Anssi Pölkki, Pirkka T Pekkarinen, Benjamin Hess, Annika Reintam Blaser, Kaspar F Bachmann, Inès Lakbar, Steven M Hollenberg, Suzana M Lobo, Ederlon Rezende, Tuomas Selander, Matti Reinikainen
Background: The vasopressor dose needed is a common measure to assess the severity of cardiovascular failure, but there is no consensus on the ranges of vasopressor doses determining different levels of cardiovascular support. We aimed to identify cutoffs for determining low, intermediate and high doses of noradrenaline (norepinephrine), the primary vasopressor used in intensive care, based on association with hospital mortality.
Methods: We conducted a binational registry study to determine cutoffs between low, intermediate and high noradrenaline doses. We required the cutoffs to be statistically rational and practical (rounded to the first decimal and easy to remember), and to result in increasing mortality with increasing doses. The highest noradrenaline dose in the first 24 h after intensive care unit (ICU) admission was used. The cutoffs were developed using data from 8079 ICU patients treated in the ICU at Kuopio University Hospital, Finland, between 2013 and 2019. Subsequently, the cutoffs were validated in the eICU database, including 39,007 ICU admissions to 29 ICUs in the United States of America in 2014-2015. The log-rank statistic, with the Contal and O'Quigley method, was used to determine the cutoffs resulting in the most significant split between the noradrenaline dose groups with regard to hospital mortality.
Results: The two most prominent peaks in the log-rank statistic corresponded to noradrenaline doses 0.20 and 0.44 μg/kg/min. Accordingly, we determined three dose ranges: low (<0.2 μg/kg/min), intermediate (0.2-0.4 μg/kg/min) and high (>0.4 μg/kg/min). Mortality increased, whereas the number of patients decreased consistently with increasing noradrenaline doses in both cohorts. In the development cohort, hospital mortality was 6.5% in the group without noradrenaline administered and 14.0%, 26.4% and 40.2%, respectively, in the low-dose, intermediate-dose and high-dose groups. Compared to patients who received no noradrenaline, the hazard ratio for in-hospital death was 1.4 for the low-dose group, 4.0 for the intermediate-dose group and 7.5 for the high-dose group in the validation cohort (p < .001).
Conclusions: The highest noradrenaline dose is a useful measure for quantifying circulatory failure. Cutoffs 0.2 and 0.4 μg/kg/min seem to be suitable for defining low, intermediate and high doses.
{"title":"Noradrenaline dose cutoffs to characterise the severity of cardiovascular failure: Data-based development and external validation.","authors":"Anssi Pölkki, Pirkka T Pekkarinen, Benjamin Hess, Annika Reintam Blaser, Kaspar F Bachmann, Inès Lakbar, Steven M Hollenberg, Suzana M Lobo, Ederlon Rezende, Tuomas Selander, Matti Reinikainen","doi":"10.1111/aas.14519","DOIUrl":"https://doi.org/10.1111/aas.14519","url":null,"abstract":"<p><strong>Background: </strong>The vasopressor dose needed is a common measure to assess the severity of cardiovascular failure, but there is no consensus on the ranges of vasopressor doses determining different levels of cardiovascular support. We aimed to identify cutoffs for determining low, intermediate and high doses of noradrenaline (norepinephrine), the primary vasopressor used in intensive care, based on association with hospital mortality.</p><p><strong>Methods: </strong>We conducted a binational registry study to determine cutoffs between low, intermediate and high noradrenaline doses. We required the cutoffs to be statistically rational and practical (rounded to the first decimal and easy to remember), and to result in increasing mortality with increasing doses. The highest noradrenaline dose in the first 24 h after intensive care unit (ICU) admission was used. The cutoffs were developed using data from 8079 ICU patients treated in the ICU at Kuopio University Hospital, Finland, between 2013 and 2019. Subsequently, the cutoffs were validated in the eICU database, including 39,007 ICU admissions to 29 ICUs in the United States of America in 2014-2015. The log-rank statistic, with the Contal and O'Quigley method, was used to determine the cutoffs resulting in the most significant split between the noradrenaline dose groups with regard to hospital mortality.</p><p><strong>Results: </strong>The two most prominent peaks in the log-rank statistic corresponded to noradrenaline doses 0.20 and 0.44 μg/kg/min. Accordingly, we determined three dose ranges: low (<0.2 μg/kg/min), intermediate (0.2-0.4 μg/kg/min) and high (>0.4 μg/kg/min). Mortality increased, whereas the number of patients decreased consistently with increasing noradrenaline doses in both cohorts. In the development cohort, hospital mortality was 6.5% in the group without noradrenaline administered and 14.0%, 26.4% and 40.2%, respectively, in the low-dose, intermediate-dose and high-dose groups. Compared to patients who received no noradrenaline, the hazard ratio for in-hospital death was 1.4 for the low-dose group, 4.0 for the intermediate-dose group and 7.5 for the high-dose group in the validation cohort (p < .001).