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  • 1.
    Abrahamsson, Pernilla
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Methodological aspects on microdialysis sampling and measurements2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background:     The microdialysis (MD) technique is widely spread and used both experi­mentally and in clinical practice. The MD technique allows continuous collection of small molecules such as glucose, lactate, pyruvate and glycerol. Samples are often analysed using the CMA 600 analyser, an enzymatic and colorimetric analyser.  Data evaluating the performance of the CMA 600 analysis system and associated sample han­dling are sparse. The aim of this work was to identify sources of variability related to han­dling of microdialysis samples and sources of error associated with use of the CMA 600 analyser. Further, to develop and compare different application techniques of the micro­dialysis probes both within an organ and on the surface of an organ.

     Material and Methods:  Papers I and II are mainly in vitro studies with the exception of the No Net Flux calibration method in paper I where a pig model (n=7) was used to exam­ine the true concen­tration of glucose and urea in subcutaneous tissue. Flow rate, sampling time, vial and caps material and performance of the analyser device (CMA 600) were examined. In papers III and IV normoventilated anaesthetised pigs (n=33) were used. In paper III, heart ischemia was used as intervention to compare microdialysis measurements in the myocardium with corresponding measurements on the heart surface. In paper IV, microdialysis measurements in the liver parenchyma were compared with measurements on the liver surface in associa­tion with induced liver ischemia. All animal studies were approved by the Animal Experi­mental Ethics Committee at Umeå University Sweden.

    Results:  In paper I we succeeded to measure true concentrations of glucose (4.4 mmol/L) and Urea (4.1 mmol/L) in subcutaneous tissue. Paper II showed that for a batch analyse of 24 samples it is preferred to store microdialysis samples in glass vials with crimp caps. For reliable results, samples should be centrifuged before analysis. Paper III showed a new application area for microdialysis sampling from the heart, i.e. surface sampling. The sur­face probe and myocardial probe (in the myocardium) showed a similar pattern for glucose, lactate and glycerol during baseline, short ischemic and long ischemic interventions. In paper IV, a similar pattern was observed as in paper III, i.e. data obtained from the probe on the liver surface showed no differences compared with data from the probe in liver paren­chyma for glucose, lactate and glycerol concentrations during baseline, ischemic and reperfusion interven­tions.

    Conclusion:  The MD technique is adequate for local metabolic monitoring, but requires methodological considerations before starting a new experimental serie. It is important to consider factors such as flow rate, sampling time and handling of samples in association with the analysis device chosen. The main finding in this thesis is that analyses of glucose, lactate and glycerol in samples from the heart surface and liver surface reflect concentra­tions sampled from the myocardium and liver parenchyma, respectively.

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  • 2.
    Abrahamsson, Pernilla
    et al.
    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.
    An assessment of calibration and performance of the microdialysis system2005In: Journal of Pharmaceutical and Biomedical Analysis, ISSN 0731-7085, E-ISSN 1873-264X, Vol. 39, no 3-4, p. 730-734Article in journal (Refereed)
    Abstract [en]

    To improve the reliability of microdialysis measurements of tissue concentrations of metabolic substances, this study was designed to test both the performance and the internal validity of the microdialysis methods in the hands of our research group. The stability of the CMA 600 analyser was tested with a known glucose solution in 72 standard microvials and in 48 plastic vials. To evaluate if variation in sampling time makes any difference in sample concentration (recovery), sampling times of 10, 20 and 30 min were compared in vitro with a constant flow rate of 1 microl/min. For testing of sampling times at different flow rates, an in vitro study was performed in which a constant sample volume of 10 microl was obtained. With the no net flux method, the actual concentration of glucose and urea in subcutaneous tissue was measured. The CMA 600 glucose analysis function was accurate and stable with a coefficient of variability (CV) of 0.2-0.55%. There was no difference in recovery for the CMA 60 catheter for glucose when sampling times were varied. Higher flow rates resulted in decreased recovery. Subcutaneous tissue concentrations of glucose and urea were 4.4 mmol/l and 4.1 mmol/l, respectively. To conclude, this work describes an internal validation of our use of the microdialysis system by calibration of vials and catheters. Internal validation is necessary in order to be certain of adequate sampling times, flow rates and sampling volumes. With this in mind, the microdialysis technique is useful and appropriate for in vivo studies on tissue metabolism.

  • 3.
    Abrahamsson, Pernilla
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Åberg, Anna-Maja
    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.
    Johansson, Göran
    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.
    Blind, Per-Jonas
    Kirurgi, Skåne Universitets sjukhus, Lund.
    Comparison between outcome of  surface and intraparenchymatous sampling using microdialysis in an experimental liver ischemia modelManuscript (preprint) (Other academic)
    Abstract [en]

    Introduction. We recently have shown that samples from MD probes placed on the surface of the heart reflect metabolic events in the myocardium. This new interesting observation challenges us to consider whether surface application of MD applies to other parenchymatous organs and their surfaces.

    Material and methods.  In thirteen anesthetized pigs transient liver ischemia was achieved by occlusion of arterial and venous inflow to the liver. Two probes on liver surface, and two in parenchyma were perfused with a flow rate of 1 µL/min (n=13). An identical set up was used for probes with a flow rate of 2 µL/min (n=9). Samples were collected for every 15 minute period during 60 minutes of baseline, 45 minutes of ischemia and 60 minutes of reperfusion. Lactate, glucose, pyruvate and glycerol were analysed in MD samples. We focused on relative changes in the present paper.

    Results. There was a strong agreement in relative lactate and glucose levels between probes placed on liver surface and parenchyma. No significant differences in relative changes of lactate and glucose levels were seen between samples from surface probes and probes in liver parenchyma during equilibration, baseline, ischemia or reperfusion with a flow rate of 1 µL/min.

    Conclusion. MD sampling applied on the liver surface is a new application area for the MD technique, and may be used to monitor liver metabolism both during physiological and pathophysiological conditions.

  • 4.
    af Klinteberg, Ingvar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Airway management and safety aspects during induction of anaesthesia. - A comparison between Rapid sequence induction and Target controlled infusion in non-cardiac surgery2018Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 5.
    Ahlberg, Hans
    et al.
    Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine (Östersund).
    Wallgren, Daniel
    Department of Surgical and € Perioperative Sciences, Anaesthesiology and Intensive Care Medicine (Sunderbyn).
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Myrberg, Tomi
    Department of Surgical and € Perioperative Sciences, Anaesthesiology and Intensive Care Medicine (Sunderbyn).
    Johansson, Joakim
    Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine (Östersund).
    Less use of rescue morphine when a combined PSP/IPP-block is used for postoperative analgesia in breast cancer surgery: A randomised controlled trial2023In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 40, no 9, p. 636-642Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Surgery for breast cancer is common, and intravenous opioids are often used to control postoperative pain. Recently, pectoralis-2 (PECS-2) block has emerged as a promising regional anaesthetic alternative. With nomenclature recently proposed, this block is termed combined PSP/IPP-block (pectoserratus plane block/interpectoral plane block).

    OBJECTIVE: We aimed to compare the need for postoperative rescue morphine between the intervention group that received a pre-operative combined PSP/IPP-block and a control group that received peri-operative long-acting opioids for postoperative analgesia.

    DESIGN: A randomised controlled study.

    SETTING: Operating theatres of two Swedish hospitals. The patients were recruited between May 2017 and October 2020.

    PATIENTS: Among the 199 women scheduled to undergo breast cancer surgery (sector resection or radical mastectomy) who were enrolled in the study, 185 were available for follow up.

    INTERVENTION: All patients received general anaesthesia. The intervention group received a combined PSP/IPP-block before surgery. The control group received intravenous morphine 30 min before emergence from anaesthesia.

    MAIN OUTCOME MEASURE: The primary endpoint was the cumulative need for intravenous rescue morphine to reach a predefined level of pain control (visual analogue scale score <40 mm) during the first 48 h after surgery.

    RESULTS: Data from 92 and 93 patients in the intervention and control groups, respectively, were analysed. The amount of rescue morphine administered in the 48 h after surgery was significantly lower in the intervention group than in the control group (median: 2.25 vs 3.0 mg, P  = 0.021). The first measured pain score was lower in the intervention group than in the control group (35 vs. 40 mm, P  = 0.035). There was no significant difference in the incidence of nausea between the groups (8.7 vs. 12.9%, P  = 0.357).

    CONCLUSION: The use of a combined PSP/IPP-block block before breast cancer surgery reduces the need for postoperative rescue morphine, even when compared with the use of intra-operative morphine.

    TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03117894.

  • 6.
    Ahlström, Katarina
    et al.
    Anesthesia and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Biber, Björn
    Anesthesia and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Åberg, Anna-Maja
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Abrahamsson, Pernilla
    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.
    Ronquist, Gunnar
    Department of Medical Chemistry, Uppsala University, Uppsala, Sweden.
    Waldenström, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Haney, Michael F.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Exogenous carbon monoxide does not affect cell membrane energy availability assessed by sarcolemmal calcium fluxes during myocardial ischaemia-reperfusion in the pig2011In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 28, no 5, p. 356-362Article in journal (Refereed)
    Abstract [en]

    Carbon monoxide is thought to be cytoprotective and may hold therapeutic promise for mitigating ischaemic injury. The purpose of this study was to test low-dose carbon monoxide for protective effects in a porcine model of acute myocardial ischaemia and reperfusion.

    In acute open-thorax experiments in anaesthetised pigs, pretreatment with low-dose carbon monoxide (5% increase in carboxyhaemoglobin) was conducted for 120 min before localised ischaemia (45 min) and reperfusion (60 min) was performed using a coronary snare. Metabolic and injury markers were collected by microdialysis sampling in the ventricular wall. Recovery of radio-marked calcium delivered locally by microperfusate was measured to assess carbon monoxide treatment effects during ischaemia/reperfusion on the intracellular calcium pool.

