Betamethasone in prevention of postoperative nausea and vomiting following breast surgery.

To investigate whether betamethasone decreases the incidence of postoperative nausea/vomiting (PONV) and reduces postoperative pain following partial mastectomy

A comparison of two emergency medical dispatch protocols with respect to accuracy

Background: Emergency medical dispatching should be as accurate as possible in order to ensure patient safety and optimize the use of ambulance resources. This study aimed to compare the accuracy, measured as priority level, between two Swedish dispatch protocols - the three-graded priority protocol Medical Index and a newly developed prototype, the four-graded priority protocol, RETTS-A. Methods: A simulation study was carried out at the Emergency Medical Communication Centre (EMCC) in Stockholm, Sweden, between October and March 2016. Fifty-three voluntary telecommunicators working at SOS Alarm were recruited nationally. Each telecommunicator handled 26 emergency medical calls, simulated by experienced standard patients. Manuscripts for the scenarios were based on recorded real-life calls, representing the six most common complaints. A cross-over design with 13 + 13 calls was used. Priority level and medical condition for each scenario was set through expert consensus and used as gold standard in the study. Results: A total of 1293 calls were included in the analysis. For priority level, n = 349 (54.0%) of the calls were assessed correctly with Medical Index and n = 309 (48.0%) with RETTS-A (p = 0.012). Sensitivity for the highest priority level was 82.6% (95% confidence interval: 76.6-87.3%) in the Medical Index and 54.0% (44.3-63.4%) in RETTS-A. Overtriage was 37.9% (34.2-41.7%) in the Medical Index and 28.6% (25.2-32.2%) in RETTS-A. The corresponding proportion of undertriage was 6.3% (4.7-8.5%) and 23.4% (20.3-26.9%) respectively. Conclusion: In this simulation study we demonstrate that Medical Index had a higher accuracy for priority level and less undertriage than the new prototype RETTS-A. The overall accuracy of both protocols is to be considered as low. Overtriage challenges resource utilization while undertriage threatens patient safety. The results suggest that in order to improve patient safety both protocols need revisions in order to guarantee safe emergency medical dispatching.Peer reviewe

A registry-based observational study comparing emergency calls assessed by emergency medical dispatchers with and without support by registered nurses

Background The requirement concerning formal education for emergency medical dispatcher (EMD) is debated and varies, both nationally and internationally. There are few studies on the outcomes of emergency medical dispatching in relation to professional background. This study aimed to compare calls handled by an EMD with and without support by a registered nurse (RN), with respect to priority level, accuracy, and medical condition. Methods A retrospective observational study, performed on registry data from specific regions during 2015. The ambulance personnel's first assessment of the priority level and medical condition was used as the reference standard. Outcomes were: the proportion of calls dispatched with a priority in concordance with the ambulance personnel's assessment; over- and undertriage; the proportion of most adverse over- and undertriage; sensitivity, specificity and predictive values for each of the ambulance priorities; proportion of calls dispatched with a medical condition in concordance with the ambulance personnel's assessment. Proportions were reported with 95% confidence intervals. chi(2)-test was used for comparisons. P-levels < 0.05 were regarded as significant. Results A total of 25,025 calls were included (EMD n = 23,723, EMD + RN n = 1302). Analyses relating to priority and medical condition were performed on 23,503 and 21,881 calls, respectively. A dispatched priority in concordance with the ambulance personnel's assessment were: EMD n = 11,319 (50.7%) and EMD + RN n = 481 (41.5%) (p < 0.01). The proportion of overtriage was equal for both groups: EMD n = 5904, EMD + RN n = 306, (26.4%) p = 0.25). The proportion of undertriage for each group was: EMD n = 5122 (22.9%) and EMD + RN n = 371 (32.0%) (p < 0.01). Sensitivity for the most urgent priority was 54.6% for EMD, compared to 29.6% for EMD + RN (p < 0.01), and specificity was 67.3% and 84.8% (p < 0.01) respectively. A dispatched medical condition in concordance with the ambulance personnel's assessment were: EMD n = 13,785 (66.4%) and EMD + RN n = 697 (62.2%) (p = 0.01). Conclusions A higher precision of emergency medical dispatching was not observed when the EMD was supported by an RN. How patient safety is affected by the observed divergence in dispatched priorities is an area for future research.Peer reviewe

Emergency medical dispatchers' experiences of managing emergency calls : a qualitative interview study

Objectives To explore the emergency medical dispatchers (EMDs) experiences of managing emergency medical calls. Design A qualitative interview study with an inductive approach. EMDs were interviewed individually using a semistructured interview guide. The verbatim transcripts were analysed using a qualitative content analysis. Setting EMDs, without a professional background as registered nurses, were recruited from emergency medical communication centers (EMCCs) within Sweden. Participants To achieve a varied description of EMDs' experiences, participants were included from several EMCCs nationally, using a convenience sampling. Interviews were performed up until saturation of data, resulting in 13 EMDs from 7 EMCCs being interviewed. All the EMDs were women, ranging in age from 28 to 61 years (mean 42 years), and had worked in emergency medical dispatching between 1 and 13.5 years (mean 6.5 years). Results The analysis revealed the main category-to attentively manage a multifaceted, interactive task-made up of three categories: utilize creativity to gather information, continuously process and assess complex information, and engage in the professional role. The content of each category was reflected in several subcategories further described and illustrated with representative quotes. Conclusions Managing emergency medical calls was experienced by EMDs to attentively manage a multifaceted interactive task. Core parts were described as: the ability to utilize creativity to gather information, continuously process and asses complex information, and engage in the professional role. Our results could be beneficial for emergency care managers when designing training programmes and organising EMD work and the EMD work environment, including further development of dispatch protocols and implementation of regular feedback sessions. Moreover, the results indicate that aspects such as self-awareness and emotional challenges encountered during EMD work could be important matters to discuss during staff evaluations.Peer reviewe

