A survey on perioperative red blood cell transfusion trigger strategies for pediatric patients in the Nordic countries.

BACKGROUND: Transfusion of red blood cells (RBC) to rapidly increase hemoglobin levels have been associated with increased risks and worse outcomes in critically ill children. The international TAXI consensus from 2018 (pediatric critical care transfusion and anemia expertise initiative) recommended restrictive RBC transfusion strategies in pediatric patients. OBJECTIVE: To elucidate physicians perioperative RBC transfusion trigger strategies for pediatric patients in the Nordic countries and to investigate what factors influence the decision to transfuse this group of patients. METHODS: An electronic web-based survey designed by the TransfUsion triggers in Pediatric perioperAtive Care (TUPAC) initiative including six different clinical scenarios was sent to anesthesiologist treating pediatric patients at university hospitals in the Nordic countries on February 1, 2023 and closed May 1, 2023. RESULTS: The study had a response rate of 67.7% (180 responders out of 266 contacted). Median hemoglobin thresholds triggering RBC transfusions were 7.0 [IQR, 7.0-7.3] g/dL in a stable young child (1-year-old), 7.0 [IQR, 7.0-7.0] g/dL in the stable older child (5-year-old), 8.5 [IQR, 8.0-9.0] g/dL in the older child with cardiac disease, 9.0 [IQR, 8.0-10.0] g/dL the older child with traumatic brain injury, 8.0 [IQR, 7.3-9.0] g/dL in stabilized older child with septic shock and 8.0 [IQR, 7.0-9.0] g/dL in the older child with active but non-life-threatening bleeding. Apart from specific hemoglobin level, RBC transfusions were mostly triggered by high lactate level (74.2%), increasing heart rate (68.0%), prolonged capillary refill time (48.3%), and lowered blood pressure (47.8%). No statistical difference was found between the Nordic countries, work experience, or enrollment in a pediatric anesthesia fellowship program regarding RBC transfusion strategies. CONCLUSIONS: Anesthesiologists in the Nordic countries report restrictive perioperative RBC transfusion strategies for children that are mostly in agreement with the international TAXI recommendations. However, RBC transfusions strategies were modified to be guided by more liberal trigger levels when pediatric patients presented with severe comorbidity such as severe sepsis, septic shock, and non-life-threatening bleeding.

End-tidal CO2 in the diagnosis of fluid responsiveness - a systematic review.

INTRODUCTION: An indication of the adequacy of the intra-vascular volume is of importance in critically ill patients. The status of the intravascular volume can be determined from a fluid challenge test. Most tests involve invasive monitoring. An exception is the capnographic measurement of changes in end-tidal (ET) CO2 after a fluid challenge. The method is appealing as it rests on solid physiological ground - the Fick principle and the Frank-Starling mechanism. Furthermore, it is non-invasive and convenient. We report the results of a systematic review of the merits of this method. METHODS: After a registration with PROSPERO, we searched MEDLINE, EMBASE, the Cochrane Library database and trial registers for studies on the diagnostic accuracy of changes in ET-CO2 in fluid responsiveness testing. Test sensitivity, specificity and area under the receiver operating charac-teristics curve (AUROC) were the primary outcome meas-ures. RESULTS: Seven papers met the inclusion criteria. The test was found to have a median sensitivity of 0.75 (range: 0.60-0.91) and a median specificity of 0.94 (range: 0.70-1.00). The median AUROC was 0.82 (range: 0.67-0.94); the diagnostic threshold was an increase in ET-CO2 of 2 mmHg/5%. CONCLUSIONS: Monitoring of ET-CO2 during fluid responsiveness testing provides good diagnostic value with few false negative tests and fewer false positive tests. The included studies have important methodological flaws. It must therefore be acknowledged that the diagnostic value of ET-CO2 monitoring found in the review is overrated and overrated to an unknown degree. Therefore, at the present state of affairs, implementation of the test cannot be considered evidence-based.

[When muscle relaxants have unexpected prolonged duration during anaesthesia]. / Uventet lang virkningsvarighed afmuskelrelaksantia kan forebygges

Muscle relaxation facilitates tracheal intubation and improves surgical conditions during anaesthesia. However, unexpected prolonged muscle relaxation may occur. This article describes important causes of prolonged muscle relaxation and gives suggestions for its prevention. Drug interactions, incomplete reversal, co-morbidity, inaccurate neuromuscular monitoring and critical illness may prolong the effect of muscle relaxants. The anaesthetist must titrate the muscle relaxants using objective neuromuscular monitoring and proper reversal of the blockade when needed.

[Challenges when improving surgical conditions by use of neuromuscular blockade]. / Udfordringer ved brug af muskelrelaksantia til forbedring af kirurgiske forhold.

