Acta Anaesthesiologica Scandinavica最新文献

Background: Estimating equations for the assessment of glomerular filtration rate (GFR) have been poorly investigated in the critical care setting. We evaluated the agreement between the GFR measured with ⁵¹CrEDTA/iohexol (mGFR) and four estimating equations based on serum concentrations of creatine and/or cystatin C (eGFR) in two cohorts: critically ill patients and outpatients with normal-to-moderately reduced GFR.

Methods: Forty-three patients in the critical care group and 48 patients in the outpatient group were included. GFR was measured (mGFR) by plasma infusion clearance of ⁵¹Cr-EDTA/iohexol (critical care group) and the single injection, one-sample plasma ⁵¹Cr-EDTA clearance technique (outpatients). The following estimating equations (eGFR) were used: the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation for creatinine (CKD-EPI_Cr), cystatin C (CKD-EPI_{Cys C}), creatinine+cystatin C (CKD-EPI_{Cr + Cys C}) and the Lund-Malmö creatinine+cystatin C equation (LM_{Cr + Cys C}). Agreement between mGFR and eGFR was assessed by the Bland-Altman method and accuracy by calculating P30 and P10.

Results: In the critically ill group, the bias between the estimating equations and mGFR was -3.6 to 2.8 mL/min/1.73 m², while the error was 121%-127% and the accuracy (P30) 33%-40%. In the outpatients, the bias between the estimating equations and mGFR was -13.0 to 7.6 mL/min/1.73 m², while the error was 31%-41% and the accuracy (P30), 67%-96%.

Conclusions: All four equations performed poorly in assessing GFR in the critically ill cohort with an unacceptably high error and low accuracy in contrast to the outpatient group. To accurately assess GFR in critically ill patients, GFR must be measured not estimated.

Editorial comment: For the assessment of glomerular filtration rate (GFR), it can be measured directly, but is frequently estimated using a point measure of serum creatinine concentration. In this study, ICU case GFR estimations, by different adjusted equations, done also for a cohort of outpatients, showed that these serum creatinine-based estimations for ICU cases are not highly precise or reliable.

Background: Acute respiratory failure (ARF) is common in critically ill patients, and 50% of patients in intensive care units require mechanical ventilation [3, 4]. The COVID-19 pandemic revealed that COVID-19 infection induced ARF caused by damage to the microvascular pulmonary endothelium. In a randomized clinical trial, mechanically ventilated COVID-19 patients with severe endotheliopathy, as defined by soluble thrombomodulin (sTM) ≥ 4 ng/mL, were randomized to evaluate the effect of a 72-h infusion of low-dose prostacyclin 1 ng/kg/min or placebo. Twenty-eight-day mortality was 21.9% versus 43.6% in the prostacyclin and the placebo groups, respectively (RR 0.50; CI 0.24 to 0.96 p = .06). The aim of the current trial is to investigate if this beneficial effect and safety of prostacyclin also are present in any patient with suspected pulmonary infection requiring mechanical ventilation and concomitant severe endotheliopathy.

Materials and methods: This is a multi-center, randomized, blinded, clinical investigator-initiated phase 3 trial in mechanically ventilated patients with suspected pulmonary infection and severe endotheliopathy, as defined by sTM ≥4 ng/mL. Patients are randomized 1:1 to a 72-h infusion of low-dose prostacyclin (iloprost) 1 ng/kg/min or placebo (an equal volume of saline). Four-hundred fifty patients will be included. The primary endpoint is 28-day all-cause mortality. Secondary endpoints include 90-day mortality, days alive without vasopressor, mechanical ventilation, and renal replacement therapy in the ICU within 28 and 90 days, and the number of serious adverse reactions or serious adverse events within the first 7 days.

Discussion: This trial will investigate the efficacy and safety of prostacyclin vs. placebo for 72-hours in mechanically ventilated patients with any suspected pulmonary infection and severe endotheliopathy, as defined by sTM ≥4 ng/mL. Trial endpoints focus on the potential effect of prostacyclin to reduce 28-day all-cause mortality.

Background: Bleeding patients face significant morbidity and mortality due to impaired haemostasis. Haemostatic 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 randomised 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 paediatric 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 31 randomised trials (n = 2756), with most patients undergoing elective cardiac surgery. TEG-/ROTEM-guided algorithms reduced the amount of transfused fresh frozen plasma (RR 0.5, 95% CI 0.32-0.72, I²: 94%), platelets (RR 0.7, 95% CI 0.55-0.91, I²: 57%), the risk for surgical reintervention (RR 0.65, 95% CI 0.47-0.94, I²: 0%), and bleeding with a standard mean difference of -0.31 (95% CI -0.55 to -0.08, I²: 75%). No statistically significant difference was demonstrated for mortality (RR 0.76, 95% CI 0.57-1.00, I²: 5%). According to GRADE methodology, the certainty of the evidence was very low for all outcomes. Trial sequential analysis of mortality analysis indicated that 54% of the optimal information size was reached with an alpha-boundary RR of 0.81 (95% CI 0.63-1.03).

