 3 (17.7%) 4 (12.1%) .677
ICU Vasopressor/ Inotrope Use 11 (64.7%) 17 (51.5%) .373
Surgery Duration – Median (Q1, Q3) 225.0 (200, 245) 225.0 (203, 285) .728
By Pass time – Median (Q1, Q3) 104.0 (70, 141) 86.0 (75, 112) .571
Clamp Time – Median (Q1, Q3) 78.0 (47, 90) 62.0 (50, 80) .407
Protamine – Mean (sd) 291.9 (105.1) 362.0 (113.6) .045*
Fluids – Mean (sd) 2111.8 (615.3) 2160.6 (795.7) .826
Length of Stay – Median (Q1, Q3) 1.0 (1, 1) 1.0 (1, 1) .865
CR % Change from baseline – Mean 8.2 (17.8) 12.0 (27.0) .608
(sd)
HB % Change from baseline – Mean -36.4 (11.7) -36.0 (10.7) .912
(sd)
HCT % Change from baseline – -36.5 (11.5) -36.8 (11.2) .926
Mean (sd)
13
Abstracts S95
39201 - SYSTEMATIC REVIEW OF TRANEXAMIC ACID FOR BLEEDING IN CESAREAN SECTION
Author(s)
Ramesh Vedagiri Sai
Clinical Fellow
Obstetric Anesthesia
Victoria Hospital, London Health Sciences Centre
Indu Singh
Associate Professor
Victoria Hospital, London Health Sciences Centre
Co-Author(s)
Philip Jones, Associate Professor - Anesthesia and Perioperative Medicine, London Health Sciences
Centre
Kamal Kumar, Clinical Associate - Anesthesia and Perioperative Medicine, Victoria Hospital, London
Health Sciences Centre
Introduction: Peripartum hemorrhage remains a major cause of maternal morbidity and mortality. The
incidence of peripartum hemorrhage appears to be increasing in developed countries due to an
increased number of placenta accreta or percreta after previous cesarean deliveries. Tranexamic acid
(TXA) has been proposed to prevent peripartum hemorrhage. We conducted a systematic review to
assess the effectiveness and safety of TXA in decreasing cesarean bleeding.
Methods: All randomised controlled trials of TXA given to prevent bleeding during cesarean delivery
were included in this review. We searched multiple electronic databases and the reference lists of eligible
trials. The last database search was conducted on 12th December 2013. There was no language
restriction imposed on the search. The keywords used for the search were (blood) and (loss or
transfusion or hemorrhage or haemorrhage) and (cesarean or caesarean or caesarian or c-section or c
section) and (tranexamic or cyklokapron or lysteda). The databases searched included PubMed/Medline
(25), Embase (90), Cochrane (12), CINAHL (2) giving a total of 129 eligible articles of which 97 were
included in the preliminary assessment of eligibility after excluding duplicates. Of these, we deemed 10
full papers and 2 abstracts met all our requirements. Authors of all the trials had obtained ethical
approval according to local guidelines. Two authors extracted data independently from these trials.
Methodological quality was assessed by two other authors. The primary outcome was blood loss.
Secondary outcomes were blood transfusion, hysterectomy, mean hemoglobin concentration, thrombo-
embolic events and other adverse effects. Meta-analysis will be performed using RevMan software.
1-6
Results: We identified 12 randomised controlled trials involving 2678 participants . 1335 women
received TXA. The trials compared TXA with no treatment or placebo and reported blood loss during and
after cesarean delivery. They also reported on blood transfusion requirements, postoperative hemoglobin
and hematocrit levels, thrombo-embolic events and mild complications. 9 trials used 1 gram TXA prior to
skin incision and 3 trials used 10 mg/kg TXA prior to skin incision. The administration of TXA was
associated with significantly reduced blood loss, reduced transfusion requirements and higher
postoperative hemoglobin concentrations and no serious side effects or complications were reported.
Discussion: Tranexamic acid may reduce blood loss during and after cesarean delivery. However, the
quality of the currently available evidence is limited. Adequately powered, high quality randomized
controlled trials are needed.
References:
1. Int J Gynecol Obstet 2011; 115(3): 224-226
2. Eur J Obstet Gynecol Reprod Biol 2004; 112(2): 154-157
3. J Obstet Gynecol India 2007; 57(3): 227-230
4. J Matern Fetal Neonatal Med 2009; 22(1): 72-75
5. Am J Perinatol 2011; 28(3): 233-240
6. Arch Gynecol Obstet 2013; 287: 641-645
13
S96 Abstracts
39203 - A NOVEL ANALYTICAL PLATFORM ASSESING FUNCTION OF TRANSPLANTED LIVER
Author(s)
Marcin Wasowicz
Associate Professor of Anesthesia
Toronto General Hospital/University of Toronto
Michael Kluger
Dept. of Anesthesia
Toronto General Hospital
Co-Author(s)
Angela Jerath, FRCPC - Dept. of Anesthesia and Pain Management, Toronto General Hospital/University
of Toronto
Janusz Pawliszyn, PhD - Dept. of Chemistry, University of Waterloo
Stuart McCluskey, FRCPC - Dept. of Anesthesia and Pain management, Toronto General
Hoospital/University of Toronto
Erik Yao, BSc (yao.eric) - Anesthesia and Pain Management, Toronto General Hospital/University of
Toronto
Barbara Bojko, PhD - Dept. of Chemistry, University of Waterloo
Introduction: Poor donor graft preservation, ischemic time and reperfusion injury contribute to early graft
dysfunction (EGD) post liver transplantation (LTX). Standard laboratory tests failed to provide early
indication of EGD. Pre-eliminary studies have suggested that prolonged rocuronium-induced
neuromuscular blockade could serve as a marker of EGD following LTX [1]. Metabolomics studies in liver
transplantation have identified potential biomarkers to predict EGD. LTX is associated with abnormal
clotting function and may need significant blood product transfusions. Though tranexamic acid (TXA) is
frequently used to reduce blood transfusion, plasma TXA levels have not been modeled within this
patient group. Solid phase micro extraction (SPME) is a new sampling technique that allows
simultaneous measurement of multiple drugs and metabolites from bio-fluids and tissues [2]. Its first
clinical application was recently tested by our group [3]. Absorption of compounds within the SPME
matrix quenches metabolic pathways capturing many more short-lived metabolites when compared with
previous analytical methods. SPME combines sample extraction, preparation and inhibition of metabolic
process in one step.
The objective of this study is to demonstrate proof of concept in the application of SPME to measure
multiple parameters important to LTX with a single analytical technique. Development a pharmacokinetic
model of rocuronium bromide will serve as a marker on newly transplanted liver function. Measurement
of TXA levels will allow to formulate pharmacokinetic model and metabolomic studies will facilitate
description of metabolomics.
Methods: Local Research Ethical Board approved study and each patient signed an informed
consent. Adults undergoing cadaveric liver transplantation were administered a 1 g of TXA bolus followed
by infusion (10 mg/kg/h) till the end surgery. A 0.6mg/kg bolus of rocuronium was given prior to graft
reperfusion and return of neuromuscular function was recorded with return of train-of-four (TOF).
Concomitant measurement of plasma rocuronium, TXA and metabolomics profile was performed using
SPME. Study included 9 patients. A single testing method was developed for concomitant measurement
of rocuronium, TXA and metabolomics using SPME. Samples obtained from first 5 pts. were used for
method development. Subsequent samples were used for concomitant measurements of TXA,
rocuronium and metabolic profile.
Results: Average time to return of TOF was 102 min (SD 46min). One patient had delayed recovery of
neuromuscular function (pre-existing hepatorenal syndrome). Pharmacokinetic model for rocuronium and
TXA was developed (Fig.1). Global metabolomic profile was analyzed showing significant changes in
metabolites pre and post transplant. Metabolites showing significant changes include histidine, bile acids,
pyruvate and carbohydrates.
13
Abstracts S97
Discussion and conclusions: We have demonstrated proof of concept in developing a single test that
allows simultaneous measurement of multiple medications and metabolomic parameters clinically
important in patients undergoing liver transplantation. Results of this study will allow individual
adjustments in diagnosis and therapy of patients undergoing LTX.
References:
1. Br J Anaesth 2002 88: 764-70
2. Can J Anesth 2012 59: 14-50
3. Anaesth 2012 67: 1242-50
13
S98 Abstracts
39206 - TESTING FOR HEPARIN INDUCED THROMBOCYTOPENIA POST CARDIAC SURGERY
Author(s)
Rizwan A. Manji
Department of Anesthesia and Surgery
Co-Author(s)
Alex Villafranca - Anesthesia, University of Manitoba
Hilary Grocott, MD - Anesthesia, University of Manitoba
Alan Menkis, DDS MD - Surgery, University of Manitoba
Eric Jacobsohn, MBChB, MHPE - Anesthesia, University of Manitoba
Introduction: Thrombocytopenia (Tcp) is common after cardiac surgery and may be due to heparin
induced thrombocytopenia (HIT). HIT has a high rate of thrombosis necessitating anticoagulation with
a non-heparin anticoagulant. Inappropriate anticoagulation for HIT can lead to bleeding or
tamponade. Incorrect diagnosis can lead to morbidity, mortality, and litigation. HIT ELISA reports a
positive (pos) or negative (neg) value, and/or an optical density (OD) value. The gold standard to
diagnose HIT is the serotonin release assay (SRA), which is only done in a limited number of centers.
There are scoring systems to help diagnose HIT. The commonest one is the 4T score (1); a score of
EHLQJDQLQWHUPHGLDWHULVNIRU+,7$QRWKHUVFRULQJV\VWHPLVWKHFDUGLRSXOPRQDU\E\SDVV&3%
VFRUH ZLWK D VFRUH RI EHLQJ KLJK ULVN We sought to determine the ability of the scoring
systems and the ELISA to diagnose HIT, using SRA as the gold standard.
Methods: Local research ethics board approval was granted for this study. Informed consent was
waived for this retrospective chart review. Patients (n=150) were scored using the two systems, and
132 of these with a “pos” HIT ELISA were categorized based on the ELISA OD reading and the SRA
values.
Results: Table 1 shows that higher ELISA readings generally predict higher SRA values; however,
there are some patients with high ELISA OD that did not have high SRA (i.e. the ELISA test is too
sensitive). The two scoring systems (Tables 2a/b) were not accurate in predicting HIT but were better
at predicting who did not have HIT (specific and high negative predictive value).
Conclusions: The ELISA test is sensitive and the scoring systems are specific. ELISA tests that
provide OD values (rather than a dichotomous pos or neg) should be used. If the ELISA OD is high,
then the SRA is likely to be high, justifying the risks of starting a non-reversible, possibly expensive,
non-heparin anticoagulant on a patient at reasonable risk for bleeding/tamponade.
References:
1. J Thromb Haemost 2006; 4: 759
2. J Thromb Haemost 2004; 2: 1882
13
Abstracts S99
13
S100 Abstracts
39207 - UNRECOGNIZED ARTERIAL CANNULATION
Author(s)
Andrew Lokoff
School of Medicine, Royal College of Surgeons, Dublin
Introduction: This case report is about an inadvertent and for a period of time unrecognized
cannulation of the brachial artery using the BD Insyte Autogard ® IV cannulas. These recently
introduced IV cannulas have a membrane that prevents back bleeding upon insertion.
Methods: Consent was obtained from the patient’s family and the institution’s ethics committee. The
patient was a 10 year old with a diagnosis of appendicitis who was transferred from the ER to the
OR. The patient was otherwise in good health. BP was 89/55 in the ER with a pulse of 83. Upon
arrival in the OR, BP was 108/60. The cannla was placed in the ER after multiple attempts, in the
cubital fossa using the BD Insyte Autogard® IV cannula. As per hospital policy, the IV was connected
to an infusion pump, the Alaris CareFusion® infusion pump. The infusion pump alarmed multiple
times prior to transfer to the OR and the alarm was repeatedly silenced.
Upon arrival in the OR, the infusion pump was disconnected, but free flow of the IV could not be
demonstrated. In fact, bright red blood flowed retrograde up the tubing in a pulsatile fashion. It was
clear that the cannula was not in a vein but in an artery, most likely the brachial artery. The cannula
was removed and replaced with one in a vein, and the case proceeded uneventfully.
Results: The most likely explanation was that the cannula placed in the ER was placed into the
brachial artery. The membrane, which is a feature of these cannulas, prevents back bleeding upon
insertion of the cannula. It appears that this membrane prevented the recognition of this inadvertent
arterial cannulation. The patient does not appear to have been hypotensive, which potentially could
have contributed to a failure to recognize the arterial cannulation.
1
Conclusions: Although the risks of brachial artery cannulation are low , injection of propofol into an
2
artery has been reported to cause extreme pain and temporary blanching of the skin . It is advisable
to use caution with these recently introduced cannulas and ensure a freely flowing IV prior to injection.
References:
1, Mann, S, Jones, R, et al. The Safety of Ambulatory Intra-arterial Pressure Monitoring: a Clinical
Audit of 1000 Studies. Int J Cardiol. 1984 May; 5(5): 585-97
2, Ang, B Prolonged Cutaneous Sequelae after Intra-arterial Injection of Propofol. Singapore Med J.
1998 Mar; 39(3): 124
13
Abstracts S101
39222 - JEHOVAH’S WITNESSES IN CARDIAC SURGERY: A RETROSPECTIVE CHART REVIEW
Author(s)
Ryan C. DeCoste, BScH
Dalhousie University Faculty of Medicine
Co-Author(s)
Heather Mingo, RN - Perioperative Blood Management, CDHA
Blaine Kent, MD - Department of Anesthesia, Dalhousie University
Jean-Francois Legare, MD - Department of Cardiac Surgery, Dalhousie University
Karen Buth - Department of Cardiac Surgery, Dalhousie University
Myron Kwapisz, MD - Department of Anesthesia, Dalhousie University
Introduction: Cardiac surgery is accompanied by a substantial risk of blood loss, thus blood
1
management is an important consideration. This is especially true in the Jehovah’s Witness (JW)
2
population, who may not accept blood products for religious reasons. Recent advances in
perioperative blood management may allow these patients to undergo complex surgery with lower
3
risk. The objective of this study was to describe outcomes of JW patients in cardiac surgery at our
centre, and relate these to a comparable group of non-JW patients.
Methods: Ethics committee approval and waiver of consent were obtained. Twenty-five JW patients
underwent cardiac surgery between January, 2008 and June, 2013. Pre-operative characteristics,
operative data and outcomes were obtained through retrospective chart review. Data was collected
on a group of twenty-five non-JW patients in the same fashion. This group was manually matched for
baseline characteristics, including age, sex, body mass index (BMI), procedure, urgency, and
comorbidities.
Results: Mean age of JW patients was 63.4, with 19 male and 6 female. Mean BMI was 31.4. Three
patients underwent previous sternotomy, 1 had pre-existing renal failure, 5 had known peripheral or
cerebral vascular disease, 3 had an ejection fraction <40% and 9 had diabetes. Mean age of non-JW
patients was 64.6, with 19 male and 6 female. Mean BMI was 30.8. Three patients underwent
previous sternotomy, 1 had pre-existing renal failure, 6 had known peripheral or cerebral vascular
disease, 4 had ejection fraction <40% and 6 had diabetes. There were 2 in-hospital deaths, no
cerebrovascular accidents (CVA), 1 serious infection, 2 cases of acute kidney injury (AKI) and 1
cardiovascular intensive care unit (CVICU) readmission in JW patients. Mean CVICU length of stay
(LOS) was 138.8 hours, and mean post-operative hospital LOS was 10.3 days. One death was
attributed to low cardiac output syndrome complicated by anemia, while the other to a valve-related
complication. Of note, 2 JW patients were administered fibrinogen concentrate, available in our centre
since 2010. There were no in-hospital deaths, 2 CVAs, 4 serious infections, 5 cases of AKI, and 4
CVICU readmissions in the non-JW group. Mean CVICU LOS was 140.8 hours, and mean post-
operative in-hospital LOS was 13.4 days. Eight of these patients received blood products (transfusion
rate of 32%).
Conclusions: The low volume of JW patients precludes detection of statistically significant

differences in outcome between JW and non-JW patients undergoing cardiac surgery. However, this
study serves as a starting place to track outcomes of these patients at our centre as increasing
emphasis is placed on blood management in the surgical patient. Nonetheless, it appears that JW
patients may undergo cardiac surgery with favourable outcomes.
References:
1. J Cardiothorac Vasc Anesth 2012 26: 117-133
2. Ann Thorac Surg 2012 93: 19-25
3. J Cardiothorac Surg 2012 7: 95-101
13
S102 Abstracts
39224 - CAN ULTRASOUND SCAN OF THE AIRWAY BE USED TO PREDICT DIFFICULTY OF

AIRWAY MANAGEMENT? A COMPUTERIZED TOMOGRAPHY VALIDATION STUDY
Author(s)
Sherif Abbas, MD
Toronto Western Hospital
Co-Author(s)
Faraj Abdallah, MD. - Anesthesia, St. Michael's hospital
Phantila Cholvisudhi, MBBS. - Anaesthesia, Toronto Western Hospital
Vincent Chan, MD, FRCPC - Anesthesia, Toronto Western Hospital
Eugene Yu, MD. - Radiology, Princess Margaret Hospital
Introduction: Difficult airway management is the most common cause of major anesthesia-related
1
morbidity and mortality. Assessment of the airway to predict difficult airway management relies on
several measurements including visual assessment of the Mallampati score, an estimate of tongue
volume relative to oral cavity volume;2 but the sensitivity and specificity of this measurement is limited
3
and do not exceed 65%. Consequently, difficult airway may not be discovered until laryngoscopy is
attempted, a situation that carries potential risks. Additional bedside tests that increase the capacity to
predict difficult airway management would improve safety. Ultrasound (US) airway scan is a simple
non-invasive test that permits visualization and measurement of tongue and oral cavity dimensions
that may be related to prediction of difficult airway management. However, the exploration of its utility
as a diagnostic tool is precluded by the lack of proof of its validity and reliability. This observational
study examines the validity of US measurement of tongue thickness relative to oral cavity height as
an estimate of tongue volume relative to oral cavity volume by comparison to Computerized
Tomography (CT). We also assess the inter- and intra-observer reliability.
Methods: We recruited 42 adults undergoing high resolution CT scan of the head and neck for the
management of lymphoma, breast, bladder, and cervical cancers. As part of the CT scan, the ratio of
tongue volume to oral cavity volume was calculated; additionally, the ratio of tongue thickness to oral
cavity height was also calculated. Furthermore, two sonographers separately performed US
measurements of the ratio of tongue thickness to oral cavity height before and after CT scan. All
patients had their CT and US scans performed in the same supine position with the mouths open,
after depositing 5 mL of water in the mouth. The open mouth simulated airway dimensions in clinical
scenarios, while water permitted replication of the tongue position and improved palate visualization
by reducing air attenuation.
Results:We analyzed data from 41 patients. The value of Cohen’s kappa statistic for comparison of
CT-measured values of the ratio of tongue thickness relative to oral cavity height, and the ratio of
tongue volume to oral cavity volume was 0.94, suggesting that the first ratio is a highly accurate
approximate of the second. The kappa value for the comparison of the US-measured values of the
ratio of tongue thickness relative to oral cavity height, and the same ratio measured by CT-scan was
0.87, suggesting that the first ratio is an accurate approximation of the second. Furthermore, the
kappa values for inter- and intra-operator US scans were 0.84 and 0.81, suggesting strong inter- and
intra-operator reliability.
Conclusion: Our results indicate that US is a valid and reliable tool for measurement of airway
dimensions predictive of airway difficulty. Further trials are needed to explore the utility of US scan in
the assessment of difficulty of airway management.
References:
1. Anesthesiology 1991;75:1087-110
2. Can Anaesth Soc J 1985;32:429-34
3. Anesthesiology 2005;103:429-37
13
Abstracts S103
39226 - SIMULATION VS DIDACTIC-BASED TRAINING IN IN-SITU CRISIS MANAGEMENT
Author(s)
Eric You-Ten, MD PhD FRCPC
Anesthesia and Acute Pain Service
Co-Author(s)
Iram Ahmed, MD FRCA - Anesthesia, Mount Sinai Hospital, University of Toronto
Naveed Siddiqui, MD - Anesthesia, Mount Sinai Hospital, University of Toronto
Luke Devine, MD FRCPC - Medicine, Mount Sinai Hospital, University of Toronto
Shirley Lee, MD MHSc(Ed) CCFP(EM) - Emergency Medicine, Mount Sinai Hospital, University of
Toronto
Michael Winsbrough, MD CCFP(EM) - Emergency Medicine, Mount Sinai Hospital, University of
Toronto
Jeff Clivatti, MD - Anesthesia, Mount Sinai Hospital, University of Toronto
Sev Perelman, MD MSc CCFP(EM) - Emergency Medicine, Mount Sinai Hospital, University of
Toronto
1
Introduction: Acute critical events are one of the leading causes of adverse patient outcomes. The
unpredictable infrequent occurrence of these high acuity events challenge physician’s ability to
acquire and retain the necessary skills to manage them. High fidelity patient simulators are becoming
2
increasingly utilized in teaching successful management of critical events. While simulation-based
3
training (SBT) has been shown to improve performance in the simulation centre, there is limited
evidence that SBT enhances performance in the actual clinical environment when compared to
4
didactic teaching (DT). Training on the simulator requires significant resources that are costly, and
yet little is known on the transfer of SBT on the performance of CRM in the clinical environment. In
the present study we aim to determine the impact of SBT, compared to DT, on the performance of
CRM in-situ simulation. We hypothesize that SBT, versus DT, improves CRM performance when
managing simulated critical events in the clinical environment (in-situ simulation).
Methods: After IREB approval, consented PGY2 anesthesia and PGY1 emergency family medicine
residents were randomized to the SBT (n=15) and DT (n=17) group. In-situ simulations with on-duty
nurses and respiration therapists took place in the clinical environment using a mobile high fidelity
Simman (Laerdal Medical Canada Ltd, Toronto). Participants were unaware of the time and location
of in-situ simulations. All participants underwent a baseline performance in managing an anaphylactic
reaction in the coronary care unit. One week after the pretest baseline performance, each participant
in the respective group received a teaching intervention consisted of (i) SBT: a 10 mins simulated
respiratory distress scenario followed with a one-hour debriefing on the principles of CRM or (ii) DT: a
60 mins lecture of the Acute Critical Events Simulation Course (permitted by the University of
Ottawa). 3-4 weeks later, participants managed a posttest simulated cardiac arrest on the labour and
delivery floor. All simulation performances were videotaped. Primary outcome was nontechnical skills
as rated by three independent raters using the validated Anesthetists’ Nontechnical Skills Scale
5
(ANTS). Scores were based on a 7-point Lichert scale. (statistical significance, p<0.05)
Results: In DT group, total ANTS scores posttest versus pretest (10.9 [CI 9.6-12.2] vs 8.7,CI 7.4-
10.1, p=0.021) improved significantly. In SBT group, posttest and pretest total ANTS scores were
similar (10.7, CI 9.6-11.9 vs10.3, CI 9.1-11.5, p=.61). Overall ICC 0.77 was very good.
Discussion: Contrary to our hypothesis, DT (course based on critical events management) was more
effective than a one-time SBT in improving CRM performance in in-situ simulations. Future research
invovling deliberate practice with multiple SBT may be more effective to enhance CRM skills in in-situ
simulations and which may translate into better clinical performance.
References:
1. BMJ. 2001 3: 517-9
2. Best Pract Res Clin Anaesthesiol. 2011 25: 239-49
4. BJOG 2006 113: 177–82
5. Br J Anaesth. 2002 88: 418-29.
13
S104 Abstracts
39229 - THE INTRODUCTION OF THE FLIPPED CLASSROOM IN THE ANESTHESIA

