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Because of the difficulties involved in the invasive monitoring of conscious patients, core temperature monitoring is frequently neglected during neuraxial anaesthesia. Zero heat flux (ZHF) and double sensor (DS) are non-invasive methods that measure core temperature from the forehead skin. Here, we compare these methods in patients under spinal anaesthesia. Sixty patients scheduled for elective unilateral knee arthroplasty were recruited and divided into two groups. Of these, thirty patients were fitted with bilateral ZHF sensors (ZHF group), and thirty patients were fitted with both a ZHF sensor and a DS sensor (DS group). Temperatures were saved at 5-min intervals from the beginning of prewarming up to one hour postoperatively. Bland–Altman analysis for repeated measurements was performed and a proportion of differences within 0.5 °C was calculated as well as Lin`s concordance correlation coefficient (LCCC). A total of 1261 and 1129 measurement pairs were obtained. The mean difference between ZHF sensors was 0.05 °C with 95% limits of agreement − 0.36 to 0.47 °C, 99% of the readings were within 0.5 °C and LCCC was 0.88. The mean difference between ZHF and DS sensors was 0.33 °C with 95% limits of agreement − 0.55 to 1.21 °C, 66% of readings were within 0.5 °C and LCCC was 0.59. Bilaterally measured ZHF temperatures were almost identical. DS temperatures were mostly lower than ZHF temperatures. The mean difference between ZHF and DS temperatures increased when the core temperature decreased.Trial registration: The study was registered in ClinicalTrials.gov on 13th May 2019, Code NCT03408197.

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. This trustworthy clinical practice guideline serves as a useful decision aid for Nordic anaesthesiologists caring for critically ill patients with bleeding. Non

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. The guideline serves as a useful bedside decision aid for clinicians managing adults with suspected and confirmed septic shock and sepsis-associated organ dysfunction. Non

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the Living WHO guideline on therapeutics and COVID-19. This trustworthy continuously updated guideline serves as a highly useful decision aid for Nordic anaesthesiologists caring for patients with COVID-19. Funding Agencies|Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Background: Postpartum haemorrhage causes significant mortality among parturients. Early transfusion of blood products based on clinical judgement and conventional coagulation testing has been adapted to the treatment of postpartum haemorrhage, but rotational thromboelastometry (ROTEM) may provide clinicians means for a goal-directed therapy to control coagulation. We conducted a parallel design, randomised, controlled trial comparing these two approaches. We hypothesised that a ROTEM-guided protocol would decrease the need for red blood cell transfusion. Methods: We randomised 60 parturients with postpartum haemorrhage of more than 1500 ml to receive either ROTEM-guided or conventional treatment, with 54 patients included in the final analysis. The primary outcome was consumption of blood products, and secondarily we assessed for possible side-effects of managing blood loss such as thromboembolic complications, infections, and transfusion reactions. Results: The median (25th–75th percentile) number of RBC units transfused was 2 (1–4) in the ROTEM group and 3 (2–4) in the control group (P=0.399). The median number of OctaplasLG® units given was 0 in both groups (0–0 and 0–2) (P=0.030). The median total estimated blood loss was 2500 ml (2100–3000) in the ROTEM group and 3000 ml (2200–3100) in the control group (P=0.033). No differences were observed in secondary outcomes. Conclusions: ROTEM-guided treatment of postpartum haemorrhage could have a plasma-sparing effect but possibly only a small reduction in total blood loss. Clinical trial registration: NCT02461251. publishedVersion

