Activation of fibrinolysis in the pericardial cavity after cardiopulmonary bypass

Aprotinin is frequently administered systemically in patients undergoing cardiopulmonary bypass to preserve platelet function and ameliorate excessive activation of fibrinolysis. More recently, aprotinin topically applied in the pericardial cavity was also found to improve postoperative blood loss. However, platelet activation was not reduced locally during surgery. Hence, we investigated in the present prospective, in a randomized double-blind trial, the intra- and early postoperative state of systemic and local fibrinolytic activity, and whether topically administered aprotinin acts as an antifibrinolytic and therefore improves local hemostasis. Patients undergoing elective coronary artery bypass grafting were divided in two groups containing 22 patients each. Both, group I and II patients received highdose aprotinin (6.0 × 106 kallikrein inhibitor units (KIU)) systemically. Before resuming extracorporeal circulation (ECC), either 1.0 × 106 KIU aprotinin (group I) or vehicle solution (group II) was applied into the pericardial cavity. Plasminogen, α2-antiplasmin, plasmin-α2-antiplasmin complex, plasminogenactivator-inhibitor type-1 and D-dimers were measured in the pericardial cavity and systemic circulation immediately before resuming extracorporeal circulation (ECC), and at 1 h and 4 h postoperatively. The local fibrinolytic activity was found to significantly exceed that measured in the systemic circulation over time, whether ot not they received aprotinin into the thoracic wound surface. Furthermore, evidence was provided that topically applied aprotinin reduces not only the local fibrinolytic activity but also the postoperative blood loss significantly by 33% which demonstrates the clinical relevance. The local activation of fibrinolysis seems to play an important role in blood loss after cardiopulmonary bypass. Therefore in fibrinolysis and blood coagulation the surgeon should not only consider what happens in the systemic circulation but also on a local level.

Personality traits of emergency physicians and paramedics

OBJECTIVE

Personality influences behaviour and decision-making. This may play a particular role in emergency medical personnel (EMP) dealing with critical situations. So far very little is known about personality traits that distinguish paramedics (PM) and emergency physicians (EP) from other medical staff.

METHODS

A questionnaire including the ultra-short version of the Hamburg Personality Inventory (HPA) was distributed to EP, PM, medical doctors not practicing emergency medicine (MD) and medical students (MS).

RESULTS

274 EPs, 245 PMs, 48 MDs and 60 MSs returned the questionnaire. Four personality clusters in EPs and PMs were identified and to be found largely independent from demographic and job-related variables. For both groups one cluster revealed personality characteristics that seem particularly suitable for EMP ('resilient crisis manager'). 'Anxious' and 'insecure' personality traits were found in two clusters in PMs and in one cluster in EPs. Mental health problems in the participants or their relatives or the experience of loss increased scores in the dimensions neuroticism and openness.

CONCLUSIONS

The personality characteristics of EPs and PMs are not homogenous and do not differ substantially from those of MDs and MSs. 50-70% of EMP can be characterised as 'resilient and stable', up to 30-40% as 'anxious and insecure'. The presence of mental health problems in participants or their relatives or the experience of loss may lead to openness for new experiences and alternative behaviour or--on the other hand--may trigger feelings of insecurity and/or anxiety in emergency situations.

[Optimizing systems of care for patients with acute myocardial infarction. STEMI networks, telemetry ECG, and standardized quality improvement with systematic data feedback]

Rapid revascularization of the infarct-related artery importantly affects prognosis in the treatment of acute ST elevation myocardial infarction (STEMI). Treatment results can be improved significantly when a STEMI-specific structure of care is created and when systematic quality improvement measures are implemented. The necessary structural measures include establishing or participating in myocardial infarction networks. When local hospitals collaborate in a network, it becomes feasible to offer round-the-clock primary coronary intervention to patients of those participating hospitals that do not have a catheterization laboratory on site. Another important structural step is to acquire and install prehospital twelve-lead ECG systems capable of remote telemetric transmission. This provides a solid basis for diagnosing STEMI with speed and accuracy and can prove to be highly effective in anchoring the chain of alert and treatment. As a consequence, two important goals can be realized: (1) intentionally bypassing the non-interventional hospital, and (2) systematically bypassing the emergency room of the interventional center. Both of these measures entail important time savings. An efficient instrument for improving treatment times is the implementation of a standardized quality improvement process with formalized data collection and analysis as well as with systematic data feedback to all systems and individuals involved in the early phase of treating STEMI patients within the hospital network including the emergency medical responder systems. The positive effect of such data feedback on treatment quality is contingent on the perception by all those involved that the data obtained for each patient are absolutely valid. Thus, those data need to be verifiable and an independent monitoring process should be created.Furthermore, the systematic use of standardized risk scores should be promoted in an effort to compare and adjust patient risk when analyzing network data. It is critically important that all appropriate patients-including those with a high risk of mortality--have access to rapid interventional treatment. Only when the individual risk of treated patients is taken into account will it be possible to compare quality of care and mortality rates. In general, the comparison between different hospitals, systems and regions is highly problematic and not feasible without considering local factors. It harbors the danger of inducing changes in practice in order to compete rather than in order to advance patient care, and thus it may be counterproductive when such a comparison leads to the implication that treatment may have been inferior. Therefore, the comparison of results (e.g., treatment times and mortality rates) should be undertaken as much as possible within an established system, with the use of a "before and after" design. Quality, then, will be defined as a documented consistent effort to improve results, and this approach will be distinctly productive. It is of fundamental importance that the involved hospitals, physicians and emergency staff perceive themselves as a team. The structures and processes outlined above can and should be applied broadly. The necessary resources will need to be provided through political and societal consensus. The multicenter FITT-STEMI project ("Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction") is currently pursuing such an approach.

