Background: Parental presence has been the topic of various studies to reduce perioperative anxiety, and it has been demonstrated that the selection of the accompanying parent decreases perioperative anxiety. Nevertheless, the selection process may be another challenging factor for the child during the preoperative period. Therefore, the aim of this study was to demonstrate that the presence of both parents during the preoperative period would be more appropriate in respect of not adding to anxiety, which can be created by a selection process.
Methods: The research included 80 children, aged 5-12 years, from both genders, undergoing elective day-case surgery for otolaryngological procedures. The participants were divided randomly into two groups of 40. In Group 1, children selected one parent to accompany them during the perioperative period, while in Group 2, both parents were present with the child. The modified Yale Preoperative Anxiety Scale (mYPAS) was used to assess the anxiety levels of the children. The Pediatric Anesthesia Emergence Delirium (PAED) scale was utilized to evaluate postoperative delirium. The evaluation of parents' anxiety was conducted using the State-Trait Anxiety Inventory (STAI).
Results: The mean mYPAS scores for Group 2 were lower than those of Group 1 in the preoperative waiting area and during anesthesia induction (mean difference [95% CI]: 5.8 [-4.5 to 13.5]; 7.5 [0.0 to 15.0], respectively). The mean PAED scores were similar in both groups (mean difference [95% CI]: -1.5 [-4.5 to 1.5]). The incidence of emergence delirium and the mean STAI anxiety scores of the parents were similar in both groups.
Conclusion: This study demonstrated that the presence of both parents reduced the anxiety of the child in both the preoperative period and during anesthesia induction. Moreover, this practice did not create any change in the incidence of emergence delirium, for which there are many risk factors besides preoperative anxiety.
Editorial comment: Children's preoperative anxiety in the operating room can be mitigated through different means. In this study, presence of both parents was compared to presence of one parent only, for anxiety scoring for the child. Findings showed benefit of having two parents present in this cohort.
Trial registration: ClinicalTrials.gov: NCT06634680.
Background: Characteristics and outcomes of patients with acute pancreatitis (AP) admitted to intensive care units (ICUs) are not well described in complete population-based national cohorts. Thus, we aimed to investigate the incidence over time and predictors of short- and long-term survival of AP treated in ICUs in a national cohort.
Methods: Nationwide observational cohort study in a universal healthcare system. Adult patients with AP admitted to Norwegian ICUs from 2016 to 2021 were identified using coded data from the Norwegian Intensive Care and Pandemic Registry and the Norwegian Patient Registry. Logistic regression was used to identify predictors of 90-day mortality. Overall survival was analyzed using Cox regression, and post-discharge survival was assessed for conditional relative survival.
Results: A total of 1183 patients were identified, with a median age of 64.8 years (interquartile range [IQR] 52.0-75.3) and 60.4% men. The average annual incidence was 3.8 per 100,000 inhabitants and increased significantly (ptrend = 0.048) during the study period. In-hospital mortality was 20.5% (n = 243), 90-day mortality 22.8% (n = 270), and the overall 1-year cumulative mortality was 28.0% (n = 331). Independent predictors of 90-day mortality included age (OR 1.05; 95% CI 1.04-1.07), SAPS II score (OR 1.06; 95% CI 1.05-1.07), Charlson Comorbidity Index (CCI) score (OR 1.2; 95% CI 1.10-1.31), and pancreatitis etiology. In the multivariable survival analysis of hospital survivors, age (HR 1.05; 95% CI 1.04-1.07), SAPS II (HR 1.01; 95% CI 1.00-1.02), and CCI (HR 1.29; 95% CI 1.21-1.38) were associated with increased risk of death, whereas biliary etiology (HR 0.48; 95% CI 0.30-0.78) and longer ICU length of stay (HR 0.98; 95% CI 0.97-1.00) were associated with a reduced risk of death. No association was found between advanced organ support and the risk of death after discharge from the hospital. Compared to an age- and gender-matched population, long-term survival of patients discharged alive was approximately 90%.
Conclusions: Admissions to the ICU for AP seem to increase in a national cohort, and 90-day mortality occurred in almost every 1 of 4 patients. Patients with ICU-treated AP discharged alive from the hospital have good long-term survival, although with reduced longevity compared to the age- and gender-adjusted general population.
Editorial comment: This registry-based nationwide study assesses the incidence and short- and long-term outcomes of AP in Norwegian ICUs over a 6-year period. The incidence of intensive care-treated pancreatitis seems to be increasing over this time period. Long-term outcome for the hospital survivors is good, almost at the level of the general population.
