| 1. |
- Enlund, Mats, et al.
(författare)
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The choice of anaesthetic - sevoflurane or propofol - and outcome from cancer surgery : a retrospective analysis
- 2014
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Ingår i: Upsala Journal of Medical Sciences. - : Uppsala Medical Society. - 0300-9734 .- 2000-1967. ; 119:3, s. 251-261
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND:Commonly used inhalational hypnotics, such as sevoflurane, are pro-inflammatory, whereas the intravenously administered hypnotic agent propofol is anti-inflammatory and anti-oxidative. A few clinical studies have indicated similar effects in patients. We examined the possible association between patient survival after radical cancer surgery and the use of sevoflurane or propofol anaesthesia.PATIENTS AND METHODS:Demographic, anaesthetic, and surgical data from 2,838 patients registered for surgery for breast, colon, or rectal cancers were included in a database. This was record-linked to regional clinical quality registers. Cumulative 1- and 5-year overall survival rates were assessed using the Kaplan-Meier method, and estimates were compared between patients given propofol (n = 903) or sevoflurane (n = 1,935). In a second step, Cox proportional hazard models were calculated to assess the risk of death adjusted for potential effect modifiers and confounders.RESULTS:Differences in overall 1- and 5-year survival rates for all three sites combined were 4.7% (p = 0.004) and 5.6% (p < 0.001), respectively, in favour of propofol. The 1-year survival for patients operated for colon cancer was almost 10% higher after propofol anaesthesia. However, after adjustment for several confounders, the observed differences were not statistically significant.CONCLUSION:Propofol anaesthesia might be better in surgery for some cancer types, but the retrospective design of this study, with uneven distributions of several confounders, distorted the picture. These uncertainties emphasize the need for a randomized controlled trial.
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| 2. |
- Rhodin, Annica, 1949-
(författare)
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Long-term Effects of Opioids in the Treatment of Chronic Pain : Investigation of Problems and Hazards on Clinical, Biochemical, Cellular and Genetic Levels
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- After two decades of liberal prescribing of opioids, there has been an increasing recognition of problems connected to the prolonged use of opioids for chronic pain. The aim of my thesis was to explore some consequences of long-term opioid treatment for chronic pain such as problematic opioid use, endocrine disorders, tolerance and genetic variations in pain and opioid response. Sixty patients with severe pain and problematic opioid use were treated with a structured methadone programme. Risk factors were musculoskeletal pain, psychiatric co-morbidity and previous addiction. Treatment resulted in good pain relief and improved quality of life, but function was impaired by side effects indicating endocrine dysregulation. The possibility of opioid-induced endocrine dysfunction was explored in the second paper, where 40 pain patients treated with strong opioids and 20 pain patients without treatment of strong opioids were investigated. The opioid-treated patients had significantly higher incidence of endocrine disturbance affecting gonadal and adrenal function and prolactin levels. The functionality of the μ-receptor after long-term treatment with morphine, saline and naloxone was explored in a cell-line expressing the μ-receptor. After one and four weeks of treatment the binding was tested with morphine, methadone, fentanyl and DAMGO and function measured by GTP γ-assay. The binding of DAMGO was significantly diminished after 4 weeks in cells treated with morphine compared with saline and naloxone. Genetic variation in three genes with functional impact on opioid response and pain sensitivity was investigated in 80 patients with chronic low-back pain and differential opioid sensitivity and in 56 healthy controls. The results indicated a higher incidence of opioid-related side effects and gender differences in patients with the minor allele of the ABCB1 gene, a correlation between increased opioid sensitivity and the major CACNA2D2 allele and a possible relationship between intrinsic protection against chronic pain and the minor allele of OPRM1.
