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  • 1.
    Alkaissi, Aidah
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Intensivvårdskliniken US.
    Evertsson, Karin
    Östergötlands Läns Landsting, Anestesi- och operationscentrum, Intensivvårdskliniken US.
    Johnsson, Vivi-Ann
    Department of Anaesthesiology and Intensive Care, Västervik Hospital .
    Ofenbartl, Lilli
    Department of Anaesthesiology and Intensive Care, Eksjö Hospital, Linköping, Sweden.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    P6 acupressure may relieve nausea and vomiting after gynecological surgery: an effectiveness study in 410 women2002Ingår i: Canadian Journal of Anesthesia, ISSN 0832-610X, Vol. 49, nr 10, s. 1034-1039Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Purpose: To investigate the effect of sensory stimulation of the P6 point on postoperative nausea and vomiting (PONV) after gynecological surgery in the everyday clinical setting (effectiveness study).

    Methods: Four hundred and ten women undergoing general anesthesia for elective gynecological surgery were included in a prospective, consecutive, randomized, multicentre, placebo-controlled, double-blind clinical trial with a reference group. One group was given bilateral P6 acupressure (n = 135), a second group similar pressure on bilateral non-acupressure points (n = 139), and a third group (n = 136) served as reference group. Nausea (scale 0–6), vomiting, pain, and satisfaction with the treatment were recorded. Primary outcome was complete response, i.e., no nausea, vomiting or rescue medication for 24 hr. Results were analyzed by applying logistic regression with indicators of treatments, type of operation and risk score for PONV as explanatory variables.

    Results: Complete response was more frequent in the P6 acupressure group than in the reference group (P = 0.0194) Conversely, the incidence of PONV was 46% in the reference group, 38% after pressure on a non-acupoint and 33% after P6 acupressure. The decrease from 46% to 33% was statistically significant. When considering vaginal cases separately, the decrease in PONV was from 36% to 20% (P = 0.0168). The corresponding decrease from 59% to 55% in the laparoscopic surgery group was not statistically significant.

    Conclusion: P6 acupressure is a non-invasive method that may have a place as prophylactic antiemetic therapy during gynecological surgery.

  • 2.
    Alkaissi, Aidah
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Intensivvårdskliniken US.
    Gunnarsson, H.
    Department of Anesthesiology, Västervik Hospital, Sweden.
    Evertsson, Karin
    Department of Anesthesiology, Västervik Hospital, Sweden.
    Johnsson, V.
    Department of Anesthesiology, Västervik Hospital, Sweden.
    Ofenbartl, L.
    Department of Anesthesiology, Eksjö Hospital, Sweden.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Disturbing postoperative symptoms are not reduced by prophylactic antiemetric treatment in patients at high risk for post-operative nausea and vomiting2004Ingår i: Acta anaesthesiologica Scandinavica, ISSN 0001-5172, Vol. 48, nr 6, s. 761-71Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: To give prophylactics or timely treatment for post-operative nausea and vomiting (PONV) is the question. We compared the intensity and number of disturbing post-operative symptoms (i.e. pain, PONV, headache, fatigue, etc.) after prophylactic antiemetic treatment in a group of patients with >30% risk for post-operative vomiting. METHODS: Four hundred and ninety-five patients, from three hospitals, planned for gynaecological surgery were randomized double blind. They were given granisetron 3 mg, droperidol 1.25 mg or no prophylactic antiemetic. Post-operative symptoms were followed for 24 h using a questionnaire. Symptoms were analyzed both according to their intensity and in a dichotomous fashion. RESULTS: The intensity of different symptoms differed depending on whether droperidol, granisetron or no antiemetic had been given (P = 0.005) but the overall incidence of moderate to very severe symptoms was similar in all groups. No group fared better in general. The total number of symptoms was higher in the groups given prophylactic treatment (P < 0.05). The relative risk reduction for PONV with granisetron or droperidol prophylaxis was 27%[95% confidence interval (CI) 8-43] and 22% (2-38), respectively. The NNT (number needed to treat) for granisetron (0-24 h) was 7 and for droperidol 8. The NNH (number needed to harm) (0-24 h) for headache and visual disturbances was 6 and 13 (NS) for granisteron and, 50 (NS) and 6 for droperidol. CONCLUSION: The intensity of symptoms or the total number of disturbing symptoms did not decrease after prophylactic antiemetic treatment in a group of patients, but the profile of disturbing symptoms changed. The relevance of post-operative symptoms in terms of patients' well-being needs to be addressed.

