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Sjöblom A, Hedberg M, Gille A, Guerra A, Aanesen V, Forsberg IM, Fagerlund MJ. Pre-oxygenation using high-flow nasal oxygen versus tight facemask in trauma patients undergoing emergency anaesthesia. Acta Anaesthesiol Scand 2024; 68:447-456. [PMID: 38129931 DOI: 10.1111/aas.14368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/06/2023] [Accepted: 12/09/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients suffering from major traumatic injuries frequently require emergency anaesthesia. Due to often compromised physiology and the time-sensitive management, trauma patients may be more prone to desaturate during induction of anaesthesia. We hypothesised that pre-oxygenation using high-flow nasal oxygen would decrease the risk of desaturation during induction of anaesthesia in trauma patients and the study therefore aimed to compare the frequency of desaturation when pre-oxygenation was performed with high-flow nasal oxygen or a traditional facemask. METHODS This exploratory, prospective, before-and-after study was conducted at the Karolinska University Hospital, Sweden. Adult (≥18 years of age) patients suffering major traumatic injuries needing emergency anaesthesia were included around the clock. Patients were pre-oxygenated using a tight-fitting facemask during the first nine months of enrollment. High-flow nasal oxygen was then introduced as a method for pre-oxygenation of trauma patients. The primary outcome was the proportion of patients desaturating <93% during induction of anaesthesia, assessed from the start of pre-oxygenation until one minute after intubation. Secondary outcomes included perceived difficulty of pre-oxygenation among anaesthetists (assessed on a scale between 1 and 10) and safety outcomes, such as incidence of regurgitations and intracranial gas (assessed radiologically). RESULTS Data from 96 patients were analysed. Facemask pre-oxygenation was performed in 66 patients, while 30 patients were pre-oxygenated with high-flow nasal oxygen. The most frequent trauma mechanisms were stabbing injuries (n = 34 (35%)) and fall injuries (n = 21 (22%)). There were no differences in patient characteristics between the groups. Eight (12%) versus three (10%) patients desaturated <93% in the facemask and high-flow nasal oxygen group respectively, OR 0.81 (95% CI 0.20-3.28), p = .76. Anaesthetists assessed pre-oxygenation using high-flow nasal oxygen as easier compared to facemask pre-oxygenation. No patient in any group showed signs of regurgitation. Among patients with facial or skull fractures requiring anaesthesia before radiology was performed, intracranial gas was seen in four (40%) patients pre-oxygenated with a facemask and in no patient pre-oxygenated with HFNO (p = .23). CONCLUSION In this prospective study investigating trauma patients undergoing emergency anaesthesia, we could not see any difference in the number of patients desaturating when pre-oxygenation was performed with high-flow nasal oxygen compared to a tight-fitting facemask. Pre-oxygenation using high-flow nasal oxygen was assessed as easier compared to facemask pre-oxygenation.
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Affiliation(s)
- Albin Sjöblom
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Hedberg
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anders Gille
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Andres Guerra
- Medical school, Karolinska Institutet, Stockholm, Sweden
| | - Vilde Aanesen
- Medical school, Karolinska Institutet, Stockholm, Sweden
| | - Ida-Maria Forsberg
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
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Rosén J, Frykholm P, Jonsson Fagerlund M, Pellegrini M, Campoccia Jalde F, von Oelreich E, Fors D. Lung impedance changes during awake prone positioning in COVID-19. A non-randomized cross-over study. PLoS One 2024; 19:e0299199. [PMID: 38381730 PMCID: PMC10880988 DOI: 10.1371/journal.pone.0299199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 02/01/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND The effects of awake prone positioning (APP) on respiratory mechanics in patients with COVID-19 are not well characterized. The aim of this study was to investigate changes of global and regional lung volumes during APP compared with the supine position using electrical lung impedance tomography (EIT) in patients with hypoxemic respiratory failure due to COVID-19. MATERIALS AND METHODS This exploratory non-randomized cross-over study was conducted at two university hospitals in Sweden between January and May 2021. Patients admitted to the intensive care unit with confirmed COVID-19, an arterial cannula in place, a PaO2/FiO2 ratio <26.6 kPa (<200 mmHg) and high-flow nasal oxygen or non-invasive ventilation were eligible for inclusion. EIT-data were recorded at supine baseline, at 30 and 60 minutes after APP-initiation, and 30 minutes after supine repositioning. The primary outcomes were changes in global and regional tidal impedance variation (TIV), center of ventilation (CoV), global and regional delta end-expiratory lung-impedance (dEELI) and global inhomogeneity (GI) index at the end of APP compared with supine baseline. Data were reported as median (IQR). RESULTS All patients (n = 10) were male and age was 64 (47-73) years. There were no changes in global or regional TIV, CoV or GI-index during the intervention. dEELI increased from supine reference value 0 to 1.51 (0.32-3.62) 60 minutes after APP (median difference 1.51 (95% CI 0.19-5.16), p = 0.04) and returned to near baseline values after supine repositioning. Seven patients (70%) showed an increase >0.20 in dEELI during APP. The other EIT-variables did not change during APP compared with baseline. CONCLUSION Awake prone positioning was associated with a transient lung recruiting effect without changes in ventilation distribution measured with EIT in patients with hypoxemic respiratory failure due to COVID-19.
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Affiliation(s)
- Jacob Rosén
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Peter Frykholm
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Mariangela Pellegrini
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Francesca Campoccia Jalde
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Thoracic Anesthesiology and Intensive Care, Department of Molecular Medicine and Surgery, Karolinska Institutet, Solna, Sweden
| | - Erik von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Diddi Fors
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
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Flam B, Andersson Franko M, Skrifvars MB, Djärv T, Cronhjort M, Jonsson Fagerlund M, Mårtensson J. Trends in Incidence and Outcomes of Cardiac Arrest Occurring in Swedish ICUs. Crit Care Med 2024; 52:e11-e20. [PMID: 37747306 DOI: 10.1097/ccm.0000000000006067] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
OBJECTIVE To determine temporal trends in the incidence of cardiac arrest occurring in the ICU (ICU-CA) and its associated long-term mortality. DESIGN Retrospective observational study. SETTING Swedish ICUs, between 2011 and 2017. PATIENTS Adult patients (≥18 yr old) recorded in the Swedish Intensive Care Registry (SIR). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS ICU-CA was defined as a first episode of cardiopulmonary resuscitation and/or defibrillation following an ICU admission, as recorded in SIR or the Swedish Cardiopulmonary Resuscitation Registry. Annual adjusted ICU-CA incidence trend (all admissions) was estimated using propensity score-weighted analysis. Six-month mortality trends (first admissions) were assessed using multivariable mixed-effects logistic regression. Analyses were adjusted for pre-admission characteristics (sex, age, socioeconomic status, comorbidities, medications, and healthcare utilization), illness severity on ICU admission, and admitting unit. We included 231,427 adult ICU admissions. Crude ICU-CA incidence was 16.1 per 1,000 admissions, with no significant annual trend in the propensity score-weighted analysis. Among 186,530 first admissions, crude 6-month mortality in ICU-CA patients was 74.7% (95% CI, 70.1-78.9) in 2011 and 68.8% (95% CI, 64.4-73.0) in 2017. When controlling for multiple potential confounders, the adjusted 6-month mortality odds of ICU-CA patients decreased by 6% per year (95% CI, 2-10). Patients admitted after out-of-hospital or in-hospital cardiac arrest had the highest ICU-CA incidence (136.1/1,000) and subsequent 6-month mortality (76.0% [95% CI, 73.6-78.4]). CONCLUSIONS In our nationwide Swedish cohort, the adjusted incidence of ICU-CA remained unchanged between 2011 and 2017. More than two-thirds of patients with ICU-CA did not survive to 6 months following admission, but a slight improvement appears to have occurred over time.
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Affiliation(s)
- Benjamin Flam
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Andersson Franko
- Department of Clinical Science and Education, South General Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Therese Djärv
- Medical Unit Acute/Emergency Department, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Medicine, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Maria Cronhjort
- Department of Clinical Science and Education, South General Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesiology and Intensive Care, South General Hospital, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Johan Mårtensson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Fuchs-Buder T, Brull SJ, Fagerlund MJ, Renew JR, Cammu G, Murphy GS, Warlé M, Vested M, Fülesdi B, Nemes R, Columb MO, Damian D, Davis PJ, Iwasaki H, Eriksson LI. Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents III: The 2023 Geneva revision. Acta Anaesthesiol Scand 2023; 67:994-1017. [PMID: 37345870 DOI: 10.1111/aas.14279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 06/23/2023]
Abstract
The set of guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents was developed following an international consensus conference in Copenhagen in 1996 (Viby-Mogensen et al., Acta Anaesthesiol Scand 1996, 40, 59-74); the guidelines were later revised and updated following the second consensus conference in Stockholm in 2005 (Fuchs-Buder et al., Acta Anaesthesiol Scand 2007, 51, 789-808). In view of new devices and further development of monitoring technologies that emerged since then, (e.g., electromyography, three-dimensional acceleromyography, kinemyography) as well as novel compounds (e.g., sugammadex) a review and update of these recommendations became necessary. The intent of these revised guidelines is to continue to help clinical researchers to conduct high-quality work and advance the field by enhancing the standards, consistency, and comparability of clinical studies. There is growing awareness of the importance of consensus-based reporting standards in clinical trials and observational studies. Such global initiatives are necessary in order to minimize heterogeneous and inadequate data reporting and to improve clarity and comparability between different studies and study cohorts. Variations in definitions of endpoints or outcome variables can introduce confusion and difficulties in interpretation of data, but more importantly, it may preclude building of an adequate body of evidence to achieve reliable conclusions and recommendations. Clinical research in neuromuscular pharmacology and physiology is no exception.
