Showing papers in "Acta Anaesthesiologica Scandinavica in 2016"

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

Abstract: Background: The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enha ...

Post-anaesthetic emergence delirium in adults: incidence, predictors and consequences.

Abstract: Background Emergence delirium (ED) after general anaesthesia (GA) is a well-known phenomenon, yet the risk factors are still unclear. The aims of this study were to determine the incidence and independent predictors of ED and secondly to determine to which degree ED has any relevant, clinical consequences to medical staff as well as to patients. Method This prospective, observational cohort study assessed adult patients emerging from GA in the operating room, using the Richmond Agitation–Sedation Scale (RASS). Signs of ED, defined as RASS≥1 along with possible clinical consequences were noted. Patients with ED were re-evaluated in the post-anaesthesia care unit (PACU) and concomitant patient and anaesthesia related factors were noted. Results Among the 1970 patients enrolled, 73 (3.7%) showed signs of ED when emerging from anaesthesia. When reassessed in PACU, the number had declined to 25 patients (1.3%). Male sex, endotracheal tube (ETT) and volatile anaesthetics were found to be significantly related to developing ED after anaesthesia. In 20 cases, additional staff had to be called for and in one case, an i.v. access was accidentally removed. Neither patients nor staff were hurt. Conclusion Male sex, volatile anaesthetics and ETT were factors significantly related to ED. Whether gender, choice of respiratory devices and anaesthetics are true predictors or derived factors of surgery procedures, duration of surgery and the patients’ physical condition need further investigation. The most notable clinical consequence of ED was the need of additional staff in order to restrain the agitated patient.

Gabapentin for post-operative pain management - a systematic review with meta-analyses and trial sequential analyses.

Abstract: Background Perioperative pain treatment often consist of combinations of non-opioid and opioid analgesics, ‘multimodal analgesia’, in which gabapentin is currently used. The aim was to document beneficial and harmful effects of perioperative gabapentin treatment. Methods Randomized clinical trials comparing gabapentin vs. placebo or active placebo in adult surgical patients receiving gabapentin perioperatively were included. This review was conducted using Cochrane standards, trial sequential analysis (TSA), and Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The primary outcomes were 24-h opioid consumption and incidence of serious adverse events (SAE). Results One hundred and thirty-two trials with 9498 patients were included. Thirteen trials with low risk of bias reported a reduction in 24-h opioid consumption of 3.1 mg [0.5, 5.6; TSA-adjusted CI: −0.2, 6.3]. In the analysis of gabapentin as add-on analgesic to another non-opioid analgesic regimen, a mean reduction in 24-h morphine consumption of 1.2 mg [−0.3, 2.6; TSA-adjusted CI: −0.4, 2.8] in trials with low risk of bias was found. Nine trials with low risk of bias reported a risk ratio of SAEs of 1.61 [0.91; 2.86; TSA-adjusted CI: 0.57, 4.57]. Conclusion Based on GRADE assessment of the primary outcomes in trials with low risk of bias, the results are low or very low quality of evidence due to imprecision, inconsistency, and in some outcomes indirectness. Firm evidence for use of gabapentin is lacking as clinically relevant beneficial effect of gabapentin may be absent and harm is imminent, especially when added to multimodal analgesia.

Post-operative cognitive dysfunction at 3 months in adults after non-cardiac surgery: a qualitative systematic review.

Abstract: Background Post-operative cognitive dysfunction is defined as a decline in cognitive functions that occurs after surgery, but different diagnostic criteria and incidences have been reported in medical literature. Our aim was to determine incidence of post-operative cognitive dysfunction 3 months after non-cardiac surgery in adults. Methods A systematic review of available evidence was performed by PRISMA guidelines. A search was done in May–July 2015 on PubMed, EMBASE, CINAHL, LILACS, Scielo, Clinical Trials, and Grey Literature Reports. Inclusion criteria were prospective design studies with patients over 18 years old, surgery under general or regional anesthesia, follow-up for 3 months, and use of a neurocognitive battery for diagnosis. We excluded studies made on cardiac or brain surgery patients. Risk of bias was assessed using tools from National Heart Lung and Blood Institute. Results We selected 24 studies. Average age was 68 years. Only five studies reported incidence of cognitive decline for a non-surgical control group. Median number of tests used was 5 (range 3–13). Pooled incidence of post-operative cognitive dysfunction at 3 months was 11.7% [95% CI 10.9–12.5] but with several methodological differences between studies. Increasing age was the most consistent risk factor identified (seven studies). Conclusions Post-operative cognitive dysfunction in patients is frequent, especially in patients over 60 years old. Limitations include methodological differences in studies. Efforts must be made to reach a consensus in definition and diagnosis for future research.

Prevalence and determinants of medication non-adherence in chronic pain patients: a systematic review.