  • 3.
    Alkaissi, Aidah
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Intensivvårdskliniken US.
    Ledin, Torbjörn
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Oto-Rhino-Laryngologi. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Rekonstruktionscentrum, Öronkliniken US.
    Ödkvist, Lars
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Oto-Rhino-Laryngologi. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Rekonstruktionscentrum, Öronkliniken US.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    P6 acupressure increases tolerance to nausogenic motion stimulation in women with high risk for PONV2005Ingår i: Canadian Journal of Anesthesia, ISSN 1496-8975, Vol. 52, s. 703-709Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Purpose: In a previous study we noticed that P6 acupressure decreased postoperative nausea and vomiting (PONV) more markedly after discharge. As motion sickness susceptibility is increased by, for example, opioids we hypothesized that P6 acu-pressure decreased PONV by decreasing motion sickness susceptibility. We studied time to nausea by a laboratory motion challenge in a group of volunteers, during P6 and placebo acupressure.

    Methods: 60 women with high and low susceptibilities for motion sickness participated in a randomized and double-blind study with an active P6 acupressure, placebo acupressure, and a control group (n = 20 in each group). The risk score for PONV was over 50%. The motion challenge was by eccentric rotation in a chair, blindfolded and with chin to chest movements of the head. The challenge was stopped when women reported moderate nausea. Symptoms were recorded.

    Results: Mean time to moderate nausea was longer in the P6 acu-pressure group compared to the control group. P6 acupressure = 352 (259–445), mean (95% confidence interval) in seconds, control = 151 (121–181) and placebo acupressure = 280 (161–340); (P = 0.006). No difference was found between P6 and placebo acupressure or placebo acupressure and control groups. Previous severity of motion sickness did not influence time to nausea (P = 0.107). The cumulative number of symptoms differed between the three groups (P < 0.05). Fewer symptoms were reported in the P6 acupressure compared to the control group P < 0.009. Overall, P6 acupressure was only marginally more effective than placebo acupressure on the forearms.

    Conclusion: In females with a history of motion sickness P6 acu-pressure increased tolerance to experimental nauseogenic stimuli, and reduced the total number of symptoms reported.

  • 4.
    Alkaissi, Aidah
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Intensivvårdskliniken US.
    Stålnert, Monica
    Linköpings universitet, Institutionen för medicin och hälsa, Omvårdnad. Linköpings universitet, Hälsouniversitetet.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Effect and placebo effect of acupressure (P6) on nausea and vomiting after outpatientgynaecological surgery1999Ingår i: Acta anaesthesiologica Scandinavica, ISSN 0001-5172, Vol. 43, nr 3, s. 270-274Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Acupuncture and acupressure have previously been reported to possess antiemetic effect. We wanted to investigate the "true" and placebo effect of acupressure in prevention of postoperative nausea and vomiting (PONV). PATIENTS AND METHODS: Sixty women undergoing outpatient minor gynaecological surgery were entered into a double-blind and randomised study. One group received acupressure with bilateral stimulation of P6 (A), a second group received bilateral placebo stimulation (P) and a third group received no acupressure wrist band and served as a reference group (R). PONV was evaluated as number of patients with complete response (no PONV), nausea only or vomiting. In addition, the need for rescue antiemetic medication and nausea after 24 h was registered. RESULTS: Complete response was obtained in 11, 11 and 9 patients in groups, A, P and R, respectively. Nine, 7 and 6 patients had nausea before discharge home, and 1, 1 and 8 patients were nauseated (8 vs 1 patient: P < 0.05) 24 h after operation in A, P and R groups, respectively. When compared to placebo acupressure (2 patients vomited and 5 needed rescue), significantly (P < 0.05) fewer needed rescue antiemetic medication after acupressure at P6 (no vomiting or rescue medication). When compared to the observation group (5 vomited and 4 needed rescue antiemetics), significantly fewer vomited after acupressure (P < 0.05) CONCLUSION: In patients undergoing brief gynaecological surgery, placebo effect of acupressure decreased nausea after 24 h but vomiting and need of rescue antiemetics was reduced only by acupressure with the correct P6 point stimulation.

