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  • 1.
    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.

  • 2.
    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.

  • 3.
    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.

  • 4.
    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.

  • 5.
    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.

  • 6.
    Darvish, Bijan
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital Solna, Stockholm, Sweden.
    Dahlgren, G.
    Department of Anesthesia and Intensive Care, Capio St Görans Hospital, Stockholm, Sweden.
    Irestedt, L.
    Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital Solna, Stockholm, Sweden.
    Magnuson, A.
    Möller, Claes
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Swedish Institute of Disability Research, Örebro University, Örebro, Sweden.
    Gupta, Anil
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital Solna, Stockholm, Sweden.
    Auditory function following post-dural puncture headache treated with epidural blood patch: a long-term follow-up2015In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 59, no 10, p. 1340-1354Article in journal (Refereed)
    Abstract [en]

    Background: Epidural analgesia is commonly used for pain management during labor. Sometimes, accidental dural puncture (ADP) occurs causing severely debilitating headache, which may be associated with transient hearing loss. We investigated if auditory function may be impaired several years after ADP treated with epidural blood patch (EBP).

    Methods: Sixty women (ADP group) without documented hearing disability, who received EBP following ADP during labor between the years 2005-2011 were investigated in 2013 for auditory function using the following tests: otoscopic examination, tympanometry, pure tone audiometry, and transient-evoked otoacoustic emissions. Additionally, they responded to a questionnaire, the Speech, Spatial and Qualities (SSQ) of hearing, concerning perceived hearing impairment. The results were compared to a control group of 20 healthy, non-pregnant women in the same age group.

    Results: The audiometric test battery was performed 5.2 (1.9)years after delivery. No significant differences were found between the ADP and the control groups in tympanometry or otoacoustic emissions. Pure tone audiometry revealed a significant but small (<5dB) difference between the ADP and control groups (P<0.05). The ability to hear speech in noise as measured by SSQ was significantly reduced in the ADP group compared to the control group (P<0.05).

    Conclusions: A minor hearing loss was detected in the ADP group compared to the control group in pure tone audiometry in some women and during speech-in-noise component several years after accidental dural puncture treated with an epidural blood patch. This small residual hearing loss has minor clinical significance.

  • 7.
    Darvish, Bijan
    et al.
    Karolinska University Hospital Solna, Stockholm, Sweden.
    Dahlgren, Gunnar
    Capio St Görans Hospital, Stockholm, Sweden.
    Irestedt, Lars
    Karolinska University Hospital, Solna, Sweden.
    Magnuson, Anders
    Örebro university, Örebro, Sweden.
    Möller, Claes
    School Medicine & Health Sci, Örebro University, Örebro, Sweden.
    Gupta, Anil
    Karolinska University Hospital Solna, Stockholm, Sweden.
    Auditory function following post dural puncture headache treated with epidural blood patch A long-term follow-up of parturients2015In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 59, p. 24-25Article in journal (Other academic)
  • 8.
    Darvish, Bijan
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Dept Anesthesia & Intens Care, Sch Hlth & Med Sci, Örebro Univ Hosp, Örebro, Sweden.
    Gupta, Anil
    Dept Anesthesia & Intens Care, Sch Hlth & Med Sci, Örebro Univ Hosp, Örebro, Sweden; Dept Med & Hlth Sci, Div Anaesthesia, Linköping Univ, Linköping, Sweden..
    Alahuhta, S.
    Dept Anesthesiol, Univ Oulu, Oulu, Finland.
    Dahl, V.
    Asker & Baerum Hosp, Rud, Norway.
    Helbo-Hansen, S.
    Dept Anesthesiol & Intens Care Med, Odense Univ Hosp, Odense C, Denmark.
    Thorsteinsson, A.
    Dept Anesthesiol & Intens Care Med, Landspitali Univ Hosp, Reykjavik, Iceland.
    Irestedt, L.
    Dept Anesthesiol & Intens Care, Karolinska Univ Hospital, Stockholm, Sweden.
    Dahlgren, G.
    Dept Anesthesiol & Intens Care, Karolinska Univ Hospital, Stockholm, Sweden.
    Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey2011In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 55, no 1, p. 46-53Article in journal (Refereed)
    Abstract [en]

    Background: A major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post-dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries.

    Methods: A postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n=153) with questions relating to the year 2008.

    Results: The overall response rate was 93%. About 32% (22-47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n approximate to 900). Epidural blood patch (EBP) was performed in 86% (n approximate to 780) of the parturients. The most common time interval from diagnosis to performing EBP was 24-48 h. The success rate for EBP was > 75% in 67% (62-79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non-obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia.

    Conclusion: We found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non-obstetric population.

  • 9.
    de Leon, A.
    et al.
    Örebro University, School of Health and Medical Sciences. Örebro University Hospital, Örebro, Sweden.
    Thörn, Sven-Egron
    Örebro University, School of Health and Medical Sciences. Örebro University Hospital, Örebro, Sweden.
    Ottosson, J.
    Örebro University Hospital, Örebro, Sweden.
    Wattwil, Magnus
    Örebro University, School of Health and Medical Sciences. Örebro University Hospital, Örebro, Sweden.
    Body positions and esophageal sphincter pressures in obese patients during anesthesia2010In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 54, no 4, p. 458-463Article in journal (Refereed)
    Abstract [en]

    Background: The lower esophageal sphincter (LES) and the upper esophageal sphincter (UES) play a central role in preventing regurgitation and aspiration. The aim of the present study was to evaluate the UES, LES and barrier pressures (BP) in obese patients before and during anesthesia in different body positions.

    Methods: Using high-resolution solid-state manometry, we studied 17 patients (27-63 years) with a BMI>or=35 kg/m(2) who were undergoing a laparoscopic bariatric surgery before and after anesthesia induction. Before anesthesia, the subjects were placed in the supine position, in the reverse Trendelenburg position (+20 degrees) and in the Trendelenburg position (-20 degrees). Thereafter, anesthesia was induced with remifentanil and propofol and maintained with remifentanil and sevoflurane, and the recordings in the different positions were repeated.

    Results: Before anesthesia, there were no differences in UES pressure in the different positions but compared with the other positions, it increased during the reverse Trendelenburg during anesthesia. LES pressure decreased in all body positions during anesthesia. The LES pressure increased during the Trendelenburg position before but not during anesthesia. The BP remained positive in all body positions both before and during anesthesia.

    Conclusion: LES pressure increased during the Trendelenburg position before anesthesia. This effect was abolished during anesthesia. LES and BPs decreased during anesthesia but remained positive in all patients regardless of the body position.

  • 10.
    de Leon, Alex
    et al.
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Lundin, Stefan
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Stenqvist, Ola
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Esophageal multi-level tip manometry in morbidly obese patients during a PEEP step2017In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, no 8, p. 1028-1028Article in journal (Other academic)
    Abstract [en]

    Background: Esophageal pressure, a surrogate for pleural pressure, is used to determine transpulmonary pressure and to set appropriate PEEP levels. There is no consensus on the representativity of esophageal pressure for pleural pressure and how to position and inflate the catheter balloon. The aim of this retrospective study1 was to analyze esophageal pressure using multi-level tip manometry (no balloon).

    Methods: An esophageal catheter with 12 radially directed tip mano meters at 35 levels one centimeter apart, detecting pressure from pharynx to stomach was placed in 17 patients (BMI >35 kg/m2). Pressure was analyzed integrating measurements from five manometer levels at mid- and lower esophageal level and for all levels between the upper and lower esophageal sphincters at PEEP 0 cmH2O (ZEEP) and after increasing PEEP to 10 cmH2O.

    Results: End-expiratory esophageal pressure (PESEE) was 10–12 cmH2O at ZEEP and increased minimally and transiently in whole and mid esophagus when PEEP was increased. Lower esophageal pressure increased more, but started to recede after approximately 20 breaths.

    Conclusions: End-expiratory pressure is positive, 10–12 cmH2O at all esophageal levels at FRC in contrast to absolute pleural pressure, which according to established knowledge is negative. There was only a marginal, transient increase in PESEE in response to PEEP. The change in end-expiratory trans-pulmonary and respiratory system pressures in response to a PEEP increase is therefore equal, and lung elastance can be calculated as the chan ge in PEEP divided by the change in end-expiratory lung volume.

