Showing papers in "Acta Anaesthesiologica Scandinavica in 2017"

Anaesthetic hypersensitivity reactions in France between 2011 and 2012: the 10th GERAP epidemiologic survey

Abstract: Background Immediate hypersensitivity reactions during anaesthesia are rare but potentially life-threatening. The epidemiology changes with time and evolving professional practice, and hence needs to be monitored. Our objective was to follow this epidemiology. Methods This was a retrospective, observational study in French hospital clinics, conducted by GERAP members (Groupe d'Etude des Reactions Anaphylactoides Perioperatoires). Consecutive patients seen in allergo-anaesthesia outpatient clinics, who had experienced a hypersensitivity reaction during anaesthesia between 1 January 2011 and 31 December 2012, were included. Demographic data, allergy history, drugs received before the reaction, symptoms of the reaction, results of blood samples (histamine, tryptase, IgE-specific assays), and results of the allergy assessment were recorded. Results The most common causes of allergic reactions were (Neuromuscular Blocking Agents) NMBAs (N = 302; 60.6%), antibiotics (N = 91, 18.2%, Cephalosporin N = 49, 10%) and dyes (N = 27; 5.4%). Latex as an allergic agent was involved in 26 cases (5.2%), hypnotics in 11 cases (2.2%) and opioids in seven cases (1.4%). Of the NMBAs, Rocuronium had the highest proportion of reactions (13.8 reactions/100,000 vials sold) followed by Suxamethonium (13.3/100,000 vials sold). Cisatracurium had the lowest proportion of reactions (0.4/100,000 vials sold). Patients were sensitized to two or more NMBAs in 48.9% of cases and without testing, cross-sensitivity cannot be predicted. Conclusions When compared with the previous GERAP studies, NMBAs are still the most frequently triggering allergens, with marked differences between individual NMBAs, but they are now followed by antibiotics (of which greater than 50% were cephalosporins) and dyes. Anaesthetists must be aware of the differences between drugs and of the pattern of emerging allergens. For the future of safe anaesthesia, allergy assessment is essential.

Pain prevalence in hospitalized children: a prospective cross-sectional survey in four Danish university hospitals.

Abstract: Background Pain management in hospitalized children is often inadequate. The prevalence and main sources of pain in Danish university hospitals is unknown. Methods This prospective mixed-method cross-sectional survey took place at four university hospitals in Denmark. We enrolled 570 pediatric patients who we asked to report their pain experience and its management during the previous 24 hours. For patients identified as having moderate to severe pain, patient characteristics and analgesia regimes were reviewed. Results Two hundred and thirteen children (37%) responded that they had experienced pain in the previous 24 hours. One hundred and thirty four (24%) indicated moderate to severe pain and 43% would have preferred an intervention to alleviate the pain. In children hospitalized for more than 24 hours, the prevalence of moderate/severe pain was significantly higher compared to children admitted the same day. The single most common painful procedure named by the children was needle procedures, such as blood draw and intravenous cannulation. Conclusion This study reveals high pain prevalence in children across all age groups admitted to four Danish university hospitals. The majority of children in moderate to severe pain did not have a documented pain assessment, and evidence-based pharmacological and/or integrative (‘non-pharmacological’) measures were not systematically administered to prevent or treat pain. Thus, practice changes are needed.

Vancomycin levels are frequently subtherapeutic in critically ill patients: a prospective observational study

Abstract: Background Appropriate utilization of vancomycin is important to attain therapeutic targets while avoiding clinical failure and the development of antimicrobial resistance. Our aim was to observe the use of vancomycin in an intensive care population, with the main focus on achievement of therapeutic serum concentrations (15–20 mg/l) and to evaluate how this was influenced by dose regimens, use of guidelines and therapeutic drug monitoring. Methods A prospective observational study was carried out in the intensive care units at two tertiary hospitals in Norway. Data were collected from 83 patients who received vancomycin therapy, half of these received continuous renal replacement therapy. Patients were followed for 72 h after initiation of therapy. Blood samples were drawn for analysis of trough serum concentrations. Urine was collected for calculations of creatinine clearance. Information was gathered from medical records and electronic health records. Results Less than 40% of the patients attained therapeutic trough serum concentrations during the first 3 days of therapy. Patients with augmented renal clearance had lower serum trough concentrations despite receiving higher maintenance doses and more loading doses. When trough serum concentrations were outside of therapeutic range, dose adjustments in accordance to therapeutic drug monitoring were made to less than half. Conclusion The present study reveals significant challenges in the utilization of vancomycin in critically ill patients. There is a need for clearer guidelines regarding dosing and therapeutic drug monitoring of vancomycin for patient subgroups.

A systematic review of the analgesic efficacy of cannabinoid medications in the management of acute pain.

Abstract: Background Cannabinergic medications have been postulated to demonstrate efficacy in the management of pain. The aim of this systematic review was to assess the analgesic efficacy and adverse effects of cannabinoids when used for the management of acute pain. Methods A systematic review was performed by searching the MEDLINE, EMBASE and CENTRAL databases, and the World Health Organization International Clinical Trials Registry Platform for human randomized controlled trials that assessed the analgesic efficacy of cannabinoids compared to placebo or active comparators. The reported outcomes for analgesic efficacy and adverse effects in included studies were qualitatively analysed. Results Seven studies, including 611 patients were included in the systematic review. In five studies, cannabinoids were found to provide equivalent analgesia to placebo, in one study the analgesia provided by cannabinoids was superior to placebo, and in one study cannabinoids provided analgesia that was inferior to that provided by placebo. No synergistic or additive analgesic effect was observed when cannabinoids were used in combination with opioids. In five of the seven studies, certain adverse effects were more frequent with cannabinoid treatment than with placebo or active comparator. Conclusion On the basis of the available randomized controlled trial evidence, cannabinoids have no role in the management of acute pain.

