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Preoperative resuscitation strategies in patients with hip fracture (HF) are lacking. We aimed to investigate fluid-responsiveness, peripheral perfusion index (PPI) and blood volume (BV)-status in patients with HF undergoing resuscitation in the preoperative phase.In a prospective observational study, we evaluated preoperative fluid-responsiveness, indices of perfusion and BV before and after lumbar epidural analgesia in 50 patients with HF shortly after admittance.Initially, 18 (36%) patients were fluid-responsive (≥10% increased SV in response to 250 ml fluid bolus) and 13 (26%) presented hypovolaemia (deviation of measured BV from estimated BV ≤ 0.9). According to fluid-responsiveness, no difference in absolute values of cardiac index (CI) (2.7 L [2.1-3.3] vs. 2.8 L [2.3-3.4], p = .5) was seen, but cardiac output (CO) rose significantly in the hypovolaemic patients: 9% [5-18] vs. 1% [-3-7], p = .004. After epidural analgesia, 26 (52%) patients were again fluid-responsive and 15 (30%) were hypovolaemic. CI was now significantly lower in fluid-responsive patients (2.2 L [1.7-2.7] vs. 2.9 L [2.3-3.5], p = .001). Prior to epidural analgesia, no significant trend towards hypovolaemic patients having lower indices of perfusion was seen. After epidural analgesia, more patients with hypovolaemia presented with PPI≤1.5 (8 (53%) vs. 3 (9%), p = .001) and absolute values of PPI were also significantly lower if IBV was low (1.4 [0.9-3.2] vs. 3.2 [2.4-4.8], p = .01). PPI correlated with hypovolaemia after epidural analgesia (rho 0.4 [0.1-0.7], p = .007).Preoperative fluid-responsivity in HF patients might be attributable to elements of hypovolaemia and sympathetic compensatory ability conjointly, confounding the use of SV-guided resuscitation. PPI could be associated with BV, which may support clinicians during perioperative haemodynamic optimisation.

Background: Patients undergoing major surgery are at risk of complications, so-called serious adverse events (SAE). Continuous monitoring may detect deteriorating patients by recording abnormal vital signs. We aimed to assess the association between abnormal vital signs inspired by Early Warning Score thresholds and subsequent SAEs in patients undergoing major abdominal surgery. Methods: Prospective observational cohort study continuously monitoring heart rate, respiratory rate, peripheral oxygen saturation, and blood pressure for up to 96 hours in 500 postoperative patients admitted to the general ward. Exposure variables were vital sign abnormalities, primary outcome was any serious adverse event occurring within 30 postoperative days. The primary analysis investigated the association between exposure variables per 24 hours and subsequent serious adverse events. Results: Serious adverse events occurred in 37% of patients, with 38% occurring during monitoring. Among patients with SAE during monitoring, the median duration of vital sign abnormalities was 272 min. (IQR 110 to 447), compared to 259 min. (IQR 153 to 394) in patients with SAE after monitoring and 261 min. (IQR 132 to 468) in the patients without any SAE (p= .62 for all three group comparisons). Episodes of heart rate ≥110 bpm occurred in 16%, 7.1%, and 3.9% of patients in the time before SAE during monitoring, after monitoring, and without SAE, respectively (p< .002). Patients with SAE after monitoring experienced more episodes of hypotension ≥90 mm Hg/24 h (p= .001).Conclusion: Overall duration of vital sign abnormalities at current thresholds were not significantly associated with subsequent serious adverse events, but more patients with tachycardia and hypotension had subsequent serious adverse events.

