Neurofilament light compared to neuron-specific enolase as a predictor of unfavourable outcome after out-of-hospital cardiac arrest.

AIM: We compared the prognostic abilities of neurofilament light (NfL) and neuron-specific enolase (NSE) in patients resuscitated from out-of-hospital cardiac arrest (OHCA) of various aetiologies. METHODS: We analysed frozen blood samples obtained at 24 and 48 hours from OHCA patients treated in 21 Finnish intensive care units in 2010 and 2011. We defined unfavourable outcome as Cerebral Performance Category (CPC) 3-5 at 12 months after OHCA. We evaluated the prognostic ability of the biomarkers by calculating the area under the receiver operating characteristic curves (AUROCs [95% confidence intervals]) and compared these with a bootstrap method. RESULTS: Out of 248 adult patients, 12-month outcome was unfavourable in 120 (48.4%). The median (interquartile range) NfL concentrations for patients with unfavourable and those with favourable outcome, respectively, were 689 (146-1804) pg/mL vs. 31 (17-61) pg/mL at 24 h and 1162 (147-4360) pg/mL vs. 36 (21-87) pg/mL at 48 h, p < 0.001 for both. The corresponding NSE concentrations were 13.3 (7.2-27.3) µg/L vs. 8.5 (5.8-13.2) µg/L at 24 h and 20.4 (8.1-56.6) µg/L vs. 8.2 (5.9-12.1) µg/L at 48 h, p < 0.001 for both. The AUROCs to predict an unfavourable outcome were 0.90 (0.86-0.94) for NfL vs. 0.65 (0.58-0.72) for NSE at 24 h, p < 0.001 and 0.88 (0.83-0.93) for NfL and 0.73 (0.66-0.81) for NSE at 48 h, p < 0.001. CONCLUSION: Compared to NSE, NfL demonstrated superior accuracy in predicting long-term unfavourable outcome after OHCA.

Scandinavian SSAI clinical practice guideline on pre-hospital airway management.

BACKGROUND: The Scandinavian society of anaesthesiology and intensive care medicine task force on pre-hospital airway management was asked to formulate recommendations following standards for trustworthy clinical practice guidelines. METHODS: The literature was systematically reviewed and the grading of recommendations assessment, development and evaluation (GRADE) system was applied to move from evidence to recommendations. RESULTS: We recommend that all emergency medical service (EMS) providers consider to: apply basic airway manoeuvres and airway adjuncts (good practice recommendation); turn unconscious non-trauma patients into the recovery position when advanced airway management is unavailable (good practice recommendation); turn unconscious trauma patients to the lateral trauma position while maintaining spinal alignment when advanced airway management is unavailable [strong recommendation, low quality of evidence (QoE)]. We suggest that intermediately trained providers use a supraglottic airway device (SAD) or basic airway manoeuvres on patients in cardiac arrest (weak recommendation, low QoE). We recommend that advanced trained providers consider using an SAD in selected indications or as a rescue device after failed endotracheal intubation (ETI) (good practice recommendation). We recommend that ETI should only be performed by advanced trained providers (strong recommendation, low QoE). We suggest that videolaryngoscopy is considered for ETI when direct laryngoscopy fails or is expected to be difficult (weak recommendation, low QoE). We suggest that advanced trained providers apply cricothyroidotomy in 'cannot intubate, cannot ventilate' situations (weak recommendation, low QoE). CONCLUSION: This guideline for pre-hospital airway management includes a combination of techniques applied in a stepwise fashion appropriate to patient clinical status and provider training.

Biogas production and methanogenic archaeal community in mesophilic and thermophilic anaerobic co-digestion processes.

Over 258 Mt of solid waste are generated annually in Europe, a large fraction of which is biowaste. Sewage sludge is another major waste fraction. In this study, biowaste and sewage sludge were co-digested in an anaerobic digestion reactor (30% and 70% of total wet weight, respectively). The purpose was to investigate the biogas production and methanogenic archaeal community composition in the anaerobic digestion reactor under meso- (35-37 °C) and thermophilic (55-57 °C) processes and an increasing organic loading rate (OLR, 1-10 kg VS m(-3) d(-1)), and also to find a feasible compromise between waste treatment capacity and biogas production without causing process instability. In summary, more biogas was produced with all OLRs by the thermophilic process. Both processes showed a limited diversity of the methanogenic archaeal community which was dominated by Methanobacteriales and Methanosarcinales (e.g. Methanosarcina) in both meso- and thermophilic processes. Methanothermobacter was detected as an additional dominant genus in the thermophilic process. In addition to operating temperatures, the OLRs, the acetate concentration, and the presence of key substrates like propionate also affected the methanogenic archaeal community composition. A bacterial cell count 6.25 times higher than archaeal cell count was observed throughout the thermophilic process, while the cell count ratio varied between 0.2 and 8.5 in the mesophilic process. This suggests that the thermophilic process is more stable, but also that the relative abundance between bacteria and archaea can vary without seriously affecting biogas production.

