1

Foredragskonkurrence

Abstract 7

Korresponderende forfatter Iben Engelund Luna Email ibenengelundluna@gmail.com Afdeling Enhed for kirurgisk patofysiologi Hospital/institution Rigshospitalet Medforfattere HenrikKehlet,ClausMunkJensen,ThorbjørnChristiansen,ThomasLind,SnorreStephensen, Eske Aasvang Titel Theeffectofpreoperativeintraarticularmethylprednisoloneonpainaftertotalknee arthroplasty-adouble-blinded,randomized,placebocontrolledtrialinpatientswith high-painkneeosteoarthritisandsensitization

IntroductionAcutepainaftertotalkneearthroplasty(TKA)remainsaconsiderableclinicalproblemwith75%ofpatientshavingmoderate-se-verepainonthefirstpostoperativedayand30-40%after2weekswithimplicationsforrecoveryandthedevelopmentofpersi-stentpostsurgicalpainconditions[2].Intensepreoperativepainandcentralsensitizationhavebeenassociatedtoacutepost-TKApain,andintraarticularinflammationsuggestedastheunderlyingpathogenicmechanism[1].Intraarticularmethylprednisolone(MP)iswell-establishedtoreducepaininkneeosteoarthritis,andintraarticularadministrationinarthroscopicsurgeryreducespostoperativepain[3].Apreoperativedownregulationoftheintraarticularinflammationinpatientswithhigh-painosteoarthritisandsensitizationcouldpotentiallyserveasastratifiedpreventiveanalgesicstrategyinthissubgroupofpatients.Thus,wehy-pothesizedthatasingleintraarticulardoseof40mgMPadministeredoneweekpriortoTKAwouldreduceacutepostoperativepaininpatientswithpreoperativehigh-painknee-osteoarthritisandcentralsensitization.

Methods48patientswithhighpainosteoarthritis(NRS≥5)andsignsofcentralsensitization(pressurealgometry)wereincludedinthisdouble-blinded,randomized,placebo-controlledtrial.Primaryoutcomewasproportionofpatientwithmoderate/severepainduringa5meterwalktest24hourspostoperatively.Secondaryoutcomesincludedpainduringa5meterwalktestat48hours,painandopioidconsumptionduringthefirst14postoperativedaysandquantitativesensorytesting(QST)ofchangeinpressurepainthresholdandtemporalsummationtomechanicalstimulation(wind-up)frompriortoadministrationofMPuntiltwodaysaftersurgery.

ResultsTherewasnodifferencebetweenMP/placebogroupsinproportionofpatientswithmoderate/severepainat24hours(67%vs74%respectively,p=0.63),at48hours(p=0.46)orduringthefirst14postoperativedaysinpain(p>0.44)oropioidconsumption(p=0.16)(table1and2).MPdidnotreduceQSTsignsofsensitization(p>0.41).Inconclusion,ourstudydoesnotsupporttheuseofmethylprednisoloneadministered1weekpreoperativelytoreducemoderate-severepost-TKApaininpatientswithhighpainosteoarthritisandsignsofcentralsensitization.Theneedforanimprovedanalgesicstrategyinthissubgroupofpatientsisemphasized,andothermechanismbasedtreatmentoptionsshouldbeexplored.

Reference List[1]Arendt-Nielsenetal,Sensitizationinpatientswithpainfulkneeosteoarthritis,Pain2010;149:573-581.[2]Grosuetal,Painafterkneearthroplasty:anunresolvedissue,KneeSurgSportsTraumatolArthrosc2014;22:1744-1758.[3]Rasmussenetal,Combinedintra-articularglucocorticoid,bupivacaineandmorphinereducespainandconvalescenceafterdiagnostickneearthroscopy,ActaOrthopScand2002;73:175-178.

2

Abstract22

Korresponderende forfatter AndersGranholmEmail andersgran@gmail.com Afdeling DepartmentofIntensiveCare4131Hospital/institution Copenhagen University Hospital, RigshospitaletMedforfattere MortenHylanderMøller,MetteKrag,AndersPerner,PeterBuhlHjortrupTitel PredictiveperformanceofSAPSIIandinitialSOFAscoreinacutelyillICUpatients

IntroductionSeverityscoresincludingtheSimplifiedAcutePhysiologyScore(SAPS)II[1]andtheSequentialOrganFailureAssessment(SOFA)score[2]areusedinintensivecareunits(ICUs)toassessdiseaseseverity,predictmortalityandinresearch.WeassessedthepredictiveperformanceofSAPSIIandtheinitialSOFAscoreforin-hospitaland90-daymortalityinacontemporaryinternationalcohort.

