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  • 151.
    Rydvall, A.
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Häggmark, S.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Nyhman, H.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Reiz, S.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Effects of enflurane on coronary haemodynamics in patients with ischaemic heart disease1984In: Acta Anaesthesiol Scand, Vol. 28, no 6, p. 690-5Article in journal (Refereed)
    Abstract [en]

    The effects of enflurane with and without nitrous oxide on coronary haemodynamics and myocardial oxygenation were investigated in 11 patients with generalised atherosclerotic disease. Enflurane decreased systemic blood pressure (-50%) mainly by systemic vasodilation (SVR -41%) and to a lesser degree by impairment of cardiac performance (CO -27%). A change from 1MAC enflurane-nitrogen-oxygen (70/30) to 1MAC enflurane-nitrous oxide-oxygen (70/30) decreased blood pressure and cardiac output further (-16% and -14%). Enflurane-nitrogen-oxygen decreased coronary blood flow (-29%) and perfusion pressure (-47%). Coronary vascular resistance fell (-20%) along with decreases in myocardial oxygen consumption and extraction (-40% and -16%). Regional coronary blood flow measurements in four of the patients revealed maldistribution of blood flow. During enflurane-nitrous oxide-oxygen, myocardial oxygen consumption and extraction decreased further (-29% and -12%) without change in coronary blood flow or resistance. Myocardial ischaemia was observed in four patients during enflurane-nitrogen. During enflurane-nitrous oxide, ischaemia disappeared in two of the previously ischaemic patients and appeared in two not previously ischaemic. The regional blood flow maldistribution was abolished with nitrous oxide. It is concluded that enflurane is a powerful coronary vasodilator and in this respect slightly less potent than isoflurane. Enflurane may induce myocardial ischaemia by redistributing coronary blood flow and/or by producing hypotension. Nitrous oxide added to enflurane depresses cardiac function and augments the coronary vasodilatory effect of enflurane to a level at which coronary blood flow becomes totally pressure dependent.

  • 152.
    Rydvall, Anders
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Withhold  or  withdraw  futile  treatment in  intensive  care: arguments supported by physicians and the general public2016Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Since the 60s and with increasing intensity a discussion have continued about balance between useful and useless/harmful treatment. Different attempts have been done to create sustainable criteria and recommendations to manage the situations of futile treatment near the end of life. Obviously, to be able to withhold (WH) or withdraw (WD) treatment which is no longer appropriate or even harmful and burdensome for the patient, other processes than strict medical (or physiological) assessments are necessary.

    Aim. To shed light on the arguments regarding to WH or WD futile treatment we performed two studies of physicians’ and the general populations’ choice and prioritized arguments in the treatment of a 72-year-old woman suffering from a large intra-cerebral bleeding with bad prognosis (Papers I and II) and a new born boy with postpartum anoxic brain damage (Papers III and IV).

    Methods. Postal questionnaires based on two cases presented above involving severely ill patients were used. Arguments for and against to WH or WD treatment, and providing treatment that might hasten death were presented. The respondents evaluated and prioritized arguments for and against withholding neurosurgery, withdrawing life-sustaining treatment and providing drugs to alleviate pain and distress. We also asked what would happen to physicians’ own trust if they took the action described, and what the physician estimated would happen to the general publics’ trust in health services (Paper IV).

    Results. Approximately 70% of the physicians and 46% of the general public responded in both surveys. The 72-year-old woman: A majority of doctors (82.3%) stated that they would withhold treatment, whereas a minority of the general public (40.2%) would do so; the arguments forwarded and considerations regarding quality of life differed significantly between the two groups. Quality-of-life aspects were stressed as an important argument by the majority of both neurosurgeons and ICU-physicians (76.8% vs. 54.0%); however, significantly more neurosurgeons regarded this argument as the most important. A minority in both groups, although more ICU-physicians, supported a patient’s previously expressed wish of not ending in a persistent vegetative state as the most important argument. As the case clinically progressed, a consensus evolved regarding the arguments for decision making.

    The new born child: A majority of both physicians [56 % (CI 50–62)] and the general population [53 % (CI 49–58)] supported arguments for withdrawing ventilator treatment. A large majority in both groups supported arguments for alleviating the patient’s symptoms even if the treatment hastened death, but the two groups display significantly different views on whether or not to provide drugs with the additional intention of hastening death, although the difference disappeared when we compared subgroups of those who were for or against euthanasia-like actions.

    Conclusions. There are indeed considerable differences in how physicians and the general public assess and reason in critical care situations, but the more hopelessly ill the patient became the more the groups' assessments tended to converge, although they prioritized different arguments. In order to avoid unnecessary dispute and miscommunication, it is important that health care providers are aware of the public's views, expectations, and preferences. Our hypothesis—physicians’ estimations of others’ opinions are influenced by their own opinions—was corroborated. This might have implications in research as well as in clinical decision-making.

  • 153.
    Rydvall, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Bergenheim, Tommy
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurosurgery.
    Lynöe, Niels
    Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Decision making in a life-threatening cerebral condition: a comparative study of the ethical reasoning of intensive care unit physicians and neurosurgeons2007In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 51, no 10, p. 1338-1343Article in journal (Other academic)
    Abstract [en]

    Severe traumatic brain injury (TBI) is one of the major causes of death in younger age groups. In Umea, Sweden, an intracranial pressure (ICP) targeted therapy protocol, the Lund concept, has been used in treatment of severe TBI since 1994. Decompressive craniectomy is used as a protocol-guided treatment step. The primary aim of the investigation was to study the effect of craniectomy on ICP changes over time in patients with severe TBI treated by an ICP-targeted protocol. In this retrospective study, all patients treated for severe TBI during 1998-2001 who fulfilled the following inclusion criteria were studied: GCS <or= 8 at intubation and sedation, first recorded cerebral perfusion pressure (CPP) of >10 mm Hg, arrival within 24 h of trauma, and need of intensive care for >72 h. Craniectomy was performed when the ICP could not be controlled by evacuation of hematomas, sedation, ventriculostomy, or low-dose pentothal infusion. Ninety-three patients met the inclusion criteria. Mean age was 37.6 years. Twenty-one patients underwent craniectomy as a treatment step. We found a significant reduction of the ICP directly after craniectomy, from 36.4 mm Hg (range, 18-80 mm Hg) to 12.6 mm Hg (range, 2-51 mm Hg). During the following 72 h, we observed an increase in ICP during the first 8-12 h after craniectomy, reaching approximately 20 mm Hg, and later levelling out at approximately 25 mm Hg. The reduction of ICP was statistically significant during the 72 h. The outcome as measured by Glasgow Outcome Scale (GOS) did not significantly differ between the craniectomized group (DC) and the non-craniectomized group (NDC). The outcome was favorable (GOS 5-4) in 71% in the craniectomized group, and in 61% in the non-craniectomized group. Craniectomy is a useful tool in achieving a significant reduction of ICP overtime in TBI patients with progressive intracranial hypertension refractory to medical therapy. The procedure seems to have a satisfactory effect on the outcome, as demonstrated by a high rate of favorable outcome and low mortality in the craniectomized group, which did not significantly differ compared with the non-craniectomized group.

  • 154.
    Rydvall, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Juth, Niklas
    Inst för lärande, informatik, management och etik /Centrum för Hälso- och sjukvårdsetik.
    Sandlund, Mikael
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Domellöf, Magnus
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Lynöe, Niels
    Inst för lärande, informatik, management och etik /Centrum för Hälso- och sjukvårdsetik.
    To treat or not to treat a newborn child with severe brain damage?: A cross-sectional study of physicians' and the general population's perceptions of intentions2014In: Medicine, Health care and Philosophy, ISSN 1386-7423, E-ISSN 1572-8633, Vol. 17, no 1, p. 81-88Article in journal (Refereed)
    Abstract [en]

    Ethical dilemmas are common in the neonatal intensive care setting. The aim of the present study was to investigate the opinions of Swedish physicians and the general public on treatment decisions regarding a newborn with severe brain damage. We used a vignette-based questionnaire which was sent to a random sample of physicians (n = 628) and the general population (n = 585). Respondents were asked to provide answers as to whether it is acceptable to discontinue ventilator treatment, and when it actually is discontinued whether or not it was acceptable to use drugs which hasten death unintentionally or intentionally. The response rate was 67 % of physicians and 46 % of the general population. A majority of both physicians [56 % (CI 50-62)] and the general population [53 % (CI 49-58)] supported arguments for withdrawing ventilator treatment. A large majority in both groups supported arguments for alleviating the patient's symptoms even if the treatment hastened death, but the two groups display significantly different views on whether or not to provide drugs with the additional intention of hastening death, although the difference disappeared when we compared subgroups of those who were for or against euthanasia-like actions. The study indicated that physicians and the general population have similar opinions regarding discontinuing life-sustaining treatment and providing effective drugs which might unintentionally hasten death but seem to have different views on intentions. The results might be helpful to physicians wanting to examine their own intentions when providing adequate treatment at the end of life.

