Anaesthesia practice, quality indices including all-cause 30-day mortality associate to wrist fracture repositioning and surgery in Sweden: A perioperative register-based study 2018-2021.

BACKGROUND: Wrist fracture is one of most common fractures frequently requiring surgical anaesthesia. There is limited information related to the anaesthetic practice and quality including 30-day mortality associated with wrist fracture in Sweden in recent years. AIM: The aim of the present register-based study was to investigate the anaesthesia techniques used and quality indices including 30-day mortality associated with wrist fracture surgery in Sweden during the period 2018-2021. MATERIALS AND METHODS: All fracture repositions, and surgical interventions related to wrist fracture requiring anaesthesia in patients aged >18 years registered in the Swedish Perioperative Register (SPOR) between 2018 and 2021 were included in the analysis. Information on age, ASA class, anaesthesia technique, severe operative events, most reported side-effects during recovery room stay and all-cause 30-day mortality was collected. RESULTS: The data set included 25,147 procedures split into 14,796 females and 10,252 males (missing information n = 99) with a mean age of 52.9 ± 18.7 years and a significant age difference between females and males, 60.3 ± 15.4 and 42.2 ± 17.7 years, respectively. Mean age and ASA class increased during the study period (2018-2021), from 52.8 ± 18.6 to 54.0 ± 18.4 and ASA class 3-5 from 8.1% to 9.4% (p < .001 and p < .041, respectively). General anaesthesia (GA), GA combined with regional anaesthesia (RA), RA with or without sedation and sedation only was used in 41%, 13%, 40% and 6% of procedures, respectively, with minor changes over the study period. Pain at arrival in the recovery room (RR), (3.4%), severe pain during RR stay (2.1%), hypothermia (1.4%), postoperative nausea and vomiting (PONV) (1.2%) and urinary retention (0.5%) were the most reported side-effects during the RR stay. (RA) was associated with significantly lower occurrence of pain and PONV, and shorter RR stay, compared with GA (p < .001). The all-cause 30-day mortality was low (19 of 25,147 (0.08%)) with no differences over the period studied or anaesthetic technique. CONCLUSION: General anaesthesia or general anaesthesia combined with regional anaesthesia are the most used anaesthetic techniques for wrist fracture procedures in Sweden. Recovery room pain, PONV, hypothermia and urinary retention is reported in overall low frequencies, with no change over the period studied, but in lower frequencies for regional anaesthesia. All-cause 30-day mortality was low; 0.08% with no change over time or between anaesthetic techniques. Thus, the present quality review based on SPOR data supports high quality of perioperative anaesthesia care.

Quantitative assessment of atelectasis formation under high frequency jet ventilation during liver tumour ablation-A computer tomography study.

BACKGROUND: High frequency jet ventilation (HFJV) can be used to minimise sub-diaphragmal organ displacements. Treated patients are in a supine position, under general anaesthesia and fully muscle relaxed. These are factors that are known to contribute to the formation of atelectasis. The HFJV-catheter is inserted freely inside the endotracheal tube and the system is therefore open to atmospheric pressure. AIM: The aim of this study was to assess the formation of atelectasis over time during HFJV in patients undergoing liver tumour ablation under general anaesthesia. METHOD: In this observational study twenty-five patients were studied. Repeated computed tomography (CT) scans were taken at the start of HFJV and every 15 minutes thereafter up until 45 minutes. From the CT images, four lung compartments were defined: hyperinflated, normoinflated, poorly inflated and atelectatic areas. The extension of each lung compartment was expressed as a percentage of the total lung area. RESULT: Atelectasis at 30 minutes, 7.9% (SD 3.5, p = 0.002) and at 45 minutes 8,1% (SD 5.2, p = 0.024), was significantly higher compared to baseline 5.6% (SD 2.5). The amount of normoinflated lung volumes were unchanged over the period studied. Only a few minor perioperative respiratory adverse events were noted. CONCLUSION: Atelectasis during HFJV in stereotactic liver tumour ablation increased over the first 45 minutes but tended to stabilise with no impact on normoinflated lung volume. Using HFJV during stereotactic liver ablation is safe regarding formation of atelectasis.

