BACKGROUND:Fluid balance in patients who have undergone gastrointestinal surgery is known to be challenging to monitor, resulting in imprecise and inaccurate measurements. Despite this knowledge, any association between fluid balance accuracy and the development of postoperative complications in the early postoperative period is limited. This scoping review aims to map the existing knowledge between fluid monitoring and the development of postoperative morbidity, mortality, and length of hospital stays (LoS) in patients who have undergone gastrointestinal surgery. METHODS:The review will follow the Joanna Briggs Institute (JBI) guidelines for scoping reviews and will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping reviews (PRISMA-ScR) recommendations. The search will be conducted using MEDLINE, EMBASE, CINAHL, and Cochrane Library. Data extraction will be charted based on trial characteristics and include study information, methodology, basic data, surgical data, methods for the monitoring of fluid balance, accuracy of fluid balance monitoring, guidelines used for postoperative fluids, fluid intake, fluid loss, LoS, morbidity, and mortality. RESULTS:A structured overview will be summarized using descriptive statistics and presented in tables and figures with a supplementary narrative summary of additional findings. CONCLUSION:This planned scoping review will help identify existing knowledge and gaps in literature regarding methods in fluid monitoring, as well as any correlation between fluid monitoring and the development of postoperative complications to support further research in the area.
BACKGROUND:Perioperative hypotension in patients undergoing gastrointestinal surgery is a known and well-described condition. Timely treatment of perioperative hypotension, regardless of the reason, is important in order to reduce the associated postoperative complications. The treatment consists of vasoactive agents and/or fluids; however, the ideal vasoactive agent in gastrointestinal surgery has yet to be identified. METHODS:We will conduct a scoping review of studies assessing the use of vasoactive agents in patients undergoing gastrointestinal surgery. We will investigate in which gastrointestinal populations the use of vasoactive agents has been assessed, if the agents are used as part of a goal-directed therapy protocol, evaluate the desirable or undesirable effects assessed, and if there are any differences between the agents assessed depending on the urgency of the surgery. The review will be developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement. RESULTS:Results will be presented descriptively. CONCLUSION:The outlined scoping review will provide a descriptive summary of the body of evidence on the use of vasoactive agents in patients undergoing gastrointestinal surgery.
BACKGROUND:Meropenem and piperacillin/tazobactam are commonly used empirical antibiotics in critically ill adults with sepsis, but whether one is superior to the other is uncertain. METHODS:The Empirical Meropenem versus Piperacillin/Tazobactam for Adult Patients with Sepsis (EMPRESS) trial is an ongoing investigator-initiated, randomised, open-label, adaptive clinical trial with an integrated feasibility phase comparing empirical treatment with meropenem versus piperacillin/tazobactam in critically ill adults with sepsis. The integrated feasibility phase enrolled 200 participants across 10 intensive care units (ICUs) in Denmark between 28 June and 12 December 2025. Five pre-specified feasibility criteria were evaluated; if all feasibility criteria were met, the trial would proceed unaltered, whereas failure to meet one or more criteria would require intervention and re-evaluation. RESULTS:We randomised 200 of 284 screened patients (70.4%). The median age was 70 years (interquartile range (IQR): 60-77), 65.5% were males. At randomisation, 80.0% received vasopressors or inotropes, and 43.5% were on invasive mechanical ventilation. Four of five pre-specified feasibility criteria were met: time to completion of the feasibility phase (5.5 months vs. threshold < 12.0 months), recruitment proportion (70.4% vs. threshold ≥ 50.0%), proportion of participants without consent to the continued collection of data (2.5% vs. threshold < 5.0%) and protocol adherence (81.0% vs. threshold ≥ 75.0%). The proportion of participants with timely primary outcome data availability (30-day mortality) within 45 days was 85.5% and below the pre-specified threshold of ≥ 95.0%. The proportions were low in the first 3 months (33.3%, 22.2% and 30.8%, respectively), increasing to 95.8% in the last month of the feasibility phase. All-cause mortality at 30 days was 30.5%, and specific serious adverse reactions occurred in 4.0% of participants. CONCLUSIONS:In this integrated feasibility evaluation of the EMPRESS trial comparing empirical meropenem versus piperacillin/tazobactam in critically ill adults with sepsis, four of five pre-specified feasibility criteria were met. The unmet criterion, timely primary outcome data availability, improved substantially during the feasibility phase. We consider the trial feasible and will proceed without modifications. EDITORIAL COMMENT:This feasibility study assessed recruitment, randomised allocation and data collection for the multicentre EMPRESS trial. For adaptive trials on trial platforms, careful interim checking of trial design functions is an important and necessary process. TRIAL REGISTRATION:Clinical Trials Information System EUCT number: 2023-509703-33-00; ClinicalTrials.gov identifier: NCT06184659; Universal Trial Number: U1111-1301-6379.