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Affiliation(s)
- Thomas Fuchs-Buder
- Department of Anaesthesia, Critical Care & Perioperative Medicine, University Hospital Nancy, Nancy, France
| | - Sorin J Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Guy Cammu
- Department of Anesthesiology, Critical Care and Emergency Medicine, Aalst, Belgium
| | - Glenn S Murphy
- Department of Anesthesiology, NorthShore University HealthSystem, Chicago, Illinois, USA
| | - Michiel Warlé
- Department of Surgery, Radbound University Medical Center, Nijmegen, The Netherlands
| | - Matias Vested
- Department of Anesthesia Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Reka Nemes
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Malachy O Columb
- Anaesthesia & Intensive Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Daniela Damian
- Anesthesiology and Perioperative Medicine, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Peter J Davis
- Anesthesia and Pediatrics, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Hajime Iwasaki
- Department of Anesthesiology and Crtical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Lars I Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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Sjöblom A, Hedberg M, Johansson S, Henningsson R, Soumpasis I, Lafrenz H, Törnberg D, Lodenius Å, Fagerlund MJ. Pre-oxygenation using high-flow nasal oxygen in parturients undergoing caesarean section in general anaesthesia: A prospective, multi-centre, pilot study. Acta Anaesthesiol Scand 2023; 67:1028-1036. [PMID: 37164448 DOI: 10.1111/aas.14264] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/19/2023] [Accepted: 04/25/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Parturients undergoing caesarean section in general anaesthesia have an increased risk of desaturating during anaesthesia induction. Pre- and peri-oxygenation with high-flow nasal oxygen prolong the safe apnoea time but data on parturients undergoing caesarean section under general anaesthesia are limited. This pilot study aimed to investigate the clinical effects and frequency of desaturation in parturients undergoing caesarean section in general anaesthesia pre- and peri-oxygenated with high-flow nasal oxygen and compare this to traditional pre-oxygenation using a facemask. METHODS In this prospective, non-randomised, multi-centre study we included pregnant women with a gestational age ≥30 weeks undergoing caesarean section under general anaesthesia. All parturients were asked to participate in the intervention group consisting of pre-oxygenation using high-flow nasal oxygen. Parturients declining participation were pre-oxygenated with a traditional facemask. Primary outcome was the proportion of parturients desaturating below 93% from start of pre-oxygenation until 1 min after tracheal intubation. Secondary outcomes investigated end-tidal oxygen concentrations after tracheal intubation and the proportion of parturients with signs of regurgitation. RESULTS A total of 34 parturients were included, 25 pre- and peri-oxygenated with high-flow nasal oxygen and 9 pre-oxygenated with facemask. No difference in patient or airway characteristics could be seen except for a higher BMI in the high-flow nasal oxygen group (31.4 kg m-2 [4.7] vs. 27.7 kg m-2 [3.1]; p = .034). No woman in any of the two groups desaturated below 93%. The lowest peripheral oxygen saturation observed, in any parturient, was 97%. There was no difference detected in end-tidal oxygen concentration after tracheal intubation, 87% (6) in the high-flow nasal oxygen group vs 80% (15) in the facemask group (p = .308). No signs of regurgitation, in any parturient, were seen. CONCLUSION Pre- and peri-oxygenation with high-flow nasal oxygen maintain adequate oxygen saturation levels during induction of anaesthesia also in parturients. Regurgitation of gastric content did not occur in any parturient and no other safety concerns were observed in this pilot study.
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Affiliation(s)
- Albin Sjöblom
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Hedberg
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Sofia Johansson
- Department of Anaesthesia and Intensive Care, Central Hospital of Karlstad, Karlstad, Sweden
| | - Ragnar Henningsson
- Department of Anaesthesia and Intensive Care, Central Hospital of Karlstad, Karlstad, Sweden
| | - Ioannis Soumpasis
- Department of Anaesthesia and Intensive Care, South General Hospital, Stockholm, Sweden
| | - Hannah Lafrenz
- Department of Anaesthesia, Surgery and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Daniel Törnberg
- Department of Anaesthesia and Intensive Care, Danderyd University Hospital, Stockholm, Sweden
| | - Åse Lodenius
- Department of Anaesthesia and Intensive Care, Danderyd University Hospital, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
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Sundelin A, Fagerlund MJ, Flam B, Djärv T. In-situ simulation of CPR in the emergency department - A tool for continuous improvement of the initial resuscitation. Resusc Plus 2023; 15:100413. [PMID: 37408538 PMCID: PMC10319310 DOI: 10.1016/j.resplu.2023.100413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
Background Simulating CPR scenarios in a clinical environment has been described as a method for mitigating latent safety threats. Therefore, we implemented regular inter-professional, multidisciplinary in-situ simulations in the emergency department (ED). Aim To iterate a line-up and action cards for initial CPR management. To examine the experiences among participants regarding attitudes towards simulation and if they perceived any benefits for their patients after the participation. Method In 2021 we performed 7 in-situ simulations (15-minute simulation, 15-minute hot debrief) in the ED with the CPR team including doctors and nurses from the ED and anaesthesiology department. A questionnaire was sent to the 48 participants the same day and after 3 and 18 months. Answers were given as yes/no or on a Likert scale 0-5 and are presented as median values with interquartile range (IQR) or frequencies. Results A line-up and 9 action cards were created. The response rate of the three questionnaires were 52, 23, and 43%, respectively. In total, 100% would recommend the in-situ simulation to a co-worker. Participants perceived that real patients (5 [3-5]) as well as themselves, (5 [3.5-5]), had benefited from the simulation up to 18 months after. Conclusion Thirty-minute in-situ simulations are feasible to implement in the ED and simulation observations were useful for development of standardised role descriptions for resuscitation in the ED. Participants self-report benefit for themselves as well as their patients.
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Affiliation(s)
- Anna Sundelin
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Benjamin Flam
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Therese Djärv
- Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Emergency Department, Karolinska University Hospital, Stockholm, Sweden
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Forsberg IM, Al-Saadi J, Sjöblom A, Grape L, Petersson J, Lundberg J, Lodenius Å, Eriksson LI, Fagerlund MJ. Cardiopulmonary haemodynamic effects and gas exchange during apnoeic oxygenation with high-flow and low-flow nasal oxygen: A large animal study. Eur J Anaesthesiol 2023:00003643-990000000-00095. [PMID: 37232391 DOI: 10.1097/eja.0000000000001854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Apnoeic oxygenation with high-flow nasal oxygen prolongs the safe apnoeic period during induction of general anaesthesia. However, central haemodynamic effects and the characteristics of central gaseous exchange remain unexplored. OBJECTIVE To describe mean pulmonary arterial pressure along with arterial and mixed venous blood gases and central haemodynamic parameters during apnoeic oxygenation with low-flow and high-flow nasal oxygen in pigs. DESIGN Experimental crossover study. SETTING Animal study of 10 healthy Swedish landrace pigs at Karolinska Institutet, Sweden, April-May 2021. INTERVENTION The pigs were anaesthetised, their tracheas intubated and their pulmonary arteries catheterised. The animals were preoxygenated and paralysed before apnoea. Apnoeic periods between 45 and 60 min were implemented with either 70 or 10 l min-1 100% O2 delivered via nasal catheters. In addition, seven animals underwent an apnoea without fresh gas flow. Cardiopulmonary parameters and blood gases were measured repeatedly. MAIN OUTCOME MEASURES Mean pulmonary arterial pressure during apnoeic oxygenation with high-flow and low-flow oxygen. RESULTS Nine pigs completed two apnoeic periods of at least 45 min with a PaO2 not lower than 13 kPa. The mean pulmonary arterial pressure increased during 45 min of apnoea, from 18 ± 1 to 33 ± 2 mmHg and 18 ± 1 to 35 ± 2 mmHg, at 70 and 10 l min-1 O2, respectively (P < 0.001); there was no difference between the groups (P = 0.87). The PaCO2 increased by 0.48 ± 0.07 and 0.52 ± 0.04 kPa min-1, at 70 and 10 l min-1 O2, respectively; there was no difference between the groups (P = 0.22). During apnoea without fresh gas flow, the SpO2 declined to less than 85% after 155 ± 11 s. CONCLUSION During apnoeic oxygenation in pigs, the mean pulmonary arterial pressure increased two-fold and PaCO2 five-fold after 45 min, while the arterial oxygen levels were maintained over 13 kPa, irrespective of high-flow or low-flow oxygen.
