Showing papers in "Acta Anaesthesiologica Scandinavica in 2013"

Acute kidney injury in patients with severe sepsis in Finnish Intensive Care Units.

Abstract: Background Severe sepsis is one of the leading causes of acute kidney injury (AKI). Patients with sepsis-associated AKI demonstrate high-hospital mortality. We evaluated the incidence of severe sepsis-associated AKI and its association with outcome in intensive care units (ICUs) in Finland. Methods This was a predetermined sub-study of the prospective, observational, multicentre FINNAKI study conducted in 17 ICUs during 1 September 2011 and 1 February 2012. All emergency ICU admissions and elective admissions exceeding 24 hours in the ICU were screened for presence of severe sepsis and AKI up to 5 days in ICU. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria and severe sepsis according to the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria. Results Of the 2901 included patients, severe sepsis was diagnosed in 918 (31.6%, 95% confidence interval [CI] 29.9–33.4%) patients. Of these 918 patients, 488 (53.2% [95% CI 49.9–56.5%]) had AKI. The 90-day mortality rate was 38.1% (95% CI 33.7–42.5%) for severe sepsis patients with AKI and 24.7% (95% CI 20.5–28.8%) for those without AKI. After adjusting for covariates, KDIGO stage 3 AKI was associated with an increased risk for 90-day mortality with an adjusted odds ratio (OR) of 1.94 (95% CI 1.28–2.94), but stages 1 and 2 were not. Conclusions More than half of the patients with severe sepsis had AKI according to the KDIGO classification, and AKI stage 3 was independently associated with 90-day mortality.

Perioperative glucocorticoids in hip and knee surgery - benefit vs. harm? A review of randomized clinical trials.

Abstract: Glucocorticoids are frequently used to prevent post-operative nausea and vomiting (PONV), and may be part of multimodal analgesic regimes. The objective of this review was to evaluate the overall benefit vs. harm of perioperative glucocorticoids in patients undergoing hip or knee surgery. A wide search was performed in PubMed, Embase, and Cochrane Central to identify relevant randomized clinical trials. A systematic approach was used, starting from the PRISMA recommendations. The Cochrane Collaboration's tool was used for risk of bias assessment. Studies were divided into three groups: systemic glucocorticoid administration analogous to > 10 mg or ≤ 10 mg dexamethasone, and local glucocorticoid administration. Seventeen studies with data from 1081 patients were included in the final qualitative synthesis. Benefit (of any kind) with glucocorticoid vs. placebo was reported in 15 studies. PONV was reduced with systemic glucocorticoid. Pain was reduced with high-dose systemic and local glucocorticoid, but not with low-dose systemic glucocorticoid. Systemic inflammatory markers were reduced with low-dose and high-dose systemic glucocorticoid, and with local glucocorticoid. Functional recovery was improved with local glucocorticoid. All studies were small-sized and none sufficiently powered to meaningfully evaluate uncommon adverse events. Most of the local administration studies had poor scientific quality (high risk of bias). Due to clinical heterogeneity and poor scientific quality, no meta-analysis was performed. In conclusion, in addition to PONV reduction with low-dose systemic glucocorticoid, this review supports high-dose systemic glucocorticoid to ameliorate post-operative pain after hip and knee surgery. However, large-scale safety and dose-finding studies are warranted before final recommendations.

Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to 2009

Abstract: Background Analyses of closed claims provide insight into the characteristics of rare complications. Serious complications related to spinal and epidural blocks are relatively rare. In Finland, all malpractice cases are primarily handled by the Patient Insurance Centre (PIC) within a ‘no-fault scheme’. Methods All claims attributed to central neuraxial blocks and settled by the PIC during the period, 2000–2009 were analysed. The number of spinal and epidural procedures performed during this time was estimated based on a questionnaire sent to all surgical hospitals in Finland in 2009, surveying the numbers and types of neuraxial blocks carried out in 2008. Results During the study period, 216 closed claims were flagged with spinal or epidural blocks. In 41 of 216 instances, the neuraxial block was apparently responsible for a serious (fatal or critical or lasting >1 year) complication. These included six fatalities and 13 epidural haematomata (two in conjunction with fondaparinux, three with excessive doses of low molecular weight heparins, six where present guidelines were not observed). Fatalities occurred in 1 : 775,000 spinals for surgery, 1 : 62,000 in epidurals for surgery or acute pain relief, 1 : 12,000 epidurals for chronic pain relief, 1 : 89,000 in combined spinal and epidural for surgery, and 1 : 144,000 epidurals for labour. The incidence of neuraxial haematoma after spinal block was 1 : 775,000, that for epidural block 1 : 26,400, and in the case of combined spinal and epidural, 1 : 17,800. Irrespective of the method of neuraxial technique, the majority of patients suffering serious complications were the elderly having comorbidities. Conclusions In this closed claims analysis, major problems related to neuraxial blocks were rare. Epidural or a combined spinal and epidural technique resulted in more complications than did spinal procedure.

Acute respiratory distress syndrome: nationwide changes in incidence, treatment and mortality over 23 years.

