Acta Anaesthesiologica Scandinavica最新文献

Background: The initial treatment for distal forearm fractures, including Colles' fractures, involves closed reduction, for which effective pain management is essential. In Colles' fractures, achieving a satisfactory closed reduction may eliminate the need for surgical intervention. While ultrasound-guided nerve blocks are effective, hematoma blocks (HB) are often favored due to their feasibility in the emergency care setting. Further research comparing treatment outcomes is warranted.

Methods: In a multicentre randomised controlled trial, adults with distal forearm fractures were assigned to either ultrasound-guided blocks of the radial and median nerves (US) or HB for closed fracture reduction. The primary endpoint was satisfactory fracture reduction. Secondary endpoints were secondary fracture dislocation, self-reported pain, and time spent in the emergency department.

Results: Among 238 patients with Colles' fracture, 117 received US and 121 received HB. Satisfactory fracture reduction was achieved in 73 (62%) and 49 (40%) patients, respectively (p = 0.01). Surgical correction was conducted in 61 (52%) patients in the US group, contrasting 80 (66%) patients in the HB group (p = 0.03). During the fracture reduction, no difference in self-reported pain was observed (p = 0.21) for patients with distal forearm fractures (n = 247). The median time from block application to fracture reduction was 45 min in the US group and 25 min in the HB group (p < 0.01).

Conclusion: Ultrasound-guided median and radial nerve blocks had a higher success rate for Colles' fracture reduction than the hematoma block group. The influence of anesthetic techniques on the eventual need for surgery requires further investigation.

Background: Surgery and anesthesia in neonates and infants are performed only when necessary due to their immature physiological systems and limited cardiorespiratory reserves, rendering them particularly susceptible to complications. Effective pain management in the context of major surgical procedures presents a considerable challenge. Untreated pain activates cellular and humoral pathways that are detrimental to recovery. Although opioids are effective analgesics, their use is associated with hypoventilation and may exacerbate the physiological apnea commonly observed in newborns. This can extend the requirement for positive pressure ventilation, increasing the risks of both immediate and long-term adverse outcomes. Epidural anesthesia and analgesia offer a promising alternative by providing effective pain relief while reducing opioid consumption, thus minimizing respiratory impairment and promoting more rapid recovery. This scoping review aims to map existing knowledge, to shed light on knowledge gaps, and lay the groundwork for further research.

Methods: This review will follow the JBI methodology and adhere to the PRISMA guidelines for Scoping Reviews. A comprehensive search will be conducted across peer-reviewed databases, published literature, online resources, ongoing studies, and gray literature to identify all available evidence on epidural anesthesia and analgesia in thoracic and abdominal surgeries in neonates and infants.

Results: The findings from the included studies will be synthesized narratively and presented with tables and figures to ensure a clear and structured overview.

Conclusion: This scoping review aims to summarize the current evidence on epidural anesthesia and analgesia in neonates and infants. It will highlight well-researched areas, identify gaps in the literature, and outline existing knowledge and unmet research needs in this field.

Background: During air travel, the decrease in air pressure leads to a decrease in oxygen partial pressure causing oxygen desaturation. Every year, several commercial aircraft need to divert and perform unscheduled landings due to hypoxic symptoms or medical emergencies. How individuals are affected depends on their physical and medical conditions, as well as the cabin pressure of the aircraft. The phenomenon is of particular concern for individuals with pre-existing medical conditions, as it may lead to hypoxic symptoms and necessitate unscheduled landings in some cases. The investigators aim to investigate the existing literature to explore how the impact of reduced oxygen partial pressure affects the oxygen saturation as a result of a decrease in cabin pressure due to aircraft altitude, and to assess the frequency of hypoxic symptoms reported during air travel. The purpose of the scoping review is to investigate the relationship between altitude, cabin pressure, and patient oxygenation during air travel. Further, the investigators will report the frequency of the reporting of hypoxic symptoms in the studies conducted.

Methods and analysis: This scoping review will be conducted in accordance with the Cochrane Handbook and Joanna Briggs Institute Manual for Scoping Reviews. The review question will be formulated using the Population, Intervention, Comparator, Outcome, Study Design, Timeframe (PICOST) framework. Every study design is eligible, apart from reviews, meta-analyses, comments/letters without original data, case reports with less than five cases, animal studies, and in vitro studies. The investigators will include all articles in English or Scandinavian. The investigators will base their conclusions on the findings of the review.

