Short-term perioperative parecoxib is not detrimental to shaft fracture healing in a rat model.

OBJECTIVES: Experimental studies indicate that non-steroidal anti-inflammatory drugs (NSAIDs) may have negative effects on fracture healing. This study aimed to assess the effect of immediate and delayed short-term administration of clinically relevant parecoxib doses and timing on fracture healing using an established animal fracture model. METHODS: A standardized closed tibia shaft fracture was induced and stabilized by reamed intramedullary nailing in 66 Wistar rats. A 'parecoxib immediate' (Pi) group received parecoxib (3.2 mg/kg bodyweight twice per day) on days 0, 1, and 2. A 'parecoxib delayed' (Pd) group received the same dose of parecoxib on days 3, 4, and 5. A control group received saline only. Fracture healing was evaluated by biomechanical tests, histomorphometry, and dual-energy x-ray absorptiometry (DXA) at four weeks. RESULTS: For ultimate bending moment, the median ratio between fractured and non-fractured tibia was 0.61 (interquartile range (IQR) 0.45 to 0.82) in the Pi group, 0.44 (IQR 0.42 to 0.52) in the Pd group, and 0.50 (IQR 0.41 to 0.75) in the control group (n = 44; p = 0.068). There were no differences between the groups for stiffness, energy, deflection, callus diameter, DXA measurements (n = 64), histomorphometrically osteoid/bone ratio, or callus area (n = 20). CONCLUSION: This study demonstrates no negative effect of immediate or delayed short-term administration of parecoxib on diaphyseal fracture healing in rats.Cite this article: G. A. Hjorthaug, E. Søreide, L. Nordsletten, J. E. Madsen, F. P. Reinholt, S. Niratisairak, S. Dimmen. Short-term perioperative parecoxib is not detrimental to shaft fracture healing in a rat model. Bone Joint Res 2019;8:472-480. DOI: 10.1302/2046-3758.810.BJR-2018-0341.R1.

Remifentanil as an adjunct to anaesthesia for electroconvulsive therapy fails to confer long-term benefits.

BACKGROUND: Adding the µ-opioid receptor agonist remifentanil to agents used to induce general anaesthesia in electroconvulsive therapy (ECT) can reduce the required doses of induction agents and their unfavourable effects on seizure threshold and quality. However, whether remifentanil has favourable long-term treatment effects in terms of response and remission rates, speed of response and remission, and side-effects has not been studied. METHODS: This retrospective, register-based cohort study involved patients with major depression consecutively treated at two units at different hospitals in Norway with the same ECT procedure. Both units used thiopental for ECT anaesthesia, but only one unit added remifentanil (R+; n=47; 541 sessions), whereas the other did not (R-; n=119; 1166 sessions). A Cox proportional hazards model for interval-censored data was conducted to examine the effects of remifentanil on the time to response and remission from depressive symptoms, whilst adjusting for age, sex, and baseline depression score. RESULTS: Both R+ and R- patients showed substantial reductions of depressive symptoms, with no difference in the response (76% in both groups) or remission (63% vs 65%) rate. However, R+ patients responded (hazard ratio=0.59; 95% confidence interval: 0.4-0.8) and remitted (hazard ratio=0.72; 95% confidence interval: 0.5-1.0) more slowly, and reported more often side-effects of nausea (30% vs 8%; P<0.001), dizziness (22% vs 8%; P=0.027), and headache (48% vs 23%; P=0.004). CONCLUSIONS: The use of adjunctive remifentanil was associated with more short-term side-effects and no favourable long-term clinical outcomes. The practice of routinely adding remifentanil to barbiturate anaesthesia should therefore be reconsidered.

Treatment of Dupuytren's contracture: a systematic review.

Aims: Dupuytren's contracture is a benign, myoproliferative condition affecting the palmar fascia that results in progressive contractures of the fingers. Despite increased knowledge of the cellular and connective tissue changes involved, neither a cure nor an optimum form of treatment exists. The aim of this systematic review was to summarize the best available evidence on the management of this condition. Materials and Methods: A comprehensive database search for randomized controlled trials (RCTs) was performed until August 2017. We studied RCTs comparing open fasciectomy with percutaneous needle aponeurotomy (PNA), collagenase clostridium histolyticum (CCH) with placebo, and CCH with PNA, in addition to adjuvant treatments aiming to improve the outcome of open fasciectomy. A total of 20 studies, involving 1584 patients, were included. Results: PNA tended to provide higher patient satisfaction with fewer adverse events, but had a higher rate of recurrence compared with limited fasciectomy. Although efficacious, treatment with CCH had notable recurrence rates and a high rate of transient adverse events. Recent comparative studies have shown no difference in clinical outcome between patients treated with PNA and those treated with CCH. Conclusion: Currently there remains limited evidence to guide the management of patients with Dupuytren's contracture. Cite this article: Bone Joint J 2018;100-B:1138-45.