  • 5.
    Bartha, Erzsebet
    et al.
    Department of Anaesthesiology and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.
    Rudin, Å.
    Department of Anaesthesiology and Intensive Care, Lund University Hospital, Lund, Sweden.
    Flisberg, P.
    Department of Anaesthesiology and Intensive Care, Lund University Hospital, Lund, Sweden, .
    Lundberg, CJ.
    Department of Anaesthesiology, Malmö University Hospital, Malmö, Sweden.
    Carlsson, Per
    Linköpings universitet, Institutionen för hälsa och samhälle, Centrum för utvärdering av medicinsk teknologi. Linköpings universitet, Hälsouniversitetet.
    Kalman, Sigga
    Department of Anaesthesiology and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.
    Could benefits of epidural analgesia following oesophagectomy be measured by perceived perioperative patient workload?2008Ingår i: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 52, nr 10, s. 1313-1318Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    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.

    Methods: Clinical data and rates of post-operative complications were extracted from a previously reported trial following thoraco-abdominal oesophagectomy. Cost data for individual patients included in that trial were retrospectively obtained from administrative records. Two separate phases were defined: costs of pain treatment and the direct cost of intensive care.

    Results: Higher calculated costs of epidural vs. intravenous pain treatment, 1,037 vs. 410 Euros/patient, were outweighed by lower post-operative costs of intensive care 5,571 vs. 7,921 Euros/patient (NS).

    Conclusion: Higher costs and better analgesic effects of epidural analgesia compared with intravenous analgesia do not reduce total costs for post-operative care following major surgery.

  • 6.
    Bartha, Erzsébet
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi.
    Carlsson, Per
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för hälsa och samhälle, Centrum för utvärdering av medicinsk teknologi.
    Kalman, Sigga
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Evaluation of costs and effects of epidural analgesia and patient-controlled intravenous analgesia after major abdominal surgery2006Ingår i: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 96, nr 1, s. 111-117Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background. The outcome of different treatment strategies for postoperative pain has been an issue of controversy. Apart from efficacy and effectiveness a policy decision should also consider cost-effectiveness. Since economic analyses on postoperative pain treatment are rare we developed a decision model in a pilot cost-effectiveness analysis (CEA) comparing epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) after major abdominal surgery in routine care. Methods. Using a decision-tree model, treatment with EDA (ropivacaine and morphine) was compared with PCIA (morphine). Effects and costs of treatment were established. The number of pain-free days at rest (pain intensity <30 using visual analogue scale 1-100 mm) was the primary measure of effect. An incremental cost-effectiveness ratio (ICER) was calculated as the difference in direct costs divided by the difference in effect. A database on 644 patients collected for the purpose of quality control during the period of 1997 to 1999 was the main data source. Sensitivity analysis was used to test uncertain data. Results. EDA was more effective in terms of pain-free days but more expensive. The additional cost for each pain-free day was 5652 Euros. Conclusion. It is a judgement of value if the additional cost is reasonable. When the cost of around 55 000 Euros per gained life-year with full health for other interventions is debated, our result indicates poor cost-effectiveness for EDA. Before any conclusion can be drawn concerning policy recommendations the difference in costs has to be related to other outcome measures as length of hospital stay, morbidity and mortality are required. © The Board of Management and Trustees of the British Journal of Anaesthesia 2005. All rights reserved.

  • 7.
    Bartha, Erzsébet
    et al.
    Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Linköpings universitet, Hälsouniversitetet.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN. Linköpings universitet, Hälsouniversitetet.
    Carlsson, Per
    Linköpings universitet, Institutionen för hälsa och samhälle, Centrum för utvärdering av medicinsk teknologi. Linköpings universitet, Hälsouniversitetet.
    Postoperativ smärtlindring - till vilket pris?: En hälsoekonomisk modellanalys av två smärtlindringsmetoder2006Rapport (Övrigt vetenskapligt)
    Abstract [sv]

    Utgångspunkten för denna rapport var en kvalitetskontroll av rutiner för postoperativ smärtlindring vid Anestesikliniken på US i Linköping under 1997-1999. Vid denna kontroll upptäckte vi en del svagheter i rutiner, bl.a. att epiduralsmärtlindring avslutades tidigare än avsetts i högre frekvens än väntat. Under denna period registrerades en mängd uppgifter om aktuell behandling och olika utfall i en databas. Resultatet pekade på att den mest använda metoden i praktiken var förenad med extrainsatser som bidrog till högre kostnader. Denna kunskap ledde fram till en vidare frågeställning än vad som traditionellt diskuterats i dessa sammanhang nämligen hur de aktuella metoderna förhåller sig till varandra när även kostnader för behandlingen tas i beaktande. Det första steget att besvara denna fråga var ett projektarbete i kursen om Klinisk Utvärderingsvetenskap (KLUV) som anordnades av Linköpings universitet med stöd av Forskningsrådet i Sydvästra Sjukvårdsregionen. Studien har sedan vidareutvecklats och färdigställts vid CMT med ekonomiskt stöd från Landstinget i Östergötland.

