Showing papers in "Acta Anaesthesiologica Scandinavica in 2015"

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations.

Abstract: Background The present article has been written to convey concepts of anaesthetic care within the context of an Enhanced Recovery After Surgery (ERAS) programme, thus aligning the practice of anaesthesia with the care delivered by the surgical team before, during and after surgery. Methods The physiological principles supporting the implementation of the ERAS programmes in patients undergoing major abdominal procedures are reviewed using an updated literature search and discussed by a multidisciplinary group composed of anaesthesiologists and surgeons with the aim to improve perioperative care. Results The pathophysiology of some key perioperative elements disturbing the homoeostatic mechanisms such as insulin resistance, ileus and pain is here discussed. Conclusions Evidence-based strategies aimed at controlling the disruption of homoeostasis need to be evaluated in the context of ERAS programmes. Anaesthesiologists could, therefore, play a crucial role in facilitating the recovery process.

Neuromuscular blockade for optimising surgical conditions during abdominal and gynaecological surgery: a systematic review

Abstract: Background The level of neuromuscular blockade (NMB) that provides optimal surgical conditions during abdominal surgery has not been well established. The aim of this systematic review was to evaluate current evidence on the use of neuromuscular blocking agents in order to optimise surgical conditions during laparoscopic procedures and open abdominal surgery. Methods A wide search was performed in PubMed, Cochrane library and Embase with systematic approach including PRISMA recommendations. Individual risk of bias was assessed and systematic data extraction were performed. Results Fifteen studies with data from 998 patients were included. There is good evidence that the use of deep NMB compared with moderate NMB is associated with optimised surgical conditions during laparoscopic cholecystectomy, hysterectomy and nephrectomy/prostatectomy. In laparoscopic cholecystectomy during low pressure pneumoperitoneum, deep NMB marginally improves the surgical conditions. However, to ensure acceptable surgical conditions, it may be necessary to increase the intra-abdominal pressure in up to half of the patients regardless of level of NMB. There is good evidence that moderate NMB improves surgical conditions in some cases during open radical retropubic prostatectomy. However, good and excellent surgical conditions may be achievable even without NMB. There is good evidence to recommend deep NMB in laparoscopic cholecystectomy, nephrectomy and prostatectomy to improve surgical conditions. There is insufficient evidence to recommend an ideal level of NMB creating optimal surgical condition during laparotomy. Conclusion Use of deep NMB in certain laparoscopic procedures may improve surgical conditions. In open abdominal surgery, use of NMB may optimise surgical conditions under certain circumstances.

Complex regional pain syndrome type I: a comprehensive review.

Abstract: Background Complex regional pain syndrome type I (CRPS I), formerly known as reflex sympathetic dystrophy (RSD), is a chronic painful disorder that usually develops after a minor injury to a limb. This topical review gives a synopsis of CRPS I and discusses the current concepts of our understanding of CRPS I in adults, the diagnosis, and treatment options based on the limited evidence found in medical literature. CRPS I is a multifactorial disorder. Possible pathophysiological mechanisms of CRPS I are classic and neurogenic inflammation, and maladaptive neuroplasticity. At the level of the central nervous system, it has been suggested that an increased input from peripheral nociceptors alters the central processing mechanisms. Methods A literature search was conducted using, as electronic bibliographic database, Medline from 1980 until 2014. Results An early diagnosis and multidisciplinary treatment are necessary to prevent permanent disability. Conclusions The pharmacological treatment of CRPS I is empirical and insufficiently effective. Further research is needed regarding the therapeutic modalities discussed in the guidelines. Physical therapy is widely recommended as a first-line treatment. The efficacy of local anesthetic sympathetic blockade as treatment for CRPS I is questionable.

Stress ulcer prophylaxis in the intensive care unit: an international survey of 97 units in 11 countries.

Abstract: Background: Stress ulcer prophylaxis (SUP) may decrease the incidence of gastrointestinal bleeding in patients in the intensive care unit (ICU), but the risk of infection may be increased. In this study, we aimed to describe SUP practices in adult ICUs. We hypothesised that patient selection for SUP varies both within and between countries. MethodsAdult ICUs were invited to participate in the survey. We registered country, type of hospital, type and size of ICU, preferred SUP agent, presence of local guideline, reported indications for SUP, criteria for discontinuing SUP, and concerns about adverse effects. Fisher's exact test was used to assess differences between groups. ResultsNinety-seven adult ICUs in 11 countries participated (eight European). All but one ICU used SUP, and 64% (62/97) reported having a guideline for the use of SUP. Proton pump inhibitors were the most common SUP agent, used in 66% of ICUs (64/97), and H2-receptor antagonists were used 31% (30/97) of the units. Twenty-three different indications for SUP were reported, the most frequent being mechanical ventilation. All patients were prescribed SUP in 26% (25/97) of the ICUs. Adequate enteral feeding was the most frequent reason for discontinuing SUP, but 19% (18/97) continued SUP upon ICU discharge. The majority expressed concern about nosocomial pneumonia and Clostridium difficile infection with the use of SUP. ConclusionsIn this international survey, most participating ICUs reported using SUP, primarily proton pump inhibitors, but many did not have a guideline; indications varied considerably and concern existed about infectious complications. (Less)

