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  • 1.
    Abad-Gurumeta, A.
    et al.
    Dept Anaesthesia, Hosp Univ la Paz, Madrid, Spain.
    Ripolles-Melchor, J.
    Dept Anaesthesia, Hosp Univ Infanta Leonor, Univ Complutense Madrid, Madrid, Spain.
    Casans-Frances, R.
    Dept Anaesthesia, Hosp Clin Univ Lozano Blesa, Zaragoza, Spain.
    Espinosa, A.
    Dept Anaesthesia, Örebro University Hospital, Örebro, Sweden.
    Martinez-Hurtado, E.
    Dept Anaesthesia, Hosp Univ Infanta Leonor, Univ Complutense Madrid, Madrid, Spain.
    Fernandez-Perez, C.
    Dept Consultant Prevent Med & Publ Hlth, Univ Complutense Madrid, Madrid, Spain.
    Ramirez, J. M.
    Dept Colorectal Surg, Univ Zaragoza, Zaragoza, Spain.
    Lopez-Timoneda, F.
    Hosp Clin San Carlos, Dept Anaesthesia, Univ Complutense Madrid, Madrid, Spain.
    Calvo-Vecino, J. M.
    Hosp Univ Infanta Leonor, Dept Anaesthesia, Univ Complutense Madrid, Madrid, Spain.
    A systematic review of sugammadex vs neostigmine for reversal of neuromuscular blockade2015In: Anaesthesia, ISSN 0003-2409, E-ISSN 1365-2044, Vol. 70, no 12, p. 1441-1452Article, review/survey (Refereed)
    Abstract [en]

    We reviewed systematically sugammadex vs neostigmine for reversing neuromuscular blockade. We included 17 randomised controlled trials with 1553 participants. Sugammadex reduced all signs of residual postoperative paralysis, relative risk (95% CI) 0.46 (0.29-0.71), p=0.0004 and minor respiratory events, relative risk (95% CI) 0.51 (0.32-0.80), p=0.0034. There was no difference in critical respiratory events, relative risk (95% CI) 0.13 (0.02-1.06), p=0.06. Sugammadex reduced drug-related side-effects, relative risk (95% CI) 0.72 (0.54-0.95), p=0.02. There was no difference in the rate of postoperative nausea or the rate of postoperative vomiting, relative risk (95% CI) 0.94 (0.79-1.13), p=0.53, and 0.87 (0.65-1.17), p=0.36 respectively.

  • 2.
    Acosta, Stefan
    et al.
    Vascular Center, Malmö University Hospital, Malmö, Sweden.
    Block, Tomas
    Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden.
    Björnsson, Steinarr
    Vascular Center, Malmö University Hospital, Malmö, Sweden.
    Resch, Timothy
    Vascular Center, Malmö University Hospital, Malmö, Sweden.
    Björck, Martin
    Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden.
    Nilsson, Torbjörn
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Clinical Chemistry, Örebro University Hospital, Örebro, Sweden.
    Diagnostic pitfalls at admission in patients with acute superior mesenteric artery occlusion2012In: Journal of Emergency Medicine, ISSN 0736-4679, E-ISSN 1090-1280, Vol. 42, no 6, p. 635-641Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Acute superior mesenteric artery (SMA) occlusion leads to acute intestinal ischemia and is associated with high mortality. Early diagnosis is often missed, and confounding factors leading to diagnostic delays need to be highlighted.

    OBJECTIVES: To identify potential diagnostic laboratory pitfalls at admission in patients with acute SMA occlusion.

    METHODS: Fifty-five patients with acute SMA occlusion were identified from the in-hospital register during a 4-year period, 2005-2009.

    RESULTS: The median age was 76 years; 78% were women. The occlusion was embolic in 53% and thrombotic in 47% of patients. At admission, troponin I was above the clinical decision level (> 0.06 μg/L) for acute ischemic myocardial injury in 9/19 (47%) patients with embolic occlusion. Elevated pancreas amylase and normal plasma lactate were found in 12/45 and 13/27, respectively. A troponin I (TnI) above the clinical decision level was associated with a high frequency of referrals from the general surgeon to a specialist in internal medicine (p = 0.011) or a cardiologist (p = 0.024). The diagnosis was established after computed tomography angiography in 98% of the patients. The overall in-hospital mortality rate was 33%. Attempting intestinal revascularization (n = 43; p < 0.001), with a 95% frequency rate of completion control of the vascular procedure, was associated with a higher survival rate, whereas referral to the cardiologist was associated with a higher mortality rate (p = 0.018).

    CONCLUSION: Elevated TnI was common in acute SMA occlusion, and referral to the cardiologist was found to be associated with adverse outcome. Elevated pancreas amylase and normal plasma lactate values are also potential pitfalls at admission in patients with acute SMA occlusion.

  • 3.
    Ahl, Rebecka
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Sarani, Babak
    Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, USA.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    The Association of Intracranial Pressure Monitoring and Mortality: A Propensity Score-Matched Cohort of Isolated Severe Blunt Traumatic Brain Injury2019In: Journal of Emergencies, Trauma and Shock, ISSN 0974-2700, E-ISSN 0974-519X, Vol. 12, no 1, p. 18-22Article in journal (Refereed)
    Abstract [en]

    Background: Intracranial pressure (ICP) monitoring in traumatic brain injury (TBI) is common. Yet, its efficacy varies between studies, and the actual effect on the outcome is debated. This study investigates the association of ICP monitoring and clinical outcome in patients with an isolated severe blunt TBI.

    Patients and Methods: Patients were recruited from the American College of Surgeons-Trauma Quality Improvement Program database during 2014. Inclusion criteria were limited to adult patients (>= 18 years) who had a sustained isolated severe intracranial injury (Abbreviated Injury Scale [AIS] head of >= 3 and Glasgow Coma Scale [GCS] of <= 8) following blunt trauma to the head. Patients with AIS score >0 for any extracranial body area were excluded. Patients' demographics, injury characteristics, interventions, and outcomes were collected for analysis. Patients receiving ICP monitoring were matched in a 1:1 ratio with controls who were not ICP monitored using propensity score matching.

    Results: A total of 3289 patients met inclusion criteria. Of these, 601 (18.3%) were ICP monitored. After propensity score matching, 557 pairs were available for analysis with a mean age of 44 (standard deviation 18) years and 80.2% of them were male. Median GCS on admission was 4[3,7], and a third of patients required neurosurgical intervention. There were no statistical differences in any variables included in the analysis between the ICP-monitored group and their matched counterparts. ICP-monitored patients required significantly longer intensive care unit and hospital length of stay and had an increased mortality risk with odds ratio of 1.6 (95% confidence interval: 1.1-2.5, P = 0.038).

    Conclusion: ICP monitoring is associated with increased in-hospital mortality in patients with an isolated severe TBI. Further investigation into which patients may benefit from this intervention is required.

  • 4.
    Ahlstrand, Erik
    et al.
    Örebro University Hospital. Örebro University, School of Medical Sciences. Department of Medicine.
    Cajander, Sara
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Infectious Diseases.
    Cajander, Per
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care.
    Ingberg, Edvin
    Faculty of Medicine and Health, Department of Infectious Diseases, Örebro University, Örebro, Sweden.
    Löf, Erika
    Department of Infectious Diseases, Örebro University Hospital, Örebro, Sweden.
    Wegener, Matthias
    Department of Radiology, Örebro University Hospital, Örebro, Sweden.
    Lidén, Mats
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Radiology.
    Visual scoring of chest CT at hospital admission predicts hospitalization time and intensive care admission in Covid-192021In: Infectious Diseases, ISSN 2374-4235, E-ISSN 2374-4243, Vol. 53, no 8, p. 622-632Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Chest CT is prognostic in Covid-19 but there is a lack of consensus on how to report the CT findings. A chest CT scoring system, ÖCoS, was implemented in clinical routine on 1 April 2020, in Örebro Region, Sweden. The ÖCoS-severity score measures the extent of lung involvement. The objective of the study was to evaluate the ÖCoS scores as predictors of the clinical course of Covid-19.

    METHODS: Population based study including data from all hospitalized patients with Covid-19 in Örebro Region during March to July 2020. We evaluated the correlations between CT scores at the time of admission to hospital and intensive care in relation to hospital and intensive care length of stay (LoS), intensive care admission and death. C-reactive protein and lymphocyte count were included as covariates in multivariate regression analyses.

    RESULTS: In 381 included patients, the ÖCoS-severity score at admission closely correlated to hospital length of stay, and intensive care admission or death. At admission to intensive care, the ÖCoS-severity score correlated with intensive care length of stay. The ÖCoS-severity score was superior to basic inflammatory biomarkers in predicting clinical outcomes.

    CONCLUSION: Chest CT visual scoring at admission to hospital predicted the clinical course of Covid-19 pneumonia.

  • 5.
    Ahlstrand, Rebecca
    Örebro University, School of Health and Medical Sciences.
    Effects of anasthesia on esophageal sphincters2011Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The esophageal sphincters constitute the anatomical protection against pulmonary aspiration. The aim of this thesis was to study the esophageal sphincters and how they are affected by different components of emergency anesthesia using high-resolution solid-state manometry.

    The effect of propofol (0.3 mg/kg) was studied in young and elderly volunteers. Propofol can be given as an anxiolytic agent for manometric studies of the lower esophageal sphincter (LES) without affecting the results. However, propofol is not recommended for studies of the upper esophageal sphincter (UES).

    The effects of cricoid pressure (CP) and peripheral pain were studied in awake volunteers, with and without remifentanil infusion (5 ng/ml). Pain did not affect pressure in the LES, but CP or remifentanil induced a significant decrease in LES pressure. However, neither CP nor remifentanil affected the barrier pressure (LES-intra gastric pressure). When CP was applied during ongoing remifentanil infusion, no further decrease in LES pressure was measured. CP induced high pressures in the area of the UES independent of remifentanil infusion, indicating that CP is effective in preventing gastroesophageal regurgitation.

    Barrier pressure was also studied in anesthetized patients after rocuronium (0.6 mg/kg) administration and no decrease was measured. In addition, alfentanil (20 μ/kg) added during anesthesia induction with propofol did not decrease the barrier pressure.

    In conclusion, CP seems to be effective in preventing regurgitation and does not affect barrier pressure. Muscle relaxation with rocuronium does not risk gastro-esophageal integrity. In addition, opioids can be integrated, even during emergency anethesia, without increasing the risk for pulmonary aspiration.

    List of papers
    1. Effects of propofol on oesophageal sphincters: a study on young and elderly volunteers using high-resolution solid-state manometry
    Open this publication in new window or tab >>Effects of propofol on oesophageal sphincters: a study on young and elderly volunteers using high-resolution solid-state manometry
    2011 (English)In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 28, no 4, p. 273-278Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND AND OBJECTIVE:

    The oesophageal sphincters play an important role in protecting the airway. During manometric studies, administration of an anxiolytic agent is often required to make insertion of the catheter acceptable for the patient. The anxiolytic should not affect the results of the measurements. This study evaluates the effects of two different doses of propofol on the pressures in the oesophageal sphincters. The effect of increased abdominal pressure was also studied.

    METHODS:

    Twenty healthy volunteers, 10 young (mean age 25 years) and 10 elderly (mean age 71 years), were recruited. The effects of a low dose of propofol [0.3 mg kg(-1) intravenously (i.v.)] and a high dose of propofol (young group 0.9 mg kg(-1) i.v. and elderly group 0.6 mg kg(-1) i.v.) were studied with and without external abdominal pressure.

    RESULTS:

    There were no statistically significant changes in lower oesophageal sphincter (LOS) pressure after the low dose of propofol. After the high dose, there was an increase in LOS pressure, which was statistically significant in the young group (P < 0.05). The upper oesophageal sphincter (UOS) pressure decreased after both doses of propofol (P < 0.01 for the higher dose and P < 0.05 for the lower dose).

    CONCLUSION:

    A low dose of propofol (0.3 mg kg(-1) i.v.) leaves the LOS unaffected in young and elderly volunteers and can be used safely as an anxiolytic agent during studies of the LOS without influencing the results. However, the UOS is more sensitive to the effects of propofol and we do not recommend the use of propofol as an anxiolytic agent during manometric studies of the UOS.

    Place, publisher, year, edition, pages
    Lippincott Williams & Wilkins, 2011
    National Category
    Medical and Health Sciences Anesthesiology and Intensive Care
    Research subject
    Anaesthesiology
    Identifiers
    urn:nbn:se:oru:diva-15384 (URN)10.1097/EJA.0b013e3283413211 (DOI)000288196000009 ()21119519 (PubMedID)2-s2.0-79953874254 (Scopus ID)
    Available from: 2011-04-26 Created: 2011-04-26 Last updated: 2017-12-11Bibliographically approved
    2. Effects of cricoid pressure and remifentanil on the esophageal sphincters using high-resolution solid-state manometry
    Open this publication in new window or tab >>Effects of cricoid pressure and remifentanil on the esophageal sphincters using high-resolution solid-state manometry
    2011 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 55, no 2, p. 209-215Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: Cricoid pressure has been shown to decrease the pressure in the lower esophageal sphincter (LES), increasing the risk of aspiration. Whether this reaction is due to pain associated with the application of cricoid pressure has not been studied. The aim of this study was to compare the effects of cricoid pressure with those of peripheral pain on pressures in the LES, and to study whether remifentanil influences these effects. Data from the upper esophageal sphincter (UES) are also described.

