• Clinical practice guideline on atraumatic (pencil-point) vs conventional needles for lumbar puncture: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

      Rehn, Marius; Chew, Michelle S; Olkkola, Klaus T; Sverrison, Kristinn Ö; Yli-Hankala, Arvi; Møller, Morten Hylander; 1 Pre-Hospital Division, Air Ambulance Department, Oslo University Hospital, Oslo, Norway. 2 The Norwegian Air Ambulance Foundation, Oslo, Norway. 3 Faculty of Health Sciences, University of Stavanger, Stavanger, Norway. 4 Department of Anaesthesia and Intensive Care, Medicine and Health, Linköping University, Linköping, Sweden. 5 Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. 6 Department of Anaesthesia and Intensive Care Medicine, Landspitali University Hospital, Reykjavík, Iceland. 7 Department of Anaesthesia, Tampere University Hospital, Tampere, Finland. 8 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland. 9 Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark. (Wiley, 2019-04)
      The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical Practice Committee endorses the BMJ Rapid Recommendation clinical practice guideline on atraumatic (pencil-point) vs conventional needles for lumbar puncture. This includes the strong recommendation for the use of atraumatic needles for lumbar puncture in all patients regardless of age or indication.
    • The demographics of persistent opioid consumption following limb amputation.

      Steen, Talora; Lirk, Philipp B; Sigurdsson, Martin I; 1 Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. 2 Division of Anesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland. 3 Faculty of Medicine, University of Iceland, Reykjavik, Iceland. (Wiley, 2019-10-24)
      BACKGROUND: Patients who have limb amputation are at risk of chronic pain, including phantom limb pain that can be challenging to treat. The aim of this study was to describe the incidence of pre-operative opioid usage and the incidence and risk factors for new persistent post-operative opioid usage in opioid-naïve patients after limb amputation. METHODS: A retrospective study of all patients 18 years and older underwent upper or lower extremity amputations in Landspitali University Hospital between 2005 and 2015. Patients were considered to use opioids pre-operatively if they filled an opioid prescription 1-6 months prior to amputation and were considered to have persistent opioid use if opioid prescriptions were filled between post-operative months four to twenty-four. In addition to incidence estimate, uni- and multivariate analysis was performed to identify risk factors for persistent post-operative opioid usage. RESULTS: Of 328 total patients, 216 (66%) were opioid naïve and 112 (34%) were chronic opioid users. Of the opioid-naïve patients surviving more than 3 months 40 (20%) developed persistent post-operative opioid usage. In multivariate analysis, factors independently associated with persistent post-operative opioid usage were younger age, male gender, pre-operative use of neuropathic medications or benzodiazepines and lower (opposed to upper) extremity amputation. CONCLUSION: Opioid naïve patients undergoing major amputation had a 20% chance of having a persistent opioid requirement following surgery. This could represent new-onset phantom limb pain or other chronic pain. Our findings should encourage perioperative multimodal efforts to reduce the burden of chronic pain after limb amputations.
    • Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU)-Protocol for a randomised clinical trial comparing a lower vs a higher oxygenation target in adults with acute hypoxaemic respiratory failure.

      Schjørring, Olav L; Perner, Anders; Wetterslev, Jørn; Lange, Theis; Keus, Frederik; Laake, Jon H; Okkonen, Marjatta; Siegemund, Martin; Morgan, Matthew; Thormar, Katrin M; et al. (Wiley, 2019-08)
      BACKGROUND: Acutely ill adults with hypoxaemic respiratory failure are at risk of life-threatening hypoxia, and thus oxygen is often administered liberally. Excessive oxygen use may, however, increase the number of serious adverse events, including death. Establishing the optimal oxygenation level is important as existing evidence is of low quality. We hypothesise that targeting an arterial partial pressure of oxygen (PaO2 ) of 8 kPa is superior to targeting a PaO2 of 12 kPa in adult intensive care unit (ICU) patients with acute hypoxaemic respiratory failure. METHODS: The Handling Oxygenation Targets in the ICU (HOT-ICU) trial is an outcome assessment blinded, multicentre, randomised, parallel-group trial targeting PaO2 in acutely ill adults with hypoxaemic respiratory failure within 12 hours after ICU admission. Patients are randomised 1:1 to one of the two PaO2 targets throughout ICU stay until a maximum of 90 days. The primary outcome is 90-day mortality. Secondary outcomes are serious adverse events in the ICU, days alive without organ support and days alive out of hospital in the 90-day period; mortality, health-related quality-of-life at 1-year follow-up as well as 1-year cognitive and pulmonary function in a subgroup; and an overall health economic analysis. To detect or reject a 20% relative risk reduction, we aim to include 2928 patients. An interim analysis is planned after 90-day follow-up of 1464 patients. CONCLUSION: The HOT-ICU trial will test the hypothesis that a lower oxygenation target reduces 90-day mortality compared with a higher oxygenation target in adult ICU patients with acute hypoxaemic respiratory failure.
    • The importance of recovery of renal function following acute kidney injury after CABG

