University of Ottawa, Department

UNIVERSITY OF OTTAWA
DEPARTMENT OF ANESTHESIOLOGY
22nd Annual Anesthesia Winterlude Symposium
Perioperative Pharmacotherapy
What’s New, What’s Next?
The Westin Hotel, Ottawa, ON
January 30 & 31, 2016
(www.anesthesia.org/winterlude)
Foreword
As the Chair of the Planning Committee and on behalf of the
University of Ottawa, Department of Anesthesiology, it is my privilege to
welcome you to the 22st Annual Anesthesia Winterlude Symposium on
January 30th & 31st 2016. This meeting has always been a great opportunity
not only to listen to some great talks and speakers, but meet up with old
friends and colleagues and make new acquaintances.
The theme of the 2016 meeting is Perioperative Pharmacotherapy- What’s New,
What’s Next?,. Once again we have a nice mix of topics – all contemporary, most cutting edge
and some even controversial. With an overall focus on pharmacology there are plenary sessions
dedicated to General Anesthetics, Regional Anesthesia and Pain Management. This year, our
keynote address The Earl Wynands Lecture will feature the ‘Founding Father of Fast- Track
Surgery’- Prof. Henrik Kehlet from Denmark. We will also have a very special lecture and panel
discussion on Physician Assisted Death.
The content for this meeting has been developed by our planning committee from
previous delegate feedback. I hope that you will find the lectures; problem based learning
sessions and Meet the Expert sessions stimulating and rewarding. We look forward to your
feedback and comments.
This year we are privileged to once again welcome to our meeting the Chairs of the
Anesthesiology Departments from across Canada (ACUDA) and office bearers of the Canadian
Anesthesiologists Society (CAS). We also host for the first time the national research think-tank
of our specialty- the Perioperative Anesthesia Clinical Trails (PACT) meeting. These associations
are bringing not just a special delegate presence to our meeting, but a visibility that extends
widely and lasts long after the event. We look forward to strengthening these relationships
both regionally and nationally.
Winterlude is also one of most spectacular times of the year to visit Canada’s Capital
with the skating on the canal, ice sculptures and other festivities. I hope you will enjoy our
meeting and your time here in the city of Ottawa.
Finally, this will be my fifth and last Winterlude Symposium as Chair. I would like to
record my thanks to the Department, Planning Committee and administrative staff, especially
Lynne McHardy; for the past five smooth and successful meetings we have had.
Thank you and Welcome!
Naveen Eipe, MD.
[email protected]
Chair, Planning Committee (2011-16)
Annual Anesthesia Winterlude Symposium.
Acknowledgements
This meeting was a result of a team effort and hard work from many people behind the scene. I
would like to thank the following people for the extraordinary efforts, creativity and time:
Lynne McHardy, (Meeting Coordinator) and her support team;
Amber Devlin, (Meeting Registrar)
Vanessa Manning, (Interim Meeting Registrar)
Julie Ghatalia, (Post Graduate Medical Education Co-ordinator)
Dr. Ian Zunder; who maintains the database
I would like to thank our guest speakers for their work and time, as well as all University of
Ottawa faculty members who participated in this event.
I am also grateful to our industry partners. We recognize that our sponsors continue to provide
unrestricted financial support during a recession. This type of support makes the running of this
symposium affordable.
Finally, I would like to thank the members of the Winterlude committee for their support help
and ideas. Please complete the online evaluations as we use these to evaluate the current
symposium and plan future meetings.
Hopefully, we will have a successful meeting and look forward to welcoming you back in 2017!
Naveen Eipe, MD.
[email protected]
Chair, Planning Committee (2011-16)
Annual Anesthesia Winterlude Symposium.
2016 Planning Committee
Dr. Naveen Eipe
Dr. C. McCartney
Dr. A. Chaput
Dr. J. McVicar
Dr. R. Jee
Dr. J. Earl Wynands
Dr. L. Jeyaraj
Dr. L. Jeyaraj
Dr. W. Splinter
Dr. M. Andrews
Dr. K. Duncan
Dr. B. Duan
G. Caporale
C. Mann
J. Lalonde
L. McHardy
V. Manning
A. Devlin
Dr. D. Tran
Meeting Administration
Lynne McHardy
Winterlude Anesthesia Symposium
Department of Anesthesiology
University of Ottawa
The Ottawa Hospital, Civic Campus
1053 Carling Avenue, B309 (Mail Stop 249C)
Ottawa, Ontario K1Y 4E9
Tel: 613-761-4940
Fax: 613-761-5032
Goals and Objectives for
2016 Anesthesia Winterlude Symposium
Conference Objectives
The mandate of this conference is to focus on current peri-operative challenges and
controversies encountered by anesthesiologists. The main objectives are to understand the role
of perioperative pharmacology in improving patient safety and outcomes. The meeting aims to
promote the introduction of cutting edge research, review standards of practice and facilitate
learning needs of delegates.
Specific Objectives of the 22nd Annual Anesthesia Winterlude Symposium
“At the end of this conference, participants will be able to:”
 Evaluate recent developments in Perioperative Pharmacotherapy and recognize its role
in improving perioperative patient safety and outcomes
 Explain how anesthesiologist can impact Enhanced Recovery programs
 Appraise the role of physicians and anesthesiologists in Assisted Dying
Winterlude 2016 Faculty
Visiting Faculty
University of Ottawa
Anesthesiology Faculty
Dr. David Juurlink, Toronto, ON
Dr. Gregory Bryson
Dr. Henrik Kehlet, Copenhagen, DNK
Dr. Alan Chaput
Dr. Stuart McCluskey, Toronto, ON
Dr. Edward Crosby
Dr. Mohamed Naguib, Cleveland, OH
Dr. Naveen Eipe
Dr. Beverley Orser, Toronto, ON
Dr. George Evans
Dr. Chris Simpson, Kingston, ON
Dr. Sanjiv Gupta
Dr. Eugene Viscusi, Philadelphia, PA
Dr. Colin McCartney
Dr. Francesco Carli, Montreal, QC
Dr. Edward Crosby
Dr. Susan O’Leary, St. John’s, NFLD
Dr. Wesley Edwards
Dr. John Penning
University of Ottawa Faculty
Dr. Robert Johnston
Dr. Philip Wells, Medicine
Dr. Viren Naik
Declaration of Potential Conflict of Interest
Speakers are requested to disclose to the audience any real or apparent conflict(s) of interest
that may have a direct bearing on the subject matter of this program.
Accreditation
This event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of
Certification program of the Royal College of Physicians and Surgeons of Canada for 9,5 credits.
This program has also been accredited by the College of Family Physicians of Canada for up to
9,5 Mainpro-M1 credits.
This program has been reviewed and approved by the University of Ottawa, Office of Continuing
Professional Development.
Feedback, Evaluation and Certificate of Attendance
To improve our future programs, we have designed a web based survey that will allow
delegates to evaluate the Winterlude Symposium. The link to the survey will be available online
and on the Winterlude webpage. After attending the Symposium, the delegates will be able to
complete the evaluation and obtain their Certificate of Attendance.
Saturday January 30th
0720 - 0750
Registration and Breakfast
0750 -0755
Welcome and Opening Remarks
Plenary Session 1
0800 - 0830
What’s New in Anesthesia
Moderator: Gregory Bryson
Each speaker will have a 30 minute time-slot. At the end of the 3-lecture
session there will be a 15 minute moderated question period where all
speakers are invited to answer questions from the floor. We will provide a
system for written questions to be forwarded to the moderator from the
delegate floor during the session for delegates that wish to ask questions in
this way.
Long Term Consequences of General Anesthesia: Are Our Assumptions
Wrong?
Dr. Beverly Orser



