| 1. |
- Ahlstrand, Rebecca, 1973-, et al.
(författare)
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Effects of cricoid pressure and remifentanil on the esophageal sphincters using high-resolution solid-state manometry
- 2011
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Ingår i: Acta Anaesthesiologica Scandinavica. - : Wiley-Blackwell. - 0001-5172 .- 1399-6576. ; 55:2, s. 209-215
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Cricoid pressure has been shown to decrease the pressure in the lower esophageal sphincter (LES), increasing the risk of aspiration. Whether this reaction is due to pain associated with the application of cricoid pressure has not been studied. The aim of this study was to compare the effects of cricoid pressure with those of peripheral pain on pressures in the LES, and to study whether remifentanil influences these effects. Data from the upper esophageal sphincter (UES) are also described.METHODS: Continuous solid-state manometry was performed in 14 healthy volunteers. Initially, the effect of remifentanil (target-controlled infusion with a plasma target concentration of 5.0 ng/ml) was studied, and thereafter, the effects of cricoid pressure and peripheral pain stimulation (cold stimulation). Finally, these two interventions were repeated under ongoing remifentanil infusion.RESULTS: Remifentanil decreased the LES pressure significantly [ΔP-6.5 mmHg, 95% confidence interval (95% CI) -1.7 to -11.2]. Cricoid pressure application decreased the LES pressure significantly (ΔP-3.7 mmHg, 95% CI -1.4 to 6.1), whereas peripheral pain did not (ΔP 1.2 mmHg, 95% CI -3.5 to 1.1). Under ongoing remifentanil infusion, no cricoid pressure-induced LES relaxation was observed. Cricoid pressure induced high pressures in the area of the UES, 215.7 (±91.2) mmHg without remifentanil vs. 219.4 (±74.2) mmHg with remifentanil.CONCLUSIONS: Remifentanil as well as cricoid pressure per se induced decreases in LES pressure. However, cricoid pressure-induced changes of the barrier pressure were not significant whether induced with or without an infusion of remifentanil.
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| 2. |
- Cajander, Per, 1976-, et al.
(författare)
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Effects of dexmedetomidine on pharyngeal swallowing and esophageal motility : A double-blind randomized cross-over study in healthy volunteers
- 2023
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Ingår i: Neurogastroenterology and Motility. - : Wiley-Blackwell Publishing Inc.. - 1350-1925 .- 1365-2982. ; 35:1
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Sedative agents increase the risk of pulmonary aspiration, where an intact swallowing function is an important defense mechanism. Dexmedetomidine is an α2 -adrenoceptor agonist widely used during procedural sedation due to beneficial properties with minimal respiratory effects. The effects of dexmedetomidine on pharyngeal swallowing and esophageal motility are not known in detail.METHODS: To determine the effects of dexmedetomidine on pharyngeal swallowing and esophageal motility, nineteen volunteers were included in this double-blinded, randomized placebo-controlled cross-over study. Study participants received target-controlled dexmedetomidine and placebo infusions. Recordings of pressure and impedance data were acquired using a manometry and impedance solid-state catheter. Data were analyzed from three bolus swallows series: baseline, during dexmedetomidine/placebo infusion at target plasma concentrations 0.6 ng ml-1 and 1.2 ng ml-1 . Subjective swallowing difficulties were also recorded.KEY RESULTS: On pharyngeal swallowing, dexmedetomidine affected the upper esophageal sphincter with decreased pre- and post-swallow contractile pressures and an increase in residual pressure during swallow-related relaxation. On esophageal function, dexmedetomidine decreased contractile vigor of the proximal esophagus and increased velocity of the peristaltic contraction wave. Residual pressures during swallow-related esophagogastric junction (EGJ) relaxation decreased, as did basal EGJ resting pressure. The effects on the functional variables were not clearly dose-dependent, but mild subjective swallowing difficulties were more common at the higher dose level.CONCLUSIONS AND INFERENCES: Dexmedetomidine induces effects on pharyngeal swallowing and esophageal motility, which should be considered in clinical patient management and also when a sedative agent for procedural sedation or for manometric examination is to be chosen.
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| 3. |
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| 4. |
- Cajander, Per, 1976-, et al.
