Search

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. [ABSTRACT FROM AUTHOR]

Background Post-operative pain continues to be a major problem. Some previous studies have suggested that patients anaesthetised with propofol have less pain after surgery than those anesthetised with volatiles. However, the results of previous studies are conflicting. We designed a large-scale trial to study, whether propofol or sevoflurane is more analgesic than the other. We measured opioid consumption in the acute post-operative phase after laparoscopic hysterectomy. Methods In a randomised, prospective single-blind trial, we evaluated the consumption of oxycodone and pain intensity in 148 women for 20 h after laparoscopic hysterectomy under propofol or sevoflurane anaesthesia. The primary endpoint was the cumulative amount of oxycodone consumed. Secondary endpoints were pain scores [numeric rating scale ( NRS)] at rest and with coughing, severity of nausea and state of sedation. Results The consumption of oxycodone and the NRS pain scores did not differ between the groups. The oxycodone consumed during first 20 h after surgery was 42.5 (95% confidence interval 38.3-46.6) mg and 42.8 (37.3-48.4) mg in propofol- and sevoflurane-anaesthetised patients, respectively ( P = 0.919). NRS scores for nausea were higher in the patients receiving sevoflurane during the first 60 min in the post-anaesthesia care unit, leading to higher consumption of rescue antiemetics. Sedation scores differed in favour of sevoflurane only at 4 h time point after anaesthesia. Patient characteristics did not differ. Conclusions In this study, comparing sevoflurane with propofol for maintenance of general anaesthesia, the choice of anaesthetic had no effect on the requirement of oxycodone or intensity of pain after surgery. [ABSTRACT FROM AUTHOR]

Background Electroencephalogram ( EEG)-based depth of anaesthesia monitoring is susceptible to contaminating electromyographic ( EMG) activity. Many authorities have suggested that anaesthesiologists using these monitors should interpret the raw EEG waveform seen on the anaesthesia monitor. Methods In 34 patients anaesthetized with propofol using two doses of rocuronium (0.6 and 1.2 mg/kg), we studied whether the EMG arousal can be detected visually on the anaesthesia monitor. The Bispectral Index ( BIS) and Entropy biosignals on the monitor were recorded with a video camera, and the one-channel EEG recorded by the Entropy strip was collected on a laptop computer. The recordings and the one-channel EEG were analyzed offline by two experts (anaesthesiologist and neurophysiologist), both with a long experience on anaesthesia-related EEG. Results EMG arousal existed in 14/34 and 13/33 patients in the BIS and Entropy biosignals, respectively. The anaesthesiologist detected EMG on the monitor in 7/14 patients with BIS (sensitivity 50%) and in 4/13 patients with Entropy (31%). The clinical neurophysiologist detected EMG in 6/14 (43%) patients with BIS and in 5/13 (38%) with Entropy. The specificity of the EMG analyses was 55 and 65% with BIS, and 85 and 90% with Entropy. EMG arousal was detected in BIS biosignal in 10/17 and 4/17 patients with 0.6 and 1.2 mg/kg doses of rocuronium ( P = 0.04). Conclusions In contrast to many EEG phenomena, EMG activity cannot be accurately detected visually from the raw EEG on the anaesthesia monitor. Further development in the quality of the anaesthesia monitors is warranted. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Analgesia is an important part of general anaesthesia, but no direct indicators of nociceptive–anti-nociceptive balance have been validated in detail. The Response Index of Nociception (RN) is a multiparameter approach which combines photoplethysmographic waveform (PPG), State Entropy (SE), Response Entropy (RE), and heart rate variability (HRV). We aimed at evaluating RN during general anaesthesia; especially we wanted to compare pre- and post-index values of certain noxious stimuli to the average index values. Our assumption was that RN could be a useful indicator of nociceptive–anti-nociceptive balance during the surgery. Methods: Sixty women undergoing gynaecological or breast surgery participated in the study. All patients had elective surgery and anaesthesia was maintained with propofol–remifentanil target controlled infusion. Neuromuscular blocking agent rocuronium was used at the beginning of the surgery. Electrocardiography (ECG), photoplethysmography (PPG) and electroencelophalography (EEG) were registered and extracted off-line. An index, reflecting amplitude and frequency of occurrence of abrupt increases (“peaks”) in the RN was evaluated during surgery in general and around occurrences of predefined noxious stimuli in particular. Results: Fifty-four patients were eligible for analysis. Patient movement was associated with increased index values, both before and after the event. Post-event values of the index for intubation and skin incision were higher than its intra-surgery baseline, while pre-event values remained unchanged. Conclusion: Changes in RN can be used to detect noxious stimuli during surgery. RN also predicted movement in our patients under propofol–remifentanil anaesthesia. [Copyright &y& Elsevier]

Photoplethysmography (PPG), i.e. pulse oximetric wave, is a non-invasive technique that is used in anaesthesia monitoring primarily to monitor blood oxygenation. The PPG waveform resembles that of the arterial blood pressure but instead of pressure it is related to the volume changes in the measurement site and hence contains information related to the peripheral blood circulation, including skin vasomotion, which is controlled by the sympathetic nervous system. Because of this link, skin vasomotor response and PPG amplitude response have been associated with nociception under general anaesthesia. Recently, there has been interest in monitoring nociception during general anaesthesia. In many of the published studies, PPG waveform information has been included. The focus of this topical review is to provide an overview on the information embedded in the PPG waveform especially in the context of the autonomic nervous system and analgesia monitoring. [ABSTRACT FROM AUTHOR]

