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  • 1. Ekman, A
    et al.
    Lindholm, ML
    Lennmarken, Claes
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Anaesthesiology. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Intensive Care UHL.
    Sandin, R
    Reduction in the incidence of awareness using BIS monitoring2004In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 48, no 1, p. 20-26Article in journal (Refereed)
    Abstract [en]

    Background: Explicit recall (ER) is evident in approximately 0.2% of patients given general anaesthesia including muscle relaxants. This prospective study was performed to evaluate if cerebral monitoring using BIS to guide the conduction of anaesthesia could reduce this incidence significantly. Patients and methods: A prospective cohort of 4945 consecutive surgical patients requiring muscle relaxants and/or intubation were monitored with BIS and subsequently interviewed for ER on three occasions. BIS values between 40 and 60 were recommended. The results from the BIS-monitored group of patients was compared with a historical group of 7826 similar cases in a previous study when no cerebral monitoring was used. Results: Two patients in the BIS-monitored group, 0.04%, had ER as compared with 0.18% in the control group (P < 0.038). Both BIS-monitored patients with ER were aware during intubation when they had high BIS values (>60) for 4 min and more than 10 min, respectively. However, periods with high BIS = 4 min were also evident in other patients with no ER. Episodes with high BIS, 4 min or more, were found in 19% of the monitored patients during induction, and in 8% of cases during maintenance. Conclusions: The use of BIS monitoring during general anaesthesia requiring endotracheal intubation and/or muscle relaxants was associated with a significantly reduced incidence of awareness as compared with a historical control population.

  • 2.
    Järemo, Peter
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Cardiology. Östergötlands Läns Landsting, Heart Centre, Department of Cardiology.
    Lindahl, Tomas
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Biomedicine and Surgery, Clinical Chemistry. Östergötlands Läns Landsting, Centre for Laboratory Medicine, Department of Clinical Chemistry.
    Lennmarken, Claes
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Anaesthesiology.
    Forsgren, H
    The use of platelet density and volume measurements to estimate the severity of pre-eclampsia.2001In: European Journal of Clinical Investigation, ISSN 0014-2972, E-ISSN 1365-2362, Vol. 30, p. 1113-1118Article in journal (Refereed)
  • 3.
    Lennmarken, Claes
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Anaesthesiology. Östergötlands Läns Landsting, MKC - Medicin och kirurgicentrum, Anestesi.
    Bildfors, K
    Enlund, G
    Samuelsson, P
    Sandin, R
    Victims of awareness2002In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 46, p. 229-231Article in journal (Refereed)
  • 4.
    Lennmarken, Claes
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Anesthesiology . Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Intensive Care UHL.
    Sandin, R
    Neuromonitoring for awareness during surgery2004In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 363, no 9423, p. 1747-1748Other (Other academic)
  • 5.
    Lennmarken, Claes
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Anaesthesiology. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Intensive Care UHL.
    Sandin, R
    Neuromonitoring for awareness during surgery2004In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 29, p. 1747-1748Article in journal (Refereed)
  • 6.
    Lennmarken, Claes
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Anaesthesiology. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Intensive Care UHL.
    Sydsjö, Gunilla
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Molecular and Clinical Medicine, Obstetrics and gynecology. Östergötlands Läns Landsting, Centre of Paediatrics and Gynecology and Obstetrics, Department of Gynecology and Obstetrics in Linköping.
    Psychological consequences of awareness and their treatment2007In: Best Practice & Research Clinical Anaesthesiology, ISSN 1521-6896, Vol. 21, no 3, p. 357-367Article in journal (Refereed)
    Abstract [en]

    Intraoperative awareness with subsequent recall is a rare but serious complication with an incidence of 0.1-0.2%. In approximately one third of the patients who have experienced awareness, late severe psychiatric sequelae may develop. The psychiatric symptoms in these patients fulfil the diagnostic criteria for post traumatic stress disorder. To prevent awareness as a negative outcome after anaesthesia, a thorough perioperative management of anaesthesia is necessary. The definite risk for post traumatic stress disorder following awareness indicates the necessity of postoperative clinical routines to identify awareness patients. The problem must be acknowledged. Professional psychiatric assessment and follow up should constitute standard practice. The treatments of choice are Eye Movement Desensitisation Reprocessing and Cognitive Behaviour Therapy. © 2007 Elsevier Ltd. All rights reserved.

