Wiley: Acta Anaesthesiologica Scandinavica: Table of Contents

Swedish Intensive Care Physicians' Attitudes Towards Withholding or Withdrawing Life‐Sustaining Treatment in Critically Ill Children

Fri, 15 May 2026 06:14:13 -0700

ABSTRACT

Background

Decisions to withhold or withdraw life-sustaining treatments for critically ill children are challenging. This study aims to identify Swedish intensivists' attitudes, values and experiences towards the decision-making process concerning withholding or withdrawal of life-sustaining treatment in critically ill children.

Methods

The nine intensive care units in Sweden that treated more than 10 children for more than 48 h during 2023 were approached. A web-based questionnaire on attitudes and experiences on end-of-life decision-making in critically ill children was distributed to the 360 physicians employed at the above-mentioned intensive care units. The results were analysed descriptively.

Results

Fifty-five answers were retrieved. The participating physicians were experienced, 93% having personal experience with end-of-life decision-making in children. The main findings were that the child's wishes were considered important or very important by 93% of respondents. The guardians' wishes were considered important or very important by 82% of respondents. Seventy-three percent of physicians considered it ethically acceptable to withdraw life-sustaining treatment against the patients' and guardians' wishes. To continue life-sustaining treatment without the patient's and guardian's consent was considered ethically acceptable by 26% of participants.

Conclusions

This study demonstrated that Swedish intensivists share common attitudes and values regarding most issues related to end-of-life decisions in critically ill children. However, there is variability in attitudes concerning patients' and guardians' wishes. Further studies concerning end-of-life decisions in critically ill children within a Nordic context are warranted.

Editorial Comment

This survey study presents a sampling of views on pediatric intensive care withholding or withdrawing of treatment and from specialist physicians in one Nordic country.

Association of Suspected Aspiration During of Out‐Of‐Hospital Cardiac Arrest With Development of Early‐Onset Pneumonia

Thu, 14 May 2026 23:39:04 -0700

ABSTRACT

Background

Early-onset pneumonia is a possible complication after out-of-hospital cardiac arrest (OHCA) resuscitation. Whether or not a suspected aspiration during prehospital care is associated with the development of early-onset pneumonia has not been studied.

Methods

We conducted a single-centre prospective observational study among comatose out-of-hospital cardiac arrest survivors treated in the intensive care unit (ICU). Both prehospital emergency physicians and nurse-paramedics completed a structured survey on possible aspiration after each successful resuscitation. The primary outcome was being diagnosed with early-onset pneumonia within the first 96 h of ICU stay.

Results

A total of 55 patients were included, and 11 patients were suspected of having aspirated during their out-of-hospital cardiac arrest. Patients with suspected aspiration were younger, had a lower Charlson comorbidity index, and their out-of-hospital cardiac arrest was more often due to non-cardiac aetiology with a non-shockable primary rhythm. Patients with suspected aspiration had comparable oxygenation, ventilation, and ventilator parameters to the patients without suspected aspiration. Pneumonia findings on chest X-rays, CT imaging, and infection parameters were similar across the patient groups. Early-onset pneumonia during the first 96 h was as common in both groups (91% vs. 68%, p = 0.130). Prehospital suspicion of aspiration was not associated with early-onset pneumonia in multivariable regression analysis (odds ratio 2.8, 95% confidence interval 0.29–28).

Conclusion

Suspicion of aspiration during out-of-hospital cardiac arrest was not associated with early-onset pneumonia. However, this study was possibly underpowered to detect clinically relevant differences.

Editorial Comment

This study presents associations between post-cardiac arrest and resuscitation early pneumonia and suspicion of pulmonary aspiration at the time of the out of hospital cardiac arrest and first treatment. In this cohort, there did not seem to be a clear association.

A Systematic Review and Expert Evaluation of Perioperative SGLT2 Inhibitor‐Associated Ketoacidosis Case Reports

Wed, 13 May 2026 22:26:44 -0700

ABSTRACT

Introduction

The use of sodium–glucose cotransporter-2 inhibitors (SGLT2i) in the perioperative setting may lead to SGLT2i-associated postoperative ketoacidosis (SAPKA) in patients with type 2 diabetes (T2D). Therefore, cessation of this drug is recommended before surgery. We aimed to study reported cases to assess the causality of SGLT2i, identify common characteristics, potential risk factors, treatment and outcomes of SAPKA.

Methods

We conducted a systematic literature search to identify case reports of patients with metabolic acidosis and the presence of ketones who used SGLT2i in the perioperative setting. Case reports were summarised for common characteristics, assessed for quality and distributed to a panel of diabetes experts, who evaluated the likelihood of SAPKA using a questionnaire.

Results

Ninety-three papers containing 128 case reports fulfilled the inclusion criteria. The expert panel found SAPKA to be ‘likely’ in 53 (41%), ‘possible’ in 38 (30%) and ‘unlikely’ in 27 (21%) cases; 10 cases (8%) could not be validated due to insufficient data or implausible timing. SAPKA was therefore considered likely or possible in 71% (91/128) of cases. Common factors identified in the SAPKA reports included a diagnosis of T2D mellitus (n = 115), impaired perioperative intake (n = 30) and insufficient insulin supplementation (n = 10). Treatment with insulin was effective, and ketoacidosis resolved in all surviving patients, although significant morbidity, including ICU admission, was reported in a substantial proportion of cases.

