Intravenous dexamethasone in pain treatment after video-assisted thoracoscopic surgery.

INTRODUCTION: Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure. Despite being less invasive than thoracotomy, post-operative pain remains a significant clinical problem. The aim of this study was to investigate if perioperative intravenous (IV) dexamethasone improves pain management in VATS. METHODS: Thirty-seven patients undergoing VATS with confirmed or suspected lung cancer were enrolled. The first 20 patients received standard care (Group 1) and the following 17 patients received standard care with addition of IV dexamethasone 8 mg (Group 2). The primary outcome was total opioid consumption during the first 24 hours after surgery. RESULTS: The baseline characteristics between groups were comparable. After adjusting for gender and duration of surgery, the median difference of total equianalgesic dose of opioid was 23 mg (p = 0.005). Group 2 had a significantly lower median pain score at rest. The first opioid dose was administered earlier in Group 1: 1.5 hours compared with to 6.9 hours in Group 2 (p = 0.020). Time to full mobilisation was longer in Group 1, with a mean of 12 hours (p = 0.018). CONCLUSION: This study suggests that addition of IV dexamethasone in VATS may reduce the need for opioids and facilitate early mobilisation. FUNDING: The study was funded by the Department of Clinical Medicine, Aalborg University, Aalborg, Denmark TRIAL REGISTRATION. The study is registered with ClinicalTrials.gov (NCT04633850). The study was conducted in accordance with the Declaration of Helsinki and all participants provided written consent.

Neuropathic pain after orthopaedic surgery with continuous peripheral nerve block.

INTRODUCTION: Continuous peripheral nerve blocks (cPNBs) have shown favourable post-operative pain control results but may be associated with a risk for long-term neurological complications. This study sought to examine factors associated with persistent post-operative pain and potential neuropathy after orthopaedic lower-limb surgery with the use of post-operative cPNB. METHODS: Patients who underwent lower limb orthopaedic procedures with cPNBs between November 2021 to May 2022 were included. Patient demographics and perioperative data were noted. At discharge, patients completed the PainDetect (PD) questionnaire and were followed up six months after discharge. RESULTS: Seventy-seven patients with a total of 171 catheters completed the follow up. The median time to follow-up was 214 days after catheter removal, and 18 patients (23%) had a PD score ≥ 13. Univariate analysis showed that multiple variables were associated with a PD score ≥ 13 at the six-month follow-up. Multiple logistic regression showed that a high PD score at discharge, high BMI and longer duration of cPNBs were associated with higher risk of having a PD score ≥ 13 at the six-month follow-up. CONCLUSION: Several factors were associated with a higher risk of having possible neuropathy after six months. BMI, duration of catheter and PD score at discharge were correlated with risk of possible neuropathic pain. FUNDING: None. TRIAL REGISTRATION: The study was a quality control project and therefore did not require registration under Danish law.

Outpatient pain service in trauma and orthopaedic surgery.

INTRODUCTION: Chronic pain is a common complication after surgery and trauma. The incidence of chronic pain may potentially be reduced by effective management of severe acute pain, in hospital and during the subacute post-operative phase at home. METHODS: This was a cohort study from an outpatient follow-up service for patients with pain at discharge after orthopaedic surgery and trauma in a level 1 university hospital setting. The patients' charts were reviewed. Demographics, diagnosis and treatment were registered. The objective of this study was to describe the first five years of experience with this service. RESULTS: A total of 261 patients were included. The median age was 39 (interquartile range (IQR): 26-76) years, and 53% were men. The median pain duration was ten (IQR: 5-22) months. Neuropathic pain was diagnosed in 83% of patients. Complex regional pain syndrome was diagnosed in 10% and suspected in 8%. Before the consultation, 48% were using paracetamol and/or non-steroid anti-inflammatory drugs (NSAIDs), 25% opioids, and 36% used gabapentioids or antidepressants. After their consultation, only 13% used paracetamol and/or NSAIDs and 8% opioids, whereas 86% were treated with gabapentinoids or antidepressants. A plan for opioid weaning was provided for all patients if opioids were continued (8%). CONCLUSIONS: Establishing an outpatient pain service for persistent pain after surgery and trauma may encourage the use of analgesia regimens that are in accordance with international guidelines and ensure that opioids are not continued inappropriately. FUNDING: None. TRIAL REGISTRATION: Not relevant.

