Måndag 21/9 kl 14:00–15:30
Abdominal perfusion assessment using Diffusion
Weighted Imaging Magnetic Resonance.
Moderatorer: Karin Björnström, Ulrik Sartipy
Silvia Marchesi MD, Aki Hata MD, Francisco Ortiz-Nieto MS,
Anders Larsson PhD, Göran Hedenstierna PhD
Hemodynamic, metabolic and end-organ effects
Hedenstierna Laboratoriet, Akademiska Sjukhuset, Uppsala of endovascular thoracic aortic balloon occlusion
and reperfusion in pigs
Background: Assessment of perfusion, especially of the abdomen, is
challenging in clinical settings as well as in the research field. The com- Nilsson KF1, 2, Sadeghi M4, Dogan E1, Jansson K3, Hörer TM1
monly used imaging techniques, PET and CT, employ contrast agents and are not appropriate in all scenarios.
1 Department of Cardiothoracic and Vascular Surgery, 2 Department of Anesthesiology and Intensive Care and 3 Department of Surgery, Örebro University Hospital, Faculty of Medicine and Health, Örebro University. Aim of the study: To evaluate whether DWI-MR technique could
be used to assess perfusion in abdominal organs in an endotoxemic 4 Department of Surgery, Västerås Hospital. Background: Endovascular aortic balloon occlusion (ABO) can
Material and Methods: Endotoxemic shock was induced in 12 anest-
be used to temporarily stop life threatening bleedings in severe hetized piglets. Animals were randomized into 2 groups with different trauma as an alternative to emergency thoracotomy. In a non- MAP (Group1: MAP ≥ 65 mmHg; Group2: 50 < MAP ≤ 60 mmHg). haemorrhagic pig model, we investigated circulatory, metabolic and The desired MAP was maintained with infusion of Noradrenaline. Af- end-organ effects of ABO and reperfusion, and their relation to ter six hours, DW-MRI was performed. DWI-MR technique utilizes occlusion time.
water motion as internal contrast, making possible to study diffusion (movement of water within tissue) and perfusion (movement of water Methods: Anesthetized pigs (25–35 kg) were randomized to
inside capillary net). Perfusion was calculated as a fraction (f), which either of four groups (n=6/group): 15 min (ABO15), 30 min represents the contribution of water in capillary on the total amount (ABO30) or 60 min (ABO60) of thoracic ABO followed by 3 h of of water molecules movement in one region of interest (ROI). Several reperfusion, or sham (control). Central haemodynamics, blood ROIs were defined in 5 target organs: intestine, stomach, liver, spleen flow in the superi-or mesenteric artery (SMA) and arterial blood and kidneys. In addition, perfusion was assessed with indirect markers, gases were measured during ABO and reperfusion. Plasma i.e., arterial lactate, SvO2 and urinary output.
concentrations of markers of end-organ damage and intraperitoneal concentrations of lactate, pyru-vate and glycerol by microdialysis, Results: The f-value indicated a reduced perfusion in the stomach and
were analyzed.
intestine (p<0.05) in Group2 compared with Group1, which also was reflected in arterial lactate ( Group1 3,5 ± 0,94 mmol/L, Group2 4,6 Results: ABO increased mean arterial blood pressure (MAP) and
± 0,63 mmol/L, p 0,04) and in SvO2: (Group1 41 ± 5,5%, Group2 decreased blood flow in SMA to almost zero. At reperfusion, MAP 27± 8,9%, p < 0,01).
initially dropped but normalized throughout reperfusion. Blood flow in SMA returned to normal at reperfusion. At reperfusion, arterial Conclusion: Since DWI-MR was related to the indirect measures of
pH decreased in parallel with increased arterial lactate concentrations abdominal perfusion it has the potential to be used as a non-invasive in all ABO-groups, but most pronounced in ABO60. In ABO30 and technique to assess abdominal perfusion both in the experimental and ABO60, arterial pH and lactate concentrations were still abnormal clinical setting.
after 3 h of reperfusion. Arterial potassium concentrations increased throughout reperfusion in all ABO-groups, most expressed in ABO60. Intraperitoneal lactate/pyruvate ratios and glycerol concentrations in-creased in all ABO groups, and the increases were largest in ABO30 and ABO60. During reperfusion the plasma Differential regulation of cerebral metabolic genes
concentrations of creatini-ne, aspartate aminotransferase and lipase after hyperglycemic and normoglycemic cardiac
increased in the ABO30 and ABO60, whereas creatine kinase only increased in ABO60.
Maria Molnar, MD*1; Rickard P.F. Lindblom, MD, PhD*2;
Conclusion: In a non-haemorrhagic pig model, thoracic ABO
Charlotte Israelsson, PhD3; Belinda Fridman, MSc4;
causes metabolic acidosis, hyperlactatemia and hyperkalemia as well Lars Wiklund, MD, PhD1; Fredrik Lennmyr, MD, PhD2
as pos-sible damage to visceral end-organs. The severity of these end-organ effects is dependent on occlusion time. Risk and benefit *Equal contribution. Department of Surgical Sciences, 1Section of considerations are important when using ABO and the Anesthesiology and Intensive Care, 2Section of cardiothoracic surgery and anaesthesiologist must take part in that decision.
Anesthesiology, Uppsala University Hospital, 3Department of Neuroscience, Developmental Neuroscience, Biomedical Center, Uppsala University, 4Science for Life Laboratory, Department of Medical Sciences, in skeletal muscle harvested from healthy humans wide a large inter-in- dividual difference in the COX IV-2/COX IV-1 ratio. This ratio corre- lated strongly to whole body (RMR) measured in the same individuals Background: Cerebral ischemia is a life-threatening condition, where
(Fig A). In isolated primary human skeletal myotubes overexpressing survivors often suffer from neurological deficits. To date, treatment op- COX IV-2, the same pattern was observed. These cells displayed a tions are limited. Hyperglycemia is frequently seen in conjunction with >60% lower basal respiration and a >50% reduction in respiration the ischemia and is believed to further worsen the neurological outcome.
without ADP compared to control cells, the latter suggesting either Material and methods: Pigs were openly randomized to high or normal less proton conductance or less proton slip at COX (Fig B). In addi- glucose levels, as regulated by glucose and insulin infusions with target tion, reduced cellular H2O2 production was observed in COX IV-2 levels of 8.5–10 mM and 4–5.5 mM, respectively. The animals were subjected to cardiac arrest (CA) of 5 min followed by 8 min of cardio- pulmonary resuscitation and direct current shock to restore spontaneous circulation. Global expression profiling of the cortex using microarrays was performed in both groups.
Results: 102 genes differed in expression at p<0.001 between the hy-
perglycemic and normoglycemic pigs. Several of the most strongly dif- ferentially regulated genes were involved in transport and metabolism of glucose. Functional clustering using bioinformatics tools revealed enrichment of multiple biological processes, including membrane pro- Conclusion: These results suggest an important role of the mito-
cesses, ion transport and glycoproteins. chondrial subunit isoform COX IV-2 in control of energy expenditure and mitochondrial reactive oxygen species homeostasis in humans.
Conclusions: Hyperglycemia during CA leads to differential early
gene expression compared with normoglycemia. Whether these trans- criptional changes represent epiphenomena or early steps in a cascade that contribute to the increased pathology that follows hyperglycemic ischemia cannot be deduced from this study. However, the identified The effect of plasma from septic ICU patients on
candidates constitute interesting targets for further studies.
healthy rat muscle mitochondria
Jonathan Grip, Towe Jacobsson, Nicolas Tardif, Olav Rooyackers
Clintec and AnOpIVA Karolinska University Hospital and Control of Human Energy Expenditure by
Institute, Huddinge Cytochrome C Oxidase Subunit IV-2
Introduction: Even though sepsis induced organ failure is a major
Tomas Schiffer1, Björn Ekblom2, Michaela Sundqvist1, Jon Lund-
cause of death in ICU:s worldwide, the mitochondrial dysfunction berg1, Filip Larsen1 and Eddie Weitzberg1
associated with this is not fully characterized and there is no evidence Dept. of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Karolinska Institutet and Swedish School of Sports and Objective: We examined whether a central factor in septic plasma
Health Sciences, Stockholm. could affect respirational function of healthy rat muscle mitochondria. Background: Human resting metabolic rate shows pronounced va-
Methods: ICU patients with severe sepsis or septic shock were recru-
riations between subjects, but the underlying molecular mechanism ited within 24hrs of admission together with age-matched controls. remains elusive. Cytochrome C oxidase (COX) plays a key role in con- Blood samples were centrifuged and frozen. Two trials were performed trol of metabolic rate being the terminal enzyme of the mitochondrial and mitochondrial respiration was analyzed using an Oxygraph cham- respiratory chain. A number of regulatory mechanisms exist to control ber with a Clarke-electrode. 1) Isolated mitochondria from rat skeletal oxygen consumption and proton pumping at COX. One such regula- muscle were divided and incubated for 30 minutes with plasma from tion may occur through a shift in COX subunit composition. Recent patients or postoperative controls (n=10). Respiration was normalized in vitro studies of the subunit isoform COX IV-2 indicate a role for for citrate synthase (CS). 2) Permebealized muscle fibers from rats were this protein in the cellular response to hypoxia and oxidative stress. divided and incubated with plasma from patients or healthy controls, However, it remains unclear if COX IV-2 is expressed in human tissues for 30 and 120 minutes, and analyzed for mitochondrial respiration and if it regulates respiration in vivo.
(n=10). Respiration was normalized for fiber weight. Primary outcome was state 3 respiration, which the maximal respiration initiated with Methods: Resting metabolic rate (RMR) was measured in healthy
ADP and adequate energy substrates (malate and pyruvate). T-test was subjects by indirect calorimetry and skeletal muscle biopsies were used for statistical comparison. obtained for western blot analysis of COX-IV subunits. From these biopsies myogenic satellite cells were extracted and grown after which Results: No differences in respirational function of the mitochondria
parts of them were transfected to achieve COX IV-2 overexpression were seen between the groups in either of the experiments. 1) State 3 and COX IV-1 knock down (COX IV-1-/2+). These cells were then respiration in isolated mitochondria were 19.9 ±6.7 vs. 20.2 ±8.8 nmol subjected to respirometric measurements as well as measurement of O *U CS -1*min-1 for sepsis vs. control respectively 2) State 3 respi- hydrogen peroxide (H O ) generation.
ration for fibers incubated with septic and control plasma were after 30 minutes 2.6 ±0.3 vs. 2.4 ±0.7 and after 120 minutes 2.5 ±0.4 vs. Results: We show that COX IV-2 protein is constitutively expressed
2.5 ±0.6 nmol O *mg w.w-1*min-1. Respiratory control ratios (state 3/state 4) were good in all experiments (8.8–11.2), ensuring adequate 1ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, quality of the mitochondria.
Sweden, 2Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institutet, Conclusion: These findings indicate that the effect on muscle mito-
Stockholm, Sweden, 3Department of Medicine, Translational Immuno- chondria in sepsis is secondary rather than directly influenced by a logy Unit, Karolinska Institutet Stockholm, Sweden, 5Anesthesiology and factor in plasma of septic patients.
Intensive Care, Department of Surgical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden. Aim: In systemic inflammation like sepsis and ARDS functional he-
terogeneity of neutrophils (PMNs) occurs. Mature (high expression Effects of hyperbaric oxygen on nitric oxide gene-
of the CD16 receptor) and immature (intermediate expression of the ration in humans
CD16 receptor) PMNs seem to play an important role in the develop- ment of secondary infection and ongoing tissue damage. The PMNs Johan Uusijärvi1,2, Karin Eriksson1,2, Agneta C. Larsson1, Carina
express CXCR1 and are attracted by Interleukin-8 (IL-8), which is re- Nihlén1, Tomas Schiffe 1, Peter Lindholm1,3 , Eddie Weitzberg1,2
leased at the site of inflammation. We describe our findings of neutrop- hil heterogeneity seven ARDS patients treated with ECMO.
1 Dept. of Physiology and Pharmacology, Karolinska Institutet, 2 Dept. of Anesthesia & Intensive Care, Karolinska University Hospital and 3 Dept. Methods: Approval from the local ethical committee and written in-
of Radiology, Karolinska University Hospital, Stockholm, Sweden. formed consent from the closest relative were obtained. Heparinized whole blood from ARDS patients and one healthy control (HC) was Background: Hyperbaric oxygen (HBO ) has been suggested to affect
analyzed by flow cytometry. Cells were stained with monoclonal anti- nitric oxide (NO) generation in humans. NO is produced by NO synt- bodies: CD16 PE Cy7, HLA-DR APC Cy7, CXCR1 APC, CXCR2 hases (NOSs) from L-arginine and molecular oxygen, and may also PE, CCR5 PE (Biolegend), IgG2b APC, IgG1 PE and IgG2a PE iso- be formed by reduction of the inorganic anions nitrate and nitrite. type controls (BD Biosciences). Flow cytometry was performed on a Interestingly, oral facultative anaerobic bacteria are necessary for the FACSCanto cytometer and analyzed with FACSDiva software (BD first step to reduce nitrate to nitrite. The nitrate-nitrite-NO pathway Biosciences). Subpopulations of cells are given as percentage of total is potentiated by hypoxia and low pH in contrast to classical NOS-de- pendent NO generation. We investigated the effects of HBO on NO generation in healthy subjects including orally and nasally exhaled Results: In the beginning of ECMO the frequency of immature
NO, plasma, salivary nitrate and nitrite as well as plasma cGMP and PMNs was elevated. The majority of the immature PMN population citrulline/arginine ratio. We also conducted in-vitro experiments to in- expressed CXCR1. When lung function was improving the immature vestigate the effects of hyperoxia on nitrate/nitrite metabolism and NO PMNs population decreased. Mature PMNs showed CD16 expression generation by oral bacteria.
and CXCR1 expression corresponding to the HC. Methods: Two HBO experiments were performed. In a cross-over ex-
Conclusions: Immature CXCR1 expressing PMNs decreased when
periment (EXP1) subjects breathed air at 130 kPa (control) or oxygen lung function recovered. A therapeutical approach to decrease imma- at 250 kPa for 100 minutes and parameters were measured before and ture CXCR1 expressing PMNs could possibly facilitate lung recovery after exposure. In experiment 2 (EXP 2) measurements were perfor- in ECMO-treated ARDS.
med also during HBO at 250 kPa for 110 minutes.
Results: HBO acutely reduced orally and nasally exhaled NO by
30% and 16%, respectively. There was a decrease in salivary nitrite/ nitrate ratio during and after HBO indicating a reduced bacterial con- Sevoflurane exposure alters muscarinic acetyl-
version of nitrate to nitrite and NO, also supported by in vitro expe- choline receptor protein content and acetylcho-
riments with oral bacteria showing that hyperoxia inhibited bacterial line-induced ERK 1/2 phosphorylation in PC12
nitrate and nitrite reduction leading to decreased NO generation. Plas- ma nitrate was unaffected by HBO while plasma nitrite was reduced during HBO . In contrast, plasma cGMP increased during HBO as Andreas Wiklunda,b, M.D, Ph.D., Daniel Gustavssona, B.Sc,
did citrulline/arginine ratio after treatment and control.
Anette Ebberyda, B.Sc, Souren Mkrtchian, Ph.Da, Malin Jonsson
Fagerlunda,b, M.D, Ph.D., Lars I. Erikssona,b, M.D, Ph.D., FRCA.
Conclusion: HBO -exposure in humans affects NO generation in the
, Gunnar Schultec, Ph.D.
airways and systemically differently. These data suggests that the indi- vidual NOSs as well as the nitrate-nitrite-NO pathway do not respond a. Department of Physiology and Pharmacology, Section for Anesthesiology in a similar way to HBO .2 and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden. b. Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden Neutrophil heterogeneity in severe respiratory
Background: Exposure to volatile anaesthetics may affect cognitive
function and learning, but the underlying mechanisms for this effect are still largely unknown. On a cellular level, activation of extracellular signal-regulated kinase ERK 1/2 is essential for learning and long term B. Holzgraefe1,2, P. Jones3, M. Jones3, K. Palmér1, B. Frenckner1,
memory formation. Acetylcholine, acting on G-protein coupled mus- A. Larsson5, O. Winqvist3
carinic acetylcholine receptors (mAChRs) in the cellular membrane, activates ERK 1/2. The volatile anaesthetic sevoflurane attenuates the acetylcholine-induced activation of ERK 1/2. This study was designed to investigate whether receptor internalization or reduction in receptor protein amount could explain this effect. Måndag 21/9 kl 14:00–15:30
Results: Exposure to 5% sevoflurane over 2 hours significantly redu-
ced the acetylcholine-induced activation of ERK 1/2. Whereas quan- Moderatorer: Carolina Samuelsson, Claes Frostell
tification of receptor mRNA (M , M , M , M , M , α ) and receptor localization were not significantly altered, we demonstrated a signifi- Single deranged physiological parameters are
cant change in muscarinic receptor proteins. A transient decrease in associated with mortality in a low-income country
of M mAChR protein and an increase in M mAChR protein was observed following sevoflurane exposure. Baker T, Blixt J, Lugazia E, Schell O, Mulungu M, Milton A, Caste-
gren M, Eriksen J, Konrad D.
Conclusion: We conclude that the attenuation of acetylcholine-in-
duced ERK 1/2 phosphorylation correlates to changes in muscarinic receptor protein content. Our interpretation of the results supports Dept. of Physiology and Pharmacology, Section of Anesthesiology and In- previous hypotheses suggesting that memory impairment following tensive Care, Karolinska Institutet and Karolinska University Hospital, sevoflurane exposure may be caused by disruption of acetylcholine signalling pathways due to altered muscarinic receptor protein levels. Objective: To investigate whether deranged physiological parameters
at admission to an Intensive Care Unit (ICU) in Tanzania are associa- ted with in-hospital mortality, and compare single deranged physiolo- gical parameters to a more complex scoring system. Clearance of Nitrate and Nitrite - An observational
study of continuous renal replacement therapy on
Design: Prospective, observational, cohort study of patient notes and
intensive care patients
admission records. Data were collected on vital signs at admission to the ICU, patient characteristics and outcomes. Cut-offs for deranged Fredrik Eidhagen, Carl-Jonas Lindskog and Eddie Weitzberg
physiological parameters were defined a priori and their association with in-hospital mortality was analyzed using multivariable logistic Dept. of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm. Setting: ICU at Muhimbili National Hospital, Dar es Salaam,
Background: Nitric oxide (NO) has sparked a vast scientific interest
in the past decades. It is involved in various vital processes such as up- holding vascular homeostasis and regulating mitochondrial function. Patients: All adults admitted to the ICU in a 15 month period.
The supposedly stable end products of NO oxidation, nitrate and ni- trite, have been established to play a crucial part in the bioavailability Measurements and Main Results: 269 patients were included:
of NO, since they can be recycled back to bioactive NO. This study 54% female, median age 35 years. In-hospital mortality was 50%. At aimed to examine if CRRT had a scavenging effect on arterial plasma admission, 69% of patients had one or more deranged physiological nitrate and nitrite as well as determine the clearance and mass removal parameter. Sixty-four percent of the patients with a deranged physiolo- rate of these anions. gical parameter died in-hospital, compared to 18% without (p<0.001). The presence of a deranged physiological parameter was associated with Methods: In this observational study, 9 patients with acute renal failu-
mortality (adjusted Odds Ratio (OR) 4.64 95% Confidence Interval re treated with PrismaFlex CRRT system were included. To determine 1.95–11.09). Mortality increased with increasing number of deranged nitrate and nitrite levels samples from arterial blood were collected dai- physiological parameters (OR per deranged physiological parameter ly during and after CRRT. Samples were also collected from the CRRT 2.24 (1.53–3.26)). Every individual deranged physiological parameter system in order to determine clearance and mass removal. was associated with mortality with unadjusted ORs between 1.92 and 16.16. A National Early Warning Score (NEWS) of ≥7 had an associa- Results: Arterial plasma nitrate decreased significantly during CRRT,
tion with mortality (OR 2.51 (1.23–5.14)). 59% after 24h, and increased towards baseline levels 24h after termina- tion. In contrast, nitrite levels were not significantly altered by CRRT. Conclusion: Single deranged physiological parameters on admission
Clearance of nitrate ranged from 54,0±4,0 to 118,3±36 ml/min at efflu- are associated with mortality in a critically ill population in a low-in- ent flow rates of 50–80 mL/min. Mass removal rate of nitrate declined in- come country. As a measure of illness severity, single deranged physio- itially and stabilized after 12 hours and correlated to arterial nitrate levels. logical parameters are as useful as a compound scoring system in this Conclusions: CRRT had a scavenging effect on nitrate. Nitrate passes
setting and could be termed "danger signs". Danger signs may be sui- freely across the CRRT filter, exhibiting a clearance superior to both table for the basis of routines to identify and treat critically ill patients.
creatinine and urea.
Vital Signs Directed Therapy on an Intensive Care
Unit in a Low-income Country
Baker T, Schell O, Lugazia E, Blixt J, Mulungu M, Castegren M,
Eriksen J, Konrad D.
Dept. of Physiology and Pharmacology, Section of Anesthesiology and Method: Demographical data, mortality, time to antibiotics and time
Intensive Care, Karolinska Institutet and Karolinska University Hospital, to primary surgery on all patients treated between January 2008 and Stockholm. September 2014 were extracted from the registry. Patients under the age of 18 were excluded. Calcualtions were made in SPSS Statistics Background: Global Critical Care is attracting increasing attention.
v. 22. Confidence intervals (CI) are stated at the 95% confidence level.
At 58 million deaths per year, the worldwide burden of critical illness is greater than generally appreciated. Low income countries (LIC) have Results: Mean time from hospital arrival until administration of anti-
a disproportionally greater share of critical illness, and yet critical care biotics and primary surgery were 5.1 (CI=3.6, 6.7) and 21.5 (CI=16.1, facilities are scarce in such settings. Routines utilizing deranged vital 26.9) hours, respectively. HBOT (280kPa, 70–90 minutes) was given signs to identify critical illness and trigger medical interventions have to 60 (76.9%) of the patients. Mean number of treatments was 4.4 become common in high-income countries but have not been investi- (CI=3.8, 5.0 range 1–20). No correlation was found between mortality gated in LIC. We aimed to assess whether a vital signs directed protocol and time to antibiotics or time to surgery. could improve care and reduce mortality on an Intensive Care Unit The overall estimated mortality rate based on APACHE-II and SA- (ICU) in Tanzania. PS-III was 43.0% (CI=36.4, 49.6). The actual mortality was 11.5% at one month and 19.2% at six months. The six month mortality was Method: Prospective, before-and-after interventional study on the
16.7% in the HBOT-group and 27.8% in the non-HBOT-group ICU of a university hospital in Tanzania. A context-appropriate pro- tocol that defined danger signs and actions was designed and then im- plemented in a four week period using sensitisation, training, job aids, Conclusions: Mortality, with or without HBOT, was significantly
supervision and feedback. Adherence to the protocol was compared pre lower than predicted by standard ICU scoring systems. This might be and post-intervention at admission and during care on the ICU. Adhe- due to centralization and multimodality care, including HBOT. rence and in-hospital mortalities were analysed with regression models.
Continued registration will provide more clinical useful information.
Results: Danger signs from 447 patients were included: 269 pre-in- tervention and 178 post-intervention. Adherence was higher post-in- tervention (At-admission: 79% vs 23%, p<0.001; On-ICU: 17% vs 3%, p<0.001). A danger sign was five times more likely to be treated post-intervention (Prevalence Ratio (PR) 4.97 (2.94–8.38) p<0.001). Kinetics of serum S100b after traumatic brain injury
36% of hypotension occasions were treated with fluids post-interven- tion, as compared to 4% pre-intervention (p=0.001) (PR 6.4 (2.5– A Ercole1, EP Thelin2, A Holst3, BM Bellander2, DW Nelson4*
16.1) p<0.001). In the subgroup of patients admitted with hypoten- sion, mortality was lower post-intervention (69.2% vs 92.3% p=0.02) 1Division of Anaesthesia, University of Cambridge, Cambridge, United giving a numbers-needed-to-treat of 4.3. Overall in-hospital mortality Kingdom. 2Section for Neurosurgery, Department of Clinical Neuroscience, rates were unchanged (50.2% vs 50.9%, p=0.89).
Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden. 3School of Computer Science and Communication, KTH Royal Conclusion: The introduction of a vital signs directed therapy proto-
Institute of Technology, Stockholm, Sweden. 4Section for Anesthesiology col improved the care of patients with deranged vital signs on an ICU and Intensive Care, Department of Physiology and Pharmacology, in a LIC. Mortality rates were reduced in hypotensive patients but not Karolinska Institutet, Stockholm, Sweden. for all patients.
Purpose: To develop a kinetic model to characterise the temporal va-
riation of serum S100b concentration after primary traumatic brain Necrotizing soft tissue infection - First eight years
Methods. Data of serial serum S100b samples from 154 traumatic
of registered HBO-treatments
brain injury patients in a neurointensive care unit were retrospective- ly analysed, including only patients without secondary peaks of this Rosén Anders, Arnell Per, Lycke Hans, Oscarsson Nicklas
biomarker. A hierarchical, Bayesian gamma variate kinetic model was constructed and the parameters estimated by Markov chain Monte Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Carlo sampling.
University Hospital/Östra and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Results: We demonstrated that S100b concentration changes drama-
tically over timescales that are clinically important for early prognosti- Background: Prompt antibiotics and early surgery are the mainstay
cation with a peak at 27.2 hours (95% credible interval [25.6, 28.8]). of treatment for necrotizing soft tissue infections (NSTI). Hyperbaric Baseline S100b levels was found to be 0.11 μg/L (95% credible interval oxygen treatment (HBOT) is considered an adjuvant, but important [0.10, 0.12]).
resource. Centralizing the treatment of patients with NSTI has been shown to lower the mortality rates. Sahlgrenska University Hospital/ Conclusions: Even small differences in injury to sample time may
Östra (SU/Ö) has been a regional NSTI-center since 2008. Data con- lead to large changes in S100b in the first days after injury. Kinetic cerning patients treated for NSTI that require ICU-care is prospecti- modelling may offer a way to reduce the ambiguity in interpretation of vely entered into a quality registry. Aggregation of individual patient randomly sampled acute biomarkers.
data enables assessment of risk factors, treatment effects and actual Take home message: The kinetics of S100b mean that levels vary
dramatically over the first few days post injury which is also the time Objective: o assess mortality and describe characteristics of patients
that their potential for prognosis and for detecting secondary injury treated for NSTI.
may be most valuable. A failure to appreciate this time variation may lead to substantial errors in evaluating initial injury severity or failing administered she became unconscious and was hastily intubated, due to detect subsequent secondary injuries in later measurements.
to loss of airway. The patient presented to the ICU with hypotension, vasopressor treatment and volume resuscitation was initiated. Sodium valproic concentrations was initially 1970 μmol/l and increased shortly to 2990  μmol/l. Ammonium levels increased from 190 to 640 μmol/l Pediatric population and management strategies
during the first day. Carnitine was initiated at the dose of 100 mg/kg in longterm PICU
and thereafter 15 mg/kg was given every 4 hour. The patient was kept on a ventilator and blood pressure was stabili- Eva Wesslen-Eriksson, MD, Director
zed with a low dose of norepinephrine. She developed a few episodes of seizures. In the second day ammonium levels increased from 60 to 150 Longterm PICU, Astrid Lindgren Children´s Hospital, Karolinska to 430 μmol/l and a CRRT was started. After 24 hours with CRRT University Hospital, Stockholm, Sweden and repeated doses of carnitine the level of valproic acid decreased from 430 to 81 μmol/l and ammonium levels decreased from 1030 Children with severe, unusual and often complex diseases or malfor- to 360 μmol/l. mations need technical and advanced respiratory management in order The patient could be extubated after seven days on a ventilator and to promote optimal medical and psychosocial care . Starting in 1990 was transferred to a medical ward. In that stage she still hallucinated in order to support individual growth, development and social interac- and presented paranoid delusions which resolved completely two weeks tions with families, the Longterm PICU at the Karolinska University later. A psychiatrist refereed her psychotic episode to medical treatment Hospital has a key role within the Pediatric Respiratory Centre. Here with valproic acid. She had no history of previous psychotic episodes.
a dedicated multidisciplinary team including intensive care medicine, anesthesia, ENT surgery, pulmonary medicine, physiotherapy, speech Conclusions: Carnitine may be of help in reducing hepatic injury
and language therapy, nutrition and occupation therapy provides after overdose of valproic acid. CRRT may be helpful in reducing tox- unique expertise upon which this highly specialized unit is based. icity and increasing elimination. It is possible that psychosis may be an A key feature in treatment strategies involves advanced non-inva- inadvertent effect due to valproic acid.
sive or invasive ventilation with or without tracheostomy. Duration of stay may sometimes exceed 6 months in order to transfer to home. For successful transition to home of patients, the unit also operates in close collaboration with community health care providers with home assistance. In this context, home ventilators are applied and techniques A fatal case of consumption of fat-burning
are currently under strong development within this segment of respira- formulas containing beta-metylphenylamine
tory care. For children with malformations or impaired airway, surgical strategies may be necessary in order to provide safe long term ventila- tion and spontaneous breathing. The unit also has a close follow-up of Kai Knudsen
discharged patients. AnOpIVA Sahlgrenska University Hospital, Göteborg Background: Beta-metylphenylamine is a component in some com-
A case of severe overdose with valproic acid
mercially available formulas called fat burners increasingly used by body builders. Some formulas of fat burners also contain high amounts treated with carnitine and CRRT.
of caffeine (150 mg of caffeine per cap). In treatment of adult patients with ADHD a licensed preparation of Kai Knudsen
amphetamine has become common in Sweden. Mixtures of fat burners and central stimulating drugs may induce profound adrenergic activity AnOpIVA, Sahlgrenska University Hospital, Göteborg. leading to agitation, muscular rigidity, hyperthermia, seizures, rhabdo- myolysis, confusion and finally circulatory collapse. Background: Valproic acid is an antiepileptic medication that is incre-
asingly being used in the treatment of bipolar disorders and depression. Objectives: To report a case of agitation and confusion after ingestion
An overdose is associated with hypotension, respiratory failure, and of multiple fat burners when on treatment with multiple psychiatric somnolence and may cause hepatic injury. Lactic acidosis and incre- medications. A possible interaction was likely leading to a hyperad- ased ammonium ion levels may be present. Treatment with carnitine renergic syndrome finally leading to cardiovascular collapse and death.
has been suggested to improve metabolism and reduce hepatic injury. Hemodialysis may improve elimination of valproic acid.
