Acta Anaesthesiologica Scandinavica最新文献

Background: Disturbances in plasma sodium and chloride are common in adults admitted to the intensive care unit (ICU) and may affect patient outcomes. Fluid administration practices in the ICU have changed in recent years with a trend toward using more restrictive fluid strategies. These changes may have influenced the patterns and proportions of electrolyte disturbances in ICU patients. Therefore, we aim to provide contemporary data on the frequency of hypernatremia, hyponatremia, hyperchloremia, and hypochloremia in adult ICU patients, assess risk factors, and association with clinical outcomes in an international cohort.

Methods: This is the protocol for a sub-study of the FLUID-ICU study ("Fluid administration and fluid accumulation in intensive care units-an international inception cohort study"). The FLUID-ICU study is a prospective international 14-day inception cohort study with a minimum sample size of 1000 patients from more than 50 ICUs. Patients are followed daily from ICU admission to discharge or death with a maximum of 28 days. A follow-up is performed at Day 90 after ICU admission. The primary outcomes of this sub-study are the proportion of patients with hypernatremia, hyponatremia, hyperchloremia, and hypochloremia. We will assess days alive without the use of life support at Day 90, and risk factors for developing disturbances in sodium and chloride including disease severity by SMS-ICU score, type of ICU, use of diuretics, and presence of fluid accumulation. Furthermore, days alive and out of hospital and mortality at Day 90 will be reported descriptively.

Conclusion: In this study, we will provide important new epidemiological data on the burden of sodium and chloride disturbances in adult ICU patients internationally.

Background: Childbirth is a significant life event often accompanied by intense pain. Although pain perception is highly subjective and influenced by multiple factors, its management is frequently focused solely on pain intensity. Epidural analgesia (EA) is the most effective form of labor pain relief; however, there is limited qualitative research on which aspects of pain relief parturients perceive as successful with EA. Understanding parturients' perspectives on successful pain relief with EA can help improve patient-centered care and enhance labor pain management strategies.

Aim: This qualitative study aims to explore parturients' perspectives on successful pain management during labor with EA, identifying key aspects that contribute to their overall childbirth experience.

Methods: A qualitative, semi-structured interview study will be conducted at Herlev Hospital, Denmark. Approximately 10-15 parturients who received EA during labor will be recruited using purposive sampling within 24 hours postpartum. Interviews will be recorded, transcribed, and analyzed using Braun and Clarke's thematic analysis framework. Data collection will continue until sufficient information power is reached.

Ethical considerations: The study has been approved by the Danish Data Protection Agency (case no. P-2025-18241) and adheres to the Declaration of Helsinki. Informed consent will be obtained from all participants, and data will be anonymized to ensure confidentiality.

Expected outcomes: The study is expected to generate new insights into parturients' experiences of labor pain and EA, contributing to the development of patient-reported outcome measures and informing future clinical practice. Findings may also support the creation of standardized pain assessment tools and influence policies on labor pain management.

Dissemination: Results will be published in a peer-reviewed journal and presented at national and international conferences to inform both clinical practice and future research.

Background: Nasotracheal intubation is commonly used in oral and maxillofacial surgeries due to its improved access to the surgical field. However, the technique can lead to complications like epistaxis and mucosal injuries. The choice of tube and other equipment may impact patient outcomes. This review aims to explore how different tubes and equipment affect patient outcomes during nasotracheal intubation.

Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement, we plan to carry out a scoping review of studies examining the impact of different tubes and equipment on patient outcomes during nasotracheal intubation in adults. We will assess study design, population, type of tube and equipment, and patient outcomes across the included studies.

Results: We plan to provide descriptive analyses of the included studies accompanied by tabulated results to summarize key findings and identify patterns in the data.

Conclusion: This scoping review will summarize the existing evidence on how tube and equipment choices affect patient outcomes during nasotracheal intubation.

Background: During the COVID-19 pandemic, Norway experienced successive waves of hospital and intensive care unit (ICU) admissions, each with distinct characteristics, including patient demographics, medical therapies, vaccine coverage, respiratory failure management and mortality rates. The aim of this study was to analyse survival in a national cohort of adult COVID-19 patients admitted to Norwegian ICUs (March 2020-May 2023) and examine how patient characteristics and management strategies were associated with mortality across successive stages of the pandemic.

