Patricia Duch, Christoffer Calov Jørgensen, Helene Korvenius Nedergaard
Background: Inadequate pain relief with moderate to severe pain remains a challenge after cesarean section and may significantly impair postoperative recovery. However, detailed assessment on the timing of severe pain, opioid consumption, influence on activities such as mobilization, breastfeeding, and caring for the infant are difficult to conduct, especially after discharge. Short message services (SMS)-based questionnaires may offer a low-cost way of providing such data but with the risk of insufficient response rates. We assessed the feasibility of collecting detailed, prospective data on postoperative pain and recovery during the initial hours and days following cesarean section using SMS-based questionnaires.
Methods: Prospective Danish single-center cohort study involving elective cesarean sections under spinal anesthesia with fentanyl and bupivacaine. The postoperative pain regimen consisted of paracetamol, NSAID and oral morphine by request. Patients received an SMS-based questionnaire at 6, 12, 18, 24, and 48 h postoperatively, as well as on days 7 and 30.
Primary outcome: Response rate and time from receiving the SMS to completion of the questionnaires.
Secondary outcomes: Opioid consumption and Patient Reported Outcomes Measures on pain and recovery.
Results: From December 2022 to June 2023; 100 patients were included. The response rate was 78% at 6 h postoperatively, decreasing to 63% at 24 h. The median response time from receiving to answering the SMS-based questionnaire at 6 h after cesarean section was 23 min (IQR 2-72), decreasing to 20 min (IQR 2-78) after 24 h. Severe pain, corresponding to a Numeric Rating Scale (NRS) score >6, was reported by 57% (95% CI 65-84) at 6 h, decreasing to 28% (95% CI 34-58) at 24 h. Median opioid consumption within the first 24 h was 30 mg (IQR 20-50).
Conclusion: SMS-based questionnaires on Patient Reported Outcome Measures are a feasible and cost-effective way of prospectively collecting frequent data with acceptable response rates, even shortly after cesarean section. Secondarily 66% of patients reported severe pain during the first 24 h following cesarean section, with the highest pain scores within the initial 12 h. Future studies should focus on optimizing pain-management within this timeframe.
{"title":"Text message questionnaires for Patient-Reported Outcome Measures after Cesarean section-A feasibility study.","authors":"Patricia Duch, Christoffer Calov Jørgensen, Helene Korvenius Nedergaard","doi":"10.1111/aas.14477","DOIUrl":"https://doi.org/10.1111/aas.14477","url":null,"abstract":"<p><strong>Background: </strong>Inadequate pain relief with moderate to severe pain remains a challenge after cesarean section and may significantly impair postoperative recovery. However, detailed assessment on the timing of severe pain, opioid consumption, influence on activities such as mobilization, breastfeeding, and caring for the infant are difficult to conduct, especially after discharge. Short message services (SMS)-based questionnaires may offer a low-cost way of providing such data but with the risk of insufficient response rates. We assessed the feasibility of collecting detailed, prospective data on postoperative pain and recovery during the initial hours and days following cesarean section using SMS-based questionnaires.</p><p><strong>Methods: </strong>Prospective Danish single-center cohort study involving elective cesarean sections under spinal anesthesia with fentanyl and bupivacaine. The postoperative pain regimen consisted of paracetamol, NSAID and oral morphine by request. Patients received an SMS-based questionnaire at 6, 12, 18, 24, and 48 h postoperatively, as well as on days 7 and 30.</p><p><strong>Primary outcome: </strong>Response rate and time from receiving the SMS to completion of the questionnaires.</p><p><strong>Secondary outcomes: </strong>Opioid consumption and Patient Reported Outcomes Measures on pain and recovery.</p><p><strong>Results: </strong>From December 2022 to June 2023; 100 patients were included. The response rate was 78% at 6 h postoperatively, decreasing to 63% at 24 h. The median response time from receiving to answering the SMS-based questionnaire at 6 h after cesarean section was 23 min (IQR 2-72), decreasing to 20 min (IQR 2-78) after 24 h. Severe pain, corresponding to a Numeric Rating Scale (NRS) score >6, was reported by 57% (95% CI 65-84) at 6 h, decreasing to 28% (95% CI 34-58) at 24 h. Median opioid consumption within the first 24 h was 30 mg (IQR 20-50).</p><p><strong>Conclusion: </strong>SMS-based questionnaires on Patient Reported Outcome Measures are a feasible and cost-effective way of prospectively collecting frequent data with acceptable response rates, even shortly after cesarean section. Secondarily 66% of patients reported severe pain during the first 24 h following cesarean section, with the highest pain scores within the initial 12 h. Future studies should focus on optimizing pain-management within this timeframe.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141454514","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Despite advancements in surgical and anesthesia techniques, acute and persistent postoperative pain are still a common challenge. Postoperative pain has direct effects on individual patient care and outcome, as well as putting strain on limited health care resources. Several prediction methods for postoperative pain have been described. One such method is the assessment of pain during peripheral venous cannulation (VCP). It is not known if different approaches to anesthesia and analgesia, depending on the evaluation of risk for postoperative pain, can improve outcome. The aim of this study is to evaluate if individualized anesthesia and analgesia can affect postoperative pain and recovery after surgery, in patients stratified by VCP.