  • 155.
    Rydvall, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Juth, Niklas
    Inst för lärande, informatik, management och etik /Centrum för Hälso- och sjukvårdsetik.
    Sandlund, Mikael
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Lynøe, Nils
    Inst för lärande, informatik, management och etik /Centrum för Hälso- och sjukvårdsetik.
    Are physicians' estimations of future events value-impregnated?: Cross-sectional study of double intentions when providing treatment that shortens a dying patient's life2014In: Medicine, Health care and Philosophy, ISSN 1386-7423, E-ISSN 1572-8633, Vol. 17, no 3, p. 397-402Article in journal (Refereed)
    Abstract [en]

    The aim of the present study was to corroborate or undermine a previously presented conjecture that physicians' estimations of others' opinions are influenced by their own opinions. We used questionnaire based cross-sectional design and described a situation where an imminently dying patient was provided with alleviating drugs which also shortened life and, additionally, were intended to do so. We asked what would happen to physicians' own trust if they took the action described, and also what the physician estimated would happen to the general publics' trust in health services. Decrease of trust was used as surrogate for an undesirable action. The results are presented as proportions with a 95 % Confidence Interval (CI). Statistical analysis was based on inter-rater agreement (Weighted Kappa)-test as well as chi (2) test and Odds Ratio with 95 % CI. We found a moderate inter-rater agreement (Kappa = 0.552) between what would happen with the physicians' own trust in healthcare and their estimations of what would happen with the general population's trust. We identified a significant difference between being pro et contra the treatment with double intentions and the estimation of the general population's trust (chi(2) = 72, df = 2 and p < 0.001). Focusing on either decreasing or increasing own trust and being pro or contra the action we identified a strong association [OR 79 (CI 25-253)]. Although the inter-rater agreement in the present study was somewhat weaker compared to a study about the explicit use of the term 'physicians assisted suicide' we found that our hypothesis-physicians' estimations of others' opinions are influenced by their own opinions-was corroborated. This might have implications in research as well as in clinical decision-making. We suggest that Merton's ideal of disinterestedness should be highlighted.

  • 156.
    Rydvall, Anders
    et al.
    Department of Surgical and Perioperative Sciences, Anaesthesiology, University Hospital of Northern Sweden, Lasarettsbacken SE-90185 Umeå, Sweden.
    Lynöe, Niels
    Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Berzelius vaeg 3 SE-17177 Stockholm, Sweden.
    Withholding and withdrawing life-sustaining treatment: a comparative study of the ethical reasoning of physicians and the general public2008In: Critical Care, ISSN 1364-8535, E-ISSN 1466-609X, Vol. 12, no 1, article id R13Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Our objective was to investigate whether a consensus exists between the general public and health care providers regarding the reasoning and values at stake on the subject of life-sustaining treatment. METHODS: A postal questionnaire was sent to a random sample of members of the adult population (n = 989) and to a random sample of intensive care doctors and neurosurgeons (n = 410) practicing in Sweden in 2004. The questionnaire was based on a case involving a severely ill patient and presented arguments for and against withholding and withdrawing treatment, and providing treatment that might hasten death. RESULTS: Approximately 70% of the physicians and 51% of the general public responded. A majority of doctors (82.3%) stated that they would withhold treatment, whereas a minority of the general public (40.2%) would do so; the arguments forwarded (for instance, belief that the first task of health care is to save life) and considerations regarding quality of life differed significantly between the two groups. Most physicians (94.1%) and members of the general public (77.7%) were prepared to withdraw treatment, and most (95.1% of physicians and 82% of members of the general public) agreed that sedation should be provided. CONCLUSION: There are indeed considerable differences in how physicians and the general public assess and reason in critical care situations, but the more hopelessly ill the patient became the more the groups' assessments tended to converge, although they prioritized different arguments. In order to avoid unnecessary dispute and miscommunication, it is important that health care providers be aware of the public's views, expectations, and preferences.

  • 157.
    Rönnberg, Linda
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Department of Anaesthesia, Ostersunds Hospital, Sweden.
    Nilsson, Ulrica
    Swedish Nurse Anesthetists' Experiences of the WHO Surgical Safety Checklist2015In: Journal of Perianesthesia Nursing, ISSN 1089-9472, E-ISSN 1532-8473, Vol. 30, no 6, p. 468-475Article in journal (Refereed)
    Abstract [en]

    Purpose: The World Health Organization (WHO) surgical safety checklist aims to increase communication, build teamwork, and standardize routines in clinical practice in an effort to reduce complications and improve patient safety. The checklist has been implemented in surgical departments both nationally and internationally. The purpose of this study was to describe the registered nurse anesthetists' (RNA) experience with the use of the WHO surgical safety checklist. Design: This was a cross-sectional study with a descriptive mixed methods design, involving nurse anesthetists from two different hospitals in Sweden. Methods: Data were collected using a study-specific questionnaire. Findings: Forty-seven RNAs answered the questionnaire. There was a statistically significant lower compliance to "Sign-in'' compared with the other two parts, "Timeout'' and "Sign-out.'' The RNAs expressed that the checklist was very important for anesthetic and perioperative care. They also expressed that by confirming their own area of expertise, they achieved an increased sense of being a team member. Thirty-four percent believed that the surgeon was responsible for the checklist, yet this was not the reality in clinical practice. Although 23% reported that they initiated use of the checklist, only one RNA believed that it was the responsibility of the RNA. Forty-three percent had received training about the checklist and its use. Conclusion: The WHO surgical checklist facilitates the nurse anesthetist's anesthetic and perioperative care. It allows the nurse anesthetist to better identify each patient's specific concerns and have an increased sense of being a team member. (C) 2015 by American Society of PeriAnesthesia Nurses

  • 158.
    Samuelsson, Line
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Tyden, Jonas
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Herwald, Heiko
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Walldén, Jakob
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Steinvall, Ingrid
    Sjöberg, Folke
    Johansson, Joakim
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Renal clearance of heparin-binding protein and elimination during renal replacement therapy: Studies in ICU patients and healthy volunteers2019In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, no 8, article id e0221813Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Heparin-binding protein (HBP) is released by neutrophils upon activation, and elevated plasma levels are seen in inflammatory states like sepsis, shock, cardiac arrest, and burns. However, little is known about the elimination of HBP. We wanted to study renal clearance of HBP in healthy individuals and in burn patients in intensive care units (ICUs). We also wished to examine the levels of HBP in the effluent of renal replacement circuits in ICU patients undergoing continuous renal replacement therapy (CRRT).

    METHODS: We measured plasma and urine levels of HBP and urine flow rate in 8 healthy individuals and 20 patients in a burn ICU. In 32 patients on CRRT, we measured levels of HBP in plasma and in the effluent of the CRRT circuit.

    RESULTS: Renal clearance of HBP (median (IQR) ml/min) was 0.19 (0.08-0.33) in healthy individuals and 0.30 (0.01-1.04) in burn ICU patients. In ICU patients with cystatin C levels exceeding 1.44 mg/l, clearance was 0.45 (0.15-2.81), and in patients with cystatin C below 1.44 mg/l clearance was lower 0.28 (0.14-0.55) (p = 0.04). Starting CRRT did not significantly alter plasma levels of HBP (p = 0.14), and the median HBP level in the effluent on CRRT was 9.1 ng/ml (IQR 7.8-14.4 ng/ml).

    CONCLUSION: In healthy individuals and critically ill burn patients, renal clearance of HBP is low. It is increased when renal function is impaired. Starting CRRT in critically ill patients does not alter plasma levels of HBP significantly, but HBP can be found in the effluent. It seems unlikely that impaired kidney function needs to be considered when interpreting concentrations of HBP in previous studies. Starting CRRT does not appear to be an effective way of reducing HBP concentrations.

