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  • 1.
    Carnlöf, Carina
    et al.
    Department of Cardiology Karolinska University Hospital, Stockholm.
    Insulander, Per
    Department of Cardiology Karolinska University Hospital, Stockholm.
    Holmér Pettersson, Pia
    Red Cross University College of Nursing. Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm.
    Jensen-Urstad, Mats
    Department of Cardiology Karolinska University Hospital, Stockholm.
    Fossum, Bjöörn
    Sophiahemmet University College, Stockholm.
    Health-related quality of life in patients with atrial fibrillation undergoing pulmonary vein isolation, before and after treatment2010In: European Journal of Cardiovascular Nursing, ISSN 1474-5151, E-ISSN 1873-1953, ISSN 1474-5151, Vol. 9, no 1, p. 45-49Article in journal (Refereed)
    Abstract [en]

    Background: Atrial fibrillation (AF) is the most common arrhythmia and many AF patients experience a significantly impaired health-related quality of life (HRQOL). AF is also associated with a high risk of stroke and death. Many pharmacologic treatments for AF are ineffective and may have adverse effects. New methods, such as pulmonary vein isolation (PVI), have been developed to treat AF.

    Aims: The aim of this study was to investigate the HRQOL issues in severe symptomatic AF patients before and after pulmonary vein isolation.

    Methods: Forty patients treated with PVI were included of which 36 concluded the study with the self-reported HRQOL questionnaires before and once after PVI. A standardized control group was used.

    Results: Compared to the control group the HRQOL before PVI was significantly lower in all domains except for bodily pain. The preoperative scores were compared with the scores obtained at the follow-up. All subscales of the SF-36 significantly improved after the PVI except for bodily pain, which remained unaltered.

    Conclusion: HRQOL is improved in AF patients with severe symptoms after PVI intervention.

  • 2.
    Holmér Pettersson, Pia
    Karolinska Institutet, Stockholm.
    Pain treatment after surgery: With special reference to patient-controlled analgesia, early extubation and the use of paracetamol2004Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The introduction of general anaesthesia eliminated pain during surgical operations. After surgery, however, pain and postoperative nausea and vomiting (PONV) have remained a persistent problem for many patients. The need for analgesics varies widely among patients, therefore standardised treatment protocols are often insufficient pain treatment. Our studies dealt with the incidence and severity of pain and PONV after cardiac surgery. Study aims were to use and develop techniques for better evaluation of analgesic needs – visual analogue scale (VAS; 0 to 10) – and to develop a multimodal treatment of pain with opioids administered by the patients themselves – Patient Controlled Analgesia (PCA) – combined with paracetamol. In 48 patients, PCA was compared to conventional Nurse Controlled Analgesia (NCA) on the ward after coronary artery bypass surgery. PCA led to lower VAS-scores, i.e. less pain, with the use of more opioids. In 57 patients, pain after heart surgery was compared for extubation “early” at 3 hours or “late” at 7 hours after surgery. VAS-scores, PONV and the amount of opioids used were similar whether patients were extubated early or late. Rectal and intravenous (i.v.) administration of paracetamol was compared in 28 patients after heart surgery with respect to its bioavailability after repeated doses. Plasma concentrations after the first dose were low with rectal administration. After the fourth dose at 24 hours they reached a plateau. With i.v. administration concentrations were higher both after the first and fourth dose. Oral and i.v. paracetamol was compared in 80 patients after heart surgery and in 35 patients after day surgery (hernia repairs etc). After heart surgery the use of opioids was less in the i.v. group but VAS-scores and PONV were similar. A majority of the patients scored higher than 3 once or more than once on the 10 degree VAS-scale. In the oral group after day surgery, the plasma concentration increased in a dose-dependent manner but the scatter was wide and unpredictable as compared to the i.v. group. Conclusions: PCA is a promising alternative to NCA for adequate pain treatment in the wards after heart surgery and is “by itself” adjusted to the needs of the individual patient. There is no risk that early extubation after cardiac surgery is followed by more postoperative pain. Intravenous paracetamol seems to have an opioid-sparing potential after heart surgery. Our routines must be further developed and more studies are needed to find an optimal regimen, since pain treatment sometimes was insufficient in many patients receiving the combined therapy.