Abstract: Introduction The aim of this study was to assess population-based changes in incidence, treatment, and in short- and long-term survival of patients with acute respiratory distress syndrome (ARDS) over 23 years. Materials and Methods Analysis of all patients in Iceland who fulfilled the consensus criteria for ARDS in 1988–2010. Demographic variables, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and ventilation parameters were collected from hospital charts. Results The age-standardised incidence of ARDS during the study period was 7.2 cases per 100,000 person-years and was increased by 0.2 cases per year (P < 0.001). The most common causes of ARDS were pneumonia (29%) and sepsis (29%). The use of pressure-controlled ventilation became almost dominant from 1993. The peak inspiratory pressure (PIP) has significantly decreased (−0.5 cmH2O/year), but the peak end-expiratory pressure (PEEP) has increased (0.1 cmH2O/year) during the study period. The hospital mortality decreased by 1% per year (P = 0.03) during the study period, from 50% in 1988–1992 to 33% in 2006–2010. A multivariable logistic regression model revealed that higher age and APACHE II score increased the odds of hospital mortality, while a higher calendar year of diagnosis reduced the odds of mortality. This was unchanged when dominant respiratory treatment, PIP and PEEP were added to the model. The 10-year survival of ARDS survivors was 68% compared with 90% survival of a reference population (P < 0.001). Conclusion The incidence of ARDS has almost doubled, but hospital mortality has decreased during the 23 years of observation. The 10-year survival of ARDS survivors is poor compared with the reference population.

Gender disparity among US anaesthesiologists: are women underrepresented in academic ranks and scholarly productivity?

Abstract: Introduction The h-index is an objective indicator of research productivity and influence on scholarly discourse within a discipline. It may be a valuable adjunct for measuring research productivity, a key component in decisions regarding appointment and promotion in academic medicine. The objectives of this analysis were to (1) examine whether there are gender disparities in research productivity among academic anaesthesiologists, and (2) compare results to measures of research productivity in other specialties. Methods A bibliometric analysis of faculty members from 25 academic anaesthesiology departments was performed using the Scopus database. Academic anaesthesiologists were organised by academic rank and gender. The h-index and publication range (in years) of faculty members were calculated. Results Male anaesthesiologists had higher research productivity, as measured by the h-index, than female colleagues. Organised by rank, this difference was noted only among full professors. Men had higher overall and early-career research productivity, while women had mid-career research productivity rates equivalent to and surpassing that of their male colleagues. Gender disparities in research productivity were also noted among a sample of academic physicians in other specialties. Conclusions While men had higher overall research productivity, women had equivalent or higher mid-career research output, suggesting that early-career considerations unique to women should be taken into account during appointment and promotion in academic anaesthesiology. While disparities in gender representation among anaesthesiologists have also been noted in Europe, further study as to whether these differences also extend to research productivity and academic promotion outside of the US would be of interest.

The use of 2-chloroprocaine for spinal anaesthesia.

Abstract: Spinal anaesthesia is a safe and reliable anaesthetic modality for surgical procedures on the lower part of the body. However, because of the description of transient neurologic symptoms (TNS), most practitioners have abandoned intrathecal lidocaine. Chloroprocaine (2-chloroprocaine, CP) has been one candidate to replace lidocaine for short procedures, despite the fact that neurologic sequelae have been described following the intrathecal injection of large doses of preservative-containing CP intended for epidural use. The National Library of Medicine's Medline and the EMBASE databases were searched for the time period 1966 to April 2012. Fourteen studies of the use of intrathecal CP were analysed, including seven volunteer and seven clinical studies. Preservative-free CP appears to be a reliable local anaesthetic for short procedures. The duration of the surgical block can be adjusted by varying the dose between 30 and 60 mg. Two double-blind randomised controlled studies demonstrate decreased time to ambulation and discharge when CP is used for spinal anaesthesia when compared with other local anaesthetics. The addition of fentanyl appears to prolong the surgical block without significantly prolonging the time to discharge. There have been five possible cases of TNS following CP spinal anaesthesia in over 4000 patients, and a regressive incomplete cauda equina syndrome has been described. The short duration of spinal CP makes it a strong contender for outpatient anaesthesia. It appears to have a lower risk of TNS than lidocaine.

Peripherally inserted central catheters in infants and children - indications, techniques, complications and clinical recommendations.

Abstract: Venous access required both for blood sampling and for the delivery of medicines and nutrition is an integral element in the care of sick infants and children. Peripherally inserted central catheters (PICCs) have been shown to be a valuable alternative to traditional central venous devices in adults and neonates. However, the evidence may not extrapolate directly to older paediatric patients. In this study, we therefore review the indications, methods of insertion and complications of PICC lines for children beyond the neonatal age to provide clinical recommendations based on a search of the current literature. Although the literature is heterogeneous with few randomised studies, PICCs emerge as a safe and valuable option for intermediate- to long-term central venous access in children both in and out of hospital. Insertion can often be performed in light or no sedation, with little risk of perioperative complications. Assisted visualisation, preferably with ultrasound, yields high rates of insertion success. With good catheter care, rates of mechanical, infectious and thrombotic complications are low and compare favourably with those of traditional central venous catheters. Even in the case of occlusion or infection, fibrinolytics and antibiotic locks often allow the catheter to be retained.

Effects of dexmedetomidine on inflammatory responses in patients undergoing laparoscopic cholecystectomy.

Abstract: Background Dexmedetomidine has been shown to reduce pro-inflammatory cytokine levels in rats with sepsis and in severely ill patients. The aim of this study was to document the effects of dexmedetomidine on inflammatory responses during and after surgery. Materials and Methods Patients undergoing laparoscopic cholecystectomy were enrolled. After induction of anaesthesia, patients in the dexmedetomidine group (n = 24, group D) received a loading dose of dexmedetomidine (1.0 μg/kg), followed by infusion of dexmedetomidine at 0.5 μg/kg/h. A saline-treated group (n = 23, group S) served as a control. Intraoperative mean arterial pressure (MAP), heart rate (HR), and amount of rescue analgesic administered as post-anaesthetic care were compared between the groups. The pro-inflammatory cytokines tumour necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6, and anti-inflammatory cytokines IL-4 and IL-10 were quantified by sandwich enzyme-linked immunoassay at three times: after anaesthesia induction (T0), at the end of peritoneal closure (T1), and 60 min after surgery (T2). The C-reactive protein (CRP) level and leukocyte count were measured on post-operative day 1. Results At time points T1 and T2, the IL-1β, TNF-α, and IL-10 levels were lower in group D than in group S (P < 0.05). The CRP level and leukocyte count on post-operative day 1 were also lower in group D (P < 0.05), as were intraoperative MAP, HR, and amount of rescue analgesic administered after surgery. Conclusions Dexmedetomidine administration during surgery reduced intraoperative and post-operative secretion of cytokines, as well as post-operative leukocyte count and CRP level.