BACKGROUND:Pre-anaesthetic assessment is essential for safe perioperative care but is resource-intensive and applied variably in clinical practice. Increasing surgical demand and workforce constraints have prompted interest in alternative models, including digital approaches and AI-supported clinical decision support tools. However, limited knowledge exists on clinicians' perspectives, values, and perceived information requirements in relation to pre-anaesthetic assessment, including which information they consider essential prior to anaesthesia. METHODS:This international, cross-sectional survey aims to explore clinicians' perspectives on pre-anaesthetic assessment practices and their attitudes towards AI-supported clinical decision support tools. The survey will be conducted in two phases, beginning with Nordic centres before broader international expansion, using two linked instruments: an organisational survey completed once by a local site investigator at each site, and an individual survey completed by anaesthesia personnel recruited via site-based convenience sampling. The primary outcome is clinicians' perspectives on pre-anaesthetic assessment, comprising perceived importance, information not readily available from chart review considered essential prior to anaesthesia, and use in subsequent anaesthetic management; secondary outcomes include airway assessment practices and attitudes towards AI-supported tools, including willingness to adopt them. Exploratory outcomes include organisational workflows and time-use in pre-anaesthetic assessment. Responses will be summarised descriptively across clinician and organisational subgroups. CONCLUSION:This survey will provide an international overview of clinicians' perspectives on pre-anaesthetic assessment and its role in clinical decision-making. The findings may contribute to the development of more efficient, stratified, and clinically aligned assessment models while recognising that implementation of digital and AI-supported approaches will also depend on organisational, technical, ethical, legal, and patient-related factors.
BACKGROUND:There is limited high-quality evidence to guide haemodynamic and respiratory management during general anaesthesia. The goal of this trial was to test the feasibility of testing different ventilatory settings and blood pressure targets. Previous trials on blood pressure targets have suffered from poor adherence and limited between-group separation. This manuscript focuses on the overall feasibility, as well as blood pressure targets. METHODS:This was a multicentre, randomised, factorial, clinical trial conducted at eight hospitals in Denmark. 483 patients ASA 3-5, scheduled for major surgery under general anaesthesia, were included. Patients were randomised to a minimum mean arterial blood pressure (MAP) target of 60, 70 or 80 mmHg, or 90% of baseline systolic blood pressure. The primary outcomes focused on feasibility, while secondary outcomes included intra- and postoperative complications, hospital length of stay, quality of life and recovery and mortality. RESULTS:Out of 1690 eligible patients, 483 (29%) were randomised, below the goal of 50%. Separation in blood pressure was achieved and blood pressure during vasoactive treatment was within predefined target ranges. There was no difference in most of the postoperative outcomes. Some complications, including acute kidney injury (OR 4.74, 95% CI 1.17; 31.8) and cardiac arrhythmias (OR 8.13, 95% CI 1.35; 156), were more common in the MAP-80-mmHg group compared to the MAP-60-mmHg group. The MAP-80-mmHg group had fewer days alive and out of hospital within 30 days (median difference -1.88 days, 95% CI -3.50; -0.26). CONCLUSIONS:While not all feasibility goals were achieved, separation in blood pressure and adherence to targets were adequate. Larger trials are needed to determine the optimal blood pressure target during general anaesthesia. TRIAL REGISTRATION:Clinicaltrials.gov: NCT06047119.
BACKGROUND:Coagulopathy is a common complication in patients with sepsis, ranging from subclinical coagulation activation only seen in laboratory values to disseminated intravascular coagulation (DIC). Over the past 25 years, several scoring systems have been developed to diagnose coagulopathy and DIC in critically ill patients. However, the presence of multiple overlapping definitions, diagnostic criteria and numerous scoring systems adds complexity and poses challenges for clinical decision-making. OBJECTIVES:This scoping review aims to systematically map how coagulopathy and DIC in adult patients with sepsis are defined, diagnosed and managed, and to summarise risk factors and reported clinical outcomes. Knowledge gaps will be identified to inform future research and clinical practice. ELIGIBILITY CRITERIA:Eligible studies will include original clinical research of any design published from 1 January 1996 onwards reporting on coagulopathy or DIC in adult patients (≥ 18 years) with sepsis. Non-original articles (reviews, opinion pieces, editorials, guidelines, case reports, consensus statements) and conference abstracts will be excluded. We will only include studies published in English. SOURCES OF EVIDENCE:Searches will be conducted in PubMed, EMBASE, Web of Science and CENTRAL, and supplemented by reference list screening. CHARTING METHODS:Two reviewers will independently screen abstracts and full texts, and extract data in duplicate using a piloted extraction form. In case of disagreement, a third senior reviewer will adjudicate and make the final decision on study inclusion. Extracted information will include study characteristics, population details, diagnostic approaches, frequency of coagulopathy, management strategies and clinical outcomes, as well as contextual factors such as hospital settings and geographical origin. Results will be presented using descriptive statistics, tables and narrative summaries. A critical appraisal of the quality of the included studies will be conducted. CONCLUSIONS:This scoping review will provide a comprehensive overview of definitions, diagnostic methods, management patterns and reported outcomes of coagulopathy and DIC in adult patients with sepsis. The findings will clarify the current practice variation, highlight knowledge gaps and areas of uncertainty, and guide priorities for future research and clinical decision-making.
