Surgery cancelation on the day of surgery in same-day admission in a Finnish hospital.

BACKGROUND AND AIMS: Surgery cancelations cause inappropriate use of hospital resources and additional financial and psychological stress to patients. Cancelation rates have been described to be even more than 10% of scheduled cases. Preoperative anesthesia evaluation clinics have been initialized to decrease cancelation rates. At Hyvinkää hospital, 95% of elective surgical patients are admitted on the morning of operation, and only 25% of these patients visit preoperative anesthesia evaluation clinic prior to surgery. Cancelation rate in Finnish hospitals has not been described. MATERIAL AND METHODS: We studied retrospectively 12,205 scheduled elective same-day admission surgical cases at Helsinki and Uusimaa Hospital District, Hyvinkää hospital for a period of 2 years. Obstetric cases, emergency cases, and a few inpatient cases were excluded. A case was considered as canceled if surgery was canceled after the finalization of operation room schedule for the next day. Cancelation rates among different specialties and reasons for cancelation were analyzed. RESULTS: A total of 12,205 surgeries were scheduled during the study period, and 551 (4.5%) of these were canceled. The highest cancelation rate was in hand surgery, with 8.2% of scheduled cases, followed by orthopedic surgery with 5.4%, and pediatric surgery with 5.1% cancelation rate. Endocrinology had no cancelations, and breast, urology, and vein surgery also had less than 2% of canceled cases. Patient-related issues caused 72.4% of cancelations, and operation no longer being necessary caused 26% of all cancelations. CONCLUSIONS: Day of surgery cancelation rate was low in same-day admission, although it varied between specialties. Specialties having explicit surgery indications had fewer cancelations than specialties having surgery indications based on more subjective diagnostic. Process improvements need to be considered continuously to further decrease cancelation rate.

Pandemic influenza: human rights, ethics and duty to treat.

The 2009 influenza A/H1N1 pandemic seems to be only moderately severe. In the future, a pandemic influenza with high lethality, such as the Spanish influenza in 1918-1919 or even worse, may emerge. In this kind of scenario, lethality rates ranging roughly from 2% to 30% have been proposed. Legal and ethical issues should be discussed before the incident. This article aims to highlight the legal, ethical and professional aspects that might be relevant to anaesthesiologists in the case of a high-lethality infectious disease such as a severe pandemic influenza. The epidemiology, the role of anaesthesiologists and possible threats to the profession and colleagueship within medical specialties relevant to anaesthesiologists are reviewed. During historical plague epidemics, some doctors have behaved like 'deserters'. However, during the Spanish influenza, physicians remained at their jobs, although many perished. In surveys, more than half of the health-care workers have reported their willingness to work in the case of severe pandemics. Physicians have the same human rights as all citizens: they have to be effectively protected against infectious disease. However, they have a duty to treat. Fair and responsible colleagueship among the diverse medical specialties should be promoted. Until disaster threatens humanity, volunteering to work during a pandemic might be the best way to ensure that physicians and other health-care workers stay at their workplace. Broad discussion in society is needed.

Increase in the use of rebreathing gas flow systems and in the utilization of low fresh gas flows in Finnish anaesthetic practice from 1995 to 2002.

BACKGROUND: The use of rebreathing systems together with low fresh gas flows saves anaesthetic gases, reduces the costs of anaesthesia, causes less environmental and ergonomic adverse effects, i.e. less air contamination in the operating room, and has favourable physiological effects. We assessed whether the use of non-rebreathing vs. rebreathing gas flow systems and high vs. lower fresh gas flows has changed during recent years. METHODS: The use of rebreathing and non-rebreathing systems and the utilization of fresh gas flows were evaluated by sending a questionnaire to the heads of anaesthesia departments at all public health care hospitals in Finland in 1996 and 2003. The data was gathered from the previous years 1995 and 2002, respectively. RESULTS: The use of rebreathing systems increased from 62% to 83% of all instances of general anaesthesia (P < 0.001). In rebreathing gas flow systems, there was a significant shift from high fresh gas flows (3 l min(-1) and more) towards lower fresh gas flows (between 1 to 2 l min(-1) and even below 1 l min(-1)) (P < 0.001). CONCLUSIONS: The benefits of low fresh gas flows have now been achieved in most instances of rebreathing system anaesthesia, which was not the case in 1995.

