| 1. |
- Ander, Fredrik, 1978-, et al.
(författare)
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Does the β-receptor antagonist esmolol have analgesic effects? : A randomised placebo-controlled cross-over study on healthy volunteers undergoing the cold pressor test
- 2018
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Ingår i: European Journal of Anaesthesiology. - : Lippincott Williams & Wilkins. - 0265-0215 .- 1365-2346. ; 35:3, s. 165-172
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Esmolol may attenuate the sympathetic response to pain and reduce postoperative opioid consumption. It is not clear whether esmolol has an analgesic effect per se.OBJECTIVES: The aim of this study was to evaluate the analgesic effect of esmolol in the absence of anaesthetics and opioids. We tested the hypothesis that esmolol would reduce the maximum pain intensity perceived during the cold pressor test (CPT) by 2 points on a 0 to 10 numeric pain rating scale (NRS) compared to placebo.DESIGN: Randomised, placebo-controlled cross-over study.SETTING: Postoperative recovery area, Örebro University Hospital. Study period, November 2013 to February 2014.PARTICIPANTS: Fourteen healthy volunteers. Exclusion criteria included ongoing medication, pregnancy and breastfeeding and participation in other medical trials.INTERVENTIONS: At separate study sessions, participants received interventions: esmolol (0.7 mg kg bolus over 1 min followed by infusion at 10 μg kg min); 0.9% normal saline bolus then remifentanil infusion at 0.2 μg kg min and 0.9% normal saline bolus and infusion according to a random sequence. All infusions were administered over 30 min.MAIN OUTCOME MEASURES: Perceived maximum pain intensity score, pain tolerance and haemodynamic changes during CPT, and occurrence of side-effects to interventions compared to placebo, respectively.RESULTS: Esmolol did not reduce perceived pain intensity or pain tolerance during the CPT. The NRS-max score was similar for esmolol, 8.5 (±1.4) and placebo, 8.4 (±1.3). The mean difference was 0.1 [95% confidence interval (-1.2 to 1.4)], P value equal to 0.83. Remifentanil significantly reduced NRS-max scores, 5.4 (±2.1) compared to placebo, [mean difference -3.1 (95% confidence interval (-4.4 to -1.8)), P < 0.001]. Side-effects were seen with remifentanil but not with esmolol.CONCLUSION: No direct analgesic effect of esmolol could be demonstrated in the present study. The postoperative opioid-sparing effect demonstrated in previous studies, could therefore be secondary to other factors such as avoidance of opioid-induced hyperalgesia, synergy with coadministered opioids or altered pharmacokinetics of those drugs.TRIAL REGISTRATION: European clinical trials database, https://eudract.ema.europa.eu/, EudraCT no. 2011-005780-24.
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| 2. |
- Ander, Fredrik, 1978-, et al.
(författare)
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Effects of Esmolol on the Esophagogastric Junction : A Double-Blind, Randomized, Crossover Study on 14 Healthy Volunteers
- 2017
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Ingår i: Anesthesia and Analgesia. - Philadelphia, USA : Lippincott Williams & Wilkins. - 0003-2999 .- 1526-7598. ; 125:4, s. 1184-1190
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Passive regurgitation may occur throughout the perioperative period, increasing the risk for pulmonary aspiration and postoperative pulmonary complications. Hypnotics and opioids, especially remifentanil, that are used during anesthesia have been shown to decrease the pressure in the esophagogastric junction (EGJ), that otherwise acts as a barrier against passive regurgitation of gastric contents. Esmolol, usually used to counteract tachycardia and hypertension, has been shown to possess properties useful during general anesthesia. Like remifentanil, the beta-1-adrenoreceptor antagonist may be used to attenuate the stress reaction to tracheal intubation and to modify perioperative anesthetic requirements. It may also reduce the need for opioids in the postoperative period. Its action on the EGJ is however unknown. The aim of this trial was to compare the effects of esmolol and remifentanil on EGJ pressures in healthy volunteers, when administrated as single drugs.METHODS: Measurements of EGJ pressures were made in 14 healthy volunteers using high resolution solid-state manometry. Interventions were administered in a randomized sequence and consisted of esmolol that was given IV as a bolus dose of 1 mg/kg followed by an infusion of 10 mu g.kg(-1).minute(-1) over 15 minutes, and remifentanil with target-controlled infusion of 4 ng/mL over 15 minutes. Interventions were separated by a 20-minute washout period. Analyses of EGJ pressures were performed at baseline, and during drug administration at 2 (T2) and 15 minutes (T15). The primary outcome was the inspiratory EGJ augmentation, while the inspiratory and expiratory EGJ pressures were secondary outcomes.RESULTS: There was no effect on inspiratory EGJ augmentation when comparing remifentanil and esmolol (mean difference -4.0 mm Hg [-9.7 to 1.7]; P = .15). In contrast, remifentanil significantly decreased both inspiratory and expiratory pressures compared to esmolol (-12.2 [-18.6 to 5.7]; P = .003 and 8.0 [-13.3 to 2.8]; P = .006).CONCLUSIONS: Esmolol, compared with remifentanil, does not affect EGJ function. This may be an advantage regarding passive regurgitation and esmolol may thus have a role to play in anesthesia where maintenance of EGJ barrier function is of outmost importance.
