Topical pharyngeal anesthesia with articaine for gastroscopy: a double-blinded, randomized cross-over study in healthy volunteers.

OBJECTIVES: The benefits of topical pharyngeal anesthesia for gastroscopy remain under debate. Articaine, a local anesthetic with fast onset and offset of action as well as low systemic toxicity, could be a promising choice for topical anesthesia. The objective of this study was to assess whether topical pharyngeal anesthesia with articaine is beneficial in sedated gastroscopy. MATERIALS AND METHODS: This randomized double-blinded cross-over study included nine volunteers who underwent two gastroscopies under conscious sedation. One was performed with topical pharyngeal anesthesia with articaine and the other with placebo. Hemodynamic parameters including autonomic nervous system state were recorded prior to and during the endoscopic procedure. The endoscopist and the volunteer assessed the endoscopy after the examination. RESULTS: Topical pharyngeal anesthesia with articaine resulted in less discomfort during esophageal intubation and higher patient satisfaction with the procedure. Topical pharyngeal anesthesia with articaine did not increase satisfaction or facilitate the procedure as rated by the endoscopist. There were no clinically relevant differences in hemodynamic parameters. CONCLUSION: The use of articaine for topical pharyngeal anesthesia results in less intubation-related discomfort and better satisfaction.

Spiritual well-being correlates with quality of life of both cancer and non-cancer patients in palliative care - further validation of EORTC QLQ-SWB32 in Finnish.

BACKGROUND: The European Organisation for Research and Treatment of Cancer (EORTC) has developed the Spiritual Well-being Questionnaire (EORTC QLQ-SWB32), a measure of spiritual well-being validated with people receiving palliative care for cancer, although its usefulness is not restricted to that population. We aimed to translate and validate this tool in Finnish and to study the relationship between spiritual well-being (SWB) and quality of life (QOL). METHODS: A Finnish translation was produced according to the guidelines of EORTC and included forward- and back-translations. Face, content, construct and convergence/divergence validity and reliability were studied in a prospective manner. QOL was assessed with EORTC QLQ-C30 and 15D questionnaires. Sixteen individuals participated in the pilot testing. 101 cancer patients drawn from oncology units, and 89 patients with other chronic diseases drawn from religious communities in different parts of the country participated in the validation stage. Retest was obtained from 16 individuals (8 cancer and 8 non-cancer patients). Inclusion criteria included patients with either a well-defined palliative care plan, or who would benefit from palliative care, as well as the capacity to understand and communicate in Finnish. RESULTS: The translation appeared understandable and acceptable. Factorial analysis identified four scoring scales with high Cronbach alfa values: Relationship with Self (0.73), Relationship with Others (0.84), Relationship with Something Greater (0.82), Existential (0.81), and, additionally, a scale on Relationship with God (0.85). There was a significant correlation between SWB and QOL in all participants. CONCLUSIONS: The Finnish translation of EORTC QLQ-SWB32 is a valid and reliable measure both for research and clinical practice. SWB is correlated with QOL in cancer and non-cancer patients undergoing palliative care or who are eligible for it.

What do Finnish physiotherapists and physiotherapy students know about the neurophysiology of pain? The Finnish version of the revised Neurophysiology of Pain Questionnaire.

BACKGROUND: Understanding the concept of pain and its underlying biological mechanisms is an essential part of physiotherapists' professional knowledge. OBJECTIVES: The first aim of the study was to translate and cross-culturally adapt the revised Neurophysiology of Pain Questionnaire into Finnish (RNPQ-FI) and to evaluate its reliability (internal consistency and test-retest reliability) in a sample of Finnish physiotherapists and physiotherapy students. The second aim was to compare the knowledge of pain neurophysiology between these two groups. METHODS: Translation and cross-cultural adaptation followed the COSMIN Study Design checklist. Participants (202 physiotherapists and 97 physiotherapy students) completed an online survey containing RNPQ-FI. Internal consistency was assessed with Cronbach's alpha and test-retest reliability using Intraclass correlation coefficient (ICC3,1). RESULTS: Cronbach's alpha was 0.44 and ICC was 0.70 (p < .001). The mean percentage of correct responses was 61.4% for physiotherapists and 62.1% for students. Forty-seven percent of the physiotherapists and 35.1% of the students reported difficulties in understanding the items. A higher amount of pain education was associated with higher RNPQ-FI scores. CONCLUSIONS: The RNPQ-FI showed low internal consistency and moderate test-retest reliability among Finnish physiotherapists and physiotherapy students. Physiotherapists and students had equal amount of pain neurophysiology knowledge. Pain education is encouraged.