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| 3. |
- Burström, Lena
(författare)
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Patient Safety in the Emergency Department : Culture, Waiting, and Outcomes of Efficiency and Quality
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to investigate patient safety in the emergency department (ED) and to determine whether this varies according to patient safety culture, waiting, and outcomes of efficiency and quality variables.I: Patient safety culture was described in the EDs of two different hospitals before and after a quality improvement project. The questionnaire “Hospital Survey on Patient Safety Culture” was used to investigate the patient safety culture. The main finding was that the staff at both hospitals scored more positively in the dimension Team-work within hospital after implementing a new work model aimed at improving patient flow and patient safety in the ED. Otherwise, we found only modest improvements.II: Grounded theory was used to explore what happens in the ED from the staff perspective. Their main concern was reducing patients’ non-acceptable waiting time. Management of waiting was improved either by increasing the throughput of patient flow by structure pushing and by shuffling patients, or by changing the experience of waiting by calming patients and by feinting to cover up.III: Three Swedish EDs with different triage models were compared in terms of efficiency and quality. The median length of stay was 158 minutes for physician-led team triage compared with 243 and 197 minutes for nurse–emergency physician and nurse–junior physician triage, respectively. Quality indicators (i.e., patients leaving before treatment was completed, the rate of unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days) improved under the physician-led team triage.IV: Efficiency and quality variables were compared from before (2008) to after (2012) a reorganization with a shift of triage model at a single ED. Time from registration to physician decreased by 47 minutes, and the length of stay decreased by 34 minutes. Several quality measures differed between the two years, in favour of 2012. Patients leaving before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days all improved despite the reduced admission rate.In conclusion, the studies underscore the need to improve patient safety in the ED. It is important to the patient safety culture to reduce patient waiting because it dynamically affects both patients and staff. Physician-led team triage may be a suitable model for reducing patient waiting time and increasing patient safety.
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| 4. |
- Burström, Lena, et al.
(författare)
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Physician-led team triage based on lean principles may be superior for efficiency and quality? : A comparison of three emergency departments with different triage models
- 2012
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 20:1, s. 57-
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND:The management of emergency departments (EDs) principally involves maintaining effective patient flow and care. Different triage models are used today to achieve these two goals. The aim of this study was to compare the performance of different triage models used in three Swedish EDs. Using efficiency and quality indicators, we compared the following triage models: physician-led team triage, nurse first/emergency physician second, and nurse first/junior physician second.METHODS: All data of patients arriving at the three EDs between 08:00- and 21:00 throughout 2008 were collected and merged into a database. The following efficiency indicators were measured: length of stay (LOS) including time to physician, time from physician to discharge, and 4-hour turnover rate. The following quality indicators were measured: rate of patients left before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days.RESULTS: Data from 160,684 patients were analysed. The median length of stay was 158 minutes for physician-led team triage, compared with 243 and 197 minutes for nurse/emergency physician and nurse/junior physician triage, respectively (p < 0.001). The rate of patients left before treatment was completed was 3.1 % for physician-led team triage, 5.3 % for nurse/emergency physician, and 9.6 % for nurse/junior physician triage (p < 0.001). Further, the rates of unscheduled return within 24 hours were significantly lower for physician-led team triage, 1.0 %, compared with 2.1 %, and 2.5 % for nurse/emergency physician, and nurse/junior physician, respectively (p < 0.001). The mortality rate within 7 days was 0.8 % for physician-led team triage and 1.0 % for the two other triage models (p < 0.001).CONCLUSIONS: Physician-led team triage seemed advantageous, both expressed as efficiency and quality indicators, compared with the two other models.
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| 5. |
- Burström, Lena, et al.
(författare)
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The patient safety culture as perceived by staff at two different emergency departments before and after introducing a flow-oriented working model with team triage and lean principles : A repeated cross-sectional study
- 2014
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Ingår i: BMC Health Services Research. - : Springer Science and Business Media LLC. - 1472-6963. ; 14
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Tidskriftsartikel (refereegranskat)abstract
- Background: Patient safety is of the utmost importance in health care. The patient safety culture in an institution has great impact on patient safety. To enhance patient safety and to design strategies to reduce medical injuries, there is a current focus on measuring the patient safety culture. The aim of the present study was to describe the patient safety culture in an ED at two different hospitals before and after a Quality improvement (QI) project that was aimed to enhance patient safety. Methods: A repeated cross-sectional design, using the Hospital Survey On Patient Safety Culture questionnaire before and after a quality improvement project in two emergency departments at a county hospital and a university hospital. The questionnaire was developed to obtain a better understanding of the patient safety culture of an entire hospital or of specific departments. The Swedish version has 51 questions and 15 dimensions. Results: At the county hospital, a difference between baseline and follow-up was observed in three dimensions. For two of these dimensions, Team-work within hospital and Communication openness, a higher score was measured at the follow-up. At the university hospital, a higher score was measured at follow-up for the two dimensions Team-work across hospital units and Team-work within hospital. Conclusion: The result showed changes in the self-estimated patient safety culture, mainly regarding team-work and communication openness. Most of the improvements at follow-up were seen by physicians, and mainly at the county hospital.
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| 6. |
- Edmark, Lennart, et al.