The spread of injectate during saphenous nerve block at the adductor canal: a cadaver study

Abstract: Background The spread of injectate during a saphenous nerve block at the adductor canal has not been clearly described. Methods We examined the spread of 15 ml dyed injectate during ultrasound-guided saphenous nerve blocks at the adductor canal in 15 unembalmed cadavers' lower limbs followed by comparative dissections of the same limbs. Results The spread of the injectates was determined by the fascial limits and the muscles surrounding the adductor canal. The anteromedial limit of the adductor canal (the roof) was found to be a continuous fascia, with a thin proximal part and a thicker distal part (the vastoadductor membrane) covering the canal from the apex of the femoral triangle to the adductor hiatus. The fascial limits of the adductor canal formed a conduit around the femoral neurovascular bundle. The dyed aqueous injectate spread throughout the entire adductor canal to the femoral triangle and reached 1–2 cm into the popliteal fossa. Injections superficial to the adductor canal spread over the femoral artery within the subsartorial fat compartment resembling the injections within the canal but with ultrasonographic distinct features. These injections spread only half the length of the adductor canal. The only nerve observed within the adductor canal was the saphenous nerve. Conclusions Injection of 15 ml dye was sufficient to spread throughout the adductor canal and beyond both proximally and distally. Distinct ultrasonographic features could be identified separating a subsartorial injection from an injection within the adductor canal with consequent differences in the spread.

Crew Resource Management in the Intensive Care Unit: a prospective 3-year cohort study.

Abstract: BACKGROUND: Human factors account for the majority of adverse events in both aviation and medicine. Human factors awareness training entitled "Crew Resource Management (CRM)" is associated with improved aviation safety. We determined whether implementation of CRM impacts outcome in critically ill patients. METHODS: We performed a prospective 3-year cohort study in a 32-bed ICU, admitting 2500-3000 patients yearly. At the end of the baseline year, all personnel received CRM training, followed by 1 year of implementation. The third year was defined as the clinical effect year. All 7271 patients admitted to the ICU in the study period were included. The primary outcome measure was ICU complication rate. Secondary outcome measures were ICU and hospital length of stay, and standardized mortality ratio. RESULTS: Occurrence of serious complications was 67.1/1000 patients and 66.4/1000 patients during the baseline and implementation year respectively, decreasing to 50.9/1000 patients in the post-implementation year (P = 0.03). Adjusted odds ratios for occurrence of complications were 0.92 (95% CI 0.71-1.19, P = 0.52) and 0.66 (95% CI 0.51-0.87, P = 0.003) in the implementation and post-implementation year. The incidence of cardiac arrests was 9.2/1000 patients and 8.3/1000 patients during the baseline and implementation year, decreasing to 3.5/1000 patients (P = 0.04) in the post-implementation year, while cardiopulmonary resuscitation success rate increased from 19% to 55% and 67% (P = 0.02). Standardized mortality ratio decreased from 0.72 (95% CI 0.63-0.81) in the baseline year to 0.60 (95% CI 0.53-0.67) in the post-implementation year (P = 0.04). CONCLUSION: Our data indicate an association between CRM implementation and reduction in serious complications and lower mortality in critically ill patients.

Total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty: a randomised, controlled trial.

Abstract: The choice of anaesthetic technique for patients undergoing joint arthroplasty is debatable. The hypothesis of this study was that general anaesthesia would generate a more favourable recovery profile than spinal anaesthesia.

Bystander first aid in trauma – prevalence and quality: a prospective observational study

Abstract: Background Bystander first aid and basic life support can likely improve victim survival in trauma. In contrast to bystander first aid and out-of-hospital cardiac arrest, little is known about the role of bystanders in trauma response. Our aim was to determine how frequently first aid is given to trauma victims by bystanders, the quality of this aid, the professional background of first-aid providers, and whether previous first-aid training affects aid quality. Methods We conducted a prospective 18-month study in two mixed urban–rural Norwegian counties. The personnel on the first ambulance responding to trauma calls assessed and documented first aid performed by bystanders using a standard form. Results A total of 330 trauma calls were included, with bystanders present in 97% of cases. Securing an open airway was correctly performed for 76% of the 43 patients in need of this first-aid measure. Bleeding control was provided correctly for 81% of 63 patients for whom this measure was indicated, and prevention of hypothermia for 62% of 204 patients. Among the first-aid providers studied, 35% had some training in first aid. Bystanders with documented first-aid training gave better first aid than those where first-aid training status was unknown. Conclusions A majority of the trauma patients studied received correct pre-hospital first aid, but still there is need for considerable improvement, particularly hypothermia prevention. Previous first-aid training seems to improve the quality of first aid provided. The effect on patient survival needs to be investigated.

Real-time ventilation and perfusion distributions by electrical impedance tomography during one-lung ventilation with capnothorax.

Abstract: Background: Carbon dioxide insufflation into the pleural cavity, capnothorax, with one-lung ventilation (OLV) may entail respiratory and hemodynamic impairments We investigated the online physiolo

Translation and validation of the Danish version of the postoperative quality of recovery score QoR-15.