0830 - 0900
Reversing Muscle Relaxants
Dr. Mohammed Naguib



0900 - 0930
Learn about the key receptor in the brain that is targeted by most
commonly used anesthetics
Understand how receptor-drug interactions underline the clinical
properties of anesthetics
Learn how anesthetics trigger persistent alterations in receptor function
that contribute to long-term memory defects. We will need also discuss
potential treatment and prevention strategies.
Describe the different mechanisms of reversal
Outline the limitations of pharmacologic reversal
Summarize the proper use of reversal drugs to prevent residual
neuromuscular blockade
Giving the Right IV Fluids
Dr. Stuart McCluskey

Describe the composition of intravenous fluids used in the operating
room.
 Determine the type of fluid that should be given and how much should
be given.
 Propose protocols to support or refute clinical practice.
0930 - 0945
Panel Discussion/Questions
0950-1010
Nutrition Break & Exhibits
Plenary Session
1010-1045
Dr. J. Earl Wynands Lecture
Moderator: Dr. Francesco Carli
The speaker will have a 35 minute time-slot. At the end of the lecture session
there will be a 10 minute moderated question period where both speakers
are invited to answer questions from the floor. We will provide a system for
written questions to be forwarded to the moderator from the delegate floor
during the session for delegates that wish to ask questions in this way
Implementation of ERAS- Past, Present and Future
Dr. Henrik Kehlet


Summarize an update of procedure-specific results
Explore implementation issues and outline strategies for future
developments
1045 - 1055
Panel Discussion/Questions
1100-1200
Concurrent Break-Out Sessions: Meet the Expert
Confederation l
Drug Errors: No Longer Everybody Else’s Problem
Dr. Beverley Orser

Learn about the high incidence of drug errors.

