Acta Anaesthesiologica Scandinavica最新文献

Background: The inflammatory response to whole-body ischemia, as seen in comatose survivors after out-of-hospital cardiac arrest (OHCA), is associated with increased morbidity and mortality. Early high-dose dexamethasone may dampen the inflammatory response, which may diminish secondary brain damage and other organ injury and decrease mortality. The aim is to evaluate the effect of high-dose dexamethasone in post-resuscitation care.

Methods: The Danish Out-of-Hospital Cardiac Arrest (DANOHCA) trial is an investigator-initiated, multicenter, randomized, controlled trial evaluating four post-resuscitation interventions in adult patients resuscitated after OHCA including blinded early administration of high-dose dexamethasone compared with placebo (isotonic saline). Adult OHCA patients with presumed cardiac etiology and sustained return of spontaneous circulation will be randomized 1:1 to receive 20 mg of dexamethasone or placebo immediately after inclusion in the trial and repeated the following two mornings for a total of three doses. The primary outcome is all-cause mortality within 90 days using a log-binomial regression analysis to estimate the relative risk of death from any cause between randomization and Day 90. Enrollment began in June 2023, with the aim to include 1000 patients at five sites in 3-4 years. The trial is registered at clinicaltrials.gov (identifier: NCT05895838) and euclinicaltrials.eu (2024-515997-28-00).

Perspectives: It is of paramount importance to optimize post-resuscitation care through large-scale randomized trials. Global ischemia-reperfusion-induced inflammatory response with resulting organ failures represents a possible target for interventions after OHCA. This part of the DANOHCA trial will provide new evidence on the impact of high-dose dexamethasone in survivors of OHCA.

Trial registration: Clinical Trials Information System (CTIS): 2024-515997-28-00.

Background: Intensive care following resuscitation from out-of-hospital cardiac arrest (OHCA) is based on a set of interventions, all of which are intended to reduce anoxic brain injury and improve outcomes, including sedation, mechanical ventilation, circulatory optimization, and temperature control protocols. The backrest position impacts intracranial pressure and cerebral blood flow in traumatic brain injury, and the optimal position for improving outcomes after OHCA is unknown; guidelines advocate for an elevated backrest position. This trial compared outcomes of two backrest positions.

Methods: The Danish Out-of-Hospital Cardiac Arrest (DANOHCA) trial is an investigator-initiated, multicenter, randomized, controlled trial evaluating four interventions, including two different backrest positions, for improving outcomes. Comatose adult patients with OHCA of presumed cardiac cause and sustained return of spontaneous circulation will be included. Patients were randomized 1:1 to a backrest positioned at 5° or 35° straight elevation of backrest in the Semi-Fowler's position (elevated lower limb position) during the initial 72 h or until extubation. The primary outcome was mortality within 90 days of cardiac arrest. Inclusion began in June 2023, and the study aims to include 1000 patients from five sites over an estimated time period of 3-4 years. Kaplan-Meier curves with Cox regression will be used for statistical analyses. The trial is registered at clinicaltrials.gov (identifier: NCT05895838) and euclinicaltrials.eu (2024-515997-28-00).

Perspectives: Post-resuscitation care of comatose cardiac arrest is complex, and each part should be tested in randomized trials. This part of the DANOHCA trial will provide evidence on one of these factors, namely position of the patients' head relative to the heart.

Trial registration: EudraCT number 2016-003265-26; EU CTIS no 2024-515997-28-00; ClinicalTrials.gov identifier: NCT05895838.

Background: Mortality among critically ill COVID-19 patients has varied globally. In Sweden, geographic differences in mortality have also been observed. The current study aimed to determine whether mortality differences persist after adjusting for differences in case-mix, and to identify potential independent factors contributing to regional variations in mortality.

Methods: We conducted a multicenter cohort study including adult patients admitted to seven hospital ICUs across three Swedish healthcare counties between March 1, 2020 and July 31, 2021. These ICUs include one university hospital, three county hospitals and three local hospitals, and cover the intensive care infrastructure for approximately one million inhabitants. Patients were assigned to the hospital of initial ICU admission, even if transferred later during the course. Patient characteristics, disease severity, respiratory support, and treatments were registered. Primary outcome was 90-day mortality. A mixed-effects Cox proportional hazards model was used.

Results: Seven hundred and forty seven patients were included. The unadjusted 90-day mortality varied significantly, with the highest rate at 30%, and the lowest at 8.5% (p < 0.001). After adjustment for baseline confounders (Charlson comorbidity index, sex, SAPS3, age, smoking status, BMI), calendar time and healthcare county (random intercept), all hospitals were significantly associated with increased 90-day mortality compared with the lowest mortality hospital. Hazard ratios ranged from 2.38 to 5.06.

