Abstract 1

(1)

Abstract 1

Korresponderende forfatter *

Peter Martin Hansen

Email * peter.hansen@ph.rm.dk

Afdeling * Den Landsdækkende Akutlægehelikopter

Hospital/institution

*

Præhospitalet, Region Midtjylland, Aarhus

Medforfattere Christian Juul Terkelsen, Ingunn Skogstad Riddervold, Lars Knudsen

Overskrift * Heliport proximity is crucial in reducing treatment delay in patients with ST-elevation myocardial infarction transported by helicopter - HELIPROXY STUDY

Tekst Introduction:

Since 2014, HEMS (Helicopter Emergency Medical System) has been an integrated part of the emergency medical system, providing fast and high-competence helicopter transport of patients to highly specialized care. Different heliport solutions at the receiving hospitals may have an impact on the time delay from landing to treatment (LTT). In this study, we compared the time delay from landing to arrival at the catheterization laboratory in patients with ST Elevation Myocardial Infarction (STEMI) accepted for primary Percutaneous Coronary Intervention (pPCI) at one of the four PCI centers in Denmark. We hypothesized that heliport proximity strongly influence the LTT.

Methods:

We prospectively recorded the time from the landing at the heliport to arrival at the catheterization laboratory, at the four PCI-centers, from October 1st 2014 to December 31st 2016 in all STEMI patients transported by HEMS Denmark.

LTT was compared between two PCI center with heliports at the hospital, and two centers with heliport at distance from hospital which necessitated ground transportation in ambulance.

Results.:

1163 patients were included in the study. 310 were excluded due to missing data. The two hospitals with hospital based heliports showed shorter LTT (5 ± 2.18 and 6 ± 2.94) compared to the two hospitals with heliport outside the hospital (9 ± 3.94 and 12 ± 3.49, p<0.001).

Discussion:

The results of this study demonstrates the importance of heliport proximity in reducing LTT in STEMI patients. In Denmark, the Government has planned a multi-billion upgrade of the university hospitals including new locations.

Many essential investments in logistics and pending renewals at the older units have been cancelled or postponed.

That is also the case of heliports in at least to of the university hospitals. However, due to delays in the new units, the current solution for time-critical patients is sub-standard. Near-fatal incidents have been reported due to insufficient landing sites. The higher LTT at the suboptimal heliports can be calculated to flying distance, suggesting that a very expensive HEMS system is not fully utilized due to the economic challenges that the Danish National Health System is facing presently. But from a professional point of view, it seems irrational that reluctancy towards relatively small investments compromises the chain of survival in time-cri tical patients and renders a HEMS organization with very high ambitions with a difficult task.

Conclusion: Hospital based heliports ensures shorter time delay from landing to pPPCI in patients with STEMI. We strongly recommend that heliports are located close to the treating facility. Transfer from landing site to hospital by ground ambulance seems unfeasible in time critical patients.

(2)

HELIPROXY RESULTS

OUH RH SKS AAUH

Assessed 201 453 426 83

Included 157 326 319 51

% 78.11 71.96 74.88 61.45

Heliport -> Sgh Median 9 ± 3.94 5 ± 2.18 6 ± 2.94 12 ± 3.49

Patient Time Median 50 ± 14.98 43 ± 25.25 48 ± 14.18 64 ± 14.70

LTT Median 9 ± 3.94 5 ± 2.18 6 ± 2.94 12 ± 3.49

Mission Total Median 137 ± 46.44 106 ± 56.65 123 ± 28.07 148 ± 31.99

(3)

Abstract 2

Rasmus Ejlersgård Christensen

Email * rasmus.ejlersgaard.christensen@regionh.dk Afdeling * Anæstesi- og operationsklinikken og Traumecentret

*

HovedOrtoCentret, Rigshospitalet

Medforfattere Rasmus E. Christensen, Josefine Stokholm Bækgaard, Trine G. Eskesen, Jacob Steinmetz, Lars S.

Rasmussen

Overskrift * Hvornår fjernes halskraven hos traumepatienter, hvis den kliniske undersøgelse er usikker?

Introduktion: Hos traumepatienter anvendes stiv halskrave for at stabilisere columna cervikalis, selvom dette kan medføre en række ulemper. Halskraven kan ofte fjernes efter klinisk undersøgelse, men hvis denne er usikker, må man afvente billeddiagnostik.

Formålet med studiet var at undersøge, hvor lang tid der går, før halskraven fjernes hos traumepatienter med en usikker klinisk undersøgelse samt årsagerne hertil. Desuden ville vi undersøge forekomsten af mulige komplikationer til brug af halskrave.

Metode: I et prospektivt studie inkluderede vi i perioden fra februar til juni 2017 patienter med anlagt stiv halskrave, hvor den kliniske undersøgelse af cervikale columna var usikker. Den primære analyse fokuserede på tiden fra ankomst til traumecenter til fjernelse af halskraven. Vi registrerede desuden tiden fra ankomst til CT-scanning og komplikationer under indlæggelsen. Undersøgelsen var godkendt af Datatilsynet, mens etisk komite besluttede, at projektet ikke krævede deres godkendelse.

Resultater: Vi inkluderede 57 patienter med en median alder på 47 år. Af disse havde 41 patienter (71,9 %) væsentlige skader, flest svarende til thorax (38,6 %) eller ekstremiteter (33,3 %).

Mediantiden fra ankomst til fjernelse af halskraven var 49 minutter (interkvartil range (IQR): 39-68). Vi fandt en positiv korrelation mellem injury severity score (ISS) og tid til fjernelse af halskraven (P=0,009).

De hyppigste årsager til usikker klinisk undersøgelse var sedation (24,6 %), smerter som følge af distraherende skader (22,8 %) og forgiftning (14 %). CT-scanning blev brugt til at udelukke skader på columna cervikalis hos alle patienter, og mediantiden fra ankomst til CT-scanning var 17,5 minutter (IQR: 14-22). Ingen blev MR skannet.

Hos 18 af patienterne (31,6 %) opstod en eller flere komplikationer potentielt relateret til halskraven under indlæggelsen, og dette omfattede behov for mekanisk ventilation (28,1 %), infektioner (19,3 %) og forhøjet

intrakranielt tryk (12,3 %). I alt 9 patienter (15,8 %) døde på hospitalet primært på baggrund af svære hovedtraumer.

En patient havde forbigående neurologiske symptomer, men ingen fik permanente neurologiske skader.

Diskussion: Vi fandt, at CT-scanning blev brugt til at udelukke læsioner i columna cervikalis i de tilfælde, hvor den kliniske undersøgelse var usikker. Halskraven kunne fjernes hos flertallet inden for 1 time. Hos patienter med høj ISS var halskraven anlagt længere tid, formentlig fordi initiale behandling tog længere tid.

Det er en begrænsning, at de neurologiske følger ikke kunne vurderes hos patienter, der afgik ved døden, men ingen patienter havde objektive symptomer på neurologiske skader i columna cervikalis.

Konklusion: Hos traumepatienter, hvor klinisk undersøgelse af columna cervikalis var usikker, blev en anlagt halskrave fjernet hos flertallet indenfor 1 time på baggrund af CT-scanning.

(4)

Nina Buch

Email * nina.buch@clin.au.dk Afdeling * Operation og Intensiv Syd

*

Aarhus Universitetshospital

Medforfattere Nanna Finnerup, Erisela Qerama, Lone Nikolajsen

Overskrift * Neuromas as the cause of neuropathic pain in amputees?

Tekst

Background and aims:

Post-amputation pain is highly prevalent but remains a challenging condition to treat. Peripheral nerve injury caused by accidental or surgical trauma (e.g. after amputation) may lead to the formation of neuromas. These neuromas can be painful, especially due to pressure from prosthetic devices. However, the association between neuromas and neuropathic pain in amputees is not fully understood. This ongoing study examines whether neuromas are more frequent in patients experiencing pain after amputation than in patients without pain.