The work, duties and prestige of Finnish anesthesiologists: patients' view.

BACKGROUND: Patients' awareness of the medical qualifications and duties of anesthesiologists outside the operating theatres may be limited. How are anesthesiologists ranked with regard to prestige and academic qualifications among other hospital employees? METHODS: One hundred and sixty operative patients were interviewed in one tertiary care center and another secondary care center in Finland. RESULTS: Nearly all (90%) of the patients knew that anesthesiologists are medical doctors and that they work in operation theatres (87%). Many patients thought that anesthesiologists do not work in pain clinics (41%), obstetric departments (36%) and in the departments of radiology (68%), in ambulances (58%) and in research work (46%). Anesthesiologists were ranked second after surgeons with regard to prestige among health service professionals. CONCLUSIONS: Patients knew the medical qualification of anesthesiologists very well. The work of anesthesiologists was highly appreciated, but the duties outside the operation theatres were poorly known.

Prolonged impairment in activities of daily living due to postdural puncture headache after diagnostic lumbar puncture.

To assess the incidence of postdural puncture headache and its effects on patients' activities of daily living, we interviewed 325 adult patients subjected to a diagnostic lumbar puncture during a 1-year period. Two hundred and eighteen (67%) of the subjects replied to the questionnaire; 41 (19%) of these were diagnosed as having suffered a postdural puncture headache. Impairment of the activities of daily living persisting for 1 week or more was experienced by 16 (7%) of the subjects.

Enalaprilat decreases plasma endothelin and atrial natriuretic peptide levels and preload in patients with left ventricular dysfunction after cardiac surgery.

OBJECTIVE: To study the acute effects of angiotensin-converting enzyme inhibition by intravenous enalaprilat infusion in patients with left ventricular dysfunction after cardiac surgery. DESIGN: Prospective, consecutive sample, before-after trial. SETTING: Surgical intensive care unit in a tertiary care university hospital. PARTICIPANTS: Eight patients with left ventricular dysfunction after cardiac surgery. Patients were defined as having left ventricular dysfunction if the pulmonary capillary wedge pressure persisted above 18 mmHg in spite of conventional vasoactive medication (inotropic or vasodilating and diuretic drugs) and intermittent mandatory ventilation during the first postoperative week. INTERVENTIONS: Enalaprilat was infused initially at 1 mg/ hour. The rate was doubled every 30 minutes until pulmonary capillary wedge pressure decreased at least 20% or until a maximum total dose of 10 mg was achieved. MEASUREMENTS AND RESULTS: Central hemodynamics, systemic oxygenation, and hormonal regulation of circulation (plasma renin activity, plasma endothelin, atrial natriuretic peptide, norepinephrine, epinephrine, and vasopressin concentrations, serum angiotensin-converting enzyme activity, and serum levels of aldosterone) were assessed at baseline before enalaprilat infusion, and repeatedly over 2 hours after the infusion. Enalaprilat infusion (median dose, 2.0 mg; infusion time, 48 minutes) caused a significant decrease in pulmonary capillary wedge pressure (p = 0.004), lasting until the end of the 2 hours' follow-up. This coincided with inhibition of serum angiotensin-converting enzyme activity (p < 0.001), an increase in plasma renin activity (p = 0.022), and decreases in plasma endothelin (p = 0.035), atrial natriuretic peptide (p = 0.005), and serum aldosterone (p = 0.001) concentrations. Cardiac output, venous admixture, and oxygen delivery and consumption remained unchanged. CONCLUSIONS: Adding enalaprilat to conventional therapy makes it possible to unload the left ventricle and to relieve overt neurohormonal activation temporarily while maintaining cardiac function and systemic oxygenation.