Methods: Adult patients scheduled for laparoscopic surgery undergo pain-sensitivity stratification using VCP on the day of surgery. Patients scoring VCP ≥2.0 on the visual analogue scale (pain-sensitive) are randomized to multimodal anaesthesia and analgesia with opioids or standard of care. Patients scoring VCP ≤1.9 (pain-tolerant) are randomized to opioid-free anaesthesia or standard of care. The primary outcome is acute postoperative pain measured with numeric rating scale in the postoperative care unit. Secondary outcomes include analysis of pain after 24 h, persistent postoperative pain and quality of recovery.
Discussion: Individualized perioperative pain management has the potential to improve patient care. This study will examine the impact of different anesthesia and analgesia regimes, in patients with differing pain sensitivity, on postoperative pain.
Trial registration: Prospectively posted at ClinicalTrials.gov, identifier NCT04751812.
{"title":"Effect of individualized anesthesia and analgesia on postoperative pain in patients stratified for pain sensitivity: A study protocol for the PeriOPerative individualization trial randomized controlled trial.","authors":"Krister Mogianos, Johan Undén, Anna Persson","doi":"10.1111/aas.14487","DOIUrl":"https://doi.org/10.1111/aas.14487","url":null,"abstract":"<p><strong>Background: </strong>Despite advancements in surgical and anesthesia techniques, acute and persistent postoperative pain are still a common challenge. Postoperative pain has direct effects on individual patient care and outcome, as well as putting strain on limited health care resources. Several prediction methods for postoperative pain have been described. One such method is the assessment of pain during peripheral venous cannulation (VCP). It is not known if different approaches to anesthesia and analgesia, depending on the evaluation of risk for postoperative pain, can improve outcome. The aim of this study is to evaluate if individualized anesthesia and analgesia can affect postoperative pain and recovery after surgery, in patients stratified by VCP.</p><p><strong>Methods: </strong>Adult patients scheduled for laparoscopic surgery undergo pain-sensitivity stratification using VCP on the day of surgery. Patients scoring VCP ≥2.0 on the visual analogue scale (pain-sensitive) are randomized to multimodal anaesthesia and analgesia with opioids or standard of care. Patients scoring VCP ≤1.9 (pain-tolerant) are randomized to opioid-free anaesthesia or standard of care. The primary outcome is acute postoperative pain measured with numeric rating scale in the postoperative care unit. Secondary outcomes include analysis of pain after 24 h, persistent postoperative pain and quality of recovery.</p><p><strong>Discussion: </strong>Individualized perioperative pain management has the potential to improve patient care. This study will examine the impact of different anesthesia and analgesia regimes, in patients with differing pain sensitivity, on postoperative pain.</p><p><strong>Trial registration: </strong>Prospectively posted at ClinicalTrials.gov, identifier NCT04751812.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141465344","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jasmin Davodi, Christina V Intzilaki, Casper Steenholdt, Ann M Moeller
Background: In settings where general anaesthesia is unnecessary, effective sedation, analgesia and local anaesthesia are crucial for optimal outcomes. Traditionally, sedation have been managed and controlled by healthcare professionals, but advancements in pharmacology and technology have renewed the way we are able to sedate. Patient-controlled sedation (PCS) offers a promising approach, allowing patients to adjust their sedation levels during procedures. This shift aims to enhance sedation quality, improve patient satisfaction and involvement and expedite discharge.
Methods: The search strategy will be crafted in partnership with the Librarian well-versed in scoping reviews. 'Patient controlled sedation' is a wide search. The search will include databases, as MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and Google Scholar. All literature findings will be entered into a web-based screening and data extraction tool. Two independent reviewers will assess the eligibility and inclusion of all studies. The variables to be extracted will encompass trial characteristics, participant characteristics, assessment of PCS, identified risk factors for PCS, and the evaluation of patient satisfaction as assessed in the included studies.
Results: Following PRISMA-P and PRISMA-ScR guidelines, this scoping review includes studies of any design. Data synthesis involves descriptive statistics and narrative presentations to explore the relationship between results and objectives. The outcome will be which procedures/surgeries PCS is used for and which patients are eligible for PCS. Additionally, aspects such as patient and operator satisfaction, economical pros and cons adverse effects will be considered.
Conclusion: The scoping review will aim to give a better understanding of in which settings PCS is used. This scoping review provides a comprehensive understanding of PCS and identifies gaps in the literature to shape future research, so we can ensure the best possible sedation for patients in the future.