Pre-hospital critical care by anaesthesiologist-staffed pre-hospital services in Scandinavia: a prospective population-based study.

BACKGROUND: All Scandinavian countries provide anaesthesiologist-staffed pre-hospital services. Little is known of the incidence of critical illness or injury attended by these services. We aimed to investigate anaesthesiologist-staffed pre-hospital services in Scandinavia with special emphasis on incidence and severity. METHODS: This population-based, prospective study recorded activity in 16 anaesthesiologist-staffed pre-hospital services in Denmark, Finland, Norway and Sweden serving half of the Scandinavian population. We calculated population incidence of medical conditions, and the proportion of patients with severely deranged vital signs and/or receiving advanced therapy. RESULTS: Four thousand two hundred thirty-six alarm calls were recorded during 4 weeks. Two thousand two hundred fity-six alarms resulted in a patient encounter. The population incidence varied from 74.9 missions per 10,000 person-years (Denmark), followed by Finland with 14.6, Norway with 11, and Sweden with 5. Medical aetiology was most frequent (14.9 missions per 10,000 person-years, 95% CI: 14.2-15.8). Trauma was second (5.6 missions per 10,000 person-years, 95%CI: 5.12-6.09). Twenty-three per cent of patients had severely deranged vital functions, and advanced emergency medical procedures were performed in every four to twelve encounters (Denmark 8%, Sweden 15%, Norway 23%, and Finland 25%). The probability that the patient was physiologically deranged, received advanced medication, or procedure was 35%. Critical illness or injury occured at a rate of 25-30 per 10,000 person-years. CONCLUSIONS: The incidence of pre-hospital anaesthesiologist patient encounters in Scandinavia varies. Medical aetiology is most frequent. Almost one-quarter of patients presents with deranged vital functions requiring emergency measures. The Scandinavian pre-hospital population incidence of critical illness and injury is 25-30 per 10,000 person-years.

Feasibility of a laryngeal tube for airway management during cardiac arrest by first responders.

Airway management is of major importance in prehospital emergency care. Bag-valve mask (BVM) ventilation and endotracheal intubation (ETI) have been shown to be difficult, especially when caregivers are inexperienced. Alternative methods have been studied, and supraglottic devices have been shown to provide reasonable ease of placement and effective ventilation in manikin studies and anaesthetised patients. First responders (FR) are employed by many emergency medical services (EMS) to shorten initiation of emergency care, and they are trained to provide basic CPR including BVM and use of automated external defibrillators (AED) in case of out-of-hospital cardiac arrest (OCHA). The aim of this research was to study the feasibility of manikin-trained FRs using a laryngeal tube (LT) as a primary airway method during cardiac arrest. We trained 300 FRs to use a LT during OHCA. The FRs used a LT in 64 OHCA cases. The LT was correctly placed on the first attempt in 46/64 cases (71.9%) and on the second attempt in 13/64 cases (20.3%). Insertion was reported as being easy in 55/64 cases (85.9%). Median insertion time was 23.1s, with a range of 3-240s. We found that after manikin training, the FRs inserted the LT and performed adequate ventilation with a reasonable success rate and insertion time.

Mortality in out-of-hospital cardiac arrest patients has decreased in the era of therapeutic hypothermia.

BACKGROUND: Mild therapeutic hypothermia (TH) improves survival after out-of-hospital cardiac arrest (OHCA). This treatment was implemented in most Finnish intensive care units (ICUs) in 2003. The aim of this study was to find out whether hospital mortality of ICU-treated OHCA patients has changed in the era of TH. METHODS: This was a retrospective study of data collected prospectively into the database of the Finnish Intensive Care Consortium during the years 2000-2008. The study population consisted of 3958 patients for whom cardiac arrest was registered as the reason for ICU admission and who were transferred to the ICU from the emergency department. We divided the patients into those treated in the pre-hypothermia era (2000-2002) and those treated in the hypothermia era (2003-2008). We investigated whether the treatment period had any impact on hospital mortality. RESULTS: There were no differences between the periods regarding the age or initial Glasgow Coma Scores of the patients. Mean severity of illness was higher in the latter period. Despite this, mortality decreased: the hospital mortality rate was 57.9% in 2000-2002 and 51.1% in 2003-2008, P < 0.001. In a multivariate logistic regression analysis, treatment in 2003-2008 was associated with a reduced risk of in-hospital death (adjusted odds ratio 0.54, 95% confidence interval 0.45-0.64 and P < 0.001). Survival improved markedly between the years 2002 and 2003. This improvement has persisted, but there has been no further improvement. CONCLUSION: Concurrently with the implementation of TH, hospital mortality of OHCA patients treated in Finnish ICUs decreased.

