Acta Anaesthesiologica Scandinavica最新文献

Introduction: Leadership is a key skill for physicians, but studies show that many junior doctors feel unprepared for the role as a leader. In recent years, there has been increasing interest and research into the training and development of clinical leadership, revolving around leadership in situations with direct patient care and as opposed to the administrative leadership of a department. However, the lack of consensus on how best to teach leadership, how the education should be structured, as well as a standardized definition and measure for good leadership, complicates training, assessment, and comparison of approaches in both research and education.

Objective: The aim of this study is to map out the existing body of research on leadership education for physicians and medical students and identify any gaps in this literature.

Methods: The scoping review will follow the Arksey and O'Malley (Arksey and O'Malley, Int J Soc Res Methodol. 2005; 8(1):19-32) framework, Joanna Briggs Institute methodology (JBI Manual for Evidence Synthesis-JBI Global Wiki) and PRISMA_ScR (Tricco et al., Ann Intern Med. 2018; 169(7):467-473). A systematic search will be conducted across the following databases: PubMed, Cochrane, Embase, Ebsco, Medline, and Google scholar. Two independent reviewers will screen titles and abstracts, then review the full texts of articles. Data will be extracted and presented in line with the review questions.

Strengths and limitations of this study: The study will use a structured approach, as guided by Arksey and O'Malley and JBI methodology. Studies not written in English, Danish, German, Swedish, and Norwegian will be translated using available software. This review will not include a formal assessment of the study quality or meta-analysis, as it is a scoping review.

Background: Hypotension is commonly observed after induction of anesthesia. Risk factors for intraoperative hypotension include higher ASA class, older age, propofol use, combined general/regional anesthesia, emergency surgery, and use of antihypertensives. Patients who are treated with tricyclic antidepressants (TCAs) may develop severe hypotension in connection with surgery and anesthesia, not responding to vasopressors such as phenylephrine and ephedrine, and use of adrenaline or noradrenaline are necessary to restore the blood pressure. Anaphylaxis may be suspected due to the rapid onset and resistance to usual treatments leading to referral for allergy investigation. The aim of this paper was to identify and describe the clinical characteristics of patients referred to the Danish Anesthesia Allergy Center (DAAC) with perioperative hypotension, without elevation in tryptase, and with negative allergy investigations, who were on regular treatment with TCAs. The pharmacological mechanism behind this phenomenon will also be explored.

Methods: Patients were identified from the DAAC database. Patients with hypotension (systolic blood pressure <75 mmHg) as the only symptom and negative allergy investigations and patients on antidepressants were included. The study period was 2011-2019.

Results: Ten patients were identified. Hypotension occurred after anesthesia induction, the median time from induction to the onset of hypotension was 7.5 min. Eight needed adrenaline or noradrenaline to restore blood pressure. No allergen was identified on detailed investigation and serum tryptase was not significantly elevated.

Conclusion: Monosymptomatic perioperative hypotension without a significant increase in serum tryptase can be caused by TCAs and this is an important differential diagnosis to anaphylaxis. In patients on regular treatment with TCA perioperative hypotension responds well to noradrenaline or adrenaline but less well to vasopressors such as phenylephrine and ephedrine used perioperatively.

Background: The impact of demographic- and surgical factors on individual perioperative opioid requirements is not fully understood. Anaesthesia personnel adjust opioid administrations based on their own clinical experience, expert opinions and local guidelines. This survey aimed to assess the current practice of anaesthesia personnel regarding intraoperative opioid treatment for postoperative analgesia and rescue opioid dosing strategies in the post-anaesthesia care unit in Denmark.

Methods: We conducted a cross-sectional online survey with 37 questions addressing pain management and opioid-dosing strategies. Local site investigators from 46 of 47 public Danish anaesthesia departments distributed the survey. Data collection took place from 5 February to 30 April 2024.

Results: Of the 4187 survey participants, 2025 (48%) answered. Intra- and postoperative opioid doses were adjusted based on chronic pain, age, preoperative opioid use, body weight and type of surgery. Between 84% and 89% of respondents adhered to and had perioperative pain management guidelines available. Respondents preferred intraoperative fentanyl (44%) and morphine (36%) to prevent postoperative pain. Median intraoperative intravenous morphine equivalents ranged from 0.12 to 0.38 mg/kg in clinical scenarios. In these cases, the following variables were assembled in different combinations to assess their impact on dosing: age (30 vs. 65 years), sex (female vs. male), ASA score (1 vs. 3) and type of surgery (anterior cruciate ligament vs. laparoscopic cholecystectomy surgery). Respondents preferred intravenous morphine and fentanyl for moderate and severe postoperative pain, respectively. Median postoperative rescue doses were 0.06-0.12 mg/kg in clinical scenarios based on shifting combinations of the variables: age (30 vs. 65 years), ASA score (1 vs. 3) and degree of expected pain (moderate vs. severe).