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.

Long-term experiences of being a simulation-educator: A multinational interview study.

The long-term reactions, experiences and reflections of simulation educators have not been explored. In a semistructured, exploratory interview study, the experiences of simulation educators in either Advanced Life Support (ALS) or Crisis Resource Management (CRM) courses in Denmark, Norway and the USA were analyzed. Three overarching themes were identified: (1) general reflections on simulation-based teaching, (2) transfer of knowledge and skills from the simulation setting to clinical settings and (3) more overarching transformations in simulation educators, simulation participants, and the healthcare system. Where ALS was deemed as high on the efficiency dimension of learning, CRM courses were described as high on the innovation dimension. General reflections, transfer and transformations described were related to differences in course principles. The results are relevant for career planning, faculty development and understanding simulation as social practice.

Safety of the lateral trauma position in cervical spine injuries: a cadaver model study.

BACKGROUND: Endotracheal intubation is not always an option for unconscious trauma patients. Prehospital personnel are then faced with the dilemma of maintaining an adequate airway without risking deleterious movement of a potentially unstable cervical spine. To address these two concerns various alternatives to the classical recovery position have been developed. This study aims to determine the amount of motion induced by the recovery position, two versions of the HAINES (High Arm IN Endangered Spine) position, and the novel lateral trauma position (LTP). METHOD: We surgically created global cervical instability between the C5 and C6 vertebrae in five fresh cadavers. We measured the rotational and translational (linear) range of motion during the different maneuvers using an electromagnetic tracking device and compared the results using a general linear mixed model (GLMM) for regression. RESULTS: In the recovery position, the range of motion for lateral bending was 11.9°. While both HAINES positions caused a similar range of motion, the motion caused by the LTP was 2.6° less (P = 0.037). The linear axial range of motion in the recovery position was 13.0 mm. In comparison, the HAINES 1 and 2 positions showed significantly less motion (-5.8 and -4.6 mm, respectively), while the LTP did not (-4.0 mm, P = 0.067). CONCLUSION: Our results indicate that in unconscious trauma patients, the LTP or one of the two HAINES techniques is preferable to the standard recovery position in cases of an unstable cervical spine injury.

Great variation between ICU physicians in the approach to making end-of-life decisions.

INTRODUCTION: End-of-life (EOL) decision-making in the intensive care unit (ICU) is difficult, but is rarely practiced in simulated settings. We wanted to explore different strategies ICU physicians use when making EOL decisions, and whether attitudes towards EOL decisions differ between a small-group simulation setting and a large-group plenary setting. METHODS: The study took place during a Scandinavian anaesthesiology and intensive care conference. The simulated ICU patient had a cancer disease with a grave prognosis, had undergone surgery, suffered from severe co-morbidities and had a son present demanding all possible treatment. The participants were asked to make a decision regarding further ICU care. We presented the same case scenario in a plenary session with voting opportunities. RESULTS: In the simulation group (n = 48), ICU physicians used various strategies to come to an EOL decision: patient-oriented, family-oriented, staff-oriented and regulatory-oriented. The simulation group was more willing than the plenary group (n = 47) to readmit the patient to the ICU if the patient again would need respiratory support (32% vs. 8%, P < 0.001). Still, fewer participants in the simulation group than in the plenary group (21% vs. 38%, P = 0.019) considered the patient's life expectancy of living an independent life to be over 10%. CONCLUSION: There was great variation between ICU physicians in the approach to making EOL decisions, and large variations in their life expectancy estimates. Participants in the simulation group were more willing to admit and readmit the patient to the ICU, despite being more pessimistic towards life expectancies. We believe simulation can be used more extensively in EOL decision-making training.

Life years saved, standardised mortality rates and causes of death after hospital discharge in out-of-hospital cardiac arrest survivors.