Perioperative anaesthesia by local infiltration following median sternotomy - a study protocol.

INTRODUCTION: Post-operative pain following open heart surgery is a clinical challenge usually requiring significant amounts of opioids. Long-acting local infiltration anaesthesia may effectively reduce post-operative opioid consumption and improve recovery. The trial is a publicly funded, double-blinded, randomised, placebo-controlled trial evaluating the effect of long-acting local infiltration anaesthesia in open heart surgery. METHODS: Two Danish centres are planning to randomise 100 patients undergoing coronary artery bypass grafting to treatment with long-acting infiltration anaesthesia or placebo. We compare an active solution of bupivacaine, adrenaline, clonidine and dexamethasone with saline placebo. The primary outcome measure is the accumulated opioid use within the first 24 post-operative hours. Secondary outcome measures include evaluation of respiratory function, patient-reported pain scores, mobilisation, opioid-associated side effects and long-term opioid consumption. CONCLUSION: This trial will define whether the use of long-acting infiltration anaesthesia during heart surgery may reduce acute and prolonged post-operative opioid consumption. Reduction of opioid-related adverse effects may improve recovery. FUNDING: The trial is supported by public grants (Dansk Selskab for Anæstesiologi og Intensiv Medicin: 40,000 DKK; Regionernes Medicin og Behandlingspulje 2022: 686,000 DKK). The work of I. S. Modrau is supported by an unrestricted grant from the Health Research Foundation of the Central Denmark Region. TRIAL REGISTRATION: EudraCT 2021-005886-41.

Collaboration for Evidence-based Practice and Research in Anaesthesia (CEPRA): A consortium initiative for perioperative research.

Evidence in perioperative care is insufficient. There is an urgent need for large perioperative research programmes, including pragmatic randomised trials, testing daily clinical treatments and unanswered question, thereby providing solid evidence for effects of interventions given to a large and growing number of patients undergoing surgery and anaesthesia. This may be achieved through large collaborations. Collaboration for Evidence-based Practice and Research in Anaesthesia (CEPRA) is a novel collaborative research network founded to pursue evidence-based answers to major clinical questions in perioperative medicine. The aims of CEPRA are to (1) improve clinical treatment and outcomes and optimise the use of resources for patients undergoing anaesthesia and perioperative care, and (2) disseminate results and inform caretakers, patients and relatives, and policymakers of evidence-based treatments in anaesthesia and perioperative medicine. CEPRA is inclusive in its concept. We aim to extend our collaboration with all relevant clinical collaborators and patient associations and representatives. Although initiated in Denmark, CEPRA seeks to develop an international network infrastructure, for example, with other Nordic countries. The work of CEPRA will follow the highest methodological standards. The organisation aims to structure and optimise any element of the research collaboration to reduce economic costs and harness benefits from well-functioning research infrastructure. This includes successive continuation of trials, harmonisation of outcomes, and alignment of data management systems. This paper presents the initiation and visions of the CEPRA network. CEPRA aims to be inclusive, patient-focused, methodologically sound, and to optimise all aspects of research logistics. This will translate into faster research conduct, reliable results, and accelerated clinical implementation of results, thereby benefiting millions of patients whilst being cost and labour-saving.

The effects of ultrasound guidance on first-attempt success for difficult peripheral intravenous catheterization: a systematic review and meta-analysis.

Identifying patients at risk of difficult intravenous access (DIVA) and increasing the success rates of peripheral intravenous catheterization (PIVC), preferably on the first catheterization attempt, is of clinical importance. The aim of this study was to compare the use of dynamic ultrasound guidance for PIVC with the traditional technique of visualization and palpation in patients with predicted DIVA. A systematic review and meta-analysis comparing ultrasound-guided PIVC with the traditional technique was performed. Data were systematically collected through MEDLINE and EMBASE databases from inception to March 2021. Eligibility criteria included randomized controlled trials performed on patients meeting criteria for difficult catheterization comprising either (a) no palpable or visible veins, (b) previous history of difficult venous catheterization, (c) patient age less than 4 years, (d) suspicion of difficult catheterization by operator, or (e) two or more unsuccessful attempts using the traditional technique before enrollment were included. For all outcomes, a random-effects meta-analysis using the DerSimonian and Laird method was performed. The primary outcome was the first-attempt success rate, and the secondary outcomes were the overall success rate and the number of attempts for successful intravenous catheterization. Bias was assessed using the Revised Cochrane Risk of Bias tool. Seven studies with a total of 994 patients were included. Patients comprised both children and adults and settings included operating rooms, emergency departments, and intensive care units. Ultrasound guidance was associated with a higher first-attempt success rate (OR, 3.07; 95% CI, 1.66-5.65; P < 0.001). For the secondary outcomes, ultrasound guidance was associated with a higher overall success rate (OR, 3.02; 95% CI, 1.04-8.79; P = 0.04); however, this finding did not meet statistical significance in a sensitivity analysis (OR, 2.90; 95% CI, 0.71-11.93; P = 0.14). Ultrasound was not associated with a significantly different number of attempts compared with the traditional technique (difference in means, 0.14; 95% CI, -0.32 to 0.05; P = 0.15). The use of ultrasound guidance resulted in a three-fold increase in odds for the first-attempt success rate in patients with predicted DIVA compared with the traditional technique of PIVC.