Background Previous studies have suggested that monitoring the levels of both hypnosis and antinociception could reduce periods of inadequate anaesthesia. However, the evidence regarding associated benefits of this monitoring is still limited. Objective The primary objective of this study was to confirm that guidance of anaesthesia by depth of hypnosis and antinociception monitoring decreases the number of inadequate anaesthesia events in comparison with standard clinical practice. Design A multicentre, single-blinded, randomised controlled trial. Setting The study was conducted in four European University hospitals in four different countries between December 2013 and November 2016. Patients The study population consisted of a total of 494 adult patients undergoing elective surgery requiring tracheal intubation. Interventions The patients were allocated to one of two groups. The first group was treated using Entropy for depth of hypnosis and surgical pleth index to determine depth of antinociception (adequacy of anaesthesia group; AoA group). The second group was monitored using standard monitoring alone (control group). Anaesthesia was conducted with target-controlled infusions of propofol and remifentanil. Main outcome measures The primary outcome of the study was the number of total unwanted events for example signs of inadequately light or unintentionally deep anaesthesia. Results Evidence of inadequate anaesthesia had an incidence of around 0.7 events per patient in both groups with no difference between groups (P = 0.519). In the AoA group, the overall consumption of propofol was significantly reduced (6.9 vs. 7.5 mg kg h, P = 0.008) in comparison with the control group. The consumption of remifentanil was equal in both groups. The times to emergence [8.0 vs. 9.6 min (P = 0.005)] and full recovery in the postanaesthesia care unit (P = 0.043) were significantly shorter in the AoA group. No differences were seen in postoperative pain scores or in the use of analgesics. Conclusion In the current study, the guidance of total intravenous anaesthesia by Entropy and surgical pleth index in comparison with standard monitoring alone was not able to validate reduction of unwanted anaesthesia events. However, there was a reduction in the use of propofol, and shorter times for emergence and time spent in the postanaesthesia care unit. Trial registration at ClinicalTrials.gov NCT01928875.

Additional file 1. The study sheet with English translations.

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline Regional anaesthesia in patients on antithrombotic drugs – a joint ESAIC/ESRA guideline. This clinical practice guideline serves as a useful decision aid for Nordic anaesthesiologists providing regional anaesthesia to adult patients on antithrombotic drugs. publishedVersion Non

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. This trustworthy clinical practice guideline serves as a useful decision aid for Nordic anaesthesiologists caring for critically ill patients with bleeding. Funding Agencies|Scandinavian Society of Anaesthesiology and Intensive Care Medicine

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. The guideline serves as a useful bedside decision aid for clinicians managing adults with suspected and confirmed septic shock and sepsis-associated organ dysfunction. BACKGROUND Sepsis and septic shock remain a leading global cause of mortality and morbidity.1-3 Anaesthesiologists and intensivists are regularly involved in the identification, resuscitation and management of adults with sepsis and septic shock. In November 2021, the Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 was published.4 The Clinical Practice Committee (CPC) of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) decided to appraise this guideline for possible endorsement to guide Scandinavian anaesthesiologists and intensivists in the identification, resuscitation, and management of adults with sepsis and septic shock. METHODS The SSAI CPC assessed the guideline using the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II tool,5 as per the outlined process for endorsement of non-SSAI guidelines.6 RESULTS Five SSAI CPC members completed the appraisal. One member co-authored the guideline and was excluded from the evaluation, as per the SSAI endorsement process.6 The individual domain totals were: 1) scope and purpose 89%; 2) stakeholder involvement 92%; 3) rigor of development 81%; 4) clarity of presentation 89%; 5) applicability 73%; 6) editorial independence 85%; 7) overall assessment 87% (Figure 1).

Purpose The optimal postoperative analgesia after cesarean section (CS) remains to be determined. The primary objective of this study was to assess whether oral oxycodone provides the same or better pain control and satisfaction with pain relief as oxycodone given intravenously using a patient-controlled analgesia (PCA) infusion device. The secondary objectives were to compare the gastrointestinal symptoms and postsurgical recovery of the two groups. Methods This prospective randomized trial was conducted at a University Hospital between February 2015 and June 2017. Altogether 270 CS patients were randomly assigned to receive postoperative oxycodone pain relief by IV PCA (n = 133) or orally (n = 137). Pain control and satisfaction with pain treatment were assessed by a numeric rating scale (NRS) at 2, 4, 8, and 24 h postoperatively. Results No differences were found in NRS pain scores or satisfaction between the groups except at 24 h pain when coughing; there was a statistically significant difference favoring the IV PCA group (p = 0.006). In the IV PCA group, the patients experienced more nausea at 4 h (p = 0.001) and more vomiting at 8 h (p = 0.010). Otherwise, postoperative recovery was similar in both groups. The equianalgesic dose of oxycodone was significantly smaller in the oral group (p = 0.003). Conclusions This study indicates that oral oxycodone provides pain control and satisfaction with pain relief equal to IV oxycodone PCA for postoperative analgesia after cesarean section. Satisfaction with pain treatment was high in both groups, and both methods were well tolerated. Early nausea was less common with oral medication.