Methods:

In this observational cohort study, 80 patients with amputation will be recruited. Patients will undergo an interview (cause of amputation, duration of pain, and type of pain: phantom pain, phantom sensations, and residual limb pain), answer pain questionnaires and go through a clinical examination. This examination includes testing of sensory abnormalities including allodynia and hyperalgesia within the area of spontaneous pain. Neuromas are identified using high resolution (6-18MHz) ultrasound by an investigator blinded to the patient’s history of pain. Elastography and cross sectional areas of the neuromas are measured with ultrasound, and pressure pain thresholds are measured by a hand-held pressure algometer.

Results:

Patient inclusion is ongoing. At present, 45 amputees have participated in the study: 29 males and 16 females, aged 25-84. 32 patients had lower extremity amputations and 13 had upper extremity amputation. 73% amputees had one or more than one neuroma. 21 patients suffered from either persistent phantom pain or attacks of phantom pain. 16 patients suffered from stump pain and 11 patients were pain-free. As shown in figure 1, no significant difference was seen in the prevalence of stump pain, intermittent phantom pain, and persistent phantom pain when comparing patients with and without ultrasound-verified neuromas. A very high percentage of patients were experiencing sensory abnormalities including hypo- or hyperesthesia. 21 patients had hyperalgesia and 12 patients had allodynia.

Figure 2 shows the percentage of patients with and without neuromas experiencing sensory abnormalities, hyperalgesia, and allodynia.

Conclusion:

Preliminary data show no association between the occurrence of neither stump nor phantom pain and the presence of neuromas at the amputation site. Sensory abnormalities, pinprick hyperalgesia, and brush- and/or cold-evoked allodynia are common findings at the site of the stump, regardless of the occurrence of neuromas. Hopefully, this study will increase our understanding of the role of neuromas in patients with pain after peripheral nerve injury and amputation.

(5)

Fig. 1

Fig. 2

(6)

Nikolaj Rongsted Milandt, MD

Email * Nikolaj.Rongsted.Milandt@rsyd.dk

Afdeling * Department of Anesthesia and Intensive Care Medicine

*

Kolding Hospital, Sygehusvej 24, DK-6000 Kolding

Medforfattere Rasmus W Hauritz, MD

Overskrift * Anesthesia strategies for internal fixation of distal radial fractures in adults - A retrospective comparison of postoperative outcomes

Tekst Introduction

Distal radial fractures (DRF) are common in adults, especially among the elderly. Osteosynthesis (OS) with internal fixation is often necessary for acceptable orthopedic outcomes. To ensure surgical anesthesia, several strategies are available: Most common is ultrasound guided regional anesthesia (UGRA) of the brachial plexus, either alone or in combination with sedation or general anesthesia (GA).

If GA is chosen, alone or combined with UGRA, a period of postoperative observation in a post-anesthetic care unit (PACU) is mandatory to monitor vital organ function and postoperative pain and nausea. At our department, patients are eligible for return to the surgical wards if they are sufficiently awake, free of nausea and with pain scores NRS < 3 (Numeric Rating Scale). In this retrospective study of patients with DRF, we aimed to investigate if OS done by UGRA compared to GA resulted in reduced postoperative pain, nausea or stay in the PACU.

Method

We reviewed the Danish Anesthesia Database (DAD), identifying adult patients (age >= 18 years) receiving DRF OS at Kolding Hospital, Denmark from February 2015 to May 2017. Patients were excluded if they received regional anesthesia apart from brachial plexus blocks (n = 14) or had PACU observation periods exceeding 300 minutes (n = 2).

All nerve blocks were single-shot UGRA procedures performed or supervised by skilled regional anesthetists prior to surgery. All types of GA were included in the analysis.

Patients were grouped into a UGRA only (n = 68), UGRA+GA (n = 300) or GA only group (n = 81). The observation period in the PACU (PACU time, minutes), maximal postoperative nausea score (0-3) and pain scores (NRS 0-10) were reviewed in DAD. Patients returning to the ward immediately following surgery was assigned an observation period of 0.

Results

We included 449 cases of DRF OS, 78% were female, median age 65 years. The majority was anesthetized with a UGRA+GA approach. Infraclavicular UGRA technique was dominating (65%). The UGRA group had significantly reduced PACU time when compared to the GA groups (median 0 vs. 60 and 66 min, p < 0.001). This reduction was affected by eligibility for immediate discharge to the ward in 79% of patients. Postoperative nausea scores were significantly lower in the UGRA group when compared to UGRA+GA. Opioid-demanding pain (NRS > 3) was significantly more frequent in the GA group.

Discussion

For short PACU stay with low incidence of nausea and pain, we found surgical anesthesia with UGRA alone superior to GA or combination techniques. Patients with DRF scheduled for OS is likely to benefit from less nausea, pain and a short PACU stay. However, prospective studies are needed to verify long term outcomes and whether reduced PACU time can benefit the hospital organization.

(7)

Conclusion

Adult patients given UGRA as only surgical anesthesia for OS of DRF had shorter observation periods in a PACU and less nausea and pain compared to patients receiving GA.

(8)

Anton Lund

Email * antonlund2@gmail.com Afdeling * Neuroanæstesiologisk Klinik

*

Rigshospitalet

Medforfattere Mette B. Damholt, Jørgen Wiis, Ditte G. Strange, Kirsten Møller

Overskrift * Intracranial pressure during renal replacement therapy in patients with acute brain injury

Tekst

Background: Dialysis disequilibrium syndrome (DDS), a severe neurological complication of hemodialysis, may result in cerebral edema and intracranial hypertension. Patients with pre-existing acute brain injury are likely at increased risk.

We examined intracranial pressure (ICP) during renal replacement therapy (RRT) in this patient population.

Materials and methods: Patients with acute brain injury treated with intermittent RRT (IRRT) or continuous RRT (CRRT) while undergoing ICP monitoring were examined in a retrospective cohort. Data were collected during each patients’

first session of RRT, where the risk of DDS is theoretically at its highest. Area under the curve divided by time (AUC/t) for ICP was calculated before and during dialysis.

Results: Thirteen patients, 9 undergoing CRRT and 4 undergoing IRRT, were included. During RRT, ICP increased from a baseline of 11.9 mmHg (median; interquartile range 6.3-14.7) to a maximum of 21 mmHg (18-27) (p = 0.0024), and AUC/t for ICP was greater during dialysis (15.2 (13.4-18.8) vs. 11.7 mmHg (6.4-15.1), p = 0.042). The increase was independent of dialysis modality, but occurred earlier in patients treated with IRRT compared to CRRT (75 (30-90) vs.

375 min (180-420) after start of treatment, p = 0.0095). The maximum increase in ICP during RRT was correlated to plasma urea concentration before start of treatment (Spearman’s r = 0.69, p = 0.017).

Conclusion: RRT is associated with increased ICP in neurocritically ill patients, and the magnitude of the increase is related to initial plasma urea levels.

(9)

Abstract 6

Anders Peder Højer Karlsen

Email * andersphkarlsen@gmail.com Afdeling * Anæstesiologisk Afdeling

*

SUH Køge

Medforfattere Jørgen B. Dahl, Ole Mathiesen

Overskrift * Less bias and larger trial sample size on the horizon for postoperative pain management research after total hip and knee arthroplasty

The established evidence in postoperative pain management after total hip and knee arthroplasty is flawed by bias and small trial sample sizes. These factors can create imprecise and exaggerated treatment effect estimates. Each of the seven Cochrane bias domain can individually exaggerate positive intervention effects. To avoid this CONSORT guidelines and Cochrane Collaborations bias recommendations were developed. Unfortunately, not all trials adhere to these standards.

We investigated the development of risk of bias and trial sample size over time to detect recurrent issues impeding fulfilment of these contemporary quality standards.

Methods:

This is a post-hoc analysis of 171 trials from two systematic reviews of randomised controlled trials that investigated the procedure-specific evidence of all postoperative pain-relieving interventions after total hip or knee arthroplasty (Ref. 1). The co-primary outcomes were developments in risk of bias over time and trial sample size. For each trial a cumulated bias score ranging from 0-14 was calculated based on the seven Cochrane bias domains.

