Acta Anaesthesiologica Scandinavica

Aims/Background: This review examines current research on teamwork in highly dynamic domains of healthcare such as operating rooms, intensive care, emergency medicine, or trauma and resuscitation teams with a focus on aspects relevant to the quality and safety of patient care.

Results: Evidence from three main areas of research supports the relationship between teamwork and patient safety: (1) Studies investigating the factors contributing to critical incidents and adverse events have shown that teamwork plays an important role in the causation and prevention of adverse events. (2) Research focusing on healthcare providers' perceptions of teamwork demonstrated that (a) staff's perceptions of teamwork and attitudes toward safety‐relevant team behavior were related to the quality and safety of patient care and (b) perceptions of teamwork and leadership style are associated with staff well‐being, which may impact clinician' ability to provide safe patient care. (3) Observational studies on teamwork behaviors related to high clinical performance have identified patterns of communication, coordination, and leadership that support effective teamwork.

Conclusion: In recent years, research using diverse methodological approaches has led to significant progress in team research in healthcare. The challenge for future research is to further develop and validate instruments for team performance assessment and to develop sound theoretical models of team performance in dynamic medical domains integrating evidence from all three areas of team research identified in this review. This will help to improve team training efforts and aid the design of clinical work systems supporting effective teamwork and safe patient care.

Postoperative cognitive function (POCD) has been subject to extensive research. In the literature, large differences are apparent in methodology such as the test batteries, the interval between sessions, the endpoints to be analysed, statistical methods, and how neuropsychological deficits are defined. Traditionally, intelligence tests or tests developed for clinical neuropsychology have been used. The tests for detecting POCD should be based on well‐described sensitivity and suitability in relation to surgical patients. In tests using scores, floor/ceiling effects may compromise the evaluation if the tests are either too easy or to difficult. Uncontrolled testing facilities and change of test personnel may affect the test performance. Practice effects are pronounced in neuropsychological tests but have generally been ignored. The use of a suitable normative population is essential to allow correction for practice effects and variability between sessions. Missing follow‐up may severely compromise valid conclusions since subjects unable or unwilling to be examined are particularly prone to suffer from POCD. In the statistical analysis of the test results, the evaluation should be based on differences between pre‐ and postoperative performance. Parametric statistical tests are not relevant unless the appropriate Gaussian distributions are present, perhaps after transformation of data. The definition of cognitive dysfunction should be restrictive and the criteria should be fulfilled in only a small proportion of volunteers. In the literature, these requirements often have not been fulfilled. This precludes a reasonable estimation of the incidence of POCD and the conclusions of comparative studies should be interpreted with great caution. In this review article, we present a number of recommendations for the design and execution of studies within this area. In addition, the critical reader may use these recommendations in the evaluation of the literature.

Background:  Major surgery is frequently associated with postoperative cognitive dysfunction (POCD) in elderly patients. Type of surgery and hospitalization may be important prognostic factors. The aims of the study were to find the incidence and risk factors for POCD in elderly patients undergoing minor surgery.

Methods:  We enrolled 372 patients aged greater than 60 years scheduled for minor surgery under general anesthesia. According to local practice, patients were allocated to either in‐ (199) or out‐patient (173) care. Cognitive function was assessed using neuropsychological testing preoperatively and 7 days and 3 months postoperatively. Postoperative cognitive dysfunction was defined using Z‐score analysis.

Results:  At 7 days, the incidence (confidence interval) of POCD in patients undergoing minor surgery was 6.8% (4.3–10.1). At 3 months the incidence of POCD was 6.6% (4.1–10.0). Logistic regression analysis identified the following significant risk factors: age greater than 70 years (odds ratio [OR]: 3.8 [1.7–8.7], P = 0.01) and in‐ vs. out‐patient surgery (OR: 2.8 [1.2–6.3], P = 0.04).

Conclusions:  Our finding of less cognitive dysfunction in the first postoperative week in elderly patients undergoing minor surgery on an out‐patient basis supports a strategy of avoiding hospitalization of older patients when possible.