Case Report: A 31-year old man with history of ADHD, panic disor-
ders and substance abuse was on treatment with chlomipramine (375 Objectives: To report a case of valproic acid overdose where treatment
mg/d), lisdexamphetamine (130 mg/d) and flunitrazepam (1 mg/d). with continuous renal replacement therapy (CRRT) and carnitine was He was experienced in body-building and on his own webpage he de- successfully used.
clared a regular consumption of fat burners containing caffeine and Case Report: A 24-year old woman with a bipolar disorder but no
He was admitted to the Emergency Department after being found history of psychotic episodes was admitted to the Emergency Depart- convulsing at home. At the ED the patient with a body weight of 140 ment (ED) after being found drowsy at home, due to an estimated kilos was disorientated, confused and aggressive. A drug screening was ingestion of 30 g of a slow-release form of valproic acid (approximately positive for bensodiazepines, buprenorphine, THC and tramadol. 100 tablets). She was initially cardiorespiratory stable and responsive. The patient presented with extreme stress, tachycardia, hyperthermia, During gastric lavage at the ED where 25 g of activated charcoal was sweating and high creatin-kinase (CK) levels. The patient needed to be heavily sedated with propofol and opioids, intubated and connected to Diskussion: Enligt denna systematiska litteraturöversikt föreligger
a ventilator. Dantrolene sodium was administrated without any appar- inte några säkra vetenskapliga belägg för att lipidterapi har någon posi- ent positive effect. Treatment was instituted with dexmedetomidine, tiv effekt på människor och framför allt inte vid perorala förgiftningar. propofol, transdermal opioids and high doses of bensodiazepines. The Även negativ effekt av lipidterapi finns beskriven. Det är därför rimligt patient was transferred to the psychiatric ward after two days but the att begränsa dess indikation till direkt livshotande situationer och när patient again became agitated and confused and was brought back to etablerade behandlingsmetoder varit verkningslösa. the ICU. Shortly after arrival to the ICU he collapsed and CPR was immediately instituted but this time the patient was unresponsive to resuscitation and finally expired.
1. Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia- Amaro MF, Cwik MJ. Pretreatment or resuscitation with a lipid infusion shifts Conclusions: Medical treatment with amphetamines, tramadol and
the dose-response to bupivacaine-induced asystole in rats. Anesthe- antidepressants in a patient with a regular consumption of fat burners may induce a hyperadrenergic syndrome with agitation, confusion, ri- 2. he use of the WHO-UMC system for standardised case causality gidity, hyperthermia, hypertension and tachycardia that may become assessment The Uppsala Monitoring Centre. Available from: extremely stressful to the cardiovascular system finally leading to car- diovascular collapse and death. Warning to the public of several new fat burners containing different biogenic amines such as beta-metylphe- nylamine and caffeine seems to be appropriate as well as information to the medical profession of the dangers and risks of mixing licensed amphetamine preparations with some fat burners.
Måndag 21/9 kl 16:00–17:30
Moderatorer: Robert Hahn, Caroline Haegerstrand
Är lipidterapi effektivt vid förgiftningar?
The effect of intraoperative glucose infusion on
Sune Forsberg1,3, Matilda Forsberg2 , Jonas Höjer3,4
1Anestesi och Intensivvårdskliniken, Norrtälje Sjukhus, 2Medicinkliniken, Christina Blixt* 1, Maria Sellvall1, Olav Rooyackers1
Norrtälje Sjukhus, 3Institutionen Södersjukhuset, Karolinska Institutet, 1Dept. of Anesthesiology and Intensive Care, Karolinska Institute and University Hospital, Stockholm, Sweden Detta är en systematisk litteraturöversikt om intravenös lipidemulsion som motgift vid förgiftning med läkemedel eller droger. Lipidterapi Rationale: Perioperative insulin resistance and hyperglycemia may
är en behandlingsstrategi som har använts sedan 2006, framförallt vid inflict on postoperative outcome. We hypothesed that elimination of förgiftning med lokalanestesimedel. Flera djurstudier stödjer en positiv intraoperative glucose administration may reduce perioperative hy- effekt (1) men det finns även de som motsäger sådan. Det är fortfaran- perglycemia, and hence modulate postoperative complications.
de oklart om och i så fall hur intravenös lipidemulsion fungerar som antidot, men rådande hypotes är "lipid sink theory", som innebär att Methods: 20 patients scheduled for open hepatectomy were enrolled
intravenöst tillfört fett binder fettlösliga toxiner. in this prospective observational study. All patients received epidural anaesthesia. Ten patients (enrolled in a previously published study) Syftet: Att utröna om snabb intravenös tillförsel av lipidemulsion är
received glucose infusion (2.5 mg/kg/h; group G), and ten newly re- en effektiv behand- lingsmetod vid akut förgiftning med droger och cruited patients received Ringer-Acetate (1 ml/kg/h; group C) during läkemedel och i så fall för vilka förgiftningsmedel och vid vilka expone- ongoing surgery. After induction of anesthesia and establishing an arte- ringsvägar (parenteral/peroral). rial line, sampling was initiated. Infusions were started after the central venous line was inserted. Arterial plasma glucose was measured every Metod: Systematisk litteratursammanställning. Artiklarna, publicera-
10 min. with a bedside glucose monitor (Hemocue AB, Ängelholm, de 1998 till mars 2013, har systematiskt sökts fram via PubMed och Sweden) throughout surgery. Web of Science utifrån fördefinierade kriterier. Även förgiftningsmed- lens log p-värde, fettlöslighet, har sökts fram via Internet. Identifierade Results: Baseline characteristics between the groups were not signi-
artiklar har granskats av två intensivvårdsläkare utifrån en klassifice- ficantly different for age, BMI, blood loss or operating and resection ringsmall(2) för att bedöma sannolikheten för lipidterapins eventuellt time. Mean glucose value at start was 6.6±0.8 and 7.3±1.3 mmol/l positiva effekt. in group G and C (p 0.14, t-test). Mean glucose value during the first 240 min (last time point with enough subject in each group Resultat: Litteratursökningen resulterade i 3919 artiklar varav 126
to allow for statistical analyses; n=8 in both groups) were 8.4±1.3 uppfyllde de fördefinierade inklusionskriterierna vid genomgång av and 8.9±0.7mmol/l in group G and C (p=0.23, t-test). Individual alla abstract. Vid detaljgranskning sållades ytterligare artiklar bort och perioperative glucose levels during same time period showed no slutligen fanns 92 patientfall kvar som rapporterat positiv effekt av statistical difference (p=0.51, ANOVA). Neither did comparison of lipidbehandling. Resultaten visade ingen korrelation mellan förgift- AUC in each group for the same time period show any significant ningsmedlens ökande fettlöslighet och tydlig positiv effekt, snarare sågs difference, 195.4±36.2 vs 201.5±35.7 mmol/l in group G and C en icke statistiskt säkerställd korrelation i den andra riktningen. Vid (p 0.71,t-test).
perorala förgiftningar var det ytterst osäkert om lipidterapin haft en positiv effekt. Även vid parenteral feladministrering av lokalanestetika Conclusions: In an observational study of 20 patients scheduled for
visades lipidterapins effekt vara osäker.
open liver surgery, infusion of glucose (2.5mg/kg/h) or Ringer-Acetate both showed a perioperative hyperglycemia but no difference between Method: A web-based questionnaire was available to anaesthesiologists
the treatments was observed. on the Swedish, Norwegian, Danish, Finish National Anaesthesiology Society homepage during an 8-week period and send to anaesthesi- The authors have no conflict of interest.
ologists on Iceland; by the support of the National Anaesthesiology Results: Information around daily management of day care patients
was gained from 303 anaesthesiologists involved in day surgery in the Fluid therapy – a systematic review and
Scandinavian countries. Routine administration of preventive parac- cross-sectional study of clinical practice
etamol was common uniform across countries (80%) but NSAIDs were routinely used by 62 % only and varied between 32% and 80%. Olsson D, Lindgren S
Anaesthetic technique varied also, TIVA was the preferred in Den- mark and Norway while inhaled technique based on sevoflurane was Anestesikliniken, Sahlgrenska Sjukhuset, Göteborg common practice in Sweden and Finland. Desflurane was infrequently used. Intraoperative analgesic did also vary, fentanyl and remifentanil Intravenous fluid treatment is one of the most common interventions being used in similar amounts and combinations where used by 1/3 in the field of perioperative and intensive care medicine. The choice of or responders. Laryngeal mask airway was preferred for shoulder (172 resuscitation fluid has been debated for many decades. At the turn of responders average use 73%) and breast surgery (151 responders aver- the century the debate was reactivated as new meta-analyses surfaced. age use 80%).A laryngeal mask airway was also used by 43 responders In 1998 Schierhout and Roberts changed the view on albumin use for laparoscopic procedures, 34 responders for tonsillectomy and 91 in intensive with an analysis showing an increased risk of death using responders in prone position.
albumin vs other fluids. At Sahlgrenska University Hospital, albumin costs dropped by 64 % the following year (Haljamäe and Lindgren Conclusion: We found a variable praxis with regard to anaesthetic
2000) and the synthetic colloid hydroxyeathylstarch (HES) replaced techniques; drugs used and airway management. There seems to be no human albumin as the preferred resuscitation colloid. In 2004 prospec- firm consensus or best practice in the Scandinavian countries around tive studies on albumin showed no increased mortality risk compared anaesthesia for day case surgery. Further studies around outcome mea- to crystalloids (Finfer S. et. al) and ten years later the pendulum swung sures, morbidity but also data around the recovery/resumption of ac- as several large prospective studies showed an increased risk of kidney tivities of daily living following day surgery are warranted. Follow-up failure when resuscitating critically ill patients with HES compared to enabling "open comparisons" would be of interest.
crystalloid fluid management. (Myburgh and Mythen 2013) In 2013 international institutes issued warnings of using HES in critically ill Table 5. Main anaesthetic/main anaesthetic technique (number of re-
patients. In Sahlgrenska University Hospital the albumin costs in- sponders (average % of cases)) creased by 47 % the following year. In March 2015 we conducted a web survey, distributed to 100 physicians in the department of Anaes- thesia and Intensive Care Medicine. Out of 62 respondents 56% and 69% answered that they used both crystalloid and colloid solutions for perioperative and sepsis resuscitation respectively, and 74% that their first hand choice perioperatively were HES. However, when treating septic shock, 89% answered that their preferred colloid solution where albumin. In conclusion, there is recent evidence showing that albumin should be preferred as resuscitation colloid in septic patients. Among 1. Segerdahl M, Warrén-Stomberg M, Rawal N, Brattwall M, Jakobs- physicians in our department the adaptation to these recent fluid ther- son J. Clinical practice and routines for day surgery in Sweden: apy recommendations is high. However, the economic effect of high results from a nation-wide survey. Acta Anaesthesiol Scand. 2008; albumin use needs to be evaluated and the increased cost should be advocated by a presumed better patient outcome.
2. Brattwall M, Stomberg MW, Jakobsson JG. [Ambulatory surgery in Sweden is structured and follows unified routines. A questionn- aire on the practice of ambulatory surgery]. Lakartidningen. 2012; A web-based survey about perioperative
routines and praxis for Day Case Anaesthesia
in the Scandinavian countries.
Sellbrant I, Warrén-Stomberg M, Brattwall M, Raeder J, Haavisto
A, Felsby S, Einarsson S., Jakobsson JG.
Susanne Wagmo och Ingrid Stackeryd
Anestesikliniken, Capio Lundby Närsjukhus, Göteborg ANOPIVA-kliniken, Karolinska Universitetssjukhuset Solna Background: Day case surgery is increasing. There is no firm evidence
På ANOPIVA-kliniken, Karolinska Universitetssjukhuset, Solna arbe- or consensus around perioperative management of patients scheduled tar vi sedan mars 2010 med ett för oss, nytt arbetssätt i samband med for day case anaesthesia. The aim of the present survey was to bench- patientens operation. Den anestesi- eller operationssjuksköterska som mark and gain an overview of current clinical routines and practice for skall vårda patienten, träffar patienten redan före operationen, tar hand day case anaesthesia among Scandinavian anaesthesiologists. om patienten under operationen, och utför ett uppföljande samtal efter Vid det preoperativa samtalet får patienten möjlighet att skaffa in- Slutsats: Hög ålder, hög ASA-klass och lång anestesiduration är
formation och ställa frågor och sjuksköterskan skaffar sig genom sam- riskfaktorer för en oplanerad övernattning på UVA efter en elektiv talet kunskap om patienten.
operation. Dessa parametrar bör värderas i en postoperativ vårdbe- I det intraoperativa samtalet bekräftar patienten och sjuksköterskan hovsbedömning och resursplanering för en optimal uppvaknings- att de mötts tidigare och båda vet vad som gäller.
Vid det postoperativa samtalet utvärderar sjuksköterskan och pa- tienten den perioperativa vården tillsammans. Vården blir en samman- hängande enhet.
Perioperativa samtal ökar delaktigheten och säkerheten för patien- ten. Det bidrar också till bättre arbetsmiljö genom minskad stress, och Temperature measurement during intraabdomi-
ger möjlighet att utvärdera given vård. Personcentrerad vård är en av nal treatment with hyperthermic chemotherapy
kärnkompetenserna i avancerad vård. Arbetssättet ger vård av utmärkt – oesophagus thermometer vs. pulmonary artery
kvalitet och säkerhet. Sjuksköterskorna känner att de är effektiva och ger patienterna ett personligt bemötande och bör verkligen ses som förebild i utveckling av den peri operativa vården.
Sammanfattningsvis så visar arbetssättet att vi väl uppfyller Karolin- ska Universitetssjukhusets vision Patienten först.
ANOPIVA-kliniken, Karolinska Universitetssjukhuset, Solna Cytoreductive surgery with hyperthermic intreaperitoneal chemother- apy (HIPEC) is a well established method to treat colorectal malignan- cy with peritonal cancinosis. During the surgery the patient is exposed Is unexpected prolonged postoperative care
to 42 C° chemotherapy intraabdominally. It is crucial to accurately possible to predict?
measure and regulate the patients temp. during the hyperthermic treat- ment. In spite of preparatory cooling of the patient, sometimes the Hawraz Karim, Camillla Brorsson, Göran Johansson
temperature of the inflowing chemotherapy has to be lowered to avoid overheating of the patient. This may lead to a less efficient treatment.
Institutionen för kirurgisk och perioperativ vetenskap, enheten för anestesi We aimed to compare simultaneous peroperative measurements by och intensivvård, Universitetssjukhuset, Umeå oesophageal thermometer and pulmonary arthery (PA) catheter situ- ated in the heart, mirroring the temp. of the circulating blood. Our Bakgrund: Patienter som genomgår elektiva operationer får en vård-
hypothesis was that the PA catheter would register lower temp. during bedömning av kirurger och anestesiologer om det postoperativa vård- the HIPEC treatment phase than the oesophagus thermometer.
behovet. Det förekommer att patienter blir kvarliggande på uppvak- 15 patients (ASA I-III), with mean age of 56 years (21-78), weight ningsvårdavdelningen (UVA) och blir övernattare trots en postoperativ 75 kg (45-106) undergoing cytoreductive surgery and HIPEC were vårdbehovsbedöming som icke övernattare eller UVA mindre än 8 tim- included in the study. All patients received a PA catheter in the internal mar. Detta försvårar bland annat resursplaneringen på uppvaknings- jugular vein, and an esophagus thermometer.
vårdavdelningen. The temp. was recorded in intervals of 5-30 minuter from placement Den postoperativa vårdbehovsbedömningen för en patient görs idag of the catheters until after the end of the HIPEC treatment. Statistics av både opererande kirurger och anestesiologer. Detta dokumenteras used were Bland-Altman and correlation analysis.
på olika sätt men innefattar samma bedömningsalternativ. The mean temperatures were 36.3 °C (33.5–39.8) and 36.1 °C (33.5–39.9) for oesophagus and PA catheter respectively. There was a Syfte: Undersöka om patienter som genomgår en elektiv operation
high correlation (R=0.93) between measurement methods. However, med oplanerad förlängd tid på UVA (övernattare) har högre ålder, with higher temperature more deviations were seen.
ASA Physical Status Classification System(ASA) poäng och/eller längre This may to some extent verify our hypothesis that the oesophagus anestesi duration i jämförelse med patienter som opereras elektivt och thermometer sometimes overestimates the temperature. kvarstannar mindre än 8 timmar på UVA. Har anestesiologerna en sig- During hypothermia and normothermia, the temperatures mea- nifikant oftare korrekt prognos av vårdbehovet på UVA postoperativt i sured by the esophageal thermometer and the PA catheter correlated jämförelse med kirurgernas bedömning? well. However, during HIPEC treatment, when the patient is exposed to hyperthermic chemotherapy, the oesophagus temp. in some cases Metod: Data extraherades från perioperativt planerings system för
diverge from the PA, showing higher temperatures. patienter som opererades elektivt vid Norrlands universitetssjukhus mellan januari-maj 2014, totalt 9003 ingrepp. Tiden som patienten spenderade på UVA användes som utfall jämfört med preoperativa vårdbehovsbedömningen. Ålder, ASA-klass, kirurgisk postoperativ P24
vårdbehovsbedömning och anestesiduration extraherades från det pe- HIPEC – hur gör vi?
rioperativa planerings systemet. Anestesiologernas postoperativa vård- behovsbedömningar jämfördes med kirurgernas. Susanne Wagmo, Marja Lindqvist
Resultat: Patienter äldre än 59 år eller som har ASA-klass ≥ 3 löper
ANOPIVA-kliniken, Karolinska Universitetssjukhuset, Solna dubbelt så stor risk att bli oplanerade övernattare på UVA trots vårdbe- hovsbedömning som icke övernattare. Patienter med anestesitid > 215 HIPEC (Hyperthermic IntraPEritional Chemotherapy) tillsammans minuter löper 25 gånger högre risk att bli övernattare på UVA trots en med tumörreducerande kirurgi är en behandlingsmetod med kurativt postoperativ vårdbehovsbedömning som icke övernattare. Det fanns syfte aktuell för patienter med tarmcancer spridd till bukhinnan.
inga skillnader mellan träffsäkerheten i kirurgernas och anestesiologer- På Karolinska Universitetssjukhuset Solna har 115 patienter mellan nas postoperativa vårdbehovsbedömningar. september 2012 och maj 2015 genomgått denna behandling. De tre diagnoser som idag är indicerade för HIPEC hos oss är kolorektal- sätt har våra utbildningsdagar lyckats sprida kunskap om patientens cancer, pseudomyxoma peritonei (PMP) och mesoteliom.
hela resa genom behandlingen. Operationsmetoden innebär att all makroskopisk tumörvävnad Våra utbildningar har blivit mycket uppskattade, starkt bidragit avlägsnas (cytoreduktiv kirurgi) varefter varm cytostatika tillsätts in- till att rädslan minskat och intresset för att delta i behandlingsmeto- traperitonellt. Värmen på vätskan är 40-42 C och behandlingen varar den ökat. Idag ingår ett stort antal medarbetare i det perioperativa mellan 30 och 90 minuter beroende på cytostatikasort. Utöver detta HIPEC-teamet. Förskräckelse har blivit till förtjusning.
ges patienten peroperativ intravenös cytostatika. Efter avslutad cyto- statikabehandling vidtar en rekonstuktionsfas, därefter slutes buken, patienten väcks och förs till postoperativa avdelningen för postoperativ vård. Operationen varar ofta i minst 10 timmar.
Förutom de utmaningar den extensiva bukkirurgi utgör vad gäller Akut njurskada efter HIPEC-kirurgi
t ex vätskebalans, konsekvenser av inflammatoriskt påslag mm, innebär HIPEC-behandlingen i sig ett antal specifika anestesiologiska utma- ningar då patientens kroppstemperatur, hemodynamik, vätskebalans och glukos/elektrolytbalans avsevärt derangeras inför och under denna ANOPIVA-kliniken, Karolinska Universitetssjukhuset, Solna Vår behandlingsmetod är baserad på intryck från såväl nationella Bakgrund: Målstyrd vätsketerapi (GDT) har evidens för att minska
som internationella HIPEC centra och även på de väl etablerade komplikationsfrekvensen efter stor kirurgi. GDT har dock ännu inte rutiner vi praktiserar på övrig stor bukkirurgi. Sedan starten 2012 har etablerats i samma utsträckning vid cytoreduktiv kirurgi med hyperter- vi arbetat aktivt med kontinuerliga förbättringar av vårt omhänderta- misk intraperitoneal cytostatika (CRS/HIPEC) av flera orsaker. Bland gande av HIPEC-patienten och har idag ett väl fungerande per- och annat finns oro kring postoperativ njurskada. postoperativt koncept för att kunna hantera de specifika svårigheter behandlingsmetoden kan medföra. Syfte: Syftet med projektet var att utvärdera postoperativ njurskada
efter CRS/HIPEC med GDT på Karolinska sjukhuset Solna, samt att kartlägga patientgruppen utifrån preoperativa karakteristika, peropera- tiv handläggning och postoperativ komplikationsfrekvens. Från förskräckelse till förtjusning
Metod: Samtliga sextiotre patienter som genomgick CRS/HIPEC
– implementeringen av en ny operationsmetod.
mellan oktober 2012 och september 2014, inkluderades. Retrospektiv granskning av patientjournaler genomfördes och data om komorbidi- Marja Lindqvist, Susanne Wagmo
tet, preoperativa riskfaktorer, peroperativ handläggning och postopera- tiv komplikationsfrekvens registrerades. Njurskada utvärderades med ANOPIVA-kliniken, Karolinska Universitetssjukhuset, Solna hjälp av RIFLE och postoperativa komplikationer summerades enligt Clavien Dindo. Signifikansnivån sattes till p<0,05. På Anestesi, Operations och Intensivvårds-kliniken (ANOPIVA) Ka- rolinska Universitetssjukhuset Solna har cytoreduktiv kirurgi och Hy- Resultat: Postoperativ njurskada kunde ses hos 28 patienter (44 %).
perterm IntraPEritoneal Kemoterapi (HIPEC) på patienter med tarm- Två patienter (3 %) nådde nivån F på skalan. Alla utom en patient cancer spridd till peritoneum bedrivits sedan september 2012. tillfrisknade spontant från sin njurskada inom 3 veckor. Anestesitid Dessa patienter remitterades tidigare till Uppsala, men 2011 in- var i median 790 minuter (525-1440) och kirurgitid 530 minuter leddes arbetet för att Stockholm och Karolinska sjukhuset själva (306-966). Administrerad vätska peroperativt var i median 6000 ml skulle kunna ta hand om sina patienter. En multidiciplinär grupp (3000-14870) och peroperativ blödning 1200 ml (150-5300). Femton av kirurger, onkologer, anestesiologer, radiologer, operation- och procent hade en komplikationsnivå högre än 3a på Clavien Dindos anestesisjuk sköterskor, mottagnings- och avdelningspersonal samla- komplikationsskala. Ingen procedurrelaterad mortalitet och ingen des för att planera den framtida verksamheten tillsammans.
30-dagarsmortalitet kunde ses. Ettårsmortaliteten uppgick till 15 %.
En riskanalys initierades tidigt i processen, med syfte att klar- Gruppen med njurskada hade signifikant längre anestesi- och opera- lägga eventuella riskområden under det per- och postoperativa tionstid, för övrigt kunde ingen skillnad beträffande komorbiditet, patient omhändertagandet. Bland operation och anestesipersonal på peroperativ hantering, komplikationsfrekvens eller mortalitet ses mel- ANOPIVA-kliniken fanns i detta skede en uttalad oro inför risker- lan grupperna.
na med hantering av cytostatika, och många medarbetare uttryckte ovilja att delta i behandlingsmetoden. Riskanalysen pågick februa- Slutsats: Nivån av njurskada var hög bland patienter som opererats
ri-augusti 2012 och konkluderade vikten av obligatorisk cytostati- med CRS/HIPEC men var sannolikt av låg klinisk signifikans. Läng- kautbildning för alla i det perioperativa teamet. Denna utbildning re anestesi- och operationstid ökar sannolikt risken för postoperativ skulle ge kunskap i praktisk hantering av cytostatika, nödvändig njurskada. Den per- och postoperativa vården var tillfredställande men skyddsutrustning och riskavfallshantering.
det finns behov av att prospektivt kvantifiera graden av postoperativ Den första operationen utfördes i september 2012, och inlednings- vis ingick endast en mindre grupp anestesisjuksköterskor, operations- sköterskor och anestesiologer i det perioperativa teamet. De initiala cytostatikautbildningarna hölls av onkologer och medarbetare från onkologiska avdelningar med fokus enbart på cytostatika, men succes- sivt tog ANOPIVA-kliniken över utbildningsansvaret och designade om dem till att även handla om den kirurgiska bakgrunden, det pero- perativa förloppet ur både anestesi-och operationssynpunkt samt den postoperativa vården fram till utskrivning till hemmet. Varje inblandad vårdenhet bjöds in för att berätta om sitt kunskapsområde, och på så Posterpresentation 4
Postoperative inflammatory response after neo-
adjuvant chemoradiotherapy or chemoradiothera-
Måndag 21/9 kl 16:00–17:30
py for cancer of the esophagus or gastroesophag-
eal junction – a substudy within a randomized trial
Moderatorer: Emma Larsson, Sten Walther
Mikael Lunda, T Moines, K Nilsson-Ekdahl, Magnus Nilssonb,
Lars Lundellb, Sigridur Kalmana. Jon A Tsaib
Mortalitet hos intensivvårdspatienter – retrospek-
aDepartment of Anaesthesiology and Intensive Care, and Division of tiv analys och identifiering av möjliga förbättrings-
Anaesthesiology, CLINTEC, Karolinska Institutet, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden. bCentre for Digestive Diseases and Division of Surgery, CLINTEC, Karolinska Institutet, Emma Jerkegren Olsson, Brian Cleaver, Eva Joelsson-Alm.
Karolinska University Hospital Huddinge, 141 86 Sweden. Anestesi och Intensivvårdskliniken, Södersjukhuset, Stockholm Background: Neoadjuvant chemoradiotherapy for cancer of the
esophagus or gastroesophageal (GE) junction may improve long-term Bakgrund: Riskjusterad dödlighet (SMR) är ett övergripande kvali-
survival compared to neoadjuvant chemotherapy. However radiothe- tetsmått för intensivvården. Det ett mått som ofta diskuteras och refe- rapy will also affect adjacent organs causing an inflammatory reaction reras till trots att det är komplext och svårtolkat, t ex avspeglar SMR all possibly increasing postoperative morbidity and mortality. The inflam- given vård under 30 dygn efter IVA-inskrivning men medelvårdtiden matory effects of these neoadjuvant regimes have not been described på en intensivvårdsavdelning är endast ca 2 dygn. IVA på Södersjuk- perioperatively. The aim of this study was to compare perioperative huset hade år 2013 något högre SMR än andra sjukhus i Stockholms- inflammatory profile in patients following chemoradiotherapy or che- området, och också strax över riksgenomsnittet. Syftet med studien var att studera skillnader i inskrivningsmönster, vårdtid och beslut rörande behandlingsstrategi mellan avlidna och överlevande intensivvårdspa- Patients and methods: This was a singel center substudy within the
NeoRes trial that compared neoadjuvant chemoradiotherapy vs. che- motherapy for cancer of the esophagus or GE-junction. Patients were Material och metod: En register- och journalgranskningsstudie av
randomized to receive neoadjuvant cisplatin and 5-fluorouracil with alla patienter på Södersjukhusets IVA 2013 som avlidit inom 30 dagar or without 40 Gy concurrent radiotherapy prior to surgery. Consecu- (137 patienter) samt en kontrollgrupp av 144 överlevande patienter. tive patients (n=14 chemoradiotherapy and n=17 chemotherapy as per Data hämtades från Svenska Intensivvårdsregistret (SIR) angående protocol), underwent an extended protocol with assessment of posto- ålder, kön, SAPS3, IVA-diagnos, vårdtid på IVA och ankomstväg till perative respiratory physiology and inflammatory response. IL-1 beta, IVA. Från journalsystemet TakeCare hämtades data om dokumente- IL-6, IL-8, IL-10 and MCP-1 mRNA in lung biopsies acquired at the rad behandlingsstrategi, vårdtid på sjukhuset och var patienten hade end of surgery and measurements of these and other compounds in plasma during the postoperative course. Statistical analysis was perfor- med using linear mixed models and Mann Whitney U-test.
Preliminära resultat: De avlidna patienterna var äldre och hade
högre SAPS3-poäng än de överlevande patienterna. Fler patienter i Results: Expression of IL-1β mRNA was significantly higher in lung
gruppen avlidna kom till IVA från en vårdavdelning jämfört med de biopsies from subjects in the chemoradiotherapy group compared to överlevande patienterna. Könsfördelningen var jämn i båda grupperna the chemotherapy group; 4.4 vs 2.0 arbitrary units (p=0.007). During men kvinnorna hade signifikant lägre SAPS3-poäng vid inskrivning till the postoperative period, respiratory parameters and plasma levels of IVA trots att mortaliteten var lika stor oavsett kön. Det var endast 34% the inflammatory mediators, complement and coagulation factors, av patienterna som avled på IVA, de flesta (50%) avled på vårdavdel- CRP and leukocyte counts were similar between the two groups. There ning och 16% efter utskrivning från sjukhuset.
was a trend towards an increased pulmonary complication rate in the Vid inskrivning till IVA fanns beslut om begränsad behandling hos chemoradiotherapy group (p=0.09).
3% av de överlevande patienterna, och 17% av de avlidna patienterna. Av de som kunde skrivas ut levande från IVA hade 3% av överlevande Conclusion: Neoadjuvant CRT for cancer of the esophagus or GE
patienterna behandlingsbegränsning införd och 44% av de som seder- junction induces a local inflammatory reaction in lung tissue, which mera avled hade dokumenterade behandlingsbegränsningar. may play a role for the course of respiratory complications after esop- Studien har identifierat flera områden där det finns förbättringspo- hagectomy. There were no significant differences in systemic inflamma- tential, t ex beslut och dokumentation av behandlingsstrategi. Det tion or respiratory parameters during the perioperative period between skulle även vara intressant att titta närmare på könsskillnader gällande the treatment groups.
Risken för fysiska och funktionella besvär är dock hög för de överlevan- Delirium, sepsis and cognitive complaints after
de patienterna och kan negativt påverka patienternas hälsorelaterade critical illness and ICU stay
livskvalitet (HRQoL), vilket i sin tur förknippas med dålig prognos. Syftet var att undersöka hur HRQoL utvecklas över tid för intensiv- vårdspatienter med lång vårdtid (>96 timmar). Data är rikstäckande E Brück, A Schandl, M Bottai, P Sackey.
från SIR inskickat 2008–2014. Intensivvårdsrelaterade data av vikt för HRQoL (SF-36) analyserades för hela kohorten samt för specifika di- Dept. of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm. Resultatet visar att de 1438 patienter som hade en komplett longi- tudinell uppföljning skattar en ökad nivå i HRQoL över tid i samtliga Objective To study the relation between acute brain dysfunction and dimensioner. Skillnad fanns dock mellan olika diagnosgrupper, såsom sepsis during the Intensive Care Unit (ICU) stay and later self-assessed sepsis, COPD oh ARDS. En stor del av patienterna (10-25%) skattade cognitive function.
lägre nivå i HRQoL 12 månader efter intensivvård jämfört med svensk Background: Delirium and sepsis have independently been associated
with increased mortality and morbidity after ICU stay. Cognitive com- Tabell. Förändring av HRQoL över tid efter utskrivning från IVA
plaints after ICU-stay have been reported. The relation between sepsis, (N=1438), Median (IQR) delirium and longer-term cognitive problems remains unclear.