Sevoflurane causes neuronal apoptosis and adaptability changes of neonatal rats.

Abstract: Background Neonatal exposure to sevoflurane can induce neurodegeneration and learning deficits in developing brain. We hypothesised that with the increase in the concentration and duration of sevoflurane, neurodegeneration of neonatal rats aggravates and causes behaviour changes as the rats grow. Methods Twenty-one post-natal day (P)7 Wistar rats were randomly divided into seven groups. Blood analysis was performed after anaesthesia. According to the results, 120 P7 Wistar rats were randomly divided into five groups: Con sham anaesthesia; Sevo 1%-2 h: exposed to 1% sevoflurane for 2 h; Sevo 1%-4 h, Sevo 2%-2 h and Sevo 2%-4 h. Caspase-3 positive cells in brain were detected by immunohistochemistry at 6 h after the end of anaesthesia. The cleaved poly(ADP-ribose) polymerase (c-PARP-1) in cortex and hippocampus was detected by Western blot analysis. Behavioural tests such as Morris water maze and Open-field Test were performed when the rats were 5-week old, 8-week old, and 14-week old. Results Three per cent sevoflurane induced carbon dioxide accumulation. The level of c-PARP-1 in hippocampus area was significantly increased in Group 2%-4h. The number of caspase-3 positive cells in Group Sevo 1%-2h, Group Sevo 2%-2h and Group Sevo 2%-4h was greater than that in Group Con. Rats exposed to sevoflurane had longer travel distance and time in open field when they were 5 weeks old. Animals from different groups had similar performance in Morris water maze. Conclusion Exposure to 2% sevoflurane causes neuronal apoptosis of neonatal rats, and long-time exposure aggravates that. The adaptability in new environment is transiently decreased when the anaesthesia rats are 5 weeks old.

Association between inotrope treatment and 90-day mortality in patients with septic shock.

Abstract: Background Administration of inotropes in septic patients with low cardiac output or low central/mixed venous saturation is recommended in current guidelines. However, the impact of inotrope use on the outcome of these patients is controversial. We aimed to analyse the association of inotrope treatment with 90-day mortality. Methods Data from 420 consecutive patients with septic shock were retrospectively collected from the intensive care unit (ICU) data management system. Factors associated with inotrope treatment were assessed. The association of 90-day mortality with inotrope treatment was first analysed using logistic regression analysis, and second including propensity score based on observed variables for selection to inotrope treatment. A subgroup analysis was performed for the 252 patients with pulmonary artery catheter. Results One hundred eighty-six (44.3%) patients received inotrope treatment during the first 24 h in ICU. Of those, 168 (90.3%) received dobutamine, 29 (15.6%) levosimendan, and 23 (12.4%) epinephrine. Blood lactate (P < 0.001), central venous pressure, (P < 0.001), and norepinephrine dose (P = 0.03) were independently associated with inotrope treatment. Patients with inotrope treatment had a higher 90-day mortality (42.5% vs. 23.9%, P < 0.001). Age (P < 0.001), Acute Physiology and Chronic Health Evaluation II score (P < 0.001), and inotrope treatment (P = 0.003) were independently associated with 90-day mortality also after adjustment with propensity score. Conclusion The use of inotrope treatment in septic shock was associated with increased 90-day mortality without and after adjustment with propensity to receive inotrope. To differentiate between non-observed biases of severity of septic shock and an unfavourable effect of inotropes, prospective studies are needed.

Ultrasound measurement of subglottic diameter and an empirical formula for proper endotracheal tube fitting in children

Abstract: Background The appropriate endotracheal tube (ETT) size is commonly determined using age-based formula; ETT size determination based on ultrasound (US) measurement of subglottic diameter (SD), the narrowest portion of the paediatric upper airway, may provide a better method for accurate fit. We aimed to validate ETT size determination using US measures of SD before intubation to establish an empirical formula for ETT fitting based on SD and biographic parameters. Methods We included 215 children aged 1–72 months undergoing general anaesthesia. US was performed on the anterior neck to measure SD during mask ventilation under anaesthesia. Endotracheal intubation was performed with a cuffed ETT selected by age-based recommendation; the transverse outer diameter (OD) of the ETT within the trachea at the subglottis level (OD-ETT at SD) was measured. Results The OD-ETT at SD was correlated with the actual OD-ETT outside the trachea (R2 = 0.635), showing the validity of ultrasonographic measurement; moreover, the US-measured SD revealed strong correlation with the actual OD-ETT (R2 = 0.834). US-measured SD and biographic data (age, height and weight) showed little correlation in children less than 12 months but good correlation (age, height) in children older than 12 months (P < 0.01). Conclusions US-measured OD-ETT at SD was in good agreement with the actual OD-ETT, suggesting that US-measured SD helps in choosing the appropriate ETT diameter for children. In children older than 12 months, the equation ‘OD (mm) = 0.01 × age (months) + 0.02 × height (cm) + 3.3’ may help select the appropriate ETT.

