Acta Anaesthesiologica Scandinavica最新文献

Background: In Central Denmark Region, early management of COVID-19 patients was delegated to emergency departments. This study aims to evaluate the mortality of patients admitted with pulmonary embolism, before and during the pandemic, as symptoms could mimic COVID-19.

Methods: In this multicenter retrospective cohort study, we included all patients with the action diagnosis of pulmonary embolism admitted to emergency departments in Central Denmark Region between March 1, 2019, and February 28, 2021. The inclusion period defined two equivalent periods before (pre-COVID) and during the COVID-19 pandemic (COVID). The COVID period was used as exposure. 30-day mortality was the primary outcome, while 7-day mortality and transfer to intensive care units were two of the secondary outcomes.

Results: A total of 328 and 300 patients with pulmonary embolism were admitted to an emergency department in Central Denmark Region pre and during COVID, respectively. There were no significant associations between admission during COVID and death within 30 days from admission date compared to pre-COVID patients (OR 1.63, 95% CI: 0.88-3.05). Comparing COVID to pre-COVID there were no significant differences in severity upon arrival to hospital (simplified pulmonary Embolism Severity Index 0 or ≥ 1 point(s), p = 0.759) or number of patients transferred to intensive care unit (6 vs. 9, p = 0.340).

Conclusion: We found no differences in mortality or in transfer to ICU for patients with pulmonary embolism admitted in Central Denmark Region before or during the COVID-19 pandemic. This study addressed hospital resource management adjustments during the COVID-19 pandemic, and how cases with emergency admission diagnosis of pulmonary embolism fared during the pandemic period compared to other periods outside of the pandemic. For this Danish cohort analysis, pandemic conditions were not associated with different outcomes or ICU access compared to comparison periods.

Introduction: Propofol is commonly used in procedural sedation in oncology due to its rapid sedative effect and favorable recovery profile. However, several preclinical and clinical studies have demonstrated a dose-dependent neurotoxic effect of this drug. Dexmedetomidine and midazolam are potential adjuvants that, if used as premedication, could reduce the required dose of propofol. This study compares the use of dexmedetomidine and midazolam in terms of propofol dose reduction during procedural sedation in oncology patients.

Methods: This one-year retrospective study compared the outcomes of procedural sedation, in terms of propofol-sparing, in 24 pediatric oncology patients who received midazolam (MP group, 52 procedures) or dexmedetomidine (DP group, 51 procedures) as premedication combined with propofol during bone marrow aspiration and/or lumbar puncture procedures. Data on propofol dosage, awakening time, vital parameters, and adverse events were examined.

Results: Premedication with dexmedetomidine was associated with a significantly lower dose of propofol than midazolam (2.51 vs. 4.00 mg/kg, p < 0.001). Wake-up times were longer in the DP group (92 vs. 65 min; p = 0.045). Adverse events were very rare in both groups.

Conclusions: Dexmedetomidine demonstrates superior propofol-sparing effects compared to midazolam, although it requires longer recovery times. These results support dexmedetomidine as a promising alternative in sedation protocols in pediatric oncology.

Editorial comment: This retrospectively analysis of a single center series compared procedural sedation strategies for children involving propofol after standardized intravenous premedication with dexmedetomidine or midazolam. The findings demonstrated that dexmedetomidine in those doses and in combination with propofol confirmed sedative potency and duration more than that of the chosen midazolam premedication dosing.

Introduction: Respiratory rate (RR) is a critical vital sign for assessing a patient's respiratory and overall health status. Despite its importance, RR is often underutilized and inconsistently measured in clinical practice. Monitoring RR can identify early signs of clinical deterioration, as it is often the first vital sign to deviate when a patient's condition worsens. This scoping review aims to map the current evidence on the role of RR monitoring in predicting mortality among hospitalized adult patients. We also evaluate the association of RR monitoring with early detection of clinical deterioration.

Method: A scoping review was performed using a structured search strategy across MEDLINE Ovid, EMBASE Ovid, and PubMed. The search was structured using the PICO framework, with mortality defined as the primary outcome of interest. Inclusion criteria were randomized controlled trials, cohort, cross-sectional, and observational studies in English, involving adults aged ≥ 16 years. Exclusion criteria included reviews, meta-analyses, and nonhuman studies. Two independent reviewers screened articles, with disagreements resolved by a third reviewer. Data extraction included study design, outcomes, and study-reported limitations.

Results: The literature search identified 881 records, with 562 studies screened after removing duplicates. After final screening, 21 studies were included, with sample sizes ranging from 34 to 556,848 patients. Most studies were observational, including 6 retrospective, 10 prospective, 1 case-control, and 2 comparative cohort studies. RR was reported to be frequently associated with mortality and clinical deterioration; though findings varied depending on clinical context and measurement method. Continuous monitoring detected more cases of sustained respiratory abnormalities than intermittent measurements and could hypothetically lead to earlier clinical interventions; though clinical impact requires further investigation.