Discuss strategies to reduce medication errors in your
practice.
Alberta
Monitoring Neuromuscular Blockade
Dr. Mohammed Naguib



Discuss the proper use of a peripheral nerve stimulator or
neuromuscular function monitor
Understand the sensitivity of different muscle groups to
neuromuscular blockers
Discuss the different modes of nerve stimulation
Newfoundland
Goal Directed Fluid Therapy
Dr. Stuart McCluskey



Nova Scotia
Acute Pain Management
Dr. Eugene Viscusi



Quebec
Describe how goal directed fluid therapy can be used every day in
the operating room.
Identity the patient populations that may benefit from goal directed
fluid therapy.
Consider the use of albumin as a pharmacological treatment or
replacement strategy managed with goal directed fluid therapy.
Identify current unmet needs in acute pain
Discuss current strategies in multimodal analgesia
Design treatment strategies using the latest approaches in acute pain
Bridging Patients on Oral Anticoagulation: When, Why, How?
Dr. Philip Wells



Manage anticoagulants around surgery
Understand the risks and benefits of bridging
Identify the gaps in knowledge in this area
1205-1245
LUNCH & EXHIBITS
1250-1420
What’s Next in Regional Anesthesia and Pain Management
Moderator: Dr. Alan Chaput
Each speaker will have a 30 minute time‐slot. At the end of the 2‐lecture
session there will be a 15 minute moderated question period where both
speakers are invited to answer questions from the floor. We will provide a
system for written questions to be forwarded to the moderator from the
delegate floor during the session for delegates that wish to ask questions in
this way
1250-1320
Long Acting Local Anesthetics
Dr. Eugene Viscusi



1320-1350
What do you need to know about the Direct Oral Anticoagulants (DOACs)
Dr. Philip Wells




1350-1420
Identify unmet needs of current local anesthetic approaches
Evaluate the evidence supporting novel and emerging formations of
long acting local anesthetics.
Compare the utility of various platforms for extending the duration of
local anesthetic effects.
Compare outcomes with the DOACs in patients with Atrial fibrillation and
Venous thrombosis, to those with Vitamin K antagonists
Recommend the ideal management of DOACs in the perioperative
situation
Manage patients who bleed on the DOACs
Explain the pharmacokinetics in DOACs
Medical Marijuana: An Overview
Dr. David Juurlink



Characterize in general terms the evidence base for medicinal cannabis
relative to other medications
Describe concerns associated with the prescribing of medical cannabis
Discuss the potential benefits of cannabis over conventional medications
1420-1435
Panel Discussion/Questions
1500-1540
Winterlude Symposium Lecture
Moderator: Dr. Viren Naik
The speaker will have a 35 minute time‐slot. At the end of the lecture session
there will be a 10 minute moderated question period where both speakers
are invited to answer questions from the floor. We will provide a system for
written questions to be forwarded to the moderator from the delegate floor
during the session for delegates that wish to ask questions in this way
Physician Assisted Death
Dr. Chris Simpson




Describe the Canadian Medical Association’s proposed principles-based
approach to assisted dying in Canada
Recognize the ethical and practical challenges of implementing assisted
dying
Identify and compare the parameters of the Supreme Court decision with
the legal landscape in other jurisdictions that permit physician assisted
dying
Better examine the role of anesthesiologists’ in this new legal and clinical
landscape
1540 – 1610
Special Panel Discussion
1615 – 1800
Winterlude Reception
Dr. Chris Simpson
Dr. Susan O’Leary
Dr. Edward Crosby
Dr. David Juurlink
Sunday, January 31st
0715 - 0745
Breakfast & Registration
0800-0930
Westin PBLs Round One
Alberta
PBL A: Clinical Pharmacology and Applications of Dexmedetomidine
Dr. Sanjiv Gupta



Explain the pharmacokinetics and pharmacodynamics of dexmedetomidine
Choose appropriate clinical indications for the perioperative use of
dexmedetomidine
Describe common adverse effects associated with the use of dexmedetomidine
New Brunswick PBL B: Peri-Operative Buprenorphine
Dr. George Evans



Understand the pharmacology of Buprenorphine.
Appreciate common doses, uses and conversions for Buprenorphine/ Suboxone
Review several peri-operative scenario’s and suggested management
Newfoundland



Nova Scotia



PBL C: Pharmacology – Prevention and Treatment of PostPartum Hemorrhage
Dr. Wesley Edwards
Describe the mechanism of action of pharmcological agents used in the
prevention and treatment of post-partum hemorrhage
Be able to choose the most appropriate pharmacological agent for a variety of
obstetric clinical scenarios
Describe the role of tranexamic acid in obstetric hemorrhage
PBL D: Perioperative Hemodynamic Management
Dr. Ashraf Fayad
To identify common causes of perioperative hypotension and hemodynamic
instability.
To describe pathophysiology and mechanism of cardiovascular collapse in
selected cases.
To identify appropriate pharmacological approach in a hemodynamic unstable
patient.
Quebec
PBL E: Trauma and Transfusion: Emerging Practices
Dr. Rob Johnston