Ambulatory anesthesia and discharge: an update around guidelines and trends.

PURPOSE OF REVIEW: Provide an oversight of recent changes in same-day discharge (SDD) of patient following surgery/anesthesia. RECENT FINDINGS: Enhanced recovery after surgery pathways in combination with less invasive surgical techniques have dramatically changed perioperative care. Preparing and optimizing patients preoperatively, minimizing surgical trauma, using fast-acting anesthetics as well as multimodal opioid-sparing analgesia regime and liberal prophylaxis against postoperative nausea and vomiting are basic cornerstones. The scope being to maintain physiology and minimize the impact on homeostasis and subsequently hasten and improve recovery. SUMMARY: The increasing adoption of enhanced protocols, including the entire perioperative care bundle, in combination with increased use of minimally invasive surgical techniques have shortened hospital stay. More intermediate procedures are today transferred to ambulatory pathways; SDD or overnight stay only. The traditional scores for assessing discharge eligibility are however still valid. Stable vital signs, awake and oriented, able to ambulate with acceptable pain, and postoperative nausea and vomiting are always needed. Drinking and voiding must be acknowledged but mandatory. Escort and someone at home the first night following surgery are strongly recommended. Explicit information around postoperative care and how to contact healthcare in case of need, as well as a follow-up call day after surgery, are likewise of importance. Mobile apps and remote monitoring are techniques increasingly used to improve postoperative follow-up.

Supraclavicular block with Mepivacaine vs Ropivacaine, their impact on postoperative pain: a prospective randomised study.

BACKGROUND: Supraclavicular block (SCB) with long-acting local anaesthetic is commonly used for surgical repair of distal radial fractures (DRF). Studies have shown a risk for rebound pain when the block fades. This randomised single-centre study aimed to compare pain and opioid consumption the first three days post-surgery between SCB-mepivacaine vs. SCB-ropivacaine, with general anaesthesia (GA) as control. METHODS: Patients (n = 90) with ASA physical status 1-3 were prospectively randomised to receive; SCB with mepivacine 1%, 25-30 ml (n = 30), SCB with ropivacaine 0.5%, 25-30 ml (n = 30) or GA (n = 30) with propofol/fentanyl/sevoflurane. Study objectives compared postoperative pain with Numeric Rating Scale (NRS) and sum postoperative Opioid Equivalent Consumption (OEC) during the first 3 days post-surgery between study-groups. RESULTS: The three groups showed significant differences in postoperative pain-profile. Mean NRS at 24 h was significantly lower for the SCB-mepivacaine group (p = 0.018). Further both median NRS and median OEC day 0 to 3 were significanly lower in the SCB-mepivacaine group as compared to the SCB-ropivacaine group during the first three days after surgery; pain NRS 1 (IQR 0.3-3.3) and 2.7 (IQR 1.3-4.2) (p = 0.017) and OEC 30 mg (IQR 10-80) and 85 mg (IQR 45-125) (p = 0.004), respectively. The GA-group was in between both in pain NRS and median sum OEC. Unplanned healthcare contacts were highest among SCB-ropivacaine patients (39.3%) vs. SCB-mepivacaine patients (0%) and GA-patients (3.4%). CONCLUSIONS: The potential benefit of longer duration of analgesia, associated to a long-acting local anaesthetic agent, during the early postoperative course must be put in perspective of potential worse pain progression following block resolution. TRIAL REGISTRATION: NCT03749174 (clinicaltrials.gov, Nov 21, 2018, retrospectively registered).

Emergencies in freestanding ambulatory surgery centre.