(författare)
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A ventilation strategy during general anaesthesia to reduce postoperative atelectasis
- 2014
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Ingår i: Upsala Journal of Medical Sciences. - : Uppsala Medical Society. - 0300-9734 .- 2000-1967. ; 119:3, s. 242-250
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Tidskriftsartikel (refereegranskat)abstract
- Background:Atelectasis is common during and after general anaesthesia. We hypothesized that a ventilation strategy, without recruitment manoeuvres, using a combination of continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP) and a reduced end-expiratory oxygen fraction (FETO2) before ending mask ventilation with CPAP after extubation would reduce the area of postoperative atelectasis.Methods:Thirty patients were randomized into three groups. During induction and emergence, inspiratory oxygen fractions (FIO2) were 1.0 in the control group and 1.0 or 0.8 in the intervention groups. No CPAP/PEEP was used in the control group, whereas CPAP/PEEP of 6 cmH2O was used in the intervention groups. After extubation, FIO2 was set to 0.30 in the intervention groups and CPAP was applied, aiming at FETO2 < 0.30. Atelectasis was studied by computed tomography 25 min postoperatively.Results:The median area of atelectasis was 5.2 cm(2) (range 1.6-12.2 cm(2)) and 8.5 cm(2) (3-23.1 cm(2)) in the groups given FIO2 1.0 with or without CPAP/PEEP, respectively. After correction for body mass index the difference between medians (2.9 cm(2)) was statistically significant (confidence interval 0.2-7.6 cm(2), p = 0.04). In the group given FIO2 0.8, in which seven patients were ex- or current smokers, the median area of atelectasis was 8.2 cm(2) (1.8-14.7 cm(2)).Conclusion:Compared with conventional ventilation, after correction for obesity, this ventilation strategy reduced the area of postoperative atelectasis in one of the intervention groups but not in the other group, which included a higher proportion of smokers.
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| 7. |
- Edmark, Lennart, 1954-, et al.
(författare)
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Oxygen concentration and characteristics of progressive atelectasis formation during anaesthesia
- 2011
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Ingår i: Acta Anaesthesiologica Scandinavica. - : Wiley. - 0001-5172 .- 1399-6576. ; 55:1, s. 75-81
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Tidskriftsartikel (refereegranskat)abstract
- Background: Atelectasis is a common consequence of pre-oxygenation with 100% oxygen during induction of anaesthesia. Lowering the oxygen level during pre-oxygenation reduces atelectasis. Whether this effect is maintained during anaesthesia is unknown.Methods: During and after pre-oxygenation and induction of anaesthesia with 60%, 80% or 100% oxygen concentration, followed by anaesthesia with mechanical ventilation with 40% oxygen in nitrogen and positive end-expiratory pressure of 3 cmH2O, we used repeated computed tomography (CT) to investigate the early (0–14 min) vs. the later time course (14–45 min) of atelectasis formation.Results: In the early time course, atelectasis was studied awake, 4, 7 and 14 min after start of pre-oxygenation with 60%, 80% or 100% oxygen concentration. The differences in the area of atelectasis formation between awake and 7 min and between 7 and 14 min were significant, irrespective of oxygen concentration (P<0.05). During the late time course, studied after pre-oxygenation with 80% oxygen, the differences in the area of atelectasis formation between awake and 14 min, between 14 and 21 min, between 21 and 28 min and finally between 21 and 45 min were all significant (P<0.05).Conclusion: Formation of atelectasis after pre-oxygenation and induction of anaesthesia is oxygen and time dependent. The benefit of using 80% oxygen during induction of anaesthesia in order to reduce atelectasis diminished gradually with time.
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| 8. |
- Edmark, Lennart, et al.