Influences of COVID-19 pandemic on hospital-at-home functions in Finland - a questionnaire survey.

OBJECTIVE: To investigate functions of Finnish hospital-at-home (HAH) during the first year of COVID19-pandemic 2020 compared with the previous year 2019. DESIGN: Retrospective questionnaire survey. SETTING: Finnish HAHs from Northern, Eastern, Southern, Western and Central parts of Finland participated in a questionnaire web-based questionnaire survey. The numbers of patients, activities and staff in 2019 and 2020, participation in the care of COVID19 patients, availability of protective clothing, attitudes of patients towards home care and development of new practices in the corona era were asked using both predefined and free questions. SUBJECTS: questionnaire was sent to the nurses and physicians in charge of the HAHs (N = 13), 77% responded. The HAHs provided services to a total of 1,196,783 inhabitants in their municipalities. RESULTS: There were no significant changes in the numbers of patients, staff or activities between the years 2019 and 2020. Although nurses did viral tests, COVID19 patients were cared only in 40% of HAHs. Protective clothing was well available. New instructions for infection management were created. CONCLUSIONS: The COVID-19 pandemic did not largely influence the functions of the examined Finnish HAHs in 2020. Most activities and patients' characteristics remained unchanged from 2019. The role of HAHs should be further developed in Scandinavian countries, particularly during pandemics.Key PointsHospital-at-home (HAH) is a cost-effective model to provide hospital-like services.Data about the role of HAHs during COVID19 pandemics is lacking in the Nordic countries.This study shows that, the large Finnish municipal HAHs have been not influenced by pandemics.

Effects of Dexmedetomidine on Basic Cardiac Electrophysiology in Adults; a Descriptive Review and a Prospective Case Study.

Dexmedetomidine (DEX) is a commonly used sedative agent with no or minimal effects on breathing. DEX may also be beneficial in myocardial protection. Since the mechanisms of cardiac effects are not well known, we carried out a descriptive review and examined the effects of DEX on myocardial electrical conduction in a prospective and controlled manner. For the review, clinical studies exploring DEX in myocardial protection published between 2020-2022 were explored. A case study included 11 consecutive patients at a median (range) age of 48 (38-59), scheduled for elective radiofrequency ablation of paroxysmal atrial fibrillation. A bolus dose of DEX 1 µg/kg given in 15 min was followed by a continuous infusion of 0.2-0.7 µg/kg/h. Direct intracardiac electrophysiologic measurements, hemodynamics and oxygenation were measured before and after the DEX bolus. Experimental studies show that DEX protects the heart both via stabilizing cardiac electrophysiology and reducing apoptosis and autophagy after cell injury. The clinical evidence shows that DEX provides cardiac protection during different surgeries. In a clinical study, DEX increased the corrected sinus node recovery time, prolongated the atrioventricular (AV) nodal refractory period and cycle length producing AV nodal Wenckebach retrograde conduction block. DEX has a putative role in organ protection against hypoxic, oxidative and reperfusion injury. DEX slows down the firing of the sinus node and prolongs AV refractoriness.

Psychometric properties and factor structure of the Finnish version of the Health Care Providers' Pain and Impairment Relationship Scale.