Biogasification of biowaste and sewage sludge--measurement of biogas quality.

Biogas quality, the presence of some trace components (siloxanes, sulfur compounds, volatile organic compounds, VOCs) in biogas, is in a decisive role when determining the biogas utilization and the purification requirements and equipments. In the present work, the effects of process changes related to reactor loading variations on the concentrations of selected trace compounds in biogas were studied. Source separated biowaste and sewage sludge were co-digested in a mesophilic pilot reactor (200 L) for four months during which the organic load was stepwise increased. The results showed that the process worked steadily up to the load of 8 kgVS m(-3)d(-1). Also the community composition of methanogenic archae stayed largely unaffected by the load increase, and was at all stages typical for a mesophilic biogasification process. Gaseous concentrations of siloxanes, hydrogen sulfide and most VOCs remained at a constant low level, showing no sensitivity to variations in the load and related process changes. However, the total siloxane concentration in the biogas was dependent on feed quality, and the detected concentrations require removal prior to use in turbines or fuel cells. Otherwise, after the removal of siloxanes, the biogas studied in this work is well applicable in various electricity production options, like in gas engines, turbines, microturbines and fuel cells.

Vasopressor agents after experimental brain death: effects of dopamine and vasopressin on vitality of the small gut.

BACKGROUND: Both congenital and acquired short bowel syndrome frequently leads to the necessity for long-term parenteral nutrition, which in turn may lead to any of several complications or death. Transplantation of the small bowel from brain-dead organ donors has been successfully performed over the last years. However, systemic blood pressure and blood perfusion to the splanchnic area decrease rapidly after brain death, which comprises the vitality of the small bowel. OBJECTIVE: To evaluate the differences between dopamine and low-dose vasopressin on perfusion and vitality of the small bowel after brain death. METHODS: Fifteen pigs were randomized into 3 groups: vasopressin (n = 6), dopamine (n = 6), or control (n = 3). Brain death was induced via stepwise filling of an epidural balloon. When the hypotensive phase was achieved, vasopressin, maximum dose of 0.04 IU/kg/h, or dopamine, maximum dose of 20 µg/kg/min, was administered for 5 hours with the objective of increasing mean arterial blood pressure by 15 mm Hg. RESULTS: Target blood pressure was achieved in the vasopressin group but not the dopamine group. Vasopressin reduced cardiac output, superior mesenteric artery (SMA) blood flow and oxygen delivery, and systemic oxygen delivery and consumption, and increased oxygen extraction. Dopamine increased SMA blood flow, and had no effect on systemic oxygen delivery or consumption. CONCLUSIONS: Vasopressin reversed hypotension but compromised both the systemic and SMA blood flow. Vasopressin was associated with inadequate oxygen delivery, estimated from decreased oxygen delivery and increased oxygen extraction. These adverse effects were not observed with dopamine.

Determination of fungal succession during municipal solid waste composting using a cloning-based analysis.

AIMS: The microbiota at industrial full-scale composting plants has earlier been fragmentarily studied with molecular methods. Here, fungal communities from different stages of a full-scale and a pilot-scale composting reactors were studied before and after wood ash amendment. METHODS AND RESULT: The portion of fungal biomass, determined using phospholipid fatty acid analysis, varied between 6.3% and 38.5% in different composting phases. The fungal internal transcribed spacer (ITS) area was cloned and sequenced from 19 samples representing different stages of the composting processes. Altogether 2986 sequenced clones were grouped into 166 phylotypes from which 35% had a close match in the sequence databases. The fungal communities of the samples were related with the measured environmental variables in order to identify phylotypes typical of certain composting conditions. The fungal phylotypes could be grouped into those that dominated the mesophilic low pH initial phases (sequences similar to genera Candida, Pichia and Dipodascaceae) and those found mostly or exclusively in the thermophilic phase (sequences clustering to Thermomyces, Candida and Rhizomucor), but a few were also present throughout the whole process. CONCLUSIONS: The community composition was found to vary between suboptimally and optimally operating processes. In addition, there were differences in fungal communities between processes of industrial and pilot scale. SIGNIFICANCE AND IMPACT OF THE STUDY: The results of this study reveal the fungal diversity with molecular methods in industrial composting process. This is also one of the first studies conducted with samples from an industrial biowaste composting process.