Impact of a physician-staffed helicopter on a regional trauma system: a prospective, controlled, observational study

Abstract: Preventing trauma-related deaths remains a major challenge for the health care system.* Intermediate admission of severely injured trauma patients to a local hospital facility can cause delay in definitive care, and direct transport to a tertiary trauma centre (TC) is associated with improved outcome.1,2 Despite this, local emergency medical services (EMS) often bring severely injured patients to the nearest hospital.3,4 The Swiss-German physician-staffed helicopter emergency medical service (PS-HEMS) model was introduced and adapted in Scandinavia decades ago, as was the use of anaesthesiologists as pre-hospital emergency physicians.5 Trauma patients are thought to benefit from such advanced pre-hospital systems,6,7 and HEMS have been associated with a reduced mortality.8,9 Nevertheless, the current literature is often limited by retrospective study designs, and the heterogeneity of trauma systems complicate generalisation of conclusions. Moreover, the risk of helicopter accidents10,11 and increased cost12 of helicopter-based systems compared with conventional EMS request a thorough documentation of the effect. Hence, more data from Europe/Scandinavia are needed to illuminate the impact of PS-HEMS on time to definitive care, triage, and mortality for the regional trauma population. We used the implementation of the first Danish PS-HEMS to conduct a prospective study, aiming to evaluate the pre-hospital trauma system in eastern Denmark, using a ‘before’ and ‘after’ design. We hypothesised that the implementation of a PS-HEMS would reduce time from injury to definitive care at the trauma centre. In addition, we sought to assess whether the PS-HEMS would be associated with a reduced number of secondary transfers and reduced 30-day mortality for severely injured trauma patients.

Levels and sources of sound in the intensive care unit – an observational study of three room types

Abstract: BackgroundMany intensive care unit (ICU) patients describe noise as stressful and precluding sleep. No previous study in the adult setting has investigated whether room size impacts sound levels or ...

Fluctuations in sedation levels may contribute to delirium in ICU patients.

Abstract: Background Delirium in patients admitted to the intensive care unit (ICU) is a serious complication potentially increasing morbidity and mortality. The aim of this study was to investigate the impact of fluctuating sedation levels on the incidence of delirium in ICU. Methods A prospective cohort study of adult patients at three multidisciplinary ICUs. The Richmond Agitation and Sedation Scale (RASS) and the Confusion Assessment Method for the ICU were used at least twice a day. Results Delirium was detected at least once in 65% of the patients (n = 640). Delirious patients were significantly older, more critically ill, more often intubated, had longer ICU stays, and had higher ICU mortality than non-delirious patients. The median duration of delirium was 3 days (interquartile range: 1;10), and RASS was less than or equal to 0 (alert and calm) 91% of the time. The odds ratio (OR) for development of delirium if RASS changed more than two levels was 5.19 when adjusted for gender, age, severity of illness, and ICU site and setting. Continuous infusion of midazolam was associated with a decrease in delirium incidence (OR: 0.38; P = 0.002). Conclusions Fluctuations in sedation levels may contribute to development of delirium in ICU patients. The risk of developing delirium might be reduced by maintaining a stable sedation level or by non-sedation.

Early thromboelastometric variables reliably predict maximum clot firmness in patients undergoing cardiac surgery: a step towards earlier decision making.

Abstract: Background While much effort has been spent on guiding coagulation and transfusion therapy in patients undergoing cardiopulmonary bypass (CPB) surgery, the use of conventional laboratory-based coagulation tests is hampered by long turnaround times and interference with heparin and protamine. To allow faster assessment of maximum clot firmness (MCF) by point-of-care thromboelastometry (ROTEM®, TEM International GmbH, Munich, Germany), we tested whether clotting time (CT), clot formation time (CFT), or early values of clot firmness (CF) predict MCF. Methods Results of 437 ROTEM® assays (EXTEM®, INTEM®, FIBTEM®, and HEPTEM®) from 84 patients undergoing CPB surgery were analyzed. Measurements were performed prior to and after heparin administration, as well as after protamine administration and CT, CFT, and CF after 5, 10, and 15 min (A5, A10, and A15) after initial clotting (CT) were related to MCF. Statistics Regression and Bland–Altman analyses and receiver-operating characteristics (ROCs). Results CFT (r = 0.87–0.95), A5 (r = 0.84−0.98; P < 0.0001), A10 (r = 0.86−0.98; P < 0.0001), and A15 (r = 0.86−0.98; P < 0.0001) demonstrated high correlation coefficients with MCF, whereas CT correlated weakly (r = 0.07−0.41). As expected, correlation coefficients increased with the time allowed to assess a specific variable. ROC analyses demonstrated excellent accuracy for CFT, A5, A10, and A15 [area under the curve (AUC): 0.9476−0.9931] to predict a subnormal MCF, whereas CT demonstrated poor accuracy (AUC: 0.5796−0.6774). Conclusion Taking into account specific bias, early values of CF (A5–A15) reliably predict maximum CF under all conditions and, therefore, allow for marked time savings in the interpretation of ROTEM® measurements. This may guide earlier and more specific treatment of CPB-related coagulation disorders.

