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Background: Acute high‐risk abdominal (AHA) surgery is associated with a high short‐term mortality rate. This might be partly attributed to myocardial injury after non‐cardiac surgery (MINS) defined by elevated postoperative troponin levels. The myocardial injury is often asymptomatic; thus, troponin screening seems to be the best diagnostic method. We aimed to assess whether implementing troponin screening with subsequent individualised interventions as standard care is associated with reduced mortality after AHA surgery. We also explored the treatment implications in the screening period. Methods: A retrospective cohort of 558 patients undergoing surgery from February 2018 to March 2021 was included. The patients undergoing surgery before March 2019 served as the historical control group, while the screening group consisted of patients undergoing surgery from March 1, 2019. Troponin I was to be measured 6–12 h postoperatively and in the morning of the succeeding 4 days. Patients with myocardial injury were assessed, and treatment was individualised after multiple disciplinary consultations. The primary outcome was the unadjusted 30‐day mortality rates. Inverse probability treatment weighting was used to adjust for selection bias. Results: We included 558 patients: 382 in the screening group and 176 in the historical control group. In the screening group, 15 patients (3.9%) died before the first blood sampling, and in 31 patients (8.1%), troponin screening was omitted, leaving only 336 patients screened. Myocardial injury was diagnosed in 81 patients (24.1%) of the 336 patients. Of these, 59 (72.8%) had a cardiac consultation. No interventions or alterations in relation to myocardial injury were done in 67 patients (82.7%). The 30‐day mortality was 13.8% (95% CI 8.7%–18.9%) in the control group and 11.1% (95% CI 8.0%–14.3%) in the screening group. The absolute risk difference was −2.7% (95% CI −8.7%–3.3%; p =.38), which was unchanged after adjustment. The difference remained unchanged after 90 days and 1 year. Conclusion: The implementation of postoperative troponin screening was not associated with reduced mortality after AHA surgery. Research on the prevention and treatment of MINS is warranted before the implementation of standard troponin screening. [ABSTRACT FROM AUTHOR]

Background: Myocardial injury after noncardiac surgery (MINS) is associated with 30‐day mortality in heterogeneous surgical populations but is barely described after acute high‐risk abdominal surgery. The impact of dynamic changes has not previously been investigated. The objectives were to determine the incidence of MINS in this population, the association between mortality and MINS, and whether plasma troponin I (TnI) dynamics have any impact on mortality. Methods: A prospective cohort study of 341 patients undergoing acute high‐risk gastrointestinal surgery was conducted. Plasma TnI was measured at the first four postoperative days. MINS was defined as any increased TnI level >59 ng/L. TnI dynamic required either two succeeding measurements of TnI >59 ng/L with a >20% increase/fall or one measurement of TnI >59 ng/L with a succeeding measurement of TnI <59 ng/L with a >50% decrease. Adjusted mortality rates were calculated using inverse probability of treatment weighting and competing risk analyses. Results: The incidence of MINS was 23.8% and dynamic TnI changes occurred in 15.6% of the patients. The unadjusted 30‐day and 1‐year mortality were 19.8% and 35.9% in patients with MINS, compared with 2.7% and 11.6%, respectively, in patients without MINS (p < 0.001). After adjusting, the differences remained significant. There was no difference in mortality between patients with or without dynamic changes in TnI level. Conclusion: MINS occurred frequently and was associated with increased mortality. TnI monitoring might help identify patients with increased risk of mortality and improve care. Research on preventive measures and treatments is warranted. Trial Registration Number and Agency: ClinicalTrials.gov Identifier: NCT05933837, retrospective registered. [ABSTRACT FROM AUTHOR]