Post-operative nausea and vomiting in bariatric surgery patients: an observational study.

Abstract: Background: The risk of post-operative nausea and vomiting (PONV) in patients undergoing bariatric surgery is unclear. The aim of the study was to investigate the risk of PONV and the use and effec ...

Spontaneous breathing trials after prolonged mechanical ventilation monitored by electrical impedance tomography: an observational study.

Abstract: Background The study objective was to examine the correlation between regional ventilation distribution measured with electrical impedance tomography (EIT) and weaning outcomes during spontaneous breathing trial (SBT). Methods Fifteen patients received 100% automatic tube compensation (ATC) during the first and 70% during the second hour. Another 15 patients received external continuous positive airway pressure (CPAP) of 5 and 7.5 cmH2O during the first and second hours, respectively. Regional ventilation distributions were monitored with EIT. Results Tidal volume and tidal variation of impedance correlated significantly during assist-control ventilation and ATC in all patients (r2 = 0.80 ± 0.18, P < 0.001). Higher support levels resulted in similar ventilation distribution and tidal volume, but higher end-expiratory lung impedance (EELI) (P < 0.05). Analysis of regional intratidal gas distribution revealed a redistribution of ventilation towards dorsal regions with lower support level in 13 of 30 patients. These patients had a higher weaning success rate (only 1 of 13 patients failed). Eight of 17 other patient failed (P < 0.05). The number of SBT days needed for weaning was significantly lower in the former group of 13 patients (13.1 ± 4.0 vs. 20.9 ± 11.2 days, P < 0.05). Conclusions Regional ventilation distribution patterns during inspiration were associated with weaning outcomes, and they may be used to predict the success of extubation.

A comparison of ultrasound-guided interscalene and supraclavicular blocks for post-operative analgesia after shoulder surgery.

Abstract: Background In contrast to interscalene block, there was little information regarding the analgesic efficacy of supraclavicular block for shoulder surgery. This study aimed to compare the analgesic efficacy and side effects of interscalene and supraclavicular blocks for shoulder surgery. Methods Patients scheduled for shoulder surgery were assigned to receive either ultrasound-guided interscalene (n = 25) or supraclavicular block (n = 24) with 20 ml of 0.375% ropivacaine. We assessed the duration of post-operative analgesia as a primary outcome and pain scores, supplemental analgesia, diaphragmatic excursion, motor block, fingertip numbness, side effects, and patient satisfaction as secondary outcomes. Results The duration of post-operative analgesia was not statistically different between groups: 868 (800–1440) min for supraclavicular block vs. 800 (731–922) min for interscalene block (median difference −85 min, 95% CI, −283 to 3 min, P = 0.095). The incidence of diaphragmatic paresis was significantly lower in the supraclavicular block group compared with that in the interscalene block group, both at 30 min after the block (66.7% vs. 92%, P = 0.021) and in the post-anaesthesia care unit (62.5% vs. 92%, P = 0.024). Motor block was higher in the supraclavicular block group in the post-anaesthesia care unit, however, not at 24 h. Other secondary outcomes were similar for both groups. Conclusions This study showed no statistically significant difference in the duration of post-operative analgesia between the supraclavicular and interscalene blocks. However, the supraclavicular block was associated with a lower incidence of diaphragmatic paresis compared with that of the interscalene block after shoulder surgery.

Delirium after fast-track hip and knee arthroplasty - a cohort study of 6331 elderly patients.

Abstract: Background Postoperative delirium (PD) is a well-known complication among elderly surgical patients and associated with increased morbidity, mortality and length of stay (LOS). In elective orthopedic surgery, including hip and knee arthroplasty (THA/TKA), most studies report incidences between 5% and 10%. The multimodal optimization of perioperative care (fast-track) aims to enhance recovery and reduce morbidity and LOS, but limited data are available on the effect on PD. Consequently, the study investigated signs of PD associated with LOS > 4 days. Methods Prospective risk assessment study with retrospective analysis of discharge notes or medical records of signs of PD in 6331 elective primary unilateral THA and TKA patients ≥ 70 years, and LOS > 4 days. Preoperative patient characteristics collected from eight high volume centers with similar standardized fast-track protocols from January 2010 to November 2013. Results We identified 43 (0.7%) cases of PD symptoms mentioned as a reason for LOS > 4 days among the 789 patients with LOS > 4 days (12.5% of all THA and TKA). PD patients had a mean age of 80.7 [[95% CI] 79.3–82.1] years, being 4.0 [[95% CI] 2.5–5.5] years older compared to patients without PD (P < 0.001). LOS was median 10 [[Q2–Q3] 7–14] days in the PD group vs. 3 [2–3] days in the non-PD group (P < 0.001), without differences in gender or site of arthroplasty (P = 0.139 and 0.499, respectively). Conclusion Postoperative delirium symptoms contributing to LOS > 4 days in fast-track THA and TKA are rare in elderly patients.