Outcomes in smokers and alcohol users after fast-track hip and knee arthroplasty

Abstract: Background Smoking and alcohol use impair post-operative outcomes. However, no studies include fast-track surgery, which is a multimodal-enhanced recovery programme demonstrated to improve outcome. We hypothesised that outcome is similar in smokers and alcohol users as in non-users after fast-track hip and knee arthroplasty. Methods Prospective questionnaires on co-morbidity and smoking/alcohol use were cross-referenced with the Danish National Health Registry to investigate relationship between smoking/alcohol use and length of stay of > 4 days and readmissions ≤ 90 days after fast-track hip and knee arthroplasty. Results In 3041 consecutive patients, 458 reported smoking and 216 drinking > 2 drinks a day, of which 66 did both. Smokers/alcohol users were younger than non-users (mean age: 64.3 vs. 68.0 years, P 4 days and smoking (odds ratio [95% confidence interval], P) (1.34 [0.92–1.95], 0.127) or alcohol use (0.59 [0.30–1.16], 0.127). Thirty- and ninety-day readmission rate was 6.6% (n = 201) and 9.4% (n = 285). Multiple logistic regression analysis showed an increased risk of readmissions in smokers at 30 (1.60 [1.05–2.44], 0.028) but not 90-day follow-up (1.17 [0.80–1.73], 0.419). No increased risk of readmissions was found in alcohol users at 30 (0.94 [0.50–1.76], 0.838) or 90-day follow-up (0.83 [0.47–1.49], 0.532). No increased risk of specific readmissions (i.e. wound infections or pneumonia) typically related to smoking/alcohol use was found in smokers (1.56 [0.93–2.62], 0.091) or alcohol users (1.00 [0.47–2.15], 0.999) at 90-day follow-up. Conclusion Influence of smoking or alcohol use may be less pronounced in fast-track hip and knee arthroplasty compared with data with conventional care programmes.

Prevention of post-dural puncture headache in parturients: a systematic review and meta-analysis.

Abstract: Post-dural puncture headaches (PDPHs) present an important clinical problem. We assessed methods to decrease accidental dural punctures (ADPs) and interventions to reduce PDPH following ADP. Multiple electronic databases were searched for randomised clinical trials (RCTs) of parturients having labour epidurals, in which the studied intervention could plausibly affect ADP or PDPH, and the incidence of at least one of these was recorded. Forty RCTs (n = 11,536 epidural insertions) were included, studying combined spinal-epidurals (CSEs), loss of resistance medium, prophylactic epidural blood patches, needle bevel orientation, ultrasound-guided insertion, epidural morphine, Special Sprotte needles, acoustic-guided insertion, administration of cosyntropin, and continuous spinal analgesia. The RCTs for CSE, loss of resistance medium, and prophylactic epidural blood patches were meta-analysed. Five methods reduced PDPH: prophylactic epidural blood patch {four trials, median quality score = 2, risk difference = -0.48 [95% confidence interval (CI): -0.88 to -0.086]}, lateral positioning of the epidural needle bevel upon insertion (one trial, quality score = 1), Special Sprotte needles [one trial, quality score = 5, risk difference = -0.44 (95% CI: -0.67 to -0.21)], epidural morphine [one trial, quality score = 4, risk difference = -0.36 (95% CI -0.59 to -0.13)], and cosyntropin [one trial, quality score = 5, risk difference = -0.36 (95% CI -0.55 to -0.16)]. Several methods potentially reduce PDPH. Special Sprotte needles, epidural morphine, and cosyntropin are thus far each supported by a single, albeit good quality trial. Prophylactic blood patches are supported by three trials, but these had flawed methodology. Mostly, trials were of limited quality, and further well-conducted, large studies are needed.

Handover of patients: a topical review of ambulance crew to emergency department handover

Abstract: Handover has major implications for patient care. The handover process between ambulance and emergency department (ED) staff has been sparsely investigated. The purpose of this paper is, based on a literature review, to identify and elaborate on the major factors influencing the ambulance to ED handover, and to bring suggestions on how to optimize this process. A literature search on handovers to EDs was performed in PubMed, Embase, Web of Science and Cochrane databases. A total of 18 papers were included. Issues regarding transfer of information are highlighted. Newer studies suggest that implementing a structured handover format holds the possibilities for improving the process. Electronic equipment could play a part in reducing problems. Cultural and organizational factors impact the process in different ways. The professions perceive the value and quality of information given differently. Giving and taking over responsibility is an important issue. The handover of patients to the ED has the potential to be improved. Cultural issues and a lack of professional recognition of handover importance need to be approached. Multidisciplinary training in combination with a structured tool may have a potential for changing the culture and improving handover.

Transversus abdominis plane block or subcutaneous wound infiltration after open radical prostatectomy: a randomized study.

Abstract: Background Open radical retropubic prostatectomy (ORRP) is associated with moderate pain. We hypothesized that a transversus abdominis plane (TAP) block would reduce post-operative pain, morphine consumption and opioid-related side effects compared with wound infiltration and placebo in this population. Methods This was a randomized, double-blind and placebo-controlled study. The operations were performed with patients in general anaesthesia. Patients were allocated to receive either bilateral TAP block (n = 23), wound infiltration (n = 25) or placebo (n = 25). Treatment was 40 ml ropivacaine 0.75% and placebo was 40 ml saline 0.9%. Pre-operatively, all patients received oral gabapentin, ibuprofen and paracetamol, followed by oral paracetamol and ibuprofen at regular doses and intervals, and patient-controlled analgesia with IV morphine from 0 h to 24 h post-operatively. Results Visual analogue scale pain score during mobilization 4 h post-operatively (primary outcome) did not differ significantly between the TAP block and placebo group (TAP 28 ± 22 mm vs. placebo 33 ± 18 mm, P = 0.64). Pain scores (as area under the curve) during the first 24 h were not significantly different among any of the three groups, neither at rest nor during mobilization. Morphine consumption (0–24 h) did not differ significantly between groups {TAP block = 15 [8–23] mg, infiltration 15 [8–36] mg, placebo 15 [3–30] mg, [median (interquartile range)]}. Levels of nausea, sedation and number of vomits were not different among the groups. Conclusion Neither TAP block nor wound infiltration with ropivacaine improved a basic multimodal analgesic regimen with paracetamol, ibuprofen and gabapentin after ORRP.