Discussion

Confirming a SAPKA diagnosis is challenging due to the variable reporting quality and numerous confounding factors present during the perioperative period. Clinicians should remain aware of SAPKA given the increasing prevalence of SGLT2i use. Focusing on early recognition and treatment represents a potential alternative strategy to routine preoperative SGLT2i discontinuation, though this requires further prospective evaluation.

Editorial Comment

This systematic review presents an overview and discussion of the many, to date, case reports of ketoacidosis thought to be associated with perioperative SGLT2 inhibitor treatment.

Malignant Hyperthermia in Sweden: Clinical Presentations and Genetic Findings

Anna Hellblom, Maria Soller, Carolina Samuelsson — Wed, 13 May 2026 07:04:29 -0700

ABSTRACT

Introduction

Malignant hyperthermia (MH) is a pharmacogenetic, hypermetabolic and potentially lethal reaction to potent volatile anaesthetics and the muscle relaxant succinylcholine. To improve the understanding of MH, the aim of this retrospective study was to describe the Swedish cohort with respect to clinical manifestations, demographics and genetic findings.

Method

The Swedish MH Registry covers a total of 2852 individuals belonging to 544 different families investigated for MH since 1980. For this study, the index case in each family was included for further description.

Results

In total, MH was confirmed in 1555 individuals. Among the 288 index cases with a history of an MH reaction and confirmed MH, 58% were male and 57% were < 18 years of age. MH was confirmed in 41% of index cases where masseter muscle spasm was the only clinical sign of MH. The overall case fatality following an MH reaction in Sweden was 5.2%, but no fatal MH reaction has been reported since 2001. Out of 163 genetically investigated MH families, 61 had a diagnostic variant and 23 had a variant of unknown significance.

Conclusions

We found that MH reactions predominantly occur in young individuals and that case fatality has declined over recent decades, with no deaths reported in the past 20 years. Less than 40% of the genetically investigated MH families, corresponding to around 20% of all Swedish MH families, currently have an identified genetic diagnostic variant.

Editorial Comment

This analysis of the national Swedish Malignant Hyperthermia patient registry presents case factors and outcomes from cases among recognised families from the last 45 years. Presenting symptoms and then case confirmation details are presented, along with results from cases and families where genetic variants has been assessed.

Ultrasound‐Guided Superficial Parasternal Intercostal Plane Block for Early Pain Management in Patients Undergoing Cardiac Surgery—A Randomized Controlled Trial

Wed, 13 May 2026 06:44:47 -0700

ABSTRACT

Background

Sternotomy causes substantial postoperative pain. Recently, several less invasive nerve blocks have been described that are safer to use even on anticoagulated patients. This study aims to evaluate early pain management using ultrasound-guided superficial parasternal intercostal plane block (SPIP) in patients undergoing aortic valve replacement via full sternotomy.

Methods

This was a randomized, placebo-controlled trial performed in a tertiary referral hospital. Seventy-four elective patients scheduled for aortic valve replacement via full sternotomy were included. Patients were randomized to receive a preoperative SPIP block using either 40 mL of ropivacaine 7.5 mg/mL or 40 mL of 0.9% saline. Cumulative oxycodone consumption during the first 24 postoperative hours was recorded and analyzed as the primary outcome. Pain at rest was assessed using the numerical rating scale (NRS) scores 48 h postoperatively. Additional secondary outcomes included the need for vasopressors and antiemetics, recovery of bowel function, time spent in the intensive care unit (ICU), and nerve block-related complications.

Results

The 24-h cumulative consumption was not significantly different between groups (93.8 mg ± 33.3 vs. 109.4 mg ± 37.9, p = 0.066). NRS pain scores at rest were reduced in the patients with SPIP at 4 (5.0 ± 1.8 vs. 3.3 ± 2.4, p = 0.002). No differences were found in additional secondary outcomes.

Conclusion

In this randomized controlled trial a single-shot SPIP block did not reduce the 24-h cumulative opioid consumption after cardiac surgery.

Editorial Comments

This trial in a cardiac surgical cohort tested for possible benefit of a single injection superficial parasternal intercostal plane block for post-operative analgesia for post-sternotomy pain. The study found no post-op opioid treatment reduction with the treatment, but some analgesia effect cannot be ruled out.

Whole Blood Transcriptomic Response to Perioperative Dexamethasone in Total Knee Arthroplasty: A Targeted Panel Analysis

Wed, 13 May 2026 02:40:27 -0700

ABSTRACT

Background

Changes in the transcriptome of immune cells are predictive of clinical outcomes. These effects may be surgery-specific and possibly modulated by glucocorticoids. We investigated the immune response and the impact of dexamethasone on the response in patients undergoing total knee arthroplasty (TKA).