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| 3. |
- Ander, Fredrik, 1978-
(författare)
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Perioperative complications in obese patients : A thesis on risk reducing strategies
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aspiration of gastric content and delayed or failed intubation are the leading causes of anesthesia-related mortality and morbidity. In the recovery period, airway obstruction with subsequent hypoxia is a relatively common cause of morbidity, and is highly associated to the amount of opioids administered, especially in obese patients.The overall aim of this thesis was to study these risk factors for airway complications and postoperative hypoxia in obese patients, and to evaluate possible strategies for their prevention.In Study I, intubation times and incidence of failed intubation in obese patients were compared between direct laryngoscopy and videolaryngoscopy with the Stortz® C-MAC™. In Studies II and III, the effect of esmolol vs. remifentanil on the esophageal junction, and the possible analgesic properties of low-dose esmolol vs. placebo were evaluated using high-resolution manometry and the cold pressor test, respectively. Finally, in Study IV, the possible opioid-sparing effect of esmolol after laparoscopic gastric bypass surgery was evaluated.The use of videlaryngoscopy did not shorten intubation times, however appeared to reduce the incidence of failed intubation. Our results also show that esmolol has a favorable profile, compared to remifentanil, with regard to the protection against passive regurgitation and aspiration of gastric content. No analgesic effect of low-dose esmolol was however demonstrated. The intraoperative administration of esmolol instead of remifentanil also did not reduce the requirement of morphine for treatment of post-operative pain.The use of Stortz® C-MAC™ may be recommended for intubation of obese patients. Further studies are however required to clarify the possible role of esmolol in anesthesia.
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| 4. |
- Ander, Fredrik, 1978-, et al.
(författare)
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Time-to-intubation in obese patients : A randomized study comparing direct laryngoscopy and videolaryngoscopy in experienced anaesthetists
- 2017
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Ingår i: Minerva Anestesiologica. - : Edizioni Minerva Medica. - 0375-9393 .- 1827-1596. ; 83:9, s. 906-913
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Airway management may be difficult in obese patients. Moreover, during prolonged intubation, oxygen desaturation develops rapidly. Videolaryngoscopy improves the view of the larynx, and the Storz® C-MACTM has been shown to be superior to other videolaryngoscopes in terms of intubation time in obese patients. However, no effort has been made to compare the Storz® C-MACTM with direct laryngoscopy. The aim of the study was to evaluate if the use of Storz® C-MACTM may reduce intubation time when compared to direct laryngoscopy (classic Macintosh® blade).METHODS: eighty patients with body mass index > 35kg/m2 were randomized to orotracheal intubation using either Macintosh® laryngoscope, or the Storz® C-MACTM with the standard Macintosh blade. Patients had no previous history of a difficult airway. Time- to-intubation (TTI) was defined as the time from the moment anaesthetist took the laryngoscope until end-tidal carbon dioxide was detected.RESULTS: no significant difference in TTI could be demonstrated between the two devices tested (mean difference -1.7s (95% CI -6.9 to 3.5s). All patients in the videolaryngoscopy group were successfully intubated with the allocated device, whereas five patients in the direct laryngoscopy group required an alternative device for successful intubation. No significant difference regarding the subjective difficulty of intubation and postoperative sore throat between groups was demonstrated.CONCLUSION: in obese patients the airway may be secured equally fast using direct laryngoscopy (Macintosh®) and with videolaryngoscopy using the Stortz® C-MACTM. The risk for failed intubation, however, appears to be greater with direct laryngoscopy, especially in male obese patients.
