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Abstracts Posterpresentation 1 P2 P1
Abstracts
Posterpresentation 1
P2
Abdominal perfusion assessment using Diffusion
Weighted Imaging Magnetic Resonance.
Måndag 21/9 kl 14:00–15:30
Lokal: Utställningen
Moderatorer: Karin Björnström, Ulrik Sartipy
Silvia Marchesi MD, Aki Hata MD, Francisco Ortiz-Nieto MS,
Anders Larsson PhD, Göran Hedenstierna PhD
P1
Hemodynamic, metabolic and end-organ effects
of endovascular thoracic aortic balloon occlusion
and reperfusion in pigs
Nilsson KF , Sadeghi M , Dogan E , Jansson K , Hörer TM
1, 2
4
1
3
1
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.
4
Department of Surgery, Västerås Hospital.
Background: Endovascular aortic balloon occlusion (ABO) can
be used to temporarily stop life threatening bleedings in severe
trauma as an alternative to emergency thoracotomy. In a nonhaemorrhagic pig model, we investigated circulatory, metabolic and
end-organ effects of ABO and reperfusion, and their relation to
occlusion time.
Anesthetized pigs (25–35 kg) were randomized to
either of four groups (n=6/group): 15 min (ABO15), 30 min
(ABO30) or 60 min (ABO60) of thoracic ABO followed by 3 h of
reperfusion, or sham (control). Central haemodynamics, blood
flow in the superi-or mesenteric artery (SMA) and arterial blood
gases were measured during ABO and reperfusion. Plasma
concentrations of markers of end-organ damage and intraperitoneal
concentrations of lactate, pyru-vate and glycerol by microdialysis,
were analyzed.
Methods:
Results: ABO increased mean arterial blood pressure (MAP) and
decreased blood flow in SMA to almost zero. At reperfusion, MAP
initially dropped but normalized throughout reperfusion. Blood flow
in SMA returned to normal at reperfusion. At reperfusion, arterial
pH decreased in parallel with increased arterial lactate concentrations
in all ABO-groups, but most pronounced in ABO60. In ABO30 and
ABO60, arterial pH and lactate concentrations were still abnormal
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
concentrations of creatini-ne, aspartate aminotransferase and lipase
increased in the ABO30 and ABO60, whereas creatine kinase only
increased in ABO60.
In a non-haemorrhagic pig model, thoracic ABO
causes metabolic acidosis, hyperlactatemia and hyperkalemia as well
as pos-sible damage to visceral end-organs. The severity of these
end-organ
effects is dependent on occlusion time. Risk and benefit
...........................................................................................
considerations are important when using ABO and the
anaesthesiologist must take part in that decision.
Conclusion:
Hedenstierna Laboratoriet, Akademiska Sjukhuset, Uppsala
Background: Assessment of perfusion, especially of the abdomen, is
challenging in clinical settings as well as in the research field. The commonly used imaging techniques, PET and CT, employ contrast agents
and are not appropriate in all scenarios.
To evaluate whether DWI-MR technique could
be used to assess perfusion in abdominal organs in an endotoxemic
animal-model.
Aim of the study:
Material and Methods: Endotoxemic shock was induced in 12 anest-
hetized piglets. Animals were randomized into 2 groups with different
MAP (Group1: MAP ≥ 65 mmHg; Group2: 50 < MAP ≤ 60 mmHg).
The desired MAP was maintained with infusion of Noradrenaline. After six hours, DW-MRI was performed. DWI-MR technique utilizes
water motion as internal contrast, making possible to study diffusion
(movement of water within tissue) and perfusion (movement of water
inside capillary net). Perfusion was calculated as a fraction (f ), which
represents the contribution of water in capillary on the total amount
of water molecules movement in one region of interest (ROI). Several
ROIs were defined in 5 target organs: intestine, stomach, liver, spleen
and kidneys. In addition, perfusion was assessed with indirect markers,
i.e., arterial lactate, SvO2 and urinary output.
Results: The f-value indicated a reduced perfusion in the stomach and
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
± 0,63 mmol/L, p 0,04) and in SvO2: (Group1 41 ± 5,5%, Group2
27± 8,9%, p < 0,01).
Conclusion: Since DWI-MR was related to the indirect measures of
abdominal perfusion it has the potential to be used as a non-invasive
technique to assess abdominal perfusion both in the experimental and
clinical setting.
...........................................................................................
P3
Differential regulation of cerebral metabolic genes
after hyperglycemic and normoglycemic cardiac
arrest
Maria Molnar, MD*1; Rickard P.F. Lindblom, MD, PhD*2;
Charlotte Israelsson, PhD3; Belinda Fridman, MSc4;
Lars Wiklund, MD, PhD1; Fredrik Lennmyr, MD, PhD2
*Equal contribution. Department of Surgical Sciences, 1Section of
Anesthesiology and Intensive Care, 2Section of cardiothoracic surgery and
Anesthesiology, Uppsala University Hospital, 3Department of Neuroscience,
Developmental Neuroscience, Biomedical Center, Uppsala University,
27
Science for Life Laboratory, Department of Medical Sciences,
Uppsala University.
4
Background: Cerebral ischemia is a life-threatening condition, where
survivors often suffer from neurological deficits. To date, treatment options are limited. Hyperglycemia is frequently seen in conjunction with
the ischemia and is believed to further worsen the neurological outcome.
Material and methods: Pigs were openly randomized to high or normal
glucose levels, as regulated by glucose and insulin infusions with target
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 cardiopulmonary resuscitation and direct current shock to restore spontaneous
circulation. Global expression profiling of the cortex using microarrays
was performed in both groups.
102 genes differed in expression at p<0.001 between the hyperglycemic and normoglycemic pigs. Several of the most strongly differentially regulated genes were involved in transport and metabolism
of glucose. Functional clustering using bioinformatics tools revealed
enrichment of multiple biological processes, including membrane processes, ion transport and glycoproteins.
in skeletal muscle harvested from healthy humans wide a large inter-individual difference in the COX IV-2/COX IV-1 ratio. This ratio correlated strongly to whole body (RMR) measured in the same individuals
(Fig A). In isolated primary human skeletal myotubes overexpressing
COX IV-2, the same pattern was observed. These cells displayed a
>60% lower basal respiration and a >50% reduction in respiration
without ADP compared to control cells, the latter suggesting either
less proton conductance or less proton slip at COX (Fig B). In addition, reduced cellular H2O2 production was observed in COX IV-2
overexpressing cells.
Results:
Conclusions: Hyperglycemia during CA leads to differential early
gene expression compared with normoglycemia. Whether these transcriptional 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
candidates constitute interesting targets for further studies.
...........................................................................................
P4
Control of Human Energy Expenditure by
Cytochrome C Oxidase Subunit IV-2
Conclusion: These results suggest an important role of the mitochondrial subunit isoform COX IV-2 in control of energy expenditure
and mitochondrial reactive oxygen species homeostasis in humans.
...........................................................................................
P5
The effect of plasma from septic ICU patients on
healthy rat muscle mitochondria
Jonathan Grip, Towe Jacobsson, Nicolas Tardif, Olav Rooyackers
Clintec and AnOpIVA Karolinska University Hospital and
Institute, Huddinge
Tomas Schiffer1, Björn Ekblom2, Michaela Sundqvist1, Jon Lundberg1, Filip Larsen1 and Eddie Weitzberg1
Even though sepsis induced organ failure is a major
cause of death in ICU:s worldwide, the mitochondrial dysfunction
associated with this is not fully characterized and there is no evidence
of causality.
Dept. of Physiology and Pharmacology, Section of Anesthesiology and
Intensive Care, Karolinska Institutet and Swedish School of Sports and
Health Sciences, Stockholm.
Objective:
Introduction:
Background: Human resting metabolic rate shows pronounced variations between subjects, but the underlying molecular mechanism
remains elusive. Cytochrome C oxidase (COX) plays a key role in control of metabolic rate being the terminal enzyme of the mitochondrial
respiratory chain. A number of regulatory mechanisms exist to control
oxygen consumption and proton pumping at COX. One such regulation may occur through a shift in COX subunit composition. Recent
in vitro studies of the subunit isoform COX IV-2 indicate a role for
this protein in the cellular response to hypoxia and oxidative stress.
However, it remains unclear if COX IV-2 is expressed in human tissues
and if it regulates respiration in vivo.
Resting metabolic rate (RMR) was measured in healthy
subjects by indirect calorimetry and skeletal muscle biopsies were
obtained for western blot analysis of COX-IV subunits. From these
biopsies myogenic satellite cells were extracted and grown after which
parts of them were transfected to achieve COX IV-2 overexpression
and COX IV-1 knock down (COX IV-1-/2+). These cells were then
subjected to respirometric measurements as well as measurement of
hydrogen peroxide (H2O2) generation.
Methods:
Results:
28
We show that COX IV-2 protein is constitutively expressed
We examined whether a central factor in septic plasma
could affect respirational function of healthy rat muscle mitochondria.
ICU patients with severe sepsis or septic shock were recruited within 24hrs of admission together with age-matched controls.
Blood samples were centrifuged and frozen. Two trials were performed
and mitochondrial respiration was analyzed using an Oxygraph chamber with a Clarke-electrode. 1) Isolated mitochondria from rat skeletal
muscle were divided and incubated for 30 minutes with plasma from
patients or postoperative controls (n=10). Respiration was normalized
for citrate synthase (CS). 2) Permebealized muscle fibers from rats were
divided and incubated with plasma from patients or healthy controls,
for 30 and 120 minutes, and analyzed for mitochondrial respiration
(n=10). Respiration was normalized for fiber weight. Primary outcome
was state 3 respiration, which the maximal respiration initiated with
ADP and adequate energy substrates (malate and pyruvate). T-test was
used for statistical comparison.
Methods:
Results: No differences in respirational function of the mitochondria
were seen between the groups in either of the experiments. 1) State 3
respiration in isolated mitochondria were 19.9 ±6.7 vs. 20.2 ±8.8 nmol
O2*U CS -1*min-1 for sepsis vs. control respectively 2) State 3 respiration 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.
2.5 ±0.6 nmol O2*mg w.w-1*min-1. Respiratory control ratios (state
3/state 4) were good in all experiments (8.8–11.2), ensuring adequate
quality of the mitochondria.
Conclusion: These findings indicate that the effect on muscle mitochondria in sepsis is secondary rather than directly influenced by a
factor in plasma of septic patients.
...........................................................................................
P6
Effects of hyperbaric oxygen on nitric oxide generation in humans
Johan Uusijärvi1,2, Karin Eriksson1,2, Agneta C. Larsson1, Carina
Nihlén1, Tomas Schiffe 1, Peter Lindholm1,3 , Eddie Weitzberg1,2
Dept. of Physiology and Pharmacology, Karolinska Institutet, 2 Dept. of
Anesthesia & Intensive Care, Karolinska University Hospital and 3 Dept.
of Radiology, Karolinska University Hospital, Stockholm, Sweden.
1
Background: Hyperbaric oxygen (HBO2) has been suggested to affect
nitric oxide (NO) generation in humans. NO is produced by NO synthases (NOSs) from L-arginine and molecular oxygen, and may also
be formed by reduction of the inorganic anions nitrate and nitrite.
Interestingly, oral facultative anaerobic bacteria are necessary for the
first step to reduce nitrate to nitrite. The nitrate-nitrite-NO pathway
is potentiated by hypoxia and low pH in contrast to classical NOS-dependent NO generation. We investigated the effects of HBO2 on NO
generation in healthy subjects including orally and nasally exhaled
NO, plasma, salivary nitrate and nitrite as well as plasma cGMP and
citrulline/arginine ratio. We also conducted in-vitro experiments to investigate the effects of hyperoxia on nitrate/nitrite metabolism and NO
generation by oral bacteria.
Methods: Two HBO2 experiments were performed. In a cross-over ex-
periment (EXP1) subjects breathed air at 130 kPa (control) or oxygen
at 250 kPa for 100 minutes and parameters were measured before and
after exposure. In experiment 2 (EXP 2) measurements were performed also during HBO2 at 250 kPa for 110 minutes.
Results: HBO2 acutely reduced orally and nasally exhaled NO by
30% and 16%, respectively. There was a decrease in salivary nitrite/
nitrate ratio during and after HBO2 indicating a reduced bacterial conversion of nitrate to nitrite and NO, also supported by in vitro experiments with oral bacteria showing that hyperoxia inhibited bacterial
nitrate and nitrite reduction leading to decreased NO generation. Plasma nitrate was unaffected by HBO2 while plasma nitrite was reduced
during HBO2. In contrast, plasma cGMP increased during HBO2 as
did citrulline/arginine ratio after treatment and control.
Conclusion: HBO2-exposure in humans affects NO generation in the
airways and systemically differently. These data suggests that the individual NOSs as well as the nitrate-nitrite-NO pathway do not respond
in a similar way to HBO2.
...........................................................................................
P7
Neutrophil heterogeneity in severe respiratory
failure
B. Holzgraefe1,2, P. Jones3, M. Jones3, K. Palmér1, B. Frenckner1,
A. Larsson5, O. Winqvist3
1
ECMO Centre Karolinska, Karolinska University Hospital, Stockholm,
Sweden, 2Department of Physiology and Pharmacology, Section for
Anaesthesiology and Intensive Care Medicine, Karolinska Institutet,
Stockholm, Sweden, 3Department of Medicine, Translational Immunology Unit, Karolinska Institutet Stockholm, Sweden, 5Anesthesiology and
Intensive Care, Department of Surgical Sciences, Hedenstierna Laboratory,
Uppsala University, Uppsala, Sweden.
In systemic inflammation like sepsis and ARDS functional heterogeneity of neutrophils (PMNs) occurs. Mature (high expression
of the CD16 receptor) and immature (intermediate expression of the
CD16 receptor) PMNs seem to play an important role in the development of secondary infection and ongoing tissue damage. The PMNs
express CXCR1 and are attracted by Interleukin-8 (IL-8), which is released at the site of inflammation. We describe our findings of neutrophil heterogeneity seven ARDS patients treated with ECMO.
Aim:
Approval from the local ethical committee and written informed consent from the closest relative were obtained. Heparinized
whole blood from ARDS patients and one healthy control (HC) was
analyzed by flow cytometry. Cells were stained with monoclonal antibodies: CD16 PE Cy7, HLA-DR APC Cy7, CXCR1 APC, CXCR2
PE, CCR5 PE (Biolegend), IgG2b APC, IgG1 PE and IgG2a PE isotype controls (BD Biosciences). Flow cytometry was performed on a
FACSCanto cytometer and analyzed with FACSDiva software (BD
Biosciences). Subpopulations of cells are given as percentage of total
leukocytes.
Methods:
Results: In the beginning of ECMO the frequency of immature
PMNs was elevated. The majority of the immature PMN population
expressed CXCR1. When lung function was improving the immature
PMNs population decreased. Mature PMNs showed CD16 expression
and CXCR1 expression corresponding to the HC.
Conclusions: Immature CXCR1 expressing PMNs decreased when
lung function recovered. A therapeutical approach to decrease immature CXCR1 expressing PMNs could possibly facilitate lung recovery
in ECMO-treated ARDS.
...........................................................................................
P8
Sevoflurane exposure alters muscarinic acetylcholine receptor protein content and acetylcholine-induced ERK 1/2 phosphorylation in PC12
cells.
Andreas Wiklunda,b, M.D, Ph.D., Daniel Gustavssona, B.Sc,
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.
, Gunnar Schultec, Ph.D.
a. Department of Physiology and Pharmacology, Section for Anesthesiology
and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden.
b. Department of Anesthesiology, Surgical Services and Intensive Care
Medicine, Karolinska University Hospital, Stockholm, Sweden
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
memory formation. Acetylcholine, acting on G-protein coupled muscarinic acetylcholine receptors (mAChRs) in the cellular membrane,
activates ERK 1/2. The volatile anaesthetic sevoflurane attenuates the
29
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.
Results: Exposure to 5% sevoflurane over 2 hours significantly reduced the acetylcholine-induced activation of ERK 1/2. Whereas quantification of receptor mRNA (M1, M2, M3, M4, M5, α7) and receptor
localization were not significantly altered, we demonstrated a significant change in muscarinic receptor proteins. A transient decrease in
of M1 mAChR protein and an increase in M4 mAChR protein was
observed following sevoflurane exposure.
We conclude that the attenuation of acetylcholine-induced ERK 1/2 phosphorylation correlates to changes in muscarinic
receptor protein content. Our interpretation of the results supports
previous hypotheses suggesting that memory impairment following
sevoflurane exposure may be caused by disruption of acetylcholine
signalling pathways due to altered muscarinic receptor protein levels.
Conclusion:
...........................................................................................
P9
Clearance of Nitrate and Nitrite - An observational
study of continuous renal replacement therapy on
intensive care patients
Fredrik Eidhagen, Carl-Jonas Lindskog and Eddie Weitzberg
Dept. of Physiology and Pharmacology, Section of Anesthesiology and
Intensive Care, Karolinska Institutet, Stockholm.
Background: Nitric oxide (NO) has sparked a vast scientific interest
in the past decades. It is involved in various vital processes such as upholding vascular homeostasis and regulating mitochondrial function.
The supposedly stable end products of NO oxidation, nitrate and nitrite, have been established to play a crucial part in the bioavailability
of NO, since they can be recycled back to bioactive NO. This study
aimed to examine if CRRT had a scavenging effect on arterial plasma
nitrate and nitrite as well as determine the clearance and mass removal
rate of these anions.
Methods: In this observational study, 9 patients with acute renal failu-
re treated with PrismaFlex CRRT system were included. To determine
nitrate and nitrite levels samples from arterial blood were collected daily during and after CRRT. Samples were also collected from the CRRT
system in order to determine clearance and mass removal.
Results: Arterial plasma nitrate decreased significantly during CRRT,
59% after 24h, and increased towards baseline levels 24h after termination. In contrast, nitrite levels were not significantly altered by CRRT.
Clearance of nitrate ranged from 54,0±4,0 to 118,3±36 ml/min at effluent flow rates of 50–80 mL/min. Mass removal rate of nitrate declined initially and stabilized after 12 hours and correlated to arterial nitrate levels.
Conclusions: CRRT had a scavenging effect on nitrate. Nitrate passes
freely across the CRRT filter, exhibiting a clearance superior to both
creatinine and urea.
...........................................................................................
Posterpresentation 2
Måndag 21/9 kl 14:00–15:30
Lokal: Utställningen
Moderatorer: Carolina Samuelsson, Claes Frostell
P10
Single deranged physiological parameters are
associated with mortality in a low-income country
Baker T, Blixt J, Lugazia E, Schell O, Mulungu M, Milton A, Castegren M, Eriksen J, Konrad D.
Dept. of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Karolinska Institutet and Karolinska University Hospital,
Stockholm.
To investigate whether deranged physiological parameters
at admission to an Intensive Care Unit (ICU) in Tanzania are associated with in-hospital mortality, and compare single deranged physiological parameters to a more complex scoring system.
Objective:
Design: Prospective, observational, cohort study of patient notes and
admission records. Data were collected on vital signs at admission to
the ICU, patient characteristics and outcomes. Cut-offs for deranged
physiological parameters were defined a priori and their association
with in-hospital mortality was analyzed using multivariable logistic
regression.
Setting:
Tanzania.
Patients:
ICU at Muhimbili National Hospital, Dar es Salaam,
All adults admitted to the ICU in a 15 month period.
Measurements and Main Results: 269 patients were included:
54% female, median age 35 years. In-hospital mortality was 50%. At
admission, 69% of patients had one or more deranged physiological
parameter. Sixty-four percent of the patients with a deranged physiological parameter died in-hospital, compared to 18% without (p<0.001).
The presence of a deranged physiological parameter was associated with
mortality (adjusted Odds Ratio (OR) 4.64 95% Confidence Interval
1.95–11.09). Mortality increased with increasing number of deranged
physiological parameters (OR per deranged physiological parameter
2.24 (1.53–3.26)). Every individual deranged physiological parameter
was associated with mortality with unadjusted ORs between 1.92 and
16.16. A National Early Warning Score (NEWS) of ≥7 had an association with mortality (OR 2.51 (1.23–5.14)).
Conclusion: Single deranged physiological parameters on admission
are associated with mortality in a critically ill population in a low-income country. As a measure of illness severity, single deranged physiological parameters are as useful as a compound scoring system in this
setting and could be termed “danger signs”. Danger signs may be suitable for the basis of routines to identify and treat critically ill patients.
...........................................................................................
P11
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.
30
Dept. of Physiology and Pharmacology, Section of Anesthesiology and
Intensive Care, Karolinska Institutet and Karolinska University Hospital,
Stockholm.
Background: Global Critical Care is attracting increasing attention.
At 58 million deaths per year, the worldwide burden of critical illness is
greater than generally appreciated. Low income countries (LIC) have
a disproportionally greater share of critical illness, and yet critical care
facilities are scarce in such settings. Routines utilizing deranged vital
signs to identify critical illness and trigger medical interventions have
become common in high-income countries but have not been investigated in LIC. We aimed to assess whether a vital signs directed protocol
could improve care and reduce mortality on an Intensive Care Unit
(ICU) in Tanzania.
Prospective, before-and-after interventional study on the
ICU of a university hospital in Tanzania. A context-appropriate protocol that defined danger signs and actions was designed and then implemented in a four week period using sensitisation, training, job aids,
supervision and feedback. Adherence to the protocol was compared pre
and post-intervention at admission and during care on the ICU. Adherence and in-hospital mortalities were analysed with regression models.
Results: Danger signs from 447 patients were included: 269 pre-intervention and 178 post-intervention. Adherence was higher post-intervention (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).
36% of hypotension occasions were treated with fluids post-intervention, as compared to 4% pre-intervention (p=0.001) (PR 6.4 (2.5–
16.1) p<0.001). In the subgroup of patients admitted with hypotension, mortality was lower post-intervention (69.2% vs 92.3% p=0.02)
giving a numbers-needed-to-treat of 4.3. Overall in-hospital mortality
rates were unchanged (50.2% vs 50.9%, p=0.89).
Method:
Conclusion: The introduction of a vital signs directed therapy protocol improved the care of patients with deranged vital signs on an ICU
in a LIC. Mortality rates were reduced in hypotensive patients but not
for all patients.
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P12
Necrotizing soft tissue infection - First eight years
of registered HBO-treatments
Rosén Anders, Arnell Per, Lycke Hans, Oscarsson Nicklas
Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska
University Hospital/Östra and Sahlgrenska Academy, University of
Gothenburg, Gothenburg, Sweden
Background: Prompt antibiotics and early surgery are the mainstay
of treatment for necrotizing soft tissue infections (NSTI). Hyperbaric
oxygen treatment (HBOT) is considered an adjuvant, but important
resource. Centralizing the treatment of patients with NSTI has been
shown to lower the mortality rates. Sahlgrenska University Hospital/
Östra (SU/Ö) has been a regional NSTI-center since 2008. Data concerning patients treated for NSTI that require ICU-care is prospectively entered into a quality registry. Aggregation of individual patient
data enables assessment of risk factors, treatment effects and actual
mortality.
o assess mortality and describe characteristics of patients
treated for NSTI.
Objective:
Demographical data, mortality, time to antibiotics and time
to primary surgery on all patients treated between January 2008 and
September 2014 were extracted from the registry. Patients under the
age of 18 were excluded. Calcualtions were made in SPSS Statistics
v. 22. Confidence intervals (CI) are stated at the 95% confidence level.
Method:
Results: Mean time from hospital arrival until administration of antibiotics and primary surgery were 5.1 (CI=3.6, 6.7) and 21.5 (CI=16.1,
26.9) hours, respectively. HBOT (280kPa, 70–90 minutes) was given
to 60 (76.9%) of the patients. Mean number of treatments was 4.4
(CI=3.8, 5.0 range 1–20). No correlation was found between mortality
and time to antibiotics or time to surgery.
The overall estimated mortality rate based on APACHE-II and SAPS-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
16.7% in the HBOT-group and 27.8% in the non-HBOT-group
(p<0.001).
Conclusions: Mortality, with or without HBOT, was significantly
lower than predicted by standard ICU scoring systems. This might be
due to centralization and multimodality care, including HBOT.
Continued registration will provide more clinical useful information.
...........................................................................................
P13
Kinetics of serum S100b after traumatic brain injury
A Ercole1, EP Thelin2, A Holst3, BM Bellander2, DW Nelson4*
Division of Anaesthesia, University of Cambridge, Cambridge, United
Kingdom. 2Section for Neurosurgery, Department of Clinical Neuroscience,
Karolinska Institutet, Karolinska University Hospital Solna, Stockholm,
Sweden. 3School of Computer Science and Communication, KTH Royal
Institute of Technology, Stockholm, Sweden. 4Section for Anesthesiology
and Intensive Care, Department of Physiology and Pharmacology,
Karolinska Institutet, Stockholm, Sweden.
1
Purpose: To
develop a kinetic model to characterise the temporal variation of serum S100b concentration after primary traumatic brain
injury.
Data of serial serum S100b samples from 154 traumatic
brain injury patients in a neurointensive care unit were retrospectively analysed, including only patients without secondary peaks of this
biomarker. A hierarchical, Bayesian gamma variate kinetic model was
constructed and the parameters estimated by Markov chain Monte
Carlo sampling.
Methods.
Results: We demonstrated that S100b concentration changes dramatically over timescales that are clinically important for early prognostication with a peak at 27.2 hours (95% credible interval [25.6, 28.8]).
Baseline S100b levels was found to be 0.11 μg/L (95% credible interval
[0.10, 0.12]).
Conclusions: Even small differences in injury to sample time may
lead to large changes in S100b in the first days after injury. Kinetic
modelling may offer a way to reduce the ambiguity in interpretation of
randomly sampled acute biomarkers.
The kinetics of S100b mean that levels vary
dramatically over the first few days post injury which is also the time
that their potential for prognosis and for detecting secondary injury
may be most valuable. A failure to appreciate this time variation may
Take home message:
31
lead to substantial errors in evaluating initial injury severity or failing
to detect subsequent secondary injuries in later measurements.
...........................................................................................
P14
Pediatric population and management strategies
in longterm PICU
Eva Wesslen-Eriksson, MD, Director
Longterm PICU, Astrid Lindgren Children´s Hospital, Karolinska
University Hospital, Stockholm, Sweden
Children with severe, unusual and often complex diseases or malformations need technical and advanced respiratory management in order
to promote optimal medical and psychosocial care . Starting in 1990
in order to support individual growth, development and social interactions with families, the Longterm PICU at the Karolinska University
Hospital has a key role within the Pediatric Respiratory Centre. Here
a dedicated multidisciplinary team including intensive care medicine,
anesthesia, ENT surgery, pulmonary medicine, physiotherapy, speech
and language therapy, nutrition and occupation therapy provides
unique expertise upon which this highly specialized unit is based.
A key feature in treatment strategies involves advanced non-invasive 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
are currently under strong development within this segment of respiratory care. For children with malformations or impaired airway, surgical
strategies may be necessary in order to provide safe long term ventilation and spontaneous breathing. The unit also has a close follow-up of
discharged patients.
administered she became unconscious and was hastily intubated, due
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
during the first day. Carnitine was initiated at the dose of 100 mg/kg
and thereafter 15 mg/kg was given every 4 hour.
The patient was kept on a ventilator and blood pressure was stabilized with a low dose of norepinephrine. She developed a few episodes of
seizures. In the second day ammonium levels increased from 60 to 150
to 430 µmol/l and a CRRT was started. After 24 hours with CRRT
and repeated doses of carnitine the level of valproic acid decreased
from 430 to 81 µmol/l and ammonium levels decreased from 1030
to 360 µmol/l.
The patient could be extubated after seven days on a ventilator and
was transferred to a medical ward. In that stage she still hallucinated
and presented paranoid delusions which resolved completely two weeks
later. A psychiatrist refereed her psychotic episode to medical treatment
with valproic acid. She had no history of previous psychotic episodes.
Conclusions: Carnitine may be of help in reducing hepatic injury
after overdose of valproic acid. CRRT may be helpful in reducing toxicity and increasing elimination. It is possible that psychosis may be an
inadvertent effect due to valproic acid.
...........................................................................................
P16
A fatal case of consumption of fat-burning
formulas containing beta-metylphenylamine
and caffeine.
Kai Knudsen
...........................................................................................
AnOpIVA Sahlgrenska University Hospital, Göteborg
P15
Background:
A case of severe overdose with valproic acid
treated with carnitine and CRRT.
Kai Knudsen
AnOpIVA, Sahlgrenska University Hospital, Göteborg.
Background: Valproic acid is an antiepileptic medication that is incre-
asingly being used in the treatment of bipolar disorders and depression.
An overdose is associated with hypotension, respiratory failure, and
somnolence and may cause hepatic injury. Lactic acidosis and increased ammonium ion levels may be present. Treatment with carnitine
has been suggested to improve metabolism and reduce hepatic injury.
Hemodialysis may improve elimination of valproic acid.
Objectives: To report a case of valproic acid overdose where treatment
with continuous renal replacement therapy (CRRT) and carnitine was
successfully used.
