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Showing papers in "Acta Anaesthesiologica Scandinavica in 2003"


Journal ArticleDOI
TL;DR: It is hypothesized that the incidence of POCD would be less with regional anaesthesia rather than general, and this work has shown this to be the case.
Abstract: Results: At 7 days, POCD was found in 37/188 patients (19.7%, [14.3—26.1%]) after general anaesthesia and in 22/176 (12.5%, [8.0—18.3%]) after regional anaesthesia, P ¼ 0.06. After 3 months, POCD was present in 25/175 patients (14.3%, [9.5—20.4%]) after general anaesthesia vs. 23/165 (13.9%, [9.0—20.2%]) after regional anaesthesia, P ¼ 0.93. The incidence of POCD after 1 week was significantly greater after general anaesthesia when we excluded patients who did not receive the allocated anaesthetic: 33/156 (21.2% [15.0—28.4%]) vs. 20/158 (12.7% [7.9—18.9%]) (P ¼ 0.04). Mortality was significantly greater after general anaesthesia (4/217 vs. 0/211 (P < 0.05)). Conclusion: No significant difference was found in the incidence of cognitive dysfunction 3 months after either general or regional anaesthesia in elderly patients. Thus, there seems to be no causative relationship between general anaesthesia and long-term POCD. Regional anaesthesia may decrease mortality and the incidence of POCD early after surgery.

540 citations


Journal ArticleDOI
TL;DR: Find the incidence and risk factors for POCD in elderly patients undergoing minor surgery and type of surgery and hospitalization are found to be important prognostic factors.
Abstract: Keywords:General anesthesia;minor surgery;out-patient surgery;cognitive dysfunction Background: Major surgery is frequently associated with postoperative cognitive dysfunction (POCD) in elderly patients. Type of surgery and hospitalization may be important prognostic factors. The aims of the study were to find the incidence and risk factors for POCD in elderly patients undergoing minor surgery. Methods: We enrolled 372 patients aged greater than 60 years scheduled for minor surgery under general anesthesia. According to local practice, patients were allocated to either in- (199) or out-patient (173) care. Cognitive function was assessed using neuropsychological testing preoperatively and 7 days and 3 months postoperatively. Postoperative cognitive dysfunction was defined using Z-score analysis. Results: At 7 days, the incidence (confidence interval) of POCD in patients undergoing minor surgery was 6.8% (4.3–10.1). At 3 months the incidence of POCD was 6.6% (4.1–10.0). Logistic regression analysis identified the following significant risk factors: age greater than 70 years (odds ratio [OR]: 3.8 [1.7–8.7], P = 0.01) and in- vs. out-patient surgery (OR: 2.8 [1.2–6.3], P = 0.04). Conclusions: Our finding of less cognitive dysfunction in the first postoperative week in elderly patients undergoing minor surgery on an out-patient basis supports a strategy of avoiding hospitalization of older patients when possible.

289 citations


Journal ArticleDOI
TL;DR: Whether oral carbohydrate or carbohydrate with peptide drinks preoperatively instead of fasting would improve postoperative voluntary muscle strength, nutritional intake and ambulation, decrease postoperative fatigue, anxiety and discomfort, and reduce the endocrine response to surgery is investigated.
Abstract: Background: Surgery is succeeded by long-lasting state of relative peripheral insulin resistance, which is reduced by giving glucose infusion or oral carbohydrate-rich drinks immediate before operating instead of fasting. The aim of the present study was to investigate whether oral carbohydrate or carbohydrate with peptide drinks preoperatively instead of fasting would improve postoperative voluntary muscle strength, nutritional intake and ambulation, decrease postoperative fatigue, anxiety and discomfort, and reduce the endocrine response to surgery. Methods: Forty-eight patients were included and randomized into three groups to receive 2 × 400 ml of carbohydrate-rich drinks or to fast overnight and allowed only water. Voluntary grip and quadriceps strength, body composition, pulmonary function, VAS-score of eight parameters of wellbeing, muscle biopsies and insulin, glucagon, IGF-1 and free fatty acids were measured before and after the operation. The basic postoperative regimen for all groups were immediate oral nutrition and early enforced mobilization. Results: Significant postoperative decrease in glycogen synthase activity in the muscle biopsies was reduced in the intervention groups, and in combination, the intervention groups had a less reduced quadriceps strength after one week (−10% vs. −16%, NS) and one month (−5% vs. −13%, P < 0.05). Minor changes in the endocrine response to surgery were found without differences between the groups, and there were no differences between the groups in ambulation time, nutritional intake or subjective measures of wellbeing.

215 citations


Journal ArticleDOI
TL;DR: The gender aspect in pharmacokinetics and pharmacodynamics of anesthetics has attracted little attention and knowledge of previous work is required to decide if gender‐based differences in clinical practice is justified, and to determine the need for research.
Abstract: Background: The gender aspect in pharmacokinetics and pharmacodynamics of anesthetics has attracted little attention. Knowledge of previous work is required to decide if gender-based differences in clinical practice is justified, and to determine the need for research. Methods: Basis for this paper was obtained by Medline searches using the key words ‘human’ and ‘gender’ or ‘sex,’ combined with individual drug names. The reference lists of these papers were further checked for other relevant studies. Results: Females have 20–30% greater sensitivity to the muscle relaxant effects of vecuronium, pancuronium and rocuronium. When rapid onset of or short duration of action is very important, gender-modified dosing may be considered. Males are more sensitive than females to propofol. It may therefore be necessary to decrease the propofol dose by 30–40% in males compared with females in order to achieve similar recovery times. Females are more sensitive than males to opioid receptor agonists, as shown for morphine as well as for a number of kappa (OP2) receptor agonists. On this basis, males will be expected to require 30–40% higher doses of opioid analgesics than females to achieve similar pain relief. On the other hand, females may experience respiratory depression and other adverse effects more easily if they are given the same doses as males. Conclusion: These examples illustrate that gender should be taken into account as a factor that may be predictive for the dosage of several anesthetic drugs. Moreover, there is an obvious need for more research in this area in order to further optimize drug treatment in anesthesia.

