The Swedish Perioperative Register: Description, validation of data mapping and utility.

BACKGROUND: Since 2013 surgical units in Sweden have reported procedures to the national Swedish Perioperative Register (SPOR). More than four million cases have been documented. Data consist of patient ID, type of surgery, diagnoses, time stamps during the perioperative process (from the decision to operate to the time of discharge from the postoperative recovery area) and quality measures. This article aims to describe SPOR and validate data mapping. Also, we wished to illustrate the utility of the SPOR in assessing variations in national surgical capacity during the COVID-19 pandemia years 2020-2021. METHODS: After a detailed description of SPOR, we report on the validation of data performed by comparing data from local databases with data stored in the central SPOR database, assessing missing values and accuracy. Effects of the pandemic on surgical capacity were described by developing an index, based on the number of performed surgical procedures per week during four production weeks in January 2020. Subsequent weeks were then compared with this baseline. RESULTS: The validation effort demonstrated nearly 100% data accuracy for the number and type of surgical procedures between local and central data. Missing data was a problem for some parameters. The number of performed surgical procedures decreased dramatically from week 11 in 2020 compared with normal production on a national basis, mainly impairing elective surgery. DISCUSSION: Data validation revealed good agreement between local and central databases. The changes in national surgical capacity during the pandemic were illustrated by an index based on the reported surgical production.

Rapid Improvement Following Receipt of Infliximab in Steroid-refractory Durvalumab-Associated Grade 3 Pneumonitis.

Immune checkpoint inhibitors (ICIs) are important novel agents used in advanced non-small cell lung cancer (NSCLC) standard regimens; however, their use increases the risk of immune-related adverse effects (IRAEs). The incidence of IRAE pneumonitis is well documented in ICI use. Corticosteroids continue to be the mainstay of treatment for IRAEs. Here we report one of the first cases of using infliximab to treat durvalumab-associated pneumonitis.

Cancer-Associated Venous Thromboembolic Disease, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology.

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cancer-Associated Venous Thromboembolic Disease focus on the prevention, diagnosis, and treatment of patients with cancer who have developed or who are at risk for developing venous thromboembolism (VTE). VTE is a significant concern among cancer patients, who are at heightened risks for developing as well as dying from the disease. The management of patients with cancer with VTE often requires multidisciplinary efforts at treating institutions. The NCCN panel comprises specialists from various fields: cardiology, hematology/hematologic oncology, internal medicine, interventional radiology, medical oncology, pharmacology/pharmacy, and surgery/surgical oncology. This article focuses on VTE prophylaxis for medical and surgical oncology inpatients and outpatients, and discusses risk factors for VTE development, risk assessment tools, as well as management methods, including pharmacological and mechanical prophylactics. Contraindications to therapeutic interventions and special dosing, when required, are also discussed.

NCCN Guidelines Insights: Cancer-Associated Venous Thromboembolic Disease, Version 2.2018.

Venous thromboembolism (VTE) is common in patients with cancer and increases morbidity and mortality. VTE prevention and treatment are more complex in patients with cancer. The NCCN Guidelines for Cancer-Associated Venous Thromboembolic Disease outline strategies for treatment and prevention of VTE in adult patients diagnosed with cancer or in whom cancer is clinically suspected. These NCCN Guidelines Insights explain recent changes in anticoagulants recommended for the treatment of cancer-associated VTE.

The Efficacy and Safety of Rivaroxaban and Dalteparin in the Treatment of Cancer Associated Venous Thrombosis.

Venous thromboembolism (VTE) is a complication of malignancy that is associated with significant mortality. The CLOT trial showed superiority of dalteparin in comparison to warfarin in preventing VTE recurrence. Rivaroxaban has been approved for treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE). In the absence of large randomized trials in the oncology population, the efficacy and safety of rivaroxaban for the treatment of VTE in cancer patients needs to be assessed. A single-center retrospective chart review was conducted to assess the efficacy and safety of rivaroxaban compared with dalteparin in cancer-associated thrombosis. Out of 671 patients identified, 286 patients (107 in the rivaroxaban group and 179 in the dalteparin group) were eligible for analysis. The rivaroxaban group had a rate of VTE recurrence at 6 months of 4.9 versus 11.1% with dalteparin (p = 0.252). The incidence of recurrent DVT at 6 months was lower in patients treated with rivaroxaban (0%) compared with dalteparin (8.2%) at 6 months (p = 0.025). Incidence of recurrent PE in the rivaroxaban group (5%) versus dalteparin group (3.1%) at 6 months was not statistically significant (p = 0.675). No significant difference was identified between the rivaroxaban group and dalteparin group in the rate of major bleeding (2.8 vs. 1.1%, respectively). Rivaroxaban was comparable to dalteparin in prevention of VTE recurrence while having no significant differences with major or minor bleeding.