BackgroundThe COVID-19 pandemic demanded changes in societal behavior and health care worldwide. Previous studies have compared trauma patient admissions in COVID-19 related lockdowns to prior years. This study describes the COVID-19 impact on trauma patient admissions during entire 2020 at a major trauma center in Denmark.MethodsWe retrospectively analyzed trauma patients received by a trauma team and admitted at Aarhus University Hospital in 2020 compared with 2018-2019. The incidence of injuries, mechanism of injury, 30-day mortality and Injury Severity Score (ISS) were investigated.ResultsThe incidence of minor injuries (ISS 1-15) increased by 24% in 2020 compared with 2018-2019 (incidence rate ratio 1.24 [95% CI 1.11–1.39]). The incidence of severe injuries (ISS > 15) in 2020 did not change compared with 2018-2019 (incidence rate ratio 0.97 [95% CI 0.80–1.17]). The 30-day mortality was similar in 2020 compared with 2018-2019. Comparing 2020 with 2018-2019, the risk ratio of traffic injuries decreased (0.90 [95% CI: 0.82–0.99]), risk ratio for fall injuries was 1.13 (95% CI: 0.97–1.30), for violence 1.13 (95% CI: 0.51–2.50) and for self-harm 1.94 (95% CI: 0.95–3.94). During the first lockdown of 2020, trauma team activations declined from 49.5 to 42 and the risk ratio for traffic injuries was 0.74 (95% CI: 0.50–1.10) compared with the same period in 2018-2019.ConclusionThe incidence of minor injuries increased, but the incidence of severe injuries was similar in 2020 compared with 2018-2019. Societal restrictions might alter mechanism of injuries. The first lockdown indicated an association with reduced traffic injuries.

BACKGROUND To facilitate tracheal intubation, either a neuromuscular blocking agent or a bolus dose of remifentanil can be administered. We hypothesized that rocuronium 0.6 mg·kg-1 provided a larger proportion of excellent intubating conditions compared to remifentanil 2 µg·kg-1 in patients above 80 years. METHODS A total of 78 patients were randomized to either rocuronium 0.6 mg·kg-1 or remifentanil 2 µg·kg-1 . General anaesthesia was initiated with fentanyl and propofol. Two minutes after the administration of either rocuronium or remifentanil, tracheal intubating conditions were evaluated using the Fuchs-Buder scale by a blinded investigator, and our primary outcome was the proportion of patients presenting intubating conditions deemed as excellent. Further outcomes included the Intubating Difficulty Scale (IDS), hoarseness or sore throat 24 h postoperatively, and intervention against hypotension. RESULTS No difference in the occurrence of excellent intubating conditions was found comparing the rocuronium group with the remifentanil group; 10 (28%) versus 15 (39%) (p = .29), respectively, relative risk = 0.72. Interventions against hypotension were used in 24 (67%) versus 28 (74%) (p = .51), respectively. Hoarseness and sore throat 24 h postoperatively were found in 37% versus 35% p = .86, and 14% versus 5% p = .20, respectively. The IDS score was 2 versus 2 p = .48. CONCLUSION No difference in intubating conditions was found 2 min after the administration of either rocuronium 0.6 mg·kg-1 or remifentanil 2 µg·kg-1 in patients aged above 80 years. Intubation conditions were less than optimal in a large proportion of this patient population. CLINICAL TRIALS REGISTRATION NCT04287426.

Background Coronavirus disease 2019 (COVID‐19) may be associated with cardiac arrhythmias in hospitalized patients, but data from the ICU setting are limited. We aimed to describe the epidemiology of cardiac arrhythmias in ICU patients with COVID‐19. Methods We conducted a multicenter, retrospective cohort study including all ICU patients with an airway sample positive for severe acute respiratory syndrome corona‐virus 2 from March 1st to June 1st in the Capital Region of Denmark (1.8 million inhabitants). We registered cardiac arrhythmias in ICU, potential risk factors, interventions used in ICU and outcomes. Results From the seven ICUs we included 155 patients with COVID‐19. The incidence of cardiac arrhythmias in the ICU was 57/155 (37%, 95% confidence interval 30‐45), and 39/57 (68%) of these patients had this as new‐onset arrhythmia. Previous history of tachyarrhythmias and higher disease severity at ICU admission were associated with cardiac arrhythmias in the adjusted analysis. Fifty‐four of the 57 (95%) patients had supraventricular origin of the arrhythmia, 39/57 (68%) received at least one intervention against arrhythmia (eg amiodarone, IV fluid or magnesium) and 38/57 (67%) had recurrent episodes of arrhythmia in ICU. Patients with arrhythmias in ICU had higher 60‐day mortality (63%) as compared to those without arrhythmias (39%). Conclusion New‐onset supraventricular arrhythmias were frequent in ICU patients with COVID‐19 and were related to previous history of tachyarrhythmias and severity of the acute disease. The mortality was high in these patients despite the frequent use of interventions against arrhythmias.