Abstract: Study Objective: To test the hypothesis that the recovery of gynecological day-case patients is equally fast after isoflurane and sevoflurane anesthesia, when administration of the inhaled agent is adjusted by monitoring the bispectral index (BIS). Design: Prospective, randomized, controlled, single-blinded clinical study. Setting: University-affiliated women''s hospital. Patients: 120 adult female patients, ASA physical status I or II, scheduled for ambulatory surgery under general anesthesia. Interventions: Patients were randomized to receive either isoflurane or sevoflurane as the maintenance anesthetic. BIS values were titrated to remain between 50 and 60 during the maintenance of anesthesia by adjusting the inspired concentration of the inhaled agent. Administration of the inhaled agent was discontinued abruptly at the end of the procedure. Measurements: The times to achieving several recovery end points were recorded. The main outcome parameter was the time to home-readiness. In the postoperative care unit, sedation was evaluated with the digit-symbol substitution test. The degree of pain and nausea was evaluated on the visual analog scale. Main results: There were no statistically significant differences in the times to home-readiness, or in any other parameters of early or intermediate recovery between the 2 groups. The degrees of sedation, pain, and nausea in the postoperative care unit were similar in the 2 groups. Conclusions: Isoflurane and sevoflurane are equally acceptable maintenance anesthetics in terms of the speed and quality of recovery in gynecological ambulatory surgery patients when the dose of the inhaled agent is adjusted to achieve a BIS between 50 and 60. [Copyright &y& Elsevier]

The cooling and haemodynamic effects of prehospital infusion of ice-cold Ringer’s solution were studied in 13 adult patients after successful resuscitation from non-traumatic cardiac arrest. After haemodynamics stabilisation, 30 ml/kg of Ringer’s solution was infused at a rate of 100 ml/min into the antecubital vein. Arterial blood pressure and blood gases, pulse rate, end-tidal CO2 and oesophageal temperature were monitored closely. The mean core temperature decreased from 35.8 ± 0.9 °C at the start of infusion to 34.0 ± 1.2 °C on arrival at hospital (P < 0.0001). No serious adverse haemodynamic effects occurred. It is concluded that the induction of therapeutic hypothermia using this technique in the prehospital setting is feasible. [Copyright &y& Elsevier]

Background: Time-frequency balanced spectral entropy of electroencephalogram (EEG) and frontal electromyogram (FEMG) is a novel measure of hypnosis during anesthesia. Two Entropy parameters are described: Response entropy (RE) is calculated from EEG and FEMG; and State Entropy (SE) is calculated mainly from EEG. This study was performed to validate their performance during transition from consciousness to unconsciousness under different anesthetic agents.Methods: Response entropy, SE [S/5 Entropy Module, M-ENTROPY (later in text: Entropy), Datex-Ohmeda Division, Instrumentarium Corp., Helsinki, Finland] and BIS (BIS XP, A-2000, Aspect Medical Systems, Newton, MA) data were collected from 70 patients; 30 anesthetized with propofol 2 mg kg-1, 20 with sevoflurane inhalation, and 20 with thiopental 5 mg kg-1. Loss and regaining of consciousness (LOC, ROC) was tested every 10 s, and sensitivity, specificity, and prediction probability (Pk) were calculated. Behavior of the indices was studied.Results: Sensitivity, specificity, and Pk values for consciousness were high and similar for all indices. During regaining of consciousness after propofol bolus, RE, SE, and BIS values recovered by 81 +/- 22%, 75 +/- 26%, and 59 +/- 18% (mean +/- SD), respectively, from the minimum relative to their baseline. After thiopental bolus, RE, SE, and BIS values recovered by 86+/-21%, 88 +/- 13%, and 63 +/- 14%, respectively. The relative rise was higher in RE and SE compared with BIS (P < 0.01). During deep levels of hypnosis, RE and SE decreased monotonously as a function of burst suppression ratio, while BIS showed biphasic behavior. On average, RE indicated emergence from anesthesia 11 s earlier than SE, and 12.4 s earlier than BIS.Conclusions: All indices, RE, SE, and BIS, distinguished excellently between conscious and unconscious states during propofol, sevoflurane, and thiopental anesthesia. During burst suppression, Entropy parameters RE and SE, but not BIS, behave monotonously. During regaining of consciousness after a thiopental or propofol bolus, RE and SE values recovered significantly closer to their baseline values than did BIS. Response entropy indicates emergence from anesthesia earlier than SE or BIS. [ABSTRACT FROM AUTHOR]