Background: Prehospital emergency anaesthesia and controlled ventilation are cornerstones in the treatment of traumatic brain injury patients. Currently, there is a lack of consensus regarding the choice of anaesthetic used during the induction of anaesthesia. Esketamine has gained significant popularity, but its use has been limited in patients with traumatic brain injury due to fears of increased intracranial pressure. A protocol for anaesthesia was implemented at a Finnish helicopter emergency medical services (HEMS) unit during 2015 that mandated the use of esketamine over propofol for most patients.
Methods: We performed a retrospective cohort study to evaluate the differences in mortality and physiology in patients with traumatic brain injury, intubated using either propofol or esketamine. We collected data on patients treated by a single HEMS unit in Finland between January 2014 and December 2021. Our primary outcome was mortality before hospital discharge, and our secondary outcome was physiological stability, defined as the frequency of hypotension (systolic blood pressure ≤ 90 mmHg or a decrease of ≥ 10%) after intubation. Controlling for confounders was done through a logistical regression analysis.
Results: We identified a total of 366 patients, 301 of whom were treated with esketamine and 65 with propofol. There was no significant difference in mortality between the esketamine and propofol groups (odds ratio 0.598, 95% confidence interval 0.281-1.272). The decrease in blood pressure after intubation was greater in the propofol group (absolute change -37.3 vs. -12.4 mmHg, 95% confidence interval -38 to -15 mmHg), but because the initial blood pressure was also higher, both groups had similar postintubation physiology.
Conclusion: In this study, we found no significant difference in mortality, but we found significant differences in the haemodynamic responses between esketamine and propofol, with a slightly favourable haemodynamic profile in patients treated with esketamine. The protocol implemented in 2015 heavily shifted the choice of anaesthetics from propofol to esketamine, but there was a distinct resurgence in propofol use during the study period.
Editorial comment: Patients with severe head injuries can receive advance intensive care including anaesthetic drugs in the field for intubation, when prehospital teams have this competence. This retrospective analysis presents a comparison of outcomes for traumatic brain injury cases who received either propofol or esketamine in the prehospital setting, as part of a time-interrupted series where drug choice was changed. While possibly differing in circulatory effects, the two drugs were not associated with a difference in mortality before hospital discharge.
Background: Perioperative hyperoxia may be associated with increased long-term mortality, whereas perioperative antioxidants may be associated with reduced long-term mortality. This study aimed to determine if high perioperative inspiratory oxygen fraction (FiO2) (0.80) compared with normal FiO2 (0.30) would increase mortality, hospital admissions, and myocardial infarction (MI) within 1 year after surgery, and whether antioxidants compared with placebo would reduce this.
Methods: This was the preplanned 1-year follow-up of 600 patients with cardiovascular risk factors, scheduled for noncardiac surgery. They were randomized in a 2 × 2 factorial design to perioperative FiO2 of 0.80 or 0.30 and to receive antioxidants (vitamin C and N-acetylcysteine) or matching placebo. The primary 1-year outcome was all-cause mortality, and secondary 1-year outcomes were one or more hospital admissions and MIs, respectively. All outcomes were assessed using medical records and analyzed with the Cox proportional hazards model.
Results: Follow-up was completed for 594 patients (99%). Twenty-five of 298 patients (8.4%) allocated to FiO2 of 0.80 died within 1 year as compared with 17 out of 296 (5.7%) allocated to FiO2 of 0.30, HR 1.46 (95% CI, 0.79-2.70), p = 0.23. A total of 260 patients had one or more hospital admissions (44%), and seven patients had MI (1.2%) with no significant difference when comparing FiO2 of 0.80 with 0.30. Antioxidants had a HR of 0.98 (95% CI, 0.54-1.80), p = 0.96 for all-cause mortality vs. placebo. The interaction between the FiO2 and antioxidant administration was statistically significant (p = 0.04) with fatalities overrepresented in patients given 80% oxygen and placebo.
Conclusions: Differences in all-cause mortality, hospital admission, or MI were not statistically significant at 1-year follow-up for either oxygen fractions or antioxidant administration in patients undergoing major noncardiac surgery.
Editorial comment: In this preplanned long-term study of the VIXIE trial, no differences in total mortality, hospitalization, or myocardial infarction were found for oxygen fractions of 0.80 compared to 0.30 or antioxidant administration compared to placebo. Interestingly, the study showed a higher rate of fatalities with 80% oxygen which appeared only to be present in patients not given the antioxidant intervention, but this is hypothesis-generating and needs to be further investigated in new clinical trials.