  • 11.
    de Leon, Alex
    et al.
    Örebro University Hospital, Örebro, Sweden; School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Thörn, Sven-Egron
    Örebro University, School of Health and Medical Sciences. Örebro University Hospital, Örebro, Sweden.
    Raoof, M.
    Dept Surg, Lindesberg Hosp, Lindesberg, Sweden.
    Ottosson, J.
    Dept Surg, Lindesberg Hosp, Lindesberg, Sweden; Örebro University Hospital, Örebro, Sweden.
    Wattwil, Magnus
    Örebro University, School of Health and Medical Sciences.
    Effects of different respiratory maneuvers on esophageal sphincters in obese patients before and during anesthesia2010In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 54, no 10, p. 1204-1209Article in journal (Refereed)
    Abstract [en]

    Background: Data on esophageal sphincters in obese individuals during anesthesia are sparse. The aim of the present study was to evaluate the effects of different respiratory maneuvers on the pressures in the esophagus and esophageal sphincters before and during anesthesia in obese patients.

    Methods: Seventeen patients, aged 28-68 years, with a BMI >= 35 kg/m2, who were undergoing a laparoscopic gastric by-pass surgery, were studied, and pressures from the hypopharynx to the stomach were recorded using high-resolution solid-state manometry. Before anesthesia, recordings were performed during normal spontaneous breathing, Valsalva and forced inspiration. The effects of anesthesia induction with remifentanil and propofol were evaluated, and positive end-expiratory pressure (PEEP) 10 cmH(2)O was applied during anesthesia.

    Results: During spontaneous breathing, the lower esophageal sphincter (LES) pressure was significantly lower during end-expiration compared with end-inspiration (28.5 +/- 7.7 vs. 35.4 +/- 10.8 mmHg, P < 0.01), but barrier pressure (BrP) and intra-gastric pressure (IGP) were unchanged. LES, BrP (P < 0.05) and IGP (P < 0.01) decreased significantly during anesthesia. BrP remained positive in all patients. IGP increased during Valsalva (P < 0.01) but was unaffected by PEEP. Esophageal pressures were positive during both spontaneous breathing and mechanical ventilation. Esophageal pressures increased during PEEP from 9.4 +/- 3.8 to 11.3 +/- 3.3 mmHg (P < 0.01).

    Conclusion: During spontaneous breathing, the LES pressure was the lowest during end-expiration but there were no differences in BrP and IGP. LES, BrP and IGP decreased during anesthesia but BrP remained positive in all patients. During the application of PEEP, esophageal pressures increased and this may have a protective effect against regurgitation.

  • 12.
    Feldheiser, A.
    et al.
    Department of Anesthesiology and Intensive Care Medicine Campus Charité, Mitte and Campus Virchow-Klinikum Charité, University Medicine, Berlin, Germany.
    Aziz, O.
    St. Mark’s Hospital, Harrow, UK.
    Baldini, G.
    Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal QC, Canada.
    Cox, B. P. B. W.
    Department of Anesthesiology and Pain Therapy, University Hospital Maastricht (azM), Maastricht, The Netherlands.
    Fearon, K. C. H.
    Clinical Surgery, The Royal Infirmary, University of Edinburgh, Edinburgh, UK.
    Feldman, L. S.
    Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal QC, Canada.
    Gan, T. J.
    Department of Anesthesiology, Duke University Medical Center, Durham NC, USA.
    Kennedy, R. H.
    St. Mark’s Imperial College, London, UK; St. Mark’s Hospital, Harrow, UK.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Surgery.
    Lobo, D. N.
    Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, UK.
    Miller, T.
    Department of Anesthesiology, Duke University Medical Center, Durham NC, USA.
    Radtke, F. F.
    Department of Anesthesiology and Intensive Care Medicine Campus Charité, Mitte and Campus Virchow-Klinikum Charité, University Medicine, Berlin, Germany.
    Ruiz Garces, T.
    Anestesiologa y Reanimacin, Hospital Clinico Lozano Blesa, Universidad de Zaragoza, Zaragoza, Spain.
    Schricker, T.
    Department of Anesthesia, McGill University Health Centre, Royal Victoria Hospital, Montreal QC, Canada.
    Scott, M. J.
    Royal Surrey County Hospital NHS Foundation Trust, University of Surrey, Guildford, UK.
    Thacker, J. K.
    Department of Surgery, Duke University Medical Center, Durham NC, USA.
    Ytrebø, L. M.
    Department of Anaesthesiology, University Hospital of North Norway, Tromsø, Norway.
    Carli, F.
    Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal QC, Canada.
    Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice2016In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 60, no 3, p. 289-334Article, review/survey (Refereed)
    Abstract [en]

    Background: The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme.

    Methods: Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English-language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature.

    Results: This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations.

    Conclusions: Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ((R))) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi-institutional prospective and adequately powered randomized trials.

  • 13.
    Gannedahl, Per E.
    et al.
    Departments of Anaesthesiology and Intensive Care, Karolinska Hospital and Institute, Stockholm, Sweden.
    Edner, Magnus M.
    Departments of Cardiology, Karolinska Hospital and Institute, Stockholm, Sweden.
    Lindahl, Sten
    Departments of Anaesthesiology and Intensive Care, Karolinska Hospital and Institute, Stockholm, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Departments of Anaesthesiology and Intensive Care, Karolinska Hospital and Institute, Stockholm, Sweden.
    Minimal influence of anaesthesia and abdominal surgery on computerized vectorcardiography recordings1995In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 39, no 1, p. 71-78Article in journal (Refereed)
    Abstract [en]

    Myocardial infarction still represents a major cause of morbidity and mortality following surgical procedures. Continuous computerized on‐line vector‐ECG has previously been shown to be useful in the detection of myocardial ischaemia, in acute myocardial infarction and unstable angina pectoris and for ischaemia monitoring after PTCA procedures. This method was presently tested for the possible influence of anaesthesia and surgery during cholecystectomy under general anaesthesia (n = 9), and during inguinal hernia repairs using a spinal block (n = 5). The patients had no history, symptoms or signs of ischaemic heart disease. Analyses of vectorcardiographic changes were made in relation to predefined standardized anaesthetic and surgical procedures, all of which potentially could influence the vector‐ECG. Three vectorcardiographic trend parameters were studied: QRS‐vector difference, ST‐vector magnitude and ST‐change vector magnitude. The overall vectorcardiographic changes were minimal and smaller than vectorcardiographic changes previously reported during myocardial ischaemia and infarction. Since anaesthetic and surgical procedures per se had only minor effects on the vector ECG recordings, it is concluded that continuous computerized on‐line vectorcardiography will not be skewed by these procedures. Hence, vectorcardiography has the potential of becoming a new monitor for the detection of perioperative myocardial ischaemia. 

  • 14.
    Gannerdahl, Per E.
    et al.
    Dept. Anaesthiol. and Intensive Care, Karolinska Institute and Hospital, Stockholm, Sweden.
    Odeberg, S.
    Dept. Anaesthiol. and Intensive Care, Huddinge Hospital, Stockholm, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska Institute and Hospital, Stockholm, Sweden.
    Sollevi, Alf
    Dept. Anaesthiol. and Intensive Care, Karolinska Institute and Hospital, Stockholm, Sweden.
    Vectorcardiographic changes during laparoscopiccholecystectomy may mimic signs of myocardial ischaemia1997In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 41, no 9, p. 1187-1192Article in journal (Refereed)
    Abstract [en]

    Laparoscopic surgery involves the use of intra-abdominal carbon dioxide insufflation (pneumoperitoneum). The increased intra-abdominal pressure causes marked haemodynamic changes, which may influence electrocardiographic monitoring. The aim of the present study was to elucidate the influence of pneumoperitoneum on vectorcardiographic recordings.

    METHODS:

    Vectorcardiographic changes (QRS vector difference = QRS-VD, QRS loop area, QRS magnitude, ST vector magnitude, spatial ST vector change) were recorded continuously applying computerized vectorcardiography in 12 anaesthetised cardiovascularly healthy patients, scheduled for laparoscopic cholecystectomy. Measurements were made before and during pneumoperitoneum in three different body positions (supine, Trendelenburg and reversed Trendelenburg), also employing transesophageal echocardiography and invasive blood pressure monitoring.