Abstract: Background Chronic pain is commonly treated with analgesic medication. Non-adherence to prescribed pain medication is very common and may result in sub-optimal treatment outcome. The aim of this review was to investigate the prevalence of medication non-adherence and to present determinants that may help identify patients at risk for non-adherence to analgesic medication. Methods A search was performed in PubMed and Embase with systematic approach including PRISMA recommendations. Individual risk of bias was assessed and systematic data extraction was performed. Results Twenty-five studies were included. Non-adherence rates to pain prescriptions ranged from 8% to 62% with a weighted mean of 40%. Underuse of pain medication was more common than overuse in most studies. Factors that were commonly positively associated with non-adherence were dosing frequency, polymedication, pain intensity, and concerns about pain medication. Factors negatively associated with non-adherence were age, again pain intensity and quality of the patient–caregiver relationship. Underuse was positively associated with active coping strategies and self-medication, and negatively associated with perceived need for analgesic medication. Overuse was positively associated with perceived need, pain intensity, opioid use, number of prescribed analgesics, a history of drug abuse, and smoking. Conclusion Non-adherence to analgesic medication use is very common in the chronic pain population. The choice for pharmacological therapy should not only be based upon pain diagnosis but should also take the risks of non-adherence into account. The value of adherence monitoring or adherence enhancing interventions has to be investigated in future studies.

Chronic pre-operative opioid use and acute pain after fast-track total knee arthroplasty.

Abstract: Background:Pre-operative opioid use has been suggested to increase post-operative pain and opioid consumption after total knee arthroplasty (TKA), but previous studies are either retrospective or inhomogeneous with regard to surgical procedures or control of analgesic regimes, or with few opioid-tre

Scandinavian SSAI clinical practice guideline on pre-hospital airway management

Abstract: Background: The Scandinavian society of anaesthesiology and intensive care medicine task force on pre-hospital airway management was asked to formulate recommendations following standards for trustworthy clinical practice guidelines. Methods: The literature was systematically reviewed and the grading of recommendations assessment, development and evaluation (GRADE) system was applied to move from evidence to recommendations. Results: We recommend that all emergency medical service (EMS) providers consider to: apply basic airway manoeuvres and airway adjuncts (good practice recommendation); turn unconscious non-trauma patients into the recovery position when advanced airway management is unavailable (good practice recommendation); turn unconscious trauma patients to the lateral trauma position while maintaining spinal alignment when advanced airway management is unavailable [strong recommendation, low quality of evidence (QoE)]. We suggest that intermediately trained providers use a supraglottic airway device (SAD) or basic airway manoeuvres on patients in cardiac arrest (weak recommendation, low QoE). We recommend that advanced trained providers consider using an SAD in selected indications or as a rescue device after failed endotracheal intubation (ETI) (good practice recommendation). We recommend that ETI should only be performed by advanced trained providers (strong recommendation, low QoE). We suggest that videolaryngoscopy is considered for ETI when direct laryngoscopy fails or is expected to be difficult (weak recommendation, low QoE). We suggest that advanced trained providers apply cricothyroidotomy in 'cannot intubate, cannot ventilate' situations (weak recommendation, low QoE). Conclusion: This guideline for pre-hospital airway management includes a combination of techniques applied in a stepwise fashion appropriate to patient clinical status and provider training.

Nationwide incidence of serious complications of epidural analgesia in the United States.

Abstract: Background This study aimed to describe the incidence and risk factors of in-hospital spinal hematoma and abscess associated with epidural analgesia in adult obstetric and non-obstetric populations in the United States. Methods The Nationwide Inpatient Sample was analyzed to identify patients receiving epidural analgesia from 1998 to 2010. Primary outcomes were incidence of spinal hematoma and epidural abscess. Use of decompressive laminectomy was also investigated. Regression analyses were conducted to assess predictors of epidural analgesia complications. Differences in mortality and disposition of patients at discharge were compared in patients with and without neuraxial complications. Obstetric and non-obstetric patients were studied separately. Results A total of 3,703,755 epidural analgesia procedures (2,320,950 obstetric and 1,382,805 non-obstetric) were identified. In obstetric patients, the incidence of spinal hematoma was 0.6 per 100,000 epidural catheterizations (95% CI, 0.3 to 1.0 × 10−5). The incidence of epidural abscess was zero. In non-obstetric patients, the incidence of spinal hematoma and epidural abscess were, respectively, 18.5 per 100,000 (95% CI, 16.3 to 20.9 × 10−5) and 7.2 per 100,000 (95% CI, 5.8 to 8.7 × 10−5) catheterizations. Predictors of spinal hematoma included type of surgical procedure (higher in vascular surgery), teaching status of hospital, and comorbidity score. Patients with spinal complications had higher in-hospital mortality (12.2% vs. 1.1%, P < 0.0001) and were significantly less likely to be discharged to home. Conclusions This large nationwide data analysis reveals that the incidence of epidural analgesia-related complications is very low in obstetric population epidural analgesia and much higher in patients having vascular surgery.

