Association of free maternal and fetal ropivacaine after epidural analgesia for intrapartum caesarean delivery: a prospective observational trial

BACKGROUND

Ropivacaine is present in plasma in both protein-bound and free forms. The free form is responsible for the occurrence of toxic side effects. During obstetric epidural analgesia, free ropivacaine enters the fetal circulation depending on various factors. The aim of this study was to analyse a potential association between ropivacaine concentrations in maternal and fetal plasma and hence the extent of fetal exposure to ropivacaine.

METHODS

In this prospective monocentre study, parturients who met the following criteria were included in the study: 1. epidural administration as part of obstetric anaesthesia, and 2. subsequent intrapartum caesarean delivery, which 3. was performed after an epidural bolus administration of ropivacaine within the existing epidural analgesia. Total and free ropivacaine concentrations were analysed in maternal blood at baseline, prior to epidural bolus administration for caesarean delivery, and in maternal and fetal (umbilical venous, oxygenated) blood at delivery. The results are presented as mean ± SD or median (25/75th percentile).

RESULTS

We screened 128 parturients who went into labour at term and requested epidural analgesia, of whom 39 were ultimately included in the study. An intrapartum caesarean delivery was performed after the epidural application of 207 (166/276) mg ropivacaine during an epidural treatment period of 577 (360/1010) min. Total and free ropivacaine concentrations were 1402 ± 357 ng/ml and 53 ± 46 ng/ml, respectively, in maternal venous blood and 457 ± 243 ng/ml and 43 ± 27 ng/ml, respectively, in fetal blood. The maternal total and free ropivacaine concentrations were significantly correlated (r = 0.873; P < 0.0001).

CONCLUSION

The results of the present study suggest that determining the concentration of free ropivacaine in maternal blood may be a feasible option for estimating neonatal exposure to ropivacaine.

Workload reduction through automated documentation in intensive and intermediate care - a monocentric observational study

OBJECTIVE

The global coronavirus pandemic has placed an unprecedented and enormous burden on health systems worldwide. In addition to a shortage of resources, nurses were also confronted with high levels of sick leave and an increasing exodus from the profession. Automating documentation obligations is an effective way of reducing the burden on the workplace.

PATIENTS AND METHODS

The study was conducted at a tertiary university hospital. The time required for the manual documentation of administered medication and dose changes of syringe and infusion pumps was recorded using the patient data management system (PDMS) representing all intensive and intermediate care wards (n = 6). Subsequently, all medication administration - grouped into five classes - was evaluated from January 1st, 2019, until December 31st, 2022.

RESULTS

A total of 1,373,340 drug applications were studied, treating 32,499 patients. Data were obtained from ICUs (68%) and IMC wards (32%). This corresponds to an overall time of 2,901 ± 233 hours per year. Based on publicly known national rates for intensive care nurses, an annual financial expenditure of approximately 83,300 € (~ USD 89,300) per year was estimated.

CONCLUSIONS

A non-negligible part of the daily working time in the medical sector is spent on documentation duties. This aggravates the high workload, which has increased in recent years. Automated documentation systems can lead to considerable relief and the possibility of focusing primarily on the patient and on other core competencies and activities. This is even more important, as available staff will be a key resource in patient care for the foreseeable future.

[Mechanisms of action and clinical application of diuretics in intensive care medicine]

The paired kidneys play a significant role in the human body due to the multitude of physiological tasks. Complex biochemical processes keep the sensitive electrolyte and water balance stable and thus ensure the organism's ability to adapt to exogenous and endogenous factors, which is essential for survival. The drug class of diuretics includes substances with very differing pharmacological characteristics. The functioning of the nephron is therefore indispensable for a deeper understanding of the pharmacodynamics, pharmacokinetics and side effect profile of diuretics. In the treatment of acute heart failure with pulmonary congestion, certain diuretics represent an important therapeutic option to counteract hypervolemia and thus an increase in preload. According to current data, diuretics have no proven benefits in the treatment or prevention of acute kidney injury but they can counteract hypervolemia and under certain conditions even reduce the use of renal replacement procedures.

Iron deficiency in cardiac surgical patients

Iron is an essential element and involved in a variety of metabolic processes including oxygen transport, cellular energy production, energy metabolism of heart muscles, brain function, cell growth and cell differentiation. Preoperative anaemia is an independent risk factor for poor outcome. Recently, iron deficiency was considered only in the context of anaemia. However, negative consequences of iron deficiency in the absence of anaemia have been described for patients undergoing cardiac surgery. To date, the benefit of intravenous iron supplementation in these patients has been controversially debated. In this review, we discuss the latest progress in studies of intravenous iron supplementation in iron deficient cardiac surgical patients.

