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Uten T, Chesnais M, van de Velde M, Raeder J, Beloeil H. Pain management after open colorectal surgery: An update of the systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol 2024; 41:363-366. [PMID: 38420876 DOI: 10.1097/eja.0000000000001978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Open colectomy is still performed around the world and associated with significant postoperative pain. OBJECTIVES Unpublished recommendations based on a systematic review were proposed by the PROcedure SPECific postoperative pain managemenT (PROSPECT) group in 2016. We aimed to update these recommendations by evaluating the available literature and develop recommendations for optimal pain management after open colectomy according to the PROSPECT methodology. DESIGN AND DATA SOURCES A systematic review using the PROSPECT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from 2016 to 2022 assessing postoperative pain after open colectomy using analgesic, anaesthetic or surgical interventions were identified. The primary outcome included postoperative pain scores. RESULTS The previous 2016 review included data from 93 studies. Out of 842 additional eligible studies identified, 13 new studies were finally retrieved for analysis. Intra-operative and postoperative interventions that improved postoperative pain were paracetamol, epidural analgesia. When epidural is not feasible, intravenous lidocaine or bilateral TAP block or postoperative continuous pre-peritoneal infusion are recommended. Intra-operative and postoperative Cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for colonic surgery. CONCLUSIONS The analgesic regimen for open colectomy should include intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs (restricted to colonic surgery), epidural and continued postoperatively with opioids used as rescue analgesics. If epidural is not feasible, bilateral TAP block or IV lidocaine are recommended. Safety issues should be highlighted: local anaesthetics should not be administered by two different routes at the same time. Because of the risk of toxicity, careful dosing and monitoring are necessary.
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Affiliation(s)
- Thomas Uten
- From the Trainee, Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and UZ Leuven, Leuven, Belgium (TU), CHU Rennes, Anaesthesia and Intensive Care Department, Rennes, France (MC), Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and UZ Leuven, Leuven, Belgium (MVDV), Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway (JR), Univ Rennes, CHU Rennes, Inserm, CIC 1414, COSS 1242, Anaesthesia and Intensive Care Department, Rennes, France (HB)
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Leonardsen ACL, Haugen AS, Raeder J, Finjarn TJ, Isern E, Aakre EK, Bruun AMG, Hennum K, Ramstad JP, Sand T, Monsen SA. The 2024 revision of the Norwegian standard for the safe practice of anaesthesia. Acta Anaesthesiol Scand 2024; 68:567-574. [PMID: 38317613 DOI: 10.1111/aas.14381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 01/21/2024] [Indexed: 02/07/2024]
Abstract
The Norwegian standard for the safe practice of anaesthesia was first published in 1991, and revised in 1994, 1998, 2005, 2010 and 2016 respectively. The 1998 version was published in English for the first time in Acta Anaesthesiologica Scandinavica in 2002. It must be noted that this is a national standard, reflecting the specific opportunities and challenges in a Norwegian setting, which may be different from other countries in some respects. A feature of the Norwegian healthcare system is the availability, on a national basis, of specifically highly trained and qualified nurse anaesthetists. Another feature is the geography, with parts of the population living in remote areas. These may be served by small, local emergency hospitals. Emergency transport of patients to larger hospitals is not always achievable when weather conditions are rough. These features and challenges were considered important when designing a balanced and consensus-based national standard for the safe practice of anaesthesia, across Norwegian clinical settings. In this article, we present the 2024 revision of the document. This article presents a direct translation of the complete document from the Norwegian original.
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Affiliation(s)
- Ann-Chatrin Linqvist Leonardsen
- Department of Health, Care and Organisation, Ostfold University College, Østfold, Norway
- Department of Anaesthesia, Ostfold Hospital Trust, Moss, Norway
- Department of Health and Social Sciences, University of Southeastern Norway, Norway
| | - Arvid Steinar Haugen
- Institute of Health Sciences, Acute and Critical Care, Oslo Metropolitan University, Oslo, Norway
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Johan Raeder
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Erik Isern
- Department of Anaesthesiology, St. Olavs Hospital, Trondheim, Norway
| | - Elin K Aakre
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | | | | | | | - Tina Sand
- Department of Anaesthesiology, Nord University Hospital, Tromsø, Norway
| | - Svein Arne Monsen
- Department of Anaesthesiology, Helgelandssykehuset, Nordland, Norway
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Feyling AC, Kamalo PD, Hanche-Olsen T, Chikumbanje SS, Zsidek AS, Ponzi E, Raeder J. Preventing hypothermia in pediatric neurosurgery in Africa-A randomized controlled non-inferiority trial of insulation versus active warming. Acta Anaesthesiol Scand 2024; 68:167-177. [PMID: 37882145 DOI: 10.1111/aas.14341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE The objective of this study was to compare the efficacy of a low-cost heat-preserving method in preventing intraoperative hypothermia with that of forced-air warming in a resource-limited setting. METHODS In this randomized controlled non-inferiority trial, we recruited children younger than 12 years scheduled for cranial neurosurgery in a large East-African hospital. Patients were block-randomized by age to intraoperative warming measures using Hibler's method (intervention) or warm air (comparator). Hibler's group patients were circumferentially wrapped in transparent plastic sheeting (providing a vapor-trap) over a layer of cotton blankets, then laid on an insulating foam mattress. Warm air group patients were treated with forced-air convection via an underlying Snuggle Warm™ Pediatric Full Body mattress. Allocated warming measures were initiated in the operating theatre and discontinued upon anesthesia emergence. Perioperative temperatures were measured using noninvasive forehead probes (SpotOn™). The primary outcome was incidence of hypothermia (core temperature < 36.0° for longer than 5 min). Our null hypothesis was that Hibler's method is inferior in efficacy to the warm air method by a margin exceeding 20%. Among secondary outcomes were duration of hypothermia as proportion of surgical duration, incidence of postoperative shivering and rescue measure requirements. RESULTS We analyzed data for 77 participants (Hibler's = 38; warm air = 39). There was no significant difference between the Hibler's and warm air arms of the study in the primary outcome of incidence of hypothermia (59.0% vs. 60.5% respectively; OR 1.07; 95% CI 0.43-2.65; p = .890). However, the risk difference (1.55%; 95% CI -0.20 to -0.24) exceeded the 0.2 margin and non-inferiority could not be declared. There was considerable need for rescue measures in both groups (71.1 0% vs. 69.2%; OR 1.09; 95% CI 0.41-2.90; p = .861). There was no statistically significant difference between groups for any prespecified secondary outcome. CONCLUSION Although perioperative core temperatures were not significantly different, we could not declare an inexpensive heat-preserving method non-inferior to warm air convection in preventing intraoperative hypothermia in children undergoing anesthesia for cranial neurosurgery in a resource-limited setting. The extensive need for rescue measures may have masked important differences. TRIAL REGISTRATION US National Institutes of Health Clinicaltrials.gov database (ID no. NCT02975817).
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Affiliation(s)
- Anders C Feyling
- Department of Anaesthesia and Intensive Care, Division of Emergencies & Critical Care, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Research & Development, Division of Emergencies & Critical Care, Oslo University Hospital, Oslo, Norway
| | - Patrick D Kamalo
- Queen Elizabeth Central Hospital, Blantyre, Malawi
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Terje Hanche-Olsen
- Department of Anaesthesia and Intensive Care, Division of Emergencies & Critical Care, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Aina S Zsidek
- Department of Anaesthesia and Intensive Care, Acute Care Division, Oslo University Hospital, Oslo, Norway
| | - Erica Ponzi
- Oslo Center for Biostatistics & Epidemiology, University of Oslo, Oslo, Norway
- Department for Research Support for Clinical Trials, Oslo University Hospital, Oslo, Norway
| | - Johan Raeder
- Department of Anaesthesia and Intensive Care, Division of Emergencies & Critical Care, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Brodshaug I, Reine E, Raeder J. Maternal hypothermia during elective caesarean delivery: A prospective observational study. Acta Anaesthesiol Scand 2024; 68:247-253. [PMID: 37876139 DOI: 10.1111/aas.14340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Patients undergoing caesarean delivery are at risk of developing unintended perioperative hypothermia, defined as a core temperature <36.0°C. Most previous studies of core temperature in caesarean delivery patients have not been conducted with accurate measurements for the complete perioperative period. Therefore, we conducted a prospective observational study to identify the incidence and duration of pre- and post-operative maternal hypothermia with a high accuracy continuous temperature monitoring system. METHODS Women ≥18 years old presenting for elective caesarean delivery under spinal anaesthesia were invited to participate in the study. The primary outcomes were the incidence and duration of perioperative maternal hypothermia (<36.0°C). Maternal core temperatures were measured with the non-invasive zero-heat-flux thermometer (Bair Hugger Temperature Monitoring System, 3M) throughout the perioperative course. RESULTS A total of 40 participants were recruited to the study. The incidence of perioperative hypothermia was 32.5%, with a duration of 77 ± 40 min (mean ± standard deviation). The hypothermic patients had similar core temperature as the normothermic patients at baseline preoperatively, but significantly lower temperature at operating room arrival and during the remaining study period. Forty percent of all patients reported thermal discomfort and felt cold on admission to post anaesthesia care unit, whereas 33% had shivering. Neither thermal discomfort nor shivering were associated with hypothermia. CONCLUSION In the present study almost a third of the women undergoing elective caesarean delivery developed perioperative hypothermia with a core temperature <36.0°C. The mean duration of maternal hypothermia was 77 min, lasting well into the postoperative period for many patients. These data should remind healthcare professionals of the importance of measuring core temperature in all phases of the perioperative setting and to consider optimal warming measures to avoid and treat hypothermia.