    Syftet med rapporten är att belysa hur två metoder för postoperativ smärtlindring (epiduralbedövning och intravenös opioidbehandling med patientkontrollerad pump) fungerar i vardagssjukvård med hänsyn tagen till både kostnader och effekten på smärta. Frågan om vilken metod som är den bättre av dessa har diskuterats under senaste decenniet. Epiduralbedövning tycks ge bättre smärtlindring, men det är oklart vilket mervärde som den skillnaden i smärtintensitet ger oavsett om den mäts som patientupplevd, medicinsk eller samhällelig nytta. Frågan om vilken behandlingsform som är mest kostnadseffektiv är intressant eftersom den här typen av smärtlindring är vanlig och berör ett stort antal patienter i sjukvården. Vår förhoppning är att vi med hjälp av denna hälsoekonomiska modellanalys av beslutsproblemet kan bidra till ett bättre beslutsunderlag men också väcka ett intresse för att göra hälsoekonomiska utvärderingar av smärtlindringsmetoder vilket hittills varit relativt ovanligt.

    Studien har genomförts i samarbete mellan CMT och AnOp Centrum vid US i Linköping. Flera personer har bidragit till denna rapport och vi vill tacka Mona Lindblad och Lilian Adamsson som var ansvariga för databasen under åren 1997-1999. Vi vill vidare tacka Martin Henriksson vid CMT för värdefulla synpunkter.

  • 8.
    Johansson, Anders
    et al.
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Nilsson, Lena
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Kalman, Sigga
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Öberg, Åke
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Respiratory monitoring using photoplethysmography - evaluation in the postoperative care unit1998Ingår i: Annual International Conference of th IEEE Engineering in Medicine and Biology Society,1998, 1998Konferensbidrag (Refereegranskat)
  • 9.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Linköpings universitet, Hälsouniversitetet.
    Studies on the halothane-diethyl-ether azeotrope1994Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

    Requirements for a safe standard for anaesthesia under primitiveconditions differ from those under peaceful circumstances. It is important not to blunt the reflexes that guard vital functions. Safety requirements concerning breathing, circulation, and drug interaction must be sharpened because professional surveillance of the patient may be restricted. The halothane-diethyl-ether azeotrope (HE azeotrope) has properties that could make it suitable for anaesthesia under adverse circumstances. We have re-evaluated the HE azeotrope with special reference to safety in studies on 102 patients and 19 pigs.

    The vaporizers were calibrated to guarantee their performance. Guidelines for the use of Auotec® Mark Ill and Servo® vaporizer for halothane combined with the HE azeotrope are set out. Minimum alveolar concentration (MAC) for the HE azeotrope has not previously been published. The MAC for the HE azeotrope was determined in man (0.71 vol.%± 0.03, ± SEM) and pig (0.99 vol.%± 0.07) to allow comparison with other inhalation anaesthetics. The safety ratio defined as the ratio between fatal alveolar concentration and minimum alveolar concentration was found to be 3.1 in pig, which is about twice as high as previously reported data for halothane anaesthesia alone.

    Ventilation during surgical anaesthesia (1.1-1.2 MAC), both when resting and during challenge with raised inspiratory levels of carbon dioxide and decreased inspiratory concentration of oxygen, was measured. Ventilation was maintained during resting. Response to hypercarbia was preserved, in contrast to what was seen under isoflurane anaesthesia. Response to hypoxia was abolished.

    The central circulation was well preserved under normovolaemia in pigs during HE azeotrope anaesthesia. Haemorrhage. with a loss of30% of the blood volume was well tolerated, no matter whether the pig had received HE azeotrope or isoflurane. Isoflurane is considered in the literature to be an anaesthetic well tolerated by pigs.

    Most inhalation anaesthetics potentiate neuromuscular blockade, which is an important and sometimes dangerous component of anaesthesia. We therefore thought it important to investigate whether interaction takes place between vecuronium induced neuromuscular blockade and the HE azeotrope. Potentiation similar to that occurring during halothane anaesthesia was found.

    Early postoperative liver function was studied by tests of cellular metabolic capacity, cell integrity, cholestasis, and synthesizing capacity. No major impact on hepatic function after HE azeotrope anaesthesia was seen.

    Thus, the halothane-diethyl-ether azeotrope has properties that could make it interesting as an alternative anaesthetic drug under difficult circumstances.