Case Report: A 24-year old woman with a bipolar disorder but no
history of psychotic episodes was admitted to the Emergency Department (ED) after being found drowsy at home, due to an estimated
ingestion of 30 g of a slow-release form of valproic acid (approximately
100 tablets). She was initially cardiorespiratory stable and responsive.
During gastric lavage at the ED where 25 g of activated charcoal was
32
Beta-metylphenylamine is a component in some commercially available formulas called fat burners increasingly used by
body builders. Some formulas of fat burners also contain high amounts
of caffeine (150 mg of caffeine per cap).
In treatment of adult patients with ADHD a licensed preparation of
amphetamine has become common in Sweden. Mixtures of fat burners
and central stimulating drugs may induce profound adrenergic activity
leading to agitation, muscular rigidity, hyperthermia, seizures, rhabdomyolysis, confusion and finally circulatory collapse.
Objectives: To report a case of agitation and confusion after ingestion
of multiple fat burners when on treatment with multiple psychiatric
medications. A possible interaction was likely leading to a hyperadrenergic syndrome finally leading to cardiovascular collapse and death.
Case Report: A 31-year old man with history of ADHD, panic disor-
ders and substance abuse was on treatment with chlomipramine (375
mg/d), lisdexamphetamine (130 mg/d) and flunitrazepam (1 mg/d).
He was experienced in body-building and on his own webpage he declared a regular consumption of fat burners containing caffeine and
beta-metylphenylamine.
He was admitted to the Emergency Department after being found
convulsing at home. At the ED the patient with a body weight of 140
kilos was disorientated, confused and aggressive. A drug screening was
positive for bensodiazepines, buprenorphine, THC and tramadol.
The patient presented with extreme stress, tachycardia, hyperthermia,
sweating and high creatin-kinase (CK) levels. The patient needed to be
heavily sedated with propofol and opioids, intubated and connected to
a ventilator. Dantrolene sodium was administrated without any apparent positive effect. Treatment was instituted with dexmedetomidine,
propofol, transdermal opioids and high doses of bensodiazepines. The
patient was transferred to the psychiatric ward after two days but the
patient again became agitated and confused and was brought back to
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.
Conclusions: Medical treatment with amphetamines, tramadol and
antidepressants in a patient with a regular consumption of fat burners
may induce a hyperadrenergic syndrome with agitation, confusion, rigidity, hyperthermia, hypertension and tachycardia that may become
extremely stressful to the cardiovascular system finally leading to cardiovascular collapse and death. Warning to the public of several new fat
burners containing different biogenic amines such as beta-metylphenylamine 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.
...........................................................................................
P17
Är lipidterapi effektivt vid förgiftningar?
Sune Forsberg1,3, Matilda Forsberg2 , Jonas Höjer3,4
1
Anestesi och Intensivvårdskliniken, Norrtälje Sjukhus, 2Medicinkliniken,
Norrtälje Sjukhus, 3Institutionen Södersjukhuset, Karolinska Institutet,
4
Giftinformationscentralen
Detta är en systematisk litteraturöversikt om intravenös lipidemulsion
som motgift vid förgiftning med läkemedel eller droger. Lipidterapi
är en behandlingsstrategi som har använts sedan 2006, framförallt vid
förgiftning med lokalanestesimedel. Flera djurstudier stödjer en positiv
effekt (1) men det finns även de som motsäger sådan. Det är fortfarande oklart om och i så fall hur intravenös lipidemulsion fungerar som
antidot, men rådande hypotes är ”lipid sink theory”, som innebär att
intravenöst tillfört fett binder fettlösliga toxiner.
Syftet:
Att utröna om snabb intravenös tillförsel av lipidemulsion är
en effektiv behand- lingsmetod vid akut förgiftning med droger och
läkemedel och i så fall för vilka förgiftningsmedel och vid vilka exponeringsvägar (parenteral/peroral).
Metod:
Systematisk litteratursammanställning. Artiklarna, publicerade 1998 till mars 2013, har systematiskt sökts fram via PubMed och
Web of Science utifrån fördefinierade kriterier. Även förgiftningsmedlens log p-värde, fettlöslighet, har sökts fram via Internet. Identifierade
artiklar har granskats av två intensivvårdsläkare utifrån en klassificeringsmall(2) för att bedöma sannolikheten för lipidterapins eventuellt
positiva effekt.
Resultat:
Litteratursökningen resulterade i 3919 artiklar varav 126
uppfyllde de fördefinierade inklusionskriterierna vid genomgång av
alla abstract. Vid detaljgranskning sållades ytterligare artiklar bort och
slutligen fanns 92 patientfall kvar som rapporterat positiv effekt av
lipidbehandling. Resultaten visade ingen korrelation mellan förgiftningsmedlens ökande fettlöslighet och tydlig positiv effekt, snarare sågs
en icke statistiskt säkerställd korrelation i den andra riktningen. Vid
perorala förgiftningar var det ytterst osäkert om lipidterapin haft en
positiv effekt. Även vid parenteral feladministrering av lokalanestetika
visades lipidterapins effekt vara osäker.
Diskussion:
Enligt denna systematiska litteraturöversikt föreligger
inte några säkra vetenskapliga belägg för att lipidterapi har någon positiv effekt på människor och framför allt inte vid perorala förgiftningar.
Även negativ effekt av lipidterapi finns beskriven. Det är därför rimligt
att begränsa dess indikation till direkt livshotande situationer och när
etablerade behandlingsmetoder varit verkningslösa.
Referenser
1. Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-­Amaro MF,
Cwik MJ. Pretreatment or resuscitation with a lipid infusion shifts
the dose-response to bupivacaine-induced asystole in rats. Anesthesiology. 1998;88(4):1071-5.
2. he use of the WHO-UMC system for standardised case causality
assessment The Uppsala Monitoring Centre. Available from:
http://who-umc.org/Graphics/24734.pdf
...........................................................................................
Posterpresentation 3
Måndag 21/9 kl 16:00–17:30
Lokal: utställningen
Moderatorer: Robert Hahn, Caroline Haegerstrand
P18
The effect of intraoperative glucose infusion on
perioperative hyperglycemia
Christina Blixt* 1, Maria Sellvall1, Olav Rooyackers1
Dept. of Anesthesiology and Intensive Care, Karolinska Institute and
University Hospital, Stockholm, Sweden
1
Rationale:
Perioperative insulin resistance and hyperglycemia may
inflict on postoperative outcome. We hypothesed that elimination of
intraoperative glucose administration may reduce perioperative hyperglycemia, and hence modulate postoperative complications.
Methods: 20 patients scheduled for open hepatectomy were enrolled
in this prospective observational study. All patients received epidural
anaesthesia. Ten patients (enrolled in a previously published study)
received glucose infusion (2.5 mg/kg/h; group G), and ten newly recruited patients received Ringer-Acetate (1 ml/kg/h; group C) during
ongoing surgery. After induction of anesthesia and establishing an arterial line, sampling was initiated. Infusions were started after the central
venous line was inserted. Arterial plasma glucose was measured every
10 min. with a bedside glucose monitor (Hemocue AB, Ängelholm,
Sweden) throughout surgery.
Results: Baseline characteristics between the groups were not signi-
ficantly different for age, BMI, blood loss or operating and resection
time. Mean glucose value at start was 6.6±0.8 and 7.3±1.3 mmol/l
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
to allow for statistical analyses; n=8 in both groups) were 8.4±1.3
and 8.9±0.7mmol/l in group G and C (p=0.23, t-test). Individual
perioperative glucose levels during same time period showed no
statistical difference (p=0.51, ANOVA). Neither did comparison of
AUC in each group for the same time period show any significant
difference, 195.4±36.2 vs 201.5±35.7 mmol/l in group G and C
(p 0.71,t-test).
Conclusions: In an observational study of 20 patients scheduled for
open liver surgery, infusion of glucose (2.5mg/kg/h) or Ringer-Acetate
33
both showed a perioperative hyperglycemia but no difference between
the treatments was observed.
The authors have no conflict of interest.
...........................................................................................
P19
Fluid therapy – a systematic review and
cross-sectional study of clinical practice
Olsson D, Lindgren S
Anestesikliniken, Sahlgrenska Sjukhuset, Göteborg
Intravenous fluid treatment is one of the most common interventions
in the field of perioperative and intensive care medicine. The choice of
resuscitation fluid has been debated for many decades. At the turn of
the century the debate was reactivated as new meta-analyses surfaced.
In 1998 Schierhout and Roberts changed the view on albumin use
in intensive with an analysis showing an increased risk of death using
albumin vs other fluids. At Sahlgrenska University Hospital, albumin
costs dropped by 64 % the following year (Haljamäe and Lindgren
2000) and the synthetic colloid hydroxyeathylstarch (HES) replaced
human albumin as the preferred resuscitation colloid. In 2004 prospective studies on albumin showed no increased mortality risk compared
to crystalloids (Finfer S. et. al) and ten years later the pendulum swung
as several large prospective studies showed an increased risk of kidney
failure when resuscitating critically ill patients with HES compared to
crystalloid fluid management. (Myburgh and Mythen 2013) In 2013
international institutes issued warnings of using HES in critically ill
patients. In Sahlgrenska University Hospital the albumin costs increased by 47 % the following year. In March 2015 we conducted a
web survey, distributed to 100 physicians in the department of Anaesthesia 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
physicians in our department the adaptation to these recent fluid therapy recommendations is high. However, the economic effect of high
albumin use needs to be evaluated and the increased cost should be
advocated by a presumed better patient outcome.
...........................................................................................
P20
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.
Method: A web-based questionnaire was available to anaesthesiologists
on the Swedish, Norwegian, Danish, Finish National Anaesthesiology
Society homepage during an 8-week period and send to anaesthesiologists on Iceland; by the support of the National Anaesthesiology
Societies. Results:
Information around daily management of day care patients
was gained from 303 anaesthesiologists involved in day surgery in the
Scandinavian countries. Routine administration of preventive paracetamol was common uniform across countries (80%) but NSAIDs
were routinely used by 62 % only and varied between 32% and 80%.
Anaesthetic technique varied also, TIVA was the preferred in Denmark and Norway while inhaled technique based on sevoflurane was
common practice in Sweden and Finland. Desflurane was infrequently
used. Intraoperative analgesic did also vary, fentanyl and remifentanil
being used in similar amounts and combinations where used by 1/3
or responders. Laryngeal mask airway was preferred for shoulder (172
responders average use 73%) and breast surgery (151 responders average use 80%).A laryngeal mask airway was also used by 43 responders
for laparoscopic procedures, 34 responders for tonsillectomy and 91
responders in prone position.
Conclusion: We found a variable praxis with regard to anaesthetic
techniques; drugs used and airway management. There seems to be no
firm consensus or best practice in the Scandinavian countries around
anaesthesia for day case surgery. Further studies around outcome measures, morbidity but also data around the recovery/resumption of activities of daily living following day surgery are warranted. Follow-up
enabling “open comparisons” would be of interest.
Table 5.
Main anaesthetic/main anaesthetic technique (number of responders (average % of cases))
Sweden
(n=89)
Denmark
(n=50)
Norway
(n=59)
Finland
(n=95)
Iceland
(n=10)
TIVA
81 (46%)
46 (89%)
57 (83%)
91 (40%)
9 (43%)
Sevoflurane
81 (57%)
28 (25%)
40 (13%)
93 (55%)
10 (46%)
Desflurane
17 (24%)
2 (5%)
18 (18%)
48 (14%)
2 (30%)
Reference
1. Segerdahl M, Warrén-Stomberg M, Rawal N, Brattwall M, Jakobsson J. Clinical practice and routines for day surgery in Sweden:
results from a nation-wide survey. Acta Anaesthesiol Scand. 2008;
52: 117-24.
2. Brattwall M, Stomberg MW, Jakobsson JG. [Ambulatory surgery
in Sweden is structured and follows unified routines. A questionnaire on the practice of ambulatory surgery]. Lakartidningen. 2012;
109: 1824-7
...........................................................................................
P21
Perioperativa samtal
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 arbetar vi sedan mars 2010 med ett för oss, nytt arbetssätt i samband med
patientens operation. Den anestesi- eller operationssjuksköterska som
skall vårda patienten, träffar patienten redan före operationen, tar hand
om patienten under operationen, och utför ett uppföljande samtal efter
operationen.
or consensus around perioperative management of patients scheduled
for day case anaesthesia. The aim of the present survey was to benchmark and gain an overview of current clinical routines and practice for
day case anaesthesia among Scandinavian anaesthesiologists.
34
Vid det preoperativa samtalet får patienten möjlighet att skaffa information och ställa frågor och sjuksköterskan skaffar sig genom samtalet kunskap om patienten.
I det intraoperativa samtalet bekräftar patienten och sjuksköterskan
att de mötts tidigare och båda vet vad som gäller.
Vid det postoperativa samtalet utvärderar sjuksköterskan och patienten den perioperativa vården tillsammans. Vården blir en sammanhängande enhet.
Perioperativa samtal ökar delaktigheten och säkerheten för patienten. Det bidrar också till bättre arbetsmiljö genom minskad stress, och
ger möjlighet att utvärdera given vård. Personcentrerad vård är en av
kärnkompetenserna i avancerad vård. Arbetssättet ger vård av utmärkt
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 peri­operativa vården.
Sammanfattningsvis så visar arbetssättet att vi väl uppfyller Karolinska Universitetssjukhusets vision Patienten först.
..........................................................................................
P22
Is unexpected prolonged postoperative care
possible to predict?
Hawraz Karim, Camillla Brorsson, Göran Johansson
Institutionen för kirurgisk och perioperativ vetenskap, enheten för anestesi
och intensivvård, Universitetssjukhuset, Umeå
Bakgrund: Patienter som genomgår elektiva operationer får en vårdbedömning av kirurger och anestesiologer om det postoperativa vårdbehovet. Det förekommer att patienter blir kvarliggande på uppvakningsvårdavdelningen (UVA) och blir övernattare trots en postoperativ
vårdbehovsbedöming som icke övernattare eller UVA mindre än 8 timmar. Detta försvårar bland annat resursplaneringen på uppvakningsvårdavdelningen.
Den postoperativa vårdbehovsbedömningen för en patient görs idag
av både opererande kirurger och anestesiologer. Detta dokumenteras
på olika sätt men innefattar samma bedömningsalternativ.
Syfte: Undersöka om patienter som genomgår en elektiv operation
med oplanerad förlängd tid på UVA (övernattare) har högre ålder,
ASA Physical Status Classification System(ASA) poäng och/eller längre
anestesi duration i jämförelse med patienter som opereras elektivt och
kvarstannar mindre än 8 timmar på UVA. Har anestesiologerna en signifikant oftare korrekt prognos av vårdbehovet på UVA postoperativt i
jämförelse med kirurgernas bedömning?
Metod:
Data extraherades från perioperativt planerings system för
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
vårdbehovsbedömning och anestesiduration extraherades från det perioperativa planerings systemet. Anestesiologernas postoperativa vårdbehovsbedömningar jämfördes med kirurgernas.
Resultat:
Patienter äldre än 59 år eller som har ASA-klass ≥ 3 löper
dubbelt så stor risk att bli oplanerade övernattare på UVA trots vårdbehovsbedömning som icke övernattare. Patienter med anestesitid > 215
minuter löper 25 gånger högre risk att bli övernattare på UVA trots en
postoperativ vårdbehovsbedömning som icke övernattare. Det fanns
inga skillnader mellan träffsäkerheten i kirurgernas och anestesiologernas postoperativa vårdbehovsbedömningar.
Slutsats: Hög ålder, hög ASA-klass och lång anestesiduration är
riskfaktorer för en oplanerad övernattning på UVA efter en elektiv
operation. Dessa parametrar bör värderas i en postoperativ vårdbehovsbedömning och resursplanering för en optimal uppvakningsvård.
...........................................................................................
P23
Temperature measurement during intraabdominal treatment with hyperthermic chemotherapy
– oesophagus thermometer vs. pulmonary artery
catheter.
Marja Lindqvist
ANOPIVA-kliniken, Karolinska Universitetssjukhuset, Solna
Cytoreductive surgery with hyperthermic intreaperitoneal chemotherapy (HIPEC) is a well established method to treat colorectal malignancy with peritonal cancinosis. During the surgery the patient is exposed
to 42 C° chemotherapy intraabdominally. It is crucial to accurately
measure and regulate the patients temp. during the hyperthermic treatment. In spite of preparatory cooling of the patient, sometimes the
temperature of the inflowing chemotherapy has to be lowered to avoid
overheating of the patient. This may lead to a less efficient treatment.
We aimed to compare simultaneous peroperative measurements by
oesophageal thermometer and pulmonary arthery (PA) catheter situated in the heart, mirroring the temp. of the circulating blood. Our
hypothesis was that the PA catheter would register lower temp. during
the HIPEC treatment phase than the oesophagus thermometer.
15 patients (ASA I-III), with mean age of 56 years (21-78), weight
75 kg (45-106) undergoing cytoreductive surgery and HIPEC were
included in the study. All patients received a PA catheter in the internal
jugular vein, and an esophagus thermometer.
The temp. was recorded in intervals of 5-30 minuter from placement
of the catheters until after the end of the HIPEC treatment. Statistics
used were Bland-Altman and correlation analysis.
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
high correlation (R=0.93) between measurement methods. However,
with higher temperature more deviations were seen.
This may to some extent verify our hypothesis that the oesophagus
thermometer sometimes overestimates the temperature.
During hypothermia and normothermia, the temperatures measured by the esophageal thermometer and the PA catheter correlated
well. However, during HIPEC treatment, when the patient is exposed
to hyperthermic chemotherapy, the oesophagus temp. in some cases
diverge from the PA, showing higher temperatures.
...........................................................................................
P24
HIPEC – hur gör vi?
Susanne Wagmo, Marja Lindqvist
ANOPIVA-kliniken, Karolinska Universitetssjukhuset, Solna
HIPEC (Hyperthermic IntraPEritional Chemotherapy) tillsammans
med tumörreducerande kirurgi är en behandlingsmetod med kurativt
syfte aktuell för patienter med tarmcancer spridd till bukhinnan.
På Karolinska Universitetssjukhuset Solna har 115 patienter mellan
september 2012 och maj 2015 genomgått denna behandling. De tre
35
diagnoser som idag är indicerade för HIPEC hos oss är kolorektal­
cancer, pseudomyxoma peritonei (PMP) och mesoteliom.
Operationsmetoden innebär att all makroskopisk tumörvävnad
avlägsnas (cytoreduktiv kirurgi) varefter varm cytostatika tillsätts intraperitonellt. Värmen på vätskan är 40-42 C och behandlingen varar
mellan 30 och 90 minuter beroende på cytostatikasort. Utöver detta
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
t ex vätskebalans, konsekvenser av inflammatoriskt påslag mm, innebär
HIPEC-behandlingen i sig ett antal specifika anestesiologiska utmaningar då patientens kroppstemperatur, hemodynamik, vätskebalans
och glukos/elektrolytbalans avsevärt derangeras inför och under denna
behandling.
Vår behandlingsmetod är baserad på intryck från såväl ­nationella
som internationella HIPEC centra och även på de väl etablerade
­rutiner vi praktiserar på övrig stor bukkirurgi. Sedan starten 2012 har
vi arbetat aktivt med kontinuerliga förbättringar av vårt omhändertagande av HIPEC-patienten och har idag ett väl fungerande per- och
postoperativt koncept för att kunna hantera de specifika svårigheter
behandlingsmetoden kan medföra.
...........................................................................................
P25
Från förskräckelse till förtjusning
– implementeringen av en ny operationsmetod.
Marja Lindqvist, Susanne Wagmo
ANOPIVA-kliniken, Karolinska Universitetssjukhuset, Solna
På Anestesi, Operations och Intensivvårds-kliniken (ANOPIVA) Karolinska Universitetssjukhuset Solna har cytoreduktiv kirurgi och Hyperterm IntraPEritoneal Kemoterapi (HIPEC) på patienter med tarm­
cancer spridd till peritoneum bedrivits sedan september 2012.
Dessa patienter remitterades tidigare till Uppsala, men 2011 inleddes arbetet för att Stockholm och Karolinska sjukhuset själva
skulle kunna ta hand om sina patienter. En multidiciplinär grupp
av ­
k irurger, onkologer, anestesiologer, radiologer, operation- och
anestesisjuk­sköterskor, mottagnings- och avdelningspersonal samlades för att ­planera den framtida verksamheten tillsammans.
En riskanalys initierades tidigt i processen, med syfte att klarlägga eventuella riskområden under det per- och postoperativa
patient­omhändertagandet. Bland operation och anestesipersonal på
­A NOPIVA-kliniken fanns i detta skede en uttalad oro inför riskerna med hantering av cytostatika, och många medarbetare uttryckte
ovilja att delta i behandlingsmetoden. Riskanalysen pågick februari-augusti 2012 och konkluderade vikten av obligatorisk cytostatikautbildning för alla i det perioperativa teamet. Denna utbildning
skulle ge kunskap i praktisk hantering av cytostatika, nödvändig
skyddsutrustning och riskavfallshantering.
Den första operationen utfördes i september 2012, och inledningsvis ingick endast en mindre grupp anestesisjuksköterskor, operationssköterskor och anestesiologer i det perioperativa teamet. De initiala
cytostatikautbildningarna hölls av onkologer och medarbetare från
onkologiska avdelningar med fokus enbart på cytostatika, men successivt tog ANOPIVA-kliniken över utbildningsansvaret och designade
om dem till att även handla om den kirurgiska bakgrunden, det peroperativa 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
36
sätt har våra utbildningsdagar lyckats sprida kunskap om patientens
hela resa genom behandlingen.
Våra utbildningar har blivit mycket uppskattade, starkt bidragit
till att rädslan minskat och intresset för att delta i behandlingsmetoden ökat. Idag ingår ett stort antal medarbetare i det perioperativa
­HIPEC-teamet. Förskräckelse har blivit till förtjusning.
...........................................................................................
P26
Akut njurskada efter HIPEC-kirurgi
Andreas Lundholm
ANOPIVA-kliniken, Karolinska Universitetssjukhuset, Solna
Bakgrund: Målstyrd vätsketerapi (GDT) har evidens för att minska
komplikationsfrekvensen efter stor kirurgi. GDT har dock ännu inte
etablerats i samma utsträckning vid cytoreduktiv kirurgi med hypertermisk intraperitoneal cytostatika (CRS/HIPEC) av flera orsaker. Bland
annat finns oro kring postoperativ njurskada.
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, peroperativ handläggning och postoperativ komplikationsfrekvens.
Metod:
Samtliga sextiotre patienter som genomgick CRS/HIPEC
mellan oktober 2012 och september 2014, inkluderades. Retrospektiv
granskning av patientjournaler genomfördes och data om komorbiditet, preoperativa riskfaktorer, peroperativ handläggning och postoperativ komplikationsfrekvens registrerades. Njurskada utvärderades med
hjälp av RIFLE och postoperativa komplikationer summerades enligt
Clavien Dindo. Signifikansnivån sattes till p<0,05.
Resultat:
Postoperativ njurskada kunde ses hos 28 patienter (44 %).
Två patienter (3 %) nådde nivån F på skalan. Alla utom en patient
tillfrisknade spontant från sin njurskada inom 3 veckor. Anestesitid
var i median 790 minuter (525-1440) och kirurgitid 530 minuter
(306-966). Administrerad vätska peroperativt var i median 6000 ml
(3000-14870) och peroperativ blödning 1200 ml (150-5300). Femton
procent hade en komplikationsnivå högre än 3a på Clavien Dindos
komplikationsskala. Ingen procedurrelaterad mortalitet och ingen
30-dagarsmortalitet kunde ses. Ettårsmortaliteten uppgick till 15 %.
Gruppen med njurskada hade signifikant längre anestesi- och operationstid, för övrigt kunde ingen skillnad beträffande komorbiditet,
peroperativ hantering, komplikationsfrekvens eller mortalitet ses mellan grupperna.
Slutsats:
Nivån av njurskada var hög bland patienter som opererats
med CRS/HIPEC men var sannolikt av låg klinisk signifikans. Längre anestesi- och operationstid ökar sannolikt risken för postoperativ
njurskada. Den per- och postoperativa vården var tillfredställande men
det finns behov av att prospektivt kvantifiera graden av postoperativ
njurskada.
..........................................................................................
P27
Postoperative inflammatory response after neoadjuvant chemoradiotherapy or chemoradiotherapy for cancer of the esophagus or gastroesophageal junction – a substudy within a randomized trial
Mikael Lunda, T Moines, K Nilsson-Ekdahl, Magnus Nilssonb,
Lars Lundellb, Sigridur Kalmana. Jon A Tsaib
a
Department of Anaesthesiology and Intensive Care, and Division of
Anaesthesiology, CLINTEC, Karolinska Institutet, Karolinska University
Hospital Huddinge, 141 86 Stockholm, Sweden. bCentre for Digestive
Diseases and Division of Surgery, CLINTEC, Karolinska Institutet,
Karolinska University Hospital Huddinge, 141 86 Sweden.
Background:
Neoadjuvant chemoradiotherapy for cancer of the
esophagus or gastroesophageal (GE) junction may improve long-term
survival compared to neoadjuvant chemotherapy. However radiotherapy will also affect adjacent organs causing an inflammatory reaction
possibly increasing postoperative morbidity and mortality. The inflammatory effects of these neoadjuvant regimes have not been described
perioperatively. The aim of this study was to compare perioperative
inflammatory profile in patients following chemoradiotherapy or chemotherapy.
Patients and methods:
This was a singel center substudy within the
NeoRes trial that compared neoadjuvant chemoradiotherapy vs. chemotherapy for cancer of the esophagus or GE-junction. Patients were
randomized to receive neoadjuvant cisplatin and 5-fluorouracil with
or without 40 Gy concurrent radiotherapy prior to surgery. Consecutive patients (n=14 chemoradiotherapy and n=17 chemotherapy as per
protocol), underwent an extended protocol with assessment of postoperative respiratory physiology and inflammatory response. IL-1 beta,
IL-6, IL-8, IL-10 and MCP-1 mRNA in lung biopsies acquired at the
end of surgery and measurements of these and other compounds in
plasma during the postoperative course. Statistical analysis was performed using linear mixed models and Mann Whitney U-test.
Results:
Expression of IL-1β mRNA was significantly higher in lung
biopsies from subjects in the chemoradiotherapy group compared to
the chemotherapy group; 4.4 vs 2.0 arbitrary units (p=0.007). During
the postoperative period, respiratory parameters and plasma levels of
the inflammatory mediators, complement and coagulation factors,
CRP and leukocyte counts were similar between the two groups. There
was a trend towards an increased pulmonary complication rate in the
chemoradiotherapy group (p=0.09).
Conclusion: Neoadjuvant CRT for cancer of the esophagus or GE
junction induces a local inflammatory reaction in lung tissue, which
may play a role for the course of respiratory complications after esophagectomy. There were no significant differences in systemic inflammation or respiratory parameters during the perioperative period between
the treatment groups.
...........................................................................................
Posterpresentation 4
Måndag 21/9 kl 16:00–17:30
Lokal: utställningen
Moderatorer: Emma Larsson, Sten Walther
P28
Mortalitet hos intensivvårdspatienter – retrospektiv analys och identifiering av möjliga förbättringsområden
Emma Jerkegren Olsson, Brian Cleaver, Eva Joelsson-Alm.
Anestesi och Intensivvårdskliniken, Södersjukhuset, Stockholm
Bakgrund: Riskjusterad dödlighet (SMR) är ett övergripande kvalitetsmått för intensivvården. Det ett mått som ofta diskuteras och refereras till trots att det är komplext och svårtolkat, t ex avspeglar SMR all
given vård under 30 dygn efter IVA-inskrivning men medelvårdtiden
på en intensivvårdsavdelning är endast ca 2 dygn. IVA på Södersjukhuset hade år 2013 något högre SMR än andra sjukhus i Stockholmsområdet, och också strax över riksgenomsnittet. Syftet med studien var
att studera skillnader i inskrivningsmönster, vårdtid och beslut rörande
behandlingsstrategi mellan avlidna och överlevande intensivvårdspatienter.
Material och metod:
En register- och journalgranskningsstudie av
alla patienter på Södersjukhusets IVA 2013 som avlidit inom 30 dagar
(137 patienter) samt en kontrollgrupp av 144 överlevande patienter.
Data hämtades från Svenska Intensivvårdsregistret (SIR) angående
ålder, kön, SAPS3, IVA-diagnos, vårdtid på IVA och ankomstväg till
IVA. Från journalsystemet TakeCare hämtades data om dokumenterad behandlingsstrategi, vårdtid på sjukhuset och var patienten hade
avlidit.
Preliminära resultat: De avlidna patienterna var äldre och hade
­ ögre SAPS3-poäng än de överlevande patienterna. Fler patienter i
h
gruppen avlidna kom till IVA från en vårdavdelning jämfört med de
överlevande patienterna. Könsfördelningen var jämn i båda grupperna
men kvinnorna hade signifikant lägre SAPS3-poäng vid inskrivning till
IVA trots att mortaliteten var lika stor oavsett kön. Det var endast 34%
av patienterna som avled på IVA, de flesta (50%) avled på vårdavdelning och 16% efter utskrivning från sjukhuset.