Background: Sevoflurane inhalation induction of anaesthesia is widely used in paediatric anaesthesia. We have found that this method is frequently associated with epileptiform electroencephalogram (EEG) in adults, especially if controlled hyperventilation is used.Methods: We assessed EEG during sevoflurane inhalation induction in 31 children, aged 2-12 yr. Anaesthesia was induced with 8% sevoflurane in O2 in N2O 1:2. The patients were randomized to undergo controlled ventilation (CV group), or to breathe spontaneously (SB group) for 5 min. EEG was recorded as were noninvasive blood pressure and heart rate (HR). EEG recordings were classified by a clinical neurophysiologist.Results: Three different types of interictal epileptiform discharge were detected. Suppression with spikes (SSP) was found in 25% and 0% in the CV and SB groups, rhythmic polyspikes (PSR) in 44% and 20%, and periodic epileptiform discharges (PED) in 44% and 0% (P<0.01), respectively. The incidence of all different types of interictal epileptiform discharge (SSP+PSR+PED) was 88% and 20% (P<0.001), respectively. Epileptiform EEG was associated with increased heart rate and blood pressure during anaesthetic induction.Conclusion: Both ventilation modes produced epileptiform EEG. With controlled ventilation, epileptiform discharges were seen in 88% of children. This warrants further studies of the suitability of this induction type in general, and especially in children with epilepsy. [ABSTRACT FROM AUTHOR]

Background: The monitoring of electroencephalogram bispectral index (EEG-BIS) during anaesthesia reduces anaesthetic use and improves recovery. However, it also increases the direct costs of anaesthesia due to the need for special EEG electrodes. In the present study we tested the feasibility of less expensive electrocardiogram (ECG) electrodes for EEG-BIS monitoring.Methods: In the first part of the study we compared skin-electrode impedances when EEG electrodes were used after alcohol swab pretreatment of skin to impedances when ECG electrodes were used after alcohol swab pretreatment with or without skin abrasion paste. In the second part of the study we evaluated the difference in parallel BIS values collected with two BIS monitors, using either ECG electrodes or EEG electrodes. In the third part of the study we compared parallel BIS values collected with two sets of EEG electrodes.Results: Skin pretreatment with abrasion paste led to lower impedances with ECG electrodes than did alcohol swab pretreatment of skin with EEG electrodes. When the skin was pretreated with alcohol swab, higher impedances were measured with ECG electrodes than with EEG electrodes. In most patients, BIS values collected with ECG electrodes were also higher than those collected with adhesive EEG electrodes. The difference between parallel BIS values collected with two sets of adhesive EEG electrodes was smaller than the difference between BIS values collected with ECG and EEG electrode sets.Conclusion: Low skin-electrode impedances indicating reliable skin-electrode contact can be ensured with inexpensive pregelled ECG electrodes only if the skin is carefully prepared with both abrasion paste and alcohol. When only alcohol pretreatment of skin is used, the BIS values collected with EEG electrodes and ECG electrodes are not equal. EEG-BIS monitoring with pregelled ECG electrodes is recommended only if skin is prepared with abrasion paste before attaching the electrodes. [ABSTRACT FROM AUTHOR]

Background: Hypothermia is a known side effect of laparoscopic operations. It may increase the sympathetic activity of the autonomic nervous system (ANS), which can be evaluated noninvasively by heart rate variability (HRV). We tested the hypothesis that warming of the delivered CO2 insufflation gas helps to maintain the normal body temperature.Methods: Thirty-seven healthy women undergoing laparoscopic hysterectomy were randomized into heated (37 degrees C, n=18) or unheated (24 degrees C, n = 19) gas insufflation groups. Anesthesia was induced with propofol and maintained with sevoflurane in O2-air. Tympanic (ttymp) temperature was recorded before, during and after the operation. Nasopharyngeal (tnaso) temperature was recorded only during operation. Electrocardiograms were recorded and stored to evaluate changes in HRV. The individual changes in HRV were compared after decibel (dB) transformation.Results: A median decrease in tympanic temperatures during the operation was 0.7 degrees C in the heated and 0.3 degrees C in the unheated group (P = 0.01 between groups), and in nasopharyngeal 0.3 degrees C and 0.1 degrees C (P = 0.03), respectively. Preanesthetic tympanic values were reached within 90 min after anesthesia. After dB transformation, HRV high frequency power differed between the groups. It was better preserved in the patients receiving unheated gas.Conclusion: The heating of insufflation gas does not prevent a decrease in body temperature and is thus unnecessary during laparoscopic hysterectomy. [ABSTRACT FROM AUTHOR]

Background: Recent studies have suggested that electroencephalogram (EEG) bispectral index (BIS) monitoring can improve recovery after anaesthesia and save money by shortening patients' postoperative stay. We wanted to evaluate the direct costs of BIS monitoring and to measure immediate recovery after anaesthesia in patients with or without BIS monitoring.Methods: Eighty patients undergoing gynaecological surgery were studied. At first, 40 patients were randomized to receive either propofol or sevoflurane anaesthesia. In these patients, BIS was collected but the information was not displayed. Thereafter, the anaesthesiologists were trained to follow and understand the BIS information, and 40 patients were anaesthetized with aid of the monitoring. Recovery times were measured by a study coordinator. Drug consumption was calculated.Results: BIS monitoring improved the immediate recovery after propofol anaesthesia, while no differences were seen in patients receiving sevoflurane. The consumption of both propofol and sevoflurane decreased significantly (29% and 40%, respectively). BIS monitoring increased direct costs in these patients; the break-even times (704 min for propofol and 282 min for sevoflurane) were not reached.Conclusion: BIS monitoring decreased the consumption of both propofol and sevoflurane and hastened the immediate recovery after propofol anaesthesia. Detailed cost analysis showed that the monitoring increased direct costs of anaesthesia treatment in these patients, mainly due to the price of special EEG electrodes used for relatively short anaesthesias. [ABSTRACT FROM AUTHOR]