212 citations


Journal ArticleDOI
TL;DR: The relationship between psychological variables, including anxiety, depression, and patient‐controlled analgesia (PCA) use in patients who underwent radical mastectomy was examined.
Abstract: Background: The present study examined the relationship between psychological variables, including anxiety, depression, and patient-controlled analgesia (PCA) use in patients who underwent radical mastectomy. Methods: Ninety-nine ASA I–II women with breast cancer between 18 and 60 years scheduled for modified radical mastectomy completed the state scale of the state-trait anxiety inventory and the Beck depression inventory before the day of surgery. Standard general anesthesia, surgery, and IV-PCA therapy was conducted. Postoperative ratings of pain intensity, opioid consumption and satisfaction with PCA were recorded for the first 24 h on the ward. The degree of pain intensity was evaluated by a visual analog scale (VAS, 1–10). Satisfaction with pain control was reported using an five-point scale from 1 (very dissatisfied) to 5 (very satisfied). Results: The pain intensity, total analgesic consumption and dose/demand ratio were significantly related to preoperative anxiety and depression (P<0.05). Degree of dissatisfaction with PCA was significantly correlated with preoperative anxiety and depression (P<0.01). Conclusion: Patients with higher anxiety and depression levels had higher postoperative pain and analgesic requirements in this study.

202 citations


Journal ArticleDOI
TL;DR: The need to comprehensively examine the events of cardiac arrest as well as mortality prompted the first national study in Japan, which reported data of mortality and morbidity related to anesthesia since World War II.
Abstract: Background: Statistical data of mortality and morbidity related to anesthesia have not been reported in Japan since World War II. The need to comprehensively examine the events of cardiac arrest as well as mortality prompted the first national study in Japan. Methods: Confidential questionnaires were sent to all Japan Society of Anesthesiologists Certified Training Hospitals every year from 1994 through 1998. Collected data were analyzed for incidence of cardiac arrest and other critical events during anesthesia and surgery, and their outcomes within 7 postoperative days. The principal causes of the critical incidents were also analyzed. Results: With an average response rate of 39.9%, a total of 2,363,038 cases were documented over 5 years. The average incidence per year of cardiac arrest during surgery due to all etiologies and that totally attributable to anesthesia was 7.12 [95%CI: 6.30,7.94] and 1.00 [0.88, 1.12]) per 10,000 cases, respectively. The average mortality per year in the operating room or within 7 postoperative days due to all etiologies and that totally attributable to anesthesia was 7.18 [6.22, 8.13] and 0.21 [0.15, 0.27] per 10,000 cases, respectively. The two principal causes of cardiac arrest during anesthesia and surgery due to all etiologies were massive hemorrhage (31.9%) and surgery (30.2%), and those totally attributable to anesthesia were drug overdose or selection error (15.3%) and serious arrhythmia (13.9%). Preventable human errors caused 53.2% of cardiac arrest and 22.2% of deaths in the operating room totally attributable to anesthesia. Conclusions: The rates in Japan of cardiac arrest and death during anesthesia and surgery due to all etiologies as well as those totally attributable to anesthesia are comparable to those of other developed countries.

147 citations


Journal ArticleDOI
TL;DR: There is compelling evidence that the first intensive care unit was established at Kommunehospitalet in Copenhagen in December 1953, and the pioneer was the Danish anaesthetist Bjørn Ibsen.
Abstract: After an extensive survey of the medical literature we present compelling evidence that the first intensive care unit was established at Kommunehospitalet in Copenhagen in December 1953. The pioneer was the Danish anaesthetist Bjorn Ibsen. The many factors that interacted favourably in Copenhagen to promote the idea of intensive care therapy, half a century ago, are also described.

133 citations


Journal ArticleDOI
TL;DR: Recent data indicating that the present view of the interstitium as a passive fluid reservoir has to be revised are presented, suggesting that the connective tissue can serve as a novel target for pharmacological intervention.
Abstract: Here we present recent data indicating that the present view of the interstitium as a passive fluid reservoir has to be revised. The connective tissue cells and extracellular matrix have a role in the control of P(if) and a fundamental role in the rapid development of edema in burns and in the initial swelling in inflammation by generating a lowering of interstitial fluid pressure. In this process, the beta1-integrin system seems to provide a common pathway by which the cells can lower as well as raise P(if). Inflammatory swelling can be reversed by endo- and exogenous substances, thereby suggesting that the connective tissue can serve as a novel target for pharmacological intervention. Furthermore, the new knowledge in interstitial physiology on means to reduce interstitial fluid pressure may be of importance for drug delivery into solid tumors, where a high P(if) limits the uptake of therapeutic agents.

132 citations


Journal ArticleDOI
TL;DR: This study was designed to determine whether music, or music in combination with therapeutic suggestions, could improve the postoperative recovery in the immediate postoperative in daycare surgery.
Abstract: 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 postoperati ...

120 citations


Journal ArticleDOI
TL;DR: This study aims to find out if active use of TEA, combined with extended pain management at home, reduces the incidence of chronic post‐thoracotomy pain.
Abstract: Background: Pain becomes chronic in 22–67% of patients who undergo a thoracotomy. Thoracic epidural analgesia (TEA) has replaced less invasive methods to manage postoperative pain. We wanted to find out if active use of TEA, combined with extended pain management at home, reduces the incidence of chronic post-thoracotomy pain. Methods: All consecutive thoracotomy patients during a 16-month period were included. On the ward, pain was measured daily by VAS during rest and coughing and the consumption of analgesics was registered. The patients were interviewed one week after discharge by telephone and by a questionnaire after 3 and 6 months to find out how much pain they had. Results: A total of 114 patients were recruited. The data were analysed from 89 patients who had had TEA and 22 who had had other methods. TEA was effective in alleviating pain at rest and during coughing. In the TEA patients the incidence of chronic pain of at least moderate severity was 11% and 12% at 3 and 6 months, respectively. One week after discharge 92% of all patients needed daily pain medication. Conclusions: TEA seems effective in controlling evoked postoperative pain, but technical problems occurred in 24% of the epidural catheters. The incidence of chronic pain was lower compared with previous studies where TEA was not used. The patients had significant pain and needed regular pain medication and instructions during the first week after discharge. Extended postoperative analgesia up to the first week at home is warranted.