Trial registration: Clinicaltrials.gov identifier: NCT03494387.
Background: Negative postoperative behaviour changes (NPOBC) are known to occur after general anaesthesia in children. A significantly increased risk of NPOBC has been reported in children who exhibited a reduction in cerebral regional oxygen saturation (crSO2) of as little as 5% below baseline levels. These results were unexpected, and we therefore aimed to investigate the association between degrees of regional cerebral desaturation and NPOBC after routine surgery in young children.
Methods: In this prospective cohort study, 180 healthy children between 2 and 6 years old undergoing routine surgery were enrolled. The primary outcome was NPOBC, assessed using the Post Hospitalization Behavior Questionnaire (PHBQ), reported by parents and evaluated on Postoperative Day 7. The results were stratified according to decreases in crSO2 from baseline of at least 5, 10, 15 or 20 percentage points sustained for a minimum duration of 2 min. The χ2 or Fisher's exact test was used to analyse differences in categorical variables. Using logistic regression, outcome data were expressed as odds ratios with 95% confidence intervals.
Results: The incidence of NPOBC was 13% on Day 7, and 15% on Day 30, respectively. No significant differences were found between children with or without NPOBC for any of the thresholds of crSO2 reduction (≥ 5%: 2 [11%] vs. 2 [1.8%] cases, p = 0.09; ≥ 10%: 1 [5.6%] vs. 2 [1.8%] cases, p = 0.36; ≥ 15% and ≥ 20%: 0 vs. 0 cases). The rate of NPOBC was not associated with intraoperative reduction in crSO2 (OR 1.25, CI 0.71-2.20, p = 0.46). Older age was associated with lower odds of NPOBCs (OR 0.39, CI 0.15-0.99, p = 0.048). Using the area under the curve for quantifying crSO2 changes did not result in a statistically significant correlation between crSO2 and NPBOCs (r = 0.11).
Conclusion: Regional cerebral desaturation and negative postoperative behaviour may be less common than previously reported in young children undergoing uneventful general anaesthesia. We could not corroborate the strong association between these entities reported previously. Studies investigating the effects of cerebral desaturation on patient-centred outcomes will need large sample sizes.
Editorial comment: This prospective observational study describes a low incidence and magnitude of NIRS desaturation in healthy children. In contrast to previous reporting, there was no association with new negative postoperative behaviours in children in this cohort.
Trial registration: ISCRTN11799594.
Background: Bleeding patients face significant morbidity and mortality due to impaired hemostasis. Hemostatic resuscitation has evolved, yet the optimal approach remains unclear. The primary objective was to assess the benefits and risks of transfusion guided by TEG/ROTEM versus standard of care in bleeding patients in an updated review.
Methods: This systematic review of randomized controlled trials with meta-analyses and trial sequential analysis was conducted according to Cochrane Collaboration methodology, PRISMA, and GRADE guidelines. A literature search was conducted in five major databases. Both pediatric and adult patients were included. The primary outcome was mortality, and secondary outcomes were the administration of blood products, blood loss, surgical reintervention, and dialysis-dependent renal injury.
Results: This systematic review included 35 randomized trials (n = 3096), primarily elective cardiac surgery. TEG-/ROTEM-guided algorithms led to a statistically significant reduction in mortality (RR = 0.76, 95% CI 0.63-0.92) I2: 0%. Furthermore, a significant reduction in transfused fresh frozen plasma (RR = 0.52, 95% CI 0.35-0.76) I2: 94%, platelets (RR = 0.69, 95% CI 0.55-0.87) I2: 60%, the risk for surgical reintervention (RR = 0.63, 95% CI 0.45-0.88) I2: 0%, and bleeding with a standard mean difference of -0.31 (95% CI, -0.51 to -0.11) I2: 72% was found. According to GRADE methodology, the certainty of the evidence was very low for all outcomes. Trial sequential analysis of mortality analysis indicated that 64% of the optimal information size was reached with a crossed alpha-boundary.
Conclusions: TEG-/ROTEM-guided transfusion algorithms may reduce the risk of mortality, bleeding volume, and the need for fresh frozen plasma, platelets, and surgical reintervention, but the evidence is very uncertain. Furthermore, the results were primarily based on the adult population undergoing elective cardiac surgery.
Editorial comment: This updated systematic review presents a synthesis of evidence for how thromboelastography or rotational thromboelastometry has been implemented in study conditions to guide tranfusion in bleeding patients. The certainty for the evidence is very limited.
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