  • 159.
    Sandberg, Karolina
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Peer-simulation training -effects on student´s confidence in clinical situations.2018Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 160.
    Sangfelt, Amalia
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Interhospital air ambulance transfer: impaired oxygenation as a risk factor for mortality in critically ill patients2019Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 161. Seeman-Lodding, Helene
    et al.
    Biber, Björn
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Jern, Christina
    Jern, Sverker
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Anesthesia and surgery influences regional net release and uptake rates of tissue-type plasminogen activator. An experimental study in the intact pig1997In: Acta Anaesthesiol Scand Suppl, Vol. 110, p. 151-3Article in journal (Refereed)
  • 162. Seeman-Lodding, Helene
    et al.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Jern, Christina
    Jern, Sverker
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Biber, Björn
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Aortic cross-clamping influences regional net release and uptake rates of tissue-type plasminogen activator in pigs1997In: Acta Anaesthesiol Scand, Vol. 41, no 9, p. 1114-23Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The key regulator of intravascular fibrinolysis, tissue-type plasminogen activator (t-PA), is released from a dynamic endothelial storage pool. The aim of the study was to investigate regional t-PA net release and uptake rates in response to infra-renal aortic cross-clamping (AXC) and declamping (DC). METHODS: Anesthetized pigs were studied during 5 min of AXC, followed by a 35-min declamping (DC) period. Arterio-venous concentration gradients of total and active t-PA, as well as respective plasma flows, were simultaneously obtained across the preportal, hepatic, coronary and pulmonary vascular beds. Plasma levels of total t-PA (ELISA with purified porcine t-PA as standard), and active t-PA (spectrophotometric functional assay) were determined. RESULTS: Prior to AXC, we found a high net release rate of total t-PA across the preportal vascular bed (1700 ng.min-1 P < 0.001), and a high hepatic net uptake (4900 ng.min-1, P < 0.001), while coronary and pulmonary t-PA net fluxes were small and variable. AXC per se did not induce significant alterations in net fluxes of t-PA. Following DC, preportal and coronary net releases of total t-PA increased (to 2900 ng.min-1 and 60 ng.min-1, respectively). Despite an increase in hepatic net uptake of total t-PA (to 6100 ng.min-1) after DC, a significant increase in hepatic venous total t-PA occurred. CONCLUSIONS: The release and uptake of t-PA is indicated to be dynamic and organ-specific. DC induces an acute profibrinolytic reaction in preportal organs. The high hepatic t-PA uptake capacity restricts preportal profibrinolytic events to affect the systemic circulation.

  • 163.
    Sehlin, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Brändström, Helge
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Wadell, Karin
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Öhberg, Fredrik
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Simulated flying altitude and performance of continuous positive airway pressure devices2014In: Aviation, Space and Environmental Medicine, ISSN 0095-6562, E-ISSN 1943-4448, Vol. 85, no 11, p. 1092-1099Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Continuous positive airway pressure (CPAP) is used in air ambulances to treat patients with impaired oxygenation. Differences in mechanical principles between CPAP devices may affect their performance at different ambient air pressures as will occur in an air ambulance during flight. METHODS: Two different CPAP systems, a threshold resistor device and a flow resistor device, at settings 5 and 10 cm H2O were examined. Static pressure, static airflow and pressure during simulated breathing were measured at ground level and at three different altitudes (2400 m (8 kft), 3000 m (10 kft) and 10700 m (35 kft)). RESULTS: When altitude increased, the performance of the two CPAP systems differed during both static and simulated breathing pressure measurements. With the threshold resistor CPAP, measured pressure levels were close to the preset CPAP level. Static pressure decreased 0.71 ± 0.35 cm H2O, at CPAP 10 cm H2O, comparing ground level and 35 kft. With the flow resistor CPAP, as the altitude increased CPAP produced pressure levels increased. At 35 kft, the increase was 5.13 ± 0.33 cm H2O at CPAP 10 cm H2O. DISCUSSION: The velocity of airflow through the flow resistor CPAP device is strongly influenced by reduced ambient air pressure leading to a higher delivered CPAP effect than the preset CPAP level. Threshold resistor CPAP devices seem to have robust performance regardless of altitude. Thus, the threshold resistor CPAP device is probably more appropriate for CPAP treatment in an air ambulance cabin, where ambient pressure will vary during patient transport.

  • 164.
    Sehlin, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Sandkvist Törnell, Siv
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Öhberg, Fredrik
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Pneumatic performance of the boussignac CPAP system in healthy humans2011In: Respiratory care, ISSN 0020-1324, E-ISSN 1943-3654, Vol. 56, no 6, p. 818-826Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The Boussignac CPAP has been found to effectively treat acute pulmonary oedema. However, data on airway pressure in association with the Boussignac CPAP are sparse. We therefore designed this study to evaluate the stability of the Boussignac CPAP in terms of maintaining adequate inspiratory and expiratory pressure levels. We also wanted to evaluate the perceived exertion when breathing with the Boussignac CPAP.

    METHODS: Continuous recordings of airway pressure and airflow were made in 18 healthy volunteers during breathing with the Boussignac CPAP at 5, 7.5 and 10 cm H₂O for three sessions of 10 minutes at each CPAP level. Participants were blinded for the sequential order of the investigated CPAP levels. They terminated each session, at the respective CPAP level, by taking 10 forced breaths.

    RESULTS: During 10 minutes normal breathing periods, when participants breathed at 20 % of their VC with a peak expiratory airflow of 14 % of FEV₁, the maximal pressure difference was 4.0 cm H₂O between inspiration and expiration at CPAP 10 cm H₂O. Changes in airway pressure were never large enough to reduce airway pressure below zero. When taking forced breaths, expiratory volume was 38-42 % of VC and peak expiratory airflow was 49-56 % of FEV ₁. As airflow increased, both the drop in inspiratory airway pressure and the increase in expiratory airway pressure were enhanced.

    CONCLUSIONS: Pressure changes during breathing with CPAP are considered to be associated with increased work of breathing. The pneumatic performance of the Boussignac CPAP is adequate during normal breathing with low airflow. However, during forced breathing resulting in increased airflow, the Boussignac CPAP is unable to maintain stable airway pressure levels, possibly resulting in increased work of breathing and respiratory fatigue. Thus, the Boussignac CPAP system might be less suitable for patients breathing at a higher frequency.

  • 165.
    Sehlin, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Wadell, Karin
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
    Öhberg, Fredrik
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Immediate effects of positive expiratory pressure and continuous positive airway pressure breathing on changes in inspiratory capacity as an indirect measure of induced changes in functional residual capacity in healthy individualsManuscript (preprint) (Other academic)
    Abstract [en]

    Introduction: Positive expiratory pressure (PEP) and continuous positive airway pressure (CPAP) are used to enhance breathing parameters such as functional residual capacity (FRC) in patients. Studies comparing effects of PEP and CPAP on FRC are sparse. One reason for this may be that sophisticated equipment, not suitable in the clinical setting, is required. Total lung capacity consists of inspiratory capacity (IC) and FRC and a change in IC should therefore result in a corresponding change in FRC. We aimed to investigate if PEP and CPAP induced changes in IC could be used as an indirect measure of changes in FRC and also to evaluate immediate effects of PEP and CPAP devices, with different kinds of resistors, on IC. 

    Methods: 20 healthy volunteers breathed with two PEP devices, a PEP-mask (flow resistor) and a PEP-bottle (threshold resistor) and two CPAP devices, a flow resistor device and a threshold resistor device, in a randomized order. The measurement sequence consisted of 30 breaths with an IC measurement performed before and immediately after the 30th breath, while the participants were still connected to the respective breathing device. Perceived exertion of the respective 30 breaths was measured with Borg CR10 scale.

    Results: Three of the four breathing devices, the PEP-mask and the two CPAP devices, significantly decreased IC (p < 0.001). Median perceived exertion was quite low for all four breathing devices but the difference in perceived exertion within the different breathing devices was large.

    Conclusion: When measured in direct continuation of PEP and CPAP breathing, changes in IC could be used as an indirect measure of changes in FRC. All investigated breathing devices except the PEP-bottle decreased IC, i.e. increased FRC.

