Self-warming blanket versus forced-air warming blanket during total knee arthroplasty under spinal anaesthesia: A randomised non-inferiority trial.

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.

Thromboelastometry-guided treatment algorithm in postpartum haemorrhage: a randomised, controlled pilot trial.

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.

Regional anaesthesia in patients on antithrombotic drugs - a joint ESAIC/ESRA guideline: Endorsement by the 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 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.

Advising and limiting medical treatment during phone consultation: a prospective multicentre study in HEMS settings.

BACKGROUND: We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT). METHODS: A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period. RESULTS: Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or 'not eligible for intensive care' (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician. CONCLUSION: Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care.

Therapeutics and COVID-19-A living WHO guideline: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

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.

Transfusion strategies in bleeding critically ill adults: A clinical practice guideline from the European Society of Intensive Care Medicine: Endorsement by the 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 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.

Surviving sepsis campaign: International guidelines for management of sepsis and septic shock in adults 2021 - endorsement by the 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.

Comparison of zero heat flux and double sensor thermometers during spinal anaesthesia: a prospective observational study.

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.

Clinical practice guideline on the management of septic shock and sepsis-associated organ dysfunction in children: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

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.

Clinical practice guideline on spinal stabilisation of adult trauma patients: Endorsement by the 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 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.

Spurious electroencephalographic activity due to pulsation artifact in the depth of anesthesia monitor.

BACKGROUND: The depth of anesthesia (DOA) is estimated based on the anesthesia-induced electroencephalogram (EEG) changes. However, the surgical environment, as well as the patient him/herself, generates electrical interferences that cause EEG waveform distortion. CASE PRESENTATION: A 52-year-old patient required general anesthesia due to the right femur necrotizing fasciitis. He had no history of epilepsy or head injury. His cardiovascular status was stable without arrhythmia under propofol and remifentanil anesthesia. The DOA was evaluated with Root® with SedLine® Brain Function Monitoring (Masimo Inc, Irvine, CA). The EEG showed a rhythmic, heart rate time-locked pulsation artifact, which diminished after electrode repositioning. Offline analysis revealed that the pulse wave-like interference in EEG was observed at the heart rate frequency. CONCLUSIONS: We experienced an anesthesia case that involves a pulsation artifact generated by the superficial temporal artery contaminating the EEG signal. Numerous clinical conditions, including pulsation artifact, disturb anesthesia EEG.

Clinical practice guideline on gastrointestinal bleeding prophylaxis for critically ill patients: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

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.

Comparison of adequacy of anaesthesia monitoring with standard clinical practice monitoring during routine general anaesthesia: An international, multicentre, single-blinded randomised controlled trial.

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.

Thermal suit connected to a forced-air warming unit for preventing intraoperative hypothermia: A randomised controlled trial.

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.

Limiting treatment in pre-hospital care: A prospective, observational multicentre study.

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.

Limitation of treatment in prehospital care - the experiences of helicopter emergency medical service physicians in a nationwide multicentre survey.

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.

Oral versus patient-controlled intravenous administration of oxycodone for pain relief after cesarean section.

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.

Clinical practice guideline on prevention of rhabdomyolysis induced acute kidney injury: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

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 guideline on atraumatic (pencil-point) vs conventional needles for lumbar puncture: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

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.

Cortical Excitability and Activation of TrkB Signaling During Rebound Slow Oscillations Are Critical for Rapid Antidepressant Responses.

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 GSK3ß (glycogen synthase kinase 3ß) 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-GSK3ß 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 GSK3ß signaling during homeostatic emergence of slow oscillations are critical components for rapid antidepressant responses.