  • 7.
    Lennmarken, Claes
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Anaesthesiology. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Intensive Care UHL.
    Vegfors, Magnus
    Perioperativ övervakning2000In: Anestesi / [ed] Matts Halldin; Sten Lindahl, Stockholm: Liber , 2000, 1, p. 341-351Chapter in book (Other academic)
  • 8.
    Lindberg, Lars-Göran
    et al.
    Linköping University, The Institute of Technology. Linköping University, Department of Biomedical Engineering, Physiological Measurements.
    Lennmarken, Claes
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Anaesthesiology. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Intensive Care UHL.
    Vegfors, Magnus
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Anaesthesiology. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Anaesthesiology and Intensive Care VHN.
    Pulse oximetry-clinical implications and recent technical developments1995In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 39, p. 279-287Article in journal (Refereed)
  • 9.
    Lindberg, Lars-Göran
    et al.
    Linköping University, The Institute of Technology. Linköping University, Department of Biomedical Engineering, Physiological Measurements.
    Vegfors, Magnus
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Anaesthesiology. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Anaesthesiology and Intensive Care VHN.
    Lennmarken, Claes
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Anaesthesiology. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Intensive Care UHL.
    Öberg, Åke
    Linköping University, The Institute of Technology. Linköping University, Department of Biomedical Engineering, Physiological Measurements.
    Pulse oximeter signal at various blood flow conditions in an In vitro model1995In: Medical & Biological Engineering & Computing, ISSN 0140-0118, Vol. 33, p. 87-91Article in journal (Refereed)
  • 10.
    Lindholm, Maj-Lis
    et al.
    Karolinska Institute.
    Traff, Stefan
    Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Anaesthesiology and Intensive Care VHN.
    Granath, Fredrik
    Karolinska Institute.
    Greenwald, Scott D
    Aspect Medical Systems.
    Ekbom, Anders
    Karolinska Institute.
    Lennmarken, Claes
    Linköping University, Department of Medicine and Health Sciences, Anesthesiology . Linköping University, Faculty of Health Sciences.
    Sandin, Rolf H
    Karolinska Institute.
    Mortality Within 2 Years After Surgery in Relation to Low Intraoperative Bispectral Index Values and Preexisting Malignant Disease2009In: ANESTHESIA AND ANALGESIA, ISSN 0003-2999, Vol. 108, no 2, p. 508-512Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A correlation between deep anesthesia (defined as time with Bispectral Index (BIS) &lt;45; T-BIS &lt;45 and death within 1. yr after surgery has previously been reported. In order to confirm or refute these findings, we evaluated T-BIS (&lt;45) as an independent risk factor for death within I and 2 yr after surgery and also the impact of malignancy, the predominant cause of death in the previous report.

    METHODS: Mortality within 2 yr after surgery, causes of death and the occurrence of malignant disease at the time of surgery were identified in a cohort of 4087 BIS-monitored patients. Statistically significant univariate predictors of mortality were identified. In order to allow for comparison with previous data, the following multivariate analysis was first done without, and thereafter with, preexisting malignancy status, the predominant cause of death.

    RESULTS: One-hundred-seventy-four (4.3%) patients died within I yr and another 92 during the second year (totaling 6.5% in 2 yr). T-BIS &lt;45 was a significant predictor of 1- and 2-yr mortality when preexisting malignant disease was not among the co-variates (hazard ratio [HR] 113 [1.01-1.27] and 1.18 [1.08-1.29], respectively). Further exploration confined the significant relation between postoperative mortality and T-BIS &lt;45 to Patients with preexisting malignant diagnoses associated with extensive Surgery and less favorable prognosis. The most powerful predictors of 2-yr mortality in the model, including preexisting malignancy, were ASA physical score class IV (HR 19.3 [7.31-51.1]), age &gt;80 yr (HR 2.93 [1.79-4.79]), and preexisting malignancy associated with less favorable prognosis (HR 9.30 [6.60-13.1]). When the initial multivariate regression was repeated using preexisting malignancy status among the co-variates in the model, the previously significant relation between 1, and 2-yr mortality and T-BIS &lt;45 did not reach statistical significance.

    CONCLUSION: Using a similar set of co-variates as in previous work, we confirmed the statistical relation between 1-yr mortality and T-BIS &lt;45, and we extended this observation to 2-yr mortality. However, this relation is sensitive to the selection of co-variates in the statistical model, and a randomized study is required to demonstrate that there really is a causal impact from and T-BIS (&lt;45) on postoperative mortality and, if it does, the effect is probably very weak in comparison with co-morbidity as assessed by ASA physical score, the preexisting malignancy status at surgery and age.

  • 11.
    Nilsson, Andreas
    et al.
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
    Sjöberg, Folke
    Linköping University, Department of Clinical and Experimental Medicine, Burn Center. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Öster, Susanne
    Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
    Bek-Jensen, Hanne
    Östergötlands Läns Landsting, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Lennmarken, Claes
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
    Patient-Controlled Sedation and Analgesia with Propofol and Alfentanil: A Preliminary Safety Evaluation Prior to Use of Non-Anaesthesiology Doctors2012In: Open Journal of Anesthesiology, ISSN 2164-5558, Vol. 2, no 2, p. 47-52Article in journal (Refereed)
    Abstract [en]