Comparing efficacy and safety of fibrinogen concentrate to cryoprecipitate in bleeding patients: a systematic review.

Abstract: Background Bleeding is associated with the depletion of fibrinogen, thus increasing the risk of coagulopathy, further bleeding and transfusion requirements. Both fibrinogen concentrate and cryoprecipitate replenish low plasma fibrinogen levels. This systematic review aims to identify and evaluate evidence of efficacy and safety of fibrinogen concentrate and cryoprecipitate in bleeding patients. Method Cochrane Central Register of Controlled Trials (CENTRAL), Medline, EMBASE up to 2nd of March 2015 were among the electronic search strategies of randomized controlled trials and non-randomized studies with meta-analysis employed. Studies for inclusion required bleeding patients being treated with either fibrinogen concentrate or cryoprecipitate. Mortality was the primary endpoint. Secondary outcomes included bleeding, coagulopathy, transfusion requirements and clinical complications related to the intervention. PRISMA methodology, a data-extraction form and the Cochrane risk of bias tool were all employed. Results Four studies were eligible for inclusion in this systematic review; one randomized controlled trial (RCT) consisting of 66 patients and three observational studies involving 218 patients in total. No mortality was reported in the published papers. There were no differences in fibrinogen-level increase, bleeding, RBC transfusions or thromboembolic complications. The RCT showed a possible increased functional improvement of haemostasis after cryoprecipitate therapy compared to fibrinogen concentrate. Conclusion The available evidence directly comparing fibrinogen concentrate to cryoprecipitate is sparse and with high risk of bias. Recommendation of one product over the other for fibrinogen substitution in the bleeding patient with acquired hypofibrinogenaemia is currently not possible. Future research should guide us towards evidence-based decisions of product superiority.

Chronic non-cancer pain and the epidemic prescription of opioids in the Danish population: trends from 2000 to 2013.

Abstract: Background Chronic pain has serious consequences for individuals and society. In addition, opioid prescription for chronic non-cancer pain (CNCP) has become more frequent. This study aims to examine the trends regarding the prevalence of CNCP, dispensed opioids, and concurrent use of benzodiazepine (BZD)/BZD-related drugs in the Danish population. Methods Data from the cross-sectional national representative Danish Health and Morbidity Surveys (2000, 2005, 2010, and 2013) were combined with The Danish National Prescription Registry at an individual level. The study populations varied between 5000 and 13,000 individuals ≥16 years (response rates: 51–63%). Respondents completed a self-administered questionnaire, which included the analyzed items on identification of chronic pain (≥6 months). Results From 2000 to 2013, the prevalence of CNCP increased and subsequently the annual prevalence of opioid use from 4.1% to 5.7% among CNCP individuals. Higher CNCP prevalence was related to female gender, no cohabitation partner, short education, non-Western origin, and overweight/obesity. In addition, women with CNCP, especially >65 years, became more frequent users of opioids and used higher doses than men. Concurrent use of BZD/BZD-related drugs decreased (13%) from 2010 to 2013, still one-third of long-term opioid user were co-medicated with these drugs. Conclusions The use of opioids has increased in Denmark, especially among elderly women. The concurrent use of BZD/BZD-related drugs has decreased from 2010 to 2013, but still one-third of long-term opioid users were co-medicated.

Persistent postsurgical pain after video‐assisted thoracic surgery – an observational study

Abstract: Background The risk of persistent postsurgical pain (PPP) and subsequent pain-related functional impairment may potentially be reduced by video-assisted thoracic surgery (VATS) compared to thoracotomy. The aim of the study was therefore to assess in detail the incidence and consequences on activities of daily living of PPP after VATS. Methods Using a prospective observational design, 47 patients undergoing VATS completed both preoperative, early postoperative and 3 months follow-up. Preoperative pain, pain characteristics, psychological factors, pain-related functional impairment and quantitative sensory testing (QST) including nociceptive thresholds were compared with postoperative data. Results Only five (11%) patients developed PPP with NRS > 3 originating from the surgical area. However, about 30% of patients still reported some pain-related functional impairment from the surgical area within four well-defined domains of everyday activities. Psychological and sensory thermal tests did not predict persistent postoperative pain, except preoperative pin-prick sensitivity was higher in patients with PPP. Postoperative pain 7 days after surgery was significantly higher in PPP patients. Preoperative pain originating from remote areas did not predict PPP. Conclusion The incidence of PPP, nerve damage (based on QST) and pain-related functional impairment following VATS was lower than reported following thoracotomy. No psychological or other factors predicted PPP. These findings call for further large-scale studies to support VATS to decrease PPP.