AIM OF THE STUDY: Out-of-hospital cardiac arrest (OHCA) accounts for many unexpected deaths in Europe and the survival rates in different regions vary considerably. We have previously reported excellent survival to discharge rates in the Stavanger region. We now describe the long-term outcome of OHCA victims in our region. METHODS: In this retrospective observational study, we followed all OHCA hospital discharge survivors between 01.07.2002 and 30.06.2011 (n=213) for a minimum of 1 year and up to 10 years. Based on the national death statistics stratified for gender and age, we could calculate the potential life years saved, standardised mortality rates (SMR) and delineate the causes of death after hospital discharge. RESULTS: Of the 213 patients who were discharged from the hospital, 91% had a cardiac origin of their OHCA. The mean potential life years saved per patient was 22.8 years. The observed five-year survival rate was 76%. The overall SMR in our study cohort was 2.3 when compared to the age- and gender-matched population. Cardiac disease was a prominent cause of late deaths, with the specific SMR for cardiac disease-related deaths being as high as 42 in males and 140 in females. CONCLUSION: Resuscitation of OHCA victims lead to a significant long-term benefit with respect to life years saved. Cardiac disease was the main cause of death after hospital discharge. More studies are needed to identify the potential of therapeutic interventions and rehabilitation efforts that may further enhance the long-term outcomes in OHCA hospital discharge survivors.

Factors predicting the use of therapeutic hypothermia and survival in unconscious out-of-hospital cardiac arrest patients admitted to the ICU.

INTRODUCTION: Therapeutic hypothermia (TH) after out-of-hospital cardiac arrest (OHCA) was adopted early in Norway. Since 2004 the general recommendation has been to cool all unconscious OHCA patients treated in the intensive care unit (ICU), but the decision to cool individual patients was left to the responsible physician. We assessed factors that were associated with use of TH and predicted survival. METHOD: We conducted a retrospective observational study of prospectively collected cardiac arrest and ICU registry data from 2004 to 2008 at three university hospitals. RESULTS: A total of 715 unconscious patients older than 18 years of age, who suffered OHCA of both cardiac and non-cardiac causes, were included. With an overall TH use of 70%, the survival to discharge was 42%, with 90% of the survivors having a favourable cerebral outcome. Known positive prognostic factors such as witnessed arrest, bystander cardio pulmonary resuscitation (CPR), shockable rhythm and cardiac origin were all positive predictors of TH use and survival. On the other side, increasing age predicted a lower utilisation of TH: Odds Ratio (OR), 0.96 (95% CI, 0.94 to 0.97); as well as a lower survival: OR 0.96 (95% CI, 0.94 to 0.97). Female gender was also associated with a lower use of TH: OR 0.65 (95% CI, 0.43 to 0.97); and a poorer survival: OR 0.57 (95% CI, 0.36 to 0.92). After correcting for other prognostic factors, use of TH remained an independent predictor of improved survival with OR 1.91 (95% CI 1.18-3.06; P <0.001). Analysing subgroups divided after initial rhythm, these effects remained unchanged for patients with shockable rhythm, but not for patients with non-shockable rhythm where use of TH and female gender lost their predictive value. CONCLUSIONS: Although TH was used in the majority of unconscious OHCA patients admitted to the ICU, actual use varied significantly between subgroups. Increasing age predicted both a decreased utilisation of TH as well as lower survival. Further, in patients with a shockable rhythm female gender predicted both a lower use of TH and poorer survival. Our results indicate an underutilisation of TH in some subgroups. Hence, more research on factors affecting TH use and the associated outcomes in subgroups of post-resuscitation patients is needed.

A one-day "Helping Babies Breathe" course improves simulated performance but not clinical management of neonates.

