Intensive care doctors' preferences for arterial oxygen tension levels in mechanically ventilated patients.

BACKGROUND: Oxygen is liberally administered in intensive care units (ICUs). Nevertheless, ICU doctors' preferences for supplementing oxygen are inadequately described. The aim was to identify ICU doctors' preferences for arterial oxygenation levels in mechanically ventilated adult ICU patients. METHODS: In April to August 2016, an online multiple-choice 17-part-questionnaire was distributed to 1080 ICU doctors in seven Northern European countries. Repeated reminder e-mails were sent. The study ended in October 2016. RESULTS: The response rate was 63%. When evaluating oxygenation 52% of respondents rated arterial oxygen tension (PaO2 ) the most important parameter; 24% a combination of PaO2 and arterial oxygen saturation (SaO2 ); and 23% preferred SaO2 . Increasing, decreasing or not changing a default fraction of inspired oxygen of 0.50 showed preferences for a PaO2 around 8 kPa in patients with chronic obstructive pulmonary disease, a PaO2 around 10 kPa in patients with healthy lungs, acute respiratory distress syndrome or sepsis, and a PaO2 around 12 kPa in patients with cardiac or cerebral ischaemia. Eighty per cent would accept a PaO2 of 8 kPa or lower and 77% would accept a PaO2 of 12 kPa or higher in a clinical trial of oxygenation targets. CONCLUSION: Intensive care unit doctors preferred PaO2 to SaO2 in monitoring oxygen treatment when peripheral oxygen saturation was not included in the question. The identification of PaO2 as the preferred target and the thorough clarification of preferences are important when ascertaining optimal oxygenation targets. In particular when designing future clinical trials of higher vs lower oxygenation targets in ICU patients.

Gender differences in randomised, controlled trials in intensive care units.

There is a male dominance among patients in intensive care units (ICUs). Potentially, this will increase the risk of a skewed male/female distribution in randomised, controlled trials (RCTs). We have evaluated if this has in fact happened when randomising and whether the authors have been aware of that. We performed a systematic search on PubMed from 1 January 2011 to 31 May 2012 using the mesh terms 'randomized controlled trial' and 'intensive care unit'. Twenty-five RCTs with a total of 12,788 patients met the inclusion criteria, with an overall male dominance of 63.6% (P < 0.0001). Eighteen of the 25 papers had an individually statistically significant gender difference in their total trial population. None of the 18 trials with a significant gender difference in their overall trial population had calculated the P-value for this overall difference. In the randomised groups, there was a significant gender difference in five papers. Seventeen had no significant gender difference in the randomised groups, and three papers did not state gender in the randomised groups. This study show that there is a marked male dominance in RCTs conducted in ICUs. We recommend that when planning future RCTs, the authors contemplate if their results can be used indiscriminately among ICU patients if the distribution of males and females is much skewed. It is relevant to determine if ones endpoint can be influenced by gender differences and if there is a risk of gender influence on data, proportional allocation or stratification should be considered.

Non-invasive ventilation in do-not-intubate patients: five-year follow-up on a two-year prospective, consecutive cohort study.

BACKGROUND: End-of-life decisions are common in intensive care units (ICUs), and increasingly, non-invasive ventilation (NIV) is used as a ceiling of ventilatory care. However, little is known about the outcome following that decision. METHODS: An observational, single-center, retrospective, follow-up study with no interventions, on ICU patients treated with NIV and a do-not-intubate (DNI) order. The patients were followed until a 5-year survival rate could be calculated. RESULTS: One hundred and fifty-seven patients were treated with NIV during 2002 and 2003, and among 38 a DNI order was in effect. Of the 38 DNI patients, 11 died in the ICU, 16 died on the ward and 11 survived the hospital stay. Five of these 11 survivors died within 6 months, two died after 2.7 and 3.3 years, respectively, but four were still alive after 5 years. The long-term (>6 months) survivors have, surprisingly only been admitted to the hospital 0-2 times a year - and seldom with the need for ICU treatment. CONCLUSIONS: According to this study, and previous ones, it seems worthwhile treating DNI patients with NIV. Twenty-five to 35% leave the hospital alive, every 6th patient lives for at least 1 year, and this paper shows that 10% may survive for 5 years or more. However, only chronic obstructive pulmonary disease and chronic heart failure patients (both with a concomitant low APACHE score) seem to have a reasonable outcome, and patients should be informed about this. So far, no study has investigated the quality of life of these survivors.

