Depth of anesthesia monitoring in Norway-A web-based survey.

BACKGROUND: The bispectral index (BIS) monitor is the most frequently used electroencephalogram (EEG)-based depth of anesthesia (DoA) technology in Norwegian hospitals. However, there is limited knowledge regarding the extent and clinical impact of its use and how anesthesiologists and nurse anesthetists use the information provided by the DoA monitors in their clinical practice. METHODS: This cross-sectional survey on the use of DoA monitors in Norway used a web-based questionnaire distributed to anesthesia personnel in all hospitals in Norway. Participation was voluntary and anonymized, and the web form could not track IP sources or respondents' locations. RESULTS: Three hundred and ninety-one nurse anesthetists (n = 324) and anesthesiologists (n = 67) responded. Among the EEG-based DoA monitoring tools, BIS was most often used to observe and assess patients' DoA (98%). Raw EEG waveform analysis (10%), EEG-spectrogram (9%), and suppression rate (10%) were seldom used. Twenty-seven percent of the anesthesia personnel were able to recognize a burst suppression pattern on EEG and its significance. Fifty-eight percent of the respondents considered clinical observations more reliable than BIS. Almost all respondents reported adjusting anesthetic dosage based on the BIS index values (80%). However, the anesthetic dose was more often increased (90%) because of high BIS index values than lowered (55%) because of low BIS index values. CONCLUSION: Despite our respondents' extensive use of DoA monitoring, the anesthesia personnel in our survey did not use all the information and the potential to guide the titration of anesthetics the DoA monitors provide. Thus, anesthesia personnel could generally benefit from increased knowledge of how EEG-based DoA monitoring can be used to assess and determine individual patients' need for anesthetic medication.

Identifying excessive chronic alcohol use with phosphatidylethanol in patients with suspected severe injury-results from the IDART study.

INTRODUCTION: Acute and chronic alcohol use are well-known risk factors for accidents and injuries, and concurrent psychoactive drug use can increase injury risk further. Phosphatidylethanol (PEth) 16:0/18:1 is a biomarker used to determine alcohol consumption the previous 3-4 weeks. The aim was to investigate the prevalence of chronic alcohol use in trauma patients, as determined by PEth 16:0/18:1 concentrations, and how excessive chronic alcohol use relate to demographic variables, injury mechanisms and drug use. SETTING: Patients received at Norwegian trauma hospitals from March 2019 to February 2020. The study is part of the Impairing Drugs and Alcohol as Risk factors for Traumatic Injuries study. METHODS: All patients aged ≥ 16 years received with trauma team were included in the study. Data on injury date and mechanism, gender and age was registered. Blood samples were analyzed for 22 psychoactive medicinal and illicit drugs, ethanol and phosphatidylethanol 16:0/18:1. Regression analyses were conducted to assess associations between alcohol use and gender, age, injury mechanism and drug use. RESULTS AND CONCLUSION: Of the 4845 patients included in the study, 10% had PEth 16:0/18:1 concentration ≥ 600 nM (~430 ng/mL), indicative of excessive chronic alcohol use. Being male, between 44-61 years old, involved in violence, and testing positive for medicinal drugs was associated with excessive chronic alcohol use.Excessive chronic alcohol use was common among males, middle-aged, patients with violence as injury mechanism and those with medicinal drug use. These findings emphasize the need to detect and treat excessive chronic alcohol use among trauma patients.

A qualitative longitudinal study of traumatic orthopaedic injury survivors' experiences with pain and the long-term recovery trajectory.

OBJECTIVES: To explore trauma patients' experiences of the long-term recovery pathway during 18 months following hospital discharge. DESIGN: Longitudinal qualitative study. SETTING AND PARTICIPANTS: Thirteen trauma patients with injuries associated with pain that had been interviewed 6 weeks after discharge from Oslo University Hospital in Norway, were followed up with an interview 18 months postdischarge. METHOD: The illness trajectory framework informed the data collection, with semistructured, in-depth interviews that were analysed thematically. RESULTS: Compared with the subacute phase 6 weeks postdischarge, several participants reported exacerbated mental and physical health, including increased pain during 18 months following discharge. This, andalternating periods of deteriorated health status during recovery, made the pathway unpredictable. At 18 months post-discharge, participants were coping with experiences of reduced mental and physical health and socioeconomic losses. Three main themes were identified: (1) coping with persistent pain and reduced physical function, (2) experiencing mental distress without access to mental healthcare and (3) unmet needs for follow-up care. Moreover, at 18 months postdischarge, prescribed opioids were found to be easily accessible from GPs. In addition to relieving chronic pain, motivations to use opioids were to induce sleep, reduce withdrawal symptoms and relieve mental distress. CONCLUSIONS AND IMPLICATIONS: The patients' experiences from this study establish knowledge of several challenges in the trauma population's recovery trajectories, which may imply that subacute health status is a poor predictor of long-term outcomes. Throughout recovery, the participants struggled with physical and mental health needs without being met by the healthcare system. Therefore, it is necessary to provide long-term follow-up of trauma patients' health status in the specialist health service based on individual needs. Additionally, to prevent long-term opioid use beyond the subacute phase, there is a need to systematically follow-up and reassess motivations and indications for continued use throughout the recovery pathway.

