Background Elderly patients are more frail and have a higher burden of comorbidity, which could influence the risk of complications after anaesthesia. The aim of this study was to describe the elderly patient population undergoing general anaesthesia in Denmark.Methods This was a national registry-based observational cohort study of adult patients (>= 18 years) undergoing general anaesthesia in Denmark in 2020 and 2021, with a primary focus on patients 80 years and above. Patient and procedure characteristics of interest were age, sex, BMI, ASA classification, Elixhauser Comorbidity Index, comorbidities, type of procedure, and class of priority. The primary outcome of interest was 30-day mortality. Secondary outcomes included acute kidney injury within 7 days, length of hospital stay, and number of days in the ICU.Results A total of 453,133 cases of general anaesthesia in 328,951 unique patients in Denmark during 2020 and 2021 were included in this study. Of these, 25,955 (8%) patients were 80 years of age and above. Elderly patients undergoing general anaesthesia were of higher ASA classification, suffered from a higher degree of comorbidity measured by Elixhauser Comorbidity Index, had a lower proportion of elective procedures and a higher proportion of expedited and urgent procedures. Mortality for all patients at 30 days was 1.5% (n = 4814). While mortality was low for cases aged between 18 and 65 years, 30-day mortality increased for each year after 65 years of age even after adjusting for covariates. Mortality was especially high for patients with high Elixhauser Comorbidity Index, high ASA classification, and for non-elective procedures.Conclusion In this nationwide registry-based cohort study, we described the elderly patient population undergoing general anaesthesia in Denmark. We found that 30-day mortality increased for each year after 65 years of age even after adjusting for covariates.Editorial Comment This large cohort study from Denmark assesses perioperative case factors including age, comorbidity and more, then describing different risk levels for 30 day mortality, particularly with advanced age.
ABSTRACT Background Implementing evidence‐based recommendations in anaesthesiology and critical care remains challenging due to guideline, workflow and contextual barriers. Guideline‐based computerised clinical decision support systems (CDSS), embedded in structured pathways linking international guidelines to Scandinavian‐endorsed recommendations and delivered via electronic health records, may help strengthen the evidence‐to‐practice pathway. This study aimed to explore perceived barriers and facilitators to their use. Methods This qualitative study interviewed 10 clinicians (anaesthesiologists and intensivists; specialists and non‐specialists; < 40 and ≥ 40 years; male and female) and nine system‐level stakeholders (hospital and health authority representatives) from Denmark, Finland, Iceland, Norway and Sweden. We integrated endorsed international guidelines into a CDSS providing patient‐specific reminders linked to recommendations, as well as shared decision‐making tools and decision‐analytic components. Using a simulation application, participants explored the CDSS in a demo electronic health record. Through a framework analysis based on the GUIDES checklist, we categorised perspectives as barriers, facilitators or suggestions. Results Clinicians and system‐level interest holders expressed broad interest in this multifunctional CDSS to support evidence‐based, patient‐centred care and appreciated the collaborative international pathway facilitated by digital tools. Key themes included the challenges hospitals face in translating international guidelines into up‐to‐date, locally adapted guidance. Artificial intelligence (AI) was perceived as having the potential to both enhance and challenge traditional CDSS. Opportunities were identified to strengthen shared decision‐making for major decisions through the proposed system. Finally, participants highlighted the potential value of using a decision‐analytic tool to prioritise reminders, although the tool was considered conceptually challenging in its current form and would require clearer presentation before being applied in CDSS. Conclusions This prototype study indicates support for a multifunctional CDSS. Building on the barriers and facilitators identified in this study, interviewees advocated for real‐world evaluation with particular attention to sustainable implementation. Editorial Comment This study aimed to describe how ICU clinicians experience interaction in a simulated electronic health record where there were chosen elements of decision support based on international treatment guidelines incorporated into the simulation. Participants were interviewed for their perceptions of what types of decision support might be most helpful to support their clinical work in future patient information and management systems.