Methods

The transcript levels (n = 579) in whole blood of 63 patients undergoing TKA and receiving either dexamethasone (DXM, n = 46) or placebo (n = 17) perioperatively were characterised by the Nanostring nCounter platform and the Immunology V2 panel. Samples were collected before surgery and on the first postoperative day (POD1).

Results

Dexamethasone induced differential expression of 113 genes (|log2 fold change| > 0.5, adjusted p-value [p-adj] < 0.05). Pathway enrichment analysis using an Over-Representation Analysis (ORA) indicated an up-regulation of IL6/JAK-STAT3-signalling (p-adj 0.016) and down-regulation of a pathway related to allograft-rejection (p-adj 0.032). The immune response itself induced differential expression of 169 genes and ORA only found an allograft rejection pathway significant (p-adj 0.016). Cell type deconvolution indicated that dexamethasone increased the granulocyte fraction (69.6% vs. 73.6%, p-adj = 0.005) and reduced B- and Plasma-cell fraction (10.1% vs. 8.4%, p-adj = 0.016). The granulocyte fraction on POD1 was significantly different between dexamethasone and placebo-treated patients (73.6% vs. 70.1%, p-adj = 0.048).

Conclusions

Perioperative dexamethasone in TKA induced differential expression of genes related to IL6-JAK/STAT3-signalling as estimated by the Immunology V2 panel. This, however, is not supported by the literature or a rank-based interpretation of the most differentially expressed genes and was most likely due to technical reasons. Future studies should focus on broader panels, different techniques or measures leading to fewer exclusions of genes during quality control when seeking to characterise the immune response to TKA and dexamethasone.

Editorial Comment

This transcriptomic sub‑study shows that perioperative dexamethasone does not simply suppress, but distinctly reshapes, the early whole‑blood immune response to total knee arthroplasty. However, the study investigated an early postoperative snapshot after a single perioperative dose only. Thus, longitudinal linkage to circulating biomarkers of inflammation and injury as well as clinical outcomes could not be assessed. This study therefore should be regarded as hypothesis‑generating, urging for extended, multi‑modal and outcome‑oriented studies before concluding on the broader clinical effects of perioperative dexamethasone.

Pre‐ and Postoperative N‐Terminal Pro B‐Type Natriuretic Peptide Dynamics and Outcomes After Emergency Laparotomy

Wed, 13 May 2026 02:21:09 -0700

ABSTRACT

Background

The prognostic value of N-terminal pro B-type natriuretic peptide has only been sparsely studied in patients undergoing emergency laparotomy, where acute systemic inflammation and physiological derangement may affect perioperative N-terminal pro B-type natriuretic peptide dynamics. Our objective was to assess the prognostic association of preoperative and postoperative N-terminal pro B-type natriuretic peptide concentrations in patients undergoing emergency laparotomy.

Methods

We conducted an exploratory retrospective cohort study using prospectively registered data. The association between preoperative and postoperative N-terminal pro B-type natriuretic peptide concentrations and 90-day mortality was analysed using logistic regression after logarithmic transformation, with effect estimates expressed as odds ratios per doubling in biomarker concentration. Secondary exploratory analyses included internally derived threshold-based analyses and assessment of perioperative N-terminal pro B-type natriuretic peptide patterns.

Results

In total, we included 249 patients. Each doubling of preoperative and postoperative N-terminal pro B-type natriuretic peptide concentrations was associated with increased unadjusted odds of 90-day mortality (preoperative OR 1.89, 95% CI 1.49–2.40; postoperative OR 2.29, 95% CI 1.71–3.06). Secondary exploratory analyses using internally derived thresholds showed a similar directional pattern. Patients with elevated preoperative but lower postoperative N-terminal pro B-type natriuretic peptide concentrations displayed lower observed mortality compared to those with persistently elevated concentrations.

Discussion

Preoperative and postoperative N-terminal pro B-type natriuretic peptide concentrations were associated with 90-day mortality in patients undergoing emergency laparotomy. The prognostic relevance of N-terminal pro B-type natriuretic peptide trajectories warrants further study.

Editorial Comment

This study examines perioperative NT-proBNP dynamics in emergency laparotomy patients, showing higher pre- and postoperative levels predict increased 90-day mortality. It suggests biomarker trajectories, not just absolute values, may refine risk stratification, as declining postoperative levels were associated with lower mortality than persistently elevated concentrations, highlighting potential clinical value while emphasising need for prospective validation.

Mapping the Clinical Evidence on Remimazolam in Anaesthesia: A Protocol for a Scoping Review

Emma Hansine Vangsgaard Skuldbøl Nilsson, Ibrahim Abood, Ann Merete Møller — Tue, 12 May 2026 05:18:42 -0700

ABSTRACT

Background

Remimazolam is a recently introduced benzodiazepine used for procedural sedation and general anaesthesia. Its pharmacokinetic profile, including rapid metabolism and predictable recovery, has generated interest in its potential advantages compared with traditional sedatives such as midazolam and propofol.