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Affiliation(s)
- Ida-Maria Forsberg
- From the Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine (IMF, AS, JP, AL, LIE, MJF), Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital (IMF, AS, LG, JP, LIE, MJF), Department of Clinical Neuroscience, Karolinska Institutet (JAS, JL) and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (JL)
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8
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Ohlén D, Hedberg M, Martinsson P, von Oelreich E, Djärv T, Jonsson Fagerlund M. Characteristics and outcome of traumatic cardiac arrest at a level 1 trauma centre over 10 years in Sweden. Scand J Trauma Resusc Emerg Med 2022; 30:54. [PMID: 36253786 PMCID: PMC9575295 DOI: 10.1186/s13049-022-01039-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/16/2022] [Indexed: 12/05/2022] Open
Abstract
Background Historically, resuscitation in traumatic cardiac arrest (TCA) has been deemed futile. However, recent literature reports improved but varying survival. Current European guidelines emphasise the addressing of reversible aetiologies in TCA and propose that a resuscitative thoracotomy may be performed within 15 min from last sign of life. To improve clinician understanding of which patients benefit from resuscitative efforts we aimed to describe the characteristics and 30-day survival for traumatic cardiac arrest at a Swedish trauma centre with a particular focus on resuscitative thoracotomy. Methods Retrospective cohort study of adult patients (≥ 15 years) with TCA managed at Karolinska University Hospital Solna between 2011 and 2020. Trauma demographics, intra-arrest factors, lab values and procedures were compared between survivors and non-survivors. Results Among the 284 included patients the median age was 38 years, 82.2% were male and 60.5% were previously healthy. Blunt trauma was the dominant injury in 64.8% and median Injury Severity Score (ISS) was 38. For patients with a documented arrest rhythm, asystole was recorded in 39.2%, pulseless electric activity in 24.8% and a shockable rhythm in 6.8%. Thirty patients (10.6%) survived to 30 days with a Glasgow Outcome Scale score of 3 (n = 23) or 4 (n = 7). The most common causes of death were haemorrhagic shock (50.0%) and traumatic brain injury (25.5%). Survivors had a lower ISS (P < 0.001), more often had reactive pupils (P < 0.001) and a shockable rhythm (P = 0.04). In the subset of prehospital TCA, survivors less frequently received adrenaline (epinephrine) (P < 0.001) and in lower amounts (P = 0.02). Of patients that underwent resuscitative thoracotomy (n = 101), survivors (n = 12) had a shorter median time from last sign of life to thoracotomy (P = 0.03), however in four of these survivors the time exceeded 15 min. Conclusion Survival after TCA is possible. Determining futility in TCA is difficult and this study demonstrates survivors outside of recent guidelines. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01039-9.
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Affiliation(s)
- Daniel Ohlén
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden. .,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Magnus Hedberg
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Paula Martinsson
- Department of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Erik von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Therese Djärv
- Department of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Section for Anaesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
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Rysz S, Fagerlund MJ, Lundberg J, Ringh M, Hollenberg J, Lindgren M, Jonsson M, Djärv T, Nordberg P. The Use of Levosimendan after Out-of-Hospital Cardiac Arrest and Its Association with Outcome-An Observational Study. J Clin Med 2022; 11:jcm11092621. [PMID: 35566747 PMCID: PMC9103888 DOI: 10.3390/jcm11092621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Levosimendan improves resuscitation rates and cardiac performance in animal cardiac arrest models. The aim of this study was to describe the use of levosimendan in out-of-hospital cardiac arrest (OHCA) patients and its association with outcome. Methods: A retrospective observational study of OHCA patients admitted to six intensive care units in Stockholm, Sweden, between 2010 and 2016. Patients treated with levosimendan within 24 h from admission were compared with those not treated with levosimendan. Propensity score matching and multivariable logistic regression analysis were used to assess the association between levosimendan treatment and 30-day mortality Results: Levosimendan treatment was initiated in 94/940 (10%) patients within 24 h. The proportion of men (81%, vs. 67%, p = 0.007), initial shockable rhythm (66% vs. 37%, p < 0.001), acute myocardial infarction, AMI (47% vs. 24%, p < 0.001) and need for vasoactive support (98% vs. 61%, p < 0.001) were higher among patients treated with levosimendan. After adjustment for age, sex, bystander cardiopulmonary resuscitation, witnessed status, initial rhythm and AMI, the odds ratio (OR) for 30-day mortality in the levosimendan group compared to the no-levosimendan group was 0.94 (95% Confidence interval [CI], 0.56−1.57, p = 0.82). Similar results were seen when using a propensity score analysis comparing patients with circulatory shock. Conclusions: In this observational study of OHCA patients, levosimendan was used in a limited patient group, most often in those with initial shockable rhythms, acute myocardial infarction and with a high need for vasopressors. In this limited patient cohort, levosimendan treatment was not associated with 30-day mortality. However, a better matching of patient factors and indications for use is required to derive conclusions on associations with outcome.
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Affiliation(s)
- Susanne Rysz
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76 Stockholm, Sweden; (S.R.); (M.J.F.)
- Department of Medicine Solna, Karolinska Institutet, 171 77 Stockholm, Sweden;
| | - Malin Jonsson Fagerlund
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76 Stockholm, Sweden; (S.R.); (M.J.F.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Johan Lundberg
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden;
- Department of Neuroradiology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Mattias Ringh
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
| | - Jacob Hollenberg
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
| | - Marcus Lindgren
- Department of Medicine, Piteå Hospital, 941 50 Piteå, Sweden;
| | - Martin Jonsson
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institutet, 171 77 Stockholm, Sweden;
- Function Emergency Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Per Nordberg
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76 Stockholm, Sweden; (S.R.); (M.J.F.)
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
- Correspondence:
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10
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Rysz S, Jonsson Fagerlund M, Rimes‐Stigare C, Larsson E, Campoccia Jalde F, Mårtensson J. Chronic dysglycemia and risk of SARS-CoV-2 associated respiratory failure in hospitalized patients. Acta Anaesthesiol Scand 2022; 66:48-55. [PMID: 34582033 PMCID: PMC8653023 DOI: 10.1111/aas.13982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/13/2021] [Accepted: 09/18/2021] [Indexed: 11/28/2022]
Abstract
Background Diabetes is common among patients with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)‐induced respiratory failure. We aimed to investigate the relationship between different stages of chronic dysglycemia and development of respiratory failure in hospitalized SARS‐CoV‐2 positive patients. Methods In this retrospective observational study, we included 385 hospitalized SARS‐CoV‐2 positive patients at Karolinska University Hospital, Sweden with an HbA1c test obtained within 3 months before admission. Based on HbA1c level and previous diabetes history, we classified patients into the following dysglycemia categories: prediabetes, unknown diabetes, controlled diabetes, or uncontrolled diabetes. We used multivariable logistic regression analysis adjusted for age, sex, and body mass index, to assess the association between dysglycemia categories and development of SARS‐CoV‐2‐induced respiratory failure. Results Of the 385 study patients, 88 (22.9%) had prediabetes, 68 (17.7%) had unknown diabetes, 36 (9.4%) had controlled diabetes, and 83 (21.6%) had uncontrolled diabetes. Overall, 299 (77.7%) patients were admitted with or developed SARS‐CoV‐2‐induced respiratory failure during hospitalization. In multivariable logistic regression analysis compared with no chronic dysglycemia, prediabetes (OR 14.41, 95% CI 5.27–39.43), unknown diabetes (OR 15.86, 95% CI 4.55–55.36), and uncontrolled diabetes (OR 17.61, 95% CI 5.77–53.74) was independently associated with increased risk of SARS‐CoV‐2‐induced respiratory failure. Conclusion In our cohort of hospitalized SARS‐CoV‐2 positive patients with available HbA1c data, prediabetes, undiagnosed diabetes, and poorly controlled diabetes were associated with a markedly increased risk of SARS‐CoV‐2‐associated respiratory failure.
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Affiliation(s)
- Susanne Rysz
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Medicine Solna Karolinska Institutet Stockholm Sweden
| | - Malin Jonsson Fagerlund
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Karolinska Institutet Stockholm Sweden
| | - Claire Rimes‐Stigare
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
| | - Emma Larsson
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Karolinska Institutet Stockholm Sweden
| | - Francesca Campoccia Jalde
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - Johan Mårtensson
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Karolinska Institutet Stockholm Sweden
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11
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Spyckerelle I, Jonsson Fagerlund M, Holmgren E, Johansson G, Sahlin C, Thunberg J, Franklin KA. Positive Expiratory Pressure Therapy on Oxygen Saturation and Ventilation After Abdominal Surgery: A Randomized Controlled Trial. Ann Surg Open 2021; 2:e101. [PMID: 37637885 PMCID: PMC10455159 DOI: 10.1097/as9.0000000000000101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/04/2021] [Indexed: 11/25/2022] Open
Abstract
Objective To evaluate the immediate effects of positive expiratory pressure therapy on oxygen saturation and ventilation after abdominal surgery. Background Positive expiratory pressure therapy to treat postoperative hypoxia is widespread, despite a lack of evidence of effect. Methods This randomized, sham-controlled, crossover trial investigated adults 1-2 days after abdominal surgery at Umeå University Hospital, Sweden. The intervention was positive expiratory pressure of 10-15 cm H2O. The control was a sham device. The investigations were ended with deep-breathing maneuvers. Outcomes were the gradient of changes in peripheral oxygen saturation and transcutaneous carbon-dioxide partial pressure (PtcCO2). Results Eighty patients were included and randomized and 76 patients were analyzed. Oxygen saturation increased from a baseline mean of 92% to 95%, P < 0.001, during positive expiratory pressure breathing, while PtcCO2 decreased from a mean of 36 to 33 mm Hg, P < 0.001. This was followed by apnea, oxygen desaturations to a mean of 89%, P < 0.001, and increased PtcCO2 before returning to baseline values. The changes in oxygen saturation and PtcCO2 did not differ from sham breathing or deep-breathing maneuvers. Conclusions Positive expiratory pressure breathing after abdominal surgery improves oxygen saturation during the maneuver because of hyperventilation, but it is followed by apnea, hypoventilation, and oxygen desaturation. The effect is not different from the expiration to a sham device or hyperventilation. It is time to stop positive expiratory pressure therapy after abdominal surgery, as there is no evidence of effect in previous trials, apart from the adverse effects reported here.
