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Biomedical subjects

H Haljamäe

Publications and source records attributed to H Haljamäe.

At least 37 records · Page 2Linked to original sources
PubMed1997

Acting at a disaster site: experiences expressed by Swedish nurses.

In a previous study the knowledge and views of nursing students on how they thought nurses, both in their professional role and as private persons, should act at a disaster site were evaluated. In the present study the practical functional role and experiences of nurses (n = 16) in two major disaster situations (one 'load and go' and one 'stay and play' type of emergency situation) were assessed from personal interviews along a standardized questionnaire. Nurses more routinely involved in emergency care and nurses with no or limited previous practical experience of disaster nursing were included in the study. Leadership-type actions, i.e. a systematic way of attempting to survey and to comprehend the situation, what has happened, and how many injured there may be at the site of the accident, were reported by most of the experienced nurses, while inexperienced nurses were involved mainly in the immediate care of injured according to directions given by more experienced members of the emergency team. Readiness for action, reflected by having a feeling of being prepared for work at the disaster site, was experienced more often by nurses with considerable previous experience of disaster nursing than by nurses with limited experience. Negative experiences, such as feelings of being insufficient, of unreality, mental strain, and problems in understanding the organization, were commonly mentioned by the inexperienced nurses. The present study stresses the importance, for all types of nurses, of more systematic training in disaster nursing.

Adult↗
PubMed1997

Assessment of postoperative pain: impact of clinical experience and professional role.

BACKGROUND: Unrelieved postoperative pain is still reported to be a rather common clinical problem which may be related to inadequate routines for pain assessment. Therefore, the aim of the study was to describe strategies used by experienced and less experienced nurses and physicians in their assessment of postoperative pain and to relate different approaches, clinical experience, and professional role to the accuracy of the pain ratings. METHODS: Data collection was based on repeated interviews with nurses (n = 30) and physicians (n = 30) in connection with clinical pain assessments (n = 180) including VAS-scoring. RESULTS: Commonly used strategies in the pain assessment were: -how the patient looks, -what the patient says, -the manner of talking, and -past experience of similar circumstances. The mean VAS-score given by the patients (6.1 +/- 1.1) was significantly (P < 0.001) higher than that rated by the staff members (4.9 +/- 1.2). Nurses as well as physicians overestimated low and underestimated high levels of pain indicated by the patients. The accuracy of the ratings by nurses, especially by more experienced ones (> or = 10 years in nursing), was found to be less precise than that of physicians. The pain assessment of these very experienced nurses was characterized by a systematic underestimation. CONCLUSIONS: The present study emphasizes a need for definition of more precise strategies for clinical postoperative pain assessment which better take into consideration the pain experiences and needs of individual patients.

Clinical Competence↗
PubMed1996

Thromboprophylaxis, coagulation disorders, and regional anaesthesia.

The surgery and trauma-induced modulation of the coagulation system includes a considerable risk of perioperative thromboembolic complications unless effective thromboprophylactic treatment is given. In the present survey the patient at risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) is characterized and the documented efficacy of different currently used thromboprophylactic regimens is summarized. Systemic thromboprophylactic treatment may include a risk of an increased bleeding tendency which may lead to haemorrhagic complications. In patients with a coagulation abnormality or in patients receiving anticoagulants for perioperative thromboprophylaxis there is a fear among anaesthesiologists that the use of regional anaesthesia (spinal or epidural) may be associated with spinal haemorrhagic complications, i.e. with spinal haematoma formation leading to compression of the spinal cord and severe neurologic sequelae. Present aspects on the risk of spinal haematoma formation at the combined use of pharmacological thromboprophylactic regimens and spinal or epidural anaesthesia/ analgesia are therefore summarized. Pregnancy is associated with changes in the haemostatic system, which in the preeclamptic or eclamptic patient may be rather pronounced and constitute a clinical problem since regional anaesthetic techniques are often preferred for obstetric anaesthesia/analgesia. The specific problems to be considered prior to the choice of regional anaesthesia/analgesia for a parturient with a suspected coagulation disorder are therefore commented on in more detail. Finally, recommendations are given for safe spinal and epidural analgesic and anaesthetic routines in patients with potential haemostatic disturbances due to thromboprophylactic treatment with anticoagulants or bleeding disorders.