Methods: Patients admitted to ICUs between 10 March 2020 and 5 May 2023, were identified via the Norwegian Intensive Care and Pandemic Registry. We included all adults (≥18 years) and analysed data on demographics, predefined risk factors, severity, patient management and outcomes. We quantified associations between patient demographics, risk factors and admission period with mortality and ICU length of stay (LOS).

Results: The study included 2655 patients with confirmed COVID-19. Patients admitted from 2022 onwards were significantly older (median age >70) and had more predefined risk factors compared to those admitted during earlier periods (median age < 65 years). Management of respiratory failure shifted towards less frequent use of invasive mechanical ventilation. The crude 90-day mortality rate doubled from 21% (95% CI 14; 24) in the first half of 2020 to 43.5% (95% CI 31.1; 45.7) in the first half of 2023. ICU LOS decreased substantially from a median of 14.1 days (interquartile range [IQR] 6.8; 23.1) to 2.6 days (IQR 1.1; 5.0). The time period of admission, patient age, pre-defined risk factors and Simplified Acute Physiology Score (SAPS II) were significantly associated with mortality. Prolonged ICU LOS was primarily associated with respiratory support mode, age and higher SAPS II scores.

Conclusion: In this nationwide study of the COVID-19 pandemic in Norway, ICU mortality was significantly higher in later compared to earlier admission periods, largely explained by changes in case mix, such as older patients with more co-morbidities. While ICU therapies were modified over the course of the pandemic, their impact on survival cannot be determined from our analyses (NCT04601090).

Editorial comment: In this article, findings from Norway's national Intensive care database are presented for critically ill SARS-CoV-2 cases, including the different pandemic waves throughout the whole period. Characteristics and trends related to illness and ICU care are presented.

Background: End-of-life care in the Intensive Care Unit (ICU) is complex, requiring a balance of ethical, cultural and medical considerations while ensuring comfort and dignity for critically ill patients and their families.

Aim: We aimed to develop a set of core domains for end-of-life care at Scandinavian ICUs along with corresponding consensus statements from patients, families and multidisciplinary experts.

Methods: In a three-round Delphi study, a multidisciplinary advisory board from Norway, Sweden, Finland, Iceland and Denmark, including ICU physicians, ICU nurses, palliative care specialists and a former ICU patient and family, developed potential end-of-life care domains of interest. Specialists with special competence/interest in end-of-life care and clinicians in all five countries were invited to rank these domains according to their importance and provide recommendations within each domain. The advisory board rephrased the recommendations into statements, which were sent out in the second round for participants to rate based on their level of agreement. Statements that did not achieve consensus in the second round were rephrased and redistributed in the third round.

Results: After the third Delphi round, 59 statements across 10 domains reached consensus. The domains were: 1. Communication at ICU admission, 2. Withholding and withdrawal of therapy and end-of-life care decisions in the ICU, 3. Meeting religious and spiritual needs and the needs of vulnerable patients in the ICU, 4. Extubation and termination of mechanical ventilation at the end of life in the ICU, 5. Management and monitoring of symptoms at the end of life in the ICU, 6. Continuous sedation at the end of life in the ICU, 7. Indicators for specialist palliative care consultations in the ICU, 8. Patient transfers from the ICU at the end of life, 9. Bereavement care and 10. Debriefing in the ICU following a patient's death.

Discussion: We developed core domains and consensus statements aiming at optimising end-of-life care that considers cultural and ethical nuances. The domains may help to shape end-of-life care guidelines in Scandinavian ICUs.

Background: Adult intensive care unit (ICU) patients receive many interventions, but few are supported by high-certainty evidence. Randomised clinical trials (RCTs) are essential for trustworthy comparisons of intervention effects, but conventional RCTs are costly, cumbersome, inflexible, and often turn out inconclusive. Adaptive platform trials may mitigate these issues and have higher probabilities of obtaining conclusive results faster and at lower costs per participant.

