Acta Anaesthesiologica Scandinavica最新文献

Background: Acute kidney injury (AKI) is a serious complication after lung transplantation, but the reported incidence varies in the literature. No data on AKI have been published from the Swedish lung transplantation program.

Methods: The aim of our study was to investigate the incidence, perioperative risk factors, and effects of early postoperative acute kidney injury (Kidney Disease Improving Global Outcomes [KDIGO] criteria) after lung transplantation. A retrospective, nationwide study of 568 lung-transplanted patients in Sweden between 2011 and 2020 was performed.

Results: The incidence of AKI (any grade) was 42%. Renal replacement therapy was used in 5% of the patients. Preoperative factors independently associated with increased incidence of AKI were higher body mass index (odds ratio [OR]: 1.07, 95% CI: 1.02, 1.12) longer time on transplantation waiting list (OR: 1.05 [1.01, 1.09]), re-transplantation (OR: 2.24 [1.05, 4.80]) and moderate to severe tricuspid regurgitation (OR: 2.61 [1.36, 5.03]). Intraoperative factors independently associated with increased incidence of AKI were use of cardiopulmonary bypass (OR: 2.70 [1.57, 4.63]), increasing number of transfused red blood cell units, and use of immunosuppressive therapy other than routine (OR: 2,56 [1.47, 4.46]). A higher diuresis (OR: 0.70, 95% CI: 0.58-0.85) was associated with less incidence of acute kidney injury. Development of AKI was associated with increased time to extubation (median 30 h, IQR [9, 118] vs. 6 [3, 16]), length of stay in the intensive care unit (9 days [4, 25] vs. 3 [2, 5]) and increased rate of primary graft dysfunction (OR 2.33 [1.66, 3.29]) and 30-day mortality (OR: 10.8 [3.0, 69]).

Conclusions: Acute kidney injury is common after lung transplantation and affects clinical outcomes negatively. Preoperative factors may be used for risk assessment. The use of cardiopulmonary bypass is a potentially modifiable intraoperative risk factor.

Editorial comment: Acute kidney injury is a common complication after lung transplantation that severely influences patient outcomes. This large study of more than 500 patients treated over a decade identified potentially modifiable factors associated with the development of acute kidney injury.

Background: Venous thromboembolism (VTE) is a frequent complication in critically ill patients, who often have multiple risk factors. Pharmacological thromboprophylaxis is widely applied to lower this risk, but guidelines lack dosing recommendations.

Objective: This survey aims to assess current thromboprophylaxis preferences and willingness to participate in future randomized clinical trials (RCTs) on this topic.

Method: We conducted an international online survey between February and May 2023 among intensive care unit (ICU) physicians, including 16 questions about preferences in relation to thromboprophylaxis and preferences on topics for a future RCT. The survey was distributed through the network of the Collaboration for Research in Intensive Care.

Results: A total of 715 physicians from 170 ICUs in 23 countries contributed information, with a mean response rate of 36%. In most ICUs, both pharmacological (n = 166, 98%) and mechanical thromboprophylaxis (n = 143, 84%) were applied. A total of 36 pharmacological thromboprophylaxis regimens were reported. Use of low-molecular-weight heparin (LMWH) was most common (n = 149 ICUs, 87%), followed by subcutaneous unfractionated heparin (n = 44 ICUs, 26%). Seventy-five percent of physicians indicated that they used enoxaparin 40 mg (4000 IU), dalteparin 5000 IU, or tinzaparin 4500 IU once daily, whereas 25% reported the use of 16 other LMWH type and dose combinations. Dose adjustment according to weight was common (78 ICUs, 46%). Participants perceived high variation in the application of thromboprophylaxis and were willing to consider an alternative LMWH type (n = 542, 76%) or dose (n = 538, 75%) in the context of an RCT.

Conclusion: LMWH was the preferred agent for thromboprophylaxis in critically ill patients. There was considerable variation in the application of LMWH for prophylaxis, reflected by the use of different types, doses, and dosing strategies. Most physicians would be willing to participate in an RCT on thromboprophylaxis.

Editorial comment: This survey demonstrates current patterns in implementation preferences for critically ill patients. While there is one approach and drug that is commonly preferred, these findings show that there is some variation in practice.

Background: Epidural analgesia (EA) is widely used for postoperative and labour pain management. Systematic training of healthcare professionals, particularly nurses, is essential for the safe administration and management. This scoping review aimed to identify and map existing EA training programmes.

Methods: A PRISMA-ScR-guided search was conducted across multiple databases and grey literature. Studies on educational interventions for healthcare professionals in EA management were included. Data extraction and categorisation were performed using Kirkpatrick's Four-Level Training Evaluation Model.

Results: Eighteen studies were included, covering classroom training, workshops, self-directed learning, simulation-based training, and on-the-job training. Participants were primarily nurses. Programmes addressed epidural techniques, monitoring and assessment, spinal anatomy and pharmacology, complication management, and patient care. Most studies focused on short-term knowledge gains, with a limited assessment of long-term clinical impacts.

Conclusion: Limited research exists on EA training, with most programmes targeting nurses and relying on classroom-based training. Training structures varied, and evaluations primarily assessed short-term knowledge gains.