Anesthesia, Conduction↗
PubMed1995

Effects of hypertonic saline on myocardial function and metabolism in nonischemic and ischemic isolated working rat hearts.

OBJECTIVE: To study the direct effects of hypertonic saline on the function of non-ischemic and ischemic myocardium by the use of an isolated working rat heart model. DESIGN: A prospective, randomized, controlled study. SETTING: Animal laboratory at a university medical center. SUBJECTS: Adult Wistar rats (n = 32) of both sexes. INTERVENTIONS: The heart was excised via thoracotomy in anesthetized rats and prepared for antegrade perfusion at a constant heart rate in an antegrade perfusion apparatus at predetermined preloads and afterloads. Hearts were exposed to ischemia, ischemia followed by repeated hypertonic saline treatment, or repeated hypertonic saline without preceding ischemia. Myocardial ischemia was induced by decreasing the mean aortic pressure to 25 mm Hg. MEASUREMENTS AND MAIN RESULTS: Variables that were measured or calculated included the following: left atrial pressure; mean aortic pressure; heart rate; coronary flow; aortic flow; cardiac output; stroke volume; PO2, electrolyte content, osmolality, and lactate concentration of the perfusate and/or venous effluent; myocardial oxygen extraction; myocardial oxygen consumption; and myocardial lactate efflux. Ischemia resulted in pronounced impairment of myocardial function and metabolism. Hypertonic saline administration during ischemia induced an additional transient myocardial depression. In the nonischemic heart, a transient myocardial-depressant effect after hypertonic saline administration was also seen. CONCLUSIONS: The present results from an isolated working heart preparation show that hypertonic saline exerts myocardial-depressive effects in the ischemic as well as in the nonischemic heart. Systemic rather than direct myocardial effects may therefore be responsible for the previously reported beneficial hemodynamic effects of hypertonic saline in shock treatment.

Animals↗
PubMed1995

Protective effects of halothane but not isoflurane against global ischaemic injury in the isolated working rat heart.

The effects of equi-anaesthetic concentrations of halothane (HAL) and isoflurane (ISO) on myocardial performance, perfusion, oxygenation and lactate release were studied before, during and after a low-flow, global ischaemic insult in isolated, paced rat left heart preparations. An antegrade perfusion technique was used, where left atrial pressure (LAP) and mean aortic pressure (MAP) could be altered independently of each other. Aortic flow, coronary flow (CF) and PO2 in venous coronary effluent were continuously recorded and stroke volume, myocardial oxygen consumption (MVO2) and myocardial oxygen extraction as well as lactate release were calculated. The hearts were exposed for at least ten minutes to the perfusate without (control, n = 10) or with HAL (n = 10) or ISO (n = 10) at a MAP of 80 mmHg (10.4 kPa) and a LAP of 7.5 mmHg (1.0 kPa). After baseline measurements, MAP was reduced to 25 mmHg (3,2 kPa) for a total of nine minutes. Thereafter MAP was increased to 80 mmHg (10.4 kPa) for another nine minute period. During the whole experimental procedure, LAP was maintained at 7.5 mmHg (1.0 kPa) and heart rate at 325 beats per minute. In the pre-ischaemic control period, MVO2 was lower with HAL compared to ISO (P < 0.05) and control (P < 0.05). Stroke volume was also lower with HAL compared to control (P < 0.05). During hypoperfusion, lactate release was twice as high in the control group (P < 0.01) and with ISO (P < 0.01) compared to HAL.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1995

Purine metabolite washout and platelet aggregation at reflow after tourniquet ischemia: effect of intravenous regional lidocaine.