PURPOSE OF REVIEW: Ambulatory surgery is increasing, more procedures as well as more complex procedures are transferred to ambulatory surgery. Patients of all ages including elderly and more fragile are nowadays scheduled for ambulatory surgery. Enhanced recovery after surgery (ERAS) protocols are now developed for further facilitating readily recovery, ambulation, and discharge. Thus, to secure safety, a vigilant planning and preparedness for adverse events and emergencies is mandatory. RECENT FINDINGS: Proper preoperative assessment, preparation/optimization and collaboration between anaesthetist and surgeon to plan for the optimal perioperative handling has become basic to facilitate well tolerated perioperative course. Standard operating procedures for rare emergencies must be in place. These SOPs should be trained and retrained on a regular basis to secure safety. Check lists and cognitive aids are tools to help improving safety. Audit and analysis of adverse outcomes and deviations is likewise of importance to continuously analyse and implement corrective activity plans whenever needed. SUMMARY: The present review will provide an oversight of aspects that needs to be acknowledged around planning handling of rare but serious emergencies to secure quality and safety of care in freestanding ambulatory settings.

Post-operative hypertension during early recovery following liver tumour ablation: A retrospective study.

BACKGROUND: High-frequency jet ventilation is necessary to reduce organ movements during stereotactic liver ablation. However, post-operative hypertensive episodes especially following irreversible electroporation ablation compared with microwave ablation initiated this study. The hypothesis was that hypertensive episodes could be related to ventilation or ablation method. METHODS: The aim of this retrospective study was to assess the proportion of patients with hypertensive events during recovery following liver ablation under general anaesthesia and to analyse the relation to ventilation and ablation technique. A medical chart review of 134 patients undergoing either high-frequency jet ventilation and microwave ablation (n = 45), high-frequency jet ventilation and irreversible electroporation (n = 44), or conventional ventilation and microwave ablation (n = 45) was performed. The proportion of patients with at least one episode of systolic arterial pressure 140-160, 160-180 or >180 mmHg during early recovery and the impact of ventilation method was studied. RESULTS: Out of 134 patients, 100, 75 and 34 patients had at least one episode of mild, moderate and severe hypertension. Microwave ablation, as well as high frequency jet ventilation, was associated with an increased odds ratio for post-operative hypertension. The proportion of patients with at least one severe hypertensive event was 18/45, 9/44 and 7/45, respectively. CONCLUSION: Both ventilation and ablation technique had an impact on post-operative hypertensive episodes. The microwave ablation/high-frequency jet ventilation combination increased the risk as compared with irreversible electroporation/high-frequency jet ventilation and microwave ablation/conventional ventilation.

Workplace exposure to carbon dioxide during routine laparoscopy - is it safe?

Background: Minimally invasive surgeries have increased dramatically during the last decades. Carbon dioxide (CO 2) is the gas used for insufflation during laparoscopies, creating space and visibility. The CO 2 leaks into ambient air through ports where instruments are inserted. If the CO 2 reaches a certain concentration it affects personnel health. There are national occupational exposure limits (OEL) for CO 2, including a level limit value (LLV) of 5000 ppm. We are not aware of any previous studies addressing occupational exposure to CO 2 during laparoscopies. The aim of this study was to assess the compliance to national OELs for CO 2 during laparoscopies. Methods: A gas detector was placed in the breathing zone of personnel in the operating theatre. The detector measured CO 2 concentrations every tenth minute during laparoscopies in three locations. Results: During 27 laparoscopies, the measured CO 2 reached a maximum concentration of 1100 ppm, less than one fourth of the LLV. Median CO 2 concentration was 700 ppm. Conclusion: Results show that the occupational exposure to CO 2 during laparoscopies is well below set OELs. Our findings support personnel safety associated with routine use of CO 2 during laparoscopies.

High Frequency Jet Ventilation during stereotactic ablation of liver tumours: an observational study on blood gas analysis as a measure of lung function during general anaesthesia.

