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

Can J Anesth/J Can Anesth (2014) 61:S1–S165DOI 10.1007/s12630-014-0239-1

1 3© Canadian Anesthesiologists’ Society 2014

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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

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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 Role: Primary & Presenting Author 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.

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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 Role: Primary & Presenting Author 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 the spinal canal1, 2 is enough to warrant epidural placement when a patient gives a history of spinal canal problem such as spina bifida occulta3 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 Remifentanil PCA as an alternate analgesia-technique4-6. 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

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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 Role: Primary & Presenting Author Co-Author(s) Patrick Thornton, FCAI - Dept. of Anesthesia, Rotunda Hospital, Dublin, Ireland Introduction: Abnormalities in intracranial blood vessels predispose Moyamoya disease patients to frequent ischemic and hemorrhagic strokes1. 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 interest and is an indirect measure of the cerebral perfusion in that area2. 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 been used in a Moyamoya parturient previously, however only for a portion of the cesarean delivery3. 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 flow4 (CBF), although other articles suggest an increase in CBF in experimental animals5. The rSO2 monitoring in obstetric anesthesia is currently scarce6. 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

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

Author(s) Cameron Goldie, M.D. Anesthesia and Perioperative Medicine University of Manitoba Role: Presenting Author Caleb Zelenietz, M.D. Department of Anesthesia and Perioperative Medicine University of Manitoba Role: Primary Author 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 resuscitation1,2. ACS in adults is defined as a sustained intra abdominal pressure (IAP) greater than 20 mm Hg that is associated with new organ dysfunction or failure1. In children, ACS is defined as "a sustained IAP greater than 10 mm Hg with new or worsening organ dysfunction that can be attributed to elevated IAP" 1. The normal range of IAP in critically ill children is 4-10 mm Hg. ACS has multiple risk factors, including major trauma, shock and resuscitation1. 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 positive cumulative fluid balance in at risk patients1,3. The incidence of ACS after trauma and the frequency of leaving the abdomen open after trauma laparotomy may be declining due to the decreased amount of crystalloid resuscitation4. 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

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36987 - VALIDATING PATIENT SELF-REPORT TOOL IN PREOPERATIVE TRIAGE

Author(s) Jeremy Russell Neufeld, BSc, MD Anesthesiology The Ottawa Hospital Role: Presenting Author 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 used in many institutions to help streamline pre-anesthetic care1, 2, 3, 4. 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

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

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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 Role: Primary & Presenting Author 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, and supplementing information derived from angiography during endograft deployment”(1). TEE is useful for guidewire positioning. Rocchi et al(2) 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 angiography,(3) 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.

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36993 - POSTOPERATIVE OUTCOME OF PATIENTS WITH KNOWN OBSTRUCTIVE SLEEP APNEA

Author(s) Eugene KH. Choo, MD Anesthesiology University of Ottawa Role: Primary & Presenting Author Co-Author(s) Claudia Gomez, MD - Anesthesiology, The Ottawa Hospital Monica Taljaard, PhD - Clinical Epidemiology Program, Ottawa Hospital Research Institute 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)

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

Author(s) Sheila Riazi, MSc, MD Anesthesia University Health Network Role: Primary & Presenting Author 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 family history, patients will undergo caffeine-halothane contracture (CHCT) and/ or genetic testing.1 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.

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Abstracts S17

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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 Role: Primary & Presenting Author 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 outcomes is a major complication of cardiac surgery with cardiopulmonary bypass.1,2 Current management of coagulopathic bleeding relies on conventional coagulation testing that have long turnaround times3 and are not able to detect important coagulation defects such as fibrinolysis, platelet dysfunction, or specific factor deficiencies.4 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-exploration, and to overuse of blood products in others.2,5 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

S18 Abstracts

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Abstracts S19

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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 Role: Primary & Presenting Author 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 CDSR) was conducted to include studies published from 1948 (MEDLINE) until January 31st, 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.

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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.

