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- Grossmann, Benjamin, et al.
(author)
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Patient-controlled Sedation During Flexible Bronchoscopy : A Randomized Controlled Trial
- 2020
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In: Journal of Bronchology & Interventional Pulmonology. - : Lippincott Williams & Wilkins. - 1944-6586 .- 1948-8270. ; 27:2, s. 77-85
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Journal article (peer-reviewed)abstract
- Background: Patient-controlled sedation (PCS) is a documented method for endoscopic procedures considered to facilitate early recovery. Limited data have been reported, however, on its use during flexible bronchoscopy (FB).Materials and Methods: This study hypothesized that PCS with propofol during FB would facilitate early recovery, with similar bronchoscopist and patient satisfaction compared with nurse-controlled sedation (NCS) with midazolam. A total of 150 patients were randomized 1:1:1 into a control group (premedication with morphine-scopolamine and NCS with midazolam), PCS-MS group (premedication with morphine-scopolamine and PCS with propofol), and PCS-G group (premedication with glycopyrronium and PCS with propofol).Results: The procedures included transbronchial biopsy, transbronchial needle aspiration, cryotherapy/biopsy, and/or multistation endobronchial ultrasound. FB duration values in median (range) were 40 (10 to 80), 39 (12 to 68), and 44 (10 to 82) minutes for the groups NCS, PCS-MS, and PCS-G, respectively. An overall 81% of the patients in the combined PCS groups were ready for discharge (modified Post Anaesthetic Discharge Scoring System, score 10) 2 hours after bronchoscopy compared with 40% in the control group (P<0.0001). Between PCS groups, 96% of the PCS-G group patients were ready for discharge compared with 65% in the PCS-MS group (P=0.0002) at 2 hours. Bronchoscopists’ and patients’ satisfaction scores were high in all groups. Postdischarge quality scores showed no differences among the groups.Conclusion: PCS with propofol during FB is feasible, as it shortened recovery time without compromising procedure conditions for bronchoscopists or patients. A rapid postsedation stabilization of vital signs facilitates surveillance before the patient leaves the hospital.
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- Grossmann, Benjamin, et al.
(author)
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Patient-controlled sedation with propofol for endoscopic procedures : A cost analysis
- 2020
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In: Acta Anaesthesiologica Scandinavica. - : John Wiley & Sons. - 0001-5172 .- 1399-6576. ; 64:1, s. 53-62
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Journal article (peer-reviewed)abstract
- BackgroundPatient‐controlled sedation (PCS) with propofol accompanied by a bedside nurse anaesthetist is an alternative sedation method for endoscopic procedures compared with midazolam administered by a nurse or endoscopist. Increasing costs in health care demands an economic perspective when introducing alternative methods. We applied a hospital perspective on a cost analysis comparing different methods of sedation and the resource use that were expected to affect cost differences related to the sedation.MethodsBased on two randomised previous studies, the direct costs were determined for different sedation methods during two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and flexible bronchoscopy including endobronchial ultrasound. ERCP comparisons were made between midazolam sedation by the endoscopic team, PCS with a bedside nurse anaesthetist and propofol sedation administered by a nurse anaesthetist. Bronchoscopy comparisons were made between midazolam sedation by the endoscopic team and PCS with a bedside nurse anaesthetist, categorised by premedication morphine‐scopolamine or glycopyrronium.ResultsPropofol PCS with a bedside nurse anaesthetist resulted in lower costs per patient for sedation for both ERCP (233 USD) and bronchoscopy (premedication morphine‐scopolamine 267 USD, premedication glycopyrronium 269 USD) compared with midazolam (ERCP 425 USD, bronchoscopy 337 USD). Aborted procedures that needed to be repeated and prolonged hospital stays significantly increased the cost for the midazolam groups.ConclusionPropofol PCS with a bedside nurse anaesthetist reduces the direct sedation costs for ERCP and bronchoscopy procedures compared with midazolam sedation.