Vid inskrivning till IVA fanns beslut om begränsad behandling hos
3% av de överlevande patienterna, och 17% av de avlidna patienterna.
Av de som kunde skrivas ut levande från IVA hade 3% av överlevande
patienterna behandlingsbegränsning införd och 44% av de som sedermera avled hade dokumenterade behandlingsbegränsningar.
Studien har identifierat flera områden där det finns förbättringspotential, t ex beslut och dokumentation av behandlingsstrategi. Det
skulle även vara intressant att titta närmare på könsskillnader gällande
intensivvårdspatienter.
...........................................................................................
37
P29
Delirium, sepsis and cognitive complaints after
critical illness and ICU stay
E Brück, A Schandl, M Bottai, P Sackey.
Dept. of Physiology and Pharmacology, Section of Anesthesiology and
Intensive Care, Karolinska Institutet, Stockholm.
Objective To study the relation between acute brain dysfunction and
sepsis during the Intensive Care Unit (ICU) stay and later self-assessed
cognitive function.
Background: Delirium and sepsis have independently been associated
with increased mortality and morbidity after ICU stay. Cognitive complaints after ICU-stay have been reported. The relation between sepsis,
delirium and longer-term cognitive problems remains unclear.
­ isken för fysiska och funktionella besvär är dock hög för de överlevanR
de patienterna och kan negativt påverka patienternas hälsorelaterade
livskvalitet (HRQoL), vilket i sin tur förknippas med dålig prognos.
Syftet var att undersöka hur HRQoL utvecklas över tid för intensivvårdspatienter med lång vårdtid (>96 timmar). Data är rikstäckande
från SIR inskickat 2008–2014. Intensivvårdsrelaterade data av vikt för
HRQoL (SF-36) analyserades för hela kohorten samt för specifika diagnosgrupper.
Resultatet visar att de 1438 patienter som hade en komplett longitudinell uppföljning skattar en ökad nivå i HRQoL över tid i samtliga
dimensioner. Skillnad fanns dock mellan olika diagnosgrupper, såsom
sepsis, COPD oh ARDS. En stor del av patienterna (10-25%) skattade
lägre nivå i HRQoL 12 månader efter intensivvård jämfört med svensk
norm.
Tabell. Förändring av HRQoL över tid efter utskrivning från IVA
(N=1438), Median (IQR)
SF-36 dimension
Design:
Prospective cohort study
Fysisk
Fysisk
Social
rollAllmän VitalifunkSmärta
funkfunkhälsa tet
tion
tion
tion
Setting: General ICU at Karolinska University Hospital, Solna, Stock-
holm.
Emotionell
rollfunktion
Mental
hälsa
Methods: 240 patients staying more than 24 hours at the I­ntensive
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 Questionnaire (CFQ), Hospital Anxiety and Depression Scale (HADS) and Posttraumatic Stress Symptoms -10 questionnaire (PTSS-10).
2m
50
0
(25-75) (0-25)
6m
65
25
62
57
55
75
100
80
(40-85) (0-100) (41-100) (40-77) (35-70) (50-100) (0-100) (60-92)
12 m
70
25
62
57
55
75
100
80
(40-85) (0-100) (41-100) (35-77) (35-75) (50-100) (0-100) (60-92)
Results:
Sammanfattningsvis visar dessa nationella data att HRQoL efter intensivvård för patienter med lång vårdtid på IVA förbättras över tid för en
selekterad grupp. En stor del av patienterna skattar markant låga nivåer
i HRQoL vilket kan få konsekvenser för återhämtningen efter IVA
125 patients, 60% of those alive, responded at 3 months.
The incidence of delirium was 33.6% among the responders. 41.6% of
the patients had severe sepsis or septic shock. The incidence of delirium was higher in patients with severe sepsis and septic shock, yielding
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 significantly correlated with self-assessed cognitive function complaints
(r = 0.83; p < 0.001). We estimated a 0.73 (95% CI, 0.53-0.94;
p<.001) increase in complaints by a unit increase in PTSS-10. After
adjusting for confounders, the estimated increase was 0.54 (95% CI,
0.16-0.92 p<.01) using linear regression.
Conclusions: The incidence of delirium is higher in patients suffering
from systemic inflammation (severe sepsis/septic shock). Posttraumatic stress symptoms are strongly correlated with later self-assessed cognitive complaints. These findings imply that posttraumatic stress needs
to be assessed when evaluating cognitive function in ICU survivors.
...........................................................................................
P30
Hälsorelaterad livskvalitet upp till 12 månader efter intensivvård – rikstäckande lärdomar från SIR
L.Orwelius1,2,3, E. Åkerman3, CJ Wickerts3, S. Walther 3,4
Intensivvårdskliniken, 2Institutionen för klinisk och experimentell
medicin, 4Institutionen för Medicin och Hälsa, Linköpings Universitet,
3
Svenska Intensivvårdsregistret.
1
Utvecklingen av intensivvård har möjliggjort en ökad överlevnad för
patienter även med komplexa sjukdomar och omfattande skador.
38
52
54
45
63
33
72
(32-84) (37-72) (25-60) (38-88) (0-100) (52-88)
...........................................................................................
P31
Hälsorelaterad livskvalitet efter intensivvård
Gisela Vogel leg ssk, doktorand, Eva Joelsson-Alm leg ssk, PhD,
Anna Sandgren, leg ssk, PhD, Christer Svensén, MD, PhD,
­professor, Ulla Forinder, socionom, PhD, docent.
Anestesi och Intensivvårdskliniken, Södersjukhuset, Stockholm
Bakgrund: Tidigare studier visar att svår kritisk sjukdom och vård på
en intensivvårdsavdelning (IVA) kan leda till komplikationer lång tid
efter vårdtiden såsom depression, PTSD, stress, sömnstörningar, kognitiv svikt och påverkan på patientens fysiska funktioner. Det finns
även studier som visar att patientens hälsorelaterade livskvalitet (HRQoL) är påverkad lång tid efter intensivvård och att framförallt komorbiditet är en bidragande faktor.
Syfte: Att undersöka hälsorelaterad livskvalitet 3, 6 och 12 månader
efter intensivvård och att undersöka faktorer som är associerade med
hälsorelaterad livskvalitet.
Frågeställningar:
Hur påverkas HR-QoL efter svår kritisk sjukdom
och intensivvård på en allmänkirurgisk intensivvårdsavdelning? Förändras den hälsorelaterade livskvaliteten över tid? Finns det faktorer
som påverkar hälsorelaterad livskvalitet efter svår kritisk sjukdom och
intensivvård?
Metod:
Data samlades in via en allmänkirurgisk IVAs uppföljningsmottagning med SF-36, 3, 6 och 12 månader efter intensivvård samt
att faktorer såsom ålder, kön, inskrivningsdiagnos, komorbiditet,
APACHE II, opererad/ej opererad, familjesituation, tid på IVA och
förekomst av ventilatorbehandling registrerades. Data är insamlade
mellan 2004–2013 och 276 patienter är inkluderade i studien.
Materialet kommer att redovisas med deskriptiv och analytisk statistik och resultaten kommer att kunna presenteras på SFAIs kongress
21-23 september 2015.
Metod: Patienter, 18 år eller äldre med en skadegrad enligt New Injury
(Tabell 1): visar att patienter vårdade på en allmänkirurgisk IVA (Study I) har sämre livskvalitet 12 månader efter
svår kritisk sjukdom och intensivvård än patienter i tidigare studier och
jämfört med svensk norm population.
på de utvalda sjukhusen. Av dessa uppfyllde 74 (40 %) inklusionskriterierna för uppföljning. Andelen svarande vid 3,6 och 12 månader efter
traumatillfället var 70 %, 64 % samt 67 %.
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.
Preliminära resultat
Tabell 1
Study I
100
80
Resultat: Totalt registrerades 189 patienter i SweTrau september 2013
Konklusion:
60
Orwelius, et
al, 2010
40
20
0
Severity Score (NISS) ≥ 9 som registrerats i SweTrau under september
månad 2013 på fem sjukhus inkluderades. Uppföljningen gjordes med
telefonintervjuer vid tre, sex och tolv månader efter traumatillfället.
Vid dessa uppföljningstillfällen ställdes frågor gällande livskvalitet,
funktionsförmåga, arbetsförmåga samt smärta. De PROM enkäter
som användes var EQ5d, RAND 36 och PTSS 10. PTSS 10 poäng >
35 användes som gräns för symtom på post traumatisk stress (PTSD).
PF RP BPGHVT SF REMH
Norm
population
Sweden 1992
(SF-36)
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
quality of life.
...........................................................................................
P32
Långtidsuppföljning av patienter vårdade efter
traumamatisk skada med patientrapporterade
utfallsmått (PROM).
Gunilla Wihlke, Olof Brattström
Svenska Traumaregistret(SweTrau) och ANOPIVA-kliniken Karolinska
Universitetssjukhuset.
Bakgrund: Trauma, skador på grund av yttre våld, utgör ett omfattande folkhälsoproblem. Skador är den vanligaste dödsorsaken bland
yngre människor, och för patienter som överlever den initiala fasen
efter trauma finns risk för kvarstående fysisk och psykisk sjuklighet.
Utveckling av traumavården har lett till att vi idag ser allt mer svårt
skadade patienter som överlever den initiala skadan. Patentrapporterade utfallsmått som sjukdomssymtom, funktionsförmåga och hälsorelaterad livskvalitet är parametrar som har blivit allt viktigare att följa över
tid för att dels kunna mäta konsekvensen av trauma utöver mortalitet,
men också för att kunna utvärdera omhändertagandet generellt men
även möjliggöra identifiering av riskgrupper för specifika interventioner i vården av denna patientgrupp.
Vårt syfte med detta projekt var att se om det är möjligt att införa patientrapporterade utfallsmått i det nationella kvalitetsregistret
SweTrau och på så sätt kunna mäta konsekvensen av trauma på nationell nivå i form av bl.a sjukdomssymtom, funktionsförmåga och
hälsorelaterad livskvalitet på lång sikt.
I detta pilotprojekt visar vi att traumapatienter har kvarstående 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 patientpopulationen är heterogen. Arbetet med uppföljning av denna patientgrupp är tidskrävande och för bästa möjliga utnyttjande av resurser
och kunskap anser vi att uppföljning på detta sätt bör regionaliseras. ...........................................................................................
P33
Har den riskjusterade 30-dagars mortaliteten
ändrats mellan 2001–2011?
Larsen Robert, Sjöberg Folke
AnOpIVA Universitetssjukhuset Linköping
Trauma är en dynamisk sjuka och det finns dynamik i de Svenska traumasiffrorna. Vi vet att antalet trafikolyckor minska i samhället idag,
men vi vet inte om dödligheten följer efter i samma takt. Det har publicerats skillnader i Europeiska/skandinaviska trauma och vi fortsätter
med en totalstudie av slutenvårdskrävande trauman i Sverige.
Vi har gjort en riskjusterad traumadatabas av samtliga slutenvårdskrävande trauman i Sverige under åren 2001–2011 genom att kombinera slutenvårdsregistret och dödsorsaksregistret. Vi har valt att
specialstudera fallolyckor (som är den största bidragande orsaken till
slutenvårdskrävande traumadödlighet), trafikolyckor och även övergrepp för att få tre helt olika grupper. Vi jämför dessa tre grupper mot
resterande traumafall i databasen, då vi är övertygade om att traumapopulationen skiljer sig från resterande befolkning, och får då två ben
med ca en miljon patienter i var ben. För att få en korrekt riskjustering
har vi gjort en International Classification of disease 10 Injury Severity
Score (ICISS) modell med en huvuddiagnos och upp till nio bidiagnoser för att spegla att vi tror att multitrauma är dödligare än singeltrauma. Med hjälp av logistiska regressioner mot 30 dagars mortalitet kan
vi inkludera kön, ålder, vårdtid och diagnosgrupper.
Med frekvenser som inte skiljer sig signifikant på fall och övergrepp
medans trafikolyckor minskar och ett OR som mestadels passerar ett
är det svårt att uttala sig om att det finns en dynamik i mortaliteten.
Börjar man sedan subgruppera på olycksbas och kön kan man se att
fallolyckor är nästintill oförändrat över tid. Trafikolyckor uppdelat på
kön så ser man en mortalitetsminskning för män och de sista fyra är
det signifikant medans kvinnor bara har en minskning det sista året.
39
Män har en minskning i trafikrelaterad mortalitet och fall verkar vara
en utmärkt referensgrupp.
...........................................................................................
P34
Long term cerebral outcome after prolonged
hypoxemia during Extracorporeal Membrane
Oxygenation
Bernhard Holzgraefe1, Christin Andersson2, Håkan Kalzén3,
Mikael Mosskin4, Kenneth Palmér3, Björn Frenckner, Anders
Larsson6
ECMO Department Karolinska, Karolinska University Hospital and
Department of Physiology and Pharmacology, Section for Anesthesiology
and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden;
2
Department of Psychology, Karolinska University Hospital, Huddinge
and Karolinska Institutet, Stockholm, Sweden; 3ECMO Department
Karolinska, Karolinska University Hospital, Stockholm, Sweden; 4Department of Neuroradiology, Karolinska University Hospital, Stockholm,
Sweden; 5Department of Pediatric Surgery, Karolinska University
Hospital and Karolinska Institutet, Stockholm, Sweden; 6Department of
Anesthesiology and Intensive Care and Hedenstierna Laboratory, Uppsala
University Hospital, Uppsala, Sweden;
1
Rationale: Uncontrolled hypoxemia in severe refractory respiratory
failure is associated with cognitive impairment in survivors. However, whether maintaining adequate tissue oxygen delivery but accepting
hypoxemia during Extracorporeal Membrane Oxygenation (ECMO)
as a part of a lung protective strategy would affect cognitive outcome
is not known.
Objectives: The present study investigated the prevalence of brain
lesions and cognitive dysfunction in long-term survivors from influenza A/H1N1 2009 induced hypoxemic respiratory failure treated with
ECMO.
Methods: The study (NCT01763060) was approved by the local ethical committee and written informed consent was obtained of every
participant. Brain lesion and cognitive function outcome were investigated with magnetic resonance imaging and standardized neuropsychological tests, respectively.
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
mmol/L. Full-scale intelligence quotient (FSIQ) was normal in five of
six patients (within mean ± 1 SD). In one patient FSIQ could not be
determined due to lack of formal education. Memory functioning and
general cognitive ability were normal in all seven subjects (within mean
± 1 SD). Four patients showed brain lesions, which were unrelated to
treatment or hypoxemia.
Conclusions: If adequate organ perfusion is preserved during ECMO,
hypoxemic conditions could be accepted to avoid further harm by aggressive mechanical ventilation or oxygen toxicity.
...........................................................................................
40
P35
Student- and patient centered supervision in
critical care
Ann-Charlotte Falk CCRN, Med.dr, Tarja Huhatoja CCRN,
Eva-Maria Wallin CCRN
ANOPIVA kliniken, Karolinska Universitetssjukhuset, Solna
Introduction:
There is a growing need to improve clinical supervision 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 degree to become a nursing-specialist puts high demands on feedback,
reflection and evidence-based care. To meet those needs a studentand patientcentred supervision has been developed in the critical care
setting. The aim is to improve supervision to meet demands on more
students per supervisor and to make students take responsibility over
patient-care during critical care.
Setting: The supervision was performed by reg.nurses with a specialist
degree at a Critical Care Unit at a level one trauma center with 13 beds
for intensive care patients. All patients are care for by one reg. nurse
(1:1) with specialist competence.
Method: All students and supervisors evaluated the supervision (both
orally and written) during the student-and patient centered supervision.
Results: Supervision was performed in one regular patient-room with
three-four patients requiring intensive care. Two specialist-nursing
students care for every patient. One supervisor is responsible for 2–4
students which led’s to improved peer learning before reflection is initiated together with the supervisor. The result shows that students
improve they’re clinical- and decision making skills as well as inner and
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
peers, high demands with severely ill patients and lack of time for reflection.
Conclusion: Student- and patient centered supervision in the critical
care setting improves students clinical- and decision making skills as
well as inner and external authenticity.
...........................................................................................
P36
Tvärprofessionellt team
Jenny Jonsson och Tuula Mäklin (undersköterskor), Kristina
Norden­skjöld, Leyla Sheikdon och Marie Eivarsson (sjuk­
sköterskor), Marianne Mörrby Ramberg, Brian Cleaver och
Emma Jerkegren Olsson (läkare) och Eva Joelsson-Alm (coach)
Anestesi och Intensivvårdskliniken, Södersjukhuset, Stockholm
Riskjusterad dödlighet (SMR) är ett övergripande kvalitetsmått för intensivvården. Det ett mått som ofta diskuteras och refereras till trots
att det är komplext och svårtolkat, t ex avspeglar SMR all given vård
under 30 dygn efter IVA-inskrivning medan medelvårdtiden på en intensivvårdsavdelning är endast ca 2 dygn. En annan faktor som kan
påverka SMR är i hur stor utsträckning patienter med behandlingsbegränsningar vårdas på IVA.
IVA på Södersjukhuset har haft en något högre riskjusterad dödlighet än andra sjukhus i Stockholmsområdet, och också strax över riksgenomsnittet. En pilotanalys gjordes av några journaler från avlidna
patienter som bland annat visade att beslut om behandlingsstrategi och
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 utvecklingsprogram på Kvalitetsregistercentrum Stockholm (QRC) för
förbättringsarbete med stöd av kvalitetsregister.
Övergripande mål var att förbättra möjligheterna för patienterna att
få vård på rätt nivå i rätt tid genom att ställningstagande angående
behandlingsstrategi genomförs kontinuerligt under hela vårdtiden på
IVA. Till förbättringsprojekt har data använts från Svenska Intensivvårdsregistret – SIR. En stor register- och journalgranskningsstudie av
patienter som vårdats på IVA 2013 har utförts inom projektet.
Teamet har arbetat med att förbättra rutinerna för och följsamheten
till beslut angående behandlingsstrategi. Förbättringsförslag var att använda en rondmall där behandlingsstrategi står med som obligatorisk
punkt, att planera för regelbundna tvärprofessionella vårdkonferenser
tillsammans med patient eller närstående och att utse en patientansvarig sjuksköterska och undersköterska.
Resultatet visar en kraftigt förhöjd följsamhet till rondmallen, att
behandlingsstrategi diskuteras dagligen, att vårdkonferenser planeras i
betydligt högre utsträckning än tidigare och att de flesta patienter nu
får en patientansvarig sjuksköterska och undersköterska. Teamet har
även lyckats få hela Södersjukhuset att ändra dokumentation av behandlingsbeslut i patientjournalen.
...........................................................................................
Posterpresentation 5
Måndag 21/9 kl 17:45–19:00
Lokal: utställningen
Moderatorer: Karl-Fredrik Sjölund, Malin Jonsson Fagerlund
P37
Glial dysfunction and persistent neuropathic
postsurgical pain
Linda Block, Specialistläkare, Med Dr
AnOpIVA, Sahlgrenska Universitetssjukhuset, Göteborg
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
treat, and conventional pain therapies are often insufficient. A possible
mechanism for the transition from acute physiological pain to persistent neuropathic pain involves low-grade inflammation in the central nervous system, glial dysfunction and subsequently an imbalance
in the neuron-glial interaction that causes enhanced and prolonged
pain transmission. A peripheral injury can cause low-grade neuroinflammation that in turn activates glial cells. The activated glial cells
exhibit cellular changes, and their communication is altered. Astrocyte
dysfunction, which occurs as a component of low-grade neuroinflammation, can be experimentally restored using the combined actions of a
µ-opioid receptor agonist, a µ-opioid receptor antagonist, and an anti­
epileptic agent. To achieve this response, the use of an ultralow dose
of the µ-opioid receptor antagonist naloxone seems to be particularly
crucial. Clinically, a pilot study that involved patients with persistent
pain demonstrated that intrathecal administration of an ultralow dose
of naloxone in combination with morphine had beneficial effects in
terms of perceived quality of sleep. The concept of targeting glial dysregulation instead of neural excitability to reduce the development of
persistent neuropathic pain is a promising path that merits further
evaluation in clinical settings.
...........................................................................................
P38
Local Infiltration Analgesia for Pain Relief
following Abdominal Hysterectomy. A randomized, double-blind study
J Hayden, O Carlsson, K Olausson, S E Thörn, A Gupta
AnOpIva, Sahlgrenska Universitetssjukhuset, Göteborg
Introduction: In Sweden, approximately 10,000 women undergo hys-
terectomy each year and over 60% of these are performed via open abdominal surgery. Postoperative pain during the first 24 h is moderate to
severe. Several methods have been used for postoperative pain management. This study (Clinical Trials NCT01782781) assessed the efficacy
of local infiltration analgesia (LIA) during abdominal hysterectomy.
Methods: Following Ethics Committee approval, 60 patients undergoing open abdominal hysterectomy were randomized to Group LIA
(150 ml of a mixture of 0.2% ropivacaine + 30 mg toradol + 0.5 mg
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. Postoperative pain, analgesic consumption (patient controlled i.v. morphine),
side effects and home discharge were recorded.
Results:
Rescue morphine consumption during the first 24 hours
a­ fter 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
intensity at the incision site was significantly lower in group LIA compared to group C during the first two hours at PACU. Postoperative
opiate-related complications were significantly lower in group LIA.
Discussion:
Local infiltration analgesia for management of postoperative pain was superior to saline and resulted in lesser rescue analgesic
consumption, lower pain intensity and a lower incidence of side effects.
Future studies should be directed towards comparison between LIA
and other standardized or routinely used methods.
...........................................................................................
P39
Morfin intratekalt och epiduralt vid obstetriska
och gynekologiska operationer i Sverige
– enkätstudie.
Anette Hein, överläkare1, Caroline Haegerstrand1, Gunnar
Dahlgren2, Jan Jakobson1
1
Anestesi och Intensivvårdskliniken Danderyds sjukhus, 2Anestesi och
Intensivvårdskliniken St Görans sjukhus Capio
Bakgrund: Intratekalt och epiduralt administrerat morfin till kejsarsnitt och hysterektomi samt vid värkarbete har visats förbättra smärtlindring postoperativt respektive under förlossning. Hur vanlig användningen av neuroaxialt morfin är till dessa patientgrupper är dock
inte känt. Biverkningar av neuroaxialt morfin förekommer och kan
begränsa användandet liksom behovet av övervakning.
41
Material och metoder: I enkätstudie efterfrågas intratekal och epidural rutinanvändning av morfin, sufentanil och fentanyl, vid förlossningssmärta, kejsarsnitt och hysterektomi. Förekomst av riktlinjer
avseende neuroaxiala opioider, ffa morfin, och hur övervakning är
­organiserad efterhörs. Genom socialstyrelsens medicinska födelseregister identifierades 47 kliniker med förlossningsenheter, till vilka enkäten
sändes via mail.
Resultat:
Vid de 29 kliniker som hittills svarat sker 77 % av landets
förlossningar och utförs 79 % av Sveriges kejsarsnitt.
Rutinmässigt använder 18/29 svarande kliniker intratekalt morfin
vid kejsarsnitt. Vid dessa 18 utförs 76 % av svarande klinikers kejsarsnitt. Intratekalt morfin till gynekologiska operationer används av
18/29 kliniker. Elva av 29 klinker använder epiduralt morfin vid kejsarsnitt (56%) medan endast 5/29 använder epiduralt morfin vid gynekologiska operationer. Sju av 11 svarande kliniker som inte använder
intratekalt/epiduralt morfin anger ”risk för andningsdepression” och
”svårigheter att övervaka” som skäl. Vid kejsarsnitt är vanligast förekommande intratekal morfindos 100 mg (15/18) -125 mg (3/18) och
tillsats av intratekalt fentanyl 10-20 mg (20/29) respektive sufentanil
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
oftare förekommande (23/29).
Arton av 29 kliniker använder intratekalt morfin vid hysterektomi och vanligaste dos är 200 mg (9/29) medan övriga använder 80–
140 mg (9/29). Postoperativ övervakning följer SFAIs riktlinjer och
organiseras vanligen uppdelat med inledande 2–6 timmar på postoperativ avdelning eller förlossning och därefter upp till totalt 12 timmar
på bb/vårdavdelning.
Konklusion:
Användandet av neuroaxialt morfin är utbrett men begränsas fortfarande av oro för andningsdepression och övervakningssvårigheter.
...........................................................................................
P40
Auditory function following post dural puncture
headache treated with epidural blood patch
– A long-term follow-up
Bijan Darvish, Gunnar Dahlgren, 3Lars Irestedt, 1Anders Magnuson, 4Claes Möller, 5Anil Gupta, 1,6
ANOPIVA, Karolinska Universitetssjukhuset, Solna
Background: Epidural analgesia is commonly used for pain management during labor. Sometimes, accidental dural puncture (ADP) occurs
causing severely debilitating headache, which may be associated with
transient hearing loss. We investigated if auditory function may be impaired several years after ADP treated with epidural blood patch (EBP).
Methods: Sixty women (ADP group) without documented hearing
disability, who received EBP following ADP during labor between
the years 2005–2011 were investigated in 2013 for auditory function
using the following tests: otoscopic examination, tympanometry, pure
tone audiometry and transient evoked otoacoustic emissions. Additionally, they responded to a questionnaire, the Speech, Spatial and Qualities (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
42
and the control groups in tympanometry or otoacoustic emissions.
Pure tone audiometry revealed a significant but small (< 5 dB) difference between the ADP and control groups (p<0.05). The ability to
hear speech in noise as measured by SSQ was significantly reduced in
the ADP group compared to the control group (p<0.05).
Conclusions: A minor hearing loss was detected in the ADP group
compared to the control group in pure tone audiometry in some women and during speech in noise component several years after accidental dural puncture treated with an epidural blood patch. This small
residual hearing loss has minor clinical significance.
...........................................................................................
P41
Alteration in hearing following Accidental Dural
Puncture (ADP) in the Parturient. The effect of an
Epidural Blood Patch
B Darvish, G Dahlgren, C Möller, L Irestedt, A Gupta
Karolinska University Hospital, Solna and Örebro University Hospital,
Introduction:
Post dural puncture headache (PDPH) affects 1% of
parturients having epidural analgesia. The incidence of PDPH following ADP is between 50- 86%. Changes in hearing function following
PDPH are not uncommon. Reduction in hearing is almost always in
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
(EBP) on hearing.
Method: Twenty-one patients having an ADP and confirmed diagnosis 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
number of patients having an epidural (Group A) or without epidural
(Group B) served as control groups.
Results:
There were no differences in demographic data, parity or incidence of instrumental delivery. Length of hospital stay was statistically 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
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
10 (48%). Headache was significantly lower 4 hours after treatment
with EBP (p<0.05). No differences were found on the audiometric
test battery between the groups. There was, however, a significant difference in the number of patients with clinically important hearing
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).
Conclusions: EBP resulted in a significant reduction of PDPH after
4 h Length of hospital stay was prolonged following PDPH treated
with EBP. A significantly greater number of patients with PDPH had
hearing loss > 20 dB at low frequency
...........................................................................................
P42
Dexmedetomidine as adjunct to ilioinguinal/
iliohypogastric nerve blocks for pediatric inguinal
hernia repair: An exploratory randomized
controlled trial
M Lundblad1, D Marhofer2, S Eksborg3, PA Lönnqvist4
Dept of Paediatric Anaesthesia & Intensive Care, Karolinska University Hospital, Stockholm, Sweden. 2Dept of Anaesthesia and Intensive
Care Medicine, Medical University of Vienna, Vienna, Austria. 3Dept
of Women´s and Children´s Health, Karolinska Institutet, Stockholm,
Sweden . 4Dept of Physiology & Pharmacology, Section of Anaesthesiology
& Intensive Care, Karolinska Institutet, Stockholm, Sweden
1
Background:
Adult meta-analysis has identified dexmedetomidine as
a potentially useful adjunct to prolong the duration of peripheral nerve
blocks. However, no data exist regarding the adjuvant use of dexmedetomidine in the setting of pediatric peripheral nerve blocks.
Methods:
Using a prospective, randomized, double-blind design,
children (1½-8 yrs, ASA 1-2) scheduled for outpatient inguinal hernia repair were randomized to receive either an ultrasound guided
­ilioinguinal/iliohypogastric nerve block (IINB) with plain ropivacaine
0.197 % (Group LA; n = 21) or ropivacaine 0.197 % with adjunct
dexmedetomidine 0.3 mcg kg-1 (Group LAD; n = 22). The primary endpoint of the study was time to first postoperative administration of supplemental analgesia (FPASA) triggered by a pain score > 4
(CHIPPS or NRS scale). Intention-to-treat (ITT) analysis was decided
as the primary statistical analysis of the data.
Results:
The median time to FPASA was prolonged by 88 % following the use of adjunct dexmedetomidine (4.0 hours and 7.6 hours in
group LA and LAD, respectively) (p = 0.0717). Patients in Group LA
displayed a significantly higher number of patients with a CHIPPS
score > 4 in the PACU (7 vs. 0; p = 0.0029) as well as a higher incidence of PAED (4 vs. 0; p = 0.0485) when compared to patients
in Group LAD. No adverse events were recorded in any of the study
groups.
