| 1. |
- Jildenstål, Pether, et al.
(författare)
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Agreement between frontal and occipital regional cerebral oxygen saturation in infants during surgery and general anesthesia an observational study
- 2019
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Ingår i: Pediatric Anesthesia. - : Wiley. - 1460-9592 .- 1460-9592 .- 1155-5645. ; 29:11, s. 1122-1127
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Tidskriftsartikel (refereegranskat)abstract
- Abstract Background: Advances in perioperative pediatric care have resulted in an increased number of procedures requiring anesthesia. During anesthesia and surgery, the patient is subjected to factors that affect the circulatory homeostasis, which can influence oxygenation of the brain. Near‐infrared spectroscopy (NIRS) is an easy applicable noninvasive method for monitoring of regional tissue oxygenation (rScO₂%). Alternate placements for NIRS have been investigated; however, no alternative cranial placements have been explored. Aim: To evaluate the agreement between frontal and occipital recordings of rScO₂% in infants using INVOSTM during surgery and general anesthesia. Method: A standard frontal monitoring of rScO₂% with NIRS was compared with occipital rScO₂% measurements in fifteen children at an age <1 year, ASA 1‐2, undergoing cleft lip and/or palate surgery during general anesthesia with sevoflurane. An agreement analysis was performed according to Bland and Altman. Results: Mean values of frontal and occipital rScO₂% at baseline were largely similar (70.7 ± 4.77% and 69.40 ± 5.04%, respectively). In the majority of the patients, the frontal and occipital recordings of rScO2 changed in parallel. There was a moderate positive correlation between frontal and occipital rScO₂% INVOS™ readings (rho[ρ]: 0.513, P < .01). The difference between frontal and occipital rScO₂ ranged from −31 to 28 with a mean difference (bias) of −0.15%. The 95% limit of agreement was −18.04%‐17.74%. The error between frontal and occipital rScO₂ recordings was 23%. Conclusion: The agreement between frontal and occipital recordings of brain rScO₂% in infants using INVOSTM during surgery and general anesthesia was acceptable. In surgical procedures where the frontal region of the head is not available for monitoring, occipital recordings of rScO₂% could be an option for monitoring.
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| 2. |
- Leonhardt, Henrik, 1963, et al.
(författare)
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Endovascular management of acute bleeding arterioenteric fistulas.
- 2008
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Ingår i: Cardiovascular and interventional radiology. - : Springer Science and Business Media LLC. - 1432-086X .- 0174-1551. ; 31:3, s. 542-9
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Tidskriftsartikel (refereegranskat)abstract
- The objective of this study was to review the outcome of endovascular transcatheter repair of emergent arterioenteric fistulas. Cases of abdominal arterioenteric fistulas (defined as a fistula between a major artery and the small intestine or colon, thus not the esophagus or stomach), diagnosed over the 3-year period between December 2002 and December 2005 at our institution, were retrospectively reviewed. Five patients with severe enteric bleeding underwent angiography and endovascular repair. Four presented primary arterioenteric fistulas, and one presented a secondary aortoenteric fistula. All had massive persistent bleeding with hypotension despite volume substitution and transfusion by the time of endovascular management. Outcome after treatment of these patients was investigated for major procedure-related complications, recurrence, reintervention, morbidity, and mortality. Mean follow-up time was 3 months (range, 1-6 months). All massive bleeding was controlled by occlusive balloon catheters. Four fistulas were successfully sealed with stent-grafts, resulting in a technical success rate of 80%. One patient was circulatory stabilized by endovascular management but needed immediate further open surgery. There were no procedure-related major complications. Mean hospital stay after the initial endovascular intervention was 19 days. Rebleeding occurred in four patients (80%) after a free interval of 2 weeks or longer. During the follow-up period three patients needed reintervention. The in-hospital mortality was 20% and the 30-day mortality was 40%. The midterm outcome was poor, due to comorbidities or rebleeding, with a mortality of 80% within 6 months. In conclusion, endovascular repair is an efficient and safe method to stabilize patients with life-threatening bleeding arterioenteric fistulas in the emergent episode. However, in this group of patients with severe comorbidities, the risk of rebleeding is high and further intervention must be considered. Patients with cancer may only need treatment for the acute bleeding episode, and an endovascular approach has the advantage of low morbidity.
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| 3. |
- Abrahamsson, A., et al.