CLERKSHIP
Author(s)
Isabella Devito, MD FRCPC
Co-Author(s)
Anita Sarmah, MD FRCPC (MD FRCPC) - Anesthesia, Sunnybrook Health Sciences Centre
Clyde Matava, MBcHB MMed - The Hospital for Sick Children, University of Toronto
Agnes Ryzynski - Sunnybrook Health Science Centre, University of Toronto
Susan DeSousa - Sunnybrook Health Science Centre, University of Toronto
Gary Cronin - Anesthesia, University of Toronto
Introduction: In 2010 the Future of Medical Education in Canada (FMEC) report recommended
increased exposure to the community .(1) Expansion into the community created a barrier, in that all
seminars for our anesthesia clerkship rotation were held centrally. To allow these students equal
access, videoconferencing was initiated; however there were often technical problems. There was a
need to develop a new platform to deliver the curriculum. The “flipped classroom” has been proposed
as a model for delivering medical education, where the learning occurs at home and the application of
knowledge occurs in the classroom. (2, 3) This was an ideal format to remedy our problem.
Methods: A “flipped classroom” was created where e-modules were used to replace the core
seminars. Six interactive e-modules were developed, with pre and post module tests embedded
within for self-assessment. Faculty were available through a discussion board to answer all e-module
related questions.
An exit simulation day was also developed for the second last day of the rotation. Students working in
teams rotated through cases involving preoperative, intraoperative and postoperative cases using
high fidelity simulation, followed by Anesthesia Jeopardy and case based learning (CBL) to review the
e-module content and to allow them to integrate core knowledge. The high fidelity cases highlighted
assessment, risk stratification, patient communication, mental practice, crisis management, closed
loop communication, situational awareness and team function.
Results: Two blocks of students have rotated through the new program to date. Preliminary results
are very positive, with common themes occurring in the comment section regarding the benefits of
mental practice and highlighting situational awareness.
Comparative data from previous years yielded a higher response to the question, “The rotation was a
good educational experience”. For the academic year 2013-14 the response was 4.61/5, in
comparison to 4.45/5, 4.55/5 and 4.38/5 for previous years. In response to the question “Overall the
modules were excellent”, the response was 4.1/5.
Discussion: In alignment with the FMEC recommendations (community) and enabling

recommendations (use of technology), a novel Anesthesia course was developed using the flipped
classroom model. Results to date have been positive. Students are able to learn and review the e-
module content outside of clinical time, allowing them more clinical exposure. They then attended an
exit simulation where the knowledge learned through the modules was applied to clinical cases, thus
allowing them to solidify and apply knowledge related to the core curriculum. As we move forward to
competency based medical education (CBME), this model of the flipped classroom may be useful for
both undergraduate and postgraduate education.
References:
1. http://www.afmc.ca/fmec/pdf/collective_vision.pdf
2. Prober CG, Heath C Lecture Halls without Lectures- A Proposal for Medical Education N Engl J
Med 366;18 1657-1659 May 2012
3. MClaughlin JE, Roth MT, et al The Flipped Classroom: A Course Redesign to Foster Learning
and Engagement in a Health Professions School Academic Medicine Vol 89 No 2 Feb 2014
13
Abstracts S105
39230 - DOES THE TRENDELENBURG POSITION ACTUALLY INCREASE AIRWAY PRESSURES?
Author(s)
Margaret Casey
Medical Student
Michael G DeGroote School of Medicine
McMaster University
Andrew Syrett
Medical Student
Department of Health Sciences
McMaster University
Stephen Bates
Clinical Professor
Department of Obstetrics and Gynecology
McMaster University
Co-Author(s)
Joan Li, M.D. - Department of Family Medicine, McMaster University
Mara Sorbel, M.D. - Department of Obstetrics and Gynecology, McMaster University
Ali Namazie, M.D. - Department of Anesthesiology, Brantford General Hospital
Introduction: Many gynecologic laparascopic surgeries require the use of the head-down
1
(Trendelenburg) position to optimize surgical exposure of the pelvis . This position, combined with
abdominal CO2 insufflation, is known to have a deleterious impact on respiratory mechanics, including
2,3
potentially harmful increases in airway pressures . It is not clear, however, the extent to which the
Trendelenburg position, itself, contributes to this increase. Here, we investigate in women undergoing
major gynecologic laparoscopic surgery whether moving from the horizontal to the head-down
(Trendelenburg) position results in elevated airway pressures.
Methods: This study received approval from the local research ethics committee. Thirty sequential
women undergoing major laparoscopic surgery at a community teaching hospital for the period ending
April 2013 were invited and gave informed consent for enrolment in the study.
All women were placed in the lithotomy position and had standardized general anesthetics with
endotracheal intubation and volume-controlled mechanical ventilation. The peak inspiratory pressure
(PIP), in cm H2O, was the metric chosen to reflect airway pressure. This was measured at the following
points in the surgery: a) patient in the supine position with pneumoperitoneum pressures of 3, 15 and 25
mm Hg respectively and, b) with pneumoperitoneum pressures of 15 mmHg in the degree of
Trendelenburg that provided adequate exposure for the surgeon to safely begin the case. Data was
analyzed using ANOVA and multiple regression models.
Results: With all interventions, PIP equilibrated within five ventilatory cycles in 100 % of women. BMI
was a strong predictor of PIP at baseline (r = 0.66, p<0.0001). There was a strong positive and
statistically significant linear relationship between pneumoperitoneum pressures and PIP (p<0.0001).
Tilting to the Trendelenburg position resulted in a trivial, 1.1 cm H2O (4%) mean increase in PIP. BMI did
not have a statistically significant influence on this increase. (p=0.47).
Discussion: Pneumperitoneum pressures, but not the Trendelenburg position were strong predictors of
airway pressures. In this patient population each 5 mmHg decrease in pneumperitoneum pressure led to
a 10 % decline in PIP. Therefore, during procedures involving higher-than-ideal-ventilator pressures
anesthesiologists and gynecologic surgeons should consider minimizing pneumperitoneum pressures
rather than reducing the degree of head-down tilt.
References:
1. J Am Assoc Gynecol Laparosc 1999 6(3): 245-58
2. J Clin Anesth 2006 18(1): 67-78
3. J Clin Anesth 2001 13(5): 361-5
13
S106 Abstracts
39235 - BESIDE ULTRASOUND OF THE CRICOTHYROID MEMBRANE IN LABOURING

PATIENTS
Author(s)
Eric You-Ten, MD PhD FRCPC
Devdatta Desai
Co-Author(s)
Naveed Siddiqui, MD - Anesthesia, Mount Sinai Hospital, University of Toronto
Introduction: Obesity, defined as a BMI > 30 kg/m2, in the pregnant population has increased
dramatically over the past decade.1 ). In a recent UK national report of over 6400 general anesthesia
in the pregnant population the incidence of failed intubation is estimated to be up to eight times that of
2
the the non-pregnant adult population with an increased risk of 7% for every 1 kg/m gain in
2
BMI. Failed intubation in the obese parturient can rapidly deteriorate into the most feared airway
crisis of “cannot intubate-cannot ventilate”. In this life-threatening airway crisis an emergency
cricothryotomy is the only life-saving procedure. Success with this emergency procedure depends on
the accurate and rapid identification of percutaneous anatomical landmarks. Clinical cases from the
Fourth National Aiway Project 4 and cadaveric studies demonstrated that misidentification of the
cricothyroid membrane (CTM) is among the most common errors for failed cricothyrotomies and
serious airway injuries.3 Over the past few years there is increasing evidence of ultrasonography
(US) in airway management.4 Our HYPOTHESIS is that direct visualization with US-guidance is more
accurate in identifying the CTM in obese parturients. To date, no study has determined the role of
preoperative bedside US in the identification of the CTM in labouring obese parturients. The present
study was to determine the accuracy of US-guided versus conventional finger palpation identification
of the CTM in the obese and non-obese labouring parturients.
Methods: This is an institutional REB-approved prospective single blinded study. Obese (n = 28, BMI
< 30) and non-obese (n = 28, BMI > 30) parturients who were in labour but not in distressed were
recruited and consented. With the parturients in the supine position, voluntary consented anesthesia
staff, residents, or fellows first identified the CTM using the conventional finger palpation method
where the location of the CTM was marked (first spot) on the skin with an ultraviolet invisible
marker. Following the finger palpation, a single operator who is an expert in airway ultrasound then
identified and marked the CTM using a 10-15 MHz linear probe (MicroMaxx system, Sonosite
Canada Inc, Markham, Ontario, Canada). The distance (in mm) of the first (finger palpation)
compared to the second (US-guided) spot was calculated to determine the accuracy of identifying the
CTM.
Results: Our data showed a greater distance between finger palpation and US-guided identification
of the CTM in the obese versus non-obese parturients (mean 6.5 +/- 6.6, median 5.0, range 0.0 , 34.0
mm versus mean 3.5 +/- 4.5, median 1.8, range 0.0 , 15.0 mm; p < 0.0215). Finger palpation was as
accurate (defined as < 1 mm) as US-guided in 48% (n=12/28) of non-obese parturients but only
10.7% (n=3/28) in the obese pregnant population.
Discussion: Our study demonstrates that conventional finger palpation of the CTM in obese
labouring parturients is less accurate than in the non-obese counterparts. This suggests that
preoperative bedside US may play an important pre-emptive strategy to increase the accuracy of
identifying the CTM in labouring obese pregnant patients.
References:
1. J Obstet Gynaecol Can 2010 32: 165-173
2. Br J Anaesth. 2013 110: 74-80
3. Br J Anaesth. 2011 106: 617-31
4. Acta Anaesthesiol Scand. 2011 55: 1155-73
13
Abstracts S107
39236 - PROFOUND HYPERTENSION WITH DEXMEDETOMIDINE SEDATION FOR DBS

SURGERY
Author(s)
Allison Tedder, MBBCH FCA(SA)
Anesthesia
Lakshmikumar Venkat Raghavan, MD FRCPC

Anesthesia
Co-Author(s)
Pirjo Manninen, MD FRCPC - Anesthesia, Toronto Western Hospital
Introduction: Insertion of a deep brain stimulator (DBS) is used in the treatment of various
movement disorders such as Parkinson’s disease. During the procedure having an awake patient
allows for good microelectrode recordings (MER) and stimulation testing for localization of the nuclei
and neurological examination. However not all patients tolerate the procedure without sedation.
'H[PHGHWRPLGLQH D SRWHQW Į-adrenoceptor agonist with anxiolysis, analgesia, sedation,
sympatholysis, and no respiratory depression. It has been used for awake cranitomy and DBS
insertion. (1) We report two patient who developed profound hypertension and oversedation with
dexmedetomidine during DBS surgery. Written informed consent was obtained from both patients for
publication.
Case Report : The first patient was a 70 year old male (72 kg)with history of dystonia with
Parkinson’s disease, hypertension treated with ramipril, and past history of myaesthenia gravis. For
the DBS procedure, sedation was requested as the patient had marked dystonia. In the OR, after
placement of routine monitors (ECG, non invasive BP, SO2, and PETCO2 from oxygen delivering
nasal prongs) sedation with dexmedetomidine was started with a loading dose of 1μg/kg over 10
minutes. At approximately 9 min the patient suddenly became very hypertensive, BP increased from
150/85 to 230/110 mmHg, pulse from 60 to 70 bpm, respiratory rate remained 12-14 bpm. He was
noted to be very drowsy, and unresponsive to commands. Blood pressure was treated with labetolol
and returned to 150/85 in about 10 min. After discussion with neurosurgeons, the patient was taken
for a CT which was normal but surgery was cancelled. After 30 min he was awake and neurologically
intact. He returned for surgery 2 weeks later under propofol and remifentanil anesthesia with no
untoward events. The second patient was 70 yr old male (105 kg) with Parkinson’s disease and
hypertension. He also developed profound hypertension (158/80 to 200/90 mmHg) and increased
drowsiness at about 10 after loading dose of dexmedetomidine (1μg/kg over 10 min) . He was able
communicate. His blood pressure was treated with hydralazine nitroglycerine and returned to normal
in 5 min and surgery proceeded without any complications.
Discussion : The sudden onset of hypertension and severe drowsiness is of concern especially in a
neurosurgical patient. The possible causes considered included an intracerebral bleed, or severe pain
or accidental vascular injection of local with epinephrine causing hypertension, or neuroleptic
malignant syndrome. Dexmedetomidine has been shown to be useful in DBS surgery for sedation and
for controlling blood pressure as it does not interfere with mapping using MER. In our patients we
followed the recommended dosage for dexmedetomidine. However it is possible that this loading
dose was too high for this group of patients. Patients that are elderly, hypertensive, or with known
neurological diseases such as Parkinson’s and their medications may have an unknown reaction or a
SRVVLEOH LQFUHDVHG VHQVLWLYLW\ WR Į-adrenoreceptors. Hypertension has been reported to occur with
dexmedetomidine, but not to the level we observed in our patients.(2)
References:
1. Rozet, I et al. Anesth Anal 2006;103:1224.
2. Byron C, et al. Anesthesiology 1992; 77:1134
13
S108 Abstracts
39239 - SCAVENGING OF VOLATILE ANESTHETICS DURING LONG-TERM SEDATION OF

CRITICAL CARE PATIENTS
Author(s)
Kelvin Wong
Medicine
Co-Author(s)
Marcin Wasowicz, PhD (Marcin.wasowicz) - Anesthesia, TGH
Niall Ferguson, FRCPC, MD - ICU, UHN
Deep Grewal, MD - Anesthesia, TGH
Margaret Doherty, MBBS - Anesthesia, TGH
Andrew Steel, FRCPC. MBBS - ICU, TGH
Introduction: Volatile anesthetics are theoretically ideal intensive care unit (ICU) sedative agents
and represent an attractive modality for long-term sedation. However, the administration of volatile-
based sedation within ICUs has been partly limited by concerns regarding staff exposure and
atmospheric pollution. Previously, our group developed a simple scavenging system to be used with
the Anesthesia Conserving Device (AnaConDa®, Sedana Medical, Sweden) and demonstrated
environmental volatile gas levels to be within current accepted Canadian limits (< 2 ppm) during short-
term sedation in a cardiovascular ICU.1,2
We are currently running the ‘Volatile Anesthetics for Long-term Sedation in Critically Ill Patients
(VALTS)’ study. This substudy reports our initial data on the atmospheric isoflurane levels during this
long-term ICU sedation study.
Methods: The VALTS trial is a prospective, multi-center, randomized control trial recruiting 60 ICU
patients requiring mechanical ventilation > 48 hours. With Research Ethics Board (REB) approval
and patient or surrogate consent, 60 patients will be randomized to receive either isoflurane via the
AnaConDa® device (40 patients) or standard intravenous propofol and/or midazolam (20 patients).
Sedation is titrated to a Riker Sedation Agitation Scale (SAS) score of 3-4 (unless medically indicated
otherwise) using an explicit sedation-analgesia protocol until extubation or tracheostomy. Isoflurane
is infused into AnaConDa® at low rates of 0.5-5 ml/hour. Atmospheric pollution of volatile agents
within the ICU is minimized using a combination of room air exchanges and our previously developed
active scavenging system. This system comprises of two Deltasorb® canisters (Bluezone, ON,
Canada) arranged in-series from the expiratory port of the ICU ventilator to wall outlet
suction. Isoflurane concentrations were measured daily using the InfraRan Specific Vapour Analyzer
st
(Wilkins Enterprise Inc.) at 4 points along the system - (1) Expiratory port, (2) Post 1 Deltasorb, (3)
nd
Post 2 Deltasorb, (4) Patient’s head.
Results: Six patients received isoflurane for mean (SD) 5.7 (3.7) days with average infusion rate of 2
ml/hour. No issues pertaining to the scavenging system or AnaConDa® were encountered. The
mean (SD) isoflurane levels at the expiratory port, post 1st Deltasorb, post 2nd Deltasorb and around
the patients head were 2.9 (1.2) ppm, 2.3 (1.0) ppm, 1.3 (0.9) ppm, and 0.3 (0.4) ppm respectively
(Table 1). No daily measurement around the patients heads exceeded 1 ppm.
Conclusions: This substudy shows volatile anesthetics can be safely administered, with atmospheric
levels well below current Canadian occupational exposure guidelines for long-term sedation in critical
care environments.
References:
1. Pickworth T, et al. Can J Anesth 2013; 60: 38
2. Ontario Ministry of Labour. Occupational Exposure Limits. Available from URL:
http://www.labour.gov.on.ca/english/hs/topics/oels.php
13
Abstracts S109
13
S110 Abstracts
39240 - USE OF FOCUS ECHOCARDIOGRAPHY TO DIAGNOSE AN INCIDENTAL CATHETER

RELATED RIGHT ATRIAL THROMBUS IN A RENAL TRANSPLANT RECIPIENT
Author(s)
Warren Luksun, FRCPC MD
Anesthesia
TGH
Angela Jerath, FRCPC, FANZCA, MBBS,BSc