    METHODS: Continuous solid-state manometry was performed in 14 healthy volunteers. Initially, the effect of remifentanil (target-controlled infusion with a plasma target concentration of 5.0 ng/ml) was studied, and thereafter, the effects of cricoid pressure and peripheral pain stimulation (cold stimulation). Finally, these two interventions were repeated under ongoing remifentanil infusion.

    RESULTS: Remifentanil decreased the LES pressure significantly [ΔP-6.5 mmHg, 95% confidence interval (95% CI) -1.7 to -11.2]. Cricoid pressure application decreased the LES pressure significantly (ΔP-3.7 mmHg, 95% CI -1.4 to 6.1), whereas peripheral pain did not (ΔP 1.2 mmHg, 95% CI -3.5 to 1.1). Under ongoing remifentanil infusion, no cricoid pressure-induced LES relaxation was observed. Cricoid pressure induced high pressures in the area of the UES, 215.7 (±91.2) mmHg without remifentanil vs. 219.4 (±74.2) mmHg with remifentanil.

    CONCLUSIONS: Remifentanil as well as cricoid pressure per se induced decreases in LES pressure. However, cricoid pressure-induced changes of the barrier pressure were not significant whether induced with or without an infusion of remifentanil.

    Place, publisher, year, edition, pages
    Wiley-Blackwell, 2011
    National Category
    Anesthesiology and Intensive Care
    Research subject
    Anaesthesiology
    Identifiers
    urn:nbn:se:oru:diva-15386 (URN)10.1111/j.1399-6576.2010.02367.x (DOI)000286208600010 ()21226863 (PubMedID)2-s2.0-78651516200 (Scopus ID)
    Available from: 2011-04-26 Created: 2011-04-26 Last updated: 2018-02-20Bibliographically approved
    3. High resolution solid-state manometry of the effect of rocuronium on esophagogastric junction integrity
    Open this publication in new window or tab >>High resolution solid-state manometry of the effect of rocuronium on esophagogastric junction integrity
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Background: The pressure in the lower esophageal sphincter (LES) is partly dependent on striated muscles derived from the crural portion of the diaphragm. The effect of neuromuscular blockade on the integrity of the esophagogastric junction is not well studied. We conducted a prospective interventional study to determine the effect of rocuronium on the pressure in the LES and the barrier pressure (LES pressure – intra gastric pressure). We also studied the effect of positive pressure ventilation on the barrier pressure after neuromuscular blockade with rocuronium.

    Methods: Fourteen patients classified as ASA I or II (aged 18-75 years) who presented for elective surgery (11 cholecystectomy, 3 inguinal hernia) participated in the study. Esophageal manometry was performed after anesthetization with propofol, fentanyl and sevoflurane. After the insertion of a laryngeal mask airway, the patients breathed spontaneously for one minute. Rocuronium was administrated and the patients observed during the onset of apnea and during one minute of apnea and complete neuromuscular blockade. Volume controlled positive pressure ventilation followed.

    Results: Muscle relaxation with rocuronium showed no significant changes in barrier pressure comparing the pressure immediately before rocuronium administration with the pressure obtained at the time point of 0% TOF. Conversion to positive pressure ventilation did not change the barrier pressure with inspiration or expiration. The greatest decrease in barrier pressure was measured after inducing anesthesia when comparing pressures during inspiration (P< 0.01)

    National Category
    Medical and Health Sciences Anesthesiology and Intensive Care
    Research subject
    Anaesthesiology
    Identifiers
    urn:nbn:se:oru:diva-15387 (URN)
    Available from: 2011-04-26 Created: 2011-04-26 Last updated: 2017-10-17Bibliographically approved
    4. Integrity of the esophagogastric junction during propofol induction with and without remifentanil: a double-blind,randomized, crossover study in volunteers
    Open this publication in new window or tab >>Integrity of the esophagogastric junction during propofol induction with and without remifentanil: a double-blind,randomized, crossover study in volunteers
    Show others...
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Context: Practice varies regarding the use of opioids during rapid sequence induction. Controversy exists as to whether opioids may increase the risk of pulmonary aspiration by decreasing the barrier pressure (lower oesophageal sphincter pressure – intragastric pressure).

    Objectives: To evaluate the effects of adding alfentanil during anaesthesia induction with propofol with respect to the barrier pressure in the oesophagogastric junction.

    Participants and Setting: Seventeen healthy volunteers (11 males and 6 females) participated in a double-blind, randomised, crossover trial at the University Hospital in Örebro, Sweden.

    Interventions and outcome measures: The volunteers were anaesthetised on two different occasions, randomly assigned to receive either alfentanil 20 g kg ˉ1 or an equivalent amount of saline, administered intravenously, one minute before induction with propofol 2 mg kg ˉ1. One minute after propofol administration, a cricoid pressure of 30N was applied. The primary outcome was the difference in the change in barrier pressure between the alfentanil and the placebo occasion one minute after propofol administration. The secondary outcomes were differences in the changes in barrier pressure one minute after alfentanil or placebo administration and during ongoing cricoid pressure application.

    Results: There were no statistically significant differences in barrier pressure, at any time point, between anaesthesia induction with alfentanil and propofol compared with induction with placebo and propofol. The barrier pressure never decreased to less than 2.4 mmHg in any volunteer.

    Conclusion: Our study showed no increased risk regarding the integrity of the gastrooesophageal junction when alfentanil is added during an induction with propofol in volunteers. This supports the practice of adding opioids as adjuvants during rapid sequence induction.

    National Category
    Medical and Health Sciences Anesthesiology and Intensive Care
    Research subject
    Anaesthesiology
    Identifiers
    urn:nbn:se:oru:diva-15388 (URN)
    Available from: 2011-04-26 Created: 2011-04-26 Last updated: 2017-10-17Bibliographically approved
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  • 6.
    Ahlstrand, Rebecca
    et al.
    Örebro University, School of Health and Medical Sciences.
    Magnuson, Anders
    Thörn, Sven-Egron
    Dahlkvist, Anette
    Wattvil, Magnus
    Integrity of the esophagogastric junction during propofol induction with and without remifentanil: a double-blind,randomized, crossover study in volunteersManuscript (preprint) (Other academic)
    Abstract [en]

    Context: Practice varies regarding the use of opioids during rapid sequence induction. Controversy exists as to whether opioids may increase the risk of pulmonary aspiration by decreasing the barrier pressure (lower oesophageal sphincter pressure – intragastric pressure).

    Objectives: To evaluate the effects of adding alfentanil during anaesthesia induction with propofol with respect to the barrier pressure in the oesophagogastric junction.

    Participants and Setting: Seventeen healthy volunteers (11 males and 6 females) participated in a double-blind, randomised, crossover trial at the University Hospital in Örebro, Sweden.

    Interventions and outcome measures: The volunteers were anaesthetised on two different occasions, randomly assigned to receive either alfentanil 20 g kg ˉ1 or an equivalent amount of saline, administered intravenously, one minute before induction with propofol 2 mg kg ˉ1. One minute after propofol administration, a cricoid pressure of 30N was applied. The primary outcome was the difference in the change in barrier pressure between the alfentanil and the placebo occasion one minute after propofol administration. The secondary outcomes were differences in the changes in barrier pressure one minute after alfentanil or placebo administration and during ongoing cricoid pressure application.

    Results: There were no statistically significant differences in barrier pressure, at any time point, between anaesthesia induction with alfentanil and propofol compared with induction with placebo and propofol. The barrier pressure never decreased to less than 2.4 mmHg in any volunteer.

    Conclusion: Our study showed no increased risk regarding the integrity of the gastrooesophageal junction when alfentanil is added during an induction with propofol in volunteers. This supports the practice of adding opioids as adjuvants during rapid sequence induction.

  • 7.
    Ahlstrand, Rebecca
    et al.
    Örebro University, School of Health and Medical Sciences. Department of Anesthesiology and Intensive Care.
    Savilampi, Johanna
    Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Thörn, Sven-Egron
    Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Wattwil, Magnus
    Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Effects of cricoid pressure and remifentanil on the esophageal sphincters using high-resolution solid-state manometry2011In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 55, no 2, p. 209-215Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Cricoid pressure has been shown to decrease the pressure in the lower esophageal sphincter (LES), increasing the risk of aspiration. Whether this reaction is due to pain associated with the application of cricoid pressure has not been studied. The aim of this study was to compare the effects of cricoid pressure with those of peripheral pain on pressures in the LES, and to study whether remifentanil influences these effects. Data from the upper esophageal sphincter (UES) are also described.

    METHODS: Continuous solid-state manometry was performed in 14 healthy volunteers. Initially, the effect of remifentanil (target-controlled infusion with a plasma target concentration of 5.0 ng/ml) was studied, and thereafter, the effects of cricoid pressure and peripheral pain stimulation (cold stimulation). Finally, these two interventions were repeated under ongoing remifentanil infusion.

    RESULTS: Remifentanil decreased the LES pressure significantly [ΔP-6.5 mmHg, 95% confidence interval (95% CI) -1.7 to -11.2]. Cricoid pressure application decreased the LES pressure significantly (ΔP-3.7 mmHg, 95% CI -1.4 to 6.1), whereas peripheral pain did not (ΔP 1.2 mmHg, 95% CI -3.5 to 1.1). Under ongoing remifentanil infusion, no cricoid pressure-induced LES relaxation was observed. Cricoid pressure induced high pressures in the area of the UES, 215.7 (±91.2) mmHg without remifentanil vs. 219.4 (±74.2) mmHg with remifentanil.

    CONCLUSIONS: Remifentanil as well as cricoid pressure per se induced decreases in LES pressure. However, cricoid pressure-induced changes of the barrier pressure were not significant whether induced with or without an infusion of remifentanil.

  • 8.
    Ahlstrand, Rebecca
    et al.
    Örebro University, School of Health and Medical Sciences.
    Thörn, Sven-Egron
    Wattvil, Magnus
    High resolution solid-state manometry of the effect of rocuronium on esophagogastric junction integrityManuscript (preprint) (Other academic)
    Abstract [en]

    Background: The pressure in the lower esophageal sphincter (LES) is partly dependent on striated muscles derived from the crural portion of the diaphragm. The effect of neuromuscular blockade on the integrity of the esophagogastric junction is not well studied. We conducted a prospective interventional study to determine the effect of rocuronium on the pressure in the LES and the barrier pressure (LES pressure – intra gastric pressure). We also studied the effect of positive pressure ventilation on the barrier pressure after neuromuscular blockade with rocuronium.

    Methods: Fourteen patients classified as ASA I or II (aged 18-75 years) who presented for elective surgery (11 cholecystectomy, 3 inguinal hernia) participated in the study. Esophageal manometry was performed after anesthetization with propofol, fentanyl and sevoflurane. After the insertion of a laryngeal mask airway, the patients breathed spontaneously for one minute. Rocuronium was administrated and the patients observed during the onset of apnea and during one minute of apnea and complete neuromuscular blockade. Volume controlled positive pressure ventilation followed.

    Results: Muscle relaxation with rocuronium showed no significant changes in barrier pressure comparing the pressure immediately before rocuronium administration with the pressure obtained at the time point of 0% TOF. Conversion to positive pressure ventilation did not change the barrier pressure with inspiration or expiration. The greatest decrease in barrier pressure was measured after inducing anesthesia when comparing pressures during inspiration (P< 0.01)

  • 9.
    Al Dabbagh, Z.
    et al.
    Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
    Jansson, K. Å.
    Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
    Stiller, C. O.
    Department of Medicine, Clinical Pharmacology Unit, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
    Montgomery, Scott
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Clinical Epidemiology Unit, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology and Public Health, University College London, London, UK.
    Weiss, R. J.
    Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
    Long-term pattern of opioid prescriptions after femoral shaft fractures2016In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 60, no 5, p. 634-641Article in journal (Refereed)
    Abstract [en]

    Background: The use of opioids in non-cancer-related pain following skeletal trauma is controversial due to the presumed risk of dose escalation and dependence. We therefore examined the pattern of opioid prescriptions, that is, those actually dispensed, in patients with femoral shaft fractures.

    Methods: We analysed data from the Swedish National Hospital Discharge Register and the Swedish Prescribed Drug Register between 2005 and 2008.

    Results: We identified 1471 patients with isolated femoral shaft fractures. The median age was 75 (16-102) years and 56% were female. In this cohort, 891 patients (61%) received dispensed opioid prescriptions during a median follow-up of 20 months (interquartile range 11-32). In the age- and sex-matched comparison cohort (7339 individuals) without fracture, 25% had opioid prescriptions dispensed during the same period. The proportions of patients receiving opioid analgesics at 6 and 12 months after the fracture were 45% (95% CI 42-49) and 36% (32-39), respectively. The median daily morphine equivalent dose (MED) was between 15 and 17 mg 1-12 months post-fracture. After 3 months, less than 5% used prescription doses higher than 20 mg MED per day. Older age (≥ 70 compared with < 70 years) was a significant predictor of earlier discontinuation of opioid use (Hazard ratio [HR] 1.9).