BACKGROUND:Epidural analgesia is widely used during labor, and postpartum nerve injury is an uncommon but clinically relevant outcome. Neurological symptoms after childbirth may be related to obstetric or anesthetic factors. Studies vary considerably in how postpartum nerve injury is identified, defined, assessed, and followed, limiting comparability and interpretation of findings. OBJECTIVE:To map the methodological approaches used to study postpartum nerve injury following epidural analgesia, including case identification strategies, diagnostic assessment methods, follow-up procedures, and reporting of obstetric and anesthetic attribution. METHODS:A scoping review will be conducted in accordance with the PRISMA-ScR framework. Studies reporting postpartum nerve injury in relation to epidural procedures will be identified through systematic database searching. Data will be charted on study design, exposure definitions, strategies for etiological attribution, outcome ascertainment, and follow-up methods. DISCUSSION:The scoping review aims to map how postpartum nerve injury has been defined, identified, assessed, and followed in the literature, as well as clarify methodological patterns and inconsistencies. The findings may inform future research by highlighting variation in methodology, reporting practices and terminology. Thereby indicating areas where more consistent approaches to neurological assessment, exposure reporting, and attribution of obstetric and anesthetic factors are needed.
BACKGROUND:Hip and knee replacement are common procedures with an increasing focus on same-day surgery. However, capacity constraints limit the number of eligible patients actually being scheduled for same-day discharge, calling for further selection of those with the highest likelihood of same-day discharge. METHODS:A prognostic study from September 2022 to April 2024 aiming to develop and evaluate three machine learning models of increasing complexity for prediction of successful same-day discharge after hip and knee replacement. Data was collected from six Danish departments with similar same-day surgery protocols and same-day surgery eligibility was according to predefined clinical criteria. The models were evaluated using receiver operating characteristic and clinical utility curves depicting the potential increase in same-day discharge at different same-day surgery capacities. RESULTS:Of 5387 eligible patients, 4466 (82.9%) were scheduled for same-day surgery. Of these, 3085 (69.1%) achieved same-day discharge and 1381 (30.9%) were admitted. The remaining 921 (17.1%) were planned as in-patients. The area under the receiver operating curve showed poor but marginally increasing predictive ability (0.586, 0.602, and 0.603, respectively). Mean probability for same-day discharge in scheduled same-day patients was significantly increased in discharged vs. admitted patients (69.90% SD: 7.6 vs. 67.03 SD: 8.3 p < 0.001), but not in admitted same-day versus planned in-patients (67.52% SD: 7.5 p = 0.14). The potential increase in same-day discharge at the current same-day surgical capacity of 82.9% of procedures was 2.2% but increased with lower capacities. CONCLUSIONS:Machine learning based prognostic probability scores for planning same-day hip and knee replacement in pre-selected eligible patients did not provide relevant potential increases in same-day discharge rates. EDITORIAL COMMENT:This study assessed if an advanced model using routinely available clinical data could confidently predict whether of not cases planned for same-day hip or knee arthroplasty would be successfully discharged as planned. Data from multiple collaborating fast-track surgical centers in Denmark contributed to the model. The advanced model here based on the available clinical data did not perform clearly better than other simpler predictive models that have already been reported.
