Acta Anaesthesiologica Scandinavica最新文献

Background: Clinical practice guidelines recommend use of buffered crystalloid solutions in critically ill patients but do not distinguish between solutions based on different buffering anions, that is, acetate- versus lactate-buffered solutions. We therefore surveyed relevant physicians about their preferences and attitudes toward each solution.

Methods: We conducted an international online survey of anesthesiologists (within perioperative care) and intensive care unit (ICU) physicians. The survey comprised 13 questions on respondents' attitudes and preferences regarding the use of acetate- and/or lactate-buffered crystalloid solutions, including their opinions on a potential clinical trial comparing these solutions and the clinical importance of such a trial.

Results: A total of 1321 respondents participated, with a response rate of 34%, ranging from 14% to 96% across 18 countries. Most surveyed physicians reported using buffered crystalloid solutions "very often" (76%) or "often" (16%). Availability of acetate- and lactate-buffered solutions varied, as 35% of respondents reported having both types available, 35% reported having only acetate-, and 24% reported having only lactate-buffered solutions available. Most respondents (87%) would support a randomized trial in adult emergency surgical patients and ICU patients comparing an acetate- versus lactate-buffered crystalloid solution. The median rating of the clinical importance of this question was 5 (interquartile range 4-6) on a scale from 1 to 9.

Conclusions: In this international survey, the reported use of buffered crystalloid solutions was high. Availability of the different solutions varied widely. The support for a potential randomized trial was high, with the clinical importance rated important but not critical by most respondents.

Background: Patients who achieve return of spontaneous circulation (ROSC) after in-hospital cardiac arrest (IHCA) may re-arrest. This phenomenon has not been sufficiently investigated. The aim of this study was to examine the immediate (1-min) and short-term (20-min) risks of re-arrest in IHCA.

Methods: We retrospectively analyzed four datasets of IHCA episodes, comprising defibrillator recordings collected between 2002 and 2022. Re-arrest was defined as the resumption of chest compressions following a period of ROSC after cardiac arrest of any duration. Parametric models were applied to calculate the immediate risk of re-arrest. In addition, we estimated the short-term risk of re-arrest within 20 min.

Results: In 763 episodes of IHCA, we observed 316 re-arrests: 68% to pulseless electrical activity (PEA), 25% to ventricular fibrillation/ventricular tachycardia (VF/VT), and 7% to asystole. Most re-arrests occurred with the same rhythm as in the initial arrest. When ROSC was achieved from a non-shockable rhythm, the risk of re-arrest to a non-shockable rhythm was initially 2% per minute and decreased to 1% per minute after 9 min. The corresponding risk of re-arrest to VF/VT was constant at 2% per minute. If ROSC was obtained from a shockable rhythm, the risk of re-arrest to a shockable rhythm was initially 5% per minute, decreasing to 4% per minute after 9 min. The corresponding risk to a non-shockable rhythm was constant at 1% per minute. The risk of re-arrest within 20 min was 27%, and the overall risk of at least one re-arrest per episode was 33%.

Conclusions: The immediate risk of re-arrest was approximately 2% per minute, with the highest risk occurring as a reversion to VF/VT if ROSC was obtained from VF/VT. The risk of re-arrest within 20 min of the initial arrest was 27%, and the overall risk of at least one re-arrest per episode was 33%.

Background: The combined spinal epidural (CSE) technique may associate with a lower failure rate of epidural catheters compared to traditional epidural catheters. This may be significant for the parturients as failure of neuraxial analgesia has been associated with a negative impact on birth experience.

Methods: In this one-year retrospective study, the failure rate of epidural catheters was compared between 3201 and 5952 epidural catheters after initiation of neuraxial analgesia by the CSE or traditional epidural technique, respectively. Parturient background information, labor parameters, and neuraxial interventions were collected from 9153 parturients. Failure was defined as replacement of a used epidural catheter by new regional analgesia procedures or general anesthesia during intrapartum cesarean delivery. The primary outcome was the failure rate of epidural catheters. The secondary outcome was the time from the initial analgesia intervention to the epidural catheter replacement and progression of labor during this time.

Results: The CSE method was used at an earlier stage of labor, and the parturients were more often primiparous and undergoing induced labor. Earlier onset of analgesia, obesity, induced labor, anesthesiologist experience, and cesarean delivery were found to be significant cofactors for catheter failure. The unadjusted failure rate was 168/3201 (5.2%) and 223/5952 (3.7%) (OR 1.42 [1.16-1.75]) after initiation of analgesia by CSE or traditional epidural method. After controlling for the stage of labor, body mass index, induction of labor, and anesthesiologist's experience level, the adjusted OR for epidural catheter replacement was 1.04 (0.83-1.29) p = .736. The mean (SD) time until epidural catheter failure was 6.3 (4.4) and 4.0 (4.1) hours following initiation of analgesia by CSE or traditional epidural technique, respectively (p < .001). Cervical dilatation progressed from 4.3 (1.4) to 6.4 (2.1) cm and 5.1 (1.5) to 6.7 (1.7) cm between primary neuraxial analgesia and epidural catheter replacement.

Conclusion: CSE technique was not associated with a better survival rate of epidural catheters for provision of analgesia or epidural top-up anesthesia for intrapartum CD. In addition, the time to replacement of the catheter was significantly longer when analgesia was initiated with the CSE technique. Maternal satisfaction scores were lower if catheters required replacement.