    Conclusion: A notable proportion of patients continued to receive dispensed prescriptions for opioids for over 6 months (45%) and more than a third of them (36%) continued treatment for at least 12 months. However, the risk of dose escalation seems to be small in opioid-naïve patients.

  • 10.
    Al Dabbagh, Zewar
    et al.
    Dept Mol Med & Surg, Sect Orthopaed & Sports Med, Karolinska Univ Hosp, Karolinska Inst, Stockholm, Sweden.
    Jansson, Karl-Åke
    Dept Mol Med & Surg, Sect Orthopaed & Sports Med, Karolinska Univ Hosp, Karolinska Inst, Stockholm, Sweden.
    Stiller, Carl-Olav
    Dept Med, Clin Pharmacol Unit, Karolinska Univ Hosp, Karolinska Inst, Stockholm, Sweden.
    Montgomery, Scott
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Dept Med, Clin Epidemiol Unit, Karolinska Univ Hosp, Karolinska Inst, Stockholm, Sweden; Dept Epidemiol & Publ Hlth, University College London (UCL), London, England .
    Weiss, Rudiger J.
    Dept Mol Med & Surg, Sect Orthopaed & Sports Med, Karolinska Univ Hosp, Karolinska Inst, Stockholm, Sweden.
    No signs of dose escalations of potent opioids prescribed after tibial shaft fractures: a study of Swedish National Registries2014In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 14, p. 4-Article in journal (Refereed)
    Abstract [en]

    Background: The pattern of opioid use after skeletal trauma is a neglected topic in pain medicine. The purpose of this study was to analyse the long-term prescriptions of potent opioids among patients with tibial shaft fractures.

    Methods: Data were extracted from the Swedish National Hospital Discharge Register, the National Pharmacy Register, and the Total Population Register, and analysed accordingly. The study period was 2005-2008.

    Results: We identified 2,571 patients with isolated tibial shaft fractures. Of these, 639 (25%) collected a prescription for opioids after the fracture. The median follow-up time was 17 (interquartile range [IQR] 7-27) months. Most patients with opioid prescriptions after fracture were male (61%) and the median age was 45 (16-97) years. The leading mechanism of injury was fall on the same level (41%). At 6 and 12 months after fracture, 21% (95% CI 17-24) and 14% (11-17) were still being treated with opioids. Multiple Cox regression-analysis (adjusted for age, sex, type of treatment, and mechanism of injury) revealed that older patients (age >50 years) were more likely to end opioid prescriptions (Hazard ratio 1.5 [95% CI 1.3-1.9]). During follow-up, the frequency of patients on moderate and high doses declined. Comparison of the daily morphine equivalent dose among individuals who both had prescriptions during the first 3 months and the 6th month indicated that the majority of these patients (11/14) did not have dose escalations.

    Conclusions: We did not see any signs in registry-data of major dose escalations over time in patients on potent opioids after tibial shaft fractures.

  • 11.
    Alm, Fredrik
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Hälsorisker för personal i operationsrum som yrkesexponeras för anestesigaser2011Independent thesis Advanced level (professional degree), 5 credits / 7,5 HE creditsStudent thesis
  • 12.
    Alm, Fredrik
    et al.
    Örebro University, School of Health Sciences. Department of Anaesthesia and Intensive Care.
    Stalfors, Joacim
    Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Sheikh Khalifa Medical City, Ajman, United Arab Emirates.
    Nerfeldt, Pia
    Department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden; Division of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Patient reported pain-related outcome measures after tonsil surgery: an analysis of 32,225 children from the National Tonsil Surgery Register in Sweden 2009–20162017In: European Archives of Oto-Rhino-Laryngology, ISSN 0937-4477, E-ISSN 1434-4726, Vol. 274, no 10, p. 3711-3722Article in journal (Refereed)
    Abstract [en]

    The objective of this study was to describe factors affecting pain after pediatric tonsil surgery, using patient reported pain-related outcome measures (pain-PROMs) from the National Tonsil Surgery Register in Sweden. In total, 32,225 tonsil surgeries on children (1 to\18 years) during 2009–2016 were included; 13,904 tonsillectomies with or without adenoidectomy (TE ± A), and 18,321 tonsillotomies with or without adenoidectomy (TT ± A). Adjustments were made for variables included in the register to compensate for contributable factors in the analysis. When compared to TE ± A for surgical indication obstruction, TT ± A resulted in lower pain-PROMs, shorter use of postoperative analgesics, earlier return to regular food intake, and lower risk for contact with health care services due to pain. Children who underwent TE ± A because of obstruction problems stopped taking painkillers and returned to normal eating habits sooner, compared to children who underwent TE ± A for infectious indications. In both indication groups, TE ± A performed with hot rather than cold technique (dissection and haemostasis) generally resulted in higher pain-PROMs. Older children reported more days on analgesics and a later return to regular food intake after TE ± A than younger ones. No clinically relevant difference between sexes was found. Between 2012 and 2016 (pre-and post-implementation of Swedish national guidelines for pain treatment), the mean duration of postoperative analgesic use had increased. In conclusion, TE ± A caused considerably higher ratings of pain-related outcome measures, compared to TT ± A. For TE ± A, cold surgical techniques (dissection and haemostasis) were superior to hot techniques in terms of pain-PROMs. Older children reported higher pain-PROMs after TE ± A than younger ones.

  • 13.
    Anand, K J S
    et al.
    Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Anestheslogy, Neurobiology, and Pharmacology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
    Hall, R Whit
    Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
    Desai, Nirmala
    Department of Pediatrics, University of Kentucky Medical Center, Lexington, KY.
    Shephard, Barbara
    Department of Pediatrics, Tufts University School of Medicine, Boston, MA.
    Bergqvist, Lena L
    Neonatal Research Unit, Karolinska Institute, Astrid Lindgren's Children's Hospital, Stockholm, Sweden.
    Young, Thomas E
    Department of Pediatrics, University of North Carolina at Chapel Hill and Wake Medical Center, Raleigh, NC, USA.
    Boyle, Elaine M
    Simpson Memorial Maternity Pavilion, University of Edinburgh, Edinburgh, UK.
    Carbajal, Ricardo
    Service de Pédiatrie et Médecine Néonatale, Centre Hospitaller Poissy Saint Germain, Poissy, France.
    Bhutani, Vinod K
    Department of Pediatrics, University of Pennsylvania and Pennsylvania Hospital, Philadelphia, PA, USA.
    Moore, Mary Beth
    Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
    Kronsberg, Shari S
    Maryland Medical Research Institute, Baltimore, MD.
    Barton, Bruce A
    Maryland Medical Research Institute, Baltimore, MD.
    Effects of morphine analgesia in ventilated preterm neonates: primary outcomes from the NEOPAIN randomised trial2004In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 363, no 9422, p. 1673-82Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Opioid analgesia is commonly used during neonatal intensive care. We undertook the Neurologic Outcomes and Pre-emptive Analgesia in Neonates (NEOPAIN) trial to investigate whether pre-emptive morphine analgesia decreases the rate of a composite primary outcome of neonatal death, severe intraventricular haemorrhage (IVH), and periventricular leucomalacia (PVL) in preterm neonates.

    METHODS: Ventilated preterm neonates (n=898) from 16 centres were randomly assigned masked placebo (n=449) or morphine (n=449) infusions. After a loading dose (100 microg/kg), morphine infusions (23-26 weeks of gestation 10 microg kg(-1) h(-1); 27-29 weeks 20 microg kg(-1) h(-1); 30-32 weeks 30 microg kg(-1) h(-1)) were continued as long as clinically justified (maximum 14 days). Open-label morphine could be given on clinical judgment (placebo group 242/443 [54.6%], morphine group 202/446 [45.3%]). Analyses were by intention to treat.

    FINDINGS: Baseline variables were similar in the randomised groups. The placebo and morphine groups had similar rates of the composite outcome (105/408 [26%] vs 115/419 [27%]), neonatal death (47/449 [11%] vs 58/449 [13%]), severe IVH (46/429 [11%] vs 55/411 [13%]), and PVL (34/367 [9%] vs 27/367 [7%]). For neonates who were not given open-label morphine, rates of the composite outcome (53/225 [24%] vs 27/179 [15%], p=0.0338) and severe IVH (19/219 [9%] vs 6/189 [3%], p=0.0209) were higher in the morphine group than the placebo group. Placebo-group neonates receiving open-label morphine had worse rates of the composite outcome than those not receiving open-label morphine (78/228 [34%] vs 27/179 [15%], p<0.0001). Morphine-group neonates receiving open-label morphine were more likely to develop severe IVH (36/190 [19%] vs 19/219 [9%], p=0.0024).

    INTERPRETATION: Pre-emptive morphine infusions did not reduce the frequency of severe IVH, PVL, or death in ventilated preterm neonates, but intermittent boluses of open-label morphine were associated with an increased rate of the composite outcome. The morphine doses used in this study decrease clinical signs of pain but can cause significant adverse effects in ventilated preterm neonates.

  • 14.
    Ander, Fredrik
    et al.
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Magnuson, Anders
    Berggren, Lars
    Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    de Leon, Alex
    Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Effects of Esmolol on the Esophagogastric Junction: A Double-Blind, Randomized, Crossover Study on 14 Healthy Volunteers2017In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 125, no 4, p. 1184-1190Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Passive regurgitation may occur throughout the perioperative period, increasing the risk for pulmonary aspiration and postoperative pulmonary complications. Hypnotics and opioids, especially remifentanil, that are used during anesthesia have been shown to decrease the pressure in the esophagogastric junction (EGJ), that otherwise acts as a barrier against passive regurgitation of gastric contents. Esmolol, usually used to counteract tachycardia and hypertension, has been shown to possess properties useful during general anesthesia. Like remifentanil, the beta-1-adrenoreceptor antagonist may be used to attenuate the stress reaction to tracheal intubation and to modify perioperative anesthetic requirements. It may also reduce the need for opioids in the postoperative period. Its action on the EGJ is however unknown. The aim of this trial was to compare the effects of esmolol and remifentanil on EGJ pressures in healthy volunteers, when administrated as single drugs.

    METHODS: Measurements of EGJ pressures were made in 14 healthy volunteers using high resolution solid-state manometry. Interventions were administered in a randomized sequence and consisted of esmolol that was given IV as a bolus dose of 1 mg/kg followed by an infusion of 10 mu g.kg(-1).minute(-1) over 15 minutes, and remifentanil with target-controlled infusion of 4 ng/mL over 15 minutes. Interventions were separated by a 20-minute washout period. Analyses of EGJ pressures were performed at baseline, and during drug administration at 2 (T2) and 15 minutes (T15). The primary outcome was the inspiratory EGJ augmentation, while the inspiratory and expiratory EGJ pressures were secondary outcomes.

    RESULTS: There was no effect on inspiratory EGJ augmentation when comparing remifentanil and esmolol (mean difference -4.0 mm Hg [-9.7 to 1.7]; P = .15). In contrast, remifentanil significantly decreased both inspiratory and expiratory pressures compared to esmolol (-12.2 [-18.6 to 5.7]; P = .003 and 8.0 [-13.3 to 2.8]; P = .006).

    CONCLUSIONS: Esmolol, compared with remifentanil, does not affect EGJ function. This may be an advantage regarding passive regurgitation and esmolol may thus have a role to play in anesthesia where maintenance of EGJ barrier function is of outmost importance.

  • 15.
    Ander, Fredrik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anaesthesia and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Magnuson, Anders
    Berggren, Lars
    Department of Anaesthesia and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Medical Sciences. Department of Anaesthesia and Intensive Care, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    de Leon, Alex
    Department of Anesthesia and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Time-to-intubation in obese patients: A randomized study comparing direct laryngoscopy and videolaryngoscopy in experienced anaesthetists2017In: Minerva Anestesiologica, ISSN 0375-9393, E-ISSN 1827-1596, Vol. 83, no 9, p. 906-913Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Airway management may be difficult in obese patients. Moreover, during prolonged intubation, oxygen desaturation develops rapidly. Videolaryngoscopy improves the view of the larynx, and the Storz® C-MACTM has been shown to be superior to other videolaryngoscopes in terms of intubation time in obese patients. However, no effort has been made to compare the Storz® C-MACTM with direct laryngoscopy. The aim of the study was to evaluate if the use of Storz® C-MACTM may reduce intubation time when compared to direct laryngoscopy (classic Macintosh® blade).

    METHODS: eighty patients with body mass index > 35kg/m2 were randomized to orotracheal intubation using either Macintosh® laryngoscope, or the Storz® C-MACTM with the standard Macintosh blade. Patients had no previous history of a difficult airway. Time- to-intubation (TTI) was defined as the time from the moment anaesthetist took the laryngoscope until end-tidal carbon dioxide was detected.

