Acta Anaesthesiologica Scandinavica最新文献

Background: Ventilator-associated pneumonia (VAP) may be a particular concern in patients with severe coronavirus disease 2019 (COVID-19). We aimed to determine the prevalence and etiology of VAP in critically ill COVID-19 patients in a Danish intensive care unit (ICU) during the first three waves of the COVID-19 pandemic and to study associations between dexamethasone (DXM) use and development of VAP.

Methods: In an observational single-center study patients were retrospectively screened for VAP including causative pathogens, use of DXM and commonly used antibiotics. Diagnosis of VAP required invasive mechanical ventilation (IMV) >48 h with presence of a new bacterial agent and clinical signs of infection. For analysis, common descriptive statistics were applied. Cox proportional hazards models were used to analyze the association between DXM use and VAP.

Results: VAP was detected in 53/119 (44.5%) mechanically ventilated patients across all three COVID-19 waves. Median length of IMV for VAP patients was 24 [15-41] days, and 3 out of 4 were males. VAP was most prevalent (47.0%) during the second wave. Common pathogens included Klebsiella pneumoniae (24.5%), Enterobacter aerogenes (17.0%) and Pseudomonas aeruginosa (13.2%), Staphylococcus aureus (13.2%), and Escherichia coli (13.2%). A change from Gram-negative bacteria only to a combination of Gram-positive and Gram-negative bacteria was observed in the second wave compared to first. Use of DXM was not associated with VAP (adjusted hazard ratio 1.63 95% CI: 0.84-3.17).

Conclusion: The prevalence of VAP was high across all three COVID-19 waves and showed a different distribution of pathogens between the first and second wave. Use of DXM was not associated with VAP development. Further and larger studies are needed to understand the risk factors associated with VAP in patients with COVID-19.

Background: Platelet transfusions are frequently used in the intensive care unit (ICU), but current practices including used product types, volumes, doses and effects are unknown.

Study design and methods: Sub-study of the inception cohort study 'Thrombocytopenia and Platelet Transfusions in the ICU (PLOT-ICU)', including acutely admitted, adult ICU patients with thrombocytopenia (platelet count <150 × 10⁹/L). The primary outcome was the number of patients receiving platelet transfusion in ICU by product type. Secondary outcomes included platelet transfusion details, platelet increments, bleeding, other transfusions and mortality.

Results: Amongst 504 patients with thrombocytopenia from 43 hospitals in 10 countries in Europe and the United States, 20.8% received 565 platelet transfusions; 61.0% received pooled products, 21.9% received apheresis products and 17.1% received both with a median of 2 (interquartile range 1-4) days from admission to first transfusion. The median volume per transfusion was 253 mL (180-308 mL) and pooled products accounted for 59.1% of transfusions, however, this varied across countries. Most centres (73.8%) used fixed dosing (medians ranging from 2.0 to 3.5 × 10¹¹ platelets/transfusion) whilst some (mainly in France) used weight-based dosing (ranging from 0.5 to 0.7 × 10¹¹ platelets per 10 kg body weight). The median platelet count increment for a single prophylactic platelet transfusion was 2 (-1 to 8) × 10⁹/L. Outcomes of patients with thrombocytopenia who did and did not receive platelet transfusions varied.

Conclusions: Among acutely admitted, adult ICU patients with thrombocytopenia, 20.8% received platelet transfusions in ICU of whom most received pooled products, but considerable variation was observed in product type, volumes and doses across countries. Prophylactic platelet transfusions were associated with limited increases in platelet counts.

Background: Piperacillin/tazobactam may be associated with less favourable outcomes than carbapenems in patients with severe bacterial infections, but the certainty of evidence is low.

Methods: The Empirical Meropenem versus Piperacillin/Tazobactam for Adult Patients with Sepsis (EMPRESS) trial is an investigator-initiated, international, parallel-group, randomised, open-label, adaptive clinical trial with an integrated feasibility phase. We will randomise adult, critically ill patients with sepsis to empirical treatment with meropenem or piperacillin/tazobactam for up to 30 days. The primary outcome is 30-day all-cause mortality. The secondary outcomes are serious adverse reactions within 30 days; isolation precautions due to resistant bacteria within 30 days; days alive without life support and days alive and out of hospital within 30 and 90 days; 90- and 180-day all-cause mortality and 180-day health-related quality of life. EMPRESS will use Bayesian statistical models with weak to somewhat sceptical neutral priors. Adaptive analyses will be conducted after follow-up of the primary outcome for the first 400 participants concludes and after every 300 subsequent participants, with adaptive stopping for superiority/inferiority and practical equivalence (absolute risk difference <2.5%-points) and response-adaptive randomisation. The expected sample sizes in scenarios with no, small or large differences are 5189, 5859 and 2570 participants, with maximum 14,000 participants and ≥99% probability of conclusiveness across all scenarios.

Conclusions: EMPRESS will compare the effects of empirical meropenem against piperacillin/tazobactam in adult, critically ill patients with sepsis. Due to the pragmatic, adaptive design with high probability of conclusiveness, the trial results are expected to directly inform clinical practice.

Background: Western Norway has the lowest number of actual deceased organ donors per million inhabitants in Norway. We wished to find the total number of potential donors and donor organs during 2 years at Haukeland University Hospital, the largest hospital in the region, and evaluate where and why potential donors were lost.

Methods: We evaluated all patients who died at Haukeland University Hospital in 2018-19. We checked if intensive care patients, filling the criteria as organ donors after brain death, became donors, and the reasons why potential donors were lost. We also estimated the number of potential donors after circulatory death. We checked if patients transferred from the intensive care units and patients never admitted to intensive care were potential donors. Location, gender, age, and possible number of organs were registered.

Results: Of 1453 in-hospital deaths, 20 brain-dead patients became actual donors. One brain-dead and two other potential donors, one of them discharged to a bed ward, were not evaluated at the intensive care units. Relatives refused in five patients. Three fulfilled the Norwegian criteria from 2021 as organ donors after circulatory death. Ten potential donors after brain death were never admitted to intensive care and died on neurological or neurosurgical wards. If all potential organ donors were realised, the number of donors would double. The number of transplanted organs would increase less, as organs used per donor would drop from 3.50 to 2.90.

Conclusion: Our study cannot explain the low number of donors in our region compared with the rest of Norway. If all potential donations were implemented, the number of actual donors would double. Patients dying outside the intensive care units represent the largest potential source for extra donors, maximally increasing the number of donors by 42%, high-quality livers 44% and kidneys 18%. Introducing organ donation after circulatory death may increase the number of donors by 15% and the number of high-quality livers and kidneys by 12%.