Background: Stereotactic ablation of tumours in solid organs is a promising curative procedure in clinical oncology. The technique demands minimal target organ movements to optimise tumour destruction and prevent injury to surrounding tissues. High frequency jet ventilation (HFJV) is a novel option during these procedures, reducing the respiratory-associated movements of the liver. The effects of HFJV via endotracheal catheter on gas exchange during liver tumour ablation is not well studied. Methods: The aim of this explorative study was to assess lung function and the effects on blood gas and lactate during HFJV in patients undergoing stereotactic liver ablation. Blood gases were analysed in 25 patients scheduled for stereotactic liver ablation under general anaesthesia pre-induction, every 15 minutes during HFJV and following extubation in the recovery room. The HFJV was set at fixed settings. Results: None of the patients developed hypoxia or signs of increased lactate production but a great variation in PaO 2/FiO 2 ratio was found; from 13.1 to 71.3. An increase in mean PaCO 2 was observed, from a baseline of 5.0 to a peak of 7.1 at 30 minutes (p <0.001) and a decrease was found in median pH, from a baseline of 7.44 to 7.31 at 15 minutes (p=0.03). We could not see any clear association between a decrease in PaO 2/FiO 2 ratio and PaCO 2 elevation. Conclusions: HFJV during general anaesthesia in patients undergoing stereotactic liver ablation is feasible and it did not cause hypoxemia or signs of increased lactate production. A reversible mild to moderate impairment of gas exchange was found during HFJV.

Recovery and discharge criteria after ambulatory anesthesia: can we improve them?

PURPOSE OF REVIEW: Day surgery coming and leaving hospital day of surgery is growing. From minor and intermediate procedure performed on health patient, day surgery is today performed on complex procedures and elderly patient and on patients with comorbidities. Thus, appropriate discharge assessment is of huge importance to secure safety and quality of care. RECENT FINDINGS: Discharge has since decades been assessed on a combination of stable vital signs, control of pain and postoperative nausea and vomiting and securing that patients can stand walk unaided. There is controversy around whether patients must drink and void before discharge. The absolute need for escort when leaving hospital and someone at home first night after surgery is argued but it does support safety. Discharge is not being 'street fit,' it merely allows patients to go back home for further recovery in the home environment. A structured discharge timeout checklist securing that patients are informed of further plans, signs, and symptoms to watch out for and what to do in case recovery don't follow plans facilitate safety. SUMMARY: Discharge following day surgery must be based on appropriate assessment of stable vital signs and reasonable resumption of activity of daily living performance. Rapid discharge must not jeopardize safety. Classic discharge criteria are still basis for safe discharge, adding a structured discharge checklist facilitates safe discharge.

Can simple perioperative measures improve quality of recovery following ambulatory laparoscopic surgery in females? An open prospective randomised cohort study, comparing nutritional preoperative drink and chewing gum during recovery to standard care.

One major goal in modern perioperative anaesthesia care is to facilitate a rapid, yet safe recovery process, with focus on improving time to regained consciousness and subsequent resuming of activities of daily living. Laparoscopic cholecystectomy and gynaecological laparoscopy are a "high volume" procedure commonly performed in young females expecting rapid resumption of health.The aim of this study was to assess whether it was possible to improve patients' self-assessed quality of recovery in female patient undergoing laparoscopic cholecystectomy by simple perioperative measures in the form of a preoperative 200 ml nutritional drink and chewing gum during early recovery. METHODS: Patients were randomised to an active group receiving the intervention, and controls provided with standard care only. Patients were followed by questionnaire interviews preoperatively and at 2, 24 and 48 h after surgery. The Quality of Recovery scale (QoR) 15 items and 5 additional questions around gastro-intestinal symptoms were self-assessed by patients at each occasion. RESULT: Seventy-three ASA 1-2 female patients' undergoing elective laparoscopic surgery were included, surgery and anaesthesia was uneventful. The QoR score was significantly higher both at 24 and 48 h, 113 SD 20 vs 101 SD 25 (p = 0.026) and 123 SD 13 vs 111 SD 13 (p = 0.006) in the active group of patients as compared to controls. CONCLUSION: Simply providing 200 ml nutritional preoperative drink and chewing gum during recovery was found effective, improving patients assessed quality of recovery.

In-hospital cardiac arrest resuscitation performed by the hospital emergency team: A 6-year retrospective register analysis at Danderyd University Hospital, Sweden.