Enalaprilat controls postoperative hypertension while maintaining cardiac function and systemic oxygenation after neurosurgery.

OBJECTIVE: The efficacy of intravenous enalaprilat in lowering postoperative hypertension. DESIGN: Prospective, randomized, controlled, single blind trial. SETTING: Surgical ICT in a university hospital (tertiary care center). PATIENTS: 18 neurosurgical patients subjected to the extirpation of a supratentorial intracerebral tumour were studied after detection of postoperative hypertension. This was defined as a constant elevation of systolic arterial pressure over 160 mmHg or diastolic arterial pressure over 95 mmHg. INTERVENTIONS: Enalaprilat 0.015 mg kg-1 was injected within 5 min to 9 patients. MEASUREMENTS AND RESULTS: Central haemodynamics and systemic oxygenation were assessed at baseline before enalaprilat injection, and repeatedly during four hours after the injection. The statistical analysis was performed with analysis of variance for repeated measurements. As compared to control patients, the blood pressure lowering effect of enalaprilat became evident within 15 min and lasted for over four hours (p = 0.008). It was mainly due to the reduced systemic vascular resistance. Enalaprilat also induced a small decline in myocardial perfusion pressure. Cardiac performance, preload, heart rate and systemic oxygenation were not affected by enalaprilat. CONCLUSIONS: We found intravenous enalaprilat effective and safe in lowering postoperative hypertension following neurosurgery as assessed by it's effects on central haemodynamics and systemic oxygenation.

Angio-oedema induced by enalapril.

We report the case of a patient who, 9 months after initiation of enalapril and hydrochlorothiazide combination treatment for hypertension, developed angio-oedema with near fatal outcome. Our patient was successfully intubated using a flexible bronchofiberoscope. This case demonstrates that patients given an angiotensin-converting enzyme (ACE) inhibitor may develop serious facial and laryngeal swelling even several months after the initiation of treatment. The occurrence of even mild swelling should lead to prompt cessation of the drug. Patients with incipient ACE inhibitor-related angio-oedema should, without any delay, be referred to hospital for emergency treatment.

Enalaprilat in acute intractable heart failure after myocardial infarction: a prospective, consecutive sample, before-after trial.

OBJECTIVE: To evaluate the acute effects of intravenous enalaprilat infusion in critically ill patients with intractable heart failure after acute myocardial infarction. DESIGN: Prospective, consecutive sample, before-after trial. SETTING: Medical intensive care unit in a university hospital. PATIENTS: Eight consecutive patients with intractable acute heart failure after acute myocardial infarction. All study patients continued receiving inotropic, vasodilating, and diuretic medication at a constant rate. Six patients received steady intermittent mandatory ventilation and two patients were on a continuous positive airway pressure mask during the investigation, all with constant positive end-expiratory pressure. Heart failure was defined as intractable if the pulmonary artery occlusion pressure remained > 20 mm Hg despite this conventional therapy. INTERVENTIONS: Enalaprilat was infused at a rate of 1 mg/hr until the pulmonary artery occlusion pressure decreased by > or = 20%. MEASUREMENTS AND MAIN RESULTS: Central hemodynamics, oxygenation, and hormonal regulation (plasma renin activity, plasma norepinephrine, epinephrine, endothelin, atrial natriuretic peptide, and vasopressin concentrations, serum angiotensin-converting enzyme activity, and serum concentrations of aldosterone) were assessed at baseline before enalaprilat infusion, and repeatedly during 2 hrs after the infusion. The statistical analysis was performed with analysis of variance for repeated measurements. Enalaprilat infusion (median dose 0.3 mg and infusion time 21 mins) caused significant but short-lasting decreases in pulmonary artery occlusion pressure (p = .007), mean arterial pressure (p = .003), mean pulmonary arterial pressure, and rate pressure product. These findings coincided with inhibition of serum angiotensin-converting enzyme activity, an increase in plasma renin activity, and a decrease in plasma endothelin concentrations (p = .041). Enalaprilat had no significant effects on the other hormones studied. Cardiac output and stroke volume index, venous admixture, oxygen extraction ratio, and mixed venous and arterial oxygen saturations remained unchanged. CONCLUSIONS: Adding enalaprilat to conventional therapy makes it possible to transiently relieve pulmonary congestion while maintaining cardiac function and systemic oxygenation. The decrease in plasma endothelin concentrations may have further clinical implications, because endothelin is known to have potent vasoconstricting effects on the coronary circulation and it may also contribute to the extension of myocardial infarction. Whether these observed benefits can be maintained with repeated bolus injections or with continuous infusion of enalaprilat, remains to be settled.