  • 3.
    Holmér Pettersson, Pia
    et al.
    Department of Surgical Sciences, Karolinska Institute, Division of Cardiothoracic Anaesthesia and Intensive Care, Karolinska Hospital, Stockholm.
    Anjou Lindskog, Elisabet
    Öwall, Anders
    Patient-controlled versus nurse-controlled pain treatment after coronary artery bypass surgery2000In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, ISSN 1399-6576, Vol. 44, no 1, p. 43-47Article in journal (Refereed)
    Abstract [en]

    Background: Pain after coronary artery bypass surgery persists for several days. A continuous intravenous infusion of an opioid adequately accomplishes good pain control in the intensive care unit, but it is often not suitable on the ordinary ward. Patient-controlled analgesia (PCA) with intermittent injections delivered by one of the new devices now available could be an alternative to conventional nurse-controlled analgesia (NCA) based on intermittent injections. The aim was to compare these two techniques with respect to efficacy and the amount of opioid used.

    Methods: Forty-eight patients randomly received PCA or NCA with ketobemidone following extubation after coronary artery bypass grafting. Drug consumption, pain assessment with the visual analogue score (VAS) and possible side effects were evaluated from extubation to the end of the second postoperative day.

    Results: On the day of surgery the VAS scores did not differ between the groups. From the afternoon of the first postoperative day the VAS scores were higher in the NCA group with mean values at 3–4 out of 10 as compared with mean values around 2 in the PCA group (P<0.01). During the study period the patients in the PCA group received more ketobemidone as compared with the NCA group, 61.9±24.0 mg and 36.3±20.2 mg, respectively (P<0.01). Additional oral analgesics were used in 12 of the patients in the NCA group compared with none in the PCA group. The few side effects reported were equally distributed between the two groups.

    Conclusion: PCA treatment after coronary artery bypass surgery resulted in better pain treatment and the use of more opioid without an increase in side effects compared with traditional NCA treatment.

  • 4.
    Holmér Pettersson, Pia
    et al.
    Department of Surgical Sciences, Karolinska Institute, Stockholm.
    Jakobsson, Jan
    Division of Anaesthesia, Sabbatsberg Day Surgical Centre, Stockholm.
    Öwall, Anders
    Department of Surgical Sciences, Karolinska Institute, Stockholm.
    Intravenous acetaminophen reduced the use of opioids compared with oral administration after coronary artery bypass grafting2005In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 19, no 3, p. 306-309Article in journal (Refereed)
    Abstract [en]

    Objective: The purpose of this study was to evaluate if intravenous acetaminophen compared to oral administration reduced the consumption of opioids and their side effects without an increase in pain during the stay in the intensive care unit (ICU).

    Design: Prospective, randomized study.

    Setting: An ICU in a university hospital.

    Participants: Eighty patients with written informed consent undergoing coronary artery bypass grafting with cardiopulmonary bypass. Anesthesia was based on propofol and fentanyl combined with sevoflurane.

    Interventions: Patients were randomized to 2 groups: acetaminophen, 1 g every sixth hour during the postoperative period, either as tablets or intravenously after extubation.

    Measurements and Main Results: The amount of opioids administered during the study period was measured starting with acetaminophen administration during the stay in the ICU until 9 o'clock the following morning. Incidence of postoperative nausea and vomiting (PONV) was noted. Pain was evaluated with a visual analog scale (VAS) from 0 to 10. Three patients, 2 in the oral and 1 in the intravenous group, were excluded because of incomplete data. The intravenous group received less opioids than the orally treated group, 17.4 +/- 7.9 mg compared with 22.1 +/- 8.6 mg (p = 0.016). PONV incidence and VAS scores did not differ. During the first hours after extubation, 50 of 77 patients reported VAS scores >3 with no difference between groups.

    Conclusions: Intravenous acetaminophen had a limited opioid-sparing effect when compared with oral administration after coronary artery bypass graft surgery. The opioid-sparing effect was not accompanied by any reduction in the incidence of PONV. The clinical significance of the opioid-sparing effect could therefore be questioned.

  • 5.
    Holmér Pettersson, Pia
    et al.
    Department of Cardiothoracic Surgery and Anaesthesiology Karolinska University Hospital Solna S-171 76 Stockholm.
    Jakobsson, Jan
    Öwall, Anders
    Plasma concentrations following repeated rectal or intravenous administration of paracetamol after heart surgery2006In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 50, no 6, p. 673-677Article in journal (Refereed)
    Abstract [en]

    Background:  Paracetamol is commonly used for post-operative pain management in combination with more potent analgesics. The best route of paracetamol administration after major surgery, when oral intake may not be optimal, is not known. Our primary purpose was to study plasma concentrations after the 1st and 4th dose of 1 g of paracetamol given either rectally or intravenously (i.v.) after major surgery.