Design: Prospective cohort study
Social tionell
Setting: General ICU at Karolinska University Hospital, Solna, Stock-
Methods: 240 patients staying more than 24 hours at the Intensive
(32-84) (37-72) (25-60) (38-88) (0-100) (52-88) Care Unit were screened for delirium with Confusion Assessment Method-ICU (CAM-ICU) during the stay at the ICU. Three months later, they received via regular mail the Cognitive Failures Questionn- (40-85) (0-100) (41-100) (40-77) (35-70) (50-100) (0-100) (60-92) aire (CFQ), Hospital Anxiety and Depression Scale (HADS) and Post- traumatic Stress Symptoms -10 questionnaire (PTSS-10).
12 m (40-85) (0-100) (41-100) (35-77) (35-75) (50-100) (0-100) (60-92) Results: 125 patients, 60% of those alive, responded at 3 months.
Sammanfattningsvis visar dessa nationella data att HRQoL efter inten- The incidence of delirium was 33.6% among the responders. 41.6% of sivvård för patienter med lång vårdtid på IVA förbättras över tid för en the patients had severe sepsis or septic shock. The incidence of deliri- selekterad grupp. En stor del av patienterna skattar markant låga nivåer um was higher in patients with severe sepsis and septic shock, yielding i HRQoL vilket kan få konsekvenser för återhämtningen efter IVA an odds ratio (OR) of 3.7 (95% confidence interval (CI), 1.7-8.1) by using logistic regression. We found no correlation between cognitive complaints and the incidence of sepsis or delirium. PTSS-10 was sig- nificantly correlated with self-assessed cognitive function complaints (r = 0.83; p < 0.001). We estimated a 0.73 (95% CI, 0.53-0.94; Hälsorelaterad livskvalitet efter intensivvård
p<.001) increase in complaints by a unit increase in PTSS-10. After adjusting for confounders, the estimated increase was 0.54 (95% CI, Gisela Vogel leg ssk, doktorand, Eva Joelsson-Alm leg ssk, PhD,
0.16-0.92 p<.01) using linear regression.
Anna Sandgren, leg ssk, PhD, Christer Svensén, MD, PhD,
professor, Ulla Forinder, socionom, PhD, docent.
Conclusions: The incidence of delirium is higher in patients suffering
from systemic inflammation (severe sepsis/septic shock). Posttrauma- Anestesi och Intensivvårdskliniken, Södersjukhuset, Stockholm tic stress symptoms are strongly correlated with later self-assessed cog- nitive complaints. These findings imply that posttraumatic stress needs Bakgrund: Tidigare studier visar att svår kritisk sjukdom och vård på
to be assessed when evaluating cognitive function in ICU survivors.
en intensivvårdsavdelning (IVA) kan leda till komplikationer lång tid efter vårdtiden såsom depression, PTSD, stress, sömnstörningar, kog- nitiv svikt och påverkan på patientens fysiska funktioner. Det finns även studier som visar att patientens hälsorelaterade livskvalitet (HR- QoL) är påverkad lång tid efter intensivvård och att framförallt komor- Hälsorelaterad livskvalitet upp till 12 månader ef-
biditet är en bidragande faktor.
ter intensivvård – rikstäckande lärdomar från SIR
Syfte: Att undersöka hälsorelaterad livskvalitet 3, 6 och 12 månader
L.Orwelius1,2,3, E. Åkerman3, CJ Wickerts3, S. Walther 3,4
efter intensivvård och att undersöka faktorer som är associerade med 1Intensivvårdskliniken, 2Institutionen för klinisk och experimentell medicin, 4Institutionen för Medicin och Hälsa, Linköpings Universitet, Frågeställningar: Hur påverkas HR-QoL efter svår kritisk sjukdom
3Svenska Intensivvårdsregistret. och intensivvård på en allmänkirurgisk intensivvårdsavdelning? För- ändras den hälsorelaterade livskvaliteten över tid? Finns det faktorer Utvecklingen av intensivvård har möjliggjort en ökad överlevnad för som påverkar hälsorelaterad livskvalitet efter svår kritisk sjukdom och patienter även med komplexa sjukdomar och omfattande skador. Metod: Data samlades in via en allmänkirurgisk IVAs uppföljnings-
Metod: Patienter, 18 år eller äldre med en skadegrad enligt New Injury
mottagning med SF-36, 3, 6 och 12 månader efter intensivvård samt Severity Score (NISS) ≥ 9 som registrerats i SweTrau under september att faktorer såsom ålder, kön, inskrivningsdiagnos, komorbiditet, månad 2013 på fem sjukhus inkluderades. Uppföljningen gjordes med APACHE II, opererad/ej opererad, familjesituation, tid på IVA och telefonintervjuer vid tre, sex och tolv månader efter traumatillfället. förekomst av ventilatorbehandling registrerades. Data är insamlade Vid dessa uppföljningstillfällen ställdes frågor gällande livskvalitet, mellan 2004–2013 och 276 patienter är inkluderade i studien. funktionsförmåga, arbetsförmåga samt smärta. De PROM enkäter Materialet kommer att redovisas med deskriptiv och analytisk sta- som användes var EQ5d, RAND 36 och PTSS 10. PTSS 10 poäng > tistik och resultaten kommer att kunna presenteras på SFAIs kongress 35 användes som gräns för symtom på post traumatisk stress (PTSD).
21-23 september 2015.
Resultat: Totalt registrerades 189 patienter i SweTrau september 2013
Preliminära resultat (Tabell 1): visar att patienter vårdade på en all-
på de utvalda sjukhusen. Av dessa uppfyllde 74 (40 %) inklusionskrite- mänkirurgisk IVA (Study I) har sämre livskvalitet 12 månader efter rierna för uppföljning. Andelen svarande vid 3,6 och 12 månader efter svår kritisk sjukdom och intensivvård än patienter i tidigare studier och traumatillfället var 70 %, 64 % samt 67 %.
jämfört med svensk norm population.
Vi fann att andelen med någon form av funktionsnedsättning mätt som Glasgow Outcome Scale (GOS) <5 minskade mellan 3 och 12 månader från 47 % till 30 %. Andelen förvärvsarbetande steg från 30 % till 50 % vid uppföljning 3 respektive 12 månader. En femtedel av patienterna uppvisade symtom på PTSD vid de olika mättillfällena. Konklusion: I detta pilotprojekt visar vi att traumapatienter har kvar-
stående fysiska och psykiska besvär lång tid efter skadetillfället. Det finns därför behov av långtidsuppföljning i denna patientgrupp som dock är förknippat med vissa svårigheter pga. att skadepanoramat är mångfacetterat, omhändertagandet är multidisciplinärt och patientpo- pulationen är heterogen. Arbetet med uppföljning av denna patient- grupp är tidskrävande och för bästa möjliga utnyttjande av resurser PF RP BPGHVT SF REMH och kunskap anser vi att uppföljning på detta sätt bör regionaliseras.  Health related quality of life measured with SF-36 (mean value) Measured one year after discharge from the intensive care unit in study I and Orwelius, et al, 2010. 100 = highest mean level of health related Har den riskjusterade 30-dagars mortaliteten
quality of life.
ändrats mellan 2001–2011?
Larsen Robert, Sjöberg Folke
AnOpIVA Universitetssjukhuset Linköping Långtidsuppföljning av patienter vårdade efter
traumamatisk skada med patientrapporterade
Trauma är en dynamisk sjuka och det finns dynamik i de Svenska trau- utfallsmått (PROM).
masiffrorna. Vi vet att antalet trafikolyckor minska i samhället idag, men vi vet inte om dödligheten följer efter i samma takt. Det har publ- Gunilla Wihlke, Olof Brattström
icerats skillnader i Europeiska/skandinaviska trauma och vi fortsätter med en totalstudie av slutenvårdskrävande trauman i Sverige. Svenska Traumaregistret(SweTrau) och ANOPIVA-kliniken Karolinska Vi har gjort en riskjusterad traumadatabas av samtliga slutenvårds- krävande trauman i Sverige under åren 2001–2011 genom att kom- binera slutenvårdsregistret och dödsorsaksregistret. Vi har valt att Bakgrund: Trauma, skador på grund av yttre våld, utgör ett omfat-
specialstudera fallolyckor (som är den största bidragande orsaken till tande folkhälsoproblem. Skador är den vanligaste dödsorsaken bland slutenvårdskrävande traumadödlighet), trafikolyckor och även över- yngre människor, och för patienter som överlever den initiala fasen grepp för att få tre helt olika grupper. Vi jämför dessa tre grupper mot efter trauma finns risk för kvarstående fysisk och psykisk sjuklighet. resterande traumafall i databasen, då vi är övertygade om att traumapo- Utveckling av traumavården har lett till att vi idag ser allt mer svårt pulationen skiljer sig från resterande befolkning, och får då två ben skadade patienter som överlever den initiala skadan. Patentrapportera- med ca en miljon patienter i var ben. För att få en korrekt riskjustering de utfallsmått som sjukdomssymtom, funktionsförmåga och hälsorela- har vi gjort en International Classification of disease 10 Injury Severity terad livskvalitet är parametrar som har blivit allt viktigare att följa över Score (ICISS) modell med en huvuddiagnos och upp till nio bidiagno- tid för att dels kunna mäta konsekvensen av trauma utöver mortalitet, ser för att spegla att vi tror att multitrauma är dödligare än singeltrau- men också för att kunna utvärdera omhändertagandet generellt men ma. Med hjälp av logistiska regressioner mot 30 dagars mortalitet kan även möjliggöra identifiering av riskgrupper för specifika interventio- vi inkludera kön, ålder, vårdtid och diagnosgrupper.
ner i vården av denna patientgrupp.
Med frekvenser som inte skiljer sig signifikant på fall och övergrepp Vårt syfte med detta projekt var att se om det är möjligt att infö- medans trafikolyckor minskar och ett OR som mestadels passerar ett ra patientrapporterade utfallsmått i det nationella kvalitetsregistret är det svårt att uttala sig om att det finns en dynamik i mortaliteten. SweTrau och på så sätt kunna mäta konsekvensen av trauma på na- Börjar man sedan subgruppera på olycksbas och kön kan man se att tionell nivå i form av bl.a sjukdomssymtom, funktionsförmåga och fallolyckor är nästintill oförändrat över tid. Trafikolyckor uppdelat på hälsorelaterad livskvalitet på lång sikt.
kön så ser man en mortalitetsminskning för män och de sista fyra är det signifikant medans kvinnor bara har en minskning det sista året. Män har en minskning i trafikrelaterad mortalitet och fall verkar vara en utmärkt referensgrupp.
Student- and patient centered supervision in
Ann-Charlotte Falk CCRN, Med.dr, Tarja Huhatoja CCRN,
Long term cerebral outcome after prolonged
Eva-Maria Wallin CCRN
hypoxemia during Extracorporeal Membrane
ANOPIVA kliniken, Karolinska Universitetssjukhuset, Solna Bernhard Holzgraefe1, Christin Andersson2, Håkan Kalzén3,
Introduction: There is a growing need to improve clinical supervi-
Mikael Mosskin4, Kenneth Palmér3, Björn Frenckner, Anders
sion in the health care system. In Sweden there has been an increased demand for clinical placements with more nursing students in critical care to reduce the lack of reg.nurses in the future. The academic de- 1ECMO Department Karolinska, Karolinska University Hospital and gree to become a nursing-specialist puts high demands on feedback, Department of Physiology and Pharmacology, Section for Anesthesiology reflection and evidence-based care. To meet those needs a student- and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden; and patientcentred supervision has been developed in the critical care 2Department of Psychology, Karolinska University Hospital, Huddinge setting. The aim is to improve supervision to meet demands on more and Karolinska Institutet, Stockholm, Sweden; 3ECMO Department students per supervisor and to make students take responsibility over Karolinska, Karolinska University Hospital, Stockholm, Sweden; 4De- patient-care during critical care. partment of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden; 5Department of Pediatric Surgery, Karolinska University Setting: The supervision was performed by reg.nurses with a specialist
Hospital and Karolinska Institutet, Stockholm, Sweden; 6Department of degree at a Critical Care Unit at a level one trauma center with 13 beds Anesthesiology and Intensive Care and Hedenstierna Laboratory, Uppsala for intensive care patients. All patients are care for by one reg. nurse University Hospital, Uppsala, Sweden; (1:1) with specialist competence. Rationale: Uncontrolled hypoxemia in severe refractory respiratory
Method: All students and supervisors evaluated the supervision (both
failure is associated with cognitive impairment in survivors. Howev- orally and written) during the student-and patient centered supervision. er, whether maintaining adequate tissue oxygen delivery but accepting hypoxemia during Extracorporeal Membrane Oxygenation (ECMO) Results: Supervision was performed in one regular patient-room with
as a part of a lung protective strategy would affect cognitive outcome three-four patients requiring intensive care. Two specialist-nursing is not known.
students care for every patient. One supervisor is responsible for 2–4 students which led's to improved peer learning before reflection is ini- Objectives: The present study investigated the prevalence of brain
tiated together with the supervisor. The result shows that students lesions and cognitive dysfunction in long-term survivors from influen- improve they're clinical- and decision making skills as well as inner and za A/H1N1 2009 induced hypoxemic respiratory failure treated with external authenticity. Evaluation shows that 98 percent of all students have been highly satisfied with this supervision style. A few negative aspects has been described i.e. lack of communication between student Methods: The study (NCT01763060) was approved by the local eth-
peers, high demands with severely ill patients and lack of time for re- ical committee and written informed consent was obtained of every participant. Brain lesion and cognitive function outcome were inves- tigated with magnetic resonance imaging and standardized neuropsy- Conclusion: Student- and patient centered supervision in the critical
chological tests, respectively. care setting improves students clinical- and decision making skills as well as inner and external authenticity. Measurements and Main Results: Seven survivors participated in
this study 3.22 years (median) after ECMO. Four patients were lost to follow up. Median P/F ratio before ECMO was 51 (IQR 18) with a FiO2 of 1.0. During the first ten days of ECMO median peripheral measured SaO2 was 78 % (IQR 15). Adequate tissue oxygen delivery was maintained as indicated by a median blood lactate level of 1.3 Jenny Jonsson och Tuula Mäklin (undersköterskor), Kristina
mmol/L. Full-scale intelligence quotient (FSIQ) was normal in five of Norden skjöld, Leyla Sheikdon och Marie Eivarsson (sjuk-
six patients (within mean ± 1 SD). In one patient FSIQ could not be sköterskor), Marianne Mörrby Ramberg, Brian Cleaver och
determined due to lack of formal education. Memory functioning and Emma Jerkegren Olsson (läkare) och Eva Joelsson-Alm (coach)
general cognitive ability were normal in all seven subjects (within mean ± 1 SD). Four patients showed brain lesions, which were unrelated to Anestesi och Intensivvårdskliniken, Södersjukhuset, Stockholm treatment or hypoxemia. Riskjusterad dödlighet (SMR) är ett övergripande kvalitetsmått för in- Conclusions: If adequate organ perfusion is preserved during ECMO,
tensivvården. Det ett mått som ofta diskuteras och refereras till trots hypoxemic conditions could be accepted to avoid further harm by ag- att det är komplext och svårtolkat, t ex avspeglar SMR all given vård gressive mechanical ventilation or oxygen toxicity.
under 30 dygn efter IVA-inskrivning medan medelvårdtiden på en in- tensivvårdsavdelning är endast ca 2 dygn. En annan faktor som kan påverka SMR är i hur stor utsträckning patienter med behandlingsbe- gränsningar vårdas på IVA.
IVA på Södersjukhuset har haft en något högre riskjusterad dödlig- terms of perceived quality of sleep. The concept of targeting glial dys- het än andra sjukhus i Stockholmsområdet, och också strax över riks- regulation instead of neural excitability to reduce the development of genomsnittet. En pilotanalys gjordes av några journaler från avlidna persistent neuropathic pain is a promising path that merits further patienter som bland annat visade att beslut om behandlingsstrategi och evaluation in clinical settings.
eventuella behandlingsbegränsningar var dåligt dokumenterade. Det framkom att det fanns flera förbättringsområden att arbeta vidare med och ett tvärprofessionellt team anmäldes därför till ett nationellt ut- vecklingsprogram på Kvalitetsregistercentrum Stockholm (QRC) för förbättringsarbete med stöd av kvalitetsregister. Local Infiltration Analgesia for Pain Relief
Övergripande mål var att förbättra möjligheterna för patienterna att following Abdominal Hysterectomy. A random-
få vård på rätt nivå i rätt tid genom att ställningstagande angående ized, double-blind study
behandlingsstrategi genomförs kontinuerligt under hela vårdtiden på IVA. Till förbättringsprojekt har data använts från Svenska Intensiv- J Hayden, O Carlsson, K Olausson, S E Thörn, A Gupta
vårdsregistret – SIR. En stor register- och journalgranskningsstudie av patienter som vårdats på IVA 2013 har utförts inom projektet.
AnOpIva, Sahlgrenska Universitetssjukhuset, Göteborg Teamet har arbetat med att förbättra rutinerna för och följsamheten till beslut angående behandlingsstrategi. Förbättringsförslag var att an- Introduction: In Sweden, approximately 10,000 women undergo hys-
vända en rondmall där behandlingsstrategi står med som obligatorisk terectomy each year and over 60% of these are performed via open ab- punkt, att planera för regelbundna tvärprofessionella vårdkonferenser dominal surgery. Postoperative pain during the first 24 h is moderate to tillsammans med patient eller närstående och att utse en patientansva- severe. Several methods have been used for postoperative pain manage- rig sjuksköterska och undersköterska. ment. This study (Clinical Trials NCT01782781) assessed the efficacy Resultatet visar en kraftigt förhöjd följsamhet till rondmallen, att of local infiltration analgesia (LIA) during abdominal hysterectomy.
behandlingsstrategi diskuteras dagligen, att vårdkonferenser planeras i betydligt högre utsträckning än tidigare och att de flesta patienter nu Methods: Following Ethics Committee approval, 60 patients under-
får en patientansvarig sjuksköterska och undersköterska. Teamet har going open abdominal hysterectomy were randomized to Group LIA även lyckats få hela Södersjukhuset att ändra dokumentation av be- (150 ml of a mixture of 0.2% ropivacaine + 30 mg toradol + 0.5 mg handlingsbeslut i patientjournalen. adrenaline) injected systematically in the uterine ligaments, different tissue planes and subcutaneously, or Group C (Control) who received the same volume of normal saline, in a double-blind study. Postoper- Posterpresentation 5
ative pain, analgesic consumption (patient controlled i.v. morphine), side effects and home discharge were recorded. Måndag 21/9 kl 17:45–19:00
Results: Rescue morphine consumption during the first 24 hours
after surgery was significantly lower in the group LIA, 18 (0–54) mg compared to group P 27 (8–67) mg, p = 0.028. Postoperative pain Moderatorer: Karl-Fredrik Sjölund, Malin Jonsson Fagerlund
intensity at the incision site was significantly lower in group LIA com- pared to group C during the first two hours at PACU. Postoperative Glial dysfunction and persistent neuropathic
opiate-related complications were significantly lower in group LIA.
Discussion: Local infiltration analgesia for management of postoper-
Linda Block, Specialistläkare, Med Dr
ative pain was superior to saline and resulted in lesser rescue analgesic consumption, lower pain intensity and a lower incidence of side effects. AnOpIVA, Sahlgrenska Universitetssjukhuset, Göteborg Future studies should be directed towards comparison between LIA and other standardized or routinely used methods.
Persistent pain that remains long after the physiological trigger has been resolved is a disabling condition. Persistent postsurgical pain is a significant clinical problem, and it is closely associated with neuro- pathic pain. Once established, this type of pain is often difficult to Morfin intratekalt och epiduralt vid obstetriska
treat, and conventional pain therapies are often insufficient. A possible mechanism for the transition from acute physiological pain to per- och gynekologiska operationer i Sverige
sistent neuropathic pain involves low-grade inflammation in the cen- tral nervous system, glial dysfunction and subsequently an imbalance in the neuron-glial interaction that causes enhanced and prolonged Anette Hein, överläkare1, Caroline Haegerstrand1, Gunnar
pain transmission. A peripheral injury can cause low-grade neuroin- Dahlgren2, Jan Jakobson1
flammation that in turn activates glial cells. The activated glial cells exhibit cellular changes, and their communication is altered. Astrocyte 1Anestesi och Intensivvårdskliniken Danderyds sjukhus, 2Anestesi och dysfunction, which occurs as a component of low-grade neuroinflam- Intensivvårdskliniken St Görans sjukhus Capio mation, can be experimentally restored using the combined actions of a μ-opioid receptor agonist, a μ-opioid receptor antagonist, and an anti- Bakgrund: Intratekalt och epiduralt administrerat morfin till kejsar-
epileptic agent. To achieve this response, the use of an ultralow dose snitt och hysterektomi samt vid värkarbete har visats förbättra smärt- of the μ-opioid receptor antagonist naloxone seems to be particularly lindring postoperativt respektive under förlossning. Hur vanlig an- crucial. Clinically, a pilot study that involved patients with persistent vändningen av neuroaxialt morfin är till dessa patientgrupper är dock pain demonstrated that intrathecal administration of an ultralow dose inte känt. Biverkningar av neuroaxialt morfin förekommer och kan of naloxone in combination with morphine had beneficial effects in begränsa användandet liksom behovet av övervakning. Material och metoder: I enkätstudie efterfrågas intratekal och epi-
and the control groups in tympanometry or otoacoustic emissions. dural rutinanvändning av morfin, sufentanil och fentanyl, vid för- Pure tone audiometry revealed a significant but small (< 5 dB) diffe- lossningssmärta, kejsarsnitt och hysterektomi. Förekomst av riktlinjer rence between the ADP and control groups (p<0.05). The ability to avseende neuroaxiala opioider, ffa morfin, och hur övervakning är hear speech in noise as measured by SSQ was significantly reduced in organiserad efterhörs. Genom socialstyrelsens medicinska födelseregis- the ADP group compared to the control group (p<0.05). ter identifierades 47 kliniker med förlossningsenheter, till vilka enkäten sändes via mail.
Conclusions: A minor hearing loss was detected in the ADP group
compared to the control group in pure tone audiometry in some wo- Resultat: Vid de 29 kliniker som hittills svarat sker 77 % av landets
men and during speech in noise component several years after acci- förlossningar och utförs 79 % av Sveriges kejsarsnitt. dental dural puncture treated with an epidural blood patch. This small Rutinmässigt använder 18/29 svarande kliniker intratekalt morfin residual hearing loss has minor clinical significance. vid kejsarsnitt. Vid dessa 18 utförs 76 % av svarande klinikers kej- sarsnitt. Intratekalt morfin till gynekologiska operationer används av 18/29 kliniker. Elva av 29 klinker använder epiduralt morfin vid kej- sarsnitt (56%) medan endast 5/29 använder epiduralt morfin vid gyne- kologiska operationer. Sju av 11 svarande kliniker som inte använder Alteration in hearing following Accidental Dural
intratekalt/epiduralt morfin anger "risk för andningsdepression" och Puncture (ADP) in the Parturient. The effect of an
"svårigheter att övervaka" som skäl. Vid kejsarsnitt är vanligast före- Epidural Blood Patch
kommande intratekal morfindos 100 mg (15/18) -125 mg (3/18) och tillsats av intratekalt fentanyl 10-20 mg (20/29) respektive sufentanil B Darvish, G Dahlgren, C Möller, L Irestedt, A Gupta
2,5 -5 mg (8/29). Epiduralt morfin är mindre utbrett (10/29) medan tillsats av antingen fentanyl 50-100 mg eller sufentanil 5-25 mg är Karolinska University Hospital, Solna and Örebro University Hospital, oftare förekommande (23/29).
Arton av 29 kliniker använder intratekalt morfin vid hysterekto- Introduction: Post dural puncture headache (PDPH) affects 1% of
mi och vanligaste dos är 200 mg (9/29) medan övriga använder 80– parturients having epidural analgesia. The incidence of PDPH follow- 140  mg (9/29). Postoperativ övervakning följer SFAIs riktlinjer och ing ADP is between 50- 86%. Changes in hearing function following organiseras vanligen uppdelat med inledande 2–6 timmar på postope- PDPH are not uncommon. Reduction in hearing is almost always in rativ avdelning eller förlossning och därefter upp till totalt 12 timmar the low frequency range, occurs even during normal pregnancy and normalizes during the post partum period. The primary aim of this study was to investigate the effect of ADP and epidural blood patch Konklusion: Användandet av neuroaxialt morfin är utbrett men be-
(EBP) on hearing.
gränsas fortfarande av oro för andningsdepression och övervaknings- Method: Twenty-one patients having an ADP and confirmed diagno-
sis of PDPH were included (Group E). Audiometry (tympanometry, pure tone audiometry, otto-acoustic emission and KUDU wave) was performed before and after application of EBP with a follow-up after 3 months. Pain intensity was registered before and after EBP. An equal Auditory function following post dural puncture
number of patients having an epidural (Group A) or without epidural headache treated with epidural blood patch
(Group B) served as control groups. – A long-term follow-up
Results: There were no differences in demographic data, parity or in-
Bijan Darvish, Gunnar Dahlgren, 3Lars Irestedt, 1Anders Magnu-
cidence of instrumental delivery. Length of hospital stay was statistical- son, 4Claes Möller, 5Anil Gupta, 1,6
ly longer for group E (5.5 days ±0.98) compared to group A (4.3 ±1.0, p= 0.0003) and group B (4.4 ±1.31, p= 0.007) respectively. ADP was ANOPIVA, Karolinska Universitetssjukhuset, Solna recognized in the group E via the needle in 8 (38%) parturients, deep analgesia after test dose in 3 (14%) and by PDPH symptoms alone in Background: Epidural analgesia is commonly used for pain manage-
10 (48%). Headache was significantly lower 4 hours after treatment ment during labor. Sometimes, accidental dural puncture (ADP) occurs with EBP (p<0.05). No differences were found on the audiometric causing severely debilitating headache, which may be associated with test battery between the groups. There was, however, a significant dif- transient hearing loss. We investigated if auditory function may be im- ference in the number of patients with clinically important hearing paired several years after ADP treated with epidural blood patch (EBP). impairment (> 20 dB) at 0.25 kHz in the left ear between group E and group B, 9 (43%) vs. 1 (4.8%) (p = 0.005).
Methods: Sixty women (ADP group) without documented hearing
disability, who received EBP following ADP during labor between Conclusions: EBP resulted in a significant reduction of PDPH after
the years 2005–2011 were investigated in 2013 for auditory function 4 h Length of hospital stay was prolonged following PDPH treated using the following tests: otoscopic examination, tympanometry, pure with EBP. A significantly greater number of patients with PDPH had tone audiometry and transient evoked otoacoustic emissions. Additio- hearing loss > 20 dB at low frequency nally, they responded to a questionnaire, the Speech, Spatial and Qua- lities (SSQ) of hearing, concerning perceived hearing impairment. The results were compared to a control group of 20 healthy, non-pregnant women in the same age group. Results: The audiometric test battery was performed 5.2 (1.9) years
after delivery. No significant differences were found between the ADP in patients with hip fracture we observed that the routine group reduced Dexmedetomidine as adjunct to ilioinguinal/
the oxygen delivery index (DO I) in average by 16 % (95% CI 15%; iliohypogastric nerve blocks for pediatric inguinal
hernia repair: An exploratory randomized
Aims: To explore the haemodynamic changes during the first 45 min-
utes after the SPA: 1. in the routine fluid group as a whole M Lundblad1, D Marhofer2, S Eksborg3, PA Lönnqvist4
2. in subgroups of patients with and without post-spinal hypotension 1Dept of Paediatric Anaesthesia & Intensive Care, Karolinska Univer- Methods: Population: patients who were allocated to routine fluid
sity Hospital, Stockholm, Sweden. 2Dept of Anaesthesia and Intensive regime during the RCT and were anaesthetized by SPA are included. Care Medicine, Medical University of Vienna, Vienna, Austria. 3Dept of Women´s and Children´s Health, Karolinska Institutet, Stockholm, Monitoring: LiDCOplus™ was used, but concealed to the clinician Sweden . 4Dept of Physiology & Pharmacology, Section of Anaesthesiology & Intensive Care, Karolinska Institutet, Stockholm, Sweden Data extraction: by the LiDCOviewPro software; data collected be- tween the calibration of LiDCOplus™ (T0) and 45 minutes after Background: Adult meta-analysis has identified dexmedetomidine as
SPA (T45) was used analysed. Mean values/minute were calculated. a potentially useful adjunct to prolong the duration of peripheral nerve Missing values were generated by linear interpolation between the two blocks. However, no data exist regarding the adjuvant use of dexmede- tomidine in the setting of pediatric peripheral nerve blocks.
Haemodynamic variables: MAP (mean arterial pressure), HR (heart Methods: Using a prospective, randomized, double-blind design,
rate), SVI (stroke volume index), CI (cardiac index ), DO I (oxygen children (1½-8 yrs, ASA 1-2) scheduled for outpatient inguinal her- delivery index index), SVRI (systemic vascular resistance index).
nia repair were randomized to receive either an ultrasound guided ilioinguinal/iliohypogastric nerve block (IINB) with plain ropivacaine Statistical analyse: The haemodynamic changes were analyzed by 0.197 % (Group LA; n = 21) or ropivacaine 0.197 % with adjunct ANOVA (one-way, repeated measures) by compensation of for mul- dexmedetomidine 0.3 mcg kg-1 (Group LAD; n = 22). The prima- tiple comparisons (Dunnett´s test). The level of significance was 0.05 ry endpoint of the study was time to first postoperative administra- (GraphPad Prism 6™).
tion of supplemental analgesia (FPASA) triggered by a pain score > 4 (CHIPPS or NRS scale). Intention-to-treat (ITT) analysis was decided Results: We analyzed data of 64 patients: mean age 85 years; ASA-PS
as the primary statistical analysis of the data.
≥3 in 70 %.
In the whole group: MAP and SVRI reduced within 2–5 minutes; CI Results: The median time to FPASA was prolonged by 88 % follow-
and DO I reduced and SVRI increased after 23 minutes. The median ing the use of adjunct dexmedetomidine (4.0 hours and 7.6 hours in DO I reduction after 45 minutes was -17% (range: -100% +45 %).
group LA and LAD, respectively) (p = 0.0717). Patients in Group LA displayed a significantly higher number of patients with a CHIPPS Subgroups with/without post-spinal hypotension: the post-spinal hypo- score > 4 in the PACU (7 vs. 0; p = 0.0029) as well as a higher in- tension (n=48) was treated by phenylephrine, or ephedrine. The hemo- cidence of PAED (4 vs. 0; p = 0.0485) when compared to patients dynamic patterns of "no hypotension" were biphasic; of "hypotension" in Group LAD. No adverse events were recorded in any of the study Given that the DO I might be associated with negative outcomes, the treatment of post-spinal hypotension in this context needs research.