Harlequin Syndrome Related to Perioperative Intercostal Blockade: A Case Report.

Harlequin syndrome is a rare syndrome characterized by hemifacial flushing and altered facial sweating, with only a few case reports related to intercostal blockades. We present a case of Harlequin syndrome in a 65-year-old woman after intercostal blockade for video-assisted thoracoscopic lobectomy. One hour postoperatively, the patient became nauseated and presented with flushing of the right half of the face with a clear line of demarcation. Within 3 hours, the flushing disappeared. In this case report, we discuss Harlequin syndrome in relation to intercostal blockade and encourage clinicians to consider this syndrome in the differential diagnosis when encountering similar symptoms.

Does the performance of lower limb peripheral nerve blocks differ among orthopedic sub-specialties? A single institution experience in 246 patients.

OBJECTIVES: Continuous peripheral nerve blocks (cPNBs) have shown promising results in pain management after orthopaedic surgeries. However, they can be associated with some risks and limitations. The purpose of this study is to describe our experience with the cPNBs regarding efficacy and adverse events in patients undergoing orthopedic surgeries on the lower extremity in different subspecialties. METHODS: This is a prospective cohort study on collected data from perineural catheters for pain management after orthopedic surgeries in lower limbs. Catheters were placed by experienced anesthesiologists using sterile technique. After an initial bolus dose of 10-20 mL ropivacaine 0.5% (weight adjusted), the catheters were secured and connected to disposable mechanical infusion pumps with ropivacaine 0.2% (basal infusion rate = 6 mL/h; weight adjusted (0.2 mL/kg/h)). After catheterization, the patients were examined daily, by specially educated acute pain service nurses. Pro re nata (PRN) or fixed boluses (10 mL bupivacaine 0.25%; weight adjusted) with an upper limit of 4 times/day, were administered if indicated. Patients' demographic data, physiological status, and pre-op intake of opioids and other analgesics were registered. The severity of post-operative pain was assessed with 'Numeric Rating Scale' (NRS) and 'Face, legs, Activity, Cry, Consolability' (FLACC) scale for adults and children, respectively. The need for additional opioids and possible complications were registered. RESULTS: We included 547 catheters of 246 patients (Range 1-10 catheters per patient). Overall, 115 (21%) femoral, 162 (30%) saphenous, 66 (12%) sciatic, and 204 (37%) popliteal sciatic nerve catheter were used. 452 (83%) catheters were inserted by a primary procedure, 61(11%) catheters employed as a replacement, and 34 catheters (6.2%) used as a supplement. For guiding the catheterization, ultrasound was applied in 451 catheters (82%), nerve stimulator in 90 catheters (16%), and both methods in 6 catheters (1.1%). The median duration a catheter remained in place was 3 days (IQR = 2-5). The proportion of catheters with a duration of two days was 81, 79, 73, and 71% for femoral, sciatic, saphenous, and popliteal nerve, respectively. In different subspecialties, 91% of catheters in wound and amputations, 89% in pediatric surgery, 76% in trauma, 64% in foot and ankle surgery, and 59% in limb reconstructive surgery remained more than two days. During first 10 days after catheterization, the proportion of pain-free patients were 77-95% at rest and 63-88% during mobilization, 79-92% of the patients did not require increased opioid doses, and 50-67% did not require opioid PRN doses. In addition to 416 catheters (76%), which were removed as planned, the reason for catheter removal was leaving the hospital in 27 (4.9%), loss of efficacy in 69 (13%), dislodgement in 23 (4.2%), leakage in 8 (1.5%), and erythema in 4 catheters (0.73%). No major complication occurred. CONCLUSIONS: After orthopaedic procedures, cPNBs can be considered as an efficient method for improving pain control and minimizing the use of additional opioids. However, the catheters sometimes might need to be replaced to achieve the desired efficacy.