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Affiliation(s)
- Irene Brodshaug
- Department of Nurse Anaesthesia, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Elizabeth Reine
- Department of Nurse Anaesthesia, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Johan Raeder
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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Kavosi S, Raeder J, Johnson JR, Nykyri K, Farrugia CJ. Seasonal and diurnal variations of Kelvin-Helmholtz Instability at terrestrial magnetopause. Nat Commun 2023; 14:2513. [PMID: 37142596 PMCID: PMC10160038 DOI: 10.1038/s41467-023-37485-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 03/16/2023] [Indexed: 05/06/2023] Open
Abstract
Kelvin-Helmholtz Instability is ubiquitous at Earth's magnetopause and plays an important role in plasma entry into the magnetosphere during northward interplanetary magnetic fields. Here, using one solar cycle of data from NASA THEMIS (Time History of Events and Macro scale Interactions during Substorms) and MMS (Magnetospheric Multiscale) missions, we found that KHI occurrence rates show seasonal and diurnal variations with the rate being high near the equinoxes and low near the solstices. The instability depends directly on the Earth's dipole tilt angle. The tilt toward or away from the Sun explains most of the seasonal and diurnal variations, while the tilt in the plane perpendicular to the Earth-Sun line explains the difference between the equinoxes. The results reveal the critical role of dipole tilt in modulating KHI across the magnetopause as a function of time, highlighting the importance of Sun-Earth geometry for solar wind-magnetosphere interaction and for space weather.
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Affiliation(s)
- S Kavosi
- Embry-Riddle Aeronautical University, Daytona Beach, FL, USA.
| | - J Raeder
- University of New Hampshire, Institute for the Study of Earth, Oceans and Space, Durham, NH, USA
| | - J R Johnson
- Andrews University, Berrien Springs, MI, USA
| | - K Nykyri
- Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - C J Farrugia
- University of New Hampshire, Institute for the Study of Earth, Oceans and Space, Durham, NH, USA
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Sørenstua M, Zantalis N, Raeder J, Vamnes JS, Leonardsen ACL. Reply to letter to editor regarding 'Variable anterior spread of local anesthetic after erector spinae plane block (ESPB): time to turn the spotlight on the 'retro-SCTL space'. Reg Anesth Pain Med 2023:rapm-2023-104392. [PMID: 36805497 DOI: 10.1136/rapm-2023-104392] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Marie Sørenstua
- Department of Anesthesia, Sykehuset Østfold HF, Grålum, Norway .,Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Johan Raeder
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Sørenstua M, Zantalis N, Raeder J, Vamnes JS, Leonardsen ACL. Spread of local anesthetics after erector spinae plane block: an MRI study in healthy volunteers. Reg Anesth Pain Med 2023; 48:74-79. [PMID: 36351741 DOI: 10.1136/rapm-2022-104012] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/26/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Erector spinae plane block (ESPB) is a truncal fascial block with a disputed mechanism and anatomical site of effect. This study aimed to perform a one-sided ESPB and use MRI to investigate the spread of the local anesthetic (LA) and the corresponding cutaneous loss of sensation to pinprick and cold. METHODS Ten volunteers received a right-sided ESPB at the level of the seventh thoracic vertebra (Th7), consisting of 30 mL 2.5 mg/mL ropivacaine with 0.3 mL gadolinium. The primary outcome was the evaluation of the spread of LA on MRI 1-hour postblock. The secondary outcome was the loss of sensation to cold and pinprick 30-50 min after the block was performed. RESULTS All volunteers had a spread of LA on MRI in the erector spinae muscles and to the intercostal space. 9/10 had spread to the paravertebral space and 8/10 had spread to the neural foramina. 4/10 volunteers had spread to the epidural space. One volunteer had extensive epidural spread as well as contralateral epidural and foraminal spread. Four volunteers had a loss of sensation both posterior and anterior to the midaxillary line, while six volunteers had a loss of sensation only on the posterior side. CONCLUSION We found that LA consistently spreads to the intercostal space, the paravertebral space, and the neural foramina after an ESPB. Epidural spread was evident in four volunteers. Sensory testing 30-50 min after an ESPB shows highly variable results, and generally under-represents what could be expected from the visualized spread on MRI 60 min after block performance. TRIAL REGISTRATION NUMBER NCT05012332.
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Affiliation(s)
- Marie Sørenstua
- Department of Anesthesia, Sykehuset Østfold HF, Gralum, Norway .,Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Johan Raeder
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Sørenstua M, Raeder J, Vamnes JS, Leonardsen ACL. Efficacy of a TAP block versus an anterior QLB for laparoscopic inguinal hernia repair: A randomised controlled trial. Acta Anaesthesiol Scand 2023; 67:221-229. [PMID: 36267030 PMCID: PMC10092777 DOI: 10.1111/aas.14160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 09/19/2022] [Accepted: 10/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Both the transversus abdominis plane (TAP) block and the anterior quadratus lumborum block (QLB) have been shown effective in reducing postoperative pain after laparoscopic inguinal hernia repair. Our hypothesis was that there is no difference in analgesic effect between the two blocks for this procedure. METHODS In this prospective, double-blind, randomised controlled study, 60 adult patients undergoing laparoscopic inguinal hernia repair were equally randomly assigned to either a preoperative TAP block or an anterior QLB. The primary outcome was oral morphine equivalent (OME) consumption at 4 h postoperatively. Secondary outcomes were OME consumption at 24, 48 h and 7 days, pain scores at rest and when coughing, nausea, and level of sedation measured at 1, 2, 3, 24, and 48 h and 7 days postoperatively. RESULTS Fifty-three patients completed the study. There was no significant difference in OME consumption at 4 h postoperatively, TAP group (10.3 ± 7.85 mg) (mean ± SD) versus the anterior QLB group (10.9 ± 10.85 mg) (p = .713). The pain scores were similar at rest and when coughing during the 7 day observation period, as were the level of sedation and incidence of nausea. There were no cases of serious side-effects or muscle weakness of the thigh on the same side as the block. CONCLUSION There is no difference in OME consumption, pain, nausea or sedation between the TAP and the anterior QLB. Thus, the choice between the two blocks in a clinical setting of laparoscopic inguinal hernia repair should be based on other aspects, such as skills, practicalities, and potential risks.
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Affiliation(s)
- Marie Sørenstua
- Department of Anaesthesia, Ostfold Hospital Trust, Moss, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Johan Raeder
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Ann-Chatrin Linqvist Leonardsen
- Faculty of Health, Welfare and Organisation, Ostfold University College, Fredrikstad, Norway.,Department of Anaesthesia, Ostfold Hospital Trust Kalnes, Norway
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Watne LO, Pollmann CT, Neerland BE, Quist-Paulsen E, Halaas NB, Idland AV, Hassel B, Henjum K, Knapskog AB, Frihagen F, Raeder J, Godø A, Ueland PM, McCann A, Figved W, Selbæk G, Zetterberg H, Fang EF, Myrstad M, Giil LM. Cerebrospinal fluid quinolinic acid is strongly associated with delirium and mortality in hip-fracture patients. J Clin Invest 2023; 133:163472. [PMID: 36409557 PMCID: PMC9843060 DOI: 10.1172/jci163472] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/15/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUNDThe kynurenine pathway (KP) has been identified as a potential mediator linking acute illness to cognitive dysfunction by generating neuroactive metabolites in response to inflammation. Delirium (acute confusion) is a common complication of acute illness and is associated with increased risk of dementia and mortality. However, the molecular mechanisms underlying delirium, particularly in relation to the KP, remain elusive.METHODSWe undertook a multicenter observational study with 586 hospitalized patients (248 with delirium) and investigated associations between delirium and KP metabolites measured in cerebrospinal fluid (CSF) and serum by targeted metabolomics. We also explored associations between KP metabolites and markers of neuronal damage and 1-year mortality.RESULTSIn delirium, we found concentrations of the neurotoxic metabolite quinolinic acid in CSF (CSF-QA) (OR 2.26 [1.78, 2.87], P < 0.001) to be increased and also found increases in several other KP metabolites in serum and CSF. In addition, CSF-QA was associated with the neuronal damage marker neurofilament light chain (NfL) (β 0.43, P < 0.001) and was a strong predictor of 1-year mortality (HR 4.35 [2.93, 6.45] for CSF-QA ≥ 100 nmol/L, P < 0.001). The associations between CSF-QA and delirium, neuronal damage, and mortality remained highly significant following adjustment for confounders and multiple comparisons.CONCLUSIONOur data identified how systemic inflammation, neurotoxicity, and delirium are strongly linked via the KP and should inform future delirium prevention and treatment clinical trials that target enzymes of the KP.FUNDINGNorwegian Health Association and South-Eastern Norway Regional Health Authorities.