  • 166.
    Sharma, Rajiv
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Axelsson, H.
    Öberg, Åke
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Jansson, Erica
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Clergue, F.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Reiz, Sebastian
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Diaphragmatic activity after laparoscopic cholecystectomy1999In: Anesthesiology, Vol. 91, no 2, p. 406-13Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Laparoscopic cholecystectomy is presumed to induce a reduction in diaphragmatic activity. Indirect indices of diaphragmatic function based on tidal changes in pressures and cross-section area measurements can be unreliable in the postoperative phase. The present study evaluates diaphragmatic activity by directly recording diaphragmatic EMG (EMGdia) data, along with indirect indices. METHODS: Thirteen adult patients (American Society of Anesthesiologists physical status I or II) undergoing laparoscopic cholecystectomy were examined preoperatively for inspiratory tidal changes in gastric (Pgas-insp) and esophageal (Peso-insp) pressures, and tidal changes in ribcage (Vthor) and abdominal (Vabd) cross-section areas and then again at 1, 6, and 24 h postoperatively combined with EMGdia recordings. Variations in inspiratory gastric (deltaPgas-insp) and inspiratory transdiaphragmatic (deltaPdi-insp) pressures were derived from the above. RESULTS: Laparoscopic cholecystectomy induced a significant reduction in mean deltaPgas-insp, mean deltaPdi-insp, and mean Vabd indicating a reduction of diaphragmatic activity postoperatively. DeltaPdi-insp decreased from 11.8+/-4.0 cm H2O preoperatively to 5.7+/-5.7 cm H2O at 1 h and 6.6+/-5.1 cm H2O at 6 h postoperatively (mean +/- SD; P < 0.05). Vabd decreased from 327.0+/-113.0 ml preoperatively to 174.0+/-65.0 ml at 1 h and 175.0+/-98.0 ml at 6 h postoperatively (mean +/- SD; P < 0.05). These values had partially recovered at 24 h. CONCLUSION: The direct and indirect indices of diaphragmatic activity taken together confirm the presence of reduction in diaphragmatic activity after laparoscopic cholecystectomy followed by its partial recovery at 24 h.

  • 167.
    Sjöling, Mats
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Anesthesiology and Intensive Care.
    Experiences of abandonment and anonymity among arthroplastic surgery patients in the perioperative period: some issues concerning communication, pain and suffering2005Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The overall objective of the thesis is to describe and illustrate the experience of being an arthroplastic surgery patient during the perioperative period with regard to the issues of communication, pain,suffering and satisfaction with care. While waiting for surgery, the participants in this thesis experience suffering in different ways and mainly experience health care as being unavailable and negative in a faceless system (I). Obtaining information related to their illness is difficult, as it is hard to establish contact with health care providers. The responsibility for establishing contact and obtaining information rests solely with the patients (II). In Paper I, due to poor communication, the respondents express feelings of abandonment, anonymity and being disparaged by the health care system. During the participants' journey through the health care system, the negative experience acquires a more positive nature, as personal contacts are established with health care representatives (I-IV). The findings in the different papers (I-IV) are interpreted in the light of Katie Eriksson and Lennart Fredriksson’s descriptions of suffering and the caring conversation. There are participants in this thesis who have been able to reach a personal understanding of themselves and have found reconciliation in suffering. In this way, they have been able to maintain or obtain meaning in their lifeworld. Through their own power, or with the help of family and friends, individuals may be able to attain confirmation of their suffering, have the time and space to suffer and find reconciliation. However, as long as health care is experienced as a faceless system, there are individuals in this study who are unable to face their suffering. During the patients’ journey through the system, it becomes obvious that the system obtains a face when the individuals are able to establish trustful contact with an actual person within the system. The system does not obtain a face as long as the individuals perceive themselves as being poorly treated by health care representatives. In these cases, the system is actually the cause of additional suffering. In the terms defined by Fredriksson, the system obtains a face when a turning point occurs in the form of a caring conversation. During the waiting time, there are few opportunities for a caring conversation. An opportunity is more likely to occur when the individual is admitted to hospital. This is reflected in the extensive degree of satisfaction with care as expressed in Papers II-IV. High levels of satisfaction are reported, although the participants report having experienced high levels of postoperative pain. In Paper III, 68% (n=40) and, in Paper IV, 83.5% (n=50) of the patients experienced pain of ≥ 4 on the Visual Analogue Scale (VAS). When they have been admitted to hospital, the individuals sense that they are confirmed by and visible in the system. This visibility is mutual, as the individual becomes an actual person to health care representatives. In a caring conversation, a sense of trust is established and, as this occurs, the individual and the care provider dare to communicate in an open way, where both are present in the situation.

  • 168.
    Smith Ståhl, Robin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Predictive factors for successful medical studies2017Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 169.
    Smulter, Nina
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Cardiothoracic Surgery Division, Heart Center.
    Lingehall, Helena Claesson
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Disturbances in Oxygen Balance During Cardiopulmonary Bypass: A Risk Factor for Postoperative Delirium2018In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 32, no 2, p. 684-690Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to determine risk factors for postoperative delirium after cardiac surgery, specifically associated with the conduct of cardiopulmonary bypass (CPB).

    Design: Prospective observational study.

    Setting: Heart Centre, University Hospital.

    Participants: The study included 142 patients aged 70 years and older scheduled for elective cardiac surgery with CPB.

    Interventions: Risk factor analysis comprised information collected from the hospital clinical and CPB dedicated databases in addition to the medical chart. Delirium was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criterion using the Mini Mental State Examination and the Organic Brain Syndrome scale.

    Measurements and Main Results: Assessments of delirium diagnosis were executed preoperatively and on the following first and fourth postoperative days. Delirium occurred in 55% (78/142) of the patients. Patients with delirium were identified with significantly higher body weight and body surface area preoperatively, accompanied with longer CPB time, higher positive fluid balance per CPB, and lower systemic pump flow related to body surface area. Furthermore, the duration of the mixed venous oxygen saturation (SvO2) below 75% was significantly longer during CPB. The result from the multivariable logistic regression analysis included the duration of SvO2 below 75%, fluid balance per CPB and patient age as independent risk factors for postoperative delirium.

    Conclusions: The influence of the SvO2 level during CPB, fluid balance, and patient age should be recognized as risk factors for postoperative delirium after cardiac surgery in patients 70 years and older.

  • 170.
    Stålnacke, Britt-Marie
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine.
    Postconcussion symptoms in patients with injury-related chronic pain2012In: Rehabilitation Research and Practice, ISSN 2090-2867, E-ISSN 2090-2875, no 528265Article in journal (Refereed)
    Abstract [en]

    Background: Postconcussion symptoms (PCSs)—such as fatigue, headache, irritability, dizziness, and impaired memory—are commonly reported in patients who have mild traumatic brain injuries (MTBIs). Evaluation of PCS after MTBI is proposed to have a diagnostic value although it is unclear whether PCS are specific to MTBI. After whiplash injuries, patients most often complain of headaches and neck pain; the other PCS are not as closely evaluated. In patients with chronic pain because of other injuries, the presence of PCS is unclear. This study aimed to describe the frequency of PCS in patients with injury-related pain and to examine the relationships between PCS, pain, and psychological factors.

    Methods: This study collected data using questionnaires addressing PCS (Rivermead Postconcussion Questionnaire, RPQ), pain intensity (Visual Analogue Scale), depression, anxiety (Hospital, Anxiety, and Depression Scale), and posttraumatic stress (Impact of Event Scale).

    Results: Fatigue (90.7%), sleep disturbance (84.9%), headache (73.5%), poor concentration (88.2%), and poor memory (67.1%) were some of the most commonly reported PCS. Significant relationships were found between PCS and posttraumatic stress, depression, and anxiety.

    Conclusion: To optimize treatment, it is important to assess each patient’s PCS, the mechanism of injury, and factors such as posttraumatic stress and depression.

  • 171.
    Stålnacke, Britt-Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine.
    Möller, Riitta
    Karolinska Institutet.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Visst undervisas det om smärta i Umeå och vid KI2018In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, no 115Article in journal (Other (popular science, discussion, etc.))
  • 172.
    Stålnacke, Britt-Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine.
    Nygren-Deboussard, Catharina
    Godbolt, Alison
    af Geijerstam, Jean-Luc
    Holm, Lena
    Borg, Jörgen
    Mild traumatic brain injuries and their sequelae. II: at risk of clinical neglect?2012In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 44, no 11, p. 989-990Article in journal (Refereed)
  • 173.
    Sultan, Alexander
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Investigation of compliance to the Lund concept during the CENTER-TBI study2018Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 174. Sundeman, Henrik
    et al.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Broomé, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Biber, Björn
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    The effects of desflurane on cardiac function as measured by conductance volumetry in swine1998In: Anesth Analg, Vol. 87, no 3, p. 522-8Article in journal (Refereed)
    Abstract [en]

    The purpose of the investigation was to assess the effects of desflurane (DES) on left ventricular heart function during basal barbiturate anesthesia in a closed-pericardium, closed-chest acute swine model. The study was performed in 11 normoventilated adult pigs. Hemodynamic measurements were obtained using arterial, central venous, and pulmonary artery catheters, as well as a conductance volumetry and tip manometry catheter placed in the left ventricle. Hemodynamic measurements were recorded during basal pentobarbital anesthesia and with the addition of 1%, 2%, 4%, and 6% DES. DES dose-dependently decreased mean arterial pressure, systemic vascular resistance, left ventricular end-systolic pressure, dP/dtMAX and dP/dtMIN. At doses >1%, decreases in CO, stroke volume, ejection fraction, end-systolic elastance, preload recruitable stroke work, preload adjusted maximal power, and peak filling rate were observed. Heart rate decreased at 4% and 6% DES. Isovolumetric relaxation time increased only at 6% DES. We conclude that smaller doses of DES have a significant cardiodepressive effect in the setting of barbiturate infusion, as measured by conductance volumetry. IMPLICATIONS: Desflurane, in very small doses, depressed cardiac function during pentobarbital anesthesia with ketamine and benzodiazepine premedication in swine, as assessed by conductance volumetry and left ventricular pressure and volume relationship analysis. These results suggest that desflurane, in combination with certain anesthetics, can be cardiodepressive even in very small doses.