Background The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. The guideline can serve as a useful decision aid for clinicians managing children with suspected and confirmed septic shock and sepsis-associated organ dysfunction. Funding Agencies|SSAI

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical practice Committee endorses the BMJ Rapid Recommendation Gastrointestinal bleeding prophylaxis for critically ill patients-a clinical practice guideline. The guideline serves as a useful decision aid for clinicians caring for critically ill patients, and can be used together with clinical experience to decide whether a specific critically ill patient may benefit from gastrointestinal bleeding prophylaxis.

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical practice Committee endorses the BMJ Rapid Recommendation Gastrointestinal bleeding prophylaxis for critically ill patients—a clinical practice guideline. The guideline serves as a useful decision aid for clinicians caring for critically ill patients, and can be used together with clinical experience to decide whether a specific critically ill patient may benefit from gastrointestinal bleeding prophylaxis.

Background Inadvertent intraoperative hypothermia is a common occurrence in surgical patients. A thermal suit is an option for passive insulation. However, active warming is known to be more effective. Therefore, we hypothesised that a forced-air warming (FAW) unit connected to the thermal suit is superior to a commercial FAW blanket and a warming mattress in breast cancer surgery. Methods Forty patients were randomised to this prospective, clinical trial to wear either the thermal suit or conventional hospital clothes under general anaesthesia. The Thermal suit group had a FAW unit set to 38 degrees C and connected to the legs of the suit. The Hospital clothes group had a lower body blanket set to 38 degrees C and a warming mattress set to 37 degrees C. Core temperature was measured with zero-heat-flux sensor. The primary outcome was core temperature on admission to the recovery room. Results There was no difference in mean core temperatures at anaesthetic induction (P = .4) or on admission to the recovery room (P = .07). One patient in the Thermal suit group (5%) vs six patients in the Hospital clothes group (32%) suffered from intraoperative hypothermia (P = .04, 95% CI 1.9%-49%). Mean skin temperatures (MSTs) were higher in the Thermal suit group during anaesthesia. No burns or skin irritations were reported. Two patients in the Thermal suit group sweated. Conclusions A thermal suit connected to a FAW unit was not superior to a commercial FAW blanket, although the incidence of intraoperative hypothermia was lower in patients treated with a thermal suit.

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline New clinical guidelines on the spinal stabilisation of adult trauma patients—consensus and evidence based. The guideline can serve as a useful decision aid for clinicians caring for patients with traumatic spinal cord injury. However, it is important to acknowledge that the overall certainty of evidence supporting the guideline recommendations was low, implying that further research is likely to have an important impact on the confidence in the estimate of effect. publishedVersion

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline New clinical guidelines on the spinal stabilisation of adult trauma patients-consensus and evidence based. The guideline can serve as a useful decision aid for clinicians caring for patients with traumatic spinal cord injury. However, it is important to acknowledge that the overall certainty of evidence supporting the guideline recommendations was low, implying that further research is likely to have an important impact on the confidence in the estimate of effect. Funding Agencies|Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Background Data are scarce on the withdrawal of life-sustaining therapies and limitation of care orders (LCOs) during physician-staffed Helicopter Emergency Medical Service (HEMS) missions. We investigated LCOs and the quality of information available when physicians made treatment decisions in prehospital care. Methods A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a six-month study period. All HEMS missions where a patient had pre-existing LCOs and/or a new LCO were included. Results There were 335 missions with LCOs, which represented 5.7% of all HEMS missions (n=5,895). There were 181 missions with pre-existing LCOs, and a total of 170 new LCOs were issued. Usually, the pre-existing LCO was a do not attempt cardiopulmonary resuscitation order only (n=133, 74%). The most frequent new LCO was 'termination of cardiopulmonary resuscitation' only (n=61, 36%), while 'no intensive care' combined with some other LCO was almost as common (n=54, 32%). When issuing a new LCO for patients who did not have any preceding LCOs (n=153), in every other (49%) case the physicians thought that the patient should have already had an LCO. When the physician made treatment decisions, patients' background information from on-scene paramedics was available in 260 (78%) of the LCO missions, while patients' medical records were available in 67 (20%) of the missions. Conclusion Making LCOs or treating patients with pre-existing LCOs is an integral part of HEMS physicians' work, with every twentieth mission involving LCO patients. The new LCOs mostly concerned withholding or withdrawal of cardiopulmonary resuscitation and intensive care.