</p><p><strong>Conclusions: </strong>The highest noradrenaline dose is a useful measure for quantifying circulatory failure. Cutoffs 0.2 and 0.4 μg/kg/min seem to be suitable for defining low, intermediate and high doses.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142103271","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Marwa Amer, Morten Hylander Møller, Mohammed Alshahrani, Yahya Shehabi, Yaseen M Arabi, Fayez Alshamsi, Martin Ingi Sigurðsson, Marius Rehn, Michelle S Chew, Maija-Liisa Kalliomäki, Kimberley Lewis, Faisal A Al-Suwaidan, Hasan M Al-Dorzi, Abdulrahman Al-Fares, Naif Alsadoon, Carolyn M Bell, Christine M Groth, Rachael Parke, Sangeeta Mehta, Paul E Wischmeyer, Awad Omeri, Klaus T Olkkola, Waleed Alhazzani
Background: This Rapid Practice Guideline (RPG) aimed to provide evidence-based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research.
Methods: The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities.
Results: Data from 17 randomized clinical trials (n = 898) and nine observational studies (n = 1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied.
Conclusion: The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.
{"title":"Ketamine analgo-sedation for mechanically ventilated critically ill adults: A rapid practice guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine.","authors":"Marwa Amer, Morten Hylander Møller, Mohammed Alshahrani, Yahya Shehabi, Yaseen M Arabi, Fayez Alshamsi, Martin Ingi Sigurðsson, Marius Rehn, Michelle S Chew, Maija-Liisa Kalliomäki, Kimberley Lewis, Faisal A Al-Suwaidan, Hasan M Al-Dorzi, Abdulrahman Al-Fares, Naif Alsadoon, Carolyn M Bell, Christine M Groth, Rachael Parke, Sangeeta Mehta, Paul E Wischmeyer, Awad Omeri, Klaus T Olkkola, Waleed Alhazzani","doi":"10.1111/aas.14470","DOIUrl":"https://doi.org/10.1111/aas.14470","url":null,"abstract":"<p><strong>Background: </strong>This Rapid Practice Guideline (RPG) aimed to provide evidence-based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research.</p><p><strong>Methods: </strong>The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities.</p><p><strong>Results: </strong>Data from 17 randomized clinical trials (n = 898) and nine observational studies (n = 1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied.</p><p><strong>Conclusion: </strong>The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142091372","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sine Wichmann, Dorthe Ørsnes Christensen, Claus Antonio Juel Jensen, Jette Bangsborg, Mette Kolpen, Morten Heiberg Bestle
Background: Early initiation of targeted antibiotic therapy is important to achieve the best patient outcomes in intubated patients with pneumonia in the intensive care unit (ICU). This study aimed to investigate the applicability of multiplex polymerase chain reaction (PCR) in an ICU by comparing the test results to the results of conventional microbiological methods to assess the possible impact on antibiotic therapy.
Method: This retrospective study investigated adult patients with pneumonia on mechanical ventilation in the ICU. Tracheal aspirates were collected within 24h after intubation and the initiation of mechanical ventilation. Samples were initially tested by conventional microbiological methods and subsequently re-evaluated with rapid multiplex PCR on stored samples. Concordance between the two methods was assessed. An intensivist and a microbiologist retrospectively reviewed the patients' electronic health records for relevant clinical details to evaluate the potential impact of multiplex PCR results on antibiotic therapy.
Results: In this study, 76 patients were enrolled and 55 (72.4%) tested positive for 95 pathogens using multiplex PCR, while conventional microbiological methods identified 40 pathogens in 32 (42.2%) patients. Concordance between the two methods was observed in 42 (55.3%) patients. Multiplex PCR detected 39 additional pathogens in 31 (40.7%) patients. Retrospective analysis indicated potential antibiotic de-escalation in 35 (46.1%) patients and escalation in 4 (5.3%) patients. Multiplex PCR significantly reduced the turnaround time for test results.
Conclusion: In ICU patients with suspected pneumonia, multiplex PCR identified a higher number of pathogens compared to CMM. A retrospective assessment indicates that the use of multiplex PCR could potentially have prompted the de-escalation of antibiotic therapy in nearly half of the patients. Therefore, multiplex PCR may serve as a supplement to CMM in guiding antibiotic stewardship.