Tourniquet ischemia will influence the biochemical milieu of tissue cells and affect the metabolism of purines in skeletal muscle distal to the occlusion. At reperfusion, generation of oxygen radicals by the hypoxanthine-xanthine oxidase system may ensue, influencing white blood cell and thrombocyte aggregation, causing damage to the endothelial cell barrier and inducing non-reflow type phenomena. Amide-type local anaesthetics are known to affect local vasotone, leukocyte adherence and platelet function but the influence of lidocaine on purine metabolite washout and platelet aggregation following tourniquet ischemia for lower limb surgery is not known in detail. Therefore, the effects of regional intravenous lidocaine during tourniquet ischemia for knee surgery on purine catabolite washout and platelet function following reflow were assessed. Eight patients served as control (C-group) and 8 (L-group) received 100 ml of lidocaine (2.5 mg/ml) in the emptied venous bed of the leg to be operated. All patients had spinal anaesthesia (0.5% bupivacaine). Effluent venous blood from the leg and radial arterial blood was collected and analysed for xanthine (X), hypoxanthine (HX), base excess (BE), pH and potassium before and after reperfusion. Platelet ADP-induced aggregation (ADP-agg.) and secretion of beta-thromboglobulin (beta-TG) were measured in the effluent blood as well as systemically. After tourniquet release (TR), X and HX were significantly increased in effluent venous blood but the washout was enhanced in the L-group during the initial reperfusion phase. BE was significantly higher in the L-group both before and after TR whereas pH and potassium washout was comparable between the groups. No systemic effects on platelets were detected after tourniquet release but ADP-agg. in effluent venous blood was attenuated in 6 out of 8 patients in the L-group (NS). It is concluded that HX and X are generated during leg ischemia. Regional intravenous lidocaine, most probably through a vasodilatory mechanism and inhibition of white blood cell activation, may attenuate non-reflow phenomena and thereby exert beneficial effects on post-ischemic recovery by enhancing post-ischemic tissue reperfusion.

Aged↗
PubMed1994

Epidural anaesthesia prolonged into the postoperative period prevents stress response and platelet hyperaggregability after peripheral vascular surgery.

The occlusion rate of peripheral vascular grafts depends on technical as well as endogenous factors. Platelets play an integral part in graft failure and it has been suggested that anaesthesia may influence platelet function. In order to evaluate the influence of anaesthesia on stress response and platelet function in peripheral vascular surgery, patients (n = 18) were allocated to either general anaesthesia (GA; n = 9) followed by alleviation of postoperative pain with intramuscular analgesics or to lumbar epidural anaesthesia (EPI; n = 9) which was continued for 24 hours postoperatively. Before, during, as well as after vascular surgery of the lower extremity plasma levels of cortisol, glucose, serotonin (p-5HT), and urinary 5-hydroxyindole-3-acetic acid (5-HIAA) were analysed and platelet aggregability was determined. In the GA group surgery was accompanied by a significant stress response while in the EPI group this stress response was almost completely abolished. Platelet aggregability was reduced intraoperatively in both groups but in the postoperative period there was a marked hyperaggregability only in the GA group. P-5HT was increased preoperatively in both groups but was not affected by surgery. It is concluded that epidural anaesthesia, due to its effects on platelet aggregability, may be advantageous for peripheral vascular surgery.

Aged↗
PubMed1993

Cardiac risk and peripheral vascular surgery: new approach based on a multifactorial risk index.

An inexpensive approach to stratification of patients admitted for arterial surgery into groups of high and low cardiac risk has been prospectively evaluated in 235 consecutive patients. The Goldman and Detsky indices, assessed by a nurse the day before surgery, both identified patient groups with increased risk of lethal or potentially lethal (myocardial infarction, pulmonary oedema) cardiac events within 30 days after peripheral vascular surgery. The Goldman index was the more sensitive predictor of cardiac death (overall frequency 3.1 per cent) while the Detsky index was superior for prediction of non-lethal cardiac events (overall frequency 5.9 per cent). The simplest and yet most effective stratification into high and low cardiac risk was achieved using a Detsky score of 10 as the cut-off. It is concluded that multifactorial risk index-based preoperative screening can identify low-risk patients (Detsky score < or = 10), who may be accepted for vascular surgery (aortic aneurysm surgery excluded) without additional cardiac testing.

