Jan G. Jakobsson

Contribution from upper and lower airways to exhaled endogenous nitric oxide in humans

Endogenous nitric oxide (NO) is thought to regulate many biological functions, including pulmonary circulation and bronchomotion, and it has been found in exhaled air. Our aim was to study the excretion of NO in different parts of the respiratory system.

Preoperative hypnosis reduces postoperative vomiting after surgery of the breasts

Background: Postoperative nausea and vomiting (PONV) after general anesthesia and surgery may have an incidence as high as 70% irrespective of antiemetic drug therapy. The use of preoperative hypnosis and mental preparation by means of an audio tape was investigated in the prophylaxis of nausea and vomiting before elective breast reduction surgery. Similar interventions have not been found in the literature.

Clinical practice and routines for day surgery in Sweden: results from a nation-wide survey

Background: Day surgery has expanded considerably during the last decades. Routines and standards have developed but differ between and within countries.

Perioperative care for the older outpatient undergoing ambulatory surgery.

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.

Children in day surgery: clinical practice and routines. The results from a nation-wide survey.

Background: Day surgery is common in paediatric surgical practice. Safe routines including parental and child information in order to optimise care and reduce anxiety are important. Most day surgery units are not specialised in paediatric care, which is why specific paediatric expertise is often lacking.

Postoperative nausea and vomiting. A comparison between intravenous and inhalation anaesthesia in breast surgery

Nausea and vomiting during the first 24 postoperative hours after breast surgery were studied. Ninety patients scheduled for elective breast surgery were randomly assigned to one of three anaesthetic methods: total intravenous anaesthesia with propofol, or propofol or thiopental for induction followed by isoflurane anaesthesia. All three groups received fentanyl for peroperative analgesia. A total of 46 (51%) patients experienced emetic sequelae: 19 (21%) complained about nausea and another 27 (30%) vomited once or more during the postoperative course. More than 50% of the patients with nausea and 70% with vomiting first suffered from these symptoms in the surgical wards after leaving the postoperative unit. Nausea and vomiting were seen in 18 (60%), 13 (43%) and 15 (50%) for the groups propofol–propofol, propofol–isoflurane and thiopental–isoflurane, respectively. In conclusion, every second patient experienced nausea or vomiting after breast surgery, the majority of these emetic symptoms occurring after leaving the postoperative unit. Propofol for induction or as a main anaesthetic did not make any major difference with regard to postoperative nausea or vomiting.

A review of the scope and measurement of postoperative quality of recovery

To date, postoperative quality of recovery lacks a universally accepted definition and assessment technique. Current quality of recovery assessment tools vary in their development, breadth of assessment, validation, use of continuous vs dichotomous outcomes and focus on individual vs group recovery. They have progressed from identifying pure restitution of physiological parameters to multidimensional assessments of postoperative function and patient‐focused outcomes. This review focuses on the progression of these tools towards an as yet unreached ideal that would provide multidimensional assessment of recovery over time at the individual and group level. A literature search identified 11 unique recovery assessment tools. The Postoperative Quality of Recovery Scale assesses recovery in multiple domains, including physiological, nociceptive, emotive, activities of daily living, cognition and patient satisfaction. It addresses recovery over time and compares individual patient data with base line, thus describing resumption of capacities and is an acceptable method for identification of individual patient recovery.

Cerebral state monitor, a new small handheld EEG monitor for determining depth of anaesthesia: a clinical comparison with the bispectral index during day-surgery

Background and objective: The cerebral state index (CSI™) derived from a new small handheld electroencephalogram monitor was studied during routine day surgical anaesthesia titrated according to the bispectral index (BIS™). The objective was to determine the degree of agreement between the two monitors. Methods: Anaesthesia was induced with propofol and fentanyl (0.1 mg) in 38 patients undergoing general anaesthesia for routine day‐surgery. Maintenance anaesthesia (sevoflurane (20/38), desflurane (10/38) or propofol (8/38)) titrated by BIS XP (Aspect Medical, Natwick, MA, USA) and BIS and CSI (cerebral State Monitor, Danmeter; Odense, Denmark) index values were recorded every minute. No patient received muscle relaxation. Observers Assessment of Alertness/Sedation rating scale was used to assess level of sedation. Results: Pair‐wise recordings (914) of CSI and BIS were collected. The indices showed similar pattern and decreased with increasing level of sedation, however with large ranges for each level of sedation. Median indices were similar during surgery (BIS: 50 (14–89); CSI: 51 (7–88)) and both indices increased (P < 0.01) when minor movements occurred (BIS 65 (40–83); CSI 67 (40–89)). During maintenance of anaesthesia CSI > 20% from BIS‐index in 24% of readings, and on rare occasions CSI indices deviated >100% from the BIS reading. When BIS < 40, CSI decreased slower than BIS and with wider spreading. Conclusions: When used for day‐surgery anaesthesia without muscle relaxation, CSI and BIS show similar patterns and numerical values but with the incidence of occasionally large discrepancies between pair‐wise readings. Which monitor is the more dependable remains to be established and cannot be implied from this initial explorative study.

Desflurane: A clinical update of a third‐generation inhaled anaesthetic

Available volatile anaesthetics are safe and efficacious; however, their varying pharmacology provides small but potentially clinically important differences. Desflurane is one of the third‐generation inhaled anaesthetics. It is the halogenated inhaled anaesthetic with the lowest blood and tissue solubilities, which promotes its rapid equilibration and its rapid elimination following cessation of administration at the end of anaesthesia. The low fat solubility of desflurane provides pharmacological benefits, especially in overweight patients and in longer procedures by reducing slow compartment accumulation. A decade of clinical use has provided evidence for desfluranes safe and efficacious use as a general anaesthetic. Its benefits include rapid and predictable emergence, and early recovery. In addition, the use of desflurane promotes early and predictable extubation, and the ability to rapidly transfer patients from the operating theatre to the recovery area, which has a positive impact on patient turnover. Desflurane also increases the likelihood of patients, including obese patients, recovering their protective airway reflexes and awakening to a degree sufficient to minimise the stay in the high dependency recovery area. The potential impact of the rapid early recovery from desflurane anaesthesia on intermediate and late recovery and resumption of activities of daily living requires further study.

Core temperature measured in the auricular canal: comparison between four different tympanic thermometers

Four different tympanic thermometers, absorbing infra‐red radiation, (FirstTemp, Diatek, Ivac and Genius) were studied. Variations from repeated measurements and reliability of tympanic temperature compared to oesophageal, rectal and pulmonary artery temperature were studied. Core temperature measured by the “FirstTemp” and the “Genius” thermometers showed slightly higher values than core temperature measured by oesophageal, rectal and pulmonary artery thermistors. Compared to oesophageal temperature “FirstTemp” showed 0.56°C and “Genius” 0.28°C higher values, while the “Diatek” and the “Ivac” gave slightly lower values (‐0.5°C and ‐0.28°C). All four thermometers were found accurate for repeated measurement both in terms of standard deviation and coefficient of variance. All four tympanic thermometers showed good accuracy for changes in core temperatures compared to the reference thermistors (r2 values 0.96 for “FirstTemp”, 0.88 for “Diatek”, 0.96 for “IVAC” and 0.95 for “Genius”). The tympanic thermometer was found to be a valuable alternative for measuring core temperature in most clinical settings.