117 citations


Journal ArticleDOI
TL;DR: It is postulated that postoperative epidural analgesia was more efficient, and had fewer side‐effects than intravenous morphine, in a large patient population.
Abstract: Background: Adverse effects may still limit the use of continuous epidural and intravenous analgesia in surgical wards. This study postulated that postoperative epidural analgesia was more efficient, and had fewer side-effects than intravenous morphine. The aim was to investigate efficacy, adverse effects and safety of the treatments in a large patient population. Methods: During a five-year period 2696 patients undergoing major surgery, received either epidural or intravenous analgesia for postoperative pain relief. The patients were prospectively monitored in surgical wards. Pain was evaluated with a numeric rating scale (0–10) at rest/mobilization. Treatment duration, respiratory depression, sedation/hallucinations/nightmares/confusion, nausea/vomiting, pruritus, orthostatism/leg weakness, and insufficient pain relief were registered. Pain relief for all patients aimed at a pain scoring of less than 4 at rest. Results: Epidural analgesia was used in 1670 patients, and intravenous morphine in 1026 patients. Patients with epidural analgesia experienced less pain both at rest and during mobilization. Insufficient treatment effects such as dose adjustments, orthostatism/leg weakness, and pruritus were more common in the epidural group. Respiratory depression and sedation/hallucinations/nightmares/confusion occurred more often in the intravenous group. Thoracic epidural catheters caused a lower incidence of motor blockade compared to lumbar catheter placements. Conclusion: In a large patient population the use of epidural and intravenous postoperative analgesia was considered safe in surgical wards, and the incidence of adverse effects was low. Patients with epidural analgesia experienced overall less pain, while opioid related side-effects were more common with intravenous morphine analgesia.

Journal ArticleDOI
TL;DR: This study examined the performance and independence of ionized calcium (Ca2+) in prediction of all‐cause day‐30 mortality among critically ill adult patients and found that ionized hypocalcemia correlated with increased mortality.
Abstract: Background: Ionized hypocalcemia is common among critically ill patients, and it has been shown to correlate with increased mortality. The purpose of this study was to examine the performance and independence of ionized calcium (Ca2+) in prediction of all-cause day-30 mortality among critically ill adult patients. Methods: Of 993 critically ill patients treated in the Helsinki University Hospital during a 24-month period, the study comprised 941 patients without calcium supplementation. Patient and laboratory data were obtained retrospectively from an intensive care database. The discriminative powers of admission and lowest Ca2+ values regarding day-30 mortality were evaluated by producing receiver operating curves (ROC). Hazard ratios for death of severe and mild hypocalcemia were calculated by Cox regression model. Results: The prevalence of ionized hypocalcemia (Ca2+ 1.3 mmol l−1 and were excluded from mortality analysis. Univariate Cox regression model revealed hazard ratios of 5.1 (95% confidence interval, CI 2.9–9.0) for severe (<0.90 mmol l−1) and 1.8 (95% CI 1.3–2.4) for mild ionized hypocalcemia (0.90–1.15 mmol l−1) on admission, but hypocalcemia was not shown to be independently associated with mortality by multivariate Cox regression model. In prediction of day-30 mortality admission and lowest Ca2+, levels had areas under curves of 0.636 and 0.671, respectively. Conclusion: Ionized hypocalcemia is common among critically ill adults and it is associated with increased mortality. Although non-survivors and survivors differ significantly in admission Ca2+, hypocalcemia is not independently associated with day-30 mortality.

Journal ArticleDOI
TL;DR: This work evaluates whether the addition of sedation with propofol improves patient tolerance, compared to local anesthesic of the airway only.
Abstract: Background: The techniques, drugs and depth of sedation for flexible fiberoptic bronchoscopy is controversial, and several reports consider that the routine use of sedation is not a prerequisite. We evaluate whether the addition of sedation with propofol improves patient tolerance, compared to local anesthesic of the airway only. Methods: Eighteen patients with pneumonia undergoing flexible fiberoptic bronchoscopy were included in a randomized, single blind, prospective controlled study. The non-sedation group received airway topical anesthesia, whereas the sedation group received topical anesthesia and intravenous sedation with propofol. The degree of pain, cough, sensation of asphyxiation, degree of amnesia, global tolerance and acceptance of another bronchoscopy in the future were noted. Changes in blood pressure, heart rate and saturation of oxygen by pulse oximetry were also evaluated. Results: The patients in sedation group had less cough (P < 0.05), pain (P < 0.01) and sensation of asphyxiation (P < 0.001). Global tolerance to the procedure was significantly better in the group under sedation (P < 0.01). These patients had total amnesia to the procedure (P < 0.0001), thus is more probable that will accept another bronchoscopy in the future (P < 0.01). There was a significant rise in heart rate and blood pressure in the patients without sedation. There were no differences in oxygen saturation (P = 0.75). Conclusions: Our results show that if we administer propofol for sedation, in addition to local anesthesia of the airway, the tolerance to the procedure is much better. Also it appears that sedation with propofol is safe if we carefully select and monitor the patient.

Journal ArticleDOI
TL;DR: The intra‐ and postoperative analgesia provided by the catheter‐technique psoas compartment block and the epidural block in hip‐fractured patients was compared to determine hemodynamic stability, motor blockade, ease of performing the technique, and complications.
Abstract: Background: The aim of this study was to compare the intra- and postoperative analgesia provided by the catheter-technique psoas compartment block and the epidural block in hip-fractured patients. We also compared hemodynamic stability, motor blockade, ease of performing the technique, and complications. Methods: Thirty patients who underwent partial hip replacement surgery were included in this prospective single-blind study. Subjects were randomly assigned to Group E (n=15; general anesthesia plus epidural block with 15 ml of 0.5% bupivacaine) or Group P (n=15; general anesthesia plus psoas compartment block with 30 ml of 0.5% bupivacaine). Hemodynamic parameters were recorded at 10-min intervals intraoperatively. Regional anesthesia procedure time, number of attempts at block, intraoperative blood loss, and need for supplemental fentanyl and/or ephedrine were noted. Postoperatively, a patient-controlled analgesia device delivered an infusion and boluses of bupivacaine/fentanyl. Pain, motor blockade, ambulation time, patient satisfaction with analgesia, and complications were recorded postsurgery. Results: The epidural required significantly more attempts than the psoas block, thus procedure time was longer in this group. Group E also showed significantly greater drops in mean arterial blood pressure from baseline at 30, 40 and 50 min after the start of general anesthesia. Significantly more Group E patients required epinephrine supplementation. The groups were similar regarding pain scores (at rest and on movement) and patient satisfaction, but Group E had higher motor blockade scores, longer ambulation time, and significantly more complications. Conclusion: The continuous psoas compartment block provides excellent intraoperative and postoperative analgesia with a low incidence of complications for partial hip replacement surgery