Aged↗
PubMed1993

The communication process with ventilator patients in the ICU as perceived by the nursing staff.

Intensive care unit (ICU) nurses (n = 27) were interviewed about their experiences and opinions of the communication process with ventilator treated patients. Nurses with limited ICU experience considered the initial contact with a new critically ill ventilated patient more frustrating than experienced nurses. The nurses thought that the content of the communication commonly requested by a patient was dominated by factors related to the clinical condition, prognosis and reassurance that the situation was under control. Factors considered to limit the communication and to create feelings of uncertainty and stress for nurses with an ICU experience of less than 5 years were: work overload, unstable condition of the patient, impaired communication with the patient, and their own personal problems or worries. For nurses with an ICU experience of more than 5 years stress was more commonly evoked by the presence of worried and anxious spouses/relatives, and by the feeling that something was wrong with the patient but they were unable to identify the problem. Failure to understand a ventilated patient could induce feelings of incompetence, stress and sometimes even despair. The present small scale study shows that there are many factors, in addition to ICU experience, that may influence the ability of an ICU nurse to establish and maintain a well functioning communication with ventilated patients and the likelihood of doing so.

Adult↗
PubMed1993

Cardiac risk screening of peripheral arterial surgical patients by the use of combined simple clinical and non-invasive cardiodynamic parameters.

Arterial surgical patients have a poor long-term survival and suffer significant risks of experiencing perioperative cardiac events, mainly due to a high incidence of coronary atherosclerosis impairing left ventricular function. The perioperative cardiac risk can be assessed by use of clinical cardiac risk indices, which are inexpensive but may have suboptimal sensitivity, or by more extensive cardiac tests. In this study the efficacy of a combined, non-invasive and inexpensive technique of risk assessment was prospectively evaluated in 195 patients undergoing peripheral arterial surgery (aortic aneurysms not included). All patients were preoperatively examined by a nurse registering the Detsky cardiac risk index score (DRI) and performing resting computerised bioimpedance cardiodynamic measurements (CM). Cardiac deaths (CD, n = 6), potentially lethal cardiac complications (PLC, n = 11) within 30 days and long-term survival during 20 +/- 12 (S.D.) months of follow-up were identified. CD was best predicted by combining CM and DRI, while PLC was best predicted by combining DRI and the haemoglobin concentration of the blood (Hb). A group without CD containing 88% of the cases was identified. Furthermore, the combination of DRI < or = 10 and Hb > 120 g/l identified a low risk group (57% of all cases) with no PLC or CD. Using CM, DRI and Hb in combination, patient groups with long-term survival from 0-90% were identified. We conclude that this inexpensive cardiac risk screening both identifies low risk vascular surgical patients, for whom more sophisticated preoperative cardiac testing can be omitted, and predicts long-term survival.

Aged↗
PubMed1993

The pathophysiology of shock.

Trauma often includes considerable losses of blood and plasma that may lead to hypovolemia and shock. The initial response of the body to trauma and hemorrhage is characterized by a neuroendocrine-mediated general defence reaction for the maintenance of circulatory homeostasis and substrate availability for vital organ function. Endogenous fluid is mobilized from intracellular and interstitial sources into the vascular compartment. This transcapillary refill is achieved by activation of glucose osmotic and neurogenic adaptive vascular mechanisms. The metabolic consequences of insufficient tissue perfusion are anaerobic glycolysis with increased production of lactate and hydrogen ions, acidosis, impaired mitochondrial energy production, disturbed ionic homeostasis across cell membranes, and reduced functional capacity of tissue cells. The shock- and trauma-induced alterations in tissue perfusion and metabolism vary, depending on the autoregulatory capacity of an organ, its basal metabolic requirements, its high energy phosphagen reserves, and its ongoing functional activity. Metabolic alterations impairing organ function occur early in the kidney and the liver and late in the heart and the brain. The ischemic tolerance of the skeletal muscle cell is considerable but vast amounts of lactic acid are produced, which at reperfusion will reach central blood and disturb vital organ function. Tissue factors released from mechanically traumatized or hypoxic cells will activate cascade systems and may induce alterations in remote organs, i.e. result in the development of multiorgan failure.