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Affiliation(s)
- Leiv Otto Watne
- Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,Department of Geriatric Medicine and
| | | | | | | | | | - Ane-Victoria Idland
- Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway.,Department of Anesthesiology, Akershus University Hospital, Lørenskog, Norway
| | - Bjørnar Hassel
- Department of Neurohabilitation, Oslo University Hospital, Oslo, Norway
| | - Kristi Henjum
- Oslo Delirium Research Group, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Frede Frihagen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | - Johan Raeder
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Aasmund Godø
- Department of Anesthesiology, Diakonhjemmet Hospital, Oslo, Norway
| | | | | | - Wender Figved
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Orthopaedic Department, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Geir Selbæk
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Norwegian National Centre for Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom.,UK Dementia Research Institute at UCL, London, United Kingdom.,Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Evandro F. Fang
- Department of Clinical Molecular Biology, University of Oslo, and Akershus University Hospital, Lørenskog, Norway.,The Norwegian Centre on Healthy Ageing (NO-Age), Oslo, Norway
| | - Marius Myrstad
- Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Lasse M. Giil
- Neuro-SysMed, Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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Albrecht E, Kehlet H, Raeder J, Joshi GP. Impact of country of origin on procedure-specific postoperative pain management (PROSPECT) recommendations. Anaesthesia 2022; 77:1057-1059. [PMID: 35776133 DOI: 10.1111/anae.15796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- E Albrecht
- University Hospital of Lausanne, Lausanne, Switzerland
| | - H Kehlet
- Rigshospitalet, Copenhagen, Denmark
| | - J Raeder
- Oslo University Hospital, Oslo, Norway
| | - G P Joshi
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Comelon M, Raeder J, Drægni T, Lieng M, Lenz H. Tapentadol versus oxycodone analgesia and side effects after laparoscopic hysterectomy: A randomised controlled trial. Eur J Anaesthesiol 2021; 38:995-1002. [PMID: 33428347 DOI: 10.1097/eja.0000000000001425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tapentadol is an opioid, which acts as a μ-opioid receptor agonist and inhibits noradrenaline reuptake in the central nervous system. This dual mechanism of action results in synergistic analgesic effects and potentially less side effects. This has been shown in treatment of chronic pain but postoperative studies are sparse. OBJECTIVES The main aim was to compare the analgesic effect of tapentadol with oxycodone after laparoscopic hysterectomy. Opioid side effects were recorded as secondary outcomes. DESIGN Randomised, blinded trial. SETTING Single-centre, Oslo University Hospital, Norway, December 2017 to February 2019. PATIENTS Eighty-six opioid-naïve American Society of Anesthesiologists physical status 1 to 3 women undergoing laparoscopic hysterectomy for nonmalignant conditions. INTERVENTION The patients received either oral tapentadol (group T) or oxycodone (group O) as part of multimodal pain treatment. Extended-release study medicine was administered 1 h preoperatively and after 12 h. Immediate-release study medicine was used as rescue analgesia. MAIN OUTCOME MEASURES Pain scores, opioid consumption and opioid-induced side effects were evaluated during the first 24 h after surgery. RESULTS The groups scored similarly for pain at rest using a numerical rating scale (NRS) 1 h postoperatively (group T 4.4, 95% CI, 3.8 to 5.0, group O 4.6, 95% CI, 3.8 to 5.3). No statistically significant differences were found between the groups for NRS at rest or while coughing during the 24-h follow-up period (P = 0.857 and P = 0.973). Mean dose of oral rescue medicine was similar for the groups (P = 0.914). Group T had significantly lower odds for nausea at 2 and 3 h postoperatively (P = 0.040, P = 0.020) and less need for antiemetics than group O. No differences were found for respiratory depression, vomiting, dizziness, pruritus, headache or sedation. CONCLUSION We found tapentadol to be similar in analgesic efficacy to oxycodone during the first 24 h after hysterectomy, but with significantly less nausea. TRIAL REGISTRATION ClinicalTrials.gov, NCT03314792.
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Affiliation(s)
- Marlin Comelon
- From the Division of Emergencies and Critical Care, Department of Anaesthesiology, Oslo University Hospital (MC, JR, HL), Faculty of Medicine, Institute of Clinical Medicine, University of Oslo (MC, JR, TD, ML, HL), Division of Emergencies and Critical Care, Department of Research and Development (TD) and Division of Gynaecology and Obstetrics, Oslo University Hospital, Oslo, Norway (ML)
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Henjum K, Godang K, Quist-Paulsen E, Idland AV, Neerland BE, Sandvig H, Brugård A, Raeder J, Frihagen F, Wyller TB, Hassel B, Bollerslev J, Watne LO. Cerebrospinal fluid catecholamines in delirium and dementia. Brain Commun 2021; 3:fcab121. [PMID: 34423298 PMCID: PMC8374970 DOI: 10.1093/braincomms/fcab121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 11/28/2022] Open
Abstract
Dopamine and noradrenaline are functionally connected to delirium and have been targets for pharmacological interventions but the biochemical evidence to support this notion is limited. To study the CSF levels of dopamine, noradrenaline and the third catecholamine adrenaline in delirium and dementia, these were quantified in three patient cohorts: (i) cognitively normal elderly patients (n = 122); (ii) hip fracture patients with or without delirium and dementia (n = 118); and (iii) patients with delirium precipitated by another medical condition (medical delirium, n = 26). Delirium was assessed by the Confusion Assessment Method. The hip fracture cohort had higher CSF levels of noradrenaline and adrenaline than the two other cohorts (both P < 0.001). Within the hip fracture cohort those with delirium (n = 65) had lower CSF adrenaline and dopamine levels than those without delirium (n = 52, P = 0.03, P = 0.002). Similarly, the medical delirium patients had lower CSF dopamine levels than the cognitively normal elderly (P < 0.001). Age did not correlate with the CSF catecholamine levels. These findings with lower CSF dopamine levels in hip fracture- and medical delirium patients challenge the theory of dopamine excess in delirium and question use of antipsychotics in delirium. The use of alpha-2 agonists with the potential to reduce noradrenaline release needs further examination.
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Affiliation(s)
- Kristi Henjum
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway.,Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway
| | - Kristin Godang
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, 0424 Oslo, Norway
| | | | - Ane-Victoria Idland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Heidi Sandvig
- Medical Department, Kristiansund Hospital, Møre og Romsdal Hospital Trust, 6508 Kristiansund, Norway
| | - Anniken Brugård
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Johan Raeder
- Department of Anesthesiology, Oslo University Hospital, 0424 Oslo, Norway
| | - Frede Frihagen
- Division of Orthopedic Surgery, Oslo University Hospital, 0424 Oslo, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway.,Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway
| | - Bjørnar Hassel
- Department of Neurohabilitation, Oslo University Hospital, 0424 Oslo, Norway
| | - Jens Bollerslev
- Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway.,Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, 0424 Oslo, Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
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13
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Raeder J, Joshi GP. PROSPECT guidelines for total hip arthroplasty: a reply. Anaesthesia 2021; 77:1306. [PMID: 34390583 DOI: 10.1111/anae.15566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
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14
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Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M, Raeder J. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021; 76:1082-1097. [PMID: 34015859 DOI: 10.1111/anae.15498] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 12/11/2022]
Abstract
The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.