BACKGROUND: Health care providers' beliefs influence the outcomes of low back pain patients care. OBJECTIVES: The aim of this study was to translate and cross-culturally adapt the Health Care Providers' Pain and Impairment Relationship Scale into Finnish (HC-PAIRS-FI) and to evaluate its psychometric properties and factor structure in a sample of Finnish physiotherapists and physiotherapy students. METHODS: The translation was performed using established guidelines. Participants answered an online survey consisting of HC-PAIRS-FI and the Finnish Tampa Scale of Kinesiophobia adapted for health care providers (TSK-HC-FI). Internal consistency was assessed using Cronbach's alpha. Intraclass correlation coefficient (ICC) was used to determine test-retest reliability. A second round of analysis, exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) was performed as the fit indices of the initial CFA were not satisfactory. RESULTS: A sample of 202 physiotherapists and 97 physiotherapy students completed the survey. The second round of analysis EFA and CFA, conducted on a randomly split subsample, revealed and confirmed a three-factor, 11-item HC-PAIRS-FI scale with satisfactory model fit indices. Cronbach's alpha 0.79 and ICC = 0.82 (p < 0.001) indicate good internal consistency and test-retest reliability. The standard error of measurement was 2.12. HC-PAIRS-FI scores correlated moderately with TSK-HC-FI (r = 0.69, p < 0.001). CONCLUSIONS: The 11 items HC-PAIRS-FI appears to be a valid and reliable questionnaire to evaluate Finnish physiotherapists' and physiotherapy students' attitudes and beliefs about the relationship between chronic low back pain and impairment. Future studies are required to validate this scale for other health care providers.

Twelve Years of Postgraduate Palliative Medicine Training in Finland: How International Guidelines Are Implemented.

Background and Objective: The European Association for Palliative Care (EAPC) published recommendations for postgraduate education in palliative medicine in 2009. However, it is currently unknown how the EAPC remommendations are implemented in national programs, as audits of them are lacking. In Finland, the national society of palliative medicine has been organizing postgraduate palliative medicine training for experienced physicians since 2008, but the program has not been audited. The aim of this study was to perform a comprehensive analysis of the program. Design: In 2018-2019, a questionnaire on the Finnish Training Program for Palliative Medicine Competence was sent to past participants and delivered in person to current trainees. Learning outcomes were assessed with validated instruments for received skills and attitudes. All available educational archives were examined as well. Results: Forty-five (32 %) out of 155 specialists and 13 (38 %) out of 34 trainees responded. According to their assessments, the training provided them well with most skills required to work as palliative care specialists, but poorly with research capabilities. However, the Finnish program covers the EAPC guidelines well. Problem-based education, group work, and clinical excursions have been added to the latest curriculum. Maturation through work is needed for administrative and consultant competences. Conclusion: The EAPC guidelines can be included in a national course. The course had an important positive influence on the attitudes and learning of physicians in palliative medicine. The development of the education would benefit from pedagogical consultation. Uniform standards for auditing national programs should be developed.

Nonoperating room anesthesia for patients with serious comorbidities.

PURPOSE OF REVIEW: To provide aids to deal with increasing amount of several comorbidities in nonoperating room anesthesia (NORA). RECENT FINDINGS: New indexes for assessment of comorbidities are described and guidelines for the care of patients with obesity, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), diabetes and COVID19 in NORA summarized. SUMMARY: In addition to ASA classification, such instruments as Charlson Comorbidity Index, Frailty Index, Surgical Complexity Score and Revised Cardiac Risk could supplement the prospective assessment of the risk of comorbidities. Using institutional protocols patients with significant obesity, obstructive sleep apnea, COPD, diabetes and COVID19 can be safely cared in NORA. However, the individual functioning and the severity are more important than only the number of diseases.

Sustainability of Palliative Care in a Rural Hospital in Tanzania: A Longitudinal and Prospective 4-Year Study.

BACKGROUND: Palliative care has been developed in recent years in many sub-Saharan countries in Africa due to activities of African Association for Palliative Care. Palliative care units have been established also in most hospitals in Tanzania. Yet very little is known about their functions. Long-term studies about the sustainability of palliative care have not been carried out. METHODS: The attitudes of 101 members of hospital staff and persons in charge of palliative care services of Ilembula District Designated Hospital (IDDH), Tanzania, were assessed using a modified and prevalidated questionnaire annually in 2014 to 2017. The inquiries were executed on randomly allocated days. Also, the patient and economy registries were analyzed. Additional qualitative data were obtained in personal interviews and during observational visits twice a year at the IDDH. RESULTS: Ilembula District Designated Hospital has a true multiprofessional palliative care team, which provides services in the hospital, in the villages, and at homes. The activities are based on careful 5-year planning and budgeting. Up to 17 villages have been included in the services. Ninety-five percent of the patients were HIV infected. Short-acting morphine oral solution was the only available strong opioid. The hospital staff evaluated palliative care as good or excellent; 50% of the staff would need more support in the end-of-life care. CONCLUSIONS: A sustainable palliative care service can be built in a Tanzanian rural hospital if an advanced planning and budgeting are made. In Tanzania, the biggest group of palliative care patients are still HIV-infected individuals. There is a lack of opioids in the country.