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical Practice Committee endorses the recent DASAIM/DSIT guideline for prevention of rhabdomyolysis-induced acute kidney injury. However, we emphasize the low quality of evidence with only weak recommendations for all interventions, highlighting that further research is very likely to have an important impact on the confidence in the estimate of effect and is likely to change the estimates.

We investigated the national early warning scores (NEWSs) and related outcomes of patients in a tertiary referral center's multidisciplinary emergency department (ED). Patients were further categorized into three groups: triaged directly to intensive care unit (EDICU), triaged to general ward with later ICU admission (EDwardICU) and triaged to general ward (EDward). NEWSs and subsequent outcomes among these sub groups were compared.We conducted a prospective one-month cohort study in Tampere University Hospital's ED, Finland. ED-NEWSs were obtained for all adult patients without treatment limitations, and control (ward) NEWSs were further obtained for the EDwardICU and EDward patients.Cohort consisted of 1,354 patients with a median ED-NEWS of 2, and higher ED-NEWS was associated with in-hospital mortality (OR 1.26, 95% CI 1.11-1.42; AUROC 0.75, 0.64‒0.86, p 0.001) and 30-day mortality (OR 1.27, 1.17-1.39; AUROC 0.78, 0.71‒0.84, p 0.001) irrespective of age and comorbidity. There were 64 patients in EDICU group, 12 patients in EDwardICU group and 1,278 patients in EDward group with median ED-NEWSs of 7, 3 and 2 (p 0.001), respectively. After the first 24 h in wards, median NEWSs of the EDwardICU patients had substantially increased as compared with EDward patients (6 vs. 2, p 0.001). There were no statistical differences in last NEWS before ICU admission between the EDICU and EDwardICU patients (7 vs. 8, p = 0.534), or in ICU severity-of-illness scores or patient outcomes.ED-NEWS is independently associated with in-hospital and 30-day mortality with acceptable discrimination capability. Direct and late ICU admissions occurred with comparable NEWSs at admission.

Ectopic beats are abnormal cardiac beats originating from a location different than the sino-atrial node and therefore not being controlled by the autonomous nervous system. Thus, correct heart rate variability analysis inevitably requires accurate ectopic beat detection. Furthermore, an accurate ectopic beat detection is crucial to differentiate irregular cardiac rhythm due to different types of pathological arrhythmias from those caused by isolated ectopic beats. In this paper, we present an algorithm for ectopic beat detection based on wrist plethysmographic (PPG) signals. The proposed algorithm relies on analyzing the inter-beat patterns while considering the heart-rhythm condition; whether sinus rhythm (SR) or atrial fibrillation (AF). We monitor 29 patients recovering from surgery in the post-anesthesia care unit. During the recordings, 15 patients had SR and 14 patients had AF. The proposed ectopic beat detection algorithm achieves a sensitivity of \(93.08 \pm 3.83\%\) and a specificity of \(97.80 \pm 2.12\%\).

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical Practice Committee endorses the recent DASAIM/DSIT guideline for prevention of rhabdomyolysis-induced acute kidney injury. However, we emphasize the low quality of evidence with only weak recommendations for all interventions, highlighting that further research is very likely to have an important impact on the confidence in the estimate of effect and is likely to change the estimates.

Clinical practice guidelines from other organizations or societies with assumed clinical and contextualized relevance for Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) members, may trigger a formal evaluation by The Clinical Practice Committee (CPC) for possible SSAI endorsement. This avoids unnecessary duplicate processes and minimizes resource-waste. Identified guidelines are assessed for endorsement using the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument. The SSAI CPC utilizes the AGREE II online coordinated group appraisal platform to assess the methodological rigor and transparency in which the guideline was developed. The results of the assessment, including the decision to endorse or not, are presented to the SSAI Board for sanctioning. This document briefly outlines the process for evaluation of non-SSAI guidelines by the CPC for possible SSAI endorsement.