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Affiliation(s)
- M Anger
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - T Valovska
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - H Beloeil
- Department of Anesthesiology, Henry Ford Health Systems, Wayne State School of Medicine, Detroit, MI, USA
| | - P Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - M Van de Velde
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Anaesthesiology, UZLeuven, Leuven, Belgium
| | - J Raeder
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.,Division of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
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Reine E, Aase K, Raeder J, Thorud A, Aarsnes RM, Rustøen T. Exploring postoperative handover quality in relation to patient condition: A mixed methods study. J Clin Nurs 2021; 30:1046-1059. [PMID: 33434381 DOI: 10.1111/jocn.15650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 12/03/2020] [Accepted: 12/31/2020] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To describe postoperative handover reporting and tasks in relation to patient condition and situational circumstances, in order to identify facilitators for best practices. BACKGROUND High-quality handovers in postoperative settings are important for patient safety and continuity of care. There is a need to explore handover quality in relation to patient condition and other affecting factors. DESIGN Observational mixed methods convergent design. METHODS Postoperative patient handovers were observed collecting quantitative (n = 109) and qualitative data (n = 48). Quantitative data were collected using the postoperative handover assessment tool (PoHAT), and a scoring system assessing patient condition. Qualitative data were collected using free-text field notes and an observational guide. The study adheres to the GRAMMS guideline for reporting mixed methods research. RESULTS Information omissions in the handovers observed ranged from 1-13 (median 7). Handovers of vitally stable and comfortable patients were associated with more information omissions in the report. A total of 50 handovers (46%) were subjected to interruptions, and checklist compliance was low (13%, n = 14). Thematic analysis of the qualitative data identified three themes: "adaptation of handover," "strategies for information transfer" and "contextual and individual factors." Factors facilitating best practices were related to adaptation of the handover to patient condition and situational circumstances, structured verbal reporting, providing patient assessments and dialogue within the handover team. CONCLUSIONS The variations in items reported and tasks performed during the handovers observed were related to patient conditions, situational circumstances and low checklist compliance. Adaptation of the handover to patient condition and situation, structured reporting, dialogue within the team and patient assessments contributed to quality. RELEVANCE TO CLINICAL PRACTICE It is important to acknowledge that handover quality is related to more than transfer of information. The present study has described how factors related to the patient and situation affect handover quality.
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Affiliation(s)
- Elizabeth Reine
- Department of Nurse Anaesthesia, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Karina Aase
- SHARE-Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Johan Raeder
- Department of Anaesthesia, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne Thorud
- Department of Nurse Anaesthesia, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Reidunn M Aarsnes
- Department of Nurse Anaesthesia, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Tone Rustøen
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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Aldamluji N, Burgess A, Pogatzki-Zahn E, Raeder J, Beloeil H. PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2020; 76:947-961. [PMID: 33201518 PMCID: PMC8247026 DOI: 10.1111/anae.15299] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 12/12/2022]
Abstract
Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure‐specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta‐analysis guidelines with procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre‐operative and intra‐operative interventions that improved postoperative pain were paracetamol; non‐steroidal anti‐inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra‐operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first‐line analgesics are contra‐indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.
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Affiliation(s)
- N Aldamluji
- Department of Adult Anaesthesiology, Sidra Medicine, Qatar
| | - A Burgess
- Department of Otolaryngology Head and Neck Surgery, Com Maillot-Hartmann Private Hospital, Neuilly sur Seine, France
| | - E Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - J Raeder
- Department of Anaesthesiology, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - H Beloeil
- Department of Anaesthesiology and Critical Care, Université Rennes, Rennes, France
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Brodshaug I, Tettum B, Raeder J. Thermal Suit or Forced Air Warming in Prevention of Perioperative Hypothermia: A Randomized Controlled Trial. J Perianesth Nurs 2019; 34:1006-1015. [DOI: 10.1016/j.jopan.2019.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/28/2019] [Accepted: 03/03/2019] [Indexed: 10/26/2022]
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18
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Kolstadbraaten KM, Spreng UJ, Wisloeff‐Aase K, Gaarder C, Naess PA, Raeder J. Incidence of chronic pain 6 y after major trauma. Acta Anaesthesiol Scand 2019; 63:1074-1078. [PMID: 31012096 DOI: 10.1111/aas.13380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 03/19/2019] [Accepted: 03/28/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Life saving measures is the main focus in the initial treatment of major trauma. In surviving patients, chronic pain may be a serious problem, but the long term incidence and potential risk factors are not very well studied. METHODS All adult trauma patients included in the institutional trauma registry in 2007 were assessed for eligibility. Among exclusion criteria were: Injury Severity Score < 9, endotracheal intubation before or during admission, spinal cord lesion, known chronic drug or substance abuse, major surgery within 3 h after admission. A patient questionnaire was sent out 6 y after injury focusing on frequency and intensity of pain. A subgroup analysis was done in patients with thoracic injuries, comparing patients with epidural analgesia (EDA) and patients without. RESULTS Sixty-eight patients were included in the study. Sixty-nine percent reported pain 6 y after injury and 24% had severe pain. The severity of the injury was a risk factor for development of chronic pain, whereas pain during initial hospital stay was not. In patients with thoracic injuries there was no correlation between initial treatment with EDA and decreased incidence of chronic pain, however patient numbers were small. Opioids were the main analgesics used initially; no patients received non-steroidal anti-inflammatory drugs or peripheral nerve blocks during the first 24 h. CONCLUSION Two thirds of the trauma patients had chronic pain 6 y after injury and one out of four had severe pain. The initial pain treatment was focused on opioids.
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Affiliation(s)
| | | | - Kristin Wisloeff‐Aase
- Department of Anaesthesiology Oslo University Hospital Oslo Norway
- Faculty of Medicine, Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Christine Gaarder
- Department of Traumatology Oslo University Hospital Oslo Norway
- Faculty of Medicine, Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Paal Aksel Naess
- Department of Traumatology Oslo University Hospital Oslo Norway
- Faculty of Medicine, Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Johan Raeder
- Department of Anaesthesiology Oslo University Hospital Oslo Norway
- Faculty of Medicine, Institute of Clinical Medicine University of Oslo Oslo Norway
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19
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Hainline B, Derman W, Vernec A, Budgett R, Deie M, Dvorak J, Harle CA, Herring S, McNamee M, Meeuwisse W, Moseley GL, Omololu B, Orchard J, Pipe A, Pluim BM, Raeder J, Siebert D, Stewart M, Stuart MC, Turner J, Ware M, Zideman D, Engebretsen L. Infographic. International Olympic Committee consensus statement on pain management in athletes: non-pharmacological strategies. Br J Sports Med 2019; 53:785-786. [PMID: 30952826 DOI: 10.1136/bjsports-2019-100853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Brian Hainline
- National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA
| | - Wayne Derman
- Instiute of Sport and Exercise Medicine, Department of Surgical Sciences, Stellenbosch University, Cape Town, South Africa.,International Olympic Committee Research Centre, Cape Town, South Africa
| | | | | | - Masataka Deie
- Orthopedic Surgery, Aichi Ika Daigaku, Aichi-gun, Aichi, Japan
| | - Jiri Dvorak
- Swiss Concussion Center, Zurich, Switzerland.,Spine Unit, Schulthess Clinic, Zurich, Switzerland
| | - Christopher A Harle
- Health Policy and Management, Indiana University, Indianapolis, Indiana, USA
| | - Stanley Herring
- Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | | | - Willem Meeuwisse
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | | | - Bade Omololu
- Orthopaedic Surgery, University of Ibadan College of Medicine, Ibadan, Western Nigeria, Nigeria
| | - John Orchard
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Pipe
- Sports Medicine, Royal Netherlands Lawn Tennis Association, Amersfoort, The Netherlands
| | - Babette M Pluim
- Sports Medicine, Royal Netherlands Lawn Tennis Association, Amersfoort, The Netherlands.,Home, Ede, The Netherlands
| | | | - David Siebert
- Family Medicine, University of Washington, Seattle, Washington, USA
| | - Mike Stewart
- Physical Therapy, East Kent Hospitals University, Canterbury, UK
| | | | - Judith Turner
- Psychology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Mark Ware
- Pain Management, McGill University Health Centre, Montreal, Quebec, Canada
| | - David Zideman
- International Olympic Committee Medical and Scientific Games Group, Lausanne, Switzerland
| | - Lars Engebretsen
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
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20
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Barazanchi A, MacFater W, Rahiri JL, Tutone S, Hill A, Joshi G, Kehlet H, Schug S, Van de Velde M, Vercauteren M, Lirk P, Rawal N, Bonnet F, Lavand'homme P, Beloeil H, Raeder J, Pogatzki-Zahn E. Evidence-based management of pain after laparoscopic cholecystectomy: a PROSPECT review update. Br J Anaesth 2018; 121:787-803. [DOI: 10.1016/j.bja.2018.06.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/19/2018] [Accepted: 07/09/2018] [Indexed: 02/07/2023] Open
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21
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Reine E, Rustøen T, Raeder J, Aase K. Postoperative patient handovers-Variability in perceptions of quality: A qualitative focus group study. J Clin Nurs 2018; 28:663-676. [PMID: 30183113 DOI: 10.1111/jocn.14662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 08/13/2018] [Accepted: 08/30/2018] [Indexed: 12/30/2022]
Abstract
AIMS AND OBJECTIVES (a) To explore the factors affecting quality in postoperative handovers as perceived by the different professional groups of clinicians involved. (b) To explore possible differences in perceptions of postoperative handover quality across professional groups and level of experience. BACKGROUND High quality patient handovers after surgery and anaesthesia are important to ensure patient safety. There is a paucity of research describing contextual factors related to handover quality and the perspectives of different professional groups involved. DESIGN A qualitative exploratory design was applied. METHOD A total of eight focus group interviews with 37 participants (29 nurses, eight doctors) were conducted. Anaesthesiologists, resident anaesthesiologists, nurse anaesthetists, postoperative care nurses and operating room nurses participated in the study. The interviews were conducted according to profession with two groups per profession: one with experienced clinicians and one with less experienced clinicians. The data were analysed using thematic analysis. The study adheres to the COREQ guidelines. RESULTS The data analysis identified the following factors affecting postoperative handover quality: "timing and concurrency conflicts," "handover structure," "patient conditions," "individual characteristics of clinicians involved" and "team composition." Differences across professional groups and level of experience were related to responsibility, structure and adaptation. CONCLUSION The professional groups involved describe the postoperative patient handover as a complex and variable process that needs to be carefully planned and executed according to the influencing factors. Variability exists across professional groups and level of experience. RELEVANCE TO CLINICAL PRACTICE Health care providers need to be aware that postoperative handovers are affected by a set of factors related to internal (patient conditions, individual characteristics of clinicians involved and team composition) and external (timing and concurrency conflicts, handover structure) characteristics. These issues need to be acknowledged when procedures and routines for handover quality are designed, implemented and used.