  • 175. Sundeman, Henrik
    et al.
    Åneman, Anders
    Broomé, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Biber, Björn
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Effects of desflurane on the pig intestinal circulation during hypotension1999In: Acta Anaesthesiol Scand, Vol. 43, no 10, p. 1069-77Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of the present study was to analyze the perfusion pressure dependency for the splanchnic vascular effects of desflurane (DES). METHODS: We measured portal blood flow (QPORT, perivascular ultrasound) and jejunal mucosal perfusion (JMP; laser Doppler) in pentobarbital-anesthetized pigs (n=10). Experimentally, decreases in mean arterial pressure (MAP) were produced by pericardial infusions of dextran. The protocol included sets of measurements at incremental doses of DES (1, 2, 4 and 6%) prior to and during pericardial infusions. RESULTS: Although QPORT and JMP decreased significantly during pericardial infusions, DES, irrespective of dose, did not reduce QPORT until MAP had decreased below 65-70 mm Hg. In higher MAP ranges, vasodilation in pre-portal tissues was powerful enough to maintain QPORT in spite of concurrent decreases in driving arterial pressure, as produced by either DES or pericardial infusion, or by a combination of both. We found no effects of DES on JMP even at very low MAP (about 40 mm Hg during pericardial infusion), indicating that the normal physiological response of the small intestine to redistribute blood flow from deeper to more superficial layers during hypotension was unimpaired by DES. CONCLUSIONS: Our data suggest a wide dose-tolerability of DES as regards the splanchnic circulation during hypotensive states.

  • 176.
    Sundkvist, Lina
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Impact of a failing epidural analgesia on postoperative recovery after abdominal laparotomy2017Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 177. Suominen, P. K.
    et al.
    Haney, Michael F.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. Univ Hosp Umea, Dept Anaesthesia & Intens Care Med, Umea, Sweden.
    Fast-tracking and extubation in paediatric cardiac surgery2017In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, no 8, p. 876-879Article in journal (Other academic)
  • 178.
    Svenmarker, Staffan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Hannuksela, Matias
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    A retrospective analysis of the mixed venous oxygen saturation as the target for systemic blood flow control during cardiopulmonary bypass2018In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111X, Vol. 33, no 6, p. 453-462Article in journal (Refereed)
    Abstract [en]

    Objectives: The patient's body surface area serves as the traditional reference for the determination of systemic blood flow during cardiopulmonary bypass (CPB). New strategies refer to different algorithms of oxygen delivery. This study reports on the mixed venous oxygen saturation (SvO2) as the target for systemic blood flow control. We hypothesise that an SvO2>75% (S(v)O(2)75) is associated with better preservation of renal function and improved short-term survival.

    Methods: This retrospective, 10-year, observational study analysed 6945 consecutive cardiac surgical cases requiring CPB. Endpoints included rates of acute kidney injury (AKI) and short-term survival, also the estimated glomerular filtration rate ((e)GFR), lactate levels and blood transfusions.

    Results: Seventy-seven percent of the patients attained the S(v)O(2)75 target. For this group, the median SvO2 was 78.1 (5.8) %, with a mean oxygen delivery of 331 (78) ml/min per m(2) body surface area. Overall incidence of AKI levels (I-III): 7.5% - 2.6% - 0.6%. Incidence of (e)GFR (<50%): 3.9%, increasing to 6% for haemoglobin levels <80 g/L (p<0.001). Red cell transfusion was more frequent (p<0.001) within this group (30.6%) compared to levels >100 g/L (0.3%). Further, women (52.8%) were transfused more often than men (14.6%). Lactate level at weaning from CPB was 1.3 (0.7) mmol/L. The S(v)O(2)75 target demonstrated a relative risk reduction of 22.5% (p=0.032) for AKI (I), increasing to 32.3% (p=0.026) for procedures extending >90 minutes. In addition, the risk for death 90-days postop was lower (p=0.039).

    Conclusion: The S(v)O(2)75 target showed a decreased risk for postoperative AKI and prolonged short-term survival. Good clinical outcomes were also linked to measures of lactate and the (e)GFR. However, anaemia remains a risk factor for AKI.

  • 179.
    Svenmarker, Staffan
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Axelsson, B.
    Wiklund, Urban
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Regional changes in cerebral blood flow oxygenation can indicate global changes in cerebral blood flow during coronary artery occlusion in juvenile pigs2014In: Physiological Measurement, ISSN 0967-3334, E-ISSN 1361-6579, Vol. 35, no 7, p. 1439-1450Article in journal (Refereed)
    Abstract [en]

    Near infrared spectroscopy (NIRS) is a widely employed method for assessment of regional cerebral oxygenation (R(c)StO(2)). RcStO(2) values are expected to vary with changes in the relative amount of oxyhaemoglobin. The present experimental study aimed to assess the response of RcStO(2) to controlled alterations of carotid blood flow (CQ). Landrace pigs were anesthetized followed by surgical preparation. Cyclic variations in cardiac output were accomplished by intermittently occluding the main stem of the left coronary artery. A flow measurement probe for assessing CQ was placed around the left carotid artery. One NIRS probe was placed on the left ipsilateral forehead to assess regional cerebral oximetry. Simultaneous registration of CQ and RcStO(2) was conducted. There was a strong correlation for variation in CQ and RcStO(2) signal values. Based on coherence analysis the fraction of power of the RcStO(2) that was coherent with the CQ signal reached 0.84 - 0.12 (P < 0.05) for frequencies lower than 0.1 Hz. The agreement of the sampleto- sample co-variation, as assessed by the Pearson correlation coefficient, was 0.83 +/- 0.08 (P < 0.05). One explanatory component for variations in cerebral oxygenation verified by NIRS should be attributed to variations in the cerebral blood flow.

  • 180.
    Svennerholm, Kristina
    et al.
    Anestesiologi, Sahlgrenska akademin, Göteborg.
    Bergh, Niklas
    Wallenberg lab, Sahlgrenska akademin, Göteborg.
    Larsson, Pia
    Wallenberg lab, Sahlgrenska akademin, Göteborg.
    Jern, Sverker
    Wallenberg lab, Sahlgrenska akademin, Göteborg.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Biber, Björn
    Anestesiologi, Sahlgrenska akademin, Göteborg.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Histone Deacetylase Inhibitor Treatment Increases Coronary t-PA Release in a Porcine Ischemia Model2014In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 5, p. e97260-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The expression of the tissue plasminogen activator gene can be affected by histone deacetylation inhibition and thus appears to be under epigenetic control.

    OBJECTIVES: The study aimed to test if in vivo pharmacological intervention by valproic acid treatment would lead to increase in tissue plasminogen activator release capacity. METHODS: In an anaesthetized pig model, a controlled transient coronary occlusion was used to stimulate coronary tissue plasminogen activator release in a valproic acid treated (one week) and a non-treated group. Coronary venous blood samples from the ischemic region were collected, great cardiac vein thermodilution flow measurements were performed, and trans-coronary tissue plasminogen activator fluxes were calculated. Plasminogen activator inhibitor-1 was also measured.

    RESULTS: Adequate sampling from the affected area after the 10 minute ischemic period was confirmed by lactate measurements. Fluxes for tissue plasminogen activator at minutes 1, 3, 5, 7 and 10 were measured and then used to present cumulative net tissue plasminogen activator release for the whole measurement period for both groups. Area under the curve was higher for the valproic acid treated group at 10 minutes; 932+/-173 nanograms (n = 12) compared to the non-treated group, 451+/-78 nanograms (n = 10, p = 0.023). There was no difference in levels of plasminogen activator inhibitor-1 between groups.

    CONCLUSIONS: These findings support a proof of concept for histone deacetylation inhibition positive effect on tissue plasminogen activator expression in an in vivo setting. Further studies are needed to find an optimal way to implement histone deacetylation inhibition to achieve desired clinical changes in tissue plasminogen activator expression.

