Postersession I
Abstract 16Korresponderende forfatter Anna HenningssonEmail [email protected] Afdeling Anæstesi og Intensiv afd./ AnOpIva Område5Hospital/institution Sygehus Vendsyssel, Hjørring/ Sahlgrenska Universitetssjukhuset, GöteborgMedforfattere Piergiorgio Bresil, Søren SøndergaardTitel Prædiktivefaktorerfortidligmortalitetefterhoftebrud.
IntroduktionRegionNordjyllandharsiden2011ikkeopnåetmåletforoverlevelse30dageefteroperation(>90%)forpatientermedhoftenærfraktur.Denneretrospektivestudiehartilformålatundersøge,omperioperativevariablerforudsigerstatistisksignifikantrisikofordød<30dageogpegerpåpræventiveindsatser.
MetodePatienter<65åropereretforhoftenærfrakturpåOrtopædkirurgiskafdelingHjørringSygehusmellem1/12011og28/22012erscreenet.Frajournalerregistreredeskøn,alderogblodprøvesvar.Fraanæstesiskemanoteredesperioperativblødning>500mL,hypotension(SBT<90m-mHg>10min),kolloider,transfusioneroganæstesimetode.FraDanskTværfagligtRegisterforHoftenærLårbensbrud(DTRHL)registreredesindikatorer,komorbiditetogCharlsonindex.KontinuerligedataundersøgtesmedFisher’st-ogkategoriskemedchisquaretestm.h.p.signi-fikantforskellemellem”levende”og”døde”.Signifikantevariableranalyseredesimultipellineærregression(MLR)foratfindeindependentefaktorer.
Resultater270patienterinkluderedes.30dagesmortalitetvar17%.Gruppenkendetegnedesvedatværeældre(p=<0,0001),bopåplejehjem(p=<0,0001)oghavedemens(p=0,026).Kreatininvedindkomstogzenithvarhøjere(p=<0,0001),Hbvarlaverevedindkomstogunderindlæggelse(hhv.p=0,0012og0,0185)ogligesåalbuminvedindkomst(p=0,0002).Basismobilitetvarlavereførindlæggelse(p=0,003),vedudskrivelse(p=<0,0001)ogfærreblevtidligtmobiliseret(p=0,0004).Betydendekomorbiditetervarstørre(p=0,045).IMLRvarhøjesteværdiafkreatinin(p=<0,0001),boligforhold(p=0,0036),basismobilitet(p=0,0489)ogtidligmobilisering(p=0,0358)statistisksignifikante.
DiskussionMortalitetenidettematerialeersammenligneligmedDTRHL,derforRegionNordjyllander16%(2011)og14%(2012)(1).Afindikatorererboligforhold,mobiliseringførindlæggelseogtidligmobiliseringsignifikante.Afperioperativefaktorererhøjestekreatininsignifikantformor-talitet.Dissefirevariablermarkerersiderafpatientensfysiologiskepræstationsniveau.Enmålsætningiældreomsorgenkunnesåledesværeatbevareogtrænefysiskstyrkeiegethjem,medensmålsætningenefterindlæggelsemåværeatoptimerepatientenshydreringstilstand,såfremtkreatinintagessomudtrykfordette.Kvintessensener,atpatientensfysiologiskereserveerrelaterettilpostoperativmortalitet.MLRharmålsætningenatreducereantalletaffaktorersomknyttervariablertiludfald.Modellentagersåledesikkehensyntil,atinsignifikantevariablerogsåkanværeinteressantesommålforpræventiveindsatser.
KonklusionPatienter,deropereresforhoftefraktur,erofteældre,medflerekomorbiditeterognedsatfysiologiskreserve.Foratkunneudforskeogintervenere på de faktorer, der kan påvirkes, må disse faktorer registreres.
Ref.1.DanskTværfagligtRegisterforHoftenæreLårbensbrud,Nationalårsrapport20121.Dec.2011–30.Nov.2012,Version2,18.april2013.
