Showing papers in "Acta Anaesthesiologica Scandinavica in 2018"

The role of prehabilitation in frail surgical patients: A systematic review.

Abstract: Introduction Increasing emphasis is being placed on the detection of frailty in the pre-operative setting given its association with surgical morbidity and mortality. Prehabilitation seeks to increase the physiological reserve of frail patients, attenuating the risk of irreversible functional decline following surgery. Aim/hypothesis This systematic review appraises the evidence available for prehabilitation in frail surgical patients. We proposed that exercise prehabilitation would especially benefit frail patients, with improvements in pre-operative functional capacity, and reductions in complications and length of hospital stay. Methods A literature search was conducted in MEDLINE, PubMed and CINAHL databases. Studies were included if they consisted of a prehabilitation intervention in frail patients undergoing surgery and specified a frailty model/index. Eight studies were included for analysis, 2 of which are ongoing studies. Results In 3 studies, prehabilitation consisted of an exercise intervention alone. There was a high feasibility of prehabilitation and a trend to improved pre-operative function, however, no evidence of improved post-operative functional recovery was there. In 2 studies, prehabilitation consisted of both exercise and nutritional interventions. Reductions in mortality and duration of hospital stay were reported, but the quality of evidence was judged to be very low. There was a lack of evidence of improved outcomes following pre-operative inspiratory muscle training in frail patients. Discussion This systematic review focuses on prehabilitation in frail surgical patients and reports that evidence supporting any outcome is limited, despite high feasibility and acceptability. There is a need for large randomised controlled trials to better establish the effects of prehabilitation in frail patients.

Intraoperative ketamine administration to prevent delirium or postoperative cognitive dysfunction: A systematic review and meta-analysis

Abstract: Background Postoperative cognitive complications are associated with substantial morbidity and mortality. Ketamine has been suggested to have neuroprotective effects in various settings. This systematic review evaluates the effects of intraoperative ketamine administration on postoperative delirium and postoperative cognitive dysfunction (POCD). Methods Medline, Embase and Central were searched to 4 March 2018 without date or language restrictions. We considered randomised controlled trials (RCTs) comparing intraoperative ketamine administration versus no intervention in adults undergoing surgery under general anaesthesia. Primary outcomes were postoperative delirium and POCD. Non-cognitive adverse events, mortality and length of stay were considered as secondary outcomes. Data were independently extracted. The quality of the evidence (GRADE approach) was assessed following recommendations from the Cochrane collaboration. Risk ratios were calculated for binary outcomes, mean differences for continuous outcomes. We planned to explore the effects of age, specific anaesthesia regimen, depth of anaesthesia and intraoperative haemodynamic events through subgroup analyses. Results Six RCTs were included. The incidence of postoperative delirium did not differ between groups (4 trials, 557 patients, RR 0.83, 95% CI [0.25, 2.80]), but patients receiving ketamine seemed at lower risk of POCD (3 trials, 163 patients, RR 0.34, 95% CI [0.15, 0.73]). However, both analyses presented limitations. Therefore, the quality of the evidence (GRADE) was deemed low (postoperative delirium) and very low (POCD). Conclusion The effect of ketamine on postoperative delirium remains unclear but its administration may offer some protection towards POCD. Large, well-designed randomised trials are urgently needed to further clarify the efficacy of ketamine on neurocognitive outcomes.

Implementation and effectiveness of a video‐based debriefing programme for neonatal resuscitation

Abstract: Background Approximately 5%-10% of newly born babies need intervention to assist transition from intra- to extrauterine life. All providers in the delivery ward are trained in neonatal resuscitation, but without clinical experience or exposure, training competency is transient with a decline in skills within a few months. The aim of this study was to evaluate whether neonatal resuscitations skills and team performance would improve after implementation of video-assisted, performance-focused debriefings. Methods We installed motion-activated video cameras in every resuscitation bay capturing consecutive compromised neonates. The videos were used in debriefings led by two experienced facilitators, focusing on guideline adherence and non-technical skills. A modification of Neonatal Resuscitation Performance Evaluation (NRPE) was used to score team performance and procedural skills during a 7 month study period (2.5, 2.5 and 2 months pre-, peri- and post-implementation) (median score with 95% confidence interval). Results We compared 74 resuscitation events pre-implementation to 45 events post-implementation. NRPE-score improved from 77% (75, 81) to 89% (86, 93), P 100 bpm at 2 min improved from 71% pre- vs. 82% (P = 0.22) post-implementation. Conclusion Implementation of video-assisted, performance-focused debriefings improved adherence to best practice guidelines for neonatal resuscitation skill and team performance.

Perioperative goal-directed therapy: A systematic review without meta-analysis.