      Helgadottir, S.; Sigurdsson, M. I.; Palsson, R.; Helgason, D.; Sigurdsson, G. H.; Gudbjartsson, T.; [ 1 ] Landspitali Univ Hosp, Dept Cardiothorac Surg, IS-101 Reykjavik, Iceland   Organization-Enhanced Name(s)      Landspitali National University Hospital [ 2 ] Landspitali Univ Hosp, Dept Anesthesiol & Intes care Med, Reykjavik, Iceland   Organization-Enhanced Name(s)      Landspitali National University Hospital [ 3 ] Brigham & Womens Hosp, Dept Anesthesiol Perioperat & Pain Med, 75 Francis St, Boston, MA 02115 USA [ 4 ] Landspitali Univ Hosp, Dept Nephrol, Reykjavik, Iceland; Department of Cardiothoracic Surgery; Landspitali University Hospital; Reykjavik Iceland; Department of Anesthesiology, Perioperative and Pain Medicine; Brigham and Women's Hospital; Boston MA USA; Department of Nephrology; Landspitali University Hospital; Reykjavik Iceland; et al. (Wiley-Blackwell, 2016-11)
    • Infections and outcomes after cardiac surgery-The impact of outbreaks traced to transesophageal echocardiography probes.

      Vesteinsdottir, Edda; Helgason, Kristjan Orri; Sverrisson, Kristinn Orn; Gudlaugsson, Olafur; Karason, Sigurbergur; 1 Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland. 2 Department of Clinical Microbiology, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland. 3 Department of Infectious Diseases, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland. 4 Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland. (Wiley, 2019-08)
      BACKGROUND: Infections are a frequent complication of cardiac surgery. The intraoperative use of transesophageal echocardiography (TEE) may be an underrecognized risk factor for post-operative infections. The aim of this study was to investigate infection rates and outcomes after cardiac surgery in a nationwide cohort, especially in relation to periods where surface damaged TEE probes were used. METHODS: This was a retrospective, observational study at Landspitali University Hospital. All consecutive cardiac surgery patients from 1 January 2013 to 31 December 2017 were included. Patients' charts were reviewed for evidence of infection, post-operative complications or death. RESULTS: During the study period, 973 patients underwent cardiac surgery at Landspitali and 198 (20.3%) developed a post-operative infection. The most common infections were: Pneumonia (9.1%), superficial surgical site (5.7%), bloodstream (2.8%) and deep sternal wound (1.7%). Risk factors for developing an infection included: The duration of procedure, age, insulin-dependent diabetes, EuroScore II, reoperation for bleeding and an operation in a period with a surface damaged TEE probe in use. Twenty-two patients were infected with a multidrug resistant strain of Klebsiella oxytoca, 10 patients with Pseudomonas aeruginosa and two patients developed endocarditis with Enterococcus faecalis. All three pathogens were cultured from the TEE probe in use at respective time, after decontamination. The 30-day mortality rate in the patient cohort was 3.2%. CONCLUSIONS: The intraoperative use of surface damaged TEE probes caused two serious infection outbreaks in patients after cardiac surgery. TEE probes need careful visual inspection during decontamination and probe sheaths are recommended.
    • Long-term survival after intensive care: A retrospective cohort study.