Abstract 21Korresponderende forfatterLarsBjerregaard,MD,researchfellow.Email [email protected] SectionforSurgicalPathophysiologyandtheLundbeckFoundationCentreforFast-trackHipandKnee replacementHospital/institution Rigshospitalet,Blegdamsvej9,section7621,DK-2100Copenhagen.Medforfattere StinaBogø,R.N.,SofieRaaschou,R.N.,CharlotteTroldborg,R.N.,UllaHornum,R.N.,AliciaM.Poulsen,MD, PerBagi,MD,PhD,HenrikKehlet,Prof.,MD,PhD.Titel Incidenceandriskfactorsforpostoperativeurinaryretentioninfast-tracktotalhipandkneearthroplasty. Aprospective,observationalstudy
IntroductionPostoperativeurinaryretention(POUR)isaclinicalchallenge,butevidencebasedprinciplesforpreventionandtreatmentarelacking.WeassessedtheincidenceandevaluatedpredictivefactorsforPOURinfast-tracktotalhip(THA)andkneearthroplasty(TKA).Methods:Prospective,observationalstudyof1062electivefast-trackTHAandTKAfrom4Danishorthopaedicdepartments.Primaryout-comewastheincidenceofPOUR,definedbypostoperativecatheterization.Age,gender,anaesthetictechniqueandpreoperativeInternati-
Abstracts - posterkonkurrence DASAIMs Årsmøde 2014
onalProstateSymptomScore(IPSS)werecomparedbetweencatheterizedandnon-catheterizedpatients,usingthet-test,MannWhitneyUtestorFisher’sexacttest.
ResultsIncidenceofPOURwas40.4%(Table1)withevacuatedbladdervolumesof75-1900ml(Figure1).SpinalanaesthesiaincreasedtheriskofPOUR(p=0.037,OR=1.543(95%CI:1.024-2.326)),whereashigherageandmalegenderdidnot(p=0.87and0.20).MedianpreoperativeIPSSwere6vs.8innon-catheterized/catheterizedmalesrespectively(p=0.02),and6inbothgroupsoffemales(p=0.37).
DiscussionTheincidenceofPOURinTHAandTKAhavebeenimpreciselyreportedbetween0and75%1,butthisisthefirstlargescale,prospectivestu-dytoreportaqualifiedestimateoftheincidenceofPOURinfast-trackTHAandTKA.However,wefoundconsiderabledifferencesbetweendepartments(Table1),probablyreflectingthelackofconsensusonevidencebasedguidelinesfordefiningandtreatingPOUR.About52%ofthecatheterizedpatientshadevacuatedbladdervolumesof500-800mland21%hadevacuated>800ml.(Figure1).Non-evidencebasedrecommendationsonbladdervolumesfordefiningPOURvariesfrom500mlto600ml,butsincenoconclusiveclinicaldataexistontheop-timalinterventionalthresholdforcatheterization2,onecouldhypothesizethatitmaybesafetoacceptahighertransitorybladdervolumeascatheterizationthreshold.Thiscallsforwell-designedclinicaltrialstoestablishevidencebasedprinciplesfordefiningandtreatingPOURinthefuture.SpinalanaesthesiaseemedtobeariskfactorforPOUR,whereashigherageandmalegenderdidnot.TheabsolutedifferenceinpreoperativemedianIPSSscoresbetweennon-catheterizedandcatheterizedmaleswereonly2points,therebyquestioningtheclinicalapplicabilityofIPSSforassessingtheriskofPOUR.
ConclusionTheincidenceofPOURinfast-trackTHAandTKAwas40.4%,withspinalanaesthesiaandIPSSinmalesaspredictivefactors.Largevariabi-lityinperioperativebladdermanagement,callsforrandomizedstudiestodefineevidencebasedprinciplesforpreventionandtreatmentofPOUR.
1. BalderiT,CarliF.Urinaryretentionaftertotalhipandkneearthroplasty.MinervaAnestesiol2010;76:120-302. BjerregaardLS,BagiP,KehletH.Editorial:Postoperativeurinaryretention(POUR)infast-tracktotalhipandkneearthroplasty.Acta
Orthop2014;85:8-10Abstract28
Abstract 28Korresponderende forfatterLauraSommerHansen
Email [email protected] Afdeling Anæstesiologisk-intensiv afdeling IHospital/institution Aarhus Universitets Hospital, SkejbyMedforfattere HjortdalVE,SlothE,JakobsenCJ
Titel Heartfailureistheleadingcauseofdeaththeyearaftercardiacsurgeryregardlessofpreoperativeheart function
IntroductionMortalityisafrequentlyusedoutcomeparameterincardiacsurgery,whereasreportsdescribingcauseofdeatharesparse.Tofurtherim-proveoutcomeaftercardiacsurgery,wehypothezisedthatknowingcauseofdeathinthispopulationwillenableamoretargetedapproachtopostoperativefollow-up.