  • 181. Talseth, Anne-Grethe
    et al.
    Gilje, Fredricka L.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Nurses' responses to suicide and suicidal patients: a critical interpretive synthesis*2011In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 20, no 11-12, p. 1651-1667Article, review/survey (Refereed)
    Abstract [en]

    Aims and objectives. To provide an inclusive understanding of nurses' responses to suicide and suicidal patients that can benefit nursing practice and guide research. The question was 'What is a critical interpretive synthesis of accumulated nursing research on nurses' responses to suicide and suicidal patients?' Background. Various studies address nurses' responses to suicide and suicidal patients. An understanding of accumulated research-based literature about nurses' responses to suicide and suicidal patients may guide nurses to care for suicidal patients in ways that facilitate suicide prevention and recovery. Design. The design is reflexive and iterative. Method. A Critical Interpretive Synthesis was conducted, which comprised of six phases: formulating the review question, searching the literature, sampling, determining quality, extracting data and conducting an interpretive synthesis. Qualitative content analysis and systematic review of literature was included in these phases. Results. The results report the review question, literature review strategies, purposive sample (26 full-text studies published in peer reviewed journals, 1988-July 2009, conducted mostly in Europe and North American), quality determinants, data extraction into themes and an interpretive synthesis of four key concepts, i.e. critical reflection, attitudes, complex knowledge/professional role responsibilities, desire for support services/resources. Conclusion. This understanding of accumulated research-based literature enhances contextual, conceptual and methodological perspectives. Contextually, gaps exist in international research. Conceptually, the four key concepts can serve as a useful guide for nurses to understand their own and other nurses' responses to caring for suicidal patients in various settings. Methodologically, the Critical Interpretive Synthesis approach moved a small body of knowledge that varied in quality measures beyond an aggregate understanding. Relevance to clinical practice. Understanding nurses' responses to suicide and suicidal patients may guide nurses to care for suicidal patients in ways that facilitate suicide prevention and recovery, thus addressing the urgent work of suicide prevention in the world.

  • 182.
    Talsi, Oskar
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Berggren, Ritva Kiiski
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. Swedish National Quality Registry for Intensive Care (SIR), Karlstad, Sweden.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    A national survey on routines regarding sedation in Swedish intensive care units2019In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 37, no 23, p. 3088-3096Article in journal (Refereed)
    Abstract [en]

    Background: Previous studies concerning sedation in Swedish intensive care units (ICU) have shown variability in drug choices and strategies. Currently, there are no national guidelines on this topic. As an update to a Nordic survey from 2004, and as a follow-up to a recently introduced quality indicator from the Swedish Intensive Care Registry, we performed a national survey.

    Methods: A digital survey was sent to the ICUs in Sweden, asking for sedation routines regarding hypnosedatives, analgosedatives, protocols, sedation scales, etc.

    Results: Fifty out of 80 ICUs responded to the survey. All units used sedation scales, and 88% used the RASS scale; 80% used written guidelines for sedation. Propofol and dexmedetomidine were the preferred short-term hypnosedatives. Propofol, dexmedetomidine, and midazolam were preferred for long-term hypnosedation. Remifentanil, morphine, and fentanyl were the most frequently used agents for analgosedation.

    Conclusions: All ICUs used a sedation scale, an increase compared with previous studies. Concerning the choice of hypno- and analgosedatives, the use of dexmedetomidine, clonidine, and remifentanil has increased, and the use of benzodiazepines has decreased since the Nordic survey in 2004.

  • 183.
    Thomasson, Cecilia
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Glycemic control in critically ill patients: An exploratory study at the Intensive Care Unit in Östersund2016Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 184.
    Thurm, Mascha
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Kröger Dahlin, Britt Inger
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Urology and Andrology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Ljungberg, Börje
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Urology and Andrology.
    Spinal analgesia improves surgical outcome after open nephrectomy for renal cell carcinoma: a randomized controlled study2017In: Scandinavian journal of urology, ISSN 2168-1805, E-ISSN 2168-1813, Vol. 51, no 4, p. 277-281Article in journal (Refereed)
    Abstract [en]

    Objective: This study evaluated whether more effective perioperative analgesia can be part of a multimodal approach to minimizing morbidity and improving postoperative management after the open surgical approaches frequently used in the treatment of renal cell carcinoma (RCC). The aim of the study was to determine whether spinal anesthesia with clonidine can enhance postoperative analgesia, speed up mobilization and reduce the length of hospital stay (LOS).

    Materials and methods: Between 2012 and 2015, 135 patients with RCC were randomized, in addition to general anesthesia, to receive either spinal analgesia with clonidine or epidural analgesia, stratified to surgical technique. Inclusion criteria were American Society of Anesthesiologists (ASA) score of III or less, age over 18 years and no chronic pain medication or cognitive disorders.

    Results: The median LOS was 4 days for patients in the spinal group and 6 days in the epidural group (p = 0.001). There were no differences regarding duration of surgery, blood loss, RENAL score, tumor size or complications between the given analgesia methods. A limitation was that different anesthesiologists were responsible for administering spinal or epidural anesthesia, as in a real-world clinical situation.

    Conclusions: In this randomized controlled study, spinal analgesia with clonidine was superior to continuous epidural analgesia in patients operated on with open nephrectomy, based on shorter LOS. A shorter LOS in the study group indicates faster mobilization and improved analgesia. Spinal analgesia did not carry more complications than epidural analgesia.

  • 185.
    Tydén, Jonas
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Heparin-binding protein and organ failure in critical illness2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: For patients severely ill enough to require care in an intensive care unit (ICU), both the disease itself (e.g. bacteria in the blood in sepsis or fractures after trauma) and effects of the immune system can cause circulatory, pulmonary, or renal dysfunction. Leukocytes play a dominant role in the immune system.  When activated they release a range of small proteins with different properties Heparin-binding protein (HBP) being one of these proteins, has many functions, including to increase vascular permeability. Heparin-binding protein causes plasma leakage from blood vessels into surrounding tissue (oedema), which can lead to  organ dysfunction depending on the site and degree of oedema formation. Increased concentration of HBP in plasma is associated with failing circulation and lung function in subgroups of critically ill patients.

    Aims: We investigated the possibility of using concentration of HBP in plasma for predicting circulatory, respiratory or renal failure in an ICU population with mixed diagnosis. We assessed concentration of HBP in alveoli in ventilator induced lung injury (VILI), and finally assessed elimination of HBP in urine and effluent fluid from continuous dialysis.

    Methods: In Papers I and II, HBP concentration in plasma was measured in 278 patients on admission to ICU. Sequential organ failure assessment (SOFA) scores and acute kidney injury (AKI) stage were recorded daily. In Paper III HBP concentration in bronco-alveolar fluid was measured in a pig model of ventilatory induced lung injury, in 16 healthy volunteers and in 10 intubated ICU patients. In Paper IV plasma and urine concentration of HBP was measured in 8 healthy volunteers and 20 burn ICU patients. In addition, HBP was sampled in plasma and effluent fluid in 32 ICU patients on continuous renal replacement therapy (CRRT).

    Results: In Paper I, patients developing circulatory failure (circulatory sub-score of SOFA = 4) had higher plasma concentration of HBP compared to those who did not (median(IQR)ng/ml) (63.5(32–105) vs 36.4(24–59)) p<0.01), and patients developing respiratory failure (P:F ratio < 27) had higher HBP concentration than those who did not (44.4(30-109) vs 35.2(23-57) p<0.01). Discriminatory capacity was (ROC AUC (95%CI)) (0.65 (0.54–0.76)) for circulatory failure and (0.61(0.54–0.69)) for respiratory failure. In Paper II, patients developing renal failure (AKI stage 2-3) had higher plasma concentration of HBP compared to those who did not (72.1 (13.0–131.2) vs 34.5 (19.7–49.3) p<0.01). Discriminatory capacity for AKI stage 3 was 0.68(0.54-0.83) (ROC AUC (95%CI)). In the subgroup with severe sepsis, it was  0.93 (0.85–1.00). In Paper III, HBP concentration in bronchoalveolar lavage was higher in pigs subjected to injurious ventilation over 6 hours ventilation compared to controls (1144(359–1636) vs 89(33–191) p=0.02) (median(IQR)ng/ml). The median HBP concentration in bronchoalveolar lavage from healthy volunteers was 0.90(0.79– 1.01) compared to 1959(612–3306) from intubated ICU patients (p < 0.01).In Paper IV, renal clearance of HBP was 0.19 (0.08-0.33) in healthy individuals and 0.30 (0.01-1.04)  (median, IQR, ml/min)  in burn ICU patients. Clearance of HBP was higher in burn patients with increased cystatin C (0.45(0.15-2.81) vs. 0.28(0.14-0.55) p=0.04). Starting CRRT did not alter plasma concentration of HBP (p=0.14). Median HBP concentration in effluent fluid on CRRT was 9.1 ng/ml (7.8-14.4).

