A national survey on routines regarding sedation in Swedish intensive care units

Background: Previous studies concerning sedation in Swedish intensive care units (ICU) have shown variability in drug choices and strategies. Currently, there are no national guidelines on this topic. As an update to a Nordic survey from 2004, and as a follow-up to a recently introduced quality indicator from the Swedish Intensive Care Registry, we performed a national survey. Methods: A digital survey was sent to the ICUs in Sweden, asking for sedation routines regarding hypnosedatives, analgosedatives, protocols, sedation scales, etc. Results: Fifty out of 80 ICUs responded to the survey. All units used sedation scales, and 88% used the RASS scale; 80% used written guidelines for sedation. Propofol and dexmedetomidine were the preferred short-term hypnosedatives. Propofol, dexmedetomidine, and midazolam were preferred for long-term hypnosedation. Remifentanil, morphine, and fentanyl were the most frequently used agents for analgosedation. Conclusions: All ICUs used a sedation scale, an increase compared with previous studies. Concerning the choice of hypno- and analgosedatives, the use of dexmedetomidine, clonidine, and remifentanil has increased, and the use of benzodiazepines has decreased since the Nordic survey in 2004

Morbid obesity and optimization of preoperative fluid therapy

BACKGROUND: Preoperative venous return (VR) optimization and adequate blood volume is essential in management of morbidly obese patients (MO) in order to avoid perioperative circulatory instability. In this study, all subjects underwent a preoperative 3-week preparation by rapid-weight-loss-diet (RWL) as part of their treatment program for bariatric surgery. METHODS: This is a prospective, observational study of 34 morbidly obese patients consecutively scheduled for bariatric surgery at Sunderby County Hospital, Lulea, Sweden. Preoperative transthoracic echocardiography (TTE) was performed in the awake state before and after intravascular volume challenge (VC) of 6 ml colloids/kg ideal body weight (IBW). Effects of standardized VC were evaluated by TTE. Dynamic and non-dynamic echocardiographic indices for VC were studied. Volume responsiveness and level of VR before and after VC were assessed by TTE. An increase of stroke volume >/=13 % was considered as a volume responder. RESULTS: Twenty-nine out of 34 patients were volume responders. After VC, a majority of patients (23/34) were euvolemic, and only 2/34 were hypovolemic. Post-VC hypervolemia was observed in 9/34 of patients. CONCLUSIONS: The IBW-based volume challenge regime was found to be suitable for preoperative rehydration of RWL-prepared MO. Most of the patients were volume responders. Preoperative state of VR was not associated with volume responsiveness. IBW estimates and appropriate monitoring avoids potential hyperhydration in MO. For VC assessment, conventional Doppler indices were found to be more suitable compared to tissue Doppler, giving sufficient information on pressure-volume correlation of the left ventricle in morbidly obese

Morbid obesity and optimization of preoperative fluid therapy

BACKGROUND: Preoperative venous return (VR) optimization and adequate blood volume is essential in management of morbidly obese patients (MO) in order to avoid perioperative circulatory instability. In this study, all subjects underwent a preoperative 3-week preparation by rapid-weight-loss-diet (RWL) as part of their treatment program for bariatric surgery. METHODS: This is a prospective, observational study of 34 morbidly obese patients consecutively scheduled for bariatric surgery at Sunderby County Hospital, Lulea, Sweden. Preoperative transthoracic echocardiography (TTE) was performed in the awake state before and after intravascular volume challenge (VC) of 6 ml colloids/kg ideal body weight (IBW). Effects of standardized VC were evaluated by TTE. Dynamic and non-dynamic echocardiographic indices for VC were studied. Volume responsiveness and level of VR before and after VC were assessed by TTE. An increase of stroke volume >/=13 % was considered as a volume responder. RESULTS: Twenty-nine out of 34 patients were volume responders. After VC, a majority of patients (23/34) were euvolemic, and only 2/34 were hypovolemic. Post-VC hypervolemia was observed in 9/34 of patients. CONCLUSIONS: The IBW-based volume challenge regime was found to be suitable for preoperative rehydration of RWL-prepared MO. Most of the patients were volume responders. Preoperative state of VR was not associated with volume responsiveness. IBW estimates and appropriate monitoring avoids potential hyperhydration in MO. For VC assessment, conventional Doppler indices were found to be more suitable compared to tissue Doppler, giving sufficient information on pressure-volume correlation of the left ventricle in morbidly obese

Simulated flying altitude and performance of continuous positive airway pressure devices

INTRODUCTION: Continuous positive airway pressure (CPAP) is used in air ambulances to treat patients with impaired oxygenation. Differences in mechanical principles between CPAP devices may affect their performance at different ambient air pressures as will occur in an air ambulance during flight. METHODS: Two different CPAP systems, a threshold resistor device and a flow resistor device, at settings 5 and 10 cm H2O were examined. Static pressure, static airflow and pressure during simulated breathing were measured at ground level and at three different altitudes (2400 m (8 kft), 3000 m (10 kft) and 10700 m (35 kft)). RESULTS: When altitude increased, the performance of the two CPAP systems differed during both static and simulated breathing pressure measurements. With the threshold resistor CPAP, measured pressure levels were close to the preset CPAP level. Static pressure decreased 0.71 ± 0.35 cm H2O, at CPAP 10 cm H2O, comparing ground level and 35 kft. With the flow resistor CPAP, as the altitude increased CPAP produced pressure levels increased. At 35 kft, the increase was 5.13 ± 0.33 cm H2O at CPAP 10 cm H2O. DISCUSSION: The velocity of airflow through the flow resistor CPAP device is strongly influenced by reduced ambient air pressure leading to a higher delivered CPAP effect than the preset CPAP level. Threshold resistor CPAP devices seem to have robust performance regardless of altitude. Thus, the threshold resistor CPAP device is probably more appropriate for CPAP treatment in an air ambulance cabin, where ambient pressure will vary during patient transport

