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Background: Anesthesia preinduction anxiety in children can according to some studies lead to long-term anxiety and negative behavioral changes (NBC), while other studies have not found this effect. This secondary analysis from a recent premedication trial comparing clonidine and midazolam aimed to test the relation between preoperative anxiety assessed with modified Yale Preoperative Anxiety Scale (mYPAS) and postoperative NBCs assessed with Post Hospital Behavior Questionnaire (PHBQ), regardless of premedication type.

Methods: This is a planned secondary analysis from a published premedication comparison trial in an outpatient surgery cohort, children aged 2–7 years. Participant and preoperative factors, particularly preoperative anxiety as mYPAS scores, were assessed for association with development of postoperative NBCs.

Results: Fifty-four of the 115 participants had high preinduction anxiety (mYPAS >30), and 19 of 115 developed >3 postoperative NBCs 1 week after surgery. There was no association between preinduction anxiety level as mYPAS scores and the development of postoperative NBCs at 1 week after surgery (10 of 19 had both, p =.62) nor after 4- or 26-weeks post-surgery. Only lower age was associated with development of NBCs postoperatively.

Conclusions: Based on the findings from this cohort, high preinduction anxiety does not appear to be associated with NBCs postoperatively in children premedicated with clonidine or midazolam.

Objectives: Early mobilisation and effective pain management after open nephrectomy for renal cell carcinoma often include epidural analgesia (EDA), requiring an infusion pump and a urinary catheter, thus impeding mobilisation. Spinal anaesthesia (SpA) may be an alternative. This randomised clinical trial evaluated whether SpA improves analgesia and facilitates mobilisation over EDA and which factors influence mobilisation and length of stay (LOS).

Methods: Between 2012 and 2015, 135 patients were randomised and stratified by surgical method to either SpA with clonidine or EDA. Mobility index score (MobIs), pain scale, patient satisfaction questionnaire, and LOS were the main outcome measures.

Results: SpA patients exhibited an increase in MobIs significantly earlier than EDA patients. Among SpA patients >50% reached MobIs ≥13 by postoperative day 3, while 29% of EDA patients never reached MobIs ≥13 before discharge. SpA patients had higher maximum pain scores on postoperative days 1 and 2, but both groups had similar patient satisfaction. One day before discharge, 36/64 SpA versus 22/67 EDA patients (56% and 33%, respectively) were opioid-free. SpA patients were discharged significantly earlier than EDA patients.

Conclusions: SpA facilitates postoperative pain management and is associated with faster mobilisation and shorter LOS.

The trial was registered at ClinicalTrials.org (ID-NCT02030717).

Background: Mannose-binding lectin (MBL) mediates the innate immune response either through direct opsonisation of microorganisms or through activation of the complement system. There are conflicting data whether MBL deficiency leads to increased susceptibility to infections or not. The aim of this study was to determine if low levels of mannose-binding lectin (MBL) predict sepsis development, sepsis severity and outcome from severe sepsis or septic shock.

Method: Patients aged 18 years or more with documented sepsis within 24 h after admission to the intensive care unit were included if they had participated in a health survey and donated blood samples prior to the sepsis event. A subset of these patients had stored plasma also from the acute phase. Two matched referents free of known sepsis were selected for each case. Plasma levels MBL were determined in stored samples from health surveys (baseline) and from ICU admission (acute phase). The association between MBL and sepsis, sepsis severity and in-hospital mortality were determined with 1300 ng/mL as cut-off for low levels.

Results: We identified 148 patients (61.5% women) with a first-time sepsis event 6.5 years (median with IQR 7.7) after participation in a health survey, of which 122 also had samples from the acute septic phase. Both high MBL levels in the acute phase (odds ratio [95% confidence interval]) (2.84 [1.20-6.26]), and an increase in MBL levels from baseline to the acute phase (3.76 [1.21-11.72]) were associated with increased risk for in-hospital death in women, but not in men (0.47 [0.11-2.06]). Baseline MBL levels did not predict future sepsis, sepsis severity or in-hospital mortality.

Conclusions: An increase from baseline to the acute phase as well as high levels in the acute phase associated with an unfavourable outcome in women.

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.

Objective: This study was aimed to evaluate the patients perspectives, before and one month after surgery in patients treated with open surgery for renal cell carcinoma (RCC). Can effective perioperative analgesia be part of a multimodal approach to minimize morbidity and improve postoperative management [1].

Material and Methods: A total of 135 patients with RCC in all stages 2012-2015, were randomized to receive either spinal analgesia with clonidine, or epidural analgesia in addition to the general anesthesia: The patients were stratified according to surgical technique. Inclusion criteria: ASA score I-III, age >18 years, no chronic pain medication or cognitive disorders. The patients survey used was based on the EORTC QLQ-C30. Wilcoxon Signed Rank test and Mann-Whitney-U tests were used for statistical evaluation.

Results: A majority of the patients (117 of 135, 86%) responded to the survey. Patients groups treated with partial nephrectomy or radical nephrectomy, had significantly reduced physical and social functioning while emotional functioning improved postoperatively compared with preoperatively. In both surgical groups the patients reported significant negative financial difficulties postoperatively. Similar results was achieved for patients treated with either spinal or epidural anesthesia. The epidural group of patients experienced more negative social functioning but had an improved global health. When comparing the surgical procedures there was no significant difference in the quality of life parameters. However when comparing the analgesic groups, spinal anesthesia had significantly better physical and social functioning after surgery while the patients in the epidural group reported better global health.