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Affiliation(s)
- Elizabeth Reine
- Department of Nurse Anaesthesia, Divisions of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tone Rustøen
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Research and Development, Divisions of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Johan Raeder
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Karina Aase
- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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22
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Lee B, Schug SA, Joshi GP, Kehlet H, Bonnet F, Lavand’Homme P, Lirk P, Pogatzki-Zahn E, Raeder J, Rawal N, van der Velde M. Procedure-Specific Pain Management (PROSPECT) - An update. Best Pract Res Clin Anaesthesiol 2018; 32:101-111. [PMID: 30322452 DOI: 10.1016/j.bpa.2018.06.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/18/2018] [Indexed: 11/26/2022]
Abstract
Post-operative pain management protocols may be optimised by examining procedure-specific evidence and outcomes. This recognition led to the formation of the PROcedure-SPECific Pain ManagemenT (PROSPECT) collaboration of anaesthesiologists and surgeons. The aim of PROSPECT is to provide practical and evidence-based recommendations to prevent and treat post-operative pain after specific surgical procedures, thereby overcoming the limitations of generic, non-specific guidelines. Updates in the methodology of PROSPECT in 2017 have placed an increased emphasis on the clinical relevance of studies, including a focus on interventions in the context of multimodal analgesia strategies and consideration of risks and benefits of interventions in specific surgical settings. Evidence-based reviews of analgesic measures, including advice on surgical techniques and adjuvants after diverse surgical procedures, have been completed by the PROSPECT collaboration and are accessible on the website (www.postoppain.org) and published in the peer-reviewed literature. These reviews continue to identify significant gaps in clinically relevant research on post-operative analgesia and are possibly leading to a closing of some of these gaps.
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Affiliation(s)
- Brian Lee
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
| | - Stephan A Schug
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia; Anaesthesiology and Pain Medicine, Medical School, University of Western Australia, Perth, Australia.
| | - Girish P Joshi
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Joshi G, Kehlet H, Beloeil H, Bonnet F, Fischer B, Hill A, Joshi G, Kehlet H, Lavandhomme P, Lirk P, Pogatzki-Zhan E, Raeder J, Rawal N, Schug S, Van de Velde M. Guidelines for perioperative pain management: need for re-evaluation. Br J Anaesth 2017; 119:703-706. [DOI: 10.1093/bja/aex304] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Nostdahl T, Fredheim OM, Bernklev T, Doksrod TS, Mohus RM, Raeder J. A randomised controlled trial of propofol vs. thiopentone and desflurane for fatigue after laparoscopic cholecystectomy. Anaesthesia 2017; 72:864-869. [DOI: 10.1111/anae.13909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2017] [Indexed: 12/22/2022]
Affiliation(s)
- T. Nostdahl
- Department of Anaesthesiology; Telemark Hospital; Skien Norway
| | - O. M. Fredheim
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
- Centre of Palliative Medicine, Surgical Division; Akershus University Hospital; Lørenskog Norway
- National Competence Centre for Complex Symptom Disorders; Department of Pain and Complex Disorders; Trondheim Norway
| | - T. Bernklev
- Research and Development; Vestfold Hospital Trust; Tønsberg Norway
- Institute of Clinical Medicine; Medical Faculty; University of Oslo; Oslo Norway
| | - T. S. Doksrod
- Department of Anaesthesiology; Telemark Hospital; Skien Norway
| | - R. M. Mohus
- Department of Anaesthesiology; St. Olav University Hospital; Trondheim Norway
| | - J. Raeder
- Institute of Clinical Medicine; Medical Faculty; University of Oslo; Oslo Norway
- Department of Anaesthesiology; Oslo University Hospital; Oslo Norway
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26
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Watne LO, Idland AV, Fekkes D, Raeder J, Frihagen F, Ranhoff AH, Chaudhry FA, Engedal K, Wyller TB, Hassel B. Increased CSF levels of aromatic amino acids in hip fracture patients with delirium suggests higher monoaminergic activity. BMC Geriatr 2016; 16:149. [PMID: 27484129 PMCID: PMC4970288 DOI: 10.1186/s12877-016-0324-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/28/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To examine whether delirium in hip fracture patients was associated with changes in the levels of amino acids and/or monoamine metabolites in cerebrospinal fluid (CSF) and serum. METHODS In this prospective cohort study, 77 patients admitted with an acute hip fracture to Oslo University Hospital, Norway, were studied. The concentrations of amino acids in CSF and serum were determined by high performance liquid chromatography. The patients were assessed daily for delirium by the Confusion Assessment Method (pre-operatively and post-operative day 1-5 (all) or until discharge (delirious patients)). Pre-fracture dementia status was decided by an expert panel. Serum was collected pre-operatively and CSF immediately before spinal anesthesia. RESULTS Fifty-three (71 %) hip fracture patients developed delirium. In hip fracture patients without dementia (n = 39), those with delirium had significantly higher CSF levels of tryptophan (40 % higher), tyrosine (60 % higher), phenylalanine (59 % higher) and the monoamine metabolite 5-hydroxyindoleacetate (23 % higher) compared to those without delirium. The same amino acids were also higher in CSF in delirious patients with dementia (n = 38). The correlations between serum and CSF amino acid levels were poor. CONCLUSION Higher CSF levels of monoamine precursors in hip fracture patients with delirium suggest a higher monoaminergic activity in the central nervous system during delirium in this patient group.
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Affiliation(s)
- Leiv Otto Watne
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway. .,Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PO BOX 4950, Nydalen, N-0424, Oslo, Norway. .,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway. .,Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, Scotland, UK.
| | - Ane-Victoria Idland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PO BOX 4950, Nydalen, N-0424, Oslo, Norway
| | - Durk Fekkes
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Johan Raeder
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Frede Frihagen
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Anette Hylen Ranhoff
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Knut Engedal
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Norwegian National Advisory Unit on Ageing and Health, Vestfold Health Trust, Tønsberg, Norway
| | - Torgeir Bruun Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PO BOX 4950, Nydalen, N-0424, Oslo, Norway
| | - Bjørnar Hassel
- Department of Complex Neurology and Neurohabilitation, Oslo University Hospital, N-0027, Oslo, Norway. .,Norwegian Defense Research Establishment (FFI), Kjeller, Norway.