Abstracts S21

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37079 - VALIDATION OF A PREOPERATIVE SELF-REPORT COMORBIDITY QUESTIONNAIRE

Author(s) Jennifer LC. Wilson, MD Department of Anesthesiology University of Ottawa Role: Presenting Author Homer Yang, MD, CCFP, FRCPC Department of Anesthesiology The Ottawa Hospital Role: Primary Author 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 Monica Taljaard, PhD - Clinical Epidemiology Program, Ottawa Hospital Research Institute 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 comorbidity is limited1, 2, 3. 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", based on standard cutpoints defined in the literature4. 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.

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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 (n=40)

Comorbidities

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

Abstracts S23

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37258 - PERIOPERATIVE OUTCOMES OF HIGH SPINAL ANESTHESIA FOR CARDIAC SURGERY

Author(s) Daniela Goldie Anesthesia University of Manitoba Role: Primary & Presenting Author 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

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Abstracts S25

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37354 - OBSTRUCTIVE SLEEP APNEA AND 30-DAY POSTOPERATIVE MORTALITY

Author(s) Daniel I. McIsaac, MD, MPH University of Ottawa Role: Primary & Presenting Author 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

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37624 - EVALUATION OF RETROMOLAR SPACE SIZE FOR INTUBATION FEASIBILITY

Author(s) Angela Truong Anesthesiology & Perioperative Medicine University of Texas MD Anderson Cancer Center Role: Presenting Author Dam-Thuy Truong Anesthesiology & Perioperative Medicine University of Texas MD Anderson Cancer Center Role: Primary Author 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

Abstracts S27

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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

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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 Role: Primary & Presenting Author 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, p0.74) 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.

Abstracts S29

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38382 - IMPACT OF TRENDELENBURG POSITION ON RESPIRATORY MECHANICS IN PEDIATRIC LAPAROSCOPIC SURGERY

Author(s) Victor M. Neira Assistant Professor. Department of Anesthesiology Children's Hospital of Eastern Ontario. University of Ottawa Role: Primary & Presenting Author Co-Author(s) Luis Guerra, Associate Professor - Department of Surgery, Children's Hospital of Eastern Ontario. University of Ottawa 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

S30 Abstracts

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Abstracts S31

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

Author(s) Vincent Lecluyse Anesthesiology Université de Sherbrooke Role: Primary & Presenting Author 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

-blocker group (BB, n = 18) with rocuronium for muscle relaxation. Anesthesia was maintained with sevoflurane in an air/oxygen mixture. Per-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 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.

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38436 - PROFESSIONAL, HEALTH ADVOCATE AND SCHOLAR SIMULATION ASSESSMENT

Author(s) Victor M. Neira Assistant Professor Department of Anesthesiology Children's Hospital of Eastern Ontario. University of Ottawa Role: Primary & Presenting Author 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

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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

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38515 - DIAGNOSING MURMURS AND DESIGNING LEARNING

Author(s) Gianni R. Lorello, BSc, MD, MSc(c) Department of Anesthesiology University of Toronto and The Wilson Centre Role: Primary & Presenting Author 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 Introduction: Physical exam skills are declining amongst trainees at all levels,1-4 a trend common in specialties with access to technologies like echocardiography.5 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.

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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.

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

Author(s) Zeev Friedman Associate Professor Department of Anesthesiology Mount Sinai Hospital, University of Toronto Role: Primary & Presenting Author 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, University of Toronto Clyde Matava, Assistant Professor - Department of Anesthesiology, The Hospital for Sick Children, University of Toronto 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 transient care providers, are reluctant to challenge incorrect decisions made by a superior.1 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 Scale (GRS).2 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

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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 Role: Presenting Author Ronit Lavi, MD, FRCPC Department of Anesthesia & Perioperative Medicine Schulich School of Medicine and Dentistry, Western University Role: Primary Author 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%. According to ACCF/AHA 2011 guideline1, previous publications and case reports 2-6, surgical treatment of post-infarction ventricular septal rupture should not be delayed.

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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.

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38830 - INTERSPECIALTY CRISIS RESOURCE MANAGEMENT TEAM TRAINING PROGRAM

Author(s) Milene A. Azzam, MDCM Anesthesia McGill University Role: Primary & Presenting Author 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