背景:在没有必要进行全身麻醉的情况下,有效的镇静、镇痛和局部麻醉对取得最佳疗效至关重要。传统上,镇静一直由医护人员管理和控制,但药理学和技术的进步更新了我们的镇静方式。患者控制镇静(PCS)提供了一种前景广阔的方法,允许患者在手术过程中调整自己的镇静水平。这一转变旨在提高镇静质量,改善患者满意度和参与度,并加快患者出院:将与精通范围界定综述的图书管理员合作制定搜索策略。患者控制镇静 "是一个广泛的搜索。搜索范围包括 MEDLINE/PubMed、EMBASE、Cochrane Central Register of Controlled Trials、CINAHL 和 Google Scholar 等数据库。所有文献结果都将输入网络筛选和数据提取工具。两名独立审稿人将对所有研究的资格和纳入情况进行评估。提取的变量将包括试验特征、参与者特征、PCS 评估、已确定的 PCS 风险因素以及纳入研究中对患者满意度的评估:根据 PRISMA-P 和 PRISMA-ScR 指南,本次范围界定综述包括任何设计的研究。数据综合包括描述性统计和叙述性陈述,以探讨结果与目标之间的关系。研究结果将包括 PCS 用于哪些程序/手术以及哪些患者符合 PCS 的条件。此外,还将考虑患者和操作者的满意度、经济利弊和不良影响等方面:此次范围界定审查旨在更好地了解 PCS 在哪些情况下使用。该范围界定综述提供了对 PCS 的全面了解,并找出了文献中的不足之处,为今后的研究提供了参考,从而确保今后为患者提供最佳镇静效果。
{"title":"Protocol for scoping review: Patient-controlled sedation.","authors":"Jasmin Davodi, Christina V Intzilaki, Casper Steenholdt, Ann M Moeller","doi":"10.1111/aas.14478","DOIUrl":"https://doi.org/10.1111/aas.14478","url":null,"abstract":"<p><strong>Background: </strong>In settings where general anaesthesia is unnecessary, effective sedation, analgesia and local anaesthesia are crucial for optimal outcomes. Traditionally, sedation have been managed and controlled by healthcare professionals, but advancements in pharmacology and technology have renewed the way we are able to sedate. Patient-controlled sedation (PCS) offers a promising approach, allowing patients to adjust their sedation levels during procedures. This shift aims to enhance sedation quality, improve patient satisfaction and involvement and expedite discharge.</p><p><strong>Methods: </strong>The search strategy will be crafted in partnership with the Librarian well-versed in scoping reviews. 'Patient controlled sedation' is a wide search. The search will include databases, as MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and Google Scholar. All literature findings will be entered into a web-based screening and data extraction tool. Two independent reviewers will assess the eligibility and inclusion of all studies. The variables to be extracted will encompass trial characteristics, participant characteristics, assessment of PCS, identified risk factors for PCS, and the evaluation of patient satisfaction as assessed in the included studies.</p><p><strong>Results: </strong>Following PRISMA-P and PRISMA-ScR guidelines, this scoping review includes studies of any design. Data synthesis involves descriptive statistics and narrative presentations to explore the relationship between results and objectives. The outcome will be which procedures/surgeries PCS is used for and which patients are eligible for PCS. Additionally, aspects such as patient and operator satisfaction, economical pros and cons adverse effects will be considered.</p><p><strong>Conclusion: </strong>The scoping review will aim to give a better understanding of in which settings PCS is used. This scoping review provides a comprehensive understanding of PCS and identifies gaps in the literature to shape future research, so we can ensure the best possible sedation for patients in the future.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141454513","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Vibeke Lind Jørgensen, Janne Adelsten, Steffen Christensen, Dorthe Viemose Nielsen, Camilla Tofte Eschen, Hasse Møller Sørensen, Marc Sørensen, Søren Aalbæk Madsen, Jakob Gjedsted, Finn Møller Pedersen, Jonas Nielsen, Lars Grønlykke
Background: Prone position ventilation (PPV) is recommended for patients with COVID-19 induced severe Adult Respiratory Distress Syndrome (ARDS) and is used for patients supported with V-V ECMO as well. The purpose of this study was to describe the use of PPV in these patients focusing on physiological effects with the hypothesis that PPV could reduce oxygen need and improve dynamic compliance.
Methods: This study was a nationwide retrospective analysis of all COVID-19 patients in Denmark from March 2020 - December 2021 with severe ARDS and need of V-V ECMO support. Data on the number of patients treated with PPV, number of PPV sessions, timing, the time spent in prone position, pulmonary physiological response types with analysis of variables affecting the response are reported.
Results: Out of 68 patients 44 were treated with 220 PPV sessions and a positive clinical response was observed in 80% of patients but only in 45% of sessions. On a single session level, increased compliance was observed in 38% and increased oxygenation in only 15% of 220 sessions, with within-patient heterogeneity. Higher dynamic compliance at the beginning of a PPV session was associated with a lower delta change in dynamic compliance during PPV. The response to a PPV session could not be predicted by the response in the prior session. Dynamic compliance did not change during the ECMO course.
Conclusion: Eighty percent of patients responded positively during a PPV session, but this was not associated with overall pulmonary improvement. On a single patient level, responses were heterogenous and only 45% of sessions resulted in clinical improvement. Response in dynamic compliance was associated with starting values of compliance.