Abstract: Background Perioperative goal-directed therapy aims to optimise haemodynamics by titrating fluids, vasopressors and/or inotropes to predefined haemodynamic targets. Perioperative goal-directed therapy is a complex intervention composed of several independent component interventions. Trials on perioperative goal-directed therapy show conflicting results. We aimed to conduct a systematic review and meta-analysis to investigate the benefits and harms of perioperative goal-directed therapy. Methods PubMED, EMBASE, Web of Science and Cochrane Library were searched. Trials were included if they had a perioperative goal-directed therapy protocol. The primary outcome was all-cause mortality. The first secondary outcome was serious adverse events excluding mortality. Risk of bias was assessed, and GRADE was used to evaluate quality of evidence. Results One hundred and twelve randomised trials were included of which one trial (1%) had low risk of bias. Included trials varied in patients: types of surgery which was expected due to inclusion criteria; in intervention and comparison: timing of intervention, monitoring devices, haemodynamic variables, target values, use of fluids, vasopressors and/or inotropes as well as combinations of these within protocols; and in outcome: mortality was reported in 87 trials (78%). Due to substantial clinical heterogeneity also within the various types of surgery a meta-analysis of data, including subgroup analyses, as defined in our protocol was considered inappropriate. Conclusion Clinical heterogeneity in patients, interventions and outcomes in perioperative goal-directed therapy trials is too large to perform meta-analysis on all trials. Future trials and meta-analyses highly depend on universally agreed definitions on aspects beyond type of surgery of the complex intervention and its evaluation.

Pain assessment by pupil dilation reflex in response to noxious stimulation in anaesthetized adults

Abstract: BACKGROUND In response to noxious stimulation, pupillary dilation reflex (PDR) occurs even in anaesthetized patients. The aim of the study was to evaluate the ability of pupillometry with an automated increasing stimulus intensity to monitor intraoperative opioid administration. METHODS Thirty-four patients undergoing elective surgery were enrolled. Induction by propofol anaesthesia was increased progressively until the sedation depth criteria (SeD) were attained. Subsequently, a first dynamic pupil measurement was performed by applying standardized nociceptive stimulation (SNS). A second PDR evaluation was performed when remifentanil reached a target effect-site concentration. Automated infrared pupillometry was used to determine PDR during nociceptive stimulations generating a unique pupillary pain index (PPI). Vital signs were measured. RESULTS After opioid administration, anaesthetized patients required a higher stimulation intensity (57.43 mA vs 32.29 mA, P < .0005). Pupil variation in response to the nociceptive stimulations was significantly reduced after opioid administration (8 mm vs 28 mm, P < .0005). The PPI score decreased after analgesic treatment (8 vs 2, P < .0005), corresponding to a 30% decrease. The elicitation of PDR by nociceptive stimulation was performed without changes in vital signs before (HR 76 vs 74/min, P = .09; SBP 123 vs 113 mm Hg, P = .001) and after opioid administration (HR 63 vs 62/min, P = .4; SBP 98.66 vs 93.77 mm Hg, P = .032). CONCLUSIONS During propofol anaesthesia, pupillometry with the possibility of low-intensity standardized noxious stimulation via PPI protocol can be used for PDR assessment in response to remifentanil administration.

Development and internal validation of the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU).

Abstract: BACKGROUND Intensive care unit (ICU) mortality prediction scores deteriorate over time, and their complexity decreases clinical applicability and commonly causes problems with missing data. We aimed to develop and internally validate a new and simple score that predicts 90-day mortality in adults upon acute admission to the ICU: the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU). METHODS We used data from an international cohort of 2139 patients acutely admitted to the ICU and 1947 ICU patients with severe sepsis/septic shock from 2009 to 2016. We performed multiple imputations for missing data and used binary logistic regression analysis with variable selection by backward elimination, followed by conversion to a simple point-based score. We assessed the apparent performance and validated the score internally using bootstrapping to present optimism-corrected performance estimates. RESULTS The SMS-ICU comprises seven variables available in 99.5% of the patients: two numeric variables: age and lowest systolic blood pressure, and five dichotomous variables: haematologic malignancy/metastatic cancer, acute surgical admission and use of vasopressors/inotropes, respiratory support and renal replacement therapy. Discrimination (area under the receiver operating characteristic curve) was 0.72 (95% CI: 0.71-0.74), overall performance (Nagelkerke's R2 ) was 0.19 and calibration (intercept and slope) was 0.00 and 0.99, respectively. Optimism-corrected performance was similar to apparent performance. CONCLUSIONS The SMS-ICU predicted 90-day mortality with reasonable and stable performance. If performance remains adequate after external validation, the SMS-ICU could prove a valuable tool for ICU clinicians and researchers because of its simplicity and expected very low number of missing values.

Spread of injectate around hip articular sensory branches of the femoral nerve in cadavers.

Abstract: Background Anatomical knowledge dictates that regional anaesthesia after total hip arthroplasty requires blockade of the hip articular branches of the femoral and obturator nerves. A direct femoral nerve block increases the risk of fall and impedes mobilisation. We propose a selective nerve block of the hip articular branches of the femoral nerve by an ultrasound-guided injection in the plane between the iliopsoas muscle and the iliofemoral ligament (the iliopsoas plane). The aim of this study was to assess whether dye injected in the iliopsoas plane spreads to all hip articular branches of the femoral nerve. Methods Fifteen cadaver sides were injected with 5 mL dye in the iliopsoas plane guided by ultrasound. Dissection was performed to verify the spread of injectate around the hip articular branches of the femoral nerve. Results In 10 dissections (67% [95% confidence interval: 38-88%]), the injectate was contained in the iliopsoas plane staining all hip articular branches of the femoral nerve without spread to motor branches. In four dissections (27% [8-55%]), the injection was unintentionally made within the iliopectineal bursa resulting in secondary spread. In one dissection (7% [0.2-32%]) adhesions partially obstructed the spread of dye. Conclusion An injection of 5 mL in the iliopsoas plane spreads around all hip articular branches of the femoral nerve in 10 of 15 cadaver sides. If these findings translate to living humans, injection of local anaesthetic into the iliopsoas plane could generate a selective sensory nerve block of the articular branches of the femoral nerve without motor blockade.