Abstract: Background Patient perceived quality of recovery is an important outcome after surgery and should be measured in clinical trials. Quality of recovery after surgery and general anaesthesia can be measured by the QoR-15. A high score indicates a good recovery and the score ranges from 0 to 150. The aim of this study was to translate the QoR-15 questionnaire into Danish and do a full psychometric evaluation of the Danish version. Methods A translation and cultural adaption of the original version of the QoR-15 into a Danish version, the QoR-15D, was performed. After obtaining consent, patients undergoing elective abdominal, orthopaedic or gynaecological surgery under general anaesthesia were included. Patients completed the QoR-15D before surgery and on the first postoperative day. The validity, reliability, responsiveness and clinical feasibility of the QoR-15D were evaluated. Results One hundred and forty patients returned their pre- and postoperative questionnaire successfully giving a completion rate of 56%. The postoperative QoR-15 score was negatively correlated with duration of surgery (ρ = −0.21, 95% CI: −0.04 to −0.36, P < 0.02) and postoperative stay (ρ = −0.28, 95% CI: −0.12 to −0.43, P < 0.01). Postoperative QoR-15D scores were inversely related to the extent of surgery: minor, intermediate or major (127 ± 22, 106 ± 29 and 96 ± 24, respectively, P < 0.01). Cronbach's alpha and split-half reliability was 0.90 and 0.88. Test–retest reliability was 0.99 (95% CI: 0.94–1.00). Cohen's effect size was 1.13 and the standardized response mean was 0.82. Conclusion The QoR-15D has preserved the validity, excellent reliability, high degree of responsiveness and the clinical feasibility of the original English version.

Effect of unfractionated heparin on endothelial glycocalyx in a septic shock model

Abstract: Background The constituents of vascular endothelial glycocalyx, such as syndecan-1 and heparan sulphate (HS), can be detected in the plasma of patients and animals with septic shock. However, the dynamics of glycocalyx degradation and its association with inflammation remains largely unknown. In this study, we investigated the association between the biomarkers of acute endothelial glycocalyx degradation and inflammatory factors. We also evaluated the effect of unfractionated heparin (UFH) on glycocalyx shedding in a canine septic shock model. Methods Twenty adult beagle dogs were randomly allocated to one of the following four groups (n = 5): (1) a sham group; (2) a shock group [3.5 × 108 colony-forming unit (cfu) Escherichia coli (E. coli)/kg]; (3) a basic therapy group (sensitive antibiotics and 0.9% saline, 10 ml/kg/h); and (4) a heparin group (40 units/kg/h UFH plus basic therapy). After the onset of septic shock, systemic haemodynamic indices were measured. Endothelial glycocalyx degradation markers (i.e., syndecan-1, HS) and inflammatory factors [i.e., interleukin 6 (IL-6), tumour necrosis factor (TNF)-α], platelet count and activated partial thromboplastin time were measured at various time points. Results A lethal dose of E. coli induced a progressive septic shock model. We observed increased syndecan-1 and HS levels, which correlated with IL-6 and TNF-α in the septic shock model. The glycocalyx shedding was reduced by UFH, which might be regulated by the inhibition of inflammatory factors. Conclusions A therapeutic dose of UFH can protect glycocalyx from shedding by inhibiting inflammation. Additional studies with larger sample sizes are needed to confirm our conclusions.

Prevalence and predictors of persistent post-surgical pain 12 months after thoracotomy

Abstract: Background Persistent post-surgical pain is recognised as a major problem. Prevalence after different surgical procedures has been reported to range from 5% up to 85%. Limb amputation and thoracotomy have the highest reported prevalence. Prediction of persistent post-surgical pain has over the last decade caught attention. Several factors have been investigated, but in-depth knowledge is still scarce. The purpose of this study was to investigate the prevalence of persistent post-surgical pain, and predictive factors for persistent post-surgical pain 12 months after thoracotomy. Methods A prospective longitudinal study was conducted. One-hundred and seventy patients were recruited before scheduled thoracotomy, and asked to answer a questionnaire. One-hundred and six patients completed the same questionnaire at 12-month follow-up. Regression analysis was performed to explore variables assumed predictive of persistent post-surgical pain. Results One-hundred and six patients (62%) filled out the questionnaire at both time points. Preoperative, 34% reported muscle-skeletal related chronic pain. At 12-month follow-up, 50% of the patients reported persistent post-surgical pain. Of the variables explored in the logistic regression model, only preoperative pain (P < 0.001) and dispositional optimism (P = 0.04) were statistically significant. In this study, preoperative pain was a predominant predictor for persistent postoperative pain (OR 6.97, CI 2.40–20.21), while dispositional optimism (OR 0.36, CI 0.14–0.96) seem to have protective properties. Conclusion Our results show that preoperative pain is a predominant predictor of future pain. This implies that patients presenting with a chronic pain condition prior to surgery should be assessed thoroughly preoperatively and have an individually tailored analgesic regimen.

The demise of early goal-directed therapy for severe sepsis and septic shock.