Anesthesia
TGH
Introduction: Focused Cardiac Ultrasound (FOCUS) is rapid bedside monitoring and diagnostic
1
technique that can be utilized by acute care physicians to assist patient management. The following
case highlights a novel use of FOCUS echo, which altered patient management.
Case: Reporting of this case obtained patient consent. A 23-year-old woman presented for a living
related kidney transplant. She had end-stage kidney disease secondary to Melnick-Fraser
syndrome. Her medical history included hyperlipidaemia and 2 previous failed kidney transplants and
was currently receiving haemodialysis via a tunnelled right subclavian line. Medications included
prednisolone and lipitor. A preoperative FOCUS study was performed to assess her ventricular
function and volume status as part of a new initiative within our department to optimize
haemodynamics and lower incidence of delayed graft function. This study confirmed good cardiac
function and euvolaemia but identified a new 2 x 2 cm right atrial immobile mass adjacent to the
haemodialysis line. She underwent a transthoracic echocardiogram 1 month previously, which did not
identify this abnormality. She was asymptomatic with no prior history of cardiac masses,
thromboembolic events or received anticoagulants. The perioperative team were highly suspicious
that this was a new catheter related thrombus and less likely to be a neoplasm or endocarditis
lesion. We had already harvested the donor kidney and elected to continue with the transplant with
further assessment using intraoperative transesophageal echo (TEE). After inducing uncomplicated
general anesthesia with placement of an awake arterial line, TEE confirmed the above
findings. Contrary to our institutional practice, we elected to not place another central venous
monitoring line in case the wire or line dislodged this mass. Postoperatively, our nephrology and
cardiology teams commenced therapeutic oral coumadin therapy in addition to her standard
immunosupresants. Cardiac MRI confirmed the above diagnosis and her haemodialysis line
th
remained in-situ. She was discharged on the 15 postoperative day with good renal graft
function. She remained on oral anticoagulation for 3 months where follow up TEE confirmed
resolution of this mass with final removal of the haemodialysis catheter. A thrombophilia screen was
performed and negative.
Conclusion: FOCUS is an expanding non-invasive tool, which can management in approximately

1,2
40% patients. This case highlights the novel use of FOCUS echo to optimize fluid and
haemodynamic management for a complex group of patients who are at risk of postoperative graft
dysfunction. In addition, FOCUS identified a new thrombus, which is a well recognized complication
of long-term indwelling catheters that optimized care and safety for this renal transplant recipient.
References:
1. Manasia et al. J Cardiothroac Vasc Anesth 2005; 19:155
2. Lori B et al. Echo 2006; 23; 439
13
Abstracts S111
39241 - SENSORY BLOCK LEVELS DURING CSE IN LABOR: DOSE AND DURAL SAC
INFLUENCE
Author(s)
Cristian Arzola
Co-Author(s)
Rebecca Smith, MD - Department of Anesthesia and Pain Management, Mount Sinai Hospital,
Mrinalini Balki, MD - Department of Anesthesia and Pain Management, Mount Sinai Hospital,
Xiang Y. Ye, MSc - Maternal-Infant Care Research Center, Mount Sinai Hospital, University of
Toronto
Jose CA Carvalho, MD PhD - Department of Anesthesia and Pain Management, Mount Sinai
Hospital, University of Toronto
Introduction: Lumbar cerebrospinal fluid volume measured by magnetic resonance imaging (MRI)
1
bears an inverse correlation with the intrathecal spread of anesthetic solutions. While MRI is a
valuable research tool, it cannot be used at bedside to guide clinical practice. Ultrasound (US) is a
practical bedside resource used to facilitate spinal and epidural anesthesia. A previous study using
one standard dose of bupivacaine determined that US measurements contribute to predict the
2
intrathecal spread during CSE analgesia for labor. We hypothesized that the predictive model could
be improved by studying a dose range of bupivacaine in conjunction with dural sac dimensions and
patient’s characteristics.
Methods: We obtained REB approval and consent for study participation in this randomized, double-
blind controlled trial. We recruited women with singleton term pregnancies requesting neuraxial
analgesia while in labor. US imaging was performed with a 5-2 MHz curved array probe in the left
paramedian sagittal plane at levels L5-S1 to L1-L2. We measured the dural sac width (DSW) at each
lumbar interspace; the lumbar dural sac length (DSL: distance between L5-S1 and L1-L2
interspaces); and the vertebral column length (VCL: distance from C7 prominence to L5-S1
interspace). (Figure1)The lumbar dural sac volume (DSV) was subsequently calculated, assuming
the spinal canal being a cylinder with a diameter equal to the mean value of the 5 DSW
measurements. CSE analgesia was induced with one of 3 doses of 0.25% bupivacaine: 1.5 mg, 2 mg
or 2.5 mg – LQDVVRFLDWLRQZLWKȝJIHQWDQ\O6HQVRU\EORFNOHYHOV6%/WRLFHDQGSLQSULFNJ9on
Frey filament) were assessed at 5, 10, 20, and 30 min. We used mixed effect models for repeated
measures to examine the association of SBL to ice or pinprick with dose, time and patient
characteristics. A predictive model was constructed by multiple linear regression to examine the peak
SBL considering dose, patient characteristics, and US measurements as covariates.
Results: We recruited 60 women (20/dose group). Height, weight, and BMI: mean (SD) of 161.8(6.5)
2
cm, 75.5(11.2) kg, and 28.8(3.8) kg/m . Mean DSW, DSL, VCL and DSV were 1.2 cm, 11.4 cm, 51.5
3
cm and 14.6 cm respectively. The median peak SBL for 1.5, 2.0 and 2.5 mg were reached at 20 min:
T6, T5, T4 (ice) and T8, T7, T6 (pinprick), respectively. We found significant covariates for the
predictive model that includes positive correlation for dose, BMI and inverse correlation for the DSW.
Discussion: We constructed a predictive model of peak SBL that includes the dose, BMI and DSW
obtained by bedside US evaluation of dural sac dimensions. This may assist in predicting block levels
in patients undergoing CSE for labor. Our findings represent another step toward the understanding of
the pharmacology of spinal anesthesia.
References:
1) Anesthesiology 2004; 100: 106-114
2) Reg Anesth Pain Med 2012; 37: 283–288.
13
S112 Abstracts
13
Abstracts S113
39242 - REGIONAL ANESTHESIA IN CANADIAN RESIDENCY: PRELIMINARY SURVEY DATA
Author(s)
Ehtesham Baig
Co-Author(s)
Gianni Lorello, MD - Department of Anesthesia, University of Toronto
Vincent Chan, MD, FRCPC - Department of Anesthesia and Pain Management, Toronto Western
Ahtsham Niazi, MB, FCARCSI, FRCPC - Department of Anesthesia and Pain Management, Toronto
Western Hospital, University Health Network
Introduction: Peripheral nerve blocks (PNBs) have gained popularity over the last decade. In
1
consideration of this there has been a change in regional anesthesia training. Most programs in
America have implemented dedicated regional anesthesia rotations and mandated a minimum
2
number of procedures be completed prior to residency completion. However, a detailed search of the
Royal College of Physicians and Surgeons of Canada (RCPSC) Anesthesiology learning objectives
reveals that there is no stated minimum for Canadian trainees. The objective of this study is to
determine anesthesia residents’ experience in regional anesthesia at the 13 English-speaking
programs across Canada.
Methods: After local research ethics approval, an online survey was emailed to anesthesia program
directors across the 13 English programs in Canada for distribution to their Post Graduate Year (PGY)
2-5 residents. The survey consisted of 3 parts: background and program information, regional
anesthesia experience, and confidence level with each regional anesthesia procedure using a 5-point
Likert scale. Incomplete surveys were excluded. A reminder was sent to all program directors two
months later and the response is ongoing.
Results: Eleven of the thirteen program directors agreed to forward the link to their residents. Based
on resident numbers available on the Canadian Resident Matching Service (CaRMS) website, we
estimated that 300-320 residents received the invitation to participate. To date, 60 responses have
been received to the survey out of which 41 (13% response rate) were complete and included in the
analysis. The survey is currently ongoing and reminder reminders are being sent to increase
response rate. Our preliminary data shows that as expected the number of procedures for each block
increased with each year of training (Table 1). As the experience in performing a specific procedure
increased, the residents also reported having more confidence in performing that procedure. By year
5 of training the most widely practiced procedures were spinals and lumbar epidurals.
Discussion: Our survey is being conducted to assess the experience of Anesthesiology residents
with regional anesthesia procedures during their training. We have found in our preliminary data that
as residents progress through their training they get more exposure to different regional anesthesia
procedures. As well, with increased exposure comes an increased sense of confidence with the
specific procedure. Smith and colleagues have described similar results for American anesthesiology
3
trainees. At present our data shows that the Canadian anesthesia training has a similar exposure to
regional anesthesia techniques as American anesthesia training with spinal and lumbar epidural
blocks being most widely practiced. However, there still seems to be a lack of experience and
confidence in more advanced regional anesthesia procedures. How to address these deficiencies in
resident education in regional anesthesia in the face of reduced work hours remains a challenge.
References:
1. Curr Opin Anaesthesiol. 2008 21(5): 624-31
2. Reg Anesth Pain Med. 2002 27(1): 9-14
3. Reg Anesth Pain Med.1999 24(1): 11-16
13
S114 Abstracts
13
Abstracts S115
39243 - EFFECT OF GENERAL ANESTHESIA ON MICROELECTRODE RECORDINGS
Author(s)
Lakshmikumar Venkat raghavan, MD FRCPC
Anesthesia
Co-Author(s)
Evgeny Rakhman, MD - anesthesia, Toronto Western Hospital
Pirjo Manninen, MD FRCPC - Anesthesia, Toronto Western Hospital
Allison Tedder, MD - Anesthesia, Toronto Western Hospital
Background: Deep brain stimulation (DBS) is well-established treatment for patients with Parkinson’s
disease and other movement disorders. The anesthetic approach may be with general anesthesia,
conscious sedation or monitored anesthesia care with local anesthesia. (1,2) Aim of this study was to
investigate the impact of general anesthetics on microelectrode recordings (MER) and to evaluate
perioperative complications of the patients undergoing insertion of DBS.
Methods: After IRB approval, medical records of all patients who had insertion of DBS under general
anesthesia from 2009 to 2013 were reviewed retrospectively. Data collected and analyzed included
demographics, indications for DBS, targets of insertion, MER, anesthetic management and all
perioperative complications.
Results: There were 20 patients with mean age 33yr; 11 male and 9 female. Indications for DBS
were Dystonia (85%), Parkinson's disease, Epilepsy and others. Most common target of DBS
electrode insertion was GPi (75%). General anesthesia consisted of either total intravenous
anesthesia (propofol, remifentanil) (n= 4 ), inhalation anesthetics (n= 6 ) or combined (n= 10 ). MER
data of 11 patients was analyzed and showed that under anesthesia both firing rates and the patterns
were changed in several nuclei and spontaneous and evoked potentials were suppressed. Further,
there maybe a “bias effect” of anesthetics such that some neuronal subpopulations are more
susceptible to anesthetics than others. Identification of optic tract was difficult under anesthesia. Nine
patients (45%) developed perioperative complications. These include respiratory (n=2, 10%) airway
related (n=3, 15%), and intraoperative hemodynamic complications (n=3, 15%).
Conclusions: In our practice, patients with Dystonia most commonly require general anesthesia for
the DBS. Anesthetics are an additional confounding factor when attempting to determine location of
electrode trajectory, because firing rates and patterns are changed in several nuclei. MER from GPi is
the best under a combination of anesthetics including low dose propofol infusion (25-75 mcg/kg/min),
remifentanil infusion (0.03 mcg/kg/min) and sevoflurane (0.4 vol%). Propofol infusion over 100
mcg/kg/min should be avoided where possible.
References:
1. Br J Anaesth 2009; 103: 152–65.
2. Clin Neurophysiol. 2012;123(12):2406-13.
13
S116 Abstracts
39246 - SPECKLE TRACKING OF THE AORTA AND GENERATION OF PRESSURE-VOLUME

LOOPS
Author(s)
Alexander J. Gregory, MD, FRCPC
Anesthesia
Co-Author(s)
Marelise Kruger, MD, FRCPC - Anesthesia, University of Calgary
Randy Moore, MD - Vascular Surgery, University of Calgary
Neal Maher, MD, FRCPC - Anesthesia, University of Calgary
Gary Dobson, MDCM, MSc, DIC, FRCPC - Anesthesia, University of Calgary
Introduction: Reduced aortic compliance is associated with mortality in hypertensive patients,

impaired systolic and diastolic heart function, reduced coronary blood flow, and the pathophysiology
1,2
of hereditary aortopathies. Measures of aortic compliance often ignore the contribution of
longitudinal stretch to aortic volume change, assume uniform aortic expansion during systole and are
3,4
unable to evaluate compliance throughout the cardiac cycle. Speckle tracking imaging (STI) tracks
echocardiographic tissue motion, provides values for velocity or strain, and has been validated using
5
cardiac MRI and sonomicrometry. Our hypothesis is that STI of the proximal ascending aorta, in
conjunction with invasive pressure monitoring, will allow measurement of aortic volume change and
produce pressure-volume loops similar to those previously obtained from invasive animal studies, a
6
first step in more precisely measuring aortic compliance.
Methods: This study received local ethics committee approval. Data was acquired during general
anesthesia for endovascular abdominal aortic repair. Transesophageal echocardiography was
performed and the volume change of the aortic root and proximal ascending aorta was calculated
using STI-based radial velocities and longitudinal strain rates from the mid-esophageal aortic valve
long axis view. Aortic flow was calculated with LVOT diameter and pulsed-wave Doppler from the
transgastric long axis view. Aortic pressure was derived by recording radial artery pressure and using
a validated transfer function. Graphs were generated for aortic pressure, aortic flow and the rates of
change of aortic pressure (dP/dt) and volume (dV/dt). Aortic pressure as it relates to aortic volume
and pressure-volume loops were also graphed. All graphs were produced using Maple v16.0
(MapleSoft, Waterloo, Ontario).
Results: Thirty-five data sets were acquired from 18 patients (89% male, aged 71 +/- 7 years, MAP
80.7 +/- 13.9mmHg). Three graphs were produced for each patient: 1) aortic pressure, aortic flow,
dP/dt and dV/dt (Fig1A), 2) aortic pressure and volume change (Fig1B) and 3) pressure-volume loop
(Fig1C).
Discussion: Our STI-based method of calculating aortic volume change allows for the production of
pressure-volume loops comparable to those previously obtained. This will allow for the evaluation of
aortic compliance in a more precise fashion than other non-invasive approaches. Furthermore, it will
be possible to calculate compliance in systole and diastole as well as evaluate visco-elastic properties
of the aorta. In addition to further validation of our STI technique, future studies should evaluate
changes in aortic compliance associated with ageing, cardiovascular disease, aortic aneurysm,
heritable aortopathies and following surgical interventions on the aorta.
References:
1. Circulation 2003;107:714-20
2. J Am Coll Cardiol 1994;24:1406-14
3. Cardiovasc Res 1987;21:678-87
4. Eur Heart J 1992;13:1040-45
5. J Am Soc Echocardiogr 2010;23:351-69
6. Am J Physiol Heart Circ Physiol 2011;301:H382-90
13
Abstracts S117
Uploaded File(s)
13
S118 Abstracts
39248 - USE OF INTRA-OPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY TO ASSESS

SUITABILITY FOR UNEXPECTED PNEUMONECTOMY
Author(s)
Andrew Reda
Co-Author(s)
Caleb Zelenietz, Dr - Department of Anesthesia & Perioperative Medicine , University of Manitoba
Heather McDonald, Dr - Department of Anesthesia & Perioperative Medicine , University of Manitoba
Introduction: Pre-operative evaluation of suitability for lung resection has previously been described
(1). Evaluation centres on determining the pre-operative and post-operative predicted respiratory
mechanics, cardiopulmonary reserve and lung parenchymal function. Lung resection is only pursued
when the post-operative predicted function is favourable. Intra-operative events may necessitate
revision of the original surgical plan. The anesthesiologist plays a crucial role in rapidly assessing and
planning in these situations. The use of intra-operative trans esophageal echocardiography (TEE) in
cardiac surgery is well established but its role in non cardiac surgery is still in evolution (2). When
intra-operative findings indicate a need to resect more lung tissue than planned, TEE estimates of
cardiac function can be useful in assessing the cardiopulmonary reserve of patients intra operatively,
and determining suitability for further resection. Additionally, TEE can be useful in determining the
etiology of intra-operative hypotension, especially in patients with preoperative cardiac dysfunction,
and assessing the effects of the chosen treatment (3).
Case Discussion: Patient consent was granted for publication of this case report. An 81 year old
woman with a left lower lobe mass and a history of congestive heart failure (left ventricular ejection
fraction (EF) approximately 35%) underwent elective thoracotomy and left lower lobe resection. She
reported ability to climb three flights of stairs, and was evaluated by a cardiologist prior to surgery.
She had no other objective measurement of cardiopulmonary reserve. Her post operative predicted
pulmonary mechanics and gas exchange were satisfactory for pneumonectomy. The intra-operative
course was complicated by inadvertent division of the left main bronchus. We performed
intraoperative TEE with the pulmonary artery clamped as a surrogate for the patient's ability to
tolerate a pneumonectomy. The TEE findings indicated left ventricular EF of 40% and only slightly
decreased right ventricular function. Although the surgeon was able to perform a bronchoplasty and
avoid pneumonectomy, we felt confident in advising that the patient would likely tolerate the latter
procedure. Intra-operative TEE findings were helpful in making this determination.
Conclusion: Clear communication between the surgical and anesthetic teams is paramount when
intra operative events necessitate deviation from the original surgical plan. Intra operative TEE can
provide valuable information in assessing the suitability of patients with borderline lung function for
unexpected pneumonectomy.
References:
1. Anesthesiol Clin North America 2001;19(3):411-433
2. Curr Cardiol Rev. 2011 Aug;7(3):184-96
3. J Cardiothorac Vasc Anesth. 2012 Jun;26(3):362-70
13
Abstracts S119
39253 - CHANGES IN PAIN PERCEPTION AND BRAIN RESPONSES TO HEAT PAIN

STIMULATION DURING TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION
APPLICATION: A FUNCTIONAL MAGNETIC RESONANCE IMAGING STUDY
Author(s)
Jae Chan Choi
Department of Anesthesiology and Pain Medicine
Brain Research Group, Yonsei University Wonju College of Medicine
Co-Author(s)
Do-Joon Yi - Department of Psychology , Yonsei University, Seodaemun-gu, Seoul, South Korea
Jinhee Kim - Department of Psychology, Kangwon National University, Chuncheon, Kwangwon-Do,
South Korea
Jong-Min Lee - Department of Biomedical Engineering, Hanyang University, Seoul, South Korea
Jungho Cha - Department of Biomedical Engineering, Hanyang University, Seoul, South Korea
Introduction: The present study investigated whether pain and brain responses to pain stimulation
are modulated during transcutaneous electrical nerve stimulation (TENS) treatment. We compared
pain perception and brain responses to pain stimulation with and without TENS treatment in healthy
volunteers.
Methods: Twenty-four participants aged 22.46 ± 3.92 years were recruited. Local ethics committee
approval was obtained. During functional magnetic resonance imaging (fMRI) scanning, thermal pain
was applied to the lateral skin of the left lower leg through a thermode that was located between the
cathodes (fibular head level) and anodes (ankle level) of the TENS device. The same pain
experiments were conducted twice for each participant, once with the TENS treatment (TENS
condition) and once without (control condition). The participants were given an advance visual cue 2 s
prior to pain stimulation. Participants then received a 15-second, 45°C pain stimulation, followed by a
30-second resting period. This 47-second (2+15+30) block was repeated 10 times in both conditions.
We selected TENS intensities that were strong yet comfortable for each individual participant. In the
7(16 FRQGLWLRQ 7(16 +] ȝV VZDV DSSOLHG WRSDUWLFLSDQWV DW WKH WLPH SDLQVWLPXODWLRQ
started. When pain stimulation ended, TENS application ended. In the control condition, pain was
applied to participants in the same way it was in the TENS condition, but without TENS treatment. For
the first 5 seconds of the 15-second TENS application period, participants in the TENS condition
received their own comfortable TENS intensity (CTI); for the second 5-second period, they received
CTI plus 1 mA; and for the third 5-second period, they received CTI plus 2 mA. Pain threshold (°C)
was defined as the lowest temperature at which the participants reported pain. Ratings were
assessed using a numerical rating scale; 0 = no pain/anxiety/unpleasantness; 100 = maximum
imaginable pain/anxiety/unpleasantness. Images were acquired using a 3T MRI scanner.
Results: Pain thresholds were significantly lower in the control condition than in the TENS condition
(p < 0.001). Pain and unpleasantness ratings were significantly higher in the control condition than in
the TENS condition (p < 0.001). The anterior cingulum and bilateral thalamus were activated more
significantly during pain stimulation in the control condition than in the TENS condition (false
discovery rate = 0.05). The postcentral cortex and superior parietal cortex were activated more
significantly during pain stimulation in the TENS condition than in the control condition (false positive
rate = 0.05).
Discussion: The postcentral cortex and superior parietal cortex may be activated by TENS.
Activation of the postcentral cortex and superior parietal cortex may reduce pain perception during
TENS treatment.
References:
1. Arch Phys Med Rehabil. 2010 91:1160-1165.
2. Clin J Pain 2012 28 :581-588.
13
S120 Abstracts
39255 - FIBRINOGEN CONCENTRATE IN CARDIAC SURGERY: A RETROSPECTIVE CHART