{"title":"The use of prone position ventilation in Danish patients with COVID-19-induced severe acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation: A nationwide cohort study with focus on pulmonary effects.","authors":"Vibeke Lind Jørgensen, Janne Adelsten, Steffen Christensen, Dorthe Viemose Nielsen, Camilla Tofte Eschen, Hasse Møller Sørensen, Marc Sørensen, Søren Aalbæk Madsen, Jakob Gjedsted, Finn Møller Pedersen, Jonas Nielsen, Lars Grønlykke","doi":"10.1111/aas.14481","DOIUrl":"https://doi.org/10.1111/aas.14481","url":null,"abstract":"<p><strong>Background: </strong>Prone position ventilation (PPV) is recommended for patients with COVID-19 induced severe Adult Respiratory Distress Syndrome (ARDS) and is used for patients supported with V-V ECMO as well. The purpose of this study was to describe the use of PPV in these patients focusing on physiological effects with the hypothesis that PPV could reduce oxygen need and improve dynamic compliance.</p><p><strong>Methods: </strong>This study was a nationwide retrospective analysis of all COVID-19 patients in Denmark from March 2020 - December 2021 with severe ARDS and need of V-V ECMO support. Data on the number of patients treated with PPV, number of PPV sessions, timing, the time spent in prone position, pulmonary physiological response types with analysis of variables affecting the response are reported.</p><p><strong>Results: </strong>Out of 68 patients 44 were treated with 220 PPV sessions and a positive clinical response was observed in 80% of patients but only in 45% of sessions. On a single session level, increased compliance was observed in 38% and increased oxygenation in only 15% of 220 sessions, with within-patient heterogeneity. Higher dynamic compliance at the beginning of a PPV session was associated with a lower delta change in dynamic compliance during PPV. The response to a PPV session could not be predicted by the response in the prior session. Dynamic compliance did not change during the ECMO course.</p><p><strong>Conclusion: </strong>Eighty percent of patients responded positively during a PPV session, but this was not associated with overall pulmonary improvement. On a single patient level, responses were heterogenous and only 45% of sessions resulted in clinical improvement. Response in dynamic compliance was associated with starting values of compliance.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141454515","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mo H Larsen, Oscar Rosenkrantz, Brian S Rasmussen, Marie K K Nielsen, Kristian Linnet, Lars S Rasmussen, Dan Isbye
Background: Cocaine may be applied to decongest the nasal mucosa before nasotracheal intubation, but patients risk a criminal offence if cocaine is detected when patients drive a car shortly after surgery. We aimed to evaluate whether benzoylecgonine levels in saliva exceeded the cut-off point 24 h after administration in patients undergoing nasotracheal intubation and whether cocaine would be detectable above the Danish legal fixed limit in blood samples 1 and 24 h after surgery.
Methods: We conducted a prospective study following approval from the local research ethics committee and the national medicine agency. Written informed consent was obtained from all patients. We included patients scheduled for surgery under general anaesthesia with nasotracheal intubation. They received 80 mg cocaine as a nasal spray 5 min before induction and nasotracheal intubation. The primary outcome was a dichotomous assessment of benzoylecgonine levels in saliva samples measured 24 h after administration of nasal cocaine with a cut-off limit of 200 ng/mL. Secondary outcomes were dichotomous assessments of cocaine in whole blood samples measured 1 and 24 h after administration of nasal cocaine with a cut-off limit of 0.01 mg/kg.
Results: Overall, 70 patients had valid saliva samples and 75 had valid blood samples 24 h after cocaine administration. Benzoylecgonine in saliva was traceable above the cut-off in 9/70 patients (13%; CI95%: 6% to 23%), and cocaine in blood was detected above the cut-off in 2/75 patients (3%; CI95%: 0.3% to 9%).
Conclusion: We found benzoylecgonine traceable in saliva in 13% of patients and cocaine traceable in blood in 3% of patients 24 h after administration of 80 mg nasal cocaine. Patients should be informed when receiving cocaine and advised not to drive for at least 24 h.
{"title":"Detection of cocaine 24 h after administration before nasotracheal intubation.","authors":"Mo H Larsen, Oscar Rosenkrantz, Brian S Rasmussen, Marie K K Nielsen, Kristian Linnet, Lars S Rasmussen, Dan Isbye","doi":"10.1111/aas.14475","DOIUrl":"https://doi.org/10.1111/aas.14475","url":null,"abstract":"<p><strong>Background: </strong>Cocaine may be applied to decongest the nasal mucosa before nasotracheal intubation, but patients risk a criminal offence if cocaine is detected when patients drive a car shortly after surgery. We aimed to evaluate whether benzoylecgonine levels in saliva exceeded the cut-off point 24 h after administration in patients undergoing nasotracheal intubation and whether cocaine would be detectable above the Danish legal fixed limit in blood samples 1 and 24 h after surgery.</p><p><strong>Methods: </strong>We conducted a prospective study following approval from the local research ethics committee and the national medicine agency. Written informed consent was obtained from all patients. We included patients scheduled for surgery under general anaesthesia with nasotracheal intubation. They received 80 mg cocaine as a nasal spray 5 min before induction and nasotracheal intubation. The primary outcome was a dichotomous assessment of benzoylecgonine levels in saliva samples measured 24 h after administration of nasal cocaine with a cut-off limit of 200 ng/mL. Secondary outcomes were dichotomous assessments of cocaine in whole blood samples measured 1 and 24 h after administration of nasal cocaine with a cut-off limit of 0.01 mg/kg.</p><p><strong>Results: </strong>Overall, 70 patients had valid saliva samples and 75 had valid blood samples 24 h after cocaine administration. Benzoylecgonine in saliva was traceable above the cut-off in 9/70 patients (13%; CI<sub>95%</sub>: 6% to 23%), and cocaine in blood was detected above the cut-off in 2/75 patients (3%; CI<sub>95%</sub>: 0.3% to 9%).</p><p><strong>Conclusion: </strong>We found benzoylecgonine traceable in saliva in 13% of patients and cocaine traceable in blood in 3% of patients 24 h after administration of 80 mg nasal cocaine. Patients should be informed when receiving cocaine and advised not to drive for at least 24 h.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141454511","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mo H Larsen, Oscar Rosenkrantz, Andreas Creuzburg, Michael S Kristensen, Lars S Rasmussen, Dan Isbye
Background: Nasotracheal intubation is associated with a risk of epistaxis. Several drugs, including cocaine and xylometazoline may be used as decongestants prior to nasotracheal intubation to prevent this. We hypothesized that xylometazoline would prevent epistaxis more effectively than cocaine, demonstrated by a lower proportion of patients with bleeding after nasotracheal intubation.