Journal ArticleDOI
TL;DR: Background: Inguinal herniorrhaphy is commonly performed as an outpatient procedure and offers some advantages over general anesthesia in this setting.
Abstract: Background: Inguinal herniorrhaphy is commonly performed as an outpatient procedure. Spinal anesthesia offers some advantages over general anesthesia in this setting. Methods: Forty patients were randomly divided into two groups according to a double-blind protocol: Group L had spinal anesthesia with bupivacaine 6.0 mg and Group H with bupivacaine 7.5 mg; in both groups, fentanyl 25 µg was added to the spinal anesthetic. The sensory block was measured by ‘pin-prick’ and the motor block was evaluated by a modified Bromage scale. Results: No differences were seen in the spread, duration and regression of sensory block between the groups on the operated side. A greater number of patients required analgesics during the operation in Group L (6) compared with Group H (1) (P<0.05). The return of the modified Bromage scale to grade 0 was earlier in Group L than in Group H (P<0.05) but the time to mobilization and discharge was similar. Seven patients (17%) needed to be catheterized and two had the catheter retained overnight. Times to home discharge (median) were 350 and 445 min, respectively, in Groups L and H. Postoperatively and during the first week, visual analog pain scores, analgesic requirements and side-effects were similar between the groups. In Group H, 95% of the patients and in Group L 85% would have the same anesthetic again if operated upon for a similar procedure. Conclusions: Spinal anesthesia with bupivacaine 7.5 mg and fentanyl offers an alternative to general or local anesthesia for ambulatory inguinal herniorrhaphy. However, the long discharge times and risk for urinary retention restrict its routine use in all patients.

Journal ArticleDOI
TL;DR: This study compared hypnotic drug usage, recovery, patient satisfaction and incidence of inadequate sedation in BIS monitored and nonmonitored women anesthetized with desflurane or propofol.
Abstract: Background: Bispectal index (BIS™) monitoring may reduce drug usage and hasten recovery in propofol and inhalation anesthesia. The faster emergence profile of desflurane may reduce the effect of BIS monitoring on recovery from desflurane compared with propofol. This study compared hypnotic drug usage, recovery, patient satisfaction and incidence of inadequate sedation in BIS monitored and nonmonitored women anesthetized with desflurane or propofol. Methods: One hundred and sixty patients scheduled for elective gynecological surgery were randomly assigned to desflurane or propofol anesthesia with and without BIS monitoring. Fentanyl, vecuronium and remifentanil were administered according to clinical criteria. The BIS monitor was used in all patients, but the monitor screen was covered in the controls. A BIS level between 45 and 55 was targeted in the BIS monitored patients whereas depth of anesthesia was assessed by clinical criteria in the controls. Results: The mean (SD) desflurane MAC-hours administered with and without BIS were 0.70 (0.15) and 0.76 (0.12), respectively, resulting in extubation times of 6.5 (4.1) and 8.3 (6.1) min. (NS). Bispectal index monitoring was associated with improved patient satisfaction, reduced postoperative nausea and antiemetic drug requirement, and fewer episodes with sustained BIS levels > 60. The mean (SD) propofol infusion rates were 6.0 (1.4) and 6.6 (0.9) mg kg−1h−1 with and without the BIS monitor (P = 0.023), resulting in mean (SD) extubation times of 6.8 (4.6) and 10.5 min (5.9), respectively (P < 0.05). Conclusion: Bispectal index monitoring reduced propofol usage and hastened recovery after propofol anesthesia, whereas in desflurane anesthesia it was associated with improved patient satisfaction, probably because of decreased postoperative nausea and fewer episodes of inadequate hypnosis.

Journal ArticleDOI
Tero Varpula1, I Jousela1, R Niemi1, O. Takkunen1, Ville Pettilä1 
TL;DR: Whether the response of oxygenation to the prone position differs between pressure‐controlled synchronized intermittent mandatory ventilation with pressure support (SIMV‐PC/PS) and airway pressure release ventilation with unsupported spontaneous breathing (APRV) is determined.
Abstract: Background: Prone positioning has been shown to improve oxygenation in 60–70% of patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Another way to improve matching of ventilation to perfusion is the use of partial ventilatory support. Preserving spontaneous breathing during mechanical ventilation has been shown to improve oxygenation in comparison with controlled mechanical ventilation. However, no randomized studies are available exploring the effects of preserved spontaneous breathing on gas exchange in combination with prone positioning. Our aim was to determine whether the response of oxygenation to the prone position differs between pressure-controlled synchronized intermittent mandatory ventilation with pressure support (SIMV-PC/PS) and airway pressure release ventilation with unsupported spontaneous breathing (APRV). Methods: We undertook a prospective randomized intervention study in a medical-surgical adult intensive care unit of a university hospital. Of 45, 33 ALI patients (acute lung injury) within 72 h after initiation of mechanical ventilation, and in whom the prone position was applied according to a predefined strategy, were included in the study. After initial stabilization the patients were randomized to receive either SIMV-PC/PS or APRV with predefined general ventilatory goals (PEEP, tidal volume, inspiratory pressure and PaCO2-level). The protocol for prone positioning was the same for both treatment arms. Prone positioning was triggered by finding a PaO2/FiO2-ratio below 200 mmHg evaluated twice per day. The duration of each prone episode was 6 h. Results: The first two episodes of prone positioning were analyzed. Gas exchange was measured before and at the end of prone positioning. Of the 45 patients enrolled, 33 were turned prone once and 28 twice. No significant differences were detected in baseline characteristics. Changes in oxygenation were analyzed in response to the first and second prone episodes 5 h and 24 h after randomization and initiation of SIMV-PC/PS or APRV respectively. Before the first prone episode the PaO2/FiO2-ratio was significantly better (P = 0.02) in the APRV-group (median; interquartile range) (162; 108–192 mmHg) than in the SIMV-PC/PS-group (123; 78–154 mmHg). The response in oxygenation to the first prone episode was similar in both groups: PaO2/FiO2-ratio increased 39.5; 17.75–77.5 mmHg in the SIMV-PC/PS-group and 75.0; 9.0–125.0 mmHg in the APRV-group (P = 0.49). Before the second prone episode, the PaO2/FiO2-ratio was comparable (SIMV-PC/PS 130.5; 61.0–161.0 mmHg vs. APRV 134; 98.3–175.0 mmHg). Improvement in oxygenation was significantly (P = 0.02) greater in the APRV group (82; 37.0–141.0 mmHg) than in the SIMV-PC/PS group (50; 24.0–68.8 mmHg) during the second prone episode. General ventilatory and hemodynamic variables and use of sedatives were similar in both groups during the study. Conclusions: APRV during prone positioning is feasible in the treatment of ALI patients. APRV after 24 h appears to enhance improvement in oxygenation in response to prone positioning.