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 pre-hospital care.Methods: A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a 6-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 = 5895). 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. [ABSTRACT FROM AUTHOR]

Background: Arthroplasty patients are at high risk of hypothermia. Pre‐warming with forced air has been shown to reduce the incidence of intraoperative hypothermia. There is, however, a lack of evidence that pre‐warming with a self‐warming (SW) blanket can reduce the incidence of perioperative hypothermia. This study aims to evaluate the effectiveness of an SW blanket and a forced‐air warming (FAW) blanket peri‐operatively. We hypothesised that the SW blanket is inferior to the FAW blanket. Methods: In total, 150 patients scheduled for primary unilateral total knee arthroplasty under spinal anaesthesia were randomised to this prospective study. Patients were pre‐warmed with SW blanket (SW group) or upper‐body FAW blanket (FAW group) set to 38°C for 30 min before spinal anaesthesia induction. Active warming was continued with the allocated blanket in the operating room. If core temperature fell below 36°C, all patients were warmed using the FAW blanket set to 43°C. Core and skin temperatures were measured continuously. The primary outcome was core temperature on admission to the recovery room. Results: Both methods increased mean body temperature during pre‐warming. However, intraoperative hypothermia occurred in 61% of patients in the SW group and in 49% in the FAW group. The FAW method set to 43°C could rewarm hypothermic patients. Core temperature did not differ between groups on admission to the recovery room, p =.366 (CI: −0.18–0.06). Conclusions: Statistically, the SW blanket was non‐inferior to the FAW method. Yet, hypothermia was more frequent in the SW group, requiring rescue warming as we strictly held to the NICE guideline. Trial Registration: Clinicaltrials.gov identifier: NCT03408197. [ABSTRACT FROM AUTHOR]

Background: Dispatching Emergency Medical Services to treat patients with deteriorating health in nursing homes and primary care facilities is common in Finland. We examined the cardiac arrest patients to describe this phenomenon. We had a special interest in patients for whom cardiopulmonary resuscitation was considered futile.Methods: We conducted an observational study between 1 June 2013 and 31 May 2014 in the Pirkanmaa area. We included cases in which Emergency Medical Services participated in the treatment of cardiac arrest patients in nursing homes and primary care facilities.Results: Emergency Medical Services attended to a total of 355 cardiac arrest patients, and 65 patients (18%) met the inclusion criteria. The included patients were generally older than 65 years, but otherwise heterogeneous. Nineteen patients (29%) had a valid do-not-attempt-resuscitation order, but paramedics were not informed about it in 10 (53%) of those cases. Eight (12%) of the 65 patients survived to hospital admission and 3 (5%) survived to hospital discharge with a neurologically favourable outcome. Two patients were alive 90 days after the cardiac arrest; both were younger than 70 years of age and had ventricular fibrillation as primary rhythm. There were no survivors in nursing homes.Conclusions: The do-not-attempt-resuscitation orders were often unavailable during a cardiopulmonary resuscitation attempt. Although resuscitation attempts were futile for patients in nursing homes, some patients in primary care facilities demonstrated a favourable outcome after cardiac arrest. Emergency Medical Services seem to be able to recognise potential survivors and focus resources on their treatment. [ABSTRACT FROM AUTHOR]

Discusses the association of optimal intraoperative isoflurane concentration with reduced postoperative morphine needs in morbidly obese patients. Analysis of brain waves recorded during surgery; Post-operative morphine requirements of the patients; Use of an electroencephalogram variable called spectral edge frequency.

Editorial. Discusses issues related to the administration of general anesthesia to a patient scheduled for surgery. Existing unintentional awareness; Effect of anesthetics in the central nervous system; Effect of the hypnotic component of the anesthesia on the patient; Controversy regarding the use of opioids as a substitute for hypnotics.

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. 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. 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. ROTEM-guided treatment of postpartum haemorrhage could have a plasma-sparing effect but possibly only a small reduction in total blood loss. NCT02461251. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background Entropy™ is an anaesthetic EEG monitoring method, calculating two numerical parameters: State Entropy (SE, range 0–91) and Response Entropy (RE, range 0–100). Low Entropy numbers indicate unconsciousness. SE uses the frequency range 0.8–32 Hz, representing predominantly the EEG activity. RE is calculated at 0.8–47 Hz, consisting of both EEG and facial EMG. RE–SE difference (RE−SE) can indicate EMG, reflecting nociception. We studied RE−SE and EMG in patients anaesthetized without neuromuscular blockers. Methods Thirty-one women were studied in propofol–nitrous oxide (P) or propofol–nitrous oxide–remifentanil (PR) anaesthesia. Target SE value was 40–60. RE−SE was measured before and after endotracheal intubation, and before and after the commencement of surgery. The spectral content of the signal was analysed off-line. Appearance of EMG on EEG was verified visually. Results RE, SE, and RE−SE increased during intubation in both groups. Elevated RE was followed by increased SE values in most cases. In these patients, spectral analysis of the signal revealed increased activity starting from low ( Conclusions Increased RE is followed by increased SE at nociceptive stimuli in patients not receiving neuromuscular blockers. Owing to their overlapping power spectra, the contribution of EMG and EEG cannot be accurately separated with frequency analysis in the range of 10–40 Hz. [ABSTRACT FROM AUTHOR]

Discusses the abstract of the article "Entropy in real world," by Arvi Yli-Hankala submitted at the 27th Congress of The Scandinavian Society of Anesthesiology and Intensive Care Medicine. Improvements in standard hospital care through monitoring technology.