Cancer-Associated Venous Thromboembolic Disease, Version 1.2015.

The NCCN Guidelines for Cancer-Associated Venous Thromboembolic Disease outline strategies for treatment and prevention of venous thromboembolism (VTE) in adult patients with a diagnosis of cancer or for whom cancer is clinically suspected. VTE is a common complication in patients with cancer, which places them at greater risk for morbidity and mortality. Therefore, risk-appropriate prophylaxis is an essential component for the optimal care of inpatients and outpatients with cancer. Critical to meeting this goal is ensuring that patients get the most effective medication in the correct dose. Body weight has a significant impact on blood volume and drug clearance. Because obesity is a common health problem in industrialized societies, cancer care providers are increasingly likely to treat obese patients in their practice. Obesity is a risk factor common to VTE and many cancers, and may also impact the anticoagulant dose needed for safe and effective prophylaxis. These NCCN Guidelines Insights summarize the data supporting new dosing recommendations for VTE prophylaxis in obese patients with cancer.

[58 people with bullet wounds in Gothenburg during 18 months. This demonstrates the need for preparedness and competence within trauma care]. / 58 personer skottskadade i Göteborg under 18 månader - Visar på behovet av beredskap och kompetens inom traumasjukvården.

From 1 January 2013 to 30 June 2014, 58 patients sustained gunshot wounds in the city of Gothenburg. 57 were males and the median age was 26 years. The majority of injuries were musculoskeletal. Ten patients died, of these 4 patients suffered single gunshot wounds to the head, while 6 patients had wounds to mediastinal structures and large abdominal vessels. 90 % of patients presented out-of-hours. The total length of stay for the 47 patients admitted was 316 days. Direct health care costs were calculated to 6.2 MSEK.

Venous thromboembolic disease.

Venous thromboembolism (VTE) remains a common and life-threatening complication among patients with cancer. Thromboprophylaxis can be used to prevent the occurrence of VTE in patients with cancer who are considered at high risk for developing this complication. Therefore, it is critical to recognize the various risk factors for VTE in patients with cancer. Risk assessment tools are available to help identify patients for whom discussions regarding the potential benefits and risks of thromboprophylaxis would be appropriate. The NCCN Clinical Practice Guidelines in Oncology for VTE provide recommendations on risk evaluation, diagnosis, prevention, and treatment of VTE in patients with cancer.

A new electrocardiographic marker for sympathetic nerve stimulation: modulation of repolarization by stimulation of stellate ganglia.

Activation of cardiac sympathetic nerves alters ventricular repolarization; however, these changes remain poorly characterized. The goal of this study was to examine effects of sympathetic stimulation on repolarization to identify electrocardiographic markers of sympathetic activation. Pigs underwent median sternotomy and bilateral thoracotomy to expose the stellate ganglia. Changes in T-wave duration, amplitude, repolarization vector, and time from peak to end (Tp-Te) were continuously monitored. Within 15 seconds of unilateral left or right stellate ganglion (LSG/RSG) stimulation, T-wave amplitude increased 6- and 4.5-fold, respectively, in lead aVF. T-wave duration and Tp-Te both increased 200% during LSG stimulation but only 50% and 30%, respectively, with RSG stimulation. During LSG stimulation, frontal and horizontal T-wave vectors, respectively, changed from 1.9° ± 22.8° and 333.8° ± 9.7° at baseline to 83.4° ± 3.9° (inferiorly) and 306.7° ± 1.8° (posteriorly). During RSG stimulation, frontal and horizontal T-wave vectors changed from 348.2° ± 21.6° and 333.8° ± 10.3° before stimulation to 280.7° ± 4.6° (superiorly) and 118.1° ± 5.6° (anteriorly). During stellate stimulation, T-wave vectors are displaced to angles specific for LSG activation (posteroinferiorly) or RSG activation (anterosuperiorly); T-wave amplitude, duration, and Tp-Te increase; and ST-duration decreases. Displaced repolarization vector and changes in T-wave morphometrics provide a novel marker of unilateral sympathetic nerve stimulation.

Needle stylet with integrated optical fibers for spectroscopic contrast during peripheral nerve blocks.