A high proportion of prehospital emergency patients are not transported by ambulance: a retrospective cohort study in Northern Finland.

Abstract: Background The number of missions in the emergency medical services (EMS) has increased considerably in recent years. People are requesting ambulance for even minor illnesses and non-medical problems, which is placing financial and resource burdens on the EMS. The aim of this study was to determine the rate of non-transportation missions in Northern Finland and the reasons for these missions. Methods All ambulance missions in two hospital districts in Northern Finland during the 6-month period of January 1 through June 30, 2014, were retrospectively evaluated from the EMS charts to identify missions in which the patients were not transported by the EMS. The non-transportation rates and reasons were calculated and expressed as percentages. Results In 41.7% of the 13,354 missions, the patient was not transported from the scene by an ambulance. After a medical assessment and care was provided by the EMS, 48.2% of these non-transport patients were evaluated as not needing further treatment in the emergency department and were directed to contact the municipal health care center during office hours. There was no need for any medical care in 39.9% of non-transportation missions. Conclusion This study showed a high rate of EMS missions resulting in non-transportation in two hospital districts in Northern Finland. In the majority of these missions there was no need for emergency admission to an emergency department or for any medical care at all. These findings indicate that an improvement in the dispatch process and primary care resources might be of benefit.

Extracorporeal cardiopulmonary resuscitation after out-of-hospital cardiac arrest in a Danish health region.

Abstract: Background Extracorporeal Cardiopulmonary Resuscitation (ECPR) has emerged as a feasible rescue therapy for refractory, normothermic out-of-hospital cardiac arrest (OHCA). Reported survival rates vary and comparison between studies is hampered by heterogeneous study populations, differences in bystander intervention and in pre-hospital emergency service organisation. We aimed to describe the first experiences, treatment details, complications and outcome with ECPR for OHCA in a Danish health region. Methods Retrospective study of adult patients admitted at Aarhus University Hospital, Denmark between 1 January 2011 and 1 July 2015 with witnessed, refractory, normothermic OHCA treated with ECPR. OHCA was managed with pre-hospital advanced airway management and mechanical chest compression during transport. Relevant pre-hospital and in-hospital data were collected with special focus on low-flow time and ECPR duration. Survival to hospital discharge with Cerebral Performance Category (CPC) of 1 and 2 at hospital discharge was the primary endpoint. Results Twenty-one patients were included. Median pre-hospital low-flow time was 54 min [range 5-100] and median total low-flow time was 121 min [range 55-192]. Seven patients survived (33%). Survivors had a CPC score of 1 or 2 at hospital discharge. Five survivors had a shockable initial rhythm. In all survivors coronary occlusion was the presumed cause of cardiac arrest. Conclusion Extracorporeal cardiopulmonary resuscitation is feasible as a rescue therapy in normothermic refractory OHCA in highly selected patients. Low-flow time was longer than previously reported. Survival with favourable neurological outcome is possible despite prolonged low-flow duration.

No cases of perioperative allergy to local anaesthetics in the Danish Anaesthesia Allergy Centre

Abstract: Background Local anaesthetics (LA) are often suspected as possible causes of allergic reactions. The Danish Anaesthesia Allergy Centre (DAAC) is the national reference centre for investigation of perioperative allergic reactions. The purpose of this study was to investigate the incidence of IgE-mediated immediate type perioperative allergic reactions to LA. Methods In the period 2004–2013, a total of 409 patients (244 women/165 men; median age 49 years, range 1–86 years) were investigated in DAAC on suspicion of allergy associated with anaesthesia and surgery. A total of 162 (40%) patients were exposed to one or more LA. Suspected allergy to LA was investigated by prick test, intradermal test and subcutaneous provocation with the suspected drug. Patients with positive skin tests still underwent subcutaneous provocation, as false positive skin tests can occur. Results A total of 203 test series with LA were carried out on 162 patients (89 women/73 men; mean age 49 years, range 2–85 years) with the following drugs: Lidocaine n = 80 (49%), bupivacaine n = 82 (51%), ropivacaine n = 31 (19%) and mepivacaine n = 10 (6%). All 162 patients had negative subcutaneous provocation for all tested LA (95% CI: 0–1.8%). Investigations revealed another allergen in 52 of 162 patients. Conclusion None of the 162 patients with suspected perioperative allergic reactions and exposure to LA reacted on subcutaneous provocation with the relevant LA. Thus, no patients have been diagnosed with allergy to LA in DAAC in the period 2004–2013 and allergy to LA must be considered very rare in this population.

Time course and reasons for 90-day mortality in fast-track hip and knee arthroplasty.