Conclusion: Among patients admitted to ICU due to COVID-19, we observed a difference in mortality related to the hospital of first ICU admission. This difference persisted after adjustment for calendar time, baseline confounders, and healthcare county. Potential explanations are lacking within the current study. Future studies should focus on comprehensive evaluation of both organizational and contextual determinants of mortality.

Editorial comment: This analysis from 3 Swedish counties (7 hospitals) for COVID ICU cases presents factors and relations to mortality risk, including factors for first admission to university-larger-, or smaller hospital. An association was observed for higher risk if the first ICU admission was in a smaller hospital, though recognizing that this is a dataset coming from a small set of hospitals.

Introduction: Malignant hyperthermia (MH) is a pharmacogenetic, hypermetabolic and potentially lethal reaction to potent volatile anaesthetics and the muscle relaxant succinylcholine. To improve the understanding of MH, the aim of this retrospective study was to describe the Swedish cohort with respect to clinical manifestations, demographics and genetic findings.

Method: The Swedish MH Registry covers a total of 2852 individuals belonging to 544 different families investigated for MH since 1980. For this study, the index case in each family was included for further description.

Results: In total, MH was confirmed in 1555 individuals. Among the 288 index cases with a history of an MH reaction and confirmed MH, 58% were male and 57% were < 18 years of age. MH was confirmed in 41% of index cases where masseter muscle spasm was the only clinical sign of MH. The overall case fatality following an MH reaction in Sweden was 5.2%, but no fatal MH reaction has been reported since 2001. Out of 163 genetically investigated MH families, 61 had a diagnostic variant and 23 had a variant of unknown significance.

Conclusions: We found that MH reactions predominantly occur in young individuals and that case fatality has declined over recent decades, with no deaths reported in the past 20 years. Less than 40% of the genetically investigated MH families, corresponding to around 20% of all Swedish MH families, currently have an identified genetic diagnostic variant.

Editorial comment: This analysis of the national Swedish Malignant Hyperthermia patient registry presents case factors and outcomes from cases among recognised families from the last 45 years. Presenting symptoms and then case confirmation details are presented, along with results from cases and families where genetic variants has been assessed.

Background: Right atrial pressure (RAP) is a key determinant of venous return and reflects right-sided filling pressures in critically ill patients. Central venous pressure (CVP) is commonly used as a surrogate, but its accuracy depends on appropriate transducer levelling. While reference points have been evaluated in supine positions, evidence is lacking for the lateral position, despite its frequent use in intensive care. Furthermore, it remains unclear whether lateral positioning alters RAP itself.

Methods: In this prospective observational study, 16 sedated, mechanically ventilated ICU patients with central venous catheters were included. RAP was measured using a solid-state catheter positioned in the mid-right atrium, confirmed by waveform analysis and echocardiography. Simultaneous CVP was recorded with the transducer levelled 5 cm below the mid-sternum. Measurements were obtained at end-expiration in supine, 45° left lateral, and 45° right lateral positions. Agreement between RAP and CVP was assessed using Bland-Altman analysis, intraclass correlation coefficients, and predefined clinical thresholds. Stepwise hydrostatic adjustments were applied to identify optimal reference levels.

Results: In the right lateral position, CVP referenced 5 cm below the sternum closely approximated RAP (bias -0.4 mmHg; limits of agreement -3.2 to +2.4; ICC 0.85). In the left lateral position, the same reference point systematically overestimated RAP (bias -2.2 mmHg; limits of agreement -5.0 to +0.7; ICC 0.58). Adjustment to approximately 2 cm below the sternum minimised bias (-0.1 mmHg) and improved agreement (ICC 0.82). RAP increased in the right lateral position compared with both supine (Δ +2.9 mmHg, p < 0.001) and left lateral (Δ +2.8 mmHg, p < 0.001) positions, while no difference was observed between supine and left lateral positions (p = 0.78).

Conclusion: In mechanically ventilated ICU patients, central venous pressure accuracy was position-dependent, and optimal external reference levels differed between lateral positions. Right atrial pressure increased in the right lateral position, suggesting that lateral positioning influences cardiopulmonary physiology beyond hydrostatic measurement effects alone.

Trial registration: https://clinicaltrials.gov/study/NCT06705374, registration date 30 April 2024 EDITORIAL COMMENT: The study showed that central venous pressure systematically overestimated right atrial pressure in mechanically ventilated patients placed in the left lateral position. This means that preload and venostasis can be misinterpreted in this position. The influence of increased right atrium pressure on venous return and cardiac output during left lateral positioning in mechanically ventilated patients requires further studies before the clinical relevance can be assessed.

