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Daza JF, Cuthbertson BH, Myles PS, Shulman MA, Wijeysundera DN, Wijeysundera DN, Pearse RM, Myles PS, Abbott TEF, Shulman MA, Torres E, Ambosta A, Melo M, Mamdani M, Thorpe KE, Wallace S, Farrington C, Croal BL, Granton JT, Oh P, Thompson B, Hillis G, Beattie WS, Wijeysundera HC, Ellis M, Borg B, Kerridge RK, Douglas J, Brannan J, Pretto J, Godsall MG, Beauchamp N, Allen S, Kennedy A, Wright E, Malherbe J, Ismail H, Riedel B, Melville A, Sivakumar H, Murmane A, Kenchington K, Kirabiyik Y, Gurunathan U, Stonell C, Brunello K, Steele K, Tronstad O, Masel P, Dent A, Smith E, Bodger A, Abolfathi M, Sivalingam P, Hall A, Painter TW, Macklin S, Elliott A, Carrera AM, Terblanche NCS, Pitt S, Samuels J, Wilde C, Leslie K, MacCormick A, Bramley D, Southcott AM, Grant J, Taylor H, Bates S, Towns M, Tippett A, Marshall F, McCartney CJL, Choi S, Somascanthan P, Flores K, Karkouti K, Clarke HA, Jerath A, McCluskey SA, Wasowicz M, Day L, Pazmino-Canizares J, Belliard R, Lee L, Dobson K, Stanbrook M, Hagen K, Campbell D, Short T, Van Der Westhuizen J, Higgie K, Lindsay H, Jang R, Wong C, McAllister D, Ali M, Kumar J, Waymouth E, Kim C, Dimech J, Lorimer M, Tai J, Miller R, Sara R, Collingwood A, Olliff S, Gabriel S, Houston H, Dalley P, Hurford S, Hunt A, Andrews L, Navarra L, Jason-Smith A, Thompson H, McMillan N, Back G. Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery. Br J Surg 2022; 109:968-976. [PMID: 35929065 DOI: 10.1093/bjs/znac263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/17/2022] [Accepted: 07/08/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort. METHODS Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups. RESULTS The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status. CONCLUSION The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.
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Affiliation(s)
- Julian F Daza
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Brian H Cuthbertson
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Mark A Shulman
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
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Agarwal S, Karkouti K. The relationship between anaemia and poor outcomes: let's get to the meat of the matter. Anaesthesia 2021; 76:1300-1303. [PMID: 34121182 DOI: 10.1111/anae.15524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/20/2021] [Indexed: 12/01/2022]
Affiliation(s)
- S Agarwal
- Department of Anaesthesia, Manchester University Hospitals NHS Trust, Manchester, UK
| | - K Karkouti
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
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Clinkard D, Mashari A, Karkouti K, Fedorko L. Evaluation of N95 respirators, modified snorkel masks and low-cost powered air-purifying respirators: a prospective observational cohort study in healthcare workers. Anaesthesia 2021; 76:617-622. [PMID: 33470422 PMCID: PMC8014823 DOI: 10.1111/anae.15392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 01/13/2023]
Abstract
Disposable N95 respirator masks are the current standard for healthcare worker respiratory protection in the COVID‐19 pandemic. In addition to shortages, qualitative fit testing can have low sensitivity for detecting poor fit, leading to inconsistent protection. Multiple groups have developed alternative solutions such as modified snorkel masks to overcome these limitations, but validation of these solutions has been lacking. We sought to determine if N95s and snorkel masks with attached high‐efficiency filters provide consistent protection levels in healthcare workers and if the addition of positive pressure via an inexpensive powered‐air purifying respirator to the snorkel mask would provide enhanced protection. Fifty‐one healthcare workers who were qualitatively fitted with N95 masks underwent quantitative mask fit testing according to a simulated workplace exercise protocol. N95, snorkel masks with high‐efficiency filters and snorkel masks with powered‐air purifying respirators were tested. Respiratory filtration ratios were collected for each step and averaged to obtain an overall workplace protocol fit factor. Failure was defined as either an individual filtration ratio or an overall fit factor below 100. N95s and snorkel masks with high‐efficiency filters failed one or more testing steps in 59% and 20% of participants, respectively, and 24% and 12% failed overall fit factors, respectively. The snorkel masks with powered‐air purifying respirators had zero individual or overall failures. N95 and snorkel masks with high‐efficiency filter respirators were found to provide inconsistent respiratory protection in healthcare workers.