    Coronary occlusion and ischaemia/reperfusion were analysed for 16 animals (eight in each group). Changes in glucose, lactate and pyruvate from the ischaemic area were observed during ischaemia and reperfusion interventions, though there was no difference between carbon monoxide-treated and control groups during ischaemia or reperfusion. Similar results were observed for glycerol and microdialysate Ca recovery.

    These findings show that a relatively low and clinically relevant dose of carbon monoxide did not seem to provide acute protection as indicated by metabolic, energy-related and injury markers in a porcine myocardial ischaemia/reperfusion experimental model. We conclude that protective effects of carbon monoxide related to ischaemia/reperfusion either require higher doses of carbon monoxide or occur later after reperfusion than the immediate time frame studied here. More study is needed to characterise the mechanism and time frame of carbon monoxide-related cytoprotection.

  • 7.
    Aléx, Jonas
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Uppstu, Tom
    Umeå University, Faculty of Medicine, Department of Nursing.
    Saveman, Britt-Inger
    Umeå University, Arctic Research Centre at Umeå University. Umeå University, Faculty of Medicine, Department of Nursing.
    The opinions of ambulance personnel regarding using a heated mattress for patients being cared for in a cold climate - An intervention study in ambulance care2017In: International Journal of Circumpolar Health, ISSN 1239-9736, E-ISSN 2242-3982, Vol. 76, article id 1379305Article in journal (Refereed)
    Abstract [en]

    The purpose of the study was to describe the opinions of ambulance personnel regarding differences between using a heated mattress and a standard ambulance mattress. This study was an intervention study with pre- and post-evaluation. Evaluations of the opinions of personnel regarding the standard unheated mattress were conducted initially. After the intervention with new heated mattresses, follow-up evaluations were conducted. Ambulance personnel (n=64) from an ambulance station in northern Sweden took part in the study, which ran from October 2014 until February 2016. There were differences in opinions regarding the standard unheated mattress and the new heated mattress. The evaluation of the proxy ratings by the personnel showed that the heated mattress was warmer than the standard mattress, more pleasant to lie on and that patients were happier and more relaxed than when the standard mattress was used. The ambulance personnel in this study rated the experience of working with the heated mattress as very positive and proxy rated that it had a good effect on patient comfort. A heated mattress can be recommended for patients in ambulance care, even if more research is needed to receive sufficient evidence.

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  • 8.
    Andersson, Clara
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Symtom, hälsorelaterad livskvalitet och fysisk kapacitet 1 år efter covid-192022Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 9.
    Andersson, Isaac
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Intensivvårdskrävande COVID-19-patienter i en regional kohort i Sverige – nutritionsaspekter.2022Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 10.
    Andersson-Wenckert, Ingrid
    et al.
    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.
    Lindkvist, Robert
    Reiz, Sebastian
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Anevac-D, a new system for close scavenging of anesthetic gases in dental practice1989In: Scandinavian Journal of Dental Research, ISSN 0029-845X, Vol. 97, no 5, p. 456-64Article in journal (Refereed)
    Abstract [en]

    Anevac-D, a new system for close scavenging of anesthetic gases in dental practice is described. It consists of a rubber nose mask surrounded by an outer rigid shell and a chin scavenger. A vacuum in the slot between the nose masks provides scavenging of gases escaping from the inner mask. Gases escaping from the mouth are evacuated mainly by the skin scavenger. The efficiency of this system was assessed in healthy volunteers using argon as a tracer gas. Mass spectrometry was used for measurement of inspired, expired, and scavenged gas concentrations. The scavenging efficiency of the complete system was around 80% and was not affected by poor patient cooperation. It decreased to about 65% when the chin scavenger was removed. The dentist's exposure was measured by sampling of argon in the breathing zone by a Saran system. The average 4-min exposure varied between 90 and 250 ppm depending on system configuration and patient cooperation. Patient acceptance and clinical applicability were judged good. It is concluded that the Anevac-D system provides excellent scavenging properties and exposure levels well within the official recommendations by the Swedish Board of Occupational Safety and Health.

  • 11.
    Arbeus, Mikael
    et al.
    Dept of Cardiothoracic Surgery and Anesthesiology, Örebro University hospital.
    Axelsson, Birger
    Dept of Cardiothoracic Surgery and Anesthesiology, Örebro University hospital.
    Friberg, Örjan
    Dept of Cardiothoracic Surgery and Anesthesiology, Örebro University hospital.
    Magnuson, Anders
    Statistical and Epidemiological Unit, Örebro University hospital.
    Bodin, Lennart
    Statistical and Epidemiological Unit, Örebro University hospital.
    Hultman, Jan
    Dept of Thoracic and Cardiovascular Anesthesio, Uppsala University hospital.
    Milrinone increases flow in coronary artery bypass grafts after cardiopulmonary bypass: a prospective, randomized, double-blind, placebo-controlled study2009In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 23, no 1, p. 48-53Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To compare the effects of a bolus of milrinone, 50 microg/kg, versus placebo on flow in coronary artery bypass grafts after cardiopulmonary bypass (CPB).

    DESIGN: A prospective, randomized, double-blind study.

    SETTING: A university hospital.

    PARTICIPANTS: Forty-four patients with stable angina and left ventricular ejection fraction >30% scheduled for elective coronary artery bypass graft (CABG) surgery were included.

    INTERVENTION: Patients were randomized to receive 50 microg/kg of milrinone (n = 22) or placebo (n = 22) after aortic declamping.

    MEASUREMENTS AND MAIN RESULTS: The flow in coronary artery bypass grafts was measured with a transit time flow meter at 10 minutes and 30 minutes after termination of CPB. The hemodynamic evaluation included transesophageal echocardiography, mean arterial pressure (MAP), heart rate, and intracavitary measurement of left ventricular end-diastolic pressure (LVEDP). The flow in the saphenous vein grafts was significantly higher in the milrinone group when compared with the placebo group both at 10 and 30 minutes after termination of CPB (p < 0.001). At 10 minutes, the flow was 64.5 +/- 37.4 mL/min (mean +/- standard deviation) and 43.6 +/- 25.7 mL/min in nonsequential vein grafts for milrinone and placebo, respectively. Corresponding values at 30 minutes were 54.8 +/- 29.9 mL/min and 35.3 +/- 22.4 mL/min. The left internal thoracic artery (LITA) flow was higher in the milrinone group but did not reach statistical significance. The fractional area change was higher, and the MAP and calculated pressure gradient (MAP-LVEDP) were lower at 10 minutes in the milrinone group.

    CONCLUSION: Milrinone significantly increases the flow in anastomosed saphenous vein grafts after CPB, and has beneficial effects on left ventricular function.

  • 12.
    A'roch, Roman
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Left ventricular function's relation to load, experimental studies in a porcine model2011Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Loading conditions are recognized to influence ventricular function according to the Starling relationship for length/stretch and force.  Many modern echocardiographic parameters which have been announced as describing ventricular function and contractile status, may be confounded by uncontrolled and unmeasured load.  These studies aimed to measure the relation between four differ­ent types of assessments of ventricular dysfunction and degrees of load.  Study examined the ‘myo­cardial performance index’ (MPI).  Study II examined long axis segmental mechanical dyssynchrony.  Study III examined tissue velocities, and Study IV examined ventricular twist.  All studies aimed to describe the relation of these parameters both to load and to inotropic changes.

    Methods:  In anesthetized juvenile pigs, left ventricular (LV) pressure and volume were measured continuously and their relationship (LVPVR) was analysed.  Preload alterations were brought about by inflation of a balloon tipped catheter in the inferior vena cava (IVCBO).  Inotropic interventions were brought about by either an overdose of anesthetic (combine intravenous pentobarbital and inhaled isoflurane, Study I), or beta blocker and calcium channel blocker given in combination (Stud­ies III and IV).  In one study (II), global myocardial injury and dysfunction was induced by endotoxin infusion.  MPI measurements were derived from LVPVR heart cycle intervals for isovolumic contrac­tion and relaxation as well as ejection time.  Long axis segmental dyssynchrony was derived by ana­lyzing for internal flow and time with segmental dyssynchronous segment volume change during systole, hourly before and during 3 hours of endotoxin infusion.  Myocardial tissue velocities were measured during IVCBO at control, during positive and then later negative inotropic interventions.  The same for apical and base circumferential rotational velocities by speckle tracking.  Load markers (including end-diastolic volume) were identified for each beat, and the test parameters were analysed together with load for a relation.  The test parameters were also tested during single apneic beats for a relation to inotropic interventions.

    Results: MPI demonstrated a strong and linear relationship to both preload and after-load, and this was due to changes in ejection time, and not the isovolumic intervals.  Long axis segmental dyssyn­chrony increased during each hour of endotoxin infusion and global myocardial injury.  This dysyn­chrony parameter was independent of load when tested by IVCBO. Peak systolic velocities were strongly load-independent, though not in all the inotropic situations and by all measurement axes.  Peak systolic strain was load-dependent, and not strongly related to inotropic conditions.  Peak sys­tolic LV twist and untwist were strongly load-dependent.

    Conclusions: MPI is strongly load-dependent, and can vary widely in value for the same contractile status if the load is varied.  Mechanical dyssynchrony measures are load-independen in health and also in early global endotoxin myocardial injury and dysfunction.  Peak sytole velocities are a clinically robust parameter of LV regional and global performance under changing load, though peak systolic strain seems to be load-dependent.  Left ventricular twist and untwist are load-dependent in this pig model.