    RESULTS:

    Pneumoperitoneum significantly increased QRS-VD, in parallel with an enlargement in loop area and magnitude. The magnitude was significantly increased in the transversal and frontal planes and there was a tendency to increase the magnitude in the sagittal plane. The increase in QRS-VD reached levels previously associated with the development of myocardial ischaemia in patients with coronary artery disease. The ST-variables were not changed by the pneumoperitoneum. The positional changes also influenced QRS-VD significantly.

    CONCLUSIONS:

    When computerized vectorcardiography is used for ischaemia monitoring during pneumoperitoneum, the ST-variables seem reliable. However, vectorcardiographicQRS-changes should be interpreted with caution, as the QRS alterations found during pneumoperitoneum mimic the changes seen during myocardial ischaemia.

  • 15.
    Gustafsson, U O
    et al.
    Department of Clinical Science, Intervention and Technology, Centre for Gastrointestinal Disease, Ersta Hospital, Karolinska Institutet, Stockholm.
    Nygren, J
    Department of Clinical Science, Intervention and Technology, Centre for Gastrointestinal Disease, Ersta Hospital, Karolinska Institutet, Stockholm.
    Thorell, A
    Department of Clinical Science, Intervention and Technology, Centre for Gastrointestinal Disease, Ersta Hospital, Karolinska Institutet, Stockholm.
    Soop, M
    Department of Clinical Science, Intervention and Technology, Centre for Gastrointestinal Disease, Ersta Hospital, Karolinska Institutet, Stockholm.
    Hellström, P M
    Department of Medicine, Gastroenterology Unit, Karolinska University Hospital, Solna, Stockholm.
    Ljungqvist, Olle
    Department of Clinical Science, Intervention and Technology, Centre for Gastrointestinal Disease, Ersta Hospital, Karolinska Institutet, Stockholm.
    Hagström-Toft, E
    Department of Clinical Science, Intervention and Technology, Centre for Gastrointestinal Disease, Ersta Hospital, Karolinska Institutet, Stockholm; Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm.
    Pre-operative carbohydrate loading may be used in type 2 diabetes patients2008In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 52, no 7, p. 946-51Article in journal (Refereed)
    Abstract [en]

    Background: Post-operative insulin resistance and hyperglycaemia are associated with an impaired outcome after surgery. Pre-operative oral carbohydrate loading (CHO) reduces post-operative insulin resistance with a reduced risk of hyperglycaemia during post-operative nutrition. Insulin-resistant diabetic patients have not been given CHO because the effects on pre-operative glycaemia and gastric emptying are unknown.

    Methods: Twenty-five patients (45-73 years) with type 2 diabetes [glycated haemoglobin (HbA1c) 6.2 +/- 0.2%, mean +/- SEM] and 10 healthy control subjects (45-72 years) were studied. A carbohydrate-rich drink (400 ml, 12.5%) was given with paracetamol 1.5 g for determination of gastric emptying.

    Results: Peak glucose was higher in diabetic patients than in healthy subjects (13.4 +/- 0.5 vs. 7.6 +/- 0.5 mM; P<0.01) and occurred later after intake (60 vs. 30 min; P<0.01). Glucose concentrations were back to baseline at 180 vs. 120 min in diabetic patients and healthy subjects, respectively (P<0.01). At 120 min, 10.9 +/- 0.7% and 13.3 +/- 1.2% of paracetamol remained in the stomach in diabetic patients and healthy, subjects respectively. Gastric half-emptying time (T50) occurred at 49.8 +/- 2.2 min in diabetics and at 58.6 +/- 3.7 min in healthy subjects (P<0.05). Neither peak glucose, glucose at 180 min, gastric T50, nor retention at 120 min differed between insulin (HbA1c 6.8 +/- 0.7%)- and non-insulin-treated (HbA1c 5.6 +/- 0.4%) patients.

    Conclusions: Type 2 diabetic patients showed no signs of delayed gastric emptying, suggesting that a carbohydrate-rich drink may be safely administrated 180 min before anaesthesia without risk of hyperglycaemia or aspiration pre-operatively.

  • 16.
    Hannemann, P
    et al.
    Department of Surgery, University Hospital Maastricht; The Netherlands; NUTRIM Institute, Maastricht, The Netherlands.
    Lassen, K
    Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Tromsø, Norway .
    Hausel, J
    Centre for Surgical Sciences, Karolinska Institutet and Center of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Nimmo, S
    Department of Anaesthesiology, School of Clinical Sciences and Community Health, The University of Edinburgh, Edinburgh, UK.
    Ljungqvist, Olle
    Centre for Surgical Sciences, Karolinska Institutet and Center of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Nygren, J
    Centre for Surgical Sciences, Karolinska Institutet and Center of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Soop, M
    Centre for Surgical Sciences, Karolinska Institutet and Center of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Fearon, K
    Department of Clinical and Surgical Sciences (Surgery), School of Clinical Sciences and Community Health, The University of Edinburgh, Edinburgh, UK.
    Andersen, J
    Department of Surgical Gastroenterology, Hvidovre, Denmark .
    Revhaug, A
    Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Tromsø, Norway.
    von Meyenfeldt, M F
    Department of Surgery, University Hospital Maastricht; The Netherlands; NUTRIM Institute, Maastricht, The Netherlands.
    Dejong, C H C
    Department of Surgery, University Hospital Maastricht; The Netherlands; NUTRIM Institute, Maastricht, The Netherlands.
    Spies, C
    Department of Anaesthesiology and Intensive Care Medicine, Campus Charite´ Mitte and Campus Virchow-Klinikum, Charite´- University Medicine Berlin, Berlin, Germany.
    Patterns in current anaesthesiological peri-operative practice for colonic resections: a survey in five northern-European countries2006In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 50, no 9, p. 1152-60Article in journal (Refereed)
    Abstract [en]

    Background: For colorectal surgery, evidence suggests that optimal management includes: no pre-operative fasting, a thoracic epidural analgesia continued for 2 days post-operatively, and avoidance of fluid overload. In addition, no long-acting benzodiazepines on the day of surgery and use of short-acting anaesthetic medication may be beneficial. We examined whether these strategies have been adopted in five northern-European countries.

    Methods: In 2003, a questionnaire concerning peri-operative anaesthetic routines in elective, open colonic cancer resection was sent to the chief anaesthesiologist in 258 digestive surgical centres in Scotland, the Netherlands, Denmark, Sweden and Norway.

    Results: The response rate was 74% (n = 191). Although periods of pre-operative fasting up to 48 h were reported, most (> 85%) responders in all countries declared to adhere to guidelines for pre-operative fasting and oral clear liquids were permitted until 2-3 h before anaesthesia. Solid food was permitted up to 6-8 h prior to anaesthesia. In all countries more than 85% of the responders indicated that epidural anaesthesia was routinely used. Except for Denmark, long-acting benzodiazepines were still widely used. Short-acting anaesthetics were used in all countries except Scotland where isoflurane is the anaesthetic of choice. With the exception of Denmark, intravenous fluids were used unrestrictedly.

    Conclusion: In northern Europe, most anaesthesiologists adhere to evidence-based optimal management strategies on pre-operative fasting, thoracic epidurals and short-acting anaesthetics. However, premedication with longer-acting agents is still common. Avoidance of fluid overload has not yet found its way into daily practice. This may leave patients undergoing elective colonic surgery at risk of oversedation and excessive fluid administration with potential adverse effects on surgical outcome.

  • 17.
    Idvall, Ewa
    et al.
    Kalmar County Council, Kalmar, Sweden; 2 Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Berg, Katarina
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Unosson, Mitra
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Brudin, Lars
    Kalmar County Council, Kalmar, Sweden; 2 Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Nilsson, Ulrica G.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Anesthesia and Intensive Care,University Hospital, Örebro,Örebro, Sweden; Centre for Health Care Sciences, Örebro University Hospital, Örebro, Sweden.
    Assessment of recovery after day surgery using a modified version of quality of recovery-402009In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 53, no 5, p. 673-677Article in journal (Refereed)
    Abstract [en]

    A recent nationwide survey in Sweden found that day surgery accounts for 43% of all in-hospital procedures.1 Orthopaedic, general, and gynaecological procedures were the most common. About 40% of the day surgery units followed up with telephone calls within 1–2 days, and found pain to be the most common complaint. Quality of recovery had not been systematically evaluated with instruments tested for validity and reliability, and follow-ups beyond 2 days post-operative were not found.