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Torossian A, Van Gerven E, Geertsen K, Horn B, Van de Velde M, Raeder J. Active perioperative patient warming using a self-warming blanket (BARRIER EasyWarm) is superior to passive thermal insulation: a multinational, multicenter, randomized trial. J Clin Anesth 2016; 34:547-54. [PMID: 27687449 DOI: 10.1016/j.jclinane.2016.06.030] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 06/03/2016] [Accepted: 06/07/2016] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE Incidence of inadvertent perioperative hypothermia is still high; therefore, present guidelines advocate "prewarming" for its prevention. Prewarming means preoperative patient skin warming, which minimizes redistribution hypothermia caused by induction of anesthesia. In this study, we compared the new self-warming BARRIER EasyWarm blanket with passive thermal insulation regarding mean perioperative patient core body temperature. DESIGN Multinational, multicenter randomized prospective open-label controlled trial. SETTING Surgical ward, operation room, postanesthesia care unit at 4 European hospitals. PATIENTS A total of 246 adult patients, American Society of Anesthesiologists class I to III undergoing elective orthopedic; gynecologic; or ear, nose, and throat surgery scheduled for 30 to 120 minutes under general anesthesia. INTERVENTIONS Patients received warmed hospital cotton blankets (passive thermal insulation, control group) or BARRIER EasyWarm blanket at least 30 minutes before induction of general anesthesia and throughout the perioperative period (intervention group). MEASUREMENTS The primary efficacy outcome was the perioperative mean core body temperature measured by a tympanic infrared thermometer. Secondary outcomes were hypothermia incidence, change in core body temperature, length of stay in postanesthesia care unit, thermal comfort, patient satisfaction, ease of use, and adverse events related to the BARRIER EasyWarm blanket. MAIN RESULTS The BARRIER EasyWarm blanket significantly improved perioperative core body temperature compared with standard hospital blankets (36.5°C, SD 0.4°C, vs 36.3, SD 0.3°C; P<.001). Intraoperatively, in the intervention group, hypothermia incidence was 38% compared with 60% in the control group (P=.001). Postoperatively, the figures were 24% vs 49%, respectively (P=.001). Patients in the intervention group had significantly higher thermal comfort scores, preoperatively and postoperatively. No serious adverse effects were observed in either group. CONCLUSIONS Perioperative use of the new self-warming blanket improves mean perioperative core body temperature, reduces the incidence of inadvertent perioperative hypothermia, and improves patients' thermal comfort during elective adult surgery.
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Affiliation(s)
- Alexander Torossian
- Department of Anesthesiology and Critical Care, University Hospital Marburg and Medical Faculty, Philipps-University of Marburg, Germany.
| | - Elke Van Gerven
- Department Cardiovascular Sciences and Department of Anesthesiology, KU Leuven, University Hospitals Leuven, Belgium
| | - Karin Geertsen
- Department of Operative and Intensive Care, Hallands sjukhus Varberg, Sweden
| | - Bengt Horn
- Department of Orthopedics, Aleris Specialistvård, Motala Hospital, Sweden
| | - Marc Van de Velde
- Department Cardiovascular Sciences and Department of Anesthesiology, KU Leuven, University Hospitals Leuven, Belgium
| | - Johan Raeder
- Department of Anesthesiology, Oslo University Hospital and Medical Faculty, University of Oslo, Norway
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Hall RJ, Watne LO, Idland AV, Raeder J, Frihagen F, MacLullich AMJ, Staff AC, Wyller TB, Fekkes D. Cerebrospinal fluid levels of neopterin are elevated in delirium after hip fracture. J Neuroinflammation 2016; 13:170. [PMID: 27357281 PMCID: PMC4928278 DOI: 10.1186/s12974-016-0636-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 06/21/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The inflammatory cell product neopterin is elevated in serum before and during delirium. This suggests a role for disordered cell-mediated immunity or oxidative stress. Cerebrospinal fluid (CSF) neopterin levels reflect brain neopterin levels more closely than serum levels. Here we hypothesized that CSF neopterin levels would be higher in delirium. METHODS In this prospective cohort study, 139 elderly patients with acute hip fracture were recruited in Oslo and Edinburgh. Delirium was diagnosed with the confusion assessment method performed daily pre-operatively and on the first 5 days post-operatively. Paired CSF and blood samples were collected at the onset of spinal anaesthesia. Neopterin levels were measured using high-performance liquid chromatography. RESULTS Sixty-four (46 %) of 139 hip fracture patients developed delirium perioperatively. CSF neopterin levels were higher in delirium compared to controls (median 29.6 vs 24.7 nmol/mL, p = 0.003), with highest levels in patients who developed delirium post-operatively. Serum neopterin levels were also higher in delirium (median 37.0 vs 27.1 nmol/mL, p = 0.003). CSF neopterin remained significantly associated with delirium after controlling for relevant risk factors. Higher neopterin levels were associated with poorer outcomes (death or new institutionalization) 1 year after surgery (p = 0.02 for CSF and p = 0.03 for serum). CONCLUSIONS This study is the first to examine neopterin in CSF from patients with delirium. Our findings suggest potential roles for activation of cell-mediated immune responses or oxidative stress in the delirium process. High levels of serum or CSF neopterin in hip fracture patients may also be useful in predicting poor outcomes.
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Affiliation(s)
- Roanna J. Hall
- />Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland
- />Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Leiv Otto Watne
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Ane-Victoria Idland
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Johan Raeder
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- />Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Frede Frihagen
- />Department of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Alasdair M. J. MacLullich
- />Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland
- />Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Anne Cathrine Staff
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- />Department of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Torgeir Bruun Wyller
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Durk Fekkes
- />Department of Anaesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Neerland BE, Hall RJ, Seljeflot I, Frihagen F, MacLullich AMJ, Raeder J, Wyller TB, Watne LO. Associations Between Delirium and Preoperative Cerebrospinal Fluid C-Reactive Protein, Interleukin-6, and Interleukin-6 Receptor in Individuals with Acute Hip Fracture. J Am Geriatr Soc 2016; 64:1456-63. [DOI: 10.1111/jgs.14238] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Bjørn Erik Neerland
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Roanna J. Hall
- Edinburgh Delirium Research Group; University of Edinburgh; Edinburgh UK
- Centre for Cognitive Ageing and Cognitive Epidemiology; University of Edinburgh; Edinburgh UK
| | - Ingebjørg Seljeflot
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Center for Clinical Heart Research; Department of Cardiology; Oslo University Hospital; Oslo Norway
| | - Frede Frihagen
- Department of Orthopedic Surgery; Oslo University Hospital; Oslo Norway
| | - Alasdair M. J. MacLullich
- Edinburgh Delirium Research Group; University of Edinburgh; Edinburgh UK
- Centre for Cognitive Ageing and Cognitive Epidemiology; University of Edinburgh; Edinburgh UK
| | - Johan Raeder
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Anesthesiology; Oslo University Hospital; Oslo Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Basic Medical Sciences; University of Oslo; Oslo Norway
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Stankovski T, Petkoski S, Raeder J, Smith AF, McClintock PVE, Stefanovska A. Alterations in the coupling functions between cortical and cardio-respiratory oscillations due to anaesthesia with propofol and sevoflurane. Philos Trans A Math Phys Eng Sci 2016; 374:rsta.2015.0186. [PMID: 27045000 PMCID: PMC4822446 DOI: 10.1098/rsta.2015.0186] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/09/2016] [Indexed: 05/24/2023]
Abstract
The precise mechanisms underlying general anaesthesia pose important and still open questions. To address them, we have studied anaesthesia induced by the widely used (intravenous) propofol and (inhalational) sevoflurane anaesthetics, computing cross-frequency coupling functions between neuronal, cardiac and respiratory oscillations in order to determine their mutual interactions. The phase domain coupling function reveals the form of the function defining the mechanism of an interaction, as well as its coupling strength. Using a method based on dynamical Bayesian inference, we have thus identified and analysed the coupling functions for six relationships. By quantitative assessment of the forms and strengths of the couplings, we have revealed how these relationships are altered by anaesthesia, also showing that some of them are differently affected by propofol and sevoflurane. These findings, together with the novel coupling function analysis, offer a new direction in the assessment of general anaesthesia and neurophysiological interactions, in general.
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Affiliation(s)
- Tomislav Stankovski
- Department of Physics, Lancaster University, Lancaster LA1 4YB, UK Faculty of Medicine, Ss. Cyril and Methodius University, 50 Divizija 6, Skopje 1000, Macedonia
| | - Spase Petkoski
- Institut de Neurosciences des Systèmes UMR_S 1106, Aix-Marseille Université, Marseille 13005, France
| | - Johan Raeder
- Department of Anaesthesiology, Oslo University Hospital, Oslo 0424, Norway
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster LA1 4RP, UK
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Comelon M, Raeder J, Stubhaug A, Nielsen CS, Draegni T, Lenz H. Gradual withdrawal of remifentanil infusion may prevent opioid-induced hyperalgesia. Br J Anaesth 2016; 116:524-30. [PMID: 26934941 DOI: 10.1093/bja/aev547] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The aim of this study was to examine if gradual withdrawal of remifentanil infusion prevented opioid-induced hyperalgesia (OIH) as opposed to abrupt withdrawal. OIH duration was also evaluated. METHODS Nineteen volunteers were enrolled in this randomized, double-blinded, placebo-controlled, crossover study. All went through three sessions: abrupt or gradual withdrawal of remifentanil infusion and placebo. Remifentanil was administered at 2.5 ng ml(-1) for 30 min before abrupt withdrawal or gradual withdrawal by 0.6 ng ml(-1) every five min. Pain was assessed at baseline, during infusion, 45-50 min and 105-110 min after end of infusions using the heat pain test (HPT) and the cold pressor test (CPT). RESULTS The HPT 45 min after infusion indicated OIH development in the abrupt withdrawal session with higher pain scores compared with the gradual withdrawal and placebo sessions (both P<0.01. Marginal mean scores: placebo 2.90; abrupt 3.39; gradual 2.88), but no OIH after gradual withdrawal compared with placebo (P=0.93). In the CPT 50 min after end of infusion there was OIH in both remifentanil sessions compared with placebo (gradual P=0.01, abrupt P<0.01. Marginal mean scores: placebo 4.56; abrupt 5.25; gradual 5.04). There were no differences between the three sessions 105-110 min after infusion. CONCLUSIONS We found no development of OIH after gradual withdrawal of remifentanil infusion in the HPT. After abrupt withdrawal OIH was present in the HPT. In the CPT there was OIH after both gradual and abrupt withdrawal of infusion. The duration of OIH was less than 105 min for both pain modalities. CLINICAL TRIAL REGISTRATION NCT 01702389. EudraCT number 2011-002734-39.