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- Grossmann, Benjamin
(author)
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Procedural sedation : Aspects on methods, safety and effectiveness
- 2019
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Doctoral thesis (other academic/artistic)abstract
- Background: Safety and effectiveness are fundamental principles within the healthcare sector to provide quality of care and health improvement for patients. By ensuring that care is provided based on evidence-based knowledge, risks and complications can be minimised and the use of scarce resources optimised. An increasing demand for diagnostic and therapeutic procedures challenges the traditional methods for sedation regarding safety and effectiveness. It is desirable that the fundamental principles are improved when refining existing or developing new sedation methods. In this doctoral thesis, safety and effectiveness were evaluated for adult patient-controlled sedation (PCS) using propofol during two endoscopic procedures: endoscopic retrograde cholangiopancreaticography (ERCP) and flexible bronchoscopy (FB); and different doses of rectal racemic ketamine for paediatric (< 4 years) burn wound care.Methods: Data on vital functions, sedation level, safety interventions, procedure feasibility, patient-reported outcome and experience measures, and recovery, from three clinical randomised controlled trials were collected. Costs of sedation for the endoscopic procedures were compiled in a cost-analysis study.Results: PCS with propofol and bedside anaesthetic personnel was shown to be a safe and effective alternative method of sedation during ERCP and FB compared with intravenous sedation with midazolam. The PCS method gives stable cardiorespiratory conditions with few adverse events and interventions, with a low risk of oversedation. PCS offers similar (FB) or better (ERCP) procedure feasibility and patient satisfaction during the procedures than midazolam. Recovery after PCS is quick, minimises the risk for prolonged hospitalisation and is thereby a potential cost-saving sedation method. The optimal dose of rectal racemic ketamine, 6 mg/kg with the addition of 0.5 mg/kg midazolam during severely painful procedures, gives minimal risk for outbreaks of pain, offers stable vital signs conditions and allows rapid recovery without affecting procedure feasibility.Conclusions: The sedation method can be adjusted to type of procedure and patient population. PCS with propofol offers an alternative and reliable method for adult sedation during endoscopic procedures, whereas rectal racemic ketamine combined with midazolam provides good conditions for burn care dressing procedures in young children.
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| 5. |
- Grossmann, Benjamin, et al.
(author)
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Rectal ketamine during paediatric burn wound dressing procedures : a randomised dose-finding study
- 2019
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In: Burns. - : Pergamon Press. - 0305-4179 .- 1879-1409. ; 45:5, s. 1081-1088
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Journal article (peer-reviewed)abstract
- BackgroundWorldwide, ketamine is used during paediatric procedures, but no recommendations are available regarding a suitable dose for rectal administration during procedures involving high levels of pain and/or anxiety such as burn wound dressing change.MethodsWe evaluated three different single doses of rectally administered racemic ketamine mixed with a fixed dose of 0.5 mg/kg of midazolam. In total, 90 children – aged 6 months to 4 years – were randomised 1:1:1 to receive 4 mg/kg (K-4 group), 6 mg/kg (K-6 group) or 8 mg/kg (K-8 group) of racemic ketamine for a maximum of three consecutive procedures. Primary outcome measure was procedural pain evaluated by Face, Legs, Activity, Cry, Consolability (FLACC) behavioural scale. Secondary outcome included feasibility and recovery time. Patient safety was evaluated using surrogate outcomes.ResultsIn total, 201 procedures in 90 children aged 19 ± 8 months were completed. The median maximum pain was FLACC 0 in all groups (p = 0.141). The feasibility was better for groups K-6 (p = 0.049) and K-8 (p = 0.027) compared with K-4, and the mean recovery time was the longest for group K-8 (36 ± 22 min) compared with groups K-4 (25 ± 15 min; p = 0.003) and K-6 (27 ± 20 min; p = 0.025). Median maximum sedation measured by the University of Michigan Sedation Scale (UMSS) was higher in group K-8 compared with group K-4 (p < 0.0001) and K-6 (p = 0.023). One child in group K-8 had a study drug-related serious adverse event — laryngospasm/airway obstruction. No rescue analgosedative medication was administered for group K-6.ConclusionsA rectally administered mixture of racemic ketamine (6 mg/kg) and midazolam (0.5 mg/kg) during paediatric burn dressing procedures with a duration of approximately 30 min provides optimal conditions regarding pain relief, feasibility, recovery time and patient safety, with no need for rescue analgosedative medication.
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| 7. |
- Rousseau, Andreas, 1971-, et al.
(author)
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Acute hyperoxaemia-induced effects on regional blood flow, oxygen consumption and central circulation in man
- 2005
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In: Acta Physiologica Scandinavica. - 0001-6772 .- 1365-201X. ; 183:3, s. 231-240
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Journal article (peer-reviewed)abstract
- Aim: Despite numerous in vitro and animal studies, circulatory effects and mechanisms responsible for the vasoconstriction seen during hyperoxaemia are yet to be ascertained. The present study set out to: (i) set up a non-invasive human model for the study of hyperoxia-induced cardiovascular effects, (ii) describe the dynamics of this effect and (iii) determine whether hyperoxaemia also, by vasoconstriction alters oxygen consumption (O2).Methods: The study comprised four experiments (A, B, C and D) on healthy volunteers examined before, during and after 100% oxygen breathing. A: Blood flow (mL min−1·100 mL−1 tissue), venous occlusion plethysmography was assessed (n = 12). B: Blood flow was recorded with increasing transcutaneous oxygen tension (PtcO2) levels (dose–response) (n = 8). C: Heart rate (HR), stroke volume, cardiac output (CO) and systemic vascular resistance (SVR) was assessed using echocardiography (n = 8). D: O2 was measured using an open circuit technique when breathing an air-O2 mix (fraction of inhaled oxygen: FiO2 = 0.58) (n = 8).Results: Calf blood flow decreased 30% during O2 breathing. The decrease in calf blood flow was found to be oxygen dose dependent. A similar magnitude, as for the peripheral circulation, of the effect on central parameters (HR/CO and SVR) and in the time relationship was noted. Hyperoxia did not change O2. An average of 207 (93) mL O2 per subject was washed in during the experiments.Conclusion: This model appears suitable for the investigation of O2-related effects on the central and peripheral circulation in man. Our findings, based on a more comprehensive (central/peripheral circulation examination) evaluation than earlier made, suggest significant circulatory effects of hyperoxia. Further studies are warranted to elucidate the underlying mechanisms.