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  • 13.
    Arvidsson, Anna
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    ICU-care for patients ≥ 80 years of age2016Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 14.
    Attebäck, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB). APL (Apoteket Produktion & Laboratorier AB), Stockholm, Sweden.
    Hedin, Bengt
    APL (Apoteket Produktion & Laboratorier AB), Stockholm, Sweden.
    Mattsson, Sofia
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB).
    Formulation Optimization of Extemporaneous Oral Liquids Containing Naloxone and Propranolol for Pediatric Use2022In: Scientia pharmaceutica, ISSN 0036-8709, E-ISSN 2218-0532, Vol. 90, no 1, article id 15Article in journal (Refereed)
    Abstract [en]

    There is a need to develop dosage forms suitable for children to improve drug treatment. Extemporaneous compounding of drugs for children is one way to meet these needs. However, excipients generally considered as safe in adults may not be appropriate in dosage forms intended for children. The aim was to optimize the composition of two pediatric liquid preparations by substituting paraben as a microbiological preservative and ethanol as a solubilizer, with excipients more suitable for pediatric use. The oral liquids were Naloxone 1 mg/mL and Propranolol 10 mg/mL. Twelve different formulations were tested with propranolol and naloxone, respectively, during the screening process to select appropriate formulations. Sodium benzoate and glycerol were used as a preservative and solubilizer, respectively, and different pH of the formulations were evaluated. The formulations were characterized according to dispensed dose (dosing accuracy), viscosity and osmolality. The optimized formulations from the screening process were tested with two amounts of sodium benzoate and microbiological assays were performed. These formulations were shown to have satisfactory preservative properties and dosing accuracy. The results showed that the oral liquids could be prepared without the addition of solubilizer and with lower osmolality (naloxone), thus reducing the risk of gastrointestinal side effects.

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  • 15.
    Atterhem, Veronica
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Myrberg, Tomi
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    The incidence of hemodynamic and respiratory adverse events in morbidly obese presenting for Bariatric surgery2018In: International Journal of Clinical Anesthesia and Research, Vol. 2, no 1, p. 009-017Article in journal (Refereed)
    Abstract [en]

    Context: Perioperative management of morbidly obese patients undergoing bariatric surgery is challenging. Lacking standardized perioperative protocols, complication rates may be high. This retrospective study aims to quantify the incidence of significant blood pressure decreases on induction of anesthesia and intraoperative hypoxemia, before implementation of a standardized protocol designed for bariatric surgery.

    Design: Retrospective, observational study.

    Setting: A 250-bed county hospital in northern Sweden.

    Subjects: 219 morbidly obese patients (body mass index > 35 kg/m2) who underwent bariatric surgery between 2003 and 2008.

    Main outcome measures: Incidence of systolic blood pressure (SAP) falls to less than 70% of the preoperative baseline during induction of anesthesia and incidence of perioperative hypoxemia.

    Results: The incidence of confirmed SAP falls to below 70% of baseline at induction of anesthesia was 56.2% (n = 123/219). This incidence rose with increasing age (p < 0.001) but not with body mass index (BMI). 3.7% (n = 8/219) of cases were marked as difficult intubations. A transient period of hypoxemia was observed in 6.8% (n = 15/219) and was more common with increasing BMI (p = 0.005). Fourteen different drug combinations were used in the study population. Of those administered an induction anesthetic drug, 72.6% (n = 159/193) were given an overdose when calculated by lean body weight, but this did not correlate significantly to SAP falls (p = 0.468).

    Conclusions: The incidence of a significant blood pressure fall upon induction of anesthesia was common. The incidence of airway and ventilation problems were low. Overdosing of anesthetics and excessive variation in applied anesthesia methods were found.

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  • 16.
    Axelsson, Birger
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Cardiac effects of non-adrenergic inotropic drugs: clinical and experimental studies2013Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Myocardial failure and dysfunction is not uncommon during critical illness and following cardiac surgery. For optimal treatment, a better understanding of the effects of inotropic drugs is needed. In this thesis, two non-adrenergic mediated inotropes, milrinone and levosimendan were studied in different models of myocardial dysfunction. The study aims were to assess the following: the effects of milrinone on blood flow in coronary artery bypass grafts during CABG surgery; the effects of milrinone on left ventricular diastolic function during post-ischaemic myocardial dysfunction; whether milrinone or levosimendan are protective or injurious during acute myocardial ischaemia, and if levosimendan potentiates myocardial function when added to milrinone in an experimental model of post-ischaemic (stunned) myocardium.

    Material and Methods: In Study I, 44 patients undergoing coronary artery bypass surgery(CABG) were included as subjects. Milrinone or saline was administrated in a single dose during cardio-pulmonary bypass (CPB) and coronary graft flow measurements were recorded after 10 and 30 min following CPB. In Study II; 24 patients undergoing CABG had estimations of peak ventricular filling rates made before and after CPB with administration of milrinone or saline as a single dose during CPB, performed by assessment of the rate of change in diastolic cross-sectional left ventricular area. In Study III, energy-metabolic effects of milrinone and levosimendan were measured in an anaesthetized porcine model during 45 minutes of regional myocardial ischemia. Microdialysis sampling of metabolites of local ischemic metabolism allowed assessment of glycolytic activity and the degree of myocardial calcium overload. In Study IV, in a porcine model of postischaemic myocardial stunning, ventricular pressure-volume relationships were analyzed when milrinone or a combination of milrinone and levosimendan were given together.

    Results: In Study I, there was a clear increase in non-sequential saphenous vein graft blood flow with milrinone at 10 minutes (64.5 ± 37.4 compared to placebo 43.6 ± 25.7 ml/min (mean ± SD).). A decreasing but still measureable flow increase was seen for milrinone at 30 minutes. In Study II, an increase in early left ventricular filling rate (ventricular cross-sectional area rate of change,dA/dt) was seen in the milrinone treated group. Pre-bypass milrinone group dA/dt 22.0 ± 9.5 changed to post-bypass values dA/dt 27.8 ± 11.5 cm2/sec). Placebo group pre-bypass dA/dt was 21.0 ± 8.7 and post-bypass 17.1 ± 7.1 cm2/sec. A milrinone effect was demonstrated in an adjusted regression model (p = 0.001). In Study III, neither milrinone nor levosimendan led to a change in energy-metabolic activity during ischemia as reflected by interstitial glucose, pyruvate, lactate orglycerol. Neither drug exacerbated the relative myocardial calcium overload during ischemia. In Study IV, milrinone improved active relaxation (tau) in post-ischemic stunned myocardium, but did not markedly improve systolic function by preload recruitable stroke work. Levosimendan added to milrinone showed minimal effect on active relaxation but a positive effect on systolic function in combination with milrinone.

    Conclusions: We conclude that milrinone treatment leads to an increase in blood flow in newly implanted coronary saphenous vein grafts, and improves ventricular relaxation post-cardiopulmonary bypass. Neither milrinone nor levosimendan, in this porcine model, negatively influence myocardial energy metabolism or calcium overload during acute ischaemia. Addition of levosimendan to milrinone treatment during post-ischaemic ventricular dysfunction may provide additive inotropic effects on systolic function but probably not for active relaxation.

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  • 17.
    Axelsson, Birger
    et al.
    Dept of Cardiothoracic Surgery and Anestesiology, Örebro University hospital.
    Arbeus, Mikael
    Dept of Cardiothoracic Surgery and Anestesiology, Örebro University hospital.
    Magnuson, Anders
    Statistical and Epidemiological Unit, Örebro University hospital.
    Hultman, Jan
    Thoracic clinic, Karolinska University hospital.
    Milrinone improves diastolic function in coronary artery bypass surgery as assessed by acoustic quantification and peak filling rate: a prospective randomized study2010In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 24, no 2, p. 244-249Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To compare the effects of a bolus dose of milrinone, 50 microg/kg, to placebo on diastolic function (active relaxation) in patients undergoing on-pump coronary artery bypass grafting (CABG).

    DESIGN: Prospective, randomized, double-blind, placebo-controlled study.

    SETTING: University hospital.

    PARTICIPANTS: Twenty-four patients with stable angina and left ventricular ejection fraction >30%, scheduled for elective CABG using cardiopulmonary bypass (CPB), were included.

    INTERVENTION: Patients were randomized to receive either 50 microg/kg of milrinone (n = 12) or placebo (n = 12) after aortic declamping.

    MEASUREMENTS AND MAIN RESULTS: The diastolic function of the left ventricle (LV) was measured as peak filling rate (dA/dt [maximal diastolic area change over time]) with transesophageal echocardiography (TEE) using acoustic quantification (AQ) before CPB and 10 minutes after termination of CPB. The normalized peak filling rate (dA/dt)/EDA was also calculated. Active relaxation was statistically significantly increased in the milrinone group compared with the placebo group after CPB.

    CONCLUSION: Patients undergoing CABG surgery and treated with milrinone after aortic declamping had better diastolic function following cardiopulmonary bypass.