Methods

This protocol follows established methodological guidance for scoping reviews. The review will map the available evidence on the clinical use of remimazolam and identify gaps in the current literature. Specifically, it will examine studied patient populations, the reported pharmacokinetic profile of remimazolam and the clinical settings in which the drug has been investigated.

Results

The review will provide an overview of the existing literature on remimazolam, with particular focus on underrepresented patient populations, its current clinical applications, and reported short- and long-term adverse effects.

Conclusion

The planned review will map the current evidence regarding remimazolam, identify underrepresented populations, the clinical contexts in which remimazolam is used, and gaps for future research.

Effect of Ultrasound‐Guided Lateral Infraclavicular Brachial Plexus Block With Lidocaine or Ropivacaine for Closed Reduction of Distal Radius Fractures: A Randomized Controlled Noninferiority Trial

Sat, 09 May 2026 01:04:47 -0700

ABSTRACT

Background

Closed reduction of distal radius fractures is painful, and current analgesic strategies may be inadequate. Ultrasound-guided lateral infraclavicular brachial plexus block may offer complete analgesia and muscle relaxation, potentially improving patient comfort and reduction quality. However, benefits and challenges regarding anesthetic agents for this procedure remain unclear.

Methods

In this randomized, controlled, blinded, noninferiority trial, 63 adults with distal radius fractures requiring closed reduction received a lateral infraclavicular block with either 30 mL of ropivacaine 0.5%, lidocaine 1% with epinephrine, or ropivacaine 0.2%. The primary outcome was block success at 45 min, defined as complete sensory and extensive motor block of the radial, musculocutaneous, ulnar, and median nerves. Noninferiority was assessed using a margin of 20%. Exploratory outcomes included sensory and motor block assessments, time to pain relief, block duration, pain during reduction, patient satisfaction, quality of closed reduction, fracture treatments, and safety.

Results

Ropivacaine 0.2% was statistically inferior to ropivacaine 0.5% in achieving block success at 45 min (risk ratio (RR) 0.63, 97.5% CI 0.40–0.99). Lidocaine 1% with epinephrine did not meet the predefined noninferiority criteria for block success (RR 0.95, 97.5% CI 0.73–1.22) but did provide comparable analgesia with a shorter block duration. Pain scores during reduction were low across all groups, with a significant decrease in pain from baseline. Patient satisfaction was high in all groups. No significant differences were found in the quality of closed reduction, safety, or fracture treatments.

Conclusion

Lateral infraclavicular block with ropivacaine 0.2% failed to demonstrate noninferiority for block success and was statistically inferior to ropivacaine 0.5%. Inferiority testing should be interpreted cautiously within the context of a noninferiority design, although the results suggest reduced effectiveness for distal radius fracture reduction. Lidocaine 1% with epinephrine yielded inconclusive results for noninferiority on block success, but provided a shorter block duration without compromising analgesia, patient satisfaction, or quality of reduction.

Trial Registration: ClinicalTrials.gov Identifier NCT06379490 (released April 23, 2024); https://clinicaltrials.gov/study/NCT06379490; EUCT Identifier 2024–510,572–20-00; https://euclinicaltrials.eu/ctis-public/view/2024-510572-20-00

Cognitive Functioning After Circulatory Shock: A Prospective Observational Study

Thu, 07 May 2026 00:46:20 -0700

ABSTRACT

Background

Cognitive impairment in intensive care unit (ICU) survivors is multifactorial and can affect especially memory, attention, and executive functions. This study aimed to determine the cognitive functioning of patients with circulatory shock immediately after ICU discharge and 3 months later.

Methods

This study, ASSESS-SHOCK 2, is a preplanned sub-study of the observational ASSESS-SHOCK study conducted at Helsinki University Hospital ICU. We included adults with circulatory shock, defined as hypotension requiring vasopressor infusion and concomitant signs of hypoperfusion. We excluded patients with severe neurological or psychiatric diagnoses, impairment of hearing or vision, developmental disability, and language barriers. Cognitive functioning of patients was assessed within 3 days of ICU discharge and 3 months thereafter with the Montreal Cognitive Assessment (MoCA) test. We defined cognitive impairment as MoCA score < 26 points. We also included data of 48 volunteer controls, tested once, to analyses.

Results

Fifty-five patients underwent an assessment within 3 days of ICU discharge, and 36 of them completed a follow-up assessment at 3 months. At discharge median MoCA-score was 22 (IQR 17–25). At the 3 months follow-up, the median MoCA-score was 26.5 points (IQR 24.25–28) showing improvement from discharge to follow-up (p < 0.001). The prevalence of cognitive impairment at discharge was 78.2%, and, at the 3-month follow-up 44.4%. In the control group, the median MoCA score was 27 points (IQR 25–28) and the prevalence of cognitive impairment 33%.

Conclusion

We found cognitive impairment in more than three out of four ICU survivors immediately after ICU treatment for circulatory shock. We observed an improvement in cognitive functioning between ICU discharge and 3 months follow-up. These results have importance considering the optimal timing of information given to patients and when involving patients in decision-making.