Evidence in perioperative care is insufficient. There is an urgent need for large perioperative research programmes, including pragmatic randomised trials, testing daily clinical treatments and unanswered question, thereby providing solid evidence for effects of interventions given to a large and growing number of patients undergoing surgery and anaesthesia. This may be achieved through large collaborations. Collaboration for Evidence‐based Practice and Research in Anaesthesia (CEPRA) is a novel collaborative research network founded to pursue evidence‐based answers to major clinical questions in perioperative medicine. The aims of CEPRA are to (1) improve clinical treatment and outcomes and optimise the use of resources for patients undergoing anaesthesia and perioperative care, and (2) disseminate results and inform caretakers, patients and relatives, and policymakers of evidence‐based treatments in anaesthesia and perioperative medicine. CEPRA is inclusive in its concept. We aim to extend our collaboration with all relevant clinical collaborators and patient associations and representatives. Although initiated in Denmark, CEPRA seeks to develop an international network infrastructure, for example, with other Nordic countries. The work of CEPRA will follow the highest methodological standards. The organisation aims to structure and optimise any element of the research collaboration to reduce economic costs and harness benefits from well‐functioning research infrastructure. This includes successive continuation of trials, harmonisation of outcomes, and alignment of data management systems. This paper presents the initiation and visions of the CEPRA network. CEPRA aims to be inclusive, patient‐focused, methodologically sound, and to optimise all aspects of research logistics. This will translate into faster research conduct, reliable results, and accelerated clinical implementation of results, thereby benefiting millions of patients whilst being cost and labour‐saving. [ABSTRACT FROM AUTHOR]

Background: We aimed to determine the development in the use of video laryngoscopy over a 9‐year period, and its possible impact on airway planning and management. Methods: We retrieved 822,259 records of tracheal intubations recorded from 2008 to 2016 in the Danish Anaesthesia Database. The circumstances regarding pre‐operative airway assessment, the scheduled airway management plan and the actual airway management concerning video laryngoscopy were reported for each year of observation. Further, the association between year of observation and various airway management related outcomes was evaluated by multivariate logistic regression. Results: There was a significant increase in airway management with 'advanced technique successfully used within two attempts' from 2.7% in 2008 to 15.5% in 2016 (p <.0001). This predominantly reflects use of video laryngoscopy. The prevalence of tracheal intubations 'scheduled for video laryngoscopy' increased from 3.5% in 2008 to 10.6% in 2016 (p <.0001). We found a significant increase in the prevalence of anticipated difficulties with intubations by direct laryngoscopy from 1.8% in 2008 to 5.2% in 2016 (p <.0001). The prevalence of failed tracheal intubations decreased from 0.14% in 2008 to 0.05% in 2016 (p <.0001). Conclusion: From 2008 to 2016, a period of massive implementation of video laryngoscopes, a significant change in airway management behaviour was recorded. Increasingly, video laryngoscopy is becoming a first‐choice device for both acute and routine airway management. Most importantly, the data showed a noticeable reduction in failed intubation over the time of observation. [ABSTRACT FROM AUTHOR]

Background: E‐learning is increasingly used in postgraduate medical education. Its numerous benefits include an enhanced learning experience through learning style individualisation, interactive elements, and assessment through tests and quizzes. Current meta‐analyses conclude that the overall effectiveness of e‐learning is comparable to traditional teaching modalities. However, studies demonstrating its benefits are heterogeneous and of varying quality. This randomised controlled trial aims to investigate whether contemporary e‐learning completed prior to a course in obstetric anaesthesia prepares the course participants better than self‐study of written course material. Methods: A randomised controlled trial allocated second‐year resident anaesthetists to receive either e‐learning in postpartum haemorrhage and written course material in preeclampsia or e‐learning in preeclampsia and written course material in postpartum haemorrhage, prior to a compulsory course in obstetric anaesthesia. The primary outcome was knowledge after completion of e‐learning before the course, assessed by type X multiple‐choice questions with a score ranging from zero to 35. The secondary outcomes were anxiety level before course simulations, performance during course simulations, and knowledge four and 12 weeks after the course. Results: The per protocol analysis of the primary outcome included 45 participants and demonstrated a mean difference of 1.8 (95% CI 0.7–2.9; p =.002) in knowledge after completion of e‐learning before the course, in favour of e‐learning compared to written course material. There were no statistically significant differences in the secondary outcomes. Conclusion: This blinded parallel group randomised controlled trial found a numerically small but statistically significant difference in knowledge favouring e‐learning over written course material. [ABSTRACT FROM AUTHOR]