Ethics and dissemination: According to Danish law, scoping reviews are exempt from ethics committee approval. The investigators will publish results from the scoping review in a peer-reviewed journal and present the results at scientific conferences.

Background: Sedation is often provided to resuscitated out-of-hospital cardiac arrest (OHCA) patients to tolerate post-cardiac arrest care, including temperature management. However, the evidence of benefit or harm from routinely administered deep sedation after cardiac arrest is limited. The aim of this trial is to investigate the effects of continuous deep sedation compared to minimal sedation on patient-important outcomes in resuscitated OHCA patients in a large clinical trial.

Methods: The SED-CARE trial is part of the 2 × 2 × 2 factorial Sedation, Temperature and Pressure after Cardiac Arrest and Resuscitation (STEPCARE) trial, a randomized international, multicentre, parallel-group, investigator-initiated, superiority trial with three simultaneous intervention arms. In the SED-CARE trial, adults with sustained return of spontaneous circulation (ROSC) who are comatose following resuscitation from OHCA will be randomized within 4 hours to continuous deep sedation (Richmond agitation and sedation scale (RASS) -4/-5) (intervention) or minimal sedation (RASS 0 to -2) (comparator), for 36 h after ROSC. The primary outcome will be all-cause mortality at 6 months after randomization. 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 the allocation group. To detect an absolute risk reduction of 5.6% with an alpha of 0.05, 90% power, 3500 participants will be enrolled. The secondary outcomes will be the proportion of participants with poor functional outcomes 6 months after randomization, serious adverse events in the intensive care unit, and patient-reported overall health status 6 months after randomization.

Conclusion: The SED-CARE trial will investigate if continuous deep sedation (RASS -4/-5) for 36 h confers a mortality benefit compared to minimal sedation (RASS 0 to -2) after cardiac arrest.

Background: Basic management for patients who have suffered a cardiac arrest and are admitted to an intensive care unit (ICU) after resuscitation includes setting targets for blood pressure and managing sedation and temperature. However, optimal targets and management are unknown.

Methods: The STEPCARE (Sedation, Temperature and Pressure after Cardiac Arrest and Resuscitation) trial is a multicenter, parallel-group, randomized, factorial, superiority trial in which sedation, temperature, and blood pressure strategies will be studied in three separate comparisons (SED-CARE, TEMP-CARE, and MAP-CARE). The trial population will be adults admitted to intensive care who are comatose after resuscitation from out-of-hospital cardiac arrest. The primary outcome will be all-cause mortality, and the secondary outcomes will be poor functional outcome (modified Rankin Scale 4-6), Health-Related Quality of Life using EQ-VAS, and specific serious adverse events in the intensive care unit predefined for each trial. All outcomes will be assessed at 6 months after randomization. The prognosticators, outcome assessors, statisticians, data managers, steering group, and manuscript writers will be blinded to treatment allocation. This statistical analysis plan includes a comprehensive description of the statistical analyses, handling of missing data, and assessments of underlying statistical assumptions. Analyses will be conducted according to the intention-to-treat principle, that is, all randomized participants with available data will be included. The analyses will be performed independently by two statisticians following the present plan.

Conclusion: This statistical analysis plan describes the statistical analyses for the STEPCARE trial in detail. The aim of this predefined statistical analysis plan is to minimize the risk of analysis bias.

Background: Venous return (VR) physiology may be elucidated using a calculated mean systemic filling pressure analogue (P_msa) that reflects the stressed intravascular volume. The aim of this study was to explore differences in VR physiological variables with the hypothesis that vasopressor therapy targeting a higher mean arterial pressure (MAP) would associate with an increased volume state. This would be important to appreciate the intravascular volume effect of an intervention that traditionally is judged by the pressure response alone.