REVIEW
Author(s)
Antonio C. Weingartshofer, B.Sc. (Hons)
Perioperative Blood Management
Capital Health District Authority
Co-Author(s)
Heather Mingo, RN - Perioperative Blood Management, Capital Health District Authority
Blaine Kent, MD - Department of Anesthesia, Capital Health District Authority
Jean-Francois Legare, MD - Department of Cardiac Surgery, Capital Health District Authority
Karen Buth - Department of Cardiac Surgery, Capital Health District Authority
Myron Kwapisz, MD - Department of Anesthesia, Capital Health District Authority
1
Background: Cardiac surgery is often accompanied by excessive perioperative bleeding. As a
precursor to fibrin, adequate levels of fibrinogen are necessary to improve clot strength via the
2
interaction between fibrin and platelets. A retrospective chart review seeks to show the effectiveness
of fibrinogen as a primary line of treatment for excessive bleeding in a perioperative setting over
conventional treatments alone, specifically fresh frozen plasma (FFP) and cryoprecipitate.
Methods: Ethics committee approval was obtained. 50 patients receiving fibrinogen between January
2010 and June 2013 were matched manually based on age, sex, procedure and redo (any previous
sternotomy). Pre-operative characteristics, operative data and post-operative outcomes were
collected through retrospective chart review for both groups. Groups were subsequently narrowed to
20 patients each and matched based on hemoglobin values, using World Health Organization (WHO)
criteria, to define categories for normal hemoglobin, mild anemia and moderate to severe anemia,
procedure type, and redo procedures. Data were subjected to statistical analyses of the results via
paired t-test (for continuous data, normally distributed), Wilcoxon signed rank test (for ordinal data
and for continuous data not normally distributed), and McNemar test (for dichotomous data).
Results: The high number of urgent and emergent cases in the fibrinogen group lead to a lower
baseline hemoglobin value than the non-fibrinogen group, subsequently leading to a higher
transfusion rate of red blood cells (RBC), platelets, and FFP. No significant difference was found in
transfusion rate of cryoprecipitate (see Table 1 below). Patients matched in smaller groups showed
similar results. The fibrinogen group had a significantly higher transfusion rate for RBC (3.05 units per
patient compared to 0.95 in the non-fibrinogen group) and platelets (1.55 units per patient compared
to 0.15 in the non-fibrinogen group). Post-op hemoglobin values were also significantly lower in the
fibrinogen group than in the non-fibrinogen group (90.2 g/L and 97.4 g/L, respectively). No significant
difference was noted in transfusion rate for FFP or cryoprecipitate. In-hospital mortality and stroke
rates, along with cardiopulmonary bypass (CPB) time, ventilation time, length of stay in the
cardiovascular intensive care unit (CVICU) and total hospital length of stay (LOS) all reported non-
significant differences.
Discussion: Fibrinogen concentrate did not lower transfusion rate, nor did it increase the risk in post-
operative adverse events. As the study was retrospective in nature, it is important to take confounding
variables into consideration, including different transfusion triggers among different surgeons and
anesthetists, higher probability patients who had more bleeding and blood transfusions receiving
fibrinogen concentrate and inconsistent timing and dosage. However, the study is an inaugural step in
emphasizing the growing importance of perioperative blood management, and further demonstrates
the need for a larger scale randomized prospective study to fully show the effects of fibrinogen
concentrate.
References:
1. J Cardiothorac Vasc Anesth 2012 26: 117-133
2. Br J Haematol 2010 149: 834-843
13
Abstracts S121
13
S122 Abstracts
39256 - PERIOPERATIVE MANAGEMENT OF URGENT SURGERY: A QUALITY IMPROVEMENT

INITIATIVE
Author(s)
Josie Xu, BHSc
School of Medicine
Queen's University
Co-Author(s)
Michael McMullen, MD FRCPC - Department of Anesthesiology and Perioperative Medicine, Queen's
University, Kingston General Hospital
Dale Engen, MD FRCPC - Department of Anesthesiology and Perioperative Medicine, Queen's
Rob Tanzola, MD FRCPC - Department of Anesthesiology and Perioperative Medicine, Queen's
Introduction: The perioperative management of patients requiring urgent or emergent surgery is a

1
complex process involving multiple interdisciplinary interactions . Current practice at our academic
center involves the surgical service triaging patients in a classification system with stated maximum
accepted wait times (A case <2 h, B case <8h, C case <24h). This triaging system can be inefficient
for numerous reasons. The objective of this project is to review the process of care from initial
presentation to definitive treatment in the operating room in order to identify barriers to optimal care.
Methods: Following local ethics approval, all patients who were scheduled for emergency surgery (A
or B cases) at our academic hospital from January to March 2013 were identified from the hospital
database. A detailed chart review was done for each case to develop an individual perioperative care
timeline from time of presentation until the start of the surgical procedure.
Results: A total of 285 patients underwent emergent/urgent surgery during the study and were
included in our review. General Surgery was the most highly represented service (41%) amongst all
cases. The majority (75%) of cases and in particular 94% of the emergent (A cases) occurred during
the on call period (outside of weekdays 07:45-15:30). With respect to local guidelines, 83% of the
fully-documented cases were started within the accepted time limits (Figure 1). The average wait
times from initial physician assessment to OR arrival was 2:35 ± 2:11 for emergent (A) cases and
14:03 ± 17:25 for urgent (B) cases. However, this data was limited by incomplete booking forms in
29% of cases.
Discussion: In assessing the timeline of perioperative care, six distinct stages were identified: 1)
Arrival at ER 2) Assessment by ER physician 3) Consult to surgical service 4) Booking by surgical
service 5) Assessment by anesthesia 6) OR arrival. Each stage has unique requirements that can
potentially prolong the time to definitive operative treatment.
Our review suggests that the majority of emergency surgeries are meeting acceptable wait times.
However, these conclusions are limited by incomplete data capture in the current OR booking
process, especially in A cases. The recent adoption of electronic data collection in the OR will
hopefully assist in future quality improvement studies. The majority of urgent cases occured during on
call hours and this needs to be considered in the future allocation of operating room resources. Future
research efforts in this area should include looking for patterns in cause of treatment delay and value-
mapping of the various stages of care.
References :
Australian Health Review. 2006; 30(2) 219-231
13
Abstracts S123
13
S124 Abstracts
39258 - EXTERIORISATION COMPARED TO IN SITU UTERINE REPAIR FOR CESAREAN

DELIVERY: A SYSTEMATIC REVIEW AND META-ANALYSIS
Author(s)
Valerie Zaphiratos, MSc, MD, FRCPC
IWK Health Centre, Halifax, NS & Hôpital Maisonneuve-Rosemont, Montreal, QC
Co-Author(s)
John Colin Boyd, MSc - Women's and Obstetric Anesthesia, IWK Health Centre, Dalhousie
University, Halifax, NS
Ronald B George, MD, FRCPC - Women's and Obstetric Anesthesia, IWK Health Centre, Dalhousie
University, Halifax, NS
Ashraf S Habib, MB, ChB, MSc, MHS, FRCA - Women's and Obstetric Anesthesia, Duke University
Medical Center, Durham, NC, USA
Introduction: Cesarean delivery (CD) is one of the most common surgical procedure performed in
the world. The optimal surgical technique to limit maternal morbidity is debatable. One aspect of this
debate relates to the method of uterine repair following delivery. Proponents of uterine exteriorisation
(UE) claim better surgical visualisation, faster repair, and better control of hemostasis, whereas those
who favour in situ repair are concerned about uterine traction causing nausea and vomiting, pain, and
hemodynamic instability, as well as trauma and infection to the surrounding structures. Therefore, we
performed a systematic review of randomised controlled trials to compare UE versus in situ repair
during CD on maternal complications.
Methods: The systematic review adhered to PRISMA guidelines. CENTRAL, MEDLINE (PubMed),
EMBASE, and CINAHL were systematically searched. The MeSH term for CD and its different
spellings were combined with text searches for “repair”, “uterus”, “exteriorisation”. The results of these
searches were combined with a sensitive methodological filter for randomised trials, meta-analyses,
and systematic reviews. All published randomised controlled trials involving a comparison of in situ
uterine repair during CD compared to UE were included. Primary outcomes sought included incidence
of intraoperative complications (nausea, vomiting, pain), blood loss (reduction in hemoglobin,
estimated blood loss) and postoperative infection (endometritis, wound infection). Secondary
outcomes included operative time, hospital stay, blood transfusion, fever, postoperative pain, and
return of bowel function. Studies were included if they reported any of the primary outcomes.
Results: Refer to table 1 for summary of results. Sixteen manuscripts were selected for in-depth full-
text review, from which 14 manuscripts were deemed low-risk of bias and included in this systematic
review. A total of 9077 subjects underwent UE, while 9054 subjects had in situ repair. Pooled results
of the two repair techniques did not show a difference in intraoperative nausea, nor intraoperative
vomiting. The data for intraoperative pain is inadequate to reach a conclusion due to the wide
confidence intervals. Analysis of drop in hemoglobin revealed no significant difference between repair
techniques. Although there was a tendency to favour UE for estimated blood loss, this difference was
not statistically significant. Endometritis pooled results showed a statistically significant difference
favouring in situ repair. There was no difference in wound infection between the two repair
techniques. There was a statistically significant difference favouring in situ repair for return of bowel
function. Additional outcomes such as operative time, hospital stay, blood transfusion, and fever did
not show a significant difference between groups.
Discussion: In contrast to an earlier systematic review, we found that in situ repair may be
associated with less endometritis and faster return of bowel function. More well conducted
randomised controlled trials are needed that focus specifically on intraoperative complications such as
nausea, vomiting and hemodynamic instability.
References:
1. Cochrane Database Syst Rev 2004 4: CD000085
2. Am J Obstet Gynecol 2009 200: 625 e621-628
3. Ann Intern Med 2009 151: 264-269, W264
13
Abstracts S125
Number
Exteriorisation In Situ patients Odds Ratio (OR) or Mean
Analysis of RCTs p-value Heterogeneity
patients n = 9077 n = 9054 Difference (MD)
n = 14
Intraoperative Nausea 4 534 537 OR 1.14; 95% CI [0.70, 1.87] 0.60 50%
Intraoperative Vomiting 4 536 539 OR 1.10; 95% CI [0.65, 1.83] 0.73 33%
Intraoperative Pain 3 213 226 OR 1.57; 95% CI [0.91, 2.74] 0.11 0%

Drop in Hemoglobin
5 3297 3288 MD -0.14; 95% CI [-0.31, 0.04] 0.13 85%
(g/dL)
MD -61.03; 95% CI [-127.34,
Estimated Blood Loss (ml) 6 454 454 0.07 76%
5.28]
Endometritis 7 8340 8320 OR 1.40; 95% CI [1.08, 1.81] 0.01 44%
Wound Infection 8 8096 8092 OR 1.07; 95% CI [0.60, 1.89] 0.83 89%
Return of Bowel Function 3 2739 2734 MD 3.16; 95% CI [1. 05, 5.27] 0.003 92%
Operative Time (min) 12 8551 8534 MD 0.61; 95% CI [-2.70, 3.91] 0.72 99%
Hospital Stay (days) 8 8084 8077 MD 0.15; 95% CI [-0.11, 0.41] 0.25 98%
Blood Transfusion 9 8288 8280 OR 1.02; 95% CI [0.43, 2.42] 0.96 56%
Fever 5 5305 5305 OR 1.03; 95% CI [0.73, 1.44] 0.88 0%
13
S126 Abstracts
39259 - CASE REPORT OF VERTEBRAL OSTEOMYELITIS AFTER EPIDURAL ANALGESIA
Author(s)
Ahmed Bokhari
Obstetrical Anesthesia Fellow
Anesthesia
University of Manitoba-WRHA
Co-Author(s)
fahd AlGurashi, MBBS,FRCPC,MBA - Department of Anesthesia and Perioperative Medicine,
1-2
Introduction: Vertebral osteomyelitis after epidural catheterization is extremely rare complications .
A literature search of published articles found only ten cases of vertebral osteomyelitis as a
3
complication of epidural catheter use . We present a rare case of vertebral osteomyelitis in healthy
parturient who had an epidural catheterization for labour analgesia and used for emergency cesarean
section.
Methods: The patient and her family were consented to publish this data as case report. A 29 years
old female patient G2P1 presented to emergency department one week after her surgery with history
of backache associated with fever, chills and lethargy. The patient was readmitted with sever sepsis.
The initial differential diagnosis of endometritis, deep wound infection and urosepsis were considered.
She was resuscitated and treated with antibiotics. Physical exam and Echocardiogram confirm the
diagnosis of infective endocarditis, which has been treated medically. Blood culture grows Methicillin
sensitive staphylococcus aureus, which was sensitive to antibiotic regime. The patient continues to
complain of backache despite the initial normal studies of Magnetic resonance imaging (MRI) of
lumber spine. The second MRI confirmed the diagnose of Vertebral osteomyelitis at levels of L2 and
L3, which where was the insertion of epidural catheter. A concealed course with no neurological
deficit resulted in a delayed diagnosis in this case. The patient was treated with long term IV
antibiotics and serial MRI scans of the lumber spine.
Results and Discussion: Anesthesiologists and obstetricians should be aware that serious epidural
analgesia-related infections could happen. Vigilance for these infections, especially in postpartum
patients with backache, is needed
References:
1. Coapes CM, Roysam GS. Vertebral osteomyelitis secondary to epidural catheter use: a case
report. Spine 2001;26:1492–1494
2. Wenningsted-Torgard K, Heyn J, Willumsen L. Spondylitis following epidural morphine. A case
report. Acta Anaesthesiol Scand 1982;26:649–651
3. Krishnakumar, Renjitkumar. Methicillin-Resistant Staphylococcus aureus Vertebral Osteomyelitis
Following Epidural Catheterization: A Case Report and Literature Review. Global Spine J
2012;2:231–234
13
Abstracts S127
39261 - GASTRIC ULTRASOUND IN FASTED PREGNANT WOMEN FOR CESAREAN DELIVERY
Author(s)
Cristian Arzola
Dr Cristian Arzola
Co-Author(s)
Naveed Siddiqui, MD MSc - Department of Anesthesia and Pain Management, Mount Sinai Hospital,
Anahi Perlas, MD - Department of Anesthesia and Pain Management, Toronto Western Hospital-
UHN, University of Toronto
Jose CA Carvalho, MD PhD - Department of Anesthesia and Pain Management, Mount Sinai
Hospital, University of Toronto
Introduction: Pulmonary aspiration of gastric content is one of the most feared complications in
obstetric anesthesia. Bedside gastric ultrasonography (US) can be reliably performed by
1 2
anesthesiologists to assess gastric content in the perioperative period, and may be useful in risk
assessment and clinical management. We aimed to describe the qualitative and quantitative US
assessment of the gastric antrum in fasted pregnant women.
Methods: We obtained REB approval and consent for study participation in this prospective,
descriptive study in non-laboring pregnant women at term scheduled for elective cesarean delivery.
Subjects were examined after a minimum period of overnight fasting (solid food-8 hrs; clear fluids-2
hrs) and prior to the cesarean delivery. Two anesthesiologists performed a standardized scanning
protocol of the gastric antrum: subjects on a 45-degree semi-recumbent position, first supine and then
in the right lateral decubitus (RLD), using a 2-5 MHz curvilinear array transducer in a sagittal to right
parasagittal plane on the epigastric area. Based on the qualitative assessment of the antrum, subjects
2
were classified following a 3-point grading system : grade 0, the antrum appears empty; grade 1,
small fluid volume only seen in RLD suggesting residual gastric secretions; and grade 2: larger fluid
volume seen both in supine and RLD. In addition, quantitative assessment was performed using 3 still
images of the antrum at rest (between peristaltic contractions) in RLD to measure the cross-sectional
area (CSA) with aid of the built-in caliper (Figure 1).
Results: We have recruited 40 of the 110 planed subjects. Age, height, weight, BMI, and gestational
2
age: mean (SD) of 35.6(5) years, 163.1(8.2) cm, 79.1(15.3) kg, and 29.6(4.7) kg/m , 38.6(0.9) weeks.
Fasting period for solid food and clear fluids: median (IQR) of 13(3) and 3.75(6.5) hours. Qualitative
assessment: grade 0 (18/40,45%), grade 1 (22/40, 55%), grade 2 (0%). Quantitative assessment,
2
mean (SD) [min-max] of CSA in RLD: 4.71(2.1) [1.8-9.7] cm . The qualitative grading system showed
2 2
significant differences for the CSA in RLD: grade 0= 3.11(0.8) cm ; and grade 1=6.09(1.8) cm ; p-
value<0.0001. There was no correlation between hours of fasting and CSA or qualitative grade.
3
Discussion: All women in our study presented with antral CSA compatible with residual gastric fluid.
4
Furthermore, applying the predictive model obtained in non- pregnant population, our subjects
presented with gastric volumes no greater than 110 ml. The qualitative 3-point grading system may be
used to assess individual risk of perioperative gastric content aspiration. The quantitative
measurement of antral CSA is a promising tool for predicting gastric fluid volume.
References:
1) CJA 2013; 60: 771–779
2) Anesth Analg 2011; 113: 93–97
3) BJA 2014, Jan 8.
4) Anesth Analg 2013; 116: 357–363.
13
S128 Abstracts
13
Abstracts S129
39263 - FACTORS INFLUENCING FELLOWSHIP TRAINING AND FUTURE RESEARCH
Author(s)
James S. Khan
Anesthesia
Co-Author(s)
Jaclyn Gilbert, M. Biotech, MD - Anesthesia, McMaster University
Karman Chaudhry, BHSc - Medicine, McMaster University
Yannick LeManach, MD, PhD - Anesthesia, McMaster University
Doreen Yee, MD - Anesthesia, University of Toronto
Introduction: Recent data suggests that graduating physicians are becoming less interested in an
1
academic career. Within anesthesia, there has also been a documented decline in both basic and
2
clinical research over the last two decades. It has been proposed that fostering resident interest in
fellowship training and research can promote future academic physicians. This study aimed to
determine preferences of Canadian anesthesia residents towards fellowships, academic practice, and
future research activities and elucidate factors that affect those preferences.
Methods: An anonymous online survey was sent to all anesthesiology residents currently enrolled in
an accredited Canadian anesthesiology residency program. Local ethics committee approval was
obtained prior to survey distribution. Information relating to demographics, and data on fellowship
training, practice setting, and research were collected from the survey. A multivariable logistic
regression model was used to determine significant factors associated with the decision to pursue a
fellowship, an academic practice, and research after residency.
Results: The response rate of the survey was 44.7% (244 respondents) of all Canadian anesthesia
residents. The mean age of residents was 30 years (SD 4.1). Thirty-five residents (14.3%) possessed
a Master’s degree and 11 residents (4.5%) possessed a PhD. Seventy percent of residents indicated
that they plan on pursuing fellowship training. The top three sought after fellowships were regional
anesthesia (34.1%), intensive care (32.3%), and acute/chronic pain (25.0%). Enhanced employability,
personal interest, and interest in an academic career were the top factors most influential in the
decision to pursue a fellowship. Male gender significantly predicted a resident`s decision to pursue
fellowship training (adjusted odds ratio (OR) 1.87, 95% CI 1.03 to 3.40, p = 0.04) while presence of a
graduate degree reduced a resident’s decision (adjusted OR 0.52, 95% CI 0.30 to 0.91, p = 0.02).
Fifty-seven percent of residents preferred to work at an academic institution upon graduating.
Although 70% of residents indicated current involvement in research activities, only 34% indicated a
desire to incorporate research into their future practice. Interest, lifestyle demands, and lack of
experience were top factors most influential in the decision to pursue research after residency.
Current research activity (adjusted OR 3.50, 95% CI 1.56 to 7.90, p = 0.003) and publishing while in
residency (adjusted OR 4.40, 95% CI 2.02 to 9.56, p < 0.001) were the only significant factors
associated with the intention of future research activities.
Discussion: Although the majority of Canadian anesthesia residents intend on pursuing fellowship
training, only a third intend on pursuing research activities after residency. Several factors have been
identified that influence an anesthesia resident’s decision to pursue a fellowship, academic practice,
or future research. Initiatives to promote future research activities should focus on promoting interest
and exposure to research while in residency.
References:
Borges NJ, Navarro AM, Grover A, Hoban JD. How, when, and why do physicians choose careers in
academic medicine? A literature review. Academic Medicine 2010 85:680–686
Schwinn DA, Balser JR. Anesthesiology physician scientists in academic medicine: a wake-up
call. Anesthesiology 2006 104: 170–178
13
S130 Abstracts
39264 - HIGH VENOUS PRESSURE A RISK FOR LIVER INJURY & DEATH IN HEART SURGERY
Author(s)
Anesthesia
Co-Author(s)
Prashanth Vallabhajosyula, MD - Surgery, University of Pennsylvania
Michael Acker, MD - Surgery, University of Pennsylvania
Warren Levy, MD - Anesthesiology and Critical Care, University of Pennsylvania
Introduction: Post-operative liver failure (POLF) following cardiac surgery in patients with pre-existing
1-3
cirrhosis is associated with high mortality. Chronic venous hypertension may lead to congestive
4,5
hepatopathy and liver fibrosis but there is little data on the risk of POLF in this group. Our objective
was to study the incidence of POLF and the resulting mortality in cardiac surgery patients with high
baseline central venous pressure (CVP). We also evaluated several perioperative factors as
predictors for POLF.
Methods: This study received local ethics committee approval. Data was retrospectively acquired of
on-pump cardiac surgeries over a 15-month period with a CVP of 20-40 mmHg following induction of
anesthesia. Emergency cases were excluded. POLF was defined as 1) post-operative serum total
bilirubin, AST or ALT levels greater than 2.0 mg/dL, 100 IU/L or 100 IU/L respectively within 48 hours
and 2) increase greater than twice pre-operative levels. Both 7-day and 30-day mortality were
assessed. Data included in the analysis for risk factors of ALF are shown on Table 1. POLF and
non-POLF groups were compared with paired t-tests, Chi-squared tests, as well as univariate and
multivariate regression analysis (SPSS v.21, IBM, Armonk, NY).
Results: A total of 1465 cases were evaluated with 9.1% (134/1465) meeting high CVP criteria.
Following exclusion of emergency cases, 106 patients were analyzed. POLF occurred in 34.0%
(36/106) of cases with a 7-day mortality of 22.2% (8/36) and 30-day mortality of 27.8% (10/36)
compared with 2.9% (2/70) and 2.9% (2/70) in the group without POLF (P<0.001). POLF and non-
POLF patients had similar pre-operative STS mortality (3.02% vs 2.40%, p=0.45) and STS
mortality/morbidity (21.23% vs 18.11%, p=0.4) scores. Patients with POLF had lower pre-op albumin
levels and BMI (P<0.01). There where trends towards CVP (p=0.06) and more inpatients (p=0.06) in
the POLF group. No factors were significant in univariate or multivariate analysis, though higher CVP,
low BMI and inpatient status trended as possible predictors for POLF.
Conclusion: Patients with pre-operative venous hypertension are at increased risk for developing
POLF, which is associated with high mortality. Our hypothesis is that these patients suffer from occult
congestive hepatopathy and liver fibrosis which is exacerbated perioperatively. Their risk is not
captured by traditional risk stratification models and is challenging to predict. Future research should
1) analyze the entire spectrum of CVP to identify the threshold for elevated POLF risk, 2) involve
larger sized studies to aid in developing POLF prediction models, 3) incorporate non-traditional pre-op
6
lab tests that correlate with liver fibrosis and 4) determine how best to reduce POLF risk in this group.
References:
1. Ann Thorac Surg 2012; 94:1947-1952
2. Interact Cardiovasc Thorac Surg 2013; 16:332-338
3. Eur J Cardiothorac Surg 2010; 38:592-599
4. Int J Cardiol 2013; 166:554-558
5. Med Sci Monit 2011; 17:CR537-541
6. Clin Chim Acta 2010; 411:86-91
13
Abstracts S131
13
S132 Abstracts
39273 - AN EVALUATION OF THE RESESARCH CLIMATE IN ONE TRAINING PROGRAM
Author(s)
Jennifer M. O'Brien, PhD candidate
Department of Educational Administration & Department of Anesthesiology, Perioperative Medicine and
Pain Management
Introduction: Most Canadian anesthesiology residents are involved in research projects to meet
program requirements for engagement in scholarly activity. Despite this near-universal involvement in
1
research, most residents do not intend to pursue academic careers. We also face a lack of available
2 3
research mentors, and research funding to anesthesia departments relative to other specialties. The
role of organizational climate and culture in resident research programs has not been
explored. Research culture in postgraduate medical education has been conceptualized to include the
extent to which research activity has been integrated into the shared vision and values, and
communicated within the residency program, and can be recognized through the shared language,
4
symbols and artifacts, beliefs, assumptions, and practices of the residency program. Climate is a
tangible artifact of the research culture. Therefore, the purpose of this program evaluation phase was to
gauge the resident-perceived shortcomings in the research climate of a single anesthesia residency
program as the first step towards enhancement of the program’s research culture.
Methods: Following REB approval, anesthesiology residents in years 1-5 were invited to complete the
5
54-item Research Training Environment Scale (R-RTES). This program evaluation phase was exempt
from collecting written consent; completion of scale implied consent. The R-RTES measured the
research training environment on nine subscales. Responses were ranked according to a 5-point Likert
Scale (Disagree, Somewhat Disagree, Neutral, Somewhat Agree, Agree), and negative questions were
reverse-scored. Median and interquartile ranges were calculated for each question, and means for each
subscale, to identify areas for targeted improvement in the research training climate.
Results: See Table 1.
Discussion: These results highlight how residents perceive nine aspects of the research climate of the
residency program. Lower scores in subscales “faculty modelling of appropriate scientific behavior,”
teaching relevant statistics and the logic of design ,” “teaching students to look inward for research ideas”
and “focus on varied investigative styles” are consistent with previous literature citing challenges with
2
mentorship and knowledge of design and statistics. Furthermore, these results suggest general areas
for improvement of the research climate in this residency program, and responses to individual questions
might provide targeted actions for improving climate (e.g. “Many of our faculty do not seem to be very
interested in doing research”). Semi-structured interviews are planned for the next phase to elucidate the
reasons for, and the cultural assumptions underlying these results, and to obtain guidance in deciding
upon interventions with the most potential to enhance the research culture of the program as previously
4
conceptualized.
References:
1. Anesth Analg 2006 102: 859-864
2. Acad Med 2003 78: 61-68
4. J Med Humanit Oct 2013 [Epub ahead of print]
5. Couns Psychol 1996 24(2): 304-322
5
Table 1. Resident (n=30) Subscale Means on the 54-Item Research Training Environment Scale
R-RTES Subscales Mean (SD)
1) Faculty modeling of appropriate scientific behavior 3.8 (0.6)
2) Positive reinforcement of scholarly activities 4.0 (0.6)
3) Early, minimally threatening research involvement 4.1 (0.5)
4) Teaching relevant statistics and the logic of design 3.7 (0.5)
5) Teaching students to look inward for research ideas 3.8 (0.4)
6) Science as a partly social experience 4.2 (0.4)
7) Emphasizing that all studies are flawed and limited 4.0 (0.0)
8) Focus on varied investigative styles 3.5 (0.5)
9) Wedding of science and clinical practice 4.0 (0.0)
13
Abstracts S133
39274 - REEXPANSION PULMONARY EDEMA AFTER CARDIAC SURGERY
Author(s)
Mark P. Tutschka, FRCPC
Division of Critical Care
London Health Science Centre, The University of Western Ontario
Co-Author(s)
Daniel Bainbridge, MD, FRCPC - Department of Anesthesia and Perioperative Medicine, London
Health Science Centre, The University of Western Ontario
Michael Chu, MD, MEd, FRCSC - Division of Cardiac Surgery, London Health Science Centre, The
Philip Jones, MD, FRCPC - Department of Anesthesia and Perioperative Medicine, London Health
Science Centre, The University of Western Ontario
Introduction: Increased radiographic opacification of the right versus left hemithorax has been
observed in patients who have undergone minimally-invasive cardiac surgery at our institution.
Significant complications occurred in several of these patients. We believe this finding represents an
underreported variant of reexpansion pulmonary edema and sought to characterize its incidence, risk
1,2
factors and morbidity .
Methods: Institutional Review Board approval was obtained before data collection commenced. We
retrospectively reviewed all cardiac surgery cases that combined a right-sided thoracotomy approach
with cardiopulmonary bypass at our institution for the period January 1, 2005 to December 31, 2012.
Reexpansion pulmonary edema was defined on the first postoperative day chest radiograph as
relatively increased opacification of the right versus left hemithorax involving at least 20% of the chest
field, not better explained by atelectasis. Two independent investigators reviewed each radiograph for
presence of reexpansion pulmonary edema. Patient data was obtained from a prospectively collected
database maintained by The Division of Cardiac Surgery or directly from the patient record.
Results: 278 patients underwent minimally-invasive cardiac surgery employing a right-sided