{"title":"Antibiotic stewardship with multiplex PCR for pneumonia in intensive care patients: A retrospective study.","authors":"Sine Wichmann, Dorthe Ørsnes Christensen, Claus Antonio Juel Jensen, Jette Bangsborg, Mette Kolpen, Morten Heiberg Bestle","doi":"10.1111/aas.14516","DOIUrl":"https://doi.org/10.1111/aas.14516","url":null,"abstract":"<p><strong>Background: </strong>Early initiation of targeted antibiotic therapy is important to achieve the best patient outcomes in intubated patients with pneumonia in the intensive care unit (ICU). This study aimed to investigate the applicability of multiplex polymerase chain reaction (PCR) in an ICU by comparing the test results to the results of conventional microbiological methods to assess the possible impact on antibiotic therapy.</p><p><strong>Method: </strong>This retrospective study investigated adult patients with pneumonia on mechanical ventilation in the ICU. Tracheal aspirates were collected within 24h after intubation and the initiation of mechanical ventilation. Samples were initially tested by conventional microbiological methods and subsequently re-evaluated with rapid multiplex PCR on stored samples. Concordance between the two methods was assessed. An intensivist and a microbiologist retrospectively reviewed the patients' electronic health records for relevant clinical details to evaluate the potential impact of multiplex PCR results on antibiotic therapy.</p><p><strong>Results: </strong>In this study, 76 patients were enrolled and 55 (72.4%) tested positive for 95 pathogens using multiplex PCR, while conventional microbiological methods identified 40 pathogens in 32 (42.2%) patients. Concordance between the two methods was observed in 42 (55.3%) patients. Multiplex PCR detected 39 additional pathogens in 31 (40.7%) patients. Retrospective analysis indicated potential antibiotic de-escalation in 35 (46.1%) patients and escalation in 4 (5.3%) patients. Multiplex PCR significantly reduced the turnaround time for test results.</p><p><strong>Conclusion: </strong>In ICU patients with suspected pneumonia, multiplex PCR identified a higher number of pathogens compared to CMM. A retrospective assessment indicates that the use of multiplex PCR could potentially have prompted the de-escalation of antibiotic therapy in nearly half of the patients. Therefore, multiplex PCR may serve as a supplement to CMM in guiding antibiotic stewardship.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142078771","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mikkel Schjødt Heide Jensen, Johan Kløvgaard Sørensen, Lone Nikolajsen, Charlotte Runge
Background: Peripheral nerve blocks effectively alleviate postoperative pain. Animal studies and human research suggest that opioid tolerance may reduce the effectiveness of local analgesics. The reduced effectiveness has been observed in opioid-tolerant humans and animals undergoing spinal and infiltration anaesthesia with both lidocaine and bupivacaine. However, the impact on peripheral nerve blocks in humans has not been evaluated. This study aims to assess the onset time and duration of a radial nerve block in opioid-tolerant individuals compared to opioid-naive individuals. We hypothesise that peripheral nerve blocks may be less effective in producing sensory and motor blockades in opioid-tolerant individuals compared to their opioid-naive counterparts.
Methods: Twenty opioid-tolerant individuals will be matched by sex and age with opioid-naïve counterparts. Participants will receive an ultrasound-guided radial nerve block. The primary outcome is the difference in the duration of sensory nerve blockade between the two groups. The secondary outcomes include the onset time of sensory blockade, onset time of motor blockade, and difference in duration of motor nerve blockade.
Conclusion: This study will compare the effectiveness of a peripheral nerve block between opioid-tolerant and opioid-naïve individuals. Any found differences could support a specific postoperative protocol for opioid-tolerant individuals regarding the use of peripheral nerve blocks.