(författare)
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Perioperative COX-2 inhibitors may increase the risk of post-operative acute kidney injury
- 2017
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Ingår i: Acta Anaesthesiologica Scandinavica. - : Wiley. - 0001-5172. ; 61:7, s. 714-721
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundIn enhanced recovery protocols (ERP), a restrictive fluid regimen is proposed. Patients who undergo major surgery have an increased risk of post-operative acute kidney injury (AKI). This combination may pose difficulties when ERP is used for patients undergoing major surgery. The aim of this study was to evaluate whether patients undergoing pancreatic surgery and treated with a restrictive fluid regimen are at greater risk of post-operative AKI. Furthermore, if there was an increased risk of AKI, we aimed to identify its cause. MethodsWe reviewed the medical records of patients who underwent pancreatic surgery during 2014 (preERP, n = 58) and 2015 (ERP, n = 65). Fluid balance, the administration of cyclooxygenase-2 inhibitors, creatinine levels and mean arterial pressure were recorded. The Kidney Disease: Improving Global Outcomes criteria were used to define AKI. ResultsThe incidence of AKI was higher in the ERP group than in the PreERP group (12.5% vs. 1.8%, respectively, P = 0.035). The increased incidence of AKI could not be explained by differences in comorbidities, age, pre-operative creatinine or perioperative hypotension. Administration of coxibs was higher in the ERP group and was associated with increased incidence of post-operative AKI (P = 0.018). The combination of coxibs and restrictive fluid regimen seems particularly harmful. ConclusionPancreatic surgery with a restrictive fluid regimen carries an increased risk of post-operative AKI if patients are also treated with cyclooxygenase-2 inhibitors. It is therefore suggested that in protocols including a restrictive fluid regimen for open pancreatic surgery, the use of cyclooxygenase-2 inhibitors should be avoided.
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| 4. |
- Alvekrans, Anna-Lena, et al.
(författare)
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From Knowledge to Decision - A Case Study of Sales and Operations Planning in Health Care
- 2016
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Ingår i: Production planning & control. - : Informa UK Limited. - 0953-7287 .- 1366-5871. ; 27:12, s. 1019-1026
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Tidskriftsartikel (refereegranskat)abstract
- One of the most important challenges in health care management is balancing resources with fluctuating and uncertain demand. This study examines whether introducing a standardised process for Sales and Operations planning at a large university hospital improved specialty department managers’ knowledge of planning conditions and if so, whether decisions were made based on this knowledge. Using responses from a survey of 30 specialty department managers at Sahlgrenska University Hospital in Sweden, the analyses indicate that operational knowledge strengthens insights about the needs for strategic decisions, and vice versa. Moreover, knowledge is a necessary, but not sufficient, condition for making decisions at the department level. An overall planning and decision structure is required and should be implemented first at the hospital level to effectively allocate resources.
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| 5. |
- Jildenstål, Pether, et al.
(författare)
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Cerebral autoregulation in infants during sevoflurane anesthesia for craniofacial surgery
- 2021
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Ingår i: Pediatric Anesthesia. - : Wiley. - 1155-5645 .- 1460-9592. ; 31:5, s. 563-569
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Tidskriftsartikel (refereegranskat)abstract
- Background: Data on cerebral pressure-flow autoregulation in the youngest children are scarce. We studied the correlation between mean arterial pressure and cerebral tissue oxygen saturation (rSO(2)) by near-infrared spectroscopy (NIRS) in patients undergoing nose, lip, and palate surgery. Aim: We tested the hypothesis that cerebral pressure-flow autoregulation is impaired in children less than 1 year undergoing surgery and general anesthesia with sevoflurane under controlled mechanical ventilation. Method: After approval from the Ethical board, 15 children aged <1 year were included. Before anesthesia induction, a NIRS sensor (INVOS (TM), Medtronic, Minneapolis, USA) was placed over the cerebral frontal lobe. Frontal rSO(2), a surrogate for cerebral perfusion, mean arterial pressure, end-tidal CO2- and sevoflurane concentration, and arterial oxygen saturation were sampled every minute after the induction. A repeated measures correlation analysis was performed to study correlation between mean arterial pressure and cerebral rSO(2), and the repeated measures correlation coefficient (r(rm)) was calculated. Results: Fifteen patients, aged 7.7 +/- 1.9 months, were studied. rSO(2) showed a positive correlation with mean arterial pressure ([95% CI: 9.0-12.1], P < 0.001) with a moderate to large effect size (r(rm) = 0.462), indicating an impaired cerebral pressure-flow autoregulation. The slopes of the rSO(2)-mean arterial pressure correlations were steeper in patients who were hypotensive (mean arterial pressure <50 mm Hg) compared to patients having a mean arterial pressure >= 50 mm Hg, indicating that at lower mean arterial pressure, the cerebral pressure dependence of cerebral oxygenation is even more pronounced. Conclusion: During sevoflurane anesthesia in the youngest pediatric patients, cerebral perfusion is pressure-dependent, suggesting that the efficiency of the cerebral blood flow autoregulation is limited.
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| 6. |
- Sallam, Mohammed, et al.