Methods: We conducted a single-center, outcome assessor and analyst-blinded, clinical randomized controlled trial following approval from the local research ethics committee and the national medicine agency. Written informed consent was obtained from all patients. Patients scheduled for surgery under general anesthesia with nasotracheal intubation were randomized to receive either 2 mL 4% cocaine or 2 mL 0.05% xylometazoline prior to nasotracheal intubation. Immediately following intubation, epistaxis was evaluated by the blinded intubating anesthetist on a four-point scale. We measured heart rate and blood pressure the first 5 min after drug administration. Adverse events were followed up after 24 h.
Results: A total of 53 patients received cocaine and 49 patients received xylometazoline. Bleeding occurred in 32 patients receiving cocaine (60.4%) and in 34 patients receiving xylometazoline (69.4%) (p = .41, Fisher's exact test) with a difference of 9.0% (95% CI: -9.4% to 27%). There was no statistically significant difference between groups regarding the heart rate or blood pressure. No adverse cardiac events were recorded in either group.
Conclusion: We found no statistically significant difference between cocaine and xylometazoline in preventing epistaxis after nasotracheal intubation, and the choice of vasoconstrictor should be based on other considerations, such as pricing, availability and medicolegal issues.
背景:鼻气管插管有鼻衄的风险。在鼻气管插管前,包括可卡因和西甲唑啉在内的几种药物可用作减充血剂来预防鼻衄。我们假设西甲唑啉能比可卡因更有效地预防鼻衄,这体现在鼻气管插管后出血患者的比例较低:在获得当地研究伦理委员会和国家医药机构的批准后,我们进行了一项单中心、结果评估者和分析者盲法临床随机对照试验。我们获得了所有患者的书面知情同意。计划在鼻气管插管全身麻醉下进行手术的患者在鼻气管插管前随机接受 2 mL 4% 可卡因或 2 mL 0.05% 甲基甲唑啉。插管后,盲插管麻醉师立即对鼻衄进行四级评分。我们在用药后最初 5 分钟测量了心率和血压。24 小时后对不良反应进行随访:共有 53 名患者接受了可卡因治疗,49 名患者接受了西甲唑啉治疗。32名接受可卡因治疗的患者(60.4%)和34名接受西甲唑啉治疗的患者(69.4%)发生了出血(P = .41,费舍尔精确检验),差异为9.0%(95% CI:-9.4% 至 27%)。在心率或血压方面,组间差异无统计学意义。两组均未出现不良心脏事件:我们发现可卡因和甲氧甲唑啉在预防鼻气管插管后鼻衄方面没有统计学意义上的显著差异。
{"title":"Cocaine versus xylometazoline to prevent epistaxis after nasotracheal intubation: A randomized trial.","authors":"Mo H Larsen, Oscar Rosenkrantz, Andreas Creuzburg, Michael S Kristensen, Lars S Rasmussen, Dan Isbye","doi":"10.1111/aas.14484","DOIUrl":"https://doi.org/10.1111/aas.14484","url":null,"abstract":"<p><strong>Background: </strong>Nasotracheal intubation is associated with a risk of epistaxis. Several drugs, including cocaine and xylometazoline may be used as decongestants prior to nasotracheal intubation to prevent this. We hypothesized that xylometazoline would prevent epistaxis more effectively than cocaine, demonstrated by a lower proportion of patients with bleeding after nasotracheal intubation.</p><p><strong>Methods: </strong>We conducted a single-center, outcome assessor and analyst-blinded, clinical randomized controlled trial following approval from the local research ethics committee and the national medicine agency. Written informed consent was obtained from all patients. Patients scheduled for surgery under general anesthesia with nasotracheal intubation were randomized to receive either 2 mL 4% cocaine or 2 mL 0.05% xylometazoline prior to nasotracheal intubation. Immediately following intubation, epistaxis was evaluated by the blinded intubating anesthetist on a four-point scale. We measured heart rate and blood pressure the first 5 min after drug administration. Adverse events were followed up after 24 h.</p><p><strong>Results: </strong>A total of 53 patients received cocaine and 49 patients received xylometazoline. Bleeding occurred in 32 patients receiving cocaine (60.4%) and in 34 patients receiving xylometazoline (69.4%) (p = .41, Fisher's exact test) with a difference of 9.0% (95% CI: -9.4% to 27%). There was no statistically significant difference between groups regarding the heart rate or blood pressure. No adverse cardiac events were recorded in either group.</p><p><strong>Conclusion: </strong>We found no statistically significant difference between cocaine and xylometazoline in preventing epistaxis after nasotracheal intubation, and the choice of vasoconstrictor should be based on other considerations, such as pricing, availability and medicolegal issues.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141454510","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Martine S Nielsen, Frederik V Ilkjær, Anders M Grejs, Anders B Nielsen, Lars Konge, Anne C Brøchner
Background: Access to the neuraxial space, including lumbar punctures and neuraxial anaesthesia, is an everyday procedure in clinical practice. Traditionally these procedures rely on manual palpation technique, but ultrasound is a useful tool when patients prove challenging. Presently, there is a lack of evidence-based guidelines for technical skills acquisition, both with and without ultrasound, and likewise, competency assessment approaches vary globally. Accordingly, we aim to assess the current evidence regarding learning and assessment in neuraxial access ultrasound, for future educational recommendations.