{"title":"Duration of peripheral nerve blocks in opioid-tolerant individuals: A study protocol.","authors":"Mikkel Schjødt Heide Jensen, Johan Kløvgaard Sørensen, Lone Nikolajsen, Charlotte Runge","doi":"10.1111/aas.14513","DOIUrl":"https://doi.org/10.1111/aas.14513","url":null,"abstract":"<p><strong>Background: </strong>Peripheral nerve blocks effectively alleviate postoperative pain. Animal studies and human research suggest that opioid tolerance may reduce the effectiveness of local analgesics. The reduced effectiveness has been observed in opioid-tolerant humans and animals undergoing spinal and infiltration anaesthesia with both lidocaine and bupivacaine. However, the impact on peripheral nerve blocks in humans has not been evaluated. This study aims to assess the onset time and duration of a radial nerve block in opioid-tolerant individuals compared to opioid-naive individuals. We hypothesise that peripheral nerve blocks may be less effective in producing sensory and motor blockades in opioid-tolerant individuals compared to their opioid-naive counterparts.</p><p><strong>Methods: </strong>Twenty opioid-tolerant individuals will be matched by sex and age with opioid-naïve counterparts. Participants will receive an ultrasound-guided radial nerve block. The primary outcome is the difference in the duration of sensory nerve blockade between the two groups. The secondary outcomes include the onset time of sensory blockade, onset time of motor blockade, and difference in duration of motor nerve blockade.</p><p><strong>Conclusion: </strong>This study will compare the effectiveness of a peripheral nerve block between opioid-tolerant and opioid-naïve individuals. Any found differences could support a specific postoperative protocol for opioid-tolerant individuals regarding the use of peripheral nerve blocks.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142078772","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Björn Ahlström, Robert Frithiof, Ing-Marie Larsson, Gunnar Strandberg, Miklos Lipcsey, Michael Hultström
Background: Comorbidities are similarly associated with short-term mortality for COVID-19, acute respiratory distress syndrome (ARDS) and sepsis in intensive care unit (ICU) patients, but their adjusted frequencies at admission are unknown. Thus, we aimed to evaluate the adjusted distribution, reported as odds ratios, of known risk factors (i.e., age, sex and comorbidities) for ICU admission between COVID-19, sepsis and ARDS patients in this nationwide registry-based study.
Methods: In this cohort study, we included adult patients admitted to Swedish ICUs with COVID-19 (n = 7382) during the pandemic and compared them to patients admitted to ICU with sepsis (n = 22,354) or ARDS (n = 2776) during a pre-COVID-19 period. The main outcomes were the adjusted odds for comorbidities, sex, and age in multivariable logistic regression on diagnostic categories in patients admitted to ICU, COVID-19 or sepsis and COVID-19 or ARDS.
Results: We found that most comorbidities, as well as age, had a stronger association with sepsis admission than COVID-19 admission with the exception of male sex, type 2 diabetes mellitus, and asthma that were more strongly associated with COVID-19 admission, while no difference was seen for chronic renal failure and obesity. For COVID-19 and ARDS admission most risk factors were more strongly associated with ARDS admission except for male sex, type 2 diabetes mellitus, chronic renal failure, and obesity which were more strongly associated with COVID-19 admission, whereas hypertension, chronic obstructive pulmonary disease and asthma were not different.
Conclusions: Patients admitted to ICU with sepsis or ARDS carry a heavier burden of comorbidity and high age than patients admitted with COVID-19. This is likely caused by a combination of: (1) respiratory failure in COVID-19 being less dependent on comorbidities than in other forms of ARDS, and the cause of critical illness in other infections causing sepsis and (2) COVID-19 patients being deferred admission in situations where patients with the other syndromes were admitted.
{"title":"Comorbid burden at ICU admission in COVID-19 compared to sepsis and acute respiratory distress syndrome.","authors":"Björn Ahlström, Robert Frithiof, Ing-Marie Larsson, Gunnar Strandberg, Miklos Lipcsey, Michael Hultström","doi":"10.1111/aas.14514","DOIUrl":"https://doi.org/10.1111/aas.14514","url":null,"abstract":"<p><strong>Background: </strong>Comorbidities are similarly associated with short-term mortality for COVID-19, acute respiratory distress syndrome (ARDS) and sepsis in intensive care unit (ICU) patients, but their adjusted frequencies at admission are unknown. Thus, we aimed to evaluate the adjusted distribution, reported as odds ratios, of known risk factors (i.e., age, sex and comorbidities) for ICU admission between COVID-19, sepsis and ARDS patients in this nationwide registry-based study.</p><p><strong>Methods: </strong>In this cohort study, we included adult patients admitted to Swedish ICUs with COVID-19 (n = 7382) during the pandemic and compared them to patients admitted to ICU with sepsis (n = 22,354) or ARDS (n = 2776) during a pre-COVID-19 period. The main outcomes were the adjusted odds for comorbidities, sex, and age in multivariable logistic regression on diagnostic categories in patients admitted to ICU, COVID-19 or sepsis and COVID-19 or ARDS.</p><p><strong>Results: </strong>We found that most comorbidities, as well as age, had a stronger association with sepsis admission than COVID-19 admission with the exception of male sex, type 2 diabetes mellitus, and asthma that were more strongly associated with COVID-19 admission, while no difference was seen for chronic renal failure and obesity. For COVID-19 and ARDS admission most risk factors were more strongly associated with ARDS admission except for male sex, type 2 diabetes mellitus, chronic renal failure, and obesity which were more strongly associated with COVID-19 admission, whereas hypertension, chronic obstructive pulmonary disease and asthma were not different.</p><p><strong>Conclusions: </strong>Patients admitted to ICU with sepsis or ARDS carry a heavier burden of comorbidity and high age than patients admitted with COVID-19. This is likely caused by a combination of: (1) respiratory failure in COVID-19 being less dependent on comorbidities than in other forms of ARDS, and the cause of critical illness in other infections causing sepsis and (2) COVID-19 patients being deferred admission in situations where patients with the other syndromes were admitted.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142054623","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Julie Krath, Jesper Fredskilde, Simone Krogh Christensen, Cecilie Dahl Baltsen, Kamilla Valentin, Ryan Offersen, Peter Juhl-Olsen
Background: Intravenous therapies are essential for hospitalised patients. The rapid dissemination of portable ultrasound machines has eased ultrasound-guided intravenous access and facilitated increased use of long peripheral venous catheters (LPCs). This study aimed to evaluate the clinical performance and complications of LPCs.