Conclusions: TEG-/ROTEM-guided transfusion algorithms may reduce the risk of mortality, bleeding volume, and the need for fresh frozen plasma and platelets, but the evidence is very uncertain. Further, the results were primarily based on the adult population undergoing elective cardiac surgery.

Background: In the intensive care unit (ICU), delirium in patients and long-term mental health challenges in both patients and their family members are highly prevalent. To address these issues, patient- and family-centered care has been recommended to alleviate the burdens associated with critical illness and ICU admission. We have developed the patient- and FAMily-centered care in the adult ICU intervention (FAM-ICU intervention). This multi-component intervention comprises several concrete and manageable components and operationalizing patient- and family-centered care principles in clinical practice. In this protocol, we describe a study aiming to evaluate the feasibility and acceptability of the FAM-ICU intervention in the adult ICU setting, including the feasibility of collecting relevant patient- and family-member outcome data.

Method: We will conduct a pre-/post two-group study design. We plan to recruit 30 adult ICU patients and their close family members at Herlev University Hospital in Denmark. The pre-group (n = 15) will receive usual care and the post-group (n = 15) will receive the FAM-ICU intervention. The FAM-ICU intervention involves interdisciplinary training of the ICU team and a systematic approach to information sharing and consultations with the patients and their family. Feasibility outcomes will include recruitment and retention rates, intervention fidelity, and the feasibility of participant outcome data collection. Acceptability will be assessed through questionnaires and interviews with clinicians, patients, and family members. Data collection is scheduled to begin in January 2025.

Discussion: This study will assess the feasibility and acceptability when implementing the FAM-ICU intervention and the feasibility of conducting a main trial to investigate its effectiveness on delirium in patients and the mental health of patients and family members. The data from the feasibility study will be used to guide sample size calculations, trial design, and final data collection methods for a subsequent stepped-wedge randomized controlled trial.

Background: Acute pain management is critical in sports-related musculoskeletal injuries to facilitate recovery and minimize long-term impact. While current practices vary, incorporating both pharmacological and non-pharmacological approaches, the quality and breadth of existing evidence have not been thoroughly assessed. This scoping review aims to explore the clinical role of different pain management strategies and provide a comprehensive overview of the field.

Methods: The review will follow the Joanna Briggs Institute (JBI) methodology for scoping reviews and adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews (PRISMA-ScR) guidelines. Searches will be conducted in major peer-reviewed databases and relevant gray literature. Studies involving athletes of any level undergoing treatment for acute musculoskeletal injuries will be considered. Data extraction will include study and participant characteristics, intervention details, reported outcomes, efficacy comparisons, and economic analyses.

Results: This review will provide a descriptive synthesis of the data, utilizing statistical analysis, figures, and tables where relevant to introduce the different treatment modalities. In line with PRISMA-P and PRISMA-ScR guidelines, this scoping review incorporates studies of diverse designs. The data synthesis involves descriptive statistics and narrative presentations, aimed at exploring the relationship between study results and research objectives.

Conclusion: This scoping review will evaluate various pain management interventions for acute musculoskeletal injuries in sports, mapping the current evidence and identifying gaps in research. The findings will help inform clinical practices and guide future research efforts to optimize pain management strategies in sports medicine.

Background: Patients who achieve return of spontaneous circulation (ROSC) after in-hospital cardiac arrest (IHCA) may re-arrest. This phenomenon has not been sufficiently investigated. The aim of this study was to examine the immediate (1-min) and short-term (20-min) risks of re-arrest in IHCA.

Methods: We retrospectively analyzed four datasets of IHCA episodes, comprising defibrillator recordings collected between 2002 and 2022. Re-arrest was defined as the resumption of chest compressions following a period of ROSC after cardiac arrest of any duration. Parametric models were applied to calculate the immediate risk of re-arrest. In addition, we estimated the short-term risk of re-arrest within 20 min.

Results: In 763 episodes of IHCA, we observed 316 re-arrests: 68% to pulseless electrical activity (PEA), 25% to ventricular fibrillation/ventricular tachycardia (VF/VT), and 7% to asystole. Most re-arrests occurred with the same rhythm as in the initial arrest. When ROSC was achieved from a non-shockable rhythm, the risk of re-arrest to a non-shockable rhythm was initially 2% per minute and decreased to 1% per minute after 9 min. The corresponding risk of re-arrest to VF/VT was constant at 2% per minute. If ROSC was obtained from a shockable rhythm, the risk of re-arrest to a shockable rhythm was initially 5% per minute, decreasing to 4% per minute after 9 min. The corresponding risk to a non-shockable rhythm was constant at 1% per minute. The risk of re-arrest within 20 min was 27%, and the overall risk of at least one re-arrest per episode was 33%.