The effectiveness of peripheral nerve blocks is highly dependent on the accuracy at which the needle tip is navigated to the target injection site. Even when electrical stimulation is utilized in combination with ultrasound guidance, determining the proximity of the needle tip to the target region close to the nerve can be challenging. Optical reflectance spectroscopy could provide additional information about tissues that is complementary to these navigation methods. We demonstrate a novel needle stylet for acquiring spectra from tissue at the tip of a commercial 20-gauge needle. The stylet has integrated optical fibers that deliver broadband light to tissue and receive scattered light. Two spectrometers resolve the light that is received from tissue across the wavelength range of 500-1600 nm. In our pilot study, measurements are acquired from a postmortem dissection of the brachial plexus of a swine. Clear differences are observed between spectra acquired from nerves and those acquired from adjacent tissue structures. We conclude that spectra acquired with the stylet have the potential to increase the accuracy with which peripheral nerve blocks are performed.

Optical detection of the brachial plexus for peripheral nerve blocks: an in vivo swine study.

BACKGROUND AND OBJECTIVES: Accurate identification of nerves is critical to ensure safe and effective delivery of regional anesthesia during peripheral nerve blocks. Nerve stimulation is commonly used, but it is not perfect. Even when nerve stimulation is performed in conjunction with ultrasound guidance, determining when the needle tip is at the nerve target region can be challenging. In this in vivo pilot study, we investigated whether close proximity to the brachial plexus and penetration of the axillary artery can be identified with optical reflectance spectroscopy, using a custom needle stylet with integrated optical fibers. METHODS: Ultrasound-guided insertions to place the needle tip near the brachial plexus at the axillary level were performed at multiple locations in 2 swine, with the stylet positioned in the cannula of a 20-gauge stimulation needle. During each insertion, optical reflectance spectra were acquired with the needle tip in skeletal muscle, at the surface of muscle fascia, and at the nerve target region; confirmation of the final needle position was provided by nerve stimulation. In addition, an insertion to the lumen of the axillary artery was performed in a third swine. Differences in the spectra were quantified with lipid and hemoglobin parameters that provide contrast for optical absorption by the respective chromophores. RESULTS: The transition of the needle tip from skeletal muscle to the nerve target region was associated with higher lipid parameter values (P < 0.001) and lower hemoglobin parameter values (P < 0.001). The transition of the needle tip from muscle fascia to the nerve target region was associated with higher lipid parameter values (P = 0.001). Intraluminal access of the axillary artery was associated with an elevated hemoglobin parameter. CONCLUSIONS: Spectroscopic information obtained with the optical needle is distinct from nerve stimulation and complementary to ultrasound imaging, and it could potentially allow for reliable identification of the injection site during peripheral nerve blocks.

Epidural needle with embedded optical fibers for spectroscopic differentiation of tissue: ex vivo feasibility study.

Epidural injection is commonly used to provide intraoperative anesthesia, postoperative and obstetric analgesia, and to treat acute radicular pain. Identification of the epidural space is typically carried out using the loss of resistance (LOR) technique, but the usefulness of this technique is limited by false LOR and the inability to reliably detect intravascular or subarachnoid needle placement. In this study, we present a novel epidural needle that allows for the acquisition of optical reflectance spectra from tissue close to the beveled surface. This needle has optical fibers embedded in the cannula that deliver and receive light. With two spectrometers, light received from tissue is resolved across the wavelength range of 500 to 1600 nm. To determine the feasibility of optical tissue differentiation, spectra were acquired from porcine tissues during a post mortem laminectomy. The spectra were processed with an algorithm that derives estimates of the hemoglobin and lipid concentrations. The results of this study suggest that the optical epidural needle has the potential to improve the accuracy of epidural space identification.

Identification of the epidural space with optical spectroscopy: an in vivo swine study.

BACKGROUND: Accurate identification of the epidural space is critical for safe and effective epidural anesthesia or treatment of acute lumbar radicular pain with epidural steroid injections. The loss-of-resistance technique is commonly used, but it is known to be unreliable. Even when it is performed in conjunction with two-dimensional fluoroscopic guidance, determining when the needle tip enters the epidural space can be challenging. In this swine study, we investigated whether the epidural space can be identified with optical spectroscopy, using a custom needle with optical fibers integrated into the cannula. METHODS: Insertion of the needle tip into the epidural space was performed with midline and paramedian approaches in a swine. In each insertion, optical spectra were acquired at different insertion depths, and anatomical localization of the needle was determined by three-dimensional imaging with rotational C-arm computed tomography. Optical spectra that included both visible and near-infrared wavelength ranges were processed to derive estimates of the blood and lipid volume fractions. RESULTS: In all insertions, the transition of the needle tip to the epidural space from an adjacent tissue structure (interspinous ligament or the ligamentum flavum) was found to be associated with an increase in the lipid volume fraction. These increases, which ranged from 1.6- to 3.0-fold, were statistically significant (P = 0.0020). Lipid fractions obtained from the epidural space were 1.9- to 20-fold higher than those obtained from muscle (P = 0.0013). Accidental penetration of an epidural vein during one insertion coincided with a high blood volume fraction. CONCLUSIONS: The spectroscopic information obtained with the optical spinal needle is complementary to fluoroscopic images, and it could potentially allow for reliable identification of the epidural space during needle placement.