Methods: Retrospective, observational single-site study. Data from all consecutively inserted LPCs during a period of 18 months was evaluated. The primary endpoint was the all-cause incidence rate of catheter removal. Secondary endpoints included specific reasons for the catheter removal and the associations between predefined characteristics of the patients, the infusions and the catheters with catheter failure.
Results: During the period, 751 PVCs were inserted in 457 patients. The reasons for catheter removal were recorded in 563 cases. The overall incidence rate of catheter removal was 95.8/1000 catheter days (95% CI 88.4-103.8). The median dwell time was 8 days (IQR 5-14), and the total dwell time was 6136 days. Catheter failure occurred in 283 (50.3%) cases, of which the most common cause was phlebitis (n = 101, 17.9%). In multivariable analyses, the use of the cephalic vein was significantly associated with both all-cause catheter failure (p < .001) and catheter failure due to phlebitis (p < .001). In multivariable analyses, vancomycin infusion was not significantly associated with all-cause catheter failure (HR 1.15 (0.55-2.42), p = .71) or catheter failure due to phlebitis (HR 1.49 (0.49-4.53), p = .49).
Conclusion: The overall incidence rate of catheter removal was 95.8/1000 catheter days, and the most common causes of catheter failure were phlebitis, infiltration and unintended catheter removal. The use of the cephalic vein was significantly associated with catheter failure in multivariable analyses. We did not find an association between vancomycin infusion and catheter failure in multivariable analyses.
{"title":"The performance and complications of long peripheral venous catheters: A retrospective single-centre study.","authors":"Julie Krath, Jesper Fredskilde, Simone Krogh Christensen, Cecilie Dahl Baltsen, Kamilla Valentin, Ryan Offersen, Peter Juhl-Olsen","doi":"10.1111/aas.14517","DOIUrl":"https://doi.org/10.1111/aas.14517","url":null,"abstract":"<p><strong>Background: </strong>Intravenous therapies are essential for hospitalised patients. The rapid dissemination of portable ultrasound machines has eased ultrasound-guided intravenous access and facilitated increased use of long peripheral venous catheters (LPCs). This study aimed to evaluate the clinical performance and complications of LPCs.</p><p><strong>Methods: </strong>Retrospective, observational single-site study. Data from all consecutively inserted LPCs during a period of 18 months was evaluated. The primary endpoint was the all-cause incidence rate of catheter removal. Secondary endpoints included specific reasons for the catheter removal and the associations between predefined characteristics of the patients, the infusions and the catheters with catheter failure.</p><p><strong>Results: </strong>During the period, 751 PVCs were inserted in 457 patients. The reasons for catheter removal were recorded in 563 cases. The overall incidence rate of catheter removal was 95.8/1000 catheter days (95% CI 88.4-103.8). The median dwell time was 8 days (IQR 5-14), and the total dwell time was 6136 days. Catheter failure occurred in 283 (50.3%) cases, of which the most common cause was phlebitis (n = 101, 17.9%). In multivariable analyses, the use of the cephalic vein was significantly associated with both all-cause catheter failure (p < .001) and catheter failure due to phlebitis (p < .001). In multivariable analyses, vancomycin infusion was not significantly associated with all-cause catheter failure (HR 1.15 (0.55-2.42), p = .71) or catheter failure due to phlebitis (HR 1.49 (0.49-4.53), p = .49).</p><p><strong>Conclusion: </strong>The overall incidence rate of catheter removal was 95.8/1000 catheter days, and the most common causes of catheter failure were phlebitis, infiltration and unintended catheter removal. The use of the cephalic vein was significantly associated with catheter failure in multivariable analyses. We did not find an association between vancomycin infusion and catheter failure in multivariable analyses.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142054624","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: The COVID-19 pandemic stretched Swedish intensive care unit (ICU) resources to an extent never experienced before, but even before the pandemic staffing was difficult and the number of staffed ICU beds was low. Studies have revealed high levels of COVID-19 ICU staff burn-out and fatigue, and as similar situations with high demands are likely to occur in the future a better understanding of resources that improve staff resilience is important. Using the job-demand resource theory as a framework, we explored ICU professionals' views on demands and resources when working in COVID-19 ICUs with the aim to highlight factors that increased the job resources.