  • 18.
    Axelsson, Birger
    et al.
    Örebro University, Örebro, Sweden .
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Gupta, Anil
    Örebro University, Örebro, Sweden .
    Tyden, Hans
    Örebro University, Örebro, Sweden .
    Wouters, Patrick
    Ghent, Belgium.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Effects of Combined Milrinone and Levosimendan Treatment on Systolic and Diastolic Function During Postischemic Myocardial Dysfunction in a Porcine Model2016In: Journal of Cardiovascular Pharmacology and Therapeutics, ISSN 1074-2484, E-ISSN 1940-4034, Vol. 21, no 5, p. 495-503Article in journal (Refereed)
    Abstract [en]

    It is not known whether there are positive or negative interactions on ventricular function when a calcium-sensitizing inotrope is added to a phosphodiesterase inhibitor in the clinical setting of acute left ventricular (LV) dysfunction. We hypothesized that when levosimendan is added to milrinone treatment, there will be synergetic inotropic and lusitropic effects. This was tested in an anesthetized porcine postischemic global LV injury model, where ventricular pressures and volumes (conductance volumetry) were measured. A global ischemic injury was induced by repetitive left main stem coronary artery occlusions. Load-independent indices of LV function were assessed before and after ventricular injury, after milrinone treatment, and finally after addition of levosimendan to the milrinone treatment. Nonparametric, within-group comparisons were made. The protocol was completed in 12 pigs, 7 of which received the inotrope treatment and 5 of which served as controls. Milrinone led to positive lusitropic effects seen by improvement in tau after myocardial stunning. The addition of levosimendan to milrinone further increased lusitropic state. The latter effect could however not be attributed solely to levosimendan, since lusitropic state also improved spontaneously in time-matched controls at the same rate during the corresponding period. When levosimendan was added to milrinone infusion, there was no increase in systolic function (preload recruitable stroke work) compared to milrinone treatment alone. We conclude that in this model of postischemic LV dysfunction, there appears to be no clear improvement in systolic or diastolic function after addition of levosimendan to established milrinone treatment but also no negative effects of levosimendan in this context.

  • 19.
    Axelsson, Birger
    et al.
    Dept of Cardiovascular and Thoracic Surgery and Anesthesiology and Intensive Care, Örebro University Hospital.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Svenmarker, Staffan
    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.
    Gupta, Anil
    Dept of Clinical Medicine, School of Health and Medical Sciences, Örebro University.
    Tydén, Hans
    Dept of Clinical Medicine, School of Health and Medical Sciences, Örebro University.
    Wouters, Patrick
    Dept of Anesthesiology, University Hospital Ghent, Ghent, Belgium.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Systolic and diastolic effects of milrinone and levosimendan in porcine post-ischemic myocardial dysfunctionManuscript (preprint) (Other academic)
  • 20.
    Axelsson, Birger
    et al.
    Dept of Cardiovascular and Thoracic Surgery, Örebro University hospital.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Abrahamsson, Pernilla
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Gupta, Anil
    Dept of Anesthesiology and Intensive Care, Örebro University hospital.
    Tydén, Hans
    Dept of Cardiovascular and Thoracic Surgery, Örebro University hospital.
    Wouters, Patrick
    Dept of Anesthesiology, University hospital Ghent, Belgium.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Milrinone and levosimendan during porcine myocardial ischemia: no effects on calcium overload and metabolism2013In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 57, no 6, p. 719-728Article in journal (Refereed)
    Abstract [en]

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

    METHODS: Anaesthetised juvenile pigs, average weight 36 kg, were randomised to one of three intravenous treatment groups: milrinone 50 μg/kg bolus plus infusion 0.5 μg/kg/min (n = 7), levosimendan 24 μg/kg plus infusion 0.2 μg/kg/min (n = 7), or placebo (n = 6) for 60 min prior to and during a 45 min acute regional coronary occlusion. Systemic and myocardial haemodynamics were assessed, and microdialysis was performed with catheters positioned in the left ventricular wall. (45) Ca(2+) was included in the microperfusate in order to assess local calcium uptake into myocardial cells. The microdialysate was analysed for glucose, lactate, pyruvate, glycerol, and for (45) Ca(2+) recovery.

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

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

  • 21.
    Baetzner, Anke S.
    et al.
    Institute of Sports and Sports Sciences, Heidelberg University, Heidelberg, Germany.
    Wespi, Rafael
    Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
    Hill, Yannick
    Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands; Institute of Brain and Behaviour Amsterdam, Amsterdam, Netherlands; Lyda Hill Institute for Human Resilience, Colorado Springs, United States.
    Gyllencreutz, Lina
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sauter, Thomas C.
    Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland.
    Saveman, Britt-Inger
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Mohr, Stefan
    Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany.
    Regal, Georg
    Center for Technology Experience, AIT Austrian Institute of Technology, Vienna, Austria.
    Wrzus, Cornelia
    Psychological Institute and Network Aging Research, Heidelberg University, Heidelberg, Germany.
    Frenkel, Marie O.
    Institute of Sports and Sports Sciences, Heidelberg University, Heidelberg, Germany.
    Preparing medical first responders for crises: a systematic literature review of disaster training programs and their effectiveness2022In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 30, no 1, article id 76Article, review/survey (Refereed)
    Abstract [en]

    Background: Adequate training and preparation of medical first responders (MFRs) are essential for an optimal performance in highly demanding situations like disasters (e.g., mass accidents, natural catastrophes). The training needs to be as effective as possible, because precise and effective behavior of MFRs under stress is central for ensuring patients’ survival and recovery. This systematic review offers an overview of scientifically evaluated training methods used to prepare MFRs for disasters. It identifies different effectiveness indicators and provides an additional analysis of how and to what extent the innovative training technologies virtual (VR) and mixed reality (MR) are included in disaster training research.

    Methods: The systematic review was conducted according to the PRISMA guidelines and focused specifically on (quasi-)experimental studies published between January 2010 and September 2021. The literature search was conducted via Web of Science and PubMed and led to the inclusion of 55 articles. Results: The search identified several types of training, including traditional (e.g., lectures, real-life scenario training) and technology-based training (e.g., computer-based learning, educational videos). Most trainings consisted of more than one method. The effectiveness of the trainings was mainly assessed through pre-post comparisons of knowledge tests or self-reported measures although some studies also used behavioral performance measures (e.g., triage accuracy). While all methods demonstrated effectiveness, the literature indicates that technology-based methods often lead to similar or greater training outcomes than traditional trainings. Currently, few studies systematically evaluated immersive VR and MR training.

    Conclusion: To determine the success of a training, proper and scientifically sound evaluation is necessary. Of the effectiveness indicators found, performance assessments in simulated scenarios are closest to the target behavior during real disasters. For valid yet inexpensive evaluations, objectively assessible performance measures, such as accuracy, time, and order of actions could be used. However, performance assessments have not been applied often. Furthermore, we found that technology-based training methods represent a promising approach to train many MFRs repeatedly and efficiently. These technologies offer great potential to supplement or partially replace traditional training. Further research is needed on those methods that have been underrepresented, especially serious gaming, immersive VR, and MR.

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  • 22. Bergquist, Maria
    et al.
    Samuelsson, Line
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Larsson, Anders
    Tydén, Jonas
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Johansson, Joakim
    Lipcsey, Miklos
    TNFR1, TNFR2, neutrophil gelatinase-associated lipocalin and heparin binding protein in identifying sepsis and predicting outcome in an intensive care cohort2020In: Scientific Reports, E-ISSN 2045-2322, Vol. 10, no 1, article id 15350Article in journal (Refereed)
    Abstract [en]

    To date no biomarkers can aid diagnosing sepsis with adequate accuracy. We set out to assess the ability of Tumor necrosis factor receptor (TNFR) 1 and 2, Neutrophil gelatinase-associated lipocalin (NGAL) and Heparin binding protein (HBP) to discriminate sepsis from non-infected critically ill patients in a large ICU cohort, and to evaluate their value to predict mortality at 30 days. Adult patients admitted to the ICU with an arterial catheter were included. Clinical data and blood samples were prospectively recorded daily. Diagnoses were set retrospectively. Descriptive statistics and logistic regression models were used. NGAL, TNFR1 and TNFR2 were higher in sepsis patients compared to other diagnoses, as well as in non-survivors compared to survivors. In addition, these biomarkers increased with increasing stages of acute kidney injury. TNFR1 and TNFR2 performed similarly to NGAL and CRP in identifying sepsis patients, but they performed better than CRP in predicting 30-day mortality in this ICU cohort. Thus, TNFR1 and TNFR2 may be particularly useful in identifying high risk sepsis patients and facilitate relevant health care actions in this group of sepsis patients.

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  • 23.
    Bergström, Alexandra
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Interhospitala transporter till endovaskulär behandling vid akut ischemisk stroke: En kohortanalys från norra Sverige2021Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 24.
    Birnefeld, Johan
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Petersson, Karl
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Wåhlin, Anders
    Umeå University, Faculty of Medicine, Umeå Centre for Functional Brain Imaging (UFBI). Umeå University, Faculty of Science and Technology, Centre for Biomedical Engineering and Physics (CMTF). Umeå University, Faculty of Science and Technology, Department of Applied Physics and Electronics. Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Eklund, Anders
    Umeå University, Faculty of Science and Technology, Centre for Biomedical Engineering and Physics (CMTF). Umeå University, Faculty of Medicine, Department of Radiation Sciences. Umeå University, Faculty of Science and Technology, Department of Applied Physics and Electronics.
    Birnefeld, Elin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Qvarlander, Sara
    Umeå University, Faculty of Medicine, Department of Radiation Sciences. Umeå University, Faculty of Science and Technology, Centre for Biomedical Engineering and Physics (CMTF).
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Malm, Jan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Zarrinkoob, Laleh
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Cerebral blood flow assessed with phase-contrast magnetic resonance imaging during blood pressure changes with noradrenaline and labetalol: a trial in healthy volunteers 2024In: Anesthesiology, ISSN 0003-3022, E-ISSN 1528-1175, Vol. 140, no 4, p. 669-678Article in journal (Refereed)
    Abstract [en]

    Background: Adequate cerebral perfusion is central during general anesthesia. However, perfusion is not readily measured bedside. Clinicians currently rely mainly on MAP as a surrogate even though the relationship between blood pressure and cerebral blood flow is not well understood. The aim of this study was to apply phase contrast MRI to characterize blood flow responses in healthy volunteers to commonly used pharmacological agents that increase or decrease arterial blood pressure.

