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Background: Immobilisation following surgical treatment of distal radial fractures (DRF) is traditionally performed with a dorsal cast splint. There is an interest in changing the rigid cast to a removable brace. This can reduce the risk for cast-corrections, complications and improve recovery of function. The aim of the study was to compare quality of recovery (QoR) between brace and traditional cast for immobilisation during the first postoperative week. Methods: 60 patients with American Society of Anesthesiologists (ASA) physical status 1–3, scheduled for surgical treatment of DRF under a supraclavicular block (SCB) in a day-surgery setting were randomised into two groups of immobilisation post-surgery; brace (n=30) versus traditional cast (n=30). Study objectives were: differences in self-assessed QoR using the QoR-15 questionnaire, postoperative oral oxycodone consumption, perioperative time events and unplanned healthcare contacts one week postoperatively. Results: 54 patients, 46 females/eight males were included in the analysis; 27 with brace and 27 with traditional cast. QoR-15 median scores improved significantly from baseline/preoperative to day 7 (brace p=0.001, cast p=0.001) with no differences between the two groups. The only difference found was that patients in the brace group had significantly worse pain score 24-hours post-surgery (p=0.022). No significant differences were seen in total median oxycodone consumption the first three postoperative days. No differences were found in perioperative events or unplanned healthcare contacts. Conclusions: Brace appears to be a feasible option to traditional cast for immobilisation following surgical treatment of DRF. The early QoR was similar in both groups apart from more pain in the brace group the first 24 postoperative hours.

Background: Immobilisation following surgical treatment of distal radial fractures (DRF) is traditionally performed with a dorsal cast splint. There is an interest in changing the rigid cast to a removable brace. This can reduce the risk for cast-corrections, complications and improve recovery of function. The aim of the study was to compare quality of recovery (QoR) between brace and traditional cast for immobilisation during the first postoperative week. Methods: 60 patients with American Society of Anesthesiologists (ASA) physical status 1–3, scheduled for surgical treatment of DRF under a supraclavicular block (SCB) in a day-surgery setting were randomised into two groups of immobilisation post-surgery; brace (n=30) versus traditional cast (n=30). Study objectives were: differences in self-assessed QoR using the QoR-15 questionnaire, postoperative oral oxycodone consumption, perioperative time events and unplanned healthcare contacts one week postoperatively. Results: 54 patients, 46 females/eight males were included in the analysis; 27 with brace and 27 with traditional cast. QoR-15 median scores improved significantly from baseline/preoperative to day 7 (brace p=0.001, cast p=0.001) with no differences between the two groups. The only difference found was that patients in the brace group had significantly worse pain score 24-hours post-surgery (p=0.022). No significant differences were seen in total median oxycodone consumption the first three postoperative days. No differences were found in perioperative events or unplanned healthcare contacts. Conclusions: Brace appears to be a feasible option to traditional cast for immobilisation following surgical treatment of DRF. The early QoR was similar in both groups apart from more pain in the brace group the first 24 postoperative hours.

Background: Immobilisation following surgical treatment of distal radial fractures (DRF) is traditionally performed with a dorsal cast splint. There is an interest in changing the rigid cast to a removable brace. This can reduce the risk for cast-corrections, complications and improve recovery of function. The aim of the study was to compare quality of recovery (QoR) between brace and traditional cast for immobilisation during the first postoperative week. Methods: 60 patients with American Society of Anesthesiologists (ASA) physical status 1–3, scheduled for surgical treatment of DRF under a supraclavicular block (SCB) in a day-surgery setting were randomised into two groups of immobilisation post-surgery; brace (n=30) versus traditional cast (n=30). Study objectives were: differences in self-assessed QoR using the QoR-15 questionnaire, postoperative oral oxycodone consumption, perioperative time events and unplanned healthcare contacts one week postoperatively. Results: 54 patients, 46 females/eight males were included in the analysis; 27 with brace and 27 with traditional cast. QoR-15 sum median scores improved significantly from baseline/preoperative to day 7 (brace p=0.001, cast p=0.001) with no differences between the two groups. The only difference found was that patients in the brace group had significantly worse pain score 24-hours post-surgery (p=0.022). No significant differences were seen in sum median oxycodone consumption the first three postoperative days. No differences were found in perioperative events or unplanned healthcare contacts. Conclusions: Brace appears to be a feasible option to traditional cast for immobilisation following surgical treatment of DRF. The early QoR was similar in both groups apart from more pain in the brace group the first 24 postoperative hours.