Abstract: Background Post-operative mortality is an important adverse outcome, including in total hip (THA) and knee arthroplasty (TKA). However, whether mortality is due to anaesthetic/surgical complications, surgically induced organ dysfunction or unrelated to surgery is rarely considered. Methods Prospective observational study in 13,775 consecutive THA/TKAs with similar fast-track protocols and a median length of stay of 2 days. Complete 90-days follow-up through national registries, followed by review of medical records and death certificates. Relation between mortality and surgically induced organ dysfunction were classified as certain, probable, possible or unlikely. Results Of a total of 44 deaths (0.3%), 28 (0.2%) were found to have certain or probably relation with surgery and were considered as surgery-related. Surgery-related deaths were more common after THA than TKA (0.3% vs. 0.1% P = 0.044), occurred after median 14 days and 19 of 28 were between day 0–30. Of the remaining 16 deaths (0.1%), nine were found to be possible and seven to be unlikely related to surgery, and occurred a median of 42 and 61 days after surgery. The most common initial organ dysfunction for surgery-related deaths was pulmonary (6/28) and gastrointestinal (6/28), while the most common reported cause of death were pulmonary (9/28) and cardiac events (6/28). In five of the seven unlikely related deaths mortality was attributed to underlying cancer. Conclusion Ninety-days mortality was 0.3% in THA and TKA, but only 28 of 44 deaths (64%) were found to be surgery-related. Reporting total mortality rate or cause of death without considerations on surgery induced organ dysfunction, may be insufficient for future aims to reduce post-operative mortality.

A comparison of sugammadex and neostigmine for reversal of rocuronium-induced neuromuscular blockade in children.

Abstract: Sugammadex is designed to be a reversal agent for steroidal muscle relaxants. The current trial was aimed to compare between sugammadex and neostigmine concerning the recovery time from neuromuscular blockade. We hypothesised that sugammadex might have shorter recovery time than neostigmine.Sixty paediatric patients aged 2-10 years scheduled for lower abdominal surgeries were randomly assigned into two equal groups to receive 4 mg/kg sugammadex (Group S) or 0.35 mg/kg neostigmine and 0.02 mg/kg atropine (Group N) as a reversal agent for rocuronium at the end of surgery. Primary outcome was the recovery time [time from starting of sugammadex or neostigmine till reaching train of four (TOF) ratio> 0.9] whereas secondary outcomes included number of patients who needed another dose of sugammadex or neostigmine to reach TOF ratio> 0.9, extubation time (time from stoppage of anaesthetic inhalation until the patient fulfilled criteria for safe extubation, post-anaesthesia care unit (PACU) discharge time and post-operative adverse effects.The mean recovery and extubation times were significantly shorter (P = 0.002 and 0.005) in Group S compared with Group N (2.5 and 2.0 min vs. 12.6 min and 4.3 min respectively). In the Group N, eight patients needed another reversal dose compared with one patient in Group S (P = 0.035). PACU discharge time showed no significant difference between both groups. Incidence of nausea, vomiting, tachycardia, and dry mouth were significantly higher in Group N.Sugammadex administration in children resulted in faster recovery and extubation times and lower incidence of adverse events compared with neostigmine.

Load-dependence of myocardial deformation variables - a clinical strain-echocardiographic study.

Abstract: Background The effects of left ventricular (LV) loading on myocardial deformation variables are not well-studied in the clinical setting. In the present study, we evaluated the effects of isolated changes in preload, afterload and heart rate on LV longitudinal strain, systolic (SR-S) and early diastolic strain rate (SR-E) in post-cardiac surgery patients. Methods Twenty-one patients were studied early after cardiac surgery. Longitudinal myocardial strain and SR were analysed off-line using 2-D speckle echocardiography. The experimental protocol consisted of three consecutive interventions: (1) preload was increased by passive leg elevation, (2) afterload was increased by an infusion of phenylephrine to increase arterial blood pressure by 10–15% and (3) heart rate was increased 10% and 20% by atrial pacing. During both the preload and afterload challenges heart rate was kept constant by atrial pacing. Central venous pressure was kept constant during pacing by infusion of hetastarch/albumin. Results The increase in preload increased LV strain, SR-S and SR-E by 20%, 11% and 17%, respectively. The phenylephrine-induced increase in afterload, did not affect LV strain, SR-S or SR-E. LV strain was not affected while SR-S and SR-E increased by pacing-induced heart rate increase. Conclusion After cardiac surgery, systolic and early diastolic strain rate are dependent on both preload and heart rate, while neither of these variables was afterload-dependent. LV strain was preload-dependent but not affected by atrial pacing. When evaluating the direct effects of various pharmacological or other interventions on myocardial contractility and relaxation, preload and heart rate must be controlled.

High frequency jet ventilation for motion management during ablation procedures, a narrative review.

Abstract: Background High frequency jet ventilation (HFJV) is a method of ventilation that has gained renewed interest over the recent years as it can reduce organ movement to near static conditions, thus enhancing surgical precision in minimal invasive procedures, for example, ablation procedures for atrial fibrillation and solid organ tumours. The aim of this review was to create a summary of the current evidence concerning the clinical use of HFJV for ablative procedures. Method PubMed was searched for the key words high frequency ventilation and ablation January 1990–December 2016. Result The search initially identified 34 papers, 14 met the inclusion criteria. Articles in other languages than English (n = 1), comments regarding other articles (n = 4) and articles that did not include HFJV or ablative procedures (n = 15) were excluded. Two articles were added from references in papers included from the primary search. Sixteen studies were finally included in the review; four updates/reviews and 12 papers with results from studies of HFJV on humans, with a total of 889 patients; 498 patients ventilated with HFJV and 391 controls. There were no randomised studies. The overall scientific quality of the studies was low. Conclusion There is a lack of well-designed studies evaluating HFJV during ablation procedures. The available information, while sparse, supports the effect of less tissue movement, resulting in better surgical precision and outcome; such as shorter procedural time, fewer shock waves (ESWL) and less recurrence of atrial fibrillation. Randomised controlled studies are needed in this promising area of research to prove its superiority to standard ventilation.