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Affiliation(s)
- Iris Spyckerelle
- From the Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care Medicine and Department of Physiology and Pharmacology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Erik Holmgren
- From the Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Göran Johansson
- Department of Surgical and Perioperative Sciences, Anesthesiology, Umeå University, Umeå, Sweden
| | - Carin Sahlin
- Department of Public Health and Clinical Medicine, Medicine, Umeå University, Umeå, Sweden
| | - Johan Thunberg
- Department of Surgical and Perioperative Sciences, Anesthesiology, Umeå University, Umeå, Sweden
| | - Karl A. Franklin
- From the Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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12
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Forsberg I, Mkrtchian S, Ebberyd A, Ullman J, Eriksson LI, Lodenius Å, Jonsson Fagerlund M. Biomarkers for oxidative stress and organ injury during Transnasal Humidified Rapid-Insufflation Ventilatory Exchange compared to mechanical ventilation in adults undergoing microlaryngoscopy: A randomised controlled study. Acta Anaesthesiol Scand 2021; 65:1276-1284. [PMID: 34028012 DOI: 10.1111/aas.13927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/14/2021] [Accepted: 05/10/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Apnoeic oxygenation using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) during general anaesthesia prolongs the safe apnoeic period. However, there is a gap of knowledge how THRIVE-induced hyperoxia and hypercapnia impact vital organs. The primary aim of this randomised controlled trial was to characterise oxidative stress and, secondary, vital organ function biomarkers during THRIVE compared to mechanical ventilation (MV). METHODS Thirty adult patients, American Society of Anesthesiologists (ASA) 1-2, undergoing short laryngeal surgery under general anaesthesia were randomised to THRIVE, FI O2 1.0, 70 L min-1 during apnoea or MV. Blood biomarkers for oxidative stress, malondialdehyde and TAC and vital organ function were collected (A) preoperatively, (B) at procedure completion and (C) at PACU discharge. RESULTS Mean apnoea time was 17.9 (4.8) min and intubation to end-of-surgery time was 28.1 (12.8) min in the THRIVE and MV group, respectively. Malondialdehyde increased from 11.2 (3.1) to 12.7 (3.1) µM (P = .02) and from 9.5 (2.2) to 11.6 (2.6) µM (P = .003) (A to C) in the THRIVE and MV group, respectively. S100B increased from 0.05 (0.02) to 0.06 (0.02) µg L-1 (P = .005) (A to C) in the THRIVE group. No increase in TAC, CRP, leukocyte count, troponin-T, NTproBNP, creatinine, eGFRcrea or NSE was demonstrated during THRIVE. CONCLUSION While THRIVE and MV was associated with increased oxidative stress, we found no change in cardiac, inflammation or kidney biomarkers during THRIVE. Further evaluation of stress and inflammatory response and cerebral and cardiac function during THRIVE is needed.
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Affiliation(s)
- Ida‐Maria Forsberg
- Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Souren Mkrtchian
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Anette Ebberyd
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Johan Ullman
- Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Lars I. Eriksson
- Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Åse Lodenius
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
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13
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Rosén J, von Oelreich E, Fors D, Jonsson Fagerlund M, Taxbro K, Frykholm P. Letter to the Editor in response to "Find the real responders and improve the outcome of awake prone positioning". Crit Care 2021; 25:273. [PMID: 34348787 PMCID: PMC8334335 DOI: 10.1186/s13054-021-03707-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 12/04/2022] Open
Affiliation(s)
- Jacob Rosén
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Entrance 78, 1 floor, 751 85, Uppsala, Sweden.
| | - Erik von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Solna, Sweden
| | - Diddi Fors
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Entrance 78, 1 floor, 751 85, Uppsala, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Solna, Sweden
| | - Knut Taxbro
- Department of Anaesthesiology and Intensive Care Medicine, Ryhov County Hospital, Jönköping, Sweden
| | - Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Entrance 78, 1 floor, 751 85, Uppsala, Sweden
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14
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Christensson E, Mkrtchian S, Ebberyd A, Österlund Modalen Å, Franklin KA, Eriksson LI, Jonsson Fagerlund M. Whole blood gene expression signature in patients with obstructive sleep apnea and effect of continuous positive airway pressure treatment. Respir Physiol Neurobiol 2021; 294:103746. [PMID: 34302993 DOI: 10.1016/j.resp.2021.103746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/23/2021] [Accepted: 07/18/2021] [Indexed: 10/20/2022]
Abstract
The molecular mechanisms of obstructive sleep apnea (OSA), in particular the gene expression patterns in whole blood of patients with OSA, can shed more light on the underlying pathophysiology of OSA and suggest potential biomarkers. In the current study, we have enrolled thirty patients with untreated moderate-severe OSA together with 20 BMI, age, and sex-matched controls and 15 normal-weight controls. RNA-sequencing of whole blood and home sleep apnea testing were performed in the untreated state and after three and twelve months of continuous positive airway pressure (CPAP) treatment. Analysis of the whole blood transcriptome of the patients with OSA revealed a unique pattern of differential expression with a significant number of downregulated immune-related genes including many heavy and light chain immunoglobulins and interferon-inducible genes. This was confirmed by the gene ontology analysis demonstrating enrichment with the biological processes associated with various immune functions. Expression of these genes was recovered after three months of CPAP treatment. After 12 months of CPAP treatment, the overall gene expression profile returns to the initial, untreated level. In addition, we have confirmed the importance of choosing BMI-matched controls as a reference group as opposed to normal-weight healthy individuals based on the significantly different gene expression signatures between these two groups.
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Affiliation(s)
- Eva Christensson
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Souren Mkrtchian
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anette Ebberyd
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Karl A Franklin
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Lars I Eriksson
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
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15
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Wong DJN, El-Boghdadly K, Owen R, Johnstone C, Neuman MD, Andruszkiewicz P, Baker PA, Biccard BM, Bryson GL, Chan MTV, Cheng MH, Chin KJ, Coburn M, Jonsson Fagerlund M, Lobo CA, Martinez-Hurtado E, Myatra SN, Myles PS, Navarro G, O'Sullivan E, Pasin L, Quintero K, Shallik N, Shamim F, van Klei WA, Ahmad I. Emergency Airway Management in Patients with COVID-19: A Prospective International Multicenter Cohort Study. Anesthesiology 2021; 135:292-303. [PMID: 33848324 PMCID: PMC8274456 DOI: 10.1097/aln.0000000000003791] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Tracheal intubation for patients with COVID-19 is required for invasive mechanical ventilation. The authors sought to describe practice for emergency intubation, estimate success rates and complications, and determine variation in practice and outcomes between high-income and low- and middle-income countries. The authors hypothesized that successful emergency airway management in patients with COVID-19 is associated with geographical and procedural factors. Methods: The authors performed a prospective observational cohort study between March 23, 2020, and October 24, 2020, which included 4,476 episodes of emergency tracheal intubation performed by 1,722 clinicians from 607 institutions across 32 countries in patients with suspected or confirmed COVID-19 requiring mechanical ventilation. The authors investigated associations between intubation and operator characteristics, and the primary outcome of first-attempt success. Results: Successful first-attempt tracheal intubation was achieved in 4,017/4,476 (89.7%) episodes, while 23 of 4,476 (0.5%) episodes required four or more attempts. Ten emergency surgical airways were reported—an approximate incidence of 1 in 450 (10 of 4,476). Failed intubation (defined as emergency surgical airway, four or more attempts, or a supraglottic airway as the final device) occurred in approximately 1 of 120 episodes (36 of 4,476). Successful first attempt was more likely during rapid sequence induction versus non–rapid sequence induction (adjusted odds ratio, 1.89 [95% CI, 1.49 to 2.39]; P < 0.001), when operators used powered air-purifying respirators versus nonpowered respirators (adjusted odds ratio, 1.60 [95% CI, 1.16 to 2.20]; P=0.006), and when performed by operators with more COVID-19 intubations recorded (adjusted odds ratio, 1.03 for each additional previous intubation [95% CI, 1.01 to 1.06]; P=0.015). Intubations performed in low- or middle-income countries were less likely to be successful at first attempt than in high-income countries (adjusted odds ratio, 0.57 [95% CI, 0.41 to 0.79]; P=0.001). Conclusions: The authors report rates of failed tracheal intubation and emergency surgical airway in patients with COVID-19 requiring emergency airway management, and identified factors associated with increased success. Risks of tracheal intubation failure and success should be considered when managing COVID-19. The authors report a secondary analysis of associations of intubation and operator characteristics related to the primary outcome of first-attempt intubation success in 4,476 intubations among 1,722 clinicians at 607 institutions across 32 countries, also considering differential rates of success between high-income and low- and middle-income countries. Although successful first-attempt intubation was noted in 89.7% of intubations, 0.5% required four or more attempts, an emergency surgical airway was required in 0.2%, and a composite variable of failed intubation occurred in 0.8%. Multivariable analysis demonstrated that successful first attempts were more likely with rapid sequence intubations, when operators used powered air-purifying respirators, and with increasing operator experience. Intubations performed in low- and middle-income countries were nearly half as likely to be successful on first attempt than in high-income countries. These results provide potentially useful information for global and local policy-making related to this and future pandemics. However, the observational nature, along with lack of patient level characteristics, leave room for substantial residual confounding of these associations. Supplemental Digital Content is available in the text.