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Affiliation(s)
- D Clinkard
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - A Mashari
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - L Fedorko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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Ho LTS, Lenihan M, McVey MJ, Karkouti K, Wijeysundera DN, Rao V, Crowther M, Grocott HP, Pinto R, Scales DC, Achen B, Brar S, Morrison D, Wong D, Bussières JS, Waal T, Harle C, Médicis É, McAdams C, Syed S, Tran D, Waters T. The association between platelet dysfunction and adverse outcomes in cardiac surgical patients. Anaesthesia 2019; 74:1130-1137. [PMID: 30932171 DOI: 10.1111/anae.14631] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypass-associated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.
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Affiliation(s)
- L T S Ho
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - M Lenihan
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - M J McVey
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, ON, Canada
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada.,Toronto General Research Institute and the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, ON, Canada
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Shulman M, Cuthbertson B, Wijeysundera D, Pearse R, Thompson B, Torres E, Ambosta A, Wallace S, Farrington C, Myles P, Wallace S, Thompson B, Ellis M, Borg B, Kerridge R, Douglas J, Brannan J, Pretto J, Godsall M, Beauchamp N, Allen S, Kennedy A, Wright E, Malherbe J, Ismail H, Riedel B, Melville A, Sivakumar H, Murmane A, Kenchington K, Gurunathan U, Stonell C, Brunello K, Steele K, Tronstad O, Masel P, Dent A, Smith E, Bodger A, Abolfathi M, Sivalingam P, Hall A, Painter T, Macklin S, Elliott A, Carrera A, Terblanche N, Pitt S, Samuels J, Wilde C, MacCormick A, Leslie K, Bramley D, Southcott A, Grant J, Taylor H, Bates S, Towns M, Tippett A, Marshall F, McCartney C, Choi S, Somascanthan P, Flores K, Beattie W, Karkouti K, Clarke H, Jerath A, McCluskey S, Wasowicz M, Granton J, Day L, Pazmino-Canizares J, Hagen K, Campbell D, Short T, Van Der Westhuizen J, Higgie K, Lindsay H, Jang R, Wong C, Mcallister D, Ali M, Kumar J, Waymouth E, Kim C, Dimech J, Lorimer M, Tai J, Miller R, Sara R, Collingwood A, Olliff S, Gabriel S, Houston H, Dalley P, Hurford S, Hunt A, Andrews L, Navarra L, Jason-Smith A, Thompson H, McMillan N, Back G, Melo M, Mamdani M, Hillis G, Wijeysundera H. Using the 6-minute walk test to predict disability-free survival after major surgery. Br J Anaesth 2019; 122:111-119. [DOI: 10.1016/j.bja.2018.08.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/13/2018] [Accepted: 08/29/2018] [Indexed: 11/16/2022] Open
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Karkouti K, Wijeysundera DN. The clinical dilemma of managing patients who are on dual antiplatelet therapy and require major non-cardiac surgery. Br J Anaesth 2018; 122:162-164. [PMID: 30686300 DOI: 10.1016/j.bja.2018.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/28/2018] [Accepted: 10/03/2018] [Indexed: 10/27/2022] Open
Affiliation(s)
- K Karkouti
- Department of Anesthesia and Pain Management, and the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada.
| | - D N Wijeysundera
- Department of Anesthesia and Pain Management, and the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
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Baumann Kreuziger L, Karkouti K, Tweddell J, Massicotte MP. Antithrombotic therapy management of adult and pediatric cardiac surgery patients. J Thromb Haemost 2018; 16:2133-2146. [PMID: 30153372 DOI: 10.1111/jth.14276] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Indexed: 12/16/2022]
Abstract
Despite the development of catheter-based interventions for ischemic and valvular heart disease, hundreds of thousands of people undergo open heart surgery annually for coronary artery bypass graft (CABG), valve replacement or cardiac assist device implantation. Cardiac surgery patients are unique because therapeutic anticoagulation is required during cardiopulmonary bypass. Developmental hemostasis and altered drug metabolism affect management in children. This narrative review summarizes the current evidence-based and consensus guidelines regarding perioperative, intraoperative and postoperative antithrombotic therapy in patients undergoing cardiac surgery. Anticoagulation preoperatively is required in the setting of cardiac arrhythmias, prior valve replacement or history of venous thromboembolism. In patients with ischemic heart disease, aspirin is continued in the perioperative period, whereas oral P2Y12 antagonists are withheld for 5-7 days to reduce the risk of perioperative bleeding. Intraoperative management of cardiopulmonary bypass in adults and children includes anticoagulation with unfractionated heparin. Variability in dose-response to heparin and influence of other medical conditions on dosing and reversal of heparin make intraoperative anticoagulation challenging. Vitamin K antagonist therapy is the standard anticoagulant after mechanical heart valve or left ventricular assist device (LVAD) implantation. Longer duration of dual antiplatelet therapy is recommended after CABG if patients undergo surgery because of acute coronary syndrome. Antiplatelet therapy after LVAD implantation includes aspirin, dipyridamole and/or clopidogrel in children and aspirin in adults. A coordinated approach between hematology, cardiology, anesthesiology, critical care and cardiothoracic surgery can assist to balance the risk of thrombosis and bleeding in patients undergoing cardiac surgery.
