Acta Anaesthesiologica Scandinavica最新文献

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: 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.

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: Feeding intolerance is common in critically ill patients and can lead to malnutrition. Prokinetic agents may be used to enhance the uptake of nutrition. However, the evidence on the effectiveness and safety of prokinetic agents is sparse, and there is a lack of data on their use in intensive care units (ICU).

Methods: We will conduct an international 14-day inception cohort study of 1000 acutely admitted adult ICU patients. Data will be collected from ICU admission and daily during ICU stay for up to 90 days. The primary outcome will be the proportion of ICU patients who receive prokinetic agents. Secondary outcomes include mortality, days alive without life support, days alive out of ICU, days alive out of hospital (all within 90 days) and the number of patients with one or more serious adverse events.

Results: We will present data on the use of prokinetic agents descriptively and use Cox regressions with death and ICU discharge as competing events to evaluate the association between patient characteristics and the use of prokinetic agents. We will use extended Cox models with time-varying covariates and linear regression models to assess the associations between the use of prokinetic agents and the secondary outcomes.

Conclusion: The outlined international cohort study will provide valuable epidemiological data on the use of prokinetic agents in adult, acutely admitted ICU patients.

Background: Frailty is strongly correlated with mortality in intensive care unit patients, yet routine screening among intensive care patients is rarely performed. The aim of this study is to assess frailty and health-related quality of life (HRQoL) in patients before intensive care admission and to compare this with outcomes after 3 and 12-months. The Clinical Frailty Scale and EQ-5D-5L will be used to assess frailty and HRQoL, respectively.

Methods: This is an ongoing, prospective observational study including patients from five Norwegian ICU's. Inclusion criteria are patients aged ≥65 years requiring invasive mechanical ventilation for ≥24 h. The Clinical Frailty Scale and EQ-5D-5L are administered at baseline (before critical illness) and at 3- and 12-months post-inclusion. Additional data collected includes patient characteristics, ICU treatment details, illness severity and mortality. The EQ-5D-5L will be compared to Norwegian population norms and assessed for measurement properties.

Results: Inclusion started July 2022 and will be stopped at 350 patients. The study will be completed in 2025.

Conclusion: The study will assess the feasibility and measurement properties of the Clinical Frailty Scale and EQ-5D-5L in ICU survivors by telephone at long-term follow-up study and will give additional information on the frailty and HRQoL of intensive care survivors.

Clinical trial registration: The study is registered in ClinicalTrials.gov NCT06012942. Protocol version 2.7.1, 19.05.2023.

Background: Burnout is frequent among intensive care unit (ICU) healthcare professionals and may result in medical errors and absenteeism. The COVID-19 pandemic caused additional strain during working hours and also affected off-duty life. The aims of this study were to survey burnout levels among ICU healthcare professionals during the first year of COVID-19, describe those who reported burnout, and analyse demographic and work-related factors associated with burnout.

Methods: This was a national prospective longitudinal cohort study of 484 nurses, physicians and leaders working in intensive care units with COVID-19 patients in Norway. Burnout was measured at 6- and 12-month follow-up, after a registration of baseline data during the first months of the COVID epidemic. The Copenhagen Burnout Inventory (CBI), was used (range 0-100), burnout caseness defined as CBI ≥50. Bi- and multivariable logistic regression analyses were performed to examine baseline demographic variables and work-related factors associated with burnout caseness at 12 months.

Results: At 6 months, the median CBI score was 17, increasing to 21 at 12 months (p = .037), with nurses accounting for most of the increase. Thirty-two per cent had an increase in score of more than 5, whereas 25% had a decrease of more than 5. Ten per cent reported caseness of burnout at 6 months and 14% at 12 months (n.s.). The participants with burnout caseness were of significantly lower age, had fewer years of experience, reported more previous anxiety and/or depression, more moral distress, less perceived hospital recognition, and more fear of infection in the bivariate analyses. Burnout was the single standing most reported type of psychological distress, and 24 out of 41 (59%) with burnout caseness also reported caseness of anxiety, depression and/or post-traumatic stress disorder (PTSD) symptoms. Multivariate analysis showed statistically significant associations of burnout caseness with fewer years of professional experience (p = .041) and borderline significance of perceived support by leader (p = .049).

Conclusion: In Norway, a minority of ICU nurses, physicians and leaders reported burnout 1 year into the pandemic. A majority of those with burnout reported anxiety, depression and/or PTSD symptoms combined. Burnout was associated with less years of professional experience.