    Methods: Eighteen healthy volunteers aged 30-50 years were investigated with phase contrast MRI. Intraarterial blood pressure monitoring was used. First, intravenous noradrenaline was administered to a target MAP of 20% above baseline. After a wash-out period, intravenous labetalol was given to a target MAP of 15% below baseline. Cerebral blood flow was measured using phase contrast MRI and defined as the sum of flow in the internal carotid arteries and vertebral arteries. CO was defined as the flow in the ascending aorta.

    Baseline median cerebral blood flow was 772 ml/min (interquartile range, 674 to 871), and CO was 5,874 ml/min (5,199 to 6,355). The median dose of noradrenaline was 0.17 µg · kg−1 · h−1 (0.14 to 0.22). During noradrenaline infusion, cerebral blood flow decreased to 705 ml/min (606 to 748; P = 0.001), and CO decreased to 4,995 ml/min (4,705 to 5,635; P = 0.01). A median dose of labetalol was 120 mg (118 to 150). After labetalol boluses, cerebral blood flow was unchanged at 769 ml/min (734 to 900; P = 0.68). CO increased to 6,413 ml/min (6,056 to 7,464; P = 0.03).

    Conclusion: In healthy awake subjects, increasing MAP using intravenous noradrenaline decreased cerebral blood flow and CO. This data does not support inducing hypertension with noradrenaline to increase cerebral blood flow. Cerebral blood flow was unchanged when decreasing MAP using labetalol.

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  • 25.
    Bjornestad, Elin Eb
    et al.
    Kirurgisk serviceklinikk, Klinikkoverlege, Helse Bergen HF, Norway.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    An obstetric anaesthetist: A key to successful conversion of epidural analgesia to surgical anaesthesia for caesarean delivery?2020In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 64, no 2, p. 142-144Article in journal (Refereed)
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  • 26.
    Björklin, Josefin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    The effect of spinal anaesthesia in postoperative analgesia after caesarean sections - comparison between adjuvant morphine and fentanyl2017Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 27.
    Björkström, Viktor
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. Umeå University, Faculty of Medicine, Department of Molecular Biology (Faculty of Medicine).
    Extracellulärt ATP hos COVID-19-patienter2021Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 28.
    Björsell, Tove
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology.
    Lungfunktion tre till sex månader efter COVID-19 infektion.2021Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 29.
    Blank, Johanna
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Illamående och kräkning efter utskrivning (PDNV) hos dagkirurgiska patienter med låg risk för PDNV – en observationsstudie2019Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 30.
    Blom, Mikaela
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Tidigt postoperativt illamående och kräkning efterlaparoskopisk kolecystektomi2022Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 31. Bockhop, Fabian
    et al.
    Zeldovich, Marina
    Cunitz, Katrin
    Van Praag, Dominique
    van der Vlegel, Marjolein
    Beissbarth, Tim
    Hagmayer, York
    von Steinbuechel, Nicole
    Kondziella, Daniel (Contributor)
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Koskinen, Lars-Owe D. (Contributor)
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Sundström, Nina (Contributor)
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Measurement invariance of six language versions of the post-traumatic stress disorder checklist for DSM-5 in civilians after traumatic brain injury2022In: Scientific Reports, E-ISSN 2045-2322, Vol. 12, no 1, article id 16571Article in journal (Refereed)
    Abstract [en]

    Traumatic brain injury (TBI) is frequently associated with neuropsychiatric impairments such as symptoms of post-traumatic stress disorder (PTSD), which can be screened using self-report instruments such as the Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5). The current study aims to inspect the factorial validity and cross-linguistic equivalence of the PCL-5 in individuals after TBI with differential severity. Data for six language groups (n ≥ 200; Dutch, English, Finnish, Italian, Norwegian, Spanish) were extracted from the CENTER-TBI study database. Factorial validity of PTSD was evaluated using confirmatory factor analyses (CFA), and compared between four concurrent structural models. A multi-group CFA approach was utilized to investigate the measurement invariance (MI) of the PCL-5 across languages. All structural models showed satisfactory goodness-of-fit with small between-model variation. The original DSM-5 model for PTSD provided solid evidence of MI across the language groups. The current study underlines the validity of the clinical DSM-5 conceptualization of PTSD and demonstrates the comparability of PCL-5 symptom scores between language versions in individuals after TBI. Future studies should apply MI methods to other sociodemographic (e.g., age, gender) and injury-related (e.g., TBI severity) characteristics to improve the monitoring and clinical care of individuals suffering from PTSD symptoms after TBI.

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  • 32.
    Bromfalk, Åsa
    Umeå University, Faculty of Medicine, Department of Diagnostics and Intervention. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Intervention for prevention: easing children’s preoperative anxiety2024Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Preoperative anxiety in children is associated with several adverse outcomes and consequences that can have a negative impact on the perioperative outcome and delay recovery. Anxiety can cause stress-induced cardiorespiratory instability, increased postoperative pain, nausea, emergence delirium, and long-term behavior changes. The ideal premedication for children is still debated. Only a few studies have examined the use of premedication in relation to total intravenous anesthesia (TIVA), and there is also a lack of studies exploring staff’s experiences of premedication. The aim of this thesis was to compare midazolam (a benzodiazepine), clonidine, and dexmedetomidine (a2-agonists) given as premedication to preschool children, regarding anxiety, cardiorespiratory response to sedation, time to postoperative recovery, posthospital negative behavior changes (NBCs), and staff’s experiences of the interventions.

    Methods: In a randomized clinical trial, 90 children aged 2–6 years, scheduled for TIVA and ear, nose, and throat surgery, were randomized to one of three groups, receiving midazolam 0.5 mg/kg, clonidine 4 mg/kg, or dexmedetomidine 2 mg/kg. The children were included at a 200-bed county hospital in northern Sweden and observed with validated tools from the day of surgery until two weeks postoperatively (Studies I–IV). To explore the clinical aspects, we conducted focus group interviews to elicit perioperative staff’s experiences of the studied interventions and analyzed the data with qualitative content analysis (Study V). 

    Results: Midazolam reduced preoperative anxiety and provided perioperative cardiorespiratory stability. Clonidine and dexmedetomidine provided deeper sedation along with a minor decrease in heart rate. Some children, mainly from the clonidine group, awoke during the preoperative preparation, triggering anxiety, while the midazolam group remained conscious, calm, and cooperative. Postoperatively, the midazolam group emerged earlier from anesthesia compared to the two a2-agonist groups. However, the midazolam group had more episodes of postoperative anxiety, delirium, and pain compared to both groups receiving a2-agonists, and the overall recovery and discharge time from the post-anesthesia care unit was thus the same for all groups. The posthospital study showed at least one NBC in half of the children during the first two weeks after surgery. The staff’s experiences of premedication could be summarized in three themes: a matter of time, covering the efforts of building trust along with timing the administration and onset; don’t wake the sleeping bear, covering the challenge of maintaining sleep in the sleeping child in order to avoid a backlash if woken; and on responsive tiptoes, covering safety precautions and ethical perspectives on the interventions.

    Conclusion: The different premedications varied in their ability to reduce anxiety and to induce sleep, and this manifested itself throughout the perioperative process. Short-acting midazolam reduced preoperative anxiety but did not provide adequate sleep, and early postoperative emergence occasionally caused a rise in adverse symptom intensification. The long-lasting and sleep-inducing a2-agonists showed an unsatisfactory anxiolytic effect in comparison to midazolam. The sleep was superficial, and an awakening risked triggering anxiety. The staff strove to keep the sedated child asleep, and the recovery time was better and more peaceful when the children slept for a long time postoperatively. However, despite a calm perioperative process, one in two children presented with posthospital NBC. At the doses used in this study, all these premedications seem to be safe in cardiorespiratory terms, and the decision of which one to use should be tailored by individual and time.

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  • 33.
    Bromfalk, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Engström, Åsa
    Department of Health, Education and Technology, Division of Nursing and Medical Technology, Luleå University of Technology, Sweden.
    Walldén, Jakob
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Myrberg, Tomi
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Posthospital negative behavioural changes in children: a secondary analysis of a previous randomized clinical trial including a narrative reviewManuscript (preprint) (Other academic)
  • 34.
    Bromfalk, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Myrberg, Tomi
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Engström, Åsa
    Luleå Tekniska universitet.
    Walldén, Jakob
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Postoperative recovery in preschool-aged children: A secondary analysis of a randomized controlled trial comparing premedication with midazolam, clonidine, and dexmedetomidine2023In: Pediatric Anaesthesia, ISSN 1155-5645, E-ISSN 1460-9592, Vol. 33, no 11, p. 962-972Article in journal (Refereed)
    Abstract [en]

    Background: Preoperative anxiety in pediatric patients can worsen postoperative outcomes and delay discharge. Drugs aimed at reducing preoperative anxiety and facilitating postoperative recovery are available; however, their effects on postoperative recovery from propofol-remifentanil anesthesia have not been studied in preschool-aged children. Thus, we aimed to investigate the effects of three sedative premedications on postoperative recovery from total intravenous anesthesia in children aged 2–6 years.

    Methods: In this prespecified secondary analysis of a double-blinded randomized trial, 90 children scheduled for ear, nose, and throat surgery were randomized (1:1:1) to receive sedative premedication: oral midazolam 0.5 mg/kg, oral clonidine 4 μg/kg, or intranasal dexmedetomidine 2 μg/kg. Using validated instruments, outcome measures including time for readiness to discharge from the postoperative care unit, postoperative sedation, emergence delirium, anxiety, pain, and nausea/vomiting were measured.