Results:

Included trials were published from 1989 to 2016. In this period the mean cumulated risk of bias score declined from 6.0 to 2.5. Primary bias domains improved significantly (Fig. 2). The percentage of high domains decreased

significantly, while the number of low domains increased.

The proportion of trials at unclear or high risk of bias in the time period 1990-1999 compared with 2010-2016 changed from 68% to 21% for random sequence generation, from 91% to 59% for allocation concealment, from 77% to 41% for blinding of participants and personnel, from 50% to 27% for blinding of outcome assessors, from 23% to 19% for incomplete outcome data, from 14% to 18% for selective outcome reporting and from 32% to 28% for other bias.

The mean total trial sample size increased from 48 to 87 patients (Fig. 2).

The risk of sample size bias was high (<50 patients) in 58 trials, moderate (50 to 199 patients) in 109 trials, lower (200- 499 patients) in 3 trials, and low (≥ 500 patients) in 1 trial.

Discussion:

Our finding are reflected in a review of 20.920 trials in the general research literature (Ref. 2).

Evidence suggest that trials including 50-99 participants report 34% larger intervention effects compared with trials including >1000 participants, probably due to publication bias (Ref. 3). Thus, we have not reached the goal for trial sample size yet.

Conclusion:

Measures to reduce bias have improved through the years especially for randomisation, allocation and blinding, but

(10)

up-scale trials could reduce the risk of overestimated intervention effects.

Ref. 1: Karlsen et al. doi: 10.1016/j.pain.0000000000000003 Ref. 2: Dechartres et al. doi: 10.1136/bmj.j2490.

Ref. 3: Dechartres et al. doi: 10.1136/bmj.f2304

(11)

(12)

Stine Estrup

Email * sed@regionsjaelland.dk Afdeling * Anæstesiologisk afdeling

*

Sjællands Universitetshospital, Køge

Medforfattere Cilia KW Kjer, Frederik Vilhelmsen, Lone Museaus Poulsen, Ismail Gøgenur, Ole Mathiesen

Overskrift * Cognitive function three months after intensive care – a prospective cohort study

Studies have shown impaired cognitive function after Intensive Care Unit (ICU) discharge affecting significant aspects of life for both patients and their families, including institutionalization, independency and mortality. We aimed to describe long-term cognitive functions in a Danish cohort of patients who had been treated in an ICU.

Methods

We conducted a prospective cohort study of all adult patients admitted for more than 24 hours in the period of February 1st 2016 to January 31st 2017 at the ICU, Zealand University Hospital, Koege.

Exclusion criteria were severe dementia, inability to communicate in Danish (including aphasia, deafness or severe brain damage), moribund or actively psychotic patients, transferal to another ICU, and patients living outside the Region of Zealand.

Three months after discharge, a home visit took place and the patients were tested with Repeatable Battery for the Assessments of Neuropsychological Status (RBANS), Chelsea Critical Care Physical Assessment Tool (CPAx), Short Form Health Survey (SF 36) and Hospital Anxiety and Depression Scale (HADS). Information about use of medication and healthcare since hospital discharge was recorded. The results of CPAx, SF36 and HADS are reported in a following paper.

Results

A total of 504 ICU admissions, with 444 patients, were screened, 161 patients were included and 79 home visits took place. Median age was 70 (IQR 63-76) yrs., 55% was male and 35% were surgical patients.

The mean RBANS score was 67 (SD 21), compared to an age corrected normal value of 100 (SD 15). We examined protective and risk factors using multiple linear regression (Table 2) and found protective associated effects of being employed before admission (p=0.005) and being admitted to ICU from a surgical ward (p=0.019).

Discussion

We found a RBANS score that was two standard deviations below normal level, corresponding to the cognitive function of patients with mild Alzheimers disease. As we do not know the pre-admission cognitive level of these ICU patients, results should be interpreted carefully.

Conclusion

In this prospective cohort study, we found reduced cognitive function three months after discharge from the ICU and that surgical admission and pre-admission employment was associated with a better cognitive function.

(13)

(14)

Stine Estrup

Email * sed@regionsjaelland.dk Afdeling * Anæstesiologisk afdeling

*

Sjællands Universitetshospital, Køge

Medforfattere Cilia KW Kjer, Frederik Vilhelmsen, Lone Musaeus Poulsen, Ismail Gøgenur, Ole Mathiesen

Overskrift * Physical function and actigraphy in intensive care survivors – a prospective cohort study

Impaired physical function after treatment in the Intensive Care Unit (ICU) affecting long term outcome and mortality has been demonstrated. Early mobilization in the ICU has shown a positive effect on outcomes. We wanted to study the association between level of activity in the ward after discharge from ICU and the physical function at three- month follow-up.

Methods

We conducted a prospective cohort study of all adult patients admitted for more than 24 hours in a one-year the period at the ICU, Zealand University Hospital, Koege. The present study is a sub-study on these patients from September 21st 2016 to January 31st 2017. Exclusion criteria for the main study were severe dementia, inability to communicate in Danish, moribund or actively psychotic patients, transferal to another ICU, and patients living outside the Region of Zealand. For this sub-study, we also excluded paralyzed patients. Included patients were equipped with an Actigraph (Ambulatory Monitoring Ardsley, NY, USA) at discharge from ICU and monitored for 7 days at the ward or until death or discharge from hospital. At discharge from the ICU and at the three months post-discharge home visit, patients were tested with the Chelsea Critical Care Physical Assessment Tool (CPAx).

Results

We screened 66 patients for inclusion. Forty-one patients completed the actigraphy measurement. A total of 19 patients were available for follow up visit at three months and were included in the analyses. Mean (SD) age were 72 (10) years, 59% were males and 36% were admitted from a surgical ward (Table 1).

The CPAx increased significantly from ICU-discharge, median (IQR): 31 (23-41) to follow-up, 47 (44-49), p<0.0001.

Seventeen of nineteen patients improved CPAx level over time (Fig. 1). The maximum reference CPAx level is 50. We found a negative association between actigraphy measured activity and change in CPAx; (regression slope estimate pr.

1000 activity counts pr. day: -0.10 (-0.18; - 0.01), p=0.028).

Discussion

In this sample of 19 patients, we found that nearly all had improved their physical function from ICU discharge to 3 months after ICU treatment. The few that did not improve, kept their high functional score. A higher activity level at the ward was associated with a smaller increase in the CPAx-measured physical function. This could be due to ceiling effect or that these patients had good physical function before their admission. It remains to be shown if patients with low activity measurements will benefit from extra rehabilitation efforts.

Conclusion

In this prospective cohort, we found that all patients maintained or improved their physical function form ICU discharge to three-month follow-up. We also found a negative correlation between level of early physical activity in the ward and difference in physical function from ICU discharge to three-month follow-up.

(15)

Table 1: Demographics and clinical characteristics

Included (n=44) Visited (n=19) p-value difference visited/not visited

Age, years, mean (SD) 72 (10) 69 (10) 0.12

Gender, male % 59 60 0.91

BMI, mean (SD) 28 (8) 31 (10) 0.021

Opioids, % 34 35 0.91

Admission type, surgical % 36 40 0.65

LOS hosp, days, median (IQR) 17 (12-33) 18 (12-33) 0.33

LOS ICU, days, median (IQR) 4 (2-7) 3 (2-8) 0.84

SAPS II, mean (SD) 54 (15) 49 (14) 0.032

APACHE II, mean (SD) 20 (6) 18 (5) 0.14

Mortality, % 27

Ventilator, % 41 45 0.61

(16)

Anders Møller

Email * dr.andersm@gmail.com Afdeling * Anæstesi- og Intensivafdelingen

*

Slagelse Sygehus

Medforfattere Anders Møller, Henning Bay Nielsen, Jørn Wetterslev, Ole Pedersen, Dorthe Hellemann, Klaus Marcussen, Benedicte Ramsing, Anette Mortensen and Saeid Shahidi

Overskrift * Low versus high haemoglobin trigger for perioperative separation of red blood cell Transfusion in Vascular surgery: a randomised trial (The TV trial)

Tekst

Introduction: Vascular surgical patients have high rates of cardiovascular disease making them vulnerable to ischaemia following blood loss. Therefore, red blood cell (RBC) transfusion is often considered at higher haemoglobin (Hb) levels than in other surgical populations. As there is no firm evidence available to guide the RBC trigger we assessed the feasibility and effects of a perioperative protocol aimed to restrict RBC transfusion compared to standard recommendations in elective vascular surgery.

