Introduction We prospectively evaluated an ERAS in a large gynaecologic oncology tertiary centre serving the South East Health region in Norway. Methods Patients undergoing laparotomy for (suspected) ovarian cancer at the Oslo University Hospital were prospectively included in a pre-implementation and post-implementation cohort. Baseline characteristics, adherence to the pathway and clinical outcomes were assessed. Results Of the 439 patients, 235 (54%) underwent surgery for advanced ovarian cancer and 204 (46%) for a suspicious ovarian mass. Median fasting times for solids (13 vs 16 h, p<0.001) and fluids (3.7 vs 11.9 h, p<0.001) were significantly reduced. Perioperative fluid administration varied less (p<0.001) and was reduced (median 11.5 vs 15.8 ml/kg/h, p<0.001). Epidural analgesia was the mainstay of analgesia in both cohorts, but with ERAS more patients received continuous vasopressor intraoperatively (87% vs 70%, p=0.003). More patients received dual PONV prophylaxis (85% vs 64%, p<0.001). Length of stay remained unchanged for patients with advanced disease with a median of 5 days both before and after the implementation (p=0.94), but patients undergoing surgery for an ovarian mass stayed shorter in hospital after the implementation of ERAS (p=0.026). For all patients, more patients were discharged directly home as opposed to transferred to local referring hospital after ERAS implementation (70% vs 51%, p<0.001). There was no difference in re-admission rates or postoperative 30 d morbidity. Conclusion Introduction of an ERAS pathway resulted in less variance in practice and increased adherence to current standards in perioperative management. Patients were more often able to be discharged directly home without an increase in admission rates.

Aims: To evaluate potential prognostic factors for predicting survival after radiotherapy in patients with painful spinal metastases and normal neurological function.Materials and methods: In total, 173 patients were included. The following prognostic factors were assessed: primary cancer site, age, gender, albumin and haemoglobin levels, Karnofsky performance status (KPS), analgesic use, pain intensity, number of extraspinal bone metastases and visceral metastases, presence of tumour-conditioned spinal canal stenosis and metastatic spinal cord compression, and extension of spinal metastatic disease on magnetic resonance imaging (MRI). Ongoing systemic treatment, use of bisphosphonates and response to radiotherapy were also evaluated. A simple scoring system for predicting survival was used.Results: The following predictive factors were found to be significant in multivariate analysis: primary cancer site, KPS, albumin level, number of visceral metastases and analgesic use. Three survival groups were proposed. The overall survival probabilities for groups 1-3 were 13, 46 and 94% at 6 months; 4, 28 and 79% at 12 months, respectively. The median survival times for groups 1-3 were 2.1, 5.5 and 24.9 months, respectively (P < 0.001).Conclusion: The pretreatment albumin level was a significant prognostic indicator for survival. Similarly, the primary cancer site, KPS and number of visceral metastases were associated with survival; these findings were consistent with the results of previous studies. The pretreatment analgesic use was significant using the univariate and multivariate analyses and this factor can be verified in future trials. Self-reported pain intensity, pain response to radiotherapy and MRI findings did not influence survival times. (C) 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

AIMS:The purpose of the study was to evaluate the response to palliative radiotherapy in patients with painful spinal metastatic disease (SMD).MATERIALS AND METHODS:Three hundred and fifty-five patients admitted to the Norwegian Radium Hospital for radiotherapy for painful SMD were included in a prospective study and were followed up 2 months later. The Brief Pain Inventory was used to assess pain. Analgesic consumption was recalculated into the daily oral morphine-equivalent dose. The radiotherapy-related response rates were calculated using the criteria of the International Bone Metastases Consensus Group (IBMCG), taking into account the use of concomitant analgesics. The response to radiotherapy was assessed as complete or partial and non-response as stable pain, pain progression or 'other'.RESULTS:Brief Pain Inventory forms were obtained at follow-up from 229 of the 355 patients. Two months after radiotherapy, the median self-reported worst pain decreased significantly, but the median oral morphine-equivalent dose increased from 40 to 60 mg (P<0.001). Forty-three per cent of the patients reported pain relief, but a radiotherapy-related response was found in 37% of the patients. Overall correspondence between the patients' self-reported changes in pain experience and the IBMCG-based response categories was obtained in 63% of the patients.CONCLUSIONS:The radiotherapy-related response rates in our study were lower than those reported previously in patients with bone metastases in general, which possibly indicates the presence of more complex pathophysiological mechanisms of pain in SMD.

Forty patients undergoing CPB for coronary artery surgery, using a standardized technical setting, were randomized to receive either Ringer's acetate, dextran 70 (Macrodex), polygeline (Haemaccel) or albumin 4% for volume replacement during and after surgery. The choice of fluid did not affect early complement activation (C3 activation products). Higher values of the terminal complement complex (TCC) were found only at the end of the operation in patients receiving polygeline. There were no differences between any two of the four groups during the postoperative course. The use of blood transfusion or autotransfusion and the degree of haemodilution and hypothermia did not affect complement activation. We conclude that complement activation in association with open-heart surgery is only marginally affected by the choice of fluid for volume replacement.