Experiences from introducing non-invasive ventilation in the intensive care unit: a 2-year prospective consecutive cohort study.

OBJECTIVE: To describe 2 years of experience and staff learning curves after the introduction of non-invasive ventilation (NIV). METHODS: A prospective, consecutive, strictly observational, 2-year cohort study of all patients treated with NIV in a county general hospital intensive care unit (ICU), with no interventions, was performed. RESULTS: One hundred and fifty-seven patients with 15 different diagnoses were treated with NIV. An increasing number of patients were treated in the second year and, probably as a result of increased staff experience, the NIV treatment time and overall time spent in the ICU were less in the second year of the study period (30 h vs. 19 h and 55 h vs. 34 h, respectively; P < 0.05). Patients were also intubated earlier if NIV failed during the second year. Of the 157 patients, 119 had a full treatment option (i.e. including the possibility of invasive mechanical ventilation) and 26% died; their Acute Physiology and Chronic Health Evaluation II (APACHE II)- and Simplified Acute Physiology II (SAPS II)-predicted death rates were 31% and 32% respectively (not significant, NS). The overall mortality rate in all NIV patients was 38%, compared with predicted death rates of 36% and 33%, respectively (NS). 'Do-not-intubate' orders were issued for 38 of the 157 patients, and 11 of these (29%) left the hospital alive. Patients treated successfully with NIV had significantly lower APACHE II scores than those in whom it failed (18.8 vs. 22, P= 0.01). CONCLUSION: With increasing staff experience, more patients may be treated with NIV and the treatment period decreases significantly. Weaning from NIV has almost exclusively been taken over by nurses. Unselected cohorts of patients with chronic obstructive pulmonary disease can be treated successfully with NIV, and NIV offers a treatment option even for some patients with a 'do-not-intubate' order.

Lactic acidosis following convulsions.

Lactic acidosis is a common cause of metabolic acidosis and is usually connected with high mortality. However, changes in the level of lactate and pH can also be seen after generalized epileptic attacks, due to local muscle hypoxia during the seizures. Although these changes can be quite marked, the condition is self-limiting and usually does not call for any specific treatment. We report five cases of lactic acidosis following convulsions from our centre.

Management of postoperative pain. An intervention study.

BACKGROUND: In 1989 a study had shown that the quality of postoperative pain treatment (PPT) in a district general hospital was not satisfactory. Therefore, new instructions for PPT were issued, intra-venous medication with morphine was introduced on the wards, and the staff was educated in PPT. The purpose of this study was to investigate the quality of PPT in 1992 compared to the quality in 1989. METHODS: Using identical questionnaires, 191 patients in 1989 and 126 patients in 1992 were interviewed before and 2-5 days after surgery regarding postoperative pain. At the postoperative interview patients in pain also filled out the McGill Pain Questionnaire. A questionnaire was also answered by the nurses regarding PPT in 1989 and in 1992. RESULTS: 1992 compared to 1989 (1992/1989): all patients were now medicated (100%/93%), most of them regularly (79%/ 4%) and the majority (94%/15%) also received non-opioid analgesic. Fewer patients (65%/80%) experienced postoperative pain lasting more than one day following surgery. Analgesic prescription was more standardized. In 1992 the nurses were more satisfied than in 1989 with the PPT and the physicians' prescribing patterns. All the above-mentioned parameters were significantly improved from 1989 to 1992. All the different pain-scores showed a reduction (8-30%) but did not reach statistical significance (P = 0.2). CONCLUSIONS: Our two investigations show that it is possible to improve the quality of pain management with rather simple reforms.