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
repair. In addition, the use of adjunct dexmedetomidine was associated
with a prolongation of the period to first supplemental analgesia demand. The results of the present exploratory study must be viewed as
preliminary and need further validation by future larger sized studies
and/or meta-analysis.
...........................................................................................
P43
Hemodynamic effects of spinal anesthesia (SPA)
in patients with proximal femoral fracture
Marcus Hellkvist, Sigridur Kalma, Erzsébet Bartha
Department of Anesthesia and Intensive care, Karolinska University
Hospital Huddinge, and Karolinska Institutet, CLINTEC, Stockholm,
Sweden
Background: During our randomized controlled trial (RCT) on per-­
operative Goal Directed Haemodynamic Treatment (NCT01141894)
in patients with hip fracture we observed that the routine group reduced
the oxygen delivery index (DO2I) in average by 16 % (95% CI 15%;
21%).
Aims: To explore the haemodynamic changes during the first 45 minutes after the SPA:
1. in the routine fluid group as a whole
2. in subgroups of patients with and without post-spinal hypotension
Methods: Population: patients who were allocated to routine fluid
regime during the RCT and were anaesthetized by SPA are included.
Monitoring: LiDCOplus™ was used, but concealed to the clinician
during the RCT.
Data extraction: by the LiDCOviewPro software; data collected between the calibration of LiDCOplus™ (T0) and 45 minutes after
SPA (T45) was used analysed. Mean values/minute were calculated.
Missing values were generated by linear interpolation between the two
closest values.
Haemodynamic variables: MAP (mean arterial pressure), HR (heart
rate), SVI (stroke volume index), CI (cardiac index ), DO2I (oxygen
delivery index index), SVRI (systemic vascular resistance index).
Statistical analyse: The haemodynamic changes were analyzed by
ANOVA (one-way, repeated measures) by compensation of for multiple comparisons (Dunnett´s test). The level of significance was 0.05
(GraphPad Prism 6™).
Results: We analyzed data of 64 patients: mean age 85 years; ASA-PS
≥3 in 70 %.
In the whole group: MAP and SVRI reduced within 2–5 minutes; CI
and DO2I reduced and SVRI increased after 23 minutes. The median
DO2I reduction after 45 minutes was -17% (range: -100% +45 %).
Subgroups with/without post-spinal hypotension: the post-spinal hypotension (n=48) was treated by phenylephrine, or ephedrine. The hemodynamic patterns of “no hypotension” were biphasic; of “hypotension”
progressively declining.
Given that the DO2I might be associated with negative outcomes,
the treatment of post-spinal hypotension in this context needs research.
...........................................................................................
Posterpresentation 6
Måndag 21/9 kl 17:45–19:00
Lokal: utställningen
Moderatorer: Lill Bergenzaun, Lars Berggren
P44
Variationen i antalet organdonationer per landsting minskar när hänsyn tas till donatorns hemvist
Thomas Nolin, Caroline Mårdh, Göran Karlström och Sten
Walther.
Svenska Intensivvårdsregistret, SIR.
Bakgrund: I direktiven till den pågående statliga utredningen om donations- och transplantationsfrågor konstateras att det finns stora skillnader mellan landstingen i antalet organdonationer. Syftet med denna
analys var att se i vilken omfattning som skillnaderna kan förklaras av
att organdonationer kommer till stånd utanför hemortens landsting.
43
Metod:
Ur Svenska Intensivvårdsregistrets databas hämtades data från
2009–2014 för avlidna på IVA. De avlidna kategoriserades utifrån två
perspektiv: vårdgivarperspektivet avsåg landsting där patienten avled
och befolkningsperspektivet avsåg det landsting i vilken patienten hade
sin hemvist. Hemvisten (folkbokföringsorten) bestämdes genom den
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 etikprövningsnämnd. Variationen mellan landstingen beskrevs med variationskoefficienten (C.V. = medelvärdet/SD).
Konklusioner:
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
utvärderingsbara protokoll (varav 810 var organdonatorer). För 18 226
(92,5 %) avlidna och 667 (82,3 %) organdonatorer sammanföll vårdgivar- och befolkningsperspektiven, dvs. vården skedde inom det
”egna” landstinget. För 1 475 (7,5 %) avlidna och 143 (17,7 %) organ­
donatorer ägde vården rum i ”annat” landsting än där den ­avlidne var
folkbokförd.
Variationskoefficienten beräknad utifrån ett vårdgivarperspektiv var
0,54 med variation från 3,6 till 31,3 organdonatorer per miljon invånare (pmp) och landsting. Ur ett befolkningsperspektiv var C.V. 0,31
med en relativ spridning från 6,9 till 27,7 pmp och landsting.
Slutsats:
Variationen i antalet organdonationer per landsting minskade när analysen gjordes ur ett befolkningsperspektiv jämfört med
ett vårdgivarperspektiv. En avsevärd variation kvarstod som behöver
analyseras. Den kan t.ex. bero på befolkningens ålderssammansättning,
intagningskriterier för intensivvård eller avdelningarnas identifiering av
möjliga organdonatorer.
...........................................................................................
P45
Sjuksköterskors upplevelser av att vårda en
avliden organdonator under donationsprocessen
på operationsavdelning.
Maria Hellström, Maria Söderström
ANOPIVA, Karolinska Universitetssjukhuset, Solna
Sammanfattning
Introduktion:
Vid omhändertagande av en avliden organdonator under donationsprocessen på operation, ställs sjuksköterskor inför olika
känslomässiga konflikter och dilemman. Det är svårt för sjuksköterskorna 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 transplantationsteam, oftast från andra sjukhus. Detta gör att donationsprocessen på
operation är en speciell upplevelse för sjuksköterskor.
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
med kvantitativ ansats analyserades.
Resultat:
Sjuksköterskors upplevelser är att det är en stressande och
känslomässig situation att vårda en avliden organdonator under donationsprocessen på operation. Det är en lång process som startar innan
donatorn anländer till operationsavdelningen och kan sträcka sig lång
tid efter för sjuksköterskan.
44
En organdonation är en känslomässig och stressande
situation för sjuksköterskor. Behovet av utbildning i hjärndödsdiagnostik och donationsprocessen i stort var något som önskades . Återkoppling om de donerade organens funktion var något som upplevdes som
positivt och önskades i högre grad.
...........................................................................................
P46
Tidig identifiering av etiska frågeställningar
hos den intensivvårdade patienten
Karolinska Universitetssjukhuset Huddinge, Intensivvårdsavdelning B46
Patienterna på intensivvårdsavdelningen (IVA) är kritiskt sjuka och
har ofta ett livshotande tillstånd. Vården av dessa patienter är många
gånger komplex, vilket leder till etiskt svåra situationer som personalen
ställs inför.
Hösten 2012 fick jag och min kollega i vår etikgrupp uppdrag från
avdelningens ledningsgrupp att ta fram en arbetsform för att tidigt
identifiera etiska problem hos patienter som vårdas på IVA. Detta resulterade i framtagande av ”Etisk rond på IVA”. Den etiska ronden är
ett tillfälle där teamet kring patienten belyser och diskuterar etiska frågeställningar kring patientens vård. Det kan innebära diskussion kring
behandlingsbegränsning, fortsatt vård och behandling, bemötande av
närstående eller patientens möjlighet att behålla sin autonomi. Det är
av vikt att diskussionen kretsar kring den aktuella etiska frågeställningen och att argumentationen utgår från den etiska plattformen för hälso- 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. Närvarande 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
behov. Teamet identifierar en eller flera etiska frågeställningar och lyfter
dessa i en interprofessionell diskussion. Teamet tar ett gemensamt beslut om hur den etiska frågeställningen ska lösas. Vid behov kan andra
resurser, till exempel fysioterapeut eller kurator, kallas in för att ge andra handlingsalternativ eller för att gå vidare med en etisk analys. Den
etiska ronden syftar till att teamet gemensamt, förutsättningslöst och
icke-hierarkiskt ska diskutera de etiska frågeställningarna som uppstår
kring patientens vårdsituation.
Utvärdering av arbetssättet har visat att personalen anser att den etiska ronden är ett hjälpmedel för de att belysa de etiska frågeställningarna och att det kan vara ett sätt att minska lidande för patienten och att
förstärka patientens autonomi.
...........................................................................................
P47
How are paediatric anaesthesia-related adverse events reported at university hospitals in the
Nordic countries?
Mattsson, Per1, Hanke, G2., Vieri, J3., Ulvik, A.4
1
Karolinska University Hospital, Stockholm, Sweden, 2Altonaer Kinderkrankenhaus, Hamburg, Germany, 3Tampere University Hospital,
Tampere, Finland, 4Haukeland University Hospital, Bergen, Norway.
Paediatric Anaesthesia Training Program
Introduction: Reporting of adverse events in healthcare may play a
key role in learning from mistakes and thus improve patient safety.
The aim of the present study was to investigate how adverse events in
paediatric anaesthesia are reported at university hospitals in the Nordic
countries.
Methods: The heads of anaesthesia departments at all Nordic university hospitals were asked to answer a questionnaire concerning reporting
of adverse events in 2013. The data was collected by email and tele­
phone.
Results:
Of 32 eligible hospitals 30 (93.8%) answered the questionnaire. All the hospitals had at least one written system for reporting
of adverse events. Twenty different systems were used. Seven systems
were anaesthesia-specific. None of the systems was specifically designed
for reporting of adverse events in paediatric anaesthesia. Reported adverse events ranged from 4 to 147 (median 35). Physicians, nurses,
other staff and relatives were able to report. Twenty-one (70.0%) of the
departments were not able to report the number of paediatric anaesthesia-related adverse events. Laryngospasm, hypoxia, and intubation
difficulties were the most frequently reported adverse events in children. Minor injuries and near misses were considered underreported.
Conclusions: A large number of systems for reporting adverse events
is used in the Nordic university hospitals. Most of the heads of the
anaesthesia departments were not aware of the type and frequency of
adverse events, but consider them to be underreported. A uniform validated anaesthesia-specific reporting system should be implemented in
all Nordic countries in order to improve future quality of reporting
adverse events.
...........................................................................................
P48
Finns det könsfördelar för kvinnor inom
traumatologin i Sverige?
Larsen R, Sjöberg
AnOpIva, Universitetssjukhuset, Linköping
I djurstudier är det upprepade gånger visat att det finns en överlevnadsfördel för kvinnligt kön vid både trauma och sepsis. Två förklaringsmodeller är vanligt förekommande; den ena som tillskriver östrogen
en skyddande effekt, den andra tillskriver de dubbla X-kromosomerna
överlevnadsfördelarna. I humanstudier har man dock inte kunnat påvisa detta övertygande annat än i mycket små kohorter. Multicenterstudier pågår för tillfället med att bland annat substituera traumapatienter
med östrogen för att komma närmare svaret på frågan.
Vi har gjort en riskjusterad traumadatabas av samtliga slutenvårdskrävande trauman i Sverige under åren 2001-2011 genom att kombinera slutenvårdsregistret och dödsorsaksregistret. Vi har sedan valt att
specialstudera fallolyckor (som är den största bidragande orsaken till
slutenvårdskrävande traumadödlighet), trafikolyckor och även övergrepp för att få tre helt olika grupper. Vi jämför dessa tre grupper mot
resterande traumafall i databasen, då vi är övertygade om att traumapopulationen skiljer sig från resterande befolkning, och får då två ben
med ca en miljon patienter i var ben. För att få en korrekt riskjustering
har vi gjort en International Classification of disease 10 Injury Severity
Score (ICISS) modell med en huvuddiagnos och upp till nio bidiagnoser för att spegla att vi tror att multitrauma är dödligare än singeltrauma. Med hjälp av logistiska regressioner mot 30 dagars mortalitet kan
vi inkludera kön, ålder, vårdtid och diagnosgrupper.
Med ungefär lika stora grupper och riskjusterat på diagnoser kan vi
med p-värden på under 0.000 hos vuxna få ut OR på 0,78 (CI 0,71–
0,86) till 0,51 (0,50–0,53) hos post menopaus, beroende på ålderskategori. 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
verkar effekten inte vara helt säker för barn.
...........................................................................................
P49
Uppdaterad information om CAN-studien
(Cancer and Anaesthesia).
Mats Enlund
Operationskliniken, Västmanlands sjukhus, Västerås
Spelar valet av anestesimedel roll för överlevnaden efter cancerkirurgi?
Baserat på djurstudier är svaret ja. Flera möjliga mekanismer finns, var­
av samtliga tycks gälla för människor. Med denna bakgrund har flera
välrenommerade centra i USA gått över från inhalationsbaserad anestesi till propofol-underhåll, vilket är essensen av djurstudierna. Rätt
eller fel? Detta är i nuläget inte förenligt med att praktisera evidensbaserad medicin. Djurdata kan inte säkert överföras till människor, för
vilka data saknas. Således krävs en kontrollerad, randomiserad studie. I
CAN-studien randomiseras patienter med bröst- eller kolorektalcancer
till anestesiunderhåll med antingen sevofluran eller propofol.
Tänkbara mekanismer för att förklara hypotesen att propofol ­”skyddar”
från recidiv och/eller metastasering jämfört sevofluran:
• Diametralt motsatta effekter på olika komponenter i immunsystemet; sevofluran är sammantaget proinflammatoriskt, propfol är
antiinflammatoriskt.
• Diametralt motsatta effekter på DNA; sevofluran ger DNA-skada,
propofol är inert.
• Diametralt motsatta effekter på transkriptionsfaktorn HypoxiaInducible Factor (en cancercellernas försvarsmekanism); sevofluran
uppreglerar faktorn, propofol är inert eller möjligen nedreglerande.
Fakta:
• Beslut från EPN (Uppsala): 2013-08-14, Dnr 2013/314.
• Beslut från Läkemedelsverket: 2013-08-16, Eu-nr 2013-00238025, Dnr 5.1-2013-64999.
• Registrering ClinicalTrials.gov: 2013-11-02, NCT01975064.
Vad har hänt sedan CAN-studien beskrevs vid förra årets SFAI-möte
i Jönköping?
Förutom vid anestesikliniken i Västerås bedrivs studien i Lund, Linköping, Örebro, Kalmar, Uppsala, Skellefteå och Wroclaw. Klinker i
Dublin och Peking är på gång. Det sammanlagda antalet inkluderade
patienter var 446 i slutet av april.
De första patienterna, av de 8000 (inkl. marginal) som behövs, inkluderades november 2013. Vi håller nu att glida över från ett stadium
av ”feasibility study” till ”full inclusion”. Projektets organisation fungerar, central liksom lokalt och hos den monitorerande organisationen,
Uppsala Clinical Research Centre. Vår elektroniska CRF fungerar och
är nu översatt till engelska. De svaga punkterna är att det behövs någon
eller några kliniker ytterligare, och finansieringen är inte fullständig.
En realistisk bedömning är att bägge punkterna kommer att uppfyllas.
...........................................................................................
45
P50
Academic performance after anesthesia and
surgery during childhood: a large-scale nationwide study
P. Glatz, R. H. Sandin, N. L. Pedersen, AK Bonamy,
L. I. Eriksson, F. N. Granath
Anestesi- och intensivvårdskliniken, Länssjukhuset Kalmar
Background and Aim: While preclinical studies suggest that exposure
to general anesthetics during infancy leads to increased neuronal apoptosis and later neurocognitive impairment1, there is contradictory information from human studies aiming to translate preclinical findings
into outcome studies of children exposed to anesthesia and surgery
before age 4 years2.
Method:
Among 2 million children born in Sweden 1973–93, we
identified 33,514 children who had one single surgical procedure before age 4 years and no subsequent hospitalization; and 161,731 unexposed control children matched for sex, place of birth, and year and
month of birth. This primary cohort was combined with an array of
national health care databases and registries of school achievements to
determine the association between childhood exposure to anesthesia
and surgery and later academic performance.
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,
7–12 or 13–24 months. A minor difference (0.79 %, 95% CI 0.25–
1.33) in academic performance was found in children exposed at 3–4
years of age, which disappeared when the ear-nose-throat and urology surgery groups were excluded. When pooling all age intervals 0–4
years, children having one exposure had 0.40 % lower average marks at
age 16 years (p< 0.001) and those exposed two or ≥3 times had 1.40 %,
and 1.82 % lower average marks, respectively.
To put the minimal difference in school results into context, the data
were compared to other variables known to affect school results such
as gender, month of birth and mothers’ educational level. In general,
effects of these variables were several orders of magnitude greater than
the effects of exposure to anesthesia and surgery.
Conclusion: Exposure to anesthesia and surgery does not constitute
a public health problem and there is no reason to postpone imperative
surgery during early childhood due to fear for potentially negative impact on later academic performance.
References:
1. J Neurosci 2003 Feb 1;23(3):876-82
2. JAMA (2015) 313:1515-1516
...........................................................................................
Posterpresentation 7
(ST-projekt)
Tisdag 22/9 kl 12:00–13:30
Lokal: utställningen
Moderatorer: Kristina Hambraeus Jonzon, Mikael Bodelsson
P51
Intensivvård av patienter med ALS i Stockholms
Läns Landsting 2005-14
O. Ankarcrona, J. Jakobsson
Anestesi- och Intensivvårdskliniken, Danderyds Sjukhus
Det tycks i Sverige under de senaste 10 åren ha skett ett skifte i inställningen till trakeotomi hos ALS-patienter. Mekanisk ventilation för
dock med sig en mängd dilemman av etisk, humanistisk och ekonomisk art. En systematisk genomgång av data på svenskt material har så
vitt vi känner till inte gjorts.
Syftet med studien var att
• Undersöka utvecklingen inom SLL 2005-14 avseende trakeotomi
av ALS-patienter.
• Kartlägga skedet när planerad eller akut trakeotomi aktualiseras.
Totalt har 32 ALS-patienter vårdats på IVA under studietiden; 18 av
dessa trakeotomerades och bland dem skedde det planerat för hälften
(9 patienter) och akut för hälften (9 patienter).
Nio (9) patienter intuberades utan att senare trakeotomeras. Av
dessa avled 6 personer och 3 överlevde till utskrivning från IVA.
Antalet ALS patienter som trakeotomeras har ökat i SLL. Med reservation för att det rör sig om ett litet patientmaterial tycks en skillnad
finnas mellan de första åren 2005–06 då ingen trakeotomerades, till de
2011–14 då i snitt 3 patienter trakeotomerats per år. 2014 utmärker sig
som det första år då 3 planerade trakeotomier genomfördes.
Relativt fler män än kvinnor trakeotomeras. Medelåldern för trakeotomi är <60 år, vilket är i överensstämmelse med internationell forskning avseende vilka patienter som gagnas av ingreppet. Skillnaden i
medelålder mellan dem som trakeotomeras planerat och de som inte
trakeotomeras är 21,1 år (47,7 resp. 68,8 år).
Avseende IVA-vård finns stora variationer mellan åren. Variationerna beror dels på en ökning av antalet patienter som trakeotomeras, dels
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.
Antalet återinläggningar av ALS-patienter är lågt.
Sammanfattningsvis är det ett fåtal men ökande antal ALS-patienter
som trakeotomeras. För såväl patient som vårdgivare är det angeläget
att det genomförs planerat.
...........................................................................................
46
P52
CASE REPORTS– Chronic adhesive arachnoiditis
after repeat epidural blood patch
C. Carlswärd, MD1, B. Darvish, MD, DESA2,3, J. Tunelli, MD2,
L. Irestedt, MD, PhD2
Department of Anesthesiology, Capio St Görans Hospital, Stockholm,
Sweden, 2Department of Anesthesiology, Surgical Services and Intensive
Care Medicine, Karolinska University Hospital, Solna, Stockholm, Sweden, 3School of Medicine and Health Science, Örebro University, Sweden
1
Epidural blood patch (EBP) is an efficient treatment for post dural
puncture headache (PDPH). Despite its efficiency there are some potential risks with EBP. Arachnoiditis is a very rare disabling condition
and few cases have been described following EBP.
We present a case of Chronic Adhesive Arachnoiditis (CAA) in a
parturient treated with repeat EBP.
A healthy 29-year old female had an accidental dural puncture following epidural insertion. The first EBP as part of treatment of her
PDPH was ineffective and therefore she received a second EBP. She
gradually developed severe neurological symptoms consistent with
arachnoiditis confirmed with MRI. Despite intensive multimodal
treatment with analgesics and physiotherapy, her neurological condition is still precarious two years later.
We would like to warn the readers about a serious but rare complication following repeat EBP, and encourage caution when treating
PDPH with repeat EBP in parturients.
...........................................................................................
P53
Sömnapnéförekomst bland patienter som opereras för kolorektalcancer
Claesson M1, Franklin KA1, Jonsson Fagerlund M2
Kirurgiska och perioperativa vetenskaper, Avd för Kirurgi, Umeå Universitet, 2Inst för Fysiologi och Farmakologi, Sektionen för Anestesi och
Intensivvård, Karolinska Institutet, Stockholm
1
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
är riskfaktorer för både kolorektalcancer och sömnapné. Vi avsåg att
undersöka förekomsten av sömnapné bland patienter med kolorektalcancer, eftersom den är okänd.
Metod:
Femtio patienter varav 16 kvinnor med kolorektalcancer
medel ålder 69 ± 11 år, BMI 26 ± 4 kg/m2 inkluderades. De gjorde
sömnapnéutredning med polysomnografi där andning, EEG, pulsoximetri mm registrerades kontinuerligt under natten före operation.
Resultat:
Fyrtioen av femtio patienter (82%) hade sömnapné. Fyrtio
procent hade mild sömnapné med 5-15 apnéer/ timme sömn, 28%
hade måttlig sömnapné och 14% grav sömnapné med mer än 30 apnéer per timme sömn. Patienterna sov i genomsnitt 41% av tiden i
ryggläge. I ryggläge hade de i medel 29 ± 22 apnéer per timme sömn
mot 8 ± 9 i sidoläge.
ingen tidigare undersökt population där sömnapné är så vanligt som
vid kolorektalcancer. Delvis kan den höga förekomsten förklaras av ålder och övervikt, men det är ännu oklart varför sömnapné är så vanligt
vid kolorektalcancer och vilken betydelse det har för dessa patienter.
...........................................................................................
P54
Can we predict who will benefit from non-invasive
ventilation in hypoxemic acute respiratory failure?
Apostolos Genaridis, Lars Engerström, Johan Berkius, Carl-Johan
Wickerts, Sten Walther
Swedish Intensive Care Registry
Background:
The increasing early use of non-invasive positive pressure ventilation (NIV) in patients with hypoxemic acute respiratory
failure (HARF) is controversial 1. Successful NIV is associated with
shorter length of stay and improved survival compared to initial invasive ventilation (InvV), while failed NIV was recently found associated
with lower survival than initial InvV 2. The purpose of the present
study was to identify predictors of NIV failure that were present on
admission to ICU.
Material and Methods: We examined the use of initial ventilator
support in records of patients with HARF who were admitted to 66
Swedish ICUs during 2008-2014. Exclusions were age<16 yrs, patients
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
ventilation. Variables that were present on admission to ICU and considered important were used to build NIV failure prediction models.
Model fit is presented as the c-statistic and McFadden’s pseudo R2.
Results:
We identified 4,990 admissions with HARF, 1,561 failed
NIV and were intubated within 24 hrs after start of NIV. Patient age,
gender, presence of comorbidities, circumstances on admission and
SAPS3 scores differed significantly between patients with successful or
failed NIV (P<0.01 for all variables). Results of the model building are
shown in the table below.
Model
Variables
c
R2
A
SAPS3 score 3
0,62
0,03
B
SAPS3 score 3, gender
0,62
0,03
C
Gender, age, comorbidity score 3, Box II 3
and Box III 3
0,67
0,07
D
Gender, age, comorbidity score 3, route
and reasons for ICU admission 3
and Box III 3
0,71
0,10
E
Gender, age, comorbidity score 3, route
and reason for ICU admission 3,
PaO2/FiO2, pH and RLS85 on admission
0,71
0,11
Conclusion: The prediction models that were built based on information that was present on admission to ICU performed poorly. Additional information collected during the first hours in ICU may be one
way to improve model performance.
Konklusion:
Sömnapné är ytterst vanligt bland patienter som skall
opereras för kolorektalcancer. Detta är ett helt nytt fynd och det finns
47
References
1. Walkey et al, Ann Am Thorac Soc 2013; 10: 10–17
2. Genaridis et al, Best Free Paper Session, 33rd SSAI Congress
(Reykjavik) 2015
3. Moreno et al, Intensive Care Med 2005;31: 1345-55.
the standard care group.1 There are few studies using modern minimal-invasive monitoring to describe hemodynamic changes after spinal
anesthesia(SPA) in the elderly.2
...........................................................................................
Aim: To describe hemodynamic changes during spinal anesthesia in
elderly at hypotension and non-hypotension after SPA in a prospective
study.
P55
Materials and methods:
Dept of Anesthesia and Intensive Care Medicine,
Karolinska University Hospital, Solna
20 patients, >65 years, undergoing elective arthroplasty. Monitoring: LiDCOplus™. Data collection: at baseline 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.
Hypotension was defined as SBP <100mmHg or >30% decrease from
baseline.
Background:
Results:
Intraoperative hypotension is associated with
myocardial damage in non-cardiac surgery
Linn Hallqvist
Perioperative myocardial damage and infarction (MI)
are associated with increased mortality and other postoperative complications. The study objectives were to investigate how intraoperative
events, with focus on hypotension, were related to perioperative myocardial damage, as detected by the novel high-sensitivity troponin-T
(hs-cTnT). Moreover, we assessed if these intraoperative events were
related to perioperative myocardial infarction.
Methods: In this observational cohort study of all patients undergoing
major elective noncardiac surgery who required an overnight admission at the post operative unit at the Karolinska University Hospital,
Stockholm, Sweden, between October 2012 and May 2013, preoperative risk factors (comorbidities), intraoperative events (hypotension defined as a 50% decrease in systolic blood pressure relative each patient’s
baseline and lasting > 5 min) and postoperative data were collected
from medical records. Levels of hs-cTnT were measured on postoperative day 1. Myocardial damage was defined as an increase in the
hs-cTnT value above 14 ng/l. Cases of MI within 30 days after surgery
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
day 1 and 15 (5%) developed MI within 30 days. Multivariate logistic
regression analysis demonstrated that an intraoperative hypotensive
event >50% (OR, 4.4; 95% CI 1.8-11.1) was an independent predictor of postoperative hs-cTnT elevation.
Conclusions:
In patients undergoing major elective noncardiac surgery, there is an association between an intraoperative fall in systolic
blood pressure >50% from baseline and the novel hs-cTnT biomarker
measured postoperatively.
...........................................................................................
P56
Hemodynamic changes during spinal anesthesia
in the elderly- a prospective observational pilot
study in patients undergoing elective arthroplasty
Julia Jakobsson, Sigridur Kalman, Marge Lindeberg-Lindvet,
Erszébet Bartha
AnOpIVA, Karolinska Huddinge
Background:
A post-hoc analysis of our RCT on goal-directed hemodynamic therapy in elderly patients with hip fracture revealed an
unexpected reduction of SVI (stroke volume index) before surgery in
48
After pre-spinal fluid preloading, SVI decreased by
12.7±7.1%(mean±SD) in 19/20 patients. Hemoglobin decreased from
131±10 g/L to 121±12 g/L. Patients developing hypotension after
SPA had a higher heart rate(73±10 vs 60±12) and a lower SVI(38±8
vs 48±10) at baseline compared to non-hypotensive. CI(cardiac index)
and DO2I (oxygen delivery index) decreased progressively in hypotensive while reduction in SVRI(systemic vascular resistance index) was
similar in both groups.
Conclusions: Based on these observations, further studies should focus on: 1. Baseline SVI and HR as possible predictors of postspinal
hypotension. 2. Effects of fluid pre- and coloading during spinal anesthesia in the elderly. 3. Reduction of cardiac and oxygen delivery index
in the context of perioperative oxygen consumption.
References:
1. Bartha et al. Br J Anaesth 2013; 110: 545-53
2. Meyoff et al. Eur J Anaesth 2007;24:770-5
...........................................................................................
P57
Accuracy of stroke volume estimation.
Oesophageal Dopplear compared to cardiac
magnetic resonance
Johansson Patrik
Anestesi- och operationskliniken, Universitetssjukhuset, Linköping
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 agreement between OD and thermodilution via pulmonary artery catheter
(PAC) for hemodynamic trends, but also indicated that OD lacks in
accuracy and precision. Since PAC is less frequently used, cardiac magnetic resonance imaging (CMR) has instead become the non-invasive
gold standard for measurement of hemodynamic variables. This study
aims to evaluate the accuracy of estimation of stroke volume (SV) by
OD, using CMR as reference method.
Method: The study population consisted of 19 healthy subjects (10
females) aged 20-30 years. In each subject SV was measured by OD
followed by CMR. Agreement in SV estimation between the methods
was analyzed using the Bland-Altman method, difference in SV between methods was calculated using the t-test, and Pearson’s formula
was used to calculate correlation between the methods.