Intestinal ischemia and reperfusion. Proinflammatory response and organ dysfunction

Intestinal I/R is considered to be an important initiating event in several pathophysiological conditions such as trauma, bleeding, sepsis and pancreatitis, frequently leading to concomitant both single and potentially multiple organ dysfunction. The purpose of this thesis was to study mechanims underlying the development of multiple organ dysfunction, with special focus on intercellular proinflammatory regulation in the concurrent development of tissue injury. A further aim was to evaluate novel forms of therapy and prevention against the development of multipel organ dysfunction. Experimental intestinal I/R was induced by clamping the superior mesenteric artery in male Sprague-Dawley rats for 40 min, followed by reperfusion up to 12 hrs. Treatment attempts with N-Acetylcystein (NAC), the platelet activating factor (PAF) inhibitor lexipafant, monoclonal antibodies (MAbs) against platelet endothelial cell adhesion molecule-1 (PECAM-1), active-site-inactivated FVIIa (FVIIai) or the FXa inhibitor fondaparinux were tested. It was found that intestinal I/R induced an increase in intercellular adhesion molecule-1 (ICAM-1) expression in different tissues with marked organ variability. In parallel, an inflammatory response with neutrophil recruitment in the lungs and intestines as well as an increased endothelial barrier permeability in several organs was observed. Inflammatory mediators such as TNF-a, IL-1b, MCP-1 and MIP-2 also increased, with an earlier response in organs directly affected by the I/R-injury than in organs more distantly located. Treatment 15 min after the start of reperfusion with NAC and lexipafant attenuated the inflammatory response, but did not affect the ICAM-1 expression, suggesting that the protective effects of NAC and PAF-inhibition is not mediated via decreased expression of ICAM-1. Therapy inserted at 3 hrs of reperfusion, also decreased the inflammatory response and tissue injury, although not as pronounced as demonstrated after early treatment. Administration of the anticoagulants FVIIai or fondaparinux resulted in decreased plasma levels of the neutrophil chemoattractant MIP-2, whereas only FVIIai restored endothelial barrier dysfunction and decreased intestinal neutrophil recruitment. This demonstrates that inhibition of the TF-FVIIai complex formation by FVIIai can attenuate inflammatory responses in connection with intestinal I/R. Based on our results, we suggest that a multimodal treatment regime with inhibitors against inflammatory mediators such as oxygen free radicals, platelet activating factor and coagulation factors such as FVIIa and FXa, could represent potential future strategies in the prevention and treatment of organ dysfunction in hyperinflammatory states, seen e.g. in association with critical illness

Free oscillation rheometry monitoring of haemodilution and hypothermia and correction with fibrinogen and factor XIII concentrates

Background Haemodilution and hypothermia induce coagulopathy separately, but their combined effect on coagulation has not been widely studied. Fibrinogen concentrate can correct dilutional coagulopathy and has an additional effect when combined with factor XIII concentrate. However, their effect on dilutional coagulopathy concomitant with hypothermia has not been studied previously. Free oscillation rheometry – FOR (Reorox®) – is a novel viscoelastic haemostatic assay that has not been studied in this context before. Methods Blood from 10 healthy volunteers was diluted by 33% with hydroxyethyl starch or Ringer’s acetate solutions. Effects of fibrinogen added in vitro with and without factor XIII were studied at 33°C and 37°C. Coagulation velocity (coagulation time) and clot strength (elasticity) were assessed with FOR. Coagulation was initiated in vitro with thromboplastin alone, or thromboplastin plus a platelet inhibitor. Results Hydroxyethyl starch increased the coagulation time and decreased clot strength significantly more than Ringer’s acetate solution, both in the presence and absence of a platelet inhibitor. There was a significant interaction between haemodilution with hydroxyethyl starch and hypothermia, resulting in increased coagulation time. After addition of fibrinogen, coagulation time shortened and elasticity increased, with the exception of fibrinogen-dependent clot strength (i.e., elasticity in the presence of a platelet inhibitor) after hydroxyethyl starch haemodilution. Factor XIII had an additional effect with fibrinogen on fibrinogen-dependent clot strength in blood diluted with Ringer’s acetate solution. Hypothermia did not influence any of the coagulation factor effects. Conclusions Both haemodilution and mild hypothermia impaired coagulation. Coagulopathy was more pronounced after haemodilution with hydroxyethyl starch than with Ringer’s acetate. Addition of fibrinogen with factor XIII was unable to reverse hydroxyethyl starch induced clot instability, but improved coagulation in blood diluted with Ringer’s acetate solution. Fibrinogen improved coagulation irrespective of hypothermia.Funding Agencies|Region Skane (Sweden)||CSL Beehring||</p