Prevalence of use and impairment from drugs and alcohol among trauma patients: A national prospective observational study.

BACKGROUND: Being under the influence of psychoactive substances increases the risk of involvement in and dying from a traumatic event. The study is a prospective population-based observational study that aims to determine the prevalence of use and likely impairment from psychoactive substances among patients with suspected severe traumatic injury. METHOD: This study was conducted at 35 of 38 Norwegian trauma hospitals from 1 March 2019 to 29 February 2020. All trauma admissions for patients aged ≥ 16 years admitted via trauma team activation during the study period were eligible for inclusion. Blood samples collected on admission were analysed for alcohol, benzodiazepines, benzodiazepine-like hypnotics (Z-drugs), opioids, stimulants, and cannabis (tetrahydrocannabinol). RESULTS: Of the 4878 trauma admissions included, psychoactive substances were detected in 1714 (35 %) and in 771 (45 %) of these, a combination of two or more psychoactive substances was detected. Regarding the level of impairment, 1373 (28 %) admissions revealed a concentration of one or more psychoactive substances indicating likely impairment, and 1052 (22 %) highly impairment. Alcohol was found in 1009 (21 %) admissions, benzodiazepines and Z-drugs in 613 (13 %), opioids in 467 (10 %), cannabis in 352 (7 %), and stimulants in 371 (8 %). Men aged 27-43 years and patients with violence-related trauma had the highest prevalence of psychoactive substance use with respectively 424 (50 %) and 275 (80 %) testing positive for one or more compounds. CONCLUSION: The results revealed psychoactive substances in 35 % of trauma admissions, 80 % of which were likely impaired at the time of traumatic injury. A combination of several psychoactive substances was common, and younger males and patients with violence-related injuries were most often impaired. Injury prevention strategies should focus on high-risk groups and involve the prescription of controlled substances. We should consider toxicological screening in trauma admissions and incorporation of toxicological data into trauma registries.

Haemodynamic effects of methoxyflurane versus fentanyl and placebo in hypovolaemia: a randomised, double-blind crossover study in healthy volunteers.

Background: Methoxyflurane is approved for relief of moderate to severe pain in conscious adult trauma patients: it may be self-administrated and is well suited for use in austere environments. Trauma patients may sustain injuries causing occult haemorrhage compromising haemodynamic stability, and it is therefore important to elucidate whether methoxyflurane may adversely affect the haemodynamic response to hypovolaemia. Methods: In this randomised, double-blinded, placebo-controlled, three-period crossover study, inhaled methoxyflurane 3 ml, i.v. fentanyl 25 µg, and placebo were administered to 15 healthy volunteers exposed to experimental hypovolaemia in the lower body negative pressure model. The primary endpoint was the effect of treatment on changes in cardiac output, while secondary endpoints were changes in stroke volume and mean arterial pressure and time to haemodynamic decompensation during lower body negative pressure. Results: There were no statistically significant effects of treatment on the changes in cardiac output, stroke volume, or mean arterial pressure during lower body negative pressure. The time to decompensation was longer for methoxyflurane compared with fentanyl (hazard ratio 1.9; 95% confidence interval 0.4-3.4; P=0.010), whereas there was no significant difference to placebo (hazard ratio -1.3; 95% confidence interval -2.8 to 0.23; P=0.117). Conclusions: The present study does not indicate that methoxyflurane has significant adverse haemodynamic effects in conscious adults experiencing hypovolaemia. Clinical trial registration: ClinicalTrials.gov (NCT04641949) and EudraCT (2019-004144-29) https://www.clinicaltrialsregister.eu/ctr-search/trial/2019-004144-29/NO.