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. [ABSTRACT FROM AUTHOR]

Background and aims Previous studies have shown that pelvic pain is common after hysterectomy. It is stated that only a minor part of that pain can be defined as persistent postsurgical pain. Our primary aim was to find out if the pelvic pain after hysterectomy may be classified as postsurgical. Secondary aims were to characterize the nature of the pain and its consequences on the health related quality of life. Methods We contacted the 56 women, who had reported having persistent pelvic pain six months after hysterectomy in a previously sent questionnaire. Sixteen women participated. Clinical examinations included gynaecological examination and clinical sensory testing. Patients also filled in quality of life (SF-36) and pain questionnaires. Results Ten out of sixteen patients still had pain at the time of examination. In nine patients, pain was regarded as persistent postsurgical pain and assessed probable neuropathic for five patients. There were declines in all scales of the SF-36 compared with the Finnish female population cohort. Conclusions In this study persistent pelvic pain after vaginal or laparoscopic hysterectomy could be defined as persistent postsurgical pain in most cases and it was neuropathic in five out of nine patients. Pain had consequences on the health related quality of life. Implications Because persistent postsurgical pain seems to be the main cause of pelvic pain after hysterectomy, the decision of surgery has to be considered carefully. The management of posthysterectomy pain should be based on the nature of pain and the possibility of neuropathic pain should be taken into account at an early postoperative stage. [ABSTRACT FROM AUTHOR]

Purpose: To find out whether the severity of acute postoperative pain differs between laparoscopic (LH) or laparoscopically assisted vaginal hysterectomy (LAVH) and vaginal hysterectomy. Methods: In a prospective, powered, non-randomized trial, the consumption of oxycodone and pain scores were evaluated in 164 women up to 20 h after VH or LH/LAVH. All hysterectomies were performed under standardized general anesthesia and the pain medication was similar in both groups. The primary endpoint was the cumulative oxycodone consumed. Main secondary endpoints were pain scores (numeric rating scale NRS), operative time and hospital stay. Results: The patients in LH/LAHV group consumed less opioid than the patients in the vaginal group during the 20 h period after surgery. The difference was significant at time point 4 and 6 h. The oxycodone consumed at time point 4 h was 19.9 (95 % CI 18.1-21.7) mg in laparoscopic group and 22.8 (20.7-25.0) mg in vaginal group ( p = 0.040) and at time point 6 h was 23.5 (21.5-25.6) mg in laparoscopic group and 27.4 (24.7-30.0) mg in vaginal group ( p = 0.026). Pain scores were lower after laparoscopic approach and the difference was significant at time point 60 min after surgery ( p = 0.026). Conclusion: In this study, LH was associated with reduced need of analgesics and lower acute postoperative pain scores than VH. [ABSTRACT FROM AUTHOR]

Background Sugammadex is designed to antagonize neuromuscular blockade ( NMB) induced by rocuronium or vecuronium. In clinical practice, we have noticed a rise in the numerical values of bispectral index ( BIS) and Entropy, two electroencephalogram ( EEG) - based depth of anesthesia monitors, during the reversal of the NMB with sugammadex. The aim of this prospective, randomized, double-blind study was to test this impression and to compare the effects of sugammadex and neostigmine on the BIS and Entropy values during the reversal of the NMB. Methods Thirty patients undergoing gynecological operations were studied. Patients were anesthetized with target-controlled infusions of propofol and remifentanil, and rocuronium was used to induce NMB. After operation, during light propofol-remifentanil anesthesia, NMB was antagonized with sugammadex or neostigmine. During the following 5 min, the numerical values of BIS, BIS electromyographic ( BIS EMG) and Entropy were recorded on a laptop computer, as well as the biosignal recorded by the Entropy strip. The Entropy biosignal was studied off-line both in time and frequency domain to see if NMB reversal causes changes in EEG. Results In some patients, administration of sugammadex or neostigmine caused a significant rise in the numerical values of BIS, BIS EMG and Entropy. This phenomenon was most likely caused by increased electromyographic ( EMG) activity. The administration of sugammadex or neostigmine appeared to have only minimal effect on EEG. Conclusion The EMG contamination of EEG causes BIS and Entropy values to rise during reversal of rocuronium-induced NMB in light propofol-remifentanil anesthesia. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background Entropy™, an anaesthetic EEG monitoring method, yields two parameters: State Entropy (SE) and Response Entropy (RE). SE reflects the hypnotic level of the patient. RE covers also the EMG-dominant part of the frequency spectrum, reflecting the upper facial EMG response to noxious stimulation. We studied the EEG, EMG, and Entropy values before and after skin incision, and the effect of rocuronium on Entropy and EMG at skin incision during sevoflurane–nitrous oxide (N2O) anaesthesia. Methods Thirty-eight patients were anaesthetized with sevoflurane–N2O or sevoflurane–N2O–rocuronium. The biosignal was stored and analysed off-line to detect EEG patterns, EMG, and artifacts. The signal, its power spectrum, SE, RE, and RE–SE values were analysed before and after skin incision. The EEG arousal was classified as β (increase in over 8 Hz activity and decrease in under 4 Hz activity with a typical β pattern) or δ (increase in under 4 Hz activity with the characteristic rhythmic δ pattern and a decrease in over 8 Hz activity). Results The EEG arousal appeared in 17 of 19 and 15 of 19 patients (NS), and the EMG arousal in 0 of 19 and 13 of 19 patients (P<0.01) with and without rocuronium, respectively. Both β (n=30) and EMG arousals increased SE and RE. The δ arousal (n=2) decreased both SE and RE. A significant increase in RE–SE values was only seen in patients without rocuronium. Conclusions During sevoflurane–N2O anaesthesia, both EEG and EMG arousals were seen. β and δ arousals had opposite effects on the Entropy values. The EMG arousal was abolished by rocuronium at the train of four level 0/4. [ABSTRACT FROM AUTHOR]