Provinces II



0930 – 1000
1000-1130
Identify challenges to providing Hemostatic Resuscitation
Develop strategies to overcome these challenges
Identify emergency areas of research in restoring Hemostasis
PBL F: Non Opioid Adjuvants
Dr. John Penning
List six classes of non-opioid analgesics used in acute pain
Define the role of Ketamine in the opioid tolerant patient.
Compare tapentadol with tramadol and classic opioids
COFFEE BREAK
PBLs Round Two (Same as 0800-0930 Sessions)
UNIVERSITY OF OTTAWA
DEPARTMENT OF ANESTHESIOLOGY
SPONSORS
The 22nd Annual Anesthesia Winterlude Symposium 2016 has been made possible by the
generous support of the following sponsors:
Gold Sponsors
Silver Sponsors
AbbVie
Edwards Lifesciences
Karl Storz
Merck
Olympus
Scotiabank
SonoSite
Teleflex
UNIVERSITY OF OTTAWA
DEPARTMENT OF ANESTHESIOLOGY
22nd Annual Anesthesia Winterlude Symposium
Saturday, January 30th, 2016
MORNING LECTURES
Long-term consequences of general anesthetics; Are our assumptions wrong?
Dr. Beverly Orser
Learning Objectives:



Learn about the key receptor in the brain that is targeted by most commonly used anesthetics
Understand how receptor-drug interactions underlie the clinical properties of anesthetics
Learn how anesthetics trigger persistent alterations in receptor function that contribute to
long-term memory deficits. We will also discuss potential treatment and prevention strategies.
Reversing Muscle Relaxants
Dr. Mohammed Naguib
Learning Objectives:



Describe the different mechanisms of reversal
Discuss the limitations of pharmacologic reversal
Discuss the proper use of reversal drugs to prevent residual neuromuscular blockade
Abstract:
Mohamed Naguib, MD MB, BCh, MSc, FFARCSI, MD
Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve
University
Staff Anesthesiologist, Department of General Anesthesiology, Cleveland Clinic
[email protected]
The anticholinesterase, neostigmine is the only drugs available in North America for the
antagonism of nondepolarizing agent-induced neuromuscular block. Even in Asia and Europe,
where sugammadex is available, economic considerations limit its use. Thus neostigmine remains
the primary antagonist of nondepolarizing block in the anesthesiologist’s armamentarium.
Nondepolarizing neuromuscular block is competitive in nature. Molecules of acetylcholine (ACh)
and neuromuscular blocking drugs (each of which having a receptor occupancy time measured in
msec) are competing for access to nicotinic receptors at the myoneural junction. If the
concentration of neuromuscular blocking drugs is sufficiently high, it “wins” this competition,
binds to the nicotinic receptor, and renders it inactive resulting in muscle paralysis. If the
enzymatic destruction of ACh is slowed by the administration of an acetylcholinesterase, the
concentration of ACh at the neuromuscular junction increases, shifting the concentration balance
in favor of the neurotransmitter (i.e., ACh), and recovery phase commences. However, once
acetylcholinesterase is maximally inhibited, additional doses of neostigmine will have no further
effect. In fact, additional neostigmine at this time could produce an opposite effect, resulting in
muscle weakness. Thus, there is a ceiling to the concentration of ACh that can be reached at the
neuromuscular junction. This “ceiling” effect has several important clinical implications: first, it is
clear that neostigmine will be ineffective at reversing deep block. However, interestingly,
neostigmine may also induce neuromuscular weakness during near-complete spontaneous
recovery. The mechanism for this muscular weakness induced by neostigmine is impairment of
normal function of the genioglossus and diaphragm muscles, resulting in a decrease in the volume
of the upper airway. In contrast, some of newer reversal agents may solve many, if not all, of the
limitations of current anticholinesterases.
Sugammadex, which is not currently available in the United States, has been used in clinical
settings since 2008, and is now approved in 72 countries world-wide. Sugammadex is a modified
gamma-cyclodextrin that forms very tight complexes with aminosteroid neuromuscular blocking
drugs, particularly rocuronium and vecuronium. The complexation is nearly irreversible, and
results in a decrease in the plasma levels of free (unbound) sugammadex molecules, which results
in diffusion of free drug away from the neuromuscular junction. The inactive sugammadexrocuronium complex is excreted almost entirely in the urine. The dosing recommendations are
based on the depth of neuromuscular block it is intended to antagonize: a 2 mg/kg dose is
recommended for reversal of shallow block (TOF count of 1-2); a dose of 4 mg/kg is recommended
for reversal of deep block (PTC count of 1-2); and a dose of 16 mg/kg is recommended for rapid
reversal of rocuronium-induced block almost immediately after neuromuscular blocking drugs
administration. The reversal of neuromuscular block occurs within 3 min from any depth of block
provided that adequate doses of sugammadex are administered.
Giving the Right IV Fluids
Dr. Stuart McCluskey
Learning Objectives:



To describe the composition of intravenous fluids used in the operating room.
To use evidence to determine the type of fluid that should be given and how much should be
given.
To propose protocols to support or refute clinical practice.
Perioperative fluid management has an important influence on patient outcome and is an integral
component of enhances recovery after surgery programs. Until recently, intravenous fluids
administration been given by protocol based on faulty research, expert assumptions and a one size
fits all strategy. While one of the indication for intravenous fluid is the administration of
pharmacological agents, but should not be forgotten that intravenous fluids are in and of
themselves pharmacological agents. As with any medication the efficacy and toxicity of
intravenous fluids is going to be effected by the dose (i.e. volume), timing, the type of fluid
administered and the status of the patient. The debate of colloid versus crystalloid has been
largely replaced by more precise questions referring to the type of crystalloid and does albumin
have a role in perioperative care. Anesthesiologists are experts in this area and new tools will
provide us more information that may improve patient care and enhance recovery. We will review
the available evidence, look forward to studies nearing completion and consider new study
protocols to help answer critical questions for patient care.
Implementation of ERAS – past, present and future
Dr. Henrik Kehlet
Learning Objectives:




To understand the background for enhanced recovery programs
To provide an update of procedure-specific results
To discuss implementation issues
To outline strategies for future developments
The concept of fast-track surgery, enhanced recovery after surgery (ERAS) or multimodal
postoperative recovery programs were initiated about 20 years ago initially based on experience
from relatively small operations like cholecystectomy, herniorrhaphy, minor gynaecological
procedures, etc., but since then expanded to include even the most major procedures. The basic
components of fast-track programs include preoperative optimisation of organ dysfunctions (as
usual), but then intensified detailed information to the patient and the relatives about active
engagement in the perioperative course including information on procedure-specific discharge
criteria. Fast-track programs are essentially based upon the question “Why is the patient still in
hospital today?” to identify individual patients’ recovery problems and then to address those
based on current evidence. Optimisation programs include reduction of surgical stress responses
with regional anaesthetic techniques as appropriate, minimal invasive procedures as appropriate
and then an effort with further stress reduction by pharmacological agents like statins or
glucocorticoids. Especially, the preoperative administration of a single high-dose glucocorticoid has
proven successful in many operations to decrease the inflammatory response, early fatigue, pain
and nausea and vomiting, the latter beyond the usual administration of small doses of
dexamethasone. Subsequently, nursing care has to be changed into an active rehabilitation
program with early mobilisation and oral feeding based upon the concomitant optimised
multimodal opioid sparing analgesia.
It has been documented across many procedures, but mostly following colonic operations, that
fast-track programs also reduce medical complications and a pronounced reduction of hospital
stay because of earlier achievement of discharge criteria and without an increase in readmission
rates.
Based on these successful results of fast-track programs, the question is what to do next? First of
all, implementation of current evidence has repeatedly been demonstrated to be rather slow.
However, the implementation process has been well described starting with reading the literature,
collecting own data, adjust perioperative care where necessary, share results and adjust to
developing new evidence and share the economic benefits on a multidisciplinary basis.
Another problem for future progress is to adjust the current ERAS Society guidelines often
involving more than 17 components thereby apparently hindering full implementation of the key
elements. To start a fast-track program therefore must include full achievement to the important
components of fast-track surgery and then later adjust to other more “soft” evidence.
Consequently, in order to enhance clinical progress, a detailed scientific analysis of the essential
components of fast-track programs will be important and especially to critically reanalyse the
