Papers by Adalbjorn Thorsteinsson
Laeknabladid, Jun 1, 2010
British Journal of Anaesthesia, 2020
Background: Accidental dural puncture is an uncommon complication of epidural analgesia and can c... more Background: Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. Methods: Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. Results: A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19e1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score 3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. Conclusions: Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.
Objectives: Primarily, to determine if respiratory variables, assessed on a daily basis on days 1... more Objectives: Primarily, to determine if respiratory variables, assessed on a daily basis on days 1±6 after ICU admission, were associated with mortality in non-ARDS and ARDS patients with respiratory failure requiring mechanical ventilation. Secondarily, to determine non-respiratory factors associated with mortality in ARDS and non-ARDS patients. Design: Prospective multicentre clinical study. Setting: Seventy-eight intensive care units in Sweden and Iceland. Patients: Five hundred twenty non-ARDS and 95 ARDS patients. Measurements and results: Potentially prognostic factors present at inclusion were tested against 90-day mortality using a Cox regression model. Respiratory variables (PaO 2 / FIO 2 , PEEP, mean airway pressure (MAP) and base excess (BE)) were tested against mortality using the model. Primary aim: in non-ARDS a low PaO 2 /FIO 2 on day 1, RR (risk ratio) = 1.17, CI (95 % confidence interval) (1.
A 16-year-old female developed severe ARDS in her single remaining lung following pneumonectomy f... more A 16-year-old female developed severe ARDS in her single remaining lung following pneumonectomy for blunt trauma. Total extracorporeal lung assist (ECLA) for 40 days using a covalently heparin-coated circuit proved lifesaving. Systemic heparinization was not applied, as the heparinized surface by itself prevented clotting of the extracorporeal circuit. Systemic primary fibrinolysis developed but was not associated with major bleeding. A veno-right ventricular cannulation technique was used and maximum venous drainage for the extracorporeal circulation was achieved by elevating the bed 50 cm from the floor. This allowed extracorporeal blood flow (ECBF) approaching cardiac output (GO) and complete extracorporeal replacement of lung function. After 40 days, lung recovery allowed discontinuation of ECLA. Five days later the patient suffered serious lung collapse and was operated for a bronchopleural fistula. The patient was extubated 4 weeks after terminating ECLA and discharged in good condition 5 weeks later.
We report a case of a large labetalol overdose in an eight-month-old infant that was being treate... more We report a case of a large labetalol overdose in an eight-month-old infant that was being treated for hypertension following surgery for coarctation of the aorta. Labetalol, both alpha and beta adrenergic blocking agent was used for treating postoperative hypertension. By mistake, the patient was given an extremely high dose of labetalol intravenously (17.2 mgAEkg)1). Remarkably, the medication error had a surprisingly limited clinical effect on the infant who survived the incident. We discuss the pharmacokinetic, pharmocodynamic and possible explanations for this fortunate turn of events.
We sought to estimate effectiveness of transdermal scopolamine to prevent postoperative nausea an... more We sought to estimate effectiveness of transdermal scopolamine to prevent postoperative nausea and vomiting after gynecologic laparoscopy. Design: Patients were randomized to receive preoperative transdermal scopolamine or placebo. Main outcome measure was incidence of nausea during the first 24 hours postoperatively. Wilcoxon rank sum, Student t, 2 , and Fischer exact tests were used for data analysis (Canadian Task Force classification IA). Setting: Academic teaching hospital. Patients: A total of 48 patients undergoing gynecologic laparoscopy were studied. Interventions: Randomized administration of transdermal Scopolamine or placebo in patients having gynecologic laparoscopic surgery. Measurements and Main Results: Patients in the scopolamine group had significantly less incidence of nausea (20.8% vs 62.5%, p ϭ .003) and vomiting (8.3% vs 37.5%, p ϭ .016) during the first 24 hours after surgery. Number needed to treat was 3 (95% CI 1.5, 6.1) for nausea and 4 (95% CI 1.9, 14.6) for vomiting. Symptoms of visual disturbance and dry mouth were more common in the scopolamine group. Conclusion: Scopolamine patch significantly reduces incidence and severity of nausea and vomiting in the first 24 hours after gynecologic laparoscopic surgery.