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.

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.

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 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.

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 PaO2/FiO2 ratio was found; from 13.1 to 71.3. An increase in mean PaCO2 was observed, from a baseline of 5.0 to a peak of 7.1 at 30 minutes (p

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/min. 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.

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.

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.

Background: Hip fractures affect 1.6 million patients yearly worldwide, often elderly with complex comorbidity. Mortality following surgery for acute hip fracture is high and 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 elderly undergoing 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; 11,257, 82%), followed by general anaesthesia (GA; 2,190, 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 in patients. Increasing age, ASA class and male gender increased the 30-day mortality.

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.

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.

Background: Obesity, abdominal surgery, and intrathecal opioids are all factors associated with a risk for respiratory compromise. The aim of this explorative trial was to study the apnoea/hypopnea index 1st postoperative night in obese mothers having had caesarean section (CS) in spinal anaesthesia with a combination of bupivacaine/morphine and fentanyl. 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 1 st postoperative night. The apnoea/hypopnea index (AHI) was identified by clinical algorithm and assessed in accordance to general guidelines; number of apnoea/hypopnea episodes per hour: mild sleep apnoea, ≥15 and moderate sleep apnoea, ≥ 30 severe sleep apnoea. Oxygen desaturation events were in similar manner calculated per hour as oxygen desaturation index (ODI). Results: Forty mothers were invited to participate: 27 consented, 23 were included, but polysomnography registration failed in 3. Among the 20 mothers studied: 11 had an AHI normal), 7 mothers had AHI ≥5 but mild OSAS) and 2 mothers had AHI ≥15 ( moderate OSA), none had an AHI ≥ 30. The ODI was on average 4.4, and eight patients had an ODI >5. Mothers with a high AHI (15.3 and 18.2) did not show high ODI. Mean saturation was 94% (91-96%), and four mothers had mean SpO 2 90-94%, none had a mean SpO2 Conclusion: Respiratory polygraphy 1 st night after caesarean section in spinal anaesthesia with morphine in moderately obese mothers showed AHIs that in sleep medicine terms are considered normal, mild and moderate. Obstructive events and episodes of desaturation were commonly not synchronised. Further studies looking at preoperative screening for sleep apnoea in obese mothers are warranted but early postop respiratory polygraphy recording is cumbersome and provided sparse important information.

Low-flow anaesthesia is considered beneficial for the patient and the environment, and it is cost reducing due to reduced anaesthetic gas consumption. An initial high-flow to saturate the circle system ( wash-in) is desirable from a clinical point of view. We measured the wash-in and wash-out times (time to saturate and to eliminate the anaesthetic agent, AA), for sevoflurane and desflurane, in a test-lung with fixed 3 MAC vaporizer setting at different fresh gas flow (FGF) and calculated the consumption of AA. We tried to find an optimal flow rate for speed and gas consumption, comparing two anaesthesia machines (AMs): Aisys and Flow-i. Time to reach 1 minimal alveolar concentration (MAC) (wash-in) decreased (p

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) 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 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.

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 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 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.

Low-flow anaesthesia is considered beneficial for the patient and the environment, and it is cost reducing due to reduced anaesthetic gas consumption. An initial high-flow to saturate the circle system ( wash-in) is desirable from a clinical point of view. We measured the wash-in and wash-out times (time to saturate and to eliminate the anaesthetic agent, AA), for sevoflurane and desflurane, in a test-lung with fixed 3 MAC vaporizer setting at different fresh gas flow (FGF) and calculated the consumption of AA. We tried to find an optimal flow rate for speed and gas consumption, comparing two anaesthesia machines (AMs): Aisys and Flow-i. Time to reach 1 minimal alveolar concentration (MAC) (wash-in) decreased (p

Anaesthetic technique for open surgery of acute distal for arm fracture in adults/elderly is not well defined. Regional anaesthesia, general anaesthesia or a combined general and regional block may be considered. General anaesthetic technique, the timing and drug/drug combination for the regional block must also be considered. This is a study around published studies assessing anaesthtic technique for wrist surgery. A systematic database search was performed and papers describing the effect of anaesthetic techniques were included. We found sparse evidence for what anaesthetic technique is optimal for open wrist fracture repair. In total only six studies were found using our inclusion criteria, which all supported the short term, early recovery benefits of regional anaesthesia as part of multi-modal analgesia. More protracted outcomes and putting the type of block into context of quality of recovery and patients’ satisfaction is lacking in the literature. The risk for a pain rebound when the block vanishes should also be acknowledged. Therefore, further high quality studies are warranted concerning the anaesthetic technique for this type of surgery.