  • 10.
    Kalman, Sigga
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Ekbäck, Gustav
    Örebro.
    Nilsson, Lena
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Metcalf, Kerstin
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Intensivvårdskliniken US.
    Ranklev Twetman, Eva
    Anestesiläkarnas arbetsmiljö kan förbättras. Slutrapport från ett arbetsmiljöprojekt2006Ingår i: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 103, s. 1603-1610Artikel i tidskrift (Refereegranskat)
  • 11.
    Kalman, Sigga
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Linderfalk, C
    Wårdell, Karin
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Biomedicinsk instrumentteknik.
    Eintrei, Christina
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Intensivvårdskliniken US.
    Lisander, Björn
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi.
    Differential effect on vasodilatation and pain after intradermal capsaicin in humans during decay of intravenous regional anesthesia with mepivacaine1998Ingår i: Regional anesthesia and pain medicine, ISSN 1098-7339, E-ISSN 1532-8651, Vol. 23, nr 4, s. 402-408Artikel i tidskrift (Refereegranskat)
  • 12.
    Kalman, Sigga
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, MKC - Medicin och kirurgicentrum, Anestesi.
    Svensson, H
    Lisander, Björn
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, MKC - Medicin och kirurgicentrum, Anestesi.
    Boive, Jörgen
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för nervsystem och rörelseorgan. Östergötlands Läns Landsting, Närsjukvården i centrala Östergötland, Neurologiska kliniken.
    Quantitative sensory changes in humans after itravenous regional block with mepivacaine.1999Ingår i: Regional anesthesia, ISSN 0146-521X, Vol. 24, s. 236-241Artikel i tidskrift (Refereegranskat)
  • 13.
    Kalman, Sigga
    et al.
    Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Linköpings universitet, Hälsouniversitetet.
    Österberg, Anders
    Linköpings universitet, Institutionen för nervsystem och rörelseorgan, Neurologi. Linköpings universitet, Hälsouniversitetet.
    Sörensen, Jan
    Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Linköpings universitet, Hälsouniversitetet.
    Boivie, Jörgen
    Linköpings universitet, Institutionen för nervsystem och rörelseorgan, Neurologi. Linköpings universitet, Hälsouniversitetet.
    Bertler, Åke
    Linköpings universitet, Institutionen för medicin och vård, Klinisk farmakologi. Linköpings universitet, Hälsouniversitetet.
    Morphine responsiveness in a group of well-defined multiple sclerosis patients: a study with i.v. morphine2002Ingår i: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 6, nr 1, s. 69-80Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Pain in multiple sclerosis (MS) is more common than has previously been believed. About 28% of all MS patients suffer from central pain (CP), a pain that is difficult to treat. In the present study we have investigated the responsiveness of this pain to morphine. Fourteen opioid-free patients (eight woman and six men) with constant, non-fluctuating, long-lasting CP caused by MS were investigated. Placebo (normal saline), morphine and naloxone were given intravenously in a standardized manner. The study design was non-randomized, single blind and placebo controlled. Ten patients experienced less than 50% pain reduction by placebo and less than 50% pain reduction by morphine. Four patients were opioid responders, i.e. had minimal or no effect on pain by placebo, >50% pain reduction after morphine and >25% pain increase after naloxone, given intravenously following morphine. However, this response was obtained after high doses of morphine (43 mg, 47 mg, 50 mg and 25 mg; mean 41 mg). Thus, compared with nociceptive pain, only a minority of the patients with CP due to MS responded to morphine and only at high doses. The present results are in accord with experimental studies indicating that neuropathic pain is poorly responsive but not totally unresponsive to opioids. The results do not support the routine use of strong opioids in MS patients with CP.