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Affiliation(s)
- L Baumann Kreuziger
- BloodCenter of Wisconsin, Blood Research Institute, Milwaukee, WI, USA
- Medical College of Wisconsin, Department of Medicine, Division of Hematology and Oncology, Milwaukee, WI, USA
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - J Tweddell
- Department of Surgery and Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - M P Massicotte
- University of Alberta, Department of Pediatrics, Edmonton, Alberta, Canada
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McIlroy D, Bellomo R, Billings F, Karkouti K, Prowle J, Shaw A, Myles P. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: renal endpoints. Br J Anaesth 2018; 121:1013-1024. [DOI: 10.1016/j.bja.2018.08.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/21/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023] Open
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Fitzgerald J, Lenihan M, Callum J, McCluskey S, Srinivas C, van Rensburg A, Karkouti K. Use of prothrombin complex concentrate for management of coagulopathy after cardiac surgery: a propensity score matched comparison to plasma. Br J Anaesth 2018; 120:928-934. [DOI: 10.1016/j.bja.2018.02.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 02/01/2018] [Accepted: 02/18/2018] [Indexed: 12/25/2022] Open
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Abbott T, Fowler A, Pelosi P, Gama de Abreu M, Møller A, Canet J, Creagh-Brown B, Mythen M, Gin T, Lalu M, Futier E, Grocott M, Schultz M, Pearse R, Myles P, Gan T, Kurz A, Peyton P, Sessler D, Tramèr M, Cyna A, De Oliveira G, Wu C, Jensen M, Kehlet H, Botti M, Boney O, Haller G, Grocott M, Cook T, Fleisher L, Neuman M, Story D, Gruen R, Bampoe S, Evered L, Scott D, Silbert B, van Dijk D, Kalkman C, Chan M, Grocott H, Eckenhoff R, Rasmussen L, Eriksson L, Beattie S, Wijeysundera D, Landoni G, Leslie K, Biccard B, Howell S, Nagele P, Richards T, Lamy A, Gabreu M, Klein A, Corcoran T, Jamie Cooper D, Dieleman S, Diouf E, McIlroy D, Bellomo R, Shaw A, Prowle J, Karkouti K, Billings J, Mazer D, Jayarajah M, Murphy M, Bartoszko J, Sneyd R, Morris S, George R, Moonesinghe R, Shulman M, Lane-Fall M, Nilsson U, Stevenson N, van Klei W, Cabrini L, Miller T, Pace N, Jackson S, Buggy D, Short T, Riedel B, Gottumukkala V, Alkhaffaf B, Johnson M. A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications. Br J Anaesth 2018; 120:1066-1079. [DOI: 10.1016/j.bja.2018.02.007] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/01/2018] [Accepted: 02/12/2018] [Indexed: 02/02/2023] Open
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Karkouti K, Yip P, Chan C, Chawla L, Rao V. Pre-operative anaemia, intra-operative hepcidin concentration and acute kidney injury after cardiac surgery: a retrospective observational study. Anaesthesia 2018. [PMID: 29529338 DOI: 10.1111/anae.14274] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Acute kidney after cardiac surgery is more common in anaemic patients, whereas haemolysis during cardiopulmonary bypass may lead to iron-induced renal injury. Hepcidin promotes iron sequestration by macrophages: hepcidin concentration is reduced by anaemia and increased by inflammation. We analysed the associations in 525 patients between pre-operative anaemia (haemoglobin < 130 g.l-1 in men and < 120 g.l-1 in women), intra-operative hepcidin concentration and acute kidney injury (dialysis or > 26.4 μmol.l-1 or > 50% creatinine increase during the first two days after cardiac surgery. Rates of pre-operative anaemia and postoperative kidney injury were 109/525 (21%) and 36/525 (7%), respectively. The median (IQR [range]) intra-operative hepcidin concentration was 20 (10-33 [0-125]) μg.l-1 and was lower in anaemic patients than those who were not: 15 (4-28 [0-125]) μg.l-1 vs. 21 (12-33 [0-125]) μg.l-1 , respectively, p = 0.002. Four variables were independently associated with postoperative kidney injury, for which the beta-coefficients (SE) were: minutes on cardiopulmonary bypass, 0.016 (0.004), p < 0.001; intra-operative hepcidin concentration, 0.032 (0.008), p < 0.001; pre-operative anaemia, 1.97 (0.56), p < 0.001; and Cleveland clinic risk score, 0.88 (0.35), p = 0.005. Contrary to generally increased rates of kidney injury in patients with higher hepcidin concentrations, rates of kidney injury in anaemic patients were lower in patients with higher hepcidin concentrations, beta-coefficient (SE) -0.037 (0.01), p = 0.007. In cardiac surgical patients the rate of postoperative acute kidney injury predicted by the Cleveland risk score might be adjusted for pre-operative anaemia and intra-operative cardiopulmonary bypass time and hepcidin concentration. Pre-operative correction of anaemia, reduction in intra-operative bypass time and modification of iron homeostasis and hepcidin concentration might reduce acute kidney injury.