Optimising stroke volume and oxygen delivery in abdominal aortic surgery: a randomised controlled trial.

Abstract: Background Post-operative complications after open elective abdominal aortic surgery are common, and individualised goal-directed therapy may improve outcome in high-risk surgery. We hypothesised that individualised goal-directed therapy, targeting stroke volume and oxygen delivery, can reduce complications and minimise length of stay in intensive care unit and hospital following open elective abdominal aortic surgery. Methods Seventy patients scheduled for open elective abdominal aortic surgery were randomised to individualised goal-directed therapy or conventional therapy. In the intervention group, stroke volume was optimised by 250 ml colloid boluses intraoperatively and for the first 6 h post-operatively. The optimisation aimed at an oxygen delivery of 600 ml/min/m2 in the post-operative period. Haemodynamic data were collected at pre-defined time points, including baseline, intraoperatively and post-operatively. Patients were followed up for 30 days. Results Stroke volume index and oxygen delivery index were both higher in the post-operative period in the intervention group. In this group, 27 of 32 achieved the post-operative oxygen delivery index target vs. 18 of 32 in the control group (P = 0.01). However, the number of complications per patient or length of stay in the intensive care unit or hospital did not differ between the groups. Conclusion Perioperative individualised goal-directed therapy targeting stroke volume and oxygen delivery did not affect post-operative complications, intensive care unit or hospital length of stay in open elective abdominal aortic surgery.

Regional anaesthesia and cancer metastases: the implication of local anaesthetics

Abstract: Clinical and basic science studies have demonstrated the anti-inflammatory properties of local anaesthetics. Recent studies have begun to unravel molecular pathways linking inflammation and cancer. Regional anaesthesia is associated in some retrospective clinical studies with reduced risk of metastasis and increased long-term survival. The potential beneficial effects of regional anaesthesia have been attributed mainly to the inhibition of the neuroendocrine stress response to surgery and to the reduction in the requirements of volatile anaesthetics and opioids. Because cancer is linked to inflammation and local anaesthetics have anti-inflammatory effects, these agents may participate in reducing the risk of metastasis, but their mechanism of action is unknown. We demonstrated in vitro that amide local anaesthetics attenuate tumour cell migration as well as signalling pathways enhancing tumour growth and metastasis. This has provided the first evidence of a molecular mechanism by which regional anaesthesia might inhibit or reduce cancer metastases.

Emergence agitation in children undergoing adenotonsillectomy: a comparison of sevoflurane vs. sevoflurane‐remifentanil administration

Abstract: Background Sevoflurane is widely used in paediatric anaesthesia but frequently causes emergence agitation (EA). This study evaluated whether limiting the sevoflurane concentration by combining remifentanil with sevoflurane reduced the incidence of EA. Methods Eighty-four preschool children scheduled for adenotonsillectomy were randomly assigned to either the remifentanil or sevoflurane group. In the remifentanil group, anaesthesia was induced with thiopental, rocuronium, and 1% sevoflurane. It was maintained with 1% sevoflurane, 60% nitrous oxide in oxygen, and a continuous infusion of remifentanil. For the sevoflurane group, anaesthesia was induced with thiopental, rocuronium, and 8% sevoflurane, and was maintained with 2–3% sevoflurane. Both groups received ketorolac 1 mg/kg and dexamethasone 0.15 mg/kg. EA was measured using the paediatric anaesthesia emergence delirium (PAED) scale and a four-point EA scale in the post-anaesthesia care unit. Results The scores on the PAED scales were significantly lower in the remifentanil group than in the sevoflurane group [median (interquartile range); 6 (4.25–10.25) vs. 11 (7.75–14.0), P = 0.007], and the proportion of patients with PAED scores ≥ 10 was significantly lower in the remifentanil group than in the sevoflurane group [15 (35.7%) vs. 27 (64.2%), P = 0.009]. The incidence of EA evaluated using the four-point scale was also lower in the remifentanil group [11 (26.1%) vs. 21 (50%), respectively, P = 0.025]. Conclusion The incidence of EA was lower in children undergoing adenotonsillectomy who received a lower concentration of sevoflurane combined with remifentanil than in those given a higher concentration of sevoflurane without remifentanil.

Continuous evaluation of neurological prognosis after cardiac arrest.

Abstract: Post-resuscitation care has changed in the last decade, and outcome after cardiac arrest has improved, thanks to several combined measures. Induced hypothermia has shown a treatment benefit in two randomized trials, but some doubts remain. General care has improved, including the use of emergency coronary intervention. Assessment of neurological function and prognosis in comatose cardiac arrest patient is challenging, especially when treated with hypothermia. In this review, we evaluate the recent literature and discuss the available evidence for prognostication after cardiac arrest in the era of temperature management. Relevant literature was identified searching PubMed and reading published papers in the field, but no standardized search strategy was used. The complexity of predicting outcome after cardiac arrest and induced hypothermia is recognized in the literature, and no single test can predict a poor prognosis with absolute certainty. A clinical neurological examination is still the gold standard, but the results need careful interpretation because many patients are affected by sedatives and by hypothermia. Common adjuncts include neurophysiology, brain imaging and biomarkers, and a multimodal strategy is generally recommended. Current guidelines for prediction of outcome after cardiac arrest and induced hypothermia are not sufficient. Based on our expert opinion, we suggest a multimodal approach with a continuous evaluation of prognosis based on repeated neurological examinations and electroencephalography. Somatosensory-evoked potential is an established method to help determine a poor outcome and is recommended, whereas biomarkers and magnetic resonance imaging are promising adjuncts. We recommend that a decisive evaluation of prognosis is performed at 72 h after normothermia or later in a patient free of sedative and analgetic drugs.