    Methods:  In this prospective, randomized study, 48 patients undergoing heart surgery were randomized upon arrival to the intensive care unit (ICU) to receive paracetamol every 6th hour either as suppositories or intravenous injections. In half the patients (n= 24), blood samples for paracetamol concentration were obtained before and 20, 40 and 80 min after the first dose. In the other patients (n= 24), additional samples were taken prior to, and at 20, 40, 80 min and 4 and 6 h after, the 4th dose.

    Results:  Plasma paracetamol concentration peaked (95 ± 36 μmol/l) within 40 min after initial i.v. administration but did not increase within 80 min after the 1st suppository. Plasma concentration before the 4th dose was 74 ± 51 and 50 ± 27 in the rectal and i.v. groups, respectively. Paracetamol concentration peaked 20 min after the 4th dose for the i.v. patients (210 ± 84 μmol/l) and declined to 99 ± 27 μmol/l at 80 min as compared with the rectal patients 69 ± 44 to 77 ± 48 μmol/l.

    Conclusion:  Both time course and peak plasma concentrations of paracetamol given rectally differ from the one seen after intravenous administration. The clinical impact of these differences needs further investigation.

  • 6.
    Holmér Pettersson, Pia
    et al.
    Department of Surgical Sciences, Karolinska Institute, Division of Cardiothoracic Anaesthetics and Intensive Care, Karolinska Hospital, Stockholm.
    Settergren, Göran
    Department of Surgical Sciences, Karolinska Institute, Division of Cardiothoracic Anaesthetics and Intensive Care, Karolinska Hospital, Stockholm.
    Öwall, Anders
    Department of Surgical Sciences, Karolinska Institute, Division of Cardiothoracic Anaesthetics and Intensive Care, Karolinska Hospital, Stockholm.
    Similar pain scores after early and late extubation in heart surgery with cardiopulmonary bypass2004In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, ISSN 1053-0770, Vol. 18, no 1, p. 64-67Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate if early extubation, 2 hours after surgery, would result in more postoperative pain or in an increased use of opioid analgesics compared with late extubation, 6 hours after surgery.

    Design: Prospective, randomized study.

    Setting: Intensive care unit, university hospital.

    Participants: Sixty patients undergoing cardiac surgery with cardiopulmonary bypass.

    Interventions: Patients were randomized into 2 groups: extubation at about 2 (early) or 6 (late) hours. Anesthesia was based on propofol and remifentanil. There was no epidural analgesia and no local anesthesia in the wound. A bolus of the opioid ketobemidone was administered toward the end of surgery followed by a continuous infusion.

    Measurements and Main Results: Pain, provoked during deep breathing or coughing, evaluated with a visual analog scale (VAS) going from 0 to 10, was measured after extubation, and at 8 and 16 hours after surgery. Unprovoked pain was measured hourly. If VAS was greater than 3, the infusion rate was increased and a bolus of ketobemidone was given. Three patients in the late group were excluded because of incomplete data. Pain did not differ between the early and late groups at any time. In all patients, 21 never scored >3, 11 scored >3 once, and 25 scored >3 more than once. Nine patients had 1 score >5. The amount of ketobemidone was similar in both groups.

    Conclusions: Early extubation had no negative effect on the quality of postoperative pain control and was not followed by an increased use of analgesics.

  • 7.
    Holmér Pettersson, Pia
    et al.
    Red Cross University College of Nursing. Karolinska Institutet, Department of Molecular Medicine and Surgery.
    Wengström, Yvonne
    Division of Nursing, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm.
    Acupuncture prior to surgery to minimise postoperative nausea and vomiting: A systematic review2012In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, ISSN 0962-1067, Vol. 21, no 13/14, p. 1799-1805Article, review/survey (Refereed)
    Abstract [en]

    Aims and objectives: The aim of this systematic review was to assess the outcome of acupuncture treatment prior to surgery in order to avoid or minimise postoperative nausea and vomiting.