Background: Cardiac arrest requires rapid and effective handling. Huge efforts have been implemented to improve resuscitation of sudden cardiac arrest patients. Guidelines around the various parts of effective management, the chain of survival, are available. The aim of the present retrospective study was to study sudden in-hospital cardiac arrest (IHCA) and the outcomes of emergence team resuscitation in a university hospital in Sweden. Methods: The Swedish Cardiopulmonary Resuscitation Registry was used to access all reported cases of IHCA at Danderyd Hospital from 2012 through 2017. Return of spontaneous circulation (ROSC), discharge alive, 30-day mortality and Cerebral Performance Scales score (CPC) were analysed. Results: 574 patients with cardiac arrests were included in the study: 307 patients (54%) had ROSC; 195 patients (34%) were alive to be discharged from hospital; and 191 patients (33%) were still alive at day-30 after cardiac arrest. Witnessed cardiac arrests, VT/VF as initial rhythm and experiencing cardiac arrest in high monitored wards were factors associated with success. However, 53% of patients' alive at day-30 had a none-shockable rhythm, 16% showed initially a pulseless electrical activity and 37% asystole. CPC score was available for 188 out of the 195 patients that were alive to be discharged: 96.5% of patients where data was available had a favourable neurological outcome, a CPC-score of 1 or 2 at discharge, and only 6 of these patients had a CPC-score of 3 or higher (3%). Conclusions: One third of patients with sudden IHCA were discharged from hospital and alive at day-30, a clear majority without cognitive deficit related to the cardiac arrest. High monitored care, witnessed cardiac arrest and shockable rhythm were factors associated with high success; however, more than half of surviving patients had initially a none-shockable rhythm.

Acute hip fracture surgery anaesthetic technique and 30-day mortality in Sweden 2016 and 2017: A retrospective register study.

Background: Hip fractures yearly affect 1.6 million patients worldwide, often the elderly with complex comorbidity. Mortality following surgery for acute hip fracture is high. The high mortality rate is multifactorial; high age, comorbidities and complication/deterioration in health following surgery. Whether the anaesthesia technique affects the 30-day mortality rate has been studied widely without reaching a consensus. The primary aim of this study was to determine anaesthetic techniques used in Sweden and their impact on the 30-day mortality rate in the elderly, who underwent acute hip fracture surgery. Other aims were to study the impact of age, gender, ASA class, fracture type and delay in surgery on the 30-day mortality rate. Methods: Data from 13,649 patients ≥50 years old who had undergone acute hip fracture surgery and been reported to Swedish perioperative register (SPOR) between 2016 and 2017 were analysed.     Results: The most commonly used anaesthetic technique was neuraxial anaesthesia (NA; 11257, 82%), followed by general anaesthesia (GA; 2190, 16%) and combined general and neuraxial anaesthesia (CA; 202, 1.5%) out of the 13,649 studied. The 30-day mortality rate was 7.7% for the entire cohort; GA 7.8%, NA 7.7% and CA 7.4%. Mortality was higher in elderly patients, those with a high ASA class, pertrochanteric fracture and males.     Conclusions: The present study showed that NA is by far the most common anaesthetic technique for acute hip fracture surgery in Sweden. However, the anaesthetic technique used during this type of surgery had no impact on the 30-day mortality rate of patients. Increasing age, ASA class and male gender increased the 30-day mortality.

Postoperative delirium and postoperative cognitive dysfunction: updates in pathophysiology, potential translational approaches to clinical practice and further research perspectives.