Methods: In a single-centre, open-label, assessor blinded trial, fifty-eight vascular surgical patients (> 40 years of age) planned for infrainguinal arterial bypass (n=33) or open surgery of infrarenal aortic aneurysm (n=25) underwent a web-based randomisation upon Hb decrease below 6 mmol/l to one of two groups: perioperative RBC transfusion triggered by Hb < 5 mmol/l (intervention) or Hb < 6 mmol/l (control). Administration of fluid followed an individualised strategy by optimising cardiac stroke volume. Patients were monitored by near-infrared spectroscopy to determine tissue oxygenation in blinded “study modus”. A follow up visit took place thirty days after surgery.

Results:

Participant consent rate was 112/143 (78%), eleven operations were cancelled and Hb decreased below 6 mmol/l in 58 of the remaining 101 (57 %) yielding a recruitment rate of 58/143 (41%). The primary outcome, mean

postoperative Hb level within the first 15 days after surgery, was 5.87 mmol/l in the intervention group vs. 6.41 mmol/l in the control group. Longitudinal analysis by generalised estimated equations showed that this difference was significant (coefficient 0.45; 95% CI 0.84-0.07; p= 0.022) also immediately after surgery and on day 30 (table 1). A total of 57 RBC units were transfused in the intervention group compared to 136 in the control group (p=0.0015). Severe adverse events (myocardial injury, acute kidney injury, death, stroke or severe transfusion reactions) occurred in 13/29 of patients in the intervention group vs. 18/29 in the control group (relative risk 0.73; 95% CI 0.53-1.41; p =0.28;

(table 2). To answer whether the control group maintained a higher ti ssue oxy genation requires additional analysis and results are expected to be presented at the DASAIM meeting.

Discussion: This is the first trial demonstrating statistically significant perioperative separation of Hb levels and use of RBCs in vascular surgery. The rates of severe adverse events were high (53%) but did not differ significantly between groups. The results may inform the design of further trials for evaluation of both the intra- and postoperative transfusion strategy.

Conclusion: The restrictive transfusion protocol more than halved the exposure to RBC units compared to the control group. A multi-centre trial on a larger vascular surgery population is in need to evaluate whether restricting RBC transfusions also protects against severe adverse events.

ClinicalTrials.gov: NCT02465125.

(17)

(18)

Nicola Groes Clausen

Email * nicola@nicola.dk

Afdeling * (1)Department of Anaesthesiology and Intensive Care; (2)Children’s Research Center;

(3)Department of Anaesthesiology

*

(1)Odense University Hospital, Denmark; (2)+(3)University Children’s Hospital of Zurich, Switzerland

Medforfattere Steen Antonsen, Nelly Spielmann, Tom G. Hansen, Markus Weiss, Simone K. Ringer

Overskrift * Calcium-binding protein s100b: a potential biomarker of cerebral tissue injury during general anaesthesia in piglets?

Tekst

Introduction: Moderate and severe hypotension (HT) and hypocapnia (HC) might cause neuro-morbidity following general anaesthesia (GA) in infants.1 Increased serum levels of calcium-binding protein s100b have been associated with cerebral injury (head trauma, perinatal intraventricular haemorrhage and asphyxia)2. Our objective was to investigate if s100b can be used as a biomarker of cerebral cell injury during GA in an animal model.

Method: A total of 57 sevoflurane-midazolam anaesthetized piglets (4-6 weeks of age) were randomised to normotension (C), mHT or sHT (n=27; group ‘HT’) or mHC, sHC or mHC/mHT combined (HTC) (n=30; group ‘HC’).

Monitoring included ECG, pulse oxymetry, rectal temperature, invasive blood pressure measurement, end-tidal anaesthetic volatile analysis, capnography, spirometry and repeated arterial blood gas analysis. Hypotension was induced by blood withdrawal (10 ml/kg) and nitroprusside infusion (target MAP: 35–38 (mHT) and 27-30 (sHT) mmHg).

Ventilation was adjusted as per protocol to target PaCO2 of 35-45 (normocapnia), 28-30 (mHC) or 23-25 (sHC) mmHg.

S100b was measured by chemiluminescent immunoassay of serum samples taken at baseline (B), before (Tr0), after treatment (Tr60) and recovery (postTr60) maintained for 60 min each. Simultaneously, serum concentration of albumin was analysed to exclude dilutional artefacts induced by maintenance fluid (Ringer& rsquo;s acetate + glucose 1%, rate 5ml/kg/hour).

Data were analysed using mixed repeated measures ANOVA followed by Sidak post-hoc tests (p<0.05).

Results: All 57 piglets completed the study without non-intended adverse events. In both ‘HT’ and ‘HC’, serum levels of s100b decreased significantly from B to postTr60 (p(HT) =0.037; p(HC) <0.001). Within groups, s100b values at specific time points did not differ between the treatment arms (p(HT)=0.118; p(HC)=0.536). S-Albumin decreased with time in all treatment groups. Mean values with standard deviations (SD) are shown (figure 1: s100b; figure 2:

albumin).

Discussion: Neuronal dysfunction and ischemia caused by hypotension and/or hypocapnia during sevoflurane

anaesthesia has previously been demonstrated in an identical piglet study setting by magnetic resonance imaging.3 In the current study, s100b did not reflect cerebral damage caused by moderate and severe hypotension/hypocapnia during GA in piglets. Since sampling of liquor was not part of our model it is unclear, whether the blood-brain-barrier remained intact preventing release of s100b. Further, the glial rather than neuronal origin of the protein might explain the lack of increase. Explanation by accelerated renal clearance of s100b seems less likely in the setting of global hypotension and regional hypoperfusion.

Conclusion: In the current study s100b does not reflect cerebral tissue injury caused by circulatory and respiratory instability during GA in piglets. Whether these results apply to a human setting is unknown and awaits further clarification.

(19)

References

1 McCann ME, Schouten AN, Dobija N, et al. Infantile postoperative encephalopathy: perioperative factors as a cause for concern. Pediatrics 2014;

133: e751-7

2 Thelin EP, Jeppsson E, Frostell A, et al. Utility of neuron-specific enolase in traumatic brain injury; relations to S100B levels, outcome, and extracranial injury severity. Critical care 2016; 20: 285

3 Ringer SK, Ohlerth S, Carrera I, et al. Effects of hypotension and/or hypocapnia during sevoflurane anesthesia on perfusion and metabolites in the developing brain of piglets-a blinded randomized study. Paediatric anaesthesia 2016; 26: 909-18

Figure 1: Serum s100b (unit: µg/L) (Mean values ± standard deviation (SD))

Control (C) mHT sHT mHC sHC HTC

Baseline (B) 0.937 ± 0.375 0.681 ± 0.247 0.665 ± 0.277 0.596 ± 0.250 0.496 ± 0.136 0.621 ± 0.268 Tr0 0.462 ± 0.139 0.866 ± 1.331 0.425 ± 0.141 0.363 ± 0.153 0.297 ± 0.099 0.347 ± 0.104 Tr60 0.416 ± 0.128 0.754 ± 1.099 0.420 ± 0.164 0.297 ± 0.131 0.244 ± 0.099 0.327 ± 0.911 postTr60 0.361 ± 0.096 0.640 ± 0.995 0.386 ± 0.200 0.309 ± 0.123 0.309 ± 0.123 0.261 ± 0.808

Figure 2: Serum-albumin (unit: g/L) (Mean values ± standard deviation (SD))