Alterations in arterial blood oxygen saturation, heart rate (HR), and respiratory rate (RR) are strongly associated with intra-hospital cardiac arrests and resuscitations. A wireless, easy-to-use, and comfortable method for monitoring these important clinical signs would be highly useful. We investigated whether the Nellcor (TM) OxiMask MAX-FAST forehead sensor could provide data for vital sign measurements when located at the distal forearm instead of its intended location at the forehead to provide improved comfortability and easy placement. In a prospective setting, we recruited 30 patients undergoing surgery requiring postoperative care. At the postoperative care unit, patients were monitored for two hours using a standard patient monitor and with a study device equipped with a Nellcor (TM) Forehead SpO(2) sensor. The readings were electronically recorded and compared in post hoc analysis using Bland-Altman plots, Spearman's correlation, and root-mean-square error (RMSE). Bland-Altman plot showed that saturation (SpO(2)) differed by a mean of -0.2 % points (SD, 4.6), with a patient-weighted Spearman's correlation (r) of 0.142, and an RMSE of 4.2 points. For HR measurements, the mean difference was 0.6 bpm (SD, 2.5), r = 0.997, and RMSE = 1.8. For RR, the mean difference was -0.5 1/min (4.1), r = 0.586, and RMSE = 4.0. The SpO(2) readings showed a low mean difference, but also a low correlation and high RMSE, indicating that the Nellcor (TM) saturation sensor cannot reliably assess oxygen saturation at the forearm when compared to finger PPG measurements.

The surgical pleth index (SPI) is a measurement of intraoperative nociception. Evidence of its usability in children is limited. Given that the autonomic nervous system is still developing during the first years of life, the performance of the SPI on small children cannot be concluded from studies carried out in older age groups.Thirty children aged2 yr, planned for elective open inguinal hernia repair or open correction of undescended testicle, were recruited. The children were randomized into two groups; the saline group received ultrasound-guided saline injection in the ilioinguinal and iliohypogastric nerve region before surgery and ropivacaine after surgery, whereas the block group received the injections in the opposite order. The SPI was recorded blinded and was analysed at the time points of intubation, incision, and when signs of inadequate anti-nociception were observed.There was a significant increase in the SPI after intubation (P=0.019) and after incision in the saline group (P=0.048), but not at the time of surgical incision in the block group (P=0.177). An increase in the SPI was also seen at times of clinically apparent inadequate anti-nociception (P=0.008). The between-patient variability of the SPI was large.The SPI is reactive in small children after intubation and after surgical stimuli, but the reactivity of the SPI is rather small, and there is marked inter-individual variability in reactions. The reactivity is blunted by the use of ilioinguinal and iliohypogastric nerve block.NCT02045810.

Rapid antidepressant effects of ketamine become most evident when its psychotomimetic effects subside, but the neurobiological basis of this “lag” remains unclear. Laughing gas (N2O), another NMDA-R (N-methyl-d-aspartate receptor) blocker, has been reported to bring antidepressant effects rapidly upon drug discontinuation. We took advantage of the exceptional pharmacokinetic properties of N2O to investigate EEG (electroencephalogram) alterations and molecular determinants of antidepressant actions during and immediately after NMDA-R blockade. Effects of the drugs on brain activity were investigated in C57BL/6 mice using quantitative EEG recordings. Western blot and qPCR were used for molecular analyses. Learned helplessness (LH) was used to assess antidepressant-like behavior. Immediate-early genes (e.g., bdnf) and phosphorylation of mitogen-activated protein kinase—markers of neuronal excitability—were upregulated during N2O exposure. Notably, phosphorylation of BDNF receptor TrkB and GSK3β (glycogen synthase kinase 3β) became regulated only gradually upon N2O discontinuation, during a brain state dominated by slow EEG activity. Subanesthetic ketamine and flurothyl-induced convulsions (reminiscent of electroconvulsive therapy) also evoked slow oscillations when their acute pharmacological effects subsided. The correlation between ongoing slow EEG oscillations and TrkB-GSK3β signaling was further strengthened utilizing medetomidine, a hypnotic-sedative agent that facilitates slow oscillations directly through the activation of α2-adrenergic autoreceptors. Medetomidine did not, however, facilitate markers of neuronal excitability or produce antidepressant-like behavioral changes in LH. Our results support a hypothesis that transient cortical excitability and the subsequent regulation of TrkB and GSK3β signaling during homeostatic emergence of slow oscillations are critical components for rapid antidepressant responses. Electronic supplementary material The online version of this article (10.1007/s12035-018-1364-6) contains supplementary material, which is available to authorized users.

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical Practice Committee endorses the BMJ Rapid Recommendation clinical practice guideline on atraumatic (pencil-point) vs conventional needles for lumbar puncture. This includes the strong recommendation for the use of atraumatic needles for lumbar puncture in all patients regardless of age or indication.

