Acta Anaesthesiologica Scandinavica最新文献

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Background: Dysphagia is independently associated with adverse outcomes in intensive care units (ICU). Early identification through dysphagia screening does not occur routinely, negatively impacting optimal patient management. This study aimed to validate the Swedish version of the Gugging Swallowing Screen-Intensive Care Unit (GUSS-IVA).

Methods: This is a prospective multicentre study of 56 adult ICU patients with endotracheal intubation exceeding 48 h at three hospitals in Sweden. The GUSS-ICU was translated into Swedish (GUSS-IVA) and used to screen all prolonged intubated patients (>48 h) once extubated. The GUSS-IVA screen was conducted by ICU nursing staff and then compared with a gold standard Flexible Endoscopic Evaluation of Swallowing (FEES) within 2 h of the GUSS-IVA screen. Fifty-one of 56 patients underwent FEES (where assessors were blinded to the GUSS-IVA screen results). Sensitivity and specificity were calculated, as was the area under the receiver operating characteristic curves (AUC) with 95% confidence intervals (CI). For inter-rater reliability, within 2 h of the initial screen, 29/56 patients were GUSS-IVA screened a second time by a nursing staff blinded to the first GUSS-IVA results.

Results: Among the 56 patients, 38 (67.9%) were identified as dysphagic using the GUSS-IVA screen. With FEES, 42 of 51 patients (82.4%) were diagnosed with dysphagia; of these, 16 (31.4%) were classified as aspirating. Compared to FEES, GUSS-IVA showed high sensitivity and specificity values (81% and 89%, respectively) with an AUC of 0.85 (95% CI: 0.71-0.95) and a positive predictive value of 97%. High convergent validity was obtained for GUSS-IVA compared with the Dysphagia Outcome Severity Scale (ɸ = 0.57, p < .001) and the Functional Oral Intake Scale (ɸ = 0.52, p < .001) and moderate validity with the Penetration-Aspiration Scale (ɸ = 0.30, p = .033). The inter-rater reliability showed moderate agreement (Cohen's kappa κ = 0.501, p = .006).

Conclusions: This study indicates that the Swedish GUSS-IVA is a valid and reliable screen to identify dysphagic ICU patients. Given the negative impact of dysphagia on short and long-term patient outcomes, the Swedish GUSS-IVA is recommended as an essential first step by nursing staff for early identification of dysphagia for further diagnostics and subsequent patient management.

Background: Fever is associated with brain injury after cardiac arrest. It is unknown whether fever management with a feedback-controlled device impacts patient-centered outcomes in cardiac arrest patients. This trial aims to investigate fever management with or without a temperature control device after out-of-hospital cardiac arrest.

Methods: The TEMP-CARE trial is part of the 2 × 2 × 2 factorial Sedation, TEmperature and Pressure after Cardiac Arrest and REsuscitation (STEPCARE) trial, a randomized, international, multicenter, parallel-group, investigator-initiated, superiority trial that will evaluate sedation strategies, temperature management, and blood pressure targets simultaneously in nontraumatic/nonhemorrhagic out-of-hospital cardiac arrest patients following hospital admission. For the temperature management component of the trial described in this protocol, patients will be randomly allocated to fever management with or without a feedback-controlled temperature control device. For those managed with a device, if temperature ≥37.8°C occurs within 72 h post-randomization the device will be started targeting a temperature of ≤37.5°C. Standard fever treatment, as recommended by local guidelines, including pharmacological agents, will be provided to participants in both groups. The two other components of the STEPCARE trial evaluate sedation and blood pressure 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. A physician blinded to the intervention will determine the neurological prognosis following European Resuscitation Council and European Society of Intensive Care Medicine guidelines. The primary outcome is all-cause mortality at six months post-randomization. To detect a 5.6% absolute risk reduction (90% power, alpha .05), 3500 participants will be enrolled. Secondary outcomes include poor functional outcome at six months, intensive care-related serious adverse events, and overall health status at six months.

Conclusion: The TEMP-CARE trial will investigate if post-cardiac arrest management of fever with or without a temperature control device affects patient-important outcomes after cardiac arrest.

Background: The study aimed to compare the difference in long-term mortality in patients with moderate to severe traumatic brain injury (TBI) receiving Early interdisciplinary rehabilitation (EIR) in our Neurointensive Care Unit (NICU) to patients being discharged from NICU without EIR.

Methods: Retrospective observational cohort study of adults aged 18-67 years with moderate to severe TBI (Glasgow Coma Scale 3-14), admitted to the NICU for >72 h from 2010 to 2022. We analyzed mortality differences from the start of follow-up (cessation of sedation in the Standard of care (SC) group and start of EIR in the EIR group) until 31.12.2023, using inverse probability of treatment weighted Cox proportional hazard models and Kaplan-Meier survival curves. Adjustments using weights were made for various variables, including age, days from injury to follow-up start, sociodemographic factors, comorbidities, and injury characteristics.