Postoperative delirium, the onset of confusion/delirium during the early postoperative phase, is the most common postoperative complication in older adults and represents a medical emergency that requires immediate assessment and treatment. On the other hand, the term postoperative cognitive decline or dysfunction refers to a wide spectrum of clinical conditions featuring a decline in a variety of neuropsychological domains including memory, executive functioning, and speed of processing emerging week to months after anesthesia and surgery. Postoperative delirium and postoperative cognitive decline represent two distinct clinical entities along the continuum of cognitive impairment after anesthesia and surgery. All patients experiencing delirium does however not develop postoperative dysfunction and likewise all patients showing various degree of postoperative decline have not explicitly exhibited postoperative delirium. Although neuroinflammation seems to be main cause, the exact pathophysiology of both phenomena is very difficult to ascertain because it involves the crossroads of many mechanisms. This paper aimed to provide an update in the pathophysiology of these conditions with special attention to the roles of the neuroinflammation, the microglia activation, the surgical stress response, the impairment of neurotransmitter systems, and the direct neurotoxic effect of general anesthetic drugs. Potential translational approaches to clinical practice and further research perspectives are also given.

Continuous surgical multi-level extrapleural block for video-assisted thoracoscopic surgery: a retrospective study assessing its efficacy as pain relief following lobectomy and wedge resection.

Background: Video-assisted thoracoscopic surgery (VATS) causes less postoperative pain than thoracotomy; however, adequate analgesia remains vital. As part of a multi-modal postoperative analgesia, a continuous surgeon-placed extrapleural block catheter is an option. The aim of this retrospective study was to evaluate the analgesic efficacy of a continuous extrapleural block as part of a multimodal analgesic regimen after VATS in general, and VATS lobectomy and wedge resection in particular. Methods: Case records for patients having undergone VATS surgery and been provided a multi-level continuous extrapleural block with an elastomeric pump infusing levobupivacaine 2.7 mg/ml at a rate of 5 ml/h during 2015 and 2016 were reviewed. Pain (Numeric Rating Scale) at rest and mobilisation as well as opioid requirement (daily, postoperative days 0-3, as well as accumulated) were analysed.    Results: In all, 454 records were reviewed: 150 wedge resections, 264 lobectomies and 40 miscellaneous cases. At rest, pain was mild median NRS rated 3-3-1-1 for postoperative day (POD) 0 to 3, during movement, pain was rated moderate during POD 0 and 1 and mild the remaining days (median NRS 4-4-3-3 for POD 0-3). The proportion of patients exhibiting mild pain at rest increased from 55% on POD 0 to 81 % on POD 3. The percentage of patients experiencing severe pain at rest decreased from 15% to 6%. Median oxycodone consumption was 10 mg per day for POD 1-3. Pain after VATS wedge resection was significantly lower at POD 1 and 3 compared to pain after VATS lobectomy. Conclusion: We found a continuous surgeon-placed extrapleural catheter block to be a valuable and seemingly safe addition to our multimodal procedure specific analgesia after VATS. Whether the efficacy of the block can be improved by increasing local anaesthetic and/or adding adjuncts warrants further investigation.

The decision to delivery interval in emergency caesarean sections: Impact of anaesthetic technique and work shift.

Background: One important task of the emergency anaesthesia service is to provide rapid, safe and effective anaesthesia for emergency caesarean sections (ECS). A Decision to Delivery Interval (DDI) <30 minutes for ECS is a quality indicator for this service. The aim of this study was to assess the DDI and the impact of chosen anaesthetic technique (general anaesthesia (GA), spinal anaesthesia (SPA) with opioid supplementation, or "top-up" of labour epidural analgesia (tEDA) with local anaesthesia and fentanyl mixture) and work shift for ECS at Danderyds Hospital, Sweden. Methods: A retrospective chart review of ECS at Danderyds Hospital was performed between January and October 2016. Time between decision for CS, start of anaesthesia, time for incision and delivery, type of anaesthetic technique, and time of day, working hours or on call and day of week, Monday - Friday, and weekend was compiled and analysed. Time events are presented as mean ± standard deviation. Non-parametric tests were used. Results: In total, 135 ECS were analysed: 92% of the cases were delivered within 30 minutes and mean DDI for all cases was 17.3±8.1 minutes. GA shortened the DDI by 10 and 13 minutes compared to SPA and tEDA (p<0.0005). DDI for SPA and tEDA did not differ. There was no difference in DDI regarding time of day or weekday. Apgar <7 at 5' was more commonly seen in ECS having GA (11 out of 64) compared to SPA (2/30) and tEDA (1/41) (p<0.05). Conclusion: GA shortens the DDI for ECS, but the use of SPA as well as tEDA with opioid supplementation maintains a short DDI and should be considered when time allows. Top-up epidural did not prolong the DDI compared to SPA. The day of week or time of ECS had no influence on the anaesthesia service as measured by the DDI.