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Affiliation(s)
- K Karkouti
- Department of Anesthesia and Pain Management, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - P Yip
- Department of Clinical Biochemistry, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - C Chan
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - L Chawla
- Department of Anesthesiology and Critical Care Medicine, The George Washington University, Washington, DC, USA.,La Jolla Pharmaceutical Company, San Diego, CA, USA
| | - V Rao
- Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
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Wąsowicz M, Syed S, Wijeysundera DN, Starzyk Ł, Grewal D, Ragoonanan T, Harsha P, Travis G, Carroll J, Karkouti K, Beattie WS. Effectiveness of platelet inhibition on major adverse cardiac events in non-cardiac surgery after percutaneous coronary intervention: a prospective cohort study. Br J Anaesth 2016; 116:493-500. [PMID: 26888800 DOI: 10.1093/bja/aev556] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Platelet inhibition is mandatory therapy after percutaneous coronary intervention (PCI). Withdrawal of oral antiplatelet agents has been linked to increased incidence of postoperative adverse cardiac events in post-PCI patients having non-cardiac surgery (NCS). There is limited knowledge of temporal changes in platelet inhibition in this high-risk surgical population. We therefore performed a multicentre prospective cohort study evaluating perioperative platelet function and its association with postoperative major adverse cardiac events (MACE). METHODS In 201 post-PCI patients having NCS, we assessed the association between platelet function and postoperative MACE. We performed perioperative platelet function testing using a platelet mapping assay (PMA). Troponin-I was measured every 8 h for 2 days, then daily until day 5. Myocardial infarction was assessed using the third universal definition. We used multivariable logistic regression to assess the association between platelet inhibition and MACE. RESULTS Major adverse cardiac events occurred in 40 patients within 30 days of surgery. Thirty-two of these events were non-ST-elevation myocardial infarction, four ST-elevation myocardial infarction, and four exacerbation of congestive heart failure. We were unable to show an association between platelet inhibition and MACE. The PMA showed declining levels of platelet inhibition the longer the antiplatelet therapy was withheld before surgery. Logistic regression did not show an association between preoperative platelet function or the type of stent and MACE. We found an increased cardiac risk of MACE after surgery within 6 weeks of PCI. CONCLUSIONS The incidence of MACE in patients undergoing NCS after previous PCI is high in spite of adequate perioperative antiplatelet therapy. CLINICAL TRIAL REGISTRATION NCT 01707459 (registered at http://www.clinicaltrials.gov).