BACKGROUND:The use of coercion or persuasion raises ethical challenges but may be justified when prehospital patients require immediate treatment and are unable to consent. This study aims to describe the characteristics of coerced or persuaded adult pre-hospital patients in the Region of Southern Denmark. METHODS:A descriptive analysis of ambulance contacts in the Region of Southern Denmark from January through June 2022. We identified all cases meeting the predefined inclusion criteria for coercion or persuasion, with or without police involvement. We classified cases into four categories: coercion (forced admission with police involvement), necessity or urgent need for treatment, persuasion with police involvement, and persuasion without police involvement. Additionally, we describe the study population's substance use, instances of self-harm, and the overall police involvement in managing these patients. RESULTS:Within 39,021 prehospital patient contacts, 6743 cases indicated that coercion or persuasion could have occurred. In 416 cases (1.1% of all prehospital contacts), coercion or persuasion was confirmed. Of these, 65 patients were forcibly admitted to the hospital. Forty-six patients received non-patient-sanctioned treatment justified by necessity or an urgent need. Fifty patients were persuaded with police involvement, and 255 were persuaded through paternalistic means without police involvement. The median age of the coerced patients was 56 years; 54.8% being men. 26.9% of patients subjected to coercion were under the influence of substances. 17.8% of all coerced patients exhibited self-harming behaviours, such as attempting suicide, self-harm, or suicidal thoughts. The police were involved in 31.5% of cases of coercion. CONCLUSION:Coercive measures or persuasion to consent were identified in a small proportion of prehospital contacts. When they occur, the most common form is persuasion without police involvement, but other forms of coercion are also observed. The study emphasises the need for greater attention to this issue to ensure the appropriate use of coercion and persuasion during emergencies. EDITORIAL COMMENT:This study presents experience from one region of Denmark with ambulance missions where the patient was uncooperative but needed acute medical care. Different approaches were commonly implemented in this circumstance, to try to minimise harm related to administering urgent or emergent care.
BACKGROUND:Peripheral nerve blocks (PNBs) are a cornerstone in postoperative pain management, reducing pain, opioid consumption, and opioid-related adverse effects. However, the duration of PNBs is limited and might result in rebound pain after block cessation. Dexamethasone, a synthetic glucocorticoid, when administered in addition to PNBs, prolongs block duration and might mitigate rebound pain. We assessed the effect of adjunct dexamethasone on pain after block cessation and rebound pain. METHODS:This is a substudy pooling data from two randomised, placebo-controlled three-arm clinical trials conducted between June 9, 2022 and May 17, 2023. Participants underwent osseous surgery of either the lower or upper limb under peripheral nerve block. Participants were allocated to dexamethasone (12 mg oral, 24 mg oral, or 12 mg intravenous) or placebo (oral or intravenous). The primary outcome was pain immediately after block cessation (Numerical Rating Scale, NRS, 0 to 10) and rebound pain (NRS ≥ 7 immediately after block cessation). RESULTS:Data from 159 participants were included. Fifty-six participants received placebo and 103 participants received dexamethasone. The median pain score after block cessation was 5.0 points (IQR 3.0 to 8.0) in the placebo group and 3.0 points (IQR 1.0 to 6.0) in the dexamethasone group. Rebound pain occurred in 20 of 56 participants (35.7%) in the placebo group and in 19 out of 103 participants (18.4%) in the dexamethasone group. Dexamethasone significantly reduced pain after block cessation (mean difference: -1.7 points, 95% CI: -2.6 to -0.8, p < 0.001) and the risk of rebound pain (risk ratio: 0.51, 95% CI: 0.30 to 0.88, p = 0.014) when compared to placebo. We found no association between patient satisfaction and rebound pain. However, the satisfaction measure exhibited a ceiling effect with most participants reporting maximum satisfaction and therefore the ability to detect a difference may have been limited. CONCLUSIONS:Dexamethasone reduced pain after block cessation and the risk of rebound pain when compared with placebo. EDITORIAL COMMENT:This study combined data from two randomised controlled trials, which included patients who underwent osseous surgery on either the upper or lower limb under peripheral nerve block. The trials investigated rebound pain and patient satisfaction. When administered intravenously or orally, dexamethasone reduces pain after block cessation and the occurrence of rebound pain. No significant difference in satisfaction scores was found between patients who received systemic dexamethasone and those who received a placebo.
BACKGROUND:Surgical stress response initiates a complex pathophysiological cascade that alters fluid distribution and intravascular volume. In elective total hip arthroplasty (THA), the perioperative blood loss is potentially substantial, a significant part of the loss being hidden caused by tissue extravasation, residual joint blood, and hemolysis. This far conventional methods to quantify blood loss rely on either visual estimation of bleeding or formulas based on hematological and/or anthropometric parameters, both of which are considered imprecise. Accurate assessment of perioperative blood volume changes may inform more individualized postoperative fluid therapy and improve postoperative outcomes. METHODS:The study design is a single-center prospective observational cohort study with enrollment of 25 patients undergoing elective THA in a standardized fast-track setting. Perioperative blood volume will be assessed using the carbon monoxide (CO)-rebreathing method, enabling quantification of total hemoglobin mass, red cell-, plasma-, and total blood volume. Bioimpedance spectroscopy will be used to evaluate fluid distribution between intra- and extracellular compartments, as well as total body water. Measurements will be performed preoperatively before surgery (baseline), at 6 h postoperatively, and at 24 h postoperatively when feasible. Demographic data, inflammatory markers, and data on perioperative fluid administration will also be collected. The primary outcome is change in total blood volume from baseline to 6 h postoperatively. Secondary outcomes include changes in hemoglobin mass, fluid compartment shifts, and their associations with postoperative orthostatic intolerance. DISCUSSION:By combining CO rebreathing and bioimpedance, our study applies accurate, minimally invasive methods not previously used in surgical patients to characterize blood loss and perioperative fluid shifts. Strengths include the standardized surgical setting, detailed protocol, and transparent statistical plan, whereas limitations include the observational design, minor sample size, and exclusion of patients with major intraoperative bleeding. CONCLUSION:The study will provide detailed information on the changes in perioperative blood volume and its association with orthostatic intolerance following THA. CO rebreathing may offer a precise alternative to conventional estimations of blood loss and contribute to the development of more individualized perioperative fluid management strategies in major orthopedic surgery.