MethodsThiswasapost-hocstudyoftheStressUlcerProphylaxisintheIntensiveCareUnitinceptioncohortstudy[3],whichincludedacutelyilladultsfromgeneralICUsacross11countries(n=1034).Therelevantethicalcommitteesineachcountrywaivedinfor-med consent.WecomparedthediscriminationofSAPSIIandinitialSOFAscores,comparedthediscriminationofSAPSIIinourcohortwiththeoriginalcohort,assessedthecalibrationofSAPSIIcustomisedtoourcohort,andcomparedthediscriminationfor90-daymortali-tyvs.in-hospitalmortalityforbothscores.Discriminationwasevaluatedusingareasunderthereceiveroperatingcharacteristicscurves(AUROC).CalibrationwasevaluatedusingHosmer-Lemeshow’sgoodness-of-fitĈ-statistic.

ResultsAUROCforin-hospitalmortalitywas0.80forSAPSIIand0.73fortheinitialSOFAscore(P<0.001forcomparison,Fig.1).Discrimi-nationofSAPSIIwassignificantlyreducedcomparedwiththeoriginalSAPSIIvalidationsample(P=0.001,Fig.2).CalibrationofthecustomisedSAPSIIforpredictingin-hospitalmortalitywasadequate(P=0.60).AUROCfor90-daymortalitywas0.79(P=0.74forcomparisonwithin-hospitalmortality)forSAPSIIand0.71(P=0.66forcomparisonwithin-hospitalmortality)fortheinitialSOFAscore(Fig.1).

DiscussionWefoundthatSAPSIIwassuperiorinpredictingmortalitycomparedwiththeinitialSOFAscore,whichwasnotdevelopedforthispurpose.TheperformanceofSAPSIIhasdeterioratedovertime,andre-calibrationshowedthatthescorewasassociatedwithalowermortalityriskinourcontemporarycohortcomparedwiththeolder,originalcohort.Discriminationwascomparablefor90-dayvs.in-hospitalmortalityforbothscores.

ConclusionThepredictiveperformanceofSAPSIIwassuperiortothatoftheinitialSOFAscore,comparableforin-hospitaland90-daymortality,butappearstohavedecreasedovertime.Useofacontemporaryseverityscorewithimprovedpredictiveperformancemay be indicated.

3

References1.LeGalletal.JAMA19932.Vincentetal.IntensiveCareMed19963.Kragetal.IntensiveCareMed2015

Abstract23

Korresponderende forfatter RikkeVibekeNielsenEmail rikkevibeke@gmail.com Afdeling NeuroanæstesiologiskKlinikHospital/institution Rigshospitalet-GlostrupMedforfattere FomsgaardJS,SiegelH,MartuseviciusR,NikolajsenL,DahlJB,MathiesenOTitel Intraoperativeketaminereducesimmediatepostoperativeopioidconsumptionafterspinal fusionsurgeryinchronicpainpatientswithopioiddependency:Arandomized,blindedtrial

IntroductionPerioperativehandlingofsurgicalpatientswithopioiddependencyrepresentsanimportantclinicalproblem.Animalstudiessuggestthatketamineattenuatescentralsensitizationandhyperalgesiaandtherebyreducespostoperativeopioidtolerance.Wethereforehypothesizedthatintraoperativeketaminewouldreduceimmediatepostoperativeopioidconsumptioncomparedtoplaceboinchronicpainpatientswithopioiddependencyundergoinglumbarspinalfusionsurgery.

MethodsOnehundredandfiftypatientsundergoingspinalfusionsurgerywererandomlyassignedtointraoperativeS-ketaminebolus0.5mg/kgandinfusion0.25mg/kg/horplacebo.Postoperativelypatientsreceivedtheirusualopioids,paracetamolandIVPatientControlledAnalgesia(PCA)withmorphine.Primaryoutcomewasmorphineconsumption0-24hpostoperatively.Secondaryout-comeswereacutepainatrestandduringmobilization2-24hpostoperatively(VAS),adverseeventsandpersistentpain6monthspostoperatively..