Conclusions: The use of dexmedetomidine as an adjunct to an IINB
resulted in reduced incidences of CHIPPS pain scores > 4 and PAED scores of >11 during early recovery following pediatric inguinal hernia Posterpresentation 6
repair. In addition, the use of adjunct dexmedetomidine was associated with a prolongation of the period to first supplemental analgesia de- Måndag 21/9 kl 17:45–19:00
mand. The results of the present exploratory study must be viewed as preliminary and need further validation by future larger sized studies Moderatorer: Lill Bergenzaun, Lars Berggren
Variationen i antalet organdonationer per lands-
ting minskar när hänsyn tas till donatorns hemvist
Hemodynamic effects of spinal anesthesia (SPA)
in patients with proximal femoral fracture
Thomas Nolin, Caroline Mårdh, Göran Karlström och Sten
Marcus Hellkvist, Sigridur Kalma, Erzsébet Bartha
Svenska Intensivvårdsregistret, SIR. Department of Anesthesia and Intensive care, Karolinska University Hospital Huddinge, and Karolinska Institutet, CLINTEC, Stockholm, Bakgrund: I direktiven till den pågående statliga utredningen om do-
nations- och transplantationsfrågor konstateras att det finns stora skill- nader mellan landstingen i antalet organdonationer. Syftet med denna Background: During our randomized controlled trial (RCT) on per-
analys var att se i vilken omfattning som skillnaderna kan förklaras av operative Goal Directed Haemodynamic Treatment (NCT01141894) att organdonationer kommer till stånd utanför hemortens landsting. Metod: Ur Svenska Intensivvårdsregistrets databas hämtades data från
Konklusioner: En organdonation är en känslomässig och stressande
2009–2014 för avlidna på IVA. De avlidna kategoriserades utifrån två situation för sjuksköterskor. Behovet av utbildning i hjärndödsdiagnos- perspektiv: vårdgivarperspektivet avsåg landsting där patienten avled tik och donationsprocessen i stort var något som önskades . Återkopp- och befolkningsperspektivet avsåg det landsting i vilken patienten hade ling om de donerade organens funktion var något som upplevdes som sin hemvist. Hemvisten (folkbokföringsorten) bestämdes genom den positivt och önskades i högre grad.
avlidnes postnummer vid vårdtillfället på IVA. För båda perspektiven kategoriserades data så att den avlidne antingen "tillhörde" det "egna" landstinget eller ett "annat" landsting. Studien genomfördes efter sedvanlig FoU ansökan och godkännande av regional etikprövnings- nämnd. Variationen mellan landstingen beskrevs med variationskoeffi- Tidig identifiering av etiska frågeställningar
cienten (C.V. = medelvärdet/SD).
hos den intensivvårdade patienten
Resultat: Protokoll för 20 238 avlidna från 88 IVA analyserades. Efter
Åsa Hällström
att 61 st. avlidna med utländsk härkomst och 475 med okänt eller inget postnummer hade exkluderats (bortfall 2.4 %) återstod 19 701 Karolinska Universitetssjukhuset Huddinge, Intensivvårdsavdelning B46 utvärderingsbara protokoll (varav 810 var organdonatorer). För 18 226 (92,5 %) avlidna och 667 (82,3 %) organdonatorer sammanföll vård- Patienterna på intensivvårdsavdelningen (IVA) är kritiskt sjuka och givar- och befolkningsperspektiven, dvs. vården skedde inom det har ofta ett livshotande tillstånd. Vården av dessa patienter är många "egna" landstinget. För 1 475 (7,5 %) avlidna och 143 (17,7 %) organ- gånger komplex, vilket leder till etiskt svåra situationer som personalen donatorer ägde vården rum i "annat" landsting än där den avlidne var ställs inför.
Hösten 2012 fick jag och min kollega i vår etikgrupp uppdrag från Variationskoefficienten beräknad utifrån ett vårdgivarperspektiv var avdelningens ledningsgrupp att ta fram en arbetsform för att tidigt 0,54 med variation från 3,6 till 31,3 organdonatorer per miljon invå- identifiera etiska problem hos patienter som vårdas på IVA. Detta re- nare (pmp) och landsting. Ur ett befolkningsperspektiv var C.V. 0,31 sulterade i framtagande av "Etisk rond på IVA". Den etiska ronden är med en relativ spridning från 6,9 till 27,7 pmp och landsting.
ett tillfälle där teamet kring patienten belyser och diskuterar etiska frå- geställningar kring patientens vård. Det kan innebära diskussion kring Slutsats: Variationen i antalet organdonationer per landsting mins-
behandlingsbegränsning, fortsatt vård och behandling, bemötande av kade när analysen gjordes ur ett befolkningsperspektiv jämfört med närstående eller patientens möjlighet att behålla sin autonomi. Det är ett vårdgivarperspektiv. En avsevärd variation kvarstod som behöver av vikt att diskussionen kretsar kring den aktuella etiska frågeställning- analyseras. Den kan t.ex. bero på befolkningens ålderssammansättning, en och att argumentationen utgår från den etiska plattformen för häl- intagningskriterier för intensivvård eller avdelningarnas identifiering av so- och sjukvården samt Karolinska Universitetssjukhusets etikpolicy.
Etisk rond ska hållas när patienten vårdats i ca en vecka på IVA med en förväntad vårdtid på ytterligare en vecka eller vid behov. Närva- rande vid ronden är patientansvarig specialistläkare, planeringsansvarig sjuksköterska och undersköterska med god kännedom om patienten. Ytterligare personal med god kännedom om patienten kan kallas in vid Sjuksköterskors upplevelser av att vårda en
behov. Teamet identifierar en eller flera etiska frågeställningar och lyfter avliden organdonator under donationsprocessen
dessa i en interprofessionell diskussion. Teamet tar ett gemensamt be- slut om hur den etiska frågeställningen ska lösas. Vid behov kan andra resurser, till exempel fysioterapeut eller kurator, kallas in för att ge an- Maria Hellström, Maria Söderström
dra handlingsalternativ eller för att gå vidare med en etisk analys. Den etiska ronden syftar till att teamet gemensamt, förutsättningslöst och ANOPIVA, Karolinska Universitetssjukhuset, Solna icke-hierarkiskt ska diskutera de etiska frågeställningarna som uppstår kring patientens vårdsituation. Utvärdering av arbetssättet har visat att personalen anser att den etis- Introduktion: Vid omhändertagande av en avliden organdonator un-
ka ronden är ett hjälpmedel för de att belysa de etiska frågeställningar- der donationsprocessen på operation, ställs sjuksköterskor inför olika na och att det kan vara ett sätt att minska lidande för patienten och att känslomässiga konflikter och dilemman. Det är svårt för sjuksköter- förstärka patientens autonomi. skorna att förstå donatorn är död då kroppen är varm och ser levande ut. En organdonation är omfattande och innebär stor kirurgi i snabbt tempo, som utförs tillsammans med ett eller flera transplantationste- am, oftast från andra sjukhus. Detta gör att donationsprocessen på operation är en speciell upplevelse för sjuksköterskor. How are paediatric anaesthesia-related adver-
se events reported at university hospitals in the
Syfte: Att belysa sjuksköterskors upplevelser av att vårda en avliden
organdonator under donationsprocessen på operationsavdelning.
Metod: En allmän litteraturstudie där åtta kvalitativa artiklar och två Mattsson, Per1, Hanke, G2., Vieri, J3., Ulvik, A.4
med kvantitativ ansats analyserades.
1Karolinska University Hospital, Stockholm, Sweden, 2Altonaer Kin- Resultat: Sjuksköterskors upplevelser är att det är en stressande och
derkrankenhaus, Hamburg, Germany, 3Tampere University Hospital, känslomässig situation att vårda en avliden organdonator under dona- Tampere, Finland, 4Haukeland University Hospital, Bergen, Norway. tionsprocessen på operation. Det är en lång process som startar innan Paediatric Anaesthesia Training Program donatorn anländer till operationsavdelningen och kan sträcka sig lång tid efter för sjuksköterskan.
Introduction: Reporting of adverse events in healthcare may play a
Med ungefär lika stora grupper och riskjusterat på diagnoser kan vi key role in learning from mistakes and thus improve patient safety. med p-värden på under 0.000 hos vuxna få ut OR på 0,78 (CI 0,71– The aim of the present study was to investigate how adverse events in 0,86) till 0,51 (0,50–0,53) hos post menopaus, beroende på ålderska- paediatric anaesthesia are reported at university hospitals in the Nordic tegori. Barn under 15 är det större osäkerhet i.
Detta tolkar vi som att de dubbla X-kromosomerna har en tydlig inverkan på överlevnaden snarare än att det är östrogenbetingat. Dock Methods: The heads of anaesthesia departments at all Nordic universi-
verkar effekten inte vara helt säker för barn.
ty hospitals were asked to answer a questionnaire concerning reporting of adverse events in 2013. The data was collected by email and tele- Results: Of 32 eligible hospitals 30 (93.8%) answered the question-
Uppdaterad information om CAN-studien
naire. All the hospitals had at least one written system for reporting (Cancer and Anaesthesia).
of adverse events. Twenty different systems were used. Seven systems were anaesthesia-specific. None of the systems was specifically designed Mats Enlund
for reporting of adverse events in paediatric anaesthesia. Reported ad- verse events ranged from 4 to 147 (median 35). Physicians, nurses, Operationskliniken, Västmanlands sjukhus, Västerås other staff and relatives were able to report. Twenty-one (70.0%) of the departments were not able to report the number of paediatric anaes- Spelar valet av anestesimedel roll för överlevnaden efter cancerkirurgi? thesia-related adverse events. Laryngospasm, hypoxia, and intubation Baserat på djurstudier är svaret ja. Flera möjliga mekanismer finns, var- difficulties were the most frequently reported adverse events in chil- av samtliga tycks gälla för människor. Med denna bakgrund har flera dren. Minor injuries and near misses were considered underreported.
välrenommerade centra i USA gått över från inhalationsbaserad anes- tesi till propofol-underhåll, vilket är essensen av djurstudierna. Rätt Conclusions: A large number of systems for reporting adverse events
eller fel? Detta är i nuläget inte förenligt med att praktisera evidensba- is used in the Nordic university hospitals. Most of the heads of the serad medicin. Djurdata kan inte säkert överföras till människor, för anaesthesia departments were not aware of the type and frequency of vilka data saknas. Således krävs en kontrollerad, randomiserad studie. I adverse events, but consider them to be underreported. A uniform val- CAN-studien randomiseras patienter med bröst- eller kolorektalcancer idated anaesthesia-specific reporting system should be implemented in till anestesiunderhåll med antingen sevofluran eller propofol.
all Nordic countries in order to improve future quality of reporting adverse events.
Tänkbara mekanismer för att förklara hypotesen att propofol "skyddar" från recidiv och/eller metastasering jämfört sevofluran: • Diametralt motsatta effekter på olika komponenter i immunsys- temet; sevofluran är sammantaget proinflammatoriskt, propfol är Finns det könsfördelar för kvinnor inom
• Diametralt motsatta effekter på DNA; sevofluran ger DNA-skada, traumatologin i Sverige?
propofol är inert.
• Diametralt motsatta effekter på transkriptionsfaktorn Hypoxia- Larsen R, Sjöberg
Inducible Factor (en cancercellernas försvarsmekanism); sevofluran uppreglerar faktorn, propofol är inert eller möjligen nedreglerande.
AnOpIva, Universitetssjukhuset, Linköping I djurstudier är det upprepade gånger visat att det finns en överlevnads- • Beslut från EPN (Uppsala): 2013-08-14, Dnr 2013/314.
fördel för kvinnligt kön vid både trauma och sepsis. Två förklarings- • Beslut från Läkemedelsverket: 2013-08-16, Eu-nr 2013-002380- modeller är vanligt förekommande; den ena som tillskriver östrogen 25, Dnr 5.1-2013-64999.
en skyddande effekt, den andra tillskriver de dubbla X-kromosomerna • Registrering ClinicalTrials.gov: 2013-11-02, NCT01975064.
överlevnadsfördelarna. I humanstudier har man dock inte kunnat på- visa detta övertygande annat än i mycket små kohorter. Multicenterstu- Vad har hänt sedan CAN-studien beskrevs vid förra årets SFAI-möte dier pågår för tillfället med att bland annat substituera traumapatienter med östrogen för att komma närmare svaret på frågan. Förutom vid anestesikliniken i Västerås bedrivs studien i Lund, Lin- Vi har gjort en riskjusterad traumadatabas av samtliga slutenvårds- köping, Örebro, Kalmar, Uppsala, Skellefteå och Wroclaw. Klinker i krävande trauman i Sverige under åren 2001-2011 genom att kombi- Dublin och Peking är på gång. Det sammanlagda antalet inkluderade nera slutenvårdsregistret och dödsorsaksregistret. Vi har sedan valt att patienter var 446 i slutet av april.
specialstudera fallolyckor (som är den största bidragande orsaken till De första patienterna, av de 8000 (inkl. marginal) som behövs, in- slutenvårdskrävande traumadödlighet), trafikolyckor och även över- kluderades november 2013. Vi håller nu att glida över från ett stadium grepp för att få tre helt olika grupper. Vi jämför dessa tre grupper mot av "feasibility study" till "full inclusion". Projektets organisation fung- resterande traumafall i databasen, då vi är övertygade om att traumapo- erar, central liksom lokalt och hos den monitorerande organisationen, pulationen skiljer sig från resterande befolkning, och får då två ben Uppsala Clinical Research Centre. Vår elektroniska CRF fungerar och med ca en miljon patienter i var ben. För att få en korrekt riskjustering är nu översatt till engelska. De svaga punkterna är att det behövs någon har vi gjort en International Classification of disease 10 Injury Severity eller några kliniker ytterligare, och finansieringen är inte fullständig. Score (ICISS) modell med en huvuddiagnos och upp till nio bidiagno- En realistisk bedömning är att bägge punkterna kommer att uppfyllas.
ser för att spegla att vi tror att multitrauma är dödligare än singeltrau- ma. Med hjälp av logistiska regressioner mot 30 dagars mortalitet kan vi inkludera kön, ålder, vårdtid och diagnosgrupper.
Academic performance after anesthesia and
surgery during childhood: a large-scale nation-
wide study
Tisdag 22/9 kl 12:00–13:30
P. Glatz, R. H. Sandin, N. L. Pedersen, AK Bonamy,
L. I. Eriksson, F. N. Granath
Moderatorer: Kristina Hambraeus Jonzon, Mikael Bodelsson
Anestesi- och intensivvårdskliniken, Länssjukhuset Kalmar Intensivvård av patienter med ALS i Stockholms
Läns Landsting 2005-14
Background and Aim: While preclinical studies suggest that exposure
to general anesthetics during infancy leads to increased neuronal apop- tosis and later neurocognitive impairment1, there is contradictory in- O. Ankarcrona, J. Jakobsson
formation from human studies aiming to translate preclinical findings into outcome studies of children exposed to anesthesia and surgery Anestesi- och Intensivvårdskliniken, Danderyds Sjukhus before age 4 years2.
Det tycks i Sverige under de senaste 10 åren ha skett ett skifte i in- Method: Among 2 million children born in Sweden 1973–93, we
ställningen till trakeotomi hos ALS-patienter. Mekanisk ventilation för identified 33,514 children who had one single surgical procedure be- dock med sig en mängd dilemman av etisk, humanistisk och ekono- fore age 4 years and no subsequent hospitalization; and 161,731 un- misk art. En systematisk genomgång av data på svenskt material har så exposed control children matched for sex, place of birth, and year and vitt vi känner till inte gjorts. month of birth. This primary cohort was combined with an array of national health care databases and registries of school achievements to Syftet med studien var att determine the association between childhood exposure to anesthesia • Undersöka utvecklingen inom SLL 2005-14 avseende trakeotomi and surgery and later academic performance.
av ALS-patienter.
• Kartlägga skedet när planerad eller akut trakeotomi aktualiseras.
Results: There was no detectable difference in school results at age
16 with one exposure at any of the younger age intervals 0-6 months, Totalt har 32 ALS-patienter vårdats på IVA under studietiden; 18 av 7–12 or 13–24 months. A minor difference (0.79 %, 95% CI 0.25– dessa trakeotomerades och bland dem skedde det planerat för hälften 1.33) in academic performance was found in children exposed at 3–4 (9 patienter) och akut för hälften (9 patienter). years of age, which disappeared when the ear-nose-throat and urolo- Nio (9) patienter intuberades utan att senare trakeotomeras. Av gy surgery groups were excluded. When pooling all age intervals 0–4 dessa avled 6 personer och 3 överlevde till utskrivning från IVA.
years, children having one exposure had 0.40 % lower average marks at Antalet ALS patienter som trakeotomeras har ökat i SLL. Med reser- age 16 years (p< 0.001) and those exposed two or ≥3 times had 1.40 %, vation för att det rör sig om ett litet patientmaterial tycks en skillnad and 1.82 % lower average marks, respectively.
finnas mellan de första åren 2005–06 då ingen trakeotomerades, till de To put the minimal difference in school results into context, the data 2011–14 då i snitt 3 patienter trakeotomerats per år. 2014 utmärker sig were compared to other variables known to affect school results such som det första år då 3 planerade trakeotomier genomfördes.
as gender, month of birth and mothers' educational level. In general, Relativt fler män än kvinnor trakeotomeras. Medelåldern för trakeo- effects of these variables were several orders of magnitude greater than tomi är <60 år, vilket är i överensstämmelse med internationell forsk- the effects of exposure to anesthesia and surgery.
ning avseende vilka patienter som gagnas av ingreppet. Skillnaden i medelålder mellan dem som trakeotomeras planerat och de som inte Conclusion: Exposure to anesthesia and surgery does not constitute
trakeotomeras är 21,1 år (47,7 resp. 68,8 år).
a public health problem and there is no reason to postpone imperative Avseende IVA-vård finns stora variationer mellan åren. Variationer- surgery during early childhood due to fear for potentially negative im- na beror dels på en ökning av antalet patienter som trakeotomeras, dels pact on later academic performance.
på den postoperativa planeringen. IVA-vårdtiden har fallit under åren 2010-14, vilket sammanfaller med att andelen planerade trakeotomier ökat. Vårdkedjan har därmed fungerat och IVA-vårdtiden blir kort. 1. J Neurosci 2003 Feb 1;23(3):876-82 Antalet återinläggningar av ALS-patienter är lågt.
2. JAMA (2015) 313:1515-1516 Sammanfattningsvis är det ett fåtal men ökande antal ALS-patienter som trakeotomeras. För såväl patient som vårdgivare är det angeläget att det genomförs planerat. ingen tidigare undersökt population där sömnapné är så vanligt som CASE REPORTS– Chronic adhesive arachnoiditis
vid kolorektalcancer. Delvis kan den höga förekomsten förklaras av ål- after repeat epidural blood patch
der och övervikt, men det är ännu oklart varför sömnapné är så vanligt vid kolorektalcancer och vilken betydelse det har för dessa patienter.
C. Carlswärd, MD1, B. Darvish, MD, DESA2,3, J. Tunelli, MD2,
L. Irestedt, MD, PhD2
1Department of Anesthesiology, Capio St Görans Hospital, Stockholm, Can we predict who will benefit from non-invasive
Sweden, 2Department of Anesthesiology, Surgical Services and Intensive ventilation in hypoxemic acute respiratory failure?
Care Medicine, Karolinska University Hospital, Solna, Stockholm, Swe- den, 3School of Medicine and Health Science, Örebro University, Sweden Apostolos Genaridis, Lars Engerström, Johan Berkius, Carl-Johan
Wickerts, Sten Walther
Epidural blood patch (EBP) is an efficient treatment for post dural puncture headache (PDPH). Despite its efficiency there are some po- Swedish Intensive Care Registry tential risks with EBP. Arachnoiditis is a very rare disabling condition and few cases have been described following EBP. Background: The increasing early use of non-invasive positive pres-
We present a case of Chronic Adhesive Arachnoiditis (CAA) in a sure ventilation (NIV) in patients with hypoxemic acute respiratory parturient treated with repeat EBP. failure (HARF) is controversial 1. Successful NIV is associated with A healthy 29-year old female had an accidental dural puncture fol- shorter length of stay and improved survival compared to initial inva- lowing epidural insertion. The first EBP as part of treatment of her sive ventilation (InvV), while failed NIV was recently found associated PDPH was ineffective and therefore she received a second EBP. She with lower survival than initial InvV 2. The purpose of the present gradually developed severe neurological symptoms consistent with study was to identify predictors of NIV failure that were present on arachnoiditis confirmed with MRI. Despite intensive multimodal admission to ICU.
treatment with analgesics and physiotherapy, her neurological condi- tion is still precarious two years later. Material and Methods: We examined the use of initial ventilator
We would like to warn the readers about a serious but rare com- support in records of patients with HARF who were admitted to 66 plication following repeat EBP, and encourage caution when treating Swedish ICUs during 2008-2014. Exclusions were age<16 yrs, patients PDPH with repeat EBP in parturients.
with COPD, and when oxygenation or ventilation support data were missing. NIV failure was defined as transition to InvV within 24 hrs. Patients dying in ICU without receiving InvV were excluded as they were likely to have preexisting limits on the use of invasive mechanical Sömnapnéförekomst bland patienter som opere-
ventilation. Variables that were present on admission to ICU and con- sidered important were used to build NIV failure prediction models. ras för kolorektalcancer
Model fit is presented as the c-statistic and McFadden's pseudo R2. Claesson M1, Franklin KA1, Jonsson Fagerlund M2
Results: We identified 4,990 admissions with HARF, 1,561 failed
NIV and were intubated within 24 hrs after start of NIV. Patient age, 1Kirurgiska och perioperativa vetenskaper, Avd för Kirurgi, Umeå Uni- gender, presence of comorbidities, circumstances on admission and versitet, 2Inst för Fysiologi och Farmakologi, Sektionen för Anestesi och SAPS3 scores differed significantly between patients with successful or Intensivvård, Karolinska Institutet, Stockholm failed NIV (P<0.01 for all variables). Results of the model building are shown in the table below.
Introduktion: Obstruktiv sömnapné diagnosticeras när det finns i
medel andningsuppehåll per timme sömn = apné-hypopné index >5 åtföljd av hypoxi. Patienter med obstruktiv sömnapné har en ökad risk för hjärt-kärlsjukdom, tidig död samt en ökad risk för postoperativ hypoxi och sårinfektioner efter ortopedisk kirurgi. Ålder och övervikt SAPS3 score 3, gender är riskfaktorer för både kolorektalcancer och sömnapné. Vi avsåg att undersöka förekomsten av sömnapné bland patienter med kolorektal- Gender, age, comorbidity score 3, Box II 3 cancer, eftersom den är okänd.
Gender, age, comorbidity score 3, route Metod: Femtio patienter varav 16 kvinnor med kolorektalcancer
and reasons for ICU admission 3 medel ålder 69 ± 11 år, BMI 26 ± 4 kg/m2 inkluderades. De gjorde sömnapnéutredning med polysomnografi där andning, EEG, pulsoxi- metri mm registrerades kontinuerligt under natten före operation. Gender, age, comorbidity score 3, route and reason for ICU admission 3, PaO2/FiO2, pH and RLS85 on admission Resultat: Fyrtioen av femtio patienter (82%) hade sömnapné. Fyrtio
procent hade mild sömnapné med 5-15 apnéer/ timme sömn, 28% Conclusion: The prediction models that were built based on informa-
hade måttlig sömnapné och 14% grav sömnapné med mer än 30 ap- tion that was present on admission to ICU performed poorly. Addi- néer per timme sömn. Patienterna sov i genomsnitt 41% av tiden i tional information collected during the first hours in ICU may be one ryggläge. I ryggläge hade de i medel 29 ± 22 apnéer per timme sömn way to improve model performance.
mot 8 ± 9 i sidoläge. Konklusion: Sömnapné är ytterst vanligt bland patienter som skall
opereras för kolorektalcancer. Detta är ett helt nytt fynd och det finns the standard care group.1 There are few studies using modern mini- 1. Walkey et al, Ann Am Thorac Soc 2013; 10: 10–17 mal-invasive monitoring to describe hemodynamic changes after spinal 2. Genaridis et al, Best Free Paper Session, 33rd SSAI Congress anesthesia(SPA) in the elderly.2 3. Moreno et al, Intensive Care Med 2005;31: 1345-55.
Aim: To describe hemodynamic changes during spinal anesthesia in
elderly at hypotension and non-hypotension after SPA in a prospective Materials and methods: 20 patients, >65 years, undergoing elec-
Intraoperative hypotension is associated with
tive arthroplasty. Monitoring: LiDCOplus™. Data collection: at base- myocardial damage in non-cardiac surgery
line and until 45 minutes after spinal anesthesia. Standard fluid and vasopressor treatment: pre-spinal fluid loading with Ringer's acetate 0-500ml, Buffered Glucose 25 mg ml-1, 1ml-1kg-1h1, Ringer's acetate, 2ml kg-1 h-1, use of vasoactive agents at the discretion of the anesthetist. Dept of Anesthesia and Intensive Care Medicine, Hypotension was defined as SBP <100mmHg or >30% decrease from Karolinska University Hospital, Solna Background: Perioperative myocardial damage and infarction (MI)
Results: After pre-spinal fluid preloading, SVI decreased by
are associated with increased mortality and other postoperative com- 12.7±7.1%(mean±SD) in 19/20 patients. Hemoglobin decreased from plications. The study objectives were to investigate how intraoperative 131±10 g/L to 121±12 g/L. Patients developing hypotension after events, with focus on hypotension, were related to perioperative myo- SPA had a higher heart rate(73±10 vs 60±12) and a lower SVI(38±8 cardial damage, as detected by the novel high-sensitivity troponin-T vs 48±10) at baseline compared to non-hypotensive. CI(cardiac index) (hs-cTnT). Moreover, we assessed if these intraoperative events were and DO2I (oxygen delivery index) decreased progressively in hypoten- related to perioperative myocardial infarction. sive while reduction in SVRI(systemic vascular resistance index) was similar in both groups. Methods: In this observational cohort study of all patients undergoing
major elective noncardiac surgery who required an overnight admis- Conclusions: Based on these observations, further studies should fo-
sion at the post operative unit at the Karolinska University Hospital, cus on: 1. Baseline SVI and HR as possible predictors of postspinal Stockholm, Sweden, between October 2012 and May 2013, preopera- hypotension. 2. Effects of fluid pre- and coloading during spinal anes- tive risk factors (comorbidities), intraoperative events (hypotension de- thesia in the elderly. 3. Reduction of cardiac and oxygen delivery index fined as a 50% decrease in systolic blood pressure relative each patient's in the context of perioperative oxygen consumption. baseline and lasting > 5 min) and postoperative data were collected from medical records. Levels of hs-cTnT were measured on postop- erative day 1. Myocardial damage was defined as an increase in the 1. Bartha et al. Br J Anaesth 2013; 110: 545-53 hs-cTnT value above 14 ng/l. Cases of MI within 30 days after surgery 2. Meyoff et al. Eur J Anaesth 2007;24:770-5 were adjucated by a cardiologist.
Results: Of the final cohort of 300 patients, 34 (12%) had intraoper-
ative hypotension, 90 (30%) had myocardial damage on postoperative Accuracy of stroke volume estimation.
day 1 and 15 (5%) developed MI within 30 days. Multivariate logistic regression analysis demonstrated that an intraoperative hypotensive Oesophageal Dopplear compared to cardiac
event >50% (OR, 4.4; 95% CI 1.8-11.1) was an independent predic- magnetic resonance
tor of postoperative hs-cTnT elevation.
Conclusions: In patients undergoing major elective noncardiac sur-
gery, there is an association between an intraoperative fall in systolic Anestesi- och operationskliniken, Universitetssjukhuset, Linköping blood pressure >50% from baseline and the novel hs-cTnT biomarker Introduction: The CardioQ® oesophageal Doppler (OD) is used in the
clinical setting for estimating and monitoring hemodynamics and for guiding fluid replacement therapy. Studies have shown clinical agree- ment between OD and thermodilution via pulmonary artery catheter (PAC) for hemodynamic trends, but also indicated that OD lacks in Hemodynamic changes during spinal anesthesia
accuracy and precision. Since PAC is less frequently used, cardiac mag- in the elderly- a prospective observational pilot
netic resonance imaging (CMR) has instead become the non-invasive study in patients undergoing elective arthroplasty
gold standard for measurement of hemodynamic variables. This study aims to evaluate the accuracy of estimation of stroke volume (SV) by Julia Jakobsson, Sigridur Kalman, Marge Lindeberg-Lindvet,
OD, using CMR as reference method. Method: The study population consisted of 19 healthy subjects (10
AnOpIVA, Karolinska Huddinge females) aged 20-30 years. In each subject SV was measured by OD followed by CMR. Agreement in SV estimation between the methods Background: A post-hoc analysis of our RCT on goal-directed he-
was analyzed using the Bland-Altman method, difference in SV be- modynamic therapy in elderly patients with hip fracture revealed an tween methods was calculated using the t-test, and Pearson's formula unexpected reduction of SVI (stroke volume index) before surgery in was used to calculate correlation between the methods. Results: SV measured by OD was significantly lower compared to
CMR. Bland-Altman plot showed broad limits of agreement (LOA) Clinical outcome in patients >10-years after a
for all subjects (bias -26 mL, LOA ± 28 mL, percentage error 57 %), severe traumatic brain injury, (sTBI).
male subjects (bias -36 mL, LOA ± 26 mL percentage error 69 %), and female subjects (bias -16 mL, LOA ± 14 mL, percentage error 20 %). There was a negative correlation between OD and CMR (i.e. with larg- Andersson Emma, Svanborg Emma, Öst Martin, Csajbok Ludvig,
er CMR-measured SV, the more OD underestimated SV). Nellgård Bengt and Nellgård Per
Conclusions: Compared to CMR, the CardioQ®/OD-technique sig-
Dept. for Anesthesiology & Intensive Care, Sahlgrenska Academy, nificantly underestimates SV in young, healthy subjects. The underes- University of Gothenburg timation by OD correlates to the size of SV. Further studies of SV are suggested, comparing OD to CMR in different age groups.
Severe TBI is the single highest fatality diagnosis among young adults. The Lund Concept (LC) is used to treat sTBI in some hospitals of Sweden. As no prospective study has explored outcome >10 years following sTBI in adults we initiated this study.