Impact of the Covid-19 pandemic on melanoma and non-melanoma skin cancer inpatient treatment in Germany - a nationwide analysis

BACKGROUND

SARS-CoV-2 has massively changed the care situation in hospitals worldwide. Although tumour care should not be affected, initial reports from European countries were suggestive for a decrease in skin cancer during the first pandemic wave and only limited data are available thereafter.

OBJECTIVES

The aim of this study was to investigate skin cancer cases and surgeries in a nationwide inpatient dataset in Germany.

METHODS

Comparative analyses were performed in a prepandemic (18 March 2019 until 17 March 2020) and a pandemic cohort (18 March 2020 until 17 March 2021). Cases were identified and analysed using the WHO international classification of diseases codes (ICDs) and process key codes (OPSs).

RESULTS

Comparing the first year of the pandemic with the same period 1 year before, a persistent decrease of 14% in skin cancer cases (n = 19 063) was observed. The largest decrease of 24% was seen in non-invasive in situ tumours (n = 1665), followed by non-melanoma skin cancer (NMSC) with a decrease of 16% (n = 15 310) and malignant melanoma (MM) with a reduction of 7% (n = 2088). Subgroup analysis showed significant differences in the distribution of sex, age, hospital carrier type and hospital volume. There was a decrease of 17% in surgical procedures (n = 22 548), which was more pronounced in minor surgical procedures with a decrease of 24.6% compared to extended skin surgery including micrographic surgery with a decrease of 15.9%.

CONCLUSIONS

Hospital admissions and surgical procedures decreased persistently since the beginning of the pandemic in Germany for skin cancer patients. The higher decrease in NMSC cases compared to MM might reflect a prioritization effect. Further evidence from tumour registries is needed to investigate the consequences of the therapy delay and identify the upcoming challenges in skin cancer care.

Patient blood management during the COVID-19 pandemic: a narrative review

As COVID-19 disease escalates globally, optimising patient outcome during this catastrophic healthcare crisis is the number one priority. The principles of patient blood management are fundamental strategies to improve patient outcomes and should be given high priority in this crisis situation. The aim of this expert review is to provide clinicians and healthcare authorities with information regarding how to apply established principles of patient blood management during the COVID-19 pandemic. In particular, this review considers the impact of the COVID-19 pandemic on blood supply and specifies important aspects of donor management. We discuss how preventative and control measures implemented during the COVID-19 crisis could affect the prevalence of anaemia, and highlight issues regarding the diagnosis and treatment of anaemia in patients requiring elective or emergency surgery. In addition, we review aspects related to patient blood management of critically ill patients with known or suspected COVID-19, and discuss important alterations of the coagulation system in patients hospitalised due to COVID-19. Finally, we address special considerations pertaining to supply-demand and cost-benefit issues of patient blood management during the COVID-19 pandemic.

P1844Blood erythropoietin independently predicts mid-term survival after post-procedural recovery from transcatheter aortic valve replacement in aortic stenosis: a prospective study

Background

Erythropoietin (EPO) is an independent predictor for survival in chronic heart failure, myocardial infarction and other cardiac disorders. In a prospective observational study, independent prognostic value of EPO levels in patients with symptomatic aortic stenosis undergoing TAVR was investigated.

Methods

All consecutive patients undergoing TAVR in a high-volume centre in a 19-month period were included. A 1-year follow-up was completed. Patients with eGRF <30 mL/min/1.73m2 were excluded. WHO guidelines were used to define anaemia (Hb <12mg/dl for women, <13mg/dl for men). Chronic kidney disease (CKD) stages were used to classify eGFR: CKD 1 (>90), 2 (60–90), 3a (45–59), 3b (30–44).

Pre-procedural anaemia status, EPO levels and iron deficiency were compared in 1-year survivors vs. non-survivors. Log-EPO levels were used for a univariate Cox regression analysis of 1-year mortality. Baseline variables considered to be clinically relevant or found significant in univariate analysis were included in multivariate analysis. Kaplan-Meier curves were constructed for patients in each EPO quartile.