  • 14.
    Nilsson, Andreas
    et al.
    Östergötlands Läns Landsting, Sinnescentrum, Anestesi- och operationkliniken US. Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Sinnescentrum, Anestesi- och intensivvårdskliniken VIN.
    Arvidsson, Anders
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Brännskadevård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Sinnescentrum, Hand- och plastikkirurgiska kliniken US.
    Sjöberg, Folke
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Brännskadevård. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Sinnescentrum, Hand- och plastikkirurgiska kliniken US. Östergötlands Läns Landsting, Sinnescentrum, Anestesi- och operationkliniken US.
    Difficulties in Controlling Mobilization Pain Using a Standardized Patient-Controlled Analgesia Protocol in Burns2011Ingår i: JOURNAL OF BURN CARE and RESEARCH, ISSN 1559-047X, Vol. 32, nr 1, s. 166-171Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The aim of this study was to evaluate pain relief for patients with burns during rest and mobilization with morphine according to a standard protocol for patient-controlled analgesia (PCA). Eighteen patients with a mean (SD) burned TBSA% of 26 (20) were studied for 10 days. Using a numeric rating scale (NRS, 0 = no pain and 10 = unbearable pain), patients were asked to estimate their acceptable and worst experienced pain by specifying a number on a scale and at what point they would like additional analgesics. Patients were allowed free access to morphine with a PCA pump device. Bolus doses were set according to age, (100 - age)/24 = bolus dose (mg), and 6 minutes lockout time. Degrees of pain, morphine requirements, doses delivered and demanded, oral intake of food, and antiemetics given were used as endpoints. Acceptable pain (mean [SD]) was estimated to be 3.8 (1.3) on the NRS, and additional treatment was considered necessary at scores of 4.3 (1.6) or more. NRS at rest was 2.7 (2.2) and during mobilization 4.7 (2.6). Required mean morphine per day was 81 (15) mg, and the number of doses requested increased during the first 6 days after the burn. The authors found no correlation between dose of morphine required and any other variables. Background pain can be controlled adequately with a standard PCA protocol. During mobilization, the pain experienced was too intense, despite having the already high doses of morphine increased. The present protocol must be refined further to provide analgesia adequate to cover mobilization as well.

  • 15.
    Nilsson, Lena
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Goscinski, Tomas
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Johansson, Anders
    Linköpings universitet, Institutionen för medicinsk teknik. Linköpings universitet, Hälsouniversitetet.
    Lindberg, Lars-Göran
    Linköpings universitet, Institutionen för medicinsk teknik. Linköpings universitet, Hälsouniversitetet.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Age and gender do not influence the ability to detect respiration by photoplethysmography2006Ingår i: Journal of clinical monitoring and computing, ISSN 1387-1307, E-ISSN 1573-2614, Vol. 20, nr 6, s. 431-436Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective  The non-invasive technique photopl- ethysmography (PPG) can detect changes in blood volume and perfusion in a tissue. Respiration causes variations in the peripheral circulation, making it possible to monitor breaths using an optical sensor attached to the skin. The respiratory-synchronous part of the PPG signal (PPGr) has been used to monitor respiration during anaesthesia, and in postoperative and neonatal care. Studies addressing possible differences in PPGr signal characteristics depending on gender or age are lacking.

    Methods  We studied three groups of 16 healthy subjects each during normal breathing; young males, old males and young females, and calculated the concordance between PPGr, derived from a reflection mode PPG sensor on the forearm, and a reference CO2 signal. The concordance was quantified by using a squared coherence analysis. Time delay between the two signals was calculated. In this process, we compared three different methods for calculating time delay.

    Results  Coherence values ≥0.92 were seen for all three groups without any significant differences depending on age or gender (p = 0.67). Comparison between the three different methods for calculating time delay showed a correlation r = 0.93.

    Conclusions  These results demonstrate clinically important information implying the possibility to register qualitative PPGr signals for respiration monitoring, regardless of age and gender.

  • 16.
    Nilsson, Lena
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Goscinski, Tomas
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi.
    Kalman, Sigga
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Lindberg, Lars-Göran
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Johansson, Anders
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Detection of breaths by photoplethysmography is independent of age and sex2005Ingår i: Congress of the Scandinavian Society of Anaesthesiology and intensive care,2005, 2005, s. 19-Konferensbidrag (Refereegranskat)
  • 17.
    Nilsson, Lena
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Goscinski, Tomas
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi.
    Kalman, Sigga
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Lindberg, Lars-Göran
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Johansson, Anders
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Photoplethysmography for central and obstructive apnea detection2005Ingår i: Congress of the Scandinavian Society of Anaesthesiology and intensive care,2005, 2005, s. 19-Konferensbidrag (Refereegranskat)
  • 18.
    Nilsson, Lena
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Goscinski, Tomas
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi.
    Kalman, Sigga
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Lindberg, Lars-Göran
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Johansson, Anders
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Time relation between respiratory signals can be analysed by automated algorithms2005Ingår i: Congress of the Scandinavian Society of Anaesthesiology and intensive care,2005, 2005, s. 19-Konferensbidrag (Refereegranskat)
  • 19.
    Nilsson, Lena
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Johansson, Anders
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Kalman, Sigga
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Den andningssynkrona kompenenten av den fotopletysmorgrafiska signalen hos sövda påverkas inte av övertrycksandning2004Ingår i: Programbok SFAI-veckan 2004,2004, 2004, s. 149-19Konferensbidrag (Övrigt vetenskapligt)
    Abstract [sv]