Continuous vital sign monitoring after major abdominal surgery-Quantification of micro events.

Abstract: INTRODUCTION Millions of patients undergo major abdominal surgery worldwide each year, and the post-operative phase carries a high risk of respiratory and circulatory complications. Standard ward observation of patients includes vital sign registration at regular intervals. Patients may deteriorate between measurements, and this may be detected by continuous monitoring. The aim of this study was to compare the number of micro events detected by continuous monitoring to those documented by the widely used standardized Early Warning Score (EWS). METHODS Fifty patients were continuously monitored with peripheral arterial oxygen saturation (SpO2 ), heart rate (HR), and respiratory rate (RR) the first 4 days after major abdominal cancer surgery. EWS was monitored as routine practice. Number and duration of events were analyzed using Fisher's exact test and Wilcoxon rank sum test. RESULTS Continuous monitoring detected a SpO2 <92% in 98% of patients vs 16% of patients detected by EWS (P < .0001). Micro events of SpO2 <92% lasting longer than 60 minutes were found in 58% of patients by continuous monitoring vs 16% by the EWS (P < .0001). Fifty-two percent of patients had micro events of SpO2 <85% lasting longer than 10 minutes. Continuous monitoring found tachycardia in 60% of patients vs 6% by the EWS. Frequency of events for bradycardia, tachypnea, and bradypnea showed similar patterns. CONCLUSION Very low SpO2 and tachycardia in post-operative patients are common and under-diagnosed by the EWS. Continuous monitoring can discover these micro events and potentially contribute to earlier detection and, potentially, result in prevention of clinical complications.

Validation of the Swedish version of Quality of Recovery score ‐15: a multicentre, cohort study

Abstract: Background Quality of recovery (QoR) after surgery is often focused on morbidity, mortality and physiological changes, while well-being and emotional state are other important aspects that are often ignored. QoR is poorly investigated in clinical settings and a psychometrically tested questionnaire, QoR-15, has recently been developed. QoR-15 has not been validated for Swedish conditions. The aim of this study was to translate, adapt and validate QoR-15 to Swedish conditions (QoR-15swe). Methods A translation and cultural adaption was performed resulting in a Swedish version of the instrument, QoR-15swe. Patients answered the QoR-15swe before surgery, 24 and 48 h after surgery. Feasibility, validity, reliability and responsiveness of the QoR-15swe were evaluated. Results The QoR-15swe was feasible in 85.5% of the eligible patients. Construct validity was good, with significant correlations between QoR-15swe score and, ASA-PS class, grade of surgery, length of surgery and time in the post-anaesthesia care unit. The instrument demonstrated good internal consistency with an inter-item Cronbach's α of 0.83-0.87, and inter-dimension Cronbach's α was acceptable 0.71-0.76. Test-retest repeatability was also good with Cronbach's alpha > 0.99 and an interclass correlation coefficient of 0.992 (CI: 0.981-0.997). There were no floor and ceiling effects. Responsiveness assessed by Cliff's effect size was -0.23 indicating a moderate ability to detect change at 24 h postoperatively. Conclusion We have translated and culturally adapted the QoR-15 into Swedish. The score demonstrated acceptable validity, reliability and responsiveness. The QoR-15swe is a clinically acceptable and feasible outcome measure after surgery in a Swedish population.

A pilot study of hyperoxemia on neurological injury, inflammation and oxidative stress.

Abstract: Background Normobaric hyperoxia is used to alleviate secondary brain ischaemia in patients with traumatic brain injury (TBI), but clinical evidence is limited and hyperoxia may cause adverse events. Methods An open label, randomised controlled pilot study comparing blood concentrations of reactive oxygen species (ROS), interleukin 6 (IL-6) and neuron-specific enolase (NSE) between two different fractions of inspired oxygen in severe TBI patients on mechanical ventilation. Results We enrolled 27 patients in the Fi O2 0.40 group and 38 in the Fi O2 0.70 group; 19 and 23 patients, respectively, completed biochemical analyses. In baseline, there were no differences between Fi O2 0.40 and Fi O2 0.70 groups, respectively, in ROS (64.8 nM [22.6-102.1] vs. 64.9 nM [26.8-96.3], P = 0.80), IL-6 (group 92.4 pg/ml [52.9-171.6] vs. 94.3 pg/ml [54.8-133.1], P = 0.52) or NSE (21.04 ug/l [14.0-30.7] vs. 17.8 ug/l [14.1-23.9], P = 0.35). ROS levels did not differ at Day 1 (24.2 nM [20.6-33.5] vs. 29.2 nM [22.7-69.2], P = 0.10) or at Day 2 (25.4 nM [21.7-37.4] vs. 47.3 nM [34.4-126.1], P = 0.95). IL-6 concentrations did not differ at Day 1 (112.7 pg/ml [65.9-168.9) vs. 83.9 pg/ml [51.8-144.3], P = 0.41) or at Day 3 (55.0 pg/ml [34.2-115.6] vs. 49.3 pg/ml [34.4-126.1], P = 0.95). NSE levels did not differ at Day 1 (15.9 ug/l [9.0-24.3] vs. 15.3 ug/l [12.2-26.3], P = 0.62). There were no differences between groups in the incidence of pulmonary complications. Conclusion Higher fraction of inspired oxygen did not increase blood concentrations of markers of oxidative stress, inflammation or neurological injury or the incidence of pulmonary complications in severe TBI patients on mechanical ventilation.