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16
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Rosén J, von Oelreich E, Fors D, Jonsson Fagerlund M, Taxbro K, Skorup P, Eby L, Campoccia Jalde F, Johansson N, Bergström G, Frykholm P. Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial. Crit Care 2021; 25:209. [PMID: 34127046 PMCID: PMC8200797 DOI: 10.1186/s13054-021-03602-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023]
Abstract
Background The effect of awake prone positioning on intubation rates is not established.
The aim of this trial was to investigate if a protocol for awake prone positioning reduces the rate of endotracheal intubation compared with standard care among patients with moderate to severe hypoxemic respiratory failure due to COVID-19. Methods We conducted a multicenter randomized clinical trial. Adult patients with confirmed COVID-19, high-flow nasal oxygen or noninvasive ventilation for respiratory support and a PaO2/FiO2 ratio ≤ 20 kPa were randomly assigned to a protocol targeting 16 h prone positioning per day or standard care. The primary endpoint was intubation within 30 days. Secondary endpoints included duration of awake prone positioning, 30-day mortality, ventilator-free days, hospital and intensive care unit length of stay, use of noninvasive ventilation, organ support and adverse events. The trial was terminated early due to futility. Results Of 141 patients assessed for eligibility, 75 were randomized of whom 39 were allocated to the control group and 36 to the prone group. Within 30 days after enrollment, 13 patients (33%) were intubated in the control group versus 12 patients (33%) in the prone group (HR 1.01 (95% CI 0.46–2.21), P = 0.99). Median prone duration was 3.4 h [IQR 1.8–8.4] in the control group compared with 9.0 h per day [IQR 4.4–10.6] in the prone group (P = 0.014). Nine patients (23%) in the control group had pressure sores compared with two patients (6%) in the prone group (difference − 18% (95% CI − 2 to − 33%); P = 0.032). There were no other differences in secondary outcomes between groups. Conclusions The implemented protocol for awake prone positioning increased duration of prone positioning, but did not reduce the rate of intubation in patients with hypoxemic respiratory failure due to COVID-19 compared to standard care. Trial registration ISRCTN54917435. Registered 15 June 2020 (https://doi.org/10.1186/ISRCTN54917435). Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03602-9.
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Affiliation(s)
- Jacob Rosén
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Entrance 78, 1 floor, 751 85, Uppsala, Sweden.
| | - Erik von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Solna, Sweden
| | - Diddi Fors
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Entrance 78, 1 floor, 751 85, Uppsala, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Solna, Sweden
| | - Knut Taxbro
- Department of Anaesthesiology and Intensive Care Medicine, Ryhov County Hospital, Jönköping, Sweden
| | - Paul Skorup
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Ludvig Eby
- Acute and Reparative Medicine, Karolinska University Hospital, Solna, Sweden
| | - Francesca Campoccia Jalde
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Molecular Medicine and Surgery, Section of Thoracic Anesthesiology and Intensive Care, Karolinska Institutet, Solna, Sweden
| | - Niclas Johansson
- Department of Infectious Diseases, Karolinska University Hospital, Solna, Sweden.,Infectious Diseases Unit, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Gustav Bergström
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Entrance 78, 1 floor, 751 85, Uppsala, Sweden
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17
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Berezin L, Nagappa M, Wong J, Clivatti J, Singh M, Auckley D, Charchaflieh JG, Jonsson Fagerlund M, Gali B, Joshi GP, Overdyk FJ, Margarson M, Mokhlesi B, Moon T, Ramachandran SK, Ryan CM, Schumann R, Weingarten TN, Won CHJ, Chung F. Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey. Anesth Analg 2021; 132:1223-1230. [PMID: 33857964 DOI: 10.1213/ane.0000000000005446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Sleep disorders affect up to 25% of the general population and are associated with increased risk of adverse perioperative events. The key sleep medicine topics that are most important for the practice of anesthesiology have not been well-defined. The objective of this study was to determine the high-priority sleep medicine topics that should be included in the education of anesthesia residents based on the insight of experts in the fields of anesthesia and sleep medicine. METHODS We conducted a prospective cross-sectional survey of experts in the fields of sleep medicine and anesthesia based on the Delphi technique to establish consensus on the sleep medicine topics that should be incorporated into anesthesia residency curricula. Consensus for inclusion of a topic was defined as >80% of all experts selecting "agree" or "strongly agree" on a 5-point Likert scale. Responses to the survey questions were analyzed with descriptive statistical methods and presented as percentages or weighted mean values with standard deviations (SD) for Likert scale data. RESULTS The topics that were found to have 100% agreement among experts were the influence of opioids and anesthetics on control of breathing and upper airway obstruction; potential interactions of wake-promoting/hypnotic medications with anesthetic agents; effects of sleep and anesthesia on upper airway patency; and anesthetic management of sleep apnea. Less than 80% agreement was found for topics on the anesthetic implications of other sleep disorders and future pathways in sleep medicine and anesthesia. CONCLUSIONS We identify key topics of sleep medicine that can be included in the future design of anesthesia residency training curricula.
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Affiliation(s)
- Linor Berezin
- From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St. Joseph Health Care, Western University, London, Ontario, Canada
| | - Jean Wong
- From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Jefferson Clivatti
- Department of Anesthesia, Ajax Pickering Hospital, Lakeridge Health, Ajax, Ontario, Canada
| | - Mandeep Singh
- From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jean G Charchaflieh
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Malin Jonsson Fagerlund
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Bhargavi Gali
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Girish P Joshi
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Frank J Overdyk
- Trident Anesthesia Group, Trident Medical Center, Charleston, South Carolina
| | - Michael Margarson
- Department of Anesthesia, St Richard's Hospital, Chichester, United Kingdom
| | - Babak Mokhlesi
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Tiffany Moon
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Satya K Ramachandran
- Department of Anaesthesia, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Clodagh M Ryan
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Roman Schumann
- Departments of Anesthesiology and Surgery, Tufts University School of Medicine, Boston, Massachusetts.,Department of Anesthesiology and Critical Care, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Toby N Weingarten
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christine H J Won
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut.,Veterans Affair Connecticut Healthcare System, New Haven, Connecticut
| | - Frances Chung
- From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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18
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Sjöblom A, Lodenius Å, Hedberg M, Fagerlund MJ. Pre-oxygenation using high-flow nasal oxygen vs. tight facemask during rapid sequence induction: a reply. Anaesthesia 2021; 76:1275. [PMID: 33942891 DOI: 10.1111/anae.15503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 11/30/2022]
Affiliation(s)
- A Sjöblom
- Karolinska University Hospital, Stockholm, Sweden
| | - Å Lodenius
- Karolinska University Hospital, Stockholm, Sweden
| | - M Hedberg
- Karolinska University Hospital, Stockholm, Sweden
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19
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Rysz S, Al-Saadi J, Sjöström A, Farm M, Campoccia Jalde F, Plattén M, Eriksson H, Klein M, Vargas-Paris R, Nyrén S, Abdula G, Ouellette R, Granberg T, Jonsson Fagerlund M, Lundberg J. COVID-19 pathophysiology may be driven by an imbalance in the renin-angiotensin-aldosterone system. Nat Commun 2021; 12:2417. [PMID: 33893295 PMCID: PMC8065208 DOI: 10.1038/s41467-021-22713-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 03/23/2021] [Indexed: 12/13/2022] Open
Abstract
SARS-CoV-2 uses ACE2, an inhibitor of the Renin-Angiotensin-Aldosterone System (RAAS), for cellular entry. Studies indicate that RAAS imbalance worsens the prognosis in COVID-19. We present a consecutive retrospective COVID-19 cohort with findings of frequent pulmonary thromboembolism (17%), high pulmonary artery pressure (60%) and lung MRI perfusion disturbances. We demonstrate, in swine, that infusing angiotensin II or blocking ACE2 induces increased pulmonary artery pressure, reduces blood oxygenation, increases coagulation, disturbs lung perfusion, induces diffuse alveolar damage, and acute tubular necrosis compared to control animals. We further demonstrate that this imbalanced state can be ameliorated by infusion of an angiotensin receptor blocker and low-molecular-weight heparin. In this work, we show that a pathophysiological state in swine induced by RAAS imbalance shares several features with the clinical COVID-19 presentation. Therefore, we propose that severe COVID-19 could partially be driven by a RAAS imbalance.