Background: Trials comparing programmed, intermittent boluses (PIB) and continuous infusion in catheter‐based nerve blocks found no analgesic differences. However, as these trials used equal doses of local anesthetic (LA), the time of action of each bolus was not accounted for. Therefore, the dose‐sparing benefits of PIB may have been overlooked. We compared the analgesic effect of boluses administered in intervals resembling the time of action of each bolus with continuous infusion. We hypothesized that PIB provided non‐inferior analgesia despite consuming less LA. Methods: Eighty‐one patients undergoing fore‐ and midfoot surgery receiving a catheter‐based sciatic nerve block were randomized to ropivacaine 0.2% as PIB of 10 ml every 8th hour or as continuous infusion, 6 ml h−1. All participants could also receive boluses of 10 ml every 4th hour as needed. A non‐inferiority randomized controlled design was used. Primary outcome was pain (VAS, 0–100 mm) for 72 h using area under curve (AUC) calculation. We assumed a linear relationship between mean VAS and AUC‐VAS and used a non‐inferiority margin of VAS = 20 mm, corresponding to AUC‐VAS = 1440 mm h. Results: Mean difference in AUC‐VAS was −416 mm h (95% CI −1076 to 244; p =.217) between continuous infusion (mean AUC‐VAS 1206 mm h) and PIB (mean AUC‐VAS 1621 mm h), establishing non‐inferiority. Mean total LA consumption was significantly larger for continuous infusion compared to PIB ((468 ml (95% CI 458 to 478) vs. 136 ml (95% CI 123 to 148); p < 0.0001)). Conclusions: PIB provided non‐inferior analgesia compared to continuous infusion for 72 postoperative hours despite using significantly less LA. [ABSTRACT FROM AUTHOR]

Background: Emergency abdominal surgery carries a considerable risk of mortality and post-operative complications, including pulmonary complications. In major elective surgery, epidural analgesia reduces mortality and pulmonary complications. We aimed to evaluate the association between epidural analgesia and mortality in emergency abdominal surgery.Methods: In this population-based cohort study with prospective data collection, we included adults undergoing emergency abdominal laparotomy or laparoscopy between 1 January 2009 and 31 December 2010 at 13 Danish hospitals. Appendectomies were excluded. The primary outcome was 90-day mortality. Secondary outcomes included 30-day mortality and serious adverse events. We used binary logistic regression analyses (odds ratios (ORs) with 95% confidence intervals (CIs)).Results: We included 4920 patients, of whom 1134 (23.0%) died within 90 days. Overall, 27.9% of the patients were treated with epidural analgesia perioperatively. This increased to 34.0% among patients undergoing major laparotomy. The crude and adjusted association between epidural analgesia and 90-day mortality was OR 0.99 (95%CI: 0.86-1.15, P = .94) and OR 0.80 (95%CI: 0.67-0.94; P = .01), respectively. For 30-day mortality the corresponding estimates were OR 0.90 (95% CI: 0.76-1.06, P = .21) and OR 0.75 (95% CI: 0.62-0.90, P < .01), respectively. No serious adverse events were reported.Conclusion: In this population-based cohort study of adult patients undergoing emergency abdominal surgery, we found that the use of epidural analgesia perioperatively was associated with a decreased risk of mortality in the adjusted analysis. [ABSTRACT FROM AUTHOR]