Methods: The Intensive Care Platform Trial (INCEPT) is an investigator-initiated, pragmatic, randomised, embedded, multifactorial, international, adaptive platform trial including adults acutely admitted to ICUs. INCEPT will assess comparable groups of interventions (primarily commonly used interventions with clinical uncertainty and practice variation) nested in domains. Interventions may be either open-label or masked. New domains will continuously be added to the platform. INCEPT assesses multiple core outcomes selected following substantial stakeholder involvement: mortality, days alive without life support/out of hospital/free of delirium, health-related quality of life, cognitive function, and safety outcomes. Each domain will use one of these core outcomes as the primary outcome. INCEPT primarily uses Bayesian statistical methods with neutral, minimally informative or sceptical priors, adjustment for important prognostic baseline variables, and calculation of absolute and relative differences in the intention-to-treat populations. Domains and intervention arms may be stopped for superiority/inferiority, practical equivalence, or futility according to pre-specified adaptation rules evaluated using statistical simulation or at pre-specified maximum sample sizes. Domains may use response-adaptive randomisation, meaning that more participants will be allocated to interventions with higher probabilities of being superior.

Conclusions: INCEPT provides an efficient, pragmatic, and flexible platform for comparing the effects of many interventions used in adult ICU patients. The adaptive design enables the trial to use accumulating data to improve the treatment of future participants. INCEPT will provide high-certainty, conclusive evidence for many interventions, directly inform clinical practice, and thus improve patient-important outcomes.

Background: Deep brain stimulation has become the standard of care for refractory Parkinson's disease. Neuroimaging advances have led to image-based targeting of the subthalamic nucleus under general anaesthesia (GA), an approach that renders unnecessary microelectrode recording and stimulation tests under local anaesthesia and conscious sedation (CS). We aimed to compare procedures and incidents related to each anaesthetic approach.

Methods: Retrospective descriptive comparison of deep brain stimulation under CS versus G. We collected patient and procedure data (e.g., comorbidities, difficult airway criteria, intraoperative monitoring, duration of surgery, hospitalization and motor outcomes) and reviewed intraoperative and postoperative haemodynamic, neurologic and surgery-related incidents.

Results: Seventy-eight procedures were analysed, 36 in the CS group (47.4%) and 42 in the GA group (52.6%). One-third of the patients were women, and the median age was 62 years (range, 33-75). In total, 23 patients experienced at least one perioperative incident, 19 (24.4%) in the CS group and 4 (5.1%) in the GA group (p < .001), even though the GA group included higher-risk patients (p < .05). Fourteen patients (17.9%) presented disorientation/agitation, 12 in the CS group (p < .01). The median duration of the surgery was 5.2 h (range, 3.5-9.2 h) in the CS group, split into two sessions, and 4.6 h (range, 4.1-5.2 h) in the GA group (p < .001). The median (interquartile range [IQR]) hospital stay was also longer in the CS group, at 7.5 days (IQR 6.75-10), compared to 3 days (IQR 3-4) in the GA group (p < .0001). Pre- and postoperative movement disorder evaluations for 38 of the 78 patients (49%) showed significantly improved scores after surgery. No differences were found between the two groups either before (p = .41) or after (p = .52) the surgery.

Conclusions: Deep brain stimulation under GA was associated with fewer perioperative incidents, shorter surgeries and shorter hospital stays.

Editorial comment: Patients with Parkinson's disease who are refractory to standard drug therapy may benefit from the implantation of deep-brain stimulating electrodes. In this report, imaging-guided electrode implantation under general anaesthesia was associated with fewer adverse perioperative events as well as shorter procedure times, compared to implantation guided by intraoperative electrode recording and stimulation under conscious sedation. Since imaging- and stimulation-guided implantation confers equal long-term benefits to motor function, the results from the current study suggest that general anaesthesia and imaging-guided implantation represent an overall quality improvement for these patients.

Background: Trauma is a leading cause of death and disability in the pediatric population. CT has gained a key role in the management of pediatric trauma. Recently, there has been an increased focus on limiting exposure to ionizing radiation in pediatric patients. Furthermore, most CT scans performed in the management of pediatric trauma are without clinically relevant findings. Therefore, the proposed scoping review aims to assess the effects of introducing a guideline addressing whether pediatric trauma patients should undergo a CT scan.

Methods: In accordance with the Preferred reporting items for systematic review and meta-analysis extension for scoping reviews (PRISMA-ScR) we will conduct a scoping review assessing the effect of implementing CT-scan guidelines in the management of pediatric trauma. We will examine study design, patient characteristics, details of implemented guidelines, and outcomes across included studies.

Results: Results will be reported both descriptively and in tabulated form.

Conclusion: The proposed scoping review will provide an overview of the published evidence concerning the introduction of CT-scan guidelines for the management of pediatric trauma. This might aid in the implementation of further initiatives to reduce ionizing radiation exposure in the pediatric trauma population.