Respiratory changes during treatment of postoperative pain with high dose transdermal fentanyl.

This study made a longterm (72 hours) evaluation of the efficacy and possible side-effects of transdermal delivery of fentanyl (TTS-system) for post-operative pain relief. The study was double-blind, placebo-controlled with either a TTS-system delivering fentanyl 100 micrograms.h-1 and rescue analgesic on demand or a placebo system and analgesic on demand. Analgesic consumption, pain, general satisfaction, respiratory rate, and levels of SpO2 and tcCO2 (pulse oximetry and transcutaneous CO2 measuring) were evaluated. Recruitment was stopped after enrolment of 24 patients, on safety grounds. The Fentanyl group was more satisfied with postoperative pain relief (P = 0.008); they had a lower analgesic demand (P < 0.05) but also a lower respiratory rate (P < 0.05) and a higher level of tcCO2 23 hours after application (P < 0.05). There were three cases (25%) of increased PaCO2 (> 6.5 kPa) in the Placebo group but without low PaO2 levels, sedation or bradypnoea. Conversely, there were three cases (33%) in the Fentanyl group with bradypnoea (< 10 breaths/minute), two without influence on PaO2 or PaCO2, but one (no. 24) with bradypnoea, heavy sedation, a marked decrease in PaO2 (5.8 kPa) and increased PaCO2 (7.5 kPa). These findings terminated the study. The 100 micrograms transdermal fentanyl system is agreeable to the patients, but apparently too potent for routine postoperative pain relief due to a risk of respiratory depression. Respiratory frequency can not be relied upon as sole indicator of insufficient respiration.

[Quality assurance in postoperative pain treatment]. / Kvalitetsvurdering af postoperativ smertebehandling.

One hundred and ninety-one patients were interviewed before and after surgery about their attitude toward and the quality of received pain relief. The nurses working in the same surgical units answered a questionnaire covering attitudes to postoperative pain and pain treatment. Forty-seven percent of the patients were in pain at the time of the postsurgical interview, 10% had not any analgesic prescribed at all, and 15% had received less than prescribed. Fifty-one nurses (71% of the total nursing staff) answered the questionnaire. Of these, 63% were sometimes in doubt about the physicians' prescriptions, 55% would occasionally refuse to give analgesics for various reasons, and 37% were not satisfied with the routines of pain control in their ward. Knowledge of pain treatment and communication between surgeons, anaesthesiologists, nurses and patients must be improved to make postsurgical pain relief adequate.

[Acupuncture treatment of knee arthrosis. A long-term study]. / Akupunkturbehandling til knaeartrose. Et langtidsstudie.

The purpose of this study was to examine acupuncture treatment of patients with osteoarthrosis of the knee. Twenty-nine patients with a total of 42 osteoarthritic knees were randomized to two groups. Group A was treated while group B served as a no treatment control group for nine weeks. Analgesic consumption, pain and objective measurements were registered. In the second part of the study 17 patients (26 knees) continued with treatments once a months. Registrations were continued for a total study period of 49 weeks. Comparing group A with B, there was a significant reduction in pain, analgesic consumption and in most objective measures. In group A + B combined there was an 80% subjective improvement, and a significantly increased range of movement of the knee. Results were significantly better in those who had not been ill for a long time. The second part of the study showed that it was possible to maintain the improvements.

[Loop diuretics. Rational pharmacotherapy]. / Slyngediuretika. Rationel farmakoterapi.

UNLABELLED: The pharmacodynamics and -kinetics as well as rational pharmacotherapy of furosemide and bumetanide is reviewed. In renal insufficiency, a reduced response to diuretics is due to altered pharmacokinetics. The optimum dose can be determined within three to four hours by titration and the effect is measured by the amount of excreted sodium. In nephrotic syndrome, both pharmaco-kinetics and--dynamics are altered. The optimum dose is established as above. Starting and ceiling doses are given in tables for both drugs in renal insufficiency and nephrotic syndrome. In congestive heart failure, the difference is greater between oral and intravenous doses than apparent from the bioavailability of the drugs. If potent diuretics are without effect, the heart failure must be treated more vigorously or a combination with thiazides tried out. Potent diuretics are seldom used in the treatment of liver cirrhosis, but, if used, large doses are necessary. Non-steroidal antiinflammatory drugs are usually considered contra-indicated in patients with severe renal insufficiency, since the pharmacodynamics of the diuretics are altered. CONCLUSION: The general strategy when using potent diuretics is titration to an effective dose and then using this dose as frequently as needed in order to obtain the desired response.