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) 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 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.

Background : Day surgery is increasing, and safe and effective logistics are sought. One part of the in-theatre logistics commonly discussed is whether surgical scrub and sterile covering should be done before or after induction of anaesthesia. The aim of the present study was to compare the impact of surgical scrub and sterile covering before vs. after the induction of anaesthesia in male patients scheduled for open hernia repair. Methods : This is a prospective randomised study. Sixty ASA 1-3 patients scheduled for open hernia repair were randomised to surgical scrub and sterile covering before or after induction of anaesthesia; group “awake” and “anaesthetised”. Need for vasoactive medication during anaesthesia was primary study objective. Duration of anaesthesia and surgery, theatre time, recovery room stay and time to discharge, patients and theatre nurses experiences and willingness to have the same logistics on further potential surgeries, by a questionnaire provided before discharge was also assessed. Results : The duration of anaesthesia was shorter and doses of propofol and remifentanil were reduced by 10 and 13%, respectively, in the awake group. We found still no difference in the need for vasoactive medication during anaesthesia Time in recovery area was significantly reduced in the awake group 39 (SD 15) vs. 48 SD 16) (p Conclusion : Surgical scrub and sterile covering before the induction of anaesthesia can be done safely and without jeopardising patients’ quality of care and possibly improve perioperative logistics. Further studies are warranted assessing impact of awake scrubbing and sterile covering on quality and efficacy of perioperative care.

Background: Day surgery is increasing, and safe and effective logistics are sought. One part of the in-theatre logistics commonly discussed is whether surgical scrub and sterile covering should be done before or after induction of anaesthesia. The aim of the present study was to compare the impact of surgical scrub and sterile covering before vs. after the induction of anaesthesia in male patients scheduled for open hernia repair. Methods: This is a prospective randomised study. Sixty ASA 1-3 patients scheduled for open hernia repair were randomised to surgical scrub and sterile covering before or after induction of anaesthesia; group “awake” and group “anaesthetised”, respectively. Patients and theatre nurses were asked about their experiences and willingness to have the same logistics on further potential surgeries, through a survey provided before post-surgery. Duration of anaesthesia, surgery, theatre time, recovery room stay and time to discharge was studied. Results: There was no difference in the patients’ assessment of quality of care, and only one patient in the awake group would prefer to be anaesthetised on a future procedure. All nurses found pre-anaesthesia scrubbing acceptable as routine. The duration of anaesthesia was shorter and doses of propofol and remifentanil were reduced by 10 and 13%, respectively, in the awake group. Time in recovery area was significantly reduced in the awake group (p Conclusion: Surgical scrub and sterile covering before the induction of anaesthesia can be done safely and without jeopardising patients’ quality of care.

Background: Obstructive sleep apnoea and obese hypoventilation is not uncommon in patients with obesity. Residuals effect from surgery/anaesthesia and opioid analgesics may worsen respiration during the first nights after bariatric surgery. The aim of this observational study was to monitor respiration on the first postoperative night following elective bariatric surgery. Methods: This observational study aimed to determine the incidence and severity of hypo/apnoea in low risk obsess patients undergoing elective bariatric surgery in general anesthaesia. Patients with known or suspected sleep respiratory disturbances was not included. ESS was scored prior to surgery. Oxygen desaturation was analyzed by continuous respiratory monitoring. Mean oxygen saturation (SpO2), nadir SPo2, apnoea/hypopnea index and oxygen desaturation index was assess by standard tools. Results: 45 patients were monitored with portable polygraphy equipment (Embletta, ResMed) during the first postoperative night at the general ward following elective laparoscopic bariatric surgery. The prop ESS was 0-5 in 22, 6-10 in 14 and 11-16 in 6 of the patients studied (missing data 3). Mean SpO2 was 93%; 10 patients had a mean SpO2 of less than 92% and 4 of less than 90%. The lowest mean SpO2 was 87%. There were 16 patients with a nadir SpO2 of less than 85%, lowest nadir SpO2 being 63%. An Apnoea Hypo/apnoea Index (AHI) > 5 was found in 2 patients only (AHI 10 and 6), and an Oxygen Desaturation index (ODI) > 5 was found in 3 patients (24, 10 and 6, respectively). 3 patients had more prolonged (> 30 seconds) apnoea with nadir SpO2 81%, 83% and 86%. ESS score and type of surgery did not impact on respiration/oxygenation during the observation period. Conclusions: A low mean SpO2 and episodes of desaturation were not uncommon during the first postoperative night following elective bariatric surgery in patients without history of night time breathing disturbance. AHI and/or ODI of more than 5 were only rarely seen. Night-time respiration monitoring provided seemingly sparse additional information. Further studies are need to assess risk factors and potential impact of the desaturation episodes that occurs during sleep.