Abstract: A protocol for the quantitative resuscitation of severe sepsis and septic shock known as early goal-directed therapy (EGDT) was published in 2001 Despite serious limitations, this study became widely adopted around the world and formed the basis of the Surviving Sepsis Campaign 6 h resuscitation bundle Subsequently, a large number of observational before-and-after studies were published which demonstrated that EGDT reduced mortality However, during this time period, there has been a substantial reduction in the mortality from sepsis in many Western nations that appears unrelated to EGDT Recently, the Protocolized Care for Early Septic Shock (ProCESS) and The Australasian Resuscitation in Sepsis Evaluation (ARISE) trials failed to demonstrate any outcome benefit from EGDT These two large, multicenter, randomized controlled studies raise serious questions regarding the validity of the original EGDT study and the scientific rigor of the uncontrolled, largely retrospective before-after clinical studies Furthermore, accruing data suggest an association between the amount of fluid administered in the first 72 h and the mortality of patients with severe sepsis Patients in all arms of the ProCESS and ARISE trials received substantial and nearly equivalent amounts of fluid It is proposed that a more conservative fluid strategy and the earlier use of norepinephrine in patients with septic shock may be associated with further improvements in the outcome of patients with sepsis

Optimising abdominal space with deep neuromuscular blockade in gynaecologic laparoscopy – a randomised, blinded crossover study

Abstract: Background Insufflation of the abdomen during laparoscopy improves surgical space, but may cause post-operative shoulder pain. The incidence of shoulder pain is reduced using a lower insufflation pressure, but this may, however, compromise the surgical space. We aimed at investigating whether deep neuromuscular blockade (NMB) would enlarge surgical space, measured as the distance from the sacral promontory to the trocar in patients undergoing gynaecologic laparoscopy. Methods Fourteen patients were randomised in an assessor-blinded crossover design. The distance from the sacral promontory to the trocar was measured during deep NMB and without NMB at pneumoperitoneum 8 and 12 mmHg both. Additionally, we assessed surgical conditions while suturing the abdominal fascia using a 4-point subjective rating scale. Deep NMB was established with rocuronium and reversed with sugammadex. Results At 12 mmHg pneumoperitoneum, deep NMB improved surgical space with a mean of 0.33 cm (95% confidence interval 0.07–0.59) (P = 0.01, paired t-test) compared with no NMB. At 8 mmHg pneumoperitoneum deep NMB improved surgical space with a mean of 0.3 cm (95% confidence interval, 0.06–0.54) (P = 0.005) compared with no NMB. Deep NMB resulted in significantly better ratings of surgical conditions during suturing of the fascia (P = 0.03, Mann–Whitney U-test). Conclusion Deep NMB enlarged surgical space measured as the distance from the sacral promontory to the trocar. The enlargement, however, was minor and the clinical significance is unknown. Moreover, deep NMB improved surgical conditions when suturing the abdominal fascia.

Low Apgar score, neonatal encephalopathy and epidural analgesia during labour: a Swedish registry-based study

Abstract: Background Maternal intrapartum fever (MF) is associated with neonatal sequelae, and women in labour who receive epidural analgesia (EA) are more likely to develop hyperthermia. The aims of this study were to investigate if EA and/or a diagnosis of MF were associated to adverse neonatal outcomes at a population level. Methods Population-based register study with data from the Swedish Birth Register and the Swedish National Patient Register, including all nulliparae (n=294,329) with singleton pregnancies who gave birth at term in Sweden 1999-2008. Neonatal outcomes analysed were Apgar score (AS) Results EA was used in 44% of the deliveries. Low AS or encephalopathy was found in 1.26% and 0.39% of the children in the EA group compared with 0.80% and 0.29% in the control group. In multivariate analysis, EA was associated with increased risk with low AS, AOR 1.27 (95% CI 1.16-1.39), but not with diagnosis of encephalopathy, 1.11 (0.96-1.29). A diagnosis of MF was associated with increased risk for both low AS, 2.27 (1.71-3.02), and of neonatal encephalopathy, 1.97 (1.19-3.26). Conclusion Diagnosis of MF was associated with low AS and neonatal encephalopathy, whereas EA was only associated with low AS and not with neonatal encephalopathy. The found associations might be a result of confounding by indication, which is difficult to assess in a registry-based population study.

Scandinavian clinical practice guideline on mechanical ventilation in adults with the acute respiratory distress syndrome

Abstract: Background The objective of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) task force on mechanical ventilation in adults with the acute respiratory distress syndrome (ARDS) is to formulate treatment recommendations based on available evidence from systematic reviews and randomised trials. Methods This guideline was developed according to standards for trustworthy guidelines through a systematic review of the literature and the use of the Grading of Recommendations Assessment, Development and Evaluation system for assessment of the quality of evidence and for moving from evidence to recommendations in a systematic and transparent process. Results We found evidence of moderately high quality to support a strong recommendation for pressure limitation and small tidal volumes in patients with ARDS. Also, we suggest positive end-expiratory pressure (PEEP) > 5 cm H2O in moderate to severe ARDS and prone ventilation 16/24 h for the first week in moderate to severe ARDS (weak recommendation, low quality evidence). Volume controlled ventilation or pressure control may be equally beneficial or harmful and partial modes of ventilatory support may be used if clinically feasible (weak recommendation, very low quality evidence). We suggest utilising recruitment manoeuvres as a rescue measure in catastrophic hypoxaemia only (weak recommendation, low quality evidence). Based on high-quality evidence, we strongly recommend not to use high-frequency oscillatory ventilation. We could find no relevant data from randomised trials to guide decisions on choice of FiO2 or utilisation of non-invasive ventilation. Conclusion We strongly recommend pressure- and volume limitation and suggest using higher PEEP and prone ventilation in patients with severe respiratory failure.