Background: Postoperative pain management is a challenge after robot-assisted cystectomy (RAC). Methadone has a long duration of action, and we therefore hypothesized that a single dose of intraoperative methadone would reduce postoperative opioid requirements and pain intensity in bladder cancer patients undergoing RAC.

Methods: We conducted a blinded randomized controlled clinical trial from July 2020 to August 2023. Patients scheduled to undergo RAC because of bladder cancer were randomized to receive intraoperative methadone (0.15 mg/kg^-1) or morphine (0.15 mg kg^-1) 1 h before endotracheal extubation. The primary outcome was opioid requirements after 24 h. Secondary outcomes were opioid requirements after 3 h, pain intensity at rest and during coughing, postoperative nausea and vomiting (PONV), sedation, hypoxemia, hypoventilation, time spent in the post-anesthetic care unit, and patient satisfaction.

Results: A total of 114 patients were randomized. Data from 99 patients (14 females, 85 males; mean age 69.8 ± 8.9 years) were available for analysis; 52 received methadone and 47 received morphine. Opioid consumption was similar between the methadone group and morphine group at 3 h (median, mg, 45 (IQR 30 to 75) vs. 45 (IQR 15 to 82.5) p = .97) and at 24 h (median, mg, 125 (IQR 75 to 198.5) versus 105 (IQR 72 to 157.5), p = .29). Pain intensity was significantly lower in the morphine group at 48 h compared with the methadone group. Patient satisfaction at 24 h was increased in the methadone group compared with the morphine group (median, (IQR), NRS; 9 (IQR 7 to 10) versus 7 (IQR 4 to 9), p = .020). There were no differences between treatment groups in terms of time spent in the post-anesthetic care unit and the occurrence of opioid-related side effects.

Conclusion: A single dose of intraoperative methadone does not reduce postoperative opioid requirements compared with a single dose of morphine in bladder cancer patients undergoing RAC.

Background: Chronic postsurgical pain (CPSP) has a great impact on quality of life and socioeconomic status. The mechanisms behind CPSP remain poorly understood, however type of surgical intervention seems to play a role. Gastrointestinal surgeries are common procedures, yet research in CPSP following gastrointestinal surgery is limited. The objective of this scoping review was to map the current literature on CPSP following gastrointestinal surgery, identifying how CPSP have been investigated, and which evidence gaps exist.

Methods: This scoping review followed a pre-published protocol and PRISMA-ScR guidelines. A search was carried out in Medline, Embase, CINAHL, Cochrane Central, Clinicaltrials.Gov, and Google Scholar. Eligible studies were original studies involving adults, undergoing gastrointestinal surgery, who had a pain assessment ≥30 days postoperatively. A two-phase screening process and data charting were done by two independent reviewers.

Results: A total of 53 studies were included, published between 2001 and 2024, predominantly across Europe and Asia. The range of CPSP prevalence reported was 3.3%-46.1%. Only half the studies clearly defined CPSP, and the timing and manner of pain assessment varied considerably. Twenty-seven studies assessed risk factors for developing CPSP: preoperative pain and acute postoperative pain were consistently significant.

Conclusions: There was a wide consensus on CPSPs' negative impact on quality of life. CPSP following gastrointestinal surgery is prevalent and significantly impacts quality of life. Standardized definitions and methodologies to improve the comparability and reliability of the findings across studies are needed. Future research should focus on CPSP following specific surgical procedures to develop tailored prevention and treatment strategies.

Background: The glycemic response to critical COVID-19 remains uncertain. We aimed to assess the association between COVID-19, insulin requirements, glycemic control, and mortality in intensive care unit (ICU) patients.

Methods: We conducted a retrospective observational study of 350 COVID-19 patients and 1067 non-COVID-19 patients admitted to the ICU. Insulin requirement was defined as the total units of exogenous insulin required to cover one gram of administered carbohydrates (insulin-to-carbohydrate ratio, ICR). We used multivariable generalized linear mixed-model (GLMM) analysis to assess the association of the interaction between COVID-19 and ICU-day with daily ICR, adjusted for fixed and time-dependent covariates. Glycemic control was assessed after stratification on diabetes and COVID-19. We used multivariable logistic regression analysis to assess the association between ICR and 90-day mortality.

Results: The mean (95% CI) of the mean daily ICR among patients without diabetes was 0.09 (0.08-0.11) U/g and 0.15 (0.11-0.18) U/g in the non-COVID-19 group and COVID-19 group (p = .01), respectively. In diabetes patients, the corresponding ICRs were 0.52 (0.43-0.62) U/g and 0.59 (0.50-0.68) U/g (p = .32). In multivariable GLMM analysis, the interaction between COVID-19 and ICU-day was independently associated with ICR (risk estimate 1.22, 95% CI 1.15-1.31, p < .001). COVID-19 was associated with higher hypoglycemia prevalence irrespective of diabetes status, higher average glucose levels, more pronounced glucose variability, and a lower proportion of glucose values within target range among patients without diabetes. On multivariable logistic regression analysis, the adjusted odds ratio for 90-day mortality was 1.77 (95% CI 0.94-3.34, p = .076) per one unit increase in mean ICR.

Conclusion: In our cohort of ICU patients, COVID-19 was associated with higher daily insulin requirements per gram of administered carbohydrates, and worse glycemic control. We found no robust association between ICR and increased odds of death at 90 days.