    RESULTS: no significant difference in TTI could be demonstrated between the two devices tested (mean difference -1.7s (95% CI -6.9 to 3.5s). All patients in the videolaryngoscopy group were successfully intubated with the allocated device, whereas five patients in the direct laryngoscopy group required an alternative device for successful intubation. No significant difference regarding the subjective difficulty of intubation and postoperative sore throat between groups was demonstrated.

    CONCLUSION: in obese patients the airway may be secured equally fast using direct laryngoscopy (Macintosh®) and with videolaryngoscopy using the Stortz® C-MACTM. The risk for failed intubation, however, appears to be greater with direct laryngoscopy, especially in male obese patients.

  • 16.
    Ander, Fredrik
    et al.
    Örebro University, School of Medical Sciences. Department of Anaesthesia and Intensive Care, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Magnuson, Anders
    de Leon, Alex
    Department of Anaesthesia and Intensive Care, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anaesthesia and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Does the β-receptor antagonist esmolol have analgesic effects?: A randomised placebo-controlled cross-over study on healthy volunteers undergoing the cold pressor test2018In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 35, no 3, p. 165-172Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Esmolol may attenuate the sympathetic response to pain and reduce postoperative opioid consumption. It is not clear whether esmolol has an analgesic effect per se.

    OBJECTIVES: The aim of this study was to evaluate the analgesic effect of esmolol in the absence of anaesthetics and opioids. We tested the hypothesis that esmolol would reduce the maximum pain intensity perceived during the cold pressor test (CPT) by 2 points on a 0 to 10 numeric pain rating scale (NRS) compared to placebo.

    DESIGN: Randomised, placebo-controlled cross-over study.

    SETTING: Postoperative recovery area, Örebro University Hospital. Study period, November 2013 to February 2014.

    PARTICIPANTS: Fourteen healthy volunteers. Exclusion criteria included ongoing medication, pregnancy and breastfeeding and participation in other medical trials.

    INTERVENTIONS: At separate study sessions, participants received interventions: esmolol (0.7 mg kg bolus over 1 min followed by infusion at 10 μg kg min); 0.9% normal saline bolus then remifentanil infusion at 0.2 μg kg min and 0.9% normal saline bolus and infusion according to a random sequence. All infusions were administered over 30 min.

    MAIN OUTCOME MEASURES: Perceived maximum pain intensity score, pain tolerance and haemodynamic changes during CPT, and occurrence of side-effects to interventions compared to placebo, respectively.

    RESULTS: Esmolol did not reduce perceived pain intensity or pain tolerance during the CPT. The NRS-max score was similar for esmolol, 8.5 (±1.4) and placebo, 8.4 (±1.3). The mean difference was 0.1 [95% confidence interval (-1.2 to 1.4)], P value equal to 0.83. Remifentanil significantly reduced NRS-max scores, 5.4 (±2.1) compared to placebo, [mean difference -3.1 (95% confidence interval (-4.4 to -1.8)), P < 0.001]. Side-effects were seen with remifentanil but not with esmolol.

    CONCLUSION: No direct analgesic effect of esmolol could be demonstrated in the present study. The postoperative opioid-sparing effect demonstrated in previous studies, could therefore be secondary to other factors such as avoidance of opioid-induced hyperalgesia, synergy with coadministered opioids or altered pharmacokinetics of those drugs.

    TRIAL REGISTRATION: European clinical trials database, https://eudract.ema.europa.eu/, EudraCT no. 2011-005780-24.

  • 17.
    Andersson, Pia
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Augustsson, Lena
    Preoperativa metoder som anestesisjuksköterskan kan använda sig utav för att minska den postoperativa smärtan2011Independent thesis Advanced level (professional degree), 5 credits / 7,5 HE creditsStudent thesis
  • 18.
    Ansari, Malik
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Azar, Jonny
    Barn och föräldrars behov av information och förberedelser inför ett kirurgiskt ingrepp2011Independent thesis Advanced level (professional degree), 5 credits / 7,5 HE creditsStudent thesis
  • 19.
    Appelberg, Jonas
    et al.
    Department of Clinical Physiology, Sundsvall Hospital, Sundsvall, Sweden.
    Pavlenko, Tjatjana
    Research and Development Centre, Vasternorrland County Council, Sundsvall, Sweden.
    Bergman, Henrik
    Department of Radiology, Sundsvall Hospital, Sundsvall, Sweden.
    Rothen, Hans Ulrich
    Department of Anaesthesia, University Hospital, Bern, Switzerland.
    Hedenstierna, Göran
    Department of Medical Sciences, Clinical Physiology, University Hospital, Uppsala, Sweden.
    Lung aeration during sleep2007In: Chest, ISSN 0012-3692, E-ISSN 1931-3543, Vol. 131, no 1, p. 122-129Article in journal (Refereed)
    Abstract [en]

    Background: During sleep, ventilation and functional residual capacity (FRC) decrease slightly. This study addresses regional lung aeration during wakefulness and sleep.

    Methods: Ten healthy subjects underwent spirometry awake and with polysomnography, including pulse oximetry, and also CT when awake and during sleep. Lung aeration in different lung regions was analyzed. Another three subjects were studied awake to develop a protocol for dynamic CT scanning during breathing.

    Results: Aeration in the dorsal, dependent lung region decreased from a mean of 1.14 ± 0.34 mL (± SD) of gas per gram of lung tissue during wakefulness to 1.04 ± 0.29 mL/g during non-rapid eye movement (NREM) sleep (- 9%) [p = 0.034]. In contrast, aeration increased in the most ventral, nondependent lung region, from 3.52 ± 0.77 to 3.73 ± 0.83 mL/g (+ 6%) [p = 0.007]. In one subject studied during rapid eye movement (REM) sleep, aeration decreased from 0.84 to 0.65 mL/g (- 23%). The fall in dorsal lung aeration during sleep correlated to awake FRC (R2 = 0.60; p = 0.008). Airway closure, measured awake, occurred near and sometimes above the FRC level. Ventilation tended to be larger in dependent, dorsal lung regions, both awake and during sleep (upper region vs lower region, 3.8% vs 4.9% awake, p = 0.16, and 4.5% vs 5.5% asleep, p = 0.09, respectively).

    Conclusions: Aeration is reduced in dependent lung regions and increased in ventral regions during NREM and REM sleep. Ventilation was more uniformly distributed between upper and lower lung regions than has previously been reported in awake, upright subjects. Reduced respiratory muscle tone and airway closure are likely causative factors.

  • 20.
    Aronsson, Johnas
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    DESATURATION I SAMBAND MED GENERELL ANESTESI: En litteraturgenomgång2009Independent thesis Advanced level (professional degree), 5 credits / 7,5 HE creditsStudent thesis
  • 21.
    Aspelund, Amalia Liljequist
    et al.
    Department of Research and Education, Karolinska Institutet, Stockholm, Sweden.
    Patel, Mohamed Quraish
    Department of Surgery, Khayelitsha Hospital, Cape Town, South Africa.
    Kurland, Lisa
    Örebro University, School of Medical Sciences. Department of Research and Education, Karolinska Institutet, Stockholm, Sweden.
    McCaul, Michael
    Biostatistics Unit, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, South Africa.
    van Hoving, Daniël Jacobus
    Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa.
    Evaluating trauma scoring systems for patients presenting with gunshot injuries to a district-level urban public hospital in Cape Town, South Africa2019In: African journal of emergency medicine, ISSN 2211-419X, Vol. 9, no 4, p. 193-196Article in journal (Refereed)
    Abstract [en]

    Introduction: Trauma scoring systems are widely used in emergency settings to guide clinical decisions and to predict mortality. It remains unclear which system is most suitable to use for patients with gunshot injuries at district-level hospitals. This study compares the Triage Early Warning Score (TEWS), Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Kampala Trauma Score (KTS) and Revised Trauma Score (RTS) as predictors of mortality among patients with gunshot injuries at a district-level urban public hospital in Cape Town, South Africa.

    Methods: Gunshot-related patients admitted to the resuscitation area of Khayelitsha Hospital between 1 January 2016 and 31 December 2017 were retrospectively analysed. Receiver Operating Characteristic (ROC) analysis were used to determine the accuracy of each score to predict all-cause in-hospital mortality. The odds ratio (with 95% confidence intervals) was used as a measure of association.

    Results: In total, 331 patients were included in analysing the different scores (abstracted from database n = 431, excluded: missing files n = 16, non gunshot injury n = 10, <14 years n = 1, information incomplete to calculate scores n = 73). The mortality rate was 6% (n = 20). The TRISS and KTS had the highest area under the ROC curve (AUC), 0.90 (95% CI 0.83-0.96) and 0.86 (95% CI 0.79-0.94), respectively. The KTS had the highest sensitivity (90%, 95% CI 68-99%), while the TEWS and RTS had the highest specificity (91%, 95% CI 87-94% each).

    Conclusions: None of the different scoring systems performed better in predicting mortality in this high-trauma burden area. The results are limited by the low number of recorded deaths and further studies are needed.

  • 22.
    Axelsson, Birger
    et al.
    Örebro University Hospital. Örebro University, School of Medical Sciences.
    Johansson, G.
    Department of Surgical and Perioperative Sciences, Faculty of Medicine, Umeå University, Umeå, Sweden.
    Abrahamsson, P.
    Department of Surgical and Perioperative Sciences, Faculty of Medicine, Umeå University, Umeå, Sweden.
    Gupta, Anil
    Örebro University Hospital. Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Tyden, H.
    Anaesthesia and Intensive Care, Department of Cardiovascular and Thoracic Surgery, Örebro University Hospital, Örebro, Sweden.
    Wouters, P.
    Department of Anesthesiology, University Hospital Ghent, Ghent, Belgium.
    Haney, M.
    Department of Surgical and Perioperative Sciences, Faculty of Medicine, Umeå University, Umeå, Sweden.
    Milrinone and levosimendan during porcine myocardial ischemia: no effects on calcium overload and metabolism2013In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 57, no 6, p. 719-728Article in journal (Refereed)
    Abstract [en]

    Background: Although inotropic stimulation is considered harmful in the presence of myocardial ischaemia, both calcium sensitisers and phosphodiesterase inhibitors may offer cardioprotection. We hypothesise that these cardioprotective effects are related to an acute alteration of myocardial metabolism. We studied in vivo effects of milrinone and levosimendan on calcium overload and ischaemic markers using left ventricular microdialysis in pigs with acute myocardial ischaemia.

    Methods: Anaesthetised juvenile pigs, average weight 36kg, were randomised to one of three intravenous treatment groups: milrinone 50g/kg bolus plus infusion 0.5g/kg/min (n=7), levosimendan 24g/kg plus infusion 0.2g/kg/min (n=7), or placebo (n=6) for 60min prior to and during a 45min acute regional coronary occlusion. Systemic and myocardial haemodynamics were assessed, and microdialysis was performed with catheters positioned in the left ventricular wall. 45Ca2+ was included in the microperfusate in order to assess local calcium uptake into myocardial cells. The microdialysate was analysed for glucose, lactate, pyruvate, glycerol, and for 45Ca2+ recovery.

    Results: During ischaemia, there were no differences in microdialysate-measured parameters between control animals and milrinone- or levosimendan-treated groups. In the pre-ischaemic period, arterial blood pressure decreased in all groups while myocardial oxygen consumption remained stable.

    Conclusions: These findings reject the hypothesis of an immediate energy-conserving effect of milrinone and levosimendan during acute myocardial ischaemia. On the other hand, the data show that inotropic support with milrinone and levosimendan does not worsen the metabolic parameters that were measured in the ischaemic myocardium.

  • 23.
    Axelsson, Kjell
    et al.
    Örebro University, School of Health and Medical Sciences.
    Gupta, Anil
    Örebro University, School of Health and Medical Sciences.
    Johanzon, Eva
    Berg, Elisabeth
    Ekbäck, Gustav
    Rawal, Narinder
    Enström, Peter
    Nordensson, Ulf
    Intraarticular administration of ketorolac, morphine, and ropivacaine combined with intraarticular patient-controlled regional analgesia for pain relief after shoulder surgery: a randomized, double-blind study2008In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 106, no 1, p. 328-333Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In this study we assessed the efficacy of intraarticular regional analgesia on postoperative pain and analgesic requirements. METHODS: Fifty-one patients undergoing shoulder surgery (Bankart) were recruited into this double-blind study. At the end of the operation, patients were randomized to three groups to receive intraarticularly via a catheter: Group 1: ropivacaine 90 mg (9 mL), morphine 4 mg (10 mL), and ketorolac 30 mg (1 mL) (total volume 20 mL); Groups 2 and 3: saline (20 mL). In addition, Groups 1 and 3 received 1 mL saline IV while Group 2 received ketorolac 30 mg (1 mL) IV. Postoperatively, Group 1 received pain relief using 10 mL 0.5% ropivacaine on demand via the intraarticular catheter while Groups 2 and 3 received 10 mL of saline intraarticularly. Group 3 was the Control group. RESULTS: Postoperative pain at rest and on movement were lower in Group 1 than in Groups 2 and 3 during the first 30 and 120 min, respectively. The time to first request for local anesthetic infusion was longer in Group 1 than in Groups 2 and 3 (P < 0.001). The median morphine consumption during the first 24 postoperative hours was less in Groups 1 and 2 than in Group 3 (P < 0.001). There was no significant difference in analgesic consumption between Group 1 and Group 2. The median satisfaction score was higher in Group 1 compared with Groups 2 (P < 0.05) and 3 (P < 0.001). CONCLUSIONS: A combination of intraarticular ropivacaine, morphine, and ketorolac followed by intermittent injections of ropivacaine as needed provided better pain relief, less morphine consumption, and improved patient satisfaction compared with the control group. The group that received IV ketorolac consumed less morphine and was more satisfied with treatment than patients in the control group.