The effects on fluid balance, pulmonary tunctions and economics were evaluated in a randomized comparison of one colloid free and three colloid containing fluid regimens, for 48 hours during and after coronary artery‐bypass (CAB) surgery.A standard regimen for anaesthesia, extracorporeal circulation and monitoring was used. Only Ringer's acetate (RAc) was used as priming solution for extracorporeal circulation. Forty patients were randomized to receive either RAc, polygeline 35 mg‐ml‐1 (Haemaccel®), dextran 70 (Macrodex®) 60 mg ml‐14, or albumin 40 mg‐ml‐1 in saline whenever fluid volume was needed to stabilize haemodynamics.At the end of the operation, fluid retention was significantly lower in patients receiving polygeline and dextran 70, compared with patients receiving RAc. At 48 hours, however, there were no differences in cumulative fluid balance. Patients in the colloid groups postoperatively had a higher serum colloid osmotic pressure (s‐COP), bui a higher net lung capillary filtration pressure (AP) only on the second postoperative day than the RAc group. However, this did not adversely atfect intrapulmonary venous admixture, arterial oxygen tension, or time on respirator in the RAc group compared with the colloid groups. The most expensive colloid fluid regimen (albumin) cost about 230 USS more per patient than the RAc fluid regimen.We conclude that Ringer's acetate for volume replacement to stabilize haemodynamics during and after CAB surgery is associated with increased fluid retention only during the intraoperative period, compared with dextran 70 or polygeline, and with a lower serum colloid osmotic pressure and net lung capillary filtration pressure postoperatively, compared with all three colloid groups. This does not affect pulmonary functions adversely. Thus, the RAc regimen is clinically fully acceptable and economically more favourable than the polygeline, dextran 70, and albumin‐containing fluid regimens.

Autotransfusion of mediastinal shed blood after open heart surgery has become a common and accepted procedure in reducing the need for homologous transfusion during the last 15 years. The objectives of the present study were to investigate the oxygen delivery capacity of autotransfused shed mediastinal blood, compared to patient-blood, during cardiopulmonary bypass and in the postoperative period. Ten consecutive patients undergoing elective cardiac surgery were studied. Mediastinal shed blood was collected in the cardiotomy reservoir and retransfused during the first 18 postoperative hours. The oxygen delivery capacity of the blood to the tissues was calculated by use of the oxygen status algorithm (OSA 2.0) programme and measurement of the 2,3-diphosphoglycerate (2,3-DPG) concentration. Autotransfusion volume ranged from 450-1530 ml per patient (median 824 ml). Shed blood had a mean haemoglobin level of 8.8 g/dl and 7.4 g/dl at 1 h and 6 h of autotransfusion, respectively. There were no significant changes of 2,3-DPG concentration in the patient-blood during cardiopulmonary bypass or after autotransfusion compared to preoperative values. P50 for oxygen (3.6 and 3.6 kPa) and 2,3-DPG concentrations (5.3 and 5.1 mikromol/ml erythrocyte) in shed mediastinal blood (1h and 6h postoperatively) were not significantly different compared to patient-blood. The results demonstrate that the oxygen delivery capacity of shed mediastinal blood is maintained and that the oxygen affinity of patient-blood is not influenced by autotransfusion.

The effects of Ringer's acetate (RAc) infusion with different temperatures, 18d̀C compared to 36d̀C, were studied in 20 healthy volunteers. An infusion volume of 20% of the estimated extracellular volume was given over 45 min. Before and after the RAc infusion, interstitial colloid osmotic pressure and interstitial fluid hydrostatic pressure were measured on the lateral part of the thorax and in the lower leg. Blood sampling and pressure measurements were performed through a cannula placed in the left radial artery, and arterial oxygen saturation was measured by pulse oximetry. Atrial peptides ANF (99–126) and ANF (1–98) in plasma were measured as indicators of volume loading. Cold RAc infusion increased mean arterial pressure from 82 (s.d. ± 7) to 96 (s.d. ± 9) mmHg (10.9–12.8 kPa) at the end of the infusion with a simultaneous fall in heart rate. Warm RAc infusion gave no changes in blood pressure or heart rate. The arterial oxygen saturation during the infusion of cold RAc was higher than during warm RAc infusion. Cold infusion produced the expected haemodilution with a fall in erythrocyte volume fraction (EVF) from 0.39 (± 0.03) to 0.33 (± 0.03) and a fall in plasma colloid osmotic pressure (COPp) from 21.7 (± 1.1) mmHg to 15.0 (± 1.3) mmHg (2.9–2.0 kPa). Warm infusion induced a nearly identical haemodilution. Interstitial colloid osmotic pressure fell from 11.6 (± 2.3) mmHg to 8.9 (± 2.7) mmHg (1.5–1.2 kPa) after warm infusion while cold infusion gave no changes. The changes in interstitial fluid hydrostatic pressure were not significant. Cold infusion induced a higher diuresis compared to warm RAc infusion. ANF increased during cold, but not during warm infusion. We conclude that infusions of RAc at 18d̀C vs. 36d̀C have different volume effects. Cold infusion increased blood pressure and diuresis, while warm infusion induced peripheral vasodilation with increased capillary leakage and subcutaneous oedema formation.