Conclusion: Patients randomized to be treated with spinal analgesia with clonidine, had better physical and social functioning postoperatively than patients randomized to be treated with epidural analgesia.

AIMS: The activity of the sympathetic nervous system (SNS) is crucial at an early stage in the development of an inflammatory reaction. A study of metabolic events globally and locally in the early phase of acute pancreatitis (AP), implying hampered SNS activity, is lacking. We hypothesized that thoracic epidural anaesthesia (TEA) modulates the inflammatory response and alleviates the severity of AP in pigs.

MATERIAL AND METHODS: The taurocholate (TC) group (n = 8) had only TC AP. The TC + TEA group (n = 8) had AP and TEA. A control group (n = 8) underwent all the preparations, without having AP or TEA. Metabolic changes in the pancreas were evaluated by microdialysis and by histopathological examination.

RESULTS: The relative increase in serum lipase concentrations was more pronounced in the TC group than in TC + TEA and control groups. A decrease in relative tissue oxygen tension (PtiO₂) levels occurred one hour later in the TC + TEA group than in the TC group. The maintenance of normoglycaemia in the TC group required a higher glucose infusion rate than in the TC + TEA group. The relative decrease in serum insulin concentrations was most pronounced in the TC + TEA group.

CONCLUSION: TEA attenuates the development of AP, as indicated by changes observed in haemodynamic parameters and by the easier maintenance of glucose homeostasis. Further, TEA was associated with attenuated insulin resistance and fewer local pathophysiological events.

Background: Children get sedative premedication in order to avoid preoperative anxiety/distress and to get a smooth induction of anaesthesia. Midazolam has been the standard premedication since many years. Recent studies with clonidine has shown good results. We hypothesized that clonidine would be as good as midazolam at getting a calm child and a less distressful induction.

Material and methods: A prospective, randomised, blinded study including 116 children 2 - <8 years of age, ASA I-II who underwent ear-nose-throat outpatient surgery in Skellefteå Hospital. EudraCT Number: 2012-005215-42. The children were randomised to premedication with either oral clonidine 4 µg/kg body weight or oral midazolam 0.5 mg/kg body weight. The children were observed preoperatively, from entering the operating room and during the induction of anaesthesia and evaluated using the modified observational instrument Yale Preoperative Anxiety Scale (m-YPAS). The values in the two groups were statistically compared with chi-square test.

Results: There was a significant difference between the two groups in favour of midazolam. The children in the clonidine group had higher  m-YPAS score  showing more anxiety/distress during induction. With prospective subgroup analysis for age groups, there was a much more pronounced difference between groups for the younger children aged 2 up to 5 years of age.

Conclusion: Premedication with midazolam, compared to clonidine, appears to lead to less anxiety/distress during induction of anaesthesia in younger children from 2 up to 5, though with less pronounced effect for children 5 up to  8 years of age. 

Background: Sepsis is a life-threatening condition and obesity is related to the clinical outcome. The underlying reasons are incompletely understood, but the adipocyte derived hormones leptin and adiponectin may be involved.

Methods: Patients aged 18 years or more with documented first time sepsis events were included in a nested case-referent study if they had participated in previous health surveys. Two matched referents free of known sepsis were identified. Circulating levels of leptin and adiponectin were determined in stored plasma, and their impact on a future sepsis event and its outcome was evaluated.

Results: We identified 152 patients (62% women) with a sepsis event and a previous participation in a health survey. Eighty-three % had also blood samples from the acute event. Hyperleptinemia at health survey associated with a future sepsis event (OR 1.77, 95% CI 1.04-3.00) and with hospital death. After adjustment for BMI leptin remained associated with sepsis in men, but not in women. High levels in the acute phase associated with increased risk for in hospital death in women (OR 4.18, 95% CI 1.17-15.00), while being protective in men (OR 0.05, 95% CI 0.01-0.48). Furthermore, leptin increased more from baseline to the acute phase in men than in women. Adiponectin did not predict sepsis and did not relate to outcome.

Conclusions: Hyperleptinemia independently predicted the development of sepsis and an unfavourable outcome in men, and inertia in the acute response related to worse outcome.

Background: Up to 30–50% of children subject to general anaesthesia develop negative postoperative behaviour and emotional problems. Children are given sedative premedication in order to avoid preoperative anxiety/distress, get a smooth induction of anaesthesia and hopefully fewer cases of negative postoperative behaviour. The aim of this study was to find out whether premedication with clonidine or midazolam is better at preventing negative postoperative behaviour evaluated by the parent rating instrument: the Post Hospital Behaviour Questionnaire (PHBQ).

Materials and methods: A prospective, randomised, blinded study including 116 children 2–7 years of age, ASA I-II who underwent earnose-throat day surgery at Skelleftea Hospital, Sweden. The children were randomized to premedication with either oral clonidine 4 micrograms/kg body weight or oral midazolam 0.5 mg/ kg body weight. The parents were asked to fill in the PHBQ form one week, one month and six months after the surgery. The incidence of negative postoperative behaviour in the two groups was statistically compared with chi-square test.

Results: There were postoperative negative behaviours in both groups. Among children aged 2–4 there were significantly more negative behaviours in the clonidine group than in the midazolam group both one week and one month after the surgery. The difference between the two groups did not remain after six months but there were still postoperative negative behaviours in both groups at that time.

Conclusion: Oral midazolam is better than oral clonidine in preventing negative postoperative behaviour in children aged 2–4 years, one week and one month after surgery and anaesthesia.