Background: Cyclic opening and closing of lung units during tidal breathing may be an important c... more Background: Cyclic opening and closing of lung units during tidal breathing may be an important cause of iatrogenic lung injury. We hypothesized that airway closure is uncommon in children with healthy lungs when inspiratory pressures are kept low, but paradoxically may occur when inspiratory pressures are increased. Methods: Elastic equilibrium volume (EEV) and closing capacity (CC) were measured with a tracer gas (SF 6) technique in 11 anesthetized, muscle-relaxed, endotracheally intubated and artificially ventilated healthy children, aged 0.6-13 years. Airway closing was studied in a randomized order at two inflation pressures, π20 or π30 cmH 2 O, and CC and CC/EEV were calculated from the plots obtained when the lungs were exsufflated to ª20 cmH 2 O. (CC/EEV Ͼ1 indicates that airway closure might occur during tidal breathing). Furthermore, a measure of uneven ventilation, multiple breath alveolar mixing efficiency (MBA-ME), was obtained. Results: Airway closure within the tidal volume (CC/EEV Ͼ1)
Objectives: To reexamine the epidemiology of acute lung injury (ALI) in European intensive care u... more Objectives: To reexamine the epidemiology of acute lung injury (ALI) in European intensive care units (ICUs). Design and setting: A 2-month inception cohort study in 78 ICUs of 10 European countries. Patients: All patients admitted for more than 4 h were screened for ALI and followed up to 2 months. Measurements and main results: Acute lung injury occurred in 463 (7.1%) of 6,522 admissions and 16.1% of all mechanically ventilated patients; 65.4% cases occurred on ICU admission. Among 136 patients initially presenting with "mild ALI" (200< PaO 2 /FiO 2 £300), 74 (55%) evolved to acute respiratory distress syndrome (ARDS) within 3 days. Sixty-two patients (13.4%) remained with mild ALI and 401 had ARDS. The crude ICU and hospital mortalities were 22.6% and 32.7% (p<0.001), and 49.4% and 57.9% (p=0.0005), respectively, for mild ALI and ARDS. ARDS patients initially received a mean tidal volume of 8.3±1.9 ml/kg and a mean PEEP of 7.7±3.6 cmH 2 O; air leaks occurred in 15.9%. After multivariate analysis, mortality was associated with age (odds ratio (OR) =1.2 per 10 years; 95% confidence interval (CI): 1.05-1.36), immuno-incompetence (OR: 2.88; Cl: 1.57-5.28), the severity scores SAPS II (OR: 1.16
Background: A major risk with epidural analgesia is accidental dural puncture (ADP), which may re... more Background: A major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post-dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries. Methods: A postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n 5 153) with questions relating to the year 2008. Results: The overall response rate was 93%. About 32% (22-47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n 900). Epidural blood patch (EBP) was performed in 86% (n 780) of the parturients. The most common time interval from diagnosis to performing EBP was 24-48 h. The success rate for EBP was 475% in 67% (62-79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non-obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia. Conclusion: We found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non-obstetric population.
To determine the incidence and 90-d mortality of acute respiratory failure (ARF), acute lung inju... more To determine the incidence and 90-d mortality of acute respiratory failure (ARF), acute lung injury (ALI), and the acute respiratory distress syndrome (ARDS), we carried out an 8-wk prospective cohort study in Sweden, Denmark, and Iceland. All intensive care unit (ICU) admissions (n ϭ 13,346) у 15 yr of age were assessed between October 6th and November 30th, 1997 in 132 of 150 ICUs with resources to treat patients with intubation and mechanical ventilation (I ϩ MV) у 24 h. ARF was defined as I ϩ MV у 24 h. ALI and ARDS were defined using criteria recommended by the American-European Consensus Conference on ARDS. Calculation to correct the incidence for unidentified subjects from nonparticipating ICUs was made. No correction for in-or out-migration from the study area was possible. The population in the three countries у 15 yr of age was 11.74 million. One thousand two hundred thirty-one ARF patients were included, 287 ALI and 221 ARDS patients were identified. The incidences were for ARF 77.6, for ALI 17.9, and for ARDS 13.5 patients per 100,000/yr. Ninety-day mortality was 41.0% for ARF, including ALI and ARDS patients, 42.2% for ALI not fulfilling ARDS criteria, and 41.2% for ARDS. Luhr OR, Antonsen K, Karlsson M, Aardal S, Thorsteinsson A, Frostell CG, Bonde J, and the ARF Study Group. Incidence and mortality after acute respiratory failure and acute respiratory distress syndrome in Sweden, Denmark, and Iceland.