Background: Core outcome measurement sets (COMS) enhance the consistency and comparability of outcome reporting in clinical research. However, their effectiveness depends on the selection of valid, reliable, and feasible measurement instruments. Core outcome sets (COS) and COMS have been developed for specific intensive care unit (ICU) patient subgroups. The aim of this study is to establish a standardised approach to outcome measurement and operationalisation for adults acutely admitted to the ICU who are participating in clinical trials and other clinical research.

Methods: This protocol describes the development of a COMS for adults acutely admitted to the ICU, the CoreMS-ICU, consisting of six core outcomes: survival, free of life support, free of delirium, out of hospital, health-related quality of life, and cognitive function. We will follow the Consensus-based Standards for the Selection of Health Measurement Instruments guideline and report according to the Core Outcome Set-STAndardised Protocol Items guideline. The development of the CoreMS-ICU will follow five predefined steps: (1) conceptual considerations for the six core outcomes; (2) systematic searches for outcome measurement instruments, including consideration of existing COMS; (3) quality assessment of relevant outcome measurement instruments; (4) consensus-based selection of outcome measurement instruments; and (5) recommendations and guidance on how to operationalise and report the measurement of the six core outcomes. We will involve research panels consisting of key stakeholders: patients, family members, healthcare professionals, and researchers in steps 1 and 4.

Conclusions: We aim to develop a COMS for adults acutely admitted to ICU patients to facilitate the consistent use of outcomes in trials and enhance the translation of research findings into clinical practice.

Background: Burn injuries are associated with substantial morbidity and mortality worldwide, with infections representing a major complication. The desirable and undesirable effects of perioperative antibiotic prophylaxis in burn patients are unresolved.

Methods/design: We will conduct a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials assessing the desirable and undesirable effects of systemic antibiotic prophylaxis in burn patients undergoing surgery, compared with placebo or no prophylaxis/standard of care. The primary outcome will be the number of patients with one or more bloodstream infections. Secondary outcomes include 30-day and 90-day mortality, the number of patients with one or more skin and soft tissue infections, ventilator-associated pneumonias, clostridium difficile infections, antimicrobial-resistant bacteria, serious adverse events, days alive without organ support (renal replacement therapy, mechanical ventilation, vasopressor), ICU- and hospital-free days. We will search the following databases: CENTRAL, MEDLINE, EMBASE, BIOSIS, Web of Science, and CINAHL. The review will follow the recommendations provided by the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

Discussion: The outlined systematic review and meta-analysis will evaluate the desirable and undesirable effects of perioperative antibiotic prophylaxis on patient-important outcomes and may inform clinical practice and future research in this area.

Trial registration: ClinicalTrials.gov identifier: CRD420261378296.

Background: Manual removal of placenta (MRP) is required in 0.1%-3.3% of vaginal births. For patients who give birth without labor epidural analgesia, the choice between neuraxial or general anesthesia (GA) with or without tracheal intubation presents unique challenges. This study describes anesthetic management practices for these cases.

Methods: This multicenter retrospective cohort study analyzed 423 patients undergoing MRP at two tertiary centers in Israel (Soroka and Rabin Medical Centers) from 2016 to 2022. We collected data on anesthetic techniques, patient characteristics, and clinical outcomes, comparing patients managed with and without tracheal intubation during GA.

Results: GA was used in 409 (96.7%) cases, with 269 (65.8%) patients managed with tracheal intubation and 140 (34.2%) receiving tubeless GA. Patients who received tubeless GA had lower rates of intraoperative complications, including hypotension (16.4% vs. 26.0%, p = 0.034), vasopressor use (10.0% vs. 20.8%, p = 0.006), and blood product transfusions (3.6% vs. 11.9%, p = 0.006). Multivariable analysis revealed associations between higher body mass index (aOR = 2.19), elevated heart rate (aOR = 1.86), and tracheal intubation. Tracheal intubation rates significantly declined from 2016 to 2022 following the introduction of gastric ultrasound in our practice.

Conclusion: Anesthetic management for MRP should be individualized based on clinical factors. In our cohort, tubeless GA was preferred for fasted, lower BMI, and hemodynamically stable patients, with tracheal intubation typically reserved for more complex cases, reflecting inherent selection bias. This study was descriptive in nature and was not designed to establish the safety of any particular technique. Further high-quality research is needed to validate these findings and refine anesthetic guidelines for MRP.

Editorial comment: MRP is a rare obstetric procedure that can be challenging to manage without prior epidural analgesia. A retrospective study of 423 patients in two Israeli hospitals (2016-2022) found that most cases (96.7%) used GA, with about two-thirds involving tracheal intubation and one-third using tubeless techniques. Tubeless anesthesia was associated with less hypotension, reduced need for vasopressors, and fewer blood transfusions. Patients with higher BMI and heart rate were more likely to be intubated. Intubation rates decreased over time after gastric ultrasound was introduced in this cohort. Overall, the study suggests tailoring anesthesia choice to the patient, with no endotracheal intubation approaches safe for selected stable cases, though more research is needed.