Cell Hypoxia↗
PubMed1993

Volume substitution in shock.

Shock treatment seems optimal when a "balanced" fluid and volume regimen, including both crystalloid (Ringer's acetate) and about 3% colloid, is used. Dextran is the colloid of choice due to its beneficial effects on plasma volume, hemorheology, and microvascular blood flow. Dextrans exert, in addition, inhibiting effects on the shock- and trauma-induced activation of the cascade system, whereby the risk of complications in the form of multiple organ failure is reduced. Infusion of red blood cells, plasma or thrombocytes should be based on a proper assessment of each individual patient's actual need of oxygen transporters and coagulation factors.

Biological Transport↗
PubMed1993

Efficacy of osmolality and ionic composition of resuscitation fluids for treatment of acute blood loss in the spontaneously hypertensive rat (SHR).

The spontaneously hypertensive rat (SHR) has a deficient glucose mobilization in response to blood loss. Treatment of blood loss with hypertonic glucose might consequently be advantageous in SHR, but the importance of osmolality as compared to ionic composition of resuscitation fluids is still not fully elucidated. Therefore, SHR (n = 32) were subjected to hemorrhage (30% of calculated blood volume) followed by treatment with (1) hypertonic saline (HS; 4.5 ml/kg of 7.5% NaCl, 2,400 mOsm/L), (2) hypertonic glucose (HG; 4.5 ml/kg of 42.3% solution, 2,400 mOsm/L), and (3) normal saline (NS; 37.5 ml/kg of 0.9% NaCl) to provide an equal sodium load as with HS. All fluid regimens increased (P < 0.001 vs. control) mean arterial pressure (MAP). Hemodilution was more pronounced after HS and NS than after HG. Hypernatremia was evoked by HS. The hyperglycemic response to hemorrhage was intensified by HG, but it was accompanied by increased blood lactate levels. All three treatment regimens prolonged posthemorrhagic times until death (P < 0.01-0.05) (mean values: NS 363 min; HS 170 min; HG 146 min; nontreated controls 60 min). It is concluded, on the basis of hemodynamic, metabolic, and times-until-death data, that although treatment with small-volume HS seems superior to small-volume HG, an equal load of sodium given as NS is more effective for resuscitation after blood loss than HS in SHR.

Acute Disease↗
PubMed1992

Colloid (3% Dextran 70) with or without ephedrine infusion for cardiovascular stability during extradural caesarean section.

Using a non-invasive cardiac output monitor (Bo-Med NCCOM 3-R7), we have compared cardiovascular responses, degree of haemodilution and incidence of nausea during extradural Caesarean section in healthy non-labouring mothers given either ephedrine 17.5 mg and 3% Dextran 70 7.5 ml kg-1 before delivery (group A) or volume loading with Dextran 15 ml kg-1 without infusion of ephedrine (group B). Smallest systolic arterial pressures before delivery were 114 (SEM 4) mm Hg (group A) and 105 (5) (group B). There were no significant differences between the groups in mean arterial pressure, heart rate, systemic vascular resistance or central venous pressure, while cardiac output increased more with the ephedrine infusion (P less than 0.05). Haemodilution was 8% in group A and 16% in group B at the time of delivery. Ephedrine infusion was associated with a smaller incidence of nausea (P less than 0.01). Umbilical arterial pH values were not different between the two groups. We conclude that infusion of ephedrine, combined with low volume colloid administration, is a safe alternative to more extensive colloid volume expansion for control of hypotension and provides effective prophylaxis against nausea during extradural Caesarean section in healthy non-labouring mothers.

