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

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