Methods: Data were collected via a web survey distributed to COVID-19 ICU professionals, including both regular and temporary roles, working in 13 COVID-19 ICU wards in Stockholm and Sörmland counties during the spring 2021. A total of 251 written responses to the question "What would have made work in the COVID-19 ICU less demanding?" were analyzed using thematic analysis. One year later a member-checking focus group interview was conducted to validate and further explore staff experiences.
Results: The main themes were work strategy, fairness and support, continuity, accessible leadership, introduction/information, and crisis preparedness. The analysis of the focus group conducted confirmed the main results and the extreme demands on ICU staff during the initial stages of the pandemic.
Conclusion: To increase staff health and performance in a long-term crisis our results suggest; maintaining workplace leadership, scheduling work in advance and, when possible, schedule for recovery.
{"title":"What would have made work in the COVID-19 ICU less demanding? A qualitative study from 13 Swedish COVID-19 ICUs.","authors":"Cecilia Escher, Fanny Engqvist, Johan Creutzfeldt, Oili Dahl, Mats Ericson, Lisbet Meurling","doi":"10.1111/aas.14518","DOIUrl":"https://doi.org/10.1111/aas.14518","url":null,"abstract":"<p><strong>Background: </strong>The COVID-19 pandemic stretched Swedish intensive care unit (ICU) resources to an extent never experienced before, but even before the pandemic staffing was difficult and the number of staffed ICU beds was low. Studies have revealed high levels of COVID-19 ICU staff burn-out and fatigue, and as similar situations with high demands are likely to occur in the future a better understanding of resources that improve staff resilience is important. Using the job-demand resource theory as a framework, we explored ICU professionals' views on demands and resources when working in COVID-19 ICUs with the aim to highlight factors that increased the job resources.</p><p><strong>Methods: </strong>Data were collected via a web survey distributed to COVID-19 ICU professionals, including both regular and temporary roles, working in 13 COVID-19 ICU wards in Stockholm and Sörmland counties during the spring 2021. A total of 251 written responses to the question \"What would have made work in the COVID-19 ICU less demanding?\" were analyzed using thematic analysis. One year later a member-checking focus group interview was conducted to validate and further explore staff experiences.</p><p><strong>Results: </strong>The main themes were work strategy, fairness and support, continuity, accessible leadership, introduction/information, and crisis preparedness. The analysis of the focus group conducted confirmed the main results and the extreme demands on ICU staff during the initial stages of the pandemic.</p><p><strong>Conclusion: </strong>To increase staff health and performance in a long-term crisis our results suggest; maintaining workplace leadership, scheduling work in advance and, when possible, schedule for recovery.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142071713","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Bettina N Nielsen, Steen W Henneberg, Eva Malmros Olsson, Stefan Lundeberg
Background: Minor but painful medical procedures are often handled at the operating room. If safe and effective treatment options are available many procedures may be performed outside of the operating room.
Objective(s): The objective of this study is to assess the adverse events of intranasal s-ketamine and/or sufentanil alone or as part of a multimodal analgesic regime for medical procedures outside of the operating room. Secondary outcomes included analgesic effect, doses and indications for use.
Design: Retrospective observational study.
Setting: Tertiary care paediatric hospital.
Patients: Children 1 year up till 18 years.
Intervention(s): Intranasal (IN) sufentanil (S), intranasal s-ketamine (K) or the free combination of the two drugs (SK).
Main outcome measure(s): The frequency of adverse events including serious adverse events reported by intervention.