Pre-hospital airway management: guidelines from a task force from the Scandinavian Society for Anaesthesiology and Intensive Care Medicine.

This article is intended as a generic guide to evidence-based airway management for all categories of pre-hospital personnel. It is based on a review of relevant literature but the majority of the studies have not been performed under realistic, pre-hospital conditions and the recommendations are therefore based on a low level of evidence (D). The advice given depends on the qualifications of the personnel available in a given emergency medical service (EMS). Anaesthetic training and routine in anaesthesia and neuromuscular blockade is necessary for the use of most techniques in the treatment of patients with airway reflexes. For anaesthesiologists, the Task Force commissioned by the Scandinavian Society of Anaesthesia and Intensive Care Medicine recommends endotracheal intubation (ETI) following rapid sequence induction when securing the pre-hospital airway, although repeated unsuccessful intubation attempts should be avoided independent of formal qualifications. Other physicians, as well as paramedics and other EMS personnel, are recommended the lateral trauma recovery position as a basic intervention combined with assisted mask-ventilation in trauma patients. When performing advanced cardiopulmonary resuscitation, we recommend that non-anaesthesiologists primarily use a supraglottic airway device. A supraglottic device such as the laryngeal tube or the intubation laryngeal mask should also be available as a backup device for anaesthesiologists in failed ETI.

Outcome from intensive care after cardiac arrest: comparison between two patient samples treated in 1986-87 and 1999-2001 in Finnish ICUs.

BACKGROUND: The aim of the study was to find out whether the characteristics of patients and the outcome from intensive care after cardiac arrest have changed over time. METHODS: Two nationwide databases were compared: (i) The Finnish National Intensive Care Study data in 1986-87 and (ii) data on 28,640 admissions to Finnish ICUs in 1999-2001. Patients whose reason for ICU admission was cardiac arrest were included. The former study included 604 patients treated in 18 medical and surgical ICUs in and the latter 1036 patients in 25 medical and surgical ICUs. Data on the components of Acute Physiology and Chronic Health Evaluation (APACHE II) were prospectively collected in both study periods. Logistic regression analysis was used to test the independent contribution of the study period on hospital mortality. RESULTS: In 1986-87, patients were younger and the proportion of males was lower than in 1999-2001. The hospital mortality in 1986-87 was 61.3% and in 1999-2001 59.1% (P= 0.396). Among patients aged < 57 years, the hospital mortality in 1986-87 was 62.1% and in 1999-2001 48.8% (P < 0.01). In multivariate analysis, controlling for age, gender, Glasgow coma score (GCS), chronic health evaluation points and source of admission, treatment during 1986-87 was an independent predictor for hospital death among all patients (OR 1.273; 95% CI 1.015-1.594), those aged < 57 years (OR 1.959; 95% CI 1.270-3.021) and among males (OR 1.384; 95% CI 1.050-1.825). CONCLUSION: Since the late 1980s, the outcome from intensive care after cardiac arrest may have improved especially among younger patients and males.

Comparison of airway management with the intubating laryngeal mask, laryngeal tube and CobraPLA by paramedical students in anaesthetized patients.

BACKGROUND: Because of the importance of airway management in emergency care, alternative methods with shorter learning curves for inexperienced personnel have been looked for as a substitute for endotracheal intubation (ETI). METHODS: We compared the success of insertion, oxygenation and ventilation of the intubating laryngeal mask (ILMA), laryngeal tube (LT) and CobraPLA (COB) in anaesthetized patients when used by paramedical students. After informed consent, 96 patients were monitored and anaesthetized for general surgery without the use of a muscle relaxant. After the induction of anaesthesia, 32 paramedical students inserted the ILMA, LT or COB in a random order and ventilated the patient for a 60-s period. The number of insertion attempts, the time needed for insertion, and oxygenation and ventilation parameters were recorded. The students gave a subjective evaluation of the airway devices after the test. RESULTS: Twenty-four of the 32 students (75%) successfully inserted ILMA at the first attempt, compared with 14 of 32 (44%) for LT and seven of 32 (22%) for COB (P<0.001, ILMA vs. COB). One student failed to insert ILMA after all three attempts, compared with seven of 32 (21%) using LT and seven of 32 (21%) using COB (P=not significant). Oxygenation and ventilation parameters did not differ between the groups after successful insertion. CONCLUSION: Clinically inexperienced paramedical students can successfully use ILMA in anaesthetized patients. Further investigations are warranted to study whether ILMA or LT can replace ETI in emergency airway management when used by inexperienced medical or paramedical staff.