Conclusion: Respondents preferred fentanyl and morphine for postoperative pain control with considerable variation in choice of opioid and morphine equivalent dose. Respondents expressed that guidelines were highly available and strongly adhered to. Opioid dosing was predominantly guided by chronic pain, age, preoperative opioid use, body weight and type of surgery.

Introduction: Decision-support tools for detecting physiological deterioration are widely used in clinical medicine but have been criticised for fostering a task-oriented culture and reducing the emphasis on clinical reasoning. Little is understood about what influences clinical decisions aided by decision-support tools, including professional standards, policies, and contextual factors. Therefore, we explored management reasoning employed by anaesthesiologists and PACU nurses in the post-anaesthesia care unit during the discharge of high-risk postoperative patients.

Methods: A qualitative constructivist study, conducting 18 semi-structured with 6 anaesthesiologists and 12 nurses across three Danish teaching hospitals. We analysed data through thematic analysis, utilising Michael Lipsky's theory of "street-level bureaucracy" in combination with David A. Cook's Management Reasoning Framework as a sensitising concept.

Results: Standards are frequently ambiguous, requiring interpretation and prioritisation. This allows for professional discretion by circumventing established policies, reducing task-oriented culture and enhancing the clinical reasoning processes. However, discretion in management reasoning depends on whether the clinician is inclined to uphold or adjust policies to maintain professional standards, influencing discharge decisions.

Conclusion: While decision-support tools offer cognitive aid and help standardise patient trajectories, they also limit professional discretion in management reasoning and can potentially compromise care and treatment. This highlights the need for a balanced approach that considers both the benefits and limitations of these tools in clinical decision-making.

Background: Fast recovery after cesarean section is vital since the mother not only has to take care of herself but also the newborn. Recovery scores are useful tools to measure and compare recovery; however, standardized questionnaires may miss in-depth patient experiences. What is important to women in the postoperative period after cesarean section can vary in different populations, making it crucial to understand the specific needs of one's own population. This study aims to explore what matters most to Danish mothers during the early phase of recovery following elective cesarean section.

Methods: Qualitative design: Adult, Danish-speaking women undergoing elective cesarean section under spinal anesthesia were included in three Danish hospitals. Semi-structured interviews focusing on women's experiences of recovery, pain, and mobilization both in hospital and after discharge were conducted for 4-7 days following their cesarean section. Baseline characteristics and maternal outcomes were collected from patient files. The interviews were recorded, transcribed verbatim, and analyzed using manifest content analysis.

Results: In total, 25 women were interviewed a median of 6 days post cesarean section (IQR 5-8). Three themes emerged: "Experience of being a cesarean section patient," "I'm doing good - and better than expected," and "Challenges when going home." The cesarean section itself was described as a disturbing experience. The initial days post-cesarean section were described as very painful, but hereafter, many patients expressed surprise at their rapid recovery. None used opioids after discharge. Post-discharge, having a partner's support, especially with other children to care for, was helpful, and moving from lying to sitting position and getting out of bed were noted as particularly painful. Many women requested more information and specific rehabilitation programs.

Conclusions: In this qualitative study of Danish women 4-7 days after elective cesarean sections, the women described the initial days as very painful but felt that they recovered rather quickly thereafter. The study indicated a need for enhanced communication, especially regarding the experience of surgery, pain after cesarean section, and physical rehabilitation plans.

Editorial comment: In this qualitative, explorative study, participants were interviewed by telephone 4-7 days following their elective cesarean section. The focus was the women's experience of recovery, pain, and mobilization, both in hospital and when going home. The findings identified a need for more information about the perioperative course, as most participants were surprised and unprepared both for the pain from other areas than the scar and for the surgery experience being unpleasant, and many requested physical rehabilitation plans.

Background: Remimazolam, a novel ultra-short-acting benzodiazepine, has gained popularity in various anesthetic applications due to its pharmacokinetic advantages. However, as its use increases, safety concerns also rise, necessitating thorough examination. Additionally, the limited reports on its side effects require a broader investigation to better understand the drug's safety profile.

Methods: This observational study systematically investigated adverse drug events (ADEs) associated with remimazolam using the FAERS database from Q1 2020 to Q4 2023. The primary objective was to assess potential safety signals and provide comprehensive information for clinical and regulatory purposes.

Results: A total of 67 cases and 161 ADEs were identified. The incidence of ADEs was higher in patients aged >45 years, particularly those >65 years. Intravenous general anaesthesia was the most common administration method. Notable ADE signals included serious events such as allergic reactions, respiratory and cardiac arrest, and vascular access occlusion.