MethodsAmulticenterregistry-baseddescriptivecohortstudyincludingalladultpatientswhounderwentopenheart-surgeryatAarhus,AalborgandOdenseUniversityHospitalsduringtheperiodApril1,2006–December31,2012.ThecohortwasobtainedfromtheWesternDenmark
HeartRegistrywhichholdsextensivemandatoryandprospectivelyregistereddataonpatientandproceduralcharacteristics.WematchedthecohortwiththeDanishNationalHospitalRegisterandtheDanishRegisterofCausesofDeath.Alldataweremanualcomparedtomedicalrecordentriestovalidatedateofdischarge,causeofdeath,andplaceofdeath.
ResultsAcohortof11,988patientswasidentified(8,654men),age69(62;76)years,range[15-97].Within1yearfromsurgery,802patientsdied(512men),age75(68;80)years,range[24-97].Leadingcauseofdeathwascardiac(38%),persistentthroughouttheentirefirstpostoperativeyear.50.0%ofcardiacdeathswascategorizedaseitherheartfailureorcardiacshock.Inthepreoperativeassessmentofheartfunction(asclassi-fiedintheEuroSCORE),37%ofthesepatientswerecategorizedashavingnormalleftventricularfunction(EF>50%),27%ashavingmildlytomoderatelyimpairedleftventricularfunction(EF30%-50%),and36%ashavingseverelyimpairedleftventricularfunction(EF<30%).
DiscussionDespitesurgery,cardiacdiseaseaccountedfor38%ofdeathstheyearaftersurgery,halfofwhichcouldbeattributedtoheartfailure.Distur-bingly,morethanhalf(54%)ofthesepatientswerepreoperativelyassessedashavingeithernormaloronlymildlytomoderatelyreducedEF.Thus,only36%ofpatientsdyingfrompostoperativeheartfailurehadseverelyimpairedheartfunctionpriortosurgery.Recentstudies(1,2)havedemonstratedadepressedsystolicheartfunctionatleast30daysafteron-pumpsurgery,bothbymeansofeye-ballingejectionfractionandwhenmeasuringmyocardialdeformationusingstrain.Allthoughoneofthestudiesfoundheartfunctiontoberestoredafter6months,our results imply that it may prove fatal if disregarded.
ConclusionRegardlessofpreoperativeheartfunction,heartfailureisconsistentleadingcauseofdeath,demonstratingtheneedforfurtherstudiesconcerningpostoperativeassessmentofheartfunction.
1. ChristiansenLKetal:Point-of-careultrasonographychangespatientmanagementfollowingopenheartsurgery.Scandinaviancardi-ovascularjournal:SCJ.Dec2013;47(6):335-343.
2. Juhl-OlsenPetal:Systolicheartfunctionremainsdepressedforatleast30daysafteron-pumpcardiacsurgery.InteractCardiovascThoracSurg.Sep2012;15(3):395-399.
Abstract 32Korresponderende forfatterNicolaGroesClausen
Email [email protected] DepartmentofAnesthesiaandIntensiveCare&ClinicalInstituteHospital/institution Odense University Hospital and University of Southern DenmarkMedforfattere TomG.Hansen,JacobK.Pedersen,KaareChristensen
Titel Anesthesia-relatedneurotoxicityandthedevelopingbrain:Pathologyismoreimportantthanageandnumber ofexposures:aDanishfollow-upstudyonchildrenwithoralclefts
IntroductionThequestionwhethergeneralanestheticsareneurotoxictodevelopingneuronsremainsanunresolvedconundrum(1).Whileanimalstudieshaveunequivocallydemonstratedneuropathologicalchanges(2)andlong-termneurocognitivedeficits,resultsfromobservationalhumanstudieshavebeenlessclear(3).Thisstudyinvestigatedtheassociationbetweenexposuretoanesthesiaandsurgeryfororalcleftsandsubse-quentacademicachievementsinadolescence.