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Affiliation(s)
- M Comelon
- Division of Emergencies and Critical Care, Department of Anesthesiology Faculty of Medicine, University of Oslo, 0316 Oslo, Norway
| | - J Raeder
- Division of Emergencies and Critical Care, Department of Anesthesiology Faculty of Medicine, University of Oslo, 0316 Oslo, Norway
| | - A Stubhaug
- Division of Emergencies and Critical Care, Department of Pain Management and Research Faculty of Medicine, University of Oslo, 0316 Oslo, Norway
| | - C S Nielsen
- Division of Emergencies and Critical Care, Department of Pain Management and Research Norwegian Institute of Public Health, Department of Mental Health, P.O Box 4404 Nydalen, 0403 Oslo, Norway
| | - T Draegni
- Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway
| | - H Lenz
- Division of Emergencies and Critical Care, Department of Anesthesiology
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Kenwright DA, Bernjak A, Draegni T, Dzeroski S, Entwistle M, Horvat M, Kvandal P, Landsverk SA, McClintock PVE, Musizza B, Petrovčič J, Raeder J, Sheppard LW, Smith AF, Stankovski T, Stefanovska A. The discriminatory value of cardiorespiratory interactions in distinguishing awake from anaesthetised states: a randomised observational study. Anaesthesia 2015; 70:1356-68. [PMID: 26350998 PMCID: PMC4989441 DOI: 10.1111/anae.13208] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2015] [Indexed: 12/20/2022]
Abstract
Depth of anaesthesia monitors usually analyse cerebral function with or without other physiological signals; non‐invasive monitoring of the measured cardiorespiratory signals alone would offer a simple, practical alternative. We aimed to investigate whether such signals, analysed with novel, non‐linear dynamic methods, would distinguish between the awake and anaesthetised states. We recorded ECG, respiration, skin temperature, pulse and skin conductivity before and during general anaesthesia in 27 subjects in good cardiovascular health, randomly allocated to receive propofol or sevoflurane. Mean values, variability and dynamic interactions were determined. Respiratory rate (p = 0.0002), skin conductivity (p = 0.03) and skin temperature (p = 0.00006) changed with sevoflurane, and skin temperature (p = 0.0005) with propofol. Pulse transit time increased by 17% with sevoflurane (p = 0.02) and 11% with propofol (p = 0.007). Sevoflurane reduced the wavelet energy of heart (p = 0.0004) and respiratory (p = 0.02) rate variability at all frequencies, whereas propofol decreased only the heart rate variability below 0.021 Hz (p < 0.05). The phase coherence was reduced by both agents at frequencies below 0.145 Hz (p < 0.05), whereas the cardiorespiratory synchronisation time was increased (p < 0.05). A classification analysis based on an optimal set of discriminatory parameters distinguished with 95% success between the awake and anaesthetised states. We suggest that these results can contribute to the design of new monitors of anaesthetic depth based on cardiovascular signals alone.
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Affiliation(s)
| | | | - T Draegni
- Oslo University Hospital, Ullevaal, Norway
| | - S Dzeroski
- Jožef Stefan Institute, Ljubljana, Slovenia
| | | | - M Horvat
- Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
| | - P Kvandal
- Oslo University Hospital, Ullevaal, Norway
| | | | | | - B Musizza
- Jožef Stefan Institute, Ljubljana, Slovenia
| | | | - J Raeder
- Oslo University Hospital, Ullevaal, Norway
| | | | - A F Smith
- Royal Lancaster Infirmary, Lancaster, UK
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Watne LO, Torbergsen AC, Conroy S, Engedal K, Frihagen F, Hjorthaug GA, Juliebo V, Raeder J, Saltvedt I, Skovlund E, Wyller TB. The effect of a pre- and postoperative orthogeriatric service on cognitive function in patients with hip fracture: randomized controlled trial (Oslo Orthogeriatric Trial). BMC Med 2014; 12:63. [PMID: 24735588 PMCID: PMC4022270 DOI: 10.1186/1741-7015-12-63] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 03/17/2014] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Delirium is a common complication in patients with hip fractures and is associated with an increased risk of subsequent dementia. The aim of this trial was to evaluate the effect of a pre- and postoperative orthogeriatric service on the prevention of delirium and longer-term cognitive decline. METHODS This was a single-center, prospective, randomized controlled trial in which patients with hip fracture were randomized to treatment in an acute geriatric ward or standard orthopedic ward. Inclusion and randomization took place in the Emergency Department at Oslo University hospital. The key intervention in the acute geriatric ward was Comprehensive Geriatric Assessment including daily interdisciplinary meetings. Primary outcome was cognitive function four months after surgery measured using a composite outcome incorporating the Clinical Dementia Rating Scale (CDR) and the 10 words learning and recalls tasks from the Consortium to Establish a Registry for Alzheimer's Disease battery (CERAD). Secondary outcomes were pre- and postoperative delirium, delirium severity and duration, mortality and mobility (measured by the Short Physical Performance Battery (SPPB)). Patients were assessed four and twelve months after surgery by evaluators blind to allocation. RESULTS A total of 329 patients were included. There was no significant difference in cognitive function four months after surgery between patients treated in the acute geriatric and the orthopedic wards (mean 54.7 versus 52.9, 95% confidence interval for the difference -5.9 to 9.5; P = 0.65). There was also no significant difference in delirium rates (49% versus 53%, P = 0.51) or four month mortality (17% versus 15%, P = 0.50) between the intervention and the control group. In a pre-planned sub-group analysis, participants living in their own home at baseline who were randomized to orthogeriatric care had better mobility four months after surgery compared with patients randomized to the orthopedic ward, measured with SPPB (median 6 versus 4, 95% confidence interval for the median difference 0 to 2; P = 0.04). CONCLUSIONS Pre- and postoperative orthogeriatric care given in an acute geriatric ward was not effective in reducing delirium or long-term cognitive impairment in patients with hip fracture. The intervention had, however, a positive effect on mobility in patients not admitted from nursing homes. TRIAL REGISTRATION ClinicalTrials.gov NCT01009268 Registered November 5, 2009.
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Affiliation(s)
- Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.
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Watne LO, Hall RJ, Molden E, Raeder J, Frihagen F, MacLullich AMJ, Juliebø V, Nyman A, Meagher D, Wyller TB. Anticholinergic Activity in Cerebrospinal Fluid and Serum in Individuals with Hip Fracture with and without Delirium. J Am Geriatr Soc 2014; 62:94-102. [DOI: 10.1111/jgs.12612] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Leiv Otto Watne
- Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Roanna J. Hall
- Edinburgh Delirium Research Group; University of Edinburgh; Edinburgh UK
- Centre for Cognitive Ageing and Cognitive Epidemiology; University of Edinburgh; Edinburgh UK
| | - Espen Molden
- Department of Pharmaceutical Biosciences; School of Pharmacy; University of Oslo; Oslo Norway
| | - Johan Raeder
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Anesthesiology; Oslo University Hospital; Oslo Norway
| | - Frede Frihagen
- Department of Orthopedic Surgery; Oslo University Hospital; Oslo Norway
| | - Alasdair M. J. MacLullich
- Edinburgh Delirium Research Group; University of Edinburgh; Edinburgh UK
- Centre for Cognitive Ageing and Cognitive Epidemiology; University of Edinburgh; Edinburgh UK
| | - Vibeke Juliebø
- Department of Cardiology; Oslo University Hospital; Oslo Norway
| | - Armika Nyman
- Department of Pharmaceutical Biosciences; School of Pharmacy; University of Oslo; Oslo Norway
| | - David Meagher
- Cognitive Impairment Research Group; Centre for Interventions in Infection; Inflammation and Immunity; Graduate Entry Medical School; University of Limerick; Limerick Ireland
- Department of Psychiatry; University Hospital Limerick; Limerick Ireland
| | - Torgeir B. Wyller
- Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
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Abstract
Current sheet configurations in natural and laboratory plasmas are often accompanied by a finite normal magnetic component that is known to stabilize the two-dimensional resistive tearing instability in the high Lundquist number regime. Recent magnetohydrodynamic simulations indicate that the nonlinear development of ballooning instability is able to induce the formation of X lines and plasmoids in a generalized Harris sheet with a finite normal magnetic component in the high Lundquist number regime where the linear two-dimensional resistive tearing mode is stable.