Palliative Care Volunteers Have High Workload but No Burnout: A Questionnaire Survey from Tanzania.

Background: In Africa, the core of home-based care (HBC) in the villages is provided by volunteer helpers, individuals chosen to provide both support to patients and important information to health officers. Yet, voluntary work in palliative care and the burden of being a volunteer have not been studied in Africa. Objective: To study the content and burden of volunteer work in the palliative home care of Ilembula District Designated Hospital (IDDH), a secondary care institution in Tanzania. Design: A descriptive prospective study using semistructured and closed questionnaires. Setting/subjects: The modified Palliative Care Evaluation Tool Kit (PCETK) and Professional Quality-of-Life Scale (ProQOL) were used to study the work content and workload of 47 volunteers in the palliative HBC of IDDH. ProQOL was translated to Kiswahili. Fifty-seven health care professionals and students validated the translation. Factorial analysis and Cronbach's alphas were calculated for reliability. Results: Responses to PCETK and ProQOL were received from 34 (72%) to 20 (42%) volunteers, respectively. The Kiswahili translation of ProQSL appeared to be highly reliable. On average, a volunteer worked 20 hours/month and had 22 patients. The main activities included helping with daily tasks, preparing meals, assisting with transport, and reporting the patient's clinical condition to the health care officers. The volunteers reported high satisfaction ratings (average 4.2, standard deviations 0.38) and had higher scores than the validation group in the compassion fatigue scale (2.42 vs. 1.55, p < 0.01) but no burnout. Conclusions: The volunteers had high commitment and workload. Even so, coping strategies for dealing with suffering and death should be better addressed in training.

Assessment of sedation level for endoscopic retrograde cholangiopancreatography - a prospective validation study.

BACKGROUND AND AIMS: There is no consensus on how to assess the depth of sedation for endoscopic retrograde cholangiopancreatography (ERCP). This study was carried out in order to evaluate different methods of assessment of depth of sedation: bispectral index (BiS), modified Richmond Agitation/Sedation Scale (mRASS), modified Ramsay Sedation Scale (mRSS) and modified Observer Assessment of Alertness and Sedation (mOAAS) and their applicability to clinical practice. METHODS: Two hundred patients were recruited. Sedation was given by standard clinical practice using propofol sedation or patient controlled sedation. Sedation was assessed on all patients using the above-mentioned methods. BiS was considered the reference point for sedation scales. Cronbach's alpha was calculated to determine the consistency of different scales in respect to each other and prediction probability and Spearman's correlation coefficients of sedation scales were calculated to show the relationship between sedation scales and BiS. RESULTS: All scales showed high reliability with overall Cronbach's alpha 0.943. Dropping scales suggested better consistency between mOAAS, mRSS and mRASS than with BiS. Spearman's correlation and prediction probability showed similar results with all tested scales: mOAAS (0.695, 0.739), mRSS (0.673, 0.735), mRASS (0.683, 0.738), p < .01 for all scales. CONCLUSIONS: All tested methods were found to be reliable in the assessment of the depth of sedation when compared with each other. However, mRASS, mRSS and mOAAS require the patient to respond to verbal or tactile stimulus, which may impair execution of ERCP, whereas BiS information is collected directly from electroencephalogram and thus may be preferable in clinical setting.

How patient-controlled sedation is adopted in clinical practice of sedation for endoscopic retrograde cholangiopancreatography? A prospective study of 1196 cases.