Background: Continuous vital sign monitoring with wearable biosensors enables earlier detection of clinical deterioration and improves patient safety. This study validated an integrated wireless photoplethysmography-based chest patch biosensor (Biobeat technology Ltd) capable of measuring five vital signs relevant for Early Warning Score calculation, by comparison with standard continuous bedside monitoring in the intensive care unit.

Methods: Agreement between the wearable biosensor and the reference monitor was assessed using Bland-Altman analysis for repeated measurements. Bias and limits of agreement were calculated for all vital signs. Measurement differences were compared with predefined accuracy limits. Data were aligned at 5- and 15-min intervals using median reference values. Deming regression, Pearson correlation, and Clarke Error Grid analyses were performed.

Results-: A total of 1931.8 monitoring hours were collected from 32 intensive care patients (mean 60.4 ± 28.5 h). Heart rate showed a bias of 0.16 beats per minute (LoA -17.06 to 17.38), with 18.8% exceeding the 10% threshold and 0.42% in Clarke Error Grid zones D-E. Respiratory rate showed a bias of 3.77 breaths per minute (LoA -6.78 to 14.31), with 61.4% exceeding the 10% threshold and 18.6% in zones D-E. Systolic blood pressure, oxygen saturation, and temperature showed biases of -4.69 mmHg, -1.34%, and -0.29°C, respectively.

Conclusion: Agreement between a wearable chest-patch biosensor and standard bedside monitoring was evaluated in intensive care patients. Overall agreement was variable, with wide limits of agreement and a substantial proportion of measurements outside predefined thresholds. Further optimisation and validation are required before broader clinical application.

Editorial comment: In this article, limitations in agreement between signals from wearable wireless sensors for vital signs and usual vital signs monitor values in intensive care cases are described for data collected from a practical and pragmatic setting where the study participants were in early phase of their illness with some expected clinical deterioration. There were enough test device values outside of predefined limits of agreement based on clinically relevant differences, that the authors interpret this as a need for further improvement in device performance.

Use of neuraxial analgesia requires communication between the parturient and her caretakers. In this retrospective study, the use of labor analgesia is compared between parturients whose primary language is other than Finnish or Swedish and who don't communicate in these languages or English without an interpreter (Category I), who communicate in Finnish, Swedish, or English (Category II), and primary Finnish or Swedish speakers (Category III). The primary outcome of this study is the association of communication language categories with neuraxial analgesia use. The secondary outcome is the incidence of vaginal delivery without pharmacological pain relief. The parturient and labor parameters (age, body mass index (BMI), primiparity, gestational age, prior consultations for fear-of-childbirth (FOC), induction of labor, use of oxytocin, labor analgesia interventions, outcome of the attempted labor) were recorded from the electronic patient database for all 13,707 parturients that attempted vaginal delivery in the Helsinki region delivery hospitals during 2022. The distribution of parturients was 15.3%, 10.3%, and 74.4% in the language categories I, II, and III, respectively. The use rate of neuraxial analgesia was 60.8%, 65.8%, and 75.3% in the categories I, II, and III respectively. After adjustment for primiparity, maternal BMI, gestational age, FOC diagnosis, induction of labor, oxytocin use, episiotomy, and outcome of labor, the adjusted OR (aOR) for neuraxial analgesia use was (1.283 [1.093-1.506]) among parturients in Cat II compared to Cat I. Correspondingly, the ability to communicate directly (Cat II) was associated with lower use of only non-neuraxial pharmacological analgesia (aOR 0.789 [0.654-0.951]) compared to those incapable of direct communication (Cat I). No association was seen with language capability (Cat II vs. Cat I) and delivery without pharmacological pain relief (any delivery type: aOR 0.815 [0.652-1.019]; vaginal delivery: aOR 0.825 [0.645-1.055]). Ability to communicate directly with the staff is associated with shifting from non-neuraxial techniques to neuraxial analgesia but not an increase in general labor analgesia use. Cultural trends may be associated with labor analgesia choices more than language capabilities. Promotion of labor analgesia use should go beyond translation services and requires antenatal education of the available options. EDITORIAL COMMENT: This study demonstrates that language ability alone does not determine labor analgesia use but instead shapes the selection of analgesia methods. Cultural context and antenatal knowledge appear to play a central role in analgesia decision-making. Efforts to promote equitable maternity care should therefore extend beyond translation services to include culturally responsive education and communication strategies that support informed maternal choice.