(författare)
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Post-operative atelectasis : a randomised trial investigating a ventilatory strategy and low oxygen fraction during recovery
- 2014
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Ingår i: Acta Anaesthesiologica Scandinavica. - : John Wiley & Sons. - 0001-5172 .- 1399-6576. ; 58:6, s. 681-688
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Atelectasis is common during and after general anaesthesia. We hypothesized that a ventilation strategy with a combination of 1) continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP) and 2) a reduced end-expiratory oxygen concentration during recovery would reduce post-operative atelectasis.METHODS: Sixty patients were randomized into two groups. During anaesthesia induction, inspiratory oxygen fraction (FI O2 ) was 1.0, and depending on weight, CPAP 6, 7 or 8 cmH2 O was applied in both groups via facemask. During maintenance of anaesthesia, a laryngeal mask airway (LMA) was used, and PEEP was 6-8 cmH2 O in both groups. Before removal of the LMA, FI O2 was set to 0.3 in the intervention group and 1.0 in the control group. Atelectasis was studied by computed tomography (CT) approximately 14 min post-operatively.RESULTS: In one patient in the group given an FI O2 of 0.3 before removal of the LMA a CT scan could not be performed so the patient was excluded. The area of atelectasis was 5.5, 0-16.9 cm(2) (median and range), and 6.8, 0-27.5 cm(2) in the groups given FI O2 0.3 or FI O2 1.0 before removal of the LMA, a difference that was not statistically significant (P = 0.48). Post-hoc analysis showed dependence of atelectasis on smoking (despite all were clinically lung healthy) and American Society of Anesthesiologists class (P = 0.038 and 0.015, respectively).CONCLUSION: Inducing anaesthesia with CPAP/PEEP and FI O2 1.0 and deliberately reducing FI O2 during recovery before removal of the LMA did not reduce post-operative atelectasis compared with FI O2 1.0 before removal of the LMA.
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| 9. |
- Edmark, Lennart, 1954-
(författare)
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Reducing Atelectasis during General Anaesthesia – the Importance of Oxygen Concentration, End-Expiratory Pressure and Patient Factors : A Clinical Study Exploring the Prevention of Atelectasis in Adults
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The use of pure oxygen during preoxygenation and induction of general anaesthesia is a major cause of atelectasis. The interaction between reduced lung volume, resulting in airway closure, and varying inspiratory fractions of oxygen (FIO2) in determining the risk of developing atelectasis is still obscure.Methods: In this thesis, computed tomography (in studies I and II during anaesthesia, in studies III and IV postoperatively) was used to investigate the area of atelectasis in relation to FIO2 and varying levels of continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP).Study I investigated the short-term influence of reducing FIO2 during preoxygenation and induction of general anaesthesia, and the time to hypoxia during apnoea.Study II focused on the long-term effect of an FIO2 of 0.8 for preoxygenation.Study III applied CPAP/PEEP with an FIO2 of 1.0 or 0.8 for pre- and postoxygenation until extubation. After extubation, CPAP with an FIO2 of 0.3 was applied before the end of mask ventilation.Study IV compared two groups given CPAP/PEEP during anaesthesia and an FIO2 of 1.0 or 0.3 during postoxygenation, but without CPAP after extubation.Results: Study I showed a reduction in atelectasis with an FIO2 of 0.8 or 0.6, compared with 1.0, but the time to hypoxia decreased. In study II, atelectasis evolved gradually after preoxygenation. In study III, atelectasis was reduced with an FIO2 of 1.0 and CPAP/PEEP compared with an FIO2 of 1.0 without CPAP/PEEP. The intervention failed in the group given an FIO2 of 0.8, this group had more smokers. Atelectasis and age were correlated. In study IV, no difference was found between the groups. Post hoc analysis showed that smoking and ASA class increased the risk for atelectasis.Conclusion, the effect of reducing FIO2 during preoxygenation to prevent atelectasis might be short-lived. A lower FIO2 shortened the time to the appearance of hypoxia. Increasing lung volume by using CPAP/PEEP also decreased the risk of atelectasis, but the method might fail; for example in patients who are heavy smokers. In older patients care must be taken to reduce a high FIO2 before ending CPAP.
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| 10. |
- Hök, Bertil, et al.
(författare)
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Unobtrusive and Highly Accurate Breath Alcohol Analysis Enabled by Improved Methodology and Technology
- 2014
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Ingår i: Journal of Forensic Investigation. - : Avens Publishing Group. - 2330-0396. ; 2:4, s. 1-8
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Tidskriftsartikel (refereegranskat)abstract
- The study objective was to evaluate a novel method and technology for unobtrusive determination of breath alcohol in relation to current industrial accuracy standards. The methodology uses carbon dioxide as a tracer gas detected by sensor technology based on infrared spectroscopy. Part one of the investigation was to analyse the performance of hand-held prototype devices and included tests of resolution, unit-to-unit variation during calibration, response to alcohol containing gas pulses created with a wet gas simulator, and cross sensitivity to other substances. In part two of the study, 30 human participants provided 1465 breath tests in both unobtrusive and obtrusive use modes. The results of both parts of the study indicate that the prototype devices exceeded present industrial accuracy requirements. The proposed methodology and technology eliminate the previous contradiction between unobtrusiveness and high accuracy.
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