    Quality of Recovery-40 (QoR-40)2,3 is a 40-item instrument to assess the quality of post-operative recovery. The instrument is divided into five dimensions; emotional state, physical comfort, psychological support, physical independence, and pain. These dimensions represent aspects of good-quality recovery after anaesthesia and surgery. QoR-40 has been used for patients undergoing different surgical procedures and tests for validity and reliability yielded initial support for the instrument. Myles et al.3 concluded that QoR-40 would be a useful outcome measure to assess the impact of changes in health care delivery on quality of care, but anaesthesia and surgery studies have rarely used this approach. Although QoR-40 has not been used exclusively for day surgery patients, some day surgery patients were included when the instrument was developed.2,3 Another study on day surgery patients4 used eight items from QoR-40 relevant to that study. In a systematic review of post-operative recovery outcomes measurements after ambulatory surgery, the QoR-40 was the only instrument that fulfilled the criteria that were set up but was not specifically designed for day surgery and anaesthesia.5 Another systematic review from 2008 also advises to use the QoR-40 in future validation and application studies.6 Day surgery is increasing, and it is important to measure the quality of care and the impact of change. When using an instrument such as QoR-40, each item must be carefully considered for the purpose and context it will be used in, especially when it differs from the original context, both concerning cultural differences between countries and the type of surgical procedure used. Therefore, our study created and used a modified version of the QoR-40 to measure the quality of recovery in day surgery patients. The study aimed to test this modified version in a Swedish context for day surgery patients, to assess the quality of recovery on days 1, 7, and 14 post-operative.

  • 18.
    Jaensson, Maria
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Gupta, Anil
    Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Ulrica
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden; Centre of Health Care Sciences, Örebro University Hospital, Örebro, Sweden.
    Gender differences in risk factors for airway symptoms following tracheal intubation2012In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 56, no 10, p. 1306-1313Article in journal (Refereed)
    Abstract [en]

    Background: A common complaint after endotracheal intubation is sore throat and hoarseness. The aim of this study was to describe gender differences and independent risk factors in the development of post-operative sore throat and hoarseness after endotracheal intubation in adults.

    Methods: This prospective cross-sectional observational study was conducted at a university hospital in Sweden. A total of 495 patients were included (203 men and 292 women) and enrolled from a total of eight different surgical departments. Outcome variables were post-operative sore throat and hoarseness evaluated post-operatively in the post-anaesthesia care unit. A total of 31 variables were recorded which described the intubation process, intraoperative factors as well as the extubation process. Bivariate and multivariate analyses were performed.

    Results: The overall incidence of post-operative sore throat was 35% and hoarseness 59%. The results show different predictors for men and women in the development of airway symptoms. The main risk factor for developing sore throat in men was intubation by personnel with <?3 months' work experience. In women, it was endotracheal tube size 7.0 and multiple laryngoscopies during intubation. The main risk factors for hoarseness were cuff pressure for both men and women, and oesophageal temperature probe in women.

    Conclusion: Post-operative sore throat and hoarseness result from several factors, and the cause of these symptoms are multifactorial and differs by gender. Identification of these factors pre-operatively may increase awareness among anaesthesia personnel and possibly reduce the incidence of these minor but distressing symptoms.

  • 19.
    Jaensson, Maria
    et al.
    Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Olowsson, Lena L.
    Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    NIlsson, Ulrica G.
    Örebro University, School of Health and Medical Sciences. Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden; Centre for Health Care Sciences, Örebro University Hospital, Örebro, Sweden.
    Endotracheal tube size and sore throat following surgery: a randomized-controlled study2010In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 54, no 2, p. 147-153Article in journal (Refereed)
    Abstract [en]

    Background: Sore throat following endotracheal intubation is a common problem following surgery and one of the factors that affects the quality of recovery. This study was carried out with the primary aim of assessing whether the size of the endotracheal tube (ETT) affects the risk of sore throat in women following anaesthesia.

    Methods: One hundred healthy adult women undergoing elective surgery were randomly allocated to oral intubation with either ETT size 6.0 or 7.0. Anaesthesia was based on either inhalation or total intravenous anaesthesia according to standardized routines. Pre- and post-operatively, sore throat and discomfort were assessed on a four-graded scale and for hoarseness on a binary scale (yes or no). Post-operatively, the assessments were performed after 1–2 and 24 h, and if there was discomfort at 24 h, a follow-up call was made at 72 and 96 h.

    Results: After 1–2 h post-operatively, there were a higher proportion of patients with sore throat in ETT 7.0 vs. ETT 6.0 (51.1% vs. 27.1%), P50.006. This difference between the groups was also evident, P50.002, when comparing changes between the pre- and the post-operative values. The severity of discomfort from sore throat was also higher in ETT 7.0 (38.8%) compared with ETT 6.0 (18.8%), P 50.02. No differences were found in the incidence of hoarseness between the groups. The remaining symptoms lasted up to 96 h post-operatively in 11%, irrespective of the tube size.

    Conclusion:Use of a smaller-sized ETT can alleviate sore throat and discomfort in women at the post-anaesthesia care unit.

  • 20.
    Kalman, Sigridur
    et al.
    Karolinska University Hospital, Huddinge, Sweden.
    Wiklund, Andreas
    Karolinska University Hospital, Solna, Sweden.
    Semenas, Egidijus
    Uppsala University Hospital, Uppsala, Sweden.
    Nilsson, Lena
    Uppsala University Hospital, Uppsala, Sweden.
    Brattström, Olof
    Uppsala University Hospital, Uppsala, Sweden.
    Björne, Hakan
    Uppsala University Hospital, Uppsala, Sweden.
    Bell, Max
    Uppsala University Hospital, Uppsala, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Bartha, Erzsebet
    Karolinska University Hospital, Huddinge, Sweden.
    Postoperative complications in high-risk surgical patients - predictors, risk factors, and outcomes following major surgery study (PROFS study NCT02626546): validation of three prediction models2017In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, no 8, p. 1056-1056Article in journal (Other academic)
    Abstract [en]

    Background: Postoperative complications increase the risk of death 2–3 years postoperatively. Prediction of complications can support clinical decisions. Before clinical use of any prediction model, validation is reasonable. We aimed to validatethree models: Revised Cardiac Risk Index (RCRI), ARISCAT and POSSUM.

    Methods: The PROF S-study was performed in four Swedish university hospitals. Patients werere cruited between 2015-11-01 and 2016-02-15. Inclusion criteria were adults, ASA classification ≥3, major/complex upper and lower gastrointestinal, urogenital or orthopedic surgery. Complications were screened on days 3, 7 and 10 by the postoperative morbidity survey (POMS). Only patients with grade≥2 (Clavien-Dindo classification) were accounted for. Study outcomes were cardiovascular (RCRI model) and pulmonary (ARISCAT model) complications, and a composite of the POMS domains (POSSUM model). Discrimination was evaluated by C-statistics (area under receiver operator characteristic curve; AUC ROC).

    Results: The number of patients included was 1089. Thirteen patients were excluded due to wrong inclusion, and another three were lost to follow-up. Presen ce of malignancy was 41%. Patient characteristics and outcomes are displayed in Table 1. The RCRI underestimated the risk for cardiovascular complications, and discrimination was low (AUC ROC 0.64; 95% CI 0.59–0.68). The prediction by the ARISCAT model was fair (AUC 0.72; CI 0.69–0.76). The POSSUM model had poor /fair discrimination (AUC 0.70; CI 0.67–0.73).

    Conclusions: The ARISCAT model predicted pulmonary complications with fair discrimina-tion and so could be used as decision support. Parameters with significant odds ratios of the RCRI and POSSU M models might be used as complements of clinical judgement.

