Acta Anaesthesiologica Scandinavica最新文献

Background: Severe acute respiratory syndrome (ARDS) may require veno-venous extracorporeal membrane oxygenation (V-V ECMO). The aim of this study was to provide data on patient selection and outcome in a nationwide cohort study of patients with COVID-19 associated ARDS supported with V-V ECMO.

Methods: We identified all patients with COVID-19, who were supported with V-V ECMO in Denmark from March 10, 2020, to December 31, 2021, and retrieved data on patients who were referred to- and accepted for ECMO, demographics, outcome data, and complications. Risk factors for mortality were analysed using multivariate Cox regression analysis.

Results: During the study period, 1836 patients were admitted to Danish intensive care units (ICUs). In the same period, there were 197 enquiries for ECMO of whom 118 patients were considered eligible. Overall, 71 patients were cannulated for ECMO; three patients were cannulated for veno-arterial extracorporeal membrane oxygenation (V-A ECMO) due to right sided heart failure and 68 patients were cannulated for V-V ECMO. Two patients accepted for V-V ECMO died during cannulation. The median age was 55 years (IQR 45-60) and 66% were males. The median duration of ECMO support was 13 days (IQR 7-21), mechanical ventilation median 26 days (IQR 14-42), ICU stay median 34 days (IQR 17-46), and length of hospital stay median 41 days (IQR 25-56). Ninety-day mortality was 43%. Age of 60 years or more was associated with an increased risk of mortality. Pre-existing hypertension was associated with a decreased risk of mortality.

Conclusion: A nationwide, Danish cohort study of 68 COVID-19 patients supported with V-V ECMO, showed a 90-day survival of 43%, which is in accordance with reports from comparable cohorts. Age of 60 years or more was associated with an increased risk of mortality. Pre-existing hypertension was associated with a decreased risk of mortality.

Background: The anterior quadratus lumborum (QL) block may be used for postoperative pain management for intra-abdominal surgeries, but the evidence is uncertain. We aimed to investigate the benefit and harm of the anterior QL block compared to placebo/no block for intra-abdominal surgery.

Methods: We searched Medline, Embase, and CENTRAL for randomized controlled trials investigating anterior QL block for postoperative pain management for adult patients undergoing any intra-abdominal surgery. The two co-primary outcomes were cumulative 24-h opioid consumption and serious adverse events. We performed meta-analysis, trial sequential analysis (TSA), assessed the risk of bias, and present the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation approach.

Results: Thirty-five trials randomizing 2418 patients were included in the meta-analyses. Anterior QL block may reduce cumulative 24-h intravenous opioid consumption compared to placebo/no block (MD -10.42 mg, 96.7% CI -14.83 to -6.01, TSA-adjusted CI -17.03 to -3.82, p < .01). Two trials reported on SAEs. Anterior QL block may have little to no effect on the number of serious adverse events compared to placebo (RR 1.49, 96.7% CI 0.19 to 11.47, p = .68), but the evidence is very uncertain. All trial results were assessed as being high risk of bias.

Conclusions: The anterior QL block may reduce cumulative 24-h opioid consumption. Reported serious adverse events were few and the anterior QL block may have little to no effect on the number of SAEs, but the evidence was very uncertain.

Introduction: Viscoelastic testing (VET) has been implemented in clinical care to diagnose and manage coagulation in patients with manifest or high risk of major bleeding. However, the breakdown of formed blood clots, that is, fibrinolysis, has been comparatively less studied. There is an increasing recognition that acute infections trigger a dysregulated immunothrombotic response, which has focused attention on viscoelastic testing to identify in particular fibrinolysis resistant states.

Methods: This scoping review on fibrinolysis assessment using viscoelastic testing will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Publications will be included in the review if they evaluate the fibrinolytic capacity of adult patients admitted to an intensive care unit (ICU) for acute infection (including SARS-CoV2) using VET assays that included a fibrinolytic agent. No date or language restrictions will be applied, and all study designs will be considered. A peer-reviewed search strategy will be employed in multiple electronic bibliographic databases and will also include the grey literature.

Results: The included studies will be reported by descriptive analyses and tabulated results.

Conclusion: This scoping review aims to map the research describing viscoelastic testing (VET) to assess fibrinolysis in acutely infected critically ill patients, with the goal of identifying diagnostic capabilities, any associations with patient outcomes, and the potential to guide clinical management.

Background: Many prehospital emergency patients receive suboptimal treatment for their moderate to severe pain. Various factors may contribute. We aim to systematically review literature pertaining to prehospital emergency adult patients with acute pain and the pain-reducing effects, adverse events (AEs), and safety issues associated with inhaled analgetic agents compared with other prehospital analgesic agents.

Methods: As part of an initiative from the Scandinavian Society of Anaesthesia and Intensive Care Medicine, we conducted a systematic review (PROSPERO CRD42018114399), applying the PRISMA guidelines, Grading of Recommendations Assessment, Development, and Evaluation (GRADE), and Cochrane methods, searching the Cochrane Library, Epistemonikos, Centre for Reviews and Dissemination, PubMed, and EMBASE databases (updated March 2024). Inclusion criteria were the use of inhaled analgesic agents in adult patients with acute pain in the prehospital emergency care setting. All steps were performed by minimum of two individual researchers. The primary outcome was pain reduction; secondary outcomes were speed of onset, duration of effect, and relevant AEs.