(författare)
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Effects of remifentanil on pharyngeal swallowing and esophageal motility : no impact of different bolus volumes, and partial antagonism by methylnaltrexone
- 2021
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Ingår i: American Journal of Physiology - Gastrointestinal and Liver Physiology. - : HighWire Press. - 0193-1857 .- 1522-1547. ; 321:4, s. G367-G377
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Tidskriftsartikel (refereegranskat)abstract
- Background: Remifentanil impairs swallowing, and disturbed accommodation to bolus volume may be one of the underlying causes. It is not fully understood whether remifentanil-induced swallowing dysfunction is mediated by peripheral or central mechanisms.Aims: To investigate if remifentanil-induced swallowing dysfunction is dependent on the bolus volume and whether the effect of remifentanil could be counteracted by methylnaltrexone, a peripherally acting opioid antagonist.Methods: Nineteen healthy volunteers were included in this double-blinded, randomized, placebo-controlled, crossover study. Study participants received target-controlled remifentanil infusions and placebo infusions in a randomized order. Methylnaltrexone was administered by intravenous injection of doses of 0.3 mg/kg. Recordings of pressure and impedance data were acquired using a combined manometry and impedance solid state catheter. Data was analyzed from three series of bolus swallows, baseline, during remifentanil exposure, and 15 min after methylnaltrexone.Results: Remifentanil induced significant effects on multiple pharyngeal and esophageal function parameters. No significant differences in remifentanil-induced swallowing dysfunction related to different bolus volumes were found. Pharyngeal effects of remifentanil were not significantly counteracted by methylnaltrexone, whereas on the distal esophageal level, effects on distension pressures were counteracted. Conclusions Changes in pharyngeal and esophageal pressure flow variables were consistent with previous results on remifentanil-induced swallowing dysfunction, and uniform across all bolus volumes. The effects of remifentanil on the pharyngeal level and on the proximal esophagus appear to be predominantly centrally mediated, whereas the effects of remifentanil on the distal esophagus may be mediated by both central and peripheral mechanisms.NEW & NOTEWORTHY: In this randomized controlled trial, we used the "Swallow Gateway" online platform to analyze the effects of remifentanil on pharyngeal and esophageal swallowing. It is not fully understood whether remifentanil-induced swallowing dysfunction is mediated by peripheral or central mechanisms. By using methylnaltrexone, we demonstrated that effects of remifentanil on pharyngeal swallowing were predominantly centrally mediated, whereas its effects on the distal esophagus may be mediated by both central and peripheral mechanisms.
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| 5. |
- Cajander, Per, 1976-, et al.
(författare)
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Response to Letter to the Editor
- 2023
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Ingår i: Neurogastroenterology and Motility. - : Wiley-Blackwell. - 1350-1925 .- 1365-2982. ; 35:8
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Tidskriftsartikel (refereegranskat)abstract
- It is crucial to consider the possible influence of anesthetic agents on esophageal function testing. Dexmedetomidine has been shown to affect primary peristalsis during esophageal manometry. In the two case reports presented by Toaz et al., secondary peristalsis during FLIP panometry was also affected. This may be attributed to an alternate pharmacodynamic effect, with a transient direct α2-mediated effect on esophageal smooth muscle, associated with a high plasma concentration following bolus injection, prior to the onset of sympathetic inhibition.
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| 6. |
- Cajander, Per, 1976-
(författare)
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Risk of pulmonary aspiration during anesthesia and sedation
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Pulmonary aspiration is a feared complication in anesthesia practice. Even if it is a rare event it is the most common cause of anesthesia related death. There are two different types of pulmonary aspiration, macroaspirationwhere large amounts of gastric content are inhaled to the lungs, and the silent, often unnoticed, microaspiration, where small amounts of gastric or oropharyngeal contents are aspirated. Micro aspirations is much more common and can occur at any time during the perioperative period, presenting as postoperative pulmonary complications, often several days after the anesthesia procedure. Human physiology features multiple mechanisms of protection against pulmonary aspiration, including the esophageal sphincters that prevent gastric regurgitation and complex laryngeal reflex systems protecting the airway. An additional vital defense against pulmonary aspiration is an intact swallowing function, with dysphagia being the primary cause of aspiration pneumonia. Anesthetic agents affect these protective mechanisms to various extent.The aim of this thesis was to study the effects of sedative agents on swallowing function, and different ventilatory techniques during anesthesia induction in healthy volunteers. In study I, the use of positive end expiratory pressure during mask ventilation after anesthesia induction was studied in regard of risk of gastric insufflation. In study II and IV the pharmacological effects of the opioid remifentanil on swallowing function were studied. Study III was the first study on effects of dexmedetomidine on human swallowing physiology. The experiments in this thesis has led to a deeper understanding in how different anesthetic agents affects the physiological protective mechanisms against pulmonary aspiration, both during anesthesia induction and sedation. The findings may facilitate clinical decisions, leading to better risk management in terms of macroaspiration during anesthesia and sedation, and postoperative pulmonary complications related to microaspirations.
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| 7. |
- Cock, C., et al.
