Acta Anaesthesiologica Scandinavica最新文献

Background: Firm consensus on the best perioperative pain management after Video-Assisted Thoracic Surgery (VATS) is lacking. Recommendations often assess different loco-regional techniques as part of a multimodal approach, but few discuss omitting regional analgesia altogether, eliminating any risk of procedural complications. A reasonable prerequisite for this approach would be that the alternative provides comparable pain relief. To compare the efficacy of systemic opioids and epidural analgesia for postoperative pain management, we conducted a systematic review and meta-analysis of current studies.

Methods: We did a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies on VATS with the primary objective of examining postoperative pain at rest and during activity at POD1, POD2, and POD3. The secondary objectives were to evaluate the efficacy of the treatments, examining the need for postoperative "rescue" opioid, the hospital length of stay, and side effects. We did literature searches of Medline, Embase, and the Cochrane Library from inception to 07 April 2025. Additionally, we searched ClinicalTrials.gov, the EU Clinical Trials Register, the WHO International Clinical Trials Registry Platform, Scopus, and Google Scholar. We included adult patients undergoing VATS receiving either epidural analgesia or systemic opioids for postoperative pain management.

Results: We included four randomized controlled trials (RCTs) and four observational studies encompassing 946 patients. The primary meta-analysis of the RCTs found that epidural analgesia reduced pain compared with systemic opioids by a pooled mean difference of 0.8 NRS/VAS points (95% CI 0.2-1.3) at rest and 1.1 points (0.7-1.5) during activity over POD 1 to 3. Heterogeneity was substantial (I² 99% and 98%, respectively) and was largely explained by the presence of baseline multimodal analgesia on POD 2. Rescue-opioid use was lower with epidurals in three of four trials, with no consistent differences in length of stay or adverse effects. Evidence certainty was moderate. The observed difference is below or at the lower bound of the minimal clinically important difference of 1-2 NRS/VAS points.

Conclusion: Epidural analgesia offers a small but possibly subclinical reduction in acute postoperative pain after VATS compared with systemic opioids, particularly when combined with baseline multimodal analgesia. High heterogeneity and moderate certainty underscore the need for adequately powered trials.

Prospero registration: CRD42024598757.

Background: Early restitution of electroencephalogram (EEG) slow wave activity (SWA) may be able to predict favorable functional outcome after cardiac arrest. SWA can be monitored using the C-Trend Index, a recently developed dynamic numerical index computed using commercially available medical device software.

Methods: This is a pre-planned prospective substudy of the randomized controlled Sedation, TEmperature and Pressure after Cardiac Arrest and REsuscitation (STEPCARE) trial. With a factorial design, the STEPCARE trial evaluates the effects of three different interventions (sedation, temperature management, and mean arterial blood pressure) on functional outcomes in adult out-of-hospital cardiac arrest (OHCA) patients. We will record continuous EEG (cEEG) starting as early as possible after ICU admission. We will compare the accuracy (the proportion of correct predictions of all predictions) of C-Trend Index with that of blinded retrospective visual analysis of cEEG at 12 h after return of spontaneous circulation in predicting favorable functional outcome (modified Rankin Scale 0-3) 6 months after cardiac arrest. We aim to recruit 300 patients to show noninferiority in prognostic accuracy of the C-Trend Index compared with the visual analysis of cEEG, using a 2% limit for noninferiority. Furthermore, we will assess whether the therapeutic intervention related to sedation, carried out as a part of the STEPCARE trial modifies the performance of the EEG-based predictors.

Conclusion: The study will compare the accuracy of SWA measured using C-Trend Index with the gold standard, visual analysis of cEEG, in predicting favorable functional outcome after OHCA. The study will also assess the effect of the sedation intervention of the STEPCARE trial on the predictive accuracy of C-Trend Index. If the accuracy of the C-Trend Index is non-inferior to the comparator's, it may provide a feasible and easy-to-learn bedside method, especially in hospitals with limited availability of neurophysiology expertise.

Trial registration: ClinicalTrials.gov identifier: NCT06564675.

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.

Background: In patients resuscitated after cardiac arrest, a higher mean arterial pressure (MAP) may increase cerebral perfusion and attenuate hypoxic brain injury. Here we present the protocol of the mean arterial pressure after cardiac arrest and resuscitation (MAP-CARE) trial aiming to investigate the influence of MAP targets on patient outcomes.

Methods: MAP-CARE is one component of the Sedation, Temperature and Pressure after Cardiac Arrest and Resuscitation (STEPCARE) 2 x 2 x 2 factorial randomized trial. The MAP-CARE trial is an international, multicenter, parallel-group, investigator-initiated, superiority trial designed to test the hypothesis that targeting a higher (>85 mmHg) (intervention) versus a lower (>65 mmHg) (comparator) MAP after resuscitation from cardiac arrest reduces 6-month mortality (primary outcome). Trial participants are adults with sustained return of spontaneous circulation who are comatose following resuscitation from out-of-hospital cardiac arrest. The two other components of the STEPCARE trial evaluate sedation and temperature control strategies. Apart from the STEPCARE trial interventions, all other aspects of general intensive care will be according to the local practices of the participating site. Neurological prognostication will be performed according to European Resuscitation Council and European Society of Intensive Care Medicine guidelines by a physician blinded to allocation group. The sample size of 3500 participants provides 90% power with an alpha of 0.05 to detect a 5.6 absolute risk reduction in 6-month mortality, assuming a mortality of 60% in the control group. Secondary outcomes will be poor functional outcome 6 months after randomization, patient-reported overall health 6 months after randomization, and the proportion of participants with predefined severe adverse events.

Conclusion: The MAP-CARE trial will investigate if targeting a higher MAP compared to a lower MAP during intensive care of adults who are comatose following resuscitation from out-of-hospital cardiac arrest reduces 6-month mortality.

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.