Results: Between 2004 and 2014, 2185 medical procedures were registered, including 652 procedures with IN SK, 1469 procedures with IN S and 64 procedures with IN K. The children's median age was 5.6 years (range 1.0-17.9). Medical procedures with at least one adverse event were 18% with IN SK, 25% with IN K and 18% with IN S. Common adverse events included episodes of vomiting (9%), nausea (8%) and dizziness (3%). In two patients receiving IN S, serious adverse events occurred. One patient had respiratory depression and bronchospasm and another patient with cerebral palsy had a seizure. Both were handled immediately and did not result in any sequelae. The median doses of intranasal sufentanil were 38% lower when combined with s-ketamine (IN SK free combination: sufentanil dose 0.5 μg/kg (range 0.2-1.3) and s-ketamine dose 0.5 mg/kg (range 0.2-1.5). IN S monotherapy, sufentanil dose 0.8 μg/kg (range 0.2-2.7)). Similar analgesic effect was reported for S and SK.
Conclusions: Intranasal sufentanil and/or s-ketamine are feasible for the treatment of procedural pain in an ambulatory setting with appropriate per- and post-procedural observations and trained staff.
背景:轻微但痛苦的医疗程序通常在手术室进行。如果有安全有效的治疗方案,许多手术可以在手术室外进行:本研究的目的是评估鼻内氯胺酮和/或舒芬太尼单独或作为多模式镇痛方案的一部分用于手术室外医疗程序的不良反应。次要结果包括镇痛效果、使用剂量和适应症:设计:回顾性观察研究:患者:1岁至18岁的儿童:干预措施:干预措施:鼻内注射舒芬太尼(IN)、鼻内注射氯胺酮(K)或两种药物的自由组合(SK):结果:2004 年至 2014 年间,2185 名医护人员使用了舒芬太尼(IN)、鼻内氯胺酮(K)或两种药物的自由组合(SK):2004年至2014年期间,共登记了2185例医疗程序,其中652例使用IN SK,1469例使用IN S,64例使用IN K。使用 IN SK、IN K 和 IN S 的医疗程序中,至少出现一次不良事件的比例分别为 18%、25% 和 18%。常见的不良反应包括呕吐(9%)、恶心(8%)和头晕(3%)。两名接受 IN S 治疗的患者出现了严重的不良反应。一名患者出现呼吸抑制和支气管痉挛,另一名脑瘫患者出现癫痫发作。这两起事件都得到了及时处理,没有造成任何后遗症。与 s-Ketamine 联用时,鼻内舒芬太尼的中位剂量降低了 38%(IN SK 自由联用:舒芬太尼剂量为 0.5 μg/kg(范围为 0.2-1.3),s-Ketamine 剂量为 0.5 mg/kg(范围为 0.2-1.5)。在 S 单一疗法中,舒芬太尼剂量为 0.8 μg/kg(范围为 0.2-2.7))。S 和 SK 的镇痛效果相似:结论:在非卧床环境中,通过适当的术前术后观察和训练有素的工作人员,鼻内舒芬太尼和/或氯胺酮可用于治疗手术疼痛。
{"title":"The use of intranasal sufentanil and/or s-ketamine for treatment of procedural pain in children in an ambulatory setting: A retrospective observational study.","authors":"Bettina N Nielsen, Steen W Henneberg, Eva Malmros Olsson, Stefan Lundeberg","doi":"10.1111/aas.14510","DOIUrl":"https://doi.org/10.1111/aas.14510","url":null,"abstract":"<p><strong>Background: </strong>Minor but painful medical procedures are often handled at the operating room. If safe and effective treatment options are available many procedures may be performed outside of the operating room.</p><p><strong>Objective(s): </strong>The objective of this study is to assess the adverse events of intranasal s-ketamine and/or sufentanil alone or as part of a multimodal analgesic regime for medical procedures outside of the operating room. Secondary outcomes included analgesic effect, doses and indications for use.</p><p><strong>Design: </strong>Retrospective observational study.</p><p><strong>Setting: </strong>Tertiary care paediatric hospital.</p><p><strong>Patients: </strong>Children 1 year up till 18 years.</p><p><strong>Intervention(s): </strong>Intranasal (IN) sufentanil (S), intranasal s-ketamine (K) or the free combination of the two drugs (SK).</p><p><strong>Main outcome measure(s): </strong>The frequency of adverse events including serious adverse events reported by intervention.</p><p><strong>Results: </strong>Between 2004 and 2014, 2185 medical procedures were registered, including 652 procedures with IN SK, 1469 procedures with IN S and 64 procedures with IN K. The children's median age was 5.6 years (range 1.0-17.9). Medical procedures with at least one adverse event were 18% with IN SK, 25% with IN K and 18% with IN S. Common adverse events included episodes of vomiting (9%), nausea (8%) and dizziness (3%). In two patients receiving IN S, serious adverse events occurred. One patient had respiratory depression and bronchospasm and another patient with cerebral palsy had a seizure. Both were handled immediately and did not result in any sequelae. The median doses of intranasal sufentanil were 38% lower when combined with s-ketamine (IN SK free combination: sufentanil dose 0.5 μg/kg (range 0.2-1.3) and s-ketamine dose 0.5 mg/kg (range 0.2-1.5). IN S monotherapy, sufentanil dose 0.8 μg/kg (range 0.2-2.7)). Similar analgesic effect was reported for S and SK.</p><p><strong>Conclusions: </strong>Intranasal sufentanil and/or s-ketamine are feasible for the treatment of procedural pain in an ambulatory setting with appropriate per- and post-procedural observations and trained staff.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141999245","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mark Puch Oernskov, Geana Paula Kurita, Suzanne Forsyth Herling, Per Sjøgren, Svetlana Ondrasova Skurtveit, Ingvild Odsbu, Ola Ekholm, Kim Wildgaard