Preoperative anxiety level is not associated with postoperative negative behavioral changes in premedicated children

Background: Anesthesia preinduction anxiety in children can according to some studies lead to long-term anxiety and negative behavioral changes (NBC), while other studies have not found this effect. This secondary analysis from a recent premedication trial comparing clonidine and midazolam aimed to test the relation between preoperative anxiety assessed with modified Yale Preoperative Anxiety Scale (mYPAS) and postoperative NBCs assessed with Post Hospital Behavior Questionnaire (PHBQ), regardless of premedication type. Methods: This is a planned secondary analysis from a published premedication comparison trial in an outpatient surgery cohort, children aged 2–7 years. Participant and preoperative factors, particularly preoperative anxiety as mYPAS scores, were assessed for association with development of postoperative NBCs. Results: Fifty-four of the 115 participants had high preinduction anxiety (mYPAS >30), and 19 of 115 developed >3 postoperative NBCs 1 week after surgery. There was no association between preinduction anxiety level as mYPAS scores and the development of postoperative NBCs at 1 week after surgery (10 of 19 had both, p =.62) nor after 4- or 26-weeks post-surgery. Only lower age was associated with development of NBCs postoperatively. Conclusions: Based on the findings from this cohort, high preinduction anxiety does not appear to be associated with NBCs postoperatively in children premedicated with clonidine or midazolam

Levels of mannose-binding lectin (MBL) associates with sepsis-related in-hospital mortality in women

Background: Mannose-binding lectin (MBL) mediates the innate immune response either through direct opsonisation of microorganisms or through activation of the complement system. There are conflicting data whether MBL deficiency leads to increased susceptibility to infections or not. The aim of this study was to determine if low levels of mannose-binding lectin (MBL) predict sepsis development, sepsis severity and outcome from severe sepsis or septic shock. Method: Patients aged 18 years or more with documented sepsis within 24 h after admission to the intensive care unit were included if they had participated in a health survey and donated blood samples prior to the sepsis event. A subset of these patients had stored plasma also from the acute phase. Two matched referents free of known sepsis were selected for each case. Plasma levels MBL were determined in stored samples from health surveys (baseline) and from ICU admission (acute phase). The association between MBL and sepsis, sepsis severity and in-hospital mortality were determined with 1300 ng/mL as cut-off for low levels. Results: We identified 148 patients (61.5% women) with a first-time sepsis event 6.5 years (median with IQR 7.7) after participation in a health survey, of which 122 also had samples from the acute septic phase. Both high MBL levels in the acute phase (odds ratio [95% confidence interval]) (2.84 [1.20-6.26]), and an increase in MBL levels from baseline to the acute phase (3.76 [1.21-11.72]) were associated with increased risk for in-hospital death in women, but not in men (0.47 [0.11-2.06]). Baseline MBL levels did not predict future sepsis, sepsis severity or in-hospital mortality. Conclusions: An increase from baseline to the acute phase as well as high levels in the acute phase associated with an unfavourable outcome in women

Does carbon monoxide treatment alter cytokine levels after endotoxin infusion in pigs? : A randomized controlled study

ABSTRACT: BACKGROUND: Carbon monoxide (CO) has recently been suggested to have anti-inflammatory properties, but data seem to be contradictory and species-specific. Thus, in studies on macrophages and mice, pretreatment with CO attenuated the inflammatory response after endotoxin exposure. On the other hand, human studies showed no effect of CO on the inflammatory response. Anti-inflammatory efficacy of CO has been shown at concentrations above 10% carboxyhaemoglobin. This study was undertaken to elucidate the possible anti-inflammatory effects of CO at lower CO concentrations. METHODS: Effects of CO administration on cytokine (TNF-alpha, IL-6, IL-1beta and IL-10) release were investigated in a porcine model in which a systemic inflammatory response syndrome was induced by endotoxin infusion. Endotoxin was infused in 20 anaesthetized and normoventilated pigs. Ten animals were targeted with inhaled CO to maintain 5% COHb, and 10 animals were controls. RESULTS: In the control group, mean pulmonary artery pressure increased from a baseline value of 17 mmHg (mean, n = 10) to 42 mmHg (mean, n = 10) following 1 hour of endotoxin infusion. Similar mean pulmonary artery pressure values were found in animals exposed to carbon monoxide. Plasma levels of all of the measured cytokines increased in response to the endotoxin infusion. The largest increase was observed in TNF-alpha, which peaked after 1.5 hours at 9398 pg/ml in the control group and at 13395 pg/ml in the carbon monoxide-exposed group. A similar peak was found for IL-10 while the IL-6 concentration was maximal after 2.5 hours. IL-1beta concentrations increased continuously during the experiment. There were no significant differences between carbon monoxide-exposed animals and controls in any of the measured cytokines. CONCLUSION: Our conclusion is that 5% COHb does not modify the cytokine response following endotoxin infusion in pigs