[CT and magnetic resonance imaging and spectroscopy for non-invasive study of regeneration of skeletal musculature after intensive therapy]. / CT og magnetisk resonansbilleddannelse og-spektroskopi anvendt til ikkeinvasiv undersøgelse af skeletmuskulaturs regeneration efter intensiv terapi.

UNLABELLED: A 50 year old man was treated in the intensive care unit. Due to a prolonged catabolic state with a loss of 35 kg of body weight, he was practically paralyzed following 70 days of treatment. After 200 days of intensive physical training, he had recuperated remarkably. CT-scans before and after the physical training revealed 90-180% increase in the muscles examined. At the femoral level the muscle/fat ratio increased from 40% to 70%, indicating less atrophy. MR-imaging of the crural muscles showed a substantial increase in the muscle mass after training. MR-fat/water proton spectra showed a decrease in the relative fat content from 0.31 to 0.13 during training, objectively measuring the remission of the severe atrophy. CONCLUSION: CT- and MR-techniques can be used for objective, non-invasive, evaluations of muscle condition, and MR-proton spektroscopy can probably be used for following the remission of muscle atrophy during physical training.

[Infections after insertion of epidural catheters]. / Infektioner efter anlaeggelse af epiduralkateter.

Three cases of iatrogenic infection following the insertion and subsequent use of an epidural catheter are described. The development, symptoms, diagnostic possibilities and treatment of epidural abscess are described. It is stressed that patients with decreased immunological defences are more prone to infection. Two patients with epidural abscesses are described. In both cases there was a "doctors-delay" before diagnosis was reached. Despite neurosurgical intervention both patients developed paralysis of the lower extremities, bladder and intestinal function, in one of them irreversibly. We also describe one patient who developed meningitis following eight attempts to insert an epidural catheter. The importance of quick diagnosis and intervention is stressed as well as the importance of strict sterility while inserting and using epidural catheters.

Postoperative pain relief, from the patients' and the nurses' point of view.

UNLABELLED: In this prospective, consecutive study, 191 patients were interviewed before and after surgery (orthopaedic, gynaecological, abdominal and urological operations) about their attitude to and the quality of received pain relief, respectively. In addition, nurses working in the surgical units involved in the study were asked to answer a questionnaire covering attitudes to postoperative pain and pain treatment. Of the patients, 47% were in pain at the time of the postsurgical interview, 10% had not any analgesic prescribed at all and 15% had received less than prescribed. In 36% of the cases there was a discrepancy between the amount of analgesic prescribed by the surgeon and the amount prescribed by the anaesthetist. In 80% of the patients the pain outlasted the first postoperative day, but only 64% would always tell the staff if they had pain. Seventeen per cent of the patients had never been asked about their postoperative pain status. Preoperative pain had a significant correlation to postoperative pain. Although the results are not impressive, they do constitute some improvement compared to previously published studies. Fifty-one nurses (71% of the total nursing staff) answered the questionnaire. Of these, 63% were sometimes in doubt about the physicians' prescriptions, 55% would occasionally refuse to give analgesics for various reasons, and 37% were not satisfied with the routines of pain control in their ward. CONCLUSION: Knowledge of pain treatment and communication between surgeons, anaesthesiologists, nurses and patients must be improved to make postsurgical pain relief adequate.

Acupuncture treatment of severe knee osteoarthrosis. A long-term study.

