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. neipe@toh.on.ca 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. neipe@toh.on.ca Chair, Planning Committee (2011-16) Annual Anesthesia Winterlude Symposium.

2016 Planning Committee

Dr. Naveen Eipe Dr. M. Andrews Dr. C. McCartney Dr. K. Duncan Dr. A. Chaput Dr. B. Duan Dr. J. McVicar G. Caporale Dr. R. Jee C. Mann Dr. J. Earl Wynands J. Lalonde Dr. L. Jeyaraj L. McHardy Dr. L. Jeyaraj V. Manning

Dr. W. Splinter 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 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.

0800 - 0830 Long Term Consequences of General Anesthesia: Are Our Assumptions Wrong? Dr. Beverly Orser

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.

0830 - 0900 Reversing Muscle Relaxants Dr. Mohammed Naguib

Describe the different mechanisms of reversal

Outline the limitations of pharmacologic reversal

Summarize the proper use of reversal drugs to prevent residual neuromuscular blockade

0900 - 0930

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 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

1010-1045 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

Alberta

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.

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

Nova Scotia

Quebec

Goal Directed Fluid Therapy Dr. Stuart McCluskey

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.

Acute Pain Management Dr. Eugene Viscusi

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

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.

1320-1350 What do you need to know about the Direct Oral Anticoagulants (DOACs) Dr. Philip Wells

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

1350-1420

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 1615 – 1800

Special Panel Discussion Dr. Chris Simpson Dr. Susan O’Leary Dr. Edward Crosby Dr. David Juurlink Winterlude Reception

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 PBL C: Pharmacology – Prevention and Treatment of Post- Partum 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

Nova Scotia 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

Identify challenges to providing Hemostatic Resuscitation

Develop strategies to overcome these challenges

Identify emergency areas of research in restoring Hemostasis

Provinces II 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

0930 – 1000 COFFEE BREAK

1000-1130 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 naguibm@ccf.org

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 sugammadex-rocuronium 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;106:289-291.

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 multi-disciplinary 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:

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

Learn about the high incidence of drug errors.

Discuss strategies to reduce medication errors in your practice.

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

Goal Directed Fluid Therapy Dr. Stuart McCluskey

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

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

UNIVERSITY OF OTTAWA

DEPARTMENT OF ANESTHESIOLOGY

22nd Annual Anesthesia Winterlude Symposium Sunday, January 31st, 2016

PBL SESSIONS

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.

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

Pharmacology – Prevention and Treatment of Post-Partum 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

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.

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

Trauma and Transfusion: Emerging Practices

Dr. Rob Johnston

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