Should impaired mobility on presentation be a vital sign

Abstract: INTRODUCTION Vital signs are routinely used to assess acutely ill patients, but they do not detect all patients at risk of death. This retrospective multicenter cohort study compares the prediction of death by impaired mobility with age, co-morbidities, and vital sign changes. METHODS On first assessment, patients from a combined cohort of 9684 Danish and Irish patients and a separate cohort of 1010 Ugandan patients were stratified by impaired mobility on presentation (IMOP), vital sign changes assessed by the National Early Warning Score (NEWS), the Charlson Co-morbidity Index, and age. RESULTS Fourteen percent of Danish and Irish patients had IMOP compared with 42% of Ugandan patients. The odds ratios of IMOP for 7-day mortality were similar for both cohorts (i.e. 11.8, 95% CI 5.8-24.0 for Ugandan patients versus 6.7, 95% CI 5.0-9.0 for Danish and Irish patients). Univariate analysis of Ugandan patients showed that none of the parameters tested (i.e. low blood pressure, pulse, elevated respiratory rate, hypothermia, low oxygen saturation, old age, and coma) had a statistically higher odds ratio for either 7-day mortality than IMOP. Multivariate logistic regression analysis of Danish and Irish patients also showed that none of these parameters or the Charlson Co-morbidity Index had a statistically higher odds ratio than IMOP for either 7-day or 30-day mortality. CONCLUSION Immobility on presentation is a vital sign and predicts mortality for acutely ill patients independently of the traditional vital signs, age, and co-morbidities.

Accuracy of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity score and the Nottingham risk score in hip fracture patients in Sweden — A prospective observational study

Abstract: Background: Little is known about accuracy of common risk prediction scores in elderly patients suffering from hip fractures. The objective of this study was to investigate accuracy of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) score, Portsmouth-POSSUM (P-POSSUM) score and the Nottingham Hip Fracture Score (NHFS) for prediction of mortality and morbidity in this patient group. Methods: This was a prospective single centre observational study on 997 patients suffering out-of-hospital cervical, trochanteric or subtrochanteric fracture of the neck of the femur. Calibration and discrimination was assessed by calculating the ratio of observed to expected events (O:E) and areas under receiver operating characteristics curves (ROC). Results: The 30-day mortality was 6.2% and complications, as defined by POSSUM, occurred in 41% of the patients. Overall O:E ratios for POSSUM, P-POSSUM and NHFS scores for 30-day mortality were 0.90, 0.98, and 0.79 respectively. The models underestimated mortality in the lower risk bands and overestimated mortality in the higher risk bands. In contrast, POSSUM predicted morbidity well with O:E ratios close to unity in most risk bands. The areas under the ROC curves for the scoring systems was 0.60-0.67. Conclusion: The POSSUM score and NHFS show moderate calibration and poor discrimination in this cohort. The results suggest that mortality and morbidity in hip fracture patients are largely dependent on factors that are not included in these scores.

Remote ischaemic preconditioning increases serum extracellular vesicle concentrations with altered micro-RNA signature in CABG patients.

Abstract: BACKGROUND Remote ischaemic preconditioning (RIPC) can attenuate myocardial ischaemia/reperfusion injury but its underlying mechanisms remain largely unknown. Recently, extracellular vesicles (EVs) containing microRNAs (miRNAs) were shown to mediate distant intercellular communication that may be involved in cardioprotection. We tested the hypothesis that RIPC in anaesthetized patients undergoing coronary artery bypass (CABG) surgery results in the release of EVs from the ischaemic/reperfused arm into the blood stream harbouring cardioprotective miRNAs. METHODS In 58 patients randomised to RIPC (three 5/5 minutes episodes of left arm ischaemia/reperfusion by suprasystolic blood pressure cuff inflations/deflations) or Sham, a subprotocol comprising of parallel right radial artery and regional (left subclavian) venous blood sampling before (awake) and 5 and 60 minutes after RIPC/Sham during isoflurane/sufentanil anaesthesia could be completed. EVs were extracted by polymer-based precipitation methods, their concentrations measured, and their miRNA signature analysed. RESULTS Five minutes after RIPC, regional venous EV concentrations downstream from the cuff increased and arterial concentrations increased after 60 minutes (fold change [fc]: RIPC: 1.33 ± 0.5, Sham: 0.91 ± 0.31; P = 0.003 for interaction). Already 5 minutes after RIPC, expression of 26 miRNAs (threshold fc: 3.0, P < 0.05) isolated from EVs including the cardioprotective miR-21 had increased. RIPC also decreased postoperative Troponin I concentrations (AUC RIPC: 336 ng/mL × 72 hours ± 306 vs Sham: 713 ± 1013; P = 0.041). CONCLUSIONS Remote ischaemic preconditioning increases serum EV concentrations, most likely by early EV release from the patients' left (RIPC) arm, alters their miRNA signature, and is associated with myocardial protection. Thus, an increased EV concentration with an altered miR-signature may mediate the RIPC effect.

Lactate, lactate clearance and outcome after cardiac arrest: A post-hoc analysis of the TTM-Trial.