Transversus abdominis plane block vs. wound infiltration in Caesarean section: a randomised controlled trial

Abstract: Background Multiple studies suggest that transversus abdominis plane (TAP) block (without intrathecal morphine) after Caesarean section (CS) reduces post-operative morphine consumption. In our study, we wanted to compare the analgesic effect of TAP block with infiltration of the wound after CS. Methods We included 60 pregnant women scheduled for elective CS under spinal anaesthesia in a randomised, single-centre, double-blind study. Thirty patients received ultrasound-guided TAP block using 20 ml bupivacaine 0.25% with adrenaline 5 μg/ml bilaterally and 20 ml normal saline as wound infiltration (TAP group). The other 30 patients (the control group) received normal saline 20 ml bilaterally in the TAP, and 20 ml bupivacaine 0.25% with adrenaline 5 μg/ml as wound infiltration. The main outcome was cumulative morphine consumption at 48 h after surgery. In addition, continuous morphine consumption, pain scores and side effects were registered. Results Fifty-seven patients completed the study. Cumulative morphine consumption at 48 h (mean ± standard deviation) was 41 ± 34 mg in the TAP group and 38 ± 27 mg in the control group (P = 0.7); a difference of 3 mg (95% confidence interval −13 to 19 mg). Morphine consumption at any time up to 48 h was virtually identical in both groups. Side effects were similar, except for a higher degree of sedation in the TAP group (P = 0.04). Conclusion Compared with wound infiltration with local anaesthetics, TAP block did not reduce cumulative morphine consumption following CS. The TAP block was associated with more pronounced sedation.

Microcirculatory dysfunction and tissue oxygenation in critical illness.

Abstract: Severe sepsis is defined by organ failure, often of the kidneys, heart, and brain. It has been proposed that inadequate delivery of oxygen, or insufficient extraction of oxygen in tissue, may explain organ failure. Despite adequate maintenance of systemic oxygen delivery in septic patients, their morbidity and mortality remain high. The assumption that tissue oxygenation can be preserved by maintaining its blood supply follows from physiological models that only apply to tissue with uniformly perfused capillaries. In sepsis, the microcirculation is profoundly disturbed, and the blood supply of individual organs may therefore no longer reflect their access to oxygen. We review how capillary flow patterns affect oxygen extraction efficacy in tissue, and how the regulation of tissue blood flow must be adjusted to meet the metabolic needs of the tissue as capillary flows become disturbed as observed in critical illness. Using the brain, heart, and kidney as examples, we discuss whether disturbed capillary flow patterns might explain the apparent mismatch between organ blood flow and organ function in sepsis. Finally, we discuss diagnostic means of detecting capillary flow disturbance in animal models and in critically ill patients, and address therapeutic strategies that might improve tissue oxygenation by modifying capillary flow patterns.

Deep neuromuscular block reduces intra-abdominal pressure requirements during laparoscopic cholecystectomy: a prospective observational study.

Abstract: Background Laparoscopic surgery causes specific post-operative discomfort and intraoperative cardiovascular, pulmonary, and splanchnic changes. The CO2 pneumoperitoneum-related intra-abdominal pressure (IAP) remains one of the main drivers of these changes. We investigated the influence of deep neuromuscular blockade (NMB) on IAP and surgical conditions. Methods This is an open prospective single-subject design study in 20 patients (14 female/6 male) undergoing laparoscopic cholecystectomy. Inclusion criteria were 18 years or older, and American Society of Anesthesiologists classification 1 to 3. Under a standardised anaesthesia, lowest IAP providing adequate surgical conditions was assessed without NMB and with deep NMB [post-tetanic count (PTC) < 2] with rocuronium. The differences between IAP allowing for an adequate surgical field before and after administration of rocuronium were determined, as were effects of patient gender, age, and body mass index. Results Mean IAP without NMB was 12.75 (standard deviation 4.49) mmHg. Immediately after achieving a deep NMB, this was 7.20 (2.51). This pressure difference of 5.55 mmHg (5.08, P < 0.001) dropped to 3.00 mmHg (4.30, P < 0.01) after 15 min. Higher IAP differences were found in women compared with men. A modest inverse relationship was found between pressure difference and age. Conclusions We found an almost 25% lower IAP after a deep NMB compared with no block in laparoscopic cholecystectomy. Younger and female patients appear to benefit more from deep neuromuscular blockade to reduce IAP.

Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials.