SV measured by OD was significantly lower compared to
CMR. Bland-Altman plot showed broad limits of agreement (LOA)
for all subjects (bias -26 mL, LOA ± 28 mL, percentage error 57 %),
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 larger CMR-measured SV, the more OD underestimated SV).
P59
Conclusions: Compared to CMR, the CardioQ®/OD-technique significantly underestimates SV in young, healthy subjects. The underestimation by OD correlates to the size of SV. Further studies of SV are
suggested, comparing OD to CMR in different age groups.
Dept. for Anesthesiology & Intensive Care, Sahlgrenska Academy,
University of Gothenburg
Results:
...........................................................................................
P58
Definition av en välfungerande/icke optimal
epidural
Camilla Linnarsson, Sigga Kalman, Erzsébet Bartha
AnOpIva, Karolinska Universitetssjukhuset, Huddinge
Bakgrund: På KS/Huddinge läggs ca 760 thorakala epiduralkatetrar
(EDA) varje år för postoperativ smärtlindring efter stor kirurgi. Den
postoperativa smärtenheten har i sitt uppdrag bl. annat att följa upp
och kvalitetssäkra epiduralsmärtlindring. Vårt mål var att föreslå definition(er) för välfungerande respektive icke optimalt fungerande EDA
som kan användas för kvalitetssäkring.
Metod: Initialt gjordes en systematisk litteraturgenomgång (PICO) för
att se vilka definition(er) som används (t.ex. behandlingslängd, smärtnivå). Dessa definitioner användes sedan för att skapa frågor till en
webbaserad enkät som skickades ut till anestesiologer, specialistutbildade sjuksköterskor på postoperativa smärtenheten samt till kirurger
(övre buk kirurgi).
Resultat:
Viktiga behandlingsmål med en välfungerande epidural var
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.
Diskussion:
Med tanke på det stora antalet epiduraler, har den post­
operativa smärtenheten en hög arbetsbelastning. Det är viktigt att koncentrera uppföljningsverksamheten till områden där nyttan är störst
ur ett patientperspektiv. Vi föreslår att kvalitetsuppföljningens mål i
första hand är att identifiera icke optimalt fungerande EDA så tidigt
som möjligt. Dessa bör optimeras, konverteras till en annan smärtlindringsstrategi, alternativt få en ny EDA. Som kvalitetsindikator föreslår
vi att använda antalet (%) av patienter som behöver PCA (eller annan
­metod) eller ny epidural inom 48 h. Med en sådan kvalitetsindikator kan eventuella problemgrupper identifieras och förbättringsarbete
inriktas. Vår undersökning begränsades till professionens åsikter, även
patienter bör intervjuas för att definiera patientrelaterade kvalitetsindikatorer.
...........................................................................................
Clinical outcome in patients >10-years after a
severe traumatic brain injury, (sTBI).
Andersson Emma, Svanborg Emma, Öst Martin, Csajbok Ludvig,
Nellgård Bengt and Nellgård Per
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.
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 questionnaire, with patients or next-of-kin. The questionnaire was transformed
into Glasgow Outcome Scale (GOS) 1-5; (1=dead to 5=good recovery).
100 patients, (women, n=27; men, n=73), met the inclusion criteria. Patients had a median age at trauma of 38 years, (range 8-81).
Mortality from study enclosure to present was 35% (n= 35, GOS 1).
Totally 57 of 65 patients or next-of-kin could be contacted to answer
the questionnaire, representing: GOS 2 (n=0); GOS 3, (n=15); GOS
4, (n=29) and GOS 5, (n=13).
We demonstrated increased mortality from 1-year (15%) to >10
years (35%) post-trauma. Outcome in surviving patients at 1-year vs.
>10 years post-trauma was dichotomized into Favorable (GOS 4-5)
or Poor (GOS 2-3). Poor outcome at 1-year decreased from 32% to
26%, while Favorable outcome increased from 52% at 1-year to 56%
at >10 years post-trauma. The results demonstrate, on cohort-basis, a
doubling of mortality from 1-year to >10 years post-injury. In surviving patients a slight improvement over time is also noted. These results
confirm that the LC treatment protocol improves outcome even on
long-term basis after sTBI.
...........................................................................................
Posterpresentation 8
Tisdag 22/9 kl 12:00–13:30
Lokal: utställningen
Moderatorer: Johan Pettersson, Anders Larsson
P60
”Pleural” pressure in a model with an elastic
recoiling lung and an expanding chest wall
Per Persson, Stefan Lundin, Ola Stenqvist
Sahlgrenska Universitetssjukhuset, Göteborg
We have shown in a porcine and an ARDS patient study that lung
compliance can be determined (without esophageal pressure measurements) 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, preventing 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,
49
i.e. end-expiratory esophageal pressure, because of extra-pleural effects
on measurements.
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):
P61
The Chest Wall has Minimal Protecting Effect on
the Lungs in Situations with High Airway Pressures
T. Johansson1, A. Larsson1, O. Stenqvist2, S. Lundin2
Uppsala University, Uppsala, 2Sahlgrenska University Hospital, Göteborg
1
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) measurement. 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 similar pressures when pneumothorax occurred were recorded. Ers ,Ecw
and lung elastance (EL) were obtained as the steepest slope below and
above UIP.
Results:
At UIP Paw, Ptr and Pes were 60±14, 44±10, and 14±6 cmH2O, respectively, while similar pressures when pneumothorax occurred 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 enforcing 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-expiratory transpulmonary pressure (blue) increased until it equaled the
change in end-expiratory airway (red) (ΔPEEP).
Conclusion:
As end-expiratory “pleural” pressure remains unchanged when changing PEEP, the end-expiratory transpulmonary pressure
changes as much as PEEP is changed and as a consequence lung compliance can be determined as ΔEELV/ΔPEEP.
...........................................................................................
50
Conclusion: In this experiment, despite a high intra-abdominal pressure, the chest wall had a minimal lung protective effect.
References:
1. Am J Resp Crit Care Med 1994: 150:421-30
...........................................................................................
P62
P63
T. Johansson1, A. Larsson1 , S. Lundin2, O. Stenqvist2
T. Johansson1, A. Larsson1, O. Stenqvist2, S. Lundin2
1
Uppsala University, Uppsala/SE, 2Sahlgrenska University Hospital,
Goteborg/SE
1
Background:
Background:
Methods: 10 anesthetized, muscle paralyzed and mechanically ventilated piglets were subjected to either hydroperitoneum (3 L starch-­
solution infused intra-peritoneally) and/or lung lavage (30 ml saline/
kg, repeated until P/F < 200 mmHg). Measurements of tidal volume,
airway and esophageal (Pes) pressures, end-expiratory lung volume,
EELV at PEEP of 0,5,10, and 15cmH2O and registration of V-P relations of the lung using slow interrupted insufflation/desufflation from/
to ZEEP to/from 40 cmH2O airway pressure were performed. Lung
elastance (EL) was obtained as the steepest slope of the expiratory part
of the transpulmonary PV-curve and Ers-PEEP was calculated.
Methods: 10 anesthetized, paralyzed and mechanically ventilated
piglets were subjected to either hydroperitoneum (3 L starch-solution intra-peritoneally) and/or lung lavage (30 ml isotonic saline/kg,
repeated until P/F < 200 mmHg). Measurements of VT, airway (Paw)
and esophageal (Pes) pressures, end-expiratory lung volume, EELV
at PEEP 0,5,10,15 and 20cmH2O and registration of P-V relations
of the respiratory system (Ers), lung (EL) and chest wall (Ecw) using
slow interrupted insufflation/desufflation from ZEEP to 40cmH2O
in airway pressure were performed. Ers, EL, Ecw were defined as the
steepest slopes of the expiratory part of the respective curves. Ers-VT
was calculated as: (End-inspiratory plateau pressure - PEEP)/VT, and
EL-VT was calculated subtracting corresponding Pes. Ers- PEEP and
EL-PEEP were calculated as the airway and transpulmonary pressure
differences between two adjacent PEEP/EELV levels.
Results:
Results: See table. The correlation (R-squared) between the breath-de-
Can Lung Elastance be Estimated Without the
Use of Esophageal Catheter?
It has been suggested that the chest wall extends the
lungs up to about 80% of total lung capacity, chest wall elastance
at lung volumes below this value would be minor1. This implicates
that the pleural end-expiratory pressure would only be affected by the
weight of the abdomen2 and be similar at different lung volumes independent of end-expiratory airway pressures. We have previously found
that elastance obtained from end-expiratory lung volume differences
(ΔEELV) at two adjacent PEEP levels (PEEP-step method) were identical to lung elastance obtained with esophageal pressure (Pes) measurements3. In theory, the locations of the different EELV/PEEP –points
would follow the expiratory portion of a full transpulmonary pressure–
volume (PV)-loop. Therefore, in this study we compared the PEEPstep method with the PV-curve method in different lung conditions.
The R-squared between Ers-PEEP and the expiratory PVcurve-derived EL at similar pressure values was 0.44 with a regression
equation: EL(cmH2O/l) = -1+ 1.05 x Ers-PEEP. Bland & Altman
showed a bias of 0.0, with an agreement of ±37cmH2O/l.
Conclusion: Elastance values obtained by the PEEP-step method
were closely related with lung elastance values obtained from a full PVcurve. This suggests that with the PEEP step method, lung elastance
might be estimated without esophageal pressure measurements.
Different Estimates of Respiratory Elastance.
How Do They Relate?
Uppsala University, Uppsala/SE, 2Sahlgrenska University Hospital,
Goteborg/SE
Lung elastance, breath-by-breath quasi-static elastance
of the respiratory system and different elastance- values obtained from
inspiratory or expiratory pressure-volume (PV) loops are commonly
used as interchangeable entities. However, the relations between these
parameters have not been investigated. We obtained full PV- loops of
the lung-chest wall, breath-by-breath elastance of the respiratory system and lungs (Ers-VT, EL-VT) as well as elastance obtained from
lung volume differences at two adjacent PEEP levels (Ers-PEEP, ELPEEP).
rived (at PEEP 10 cmH2O) and expiratory PV- curve-derived elastance
values were excellent and both were well correlated to EELV. However, Ers-VT was significantly higher than Ers (mean for all conditions
73±37 and 35±28 cmH2O/l, respectively, p<0.001).
Conclusion: Breath-by-breath derived elastance values were significantly, around two times, higher but well correlated to those of the
expiratory PV-curve. Elastance derived from the steepest part of the
inspiratory PV-curve had only minor relation to tidal breath elastance.
References:
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.
...........................................................................................
...........................................................................................
51
O2 female
hesia (ml/min)
115
123
132
140
149
157
166
174
183
191
P64
A simple method for isocapnic hyperventilation
evaluated in a lung model
P65
Hallén K, Stenqvist O, Ricksten SE, Lindgren S
Obstructive sleep apnea in the intensive care unit
– Prevalence studied prospectively by diagnosis,
the STOP-BANG questionnaire and oxygen desaturation index
Anestesikliniken, Sahlgrenska, Göteborg
Adam Carlson1, Karl A Franklin2, Malin Jonsson Fagerlund3
Isocapnic hyperventilation has the potential to increase the elimination
rate of anaesthetic gases and the method has been shown to shorten
time to wake up after inhalation anaesthesia. In this bench test, we
describe a simple technique to achieve isocapnia during hyperventilation by administering carbon dioxide (DCO2) to the inspiratory limb
of the anaesthesia circuit using a standard anaesthesia apparatus with
standard monitoring equipment. Carbon dioxide was added to a mechanical lung to simulate CO2 production (VCO2) and hyperventilation was achieved by doubling the minute ventilation and fresh gas
flow. During hyperventilation, the amount of delivered CO2 needed
to maintain isocapnia varied between 147±8 and 325±13 ml/min and
the FICO2-level varied between 2.3 and 3.3 %, depending on CO2
production and dead-space. From known relationships between CO2
production, body weight and gender an estimation of delivered CO2
to maintain isocapnia during physiologic conditions could be made.
Medical student T10, Karolinska Institutet, Stockholm, 2Department of
Surgical and Perioperative Sciences, Umeå University, Umeå, 3Dept of
Anesthesiology, Surgical Services and Intensive Care Medicine. Karolinska
University Hospital and Dept of Physiology and Pharmacology, Section
for Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm.
Estimated awake CO2 production, VCO2 (ml/min) according to Radford.
Correction of VCO2 for anaesthesia according to Nunn and from lung model
predicted CO2 delivery, DCO2 (ml/min) to maintain isocapnic hyperventilation
during weaning from anaesthesia.
Body weight
(kg)
40
50
60
70
80
90
100
110
120
130
DCO2 female
(ml/min)
377
358
340
322
305
289
274
259
245
232
VCO2 female awake
VCO2 female
(ml/min)
anaesthesia (ml/min)
135
115
145
123
155
132
165
140
175
149
185
157
195
166
205
174
215
183
225
191
VCO2 male awake
(ml/min)
147
165
188
205
222
240
260
280
300
320
VCO2 male
anaesthesia (ml/min)
125
140
160
174
189
204
221
238
255
272
DCO2 female
(ml/min)
377
358
340
322
305
289
274
259
245
232
DCO2 male
(ml/min)
354
322
285
259
236
213
191
171
154
140
1
Introduction:
The prevalence of obstructive sleep apnea (OSA) in the
intensive care unit has not been investigated in a prospective study.
OSA has been identified as an important co-morbidity in the perioperative period, leading to adverse outcomes postoperatively. The prevalence of OSA is 9-24% in the general population and a large part of
OSA patients are undiagnosed. Thus, it is likely that there are a significant number of patients with OSA in the intensive care unit (ICU).
Aims: The overall aim was to explore the prevalence of OSA and patients at high risk for OSA in the ICU by using the STOP-BANG
screening questionnaire and oxygen desaturation index post ICU.
Material and Methods: Adult patients were recruited upon discharge
from the intensive care unit. OSA-diagnosis, the STOP-BANG screening questionnaire and oxygen desaturation index derived from nocVCO2 turnal
male awake
VCO2 male
2 male
pulse oximetry
were used toDCO
approximate
the prevalence of OSA
(ml/min)
anaesthesia
(ml/min)
(ml/min)
among intensive
care patients.
147
125
354
165
140
322
38
patients
were
included.
The prevalence of OSA was
188
160
285
13.2%,
and
76.3%
of
the
patients
had
205
174
259 a high risk of OSA according
to222
STOP-BANG. ODI
patients negative at STOP189 was lower among
236
240
213 positive at STOP-BANG. The
BANG
compared to204
patients who were
260
number
of samples 221
were lower than 191
expected because many patients
280
238
171
regarded
the
pulse
oximeter
as
an
inconvenience
or too invasive.
300
255
154
320
272
140
Results:
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
STOP-BANG therefore merits further investigation.
...........................................................................................
P66
Effekt på sömnapné, hypoxi och lungfunktion
av öppen kirurgi av kolorektalcancer
Franklin KA1, Claesson M1, Jonsson Fagerlund M2
Kirurgiska och perioperativa vetenskaper, Avd för Kirurgi, Umeå
Universitet, 2Inst för Fysiologi och Farmakologi, Sektionen för Anestesi
och Iintensivvård, Karolinska Institutet, Stockholm
1
Presenterat på ESA Berlin 2015
...........................................................................................
52
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 andnings­uppehåll
per timme sömn (= apné-hypopné index, AHI >5). Vår målsättning var
att undersöka hur sömnapné, syresättning, kol­dioxid och lungfunktion
påverkas vid öppen kirurgi av kolorektalcancer.
Metod:
28 patienter varav 8 kvinnor med kolorektalcancer inkluderades. De undersöktes med artärgas, lungfunktion och polysomnografisk
sömnapnéutredning med bl.a. kontinuerlig mätning av andning, syresättning och EEG under natten före kirurgi och andra postoperativa
natten.
Resultat:
Sömnapnéförekomsten var hög bland patienterna men det
var ingen skillnad preoperativt (AHI: 19 ±15) och postoperativt (AHI:
17 ±23), däremot minskade apnéförekomsten signifikant i såväl rygg
som sidoläge postoperativt. Apnéförekomsten var signifikant högre i
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
PCO2 steg, däremot minskade PO2 signifikant med nästan 2 kPa
postoperativt.
Konklusion:
Sömnapnéförekomsten är hög såväl före som efter kirurgi av kolorektalcancer, särskilt under tiden patienten sover på rygg.
Sömnapnéförekomsten minskar i såväl sidoläge som i ryggläge postoperativt, men patienterna sover dubbelt så mycket på rygg postoperativt, vilket förklarar varför sömnapnéförekomsten är lika hög pre- som
postoperativt. Sömnapné med intermittent hypoxi skulle teoretiskt sett
kunna förebyggas om patienterna förhindrades att sova på rygg postoperativt.
...........................................................................................
P67
Nattlig andningsstörning 1:a natten efter Bariatrisk
operation i generell anestesi, initiala resultat
Lotta Wickerts, Sune Forsberg, Jan Jakobsson
Anestesiklinikerna Norrtälje och Danderyds sjukhus, Institutionen för
Klinisk Vetenskap, Karolinska Institutet
Påverkan på andning och syresättning efter operation och anestesi kan
orsakas av en rad faktorer. Övervikt är en känd faktor kopplad till sömnapne syndrom. Syftet med denna studie är att med standardiserad
sömnapnediagnostikutrustning studera förekomst av andningsstörning 1:a postoperativa natten.
Metod: Studien är godkänd av Regionala Etikprövningsnämnden.
­ atienter som planerats för elektiv bariatrisk operation vid N
P
­ orr­tälje
sjukhus inkluderades. Patienter som givit skriftligt medgivande genom­­
gick operation och anestesi enligt klinikens gängse rutiner. Registreringen startades klockan 22 med konventionell nattregistreringsutrustning
(EmblettaR). Thoraxband för att registrera bröstkorgsrörelse, pulsoximetri, nasalt flöde och andningsbiljud samlades automatiskt med utrustningen. Registreringen pågick till klockan 6 påföljande morgon.
Andningen analyserades med Emblettas standardiserade tokningsprogram och eftergranskades. Apne/hypopne index (AHI), oxygendesaturations index (ODI), lägsta SpO2, samlades per patient förutom
sedvanliga demografiska data.
Resultat:
Här redovisas nuvarande insamlade 16 patienter. Medel­
ålder 40 år, medel BMI 38; 33–49 (medel 107; 82–136kg). Medel­
operationstid 77 minuter och anestesitid 143 minuter. AHI medel 1,6;
0–9,5/h. ODI medel 3,8; 0–22,7/h. Medel SpO2 93; 88–97 %, Lägsta
SpO2 87; 79–94 %. Längsta hypo/apne var knappt 2 minuter.
Diskussion & sammanfattning:
Förekomsten av andningsstörning
första nätterna efter operation/anestesi är inte väl studerat. Olika grad
av nattlig andningsstörning ökar i befolkningen, kopplat till ökande
ålder och högt BMI.
Det förefaller fullt möjligt att studera patienter med konventionell
sömnapneutrustning redan första natten efter operation.
Dessa initiala resultat visar att det förekommer nattlig andningsstörning efter bariatrisk kirurgi dock av relativt ringa grad. Det behövs
ytterligare studier för att bättre kunna identifiera om det finns några
speciella riskfaktor som medför ökad risk för alvarlig nattlig andningsstörning och hur man i sådant fall kan försöka förebygga dess uppkomst. Vi avser att studera 75 patienter för att få en bättre bild och
planerar också prospektiva studier.
Referens:
Stierer TL. Obstructive Sleep Apnea, Sleep Disorders, and ­Perioperative
Considerations. Anesthesiol Clin. 2015 Jun;33(2):305-314.
...........................................................................................
P68
Kronisk invasiv ventilation hos vuxna i Stockholm
Marie Roos, Klara Geisewall, Jan Jakobsson NRC
Anestesi & Intensivvårdskliniken Danderyds sjukhus
Bakgrund
Oförmågan att andas, otillräcklig alveolär ventilation, kan orsakas av
en rad sjukdomar och skador. Polio och Guillain–Barrés syndrom
är exempel på sjukdomar som kan drabba andningsmuskulaturen.
Neuromuskulära sjukdomar som amyotrofisk lateralskleros (ALS) och
muskeldystrofier leder också till successiv andningsförlamning. Höga
ryggmärgsskador och stroke ger varierande grad av andningssvikt,
där andningsstöd i vissa fall kan bli aktuellt. Detta abstract vill belysa
komplexiteten i det som kallas invasiv hemventilation, att leva med
trakealkanyl och andningsstöd av ventilator i hemmet. Gruppen med
patienter som har livsuppehållande andningsstöd kräver ofta IVA-vård
vid försämring, akuta infektioner, och/eller när vården i hemmet med
assistenter sviktar.
Nationellt respirationscentrum
Nationellt respirationscentrum (NRC) vid Danderyds sjukhus är en
öppenvårdsmottagning som sedan 1970-talet och Gillis Anderssons
pionjärinsatser vårdat patienter med invasivt andningsstöd i hemmet,
utanför intensivvårds- och intermediärvårdsavdelning. I dag finns det
knappt 60 patienter i Stockholms läns landsting med kronisk invasiv
ventilation varav drygt 60 % är män och resten kvinnor. Över hälften
av dessa patienter är helt beroende av sin ventilator dygnet runt, ca 1/3
är uppkopplade nattetid och bara 2 % behöver sin ventilator några få
timmar/dag. Åldersintervallet har en stor spridning men den största
gruppen finner man i intervallet 61–70 år följt av patienter som är
mellan 51 och 60 år gamla.
God, trygg och jämlik vård
Att arbeta för god, trygg och jämlik vård för den lilla men resurskrävande och stadigt växande grupp av patienter med livsuppehållande andningsstöd ställer nya krav och väcker nya frågor. Vad är god vård, vad
är säker vård, var ska vi sätta gränserna? Detta kräver samarbete mellan
många medicinska discipliner men också med paramedicinare och personer med kompetens inom sjukförsäkring, kommun och social service. Dessa patienter kräver inte sällan IVA-vård i samband med akut
försämring eller svikt i assistanshjälp. Vi ställs också inför frågor kring
värdegrund, etik och hur man bäst ska utnyttja vårdens resurser.
53
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 hypopnea 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.
...........................................................................................
Posterpresentation 9
(ST-projekt)
Tisdag 22/9 kl 13:45–14:45
Lokal: utställningen
Moderatorer: Anil Gupta, Mikael Bodelsson
Referenser
Geisewall K, Håkansson S, Ek M, Oddby E, Jakobsson J. Nationellt
respirationscentrum stöttar patienter med trakealkanyl – Öppenvårds­
mottagning för andningsstöd i hemmet. Lakartidningen. 2015 Apr
22;112. pii: DD3Y. Swedish.
...........................................................................................
P69
Evaluation of the STOP Bang questionnaire for
OSA in a sleep clinic population
Eva Christensson1, Karl Franklin2, Carin Sahlin3, Eva Lindberg4,
Malin Jonsson Fagerlund1
Dept of Anesthesiology, Surgical Services and Intensive Care Medicine.
Karolinska University Hospital and Dept of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care, Karolinska Institutet,
Stockholm. 2Department of Surgical and Perioperative Sciences, Umeå
University, Umeå. 3Department of Public Heath and Clinical Medicine,
Umeå University, Umeå. 4Department of Medical Sciences, Lung­allergy- and sleep research, Uppsala University
1
Background:
Although obstructive sleep apnea (OSA) is common
and associated with several co-morbidities, most of the patients are
undiagnosed. Current screening tools are quite unspecific and the golden standard methodology for diagnosis, polysomnography (PSG),
is expensive and time consuming, thus not suitable for screening. In
perioperative medicine the STOP Bang screening questionnaire is currently the recomended screening tool, however this questionnaire has
only been evaluated in a very limited numbers of sleep clinic patients.
The STOP Bang questionnaire includes eight yes or no questions and
yes to more than three items merits a positive result.
Aim:
Does the STOP Bang score correlate to OSA diagnosis at a sleep
clinic?
54
P70
Hemodynamisk övervakning på IVA
– en systematisk litteraturöversikt
Erik Nyberg, Olof Wall, Maria Cronhjort, Eva Joelsson-Alm
Anestesi/IVA, Södersjukhuset, Stockholm
Bakgrund: Hemodynamisk monitorering i syfte att styra vätskeresuscitering hos intensivvårdspatienter har länge varit föremål för studier.
Även om det i Surviving Sepsis Campaign rekommenderas hemo­
dynamisk övervakning vid sepsis1 så har värdet av detta ej tydligt kunnat ­visas i randomiserade studier. Tidigare stora studier på området har
ofta undersökt hemodynamisk monitorering på akutrummet och inte
i IVA miljö, och har dessutom haft motstridiga resultat2,3. Syftet med
denna systematiska litteraturöversikt var att undersöka om en strukturerad algoritm för vätskeersättning – styrd av hemodynamisk övervakning – kan minska mortalitet under och efter intensivvård.
Metod: Vi följde Cochrane Handbook of Systematic Reviews. Artikel­
sökning har skett i PubMed, Embase samt i Cochrane Central Register
of Controlled Trials.
Inklusionskriterier:
Randomiserade kontrollerade studier (RCT)
av vuxna patienter på IVA där algoritmer för vätskeersättning styrda
av hemo­dynamisk övervakning har studerats. Hemodynamisk övervakning definierades som minst ett av följande: mätning av hjärtminutvolym (CO), slagvolym (SV) slagvolymsvariation, syrgasleverans
(DO2), centralvenös oxygenering (ScvO2) eller mixad venös oxygenering (SvO2). Studierna skall ha haft en kontrollgrupp utan hemodynamisk övervakning. Studier där interventionen inletts innan patienten
befunnit sig på IVA exkluderades. Studierna har haft mortalitet som
utfallsvariabel.
Resultat:
Litteratursökningen resulterade i 403 träffar på PubMed
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 skillnad i mortalitet mellan grupperna. Slutgiltiga resultat kommer att presenteras under SFAI-veckan 2015.
Diskussion: Resultaten från denna litteraturgenomgång kommer tro-
ligen inte att visa någon skillnad mellan hemodynamiskt styrda protokoll för vätskeresuscitering jämfört med konventionell vätsketerapi.
Endast ett fåtal studier av tillräckligt god kvalitet kunde hittas, vilket
talar för ett behov av flera, stora randomiserade studier i ämnet.
Referenser:
1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach, Opal SM,
et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012 Crit Care Med.
2013;41:580-637.
2. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, et al. Early
goal-directed therapy in the treatment of sepsis and septic shock. N
Engl J Med. 2001;345:1368-77.
3. ARISE-investigators, Goal-directed resuscitation for patients with
early septic shock. N Engl J Med. 2014;371:1496-506.
...........................................................................................
P71
Novel capnodynamic method for assessment
of effective lung volume in intubated patients
Tomas Öhman
ANOPIVA, Karolinska Universitetssjukhuset, Solna
Introduction: Effective lung volume (ELV) equals the volume that
participates in gas exchange. ELV can be calculated continuously in
a capnodynamic equation and has been shown in animals to correlate well with functional residual capacity (FRC) using various reference methods. The aim of the current pilot study is to evaluate the
ELV-method in mechanically ventilated patients.
Method: A cyclic sequence of breaths with either inspiratory or expiratory holds alternated with normal breaths induces periodic changes
in alveolar concentration of carbon dioxide. By integrating these variations into the capnodynamic equation, ELV is calculated.
Effective lung volume will be measured in 30 healthy patients intubated and mechanically ventilated for surgery. ELV is measured in
PEEP steps 0, 10 and 5 cmH2O. A reference method measuring FRC
using a partial nitrogen wash in/out technique is used to get paired data
at 0 and 5 PEEP.
Results:
ELV changes significantly in response to changes in PEEP
from 0 to 10 and finaly 5 PEEP in both breathing patterns. The corresponding mean values of inspiratory group ELV were 1500, 2268
and 2074 mL respectively. Four-quadrant plot for the inspiratory hold
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 patterns, most notably in the expiratory hold group.
P72
Modulation of expiratory diaphragmatic contraction preserve injured lung from end-expiratory
collapse: experimental study.
Mariangela Pellegrini1,2, Göran Hedenstierna3, Agneta Roneus1,
Monica Segelsjö4, Anders Larsson1, Gaetano Perchiazzi1,2
Hedenstierna Laboratory – Department of Surgical Sciences, Uppsala
University, Uppsala, Sweden, 2Department of Emergency and Organ
Transplant, Bari University, Bari, Italy, 3Hedenstierna Laboratory –
Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
4
Section of Radiology, Department of Surgical Sciences,Uppsala
­University, Uppsala, Sweden
1
Introduction:
The diaphragm interacts with the respiratory system
also during expiration. We hypothesized a modulation of the expiratory diaphragmatic tone aiming at counteracting the end-expiratory lung
collapse during spontaneous breathing (SB). We studied this hypothesis by exploring the relation between the expiratory electrical diaphragmatic activity (EAdiexp), the trans-diaphragmatic pressure (Pdiexp) and
the consequent variation of expiratory volume (Volexp) in a model of
acute respiratory failure.
