Mortality and complications after emergency laparotomy in patients above 80 years.

Emergency laparotomy (EL) is a high-risk procedure. However, available evidence regarding outcome after emergency surgery in very old patients is limited. The aim of this observational study was to investigate outcome following EL in patients ≥80 years of age. METHODS: This single-center retrospective study was undertaken at Haukeland University Hospital, Norway. Demographic data, pre-operative risk assessment, surgical procedures, intrahospital logistics, complications, mortality, and discharge data were collected from the medical records. Primary outcome was 30-day mortality. Secondary outcomes were 90-day mortality, 1-year mortality, post-operative complications, and level of care at discharge. RESULTS: One hundred and six patients aged 80-96 years underwent EL between 2015 and 2016. Of these, 58% had cardiopulmonary disease, and 16% lived in a nursing home before surgery. Resection of colon was performed in 26 cases, adhesiolysis was performed in 24, and resection of small intestine in 18. Within 30 days, 28 patients died (26%), 15 during the first post-operative week. For 82% of the patients, at least one complication occurred, and medical complications were far more frequent than surgical. Post-operatively, pulmonary morbidity was found in 51 patients (48%) and delirium in 42 (40%). The number of intrahospital deaths was 25 (24%). Among the 81survivors, 53 were discharged to a nursing home (65%). One-year mortality was 47% (50/106). CONCLUSIONS: Mortality after EL in octo- and nonagenarians is very high. Medical complications are more common than surgical, and functional decline is frequent. Future studies should focus on the effect of a care bundle including geriatric intervention in these patients.

Stroke volume variation to guide fluid therapy: is it suitable for high-risk surgical patients? A terminated randomized controlled trial.

BACKGROUND: Perioperative goal-directed fluid therapy (GDFT) may improve outcome after high-risk surgery. Minimal invasive measurement of stroke volume variation (SVV) has been recommended to guide fluid therapy. We intended to study how perioperative GDFT with arterial-based continuous SVV monitoring influences postoperative complications in a high-risk surgical population. METHODS: From February 1st 2012, all ASA 3 and 4 patients undergoing abdominal surgery in two university hospitals were assessed for randomization into a control group or GDFT group. An arterial-line cardiac output monitor was used to measure SVV, and fluid was given after an algorithm in the intervention group. Restrictions of the method excluded patients undergoing laparoscopic surgery, patients with atrial fibrillation and patients with severe mitral/aortal stenosis. To detect a decrease in number of complication from 40 % in the control group to 20 % in the GDFT group, n = 164 patients were needed (power 80 %, alpha 0.05, two-sided test). To include the needed amount of patients, the study was estimated to last for 2 years. RESULTS: After 1 year, 30 patients were included and the study was halted due to slow inclusion rate. Of 732 high-risk patients scheduled for abdominal surgery, 391 were screened for randomization. Of those, n = 249 (64 %) were excluded because a laparoscopic technique was preferred and n = 95 (24 %) due to atrial fibrillation. CONCLUSIONS: Our study was stopped due to a slow inclusion rate. Methodological restrictions of the arterial-line cardiac output monitor excluded the majority of patients. This leaves the question if this method is appropriate to guide fluid therapy in high-risk surgical patients. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01473446.

Does central venous oxygen saturation-directed fluid therapy affect postoperative morbidity after colorectal surgery? A randomized assessor-blinded controlled trial.

BACKGROUND: The optimal amount and method for monitoring intravenous fluid in surgical patients is unresolved. Central venous oxygen saturation (Scvo2) has been used to guide therapy and predict outcome in high-risk and intensive-care patients. The aim of this prospective, randomized trial was to compare the rate of postoperative complications in patients receiving fluid therapy guided by Scvo2 and those treated with a traditional effluent fluid scheme. METHODS: Patients undergoing open colorectal and lower intestinal surgery (n = 241) were randomized to the Scvo2 group or the control group. The Scvo2 group received perioperatively crystalloid infusion 100 ml/h. When Scvo2 was less than 75%, a bolus of 3 ml/kg hydroxyethyl starch was given. The bolus was repeated if Scvo2 increased by 1 percentage point or more. The control group was maintained with crystalloid 800 ml/h and given extra fluid if there were clinical signs of hypovolemia. The participating surgeon, unaware of the group allocation, registered complications within day 30. RESULTS: Until 8:00 am on the first postoperative day, the Scvo2 group had received 3,869 ± 992 ml (mean ± SD) intravenous fluid compared with 6,491 ± 1,649 ml in the control group. Increase in weight was 0.8 ± 1.8 kg and 2.5 ± 1.6 kg in the two groups, respectively. The postoperative complication rate was 42% in both groups. CONCLUSION: Clinical outcomes among patients receiving Scvo2-guided perioperative fluid therapy were similar to those for patients treated with a traditional fluid regimen. Limitations in study design prevent full interpretation of these findings, and further large trials of this treatment algorithm are still required.

[Paediatric anaesthesia]. / Anestesi til barn.

BACKGROUND: Paediatric anaesthesia comprises newborn, infants and children, necessitating a variety of techniques and approaches. MATERIAL AND METHODS: This review is based on textbooks in paediatric anaesthesia, papers from major anaesthetic journals and many years of clinical experience. RESULTS: Only a few Norwegian university hospitals have full-time paediatric anaesthesiologists. Anaesthesia in infants is associated with a higher frequency of morbidity and mortality than in adults; laryngospasm and emergency delirium are more common. Calculation of the amount of intravenous fluid and medication doses must be based on weight. Techniques such as mask inhalation for induction and caudal regional anaesthesia are used more frequently in children. Disease and congenital malformations can lead to anaesthetic problems. It is therefore important for the anaesthesiologist to have all available information preoperatively. INTERPRETATION: Paediatric anaesthesia presents special challenges. Safe practice requires experience and knowledge of age-related anatomy, physiology and pathology.