Helicopter-based emergency medical services for a sparsely populated region: A study of 42,500 dispatches

Abstract: Background The Helicopter Emergency Medical Service (HEMS) in Norway is operated day and night, despite challenging geography and weather. In Western Norway, three ambulance helicopters, with a rapid response car as an alternative, cover close to 1 million inhabitants in an area of 45,000 km2. Our objective was to assess patterns of emergency medical problems and treatments in HEMS in a geographically large, but sparsely populated region. Methods Data from all HEMS dispatches during 2004–2013 were assessed retrospectively. Information was analyzed with respect to patient treatment and characteristics, in addition to variations in services use during the day, week, and seasons. Results A total of 42,456 dispatches were analyzed. One third of the patients encountered were severely ill or injured, and two thirds of these received advanced treatment. Median activation time and on-scene time in primary helicopter missions were 5 and 11 min, respectively. Most patients (95%) were reached within 45 min by helicopter or rapid response car. Patterns of use did not change. More than one third of all dispatches were declined or aborted, mostly due to no longer medical indication, bad weather conditions, or competing missions. Conclusion One third of the patients encountered were severely ill or injured, and more than two thirds of these received advanced treatment. HEMS use did not change over the 10-year period, however HEMS use peaked during daytime, weekends, and the summer. More than one third of all dispatches were declined or aborted.

Association of plasma chloride values with acute kidney injury in the critically ill - a prospective observational study.

Abstract: Background Chloride-rich fluids have been found to associate with an increased risk for acute kidney injury (AKI) among intensive care unit (ICU) patients. Studies evaluating the association of plasma chloride (Cl) with the development of AKI are few. We hypothesized that higher plasma Cl is associated with an increased risk for the development of AKI. Methods In this sub-study of the prospective FINNAKI study, we analyzed Cl values measured during ICU stay in two ICUs at a tertiary center including 445 patients. We calculated time-weighted mean values within the first 24 h in ICU for plasma Cl (ClTWM 24). We analyzed the association of ClTWM 24 primarily with the development of AKI, and secondarily with 90-day mortality. Results Based on the first measured Cl value, 350 of 445 patients [78.7 (95 CI, 74.8–82.5)] had hyperchloremia (P-Cl > 106 mmol/l) and 48 [10.8 (95 CI, 7.9–13.7)] severe hyperchloremia (P-Cl > 114 mmol/l). Altogether 217 of 445 [48.8% (95% CI 44.2–53.4%)] patients developed AKI. Of these 217, AKI was diagnosed in 62 (28.6%) after 24 h from ICU admission and were included in the analysis regarding development of AKI. ClTWM 24 was associated with an increased risk for the development of AKI (OR1.099; 1.003–1.205) after multivariable adjustments. According to ClTWM 24, no difference in 90-day mortality between severely hyperchloremic patients and others existed. Conclusions More than three of four critically ill patients had hyperchloremia and 1 of 10 had its severe form. Higher time-weighted mean chloride was independently associated with an increased risk for AKI.

Scandinavian clinical practice guideline on fluid and drug therapy in adults with acute respiratory distress syndrome

Abstract: Background The objective of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) task force on fluid and drug therapy in adults with acute respiratory distress syndrome (ARDS) was to provide clinically relevant, evidence-based treatment recommendations according to standards for trustworthy guidelines. Methods The guideline was developed according to standards for trustworthy guidelines, including a systematic review of the literature and use of the GRADE methodology for assessment of the quality of evidence and for moving from evidence to recommendations. Results A total of seven ARDS interventions were assessed. We suggest fluid restriction in patients with ARDS (weak recommendation, moderate quality evidence). Also, we suggest early use of neuromuscular blocking agents (NMBAs) in patients with severe ARDS (weak recommendation, moderate quality evidence). We recommend against the routine use of other drugs, including corticosteroids, beta2 agonists, statins, and inhaled nitric oxide (iNO) or prostanoids in adults with ARDS (strong recommendations: low- to high-quality evidence). These recommendations do not preclude the use of any drug or combination of drugs targeting underlying or co-existing disorders. Conclusion This guideline emphasizes the paucity of evidence of benefit – and potential for harm – of common interventions in adults with ARDS and highlights the need for prudence when considering use of non-licensed interventions in this patient population.

Scandinavian SSAI clinical practice guideline on choice of first-line vasopressor for patients with acute circulatory failure.

Abstract: BACKGROUND: Adult critically ill patients often suffer from acute circulatory failure, necessitating use of vasopressor therapy. The aim of the Scandinavian Society of Anaesthesiology and Intensive ...

Is deep neuromuscular block beneficial in laparoscopic surgery? No, probably not.

Abstract: Background There is currently a controversy regarding the need for and clinical benefit of maintaining deep neuromuscular block (post-tetanic counts of 1 or 2) vs. moderate block (train-of-four counts of 1–3) for routine laparoscopic surgery. Two recent review articles on this subject arrived at rather different conclusions. This manuscript is part of Pro/Con debate from the authors of these two reviews. Methods The authors of the Pro and Con sides of the debate had the opportunity to read each other manuscripts and worked from the same basic database of references. Results The present authors could find only one peer-reviewed paper which presented objective evidence supporting the proposition that deep neuromuscular block provides superior operating conditions for the surgeon during laparoscopic surgery. Conclusion There is not enough good evidence available to justify the routine use of deep neuromuscular block for laparoscopic surgery and the associated expense of high-dose sugammadex.