Methods: This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) statement, together with the PRISMA Extension for Scoping Reviews. A systematic search strategy will be based on a PICO approach, focusing on physicians, medical students, or nurses being exposed to education, training, or assessment in procedural neuraxial access ultrasound. No comparators are obligated, but outcomes should be assessable using the Kirkpatrick four levels of training evaluation. The search will be performed in Cochrane Library, Embase, Medline, Scopus, PubMed, and CINAHL. Independently, two authors will screen the studies and conflicts will be resolved by a third author. Relevant predefined data will be extracted and analysed using a descriptive approach. The quality of the studies will be assessed using the Medical Education Research Study Quality Instrument.
Discussion: This scoping review will contribute by presenting gathered evidence of an overview of the different approaches to achieving education and training of technical skills in neuraxial access, and how skills are tested, which could guide research and future recommendations for skills development and assessment.
{"title":"Training and assessment of skills in neuraxial access-Protocol of a scoping review.","authors":"Martine S Nielsen, Frederik V Ilkjær, Anders M Grejs, Anders B Nielsen, Lars Konge, Anne C Brøchner","doi":"10.1111/aas.14483","DOIUrl":"https://doi.org/10.1111/aas.14483","url":null,"abstract":"<p><strong>Background: </strong>Access to the neuraxial space, including lumbar punctures and neuraxial anaesthesia, is an everyday procedure in clinical practice. Traditionally these procedures rely on manual palpation technique, but ultrasound is a useful tool when patients prove challenging. Presently, there is a lack of evidence-based guidelines for technical skills acquisition, both with and without ultrasound, and likewise, competency assessment approaches vary globally. Accordingly, we aim to assess the current evidence regarding learning and assessment in neuraxial access <math> <semantics><mrow><mo>±</mo></mrow> <annotation>$$ pm $$</annotation></semantics> </math> ultrasound, for future educational recommendations.</p><p><strong>Methods: </strong>This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) statement, together with the PRISMA Extension for Scoping Reviews. A systematic search strategy will be based on a PICO approach, focusing on physicians, medical students, or nurses being exposed to education, training, or assessment in procedural neuraxial access <math> <semantics><mrow><mo>±</mo></mrow> <annotation>$$ pm $$</annotation></semantics> </math> ultrasound. No comparators are obligated, but outcomes should be assessable using the Kirkpatrick four levels of training evaluation. The search will be performed in Cochrane Library, Embase, Medline, Scopus, PubMed, and CINAHL. Independently, two authors will screen the studies and conflicts will be resolved by a third author. Relevant predefined data will be extracted and analysed using a descriptive approach. The quality of the studies will be assessed using the Medical Education Research Study Quality Instrument.</p><p><strong>Discussion: </strong>This scoping review will contribute by presenting gathered evidence of an overview of the different approaches to achieving education and training of technical skills in neuraxial access, and how skills are tested, which could guide research and future recommendations for skills development and assessment.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141454544","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Praleene Sivapalan, Karen Louise Ellekjaer, Anders Perner, Morten Hylander Møller, Anders Granholm, Lasse Grønningsæter, Marlies Ostermann, Rob Mac Sweeney, Maria Cronhjort, Johanna Hästbacka, Carmen Pfortmueller, Jan De Waele, Marek Nalos, Tomas Jovaisa, Annika Reintam Blaser, Maurizio Cecconi, Begum Ergan, Abdulrahman Al‐Fares, Paul J. Young, Wojciech Szczeklik, Eric Keus, Fayez Alshamsi, Ashish K. Khanna, Martin Ingi Sigurdsson, Tomoko Fujii, Yaseen M. Arabi, Tine Sylvest Meyhoff
IntroductionUse of albumin is suggested for some patients with shock, but preferences for its use may vary among intensive care unit (ICU) physicians.MethodsWe conducted an international online survey of ICU physicians with 20 questions about their use of albumin and their opinion towards a randomised trial among adults with shock comparing the use versus no use of albumin.ResultsA total of 1248 respondents participated, with a mean response rate of 37%, ranging from 18% to 75% across 21 countries. Respondents mainly worked in mixed ICUs and 92% were specialists in intensive care medicine. The reported use of albumin in general shock varied as 18% reported ‘almost never’, 22% ‘rarely’, 34% ‘occasionally’, 22% ‘frequently’ and 4% ‘almost always’ using albumin. In septic shock, 19% reported ‘almost never’, 22% ‘rarely’, 29% ‘occasionally’, 22% ‘frequently’ and 7% ‘almost always’ using albumin. Physicians’ preferences were more consistent for haemorrhagic‐ and cardiogenic shock, with more than 45% reporting ‘almost never’ using albumin. While the reported use of albumin for other purposes than resuscitation was infrequent (40%–85% reported ‘almost never’ for five other indications), the most frequent other indications were low serum albumin levels and improvement of the efficacy of diuretics. Most respondents (93%) would randomise adult ICU patients with shock to a trial of albumin versus no albumin.ConclusionsIn this international survey, the reported preferences for the use of albumin in adult ICU patients with shock varied considerably among surveyed ICU physicians. The support for a future randomised trial was high.