Ketamine does not enhance the quality of recovery following laparoscopic cholecystectomy: a randomized controlled trial

Abstract: Background Ketamine has been used as part of the multimodal analgesia technique in the acute perioperative period. The effect of perioperative intravenous small-dose ketamine on the quality of recovery from the patient point-of-view has not been assessed. We hypothesized that low-dose ketamine would enhance recovery following laparoscopic cholecystectomy under total intravenous anesthesia. Methods One hundred thirty five patients undergoing laparoscopic cholecystectomy were enrolled in this randomized, double-blind placebo-controlled trial. Subjects were randomly assigned to one of three groups: saline, ketamine 0.2 mg/kg, or ketamine 0.4 mg/kg immediately following the induction of anesthesia and before skin incision. The primary endpoint was assessed using the Quality of Recovery Questionnaire (QoR-40), a 40-item quality of recovery scoring system. In addition, early clinical recovery variables, such as time to eye opening, occurrence of nausea and vomiting, pain score, analgesic use, and length of PACU stay were assessed. Results No differences were detected in the total or individual dimension scores of the QoR-40 questionnaire. The incidence of nausea, vomiting, and other complications did not differ among the three groups. Conclusions Small doses of ketamine do not improve the quality of recovery after remifentanil-based anesthesia for laparoscopic cholecystectomy.

Routine coagulation tests on ICU admission are associated with mortality in sepsis: an observational study.

Abstract: Background: Low platelet count on admission to an intensive care unit (ICU) is associated with increased mortality and is thus included in some severity scoring systems such as the simplified acute physiologic score 3 (SAPS 3); however it is unclear whether other routine coagulation tests also predict mortality. The purpose of this retrospective single-centre study was to investigate whether activated partial thromboplastin time (APTT) or prothrombin time – international normalized ratio (PT-INR) measured on admission to the ICU in patients with severe sepsis or septic shock may be associated with mortality independent of SAPS 3 score. Methods: All patients admitted to a tertiary general ICU from 2007 to 2014 diagnosed with severe sepsis or septic shock were eligible. Results from APTT and PT-INR within 1.5 h of admission as well as SAPS 3 were used as independent variables in a Cox regression. Results: Of total 5485 ICU admissions during the study period we identified 647 unique patients with severe sepsis or septic shock. APTT and PT-INR were found to correlate significantly with mortality with a hazard ratio (HR) of 1.014 [95% confidence interval of HR (1.006–1.023)] for APTT and 1.422 (1.117–1.811) for PT-INR. HR for SAPS 3 was 1.036 (1.028–1.044). Conclusion: Activated partial thromboplastin time prolongation and raised PT-INR on ICU admission in patients with severe sepsis or septic shock is associated with increased mortality independent of SAPS 3 score. This indicates that APTT prolongation and PT-INR increase represents morbidity that is not accounted for in SAPS 3. (Less)

Norepinephrine reduces arterial compliance less than phenylephrine when treating general anesthesia-induced arterial hypotension.

Abstract: Introduction: During general anesthesia, arterial hypotension is frequent and may be an important contributor to peri-operative morbidity We assessed the effect of a 5µg bolus of Norepinephrine (NA) when compared with 50 µg bolus of Phenylephrine (PE) administered to treat hypotension during maintenance anesthesia, on MAP, derived cardiac output and arterial stiffness parameters Methods: Patients scheduled for a neurosurgical procedure under general anesthesia were prospectively included Monitoring included invasive blood pressure, esophageal Doppler and arterial tonometer used to estimate central aortic pressure with arterial stiffness parameters, such as augmentation index (Aix) After initial resuscitation, hypotensive episodes were corrected by a bolus administration of NA or PE in a peripheral venous line Results: There were 269 bolus administrations of vasopressors (149 NA, 120 PE) in 47 patients with no adverse effects detected A decrease in stroke volume (SV) was observed with PE compared with NA (-18±9% vs -14±7%, p<0001) This decrease was associated with an increase in Aix, which was greater for PE than for NA (+10±8% vs +6±6%, p<00001), and a decrease in total arterial compliance greater for PE compared to NA (Ctot=SV/Central Pulse Pressure) (-35±9% vs -29±10%, p<0001) Discussion: This study suggests that 5 µg of NA administered as a bolus in a peripheral venous line could treat general-anesthesia-induced arterial hypotension with a smaller decrease in SV and arterial compliance when compared to PE

Objective neuromuscular monitoring of neuromuscular blockade in Denmark: an online‐based survey of current practice

Abstract: Background Neuromuscular blocking agents are commonly used during general anaesthesia but can lead to postoperative residual neuromuscular blockade and associated morbidity. With appropriate objective neuromuscular monitoring (objNMM) residual blockade can be avoided. In this survey, we investigated the use of objNMM in Denmark. Methods We conducted an anonymous Internet-based survey distributed through e-mails to Danish public anaesthesia departments. The survey consisted of 15–17 short questions regarding the use of objNMM. Results A total of 653 (27%) anaesthetists from 90% of the hospitals answered the questionnaire. ObjNMM was always used by 58% of the anaesthetists and 86% used objNMM at least 75% of the times. Despite the frequent use, 75% of the anaesthetists experienced difficulties with objNMM in at least 25% of the cases. The likelihood of using objNMM was higher among nurse anaesthetists vs. anaesthesiologists (odds ratio (OR) 2.24 [95% confidence interval (CI): 1.62–3.08]), if the department had an employee with special interest in objNMM (OR 1.66 [95% CI: 1.12–2.47]), if the anaesthetist had < 5 years of experience (OR 1.88 [95% CI: 1.29–2.73]), or if experiencing difficulties with objNMM < 25% of the cases (OR 1.60 [95% CI: 1.00–2.57]). Conclusion In this survey, Danish anaesthetists frequently, in an international perspective, use objNMM, but the use is often associated with technical difficulties.