MethodInthisnation-wideunselected,register-basedfollow-upstudyoftheDanishbirthcohort1986-1990wecomparedacademicachievementsofallchildrenhavingundergonesurgeryfororalcleftswitharandomlyselected,age-matched5%sampleofthesamecohort.Primaryanalysiscomparedaveragetestscoresat9thgradeadjustingforgender,birthweight,andparentalageandeducation.Secondaryanalysiscomparedtheproportionofchildrennotattainingtestscoresbetweenthetwogroups.
ResultsTheexposuregroupcomprised558childrenwhounderwentsurgeryforCL,CLPorCPandthecontrolgroupcomprised13735individuals.Overall,theoralcleftgroupperformedtoanequaldegreecomparedtocontrols(table1).WhenstratifiedaccordingtoCL,CP,andCLP,chil-drenintheCL-groupachievedhigheraveragetestandteacher’sscorethanCP,CLPandcontrols,resultsinsignificantinunadjustedanalysis.Afteradjustmentinregressionanalysis,individualswithCPscoredonefifthofastandarddeviation(SD)lowerthanthecontrolgroup(meandifference-0.20,95%CI-0.38;-0.03)(table2).ResultsforCLandCLPremainedsimilartothoseofthecontrolgroupafteradjustment.Theproportionnotattainingatestscorewas14.7%higherintheCPgroupcomparedtothecontrolgroupcorrespondingtoanadjustedoddsratioof2.6(95%CI1.78;3.76).Nostatisticallysignificantdifferencesofnon-attainmentcouldbefoundforCLandCLPcomparedtothecontrolgroup.Discussion:CPchildrenperformpooreracademicallyinadolescencethanarandomlyselected,controlgroupandCLandCLPchildren.AlargerproportionoftheCP-childrendoesnotpassfinalexamatallcomparedtobothcontrolsandCLandCLPchildren.
ConclusionOurfindingssuggestthatregardingacademicachievementsinadolescence,pathologyismoreimportantthanexposuretoanesthesiaandsurgeryatanearlyageaswellasnumberofexposures.
References1. Lin,E.P.,S.G.Soriano,andA.W.Loepke,Anestheticneurotoxicity.AnesthesiolClin,2014.32(1):p.133-55.2. Jevtovic-Todorovic,V.,etal.,Earlyexposuretocommonanestheticagentscauseswidespreadneurodegenerationinthedevelopingrat
brainandpersistentlearningdeficits.JNeurosci,2003.23(3):p.876-82.3. Hansen,T.G.,etal.(2010).Pro-condebate:cohortstudiesvstherandomizedclinicaltrialmethodologyinpediatricanesthesia.Paediatr
Anaesth20(9):880-894
Abstract 34Korresponderende forfatterKai-DieterJung,MD,FRCA,MIH
Email [email protected] DepartmentofAnaesthesiaandIntensiveCareMedicineHospital/institution QueenElizabethCentralHospital,CollegeofMedicine,Blantyre,MalawiMedforfattere GregorPollach
Titel CounteractbraindraininSub-SaharanAfrica-CreationofaspecialisttrainingprograminAnaesthesiaand IntensiveCareinMalawi
Malawi,asmallbeautifullandlockedcountrystretchingalongtheGreatRiftValley,hasaveryfastgrowing(3.2%p.a.)andyoungpopulation.Withveryfewnaturalresourcesitisoneofthepoorestcountriesintheworld(HDIranking170/187).50yearsofforeignaidhavedonelittletoimproveaninsufficienthealthcaresystem.Lifeexpectancyof54yrs.atbirth(DK88)andHIVprevalencerangingfrom10%(10-49yr)to80%(medicalinpatients)isonlyworseinwar-torncountries.
Atindependencein1963,Malawihad4doctorsand1healthunitper25.000people.Until1991alldoctorsweretrainedabroadbutonly25%returned.TheCollegeofMedicine,internationallyrecognizedforitshighstandard,openedin1991andisnowproducing80-100graduatesperyear.Oneofthemainfocusesofthemedicalschoolistoteachtheprinciplesofcommunityhealthasabasisinwhichtheotherspecialti-esareintegrated.Duringinternshipyoungdoctorsacquirenecessaryskillsindifferentclinicalsubjects(e.g.caesariansection)beforebeingplacedinthedistrictswheretheyhavetoworksinglehanded.Anesthesiaismainlyprovidedbynon-medicalpersonaltheAnestheticClinicalOfficer(ACO).ACOsaremedicalassistants,whopassthrougha18monthsspecializedtrainingprogramintheMalawiSchoolofAnesthesia,whichisintegratedinthedepartmentofAnesthesiaattheuniversityhospital-QueenElizabethCentralHospital(QECH).