{"title":"Preferences for albumin use in adult intensive care unit patients with shock: An international survey","authors":"Praleene Sivapalan, Karen Louise Ellekjaer, Anders Perner, Morten Hylander Møller, Anders Granholm, Lasse Grønningsæter, Marlies Ostermann, Rob Mac Sweeney, Maria Cronhjort, Johanna Hästbacka, Carmen Pfortmueller, Jan De Waele, Marek Nalos, Tomas Jovaisa, Annika Reintam Blaser, Maurizio Cecconi, Begum Ergan, Abdulrahman Al‐Fares, Paul J. Young, Wojciech Szczeklik, Eric Keus, Fayez Alshamsi, Ashish K. Khanna, Martin Ingi Sigurdsson, Tomoko Fujii, Yaseen M. Arabi, Tine Sylvest Meyhoff","doi":"10.1111/aas.14479","DOIUrl":"https://doi.org/10.1111/aas.14479","url":null,"abstract":"IntroductionUse of albumin is suggested for some patients with shock, but preferences for its use may vary among intensive care unit (ICU) physicians.MethodsWe conducted an international online survey of ICU physicians with 20 questions about their use of albumin and their opinion towards a randomised trial among adults with shock comparing the use versus no use of albumin.ResultsA total of 1248 respondents participated, with a mean response rate of 37%, ranging from 18% to 75% across 21 countries. Respondents mainly worked in mixed ICUs and 92% were specialists in intensive care medicine. The reported use of albumin in general shock varied as 18% reported ‘almost never’, 22% ‘rarely’, 34% ‘occasionally’, 22% ‘frequently’ and 4% ‘almost always’ using albumin. In septic shock, 19% reported ‘almost never’, 22% ‘rarely’, 29% ‘occasionally’, 22% ‘frequently’ and 7% ‘almost always’ using albumin. Physicians’ preferences were more consistent for haemorrhagic‐ and cardiogenic shock, with more than 45% reporting ‘almost never’ using albumin. While the reported use of albumin for other purposes than resuscitation was infrequent (40%–85% reported ‘almost never’ for five other indications), the most frequent other indications were low serum albumin levels and improvement of the efficacy of diuretics. Most respondents (93%) would randomise adult ICU patients with shock to a trial of albumin versus no albumin.ConclusionsIn this international survey, the reported preferences for the use of albumin in adult ICU patients with shock varied considerably among surveyed ICU physicians. The support for a future randomised trial was high.","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":2.1,"publicationDate":"2024-06-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141501536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Anders H. Springborg, Henrik Kehlet, Niklas I. Nielsen, Kirill Gromov, Anders Troelsen, Claus Varnum, Nicolai B. Foss
BackgroundTotal knee arthroplasty is associated with an inflammatory response and high levels of pain in a subset of patients. Pain catastrophizing has been associated with acute postoperative pain. The association between these variables has not been investigated in an optimised fast‐track setup including preoperative glucocorticoids. The aim of this study was, first, to investigate the correlation between the increase in postoperative c‐reactive protein (CRP) and acute postoperative pain after total knee arthroplasty, and second, to investigate the correlation between the increase in CRP and preoperative pain catastrophizing.MethodsThis study is a secondary analysis of data from 119 patients participating in two randomised controlled trials. Correlation analyses were performed for preoperative CRP and CRP increase at 24 and 48 h and pain during a well‐defined mobilisation at 24 and 48 h after total knee arthroplasty. Additionally, correlation analyses were performed between CRP increase and pain catastrophizing using the pain catastrophizing scale.ResultsThere was no correlation between preoperative CRP or postoperative CRP increase and pain at both 24 and 48 h. Analyses were similar when separated into high and low pain catastrophizers. There was no correlation between preoperative CRP or postoperative CRP increase and pain catastrophizing.ConclusionThere was no association between the postoperative CRP response and postoperative acute pain or pain catastrophizing in patients undergoing total knee arthroplasty in a well‐defined multimodal fast‐track regime including preoperative glucocorticoids. These results suggest that acute pain after knee arthroplasty is not reflected by CRP when applying preoperative glucocorticoids.
{"title":"Perioperative association between c‐reactive protein, pain catastrophizing and acute pain after total knee arthroplasty: A secondary analysis of two randomised trials","authors":"Anders H. Springborg, Henrik Kehlet, Niklas I. Nielsen, Kirill Gromov, Anders Troelsen, Claus Varnum, Nicolai B. Foss","doi":"10.1111/aas.14476","DOIUrl":"https://doi.org/10.1111/aas.14476","url":null,"abstract":"BackgroundTotal knee arthroplasty is associated with an inflammatory response and high levels of pain in a subset of patients. Pain catastrophizing has been associated with acute postoperative pain. The association between these variables has not been investigated in an optimised fast‐track setup including preoperative glucocorticoids. The aim of this study was, first, to investigate the correlation between the increase in postoperative c‐reactive protein (CRP) and acute postoperative pain after total knee arthroplasty, and second, to investigate the correlation between the increase in CRP and preoperative pain catastrophizing.MethodsThis study is a secondary analysis of data from 119 patients participating in two randomised controlled trials. Correlation analyses were performed for preoperative CRP and CRP increase at 24 and 48 h and pain during a well‐defined mobilisation at 24 and 48 h after total knee arthroplasty. Additionally, correlation analyses were performed between CRP increase and pain catastrophizing using the pain catastrophizing scale.ResultsThere was no correlation between preoperative CRP or postoperative CRP increase and pain at both 24 and 48 h. Analyses were similar when separated into high and low pain catastrophizers. There was no correlation between preoperative CRP or postoperative CRP increase and pain catastrophizing.ConclusionThere was no association between the postoperative CRP response and postoperative acute pain or pain catastrophizing in patients undergoing total knee arthroplasty in a well‐defined multimodal fast‐track regime including preoperative glucocorticoids. These results suggest that acute pain after knee arthroplasty is not reflected by CRP when applying preoperative glucocorticoids.","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":2.1,"publicationDate":"2024-06-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141530674","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Suvi-Maria Tiainen, Brian J Anderson, Ella Rinne, Aleksi Tornio, Marica T Engström, Teijo I Saari, Panu Uusalo
Background: The use of intranasal dexmedetomidine is hampered by a limited understanding of its absorption pharmacokinetics.