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Affiliation(s)
- M Wąsowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 The Peter Munk Cardiac Centre, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 Department of Anesthesia, University of Toronto, 12 Floor, 123 Edward Street, Toronto, ON Canada M5G 1E2
| | - S Syed
- Department of Anesthesia Hamilton Health Sciences Corporation, McMaster University, 237 Barton Street East, Hamilton, ON, Canada L8L 2X2
| | - D N Wijeysundera
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 Department of Anesthesia, University of Toronto, 12 Floor, 123 Edward Street, Toronto, ON Canada M5G 1E2 Li Ka Shing Knowledge Institute of St Michael's Hospital, 209 Victoria Street, Toronto, ON, Canada M5B 1T8 Institute of Health Policy Management and Evaluation, 155 College Street, Toronto, ON, Canada M5T 3M6
| | - Ł Starzyk
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4
| | - D Grewal
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4
| | - T Ragoonanan
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4
| | - P Harsha
- Department of Anesthesia Hamilton Health Sciences Corporation, McMaster University, 237 Barton Street East, Hamilton, ON, Canada L8L 2X2
| | - G Travis
- Department of Anesthesia Hamilton Health Sciences Corporation, McMaster University, 237 Barton Street East, Hamilton, ON, Canada L8L 2X2
| | - J Carroll
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 The Peter Munk Cardiac Centre, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 Department of Anesthesia, University of Toronto, 12 Floor, 123 Edward Street, Toronto, ON Canada M5G 1E2 Institute of Health Policy Management and Evaluation, 155 College Street, Toronto, ON, Canada M5T 3M6
| | - W S Beattie
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 The Peter Munk Cardiac Centre, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 Department of Anesthesia, University of Toronto, 12 Floor, 123 Edward Street, Toronto, ON Canada M5G 1E2
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Corredor C, Wasowicz M, Karkouti K, Sharma V. The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis. Anaesthesia 2015; 70:715-31. [PMID: 25916344 DOI: 10.1111/anae.13083] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 12/23/2022]
Abstract
This systematic review and meta-analysis appraises the utility of point-of-care platelet function tests for predicting blood loss and transfusion requirements in cardiac surgical patients, and analyses whether their use within a transfusion management algorithm is associated with improved patient outcomes. We included 30 observational studies incorporating 3044 patients in the qualitative assessment, and nine randomised controlled trials including 1057 patients in the meta-analysis. Platelet function tests demonstrated significant variability in their ability to predict blood loss and transfusion requirements. Their use within a blood transfusion algorithm demonstrated a reduction in blood loss at longest follow-up (mean difference -102.9 ml (95% CI -149.9 to -56.1 ml), p < 0.001), and transfusion of packed red cells (RR 0.86 (95% CI 0.78-0.94), p = 0.001) and fresh frozen plasma (RR 0.42 (95% CI 0.30-0.59), p < 0.001). Viscoelastic methods used in combination with other platelet function tests achieved greater reduction in blood loss (mean difference -111.8 ml (95% CI -174.9 to -49.1 ml), p = 0.0005) compared with their use alone (mean difference -90.6 ml (95% CI 166.1-15.0 ml), p = 0.02). We conclude that incorporation of point-of-care platelet function tests into transfusion management algorithms is associated with a reduction in blood loss and transfusion requirements in cardiac surgery patients.
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Affiliation(s)
- C Corredor
- Department of Anaesthesia, St. George's Hospital, London, UK
| | - M Wasowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - V Sharma
- Department of Anaesthesia, St. George's Hospital, London, UK
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Abstract
Red cell transfusion therapy is a common treatment modality in contemporary medical practice. Although blood collection and administration is safer and more efficient than ever before, red cells undergo multiple metabolic and structural changes during storage that may compromise their functionality and viability following transfusion. The clinical relevance of these changes is a hotly debated topic that continues to be a matter of intense investigation. In the current review, we begin with an in-depth overview of the pathophysiological mechanisms underlying red cell storage, with a focus on altered metabolism, oxidative stress and red cell membrane damage. We proceed to review the current state of evidence on the clinical relevance and consequences of the red cell storage lesion, while discussing the strengths and limitations of clinical studies.
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Affiliation(s)
- D Orlov
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Abstract
Acute kidney injury (AKI) is a serious and common complication of major surgery. This narrative review focuses on the relationship between perioperative red blood cell transfusion and AKI after cardiac surgery with cardiopulmonary bypass (CPB). Numerous observational studies have shown that these two factors are independently associated with each other. Several lines of evidence suggest that the nature of this association is one of cause and effect. The pathophysiological mechanism by which transfusions might harm the kidney has not been fully elucidated, but it is known that erythrocytes undergo irreversible morphological and biochemical changes during storage. As a result, after transfusion, they can promote a pro-inflammatory state, impair tissue oxygen delivery, and exacerbate tissue oxidative stress. This in turn can cause AKI in susceptible patients undergoing cardiac surgery with CPB, such as those with pre-existing kidney dysfunction or anaemia. Interventions aimed at avoiding perioperative blood transfusion might, therefore, reduce the risk of AKI after cardiac and other types of surgery.
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Affiliation(s)
- K Karkouti
- Department of Anesthesia and Pain Management, Institute of Health Policy, Management, and Evaluation, Toronto General Research Institute, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, ON, Canada.
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de Perrot M, McRae K, Anraku M, Karkouti K, Waddell T, Pierre A, Darling G, Keshavjee S, Johnston M. 122 Risk factors for major complications after extrapleural pneumonectomy. Lung Cancer 2006. [DOI: 10.1016/s0169-5002(07)70198-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Affiliation(s)
- K Karkouti
- Department of Anesthesia, Health Network, University of Toronto, Toronto, ON, Canada.