Abstract: Background: Admission lactate and lactate clearance are implemented for risk stratification in sepsis and trauma. In out-of-hospital cardiac arrest, results regarding outcome and lactate are conflicting. Methods: This is a post-hoc analysis of the Target Temperature Management trial in which 950 unconscious patents after out-of-hospital cardiac arrest were randomized to a temperature intervention of 33°C or 36°C. Serial lactate samples during the first 36 hours were collected. Admission lactate, 12-hour lactate, and the clearance of lactate within 12 hours after admission were analyzed and the association with 30-day mortality assessed. Results: Samples from 877 patients were analyzed. In univariate logistic regression analysis, the odds ratio for death by day 30 for each mmol/L was 1.12 (1.08-1.16) for admission lactate, P <.01, 1.21 (1.12-1.31) for 12-hour lactate, P <.01, and 1.003 (1.00-1.01) for each percentage point increase in 12-hour lactate clearance, P =.03. Only admission lactate and 12-hour lactate levels remained significant after adjusting for known predictors of outcome. The area under the receiver operating characteristic curve was 0.65 (0.61-0.69), P <.001, 0.61 (0.57-0.65), P <.001, and 0.53 (0.49-0.57), P =.15 for admission lactate, 12-hour lactate, and 12-hour lactate clearance, respectively. Conclusions: Admission lactate and 12-hour lactate values were independently associated with 30-day mortality after out-of-hospital cardiac arrest while 12-hour lactate clearance was not. The clinical value of lactate as the sole predictor of outcome after out-of-hospital cardiac arrest is, however, limited. (Less)

Scandinavian SSAI clinical practice guideline on choice of inotropic agent for patients with acute circulatory failure

Abstract: BACKGROUND: Adult critically ill patients often suffer from acute circulatory failure and those with low cardiac output may be treated with inotropic agents. The aim of this Scandinavian Society of ...

Simulation-based point-of-care ultrasound training: a matter of competency rather than volume

Abstract: Background Point-of-care ultrasonography plays an increasingly important role in the initial resuscitation of critically ill patients but acquisition of the skill is associated with long learning curves. The skills required to perform ultrasound examinations can be practiced in a simulated setting before being performed on actual patients. The aim of this study was to investigate the learning curves for novices training the FAST protocol on a virtual-reality simulator. Methods Ultrasound novices (N = 25) were instructed to complete a FAST training program on a virtual-reality ultrasound simulator. Participants were instructed to continue training until they reached a previously established mastery learning level, which corresponds to the performance level of a group of ultrasound experts. Performance scores and time used during each FAST examination were used to determine participants' learning curves. Results The participants attained the mastery learning level within a median of three (range two to four) attempts corresponding to a median of 1 h 46 min (range 1 h 2 min to 3 h 37 min) of simulation training. The ultrasound novices' examination speed improved significantly with training, and continued to improve even after they attained the mastery learning level (P = 0.011). Twenty-three participants attained the mastery learning level. Conclusion Novices can attain mastery learning levels using simulation-based ultrasound training with less than, on average, 2 h of practice. However, we found large variations in the amount of training needed, which raises questions about the adequacy of current volume-based models for determining ultrasound competency.

Necrotizing soft tissue infections - a multicentre, prospective observational study (INFECT): Protocol and statistical analysis plan

Abstract: Background The INFECT project aims to advance our understanding of the pathophysiological mechanisms in necrotizing soft tissue infections (NSTIs). The INFECT observational study is part of the INFECT project with the aim of studying the clinical profile of patients with NSTIs and correlating these to patient-important outcomes. With this protocol and statistical analysis plan we describe the methods used to obtain data and the details of the planned analyses. Methods The INFECT study is a multicentre, prospective observational cohort study. Patients with NSTIs are enrolled in five Scandinavian hospitals, which are all referral centres for NSTIs. The primary outcomes are the descriptive variables of the patients. Secondary outcomes include identification of factors associated with 90-day mortality and amputation; associations between affected body part, maximum skin defect and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score and 90-day mortality; 90-day mortality in patients with and without acute kidney injury (AKI) and LRINEC score of six and above or below six; and association between affected body part at arrival and microbiological findings. Exploratory outcomes include univariate analyses of baseline characteristics associations with 90-day mortality. The statistical analyses will be conducted in accordance with the predefined statistical analysis plan. Conclusion Necrotizing soft tissue infections result in severe morbidity and mortality. The INFECT study will be the largest prospective study in patients with NSTIs to date and will provide important data for clinicians, researchers and policy makers on the characteristics and outcomes of these patients.

Attitudes of physicians towards the care of critically ill elderly patients - a European survey.

Abstract: © 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Delirium and effect of circadian light in the intensive care unit: a retrospective cohort study.

Abstract: Background Delirium is a serious condition often experienced by critically ill patients in intensive care units (ICUs). The role of circadian light for this condition is unclear. The aim of this study was to describe incidence of delirium, risk factors for delirium, and the association between delirium and circadian light for patients in the ICU. Methods This is a retrospective cohort study of all patients at a Danish ICU from 1 August 2015 to 31 January 2016. Exclusion criteria were heavy sedation, no Confusion Assessment Method for the ICU (CAM-ICU) scores, or inability to communicate in Danish. Delirium was defined as at least one positive CAM-ICU score or treatment with haloperidol. Three of nine beds at the ICU had a circadian light installation. Allocation to ICU beds with or without circadian light depended on availability at admission. Risk factors for development of delirium were analyzed by simple and multiple logistic regression. Results We included 183 patients in the study. The incidence of delirium was 28% (95% CI 22, 35). Allocation to beds with or without circadian lighting was not associated with delirium incidence (OR 1.14; 95% CI 0.55, 2.37; P = 0.73). We found that Simplified Acute Physiology Score II (SAPS II) (OR 1.03; 95% CI 1.01, 1.06; P = 0.002), and dexmedetomidine was associated with delirium (OR 4.14; 95% CI 1.72, 10.03; P = 0.002). Conclusion In this population of patients admitted to an ICU during 6 months, the incidence of delirium was 28%. We did not find an association between circadian light and development of delirium.