Methods: We examined the pharmacokinetics and feasibility of intranasal dexmedetomidine administered in the supine position to adult patients undergoing general anaesthesia. Twenty-eight patients between 35 and 80 years of age, ASA 1-3 and weight between 50 and 100 kg, who underwent elective unilateral total hip or knee arthroplasty under general anaesthesia were recruited. All patients received 100 μg of intranasal dexmedetomidine after anaesthesia induction. Six venous blood samples (at 0, 5, 15, 45, 60, 240 min timepoints from dexmedetomidine administration) were collected from each patient and dexmedetomidine plasma concentrations were measured. Concentration-time profiles after nasal administration were pooled with earlier data from a population analysis of intravenous dexmedetomidine (n = 202) in order to estimate absorption parameters using nonlinear mixed effects. Peak concentration (CMAX) and time (TMAX) were estimated using simulation (n = 1000) with parameter estimates and their associated variability.
Results: There were 28 adult patients with a mean (SD) age of 66 (8) years and weight of 83 (10) kg. The mean weight-adjusted dose of dexmedetomidine was 1.22 (0.15) μg kg-1. CMAX 0.273 μg L-1 was achieved at 98 min after intranasal administration (TMAX). The relative bioavailability of dexmedetomidine was 80% (95% CI 75-91%). The absorption half-time (TABS = 120 min; 95% CI 90-147 min) was slower than that in previous pharmacokinetic studies on adult patients. Perioperative haemodynamics of all patients remained stable.
Conclusions: Administration of intranasal dexmedetomidine in the supine position during general anaesthesia is feasible with good bioavailability. This administration method has slower absorption when compared to awake patients in upright position, with consequent concentrations attained after TMAX for several hours.
{"title":"Absorption pharmacokinetics and feasibility of intranasal dexmedetomidine in patients under general anaesthesia.","authors":"Suvi-Maria Tiainen, Brian J Anderson, Ella Rinne, Aleksi Tornio, Marica T Engström, Teijo I Saari, Panu Uusalo","doi":"10.1111/aas.14473","DOIUrl":"https://doi.org/10.1111/aas.14473","url":null,"abstract":"<p><strong>Background: </strong>The use of intranasal dexmedetomidine is hampered by a limited understanding of its absorption pharmacokinetics.</p><p><strong>Methods: </strong>We examined the pharmacokinetics and feasibility of intranasal dexmedetomidine administered in the supine position to adult patients undergoing general anaesthesia. Twenty-eight patients between 35 and 80 years of age, ASA 1-3 and weight between 50 and 100 kg, who underwent elective unilateral total hip or knee arthroplasty under general anaesthesia were recruited. All patients received 100 μg of intranasal dexmedetomidine after anaesthesia induction. Six venous blood samples (at 0, 5, 15, 45, 60, 240 min timepoints from dexmedetomidine administration) were collected from each patient and dexmedetomidine plasma concentrations were measured. Concentration-time profiles after nasal administration were pooled with earlier data from a population analysis of intravenous dexmedetomidine (n = 202) in order to estimate absorption parameters using nonlinear mixed effects. Peak concentration (C<sub>MAX</sub>) and time (T<sub>MAX</sub>) were estimated using simulation (n = 1000) with parameter estimates and their associated variability.</p><p><strong>Results: </strong>There were 28 adult patients with a mean (SD) age of 66 (8) years and weight of 83 (10) kg. The mean weight-adjusted dose of dexmedetomidine was 1.22 (0.15) μg kg<sup>-1</sup>. C<sub>MAX</sub> 0.273 μg L<sup>-1</sup> was achieved at 98 min after intranasal administration (T<sub>MAX</sub>). The relative bioavailability of dexmedetomidine was 80% (95% CI 75-91%). The absorption half-time (T<sub>ABS</sub> = 120 min; 95% CI 90-147 min) was slower than that in previous pharmacokinetic studies on adult patients. Perioperative haemodynamics of all patients remained stable.</p><p><strong>Conclusions: </strong>Administration of intranasal dexmedetomidine in the supine position during general anaesthesia is feasible with good bioavailability. This administration method has slower absorption when compared to awake patients in upright position, with consequent concentrations attained after T<sub>MAX</sub> for several hours.</p>","PeriodicalId":6909,"journal":{"name":"Acta Anaesthesiologica Scandinavica","volume":null,"pages":null},"PeriodicalIF":2.1,"publicationDate":"2024-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141417120","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}