Journal ArticleDOI
TL;DR: The aims of the present study were to assess the analgesic effect of ketamine and lidocaine and to investigate if measurement of different variables of sensibility could be used to identify responders.
Abstract: Neuropathic pain of central and peripheral origin presents a substantial clinical problem as it is often resistant to pharmacological treatment.The health related quality of life of 126 patients with peripheral neuropathic pain was studied, to provide a cross sectional description from this point of view. Two generic health-related quality of life instruments; the SF-36 and the Nottingham Health Profile were used together with pain assessments, global rating of health and verbal rating scales of pain and other symptoms, as well as patient descriptors.The analgesic effect of ketamine, lidocaine and morphine were assessed in a double blind, placebo-controlled, randomized study design. Three groups of patients were studied: patients with peripheral neuropathic pain of traumatic origin, patients with central post-stroke pain and patients with neuropathic pain after spinal cord injury. Somatosensory function was examined to see if this could predict response to treatment and to investigate if the drugs caused changes in thermal or mechanical sensibility.The results shows that the intense pain, limited efficacy and tolerability of available treatments, the low overall rating of health, reduced work status and troublesome symptoms constitute a substantial impact on the quality of life for patients with peripheral neuropathic pain.The NMDA-antagonist ketamine yielded substantial pain relief to patients with peripheral neuropathic pain and patients with neuropathic pain after spinal cord injury. However, the reported side effects limit the clinical usefulness of the treatment. Lidocaine did not give significant pain relief to the patients in the three studied groups. Morphine may represent a therapeutic alternative for some patients with central post-stroke pain, although only a small group of this category of patients responded with analgesia.Assessment of baseline somatosensory functions could not be used to identify responders to treatment with either drug, nor did ketamine, lidocaine or morphine cause any changes in thermal or mechanical sensibility.

Journal ArticleDOI
TL;DR: The present series describes the 24‐h hemodynamic effects of levosimendan as add‐on therapy in desperately ill patients with cardiogenic shock requiring catecholamines.
Abstract: Background: Levosimendan, a novel inodilator, has been shown to improve hemodynamic function in patients with decompensated heart failure with preserved arterial blood pressure. Data on its use in patients with cardiogenic shock are rare. The present series describes the 24-h hemodynamic effects of levosimendan as add-on therapy in desperately ill patients with cardiogenic shock requiring catecholamines. Methods: Ten patients with cardiogenic shock received levosimendan as continuous infusion of 0.1 µg kg−1 min−1 for 24 h. The patients were otherwise unselected. Hemodynamic measurements were routinely performed at baseline (time 0) and at 1, 8, 16 and 24 h after start of levosimendan (LS) using a Swan-Ganz thermodilution catheter. Results: During the levosimendan infusion there was a significant increase in cardiac index from 1.8 ± 0.4 to 2.4 ± 0.6 L*min−1*m−2 (P = 0.023) and a significant decrease in systemic vascular resistance from 1559 ± 430 to 1109 ± 202 dyn*s*cm−5 (P = 0.001), respectively. Changes in catecholamine dose, and in systolic and diastolic blood pressure were not significant. Given the individual response to LS, 8/10 patients showed an increase in left ventricular stroke work index under reduced or roughly unchanged preload conditions after 8 h. Conclusion: This series shows that a LS infusion is feasible and able to improve hemodynamics in severely compromized, critically ill patients with cardiogenic shock requiring catecholamine therapy. Its potential advantages when compared with other inotropes are unclear. To clarify the potential role of LS in this clinical setting randomized controlled trials on hemodynamic and mortality endpoints are needed.

Journal ArticleDOI
TL;DR: The correlation between serum paracetamol concentrations and the analgesic effect was studied and it was found that low concentrations are more likely to cause pain than high concentrations.
Abstract: Background: Despite the widespread use of paracetamol for many years, the analgesic serum concentrations of paracetamol are unknown Therefore the correlation between serum paracetamol concentrations and the analgesic effect was studied Methods: Sixty-four women undergoing laparoscopic sterilization were included in a double-blind, placebo-controlled, randomized study Patients were given iv propacetamol 40 mg kg−1 (group H), 20 mg kg−1 (group I), 10 mg kg−1 (group L) or placebo after surgery Alfentanil was available via patient-controlled analgesia (PCA) during the 4-h postoperative study period The patients' self-reported pain was registered on the visual analog scale (VAS) A pharmacokinetic model was fitted to the paracetamol data Results: One to 3 h after injection of propacetamol the alfentanil consumption was significantly (P = 001–004) higher in the placebo group compared with groups H, I, and L receiving propacetamol There were no significant differences between the amounts of alfentanil consumed in groups H, I, and L Initial VAS-scores were moderate (54–62), and declined significantly (P < 00001) over time, with no difference between groups Paracetamol followed an open two-compartment model with iv administration and first order elimination The estimated concentrations immediately (t = 0) after injection were 56 mg l−1 (H), 28 mg l−1 (I) and 14 mg l−1 (L) Conclusion: We showed a significant opioid-sparing effect of paracetamol in the immediate postoperative period Pharmacokinetic data were in accordance with other studies Our results suggest that a ceiling effect of paracetamol may be present at iv doses of 5 mg kg−1, ie a serum concentration of 14 mg l−1, which is a lower dose than previously suggested

