Carl Johan Svensson

Background: Right atrial pressure (RAP) is a key determinant of venous return and reflects right‐sided filling pressures in critically ill patients. Central venous pressure (CVP) is commonly used as a surrogate, but its accuracy depends on appropriate transducer levelling. While reference points have been evaluated in supine positions, evidence is lacking for the lateral position, despite its frequent use in intensive care. Furthermore, it remains unclear whether lateral positioning alters RAP itself. Methods: In this prospective observational study, 16 sedated, mechanically ventilated ICU patients with central venous catheters were included. RAP was measured using a solid‐state catheter positioned in the mid‐right atrium, confirmed by waveform analysis and echocardiography. Simultaneous CVP was recorded with the transducer levelled 5 cm below the mid‐sternum. Measurements were obtained at end‐expiration in supine, 45° left lateral, and 45° right lateral positions. Agreement between RAP and CVP was assessed using Bland–Altman analysis, intraclass correlation coefficients, and predefined clinical thresholds. Stepwise hydrostatic adjustments were applied to identify optimal reference levels. Results: In the right lateral position, CVP referenced 5 cm below the sternum closely approximated RAP (bias −0.4 mmHg; limits of agreement −3.2 to +2.4; ICC 0.85). In the left lateral position, the same reference point systematically overestimated RAP (bias −2.2 mmHg; limits of agreement −5.0 to +0.7; ICC 0.58). Adjustment to approximately 2 cm below the sternum minimised bias (−0.1 mmHg) and improved agreement (ICC 0.82). RAP increased in the right lateral position compared with both supine (Δ +2.9 mmHg, p < 0.001) and left lateral (Δ +2.8 mmHg, p < 0.001) positions, while no difference was observed between supine and left lateral positions ( p = 0.78). Conclusion: In mechanically ventilated ICU patients, central venous pressure accuracy was position‐dependent, and optimal external reference levels differed between lateral positions. Right atrial pressure increased in the right lateral position, suggesting that lateral positioning influences cardiopulmonary physiology beyond hydrostatic measurement effects alone. Trial Registration: https://clinicaltrials.gov/study/NCT06705374 , registration date 30 April 2024 Editorial Comment: The study showed that central venous pressure systematically overestimated right atrial pressure in mechanically ventilated patients placed in the left lateral position. This means that preload and venostasis can be misinterpreted in this position. The influence of increased right atrium pressure on venous return and cardiac output during left lateral positioning in mechanically ventilated patients requires further studies before the clinical relevance can be assessed.

Introduction: Septic shock necessitates timely antibiotic therapy, often with broad‐spectrum beta‐lactam antibiotics (ß‐LA). To our knowledge, no previous study has examined antibiotic concentrations repeatedly during the initial phase of treatment. This observational study aimed to assess early‐phase plasma concentrations of ß‐LA in patients with septic shock.Method: Prospective observational study of patients with septic shock, according to the SEPSIS‐3 criteria, who received cefotaxime, piperacillin/tazobactam, or meropenem in accordance with Swedish practice. Demographic and clinical data were recorded for each patient. Consecutive blood samples were obtained during the first 24 h of treatment, and total antibiotic concentrations were measured using liquid chromatography mass spectrometry. Target concentrations were defined as 100% of the time that free (unbound) antibiotic concentrations remained above the minimal inhibitory concentration (fT > MIC).Results: Twenty‐two patients were included, 15 (68%) were male and the median age was 65.5 years (IQR 46.3–65.5). In‐hospital mortality was 7/22 (32%). Antibiotic exposure exceeding 100% fT > MIC was achieved in 16 (73%) of the patients. Four patients did not receive the recommended additional dose between the first and second doses of antibiotics; two of them still achieved 100% fT > MIC, whereas the other two attained 66% and 33% fT > MIC, respectively. Among the patients who received the additional dose, four did not achieve 100% fT > MIC. No relationship between mortality and fT > MIC was observed. Significant associations with achieving 100% fT > MIC were observed for older age (p = 0.045) and illness severity (SAPS3, p = 0.025).Conclusion: Our findings demonstrate considerable variability in antibiotic exposure during the initial 24 h of septic shock treatment, highlighting a critical gap in understanding the clinical relevance of sub‐optimal serum antibiotic concentrations and their potential impact on patient outcomes.Editorial Comment: Therapeutic drug monitoring of antimicrobials is increasingly being used in research and clinical practice.