Implementing screening for myocardial injury in non-cardiac surgery: perspectives of an ad-hoc interdisciplinary expert group.

Objectives. Perioperative myocardial injury (PMI) is increasingly recognised as an important complication of non-cardiac surgery, with often clinically silent presentation, but detrimental prognosis. Active screening for PMI, involving the detection of dynamic and elevated levels of cardiac troponin, has recently been advocated by an increasing number of guidelines; however, active PMI screening has not been reflected in clinical practice. Design. As consensus on a common screening and management pathway is lacking, we synthesise the current evidence to provide suggestions on the selection of patients for screening, organisation of a screening program, and a potential management pathway, building upon a recently published perioperative screening algorithm. Results. Screening should be performed using high-sensitivity assays both preoperatively and postoperatively (postoperative Days 1 and 2) in patients at high-risk of experiencing perioperative complications. Conclusion. This expert opinion piece by an interdisciplinary group of predominantly Norwegian clinicians aims to assist healthcare professionals planning to implement guideline-recommended PMI screening at a local level in order to improve patient outcomes following non-cardiac surgery.

Long-term changes of health-related quality of life in patients with peripheral vascular malformations - a prospective observational study.

PURPOSE: The aim of this observational study was to assess health-related quality of life (HRQOL) changes in patients with vascular malformations, over a period of almost eight years, and to assess clinical and demographic characteristics possibly associated with HRQOL changes. METHODS: Eighty out of 111 patients who were included in a previously published comparative HRQOL study accepted inclusion in this follow-up study. HRQOL at baseline and follow-up was assessed with the Short-Form 36-item questionnaire (SF-36). Median observation time was 7.9 years. Linear mixed models and linear regression models were applied to assess HRQOL change and possible associations with demographic and clinical variables. RESULTS: The median age of the patient cohort at baseline evaluation (n = 111) was 27.0 years. Ninety-six out of 111 (86.5%) patients were diagnosed with venous malformations. Significantly higher SF-36 scores at follow-up were found for the physical domains Role limitations due to (RLDT) physical problems (difference=13.5; 95% CI [1.6, 25.3]) and Bodily pain (difference=11.3; 95% CI [3.8, 18.8]). No deterioration of HRQOL was found in any domain. In multivariate analyses, female gender, muscle/bone involvement, and higher age were associated with a positive relative change in SF-36 in the domains Physical functioning, RLDT physical problems, and RLDT emotional problems, respectively. Invasive treatment was not associated with long-term HRQOL change. CONCLUSIONS: Over a period of almost eight years, significant improvement of SF-36 scores was observed in the physical domains RLDT physical problems and bodily pain. Female gender, muscle/bone involvement, and higher age were associated with HRQOL improvement in certain domains.

Study protocol for the BUSCopan in LABor (BUSCLAB) study: A randomized placebo-controlled trial investigating the effect of butylscopolamine bromide to prevent prolonged labor.

BACKGROUND: First-time mothers are prone to prolonged labor, defined as the crossing of partograph alert or action lines. Prolonged labor may occur among as many as one out of five women, and is associated with a range of adverse birth outcomes. Oxytocin is the standard treatment for prolonged labor, but has a narrow therapeutic window, several adverse effects and limited efficacy. Despite poor evidence, labor wards often use antispasmodic agents to treat prolonged labor. The antispasmodic drug butylscopolamine bromide (Buscopan®) may shorten duration of labor, but studies on prevention of prolonged labor are lacking. In this randomized double-blind placebo-controlled clinical trial, we aim to evaluate the effect of butylscopolamine bromide on duration of labor in first-time mothers showing first signs of slow labor progress by crossing the World Health Organization partograph alert line. METHODS AND ANALYSIS: The study is a single center study at Oslo University Hospital, Oslo, Norway. We will recruit 250 primiparous women with spontaneous labor start at term. Women are included in the first stage of labor if they show signs of slow labor progress, defined as the crossing of the partograph alert line with a cervical dilation between 3-9 cm. Participants are randomized 1:1 to either 20 mg intravenous butylscopolamine bromide or intravenous placebo (1 mL sodium chlorine 9 mg/mL). We considered a mean difference of 60 minutes in labor duration clinically relevant. The primary outcome is duration of labor from the provision of the investigational medicinal product to vaginal delivery. The secondary outcomes include change in labor pain, use of oxytocin augmentation, delivery mode, and maternal birth experience. The primary data for the statistical analysis will be the full analysis set and will occur on completion of the study as per the prespecified statistical analysis plan. The primary outcome will be analyzed using Weibull regression, and we will treat cesarean delivery as a censoring event.