  • 21. Kroigaard, M.
    et al.
    Garvey, L. H.
    Gillberg, L.
    Johansson, S. G. O.
    Mosbech, H.
    Florvaag, E.
    Harboe, T.
    Eriksson, L. I.
    Dahlgren, G.
    Seeman-Lodding, H.
    Takala, R.
    Wattwil, Magnus
    Örebro University, School of Health and Medical Sciences.
    Hirlekar, G.
    Dahlén, B.
    Guttormsen, A. B.
    Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up of anaphylaxis during anaesthesia2007In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 51, no 6, p. 655-670Article in journal (Refereed)
    Abstract [en]

    The present approach to the diagnosis, management and follow-up of anaphylaxis during anaesthesia varies in the Scandinavian countries. The main purpose of these Scandinavian Clinical Practice Guidelines is to increase the awareness about anaphylaxis during anaesthesia amongst anaesthesiologists. It is hoped that increased focus on the subject will lead to prompt diagnosis, rapid and correct treatment, and standardised management of patients with anaphylactic reactions during anaesthesia across Scandinavia. The recommendations are based on the best available evidence in the literature, which, owing to the rare and unforeseeable nature of anaphylaxis, mainly includes case series and expert opinion (grade of evidence IV and V). These guidelines include an overview of the epidemiology of anaphylactic reactions during anaesthesia. A treatment algorithm is suggested, with emphasis on the incremental titration of adrenaline (epinephrine) and fluid therapy as first-line treatment. Recommendations for primary and secondary follow-up are given, bearing in mind that there are variations in geography and resources in the different countries. A list of National Centres from which anaesthesiologists can seek advice concerning follow-up procedures is provided. In addition, an algorithm is included with advice on how to manage patients with previous suspected anaphylaxis during anaesthesia. Lastly, Appendix 2 provides an overview of the incidence, mechanisms and possibilities for follow-up for some common drug groups.

  • 22.
    Laake, J. H.
    et al.
    Department of Anaesthesiology, Division of Critical Care and Emergencies, Oslo University Hospital, Oslo, Norway.
    Tønnessen, T. I.
    Department of Anaesthesiology, Division of Critical Care and Emergencies, Oslo University Hospital, Oslo, Norway.
    Chew, M. S.
    Department of Anaesthesia and Intensive Care, Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Lipcsey, M.
    Hedenstierna laboratory, Department of Surgical Sciences, Anaesthesiology and Intensive Care, CIRRUS, Uppsala University Hospital, Uppsala, Sweden.
    Hjelmqvist, Hans
    Örebro University, School of Medical Sciences. Department of Anaesthesia and Intensive Care, School of Medical Sciences, Örebro University, Örebro, Sweden; University Hospital, Örebro, Sweden.
    Wilkman, E.
    Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
    Pettilä, V.
    Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
    Hoffmann-Petersen, J.
    Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.
    Møller, M. H.
    Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
    the Board of the Scandinavian Society of Anaesthesiology Intensive Care Medicine, (SSAI)
    The SSAI fully supports the suspension of hydroxyethyl-starch solutions commissioned by the European Medicines Agency2018In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 62, no 6, p. 874-875Article in journal (Refereed)
  • 23.
    Ljungqvist, Olle
    et al.
    Örebro University Hospital. Department of Surgery, Karolinska Institutet, Stockholm, Sweden; Örebro University Hospital, Örebro, Sweden.
    Rasmussen, L S
    Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
    Recovery after anaesthesia and surgery2014In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 58, no 6, p. 639-641Article in journal (Refereed)
  • 24.
    Nilsson, Lena
    et al.
    Division of Drug Research, Anesthesiology and Intensive Care, Department of Medical and Health Sciences, Linköpings university, Linköping, Sweden; Department of Anesthesia and Intensive Care, University Hospital, Linköping, Sweden.
    Pihl, A.
    Department of Anesthesia and Intensive Care, Vrinnevi Hospital, Norrköping, Sweden; Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Tågsjö, M
    Department of Anesthesia and Intensive Care, Vrinnevi Hospital, Norrköping, Sweden; Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Ericsson, Elisabeth
    Department of Anesthesia and Intensive Care, University Hospital, Linköping, Sweden; Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Adverse events are common on the intensive care unit: results from a structured record review2012In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 56, no 8, p. 959-965Article in journal (Refereed)
    Abstract [en]

    Background: Intensive care is advanced and highly technical, and it is essential that, despite this, patient care remains safe and of high quality. Adverse events (AEs) are supposed to be reported to internal quality control systems by health-care providers, but many are never reported. Patients on the intensive care unit (ICU) are at special risk for AEs. Our aim was to identify the incidence and characteristics of AEs in patients who died on the ICUduring a 2-year period.

    Methods: A structured record review according to the Global Trigger Tool (GTT) was used to review charts from patients cared for at the ICU of a middle-sized Swedish hospital during 2007 and 2008 and who died during or immediately after ICU care. All identified AEs were scored according to severity and preventability.

    Results: We reviewed 128 records, and 41 different AEs were identified in 25 patients (19.5%). Health care-associated infections, hypoglycaemia, pressure sores and procedural complications were the most common harmful events. Twenty two (54%) of the AEs were classified as being avoidable. Two of the 41AEs were reported as complications according to the Swedish Intensive Care Registry, and one AE had been reported in the internal AE-reporting system.

    Conclusion: Almost one fifth of the patients who died on the ICU were subjected to harmful events. GTT has the advantage of identifying more patient injuries caused by AEs than the traditional AE-reporting systems used on many ICUs.

  • 25.
    NIlsson, Ulrica
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Medicine and Care, Division of Nursing Science, Faculty of Health Science, Linköping,Sweden; Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro,Sweden.
    Rawal, Narinder
    Department of Clinical Medicine, Division of Anaesthesiology, Örebro University Hospital, Örebro, Sweden.
    Enqvist, Björn
    Department of Oro-Maxillary Surgery, Eastman Institute, Stockholm, Sweden.
    Unosson, Mitra
    Department of Medicine and Care, Division of Nursing Science, Faculty of Health Science, Linköping, Sweden.
    Analgesia following music and therapeutic suggestions in the PACU in ambulatory surgery: a randomized controlled trial2003In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 47, no 3, p. 278-283Article in journal (Refereed)
    Abstract [en]

    Background: This study was designed to determine whether music (M), or music in combination with therapeutic suggestions (M/TS) could improve the postoperative recovery in the immediate post-operative in day care surgery.

    Method: One-hundred and eighty two unpremedicated patients who underwent varicose vein or open inguinal hernia repair surgery under general anesthesia were randomly assigned to

    a) listening to music, b) music in combination with therapeutic suggestions or c) blank tape in the immediate post-operative period. The surgical technique, anesthesia and postoperative analgesia were standardised. Analgesia, the total requirement of morphine, nausea, fatigue, well-being, anxiety, headache, urinary problems, heart rate and oxygen saturation were studied as outcome variables.

    Results: Pain intensity (VAS) was significantly lower (P=0.002) in the M (2.1) and the M/TS (1.9) group compared with the control group (2.9) and a higher oxygen saturation in M (99.2%) and M/TS (99.2%) group compared with the control (98.0%), P< 0.001, were  found. No differences were noted in the other outcome variables.

    Conclusion: This controlled study has demonstrated that music with or without therapeutic suggestions in the early postoperative period has a beneficial effect on patients’ experience of analgesia. Although statistically significant the improvement in analgesia is modest in this group of patients with low overall pain levels.

     

  • 26.
    Nilsson, Ulrica
    et al.
    Department of Medicine and Care, Division of Nursing Science, Faculty of Health Science, Linköping,Sweden; Department of Anaesthesiology and Intensive Care, Örebro, Sweden; Centre for Caring Science, Örebro Medical Centre Hospital, Örebro, Sweden.
    Rawal, Narinder
    Department of Anaesthesiology and Intensive Care, Örebro, Sweden.
    Uneståhl, Lars Erik
    Scandinavian International University, Örebro,Sweden.
    Zetterberg, Carina
    Department of Obstetrics & Gynaecology, Örebro Medical Centre Hospital, Örebro, Sweden.
    Unosson, Mitra
    Department of Medicine and Care, Division of Nursing Science, Faculty of Health Science, Linköping, Sweden.
    Improved recovery after music and therapeutic suggestions during general anaesthesia: a double-blind randomised controlled trial2001In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 45, no 7, p. 812-817Article in journal (Refereed)
    Abstract [en]

    Purpose: This study was designed to determine whether music or music in combination with therapeutic suggestions in the intra-operative period under general anaesthesia could improve the recovery of hysterectomy patients.