Simulation-based training program with deliberate practice for ultrasound-guided jugular central venous catheter placement.

Abstract: Background Current evidence supports the utility of simulation training for bedside procedures such as ultrasound-guided jugular central venous catheter (CVC) insertion. However, a standardized methodology to teach procedural skills has not been determined yet. The aim of this study was to evaluate the effectiveness of a simulation-based training program for improving novice technical performance during ultrasound-guided internal jugular CVC placement. Methods Postgraduate year 1 (PGY-1) residents from anesthesiology, emergency medicine, cardiology, ICU, and nephrology specialties were trained in four deliberate practice sessions. Learning objectives included principles of ultrasound (US), preparation (gown, glove, draping), procedural skills I (US scanning and puncture), and procedural skills II (catheter insertion). CVC technical proficiency was tested pre- and post-training using hand-motion analysis with the Imperial College Surgical Assessment Device (ICSAD) and a global rating scale (GRS). Results Thirty-five PGY-1 residents successfully completed the program. These novices' GRS scores improved significantly after the training (P < 0.001). Total path length measured with the ICSAD decreased significantly after the training (P = 0.008). Procedural time decreased significantly after training from 387 (310–501) seconds to 200 (157–261) seconds (median and interquartile range) (P = 0.029). Conclusion This simulation-training program based on deliberate practice significantly increased the technical skills of residents in US-guided short-axis, out-of-plane internal jugular CVC placement. Data also confirm the validity of the ICSAD as an assessment tool for ultrasound-guided internal jugular CVC placement learning.

First-aid training in school: amount, content and hindrances.

Abstract: Background To increase knowledge and competence about first aid in the population, first-aid instruction is included in primary and secondary school curricula. This study aimed to establish how much time is spent on first-aid training, which first-aid measures are taught, and which factors prevent teachers from providing the quantity and quality of first-aid training that they wish to give. Methods A questionnaire was distributed to teachers in physical education in primary and secondary schools and to teachers in vocational subjects in higher secondary schools. Results The teachers taught a median of two lessons in first aid per year. Cardiopulmonary resuscitation (CPR) was taught by 64% of teachers, free airway and recovery position by 69% and stopping severe bleeding by 51%. Recognising heart attack and stroke was taught by 25% and 23%, respectively. The main factors that the teachers perceived as limiting the amount and quality of first-aid training were insufficient learning objective specifications in the curriculum, too many other competence aims, lack of CPR mannequins and lack of training as first-aid instructors. Discussion Norwegian teachers provide an appreciable amount of first-aid training to their students. However, several potential life-saving measures are poorly covered. The curriculum needs to contain first aid but also should specify what first-aid measures to be taught. First-aid training of teachers should adequately prepare them to be first-aid instructors.

Claims for compensation after injuries related to airway management: a nationwide study covering 15 years.

Abstract: Background Securing the airway is one of the most important responsibilities in anaesthesia Injuries related to airway management can occur Analysis from closed claims can help to identify patterns of injury, risk factors and areas for improvement Methods All claims to The Norwegian System of Compensation to Patients from 1 January 2001 to 31 December 2015 within the medical specialty of anaesthesiology were studied Data were extracted from this database for patients and coded by airway management procedures Results Of 400 claims for injuries related to airway management, 359 were classified as ‘non-severe’ and 41 as ‘severe’ Of the severe cases, 37% of injuries occurred during emergency procedures Eighty-one claims resulted in compensation, and 319 were rejected A total of €1,505,344 was paid to the claimants during the period Claims of dental damage contributed to a numerically important, but financially modest, proportion of claims More than half of the severe cases were caused by failed intubation or a misplaced endotracheal tube Conclusion Anaesthesia procedures are not without risk, and injuries can occur when securing the airway The most common injury was dental trauma Clear patterns of airway management that resulted in injuries are not apparent from our data, but 37% of severe cases were related to emergency procedures which suggest the need for additional vigilance Guidelines for difficult intubation situations are well established, but adherence to such guidelines varies Good planning of every general anaesthesia should involve consideration of possible airway problems and assessment of pre-existing poor dentition

Parecoxib, propacetamol, and their combination for analgesia after total hip arthroplasty: a randomized non-inferiority trial