OBJECTIVE: Patient-controlled sedation (PCS) has been shown to be a valid choice for sedation during endoscopic retrograde cholangiopancreatography (ERCP) in randomized studies. However, large-scale studies are lacking. MATERIAL AND METHODS: A single center, prospective observational study to determine how sedation for ERCP is administered in clinical setting. All 956 patients undergoing 1196 ERCPs in the endoscopy unit of Helsinki University Central Hospital 2012-2013, methods of sedation and adverse events associated with different sedations were recorded. RESULTS: PCS was attempted a total of 685 times (57%), successful use of PCS was achieved with 526 patients (77% of attempts). PCS device was operated by the anesthesiologist or anesthesia nurse 268 times (22%). PCS was more likely chosen for younger (80.6% for < =60 years vs. 63.8% for >60 years, p<.001) patients and by trainee anesthetists. Anesthesiologist administered propofol sedation was used 240 times (20%). The risk of failure of PCS was increased, if systolic arterial pressure was <90 mmHg, dosage of PCS >17 ml, duration of procedure exceeded 23 min. The risk of failure was lower in patients with primary sclerosing cholangitis (PSC) and if sedation was deeper RASS < =-2. Uneventful PCS was associated with less respiratory and cardiovascular depression than other methods. There were no statistically significant differences in safety profiles with all the methods of sedation. CONCLUSIONS: PCS is readily implemented in clinical practice, is suitable for younger and low-risk patients and is associated with less cardiorespiratory adverse effects.

[Decision about DNR for a palliative patient - do I dare to bring up the subject?]. / Palliatilvisessa hoidossa olevan potilaan DNR-päätös - uskallanko ottaa puheeksi?

The do not resuscitate decision (DNR) is an important choice of line of action, which should not be made on light grounds, but if neglected, may harm a patient receiving palliative care. Before making the decision, one should evaluate an unsuccessful result of possible resuscitation regarding the restoration of vital functions and quality of life. Evaluation of factors suggesting a poor prognosis should be possible already before arriving at the resuscitation situation. The decision should be discussed with the patient, trying to reach a consensus on the matter. DNRs should be made more actively for patients benefiting from the decision.

Present-day challenges and future solutions in postoperative pain management: results from PainForum 2014.

This paper is a summary of presentations on postoperative pain control by the authors at the 2014 PainForum meeting in People's Republic of China. Postoperative pain is often untreated or undertreated and may lead to subsequent chronic pain syndromes. As more procedures migrate to the outpatient setting, postoperative pain control will become increasingly more challenging. Evidence-based guidelines for postoperative pain control recommend pain assessment using validated tools on a consistent basis. In this regard, consistency may be more important than the specific tool selected. Many hospitals have introduced a multidisciplinary acute pain service (APS), which has been associated with improved patient satisfaction and fewer adverse events. Patient education is an important component of postoperative pain control, which may be most effective when clinicians chose a multimodal approach, such as paracetamol (acetaminophen) and opioids. Opioids are a mainstay of postoperative pain control but require careful monitoring and management of side effects, such as nausea, vomiting, dizziness, and somnolence. Opioids may be administered using patient-controlled analgesia systems. Protocols for postoperative pain control can be very helpful to establish benchmarks for pain management and assure that clinicians adhere to evidence-based standards. The future of postoperative pain control around the world will likely involve more and better established APSs and greater communication between patients and clinicians about postoperative pain. The changes necessary to implement and move forward with APSs is not a single step but rather one of continuous improvement and ongoing change.

Prospective, randomized, double-blinded trial of bone marrow cell transplantation combined with coronary surgery - perioperative safety study.