Patients were included from 2000-2004 if having a sTBI (i.e. Definition av en välfungerande/icke optimal
Glasgow Coma Scale < 9) and treated with LC protocol. In this cohort of patients >10 years (range 11-15) post-trauma, survival was noted and outcome in survivors was assessed with the S-GOS 04 question- Camilla Linnarsson, Sigga Kalman, Erzsébet Bartha
naire, with patients or next-of-kin. The questionnaire was transformed into Glasgow Outcome Scale (GOS) 1-5; (1=dead to 5=good recov- AnOpIva, Karolinska Universitetssjukhuset, Huddinge 100 patients, (women, n=27; men, n=73), met the inclusion cri- Bakgrund: På KS/Huddinge läggs ca 760 thorakala epiduralkatetrar
teria. Patients had a median age at trauma of 38 years, (range 8-81). (EDA) varje år för postoperativ smärtlindring efter stor kirurgi. Den Mortality from study enclosure to present was 35% (n= 35, GOS 1). postoperativa smärtenheten har i sitt uppdrag bl. annat att följa upp Totally 57 of 65 patients or next-of-kin could be contacted to answer och kvalitetssäkra epiduralsmärtlindring. Vårt mål var att föreslå defi- the questionnaire, representing: GOS 2 (n=0); GOS 3, (n=15); GOS nition(er) för välfungerande respektive icke optimalt fungerande EDA 4, (n=29) and GOS 5, (n=13). som kan användas för kvalitetssäkring.
We demonstrated increased mortality from 1-year (15%) to >10 years (35%) post-trauma. Outcome in surviving patients at 1-year vs. Metod: Initialt gjordes en systematisk litteraturgenomgång (PICO) för
>10 years post-trauma was dichotomized into Favorable (GOS 4-5) att se vilka definition(er) som används (t.ex. behandlingslängd, smärt- or Poor (GOS 2-3). Poor outcome at 1-year decreased from 32% to nivå). Dessa definitioner användes sedan för att skapa frågor till en 26%, while Favorable outcome increased from 52% at 1-year to 56% webbaserad enkät som skickades ut till anestesiologer, specialistutbil- at >10 years post-trauma. The results demonstrate, on cohort-basis, a dade sjuksköterskor på postoperativa smärtenheten samt till kirurger doubling of mortality from 1-year to >10 years post-injury. In surviv- (övre buk kirurgi). ing patients a slight improvement over time is also noted. These results confirm that the LC treatment protocol improves outcome even on Resultat: Viktiga behandlingsmål med en välfungerande epidural var
long-term basis after sTBI.
smärtskattning, NRS i vila < 3 (enligt 98 % av de tillfrågade var NRS < 3 en rimlig smärtnivå) och behandlingslängd, dock olika längd (antal dagar) för olika ingrepp. Definitioner av en icke optimalt fungerande epidural (enligt 68–80 % av de tillfrågade), var smärtskattning NRS > 3, behov av PCA (patientkontrollerad analgesi) inom 48 h, behov av ny epidural (oavsett orsak) samt inadekvat täckning.
Tisdag 22/9 kl 12:00–13:30
Diskussion: Med tanke på det stora antalet epiduraler, har den post-
operativa smärtenheten en hög arbetsbelastning. Det är viktigt att kon- Moderatorer: Johan Pettersson, Anders Larsson
centrera uppföljningsverksamheten till områden där nyttan är störst ur ett patientperspektiv. Vi föreslår att kvalitetsuppföljningens mål i "Pleural" pressure in a model with an elastic
första hand är att identifiera icke optimalt fungerande EDA så tidigt recoiling lung and an expanding chest wall
som möjligt. Dessa bör optimeras, konverteras till en annan smärtlind- ringsstrategi, alternativt få en ny EDA. Som kvalitetsindikator föreslår Per Persson, Stefan Lundin, Ola Stenqvist
vi att använda antalet (%) av patienter som behöver PCA (eller annan metod) eller ny epidural inom 48 h. Med en sådan kvalitetsindika- tor kan eventuella problemgrupper identifieras och förbättringsarbete inriktas. Vår undersökning begränsades till professionens åsikter, även We have shown in a porcine and an ARDS patient study that lung patienter bör intervjuas för att definiera patientrelaterade kvalitetsin- compliance can be determined (without esophageal pressure measu- rements) as the ratio of change in end-expiratory lung volume and change in PEEP, ΔPEEP/ΔEELV [1, 2], which is explained by the rib cage spring out force tenses the diaphragm at end-expiration, pre- venting the abdominal content to influence the lung, maintaining the end-expiratory pleural pressure negative also at increased PEEP/ EELV. Esophageal pressure, which is used as a surrogate for pleural pressure is notoriously unreliable for determining absolute pressure, i.e. end-expiratory esophageal pressure, because of extra-pleural effects on measurements.
The Chest Wall has Minimal Protecting Effect on
the Lungs in Situations with High Airway Pressures
Methods: We have built a respiratory system model with a recoiling
elastic lung and an expansive chest wall complex (rib cage, diaphragm and abdominal container): T. Johansson1, A. Larsson1, O. Stenqvist2, S. Lundin2
1Uppsala University, Uppsala, 2Sahlgrenska University Hospital, Göteborg Background: Upper inflexion point (UIP) on a pressure-volume (PV)
curve of the respiratory system indicates the airway pressure where the elastance of the respiratory system (Ers) increases steeply. However, on an ordinary PV curve it is not clear whether this increase is mainly due to distension of the lung or to restriction of chest wall expansion. In the latter case, the chest wall would protect the lung against high pressure by preventing an increase in transpulmonary pressure (Ptr). Therefore, we investigated the PV-relations of the lung, chest wall and respiratory system during a slow inspiration until pneumothorax occurred in lungs from piglets during different conditions.
Methods: 10 anesthetized and mechanically ventilated piglets (25-30
kg) were subjected to hydroperitoneum (3 L starch-solution infused intra-peritoneally) that in 5 animals was combined with lung lavage (30 ml saline/kg, repeated until P/F < 200 mmHg). An esophageal balloon catheter was introduced for esophageal pressure (Pes) measu- rement. The tracheal tube was connected to the measurement device for registration of PV-curves using slow interrupted insufflation1. The lungs were insufflated from ZEEP to an airway pressure (Paw) where the PV curve indicated pneumothorax. Paw, Pes, and Ptr at UIP and si- milar pressures when pneumothorax occurred were recorded. Ers ,Ecw and lung elastance (EL) were obtained as the steepest slope below and Results: At UIP Paw, Ptr and Pes were 60±14, 44±10, and 14±6 cm-
H2O, respectively, while similar pressures when pneumothorax occur- red were 103±10, 84±11, and 16±6 cmH2O. There was no difference between Ecw below or above UIP; 7±4 cmH20/L. The increase in Pes was 2,3±1,4 cmH2O from UIP to pneumothorax, while Paw and Ptr increased with 43±14 and 41±14 cmH2O, respectively.
The model was ventilated in volume control mode with a tidal volume of 300 ml. PEEP was increased from ZEEP to 3, 4, 6, and 9 cmH2O with baseline normal and stiff chest wall complex (achieved by enfor- cing the tank wall), while airway and "pleural" pressure was measured and ΔEELV determined by spirometry. Result: End-expiratory "pleural" pressure (green) increased during the
first expiration, but then declined back to baseline level, while end-ex- Conclusion: In this experiment, despite a high intra-abdominal press-
piratory transpulmonary pressure (blue) increased until it equaled the ure, the chest wall had a minimal lung protective effect.
change in end-expiratory airway (red) (ΔPEEP). References:
Conclusion: As end-expiratory "pleural" pressure remains unchang-
1. Am J Resp Crit Care Med 1994: 150:421-30 ed when changing PEEP, the end-expiratory transpulmonary pressure changes as much as PEEP is changed and as a consequence lung com- pliance can be determined as ΔEELV/ΔPEEP.

Can Lung Elastance be Estimated Without the
Different Estimates of Respiratory Elastance.
Use of Esophageal Catheter?
How Do They Relate?
T. Johansson1, A. Larsson1 , S. Lundin2, O. Stenqvist2
T. Johansson1, A. Larsson1, O. Stenqvist2, S. Lundin2
1Uppsala University, Uppsala/SE, 2Sahlgrenska University Hospital, 1Uppsala University, Uppsala/SE, 2Sahlgrenska University Hospital, Background: It has been suggested that the chest wall extends the
Background: Lung elastance, breath-by-breath quasi-static elastance
lungs up to about 80% of total lung capacity, chest wall elastance of the respiratory system and different elastance- values obtained from at lung volumes below this value would be minor1. This implicates inspiratory or expiratory pressure-volume (PV) loops are commonly that the pleural end-expiratory pressure would only be affected by the used as interchangeable entities. However, the relations between these weight of the abdomen2 and be similar at different lung volumes inde- parameters have not been investigated. We obtained full PV- loops of pendent of end-expiratory airway pressures. We have previously found the lung-chest wall, breath-by-breath elastance of the respiratory sys- that elastance obtained from end-expiratory lung volume differences tem and lungs (Ers-VT, EL-VT) as well as elastance obtained from (ΔEELV) at two adjacent PEEP levels (PEEP-step method) were iden- lung volume differences at two adjacent PEEP levels (Ers-PEEP, EL- tical to lung elastance obtained with esophageal pressure (Pes) measure- ments3. In theory, the locations of the different EELV/PEEP –points would follow the expiratory portion of a full transpulmonary pressure– Methods: 10 anesthetized, paralyzed and mechanically ventilated
volume (PV)-loop. Therefore, in this study we compared the PEEP- piglets were subjected to either hydroperitoneum (3 L starch-solu- step method with the PV-curve method in different lung conditions.
tion intra-peritoneally) and/or lung lavage (30 ml isotonic saline/kg, repeated until P/F < 200 mmHg). Measurements of VT, airway (Paw) Methods: 10 anesthetized, muscle paralyzed and mechanically ven-
and esophageal (Pes) pressures, end-expiratory lung volume, EELV tilated piglets were subjected to either hydroperitoneum (3 L starch- at PEEP 0,5,10,15 and 20cmH2O and registration of P-V relations solution infused intra-peritoneally) and/or lung lavage (30 ml saline/ of the respiratory system (Ers), lung (EL) and chest wall (Ecw) using kg, repeated until P/F < 200 mmHg). Measurements of tidal volume, slow interrupted insufflation/desufflation from ZEEP to 40cmH O airway and esophageal (Pes) pressures, end-expiratory lung volume, in airway pressure were performed. Ers, EL, Ecw were defined as the EELV at PEEP of 0,5,10, and 15cmH O and registration of V-P rela- steepest slopes of the expiratory part of the respective curves. Ers-VT tions of the lung using slow interrupted insufflation/desufflation from/ was calculated as: (End-inspiratory plateau pressure - PEEP)/VT, and to ZEEP to/from 40 cmH O airway pressure were performed. Lung EL-VT was calculated subtracting corresponding Pes. Ers- PEEP and elastance (EL) was obtained as the steepest slope of the expiratory part EL-PEEP were calculated as the airway and transpulmonary pressure of the transpulmonary PV-curve and Ers-PEEP was calculated. differences between two adjacent PEEP/EELV levels. Results: The R-squared between Ers-PEEP and the expiratory PV-
Results: See table. The correlation (R-squared) between the breath-de-
curve-derived EL at similar pressure values was 0.44 with a regression rived (at PEEP 10 cmH O) and expiratory PV- curve-derived elastance equation: EL(cmH O/l) = -1+ 1.05 x Ers-PEEP. Bland & Altman values were excellent and both were well correlated to EELV. Howev- showed a bias of 0.0, with an agreement of ±37cmH O/l.
er, Ers-VT was significantly higher than Ers (mean for all conditions 73±37 and 35±28 cmH O/l, respectively, p<0.001).
Conclusion: Elastance values obtained by the PEEP-step method
were closely related with lung elastance values obtained from a full PV- Conclusion: Breath-by-breath derived elastance values were signifi-
curve. This suggests that with the PEEP step method, lung elastance cantly, around two times, higher but well correlated to those of the might be estimated without esophageal pressure measurements.
expiratory PV-curve. Elastance derived from the steepest part of the inspiratory PV-curve had only minor relation to tidal breath elastance.
1. J Appl Physiol 1968;25:664-71, 2. The respiratory system, Handbook of Physiology 1986:113-30, 3. Acta Anaesthesiol Scand 2012, 56:738-47.
A simple method for isocapnic hyperventilation
Obstructive sleep apnea in the intensive care unit
evaluated in a lung model
– Prevalence studied prospectively by diagnosis,
the STOP-BANG questionnaire and oxygen desat-
Hallén K, Stenqvist O, Ricksten SE, Lindgren S
Anestesikliniken, Sahlgrenska, Göteborg Adam Carlson1, Karl A Franklin2, Malin Jonsson Fagerlund3
Isocapnic hyperventilation has the potential to increase the elimination 1Medical student T10, Karolinska Institutet, Stockholm, 2Department of rate of anaesthetic gases and the method has been shown to shorten Surgical and Perioperative Sciences, Umeå University, Umeå, 3Dept of time to wake up after inhalation anaesthesia. In this bench test, we Anesthesiology, Surgical Services and Intensive Care Medicine. Karolinska describe a simple technique to achieve isocapnia during hyperventila- University Hospital and Dept of Physiology and Pharmacology, Section tion by administering carbon dioxide (DCO ) to the inspiratory limb for Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm. of the anaesthesia circuit using a standard anaesthesia apparatus with standard monitoring equipment. Carbon dioxide was added to a me- Introduction: The prevalence of obstructive sleep apnea (OSA) in the
chanical lung to simulate CO production (VCO ) and hyperventi- intensive care unit has not been investigated in a prospective study. lation was achieved by doubling the minute ventilation and fresh gas OSA has been identified as an important co-morbidity in the periope- flow. During hyperventilation, the amount of delivered CO needed rative period, leading to adverse outcomes postoperatively. The preva- to maintain isocapnia varied between 147±8 and 325±13 ml/min and lence of OSA is 9-24% in the general population and a large part of the FICO -level varied between 2.3 and 3.3 %, depending on CO OSA patients are undiagnosed. Thus, it is likely that there are a signi- production and dead-space. From known relationships between CO2 ficant number of patients with OSA in the intensive care unit (ICU). production, body weight and gender an estimation of delivered CO2 to maintain isocapnia during physiologic conditions could be made.
Aims: The overall aim was to explore the prevalence of OSA and pa-
tients at high risk for OSA in the ICU by using the STOP-BANG Estimated awake CO production, VCO (ml/min) according to Radford. screening questionnaire and oxygen desaturation index post ICU.
Correction of VCO for anaesthesia according to Nunn and from lung model predicted CO delivery, DCO (ml/min) to maintain isocapnic hyperventilation during weaning from anaesthesia.
Material and Methods: Adult patients were recruited upon discharge
from the intensive care unit. OSA-diagnosis, the STOP-BANG scre- ening questionnaire and oxygen desaturation index derived from noc- Body weight VCO2 female awake
VCO2 female
DCO2 female VCO2turnal
male pulse o
al e used to appr
m ximate the pr
aesth e patients.
140 ere included. The pr evalence of OSA was 13.2%, and 76.3% of the patients had a high risk of OSA accor 222 OP-BANG. ODI was lo wer among patients negativ ed to patients who w e at STOP-BANG. The number of samples w 221 e lower than expected because many patients 280 ded the pulse oximeter as an inconv 171 enience or too invasive. Conclusions: The prevalence of OSA in the intensive care unit is
equal to the prevalence in the general population, but screening with the STOP-BANG questionnaire reveals a large discrepancy between diagnosed patients and patients at risk of OSA. A positive result on Body weight VCO2 female awake
VCO2 female
DCO2 female VCO2 male awake
VCO2 male
DCO2 male
STOP-BANG therefore merits further investigation.
Effekt på sömnapné, hypoxi och lungfunktion
av öppen kirurgi av kolorektalcancer
Franklin KA1, Claesson M1, Jonsson Fagerlund M2
1Kirurgiska och perioperativa vetenskaper, Avd för Kirurgi, Umeå Universitet, 2Inst för Fysiologi och Farmakologi, Sektionen för Anestesi och Iintensivvård, Karolinska Institutet, Stockholm Presenterat på ESA Berlin 2015 Introduktion: Ålder och övervikt är riskfaktorer för såväl kolorektal-
cancer som obstruktiv sömnapné. Atelektaser och andningsproblem är vanligt efter stor bukkirurgi men förekomst av sömnapné vid kolorektal- cancer och hur sömnapné påverkas av öppen kirurgi är väsentligen okänt. Sömnapné diagnosticeras när det är mer än 5 andnings uppehåll per timme sömn (= apné-hypopné index, AHI >5). Vår målsättning var att undersöka hur sömnapné, syresättning, kol dioxid och lungfunktion Diskussion & sammanfattning: Förekomsten av andningsstörning
påverkas vid öppen kirurgi av kolorektalcancer.
första nätterna efter operation/anestesi är inte väl studerat. Olika grad av nattlig andningsstörning ökar i befolkningen, kopplat till ökande Metod: 28 patienter varav 8 kvinnor med kolorektalcancer inkludera-
ålder och högt BMI. des. De undersöktes med artärgas, lungfunktion och polysomnografisk Det förefaller fullt möjligt att studera patienter med konventionell sömnapnéutredning med bl.a. kontinuerlig mätning av andning, syre- sömnapneutrustning redan första natten efter operation. sättning och EEG under natten före kirurgi och andra postoperativa Dessa initiala resultat visar att det förekommer nattlig andningsstör- ning efter bariatrisk kirurgi dock av relativt ringa grad. Det behövs ytterligare studier för att bättre kunna identifiera om det finns några Resultat: Sömnapnéförekomsten var hög bland patienterna men det
speciella riskfaktor som medför ökad risk för alvarlig nattlig andnings- var ingen skillnad preoperativt (AHI: 19 ±15) och postoperativt (AHI: störning och hur man i sådant fall kan försöka förebygga dess upp- 17 ±23), däremot minskade apnéförekomsten signifikant i såväl rygg komst. Vi avser att studera 75 patienter för att få en bättre bild och som sidoläge postoperativt. Apnéförekomsten var signifikant högre i planerar också prospektiva studier.
ryggläge än i sidoläge och patienterna sov nästan dubbelt så mycket på rygg postoperativt (82±29%) jämfört med preoperativt (44 ±28%) p<0,001. Vitalkapaciteten minskade signifikant med 32% utan att Stierer TL. Obstructive Sleep Apnea, Sleep Disorders, and Perioperative PCO2 steg, däremot minskade PO2 signifikant med nästan 2 kPa Considerations. Anesthesiol Clin. 2015 Jun;33(2):305-314.
Konklusion: Sömnapnéförekomsten är hög såväl före som efter ki-
rurgi av kolorektalcancer, särskilt under tiden patienten sover på rygg. Sömnapnéförekomsten minskar i såväl sidoläge som i ryggläge posto- Kronisk invasiv ventilation hos vuxna i Stockholm
perativt, men patienterna sover dubbelt så mycket på rygg postopera- tivt, vilket förklarar varför sömnapnéförekomsten är lika hög pre- som Marie Roos, Klara Geisewall, Jan Jakobsson NRC
postoperativt. Sömnapné med intermittent hypoxi skulle teoretiskt sett kunna förebyggas om patienterna förhindrades att sova på rygg post- Anestesi & Intensivvårdskliniken Danderyds sjukhus Bakgrund
Oförmågan att andas, otillräcklig alveolär ventilation, kan orsakas av
en rad sjukdomar och skador. Polio och Guillain–Barrés syndrom Nattlig andningsstörning 1:a natten efter Bariatrisk
är exempel på sjukdomar som kan drabba andningsmuskulaturen. operation i generell anestesi, initiala resultat
Neuromuskulära sjukdomar som amyotrofisk lateralskleros (ALS) och muskeldystrofier leder också till successiv andningsförlamning. Höga ryggmärgsskador och stroke ger varierande grad av andningssvikt, Lotta Wickerts, Sune Forsberg, Jan Jakobsson
där andningsstöd i vissa fall kan bli aktuellt. Detta abstract vill belysa komplexiteten i det som kallas invasiv hemventilation, att leva med Anestesiklinikerna Norrtälje och Danderyds sjukhus, Institutionen för trakealkanyl och andningsstöd av ventilator i hemmet. Gruppen med Klinisk Vetenskap, Karolinska Institutet patienter som har livsuppehållande andningsstöd kräver ofta IVA-vård vid försämring, akuta infektioner, och/eller när vården i hemmet med Påverkan på andning och syresättning efter operation och anestesi kan orsakas av en rad faktorer. Övervikt är en känd faktor kopplad till söm- napne syndrom. Syftet med denna studie är att med standardiserad sömnapnediagnostikutrustning studera förekomst av andningsstör- Nationellt respirationscentrum (NRC) vid Danderyds sjukhus är en ning 1:a postoperativa natten.
öppenvårdsmottagning som sedan 1970-talet och Gillis Anderssons pionjärinsatser vårdat patienter med invasivt andningsstöd i hemmet, Metod: Studien är godkänd av Regionala Etikprövningsnämnden.
utanför intensivvårds- och intermediärvårdsavdelning. I dag finns det Patienter som planerats för elektiv bariatrisk operation vid Norr tälje knappt 60 patienter i Stockholms läns landsting med kronisk invasiv sjukhus inkluderades. Patienter som givit skriftligt medgivande genom - ventilation varav drygt 60 % är män och resten kvinnor. Över hälften gick operation och anestesi enligt klinikens gängse rutiner. Registrering- av dessa patienter är helt beroende av sin ventilator dygnet runt, ca 1/3 en startades klockan 22 med konventionell nattregistreringsutrustning är uppkopplade nattetid och bara 2 % behöver sin ventilator några få (EmblettaR). Thoraxband för att registrera bröstkorgsrörelse, pulsoxi- timmar/dag. Åldersintervallet har en stor spridning men den största metri, nasalt flöde och andningsbiljud samlades automatiskt med ut- gruppen finner man i intervallet 61–70 år följt av patienter som är rustningen. Registreringen pågick till klockan 6 påföljande morgon. mellan 51 och 60 år gamla.
Andningen analyserades med Emblettas standardiserade tokningspro- gram och eftergranskades. Apne/hypopne index (AHI), oxygende- God, trygg och jämlik vård
saturations index (ODI), lägsta SpO2, samlades per patient förutom Att arbeta för god, trygg och jämlik vård för den lilla men resurskrävan- sedvanliga demografiska data. de och stadigt växande grupp av patienter med livsuppehållande and- ningsstöd ställer nya krav och väcker nya frågor. Vad är god vård, vad Resultat: Här redovisas nuvarande insamlade 16 patienter. Medel-
är säker vård, var ska vi sätta gränserna? Detta kräver samarbete mellan ålder 40 år, medel BMI 38; 33–49 (medel 107; 82–136kg). Medel- många medicinska discipliner men också med paramedicinare och per- operationstid 77 minuter och anestesitid 143 minuter. AHI medel 1,6; soner med kompetens inom sjukförsäkring, kommun och social ser- 0–9,5/h. ODI medel 3,8; 0–22,7/h. Medel SpO2 93; 88–97 %, Lägsta vice. Dessa patienter kräver inte sällan IVA-vård i samband med akut SpO2 87; 79–94 %. Längsta hypo/apne var knappt 2 minuter.
försämring eller svikt i assistanshjälp. Vi ställs också inför frågor kring värdegrund, etik och hur man bäst ska utnyttja vårdens resurser. Materials and methods: After ethical approval, adult patients were
included into this prospective non-randomized observational study at their first visit to a sleep clinic. The patients answered the STOP-Bang screening questionnaire and underwent a portable polysomnography (PSG). Data are presented as mean ± SD for continous variables and median and range for categorical variables.
Results: 203 patients with a mean age of 55 years, BMI of 30,5 and
56% male were included. 89 % of the patients were positive at STOP Bang and the median STOP-Bang score was 4 (3-6). An apnea hy- popnea index (AHI) of >5 and >15 defining mild and moderate/severe OSA was seen in 72% and 41% of the patients, respectively. The mean AHI was 20 ± 22, oxygen desaturation index (ODI) 20 ± 20. There was a good correlation between the STOP Bang score and AHI. Conclusions: The STOP BANG screening questionnaire might be a
useful screening tool in the sleep clinic. (ST­projekt)
Tisdag 22/9 kl 13:45–14:45

Moderatorer: Anil Gupta, Mikael Bodelsson
Hemodynamisk övervakning på IVA
Geisewall K, Håkansson S, Ek M, Oddby E, Jakobsson J. Nationellt respirationscentrum stöttar patienter med trakealkanyl – Öppenvårds- – en systematisk litteraturöversikt
mottagning för andningsstöd i hemmet. Lakartidningen. 2015 Apr 22;112. pii: DD3Y. Swedish. Erik Nyberg, Olof Wall, Maria Cronhjort, Eva Joelsson-Alm
Anestesi/IVA, Södersjukhuset, Stockholm Bakgrund: Hemodynamisk monitorering i syfte att styra vätskeresus-
Evaluation of the STOP Bang questionnaire for
citering hos intensivvårdspatienter har länge varit föremål för studier. OSA in a sleep clinic population
Även om det i Surviving Sepsis Campaign rekommenderas hemo- dynamisk övervakning vid sepsis1 så har värdet av detta ej tydligt kun- Eva Christensson1, Karl Franklin2, Carin Sahlin3, Eva Lindberg4,
nat visas i randomiserade studier. Tidigare stora studier på området har Malin Jonsson Fagerlund1
ofta undersökt hemodynamisk monitorering på akutrummet och inte i IVA miljö, och har dessutom haft motstridiga resultat2,3. Syftet med 1Dept of Anesthesiology, Surgical Services and Intensive Care Medicine. denna systematiska litteraturöversikt var att undersöka om en struktu- Karolinska University Hospital and Dept of Physiology and Pharmacolo- rerad algoritm för vätskeersättning – styrd av hemodynamisk övervak- gy, Section for Anesthesiology and Intensive Care, Karolinska Institutet, ning – kan minska mortalitet under och efter intensivvård. Stockholm. 2Department of Surgical and Perioperative Sciences, Umeå University, Umeå. 3Department of Public Heath and Clinical Medicine, Metod: Vi följde Cochrane Handbook of Systematic Reviews. Artikel-
Umeå University, Umeå. 4Department of Medical Sciences, Lung- sökning har skett i PubMed, Embase samt i Cochrane Central Register allergy- and sleep research, Uppsala University of Controlled Trials. Inklusionskriterier: Randomiserade kontrollerade studier (RCT)
Background: Although obstructive sleep apnea (OSA) is common
and associated with several co-morbidities, most of the patients are av vuxna patienter på IVA där algoritmer för vätskeersättning styrda undiagnosed. Current screening tools are quite unspecific and the gol- av hemo dynamisk övervakning har studerats. Hemodynamisk över- den standard methodology for diagnosis, polysomnography (PSG), vakning definierades som minst ett av följande: mätning av hjärtmi- is expensive and time consuming, thus not suitable for screening. In nutvolym (CO), slagvolym (SV) slagvolymsvariation, syrgasleverans perioperative medicine the STOP Bang screening questionnaire is cur- (DO2), centralvenös oxygenering (ScvO2) eller mixad venös oxygene- rently the recomended screening tool, however this questionnaire has ring (SvO2). Studierna skall ha haft en kontrollgrupp utan hemodyna- only been evaluated in a very limited numbers of sleep clinic patients. misk övervakning. Studier där interventionen inletts innan patienten The STOP Bang questionnaire includes eight yes or no questions and befunnit sig på IVA exkluderades. Studierna har haft mortalitet som yes to more than three items merits a positive result.
utfallsvariabel. Resultat: Litteratursökningen resulterade i 403 träffar på PubMed
Aim: Does the STOP Bang score correlate to OSA diagnosis at a sleep
samt 113 träffar på Embase. Av dessa artiklar gick sedan 14 vidare till en första analys och av dessa kunde 5 studier inkluderas med de valda inklusionskriterierna. Två av dessa artiklar ströks sedan på grund av bristande kvalitet. De preliminära resultaten visar inte på någon skill- Modulation of expiratory diaphragmatic contrac-
nad i mortalitet mellan grupperna. Slutgiltiga resultat kommer att pre- tion preserve injured lung from end-expiratory
senteras under SFAI-veckan 2015.
collapse: experimental study.
Diskussion: Resultaten från denna litteraturgenomgång kommer tro-
ligen inte att visa någon skillnad mellan hemodynamiskt styrda pro- Mariangela Pellegrini1,2, Göran Hedenstierna3, Agneta Roneus1,
tokoll för vätskeresuscitering jämfört med konventionell vätsketerapi. Monica Segelsjö4, Anders Larsson1, Gaetano Perchiazzi1,2
Endast ett fåtal studier av tillräckligt god kvalitet kunde hittas, vilket talar för ett behov av flera, stora randomiserade studier i ämnet. 1Hedenstierna Laboratory – Department of Surgical Sciences, Uppsala University, Uppsala, Sweden, 2Department of Emergency and Organ Transplant, Bari University, Bari, Italy, 3Hedenstierna Laboratory – 1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach, Opal SM, Department of Medical Sciences, Uppsala University, Uppsala, Sweden. et al. Surviving Sepsis Campaign: international guidelines for ma- 4Section of Radiology, Department of Surgical Sciences,Uppsala nagement of severe sepsis and septic shock: 2012 Crit Care Med.
University, Uppsala, Sweden 2. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, et al. Early Introduction: The diaphragm interacts with the respiratory system
goal-directed therapy in the treatment of sepsis and septic shock. N also during expiration. We hypothesized a modulation of the expirato- Engl J Med. 2001;345:1368-77.
ry diaphragmatic tone aiming at counteracting the end-expiratory lung 3. ARISE-investigators, Goal-directed resuscitation for patients with collapse during spontaneous breathing (SB). We studied this hypothe- early septic shock. N Engl J Med. 2014;371:1496-506.
sis by exploring the relation between the expiratory electrical diaphrag- matic activity (EAdi ), the trans-diaphragmatic pressure (Pdi ) and the consequent variation of expiratory volume (Vol ) in a model of acute respiratory failure. Novel capnodynamic method for assessment
Methods: Mild acute respiratory distress syndrome (PaO /FiO of
of effective lung volume in intubated patients
250 mmHg) was induced in 7 anesthetized, tracheostomized pigs by repeated lung lavages. The animals underwent to either SB and mus- Tomas Öhman
cle-relaxed controlled ventilation (MV).