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Karkouti K, Yau TM, Rensburg AV, McCluskey SA, Callum J, Wijeysundera DN, Beattie WS. The effects of a treatment protocol for cardiac surgical patients with excessive blood loss on clinical outcomes. Vox Sang 2006; 91:148-56. [PMID: 16907876 DOI: 10.1111/j.1423-0410.2006.00813.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Excessive blood loss (EBL) is a common complication of cardiac surgery that is associated with adverse events. The objective of this before/after study was to determine whether the implementation of a protocol for management of cardiac surgical patients with EBL was associated with improved clinical outcomes. MATERIALS AND METHODS In November 2002, a protocol for prompt identification and aggressive management of cardiac surgical patients with EBL was implemented at our institution. The independent relationship between protocol implementation and adverse outcomes was measured by comparing the outcomes of patients who received > or = 4 RBC (red blood cell) units within 1 day of surgery and were operated on before protocol implementation (2000-02) with those operated on after protocol implementation (2003-05), using multivariable logistic regression analysis to control for the effects of confounders. The primary outcome was a composite of adverse events that included death, renal failure, stroke, and sepsis. Bootstrapping was used to confirm the validity of the results. RESULTS Of the 11,314 patients who underwent surgery during the study period, 1875 (16.6%) received > or = 4 RBC units within 1 day of surgery, with 958 and 917 in the pre- and postprotocol periods, respectively. The composite adverse outcome occurred in 164 (17.1%) patients in the preprotocol period and 115 (12.5%) patients in the postprotocol period (P = 0.005). Protocol implementation was independently associated with reduced odds of the composite adverse outcome (odds ratio 0.67; 95% confidence interval 0.50, 0.91; P = 0.01). This estimate was stable in bootstrap sampling. CONCLUSION Implementation of a protocol to manage EBL in cardiac surgery was independently associated with improved outcomes.
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Affiliation(s)
- K Karkouti
- Department of Anaesthesia, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Karkouti K, Beattie WS, Dattilo KM, McCluskey SA, Ghannam M, Hamdy A, Fedorko L, Yau TM. Aprotinin or tranexamic acid in cardiac surgery: a propensity analysis. Can J Anaesth 2005. [DOI: 10.1007/bf03023103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Doenst T, Wijeysundera D, Karkouti K, Zechner C, Maganti M, Rao V, Borger MA. Hyperglycemia as risk factor for mortality in cardiac surgery – Is there a role of insulin resistance? Thorac Cardiovasc Surg 2004. [DOI: 10.1055/s-2004-816724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Karkouti K, Cohen MM, McCluskey SA, Sher GD. A multivariable model for predicting the need for blood transfusion in patients undergoing first-time elective coronary bypass graft surgery. Transfusion 2001; 41:1193-203. [PMID: 11606816 DOI: 10.1046/j.1537-2995.2001.41101193.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The incidence of blood transfusion in coronary artery bypass graft (CABG) surgery remains high. Preoperative identification of those at high risk for requiring blood will allow for the cost-effective use of some blood conservation modalities. Multivariable analysis techniques were used in this study to develop a prediction rule for such a purpose. STUDY DESIGN AND METHODS Data were prospectively collected for all patients undergoing elective first-time CABG surgery from January 1997 to September 1998 at a tertiary-care teaching hospital (n = 1007). The prediction rule was developed on the first two-thirds of the sample by using logistic regression methods to examine the relationship of patient demographics, comorbidities, and preoperative Hb with perioperative blood transfusion. The remaining one-third of the sample was used to validate the rule. RESULTS The transfusion rate was 29.4 percent. The prediction rule included preoperative Hb (g/dL, OR 0.928, p<0.0001), weight (kg, OR 0.938, p<0.0001), age (years, OR 1.037, p<0.01), and sex (male/female, OR 0.493, p<0.01); receiver operating characteristic = 0.86. When externally validated, the rule had a sensitivity of 82.1 percent and a specificity of 63.6 percent (at a selected probability cutoff). CONCLUSION A simple and valid prediction rule is developed for predicting the risk of blood transfusion in patients undergoing first-time elective CABG surgery.
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Affiliation(s)
- K Karkouti
- Department of Anesthesia, University Health Network, Toronto General Hospital, Centre for Research in Women's Health, Ontario, Canada.