    Background: The aim was to evaluate safety aspects of patient-controlled sedation and analgesia (PCS) for extracor-poreal shockwave lithotripsy (ESWL) and PCS to be handled by non-anaesthesiology doctors. Methods: Thirty-four ASA I-III patients used PCS with propofol and alfentanil for ESWL in this interventional study. Strict safety limits were defined regarding respiratory rate (RR), heart rate (HR), mean arterial blood pressure (MAP), oxygen saturation from pulse oximetry (SpO2), and transcutaneous partial pressures of oxygen (PtcO2) and carbon dioxide (PtcCO2). The pa-tients’ levels of consciousness was graded on a five-point scale and monitored with Bispectral Index (BIS). A nurse anaesthetist was supervising the procedure but was instructed to intervene only if safety limits were breached. No sup-plementary oxygen was given. Results: All patients responded to verbal stimuli during treatment. Cardiovascular sta-bility was maintained, but respiratory variables were affected. Two patients with SpO2 < 90% and two cases of RR ≤ 8 were diagnosed, and seven patients became hypercarbic (PtcCO2 ≥ 6.5 kPa). In 18 patients hypoxaemia was indicated as PtcO2 ≤ 8.0 kPa. All these 18 patients were given supplementary oxygen. There was no correlation between dose of drugs, age, weight or any vital variable. The 34 patients would use PCS again in the case of future treatment. Conclu-sions: During ESWL treatment PCS can be used with good patients’ satisfaction, and maintained cardiovascular stabil-ity, but PCS had an indisputable effect on pulmonary function with hypoxemia (resulting in need for supplementary oxygen) or hypercarbia. The person in charge of PCS must therefore be trained to perform according to the guidelines for sedation and/or analgesia by non-anaesthesiology doctors.

  • 12.
    Sandin, Rolf H
    et al.
    Department of Anaesthesia and Intensive Care, Länssjukhuset, Kalmar, Sweden.
    Enlund, Gunnar
    Department of Anaesthesia and Intensive Care, Vrinnevisjukhuset, Norrköping, Sweden.
    Samuelsson, Peter
    Linköping University, Department of Medicine and Health Sciences. Linköping University, Faculty of Health Sciences.
    Lennmarken, Claees
    Department of Anaesthesia and Intensive Care, Vrinnevisjukhuset, Norrköping, Sweden.
    Awareness during anaesthesia: a prospective case study2000In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 355, no 9205, p. 707-711Article in journal (Refereed)
    Abstract [en]

    Background

    Patients who are given general anaesthesia are not guaranteed to remain unconscious during surgery. Knowledge about the effectiveness of current protective measures is scarce, as is our understanding of patients' responses to this complication. We did a prospective case study to assess conscious awareness during anaesthesia.

    Methods

    11 785 patients who had undergone general anaesthesia were interviewed for awareness on three occasions: before they left the post-anaesthesia care unit, and 1–3 days and 7–14 days after the operation.

    Findings

    We identified 18 cases of awareness and one case of inadvertent muscle blockade that had occurred before unconsciousness. Incidence of awareness was 0·18% in cases in which neuromuscular blocking drugs were used, and 0·10% in the absence of such drugs. 17 cases of awareness were identified at the final interview, but no more than 11 would have been detected if an interview had been done only when the patients left the post-anaesthesia care unit. Four non-paralysed patients recalled intraoperative events, but none had anxiety during wakefulness or had delayed neurotic symptoms. This finding contrasts with anaesthesia with muscle relaxants, during which 11 of 14 patients had pain, anxiety, or delayed neurotic symptoms. After repeated discussion and information, the delayed neurotic symptoms resolved within 3 weeks in all patients. Analysis of individual cases suggests that a reduced incidence of recall of intraoperative events would not be achieved by monitoring of end-tidal anaesthetic gas concentration or by more frequent use of benzodiazepines.

    Interpretation

    The inability to prevent awareness by conventional measures may advocate monitoring of cerebral activity by neurophysiological techniques. However, the sensitivity of such techniques is not known, and in the light of our findings, at least 861 patients would need to be monitored to avoid one patient from suffering due to awareness during relaxant anaesthesia.

  • 13.
    Zdolsek, Joachim
    et al.
    Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Intensive Care UHL.
    Holmgren, Susanna
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics.
    Wedenberg, K
    Department of Obstetrics and Gynaecology, Eskilstuna, Sweden.
    Lennmarken, Claes
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Intensive Care UHL.
    Circulatory arrest in late pregnancy: caesarean section a vital decision for both mother and child2009In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 53, no 6, p. 828-829Article in journal (Refereed)
    Abstract [en]

    Circulatory arrest during pregnancy is extremely rare and there should be a well-planned strategy for its management in all hospitals. To consider the priority of the mothers life over the childs and an unwarranted pre-term delivery may lead to hesitancy and uncertainty and jeopardize both of them. In these situations, speed is a priority. Cardiopulmonary resuscitation should commence immediately. The anaesthesiologist should be well aware of the possible advantage of a caesarean section. Even if the obstetrician is responsible for the decision to perform the operation, the anaesthesiologist should strongly support the action. An emergency caesarean kit with the essential surgical instruments should be immediately available in every labour ward and emergency department.

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