BackgroundPatients with an out-of-hospital cardiac arrest (OHCA) often undergo coronary angiography, although a culprit lesion is found in only 30%-40% of patients. The aim of this study was to investigate high-sensitivity troponin T (hsTnT) levels in post cardiac arrest patients with and without coronary culprit lesions; factors affecting hsTnT levels after return of spontaneous circulation (ROSC); and the diagnostic ability of hsTnT in identifying patients with culprit lesions. We hypothesized that peak hsTnT levels were higher during the initial 48 h after cardiac arrest in patients with a coronary culprit lesion.MethodsThis was a retrospective observational study, which included patients admitted to the Intensive Care Unit after an OHCA and who received a coronary angiography. Peak values and dynamic changes in hsTnT were analyzed in relation to the presence of a culprit lesion at coronary angiography.ResultsA total of 238 patients were studied, of whom 140 had a culprit lesion. HsTnT levels during the initial 48 h were higher in patients with culprit lesions, longer time to ROSC and an unwitnessed cardiac arrest. At 6 to 12 h after ROSC, a hsTnT cut-off level of 1690 ng/L had a sensitivity of 64% and specificity of 84% to identify a culprit lesion. In patients without ST-elevations, hsTnT measured between 6 and 12 h after ROSC had a specificity above 90%, with a sensitivity of 46%.ConclusionHsTnT levels after cardiac arrest are higher in patients with coronary culprit lesions. Presence of a culprit lesion, witnessed status and the duration of CPR are important factors affecting hsTnT levels. Repeated measurement of hsTnT within the first 12 h after admission improved diagnostic accuracy but the value of hsTnT as a predictor of culprit lesions early after OHCA is limited.

Background and Aim: Assisted mechanical ventilation may alter the pressure profile in the thorax compared to normal breathing, which can affect the blood flow to and from the heart. Studies suggest that in patients with severe lung disease, airway pressure release ventilation (APRV) may be haemodynamically beneficial compared to other ventilator settings. The primary aim of this study was to investigate if APRV affects cardiac index in intubated intensive care patients without severe lung disease when compared to pressure support ventilation (PSV). The secondary aim comprised potential changes in other haemodynamic and ventilatory parameters. Methods: Twenty patients were enrolled in the intensive care unit (ICU) at Sahlgrenska University Hospital. Eligible patients met the inclusion criteria; 18 years of age or above, intubated and mechanically ventilated, triggering and stable on PSV mode, with indwelling haemodynamic monitoring via a pulse-induced continuous cardiac output (PiCCO) catheter. The study protocol started with a 30-min interval on PSV mode, followed by a 30-min interval on APRV mode, and finally a 30-min interval back on PSV mode. At the end of each interval, PiCCO outputs, ventilator outputs, arterial and venous blood gas analyses, heart rate and central venous pressure were recorded and compared between modes. Results: There was no significant difference in cardiac index (3.42 vs. 3.39 L/min/m2) between PSV and APRV, but a significant increase in central venous pressure (+1.0 mmHg, p = .027). Furthermore, we found a significant reduction in peak airway pressure (-3.16 cmH2O, p < .01) and an increase in mean airway pressure (+2.1 cmH2O, p < .01). No statistically significant change was found in oxygenation index (partial pressure of O2 [pO2]/fraction of inspired oxygen) nor in other secondary outcomes when comparing PSV and APRV. There was no significant association between global end-diastolic volume index and cardiac index (R2 = 0.0089) or central venous pressure (R2 = 0.278). All parameters returned to baseline after switching the ventilator mode back to PSV. Conclusion: We could not detect any changes in cardiac index in ICU patients without severe lung disease during APRV compared to PSV mode, despite lower peak airway pressure and increased mean airway pressure.

Background and aim: Stress cardiomyopathy in donors can potentially affect graft function and longevity. This study aims to investigate the association between echocardiographic left ventricular ejection fraction (LVEF) < 50%, and/or the presence of left ventricular regional wall motion abnormalities (RWMA) in organ donors, and short‐ and long‐term liver and kidney graft survival. Our secondary aim was to link graft survival with donor and recipient characteristics.Methods: All donors considered for liver and kidney donation with echocardiographic records at Sahlgrenska University Hospital between 2006 and 2016 were matched with their recipients through the Scandiatransplant register. The studied outcomes were graft survival, re‐transplantation, and recipient death. Kaplan–Meier curves were used to plot time to event. Multivariate Cox‐regression was used to test independence.Results: There were 370 liver donors and 312 kidney donors (matched with 458 recipients) with echocardiographic records at Sahlgrenska University Hospital between June 2006 and November 2016. Of patients with LV dysfunction by echocardiography, there were 102 liver‐ and 72 kidney donors. Univariate survival analyses showed no statistical difference in the short‐ and long‐term graft survival from donors with LV dysfunction compared to donors without. Donor age > 65 years, recipient re‐transplantation and recipient liver tumor were predictors of worse outcome in liver transplants (p < .05). Donor age > 65, donor hypertension, recipient re‐transplantation, and a recipient diagnosis of diabetes or nephritis/glomerulonephritis had a negative association with graft survival in kidney transplants (p < .05).Conclusion: We found no significant association between donor LV dysfunction and short‐ and long‐term graft survival in liver and kidney transplants, suggesting that livers and kidneys from such donors can be safely transplanted.