Conventional nonsteroidal anti-inflammatory drugs (NSAIDs) have a well-documented nephrotoxic action. Still, there are only few studies that have investigated the nephrotoxicity of cyclo-oxycenase-2-inhibitors during the perioperative period. Thirty patients scheduled for elective laparoscopic hysterectomy were enrolled in this prospective, randomized double-blind study. Patients were randomized into two groups: a saline-treated control group (placebo) and 80 mg parecoxib-treated group (parecoxib). The samples for the analyses of serum and urine were collected at the induction of anesthesia, two hours thereafter, two hours from the end of anesthesia, and on the first postoperative day (POD). S-crea, S-urea, S-cystatin C, S-Na, S-K, U-1mikroglobulin/U-crea, U-GST/U-crea, and U-GST/U-crea were analyzed from the samples. Urine output was measured every hour for the first five hours, and total amount of urine was measured until the first postoperative day. There were no clinical and few statistical significant differences between the two groups in the renal measurements during the study period. The urinary output was also similar in the two groups. A single dose of 80 mg of parecoxib was well tolerated by the kidneys in the short-term perioperative use in patients undergoing laparoscopic hysterectomy with ASA physiological status I-II and age under 60 years. [ABSTRACT FROM AUTHOR]

Summary: Aim: To report prospectively the outcome from prehospital cardiac arrest according to the Utstein template in the city of Tampere, Finland, with special reference to those patients in whom resuscitation was not attempted. Materials and methods: In Tampere (population 203,000), a two-tiered emergency medical service (EMS) system provides first response and basic life support (BLS), supported by advanced life support (ALS) units staffed with nurse-paramedics. We analysed all out-of-hospital cardiac arrests considered for resuscitation during a 12-month period. Results: Of 191 patients with prehospital cardiac arrest, resuscitation was not attempted in 98 patients (51%). Reasons to withhold from resuscitation were estimated futility (97 cases) and a do-not-attempt-resuscitation order (1). Sixty percent of the patients with no resuscitation had secondary signs of death, 97% had asystole as the initial cardiac rhythm and 98% had suffered an unwitnessed cardiac arrest. Resuscitation was successful in 45 of the remaining 93 patients with attempted resuscitation. Twelve patients were discharged (overall survival rate 13%), nine of them with a CPC score of 1 or 2. Fifteen patients were treated with therapeutic hypothermia. Of the bystander-witnessed cardiac arrests with VF as initial rhythm, 29% survived. Conclusions: The Tampere EMS system initiated resuscitation less frequently than reported from other EMS systems, but the reasons to withhold resuscitation seemed justified. The overall and Utstein''s ‘golden standard’ survival rates were comparable with previous reports. [Copyright &y& Elsevier]

Objective To determine how pre-eclampsia modifies maternal haemodynamics during caesarean delivery. Design Prospective study. Setting Tampere University Hospital, Finland. Population Ten pre-eclamptic parturients and ten healthy parturients with uncomplicated pregnancies scheduled for elective caesarean section under spinal anaesthesia. Methods Haemodynamic parameters were assessed by whole-body impedance cardiography noninvasively. Main outcome measures Stroke index (SI), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and mean arterial pressure (MAP) were recorded before operation, continuously during caesarean section, during the period of dissipation of anaesthesia and on the second to fifth postpartum day. Results Baseline haemodynamics in women with pre-eclampsia differed significantly from healthy women in higher SVRI and MAP and lower SI and CI. In women with pre-eclampsia, preload infusion increased both SI and HR, causing a significant rise in CI, while in healthy parturients, only HR rose. In both the groups, spinal blockade reduced SVRI but CI remained stable. At the moment of delivery, CI increased in both groups. In uncomplicated pregnancies, both SI and HR increased, but in women with pre-eclampsia, SI was not altered and the rise in CI was due to an increase in HR only. After the reversal of anaesthesia, haemodynamics in the control group returned to baseline values, whereas in women with pre-eclampsia, SI and CI fell to levels that were significantly lower than the levels observed before surgery. Conclusions In women with pre-eclampsia, inability to increase SI at the moment of delivery may suggest dysfunction of the left ventricle to adapt to volume load caused by delivery and prompts concern for the increased risk of pulmonary oedema. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