The laparoscopic operating technique is being applied increasingly to a variety of intra‐abdominal operations. Intra–abdominal gas insufflation, i.e. pneumoperitoneum (PP), is then used to allow surgical access. The haemodynamic effects of PP in combination with different body positions have not been fully examined. Eleven patients without signs of cardiopulmonary disease were studied before and during laparoscopic cholecystectomy under propofol–fentanyl anaesthesia with controlled ventilation. Swan‐Ganz and radial arterial catheterization were used to determine haemodynamic data in the horizontal position, with a 15–20° head–down tilt and a 15–20° head–up tilt. The measurements were repeated after insufflation of carbon dioxide to an intraabdominal pressure of 11–13 mmHg, as well as during surgery. The ventricular filling pressures of the heart were strictly dependent on body position. PP in the horizontal position increased pulmonary capillary wedge pressure by 32% (P < 0.01), central venous pressure by 58% (P < 0.01), and mean arterial pressure by 39% (P < 0.01). When PP was combined with a head–down tilt, there was a further increase in filling pressures by approximately 40% (P < 0.01), while the reduction in filling pressures during the head–up tilt was counteracted by PP. During PP with a head–up tilt, the filling pressures did not differ from those in the horizontal position without PP. CI showed a certain dependency on filling pressures. It is concluded that PP causes signs of elevated preload and afterload. The combination of PP and a head–up tilt is associated only with signs of an elevated afterload. It is suggested that the haemodynamic response to PP, especially in combination with a head–down tilt, may be hazardous to patients with compromised heart function.

Background:  Preliminary clinical studies have suggested that gabapentin may produce analgesia and reduce the need for opioids in postoperative patients. The aim of the present study was to investigate the opioid‐sparing and analgesic effects of gabapentin administered during the first 24 h after abdominal hysterectomy.

Methods:  In a randomized, double‐blind study, 80 patients received oral gabapentin 1200 mg or placebo 1 h before surgery, followed by oral gabapentin 600 mg or placebo 8, 16 and 24 h after the initial dose. Patients received patient‐controlled analgesia with morphine at doses of 2.5 mg with a lock‐out time of 10 min for 24 h postoperatively. Pain was assessed on a visual analogue scale (VAS) at rest and during mobilization, nausea, somnolence and dizziness on a four‐point verbal scale, and vomiting as present/not present at 2, 4, 22 and 24 h postoperatively.

Results:  Thirty‐nine patients in the gabapentin group, and 32 patients in the placebo group completed the study. Gabapentin reduced total morphine consumption from median 63 (interquartile range 53–88) mg to 43 (28–60) mg (P < 0.001). We observed a significant inverse association between plasma levels of gabapentin at 2 h postoperatively, and morphine usage from 0 to 2 h, and from 0 to 4 h postoperatively (R² = 0.30, P = 0.003 and R² = 0.24 P = 0.008, respectively).

No significant differences in pain at rest or during mobilization, or in side‐effects, were observed between groups.

Conclusion:  Gabapentin in a total dose of 3000 mg, administered before and during the first 24 h after abdominal hysterectomy, reduced morphine consumption with 32%, without significant effects on pain scores. No significant differences in side‐effects were observed between study‐groups.

Among 873 consecutive patients who had undergone a total of 1021 spinal anaesthesias involving puncture of the lumbar dura, 75 (7.35%) complained of Postdural Puncture headache. (PDPH). The severity of each patient's PDPH was categorized, on a scale from mild to severe, on the basis of the onset, duration, severity of the heActa ches, and the degree to which they were accompained by auditory and vestibular symptoms. In the patients who developed PDPH, 65% developed symptoms within 24 hours of the lumbar punctures and 92% developed symptoms within 48 hours.

For the patients who recovered spontaneously the mean duration of the PDPHs was 5 days, with a range of 1–12 days. PDPH was characterized by headachches that were influenced by the patient's posture and the severity of PDPH was categorized as follows:

Mild PDPH resulted in a slight restriction of their physical activity. These patients were not confined to bed and had no associated symptoms.

Moderate PDPH forced the patient to stay in bed for part of the day, and resulted in restricted physical activity. Associated symptoms were not necessarily present.

Severe PDPH Patients were bedridden for the entire day and made no attempt to raise their head or to stand. Associated symptoms were always present.

Fortyfive of the PDPH patients (60%) recovered spontaneously. Of these, 8 patients (11%) were categorized as mild cases of PDPH, 14 (19%) as moderate, and 23 (30%) patients as severe cases of PDPH. Thirty of the PDPH patients (40%) were treated with an autologous epidural bloodpatch (AEBP). Of these, 27 patients (36%) were classified as severe and 3 patients (4%) as moderate PDPH.

ASSOCIATED SYMPTOMS were present in all patients who had severe PDPH and in 86 percent of the patients who had moderate degrees of PDPH. Of all the patients with PDPH, 60% complained of nausea, 24% of vomiting, 43% of stiffness of the neck, 13% of ocular symptoms, and 12% of auditive symptoms. The headches in the PDPH patients were localized to the frontal region, bilaterally, in 25% of the cases, occipitally in 27% of the cases and in both regions in the remaining 45% of the patients.