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| 5. |
- Bartha, Erzsebet, et al.
(författare)
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Combining functional dependency and ASA III classification for risk stratification-predictors, risk factors, and outcomes following major surgery study (NCT02626546)
- 2017
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Ingår i: Acta Anaesthesiologica Scandinavica. - : John Wiley & Sons. - 0001-5172 .- 1399-6576. ; 61:8, s. 1011-1011
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Background: In elderly reclassification of ASA3 class by functional dependency improved prediction of postoperative mortality. We hypothesized that such a reclassification could improve the risk prediction of adverse outcomes also following high risk surgery.Method: We analyzed data collected by the PROFS study in four Swedish academic hospitals. The inclusion criteria were: adults, ASA≥3, major or xmajor/complex surgery (UK surgical severity coding). ASA 3 patients were reclassified into ASA 3a (functionally independent) and 3b (functionally dependent). The adverse outcomes were postoperative complications (yes/no) screened by Postoperative Morbidity Survey (days 3, 7, 10) and mortality (30-day). Complications graded ≥2 by Clavien-Dindo classification were considered. The predictive value of reclassification was analyzed by logistic regression models.Results: Between 2015 Nov2th and 2016 Feb19th 1089 patients were include; 13 were excluded (violation of inclusion criteria), 3 were lost to follow-up and 1073 were analyzed. ASA 3b (vs ASA 3a) patients had higher risk for mortality and for postoperative complications at days 7 and 10. ASA 4 (vs ASA 3) patients had higher risk of all adverse outcomes (Table 1). When age was added in the regression model ASA 3b patients still had higher risk for postoperative complications at day 10, but the significance disappeared when also urgency was added.Conclusion: The loss of significance by adding urgency in the model might be attributed to the dominance of urgent procedures in ASA3b and ASA4 groups. Reclassification of ASA 3 patients by dependency is recommended, as it may predict adverse outcomes and support clinical judgment.
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| 6. |
- Bartha, Erzsebet, et al.
(författare)
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Performance of prediction models of postoperative mortality in high-risk surgical patients in swedish university hospitals : Predictors, Risk factors and Outcome Following major Surgery study (PROFS study NCT02626546)
- 2017
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Ingår i: Acta Anaesthesiologica Scandinavica. - : John Wiley & Sons. - 0001-5172 .- 1399-6576. ; 61:8, s. 1056-1057
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Background: There are several progn ostic prediction models that estimate the probability of postoperative mortality. The role of these models is to support clinical decisions. Before implementation of a prediction model in routine care, it is necessary to analyze its performance in the target population. Our aim was to analyze the performance of four different prediction models of postoperative mortality in a high-risk surgical population.Methods: Data collected from 2015-11-01 until 2016-02-15 in a prospective consecutive observational study (PROFS study) in four university hospitals was used. The inclusion criteria were adult, ASA classification ≥3, and major/complex upper or lower gastrointestinal, urogenital or orthoped ic surgery (UK surgical severity codingA XA PPP). Four prediction models were evaluated: Surgical Outcome Risk Tool (SORT), Surgical APGAR, P-POSSUM and Surgical Risk Scale (SRS). The outcome measure was 90-day mortality. We evaluated the discrimination of the models by area under receiver operator characteristic curve (AUC ROC) before and after recalibration.Results: In total, 1 089 patients were included. Thirteen patients were excluded due to erroneous inclusion, and another three were lost to follow-up, so data from 1 073 was used in this analysis. The mean age was 73 years, the presence of malignancy was 41%, and 90-day mortality was 13% (n = 140). The SORT model had the best discrimination both before and after recalibration. The P-POSSUM model improved after recalibration. The SRS model overestimated, whereas the APGAR model underestimated, the risk of mortality.Conclusions: The original SORT model is promising and could be incorporated as decision support for high-risk surgical patients.
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| 7. |
- Cajander, Per, 1976-, et al.