Objective.In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing emergency abdominal surgery in general.Material and methods.All in-patients aged ≥18 years having emergency abdominal laparotomy or laparoscopy performed within 48 h of admission between 1 January 2009 and 31 December 2010 in 13 Danish hospitals were included. Baseline and clinical data, including surgical delay and 90-day mortality were collected. The crude and adjusted association between surgical delay by hour and 90-day mortality was assessed by binary logistic regression.Results.A total of 2803 patients were included. Median age (interquartile range [IQR]) was 66 (51–78) years, and 515 patients (18.4%) died within 90 days of surgery. Over the first 24 h after hospital admission, each hour of surgical delay beyond hospital admission was associated with a median (IQR) decrease in 90-day survival of 2.2% (1.9–3.3%). No statistically significant association between surgical delay by hour and 90-day mortality was shown; crude and adjusted odds ratio with 95% confidence interval 1.016 (1.004–1.027) and 1.003 (0.989–1.017), respectively. Sensitivity analyses confirmed the primary finding.Conclusions.In the present population-based cohort study of high-risk patients undergoing emergency abdominal surgery, no statistically significant adjusted association between mortality and surgical delay was found. Additional research in diagnosis-specific subgroups of high-risk patients undergoing emergency abdominal surgery is warranted. [ABSTRACT FROM AUTHOR]

Background Pre-operative airway assessment in Denmark is based on a non-specific clinical assessment. Systematic, evidence-based and consistent airway assessment may reduce the incidence of unanticipated difficult airway management. By assessing multiple predictors for difficult airway management, the predictive value of the assessment increases. The Simplified Airway Risk Index (SARI) is a multivariate risk score for predicting difficult intubation. This study aims to compare the use of the SARI with a non-specified clinical airway assessment on predicting difficult intubation. Further, to compare the examination and registration of predictors for difficult mask ventilation with a non-specified clinical airway assessment on prediction of difficult mask ventilation. Method/Design We cluster-randomized 28 Danish departments of anaesthesia to airway assessment either by the SARI or by usual non-specific assessment. Data from patients' pre-operative airway assessment are registered in the Danish Anaesthesia Database. Objective scores for intubation and mask ventilation grade the severity of airway managements. The accuracy of predicting difficult intubation and mask ventilation is measured for each group. The primary outcome measure is the fraction of unanticipated difficult and easy intubation. The fraction of unanticipated difficult intubation in Denmark is 1.87%. With a stratified randomization, type 1 error risk of 5% and a power of 80%, 30 departments are required to detect or reject a 30% relative risk reduction equalling a number needed to treat of 180. Sample size estimation is adjusted for the study design and based on standards for randomization on cluster-level. With an average cluster size of 2,500 patients, 70,000 patients will be enrolled over a 1-year trial period. The database is programmed so that registration of the SARI and predictors for difficult mask ventilation are mandatory for the intervention group but invisible to controls. Discussion It is innovative to use a national clinical database as the basis for a randomized clinical trial. The method can serve as a precedent for implementation of evidence-based recommendations and database registration. The trial will forward understanding of how to predict and reduce unanticipated difficult airways and how to produce evidence-based recommendations for airway assessment and clinical database development. [ABSTRACT FROM AUTHOR]