Bariatric surgery^1,2 may reduce the incidence of depressive disorders in patients with obesity^3–5. However, there are several potential adverse postoperative side effects, both physical (for example, malnutrition, gallstone development and bowel obstruction)¹ and behavioural (for example, alcohol-related disorders and opioid use)^6–8. Moreover, the rate of self-harm and suicide attempts are higher in this patient group compared with the general population^6,9 and, possibly, non-operated patients with obesity^10,11. Also, a long-term cohort study found more major depression in obese patientes of both sexes after gastric bypass compared to restrictive surgery¹².

Objectives: Pulmonary edema is a common clinical problem and lung ultrasound (LUS) presents an efficient method for evaluating this pathology. This study aims to investigate if a clinically efficient LUS protocol can quantify the level of extravascular lung fluid in patients receiving hemodialysis, and to develop a simplified B‐line scoring system based on this protocol.Methods: A simple 8‐area LUS approach was used for the assessment of the extravascular fluid status in patients before, during, and after receiving hemodialysis. The LUS assessments were compared to the amount of removed fluid over time. To determine the best B‐line score system, different scorings for each zone were tested in a linear mixed model with pseudo R‐square model fit against removed fluid. The B‐line score was further validated through correlations with changes in oxygen saturation, grade of dyspnea, and body weight over time.Results: A total of 53 patients were included and examined on 108 hemodialysis occasions. Median fluid removal was 2.3 L. The B‐line score model with best fit was a score of 0 points in a zone with 0 or 1 B‐lines, 1 point with 2 or 3 B‐lines, 2 points with 3 or more B‐lines, and 3 points with any interstitial confluence. Using this B‐line score, we found a significant association with amount of removed fluid, oxygen saturation, grade of dyspnea, and change in body weight.Conclusion: A straightforward protocol for LUS and B‐line score system was shown valid for quantification of pulmonary edema and fluid removal in hemodialysis patients. The scoring system developed here can be useful also in other patient groups, but this requires further validation.

Background: Opioid‐based treatment is used to manage stress responses during surgery and postoperative pain. However, opioids have both acute and long‐term side effects, calling for opioid‐free anaesthetic strategies. This meta‐analysis compares adverse events, postoperative recovery, discharge time from post‐anaesthesia care unit, and postoperative pain, nausea, vomiting, and opioid consumption between strict opioid‐free and opioid‐based general anaesthesia.Methods: We conducted a systematic review and meta‐analysis. We searched PubMed, Embase, Cinahl, Cochrane Library, selected reference lists, and Google Scholar. We included randomised controlled trials (RCTs) published between January 2000 and February 2021 with at least one opioid‐free study arm, i.e. no opioids administered preoperatively, during anaesthesia induction, before skin closure, or before emergence from anaesthesia.Results: The study comprised 1934 patients from 26 RCTs. Common interventions included laparoscopic gynaecological surgery, upper gastrointestinal surgery, and breast surgery. There is firm evidence that opioid‐free anaesthesia significantly reduced adverse postoperative events (OR 0.32, 95% CI 0.22 to 0.46, I² = 56%, p < 0.00001), mainly driven by decreased nausea (OR 0.27, (0.17 to 0.42), p < 0.00001) and vomiting (OR 0.22 (0.11 to 0.41), p < 0.00001). Postoperative opioid consumption was significantly lower in the opioid‐free group (−6.00 mg (−8.52 to −3.48), p < 0.00001). There was no significant difference in length of post‐anaesthesia care unit stay and overall postoperative pain between groups.Conclusions: Opioid‐free anaesthesia can improve postoperative outcomes in several surgical settings without evidence of adverse effects on patient safety and pain management. There is a need for more evidence‐based non‐opioid anaesthetic protocols for different types of surgery as well as postoperative phases.