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Affiliation(s)
- Susanne Rysz
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Jonathan Al-Saadi
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Sjöström
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Farm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Francesca Campoccia Jalde
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Michael Plattén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Helen Eriksson
- Department of Sociology, Stockholm University Demography Unit, Stockholm University, Stockholm, Sweden
| | - Margareta Klein
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology Huddinge, Karolinska University Hospital, Stockholm, Sweden
| | - Roberto Vargas-Paris
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology Solna, Karolinska University Hospital, Stockholm, Sweden
| | - Sven Nyrén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology Solna, Karolinska University Hospital, Stockholm, Sweden
| | - Goran Abdula
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Russell Ouellette
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tobias Granberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Johan Lundberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.
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20
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Rysz S, Jalde FC, Oldner A, Eriksson LI, Lundberg J, Fagerlund MJ. Treatment with angiotensin II in COVID-19 patients may not be beneficial. Crit Care 2020; 24:546. [PMID: 32887650 PMCID: PMC7472408 DOI: 10.1186/s13054-020-03233-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/09/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Susanne Rysz
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Francesca Campoccia Jalde
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Anders Oldner
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lars I Eriksson
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Johan Lundberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
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21
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Mkrtchian S, Kåhlin J, Gómez-Galán M, Ebberyd A, Yoshitake T, Schmidt S, Kehr J, Hildenborg M, Jonsson Fagerlund M, Erlandsson Harris H, Eriksson LI. The impact of damage-associated molecular patterns on the neurotransmitter release and gene expression in the ex vivo rat carotid body. Exp Physiol 2020; 105:1634-1647. [PMID: 32652583 DOI: 10.1113/ep088705] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/08/2020] [Indexed: 12/21/2022]
Abstract
NEW FINDINGS What is the central question of this study? Are carotid bodies (CBs) modulated by the damage-associated molecular patterns (DAMPs) and humoral factors of aseptic tissue injury? What are the main findings and their importance? DAMPs (HMGB1, S100 A8/A9) and blood plasma from rats subjected to tibia surgery, a model of aseptic injury, stimulate the release of neurotransmitters (ATP, dopamine) and TNF-α from ex vivo rat CBs. All-thiol HMGB1 mediates upregulation of immune-related biological pathways. These data suggest regulation of CB function by endogenous mediators of innate immunity. ABSTRACT The glomus cells of carotid bodies (CBs) are the primary sensors of arterial partial O2 and CO2 tensions and moreover serve as multimodal receptors responding also to other stimuli, such as pathogen-associated molecular patterns (PAMPs) produced by acute infection. Modulation of CB function by excessive amounts of these immunomodulators is suggested to be associated with a detrimental hyperinflammatory state. We have hypothesized that yet another class of immunomodulators, endogenous danger-associated molecular patterns (DAMPs), released upon aseptic tissue injury and recognized by the same pathogen recognition receptors as PAMPs, might modulate the CB activity in a fashion similar to PAMPs. We have tested this hypothesis by exposing rat CBs to various DAMPs, such as HMGB1 (all-thiol and disulfide forms) and S100 A8/A9 in a series of ex vivo experiments that demonstrated the release of dopamine and ATP, neurotransmitters known to mediate CB homeostatic responses. We observed a similar response after incubating CBs with conditioned blood plasma obtained from the rats subjected to tibia surgery, a model of aseptic injury. In addition, we have investigated global gene expression in the rat CB using an RNA sequencing approach. Differential gene expression analysis showed all-thiol HMGB1-driven upregulation of a number of prominent pro-inflammatory markers including Il1α and Il1β. Interestingly, conditioned plasma had a more profound effect on the CB transcriptome resulting in inhibition rather than activation of the immune-related pathways. These data are the first to suggest potential modulation of CB function by endogenous mediators of innate immunity.
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Affiliation(s)
- Souren Mkrtchian
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jessica Kåhlin
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden.,Function Perioperative Medicine and Intensive Care, Karolinska University Hospital and Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Marta Gómez-Galán
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anette Ebberyd
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Takashi Yoshitake
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Jan Kehr
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Pronexus Analytical AB, Bromma, Sweden
| | - Malin Hildenborg
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden.,Function Perioperative Medicine and Intensive Care, Karolinska University Hospital and Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden.,Function Perioperative Medicine and Intensive Care, Karolinska University Hospital and Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Helena Erlandsson Harris
- Department of Medicine Solna, Section for Rheumatology, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars I Eriksson
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden.,Function Perioperative Medicine and Intensive Care, Karolinska University Hospital and Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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22
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Rysz S, Lundberg J, Nordberg P, Eriksson H, Wieslander B, Lundin M, Fyrdahl A, Pernow J, Ugander M, Djärv T, Jonsson Fagerlund M. The effect of levosimendan on survival and cardiac performance in an ischemic cardiac arrest model - A blinded randomized placebo-controlled study in swine. Resuscitation 2020; 150:113-120. [PMID: 32234367 DOI: 10.1016/j.resuscitation.2020.02.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/03/2020] [Accepted: 02/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Survival after out-of-hospital cardiac arrest remains poor. Levosimendan could be a new intervention in this setting. Therefore, we conducted a blinded, placebo controlled randomized study investigating the effects of levosimendan on survival and cardiac performance in an ischemic cardiac arrest model in swine. METHODS Twenty-four anesthetised swines underwent experimentally-induced acute myocardial infarction and ventricular fibrillation. At the start of CPR, a bolus dose of levosimendan (12 μg kg-1) or placebo was given followed by a 24-h infusion (0.2 μg kg-1 min-1) after return of spontaneously circulation. Animals were evaluated by risk of death, post-resuscitation hemodynamics and infarction size by magnetic resonance imaging (MRI) up to 32 h post arrest. RESULTS Spontaneous circulation was restored in all (12/12) animals in the levosimendan group compared to two thirds (8/12) in the placebo group (P = 0.09). Protocol survival was higher for the levosimendan group (P = 0.02) with an estimated 88% lower risk of death compared to placebo (hazard ratio [95% confidence interval] 0.12 [0.01-0.96], P = 0.046). Cardiac output (CO) recovered 40% faster during the first hour of the intensive care period for the levosimendan group (difference 0.13 [0.01-0.26] L min-1P = 0.04). The placebo group required higher inotropic support during the intensive care period which masked an even bigger recovery in CO in the levosimendan group (58%). The MRI showed no difference in myocardial scar size or in myocardial area at risk. CONCLUSIONS Levosimendan given intra-arrest and during the first 24-h of post-resuscitation care improved survival and cardiac performance in this ischemic cardiac arrest model. Institutional Protocol Number; KERIC 5.2.18-14933.
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Affiliation(s)
- Susanne Rysz
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Johan Lundberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Per Nordberg
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Helen Eriksson
- Stockholm University Demography Unit, Department of Sociology, Stockholm University, Sweden
| | - Björn Wieslander
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Magnus Lundin
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Alexander Fyrdahl
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - John Pernow
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Sweden
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden; Kolling Institute, Royal North Shore Hospital, and Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Function Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Sweden
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23
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Christensson E, Fagerlund MJ. Sleep disturbances and residual neuromuscular blockade: future research possibilities: a reply. Anaesthesia 2020; 75:553. [PMID: 32128805 DOI: 10.1111/anae.14930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E Christensson
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - M J Fagerlund
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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24
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Forsberg IM, Mkrtchian S, Lodenius Å, Ullman J, Lars I Eriksson P, Fagerlund MJ. Organ biomarkers during apnoeic oxygenation using THRIVE compared to mechanical ventilation in adults. Trends in Anaesthesia and Critical Care 2020. [DOI: 10.1016/j.tacc.2019.12.366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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25
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Danielson M, Wiklund A, Granath F, Blennow K, Mkrtchian S, Nellgård B, Oras J, Jonsson Fagerlund M, Granström A, Schening A, Rasmussen LS, Erlandsson Harris H, Zetterberg H, Ricksten S, Eriksson LI. Neuroinflammatory markers associate with cognitive decline after major surgery: Findings of an explorative study. Ann Neurol 2020; 87:370-382. [DOI: 10.1002/ana.25678] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 01/08/2020] [Accepted: 01/08/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Mattias Danielson
- Department of Anesthesiology and Intensive Care MedicineInstitute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Gothenburg Sweden
| | - Andreas Wiklund
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care MedicineKarolinska Institutet Stockholm Sweden
- Department of Anesthesia and Intensive CareCapio Sankt Goran Hospital Stockholm Sweden
| | - Fredrik Granath
- Clinical Epidemiology Division, Department of Medicine, SolnaKarolinska Institutet Stockholm Sweden
| | - Kaj Blennow
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg Mölndal Sweden
- Clinical Neurochemistry LaboratorySahlgrenska University Hospital Mölndal Sweden
| | - Souren Mkrtchian
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care MedicineKarolinska Institutet Stockholm Sweden
| | - Bengt Nellgård
- Department of Anesthesiology and Intensive Care MedicineInstitute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Gothenburg Sweden
| | - Jonatan Oras
- Department of Anesthesiology and Intensive Care MedicineInstitute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Gothenburg Sweden
| | - Malin Jonsson Fagerlund
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care MedicineKarolinska Institutet Stockholm Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Stockholm Sweden
| | - Anna Granström
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Stockholm Sweden
| | - Anna Schening
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Stockholm Sweden
| | - Lars S. Rasmussen
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, CopenhagenUniversity of Copenhagen Copenhagen Denmark
| | - Helena Erlandsson Harris
- Rheumatology Unit, Center for Molecular Medicine, Department for Medicine SolnaKarolinska Institute Stockholm Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg Mölndal Sweden
- Clinical Neurochemistry LaboratorySahlgrenska University Hospital Mölndal Sweden
- Department of Neurodegenerative DiseaseUCL Institute of Neurology London United Kingdom
- UK Dementia Research Institute at UCL London United Kingdom
| | - Sven‐Erik Ricksten
- Department of Anesthesiology and Intensive Care MedicineInstitute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Gothenburg Sweden
| | - Lars I. Eriksson
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care MedicineKarolinska Institutet Stockholm Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Stockholm Sweden
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26
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Kirmeier E, Eriksson LI, Lewald H, Jonsson Fagerlund M, Hoeft A, Hollmann M, Meistelman C, Hunter JM, Ulm K, Blobner M. Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study. Lancet Respir Med 2018; 7:129-140. [PMID: 30224322 DOI: 10.1016/s2213-2600(18)30294-7] [Citation(s) in RCA: 195] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 06/28/2018] [Accepted: 07/03/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. METHODS We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients' preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513. FINDINGS Between June 16, 2014, and April 29, 2015, data from 22 803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21 694); ORadj 1·86, 95% CI 1·53-2·26; ARRadj -4·4%, 95% CI -5·5 to -3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15-1·49; ARRadj -2·6%, 95% CI -3·9 to -1·4) and the administration of reversal agents (1·23, 1·07-1·41; -1·9%, -3·2 to -0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85-1·25; ARRadj -0·3%, 95% CI -2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82-1·31; -0·4%, -3·5 to 2·2) was associated with better pulmonary outcomes. INTERPRETATION We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications. FUNDING European Society of Anaesthesiology.