Results: We included seven studies (56,535 patients in total) that compared inhaled agents (methoxyflurane [MF] and nitrous oxide [N₂O]) to other drugs or placebo. Study designs were randomized controlled trial (1; n = 60), randomized non-blinded study (1; n = 343), and randomized open-label study (1; n = 270). The remaining were prospective or retrospective observational studies. The evidence according to GRADE was of low or very low quality. No combined meta-analysis was possible. N₂O may reduce pain compared to placebo, but not compared to intravenous (IV) paracetamol, and may be less effective compared to morphine and MF. MF may reduce pain compared to paracetamol, ketoprofen, tramadol, and fentanyl. Both agents may be associated with marked but primarily mild AEs.

Conclusion: We found low-quality evidence suggesting that both MF and N₂O are safe and may have a role in the management of pain in the prehospital setting. There is low-quality evidence to support MF as a short-acting single analgesic or as a bridge to IV access and the administration of other analgesics. There may be occupational health issues regarding the prehospital use of N₂O.

Background: Treatment with opioids is a mainstay in perioperative pain management. While the leading treatment paradigm has been procedure-specific pain management, efforts regarding personalized pain treatment are increasing. The OPI•AID project aims to develop personalized algorithms for perioperative pain management, taking demographic, surgical, and anaesthesiologic factors into account. We will undertake five parallel reviews to illuminate current evidence on different aspects of individual responses to perioperative opioid treatment.

Methods: Inclusion of adult populations in English-written studies. Review-specific searches are developed for the following databases: CENTRAL, MEDLINE, Embase, clinicaltrials.gov, and clinicaltrial.eu. Two authors will independently screen citations, extract data, and assess the risks of bias in each review (QUIPS, PROBAST and RoB2, as relevant).

Conclusion: These reviews will evaluate various aspects of perioperative opioid treatment, including individualized treatment strategies, selection of specific opioids, and individual patient responses. These will guide future development of a personalized perioperative opioid treatment algorithm (OPI•AID) that will be validated and tested clinically against standard of care.

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.

Background: This Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) provides an evidence-based recommendation to address the question: in adult patients in intensive care units (ICUs), should we use small-volume or conventional blood collection tubes?

Methods: We included 23 panelists in 8 countries and assessed and managed financial and intellectual conflicts of interest. Methodological support was provided by the Guidelines in Intensive Care, Development, and Evaluation (GUIDE) group. We conducted a systematic review, including evidence from observational and randomized studies. Using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach, we evaluated the certainty of evidence and developed recommendations using the Evidence-to-Decision framework.

Results: We identified 8 studies (1 cluster and 2 patient-level randomized trials; 5 observational studies) comparing small-volume to conventional tubes. We had high certainty evidence that small-volume tubes reduce daily and cumulative blood sampling volume; and moderate certainty evidence that they reduce the risk of transfusion and mean number of red blood cell units transfused, but these estimates were limited by imprecision. We had high certainty that small-volume tubes have a similar rate of specimens with insufficient quantity. The panel considered that the desirable effects of small-volume tubes outweigh the undesirable effects, are less wasteful of resources, and are feasible, as demonstrated by successful implementation across multiple countries, although there are upfront implementation costs to validate small-volume tubes on laboratory instrumentation.

Conclusion: This ICM-RPG panel made a strong recommendation for the use of small-volume sample collection tubes in adult ICUs based on overall moderate certainty evidence.

Background: Hypernatremia is a common electrolyte disturbance in hospitalised patients associated with adverse outcomes. The aetiology is diverse but often related to fluid therapy and sodium-containing medicaments. We aim to outline the evidence base on hypernatremia in adult hospitalised patients.

Methods: We will conduct a scoping review and adhere to the preferred reporting items for systematic and meta-analysis extension for scoping reviews (PRISMA-ScR). We will systematically search the Cochrane Library, Medline, Pubmed, and Embase from inception with no limitations to language, and include all study designs. We will use the population, exposure, comparator, and outcome-based approach to define eligibility criteria. The population: adult hospitalised patients; exposure: hypernatremia; comparator: no hypernatremia or all types of treatments of hypernatremia; and outcomes: all reported outcomes. Two authors will independently screen and select studies followed by full-text assessment and data extraction in duplicate. All outcome measures will be reported, and descriptive analyses will be performed. The certainty of evidence will be assessed according to an adapted grading of recommendations assessment, development, and evaluation (GRADE) approach.

Discussion: This scoping review will provide an overview of the current evidence regarding the incidence of hypernatremia, treatment modalities, and outcomes reported for hospitalised adult patients with hypernatremia.

Background: Delirium is an acute and fluctuating disturbance in attention, awareness, and cognition, commonly observed in hospital settings, particularly among older adults, critically ill and surgical patients. Delirium poses significant challenges in patient care, leading to increased morbidity, mortality, prolonged hospital stays, and functional decline.

Aim: The aim of this review is to map existing evidence on delirium diagnostic tools suitable for use in patients treated surgically due to hip fracture, to inform clinical practice and enhance patient care protocols in the postoperative setting.

Method: We will conduct a scoping review on delirium diagnostic tools used for adult patients in the postoperative setting according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Eligibility criteria encompass all languages, publications dates, and study designs, with exception of case-reports. We will systematically search multiple databases and include unpublished trials, ensuring a comprehensive review based on a predefined protocol.

Results: Results will be presented descriptively, with supplementary tables and graphs. Studies will be grouped by design, surgical specialties, and diagnostic tools to identify potential variations.

Conclusion: This scoping review will provide an overview of existing delirium diagnostic tools used in the postoperative setting and highlight knowledge-gaps to support future research. Due to the large number of patients affected by postoperative delirium, evidence mapping is much needed to facilitate evidence-based practice.