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.

Circulatory collapse following epidural bolus for Caesarean section a profound vasovagal reaction? A case report.

INTRODUCTION: Reduced blood pressure is commonly seen associated to spinal anaesthesia for Caesarean section and efforts to reduce its occurrence and its magnitude is common practice. Cardiovascular collapse requiring cardio-pulmonary resuscitation after putting the spinal/epidural block for Caesarean section is however a rare but most dramatic event. PRESENTATION OF CASE: We describe a case with sudden short loss of circulation, circulatory collapse, short after start of emergency Caesarean section in top up epidural anaesthesia (3+12ml ropivaciane 7.5mg/ml), requiring CPR. The neonate was delivered during CPR with Apgar 1, 10, 10 at 1, 5 and 10min. Circulation was restored following 60-90s of CPR and administration of 0.5mg adrenaline. No cardioversion was administered sinus rhythm was regained spontaneously. The mother and child had a further uncomplicated course. No signs of cardiac damage/anomaly, emboli, septicaemia, pereclampisa or local anaesthetic toxicity was found. The patient had prior to the decision about Caesarean section had fever and was subsequently relatively dehydrated. DISCUSSION: The patient had a fast return of sinus rhythm following birth of the child, without cardioversion. None of common causes for cardiac arrest was found and the patient an uncomplicated post Caesarean section course. The combination of epidural induced sympathetic block and reduced preload possibly triggered a Bezold-Jarisch reflex with a profound vasovagal reaction. CONCLUIOSN: A structured plan for the handling of cardiovascular crisis must be available wherever Caesarean section are performed. Adequate volume loading, left tilt and vigilant control of circulation following regional block performance is of outmost importance.

[National respiration center support patients with tracheostomy tubes. Outpatient clinic for respiratory support in the home]. / Nationellt respirationscentrum stöttar patienter med trakealkanyl - Öppenvårdsmottagning för andningsstöd i hemmet.

It is now 60 years since the polio epidemic in Copenhagen and the first use of prolonged invasive positive pressure ventilation. After this pioneer work positive pressure ventilation rapidly became well established. Intubation/tracheostomy and mechanical ventilation are now standard in Intensive Care Units. In the late 1970 Gillis Andersson was the first in Sweden to discharge patients home with invasive mechanical ventilator support. His pioneer work included the development of a dedicated practical and technical support organization at National Respiration Centre at Danderyds Hospital. This unit developed skills in patient customized tracheostomy tube construction and home invasive ventilation supportive care. Tracheostomy tubes and home ventilators have since then developed rapidly. Some patients still need customized tracheostomy tubes, which the NRC supplies. The production is certified by the Swedish Medicinal Product Agency. Today invasive home ventilation is standard care. Invasive mechanical home ventilation when instituted as a life-saving therapy in, for example, progressive ALS patients is complex and resource-intensive. New aspects such as training and education in order to secure quality of care in the home environment is one of many challenges. When commencing invasive ventilation in patients with progressive neurological disease ethical considerations must also be acknowledged, e.g. aspects such as patients' perhaps changing wishes during the course of illness regarding cessation of life support.

Post-operative nausea and vomiting: update on predicting the probability and ways to minimize its occurrence, with focus on ambulatory surgery.

Postoperative nausea and vomiting "the little big problem" after surgery/anaesthesia is still a common side-effect compromising quality of care, delaying discharge and resumption of activities of daily living. A huge number of studies have been conducted in order to identify risk factors, preventive and therapeutic strategies. The Apfel risk score and a risk based multi-modal PONV prophylaxis is advocated by evidence based guidelines as standards of care but is not always followed. Tailored anaesthesia and pain management avoiding too liberal dosing of anaesthetics and opioid analgesics is also essential in order to reduce risk. Thus multi-modal opioid sparing analgesia and a risk based PONV prophylaxis should be provided in order to minimise the occurrence. There is however still no way to guarantee an individual patient that he or she should not experience any PONV. Further studies are needed trying to identify risk factors and ways to tailor the individual patient prevention/therapy are warranted. The present paper provides a review around prediction, factors influencing the occurrence and the management of PONV with a focus on the ambulatory surgical patient.