Control (C) mHT sHT mHC sHC HTC

Baseline (B) 32.33 ± 5.11 30.21 ± 6.55 31.81 ± 6.12 28.23 ± 5.16 27.03 ± 4.93 27.03 ± 3.93 Tr0 30.98 ± 4.14 29.02 ± 5.47 30.17 ± 5.58 26.89 ± 4.76 25.42 ± 5.03 25.77 ± 3.44 Tr60 30.47 ± 3.61 26.18 ± 5.69 28.33 ± 5.37 27.41 ± 4.98 25.41 ± 4.54 23.48 ± 3.14 postTr60 26.54 ± 4.99 24.22 ± 4.84 26.54 ± 4.99 26.80 ± 4.88 24.79 ± 4.41 20.99 ± 3.04

(20)

Anders Granholm

Email * andersgran@gmail.com

Afdeling * Department of Intensive Care 4131

*

Copenhagen University Hospital - Rigshospitalet

Medforfattere Anders Perner, Mette Krag, Peter Buhl Hjortrup, Nicolai Haase, Lars Broksø Holst, Søren Marker, Marie Oxenbøll Collet, Aksel Karl Georg Jensen, Morten Hylander Møller

Overskrift * The Simplified Mortality Score for the Intensive Care Unit (SMS-ICU): development and internal validation of a simple score to predict 90-day mortality

Existing intensive care unit (ICU) mortality prediction scores are imprecise due to aging, and their complexity

decreases clinical applicability and commonly causes problems with missing data. We aimed to develop and internally validate a new and simple score that predicts 90-day mortality in adults upon acute admission to the ICU: the

Simplified Mortality Score for the Intensive Care Unit (SMS-ICU).

Methods:

We developed a simple score as recently recommended [1] and according to a predefined, published protocol and statistical analysis plan [2]. We used data from an international cohort of 2139 patients acutely admitted to the ICU and 1947 ICU patients with severe sepsis/septic shock (the SUP-ICU and AID-ICU inception cohorts and the 6S, TRISS and CLASSIC trials, respectively; all approved by the relevant institutions). We performed multiple imputations for missing data and used binary logistic regression analysis with variable selection by backward elimination, followed by conversion to a simple point-based score. We assessed the apparent performance and validated the score internally using bootstrapping to present optimism-corrected performance estimates.

Results:

The SMS-ICU comprises 7 variables (Figure 1) that were available in 99.5% of the patients: age; lowest systolic blood pressure; hematologic malignancy/metastatic cancer; acute surgical admission; and use of vasopressors/inotropes;

respiratory support; and renal replacement therapy. Discrimination (area under the receiver operating characteristic curve) was 0.72 (95% CI: 0.71-0.74) (Figure 2), overall performance (Nagelkerke’s R2) was 0.19 and calibration (intercept and slope) was 0.00 and 0.99 (Figure 2), respectively. Optimism-corrected performance was similar to apparent performance.

Discussion:

The SMS-ICU is a simple score that is easy and fast to calculate, and the amount of missing data is likely lower than that of existing scores. Additionally, the score uses no biochemical variables, which are often missing and affected by different timing and sampling rates.

Conclusion:

The SMS-ICU predicted 90-day mortality with reasonable and stable performance. If performance remains adequate after external validation, the SMS-ICU could prove a valuable tool for ICU clinicians and researchers because of its simplicity and expected very low number of missing values.

References:

1. Labarère J. Intensive Care Med 2014. doi: 10.1007/s00134-014-3227-6 2. Granholm A. BMJ Open 2017. doi: 10.1136/bmjopen-2016-015339

(21)

(22)

Rikke Vibeke Nielsen

Email * rikke.vibeke.nielsen@regionh.dk Afdeling * Neuroanæstesiologisk Klinik

*

Rigshospitalet - Glostrup

Medforfattere Jonna S Fomsgaard, Lone Nikolajsen, Jørgen B Dahl, Ole Mathiesen

Overskrift * The effect of intraoperative ketamine on pain one year after spinal fusion surgery in chronic pain patients with preoperative opioid dependency: a follow-up study

Tekst

Introduction: The increasing number of surgical patients with chronic pain and opioid dependency represent a complex challenge. Low-dose S-ketamine has demonstrated perioperative opioid-sparing effects for this population, but long-term outcomes remain unsetteled1. We aimed to explore the effect of intraoperative ketamine on pain 1 year after spine surgery.

Methods: This is a prospective one-year follow up study on a single center, randomized, and blinded trial exploring the effect of intraoperative S-ketamine (bolus 0.5 mg/kg and infusion 0.25 mg·kg-1·h-1) on acute opioid consumption after spinal fusion on 147 patients with chronic pain and opioid dependency. The follow-up was performed by a written questionnaire from 2015 to 2016 and consisted of demographic data, pain levels (VAS 0–100 mm), working capability, contentment with the surgical result, Short form 36 survey (SF-36), EuroQol 5D (EQ-5D), OSWESTRY Low Back Disability Questionnaire and Douleur Neuropathique 4 (DN4).

Results: All 147 patients included in the original data analysis received a follow-up questionnaire one year

postoperatively. In the ketamine group 46 patients (62%) replied, and in the placebo group 51 patients replied (70%).

There were no differences in preoperative pain levels or patient characteristics between groups. One year

postoperatively, mobilization pain was lower in the ketamine group compared to the placebo group: 32 (12 - 64) vs 56 (28 - 79) mm, respectively, (P = 0.040) (Fig. 1). Pain at rest was also lower in the ketamine group compared to the placebo group: 18 (5 - 34) vs 29 (13 - 55) mm, respectively, (P = 0.021) (Fig. 1). Further, significantly fewer patients in the ketamine group used daily analgesics and fewer patients were still on sick leave (Table 1). Patients in the ketamine group had a lower OSWESTRY disability index score, P=0.035. We found no differences in walking distance,

contentment with the surgical result, SF-36, EQ-5D or DN4.

Discussion: To our knowledge, this is the first study exploring the effect of intraoperative ketamine infusion on persistent pain one year postoperatively in a preoperative opioid dependent population with chronic pain1. However, our results are exploratory secondary outcomes, as the sample size calculation was not based on these outcomes.

Conclusion: Intraoperative ketamine significantly reduced pain, analgesic use and duration of sick leave one year after spine surgery in a chronic opioid dependent population. These findings need further investigation as primary

outcomes.

1 Loftus RW et al. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology 2010;113:639-646.

(23)

(24)

(25)

Abstract 13

Pia Jæger

Email * pia_jaeger@hotmail.com Afdeling * Anæstesi- og Operationsklinikken

*

Rigshospitalet

Medforfattere Pia Jaeger, Jonas Baggesgaard, Johan K Sørensen, Brian M Ilfeld, Bo Gottschau, Ben Graungaard, Jørgen B Dahl, Ulrik Grevstad

Overskrift * Adductor canal block with continuous infusion versus intermittent boluses and morphine consumption: A randomized, double-blinded, controlled clinical trial

Based on the assumption that relatively large volumes of local anesthetic optimize an adductor canal block (ACB), we aimed to investigate whether an ACB administered as repeated boluses would improve analgesia without

compromising mobility, compared with a continuous infusion.

Methods

We performed a randomized, double-blinded, controlled study, including patients scheduled for total knee

arthroplasty with spinal anesthesia. All patients received an ACB with 0.2% ropivacaine via a catheter, administered as either repeated intermittent boluses (21 ml/3h) or continuous infusion (7ml/h). Supplemental analgesics included oral acetaminophen and ibuprofen, and patient controlled analgesia with intravenous morphine. The primary outcome was total opioid consumption (from end of surgery until 12:00 on POD 2). Secondary outcomes were visual analogue scale pain scores during knee flexion and at rest (analyzed using a linear mixed model with the inclusion of all time points), quadriceps muscle strength (maximum voluntary isometric contraction) and ambulation assessed by the Timed Up and Go test and a 6-minute walk test. Ethics Committees approval: H-2-2014-114. Clinicaltrial.gov ID:

NCT02539628.