Pleth variability index can predict spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery

Abstract: Background Spinal anaesthesia carries a risk of hypotension. We hypothesized that pleth variability index and perfusion index would assess maternal volume status, and thus, allow identification of patients at higher risk of developing hypotension after spinal anaesthesia for caesarean delivery. Methods Fifty patients undergoing elective caesarean delivery were enrolled. All patients received spinal anaesthesia with 0.5% hyperbaric bupivacaine (10 mg) and fentanyl (10 mcg). Blood pressure was measured every minute. Pleth variability index and perfusion index were automatically measured throughout the procedure using pulse oximetry on the index finger. In case of hypotension (systolic blood pressure below 90 mmHg or 80% of the baseline value), ephedrine 5 mg was administered. Receiver-operating characteristic and multivariate logistic regression analyses for spinal anaesthesia-induced hypotension were performed. Results Hypotension occurred in 32 patients (64%). The areas under the receiver-operating characteristic curve were 0.751 (95% confidence interval: 0.597–0.904) for pleth variability index before anaesthesia, 0.793 (95% confidence interval: 0.655–0.930) for pleth variability index after anaesthesia and 0.731 (95% confidence interval: 0.570–0.892) for perfusion index change (percent change in perfusion index induced by spinal anaesthesia). The optimal threshold value of pleth variability index (after anaesthesia) for predicting hypotension was 18% (sensitivity: 78.1%, specificity: 83.3%). Pleth variability index after spinal anaesthesia was an independent factor for hypotension (odds ratio: 1.21, P = 0.041). Conclusions Pleth variability index after spinal anaesthesia was a good predictor of spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery. In addition, perfusion index change after spinal anaesthesia has the potential to predict hypotension.

Analysis of hypo- and hypermagnesemia in an intensive care unit cohort

Abstract: Introduction: The aim of this study was to evaluate if magnesium deviations correlate with higher 180 day overall mortality or increased morbidity, compared to controls. Methods: We conducted a retrospective study on 5369 patients with 22,003 magnesium values treated at the Adult Intensive Care Unit at Skane University Hospital, Lund, Sweden during 2006-2014. The patients were retrospectively divided into a control group with only normal magnesium values 0.7-1.0 mmol/l, and three study groups; hypomagnesemic; Mg2+ 1.0 mmol/l and an unstable mixed group showing both hypo/hypermagnesemia. Gender, age, disease severity represented by maximum organ system SOFA score, renal SOFA score, lowest potassium value and diagnoses classes were included in a Cox hazard model in order to adjust for confounding factors, with time to death in the first 180 days from the ICU admission as outcome. Results: The hypermagnesemic study group and the mixed group showed increased hazard ratios for mortality; 1.4 (CI 98.3% 1.2, 1.6, P < 0.0001) and 2.1 (CI 98.3% 1.2, 2.8, P < 0.0001) respectively, compared to controls, while the hypomagnesemic group did not reach significance. In addition, patients in the hypermagnesemic and the mixed groups are older, more ill with significantly higher EMR and SOFA scores and show significantly longer ventilator times and ICU stays, compared to controls. Conclusions: Patients with magnesium deviations are more ill compared to patients with explicitly normal magnesium values throughout the ICU stay. Cox analysis suggests that the magnesium deviation itself might have an impact on mortality. (Less)

Norwegian standard for the safe practice of anaesthesia.

Abstract: 2.1 Definitions • The term anaesthesia care shall be taken to cover anaesthetic preoperative assessments, general anaesthesia, regional anaesthesia, intravenous sedation using a titrated dose, anaesthesia standby and postoperative care. • Anaesthetic staff refers to consultant anaesthetists, anaesthetists and nurse anaesthetists. • A consultant anaesthetist is a doctor who is a fully qualified specialist anaesthetist. • In this document, the term anaesthetist refers to a doctor employed at an anaesthetic department (a consultant anaesthetist or registrar anaesthetist, but not a house officer). • A nurse anaesthetist has a Master’s degree or a post graduate education as nurse anaesthetist based on the Norwegian national curriculum or equivalent. • The ASA group refers to the patient’s physical condition based on the American Society of Anesthesiologist’s classification system.3

Patients' opinions on outcomes following critical illness.

Abstract: Background Our aim was to explore which outcomes are most important to patients following ICU-discharge, and to explore whether intensive care unit (ICU)-nurses and anesthesiologists are aware of patients' priorities. Methods First, interviews with adult ICU-survivors were conducted until data saturation was achieved (10 interviews), and six areas with 36 items were identified. Second, interviews with another eight ICU-survivors were conducted, narrowing the list to 20. Finally, patients (inclusion criteria: consecutive adults, medical and surgical, ICU-admission > 5 days, 2-8 months post-ICU discharge) rated the items, as did ICU-nurses and anesthesiologists. Results A total of 32 patients participated (44% women, medians: age 70.5, time since discharge 179 days, length of stay in ICU 9 days, APACHEII 19.5). The three most important outcomes defined by patients were: lack of physical strength, fatigue, and decreased walking distance. The top three for ICU-nurses (54 participants) were: fatigue, difficulties concentrating, sadness/depression, and for anesthesiologists (17 participants): fatigue, difficulties in activities of daily living, and lack of physical strength. Conclusion Patients chose lack of physical strength, fatigue, and decreased walking distance as the three most important outcomes following critical illness. Physicians had a higher focus on these physical impairments than ICU-nurses.