In both ventilatory conditions, a decremental sequence of contin- ANOPIVA, Karolinska Universitetssjukhuset, Solna uous positive airway pressure (CPAP/PEEP) was applied from 15 to 0 cmH O, in steps of 3 cmH O. For each studied PEEP/CPAP level, Introduction: Effective lung volume (ELV) equals the volume that
EAdi and Pdi were measured and their correlation was tested. The participates in gas exchange. ELV can be calculated continuously in Vol at 50% and 75% of expiratory time were also estimated. a capnodynamic equation and has been shown in animals to cor- relate well with functional residual capacity (FRC) using various ref- Results: When CPAP was decreased during SB conditions, EAdiexp
erence methods. The aim of the current pilot study is to evaluate the increased until a CPAP of 9 cmH O and then remained unaltered (al- ELV-method in mechanically ventilated patients. though elevated) with further decrease in CPAP. EAdiexp and Pdiexp were tightly correlated as confirmed by an R2>0.82 (p<0.01). Lung Method: A cyclic sequence of breaths with either inspiratory or expi-
volumes were comparable during SB and MV when exposed to the ratory holds alternated with normal breaths induces periodic changes same CPAP/PEEP levels. Comparing the same CPAP/PEEP level, the in alveolar concentration of carbon dioxide. By integrating these varia- Volexp at 50% and at 75% of expiratory time were higher during SB tions into the capnodynamic equation, ELV is calculated.
than during CMV, indicating a delayed emptying of the lungs in SB Effective lung volume will be measured in 30 healthy patients in- tubated and mechanically ventilated for surgery. ELV is measured in PEEP steps 0, 10 and 5 cmH O. A reference method measuring FRC Conclusions: We demonstrated that the diaphragm has a braking ef-
using a partial nitrogen wash in/out technique is used to get paired data fect during the whole expiration, preserving lung patency during SB in at 0 and 5 PEEP. lungs otherwise prone to collapse. The possibility of monitoring expi- ratory EAdi can be the base for titrating CPAP in SB subjects undergo- Results: ELV changes significantly in response to changes in PEEP
ing mechanical ventilation. from 0 to 10 and finaly 5 PEEP in both breathing patterns. The cor- responding mean values of inspiratory group ELV were 1500, 2268 Grant acknowledgment: The School of Anesthesia and Intensive
and 2074 mL respectively. Four-quadrant plot for the inspiratory hold Care of Medicine, Bari University, Italy; The Swedish Heart and Lung breathing pattern showed a concordance rate of 92 %.
Conclusion: For both breathing patterns, changes in PEEP levels
resulted in expected variations in ELV. The inspiratory holds pattern showed superior trending capabilities as compared to the expiratory hold pattern. In absolute values the ELV method overestimates lung volumes in comparison with the FRC method in both breathing pat- terns, most notably in the expiratory hold group.
Hepcidin-25; en dynamisk markör vid intensivvård
In-hospital versus 30-day mortality in the
av septisk chock
critically ill – a 2-year Swedish intensive care
Christina Persson4 ST-läkare, Jon Olinder1 specialistläkare, Cecilia
Rydén1 docent, överläkare, Daniel Ehinger2 och Erik Liljenborg2
Kristina Rydenfelt , Lars Engerström , Sten Walther , Folke
med.kand., Dick Nelson3, Anders Schmidt4 med.dr., överläkare
Sjöberg , Ulf Strömberg , Carolina Samuelsson
1Infektionskliniken, Helsingborg, 2Lunds Universitet, 3Laboratoriemedi- Avdeling för anestesiologi, Universitetssykehus, Rikshospitalet, Oslo, Norge cin, 4Anestesi-och intensivvård, Helsingborg. Background: Standardised mortality ratio (SMR) is a common quali-
ty indicator in critical care and is the ratio between observed mortality Introduktion: Svår sepsis/septisk chock är livshotande tillstånd som
and expected mortality. trots modern intensivvård har hög mortalitet (ca 20 %). CRP och PCT Typically, in-hospital mortality is used to derive SMR, but the use of är biomarkörer som används för att monitorera sjukdomsförlopp, be- a time-fixed, more objective, endpoint has been advocated. This study handlingseffekt, komplikationer samt som beslutsstöd för att avgöra aimed to determine the relationship between in-hospital mortality and behandlingstid med antibiotika. CRP har långsammare kinetik än 30-day mortality on a comprehensive Swedish intensive care cohort.
PCT, men PCT anses ha en starkare association till bakteriell infektion.
Hep-25 är en akutfasreaktant som uppregleras vid inflammation och Methods: A retrospective study on patients >15 years-old, from the
infektion vilket leder till sänkta järnnivåer i blodet. Ret-MCH påverkas Swedish Intensive Care Register (SIR), where intensive care unit (ICU) vid svår sepsis/septisk chock då järnnivåerna i blodet är låga. Tidigare admissions in 2009-2010 were matched with the corresponding hospi- studier har visat förhöjda Hep-25 nivåer vid bakteriella infektioner så- tal admissions in the Swedish Hospital Discharge Register. Recalibrat- som pneumoni, neonatal infektion men även vid hepatit, HIV och ma- ed SAPS (Simplified Acute Physiology Score) 3 models were developed laria. Studiesyftet var att jämföra Hep-25, Ret-MCH, CRP och PCT to predict and compare in-hospital and 30-day mortality. SMR based hos patienter med svår sepsis/septisk chock.
on in-hospital mortality and on 30-day mortality were compared be- tween ICUs and between groups with different case-mixes, discharge Metod: Femton patienter, med IVA-krävande svår sepsis/septisk chock
destinations and length of hospital stays. som vistats på sjukhus < 24 h inkluderades i pilotstudien vid Helsing- borgs lasarett. Under 7 dygn togs studieprover, rutinprover samt daglig Results: Sixty-five ICUs with 48861 patients, of which 35610 were
SOFA (Sequential Organ Failure Assesment) bedömning. Patienter SAPS 3 scored, were included. Thirty-day mortality (17%) was higher ≤18 år, de som nyligen genomgått operativt ingrepp, eller erhållit blod- than in-hospital mortality (14%). The SMR based on 30-day mor- transfusion (<7 dagar) exkluderades.
tality and that based on in-hospital mortality differed significantly in 7/53 ICUs, for patients with sepsis, for elective surgery-admissions and Resultat: Hep-25, CRP och PCT nivåerna var kraftigt förhöjda vid
in groups categorised according to discharge destination and hospital inklusion och sjönk under studietiden. Hep-25 och PCT uppvisade likartat mönster och sjönk 24 h före CRP-förändringen (Fig.1). Vid icke-septisk komplikation steg Hep-25 1–2 dygn tidigare än CRP, Conclusion: Choice of mortality end-point influences SMR. The ex-
medan PCT-värdena inte påverkades utan fortsatte att sjunka (Fig.2). tent of the influence depends on hospital-, ICU- and patient cohort SOFA score vid intagning 10,0 (5.0,11.0) och 11 (8.0,14.3) efter 1 characteristics as well as inter-hospital transfer rates, since all these fac- dygn. Ret-MCH fungerar inte för monitorering av sjukdomsförloppet tors influence the difference between SMR based on 30-day mortality p.g.a. sin långsammare dynamik.
and SMR based on in-hospital mortality.
Konklusion: I denna hypotesgenererande pilotstudie på 15 patienter
med intensivvårdskrävande svår sepsis/septisk chock uppvisade Hepci- din-25 (Hep-25) snabbare dynamik efter insatt antibiotikabehandling jämfört med C-reaktivt protein (CRP), men med likartat mönster som ICU admittance, is it influenced by patient
procalcitonin (PCT). Patienter med komplikation efter den initiala förbättringen uppvisade stigande Hep-25 nivåer ett dygn tidigare än CRP, medan PCT nivåerna inte ökade. Reticulocyt-MCH (Ret-MCH) Zettersten, Larsson, Jäderling, Ohlsson, Bell
sjönk initialt med långsam normalisering under de 7 studiedygnen. Resultaten ligger till grund för en större studie inkluderande såväl in- ANOPIVA, Karolinska Universitetssjukhuset, Solna tensivvårdskrävande sepsis som andra IVA-krävande tillstånd. Introduction: We assume that critically ill patients are admitted to an
Fig. 1. Indexerade värden av biomarkörer under 7 dagars studietid. In- intensive care unit (ICU) based on their present illness severity coupled komstvärde = 100 % för 15 patienter. with their age and co-morbidities. Evidence-based clinical judgment Fig. 2. Hepcidin-25 i jämförelse med CRP hos en patient med icke-septisk komplikation.
and objective practice parameters derived from solid research hopefully result in sound clinical decisions. Patient attributes such as religion, na- tionality, socioeconomic class or gender are not relevant in this setting. Objectives: To explore the association of patient gender with admis-
sion to the ICU amongst hospital physicians working in Sweden.
Methods: Two different versions of an online survey, with eight pa-
tient cases, were sent to physicians in Sweden who within their field of specialty meet patients that could be eligible for intensive care. The Method: A systematic literature review and needs analysis was con-
versions of the survey were identical except that the patient gender in ducted to define the basis of the ultrasound educational program. each case was exchanged between the two surveys. Depending on the An already existing two-day course in point of care ultrasound at our respondent's birthday (odd or even number) they were directed to one department was extended and adjusted to fulfill the requirements of of the two surveys. At the end of each case the respondent was asked to CCUS and basic level of CCE. An e-based logbook was created, fa- answer if they thought that the patient needed ICU care, yes or no. The cilitating the documentation of sonographic examinations. All faculty respondents were not told in advance about the design of the survey. supervisors are intensive care physicians with extensive experience in The respondents were also asked to state their age, sex, field of specialty, focused sonographic examinations. size of hospital and title.
Results: The curriculum was adopted from international guidelines.
Results: Of 1426 respondents, 679 and 747 answered survey 1 and
It consists of an introduction course with 10h of didactics and 8h of 2, respectively. Overall, there were no significant differences in willing- hands-on sessions on healthy volunteers. The course curriculum is or- ness to admit in between cases describing a man or woman in the phy- gan system-based, covering basic ultrasound physics, knobology and sician responses. We found statistically significant differences in five image acquisition and interpretation. The course includes basic critical out of eight cases when Anesthesiology/intensive care physicians were care echocardiography, lung and pleural ultrasound, hemodynamic as- tested versus all other specialties. In those five cases the former group sessment and abdominal ultrasound including aorta and eFAST. chooses to admit more patients to the ICU. Female physicians tended Furthermore, participants receive continuous teaching in combi- to be more willing to admit patients, regardless of patient gender, than nation with lectures, bedside demonstrations and case presentations their male counterparts.
supervised by an experienced intensivist. Finally 30 adequately per- formed CCE and 20 CCUS in critically ill patients must be assessed Conclusions: Using a survey, with eight cases only differing with re-
and discussed in their clinical context with a faculty supervisor before gards to the gender of the patient, we could not find gender bias among Swedish hospital physicians. We demonstrated that anesthesiologists/ The program is voluntary and available to both residents in training intensivist were more likely to recommend ICU admission as com- and specialists in anesthesia and intensive care. pared to other specialists. Female physicians also tended to admit more patients than their male counterparts. Performance and user evaluation of a novel
capacitance-based automatic urinometer
compared with a manual standard urinometer
after elective cardiac surgery.
Tisdag 22/9 kl 13:45–14:45
Eklund A, Slettengren M, van der Linden J
Moderatorer: Mattias Schindele, Olof Ekre
Thoraxkliniken/Dep. Cardiothoracic Surgery & Anesthesiology Karolinska institutet, Karolinska Univ. hospital Critical care ultrasound- implementing interna-
tional guidelines into clinical practice.
Introduction: In the intensive care setting, most physiologic parame-
ters are monitored automatically. However, urine output (UO) is still monitored hourly by manually handled urinometers. In this study, we B. Arnason, P. Sigurjonsson, P. Rudberg, J. Elzen, J. Nordstrom,
evaluated an automatic urinometer (AU) and compared it with a man- M. Eriksson, E. Larsson, N. Jonsson, L. Bergenzaun
ual urinometer (MU).
Karolinska University Hospital, Anaesthesiology and Intensive Care, Methods: This prospective study was carried out in the intensive care
unit of a cardiothoracic surgical clinic. In postoperative patients (n = 34) with indwelling urinary catheters and an expected stay of 24 hours or Background: Meticulous assessment and critical decision-making are
more, hourly UO samples were measured with an AU (Sippi, n = 220; essential to decrease morbidity and mortality and to improve perfor- Observe Medical, Gothenburg, Sweden) or an MU (UnoMeter™ 500, mance in intensive care medicine. In recent years, point of care ultra- n = 188; Unomedical, Birkerød, Denmark) and thereafter validat- sound (PoCUS) has become an invaluable tool in the clinical evalu- ed by cylinder measurements. Malposition of the instrument at the ation of the critically ill. Recent international guidelines, stress that time of reading excluded measurement. Data were analyzed with the intensive care physicians, should be competent in critical care ultraso- Bland-Altman method. The performance of the MU was used as the nography (CCUS) and critical care echocardiography (CCE). Ensur- minimum criterion of acceptance when the AU was evaluated. The loss ing a high level of quality in CCUS and adherence to good governance of precision with the MU due to temporal deviation from fixed hourly principles is an ongoing challenge. An implementation of CCUS in measurements was recorded (n = 108). A questionnaire filled out by clinical practice requires appropriate education, credentialing, quality the ward staff (n = 28) was used to evaluate the ease of use of the AU control, continuing education and clinical governance. compared with the MU.
Purpose: The purpose of this study was to create and plan to imple-
Results: Bland-Altman analysis showed a smaller mean bias for the
ment an educational program in CCUS and basic level of CCE, in AU (+1.9 ml) compared with the MU (+5.3 ml) (P <0.0001). There accordance with international recommendations of structured ultra- was no statistical difference in measurement precision between the sound curriculum models, in the Department of Anesthesia and Inten- two urinometers, as defined by their limits of agreement (±15.2 ml vs. sive Care at Karolinska University Hospital. ±16.6 ml, P = 0.11). The mean temporal variation with the MU was ±7.4 minutes (±12.4%), and the limits of agreement were ±23.9 min- utes (±39.8%), compared with no temporal variation with the AU Uppföljning efter operation och anestesi ett led
(P <0.0001). The ward staff considered the AU easy to learn to use and i förbättringsarbetet och ett sätt att öka patient-
rated it higher than the MU (P <0.0001).
medverkan i vården (PROM och PREM).
Conclusions: The AU was not inferior to the MU and was signifi-
cantly better in terms of bias, temporal deviation and staff opinion, Pether Jildenstål PhD, Metha Brattwall, Överläkare, PhD,
although the clinical relevance of these findings may be open to dis- Margareta Warren-Stomberg PhD, Irene Sellbrant Överläkare,
Jan G. Jakobsson Överläkare Adj.Professor.
Institutionen för vårdvetenskap och hälsa, Sahlgrenska akademin vid Ökad patientsäkerhet vid utskrivning IVA
Introduktion: Intresset för olika former av telemedicn ökar (1). Inom
– ett led i att minska återinläggningar inom 72 h
anestesi/kirurgi har denna teknik inte utnyttjats som inom hälsobe- främjande enheter såsom rökning, motion/vikt och kroniska sjukdo- Erlandsson E, specialistsjuksköterska IVA och Agvald-Öhman C.
mar t.ex. diabetes (2, 3). Dagkirurgiska enheter genomför idag alltmer Överläkare, MD PhD
komplicerad kirurgi. Att kunna göra postoperativ uppföljning på ett enkelt sätt efterfrågas till exempel av SPOR, och telemedicin har börjat Karolinska Universitetssjukhuset Huddinge IVA sin entré även inom detta område (3,4,5).
Syftet med dessa pilotstudier var att utvärdera följsamheten till en Bakgrund: På Karolinska Huddinge IVA B46 har de senaste åren re-
telemedicinsk uppföljning med en "app" efter dag/korttidskirurgi samt sultaten för SIR:s (Svenska Intensivvårdsregistret) kvalitetsindikator att kartlägga vilken uppföljningsmetod patienten föredrar. "Åter in inom 72 timmar" försämrats. Metod: En prospektiv pilotstudie gjordes under 2014 vid dagkirur-
Metod: I samarbete med QRC (Kvalitetsregistercentrum Stockholm)
gienheten Mölndal Sahlgrenska universitetssjukhuset i Göteborg. och SIR genomfördes ett projekt där en medlem i teamet fick gå en Uppföljning skedde under 8 dagar med maximalt 15 registreringar via coachingutbildning på TDI (The Dartmouth Institute). Den bestod av patientens mobiltelefon och 1 SMS påminnelse om inte registrering sammanlagt sex sessioner varav en var fyra dagar på plats i Dartmouth, skett vid angiven tidpunkt 09.00 och 21.00. 98 patienter som genom- USA. TDI arbetar med en validerad metod för förbättringsarbete i gått ortopedisk dagkirurgi inkluderades. I en kompletterande pilotstu- team och den användes under projektet.
die tillfrågades 90 patienter, i åldrarna 18–40, 41–60 och mer än 60 Teamet har haft en stående mötestid varje vecka samt haft två hel- år i samband med operationstillfället om de föredrog att besvara frågor dagsmöten. Verksamheten kartlades enligt "5 P-metoden". Data togs kring återhämtning efter operationen, via "app", web-enkät eller via en fram, från SIR och ur patiendatasystemet Clinisoft, om vilka patient- diagnoser och avdelningar som var överrepresenterade bland de tidiga återinläggningarna. Ett fiskbensdiagram skapades för att visualisera de Resultat: Följsamhet att besvara frågor via app var låg. Totalt använde
faktorer som påverkar återinläggningar inom 72 h.
29/55 (53%) patienter app mer än 13ggr /15 möjliga. Äldre patienter svarade mindre frekvent. Det fanns också en åldersskillnad i önskemål Resultat: En processkarta av utskrivningsprocessen gjordes för att un-
om teknik för postoperativ uppföljning, där yngre var mer benägna derlätta identifieringen av potentiella förbättringsområden i processen. föredra app och äldre hellre såg en konventionell pappersenkät. Totalt Tre förbättringsområden identifierades.
valde 35/90 app, 27/90 web och 21/90 pappersenkät och totalt 5 svar- Genom att arbeta med dessa tre förbättringsområden förväntar vi oss stillfällen accepterades av 46/90. att öka patientsäkerheten i övergången mellan IVA och vårdavdelning.
• Förbättringsidé 1: En journalgranskning av läkarepikriser gjor- Konklusion: Den acceptans för postoperativ uppföljning som fram-
des för baslinjedata. En rekommendationsmall utarbetades och kom överensstämmer inte helt med den kliniska pilotstudien via app för postoperativ uppföljning, där svarsbortfallet var stort. Uppföljning • Förbättringsidé 2: Ingen rutin fanns för att skriva omvårdnads och återkoppling kring återhämtning, vårdkvalitet och effekter på hälsa -rekommendationer. En mall för detta togs fram.
via telemedicin behöver utvecklas och bättre /enklare tekniker behö- • Förbättringsidé 3: Bedside rapportering av undersköterska inför ver tas fram. Ytterligare studier av hur vi bäst kan få återkoppling – överflyttning till vårdavdelning.
PROM- och PREM-uppföljning efter dagkirurgi planeras.
Samtliga tre förbättringsidéer bygger på varandra. Det är ett åtgärds- paket för en säkrare utskrivning av patienten från IVA. För att under- 1. Whittaker R. Issues in mHealth: findings from key informant in- lätta stegen i rapporteringsprocessen gjordes ett flödesdiagram som ska terviews. J Med Internet Res. 2012;14(5):e129.
fungera som lathund för personalen vid utskrivning.
2. Free C, Knight R, Robertson S, Whittaker R, Edwards P, Zhou W, Rodgers A, Cairns J, Kenward MG, Roberts I. Smoking cessation Konklusion: Det tar tid att förändra och ffa att behålla en förbätt-
support delivered via mobile phone text messaging (txt2stop): a ring över tid. Framtida projekt kommer att skapas för att nå slutmålet. single-blind, randomised trial. Lancet. 2011 Jul 2;378(9785):49– Teamets har lärt sig en strukturerad metod som kommer att ligga som grund för dessa projekt och även andra kvalitetsprojekt på avdelningen.
3. WilmoreDW, Kehlet H. Management of patients in fast tracksur- gery. BMJ. 2001 Feb 24;322(7284):473–6.
4. Armstrong KA, SempleJL, Coyte PC. Replacing ambulatory surgi- cal follow-up visits with mobile app home monitoring: modelling cost-effective scenarios. J Med Internet Res. 2014;16(9):e213.
5. Semple, JL Sharpe S, Murnaghan ML, Theodoropoulos J, Metcalfe AK, Using a Mobile App for Monitoring Post-Operative Quality of Ny perkutan trakeotomiteknik – erfarenheter från
Recoveryof Patients at Home: A Feasibility Study JMIRMhealth- Uhealth. 2015 Jan-Mar; 3(1): e18.
Johan Ullman, MD, Ph.D., Dept. of Anesthesiology and Intensive care,
Karolinska University Hospital, Stockholm, Sweden Jonas Karling, SLP, Ph.D., Karolinska Institute, Stockholm, Sweden
30-dagars reklamation på din operation/anestesi!
Gregory Margolin, MD, Ph.D., Dept. of Otolaryngology and Head
Hur vill patienterna att vi följer deras återhämt-
& Neck Surgery and Dept. of Oncology, Karolinska University Hospital, Stockholm, Sweden Irene Sellbrant, Pether Jildenstål, Agnetha Folestad, Jan G Jakobsson
Perkutan trakeotomi har blivit en rutinteknik för elektiv trakeotomi. I Sverige utförs c:a 1000 st trakeotomier per år varav c:a 50% utförs Anestesikliniken, Capio Lundby Närsjukhus, Göteborg perkutant. Man har rapporterat komplikationer med perkutana dila- tationstrakeotomier (PDT). De allvarligaste har varit blödning, pneu- Bakgrund: Antalet ingrepp som utförs i dagkirurgi i Sverige ökar.
mothorax och trakealväggsskador (1). Ett genomgående problem har Dagkirurgi medför att större delen av den postoperativa vården sker varit att punktionen i trakea inte kunnat styras och säkerställas tredi- som "egenvård". Det ställer krav på vårdgivaren att följa upp och få en återkoppling på utförd vård som en del av kvalitetsprocessen. Uppfölj- För att vara säker på att penetrationen är framgångsrik kontrolleras ningen skall belysa såväl avvikelser/komplikationer, subjektiva besvär den normalt fiberoptiskt. Endotrakealtuben måste dras tillbaka med samt patients upplevelse av vården, "Patient ReportedOutcomeMea- risk för extubation.
sures" PROM.
Vi har utvecklat en metod för att göra säkra PDT även i svåra ana- Syftet med detta kvalitetsarbete var att 30 dagar postoperativt få en uppfattning om patientnöjdhet med vården, patienternas önskan om SafeTrachtekniken eliminerar svagheterna med traditionella PDT:s. uppföljningssätt samt resursåtgången för uppföljning med telefonin- SafeTrach är ett tångliknande instrument för säker bestämning av ni- vån på trakeotomin och som leder en punktionsnål två-dimensionellt mot, och med skydd av, en inre skänkel.
Metod: Ett prospektiv kvalitetsprojekt gjordes mars-maj 2015 vid
SafeTrach erbjuder en intuitiv teknik som hjälper läkaren att pene- dagkirurgiska enheten på Capio Lundby Närsjukhus i Göteborg. Upp- trera trakea utan övervakning av ett bronkoskop. Förhållandet mellan följningen skedde med telefonsamtal 30 dagar postoperativt. Femtio den inre skänkeln och den endo-trakeala tuben ger ett klart mått på patienter som genomgått 5 olika ingrepp, 10 stycken av vardera till- hur långt nedanför stämbanden punktionsplatsen är. Den inre skän- frågades preoperativt om att bli uppringda. De uppdelades sedan i 3 keln ligger alltid i mitten av luftstrupen varför punktionen genom yttre ålders grupper, 17–40, 41–65 samt >65 år. Patientdemografi; kön, ASA, skänkeln garanterar en ingång i mittlinjen. Det är omöjligt att gå för BMI, rökning registrerades.
djupt eller att hamna utanför luftstrupen. Dilatationen utförs med pa- Frågorna bestod av en PROM (EQ-5d) samt en PREM (Patient-re- tienten ventilerad hela tiden.
ported experience-measure) del. Antal uppringningsförsök samt sam- talstiden registrerades. Brytpunkt för "ej nådda" sattes till 40 dagar Metoder: Vi har just nu en pågående klinisk studie och 12 patienter
är trakeotomerade med hjälp av SafeTrach för punktionen och med Ciaglia Blue Rhino-tekniken för dilatationen. Patienterna var huvud- Resultat: De flesta patienterna (92%) kunde nås per telefon innan
och halspatienter som skulle opereras med fria lambåer till munhålan. "brytpunkt". Det krävdes i genomsnitt 2,6 uppringningsförsök/per- Dessa behöver trakeotomeras för att säkra fria andningsvägar posto- son. Det behövdes 1 samtal mer/person i den yngsta åldersgruppen vs. perativt. Patienterna representerade olika typer av halsanatomier där den äldsta. Genomsnittlig samtalstid var 15,9 minuter. I alla 3 ålders- 7 patienters cricoidbrosk och trakela ringar var svåra att identifiera grupperna föredrog patienterna att bli uppringda av vårdgivaren för genom palpation. uppföljning (17–40 år 79%, 41–65 år 88%, >65 år 100%). Enstaka Resultat och slutsatser
patienter föredrog mail, eller pappersenkät. Ingen av de tillfrågade öns- : Studien visade att penetrationsdelen av kade svara via "app". Många patienter uttryckte stor glädje över att trakeotomin var snabbt och säkert utförd trots olika anatomiska svårig- vårdgivaren brydde sig om att ringa dem och dessutom få möjlighet att heter. Tiden för förfarandet var jämförelsevis kort utan hypoxi eller själva ställa frågor. Vårdgivaren fick återkoppling i form av EQ-5d för alla 5 ingreppen. En rad förbättringssynpunkter framkom, t.ex. bättre information vid utskrivningen. 1. Percutaneous tracheostomy. Contin Educ Anaesth Crit Care Pain (2014) 14 (6): 268-272.
Konklusion: Vi fann en stor patientnöjdhet med 30-dagars telefon-
uppföljning. Resursåtgången för vårdgivaren är dock inte försumbar 2,6 uppringningsförsök/patient och varje samtal tar i genomsnitt 15,9 min. Bästa återkopplingen för vårdgivaren är när EQ-5d kan jämföras med preoperativa svar. Vidare studier planers.
2. van Boxel GI, Hart M, Kiszely A, Appleton S. Elective day-case lapa- roscopic cholecystectomy: a formal assessment of the need for out- patient follow-up. Ann R Coll Surg Engl. 2013 Nov;95(8):e142-6.
Närståendes tillfredställelse med intensivvård
Fria föredrag 1
ANOPIVA, Karolinska Universitetssjukhuset, Solna Måndag 21/9 kl 14:00–15:30
Bakgrund: För att kunna erbjuda vård av god kvalitet är det viktigt
Lokal: 27
patienternas erfarenheter av hälso- och sjukvården efterfrågas och till- varatas. Kritiskt sjuka patienter minns sällan intensivvården, vilket Moderatorer: Sven-Erik Ricksten, Olaf Rooyackers
försvårar mätning av patienttillfredsställelse. En enkät som tillvaratar närståendes upplevelser, kan ge en indikation på hur bemötande och Evaluation of a capnodynamic method for monito-
delaktighet inom intensivvården fungerar. ring effective pulmonary blood flow in a ischemic
and reperfusion porcine model
Syfte: Att utveckla en enkät för att mäta närståendes tillfredställelse
med intensivvård, utvärdera dess tillförlitlighet samt testa den kliniska Thorir Sigmundsson1,2, Caroline Hällsjö Sander1,2, Tomas
Öhman1, Magnus Hällbäck3, Håkan Björne1,2
Metod: Utifrån internationella enkäter valdes frågor som var använd-
bara för svenska förhållanden ut, och sammanställdes till en ny enkät. 1Department of Anaesthesiology, Surgical Services and Intensive Care Innehållet utvärderades av en expertpanel. Användbarheten testades Medicine, Karolinska University Hospital, Solna, Sweden, 2Department sedan genom "Think aloud"-intervjuer med tolv närstående till nyli- of Physiology and Pharmacology, Karolinska Institutet, Stockholm, gen utskrivna patienter från två intensivvårdsavdelningar. Den slutliga Sweden, 3Maquet Critical Care AB, Solna, Sweden enkäten bestod av 21 flervalsfrågor, samt fyra öppna frågor. Svarsalter- nativen angavs i en fyragradig skala, mycket nöjd (1,0p), nöjd (0,75p), Introduction: A capnodynamic equation can be used to calculate
missnöjd (0,5p), mycket missnöjd (0,25p). Två veckor efter avslutad effective pulmonary blood flow (CO ) i.e. cardiac output (CO) intensivvård skickades enkäten till närstående till patienter som vårdats minus shunt. An ischemic injury with subsequent reperfusion increas- längre än två dygn på CIVA, Karolinska Universitetssjukhuset Solna. es the concentrations of carbon dioxide temporarily, a situation that Resultatet grupperades i fem områden och medelvärden för tillfredstäl- theoretically could affect the agreement of a capnodynamic method.
The aim of the current study was to evaluate the performance of during ischemia and reperfusion in porcine model. Resultat: Under 2014, mottog 156 närstående enkäten, varav 95
(61 %) svarade. De närstående var i allmänhet mycket nöjda med Methods: The required alterations of alveolar concentration of carbon
vården. Främst var de nöjda med "Vård och bemötande av patienten" dioxide are created by a ventilatory pattern containing cyclic reoccur- (medelvärde 0,97p) och "bemötande av närstående" (0,95p). Delar av ring expiratory holds. "Information" (0,91p) och "Intensivvårdsmiljö" (0,82p) bedömdes was compared to a reference method for CO, an ultrasonic ha förbättringspotential. Angående "delaktighet inom intensivvård", flow probe around truncus pulmonalis and a pulmonary artery cathe- upplevde 58 närstående (61 %) missnöje i någon mån, eller frågan ter using three consecutive thermo dilution measurements (N=8). som ej relevant. Slutligen bedömdes "helhetsintrycket" som mycket A 10 Fr Reliant catheter (Medtronic) was placed below the dia- phragm via the femoral artery and inflated until blood flow in the con- tralateral femoral artery was abolished according to ultrasound doppler Slutsats: En enkät för att mäta närståendes tillfredställelse med in-
and released after 30 minutes. Hemodynamic measurements and lac- tensivvård har utvecklats och validerats. Enkäten kan vara användbar tate levels were obtained at baseline before the balloon was inflated genom att synliggöra områden med potential för förbättring.
(BL), at minute 27 and after deflation at minute one, three and five. Results: Lactate at BL was 1.5 mmol/L (1.2–2.4) and peaked at 10.4
mmol/L (7.8–11.4) at minute one after deflation. At BL a Bland Alt- man plot showed bias 0.6 L/min, limits of agreement (LoA) -0.5–0.7 L/min and a percentage error (PE) 27%. At minute five bias was 0.02 L/min, LoA -1.8–1.9 L/min and PE 37%. Discussion: The ischemic model resulted in significant changes in
lactate levels and severe hemodynamic changes. CO agreement at BL but markedly overestimated CO at minute one and three after deflation. Five minutes after deflation CO lished agreement with the reference method. kanalen med efterföljande systemisk inflammatorisk reaktion. Syftet Modified capnodynamic method for continuous
var att skapa en stordjursmodell där effekterna på magtarmkanalens assessment of effective pulmonary blood flow
cirkulation och metabolism av lågt cardiac output (CO) per se och i kombination med vasoaktiva och inotropa läkemedel kan studeras. Caroline Hällsjö Sander1, 2, Thorir Sigmundsson1, 2, Magnus
Metod: Sövda grisar övervakades avseende hemodynamik inklusive
Hallbäck3, Fernando Suarez Sipmann4, 5, Mats Wallin2, 3, Anders
med semi-kontinuerlig CO-mätning. Oldner1, 2, Håkan Björne1, 2
A. mesenterica superior försågs med flödesmätare. Tunntarmsslem- hinnans perfusion mättes med laser Doppler. Blodgaser från a. carotis, 1Department of Anaesthesiology, Surgical Services and Intensive Care a. pulmonalis och v. mesenterica superior analyserades. Metabolismen Medicine, Karolinska University Hospital, Solna, Sweden, 2Department i bukhålan följdes med intraperitoneal mikrodialys.
of Physiology and Pharmacology, Karolinska Institutet, Stockholm, CO sänktes stegvis till 75% (CO ), 50% (CO ) och 35% Sweden, 3Maquet Critical Care AB, Solna, Sweden, 4Department of (CO ) av utgångsvärdet under en timme vardera. Sänkningen skedde Surgical Sciences, Section of Anaesthesiology and Critical Care, Hedensti- antingen via en hjärttamponad (vätska injicerades i perikardiet, n=6), erna's laboratory, Uppsala University, Uppsala, Sweden, 5CIBERES, eller med en ballong i v. cava inferior (n=6). Sex djur var kontroller.