Meditative-based diaphragmatic breathing vs. vagus nerve stimulation in the treatment of fibromyalgia-A randomized controlled trial: Body vs. machine.

Importance: Vagus nerve innervation via electrical stimulation and meditative-based diaphragmatic breathing may be promising treatment avenues for fibromyalgia. Objective: Explore and compare the treatment effectiveness of active and sham transcutaneous vagus nerve stimulation (tVNS) and meditative-based diaphragmatic breathing (MDB) for fibromyalgia. Design: Participants enrolled from March 2019-October 2020 and randomly assigned to active tVNS (n = 28), sham tVNS (n = 29), active MDB (n = 29), or sham MDB (n = 30). Treatments were self-delivered at home for 15 min/morning and 15 min/evening for 14 days. Follow-up was at 2 weeks. Setting: Outpatient pain clinic in Oslo, Norway. Participants: 116 adults aged 18-65 years with severe fibromyalgia were consecutively enrolled and randomized. 86 participants (74%) had an 80% treatment adherence and 107 (92%) completed the study at 2 weeks; 1 participant dropped out due to adverse effects from active tVNS. Interventions: Active tVNS is placed on the cymba conchae of the left ear; sham tVNS is placed on the left earlobe. Active MDB trains users in nondirective meditation with deep breathing; sham MDB trains users in open-awareness meditation with paced breathing. Main outcomes and measures: Primary outcome was change from baseline in ultra short-term photoplethysmography-measured cardiac-vagal heart rate variability at 2 weeks. Prior to trial launch, we hypothesized that (1) those randomized to active MDB or active tVNS would display greater increases in heart rate variability compared to those randomized to sham MDB or sham tVNS after 2-weeks; (2) a change in heart rate variability would be correlated with a change in self-reported average pain intensity; and (3) active treatments would outperform sham treatments on all pain-related secondary outcome measures. Results: No significant across-group changes in heart rate variability were found. Furthermore, no significant correlations were found between changes in heart rate variability and average pain intensity during treatment. Significant across group differences were found for overall FM severity yet were not found for average pain intensity. Conclusions and relevance: These findings suggest that changes in cardiac-vagal heart rate variability when recorded with ultra short-term photoplethysmography in those with fibromyalgia may not be associated with treatment-specific changes in pain intensity. Further research should be conducted to evaluate potential changes in long-term cardiac-vagal heart rate variability in response to noninvasive vagus nerve innervation in those with fibromyalgia. Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT03180554, Identifier: NCT03180554.

Patient Experiences after Physical Trauma: The Negative Effect of the COVID-19 Pandemic on Recovery.

The coronavirus disease 2019 (COVID-19) pandemic generated a crisis within the healthcare system, during which acute, COVID-19-related health needs were prioritized over less urgent needs, including vulnerable subgroups. This study explored experiences of recovery among survivors of physical injuries associated with severe pain during the COVID-19 pandemic in Norway. In-depth interviews were conducted among 13 participants. Findings generated by a thematic analysis revealed that the pandemic, including the contagion control measures and interrupted healthcare, were of negative consequence for the participants' recovery experiences and mental and physical health. Despite experiencing severe pain and perceived needs for support, the participants experienced being deprioritized by the healthcare system. They experienced a reduced capacity to cope with pandemic-related stress and to perform everyday tasks, which they perceived as generating an additional burden for their loved ones. Alcohol was reported to be used in an effort to relieve the associated mental distress. As suggested by this study, injury survivors constitute a vulnerable subgroup for whom the continuity of rehabilitation services during a national crisis, as well as the integration of mental health support, can be essential for mitigating the negative impact of the crisis on recovery and for promoting optimal long-term health outcomes.

Exploring cardiac effects after oxytocin 2.5 IU or carbetocin 100 µg: A randomised controlled trial in women undergoing planned caesarean delivery.