  • 24. Axelsson, Patric
    et al.
    Thörn, Sven-Egron
    Örebro University, Department of Clinical Medicine.
    Lövqvist, Åsa
    Wattwil, Lisbeth
    Örebro University, Department of Clinical Medicine.
    Wattwil, Magnus
    Örebro University, Department of Clinical Medicine.
    Betamethasone does not prevent nausea and vomiting induced by the dopamine-agonist apomorphine2006In: Canadian Journal of Anesthesia, ISSN 0832-610X, E-ISSN 1496-8975, Vol. 53, no 4, p. 370-374Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The mechanism of the antiemetic actions of corticosteroids is not known. The purpose of this study was to evaluate if betamethasone can prevent nausea, vomiting or increase of vasopressin induced by apomorphine. Metoclopramide, a dopamine antagonist, was used as a control substance. METHODS: Ten healthy volunteers were studied on three occasions. In a randomized order they were allocated to receive pretreatment with betamethasone 8 mg iv, metoclopramide 10 mg iv, and normal saline 2 mL as placebo on the three different occasions, 15 min before the administration of apomorphine 30 microg x kg(-1) s.c.. After administration of apomorphine, episodes of vomiting were recorded, and the intensity of nausea was estimated by the subject on a visual analogue scale (VAS 0-10 cm). Blood samples for analysis of plasma concentrations of vasopressin were analyzed. RESULTS: One volunteer decided to withdraw, as he experienced akathisia after receiving metoclopramide. During the first two hours after apomorphine, eight of nine volunteers vomited both after betamethasone and placebo. One volunteer did not vomit after betamethasone and placebo but he experienced nausea. None of the volunteers vomited after metoclopramide (P < 0.01 vs betamethasone and placebo). The maximum VAS for nausea was significantly higher after betamethasone and placebo compared to metoclopramide (P < 0.01). The vasopressin levels increased after betamethasone and placebo, but there was no increase in any volunteer after pretreatment with metoclopramide. CONCLUSION: This study demonstrates that betamethasone does not prevent nausea, vomiting and increase of vasopressin induced by apomorphine, whereas metoclopramide prevents apomorphine-induced emesis. Our work suggests that betamethasone does not have dopamine-antagonistic effects.

  • 25.
    Axman Sara, Inga Lisa
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Kvist, Maria
    Patienters upplevelser av att fasta inför operation2012Independent thesis Advanced level (professional degree), 5 credits / 7,5 HE creditsStudent thesis
  • 26.
    Bartha, Erzsebet
    et al.
    Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Health Sciences. Department of Anaesthesiology.
    Bell, Max
    Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.
    Björne, Håkan
    Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.
    Brattström, Olof
    Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.
    Helleberg, Johan
    Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.
    Nilsson, Lena
    Department of Anesthesiology and Intensive Care, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
    Semenas, Egidijus
    Department of Anaesthesiology and Intensive Care, Uppsala University Hospital, Uppsala, Sweden.
    Kalman, Sigridur
    Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.
    ASA classification and surgical severity grading used to identify a high-risk population, a multicenter prospective cohort study in Swedish tertiary hospitals2021In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 65, no 9, p. 1168-1177Article in journal (Refereed)
    Abstract [en]

    Background: Identification of surgical populations at high risk for negative outcomes is needed for clinical and research purposes. We hypothesized that combining two classification systems, ASA (American Society of Anesthesiology physical status) and surgical severity, we could identify a high-risk population before surgery. We aimed to describe postoperative outcomes in a population selected by these two classifications system.

    Methods: Data were collected in a Swedish multicentre, time-interrupted prospective, consecutive cohort study. Eligibility criteria were age >= 18 years, ASA >= 3, elective or emergent, major to Xmajor/complex (Specialist Procedure Codes used in United Kingdom), gastrointestinal, urogenital or orthopaedic procedures. Postoperative morbidity was identified by the Postoperative Morbidity Survey on postoperative days 3 +/- 1, 7 +/- 1, 10 + 5 and graded for severity by the Clavien-Dindo system. Mortality was assessed at 30, 180 and 360 days.

    Results: Postoperative morbidity was 78/48/47 per cent on postoperative days 3/7/10. Majority of morbidities (67.5 per cent) were graded as >1 by Clavien-Dindo. Any type of postoperative morbidity graded >1 was associated with increased risk for death up to one year. The mortality was 5.7 per cent (61/1063) at 30 days, 13.3 per cent (142/1063) at 6 months and 19.1 per cent (160/1063) at 12 months.

    Conclusion: Severity classification as major to Xmajor/complex and ASA >= 3 could be used to identify a high-risk surgical population concerning postoperative morbidity and mortality before surgery. Combining the two systems future electronic data extraction is possible of a high-risk population in tertiary hospitals.

  • 27.
    Bartha, Erzsebet
    et al.
    Karolinska University Hospital, Huddinge, Sweden.
    Bertilsson, Mathias
    Karolinska University Hospital, Huddinge, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Medical Sciences.
    Bell, Max
    Periooperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.
    Björne, Håkan
    Periooperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.
    Brattström, Olof
    Periooperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.
    Nilsson, Lena
    Periooperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.
    Semenas, Egidijus
    Periooperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.
    Wiklund, Andreas
    Periooperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.
    Kalman, Sigridur
    Periooperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.
    Combining functional dependency and ASA III classification for risk stratification-predictors, risk factors, and outcomes following major surgery study (NCT02626546)2017In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, no 8, p. 1011-1011Article in journal (Other academic)
    Abstract [en]

    Background: In elderly reclassification of ASA3 class by functional dependency improved prediction of postoperative mortality. We hypothesized that such a reclassification could improve the risk prediction of adverse outcomes also following high risk surgery.

    Method: We analyzed data collected by the PROFS study in four Swedish academic hospitals. The inclusion criteria were: adults, ASA≥3, major or xmajor/complex surgery (UK surgical severity coding). ASA 3 patients were reclassified into ASA 3a (functionally independent) and 3b (functionally dependent). The adverse outcomes were postoperative complications (yes/no) screened by Postoperative Morbidity Survey (days 3, 7, 10) and mortality (30-day). Complications graded ≥2 by Clavien-Dindo classification were considered. The predictive value of reclassification was analyzed by logistic regression models.

    Results: Between 2015 Nov2th and 2016 Feb19th 1089 patients were include; 13 were excluded (violation of inclusion criteria), 3 were lost to follow-up and 1073 were analyzed. ASA 3b (vs ASA 3a) patients had higher risk for mortality and for postoperative complications at days 7 and 10. ASA 4 (vs ASA 3) patients had higher risk of all adverse outcomes (Table 1). When age was added in the regression model ASA 3b patients still had higher risk for postoperative complications at day 10, but the significance disappeared when also urgency was added.

    Conclusion: The loss of significance by adding urgency in the model might be attributed to the dominance of urgent procedures in ASA3b and ASA4 groups. Reclassification of ASA 3 patients by dependency is recommended, as it may predict adverse outcomes and support clinical judgment.

  • 28.
    Bartha, Erzsebet
    et al.
    Karolinska University Hospital, Huddinge, Sweden.
    Helleberg, Johan
    Karolinska University Hospital, Huddinge, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Bell, Max
    Karolinska University Hospital, Solna, Sweden.
    Björne, Hakan
    Karolinska University Hospital, Solna, Sweden.
    Brattström, Olof
    Karolinska University Hospital, Solna, Sweden.
    Nilsson, Lena
    University Hospital Linköping, Linköping, Sweden.
    Semenas, Egidijus
    Uppsala University Hospital, Uppsala, Sweden.
    Wiklund, Andreas
    Karolinska University Hospital, Solna, Sweden.
    Kalman, Sigridur
    Karolinska University Hospital, Huddinge, Sweden.
    Performance of prediction models of postoperative mortality in high-risk surgical patients in swedish university hospitals: Predictors, Risk factors and Outcome Following major Surgery study (PROFS study NCT02626546)2017In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, no 8, p. 1056-1057Article in journal (Other academic)
    Abstract [en]

    Background: There are several progn ostic prediction models that estimate the probability of postoperative mortality. The role of these models is to support clinical decisions. Before implementation of a prediction model in routine care, it is necessary to analyze its performance in the target population. Our aim was to analyze the performance of four different prediction models of postoperative mortality in a high-risk surgical population.

    Methods: Data collected from 2015-11-01 until 2016-02-15 in a prospective consecutive observational study (PROFS study) in four university hospitals was used. The inclusion criteria were adult, ASA classification ≥3, and major/complex upper or lower gastrointestinal, urogenital or orthoped ic surgery (UK surgical severity codingA XA PPP). Four prediction models were evaluated: Surgical Outcome Risk Tool (SORT), Surgical APGAR, P-POSSUM and Surgical Risk Scale (SRS). The outcome measure was 90-day mortality. We evaluated the discrimination of the models by area under receiver operator characteristic curve (AUC ROC) before and after recalibration.

    Results: In total, 1 089 patients were included. Thirteen patients were excluded due to erroneous inclusion, and another three were lost to follow-up, so data from 1 073 was used in this analysis. The mean age was 73 years, the presence of malignancy was 41%, and 90-day mortality was 13% (n = 140). The SORT model had the best discrimination both before and after recalibration. The P-POSSUM model improved after recalibration. The SRS model overestimated, whereas the APGAR model underestimated, the risk of mortality.

    Conclusions: The original SORT model is promising and could be incorporated as decision support for high-risk surgical patients.

  • 29.
    Bass, Gary A
    et al.
    Örebro University, School of Medical Sciences. Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA, USA; Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Örebro University, Örebro, Sweden; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA.
    Kaplan, Lewis J.
    Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia PA, USA.
    Ryan, Éanna J.
    Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Örebro University, Örebro, Sweden; Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Clinical Epidemiology and Biostatistics.
    Lane-Fall, Meghan
    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA; Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
    Duffy, Caoimhe C.
    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA; Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
    Vail, Emily A.
    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA; Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery.
    The snapshot audit methodology: design, implementation and analysis of prospective observational cohort studies in surgery2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 1, p. 5-15Article in journal (Refereed)
    Abstract [en]

    Purpose: For some surgical conditionns and scientific questions, the "real world" effectiveness of surgical patient care may be better explored using a multi-institutional time-bound observational cohort assessment approach (termed a "snapshot audit") than by retrospective review of administrative datasets or by prospective randomized control trials. We discuss when this might be the case, and present the key features of developing, deploying, and assessing snapshot audit outcomes data.

    Methods: A narrative review of snapshot audit methodology was generated using the Scale for the Assessment of Narrative Review Articles (SANRA) guideline. Manuscripts were selected from domains including: audit design and deployment, statistical analysis, surgical therapy and technique, surgical outcomes, diagnostic testing, critical care management, concomitant non-surgical disease, implementation science, and guideline compliance.

    Results: Snapshot audits all conform to a similar structure: being time-bound, non-interventional, and multi-institutional. A successful diverse steering committee will leverage expertise that includes clinical care and data science, coupled with librarian services. Pre-published protocols (with specified aims and analyses) greatly helps site recruitment. Mentored trainee involvement at collaborating sites should be encouraged through manuscript contributorship. Current funding principally flows from medical professional organizations.

    Conclusion: The snapshot audit approach to assessing current care provides insights into care delivery, outcomes, and guideline compliance while generating testable hypotheses.

  • 30.
    Bass, Gary Alan
    et al.
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Stephen, Christopher
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Bailey, Joanelle A.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Mohseni, Shahin
    Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Chreiman, Kristen
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Duffy, Caoimhe
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Seamon, Mark J.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Cannon, Jeremy W.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Martin, Niels Douglas
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Admission Triage With Pain, Inspiratory Effort, Cough Score can Predict Critical Care Utilization and Length of Stay in Isolated Chest Wall Injury2022In: Journal of Surgical Research, ISSN 0022-4804, E-ISSN 1095-8673, Vol. 277, p. 310-318Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Damage to the thoracic cage is common in the injured patient, both when the injuries are confined to this single cavity and as part of the overall injury burden of a polytraumatized patient. In a subset of these patients, the severity of injury to the intrathoracic viscera is either underappreciated at admission or blossom over the following 48-72 h. The ability to promptly identify these patients and abrogate complications therefore requires triage of such at-risk patients to close monitoring in a critical care environment. At our institution, this triage hinges on the Pain, Inspiratory effort, Cough (PIC) score, which generates a composite unitless score from a nomogram which aggregates several variables-patient-reported Pain visual analog scale, Incentive spirometry effort, and the perceived adequacy of Cough. We thus sought to audit PIC's discriminant power in predicting intensive care unit (ICU) need.