Fifty‐five patients with pain associated with cancer were selected for long‐term treatment with epidural morphine. Patients who had more than one type of pain within the same region were specially analysed concerning differential analgesic effects of the treatment, i. e. the patients served as their own control. Twenty‐eight of the 55 patients became pain free. In 21 patients alleviation of pain was complete only for one or two of several types of pain within the same area with a certain dose of epidural morphine. In six patients the treatment failed. An analysis revealed that the best response was obtained when the pain was continuous and originated from deep somatic structures. In co‐existing continuous visceral pain or intermittent somatic pain originating e. g. from a pathological fracture, the outcome of the treatment was variable. Cutaneous pain, pain classified as neurogenic, and intermittent pain due to intestinal obstruction was only occasionally relieved. Ten of the patients had co‐existing pain of non‐malignant origin and none of them was helped for that pain. The variable response to epidural morphine may indicate that different types of pain‐producing stimuli engage different kinds of receptors which differ in affinity to morphine in the spinal fluid; it is also possible that some pain‐mediating systems are non‐responsive to opiates.

Background: Assessment of postoperative nausea intensity is difficult because nausea is a subjective and unpleasant sensation. We propose using the Visual Analogue Scale (VAS) device to increase the efficiency and precision in the assessment of nausea. We carried out a pilot study on postoperative patients suffering from nausea to measure the degree of agreement between the VAS scores and those given on a 4‐point verbal descriptive scale (VDS).

Methods: Postoperative nausea was evaluated by means of a classical VAS (0–10 cm) device and a 4‐point VDS (0=no nausea, 1=mild, 2=moderate, 3=severe) in 128 surgical spontaneously complaining patients. Evaluation was repeated 45 min after rescue medication given if nausea was intractable, lasted more than 10 min or at the request of the patient. Ordinal logistic regression was used to measure the association between VAS and VDS and to determine cut‐off points on the VAS.

Results: The VAS device was easily understood and used by patients. VAS scores decreased significantly from 5.5±2.3 to 1.4±1.8 after rescue medication (P=0.002). Application of ordinal logistic regression to pre‐ and post‐medication data combined yielded an agreement of 86% between VAS and VDS and the cut‐off points on the VAS were estimated as follows: 0–1 (no nausea), 1⁺–4 (mild), 4⁺–7 (moderate) and 7⁺–10 (severe).

Conclusion: The VAS method proved to be useful for assessing quantitative nausea intensity and for testing the efficacy of rescue medication. It was found that a cut‐off value of 4 on the VAS may be considered as a critical threshold triggering anaesthesiologists or nurses to administer rescue medication.

Background: It is unclear whether positive end‐expiratory pressure (PEEP) is needed to maintain the improved oxygenation and lung volume achieved after a lung recruitment maneuver in patients ventilated after cardiac surgery performed in the cardiopulmonary bypass (CPB).

Methods: A prospective, randomized, controlled study in a university hospital intensive care unit. Sixteen patients who had undergone cardiac surgery in CPB were studied during the recovery phase while still being mechanically ventilated with an inspired fraction of oxygen (FiO₂) 1.0. Eight patients were randomized to lung recruitment (two 20‐s inflations to 45 cmH₂O), after which PEEP was set and kept for 2.5 h at 1 cmH₂O above the pressure at the lower inflexion point (14±3 cmH₂O, mean ±SD) obtained from a static pressure‐volume (PV) curve (PEEP group). The remaining eight patients were randomized to a recruitment maneuver only (ZEEP group). End‐expiratory lung volume (EELV), series dead space, ventilation homogeneity, hemodynamics and PaO₂ (oxygenation) were measured every 30 min during a 3‐h period. PV curves were obtained at baseline, after 2.5 h, and in the PEEP group at 3 h.

Results: In the ZEEP group all measures were unchanged. In the PEEP group the EELV increased with 1220±254 ml (P<0.001) and PaO₂ with 16±16 kPa (P<0.05) after lung recruitment. When PEEP was discontinued EELV decreased but PaO₂ was maintained. The PV curve at 2.5 h coincided with the curve obtained at 3 h, and both curves were both steeper than and located above the baseline curve.

Conclusions:  Positive end‐expiratory pressure is required after a lung recruitment maneuver in patients ventilated with high FiO₂ after cardiac surgery to maintain lung volumes and the improved oxygenation.