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Abstract
PURPOSE To develop a clinically useful and valid model for predicting difficult laryngoscopic tracheal intubation in patients with seemingly normal airways by adhering to the principles of multivariable model development. METHODS This was an observational study performed at a tertiary-care teaching hospital. Preoperatively, 444 randomly selected patients requiring tracheal intubation for elective surgery were assessed. In addition, 27 patients in whom tracheal intubation was difficult, but were not assessed preoperatively, were assessed postoperatively. One assessor, blinded to the intubation information, collected the predictor variables. A reliable definition for difficult intubation was used and all attempts were made to eliminate sources of bias. Multivariable modeling was performed using logistic regression and the model was validated using the bootstrapping technique. RESULTS Of the 461 patients included in the analysis, 38 were classified as difficult to intubate. Multivariable analysis identified three airway tests that were highly significant for predicting difficult tracheal intubation. These were: 1) "mouth opening", 2) "chin protrusion", and 3) "atlanto-occipital extension". Using these tests, a validated, highly reliable and predictive model is produced to determine the probability of difficult intubation for patients. At a selected probability cut-off value, the model is 86.8% sensitive and 96.0% specific. CONCLUSION A simple and accurate multivariable model, consisting of three airway tests, is produced for predicting difficult laryngoscopic tracheal intubation. Additional studies will be required to determine the accuracy and feasibility of this model when applied to a large sample of new patients by multiple anesthesiologists.
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Affiliation(s)
- K Karkouti
- Department of Anaesthesia, Toronto General Hospital, University Health Network, Ontario, Canada.
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Karkouti K. Is tranexamic acid indicated for total knee replacement surgery? Anesth Analg 2000; 91:244-5. [PMID: 10866922 DOI: 10.1097/00000539-200007000-00047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Karkouti K. Intraoperative variables and morbidity and mortality after coronary artery bypass surgery. Anesth Analg 2000; 90:1247. [PMID: 10781497 DOI: 10.1097/00000539-200005000-00056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kavanagh BP, Ngo C, Raymer K, Yang H, Alhashemi JA, Lui ACP, Reid D, Cicutti N, Krepski B, Wood G, Heyland DK, Badner NH, Murkin JM, Mohr J, McKenzie FN, van der Starre PJA, van Rooyen-Butijn WT, Wilson-Yang K, Teoh K, Lee RMKW, Hossain I, Cheng D, Karski J, Asokumar B, Sandier A, St-Amand MA, Murkin JM, Menkis AH, Downey DB, Nantau W, Adams S, Dowd N, Cheng D, Wong D, Carroll-Munro J, Trachuk C, Cregg N, Cheng DCH, Williams WG, Karski JM, Siu S, Webb G, Cheng DCH, Wong DT, Kustra R, Karski J, Tibshirani RJ, Côté DL, Lacey DE, LeDez KM, Smith JA, Crosby ET, Orkin FK, Fisher A, Volgyesi G, Silverman J, Edelstein S, Rucker J, Sommer L, Dunington S, Roy L, Crochetière C, Arsenault MY, Villeneuve E, Lortie L, Grange CS, Douglas MJ, Adams TJ, Merrick PM, Lucas SB, Morgan PJ, Halpern S, Lo J, Giesinger CL, Halpern SH, Breen TW, Vishnubala S, Shetty GR, De Kock M, Lagmiche A, Scholtes JL, Grodecki W, Duffy PJ, Hull KA, Hawboldt GS, Clark AJ, Smith JB, Norman RW, Beattie WS, Sandier A, Jewett M, Valiquette L, Katz J, Fradet Y, Redelmeier D, Sampson H, Cole J, Chedore T, Snedden W, Green RG, Sosis MB, Robles PI, Lazar ER, Jolly DT, Tarn YK, Tawfik SR, Clanachan AS, Milne A, Beamish T, Cuillerier DJ, Sharpe MD, Lee JK, Basta M, Krahn AD, Klein GJ, Yee R, Vakharia N, Francis H, Scheepers L, Vaghadia H, Carrier J, Martin R, Pirlet M, Claprood Y, Tétrault JP, Wong TD, Ryner L, Kozlowski P, Scarth G, Warrian RK, Lefevre G, Thiessen D, Girling L, Doiron L, McCudden C, Saunders J, Mutch WAC, Duffy PJ, Langevin S, Lessard MR, Trépanier CA, Hare GMT, Ngan JCS, Viskari D, Berrill A, Jodoin C, Couture J, Bellemare F, Farmer S, Muir H, Money P, Milne B, Parlow J, Raymond J, Williams JM, Craen RA, Novick T, Komar W, Frenette L, Cox