    Background: The symptoms of nausea and/or vomiting remain a huge problem for many patients after surgery. There is much debate around the best treatment for nausea and/or vomiting, and the most beneficial solution has yet to be found. Postoperative nausea and vomiting is not a life-threatening symptom, but many patients express great distress and dissatisfaction with the existing treatment. Many patients rate their nausea similar to or worse than pain. Historically, treatments often include drug therapy, but not other non-pharmacologic therapies, such as acupuncture or acupressure, which can have beneficial effects on nausea.

    Design: A systematic literature review.

    Methods: The review was undertaken using key words and electronic databases and included 21 papers from the years November 1996 until August 2009.

    Results: The results indicate that the application of acupuncture reduced the incidence of nausea but not vomiting when compared with the use of antiemetic prophylaxis alone.

    Conclusions: The results show that there is a lack of knowledge of the best treatment to minimise postoperative nausea and vomiting prior to surgery. Relevance to clinical practice. The overall results of this review conclude that all kinds of AP stimulation, both non-invasive and invasive, seem to prevent PONV with minimal side effects. The findings from this study can be used to inform future research to evaluate the effects of preoperative treatment with acupuncture vs. sham procedure before surgery to avoid PONV

  • 8.
    Holmér Pettersson, Pia
    et al.
    Department of Cardiothoracic Surgery and Anaesthesiology, Karolinska University Hospital, Stockholm.
    Öwall, Anders
    Jakobsson, Jan
    Early bioavailability in day surgery: A comparison between orally, rectally, and intravenously administered paracetamol2005In: Ambulatory Surgery, ISSN 0966-6532, E-ISSN 1873-2097, ISSN 0966-6532, Vol. 12, no 1, p. 27-30Article in journal (Refereed)
    Abstract [en]

    Purpose: Compare early bioavailability of rectal, effervescent oral, and i.v. paracetamol.

    Scope:Five groups of N = 7 patients received 1 or 2 g paracetamol orally or rectally or 1 g i.v. immediately after day surgery. Paracetamol concentrations taken after 20, 40 and 80 min. Median plasma paracetamol concentrations for 1 versus 2 g effervescents were 78 (25–114) versus 108 (95–146) μmol L−1 at 80 min and 16 (9–30) versus 17 (10–30) μmol L−1 for 1 versus 2 g suppositories. Paracetamol i.v. gave median 97 (77–135) μmol L−1 after 40 min.

    Conclusion: Only intravenously and 2 g effervescent paracetamol gave therapeutic concentrations during the period studied.

  • 9.
    Holmér Pettersson, Pia
    et al.
    Department of Cardiothoracic Surgery and Anesthesiology Karolinska University Hospital S-171 76 Stockholm.
    Öwall, Anders
    Jakobsson, Jan
    Early bioavailability of paracetamol after oral or intravenous administration2004In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, ISSN 0001-5172, Vol. 48, no 7, p. 867-870Article in journal (Refereed)
    Abstract [en]

    Background:  Paracetamol is a peripherally acting analgesic commonly used in multimodal post-operative pain management to reduce the need for more potent analgesics with their unwanted side-effects. The dose and optimal galenical form for achieving analgesic concentrations is not well defined. The primary aim of this pilot project was to study the early bioavailability for two fixed doses of orally administrated paracetamol and one dose of intravenous propacetamol, all of which were given after minor surgery.

    Methods:  Thirty-five patients undergoing day surgery were divided into five groups, seven patients each. Groups received either 1 g of an ordinary paracetamol tablet, 2 g of an ordinary paracetamol tablet, 1 g of a bicarbonate paracetamol tablet, 2 g of a bicarbonate paracetamol tablet or 2 g intravenously of prodrug propacetamol. We studied the plasma concentration of paracetamol during the first 80 min after administration.

    Results:  Within 40 min, intravenous propacetamol gave a median plasma paracetamol concentration of 85 µmol/l (range 65–161) and decreased thereafter. After oral administration, median plasma paracetamol concentration increased with increasing dose and time, but there were huge inter-individual differences at all time points studied. At 80 min after oral paracetamol the median plasma concentrations were 36 and 129 µmol/l for the 1- and 2-g groups, respectively, with an overall range between 0 and 306 µmol/l.

    Conclusion:  Oral administration of paracetamol as part of multimodal pain management immediately post-operatively resulted in a huge and unpredictable variation in plasma concentration compared with the intravenous administration.

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