Levosimendan improved haemodynamics compared with a placebo in patients undergoing high-risk cardiac surgery. The concentrations of levosimendan's metabolites were higher compared with earlier studies using perioperative dosing.

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Background Atrial fibrillation (AF) is common in intensive care unit (ICU) patients and is associated with poor outcomes. Different management strategies exist, but the evidence is limited and derived from non‐ICU patients. This international survey of ICU doctors evaluated the preferred management of acute AF in ICU patients. Method We conducted an international online survey of ICU doctors with 27 questions about the preferred management of acute AF in the ICU, including antiarrhythmic therapy in hemodynamically stable and unstable patients and use of anticoagulant therapy. Results A total of 910 respondents from 70 ICUs in 14 countries participated in the survey with 24%–100% of doctors from sites responding. Most ICUs (80%) did not have a local guideline for the management of acute AF. The preferred first‐line strategy for the management of hemodynamically stable patients with acute AF was observation (95% of respondents), rhythm control (3%), or rate control (2%). For hemodynamically unstable patients, the preferred strategy was observation (48%), rhythm control (48%), or rate control (4%). Overall, preferred antiarrhythmic interventions included amiodarone, direct current cardioversion, beta‐blockers other than sotalol, and magnesium in that order. A total of 67% preferred using anticoagulant therapy in ICU patients with AF, among whom 61% preferred therapeutic dose anticoagulants and 39% prophylactic dose anticoagulants. Conclusion This international survey indicated considerable practice variation among ICU doctors in the clinical management of acute AF, including the overall management strategies and the use of antiarrhythmic interventions and anticoagulants.

OBJECTIVES: To assess the incidence, risk factors, and outcomes of atrial fibrillation (AF) in the ICU and to describe current practice in the management of AF. DESIGN: Multicenter, prospective, inception cohort study. SETTING: Forty-four ICUs in 12 countries in four geographical regions. SUBJECTS: Adult, acutely admitted ICU patients without a history of persistent/permanent AF or recent cardiac surgery were enrolled; inception periods were from October 2020 to June 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We included 1,423 ICU patients and analyzed 1,415 (99.4%), among whom 221 patients had 539 episodes of AF. Most (59%) episodes were diagnosed with continuous electrocardiogram monitoring. The incidence of AF was 15.6% (95% CI, 13.8–17.6), of which newly developed AF was 13.3% (11.5–15.1). A history of arterial hypertension, paroxysmal AF, sepsis, or high disease severity at ICU admission was associated with AF. Used interventions to manage AF were fluid bolus 19% (95% CI 16–23), magnesium 16% (13–20), potassium 15% (12–19), amiodarone 51% (47–55), beta-1 selective blockers 34% (30–38), calcium channel blockers 4% (2–6), digoxin 16% (12–19), and direct current cardioversion in 4% (2–6). Patients with AF had more ischemic, thromboembolic (13.6% vs 7.9%), and severe bleeding events (5.9% vs 2.1%), and higher mortality (41.2% vs 25.2%) than those without AF. The adjusted cause-specific hazard ratio for 90-day mortality by AF was 1.38 (95% CI, 0.95–1.99). CONCLUSIONS: In ICU patients, AF occurred in one of six and was associated with different conditions. AF was associated with worse outcomes while not statistically significantly associated with 90-day mortality in the adjusted analyses. We observed variations in the diagnostic and management strategies for AF.

Background: Surgical treatment of ankle fracture is associated with significant pain and high postoperative opioid consumption. The anaesthesia method may affect early postoperative pain. The main objective of the study was to compare postoperative opioid consumption after ankle-fracture surgery between patients treated with spinal anaesthesia and general anaesthesia. Methods:We reviewed retrospectively the files of 586 adult patients with surgically treated ankle fracture in the years 2014 through 2016. The primary outcome was opioid consumption during the first 48 postoperative hours. Secondary outcomes were maximal pain scores, postoperative nausea and vomiting, the length of stay in the post-anaesthesia care unit, and opioid use in different time periods up to 48 h postoperatively. Propensity score matching was used to mitigate confounding variables.Results: Total opioid consumption 48 h postoperatively was significantly lower after spinal anaesthesia (propensity score-matched population: effect size −13.7 milligrams; 95% CI −18.8 to −8.5; P < .001). The highest pain score on the numerical rating scale in the post-anaesthesia care unit was significantly higher after general anaesthesia (propensity score-matched population: effect size 3.7 points; 95% CI 3.2-4.2; P < .001). A total of 60 patients had postoperative nausea and vomiting in the postanaesthesia care unit, 53 (88.3%) of whom had general anaesthesia (P = .001). Conclusions:Patients with surgically treated ankle fracture whose operation was performed under general anaesthesia used significantly more opioids in the first 48 h postoperatively, predominantly in the post-anaesthesia care unit, compared with patients given spinal anaesthesia.Surgical treatment of ankle fracture is associated with significant postoperative pain. 1,2 Inadequately treated pain and high opioid consumption after surgery can delay functional recovery, increase the risk of postoperative complications, prolong the hospital stay, and increase overall cost. High postoperative opioid consumption may be associated with an increased risk of long-term opioid use. 3,4 Persistent postsurgical pain is a common phenomenon after ankle fracture surgery. 5 Most studies comparing the postoperative outcome, including opioid consumption, 6 between spinal anaesthesia (SA) and general anaesthesia (GA) after lower limb surgical procedures have been performed in patients with total hip and/or knee arthroplasty, [6][7][8] in which neuraxial anaesthesia is recommended over GA. 8 Only a few studies have compared differences between SA and GA in patients with surgically treated ankle fracture. A prospective cohort study compared postoperative pain and function after surgical ankle fracture fixation between patients given SA and GA.SA was associated with better functional outcome and less pain, but the evaluation took place 3 months after operation and opioid consumption was not reported. 9 A retrospective cohort study investigating primary surgical ankle fracture fixation compared opioid consumption betw...