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| 9. |
- Walther, Sten, 1954-, et al.
(author)
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Influence of income and education on outcomes of intensive care in a healthcare system with full universal health insurance - a nationwide analysis of individual-level data
- 2019
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In: Intensive Care Medicine Experimental. - Santarem, Portugal : Escola Superior de Educacao de Santarem. - 2197-425X. ; 7:Supplement 3
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Journal article (other academic/artistic)abstract
- INTRODUCTION. Most patients admitted to intensive care are discharged to a general ward in the same hospital, but some patients require transfer to another hospital. Indications for interhospital transfers (IHT) include referral for specialist treatment, lack of intensive care beds at the referring ICU and repatriation to ICU in home hospital [1].OBJECTIVES. To review mortality of ICU-patients undergoing IHT and analyse whether different indications for transfer render different mortalities.METHODS. Retrospective cohort register study using the Swedish Intensive Care Registry (SIR) during 2016-2018. The SIR collects data from 98.8% of Swedish ICUs including data on discharge from ICUs to other hospitals/ICUs. Transfers were divided into three categories: transfer due to medical reasons, lack of ICU beds or repatriation to ICU in home hospital. We analysed odds ratios (ORs) for dying within 30 days after discharge from ICU using risk adjusted (SAPS3 score) multi-level mixed effect logistic regression with ICUs as random effect.RESULTS. We identified 12,356 patients who were discharged to another ICU and hospital, i.e. inter-hospital transfers. The unadjusted mortality 30 days after IHT was 17.2 % compared to 12.4 % if discharged to ward in the same hospital. Mortality after IHT varied with the cause of discharge (Figure).Main diagnoses for transfer due to specialist treatment were subarachnoid haemorrhage, head injury and multi-trauma whilst for lack of ICU beds post cardiac arrest, respiratory failure and pneumonia dominated. Risk adjusted analysis showed a significantly increased risk of dying after discharge due to lack of ICU-beds in comparison with other reasons for IHTsCONCLUSION. The adjusted risk of dying within 30 days after interhospital transfer was greater among critically ill patients when the transfer was due to lack of beds in the referring ICU. The increased mortality lingered for at least 6 months underlining the importance to identify causes and intervene to avoid unnecessary loss of life.
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| 10. |
- Abdelrahman, Islam, 1982-, et al.
(author)
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Development of delirium : Association with old age, severe burns, and intensive care
- 2020
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In: Burns. - : Elsevier. - 0305-4179 .- 1879-1409. ; 46:4, s. 797-803
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Journal article (peer-reviewed)abstract
- Background Delirium is defined as a disturbance of attention and awareness that develops over a short period of time, is a change from the baseline, and typically fluctuates over time. Burn care involves a high prevalence of known risk factors for delirium such as sedation, inflammation, and prolonged stay in hospital. Our aim was to explore the extent of delirium and the impact of factors associated with it for adult patients who have been admitted to hospital with burns. Methods In this retrospective study, all adult patients who had been admitted with burns during a four-year period were studied, including both those who were treated with intensive care and intermediate care only (no intensive care). Daily records of the assessment of delirium using the Nursing Delirium Screening Scale (Nu-DESC) were analysed together with age, sex, the percentage of total body surface area burned, operations, and numbers of wound care procedures under anaesthesia, concentrations of plasma C-reactive protein, and other clinical variables. Logistic regression was used to analyse factors that were associated with delirium and its effect on mortality, and linear regression was used to analyse its effect on the duration of hospital stay. Results Fifty-one patients (19%) of the total 262 showed signs of delirium (Nu-DESC score of 2 or more) at least once during their stay in hospital. Signs of delirium were recorded in 42/89 patients (47%) who received intensive care, and in 9/173 (5%) who had intermediate care. Independent factors for delirium in the multivariable regression were: age over 74 years; number of operations and wound care procedures under anaesthesia; and the provision of intensive care (area under the curve 0.940, 95% CI 0.899–0.981). Duration of hospital stay, adjusted for age and burn size, was 13.2 (95% CI 7.4–18.9, p < 0.001) days longer in the group who had delirium. We found no independent effects of delirium on mortality. Conclusion We found a strong association between delirium and older age, provision ofr intensive care, and number of interventions under anaesthesia. A further 5% of patients who did not receive intensive care also showed signs of delirium, which is a finding that deserves to be thoroughly investigated in the future.
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