Results

We randomized 110 patients of whom 107 were analyzed. Total opioid consumption (POD 0¬–2) was a median (range) of 23 mg (0–139) in the bolus group and 26 mg (3 –120) in the infusion group, (estimated median difference 4 mg, 95% CI: -13 to 5, P=0.29). Linear mixed models analyses revealed no difference in pain during knee flexion (mean difference 2.6 mm, 95% CI: -2.9 to 8.0) or at rest (mean difference 1.7 mm, 95% CI: -1.5 to 4.9). Patients in the bolus group had improved quadriceps sparing on POD 2 (median difference 7.4 %, 95% CI: 0.5 to 15.5 %). However, this difference was not present on POD 1 or reflected in the ambulation tests (table 1).

Discussion

Two previous studies compared intermittent boluses to continuous infusion for an ACB, but none following total knee arthroplasty. One study in healthy volunteers investigated pain scores during stimulation with electrical current in the distribution of the anterior branch of the medial femoral cutaneous nerve.1 Like us, they found no difference between the two treatments. The second study, performed in patients following anterior cruciate ligament reconstruction, showed superior pain relief in the bolus group.2 However, this study used a very low infusion rate of 2.5 ml/h, which may have affected the results.

To avoid a confounding effect of dose, both groups in the present study received the same dose of local anesthetics over time, resulting in a regimen with very frequent injections in the bolus group. It may be possible to increase the interval between boluses while keeping the same concentration.

(26)

Conclusion

Changing the mode of administration for an ACB from continuous infusion to repeated intermittent boluses did not decrease opioid consumption, pain, nor mobility.

Figure 1

(27)

(28)

Ida Guldberg

Email * ihelsoe@gmail.com Afdeling * Anæstesiologisk afdeling

*

Hvidovre Hospital

Medforfattere Mikkel Elvekjær, Christopher Clemmensen og Lars Møller Pedersen

Overskrift * Tidlig epidural kateter hos den svært overvægtige fødende - En hjælp ved akut sectio? Et kvalitetssikringsprojekt

Tekst Introduktion:

Tidligt anlagt epidural kateter på svært overvægtige fødende har længe været anbefalet mhp at undgå generel anæstesi grundet øget risiko for akut sectio samt obstetriske og anæstesiologiske komplikationer (1-3). Aktuelt findes der kun ganske få studier omhandlende anvendelse af epidural anæstesi til svært overvægtige ved akut sectio. Vi ønskede ved et kvalitetssikringsprojekt at undersøge, om tidligt anlagt epidural kateter hos svært overvægtige blev anvendt succesfuldt ved akut sectio samt at identificere prædiktorer for manglende anvendelse.

Metode:

Patienter der fik anlagt fødeepidural kateter og efterfølgende fik foretaget akut sectio i perioden 2012-2015 på Hvidovre Hospital blev opdelt i 2 grupper ud fra BMI ved 1. jordemoderkonsultation, hhv. BMI<35 (BMInorm) og BMI≥35 (BMIlhøj). Data blev hentet fra Dansk Anæstesi Database samt journalen.

Resultater:

1007 patienter fik anlagt fødeepidural kateter og fik efterfølgende foretaget akut sectio i perioden 2012-2015 på Hvidovre Hospital (30,1% af alle akutte sectio i samme periode). 93,5% tilhørte gruppen BMInorm (Tabel 1). I gruppen BMInorm fik 35 (5,2%) generel anæstesi ved akut sectio mod 0 i gruppen BMIhøj (p=0,16). Hos gruppen BMInorm fik 645 patienter (68,5%) gennemført akut sectio i epidural anæstesi mod 52(78,8%) hos gruppen BMIhøj (p=0,08). Begge grupper havde øget sandsynlighed for epidural anæstesi ved hastegrad 3 versus hastegrad 1 og 2 (BMInorm: OR 2,0;

CI95% [1,5;2,6]; BMIhøj: OR 4,1; CI95% [1,1;14,0]). For gruppen BMIhøj fandtes ingen signifikant association mellem andre faktorer og anden anæstesi end epidural anæstesi ved sectio (Tabel 2).

Konklusion:

Over tre fjerdedele af svært overvægtige gennemførte akut sectio i epidural anæstesi ved hjælp af tidligt anlagt kateter. Der kunne ikke identificeres procedurerelaterede prædiktorer for manglende brug af epidural kateter ved akut sectio hos denne gruppe. Neuroaxiale procedurer er vanskeligere hos svært overvægtige gravide; at det i perioden lykkedes helt at undgå generel anæstesi til svært overvægtige ved akut sectio tilskrives protokolleret håndtering samt tværfagligt samarbejde.

Referencer:

1. Managing anesthesia for cesarean section in obese patients: current perspectives. Lamon AM, Habib AS. Local Reg Anesth. 2016 Aug 16;9:45-57

2. Anaesthetists' experiences with the early labour epidural recommendation for obese parturients: a qualitative study. Elay VA, Callaway LK, van Zundert AA, Lipman J,Gallois C. Anaesth Intensive Care. 2016 Sep;44(5):620-7.

3. Obesity in obstetrics. Liat S, Cabero L, Hod M, Yogev Y. Best Pract Res Clin Obstet Gynaecol. 2015 Jan;29(1)79-90

Finansiering: Ingen

(29)

Tabel 1

Tabel 2

(30)

Frederik Holmgaard

Email * frederik.holmgaard@regionh.dk

Afdeling * Thoraxanæstesiologisk Klinik, Hjertecentret

*

Rigshospitalet

Medforfattere Anne G. Vedel, Theis Lange, Jens C. Nilsson, Hanne Berg Ravn

Overskrift * Impact of two distinct levels of mean arterial pressure on near infrared spectroscopy during cardiac surgery – secondary outcome from a randomized clinical trial

Tekst

INTRODUCTION

Near infrared spectroscopy (NIRS) is used worldwide to monitor regional cerebral oxygenation (rScO2) during cardiopulmonary bypass (CPB). Intervention protocols meant to mitigate cerebral desaturation advocate to increase mean arterial pressure (MAP) when cerebral desaturation occurs (1). However, the isolated effect of MAP on rScO2 is debatable. The aim of the present study was in a randomized, blinded design to elucidate the effect of two distinct levels of MAP on rScO2 values during CPB.

We hypothesized that a higher MAP would be reflected in higher rScO2 values, lower frequency of patients with desaturation and a less pronounced cerebral desaturation load.

METHODS

This is a substudy of the Perfusion Pressure Cerebral Infarct (PPCI) trial (2) (Regional Ethics Committee, Capital Region of Denmark H-3-2013-110 and clinicaltrials.gov NCT02185885), in which we investigated the impact of MAP levels during CPB on the extent of ischemic brain injury after cardiac surgery. Deviation in rScO2 was a predefined outcome in the PPCI trial. Patients were randomized to low MAP (LMAP): 40-50 mmHg or high MAP (HMAP): 70-80 mmHg during CPB. CPB pump flow was fixed at 2.4 L/minute/m2 + 10-20 % and MAP levels were targeted using norepinephrine. NIRS monitoring was performed in a blinded fashion.

RESULTS

The average MAP level during CPB was 67 mmHg in the HMAP group and 45 mmHg in the LMAP group. There was no statistically significant difference in rScO2 values at specified time points during the intraoperative period between the two groups. Mean of rScO2 during CPB was significantly lower in the HMAP group (p = 0.010). Significantly more patients experienced desaturation below 10 and 20 % relative to rScO2 baseline in the HMAP group during CPB (p = 0.013 and p = 0.009, respectively), and the cerebral desaturation load below 10 % relative to rScO2 baseline was more pronounced in the HMAP group during CPB (p = 0.042).

DISCUSSION

In a randomized, blinded study we observed that a higher MAP induced by vasopressors, with a fixed CPB pump flow, lead to lower mean rScO2 and more frequent and pronounced cerebral desaturation during CPB. The mechanism behind these observations is not clear. We cannot exclude extracranial contamination of the NIRS signal as a possible explanation.

CONCLUSION

The observed findings suggest that increasing MAP by vasoconstriction to mitigate cerebral desaturation on NIRS is not to be recommended during CPB.