    Conclusions: Papers I and II:There is an association between high concentration of HBP in plasma on ICU admission and circulatory, respiratory and renal failure. For the individual patient, the predictive value of a high HBP concentration is low, with the possible exception of renal failure in septic patients. Paper III:HBP concentration in alveoli increases in pigs subjected to injurious ventilation. HBP concentration in alveoli of intubated ICU patients ventilated protectively is elevated to similar levels, a factor of approximately 1000 times higher than the concentration seen in healthy controls. Paper IV:In healthy study participants, renal clearance of HBP is low. In critically ill burn patients with impaired renal function, clearance of HBP is increased. Starting CRRT in critically ill patients does not alter plasma concentration of HBP. Still, HBP is found in the CRRT effluent fluid, and concentration does not appear to be dependent on plasma concentration.

  • 186.
    Tydén, Jonas
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Herwald, H.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Walldén, Jakob
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Johansson, Joakim
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Heparin-binding protein as a biomarker of acute kidney injury in critical illness2017In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, no 7, p. 797-803Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There is no biomarker with high sensitivity and specificity for the development of acute kidney injury (AKI) in a mixed intensive care unit (ICU) population. Heparin-binding protein (HBP) is released from granulocytes and causes increased vascular permeability which plays a role in the development of AKI in sepsis and ischemia. The aim of this study was to investigate whether plasma levels of HBP on admission can predict the development of AKI in a mixed ICU population and in the subgroup with sepsis. METHODS: Longitudinal observational study with plasma HBP levels from 245 patients taken on admission to ICU. Presence and severity of AKI was scored daily for 1 week. RESULTS: Mean (95% CI) plasma concentrations of log HBP (ng/ml) in the groups developing different stages of AKI were: stage 0 (n = 175), 3.5 (3.4-3.7); stage 1 (n = 33), 3.7 (3.5-4.0), stage 2 (n = 20), 4.4 (3.5-4.8); and stage 3 (n = 17), 4.6 (3.8-5.2). HBP levels were significantly higher in patients developing AKI stage 3 (P < 0.01) compared to AKI stage 0 and 1. The area under the curve (AUC) for HBP to discriminate the group developing AKI stage 2-3 was 0.70 (CI: 0.58-0.82) and in the subgroup with severe sepsis 0.88 (CI: 0.77-0.99). CONCLUSION: Heparin-binding protein levels on admission to ICU are associated with the development of severe kidney injury. The relationship between HBP and AKI needs to be further validated in larger studies.

  • 187.
    Tydén, Jonas
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. Anestesiläkaravdelningen, Östersund Hospital, Östersund, Sweden.
    Larsson, Niklas
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Lehtipalo, Stefan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Herwald, H
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Walldén, Jakob
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Behndig, Annelie F.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Johansson, Joakim
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Heparin-binding protein in ventilator-induced lung injury.2018In: Intensive Care Medicine Experimental, ISSN 1646-2335, E-ISSN 2197-425X, Vol. 6, no 1, article id 33Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although mechanical ventilation is often lifesaving, it can also cause injury to the lungs. The lung injury is caused by not only high pressure and mechanical forces but also by inflammatory processes that are not fully understood. Heparin-binding protein (HBP), released by activated granulocytes, has been indicated as a possible mediator of increased vascular permeability in the lung injury associated with trauma and sepsis. We investigated if HBP levels were increased in the bronchoalveolar lavage fluid (BALF) or plasma in a pig model of ventilator-induced lung injury (VILI). We also investigated if HBP was present in BALF from healthy volunteers and in intubated patients in the intensive care unit (ICU).

    METHODS: Anaesthetized pigs were randomized to receive ventilation with either tidal volumes of 8 ml/kg (controls, n = 6) or 20 ml/kg (VILI group, n = 6). Plasma and BALF samples were taken at 0, 1, 2, 4, and 6 h. In humans, HBP levels in BALF were sampled from 16 healthy volunteers and from 10 intubated patients being cared for in the ICU.

    RESULTS: Plasma levels of HBP did not differ between pigs in the control and VILI groups. The median HBP levels in BALF were higher in the VILI group after 6 h of ventilation compared to those in the controls (1144 ng/ml (IQR 359-1636 ng/ml) versus 89 ng/ml (IQR 33-191 ng/ml) ng/ml, respectively, p = 0.02). The median HBP level in BALF from healthy volunteers was 0.90 ng/ml (IQR 0.79-1.01 ng/ml) as compared to 1959 ng/ml (IQR 612-3306 ng/ml) from intubated ICU patients (p < 0.001).

    CONCLUSIONS: In a model of VILI in pigs, levels of HBP in BALF increased over time compared to controls, while plasma levels did not differ between the two groups. HBP in BALF was high in intubated ICU patients in spite of the seemingly non-harmful ventilation, suggesting that inflammation from other causes might increase HBP levels.

  • 188.
    Törnell, Siv
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Ekeus, C.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Håkansson, Stellan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Thunberg, Johan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Högberg, U.
    Low Apgar score, neonatal encephalopathy and epidural analgesia during labour: a Swedish registry-based study2015In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 59, no 4, p. 486-495Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Maternal intrapartum fever (MF) is associated with neonatal sequelae, and women in labour who receive epidural analgesia (EA) are more likely to develop hyperthermia. The aims of this study were to investigate if EA and/or a diagnosis of MF were associated to adverse neonatal outcomes at a population level. METHODS: Population-based register study with data from the Swedish Birth Register and the Swedish National Patient Register, including all nulliparae (n = 294,329) with singleton pregnancies who gave birth at term in Sweden 1999-2008. Neonatal outcomes analysed were Apgar score (AS) < 7 at 5 min and ICD-10 diagnosis of neonatal encephalopathy (e.g. convulsions or neonatal cerebral ischaemia). Multivariate logistic regression was used to calculate adjusted odds ratios (AOR) with 95% confidence intervals (CI). RESULTS: EA was used in 44% of the deliveries. Low AS or encephalopathy was found in 1.26% and 0.39% of the children in the EA group compared with 0.80% and 0.29% in the control group. In multivariate analysis, EA was associated with increased risk with low AS, AOR 1.27 (95% CI 1.16-1.39), but not with diagnosis of encephalopathy, 1.11 (0.96-1.29). A diagnosis of MF was associated with increased risk for both low AS, 2.27 (1.71-3.02), and of neonatal encephalopathy, 1.97 (1.19-3.26). CONCLUSION: Diagnosis of MF was associated with low AS and neonatal encephalopathy, whereas EA was only associated with low AS and not with neonatal encephalopathy. The found associations might be a result of confounding by indication, which is difficult to assess in a registry-based population study.

  • 189.
    Vikner, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    s-S100B levels in intensive care patients diagnosed with traumatic brain injury, non-traumatic intracerebral hemorrhage, subarachnoid hemorrhage and successful resuscitation from cardiac arrest2018Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 190.
    Vilmi, Linda
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Is hypotension at induction of anesthesia associated with an increased risk for cardiovascular events within 30 days after surgery?2017Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 191.
    Wallden, Jakob
    Anestesi och Intensivvård, Anesthesiology.
    The influence of opioids on gastric function: -experimental and clinical studies.2008Other (Refereed)
  • 192.
    Wallden, Jakob
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. Anaesthesia and Intensive Care, Sundsvall.
    Flodin, Jesper
    Anaesthesia and Intensive Care, Sunderbyn.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. Anaesthesia and Intensive Care, Sunderbyn.
    Validation of a prediction model for post-discharge nausea and vomiting after general anaesthesia in a cohort of Swedish ambulatory surgery patients2016In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 33, no 10, p. 743-749Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In ambulatory surgery, post-discharge nausea and vomiting (PDNV) has been identified as a significant problem occurring in more than one-third of patients.

    OBJECTIVE: To validate a simplified PDNV score in a Swedish population. DESIGN: Prospective observational study.

    SETTING: Two county hospitals in Sweden: Sundsvall from June 2012 to May 2013 and Sunderbyn from January to October 2014.

    PATIENTS: Adult patients undergoing ambulatory surgery under general anaesthesia.

    MAIN OUTCOME MEASURES: Postoperative outcomes with a focus on nausea and vomiting were collected at 2, 4, and 6 h after surgery and on the first three postoperative days. The simplified PDNV score, calculated before discharge, included the factors: female sex, age less than 50 years, history of postoperative nausea and vomiting, postoperative nausea and opioids given postoperatively. The prediction performance of the simplified PDNV score was evaluated in terms of discrimination (area under receiver-operating characteristics curve) and calibration plots and was compared with that of the original development study.