    Results: After excluding eight children due to drug refusal or deviation from the protocol, 82 children were included in this study. No differences were found between the groups in terms of median time [interquartile range] to readiness for discharge (midazolam, 90 min [48]; clonidine, 80 min [46]; dexmedetomidine 100.5 min [42]). Compared to the midazolam group, logistic regression with a mixed model and repeated measures approach found no differences in sedation, less emergence delirium, and less pain in the dexmedetomidine group, and less anxiety in both clonidine and dexmedetomidine groups.

    Conclusions: No statistical difference was observed in the postoperative recovery times between the premedication regimens. Compared with midazolam, dexmedetomidine was favorable in reducing both emergence delirium and pain in the postoperative care unit, and both clonidine and dexmedetomidine reduced anxiety in the postoperative care unit. Our results indicated that premedication with α2-agonists had a better recovery profile than short-acting benzodiazepines; although the overall recovery time in the postoperative care unit was not affected.

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  • 35.
    Bromfalk, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Wallden, Jakob
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Myrberg, Tomi
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Cardiorespiratory response to sedative premedication in preschool children: a randomized controlled trial comparing midazolam, clonidine, and dexmedetomidine2023In: Journal of Perianesthesia Nursing, ISSN 1089-9472, E-ISSN 1532-8473, Vol. 38, no 3, p. 454-460Article in journal (Refereed)
    Abstract [en]

    Purpose: Sedative premedication in children may negatively impact their cardiorespiratory status during the perioperative course, and no clear consensus exists on the optimal premedication treatment for pediatric patients. The objective was to compare the perioperative cardiorespiratory responses to sedation using three different sedative premedication regimens in preschool children scheduled for surgery with total intravenous anesthesia.

    Design: A single-center randomized controlled trial.

    Methods: This is a planned secondary analysis of a study conducted at a 200-bed tertiary referral hospital. Ninety children participated in the study. They were aged 2–6 years and scheduled for ear, nose, and throat surgery with propofol/remifentanil anesthesia. Participants were randomly assigned to receive oral midazolam 0.5 mg/kg-1 (MID), oral clonidine 4 mcg/kg–1 (CLO), or intranasal dexmedetomidine 2 mcg/kg-1 (DEX). The main outcome measures were the sedation level, based on the Ramsay Sedation Scale (RSS), and cardiorespiratory status, monitored during the perioperative period.

    Findings: The final cohort had 83 children (MID, n=27; CLO, n=26; DEX, n=30), with similar intergroup patient characteristics. RSS scores were lower in the MID group than in the CLO and DEX groups before induction and within 30 min postsurgery (P<0.001 and P=0.006, respectively). A negative correlation existed between the RSS and heart rate (HR) (r=-0.570, P<0.001). Before anesthesia induction, the respiratory rate was lowest in the DEX group (MID 21.5±1.7 min–1, CLO 20.6±2.6 min–1, DEX 20.2±1.7 min–1; P=0.042). The HR was lower in the CLO and DEX groups than in the MID group (MID, 102.8±10.0 min–1; CLO, 87.4±9.6 min–1; DEX, 87.6±7.9 min–1; P<0.001). The HR was lower immediately after induction (P=0.009) and intraoperatively (P=0.025) in the CLO and DEX groups than in the MID group.

    Conclusions: When used as premedication before propofol/remifentanil anesthesia, clonidine and dexmedetomidine provided deeper preoperative sedation compared to midazolam. From a clinical perspective, all three study drugs provided essentially stable cardiovascular and respiratory conditions during the entire perioperative period.

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  • 36.
    Bromfalk, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    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.
    Myrberg, Tomi
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Engström, Åsa
    Department of Health, Education and Technology, Division of Nursing and Medical Technology, Luleå University of Technology, Sweden.
    Perioperative staff’s experiences of premedication for children2024In: Journal of Perianesthesia Nursing, ISSN 1089-9472, E-ISSN 1532-8473Article in journal (Refereed)
  • 37.
    Bromfalk, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Myrberg, Tomi
    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.
    Engström, Åsa
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Preoperative anxiety in preschool children: A randomized clinical trial comparing midazolam, clonidine, and dexmedetomidine2021In: Pediatric Anaesthesia, ISSN 1155-5645, E-ISSN 1460-9592, Vol. 31, no 11, p. 1225-1233Article in journal (Refereed)
    Abstract [en]

    Introduction: Anxiety in pediatric patients may challenge perioperative anesthesiology management and worsen postoperative outcomes. Sedative drugs aimed to reducing anxiety are available with different pharmacologic profiles, and there is no consensus on their effect or the best option for preschool children. In this study, we aimed to compare the effect of three different premedications on anxiety before anesthesia induction in preschool children aged 2-6 years scheduled for elective surgery. The secondary outcomes comprised distress during peripheral catheter (PVC) insertion, compliance at anesthesia induction, and level of sedation.

    Patients and methods: In this double-blinded randomized clinical trial, we enrolled 90 participants aged 2-6 years, who were scheduled for elective ear-, nose-and-throat surgery. The participants were randomly assigned to three groups: those who were administered 0.5 mg/kg oral midazolam, 4 µg/kg oral clonidine, or 2 µg/kg intranasal dexmedetomidine. Anxiety, distress during PVC insertion, compliance with mask during preoxygenation, and sedation were measured using the modified Yale Preoperative Anxiety Scale, Behavioral Distress Scale, Induction Compliance Checklist, and Ramsay Sedation Scale, respectively.

    Results: Six children who refused premedication were excluded, leaving 84 enrolled patients. At baseline, all groups had similar levels of preoperative anxiety and distress. During anesthesia preparation, anxiety was increased in the children who received clonidine and dexmedetomidine; however, it remained unaltered in the midazolam group. There were no differences in distress during PVC insertion or compliance at induction between the groups. The children in the clonidine and dexmedetomidine groups developed higher levels of sedation than those in the midazolam group.

    Conclusions: In preschool children, midazolam resulted in a more effective anxiolysis and less sedation compared to clonidine and dexmedetomidine.

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  • 38.
    Brorsson, Camilla
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Trauma - logistics and stress response2014Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Trauma is a major cause of death and disability. Adverse events, such as prolonged prehospital time, hypoxia, hypotension and/or hyperventilation have been reported to correlate to poor outcome.

    Adequate cortisol levels are essential for survival after major trauma. In hypotensive critically ill patients, lack of sufficient amount of cortisol can be suspected, and a concept of critical illness related corticosteroid insufficiency has been proposed. Corticosteroid therapy has many adverse effects in critically ill patients and should only be given if life-saving. Correct measurement of serum cortisol levels is important but difficult in critically ill patients with capillary leakage. Estimation of the free and biologically active cortisol is preferable. In serum less than 10% of cortisol is free and biologically active and not possible to measure with routine laboratory methods. Salivary cortisol can be used as a surrogate for free cortisol, but salivary production is reduced in critically ill patients. Liver resection could reduce cortisol levels due to substrate deficiency.

    Aims: 1. Evaluate the occurrence of early adverse events in patients with traumatic brain injury and relate them to outcome. 2. Assess cortisol levels over time after trauma and correlate to severity of trauma, sedative/analgesic drugs and cardiovascular function. 3. Evaluate if saliva stimulation could be performed without interfering with salivary cortisol levels. 4. Assess cortisol levels over time after liver resection in comparison to other major surgery.

    Results: There was no significant correlation between prehospital time ³60 minutes, hypoxia (saturation <95%), hypotension (systolic blood pressure <90 mmHg), or hyperventilation (ETCO2 <4.5 kPa) and a poor outcome (Glasgow Outcome Scale 1-3) in patients with traumatic brain injury. Cortisol levels decreased significantly over time after trauma, but there was no correlation between low (<200 nmol/L) serum cortisol levels and severity of trauma.

    Infusion of sedative/analgesic drugs was the strongest predictor for a low (<200 nmol/L) serum cortisol. The odds ratio for low serum cortisol levels (<200 nmol/L) was 8.0 for patients receiving continuous infusion of sedative/analgesic drugs. There was no significant difference between unstimulated and stimulated salivary cortisol levels (p=0.06) in healthy volunteers. Liver resection was not associated with significantly lower cortisol levels compared to other major surgery.

    Conclusion: There was no significant correlation between early adverse events and outcome in patients with traumatic brain injury. Cortisol levels decreased significantly over time in trauma patients. Low cortisol levels (<200 nmol/L) were significantly correlated to continuous infusion of sedative/analgesic drugs. Saliva stimulation could be performed without interfering with salivary cortisol levels. Liver resection was not associated with low cortisol levels compared to other major surgery.

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  • 39.
    Brorsson, Camilla
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Dahlqvist, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lundberg, Owe
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Naredi, Peter
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Naredi, Silvana
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Liver resection is not associated with decreased cortisol levels.Manuscript (preprint) (Other academic)
    Abstract [en]

    Background: Adrenal hormones are synthesized from cholesterol, produced and stored in the liver. Liver failure has been reported to be associated with adrenal insufficiency. A possible mechanism could be a limited supply of substrate for cortisol synthesis. The aims of this study was to evaluate the occurrence of total serum cortisol <200 nmol/L after major liver resection (≥ 30%) and other major surgery (hemicolectomy) and to assess associations between cholesterol and corti­sol levels after liver resection.

    Methods: Prospective, observational study. 40 patients were included (major liver resection n=15, hemicolectomy n=25). Serum and salivary cortisol were followed from morning before surgery up to five days postoperatively. Sulphated dehy­droepiandrosterone (DHEAS) and lipids (cholesterol, low density lipoproteins, high density lipoproteins and triglycerides) were obtained in liver resection patients.