REFERENCES

(31)

(1) Denault A, Deschamps A, Murkin JM. A proposed algorithm for the intraoperative use of cerebral near-infrared spectroscopy. Semin Cardiothorac Vasc Anesth. 2007;11(4):274-281.

(2) Vedel AG, Holmgaard F, Rasmussen LS, et al. Perfusion Pressure Cerebral Infarct ( PPCI ) trial - the importance of mean arterial pressure during cardiopulmonary bypass to prevent cerebral complications after cardiac surgery: study protocol for a randomised controlled trial. Trials. 2016;17:1-11.

(32)

Sofie Louise Rygård

Email * sofie.louise.rygaard@regionh.dk Afdeling * Intensiv Terapiklinik, 4131

*

Rigshospitalet

Medforfattere Anders Granholm, Maj-Brit Nørregaard Kjær og Anders Perner

Overskrift * Funding of clinical trials in intensive care medicine in Denmark 2005-2017

Tekst

INTRODUCTION

Admission to an intensive care unit (ICU) is associated with high mortality and impaired quality of life among the survivors. Research in the ICU has improved the efficacy and safety of treatments, and by this improved the outcome of ICU patients [1].

During the past ten years, the capacity of the Danish ICUs has increased with approximately 10% [2], and as the number of elderly citizens and people with co-morbidities will increase, we assume this development will continue during the next decades.

As the costs of intensive care are high, it is in the interest of both society and the future patients to invest in ICU research.

Our objective was to analyse the investments in ICU research in Denmark.

METHODS

We conducted systematic searches of clinicaltrials.gov and clinicaltrialsregister.eu and selected all randomised clinical trials conducted from 2005 to 2017 in ICUs in Denmark. We included trials where sponsor or primary investigator was located in Denmark, and we excluded ongoing trials and completed trials, with the primary results pending for publication. Trials were categorised as investigator-initiated or industry-initiated and funding as public, philanthropic or industry-based by two authors (SR and AG). If data were not presented in the publication of the primary results, we sought data by contact to the corresponding investigator.

RESULTS

We found 13 clinical trials published between 2009 and 2017 including a total of 4408 patients. Two trials were industry-initiated and completely industry-sponsored, and among the 11 investigator-initiated trials, only one was partly funded by the industry. The public funding accounted for the largest percentage of funding among all of the larger trials. RESULTS PENDING (preliminary abstract)

DISCUSSION

From 2007 to 2013 57% of the research in clinical medicine in Denmark was funded internally and 43 % was funded externally (philanthropic, public or industry-based) [3]. In this period, the main contributor to the external funding was philanthropic-based funding. This has not been the case for the large clinical trials conducted in Danish ICUs, which have relied mainly on public funding.

CONCLUSION

Admission to the ICU has a high impact on patients’ morbidity and survival, but also on healthcare expenses, and it is important to analyse the investment in research in intensive care medicine. Compared with the general distribution of research funding, the clinical research in the ICU appears to be more dependent on public funding than in clinical medicine in general.

REFERENCES

1. Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl Starch 130/0.42 versus Ringer’s Acetate in Severe Sepsis. N Engl J Med. 2012;367:82–3.

2. Bonde J, Simonsen JB, Andersen JS. www.dasaim.dk/forskning/capacity-in-danish-intensive-care-units/

(33)

3. Det Frie Forskningsråd. Pengestrømsanalyse 2007-2013. http://ufm.dk/forskning-og-innovation/rad-og- udvalg/dff/statistik/pengestromsanalyse.pdf. 2016;1–44.

(34)

Maria Petersen

Email * maria.petersen.md@gmail.com

Afdeling * Anæstesi- og Operationsklinikken, Hoved-Orto-Centeret

*

Rigshospitalet

Medforfattere Dan Isbye

Overskrift * 'Overlevelse efter 2005 og 2010 guidelines for hjertestop på Rigshospitalet'

Tekst Introduktion

Guidelines for genoplivning ved hjertestop på hospital har gennem de sidste 17 år gennemgået ændringer hvert 5. år, både i Danmark og internationalt, uden at effekten på overlevelse er fuldt belyst.

Internationale studier har antydet en bedring i korttidsoverlevelse, men begrænses af at der kun foreligger data frem til udskrivelsen1,2.

På Rigshospitalet er samtlige hjertestop siden 2004 registreret i en database. Data er dog aldrig opgjort med hensyn til om ændringer i guidelines har haft betydning for overlevelsen.

Formålet var at undersøge, om der var forskel på antallet af patienter genoplivet til ROSC (return of spontaneus cirkulation) samt efterfølgende 30 dages og 1-års overlevelse efter guidelines fra henholdsvis 2005 og 2010.

Metoder

Systematisk gennemgang af Rigshospitalets hjertestopdatabase i perioden 01.01.2006 til og med 31.12.2014.

Afmeldte alarmer, patienter uden dansk CPR-nummer samt patienter uden dokumentation af klinisk hjertestop blev sorteret fra. Resterende patienter blev krydset med CPR-registret for at sammenligne primær ROSC, 30 dages overlevelse og 1-års overlevelse for patienter behandlet efter 2005 og 2010 guidelines. Statistisk analyse blev foretaget med chi2-test og p-værdi < 0,05 blev tolket som signifikant. Godkendelse fra Videnskabsetisk Kommité var ikke påkrævet. Studiet har godkendelse fra Datatilsynet.

Resultater

Ud af totalt 1389 klinisk verificerede hjertestop i perioden blev 773 patienter genoplivet til primær ROSC (55,6%). 385 patienter (54,1 %) blev genoplivet til primær ROSC efter 2005 års guidelines og 388 patienter (57,2 %) efter 2010 års guidelines; p = 0,25.

Henholdsvis 169 patienter (23,8%) var i live efter 30 dage (2005), sammenlignet med 183 patienter (27,0%) (2010); p=

0,17.

1-års overlevelsen var hhv. 138 patienter (19,4 %) behandlet efter 2005-guidelines, og 143 (21,1% ) behandlet efter 2010-guide-lines; p = 0,44.

Diskussion

På trods af ændringer i guidelines for genoplivning, har den forventede forbedrede langtidsoverlevelse efter

hjertestop på hospital ikke kunnet påvises. Forklaringen må antages at være mangfacetteret og betinget af flere øvrige faktorer, herunder ændrede behandlingsprincipper i intensiv terapi. Type 2 fejl er ikke utænkeligt.

Hjertestopsdatabasen på Rigshospitalet indeholder forholdsvis unikke tal, idet 1-års overlevelsen er inkluderet.

Konklusion

Vores opgørelse af hjertestop på Rigshospitalet antyder en tendens mod forbedret umiddelbar, 30-dages og 1 års overlevelse med 2010 sammenlignet med 2005 guidelines, men resultaterne er ikke statistisk signifikante.

(35)

Referencer:

1. Ocal, O et al, A comparison of the outcome of CPR according to AHA 2005 ACLS and AHA 2010 ACLS guidelines in cardiac arrest: multicenter study

Int J Clin Exp Med 2015;8(11):21549-21556

2. Zhu A, et al, Meta-analysis of outcomes of the 2005 and 2010 cardiopulmonary resuscitation guidelines for adults with in-hospital cardiac arrest.

Am J Emerg Med 2016 Jun;34(6):1133-9.

NB! Den uploadede fil er beskadiget og kan ikke åbnes eller eftersendes i brugbart format

(36)

Claus Behrend Christiansen

Email * claus.behrend.christiansen@dadlnet.dk Afdeling * Anæstesiologisk Afdeling

*

Nordsjællands Hospital

Medforfattere Mikkel Herold Madsen, Christian Rothe, Lars Hyldborg Lundstrøm, Kai Henrik Wiborg Lange

Overskrift * VOLUME OF ROPIVACAINE 0.2 % AND SCIATIC NERVE BLOCK DURATION: A RANDOMISED, BLINDED DOSE-RANGING TRIAL IN HEALTHY VOLUNTEERS

Tekst

Background and Aims:

Local anaesthetic (LA) volume necessary for a successful nerve block has decreased with advancements in ultrasound (US) guided techniques. Lowering LA volume may however reduce block duration, but the extent of this is unknown (1). The aim of this study was to determine the relationship between LA volume and peripheral block duration. We hypothesised that increasing LA volume would prolong block duration.