Clinical practice guidelines from other organizations or societies with assumed clinical and contextualized relevance for Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) members, may trigger a formal evaluation by The Clinical Practice Committee (CPC) for possible SSAI endorsement. This avoids unnecessary duplicate processes and minimizes resource-waste. Identified guidelines are assessed for endorsement using the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument. The SSAI CPC utilizes the AGREE II online coordinated group appraisal platform to assess the methodological rigor and transparency in which the guideline was developed. The results of the assessment, including the decision to endorse or not, are presented to the SSAI Board for sanctioning. This document briefly outlines the process for evaluation of non-SSAI guidelines by the CPC for possible SSAI endorsement.

The differences in opinions and practices between the most experienced quartile of Finnish HEMS physicians (with 20 years or more of work experience as physician in total, n = 12) and other physicians (n = 47) analysed with Fisher’s exact test. (DOCX 16 kb)

Background Making ethically sound treatment limitations in prehospital care is a complex topic. Helicopter Emergency Medical Service (HEMS) physicians were surveyed on their experiences with limitations of care orders in the prehospital setting, including situations where they are dispatched to healthcare facilities or nursing homes. Methods A nationwide multicentre study was conducted among all HEMS physicians in Finland in 2017 using a questionnaire with closed five-point Likert-scale questions and open questions. The Ethics Committee of the Tampere University Hospital approved the study protocol (R15048). Results Fifty-nine (88%) physicians responded. Their median age was 43 (IQR 38–47) and median medical working experience was 15 (IQR 10–20) years. All respondents made limitation of care orders and 39% made them often. Three fourths (75%) of the physicians were often dispatched to healthcare facilities and nursing homes and the majority (93%) regularly met patients who should have already had a valid limitation of care order. Every other physician (49%) had sometimes decided not to implement a medically justifiable limitation of care order because they wanted to avoid conflicts with the patient and/or the next of kin and/or other healthcare staff. Limitation of care order practices varied between the respondents, but neither age nor working experience explained these differences in answers. Most physicians (85%) stated that limitations of care orders are part of their work and 81% did not find them especially burdensome. The most challenging patient groups for treatment limitations were the under-aged patients, the severely disabled patients and the patients in healthcare facilities or residing in nursing homes. Conclusion Making limitation of care orders is an important but often invisible part of a HEMS physician’s work. HEMS physicians expressed that patients in long-term care were often without limitations of care orders in situations where an order would have been ethically in accordance with the patient’s best interests.

The study survey with English translations. (DOCX 50 kb)

Atrial fibrillation (AF) can be detected by analysis of the rhythm of heartbeats. The development of photoplethysmography (PPG) technology has enabled comfortable and unobtrusive physiological monitoring of heart rate with a wrist-worn device. Therefore, it is important to examine the possibility of using PPG signal to detect AF episodes in real-world situations. The aim of this paper is to evaluate an AF detection method based on artificial neural networks (ANN) from PPG-derived beat-to-beat interval data used for primary screening or monitoring purposes. The proposed classifier is able to distinguish between AF and sinus rhythms (SR). In total 30 patients (15 with AF, 15 with SR, mean age 71.5 years) with multiple comorbidities were monitored during routine postoperative treatment. The monitoring included standard ECG and a wrist-worn PPG monitor with green and infrared light sources. The input features of the ANN are based on the information obtained from inter-beat interval (IBI) sequences of 30 consecutive PPG pulses. One of the main concerns about the PPG signals is their susceptibility to be corrupted by noise and artifacts mostly caused by subject movement. Therefore, in the proposed method the IBI reliability is automatically evaluated beforehand. The amount of uncertainty due to unreliable beats was 15.42%. The achieved sensitivity and specificity of AF detection for 30 beats sequences were 99.20 ± 1.3 and 99.54 ± 0.64, respectively. Based on these results, the ANN algorithm demonstrated excellent performance at recognizing AF from SR using wrist PPG data. acceptedVersion

The Scandinavian Society of Anaesthesiology and Intensive Care Medicine Clinical Practice Committee endorses the BMJ Rapid Recommendation clinical practice guideline on atraumatic (pencil-point) vs conventional needles for lumbar puncture. This includes the strong recommendation for the use of atraumatic needles for lumbar puncture in all patients regardless of age or indication.