Editorial Comment

This study used the MoCA score to investigate the change in cognitive impairment in patients who survived circulatory shock, from the time of discharge from intensive care to 3 months after discharge. Scores indicated more severe cognitive dysfunction compared to controls at the time of discharge, but these improved to match control scores 3 months later. The findings have important implications for strategies to inform and support newly discharged ICU survivors who have experienced circulatory shock.

Combined Transversus Abdominis Plane and Rectus Sheath Blocks in Open Inguinal Hernia Repair: Protocol for a Double‐Blind Randomized Controlled Trial (PRO‐RSTAP)

Pia Nordström, Aki Lumme, Juha Virman, Maija‐Liisa Kalliomäki — Wed, 06 May 2026 01:55:46 -0700

ABSTRACT

Background

Inguinal hernia repair is one of the most common surgical procedures worldwide and is frequently performed as day-case surgery. Postoperative pain may delay recovery and occasionally necessitate unplanned hospital admission. Regional anesthesia techniques, including transversus abdominis plane (TAP) and rectus sheath (RS) blocks, have shown promise in improving analgesia. However, their combined efficacy in open inguinal hernia repair has not been established in randomized trials.

Methods

The PRO-RSTAP trial is a prospective, double-blind, four-arm randomized controlled trial conducted at three hospitals in Finland. The study evaluates the individual and combined effects of TAP and RS blocks in adults undergoing elective open inguinal hernia repair. Two hundred patients are randomized equally into four groups: (1) placebo TAP + placebo RS, (2) active TAP + placebo RS, (3) active RS + placebo TAP, and (4) active TAP + active RS. All patients receive standardized sedation and multimodal analgesia, including paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and rescue opioids. The primary outcome is cumulative perioperative opioid consumption from block administration until hospital discharge, expressed as intravenous morphine equivalents. Secondary outcomes include pain scores, conversion to general anesthesia, postoperative nausea and vomiting, time to discharge, and unplanned admissions or emergency visits within 7 days. The planned sample size provides 80% power to detect a clinically meaningful reduction in opioid use (two-sided α = 0.05). Analyses follow the intention-to-treat principle.

Results

The first participant was enrolled in September 2025, and the trial is ongoing. No interim efficacy analysis is planned. Safety is monitored continuously throughout the study.

Conclusion

This randomized controlled trial is designed to determine whether combining TAP and RS blocks improves postoperative analgesia and recovery after open inguinal hernia repair. The results will contribute to evidence-based optimization of regional anesthesia strategies in ambulatory surgery.

Trial Registration: EU Clinical Trials Information System (CTIS): 2024-513406-59-00; ClinicalTrials.gov identifier: NCT07423910

Does Speaking the Same Language With the Caretakers Associate With a Higher Neuraxial Labor Analgesia Use Rate?

Luisa Pirsko, Anna L. U. Väänänen, Riina Jernman, Antti Väänänen — Tue, 05 May 2026 00:39:21 -0700

ABSTRACT

Use of neuraxial analgesia requires communication between the parturient and her caretakers. In this retrospective study, the use of labor analgesia is compared between parturients whose primary language is other than Finnish or Swedish and who don't communicate in these languages or English without an interpreter (Category I), who communicate in Finnish, Swedish, or English (Category II), and primary Finnish or Swedish speakers (Category III). The primary outcome of this study is the association of communication language categories with neuraxial analgesia use. The secondary outcome is the incidence of vaginal delivery without pharmacological pain relief. The parturient and labor parameters (age, body mass index (BMI), primiparity, gestational age, prior consultations for fear-of-childbirth (FOC), induction of labor, use of oxytocin, labor analgesia interventions, outcome of the attempted labor) were recorded from the electronic patient database for all 13,707 parturients that attempted vaginal delivery in the Helsinki region delivery hospitals during 2022. The distribution of parturients was 15.3%, 10.3%, and 74.4% in the language categories I, II, and III, respectively. The use rate of neuraxial analgesia was 60.8%, 65.8%, and 75.3% in the categories I, II, and III respectively. After adjustment for primiparity, maternal BMI, gestational age, FOC diagnosis, induction of labor, oxytocin use, episiotomy, and outcome of labor, the adjusted OR (aOR) for neuraxial analgesia use was (1.283 [1.093–1.506]) among parturients in Cat II compared to Cat I. Correspondingly, the ability to communicate directly (Cat II) was associated with lower use of only non-neuraxial pharmacological analgesia (aOR 0.789 [0.654–0.951]) compared to those incapable of direct communication (Cat I). No association was seen with language capability (Cat II vs. Cat I) and delivery without pharmacological pain relief (any delivery type: aOR 0.815 [0.652–1.019]; vaginal delivery: aOR 0.825 [0.645–1.055]). Ability to communicate directly with the staff is associated with shifting from non-neuraxial techniques to neuraxial analgesia but not an increase in general labor analgesia use. Cultural trends may be associated with labor analgesia choices more than language capabilities. Promotion of labor analgesia use should go beyond translation services and requires antenatal education of the available options.

Editorial Comment

This study demonstrates that language ability alone does not determine labor analgesia use but instead shapes the selection of analgesia methods. Cultural context and antenatal knowledge appear to play a central role in analgesia decision-making. Efforts to promote equitable maternity care should therefore extend beyond translation services to include culturally responsive education and communication strategies that support informed maternal choice.