Methods: Mild acute respiratory distress syndrome (PaO2/FiO2 of
250 mmHg) was induced in 7 anesthetized, tracheostomized pigs by
repeated lung lavages. The animals underwent to either SB and muscle-relaxed controlled ventilation (MV).
In both ventilatory conditions, a decremental sequence of continuous positive airway pressure (CPAP/PEEP) was applied from 15 to
0 cmH2O, in steps of 3 cmH2O. For each studied PEEP/CPAP level,
EAdiexp and Pdiexp were measured and their correlation was tested. The
Volexp at 50% and 75% of expiratory time were also estimated.
Results:
When CPAP was decreased during SB conditions, EAdiexp
increased until a CPAP of 9 cmH2O and then remained unaltered (although elevated) with further decrease in CPAP. EAdiexp and Pdiexp
were tightly correlated as confirmed by an R2>0.82 (p<0.01). Lung
volumes were comparable during SB and MV when exposed to the
same CPAP/PEEP levels. Comparing the same CPAP/PEEP level, the
Volexp at 50% and at 75% of expiratory time were higher during SB
than during CMV, indicating a delayed emptying of the lungs in SB
conditions.
Conclusions: We demonstrated that the diaphragm has a braking effect during the whole expiration, preserving lung patency during SB in
lungs otherwise prone to collapse. The possibility of monitoring expiratory EAdi can be the base for titrating CPAP in SB subjects undergoing mechanical ventilation.
Grant acknowledgment:
The School of Anesthesia and Intensive
Care of Medicine, Bari University, Italy; The Swedish Heart and Lung
Foundation.
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55
P73
P74
Christina Persson4 ST-läkare, Jon Olinder1 specialistläkare, Cecilia
Rydén1 docent, överläkare, Daniel Ehinger2 och Erik Liljenborg2
med.kand., Dick Nelson3, Anders Schmidt4 med.dr., överläkare
Kristina Rydenfelt , Lars Engerström , Sten Walther , Folke
Sjöberg , Ulf Strömberg , Carolina Samuelsson
Hepcidin-25; en dynamisk markör vid intensivvård
av septisk chock
Infektionskliniken, Helsingborg, 2Lunds Universitet, 3Laboratoriemedicin, 4Anestesi-och intensivvård, Helsingborg.
E-post: [email protected]
1
Introduktion:
Svår sepsis/septisk chock är livshotande tillstånd som
trots modern intensivvård har hög mortalitet (ca 20 %). CRP och PCT
är biomarkörer som används för att monitorera sjukdomsförlopp, behandlingseffekt, komplikationer samt som beslutsstöd för att avgöra
behandlingstid med antibiotika. CRP har långsammare kinetik än
PCT, men PCT anses ha en starkare association till bakteriell infektion.
Hep-25 är en akutfasreaktant som uppregleras vid inflammation och
infektion vilket leder till sänkta järnnivåer i blodet. Ret-MCH påverkas
vid svår sepsis/septisk chock då järnnivåerna i blodet är låga. Tidigare
studier har visat förhöjda Hep-25 nivåer vid bakteriella infektioner såsom pneumoni, neonatal infektion men även vid hepatit, HIV och malaria. Studiesyftet var att jämföra Hep-25, Ret-MCH, CRP och PCT
hos patienter med svår sepsis/septisk chock.
Metod: Femton patienter, med IVA-krävande svår sepsis/septisk chock
som vistats på sjukhus < 24 h inkluderades i pilotstudien vid Helsingborgs lasarett. Under 7 dygn togs studieprover, rutinprover samt daglig
SOFA (Sequential Organ Failure Assesment) bedömning. Patienter
≤18 år, de som nyligen genomgått operativt ingrepp, eller erhållit blodtransfusion (<7 dagar) exkluderades.
Resultat:
Hep-25, CRP och PCT nivåerna var kraftigt förhöjda vid
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,
medan PCT-värdena inte påverkades utan fortsatte att sjunka (Fig.2).
SOFA score vid intagning 10,0 (5.0,11.0) och 11 (8.0,14.3) efter 1
dygn. Ret-MCH fungerar inte för monitorering av sjukdomsförloppet
p.g.a. sin långsammare dynamik.
Konklusion:
I denna hypotesgenererande pilotstudie på 15 patienter
med intensivvårdskrävande svår sepsis/septisk chock uppvisade Hepcidin-25 (Hep-25) snabbare dynamik efter insatt antibiotikabehandling
jämfört med C-reaktivt protein (CRP), men med likartat mönster som
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)
sjönk initialt med långsam normalisering under de 7 studiedygnen.
Resultaten ligger till grund för en större studie inkluderande såväl intensivvårdskrävande sepsis som andra IVA-krävande tillstånd.
Fig. 1. Indexerade värden av biomarkörer under 7 dagars studietid. Inkomstvärde = 100 % för 15 patienter.
Fig. 2. Hepcidin-25 i jämförelse med CRP hos en patient med icke-septisk
komplikation.
In-hospital versus 30-day mortality in the
critically ill – a 2-year Swedish intensive care
cohort analysis.
Avdeling för anestesiologi, Universitetssykehus, Rikshospitalet, Oslo, Norge
Background: Standardised mortality ratio (SMR) is a common quali-
ty indicator in critical care and is the ratio between observed mortality
and expected mortality.
Typically, in-hospital mortality is used to derive SMR, but the use of
a time-fixed, more objective, endpoint has been advocated. This study
aimed to determine the relationship between in-hospital mortality and
30-day mortality on a comprehensive Swedish intensive care cohort.
Methods: A retrospective study on patients >15 years-old, from the
Swedish Intensive Care Register (SIR), where intensive care unit (ICU)
admissions in 2009-2010 were matched with the corresponding hospital admissions in the Swedish Hospital Discharge Register. Recalibrated SAPS (Simplified Acute Physiology Score) 3 models were developed
to predict and compare in-hospital and 30-day mortality. SMR based
on in-hospital mortality and on 30-day mortality were compared between ICUs and between groups with different case-mixes, discharge
destinations and length of hospital stays.
Results:
Sixty-five ICUs with 48861 patients, of which 35610 were
SAPS 3 scored, were included. Thirty-day mortality (17%) was higher
than in-hospital mortality (14%). The SMR based on 30-day mortality and that based on in-hospital mortality differed significantly in
7/53 ICUs, for patients with sepsis, for elective surgery-admissions and
in groups categorised according to discharge destination and hospital
length of stay.
Conclusion: Choice of mortality end-point influences SMR. The extent of the influence depends on hospital-, ICU- and patient cohort
characteristics as well as inter-hospital transfer rates, since all these factors influence the difference between SMR based on 30-day mortality
and SMR based on in-hospital mortality.
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P75
ICU admittance, is it influenced by patient
gender?
Zettersten, Larsson, Jäderling, Ohlsson, Bell
ANOPIVA, Karolinska Universitetssjukhuset, Solna
Introduction: We assume that critically ill patients are admitted to an
intensive care unit (ICU) based on their present illness severity coupled
with their age and co-morbidities. Evidence-based clinical judgment
and objective practice parameters derived from solid research hopefully
result in sound clinical decisions. Patient attributes such as religion, nationality, socioeconomic class or gender are not relevant in this setting.
Objectives: To explore the association of patient gender with admission to the ICU amongst hospital physicians working in Sweden.
Methods: Two different versions of an online survey, with eight patient cases, were sent to physicians in Sweden who within their field
56
of specialty meet patients that could be eligible for intensive care. The
versions of the survey were identical except that the patient gender in
each case was exchanged between the two surveys. Depending on the
respondent’s birthday (odd or even number) they were directed to one
of the two surveys. At the end of each case the respondent was asked to
answer if they thought that the patient needed ICU care, yes or no. The
respondents were not told in advance about the design of the survey.
The respondents were also asked to state their age, sex, field of specialty,
size of hospital and title.
Results:
Of 1426 respondents, 679 and 747 answered survey 1 and
2, respectively. Overall, there were no significant differences in willingness to admit in between cases describing a man or woman in the physician responses. We found statistically significant differences in five
out of eight cases when Anesthesiology/intensive care physicians were
tested versus all other specialties. In those five cases the former group
chooses to admit more patients to the ICU. Female physicians tended
to be more willing to admit patients, regardless of patient gender, than
their male counterparts.
Conclusions: Using a survey, with eight cases only differing with regards to the gender of the patient, we could not find gender bias among
Swedish hospital physicians. We demonstrated that anesthesiologists/
intensivist were more likely to recommend ICU admission as compared to other specialists. Female physicians also tended to admit more
patients than their male counterparts.
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Posterpresentation 10
(Patientsäkerhet)
Tisdag 22/9 kl 13:45–14:45
Lokal: utställningen
Moderatorer: Mattias Schindele, Olof Ekre
P76
Critical care ultrasound- implementing international guidelines into clinical practice.
B. Arnason, P. Sigurjonsson, P. Rudberg, J. Elzen, J. Nordstrom,
M. Eriksson, E. Larsson, N. Jonsson, L. Bergenzaun
Karolinska University Hospital, Anaesthesiology and Intensive Care,
Stockholm, Sweden.
Background:
Meticulous assessment and critical decision-making are
essential to decrease morbidity and mortality and to improve performance in intensive care medicine. In recent years, point of care ultrasound (PoCUS) has become an invaluable tool in the clinical evaluation of the critically ill. Recent international guidelines, stress that
intensive care physicians, should be competent in critical care ultrasonography (CCUS) and critical care echocardiography (CCE). Ensuring a high level of quality in CCUS and adherence to good governance
principles is an ongoing challenge. An implementation of CCUS in
clinical practice requires appropriate education, credentialing, quality
control, continuing education and clinical governance.
Purpose: The purpose of this study was to create and plan to implement an educational program in CCUS and basic level of CCE, in
accordance with international recommendations of structured ultrasound curriculum models, in the Department of Anesthesia and Intensive Care at Karolinska University Hospital.
Method: A systematic literature review and needs analysis was conducted to define the basis of the ultrasound educational program.
An already existing two-day course in point of care ultrasound at our
department was extended and adjusted to fulfill the requirements of
CCUS and basic level of CCE. An e-based logbook was created, facilitating the documentation of sonographic examinations. All faculty
supervisors are intensive care physicians with extensive experience in
focused sonographic examinations.
Results:
The curriculum was adopted from international guidelines.
It consists of an introduction course with 10h of didactics and 8h of
hands-on sessions on healthy volunteers. The course curriculum is organ system-based, covering basic ultrasound physics, knobology and
image acquisition and interpretation. The course includes basic critical
care echocardiography, lung and pleural ultrasound, hemodynamic assessment and abdominal ultrasound including aorta and eFAST.
Furthermore, participants receive continuous teaching in combination with lectures, bedside demonstrations and case presentations
supervised by an experienced intensivist. Finally 30 adequately performed CCE and 20 CCUS in critically ill patients must be assessed
and discussed in their clinical context with a faculty supervisor before
approval.
The program is voluntary and available to both residents in training
and specialists in anesthesia and intensive care.
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P77
Performance and user evaluation of a novel
capacitance-based automatic urinometer
compared with a manual standard urinometer
after elective cardiac surgery.
Eklund A, Slettengren M, van der Linden J
Thoraxkliniken/Dep. Cardiothoracic Surgery & Anesthesiology
Karolinska institutet, Karolinska Univ. hospital
Introduction:
In the intensive care setting, most physiologic parameters are monitored automatically. However, urine output (UO) is still
monitored hourly by manually handled urinometers. In this study, we
evaluated an automatic urinometer (AU) and compared it with a manual urinometer (MU).
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
more, hourly UO samples were measured with an AU (Sippi, n = 220;
Observe Medical, Gothenburg, Sweden) or an MU (UnoMeter™ 500,
n = 188; Unomedical, Birkerød, Denmark) and thereafter validated by cylinder measurements. Malposition of the instrument at the
time of reading excluded measurement. Data were analyzed with the
Bland-Altman method. The performance of the MU was used as the
minimum criterion of acceptance when the AU was evaluated. The loss
of precision with the MU due to temporal deviation from fixed hourly
measurements was recorded (n = 108). A questionnaire filled out by
the ward staff (n = 28) was used to evaluate the ease of use of the AU
compared with the MU.
Results:
Bland-Altman analysis showed a smaller mean bias for the
AU (+1.9 ml) compared with the MU (+5.3 ml) (P <0.0001). There
was no statistical difference in measurement precision between the
two urinometers, as defined by their limits of agreement (±15.2 ml vs.
±16.6 ml, P = 0.11). The mean temporal variation with the MU was
57
±7.4 minutes (±12.4%), and the limits of agreement were ±23.9 minutes (±39.8%), compared with no temporal variation with the AU
(P <0.0001). The ward staff considered the AU easy to learn to use and
rated it higher than the MU (P <0.0001).
Conclusions: The AU was not inferior to the MU and was significantly better in terms of bias, temporal deviation and staff opinion,
although the clinical relevance of these findings may be open to discussion.
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P78
Ökad patientsäkerhet vid utskrivning IVA
– ett led i att minska återinläggningar inom 72 h
Erlandsson E, specialistsjuksköterska IVA och Agvald-Öhman C.
Överläkare, MD PhD
Karolinska Universitetssjukhuset Huddinge IVA
Bakgrund: På Karolinska Huddinge IVA B46 har de senaste åren resultaten för SIR:s (Svenska Intensivvårdsregistret) kvalitetsindikator
”Åter in inom 72 timmar” försämrats.
Metod:
I samarbete med QRC (Kvalitetsregistercentrum Stockholm)
och SIR genomfördes ett projekt där en medlem i teamet fick gå en
coachingutbildning på TDI (The Dartmouth Institute). Den bestod av
sammanlagt sex sessioner varav en var fyra dagar på plats i Dartmouth,
USA. TDI arbetar med en validerad metod för förbättringsarbete i
team och den användes under projektet.
Teamet har haft en stående mötestid varje vecka samt haft två heldagsmöten. Verksamheten kartlades enligt ”5 P-metoden”. Data togs
fram, från SIR och ur patiendatasystemet Clinisoft, om vilka patientdiagnoser och avdelningar som var överrepresenterade bland de tidiga
återinläggningarna. Ett fiskbensdiagram skapades för att visualisera de
faktorer som påverkar återinläggningar inom 72 h.
Resultat: En processkarta av utskrivningsprocessen gjordes för att un-
derlätta identifieringen av potentiella förbättringsområden i processen.
Tre förbättringsområden identifierades.
Genom att arbeta med dessa tre förbättringsområden förväntar vi oss
att öka patientsäkerheten i övergången mellan IVA och vårdavdelning.
• Förbättringsidé 1: En journalgranskning av läkarepikriser gjordes för baslinjedata. En rekommendationsmall utarbetades och
implementerades.
• Förbättringsidé 2: Ingen rutin fanns för att skriva omvårdnads
-rekommendationer. En mall för detta togs fram.
• Förbättringsidé 3: Bedside rapportering av undersköterska inför
överflyttning till vårdavdelning.
Samtliga tre förbättringsidéer bygger på varandra. Det är ett åtgärdspaket för en säkrare utskrivning av patienten från IVA. För att underlätta stegen i rapporteringsprocessen gjordes ett flödesdiagram som ska
fungera som lathund för personalen vid utskrivning.
Konklusion:
Det tar tid att förändra och ffa att behålla en förbättring över tid. Framtida projekt kommer att skapas för att nå slutmålet.
Teamets har lärt sig en strukturerad metod som kommer att ligga som
grund för dessa projekt och även andra kvalitetsprojekt på avdelningen.
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58
P79
Uppföljning efter operation och anestesi ett led
i förbättringsarbetet och ett sätt att öka patientmedverkan i vården (PROM och PREM).
Pether Jildenstål PhD, Metha Brattwall, Överläkare, PhD,
Margareta Warren-Stomberg PhD, Irene Sellbrant Överläkare,
Jan G. Jakobsson Överläkare Adj.Professor.
Institutionen för vårdvetenskap och hälsa, Sahlgrenska akademin vid
Göteborgs Universitet Introduktion:
Intresset för olika former av telemedicn ökar (1). Inom
anestesi/kirurgi har denna teknik inte utnyttjats som inom hälsobefrämjande enheter såsom rökning, motion/vikt och kroniska sjukdomar t.ex. diabetes (2, 3). Dagkirurgiska enheter genomför idag alltmer
komplicerad kirurgi. Att kunna göra postoperativ uppföljning på ett
enkelt sätt efterfrågas till exempel av SPOR, och telemedicin har börjat
sin entré även inom detta område (3,4,5).
Syftet med dessa pilotstudier var att utvärdera följsamheten till en
telemedicinsk uppföljning med en ”app” efter dag/korttidskirurgi samt
att kartlägga vilken uppföljningsmetod patienten föredrar.
Metod:
En prospektiv pilotstudie gjordes under 2014 vid dagkirurgienheten Mölndal Sahlgrenska universitetssjukhuset i Göteborg.
Uppföljning skedde under 8 dagar med maximalt 15 registreringar via
patientens mobiltelefon och 1 SMS påminnelse om inte registrering
skett vid angiven tidpunkt 09.00 och 21.00. 98 patienter som genomgått ortopedisk dagkirurgi inkluderades. I en kompletterande pilotstudie tillfrågades 90 patienter, i åldrarna 18–40, 41–60 och mer än 60
år i samband med operationstillfället om de föredrog att besvara frågor
kring återhämtning efter operationen, via ”app”, web-enkät eller via en
konventionell pappersenkät.
Resultat: Följsamhet att besvara frågor via app var låg. Totalt använde
29/55 (53%) patienter app mer än 13ggr /15 möjliga. Äldre patienter
svarade mindre frekvent. Det fanns också en åldersskillnad i önskemål
om teknik för postoperativ uppföljning, där yngre var mer benägna
föredra app och äldre hellre såg en konventionell pappersenkät. Totalt
valde 35/90 app, 27/90 web och 21/90 pappersenkät och totalt 5 svarstillfällen accepterades av 46/90.
Konklusion:
Den acceptans för postoperativ uppföljning som framkom överensstämmer inte helt med den kliniska pilotstudien via app
för postoperativ uppföljning, där svarsbortfallet var stort. Uppföljning
och återkoppling kring återhämtning, vårdkvalitet och effekter på hälsa
via telemedicin behöver utvecklas och bättre /enklare tekniker behöver tas fram. Ytterligare studier av hur vi bäst kan få återkoppling –
PROM- och PREM-uppföljning efter dagkirurgi planeras.
Referenser:
1. Whittaker R. Issues in mHealth: findings from key informant interviews. J Med Internet Res. 2012;14(5):e129.
2. Free C, Knight R, Robertson S, Whittaker R, Edwards P, Zhou W,
Rodgers A, Cairns J, Kenward MG, Roberts I. Smoking cessation
support delivered via mobile phone text messaging (txt2stop): a
single-blind, randomised trial. Lancet. 2011 Jul 2;378(9785):49–
55.
3. WilmoreDW, Kehlet H. Management of patients in fast tracksurgery. BMJ. 2001 Feb 24;322(7284):473–6.
4. Armstrong KA, SempleJL, Coyte PC. Replacing ambulatory surgical 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
Recoveryof Patients at Home: A Feasibility Study JMIRMhealth­
Uhealth. 2015 Jan-Mar; 3(1): e18.
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P80
30-dagars reklamation på din operation/anestesi!
Hur vill patienterna att vi följer deras återhämtning?
Irene Sellbrant, Pether Jildenstål, Agnetha Folestad, Jan G Jakobsson
Anestesikliniken, Capio Lundby Närsjukhus, Göteborg
Bakgrund: Antalet ingrepp som utförs i dagkirurgi i Sverige ökar.
Dagkirurgi medför att större delen av den postoperativa vården sker
som ”egenvård”. Det ställer krav på vårdgivaren att följa upp och få en
återkoppling på utförd vård som en del av kvalitetsprocessen. Uppföljningen skall belysa såväl avvikelser/komplikationer, subjektiva besvär
samt patients upplevelse av vården, ”Patient ReportedOutcomeMeasures” PROM.
Syftet med detta kvalitetsarbete var att 30 dagar postoperativt få en
uppfattning om patientnöjdhet med vården, patienternas önskan om
uppföljningssätt samt resursåtgången för uppföljning med telefonintervju.
Metod: Ett prospektiv kvalitetsprojekt gjordes mars-maj 2015 vid
dagkirurgiska enheten på Capio Lundby Närsjukhus i Göteborg. Uppföljningen skedde med telefonsamtal 30 dagar postoperativt. Femtio
patienter som genomgått 5 olika ingrepp, 10 stycken av vardera tillfrågades preoperativt om att bli uppringda. De uppdelades sedan i 3
ålders­grupper, 17–40, 41–65 samt >65 år. Patientdemografi; kön, ASA,
BMI, rökning registrerades.
Frågorna bestod av en PROM (EQ-5d) samt en PREM (Patient-reported experience-measure) del. Antal uppringningsförsök samt samtalstiden registrerades. Brytpunkt för ”ej nådda” sattes till 40 dagar
postoperativt.
Resultat:
De flesta patienterna (92%) kunde nås per telefon innan
”brytpunkt”. Det krävdes i genomsnitt 2,6 uppringningsförsök/person. Det behövdes 1 samtal mer/person i den yngsta åldersgruppen vs.
den äldsta. Genomsnittlig samtalstid var 15,9 minuter. I alla 3 ålders­
grupperna föredrog patienterna att bli uppringda av vårdgivaren för
uppföljning (17–40 år 79%, 41–65 år 88%, >65 år 100%). Enstaka
patienter föredrog mail, eller pappersenkät. Ingen av de tillfrågade önskade svara via ”app”. Många patienter uttryckte stor glädje över att
vårdgivaren brydde sig om att ringa dem och dessutom få möjlighet att
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.
Konklusion:
Vi fann en stor patientnöjdhet med 30-dagars telefonuppföljning. 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.
P81
Ny perkutan trakeotomiteknik – erfarenheter från
Karolinska sjukhuset
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
Gregory Margolin, MD, Ph.D., Dept. of Otolaryngology and Head
& Neck Surgery and Dept. of Oncology, Karolinska University Hospital,
Stockholm, Sweden
Perkutan trakeotomi har blivit en rutinteknik för elektiv trakeotomi.
I Sverige utförs c:a 1000 st trakeotomier per år varav c:a 50% utförs
perkutant. Man har rapporterat komplikationer med perkutana dilatationstrakeotomier (PDT). De allvarligaste har varit blödning, pneumothorax och trakealväggsskador (1). Ett genomgående problem har
varit att punktionen i trakea inte kunnat styras och säkerställas tredimensionellt.
För att vara säker på att penetrationen är framgångsrik kontrolleras
den normalt fiberoptiskt. Endotrakealtuben måste dras tillbaka med
risk för extubation.
Vi har utvecklat en metod för att göra säkra PDT även i svåra anatomiska situationer.
SafeTrachtekniken eliminerar svagheterna med traditionella PDT:s.
SafeTrach är ett tångliknande instrument för säker bestämning av nivån på trakeotomin och som leder en punktionsnål två-dimensionellt
mot, och med skydd av, en inre skänkel.
SafeTrach erbjuder en intuitiv teknik som hjälper läkaren att penetrera trakea utan övervakning av ett bronkoskop. Förhållandet mellan
den inre skänkeln och den endo-trakeala tuben ger ett klart mått på
hur långt nedanför stämbanden punktionsplatsen är. Den inre skänkeln ligger alltid i mitten av luftstrupen varför punktionen genom yttre
skänkeln garanterar en ingång i mittlinjen. Det är omöjligt att gå för
djupt eller att hamna utanför luftstrupen. Dilatationen utförs med patienten ventilerad hela tiden.
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 huvudoch halspatienter som skulle opereras med fria lambåer till munhålan.
Dessa behöver trakeotomeras för att säkra fria andningsvägar postoperativt. Patienterna representerade olika typer av halsanatomier där
7 patienters cricoidbrosk och trakela ringar var svåra att identifiera
genom palpation.
Resultat och slutsatser:
Studien visade att penetrationsdelen av
trakeotomin var snabbt och säkert utförd trots olika anatomiska svårigheter. Tiden för förfarandet var jämförelsevis kort utan hypoxi eller
hyperkapni. Referens:
1. Percutaneous tracheostomy. Contin Educ Anaesth Crit Care Pain
(2014) 14 (6): 268-272.
...........................................................................................
Referens;
1. http://www.promcenter.se/sv/prem/?lid=150a21d0a8981f
2. van Boxel GI, Hart M, Kiszely A, Appleton S. Elective day-case laparoscopic cholecystectomy: a formal assessment of the need for outpatient follow-up. Ann R Coll Surg Engl. 2013 Nov;95(8):e142-6.
59
P82
Närståendes tillfredställelse med intensivvård
Johan Thermaenius
ANOPIVA, Karolinska Universitetssjukhuset, Solna
Bakgrund:
För att kunna erbjuda vård av god kvalitet är det viktigt
patienternas erfarenheter av hälso- och sjukvården efterfrågas och tillvaratas. Kritiskt sjuka patienter minns sällan intensivvården, vilket
försvårar mätning av patienttillfredsställelse. En enkät som tillvaratar
närståendes upplevelser, kan ge en indikation på hur bemötande och
delaktighet inom intensivvården fungerar.
Syfte: Att utveckla en enkät för att mäta närståendes tillfredställelse
med intensivvård, utvärdera dess tillförlitlighet samt testa den kliniska
användbarheten.
Metod:
Utifrån internationella enkäter valdes frågor som var användbara för svenska förhållanden ut, och sammanställdes till en ny enkät.
Innehållet utvärderades av en expertpanel. Användbarheten testades
sedan genom ”Think aloud”-intervjuer med tolv närstående till nyligen utskrivna patienter från två intensivvårdsavdelningar. Den slutliga
enkäten bestod av 21 flervalsfrågor, samt fyra öppna frågor. Svarsalternativen angavs i en fyragradig skala, mycket nöjd (1,0p), nöjd (0,75p),
missnöjd (0,5p), mycket missnöjd (0,25p). Två veckor efter avslutad
intensivvård skickades enkäten till närstående till patienter som vårdats
längre än två dygn på CIVA, Karolinska Universitetssjukhuset Solna.
Resultatet grupperades i fem områden och medelvärden för tillfredställelsen presenterades.
Resultat:
Under 2014, mottog 156 närstående enkäten, varav 95
(61 %) svarade. De närstående var i allmänhet mycket nöjda med
vården. Främst var de nöjda med ”Vård och bemötande av patienten”
(medelvärde 0,97p) och ”bemötande av närstående” (0,95p). Delar av
”Information” (0,91p) och ”Intensivvårdsmiljö” (0,82p) bedömdes
ha förbättringspotential. Angående ”delaktighet inom intensivvård”,
upplevde 58 närstående (61 %) missnöje i någon mån, eller frågan
som ej relevant. Slutligen bedömdes ”helhetsintrycket” som mycket
gott (0,98p).
Slutsats:
En enkät för att mäta närståendes tillfredställelse med intensivvård har utvecklats och validerats. Enkäten kan vara användbar
genom att synliggöra områden med potential för förbättring.
...........................................................................................
Fria Föredrag
Fria föredrag 1
Måndag 21/9 kl 14:00–15:30
Lokal: 27
Moderatorer: Sven-Erik Ricksten, Olaf Rooyackers
FF1
Evaluation of a capnodynamic method for monitoring effective pulmonary blood flow in a ischemic
and reperfusion porcine model
Thorir Sigmundsson1,2, Caroline Hällsjö Sander1,2, Tomas
Öhman1, Magnus Hällbäck3, Håkan Björne1,2
Department of Anaesthesiology, Surgical Services and Intensive Care
Medicine, Karolinska University Hospital, Solna, Sweden, 2Department
of Physiology and Pharmacology, Karolinska Institutet, Stockholm,
Sweden, 3Maquet Critical Care AB, Solna, Sweden
1
Introduction:
A capnodynamic equation can be used to calculate
e­ffective pulmonary blood flow (COEPBF) i.e. cardiac output (CO)
­minus shunt. An ischemic injury with subsequent reperfusion increases the concentrations of carbon dioxide temporarily, a situation that
theoretically could affect the agreement of a capnodynamic method.
The aim of the current study was to evaluate the performance of
COEPBF during ischemia and reperfusion in porcine model.
Methods: The required alterations of alveolar concentration of carbon
dioxide are created by a ventilatory pattern containing cyclic reoccurring expiratory holds.
COEPBF was compared to a reference method for CO, an ultrasonic
flow probe around truncus pulmonalis and a pulmonary artery catheter using three consecutive thermo dilution measurements (N=8).
A 10 Fr Reliant catheter (Medtronic) was placed below the diaphragm via the femoral artery and inflated until blood flow in the contralateral femoral artery was abolished according to ultrasound doppler
and released after 30 minutes. Hemodynamic measurements and lactate levels were obtained at baseline before the balloon was inflated
(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 Altman 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. COEPBF showed good
agreement at BL but markedly overestimated CO at minute one and
three after deflation. Five minutes after deflation COEPBF had re-established agreement with the reference method.
...........................................................................................