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.

Background: Obstructive sleep apnoea and obese hypoventilation is not uncommon in patients with obesity. Residuals effect from surgery/anaesthesia and opioid analgesics may worsen respiration during the first nights after bariatric surgery. The aim of this observational study was to monitor respiration on the first postoperative night following elective bariatric surgery. Methods: This observational study aimed to determine the incidence and severity of hypo/apnea. Oxygen desaturation was analysed by continuous respiratory monitoring. Results: 45 patients were monitored with portable polygraphy equipment (Embletta, ResMed) during the first postoperative night at the general ward following elective laparoscopic bariatric surgery. Mean SpO2 was 93%; 10 patients had a mean SpO2 of less than 92% and 4 of less than 90%. The lowest mean SpO2 was 87%. There were 16 patients with a nadir SpO2 of less than 85%, lowest nadir SpO2 being 63%. An Apnoea Hypo/apnea Index (AHI) > 5 was found in 2 patients only (AHI 10 and 6), and an Oxygen Desaturation index (ODI) > 5 was found in 3 patients (24, 10 and 6, respectively). 3 patients had more prolonged (> 30 seconds) apnoea with nadir SpO2 81%, 83% and 86%. Conclusions: A low mean SpO2 and short episodes of desaturation were not uncommon during the first postoperative night following elective bariatric surgery in patients without history of night time breathing disturbance. AHI and/or ODI of more than 5 were only rarely seen. Night-time respiration monitoring provided sparse additional information. Thus, it seems reasonable to have low risk patients at general ward already in their first night after bariatric surgery.

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 all anaesthetic obstetric units in Sweden concerning the use and postoperative monitoring of morphine, sufentanil and fentanyl in spinal/epidural anaesthesia. Results: A total of 32 of 47 (68%) 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 monitored 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.

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.

Low-flow anaesthesia is considered beneficial for the patient and the environment, and it is cost reducing due to reduced anaesthetic gas consumption. An initial high-flow to saturate the circle system ( wash-in) is desirable from a clinical point of view. We measured the wash-in and wash-out times (time to saturate and to eliminate the anaesthetic agent, AA), for sevoflurane and desflurane, in a test-lung with fixed 3 MAC vaporizer setting at different fresh gas flow (FGF) and calculated the consumption of AA. We tried to find an optimal flow rate for speed and gas consumption, comparing two anaesthesia machines (AMs): Aisys and Flow-i. Time to reach 1 minimal alveolar concentration (MAC) (wash-in) decreased (p

Introduction Patient outcome measures are required to assess the quality of healthcare. Tools for a patients’ self-assessment of quality of recovery, during perioperative care, have been developed during the last decade. The Postoperative Quality of Recovery Scale (PostopQRS) questionnaire is one of the most well-accepted and validated tools available. Here we assess the PostopORS questionnaire in Swedish. Methods Sixty-one students from the Bachelor Program in Nursing, (50 female and 11 male; mean age, 25; range, 21-46) filled in the Swedish translation of the PostopQRS questionnaire twice. They also evaluated whether they found the queries easy to understand and respond to . Results The participants found the Swedish translation of the PostopQRS questionnaire easy to read and understand. There were minor differences in test responses between the initial test and the re-test 48 hours later. We found that the PostopQRS questionnaire has some background noise; 12 out of 61 participants (20%) reported mild pain, 25 (41%) scored some depression and 33 scored mild anxiety (54%). The cognitive domain showed a learning effect between tests in “word recall” and “word generation”, while “digit recall forward” and “digit recall backward” showed no change. We found a difference in cognitive test performance with age; younger participants had higher mean cognitive test scores compared to participants >30 years. Overall, nine participants showed a decrease in re-test scores; two experienced a mild increase in pain; one experienced a mild increase in anxiety; and six performed more poorly on cognitive tests. Conclusion The Swedish translation of the PostopQRS was found to be adequate for use in the assessment of quality of recovery, and the questions were well understood by participants. Our study shows the importance of baseline testing for assessment of recovery, since recovery is assessed as a return to or improvement in each individual’s baseline score.