(författare)
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Effect of positive end-expiratory pressure on gastric insufflation during induction of anaesthesia when using pressure-controlled ventilation via a face mask : A randomised controlled trial
- 2019
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Ingår i: European Journal of Anaesthesiology. - : Blackwell Science Ltd.. - 0265-0215 .- 1365-2346. ; 36:9, s. 625-632
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Face mask ventilation (FMV) during induction of anaesthesia is associated with risk of gastric insufflation that may lead to gastric regurgitation and pulmonary aspiration. A continuous positive airway pressure (CPAP) has been shown to reduce gastric regurgitation. We therefore hypothesised that CPAP followed by FMV with positive end-expiratory pressure (PEEP) during induction of anaesthesia would reduce the risk of gastric insufflation.OBJECTIVE: The primary aim was to compare the incidence of gastric insufflation during FMV with a fixed PEEP level or zero PEEP (ZEEP) after anaesthesia induction. A secondary aim was to investigate the effects of FMV with or without PEEP on upper oesophageal sphincter (UES), oesophageal body and lower oesophageal sphincter (LES) pressures.DESIGN: A randomised controlled trial.SETTING: Single centre, Department of Anaesthesia and Intensive Care, Örebro University Hospital, Sweden.PARTICIPANTS: Thirty healthy volunteers.INTERVENTIONS: Pre-oxygenation without or with CPAP 10 cmH2O, followed by pressure-controlled FMV with either ZEEP or PEEP 10 cmH2O after anaesthesia induction.MAIN OUTCOME MEASURES: A combined impedance/manometry catheter was used to detect the presence of gas and to measure oesophageal pressures. The primary outcome measure was the cumulative incidence of gastric insufflation, defined as a sudden anterograde increase in impedance of more than 1 kΩ over the LES. Secondary outcome measures were UES, oesophageal body and LES pressures.RESULTS: The cumulative incidence of gastric insufflation related to peak inspiratory pressure (PIP), was significantly higher in the PEEP group compared with the ZEEP group (log-rank test P < 0.01). When PIP reached 30 cmH2O, 13 out of 15 in the PEEP group compared with five out of 15 had shown gastric insufflation. There was a significant reduction of oesophageal sphincter pressures within groups comparing pre-oxygenation to after anaesthesia induction, but there were no significant differences in oesophageal sphincter pressures related to the level of PEEP.CONCLUSION: Contrary to the primary hypothesis, with increasing PIP the tested PEEP level did not protect against but facilitated gastric insufflation during FMV. This result suggests that PEEP should be used with caution after anaesthesia induction during FMV, whereas CPAP during pre-oxygenation seems to be safe.TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02238691.
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| 8. |
- de Leon, Alex, et al.
(författare)
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Esophageal multi-level tip manometry in morbidly obese patients during a PEEP step
- 2017
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Ingår i: Acta Anaesthesiologica Scandinavica. - : John Wiley & Sons. - 0001-5172 .- 1399-6576. ; 61:8, s. 1028-1028
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Background: Esophageal pressure, a surrogate for pleural pressure, is used to determine transpulmonary pressure and to set appropriate PEEP levels. There is no consensus on the representativity of esophageal pressure for pleural pressure and how to position and inflate the catheter balloon. The aim of this retrospective study1 was to analyze esophageal pressure using multi-level tip manometry (no balloon).Methods: An esophageal catheter with 12 radially directed tip mano meters at 35 levels one centimeter apart, detecting pressure from pharynx to stomach was placed in 17 patients (BMI >35 kg/m2). Pressure was analyzed integrating measurements from five manometer levels at mid- and lower esophageal level and for all levels between the upper and lower esophageal sphincters at PEEP 0 cmH2O (ZEEP) and after increasing PEEP to 10 cmH2O.Results: End-expiratory esophageal pressure (PESEE) was 10–12 cmH2O at ZEEP and increased minimally and transiently in whole and mid esophagus when PEEP was increased. Lower esophageal pressure increased more, but started to recede after approximately 20 breaths.Conclusions: End-expiratory pressure is positive, 10–12 cmH2O at all esophageal levels at FRC in contrast to absolute pleural pressure, which according to established knowledge is negative. There was only a marginal, transient increase in PESEE in response to PEEP. The change in end-expiratory trans-pulmonary and respiratory system pressures in response to a PEEP increase is therefore equal, and lung elastance can be calculated as the chan ge in PEEP divided by the change in end-expiratory lung volume.