60
FF2
kanalen med efterföljande systemisk inflammatorisk reaktion. Syftet
var att skapa en stordjursmodell där effekterna på magtarmkanalens
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
Hallbäck3, Fernando Suarez Sipmann4, 5, Mats Wallin2, 3, Anders
Oldner1, 2, Håkan Björne1, 2
Metod:
Modified capnodynamic method for continuous
assessment of effective pulmonary blood flow
Department of Anaesthesiology, Surgical Services and Intensive Care
Medicine, Karolinska University Hospital, Solna, Sweden, 2Department
of Physiology and Pharmacology, Karolinska Institutet, Stockholm,
Sweden, 3Maquet Critical Care AB, Solna, Sweden, 4Department of
Surgical Sciences, Section of Anaesthesiology and Critical Care, Hedenstierna’s laboratory, Uppsala University, Uppsala, Sweden, 5CIBERES,
CIBER de enfermedades respiratorias, Instituto Carlos III, Madrid,
Spain
1
Introduction: A capnodynamic equation can be used to calculate
effective pulmonary blood flow (COEPBF) i.e. cardiac output minus
shunt. The method could be integrated into a standard ventilator and
provide a continuous non-invasive alternative for estimation of COEPBF
in intubated mechanically ventilated patients.
The aim of the current study was to evaluate if the performance of
COEPBF was improved by a modified breathing pattern.
Methods: Alterations of alveolar concentration of carbon dioxide are
a prerequisite to solve the capnodynamic equation and can be accomplished by a predefined ventilatory pattern including a sequence of
three breaths with an expiratory hold followed by six normal breaths.
COEPBF was compared to a reference method for cardiac output, an
ultrasonic flow probe around truncus pulmonalis, in a porcine model.
(N=8)
The circulation was altered including preload reduction and inotropic stimulation as well as changes in respiratory conditions with varied PEEP levels and increased tidal volumes. Agreement and trending
ability was evaluated using Bland-Altman statistics and four-quadrant
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
rate of 98%.
Discussion:
COEPBF with a modified breathing pattern based on expiratory holds showed improved overall agreement in absolute values
compared to our previous animal studies with a ventilatory pattern
based on inspiratory holds. Trending ability was preserved for all hemodynamic and respiratory interventions.
...........................................................................................
FF3
En stordjursmodell med lågt cardiac output för
vidare studier av gastrointestinalkanalen
Jenny Seilitz1, Tal Hörer1, Per Skoog1, Birger Axelsson1, Kjell
Jansson2, Kristofer F. Nilsson1
1
Kärl-thoraxkliniken, Universitetssjukhuset Örebro, 2Kirurgiska kliniken,
Universitetssjukhuset Örebro, Institutionen för hälsovetenskap och medicin, Örebro Universitet
Bakgrund: 20% av patienterna efter hjärtkirurgi drabbas av nedsatt
hjärtfunktion. Detta kan orsaka försämrad cirkulation till magtarm-
Sövda grisar övervakades avseende hemodynamik inklusive
med semi-kontinuerlig CO-mätning.
A. mesenterica superior försågs med flödesmätare. Tunntarmsslemhinnans perfusion mättes med laser Doppler. Blodgaser från a. carotis,
a. pulmonalis och v. mesenterica superior analyserades. Metabolismen
i bukhålan följdes med intraperitoneal mikrodialys.
CO sänktes stegvis till 75% (CO75%), 50% (CO50%) och 35%
(CO35%) av utgångsvärdet under en timme vardera. Sänkningen skedde
antingen via en hjärttamponad (vätska injicerades i perikardiet, n=6),
eller med en ballong i v. cava inferior (n=6). Sex djur var kontroller.
Resultat:
De tre grupperna var lika vid baseline. Både tamponaden
och cavaballongen sänkte CO kontrollerat. Kontrollgruppens CO
förblev oförändrad. Vid CO35% avled fyra av sex djur i tamponadgruppen. Medelartärtrycket var bibehållet vid CO75% i alla grupperna.
Vid CO50% sjönk medelartärtrycket till 35±4 mmHg respektive 42±3
mmHg i tamponad- och cavagruppen. Flödet i a. mesenterica superior
sjönk proportionerligt till CO-sänkningen i båda grupperna. Tunntarmsslemhinnans perfusion minskade vid CO50% i tamponadgruppen
till 71±16% och i cavagruppen till 73±15%, av utgångsvärdet. Metoderna orsakade jämförbar laktatökning i artär- och mesenterialvensblod. Parallellt steg den intraperitoneala laktatkoncentrationen och
laktat/pyruvat-kvoten i bägge grupperna.
Slutsats:
Båda metoderna för att inducera lågt CO är genomförbara
men cavaballongen upplevs experimentellt enklare. Sänkt CO oavsett
metod medför en snarlikt försämrad cirkulation och metabolism i
magtarmkanalen. Denna påverkan ses även vid en mindre CO-sänkning med bibehållet medelartärtryck. I våra modeller är en CO-sänkning till ungefär 60% av utgångsvärdet lämplig att använda i fortsatta
läkemedelsstudier för en rimlig balans mellan CO-sänkning, påverkan
på medelartärtrycket och förväntad effekt på magtarmkanalen.
...........................................................................................
FF4
Activation of CD137 Promotes Post-operative
Cardiovascular Inflammation in Experimental
Atherosclerosis
Leif Söderström, Hong Jin, Lars Maegdefessel, Göran K Hansson
and Peder Olofsson
Center for Molecular Medicine, Experimental atherosclerosis unit,
Karolinska Institutet, Stockholm
Perioperative mortality is most commonly caused by cardiovascular disease (CVD) and CVD contributes to perioperative morbidity. Atherosclerotic plaques are the main cause of CVD. Plaque rupture, which
often occurs during cardiovascular stress, is ultimately responsible for
most clinical symptoms of CVD. There is currently no established clinical therapy to prevent plaque rupture during excessive stress such as
surgery.
Plaque inflammation is a key factor in plaque rupture. T-cells, master controllers of plaque inflammation, are regulated by co-stimulatory
receptors. We recently discovered that CD137, a co-stimulatory receptor of T-cells, promotes development of atherosclerosis (Circulation
2008, Mol Med 2014).
61
Analysis of CD137 and CD137 ligand mRNA in human clinically significant carotid plaques showed increased levels of CD137 and
CD137 ligand in plaques vs healthy control vessels (7.84 vs 0.51,
95%CI 4.35-10.58, p<0.0001; 0.455 vs 0.094, 95%CI 0.627-0.096,
p<0.01 respectively). To investigate the effects of CD137 activation, we
used a murine model for carotid plaque rupture. CD137 was pharmacologically stimulated by intraperitoneal injections of an agonistic antiCD137 antibody (2A) or control IgG2a. 2A treatment resulted in increased inflammation in the abdominal aorta as evidenced by increased
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;
Ifnγ 12.78 ±2.548 vs 3.432 ±0.8907, p=0.0021. n=38). There was no
difference in red or white blood cell count between groups. In spleen,
cytotoxic CD8+ T-cells increased significantly in 2A treated mice compared to controls (50.95 ±1.944 vs 44.04 ±1.868, p=0.015, n=37).
Analysis of plaque rupture frequency is currently ongoing.
Taken together, these results show increased levels of CD137 in human 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
needed to evaluate CD137 interventions in prevention of perioperative
CVD.
...........................................................................................
FF5
Thioredoxin in Trauma and Post-Injury Sepsis
J. Eriksson1,2, A. Gidlöf1,2, O. Brattström1,2, B. Persson1,2,
E. Larsson1,2, A. Oldner1,2
Institute(s): 1Karolinska Institutet, Physiology and Pharmacology, Section
of Anesthesiology and Intensive Care, Stockholm, Sweden, 2Karolinska
University Hospital, Solna, Anesthesiology, Surgical Services and Intensive Care, Stockholm, Sweden
Introduction:
Trauma is one of the leading causes of mortality
worldwide, resulting in a great global burden of disability and mortality[1, 2]. Approximately half of all trauma deaths occur during the first
hours due to traumatic brain injury or massive bleeding. Later deaths
are due to, for example, sepsis or multiple organ failure[3]. Independent risk factors for post-injury sepsis are still somewhat poorly defined. Injury Severity Score (ISS), male gender, age, low Glasgow Coma
Scale (GCS) at admission and massive blood transfusion have previously been suggested as risk factors[1]. Thioredoxin (TRX) is thought
to have important anti-oxidant properties but it also functions as an
endogenous anti-inflammatory mediator[4]. The link between high
plasma levels of TRX and sepsis has been studied previously, although
with conflicting evidence[4, 5]. TRX-levels in trauma patients and the
possible correlation to secondary complications such as post-injury
sepsis have to our knowledge not been studied previously.
Objectives: To study the relationship between trauma and plasma levels of TRX as well as the possible correlation between post-traumatic
plasma-TRX and post-injury sepsis.
Methods: ICU-admitted trauma patients with an expected stay of >3
days (n=84) were included. Median ISS was 29. Plasma-TRX was analyzed on day 1 and 3. Clinical, physiological and outcome data were
retrieved from the trauma and ICU research registries. In addition, we
analyzed plasma-TRX in 10 healthy subjects.
Results:
A three-fold increase in initial TRX was seen in trauma patients when compared to healthy volunteers (median, IQR 63.9 ng/
62
ml, 39.3-114.6 vs. 22.6 ng/ml, 16.1-25.8 p=0.0001). High ISS (>25)
was associated with high plasma-TRX (median, IQR 72.1 ng/ml,
45.2-129.3 vs. 47.9 ng/ml, 35.0-81.2 p=0.049). TRX decreased significantly between day 1 and 3 (median, IQR 63.9 ng/ml, 39.3-114.6
vs. 38.6 ng/ml, 32.4-57.1 p< 0.0001). There was no significant difference between survivors and non-survivors in plasma-TRX. Day 1
plasma-TRX levels were significantly increased in patients who later
developed severe sepsis compared to those who did not (median, IQR
72.9 ng/ml, 44.8-137.3 vs. 49.8 ng/ml, 39.0-78.3 p=0.014).
Conclusions: TRX levels rise after trauma. Our data suggests that increased plasma TRX levels are associated with post-injury sepsis. The
potential usefulness of TRX as a biomarker in trauma patients needs
further evaluation in larger studies.
Grant Acknowledgment: ALF-funding through Stockholm County
Council and Karolinska Institutet.
References:
1.
2.
3.
4.
5.
6.
GBD 2013: Lancet 2015, 385(9963):117-171.
Patton GC et al: Lancet 2009, 374(9693):881-892.
Soreide K et al: World J of Surg 2007, 31(11):2092-2103.
Wafaisade A et al: Crit C Med 2011, 39(4):621-628.
Hofer S et al: Crit C Med 2009, 37(7):2155-2159.
Callister ME et al: Int C Med 2007, 33(2):364-367
...........................................................................................
FF6
Extern validering av en förenklad prediktions­
modell för illamående och kräkning efter hemgång vid dagkirurgi
Jakob Walldén1, Jesper Flodin2, Magnus Hultin2.
1
Operationscentrum, Sundsvalls Sjukhus, 2AnOpIVA, Sunderbyns Sjukhus, alla vid Enheten för Anestesi och Intensivvård, Inst för kirurgisk och
peroperativ vetenskap, Umeå Universitet.
Bakgrund: "Post discharge nausea and vomiting" (PDNV) är ett relativt ouppmärksammat problem som drabbar upp till en tredjedel av
patienter som opereras inom dagkirurgi. En förenklad publicerad prediktionsmodell för PDNV inbegriper faktorerna: kvinna, ålder < 50 år,
anamnes på PONV, illamående postoperativt och behov av opioider
postoperativt (1). Syftet med studien var att göra en oberoende och
extern validering av prediktionsmodellen i ett svenskt material.
Metod:
Vuxna patienter som genomgick dagkirurgi under generell
anestesi vid Sunderbyns Sjukhus och Sundsvalls sjukhus inkluderades
i studien. Postoperativt utvärderades patienterna med fokus på illamående, kräkning och smärta vid 2, 4 och 6 timmar efter avslutad kirurgi
samt de följande tre postoperativa dagarna. Poäng i den förenklade prediktionsmodellen beräknades utifrån patientens tillstånd vid hemgång.
Prestanda i prediktionsmodellen utvärderades med diskriminationsförmåga (Arean under the receiver operating characteristic curve, AUCROC) och kalibreringskurva och jämfördes med originalstudiens.
Resultat:
431 patients inkluderades i studien. Den generella incidensen av PONV and PDNV var 18.8% (95% CI, 15.4-22.8) respektive
28.1% (95% CI, 24.0-32.5). Prediktionsförmågan med den förenklade modellen för PDNV överensstämde men den i orginalstudien
(AUC 0.693 (95% CI, 0.638-0.748) vs. 0.706 (0.681-0.731), absolut differens 0.013). Lutningen på kalibreringskurvan (R Square) var
0.883 med en konstant på 0.021.
Den förenklade modellen för att prediktera PDNV har bra
prestanda i ett svenskt material och kan vid dagkirurgi skilja ut patienter med ökad risk för illamående och kräkning i hemmet. Våra
resultat visar på att modellen är giltig i andra populationer än den i
orginalstudien.
FF8
Referens
Marcus Brynolf, Sigridur Kalman, Erzsebet Bartha
Slutsats:
1. Apfel et al. Who is at risk for postdischarge nausea and vomiting a­ fter
ambulatory surgery? Anesthesiology. 2012 Sep;117(3):475–86.
...........................................................................................
Fria Föredrag 2
Måndag 21/9 kl 16:00–17:30
Lokal: 27
Moderatorer: Christer Svensen, Anders Oldner
FF7
Towards individualized perioperative, goal-­
directed haemodynamic algorithms for patients
of advanced age
Erzsebet Bartha, Cecilia Arfwedson, Annika Imnell, Sigridur
Kalman
Department of Anesthesia and Intensive care, Karolinska University
Hospital Huddinge, and Karolinska Institutet, CLINTEC, Stockholm,
Sweden
We report observations on unintended and unexpected effects of goal-directed haemodynamic treatment (GDHT) in patients, operated for
emergency repair of hip fracture (ClinicalTrials.gov NCT01141894).
Method: Design: single-centre, open, randomized, and controlled parallel-group superiority trial with concealed computer-generated randomization. GDHT: fluid challenges to maximize the stroke volume
index (SVI); dobutamine to achieve oxygen delivery index (DO2I) >
600 ml ∙ min-1 ∙ m-2. Patients: only those, who were allocated in the
GDHT group (age > 70 years); Monitoring: LiDCOplus™. Haemodynamic outcomes: increase of baseline SVI by ≥ 10% after the first
fluid challenge; at anaesthesia start; increase or maintenance of baseline
DO2I at the end of surgery. Clinical outcomes: postoperative complications. Independent predictors of the haemodynamic and the clinical
outcome were assessed (logistic regression analyses).
Results: GDHT/RFT (n = 70/72, mean age 85 years). First fluid chal-
lenge responders were 39%. At anaesthesia start (GDHT group received repeated challenges), the SVI increased in 6% /15% of patients
(GDHT/RFT). At the end of surgery, the DO2I was maintained or
increased in 47% /30% of patients (GDHT/RFT). Predictors: for first
fluid challenge response, the baseline SVI < 28 ml m-2; for post-operative complications, the DO2I at the end surgery < 290 ml min-1 m-2.
Passive leg raise response in normotensive
elderly patients and the effects of subdural block
LiDCOplus™ and transthoracic echocardiography
AnOpIVA, Karolinska Universitetssjukhuset i Huddinge, CLINTEC,
Karolinska Institutet
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, passive leg raise) might be helpful, but the interpretation and the relevance
of positive PLR response in per-operative clinical scenarios are unclear.
Aims: to compare the ability of LiDCOplus™ to follow SV changes
during PLR-test with transthoracic echocardiography (TTE); to estimate whether an association between PLR-test responses and post-spinal hypotension exists; and given this estimate to calculate a sample
size for a future trial
Methods:
• Design: observational pilot study (ID: 2013/995-31/3)
• Population: patients > 80 years (informed consent), urologic surgery in spinal anesthesia
• Monitors: LiDCOplus™ (calibrated two times); TTE (tracing the
velocity time integral in the left ventricular outflow tract).
• Primary outcomes: SV-changes during PLR
• Secondary outcomes: PLR responses and post-spinal hypotension
• Statistical analyses: distribution, correlation (between methods)
of repeated measurements by mixed effects model; assessment of
bias, precision and accuracy by Bland Altman plot and by percentage error; trending ability by four quadrant plot, association
between PLR-related SV-changes and post-spinal hypotension by
mixed effects model.
Results: Good agreement between TTE and LiDCOplus™ was found:
> 95% of measurements was within 95%CI of the mean difference.
The percentage error was 24%, and the coefficients of variation were
14% (LiDCOplus™) and 18% (TTE); the concordance rate of LiDCOplus™ was 75%. We observed some association between the pattern
of the PLR-related SV changes and the post-spinal hypotension; to
prove that, we would need a sample size of 80 patients. The positive
PLR-test and post-spinal hypotension had very low association, and
would need a sample size of 450 patients.
Conclusions: The PLR test at high age might not guide the prediction of post-spinal hypotension, but the pattern of PLR may still need
further research. The SV changes during PLR may be detected by LiDCOplus™ and agree well with TTE.
...........................................................................................
Conclusions: The unintended haemodynamic GDHT effects may be
predicted by haemodynamic characteristics. The DO2I at the end of
surgery was a predictor of post-operative complications.
...........................................................................................
63
FF9
Effects of neoadjuvant chemo- or chemoradio­
therapy for esophageal cancer on perioperative
hemodynamics – a prospective cohort study
within a randomized clinical trial
Mikael Lunda,*, Jon A Tsaib, Magnus Nilssonb, Lars Lundellb,
Sigridur Kalmana.
a
Department of Anaesthesiology and Intensive Care, and Division of
Anaesthesiology, CLINTEC, Karolinska Institutet, Karolinska University
Hospital Huddinge, 141 86 Stockholm, Sweden.bCentre for Digestive
Diseases and Division of Surgery, CLINTEC, Karolinska Institutet,
Karolinska University Hospital Huddinge, 141 86 Sweden. cDepartment
of Clinical Oncology and Division of Oncology-Pathology, Karolinska
Institutet, Karolinska University Hospital Solna, 171 76 Stockholm.
d
Department of Medicine, Section of Cardiology, and Division of Cardio­
logy, Karolinska Institutet, Karolinska University hospital Huddinge,
141 86 Sweden. School of Technology and Health, Royal Institute of
Technology, Stockholm, Sweden.
Background:
Postoperative complications after esophagectomy are
common. Neoadjuvant treatment improve long-term survival but neoadjuvant chemoradiotherapy could elicit perioperative challenges and
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 chemotherapy (n=24) were randomized to receive neoadjuvant cisplatin and
5-fluorouracil with or without 40 Gy concurrent radiotherapy prior
to surgery.
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
and group.
Results:
Chemotherapy n=17, Chemoradiotherapy n=14 completed
surgery. The chemoradiotherapy group were older (66 vs. 60 years
p=0.33). We found no significant interaction effect.There was a trend
towards an interaction effect for cardiac index (p=0.07) and the chemoradiotherapy group had a lower cardiac index before surgery (2.9 vs.
3.4 l/m2/ min p=0.03). These differences diminished after adjusting for
age (p=0.10) and (p=0.14) respectively.
Hemodynamic values changed in both groups during the study. On
the third postoperative day both groups displayed a hyperdynamic state compared to baseline. Operating time and bleeding were similar in
both groups as were troponin T and NT-proBNP patterns. There was
a trend towards an increased pulmonary complication rate in the chemoradiotherapy group (p=0.09).
Conclusions: Neoadjuvant chemoradiotherapy does not affect the
perioperative hemodynamic profile compared to patients receiving
neoadjuvant chemotherapy. Neoadjuvant chemoradiotherapy as administered in this study appears safe from a perioperative hemodynamic
perspective. Further studies are need as to the effect on respiratory
function.
...........................................................................................
64
FF10
Optimering av vätskebehandling vid blodförgiftning med hjälp av passivt benlyftstest
Maria Cronhjort, Magnus Bergman, Eva Joelsson-Alm, Johan
Mårtensson, Mona-Britt Divander, Christer Svensen
ANE/IVA, Södersjukhuset, Stockholm
Svår sepsis samt septisk chock är svårbehandlade tillstånd inom intensivvården. Sepsis innebär läckande kärlendotel och försvagad hjärtmuskel.
Intravenös vätska är därmed en viktig del av behandlingen vid septiska
tillstånd. Gällande rekommendationer i ”Surviving Sepsis Campaign
Guidelines” bygger på variabler såsom blodtryck, centrala fyllnadstryck
samt blodvärde. Vi vet med säkerhet idag att dessa parametrar dåligt
reflekterar individens förmåga till att svara på vätskebehandling. Mer
än 50 % av patienter med blodförgiftning på en intensivvårdsavdelning
svarar inte på given vätska med en förbättrad cirkulation. Dessa patienter får stora mängder vätska i onödan och går därmed upp i vikt vilket
är associerat med ökad morbiditet och mortalitet.
Vi genomför en öppen, randomiserad studie, där vi använder oss av
ett benlyftstest för att avgöra när patienten ska få vätska. Patienterna i
benlyftsgruppen övervakas med PiCCO(pulskonturanalys med termodilutionskalibrering).
Benlyftstest. Om slagvolymsindex ökar ≥10% vid benlyft får behandlande läkare ordinera vätska. Patienterna randomiseras till en av
två grupper där gruppen med benlyftstest endast får vätska då testet
indikerar en ”responder”. Den andra gruppen får vätska enligt behandlande läkares val. Vi testar hypotesen att benlyftstest kan ge en minskad
viktuppgång i interventionsgruppen dag 3 med 30%.
Studien är registrerad på Clinicaltrials.gov som OFTa-PLR,
NCT02301585. Vi har inkluderat 19 patienter av 132 sedan studiestart i februari 2014. Inklusionstakten har varit låg, men ökar stadigt.
Patienterna måste inkluderas inom tolv timmar från debut av septisk
chock. Det innebär ofta att inklusion är aktuell nattetid, vilket kräver
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
patienten ska vara med i studien. Vi planerar att utöka studien till flera
intensivvårdsavdelningar under 2016.
...........................................................................................
FF11
God logistik och kompletta traumateam ger
snabb kirurgisk intervention vid trauma
Pierre Sundin1, Cecilia Mitt Holm2,Olof Brattström1,3och
Therese Djärv4,5
1
ANOPIVA-kliniken, 2Med Kand, KI, 3Institutionen för fysiologi och
farmakologi, KI, 4Akutkliniken, 5Institutionen för medicin, enheten för
Internmedicin,KI. Samtliga vid Karolinska Universitetssjukhuset, Solna.
Bakgrund: Mortaliteten efter trauma med livshotande blödning minskar om tiden till akut kirurgisk intervention minimeras. En patientgrupp med särskilt behov av snabba insatser är patienter med hjärtstopp orsakat av trauma. Traditionellt tas traumapatienter emot av ett
traumateam på en akutmottagning. Vid Trauma Centrum Karolinska
(TCK) omhändertas emellertid svårt skadade patienter direkt på en
särskild traumaenhet med egen avdelad operationssal i omedelbar anslutning till traumarummet. Traumaledaren (kirurg) kan välja att låta
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
möjliggöra snabb kirurgisk intervention om så är påkallat.
Metod/Patientmaterial:I det svenska traumaregistret SweTrau
identifierades 67 patienter som förts till sjukhus med hjärtstopp ­efter
trauma i Stockholms län 2011–2014. För 22 patienter beslutades om
omedelbar kirurgi (thorako- och/eller laparotomi) utan föregående
datortomografiundersökning. Tidsuppgifter föreligger på 21 av dessa
patienter.
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
levde 2 (10 %) patienter. För 11 (52 %) av patienterna startade ­kirurgin
inom 5 minuter. Mediantid till start av kirurgi för hela ­gruppen var 5
minuter (range 1–25 min)
Konklusion:
Vi redovisar data för en patientgrupp med mycket svåra
skador och behov av omedelbar kirurgi. Resultatet visar att ett omhändertagande av traumapatienten i omedelbar anslutning till en operationssal, och med operationspersonal i traumateamet, ger förutsättningar för att mycket snabbt starta potentiellt livräddande kirurgi.
...........................................................................................
FF12
Cardiac mortality after septic shock
Lina De Geer, Anna Oscarsson, Mats Fredrikson and Sten Walther
Intensivvårdskliniken, Universitetssjukhuset, Linköping
Cardiac dysfunction is a well-known complication in septic shock, but
its long-term consequences remain elusive. We investigated cardiac
outcome in septic shock patients by assessing causes of death in a register-based cohort. Our hypothesis was that septic shock survivors are at
an increased risk of death related to cardiac failure.
A cohort of 11 214 severe sepsis and septic shock intensive care
(ICU) patients without preceding severe cardiac failure and discharged
alive was collected from the Swedish Intensive Care Registry (SIR) together with a control group matched regarding age, sex and severity of
illness, but without sepsis. In patients who died after ICU discharge,
information on causes of death was sought in the Swedish Death Registry.
After ICU discharge, 4860 sepsis patients died, 895 (18%) of which
from cardiac failure. The median (IQR; range) time from ICU discharge to death from cardiac failure was 81 (17–379; 0–2447) days.
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)
for death from cardiac failure increased significantly (1.580 (95% CI
1.192–2.095, p=0.001) in the highest quartile compared to the lowest). 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).
To eliminate the impact of directly ICU-related death, patients who
died less than one week after ICU discharge were excluded. Nonetheless, HR for death from cardiac failure did not differ between sepsis
patients and controls (0.977 (95% CI 0.791–1.207, p=0.829).
The risk of death from cardiac failure after septic shock increases
with severity of illness. However, we conclude that septic shock patients are not at an increased risk of death from cardiac failure when
compared to other ICU patients.
...........................................................................................
Fria Föredrag 3
Måndag 21/9 kl 17:45–19:00
Lokal: 27
Moderatorer: Eddie Weitzberg, Michael Wanecek
FF13
Urinary cystatin C as a marker of sepsis in
critically ill patients
Jonsson Niklas
AnOpIVA Karolinska Solna
Introduction: Specific biomarkers to detect sepsis and guide antibiotic
stewardship in critically ill patients are lacking. Structural glomerular
changes causing increased filtration of plasma proteins such as cystatin
C has been observed in septic patients. In addition, impaired renal
tubular reabsorption of filtered cystatin C leading to elevated urinary
concentrations is a proposed feature of acute kidney injury (AKI).
Objectives: To explore the association of elevated cystatin C concentrations 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
admission was identified for each patient. Sepsis was defined as a suspected or confirmed infection together with the presence of at least
three systemic inflammatory response syndrome criteria. AKI was defined by the Kidney Disease: Improving Global Outcomes (KDIGO)
criteria. We used multivariate logistic regression to explore the association of sepsis with urinary cystatin C above the median for the entire
cohort adjusting for AKI severity, demographics, admission diagnosis
and illness severity.
Results: Of 138 patients, 84 (61%) had sepsis and 67 (49%) had AKI
during ICU admission. Median urinary cystatin C was 2.48 mg/L for
the entire cohort. Peak urinary cystatin C was higher in septic as compared to non-septic patients (median 2.5 mg/L [IQR 0.58–7.8 mg/L]
vs median 0.48 mg/L [IQR 0.23–1.2 mg/L]; P<0.001). ­Sepsis was independently associated with urinary cystatin C >2.48 mg/L ­(adjusted
odds ratio 4.40 [95% CI 1.91–10.12]) whereas AKI was not (adjusted
65
odds ratio 1.73 [95% CI 0.76–3.95] for KDIGO 1 AKI and 1.10
[95% CI 0.40–3.05] for KDIGO ≥2 AKI).
Conclusions:
Urinary cystatin C >2.48 mg/L can be used to detect
sepsis in a general ICU setting where AKI is common.
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FF14
Plasma endostatin improves acute kidney injury
risk prediction in critically ill patients
Niklas Jonsson, Anders Larsson, Max Bell, Claes-Roland Martling, Johan Mårtensson
ANOPIVA, Karolinska Universitetssjukhuset, Solna
Introduction:
Acute kidney injury (AKI) is a major clinical problem
in critically ill patients characterized by a rapid loss of kidney function
and high mortality. Dysfunction of the renal microcirculation as a result of endothelial activation and damage appears to play a major role
in the initiation, maintenance and progression of AKI. Endostatin is a
potent activator of the endothelium, released by basement membrane
collagen breakdown. Animal experiments show that such collagen
breakdown occurs early on after renal insult and contributes to the
pathophysiology of AKI.
Objective: We aimed to assess whether plasma endostatin improved
prediction of AKI occurring within 72 hours in critically ill patients.
Material and methods: We enrolled patients within 48 hours of intensive care unit (ICU) admission. We excluded patients who met AKI
criteria during this time-frame. We defined AKI according to Kidney
Disease: Improving Global Outcomes criteria. The optimal combination of risk factors for AKI prediction was included in a clinical model.
Improvement in risk prediction by adding endostatin to the clinical
model was assessed by the area under the receiver operating characteristics curve (AUC), net reclassification improvement (NRI) and integrated 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
hours predicted AKI with an AUC of 0.76 (95% CI 0.65–0.87). Compared 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
prediction using NRI (0.27; P = 0.04) and IDI (0.07; P = 0.04) analyses.