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Affiliation(s)
- Eva Kirmeier
- Department of Anaesthesiology, Technical University of Munich, Munich, Germany
| | - Lars I Eriksson
- Department of Anaesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Heidrun Lewald
- Department of Anaesthesiology, Technical University of Munich, Munich, Germany
| | - Malin Jonsson Fagerlund
- Department of Anaesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Andreas Hoeft
- Department of Anaesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Markus Hollmann
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam University, Amsterdam, Netherlands
| | | | - Jennifer M Hunter
- Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, Liverpool University, Liverpool, UK
| | - Kurt Ulm
- Department of Medical Statistics and Epidemiology, Technical University of Munich, Munich, Germany
| | - Manfred Blobner
- Department of Anaesthesiology, Technical University of Munich, Munich, Germany.
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Forsberg A, Cervenka S, Jonsson Fagerlund M, Rasmussen LS, Zetterberg H, Erlandsson Harris H, Stridh P, Christensson E, Granström A, Schening A, Dymmel K, Knave N, Terrando N, Maze M, Borg J, Varrone A, Halldin C, Blennow K, Farde L, Eriksson LI. The immune response of the human brain to abdominal surgery. Ann Neurol 2017; 81:572-582. [DOI: 10.1002/ana.24909] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/15/2017] [Accepted: 02/26/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Anton Forsberg
- Department of Clinical Neuroscience; Center for Psychiatric Research, Karolinska Institutet; Stockholm Sweden
| | - Simon Cervenka
- Department of Clinical Neuroscience; Center for Psychiatric Research, Karolinska Institutet; Stockholm Sweden
| | - Malin Jonsson Fagerlund
- Department of Physiology and Pharmacology; Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet; Stockholm Sweden
- Perioperative Medicine and Intensive Care; Karolinska University Hospital; Stockholm Sweden
| | - Lars S. Rasmussen
- Department of Anesthesia; Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology; Department of Psychiatry and Neurochemistry, Sahlgrenska Academy at University of Gothenburg; Mölndal Sweden
- Clinical Neurochemistry Laboratory; Sahlgrenska University Hospital of Gothenburg; Mölndal Sweden
- Department of Molecular Neuroscience; University College London Institute of Neurology; London United Kingdom
| | - Helena Erlandsson Harris
- Center for Molecular Medicine; Department of Medicine, Karolinska Institutet; Stockholm Sweden
- Rheumatology Unit; Karolinska University Hospital; Stockholm Sweden
| | - Pernilla Stridh
- Center for Molecular Medicine; Department of Clinical Neuroscience, Karolinska Institutet; Stockholm Sweden
| | - Eva Christensson
- Department of Physiology and Pharmacology; Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet; Stockholm Sweden
- Perioperative Medicine and Intensive Care; Karolinska University Hospital; Stockholm Sweden
| | - Anna Granström
- Department of Physiology and Pharmacology; Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet; Stockholm Sweden
- Perioperative Medicine and Intensive Care; Karolinska University Hospital; Stockholm Sweden
| | - Anna Schening
- Department of Physiology and Pharmacology; Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet; Stockholm Sweden
- Perioperative Medicine and Intensive Care; Karolinska University Hospital; Stockholm Sweden
| | - Karin Dymmel
- Department of Physiology and Pharmacology; Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet; Stockholm Sweden
- Perioperative Medicine and Intensive Care; Karolinska University Hospital; Stockholm Sweden
| | - Nina Knave
- Department of Clinical Neuroscience; Center for Psychiatric Research, Karolinska Institutet; Stockholm Sweden
| | - Niccolò Terrando
- Department of Anesthesiology; Basic Science Division, Duke University Medical Center; Durham NC
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care and Center for Cerebrovascular Research; University of California; San Francisco, San Francisco CA
| | - Jacqueline Borg
- Department of Clinical Neuroscience; Center for Psychiatric Research, Karolinska Institutet; Stockholm Sweden
| | - Andrea Varrone
- Department of Clinical Neuroscience; Center for Psychiatric Research, Karolinska Institutet; Stockholm Sweden
| | - Christer Halldin
- Department of Clinical Neuroscience; Center for Psychiatric Research, Karolinska Institutet; Stockholm Sweden
| | - Kaj Blennow
- Institute of Neuroscience and Physiology; Department of Psychiatry and Neurochemistry, Sahlgrenska Academy at University of Gothenburg; Mölndal Sweden
- Clinical Neurochemistry Laboratory; Sahlgrenska University Hospital of Gothenburg; Mölndal Sweden
| | - Lars Farde
- Department of Clinical Neuroscience; Center for Psychiatric Research, Karolinska Institutet; Stockholm Sweden
- Personalized Healthcare and Biomarkers; AstraZeneca, PET Science Center, Karolinska Institutet, Karolinska University Hospital; Stockholm Sweden
| | - Lars I. Eriksson
- Department of Physiology and Pharmacology; Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet; Stockholm Sweden
- Perioperative Medicine and Intensive Care; Karolinska University Hospital; Stockholm Sweden
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Mkrtchian S, Lee KL, Kåhlin J, Ebberyd A, Poellinger L, Fagerlund MJ, Eriksson LI. Hypoxia regulates microRNA expression in the human carotid body. Exp Cell Res 2017; 352:412-419. [PMID: 28238835 DOI: 10.1016/j.yexcr.2017.02.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/09/2017] [Accepted: 02/19/2017] [Indexed: 11/19/2022]
Abstract
The carotid body (CB) is the key sensing organ for physiological oxygen levels in the body. Under conditions of low oxygen (hypoxia), the CB plays crucial roles in signaling to the cardiorespiratory center in the medulla oblongata for the restoration of oxygen homeostasis. How hypoxia regulates gene expression in the human CB remains poorly understood. While limited information on transcriptional regulation in animal CBs is available, the identity and impact of important post-transcriptional regulators such as non-coding RNAs, and in particular miRNAs are not known. Here we show using ex vivo experiments that indeed a number of miRNAs are differentially regulated in surgically removed human CB slices when acute hypoxic conditions were applied. Analysis of the hypoxia-regulated miRNAs shows that they target biological pathways with upregulation of functions related to cell proliferation and immune response and downregulation of cell differentiation and cell death functions. Comparative analysis of the human CB miRNAome with the global miRNA expression patterns of a large number of different human tissues showed that the CB miRNAome had a unique profile which reflects its highly specialized functional status. Nevertheless, the human CB miRNAome is most closely related to the miRNA expression pattern of brain tissues indicating that they may have the most similar developmental origins.