       

  • 20.
    Nilsson, Lena
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Johansson, Anders
    Linköpings universitet, Institutionen för biomedicin och kirurgi. Linköpings universitet, Hälsouniversitetet.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Macrocirculation is not the sole determinant of respiratory induced variations in the reflection mode photoplethysmographic signal2003Ingår i: Physiological Measurement, ISSN 0967-3334, E-ISSN 1361-6579, Vol. 24, nr 4, s. 925-937Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Photoplethysmography (PPG) is a non-invasive optical technique sensitive to variations in blood volume and perfusion in the tissue. Reflection mode PPG may have clinical advantages over transmission mode PPG. To improve clinical usefulness and further development of the reflection mode PPG, studies on factors that modify the signal are warranted. We studied the coherence between the respiratory induced intensity variations (RIIV) of the PPG signal and respiratory synchronous pressure variations in central venous pressure (CVP), peripheral venous pressure (PVP) and arterial blood pressure (ABP) during positive pressure ventilation on 12 patients under anaesthesia and on 12 patients with spontaneous breathing. During positive pressure ventilation the coherence between all signals was high. Inspiration was followed first by an increase in CVP, then by increases in ABP and PVP and lastly by RIIV indicating less back-scattered light. In spontaneously breathing patients the coherence was high, but the phases between the signals were changed. During inspiration, ABP decreased slightly before CVP, followed by a decrease in RIIV and PVP. The phase relation between RIIV and respiratory induced variation in macrocirculation changed with ventilatory mode, but not in a uniform way, indicating the influence of mechanisms other than macrocirculation involved in generating the RIIV signal.

  • 21.
    Nilsson, Lena
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Johansson, Anders
    Linköpings universitet, Institutionen för medicinsk teknik. Linköpings universitet, Hälsouniversitetet.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Monitoring of respiratory rate in postoperative care using a new photoplethysmographic technique2000Ingår i: Journal of clinical monitoring and computing, ISSN 1387-1307, E-ISSN 1573-2614, Vol. 16, nr 4, s. 309-315Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective.Photoplethysmography (PPG) is a non-invasive optical technique that measures variations in skin blood volume and perfusion. The PPG signal contains components that are synchronous with respiratory and cardiacrhythms. We undertook this study to evaluate PPG for monitoring patients' respiratory rate in the postoperative care unit, using a new prototype device. We compared it with the established technique, transthoracic impedance (TTI).

    Methods.PPG signals from 16 patients(ASA classes 1–2, mean age 43 years) who were recovering from general anaesthesia after routine operations were recorded continuously for 60minutes/patient. The respiratory synchronous part of the PPG signal was extracted by using a band pass filter. Detection of breaths in the filtered PPG signals was done both visually and by using an automated algorithm. In both procedures, the detected breaths were compared with the breaths detected in the TTI reference.

    Results.A total of 10.661 breaths were recorded, and the mean ± SD respiratory rate was 12.3 ± 3.5breaths/minute. When compared with TTI, the rates of false positive and false negative breaths detected by PPG (visual procedure) were 4.6 ±4.5% and 5.8 ± 6.5%, respectively. When using the algorithm for breath detection from PPG, the rates of false positive andfalse negative breaths were 11.1 ± 9.7% and 3.7 ±3.8%, respectively, when compared to TTI. Lower respiratory rates increased the occurrence of false-positive breaths that were detected by the PPG using visual identification (p< 0.05). The same tendency was seen with the automated PPG procedure (p< 0.10).

    Conclusions.Our results indicate that PPG has the potential to be useful for monitoring respiratory rate in the postoperative period.

  • 22.
    Nilsson, Lena
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, MKC - Medicin och kirurgicentrum, Anestesi.
    Johansson, Anders
    Kalman, Sigga
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, MKC - Medicin och kirurgicentrum, Anestesi.
    Phase relations between circulatory and photoplethysmographic respiratory variations2002Ingår i: Proceedings: International Federation for Medical & Biological Engineering,2002, 2002, s. 52-53Konferensbidrag (Refereegranskat)
  • 23.
    Nilsson, Lena
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Johansson, Anders
    Linköpings universitet, Institutionen för medicinsk teknik. Linköpings universitet, Hälsouniversitetet.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Respiration can be monitored by photoplethysmography with high sensitivity and specificity regardless of anaesthesia and ventilatory mode2005Ingår i: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 49, nr 8, s. 1157-1162Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background:  Photoplethysmography (PPG) is a non-invasive optical technique used, for instance, in pulse oximetry. Beside the pulse synchronous component, PPG has a respiratory synchronous variation (PPGr). Efforts have been made to utilize this component for indirect monitoring of respiratory rate and volume. Assessment of the clinical usefulness as well as of the physiological background of PPGr is required. We evaluated if anaesthesia and positive-pressure ventilation would affect PPGr.