PURPOSE: Acupuncture treatment of patients waiting for arthroplasty surgery. METHODS: 29 patients with a total of 42 osteoarthritic knees were randomized to two groups. Group A was treated while Group B served as a no-treatment control group. After 9 weeks Group B was treated too. Analgesic consumption, pain and objective measurements were registered. All objective measures were done by investigators who were "blinded" as to Group A & B. In the second part of the study 17 patients (26 knees) continued with treatments once a month. Registration of analgesic consumption, pain and objective measurements continued. Total study period 49 weeks. RESULTS: Comparing Group A to B there was a significant reduction in pain, analgesic consumption and in most objective measures. In Group A + B combined there was an 80% subjective improvement, and a significantly increased knee range movement - an increase mainly in the worst knees. Results were significantly better in those who had not been ill for a long time. In the second part of the study, it was shown that it was possible to maintain the improvements. CONCLUSIONS: Acupuncture can ease the discomfort while waiting for an operation and perhaps even serve as an alternative to surgery. Seven patients have responded so well that at present they do not want an operation. (USD 9000 saved per operation).

Predictive value of subjective and objective evaluation before acupuncture treatment.

To evaluate if it is possible to predict the outcome of acupuncture treatment in patients with knee osteoarthrosis, six treatments were given during a 3 week period. Follow-up time was 9-17 weeks. Seven parameters were evaluated to examine if they had any influence on the outcome of treatment: Age, duration of disease, pain, range of knee movement, analgesic consumption, knee score (an objective and subjective evaluation of the knees) and x-ray changes. Twenty-nine patients were included with a total of 42 osteoarthritic knees waiting for a total knee replacement. The median age was 69.2 years, and median duration of disease was 4.2 years. 85% of the participants reported a subjective effect, and in 88% an objective effect was found. Although there were some significant differences when you looked at the 7 parameters above, the pattern was not a consistent one. Follow up results also indicated that those with the best immediate results, not necessarily were the ones with the best long-term effect. It is not possible to predict the outcome of acupuncture treatment of osteoarthritic knees. Immediate results are not a guide-line for long-term results, which indicate that acupuncture research must include a follow-up period.

[Condoms and adolescents. A prospective study of a new method of teaching]. / Kondomer og unge. Prospektiv undersøgelse af en ny undervisnigsmetode.

A prospective investigation was carried out with the object of assessing the effect of supplementary sex education for 1.3 hours in addition to the compulsory sex education in Danish elementary schools. One doctor did the teaching and practice with a condom was introduced as a new method of teaching. On an average, seven weeks before and seven weeks after this teaching session, these pupils completed a questionnaire. Altogether 451 pupils from the eighth and ninth classes participated. Great changes had occurred in the methods of contraception employed by the adolescents and in their attitudes to these from 1982 to date. Many more of the adolescents consider today that condoms provide the best form of contraception as compared with oral contraception. Nevertheless, only 9% of the adolescents were able to use a condom correctly. After the teaching session, knowledge about the correct use of a condom was significantly better and more had a positive attitude to condoms. A balance in information about methods of contraception is recommended and the young people should be sent to their own general practitioners for individual advice. On the basis of the results of this investigation, this teaching should be given already to pupils in the eighth classes.

PIP: A prospective investigation was conducted to assess the effect of supplementary sex education for 1.3 house in addition to the compulsory sex education component in Danish elementary schools. 1 doctor did the teaching and practice with a condom was introduced as a new element in the teaching process. Students completed questionnaires both 7 weeks prior to 7 weeks after this teaching session; a total of 451 pupils from the 8th and 9th grades participated. From 1982 to the current time, there were great changes in the methods of contraception used by adolescents as well as in their attitudes. While more adolescents today consider the condom to provide the best form of contraception, nevertheless only 9% were able to use one correctly. After the teaching session, knowledge about how to use a condom correctly was significantly better and there was an overall improvement in attitude towards this method. A balance in information about methods of contraceptive is recommended and young people should see their own physicians for individual advice. The results of this investigation indicate that this additional teaching component is essential for those pupils already in the 8th grade. (author's modified)