Introduction: Upper gastrointestinal bleeding (UGIB) is a common emergency. Currently, there are no agreed guidelines on the level of anaesthetic support required in patients undergoing acute esophago-gastro-duodendoscopy (EGD)., Methods: An online questionnaire comprising 19 questions was distributed to all members of the Danish Association of Anaesthesiology and Intensive Care (n = 1,418) and the Danish Society of Anaesthesiologists in Training (n = 566). The questions concerned clinical practice for anaesthesia care to patients undergoing EGD for suspected UGIB and availability of local guidelines., Results: A total of 521 anaesthetists who had, on average, concluded medical school 14 years earlier (range: 9-27 years) answered the questionnaire. Of the responders, 65.5% (167/255; 95% confidence interval (CI): 59.7-71.3) had provided anaesthesia to five or more patients with suspected UGIB during the previous six months. 32.9% (110/333; 95% CI: 27.9-38.0) had a local guideline for this procedure. Rapid sequence induction was part of the guideline for 71.8% (79/110; 95% CI: 63.4-80.2) in case of general anaesthesia (GA). The preferred choice of anaesthesia was GA with endotracheal intubation (56.2%; 187/333; 95% CI: 50.9-61.5)., Conclusions: We found considerable variation in daily clinical practice of anaesthesia for patients undergoing EGD for suspected UGIB. The fact that anaesthesia for UGIB is a complex emergency procedure may underline the need for development of an international or at least a national guideline., Funding: The study received financial support from Karner's Foundation, Denmark., Trial Registration: not relevant., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Aim of Database: The aim of the Danish Anaesthesia Database (DAD) is the nationwide collection of data on all patients undergoing anesthesia. Collected data are used for quality assurance, quality development, and serve as a basis for research projects., Study Population: The DAD was founded in 2004 as a part of Danish Clinical Registries (Regionernes Kliniske Kvalitetsudviklings Program [RKKP]). Patients undergoing general anesthesia, regional anesthesia with or without combined general anesthesia as well as patients under sedation are registered. Data are retrieved from public and private anesthesia clinics, single-centers as well as multihospital corporations across Denmark. In 2014 a total of 278,679 unique entries representing a national coverage of ~70% were recorded, data completeness is steadily increasing., Main Variable: Records are aggregated for determining 13 defined quality indicators and eleven defined complications all covering the anesthetic process from the preoperative assessment through anesthesia and surgery until the end of the postoperative recovery period., Descriptive Data: Registered variables include patients' individual social security number (assigned to all Danes) and both direct patient-related lifestyle factors enabling a quantification of patients' comorbidity as well as variables that are strictly related to the type, duration, and safety of the anesthesia. Data and specific data combinations can be extracted within each department in order to monitor patient treatment. In addition, an annual DAD report is a benchmark for departments nationwide., Conclusion: The DAD is covering the anesthetic process for the majority of patients undergoing anesthesia in Denmark. Data in the DAD are increasingly used for both quality and research projects., Competing Interests: All authors are members of the steering committee of DAD. The authors have no other conflicts of interest to disclose in this work.

Background: Management and care of the acutely ill patient has improved over the last years due to introduction of systematic assessment and accelerated treatment protocols. We have, however, sparse knowledge of the association between patient status at admission to hospital and patient outcome. A likely explanation is the difficulty in retrieving all relevant information from one database. The objective of this article was 1) to describe the formation and design of the 'Acute Admission Database', and 2) to characterize the cohort included., Methods: All adult patients triaged at the Emergency Department at Hillerød Hospital and admitted either to the observationary unit or to a general ward in-hospital were prospectively included during a period of 22 weeks. The triage system used was a Danish adaptation of the Swedish triage system, ADAPT. Data from 3 different data sources was merged using a unique identifier, the Central Personal Registry number; 1) Data from patient admission; time and date, vital signs, presenting complaint and triage category, 2) Blood sample results taken at admission, including a venous acid-base status, and 3) Outcome measures, e.g. length of stay, admission to Intensive Care Unit, and mortality within 7 and 28 days after admission., Results: In primary triage, patients were categorized as red (4.4%), orange (25.2%), yellow (38.7%) and green (31.7%). Abnormal vital signs were present at admission in 25% of the patients, most often temperature (10.5%), saturation of peripheral oxygen (9.2%), Glasgow Coma Score (6.6%) and respiratory rate (4.8%). A venous acid-base status was obtained in 43% of all patients. The majority (78%) had a pH within the normal range (7.35-7.45), 15% had acidosis (pH < 7.35) and 7% had alkalosis (pH > 7.45). Median length of stay was 2 days (range 1-123). The proportion of patients admitted to Intensive Care Unit was 1.6% (95% CI 1.2-2.0), 1.8% (95% CI 1.5-2.2) died within 7 days, and 4.2% (95% CI 3.7-4.7) died within 28 days after admission., Conclusions: Despite challenges of data registration, we succeeded in creating a database of adequate size and data quality. Future studies will focus on the association between patient status at admission and patient outcome, e.g. admission to Intensive Care Unit or in-hospital mortality.