Rocuronium and sugammadex in patients with myasthenia gravis undergoing thymectomy

Abstract: Background The use of neuromuscular blocking agents is still controversial in myasthenic patients but rocuronium could be useful after the introduction of sugammadex as a selective antagonist. The aim of the study was to evaluate the use of rocuronium-sugammadex in myasthenic patients undergoing thoracoscopic thymectomy. Methods After ethical approval, 10 myasthenic patients undergoing videothoracoscopic-assisted thymectomy were enrolled in the study. Neuromuscular block was achieved with 0.3 mg/kg rocuronium and additional doses were given according to train-of-four (TOF) monitoring or movement of the diaphragm. Sugammadex 2 mg/kg was given after surgery. Recovery time (time to obtain a TOF value > 0.9) was recorded for all subjects. Result All patients were extubated in the operating room after administration of sugammadex. Mean rocuronium dose was 48 mg and the average operation time was 62 min. Recovery time after sugammadex administration was 111 s (min 35; max 240). Conclusions A rapid recovery of neuromuscular function was found in myasthenic patients receiving rocuronium when sugammadex was used for reversal. This combination could be a rational alternative for myasthenic patients for whom neuromuscular blockade is mandatory during surgery.

The frequency and nature of drug administration error during anaesthesia in a Chinese hospital

Abstract: Background Throughout the world, drug administration error remains a known and significant threat to patients undergoing anaesthesia. Estimates of the extent of the problem vary, but few are based on large prospectively collected datasets. Furthermore, little is known about whether differences in work culture are important in error rates. Methods A prospective incident monitoring study was conducted at a large tertiary hospital in China to estimate the frequency of drug administration error during anaesthesia. Anaesthetists were asked to return a study form anonymously for every anaesthetic, indicating whether or not a drug administration error had occurred, including incident details if affirmative. Results From 24,380 anaesthetics, 16,496 study forms were returned (67.7% response rate), reporting 179 errors. The frequency (95% confidence interval) of drug administration error was 0.73% (0.63% to 0.85%) based on total study anaesthetics and 1.09% (0.93% to 1.26%) based on total forms returned. The largest categories of error were omissions (27%), incorrect doses (23%) and substitutions (20%). Errors resulted in prolonged stay in recovery for 21 patients, transfer to the ICU for five and one case each of haemorrhagic shock and asthmatic attack. More respondents who were not fully rested reported inattention as a contributing factor to error (21%) than those who were fully rested (7%, P = 0.04). Conclusion Our results are comparable with other international prospective estimates indicating that drug administration error is of concern in China as elsewhere. These results will form a baseline from which to detect the effects of countermeasures.

Assessment of changes in cardiac index and fluid responsiveness: a comparison of Nexfin and transpulmonary thermodilution.

Abstract: Background The Nexfin device uses non-invasive photoplethysmography to monitor cardiac output and respiratory variations in pulse pressure and stroke volume The aim of this study was to compare rapid changes in cardiac index after fluid challenge between Nexfin and bolus transpulmonary thermodilution and the ability to predict fluid responsiveness of dynamic indices given by Nexfin Methods Simultaneous comparative cardiac index were collected from transpulmonary thermodilution and Nexfin before and after fluid challenge in 45 patients following conventional cardiac surgery Correlations, Bland–Altman analyses and percentage errors were calculated Pulse pressure variations and stroke volume variations before fluid challenge were collected to assess their discrimination in predicting fluid responsiveness Results Eight (18%) patients were excluded A weak positive relationship was found between rapid changes in cardiac index after fluid challenge given by both technologies (n = 37, r = 039, P = 0019) Bias, precision and limits of agreements were 020 l/min/m2 (95% confidence interval (CI) 002–040), 057 l/min/m2 and ± 112 l/min/m2 before fluid challenge, and 001 l/min/m2 (95% CI −024 to 026), 074 l/min/m2 and ± 145 l/min/m2 after fluid challenge Percentage errors between Nexfin and transpulmonary thermodilution were 55% and 58% before and after fluid challenge, respectively Pulse pressure variations and stroke volume variations given by Nexfin were not discriminant to predict fluid responsiveness: areas under receiver operating characteristics curves 057 (95% CI 040–073) and 050 (033–067), respectively Conclusions The Nexfin cannot be used to measure rapid changes in cardiac index following fluid challenge and to predict fluid responsiveness after cardiac surgery

Maternal and foetal effects of remifentanil for general anaesthesia in parturients undergoing caesarean section: a systematic review and meta-analysis.

Abstract: Background Remifentanil has been suggested for the induction of general anaesthesia for caesarean section. We aimed to define remifentanil effects on maternal stress response as well as neonatal effects. Methods Relevant articles were retrieved by a systematic literature search. Randomized, controlled trials comparing remifentanil use before delivery with placebo were selected. Maternal outcome parameters were blood pressure and heart rate; neonatal effects included the need for mask ventilation and intubation, base excess, pH values, Apgar < 7 at 1 and 5 min. The random effects model was used for meta-analysis; risk ratio or weighted mean difference (WMD) and 95% confidence interval (95% CI) were calculated. Results Five articles including 186 patients were identified. Highest and lowest systolic blood pressure were significantly lower in the remifentanil group (WMD: −29.98, −50.90 to −9.07 mmHg, 95% CI; P = 0.005; and WMD: −12.46, −18.21 to −6.71 mmHg, 95% CI; P < 0.0001), the lowest heart rate was significantly lower after remifentanil treatment (WMD: −8.22, −11.67 to −4.78, 95% CI; P < 0.00001). Base excess was significantly higher in infants of remifentanil-treated mothers (WMD: 1.15, −0.27 to 2.03, 95% CI; P = 0.01); pH was also higher in the remifentanil group, but significance was missed (P = 0.07). No differences were observed for Apgar values or the need of airway assist. Conclusion Remifentanil was found to attenuate the maternal circulatory response to intubation and surgery. Higher base excess and pH suggest a beneficial effect on the neonatal acid-base status. A trial with adequate power is warranted that addresses neonatal side-effects of remifentanil.

Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review.

Abstract: UNLABELLED Stress ulcer prophylaxis (SUP) is regarded as standard of care in the intensive care unit (ICU). However, recent randomized, clinical trials (RCTs) and meta-analyses have questioned the rationale and level of evidence for this recommendation. The aim of the present systematic review was to evaluate if SUP in the critically ill patients is indicated. DATA SOURCES MEDLINE including MeSH, EMBASE, and the Cochrane Library. PARTICIPANTS patients in the ICU. INTERVENTIONS pharmacological and non-pharmacological SUP. STUDY APPRAISAL AND SYNTHESIS METHODS Risk of bias was assessed according to Grading of Recommendations Assessment, Development, and Evaluation, and risk of random errors in cumulative meta-analyses was assessed with trial sequential analysis. A total of 57 studies were included in the review. The literature on SUP in the ICU includes limited trial data and methodological weak studies. The reported incidence of gastrointestinal (GI) bleeding varies considerably. Data on the incidence and severity of GI bleeding in general ICUs in the developed world as of today are lacking. The best intervention for SUP is yet to be settled by balancing efficacy and harm. In essence, it is unresolved if intensive care patients benefit overall from SUP. The following clinically research questions are unanswered: (1) What is the incidence of GI bleeding, and which interventions are used for SUP in general ICUs today?; (2) Which criteria are used to prescribe SUP?; (3) What is the best SUP intervention?; (4) Do intensive care patients benefit from SUP with proton pump inhibitors as compared with other SUP interventions? Systematic reviews of possible interventions and well-powered observational studies and RCTs are needed.

Cerebral energy metabolism during mitochondrial dysfunction induced by cyanide in piglets.

Abstract: Background Mitochondrial dysfunction is an important factor contributing to tissue damage in both severe traumatic brain injury and ischemic stroke. This experimental study explores the possibility to diagnose the condition bedside by utilising intracerebral microdialysis and analysis of chemical variables related to energy metabolism. Methods Mitochondrial dysfunction was induced in piglets and evaluated by monitoring brain tissue oxygen tension (PbtO2) and cerebral levels of glucose, lactate, pyruvate, glutamate, and glycerol bilaterally. The biochemical variables were obtained by microdialysis and immediate enzymatic analysis. Mitochondrial function was blocked by unilateral infusion of NaCN/KCN (0.5 mol/L) through the microdialysis catheter (N = 5). As a reference, NaCl (0.5 mol/L) was infused by intracerebral microdialysis in one group of animals (N = 3). Results PbtO2 increased during cyanide infusion and returned to baseline afterwards. The lactate/pyruvate (LP) ratio increased significantly following cyanide infusion because of a marked increase in lactate level while pyruvate remained within normal limits. Glutamate and glycerol increased after cyanide infusion indicating insufficient energy metabolism and degradation of cellular membranes, respectively. Conclusion Mitochondrial dysfunction is characterised by an increased LP ratio signifying a shift in cytoplasmatic redox state at normal or elevated PbtO2. The condition is biochemically characterised by a marked increase in cerebral lactate with a normal or elevated pyruvate level. The metabolic pattern is different from cerebral ischemia, which is characterised by simultaneous decreases in intracerebral pyruvate and PbtO2. The study supports the hypothesis that cerebral ischemia and mitochondrial dysfunction may be identified and separated at the bedside by utilising intracerebral microdialysis.

Open‐heart surgery increases cerebrospinal fluid levels of Alzheimer‐associated amyloid β

Abstract: Background Neurocognitive dysfunction occurs frequently after open-heart surgery. It has been suggested that cognitive decline after cardiac surgery with cardiopulmonary bypass (CPB) could be a functional consequence of Alzheimer's disease (AD)-like neuropathological changes. The aim of the present study was to evaluate the cerebrospinal fluid (CSF) levels of amyloid β peptide (Aβ1–42) and soluble fragments of amyloid precursor protein (sAPP) as well as the cerebral inflammatory response to open-heart surgery. Methods Ten patients undergoing aortic valve replacement with CPB were included. CSF was obtained the day before and 24 h after surgery for assessment of CSF levels of Aβ1–42 α-cleaved sAPP and β-cleaved sAPP (sAPP-β). Furthermore, CSF and serum levels of the inflammatory cytokines: tumour necrosis factor alpha (TNF-α), interleukin-6 (IL-6) and interleukin-8 (IL-8) were also assessed. Results Cardiac surgery with CPB increased CSF levels of Aβ1–42 from 447 ± 92 to 641 ± 83 ng/l (P = 0.011), while CSF levels of sAPP-β decreased from 276 ± 35 to 192 ± 21 ng/ml (P = 0.031). CSF levels of TNF-α increased from ≤ 0.60 to 0.79 ± 0.26 ng/l (P = 0.043), IL-6 from 1.89 ± 0.53 to 22.8 ± 6.9 ng/l (P = 0.003) and IL-8 from 39.8 ± 7.8 to 139 ± 18.3 ng/l (P < 0.001). Conclusions Cardiac surgery with CPB causes a profound cerebral inflammatory response, which was accompanied by increased post-operative CSF levels of the AD biomarker Aβ1–42. We hypothesize that these changes may be relevant to Alzheimer-associated amyloid build-up in the brain and cognitive dysfunction after cardiac surgery with CPB.