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.).

Editor's Choice - Regional Versus General Anaesthesia in Peripheral Vascular Surgery: a Propensity Score Matched Nationwide Cohort Study of 17 359 Procedures in Denmark.

OBJECTIVE: Cardiopulmonary comorbidity is common in vascular surgery. General anaesthesia (GA) may impair perfusion and induce respiratory depression. Regional anaesthesia (RA), including neuraxial or peripheral nerve blocks, may therefore be associated with a better outcome. METHODS: This was a nationwide retrospective cohort study. All open inguinal and infra-inguinal arterial surgical reconstructions from 2005 to 2017 were included. Data were extracted from national registries. Multivariable linear and logistic regression models and propensity score matching were used. The propensity score was derived by developing a model that predicted the probability that a given patient would receive GA based on age, comorbidity, anticoagulant medication, procedure type, and the urgency of surgery. Matching was performed in four groups based on American Society of Anesthesiologists' score I - II, score III - V, and gender. Outcome parameters included surgical and general complications (bleeding, thrombosis/embolus, cardiac, pulmonary, renal, cerebral, and >3 days intensive care therapy), length of stay, and 30 day mortality, hypothesising a better outcome after RA. RESULTS: There were 10 509 procedures in the GA group and 6 850 in the RA group. After propensity score matching, 6 267 procedures were included in each group. Surgical and general complications were significantly more common after GA in both matched (3.8 vs. 2.5%, p < .001 and 6.5 vs. 4.2%, p < .001) and unmatched analyses (3.8 vs. 2.5%, p < .001 and 6.5 vs. 4.2%, p < .001). The 30 day mortality rate was significantly higher after GA, in matched and un matched analyses (3.1 vs. 2.4%, p = .019 and 4.1 vs. 2.4%, p < .001). There was no difference in length of stay. CONCLUSION: RA may be associated with a better outcome, compared with GA, after open inguinal and infra-inguinal peripheral vascular surgery. In the clinical context when RA is not feasible, GA can still be considered safe.

Goal-directed therapy with bolus albumin 5% is not superior to bolus ringer acetate in maintaining systemic and mesenteric oxygen delivery in major upper abdominal surgery: A randomised controlled trial.

BACKGROUND: Goal-directed therapy (GDT) is increasingly used in abdominal surgery. Whether crystalloids can exert the same effect as colloid, and how this may affect perfusion, is still unclear. The effect of GDT on the systemic oxygen delivery index (sDO2I) and the mesenteric oxygen delivery index (mDO2I) can be quantified by measuring cardiac index and flow in the superior mesenteric artery, respectively. OBJECTIVE: The aim of this study was to test the hypothesis that intra-operative GDT with bolus human albumin 5% is superior to GDT with bolus ringer acetate in maintaining sDO2I and mDO2I in elective major upper gastrointestinal cancer surgery. DESIGN: Randomised controlled double blinded trial. SETTING: Odense University Hospital, Denmark, from May 2014 to June 2015. PATIENTS: A total of 89 adults scheduled for elective major upper gastrointestinal cancer surgery were randomised and data from 60 were analysed. EXCLUSION CRITERIA: contraindications for using the LiDCOplus system, known allergy to albumin, pre-operative renal failure, pancreatic cancer and pre-operative down staging using chemotherapy and/or radiation therapy, pregnancy. INTERVENTIONS: Patients were randomised to intra-operative GDT with either bolus human albumin or ringer acetate 250 ml, guided by pulse pressure variation and stroke volume. MAIN OUTCOME MEASURES: Changes in sDO2I and mDO2I. Secondary outcomes were changes in other haemodynamic variables, fluid balance, blood transfusions, fluid-related complications and length of stay (LOS) in ICU and hospital. RESULTS: Median [IQR] sDO2I was 522 [420 to 665] ml min m in the ringer acetate group and 490 [363 to 676] ml min m in the human albumin group, P = 0.36. Median [IQR] mDO2I was 12.1 [5.8 to 28.7] ml min m in the ringer acetate group and 17.0 [7.6 to 27.5] ml min m in the human albumin group, P = 0.17. Other haemodynamic comparisons did not differ significantly. More trial fluid was administered in the ringer acetate group. We found no significant difference in transfusions, complications or LOS. CONCLUSION: Bolus human albumin 5% was not superior to bolus ringer acetate in maintaining systemic or mesenteric oxygen delivery in elective major upper gastrointestinal cancer surgery, despite the administration of larger volumes of trial fluid in the ringer acetate group. No significant difference was seen in fluid-related complications or LOS. TRIAL REGISTRATION: https://eudract.ema.europa.eu/ Identifier: 2013-002217-36.