Journal ArticleDOI
TL;DR: This data indicates that neonatal intensive care medicine uses a disproportionate share of medical resources, and little is known about the distribution of resources between different patient groups.
Abstract: Background: Intensive care medicine uses a disproportionate share of medical resources, and little is known about the distribution of resources between different patient groups. Methods: In this prospective observational study, all patients admitted between 1 January 1998 and 31 December 1999 to our medical-surgical university's ICU were assigned to one of two groups according to length of stay (LOS): patients staying more than 7 days in the unit (group L) and those staying a maximum of 7 days (group S). Resource use was estimated using TISS−28, number of nursing shifts, use of mechanical ventilation, and use of renal replacement therapy. Further, SAPS II and ICU and hospital mortalities were recorded. Results: Of 5481 patients, 583 (10.6%) were in group L and 4898 in group S (89.4%). Patients in group L were more severely sick upon admission than those in group S. Patients in group L stayed a total of 9726 days in the ICU (52.5% of the total LOS). In group L, 69.2% of all shifts with respiratory support and 80.1% of all shifts with renal replacement were used. Further, group L patients consumed 53.4% (909225) of all TISS points provided. The ICU-mortality rates were 14.4% in group L and 7.2% in group S, and the hospital mortality rates were 19.9% and 9.8%, respectively. A mean of 1898 TISS points was used per patient surviving the hospital stay in group L compared with 190 points in group S. Conclusions: In this university-based, medical–surgical adult ICU, 11% of all patients stayed more than 7 days in the unit and consumed more than 50% of all resources. Thus, a highly disproportionate amount of resources were used per survivor in group L compared with those in group S.

Journal ArticleDOI
TL;DR: This work has documented that adrenaline 2.0 µg·ml− 1 markedly improves relief of dynamic pain when added to a thoracic epidural analgesic infusion of bupivacaine and fentanyl.
Abstract: BACKGROUND We have documented that adrenaline 2.0 micro g.ml- 1 markedly improves relief of dynamic pain when added to a thoracic epidural analgesic infusion of bupivacaine 1 mg.ml- 1 and fentanyl 2 micro g.ml- 1. Concern about possible adverse effects on spinal cord blood flow, expressed by others, prompted us to find the lowest concentration of adrenaline needed to produce effective and reliable pain relief after major surgery. METHODS A prospective, randomized, double-blind, parallel group study was carried out in 36 patients after major thoracic or upper abdominal surgery. Patients with only mild pain when coughing during titrated thoracic epidural infusion of approximately 9 ml per hour of bupivacaine 1 mg.ml- 1, fentanyl 2 micro g.ml- 1, and adrenaline 2.0 micro g.ml- 1 were included. The study was conducted as a dose-finding study comparing three different adrenaline concentrations in the epidural mixture (0.5, 1.0, and 1.5 micro g.ml- 1) with each other and with adrenaline 2.0 micro g.ml- 1 in our standard epidural mixture. On the 1st postoperative day, the patients were randomly allocated into three equal groups of 12 patients each, and given a double-blind epidural infusion at the same rate, but with different adrenaline concentrations (0.5, 1.0, or 1.5 micro g.ml- 1). The effects were observed for 4 h or until pain when coughing became unacceptable in spite of rescue analgesia. Rescue analgesia consisted of up to two patient-controlled epidural bolus injections per hour (4 ml) and subsequent i.v. morphine, if necessary. All patients received rectal paracetamol 1 g, every 6th hour. Main outcome measures were pain intensity at rest and when coughing, evaluated by a visual analogue scale and an overall quality of pain relief score. The extent of sensory blockade was evaluated by determining dermatomal hypaesthesia to cold. RESULTS Pain intensity when coughing increased (P < 0.001) and the number of hypaesthetic dermatomal segments decreased (P < 0.002) when the concentration of adrenaline was reduced below 1.5 micro g.ml- 1 in the triple epidural mixture. This change started within two hours after reducing the concentration of adrenaline below 1.5 micro g.ml- 1. The differences in pain intensities at rest were less pronounced. After 4 h with adrenaline 0.5 or 1.0 micro g.ml- 1 pain intensity when coughing was unacceptable in spite of rescue analgesia. After restarting the standard epidural mixture with adrenaline 2.0 micro g.ml- 1, pain intensity was again reduced to mild pain when coughing and the sensory blockade was restored. Occurrence of pruritus increased with a decreasing adrenaline concentration. CONCLUSIONS Adrenaline in a dose-related manner improves the pain-relieving effect and sensory blockade and decreases the occurrence of pruritus of a low-concentration thoracic epidural analgesic infusion of bupivacaine 1 mg. ml- 1 and fentanyl 2 micro g.ml- 1 after major thoracic or upper abdominal surgery. The minimally effective concentration of adrenaline, when added to bupivacaine 1 mg.ml- 1 and fentanyl 2 micro g.ml- 1, to maintain relief of dynamic pain is approximately 1.5 micro g.ml- 1. The data clearly document that dynamic, cough-provoked pain is a more sensitive outcome measure for postoperative pain relief than pain at rest.