Sexual function in ICU survivors more than 3 years after major trauma.

OBJECTIVE: To study sexual function in trauma patients 3-8 years after discharge from an ICU and to assess determinants of poor sex life. DESIGN AND SETTING: A postal questionnaire survey was conducted in 2006 on a cohort of 325 consecutive adult ICU trauma patients admitted to a university hospital during 1998-2003. PATIENTS: Of 210 eligible patients 156 (74%) answered the questionnaires. Mean age was 46 years, and 124 were males. MEASUREMENTS AND RESULTS: Sexual function was assessed by a self-report measure, and patients were asked to describe sexual life both currently and prior to trauma. The International Index of Erectile Function evaluated erectile function in males. At follow-up 50% reported sexual function to be unchanged, 41% impaired, and 9% to be better than preinjury status; 34% reported that the trauma impaired current sex life. Erectile dysfunction was found in 27% of men younger than 40 years and 51% of men 40 years or older. Age, being single, Injury Severity Score, and depression were associated with poor sexual function. Of 17 patients experiencing breakdown of a regular relationship 71% reported the trauma to be a significant contributor. CONCLUSIONS: At follow-up more than 3 years after injury one-third of our ICU trauma patients reported that the trauma impaired sexual function. Erectile dysfunction was significantly more frequent among men younger than 40 years than found in studies of the normal population. Evaluation of sexual function should be part of long-term outcome assessment after major trauma.

Multiple organ failure after trauma affects even long-term survival and functional status.

BACKGROUND: The aim of this study was to assess the incidence of organ failure in trauma patients treated in an intensive care unit (ICU), and to study the relationship between organ failure and long-term survival and functional status. METHODS: This is a cohort study of all adult ICU trauma patients admitted to a university hospital during 1998 to 2003. Organ failure was quantified by the Sequential Organ Failure Assessment (SOFA) score. A telephone interview was conducted in 2005 (2 to 7 years after trauma) using the Karnofsky Index to measure functional status, and the Glasgow Outcome Score to measure recovery. RESULTS: Of the 322 patients included, 47% had multiple organ failure (MOF), and 28% had single organ failure. In a Cox regression, MOF increased the overall risk of death 6.0 times. At follow-up, 242 patients (75%) were still alive. Patients with MOF had 3.9 times greater odds for requiring personal assistance in activities of daily living compared to patients without organ failure. Long-term survival and functional status were the same for patients suffering single organ failure and no organ failure. Complete recovery occurred in 52% of survivors, and 87% were able to look after themselves. CONCLUSION: Almost half of the ICU trauma patients had MOF. While single organ failure had no impact on long-term outcomes, the presence of MOF greatly increased mortality and the risk of impaired functional status. MOF expressed by SOFA score may be used to define trauma patients at particular risk for poor long-term outcomes.

Follow-up after intensive care: a single center study.

OBJECTIVES: To study health problems, quality of life, functional status, and memory after intensive care. SETTING: Adult patients ( n=346) discharged from a university hospital ICU. DESIGN AND METHODS: Prospective cohort study. Follow-up patients were found using the ICU database and the Peoples Registry. Quality of life (QOL) was measured with the Short Form 36 (SF-36) 6 months after ICU discharge. Semi-structured interviews, questionnaires, Glasgow Outcome Score (recovery), and Karnofsky Index (functional status) were used at consultations 7-8 months after ICU discharge. RESULTS: The SF-36 response rate was 64.5%, with scores significantly lower than population scores. Consultation patients ( n=136) did not differ from the rest ( n=210) regarding age, SAPS II scores, length of stay (LOS), and reasons for ICU admission. At follow-up 67.6% of consultation patients continued most activities, 75% looked after themselves, and 64.7% were non-workers, compared to 40.4% before the ICU admission. During and after the ICU stay, 40% lost more than 10 kg body weight. Fifty-eight (43%) could not remember anything from their ICU stay. At follow-up only 22 (16%) could remember having received information during their ICU stay. Three patients needed referral to other specialties. CONCLUSIONS: We should focus more on optimizing symptom management and giving repeated information after ICU discharge. Nutritional status and weight loss is another area of concern. More research is needed to find out how the broad range of psychosocial and physical problems following an ICU stay relates to the stay.

[Rescue helicopter service in Bodö--advanced emergency service or alternative transportation?]. / Redningshelikoptertjenesten i Bodø--avansert akuttmedisin eller alternativ transport?

BACKGROUND: An increase in fatal accidents in helicopter ambulance missions in Norway has put focus on the guidelines for use. METHODS: Ambulance records from the physician-staffed SeaKing rescue helicopter in Bodø, Northern Norway, from 1988 to 1998 were analysed retrospectively. RESULTS: 2,498 ambulance missions carried 2,590 patients. Median time to lift-off was 29 minutes, and one-way median flying time was 26 minutes. Four local communities with a total of 12,000 residents (6.3% of the population served by the helicopter) ordered 70% of the missions. 35% of the patients suffered from cardiovascular disease, 12% were in labour, 3.2% were seriously traumatized, while 20% had minor injuries. A total of 107 patients (4%) received advanced pre-hospital emergency treatment. Thirty-eight (1.5%) were intubated and received cardiopulmonary resuscitation, of whom two survived to discharge. Over a period of 11 years, 53 patients were intubated by the anaesthesiologist. Oxygen or intravenous lines as the only treatment effort were given to 72%. INTERPRETATION: It takes about an hour to reach remote locations by rescue helicopter. A substantial amount of the transports could have been carried out by ground ambulance without loss of health benefit. We question the need for an on-board anaesthesiologist.