    METHODS: This retrospective cohort study was performed at an urban, academic, level 1 trauma center. All isolated chest wall injuries (excluded any Abbreviated Injury Score >2 in head or abdomen) from January 2020 to June 2021 were identified in the local trauma registry. The electronic medical record was queried for standard demographics, admission PIC score, postadmission destination, ICU and hospital length of stay (LOS), and any unplanned admissions to the ICU. Chi-squared tests were used to determine differences between PIC score outcomes and the recursive partitioning method correlated admission PIC score to ICU LOS.

    RESULTS: Two hundred and thirty six isolated chest wall injury patients were identified, of whom 194 were included in the final analysis. The median age was 60 (interquartile range [IQR] 50-74) years, 63.1% were male, and the median (IQR) number of rib fractures was 3.0 (2.0-5.0). A cutoff PIC score of 7 or lower was associated with ICU admission (odds ratio [OR] 95% CI: 8.19 [3.39-22.55], P < 0.001 with a PPV = 41.4%, NPV = 91%), and with ICU admission for greater than 48 h [OR (95% CI): 26.86 (5.5-43.96), P < 0.001, with a PPV = 25.9%, NPV = 98.7%] but not anatomic injury severity score, hospital LOS or ICU, or the requirement for mechanical ventilation. The association between PIC score 7 or below and the presence of bilateral fractures, flail chest, or sternal fracture did not meet statistical significance. The accurate cut point of the PIC score to predict ICU admission over 48 h in our retrospective cohort was calculated as PIC ≤ 7 for P = 0.013 and PIC ≤ 6 for P = 0.001.

    CONCLUSIONS: Patients with isolated chest wall injuries require effective reproducible triage for ICU-level care. The PIC score appears to be a moderate discriminator of critical care need, per se, as judged by our recorded complication rate requiring critical care intervention. This vigilance may pay dividends in early detection and abrogation of respiratory failure emergencies. Furthermore, PIC score delineation for ICU need appears to be appropriate at 7 or less; this threshold can be used during admission triage to guide care.

  • 31.
    Bassford, Chris
    et al.
    Warwick Medical School, University of Warwick, Coventry, UK; Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
    Griffiths, Frances
    Warwick Medical School, University of Warwick, Coventry, UK.
    Svantesson, Mia
    Örebro University, School of Health Sciences. Örebro University Hospital. University Health Care Research Center.
    Ryan, Mandy
    Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
    Krucien, Nicolas
    Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
    Dale, Jeremy
    Warwick Medical School, University of Warwick, Coventry, UK.
    Rees, Sophie
    Warwick Medical School, University of Warwick, Coventry, UK.
    Rees, Karen
    Warwick Medical School, University of Warwick, Coventry, UK.
    Ignatowicz, Agnieszka
    Warwick Medical School, University of Warwick, Coventry, UK; Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
    Parsons, Helen
    Warwick Medical School, University of Warwick, Coventry, UK.
    Flowers, Nadine
    Warwick Medical School, University of Warwick, Coventry, UK.
    Fritz, Joe
    Warwick Medical School, University of Warwick, Coventry, UK; Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK; The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK.
    Perkins, Gavin
    Warwick Medical School, University of Warwick, Coventry, UK; Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK.
    Quinton, Sarah
    Warwick Medical School, University of Warwick, Coventry, UK; ealth Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
    Symons, Sarah
    White, Catherine
    Huang, Huayi
    Warwick Medical School, University of Warwick, Coventry, UK.
    Turner, Jake
    Warwick Medical School, University of Warwick, Coventry, UK.
    Brooke, Mike
    Warwick Medical School, University of Warwick, Coventry, UK.
    McCreedy, Aimee
    Warwick Medical School, University of Warwick, Coventry, UK.
    Blake, Caroline
    Warwick Medical School, University of Warwick, Coventry, UK.
    Slowhter, Anne
    Warwick Medical School, University of Warwick, Coventry, UK.
    Developing an intervention around referral and admissions to intensive care: a mixed-methods study2019Report (Other academic)
    Abstract [en]

    Background: Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.

    Objectives: To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.

    Methods: A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UKintensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records The tool was tested for inter-rater and intersite reliability in 120 patient records.

    Results: Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importanceof interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.

    Limitations: Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approachthat mitigated the potential limitations of the component studies. Conclusions: Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve thedecision-making for and, ultimately, the care of critically ill patients.

    Future work: Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of trainingfor clinicians involved in these decisions should be a priority for future work.

  • 32.
    Batchelor, Tim J. P.
    et al.
    Department of Thoracic Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Surgery.
    A surgical perspective of ERAS guidelines in thoracic surgery2019In: Current Opinion in Anaesthesiology, ISSN 0952-7907, E-ISSN 1473-6500, Vol. 32, no 1, p. 17-22Article, review/survey (Refereed)
    Abstract [en]

    PURPOSE OF REVIEW: Guidelines for enhanced recovery after surgery (ERAS) have recently been published for lung surgery. Although some of the recommendations are generic or focused on anesthetic and nursing care, other recommendations are more specific to a thoracic surgeon's practice. The present review concentrates on the surgical approach, optimal chest drain management, and the importance of early mobilization.

    RECENT FINDINGS: Most lung cancer resections are still performed via an open thoracotomy approach. If a thoracotomy is to be used, a muscle-sparing approach may result in reduced pain and better postoperative function. Sparing of the intercostal bundle also reduces pain. There is now evidence that minimally invasive surgery for early lung cancer results in superior patient outcomes. Postoperatively, single chest tubes should be used without the routine application of external suction. Digital drainage systems are more reliable and may produce superior outcomes. Conservative chest drain removal policies are unnecessary and impair patient recovery. Early mobilization protocols should be instigated to reduce postoperative complications.

    SUMMARY: The use of ERAS after lung surgery has the potential to improve patient outcomes. Although specific surgical elements are in the minority, thoracic surgeons should be involved in all aspects of perioperative care as part of the wider multidisciplinary team.

  • 33.
    Batchelor, Timothy J. P.
    et al.
    Department of Thoracic Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
    Rasburn, Neil J.
    Department of Anaesthesia, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
    Abdelnour-Berchtold, Etienne
    Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
    Brunelli, Alessandro
    Department of Thoracic Surgery, St. James’s University Hospital, Leeds, UK.
    Cerfolio, Robert J.
    Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA.
    Gonzalez, Michel
    Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Surgery.
    Petersen, René H.
    Department of Thoracic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
    Popescu, Wanda M.
    Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA.
    Slinger, Peter D.
    Department of Anesthesia, University Health Network – Toronto General Hospital, Toronto, ON, Canada.
    Naidu, Babu
    Department of Thoracic Surgery, Heart of England NHS Foundation Trust, Birmingham, UK.
    Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS)2019In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 55, no 1, p. 91-115Article, review/survey (Refereed)
    Abstract [en]

    Enhanced recovery after surgery is well established in specialties such as colorectal surgery. It is achieved through the introduction of multiple evidence-based perioperative measures that aim to diminish postoperative organ dysfunction while facilitating recovery. This review aims to present consensus recommendations for the optimal perioperative management of patients undergoing thoracic surgery (principally lung resection). A systematic review of meta-analyses, randomized controlled trials, large non-randomized studies and reviews was conducted for each protocol element. Smaller prospective and retrospective cohort studies were considered only when higher-level evidence was unavailable. The quality of the evidence base was graded by the authors and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society and the European Society for Thoracic Surgery. Recommendations were developed for a total of 45 enhanced recovery items covering topics related to preadmission, admission, intraoperative care and postoperative care. Most are based on good-quality studies. In some instances, good-quality data were not available, and subsequent recommendations are generic or based on data extrapolated from other specialties. In other cases, no recommendation can currently be made because either equipoise exists or there is a lack of available evidence. Recommendations are based not only on the quality of the evidence but also on the balance between desirable and undesirable effects. Key recommendations include preoperative counselling, nutritional screening, smoking cessation, prehabilitation for high-risk patients, avoidance of fasting, carbohydrate loading, avoidance of preoperative sedatives, venous thromboembolism prophylaxis, prevention of hypothermia, short-acting anaesthetics to facilitate early emergence, regional anaesthesia, nausea and vomiting control, opioid-sparing analgesia, euvolemic fluid management, minimally invasive surgery, early chest drain removal, avoidance of urinary catheters and early mobilization after surgery. These guidelines outline recommendations for the perioperative management of patients undergoing lung surgery based on the best available evidence. As the recommendation grade for most of the elements is strong, the use of a systematic perioperative care pathway has the potential to improve outcomes after surgery.

  • 34.
    Berggren, Rickard
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    En beskrivning av preventiva åtgärder för att minska bildandet av atelektaser perioperativt2011Independent thesis Advanced level (professional degree), 5 credits / 7,5 HE creditsStudent thesis
  • 35.
    Bergström, Gunnar
    et al.
    Division of Intervention and Implementation Research, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Bergström, Cecilia
    Division of Intervention and Implementation Research, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Hagberg, Jan
    Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Bodin, Lennart
    Division of Intervention and Implementation Research, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Jensen, Irene
    Division of Intervention and Implementation Research, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    A 7-year follow-up of multidisciplinary rehabilitation among chronic neck and back pain patients: Is sick leave outcome dependent on psychologically derived patient groups?2010In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 14, no 4, p. 426-433Article in journal (Refereed)
    Abstract [en]

    A valid method for classifying chronic pain patients into more homogenous groups could be useful for treatment planning, that is, which treatment is effective for which patient, and as a marker when evaluating treatment outcome. One instrument that has been used to derive subgroups of patients is the Multidimensional Pain Inventory (MPI). The primary aim of this study was to evaluate a classification method based on the Swedish version of the MPI, the MPI-S, to predict sick leave among chronic neck and back pain patients for a period of 7 years after vocational rehabilitation. As hypothesized, dysfunctional patients (DYS), according to the MPI-S, showed a higher amount of sickness absence and disability pension expressed in days than adaptive copers (AC) during the 7-years follow-up period, even when adjusting for sickness absence prior to rehabilitation (355.8days, 95% confidence interval, 71.7; 639.9). Forty percent of DYS patients and 26.7% of AC patients received disability pension during the follow-up period. However, this difference was not statistically significant. Further analyses showed that the difference between patient groups was most pronounced among patients with more than 60days of sickness absence prior to rehabilitation. Cost-effectiveness calculations indicated that the DYS patients showed an increase in production loss compared to AC patients. The present study yields support for the prognostic value of this subgroup classification method concerning long-term outcome on sick leave following this type of vocational rehabilitation.

  • 36.
    Beverly, Anair
    et al.
    Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston MA, USA.
    Kaye, Alan D.
    Department of Anesthesiology and Pharmacology, Anesthesiology Services, LSU School of Medicine, University Medical Center Hospital, New Orleans LA, USA.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Urman, Richard D.
    Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston MA, USA.
    Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines2017In: Anesthesiology Clinics, ISSN 1932-2275, Vol. 35, no 2, p. e115-e143Article in journal (Refereed)
    Abstract [en]

    Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.

  • 37.
    Björkman, Louise
    et al.
    Örebro University, School of Medical Sciences. Department of Pediatrics, Örebro University Hospita, Örebro, Sweden.
    Hagberg, J.
    Department of Occupational and Environmental Medicine, Örebro University Hospital, Örebro, Sweden.
    Schollin, Jens
    Örebro University, School of Medical Sciences.
    Ohlin, Andreas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Pediatrics.
    Can the use of isopropanol impregnated caps cause alcohol leakage into intravenous lines?2017Conference paper (Refereed)
  • 38.
    Bowyer, A.
    et al.
    Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville Vic, Australia.
    Jakobsson, J.
    Department for Anaesthesia and Intensive Care, Institution of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Ljungqvist, Olle
    Örebro University Hospital. Department of Surgery; Institution of Molecular medicine and Surgery, Karolinska Insitutet, Stockholm, Sweden.
    Royse, C.
    Department of Surgery, The University of Melbourne, Parkville Vic, Australia.
    A review of the scope and measurement of postoperative quality of recovery2014In: Anaesthesia, ISSN 0003-2409, E-ISSN 1365-2044, Vol. 69, no 11, p. 1266-1278Article, review/survey (Refereed)
    Abstract [en]

    To date, postoperative quality of recovery lacks a universally accepted definition and assessment technique. Current quality of recovery assessment tools vary in their development, breadth of assessment, validation, use of continuous vs dichotomous outcomes and focus on individual vs group recovery. They have progressed from identifying pure restitution of physiological parameters to multidimensional assessments of postoperative function and patient-focused outcomes. This review focuses on the progression of these tools towards an as yet unreached ideal that would provide multidimensional assessment of recovery over time at the individual and group level. A literature search identified 11 unique recovery assessment tools. The Postoperative Quality of Recovery Scale assesses recovery in multiple domains, including physiological, nociceptive, emotive, activities of daily living, cognition and patient satisfaction. It addresses recovery over time and compares individual patient data with base line, thus describing resumption of capacities and is an acceptable method for identification of individual patient recovery.