OBJECTIVE: "Helping Babies Breathe" (HBB) is a simulation-based one-day course developed to help reduce neonatal mortality globally. The study objectives were to (1) determine the effect on practical skills and management strategies among providers using simulations seven months after HBB training, and (2) describe neonatal management in the delivery room during the corresponding time period before/after a one-day HBB training in a rural Tanzanian hospital. METHODS: The one-day HBB training was conducted by Tanzanian master instructors in April 2010. Two simulation scenarios; "routine care" and "neonatal resuscitation" were performed by 39 providers before (September 2009) and 27 providers after (November 2010) the HBB training. Two independent raters scored the videotaped scenarios. Overall "pass/fail" performance and different skills were assessed. During the study time period (September 2009-November 2010) no HBB re-trainings were conducted, no local ownership was established, and no HBB action plans were implemented in the labor ward to facilitate transfer and sustainability of performance in the delivery room at birth. Observational data on neonatal management before (n=2745) and after (n=3116) the HBB training was collected in the delivery room by observing all births at the hospital during the same time period. RESULTS: The proportion of providers who "passed" the simulated "routine care" and "neonatal resuscitation" scenarios increased after HBB training; from 41 to 74% (p=0.016) and from 18 to 74% (p≤0.0001) respectively. However, the number of babies being suctioned and/or ventilated at birth did not change, and the use of stimulation in the delivery room decreased after HBB training. CONCLUSION: Birth attendants in a rural hospital in Tanzania performed significantly better in simulated neonatal care and resuscitation seven months after one day of HBB training. This improvement did not transfer into clinical practice.

Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury.

BACKGROUND: Hypothermia, acidosis and coagulopathy have long been considered critical combinations after severe injury. The aim of this review was to give a clinical update on this triad in severely injured patients. METHODS: A non-systematic literature search on hypothermia, acidosis and coagulopathy after major injury was undertaken, with a focus on clinical data from the past 5 years. RESULTS: Hypothermia (less than 35 °C) is reported in 1·6-13·3 per cent of injured patients. The occurrence of acidosis is difficult to estimate, but usually follows other physiological disturbances. Trauma-induced coagulopathy (TIC) has both endogenous and exogenous components. Endogenous acute traumatic coagulopathy is associated with shock and hypoperfusion. Exogenous effects of dilution from fluid resuscitation and consumption through bleeding and loss of coagulation factors further add to TIC. TIC is present in 10-34 per cent of injured patients, depending on injury severity, acidosis, hypothermia and hypoperfusion. More expedient detection of coagulopathy is needed. Thromboelastography may be a useful point-of-care measurement. Management of TIC is controversial, with conflicting reports on blood component therapy in terms of both outcome and ratios of blood products to other fluids, particularly in the context of civilian trauma. CONCLUSION: The triad of hypothermia, acidosis and coagulopathy after severe trauma appears to be fairly rare but does carry a poor prognosis. Future research should define modes of early detection and targeted therapy.

Risk factors of post-operative urinary retention in hospitalised patients.

BACKGROUND: Post-operative urinary retention (POUR) is most accurately determined by using ultrasound to measure bladder volume. The aim of this study was to define the risk factors of POUR in the recovery room in hospitalised patients. METHODS: An ultrasound-determined bladder volume ≥400 ml at arrival in the recovery room was used to define POUR. Multivariate regression analysis was used to identify patient and system factors linked to POUR in 773 consecutive hospitalised patients who had undergone orthopaedic, abdominal, gynaecological or plastic surgery without an indwelling urinary catheter. RESULTS: We found the incidence of POUR to be 13%. The lack of pre-operative voiding, use of regional anaesthesia, anaesthesia time >2 h and emergency surgery were all independent risk factors for POUR. CONCLUSIONS: The detected incidence of POUR at arrival in the recovery room was rather high but had easily identifiable risk factors. We recommend pre-operative voiding whenever possible. Routine bladder scanning at arrival in the recovery room should be considered, especially after spinal anaesthesia, emergency surgery or when the anaesthesia time exceeds 2 h.

Shaping the future of Scandinavian anaesthesiology: a position paper by the SSAI.

Traditionally, Scandinavian anaesthesiologists have had a very broad scope of practice, involving intensive care, pain and emergency medicine. European changes in the different medical fields and the constant reorganising of health care may alter this. Therefore, the Board of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) decided to produce a Position Paper on the future of the speciality in Scandinavia. The training in the various Scandinavian countries is very similar and provides a stable foundation for the speciality. The Scandinavian practice in anaesthesia and intensive care is based on a team model where the anaesthesiologists work together with highly educated nurses and should remain like this. However, SSAI thinks that the role of the anaesthesiologists as perioperative physicians is not fully developed. There is an obvious need and desire for further training of specialists. The SSAI advanced educational programmes for specialists should be expanded and include formal assessment leading to a particular medical competency as defined by the European Union of Medical Specialists (UEMS). In this way, Scandinavian anaesthesiologists will remain leaders in perioperative, intensive care, pain and critical emergency medicine.