BACKGROUND:The EuroQol EQ-5D-5L is recommended to assess health-related quality of life (HRQoL) in intensive care unit (ICU) survivors and included in many national ICU registries at the time of follow-up. While establishing baseline HRQoL in elderly ICU survivors is important for informing follow-up services, it is rarely performed in clinical practice. We aimed to compare pre-critical illness EQ-5D-5L scores with Norwegian general population norms in elderly adults. METHODS:We conducted a prospective multicenter observational study across five ICUs to assess pre-critical illness HRQoL in mechanically ventilated patients ≥ 65 years old using EQ-5D-5L. Data assessing HRQoL before critical illness were collected during the ICU stay, obtained primarily from proxies or via patient self-report where feasible. Response frequencies for the EQ-5D-5L dimensions, EQ-5D-5L index, and EQ VAS scores were compared with those for general population norms after random exact matching for age and sex. The five dimensions were dichotomized into the presence of health problems or not. RESULTS:Based on responses from 345 participants, the ICU population had a baseline mean EQ-5D-5L index of 0.78 (±0.24), an EQ VAS of 61 (±23), and 60 ICU patients reported no problems in any of the five domains. The norm population had a mean EQ-5D-5L index of 0.88 (±0.17), an EQ VAS of 79 (±20), and 107 had no problems in any of the five dimensions. Pearson chi-square or two-tailed t-tests showed significantly (p < 0.05) poorer scores for all EQ-5D-5L scores for the ICU population compared to the norm data. The greatest differences were found in the younger age group 65-72 years. Comorbidity was a strong independent predictor of baseline health status, whereas chronological age showed no significant association. CONCLUSION:Compared to the age- and sex-matched general population, the elderly ICU population had poorer HRQoL before critical illness occurred. To improve the interpretation of post-ICU assessments, baseline EQ-5D-5L should be assessed at ICU admission. The results highlight the need for studies in ICU patients that include HRQoL as part of a prospective study design. EDITORIAL COMMENT:This study presents pre-ICU quality of life scoring for older cases requiring mechanical ventilation. Compared to a matched non-ICU cohort, significant lower reported quality of life scoring was observed.
INTRODUCTION:The liver is essential for bacterial elimination, preventing intestinal bacteria from entering the systemic circulation, and for producing inflammatory cytokines. Glucocorticoids have been reported to exert heterogeneous effects on bacterial clearance in sepsis. Using a porcine model of gram-negative abdominal sepsis, we investigated how portal venous administration of budesonide, a glucocorticoid with extensive hepatic first-pass metabolism, affects hepatic bacterial and endotoxin elimination as well as the systemic inflammatory response, in comparison with systemic administration and no treatment. METHODS:The Portal Steroid-Sepsis (Sep-Port, n = 8) and Systemic Steroid-Sepsis (Sep-Syst, n = 8) groups were administered budesonide in the portal vein or systemically, followed by an E. coli infusion for 3 h in the portal vein. The Septic Controls (Sep-Ctrl, n = 8) received saline instead of budesonide. Non-septic Controls (NSep-Port, n = 3) were treated only with portal budesonide. Portal, arterial, and hepatic venous bacterial counts were analyzed hourly during the bacterial infusion. The levels of endotoxin and inflammatory cytokines were measured. RESULTS:There was no difference in hepatic/portal venous bacterial count ratios. However, the arterial and hepatic venous bacterial counts were higher in the Sep-Syst compared to Sep-Port group (p < 0.001 and p < 0.01, respectively), while microbiological findings were similar in the Sep-Port and Sep-Ctrl groups. Hepatic endotoxin elimination did not differ between the groups. IL-10 levels were higher in the Sep-Port compared to the Sep-Syst group at 1 h (p < 0.01), and IL-6 levels were lower in the Sep-Port compared to the Sep-Ctrl after the bacterial infusion (p < 0.05). CONCLUSIONS:In this experimental sepsis model, hepatic bacterial elimination was unaffected by portal or systemic budesonide, whereas systemic administration was associated with increased systemic bacterial levels. Endotoxin clearance was unaffected by budesonide. Portal budesonide elicited a more pronounced anti-inflammatory response compared to systemic administration. These findings suggest that hepatic exposure to budesonide may modulate the inflammatory response while limiting adverse effects on systemic bacterial clearance. EDITORIAL COMMENT:Glucocorticoids are widely used in sepsis management, yet their effects on bacterial clearance is incompletely understood. In this porcine model of gram-negative abdominal sepsis, portal venous delivery of budesonide (which has ~90% hepatic first-pass metabolism) preserved bacterial elimination and enhanced the early anti-inflammatory response, without the increase in systemic bacterial levels seen with systemic administration. These results demonstrate that route of delivery as a potentially important determinant of the risk-benefit balance of glucocorticoid therapy in sepsis, and support further investigation of hepatic-targeting strategies.