Contact-to-balloon time and door-to-balloon time after initiation of a formalized data feedback in patients with acute ST-elevation myocardial infarction

For many patients with ST-segment elevation myocardial infarctions (STEMIs), the time from presentation to percutaneous coronary intervention exceeds established goals. This study was conducted to examine the effects of formalized data assessment and systematic feedback on treatment times. All patients with STEMIs treated with percutaneous coronary intervention in a semi-rural 3-hospital network from January 1, 2006, to December 31, 2006, were prospectively analyzed (n = 114). Patients presenting during the first 3-month period (January 1, 2006, to March 31, 2006) were included as the reference group (n = 33). Time points from initial contact with the medical system to revascularization were assessed, analyzed, and presented in an interactive session to hospital and emergency services staff members. Data from patients with STEMIs presenting during the next 3 quarters were presented in the same manner (n = 28, 25, and 28). The median contact-to-balloon time was 113 minutes in the reference quarter, decreasing to 83, 66, and 74 minutes in the intervention groups (p <0.0001), whereas the median door-to-balloon time decreased from 54 minutes in the reference group to 35, 31, and 26 minutes in the intervention groups (p <0.0001). The proportion of patients with contact-to-balloon times <90 minutes increased from 21% to 79% (p <0.0001). There were significant reductions in the durations of initial treatment on location and in the emergency room and in puncture-to-balloon-time in the catheterization laboratory, and more patients were transported directly to the catheterization laboratory, bypassing the emergency room (from 23% in the reference quarter to 76% in the last intervention quarter, p <0.0001). In conclusion, formalized data feedback leads to marked reduction in revascularization times in patients with STEMIs.

A new universal laryngoscope blade: a preliminary comparison with Macintosh laryngoscope blades

The Dörges universal laryngoscope blade has several features designed to facilitate tracheal intubation. The number of laryngoscope blades may be reduced from four to two, or even one, which indicate less space requirement and costs. This new universal laryngoscope blade, has a lower profile (height 15 vs. 22 mm) than a Macintosh laryngoscope blade size 3 and 4, which may facilitate manoeuvring of the laryngoscope in the mouth. In random order, 40 non-anaesthesia senior house officers used a Macintosh laryngoscope blade size 3 or 4 in an adult airway management trainer, a Macintosh laryngoscope blade size 2 in a paediatric airway management trainer, and the Dörges universal laryngoscope blade for both airway management trainers to perform orotracheal intubation. The number of intubation attempts and failures was counted. Participants reported the laryngoscopic view according to Cormack and Lehane. The time from touching the laryngoscope to the first adequate lung insufflation was measured, and subjective assessment regarding handling of both blades was recorded. Number of intubation failures, the laryngoscopic view according to Cormack and Lehane, and subjective assessment was comparable between groups. Orotracheal intubation of the adult airway management trainer with the Dörges universal laryngoscope blade took significantly less time compared to the Macintosh laryngoscope blades (14 (7-57) vs. 20 (8-43) s; P<0.001); all other intubating times were comparable. In conclusion, in this model, the Dörges universal laryngoscope blade was comparable to the Macintosh laryngoscope blades size 2-4, and may save time, cost and space.

Excimer laser-assisted extraction of an infected bipolar left ventricular pacing lead implanted 10 years ago

Routine intraoperative transesophageal echocardiography (TEE) revealed a previously undiscovered ventricular positioning of an infected ventricular lead left in place for 10 years. This case report describes successful removal of this lead from the left ventricle by means of excimer laser and discusses some important aspects to be considered.