The future role of the Scandinavian anaesthesiologist: a web-based survey.

BACKGROUND: The Board of the Scandinavian Society for Anaesthesiology and Intensive Care Medicine (SSAI) decided in 2008 to undertake a survey among members of the SSAI aiming at exploring some key points of training, professional activities and definitions of the specialty. METHODS: A web-based questionnaire was used to capture core data on workforce demographics and working patterns together with opinions on definitions for practice/practitioners in the four areas of anaesthesia, intensive care medicine, emergency medicine and pain medicine. RESULTS: One thousand seven hundred and four responses were lodged, representing close to half of the total SSAI membership. The majority of participants reported in excess of 10 years of professional experience in general anaesthesia and intensive care medicine as well as emergency and pain medicine. While no support for separate or secondary specialities in the four areas was reported, a majority of respondents favoured sub-specialisation or recognition of particular medical competencies, notably so for intensive care medicine. Seventy-five percent or more of the respondents supported a common framework of employment within all four areas irrespective of further specialisation. CONCLUSIONS: The future of Scandinavian anaesthesiology is likely to involve further specialisation towards particular medical competencies. With such diversification of the workforce, the majority of the respondents still acknowledge the importance of belonging to one organisational body.

Cognitive dysfunction and health-related quality of life after a cardiac arrest and therapeutic hypothermia.

BACKGROUND: Evidence-based treatment protocols including therapeutic hypothermia have increased hospital survival to over 50% in unconscious out-of-hospital cardiac arrest survivors. In this study we estimated the incidence of cognitive dysfunctions in a group of cardiac arrest survivors with a high functional outcome treated with therapeutic hypothermia. Secondarily, we assessed the cardiac arrest group's level of cognitive performance in each tested cognitive domain and investigated the relationship between cognitive function and age, time since cardiac arrest and health-related quality of life (HRQOL). METHODS: We included 26 patients 13-28 months after a cardiac arrest. All patients were scored using the Cerebral Performance Category scale (CPC) and Mini-Mental State Examination (MMSE). Twenty-five of the patients were tested for cognitive function using the Cambridge Neuropsychological Test Automated Battery (CANTAB). These patients were tested using four cognitive tests: Motor Screening Test, Delayed Matching to Sample, Stockings of Cambridge and Paired Associate Learning from CANTAB. All patients filled in the Short Form-36 for the assessment of HRQOL. RESULTS: Thirteen of 25 (52%) patients were classified as having a cognitive dysfunction. Compared with the reference population, there was no difference in the performance in motor function and delayed memory but there were significant differences in executive function and episodic memory. We found no associations between cognitive function and age, time since cardiac arrest or HRQOL. CONCLUSION: Half of the patients had a cognitive dysfunction with reduced performance on executive function and episodic memory, indicating frontal and temporal lobe affection, respectively. Reduced performance did not affect HRQOL.

Pre-operative fasting: a nationwide survey of German anaesthesia departments.

BACKGROUND: Shorter pre-operative fasting improves clinical outcome without an increased risk. Since October 2004, German Anaesthesiology Societies have officially recommended a fast of 2 h for clear fluids and 6 h for solid food before elective surgery. We conducted a nationwide survey to evaluate the current clinical practice in Germany. METHODS: Between July 2006 and January 2007, standardized questionnaires were mailed to 3751 Anaesthesiology Society members in leading positions requesting anonymous response. RESULTS: The overall response rate was 66% (n=2418). Of those, 2148 (92%) claimed familiarity with the new guidelines. About a third (n=806, 34%) reported full adherence to the new recommendations, whereas 1043 (45%) reported an eased fasting practice. Traditional Nil per os after midnight was still recommended by 157 (7%). Commonest reasons reported for adopting the new guidelines were: 'improved pre-operative comfort' (84%), and 'increased patient satisfaction' (83%); reasons against were: 'low flexibility in operation room management' (19%), and 'increased risk of aspiration' (13%). CONCLUSION: Despite the apparent understanding of the benefits from reduced pre-operative fasting, full implementation of the guidelines remains poor in German anaesthesiology departments.

A comparison of SAPS II and SAPS 3 in a Norwegian intensive care unit population.