Background: The number of older patients undergoing surgical procedures with anaesthesia care is projected to rise. In order to cope with the increased demand, the expansion of outpatient surgery may play a decisive role. We aim to investigate the characteristics and outcomes of the older outpatient population.

Patients and methods: The Peri-interventional Outcome Study in the Elderly in Europe (POSE) was a prospective multicenter study investigating characteristics and outcomes in 9497 patients aged 80 years and older undergoing a procedure with anaesthesia care. This secondary analysis of the POSE data investigated characteristics, functional and cognitive outcomes, and mortality in the outpatient in comparison to the inpatient population. Functional status was assessed as independent, partially dependent, and totally dependent at baseline and 30 days postinterventional. Cognitive status was defined by the number of recalled words (0-3) in the Mini-Cog test and brief cognitive screening at baseline and follow-up.

Results: Out of the 9497 older patients, 7562 were planned inpatients and 1935 planned outpatients. Older outpatients presented with fewer comorbidities and fewer medications than older inpatients and underwent minor procedures more often Their baseline functional status was more often independent, and they had a higher estimated probability of staying independent. Outpatients recalled three words at baseline and follow-up more often than inpatients. The estimated 30-day survival probabilities with 95% confidence intervals were 0.997 [0.994; 0.999] in the group with planned outpatient surgery and 0.948 [0.942; 0.953] with planned inpatient surgery.

Conclusion: Our results indicate that functional and cognitive status at baseline and follow-up were higher in planned outpatients than in planned inpatients. However, only short screening tools for the assessment of functional and cognitive status were used. Overall, outpatient interventions were associated with low mortality. Further research is recommended to develop scores that facilitate the identification of patients suitable for outpatient surgery.

Editorial comment: This secondary analysis of a prospectively collected cohort of elderly surgical cases in Europe describes case factors related to inpatient compared to outpatient surgical interventions. The findings show that inpatient or outpatient surgery selection is associated with different degrees of risk for important perioperative outcomes in this cohort.

Background: Nasotracheal intubation is associated with a risk of epistaxis. Decongestion of the nasal mucosa reduces the risk of epistaxis, and different vasoconstrictors may be used. Cocaine has both decongestive and analgesic properties, but it also has side effects. In this systematic review, we aimed to evaluate if cocaine decreases the occurrence and severity of epistaxis when administered topically to the nasal mucosa before nasotracheal intubation.

Methods: We conducted a systematic review and meta-analysis following the PRISMA guidelines based on a predefined protocol. We included randomized clinical trials comparing nasal cocaine to active comparators or placebo for nasotracheal intubation. Two reviewers independently screened studies for eligibility and performed data extraction. Relative risk with 95% confidence intervals was calculated. Predefined primary outcome measures were the occurrence and severity of epistaxis. Secondary outcomes were pain, mechanical complications, and patient-centered side effects. The risk of bias was evaluated using the revised Cochrane Risk of Bias 2 tool for randomized trials, and certainty of evidence on outcome level was assessed according to GRADE.

Results: Six trials (n = 457) were included; one trial was judged as having a low risk of bias. All six trials provided information on the occurrence of epistaxis. The meta-analysis did not support a difference in the occurrence of epistaxis between cocaine and its comparators (fixed effect: relative risk 0.90 [95% confidence interval 0.75 to 1.09, I² of 0%, certainty of evidence: low]). The severity of epistaxis was evaluated on incompatible scales and thus not suitable for meta-analysis. No studies reported on pain or mechanical complications associated with nasotracheal intubation, and data on patient-centered side effects were sparse.

Conclusion: This systematic review with meta-analysis demonstrated that the quantity and certainty of evidence on cocaine used for nasotracheal intubation is low and that there is no firm evidence for the benefits and harms of cocaine compared to other vasoconstrictors and topical analgetics or placebo. Consequently, sufficiently powered randomized trials assessing patient-centered outcomes, including outcomes on side effects, should be conducted before firm conclusions on cocaine for nasotracheal intubation can be drawn.

Editorial comment: Epistaxis can occur with nasotracheal intubation, and topical drug vasoconstrictor effects have been used to reduce this risk. This analysis shows that the evidence base supporting the use of cocaine for reducing the risk of epistaxis in nasotracheal intubation is uncertain.