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Affiliation(s)
- P Zhu
- Department of Engineering Physics, University of Wisconsin-Madison, Madison, Wisconsin 53706, USA
| | - J Raeder
- Department of Physics, University of New Hampshire, Durham, New Hampshire 03824, USA
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Ge YS, Zhou XZ, Liang J, Raeder J, Gilson ML, Donovan E, Angelopoulos V, Runov A. Dipolarization fronts and associated auroral activities: 1. Conjugate observations and perspectives from global MHD simulations. ACTA ACUST UNITED AC 2012. [DOI: 10.1029/2012ja017676] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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White PF, White LM, Monk T, Jakobsson J, Raeder J, Mulroy MF, Bertini L, Torri G, Solca M, Pittoni G, Bettelli G. Perioperative care for the older outpatient undergoing ambulatory surgery. Anesth Analg 2012; 114:1190-215. [PMID: 22467899 DOI: 10.1213/ane.0b013e31824f19b8] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.
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Affiliation(s)
- Paul F White
- Department of Anesthesia, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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Beaussier M, White PF, Raeder J. Is a negative meta-analyses consisting of heterogenic studies on wound catheters sufficient to conclude that no additional studies are needed? Acta Anaesthesiol Scand 2012; 56:396-7; author reply 397-8. [PMID: 22192268 DOI: 10.1111/j.1399-6576.2011.02604.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2011] [Indexed: 01/06/2023]
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Raeder J, Spreng UJ. Local-infiltration anaesthesia (LIA): post-operative pain management revisited and appraised by the surgeons? Acta Anaesthesiol Scand 2011; 55:772-4. [PMID: 21749333 DOI: 10.1111/j.1399-6576.2011.02441.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lenz H, Raeder J, Draegni T, Heyerdahl F, Schmelz M, Stubhaug A. Effects of COX inhibition on experimental pain and hyperalgesia during and after remifentanil infusion in humans. Pain 2011; 152:1289-1297. [DOI: 10.1016/j.pain.2011.02.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 12/15/2010] [Accepted: 02/01/2011] [Indexed: 11/16/2022]
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Spreng UJ, Dahl V, Raeder J. Effect of a single dose of pregabalin on post-operative pain and pre-operative anxiety in patients undergoing discectomy. Acta Anaesthesiol Scand 2011; 55:571-6. [PMID: 21385158 DOI: 10.1111/j.1399-6576.2011.02410.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pregabalin acts as a membrane stabilizer and has both analgesic and anxiolytic effects. We hypothesized that one pre-operative dose of pregabalin would reduce pre-operative anxiety and post-operative pain in patients undergoing discectomy. METHODS We performed a randomized, placebo-controlled study of 150 mg pregabalin administered before lumbar discectomy in general anaesthesia. The primary endpoint was pain at rest [visual analogue scale (VAS)] 120 min after surgery. The secondary outcomes were morphine consumption, pre-operative anxiety (VAS) and the occurrence of side effects. RESULTS The VAS scores for pain at rest and morphine consumption were higher in the placebo group during the 4-h stay in the post-anaesthetic care unit (PACU), but did not differ significantly 24 h after surgery. Pain scores at 7 days were similar and there was no difference in the occurrence of side effects. Pre-operative anxiety was significantly lower in the pregabalin group (2.23±1.11 vs. 4.17±2.37, 95% confidence interval: 0.82-3.05, P=0.001) and there was a significant positive correlation between the pre-operative anxiety score and post-operative pain at 120 min in the pregabalin group. CONCLUSIONS A single dose of pregabalin (150 mg) reduced post-operative pain at rest and morphine consumption during the PACU period after lumbar discectomy. Pre-operative anxiety was lower, without increased incidence of side effects.
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Affiliation(s)
- U J Spreng
- Department of Anaesthesia and Intensive Care, Baerum Hospital, Rud, Norway.
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Abstract
BACKGROUND Most surgical procedures in Norway are performed on an ambulatory basis. Many types of health professionals are involved and need training in how to handle these patients. The paper reviews important aspects of handling ambulatory surgical patients. MATERIAL AND METHODS The authors' research, clinical experience from ambulatory anaesthesiology and literature identified through a non-systematic search in Medline and EMBASE form the basis for the article. RESULTS With the advent of modern techniques, anaesthesia is no longer a limiting factor for whether surgery can be performed on an ambulatory basis or not. The decision to hospitalize a patient after elective surgery is based on limitations in the patient's general health, daily functioning and psychosocial status or the type of surgical procedure planned. When assessing whether surgery can be elective or not it is valuable to consider the entire treatment chain and ask the following questions: Can this patient who has undergone this procedure be expected to cope with transport and staying at home or in a hotel the same day as the operation, when escorted by an adult until the next day? - and is it safe? INTERPRETATION To ensure good planning and performance, it is important that the anaesthetist has access to up-to-date information on planned surgical procedures, the patient's general health, use of medication, allergies and level of daily functioning.
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Affiliation(s)
- Johan Raeder
- Anestesiavdelingen, Oslo universitetssykehus, Ullevål, 0407 Oslo og Institutt for sykehusmedisin Det medisinske fakultet Universitetet i Oslo, Norway.
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Abstract
BACKGROUND All types of anaesthesia should ensure absence of pain, inhibit autonomic responses and provide optimal conditions for surgery. Choice of anaesthetic approach (local, regional or general anaesthesia or a combination of methods) depends on type of surgery and the patients' health and preferences. MATERIAL AND METHODS The review is based on literature identified through non-systematic searches in PubMed and own research and experience. RESULTS When selecting anaesthetic approach and anaesthetic drugs one has to consider not only the perioperative period, but also postoperative aspects such as pain relief, awakeness, functional ability and absence of nausea. After major surgery, regional anaesthesia (especially epidural anaesthesia) and postoperative analgesia have been shown to reduce pulmonary complications and chronic pain. General anaesthesia can be administered either by volatile agents for inhalation, intravenous hypnotics, potent opioids or a combination (often used). Volatile agents, shown to be cardioprotective during cardiac surgery, are recommended for major non-cardiac surgery in patients with heart disease (even though clinical documentation is limited). INTERPRETATION An appropriate anaesthetic approach, taking into account patient characteristics and type of surgery, is important for safety and potential complications. In some situations, the anaesthetic approach and anaesthetic drugs may have an impact on outcome.
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Utvoll J, Beausang-Linder M, Mesic H, Raeder J. Brief report: improved pain relief using intermittent bupivacaine injections at the donor site after breast reconstruction with deep inferior epigastric perforator flap. Anesth Analg 2010; 110:1191-4. [PMID: 20142346 DOI: 10.1213/ane.0b013e3181cf05f5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Deep inferior epigastric perforator flap surgery usually results in postoperative pain from the donor site requiring opioids. METHOD We examined the effect of bupivacaine 2.5 mg/mL, 20 mL given every third hour for 72 hours postoperatively through 2 thin catheters placed on the donor site in a double-blind placebo-controlled study consisting of 2 x 20 patients. RESULTS The bupivacaine group had significantly reduced pain at rest and during coughing. The placebo group needed 2 to 3 times more opioids in the 72-hour observation period. No difference was seen in the frequency of nausea or the consumption of antiemetic drugs. CONCLUSION We conclude that intermittent delivery of bupivacaine at the abdominal donor site significantly reduces the postoperative pain and need for narcotic rescue medication.
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Affiliation(s)
- Jørgen Utvoll
- Department of Plastic and Maxillofacial Surgery, Ullevaal University Hospital, Oslo, Kirkeveien 166, 0407 Oslo, Norway.
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Lenz H, Sandvik L, Qvigstad E, Bjerkelund CE, Raeder J. A Comparison of Intravenous Oxycodone and Intravenous Morphine in Patient-Controlled Postoperative Analgesia After Laparoscopic Hysterectomy. Anesth Analg 2009; 109:1279-83. [DOI: 10.1213/ane.0b013e3181b0f0bb] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Gravningsbråten R, Nicklasson B, Raeder J. Reply. Acta Anaesthesiol Scand 2009. [DOI: 10.1111/j.1399-6576.2009.01936.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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