ResultsInthefinalanalyses147patientswereincluded(Table1).PCAIVmorphineconsumption0-24hourspostoperativelywassignifi-cantlyreducedintheketaminegroupcomparedtotheplacebogroup:79(47)vs121(53)mgIV,meandifference42mg(95%CI-59to-25),P<0.001.Sedationwassignificantlyreducedintheketaminegroup6hand24hpostoperatively.Therewerenosig-nificantdifferencesregardingacutepain,nausea,vomiting,hallucinationsornightmares.Backpainat6monthspostoperativelycomparedtopreoperativepainlevelswassignificantlyimprovedintheketaminegroupcomparedtotheplacebogroup,P=0.005(Table2).

DiscussionRecently,intraoperativeketaminehasbeensuggestedasanidealcandidateformanagingperioperativepaintreatmentinopioid

4

dependentchronicpainpatients.Ourfindingonreducedopioidconsumptionsupportsthis.Theresultsonreduced6monthspainlevelsmustbeconsideredexploratorysecondaryoutcomes,asthesamplesizecalculationwasnotbasedontheseout-comes.

ConclusionInconclusion,intraoperativeketaminesignificantlyreducedmorphineconsumption0-24hafterlumbarfusionsurgeryinopioiddependentpatients.Thetrendregardinglesspersistentpain6monthspostoperativelyneedsfurtherinvestigation.

5

Abstract33

Korresponderende forfatter AndersKehletNørskovEmail anderskehlet@hotmail.com Afdeling AnæstesiologiskafdelingHospital/institution NordsjællandsHospital-HillerødMedforfattere RosenstockCV,NordsjællandsHospital-Hillerød;WetterslevJ,Rigshospitalet;AfshariA, Rigshospitalet;AstrupG,AarhusUniversityHospital,ThomsenJLD,HerlevHospital; LundstrømLH,NordsjællandsHospital-HillerødTitel Predictionofdifficultmaskventilationusingasystematicassessmentofriskfactorsversus existingpractice–aclusterrandomisedclinicaltrialin94006patients

IntroductionAnaesthesiologists’predictionofdifficultmaskventilationispoor.[1]IntheDanishAnaesthesiaDatabase(DAD),predictionofdifficultmaskventilationisleftatthediscretionoftheindividualanaesthetist.Preoperativeassessmentofriskfactorsfordifficultmaskventilationmayreducetheincidenceofunanticipateddifficulties.Wecomparedsystematicassessmentofriskfactorsfordifficultmaskventilationwithexistingpracticeforairwayassessmentonaccuracyonpredictingdifficulties.

Methods26departmentswerecluster-randomisedtoassess11riskfactorsfordifficultairwaymanagement(intervention)orexistingairwayassessment(control).Predictionofmaskventilationandintubationdifficulties,andactualairwaymanagementconditionswereregisteredintheDAD.Inordertoadjustfortheclusterednatureofdataweexaminedthediagnosticaccuracyofpredictingdifficultmaskventilationandthecombinationofdifficultmaskventilationanddifficultintubationusinggeneralizedestimating

6

equations.Primaryoutcomewastheproportionsofunanticipateddifficultmaskventilation.

ResultsAmong94006patientsundergoingmaskventilationtheincidenceofunanticipateddifficultmaskventilationwas427/46804(0.91%)intheinterventiongroupand414/47202(0.88%)inthecontrolgroup,OR0.98(95%CI:0.66–1.44),p=0.90.Thenum-berofpatientspredicteddifficulttomaskventilate,butinfactfoundtobeeasy(unanticipatedeasy)was298(0.64%)versus164(0.35%),OR1.56(1.01-2.42),p=0.045.Intheinterventiongroup427of495(86.3%)casesofdifficultmaskventilationwereunpredicted,comparedwith414of454(91.2%)inthecontrolgroup,OR0.61(0.41-0.91),p=0.016.In44337patientsundergoingbothmaskventilationandtrachealintubationtheincidenceofcombineddifficultmaskventilationanddifficultintubationwas0.3%inbothgroups.Intheinterventiongroup71of365(19.5%)difficultmaskventilationswerealsodifficulttointubateversus65of318(20.4%)inthecontrolgroup.Hadtheanaesthetistpredictedoneorbothofthesemodalitiesasdifficultweconsidereditcorrectlypredicted.Inpatientswithcombineddifficulties56of71(78.9%)wereunanticipatedintheinterventiongroupcomparedwith53of65(81.5%)inthecon-trolgroup,OR0.76(0.41-1.41),p=0.39.