Abstract: Background Traumatic rib fractures are a common condition associated with considerable morbidity and mortality. Observational studies have suggested improved outcome in patients receiving continuous epidural analgesia (CEA). The aim of the present systematic review of randomised controlled trials (RCTs) was to assess the benefit and harm of CEA compared with other analgesic interventions in patients with traumatic rib fractures. Methods We performed a systematic review with meta-analysis and trial sequential analysis (TSA). Eligible trials were RCTs comparing CEA with other analgesic interventions in patients with traumatic rib fractures. Cumulative relative risks (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were estimated, and risk of systematic and random errors was assessed. The predefined primary outcome measures were mortality, pneumonia and duration of mechanical ventilation. Results A total of six trials (n = 223) were included; all were judged as having a high risk of bias. In the conventional meta-analyses, there was no statistically significant difference in mortality (RR 2.18, 95% CI 0.21–22.42; P = 0.51; I2 = 0%), duration of mechanical ventilation (MD −7.53, 95% CI −16.32 to 1.26; P = 0.09; I2 = 91%) or pneumonia (RR 0.49, 95% CI 0.19–1.25; P = 0.13; I2 = 0%) between CEA and other analgesic interventions. Subgroup analyses and sensitivity analyses, including TSA confirmed the results. Conclusion The quality and quantity of evidence for the use of CEA in patients with traumatic rib fractures is low, and there is no firm evidence for benefit or harm of CEA compared with other analgesic interventions. Well-powered RCTs with low risk of bias reporting clinically relevant patient-centred outcome measures are needed.

Predictive value of NGAL for use of renal replacement therapy in patients with severe sepsis

Abstract: Background The predictive value of plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) for use of renal replacement therapy (RRT) and acute kidney injury (AKI) is not established in patients with severe sepsis. Methods This was a prospective observational study in three general intensive care units (ICUs) in adult ICU patients with severe sepsis needing fluid resuscitation and a sub-study of the 6S trial. Plasma and urine were sampled at baseline and NGAL was measured using particle-enhanced turbidimetric immunoassay (The NGAL Test). Outcome measures were use of RRT in ICU, development of AKI according to the Kidney Disease: Improving Global Outcomes plasma creatinine criteria within 48 h and 90-day mortality. Results Two-hundred- twenty-two patients had samples taken (211 had plasma and 162 urine sampled); simplified acute physiology score II was 54 (39–66). Forty patients (18%) had RRT in the ICU, 91 patients had AKI at enrolment; of the remaining 131 patients 24% developed AKI during the first 48 h, and 55% had died at 90 days. Areas under receiver-operating characteristics curve (AuROC) for predicting use of RRT in ICU were 0.70 (95% confidence interval 0.61–0.78) and 0.62 (0.51–0.73) for plasma and urine NGAL, respectively. AuROC of plasma and urine NGAL for AKI were 0.66 (0.54–0.77) and 0.71 (0.59–0.82), respectively, and for 90-day mortality 0.55 (0.47–0.63) and 0.61 (0.53–0.70), respectively. Combining NGAL values with plasma creatinine did not improve AuROCs. Conclusion In ICU patients with severe sepsis, plasma and urine NGAL had low predictive power for use of RRT, AKI and 90-day mortality. These results were supported by sensitivity and exploratory analyses.

Intravenous ketamine during spinal and general anaesthesia for caesarean section: systematic review and meta-analysis.

Abstract: Background Intravenous ketamine has been used during general and regional anaesthesia for caesarean section. No systematic review and meta-analysis on the desired effects and adverse effects of ketamine administration during caesarean section have yet been performed. Methods After a systematic literature search a meta-analysis was conducted with the random effects model. Weighted mean difference (WMD) or risk ratio and 95% confidence intervals (CIs) were computed. Results Twelve randomised controlled double-blind trials comprising 953 patients were included: seven studies reported on spinal anaesthesia and five on general anaesthesia. Significant differences in the aforementioned outcome variables were found only in the spinal anaesthesia studies. In the spinal anaesthesia studies the time to the first analgesic request was significantly longer in ketamine-treated women, the WMD was 49.36 min (95% CI 43.31–55.41); visual analogue scale pain scores at rest 2 h after surgery were significantly lower. No differences were observed for maternal nausea, vomiting, pruritus, and psychomimetic effects. Only few data were found for neonatal outcomes. Conclusions We conclude that ketamine enhances post-operative analgesia after caesarean section under spinal anaesthesia. There is a paucity of data for several maternal adverse effects as well as for neonatal well-being. Further studies are needed for general anaesthesia.

Positive end-expiratory pressure titration at bedside using electrical impedance tomography in post-operative cardiac surgery patients.