This descriptive study was designed to evaluate maternal hemodynamics and cardiovascular responses to delivery during cesarean section (CS) under spinal anesthesia. We also assessed the feasibility of a noninvasive and continuous method of measuring cardiac output, namely whole-body impedance cardiography (ICGWB), during elective CS. Because of the techniques used in previous studies, only fractionated data on maternal hemodynamics during CS are available to date.We studied 10 healthy women with normal pregnancies and two pregnant women with heart disease undergoing elective CS. Mean arterial pressure (MAP), heart rate (HR), stroke index (SI), cardiac index (CI) and systemic vascular resistance index (SVRI) were recorded continuously during CS, during the period of dissipation of anesthesia and on the second to fifth postpartum day. Analysis of variance for repeated measurements (anova) and the paired samplet-test were used in statistical analysis.The hemodynamic parameters could be registered continuously during the whole procedure. At the point of delivery, a 47% increase in CI and a 39% decrease in SVRI were recorded, while MAP remained stable. These changes occurred within 2 min of delivery of the newborn and persisted on average for 10 min.Sudden and significant hemodynamic changes take place at the moment of delivery. Intact physiological cardiovascular compensation mechanisms are needed to adapt to these challenges. Whole-body impedance cardiography may offer a useful noninvasive tool to monitor hemodynamics during cesarean section. [ABSTRACT FROM AUTHOR]

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°C and connected to the legs of the suit. The Hospital clothes group had a lower body blanket set to 38°C and a warming mattress set to 37°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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: Anesthesiologists have increasingly started to use EEG-based indexes to estimate the level and type of unconsciousness. However, the physiology and biophysics are poorly understood in anesthesiological literature. Methods: EEG was recorded from electrodes on the surface of head, including scalp, as well as DBS (deep brain stimulation) electrodes implanted deep in the brain. Mathematical modeling with a realistic head model was performed to create illustrative images of the sensitivity of electrode montages. Results: EEG pattern of anesthesia, burst-suppression, is recordable outside of scalp area as well in the depth of brain because the EEG current loops produce recordable voltage gradients in the whole head. The typical electrodes used in anesthesia monitoring are most sensitive to basal surface of frontal lobes as well as frontal and mesial parts of temporal lobes. Conclusions: EEG currents create closed-loops, which flow from the surface of the cortex and then return to the inside of the hemispheres. In the case of widespread synchronous activity like physiological sleep or anesthesia, the currents recorded with surface and depth electrodes return through the base of brain and skull. [ABSTRACT FROM AUTHOR]

Objectives: 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.Methods: 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.Results: 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.Conclusions: 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. [ABSTRACT FROM AUTHOR]

Background: Our aim was to evaluate the impact of futile resuscitation attempts to the outcome calculations of attempted resuscitation in out-of-hospital cardiac arrest (OHCA). Defined as partial resuscitations, we focused on a subgroup of patients in whom cardiopulmonary resuscitation (CPR) was initiated, but further efforts were soon abandoned due to evidence of futility.Methods: We conducted this study using the Utstein template during a 12-month study period. We compared the event characteristics between full and partial resuscitation attempts and determined the incidence, survival and neurological outcome.Results: Emergency Medical Services (EMS) attended a total of 314 OHCA cases. In 34 cases, resuscitation was not attempted due to futility. Seventy-four cases were partial resuscitation attempts where resuscitation was soon discontinued due to dismal prognostic factors. Partial attempts were associated with an unwitnessed OHCA, prolonged downtime, end-stage malignant disease, multiple trauma, asystole or pulseless electrical activity as the initial rhythm, and a first responding unit being the first unit on the scene (P < 0.05, respectively). The calculation of survival to hospital discharge rate was 14% and increased 5% when partial resuscitation attempts were excluded from the analysis. Seventy-four percentage had a Cerebral Performance Category 1-2 at hospital discharge. Shockable initial rhythm, public location and bystander CPR had a positive impact on survival.Conclusions: Resuscitative efforts were considered futile in 11% of cases and resuscitation was discontinued due to evidence of futility in additional 24% cases based on additional information. Terminating resuscitation should be identified as a separate subgroup of OHCA cases to better reflect the outcome. [ABSTRACT FROM AUTHOR]