Results

185 patients with complete data were included in analyses. Mean age was 81.8 years, 58.4% were male, and 72.4% had NYHA III/IV. Baseline anaemia was present in 51.4% and iron deficiency in 49.2%. Median ferritin was 149.5 (16–1995) μg/L, mean transferrin saturation index was 150±46.7% and median EPO was 13.8 (2.7–231.6) mU/mL.

Thirty-day and 1-year mortality were 3.8%, and 18.9%. Baseline anaemia was significantly associated to 1-year mortality: 29.5% vs 7.8%, p=0.001. Iron deficiency had no impact on mortality (18.1% vs 19.8%, p=ns). At 1 year, pre-procedural EPO levels in non-survivors were significantly higher than in survivors: median 20.30 (6.1–231.6) vs 12.9 (2.7–136) mU/mL; p=0.001.

Higher log-EPO levels predicted 1-year mortality in univariate analysis (HR 6.1, 95% CI 2.5–14.9, p=0.0001). Other significant univariate predictors were pre-procedural anaemia (HR 4.2, 95% CI 1.8–9.7, p=0.001), eGFR, EuroSCORE II, body mass index, and previous atrial fibrillation. A multivariate analysis of EPO after adjusting for such factors was also significant (HR 3.1, 95% CI 1.06–8.9, p=0.039). Kaplan-Meier analyses showed early diverging curves for anaemia vs non-anaemia, whereas the curves for patients in various EPO level quartiles started to diverge at about 100 days after the intervention, with differences consistently increasing during the whole follow-up period. Curve slopes were increasingly higher in successively higher quartiles (figure).

1-year Kaplan-Meier for EPO and anemia

Conclusion

Differently from anaemia, a strong predictor for both early and late mortality after TAVR, high pre-procedural EPO levels were an independent predictor for mid-term mortality, with its predictive value only emerging after post-procedural recovery was completed. EPO predictive value was independent from anaemia or renal dysfunction.

P3720Cerebral near-infrared spectroscopy monitoring during transcatheter aortic valve implantation

Introduction

Stroke and transient ischemic attack (TIA) are important periprocedural cerebrovascular complications of transcatheter aortic valve implantation (TAVI). Regional cerebral O2 saturation is an indicator for cerebral perfusion and can be measured in real-time and noninvasively by near-infrared spectroscopy (NIRS). In this pilot study we evaluated the feasibility and utility of NIRS during TAVI.

Methods

Regional cerebral O2 saturation (rScO2, bihemispheric) was measured by near-infrared spectroscopy during 32 transfemoral TAVI procedures (female 56.3%, mean age 81.8 years). All patients received conscious sedation and O2-supplement if peripheral oxygen saturation (SpO2) was below 95%. Baseline rScO2 was measured at the beginning of the procedure, as well as before, during and 5min after rapid pacing for valve deployment.

Results

Mean preoperative mini mental state examination score was 26.5 points (theoretically max. 30 points, >24 points no severe cognitive impairment). Two-third of the patients (n=21) required oxygen supply (mean 4.0 l/min) during the TAVI procedure. Mean baseline rScO2 was 59.3% with no differences between both cerebral hemispheres (left 60.3% vs. right 58.7% p=0.23). Compared to baseline rScO2 and rScO2 assessed immediately before rapid passing, rScO2 dropped significantly during rapid pacing (59.3% vs. 51.8%, p<0.01 and 60.9% vs. 51.8%, p<0.01 respectively). Five minutes after rapid pacing rScO2 values had normalized again (post rapid pacing 60.9% vs. 51.8% during rapid pacing, p<0.01; baseline 59.3% vs. post rapid pacing 60.9%, p=0.51). Intraprocedural cerebrovascular events were observed in two cases. One patient developed a left-sided hemiplegia (stroke, later verified by cerebral CT scan) and one patient a transient tremor of the left upper extremity (TIA, new hemorrhagic or ischemic event ruled out by cerebral CT scan). In both cases we observed an abnormal sudden rScO2 decrement by the corresponding right hemispheric NIRS sensor (left-right hemisphere sensor: 60% vs. 44% and 63% vs. 48% respectively).

Conclusion

Regional cerebral O2 saturation, an indicator for cerebral perfusion, decreases significantly during rapid pacing of TAVI procedure. Furthermore, rScO2 measurement by NIRS may be helpful to detect cerebrovascular complications early during TAVI procedure.