SincethedeclarationoftheMDGsmanydepartmentshaveprofitedfromahighinfluxofdonormoneyandwereabletoexpandconside-rably.Surgicalprocedureshaveincreasedinnumbersandbecomemoresophisticated.Astheneedforphysiciananesthetistsbecamemoreapparent,theCollegeseekedtoupgradetheanestheticdepartment.TheGermangovernmenthelpedinfindingananesthetistandin2007GregorPollach,aGermanconsultantwasappointedasheadofdepartment.IncollaborationwiththeIrishCollegeofAnesthetistsa4yearprogram-MastersofMedicalEducation(MMED)inAnesthesiaandIntensiveCare-forMalawianmedicalgraduateswasstartedin2009.TheaimistotrainspecialistsinAnesthesiaandIntensiveCaretoleadthespecialtyinMalawi.
MMEDstudentsspent3yearsatQECHandoneyearatGrooteSchuurHospitalinCapeTown.Duringtheirtrainingstudentsreceivetutorials,bedsideteaching,androtatethroughalltheatresandICU.Theycomeacrosspatientswithallsortofandoftenextremepathologies,havetodealwithlimitedresourcesandneedtoprovetheirknowledgeintwotoughseparateexamswithinternationalexternalexaminers.Thefirst4candidateshavepassedthefinalexamandareworkinginthepublicsectorinMalawiandhaveexpressedthattheyintendtostay.Impor-tantretainingfactorsmightbethatprevious’brain-draining’countries(UK,SouthAfrica)haveagreednottorecognizethespecializationandthatallnowhaveasmallfamily.Thenext4traineesstartedthisautumn.
Abstract LKorresponderende forfatterAfdelingslægeNielsFranzen
Email [email protected] Afdeling Anæstesiologisk afdelingHospital/institution Århus Universitetshospital, NørrebrrogadeMedforfattere JensKristianBehrens
Titel AnæstesitilPeroralEndoskopiskMyotomi(POEM)
IntroduktionPOEMerennyere,minimalinvasivproceduretilbehandlingaføsophagealakalasihvorderforetagesenendoskopisk,selektivoverskæringafdecirculæremuskelfibreinedredelaføsophagusogdengastroøsophagealesphincter1).Deperoperativerisiciinkludereraspiration,øsophagusperforationsamtrisicirelaterettilkontinuerligendoskopiskinsufflationafCO22).Disserisiciskalimødegåsivalgafanæstesiolo-giskmetode.Anæstesitildetteindgrebermegetsparsomtbeskrevetilitteraturen,ogformåletmednærværendepostereratbeskrivevoresanæstesiologiske teknik.
MetodeDenakalasirelateredeaspirationsrisikoiforbindelsemedindledningimødegåsafforlængetfasteperiode(14timer)samtblindsugningiesop-hagus umiddelbart før indledning.Anæstesienindledesmedpræoxygeneringogherefterakutindledningmedalfentanylogpropofolsamtropivakain1mg/kg.Anæstesienvedligeholdesmedpropofologremifentanyl.Foratminimererisikoforaccidenteløsophagusperforationpågrundafdiafragma-bevægelser,relakserestilposttetaniccount(PTC)=0,ogdettevedligeholdesindtilkirurgienerafsluttet.Denvanligemonitoreringsuppleresmed søvndybdemåling.KomplikationerrelaterettilCO2-insufflationkanvisesigmedstigendeETCO2,subcutantemfysem,capno-thorax,capno-mediastinumogcapno-peritoneummedderaffølgendeøgetpeakpressurepårespiratorenogherafventilatoriskeproblemer.Tidligetegnpåsubcutantemfysem er mindsket ekg-amplitude. JusteringafvolumenogfrekvenspårespiratorenkanoftenormaliseremindreCO2-problemer.MentætkommunikationmedkirurgenmedhenblikpåpauseforinsufflationafCO2ogevtaflastningaføgetintraabdominalttrykmedindsættelseafVeres´kanyleernødvendigt.PågrundafCO2hurtigeabsorptionnormaliseresdeventilatoriskeforholdmegethurtigtnårtilførslenstoppes.