An Observational Study of Changes in Renin Concentrations and Associations With Complications Following Cardiac Surgery

Wajid Khan, Suzanne Weightman, Anders Aneman — Tue, 05 May 2026 00:25:39 -0700

ABSTRACT

Background

Increased plasma renin concentrations have been reported in patients following cardiac surgery while correlations to clinical outcomes have varied. More evidence is needed to support the potential clinical utility of plasma renin as a biomarker guiding postoperative management, including the need for alternative pharmacotherapy when standard catecholaminergic cardiovascular support is insufficient.

Methods

Plasma concentrations were determined by direct renin immunoassay (milli-International Units per litre, mIU L⁻¹) on admission to ICU and then six and 24 h later. Postoperative complications were assessed by the composite and separate incidence of acute kidney injury, acute myocardial infarction, shock, acute respiratory failure, new onset atrial flutter/fibrillation and cerebrovascular accident. Pharmacological support required to treat postoperative haemodynamic instability was quantified using the vasoactive-inotropic score.

Results

One hundred and four patients were studied and 54 (52%) met at least one diagnostic criterion for postoperative complications. Renin concentrations on admission (130 [34–445] mIU L⁻¹) and six (119 [35–447] mIU L⁻¹) and 24 h later (184 [54-513] mIU L⁻¹) were not significantly different with substantial inter-individual variation. Cumulative renin concentrations over 24 h were higher in haemodynamically unstable patients (median difference 1296 [54–2943] mIU L⁻¹, p = 0.04) and in patients with any postoperative complication (median difference 1887 [908–6177] mIU L⁻¹, p = 0.04). Plasma renin increased by 11 mIU L⁻¹ for each unit increase in the vasoactive-inotropic score. A statistical model using all renin measurements predicted haemodynamic instability (AUC 0.77 [0.55–0.95], p = 0.04) and shock (AUC 0.95 [0.83–1.0], p = < 0.001), but not the composite or separate incidence of the other complications.

Conclusions

Haemodynamic compromise, but not postoperative complications overall, were associated with serial plasma renin concentrations during the first 24 h of ICU admission following cardiac surgery. Additional prospective studies are warranted to elucidate the relationship between renin dynamics, postoperative complications and criteria for escalating vasopressor therapy.

Editorial Comment

This prospective observational study tested whether postoperative increase in plasma renin in patients undergoing cardiac surgery was associated with postoperative complications. No such association was found, but an association between increase in plasma renin and haemodynamic compromise and need for pharmacological support was found. Larger studies are warranted to elucidate the role of plasma renin as a biomarker for postoperative complications.

Trial Registration: ClinicalTrials.gov identifier: NCT043303455.

Anesthetic Management for Manual Removal of Retained Placenta in Parturients Without Labor Epidural Analgesia: A Retrospective Multicenter Real‐World Study

Mon, 04 May 2026 00:06:53 -0700

ABSTRACT

Background

Manual removal of placenta (MRP) is required in 0.1%–3.3% of vaginal births. For patients who give birth without labor epidural analgesia, the choice between neuraxial or general anesthesia (GA) with or without tracheal intubation presents unique challenges. This study describes anesthetic management practices for these cases.

Methods

This multicenter retrospective cohort study analyzed 423 patients undergoing MRP at two tertiary centers in Israel (Soroka and Rabin Medical Centers) from 2016 to 2022. We collected data on anesthetic techniques, patient characteristics, and clinical outcomes, comparing patients managed with and without tracheal intubation during GA.

Results

GA was used in 409 (96.7%) cases, with 269 (65.8%) patients managed with tracheal intubation and 140 (34.2%) receiving tubeless GA. Patients who received tubeless GA had lower rates of intraoperative complications, including hypotension (16.4% vs. 26.0%, p = 0.034), vasopressor use (10.0% vs. 20.8%, p = 0.006), and blood product transfusions (3.6% vs. 11.9%, p = 0.006). Multivariable analysis revealed associations between higher body mass index (aOR = 2.19), elevated heart rate (aOR = 1.86), and tracheal intubation. Tracheal intubation rates significantly declined from 2016 to 2022 following the introduction of gastric ultrasound in our practice.

Conclusion

Anesthetic management for MRP should be individualized based on clinical factors. In our cohort, tubeless GA was preferred for fasted, lower BMI, and hemodynamically stable patients, with tracheal intubation typically reserved for more complex cases, reflecting inherent selection bias. This study was descriptive in nature and was not designed to establish the safety of any particular technique. Further high-quality research is needed to validate these findings and refine anesthetic guidelines for MRP.

Editorial Comment

MRP is a rare obstetric procedure that can be challenging to manage without prior epidural analgesia. A retrospective study of 423 patients in two Israeli hospitals (2016–2022) found that most cases (96.7%) used GA, with about two-thirds involving tracheal intubation and one-third using tubeless techniques. Tubeless anesthesia was associated with less hypotension, reduced need for vasopressors, and fewer blood transfusions. Patients with higher BMI and heart rate were more likely to be intubated. Intubation rates decreased over time after gastric ultrasound was introduced in this cohort. Overall, the study suggests tailoring anesthesia choice to the patient, with no endotracheal intubation approaches safe for selected stable cases, though more research is needed.