Editorial comment: The authors conducted a literature search to get an overview of programmes that aimed to train healthcare staff in managing epidural pain relief. Most of the identified 18 studies described classroom teaching and focused primarily on knowledge about complications. Patient contact in this type of training was not reported. The effectiveness of this type of training in a clinical context was difficult to evaluate based on the published evidence.

Background: Postoperative pain relief has a decisive role in recovery and early mother-child bonding. Recent Danish surveys show that 45%-66% of patients experience severe pain following caesarean section. The aim of this survey is to review the standard practice for postoperative pain management currently provided at Danish delivery centres.

Method: A questionnaire of 16 questions was sent to the anaesthetist team in charge of obstetric anaesthesia, aiming to explore local standard care for caesarean section and pain management at the postoperative care unit and at the ward. The answers were received between April 2023 and November 2023.

Results: All Danish centres provided answers (22/22). Only one centre used intrathecal morphine (dose 40 μg) for postoperative pain management combined with a lipophilic opioid and hyperbaric bupivacaine. The same centre used epidural morphine. The rest relied on oral opioids in addition to NSAID and paracetamol. One centre used opioid-free spinal anaesthesia as standard. Five (23%) centres used extended-release morphine for postoperative treatment. No centres used patient-controlled intravenous opioid analgesia. A total of 16 (73%) centres used truncal nerve blocks for 'rescue' treatment, but only 2 (9%) for prophylaxis. Paracetamol treatment was started before or during surgery in 9 (41%) centres. All centres used NSAID as part of the treatment, but at least 7 (32%) centres had 'perioperative blood loss of more than 1-1.5 L' as a contraindication. Large doses of fentanyl or sufentanil were used for caesarean section under general anaesthesia, and 2 (9%) centres used intravenous morphine before extubation. Difficult cases of severe postoperative pain were solved ad hoc between anaesthetists and obstetricians in all centres.

Conclusion: Most Danish delivery centres relied on oral morphine in addition to NSAIDs and paracetamol for postoperative pain management following caesarean section. Use of truncal nerve blocks, wound infiltration and extended-release morphine showed many differences between centres. Intrathecal morphine was hardly used despite international recommendations due to the concern of side effects. A national research initiative (www.cepra.nu) will facilitate the evaluation of evidence and treatment options following caesarean section in Denmark.

Editorial comment: Using a survey to examine the standard practice for postoperative pain management after caesarean sections in Danish delivery centres, 22 anaesthesia teams responded, reporting the most common postoperative pain management as oral morphine in addition to NSAID and paracetamol. The responses presented variation in local obstetric anaesthetist standard practice. Reporting of intrathecal morphine for post-op analgesia was also noted.

Background: The optimal use of tracheostomy in COVID-19 patients is debated, and considerable uncertainties on the frequency, timing, and outcomes of tracheostomy remain. The objective was to study the frequency and timing of tracheostomy in a real-world population of critically ill COVID-19 patients. The secondary aim was to study whether early tracheostomy was associated with days alive and out of intensive care unit (ICU), days free of invasive mechanical ventilation (IMV), 60-day mortality, ventilator weaning rate, and ICU discharge rate compared to late tracheostomy.

Methods: The study is a retrospective two-center cohort study. All COVID-19 patients admitted to critical care in the Region Östergötland County Council, Sweden, between March 2020 and September 2021 were included. Early (≤10 days from tracheal intubation) and late (>10 days) tracheostomy were compared. Through the Swedish intensive care registry, 249 mechanically ventilated COVID-19-positive patients ≥18 years old with respiratory failure were included. The pre-defined primary outcomes were the frequency and timing of tracheostomy. Secondary outcomes were days free of mechanical ventilation and intensive care, ICU discharge rate, ventilator weaning rate, and 60-day mortality.

Results: Of 319 identified patients (70% men), 249 (78%) underwent endotracheal intubation. Of these, 145 (58%) underwent tracheostomy and 99 (68%) were performed early. Tracheostomy patients (vs. non-tracheostomy) had fewer IMV-free days and ICU-free days (27 [0-43] vs. 52 [43-55], p < .001, and 24 [0-40] vs. 49 [41-52], p < .001). Late (vs. early) tracheostomy patients had fewer IMV- and ICU-free days (16 [0-31] vs. 36 [0-47], p < .001 and 8 [0-28] vs. 32 [0-44], p < .001). Early tracheostomy (vs. late) was associated with a significantly higher ICU discharge rate (adjusted HR = 0.59, 95% CI [0.40-0.86], p = .006), but not with the weaning rate (adjusted HR = 0.64, 95% CI [0.12-3.32], p = .5) or 60-day mortality (adjusted HR = 1.27, 95% CI [0.61-2.67], p = .5).

Conclusions: Tracheostomy is common in critically ill COVID-19 patients. In patients predicted to need a tracheostomy at some point, early, rather than late, tracheostomy might be a means to reduce the time spent in ICU. However, we do not have sufficient evidence to suggest that early tracheostomy reduces mortality or weaning rates, compared with late tracheostomy.

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.