      Kristinsdottir, Eyrun A; Long, Thorir E; Sigvaldason, Kristinn; Karason, Sigurbergur; Sigurdsson, Gisli H; Sigurdsson, Martin I; 1 Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland. 2 Department of Internal Medicine at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland. 3 Faculty of Medicine, University of Iceland, Reykjavik, Iceland. (Wiley, 2019-09-16)
      Background Limited data exist on long-term survival of patients requiring admission to intensive care units (ICUs). The aim of this study was to investigate long-term survival of ICU patients in Iceland and assess changes over a 15-year period. Methods Data were collected on age, gender, admission cause, length of stay, comorbidities, mechanical ventilation and survival of patients 18 years and older admitted to the ICUs in Landspitali during 2002-2016. Long-term survival of patients surviving more than 30 days from admission was estimated and its predictors assessed with Cox regression analysis. Long-term survival was compared to the survival of an age- and gender-matched reference group from the general population. Results Of 15 832 ICU admissions, 55% was medical, 38% was surgical and 7% was due to trauma. The 5-year survival of medical, surgical and trauma patients was 66%, 76% and 92% respectively. Significant survival differences were found between admission subgroups. Higher age and comorbidity burden was related to decreased survival in all patient groups. After correcting for age, gender, comorbidities, length of ICU stay and mechanical ventilation, patient survival improved during the study period only for patients admitted for infections. There was a high variability in the estimated time point where the ICU admission had no residual effect on survival. Conclusions Long-term survival of ICU patients is substantially decreased compared to the general population, but varies based on admission causes. Improved long-term survival of patients admitted with infections could be explained by earlier detection and improved treatment of septic shock.
    • New-onset postoperative atrial fibrillation after heart surgery.

      Gudbjartsson, Tomas; Helgadottir, Solveig; Sigurdsson, Martin Ingi; Taha, Amar; Jeppsson, Anders; Christensen, Thomas Decker; Riber, Lars Peter Schoedt; 1 Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland. 2 Faculty of Medicine, University of Iceland, Reykjavik, Iceland. 3 Department of Cardiothoracic Surgery and Anaesthesia, Uppsala University Hospital, Uppsala, Sweden. 4 Department of Anaesthesia and Critical Care, Landspitali University Hospital, Reykjavik, Iceland. 5 Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden. 6 Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. 7 Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden. 8 Department of Cardiothoracic and Vascular Surgery, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark. 9 Department of Cardiothoracic and Vascular Surgery, Department of Clinical Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark. (Wiley, 2019-11-14)
      BACKGROUND: New-onset postoperative atrial fibrillation (poAF) complicates approximately 20-60% of all cardiac surgical procedures and is associated with an increased periprocedural mortality and morbitity, prolonged hospital stay, increased costs, and worse long-term survival. Unfortunately multiple advances in surgery and perioperative care over the last two decades have not led to a reduction in the incidence of poAF or associated complications in the daily clinical practice. METHODS: A narrative review of the available literature was performed. RESULTS: An extensive review of the pathophysiology of poAF following cardiac surgery, clinical, and procedural risk-factors is provided, as well as prophylactic measures and treatment. CONCLUSION: Multiple strategies to prevent and manage poAF following heart surgery already exist. Our hope is that this review will facilitate more rigorous testing of prevention strategies, implementation of prophylaxis regimens as well as optimal treatment of this common and serious complication.
    • Prevention of sepsis and multiple organ failure in critically ill patients

      Sigurdsson, G H (Blackwell Publishing Inc, 1995-06)
      No abstract available
    • Prospective study on long-term outcome after abdominal surgery