Initiation of High‐Potency Benzodiazepine Prescriptions Among Survivors of Severe Trauma

Thu, 30 Apr 2026 20:30:30 -0700

ABSTRACT

Background

Trauma is a major public health concern that often leads to long-term psychological distress and chronic pain. Benzodiazepines (BZDs) are sometimes prescribed for anxiety, insomnia, or acute stress-related symptoms, but long-term use is associated with dependence and adverse outcomes. The extent to which BZDs are initiated after trauma, and their implications for long-term health, remain poorly understood. This study aimed to assess the association between trauma exposure and initiation of high-potency BZDs, identify risk factors within the trauma cohort and examine the association between new BZD use and long-term mortality.

Methods

We conducted a population-based cohort study using data from a regional trauma registry linked to Swedish national health registers. New initiation of BZD prescriptions was defined as filling at least one prescription within 6 months after trauma. Multivariable logistic regression was used to assess associations between trauma exposure and BZD initiation and to identify risk factors within the trauma cohort. Cox proportional hazards regression evaluated the association between new BZD use and 6–18-month mortality.

Results

The study included 12,206 BZD-naive trauma patients and 66,801 matched controls. Trauma exposure was independently associated with new high-potency BZD use. Within the trauma cohort, risk factors included older age, psychiatric comorbidity, substance abuse, pre-traumatic opioid or sedative-hypnotic drug use, penetrating trauma, and higher injury severity. New BZD use was associated with markedly elevated 6–18-month mortality (adjusted HR 2.9, 95% CI 2.0–4.2, p < 0.001), a finding that reflects the complex clinical and psychosocial vulnerability of this group.

Conclusions

Trauma exposure independently predicted initiation of high-potency BZDs among previously BZD-naive patients. Psychiatric comorbidity, substance use, and greater injury severity were important risk factors. The association between new BZD use and increased long-term mortality underscores the need for cautious prescribing and structured follow-up after trauma.

Editorial Comment

This study examines initiation of high-potency benzodiazepines among previously naive survivors of severe trauma using linked registry data. It shows that trauma exposure is strongly associated with new benzodiazepine use, particularly in older, comorbid, and vulnerable patients. Initiation is also associated with higher subsequent mortality, likely reflecting underlying clinical and psychosocial risk rather than a causal drug effect.

Bayesian Analysis of Postoperative Complication Risk Associated With Preoperative Exposure to Fine Particulate Matter: A Single‐Center Cohort Study

Sun, 26 Apr 2026 20:08:52 -0700

ABSTRACT

Background

Air pollution, especially particle pollution, is increasingly recognized as a potential perioperative risk factor, yet modeling environmental exposures in surgical cohorts remains methodologically underdeveloped. We demonstrate a Bayesian hierarchical framework to quantify probabilistic associations between preoperative fine particulate matter (PM_2.5) exposure and postoperative complications, highlighting its interpretability and flexibility for clinical environmental epidemiology.

Methods

We conducted a single center, retrospective cohort study using data from 49,615 surgical patients in Utah who underwent elective surgical procedures from 2016 to 2018. Patients' addresses were geocoded and linked to daily Census-tract level PM_2.5 estimates. The exposure variable was defined as the maximum PM_2.5 concentrations in the 7 days prior to surgery. The binary outcome was a composite of postoperative complications: pneumonia, surgical site infection, urinary tract infection, sepsis, stroke, myocardial infarction, or thromboembolic event. A hierarchical Bayesians regression model with weakly informative priors was used adjusting for age, sex, season, neighborhood disadvantage, and the Elixhauser index of comorbidities with census tract as a group (random) effect. We present posterior estimates with credible intervals, highlight model transparency and sensitivity, and discuss contrasts with standard frequentist methods.

Results

Postoperative complications were associated in a dose-dependent manner with higher concentrations of PM_2.5 exposure. We found a relative increase of 8.2% in the odds of complications (OR = 1.082) for every 10.ug/m³ increase in the highest single-day 24-h PM_2.5 exposure during the 7 days prior to surgery. For an increase in PM_2.5 from 1 to 30 ug/m³, the odds of complication rose to over 27% (95% CI: 4%–55%). The results were robust across prior choices and model specifications. We report full posterior distributions and highlight advantages of Bayesian modeling for uncertainty quantification and clinical interpretability.

Conclusions

This case study demonstrates the application of hierarchical Bayesian modeling to quantify the probabilistic associations between preoperative PM_2.5 exposure and postoperative complications, highlighting transparent risk estimation and uncertainty characterization that may inform the design of future multicenter perioperative environmental studies.

Editorial Comment

Using Bayesian statistical analysis, the authors demonstrate a dose-dependent risk for postoperative complications in patients exposed to air polluted with fine particulate matter with a size of less than 2.5 μm.