    Results: 8/25 (32%, hemicolectomy patients), and 3/15 (20%, liver resection patients) had serum cortisol <200 nmol/L. Neither hemicolectomy nor liver resec­tion was significantly associated with serum cortisol <200 nmol/L, p=0.49. Serum cortisol <200 nmol/L was not significantly associated with lipids below normal limits, (cholesterol; p=1.0 day 1, p=0.46 day 4, LDL; p=0.56 day 1, p=1.0 day 4, and HDL; p=0.27 day 1, p=1.0 day 4). Serum and salivary cortisol correlated sig­nificantly (rs=0.83, p<0.0001, hemicolectomy, rs=0.80, p<0.0001, liver resection).

    Conclusion: Serum cortisol levels <200 nmol/L was found in 32% (hemicolec­tomy) and 20% (liver resection) postoperatively. Compared to after hemicolec­tomy, serum cortisol <200 nmol/L was not significantly more common after liver resection. Lipids below normal limits were not associated with serum cortisol <200 nmol/L after liver resection.

  • 40.
    Brorsson, Camilla
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Dahlqvist, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Nilsson, Leif
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Naredi, Silvana
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Saliva stimulation with glycerine and citric acid does not affect salivary cortisol levels2014In: Clinical Endocrinology, ISSN 0300-0664, E-ISSN 1365-2265, Vol. 81, no 2, p. 244-248Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE:

    In critically ill patients with hypotension, who respond poorly to fluids and vasoactive drugs, cortisol insufficiency may be suspected. In serum over 90% of cortisol is protein-bound, thus routine measures of total serum cortisol may yield 'false lows' due to hypoproteinaemia. Thus, the occurrence of cortisol insufficiency could be overestimated in critically ill patients. Salivary cortisol can be used as a surrogate for free serum cortisol, but in critically ill patients saliva production is decreased, and insufficient volume of saliva for analysis is a common problem. The aim of this study was to investigate if a cotton-tipped applicator with glycerine and citric acid could be used for saliva stimulation without affecting salivary cortisol levels.

    DESIGN:

    Prospective, observational study.

    PARTICIPANTS:

    Thirty-six volunteers (six males, 30 females), age 49 ± 9 years, without known oral mucus membrane rupture in the mouth.

    MEASUREMENTS:

    Forty-two pairs of saliva samples (22 paired morning samples, 20 paired evening samples) were obtained before and after saliva stimulation with glycerine and citric acid. Salivary cortisol was analysed using Spectria Cortisol RIA (Orion Diagnostica, Finland).

    RESULTS:

    The paired samples correlated significantly (P < 0·0001) and there was no significant difference between un-stimulated and stimulated salivary cortisol levels.

    CONCLUSIONS:

    Saliva stimulation with a cotton-tipped applicator containing glycerine and citric acid did not significantly influence salivary cortisol levels in healthy volunteers. This indicates that salivary cortisol measurement after saliva stimulation may be a useful complement when evaluating cortisol status in critically ill patients.

  • 41.
    Brorsson, Camilla
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Dahlqvist, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Nilsson, Leif
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Thunberg, Johan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Sylvan, Anders
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Naredi, Silvana
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Adrenal response after trauma is affected by time after trauma and sedative/analgesic drugs2014In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 45, no 8, p. 1149-1155Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The adrenal response in critically ill patients, including trauma victims, has been debated over the last decade. The aim of this study was to assess the early adrenal response after trauma. METHODS: Prospective, observational study of 50 trauma patients admitted to a level-1-trauma centre. Serum and saliva cortisol were followed from the accident site up to five days after trauma. Corticosteroid binding globulin (CBG), dehydroepiandrosterone (DHEA) and sulphated dehydroepiandrosterone (DHEAS) were obtained twice during the first five days after trauma. The effect of time and associations between cortisol levels and; severity of trauma, infusion of sedative/analgesic drugs, cardiovascular dysfunction and other adrenocorticotropic hormone (ACTH) dependent hormones (DHEA/DHEAS) were studied. RESULTS: There was a significant decrease over time in serum cortisol both during the initial 24 h, and from the 2nd to the 5th morning after trauma. A significant decrease over time was also observed in calculated free cortisol, DHEA, and DHEAS. No significant association was found between an injury severity score >/= 16 (severe injury) and a low (< 200 nmol/L) serum cortisol at any time during the study period. The odds for a serum cortisol < 200 nmol/L was eight times higher in patients with continuous infusion of sedative/analgesic drugs compared to patients with no continuous infusion of sedative/analgesic drugs. CONCLUSION: Total serum cortisol, calculated free cortisol, DHEA and DHEAS decreased significantly over time after trauma. Continuous infusion of sedative/analgesic drugs was independently associated with serum cortisol < 200 nmol/L.

  • 42.
    Brorsson, Camilla
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Rodling-Wahlström, Marie
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Olivecrona, Magnus
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Koskinen, Lars-Owe
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Naredi, Silvana
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Severe traumatic brain injury: consequences of early adverse events2011In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 55, no 8, p. 944-951Article in journal (Refereed)
    Abstract [en]

    Background: Several factors associated with an unfavourable outcome after severe traumatic brain injury (TBI) have been described: prolonged pre-hospital time, secondary referral to a level 1 trauma centre, the occurrence of secondary insults such as hypoxia, hypotension or low end-tidal carbon dioxide (ETCO(2)). To determine whether adverse events were linked to outcome, patients with severe TBI were studied before arrival at a level 1 trauma centre.

    Methods: Prospective, observational study design. Patients with severe TBI (n = 48), admitted to Umea University Hospital between January 2002 to December 2005 were included. All medical records from the site of the accident to arrival at the level 1 trauma centre were collected and evaluated.

    Results: A pre-hospital time of >60 min, secondary referral to a level 1 trauma centre, documented hypoxia (oxygen saturation <95%), hypotension (systolic blood pressure <90 mmHg), hyperventilation (ETCO(2) <4.5 kPa) or tachycardia (heart rate >100 beats/min) at any time before arrival at a level 1 trauma centre were not significantly related to an unfavourable outcome (Glasgow Outcome Scale 1-3).

    Conclusion: Early adverse events before arrival at a level 1 trauma centre were without significance for outcome after severe TBI in the trauma system studied.

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  • 43.
    Brändström, Helge
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Accidental hypothermia and local cold injury: physiological and epidemiological studies on risk2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: (Papers I and II) The objectives were to first determine incidence and contributing factors to cold-related injuries in northern Sweden, both those that led to hospitalization and those that led to fatality.  (Papers III and IV) A further aim was to assess post-cooling hand-rewarming responses and effects of training in a cold environment, both on fingertip rewarming and on function of the autonomic nervous system, to evaluate if there was adaptation related to prolonged occupational cold exposure.

    Methods:  In a retrospective analysis, cases of accidental cold-related injury with hospital admission in northern Sweden during 2000-2007 were analyzed (Paper I).  Cases of fatal hypothermia in the same region during 1992-2008 were analyzed (Paper II).  A cohort of volunteers was studied before and after many months of occupational cold exposure. Subject hand rewarming response was measured after a cold hand immersion provocation and categorized as slow, moderate or normal in rewarming speed.  This cold provocation and rewarming assessment was performed before and after their winter training.  (Paper III).  Heart rate variability (HRV) was analyzed from the same cold provocation/recovery sequences (Paper IV).

    Results:  (Paper I) For the 379 cases of hospitalization for cold-related injury, annual incidences for hypothermia, frostbite, and drowning were 3.4/100,000, 1.5/100,000, and 1.0/100,000 inhabitants, respectively.  Male gender was more frequent for all categories.  Annual frequencies for hypothermia hospitalizations increased during the study period.  Hypothermia degree and distribution of cases were 20 % mild (between 32 and 35ºC), 40% moderate (31.9 to 28ºC), and 24% severe (< 28ºC), while 12% had temperatures over 35.0ºC.  (Paper II) The 207 cases of fatal hypothermia showed an annual incidence of 1.35 per 100,000 inhabitants, 72% in rural areas, 93% outdoors, 40% found within 100 meters of a building.  Paradoxical undressing was documented in 30%.  Ethanol was detected in femoral vein blood in 43%. Contributing co-morbidity was common including heart disease, previous stroke, dementia, psychiatric disease, alcoholism, and recent trauma.  (Paper III) Post-training, baseline fingertip temperatures and cold recovery variables in terms of final rewarming fingertip temperature and vasodilation time increased significantly in moderate and slow rewarmers.  Cold-related injury (frostbite) during winter training occured disproportionately more often in slow rewarmers (4 of the 5 injuries).  (Paper IV) At ‘pre- winter-training’, normal rewarmers had higher power for low frequency and high frequency heart rate variability.  After cold acclimatization (post-training), normal rewarmers showed lower resting power values for the low frequency and high frequency heart rate variability components. 

    Conclusions: Hypothermia and cold injury continues to cause injury and hospitalization in the northern region of Sweden.  Assessment and management is not standardized across hospitals.  With the identification of groups at high risk for fatal hypothermia, it should be possible to reduce the incidence, particularly for highest risk subjects; rural, living alone, alcohol-imbibing, and psychiatric diagnosis-carrying citizens.  Long-term cold-weather training may affect hand rewarming patters after a cold provocation, and a warmer baseline hand temperature with faster rewarming after a cold provocation may be associated with less general risk for frostbite.  Heart rate variability results support the conclusion that cold adaptation in the autonomic nervous system occurred in both groups, though the biological significance of this is not yet clear.

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  • 44.
    Brändström, Helge
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Eriksson, Anders
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Forensic Medicine.
    Giesbrecht, Gordon
    University of Manitoba, Winnipeg, Canada. Dep of Anesthesia.
    Ängquist, Karl-Axel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Fatal hypothermia: an analysis from a sub-arctic region2012In: International Journal of Circumpolar Health, ISSN 1239-9736, E-ISSN 2242-3982, Vol. 71, no 0, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Objectives. To determine the incidence as well as contributing factors to fatal hypothermia.