EfterendtkirurgireverteresdenneuromuskulærblokadefraPTComkring10medsugammadex4mg/kg,patientenvækkes,extuberesogobserveresiopvågningsafsnittet.Depostoperativesmertererfå.Patientenholdesfastendeindtilrøntgenkontrolmedperoralkontrastharvisttilfredsstillenderesultat.
ResultaterViharfraforåret2011tiljuli2014udført60akalasioperationerudenpostoperativeproblemer.Forteametompatientenharderværetenstejllæringskurvesåledesatdebeskrevneperoperativekomplikationerprimærtvartilstedeveddeførstepatienter.
KonklusionPOEMerennyere,minimalinvasivendoskopisktekniktilbehandlingafakalasi.Vibeskriverhervoresanæstesiologisketeknikveddetteind-grebsomharbidragettilgodepostoperativeresultaterfordepatienter,derindtilnuerblevetbehandletivoresklinik
Ref.1. Inoueetal.Peroralendoscpoicmyotomy(POEM)foresophagealachalasia.Endoscopy2010;42:265-2712. Renetal.Perioperativemanagementandtreatmentforcomplicationsduringandafterperoralendoscopicmyotomy(POEM)foresop-
hagealachalasia(EA)(datafrom119cases).SurgEndosc2012;213:751-56
Abstract MKorresponderende forfatterKristineHusumMünter
Email [email protected] Anæstesiologisk Afd.Hospital/institution Herlev HospitalMedforfattere TheaPalsgaardMøller,DorisØstergaard,LoneFuhrmann
Titel Preoperativepreparationofthesurgicalpatient-apilotstudyoftaskcompletionsufficiency
Thepreoperativehandoverfromthesurgicalwardtotheoperatingroom(OR)isavulnerablesituationandreportedasthemostsensiblepointforinformationandcommunicationfailuresintheperioperativepatienttrajectory(1,2).ThequalityofthehandoverisdependentofcompletionoftasksrelatedtopreparationofthepatientandinformationtransfertothereceivingteamintheOR.Nationalandlocalguide-
linesaredevelopedtoimprovepatientsafetyinthesurgicalpatientpreparation.Changemanagementtheorysupportsfollowupandsyste-maticfeedbackintheorganizationtominimizetheriskofinsufficientimplementation(3).However,atourhospital,nosystematicmonitoringofimplementationoftheseguidelineswasperformed.Theaimofthisstudywastoidentifyandquantifyinadequatepreparationofthesurgicalpatientaccordingtolocalguidelines.
MethodAprospectivedatacollectionconcerningtaskcompletionforpreparationofsurgicalpatientswasperformedatHerlevHospital.Aquesti-onnaire(Table1)basedonspecificindicatorsinthehospitalguidelineswerefilledoutforallsurgicalproceduresduringoneweek.Absolutenumbersandpercentageswerecalculatedforemergent/electiveproceduresandcompleted/not-completedtasks.Weexcludedcaseswithnoindicationsoftheprocedurebeingemergentorelective.
ResultsIntotal,314surgicalprocedureswereperformedintheORinthedatacollectionweek.215questionnaireswerecollected,ofwhich196wereeligibleforanalysis.Thepoorestresultswereseenforemergentproceduresandtheproportionofnotcompletedtasksinthesewas58%forEPMtasks,26%foranaesthesiarecordtasks,24%formedicationtasks,14%forbloodtesttasksand12%forpatientrecordtasks(Figure1.)
DiscussionAninsufficientimplementationofguidelinesforpreparationofthesurgicalpatientwasrevealedinthisstudy.Thismayincreasetheriskoffailuresandreducepatientsafetyasreportedinastudythatfoundcommunicationbreakdownin60of444observedsurgicalprocedureswithmalpracticeclaims,38%ofthosehappeninginthepreoperativehandover(2).Afailurerateofaround70percentofallchangeprogram-mesinitiatedinorganisationsisreportedandmanagementofchangetendstobereactive,discontinuousandadhoc.Thismaybeduetoalackofavalidframeworkofhowtoimplementandmanageorganisationalchange(3).Ananalysisoffactorsrelevanttoeffectuatingactualchangemustbeconductedandachangestrategybasedonthepreviousanalysismustbeperformedalongwithmonitoringandfeed-backoftheimplementationprocessbecauseonlybycarefulmonitoringintelligentandtimelyreactionsarepossible(3).