    Methods:  We recorded reflection mode PPGr, at the forearm, and the respiratory synchronous changes in central venous pressure (CVP), peripheral venous pressure (PVP) and arterial blood pressure (ABP) in 12 patients. Recordings for each patient were made on three occasions: awake with spontaneous breathing; anaesthetized with spontaneous breathing; and anaesthetized with positive-pressure ventilation. We analyzed the sensitivity, specificity, coherence and time relationship between the signals.

    Results:  PPGr sensitivity for breath detection was [mean (SD)] >86(21)% and specificity >96(12)%. Respiratory detection in the macrocirculation (CVP, PVP and ABP) showed a sensitivity >83(29)% and specificity >93(12)%. The coherence between signals was high (0.75–0.99). The three measurement situations did not significantly influence sensitivity, specificity or time shifts between the PPGr, PVP, ABP, and the reference CVP signal despite changes in physiological data between measurements.

    Conclusion:  A respiratory synchronous variation in PPG and all invasive pressure signals was detected. The reflection mode PPGr signal seemed to be a constant phenomenon related to respiration regardless of whether or not the subject was awake, anaesthetized or ventilated, which increases its clinical usefulness in respiratory monitoring.

  • 24.
    Nilsson, Lena
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Johansson, Anders
    Linköpings universitet, Institutionen för medicinsk teknik. Linköpings universitet, Hälsouniversitetet.
    Kalman, Sigga
    Linköpings universitet, Institutionen för medicin och hälsa, Anestesiologi med intensivvård. Linköpings universitet, Hälsouniversitetet.
    Respiratory variations in the reflection mode photoplethysmographic signal: relationships to peripheral venous pressure2003Ingår i: Medical and Biological Engineering and Computing, ISSN 0140-0118, E-ISSN 1741-0444, Vol. 41, nr 3, s. 249-254Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Photoplethysmography (PPG) is a non-invasive optical way of measuring variations in blood volume and perfusion in the tissue, used in pulse oximetry for instance. Respiratory-induced intensity variations (RIIVs) in the PPG signal exist, but the physiological background is not fully understood. Respiration causes variations in the blood volume in the peripheral vascular bed. It was hypothesised that the filling of peripheral veins is one of the important factors involved. In 16 healthy subjects, the respiratory synchronous variations from a PPG reflection mode signal and the peripheral venous pressure (PVP) were recorded. Variations of tidal volume, respiratory rate and contribution from abdominal and thoracic muscles gave significant and similar amplitude changes in both RIIV and the respiratory variation of PVP (p<0.01). The highest amplitudes of both signals were found at the largest tidal volume, lowest respiratory rate and during mainly thoracic breathing, respectively. The coherence between PVP and RIIV signals was high, the median (quartile range) being 0.78 (0.42). Phase analysis showed that RIIV was usually leading PVP, but variations between subjects were large. Although respiratory-induced variations in PVP and PPG showed a close correlation in amplitude variation, a causal relationship between the signals could not be demonstrated.

  • 25.
    Nilsson, Lena
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Johansson, Anders
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Kalman, Sigga
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    The phase of the respiratory variation in the photoplethysmographic signal is not affected by sympathetic tone2004Ingår i: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 21, s. 76-77Artikel i tidskrift (Refereegranskat)
  • 26.
    Nilsson, Lena
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Johansson, Anders
    Linköpings universitet, Tekniska högskolan. Linköpings universitet, Institutionen för medicinsk teknik, Fysiologisk mätteknik.
    Svanerudh, Johan
    Kalman, Sigga
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Anestesiologi. Östergötlands Läns Landsting, Anestesi- och operationscentrum, Anestesi- och intensivvårdskliniken VIN.
    Is the respiratory component of the photoplethysmographic signal of venous origin?1999Ingår i: Medical & Biological Engineering & Computing, ISSN 0140-0118, Vol. 37, s. 912-913Artikel i tidskrift (Refereegranskat)
1 - 26 av 26
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