Cerebral microemboli detected by transcranial doppler in patients treated with extracorporeal membrane oxygenation.

Abstract: Introduction Cerebrovascular complications rate in patients treated with extracorporeal membrane oxygenation (ECMO) is about 7%. Ischemic stroke may be caused by solid or gaseous microemboli due to thrombosis within the circuit or cannula. Transcranial Doppler (TCD) is the only method able to detect microembolic signals (MES) in real time. The objective of this study was to detect possible MES by TCD in patients treated with veno-venous (VV) and veno-arterial (VA) ECMO and to test for a relation between the number of MES and the 6-month clinical outcome of these patients. Methods This is a monocentric observational prospective study in patients consecutively admitted and treated with ECMO at our regional ECMO referral center in 18 months. TCD detection of MES was performed in patients upon initiation of treatment and then repeated during treatment. Results Two hundred and forty-eight TCD monitoring were performed in 42 VV and 11 VA ECMO patients. MES were detected in 26.2% of VV ECMO patients and in 81.8% of VA ECMO patients (P < 0.001). In both subgroups of patients, no correlation was found between MES detection and extracorporeal flow velocities or aPTT values. In VA ECMO patients, an inverse correlation between left ventricular ejection fraction and MES grading was found (P = 0.037). In both groups, no clinical neurological impairments correlated to MES detection were found at 6 months follow-up. Conclusions MES were found in both ECMO configurations; independently from their pathophysiology, MES do not seem to influence clinical outcome. Multicenter studies are still required with more extensive cases to confirm these results.

Sleep and delirium in unsedated patients in the intensive care unit

Abstract: Background Sleep deprivation and delirium are major problems in the ICU. We aimed to assess the sleep quality by polysomnography (PSG) in relation to delirium in mechanically ventilated non-sedated ICU patients. Methods Interpretation of 24-h PSG and clinical sleep assessment in 14 patients. Delirium assessment was done using the confusion assessment method for the intensive care unit (CAM-ICU). Results Of four patients who were delirium free, only one had identifiable sleep on PSG. Sleep was disrupted with loss of circadian rhythm, and diminished REM sleep. In the remaining three patients the PSGs were atypical, meaning that no sleep signs were found, and sleep could not be quantified from the PSGs. Clinical total sleep time (ClinTST) ranged from 2.0–13.1 h in patients without delirium. Six patients with delirium all had atypical PSGs, so sleep could not be quantified. Short periods of REM sleep were found. ClinTST was median 8.5 h (range 0.4–13.8 h). EEG reactivity and wakefulness was found in all but one PSG. Four patients were CAM-ICU “unassessable” (unresponsive to voice). PSGs were atypical without reactivity or wakefulness, even though clinical wakefulness was documented. ClinTST was median 18.3 h (range 3.7–19.8 h). Paroxystic EEG activity was found in this subgroup. Conclusions The objective signs of sleep were absent in all but one PSG, so even though patients were not sedated, sleep could not be quantified. Even in patients without delirium, sleep could only be quantified in one of four patients. Paroxystic activity is frequent in unsedated patients, unresponsive to voice, but the implication is unknown.

5-MeO-DALT; a novel designer drug on the market causing acute delirium and rhabdomyolysis

Abstract: Emergence of new psychoactive substances (NPSs) in recent years throughout the western world has caused a variety of clinical scenarios and deaths due to acute intoxications. A hallucinogenic drug, called 5-MeO-DALT (5-methoxyN,N-diallyltryptamine), has been reported in recent years in both the United States and Europe. Little is known about this substance, as is the case in general concerning this ever increasing group of substances referred to as “designer drugs”. As such, providing relevant and optimal care in an acute setting can be challenging. We present a case report in which a patient had ingested an unknown amount of the drug 5-MeO-DALT, and propose a strategy by which intoxication with the substance can be managed. A 34-year-old man with no prior medical history was brought to the emergency department by emergency medical services personnel. Details of the circumstances prior to admittance were provided by two of his peers. After having orally ingested an unknown amount of 5-MeODALT along with alcohol, the patient had been lying on the floor for several hours, shouting and exhibiting aggressive behaviour. This was followed by a period of unresponsiveness which prompted the call for an ambulance. Upon arrival at the emergency department (ED) it was clear that the patient was in an altered state of consciousness. Objective findings were as follows: tachypnea (respiratory frequency of 60) and corresponding signs of hyperventilation on arterial blood gas (ABG); tachycardia (180 beats per minute); blood pressure within normal range; GCS 12; pupils dilated with absent light reflex; temperature elevated to 38.5°C. Initial arterial blood gas showed profound lactic

Phrenic palsy and analgesic quality of continuous supraclavicular vs. interscalene plexus blocks after shoulder surgery.