ConclusionGuidelinesforpreoperativepreparationofthesurgicalpatientareinsufficientlyfollowed.1. AnnSurg.2010;252:402–7.2. JAmCollSurg.2007;204:533–40.3. Harvardbusinessreview86.7/8(2008):130.
Abstract 11Korresponderende forfatter NicolaiLohse
Email [email protected] AfdelingforAnæstesiologiogIntensivMedicinHospital/institution Hvidovre HospitalMedforfattere LarsHyldborgLundstrøm,ThereseRisomVestergaard,MartinRisom,SteffenJaisRosenstock,NicolaiBangFoss, MortenHylanderMøller
Titel Prophylacticendotrachealintubationversusconscioussedationduringemergencyendoscopyforpepticulcer bleeding.Apopulation-basedcohortstudy
BackgroundEmergencyuppergastrointestinalbleeding(UGIB)carriesa30-daymortalityofaround10%.Nouniversallyagreedapproachexiststothelevelofmonitoringandtypeofairwayprotectionneededwhenpatientsundergoemergencyesophago-gastro-duodenoscopy(EGD)forsus-pectedUGIB.Weaimedtocompareprophylacticintubationwithconscioussedationandtheassociationwith90-daymortality.
MethodsProspective,nationwide,population-basedcohortstudycombiningfourdatasources:TheDanishAnaesthesiaDatabase,theDanishClinicalRegisterofEmergencySurgery,theDanishNationalPatientRegistry,andtheDanishCivilRegistrationSystem.Weincludedpatientsunder-goingtheirfirstEGDforPUBduring2006-2013.Primaryendpointwas90-daymortality,andsecondaryendpointwaslengthofstayin-hospi-talafterEGD.Weusedlogisticandlinearregressiontoassesstheeffectofintubationvssedationontheprimaryandsecondaryendpoints,respectively.Thestudywaspoweredtodetectoddsratios(OR)oflowerthan0.77orhigherthan1.27ontheprimaryoutcome.
ResultsThestudygroupcomprised3,638patients;2158(59%)hadETIand1,480(41%)hadconscioussedation.WhereETIwasused,comparedtose-dation,morepatientshadbleedingshockatadmission(30.4%vs19.9%,p<0.0005),hadexcessivealcoholintake(18.0%vs15.0%,p=0.018),wereyounger(medianage74.2[interquartilerange,IQR63.4-83.0]vs75.9[IQR65.6-84.0]years,p=0.002),hadlowerCharlsonComorbidityIndexscore(median1[IQR0-3]vs2[IQR1-3],p<0.0005)andtheprocedurehadmoreoftenbeenattendedbyaspecialistanesthesiologist(46.2%vs30.6%,p<0.0005).Duringthefirst90daysafterEGD,18.8%diedintheETIgroup,and18.4%diedinthesedationgroup,crudeOR=1.03(95%confidenceintervals[CI]=0.87-1.22,p=0.739),adjustedOR=0.95(95%CI=0.79-1.15,p=0.598).PatientsintheETIgroupstayedslightlylongerinhospitalaftertheEGD,mean8.18days[95%CI=7.66-8.71]vs7.62days[95%=CI6.92-8.33],p=0.113inadjustedanalysis).
DiscussionThisstudyprovidestheto-datemostsolidassessmentofmorbidityandmortalityassociatedwithtwodifferenttypesofairwayprotectionduringemergencyEGDforPUB.OurfindingspointinthedirectionthatconscioussedationandprophylacticETIbotharemethods,whichinthehandsofexperiencedhealthcarepersonnelareequallysafeforpatientswithPUB.However,anobservationalstudyofaclinicalinterven-tionshouldalwaysbeinterpretedwithcaution,andthelackofdifferenceinoutcomeforthetwogroupscouldbeduetoresidualconfoun-dingbytheclinicalassessmentsanddecisionstakenbytheattendinganesthetist.
ConclusionsInthislargepopulation-basedcohortstudy,airwayprotectionwithETIwasequaltoconscioussedationinpatientsundergoingemergencyEGDforPUBintermsof90-daymortalityandLOS.Arandomizedclinicaltrialisneededtofullyanswerthisimportantclinicalquestion.