Airway management in cardiac arrest--comparison of the laryngeal tube, tracheal intubation and bag-valve mask ventilation in emergency medical training.

Tracheal intubation (ETI) is considered the method of choice for securing the airway and for providing effective ventilation during cardiac arrest. However, ETI requires skills which are difficult to maintain especially if practised infrequently. The laryngeal tube (LT) has been successfully tested and used in anaesthesia and in simulated cardiac arrest in manikins. To compare the initiation and success of ventilation with the LT, ETI and bag-valve mask (BVM) in a cardiac arrest scenario, 60 fire-fighter emergency medical technician (EMT) students formed teams of two rescuers at random and were allocated to use these devices. We found that the teams using the LT were able to initiate ventilation more rapidly than those performing ETI (P < 0.0001). The LT and ETI provided equal minute volumes of ventilation, which was significantly higher than that delivered with the BVM (P < 0.0001). Our data suggest that the LT may enable airway control more rapidly and as effectively as ETI, and compared to BVM, may provide better minute ventilation when used by inexperienced personnel.

Paramedic helicopter emergency service in rural Finland - do benefits justify the cost?

BACKGROUND: The benefit of the Helicopter Emergency Medical Service (HEMS) is not well documented. The aim of our study was to investigate the potential health benefits of HEMS, and their relation to cost of the service in a rural area in Finland. We also evaluated whether the patient benefit is due to early Advanced Life Support (ALS) procedures performed on-scene, or due to rapid transport of patients to definitive care. METHODS: We reviewed all helicopter missions during 1 year (1999). Based on given prehospital care, we divided these missions into various categories. At the time of discharge, in-hospital records were reviewed for patients who received prehospital ALS care in order to estimate the potential benefit of HEMS. RESULTS: There were 588 missions. In 40% (n = 233/588), the mission was aborted. ALS care was given on-scene to 206 patients. It was estimated that in this group lives of three patients (1.5%) were saved, and 42 (20%) patients, mostly with cardiovascular disease, otherwise benefited from the service. The majority (84%) of the patients benefited from on-scene ALS procedures only. The cost for beneficial mission was euro 28 444. CONCLUSION: A minority of all patients did benefit from HEMS. Benefit was related to early ALS care and the cost per beneficial mission was 28 444.

In-hospital cardiopulmonary resuscitation: organization, management and training in hospitals of different levels of care.

BACKGROUND: : During recent years in-hospital cardiopulmonary resuscitation (CPR) management has received much attention. This can be attributed to the Utstein model for in-hospital CPR developed in 1997. The present status of in-hospital resuscitation management in Finnish hospitals is not known. Therefore, a study was designed to describe the organization of training and clinical management of CPR in Finnish hospitals of different levels of care. METHODS: : In the summer of 2000, we performed a cross-sectional mail survey throughout Finland, including all district, central and university hospitals. The questionnaire outlined in detail in-hospital resuscitation management and training. For analysis the hospitals were divided into primary, secondary and tertiary groups, depending on levels of care. RESULTS: : Most hospitals (72%) reported having a physician or a nurse in charge of resuscitation management and training. Training in advanced life support was more common among nurses (80%) than among physicians (53%). Surprisingly, a majority of respondents (75%) reported that they felt training in CPR was insufficient. On the general wards and on wards treating cardiac patients, defibrillation was in most cases performed by a physician (91% and 51%, respectively), and less often by a nurse (16% and 31%, respectively). In the secondary and tertiary hospitals cardiac arrest was managed by a cardiac arrest team (53% and 62%, respectively) and in the primary hospitals by the ward physician (56%), anesthesiologist or emergency physician on call (44%). Most hospitals used do-not-resuscitate orders (83%) but only 33% of the hospitals had a unified style of notation. Systematic data collection was practised in 55% of hospitals, predominantly by using a model of their own. Only a few hospitals (11%) used the in-hospital Utstein model. CONCLUSION: : Our study showed that more attention needs to be paid to CPR management in Finnish hospitals. At present, 25% of hospitals do not have an appointed physician or nurse in charge of organizing CPR management. The study also revealed a lack of regular organized training in resuscitation for physicians. Fifty-five per cent of hospitals practise systematic data collection, but only 11% according to the Utstein template; and without which further quality assurance is difficult.