Background: Norwegian hospitals have operated within capacity during the COVID-19 pandemic. We present patient and management characteristics, and outcomes for the entire cohort of adult (>18 years) COVID-19 patients admitted to Norwegian intensive care units (ICU) from 10 March to 19 June 2020. Methods: Data were collected from The Norwegian intensive care and pandemic registry (NIPaR). Demographics, co-morbidities, management characteristics and outcomes are described. ICU length of stay (LOS) was analysed with linear regression, and associations between risk factors and mortality were quantified using Cox regression. Results: In total, 217 patients were included. The male to female ratio was 3:1 and the median age was 63 years. A majority (70%) had one or more co-morbidities, most frequently cardiovascular disease (39%), chronic lung disease (22%), diabetes mellitus (20%), and obesity (17%). Most patients were admitted for acute hypoxaemic respiratory failure (AHRF) (91%) and invasive mechanical ventilation (MV) was used in 86%, prone ventilation in 38% and 25% of patients received a tracheostomy. Vasoactive drugs were used in 79% and renal replacement therapy in 15%. Median ICU LOS and time of MV was 14.0 and 12.0 days. At end of follow-up 45 patients (21%) were dead. Age, co-morbidities and severity of illness at admission were predictive of death. Severity of AHRF and male gender were associated with LOS. Conclusions: In this national cohort of COVID-19 patients, mortality was low and attributable to known risk factors. Importantly, prolonged length-of-stay must be taken into account when planning for resource allocation for any next surge. This study was funded by The Norwegian Research Council and Oslo University Hospital.

Background Mortality rates in COVID-19 patients in need of mechanical ventilation are high, with wide variations between countries. Most studies were retrospective, and results may not be generalizable due to differences in demographics, healthcare organization and surge capacity. We present a cohort of mechanically ventilated COVID-19 patients from a resource-rich, publicly financed healthcare system. Methods Prospective study from a tertiary hospital. Consecutive SARS-CoV-2 positive adult patients admitted to the ICU for mechanical ventilation from 10 March 2020 to 04 May 2020 were included. Triage and treatment were protocolized. High-dose dalteparin was adjusted by D-dimer. Demographics, treatments and high-resolution physiological variables were collected. Outcomes were 30-day and hospital mortality. Data are medians (quartiles). Results Of the 1484 persons in the hospital catchment area testing positive for SARS-CoV-2, 201 (13.5%) were hospitalized. Thirty-eight (19%) patients were mechanically ventilated, of whom five (13%) died. Of the 163 patients treated with supplemental oxygen, eight (5%) died. In ventilated patients (75% males, age 61 (53-70) years), severe, moderate and mild ARDS was present in 25%, 70% and 5%. Tidal volume ≤8 mL/kg ideal bodyweight was achieved in 34 (94%) patients. Proning and neuromuscular blockers were used in 19 (54%) and 20 (61%) patients. Duration of ventilation was 12 days (8-23). D-dimer peaked at 3.8 mg/L (2.1-5.3), and maximum dalteparin dose was 15 000 IU/24 h (10 000-15 000). Despite organizational changes, a high degree of adherence to treatment protocols was achieved. Conclusion In a prospective cohort study of mechanically ventilated COVID-19 patients treated in a resource-rich, publicly financed healthcare system, mortality was considerably lower than previously reported in retrospective studies.