    Methods: In a double blind randomised clinical investigation ninety patients who underwent hysterectomy under general anaesthesia were intra-operatively exposed to, music, music in combination with therapeutic suggestion or operation room sounds. The anaesthesia was standardised. Postoperative analgesia was provided by a patient controlled analgesia (PCA). The pain scores were recorded by visual analogue scale. Nausea, emesis, bowel function, fatigue , well-being and duration of hospital stay were studied as outcome variables.

    Results: The day of surgery patients exposed to music in combination with therapeutic suggestions required less rescue analgesic compared with the controls. Patients in the music group experienced more effective analgesia the first day after surgery and could be mobilised earlier after the operation. At discharge from the hospital patients in the music and music combined with therapeutic suggestion were less fatigued compared to the controls. No differences were noted in nausea, emesis, bowel function, well-being or length of hospital stay between the groups.

    Conclusion: This double blind study has demonstrated that intra-operative music and music in combination with therapeutic suggestions may have some beneficial effects on postoperative recovery after hysterectomy. Further controlled studies are necessary to confirm our results.

  • 27.
    Odeberg, S.
    et al.
    Departments of Anaesthesiology and Intensive Care, Karolinska Institute, Huddinge Hospital, Stockholm, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska Institute, Karolinska Hospital, Stockholm, Sweden.
    Svenberg, Torgny E.
    Department of Surgery, Karolinska Institute, Karolinska Hospital, Stockholm, Sweden.
    Gannedahl, Per E.
    Departments of Anaesthesiology and Intensive Care, Karolinska Institute, Karoiinska Hospital, Stockholm, Sweden.
    Bäckdahl, Magnus
    Department of Surgery, Karolinska Institute, Karolinska Hospital, Stockholm, Sweden.
    von Rosen, Anette
    Department of Surgery, Karolinska Institute, Karolinska Hospital, Stockholm, Sweden.
    Sollevi, Alf
    Departments of Anaesthesiology and Intensive Care, Karolinska Institute, Karoiinska Hospital, Stockholm, Sweden.
    Hemodynamiceffects of pneumoperitoneum and the influence of posture during anaesthesia forlaparoscopic surgery1994In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 38, no 3, p. 276-283Article in journal (Refereed)
    Abstract [en]

    The laparoscopic operating technique is being applied increasingly to a variety of intra‐abdominal operations. Intra–abdominal gas insufflation, i.e. pneumoperitoneum (PP), is then used to allow surgical access. The haemodynamic effects of PP in combination with different body positions have not been fully examined. Eleven patients without signs of cardiopulmonary disease were studied before and during laparoscopic cholecystectomy under propofol–fentanyl anaesthesia with controlled ventilation. Swan‐Ganz and radial arterial catheterization were used to determine haemodynamic data in the horizontal position, with a 15–20° head–down tilt and a 15–20° head–up tilt. The measurements were repeated after insufflation of carbon dioxide to an intraabdominal pressure of 11–13 mmHg, as well as during surgery. The ventricular filling pressures of the heart were strictly dependent on body position. PP in the horizontal position increased pulmonary capillary wedge pressure by 32% (P < 0.01), central venous pressure by 58% (P < 0.01), and mean arterial pressure by 39% (P < 0.01). When PP was combined with a head–down tilt, there was a further increase in filling pressures by approximately 40% (P < 0.01), while the reduction in filling pressures during the head–up tilt was counteracted by PP. During PP with a head–up tilt, the filling pressures did not differ from those in the horizontal position without PP. CI showed a certain dependency on filling pressures. It is concluded that PP causes signs of elevated preload and afterload. The combination of PP and a head–up tilt is associated only with signs of an elevated afterload. It is suggested that the haemodynamic response to PP, especially in combination with a head–down tilt, may be hazardous to patients with compromised heart function.

  • 28.
    Pellrud, Richard
    et al.
    Department of Anesthesia and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anesthesia and Intensive Care.
    Pressure measurement in the upper esophagus during cricoid pressure: A high-resolution solid-state manometry study2018In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 62, no 10, p. 1396-1402Article in journal (Refereed)
    Abstract [en]

    Background: The use of cricoid pressure is controversial, and its ability to occlude the esophagus has been questioned. In this study, high-resolution solid-state manometry was used to analyze pressure changes in the upper esophagus from cricoid pressure during modified rapid sequence induction. This is a secondary analysis of data from a previous study.

    Methods: Seventeen healthy volunteers participated in a double-blind, randomized, placebo-controlled, cross-over study with primary aim to compare differences in the barrier pressure on the lower esophageal sphincter during rapid sequence induction with or without alfentanil. Standardized cricoid pressure of 30 N was applied 2 minutes after propolipid injection and held for 15 seconds and pressures in the esophagus were measured.

    Results: Cricoid pressure resulted in a pressure increase of 127 +/- 98 mmHg (95% CI: 73-182) (placebo) and 123 +/- 74 mmHg (95% CI: 84-162) (alfentanil) at the level of the upper esophageal sphincter (UES), compared to baseline.

    The pressure difference around the UES compared to the proximal esophagus during cricoid pressure application was 165 +/- 100 mmHg (placebo) and 159 +/- 87 mmHg (alfentanil) (mean +/- 1 SD).

    Conclusion: This study using high-resolution solid-state manometry under clinically relevant conditions shows that 30 N cricoid pressure generates high pressure in the area of the UES, far exceeding the levels previously considered necessary to prevent regurgitation. Additional studies are needed to clarify the effectiveness of cricoid pressure in preventing passive regurgitation before it is rejected as a part of rapid sequence induction.

  • 29.
    Proczkowska-Björklund, Marie
    et al.
    Division of Child and Adolescent Psychiatry, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Psychiatric Department, Höglandssjukhuset, Eksjö/Nässjö, Sweden.
    Gimbler Berglund, Ingalill
    Department of Nursing Science, School of Health Sciences, Jönköping.
    Ericsson, Elisabeth
    Department of Nursing Science, School of Health Sciences, Jönköping; Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Reliability and validity of the Swedish version of the modified Yale Preoperative Anxiety Scale2012In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 56, no 4, p. 491-497Article in journal (Refereed)
    Abstract [en]

    Background: The modified Yale Preoperative Anxiety Scale (m-YPAS) is an observational behavioral checklist that has been widely used as an indicator of pre-operative anxiety in children. The present study describes the translation process of m-YPAS into Swedish and the testing of its reliability and validity when used with Swedish children.

    Methods: The questionnaire was translated using standard forward-back-forward translation technique. The validation process was divided into two phases: a pilot study with 61 children as a first version and a test of a final version with 102 children.

    Results: The reliability tested with Cronbach's alpha was acceptable to good. Interrater reliability analyzed with weighted kappa was acceptable to good with Students Registered Nurse Anesthetists and Certified Registered Nurse Anesthetist (CRNA) as evaluators (phase 1) and good to excellent with CRNA's very experienced in child anesthesia (phase 2). Both concurrent and constructed validity could be demonstrated.

    Conclusion: This validation study of the Swedish version of the m-YPAS shows good consistency, interrater validity, and construct validity when used by experienced assessors.

  • 30. Sandin, M.
    et al.
    Thörn, Sven-Egron
    Örebro University, School of Health and Medical Sciences.
    Dahlqvist, A.
    Wattwil, L.
    Axelsson, Kjell
    Örebro University, School of Health and Medical Sciences.
    Wattwil, Magnus
    Örebro University, School of Health and Medical Sciences.
    Effects of pain stimulation on bispectral index, heart rate and blood pressure at different minimal alveolar concentration values of sevoflurane2008In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 52, no 3, p. 420-426Article in journal (Other academic)
    Abstract [en]

    Background: The aim of the present study was to examine the level of unconsciousness measured with bispectral index (BIS) at different minimal alveolar concentration (MAC) levels of sevoflurane, and to study the hemodynamic and BIS reactions during noxious stimulation with transcutaneous electrical nerve stimulation (TENS) and an ice water pain test (IWP).