Difficult Tracheal Intubation in Obese Gastric Bypass patients.

BACKGROUND: Endotracheal intubation is commonly perceived to be more difficult in obese patients than in lean patients. Primarily, we investigated the association between difficult tracheal intubation (DTI) and obesity, and secondarily, the association between DTI and validated scoring systems used to assess the airways, the association between DTI and quantities of anesthetics used to induce general anesthesia, and the association between DTI and difficulties with venous and arterial cannulation. METHODS: This is a monocentric prospective observational clinical study of a consecutive series of 539 obese patients undergoing gastric bypass. Tracheal intubation was done preoperatively together with scoring of Intubation Score (IS), Mallampati (MLP), and Cormack-Lehane classification (CLC) and registration of the quantities of anesthetics and total attempts on cannulation. RESULTS: The overall proportion of patients with DTI was 3.5 % and the patients with DTI were more frequently males, had higher CLC, higher American Society of Anesthesiologists physical status classification (ASA), and noticeably, a lower BMI compared to the patients with easy tracheal intubation. After adjustment with multivariable analyses body mass index (BMI) <40, CLC >2, ASA scores >2, and male gender were risk factors of DTI. Males generally had higher CLC, MLP, and ASA scores compared to females, but no difference in BMI. There was no difference in quantities of anesthetics used between the two groups with or without DTI. Intra-venous and intra-arterial cannulation was succeeded in first attempt in 85 and 86 % of the patients, respectively, and there were no association between BMI and difficult vascular access. CONCLUSIONS: We found no association between increasing BMI and DTI.

Aortic aneurysm disease vs. aortic occlusive disease: differences in outcome and intensive care resource utilisation after elective surgery: an observational study.

CONTEXT: Abdominal aortic surgery is a high-risk procedure, with aortic aneurysm and aortic occlusive diseases being the main indications. These groups are often regarded as having equal perioperative risk profiles. Previous reports suggest that the haemodynamic and inflammatory response to aortic clamping is more pronounced in patients with aortic aneurysm disease, which may affect outcome. OBJECTIVES: The aim of this observational cohort study was to evaluate outcome after open elective abdominal aortic surgery, hypothesising a higher 30-day mortality, a higher incidence of postoperative organ dysfunction and a longer length of stay in patients with aortic aneurysm compared with aortic occlusive disease. DESIGN: Cohort observational study based on prospective registrations from national databases. SETTING: Eight Danish hospitals, including four university and four non-university centres, from 1 January 2007 to 1 March 2010. PATIENTS: One thousand two hundred and ninety-three patients scheduled for primary open elective, aortoiliac bypass or aortofemoral bypass procedures or abdominal aortic aneurysm repair. MAIN OUTCOME MEASURES: Mechanical ventilation, acute dialysis, use of vasopressors or inotropes, ICU stay more than 24 h, hospital length of stay and mortality. RESULTS: Compared with aortic occlusive disease, more patients with aortic aneurysm disease had ICU stays more than 24 h (62 vs. 45%, P < 0.001) and more often needed acute dialysis or ventilatory support (17 vs. 11%, P = 0.04). No difference was found in hospital length of stay, 30-day mortality or overall risk of death. Mortality after 1 year was higher in patients with aortic aneurysm disease (8 vs. 4.7%, P = 0.04). CONCLUSION: Patients with abdominal aortic aneurysms were at higher risk of developing postoperative organ dysfunction and required more ICU resources than patients with occlusive disease, despite no differences in hospital length of stay or 30-day mortality. Distinguishing between these two diseases may be useful in planning and distribution of ICU resources and for in future studies.