many randomised controlled trials and meta-analyses with variable LOS and incomplete adherence
to the basic fast-track protocols.
Future efforts should include a focus on optimising multimodal opioid-sparing analgesic strategies
and especially to delineate what should be done after discharge. Also, much more focus should be
laid on other post-discharge problems like cognitive dysfunction, sleep disturbances, the need for
thromboembolic prophylaxis with an early mobilisation fast-track program, optimal rehabilitation
strategies including the potential role of prehabilitation, orthostatic intolerance and blood and
fluid management. In this context, hip and knee replacement may serve as a useful model on these
outcomes, since these procedures represent a standardised surgical trauma and often performed
in elderly and high risk patients. In this context, future efforts should include a clear separation
between medical and surgical complications, and especially which one comes first, since the first
example will be improved by the fast-track methodology, while the second will need a focus on
surgical expertise.
Finally, the conventional risk factors (cardio-pulmonary, cerebral, diabetes, smoking, alcohol
misuse etc.) must be reassessed in fast-track programs where the stress responses and risk of
subsequent organ dysfunctions may be reduced and therefore mask or eliminate the effect of
conventional risk factors.
Summarising, the concept of fast-track surgery has come to stay, but represents an exciting,
dynamic process and where we need more scientific investments to achieve the ultimate goal of a
“pain and risk free operation”.
Selected recent references
Berwick DM. The science of improvement. JAMA 2008;299:1182-1184.
Kehlet H, Mythen M. Why is the surgical high-risk patient still at risk? Br J Anaesth 2011;106:289291.
Slim K, Kehlet H. Commentary: Fast track surgery: the need for improved study design. Colorectal
Dis 2012;14:1013-1014.
Jørgensen CC, Jacobsen M, Søballe K, Hansen TB, Husted H, Kjaersgaard-Andersen P, Hansen L,
Laursen M, Kehlet H. Short thromboprophylaxis after fast-track hip and knee arthroplasty. A
detailed prospective consecutive unselected cohort study. BMJ Open 2013;3:e003965.
Kehlet H, Thienpont E. Fast-track knee arthroplasty - status and future challenges. The Knee
2013;20, Supplement 1:S29-S33.
Kehlet H. Fast-track hip and knee arthroplasty. Lancet 2013;381:1600-1602.
de la Motte L, Kehlet H, Vogt K, Nielsen CH, Groenvall JB, Nielsen HB, Andersen A, Schroeder TV,
Lonn L. Preoperative methylprednisolone enhances recovery after endovascular aortic repair: a
randomized, double-blind, placebo-controlled clinical trial. Ann Surg 2014;260:540-549.
Gaudilliere B, Fragiadakis GK, Bruggner RV, Nicolau M, Finck R, Tingle M, Silva J, Ganio EA, Yeh CG,
Maloney WJ, Huddleston JI, Goodman SB, Davis MM, Bendall SC, Fantl WJ, Angst MS, Nolan GP.
Clinical recovery from surgery correlates with single-cell immune signatures. Sci Transl Med
2014;6:255ra131.
Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A, Liberman AS, Stein B, Charlebois P, Feldman LS,
Carli F. Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing
colorectal resection for cancer. Anesthesiology 2014;121:937-947.
Lord JM, Midwinter MJ, Chen YF, Belli A, Brohi K, Kovacs EJ, Koenderman L, Kubes P, Lilford RJ. The
systemic immune response to trauma: an overview of pathophysiology and treatment. Lancet
2014;384:1455-1465.
Miller TE, Raghunathan K, Gan TJ. State-of-the-art fluid management in the operating room. Best
Pract Res Clin Anaesthesiol 2014;28:261-273.
Vetter TR, Boudreaux AM, Jones KA, Hunter JM, Jr., Pittet JF. The perioperative surgical home: how
anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg
2014;118:1131-1136.
Jorgensen CC, Madsbad S, Kehlet H. Postoperative morbidity and mortality in type-2 diabetics after
fast-track primary total hip and knee arthroplasty. Anesth Analg 2015;120:230-238.
Jørgensen CC, Knop J, Nordentoft M, Kehlet H. Psychiatric disorders and psychopharmacologic
treatment as risk factors in elective fast-track total hip and knee arthroplasty. Anesthesiology 2015
(Epub)
Kehlet H. Enhanced Recovery After Surgery (ERAS): good for now, but what about the future? Can J
Anaesth 2015;62:99-104.
Munoz M, Gomez-Ramirez S, Kozek-Langeneker S, Shander A, Richards T, Pavia J, Kehlet H,
Acheson AG, Evans C, Raobaikady R, Javidroozi M, Auerbach M. 'Fit to fly': overcoming barriers to
preoperative haemoglobin optimization in surgical patients. Br J Anaesth 2015;115:15-24.
www.erassociety.org
Long Acting Local Anesthetics
Dr. Eugene Viscusi
Learning Objectives:



Identify unmet needs of current local anesthetic approaches
Evaluate the evidence supporting novel and emerging formulations of long acting local
anesthetics
Compare the utility of various platforms for extending the duration of local anesthetic effect
What do you need to know about the Direct Oral Anticoagulants (DOACs)
Dr. Philip Wells
Learning Objectives:




Compare outcomes with the DOACs in patients with Atrial fibrillation and Venous thrombosis,
to those with Vitamin K antagonists
Recommend the ideal management of DOACs in the perioperative situation
Manage patients who bleed on the DOACs
Explain the pharmacokinetics in DOACs
Medical Marijuana: An Overview
Dr. David Juurlink
Learning Objectives:



Characterize in general terms the evidence base for medicinal cannabis relative to other
medications
Describe concerns associated with the prescribing of medical cannabis
Discuss the potential benefits of cannabis over conventional medications
Medicinal Marijuana
Cannabis has been used for millennia for its psychotropic effects, but the past several decades
have witnessed growing interest in its use for a variety of medical illnesses. However, the role of
cannabis in contemporary medical care is not well established, in part because the drug’s legal
status has made clinical trials more difficult. This lecture will provide an overview of the
pharmacology of cannabinoids, the evidence for and against medicinal cannabis, the safety
concerns surrounding it, and the practicalities of prescribing it for Canadian physicians and
patients.
UNIVERSITY OF OTTAWA
DEPARTMENT OF ANESTHESIOLOGY
J. Earl Wynands Lecture
22nd Annual Anesthesia Winterlude Symposium
Saturday, January 30, 2016
J EARL WYNANDS LECTURE
The meeting organizers proudly present the annual Dr J. Earl Wynands Annual Royal College
Lecture. Dr. Wynands is a Professor Emeritus in The Department of Anesthesia at The University
of Ottawa. He was born in Montréal on December 10, 1929. He graduated from McGill
University with an M.D.C.M. in 1954. He pursued his anesthesia training at McGill University
and obtained his Royal College Certification in 1969 and Fellowship in Cardiac Anesthesia in
1972. Dr. Wynands was a member of the Attending staff at The Royal Victoria Hospital from
1961 to 1988, and thereafter was recruited to the University of Ottawa as Professor and
Chairman of The Department of Anesthesia and Chief of Anesthesia at the Civic Hospital and
University of Ottawa Heart Institute in 1988, until his retirement in 1996.
Dr. Wynands has made outstanding contributions in patient care, research, and the teaching
and education missions of the Departments of Anesthesia at The University of Ottawa and
McGill University. He subspecialized in cardiac anesthesia, taught and inspired a generation of
students, residents and fellows. He as an innovative clinical researcher, and his clinical trials in
opioid anesthesia for cardiac patients and coronary revascularization were seminal during some
of the early pioneering days of adult cardiac surgery – eg: Wynands JE, Sheridan CA, Kelkar K:
Coronary artery disease and anesthesia. (Experience in 120 patients for revascularization of the
heart). Can Anaesth Soc J, 1967; 14:382-98. Dr. Wynands published > 80 peer reviewed articles,
16 book chapters, and has been a visiting professor or invited speaker on more than 120
occasions in North America and internationally.
Dr. Wynands is Past President of the Canadian Anesthesiologists’ Society, Past President of the
Society of Cardiovascular Anesthesiologists, and Founding President of The Cardiovascular and
Thoracic Section of the Canadian Anesthesiologists’ Society. Upon his retirement in 1996, he
was the tireless driving force behind the founding of the Ottawa Simulation Centre, a multidisciplinary simulation center and now the largest simulation center in Canada. Throughout his
career Dr. Wynands has received numerous awards including: Order of Canada; The
Distinguished Service Award of the Society of Cardiovascular Anesthesiologists; the Gold Medal
of the Canadian Anesthesiologists’ Society; a Living Legend Award, World Society of
Cardiothoracic Surgeons, and an Honorary Ph.D. from the University of Montréal.
Physician Assisted Death
Dr. Chris Simpson
Learning Objectives:
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Describe the Canadian Medical Association’s proposed principles-based approach to assisted
dying in Canada
Recognize the ethical and practical challenges of implementing assisted dying
Identify and compare the parameters of the Supreme Court decision with the legal landscape
in other jurisdictions that permit physician assisted dying
Better examine the role of anesthesiologists’ in this new legal and clinical landscape
In February 2015, the Supreme Court of Canada (SCC) released its decision in Carter v. Canada that
asked the SCC to consider the constitutional validity of existing Criminal Code provisions
prohibiting physician-assisted dying in Canada. In a unanimous decision, the SCC ruled that the
challenged Criminal Code provisions on voluntary euthanasia (section 14) and assisted suicide
(section 241(b)) are constitutionally invalid. The SCC suspended its decision for 12 months to allow
the Federal government and the provincial legislatures time to respond and enact legislation in
compliance with the Court’s ruling. Following the 12-month suspension, assisted dying will be legal
in Canada, and no longer a criminal act, even if legislation is not enacted in response to the Court’s
ruling.
The SCC’s reversal of the prohibition on assisted dying raises a host of complex issues that have
implications for both policy and practice. In response to the Court’s ruling, the CMA developed
principles-based recommendations to guide the implementation of assisted dying in Canada. This
presentation will review these recommendations, with the view to highlighting the ethical and
practical challenges of implementing assisted dying as regards to patient eligibility for access to
and assessment for assisted dying, procedural safeguards to ensure eligibility criteria are met, the
roles and responsibilities of the attending and consulting physicians, and how we may achieve an
appropriate balance between physicians’ freedom of conscience and patients’ request for access