    Methods: This study was approved by the Ethics Committee and was performed on 10 healthy, young volunteers (six males and four females), ASA physical status I. Anesthesia was induced and maintained with sevoflurane in an oxygen/air mixture. The volunteers were spontaneously breathing, but if necessary, ventilation was mechanically supported. TENS and IWP were performed at 1.0, 1.5 and 2.0 MAC of sevoflurane.

    Results: At 1.0 MAC, there was a significant increase in BIS during pain stimulation both with IWP (P<0.03) and with TENS (P<0.005), but at 1.5 MAC there were no changes. A marked variation in BIS was seen at 2.0 MAC, with periods of burst suppression and periods of high BIS values despite clinical signs of deep anesthesia. These marked variations in BIS were seen before, during and after pain stimulation. One volunteer (# 8) had a short episode of convulsions at 2.0 MAC.

    Conclusion: BIS, heart rate and blood pressure increased during pain stimulation at 1.0 MAC but not at 1.5 MAC of sevoflurane. There was a remarkable variation in BIS at 2.0 MAC of sevoflurane, with BIS values indicating wakefulness despite clinical signs of deep anesthesia. This BIS variation is probably caused by epileptogenic activity due to sevoflurane.

  • 31.
    Savilampi, Johanna
    et al.
    Örebro university, Örebro, Sweden.
    Ahlstrand, Rebecca
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Magnuson, Anders
    Örebro university, Örebro, Sweden.
    Effects of remifentanil on pharyngeal swallowing: a double blind, randomized, cross-over study in healthy volunteers2015In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 59, p. 46-46Article in journal (Other academic)
  • 32.
    Savilampi, Johanna
    et al.
    Örebro University Hospital. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Ahlstrand, Rebecca
    Örebro University Hospital. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Magnuson, Anders
    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 remifentanil on the esophagogastric junction and swallowing2013In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 57, no 8, p. 1002-1009Article in journal (Refereed)
    Abstract [en]

    Background: A recent study demonstrated that reflux is associated with impaired pressure augmentation in the esophagogastric junction (EGJ), caused by diaphragmal contractions during inspiration. It is unknown whether this augmentation is influenced by opioids. Swallowing difficulties can be a poorly recognised side effect of remifentanil. Here, we investigated whether remifentanil influences inspiratory EGJ augmentation and evaluated subjective swallowing difficulties induced by remifentanil. We also used the peripheral opioid receptor antagonist methylnaltrexone to evaluate whether these effects are centrally or peripherally mediated.

    Methods: Ten healthy volunteers participated in a double-blind, randomised, cross-over trial at the University Hospital in orebro, Sweden. They were studied on two different occasions, during which they were randomly assigned to receive either methylnaltrexone 0.15mg/kg or saline subcutaneously 30min before the target-controlled infusion of remifentanil of 3ng/mL. EGJ pressures were measured by high-resolution manometry. Swallowing difficulties were assessed when volunteers performed dry swallows. The outcomes were the differences in EGJ pressures at baseline and during remifentanil infusion and with methylnaltrexone vs. placebo. Differences in swallowing difficulties before and during remifentanil, and with methylnaltrexone vs. placebo were also recorded.

    Results: Remifentanil decreased the inspiratory EGJ augmentation and induced swallowing difficulties. No statistically significant differences between methylnaltrexone and placebo occasions were found.

    Conclusions: Remifentanil may increase risk for gastroesophageal reflux by decreasing the inspiratory EGJ augmentation. The clinical significance of remifentanil-induced swallowing difficulties is to be studied further. Given the limited sample size, it cannot be concluded whether these effects are centrally or peripherally mediated.

  • 33.
    Savilampi, Johanna
    et al.
    Örebro University Hospital. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Magnusson, Anders
    Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Ahlstrand, Rebecca
    Örebro University Hospital. Department of Anesthesiology and Intensive CareDepartment of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Effects of remifentanil on esophageal motility: A double blind, randomized, cross-over study in healthy volunteers2015In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 59, no 9, p. 1126-1136Article in journal (Refereed)
    Abstract [en]

    Background: Recent studies have shown that remifentanil increases the risk of aspiration and induces subjective swallowing difficulties. The mechanisms are not completely understood. Here, we investigated whether remifentanil impairs esophageal motility and hypothesized that this is one possible underlying mechanism. Naloxone was used to evaluate whether the effects of remifentanil are mediated through opioid receptors. We also examined subjective swallowing difficulties and the influence of metoclopramide on remifentanil-induced effects.

    Methods: Fourteen healthy volunteers participated in a double-blind, randomized, cross-over trial at the University Hospital in orebro, Sweden. They were studied on two different occasions, during which they were randomly assigned to receive either naloxone given as a bolus of 6g/kg followed by an infusion of 0.1g/kg/min, or saline 5min before target-controlled infusions of remifentanil at three target-site concentrations: 1, 2, and 3 ng/ml. On both occasions, 0.2mg/kg metoclopramide was given before the final measurement. Five swallows were performed during each measuring condition, and the metrics defining esophageal motility were measured by high-resolution manometry. Outcomes were differences in the metrics at baseline vs. during remifentanil infusion, with naloxone vs. placebo, and with remifentanil before and after metoclopramide administration. Differences in swallowing difficulties were also recorded.

    Results: Remifentanil decreased swallow-evoked esophagogastric junction relaxation and the latency time of esophageal peristalsis. There were no significant effects of naloxone or metoclopramide on remifentanil-induced effects, and we detected no differences in swallowing difficulties.

    Conclusions: Remifentanil induces dysfunction of esophageal motility; this may contribute to the elevated risk of regurgitation and aspiration.

  • 34.
    Scott, M. J.
    et al.
    Royal Surrey County Hospital, NHS Foundation Trust, University of Surrey, Guildford, United Kingdom.
    Baldini, G.
    Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal QC, Canada.
    Fearon, K. C. H.
    Royal Infirmary Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom.
    Feldheiser, A.
    Department of Anesthesiology, Intensive Care Medicine Campus Charite, Mitte and Campus Virchow-Klinikum Charite, University Medicine, Berlin, Germany.
    Feldman, L. S.
    Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal QC, Canada.
    Gan, T. J.
    Department of Anesthesiology, Duke University Medical Center, Durham NY, United States; Department of Anesthesiology, Stony Brook University, Stony Brook NY, United States.
    Ljungqvist, Olle
    Örebro University, School of Medicine, Örebro University, Sweden.
    Lobo, D. N.
    Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Biomedical Research Unit, Queen's Medical Centre, Nottingham University Hospitals, Nottingham, United Kingdom.
    Rockall, T. A.
    Royal Surrey County Hospital, NHS Foundation Trust, University of Surrey, Guildford, United Kingdom.
    Schricker, T.
    Department of Anesthesia, McGill University Health Centre, Royal Victoria Hospital, Montreal QC, Canada.
    Carli, F.
    Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal QC, Canada.
    Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations2015In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 59, no 10, p. 1212-1231Article, review/survey (Refereed)
    Abstract [en]

    Background: The present article has been written to convey concepts of anaesthetic care within the context of an Enhanced Recovery After Surgery (ERAS) programme, thus aligning the practice of anaesthesia with the care delivered by the surgical team before, during and after surgery.

    Methods: The physiological principles supporting the implementation of the ERAS programmes in patients undergoing major abdominal procedures are reviewed using an updated literature search and discussed by a multidisciplinary group composed of anaesthesiologists and surgeons with the aim to improve perioperative care.

    Results: The pathophysiology of some key perioperative elements disturbing the homoeostatic mechanisms such as insulin resistance, ileus and pain is here discussed.

    Conclusions: Evidence-based strategies aimed at controlling the disruption of homoeostasis need to be evaluated in the context of ERAS programmes. Anaesthesiologists could, therefore, play a crucial role in facilitating the recovery process.

  • 35.
    Seilitz, Jenny
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Westerling-Andersson, Kristian
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Axelsson, Birger
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Assessment of acute gastrointestinal injury score in postoperative cardiac surgical patients2017In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, no 8, p. 1044-1044Article in journal (Other academic)
    Abstract [en]

    Background: Gastrointestinal (GI) complications following cardiac surgery are infrequent but feared due to high morbidity and mortality. In 2012 new guidelines for grading acute GI injury (AGI score) in the intensive care setting were presented (1). We aimed to apply the AGI score in postoperative cardiac surgical patients.