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| 9. |
- Kalman, Sigridur, et al.
(författare)
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Postoperative complications in high-risk surgical patients - predictors, risk factors, and outcomes following major surgery study (PROFS study NCT02626546) : validation of three prediction models
- 2017
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Ingår i: Acta Anaesthesiologica Scandinavica. - : John Wiley & Sons. - 0001-5172 .- 1399-6576. ; 61:8, s. 1056-1056
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Background: Postoperative complications increase the risk of death 2–3 years postoperatively. Prediction of complications can support clinical decisions. Before clinical use of any prediction model, validation is reasonable. We aimed to validatethree models: Revised Cardiac Risk Index (RCRI), ARISCAT and POSSUM.Methods: The PROF S-study was performed in four Swedish university hospitals. Patients werere cruited between 2015-11-01 and 2016-02-15. Inclusion criteria were adults, ASA classification ≥3, major/complex upper and lower gastrointestinal, urogenital or orthopedic surgery. Complications were screened on days 3, 7 and 10 by the postoperative morbidity survey (POMS). Only patients with grade≥2 (Clavien-Dindo classification) were accounted for. Study outcomes were cardiovascular (RCRI model) and pulmonary (ARISCAT model) complications, and a composite of the POMS domains (POSSUM model). Discrimination was evaluated by C-statistics (area under receiver operator characteristic curve; AUC ROC).Results: The number of patients included was 1089. Thirteen patients were excluded due to wrong inclusion, and another three were lost to follow-up. Presen ce of malignancy was 41%. Patient characteristics and outcomes are displayed in Table 1. The RCRI underestimated the risk for cardiovascular complications, and discrimination was low (AUC ROC 0.64; 95% CI 0.59–0.68). The prediction by the ARISCAT model was fair (AUC 0.72; CI 0.69–0.76). The POSSUM model had poor /fair discrimination (AUC 0.70; CI 0.67–0.73).Conclusions: The ARISCAT model predicted pulmonary complications with fair discrimina-tion and so could be used as decision support. Parameters with significant odds ratios of the RCRI and POSSU M models might be used as complements of clinical judgement.
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| 10. |
- Pellrud, Richard, 1977-, et al.
(författare)
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Pressure measurement in the upper esophagus during cricoid pressure : A high-resolution solid-state manometry study
- 2018
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Ingår i: Acta Anaesthesiologica Scandinavica. - : John Wiley & Sons. - 0001-5172 .- 1399-6576. ; 62:10, s. 1396-1402
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Tidskriftsartikel (refereegranskat)abstract
- Background: The use of cricoid pressure is controversial, and its ability to occlude the esophagus has been questioned. In this study, high-resolution solid-state manometry was used to analyze pressure changes in the upper esophagus from cricoid pressure during modified rapid sequence induction. This is a secondary analysis of data from a previous study.Methods: Seventeen healthy volunteers participated in a double-blind, randomized, placebo-controlled, cross-over study with primary aim to compare differences in the barrier pressure on the lower esophageal sphincter during rapid sequence induction with or without alfentanil. Standardized cricoid pressure of 30 N was applied 2 minutes after propolipid injection and held for 15 seconds and pressures in the esophagus were measured.Results: Cricoid pressure resulted in a pressure increase of 127 +/- 98 mmHg (95% CI: 73-182) (placebo) and 123 +/- 74 mmHg (95% CI: 84-162) (alfentanil) at the level of the upper esophageal sphincter (UES), compared to baseline.The pressure difference around the UES compared to the proximal esophagus during cricoid pressure application was 165 +/- 100 mmHg (placebo) and 159 +/- 87 mmHg (alfentanil) (mean +/- 1 SD).Conclusion: This study using high-resolution solid-state manometry under clinically relevant conditions shows that 30 N cricoid pressure generates high pressure in the area of the UES, far exceeding the levels previously considered necessary to prevent regurgitation. Additional studies are needed to clarify the effectiveness of cricoid pressure in preventing passive regurgitation before it is rejected as a part of rapid sequence induction.
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