to assisted dying. The importance and complexity of what will essentially be a new medical service
cannot be overstated. It is important for anesthesiologists to understand their potential role in this
new legal and clinical landscape.
MEET THE EXPERT SESSIONS
UNIVERSITY OF OTTAWA
DEPARTMENT OF ANESTHESIOLOGY
22nd Annual Anesthesia Winterlude Symposium
Saturday, January 30th, 2016
Drug Errors: No Longer Everybody Else’s Problem
Dr. Beverley Orser
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Learn about the high incidence of drug errors.
Discuss strategies to reduce medication errors in your practice.
Monitoring Neuromuscular Blockade
Dr. Mohammed Naguib
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Discuss the proper use of a peripheral nerve stimulator or neuromuscular function
monitor
Understand the sensitivity of different muscle groups to neuromuscular blockers
Discuss the different modes of nerve stimulation
Goal Directed Fluid Therapy
Dr. Stuart McCluskey
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To describe how goal directed fluid therapy can be used every day in the operating
room.
To identity the patient populations that may benefit from goal directed fluid therapy.
To consider the use of albumin as a pharmacological treatment or replacement strategy
managed with goal directed fluid therapy.
Abstract
Ideal Perioperative Fluid Management – Barriers to Implementation.
Perioperative fluid management has improved in the last several years. Balanced salt solutions
are quickly becoming the normal crystalloid and improving intraoperative hemodynamic
monitoring is being considered particularly for higher risk cases. We have moved away from
static protocols based on faulty science and assumptions to rely more on the hemodynamic and
physiological parameters.
Why the implementation of more patient centered fluid protocols hasn’t garnered more
attention is difficult to understand. In fact, the problem is likely multifactorial ranging from
financial considerations to a lack of robust evidence. Together we will identify and consider
what an ideal perioperative fluid therapy protocol might look like and some of the barriers to
implementation. With this insight, we may be able to come up with solutions to circumvent
barriers, improve perioperative fluid therapy thereby patient outcome.
Acute Pain Management
Dr. Eugene Viscusi
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Identify current unmet needs in acute pain
Discuss current strategies in multimodal analgesia
Design treatment strategies using the latest approaches in acute pain
Bridging Patients on Oral Anticoagulation: When, Why, How?
Dr. Philip Wells
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Manage anticoagulants around surgery
Understand the risks and benefits of bridging
Identify the gaps in knowledge in this area
UNIVERSITY OF OTTAWA
DEPARTMENT OF ANESTHESIOLOGY
22nd Annual Anesthesia Winterlude Symposium
Sunday, January 31st, 2016
PBL SESSIONS
Non Opioid Adjuvants
Dr. John Penning
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List six classes of non-opioid analgesics used in acute pain
Define the role of Ketamine in the opioid tolerant patient.
Compare tapentadol with tramadol and classic opioids.
Buprenorphine
Dr. George Evans
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Understand the pharmacology of Buprenorphine.
Appreciate common doses, uses and conversions for Buprenorphine/ Suboxone
Review several peri-operative scenario’s and suggested management
Pharmacology – Prevention and Treatment of Post-Partum Hemorrhage
Dr. Wesley Edwards
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Describe the mechanism of action of pharmcological agents used in the
prevention and treatment of post-partum hemorrhage
Be able to choose the most appropriate pharmacological agent for a variety of
obstetric clinical scenarios
Describe the role of tranexamic acid in obstetric hemorrhage
Perioperative Hemodynamic Management
Dr. Ashraf Fayad
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To identify common causes of perioperative hypotension and hemodynamic
instability.
To describe pathophysiology and mechanism of cardiovascular collapse in
selected cases.
To identify appropriate pharmacological approach in a hemodynamic unstable
patient.
Clinical Pharmacology and Applications of Dexmedetomidine
Dr. Sanjiv Gupta
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Explain the pharmacokinetics and pharmacodynamics of dexmedetomidine
Choose appropriate clinical indications for the perioperative use of
dexmedetomidine
Describe common adverse effects associated with the use of dexmedetomidine
Trauma and Transfusion: Emerging Practices
Dr. Rob Johnston
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Identify challenges to providing Hemostatic Resuscitation
Develop strategies to overcome these challenges
Identify emergency areas of research in restoring Hemostatais
Abstract
Imagine you are in charge of ensuring your institution is able to resuscitate trauma victims
suffering from massive hemorrhage. How will you determine what patients fit this category?
How will you mobilize your institution's resources? What pharmacologic and nonpharmacologic
interventions do you want to have available? How will you monitor the effects of therapy?
These and other questions will be addressed in this workshop through small group discussion.
Recent advances in civilian and military transfusion practice, such as the role of a Massive
Transfusion Protocol, blood component therapy options and guidelines, nonpharmacologic
interventions, and point of care biochemical testing, will be presented. Over-the-horizon
therapies will be discussed briefly. Advanced surgical interventions such as aortic occlusion,
angiographic embolization, and other damage control procedures will not be covered.
References
Shaz, B. et al. “Transfusion Management of Trauma Patients” Anesth Analg 2009;108:1760-8
Spahn, D. et al. “Management of Bleeding and Coagulopathy Following Trauma: An Updated
European Guideline” Critical Care 2013; 17:R76
Dzik, W. et al. “Clinical Review: Canadian National Advisory Committee on Blood and Blood
Products – Massive Transfusion Consensus Conference 2011 – Report of the Panel” Critical Care
2011; 15:242