OBJECTIVES: We present here a sub-study of our prospective, randomized, double-blinded trial of bone marrow mononuclear cell (BMMC) transplantation with coronary artery bypass surgery (CABG) (ClinicalTrials.gov Identifier: NCT00418418), evaluating our secondary end-point concerning hospital stay as well as perioperative morbidity. Injecting a substantial amount of biologically active cells into a diseased myocardium inspires concerns for safety, a concern overlooked in previous trials. METHODS: We evaluated the immediate perioperative effects of intramyocardial injection of autologous BMMCs combined with CABG. In a randomized double-blinded manner, 39 patients received injections either of BMMCs (n = 20) or of vehicle medium (n = 19). The patients' haemodynamics, arterial blood gases, systemic vein oxygen level, blood glucose, acid-base balance, lactate, haemoglobin, body temperature and diuresis, as well as medications needed, were recorded in the operating theatre and in the intensive care unit (ICU) every 4 h throughout the first postoperative 24 h. RESULTS: No dissimilarities in these parameters were detectable. In the ICU, the median need for adrenaline was 0.0086 µg/kg/min (first quartile 0.0000, third quartile 0.0204) for controls and 0.0090 µg/kg/min (0.0000, 0.0353) for BMMC patients (P = 0.757); for noradrenaline, 0.0586 µg/kg/min (0.0180, 0.0888) for controls and 0.0279 µg/kg/min (0.0145, 0.0780) for BMMC patients (P = 0.405). The median stay at the ICU was 2 days for both groups (1, 2 for controls; 1, 3 for BMMCs; P = 0.967). Within the first postoperative day, one control patient had an elevated level of creatine kinase-myocardial band fraction mass (CK-MBm) up to >100 µg/l; no BMMC patient showed elevated CK-MBm levels (P = 0.474). CONCLUSIONS: Both intramyocardial BMMC and placebo injections appear safe during surgery and immediate ICU stay after treatment of heart failure.

Autologous bone marrow mononuclear cell transplantation in ischemic heart failure: a prospective, controlled, randomized, double-blind study of cell transplantation combined with coronary bypass.

BACKGROUND: Bone marrow mononuclear cell (BMMC) transplantation for heart failure has shown inconsistent therapeutic efficacy. METHODS: We enrolled 104 ischemic heart failure patients scheduled for coronary artery bypass surgery (CABG). After 4- to 12-week pharmacotherapy optimization, 39 patients with left ventricular ejection fraction (LVEF) of ≤45% received injections of BMMC or vehicle intra-operatively into the myocardial infarction border area in a randomized, double-blind manner. RESULTS: The median number of cells injected was 8.4 × 10(8) (interquartile range [IQR]: 5.2 × 10(8) to 13.5 × 10(8)). We measured LV function and myocardial scar size by magnetic resonance imaging (MRI), and viability by positron emission tomography (PET) and single-photon emission computed tomography (SPECT), pre-operatively and after 1-year follow-up. LVEF, the pre-defined primary end-point measure, improved by a median of 5.6% in the control group (IQR 0.2 to 10.1) and by 4.8% in the BMMC group (IQR -0.5 to 8.2) (p = 0.59). Wall thickening in injected segments rose by a median of 4.5% among controls (IQR -18.1 to 23.9) and by 5.5% in the BMMC group (IQR -6.6 to 26.5) (p = 0.68). Changes in viability by PET and SPECT did not differ between groups. Myocardial scar size by MRI in injected segments rose by a median of 5.1% among controls (IQR -3.3 to 10.8), but fell by 13.1% in the BMMC group (IQR -21.4 to -6.5) (p = 0.0002). CONCLUSIONS: BMMC therapy combined with CABG failed to improve LV systolic function, or viability, despite reducing myocardial scar size.

A randomized comparison of target-controlled propofol infusion and patient-controlled sedation during ERCP.

BACKGROUND AND STUDY AIMS: Propofol is widely used during endoscopic retrograde cholangiopancreatography (ERCP) but high doses are recognized as a risk factor for sedation-related complications. The aim of this study was to compare target-controlled infusion (TCI) with patient self-administration (patient-controlled sedation, PCS) of propofol during ERCP. Propofol consumption, the ease of ERCP performance, and speed of recovery were recorded. PATIENTS AND METHODS: A total of 82 patients undergoing elective ERCP were randomized 1:1 to receive propofol 10 mg/mL using TCI (initial targeted effect-site concentration 2 µg/mL) or PCS (single bolus 1 mL, lockout time set at zero). Alfentanil was administered if signs of insufficient analgesia occurred. Consumption of propofol and alfentanil was recorded, sedation levels and vital signs were monitored, the ease of ERCP performance, speed of recovery, and satisfaction with sedation were evaluated. RESULTS: All procedures were performed without interruptions or major sedation-related complications. The mean (± SD) consumption of propofol was 306 ± 124 mg in the TCI group and 224 ± 101 mg in the PCS group (P = 0.002). Patients in the PCS group recovered faster (P = 0.035). The mean (± SD) consumption of alfentanil was 0.5 ± 0.4 mg in both groups. The combination of propofol and alfentanil was associated with an increased risk of sedation-related adverse events (P = 0.031). CONCLUSIONS: No benefits of TCI over PCS could be demonstrated in this study. We recommend considering PCS as a feasible option for propofol administration during ERCP because of its ease of use, high success rate, reduced consumption of propofol, and faster recovery.