Regional anaesthesia provides effective anaesthesia and analgesia in the perioperative setting. Central neuraxial blocks—that is, spinal and epidural blocks—are well established as an alternative or adjunct to general anaesthesia. Peripheral blocks may be used as part of multimodal anaesthesia/analgesia in perioperative practice, reducing the need for opioid analgesics and enhancing early recovery. Furthermore, regional anaesthesia has increased in popularity and may be done with improved ease and safety with the introduction of ultrasound-guided techniques. The effects of local anaesthetics and regional anaesthesia on long-term outcomes such as morbidity, mortality, the quality of recovery beyond the duration of analgesia, and whether it can expedite the resumption of activities of daily living are less clear. It has also been suggested that regional anaesthesia may impact the risk of metastasis after cancer surgery. This article provides an overview of current evidence around quality of recovery, risk for delirium, long-term effects, and possible impact on cancer disease progression associated with the clinical use of local and regional anaesthetic techniques. In summary, there is still a lack of robust data that regional anaesthesia has a clinical impact beyond its well-acknowledged beneficial effects of reducing pain, reduced opioid consumption, and improved quality of early recovery. Further high-quality prospective studies on long-term outcomes are warranted.

Upper extremity blocks are useful as both sole anaesthesia and/or a supplement to general anaesthesia and they further provide effective postoperative analgesia, reducing the need for opioid analgesics. There is without doubt a renewed interest among anaesthesiologists in the interscalene, supraclavicular, infraclavicular, and axillary plexus blocks with the increasing use of ultrasound guidance. The ultrasound-guided technique visualising the needle tip and solution injected reduces the risk of side effects, accidental intravascular injection, and possibly also trauma to surrounding tissues. The ultrasound technique has also reduced the volume needed in order to gain effective block. Still, single-shot plexus block, although it produces effective anaesthesia, has a limited duration of postoperative analgesia and a number of adjuncts have been tested in order to prolong analgesia duration. The addition of steroids, midazolam, clonidine, dexmedetomidine, and buprenorphine has been studied, all being off-label when administered by perineural injection, and the potential neurotoxicity needs further study. The use of perineural catheters is an effective option to improve and prolong the postoperative analgesic effect. Upper extremity plexus blocks have an obvious place as a sole anaesthetic technique or as a powerful complement to general anaesthesia, reducing the need for analgesics and hypnotics intraoperatively, and provide effective early postoperative pain relief. Continuous perineural infusion is an effective option to prolong the effects and improve postoperative quality.

Transversus abdominal plane (TAP) block has a long history and there is currently extensive clinical experience around TAP blocks. The aim of this review is to provide a summary of the present evidence on the effects of TAP block and to provide suggestions for further studies. There are several approaches to performing abdominal wall blocks, with the rapid implementation of ultrasound-guided technique facilitating a major difference in TAP block performance. During surgery, an abdominal wall block may also be applied by the surgeon from inside the abdominal cavity. Today, there are more than 11 meta-analyses providing a compiled evidence base around the effects of TAP block. These analyses include different procedures, different techniques of TAP block administration and, importantly, they compare the TAP block with a variety of alternative analgesic regimes. The effects of TAP block during laparoscopic cholecystectomy seem to be equivalent to local infiltration analgesia and also seem to be beneficial during laparoscopic colon resection. The effects of TAP are more pronounced when it is provided prior to surgery and these effects are local anaesthesia dose-dependent. TAP block seems an interesting alternative in patients with, for example, severe obesity where epidural or spinal anaesthesia/analgesia is technically difficult and/or poses a risk. There is an obvious need for further high-quality studies comparing TAP block prior to surgery with local infiltration analgesia, single-shot spinal analgesia, and epidural analgesia. These studies should be procedure-specific and the effects should be evaluated, both regarding short-term pain and analgesic requirement and also including the effects on postoperative nausea and vomiting, recovery of bowel function, ambulation, discharge, and protracted recovery outcomes (assessed by e.g., postoperative quality of recovery scale).