Abstract: Background This study assessed non-inferiority of parecoxib vs. combination parecoxib+propacetamol and compared the opioid-sparing effects of parecoxib, propacetamol, and parecoxib+propacetamol vs. placebo after total hip arthroplasty. Methods In this randomized, placebo-controlled, parallel-group, non-inferiority study, patients received one of four IV treatments after surgery: parecoxib 40 mg bid (n = 72); propacetamol 2 g qid (n = 71); parecoxib 40 mg bid plus propacetamol 2 g qid (n = 72); or placebo (n = 38) with supplemental IV patient-controlled analgesia (morphine). Patients and investigators were blinded to treatment. Pain intensity at rest and with movement was assessed regularly, together with functional recovery (modified Brief Pain Inventory-Short Form) and opioid-related side effects (Opioid-Related Symptom Distress Scale) questionnaires up to 48 h. Results After 24 h, cumulative morphine consumption was reduced by 59.8% (P < 0.001), 38.9% (P < 0.001), and 26.8% (P = 0.005) in the parecoxib+propacetamol, parecoxib, and propacetamol groups, respectively, compared with placebo. Parecoxib did not meet criteria for non-inferiority to parecoxib+propacetamol. Parecoxib+propacetamol and parecoxib significantly reduced least-squares mean pain intensity scores at rest and with movement compared with propacetamol (P < 0.05). One day after surgery, parecoxib+propacetamol significantly reduced opioid-related symptom distress and decreased pain interference with function compared with propacetamol or placebo. Conclusion Parecoxib and parecoxib+propacetamol provided significant opioid-sparing efficacy compared with placebo; non-inferiority of parecoxib to parecoxib+propacetamol was not demonstrated. Opioid-sparing efficacy was accompanied by significant reductions in pain intensity on movement, improved functional outcome, and less opioid-related symptom distress. Study medications were well tolerated.

Heparin-binding protein as a biomarker of acute kidney injury in critical illness

Abstract: BACKGROUND: There is no biomarker with high sensitivity and specificity for the development of acute kidney injury (AKI) in a mixed intensive care unit (ICU) population. Heparin-binding protein (HB ...

Implementing point-of-care ultrasonography of the heart and lungs in an anesthesia department.

Abstract: BACKGROUND Implementation of point-of-care ultrasonography (POCUS) of the heart and lungs requires image acquisition skills among providers. We aimed to determine the effect of POCUS implementation using a systematic education program on image acquisition skills and subsequent use and barriers in a department of anesthesiology. METHODS Twenty-five anesthesiologists underwent a systematic education program in POCUS during the fall of 2012. A POCUS expert evaluated images from baseline and evaluation examinations performed on two healthy individuals as useful or not useful for clinical interpretation. In August 2016, anesthesiologists employed at the department answered a questionnaire regarding the use of POCUS and perceived barriers to its use. RESULTS The systematic education program increased the proportion of images useful for clinical interpretation from 0.70 (95% CI 0.65-0.75) to 0.98 (95% CI 0.95-0.99). This difference was significant when adjusted for prior cardiac ultrasonography courses, prior clinical cardiac ultrasonography experience, ultrasonography view, and ultrasound model (P < 0.001). After 3.5 years, 15/25 (60%) of perioperative medicine providers, 22/24 (92%) of intensive care providers, and 21/21 (100%) of pre-hospital care providers used POCUS either routinely, in selected patient groups, or sporadically. CONCLUSION Implementation of POCUS by a systematic education program increased image acquisition skills across anesthesiologists employed at the department. POCUS was used in the intensive care setting, the pre-hospital setting, and to a lesser extent in the perioperative setting. Educational strategies for obtaining images under difficult conditions, practical equipment and evidence for effect on patient outcomes are required for full implementation of POCUS.

Ventilation via the 2.4 mm internal diameter Tritube® with cuff - new possibilities in airway management.

Abstract: Background A small tube may facilitate tracheal intubation and improve surgical access. We describe our initial experience with the Tritube® that is a novel cuffed endotracheal tube with a 2.4 mm internal diameter. Methods The Tritube® was used in seven adult Ear-Nose-and Throat surgical patients with airway narrowing or whose surgical access was facilitated by this small-bore endotracheal tube. Ventilation through Tritube® is performed with the manually operated Ventrain®-ventilator that allows active suctioning during expiration, therefore facilitating normoventilation through small diameter airways. Results The small diameter of Tritube® seemed to improve glottis visualisation during intubations and gave excellent working conditions for surgery. Two patients were intubated awake with a flexible scope and a guide wire or with an angulated video laryngoscope. One patient had almost complete glottic occlusion that just allowed for passage of the Tritube®. Adequate ventilation was achieved in all patients and intratracheal pressure was kept between 5 and 20 cm H2O. The tube was well tolerated after emergence from anaesthesia and kept intratracheally in five awake patients in the post-operative recovery unit, in one case for more than 1 h. Ventilating with Ventrain® through Tritube® demands meticulous breath by breath measurement and adjustment of the intratracheal pressure. Conclusion The 2.4 mm internal diameter Tritube® seems to facilitate tracheal intubation and to provide unprecedented view of the intubated airway during oral, pharyngeal, laryngeal or tracheal procedures in adults. This technique has the potential to replace temporary tracheostomy, jet-ventilation or extra-corporal membrane oxygenation in selected patients.

Inadvertent intrathecal injections and best practice management.