Neuromuscular blockade (NMB) may pose a clinical dilemma between surgeons' requirements of muscle relaxation and the risk of residual blockade. This review has aimed at describing the challenges when using NMB for optimizing surgical conditions and reasons for inadequate relaxation despite use of NMB. Interdisciplinary collaboration, proper neuromuscular monitoring, knowledge on differences in pharmacodynamics and pharmacokinetics of NMB are essential factors when optimizing surgical conditions by use of NMB.

Guideline for stress ulcer prophylaxis in the intensive care unit.

Stress ulcer prophylaxis (SUP) is commonly used in the intensive care unit (ICU), and is recommended in the Surviving Sepsis Campaign guidelines 2012. The present guideline from the Danish Society of Intensive Care Medicine and the Danish Society of Anesthesiology and Intensive Care Medicine sums up current evidence and gives clinical recommendations for SUP in the ICU. The GRADE approach was used for grading the evidence (www.gradeworkinggroup.org). In conclusion, existing meta-analyses have been underpowered to reach firm conclusions. We recommend not using SUP routinely for adult critically ill patients in the ICU outside the context of randomized controlled trials (GRADE 1C). No robust evidence supports recommendations for subpopulations in the ICU such as septic, burn, trauma, cardiothoracic or enterally fed patients. However, if SUP is considered clinically indicated in individual patients, we suggest using proton pump inhibitors over histamine-2-receptor antagonists (GRADE 2C).

[Possible clinical potential in reverting muscular block with sugammadex in anaesthesia and surgery]. / Muligt klinisk potentiale ved revertering af neuromuskulær blokade med sugammadex ved anæstesi og kirurgi.

Neuromuscular blockers (NMBs) provide good conditions for endotracheal intubation and surgery. NMBs have been associated with higher morbidity and mortality, mainly due to post-operative residual neuromuscular block. This may become history with the advent of sugammadex - an antidote to the NMB rocuronium - which within 1-3 minutes neutralizes the effects of rocuronium. High-dose rocuronium is now an alternative to suxamethonium in acute or short procedures and in a situation, where ventilation/intubating cannot be performed, sugammadex can reverse the rocuronium blockade within minutes.

[Minor head injury can result in fracture of the anterior wall of sinus frontalis]. / Mindre hovedtraume kan medføre fraktur af den anteriore væg i sinus frontalis.

A 17 year-old boy suffered a minor head injury after a somersault in which his knee hit the forehead. He had a swelling over the right frontal sinus with unbroken skin. A computed tomography revealed a fracture of the anterior wall of the frontal sinus with a displaced bone fragment. The posterior wall was undamaged, and no intracranial injury was evident. The nasofrontal duct was intact. The fragment was repositioned surgically without complications. The frontal sinus is considered resistant to low-energy trauma. This dogma, however, has exceptions.

Chronic pain and recurrence after laparoscopic inguinal herniorrhaphy.

Chronic pain after open inguinal herniorrhaphy is a complication with an incidence of 10-20% and recurrence in 2-5% of the patients. We here present our experience with the laparoscopic technique. Patients who had undergone laparoscopic inguinal herniorrhaphy (TAPP) in our department from 1995 to 2002 received a questionnaire (N = 161). Patients were asked whether they had chronic pain or recurrence; if so, they were seen in the outpatient clinic. A total of 146 patients responded to the questionnaire (91%). Chronic pain was found in 6 patients (4%) and recurrence in 2 patients (1.4%); 134 patients (92%) had previously had inguinal herniorrhaphy with an open procedure (all Lichtenstein) on the same side. Of these, 105 (78%) preferred the laparoscopic procedure. Laparoscopic inguinal herniorrhaphy led to a very low incidence of chronic pain and recurrence compared with previous reports in open surgery. The majority of our patients were operated on for recurrent hernias, after which an even lower incidence of chronic pain and fewer recurrences in laparoscopic primary herniorrhaphies could be expected.

[Endoscopic treatment of gastroesophageal reflux disease]. / Endoskopisk behandling af gastroøsofageal reflukssygdom.

Gastroesophageal reflux disease (GERD) is highly prevalent in the general population, and the treatment is mostly medical. However, lifelong therapy with proton pump inhibitors is expensive, and some patients with GERD have surgery because of unsatisfying symptom control, poor compliance or lack of acceptance of lifelong medical therapy. In the last couple of years, four endoscopic treatment options for GERD have evolved. These are endoscopic suturing, gastroplication, local radiofrequency treatment and injection of biopolymer into the gastroesophageal junction. The results so far have been promising regarding symptomatic control and patient satisfaction. The lack of normalized pH in the lower esophagus, however, and the lack of a physiological background for the impressing symptomatic effect, plus the fact that there has been only one sham-controlled randomized clinical trial, suggest that carefulness should be exercised in utilizing the procedures until more solid evidence is available. The methods in themselves are promising, though, and will probably have a natural position in the future treatment of GERD.