Abstract: Background Post-operative positive end-expiratory pressure (PEEP) setting to minimize the risk of ventilator-associated lung injury is still controversial. Assessment of regional ventilation distribution by electrical impedance tomography (EIT) might be superior as compared with global parameters. The aim of this prospective observational study was to compare global dynamic compliance (CRS) with different EIT indices during a short clinical applicable descending PEEP trial. Methods Twenty mechanically ventilated patients after elective cardiac surgery received a standard recruitment manoeuvre (RM) following descending PEEP trial in steps of 2 cmH2O from PEEP 14 cmH2O to 6 cmH2O. During baseline and all PEEP steps, CRS was assessed and regional ventilation distribution was measured by means of EIT. The individual ‘best’ PEEP values for the derived EIT indices and CRS were calculated and compared. Results The descending PEEP trial lasted less than 10 min. CRS increased after the RM and showed a maximum value at PEEP 8 cmH2O. Ventilation distribution shifted more to dependent lung regions after RM and back to more non-dependent regions during the PEEP trial. Individual ‘best’ PEEP by CRS showed significantly lower values than ‘best’ PEEP by ventilation distribution measured with EIT indices. Conclusion During a short descending PEEP trial at bedside, EIT is capable of following the status of regional ventilation distribution in ventilated patients. The ‘best’ PEEP value identified by individual maximum CRS was lower than optimal PEEP levels as determined by means of EIT indices. EIT could help setting PEEP in post-operative ventilated patients.

Intraosseous access in neonates and infants: risk of severe complications – a case report

Abstract: Gaining vascular access in a neonate during cardiopulmonary resuscitation is crucial and challenging. Intraosseous (IO) access can offer a fast and reliable method for achieving emergency access for fluids and drugs when venous access fails in a critically ill child. IO access can however result in rare, but serious adverse events including compartment syndrome and amputation. We describe a case resulting in leg amputation due to IO infusion in a neonate after resuscitation and therapeutic hypothermia. We compared 10 tibia X-rays in three age groups. The mean medullary diameter of the proximal tibia at the recommended site for IO access was 7 mm in neonate, 10 mm in 1- to 12-month-old infants, and 12 mm in 3- to 4-year-old children. This provides a narrow margin of safety for the correct positioning and the avoidance of dislodgement of the IO needle. The correct position of the IO needle should be confirmed by bone marrow aspiration and fluid bolus. Unnecessary touching of the IO needle after fixing it in place should be avoided by inserting a luer-lock catheter with a three-way stop-cock for IO drug and fluid administration. Regular observation of the circulation and possible swelling of the leg should be performed. The IO administration of inotropic infusions should also be avoided after the initial resuscitation phase. When treating with therapeutic hypothermia, it may be wise to remove the IO needle much earlier than the currently recommended 24 h because of the problems in peripheral circulation and its monitoring.

Central venous pressure: we need to bring clinical use into physiological context

Abstract: Background The place of central venous pressure (CVP) measurement in acute care has been questioned during the past decade. We reviewed its physiological importance, utility and clinical use among anaesthetists and intensivists. Methods A literature search using the PubMed, Cochrane, Scopus and Web of Science databases was performed in regard to details of the physiology, measurement and interpretation of CVP. A questionnaire was conducted among members of the European Society of Intensive Care Medicine concerning knowledge and uses of CVP. Results Aligning pressure transducers to the phlebostatic axis was handled inadequately. The unsuitability of CVP to assess the intravascular volume state was generally recognised by clinicians. Still, many used CVP to guide volume resuscitation in the absence of a cardiac output monitor, while the literature positioned CVP as a useful haemodynamic variable only in the expanded context of being one determinant of the driving pressure for venous return and hence cardiac output. Conclusion The correct measurement of CVP is pivotal to its proper clinical application. This relates to defining the pressure gradient for venous return and heart efficiency. The clinical appreciation of CVP should be restored by educational efforts of its physiological context.

Veno-venous extracorporeal CO2 removal improves pulmonary hemodynamics in a porcine ARDS model

Abstract: Background Protective lung ventilation is recommended in patients with acute respiratory distress syndrome (ARDS) to minimize additional injuries to the lung. However, hypercapnic acidosis resulting from ventilation at lower tidal volume enhances pulmonary hypertension and might induce right ventricular (RV) failure. We investigated if extracorporeal veno-venous CO2 removal therapy could have beneficial effects on pulmonary circulation and RV function. Methods This study was performed on an experimental model of ARDS obtained in eight anaesthetized pigs connected to a volume-cycled ventilator. A micromanometer-tipped catheter was inserted into the main pulmonary artery and an admittance micromanometer-tipped catheter was inserted into the right ventricle. RV–arterial coupling was derived from RV pressure-volume loops. ARDS was obtained by repeated bronchoalveolar lavage. Protective ventilation was then achieved, and the pigs were connected to a pump-driven extracorporeal membrane oxygenator (PALP, Maquet, Germany) in order to achieve CO2 removal. Results ARDS induced severe hypercapnic acidosis. Systolic pulmonary artery pressure significantly increased from 29.6 ± 1.8 to 43.9 ± 2.0 mmHg (P < 0.001). After the PALP was started, acidosis was corrected and normocarbia was maintained despite protective ventilation. Pulmonary artery pressure significantly decreased to 31.6 ± 3.2 mmHg (P < 0.001) and RV–arterial coupling significantly improved (RV–arterial coupling index = 1.03 ± 0.33 vs. 0.55 ± 0.41, P < 0.05). Conclusion Veno-venous CO2 removal therapy enabled protective ventilation while maintaining normocarbia during ARDS. CO2 removal decreased pulmonary hypertension and improved RV function. This technique may be an effective lung- and RV-protective adjunct to mechanical ventilation.