Abstract: The intrathecal space has become an important anatomic site for medical intervention not only in anesthesia practice, but also in many other medical specialties. Undesired/inadvertent intrathecal injections (UII) are generally rare. There is tremendous variation in reported inadvertent administrations via an intrathecal route in the literature, mainly as individual cases and very small case-series reports. This review aims to identify potential sources of UII, its clinical presentations, and appropriate management. The inadvertent injectants are classified as anesthetic agents and pain medicines, chemotherapeutics, radiological contrast agents, antibiotics and corticosteroids, and miscellaneous chemical agents such as tranexamic acid. The clinical effects of UII are dependent upon inadvertent injectant(s) and dose being administered intrathecally, and can range from no adverse effect to profound neurological consequences and/or death. Prompt cerebrospinal fluid (CSF) lavage and cardiopulmonary support seem to be the mainstay of treatment. If serious consequences are anticipated, CSF lavage could be lifesaving. This review additionally provides some options for comprehensive management and preventing strategies.

Stress ulcer prophylaxis in the intensive care unit trial: detailed statistical analysis plan.

Abstract: Background In this statistical analysis plan, we aim to provide details of the pre-defined statistical analyses of the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial. The aim of the SUP-ICU trial is to assess benefits and harms of stress ulcer prophylaxis with a proton pump inhibitor in adult patients in the intensive care unit (ICU). Methods The SUP-ICU trial is an investigator-initiated, international, multicentre, randomised, blinded, parallel-group trial of intravenously pantoprazole 40 mg once daily vs. placebo in 3350 acutely ill adult ICU patients at risk of gastrointestinal bleeding. The primary outcome measure is 90-day mortality. Secondary outcomes include the proportion of patients with clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection or myocardial ischaemia, days alive without life support, serious adverse reactions, 1-year mortality, and a health economic analysis. Two formal interim analyses will be performed. The statistical analyses will be conducted according to the outlined pre-defined statistical analysis plan. The primary analysis will be a logistic regression analysis adjusted for stratification variables comparing the two intervention groups in the intention-to-treat population. In a secondary analysis, we will additionally adjust the primary outcome for potential random differences in baseline characteristics. The conclusion will be based on the intention-to-treat population. Conclusion Stress ulcer prophylaxis is standard of care in ICUs worldwide, but has never been tested in large high-quality randomised placebo-controlled trials. The SUP-ICU trial will provide important high-quality data on the balance between the benefits and harms of stress ulcer prophylaxis in adult critically ill patients.

Effects of fluid restriction on measures of circulatory efficacy in adults with septic shock

Abstract: Background The haemodynamic consequences of fluid resuscitation in septic shock have not been fully elucidated. Therefore, we assessed circulatory effects in the first 24 h of restriction of resuscitation fluid as compared to standard care in intensive care unit (ICU) patients with septic shock. Methods This was a post-hoc analysis of the multicentre CLASSIC randomised trial in which patients with septic shock, who had received the initial fluid resuscitation, were randomised to a protocol restricting resuscitation fluid or a standard care protocol in nine ICUs. The highest plasma lactate, highest dose of noradrenaline, and the urinary output were recorded in five time frames in the first 24 h after randomisation. We used multiple linear mixed effects models to compare the two groups. Results We included all 151 randomised patients; the cumulated fluid resuscitation volume in the first 24 h after randomisation was median 500 ml (Interquartile range (IQR) 0–1500) and 1250 ml (500–2500) in the fluid restriction group and standard care group, respectively. The estimated differences in the fluid restriction group vs. the standard care group were 0.1 mM (95% confidence interval −0.7 to 0.9; P = 0.86) for lactate, 0.01 μg/kg/min (−0.02 to 0.05; P = 0.48) for dose of noradrenaline, and −0.1 ml/kg/h (−0.3 to 0.2; P = 0.70) for urinary output during the first 24 h after randomisation. Conclusions We observed no indications of worsening of measures of circulatory efficacy in the first 24 h of restriction of resuscitation fluid as compared with standard care in adults with septic shock who had received initial resuscitation.

Pharmacokinetics of 400 mg ropivacaine after periarticular local infiltration analgesia for total knee arthroplasty

Abstract: Background: Although considered safe, no pharmacokinetic data of high dose, high volume local infiltration analgesia (LIA) with ropivacaine without the use of a surgical drain or intra-articular catheter have been described. The purpose of this study is to describe the maximum total and unbound ropivacaine concentrations (C-max, C-u max) and corresponding maximum times (T-max, T-u max) of a single-shot ropivacaine (200 ml 0.2%) and 0.75 mg epinephrine (1000 g/ml) when used for LIA in patients for total knee arthroplasty. Methods: In this prospective cohort study, 20 patients were treated with LIA of the knee for primary total knee arthroplasty. Plasma samples were taken at 20, 40, 60, 90, 120, 240, 360 min and at 24 h after tourniquet release, in which total and unbound ropivacaine concentrations were determined. Results: Results are given as median [IQR]. Highest ropivacaine concentration (C-max) was 1.06 mu g/ml [0.34]; highest unbound ropivacaine concentration (C-u max) was 0.09 mu g/ml [0.05]. The corresponding time to reach the maximum concentration for total ropivacaine was 312 min [120] after tourniquet release, and for the unbound fraction 265 [110] min after tourniquet release. Conclusion: Although great inter-individual variability was found between the maximum ropivacaine concentrations, both maximum total and unbound serum concentrations of ropivacaine remained well below the assumed systemic toxic thresholds of 4.3 and 0.56 mu g/ml.