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TL;DR: Newer agents, sevoflurane and desflurane, have a quicker onset and shorter emergence from anesthesia and are increasingly preferred for general Pediatrics, but their effects on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) have not been well documented.
Abstract: Background: Isoflurane has been a commonly used agent for neuroanesthesia, but newer agents, sevoflurane and desflurane, have a quicker onset and shorter emergence from anesthesia and are increasingly preferred for general pediatric anesthesia. But their effects on intracranial pressure (ICP) and cerebral perfusion pressure (CPP), especially in pediatric patients with already increased ICP, have not been well documented. Methods: We studied 36 children scheduled for elective implantation of an intraparenchymal pressure device for 24 h monitoring for suspected elevated ICP. After a standardized intravenous anesthesia, the patients were moderately hyperventilated with 60% nitrous oxide (N2O) in oxygen. The patients were then randomized to receive 0.5 and 1.0 MAC of isoflurane (Group I, n = 12), sevoflurane (Group S, n = 12) or desflurane (Group D, n = 12) in 60% N2O in oxygen. Respiratory and hemodynamic variables, ICP and CPP were recorded at baseline and after exposure to a target level of test drug for 10 min or until CPP fell below 30 mmHg (recommended lower ICP level is 25 mmHg in neonates, rising to 40 mmHg in toddlers). Results: When comparing baseline values with values at 1.0 MAC, mean arterial pressure (MAP) decreased (P < 0.001) in all groups, with no differences between the groups. ICP increased (P < 0.001) with all agents, mean +2, +5, and +6 mmHg in Group I, S and D, respectively, with no differences between the groups. Regression analyzes found no relationship between baseline ICP and the increases in ICP from baseline to 1.0 MAC for isoflurane or sevoflurane. However, increased baseline ICP tended to cause a higher ICP increase with 1.0 MAC desflurane; regression coefficient +0.759 (P = 0.077). The difference between regression coefficients for Group I and Group D were not significant (P = 0.055). CPP (MAP-ICP) decreased (P < 0.001) in all groups, mean −18, −14 and −17 mmHg in Group I, S and D, respectively, with no significant difference between the groups. Conclusions: 0.5 and 1.0 MAC isoflurane, sevoflurane and desflurane in N2O all increased ICP and reduced MAP and CPP in a dose-dependent and clinically similar manner. There were no baseline dependent increases in ICP from 0 to 1.0 MAC with isoflurane or sevoflurane, but ICP increased somewhat more, although statistically insignificant, with higher baseline values in patients given desflurane. The effect of MAP on CPP is 3–4 times higher than the effect of the increases in ICP on CPP and this makes MAP the most important factor in preserving CPP. In children with known increased ICP, intravenous anesthesia may be safer. However, maintaining MAP remains the most important determinant of a safe CPP.

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TL;DR: In this article, the authors evaluated clinical competence among anaesthetists, focusing mainly on theoretical knowledge and practical skills, and found that according to theory, however, the way anaesthetic practitioners understan...
Abstract: Background: Evaluating clinical competence among anaesthetists has so far focused mostly on theoretical knowledge and practical skills. According to theory, however, the way anaesthetists understan ...

Journal ArticleDOI
TL;DR: The purpose of this study was to compare three locoregional techniques of pain management after arthroscopic anterior cruciate ligament reconstruction (ACLR) and found that the former are more effective than the latter.
Abstract: Background: The purpose of this study was to compare three locoregional techniques of pain management after arthroscopic anterior cruciate ligament reconstruction (ACLR). Methods: Sixty ASA I-II subjects were enrolled after obtaining written informed consent. Patients were randomly allocated to three groups of 20 subjects. The first group (EPI) received epidural ropivacaine 0.2% plus sufentanil 0.2I¼gml-1, at 5mlh-1. Patients in the second group (CFB) were given a continuous infusion of the same analgesic mixture through a femoral catheter. The third group (IA) received a continuous intraarticular infusion of ropivacaine 0.2% plus sufentanil 0.2I¼gml-1, at 5mlh-1. All subjects were allowed PCA boluses of 5ml of local anesthetic. Analgesia was assessed for 36h after the end of surgery by means of a visual analog scale (VAS) and a verbal scale (VS), as well as the number of PCA boluses administered and the amount of supplementary i.v. ketorolac, if given. Results: The VAS and VS scores were significantly higher in group IA during the 24h following surgery. Ketorolac requirement was higher in group IA throughout the postoperative observation. Adverse effects were similar in all groups except for urinary retention, which was significantly more frequent in group EPI. Conclusions: We conclude that either epidural or continuous femoral nerve block provide adequate pain relief in patients who undergo ACLR, whereas intraarticular analgesia seems unable to cope satisfactorily with the analgesic requirements of this surgical procedure. © Acta Anaesthesiologica Scandinavica 47 (2003).

Journal ArticleDOI
P. Loisa, T. Rinne, S. Laine, M. Hurme1, Seppo Kaukinen 
TL;DR: The relationship between the pro‐ and anti‐inflammatory cytokine profiles in severe sepsis and their role in the development of multiple organ failure (MOF) is investigated.
Abstract: Background: The production of proinflammatory cytokines activates the systemic inflammatory response in sepsis. Patients also develop a compensatory anti-inflammatory reaction, which may have an important down-regulatory effect on the overactive inflammation. However, the role of this anti-inflammatory response in sepsis is not completely clarified. In this prospective study, we investigated the relationship between the pro- and anti-inflammatory cytokine profiles in severe sepsis and their role in the development of multiple organ failure (MOF). Methods: Thirty-eight patients meeting the criteria for severe sepsis were studied. MOF was defined as a maximum SOFA score of 10 or higher. Serial measurements of the proinflammatory IL-6 and IL-1β and the anti-inflammatory IL-10 and IL-1ra were used. The cytokine samples were taken at the onset of sepsis and on the third and fifth day during the ICU period. Results: The initial IL-10 and IL-1ra responses were identical in patients with or without MOF. The anti-inflammatory cytokine levels remained elevated in the MOF patients, whereas in patients without MOF the levels declined. The IL-6/IL-10 ratio was significantly higher in the MOF patients on days 1 and 3 compared with patients without MOF. Conclusions: We could not demonstrate overproduction of anti-inflammatory IL-10 in MOF patients. On the contrary, the high IL-6/IL-10 ratio indicates that IL-10 deficiency may contribute to the development of MOF in severe sepsis.