Results: A total of 698 patients were included, 461 received EIR and 237 SC. Sixty-three (27%) patients in the SC group and 59 (13%) patients in the EIR group died by the end of follow-up. In covariate-adjusted Kaplan-Meier curves, estimated survival at the end of follow-up was 56% (95% CI 0.36, 0.69) for the SC group and 74% (95% CI 0.58, 0.83) for the EIR group. Both groups had the highest mortality rate within 30 days. The mortality in the EIR group was significantly lower with an adjusted hazard ratio (HR) at 30 days of 0.57 (95% CI 0.37, 0.87) p-value = .010, and at the end of follow-up of 0.56 (95% CI 0.36, 0.89), p-value = .015.

Conclusions: Patients receiving EIR had better long-term survival, with both groups experiencing the highest mortality rate early on. Early rehabilitation in NICU may play an important role in preventing and identifying medical complications and should be explored as a potential mechanism in future prospective trials.

Editorial comment: Neurorehabilitation following intensive care for traumatic brain injury is important to help the patients regain function. However, it is uncertain whether survival is improved by the initiation of interdisciplinary rehabilitation already during neurointensive care, consisting of mobilization and training activities of daily living as well as swallowing. This study compared long-term survival in a retrospective cohort of patients with moderate to severe traumatic brain injury and found that those receiving early rehabilitation had a higher long-term survival, which persisted for up to 13 years but was mainly due to improved survival during the first 3 months. Whether this is due to physiological effects or an increased enthusiasm among healthcare providers to continue active treatment is unknown and should be further explored.

Background: The use of epidural analgesia has been proposed to improve the prognosis of esophageal cancer by attenuating the stress response and being less immunosuppressive than opioids. This study aims to evaluate the association, if any, between non-epidural pain management compared to epidural analgesia during minimally invasive or open esophagectomy and esophageal cancer prognosis.

Materials and methods: This was a population-based nationwide retrospective cohort study in Finland, using the Finnish National Esophago-Gastric Cancer Cohort (FINEGO). Esophagectomy patients with epidural and no epidural analgesia were compared. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (CI) non-epidural pain management compared to epidural analgesia, adjusted for the calendar period of surgery, sex, age, comorbidity (Charlson Comorbidity Index), tumor stage, tumor histology, neoadjuvant therapy, type of surgery, and esophageal cancer surgery volume.

Results: After exclusions, there were 1381 patients available with information on epidural analgesia. Of these, 969 (70.2%) were men and 832 (60.2%) had esophageal adenocarcinoma. After adjustment for confounding factors, non-epidural pain management was not associated with higher 90-day mortality (HR 1.022 95% CI 0.582-1.794), overall mortality up to 5 years (HR 1.156 95% CI 0.909-1.470), nor with 5 years cancer-specific mortality (HR 1.134 95% CI 0.884-1.456) compared to epidural analgesia.

Conclusion: Although the point estimates may hint at a potentially improved prognosis associated with epidural use, this population-based nationwide study suggests no statistically significant association between epidural analgesia during esophagectomy and esophageal cancer prognosis.

Editorial comment: This large esophagectomy (cancer) cohort in Finland was used to compare those who received epidural analgesia with those who did not for associations with late mortality in a retrospective analysis and where anesthesia and analgesia treatments were not controlled. The findings showed that when other recognized risks for mortality were taken into account, there was not a meaningful difference in relative risk for late mortality related to the presence or absence of epidural analgesia, though the analgesia treatments were not randomly allocated. These results do not rule out associations of analgesia choice with other outcomes that might be important to patients.

Background: Flexible optical intubation (FOI) is the preferred technique for managing anticipated difficult airways, particularly in awake patients when anatomical factors complicate conventional laryngoscopy. Mastering the procedure requires skills, but a comprehensive overview of the evidence on training and assessment of FOI skills is lacking. There is no evidence-based consensus on educational strategies and recommendations for skill acquisition and retention, thus highlighting a significant gap in airway management training. Accordingly, we aim to assess the current evidence on training and assessment in FOI for future educational recommendations.

Methods: This scoping review adheres to the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) statement and the PRISMA Extension for Scoping Reviews guideline. Eligible studies include qualitative and quantitative research focusing on education, technical training, and assessment of FOI skills in clinical personnel with no obligate comparator. Outcomes should be assessable using Kirkpatrick's four levels of training evaluation. A systematic literature search will be conducted across multiple databases, including Cochrane Library, EMBASE, Cinahl, Scopus, and PubMed. Two independent authors will screen the studies, with discrepancies resolved by a third reviewer. Extracted data will be analyzed descriptively, with a discussion on potential biases in the included literature. The quality of the studies will be assessed using the Medical Education Research Study Quality Instrument (MERSQI).

Discussion: The results of this scoping review may serve as a foundation for educational recommendations. By synthesizing available evidence, this review aims to guide future research and policy recommendations for FOI skill acquisition and maintenance.