Conclusion: RR was commonly identified as a predictor of mortality and clinical deterioration, with continuous monitoring showing higher detection rates of respiratory abnormalities compared with intermittent monitoring. However, variations in outcomes and study design highlight the need for standardized measurement.

Editorial comment: This scoping review presents current knowledge about how respiratory rate monitoring and assessment can inform about clinical deterioration with acute illness requiring hospitalization.

Background: Electroconvulsive therapy (ECT) is a widely used treatment for depression, but the choice of the anesthetic that is used for induction may affect both clinical outcomes and the occurrence of adverse effects (AEs). Propofol and methohexital are frequently used in Finland, yet their relative impact on treatment efficacy and AEs remains uncertain.

Methods: We conducted a systematic literature review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic databases were searched up to January 21, 2025. Studies comparing propofol and methohexital in adult patients receiving ECT for depression and utilizing numeric scales for depression assessment were included. The primary outcome was the clinical treatment response, defined by the number of ECT sessions required to achieve remission. The secondary outcome was the variation of AEs associated with ECT between comparator groups. We included eight studies in the final analysis with 194 patients in the propofol group and 198 patients in the methohexital group. Five of the studies were randomized controlled trials and three were retrospective cohort studies. Three randomized controlled trials with 131 patients: 62 (47%) in propofol group and 69 (53%) in methohexital group were included in meta-analysis.

Results: The number of ECT sessions required for recovery did not differ between groups. All studies demonstrated effective alleviation of depression through ECT, regardless of anesthetic choice. However, AEs were inconsistently reported, and a comprehensive overview of the topic was not possible.

Conclusions: Low-quality evidence suggests equal efficacy of propofol compared to methohexital with regard to clinical remission of depression after ECT.

Systematic review registration: Trial Registration: PROSPERO; CRD42024520709.

Editorial comment: This systematic review and meta-analysis presents the available but limited and low-quality evidence in this study area, and supports an interpretation that propofol and methohexital have similar efficacy when facilitating electroconfulsive therapy as treatment for depression, to relieve depression symptoms.

Background: Glucose management in intensive care unit (ICU) patients is challenging, and dysglycemia is associated with increased morbidity and mortality. Continuous glucose monitoring (CGM) could be a potential tool to improve clinical and glycemic outcomes compared with current practice which relies on intermittent glucose measurements.

Aim: The aim of this systematic review and meta-analysis is to assess the effects of CGM compared with point of care (POC) glucose measurements on clinical patient-important and glycemic outcomes in ICU patients.

Methods: This protocol is based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline. We will include all randomized clinical trials in ICU patients. The primary outcome is mortality at the longest follow-up, and the main-secondary outcome is the number of hypoglycemic events. Additional outcomes include both patient-important and glycemic outcomes. We will systematically search: PubMed, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Web of Science Core Collection. We will assess risk of bias using the Cochrane Risk of Bias 2 tool and conduct a Trial Sequential Analysis for the primary and main-secondary outcome. Clinical heterogeneity will be assessed using the Clinical Diversity in meta-analyses tool, and the certainty of evidence will be assessed using the Grading of Recommendation Assessment, Development, and Evaluation approach.

Discussion: This systematic review with meta-analysis will provide an updated overview and synthesis of the effect of CGM versus POC glucose monitoring to inform clinical practice and future trials.

Patients undergoing spine surgery often experience post-operative pain. In this context, clonidine, an alpha-2 agonist, may be relevant due to its analgesic properties. We conducted a randomised, double-blinded, placebo-controlled trial to evaluate the effect of a single dose of intraoperative intravenous clonidine on post-operative opioid consumption, pain intensity and side effects. Patients undergoing spine surgery at Aarhus University Hospital, Denmark, were randomised to receive intraoperative clonidine (3 μg/kg) or placebo. The primary outcome was opioid consumption within the first 3 h after surgery. Secondary outcomes included opioid consumption within the first 6 h, pain intensity at rest and during coughing, post-operative nausea and vomiting (PONV), and sedation in the post-anaesthesia care unit (PACU). Additional outcomes included time to discharge from the PACU, length of hospital stay and daily opioid consumption after 1 month. Data from 120 patients (49 females, 71 males, mean age 65 ± 14 years) were available for analysis; 61 received clonidine and 59 received placebo. Post-operative intravenous morphine equivalents within 3 h were similar in the clonidine group 5 mg (0-15) and the placebo group 10 mg (0-15) (p = 0.58). Pain intensity at rest was 4 (0-5.5) in the clonidine group and 3 (0-5) in the placebo group upon arrival at the PACU (p = 0.20). No differences were observed between the clonidine and placebo groups regarding any secondary outcomes, except for hypotension, which was more frequent in the clonidine group (24 vs. 13 patients). A single dose of intraoperative clonidine did not reduce post-operative opioid consumption or pain intensity in patients undergoing spine surgery.