      Brynjarsdottir, E. D.; Sigurdsson, M. I.; Sigmundsdottir, E.; Möller, P. H.; Sigurdsson, G. H.; [ 1 ] Landspitali, Dept Internal Med, Reykjavik, Iceland Show more [ 2 ] Univ Iceland, Fac Med, Reykjavik, Iceland Show more [ 3 ] Duke Univ, Sch Med, Dept Anesthesiol, Durham, NC USA [ 4 ] Landspitali, Dept Anaesthesia & Intens Care Med, Reykjavik, Iceland [ 5 ] Landspitali, Dept Surg, Reykjavik, Iceland; Department of Internal Medicine; Landspitali - The National University Hospital of Iceland; Reykjavik Iceland; Department of Anesthesiology; Duke University School of Medicine; Durham NC USA; Department of Anaesthesia and Intensive Care Medicine; Landspitali - The National University Hospital of Iceland; Reykjavik Iceland; Faculty of Medicine; University of Iceland; Reykjavik Iceland; et al. (Wiley, 2018-02)
      BACKGROUND: Complications following major abdominal surgery are common and an important cause of morbidity and mortality. The aim of this study was to describe 1-year mortality and identify factors that influence adverse outcomes after abdominal surgery. METHODS: This prospective observational cohort study was performed in Landspitali University Hospital and included all adult patients undergoing abdominal surgery requiring > 24-h hospital admission over 13 months. The follow-up period was 60 days for complications and 24 months for mortality. RESULTS: Data were available for 1113 (99.5%) of the 1119 patients who fulfilled inclusion criteria. A total of 23% of patients had at least one underlying co-morbidity. Non-elective surgeries were 48% and 13% of the patients were admitted to ICU post-operatively. A total of 20% of patients developed complications. Mortality at 30 days, 1 and 2 years was 1.8%, 5.6%, and 8.3% respectively. One-year mortality for those admitted to ICU was 18%. The long-term survival of the individuals surviving 30 days was significantly worse than for an age- and gender-matched population control group. Independent predictors for 1-year mortality were age, pre-operative acute kidney injury and intermediate- or major surgery. CONCLUSION: Post-operative complication rates and mortality following abdominal surgery in Iceland were comparable or in the lower range of previously published outcomes, validating the utility of offering a full host of abdominal surgical services in geographically isolated region with a relatively small referral base.
    • Scandinavian SSAI clinical practice guideline on choice of inotropic agent for patients with acute circulatory failure

      Møller, M. H.; Granholm, A.; Junttila, E.; Haney, M.; Oscarsson-Tibblin, A.; Haavind, A.; Laake, J. H.; Wilkman, E.; Sverrisson, K. Ö.; Perner, A.; et al. (Wiley, 2018-04)
      BACKGROUND: Adult critically ill patients often suffer from acute circulatory failure and those with low cardiac output may be treated with inotropic agents. The aim of this Scandinavian Society of Anaesthesiology and Intensive Care Medicine guideline was to present patient-important treatment recommendations on this topic. METHODS: This guideline was developed according to GRADE. We assessed the following subpopulations of patients with shock: (1) shock in general, (2) septic shock, (3) cardiogenic shock, (4) hypovolemic shock, (5) shock after cardiac surgery, and (6) other types of shock, including vasodilatory shock. We assessed patient-important outcome measures, including mortality and serious adverse reactions. RESULTS: For all patients, we suggest against the routine use of any inotropic agent, including dobutamine, as compared to placebo/no treatment (very low quality of evidence). For patients with shock in general, and in those with septic and other types of shock, we suggest using dobutamine rather than levosimendan or epinephrine (very low quality of evidence). For patients with cardiogenic shock and in those with shock after cardiac surgery, we suggest using dobutamine rather than milrinone (very low quality of evidence). For the other clinical questions, we refrained from giving any recommendations or suggestions. CONCLUSIONS: We suggest against the routine use of any inotropic agent in adult patients with shock. If used, we suggest using dobutamine rather than other inotropic agents for the majority of patients, however, the quality of evidence was very low, implying high uncertainty on the balance between the benefits and harms of inotropic agents.
    • Vasopressin-induced changes in splanchnic blood flow and hepatic and portal venous pressures in liver resection