[Various scenarios for billing and remuneration of preoperative management of iron deficiency anemia in the German healthcare system]

More than 30% of all patients undergoing surgery suffer from preoperative anemia. Iron deficiency anemia is the most common type of anemia. The diagnostics and treatment of iron deficiency anemia can be carried out before patients undergo surgery as an alternative to blood transfusion and is an interdisciplinary task. This article gives an overview of various billing modalities and payment arrangements for management of preoperative anemia in the German healthcare system.

[Imaging techniques in modern trauma diagnostics]

Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.

[Imaging techniques in modern trauma diagnostics]

Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.

The detection of microbial DNA but not cultured bacteria is associated with increased mortality in patients with suspected sepsis-a prospective multi-centre European observational study

OBJECTIVES

Blood culture results inadequately stratify the mortality risk in critically ill patients with sepsis. We sought to establish the prognostic significance of the presence of microbial DNA in the bloodstream of patients hospitalized with suspected sepsis.

METHODS

We analysed the data collected during the Rapid Diagnosis of Infections in the Critically Ill (RADICAL) study, which compared a novel culture-independent PCR/electrospray ionization-mass spectrometry (ESI-MS) assay with standard microbiological testing. Patients were eligible for the study if they had suspected sepsis and were either hospitalized or were referred to one of nine intensive care units from six European countries. The blood specimen for PCR/ESI-MS assay was taken along with initial blood culture taken for clinical indications.

RESULTS

Of the 616 patients recruited to the RADICAL study, 439 patients had data on outcome, results of the blood culture and PCR/ESI-MS assay available for analysis. Positive blood culture and PCR/ESI-MSI result was found in 13% (56/439) and 40% (177/439) of patients, respectively. Either a positive blood culture (p 0.01) or a positive PCR/ESI-MS (p 0.005) was associated with higher SOFA scores on enrolment to the study. There was no difference in 28-day mortality observed in patients who had either positive or negative blood cultures (35% versus 32%, p 0.74). However, in patients with a positive PCR/ESI-MS assay, mortality was significantly higher in comparison to those with a negative result (42% versus 26%, p 0.001).

CONCLUSIONS

Presence of microbial DNA in patients with suspected sepsis might define a patient group at higher risk of death.

[Aggression and subjective risk in emergency medicine : A survey]

BACKGROUND

Healthcare personnel may be faced with different degrees of violence and aggression, particularly concerning preclinical care. However, systematic data with respect to the frequency and type of violence in emergency medicine in Germany has not been researched.

METHODS AND OBJECTIVES

At an anesthesiology congress, an anonymous survey was distributed about the different kinds and extent of violent acts that the participants had experienced during their work in emergency medicine. Moreover, the participants' subjective feelings toward professional and personal safety when handling emergency cases were explored.

RESULTS

Every fourth participant in the survey (25.2 %) had experienced occupational physical violence within the last 12 months. Verbal harassment or insults within the last twelve months were reported by 58.2 % of the participants. While 80 % of the participants feel "entirely" or "mostly" safe with regard to the professional aspect of their occupation, personal safety was considered "entirely" in only 9.3 % and "mostly" in 46.4 % of the cases. Nearly every third participant (31.8 %) feels only "partially" safe and every eighth participant feels "rather not" or "not at all" safe during emergency medicine missions. Men appreciate their expertise as well as their personal safety more so than women (p < 0.001).

CONCLUSION

Aggression and violence towards healthcare personnel in emergency medicine occur on a regular basis in the German healthcare system. Little research has been conducted in this area, so the issue has not yet been perceived as a relevant problem. Appropriate training for healthcare personnel in emergency medicine should be targeted at developing the skills needed when encountered with aggression and occupational violence.

[Cost analysis of patient blood management]

BACKGROUND

Patient blood management (PBM) is a multidisciplinary approach focusing on the diagnosis and treatment of preoperative anaemia, the minimisation of blood loss, and the optimisation of the patient-specific anaemia reserve to improve clinical outcomes. Economic aspects of PBM have not yet been sufficiently analysed.

OBJECTIVES

The aim of this study is to analyse the costs associated with the clinical principles of PBM and the project costs associated with the implementation of a PBM program from an institutional perspective.

MATERIALS AND METHODS

Patient-related costs of materials and services were analysed at the University Hospital Frankfurt for 2013. Personnel costs of all major processes were quantified based on the time required to perform each step. Furthermore, general project costs of the implementation phase were determined.

