Myocardial injury in non-cardiac surgery | Post-dural puncture Headache in Obstetrics

Our group, led by Anil Gupta, is attempting to understand the risk factors, aetiology and prognosis of patients who have an increase in biomarkers of myocardial or kidney injury in the perioperative period in patients undergoing non-cardiac surgery.

Myocardial injury in non-cardiac surgery

Myocardial injury in non-cardiac surgery (MINS) has been identified, and several large studies have shown that MINS occurs in about 8-10% of patients. MINS is defined as an increase in perioperative troponin without necessarily signs or symptoms of myocardial ischemia. Therefore, it may be undetected unless routine biomarkers for troponin are done perioperatively.

It is also important to differentiate acute myocardial injury (rise and fall of troponin) from chronic (increased troponin both pre- and postoperatively, without a rise and fall) myocardial damage so that specific strategies may be developed to manage these events.

Although most patients diagnosed with acute myocardial infarction (AMI) in the emergency room have a thrombotic obstruction in one of the coronary arteries (type I AMI) most patients in the perioperative period likely have a mismatch between oxygen supply and demand (type II AMI) due to episodic hypotension, tachycardia, hypoxia etc.

Hypotension has recently been cited, from epidemiological studies, to be one major factor for the increase in troponin perioperatively. However, no prospective study has shown conclusively that type II MI is the cause of MINS, and one recent study found that 33% patients had evidence of pulmonary embolism that could explain the increase in troponin in the postoperative period.

Differentiating chronic myocardial or kidney injuries from acute injuries is therefore important so that treatment algorithms are correctly implemented in the individual patient.

Group members

Max Bell

Senior Lecturer/Consultant in Intesive Care

Caroline Hällsjö Sander

Assistant professor/Senior Consultant, Perioperative Medicine and Intensive Care

Linn Hällqvist

Assistant professor/Consultant, Perioperative Medicine and Intensive Care

Thorir Sigmundsson

Assistant professor/Senior Consultant, Perioperative Medicine and Intensive Care

Arman Valadkhani

PhD student and Resident, Perioperative Medicine and Intensive Care

Panagiotis Tufexis

Student, Karolinska Institutet

Post-dural puncture Headache in Obstetrics

Post-dural puncture headache (PDPH) in Obstetrics: Accidental dural puncture (ADP) and the resulting PDPH is a rare but well recognized complication of epidural analgesia during labour, affecting 1% patients.

This is devastating for a mother with a new born baby and affects bonding between the mother and child at a vulnerable period of time (post-partum). Auditory changes following ADP are well described but not in the obstetric population using large gauge epidural needles.

We have demonstrated that audiometry cannot be used as a diagnostic method for the clinical diagnosis of PDPH and long-term effects of PDPH on audiometric function (deterioration) occur, although the magnitude is small. In a multi-centre (> 150 centres in Europe, > 1000 patients enrolled), (EPiMAP Obstetrics I) we have recently published the first of a series of studies looking at the incidence of PDPH and current trends in its management.

We are now analysing the reasons for failure of epidural blood patch (EBP), which is often used as a semi-invasive method for management of PDPH (EPiMAP Obstetrics II).

I am the primary investigator and the study is sponsored and funded by the Clinical Trials Network (CTN) of the European Society of Anaesthesiology and Intensive Care (ESAIC).

Group members

Henrik Jörnvall

Assistant professor/Senior Consultant, Perioperative Medicine and Intensive Care

Johan Nordström

Consultant, Perioperative Medicine and Intensive Care

Bijan Darvish

Assistant professor/Senior Consultant, Perioperative Medicine and Intensive Care

International group of experts from Belgium, Germany, Finland, France, The Netherlands and Spain.

Research support

  • European Society of Anaesthesiology and Intensive Care (ESAIC) (Caroline Hällsjö-Sander)
  • ALF Medicin, Stockholm (Max Bell)
  • Stiftelsen Nyckeln (Örebro County Council) (Anil Gupta)
  • Other External funding (Anil Gupta)

Selected publications

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study.
Gupta A, von Heymann C, Magnuson A, Alahuhta S, Fernando R, Van de Velde M, Mercier FJ, Schyns-van den Berg AMJV,
Br J Anaesth 2020 12;125(6):1045-1055

Intraperitoneal ropivacaine reduces time interval to initiation of chemotherapy after surgery for advanced ovarian cancer: randomised controlled double-blind pilot study.
Hayden JM, Oras J, Block L, Thörn SE, Palmqvist C, Salehi S, Nordstrom JL, Gupta A
Br J Anaesth 2020 05;124(5):562-570

Assessment of platelet function after discontinuation of ticagrelor.
Söderberg M, Holm M, Gupta A
Acta Anaesthesiol Scand 2020 04;64(4):526-531

Effects of Combined Milrinone and Levosimendan Treatment on Systolic and Diastolic Function During Postischemic Myocardial Dysfunction in a Porcine Model.
Axelsson B, Häggmark S, Svenmarker S, Johansson G, Gupta A, Tydén H, Wouters P, Haney M
J Cardiovasc Pharmacol Ther 2016 09;21(5):495-503

Auditory function following post-dural puncture headache treated with epidural blood patch. A long-term follow-up.
Darvish B, Dahlgren G, Irestedt L, Magnuson A, Möller C, Gupta A
Acta Anaesthesiol Scand 2015 Nov;59(10):1340-54

Intraperitoneal local anesthetics have predominant local analgesic effect: a randomized, double-blind study.
Perniola A, Magnuson A, Axelsson K, Gupta A
Anesthesiology 2014 Aug;121(2):352-61

Postoperative pain relief after total hip arthroplasty: a randomized, double-blind comparison between intrathecal morphine and local infiltration analgesia.
Kuchálik J, Granath B, Ljunggren A, Magnuson A, Lundin A, Gupta A
Br J Anaesth 2013 Nov;111(5):793-9

Thoracic Epidural Analgesia inhibits the Neuro-Hormonal but not the Acute Inflammatory Stress Response following Radical Retropubic Prostatectomy.
Fant F, Tina E, Hultgren-Hörnquist E, Magnuson A, Sandblom D, Andersson S-O, Axelsson K, Gupta A
Br J Anaesth. 2013;110:747-57.


I am a Clinician working at the Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital and a Researcher affiliated to the Institution for Physiology and Pharmacology, Karolinska Institutet.


Anil Gupta

Group leader
Anil Gupta