BACKGROUND:Pain is common in intensive care unit (ICU) patients with up to one-third experiencing pain at rest and even more during mobilization and clinical procedures. This survey aimed to explore physicians' attitudes and preferences regarding pain management in adult ICU patients in the Nordic countries. METHODS:We conducted an electronic survey targeting physicians working regularly in an ICU in the Nordic countries: Denmark, Finland, Iceland, Norway and Sweden. The survey focused on pain assessment, pharmacological treatments, and post-discharge follow-up of adult ICU patients. RESULTS:The survey was distributed to 606 physicians, and 360 responses were received (overall response rate 59%). Respondents were primarily from Denmark, with only a few respondents from the remaining Nordic countries. Most respondents were specialists in anesthesiology working in mixed ICUs in public specialist hospitals. Standardized pain assessment tools were widely used in non-sedated patients, while only half of respondents employed standardized pain assessment tools in sedated patients. Respondents reported that pain was assessed multiple times daily in both non-sedated and sedated patients. Daily wake-up calls in sedated patients were considered important by almost all respondents. Morphine was the preferred opioid for oral- and intravenous bolus administration, while remifentanil was preferred for intravenous continuous administration. However, preferences varied across countries with regard to both opioid- and non-opioid analgesics. Nearly half of respondents expressed concerns regarding the development of opioid-induced hyperalgesia. Methadone was the most frequently preferred drug for opioid weaning, although preferences varied between countries. Most respondents acknowledged the importance of ICU-follow up programs, but only about half of respondents reported that their ICU currently offered a follow-up service. CONCLUSION:This Nordic survey explored ICU physicians' attitudes and preferences regarding pain management in adult ICU patients. Respondents reported assessing pain frequently, employing standardized pain assessment tools primarily in non-sedated patients. Daily wake-up calls in sedated patients were generally perceived as important. Interestingly, preferences regarding opioid- and non-opioid analgesics varied between Nordic countries. ICU-follow up programs were recognized as important but were not consistently implemented. Despite a high overall response rate, the generalizability of our findings is impaired by limited participation in most Nordic countries except Denmark. EDITORIAL COMMENT:This survey describes the physician perspective on predominantly pharmacological pain management in selected ICUs within the Nordic countries.
BACKGROUND:Intermediate-high risk pulmonary embolism (PE) represents a clinically challenging subgroup of acute PE, characterized by right ventricular dysfunction and increased risk of hemodynamic deterioration despite treatment with anticoagulation therapy. Although systemic thrombolysis may provide more rapid reperfusion, its use is limited by an increased risk of major bleeding. Catheter-based treatment strategies have emerged as potential alternatives, but their comparative efficacy and safety remain uncertain. OBJECTIVE:To assess the benefits and harms of catheter-based treatment strategies compared with contemporary control regimens, including standard anticoagulation with or without systemic thrombolysis, in patients with intermediate-high risk PE. METHODS:This protocol outlines a systematic review with Bayesian pairwise meta-analysis and network meta-analysis of randomized clinical trials evaluating catheter-based therapies for hospitalized patients with intermediate-high risk PE. Eligible interventions include catheter-directed thrombolysis, ultrasound-assisted thrombolysis, and catheter-based embolectomy. Comparators may include standard anticoagulation alone or in combination with systemic thrombolysis or other active control regimens reflecting standard of care. Searches will be conducted in relevant databases, supplemented by trial registries. Two reviewers will independently screen studies, extract data, and assess risk of bias using the Cochrane Risk of Bias 2 tool. Bayesian pairwise meta-analyses and network meta-analysis will be performed using weakly informative priors to synthesize direct and indirect evidence across interventions. Results will be reported as posterior effect estimates with 95% credible intervals. The primary outcome will be all-cause mortality. Secondary and exploratory outcomes include major bleeding as defined according to the criteria of the International Society on Thrombosis and Haemostasis within 7 days, hospital length of stay, and change in RV/LV ratio within 48 h. GRADE assessments will be performed where applicable. DISCUSSION:This review will synthesize direct and indirect randomized evidence on catheter-based treatment strategies for intermediate-high risk PE. The findings may help clarify the role of these interventions in contemporary management, inform future guideline recommendations, and identify persistent evidence gaps requiring further large-scale randomized trials.