Background: Assessment and treatment of the acutely ill patient have improved by introducing systematic assessment and accelerated protocols for specific patient groups. Triage systems are widely used, but few studies have investigated the ability of the triage systems in predicting outcome in the unselected acute population. The aim of this study was to quantify the association between the main component of the Hillerød Acute Process Triage (HAPT) system and the outcome measures; Admission to Intensive Care Unit (ICU) and in-hospital mortality, and to identify the vital signs, scored and categorized at admission, that are most strongly associated with the outcome measures., Methods: The HAPT system is a minor modification of the Swedish Adaptive Process Triage (ADAPT) and ranks patients into five level colour-coded triage categories. Each patient is assigned a triage category for the two main descriptors; vital signs, T(vitals), and presenting complaint, T(complaint). The more urgent of the two determines the final triage category, T(final). We retrieved 6279 unique adult patients admitted through the Emergency Department (ED) from the Acute Admission Database. We performed regression analysis to evaluate the association between the covariates and the outcome measures., Results: The covariates, T(vitals), T(complaint) and T(final) were all significantly associated with ICU admission and in-hospital mortality, the odds increasing with the urgency of the triage category. The vital signs best predicting in-hospital mortality were saturation of peripheral oxygen (SpO(2)), respiratory rate (RR), systolic blood pressure (BP) and Glasgow Coma Score (GCS). Not only the type, but also the number of abnormal vital signs, were predictive for adverse outcome. The presenting complaints associated with the highest in-hospital mortality were 'dyspnoea' (11.5%) and 'altered level of consciousness' (10.6%). More than half of the patients had a T(complaint) more urgent than T(vitals), the opposite was true in just 6% of the patients., Conclusion: The HAPT system is valid in terms of predicting in-hospital mortality and ICU admission in the adult acute population. Abnormal vital signs are strongly associated with adverse outcome, while including the presenting complaint in the triage model may result in over-triage.

Several studies have identified difficult airway management including a difficult tracheal intubation of patients undergoing general anaesthesia as a major cause of anaesthesia-related morbidity and mortality. Therefore it is presumed that a difficult tracheal intubation is a surrogate marker for morbidity and mortality, and by reducing the prevalence of difficult tracheal intubation then morbidity and mortality will be reduced as well. From the Danish Anaesthesia Database (DAD), we retrieved a cohort of consecutive patients planned and attempted for tracheal intubation by direct laryngoscopy. Based upon various data including an intubation score registered in the database, we aimed to evaluate four different parameters, 'Obesity', 'avoidance of neuromuscular blocking agents', 'a previous difficult tracheal intubation' and 'the modified Mallampati-score', as possible risk factors for a difficult tracheal intubation. All of these risk factors were statistically associated with a difficult tracheal intubation, but the clinical significance varied substantially. However, neither 'obesity', 'the modified Mallampati-score' nor 'a previous difficult tracheal intubation' were sufficient as stand-alone tests for prediction of difficult tracheal intubation. In multivariate analyses the impact of obesity on the risk of difficult tracheal intubation seems weak, while both 'the modified Mallampati-score' and 'a previous difficult tracheal intubation' demonstrated to be clinically strong risk factors for difficult tracheal intubation. The evaluation of 'avoidance of neuromuscular blocking agents' as a risk factor differ substantially from the other assessments, as it concerns the impact of an intervention rather than of a patient-related risk factor for difficult tracheal intubation. In our assessment, 'avoiding neuromuscular blocking agents' was demonstrated as a possible risk factor for difficult and abandoned tracheal intubation independent of other risk factors recorded in the DAD. Several previous studies have failed to present specific risk factors that could identify difficult intubation or laryngoscopy by itself. Therefore it seems rational to focus on the development, testing and modification of multivariate models from large scale cohort studies, hereby making the prognostication operational in everyday clinical practice. From there the challenge may be to test the effectiveness of the use of such a model in order to evaluate whether it actually has the capability to reduce difficult tracheal intubation, complications, and mortality. It seems that such a trial should and could be conducted as a cluster randomized trial of anaesthesia departments within the framework of the DAD.