Non-transport emergency medical service missions - a retrospective study based on medical charts.

Abstract: BACKGROUND In Finland, approximately 40% of emergency medical service (EMS) missions do not result in transport of the patient to a hospital by ambulance, and there is wide variability in the reasons underlying non-transport decisions. The aim of this study was to describe the context of these EMS non-transport missions. METHODS The data were collected retrospectively between 3 September and 20 October 2014 by investigating non-transport EMS charts (n = 1154). Event information and patients' main symptoms were extracted from information found in EMS charts and quantified using content and statistical analyses. RESULTS Patients' need for EMS were explained by various reasons. One-third of the missions were caused by organ-specific symptoms, whereas in 30.8% of cases the reason for EMS was unspecified. Sudden onset symptoms were noted for 38.4% of the cases, whereas in 14.7% of cases the symptoms had persisted for days or weeks before EMS contact. EMS personnel offered guidance instead of treatment in 79.2% of the missions. CONCLUSIONS Non-transport missions represent a significant daily work load for the EMS. Although most of the symptoms showed acute onset, the majority of these missions involved only assessment of medical necessity and/or guidance without any medical treatment. It is questionable whether this use of the EMS is cost-effective for any healthcare system.

Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental?

Abstract: BACKGROUND The benefits of pre-hospital emergency anaesthesia (PHEA) are controversial. Patients who are hypovolaemic prior to induction of anaesthesia are at risk of severe cardiovascular instability post-induction. This study compared mortality for hypovolaemic trauma patients (without major neurological injury) undergoing PHEA with a patient cohort with similar physiology transported to hospital without PHEA. METHODS A retrospective database review was performed to identify patients who were hypotensive on scene [systolic blood pressure (SBP) < 90 mmHg], and GCS 13-15. Patient records were reviewed independently by two pre-hospital clinicians to identify the likelihood of hypovolaemia. Primary outcome measure was mortality defined as death before hospital discharge. RESULTS Two hundred and thirty-six patients were included; 101 patients underwent PHEA. Fifteen PHEA patients died (14.9%) compared with six non-PHEA patients (4.4%), P = 0.01; unadjusted OR for death was 3.73 (1.30-12.21; P = 0.01). This association remained after adjustment for age, injury mechanism, heart rate and hypovolaemia (adjusted odds ratio 3.07 (1.03-9.14) P = 0.04). Fifty-eight PHEA patients (57.4%) were hypovolaemic prior to induction of anaesthesia, 14 died (24%). Of 43 PHEA patients (42.6%) not meeting hypovolaemia criteria, one died (2%); unadjusted OR for mortality was 13.12 (1.84-578.21). After adjustment for age, injury mechanism and initial heart rate, the odds ratio for mortality remained significant at 9.99 (1.69-58.98); P = 0.01. CONCLUSION Our results suggest an association between PHEA and in-hospital mortality in awake hypotensive trauma patients, which is strengthened when hypotension is due to hypovolaemia. If patients are hypovolaemic and awake on scene it might, where possible, be appropriate to delay induction of anaesthesia until hospital arrival.

Comparison of analgesic efficacy between two approaches of paravertebral block for thoracotomy: A randomised trial.

Abstract: Background Although several approaches for ultrasound-guided thoracic paravertebral block have been introduced, little is known regarding the differences in analgesic efficacy. We conducted this prospective randomised trial to examine whether the type of approach for ultrasound-guided thoracic paravertebral block could affect analgesic quality in thoracotomy. Methods Patients scheduled for video-assisted thoracotomy were randomly allocated into two groups by block technique: the intercostal approach (group IC) or the paralaminar approach (group PL). At the start and end of surgery, 20 mL of 0.5% ropivacaine was injected, followed by a continuous infusion of 0.2% ropivacaine at 5 mL h-1 . We also started intravenous fentanyl patient-controlled analgesia at 0.5 μg kg-1 h-1 and bolus dose of 15 μg. The main outcome was the number of rescue fentanyl use. We also evaluated postoperative pain scores and number of blocked dermatomes showing a reduced sensation. Results Enrolment was ceased because of implementation of a minimally invasive surgical method. Overall, 42 subjects completed the trial for analysis. The number of rescue fentanyl use in group PL was significantly less than that in group IC at 3, 6, 12 and 24 hour postoperatively. The numerical rating scale (NRS) at rest in group PL was significantly lower at 1, 3, 6, and 12 hour postoperatively. Patients in Group PL developed significantly wider sensory block level (median (IQR [range]); 4 (4-5 [2-7])) than those in Group IC (3 (3-3 [2-9])). Conclusions We suggested that paralaminar approach provided superior analgesia for thoracotomy rather than the intercostal approach.

