Changes over time in characteristics, resource use and outcomes among ICU patients with COVID-19-A nationwide, observational study in Denmark.

BACKGROUND: Characteristics and care of intensive care unit (ICU) patients with COVID-19 may have changed during the pandemic, but longitudinal data assessing this are limited. We compared patients with COVID-19 admitted to Danish ICUs in the first wave with those admitted later. METHODS: Among all Danish ICU patients with COVID-19, we compared demographics, chronic comorbidities, use of organ support, length of stay and vital status of those admitted 10 March to 19 May 2020 (first wave) versus 20 May 2020 to 30 June 2021. We analysed risk factors for death by adjusted logistic regression analysis. RESULTS: Among all hospitalised patients with COVID-19, a lower proportion was admitted to ICU after the first wave (13% vs. 8%). Among all 1374 ICU patients with COVID-19, 326 were admitted during the first wave. There were no major differences in patient's characteristics or mortality between the two periods, but use of invasive mechanical ventilation (81% vs. 58% of patients), renal replacement therapy (26% vs. 13%) and ECMO (8% vs. 3%) and median length of stay in ICU (13 vs. 10 days) and in hospital (20 vs. 17 days) were all significantly lower after the first wave. Risk factors for death were higher age, larger burden of comorbidities (heart failure, pulmonary disease and kidney disease) and active cancer, but not admission during or after the first wave. CONCLUSIONS: After the first wave of COVID-19 in Denmark, a lower proportion of hospitalised patients with COVID-19 were admitted to ICU. Among ICU patients, use of organ support was lower and length of stay was reduced, but mortality rates remained at a relatively high level.

A randomized, controlled trial comparing local infiltration analgesia with epidural infusion for total knee arthroplasty.

BACKGROUND: There have been few studies describing wound infiltration with additional intraarticular administration of multimodal analgesia for total knee arthroplasty (TKA). In this study, we assessed the efficacy of wound infiltration combined with intraarticular regional analgesia with epidural infusion on analgesic requirements and postoperative pain after TKA. METHODS: 40 consecutive patients undergoing elective, primary TKA were randomized into 2 groups to receive either (1) intraoperative wound infiltration with 150 mL ropivacaine (2 mg/mL), 1 mL ketorolac (30 mg/mL), and 0.5 mL epinephrine (1 mg/mL) (total volume 152 mL) combined with intraarticular infusion (4 mL/h) of 190 mL ropivacaine (2 mg/mL) plus 2 mL ketorolac (30 mg/mL) (group A), or (2) epidural infusion (4 mL/h) of 192 mL ropivacaine (2 mg/mL) combined with 6 intravenous administrations of 0.5 mL ketorolac (30 mg/mL) for 48 h postoperatively (group E). For rescue analgesia, intravenous patient-controlled-analgesia (PCA) morphine was used. Morphine consumption, intensity of knee pain (0­100 mm visual analog scale), and side effects were recorded. Length of stay and corrected length of stay were also recorded (the day-patients fulfilled discharge criteria). RESULTS: The median cumulated morphine consumption, pain scores at rest, and pain scores during mobilization were reduced in group A compared to group E. Corrected length of stay was reduced by 25% in group A compared to group E. INTERPRETATION: Peri- and intraarticular analgesia with multimodal drugs provided superior pain relief and reduced morphine consumption compared with continuous epidural infusion with ropivacaine combined with intravenous ketorolac after TKA.

Multimodal analgesia with gabapentin, ketamine and dexamethasone in combination with paracetamol and ketorolac after hip arthroplasty: a preliminary study.