thoracotomy and cardiopulmonary bypass during the study period. 277/278 chest radiographs were
available for review. Of these, 68 (25%) were positive for reexpansion pulmonary edema by our
dHILQLWLRQ ț IRU UDGLRJUDSK LQWHUSUHWDWLRQ > FRQILGHQFH LQWHUYDO -0.59, p <0.001] —
indicating moderate agreement). Patients with reexpansion pulmonary edema were more likely to:
have a lower postoperative p/f ratio (205 vs. 270, difference 65 [95% confidence interval of difference
36-93], p <0.001), require vasoactive medications for greater than 24 hours (31% vs. 9%, p = <0.001),
require mechanical ventilation for greater than 24 hours (33% vs. 2%, p <0.001), have longer
intensive care unit lengths of stay (median 2 days [interquartile range 1-4] vs. 1 day [interquartile
range 1-2] , p <0.001), have longer hospital lengths of stay (7 days [interquartile range 5-11] vs. 6
days [interquartile range 5-7], p = 0.001), and require tracheostomy (6% vs. 0% p = 0.014). Mortality
was higher in patients with reexpansion pulmonary edema (4% vs 0%, p = 0.014). On multivariate
analysis, reexpansion pulmonary edema was independently associated with chronic obstructive
pulmonary disease (odds ratio 4.44 [95% confidence interval 1.28-18.6], p = 0.02), pulmonary
hypertension and/or right-ventricular dysfunction (odds ratio 2.95 [95% confidence interval 1.41-6.15],
p=0.004) and increasing cardiopulmonary bypass time (odds ratio 1.019 [95% confidence interval
1.011-1.027] per minute of additional bypass time, p <0.001).
Discussion: Reexpansion pulmonary edema following minimally-invasive cardiac surgery occurs

more commonly than previously reported and is associated with peri-operative morbidity. Risk factor
factors have been identified. Research is required to determine if risk of reexpansion pulmonary
edema should be considered when evaluating patients for minimally-invasive cardiac surgery.
References:
1. J Card Surg 2009;24:693-694
2. J Cardiothorac Vasc Anesth 2009 Aug;23(4):549-54
13
S134 Abstracts
13
Abstracts S135
39275 - INTERPROFESSIONAL PEDIATRIC PAIN EDUCATION IMPACTS PRACTICE
Author(s)
Clyde Matava, MD
Anesthesia and Pain Management
Hospital for Sick Children, Toronto
Co-Author(s)
Basem Naser, MD - Anesthesia and Pain Management, Hospital for Sick Children, Toronto
Guy Petroz, MD - Anesthesia and Pain Management, Hospital for Sick Children, Toronto
Introduction: Effective and timely prevention and relief of pain in children has been identified as a
priority in many health institutions across the globe. A multidisciplinary team that includes physicians,
nurses, and allied health care providers best provides effective management of pediatric pain. Major
limitations for effective pain management include often lack of, and varied quality of knowledge
among health care practitioners and inter-professional communication.
Methods: Following an in depth needs assessment in June 2012 in a middle eastern country, we
utilized an interative process to develop key educational goals adapted for their inter-professional
pediatric pain curriculum. To measure the impact of the teaching, we first validated a pediatric pain
knowledge and attitude (PPKA) tool for use by physicians. We then progressed to deliver the training
over two modules delivered in two days. At the end of training, re-administered the pediatric pain
knowledge and attitude tool. To assess retention and knowledge translation, we carried out a follow-
up survey at six months. To enable sustainability of the course we identified key inter-professionals to
be trained to take over the course.
Results: In the last year, more than 300 physicians, nurses, occupation therapists, physiotherapists,
pharmacists have taken the course. Increases in the appropriate knowledge and attitudes to pain in
children were detected by the PPKA tool. Key areas of improvement were non-pharmacological
interventions with increase in appropriate knowledge and attitudes in the attendees from 30% to 70%.
Areas of team work also demonstrated shifts in appropriate attitudes from 15-25% to 74% of the
attendees. The six months follow up detected self-reported changes in practice by 80% of course
attendees. The key areas with change in practice were early assessment and use of correct pain
assessment tools, use of sucrose, multimodal pain management. Areas of continued improvement
were team work, need to educate more colleagues. Finally, key individuals were trained to teach the
course. Self-reported evaluations from the train the trainer scored 4.1/5 on a scale of 1-5.
Conclusion: We report that inter-professional education sensitive to cultural context can result in
significant changes in knowledge and attitude of a multi-disciplinary group. Furthermore, changes in
practice have also been reported after six months demonstrating a successful translation of
knowledge and attitude.
References:
1. Paediatr Child Health. 2007 February; 12(2): 97–99
13
S136 Abstracts
39277 - CAPNOGRAPHY, FLOTRAC/EV1000 AND FLUID RESPONSIVENESS
Author(s)
Francis Toupin
André Y. Denault
Professor
Co-Author(s)
Yoan Lamarche - Department of Surgery, Montreal Heart Institute, Université de Montréal
Christian Ayoub - Department of Anesthesiology, Montreal Heart Institute, Université de Montréal
Ariane Clairoux - Department of Anesthesiology, Montreal Heart Institute, Université de Montréal
Annik Fortier - Department of Public Health, Montreal Health Coordinating Centre
Montréal
Introduction: Fluid responsiveness is an important issue in cardiac anesthesia and in the critical care
unit. The concept of goal directed therapy has been shown to be associated with improved outcome
1
in several types of surgery. However, cardiac output instruments have to be available in order to
2-3
apply this concept clinically. Capnography and the FloTrac/EV1000 allow estimation and
measurement of the cardiac output. The FloTrac/EV1000 uses the arterial pressure from which is
derived stroke volume. In addition, respiratory variations allow the measurement of the variation of the
4
ejection volume (VVE) every 20 seconds. The relationship between capnography and the
FloTrac/EV1000 using the thermodilution-derived cardiac output (TDCO) obtained with the pulmonary
artery catheter has not been reported. The objective of this study was to correlate cardiac output
measurement between capnography, FloTrac/EV1000 using the TDCO as a gold standard during a
passive leg raising (PLR) maneuver. This intervention has been validated as a simple measure to
5
evaluate fluid responsiveness.
Methods: Following approval by the ethics and research committee and patient informed consent
obtained, 50 patients undergoing cardiac surgery were recruited. A total of 3 PLR maneuvers were
performed: one in the operating room (OR) before cardiopulmonary bypass and two in the intensive
care unit (ICU). A positive response to PLR was defined as an increase in TDCO or the FloTrac
FDUGLDFRXWSXW)7&2Dn increase in end-WLGDOFDUERQGLR[LGH(7&2DQGDUHGXFWLRQ
RI WKH 99( 3HDUVRQ FRUUHODWLRQ FRHIILFLHQWV ZHUH XVHG WR FDOFXODWH FRUUHODWLRQ EHWZHHQ
variables. Kappa statistics were used to evaluate concordance between measurements. McNemar
testing was used to compare the distribution between responders and non-responders. A non-
significant test indicates that there is no difference between the proportions of responders when
comparing two different methods. P <0.05 was considered significant.
Results: Responders following PLR in the OR, ICU#1 and ICU#2 were 32%, 20% and 36% (TDCO),
42%, 26% and 40% (ETCO2), 56%, 38% and 40% (FTCO), and 26%, 34% and 44% (VVE).
Correlations between all four variables (TDCO, ETCO2, FTCO and VVE) were all significant after the
first PLR (p<0.05), only significant for ETCO2 and FTCO in the second PLR (p=0.0022) and no
correlation was observed at the third PLR. When all measurements were pooled, responders and
non-responders after PLR were identical between TDCO and ETCO2 in 72% (Kappa 0.37, p<0.0001),
with TDCO and FTCO in 67% (Kappa 0.32, p<0.0001) and with TDCO and VVE in 62% (Kappa 0.17,
p=0.0442). P-values of McNemar test for the same three comparisons were 0.16, 0.0014 and 0.0627.
Conclusion: In patients mechanically ventilated before and after cardiac surgery, the correlation
between variables used in estimating cardiac output are different in the OR compared to the ICU.
When using TDCO as a reference, changes in ETCO2 compares favorably to variables measured
using the FloTrac/EV1000 in order to identify fluid responsiveness.
13
Abstracts S137
References:
1. Crit Care 2005; 9:R687-R693.
2. Crit Care Med 2004; 32:691-699.
3. Crit Care Med 2007; 35:64-68.
4. Anesth Analg1994; 79:829-833.
5. Crit Care 2009;13(6):R195.
13
S138 Abstracts
39280 - A NEW TEAMWORK ASSESSMENT SCALE IN OBSTETRIC CRISIS MANAGEMENT
Author(s)
Mrinalini Balki
Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto
David W. Hoppe, MBBS, MD

Anesthesia, Mount Sinai Hospital - Toronto
Co-Author(s)
David Monks, MBChB, FRCA - Anesthesia, Mt. Sinai - Toronto
Rory Windrim, MD - Obstetrics, Mt. Sinai - Toronto
Lynn Sharples, RNA - Nursing, Mt. Sinai - Toronto
Mary Ellen Cooke, MD - Anesthesia, Mt. Sinai - Toronto
Introduction: It is now recognized that non-technical errors are a substantial cause of increased
1
morbidity and mortality in obstetric health care . Root Cause analysis data during 2004-2012 from the
American Joint Commission showed that communication is responsible for greater than 50% of
overall sentinel events, with 82% events in 2010, 61% in 2011, and 58% in 2012. Of note,
2
communication errors contributed to 50% of maternal sentinel events.
An extensive literature search showed that there is currently no validated interdisciplinary obstetric
teamwork assessment scale used in the simulation setting. Our aim was to design a new obstetric
interdisciplinary teamwork scale and establish its face and content validity using the Delphi technique.
Methods: After REB approval, the study investigators generated a new assessment scale. The scale
was sent out electronically to an international selected panel of experts comprising of obstetric
anesthesiologists, obstetricians and nurses for a modified Delphi process. The Delphi process
required participants to indicate agreement for or against each component of the scale, and also
volunteer any additional relevant comments. Each statement was analyzed quantitatively by the
percentage of agreement ratings and each comment reviewed by the blinded investigators. The
assessment scale was then modified, with components of less than 80% agreement removed from
nd rd
the scale. This was sent to the experts again for the 2 round. It is now being sent out for the 3
round.
Results: Twenty four external raters were invited to take part in the Delphi process, of which 14
participated. These were 1 nurse, 1 obstetrician, 12 obstetric anesthetists. The initial scale comprised
of 7 main domains: Shared Mental Model, Communication, Situational Awareness, Leadership,
Followership, Workload Management, and Positive/Effective Behaviors and attitudes. In addition,
st
there was a Global score. The initial total number of items was 40. In the 1 round 3 items were
nd
removed, and 10 items rephrased. In the 2 round, 4 items were removed and five items rephrased.
rd
The results of 3 round are awaited and will be presented at the CAS meeting.
Discussion: Using a structured Delphi technique, we have obtained a consensus agreement on the
items in our new teamwork scale. We have established face and content validity of this externally-
rated interdisciplinary scale that focuses on important aspects of teamwork in obstetric crisis
situations. Further work is in place to establish the reliability and context validity of this scale, so that
this new tool can be used for formative and/or summative evaluation of teams in the multidisciplinary
simulation environment.
References:
1. Wong CA. Saving mothers' lives: the 2006-8 anaesthesia perspective. British journal of
anaesthesia. 2011;107:119-122.
2. The Joint Commission: Sentinal Event Data Root Causes by event type 2004-2012. 2012.
13
Abstracts S139
13
S140 Abstracts
39283 - DEXMEDETOMIDINE RAPID BOLUS DOSE IDENTIFICATION IN CHILDREN
Author(s)
Joy Dawes, BSc MBBS MRCP FRCA
Department of Anesthesia and Anesthesiology, Pharmacology and Therapeutics
BC Children's Hospital and University of British Columbia
Co-Author(s)
Dorothy Myers, MSc - Department of Anesthesia and Anesthesiology, Pharmacology and Therapeutics, BC
Children's Hospital and The University of British Columbia
Matthias Görges, PhD - Department of Electrical and Computer Engineering, The University of British
Columbia
Guohai Zhou, MSc - Department of Statistics, The University of British Columbia
J Mark Ansermino, MBBCh, MSc (Inf), FFA (SA), FRCPC - Department of Anesthesia and Anesthesiology,
Pharmacology and Therapeutics, BC Children's Hospital and The University of British Columbia
Carolyne J Montgomery, MD - Department of Anesthesia and Anesthesiology, Pharmacology and
Therapeutics, BC Children's Hospital and The University of British Columbia
Introduction: Dexmedetomidine (DEX) is a highly sensitive and specific alpha-2adrenoceptor agonist with
anxiolytic, sedative and analgesic effects. Its use as a perioperative sedative in pediatric anesthesia has
increased in the last decade due to the favorable side-effect profile and multitude of clinical applications
(1,2). The recommendation is to administer a loading dose as an infusion over a 10 minute period to avoid
the hemodynamic effects of hypertension and bradycardia that have been observed following a rapid or
large bolus dose (3). However, a previous study suggested that a much shorter time-frame may be used
without causing adverse hemodynamic effects (4). The purpose of this study was to determine the dose of
DEX that can be given as a rapid bolus over 5 seconds to healthy children during total intravenous
anesthesia (TIVA) without causing significant hemodynamic effects.
Methods: Research approval was obtained from the institutional Research Ethics Board and Health
Canada. Healthy ASA I-II subjects having elective surgery under TIVA using a laryngeal airway device were
recruited. Informed written consent from parents/guardians (and assent where appropriate) was obtained.
The up-and-down sequential study design (5) was employed to determine the effective dose of DEX which
caused no hemodynamic response in half the subjects (ED50). The starting dose was 0.3 mcg/kg with
intervals of 0.1 mcg/kg. Positive and negative responses were defined as mean blood pressure (MAP) and
KHDUW UDWH +5 FKDQJHV RU IURP EDVHOLQH 7KUHH SDUDPHWULF HVWLPDtors and a nonparametric
estimator were used to determine the dose (ED50) of 6 pairs of crossovers.
Results: 21 subjects (17 males) with median age 7.1 (range 5.4-9.5) years and median weight 23.6 (range
th
16.2-36.7) kg were recruited. The 6 and final crossover was obtained with subject 21. No clinical adverse
events were observed. A maximum median HR decrease of 20 beats per minute occurred at 50 seconds
and a maximum median MAP increase of 12.5 mmHg occurred at 100 seconds after bolus dose
administration (Figure 1). Four estimators led to an ED50 estimate for DEX of 0.50 mcg/kg [95% CI 0.35-
0.65 mcg/kg].
Discussion: The bolus dose of DEX (ED50) administered over 5 seconds intravenously without clinically
significant hemodynamic compromise in children is 0.50 mcg/kg. Further work is needed to determine the
“safe” (ED5 or less) and effective dose for desired perioperative clinical outcomes.
References:
1. Pediatr Crit Care Med 2007 8:115-31
2. Paediatr Anaesth 2010 20:256-64
3. PrecedexTM (dexmedetomidine HCI injection). Available at http://www.precedex.com/dosing/dosing-
basics/. Accessed 3rd January 2014
4. Anesth Analg 2010 111:1490-6
5. Anesthesiology 2007 107:144-52
13
Abstracts S141
13
S142 Abstracts
39284 - A COLLABORATIVE APPROACH TO IDENTIFYING EPAS FOR PEDIATRIC