Abstract: Background Hemidiaphragmatic palsy is a common consequence of the interscalene brachial plexus block. It occurs less commonly with the supraclavicular approach. Register data suggest that the analgesic quality of a supraclavicular blockade is sufficient for arthroscopic shoulder surgery, although data on the post-operative analgesic effect are lacking. Methods After approval by the ethics committee, patients having arthroscopic shoulder surgery under general anaesthesia were randomized to receive a continuous interscalene or supraclavicular blockade. Phrenic nerve function was evaluated through ultrasound examination of the diaphragm in combination with spirometry. Pain scores at rest and activity etc. were determined before catheter insertion, during observation in the post- anaesthesia care unit (PACU) and on post-operative day 1 (POD1). The initial application of 10 ml of ropivacaine 0.2% was followed by continuous application of 4 ml of ropivacaine 0.2%, plus a patient controlled analgesia (PCA) bolus of 4 ml/h. Results One hundred and twenty patients were randomized, of which 114 data sets were analysed. Complete hemidiaphragmatic paresis occurred in 43% of the interscalene group vs. 24% in the supraclavicular group during PACU stay. Rates of dyspnoea and hoarseness were similar. Horner's syndrome occurred in 21% of the interscalene but only 3% of the supraclavicular group on POD1. Pain scores were comparable for pain at rest and during stress at each time point. Conclusions This trial showed a significantly greater incidence of phrenic nerve palsy of the interscalene group in PACU, but not on POD1. Post-operative analgesic quality was similar in both groups. Continuous supraclavicular blockade is a suitable alternative to the continuous interscalene technique.

Distribution of crystalloid fluid changes with the rate of infusion: a population-based study.

Abstract: Background Crystalloid fluid requires 30 min for complete distribution throughout the extracellular fluid space and tends to cause long-standing peripheral edema. A kinetic analysis of the distribution of Ringer′s acetate with increasing infusion rates was performed to obtain a better understanding of these characteristics of crystalloids. Methods Data were retrieved from six studies in which 76 volunteers and preoperative patients had received between 300 ml and 2375 ml of Ringer's acetate solution at a rate of 20–80 ml/min (0.33–0.83 ml/min/kg). Serial measurements of the blood hemoglobin concentration were used as inputs in a kinetic analysis based on a two-volume model with micro-constants, using software for nonlinear mixed effects. Results The micro-constants describing distribution (k12) and elimination (k10) were unchanged when the rate of infusion increased, with half-times of 16 and 26 min, respectively. In contrast, the micro-constant describing how rapidly the already distributed fluid left the peripheral space (k21) decreased by 90% when the fluid was infused more rapidly, corresponding to an increase in the half-time from 3 to 30 min. The central volume of distribution (Vc) doubled. Conclusion The return of Ringer′s acetate from the peripheral fluid compartment to the plasma was slower with high than with low infusion rates. Edema is a normal consequence of plasma volume expansion with this fluid, even in healthy volunteers. The results are consistent with the view that the viscoelastic properties of the interstitial matrix are responsible for the distribution and redistribution characteristics of crystalloid fluid.

Impact of socioeconomic status on mortality and unplanned readmission in septic intensive care unit patients

Abstract: Background Little is known about the potential association between socioeconomic status (SES) and prognosis after sepsis. We analysed how SES impacted mortality and readmission in septic patients treated at the intensive care unit (ICU) of a university hospital. Methods We performed a cohort study including all adult patients admitted to a general tertiary ICU with severe sepsis or septic shock during 2008–2010. Data on SES (educational level, personal income, and cohabitation), comorbidity, readmissions, and mortality were obtained from public registries. We used Cox regression analysis to examine the impact of SES on 30- and 180-day mortality and on first unplanned readmission within 180 days after hospital discharge. Results A total of 387 patients were included of whom 111 (29%) died within 30 days after ICU admission, and 55 (20%) died within 180 days after hospital discharge. Adjusted for sex, comorbidity and SAPS II, patients with low income had a substantially greater risk of dying within 30 days of admission compared to those with high income (35.7% vs. 23.3%; adjusted hazard ratio (HR) 1.99; 95% confidence interval (CI) 1.24–3.21), and tended to show higher 180-day mortality (25.0% vs. 15.5%; adjusted HR 1.72; 95% CI 0.86–3.45). Among patients discharged from hospital, 125 (45%) were readmitted within 180 days. Patients with low education and low income showed a tendency towards early readmission. Conclusions Among septic ICU patients, low income was significantly associated with increased 30-day mortality. There was a trend towards earlier readmission among surviving patients with low educational level and personal income.