A Wireless Photoplethysmography Chest Patch for Continuous Vital Sign Monitoring: A Clinical Validation Study in Intensive Care Patients

Sun, 26 Apr 2026 19:48:54 -0700

ABSTRACT

Background

Continuous vital sign monitoring with wearable biosensors enables earlier detection of clinical deterioration and improves patient safety. This study validated an integrated wireless photoplethysmography-based chest patch biosensor (Biobeat technology Ltd) capable of measuring five vital signs relevant for Early Warning Score calculation, by comparison with standard continuous bedside monitoring in the intensive care unit.

Methods

Agreement between the wearable biosensor and the reference monitor was assessed using Bland–Altman analysis for repeated measurements. Bias and limits of agreement were calculated for all vital signs. Measurement differences were compared with predefined accuracy limits. Data were aligned at 5- and 15-min intervals using median reference values. Deming regression, Pearson correlation, and Clarke Error Grid analyses were performed.

Results-

A total of 1931.8 monitoring hours were collected from 32 intensive care patients (mean 60.4 ± 28.5 h). Heart rate showed a bias of 0.16 beats per minute (LoA −17.06 to 17.38), with 18.8% exceeding the 10% threshold and 0.42% in Clarke Error Grid zones D–E. Respiratory rate showed a bias of 3.77 breaths per minute (LoA −6.78 to 14.31), with 61.4% exceeding the 10% threshold and 18.6% in zones D–E. Systolic blood pressure, oxygen saturation, and temperature showed biases of −4.69 mmHg, −1.34%, and −0.29°C, respectively.

Conclusion

Agreement between a wearable chest-patch biosensor and standard bedside monitoring was evaluated in intensive care patients. Overall agreement was variable, with wide limits of agreement and a substantial proportion of measurements outside predefined thresholds. Further optimisation and validation are required before broader clinical application.

Editorial Comment

In this article, limitations in agreement between signals from wearable wireless sensors for vital signs and usual vital signs monitor values in intensive care cases are described for data collected from a practical and pragmatic setting where the study participants were in early phase of their illness with some expected clinical deterioration. There were enough test device values outside of predefined limits of agreement based on clinically relevant differences, that the authors interpret this as a need for further improvement in device performance.

Cognitive Rehabilitation Interventions in the Intensive Care Unit: A Systematic Integrative Review

Fri, 24 Apr 2026 17:44:46 -0700

ABSTRACT

Background

Because critical illness, sedation, and ICU treatment commonly disrupt attention, memory, and executive function, early cognitive rehabilitation during the ICU stay may preserve or restore these capacities, reduce the delirium burden, and support engagement and recovery. Our primary aim was to identify and describe cognitive rehabilitation interventions delivered during the ICU stay and describe the healthcare professionals providing them. Secondarily, we summarized patient-important outcomes associated with these interventions and appraised study quality to inform future research.

Method

We performed a systematic integrative review with searches in Medline, EMBASE, CINAHL, and CENTRAL. Eligible studies included adult ICU patients receiving or healthcare professionals delivering early cognitive rehabilitation initiated in the ICU. Data synthesis followed PRISMA guidelines, and risk of bias was assessed using RoB2 and ROBINS-I and narratively described.

Results

We included 27 studies: 10 randomized clinical trials, six cross-sectional studies, five cohort studies, three qualitative studies, three non-randomized trials, and one mixed-methods study. Four categories of interventions were identified: (1) orientation and multisensory stimulation, (2) activities of daily living (ADL)-focused functional occupational therapy, (3) early mobilization and physical rehabilitation, and (4) technology-based sensory and affective stimulation (music or virtual reality). Interventions were provided by nurses, physiotherapists, occupational therapists, research staff, and family members. Multi-component programs combining cognitive and physical elements indicated possible benefits for selected cognitive measures. Effects estimates on delirium and ADL were inconsistent and, in several studies, were based on secondary or exploratory outcomes analyses. Outcomes related to ventilator-free days, health-related quality of life, and survival were also inconsistent, with substantial heterogeneity in outcome definitions, measurement tools, and assessment time points.

Conclusion

Multi-component cognitive rehabilitation appeared clinically applicable, but effects on patient-important outcomes were uncertain. High-quality research is needed to assess whether interventions targeting the improvement of cognitive function benefit ICU patients.

Editorial Comment

This systematic review presents and update of published work on cognitive rehabilitation performed during ICU care and then also with assessments after critical illness in ICU survivors. The findings support the idea that this field need more robust clinical research to assess these different interventions in the ICU and their possible benefit and cost.

Issue Information

Wed, 22 Apr 2026 05:25:27 -0700

Acta Anaesthesiologica Scandinavica, Volume 70, Issue 6, July 2026.

A Possible Explanation to the Enigmatic Difference Between Ventilatory and Reversed Fick Assessments of Whole‐Body VO2

Jacob Karlsson, Per‐Arne Lönnqvist — Wed, 22 Apr 2026 05:23:41 -0700

Acta Anaesthesiologica Scandinavica, Volume 70, Issue 6, July 2026.