Methods: This exploratory study used data from the BOX trial that investigated a higher (MAP of 77 mmHg, MAP77) versus a lower (63 mmHg, MAP63) blood pressure target during intensive care of survivors from out-of-hospital cardiac arrest. Data from 730 patients (MAP63, n = 362 and MAP77, n = 368) were used to calculate P_msa, the driving pressure for VR (VRdP, the difference between P_msa and central venous pressure [CVP]), the resistance to venous return (RVR, the VRdP divided by the cardiac output [CO]) and heart efficiency (E_h, the VRdP divided by P_msa). Linear mixed models were used to evaluate longitudinal haemodynamic data captured from admission to the intensive care unit and over 36 h.

Results: The P_msa was consistently higher in the MAP77 group (p < .03) while the CVP was not statistically different. The greater P_msa translated into a progressively increasing VRdP (p < .0001) and thus an increased CO (p < .001). Similar stroke volumes in both groups meant that CO was maintained by an increased heart rate in MAP77 (p < .001). The RVR was higher in MAP77 (p < .04) but gradually decreased in both groups, while the E_h was similar overall.

Conclusion: In conclusion, a higher MAP target effectively increased the stressed intravascular volume to sustain a higher CO.

Editorial comment: This post-hoc analysis of the BOX trial explores VR physiology and how it is influenced by the use of various doses of noradrenaline and dopamine. A higher blood pressure target appears to increase VR by increasing the stressed intravascular volume. This results in an increase in the CO. These findings are important given the worry about the effect of a higher afterload on cardiac function.

Background: Peripheral nerve blocks are widely used for anaesthesia in upper or lower limb surgery, but the methods used to assess their success vary substantially across randomised controlled trials. Standardised reporting of how peripheral nerve blocks are tested and how success is defined is essential for ensuring the validity and comparability of clinical research and correct clinical implementation of nerve blocks. This scoping review aims to map existing research practices and assess the extent to which trials provide reporting on peripheral nerve block evaluation.

Methods: This scoping review will adhere to guidelines from the Joanna Briggs Institute and the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A comprehensive search will be conducted on the PubMed database for trials published in peer-reviewed journals of anaesthesia from 2014 onward. An online tool will be used for screening and data extraction. Outcomes include the proportion of trials that report whether peripheral nerve blocks were tested, describe testing methods, define successful blocks, and report success rates.

Results: The results of the review will be presented descriptively and with tables where appropriate.

Conclusion: This protocol outlines a review exploring variability in the reporting of methods used to test peripheral nerve blocks. It aims to assist with the interpretation of clinical trials and possibly guide future research to facilitate comparison of findings between clinical trials.

Background: There is limited evidence regarding the effect of invasive mechanical ventilation practice post-bilateral lung transplantation. Invasive mechanical ventilation practice may be associated with prolonged ventilation, particularly when referenced to donor anthropometrics.

Methods: This was a single-centre retrospective cohort study that included consecutive adult bilateral lung transplant recipients between 2015 and 2021 who were ventilated for a minimum of 24 h post-surgery. Lower and higher tidal volume sub-groups were defined for mean and maximum values indexed to both donor and recipient predicted body weight over the first 72 h. The primary outcome was ventilator-free days in the first 28 days, and this was analysed using the Wilcoxon rank sum test and a competing risks regression. We used a Cox proportional hazards model to examine the relationship of ventilator-free days and tidal volume and 90-day survival.

Results: The cohort included 111 recipients, and the median ventilator-free days for the entire cohort was 25 (21-26). Lower tidal volume indexed to donor predicted body weight after 48 and 72 h was associated with more ventilator-free days (25 (23-26) vs. 24 (17-26), p = .04 and 24 (21-25) vs. 20 (14-24), p = .02) and increased cumulative incidence of successful extubation (sub-distribution hazard ratio 1.54 (1.07-2.20), p = .02 and SHR 1.87 (1.07-3.27), p = .03). Ventilator-free days and lower tidal volume were associated with increased 90-day survival.

Conclusions: Lower tidal volume ventilation indexed to donor predicted body weight is associated with more ventilator-free days post-bilateral lung transplantation.

Editorial comment: Postoperative ventilation with lower tidal volume indexed to the donor's predicted body weight was associated with more ventilator-free days in patients undergoing bilateral lung transplantation. No difference was found between lower versus higher tidal volume ventilation for other patient-important outcomes. The results highlight the need for larger prospective clinical trials.