Conclusion: Plasma endostatin combined with a three-parameter
clinical model is a strong predictor of evolving AKI in critically ill
­patients.
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FF15
Pre-morbid Chronic renal dysfunction increases
the risk of death and of developing End Stage
Renal Disease in the critically ill.
Claire Rimes Stigare, Paolo Frumento, Matteo Bottai, Johan
Mårtensson, Claes-Roland Martling, Sten M Walther & Göran
Karlström, Max Bell.
66
ANOPIVA, Karolinska Universitetssjukhuset, Solna
Introduction: Prevalence
of Chronic Kidney disease (CKD) and End
Stage Renal Disease (ESRD) amongst Intensive Care Unit (ICU) admissions is rising. How Long-term mortality and the risk of developing 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 surveillance and to quantify requirements for dialysis provision.
Method: This cohort study was conducted in Swedish ICUs between
2005 and 2011 using the Swedish intensive care register (SIR) consisting of 130,134 adult patients. Incomplete cases were excluded
(26,771). Patients were classified as having ESRD, CKD, de novo
AKI, Acute on Chronic disease (AoC) or no renal dysfunction. Primary
outcome was all-cause mortality. Secondary outcome was ESRD-incidence. Maximum follow-up was seven years for mortality and six years
for ESRD (median 2.1 and 1.3 years respectively).
Results: Of 103,363 patients, 4,192 had pre-existing CKD and 1389
had ESRD. 5,273 (5.1%) developed de novo AKI and 998 CKD patients developed AoC. Mortality rates were highest in AoC-subjects
Crude mortality rate ratios (MRR) compared to controls were 3.52,
2.87 and 2.99 for AoC, AKI and CKD respectively. ESRD had a crude
MRR 2.08, adjusted MRR was higher than for AKI (1.46 vs. 1.15).
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).
5 years mortality was highest for CKD and AoC groups (71.3%, 68.2
respectively followed by AKI (61.8%) and ESRD (62.9%)(p<0.001).
Incidence of ESRD was greatest in the AoC and CKD groups (adjusted Incidence rate ratio (IRR) of 259 and 96.4) but also significantly
elevated in AKI-patients compared to controls (adjusted IRR 24).
Conclusion: Pre-ICU renal disease significantly increases the risk of
death compared to controls. Subjects with AoC disease had extreme
risk of developing ESRD. All patients with CKD who survive critical
care should receive a nephrology referral.
...........................................................................................
FF16
Acute kidney injury following severe trauma, risk
factors and long-term outcome
Eriksson Mikael
AnOpIVA Karolinska Universitetssjukhuset, Solna
Background:
The trauma patient sustains numerous potentially
harmful insults that may contribute to a notable risk of acute kidney
injury (AKI). The aim of this study was to investigate the incidence of,
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
a level-one trauma centre were included. The outcome measure was
AKI diagnosed day 2-7 of ICU-treatment. Regression analysis was performed in order to identify factors associated with AKI-development.
Results:
A quarter of the patients (103/413) developed AKI within
the first week of ICU-admission. AKI was associated with increased
30-day (17.5 % vs. 5.8 %) and 1-year (26.2 % vs. 7.1 %) mortality.
Risk factors for AKI were male gender, age, non-diabetic comorbidity,
diabetes mellitus, injury severity score >40, massive transfusion and
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
end-stage renal disease one year post-injury.
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 comorbidity, massive transfusion and resuscitation with HES were associated
with post-injury AKI. Based on the results of the current study volume
resuscitation with HES cannot be recommended in trauma-patients.
...........................................................................................
FF17
Causes of excessive late death after multiple
trauma, a matched cohort study
Eriksson Mikael
AnOpIVA Karolinska Universitetssjukhuset, Solna
Objective: To investigate a potentially sustained increase in mortality
up to three years following multiple trauma and identify causes of late
death.
Introduction: Trauma is a serious contributor to the global burden
of disease and the most common cause of death <45 years in Sweden.
Studies on mortality and causes of death following trauma have mainly
been restricted to hospital stay or 30-day mortality. Increasing evidence
indicate a sustained increase in mortality up to several years after trauma, but the causes of late death has not been elucidated.
Methods: In a cohort study 7382 multiple trauma patients were identified through a regional trauma registry 2005–2012. Trauma cases
were matched to 36760 uninjured controls by age, sex and municipality. By linkage to national registries mortality, cause of death and
comorbidity status was identified. Excess mortality was examined by
calculating all-cause mortality rate ratio (MRR).
Results:
Among the trauma cohort 755 (10.2 %) died within three
years after the index trauma, 30-day mortality was 5.0 %. When compared to the control group all-cause MRR showed a sustained increase
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.
Conclusions: This is the first study analysing late mortality and causes
of death after trauma using a matched control group. A sustained increase in mortality was seen up to three years after the index trauma.
The excess mortality was largely attributed to external causes of death
including subsequent trauma and substance abuse.
...........................................................................................
Fria Föredrag 4
(Patientsäkerhet)
Tisdag 22/9 kl 15:45–16:45
Lokal: C3
Moderatorer: Michael Haney, Christina Eintrei
FF18
Förbättringsarbete med stöd av kvalitetsregister:
Förkortad respiratortid för intensivvårdspatienter
Anna Eriksson, Ing-Marie Larsson, Annica Lindberg, Sandra
Snäckerström, Carina Wallin, Ewa Wallin, Patric Vennström, Åsa
Wilhelmsson, Rafel Kawati
ANIVA, Akademiska sjukhuset, Uppsala
Bakgrund: På Centralintensiven (CIVA), Akademiska sjukhuset i Uppsala, vårdas ca 1000 patienter per år och av dem vårdas hälften i respirator. Förlängd respiratorvård efter 24–48 timmar korreleras med ökad
mortalitet och ökad risk för komplikationer. Att förkorta respirator­
tiden kan innebära mindre komplikationer samt kortare vårdtid på IVA.
Syfte: Att förkorta patienternas vårdtid i respirator och att arbeta
med projekt och förbättringsarbeten utifrån en strukturerad metod samt att använda registerdata som stöd i förbättringsarbeten.
Metod:
The Dartmouth Microsystem Improvement Curriculum
(DMIC) Ramp användes för att genomföra förbättringsarbetet. Ett
team med medarbetare från flera professioner introducerade och implementerade förbättringsåtgärder; daglig väckning, aktiv befuktning
åt alla patienter som vårdas i respirator, höjd huvudända och checklista för tidig postoperativ extubering. Det kvalitetsregister som använts i förbättringsarbetet var Svenskt Intensivvårdsregister (SIR).
Resultat:
Den totala respiratortiden minskade med 12%, från
56,7 timmar till 49,8 timmar på 6 månader. I en subgrupp av
­patienter som inkom till avdelningen för tidig postoperativ extubation efter elektiva operationer minskade respiratortiden med 74%.
Slutsats: DMIC konceptet har visat sig vara ett effektivt sätt att arbeta med förbättringsprojekt och når snabba resultat. Projektet lyckades
med att minska tiden i respirator för samtliga patienter och hade stor
effekt på patienter som kom till IVA postoperativt för extubering.
...........................................................................................
FF19
Riskuppföljning av patienter som genomgått
omfattande kirurgi ett pilotprojekt på Centrala
Postop
Sandra Månsson, Caroline Hällsjö Sander
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 hälsotillstånd samt det perioperativa medicinska omhändertagandet (4).
Syfte: Att utvärdera hur ofta ett team bestående av postopsjuksköterska
och anestesiolog identifierar behov av ytterligare behandling, provtagning eller utökad övervakningsnivå efter utskrivning till vårdavdelning.
67
Att utvärdera vårdavdelningspersonalens upplevelse av bl.a. det pedagogiska värdet i detta besök.
Metoder: En postopsjuksköterska och anestesiolog följer upp patienter som opererats med omfattande buk/bäckenkirurgi pga. gynekologisk eller urologisk malignitet. Patienterna har vårdats minst en natt
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
tillsammans med vårdavdelningens personal. Därefter träffar teamet
patienten och gör en bedömning utifrån NEWS samt det eget utarbetade RU-score. Vid behov finns möjlighet att på avdelningen ta blodgas
för direkt analys samt ultraljud av buk- och thoraxorgan. En samlad
bedömning görs och RUteamet lämnar eventuella rekommendationer
till vårdavdelningssjuksköterska/ läkare.
Resultat: Vi har hittills gjort 53 besök, varav 37 kvinnor och 26 män.
I 27 av dessa fall har vi kommit med rekommendationer gällande
­patientens fortsatta vård och behandling. De vanligaste rekommendationerna gäller vätskebehandling, provtagning, röntgen samt övervakning av vitala funktioner. Vi har vid ett tiotal tillfällen varit behjälpliga
med t.ex. läkemedelsadministration, EKGtagning samt provtagning.
Diskussion:
RU är utvärderat på den vårdavdelning som vi arbetat
mot mest, där har det varit en mycket positiv feedback. Vi som arbetar
med RU upplever att behovet av en förlängning av den anestesiologiska/ postoperativa kompetensen fyller en viktig funktion, både ur ett
medicinskt- och ur ett omvårdnadsperspektiv. Den pedagogiska komponenten utgör en av grundpelarna i RU-verksamheten och är den
som vi tror gör störst skillnad i långa loppet.
Referenser
1. Pearse RM, Rhodes A, Moreno R, et al. EuSOS: European surgical
outcomes study. Eur J Anaesthesiol 2011; 28: 454-6
2. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009; 361:
1368-75
3. Khuri SF, Henderson WG, DePalma RG, et al. Determinants of longterm survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005; 242: 326-41; discussion 41-3
4. Grocott et al Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery. Cochrane Database Syst Rev 2012 Nov 14; 11
en kostnad av ca 250.000 kronor extra (avhandling från Karolinska
Institutet 2012 (Hyllienmark P.) och en CVKRI beräknas till en kostnad av ca 29.000 $ (Marschall J et al. Infect Control Hosp Epidemiol 2008). Båda ger också upphov till ökad morbiditet och mortalitet
och stort mänskligt lidande för våra patienter. Således finns mycket
att vinna genom att minska frekvensen av dessa infektioner på våra
intensivvårdsavdelningar.
Metod:
Genom att följa sina komplikationer på avdelningen i SIRs
utdataportal kunde Karolinska Huddinge IVA på ett strukturerat sätt
arbeta med att sänka sin infektionsfrekvens av VAP och CVKRI. Det
är ett långsiktigt arbete som har pågått sen 2002 och där man tydligt kan se att infektionsfrekvensen varierar över åren. Möjlighet att
bättre beskriva infektionerna i VAP/10.000 ventilatortimmar samt
CVKRI/1000 dagar har ökat kvalitén på in- och utdata genom åren
och gett avdelningen ett mer tillförlitligt instrument att jobba mot.
Rent konkret har återkommande hygienhappenings regelbundet med
olika fokus varit en del av arbetet och där har alltid redovisning av SIR
data till hela personalgruppen ingått som en viktig ingrediens. VAP
åtgärdspaket, checklista för CVK inläggning och punktprevalensmätningar av basala hygienrutiner samt följsamhet till SKLs åtgärdspaket
för CVK skötsel har också varit en del av det förebyggande arbetet.
Dessutom uppmuntras personalen att komma med egna förbättringsförslag och vi utgår från deras yrkesstolthet – det ger ofta bättre
resultat än pekpinnar – ”Down – Up istället för Top – Down management”. Genom att arbeta långsiktigt och med ständigt fokus på
förbättring har Karolinska Huddinge IVA sänkt infektionsfrekvensen
av både VAP (Fig 1) och CVKRI (Fig 2). Detta i sin tur har medfört
besparingar på ca 2,5 – 3,0 miljoner SEK i minskad VAP och dessutom
ca 2,6 miljoner SEK i minskad CVKRI när man jämför de sämsta åren
med de bästa (Fig 2 och Fig 3).
Slutsatser: Dessa resultat visar på ett långsiktigt arbete som både spa-
rar miljontals kronor, minskar patienternas lidande samt räddar liv! Att
använda sig av kvalitetsregisterdata från SIR och regelbundet återföra
dessa till personalen är ett effektivt verktyg att nå mätbara förbättringar
i vården på intensivvårdsavdelningen Karolinska Hudinge.
...........................................................................................
FF21
...........................................................................................
Utvärdering av blodglukos (BG) koncentrationer
efter anestesi på kirurgiska och ortopediska
patienter.
FF20
Herczeghne Edit
Långsiktigt arbete med hjälp av Svenska intensivvårdsregistret (SIR) sänkte kostnader med miljontals kronor på Karolinska Huddinge IVA.
Christina Agvald-Öhman
Anestesi- och intensivvårdskliniken Karolinska Universitetssjukhuset
Huddinge
Bakgrund och syfte:
Vårdrelaterade infektioner är ett stort problem
inom slutenvården med en incidens av ca 10%, dvs. var tionde patient
får en s.k. vårdskada. Särskilt stort är problemet inom intensivvården
där ofta en incidens på det dubbla har rapporterats. Inom SIR har
­fokus på att registrera vårdrelaterade infektioner varit stort genom åren,
detta för att kunna arbeta strukturerat med egna data och sänka infektionsfrekvensen ute på avdelningarna. Ventilator-associerad pneumoni
(VAP) och CVK (central venkateter)- relaterade infektioner (CVKRI)
är båda komplikationer som registreras i SIR. En VAP är beräknad till
68
ANIVA, Uppsalla Akademiska Sjukhus, Uppsala
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
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,
fas I,5% buffrad glucos perioperativt) och 04–06/2014 (108 patienter,
fas II, ej 5% buffrad glucos perioperativt). Patienter utan diabetes som
genomgick ett planerat kirurgisk eller ortopediskt ingrepp registrerades. Datainsamlingen : operations datum, kön, ålder, typ av ingrepp,
opertationstid, anestesi tid, mängd och typ av given vätska under operation, BG koncentrationer peroperativt och postoperativt. Deskriptiva och icke parametriska statistiska metoder har använts.
Resultat:
Fas I: anestesi tid: 263 min (245–282) (mean, minimum–
maximum). Given volym av 5% buffrad glukos: 243 ml (201–285).
BG peroperativt 7,2 mmol/l (6,8–7,6), BG postoperativt: 9,4 mmol/l
(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.
or with CPAP. Residual neuromuscular block caused a reduction in
HVR while HCVR was unaffected (Figure 1). A total of 33.2±6.8 mg
rocuronium was infused i.v. for 49±9 min to achieve a TOF ratio of
0.76±0.03.
Slutsats:
Perioperativ tillförsel av 5% buffrad glukos orsakade höga
glukos koncentrationer hos 34% av patienter utan diabetes vid rutinanestesi. Ersättning av 5% buffrad glucos med andra kristalloider minskade postoperativ hyperglikemia och ledde inte till hypoglikemiska
episoder.
...........................................................................................
Fria Föredrag 5
Conclusions: Based on the preliminary data from this study, residual neuromuscular block by rocuronium attenuates the acute HVR in
untreated OSA patients. Notably, this is not due to muscle paralysis
since the HCVR is unaffected, but rather a depression of the peripheral
chemosensitivity.
Onsdag 23/9 kl 14:30–16:00
Lokal: C3
Moderatorer: Stefan Lundin, Jonas Åkesson
FF22
Residual neuromuscular block with rocuroNium
reduces hypoxic ventilatory response in patients
with untreated obstructive sleep apnea
E Christensson , A Ebberyd , A Hårdemark Cedborg , Å Danielson1, 2, Åsa Österlund Modalen3, KA Franklin4, LI Eriksson1, 2,
M Jonsson Fagerlund1,2
1, 2
2
2
Department of Anesthesiology, Surgical Services and Intensive Care
Medicine, Karolinska University Hospital and Karolinska Institutet,
Stockholm, Sweden. 2Department of Physiology and Pharmacology,
Section for Anesthesiology and Intensive Care, Karolinska Insitutet, Stockholm, Sweden. 3Aleris FysiologLab, Stockholm, Sweden. 4Department of
Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.
1
Background:
Obstructive sleep apnea (OSA) has been identified as a
leading risk factor behind serious complications, particularly respiratory, in the postoperative period. Residual neuromuscular block markedly reduce the acute hypoxic ventilatory response (HVR) in healthy
volunteers. While untreated OSA patients has an increased HVR, it is
not known to what extent neuromuscular blocking agents interact with
hypoxic control of breathing in OSA patients.
Materials and Methods: 11 newly diagnosed and untreated OSA
patients entered the study. They were studied using a facemask, standard perioperative monitoring and thoracic and abdominal impedance
bands. Neuromuscular function was assessed by adductor pollicis trainof-four (TOF) response of the ulnar nerve. First individual baseline
HVR and hypercapnic ventilatory response (HCVR) were measured.
Thereafter, CPAP of 6–7 cm of H2O was applied and three series of
HVR and HCVR tests followed: i.e. control, during rocuronium­
induced residual neuromuscular block aiming at TOF ratio of 0.70
and after recovery to TOF ratio >0.90. At each occasion, isocapnic
HVR was studied using FiO2 of 0.08-0.12 targeting SpO2 of 80%,
while normoxic HCVR was performed by addition of 5% CO2 to
inspired air.
Results:
Figure 1: Residual paralysis by rocuronium reduced HVR but not HCVR in
untreated OSA patients. n=8.* P<0.05.
HVR and HCVR tests in eight out of 11 OSA patients have
been analysed (age 49±5 years, BMI of 30.3±0.9 and AHI of 23±1).
There was no difference in individual baseline HVR or HCVR without
...........................................................................................
FF23
Remifentanil induced dysfunction of pharyngeal
swallowing
Savilampi Johanna
Aniva-kliniken, Örebro Universitetssjuhus
Background:
Exposure to remifentanil causes swallowing difficulties
and increases the incidence of pulmonary aspiration in healthy volunteers. These effects may be explained by impairment of airway defense
mechanisms and/or altered swallow function. Automated impedance
manometry pressure-flow analysis (AIM analysis) is a technique that
allows objective assessment of swallow function based on pressure-impedance patterns recorded during bolus swallowing. The aim of this
study was to use AIM analysis to quantify the effect of remifentanil
on pharyngeal swallowing in both young and old volunteers and to
contrast these effects to morphine.
Methods: Eighteen healthy young and old volunteers participated in a
double-blind, randomized, cross-over study at the University Hospital
in Örebro, Sweden. Subjects were studied on two occasions during
which they received either target-controlled infusion of remifentanil
(young: 3 ng/ml, older: 2 ng/ml) or a bolus injection of morphine
(young: 0.1 mg/kg, older: 0.07 mg/kg). Pressure-impedance measurements were made with an indwelling catheter and ten liquid swallows
were captured during each measuring condition. The pressure-flow
variables defining swallow function were calculated and compared to
determine drug effects.
Results:
Remifentanil influenced the variables towards the direction
that is consistent with greater swallow dysfunction. Vigor of the pharyngeal contraction was weakened, pharyngeal bolus propulsion was
diminished, and flow resistance was increased. The swallow risk index,
a global index of swallowing dysfunction, increased overall. Similar effects were found with morphine but the impact of remifentanil was
greater in these experimental doses.
69
Conclusions: Remifentanil induced dysfunction of pharyngeal swallowing; this may contribute to the elevated risk of aspiration.
...........................................................................................
FF24
Effect of Incorrectly Applied Cricoid Pressure
During Rapid Sequence Induction. Evaluation
With High-Resolution Manometry
Richard Pellrud, M.D., Rebecca Ahlstrand, M.D.,Ph.D.
Department of Anesthesiology and Intensive Care, Örebro University
Hospital, Sweden
Introduction: Cricoid pressure is often performed incorrectly, due to
difficulties to locate the cricoid cartilage. Despite this, the effectiveness of an incorrectly applied cricoid pressure has not been investigated. We have used high-resolution manometry (HRM) to evaluate
pressures in the upper esophagus during correctly applied cricoid
pressure (against the cricoid cartilage) compared to incorrectly applied cricoid pressure (against the thyroid cartilage and the trachea)
during a rapid sequence induction.
Methods: 15 patients (ASA I-II), scheduled for elective surgery and
intubation, participated. Before anesthesia the cricoid cartilage, the
thyroid cartilage and the trachea (2 centimeters below the cricoid
cartilage) were identified by palpation, verified by ultrasound and
marked with a pen.
All patients were preoxygenated for 3 min with 100 % oxygen. A
rapid sequence induction with Fentanyl (2 μg/kg), Propofol (2 mg/kg)
and Rocuronium (1 mg/kg) iv was performed. The manometry catheter was inserted transnasally into the esophagus and three standardized
forces of 30 N were applied in apnea: against the thyroid cartilage, the
cricoid cartilage and the trachea for 10 seconds each. Esophageal pressures were recorded continuously by a HRM-catheter.
FF25
Capnodynamic assessment of effective lung
volume during cardiac output manipulations in ­
a porcine model
Caroline Hällsjö Sander1,2, Per-Arne Lönnqvist 3, Magnus
Hallbäck4, Fernando Suarz Sipmann5,6, Mats Wallin4, Anders
Oldner1,2, Håkan Björne 1,2
1
Department of Anaesthesiology, Surgical Services and Intensive
Care Medicine, Karolinska University Hospital, Solna, Sweden.
2
Department of Physiology and Pharmacology, Karolinska Institutet,
Stockholm, Sweden. 3Paediatric Anaesthesia and Intensive Care Astrid
Lindgrens Children’s Hospital Karolinska University Hospital, Sweden.
4
Maquet Critical Care AB, Solna, Sweden. 5Department of Surgical
Sciences, Section of Anaesthesiology and Critical Care, Hedenstierna
laboratory, Uppsala University, Uppsala, Sweden. 6CIBERES, CIBER
de enferme­dades respiratorias, Instituto Carlos III, Madrid, Spain
Background: A capnodynamic approach for calculation of effective pulmonary blood flow includes a lung volume factor (ELV) that
has to be estimated to solve the mathematical equation. In previous
studies ELV was found to closely correlate to reference methods for
functional residual capacity (FRC). The aim of the present study was
to evaluate the stability of ELV during substantial manipulations of
cardiac output (CO) and assess the agreement for absolute values and
trending capacity during PEEP changes at different lung conditions.
Methods: Ten mechanically ventilated pigs were included. The required concentration alterations of alveolar carbon dioxide were induced by a ventilatory pattern with cyclic reoccurring short inspiratory holds. The Sulphur hexafluoride wash-in/wash-out technique was
used as reference for FRCPEEP. Cardiac output was altered by preload
reduction and inotropic stimulation at PEEP 5 and 12 cm H2O both
in normal lung conditions and after repeated lung lavages.
Thyroid cartilage: 239 ± 184
Cricoid cartilage: 230 ± 180
Trachea: 301 ± 194
Results: ELV at baseline PEEP 5 was (mean (SD)), 810 (163) mL
and decreased to 400 (42) mL after lavage. ELV was not significantly
affected by CO alterations within the same PEEP level. The overall
bias (limits of agreement) was -35 (-271 to 201) mL, and percentage
error was 36 %.
Trending capability between PEEP steps assessed by the four-­
quadrant plot technique showed a concordance rate of 100 %.
Conclusion: Incorrectly applied cricoid pressure against the thyroid
Conclusion:
Results:
Mean pressures (± SD) [mmHg] in the upper esophagus
during an external force of 30N against:
cartilage or trachea generates a significant rise of pressure in the region of the upper esophagus comparable to pressures generated by a
cricoid
pressure against the cricoid cartilage. In order to prevent passive
regurgitation, the exact position of application of cricoid pressure seems to be of less importance.
...........................................................................................
70
ELV remained stable during significant changes in
CO and correlated closely to the reference method for FRCPEEP. The
trending capability was excellent both before and after surfactant depletion.
...........................................................................................
FF26
FF27
Å Danielson, A Ebberyd, A Hårdemark Cedborg, S Mkrtchian,
E Christensson, J Ullman, M Scheinin, LI Eriksson, M Jonsson
Fagerlund
Carolina Samuelsson, Folke Sjöberg, Göran Karlström, Thomas
Nolin, Sten M Walther
Sedation with dexmedetomidine or propofol
­impairs control of breathing in healthy male
­volunteers. A randomized cross-over study
ANOPIVA, Karolinska Universitetssjukhuset, Solna
Background:
The intravenous alpha2-agonist dexmedetomidine
(DEX) is being increasingly used for sedation worldwide. DEX has
been put forward as a drug with minimal effect on ventilation.
To obtain a more comprehensive understanding of the regulation
of breathing during sedation with DEX, we compared ventilatory
responses to hypoxia and hypercapnia during sedation with DEX and
propofol.
Methods:
Dexmedetomidine
HCVR (L/min/mmHg)
n
tio
D
EX
1.5 0.5
0.4
0.3
*+
0.2
0.1
1.0
0.3
0.5
**+
0.2
0.1
0.0 0.0
n
tio
da
HCVR
(L/min/mmHg)
HCVR (L/min/mmHg)
D
EX
D
EX
se
B
as
el
in
e
D
EX
re
co
ve
ry
Seda<on+ Recovery+
Baseline+
Baseline+ Seda<on+
Recovery+
D
e
Pr x B
op a
s
B eli
as n
el e
in
e
D
EX
Pr s
o p ed
s e ati
d a on
tio
n
D
EX
Pr r
op ec
re ove
co ry
ve
ry
0.0
Introduction: Preclinical data indicate that estrogen appears to play
a beneficial role in the pathophysiology of and recovery from critical
illness. Few previous epidemiologic studies, however, have analysed
premenopausal women as a separate group when addressing potential
gender differences in critical care outcome. Our aim was to see if
premenopausal aged women have a better outcome following critical
care and to investigate the association between gender and use of
intensive care unit (ICU) resources.
Methods: Based on 127 254 consecutive Simplified Acute Physiology Score 3 (SAPS 3) -scored Swedish Intensive Care Registry ICU
admissions from 2008-2012, we determined the risk-adjusted 30-day
mortality, accumulated nurse workload score, and length of ICU
stay. To investigate association with gender, we used logistic regression and multivariate analyses on the entire cohort as well as on two
subgroups stratified by median age for menopause (up to and including 45 years and >45 years), and six selected diagnostic subgroups
(sepsis, multiple trauma, chronic obstructive pulmonary disease,
acute respiratory distress syndrome, pneumonia and cardiac arrest).
Results: There was no gender difference in risk-adjusted mortality for the cohort as a whole, and there was no gender difference in
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 mortality in males admitted for cardiac arrest. For the cohort as a whole,
and for those admitted with multiple trauma, male gender was associated with a higher nurse workload score and a longer ICU stay.
Conclusions: Using information from a large multiple ICU register
0.4
HVR Prop
HVR DEX
HVR (L/min/%)
da
Propofol
0.5
B.+
se
D
EX
D
EX
B
as
el
in
e
A.+
re
co
ve
ry
HVR DEX
Eleven healthy male volunteers entered this randomized,
cross-over study. DEX or propofol was administered as an intravenous bolus followed by an infusion. The protocol was repeated for
both drugs in each volunteer on separate days. Sedation was monitored by Observer´s Assessment of Alertness/Sedation Scale (OAA/S),
Richmond Agitation Sedation Scale (RASS) and Bispectral Index
(BIS). Hypoxic and hypercapnic ventilatory responses were measured
0.5
at rest, during sedation (OAA/S 2–4) and after recovery. Drug expo0.4
sure was verified with concentration analysis
in plasma.
Results: Ten subjects completed the0.3study. Compared to baseline,
0.2
sedation reduced hypoxic ventilatory response
to 51 and 57% (see figure), and hypercapnic ventilatory response
to 74 and 71% for DEX
0.1
Figure'3'
and propofol, respectively.
0.0
Gender differences in outcome and use of resources do exist in Swedish intensive care, but
to no advantage for women of premenopausal
age
database we found that premenopausal female gender was not associated 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.
...........................................................................................
HCVR
HVR Prop
0.5
1.5
Notably,
some of the volunteers displayed
upper airway obstruction
1.5
0.4
and episodes
of apnea during sedation. The OAA/S at the sedation
*+
1.0
*+
0.3 3 (3–4) (median
goal was
(min-max))
1.0 for both drugs. BIS was 82 ±
8 and 0.275 ± 3, and the drug concentrations in plasma at the sedation
0.5
0.5
target0.1were 0.66 ± 0.14 ng/ml and 1.26
± 0.36 μg/ml for DEX and
propofol,
respectively.
0.0
0.0
0.0
n
tio
Recovery+
re
co
ve
ry
Baseline+ Seda<on+
ba
se
lin
e
re
co
ve
ry
Seda<on+ Recovery+
se
da
tio
n
PDr
oep
x
B
as
el
in e
Baseline+
Pr
op
da
se
op
Pr
PDr
EoXp
Pr
op
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.
1.5
PDr
EoXp
Conclusions:
...........................................................................................
0.5
re
co
ve
ry
Pr
op
Pr
op
se
da
tio
n
ba
se
lin
e
0.0
Pr
op
HCVR
1.0
71
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