Measuring resting energy expenditure during extracorporeal membrane oxygenation: preliminary clinical experience with a proposed theoretical model

Abstract: Background Extracorporeal membrane oxygenation (ECMO) is increasingly used in patients with severe respiratory failure. Indirect calorimetry (IC) is a safe and non-invasive method for measuring resting energy expenditure (REE). No data exist on the use of IC in ECMO-treated patients as oxygen uptake and carbon dioxide elimination are divided between mechanical ventilation and the artificial lung. We report our preliminary clinical experience with a theoretical model that derives REE from IC measurements obtained separately on the ventilator and on the artificial lung. Methods A patient undergoing veno-venous ECMO for acute respiratory failure due to bilateral pneumonia was studied. The calorimeter was first connected to the ventilator and oxygen consumption (VO2) and carbon dioxide transport (VCO2) were measured until steady state was reached. Subsequently, the IC was connected to the membrane oxygenator and similar gas analysis was performed. VO2 and VCO2 values at the native and artificial lung were summed and incorporated in the Weir equation to obtain a REEcomposite. Results At the ventilator level, VO2 and VCO2 were 29.5 ml/min and 16 ml/min. VO2 and VCO2 at the artificial lung level were 213 ml/min and 187 ml/min. Based on these values, a REEcomposite of 1703 kcal/day was obtained. The Faisy–Fagon and Harris–Benedict equations calculated a REE of 1373 and 1563 kcal/day. Conclusion We present IC-acquired gas analysis in ECMO patients. We propose to insert individually obtained IC measurements at the native and the artificial lung in the Weir equation for retrieving a measured REEcomposite.

Efficacy and safety of pregabalin for treating painful diabetic peripheral neuropathy: a meta-analysis.

Abstract: Background Pregabalin is considered to be an effective treatment for painful diabetic peripheral neuropathy (DPN), but controversy exists about its efficacy and safety. We performed a meta-analysis to systematically assess the efficacy and safety of pregabalin for managing pain associated with DPN. Methods Medline, EMBASE, and the Cochrane Central Register were searched in July 2014 for randomized, double-blind, placebo-controlled trials published in English on the use of pregabalin to treat DPN-associated pain. Principal outcomes were mean pain score after pregabalin treatment and the proportions of patients showing a pain reduction of at least 50%. Results Nine trials involving a total of 2056 participants were identified. Pooled analysis showed that pregabalin was significantly superior to placebo for improving mean pain scores [mean difference (MD) = −0.79, P < 0.001]. Pregabalin reduced pain below baseline by at least 50% in a significantly greater proportion of patients than placebo did [relative risk = 1.54, P < 0.001]. Patients were more likely to self-report their status as ‘improved’ after taking pregabalin than placebo (relative risk = 1.38, P < 0.001). Pregabalin also improved sleep quality more than placebo (MD = −0.88, P < 0.001). On the other hand, patients receiving pregabalin were more likely to experience mild side effects than were patients receiving placebo. Conclusions Our meta-analysis indicates that pregabalin is more effective than placebo for managing DPN-associated pain and other symptoms that reduce quality of life. The drug is also reasonably well tolerated.

Scandinavian clinical practice guideline on choice of fluid in resuscitation of critically ill patients with acute circulatory failure.

Abstract: BACKGROUND: The task force on Acute Circulatory Failure of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine produced this guideline with recommendations concerning the use of ...

Intra- and postoperative low-dose ketamine for adolescent idiopathic scoliosis surgery: a randomized controlled trial

Abstract: Background In this randomized controlled trial, we examined whether intra- and postoperative infusion of low-dose ketamine decreased postoperative morphine requirement and morphine-related adverse effects as nausea and vomiting after scoliosis surgery. Methods After IRB approval and informed consent, 36 patients, aged 10–19 years, undergoing posterior correction surgery for adolescent idiopathic scoliosis, were randomly allocated into two groups: intra- and postoperative ketamine infusion at a rate of 2 μg/kg/min until 48 h after surgery (ketamine group, n = 17) or infusion of an equal volume of saline (placebo group, n = 19). All patients were administered total intravenous anesthesia with propofol and remifentanil during surgery and intravenous morphine using a patient-controlled analgesia device after surgery. The primary outcome was cumulative morphine consumption in the initial 48 h after surgery. Pain scores (Numerical Rating Scale, NRS, 0–10), sedation scales, incidence of postoperative nausea and vomiting (PONV), and antiemetic consumption were recorded by nurses blinded to the study protocol for 48 h after surgery. Results Patient characteristics did not differ between the two groups. Cumulative morphine consumption for 48 h after surgery was significantly lower in the ketamine group compared to the placebo group (0.89 ± 0.08 mg/kg vs. 1.16 ± 0.07 mg/kg, 95% confidence interval for difference between the means, 0.03–0.48 mg/kg, P = 0.019). NRS pain, sedation scales, and incidence of PONV did not differ between the two groups. Antiemetic consumption was significantly smaller in ketamine group. Conclusions Intra- and postoperative infusion of low-dose ketamine reduced cumulative morphine consumption and antiemetic requirement for 48 h after surgery.