CIBER de enfermedades respiratorias, Instituto Carlos III, Madrid, Resultat: De tre grupperna var lika vid baseline. Både tamponaden
och cavaballongen sänkte CO kontrollerat. Kontrollgruppens CO Introduction: A capnodynamic equation can be used to calculate
förblev oförändrad. Vid CO avled fyra av sex djur i tamponad- effective pulmonary blood flow (CO ) i.e. cardiac output minus gruppen. Medelartärtrycket var bibehållet vid CO i alla grupperna. shunt. The method could be integrated into a standard ventilator and Vid CO sjönk medelartärtrycket till 35±4 mmHg respektive 42±3 provide a continuous non-invasive alternative for estimation of CO mmHg i tamponad- och cavagruppen. Flödet i a. mesenterica superior in intubated mechanically ventilated patients.
sjönk proportionerligt till CO-sänkningen i båda grupperna. Tunn- The aim of the current study was to evaluate if the performance of tarmsslemhinnans perfusion minskade vid CO i tamponadgruppen was improved by a modified breathing pattern. till 71±16% och i cavagruppen till 73±15%, av utgångsvärdet. Meto- derna orsakade jämförbar laktatökning i artär- och mesenterialvens- Methods: Alterations of alveolar concentration of carbon dioxide are
blod. Parallellt steg den intraperitoneala laktatkoncentrationen och a prerequisite to solve the capnodynamic equation and can be accom- laktat/pyruvat-kvoten i bägge grupperna. plished by a predefined ventilatory pattern including a sequence of three breaths with an expiratory hold followed by six normal breaths.
Slutsats: Båda metoderna för att inducera lågt CO är genomförbara
was compared to a reference method for cardiac output, an men cavaballongen upplevs experimentellt enklare. Sänkt CO oavsett ultrasonic flow probe around truncus pulmonalis, in a porcine model. metod medför en snarlikt försämrad cirkulation och metabolism i magtarmkanalen. Denna påverkan ses även vid en mindre CO-sänk- The circulation was altered including preload reduction and inotro- ning med bibehållet medelartärtryck. I våra modeller är en CO-sänk- pic stimulation as well as changes in respiratory conditions with var- ning till ungefär 60% av utgångsvärdet lämplig att använda i fortsatta ied PEEP levels and increased tidal volumes. Agreement and trending läkemedelsstudier för en rimlig balans mellan CO-sänkning, påverkan ability was evaluated using Bland-Altman statistics and four-quadrant på medelartärtrycket och förväntad effekt på magtarmkanalen. plot methodology. Results: The overall agreement for all interventions was good with
bias, limits of agreement (LoA) and percentage error 0.05, (-1.1–1.2) L/min and 36%. The trending ability was good with a concordance Activation of CD137 Promotes Post-operative
Cardiovascular Inflammation in Experimental
with a modified breathing pattern based on ex- piratory holds showed improved overall agreement in absolute values Leif Söderström, Hong Jin, Lars Maegdefessel, Göran K Hansson
compared to our previous animal studies with a ventilatory pattern and Peder Olofsson
based on inspiratory holds. Trending ability was preserved for all he- modynamic and respiratory interventions. Center for Molecular Medicine, Experimental atherosclerosis unit, Karolinska Institutet, Stockholm Perioperative mortality is most commonly caused by cardiovascular di- En stordjursmodell med lågt cardiac output för
sease (CVD) and CVD contributes to perioperative morbidity. Athe- vidare studier av gastrointestinalkanalen
rosclerotic plaques are the main cause of CVD. Plaque rupture, which often occurs during cardiovascular stress, is ultimately responsible for Jenny Seilitz1, Tal Hörer1, Per Skoog1, Birger Axelsson1, Kjell
most clinical symptoms of CVD. There is currently no established cli- Jansson2, Kristofer F. Nilsson1
nical therapy to prevent plaque rupture during excessive stress such as 1Kärl-thoraxkliniken, Universitetssjukhuset Örebro, 2Kirurgiska kliniken, Plaque inflammation is a key factor in plaque rupture. T-cells, mas- Universitetssjukhuset Örebro, Institutionen för hälsovetenskap och medi- ter controllers of plaque inflammation, are regulated by co-stimulatory cin, Örebro Universitet receptors. We recently discovered that CD137, a co-stimulatory re- ceptor of T-cells, promotes development of atherosclerosis (Circulation 2008, Mol Med 2014). Bakgrund: 20% av patienterna efter hjärtkirurgi drabbas av nedsatt
hjärtfunktion. Detta kan orsaka försämrad cirkulation till magtarm- Analysis of CD137 and CD137 ligand mRNA in human clinical- ml, 39.3-114.6 vs. 22.6 ng/ml, 16.1-25.8 p=0.0001). High ISS (>25) ly significant carotid plaques showed increased levels of CD137 and was associated with high plasma-TRX (median, IQR 72.1 ng/ml, CD137 ligand in plaques vs healthy control vessels (7.84 vs 0.51, 45.2-129.3 vs. 47.9 ng/ml, 35.0-81.2 p=0.049). TRX decreased sig- 95%CI 4.35-10.58, p<0.0001; 0.455 vs 0.094, 95%CI 0.627-0.096, nificantly between day 1 and 3 (median, IQR 63.9 ng/ml, 39.3-114.6 p<0.01 respectively). To investigate the effects of CD137 activation, we vs. 38.6 ng/ml, 32.4-57.1 p< 0.0001). There was no significant dif- used a murine model for carotid plaque rupture. CD137 was pharma- ference between survivors and non-survivors in plasma-TRX. Day 1 cologically stimulated by intraperitoneal injections of an agonistic anti- plasma-TRX levels were significantly increased in patients who later CD137 antibody (2A) or control IgG2a. 2A treatment resulted in in- developed severe sepsis compared to those who did not (median, IQR creased inflammation in the abdominal aorta as evidenced by increased 72.9 ng/ml, 44.8-137.3 vs. 49.8 ng/ml, 39.0-78.3 p=0.014).
mRNA levels of inflammatory cytokines in 2A treated mice compared to IgG2a controls (Tnf: 3.567 ±0.4009 vs 2.371 ±0.1685, p=0.0120; Conclusions: TRX levels rise after trauma. Our data suggests that in-
Ifnγ 12.78 ±2.548 vs 3.432 ±0.8907, p=0.0021. n=38). There was no creased plasma TRX levels are associated with post-injury sepsis. The difference in red or white blood cell count between groups. In spleen, potential usefulness of TRX as a biomarker in trauma patients needs cytotoxic CD8+ T-cells increased significantly in 2A treated mice com- further evaluation in larger studies.
pared to controls (50.95 ±1.944 vs 44.04 ±1.868, p=0.015, n=37). Analysis of plaque rupture frequency is currently ongoing. Grant Acknowledgment: ALF-funding through Stockholm County
Taken together, these results show increased levels of CD137 in hu- Council and Karolinska Institutet.
man atherosclerotic plaques and that activation of CD137 promotes vascular inflammation. Further analysis will clarify whether CD137 modulating treatment can impact plaque rupture. Future studies are 1. GBD 2013: Lancet 2015, 385(9963):117-171.
needed to evaluate CD137 interventions in prevention of perioperative 2. Patton GC et al: Lancet 2009, 374(9693):881-892.
3. Soreide K et al: World J of Surg 2007, 31(11):2092-2103.
4. Wafaisade A et al: Crit C Med 2011, 39(4):621-628.
5. Hofer S et al: Crit C Med 2009, 37(7):2155-2159.
6. Callister ME et al: Int C Med 2007, 33(2):364-367 Thioredoxin in Trauma and Post-Injury Sepsis
J. Eriksson1,2, A. Gidlöf1,2, O. Brattström1,2, B. Persson1,2,
Extern validering av en förenklad prediktions-
E. Larsson1,2, A. Oldner1,2
modell för illamående och kräkning efter hem-
Institute(s): gång vid dagkirurgi
1Karolinska Institutet, Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Stockholm, Sweden, 2Karolinska University Hospital, Solna, Anesthesiology, Surgical Services and Intensi- Jakob Walldén1, Jesper Flodin2, Magnus Hultin2.
ve Care, Stockholm, Sweden 1Operationscentrum, Sundsvalls Sjukhus, 2AnOpIVA, Sunderbyns Sjuk- Introduction: Trauma is one of the leading causes of mortality
hus, alla vid Enheten för Anestesi och Intensivvård, Inst för kirurgisk och worldwide, resulting in a great global burden of disability and mortali- peroperativ vetenskap, Umeå Universitet. ty[1, 2]. Approximately half of all trauma deaths occur during the first hours due to traumatic brain injury or massive bleeding. Later deaths Bakgrund: "Post discharge nausea and vomiting" (PDNV) är ett re-
are due to, for example, sepsis or multiple organ failure[3]. Indepen- lativt ouppmärksammat problem som drabbar upp till en tredjedel av dent risk factors for post-injury sepsis are still somewhat poorly defi- patienter som opereras inom dagkirurgi. En förenklad publicerad pre- ned. Injury Severity Score (ISS), male gender, age, low Glasgow Coma diktionsmodell för PDNV inbegriper faktorerna: kvinna, ålder < 50 år, Scale (GCS) at admission and massive blood transfusion have previo- anamnes på PONV, illamående postoperativt och behov av opioider usly been suggested as risk factors[1]. Thioredoxin (TRX) is thought postoperativt (1). Syftet med studien var att göra en oberoende och to have important anti-oxidant properties but it also functions as an extern validering av prediktionsmodellen i ett svenskt material.
endogenous anti-inflammatory mediator[4]. The link between high Metod: Vuxna patienter som genomgick dagkirurgi under generell
plasma levels of TRX and sepsis has been studied previously, although anestesi vid Sunderbyns Sjukhus och Sundsvalls sjukhus inkluderades with conflicting evidence[4, 5]. TRX-levels in trauma patients and the i studien. Postoperativt utvärderades patienterna med fokus på illamå- possible correlation to secondary complications such as post-injury ende, kräkning och smärta vid 2, 4 och 6 timmar efter avslutad kirurgi sepsis have to our knowledge not been studied previously.
samt de följande tre postoperativa dagarna. Poäng i den förenklade pre- Objectives: To study the relationship between trauma and plasma le-
diktionsmodellen beräknades utifrån patientens tillstånd vid hemgång. vels of TRX as well as the possible correlation between post-traumatic Prestanda i prediktionsmodellen utvärderades med diskriminationsför- plasma-TRX and post-injury sepsis.
måga (Arean under the receiver operating characteristic curve, AUC- ROC) och kalibreringskurva och jämfördes med originalstudiens. Methods: ICU-admitted trauma patients with an expected stay of >3
days (n=84) were included. Median ISS was 29. Plasma-TRX was ana- Resultat: 431 patients inkluderades i studien. Den generella inciden-
lyzed on day 1 and 3. Clinical, physiological and outcome data were sen av PONV and PDNV var 18.8% (95% CI, 15.4-22.8) respektive retrieved from the trauma and ICU research registries. In addition, we 28.1% (95% CI, 24.0-32.5). Prediktionsförmågan med den förenk- analyzed plasma-TRX in 10 healthy subjects.
lade modellen för PDNV överensstämde men den i orginalstudien (AUC 0.693 (95% CI, 0.638-0.748) vs. 0.706 (0.681-0.731), abso- Results: A three-fold increase in initial TRX was seen in trauma pa-
lut differens 0.013). Lutningen på kalibreringskurvan (R Square) var tients when compared to healthy volunteers (median, IQR 63.9 ng/ 0.883 med en konstant på 0.021. Slutsats: Den förenklade modellen för att prediktera PDNV har bra
prestanda i ett svenskt material och kan vid dagkirurgi skilja ut pa- Passive leg raise response in normotensive
tienter med ökad risk för illamående och kräkning i hemmet. Våra elderly patients and the effects of subdural block
resultat visar på att modellen är giltig i andra populationer än den i LiDCOplus™ and transthoracic echocardiography
Marcus Brynolf, Sigridur Kalman, Erzsebet Bartha
1. Apfel et al. Who is at risk for postdischarge nausea and vomiting after ambulatory surgery? Anesthesiology. 2012 Sep;117(3):475–86.
AnOpIVA, Karolinska Universitetssjukhuset i Huddinge, CLINTEC, Karolinska Institutet Fria Föredrag 2
Background: Maximization of stroke volume (SV) by fluid challenge,
i.e. the first step of Goal Directed Hemodynamic Treatment, at high age may reduce the SVI. A reversible "self-volume loading" (PLR, pas- Måndag 21/9 kl 16:00–17:30
sive leg raise) might be helpful, but the interpretation and the relevance Lokal: 27
of positive PLR response in per-operative clinical scenarios are unclear. Moderatorer: Christer Svensen, Anders Oldner
Aims: to compare the ability of LiDCOplus™ to follow SV changes
during PLR-test with transthoracic echocardiography (TTE); to esti- Towards individualized perioperative, goal-
mate whether an association between PLR-test responses and post-spi- directed haemodynamic algorithms for patients
nal hypotension exists; and given this estimate to calculate a sample of advanced age
size for a future trial Erzsebet Bartha, Cecilia Arfwedson, Annika Imnell, Sigridur
• Design: observational pilot study (ID: 2013/995-31/3) • Population: patients > 80 years (informed consent), urologic sur- Department of Anesthesia and Intensive care, Karolinska University gery in spinal anesthesia Hospital Huddinge, and Karolinska Institutet, CLINTEC, Stockholm, • Monitors: LiDCOplus™ (calibrated two times); TTE (tracing the velocity time integral in the left ventricular outflow tract).
• Primary outcomes: SV-changes during PLR We report observations on unintended and unexpected effects of goal-di- • Secondary outcomes: PLR responses and post-spinal hypotension rected haemodynamic treatment (GDHT) in patients, operated for • Statistical analyses: distribution, correlation (between methods) emergency repair of hip fracture (ClinicalTrials.gov NCT01141894).
of repeated measurements by mixed effects model; assessment of bias, precision and accuracy by Bland Altman plot and by per- centage error; trending ability by four quadrant plot, association Method: Design: single-centre, open, randomized, and controlled par-
allel-group superiority trial with concealed computer-generated ran- between PLR-related SV-changes and post-spinal hypotension by domization. GDHT: fluid challenges to maximize the stroke volume mixed effects model.
index (SVI); dobutamine to achieve oxygen delivery index (DO I) > Results: Good agreement between TTE and LiDCOplus™ was found:
-1 ∙ m-2. Patients: only those, who were allocated in the GDHT group (age > 70 years); Monitoring: LiDCOplus™. Haemo- > 95% of measurements was within 95%CI of the mean difference.
dynamic outcomes: increase of baseline SVI by ≥ 10% after the first The percentage error was 24%, and the coefficients of variation were fluid challenge; at anaesthesia start; increase or maintenance of baseline 14% (LiDCOplus™) and 18% (TTE); the concordance rate of LiD- DO I at the end of surgery. Clinical outcomes: postoperative compli- COplus™ was 75%. We observed some association between the pattern cations. Independent predictors of the haemodynamic and the clinical of the PLR-related SV changes and the post-spinal hypotension; to outcome were assessed (logistic regression analyses). prove that, we would need a sample size of 80 patients. The positive PLR-test and post-spinal hypotension had very low association, and Results: GDHT/RFT (n = 70/72, mean age 85 years). First fluid chal-
would need a sample size of 450 patients.
lenge responders were 39%. At anaesthesia start (GDHT group re- ceived repeated challenges), the SVI increased in 6% /15% of patients Conclusions: The PLR test at high age might not guide the predic-
(GDHT/RFT). At the end of surgery, the DO2I was maintained or tion of post-spinal hypotension, but the pattern of PLR may still need increased in 47% /30% of patients (GDHT/RFT). Predictors: for first further research. The SV changes during PLR may be detected by LiD- fluid challenge response, the baseline SVI < 28 ml m COplus™ and agree well with TTE.
-2; for post-oper- ative complications, the DO I at the end surgery < 290 ml min-1 m-2. Conclusions: The unintended haemodynamic GDHT effects may be
predicted by haemodynamic characteristics. The DO I at the end of surgery was a predictor of post-operative complications.
Effects of neoadjuvant chemo- or chemoradio-
Optimering av vätskebehandling vid blodförgift-
therapy for esophageal cancer on perioperative
ning med hjälp av passivt benlyftstest
hemodynamics – a prospective cohort study
within a randomized clinical trial
Maria Cronhjort, Magnus Bergman, Eva Joelsson-Alm, Johan
Mårtensson, Mona-Britt Divander, Christer Svensen
Mikael Lunda,*, Jon A Tsaib, Magnus Nilssonb, Lars Lundellb,
ANE/IVA, Södersjukhuset, Stockholm aDepartment of Anaesthesiology and Intensive Care, and Division of Svår sepsis samt septisk chock är svårbehandlade tillstånd inom intensiv- Anaesthesiology, CLINTEC, Karolinska Institutet, Karolinska University vården. Sepsis innebär läckande kärlendotel och försvagad hjärtmuskel. Hospital Huddinge, 141 86 Stockholm, Sweden.bCentre for Digestive Intravenös vätska är därmed en viktig del av behandlingen vid septiska Diseases and Division of Surgery, CLINTEC, Karolinska Institutet, tillstånd. Gällande rekommendationer i "Surviving Sepsis Campaign Karolinska University Hospital Huddinge, 141 86 Sweden. cDepartment Guidelines" bygger på variabler såsom blodtryck, centrala fyllnadstryck of Clinical Oncology and Division of Oncology-Pathology, Karolinska samt blodvärde. Vi vet med säkerhet idag att dessa parametrar dåligt Institutet, Karolinska University Hospital Solna, 171 76 Stockholm. reflekterar individens förmåga till att svara på vätskebehandling. Mer dDepartment of Medicine, Section of Cardiology, and Division of Cardio- än 50 % av patienter med blodförgiftning på en intensivvårdsavdelning logy, Karolinska Institutet, Karolinska University hospital Huddinge, svarar inte på given vätska med en förbättrad cirkulation. Dessa patien- 141 86 Sweden. School of Technology and Health, Royal Institute of ter får stora mängder vätska i onödan och går därmed upp i vikt vilket Technology, Stockholm, Sweden. är associerat med ökad morbiditet och mortalitet. Vi genomför en öppen, randomiserad studie, där vi använder oss av Background: Postoperative complications after esophagectomy are
ett benlyftstest för att avgöra när patienten ska få vätska. Patienterna i common. Neoadjuvant treatment improve long-term survival but neo- benlyftsgruppen övervakas med PiCCO(pulskonturanalys med termo- adjuvant chemoradiotherapy could elicit perioperative challenges and dilutionskalibrering). increase postoperative morbidity compared to chemotherapy through an acute radiation effect on the heart.
The aim of this study was to compare perioperative hemodynamic patterns in patients following chemoradiotherapy or chemotherapy.
Methods: Patients enrolled at our center into a multicenter trial comparing neoadjuvant chemoradiotherapy (n=17) and chemothe- rapy (n=24) were randomized to receive neoadjuvant cisplatin and 5-fluorouracil with or without 40 Gy concurrent radiotherapy prior Cardiac function was assessed with LiDCOplustm, Troponin T and NT-proBNP, before, during and after surgery. The primary outcome was stroke volume indexed for body surface area. Per protocol analyses with linear mixed models were used to analyze the effects of within group change and the interaction between trend Results: Chemotherapy n=17, Chemoradiotherapy n=14 completed
surgery. The chemoradiotherapy group were older (66 vs. 60 years Benlyftstest. Om slagvolymsindex ökar ≥10% vid benlyft får be- p=0.33). We found no significant interaction effect.There was a trend handlande läkare ordinera vätska. Patienterna randomiseras till en av towards an interaction effect for cardiac index (p=0.07) and the che- två grupper där gruppen med benlyftstest endast får vätska då testet moradiotherapy group had a lower cardiac index before surgery (2.9 vs. indikerar en "responder". Den andra gruppen får vätska enligt behand- 3.4 l/m2/ min p=0.03). These differences diminished after adjusting for lande läkares val. Vi testar hypotesen att benlyftstest kan ge en minskad age (p=0.10) and (p=0.14) respectively. viktuppgång i interventionsgruppen dag 3 med 30%.
Hemodynamic values changed in both groups during the study. On Studien är registrerad på Clinicaltrials.gov som OFTa-PLR, the third postoperative day both groups displayed a hyperdynamic sta- NCT02301585. Vi har inkluderat 19 patienter av 132 sedan studie- te compared to baseline. Operating time and bleeding were similar in start i februari 2014. Inklusionstakten har varit låg, men ökar stadigt. both groups as were troponin T and NT-proBNP patterns. There was Patienterna måste inkluderas inom tolv timmar från debut av septisk a trend towards an increased pulmonary complication rate in the che- chock. Det innebär ofta att inklusion är aktuell nattetid, vilket kräver moradiotherapy group (p=0.09).
att hela nattjourslinjen är välinformerad och kan prioritera studien. I de flesta fall är det möjligt att nå anhöriga för att få samtycke till att Conclusions: Neoadjuvant chemoradiotherapy does not affect the
patienten ska vara med i studien. Vi planerar att utöka studien till flera perioperative hemodynamic profile compared to patients receiving intensivvårdsavdelningar under 2016.
neoadjuvant chemotherapy. Neoadjuvant chemoradiotherapy as admi- nistered in this study appears safe from a perioperative hemodynamic perspective. Further studies are need as to the effect on respiratory information on causes of death was sought in the Swedish Death Reg- God logistik och kompletta traumateam ger
snabb kirurgisk intervention vid trauma
After ICU discharge, 4860 sepsis patients died, 895 (18%) of which from cardiac failure. The median (IQR; range) time from ICU dis- charge to death from cardiac failure was 81 (17–379; 0–2447) days. Pierre Sundin1, Cecilia Mitt Holm2,Olof Brattström1,3och
With increasing severity of illness (quartiles of SAPS 3; SAPS 3 27– 57, 58– 66, 67–76, and 77–133, respectively), the hazard ratio (HR) 1ANOPIVA-kliniken, 2Med Kand, KI, 3Institutionen för fysiologi och for death from cardiac failure increased significantly (1.580 (95% CI farmakologi, KI, 4Akutkliniken, 5Institutionen för medicin, enheten för 1.192–2.095, p=0.001) in the highest quartile compared to the low- Internmedicin,KI. Samtliga vid Karolinska Universitetssjukhuset, Solna. est). When compared to controls, HR for death from cardiac failure was not increased after sepsis (0.981 (95% CI 0.812–1.182, p=0.846). Bakgrund: Mortaliteten efter trauma med livshotande blödning mins-
To eliminate the impact of directly ICU-related death, patients who kar om tiden till akut kirurgisk intervention minimeras. En patient- died less than one week after ICU discharge were excluded. Nonethe- grupp med särskilt behov av snabba insatser är patienter med hjärt- less, HR for death from cardiac failure did not differ between sepsis stopp orsakat av trauma. Traditionellt tas traumapatienter emot av ett patients and controls (0.977 (95% CI 0.791–1.207, p=0.829).
traumateam på en akutmottagning. Vid Trauma Centrum Karolinska The risk of death from cardiac failure after septic shock increases (TCK) omhändertas emellertid svårt skadade patienter direkt på en with severity of illness. However, we conclude that septic shock pa- särskild traumaenhet med egen avdelad operationssal i omedelbar an- tients are not at an increased risk of death from cardiac failure when slutning till traumarummet. Traumaledaren (kirurg) kan välja att låta compared to other ICU patients. det prehospitala teamet föra patienten direkt in till operationssalen. Till skillnad från andra svenska sjukhus deltar operationssjuksköterska och operationsundersköterska i varje traumateamaktivering på TCK. Detta i kombination med omedelbar tillgång till operationssal torde Fria Föredrag 3
möjliggöra snabb kirurgisk intervention om så är påkallat.
Måndag 21/9 kl 17:45–19:00
Metod/Patientmaterial:I det svenska traumaregistret SweTrau
identifierades 67 patienter som förts till sjukhus med hjärtstopp efter Lokal: 27
trauma i Stockholms län 2011–2014. För 22 patienter beslutades om Moderatorer: Eddie Weitzberg, Michael Wanecek
omedelbar kirurgi (thorako- och/eller laparotomi) utan föregående datortomografiundersökning. Tidsuppgifter föreligger på 21 av dessa Urinary cystatin C as a marker of sepsis in
critically ill patients
Resultat: Av 21 patienter var 13 (62%) drabbade av penetrerande- res-
pektive 8 (38%) av trubbigt våld. Det utfördes 20 thorakotomier och 9 laparotomier. Hos 8 patienter utfördes bägge ingreppen i samma seans. Vid 24 timmar levde 5 (24 %) patienter. Vid 30 dagar samt vid 1 år AnOpIVA Karolinska Solna levde 2 (10 %) patienter. För 11 (52 %) av patienterna startade kirurgin inom 5 minuter. Mediantid till start av kirurgi för hela gruppen var 5 Introduction: Specific biomarkers to detect sepsis and guide antibiotic
minuter (range 1–25 min) stewardship in critically ill patients are lacking. Structural glomerular changes causing increased filtration of plasma proteins such as cystatin Konklusion: Vi redovisar data för en patientgrupp med mycket svåra
C has been observed in septic patients. In addition, impaired renal skador och behov av omedelbar kirurgi. Resultatet visar att ett om- tubular reabsorption of filtered cystatin C leading to elevated urinary händertagande av traumapatienten i omedelbar anslutning till en ope- concentrations is a proposed feature of acute kidney injury (AKI).
rationssal, och med operationspersonal i traumateamet, ger förutsätt- ningar för att mycket snabbt starta potentiellt livräddande kirurgi.
Objectives: To explore the association of elevated cystatin C concen-
trations in urine with sepsis and AKI in critically ill patients. Methods: Urinary cystatin C was quantified on a daily basis in 138
general ICU patients. The peak urinary cystatin C level during ICU Cardiac mortality after septic shock
admission was identified for each patient. Sepsis was defined as a sus- pected or confirmed infection together with the presence of at least Lina De Geer, Anna Oscarsson, Mats Fredrikson and Sten Walther
three systemic inflammatory response syndrome criteria. AKI was de- fined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We used multivariate logistic regression to explore the associ- ation of sepsis with urinary cystatin C above the median for the entire Cardiac dysfunction is a well-known complication in septic shock, but cohort adjusting for AKI severity, demographics, admission diagnosis its long-term consequences remain elusive. We investigated cardiac and illness severity.
outcome in septic shock patients by assessing causes of death in a regis- ter-based cohort. Our hypothesis was that septic shock survivors are at Results: Of 138 patients, 84 (61%) had sepsis and 67 (49%) had AKI
an increased risk of death related to cardiac failure.
during ICU admission. Median urinary cystatin C was 2.48 mg/L for A cohort of 11  214 severe sepsis and septic shock intensive care the entire cohort. Peak urinary cystatin C was higher in septic as com- (ICU) patients without preceding severe cardiac failure and discharged pared to non-septic patients (median 2.5 mg/L [IQR 0.58–7.8 mg/L] alive was collected from the Swedish Intensive Care Registry (SIR) to- vs median 0.48 mg/L [IQR 0.23–1.2 mg/L]; P<0.001). Sepsis was in- gether with a control group matched regarding age, sex and severity of dependently associated with urinary cystatin C >2.48 mg/L (adjusted illness, but without sepsis. In patients who died after ICU discharge, odds ratio 4.40 [95% CI 1.91–10.12]) whereas AKI was not (adjusted odds ratio 1.73 [95% CI 0.76–3.95] for KDIGO 1 AKI and 1.10 ANOPIVA, Karolinska Universitetssjukhuset, Solna [95% CI 0.40–3.05] for KDIGO ≥2 AKI).
Introduction: Prevalence of Chronic Kidney disease (CKD) and End
Conclusions: Urinary cystatin C >2.48 mg/L can be used to detect
Stage Renal Disease (ESRD) amongst Intensive Care Unit (ICU) ad- sepsis in a general ICU setting where AKI is common.
missions is rising. How Long-term mortality and the risk of devel- oping ESRD compare to patients with Acute Kidney Injury (AKI) or without renal dysfunction is unclear. This knowledge is essential to: optimize treatment, identify survivors requiring nephrological surveil- lance and to quantify requirements for dialysis provision.
Plasma endostatin improves acute kidney injury
risk prediction in critically ill patients
Method: This cohort study was conducted in Swedish ICUs between
2005 and 2011 using the Swedish intensive care register (SIR) con- Niklas Jonsson, Anders Larsson, Max Bell, Claes-Roland Mart-
sisting of 130,134 adult patients. Incomplete cases were excluded ling, Johan Mårtensson
(26,771). Patients were classified as having ESRD, CKD, de novo AKI, Acute on Chronic disease (AoC) or no renal dysfunction. Primary ANOPIVA, Karolinska Universitetssjukhuset, Solna outcome was all-cause mortality. Secondary outcome was ESRD-inci- dence. Maximum follow-up was seven years for mortality and six years Introduction: Acute kidney injury (AKI) is a major clinical problem
for ESRD  (median 2.1 and 1.3 years respectively).
in critically ill patients characterized by a rapid loss of kidney function and high mortality. Dysfunction of the renal microcirculation as a re- Results: Of 103,363 patients, 4,192 had pre-existing CKD and 1389
sult of endothelial activation and damage appears to play a major role had ESRD. 5,273 (5.1%) developed de novo AKI and 998 CKD pa- in the initiation, maintenance and progression of AKI. Endostatin is a tients developed AoC.  Mortality rates were highest in AoC-subjects potent activator of the endothelium, released by basement membrane Crude mortality rate ratios (MRR) compared to controls were 3.52, collagen breakdown. Animal experiments show that such collagen 2.87 and 2.99 for AoC, AKI and CKD respectively.  ESRD had a crude breakdown occurs early on after renal insult and contributes to the MRR 2.08, adjusted MRR was higher than for AKI (1.46 vs. 1.15). pathophysiology of AKI. One year mortality  was greatest in AoC group (54%) followed by AKI (48.7%) and CKD (47.6%), for ESRD it was 40.3% (P<0.001). Objective: We aimed to assess whether plasma endostatin improved
5 years mortality was highest for CKD and AoC groups (71.3%, 68.2 prediction of AKI occurring within 72 hours in critically ill patients.
respectively followed by AKI (61.8%) and ESRD (62.9%)(p<0.001). Incidence of ESRD was greatest in the AoC and CKD groups  (adjust- Material and methods: We enrolled patients within 48 hours of in-
ed Incidence rate ratio (IRR) of 259 and 96.4) but also significantly tensive care unit (ICU) admission. We excluded patients who met AKI elevated in AKI-patients compared to controls (adjusted IRR 24).
criteria during this time-frame. We defined AKI according to Kidney Disease: Improving Global Outcomes criteria. The optimal combina- Conclusion: Pre-ICU renal disease significantly increases the risk of
tion of risk factors for AKI prediction was included in a clinical model. death compared to controls. Subjects with AoC disease had extreme Improvement in risk prediction by adding endostatin to the clinical risk of developing ESRD. All patients with CKD who survive critical model was assessed by the area under the receiver operating character- care should receive a nephrology referral.
istics curve (AUC), net reclassification improvement (NRI) and inte- grated discrimination improvement (IDI). Results: Of 93 patients, 21 (22.6%) developed AKI within 72 hours.