Conclusions: The immediate risk of re-arrest was approximately 2% per minute, with the highest risk occurring as a reversion to VF/VT if ROSC was obtained from VF/VT. The risk of re-arrest within 20 min of the initial arrest was 27%, and the overall risk of at least one re-arrest per episode was 33%.

Background: The combined spinal epidural (CSE) technique may associate with a lower failure rate of epidural catheters compared to traditional epidural catheters. This may be significant for the parturients as failure of neuraxial analgesia has been associated with a negative impact on birth experience.

Methods: In this one-year retrospective study, the failure rate of epidural catheters was compared between 3201 and 5952 epidural catheters after initiation of neuraxial analgesia by the CSE or traditional epidural technique, respectively. Parturient background information, labor parameters, and neuraxial interventions were collected from 9153 parturients. Failure was defined as replacement of a used epidural catheter by new regional analgesia procedures or general anesthesia during intrapartum cesarean delivery. The primary outcome was the failure rate of epidural catheters. The secondary outcome was the time from the initial analgesia intervention to the epidural catheter replacement and progression of labor during this time.

Results: The CSE method was used at an earlier stage of labor, and the parturients were more often primiparous and undergoing induced labor. Earlier onset of analgesia, obesity, induced labor, anesthesiologist experience, and cesarean delivery were found to be significant cofactors for catheter failure. The unadjusted failure rate was 168/3201 (5.2%) and 223/5952 (3.7%) (OR 1.42 [1.16-1.75]) after initiation of analgesia by CSE or traditional epidural method. After controlling for the stage of labor, body mass index, induction of labor, and anesthesiologist's experience level, the adjusted OR for epidural catheter replacement was 1.04 (0.83-1.29) p = .736. The mean (SD) time until epidural catheter failure was 6.3 (4.4) and 4.0 (4.1) hours following initiation of analgesia by CSE or traditional epidural technique, respectively (p < .001). Cervical dilatation progressed from 4.3 (1.4) to 6.4 (2.1) cm and 5.1 (1.5) to 6.7 (1.7) cm between primary neuraxial analgesia and epidural catheter replacement.

Conclusion: CSE technique was not associated with a better survival rate of epidural catheters for provision of analgesia or epidural top-up anesthesia for intrapartum CD. In addition, the time to replacement of the catheter was significantly longer when analgesia was initiated with the CSE technique. Maternal satisfaction scores were lower if catheters required replacement.

Background: Postoperative pain management is a challenge after robot-assisted cystectomy (RAC). Methadone has a long duration of action, and we therefore hypothesized that a single dose of intraoperative methadone would reduce postoperative opioid requirements and pain intensity in bladder cancer patients undergoing RAC.

Methods: We conducted a blinded randomized controlled clinical trial from July 2020 to August 2023. Patients scheduled to undergo RAC because of bladder cancer were randomized to receive intraoperative methadone (0.15 mg/kg^-1) or morphine (0.15 mg kg^-1) 1 h before endotracheal extubation. The primary outcome was opioid requirements after 24 h. Secondary outcomes were opioid requirements after 3 h, pain intensity at rest and during coughing, postoperative nausea and vomiting (PONV), sedation, hypoxemia, hypoventilation, time spent in the post-anesthetic care unit, and patient satisfaction.

Results: A total of 114 patients were randomized. Data from 99 patients (14 females, 85 males; mean age 69.8 ± 8.9 years) were available for analysis; 52 received methadone and 47 received morphine. Opioid consumption was similar between the methadone group and morphine group at 3 h (median, mg, 45 (IQR 30 to 75) vs. 45 (IQR 15 to 82.5) p = .97) and at 24 h (median, mg, 125 (IQR 75 to 198.5) versus 105 (IQR 72 to 157.5), p = .29). Pain intensity was significantly lower in the morphine group at 48 h compared with the methadone group. Patient satisfaction at 24 h was increased in the methadone group compared with the morphine group (median, (IQR), NRS; 9 (IQR 7 to 10) versus 7 (IQR 4 to 9), p = .020). There were no differences between treatment groups in terms of time spent in the post-anesthetic care unit and the occurrence of opioid-related side effects.

Conclusion: A single dose of intraoperative methadone does not reduce postoperative opioid requirements compared with a single dose of morphine in bladder cancer patients undergoing RAC.