BACKGROUND:Hemodynamic management after out-of-hospital cardiac arrest (OHCA) is critical, yet the impact of vasopressor-driven mean arterial pressure (MAP) targets on pulmonary circulation and right ventricular (RV) function remains unclear. METHODS:In this substudy of the randomized, double-blinded BOX trial, comatose OHCA survivors were allocated to low (63 mmHg) or high (77 mmHg) MAP targets. Pulmonary artery catheters (PAC) were used for serial hemodynamic assessment for 48 h after Intensive Care Unit admission. The primary endpoint was calculated pulmonary vascular resistance (PVR), secondary endpoints included pulmonary capillary wedge pressure (PCWP), pulmonary artery pulsatility index (PAPi), and RV cardiac power output (RV-CPO)-a measurement of RV pumping function. RESULTS:Among 730 included patients (median time randomization to PAC insertion 1.3 h), mPAP was consistently higher in the high-MAP group (mean difference 1.11-1.71 mmHg, 95% CI range 0.12-2.59). Calculated PVR was transiently lower in the high-MAP group during the first 24 h (mean difference -0.16 to -0.30, 95% CI range -0.31 to 0.11), before converging between groups. RV-CPO was lower in the low-MAP group throughout the observation period (mean difference 0.01-0.04 W [95% range 0.00-0.07], with the largest difference at 48 h. PCWP decreased in both groups but was significantly lower in the low-MAP group during the first 12 h (mean difference 1.06-1.40 mmHg, 95% CI range 0.25-2.38). CONCLUSIONS:In comatose OHCA survivors, targeting a higher MAP increased pulmonary artery pressures, PCWP, RV-CPO, heart rate, and cardiac output. The proportionally greater increase in cardiac output over pulmonary artery pressures resulted in a decreased calculated PVR. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT03141099. EDITORIAL COMMENT:In this secondary analysis of a subgroup in the BOX out of hospital cardiac arrest treatment trial for oxygen level targets, blood pressure treatment target levels, higher or lower were analyzed, including central circulatory outcomes, using a pulmonary artery catheter. The higher blood pressure target group had accompanying higher pulmonary artery pressures and cardiac output, with initially a small reduction in calculated pulmonary vascular resistance.
BACKGROUND:Obesity in pregnancy increases obstetric and anaesthetic risk. Although early neuraxial access is frequently recommended for parturients with high BMI, the evidence base is limited, and national implementation has not been investigated. We aimed to describe current Danish practise regarding 'early labour epidural' for parturients with high BMI. METHODS:We conducted a national cross-sectional survey of the head of obstetric anaesthesiology at all 22 Danish hospitals with labour units (November 2024) with a 100% response rate. The questionnaire covered definitions, organisation, assessment, and management of 'early labour epidural'. Demographic context (2014-2024) was obtained from the Danish national Birth Register. Time trends in BMI > 40 kg/m2 prevalence and epidural use among parturients with BMI > 40 were analysed by binomial logistic regression using aggregated yearly counts. RESULTS:From 2014 to 2024, the proportion of parturients with BMI > 40 kg/m2 increased from 1.4% to 1.9%, while epidural use in this group rose from 42% to 58% (both p < 0.0001). Most departments defined 'high BMI' as > 40 kg/m2, but thresholds varied. Local guidelines existed in 64%, and 86% reported routine antenatal anaesthetic assessment. Written patient information was provided at 17% of centres. Definitions of 'early labour epidural' differed, and 32% reported no formal definition. A written departmental guideline was present in 68%. Ultrasound for epidural placement was used routinely in 10% and selectively in 60%, while antenatal lumbar ultrasound was performed in 32%. Test dosing, maintenance regimens, and intrapartum management strategies varied widely. CONCLUSION:In Denmark, management of 'early labour epidural' for parturients with high BMI varies considerably regarding definitions, antenatal assessment, and intrapartum practise. This variation persists despite an increasing prevalence of obesity in pregnancy and a rising use of epidural analgesia. Our findings provide an overview of current national practise and highlight areas where further evidence and consensus are needed, including the development of evidence-based national standards. EDITORIAL COMMENT:This national Danish survey identified substantial variation in the management of early labour epidurals for women with high BMI, where there are increasing obesity rates and epidural use. The findings reveal a clear evidence-practice gap and support the need for national, evidence-based guidelines. Strengths include complete national participation (100% response rate), use of registry data for clinical context, and responses reflecting institutional practice. Limitations include reliance on self-reported data, lack of patient outcome measures and limited generalisability beyond Denmark.