  • 39.
    Braatz, Erik
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Tjäder, Albin
    Prevention av Perioperativ Hypotermi2010Independent thesis Advanced level (professional degree), 5 credits / 7,5 HE creditsStudent thesis
  • 40.
    Brodin, Daniel
    et al.
    Department of Medicine, Capio S:t Göran's Hospital, Stockholm, Sweden.
    Tornhammar, Per
    Functional Area of Emergency Medicine, Karolinska Institute, Stockholm, Sweden.
    Ueda, Peter
    Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
    Krifors, Anders
    Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Västmanland, Uppsala University, Uppsala, Sweden.
    Westerlund, Eli
    Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.
    Athlin, Simon
    Örebro University, School of Medical Sciences.
    Wojt, Sandra
    Department of Internal Medicine, Danderyd Hospital, Stockholm, Sweden.
    Elvstam, Olof
    Department of Infectious Diseases, Central Hospital Växjö, Vaxjö, Sweden.
    Neumann, Anca
    Department of Medicine, Capio S:t Göran's Hospital, Stockholm, Sweden.
    Elshani, Arsim
    Department of Medicine and Geriatrics, Karlskoga Hospital, Karlskoga, Sweden.
    Giesecke, Julia
    Functional Area of Emergency Medicine, Karolinska Institute, Stockholm, Sweden.
    Edvardsson-Källkvist, Jens
    Karolinska University Hospital, Stockholm, Sweden.
    Bunpuckdee, Sayam
    Functional Area of Emergency Medicine, Karolinska Institute, Stockholm, Sweden.
    Unge, Christian
    Department of Internal Medicine, Danderyd Hospital, Stockholm, Sweden.
    Larsson, Martin
    Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Johansson, Björn
    Department of Infectious Diseases, Halland's Hospital Halmstad, Halmstad, Sweden.
    Ljungberg, Johan
    Department of Infectious Diseases, Halland's Hospital Halmstad, Halmstad, Sweden.
    Lindell, Jonas
    Department of Infectious Diseases, Visby Hospital, Visby, Sweden.
    Hansson, Johan
    Department of Infectious Diseases, Östersund Hospital, Östersund, Sweden.
    Blennow, Ola
    Department of Medicine, Capio S:t Göran's Hospital, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Andersson, Daniel Peter
    Department of Medicine Huddinge H7, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Inhaled ciclesonide in adults hospitalised with COVID-19: a randomised controlled open-label trial (HALT COVID-19)2023In: BMJ Open, E-ISSN 2044-6055, Vol. 13, no 2, article id e064374Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To assess the efficacy of inhaled ciclesonide in reducing the duration of oxygen therapy (an indicator of time to clinical improvement) among adults hospitalised with COVID-19.

    DESIGN: Multicentre, randomised, controlled, open-label trial.

    SETTING: 9 hospitals (3 academic hospitals and 6 non-academic hospitals) in Sweden between 1 June 2020 and 17 May 2021.

    PARTICIPANTS: Adults hospitalised with COVID-19 and receiving oxygen therapy.

    INTERVENTION: Inhaled ciclesonide 320 µg two times a day for 14 days versus standard care.

    MAIN OUTCOME MEASURES: Primary outcome was duration of oxygen therapy, an indicator of time to clinical improvement. Key secondary outcome was a composite of invasive mechanical ventilation/death.

    RESULTS: Data from 98 participants were analysed (48 receiving ciclesonide and 50 receiving standard care; median (IQR) age, 59.5 (49-67) years; 67 (68%) men). Median (IQR) duration of oxygen therapy was 5.5 (3-9) days in the ciclesonide group and 4 (2-7) days in the standard care group (HR for termination of oxygen therapy 0.73 (95% CI 0.47 to 1.11), with the upper 95% CI being compatible with a 10% relative reduction in oxygen therapy duration, corresponding to a <1 day absolute reduction in a post-hoc calculation). Three participants in each group died/received invasive mechanical ventilation (HR 0.90 (95% CI 0.15 to 5.32)). The trial was discontinued early due to slow enrolment.

    CONCLUSIONS: In patients hospitalised with COVID-19 receiving oxygen therapy, this trial ruled out, with 0.95 confidence, a treatment effect of ciclesonide corresponding to more than a 1 day reduction in duration of oxygen therapy. Ciclesonide is unlikely to improve this outcome meaningfully.

    TRIAL REGISTRATION NUMBER: NCT04381364.

  • 41.
    Brown, Ruth
    et al.
    Emergency Department, Imperial College Healthcare NHS Trust, London, UK.
    Kurland, Lisa
    Örebro University, School of Medical Sciences.
    Lojo Rial, Carlos
    Emergency Department, Carlos Lojo Rial, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK.
    How should we train emergency physicians for Quality and Safety activities?2023In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 30, no 6, p. 391-392Article in journal (Refereed)
  • 42.
    Buer, Nina
    et al.
    Neurotec Department, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden; Department of Health Promotion for Personnel, Örebro University Hospital, Örebro, Sweden .
    Linton, Steven J
    Department of Occupational and Environmental Medicine, Örebro University Hospital, Örebro, Sweden .
    Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population2002In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 99, no 3, p. 485-491Article in journal (Refereed)
    Abstract [en]

    Fear-avoidance beliefs and catastrophizing have been shown to be powerful cognitions in the process of developing chronic pain problems and there is a need for increased knowledge in early stages of pain.

    The objectives of this study were therefore, firstly, to examine the occurrence of fear-avoidance beliefs and catastrophizing in groups with different degrees of non-chronic spinal pain in a general population, and secondly to assess if fear-avoidance beliefs and catastrophizing were related to current ratings of pain and activities of daily living (ADL).

    The study was a part of a population based back pain project and the study sample consisted of 917 men and women, 35-45 years old, either pain-free or with non-chronic spinal pain. The results showed that fear-avoidance beliefs as well as catastrophizing occur in this general population of non-patients. The levels were moderate and in catastrophizing a 'dose-response' pattern was seen, such that more the catastrophizing was, the more was pain. The study showed two relationships, which were between fear-avoidance and ADL as well as between catastrophizing and pain intensity. Logistic regression analyses were performed with 95% confidence intervals and the odds ratio for fear-avoidance beliefs and ADL was 2.5 and for catastrophizing and pain 1.8, both with confidence interval above unity. The results suggest that fear-avoidance beliefs and catastrophizing may play an active part in the transition from acute to chronic pain and clinical implications include screening and early intervention. (C) 2002 International Association for the Study of Pain. Published by Elsevier Science B.V. All rights reserved.

  • 43.
    Bukur, M.
    et al.
    Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States; Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Department of Acute Care Surgery, Los Angeles County, Los Angeles CA, United States; University of Southern California Medical Center, Los Angeles CA, United States.
    Ley, E.
    Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States.
    Salim, A.
    Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States.
    Margulies, D.
    Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States.
    Talving, P.
    Department of Acute Care Surgery, Los Angeles County, Los Angeles CA, United States; University of Southern California Medical Center, Los Angeles CA, United States.
    Demetriades, D.
    Department of Acute Care Surgery, Los Angeles County, Los Angeles CA, United States; University of Southern California Medical Center, Los Angeles CA, United States.
    Inaba, K.
    Department of Acute Care Surgery, Los Angeles County, Los Angeles CA, United States; University of Southern California Medical Center, Los Angeles CA, United States.
    Efficacy of beta-blockade after isolated blunt head injury: Does race matter? (vol 72, pg 1013, 2012)2012In: Journal of Trauma and Acute Care Surgery, ISSN 2163-0755, E-ISSN 2163-0763, Vol. 72, no 6, p. 1725-1725Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Several retrospective clinical studies and recent prospective animal models demonstrate improved outcomes with beta-blocker administration after isolated blunt head injury. However, no investigations to date have examined the influence of race on the potential therapeutic effectiveness of these medications. Our hypothesis was that mortality benefits associated with beta-blocker exposure after isolated blunt head injury varies based on ethnicity.

    METHODS: The trauma registry and the surgical intensive care unit (ICU) databases of an academic Level I trauma center were used to identify all patients sustaining blunt head injury requiring ICU admission from July 1998 to December 2009. Patients sustaining major associated extracranial injuries (Abbreviated Injury Scale [AIS] score ≥3 in any body region) were excluded. Patient demographics, injury profile, Injury Severity Score, and beta-blocker exposure were abstracted. The primary outcome evaluated was in-hospital mortality stratified by ethnicity.

    RESULTS: During the 11-year study period, 3,750 patients were admitted to the Los Angeles County + University of Southern California Medical Center trauma ICU because of blunt trauma. Of these, 65% (n = 2,446) had an “isolated” head injury. When stratified by race, most patients were Hispanics (60%), followed by Whites (21%), Asians (11%), and African Americans (8%). After adjusting for confounding variables with multivariate regression, only those of Asian and Hispanic descent demonstrated significantly improved outcomes associated with beta-blocker administration.

    CONCLUSIONS: Our results indicate that beta-blockade after traumatic brain injury may not benefit all races equally. Further prospective research is necessary to assess this discrepancy in treatment benefit and explore other possible therapeutic interventions.

    LEVEL OF EVIDENCE: III, therapeutic study; II, prognostic study.

  • 44.
    Bulow, Hans-Henrik
    et al.
    Intensive Care, Holbaek Hospital, Holbaek, Denmark.
    Sprung, Charles L.
    Department of Anesthesiology and Critical Care Medicine, Medical Center, Hadassah Hebrew University, Jerusalem, Israel.
    Baras, Mario
    Hadassah School of Public Health, Hadassah Medical Center, Hebrew University, Jerusalem, Israel.
    Carmel, Sara
    Centre for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Negev, Israel.
    Svantesson, Mia
    Örebro University Hospital. Örebro University, School of Health Sciences. Centre for Health Care Research.
    Benbenishty, Julie
    Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
    Maia, Paulo A.
    Department of Intensive Care, Centro Hospitalar, Hospital S. Antonio, Porto, Portugal.
    Beishuizen, Albertus
    Medical Center, Vrije Universiteit, Amsterdam, The Netherlands.
    Cohen, Simon
    Intensive Care Unit, University College Hospital, London, United Kingdom.
    Nalos, Daniel
    Krajská Zdravotní A.s., ARO Masarykova Nemocnice Ústí Nad, Labem, Czech Republic.
    Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU?: The Ethicatt study2012In: Intensive Care Medicine, ISSN 0342-4642, E-ISSN 1432-1238, Vol. 38, no 7, p. 1126-1133Article in journal (Refereed)
    Abstract [en]

    This study explored differences in end-of-life (EOL) decisions and respect for patient autonomy of religious members versus those only affiliated to that particular religion (affiliated is a member without strong religious feelings).

    In 2005 structured questionnaires regarding EOL decisions were distributed in six European countries to ICUs in 142 hospital ICUs. This sub-study of the original data analyzed answers from Protestants, Catholics and Jews.

    A total of 304 physicians, 386 nurses, 248 patients and 330 family members were included in the study. Professionals wanted less treatment (ICU admission, CPR, ventilator treatment) than patients and family members. Religious respondents wanted more treatment and were more in favor of life prolongation, and they were less likely to want active euthanasia than those affiliated. Southern nurses and doctors favored euthanasia more than their Northern colleagues. Three quarters of doctors and nurses would respect a competent patient's refusal of a potentially life-saving treatment. No differences were found between religious and affiliated professionals regarding patient's autonomy. Inter-religious differences were detected, with Protestants most likely to follow competent patients' wishes and the Jewish respondents least likely to do so, and Jewish professionals more frequently accepting patients' wishes for futile treatment. However, these findings on autonomy were due to regional differences, not religious ones.

    Health-care professionals, families and patients who are religious will frequently want more extensive treatment than affiliated individuals. Views on active euthanasia are influenced by both religion and region, whereas views on patient autonomy are apparently more influenced by region.

  • 45.
    Busch, Hillevi
    et al.
    Division of Intervention and Implementation Research, Department of Public Health, Karolinska Institutet, Sweden.
    Bodin, Lennart
    Division of Intervention and Implementation Research, Department of Public Health, Karolinska Institutet, Sweden.
    Bergström, Gunnar
    Division of Intervention and Implementation Research, Department of Public Health, Karolinska Institutet, Sweden.
    Jensen, Irene B.
    Division of Intervention and Implementation Research, Department of Public Health, Karolinska Institutet, Sweden.
    Patterns of sickness absence a decade after pain-related multidisciplinary rehabilitation2011In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 152, no 8, p. 1727-1733Article in journal (Refereed)
    Abstract [en]

    Multidisciplinary programmes using a vocational approach can enhance work return in chronic pain patients, but little is known about the long-term effects of rehabilitation. The current study examined the patterns of sickness absence 10 years after participation in 3 treatment groups (physiotherapy, cognitive behavioural therapy, and vocational multidisciplinary rehabilitation) in comparison to a control group receiving treatment-as-usual. Cost-effectiveness was also assessed. Two hundred fourteen patients participated in a randomized controlled trial and were followed-up via register data 10 years after the interventions. On average, persons in multidisciplinary rehabilitation had 42.98 fewer days on sickness absence per year compared to those treated-as-usual (95% confidence interval −82.45 to −3.52, P=0.03). The corresponding reduction of sickness absence after physiotherapy and cognitive behavioural therapy was not significantly different from the control group. The effect of rehabilitation seems to be more pronounced for disability pension than for sick leave. The economic analyses showed substantial cost savings for individuals in the multidisciplinary group compared to the control group.