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TL;DR: It is hypothesized that 3’mg of hyperbaric bupivacaine with 10’µg of fentanyl permits fast‐tracking or shorter stay in post anesthesia care unit (PACU), and earlier discharge home, compared with 4 mg ofhyperbaric bicarbonate of soda.
Abstract: Background: Combination of local anesthetic and opioid enables the use of less spinal anesthetic and increases the success of anesthesia. Intrathecal opioid does not prolong motor recovery and thus should not delay discharge home. We hypothesized that 3 mg of hyperbaric bupivacaine with 10 µg of fentanyl permits fast-tracking or shorter stay in post anesthesia care unit (PACU), and earlier discharge home, compared with 4 mg of hyperbaric bupivacaine. Methods: In this double-blind study, 100 outpatients undergoing knee arthroscopy received randomly either 4 mg of bupivacaine (B4) or 3 mg of bupivacaine + 10 µg fentanyl (B3F) intrathecally. The volume of 0.8 ml was injected at the L2/3 interspace over a 2-min period. A lateral decubitus position was maintained for 10 min. The sensory block was recorded by using thermal stimuli, and motor block was assessed according to a modified Bromage scale. Fast-tracking criteria were complete recovery of motor block, sensory block Th12 or lower and stable vital signs. Results: One block (1%) failed. Motor recovery was faster in the B3F group: 60% of the patients recovered in 80 min or less compared with 28% in group B4 (P = 0.002). The PACU-time was shorter: 36 (10–103) vs. 55 (10–140) min, respectively (P = 0.005). Seventeen (B3F) vs. nine patients (B4) could bypass PACU (NS). Time to discharge home was similar in both groups. In the B3F group, 75% of the patients developed pruritus. Conclusion: Both solutions produced reliable spinal anesthesia for outpatient knee arthroscopy. The PACU-time was shorter in the bupivacaine-fentanyl group, but both groups reached home-readiness equally.

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TL;DR: This study compared the efficacy of continuous thoracic epidural analgesia (EDA) to continuous intercostal (IC) block for postoperative pain and pulmonary function in a prospective, randomized, double‐blinded clinical trial.
Abstract: Background: Pain following thoracotomy is frequently associated with clinically important abnormalities of pulmonary function The aim of the current study was to compare the efficacy of continuous thoracic epidural analgesia (EDA) to continuous intercostal (IC) block for postoperative pain and pulmonary function in a prospective, randomized, double-blinded clinical trial Methods: Fifty patients undergoing lung lobectomy for malignancies were randomized into two groups (25/group) Respiratory function (forced vital capacity, forced expiratory volume per 1 s/forced vital capacity, maximum midexpiratory flow rate, peak expiratory flow rate) were evaluated preoperatively, within 4 h after the operation and on the first postoperative day Visual analog scale (VAS: 0–10) scores were evaluated four-hourly for 20 h Results: The VAS scores were significantly lower in the EDA versus IC group at the 4th, 8th, and 12th h of observation (mean ± SD) 55 ± 29 vs 73 ± 22 P = 004; 41 ± 21 vs 51 ± 29 P = 002; 36 ± 19 vs 52 ± 24 P = 001, respectively Respiratory function parameters deteriorated significantly in both groups (P < 0001) with no significant difference between the groups Only one major adverse effect was detected: one patient suffered from rib osteomyelitis after intercostal cannulation and healed following surgical repair Conclusions: The results of the present study show that following thoracotomy in the early postoperative period continuous EDA is a better pain relieving method than continuous IC block, as indicated by the VAS scores

Journal ArticleDOI
S. Ghatge1, J. Lee1, I. Smith1
TL;DR: Sevoflurane has several properties which make it potentially useful as a day case anaesthetic and may also be used to induce anaesthesia, which is generally well‐received and causes less hypotension and apnoea compared to propofol.
Abstract: Sevoflurane has several properties which make it potentially useful as a day case anaesthetic. Following induction of anaesthesia with propofol, awakening from sevoflurane is faster compared to isoflurane, faster or similar compared to propofol and comparable (in the majority of studies) to desflurane. Subsequent recovery and discharge is generally similar following all agents. Sevoflurane may also be used to induce anaesthesia, which is generally well-received and causes less hypotension and apnoea compared to propofol. When used as a maintenance anaesthetic, the incidence of postoperative nausea and vomiting after sevoflurane is comparable to other inhaled anaesthetics, but this complication appears more common after inhaled inductions. The tolerability and low solubility of sevoflurane facilitate titration of anaesthesia and may reduce the need for opioid analgesia, which in turn may limit the occurrence of nausea and vomiting.

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TL;DR: The aim of the present study was to measure the concentration of serum mast cell tryptase (MCT), to investigate the prevalence of serum IgE antibodies against ammonium groups, choline, morphine, suxamethonium, thiopentone and latex and to perform skin prick tests in 18 patients experiencing an anaphylactic reaction during induction of general anaesthesia.
Abstract: Background: In the perioperative setting multiple agents can cause anaphylaxis. Often the reactions are dramatic, and due to their lifethreatening potential it is crucial that the responsible agent is identified in order to avoid future adverse reactions. The aim of the present study was to measure the concentration of serum mast cell tryptase (MCT), to investigate the prevalence of serum IgE antibodies against ammonium groups, choline, morphine, suxamethonium, thiopentone and latex and to perform skin prick tests (SPTs) in 18 patients experiencing an anaphylactic reaction during induction of general anaesthesia. Methods: Serum samples from 18 patients with an anaphylactic reaction during general anaesthesia were analyzed for MCT and specific IgE against ammonium groups, choline, morphine, suxamethonium, thiopentone and latex. Skin prick tests were performed in 11 out of 18 patients. Results: Ten patients had elevated MCT levels and specific IgE against ammonium ion, morphine and (with the exception of patient nos 3, 9 and 10) suxamethonium. Seven of these patients had positive SPTs to suxamethonium. One of the patients tested positive to latex in addition to suxamethonium. Two patients showed elevated MCT, while specific IgE against the drugs tested was not detected. Three patients tested positive to ammonium ion, morphine and suxamethonium, but negative to MCT. Three patients tested negative to both MCT and specific IgE. Conclusions: Fifteen out of 18 sera tested positive for MCT and/or specific IgE against neuromuscular blocking drugs (NMBDs). Ten of the 18 patients experienced an IgE-mediated anaphylactic reaction to NMBDs during anaesthesia, verified by detection of specific IgE and elevated levels of MCT.