    Methods: A total number of 352 adult patients undergoing elective heart surgery with extra-corporeal circulation completed the study. Prospectively, AGI score was assessed daily during the first three post-operative days according to normal GI function (AGI 0), risk of developing GI dysfunction (AGI 1), GI dysfunction (AGI 2), GI failure (AGI 3) and GI failure with severe impact on distant organ function (AGI 4).

    Results: Ninety-eight percent of the patients were assessed to have a daily peak score of ≤1, but only 36% were completely free from GI symptoms. Seven patients received a peak score of 2–3. The two patients with the highest peak and accumulated AGI scores died later due to GI complications.

    Conclusions: Postoperative assessment of AGI score in cardiac surgical patients is feasible. A majority presented with a risk of developing GI dysfunction but did not progress further. Early postoperative GI dys-function might predispose for later GI complications, but a larger study population is needed to further investigate this association.

    Reference:1. Reintam BA et al. Intens Care Med 2012; 38: 384–94.

  • 36.
    Siekmann, Wiebke
    et al.
    Örebro University, School of Medical Sciences. Anaesthesiology and Intensive Care, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Tina, Elisabet
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Research Laboratory, Örebro University Hospital, Örebro, Sweden.
    Gupta, Anil
    Clinical Research Laboratory, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden; Department of Physiology and Pharma cology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
    Concentration-dependent cell viability and proliferation in vitro of colon cancer cell lines SW480 and SW620 on exposure to lidocaine or ropivacaine2017In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, no 8, p. 1017-1018Article in journal (Other academic)
    Abstract [en]

    Background: Cancer cells change phenotypes and properties when evolving from primary tumor cells to metastatic cells. These changes might affect the response to local anesthetics (LA). The aim of this study was to investigate if lidocaine or ropivacaine have a dose- dependent effect on cell viability and proliferation of a primary and a secondary colon carcinoma cell line in vitro.

    Methods: The colon cancer cell lines SW 480, derived from primary tumor and SW620 from metastatic tumor in the same patient, were exposed to increasing log-concentrations of lidocaine and ropivacaine. Cell viability was measured using CellTiter Blue, and cell proliferation by PKH67, after exposure for up to 72 h.

    Results: Cell viability was not affected after 24 h of exposure. However, the metastatic cell line SW620 showed a significant increase in cell viability at low concentrati ons after 48 and 72 h. Exposure to the higher, but clinically relevant, concentrations of both LA resulted in decreased cell viability in both cell lines. These higher concentrations also showed an inhibitory effect on cell proliferation after 72 h, which was more pronounced for ropivacaine.

    Conclusions: Low concentrations of lidocaine and ropivacaine, as achieved in plasma by epidural infusion of LA, do not have direct antiproliferative effects on these colon cancer cell lines in vitro. Higher concentrations of LA, as during continuous local infiltration into tissues over 72 h, inhibit proliferation of both cancer cell lines. The increase in cell viability seen in SW620 should be investigated and underlying mechanisms further elucidated in future studies.

  • 37.
    Walldén, Jakob
    et al.
    Örebro University, School of Health and Medical Sciences.
    Lindberg, Greger
    Sandin, Mathias
    Thörn, Sven-Egron
    Örebro University, School of Health and Medical Sciences.
    Wattwil, Magnus
    Örebro University, School of Health and Medical Sciences.
    Effects of fentanyl on gastric myoelectrical activity: a possible association with polymorphisms of the mu-opioid receptor gene?2008In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 52, no 5, p. 708-715Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Opioids have inhibitory effects on gastric motility, but the mechanism is far from clear. Electrical slow waves in the stomach determine the frequency and the peristaltic nature of gastric contractions. The primary aim of this study was to investigate the effects of the opioid fentanyl on gastric myoelectric activity. As there were large variations between the subjects, we investigated whether the variation was correlated to single nucleotide polymorphisms (SNP) of the mu-opioid receptor (MOR) gene. METHODS: We used cutaneous multichannel electrogastrography (EGG) to study myoelectrical activity in 20 patients scheduled for elective surgery. Fasting EGG was recorded for 30 min, followed by intravenous administration of fentanyl 1 microg/kg and subsequent EGG recording for 30 min. Spectral analysis of the two recording periods was performed and the variables assessed were dominant frequency (DF) of the EGG and its power (DP). Genetic analysis of the SNP A118G and G691C of the MOR gene was performed with the polymerase chain reaction technique. RESULTS: There was a significant reduction in DF and DP after intravenous fentanyl. However, there was a large variation between the patients. In eight subjects EGG was unaffected, five subjects had a slower DF (bradygastria) and in six subjects the slow waves disappeared. We found no correlation between the EGG outcome and the presence of A118G or G691C in the MOR gene. CONCLUSIONS: Fentanyl inhibited gastric myoelectrical activity in about half of the subjects. The variation could not be explained by SNP in the MOR gene. Because of small sample size, the results must be regarded as preliminary observations.

  • 38.
    Walldén, Jakob
    et al.
    Örebro University, School of Health and Medical Sciences.
    Thörn, Sven-Egron
    Örebro University, School of Health and Medical Sciences.
    Lindberg, Greger
    Wattwil, Magnus
    Örebro University, School of Health and Medical Sciences.
    Effects of remifentanil on gastric tone2008In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 52, no 7, p. 969-976Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Opioids are well known for impairing gastric motility. The mechanism is far from clear and there is wide interindividual variability. The purpose of this study was to evaluate the effect of remifentanil on proximal gastric tone. MATERIALS AND METHODS: Healthy volunteers were studied on two occasions and proximal gastric tone was measured by a gastric barostat. On the first occasion (n=8), glucagon 1 mg IV was given as a reference for a maximal relaxation of the stomach. On the second occasion (n=9), remifentanil was given in incremental doses (0.1, 0.2 and 0.3 microg/kg/min) for 15 min each, followed by a washout period of 30 min. Thereafter, remifentanil was readministered, and 10 min later glucagon 1 mg was given. Mean intragastric bag volumes were calculated for each 5-min interval. RESULTS: Glucagon decreased gastric tone in all subjects. Remifentanil had a marked effect on gastric tone; we found two distinct patterns of reactions with both increases and decreases in gastric tone and, during the remifentanil infusion, glucagon did not affect gastric tone. CONCLUSIONS: Remifentanil induced changes in gastric tone with both increases and decreases. The effect of remifentanil on gastric tone is probably dependent on the current state of the systems involved.

  • 39.
    Örman, J.
    et al.
    Department of Intensive Care, Linköping University Hospital, Linköping, Sweden.
    Westerdahl, Elisabeth
    Örebro University, School of Health and Medical Sciences. Department of Medical Sciences, Clinical Physiology, Uppsala University Hospital, Uppsala, Sweden; Department of Physiotherapy and Centre for Health Care Sciences, Örebro University Hospital, Örebro, Sweden.
    Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review2010In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 54, no 3, p. 261-267Article in journal (Refereed)
    Abstract [en]

    A variety of chest physiotherapy techniques are used following abdominal and thoracic surgery to prevent or reduce post-operative complications. Breathing techniques with a positive expiratory pressure (PEP) are used to increase airway pressure and improve pulmonary function. No systematic review of the effects of PEP in surgery patients has been performed previously. The purpose of this systematic review was to determine the effect of PEP breathing after an open upper abdominal or thoracic surgery. A literature search of randomised-controlled trials (RCT) was performed in five databases. The trials included were systematically reviewed by two independent observers and critically assessed for methodological quality. We selected six RCT evaluating the PEP technique performed with a mechanical device in spontaneously breathing adult patients after abdominal or thoracic surgery via thoracotomy. The methodological quality score varied between 4 and 6 on the Physiotherapy Evidence Database score. The studies were published between 1979 and 1993. Only one of the included trials showed any positive effects of PEP compared to other breathing techniques. Today, there is scarce scientific evidence that PEP treatment is better than other physiotherapy breathing techniques in patients undergoing abdominal or thoracic surgery. There is a lack of studies investigating the effect of PEP over placebo or no physiotherapy treatment.

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