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Affiliation(s)
- Souren Mkrtchian
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, SE-171 77 Stockholm, Sweden.
| | - Kian Leong Lee
- Cancer Science Institute of Singapore, National University of Singapore, 117599 Singapore.
| | - Jessica Kåhlin
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, SE-171 77 Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Anette Ebberyd
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, SE-171 77 Stockholm, Sweden
| | - Lorenz Poellinger
- Cancer Science Institute of Singapore, National University of Singapore, 117599 Singapore; Department of Cell and Molecular Biology, Karolinska Institute, SE-171 77 Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, SE-171 77 Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Lars I Eriksson
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, SE-171 77 Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
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Kåhlin J, Mkrtchian S, Ebberyd A, Eriksson LI, Fagerlund MJ. The Human Carotid Body Gene Expression and Function in Signaling of Hypoxia and Inflammation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 860:371-7. [DOI: 10.1007/978-3-319-18440-1_42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Kåhlin J, Mkrtchian S, Ebberyd A, Hammarstedt-Nordenvall L, Nordlander B, Yoshitake T, Kehr J, Prabhakar N, Poellinger L, Fagerlund MJ, Eriksson LI. The human carotid body releases acetylcholine, ATP and cytokines during hypoxia. Exp Physiol 2014; 99:1089-98. [PMID: 24887113 DOI: 10.1113/expphysiol.2014.078873] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Studies on experimental animals established that the carotid bodies are sensory organs for detecting arterial blood O2 levels and that the ensuing chemosensory reflex is a major regulator of cardiorespiratory functions during hypoxia. However, little information is available on the human carotid body responses to hypoxia. The present study was performed on human carotid bodies obtained from surgical patients undergoing elective head and neck cancer surgery. Our results show that exposing carotid body slices to hypoxia for a period as brief as 5 min markedly facilitates the release of ACh and ATP. Furthermore, prolonged hypoxia for 1 h induces an increased release of interleukin (IL)-1β, IL-4, IL-6, IL-8 and IL-10. Immunohistochemical analysis revealed that type 1 cells of the human carotid body express an array of cytokine receptors as well as hypoxia-inducible factor-1α and hypoxia-inducible factor-2α. Taken together, these results demonstrate that ACh and ATP are released from the human carotid body in response to hypoxia, suggesting that these neurotransmitters, as in several experimental animal models, play a role in hypoxic signalling also in the human carotid body. The finding that the human carotid body releases cytokines in response to hypoxia adds to the growing body of information suggesting that the carotid body may play a role in detecting inflammation, providing a link between the immune system and the nervous system.
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Affiliation(s)
- Jessica Kåhlin
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden Department of Anesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Souren Mkrtchian
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Anette Ebberyd
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Britt Nordlander
- Department of Otorhinolaryngology (ENT), Karolinska University Hospital, Stockholm, Sweden
| | - Takashi Yoshitake
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jan Kehr
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Nanduri Prabhakar
- Institute for Integrative Physiology & Center for Systems Biology of O2 Sensing, Biological Sciences Division, University of Chicago, Chicago, IL, USA
| | - Lorenz Poellinger
- Department of Cell and Molecular Biology, Karolinska Institutet, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden Department of Anesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Lars I Eriksson
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden Department of Anesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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Jonsson Fagerlund M, Sjödin J, Dabrowski MA, Krupp J. Reduced efficacy of the intravenous anesthetic agent AZD3043 at GABAA receptors with β2 (N289M) and β3 (N290M) point-mutations. Eur J Pharmacol 2012; 694:13-9. [DOI: 10.1016/j.ejphar.2012.07.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 07/16/2012] [Accepted: 07/28/2012] [Indexed: 11/30/2022]
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Mkrtchian S, Kåhlin J, Ebberyd A, Gonzalez C, Sanchez D, Balbir A, Kostuk EW, Shirahata M, Fagerlund MJ, Eriksson LI. The human carotid body transcriptome with focus on oxygen sensing and inflammation--a comparative analysis. J Physiol 2012; 590:3807-19. [PMID: 22615433 DOI: 10.1113/jphysiol.2012.231084] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The carotid body (CB) is the key oxygen sensing organ. While the expression of CB specific genes is relatively well studied in animals, corresponding data for the human CB are missing. In this study we used five surgically removed human CBs to characterize the CB transcriptome with microarray and PCR analyses, and compared the results with mice data. In silico approaches demonstrated a unique gene expression profile of the human and mouse CB transcriptomes and an unexpected upregulation of both human and mouse CB genes involved in the inflammatory response compared to brain and adrenal gland data. Human CBs express most of the genes previously proposed to be involved in oxygen sensing and signalling based on animal studies, including NOX2, AMPK, CSE and oxygen sensitive K+ channels. In the TASK subfamily of K+ channels, TASK-1 is expressed in human CBs, while TASK-3 and TASK-5 are absent, although we demonstrated both TASK-1 and TASK-3 in one of the mouse reference strains. Maxi-K was expressed exclusively as the spliced variant ZERO in the human CB. In summary, the human CB transcriptome shares important features with the mouse CB, but also differs significantly in the expression of a number of CB chemosensory genes. This study provides key information for future functional investigations on the human carotid body.
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Affiliation(s)
- Souren Mkrtchian
- Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, SE-171 77 Stockholm, Sweden.
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Terrando N, Eriksson LI, Ryu JK, Yang T, Monaco C, Feldmann M, Jonsson Fagerlund M, Charo IF, Akassoglou K, Maze M. Resolving postoperative neuroinflammation and cognitive decline. Ann Neurol 2012; 70:986-995. [PMID: 22190370 DOI: 10.1002/ana.22664] [Citation(s) in RCA: 411] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Cognitive decline accompanies acute illness and surgery, especially in the elderly. Surgery engages the innate immune system that launches a systemic inflammatory response that, if unchecked, can cause multiple organ dysfunction. We sought to understand the mechanisms whereby the brain is targeted by the inflammatory response and how this can be resolved. METHODS C57BL/6J, Ccr2(RFP/+)Cx3cr1(GFP/+), Ikk(F/F) mice and LysM-Cre/Ikk(F/F) mice underwent stabilized tibial fracture operation under analgesia and general anesthesia. Separate cohorts of mice were tested for systemic and hippocampal inflammation, integrity of the blood-brain barrier (BBB), and cognition. The putative resolving effects of the cholinergic pathway on these postoperative responses were also studied. RESULTS Peripheral surgery disrupts the BBB via release of tumor necrosis factor-alpha (TNFα), which facilitates the migration of macrophages into the hippocampus. Macrophage-specific deletion of Ikappa B kinase (IKK)β, a central coordinator of TNFα signaling through activation of nuclear factor (NF) κB, prevents BBB disruption and macrophage infiltration in the hippocampus following surgery. Activation of the α7 subtype of nicotinic acetylcholine receptors, an endogenous inflammation-resolving pathway, prevents TNFα-induced NF-κB activation, macrophage migration into the hippocampus, and cognitive decline following surgery. INTERPRETATION These data reveal the mechanisms for bidirectional communication between the brain and immune system following aseptic trauma. Pivotal molecular mechanisms can be targeted to prevent and/or resolve postoperative neuroinflammation and cognitive decline.
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Affiliation(s)
- Niccolò Terrando
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143-0648
| | - Lars I Eriksson
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143-0648.,Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jae Kyu Ryu
- Gladstone Institute of Neurological Disease, University of California, San Francisco, CA, USA
| | - Ting Yang
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143-0648
| | - Claudia Monaco
- Kennedy Institute of Rheumatology, Faculty of Medicine, Imperial College London, London W6 8LH, United Kingdom
| | - Marc Feldmann
- Kennedy Institute of Rheumatology, Faculty of Medicine, Imperial College London, London W6 8LH, United Kingdom
| | - Malin Jonsson Fagerlund
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Israel F Charo
- Gladstone Institute of Cardiovascular Disease, University of California, San Francisco, CA, USA
| | - Katerina Akassoglou
- Gladstone Institute of Neurological Disease, University of California, San Francisco, CA, USA.,Department of Neurology, University of California, San Francisco, CA, USA
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143-0648
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Kåhlin J, Eriksson LI, Ebberyd A, Fagerlund MJ. Presence of nicotinic, purinergic and dopaminergic receptors and the TASK-1 K+-channel in the mouse carotid body. Respir Physiol Neurobiol 2010; 172:122-8. [PMID: 20452469 DOI: 10.1016/j.resp.2010.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 03/11/2010] [Accepted: 05/02/2010] [Indexed: 10/19/2022]
Abstract
We have characterized the mouse carotid body (CB) with special attention to nicotinic, purinergic and dopaminergic receptors as well as the TASK-1 K(+)-channel. Mouse CB sections were stained immunohistochemically and visualized using fluorescent and confocal microscopy. The CB type 1 cells contained the alpha3 (n=8), alpha4 (n=7), alpha7 (n=4) and beta2 (n=3) nicotinic acetylcholine receptor (nAChR) subunits, the ATP-receptors P2X(2) (n=15) and P2X(3) (n=9), the dopamine D(2) receptor (n=9) and the TASK-1 K(+)-channel (n=7). Here we report the presence of alpha3, alpha4, alpha7 and beta2 nAChR subunits, the D(2) receptor and the TASK-1 K(+)-channel in the mouse CB. Also, we confirm the presence of the P2X(2) and P2X(3) receptors in mouse CB. Thus, we have localized nicotinergic, purinergic and dopaminergic receptors and the TASK-1 K(+)-channel on a protein level in one species. Our data are in line with the theory that the CB chemoreceptor cell hosts an orchestra of receptor systems that ultimately modulate the response to hypoxia.
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Affiliation(s)
- Jessica Kåhlin
- Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden.
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Akada S, Fagerlund MJ, Lindahl SG, Sakamoto A, Prabhakar NR, Eriksson LI. Pronounced depression by propofol on carotid body response to CO2 and K+-induced carotid body activation. Respir Physiol Neurobiol 2008; 160:284-8. [DOI: 10.1016/j.resp.2007.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Revised: 10/14/2007] [Accepted: 10/20/2007] [Indexed: 10/22/2022]
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