Conclusion: Clinicians should be vigilant about potential allergic reactions to remimazolam, especially in older patients, and avoid off-label use until more data are available. Continuous monitoring of post-market surveillance data is essential for uncovering undetected ADEs and ensuring the safe use of remimazolam.

Editorial comment: This study analyzed adverse drug events (ADEs) associated with remimazolam using the FAERS database, identifying serious safety signals like allergic reactions, respiratory and cardiac arrests, and vascular access site occlusions, especially in older patients. The findings highlight the need for vigilant monitoring, cautious off-label use, and ongoing post-marketing surveillance.

Introduction: Fluid accumulation in critically ill patients is associated with adverse outcomes. However, there is a substantial variability in the terminology and definitions used to describe fluid accumulation. We aim to provide an overview of evidence describing fluid accumulation in critically ill adult patients admitted to the intensive care unit (ICU), including how it is defined, patient characteristics associated with fluid accumulation, ICU population, and outcomes assessed.

Methods: We will conduct a scoping review prepared according to the Preferred Reporting Items for Systematic and Meta-analysis extension for Scoping reviews (PRISMA-ScR). Pubmed, MEDLINE, EMBASE, and Cochrane Library will be searched systematically. All clinical studies reporting original data and investigating fluid accumulation, as defined by authors, in adult ICU patients will be included. We will assess the study design, the definition of fluid accumulation, ICU population, and the outcomes measured, categorised as patient-important or non-patient important, in the included studies. The results will be reported descriptively. The certainty of evidence will be assessed using a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) on the research question level.

Discussion: This scoping review will provide an overview of definitions used for fluid accumulation, and describe ICU patient populations, patient characteristics, and outcomes assessed in ICU research.

Background: Video-assisted thoracoscopic surgery (VATS) is widely used in lung cancer surgery, as this technique causes less pain and faster recovery than open thoracotomy. However, significant postoperative pain persists in a number of patients, often leading to increased opioid use and opioid-related adverse events in addition to prolonged admission times. Perioperatively administered glucocorticoids have been demonstrated effective in reducing pain after other types of surgeries, but the effect in VATS remains unclear.

Methods: This systematic review will assess the impact of glucocorticoids on postoperative pain in adult patients undergoing VATS. We will include randomised trials comparing higher doses of glucocorticoids to lower doses, placebo or no treatment. The review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement and Cochrane methodology. The certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation system. The primary outcome is standardised dynamic pain scores within 24 h. Secondary outcomes are opioid use, time to first mobilisation, length of hospital stay and numeric rating score >3 at any point within the first 24 h following surgery. Exploratory outcomes are opioid-related adverse effects and glucocorticoid-related adverse effects classified in major and minor events. Data will be meta-analysed with sensitivity and subgroup analyses and trial sequential analyses. Furthermore, we will assess the risk of reporting bias and heterogeneity.

Conclusion: This systematic review and meta-analysis will provide an overview of the current evidence of how glucocorticoids affect postoperative pain and recovery in adult patients undergoing VATS.

Background: Despite advancements in surgical techniques and perioperative care, pediatric cardiac patients remain at an increased risk of adverse events. The APRICOT (2017) study aimed to establish the incidence of severe critical events in children undergoing anesthesia in Europe, while the NECTARINE (2021) study aimed to assess anesthesia practices and outcomes in neonates and infants under 60 weeks postconceptual age. Our goal was to conduct a secondary analysis of the cardiac cohorts from these two studies to determine mortality rates and other outcomes after cardiac procedures at 30 and 90 days, identify factors influencing mortality, illustrate clinical practices, and assess the methodology of the two studies.

Methods: Sub-analysis of the data from APRICOT and NECTARINE. Data representativity was assessed through a systematic categorization process. European countries were divided into four income groups based on their gross national income per capita. Subsequently, the total number of patients across all four income groups was calculated for both the Apricot and Nectarine studies, and then the specific contribution of each income group to the total population of each study was determined.

Results: This analysis comprised 1016 cases (Apricot, n = 476 and Nectarine, n = 540). There was a considerable variability in clinical practice in Europe. The overall mortality rates were 0.84% (APRICOT) and 8.1% (NECTARINE). In both cohorts, substantial mortality was observed among low-age and low-weight infants. Stratifying the participating countries by income illustrated that the data originated from highest-income and upper-middle-income European countries and were not representative of low-income and middle-income countries.

Conclusions: In this secondary analysis of the APRICOT and NECTARINE studies, we found that fatal cases primarily occurred in low-age and low-weight neonates and infants.

Editorial comment: This secondary analysis of the APRICOT and NECTARINE studies focused on pediatric cardiac surgical cases. Outcomes differed according to weight and age of the children, where mortality risk was higher for very young and low-weight children.