    RESULTS: A total of 559 patients were asked to participate, of which 431 were included in the final study cohort. The overall risk of postoperative nausea and vomiting and PDNV were 18.8 [95% confidence interval (CI), 15.4-22.8]% and 28.1 (95% CI, 24.0-32.5)%, respectively. The discrimination capacity of the simplified PDNV score in our study was similar to that of the original dataset [area under the curve 0.693 (95% CI, 0.638-0.748) vs. 0.706 (0.681-0.731), absolute difference 0.013]. The slope of the calibration curve was 0.893, with a constant of 0.021 (R-square 0.884).

    CONCLUSION: In a Swedish cohort of patients, the simplified PDNV score performs well in discriminating between patients who will experience post-discharge nausea and/or vomiting after ambulatory surgery. Our results indicate that the simplified PDNV score is as valid in other cohorts as it was in the original development cohort.

  • 193.
    Walldén, J
    et al.
    Anestesi och Intensivvård, Anesthesiology.
    Gupta, A
    Carlsén, H O
    Supraventricular tachycardia induced by Datex patient monitoring system.1998Other (Refereed)
  • 194.
    Walldén, Jakob
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Halliday, T. A.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Reply to: Sorbello et al., PONV in bariatric surgery: time for opioid-free anaesthesia2017In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, no 7, p. 858-858Article in journal (Refereed)
  • 195.
    Walldén, Jakob
    et al.
    Anestesi och Intensivvård, Anesthesiology.
    Lindberg, G
    Sandin, M
    Thörn, S-E
    Wattwil, M
    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. 708-15Article 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.

  • 196.
    Walldén, Jakob
    et al.
    Anestesi och Intensivvård, Anesthesiology.
    Thörn, Sven-Egron
    Lindberg, Greger
    Wattwil, Magnus
    Effects of remifentanil on gastric tone.2008In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 52, no 7, p. 969-76Article 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.

  • 197.
    Walldén, Jakob
    et al.
    Anestesi och Intensivvård, Anesthesiology.
    Thörn, Sven-Egron
    Lövqvist, Asa
    Wattwil, Lisbeth
    Wattwil, Magnus
    The effect of anesthetic technique on early postoperative gastric emptying: -comparison of propofol-remifentanil and opioid-free sevoflurane anesthesia.2006In: Journal of Anesthesia, ISSN 0913-8668, E-ISSN 1438-8359, Vol. 20, no 4, p. 261-7Article in journal (Refereed)
    Abstract [en]

    PURPOSE: A postoperative decrease in the gastric emptying (GE) rate may delay the early start of oral feeding and alter the bioavailability of orally administered drugs. The aim of this study was to compare the effect on early gastric emptying between two anesthetic techniques.

    METHODS: Fifty patients (age, 19-69 years) undergoing day-case laparoscopic cholecystectomy were randomly assigned to received either total intravenous anesthesia with propofol/remifentanil/rocuronium (TIVA; n = 25) or inhalational opioid-free anesthesia with sevoflurane/rocuronium (mask induction; GAS; n = 25). Postoperative gastric emptying was evaluated by the acetaminophen method. After arrival in the recovery unit, acetaminophen (paracetamol) 1.5 g was given through a nasogastric tube, and blood samples were drawn during a 2-h period. The area under the serum-acetaminophen concentration curve from 0-60 min (AUC60), the maximal concentration (Cmax), and the time to reach C-max (Tmax) were calculated.

    RESULTS: Twelve patients were excluded due to surgical complications (e.g., conversion to open surgery) and difficulty in drawing blood samples (TIVA, n = 7; GAS, n = 5). Gastric emptying parameters were (mean +/- SD): TIVA, AUC60, 2458 +/- 2775 min.micromol.l(-1); Cmax, 71 +/- 61 micromol.l(-1); and Tmax, 81 +/- 37 min; and GAS, AUC60, 2059 +/- 2633 min.micromol.l(-1); Cmax, 53 +/- 53 micromol.l(-1); and Tmax, 83 +/- 41 min. There were no significant differences between groups.

    CONCLUSION: There was no major difference in early postoperative gastric emptying between inhalation anesthesia with sevoflurane versus total intravenous anesthesia with propofol-remifentanil. Both groups showed a pattern of delayed gastric emptying, and the variability in gastric emptying was high. Perioperative factors other than anesthetic technique may have more influence on gastric emptying.

  • 198.
    Walldén, Jakob
    et al.
    Anestesi och Intensivvård, Anesthesiology.
    Thörn, Sven-Egron
    Wattwil, Magnus
    The delay of gastric emptying induced by remifentanil is not influenced by posture.2004In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 99, no 2, p. 429-34, table of contentsArticle in journal (Refereed)
    Abstract [en]

    Posture has an effect on gastric emptying. In this study, we investigated whether posture influences the delay in gastric emptying induced by opioid analgesics. Ten healthy male subjects underwent 4 gastric emptying studies with the acetaminophen method. On two occasions the subjects were given a continuous infusion of remifentanil (0.2 microg. kg(-1). min(-1)) while lying either on the right lateral side in a 20 degrees head-up position or on the left lateral side in a 20 degrees head-down position. On two other occasions no infusion was given, and the subjects were studied lying in the two positions. When remifentanil was given, there were no significant differences between the two postures in maximal acetaminophen concentration (right side, 34 micromol. L(-1); versus left side, 16 micromol. L(-1)), time taken to reach the maximal concentration (94 versus 109 min), or area under the serum acetaminophen concentration time curve from 0 to 60 min (962 versus 197 min. micromol. L(-1)). In the control situation, there were differences between the postures in maximal acetaminophen concentration (138 versus 94 micromol. L(-1); P < 0.0001) and area under the serum acetaminophen concentration time curves from 0 to 60 min (5092 versus 3793 min. micromol. L(-1); P < 0.0001), but there was no significant difference in time taken to reach the maximal concentration (25 versus 47 min). Compared with the control situation, remifentanil delayed gastric emptying in both postures. We conclude that remifentanil delays gastric emptying and that this delay is not influenced by posture.

  • 199.
    Werr, J
    et al.
    Department of Physiology and .
    Johansson, Joakim
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. Pharmacology, Karolinska Institutet, Stockholm, Sweden.
    Eriksson, E E
    Hedqvist, P
    Ruoslahti, E
    Lindbom, L
    Integrin alpha(2)beta(1) (VLA-2) is a principal receptor used by neutrophils for locomotion in extravascular tissue.2000In: Blood, ISSN 0006-4971, E-ISSN 1528-0020, Vol. 95, no 5Article in journal (Refereed)
    Abstract [en]

    Cell adhesion molecules are critically involved in the multistep process of leukocyte recruitment in inflammation. The specific receptors used by polymorphonuclear leukocytes (PMN) for locomotion in extravascular tissue have as yet not been identified. By means of immunofluorescence flow cytometry and laser scanning confocal microscopy, this study demonstrated that surface expression of the alpha(2)beta(1) (VLA-2) integrin, though absent on blood PMN, is induced in extravasated PMN collected from human skin blister chambers, and rat PMN accumulated in the peritoneal cavity after chemotactic stimulation. Intravital time-lapse videomicroscopy was used to investigate chemoattractant-induced PMN locomotion in the rat mesentery in vivo. Local administration of function-blocking monoclonal antibody or peptide recognizing the alpha(2)beta(1) integrin reduced PMN migration velocity in the extravascular tissue by 73% +/- 3% and 70% +/- 10%, respectively (means +/- SD). The distance f-met-leu-phe peptide (fMLP)-stimulated human PMN migrated in a collagen gel in vitro was markedly reduced by treatment with anti-alpha(2) mAbs or peptide, whereas no effect was observed with antibodies or peptides recognizing the alpha(4)beta(1) or alpha(5)beta(1) integrins. Further evidence for a critical role of expression of alpha(2)beta(1) integrin in PMN locomotion in extravascular tissue was obtained in the mouse air pouch model of acute inflammation where chemoattractant-induced PMN recruitment was substantially inhibited by local anti-alpha(2) mAb treatment. Thus, expression of alpha(2)beta(1) integrin on extravasated PMN has been identified and a novel role of this receptor in regulating the extravascular phase of leukocyte trafficking in inflammation has been formulated. (Blood. 2000;95:1804-1809)

  • 200.
    Westman, Anton
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Letters to the editor2005In: Journal of Trauma, ISSN 0022-5282, E-ISSN 1529-8809, Vol. 59, no 4, p. 1033-1033Article in journal (Other academic)
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