DiscussionThisisthefirstclusterrandomisedtrialcomparingtwostrategiesforpredictionofdifficultmaskventilation.Inthesametrialwealsoassessedpredictionofdifficultintubation.Theseresultshavebeenpublishedpreviously.[2]

ConclusionTheinterventiondidnotreducetheoverallincidenceofunanticipateddifficultmaskventilation,butbetterpredictionwasfoundintheinterventiongroupwhenisolatingcaseswithdifficultmaskventilation.Ibothgrouptheriskofdifficultintubationincrea-sesincaseswithdifficultmaskventilation.

1.Anaesthesia.2015;70:272–81.2.Br.J.Anaesth.2016;116:680–9.

7

8

Abstract40

Korresponderende forfatter MortenThingemannBøtkerEmail moboet@rm.dk Afdeling ForskningogudviklingHospital/institution Præhospitalet,RegionMidtjyllandMedforfattere Vedlagtsombilag(dererikkepladsher)Titel PrehospitaltriageofpatientssufferingseveredyspneausingN-terminalpro-BrainNatriuretic Peptide,thePreBNPtrial:arandomizedcontrolledclinicaltrial

IntroductionPatientssufferingdyspneaintheambulancehavehighmortality.Earlyidentificationoftheunderlyingcauseofdyspneatofacilitatecorrecttriageandtreatmentmayimproveoutcome.Theaimofthisstudywastoexaminewhetheradditionofbrainnatriureticpeptidemeasurementtotheroutinediagnosticwork-upbyprehospitalcriticalcareteamphysicianimprovestriageinpatientswithseveredyspnea.

MethodsRandomizedcontrolledtrialwithClinicalTrials.govidentifierNCT02050282.Prehospitalcriticalcareteamphysiciansincludedunselectedpatients>18yearswithseveredyspneaaccordingtopre-specifiedcriteriatoroutinediagnosticwork-upordiagno-sticworkupwithincorporatedpoint-of-careN-terminalpro-BrainNatriureticPeptide(NT-proBNP)measurement.Theprimaryendpointwastheproportionofpatientssufferingdyspneaofcardiacorigintriageddirectlytoadepartmentofcardiology.Anendpoint-adjudicationcommitteedeterminedtheprimarycauseofdyspneaasheartdisease,lungdisease,orotherdisease.TheCentralDenmarkRegionCommitteeonBiomedicalandResearchEthicsapprovedthestudyasanemergencyresearchproject(approvalnr1-10-72-317-13).

ResultsAtotalof747patientswererandomizedand711patientswithamedianageof75years(interquartilerange:75-82)consentedtoparticipate.Ofthese,350patientswererandomizedtotheNT-proBNPgroupand361patientstotheroutinework-upgroup.Astatisticallynon-significantlyhigherproportionofpatientssufferingdyspneaofcardiacoriginweretriageddirectlytoadepart-mentofcardiologyintheNT-proBNPgroupthanintheroutinework-upgroup(75%vs.69%,p=0.22).Nodifferencesinhospitallengthofstay,intensivecareunitadmissionratesormortalitywereobserved.Weobservedincreasednegativepredictivevalueforheartdisease(87%vs.75%,p=0.010)andincreasedpositivepredictivevalueforlungdisease(74%vs.60%,p=0.032)intheNT-proBNPgroup.

DiscussionInclusionofunselectedpatientsrenderedapopulationthatwasolderthaninpreviouslyconductedstudiesinemergencydepart-mentsettings.Contrarytoourexpectations,thevalueofpoint-of-careNT-proBNPmeasurementintheseelderlypatientswithdyspneaseemedtolieinrule-outofheartdiseaseratherthanrule-in.Otherpoint-of-caremodalitiesmaybeneededforearlyrecognitionofhigh-riskpatientsamongthisheterogeneousgroupofmainlyelderlypatients.