ANESTHESIA
Author(s)
Clyde Matava, MD
Anesthesia and Pain Management
Hospital for Sick Children, Toronto
Co-Author(s)
Gail Wong, MD - Anesthesia and Pain Management, Hospital for Sick Children, Toronto
Background: The Royal College of Physicians and Surgeons of Canada (Royal College) has
embarked on the introduced of a Competency by Design (CBD) program. The demand for expert
pediatric anesthesiologists has risen subsequent to increasing load and complexity of pediatric
surgical patients. Six pediatric anesthesia fellowships are currently available throughout Canada,
albeit with no standardized curriculum. We have developed a Canadian competency based pediatric
anesthesia fellowship curriculum informed by contemporary needs and consensus agreement on
content by experts
Intervention: Members of the Canadian Pediatrics Anesthesia Fellowship Competency based

Curriculum Project Working Group performed relevant medical literature and beyond to create a
synopsis of models and evidence. We created a series of Entrustable Professional Activities (EPAs)
grounded in the literature and clinical practice. The EPAs were vetted with the entire working group,
engaging in an iterative process of revisions until reaching consensus around EPAs and Milestones.
Outcomes: We have completed the iteration of 12 EPAs and relevant milestones for pediatric
anesthesia fellowship training in Canada. For each EPA and milestone, we have also developed a
synopsis of relevant literature provides background and references. These EPAs and milestones
provide appropriate and relevant descriptions of behaviors that represent acquisition of knowledge,
skill, and attitude development effective for the lifelong educational continuum of training and practice.
Discussion: The pediatric anesthesia fellowship training EPAs and milestones bring us closer to
training that is competency based for the changing demands and complexities of pediatric anesthesia
training. We have also provided a framework for recognition of pediatric anesthesia as a fully-fledged
subspecialty. The next steps include implementation and evaluation of the curriculum across
pediatric anesthesia centers in Canada.
References:
J Grad Med Educ. 2010 September; 2(3): 419–422.
13
Abstracts S143
39286 - INTRAOPERATIVE DIASTOLIC FUNCTION IS DEPENDENT ON LV AFTERLOAD
Author(s)
Anesthesia
Co-Author(s)
Neal Maher, MD, FRCPC - Anesthesia, University of Calgary
Randy Moore, MD - Surgery, University of Calgary
Marelise Kruger, MD, FRCPC - Anesthesia, University of Calgary
Gary Dobson, MDCM, MSc, DIC, FRCPC - Anesthesia, University of Calgary
Introduction: Left ventricular (LV) diastolic dysfunction, defined as the ratio of the peak velocity of
early mitral inflow (E) to the early diastolic mitral annular velocity (e’), is a predictor of major adverse
1
cardiac events (MACE) in patients presenting for non-cardiac surgery. Diastolic function is
2,3
dependent on upon LV afterload, which may change as following aortic stent deployment. We
examine the effect of LV afterload on E/e’ in patients undergoing endovascular repair (EVAR) of their
abdominal aortic aneurysms.
Methods: Conjoint Health Research Ethics Board approval and patient consent was obtained.
Following induction of general anesthesia, patients presenting for EVAR had a detailed trans-
esophageal echocardiographic exam, prior to and following deployment of the endovascular
stent. Central aortic pressure was derived from a corrected radial artery pressure wave using a
4
generalized transfer function. Aortic flow was measured using LV outflow tract velocity and diameter.
Afterload was defined as systemic vascular resistance (SVR) and characteristic impedance
5
(Z0). Spectral Doppler of the early diastolic mitral valve inflow and the average of septal and lateral
wall tissue velocities were used to calculate E/e’. Statistical analysis was performed using Analyse-it
v.2.26.
Results: All results are presented as Mean(±SD). There were 18 patients (16 male) who completed
the study with an average age of 71±7 years. There were no differences in mean BP (78.5±11 v.
5
83±16 mmHg), E/e’ (10.6±1.2 v. 9.7±0.7) or SVR (1697±514 v. 1564±504 dynes-s/cm ) prior to or
5
following EVAR. Z0 decreased slightly following EVAR (149±68 v. 120±85 dynes-s/cm ,
p=0.04). Multi-linear regression modeling using SVR and Z0 as independent predictors of E/e’ (8.87-
0.028*Z0+0.003*SVR, p=0.02) demonstrated that 24% of the variation in E/e’ can be attributed to LV
afterload (Figure 1).
Discussion: Changes to LV afterload account for nearly a quarter of the variability in diastolic
function. While there was no increase in LV afterload following stent deployment the results may have
been moderated by the anesthetic agent. Anesthetics, vasoactive agents and surgery can have a
considerable, but as yet ill-defined, effect on the LV afterload and diastolic function with possible
beneficial or detrimental changes in the incidence of MACE.
References:
1. Echocardiography. 2014;31(1):42-9.
2. European Heart Journal. 2013;34(9):676-83.
3. J Endovascular Ther. 2012;19(5):661-6.
4. European Heart Journal. 1993;14(2):160-7.
5. Journal of the American College of Cardiology. 1992;20(4):952-63.
13
S144 Abstracts
13
Abstracts S145
39287 - USE OF VOLATILE ANESTHETICS FOR LONG-TERM SEDATION IN CRITICALLY ILL

PATIENTS (VALTS): PRE-STUDY INITIATION SURVEY AND DEVELOPMENT OF INTER-
PROFESSIONAL TEACHING MODALITIES
Author(s)
Kelvin Wong
Medicine
Angela Jerath
FRCPC, FANZCA, MBBS,BSc
Anesthesia
TGH
Co-Author(s)
Marcin Wasowicz, PhD - Anesthesia, TGH
Niall Ferguson, FRCPC, MD - ICU, UHN
Deep Grewal - Anesthesia, Toronto General Hospital
Margaret Doherty, MBBS - Anesthesia, TGH
Andrew Steel, FRCPC, MBBS - ICU, TGH
Introduction: Current sedation practice using intravenous agents have been shown to prolong
mechanical ventilation and increase the risk of delirium within intensive care unit (ICU)
patients.1 There is good evidence demonstrating that volatile anesthetic agents reduce extubation
times and provide a superior quality of sedation compared to standard agents.2,3 However, volatile-
based sedation within the critical care environment is a novel technique and necessitates
development of effective inter-professional education tools to facilitate safety and feasibility.
Objective: The Use of Volatile Anesthetics for Long-Term Sedation (VALTS) study is a pilot
prospective RCT assessing the safety and feasibility of delivering inhaled isoflurane using the
Anesthesia Conserving Device (AnaConDa®, Sedana Medical, Sweden) compared to standard
intravenous midazolam/propofol for long-term ICU sedation. The objectives of this project were:-
1) Development of inter-professional education tools
2) Conduct pre-study initiation surveys to assess opinions and experience of volatile-based sedation
among respiratory therapist (RT) and nursing (RN) staff.
Methods: Pre-study questionnaire designed to examine knowledge, experience and safety of using
volatile agents was delivered to 123 RT and RN staff during 30 in-service training sessions within one
medical surgical (MSICU) and one cardiovascular (CVICU) intensive care unit. Two manuals were
developed to facilitate inter-professional education on volatile agents.
Results: 7KH TXHVWLRQQDLUH VKRZV WKDW WKH PDMRULW\ RI VWDII KDYH \HDUV RI ,&8 H[SHULHQFH
(74.8%) but have limited exposure with the administration of volatile anesthetics (85.4%). Most staff
are interested in volatile-based sedation (79.8%) but only a small proportion had no concerns about
its administration (22.3%) and safety for staff (12.5%). There are no significant differences in ratings
of current sedation practice between the MSICU RNs, CVICU RNs, and RTs.
Conclusion: This project confirms a high interest in administering volatile anesthetics for ICU
sedation. However, on-going inter-professional education is required to enhance knowledge and
principles of safety, which is being provided by formal lectures, a practical bedside manual and an in-
depth teaching manual that will be available in paper format and free e-learning module. Future work
includes assessment of these teaching aids by on-going staff feedback, post-study opinion survey,
and monitoring the safety and feasibility of our pilot study.
References:
1. Barr J, et al. Crit Care Med 2013; 41: 263.
2. Mesnil M, et al. Intensive Care Med 2011; 376: 933.
3. Wasowicz M, et al. Brit J Anesth 2012; 108: paper 1003.
13
S146 Abstracts
MSICU RN CVICU RN
(n=70) (n=44) RT (n=9) Total (n=123)
How many years have you been
working in this role?
<2 yrs 3 (4.3%) 7 (15.9%) 0 (0%) 10 (8.1%)
2-5 yrs 12 (17.1%) 7 (15.9%) 2 (22.2%) 21 (17.1%)
5-10 yrs 22 (31.4%) 15 (34.1%) 5 (55.6%) 42 (34.1%)
>10 yrs 33 (47.1%) 15 (34.1%) 2 (22.2%) 50 (40.7%)
Have you ever heard of using

volatile anesthetic agents for
sedation within the ICU?
Yes 5 (7.1%) 27 (62.8%) 6 (66.7%) 38 (31.1%)
No 65 (92.9%) 16 (37.2%) 3 (33.3%) 84 (68.9%)
Do you have any experience using

volatile anesthetic agents for ICU
sedation before?
Yes 2 (2.9%) 12 (27.3%) 4 (44.4%) 18 (14.6%)
No 68 (97.1%) 32 (72.7%) 5 (55.6%) 105 (85.4%)
How keen are you in trying inhaled

anesthetic agents for ICU
sedation?
Enthusiastic 11 (15.7%) 13 (29.5%) 4 (44.4%) 28 (22.8%)
Interested 45 (64.3%) 20 (45.5%) 5 (55.6%) 70 (57.0%)
Indifferent 14 (20%) 8 (18.2%) 0 (0%) 22 (17.9%)
Not Interested 0 (0%) 3 (6.8%) 0 (0%) 3 (2.4%)
Please rate how concerned you are

running inhaled anesthetic agents
for ICU sedation.
Not concerned 11 (16.2%) 11 (25.0%) 5 (55.6%) 27 (22.3%)
A little concerned 33 (48.5%) 17 (38.6%) 4 (44.4%) 54 (44.6%)
Concerned 22 (32.4%) 12 (27.3%) 0 (0%) 34 (28.1%)
Very Concerned 2 (2.9%) 4 (9.1%) 0 (0%) 6 (5%)
Please rate what you think the

safety is for staff when running
volatile-based ICU sedation
Very safe, I have no concern 2 (2.9%) 8 (19%) 5 (55.6%) 15 (12.5%)
Safe but I have some concerns 24 (34.8%) 15 (35.7%) 3 (33.3%) 42 (35.0%)
Unsafe 3 (4.3%) 1 (2.4%) 0 (0%) 4 (3.3%)
I'm not sure 40 (60.0%) 18 (42.9%) 1 (11.1%) 59 (49.2%)
13
Abstracts S147
39288 - A PREOPERATIVE ASSESSMENT SYSTEM FOR CATARACT SURGERY PATIENTS
Author(s)
Subash Sethi
Co-Author(s)
Alexander Villafranca, MSc. Phd candidate - Anesthesiology and Perioperative Medicine, University of
Manitoba
Andre Jastrzebski, MD - Ophthalmology, University of Manitoba
Eric Jacobsohn, MBCHB - Anesthesiology and perioperative medicine, University of Manitoba
Lorne Bellan, MD - Ophthalmology, University of Manitoba
Introduction: Preoperative physical examinations (PPE) represent a significant time and cost burden
to healthcare systems. Use of a graded assessment system in cataract surgery patients may reduce
the need for these. The purpose was to evaluate the safety and potential cost savings of a system
involving preoperative questionnaires with selective referral based upon disclosed comorbidities.
Methods: A prospective cohort study was conducted at a single high-volume surgical center.
Following routine preoperative assessment and consent, participants completed a preoperative
questionnaire that screened for comorbidities (cardiac, respiratory, renal, BMI >40). The OR staff
were blinded to the preoperative physical data of patients denying major comorbidities (low risk
group). A preliminary descriptive analysis of cost savings and safety was conducted.
Results: Data was collected on 3,348 patients. Of these, 2,080 (60.3%, 95% CI= 58.6-62.3%) were
eligible to not have a PPE (low risk group). At the current billing schedule for PPE in our province, and
with adjustment for second eye surgeries, the cost savings over the course of the study would have
been $107, 774. Assuming a similar rate of preoperative assessment exemption and age distribution
for the population, this would have translated into a savings of $436, 855 in the past fiscal year at our
center alone. The rate of serious complications and case cancellations due to anaesthetic concerns
were zero in both the low-risk group (95% CI 0-0.15%) and the entire cohort (95% CI 0-0.09).
Discussion: This analysis supports the safety of our preoperative assessment system for cataract
surgery patients. The use of this system is associated with considerable cost and time savings to the
healthcare system, allowing existing resources to be distributed more effectively. Primary care
doctors, who are in short supply, can more effectively use their time for other patients. Subsequent
analysis will include cost-effectiveness analysis and evaluation of the questionnaire's ability to predict
minor complications.
References:
N/A
13
S148 Abstracts
39289 - HIGH-FIDELITY SIMULATION TO ASSESS TEAMWORK IN OBSTETRIC CRISES
Author(s)
Mrinalini Balki
David W. Hoppe
MBBS, MD
Anesthesia
Mount Sinai Hospital - Toronto
Co-Author(s)
David Monks, MBChB, FRCA - Anesthesia, Mt. Sinai - Toronto
Rory Windrim, MD - Obstetrics, Mt. Sinai - Toronto
Lynn Sharples, RNA - Nursing, Mt. Sinai - Toronto
Mary Ellen Cooke, MD - Anesthesia, Mt. Sinai - Toronto
Introduction: A systematic review of obstetric training in acute emergencies showed a lack of evaluated
1
training programs. Simulation has a significant role in education and training and a potential to improve
2
patient safety by decreasing the rate of medical errors and deaths due to preventable adverse events.
Simulation has now been widely adopted in medicine, with enthusiasts referring to simulation-based
3
medical education as an “ethical imperative”. The objective of this study is to develop a validated and
reliable interdisciplinary teamwork assessment scale (ITAS) to assess multidisciplinary team dynamics in
simulated obstetric crisis’s
Methods: This prospective, observational cohort study was performed after REB approval and written
informed consent from the study participants. Delphi technique was used to establish the face and
content validity of the newly designed ITAS. Two simulation scenarios of pre-eclampsia and PPH were
created. Teams consisting of fellows and residents from obstetrics and anesthesia, anesthesia assistants
and registered perinatal nurses participated in the simulation sessions using a high-fidelity simulator. A
checklist of expected actions specific to the scenarios and new ITAS were used as tools to facilitate
debriefing. The video recordings will be sent to 2 renowned anesthesia and obstetric experts for rating
ITAS scores of the teams.
The primary outcome is to establish the validity and reliability of a newly developed ITAS. Secondary
outcome measures include identifying areas of poor and good clinical knowledge and skills in pre-
eclampsia and PPH management.
We calculated a sample size of 52 scenarios based on determining the validity of the scale
(differentiating between poor and well performed teamwork) with a large effect size, as well as
establishing reliability between two reviewers with an intraclass correlation coefficient of 0.8 with a
confidence interval of +/- 0.10.
Results: So far 27 multidisciplinary teams participated in 13 preeclampsia, 14 PPH simulation sessions.