ABSTRACT Background Detection of cerebral ischaemia is challenging in patients who are anaesthetised, sedated or have reduced levels of consciousness, as neurological examination is difficult or even impossible to assess. Furthermore, as some patients cannot be transported for radiology, for example during surgery, a reliable blood biomarker for detecting acute cerebral events would be of considerable clinical value. We aimed to compare levels of brain injury biomarkers glial fibrillary acidic protein (GFAP), neurofilament light chain (NfL), and total tau (tau) in patients with acute ischaemic stroke (AIS) undergoing endovascular thrombectomy under general anaesthesia or sedation to controls undergoing non‐cerebral surgery under general anaesthesia. These biomarkers were chosen because previous studies have demonstrated their potential as blood biomarkers of acute cerebral injury and ischaemic stroke. Methods In this prospective, observational pilot study, conducted at the Sahlgrenska University Hospital, Gothenburg, Sweden, between 2021 and 2024, GFAP, NfL, and tau were analysed using the Simoa Neurology 4‐plex assay, before thrombectomy or surgery and at 2‐ and 24 h thereafter. Results Blood samples from 21 patients with AIS and 19 controls were analysed. GFAP concentrations in patients with AIS increased significantly from baseline to 24 h (median 301.0 → 1443.0 pg/mL; p = 0.001) and were higher than in controls at all time points ( p < 0.01). In the controls there was no significant increase in GFAP from baseline to 24 h ( p = 0.449). NfL and tau increased significantly in patients with AIS ( p = 0.001 and 0.002) but also in the controls ( p = 0.001 and 0.047). Conclusion GFAP and NfL concentrations were higher in patients with acute ischaemic stroke than in surgical controls at all sampling time points, whereas tau differed only after 24 h. Unlike NfL and tau, GFAP did not increase significantly in controls, suggesting that it may be less influenced by anaesthesia and surgery. These findings support further evaluation of GFAP as a potential biomarker of acute cerebral injury in perioperative and critical care settings. Editorial Comment A biomarker of ischaemic cerebral injury could be attractive to support treatments to protect brain health during anaesthesia and surgery. In a pilot study, glial fibrillary acidic protein emerged as a potential candidate as it was increased in patients undergoing endovascular thrombectomy for large‐vessel ischaemic stroke compared to anaesthetised patients undergoing non‐cerebral surgery. Trial Registration ClinicalTrials.gov identifier: NCT03919370
ABSTRACT Background During laparoscopic surgery, abdominal carbon dioxide (CO 2 ) insufflation in the supine position and with head‐down tilt for robotic surgery increases abdominal pressure and pushes the diaphragm cranially. This causes a decrease in end‐expiratory lung volume and in lung and chest wall compliance. These effects can be counteracted by the application of PEEP. Our study aimed to measure lung and chest wall mechanics during laparoscopic surgery using a non‐invasive method (PEEP‐step method) and to determine the optimal PEEP level for each patient. Methods Thirty‐two patients scheduled for abdominal surgery participated in this observational study with pneumoperitoneum. Fourteen patients underwent surgery for pelvic conditions in head‐down position and 18 in supine position. Data from the ventilator was collected and analysed with a dedicated software, which calculated lung compliance and transpulmonary pressure from a two‐step PEEP increase. Measurements were performed after induction, after pneumoperitoneum in supine/tilt head‐down and before emergence. Results Lung and chest wall compliance decreased during CO 2 insufflation with high individual variation, and we observed a≈90% increase in transpulmonary driving pressure. After CO 2 ‐desufflation, lung and chest wall compliance returned to near baseline levels on a group level. However, 19 patients had a remaining reduction in lung compliance, six with 20%–50%. Optimal PEEP level calculated by the software was twice the clinical routine level. Conclusions The study found substantial individual variation in lung compliance during laparoscopic surgery in patients without evident lung disease. This variability does not align well with respiratory system compliance. The findings highlight the need for individualized ventilator settings based on lung‐ rather than respiratory system mechanics. The PEEP‐step method may be a non‐invasive, real‐time bedside tool to identify patients who would benefit from higher PEEP to preserve lung volume and possibly prevent postoperative complications. Editorial Comment Laparascopic surgical conditions can affect lung mechanics, though not always predictably. This study examined how a test of higher or lower PEEP directly after anaesthesia induction might inform PEEP optimization in the same cases undergoing laparoscopic surgery. Trial Registration ClinicalTrials.gov (NCT04484727, 2022‐05‐01)
ABSTRACT Background Hypernatremia is frequent in the intensive care unit (ICU) and is associated with adverse outcomes. Despite its prevalence, robust evidence to guide treatment is lacking, and global practice patterns are largely unknown. We investigated global treatment preferences and clinicians' willingness to enroll patients in a randomized trial to inform its feasibility. Methods This international cross‐sectional online survey comprised 20 primarily closed‐ended questions, using five‐point Likert‐scale responses, across four themes: treatment method, threshold, correction rate, and opinion on a proposed trial. Respondents considered a clinical vignette of hypernatremia developing before or during ICU admission, excluding dehydration and chronic causes. It was distributed to ICU physicians worldwide. Results The survey was sent to 3053 ICU physicians in 17 countries, with 1051 respondents, yielding a response rate of 34%. Of respondents, 74% were consultants, and 26% were residents. The mean ICU experience was 14 years. Increasing free water intake via enteral route was the most frequently reported treatment strategy (80% reporting “often” or “always”). Moderate hypernatremia (plasma sodium 151–156 mmol/L) was the most frequently reported threshold for initiating correction (533/892, 60%). 45% (396/888) preferred a correction rate of 8–12 mmol/L/day, and 41% (366/888) of < 8 mmol/L/day, with the remainder having no correction rate target or correction rate target of > 12 mmol/L/day. 74% (654/882) reported no barriers to enrolling eligible patients in the proposed trial. Conclusion Among ICU physicians, correction of hypernatremia is mostly achieved by increasing free water intake using hypotonic fluids, predominantly via the enteral route. Most clinicians initiate treatment once hypernatremia reaches a moderate level, aiming for a correction rate of < 12 mmol/L/day. Most clinicians expressed willingness to enroll eligible patients in the proposed trial. Editorial Comment This survey study aimed to sample physician preferences for treatment of hypernatremia when on their way to or in the ICU. This study sampled respondents in many countries, and based on different phases of treatment and assessment, as well as participant willingness for a future treatment trial.