Aminocaproic acid administration is associated with reduced perioperative blood loss and transfusion in pediatric craniofacial surgery

Abstract: Background Severe blood loss is a common complication of craniofacial reconstruction surgery. The antifibrinolytic e-aminocaproic acid (EACA) reduces transfusion requirements in children undergoing cardiac surgery and in older children undergoing spine surgery. Tranexamic acid (TXA), another antifibrinolytic with a similar mechanism of action, has been shown to reduce blood loss and transfusion requirements in children undergoing craniofacial surgery. However, TXA has been associated with an increase in post-operative seizures and is more expensive than EACA. There is currently little published data evaluating the efficacy of EACA in children undergoing craniofacial surgery. Methods This is a retrospective study of prospectively collected data from our craniofacial perioperative registries for children under 6 years of age who underwent anterior or posterior cranial vault reconstruction. We compared calculated blood loss, blood donor exposures, and post-operative drain output between subjects who received EACA and those who did not. Results The registry queries returned data from 152 subjects. Eighty-six did not receive EACA and 66 received EACA. The EACA group had significantly lower calculated blood loss (82 ± 43 vs. 106 ± 63 ml/kg, P = 0.01), fewer intraoperative blood donor exposures (median 2, interquartile range 1-2 vs. median 2, interquartile range 1-3; P = 0.02) and lower surgical drain output in the first post-operative 24 h (28 ml/kg vs. 37 ml/kg, P = 0.001) than the non-EACA group. Conclusion In this analysis of prospectively captured observational data, EACA administration was associated with less calculated blood loss, intraoperative blood donor exposures, and post-operative surgical drain output.

Teaching ultrasound‐guided regional anesthesia remotely: a feasibility study

Abstract: Background Ultrasound-guided regional anesthesia (UGRA) requires acquisition of new skills. Learning requires one-on-one teaching, and can be limited by time and mentor availability. We investigate whether the skills required for UGRA can be developed and subsequently assessed remotely using a novel online teaching platform. This platform was developed at the University of Toronto to teach laparoscopic surgery remotely and has been termed Telesimulation. Methods Anesthesia Site Chiefs at 10 hospitals across Ontario were sent a letter inviting their anesthesia teams to participate in an UGRA remote training program. Four to five anesthetists from each site were recruited from the first four hospitals expressing interest. Simulation models and ultrasound machines were set up at each location and connected via Skype™ and web cameras with the Telesimulation center at our hospital. Training consisted of four online sessions and one offline lecture in order to teach an ultrasound-guided supraclavicular block. Participants were evaluated before and after training by on-site and off-site assessors using a validated Checklist and Global Rating Scale (GRS). Results Nineteen staff anesthetists were recruited. Post-training scores were significantly higher across both assessment tools, on-site (P < 0.001) and off-site training locations (P = 0.003). The inter-rater reliability between on-site and remote training site ratings was good for the Checklist (ICC = 0.672, 95% CI: 0.369–0.830) and excellent for the GRS (ICC = 0.847, 95% CI: 0.706–0.921). Conclusion This study demonstrates that UGRA can be taught remotely. Future research will focus on comparing this method to on-site teaching and its application in resource-restricted countries.

Is deep neuromuscular blockade beneficial in laparoscopic surgery? Yes, probably

Abstract: Background Deep neuromuscular blockade during laparoscopic surgery may provide some clinical benefit. We present the ‘Pro-’ argument in this paired position paper. Methods We reviewed recent evidence from a basic database of references which we agreed on with the ‘Con-’ side, and present this in narrative form. We have shared our analysis and text with the authors of the ‘Con-’ side of these paired position papers during the preparation of the manuscripts. Results There are a few low risk of bias studies indicating that use of deep neuromuscular blockade improve surgical conditions and improve patient outcomes such as post-operative pain in laparoscopic surgery. Conclusion Our interpretation of recent findings is that there is reason to believe that there may be some patient benefit of deep neuromuscular blockade in this context, and more detailed study is needed.

No convincing association between post-operative delirium and post-operative cognitive dysfunction: a secondary analysis.

Abstract: Background Post-operative delirium and post-operative cognitive dysfunction (POCD) are both common but it has not been clarified how closely they are associated. We aimed to assess the possible relationship in a secondary analysis of data from the ‘Surgery Depth of anaesthesia and Cognitive outcome’- study. Methods We included patients aged ≥ 60 years undergoing non-cardiac surgery planned for longer than 60 min. Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders IV criteria in the post-anaesthesia care unit (PACU) as well as within the first week after surgery. Cognitive function was assessed with a neuropsychological test battery. Multivariable analysis of POCD was performed with consideration of predisposing and precipitating factors. Results Of 1277 randomized patients, 850 (66.6%) had complete data. Delirium was found in 270 patients (32.9% of 850). We detected POCD in 162 (20.9% of 776) at 1 week and in 52 (9.4% of 553) at 3 months. In multivariable analysis (n = 808), delirium had no overall effect on POCD (P = 0.30). Patients with no delirium in PACU but with postoperative delirium within 7 days had an increased risk of POCD at 3 months (OR = 2.56 (95%-confidence interval: 1.07–6.16), P = 0.035). No significant association was found for the other subgroups. Conclusions There is no clear evidence that postoperative delirium is independently associated with POCD up to 3 months.