(författare)
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Effects of remifentanil on esophageal and esophagogastric junction (EGJ) bolus transit in healthy volunteers using novel pressure-flow analysis
- 2018
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Ingår i: Neurogastroenterology and Motility. - : John Wiley & Sons. - 1350-1925 .- 1365-2982. ; 30:2
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Remifentanil is associated with subjective dysphagia and an objective increase in aspiration risk. Studies of opioid effects have shown decreased lower esophageal sphincter relaxation. We assessed bolus transit through the esophagus and esophagogastric junction (EGJ) during remifentanil administration using objective pressure-flow analysis.METHODS: Data from 11 healthy young participants (23±3 years, 7 M) were assessed for bolus flow through the esophagus and EGJ using high-resolution impedance manometry (Manoscan™, Sierra Scientific Instruments, Inc., LES Angeles, CA, USA) with 36 pressure and 18 impedance segments. Data were analyzed for esophageal pressure topography and pressure-flow analysis using custom Matlab analyses (Mathworks, Natick, USA). Paired t tests were performed with a P-value of < .05 regarded as significant.KEY RESULTS: Duration of bolus flow through (remifentanil/R 3.0±0.3 vs baseline/B 5.0 ± 0.4 seconds; P < .001) and presence at the EGJ (R 5.1 ± 0.5 vs B 7.1 ± 0.5 seconds; P = .001) both decreased during remifentanil administration. Distal latency (R 5.2 ± 0.4 vs B 7.5 ± 0.2 seconds; P < .001) and distal esophageal distension-contraction latency (R 3.5 ± 0.1 vs B 4.7 ± 0.2 seconds; P < .001) were both reduced. Intrabolus pressures were increased in both the proximal (R 5.3 ± 0.9 vs B 2.6 ± 1.3 mm Hg; P = .01) and distal esophagus (R 8.6 ± 1.7 vs B 3.1 ± 0.8 mm Hg; P = .001). There was no evidence of increased esophageal bolus residue.CONCLUSIONS AND INFERENCES: Remifentanil-induced effects were different for proximal and distal esophagus, with a reduced time for trans-sphincteric bolus flow at the EGJ, suggestive of central and peripheral μ-opioid agonism. There were no functional consequences in healthy subjects.
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| 8. |
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| 9. |
- Doeltgen, Sebastian H., et al.
(författare)
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Remifentanil alters sensory neuromodulation of swallowing in healthy volunteers : Quantification by a novel pressure-impedance analysis
- 2016
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Ingår i: American Journal of Physiology - Gastrointestinal and Liver Physiology. - Bethesda, USA : American Physiological Society. - 0193-1857 .- 1522-1547. ; 310:11, s. G1176-G1182
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Tidskriftsartikel (refereegranskat)abstract
- Exposure to remifentanil contributes to an increased risk of pulmonary aspiration, likely through reduced pharyngeal contractile vigour and diminished bolus propulsion during swallowing. Here, we employed a novel high resolution pressure-flow analysis to quantify the biomechanical changes across the upper esophageal sphincter (UES). Eleven healthy young participants (mean age 23.3±3.1 years, 7 male) received remifentanil via intravenous target controlled infusion with an effect-site concentration of 3 ng/ml. Before and 30 min following commencement of remifentanil administration, participants performed ten 10 ml saline swallows while pharyngo-esophageal manometry and electrical impedance data were recorded using a 4.2 mm diameter catheter housing 36 circumferential pressure sensors. Remifentanil significantly shortened the time period of UES opening (p<0.001) and increased residual UES pressure (p=0.003). At the level of the hypopharynx, remifentanil significantly shortened the time latency from maximum bolus distension to peak contraction (p=0.004) and significantly increased intrabolus distension pressure (p=0.024). Novel mechanical states analysis revealed that the latencies between the different phases of the stereotypical UES relaxation sequence were shortened by remifentanil. Reduced duration of bolus flow during shortened UES opening in concert with increased hypopharyngeal distension pressures are mechanically consistent with increased flow resistance due to a more rapid bolus flow rate. These biomechanical changes are congruent with modification of the physiologic neuro-regulatory mechanism governing accommodation to bolus volume.
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| 10. |
- Milton, Anna, et al.
(författare)
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Caregiver burden and emotional wellbeing in informal caregivers to ICU survivors-A prospective cohort study
- 2022
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Ingår i: Acta Anaesthesiologica Scandinavica. - : John Wiley & Sons. - 0001-5172 .- 1399-6576. ; 66:1, s. 94-102
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Tidskriftsartikel (refereegranskat)abstract
- Background: Informal caregivers to intensive care unit (ICU) survivors may develop post-intensive care syndrome family (PICS-F), including depression, anxiety and post-traumatic stress (PTS). Our primary aim was to investigate associations between caregiver burden in informal caregivers cohabiting with ICU survivors and patients' physical and psychological outcomes.Methods: A prospective, multicentre cohort study in four ICUs in Sweden. Adults cohabiting with ICU patients included in a previous study were eligible for inclusion. Three months post-ICU, informal caregivers received questionnaires assessing caregiver burden, health-related quality of life (HRQL) and symptoms of depression, anxiety and PTS. In parallel, patients reported their three-month physical and psychological status via validated questionnaires. The primary outcome of this study was to compare caregiver burden in informal caregivers to patients with and without adverse physical and psychological outcomes 3 months post-ICU. Secondary outcomes were correlations between caregiver burden and informal caregivers' mental HRQL.Results: Among 62 included informal caregivers, 55 (89%) responded to the follow-up questionnaires. Caregiver burden was higher among informal caregivers to patients with an adverse outcome, compared to informal caregivers to patients without an adverse outcome, caregiver burden scale score mean (+/- standard deviation) 52 (11) and 41 (13) respectively (p = 0.003). There was strong negative correlation between caregiver burden and informal caregivers' mental HRQL (r(s) -0.74, p < 0.001).Conclusion: Informal caregivers to ICU survivors with adverse physical or psychological outcome experience a higher caregiver burden. A higher caregiver burden correlates with worse caregiver mental HRQL. ICU follow-up programs should consider screening and follow-up of informal caregivers for mental health problems.
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