(författare)
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Improving Antimicrobial Stewardship Program Using the Lean Six Sigma Methodology: A Descriptive Study from Mediclinic Welcare Hospital in Dubai, the UAE
- 2023
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Ingår i: Healthcare (Switzerland). - 2227-9032. ; 11:23
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Tidskriftsartikel (refereegranskat)abstract
- Background: Antimicrobial resistance (AMR) is one of the key challenges in healthcare, and effective antimicrobial stewardship programs (ASPs) can play a vital role to control it. The aim of the current study was to assess the impact of the Lean Six Sigma (LSS) methodology on a hospital-wide ASP. Methods: This retrospective descriptive study was conducted at Mediclinic Welcare Hospital (MWEL), Dubai, the United Arab Emirates (UAE). The critical-to-quality (CTQs) data were collected pre/post interventions, including leadership support, guideline implementation, and audits. The study focused on inpatients who received antimicrobials from January 2021 to July 2022, analyzing ASP metrics (utilization, processes, and outcome measures). Results: The ASP improvements led to an 81.7% decrease in hospital’s parenteral antimicrobial expenses from January 2021 to July 2022, and a 54.2% reduction in antimicrobial usage while maintaining clinical outcomes. The average defined daily dose per 100 bed-days drop of 12.5% further demonstrated this positive trend. The intervention was not accompanied by higher nosocomial infection rates, longer stays, or mortality. Additionally, intervention led to better compliance with surgical prophylaxis bundles, antimicrobial protocols, hand hygiene and other ASP CTQ metrics. Conclusions and recommendations: This study emphasized the significance of implementing the LSS methodology in addressing process variations, enhancing ASP outcomes, and reducing antimicrobial use. These findings can inform health policymakers to improve future ASP outcomes. Additionally, sustainability through continuous monitoring and ongoing education initiatives should be considered to ensure the long-term success of these improvements.
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| 7. |
- Snygg, Johan, 1963, et al.
(författare)
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Fluid therapy in acute myocardial infarction: evaluation of predictors of volume responsiveness.
- 2009
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Ingår i: Acta Anaesthesiol Scand. - : Wiley. - 1399-6576. ; 53:1, s. 26-33
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Static vascular filling pressures suffer from poor predictive power in identifying the volume-responsive heart. The use of dynamic arterial pressure variables, including pulse pressure variation (PPV) has instead been suggested to guide volume therapy. The aim of the present study was to evaluate the performance of several clinically applicable haemodynamic parameters to predict volume responsiveness in a pig closed chest model of acute left ventricular myocardial infarction. METHODS: Fifteen anaesthetized, mechanically ventilated pigs were studied following acute left myocardial infarction by temporary coronary occlusion. Animals were instrumented to monitor central venous (CVP) and pulmonary artery occlusion (PAOP) pressures and arterial systolic variations (SPV) and PPV. Cardiac output (CO) was measured using the pulmonary artery catheter and by using the PiCCO monitor also giving stroke volume variation (SVV). Variations in the velocity time integral by pulsed-wave Doppler echocardiography were determined in the left (DeltaVTI(LV)) and right (DeltaVTI(RV)) ventricular outflow tracts. Consecutive boluses of 4 ml/kg hydroxyethyl starch were administered and volume responsiveness was defined as a 10% increase in CO. RESULTS: Receiver-operator characteristics (ROC) demonstrated the largest area under the curve for DeltaVTI(RV) [0.81 (0.70-0.93)] followed by PPV [0.76 (0.64-0.88)] [mean (and 95% CI)]. SPV, DeltaVTI(LV) and SVV did not change significantly during volume loading. CVP and PAOP increased but did not demonstrate significant ROC. CONCLUSION: PPV may be used to predict the response to volume administration in the setting of acute left ventricular myocardial infarction.
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| 8. |
- Snygg, Johan, 1963, et al.
(författare)
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Intestinal nitric oxide output during reduced mucosal blood flow in healthy volunteers.
- 2003
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Ingår i: Critical care medicine. - 0090-3493. ; 31:8, s. 2198-204
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: Nitric oxide regulates epithelial permeability and other properties of the intestinal mucosal barrier. It previously has been shown in animals that intestinal mucosal nitric oxide production is impaired during gut hypoperfusion. The study was performed to confirm the presence of intestinal mucosal nitric oxide production in humans and to investigate the effect of gut hypoperfusion due to moderate arterial hypotension on intestinal nitric oxide concentrations. DESIGN: Open study where each subject served as his own control. SETTING: Clinical research laboratory. SUBJECTS: Nine healthy volunteers were intubated with a nasogastrointestinal tube for recordings in the distal duodenum. Intestinal nitric oxide output and motility were assessed by tonometry and manometry, respectively. Laser Doppler flowmetry and plasma angiotensin II concentration were used to investigate mucosal perfusion and a vasoregulatory response. INTERVENTIONS: Moderate hypotension was induced with lower body negative pressure over 1 hr. MEASUREMENTS AND MAIN RESULTS: Intestinal nitric oxide production varied in parallel with the migrating motor complex. Low values were obtained during phase I and peak values during phase III. Lower body negative pressure was initiated at a well-defined point in the migrating motor complex cycle. It was followed by a 40 +/- 6% reduction of laser Doppler flow signal, a 778 +/- 138% increase in angiotensin II, and a reduction in intestinal mucosal nitric oxide production by 48 +/- 8%. After lower body negative pressure, laser Doppler signal and angiotensin II concentrations returned to baseline levels within 1 hr, whereas intestinal nitric oxide output remained decreased. CONCLUSIONS: Intestinal tonometry in humans exhibits a considerable mucosal nitric oxide formation that varies in relation to intestinal motility. Intestinal nitric oxide production is depressed during conditions with lowered mucosal blood perfusion.