Recruitment of extravascular fluid by hyperoncotic albumin

Abstract: Background Although hyperoncotic albumin may be used to recruit oedema, its effectiveness remains unclear. Therefore, this issue was studied during infusion experiments in healthy volunteers. Method Fifteen healthy volunteers (mean age 31 years) received an infusion of 3 mL/kg of 20% albumin over 30 minutes. Their urinary excretion was recorded, and venous blood samples were taken to measure blood haemoglobin (Hb), haematocrit, colloid osmotic pressure as well as plasma albumin and sodium concentrations on 15 occasions over a period of 300 minutes. Plasma volume expansion was taken as the inverse of the fluid-induced dilution of venous plasma, as given by the blood Hb concentration. Mass balance calculations were used to estimate the mobilisation of fluid from the tissues. Results Maximum plasma volume expansion was reached 20 minutes after completing an infusion of 20% albumin. Urinary excretion was effectively increased, and the mobilised fluid from the tissues at 300 minutes amounted to 3.4 ± 1.2 mL for each infused mL of 20% albumin, of which 19% was of intracellular origin. The urinary excretion correlated strongly with the amount of recruited fluid (R2 = 0.87) and inversely with the plasma volume expansion (R2 = 0.53). Conclusion The infusion of 20% albumin significantly increases the plasma volume by recruiting interstitial fluid. After completing the infusion, there is a delay of 20 minutes until maximum plasma dilution is reached, and the duration of the plasma volume expansion lasts far beyond 5 hours.

Systematic overview and critical appraisal of meta-analyses of interventions in intensive care medicine.

Abstract: Rationale Meta-analysed intervention effect estimates are perceived to represent the highest level of evidence. However, such effects and the randomized clinical trials which are included in them need critical appraisal before the effects can be trusted. Objective Critical appraisal of a predefined set of all meta-analyses on interventions in intensive care medicine to assess their quality and assessed the risks of bias in those meta-analyses having the best quality. Methods We conducted a systematic search to select all meta-analyses of randomized clinical trials on interventions used in intensive care medicine. Selected meta-analyses were critically appraised for basic scientific criteria, (1) presence of an available protocol, (2) report of a full search strategy, and (3) use of any bias risk assessment of included trials. All meta-analyses which qualified these criteria were scrutinized by full "Risk of Bias in Systematic Reviews" ROBIS evaluation of 4 domains of risks of bias, and a "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" PRISMA evaluation. Results We identified 467 meta-analyses. A total of 56 meta-analyses complied with these basic scientific criteria. We scrutinized the risks of bias in the 56 meta-analyses by full ROBIS evaluation and a PRISMA evaluation. Only 4 meta-analyses scored low risk of bias in all the 4 ROBIS domains and 41 meta-analyses reported all 27 items of the PRISMA checklist. Conclusion In contrast with what might be perceived as the highest level of evidence only 0.9% of all meta-analyses were judged to have overall low risk of bias.

Radiologic indicators for prediction of difficult laryngoscopy in patients with cervical spondylosis.

Abstract: BACKGROUND We identified the most useful variables for prediction of difficult laryngoscopy in patients with cervical spondylosis according to physical indicators and preoperative skeletal X-ray and soft tissue MRI measurements. We hypothesized that there was a closer association between difficult laryngoscopy and radiologic indicators. METHODS We randomly enroled 315 patients undergoing elective cervical spine surgery and analysed the radiological and physical data in predicting difficult laryngoscopy. RESULTS We identified five variables that were most useful in predicting difficult laryngoscopy: the inter-incisor gap (P = 0.006), modified Mallampati test score (P = 0.004), distance from the highest point of the hyoid bone to the mandibular body (P 0.05) and that of modified Mallampati test (0.602, P < 0.05). CONCLUSION Distance from the highest point of the hyoid bone to the mandibular body appears to be the most accurate indicator for difficult laryngoscopy in patients with cervical spondylosis.

Aprepitant as a fourth antiemetic prophylactic strategy in high-risk patients: a double-blind, randomized trial.

Abstract: Background Post-operative nausea and vomiting (PONV) is one of the most important causes of patient discomfort after laparoscopic surgeries despite the use of a multimodal pharmacological approach. This study assessed whether the addition of aprepitant to a multimodal regimen would further decrease the incidence of PONV in high-risk patients. Methods Apfel-score three or four patients, scheduled for laparoscopic procedures to treat abdominal or pelvic cancer, were randomized to receive oral starch (control group) or 80 mg of oral aprepitant (treatment group) before induction of anaesthesia in a double-blind study. All patients received 4-8 mg of intravenous dexamethasone (at induction) and 4-8 mg of ondansetron (at the end) and a standardized total intravenous anaesthesia (TIVA) technique combined with neuraxial blockade. PONV was defined as any episode of nausea, vomiting or retching in the first 24 h after anaesthesia. Results Sixty-six patients completed the study. Vomiting occurred in 13/32 (40.6%) patients in the control group and in 1/34 (2.9%) patients in the treatment group (P = 0.0002, 95%CI: 18-54%) in the first 24 h after anaesthesia. Severe nausea occurred in two (6.3%) patients, and severe vomiting occurred in four (12.5%) patients in the control group. One patient presented with severe vomiting in the treatment group in the first 24 post-operative hours. Conclusion Eighty milligrams of aprepitant added to a three-drug multimodal prophylaxis strategy can bring benefits to a high-risk population by reducing PONV episodes and rescue antiemetic requirements. This study was registered in the ClinicalTrials.gov (NCT 02357693) database.