RESULTS

Direct costs of transfusing a single unit of red blood cells can be calculated to a minimum of €147.43. PBM-associated costs varied depending on individual patient requirements. The following costs per patient were calculated: diagnosis of preoperative anaemia €48.69-123.88; treatment of preoperative anaemia (including iron-deficiency anaemia and megaloblastic anaemia) €12.61-127.99; minimising perioperative blood loss (including point-of-care diagnostics, coagulation management and cell salvage) €3.39-1,901.81; and costs associated with the optimisation of the tolerance to anaemia (including patient monitoring and volume therapy) €28.62. General project costs associated with the implementation of PBM were €24,998.24.

CONCLUSIONS

PBM combines various alternatives to the transfusion of red blood cells and improves clinical outcome. Costs of PBM vary from institution to institution and depend on the extent to which different aspects of PBM have been implemented. The quantification of costs associated with PBM is essential in order to assess the economic impact of PBM, and thereby, to efficiently re-allocate health care resources. Costs were determined at a single university hospital. Thus, further analyses of both the costs of transfusion and the costs of PBM-principles will be necessary to evaluate the cost-effectiveness of PBM.

[Occupational exposure to blood in multiple trauma care]

BACKGROUND

Trauma care personnel are at risk of occupational exposure to blood-borne pathogens. Little is known regarding compliance with standard precautions or occupational exposure to blood and body fluids among multiple trauma care personnel in Germany.

AIM

Compliance rates of multiple trauma care personnel in applying standard precautions, knowledge about transmission risks of blood-borne pathogens, perceived risks of acquiring hepatitis B, hepatitis C and human immunodeficiency virus (HIV) and the personal attitude towards testing of the index patient for blood-borne pathogens after a needlestick injury were evaluated.

MATERIAL AND METHODS

In the context of an advanced multiple trauma training an anonymous questionnaire was administered to the participants.

RESULTS

Almost half of the interviewees had sustained a needlestick injury within the last 12 months. Approximately three quarters of the participants were concerned about the risk of HIV and hepatitis. Trauma care personnel had insufficient knowledge of the risk of blood-borne pathogens, overestimated the risk of hepatitis C infection and underused standard precautionary measures. Although there was excellent compliance for using gloves, there was poor compliance in using double gloves (26.4 %), eye protectors (19.7 %) and face masks (15.8 %). The overwhelming majority of multiple trauma care personnel believed it is appropriate to test an index patient for blood-borne pathogens following a needlestick injury.

CONCLUSION

The process of treatment in prehospital settings is less predictable than in other settings in which invasive procedures are performed. Periodic training and awareness programs for trauma care personnel are required to increase the knowledge of occupational infections and the compliance with standard precautions. The legal and ethical aspects of testing an index patient for blood-borne pathogens after a needlestick injury of a healthcare worker have to be clarified in Germany.

[Eleven years of core data set in intensive care medicine. Severity of disease and workload are increasing]

BACKGROUND

In the year 2000 a working group of the German Interdisciplinary Association for Intensive Care Medicine (DIVI) defined a core data set on quality assurance for the first time. In the following years the participating intensive care units sent data to the registry on a voluntary basis and received an annual report on benchmarking data. Alterations in the quality in the field of intensive care medicine have so far only been published to a very low extent.

AIM

This study analyzed the core date set of the DIVI between 2000 and 2010 in respect to changes in disease severity using the simplified acute physiology score (SAPS II), the sequential organ failure assessment (SOFA), the need for therapeutic interventions with the therapeutic intervention scoring system (TISS 28) and intensive care unit (ICU) mortality.

MATERIAL AND METHODS

Inclusion criteria were participation in the registry for at least 4 years, SAPS II, SOFA, TISS28 scores available and data on ICU discharge. A standardized mortality rate (SMR) was calculated for each year.