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| 9. |
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| 10. |
- Snygg, Johan, 1963
(författare)
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Nitric oxide production by the intestinal mucosa during hypoperfusion
- 2000
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The present thesis is based on the concept that gastrointestinal blood hypoperfusion is a common phenomenon associated with critical illness. Furthermore, the development of the multiple organ dysfunction syndrome (MODS) is proposed to be initiated by gastrointestinal mucosal barrier dysfunction, allowing intestinal luminal contents to penetrate into the tissue and activate a systemic inflammatory response. As nitric oxide (NO) influences several aspects of the barrier properties, it was considered of interest to elucidate intestinal NO formation during conditions with splanchnic blood hypoperfusion. The general aims of the investigations were to develop a technique for NO measurement in the gut, define the NO source(s) detected by the technique and relate the NO synthesis to conditions typical of critical illness.Experiments were performed on anaesthetised pigs. Isoforms of nitric oxide synthase (NOS) were located in the gut wall using immunohistochemistry. The pigs were instrumented to allow for recordings of global hemodynamics, mesenteric blood perfusion and blood sampling to calculate systemic and regional oxygen-kinetics. Gut mucosal blood perfusion was recorded by use of laser Doppler flowmetry. A tonometric approach was developed for the assessment of intestinal NO-formation and the technique was evaluated bench-side and in-situ. Gut blood hypoperfusion was induced by challenging cardiac performance using graded haemorrhage, cardiac tamponade or live E. coli-sepsis. Confirmatory studies were performed in healthy volunteers where hypovolemia was mimicked by lower body negative pressure. The results showed that luminal NO tonometry is an accurate and rather easily handled technique that reflects enzymatic NO formation by the intestinal mucosal surface epithelium. Plasma level of the endogenous NOS-inhibitor asymmetric di-methylarginine (ADMA) increases and the mucosal NO decreases during severe circulatory stress induced by hypovolaemia or cardiac tamponade. Mucosal hypoperfusion and dysoxia, rather than lack of the substrate L-Arginine or the increased concentration of ADMA, explain the decreased NO signal following circulatory stress. Sepsis is associated with maintained intestinal NO formation despite a concomitant mesenteric hypoperfusion. Intestinal NO formation in man varies in relation with the interdigestive motility pattern. LBNP-induced hypotension in man is associated with markedly decreased mucosal perfusion and decreased mucosal NO formation.
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| 11. |
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| 12. |
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| 13. |
- Vickhoff, Björn, 1946, et al.
(författare)
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Music structure determines heart rate variability of singers
- 2013
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Ingår i: Frontiers in Psychology. - : Frontiers Media SA. - 1664-1078. ; 4
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Tidskriftsartikel (refereegranskat)abstract
- Choir singing is known to promote wellbeing. One reason for this may be that singing demands a slower than normal respiration, which may in turn affect heart activity. Coupling of heart rate variability (HRV) to respiration is called Respiratory sinus arrhythmia (RSA). This coupling has a subjective as well as a biologically soothing effect, and it is beneficial for cardiovascular function. RSA is seen to be more marked during slow-paced breathing and at lower respiration rates (0.1 Hz and below). In this study, we investigate how singing, which is a form of guided breathing, affects HRV and RSA. The study comprises a group of healthy 18 year olds of mixed gender. The subjects are asked to; (1) hum a single tone and breathe whenever they need to; (2) sing a hymn with free, unguided breathing; and (3) sing a slow mantra and breathe solely between phrases. Heart rate (HR) is measured continuously during the study. The study design makes it possible to compare above three levels of song structure. In a separate case study, we examine five individuals performing singing tasks (1–3). We collect data with more advanced equipment, simultaneously recording HR, respiration, skin conductance and finger temperature. We show how song structure, respiration and HR are connected. Unison singing of regular song structures makes the hearts of the singers accelerate and decelerate simultaneously. Implications concerning the effect on wellbeing and health are discussed as well as the question how this inner entrainment may affect perception and behavior.
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