We are still conducting simulation sessions and will present completed results at the CAS meeting..
Discussion: Multidisciplinary training and assessment are essential to improve clinical practice, so that
patient safety can be improved by mitigating avoidable errors. This will help us identify deficiencies in the
system and commonly performed errors. Practice guidelines based on our study will improve clinical
practice with much needed consistency, and will have a potential impact on patient safety.
References:
1. Black RS, et al. A systematic review of training in acute obstetric emergencies. BJOG : an
international journal of obstetrics and gynaecology. Sep 2003;110(9):837-841.
2. Hunt et al. Simulation: translation to improved team performance. Anesthesiology clinics. Jun
2007;25(2):301-319.
3. Cumin D et al. Standards for simulation in anaesthesia: creating confidence in the tools. British
journal of anaesthesia. Jul 2010;105(1):45-51.
13
Abstracts S149
39291 - TRANSFER OF LEARNING AND PATIENT OUTCOME IN SIMULATED CRM
Author(s)
M. Dylan Bould, MB ChB, MEd
Children’s Hospital of Eastern Ontario
Sylvain Boet, MD, MEd, PhD(c)

The Ottawa Hospital
Co-Author(s)
Lillia Fung, MD - Anesthesiology, The Ottawa Hospital, University of Ottawa
Haytham Qosa, MD, MEd - Anesthesiology, The Ottawa Hospital
Laure Perrier, MLIS - Li Ka Shing Knowledge Institute, St Michael's Hospital
Walter Tavares, PhD(c) - Wilson Centre and Centennial College, Wilson Centre and Centennial
College
Scott Reeves, PhD - Center for Innovation in Interprofessional Education , University of California,
San Francisco
Andrea Tricco, PhD - Li Ka Shing Knowledge Institute , St Michael's Hospital
Introduction: Simulation-based learning is increasingly used by healthcare professionals to safely

learn and practice non-technical skills related to crisis resource management (CRM). This systematic
review was conducted to better understand the impact of simulation-based CRM teaching in terms of
transfer of learning to the workplace and subsequent changes in patient outcomes.
Methods: Research Ethics Board approval was not required. Studies published up to September
2012 on CRM, crisis management, crew resource management, teamwork, and simulation were
searched in Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and ERIC.
All studies that used simulation based CRM teaching with outcomes measured at Kirkpatrick level 3
(transfer of learning to workplace) or 4 (patient outcome) were included. Studies where technical skills
and nontechnical skills could not be separated and studies that only measured reaction of learners or
simple learning (Kirkpatrick level 1 or 2) were excluded. No limitations were placed on the level of
learners or study design. All titles and abstracts identified were independently reviewed for eligibility
by two authors.
Results: We identified nine articles for inclusion that measured transfer of simulation-based CRM
learning into the clinical setting, and/or translated to improved patient outcomes. All studies concluded
that simulation-based CRM training may offer an additive benefit to the traditional didactic instruction,
enhance CRM healthcare crisis management teaching impact provider’s performance, and/or may
have a positive impact on patients’ management and outcomes.
Discussion: Despite an abundance of existing literature on simulation-based education and CRM, we

identified only nine articles that examined transfer of learning to workplace for healthcare providers or
changes in patient outcome after simulation-based CRM training. The vast majority of the literature
has been limited to lower level outcomes, such as reaction of participants and learning that has been
measured using further simulation scenarios which leaves the studies open to the criticism that
learners may have only been taught to perform well in the simulator, and not necessarily in real life.
Based on a small number of studies, this systematic review found that CRM skills learnt at the
simulation center are transferred to clinical settings, and that the acquired CRM skills can translate to
improved patient outcomes.
References:
N/A
13
S150 Abstracts
39292 - A PERIOPERATIVE COURSE OF GABAPENTIN IMPROVES PAIN RELIEF AFTER

CESAREAN DELIVERY: A RANDOMIZED CONTROLLED TRIAL
Author(s)
Jose Carvalho
Department of Anesthesia and Pain Management and Department of Obstetrics and Gynecology
David Monks
Co-Author(s)
Kristi Downey, MSc - Department of Anesthesia and Pain Management, Mount Sinai Hospital,
Vibhuti Shah, MD - Department of Neonatology, Mount Sinai Hospital, University of Toronto
Paul Bernstein, MD - Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of
Toronto
David Hoppe, MD - Department of Anesthesia and Pain Management, Mount Sinai Hospital,
Introduction: One small RCT suggested a benefit from a preoperative dose of 600 mg gabapentin in
reducing postcesarean pain in the context of spinal anesthesia and a multi-modal analgesic regimen
inclusive of intrathecal morphine (1). A subsequent RCT, designed to find the optimal dose, cast
some doubt on this finding and suggested that a larger study was required (2). Based on these trials
and following a trend in the literature, we hypothesized that a perioperative course of gabapentin
would reduce postcesarean pain.
Methods: REB approval, Health Canada approval and patient informed consent was obtained for this
study. Healthy women scheduled for elective cesarean delivery performed under spinal anesthesia
with 1.6-1.8 ml of 0.75% hyperbaric bupivacaine, 10 mcg fentanyl and 100 mcg morphine were
randomized to receive a perioperative course of either gabapentin or placebo. The dosing in the
treatment group consisted of a preoperative dose of 600 mg gabapentin followed by a 48 hour
postoperative course of 200 mg three times a day. Both groups received a standardized regimen of
regular oral acetaminophen and diclofenac. Parenteral morphine was administered as required.
Postoperative pain, at rest and on movement, and satisfaction were measured on a visual analogue
scale (VAS 0-100 mm) along with opioid consumption and side effects at 24 and 48 hours after the
incision. Neonatal outcomes were APGAR scores, need for resuscitative support, umbilical blood
gases and breast feeding difficulties. Telephone interviews were conducted at 2 and 6 weeks to
assess for persistent pain. The primary outcome was pain on movement at 48 hours postoperatively.
Results: 204 women were randomized, 17 were excluded and 187 were analyzed. There was no
difference in VAS pain scores on movement at 48 hours between groups (mean
[SD]): gabapentin 33.6 [21.2] vs. placebo 35.6 [24.5], p=0.54). However, there was a significant
reduction in VAS pain scores at rest (12.2 [16.3] vs. 18.3 [17.6], p=0.015) and on movement (39.0
[21.6] vs. 46.9 [23.1], p=0.016), and greater satisfaction scores (mean [SD]: 87.9 [15.8] vs. 77.5
[22.2], p=0.003) at 24 hours in the gabapentin group. The number [%] of patients receiving additional
parenteral opioids in the first 24 hours was significantly lower in the gabapentin group (17 [17.7] vs.
29 [31.9], p=0.025). There was a significant increase in the incidence of sedation in the first 24 hours
(55.2% vs. 39.6%, p=0.032) in the gabapentin group. There was no difference in neonatal outcomes
between the groups. There was no difference in pain scores at 2 weeks postpartum. Results for pain
at 6 weeks postpartum still pending.
Discussion: A perioperative course of gabapentin reduces pain and opioid consumption in patients
undergoing cesarean delivery. Although an increase in sedation is observed with the use of
gabapentin, patient satisfaction with pain management is higher.
References:
1) Anesth Analg 2011;112:167-73;
2) Anesth Analg 2012;115:1336-42
13
Abstracts S151
39293 - Hyperbaric Oxygen Treatment for Arterial Air Embolus during Cardiopulmonary
Bypass
Author(s)
Margaret Doherty
Anesthesia
TGH
Angela Jerath, FRCPC, FANZCA, MBBS,BSc

Anesthesia
TGH
Co-Author(s)
Terrence Yau, FRCSC - Cardiac Surgery, TGH
Teurai Brown - Perfusion, TGH
Introduction: Massive air embolus during cardiopulmonary bypass (CPB) occurs in 0.003-0.007% of
cases, which makes it an exceedingly rare event. Up to 50% of these patients will have a serious
1
adverse outcome making prompt treatment vital when this complication occurs. Injury from the
arterial gas embolism (AGE) is due to combination of reduced perfusion distal to the embolus and
subsequent inflammatory reaction at the injured site triggered by the gas bubble. The degree of injury
is dependent on the amount of gas infused, rate of infusion, type of gas and the patient position at the
time. This case highlights the use of hyperbaric oxygen therapy (HBOT) for managing this potentially
critical complication.
Case: This case is reported with patient consent. A 55 year old gentleman presented for urgent
coronary artery bypass surgery following an anterolateral myocardial infarction( MI) complicated by a
cardiac arrest. His medical history includes severe peripheral vascular disease, remote silent MI,
alcohol excess, chronic hyponatremia and active smoker. General anaesthesia was induced
uneventfully as per normal institutional practice. Shortly after initiation of CPB there was difficulty with
flushing of the cardioplegia catheter and an estimated 30ml of air under pressure entered the aorta.
The catheter was immediately clamped. Our team commenced treatment for AGE which included
placing the patient in a Trendelenburg position, maintaining high systemic perfusion pressure
throughout the case and systemic cooling to 28°C on CPB for neuroprotection. Dexamethasone 8mg
was administered. The patient remained haemodynamically stable throughout and the surgery was
completed successfully with no difficulty weaning from CPB. The use of HBOT is the only definitive
treatment available for AGE and has been shown to improve outcome when commenced as soon as
2
possible following injury. This patient received HBOT within 1 hour post-surgery for 6 hours at 2.4
Bar. Following HBOT treatment the patient was transferred to intensive care unit and successfully
extubated within 12 hours with no neurological deficits. He made an uneventful recovery and was
th
discharged on the 9 postoperative day.
Conclusion: HBOT delivers a high oxygen tension which encourages nitrogen re-absorption and the
high pressure decreases the size of gas bubbles. Smaller bubbles can freely pass through the
microcirculation, potentially reversing any neurological deficit. This case highlights the use of
HBOT for this rare but potentially life-threatening complication of CPB.
References:
1. Gordy S et al. Int J Crit Illn Inj Sci. 2013; 3(1): 73
2. Blanc P et al. Inten Care Med 2002;28: 559
13
S152 Abstracts
39296 - GLOBAL HEALTH POSTGRADUATE TRAINEE EXPERIENCES IN ANESTHESIA
Author(s)
M. Dylan. Bould, MB ChB, MEd
Children’s Hospital of Eastern Ontario
Co-Author(s)
Chantalle Clarkin, RN, MScN, PhD(c) - Children’s Hospital of Eastern Ontario Research Institute,
Children’s Hospital of Eastern Ontario Research Institute
Ashlee-Ann Pigford, MSc - Anesthesiology, Research, The Ottawa Hospital Research Institute
John Kinnear, MB BCh, DCH, DObst, DA, FRCA, FFICM, FAcadMEd, FHEA, DMedEd - Postgraduate
Medical Institute, Anglia Ruskin University
Anne McCarthy, MD, MSc, FRCPC, DTM&H - Faculty of Medicine, University of Ottawa
Feruva Ismailova, MD - Anaesthesia, University Teaching Hospital, University of Zambia
Sylvain Boet, MD, MEd, PhD(c) - Anesthesiology, The Ottawa Hospital
Introduction: Global health electives are increasingly incorporated into postgraduate medical
education with the aims of increasing cultural competencies and global perspective. When part of a
true partnership between institutions in the developing and the developed world these electives can
result in mutual benefit for both visiting and host trainees. However, the interactions between these
groups of residents result in a complex relationship with ethical challenges. The potential for harm to
host trainees has in particular been neglected in previous studies, particularly in the postgraduate
context. We aim to study this interaction as a microcosm of the complex relationships of global health
partnerships.
Methods: After institutional research ethics approval was received we conducted in depth interviews
of both host residents of the University of Zambia Master of Medicine Anesthesia program and visiting
residents from the UK and Canada. We use a phenomenological approach to qualitatively analyze the
shared experiences of these residents.
Results: Two rounds of interviews and analysis have been completed. Emerging themes include the
challenges of developing a professional identity in a context where anesthesia is undervalued; the
importance of peer-learning and mentorship; access to information and learning resources; change
management and the challenges of reconciling the “developed world” teaching of visiting faculty with
the realities of local resource limitations. If this abstract is accepted, final results of this analysis will be
presented at the 2014 Canadian Anesthesiologists’ Society meeting.
Discussion: The intersection of visiting and host residents can be considered a particular focal point
of co-learning in a global health partnership. To our knowledge this will be the first analysis of the
lived experiences of these two groups of interacting trainees. We anticipate that this analysis will have
the potential to impact the planning and policy of international health electives. This
phenomenological approach will also lay the groundwork for larger scale qualitative and quantitative
research of a rapidly increasing number of similar global health partnerships in the region which have
the potential to dramatically improve patient safety in some of the most resource challenged regions
of the world.
References:
N/A
13
Abstracts S153
39297 - PREDICTORS AND CONSEQUENCES OF CHILDBIRTH RELATED PAIN
Author(s)
Ronald B. George
Associate Professor
Department of Anesthesia, Pain Management, and Perioperative Medicine
Co-Author(s)
Natalie Rosen, PhD - Department of Psychology, Dalhousie University
Jill Chorney, PhD - Department of Anesthesia, Pain Management, and Perioperative Medicine,
Erna Snelgrove - Clarke, RN, PhD - School of Nursing, Dalhousie University
Maria Glowacka, BA Hon - Department of Psychology, Dalhousie University
Introduction: Pain is learned, it not only reflects the presence of noxious stimuli, but is learned from
our experiences with the external environment. Pain associated with labour and delivery is the most
important anesthetic-related concern for expectant mothers.[1] Acute pain limits the recovery and
function of postpartum. Pain may have a significant global and local impact with considerable health,
socioeconomic, and quality of life repercussions for those affected. Unfortunately, women generally
experience more pain, recurrent pain, severe pain, and longer lasting pain than men.[2] Aggressive
management of acute pain may limit the development of chronic pain. Our objective was to examine
the preliminary associations between postpartum pain, epidural analgesic use, and psychological
indicators of pain.
Methods: This longitudinal study incorporated a convenience sample from patients presenting to the
prenatal clinic within a six-month period. The study consisted of a series of questionnaires with three
time points. The prenatal consultation was the first of t time-point. Two weeks after delivery was time-
point 2, and three months after delivery was time-point 3. Our cohort consisted of women who were
ASA Physical Status I-II, primiparous, singleton pregnancies, at 30 – 36 weeks gestation.
Questionnaires included pain intensity, Pain Catastrophizing Scale (PCS) [3,4], SF-36, McGill Pain
Questionnaire (SF-MPQ), Pain Anxiety Symptoms Scale (PASS) [5], and a questionnaire includes 25-
36 items on additional pain related characteristics and demographics..
Results: A total of 320 women were approached at the prenatal clinic and invited to participate..
Twenty-one percent declined and 79% consented. Among those who consented, 86% (219/254)
completed the first survey during pregnancy (time-point 1), 75% (165/219) completed the time-point 2
survey and 69% (151/219) completed the time-point 3 survey. The mean age of women was 30 ± 5
years.. The majority of participants were Canadian, married, and held a post-secondary degree.
Preliminary analysis reveals cesarean delivery was performed in 35.4% of participants. Epidural
analgesia was chosen by 80% of participants. Numeric rating scale worst and average pain scores in
labour were similar in women with epidural analgesia compared to those without. At time-point 2,
73.8% of participants reported having a vaginal tear or perineal injury during delivery. Forty-seven
(47.1%) percent of participants were currently taking pain medication for treatment of delivery related
pain, this fell to 33.3% at time-point 3. PASS, SF-MPQ, SF-36, PCS data is summarized in table 1.
Participants who chose to use epidural analgesia had similar results to those who chose other
modalities of analgesia.
Discussion: This study aimed to conduct an assessment of postpartum pain and epidural usage
among primiparous women. Our data analysis is ongoing, specifically psychological assessment of
women who chose epidural analgesia compared to those who didn’t has not been completed (results
will be available for CAS meeting). This project will be the basis for more research to describe the
childbirth pain experience and determining the long-term trajectory of the childbirth related pain.
References:
1. Anesth Analg 2005;101:1182-7
2. McMahon SB, Koltzenburg M (Eds.). Elsevier; 2005.
3. Psychological Assessment 1995;7:524-32
4. Journal of Behavioral Medicine 2000;23:351-65
5. Pain Res Manag 2002;7:45-50
13
S154 Abstracts
13
Abstracts S155
39298 - ADOPTING A FLAT OPERATING ROOM SCHEDULE: A QUALITY IMPROVEMENT

AUDIT
Author(s)
Soniya Sharma, BSc
School of Medicine
Queen's University
Co-Author(s)
Wilma Hopman, MA - Clinical Research Centre and Department of Public Health Services, Kingston
General Hospital, Queen's University
Robert Tanzola, MD FRCPC - Department of Anaesthesia and Perioperative Medicine, Kingston
Michael McMullen, MD FRCPC - Department of Anaesthesia and Perioperative Medicine, Kingston
Rene Allard, MD FRCPC - Department of Anaesthesia and Perioperative Medicine, Kingston General
Hospital, Queen's University
Tarit Saha, MD FRCPC - Department of Anaesthesia and Perioperative Medicine, Kingston General
Dale Engen, MD FRCPC - Department of Anaesthesia and Perioperative Medicine, Kingston General
Background: In the context of ongoing cost reduction efforts, a flat operating room (OR) schedule
was introduced at our local tertiary care hospital in September 2011. The previous OR schedule
involved a heavier fall and winter schedule (40 weeks) and a slow down in the summer, Christmas
and March break schedule (12 weeks). The new OR schedule was designed to enhance the
efficiency of bed utilization by decreasing surgical beds but maintaining elective surgical volumes by
leveling them throughout the year. Through the new schedule, there was a total reduction of 66 OR
days shared by Orthopedics and General Surgery. The purpose of this audit was to assess the
effectiveness of the new OR schedule in maintaining access for elective cases by measuring surgical
volume, wait times, and case cancellations in the years before and after implementation.
Methods: After obtaining local institutional ethics approval we conducted a retrospective cohort study
utilizing OR room records compared by service during two distinct periods (June 2010 to May 2011
and June 2012 to May 2013). The outcomes selected for this quality improvement audit were elective
surgical volumes, surgery wait times, and case cancellations. Wait time data were assessed using
2
independent samples t-tests and case cancellation data were assessed using X tests.
Results: The total surgical volume was 8048 cases from June 2010 to May 2011 cases and 8025
cases for June 2012 to May 2013. There was a significant increase in average adult wait times in
Neurosurgery, General Surgery, and Gynecology (p<0.0001) and a significant decrease in Oral
Surgery, Urology, and Vascular Surgery (p<0.003) (Figure 1). The total wait times decreased from a
mean of 73.1 (SD 23.3) to 70.4 (SD 30.6) days (p<0.0001). There was a significant increase in case
cancellations (p<0.05) in Orthopedics, Vascular Surgery, Neurosurgery, Gynecology, and Plastic
Surgery, and a significant decrease (p<0.05) in Oral Surgery. Overall, case cancellations increased
from 8.8% to 10.7% (p<0.0001).
Discussion: Our results found that the flat OR schedule maintained elective surgical volume, had a
variable effect on wait times and resulted in an overall increase in case cancellations. Case
cancellations could be due to the reduction in surgical beds, hospital renovations, and ineffective
resource allocation. Further investigation will be to required to understand the variable effect on wait
times, the impact on emergency cases, and overall cost effectiveness.
References:
N/A
13
S156 Abstracts
13
Abstracts S157
39299 - LOW FIDELITY SIMULATION TO TEACH ANESTHETISTS' NON-TECHNICAL SKILLS
Author(s)
Patricia Livingston, MD, FRCPC
Anesthesia
Teresa Skelton, MD, FRCPC, Clinical Fellow

Anesthesiology
Sick Kids, Toronto, Canada
Co-Author(s)
Isaac Nshimyumuremyi, MD - Anesthesia, National University of Rwanda
Christian Mukwesi, MD - Anesthesia, National University of Rwanda
Lauren Zolpys, MD - Anesthesia, Dalhousie University
JeanBonaventure Uwineza, MMed - Anesthesia, National University of Rwanda
Introduction: Anaesthesia is difficult to practice safely in the developing world where there are
1
severe shortages of personnel, drugs, equipment and training . Non-technical skills are critical in an
environment with major clinical demands, few mentors, and scarce resources. Fostering
communication skills amongst healthcare professionals is critical for patient safety. This pilot study
investigates whether low-fidelity instructor-driven simulation can provide effective teaching of
anaesthetists’ non-technical skills (ANTS) in a developing world context.
Methods: Study participants were anaesthesia technicians and residents. The study took place
between July 2012 and January 2013. Baseline observations were made of 20 anaesthesia providers
during elective and urgent Caesarean sections to assess non-technical skills using the established
ANTS framework. More than one observer was used therefore observer calibration was done prior to
starting the study. After the first observation participants were randomized to either the control or
intervention group. Observers were blinded to participant allocation. The intervention group
underwent training of ANTS using low-fidelity instructor-driven simulation with debriefing. All 20
participants were then observed again.
Results: The primary outcome was the overall ANTS score out of 16. Median ANTS score of the
simulation group was 13.5 (11, 16) and that of the control group 8 (8, 9) and was statistically
significant at p = 0.0016. Simulation participants showed statistically significant improvement in both
subcategories and in the overall ANTS score compared with ANTS score prior to simulation exposure.
The category with the most significant improvement was team working. Observer concordance was
established with a Kendall W coefficient that was significant.
Second observation ANTS scores