A clinical model based on age, APACHE II score and oliguria for <6 Acute kidney injury following severe trauma, risk
hours predicted AKI with an AUC of 0.76 (95% CI 0.65–0.87). Com- factors and long-term outcome
pared to non-AKI patients, endostatin at inclusion was significantly higher in patients who developed AKI within 72 hours and improved (P<0.001) the AUC (0.84 [95% CI 0.75–0.92]) when combined with the clinical model. In addition, endostatin significantly improved risk AnOpIVA Karolinska Universitetssjukhuset, Solna prediction using NRI (0.27; P = 0.04) and IDI (0.07; P = 0.04) anal- Background: The trauma patient sustains numerous potentially
harmful insults that may contribute to a notable risk of acute kidney Conclusion: Plasma endostatin combined with a three-parameter
injury (AKI). The aim of this study was to investigate the incidence of, clinical model is a strong predictor of evolving AKI in critically ill and to identify risk factors for, AKI in severely injured trauma patients admitted to the intensive care unit (ICU). The patients were followed for one year with respect to survival and end-stage renal disease.
Methods: Trauma patients admitted to the ICU for >  24 hours at
Pre-morbid Chronic renal dysfunction increases
a level-one trauma centre were included. The outcome measure was the risk of death and of developing End Stage
AKI diagnosed day 2-7 of ICU-treatment. Regression analysis was per- Renal Disease in the critically ill.
formed in order to identify factors associated with AKI-development.
Results: A quarter of the patients (103/413) developed AKI within
Claire Rimes Stigare, Paolo Frumento, Matteo Bottai, Johan
the first week of ICU-admission. AKI was associated with increased Mårtensson, Claes-Roland Martling, Sten M Walther & Göran
30-day (17.5 % vs. 5.8 %) and 1-year (26.2 % vs. 7.1 %) mortality. Karlström, Max Bell.
Risk factors for AKI were male gender, age, non-diabetic comorbidity, diabetes mellitus, injury severity score >40, massive transfusion and Fria Föredrag 4
volume-loading with hydroxyethyl starch (HES) within the first 24 hours. Unexpectedly, sepsis prior to AKI onset, admission hypotension and extensive contrast loading (> 150 mL) were not associated with AKI-development. None of the surviving AKI-patients had developed Tisdag 22/9 kl 15:45–16:45
end-stage renal disease one year post-injury.
Lokal: C3
Moderatorer: Michael Haney, Christina Eintrei
Conclusions: AKI in ICU-admitted trauma patients is a common
complication with substantial mortality. Diabetes, male gender and severe injury were strong risk factors but also age, non-diabetic comor- Förbättringsarbete med stöd av kvalitetsregister:
bidity, massive transfusion and resuscitation with HES were associated Förkortad respiratortid för intensivvårdspatienter
with post-injury AKI. Based on the results of the current study volume resuscitation with HES cannot be recommended in trauma-patients.
Anna Eriksson, Ing-Marie Larsson, Annica Lindberg, Sandra
Snäckerström, Carina Wallin, Ewa Wallin, Patric Vennström, Åsa
Wilhelmsson, Rafel Kawati
Causes of excessive late death after multiple
ANIVA, Akademiska sjukhuset, Uppsala trauma, a matched cohort study
Bakgrund: På Centralintensiven (CIVA), Akademiska sjukhuset i Upp-
sala, vårdas ca 1000 patienter per år och av dem vårdas hälften i respi- rator. Förlängd respiratorvård efter 24–48 timmar korreleras med ökad AnOpIVA Karolinska Universitetssjukhuset, Solna mortalitet och ökad risk för komplikationer. Att förkorta respirator- tiden kan innebära mindre komplikationer samt kortare vårdtid på IVA. Objective: To investigate a potentially sustained increase in mortality
up to three years following multiple trauma and identify causes of late Syfte: Att förkorta patienternas vårdtid i respirator och att arbeta
med projekt och förbättringsarbeten utifrån en strukturerad me- tod samt att använda registerdata som stöd i förbättringsarbeten. Introduction: Trauma is a serious contributor to the global burden
of disease and the most common cause of death <45 years in Sweden. Metod: The Dartmouth Microsystem Improvement Curriculum
Studies on mortality and causes of death following trauma have mainly (DMIC) Ramp användes för att genomföra förbättringsarbetet. Ett been restricted to hospital stay or 30-day mortality. Increasing evidence team med medarbetare från flera professioner introducerade och im- indicate a sustained increase in mortality up to several years after trau- plementerade förbättringsåtgärder; daglig väckning, aktiv befuktning ma, but the causes of late death has not been elucidated.
åt alla patienter som vårdas i respirator, höjd huvudända och check- lista för tidig postoperativ extubering. Det kvalitetsregister som an- Methods: In a cohort study 7382 multiple trauma patients were iden-
vänts i förbättringsarbetet var Svenskt Intensivvårdsregister (SIR). tified through a regional trauma registry 2005–2012. Trauma cases were matched to 36760 uninjured controls by age, sex and munici- Resultat: Den totala respiratortiden minskade med 12%, från
pality. By linkage to national registries mortality, cause of death and 56,7 timmar till 49,8 timmar på 6 månader. I en subgrupp av comorbidity status was identified. Excess mortality was examined by patienter som inkom till avdelningen för tidig postoperativ extuba- calculating all-cause mortality rate ratio (MRR).
tion efter elektiva operationer minskade respiratortiden med 74%. Slutsats: DMIC konceptet har visat sig vara ett effektivt sätt att arbe- Results: Among the trauma cohort 755 (10.2 %) died within three
ta med förbättringsprojekt och når snabba resultat. Projektet lyckades years after the index trauma, 30-day mortality was 5.0 %. When com- med att minska tiden i respirator för samtliga patienter och hade stor pared to the control group all-cause MRR showed a sustained increase effekt på patienter som kom till IVA postoperativt för extubering.
in mortality up to three years with MRR day 31–365 of 2.88 (95 % CI 2.37–3.50), year 1–2 1.59 (1.24–2.04) and year 2–3 1.43 (1.06–1.92) respectively. The most common causes of late death among trauma patients were diseases of the circulatory system and external causes.
Riskuppföljning av patienter som genomgått
Conclusions: This is the first study analysing late mortality and causes
omfattande kirurgi ett pilotprojekt på Centrala
of death after trauma using a matched control group. A sustained in- crease in mortality was seen up to three years after the index trauma. The excess mortality was largely attributed to external causes of death Sandra Månsson, Caroline Hällsjö Sander
including subsequent trauma and substance abuse.
ANOPIVA kliniken Karolinska Universitetssjukhuset, Solna Bakgrund: Cirka 12 % av de patienter som genomgår kirurgi drabbas
av postoperativa komplikationer (1–3). Risken att drabbas av detta är relaterat till ingreppets omfattning, patientens preoperativa hälsotill- stånd samt det perioperativa medicinska omhändertagandet (4). Syfte: Att utvärdera hur ofta ett team bestående av postopsjuksköterska
och anestesiolog identifierar behov av ytterligare behandling, provtag- ning eller utökad övervakningsnivå efter utskrivning till vårdavdelning.
Att utvärdera vårdavdelningspersonalens upplevelse av bl.a. det peda- en kostnad av ca 250.000 kronor extra (avhandling från Karolinska gogiska värdet i detta besök.
Institutet 2012 (Hyllienmark P.) och en CVKRI beräknas till en kost- nad av ca 29.000 $ (Marschall J et al. Infect Control Hosp Epidemi- Metoder: En postopsjuksköterska och anestesiolog följer upp patien-
ol 2008). Båda ger också upphov till ökad morbiditet och mortalitet ter som opererats med omfattande buk/bäckenkirurgi pga. gynekolo- och stort mänskligt lidande för våra patienter. Således finns mycket gisk eller urologisk malignitet. Patienterna har vårdats minst en natt att vinna genom att minska frekvensen av dessa infektioner på våra på Centrala Postop pga. ingreppets omfattning och/eller komorbiditet. 1–2 dygn efter utskrivning från den postoperativa avdelningen rondar postopsjuksköterska och anestesiolog patienten på vårdavdelningen Metod: Genom att följa sina komplikationer på avdelningen i SIRs
tillsammans med vårdavdelningens personal. Därefter träffar teamet utdataportal kunde Karolinska Huddinge IVA på ett strukturerat sätt patienten och gör en bedömning utifrån NEWS samt det eget utarbe- arbeta med att sänka sin infektionsfrekvens av VAP och CVKRI. Det tade RU-score. Vid behov finns möjlighet att på avdelningen ta blodgas är ett långsiktigt arbete som har pågått sen 2002 och där man tyd- för direkt analys samt ultraljud av buk- och thoraxorgan. En samlad ligt kan se att infektionsfrekvensen varierar över åren. Möjlighet att bedömning görs och RUteamet lämnar eventuella rekommendationer bättre beskriva infektionerna i VAP/10.000 ventilatortimmar samt till vårdavdelningssjuksköterska/ läkare.
CVKRI/1000 dagar har ökat kvalitén på in- och utdata genom åren och gett avdelningen ett mer tillförlitligt instrument att jobba mot. Resultat: Vi har hittills gjort 53 besök, varav 37 kvinnor och 26 män.
Rent konkret har återkommande hygienhappenings regelbundet med I 27 av dessa fall har vi kommit med rekommendationer gällande olika fokus varit en del av arbetet och där har alltid redovisning av SIR patientens fortsatta vård och behandling. De vanligaste rekommenda- data till hela personalgruppen ingått som en viktig ingrediens. VAP tionerna gäller vätskebehandling, provtagning, röntgen samt övervak- åtgärdspaket, checklista för CVK inläggning och punktprevalensmät- ning av vitala funktioner. Vi har vid ett tiotal tillfällen varit behjälpliga ningar av basala hygienrutiner samt följsamhet till SKLs åtgärdspaket med t.ex. läkemedelsadministration, EKGtagning samt provtagning. för CVK skötsel har också varit en del av det förebyggande arbetet. Dessutom uppmuntras personalen att komma med egna förbätt- Diskussion: RU är utvärderat på den vårdavdelning som vi arbetat
ringsförslag och vi utgår från deras yrkesstolthet – det ger ofta bättre mot mest, där har det varit en mycket positiv feedback. Vi som arbetar resultat än pekpinnar – "Down – Up istället för Top – Down ma- med RU upplever att behovet av en förlängning av den anestesiologis- nagement". Genom att arbeta långsiktigt och med ständigt fokus på ka/ postoperativa kompetensen fyller en viktig funktion, både ur ett förbättring har Karolinska Huddinge IVA sänkt infektionsfrekvensen medicinskt- och ur ett omvårdnadsperspektiv. Den pedagogiska kom- av både VAP (Fig 1) och CVKRI (Fig 2). Detta i sin tur har medfört ponenten utgör en av grundpelarna i RU-verksamheten och är den besparingar på ca 2,5 – 3,0 miljoner SEK i minskad VAP och dessutom som vi tror gör störst skillnad i långa loppet. ca 2,6 miljoner SEK i minskad CVKRI när man jämför de sämsta åren med de bästa (Fig 2 och Fig 3). 1. Pearse RM, Rhodes A, Moreno R, et al. EuSOS: European surgical outcomes study. Eur J Anaesthesiol 2011; 28: 454-6 Slutsatser: Dessa resultat visar på ett långsiktigt arbete som både spa-
2. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mor- rar miljontals kronor, minskar patienternas lidande samt räddar liv! Att tality associated with inpatient surgery. N Engl J Med 2009; 361: använda sig av kvalitetsregisterdata från SIR och regelbundet återföra dessa till personalen är ett effektivt verktyg att nå mätbara förbättringar 3. Khuri SF, Henderson WG, DePalma RG, et al. Determinants of long- i vården på intensivvårdsavdelningen Karolinska Hudinge. term survival after major surgery and the adverse effect of postope- rative complications. Ann Surg 2005; 242: 326-41; discussion 41-3 4. Grocott et al Perioperative increase in global blood flow to expli- cit defined goals and outcomes following surgery. Cochrane Data- Utvärdering av blodglukos (BG) koncentrationer
base Syst Rev 2012 Nov 14; 11 efter anestesi på kirurgiska och ortopediska
Långsiktigt arbete med hjälp av Svenska intensiv-
vårdsregistret (SIR) sänkte kostnader med miljon-
ANIVA, Uppsalla Akademiska Sjukhus, Uppsala tals kronor på Karolinska Huddinge IVA.
Bakgrund: Det finns olika synpunkter vilka infusioner ska ges till
patienter i narkos för en optimal vätskebehandling. Förhöjda glukos värden perioperativt har negativa konsekvenser för morbiditet och Anestesi- och intensivvårdskliniken Karolinska Universitetssjukhuset mortalitet. För optimera patientens välbefinnande behöver utvärdera blod glukos koncentration hos patienter under och efter rutin anestesi.
Metoder: Studien genomfördes under 10–12/2013 (121 patient,
Bakgrund och syfte: Vårdrelaterade infektioner är ett stort problem
fas I,5% buffrad glucos perioperativt) och 04–06/2014 (108 patienter, inom slutenvården med en incidens av ca 10%, dvs. var tionde patient fas II, ej 5% buffrad glucos perioperativt). Patienter utan diabetes som får en s.k. vårdskada. Särskilt stort är problemet inom intensivvården genomgick ett planerat kirurgisk eller ortopediskt ingrepp registrera- där ofta en incidens på det dubbla har rapporterats. Inom SIR har des. Datainsamlingen : operations datum, kön, ålder, typ av ingrepp, fokus på att registrera vårdrelaterade infektioner varit stort genom åren, opertationstid, anestesi tid, mängd och typ av given vätska under ope- detta för att kunna arbeta strukturerat med egna data och sänka infek- ration, BG koncentrationer peroperativt och postoperativt. Deskripti- tionsfrekvensen ute på avdelningarna. Ventilator-associerad pneumoni va och icke parametriska statistiska metoder har använts.
(VAP) och CVK (central venkateter)- relaterade infektioner (CVKRI) är båda komplikationer som registreras i SIR. En VAP är beräknad till Resultat: Fas I: anestesi tid: 263 min (245–282) (mean, minimum–
or with CPAP. Residual neuromuscular block caused a reduction in maximum). Given volym av 5% buffrad glukos: 243 ml (201–285). HVR while HCVR was unaffected (Figure 1). A total of 33.2±6.8 mg BG peroperativt 7,2 mmol/l (6,8–7,6), BG postoperativt: 9,4 mmol/l rocuronium was infused i.v. for 49±9 min to achieve a TOF ratio of (8,9–9,8). Fas II: anetesi tid 275 min (253–297).BG peroperativt: 6,6 mmol/l (6,3–6,8), BG postoperativt: 7,9 mmol/l (7,6–8,2). 41(34%) patienter hade BG> 10 mmol/l postoperativt i fas I och 10 (10,8%) patienter i fas II. 13 (10,7%) patienter hade BG<6 mmol/l i fas I och 8 (7,4%) patienter i fas II. Ingen patient hade BG< 4 mmol/l.
Slutsats: Perioperativ tillförsel av 5% buffrad glukos orsakade höga
glukos koncentrationer hos 34% av patienter utan diabetes vid rutina- nestesi. Ersättning av 5% buffrad glucos med andra kristalloider mins- kade postoperativ hyperglikemia och ledde inte till hypoglikemiska Figure 1: Residual paralysis by rocuronium reduced HVR but not HCVR in untreated OSA patients. n=8.* P<0.05.
Fria Föredrag 5
Conclusions: Based on the preliminary data from this study, residu-
Onsdag 23/9 kl 14:30–16:00
al neuromuscular block by rocuronium attenuates the acute HVR in Lokal: C3
untreated OSA patients. Notably, this is not due to muscle paralysis since the HCVR is unaffected, but rather a depression of the peripheral Moderatorer: Stefan Lundin, Jonas Åkesson
chemosensitivity. Residual neuromuscular block with rocuroNium
reduces hypoxic ventilatory response in patients
with untreated obstructive sleep apnea
Remifentanil induced dysfunction of pharyngeal
1, 2, A Ebberyd2, A Hårdemark Cedborg2, Å Daniel-
son1, 2, Åsa Österlund Modalen3, KA Franklin4, LI Eriksson1, 2,
M Jonsson Fagerlund1,2
1Department of Anesthesiology, Surgical Services and Intensive Care Aniva-kliniken, Örebro Universitetssjuhus Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden. 2Department of Physiology and Pharmacology, Background: Exposure to remifentanil causes swallowing difficulties
Section for Anesthesiology and Intensive Care, Karolinska Insitutet, Stock- and increases the incidence of pulmonary aspiration in healthy volun- holm, Sweden. 3Aleris FysiologLab, Stockholm, Sweden. 4Department of teers. These effects may be explained by impairment of airway defense Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden. mechanisms and/or altered swallow function. Automated impedance manometry pressure-flow analysis (AIM analysis) is a technique that Background: Obstructive sleep apnea (OSA) has been identified as a
allows objective assessment of swallow function based on pressure-im- leading risk factor behind serious complications, particularly respirato- pedance patterns recorded during bolus swallowing. The aim of this ry, in the postoperative period. Residual neuromuscular block mark- study was to use AIM analysis to quantify the effect of remifentanil edly reduce the acute hypoxic ventilatory response (HVR) in healthy on pharyngeal swallowing in both young and old volunteers and to volunteers. While untreated OSA patients has an increased HVR, it is contrast these effects to morphine. not known to what extent neuromuscular blocking agents interact with Methods: Eighteen healthy young and old volunteers participated in a
hypoxic control of breathing in OSA patients. double-blind, randomized, cross-over study at the University Hospital Materials and Methods: 11 newly diagnosed and untreated OSA
in Örebro, Sweden. Subjects were studied on two occasions during patients entered the study. They were studied using a facemask, stan- which they received either target-controlled infusion of remifentanil dard perioperative monitoring and thoracic and abdominal impedance (young: 3 ng/ml, older: 2 ng/ml) or a bolus injection of morphine bands. Neuromuscular function was assessed by adductor pollicis train- (young: 0.1 mg/kg, older: 0.07 mg/kg). Pressure-impedance measure- of-four (TOF) response of the ulnar nerve. First individual baseline ments were made with an indwelling catheter and ten liquid swallows HVR and hypercapnic ventilatory response (HCVR) were measured. were captured during each measuring condition. The pressure-flow Thereafter, CPAP of 6–7 cm of H2O was applied and three series of variables defining swallow function were calculated and compared to HVR and HCVR tests followed: i.e. control, during rocuronium- determine drug effects. induced residual neuromuscular block aiming at TOF ratio of 0.70 Results: Remifentanil influenced the variables towards the direction
and after recovery to TOF ratio >0.90. At each occasion, isocapnic that is consistent with greater swallow dysfunction. Vigor of the pha- HVR was studied using FiO2 of 0.08-0.12 targeting SpO2 of 80%, ryngeal contraction was weakened, pharyngeal bolus propulsion was while normoxic HCVR was performed by addition of 5% CO2 to diminished, and flow resistance was increased. The swallow risk index, a global index of swallowing dysfunction, increased overall. Similar ef- Results: HVR and HCVR tests in eight out of 11 OSA patients have
fects were found with morphine but the impact of remifentanil was been analysed (age 49±5 years, BMI of 30.3±0.9 and AHI of 23±1). greater in these experimental doses. There was no difference in individual baseline HVR or HCVR without Conclusions: Remifentanil induced dysfunction of pharyngeal swal-
lowing; this may contribute to the elevated risk of aspiration. Capnodynamic assessment of effective lung
volume during cardiac output manipulations in
a porcine model
Caroline Hällsjö Sander1,2, Per-Arne Lönnqvist3, Magnus
Effect of Incorrectly Applied Cricoid Pressure
Hallbäck4, Fernando Suarz Sipmann5,6, Mats Wallin4, Anders
During Rapid Sequence Induction. Evaluation
Oldner1,2, Håkan Björne 1,2
With High-Resolution Manometry
1Department of Anaesthesiology, Surgical Services and Intensive Richard Pellrud, M.D., Rebecca Ahlstrand, M.D.,Ph.D.
Care Medicine, Karolinska University Hospital, Solna, Sweden. 2Department of Physiology and Pharmacology, Karolinska Institutet, Department of Anesthesiology and Intensive Care, Örebro University Stockholm, Sweden. 3Paediatric Anaesthesia and Intensive Care Astrid Hospital, Sweden Lindgrens Children's Hospital Karolinska University Hospital, Sweden. 4Maquet Critical Care AB, Solna, Sweden. 5Department of Surgical Introduction: Cricoid pressure is often performed incorrectly, due to
Sciences, Section of Anaesthesiology and Critical Care, Hedenstierna difficulties to locate the cricoid cartilage. Despite this, the effective- laboratory, Uppsala University, Uppsala, Sweden. 6CIBERES, CIBER ness of an incorrectly applied cricoid pressure has not been investi- de enferme dades respiratorias, Instituto Carlos III, Madrid, Spain gated. We have used high-resolution manometry (HRM) to evaluate pressures in the upper esophagus during correctly applied cricoid Background: A capnodynamic approach for calculation of effec-
pressure (against the cricoid cartilage) compared to incorrectly ap- tive pulmonary blood flow includes a lung volume factor (ELV) that plied cricoid pressure (against the thyroid cartilage and the trachea) has to be estimated to solve the mathematical equation. In previous during a rapid sequence induction.
studies ELV was found to closely correlate to reference methods for functional residual capacity (FRC). The aim of the present study was Methods: 15 patients (ASA I-II), scheduled for elective surgery and
to evaluate the stability of ELV during substantial manipulations of intubation, participated. Before anesthesia the cricoid cartilage, the cardiac output (CO) and assess the agreement for absolute values and thyroid cartilage and the trachea (2 centimeters below the cricoid trending capacity during PEEP changes at different lung conditions.
cartilage) were identified by palpation, verified by ultrasound and marked with a pen.
Methods: Ten mechanically ventilated pigs were included. The re-
All patients were preoxygenated for 3 min with 100 % oxygen. A quired concentration alterations of alveolar carbon dioxide were in- rapid sequence induction with Fentanyl (2 μg/kg), Propofol (2 mg/kg) duced by a ventilatory pattern with cyclic reoccurring short inspirato- and Rocuronium (1 mg/kg) iv was performed. The manometry cathe- ry holds. The Sulphur hexafluoride wash-in/wash-out technique was ter was inserted transnasally into the esophagus and three standardized used as reference for FRC . Cardiac output was altered by preload forces of 30 N were applied in apnea: against the thyroid cartilage, the reduction and inotropic stimulation at PEEP 5 and 12 cm H2O both cricoid cartilage and the trachea for 10 seconds each. Esophageal pres- in normal lung conditions and after repeated lung lavages.
sures were recorded continuously by a HRM-catheter.
Results: ELV at baseline PEEP 5 was (mean (SD)), 810 (163) mL
Results: Mean pressures (± SD) [mmHg] in the upper esophagus
and decreased to 400 (42) mL after lavage. ELV was not significantly during an external force of 30N against: affected by CO alterations within the same PEEP level. The overall bias (limits of agreement) was -35 (-271 to 201) mL, and percentage Thyroid cartilage: 239 ± 184 Cricoid cartilage: 230 ± 180 Trending capability between PEEP steps assessed by the four- Trachea: 301 ± 194 quadrant plot technique showed a concordance rate of 100 %.
Conclusion: Incorrectly applied cricoid pressure against the thyroid
Conclusion: ELV remained stable during significant changes in
cartilage or trachea generates a significant rise of pressure in the re- CO and correlated closely to the reference method for FRC gion of the upper esophagus comparable to pressures generated by a trending capability was excellent both before and after surfactant de- pressure against the cricoid cartilage. In order to prevent passive regurgitation, the exact position of application of cricoid pressure se- ems to be of less importance.
Sedation with dexmedetomidine or propofol
Gender differences in outcome and use of re-
impairs control of breathing in healthy male
sources do exist in Swedish intensive care, but
volunteers. A randomized cross-over study
to no advantage for women of premenopausal
Å Danielson, A Ebberyd, A Hårdemark Cedborg, S Mkrtchian,
E Christensson, J Ullman, M Scheinin, LI Eriksson, M Jonsson
Carolina Samuelsson, Folke Sjöberg, Göran Karlström, Thomas
Nolin, Sten M Walther
ANOPIVA, Karolinska Universitetssjukhuset, Solna Introduction: Preclinical data indicate that estrogen appears to play
a beneficial role in the pathophysiology of and recovery from critical Background: The intravenous alpha2-agonist dexmedetomidine
illness. Few previous epidemiologic studies, however, have analysed (DEX) is being increasingly used for sedation worldwide. DEX has premenopausal women as a separate group when addressing potential been put forward as a drug with minimal effect on ventilation. gender differences in critical care outcome. Our aim was to see if To obtain a more comprehensive understanding of the regulation premenopausal aged women have a better outcome following critical of breathing during sedation with DEX, we compared ventilatory care and to investigate the association between gender and use of responses to hypoxia and hypercapnia during sedation with DEX and intensive care unit (ICU) resources.
Methods: Based on 127 254 consecutive Simplified Acute Physiol-
Methods: Eleven healthy male volunteers entered this randomized,
ogy Score 3 (SAPS 3) -scored Swedish Intensive Care Registry ICU cross-over study. DEX or propofol was administered as an intrave- admissions from 2008-2012, we determined the risk-adjusted 30-day nous bolus followed by an infusion. The protocol was repeated for mortality, accumulated nurse workload score, and length of ICU both drugs in each volunteer on separate days. Sedation was moni- stay. To investigate association with gender, we used logistic regres- tored by Observer´s Assessment of Alertness/Sedation Scale (OAA/S), sion and multivariate analyses on the entire cohort as well as on two Richmond Agitation Sedation Scale (RASS) and Bispectral Index subgroups stratified by median age for menopause (up to and includ- (BIS). Hypoxic and hypercapnic ventilatory responses were measured ing 45 years and >45 years), and six selected diagnostic subgroups at rest, during sedation (OAA/S 2–4) and a fter recovery. Drug expo- (sepsis, multiple trauma, chronic obstructive pulmonary disease, sure was verified with concentratioHVn ana 0.4 lysis in plasma.
acute respiratory distress syndrome, pneumonia and cardiac arrest).
Results: Ten subjects completed the s
0.3tudy. Compared to baseline,
sedation reduced hypoxic ventilatorXy res 0.2 ponse to 51 and 57% (see fig-
Results: There was no gender difference in risk-adjusted mortali-
ure), and hypercapnic ventilatory respo 0.1 nse to 74 and 71% for DEX
ty for the cohort as a whole, and there was no gender difference in and propofol, respectively. risk-adjusted mortality in the group ≤45 years-of-age. For the group of patients > 45 years-of-age we found a reduced risk-adjusted mor- tality in males admitted for cardiac arrest. For the cohort as a whole, and for those admitted with multiple trauma, male gender was as- sociated with a higher nurse workload score and a longer ICU stay.
Conclusions: Using information from a large multiple ICU register
database we found that premenopausal female gender was not asso- ciated with a survival advantage following intensive care in Sweden. When adjusted for age and severity of illness, male patients use more ICU-resources per admission than female patients.
Seda<on+ Recovery+ Baseline+ Seda<on+ Recovery+ Notably, some of the volunteers displayed upper airway obstruction and episodes of apnea during sedation. The OAA/S at the sedation /mmHg 0.3
goal was 3 (3–4) (median (min-ma 1.0
x)) for both drugs. BIS was 82 ± 8 oand 75 ± 3, and the drug concentrations in plasma at the sedation target were 0.66 ± 0.14 ng/ml and 1.26 ± 0.36 μg/ml for DEX and pro HCVR (L/min/mmHg) HCVHCVR (L/min/mmHg)
pofol, respectively. Seda<on+ Recovery+ Baseline+ Seda<on+ Recovery+ Conclusions: Dexmedetomidine-induced sedation reduces hypoxic
and hypercapnic ventilatory responses to a similar extent as sedation with propofol, a finding that implies that dexmedetomidine interacts with both peripheral and central control of breathing.

Source: http://sfaiveckan.se/uploads/SFAI-veckan-2015-abstracts-moderatorer.pdf

Effects of the prebiotics immunoster and immunowall on growth performance of juvenile beluga (huso huso)

Journal ofApplied Ichthyology J. Appl. Ichthyol. 27 (2011), 796–798 Received: March 28, 2010  2011 Blackwell Verlag, Berlin Accepted: December 18, 2010 Effects of the prebiotics Immunoster and Immunowall on growth performance ofjuvenile beluga (Huso huso) By R. TaÕati1, M. Soltani2, M. Bahmani3 and A. A. Zamini4 1Department of Fisheries, Islamic Azad University, Talesh Branch, Talesh, Iran; 2Department of Aquatic Animal Health, Faculty ofVeterinary Medicine, University of Tehran, Tehran, Iran; 3International Sturgeon Research Institute, Rasht, Iran; 4Department ofFisheries, Islamic Azad University, Lahijan Branch, Lahijan, Iran

Pravafenix, inn-fenofibrate/pravastatin

ZUSAMMENFASSUNG DER MERKMALE DES ARZNEIMITTELS BEZEICHNUNG DES ARZNEIMITTELS Pravafenix 40 mg/160 mg Hartkapseln 2. QUALITATIVE UND QUANTITATIVE ZUSAMMENSETZUNG Jede Hartkapsel enthält 40 mg Pravastatin-Natrium und 160 mg Fenofibrat. Sonstiger Bestandteil: Jede Hartkapsel enthält 19 mg Lactose. Die vollständige Auflistung der sonstigen Bestandteile siehe Abschnitt 6.1.

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