BACKGROUND AND OBJECTIVE: It has been hypothesized that combinations of analgesics with different mechanisms of action may reduce or even prevent postoperative pain. We, therefore, investigated the analgesic effect of gabapentin, dexamethasone and low-dose ketamine in combination with paracetamol and ketorolac as compared with paracetamol and ketorolac alone after hip arthroplasty. METHODS: In this double-blind study, 42 patients were randomly assigned to either a combination group [gabapentin 1200 mg+dexamethasone 8 mg+ketamine (0.15 mg kg(-1))+paracetamol 1 g+ketorolac 15 mg] or a control group (placebo+paracetamol 1 g+ketorolac 15 mg). The medication was given preoperatively except for ketorolac, which was given at the end of surgery. Postoperative pain treatment was paracetamol 1 gx3; ketorolac 15 mgx3; and patient-controlled intravenous morphine. Morphine consumption, pain intensity at rest and during mobilization, nausea and vomiting, sedation, dizziness, hallucination and consumption of ondansetron were recorded 2, 4 and 24 h after operation. A P value of less than 0.05 was considered statistically significant. RESULTS: Morphine consumption was not significantly different between groups (P=0.085). Overall pain scores were improved in the combination group as compared with the control group both at rest (P=0.042) and during mobilization (P=0.027). In the combination group, individual pain score above 30 mm on a 100 mm visual analogue scale was almost eliminated. The incidence of side effects did not differ between the groups. CONCLUSION: Preoperative gabapentin, dexamethasone and ketamine combined with paracetamol and ketorolac reduced overall pain scores in patients after hip arthroplasty as compared with paracetamol and ketorolac alone. Morphine consumption was not reduced.

Nurses' and physicians' sedation practices in Danish ICUs in 2003 A national survey.

OBJECTIVE: The aim of the study was to describe and compare physicians' and nurses' estimated use of sedatives and analgesics in patients requiring mechanical ventilation in Danish Intensive Care Units (ICUs) in 2003. DESIGN: Questionnaires were mailed in January 2003 to all Danish ICUs providing mechanical ventilation (n = 48). One physician and one nurse at each site were included in the study. RESULTS: Thirty-nine questionnaires were returned by physicians (response rate 81%) and 43 by the nurses (response rate 90%). Physicians and nurses agreed that sedation related decisions are predominately made during rounds and that most decisions are made by physicians and nurses collaboratively. Only 9% of the nurses and 23% of the physicians reported using a written protocol for sedation, while 30% of the nurses and 44% of the physicians reported the use of sedation scoring systems. The study generally supported the hypothesis, that nurses' and physicians' would respond similarly, but there were, however, significant variations, regarding formal sedation practices. CONCLUSIONS: Sedation decisions are made collaboratively by nurses and physicians, while sedation protocols and scoring systems are still not systematically implemented in Danish ICUs. The most common drugs for sedation of the mechanically ventilated patient are propofol and fentanyl by continuous infusion. It is recommended that the ICUs collaborate on developing evidence-based standards for sedation and that clinical databases are introduced, which may be used to assess the efficacy of such standards.

Trends in sedation practices in Danish intensive care units in 2003: a national survey.

OBJECTIVE: The aim of the study was to explore trends and changes in sedation practices for mechanically ventilated patients in Danish intensive care units (ICUs) and to compare sedation practices in 1997 and 2003. DESIGN: The study was a follow-up survey with a descriptive and comparative cross-sectional multicenter design. SETTING: Questionnaires were mailed in January 2003 to all Danish ICUs providing mechanical ventilation (n=48). PARTICIPANTS: One head physician at each ICU in Denmark. INTERVENTIONS, MEASUREMENTS, AND RESULTS: Thirty-nine questionnaires were returned, yielding a response rate of 81%, representing 82% of Danish ICU beds. The main findings were a significant increase in the use of sedation scoring systems and a significant reduction of sedation and analgesia in relation to various modalities of mechanical ventilation and disease groups. Other important findings were a significant reduction in the use of benzodiazepines and opioids and a significant increase in the use of propofol in relation to all ventilator modes. The administration routes of sedative agents remained unchanged. CONCLUSIONS: Sedatives and analgesics are still widely used in Danish ICUs. The trend is toward lighter sedation along with a shift from benzodiazepines toward propofol and from morphine toward fentanyl given by continuous infusion. More attention needs to be directed toward sedation standards and scoring systems in order to reduce the risk associated with sedation in mechanically ventilated patients.