Per Flisberg

Pain relief and safety after major surgery A prospective study of epidural and intravenous analgesia in 2696 patients.

Background:  Adverse effects may still limit the use of continuous epidural and intravenous analgesia in surgical wards. This study postulated that postoperative epidural analgesia was more efficient, and had fewer side‐effects than intravenous morphine. The aim was to investigate efficacy, adverse effects and safety of the treatments in a large patient population.

The Effects of Platelet Transfusions Evaluated Using Rotational Thromboelastometry

BACKGROUND: In this study, we assessed the immediate effects of platelet transfusion on whole blood coagulation. METHODS: Ten thrombocytopenic patients given a single unit platelet transfusion of 200–300 × 109 platelets had their coagulation status assessed before and immediately after transfusion using rotational thromboelastometry. RESULTS: Transfusion increased the median platelet count from 31.5 to 43.5 × 109/L. Clot formation time decreased by 32% (P = 0.005), whereas maximum clot strength increased by 47% (P = 0.005). CONCLUSION: Statistically significant improvements in rotational thromboelastometry-measured parameters were observed in association with a mean increase of 12 × 109/L in platelet count after platelet transfusion in these patients.

Thoracic epidural anesthesia and epidural hematoma.

This report involves a 74‐year‐old‐male who developed a thoracic epidural hematoma with paraparesis on the second postoperative day in conjunction with thoracic epidural anesthesia established before surgery for acute abdominal aortic dissection.

Morphine Metabolism After Major Liver Surgery

BACKGROUND:Impaired metabolism of morphine may lead to an increase in sedation and respiratory depression. METHODS:In the present study we investigated morphine pharmacokinetics in patients who had undergone liver resection (n = 15) compared to a control group undergoing colon resection (n = 15). Morphine was administered IV by patient-controlled analgesia. Plasma concentrations of morphine, morphine-6-glucuronide, and morphine-3-glucuronide were measured 2–3 times daily for the first two postoperative days. Pain intensity scores were assessed three times daily and respiratory rate and sedation scores every third hour. RESULTS:There were no differences in morphine requirements 1.1 (0.8–2.5 [median, interquartile range]) mg/h (liver resection) and 1.5 (1.1–1.7) mg/h (colon resection) [P = 0.84]) or in pain intensity scores (P > 0.3) between the groups. Plasma morphine concentrations were higher in patients undergoing liver resection than in the control group (P < 0.01) reflecting a lower rate of morphine metabolism. Plasma morphine concentrations were correlated with the volume of liver resection (P < 0.02). However, plasma concentrations of morphine-6-glucuronide and morphine-3-glucuronide did not differ between the groups (P = 0.62 and P = 0.48, respectively). There was a higher incidence of sedation (P = 0.02), but not respiratory depression (P = 0.48), after liver resection. CONCLUSION:The study demonstrates that plasma concentrations of morphine are higher in patients undergoing liver resection compared with patients undergoing colon resection. Sedation scores were higher in patients undergoing liver resection. Caution is therefore recommended when administering morphine to this patient group.

Physiological restitution after night‐call duty in anaesthesiologists: impact on metabolic factors

Background:  Several studies have shown impaired mental well‐being and performance in physicians work on call, but knowledge of the physiological effects is scarce. The aims of the present study were to investigate if there was a metabolic stress response in the restitutional phase after night‐call duty, indicating potential negative health effects, and determine whether there were differences between physician specialities.

Epidural lipomatosis and congenital small spinal canal in spinal anaesthesia: a case report and review of the literature

IntroductionComplications after lumbar anaesthesia and epidural blood patch have been described in patients with congenital small spinal canal and increased epidural fat or epidural lipomatosis. These conditions, whether occurring separately or in combination, require magnetic resonance imaging for diagnosis and grading, but their clinical significance is still unclear.Case presentationA 35-year-old Caucasian woman who was undergoing a Caesarean section developed a longstanding L4-L5 unilateral neuropathy after the administration of spinal anaesthesia. There were several attempts to correctly position the needle, one of which resulted in paraesthesia. A magnetic resonance image revealed that the patients bony spinal canal was congenitally small and had excess epidural fat. The cross-sectional area of the dural sac was then reduced, which left practically no free cerebrospinal fluid space.ConclusionThe combination of epidural lipomatosis of varying degrees and congenital small spinal canal has not been previously discussed with spinal anaesthesia. Due to the low cerebrospinal fluid content of the small dural sac, the cauda equina becomes a firm system with a very limited possibility for the nerve roots to move away from the puncture needle when it is inserted into the dural sac. This constitutes risks of technical difficulties and neuropathies with spinal anaesthesia.

Apnea and bradypnea in patients receiving epidural bupivacaine-morphine for postoperative pain relief as assessed by a new monitoring method.

STUDY OBJECTIVE To evaluate postoperative breathing patterns with a new monitoring device in patients given bupivacaine-morphine epidural analgesia. DESIGN Open explorative study. SETTING Inpatient anesthesia in a university hospital setting. PATIENTS 15 ASA physical status I and II patients aged 28 to 87 years and scheduled for major abdominal surgery. INTERVENTIONS All patients underwent abdominal surgery with epidural anesthesia combined with general anesthesia. Postoperatively, they continued with epidural analgesia consisting of bupivacaine and morphine. On the first postoperative night, the breathing pattern was studied with a new noninvasive monitoring device measuring respiratory frequency and apnea. Arterial blood gas analysis was performed in case of apnea or low respiratory frequency. MEASUREMENTS AND MAIN RESULTS A total of 84 alarm events were registered in 11 patients. Twenty-one percent (18/84) of the alarms were associated with arterial carbon dioxide tension (PaCO2) levels greater than 48.8 mmHg. Three of the four patients with PaCO2 levels greater than 48.8 mmHg were older than 80 years of age. CONCLUSION The tested noninvasive monitoring device may detect abnormal respiratory breathing patterns in patients at risk for respiratory depression during epidural analgesia with bupivacaine-morphine.

Local metabolic changes in subcutaneous adipose tissue during intravenous and epidural analgesia

Background: This clinical study aimed at investigating the impact of postoperative thoracic epidural analgesia on extracellular glycerol concentration and glucose metabolism in subcutaneous adipose tissue, using the microdialysis technique. The sympathetic nervous activity, which can be attenuated by epidural anesthesia, influences lipolysis and the release of glycerol.

Could benefits of epidural analgesia following oesophagectomy be measured by perceived perioperative patient workload

Background: A controversy exists whether beneficial analgesic effects of epidural analgesia over intravenous analgesia influence the rate of post‐operative complications and the length of hospital stay. There is some evidence that favours epidural analgesia following major surgery in high‐risk patients. However, there is a controversy as to whether epidural analgesia reduces the intensive care resources following major surgery. In this study, we aimed at comparing the post‐operative costs of intensive care in patients receiving epidural or intravenous analgesia.

Changes in the sublingual microcirculation during major abdominal surgery and post‐operative morbidity

Little is known about perioperative microcirculatory changes during major abdominal surgery, and the main objectives of this study were to evaluate perioperative microcirculatory alterations in this setting, and if changes in microcirculatory parameters are associated with post‐operative morbidity and/or with changes in parameters reflecting oxygen delivery.