Haemodynamic effects of enalaprilat and preload in acute severe heart failure complicating myocardial infarction.

In this study, the acute haemodynamic effects of angiotensin converting enzyme (ACE) inhibition with intravenous enalaprilat alone or in combination with preload restoration were determined in patients with severe heart failure complicating acute myocardial infarction. Ten patients with raised pulmonary arterial wedge pressure (PAWP > or = 18 mmHg) were first studied during constant conventional vasodilation with diuretic and inotropic medication, by monitoring central haemodynamics and arterial blood gases. The same variables were measured before enalaprilat infusion, after preload reduction with enalaprilat (1 mg.h-1, rate doubled every 30 min until PAWP decreased > or = 25% or up to total cumulative dose of 10 mg) and after preload restoration with fluid loading (4% albumin given 15 ml.min-1 to restore PAWP to baseline) during continuous low dose enalaprilat infusion. Enalaprilat alone (median dose 0.9 mg) reduced significantly the PAWP (from 25 to 17 mmHg; P = 0.004), the mean arterial pressure (from 87 to 83 mmHg; P = 0.008), the mean pulmonary arterial pressure and the right atrial pressure. The cardiac index, stroke volume index and systemic vascular resistance index remained unchanged. Preload restoration during continuous enalaprilat infusion (median dose of 4% albumin 230 ml, and enalaprilat 0.2 mg) did not further enhance left ventricular function; rather, there was a nearly significant decrease in myocardial perfusion pressure. Arterial oxygenation remained unchanged throughout the study. In conclusion, adding intravenous enalaprilat to conventional therapy makes it possible to relieve pulmonary congestion while maintaining the cardiac function and arterial oxygenation. Preload restoration during continuous ACE inhibition offers no further advantages, and may have adverse effects, since the myocardial perfusion pressure may fall.

Enalapril premedication attenuates the blood pressure response to tracheal intubation and stabilizes postoperative blood pressure after controlled hypotension with sodium nitroprusside in neurovascular patients.

Oral premedication with enalapril, 0.1 mg/kg was compared with placebo in 22 patients subjected to craniotomy and ligation of an intracranial aneurysm or extirpation of an arteriovenous malformation. Balanced hypotensive anesthesia was used with sodium nitroprusside (SNP) as the main hypotensive agent. The hypertensive response to laryngoscopy and tracheal intubation was significantly attenuated by enalapril (p = 0.020). The mean blood pressure was lower and more stable in the intensive care unit after enalapril than after placebo (p = 0.044). The median SNP dose rate tended to be lower in the enalapril-pretreated patients [0.6 (range of 0-3.5) micrograms/kg/min] compared to the placebo group [1.4 (0.4-5.8) micrograms/kg/min] (p = 0.12). Concentrations of plasma catecholamines, vasopressin, and endothelin as well as serum osmolality, arterial blood gases, and plasma electrolytes and level of consciousness were repeatedly measured. Enalapril had no significant effects on these variables. Plasma renin activity was increased and serum angiotensin converting enzyme (ACE) activity was reduced in the expected manner by enalapril. We found premedication with an ACE inhibitor favorable for hypotensive anesthesia in neurovascular patients as assessed by the circulatory responses.