PURPOSE. To measure hemoglobin oxygen saturation (SO 2) in retinal vessels and to test the reprod... more PURPOSE. To measure hemoglobin oxygen saturation (SO 2) in retinal vessels and to test the reproducibility and sensitivity of an automatic spectrophotometric oximeter. METHODS. Specialized software automatically identifies the retinal blood vessels on fundus images, which are obtained with four different wavelengths of light. The software calculates optical density ratios (ODRs) for each vessel. The reproducibility was evaluated by analyzing five repeated measurements of the same vessels. A linear relationship between SO 2 and ODR was assumed and a linear model derived. After calibration, reproducibility and sensitivity were calculated in terms of SO 2. Systemic hyperoxia (n ϭ 16) was induced in healthy volunteers by changing the O 2 concentration in inhaled air from 21% to 100%. RESULTS. The automatic software enhanced reproducibility, and the mean SD for repeated measurements was 3.7% for arterioles and 5.3% venules, in terms of percentage of SO 2 (five repeats, 10 individuals). The model derived for calibration was SO 2 ϭ 125 Ϫ 142 ⅐ ODR. The arterial SO 2 measured 96% Ϯ 9% (mean Ϯ SD) during normoxia and 101% Ϯ 8% during hyperoxia (n ϭ 16). The difference between normoxia and hyperoxia was significant (P ϭ 0.0027, paired t-test). Corresponding numbers for venules were 55% Ϯ 14% and 78% Ϯ 15% (P Ͻ 0.0001). SO 2 is displayed as a pseudocolor map drawn on fundus images. CONCLUSIONS. The retinal oximeter is reliable, easy to use, and sensitive to changes in SO 2 when concentration of O 2 in inhaled air is changed.
Að kanna áhrif eðlilegrar faeðingar á súrefnisflutning til fósturs. Tilfelli og aðferðir: Rannsök... more Að kanna áhrif eðlilegrar faeðingar á súrefnisflutning til fósturs. Tilfelli og aðferðir: Rannsökuð voru 50 börn sem faeddust með eðlilegri faeðingu og til viðmiðunar 50 börn sem faeddust með valkeisaraskurði. Maeldir voru í naflastrengsblóði (bláaeð og slagaeð) þaettir sem segja til um súrefnisflutning til fóstursins, það er: sýrustig blóðs (pH), hlutþrýstingur súrefnis (pO 2) og koltvísýrings (pCO 2), súrefnismettun blóðrauða (SO 2), súrefnisinnihald blóðs, umframbasi, mjólkursýra, erythrópóíetín, kjörnuð rauð blóðkorn og blóðrauði. Niðurstöður: Ekki var marktaekur munur á súrefnisinnihaldi bláaeðablóðs milli hópanna. Hins vegar var súrefnisinnihald slagaeðablóðs marktaekt laegra hjá börnunum sem faeddust með valkeisaraskurði en hjá þeim sem faeddust eðlilega (p<0,001). Börnin sem faeddust eðlilega voru með marktaekt laegra pH (p<0,001), minni umframbasa (p<0,001), haerri styrk mjólkursýru (p<0,001), haerri styrk erythrópóíetíns (p=0,01), fleiri kjörnuð rauð blóðkorn (p=0,004) og haerri þéttni blóðrauða (p=0,002) í bláaeðablóði en börnin sem faeddust
Background: Aprotinin has been used in our hospital since the year 2003 to reduce bleeding during... more Background: Aprotinin has been used in our hospital since the year 2003 to reduce bleeding during craniosynostotic surgery in children. The aim of this retrospective study was to investigate its effect, primarily on bleeding and secondarily on the need for transfusion. Methods: Thirteen children were treated with aprotinin from 2003 to 2008, while 39 were not treated in the period 1993-2002. Information on blood loss and need for transfusion during the operations in all 52 children was collected from their medical records. Results: There was a significant difference in both blood loss and need for transfusion. Estimated blood volume was used to correct for difference in the children's age and size. In the aprotinin group, blood loss was 3.9% of circulating blood volume vs. 22.0%, and the need for transfusion was 0.0% vs. 21.1%. Conclusion: Blood loss and need for blood transfusion were significantly reduced in the aprotinin group. No allergic or other possible aprotinin-specific complications were registered in the aprotinin group.
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Papers by Adalbjorn Thorsteinsson