Background: The European laryngological society predicted an increased incidence of laryngotracheal complications as a result of the COVID-19 pandemic. During the first pandemic wave in the Stockholm region, 31% of critically ill COVID-19 patients were tracheotomized by an open surgical (OST) or a percutaneous tracheotomy (PCT). The aim of this study was to investigate the incidence of visible laryngotracheal pathologies in tracheotomized and long-term intubated COVID-19 survivors ≥ 12 months after initial intubation, to examine whether these pathologies were symptomatic and to assess possible associated factors.

Methods: Study participants underwent laryngotracheoscopy under local anaesthesia, and tracheostomy skin and soft tissue scars were photo documented. Patient-reported outcome measures - the Voice Handicap Index-10 (VHI-10), the Eating Assessment Tool-10 (EAT-10) and the Dyspnea Index (DI), and demographics were retrospectively extracted from patient medical records.

Results: Of 73 included study participants (40 OST, 24 PCT and 9 long-term intubated), 58% had visible laryngotracheal pathologies. Tracheostomy tube size and the number of days with tracheostomy were associated with skin and soft tissue pathology and tracheal pathology (p < 0.05). The results of the VHI-10 and EAT-10 were congruent with both laryngeal and skin and soft tissue pathologies. Participants with the highest DI scores, indicating breathing difficulties, had both laryngeal and tracheal pathologies followed by tracheal pathology alone.

Conclusions: A high incidence of visible laryngotracheal pathologies, two airway management-related factors, and symptom-pathology associations for VHI-10 and EAT-10 scores were found in a cohort of COVID-19 survivors ≥ 12 months after critical care.

Background: Pupillary light reflex assessment is a promising modality for assessing autonomic nervous system status, given that it is fast, noninvasive, and provides quantitative results. Opioid therapy influences the pupil and is frequently used in the intensive care unit (ICU). We investigated the effect of opioids on pupillary size and dilation velocity in the pupillary light reflex in critically ill patients.

Methods: This is a sub-study on 55 patients from a prospective observational study acutely admitted to an ICU. All patients had daily blood samples and pupillary light reflex measurements. Blood samples were analyzed for opioids using mass spectrometry. Linear mixed models were used to estimate the possible association for each detected opioid to pupillary size and dilation velocity in the pupillary light reflex.

Results: The pupil size before a light stimulus was closely associated to the dilation velocity after the light stimulus. The increase in the dilation velocity was 0.2 mm/s per 1 mm increase in pupil diameter before the light stimulus, 95% confidence interval [0.2-0.3], p < 0.001. Presence of fentanyl was associated with a smaller pupil size and a slower pupillary dilation velocity.

Conclusions: The presence of fentanyl in blood samples from a mixed ICU population is associated with a slower pupillary dilation velocity in a concentration-dependent matter.

Editorial comment: This study assesses the relation of observed opioid levels and light reflex pupillary size speed of change in an ICU cohort where there can be multiple classes of drugs present which influence autonomic nerve system function. Findings for different opioids, though most specifically fentanyl, show that opioid plasma concentrations have clear association with slower pupillary dilation velocity with light reflex response.

Introduction: Septic shock necessitates timely antibiotic therapy, often with broad-spectrum beta-lactam antibiotics (ß-LA). To our knowledge, no previous study has examined antibiotic concentrations repeatedly during the initial phase of treatment. This observational study aimed to assess early-phase plasma concentrations of ß-LA in patients with septic shock.

Method: Prospective observational study of patients with septic shock, according to the SEPSIS-3 criteria, who received cefotaxime, piperacillin/tazobactam, or meropenem in accordance with Swedish practice. Demographic and clinical data were recorded for each patient. Consecutive blood samples were obtained during the first 24 h of treatment, and total antibiotic concentrations were measured using liquid chromatography mass spectrometry. Target concentrations were defined as 100% of the time that free (unbound) antibiotic concentrations remained above the minimal inhibitory concentration (fT > MIC).

Results: Twenty-two patients were included, 15 (68%) were male and the median age was 65.5 years (IQR 46.3-65.5). In-hospital mortality was 7/22 (32%). Antibiotic exposure exceeding 100% fT > MIC was achieved in 16 (73%) of the patients. Four patients did not receive the recommended additional dose between the first and second doses of antibiotics; two of them still achieved 100% fT > MIC, whereas the other two attained 66% and 33% fT > MIC, respectively. Among the patients who received the additional dose, four did not achieve 100% fT > MIC. No relationship between mortality and fT > MIC was observed. Significant associations with achieving 100% fT > MIC were observed for older age (p = 0.045) and illness severity (SAPS3, p = 0.025).

Conclusion: Our findings demonstrate considerable variability in antibiotic exposure during the initial 24 h of septic shock treatment, highlighting a critical gap in understanding the clinical relevance of sub-optimal serum antibiotic concentrations and their potential impact on patient outcomes.

Editorial comment: Therapeutic drug monitoring of antimicrobials is increasingly being used in research and clinical practice.