Acta Anaesthesiologica Scandinavica最新文献

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: The video versus face-to-face preoperative anaesthetic assessment (VIDFACE) trial is a randomised, multicentre, two-arm, superiority, assessor- and data analyst blinded clinical trial. The routine use of preoperative assessments is accepted as the gold standard for elective surgery, reducing both morbidity and mortality. In recent years, video-based assessments have been investigated with a focus on patient satisfaction and enhancing efficacy. The VIDFACE trial aims to compare video-based preoperative anaesthetic assessment with face-to-face assessments, with a focus on patient safety and satisfaction.

Objective: To report the statistical analysis plan for the VIDFACE randomised clinical trial.

Methods/design: We will enrol 2260 adult participants undergoing elective ear-nose-throat or oral and maxillofacial surgery. Participants will be randomised 1:1 stratified by 'trial site' and 'known or suspected malignant/haematological condition' to either intervention (video-based preoperative anaesthetic assessment) or control (face-to-face preoperative anaesthetic assessment). Two blinded statisticians will analyse the data. Before unblinding, we will write two abstracts based on the initial blinded analysis, one assuming A is intervention and B is control and one with the opposite assumption. Primary outcome is a composite outcome including five predefined serious complications. We assume a 30% relative risk reduction of the primary composite outcome. An interim analysis will take place after inclusion and follow-up on half of the intended sample size.

Conclusion: This statistical analysis plan of the VIDFACE trial will minimise analysis bias and add transparency to the statistics applied in the results of the trial.

Trial registration: ClinicalTrials.gov identifier: NCT06765538.

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.

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: Several drugs may be used to minimize pain during nasal intubation in awake patients. We hypothesized that the analgesic effect of cocaine would be at least as good (non-inferior) as that of lidocaine with xylometazoline rated as maximum pain felt during awake nasal intubation of healthy volunteers.

Methods: We conducted an outcome assessor blinded, randomized, triple crossover, non-inferiority study following approval from the local research ethics committee and the national medicine agency. Healthy volunteers came for three visits and received 2 mL 4% cocaine, 0.5 mL 4% lidocaine + 1.5 mL 0.1% xylometazoline, and 2 mL 0.9% saline in random order prior to nasal insertion of an endotracheal tube. Maximum pain felt during insertion was evaluated on a visual analogue scale of 0-100 mm. The non-inferiority margin was set to 11 mm on the visual analogue scale.

Results: A total of 16 volunteers were enrolled, and 14 completed all three visits. Maximum pain felt during tube insertion was a median of 69 mm (interquartile range [IQR]: 56-73 mm) after cocaine, 60 mm (IQR: 50-76 mm) after lidocaine/xylometazoline, and 70 mm (IQR: 63-81 mm) after saline. The mean difference in maximum pain scores between cocaine and lidocaine/xylometazoline was 3.3 mm (95% confidence interval: -4.6 to 11.1; p = 0.40).

Conclusion: We found no statistically significant difference in pain scores between cocaine and lidocaine/xylometazoline when administered prior to awake nasal intubation but cannot conclude that cocaine was non-inferior to lidocaine/xylometazoline.

Editorial comment: Nasal intubation may be uncomfortable and can be complicated by epistaxis. Cocaine has both vasoconstrictive and analgesic properties and was compared with placebo and lidocaine/xylometazoline for awake intubation in healthy volunteers. The trial did not identify any clinically important differences between groups in terms of pain or serious adverse events. Differences were numerically small, and non-inferiority between the active treatments was not demonstrated.

Trial registration: Clinicaltrials.gov identifier: NCT06443255.

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.