    Study design. Retrospective, registry-based analysis.

    Methods. Cases of fatal hypothermia were identified in the database of the National Board of Forensic Medicine for the 4 northernmost counties of Sweden and for the study period 1992-2008. Police reports, medical records and autopsy protocols were studied.

    Results. A total of 207 cases of fatal hypothermia were noted during the study period, giving an annual incidence of 1.35 per 100,000 inhabitants. Seventy-two percent occurred in rural areas, and 93% outdoors. Many (40%) were found within approximately 100 meters of a building. The majority (75%) occurred during the colder season (October to March). Some degree of paradoxical undressing was documented in 30%. Ethanol was detected in femoral vein blood in 43% of the victims. Contributing co-morbidity was common and included heart disease, earlier stroke, dementia, psychiatric disease, alcoholism, and recent trauma.

    Conclusions. With the identification of groups at high risk for fatal hypothermia, it should be possible to reduce risk through thoughtful interventions, particularly related to the highest risk subjects (rural, living alone, alcohol-imbibing, and psychiatric diagnosis-carrying) citizens.

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  • 45.
    Brändström, Helge
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Giesbrecht, Gordon
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Ängquist, Karl-Axel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Accidental cold-related injury leading to hospitalization in northern Sweden (2000-2007)Manuscript (preprint) (Other academic)
  • 46.
    Brändström, Helge
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Grip, Helena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Hallberg, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences. Umeå University, Faculty of Science and Technology, Centre for Biomedical Engineering and Physics (CMTF).
    Grönlund, Christer
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Ängquist, Karl-Axel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Giesbrecht, Gordon G
    Hand cold recovery responses before and after 15 months of military training in a cold climate2008In: Aviation, Space and Environmental Medicine, ISSN 0095-6562, E-ISSN 1943-4448, Vol. 79, no 9, p. 904-908Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: The ability of fingers to rapidly rewarm following cold exposure is a possible indicator of cold injury protection. We categorized the post-cooling hand-rewarming responses of men before and after participation in 15 mo of military training in a cold environment in northern Sweden to determine: 1) if the initial rewarming category was related to the occurrence of local cold injury during training; and 2) if cold training affected subsequent hand-rewarming responses. METHODS: Immersion of the dominant hand in 10 degrees C water for 10 min was performed pre-training on 77 men. Of those, 45 were available for successful post-training retests. Infrared thermography monitored the dorsal hand during 30 min of recovery. Rewarming was categorized as normal, moderate, or slow based on mean fingertip temperature at the end of 30 min of recovery (TFinger,30) and the percentage of time that fingertips were vasodilated (%VD). RESULTS: Cold injury occurrence during training was disproportionately higher in the slow rewarmers (four of the five injuries). Post-training, baseline fingertip temperatures and cold recovery variables increased significantly in moderate and slow rewarmers: TFinger30 increased from 21.9 +/- 4 to 30.4 +/- 6 degrees C (Moderate), and from 17.4 +/- 0 to 22.3 +/- 7 degrees C (Slow); %VD increased from 27.5 +/- 16 to 65.9 +/- 34% (Moderate), and from 0.7 +/- 2 to 31.7 +/- 44% (Slow). CONCLUSIONS: Results of the cold recovery test were related to the occurrence of local cold injury during long-term cold-weather training. Cold training itself improved baseline and cold recovery in moderate and slow rewarmers.

  • 47.
    Brändström, Helge
    et al.
    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.
    Giesbrecht, Gordon G.
    Kinesiology and Recreation Management, and Anesthesia, University of Manitoba, Winnipeg, Canada.
    Ängquist, Karl-Axel
    Emergency and Disaster Medical Center, Umeå University Hospital, Sweden.
    Haney, Michael F.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Accidental cold-related injury leading to hospitalization in northern Sweden: an eight-year retrospective analysis2014In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 22, p. 6-Article in journal (Refereed)
    Abstract [en]

    Background: Cold injuries are rare but important causes of hospitalization. We aimed to identify the magnitude of cold injury hospitalization, and assess causes, associated factors and treatment routines in a subarctic region. Methods: In this retrospective analysis of hospital records from the 4 northernmost counties in Sweden, cases from 2000-2007 were identified from the hospital registry by diagnosis codes for accidental hypothermia, frostbite, and cold-water drowning.Results were analyzed for pre-hospital site events, clinical events in-hospital, and complications observed with mild (temperature 34.9 - 32 degrees C), moderate (31.9 - 28 degrees C) and severe (<28 degrees C), hypothermia as well as for frostbite and cold-water drowning. Results: From the 362 cases, average annual incidences for hypothermia, frostbite, and cold-water drowning were estimated to be 3.4/100 000, 1.5/100 000, and 0.8/100 000 inhabitants, respectively. Annual frequencies for hypothermia hospitalizations increased by approximately 3 cases/year during the study period. Twenty percent of the hypothermia cases were mild, 40% moderate, and 24% severe. For 12%, the lowest documented core temperature was 35 degrees C or higher, for 4% there was no temperature documented. Body core temperature was seldom measured in pre-hospital locations. Of 362 cold injury admissions, 17 (5%) died in hospital related to their injuries. Associated co-factors and co-morbidities included ethanol consumption, dementia, and psychiatric diagnosis. Conclusions: The incidence of accidental hypothermia seems to be increasing in this studied sub-arctic region. Likely associated factors are recognized (ethanol intake, dementia, and psychiatric diagnosis).

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  • 48.
    Brändström, Helge
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Sedig, Karin
    Lundälv, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    KAMEDO report no. 77: sinking of the MS Sleipner, 26 November 19992006In: Prehospital and Disaster Medicine, ISSN 1049-023X, Vol. 21, no 2 Suppl 2, p. 115-116Article in journal (Refereed)
  • 49.
    Brändström, Helge
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Sundelin, Anna
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Hoseason, Daniela
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Sundström, Nina
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Birgander, Richard
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Diagnostic Radiology.
    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.
    Koskinen, Lars-Owe
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Risk for intracranial pressure increase related to enclosed air in post-craniotomy patients during air ambulance transport: a retrospective cohort study with simulation2017In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 25, article id 50Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Post-craniotomy intracranial air can be present in patients scheduled for air ambulance transport to their home hospital. We aimed to assess risk for in-flight intracranial pressure (ICP) increases related to observed intracranial air volumes, hypothetical sea level pre-transport ICP, and different potential flight levels and cabin pressures. METHODS: A cohort of consecutive subdural hematoma evacuation patients from one University Medical Centre was assessed with post-operative intracranial air volume measurements by computed tomography. Intracranial pressure changes related to estimated intracranial air volume effects of changing atmospheric pressure (simulating flight and cabin pressure changes up to 8000 ft) were simulated using an established model for intracranial pressure and volume relations. RESULTS: Approximately one third of the cohort had post-operative intracranial air. Of these, approximately one third had intracranial air volumes less than 11 ml. The simulation estimated that the expected changes in intracranial pressure during 'flight' would not result in intracranial hypertension. For intracranial air volumes above 11 ml, the simulation suggested that it was possible that intracranial hypertension could develop 'inflight' related to cabin pressure drop. Depending on the pre-flight intracranial pressure and air volume, this could occur quite early during the assent phase in the flight profile. DISCUSSION: These findings support the idea that there should be radiographic verification of the presence or absence of intracranial air after craniotomy for patients planned for long distance air transport. CONCLUSIONS: Very small amounts of air are clinically inconsequential. Otherwise, air transport with maintained ground-level cabin pressure should be a priority for these patients.

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  • 50.
    Brändström, Helge
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Wiklund, Urban
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Karlsson, Marcus
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Ängquist, Karl-Axel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Grip, Helena
    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.
    Autonomic nerve system responses for normal and slow rewarmers after hand cold provocation: effects of long-term cold climate training2013In: International Archives of Occupational and Environmental Health, ISSN 0340-0131, E-ISSN 1432-1246, Vol. 86, no 3, p. 357-365Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Differences among individuals concerning susceptibility to local cold injury following acute cold exposure may be related to function of the autonomic nervous system. We hypothesized that there are differences in heart rate variability (HRV) between individuals with normal or more pronounced vasoconstriction following cold exposure and that there is an adaptation related to prolonged cold exposure in autonomic nervous system response to cold stimuli.

    METHODS: Seventy-seven young men performed a cold provocation test, where HRV was recorded during cold hand immersion and recovery. Forty-three subjects were re-examined 15 months later, with many months of cold weather training between the tests. Subjects were analyzed as 'slow' and 'normal' rewarmers according to their thermographic rewarming pattern.

    RESULTS: For the 'pre-training' test, before cold climate exposure, normal rewarmers had higher power for low-frequency (P(LF)) and high-frequency (P(HF)) HRV components during the cold provocation test (ANOVA for groups: p = 0.04 and p = 0.005, respectively). There was an approximately 25 % higher P(HF) at the start in normal rewarmers, in the logarithmic scale. Low frequency-to-high frequency ratio (P(LF)/P(HF)) showed lower levels for normal rewarmers (ANOVA for groups: p = 0.04). During the 'post-training' cold provocation test, both groups lacked the marked increase in heart rate that occurred during cold exposure at the 'pre-training' setting. After cold acclimatization (post-training), normal rewarmers showed lower resting power values for the low-frequency and high-frequency HRV components. After winter training, the slow rewarmers showed reduced low-frequency power for some of the cold provocation measurements but not all (average total P(LF), ANOVA p = 0.05), which was not present before winter training.

    CONCLUSIONS: These HRV results support the conclusion that cold adaptation occurred in both groups. We conclude that further prospective study is needed to determine whether cold adaptation provides protection to subjects at higher risk for cold injury, that is, slow rewarmers.

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