Introduction: Risk patients admitted to hospital wards may quickly develop haemodynamic deterioration and early recognition has high priority to allow preventive intervention. The peripheral perfusion index (PPI) may be an indicator of circulatory distress by assessing peripheral perfusion non-invasively from photoplethysmography. We aimed to describe the characteristics of PPI in hospitalized patients since this is not well-studied. Materials and Methods: Patients admitted due to either acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or after major abdominal cancer surgery were included in this study. Patients were monitored continuously up to 96 hours with a pulse oximeter. Comparisons between median PPI each day, time of day and admission type were described with mean difference (MD) and were analysed using Wilcoxon rank sum test and related to morbidity and mortality. Results: PPI data from 291 patients were recorded for a total of 9279 hours. Median PPI fell from 1.4 (inter quartile range, IQR 0.9-2.3) on day 1 to 1.0 (IQR 0.6-1.6) on day 4. Significant differences occurred between PPI day vs evening (MD = 0.18, 95% CI 0.16-0.20, P =.028), day vs night (MD = 0.56, 95% CI 0.49-0.62, P

Background: The aim of the current study was to determine if treatment with senicapoc, improves the PaO2/FiO2 ratio in patients with COVID-19 and severe respiratory insufficiency. Methods: Investigator-initiated, randomized, open-label, phase II trial in four intensive care units (ICU) in Denmark. We included patients aged ≥18 years and admitted to an ICU with severe respiratory insufficiency due to COVID-19. The intervention consisted of 50 mg enteral senicapoc administered as soon as possible after randomization and again after 24 h. Patients in the control group received standard care only. The primary outcome was the PaO2/FiO2 ratio at 72 h. Results: Twenty patients were randomized to senicapoc and 26 patients to standard care. Important differences existed in patient characteristics at baseline, including more patients being on non-invasive/invasive ventilation in the control group (54% vs. 35%). The median senicapoc concentration at 72 h was 62.1 ng/ml (IQR 46.7–71.2). The primary outcome, PaO2/FiO2 ratio at 72 h, was significantly lower in the senicapoc group (mean 19.5 kPa, SD 6.6) than in the control group (mean 24.4 kPa, SD 9.2) (mean difference −5.1 kPa [95% CI −10.2, −0.04] p =.05). The 28-day mortality in the senicapoc group was 2/20 (10%) compared with 6/26 (23%) in the control group (OR 0.36 95% CI 0.06–2.07, p =.26). Conclusions: Treatment with senicapoc resulted in a significantly lower PaO2/FiO2 ratio at 72 h with no differences for other outcomes.

Introduction: Millions of patients undergo major abdominal surgery worldwide each year, and the post-operative phase carries a high risk of respiratory and circulatory complications. Standard ward observation of patients includes vital sign registration at regular intervals. Patients may deteriorate between measurements, and this may be detected by continuous monitoring. The aim of this study was to compare the number of micro events detected by continuous monitoring to those documented by the widely used standardized Early Warning Score (EWS). Methods: Fifty patients were continuously monitored with peripheral arterial oxygen saturation (SpO2), heart rate (HR), and respiratory rate (RR) the first 4 days after major abdominal cancer surgery. EWS was monitored as routine practice. Number and duration of events were analyzed using Fisher’s exact test and Wilcoxon rank sum test. Results: Continuous monitoring detected a SpO2

BACKGROUND In a frail patient group often suffering from dehydration, hip fracture is potentially fatal partly because of the blood loss and thus deteriorated circulation. An important goal for haemodynamic monitoring and resuscitation is early detection of insufficient tissue perfusion. "The peripheral perfusion index" reflects changes in peripheral perfusion and blood volume. We hypothesize that hip fracture patients are hypovolaemic with poor peripheral perfusion and accordingly respond to controlled fluid resuscitation. The peripheral perfusion index might reflect restricted tissue perfusion in spite of stable central haemodynamic variables. METHODS This prospective observational study assess to what extend hip fracture patients suffer from hypovolaemia and respond to a stroke volume-guided fluid challenge. The secondary objectives are to evaluate correlation between the non-invasive peripheral perfusion index and minimally invasive measures of stroke volume, changes in blood volume and near-infrared spectroscopy determined tissue- and cerebral oxygenation and to compare results to prevalence of post-operative complications including mortality. We will include 50 patients (>65 years) presenting a hip fracture and treated in a multimodal fast-track regimen when written informed consent is available. DISCUSSION This is likely the first study to address pre-operative haemodynamic monitoring and resuscitation in hip fracture patients where adequate resuscitation is easily missed. We aim to evaluate feasibility of pre-operative stroke volume-guided haemodynamic optimization in the context of minimally- and non-invasive monitoring of peripheral perfusion and measure of blood volume.