J, Lockhart B, McArdle P, Eckhoff D, Bynon S, Dobkowski WB, Grant DR, Wall WJ, Chedrawy EG, Hall RI, Nedelcu V, Parlow J, Viale JP, Bégou G, Sagnard P, Hughson R, Quintin L, Troncy É, Collet JP, Shapiro S, Guimond JG, Blair L, Ducruet T, Francœur M, Charbonneau M, Blaise G, Snedden W, Bernadska E, Manson HI, Kutt JL, Mezon BY, Nishida O, Arellano R, Boylen P, DeMajo W, Archer DP, Roth SH, Raman S, Manninen P, Boyle K, Cenic A, Lee TY, Gelb AW, Reinders FX, Brown JIM, Baker AJ, Moulton RJ, Schlichtert L, Schwarz SKW, Puil E, Finegan BA, Finucane BT, Kurrek MM, Devitt JH, Morgan PJ, Cleave-Hogg D, Bradley J, Byrick R, Spadafora SM, Fuller JG, Gelula MH, Mayson K, Forster B, Byrick RJ, McKnight DJ, Kurrek M, Kolton M, Cleave-Hogg D, Haughton J, Halpern S, Kronberg J, Shysh S, Eagle C, Dagnone AJ, Parlow JL, Blaise G, Yang F, Nguyen H, Troncy E, Czaika G, Wachowski I, Basta M, Krahn AD, Yee R, Deladrière H, Cambier C, Pendeville P, Hung OR, Coonan E, Whynot SC, Mezei M, Coonan E, Whynot SC, Ho AMH, Luchsinger IS, Ling E, Mashava D, Chinyanga HM, Cohen MM, Shaw M, Robblee JA, Labow RS, Rubens FD, Diemunsch AM, Gervais R, Rose DK, Cohen MM, O’Brien-Pallas L, Copplestone C, Rose DK, Karkouti K, Sykora K, Cheung SLW, Booker PD, Franks R, Pozzi M, Guard B, Sikich N, Lerman J, Levine M, Swan H, Cox P, Montgomery C, Dunn G, Bourne R, Kinahan A, McCormack J, Dunn GS, Reimer EJ, Sanderson P, Sanderson PM, Montgomery CJ, Betts TA, Orlay GR, Wong DH, Cohen M, Al-Kaisy AA, Chan V, Peng P, Perlas A, Miniad A, Cushing EV, Mills KR, El-Beheiry H, Jahromi SS, Weaver J, Morris M, Carien PL, Cowan RM, Manninen P, Richards J, Robblee JA, Labow RS, Rubens FD, Menkis AH, Adams S, Henderson BT, Hudson RJ, Thomson IR, Moon M, Peterson MD, Rosenbloom M, Davison PJ, Ali M, Ali NS, Searle NR, Thomson I, Roy M, Gagnon L, Lye A, Walsh F, Middleton W, Wong D, Langer A, Errett L, Mazer CD, Karski J, Tibshirani RJ, Williamson KM, Smith G, Gnanendran KP, Bignell SJ, Jones S, Sleigh J, Arnell M, Schultz JAI, Fear DW, Ganapathy S, Moote C, Wassermann R, Watson J, Armstrong K, Calikyan AO, Yilmaz O, Kose Y, Peng P, Chan V, Chung F, Claxton AR, Krishnathas A, Mezei G, Badner NH, Paul TL, Doyle JA, Mehta M, DeLima LGR, Silva LEO, May WL, Maliakkal RJ, Mehta M, Kolesar R, Arellano R, Rafuse S, Fletcher M, Dunn G, Curran M, Bragg P, Chamberlain W, Crossan M, Ganapathy S, Sandhu H, Spadafora S, Mian R, Evans B, Hurst L, Katsiris S. Abstracts. Can J Anaesth 1997. [DOI: 10.1007/bf03022274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Karkouti K, Rose DK, Ferris LE, Wigglesworth DF, Meisami-Fard T, Lee H. Inter-observer reliability of ten tests used for predicting difficult tracheal intubation. Can J Anaesth 1996; 43:554-9. [PMID: 8773859 DOI: 10.1007/bf03011765] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE To determine inter-observer reliability of ten preoperative airway assessment tests used for predicting difficult tracheal intubation. METHOD We prospectively assessed 59 patients undergoing elective surgery requiring tracheal intubation at a large metropolitan teaching hospital. Two experienced observers independently conducted the airway assessment tests on the same group of patients. Inter-observer reliability was examined using Kappa (K) and intraclass correlation coefficient (ICC). RESULTS Two tests--mouth opening (ICC = 0.93) and chin protrusion (ICC = 0.89)--had excellent inter-observer reliability. Seven tests--thyromental distance (ICC - 0.74), subluxation (K = 0.66), atlanto-occipital extension distance (ICC = 0.67) and angle (K = 0.66), profile classification (K = 0.58), ramus length (ICC = 0.53), oropharyngeal best view (K = 0.49)--were moderately reliable. One test--Mallampati technique of assessing oropharyngeal view (K = 0.31)--had poor reliability. CONCLUSION Many of the preoperative airway tests have only moderate inter-observer reliability. This may provide some insight into why previous research has failed to show that the tests accurately predict difficult tracheal intubation.
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Affiliation(s)
- K Karkouti
- Department of Anaesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
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