Dexmedetomidine impairs success of patient-controlled sedation in alcoholics during ERCP: a randomized, double-blind, placebo-controlled study.

BACKGROUND: There is a lack of studies about procedural sedation of alcoholics. Dexmedetomidine is recommended for procedural sedation and reported effective for alcohol withdrawal. We evaluated the suitability of dexmedetomidine for sedation of alcoholics during endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Fifty patients with chronic alcoholism scheduled for elective ERCP were randomized 1:1 to receive dexmedetomidine (Dex group) (loading dose 1 µg kg(-1) over 10 min, followed by constant intravenous infusion 0.7 µg kg(-1) h(-1)) or saline placebo (P group). Patient-controlled sedation with propofol-alfentanil was used by patients as a rescue method. Sedation was considered as successful if no intervention of an anesthesiologist was needed. Consumption of sedatives was registered, and sedation levels and vital signs were monitored. RESULTS: Dexmedetomidine alone was insufficient in all patients. The mean ± SD consumption of propofol was 159 ± 72 mg in the P group, and 116 ± 61 mg in the Dex group (p = 0.028). Sedation was successful in 19 of 25 (76 %) patients in the Dex group and in all patients in the P group (p = 0.022). The incidence of sedation adverse events did not differ between the groups. Dexmedetomidine was associated with delayed recovery. CONCLUSIONS: Patient-controlled sedation with propofol and alfentanil but not dexmedetomidine can be recommended for sedation of alcoholics during ERCP.

Effects of levosimendan on renal function in patients undergoing coronary artery surgery.

OBJECTIVES: To evaluate the effect of levosimendan on postoperative renal function in patients with compromised heart function undergoing on-pump coronary artery bypass graft surgery. DESIGN: A prospective, randomized, placebo-controlled, double-blind substudy. SETTING: Cardiothoracic surgery, anesthesiology, and intensive care units at 2 university hospitals. PARTICIPANTS: Sixty patients with left ventricular ejection fraction ≤50% were randomized into 2 parallel treatment groups. INTERVENTIONS: Levosimendan or placebo was started after the induction of anesthesia with a 12-µg/kg bolus in 10 minutes followed by the infusion of 0.2 µg/kg/min for the next 23 hours and 50 minutes. MEASUREMENTS AND RESULTS: Serum cystatin C and plasma creatinine were measured at baseline; at 6 and 24 hours after declamping the aorta; and on the 1st, 2nd, and 5th postoperative days. Urine N-acetyl-ß-glucosaminidase (U-NAG) was measured at baseline and at 6 and 24 hours after declamping of the aorta. Renal function was estimated with calculated glomerular filtration rate (eGFR). The changes in plasma creatinine, serum cystatin C, and urine NAG were not significant among the placebo and the levosimendan groups at any of the measuring points. CONCLUSIONS: After coronary artery surgery, levosimendan did not have a significant influence on the kidney function measured with these specific kidney markers.

[Patient controlled sedation]. / Potilassäätöinen sedaatio.

Adequate sedation is essential for successful performance of painful and uncomfortable interventional radiological, endoscopic or oncological procedures. Mild sedation is usually provided by the interventionists but an anaesthetic team is needed for deep sedation. A new alternative for intravenous sedation provided by a physician is patient controlled sedation (PCS). In PCS the patient can administer him- or herself small amounts of propofol or its combination to opioid. Spontaneous ventilation is maintained and communication with the patient is most often possible. PCS needs to be monitored adequately by an anaesthetic nurse. The advantages of PCS are appropriate level of sedation and rapid recovery. PCS has proved to be safe and effective during the change of burn injury dressings, endoscopic and radiological procedures. In Helsinki University Central Hospital the preliminary experience in over 1000 patients in the endoscopic unit has been very encouraging.