Respiratory rates measured by a standardised clinical approach, ward staff, and a wireless device.

Abstract: Background Respiratory rate is among the first vital signs to change in deteriorating patients. The aim was to investigate the agreement between respiratory rate measurements by three different methods. Methods This prospective observational study included acutely admitted adult patients in a medical ward. Respiratory rate was measured by three methods: a standardised approach over 60 s while patients lay still and refrained from talking, by ward staff and by a wireless electronic patch (SensiumVitals). The Bland-Altman method was used to compare measurements and three breaths per minute (BPM) was considered a clinically relevant difference. Results We included 50 patients. The mean difference between the standardised approach and the electronic measurement was 0.3 (95% CI: −1.4 to 2.0) BPM; 95% limits of agreement were −11.5 (95% CI: −14.5 to −8.6) and 12.1 (95% CI: 9.2 to 15.1) BPM. Removal of three outliers with huge differences lead to a mean difference of −0.1 (95% CI: −0.7 to 0.5) BPM and 95% limits of agreement of −4.2 (95% CI: −5.3 to −3.2) BPM and 4.0 (95% CI: 2.9 to 5.0) BPM. The mean difference between staff and electronic measurements was 1.7 (95% CI: −0.5 to 3.9) BPM; 95% limits of agreement were −13.3 (95% CI: −17.2 to −9.5) BPM and 16.8 (95% CI: 13.0 to 20.6) BPM. Conclusion A concerning lack of agreement was found between a wireless monitoring system and a standardised clinical approach. Ward staff's measurements also seemed to be inaccurate.

Fatal injuries in rural and urban areas in northern Finland: a 5‐year retrospective study

Abstract: The following article: Raatiniemi L, Steinvik T, Liisanantti J, Ohtonen P, Martikainen M, Alahuhta S, Dehli T, Wisborg T, Bakke HK. Fatal injuries in rural and urban areas in northern Finland: a 5-year retrospective study. Acta Anaesthesiologica Scandinavica 2016 has been published at http://dx.doi.org/10.1111/aas.12682

Exploring the relationship between anaesthesiologists' non-technical and technical skills.

Abstract: Background A combination of non-technical skills (NTS) and technical skills (TS) is crucial for anaesthetic patient management. However, a deeper understanding of the relationship between these two skills remains to be explored. We investigated the characteristics of trainee anaesthesiologists’ NTS and TS in a simulated unexpected difficult airway management scenario. Methods A mixed-method approach was used to explore the relationship between NTS and TS in 25 videos of 2nd year trainee anaesthesiologists managing a simulated difficult airway scenario. The videos were assessed using the customised version of the Anaesthetists’ Non-Technical Skills System, ANTSdk, and an adapted TS checklist for calculating the correlation between NTS and TS. Written descriptions of the observed NTS were analysed using directed content analysis. Results The correlation between the NTS and the TS ratings was 0.106 (two-tailed significance of 0.613). Inter-rater reliability was substantial. Themes characterising good NTS included a systematic approach, planning and communicating decisions as well as responding to the evolving situation. A list of desirable, concrete NTS for the specific airway management situation was generated. Conclusion This study illustrates that anaesthesiologist trainees’ NTS and TS were not correlated in this setting, but rather intertwined and how the interplay of NTS and TS can impact patient management. Themes describing the characteristics of NTS and a list of desirable, concrete NTS were developed to aid the understanding, training and use of NTS.

Israeli survey of anesthesia practice related to placenta previa and accreta.

Abstract: Background Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units. Methods After Institutional Review Board waiver, we surveyed all 26 Israeli hospitals with a labor and delivery unit by directly contacting the representatives of obstetric anesthesiology services in every department (unit director or department chair). Each director surveyed provided information about the anesthetic and transfusion management in their labor and delivery units for three types of abnormal placentation based on antenatal placental imaging: PP, low suspicion for PA, and high suspicion for PA. The primary outcome was use of neuraxial or general anesthesia for PP and PA Cesarean delivery. Univariate statistics were used for survey responses using counts and percentages. Results The response rate was 100%. Spinal anesthesia is the preferred anesthetic mode for PP cases, used in 17/26 (65.4%) of labor and delivery units. By comparison, most representatives reported that they perform general anesthesia for patients with PA: 18/26 (69.2%) for all low suspicion cases of PA and 25/26 (96.2%) for all high suspicion cases of PA. Although a massive transfusion protocol was available in the majority of hospitals (84.6%), the availability of thromboelastography and cell salvage was much lower (53.8% and 19.2% hospitals respectively). Conclusions In our survey, representatives of anesthesia labor and delivery services in Israel are almost exclusively using general anesthesia for women with high suspicion for PA; however, almost two-thirds use spinal anesthesia for PP without suspicion of PA. Among representatives, we found wide variations in anesthesia practice patterns with regard to anesthesia mode, multidisciplinary management, and hemorrhage anticipation strategies.