Browsing by Subject "anestesiologia ja tehohoito"

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  • Wilkman, Erika (Helsingin yliopisto, 2014)
    BACKGROUND Adequate blood circulation is necessary for tissue perfusion and oxygen supply. Derangements in perfusion due to circulatory failure may lead to end-organ failure without prompt and accurate restoration of circulation and perfusion, which is performed by targeting sufficient levels of preload, afterload, and cardiac contractility. Current international guidelines recommend early vigorous fluid resuscitation, restoration of mean arterial pressure (MAP) to ≥60-65 mmHg, when necessary by using vasopressor agents, and restoration of depressed cardiac contractility and output by inotrope treatment to improve survival and avoid end-organ failure. However, evidence for the beneficial impact of inotrope use in septic shock, hemodynamic targets for resuscitation in severe acute pancreatitis (SAP), or optimal blood pressure for prevention of septic acute kidney injury is rather limited. Furthermore, feasible means of assessing fluid responsiveness to prevent excessive fluid resuscitation are warranted. The objective of this study was to evaluate different hemodynamic variables in addition to vasopressor and inotrope treatment during the early phases of severe sepsis, septic shock, and SAP and their association with development of end-organ failure and outcome. We also sought to find relevant hemodynamic parameters for assessing fluid responsiveness during early resuscitation of septic shock. PATIENTS A total of 1022 patients, 440 with septic shock, 159 with SAP, and 423 with severe sepsis, were included in the study. All patients were treated in the ICUs of Helsinki University Hospital during 2005-2012, except for the 423 patients with severe sepsis, who were treated in 13 different Finnish ICUs during 2011-2012. MAIN RESULTS Of patients with septic shock, 44.3% received inotrope treatment during the first 24 hours in the ICU, the majority of these patients receiving dobutamine (90.3%). The mortality of inotrope receivers was significantly higher than that of non-receivers (42.5% vs. 23.9%). Patients who received inotropes were generally more severely ill and received higher doses of norepinephrine. The use of inotropes in these patients was independently associated with worse outcome, also after adjustment with propensity score. In patients with severe sepsis and SAP, the use of inotropes was less frequent, 16.0% and 16.4%, respectively. Vasopressors, most often norepinephrine, were administered to the majority of patients with severe sepsis, SAP, and septic shock. The highest dose of norepinephrine during the first day in ICU was associated with worse outcome. Lower MAP, higher central venous pressure (CVP), and lower cardiac index (CI), but not higher heart rate (HR), were associated with 90-day mortality in patients with SAP. Decreases in MAP and systolic arterial pressure were the best predictors of fluid responsiveness in 20 mechanically ventilated patients with septic shock during a temporary elevation of positive end-expiratory pressure (PEEP) from 10 to 20 cm H2O. A decrease of less than 8% ruled out fluid responsiveness, with a negative predictive value of 100%. The time-adjusted MAP during the first 24 hours in the ICU of patients developing acute kidney injury (AKI) during the first five days in the ICU was significantly lower than that of patients not developing AKI (74.4 mmHg vs. 78.6 mmHg). The best cut-off value for time-adjusted MAP was 72.7 mmHg. Lower time-adjusted MAP or alternatively time-adjusted MAP below 73 mmHg was independently associated with progression of AKI. CONCLUSIONS Inotropes are frequently used in patients with septic shock. In severe sepsis and SAP, inotrope use is less frequent. The vast majority of patients received vasopressor treatment. Norepinephrine was the vasopressor of choice in nearly all patients. Use of inotropes and the highest vasopressor dose during the first day in ICU were significantly associated with 90-day mortality. Although inotropes may have beneficial effects in patients with septic shock, by increasing cardiac output and perfusion, they might also have adverse effects that eventually lead to higher mortality. Although vigorous fluid resuscitation is advocated in the early treatment of SAP to maintain sufficient tissue perfusion, our study showed that overzealous resuscitation might be harmful, reflected by the association of higher CVP with worse outcome. To avoid overhydration during fluid resuscitation of patients with septic shock, a lack of a decrease in MAP during elevation of PEEP from 10 to 20 cm H2O may be used as an accessory means of assessing fluid responsiveness. Lower time-adjusted MAP in patients with severe sepsis is associated with progression of AKI. Higher targets of MAP may be indicated for ensuring adequate perfusion of the kidney in this patient group.  