BACKGROUND: Simplified Acute Physiology Score (SAPS II) is the most widely used general severity scoring system in European intensive care medicine. Because its performance has been questioned in several external validation studies, SAPS 3 was recently released. To our knowledge, there are no published validation studies of SAPS II or SAPS 3 in the Scandinavian countries. We aimed to evaluate and compare the performance of SAPS II and SAPS 3 in a Norwegian intensive care unit (ICU) population. METHOD: Prospectively collected data from adult patients admitted to two general ICUs at two different hospitals in Norway were used. Probability of mortality was calculated using the SAPS 3 global equation (SAPS 3 G), the SAPS 3 Northern European equation (SAPS 3 NE), and the original SAPS II equation. Performance was assessed by the standardized mortality ratio (SMR), area under receiving operating characteristic, and the Hosmer and Lemeshow goodness-of-fit C test. RESULTS: One thousand eight hundred and sixty-two patients were included after excluding readmissions, and patients who were admitted after coronary surgery or burns. The SMRs were SAPS 3 G 0.71 (0.65, 0.78), SAPS 3 NE 0.74 (0.68, 0.81), and SAPS II 0.82 (0.75, 0.91). Discrimination was good in all systems. Only the SAPS 3 equations displayed satisfactory calibration, as measured by the Hosmer-Lemeshow test. CONCLUSION: The performance of SAPS 3 was satisfactory, but not markedly better than SAPS II. Both systems considerably overestimated mortality and exhibited good discrimination, but only the SAPS 3 equations showed satisfactory calibration. Customization of these equations based on a larger cohort is recommended.

Percutanous dilatational tracheotomy in the ICU: a Norwegian survey focusing on perceived risk and safety attitudes.

BACKGROUND AND OBJECTIVES: Despite its popularity, serious complications do occur with percutaneous dilatational tracheotomy in the ICU. The associated risks in daily practice are probably underestimated and may reflect system flaws in training and team function. This study was performed to obtain an impression of risk perception and safety culture in connection with percutaneous dilatational tracheotomy in Norwegian ICUs. METHODS: The Medical Director or intensivist on-call in the 30 ICUs participating in the Norwegian Intensive Care Registry was telephone interviewed using a semi-structured questionnaire. Data on the practice of tracheotomy and a qualitative assessment of complications experienced during the last 2 years were collected. In the second part, percutaneous dilatational tracheotomy operators in two ICUs were questioned about their perception of risk with percutaneous dilatational tracheotomy and asked to assess their own abilities as percutaneous dilatational tracheotomy operators and the training they had undergone. RESULTS: Of the 30 ICUs, 23 used percutaneous dilatational tracheotomy. The majority reported knowledge of severe complications like bleeding, hypoxia and tube dislodgment. Percutaneous dilatational tracheotomy-related deaths were also reported. Operators rated themselves relatively low and indicated the absence of any organized training. They acknowledged the known hazards related to percutaneous dilatational tracheotomy and suggested measures like fibreoptic guidance during the percutaneous dilatational tracheotomy and fewer operators with more experience as well as better team training, to improve patient safety. CONCLUSION: Based on the frequent reporting of serious complications and the suggested safety precautions, we conclude that the percutaneous dilatational tracheotomy is considered a high-risk procedure and that there is still room for improving the safety of this much used ICU procedure.

Pre-operative fasting guidelines: an update

Liberal pre-operative fasting routines have been implemented in most countries. In general, clear fluids are allowed up to 2 h before anaesthesia, and light meals up to 6 h. The same recommendations apply for children and pregnant women not in labour. In children <6 months, most recommendations now allow breast- or formula milk feeding up to 4 h before anaesthesia.Recently, the concept of pre-operative oral nutrition using a special carbohydrate-rich beverage has also gained support and been shown not to increase gastric fluid volume or acidity. Based on the available literature, our Task Force has produced new consensus-based Scandinavian guidelines for pre-operative fasting. What is still not clear is to what extent the new liberal fasting routines should apply to patients with functional dyspepsia or systematic diseases such as diabetes mellitus. Other still controversial areas include the need for and effect of fasting in emergency patients, women in labour and in association with procedures done under ‘deep sedation’. We think more research on the effect of various fasting regimes in subpopulations of patients is needed before we can move one step further towards completely evidence-based pre-operative fasting guidelines.