Methods:

After scientific ethical approval, we included and randomised 60 healthy volunteers to US guided infragluteal sciatic nerve blocks with 5, 10, 15, 20 or 30 mL ropivacaine 0.2 %. Volunteers and investigators were blinded to group assignments. We used a catheter-based technique to optimise blinding and to ensure a constant infusion rate of 10 mL per minute. Primary outcome: Duration of sensory block defined by insensitivity towards cold. Secondary outcome: Duration of motor block. We tested every hour from onset of nerve block to complete remission. We used ANOVA for analysing the effect of LA volume on block duration.

Results:

Fifty-eight out of 60 volunteers had successful nerve block. Sensory block duration ranged from 6 to 17 hours. There was no significant effect of LA volume on either sensory or motor block duration. The variability of both sensory and motor block duration was high and did not decrease with increasing LA volume (fig. 1 and 2).

Conclusions:

We could not detect a significant effect of LA volume on sciatic nerve block duration. This contrasts previous findings from studies investigating dose response relations and duration of sciatic nerve block (2).

Disclosures: None.

References:

(1) McCartney CJ, Patel S. Local anesthetic volume for peripheral nerve blocks: How low can (or should) we go? Reg Anesth Pain Med 2012; 37: 239-41.

(2) Nader A, Kendall MC, De Oliveira GS et al. A dose-ranging study of 0.5 % bupivacaine or ropivacaine on the success and duration of the ultrasound-guided, nerve-stimulator-assisted sciatic nerve block. A double-blind, randomized clinical trial. Reg Anesth Pain Med 2013; 38: 492-502.

(37)

(38)

Damir Salskov Obad

Email * damoba@rm.dk

Afdeling * Operation og Intensiv Øst

*

Aarhus Universitetshospital

Medforfattere Birgitte Brandsborg, Janne S. Jensen, Tommy K. Nielsen, Ole Graumann

Overskrift * Lejringsskader i forbindelse med CT-vejledt cryoablation i bugleje

Tekst

INTRODUKTION: CT-vejledt cryoablation af nyretumorer kræver oftest bugleje med begge arme over hovedet i generel anæstesi (GA). Behandlingsmæssige krav og fysiske forhold umuliggør en lejring efter de accepterede standarder for bugleje (armabduktion <90 gr, anterofleksion af armen) [1,2]. Afvigelsen fra standardlejringen udsætter især plexus brachialis og n. ulnaris for tryk [3]. Der findes ingen systemiske opgørelser af lejringsskader efter CT-vejledte procedurer i GA. Formålet med dette studie er at opgøre lejringsskader efter CT-vejledte cryoablation i GA med patienter i bugleje.

METODER: Nyretumorpatienter som i GA blev behandlet med CT-vejledt cryoablation på Aarhus Universitetshospital i en seks måneders periode blev interviewet inden proceduren mhp. eksisterende muskuloskeletale eller neurologiske lidelser. På 2. og 7. postoperative dag blev patienterne telefonisk kontaktet og adspurgt om smerter eller neurologiske udfald i overekstremiteter (OE), nakke eller ansigt. Patienter med neurologiske symptomer blev fulgt yderligere indtil symptomophør.

RESULTATER: 38 patienter blev inkluderet. Patientkarakteristika og resultater er fremstillet i tabel 1. Skuldresmerter debuterede gennemsnitligt 2 dage efter proceduren; fem pt. havde fortsat smerter efter syv dage. Ingen havde varige neuropatier. Paræstesier i OE debuterede gennemsnitlig to dage efter proceduren. Én patient havde hævelse og nedsat følelse i overlæben. To patienter havde svien i øjnene som varede hhv. fem og seks dage. Ingen patienter havde symptomer som forstyrrede deres søvn. To patienter anvendte kortvarigt håndkøbsanalgetika.

DISKUSSION: Fundene i dette studie tyder på en relativ høj forekomst af forbigående påvirkning. Der er tale om alvorlige symptomer, som potentielt kunne give alvorlige varige skader. Kohorten er for lille til at kunne vurdere en eventuel sammenhæng mellem tid i bugleje og forekomst af lejringspåvirkning. Endvidere tillader materialets størrelse ikke nogen entydig konklusion om, hvorvidt patienter med præoperative smerter er mere udsatte for lejringsskader i forbindelse med denne lejring. Det vil være relevant at undersøge om andre lejringsmuligheder eller lejringsudstyr kunne være mere skånsomme for patienterne, herunder udførelsen af proceduren i sedation eller lokal anæstesi.

Selvom ingen patienter fik varige mén, er stor opmærksomhed påkrævet ved lejring. Patienterne skal informeres grundigt ved den præoperative samtale omkring mulig forekomst af disse ska der, der es symptomer og prognose.

KONKLUSION: Hos nyretumorpatienter behandlet med CT vejledt cryoablation i bugleje i GA fandt vi relativt høj forekomst af lejringsrelateret smerter- og føleforstyrrelser. Ingen patienter havde varige neuropatier. Større studier er nødvendige for at kunne finde en real sammenhæng. Præoperativ oplysning om risiko for lejringsrelateret skader er påkrævet og der bør være mere opmærksomhed på opsporing af disse i den postoperative periode.

(39)

(40)

Rasmus Aagaard

Email * rasmus.aagaard@clin.au.dk Afdeling * Anæstesiologisk Afdeling

*

Regionshospitalet Randers

Medforfattere Bo Løfgren, Thorbjørn Grøfte, Erik Sloth, Roni R Nielsen, Chrisitan A Frederiksen, Asger Granfeldt, Morten T Bøtker

Overskrift * Timing of focused cardiac ultrasound during advanced life support - a prospective clinical study

Focused cardiac ultrasound (FoCUS) can potentially identify reversible causes of cardiac arrest during advanced life support (ALS), but data on the timing of image acquisition are lacking.

The aim of this study was to compare the quality of FoCUS images obtained during either rhythm analysis, bag-mask ventilation, or chest compression.

Methods

Adult patients in cardiac arrest were prospectively included at a Danish community hospital from Feb. 2015 to Dec.

2016. Anesthesiologists trained in FoCUS obtained subcostal images during rhythm analysis, bag-mask ventilation, and chest compression. Image quality was assessed by the anesthesiologists and two blinded echocardiography experts.

Images quality was rated as either useful for interpretation or not. An image was defined as useful for interpretation if all the following characteristics could be determined: 1) right ventricle larger than left 2) pericardial fluid 3) collapsing ventricles. Logistic regression was used to compare proportions of images useful for interpretation. The ethics committee of the Central Denmark Region regarded the study as a quality assurance and waived further approval.

Results

Images were obtained from 60 of 104 patients undergoing ALS (Figure 1). Based on assessment by the echocardiography experts, a higher proportion of the images obtained during rhythm analyses and bag-mask ventilation were useful for interpretation when compared with images obtained during chest compression (rhythm analysis vs. chest compression: OR 2.2 (95%CI 1.3-3.8), P=0.005; ventilation vs. chest compression: OR 2.0 (95%CI 1.1- 3.7), P=0.03). There was no difference between images obtained during rhythm analysis and bag-mask ventilation (OR 1.1 (95%CI 0.6-2.0), P=0.74). Percentage of images in which the quality allowed determination of whether the right ventricle was larger than the left, pericardial fluid was present, and collapsing ventricles were present, are shown in Table 1. On a patient level, at least one image useful for interpretation was obtained in 72% of patients, when assessed by the echocardiography experts. At least one image useful for interpretation was obt ained in 60%, when assessed by the anesthesiologists.

Conclusion

The quality of FoCUS images obtained during rhythm analysis and bag-mask ventilation is superior to that of images obtained during chest compression. However, there is no difference in the quality of images obtained during rhythm analysis and bag-mask ventilation. Thus, FoCUS during bag-mask ventilation may constitute an overlooked opportunity for image acquisition during ALS.

(41)