      Sand Bown, L.; Ricksten, S.-E.; Houltz, E.; Einarsson, H.; Söndergaard, S.; Rizell, M.; Lundin, S.; [ 1 ] Univ Gothenburg, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Anaesthesiol & Intens Care Med, Gothenburg, Sweden [ 2 ] Landspitali Univ Hosp, Dept Anaesthesiol & Intens Care Med, Reykjavik, Iceland   Organization-Enhanced Name(s)      Landspitali National University Hospital [ 3 ] Univ Gothenburg, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Transplantat & Liver Surg, Gothenburg, Sweden; Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden; Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden; et al. (Wiley-Blackwell, 2016-05)
      Background: To minimize blood loss during hepatic surgery, various methods are used to reduce pressure and flow within the hepato-splanchnic circulation. In this study, the effect of low- to moderate doses of vasopressin, a potent splanchnic vasoconstrictor, on changes in portal and hepatic venous pressures and splanchnic and hepato-splanchnic blood flows were assessed in elective liver resection surgery. Methods: Twelve patients were studied. Cardiac output (CO), stroke volume (SV), mean arterial (MAP), central venous (CVP), portal venous (PVP) and hepatic venous pressures (HVP) were measured, intraoperatively, at baseline and during vasopressin infusion at two infusion rates (2.4 and 4.8 U/h). From arterial and venous blood gases, the portal (splanchnic) and hepato-splanchnic blood flow changes were calculated, using Fick's equation. Results: CO, SV, MAP and CVP increased slightly, but significantly, while systemic vascular resistance and heart rate remained unchanged at the highest infusion rate of vasopressin. PVP was not affected by vasopressin, while HVP increased slightly. Vasopressin infusion at 2.4 and 4.8 U/h reduced portal blood flow (-26% and -37%, respectively) and to a lesser extent hepatosplanchnic blood flow (-9% and -14%, respectively). The arterial-portal vein lactate gradient was not significantly affected by vasopressin. Postoperative serum creatinine was not affected by vasopressin. Conclusion: Short-term low to moderate infusion rates of vasopressin induced a splanchnic vasoconstriction without metabolic signs of splanchnic hypoperfusion or subsequent renal impairment. Vasopressin caused a centralization of blood volume and increased cardiac output. Vasopressin does not lower portal or hepatic venous pressures in this clinical setting.
    • Venovenous extracorporeal membrane oxygenation treatment in a low-volume and geographically isolated cardiothoracic centre.

      Ingvarsdottir, Inga L; Vidarsdottir, Halla; Valsson, Felix; Simonardottir, Liney; Sigurdsson, Martin I; Myrdal, Gunnar; Geirsson, Arnar; Gudbjartsson, Tomas; 1 Department of Anaesthesiology and Intensive Care, Landspitali University Hospital, Reykjavik, Iceland. 2 Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland. 3 Faculty of Medicine, University of Iceland, Reykjavik, Iceland. (Wiley, 2019-08)
      BACKGROUND: Extracorporeal membrane oxygenation (ECMO) treatment is generally offered in large tertiary cardiothoracic referral centres. Here we present the indications and outcome of venovenous-ECMO (VV-ECMO) treatment in a low-volume, geographically isolated single-centre in Iceland, a country of 350 000 inhabitants. Our hypothesis was that patient survival in such a centre can be similar to that at high-volume centres. METHODS: A retrospective study that included all patients treated with VV-ECMO in Iceland from 1991-2016 (n = 17). Information on demographics, indications and in-hospital survival was collected from patient charts and APACHE II and Murray scores were calculated. Information on long-term survival was collected from a centralized registry. RESULTS: Seventeen patients were treated with VV-ECMO (nine males, median age 33 years, range 14-74), the indication for 16 patients was severe acute respiratory distress syndrome, most often following pneumonia (n = 6), H1N1-infection (n = 3) or drowning (n = 2). Median APACHE-II and Murray-scores were 20 and 3.5, respectively, and median duration of VV-ECMO treatment was 9 days (range 2-40 days). In total 11 patients (64,7%) survived the treatment, with 10 patients (58,8%) surviving hospital discharge, all of who were still alive at long-term follow-up, with a median follow-up time of 9 years (August 15th, 2017). CONCLUSION: Venovenous-ECMO service can be provided in a low-volume and geographically isolated centre, like Iceland, with short- and long-term outcomes comparable to larger centres.