  • Heinonen, Juho (Helsingin yliopisto, 2016)
    Drug overdoses and poisonings are global health problems resulting in several thousands deaths annually. In out-of-hospital setting, one of the most common causes of death is an overdose of tricyclic antidepressant, such as amitriptyline. In the hospital, on the other hand, local anaesthetic systemic toxicity is one of the most feared and potentially a life-threatening complication. Both tricyclic antidepressants and local anaesthetics lack specific antidotes. However, as they all are lipophilic drugs, intravenously administered lipid emulsion has been suggested as a potential treatment for both intoxications. Originally, the proposed mechanism of action of lipid emulsion was a lipid sink that entraps lipophilic drugs and prevents their action in target tissues. Nowadays, lipid emulsion is a recommended treatment for local anaesthetic systemic toxicity in, for instance, the UK and the US in spite of the fact that its actual mechanisms of action and benefit remain uncertain. In the first study of this thesis, the incidence of local anaesthetic systemic toxicity and the adoption rates of lipid emulsion treatment in Finnish anaesthesia departments were elucidated (I). The other studies of this thesis investigate the efficacy of intravenously administered lipid emulsion in both local anaesthetic toxicity and amitriptyline. The effect on lidocaine induced central nervous system toxicity were studied in human volunteers (II). The effect of lipid emulsion on levobupivacaine intoxication in a situation simulating seizures (III), on the tissue distribution of amitriptyline (IV), and on mitochondrial respiration in bupivacaine cardiac toxicity (V) were studied in pigs. In each of these studies an assessment of the degree of the entrapment of the drug by intravenous lipid emulsion was included. The incidence of local anaesthetic systemic toxicity in Finland is low, only 0.7 per 10,000 regional anaesthesias (I). Lipid emulsion treatment is adopted to less than half of the Finnish anaesthesia departments. In human volunteers, lipid emulsion does not affect the electroencephalography changes or the subjective symptoms caused by lidocaine. Lidocaine was also not entrapped into plasma, but its volume of distribution was slightly increased (II). In pigs, lipid emulsion has no effect on levobupivacaine intoxication which is exacerbated by acidosis and hypoxaemia as measured by reversing of electrocardiogram and haemodynamics from toxic changes (III). Levobupivacaine was also not entrapped into plasma. When lipid emulsion was infused in amitriptyline intoxication, amitriptyline was slightly entrapped into circulation and the brain amitriptyline concentration was reduced by 25% (IV). After higher lipid emulsion dose than recommended, recovery from bupivacaine cardiac toxicity was improved through peripheral vasoconstriction (V). Cardiac mitochondrial respiration was also slightly improved at the same time, and bupivacaine was slightly entrapped into plasma. To conclude, this is the first Finnish study to show that the incidence of local anaesthetic toxicity is very low: 0.7 per 10,000. Lipid emulsion can reduce amitriptyline brain concentration but has no effect on local anaesthetic systemic toxicity if used in clinically recommended doses. If a higher dose is administered, lipid emulsion improves recovery from local anaesthetic toxicity through peripheral vasoconstriction in pigs. The safety of the higher dose to men remains, however, unknown.