ConclusionSupplementarypoint-of-caremeasurementofNT-proBNPinpatientssufferingseveredyspneadidnotimprovetriageorpatientoutcome,butimprovedrule-outofheartdiseaseandrule-inoflungdisease.Ourresultsencouragefurtherresearchevaluatingtheimpactofprehospitalbiomarkerpanelmeasurementorotherpoint-of-carediagnosticsonearlymanagementofpatientssufferingdyspnea.

9

Abstract41

Korresponderende forfatter Ana-Marija HristovskaEmail anamarijahristovska@gmail.com Afdeling NeuroanæstesiHospital/institution RigshospitaletMedforfattere PatriciaDuch,MikkelAllingstrup,ArashAfashariTitel SugammadexversusNeostigmineinreversingneuromuscularblockade

IntroductionThisCochranereviewcomparesSugammadex,thefirstselectiverelaxant-bindingagentwithNeostigmine,anacetylcholinestera-seinhibitorwithwell-recognizedpotentialside-effects.

MethodsOurobjectivewastoinvestigatewhetherSugammadexismoreeffectiveandmoresafeinreversingneuromuscularblockadethanNeostigmine.TheprimaryoutcomewasrecoverytimetoTOF>0.9measuredbyacceleromyography.Thesecondaryout-comewasprevalenceofadverseeventsandseriousadverseevents.WesearchedtheCochraneCentralRegisterofControlledTrials(CENTRAL)MEDLINEandEMBASEuntil01.May2016.Wein-cludedallRCTs,irrespectiveofpublicationstatus,blindingstatus,dateofpublicationorlanguage,performedonadultASAI-IVpatientsreceivingnon-depolarizingmuscleblockingagents,scheduledforelectivein-patientorday-casesurgicalprocedures.Wecontacted the corresponding authors of included studies to retrieve relevant and missing data. Weassessedriskofbiasin10methodologicaldomainsusingtheCochraneCollaborationriskofbiastoolandriskofrandomerrorthroughtrialsequentialanalysis.WeusedtheprinciplesoftheGRADE(GradesofRecommendation,Assessment,Devel-opmentandEvaluationWorkingGroup)approachtoprovideanoverallassessmentofevidencerelatedtoallofouroutcomes.Wepresentpooledestimatesoftheeffectsofinterventionsasmeandifferences(MDs)andriskratios(RRs)with95%confidenceintervals(CIs).

ResultsOverall,56relevantstudieswereidentified,ofwhich43RCTs(n=4470)metourinclusioncriteria.Elevenstudieswereeligibleformeta-analysisoftheprimaryoutcome(n=1006),26studiesofthesecondaryoutcome(n=2162)and13studies(n=2013)wereineligible for meta-analysis. Meta-analysisoftheresultsshowedthefollowing:-Sugammadex2mg/kgwasonaverage9.84minutes(95%CI,8.23-11.46,p<0.00001,I2=82%,n=892)fasterthanNeostigmi-ne0.04-0.05mg/kginreversingtheneuromuscularblockadeatT2reappearance(Fig.1).-Sugammadex4mg/kgwasonaverage45.78minutes(95%CI,39.41-52.15,p<0.00001,I2=0%,n=114)fasterthanNeostig-mine0.07mg/kginreversingtheneuromuscularblockadeatPTC1-5reappearance.-Thereweresignificantlylesssubjectswithoneormoreadverseevents(RR0.60,95%CI0.45-0.79,p=0.0003,I2=0%,n=1659)aswellassignificantlylesscompositeadverseevents(RR0.66,95CI0.54-0.81,p<0.0001,I2=20%,n=2162)intheSu-gammadexgroupwhencomparedtoNeostigmine(Fig.2).-TherewasnosignificantdifferencebetweenSugammadexandNeostigmineregardingsubjectswithoneormoreseriousadver-seeventsaswellascompositeadverseevents(RR0.54,95%CI0.13-0.2.25,p=0.4,I2=0%,n=938).

Conclusions SugammadexreversesneuromuscularblockadefasterthenNeostigmineregardlessofthedepthoftheblockandisgenerallyassociatedwithfeweradverseevents.