The combined spinal--epidural technique.

In recent years, the use of regional anaesthesia techniques for surgery, obstetrics and post operative pain management have increased in popularity. The combined spinal-epidural (CSE) technique has attained widespread popularity for patients undergoing major surgery below the umbilicus who may require prolonged and effective postoperative analgesia. The CSE technique is now well established in several institutions. This chapter includes the clinical experience, advantages and potential problems, and discusses future perspectives of the CSE technique.

Hydrocephalus as a presenting manifestation of neurosarcoidosis.

We present a case of hydrocephalus as the primary manifestation of neurosarcoidosis. Neurologic involvement is a significant cause of morbidity and mortality in patients with sarcoidosis. Detection and management of neurosarcoidosis remains problematic. Although the typical presentation of facial nerve palsy in a documented case of sarcoidosis is not a diagnostic dilemma, more atypical presentations such as hydrocephalus with increased intracranial pressure in a previously healthy patient can be a challenge.

Salvage of an acutely ruptured thoracic aortic aneurysm during CPR.

PURPOSE: To report the successful endovascular treatment of a ruptured thoracic aortic aneurysm during cardiopulmonary resuscitation. CASE REPORT: A 72-year-old woman with a type B aortic dissection treated conservatively for 8 years was referred for rupture of a 16-cm aneurysm of the descending thoracic aorta. During transfer to the operating room, the patient suffered cardiac arrest; cardiopulmonary resuscitation (CPR) was initiated. A few minutes later during CPR, the surgical procedure began with a cutdown of the right femoral artery and insertion of a guidewire and an aortic occlusion balloon, which was inflated at the origin of the left subclavian artery (LSA). Blood pressure was immediately measurable. By only partially deflating the occluding balloon, a thoracic stent-graft was advanced above it and deployed at the origin of the LSA while rapidly deflating and retracting the occluding balloon. Three stent-grafts were required to cover 27 cm of the descending aorta. The patient was partly ventilator dependent for 3 months due to a massive pleural hematoma that was not evacuated. At the 10-month follow-up, the patient is fully recovered without any sign of respiratory dysfunction or any other sequela. CT scans reveal that the massive hematoma is almost completely resolved. CONCLUSIONS: This case illustrates that optimal collaboration between anesthesiologists, interventional radiologists, and vascular surgeons with appropriate resources can significantly expand the possibilities of emergent treatment in the face of aortic rupture.

Postoperative pain relief using intermittent injections of 0.5% ropivacaine through a catheter after laparoscopic cholecystectomy.

UNLABELLED: Postoperative pain has been an important limiting factor for ambulatory laparoscopic cholecystectomy. We anesthetized 40 ASA physical status I-II patients using propofol for the induction and sevoflurane in oxygen and air for the maintenance of anesthesia. At the end of the anesthesia, the patients were randomized into one of two groups: Group P (Placebo) and Group R (0.5% Ropivacaine). Twenty milliliters of normal saline or ropivacaine, respectively, were injected intraperitoneally at the end of surgery via a catheter placed in the bed of the gall bladder. Postoperatively, intermittent injections (10 mL) of the study solution were given when required for pain. Ketobemidone 1-2 mg was given IV as rescue medication. Pain was assessed using a visual analog scale at 1, 2, 3, 4, 8, 12, 16, and 20 h after surgery and once each day for 1 wk at rest (deep pain), shoulder and incision sites, and pain during coughing. Recovery was assessed by the time to transfer from Phase 1 to 2, the ability to walk, drink, and eat, and the ability to void. Plasma concentrations of ropivacaine were measured in eight patients. Time to ability to walk, defecation, driving a car, and return to normal activities were also recorded through a questionnaire sent home with the patient. During the first 4 postoperative h, patients in Group R had lower scores for deep pain and during coughing compared with Group P (P < 0.05). No differences were found in the postoperative consumption of ketobemidone. Median times to recovery at home were similar between the groups. By the seventh day, 93% of the patients had returned to normal activities of daily living. We conclude that the early postoperative pain after ambulatory laparoscopic cholecystectomy could be relieved using intermittent injections of ropivacaine 0.5% into the bed of the gall bladder. IMPLICATIONS: Early postoperative pain can be relieved by intermittent injections of ropivacaine 0.5% through a catheter placed in the bed of the gall bladder after ambulatory laparoscopic cholecystectomy.