Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure.

BACKGROUND: Patients with acute hypoxemic respiratory failure in the intensive care unit (ICU) are treated with supplemental oxygen, but the benefits and harms of different oxygenation targets are unclear. We hypothesized that using a lower target for partial pressure of arterial oxygen (Pao2) would result in lower mortality than using a higher target. METHODS: In this multicenter trial, we randomly assigned 2928 adult patients who had recently been admitted to the ICU (≤12 hours before randomization) and who were receiving at least 10 liters of oxygen per minute in an open system or had a fraction of inspired oxygen of at least 0.50 in a closed system to receive oxygen therapy targeting a Pao2 of either 60 mm Hg (lower-oxygenation group) or 90 mm Hg (higher-oxygenation group) for a maximum of 90 days. The primary outcome was death within 90 days. RESULTS: At 90 days, 618 of 1441 patients (42.9%) in the lower-oxygenation group and 613 of 1447 patients (42.4%) in the higher-oxygenation group had died (adjusted risk ratio, 1.02; 95% confidence interval, 0.94 to 1.11; P = 0.64). At 90 days, there was no significant between-group difference in the percentage of days that patients were alive without life support or in the percentage of days they were alive after hospital discharge. The percentages of patients who had new episodes of shock, myocardial ischemia, ischemic stroke, or intestinal ischemia were similar in the two groups (P = 0.24). CONCLUSIONS: Among adult patients with acute hypoxemic respiratory failure in the ICU, a lower oxygenation target did not result in lower mortality than a higher target at 90 days. (Funded by the Innovation Fund Denmark and others; HOT-ICU ClinicalTrials.gov number, NCT03174002.).

Low-Volume Brachial Plexus Block Providing Surgical Anesthesia for Distal Arm Surgery Comparing Supraclavicular, Infraclavicular, and Axillary Approach: A Randomized Observer Blind Trial.

Background. Distal arm surgery is widely performed under regional anesthesia with brachial plexus block. The preponderance of evidence for the efficacy relies upon injection of local anesthetic in excess of 30 mL. We aimed to compare three different ultrasound-guided brachial plexus block techniques restricting the total volume to 20 mL. Methods. 120 patients were prospectively randomized to ultrasound-guided brachial plexus block with 20 mL ropivacaine 0.75% at either the supraclavicular, infraclavicular, or axillary level. Multiinjection technique was performed with all three approaches. Primary outcome measure was performance time. Results. Performance time and procedural pain were similar between groups. Needle passes and injection numbers were significantly reduced in the infraclavicular group (P < 0.01). Nerve visibility was significantly reduced in the axillary group (P = 0.01). Success-rate was significantly increased in the supraclavicular versus the axillary group (P < 0.025). Total anesthesia-related time was significantly reduced in the supraclavicular compared to the infraclavicular group (P < 0.01). Block duration was significantly increased in the infraclavicular group (P < 0.05). No early adverse effects occurred. Conclusion. Supraclavicular and infraclavicular blocks exhibited favorable characteristics compared to the axillary block. Supraclavicular brachial plexus block with the multiinjection intracluster technique exhibited significantly reduced total anesthesia-related time and higher success rate without any early adverse events.

[Anaesthesia for patients with chronic wounds]. / Anæstesi til patienter med kroniske sår.

Perioperative management of chronic wounds demands a multidisciplinary approach. Severe co-morbidities leave these patients prone to post-operative complications. To optimize wound healing, minimally invasive methods, both surgical and anaesthesiological, are applied. Ultrasound-guided peripheral nerveblocks (PNB) are an ideal anaesthesia method for wound revisions, amputations and split skin transplantations. The implementation of PNB allows continued anticoagulant treatment, provides post-operative analgesia, lowers opioid consumption and facilitates mobilization.

Subacute fat-embolism-like syndrome following high-volume intramuscular and accidental intravascular injection of mineral oil.

OBJECTIVE: We present a rare case of subacute fat-embolism-like syndrome (FES-like) following intravascular injection of mineral oil-steroid solution with delayed diagnosis, acute onset of pulmonary distress, and transient clinical deterioration. CASE REPORT: A 40-year-old man was admitted following as a pedestrian being hit by a car. Examinations revealed sternum fracture and lung contusion. The patient was discharged with oral analgesics. Seven days later he returned presenting with coughing, hemoptysis, elevated leucocytes, and increased C-reactive protein. Chest radiograph revealed basal infiltrations. Suspecting pneumonia, the patient was discharged with antibiotics. Unknown to the clinicians, the patient had self-administered a mineral oil with added anabolic steroids by intramuscular injections for cosmetic purposes. The patient had observed blood on aspiration, and then relocated the needle before injecting 140 ml in his biceps muscle. Shortly after, the patient described near fainting and hemoptysis suggesting an accidental intravascular injection. Over the next 3 days the patient experienced increasing shortness of breath and hemoptysis. Examinations confirmed the diagnosis and the patient was treated with organ-specific supportive measures, tranexamic acid, and prednisolone and discharged after 11 days in the hospital. CONCLUSION: Subacute FES-like was associated with injection of body filler in muscle tissue. FES-like can mimic pneumonia, posttraumatic lung injury, and other more frequent causes to respiratory failure.

[Late development of carotid dissection after traffic accident]. / Sen udvikling af carotisdissektion efter trafikuheld.

This case study discusses the clinical manifestations of carotid dissection in a 58-year-old male admitted with minor injuries after a traffic accident. Within 24 hours the patient developed Horner syndrome, hoarseness and possible facial nerve palsy. A CT-angiogram showed dissection of the left carotid artery in its extracranial part. The patient was treated with anticoagulants and transferred to a neurological ward for further examination. Follow-up with CT angiography was scheduled for five months later.