BACKGROUND: Oxytocin can stimulate release of myocardial biomarkers troponin I and T, prolong QTc and induce ST-depression. OBJECTIVE: To explore cardiac changes after either intravenous carbetocin or oxytocin. STUDY DESIGN: Exploratory phase 4 randomised controlled trial. SETTING: Obstetrics units of Oslo University Hospital, Norway between September 2015 and May 2018. PARTICIPANTS: Forty healthy, singleton pregnant women aged 18 to 50 years at gestational age at least 36 weeks with a planned caesarean delivery. INTERVENTIONS: Participants were randomised to receive either oxytocin 2.5 IU or carbetocin 100 µg immediately after delivery. MAIN OUTCOME MEASURES: The primary endpoint was the assessment of troponin I within 48 h of study drug administration. Troponin I and T, and creatine kinase myocardial band assessments were measured before spinal anaesthesia (baseline), and again at 4, 10 and 24 h after delivery. QTc, ST-depression and relative increase in heart rate were recorded from start of study drug administration to 10 min after delivery. All adverse events were monitored. RESULTS: Compared with the carbetocin group, higher troponin I levels were observed in the oxytocin group at 4 h and 10 h after delivery. For both treatment groups, an increase from baseline in troponin I and T was most pronounced at 10 h after delivery, and it had begun to decline by 24 h. QTc increased with time after administration of both study drugs, with a mean maximum increase of 10.4 ms observed at 9 min (P   <  0.001). No statistical differences were observed in QTc ( P  = 0.13) or ST-depression ( P  = 0.11) between the treatment groups. CONCLUSIONS: Oxytocin 2.5 IU and carbetocin 100 µg caused a similar increase in QTc. The trial was underpowered with regards to ST-depression and the release of myocardial biomarkers and these warrant further investigation. Data from this trial will inform a larger phase 4 trial to determine potential drug differences in troponin release. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02528136.

Reduced heart rate variability is related to the number of metabolic syndrome components and manifest diabetes in the sixth Tromsø study 2007-2008.

Both diabetes mellitus (DM) and the metabolic syndrome (MetS) are associated with autonomic neuropathy, which predisposes to cardiac events and death. Measures of heart rate variability (HRV) can be used to monitor the activity of the autonomic nervous system (ANS), and there are strong indications that HRV can be used to study the progression of ANS-related diabetes complications. This study aims to investigate differences in HRV in healthy, MetS and diabetic populations. Based on 7880 participants from the sixth health survey in Tromsø (Tromsø 6, 2007-2008), we found a significant negative association between the number of MetS components and HRV as estimated from short-term pulse wave signals (PRV). This decrease in PRV did not appear to be linear, instead it leveled off after the third component, with no significant difference in PRV between the MetS and DM populations. There was a significant negative association between HbA1c and PRV, showing a decrease in PRV occurring already within the normal HbA1c range. The MetS and DM populations are different from healthy controls with respect to PRV, indicating impaired ANS in both conditions. In the future, a study with assessment of PRV measurements in relation to prospective cardiovascular events seems justified.

Injuries after violence and accidents - the forgotten pandemic? / Skader etter vold og ulykker ­ den glemte pandemi?

All information on injuries should be collected in a national injury registry devised for research. This will pave the way for a new strategy for injury prevention.

Pre-injury dispensing of psychoactive prescription drugs in a ten years trauma population: a retrospective registry analysis.

BACKGROUND: The use of psychoactive prescription drugs is associated with increased risk of traumatic injury, and has negative impact on clinical outcome in trauma patients. Previous studies have focused on specific drugs or subgroups of patients. Our aim was to examine the extent of psychoactive drug dispensing prior to injury in a comprehensive population of trauma patients. METHODS: The Oslo University Hospital Trauma Registry provided data on all trauma patients admitted to the trauma centre between 2005 and 2014. We linked the data to Norwegian Prescription Database data from 2004. Opioids, benzodiazepines, z-hypnotics, gabapentinoids, and centrally acting sympathomimetics dispensed during the year before trauma of each patient were identified. We determined the pre-trauma annual prevalence of dispensing and mean annual cumulative defined daily doses (DDD) for each drug class, and compared results with corresponding figures in the general population, using standardised ratios. For each drug class, dispensing 14 days preceding trauma was analysed in patients sustaining severe injury and compared with patients sustaining non-severe injury. RESULTS: 12,713 patients (71% male) were included. Median age was 36 years. 4891 patients (38%) presented with severe injury (Injury Severity Score > 15). The ratio between annual prevalence of dispensed prescriptions for trauma patients and the general population, adjusted for age and sex, was 1.5 (95% confidence interval 1.4-1.6) for opioids, 2.1 (2.0-2.2) for benzodiazepines, 1.7 (1.6-1.8) for z-hypnotics, 1.9 (1.6-2.2) for gabapentinoids, and 1.9 (1.6-2.2) for centrally acting sympathomimetics. Compared with the general population, mean annual cumulative DDD of opioids and benzodiazepines dispensed to trauma patients were more than two and three times as high, respectively, in several age groups below 70 years. The prevalence of dispensing 14 days pre-trauma was higher in severely injured patients for opioids, benzodiazepines, and z-hypnotics compared with patients without severe injury. CONCLUSIONS: Our results support previous findings that the prevalence of psychoactive drug use is high among trauma patients. In terms of both frequency and amounts, the pre-injury dispensing of psychoactive drugs to trauma patients supersedes that of the general population, especially in younger patients.