Background: Over the past 25 years, global opioid consumption has increased. Denmark ranks fifth in opioid use globally, exceeding other Scandinavian countries. Postsurgical pain is a common reason for opioid prescriptions, but opioid use patterns after patient discharge from the hospital are unclear. This study examines trends in opioid prescription among Danish surgical patients over a year.
Methods: This register-based cohort study will use data from Danish governmental databases related to patients undergoing the 10 most frequent surgical procedures in 2018, excluding cancer-related and minor procedures. The primary outcome will be the dispensed postoperative opioid prescriptions at retail pharmacies over four quarters. Secondary analyses will include associations with sex, age, education attainment, and oral morphine equivalent quotient. Surgical treatments and diagnoses will be identified using NOMESCO procedure codes and ICD-10 codes. Opioids will be identified by ATC codes N02A and R05DA04. Subjects will be classified as preoperative opioid consumers or non-opioid consumers based on opioid prescriptions redeemed in the 6 months before surgery.
Discussion: The study will use extensive national register-based data, ensuring consistent data collection and enhancing the generalizability of the findings to similar healthcare systems. The study may identify high-risk populations for long-term opioids and provide information to support opioid prescribing guidelines and public health policies.
{"title":"Opioid use after surgical treatment in the Danish population-Protocol for a register-based cohort study.","authors":"Mark Puch Oernskov, Geana Paula Kurita, Suzanne Forsyth Herling, Per Sjøgren, Svetlana Ondrasova Skurtveit, Ingvild Odsbu, Ola Ekholm, Kim Wildgaard","doi":"10.1111/aas.14506","DOIUrl":"https://doi.org/10.1111/aas.14506","url":null,"abstract":"<p><strong>Background: </strong>Over the past 25 years, global opioid consumption has increased. Denmark ranks fifth in opioid use globally, exceeding other Scandinavian countries. Postsurgical pain is a common reason for opioid prescriptions, but opioid use patterns after patient discharge from the hospital are unclear. This study examines trends in opioid prescription among Danish surgical patients over a year.</p><p><strong>Methods: </strong>This register-based cohort study will use data from Danish governmental databases related to patients undergoing the 10 most frequent surgical procedures in 2018, excluding cancer-related and minor procedures. The primary outcome will be the dispensed postoperative opioid prescriptions at retail pharmacies over four quarters. Secondary analyses will include associations with sex, age, education attainment, and oral morphine equivalent quotient. Surgical treatments and diagnoses will be identified using NOMESCO procedure codes and ICD-10 codes. Opioids will be identified by ATC codes N02A and R05DA04. Subjects will be classified as preoperative opioid consumers or non-opioid consumers based on opioid prescriptions redeemed in the 6 months before surgery.</p><p><strong>Discussion: </strong>The study will use extensive national register-based data, ensuring consistent data collection and enhancing the generalizability of the findings to similar healthcare systems. The study may identify high-risk populations for long-term opioids and provide information to support opioid prescribing guidelines and public health policies.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141915834","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Clinical and physiological consequences of preoxygenation using high-flow nasal oxygen in emergency anaesthesia.","authors":"Albin Sjöblom","doi":"10.1111/aas.14499","DOIUrl":"https://doi.org/10.1111/aas.14499","url":null,"abstract":"","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141970349","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}