  • Brinck, Elina (Helsingin yliopisto, 2021)
    Suboptimal postoperative pain management increases complication rates and health care costs, and is a risk factor for chronic postoperative pain. Opioids have been the pharmacological cornerstone in postoperative pain management but adverse effects may limit their use. Multimodal analgesia combines different pain treatment modalities, aiming to reduce pain intensity, decrease opioid consumption and opioid-related adverse effects. Low-dose ketamine modulates molecular and cellular mechanisms behind pain and mitigates the development of opioid tolerance. The optimal dosing regimen of ketamine, and timing of dosing have not been established. The aim of the research was to evaluate the efficacy and tolerability of perioperative intravenous (IV) ketamine in adult patients when used for adjunct analgesia. The thesis constitutes of a Cochrane review (130 RCTs, 8341 patients) and two prospective, randomized, placebo-controlled and double- blinded clinical trials on adult patients undergoing spinal fusion surgery (198 patients and 100 patients, respectively). The RCTs compared two different intraperative IV infusions of S- ketamine with placebo and three different doses of S-ketamine added to an IV oxycodone patient-controlled analgesia (PCA). Perioperative IV ketamine reduced postoperative opioid consumption over 24 h and 48 h by 19%. With two different doses of intraoperative IV S-ketamine in lumbar fusion surgery, differences with placebo in 48 h oxycodone consumption were not significant. S-ketamine added to oxycodone IV-PCA in a ratio 0.75:1 reduced oxycodone need by 25% 24 h postoperatively. Postoperative pain intensity after perioperative IV ketamine administration was approximately 20% lower bot at rest and during movement. The degree of pain relief was greater following thoracic, major orthopedic, and major abdominal surgery. Both intraoperative S-ketamine infusions decreased pain scores significantly only at 4th postoperative hour after lumbar fusion surgery. A significant beneficial effect in mean change in pain intensity during the first 24 h after lumbar fusion surgery was achieved when the S-ketamine:oxycodone ratio in an IV-PCA was 0.75:1. All studies showed that perioperative IV ketamine and S-ketamine did not induce significant CNS adverse events. Approximately 5% of patients receiving perioperative IV ketamine experienced CNS adverse events, compared to 4% of controls. Perioperative IV ketamine reduced PONV from 27% with placebo to 23% with ketamine. Differences in the occurrence of PONV were nonsignificant in patients undergoing lumbar fusion surgery when S-ketamine was administered either as intraoperative infusions or as an adjunct with oxycodone IV-PCA. Conclusions: Ketamine and S-ketamine reduce postoperative pain intensity and opioid consumption especially in operations that are likely to induce more intense pain. Administration via IV-PCA in the postoperative period should be favoured over infusions after lumbar fusion surgery. Ketamine and S-ketamine cause negligible adverse events.
  • Marjamaa, Riitta (Helsingin yliopisto, 2007)
    Background: The aging population is placing increasing demands on surgical services, simultaneously with a decreasing supply of professional labor and a worsening economic situation. Under growing financial constraints, successful operating room management will be one of the key issues in the struggle for technical efficiency. This study focused on several issues affecting operating room efficiency. Materials and methods: The current formal operating room management in Finland and the use of performance metrics and information systems used to support this management were explored using a postal survey. We also studied the feasibility of a wireless patient tracking system as a tool for managing the process. The reliability of the system as well as the accuracy and precision of its automatically recorded time stamps were analyzed. The benefits of a separate anesthesia induction room in a prospective setting were compared with the traditional way of working, where anesthesia is induced in the operating room. Using computer simulation, several models of parallel processing for the operating room were compared with the traditional model with respect to cost-efficiency. Moreover, international differences in operating room times for two common procedures, laparoscopic cholecystectomy and open lung lobectomy, were investigated. Results: The managerial structure of Finnish operating units was not clearly defined. Operating room management information systems were found to be out-of-date, offering little support to online evaluation of the care process. Only about half of the information systems provided information in real time. Operating room performance was most often measured by the number of procedures in a time unit, operating room utilization, and turnover time. The wireless patient tracking system was found to be feasible for hospital use. Automatic documentation of the system facilitated patient flow management by increasing process transparency via more available and accurate data, while lessening work for staff. Any parallel work flow model was more cost-efficient than the traditional way of performing anesthesia induction in the operating room. Mean operating times for two common procedures differed by 50% among eight hospitals in different countries. Conclusions: The structure of daily operative management of an operating room warrants redefinition. Performance measures as well as information systems require updating. Parallel work flows are more cost-efficient than the traditional induction-in-room model.