Discharge from the trauma centre: exposure to opioids, unmet information needs and lack of follow up-a qualitative study among physical trauma survivors.

BACKGROUND: Physical trauma is associated with mortality, long-term pain and morbidity. Effective pain management is fundamental in trauma care and opioids are indispensable for treating acute pain; however, the use and misuse of prescribed opioids is an escalating problem. Despite this, few studies have been directed towards trauma patients in an early phase of rehabilitation with focusing on experiences and perspectives of health and recovery including pain and persistent use of prescribed opioids with abuse potential. To explore pre- and post-discharge trauma care experiences, including exposure to opioids, physical trauma survivors were recruited from a major trauma centre in Norway that provides the highest level of surgical trauma care. METHOD: Qualitative exploratory study. Individual semi-structured interviews were conducted among 13 trauma patients with orthopedic injuries, known to be associated with severe pain, six weeks post-discharge. The interviews were recorded, transcribed verbatim, and thematically analyzed with an interdisciplinary approach. RESULTS: The overarching theme was that discharge from the trauma centre and the period that immediately followed were associated with feelings of insecurity. The three main themes that were identified as contributing to this was (a) unmet information needs about the injury, (b) exposure to opioids, and (c) lack of follow-up after discharge from the hospital. Participants experienced to be discharged with prescribed opioids, but without information about their addictive properties or tapering plans. This, and lack of attention to mental health and psychological impact of trauma, gave rise to unmet treatment needs of pain management and mental health problems during hospitalization and following discharge. CONCLUSION: The findings from this study suggest that in addition to delivery of high-quality biomedical trauma care, health professionals should direct more attention to psychosocial health and safe pain management, including post-discharge opioid tapering and individually tailored follow-up plans for physical trauma survivors.

Blood pressure and cardiac output during caesarean delivery under spinal anaesthesia: a prospective cohort study.

OBJECTIVES: We have previously established a method to measure transfer of nutrients between mother, placenta and fetus in vivo. The method includes measurements of maternal and fetal blood flow by Doppler ultrasound prior to spinal anaesthesia. Spinal anaesthesia affects maternal blood pressure and cardiac output. We aimed to determine the effect of spinal anaesthesia in mothers undergoing an elective caesarean section on blood pressure, heart rate and cardiac output, and whether cardiac output levels were comparable before induction of spinal anaesthesia and before delivery. DESIGN: Prospective cohort study. SETTING: Tertiary hospital in Norway. PARTICIPANTS: 76 healthy women with uneventful pregnancies undergoing an elective caesarean section. INTERVENTIONS: We induced spinal anaesthesia with a standard prevention of hypotension including intravenous fluid coloading and phenylephrine infusion. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome measure was maternal cardiac output, and secondary outcome measures were invasive systolic blood pressure and heart rate. We measured heart rate and blood pressure by continuous invasive monitoring with a cannula in the radial artery. Cardiac output was estimated based on continuous arterial waveform. We compared maternal parameters 30 s before induction of spinal anaesthesia to 30 s before delivery. RESULTS: Median age at delivery was 34.5 (range 21-43) years and 17 of 76 women were nulliparous. The most prevalent indications were previous caesarean section and maternal request. Among 76 included women, 71 had sufficient data for analysis of endpoints. Median cardiac output was 6.51 (IQR (5.56-7.54) L/min before spinal anaesthesia and 6.40 (5.83-7.56) L/min before delivery (p=0.40)). Median invasive systolic blood pressure increased from 128.5 (120.1-142.7) mm Hg to 134.1 (124.0-146.6) mm Hg (p=0.014), and mean heart rate decreased from 86.0 (SD 13.9) to 75.2 (14.2) (p<0.001). CONCLUSIONS: Maternal cardiac output at the time of caesarean delivery is comparable to levels before induction of spinal anaesthesia. TRIAL REGISTRATION NUMBER: NCT00977769.