BACKGROUND:Acute kidney injury (AKI) is frequent and influences the prognosis of intensive care unit (ICU) patients. AKI may be categorised as contrast-associated AKI (CA-AKI). We investigated the development of CA-AKI, including temporal and dose-response relationships. METHODS:Adult patients admitted between 2010 and 2015 with a minimum ICU stay of 54 h were eligible for inclusion. AKI was scored on an hourly basis to enable temporal analyses. CA-AKI was defined as an increase in Kidney Disease: Improving Global Outcomes (KDIGO) AKI stage occurring within 48 h of contrast media administration. For the matched analysis, contrast-exposed patients were matched to unexposed patients on duration of stay and renal function. RESULTS:Of 1057 patients, 277 patients were exposed to contrast media. Sixteen percent (n = 43) developed CA-AKI (KDIGO AKI stage 1/2/3: 63%/23%/14%). AKI preceded contrast in 76.2% of cases (95% confidence interval [CI]: 66%-85%, p < 0.001). After contrast exposure, AKI reversal occurred in 65 cases. The proportion of CA-AKI was similar between dose quartiles (p = 0.746). The length of ICU stay (length of stay [LOS]) was longer in the exposed group (10.9 vs. 5.5 days, p < 0.001) regardless of CA-AKI status. In the matched analysis, exposed patients had longer remaining LOS (mean difference 1.47 days, 95% CI: 1.35-1.60) and higher ICU mortality (OR: 1.67, 95% CI: 1.1-2.6), but use of renal replacement therapy (RRT) was similar. CONCLUSIONS:CA-AKI was observed in one of six ICU patients exposed to contrast media and associated with higher mortality and ICU LOS. However, AKI most often precedes contrast. AKI reversal was more common than AKI following exposure. No clear evidence of a dose-response relationship was found. The findings question whether AKI in an ICU population is related to contrast media exposure, but the observational design precludes ruling out contrast media as a cause of AKI. EDITORIAL COMMENT:This ICU cohort analysis presents kidney injury findings where there is intravenous contrast exposure. Where some kidney injury was sometimes present before contrast exposure, this makes exploring the relation of contrast to injury and recovery more complex.
BACKGROUND:Acute kidney injury (AKI) is common in the intensive care unit (ICU) and associated with increased mortality. While diuretics are widely used to manage fluid accumulation, their impact on survival in established AKI remains uncertain. METHODS:This retrospective cohort study included adult ICU patients with AKI present on or within 48 h of ICU admission in the Capital Region of Denmark, 2022-2024. Early diuretic exposure was defined as systemic diuretic administration within 24 h after AKI onset. Primary outcome was 30-day mortality, analyzed using 24-h landmark Cox regression adjusted for sex, Simplified Acute Physiology Score 3 (SAPS 3), baseline creatinine, and AKI stage. Pre-specified subgroup analyses by AKI stage and post hoc sensitivity analyses were performed. Secondary outcomes included fluid accumulation (> 5% ideal body weight) and Major Adverse Kidney Events within 30 days (MAKE30). RESULTS:Of 4430 patients with AKI, 58% received early diuretics. In the primary adjusted analysis, early diuretics were not associated with 30-day mortality (hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.98-1.26, p = 0.113). In a post hoc time-dependent sensitivity analysis, diuretic use was associated with higher mortality (HR 1.27, 95% CI 1.08-1.49, p = 0.004). In the pre-specified AKI stage 3 subgroup, early diuretic use was associated with a higher risk of mortality (HR 1.42, 95% CI 1.16-1.73, p < 0.001). Diuretics were associated with a lower risk of fluid accumulation (odds ratio (OR) 0.58, p < 0.001) but a higher risk of MAKE30 (OR 1.23, p = 0.004). CONCLUSION:Early diuretic treatment was frequent but not associated with improved survival in the primary analysis. Given the observational design, causal relationships cannot be inferred from these findings. These results do not support routine early diuretic use in unselected AKI patients; prospective studies are needed to clarify the role of targeted diuretic therapy in patients with fluid accumulation. EDITORIAL COMMENT:This retrospective cohort analysis analyzes associations between acute renal injury development in intensive care unit patients and early diuretic use, along with fluid balance. Early diuretic use was not associated with improved survival in this cohort, where treatments were uncontrolled. Risks are described by renal injury severity subgroups and renal outcomes after ICU.