  • 46.
    Cajander, Per
    et al.
    Örebro University, School of Medical Sciences. Department of Anaesthesia and Intensive Care, Örebro, Sweden.
    Edmark, Lennart
    Department of Anaesthesia and Intensive Care, Västerås, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Medical Sciences. Department of Anaesthesia and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Magnuson, Anders
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    de Leon, Alex
    Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Göteborg, sWeden; School of Medical Sciences, Örebro University, Örebro, Sweden.
    Effect of positive end-expiratory pressure on gastric insufflation during induction of anaesthesia when using pressure-controlled ventilation via a face mask: A randomised controlled trial2019In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 36, no 9, p. 625-632Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Face mask ventilation (FMV) during induction of anaesthesia is associated with risk of gastric insufflation that may lead to gastric regurgitation and pulmonary aspiration. A continuous positive airway pressure (CPAP) has been shown to reduce gastric regurgitation. We therefore hypothesised that CPAP followed by FMV with positive end-expiratory pressure (PEEP) during induction of anaesthesia would reduce the risk of gastric insufflation.

    OBJECTIVE: The primary aim was to compare the incidence of gastric insufflation during FMV with a fixed PEEP level or zero PEEP (ZEEP) after anaesthesia induction. A secondary aim was to investigate the effects of FMV with or without PEEP on upper oesophageal sphincter (UES), oesophageal body and lower oesophageal sphincter (LES) pressures.

    DESIGN: A randomised controlled trial.

    SETTING: Single centre, Department of Anaesthesia and Intensive Care, Örebro University Hospital, Sweden.

    PARTICIPANTS: Thirty healthy volunteers.

    INTERVENTIONS: Pre-oxygenation without or with CPAP 10 cmH2O, followed by pressure-controlled FMV with either ZEEP or PEEP 10 cmH2O after anaesthesia induction.

    MAIN OUTCOME MEASURES: A combined impedance/manometry catheter was used to detect the presence of gas and to measure oesophageal pressures. The primary outcome measure was the cumulative incidence of gastric insufflation, defined as a sudden anterograde increase in impedance of more than 1 kΩ over the LES. Secondary outcome measures were UES, oesophageal body and LES pressures.

    RESULTS: The cumulative incidence of gastric insufflation related to peak inspiratory pressure (PIP), was significantly higher in the PEEP group compared with the ZEEP group (log-rank test P < 0.01). When PIP reached 30 cmH2O, 13 out of 15 in the PEEP group compared with five out of 15 had shown gastric insufflation. There was a significant reduction of oesophageal sphincter pressures within groups comparing pre-oxygenation to after anaesthesia induction, but there were no significant differences in oesophageal sphincter pressures related to the level of PEEP.

    CONCLUSION: Contrary to the primary hypothesis, with increasing PIP the tested PEEP level did not protect against but facilitated gastric insufflation during FMV. This result suggests that PEEP should be used with caution after anaesthesia induction during FMV, whereas CPAP during pre-oxygenation seems to be safe.

    TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02238691.

  • 47.
    Cajander, Per
    et al.
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care.
    Omari, Taher I.
    College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
    Cock, Charles
    Department of Gastroenterology and Hepatology, Flinders Medical Centre, Southern Adelaide Local Health Network, and College of Medicine and Public Health, Flinders University, South Australia.
    Magnuson, Anders
    Örebro University, Örebro, Sweden.
    Scheinin, Mika
    Institute of Biomedicine, University of Turku, and Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland.
    Savilampi, Johanna
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care.
    Effects of remifentanil on pharyngeal swallowing and esophageal motility: no impact of different bolus volumes, and partial antagonism by methylnaltrexone2021In: American Journal of Physiology - Gastrointestinal and Liver Physiology, ISSN 0193-1857, E-ISSN 1522-1547, Vol. 321, no 4, p. G367-G377Article in journal (Refereed)
    Abstract [en]

    Background: Remifentanil impairs swallowing, and disturbed accommodation to bolus volume may be one of the underlying causes. It is not fully understood whether remifentanil-induced swallowing dysfunction is mediated by peripheral or central mechanisms.

    Aims: To investigate if remifentanil-induced swallowing dysfunction is dependent on the bolus volume and whether the effect of remifentanil could be counteracted by methylnaltrexone, a peripherally acting opioid antagonist.

    Methods: Nineteen healthy volunteers were included in this double-blinded, randomized, placebo-controlled, crossover study. Study participants received target-controlled remifentanil infusions and placebo infusions in a randomized order. Methylnaltrexone was administered by intravenous injection of doses of 0.3 mg/kg. Recordings of pressure and impedance data were acquired using a combined manometry and impedance solid state catheter. Data was analyzed from three series of bolus swallows, baseline, during remifentanil exposure, and 15 min after methylnaltrexone.

    Results: Remifentanil induced significant effects on multiple pharyngeal and esophageal function parameters. No significant differences in remifentanil-induced swallowing dysfunction related to different bolus volumes were found. Pharyngeal effects of remifentanil were not significantly counteracted by methylnaltrexone, whereas on the distal esophageal level, effects on distension pressures were counteracted. Conclusions Changes in pharyngeal and esophageal pressure flow variables were consistent with previous results on remifentanil-induced swallowing dysfunction, and uniform across all bolus volumes. The effects of remifentanil on the pharyngeal level and on the proximal esophagus appear to be predominantly centrally mediated, whereas the effects of remifentanil on the distal esophagus may be mediated by both central and peripheral mechanisms.

    NEW & NOTEWORTHY: In this randomized controlled trial, we used the "Swallow Gateway" online platform to analyze the effects of remifentanil on pharyngeal and esophageal swallowing. It is not fully understood whether remifentanil-induced swallowing dysfunction is mediated by peripheral or central mechanisms. By using methylnaltrexone, we demonstrated that effects of remifentanil on pharyngeal swallowing were predominantly centrally mediated, whereas its effects on the distal esophagus may be mediated by both central and peripheral mechanisms.

  • 48.
    Cajander, Per
    et al.
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Omari, Taher
    College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
    Magnuson, Anders
    Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Scheinin, Harry
    Turku PET Centre, University of Turku and Turku University Hospital, Turku, Finland; Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland.
    Scheinin, Mika
    Department of Anesthesiology and Intensive Care, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Savilampi, Johanna
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anesthesiology and Intensive Care.
    Effects of dexmedetomidine on pharyngeal swallowing and esophageal motility: A double-blind randomized cross-over study in healthy volunteers2023In: Neurogastroenterology and Motility, ISSN 1350-1925, E-ISSN 1365-2982, Vol. 35, no 1, article id e14501Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Sedative agents increase the risk of pulmonary aspiration, where an intact swallowing function is an important defense mechanism. Dexmedetomidine is an α2 -adrenoceptor agonist widely used during procedural sedation due to beneficial properties with minimal respiratory effects. The effects of dexmedetomidine on pharyngeal swallowing and esophageal motility are not known in detail.

    METHODS: To determine the effects of dexmedetomidine on pharyngeal swallowing and esophageal motility, nineteen volunteers were included in this double-blinded, randomized placebo-controlled cross-over study. Study participants received target-controlled dexmedetomidine and placebo infusions. Recordings of pressure and impedance data were acquired using a manometry and impedance solid-state catheter. Data were analyzed from three bolus swallows series: baseline, during dexmedetomidine/placebo infusion at target plasma concentrations 0.6 ng ml-1 and 1.2 ng ml-1 . Subjective swallowing difficulties were also recorded.

    KEY RESULTS: On pharyngeal swallowing, dexmedetomidine affected the upper esophageal sphincter with decreased pre- and post-swallow contractile pressures and an increase in residual pressure during swallow-related relaxation. On esophageal function, dexmedetomidine decreased contractile vigor of the proximal esophagus and increased velocity of the peristaltic contraction wave. Residual pressures during swallow-related esophagogastric junction (EGJ) relaxation decreased, as did basal EGJ resting pressure. The effects on the functional variables were not clearly dose-dependent, but mild subjective swallowing difficulties were more common at the higher dose level.

    CONCLUSIONS AND INFERENCES: Dexmedetomidine induces effects on pharyngeal swallowing and esophageal motility, which should be considered in clinical patient management and also when a sedative agent for procedural sedation or for manometric examination is to be chosen.

  • 49.
    Cajander, Per
    et al.
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Omari, Taher
    College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.
    Scheinin, Harry
    Turku PET Centre, University of Turku and Turku University Hospital, and Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland.
    Scheinin, Mika
    Institute of Biomedicine, University of Turku, and Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland.
    Savilampi, Johanna
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anesthesiology and Intensive Care.
    Response to Letter to the Editor2023In: Neurogastroenterology and Motility, ISSN 1350-1925, E-ISSN 1365-2982, Vol. 35, no 8, article id e14616Article in journal (Refereed)
    Abstract [en]

    It is crucial to consider the possible influence of anesthetic agents on esophageal function testing. Dexmedetomidine has been shown to affect primary peristalsis during esophageal manometry. In the two case reports presented by Toaz et al., secondary peristalsis during FLIP panometry was also affected. This may be attributed to an alternate pharmacodynamic effect, with a transient direct α2-mediated effect on esophageal smooth muscle, associated with a high plasma concentration following bolus injection, prior to the onset of sympathetic inhibition.

  • 50.
    Cao, Yang
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Sarani, Babak
    Center of Trauma and Critical Care, George Washington University, Washington, DC 20037, USA.
    Montgomery, Scott
    Örebro University, School of Medical Sciences. Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, 171 77 Stockholm, Sweden; Department of Epidemiology and Public Health, University College London, London WC1E 7HB, UK.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates.
    Development and Validation of an XGBoost-Algorithm-Powered Survival Model for Predicting In-Hospital Mortality Based on 545,388 Isolated Severe Traumatic Brain Injury Patients from the TQIP Database2023In: Journal of Personalized Medicine, E-ISSN 2075-4426, Vol. 13, no 9, article id 1401Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Traumatic brain injury (TBI) represents a significant global health issue; the traditional tools such as the Glasgow Coma Scale (GCS) and Abbreviated Injury Scale (AIS) which have been used for injury severity grading, struggle to capture outcomes after TBI.

    AIM AND METHODS: This paper aims to implement extreme gradient boosting (XGBoost), a powerful machine learning algorithm that combines the predictions of multiple weak models to create a strong predictive model with high accuracy and efficiency, in order to develop and validate a predictive model for in-hospital mortality in patients with isolated severe traumatic brain injury and to identify the most influential predictors. In total, 545,388 patients from the 2013-2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) database were included in the current study, with 80% of the patients used for model training and 20% of the patients for the final model test. The primary outcome of the study was in-hospital mortality. Predictors were patients' demographics, admission status, as well as comorbidities, and clinical characteristics. Penalized Cox regression models were used to investigate the associations between the survival outcomes and the predictors and select the best predictors. An extreme gradient boosting (XGBoost)-powered Cox regression model was then used to predict the survival outcome. The performance of the models was evaluated using the Harrell's concordance index (C-index). The time-dependent area under the receiver operating characteristic curve (AUC) was used to evaluate the dynamic cumulative performance of the models. The importance of the predictors in the final prediction model was evaluated using the Shapley additive explanations (SHAP) value.

    RESULTS: On average, the final XGBoost-powered Cox regression model performed at an acceptable level for patients with a length of stay up to 250 days (mean time-dependent AUC = 0.713) in the test dataset. However, for patients with a length of stay between 20 and 213 days, the performance of the model was relatively poor (time-dependent AUC < 0.7). When limited to patients with a length of stay ≤20 days, which accounts for 95.4% of all the patients, the model achieved an excellent performance (mean time-dependent AUC = 0.813). When further limited to patients with a length of stay ≤5 days, which accounts for two-thirds of all the patients, the model achieved an outstanding performance (mean time-dependent AUC = 0.917).

    CONCLUSION: The XGBoost-powered Cox regression model can achieve an outstanding predictive ability for in-hospital mortality during the first 5 days, primarily based on the severity of the injury, the GCS on admission, and the patient's age. These variables continue to demonstrate an excellent predictive ability up to 20 days after admission, a period of care that accounts for over 95% of severe TBI patients. Past 20 days of care, other factors appear to be the primary drivers of in-hospital mortality, indicating a potential window of opportunity for improving outcomes.

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