The use of high-frequency ventilation during general anaesthesia: an update.

Various forms of high-frequency ventilation (HFV) have been described. HFV is broadly defined as artificial ventilation of the lungs with sub-deadspace tidal volumes delivered using supra-physiological frequencies. HFV has been used in anaesthesia and intensive care for special procedures and conditions since the 1960s. Clinical interest in the use and the technical evolution of HFV has developed over time. There is a renewed interest in HFV for avoiding parenchymal movement during stereotactic tumour ablation. The present paper aims to give an overview of the fundamental physiology, technical aspects, and clinical challenges of HFV in ablation procedures during general anaesthesia, where HFV is used to minimise the movements of the ablation target.

Wash-in and wash-out of sevoflurane in a test-lung model: A comparison between Aisys and FLOW-i.

Background: Modern anaesthesia workstations are reassuringly tight and are equipped with effective gas monitoring, thus providing good opportunities for low/minimal flow anaesthesia. A prerequisite for effective low flow anaesthesia is the possibility to rapidly increase and decrease gas concentrations in the circle system, thereby controlling the depth of anaesthesia.  Methods: We studied the wash-in and wash-out of sevoflurane in the circle system with fixed fresh gas flow and vaporizer setting. We compared two modern anaesthesia work stations, the Aisys (GE, Madison, WI, USA) and FLOW-i (Maquet, Solna, Sweden) in a test lung model.  Results: We found fresh-gas flow to have, as expected, a major influence on wash-in, as well as wash-out of sevoflurane. The wash-in time to reach a stable circle 1 MAC (2.1%) decreased from an average of 547 ± 83 seconds with a constant fresh gas flow of 300 ml/min and vaporizer setting of 8%, to a mean of 38 ± 6 seconds at a fresh gas flow of 4 L/min. There were only minor differences between the two works-stations tested; the Aisys was slightly faster at both 300 and 4 L/min flow. Time to further increase circle end-tidal concentration from 1-1.5 MAC showed likewise significant associations to fresh gas and decreased from 330 ± 24 seconds at 300 ml/L to less than a minute at constant 4 L/min (17 ± 11 seconds), without anaesthetic machine difference. Wash-out was also fresh gas flow dependent and plateaued at 7.5 L/min.  Conclusions: Circle system wash-in and wash-out show clear fresh gas dependency and varies somewhat between the Aisys and Flow-i. The circle saturation, reaching 1 MAC end-tidal or increasing from 1-1.5 MAC can be achieved with both work-stations within 1.5 minutes at a constant fresh gas flow of 2 and 4 L/min. Wash-out plateaued at 7.5 L/min.

Neuraxial opioids as analgesia in labour, caesarean section and hysterectomy: A questionnaire survey in Sweden.

Background: Neuraxial opioids improve labour analgesia and analgesia after caesarean section (CS) and hysterectomy. Undesirable side effects and difficulties in arranging postoperative monitoring might influence the use of these opioids. The aim of the present survey was to assess the use of intrathecal and epidural morphine in gynaecology and obstetrics in Sweden. Methods: A questionnaire was sent to 47 anaesthesiologists at obstetric units in Sweden concerning the use and postoperative monitoring of morphine, sufentanil and fentanyl in spinal/epidural anaesthesia. Results: A total of 32 units responded representing 83% of annual CS in Sweden. In CS spinal anaesthesia, 20/32 units use intrathecal morphine, the most common dose of which was 100 µg (17/21). Intrathecal fentanyl (10-20 µg) was used by 21 units and sufentanil (2.5 -10 µg) by 9/32 of the responding units. In CS epidural anaesthesia, epidural fentanyl (50-100 µg) or sufentanil (5-25 µg) were commonly used (25/32), and 12/32 clinics used epidural morphine, the majority of units used a 2 mg dose. Intrathecal morphine for hysterectomy was used by 20/30 units, with 200 µg as the most common dose (9/32). Postoperative monitoring was organized in adherence to the National Guidelines; the patient is in postoperative care or an obstetrical ward over 2-6 hours and up-to 12 hours in an ordinary surgical ward. Risk of respiratory depression/difficult to monitor was a reason for not using intrathecal opioids. Conclusions: Neuraxial morphine is used widely in Sweden in CS and hysterectomy, but is still restricted in some units because of the concern for respiratory depression and difficulties in monitoring.