Adult↗
PubMed1992

Failure of hypertonic saline to resuscitate intestinal ischemia shock in the rat.

The effects of resuscitation with hypertonic saline (HS), administered as a bolus injection or infusion, were studied in a model of intestinal ischemia shock in rats. The model is characterized by severe intestinal mucosal lesions, release of cardioinhibitory substances and endogenous opioid peptides, and it results in high mortality rates. The blood pressure improved after HS given as an infusion for 1 h. The effects on blood pressure of HS given as a bolus and of normotonic saline (NS) were not significant. Plasma volume was not different from unshocked control animals in either HS infusion or NS infusion groups 2 and 4 h after infusion. Liver metabolic consequences of intestinal shock did not differ comparing the HS and NS groups, and the same result was found concerning the mucosal lesions in the small intestine. The 7-day survival decreased in the HS infusion group (14%) compared to untreated shock (46%) or NS infusion (54%) groups. We conclude that HS failed to resuscitate intestinal ischemia shock. These experiments indicate that HS treatment could even, in contrast to previous reports on hemorrhagic shock, be disadvantageous or dangerous in shock states characterized by extensive tissue injury.

Animals↗
PubMed1990

Cardiac output in patients with acute lower limb ischaemia of presumed embolic origin--a predictor of severity and outcome?

Cardiodynamic studies using a non-invasive computerised thoracic electrical bioimpedance (TEB) equipment were performed in 35 patients presenting with acute lower limb ischaemia of presumed embolic origin, and in 36 age-matched control patients without emboli. Patients who presented with imminent gangrene were promptly operated upon, whereas those who had less severe ischaemia were treated initially with heparin only. In the former group, cardiac output and myocardial contractility were very low on admission, while systemic vascular resistance was high. Cardiac output was further decreased when measured immediately after revascularisation, whereas it had become normal 2 days later. In patients with less severe acute ischaemia, cardiac output and myocardial contractility values on admission were similar to those of control patients, and no changes were observed after 2 days of conservative treatment. Overall, cardiac output on admission was significantly related to the simultaneously observed severity of the limb ischaemia. A low cardiac output (less than 1.7 l/min m2) on admission was found to predict severe cardiac complications (60% mortality within 10 days), whereas clinical assessment of cardiac failure on admission was poorly related to outcome. We conclude that patients with acute lower limb ischaemia of presumed embolic origin often have unrecognised poor cardiac function, which is related to the severity of the limb ischaemia and to outcome. By routine non-invasive TEB cardiodynamic measurements, high risk patients can rapidly be identified and proper treatment regimes be instituted in each individual patient.

Aged↗
PubMed1990

Comparison of Ringer's acetate with 3% dextran 70 for volume loading before extradural caesarean section.

We have studied haemodilution and cardiovascular responses to i.v. hydration with either 3% dextran 70 (Dx70) or Ringer's acetate using a non-invasive cardiac output monitor (BoMed NCCOM3-R7) in 40 healthy parturients undergoing Caesarean section under extradural anaesthesia. Haemodilution was more pronounced, and central venous pressure, mean arterial pressure and cardiac index maintained at greater values, after treatment with Dx70. Colloid osmotic pressures (COP) decreased by 1.7 mm Hg after loading with 3% Dx70, and by 5.6 mm Hg in mothers treated with Ringer's acetate (P less than 0.001). The transthoracic fluid index decreased more after hydration with Ringer's acetate (P less than 0.001), indicating an increase in lung water. In spite of these maternal changes, there were no differences in neonatal bioimpedance or values of haemoglobin, PCV, albumin and COP in umbilical cord blood, and only one case of respiratory distress. We conclude that colloids may be preferable to crystalloids for circulatory preload for extradural Caesarean section, as greater haemodynamic stability was maintained and increases in lung water avoided.

Adult↗