Simulation group Control group P value
(N = 10) (N = 10)
Task management 3 (3, 4) 2 (2, 2) 0.0017
(median, interquartile
range)
Team working (median, 4 (2, 4) 2 (2, 2) 0.0061
interquartile range)
Situational awareness 3 (3, 4) 2 (2, 2) 0.0052
(median, interquartile
range)
Decision making (median, 3.5 (3, 4) 2.5 (2, 3) 0.0087
Overall score (median, 13.5 (11, 16) 8 (8, 9) 0.0016
13
S158 Abstracts
Discussion: Anaesthesia providers show an improvement in their non-technical skills in the operating
room environment with as little as one teaching session using low fidelity instructor driven simulation
with debriefing. High fidelity simulators involve computer driven interactive mannequins that recreate
2
an authentic environment . This set up has been used successfully to teach anaesthetists’ non-
3
technical skills (ANTS) . However, high fidelity simulators are unaffordable in most developing
countries. Psychological fidelity, or the degree to which the simulation captures the skills needed in
2
the actual task, could be as important as physical fidelity . With this in mind, low fidelity, instructor-
driven simulation has the potential to create a valuable learning situation. This method of training
could be applied to many resource-limited settings to improve non-technical skills for anaesthesia
providers with the goal of making surgery safer.
References:
1
Anaesthesia 2007 62:4 – 11
2
Med Educ 2003 37(suppl. 1): 22-28
3
Br J of Anaesth 2010 105(1): 38–44
13
Abstracts S159
39300 - GUIDELINE FOR THE ASSESSMENT OF THE MICROCIRCULATION IN THE VAGINA
Author(s)
Fiona Turpie, M.D.
Department of Anesthesia, Pain Management, and Perioperative Medicine
Co-Author(s)
Ronald George, MD, FRCPC - Department of Anesthesia, Pain Management, and Perioperative
Medicine, Dalhousie University
Christian Lehmann, MD, PhD, FRCPC - Department of Anesthesia, Pain Management, and
Perioperative Medicine, Dalhousie University
Jillian Coolen, MD FRCPS - Department of Obstetrics & Gynecology, Dalhousie University
Introduction: The microcirculation is the system used to deliver oxygen and nutrients and eliminate
waste such as carbon dioxide of the localized tissues and is represented by the capillaries and the
venules. Sidestream Dark Field (SDF) illumination can be used to enable the comprehensive
evaluation of the functional state of the microcirculation. The focus of study has been the sublingual
vessels primarily because of ease of access. There have been studies of the brain, eye, skin and
intestine.[1] The interest of our group lies in the application of the study of microcirculation in pregnant
woman. We have performed a study assessing the microcirculation of pregnant women and believe
the microcirculation of pregnant women to be different than non-pregnant women.[2] Anesthesia used
in obstetrics is typically a neuraxial technique. Neuraxial anesthetics have an influence on the
sympathetic control of microvasculature, but the impact on microcirculation measures is not yet clear.
The vagina represents a theoretical site for evaluation of the microcirculation for pregnant women with
neuraxial anesthesia, however, this has never been examined in any population.
Methods: To compare the sublingual microcirculation to the microcirculation of the vaginal mucosa
we are studying the feasibility of SDF imaging of the vaginal mucosa and calculation of the
microvascular flow index (MFI) in women undergoing a D&C procedure.[3] With REB approval,
consent was obtained from women undergoing MAC anesthesia. The study is ongoing, however we
must first assess the ability to grade the vaginal microcirculation as is done in sublingual
microcirculation. The vaginal microcirculation will be examined with the SDF device applied to the
superficial and deep vaginal mucosa followed by sublingual mucosa obtaining steady images of at
least 3 seconds duration for both surfaces.
Results: Images of the deep vagina, superficial vagina and sublingual microcirculation are seen in
Figure 1 (A - deep vaginal mucosa, B - superficial vaginal mucosa, C - sublingual mucosa). The deep
circulation presents as spiral vessels perpendicular to the wall of the vagina, while the superficial
vaginal vessels appear similar to sublingual vessls. MicroVision Automated Vascular Analysis (AVA)
3.0 © software analyzes video in two dimensions. Videos containing more than 70% overlap of
vessels must be excluded. Looping and overlap of the microcirculation in the deep vagina exclude
most of our images. In the more superficial areas of the vagina, blood flow is lateral to the microscopic
camera when compared to deep areas and permits application of the software.
Discussion: In our preliminary experience, the assessment of the microcirculation needs to be limited
to the more superficial vagina, where the vessels are lateral, not perpendicular to the camera. This
allows for better control of the secretions; identifiable access to the area in question; and the ability to
utilize the current software available for analysis. All future evaluations of vaginal microcirculation
should occur in the superficial vaginal mucosa until suitable means of recording deep vaginal
microcirculation are developed.
References:
1. Acta Anaethesiol Scand 2012; 56: 298-306.
2. Int J Obstet Anesth 2013; Sept 8: PMID 243-42223
3. Crit Care 2007; 11(5): R101
13
S160 Abstracts
13
Abstracts S161
39305 - TRACHEAL ULTRASOUND TO ASSESS ENDOTRACHEAL TUBE DEPTH
Author(s)
Mateen Raazi
Department of Anesthesiology, Perioperative Medicine and Pain Management
Co-Author(s)
Kinsha Yip, Medical Student – Anesthesiology, University of Saskatchewan
Andrew Wang, Medical Sudent – Anesthesiology, University of Saskatchewan
William McKay, FRCPC, Staff Anesthesiologist - Anesthesiology, University of Saskatchewan
Introduction: Ideal endotracheal tube (ETT) position is achieved when the distal tip is in mid-trachea
with the head in neutral alignment.Unrecognized tube misplacement is an uncommon but significant
1,2
cause of hypoxemia and death during general anesthesia and critical care. Malpositioning can be
too shallow, too deep, or esophageal, resulting in inadvertent extubation, endobronchial placement
with hypoxia orbarotraumas, or hypoxemia and inflation of the stomach. 3,4,5,6 Malposition is common,
occurring in 14% to 61% of patients.4,7,8,9 Palpation of the ETT tip by a finger in the sternal notch has
10
been described for infants, and resulted in a correct placement rate of 93%. This study explores
Tracheal Ultrasound (TU) of the ETT during intubation for correct depth compared to placement by
depth at the teeth.
Methods: With Research Ethics approval, ASA I and II patients, expected to be intubated for elective
surgery, were recruited. Intubators were asked to “advance the tube slowly once it is through the
cords.” The trachea was imaged with ultrasound from larynx to sternal notch by an investigator. When
the ETT tip was seen in the sternal notch, it was immobilized and its position determined by fibre-optic
bronchoscopy.
Results: Of 53 patients studied, ETT tip movement was visualized in 45, and bronchoscopy was
performed in 48. ETT placement by TU resulted in no more correct placements: 48 (91%) [95%
Confidence Intervals 88 to 93%] compared to our hospital standard, measurement of depth at the
incisors or gums of 23cm for men and 21cm for women, calculated to be 44 (83%) [79 to 87%] (P =
0.39). No ETTs were too shallow. The ETT tip was 5.0(2.2) cm above the carina, which was 1.9cm
[1.4 to 2.5cm] below the ideal of mid trachea. Pulling the ETT back 1 or 2cm after TU would have
improved the results.
Discussion: Tracheal Ultr asound requires special equipment and is no better than conventional pre-
determined standardized depth markers to ensure proper Endotracheal Tube depth placement.
References:
1. Anesthesiology 1990; 72: 828- 833.
2. Anesthesiology 1995; 82: 367- 376.
3. Can J Anesth 2008; 55: 685- 690.
4. Anesthesiology 1987; 67: 255- 257.
5. Br J Anaesth 2003; 91: 297- 298.
6. Br J Anaesth 1994; 73: 55- 63.
13
S162 Abstracts
39308 - PREDICTORS OF PERIOPERATIVE BLOOD TRANSFUSION IN COLORECTAL

SURGERY
Author(s)
Matthew Machina, MSc
Anesthesia
University of Toronto & University Health Network
Co-Author(s)
Stuart McCluskey, MD PhD - Anesthesia, University of Toronto and University Health Network
Keyvan Karkouti, MD MSc - Anesthesia, University of Toronto and University Health Network
Introduction: Red Blood Cells (RBCs) in colorectal surgery have been associated with increased all-
cause mortality, postoperative morbidity and increased length of stay[1]. Many colorectal surgeries
are performed for colorectal cancer - one of the most common cancers worldwide with incidence that
continues to increase[1]. It is important to understand the perioperative clinical factors that may
increase the risk of RBC transfusion in the perioperative period, and may thus impact patient
outcomes postoperatively. The objective of the study was to assess the incidence of perioperative
blood transfusions in colorectal surgical patients, and to determine which clinical factors are
associated with increased risk of perioperative blood transfusions.
Methods: After institutional REB approval, a retrospective cohort analysis was conducted on adult
patients undergoing colorectal surgery between Jan 2003 and Dec 2012 at a single institution (no
consent needed). The population consisted of adults, greater than 18 years of age, who underwent a
CRC surgical procedure at the participating institution. Data was extracted from the institution’s
surgical booking database, electronic patient records and blood transfusion database. We calculated
summary statistics (Min, Max, Mean & SD, Median & IQR) of number of units of RBCs transfused for
preop, day of surgery, and postop periods. Logistic regressions were run to determine the factors
significantly associated with RBC transfusions. Data analysis was performed in STATA v. 12.1
(StataCorp, Texas, USA).
Results: Incidence of RBC transfusions was 3.3% in the preoperative period, 13.1% on the day of
surgery, and then decreased steadily from 4.8% on postop day 1 to 1.6% on postop day 7. Of those
patients receiving an RBC transfusion, the median (IQR) number of units transfused was 2 (1-3) in the
preoperative period, 2 (1-3) on the day of surgery, and 1 (1-2) in the postoperative period. Logistic
regression revealed that age, preoperative hemoglobin, preoperative CHF, and preoperative cardiac
ischemia were significant predictors of RBC transfusions in the perioperative period (day of surgery to
postop day 2, inclusive) (84% of observations correctly classified, ROC = 0.83).
Discussion: We have shown that age, preoperative hemoglobin, preoperative CHF and preoperative
cardiac ischemia are significant predictors of RBC transfusions in the perioperative period. These
findings may inform clinical guidelines and protocols to improve surgical management for this patient
population, possibly reducing the incidence (or volume) of RBC transfusions, and improving patient
outcomes postoperatively.
References:
1. Ann Surg 2012 256: 235–244
13
Abstracts S163
39309 - USING SIMULATION TO ASSESS HOW ANESTHESIA RESIDENTS PREPARE FOR A

DISCLOSURE MEETING
Author(s)
Victor M. Neira
Assistant Professor
Introduction: Previous studies have found that trainees do not routinely receive instruction in how to
effectively perform disclosure, despite the existence of guidelines. (1,2)Trainees are often excluded
from disclosure meetings, missing a valuable learning experience.
Assessing complex skills such as ability to perform communication and professionalism skills
necessary for a successful disclosure meeting during a clinical rotation is difficult.
The objective of our study was to explore how anesthesia residents prepare for a disclosure meeting
after the occurrence of an adverse event in a simulated environment.
Methods: REB approval and informed consent were obtained from 21 anesthesia residents form a
single academic institution. A tripartite simulation scenario was constructed wich comprised of: a
clinical emergency (treating a morphine everdose), preparation for a disclosure meeting, and the
actual meeting. The resident was given 10 minutes to prepare for this meeting, the patient’s chart was
provided and also internet access, telephone and a hard copy of the CPSI disclosure guidelines and
the CMPA disclosure toolkit within line of sight.
Preparation for disclosure was classified as the chart only or the chart consultation plus other
modality. Communication and Professional performances were scored using a previously described
Generic Integrated Objective Assessment Tool (GIOSAT).(3) Four trained raters blinded form
residents’ identity and preparation modality scored the disclosure videos.
Comparison: Our primary outcome was the comparison between preparation modality with
Communication and Professional scores. Our secondary outcome was the correlation between post-
graduate year of residency (PGY) with Communicator and Professional scores. Students’ t test and
Pearson correlation coefficients were performed using SPSS version 21.
Results: Twenty one residents participated in the study. Most participants used only the chart to
prepare for disclosure. (Table 1) We found significant differences in communication scores (chart only
4.0 SD .41, Other modality 4.5 SD .52, p=.02) but Professional scores were not significant (chart only
4.37 SD± .55, other modality 4.9 SD ±.81, p=.08. There was significant correlation between
Professional scores and PGY (r=0.56, p=.008), but correlations between PGY Communication scores
(r=.36, p=.10) did not reach significance.
Debriefing session revealed that most residents did not know about the disclosure guidelines and that
they don’t receive formal teaching this topic. Complications are rare and most of the time the staff
performs the disclosure. They found the guidelines useful to prepare disclosure.
Conclusions: Disclosure seems to be not part of the formal curriculum for anesthesia residents.
Disclosure is recommended to be formally taught by multiple institutions. Simulation could be an
option to fill the gap between the formal and hidden curriculum in some professionalism topics such
as disclosure, not only for learning but also for assessing.
The availability, knowledge and application of the disclosure guidelines appear to improve
communication skills in anesthesia residents disclosing harmful events to patients.
References:
1.Archives of Internal Medicine 2008;168:40-6.
2. www.cmpa-acpm.ca
3. Canadian journal of anaesthesia60 (3), 280-289.
13
S164 Abstracts
13
Abstracts S165
39310 - HEMORRHAGIC ARREST DURING RE-STERNOTOMY OPENING; ROLE OF HYPOTHERMIA

AND EEG MONITORING
Author(s)
Gabriela Lahaie Luna
Medical Student
Victor M. Neira
Assistant Professor
Co-Author(s)
Gyaandeo Maharajh, MD. FRCS - Surgery, University of Ottawa
Sonny Dhanani, M.D. FRCPC - Pediatrics, University of Ottawa
Ganeesh Shanmugam, M.D. FRCS - Surgery, University of Ottawa
Srinivas Bulusu - Pediatrics, Children's Hospital of Eastern Ontario
Introduction: Therapeutic hypothermia (TH) (32-34°C) may be considered for neuro protection in children
who remain comatose after cardiac arrest (CA)(1). Continuous electroencephalography (cEEG) monitoring
during the first 24 h after CA in patients with TH has been recommended for prognostication (2).
Case Description: Informed consent was obtained from the mother to publish this case. A 10 year old
female presented hemorrhagic cardiac arrest during a REDO sternotomy for double outlet right ventricle,
large sub-aortic ventricular septal defect (VSD) and severe supravalvular stenosis in a parachute mitral
valve. The patient had history of VSD, PDA and persistent left vena cava correction, 8 years before in a
different country, which coursed with postoperative pulmonary hypertension. She was considered non-
operable due to severe pulmonary hypertension. Our investigations clarified the diagnosis and demonstrated
reactive systemic level pulmonary hypertension. Massive bleeding from a tear in the right atrium during
midline sternotomy, resulted in profound hypotension, exsanguination and ventricular fibrillation with 20 min
CA. Surgeons attempted manual control of bleeding, chest compressions were ineffective because of
massive bleeding, unsuccessful femoral cannulations, finally managing venous cannulation through the
atrial tear, and blind aortic cannulation. Anesthetic support consisted in transfusion, fluids, epinephrine, and
unsuccessful defibrillation. Hypothermic (28 °C) cardiopulmonary bypass was established and internal
defibrillation restored normal sinus rhythm. VSD closure and supramitral membrane resection were
performed with good surgical results, requiring milrinone 0.75 mcg/kg/min and epinephrine 0.05 mcg/kg/min
for inodilation. Controlled hypothermia (33 °C) was planned for 24 h followed by rewarming at 0.25 °C every
2 h. Sedation was performed with midazolam 0.02 mg/kg/h and morphine 20 mcg/kg/h. Multisystemic
support according to PALS guidelines were followed(1). cEEG started the first day demonstrated
generalised low amplitude alpha with overriding beta activity and no reaction to stimulation indicating alpha
coma. She then had eye movements and motor response to commands on the third day while the EEG
showed some delta activity, which progressed to slow wave activity with painful stimulation indicating severe
diffuse disorder of cerebral activity. The patient was extubated well oriented with no neurological deficit on
the fifth post operative day.
Discussion: This case illustrates an excellent neurologic outcome after CA managed with TH. Current
literature questions the effectiveness of TH in comatose adult after CA(3). Evidence in pediatric population in
limited(4). Despite its limited sensitivity, cEEG could be considered to estimate prognosis after CA (2).
Multicentric randomized trials investigating TH and cEEG in pediatric patients are required.
References:
1. Pediatrics 2010;126(5):e1361–99.
2. Crit. Care Med. 2012;40(10):2867–75.
3. N Engl J Med 2013; Dec 5 .
4. Doherty DR, Circulation 2009119(11):1492–500.
13

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Can J Anesth/J Can Anesth (2014) 61:S1–S165

33101 - RANDOMIZED PROSPECTIVE TRIAL COMPARING TWO SUPRAGLOTTIC AIRWAY

Registered clinical trial: Clinicaltrials.gov reference number NCT01001078

© Canadian Anesthesiologists’ Society 2014 13

33356 - A MOBILE DEVICE APPLICATION: CALCULATIONS TO MANAGE OBESE PATIENTS

33770 - A RANDOMIZED TRIAL OF AMITRIPTYLINE VERSUS GABAPENTIN FOR

33877 - ULTRASONOGRAPHY FOR URGENT VISUALIZATION OF SPINAL CANAL ANATOMY

36359 - CEREBRAL OXIMETRY FOR CESAREAN DELIVERY IN A CASE OF MOYAMOYA

Introduction: Abnormalities in intracranial blood vessels predispose Moyamoya disease patients to

36942 - ABDOMINAL COMPARTMENT SYNDROME IN A SEVEN YEAR OLD MALE TRAUMA

Caleb Zelenietz, M.D.

36987 - VALIDATING PATIENT SELF-REPORT TOOL IN PREOPERATIVE TRIAGE

4. Anaesthesia. 2003; 58 (9), pp. 874-877

36990 - PERIOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY AS AN ADJUNCT TO

36993 - POSTOPERATIVE OUTCOME OF PATIENTS WITH KNOWN OBSTRUCTIVE SLEEP

37002 - MALIGNANT HYPERTHERMIA (MH) TESTING IN PROBANDS WITHOUT MH-REACTION

Introduction: Malignant hyperthermia (MH) is characterized by an adverse reaction to volatile

Discussion: MH susceptibility as confirmed by the caffeine halothane contracture test may

37035 - INDIVIDUALIZED BLOOD MANAGEMENT IN CARDIAC SURGERY USING A POINT-OF-

37047 - SIMULATION AND THE MAINTENANCE OF COMPETENCE IN THE ANESTHESIOLOGY

Conclusions: Anesthesiologists perceive simulation as a positive experience with self-reported

37079 - VALIDATION OF A PREOPERATIVE SELF-REPORT COMORBIDITY QUESTIONNAIRE

Homer Yang, MD, CCFP, FRCPC

Methods: In November of 2012, 1741 patients underwent elective surgeries at our

Agreement (Kappa) Total Comorbidities

37258 - PERIOPERATIVE OUTCOMES OF HIGH SPINAL ANESTHESIA FOR CARDIAC

37354 - OBSTRUCTIVE SLEEP APNEA AND 30-DAY POSTOPERATIVE MORTALITY

Introduction: Obstructive sleep apnea (OSA) is associated with adverse postoperative

37624 - EVALUATION OF RETROMOLAR SPACE SIZE FOR INTUBATION FEASIBILITY

Table 1. Demographics and Retromolar Space Dimensions

38109 - QUANTIFYING COMPETENCY – THE DEVELOPMENT AND VALIDATION OF A HAND

38382 - IMPACT OF TRENDELENBURG POSITION ON RESPIRATORY MECHANICS IN

38413 - EFFET OF OPIOIDS REPLACEMENT BY BETA-BLOCKERS ON POST MASTECTOMY PAIN

Introduction: Substitution of opioid medication by beta-blockers during laparoscopic cholecystectomy

38436 - PROFESSIONAL, HEALTH ADVOCATE AND SCHOLAR SIMULATION ASSESSMENT

38515 - DIAGNOSING MURMURS AND DESIGNING LEARNING

38584 - POWER AND CONFLICT: RESIDENTS’ ABILITY TO CHALLENGE AUTHORITY

38672 - PERIOP. MANAGEMENT OF EMERGENCY CABG AND POST-INFARCTION VSR REPAIR

Ronit Lavi, MD, FRCPC

2. Andrew Murday, Optimal management of acute ventricular of septal rupture

38830 - INTERSPECIALTY CRISIS RESOURCE MANAGEMENT TEAM TRAINING PROGRAM

38889 - POSTOPERATIVE MYOCARDIAL ISCHEMIA & CARDIAC EVENTS – A META-ANALYSIS

Review: Event rate with postop ischemia

Study Ischemia No ischemia OR (fixed) Weight OR (fixed)

Total (95% CI) 1066 2154 100.00 12.96 [8.70, 19.31]

0.01 0.1 1 10 100

Study Ischemia No ischemia OR (random) Weight OR (random)

Ouyang 1989 8/15 1/9 3.65 9.14 [0.90, 92.40]

Total (95% CI) 1066 2154 100.00 10.92 [6.85, 17.42]

0.01 0.1 1 10 100

38890 - SUBCUTANEOUS KETAMINE FOR POSTOPERATIVE PAIN MANAGEMENT IN AFRICA

William McKay, M.D. F.R.C.P.C.

38924 - DIPHTHERIA, O'DWYER, AND THE DIFFICULT PEDIATRIC AIRWAY

38934 - A SYSTEMATIC REVIEW OF TTE AND TEE IN NON-CARDIAC SURGERY

38974 - ANESTHESIA AND PERIOPERATIVE MEDICINE

38998 - A RANDOMISED CONTROLLED TRIAL OF EPIDURAL VOLUME EXTENSION DURING A

Age (years) 27.4 ± 4.4 25.5 ± 3.7 0.0933

BMI (kg/m2) 29.8 ± 3.4 29.3 ± 3.1 0.5899

Cervical dilation at CSE (cm) 3.5 (1, 4) 3.5 (2, 4) 0.9517

Peak dermatome 15 min T6.5 (T4, L4) T6 (T1, L2) 0.2234

39024 - ULTRASOUND-GUIDED SINGLE INJECTION INFRACLAVICULAR BLOCK VS. ULTRASOUND-

1. Anesth Analg 2009; 109: 668-72.

Table 1. Characteristics of the blocks