Background: Unintentional perioperative hypothermia causes serious adverse effects to surgical patients. Thermal suit (T-Balance® ) is an option for passive warming perioperatively. We hypothesized that the thermal suit will not maintain normothermia more efficiently than conventional cotton clothes when also other preventive procedures against unintentional hypothermia are used.Methods: One hundred patients were recruited to this prospective, randomized trial. They were allocated to the Thermal Suit group or a Control group wearing conventional hospital cotton clothes. All patients received our institution's standard treatment against unintentional hypothermia including a warming mattress, a forced-air upper body warming blanket and a warming device for intravenous fluids. Eardrum temperature was measured pre-operatively. In the operating room and post-anaesthesia care unit temperatures were measured from four locations: oesophagus, left axilla, dorsal surface of the left middle finger and dorsum of the left foot. The primary outcome measure was temperature change during robotic-assisted laparoscopic radical prostatectomy.Results: The temperatures of 96 patients were analysed. There was no difference in mean core temperatures, axillary temperatures or skin temperatures on the finger between the groups. Only foot dorsum temperatures were significantly lower in the Thermal Suit group. Intraoperative temperature changes were similar in both groups. In the post-anaesthesia care unit temperature changes were minimal and they did not differ between the groups.Conclusion: Provided that standard preventive procedures in maintaining normothermia are effective the thermal suit does not provide any additional benefit over conventional cotton clothes during robotic-assisted laparoscopic radical prostatectomy. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: 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.Methods: Thirty children aged <2 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.Results: 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.Conclusions: 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.Clinical Trial Registration: NCT02045810. [ABSTRACT FROM AUTHOR]

Background: Concomitantly recorded Bispectral Index® (BIS) and Entropy™values sometimes show discordant trends during general anaesthesia. Previously, no attempt had been made to discover which EEG characteristics cause discrepancies between BIS and Entropy. We compared BIS and Entropy values, and analysed the changes in the raw EEG signal during surgical anaesthesia with sevoflurane. Methods: In this prospective, open-label study, 65 patients receiving general anaesthesia with sevoflurane were enrolled. BIS, Entropy and multichannel digital EEG were recorded. Concurrent BIS and State Entropy (SE) values were selected. Whenever BIS and SE values showed ⩾10-unit disagreement for ⩾60 s, the raw EEG signal was analysed both in time and frequency domain. Results: A ⩾10-unit disagreement ⩾60 s was detected 428 times in 51 patients. These 428 episodes accounted for 5158 (11%) out of 45 918 analysed index pairs. During EEG burst suppression, SE was higher than BIS in 35 out of 49 episodes. During delta-theta dominance, BIS was higher than SE in 141 out of 157 episodes. During alpha or beta activity, SE was higher than BIS in all 49 episodes. During electrocautery, both BIS and SE changed, sometimes in the opposite direction, but returned to baseline values after electrocautery. Electromyography caused index disagreement four times (BIS > SE). Conclusions: Certain specific EEG patterns, and artifacts, are associated with discrepancies between BIS and SE. Time frequency domain analyses of the original EEG improve the interpretation of studies involving BIS, Entropy and other EEG-based indices. [ABSTRACT FROM AUTHOR]

Background Medical emergency team ( MET) activation criteria serve as a predictor of serious adverse events on hospital wards and in the emergency department ( ED). We aimed to determine whether in-hospital MET activation criteria would be useful in identifying patients at risk in pre-hospital care. Methods The data were collected retrospectively from 610 adult patients treated by physician-staffed helicopter emergency medical services. Pre-hospital vital signs were compared with MET activation criteria and scored accordingly to receive a simplified pre-hospital ' MET' score. The primary outcome measure was hospital mortality. The secondary outcome measures were admission to intensive care unit and the length of ED stay, intensive care unit ( ICU) stay and hospital stay. The simplified pre-hospital ' MET' score was also compared with Emergency Severity Index ( ESI) used as a triage tool in ED. Results Higher simplified pre-hospital ' MET' scores were associated with hospital mortality ( P < 0.001), the need for ICU treatment ( P < 0.001) and a more urgent ESI class in the ED ( P < 0.001). Higher simplified pre-hospital ' MET' scores were associated with shorter stay in the ED ( P < 0.001), longer stay in the ICU ( P < 0.001) and longer hospital stay ( P < 0.001). A simplified pre-hospital ' MET' score was an independent predictor for hospital mortality (odds ratio 2.42, confidence interval 1.84 3.18, P < 0.001), regardless of age or patient's previous overall physical health classified by American Society of Anesthesiologists physical status classification system. Conclusion A simplified pre-hospital ' MET' score is a predictor for patient outcome and could serve as a risk assessment tool for the health care provider on-scene. [ABSTRACT FROM AUTHOR]

Background The aim of physician staffed emergency medical services ( EMS) is to supplement other EMS units in the care of prehospital patients. The need for advanced airway management in critical prehospital patients can be considered as one indicator of the severity of the patient's condition. Our primary aim was to study the long-term outcome of critically ill patients (excluding cardiac arrest) who were intubated by EMS physicians in the prehospital setting. Methods Data of 845 patients, whose airways were secured by the EMS physicians during a 5-year (2007-2011) period, were retrospectively evaluated. After exclusions, the outcome of 483 patients (8.9% of all patients treated by EMS) was studied. Evaluation was based on hospital patient records 1 year after the incident. For assessment of neurological outcome, a modified Glasgow Outcome Score ( GOS) was used. Time and cause of death were recorded. Results 55.3% of the study patients had a good neurological recovery ( GOS 4-5) with independent life 1 year after the event. The overall 1-year mortality ( GOS 1) was 35.0%. Poor neurological outcome ( GOS 2-3) was found in 9.7% of the patients. Patients with intoxication or convulsions survived best, while those with suspected intracranial pathology had the worst prognosis. Of all survivors, 85% recovered well. Conclusion The majority of the study patients had a favourable neurological recovery with independent life at 1 year after the incident. More than 80% of all deaths occurred within 30 days of the incident. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]