Maternal haemodynamics during labour epidural analgesia with and without adrenaline.

OBJECTIVES: Labour is one of the most painful experiences in a woman's life. Epidural analgesia using low-concentration local anaesthetics and lipophilic opioids is the gold standard for pain relief during labour. Pregnancy in general, particularly labour, is associated with changes in maternal haemodynamic variables, such as cardiac output and heart rate, which increase and peak during uterine contractions. Adrenaline is added to labour epidural solutions to enhance efficacy by stimulating the α2-adrenoreceptor. The minimal effective concentration of adrenaline was found to be 2 µg mL-1 for postoperative analgesia. The addition of adrenaline may also produce vasoconstriction, limiting the absorption of fentanyl into the systemic circulation, thereby reducing foetal exposure. However, adrenaline may influence the haemodynamic fluctuations, possibly adding to the strain on the circulatory system. The aim of this study was to compare the haemodynamic changes after application of labour epidural analgesia with or without adrenaline 2 µg mL-1. METHODS: This was a secondary analysis of a single-centre, randomised double-blind trial. Forty-one nulliparous women in labour requesting epidural analgesia were randomised to receive epidural solution of bupivacaine 1 mg mL-1, fentanyl 2 µg mL-1 with or without adrenaline 2 µg mL-1. The participants were monitored using a Nexfin CC continuous non-invasive blood pressure and cardiac output monitor. The primary outcomes were changes in peak systolic blood pressure and cardiac output during uterine contraction within 30 min after epidural activation. The effect of adrenaline was tested statistically using a linear mixed-effects model of the outcome variables' dependency on time, adrenaline, and their interaction. RESULTS: After excluding three patients due to poor data quality and two due to a malfunctioning epidural catheter, 36 patients (18 in each group) were analysed. The addition of adrenaline to the solution had no significant effect on the temporal changes in peak systolic blood pressure (p=0.26), peak cardiac output (0.84), or heart rate (p=0.91). Furthermore, no significant temporal changes in maternal haemodynamics (peak systolic blood pressure, p=0.54, peak cardiac output, p=0.59, or heart rate p=0.55) were associated with epidural analgesia during 30 min after epidural activation in both groups despite good analgesia. CONCLUSIONS: The addition of 2 µg mL-1 adrenaline to the epidural solution is not likely to change maternal haemodynamics during labour.

Injury Prevention and long-term Outcomes following Trauma-the IPOT project: a protocol for prospective nationwide registry-based studies in Norway.

INTRODUCTION: Traumatic injuries constitute a major cause of mortality and morbidity. Still, the public health burden of trauma in Norway has not been characterised using nationwide registry data. More knowledge is warranted on trauma risk factors and the long-term outcomes following trauma. The Injury Prevention and long-term Outcomes following Trauma project will establish a comprehensive research database. The Norwegian National Trauma Registry (NTR) will be merged with several data sources to pursue the following three main research topics: (1) the public health burden of trauma to society (eg, excess mortality and disability-adjusted life-years (DALYs)), (2) trauma aetiology (eg, socioeconomic factors, comorbidity and drug use) and (3) trauma survivorship (eg, survival, drug use, use of welfare benefits, work ability, education and income). METHODS AND ANALYSIS: The NTR (n≈27 000 trauma patients, 2015-2018) will be coupled with the data from Statistics Norway, the Norwegian Patient Registry, the Cause of Death Registry, the Registry of Primary Health Care and the Norwegian Prescription Database. To quantify the public health burden, DALYs will be calculated from the NTR. To address trauma aetiology, we will conduct nested case-control studies with 10 trauma-free controls (drawn from the National Population Register) matched to each trauma case on birth year, sex and index date. Conditional logistic regression models will be used to estimate trauma risk according to relevant exposures. To address trauma survivorship, we will use cohort and matched cohort designs and time-to-event analyses to examine various post-trauma outcomes. ETHICS AND DISSEMINATION: The project is approved by the Regional Committee for Medical Research Ethics. The project's data protection impact assessment is approved by the data protection officer. Results will be disseminated to patients, in peer-reviewed journals, at conferences and in the media.