Pulmonary emboli cardiac arrest with CPR complication: Liver laceration and massive abdominal bleed, a case report.

INTRODUCTION: Massive pulmonary emboli may cause right ventricular failure and backward stasis with parenchymal organ swelling thus increasing the risk for laceration, e.g. if CPR is needed. PRESENTATION OF CASE: A 28-year-old Colombian female with no medical history but taking contraceptive pills and having had a recent longer flight was admitted to Danderyds hospital Emergency Department because of respiratory failure. She developed cardiac arrest in the emergence department following the emergent diagnosis of pulmonary emboli. Cardio-pulmonary resuscitation was initiated, initially with manual and subsequent mechanical compressions with a so called LUCAS device. Patients did not respond properly to the CPR and showed signs of hypovolemia. Emergent ultrasound raised suspicion of abdominal bleed. Emergent laparotomy confirmed liver laceration and massive haemorrhage. CONCLUSION: Pulmonary emboli with subsequent right ventricular failure may cause backwards stasis, and parenchymal organ e.g. liver enlargement. The risk for laceration injuries and internal bleed must be acknowledged when applying external forces as in case of cardiac arrest and need for resuscitation. Frequent and vigilant control of positioning of manual as well as mechanical compressions is of importance.

Portable respiratory polygraphy monitoring of obese mothers the first night after caesarean section with bupivacaine/morphine/fentanyl spinal anaesthesia.

Background: Obesity, abdominal surgery, and intrathecal opioids are all factors associated with a risk for respiratory compromise. The aim of this observational study was to explore the use of portable respiratory polygraphy for monitoring of obese mothers for respiratory depression the first night after caesarean section (CS) with bupivacaine/morphine/fentanyl spinal anaesthesia. Methods: Consecutive obese (BMI >30 kg/m 2) mothers, ≥18 years, scheduled for CS with bupivacaine/morphine/fentanyl spinal anaesthesia were monitored with a portable polygraphy device Embletta /NOX on the first postoperative night. The apnoea-hypopnea index (AHI) was identified by clinical algorithm and assessed in accordance to general guidelines. Results: Forty mothers were invited to participate: 27 consented, 23 were included, but polysomnography registration failed in 3. Among the 20 mothers: 11 had an AHI <5; 7, AHI 5-15; and 2, AHI >15. The oxygen desaturation index (ODI) was on average 4.4, and eight patients had an ODI >5. Those mothers with a high AHI (15.3 and 18.2) did not show high ODI or signs of hypercapnia on transcutaneous CO 2 registration. Mean saturation was 94% (91-96), and four mothers had mean saturation between 90-94%, but none had a mean SpO 2 <90%. Mean nadir saturation was 71% (range, 49-81%).  None of the mothers showed clinical signs or symptoms of severe respiratory depression, shown by routine clinical monitoring. Conclusion: We found portable polygraphy registration during early post-CS in moderately obese mothers having had intrathecal morphine/fentanyl cumbersome and although episodes of oxygen saturation decrease were noticed, obstructive events and episodes of desaturation were commonly not synchronised. Upper airway obstructions seem not be of major importance in this clinical setting. Monitoring of respiratory rate, SpO 2 and possibly transcutaneous CO 2 in mothers at high risk of respiratory distress warrants further studies. Preoperative screening in obese patients, at risk for sleep breathing disorder, is of course of value.