RESULTS

The mean SAPS II score including 94,398 patients increased by 0.23 points/year with a standard error (SE) of 0.02 to 26.9 ± 12 points (p < 0.001). Similarly, the SOFA score on admission to the ICU increased by 0.14 points/year (SE 0.04) to 3.4 ± 2.7 points (p < 0.001), the proportion of patients with a two organ failure doubled to 7.1 % and the number of patients dependent on ventilation increased by 13.6 % to 59.8 %. The mean time on ventilation increased by 0.17 ventilator days/year (SE 0.01, p < 0.001) to 3.1 ± 7.5 days/patient. The mean number of therapeutic interventions increased by 8.7 % to 26.3 ± 8.3 TISS 28 points/day. The mean length of stay on the ICU (4.3 ± 8 days) and the age of the patients (63.2 ± 17.0 years) remained unchanged. The readmission rate showed no significant changes between the years 2004 and 2010. The readmission rate to the ICU within 48 h after primary discharge was 3.1 % with a 95 % confidence interval (CI) of 3.0-3.3 in contrast to 1.5 % (95 % CI 1.4-1.6) for readmission to the ICU after 48 h. The length of stay in hospital before admission to the ICU decreased for patients with scheduled surgery (6.3 ± 9.7 days vs. 4.2 ± 6.9 days), increased slightly for patients with medically indicated admission to the ICU (2.4 ± 8.2 days 3.1 ± 8.6 days) and remained unchanged for patients with unscheduled admission to the ICU after surgery (4.1 ± 8.6 days). The SMR decreased between 2000 and 2004 from 0.97 to 0.72 and increased again thereafter to 0.99 (ICU mortality 8.5 %).

CONCLUSION

The severity of disease on admission to the ICU, the proportion of patients on ventilation and the workload of therapeutic interventions increased between 2000 and 2010 in German ICUs but the length of stay of patients in the ICU remained unchanged. The SMR decreased until 2005 and increased thereafter to return to the initial values. The overall ICU mortality was low compared to international data.

Risk factors associated with adverse outcome following extracorporeal life support: analysis from 360 consecutive patients

OBJECTIVE

Risk factors for adverse outcome after extracorporeal life support (ECLS) are yet to be defined. For this purpose, we reviewed our institutional data from more than a decade, focusing on patients with ECLS.

METHODS

Between December 2001 and June 2013, 360 consecutive cardiac surgical patients received ECLS for post-cardiotomy cardiogenic shock, with high mortality risk despite optimal conventional therapy. Patient demographics, clinical characteristics, ECLS-related morbidity, as well as in-hospital and long-term mortality were analysed. Multivariate logistic regression analysis was performed to identify independent predictors of adverse outcome (failed ECLS weaning, in-hospital mortality).

RESULTS

The mean age was 62±17 years, 76% were male and the mean preoperative ejection fraction was 35±16%. ECLS was established through peripheral (90%) or central thoracic cannulation. The mean duration of ECLS was 7±1 days. Intra-aortic balloon pumps were implanted in 22% of the patients. ECLS weaning was successful in 58% and 30% could be discharged from hospital. The main cause of death was sepsis (69%). Overall, major cerebrovascular events occurred in 12% (bleeding 3%, embolic 9%), limb ischaemia in 13%, gastrointestinal complications in 16% and renal replacement therapy in 61%. Independent risk factors for adverse outcome were prior cardiorespiratory resuscitation (OR: 4.1, 95%CI: 0.34-4.21, p=0.04), pH <7.1 (OR: 2.8, 95%CI: 0.45-3.28, p=0.01), serum lactate >120 mg/dL (OR: 2.6, 95%CI: 0.75-2.96, p< 0.01), norepinephrine dosage >0.5 µg/kg/min (OR: 2.4, 95%CI: 0.35-2.92, p=0.02) and age >75 years (OR: 2.0, 95%CI: 0.41-2.88, p=0.02). Kaplan Meier estimates for long-term survival were 26±3% at one year and 22±2% at five years.

CONCLUSION

ECLS therapy offers one-year survival to one quarter of patients with an otherwise fatal prognosis. Procedural mortality is low and morbidity at the implantation site typically moderate. Thus, prolonged metabolic deterioration in combination with high-dose vasopressor support prior to ECLS therapy should be avoided, particularly in younger patients.

Remote preconditioning and major clinical complications following adult cardiovascular surgery: systematic review and meta-analysis

BACKGROUND

A number of 'proof-of-concept' trials suggest that remote ischaemic preconditioning (RIPC) reduces surrogate markers of end-organ injury in patients undergoing major cardiovascular surgery. To date, few studies have involved hard clinical outcomes as primary end-points.

METHODS

Randomised clinical trials of RIPC in major adult cardiovascular surgery were identified by a systematic review of electronic abstract databases, conference proceedings and article reference lists. Clinical end-points were extracted from trial reports. In addition, trial principal investigators provided unpublished clinical outcome data.

RESULTS

In total, 23 trials of RIPC in 2200 patients undergoing major adult cardiovascular surgery were identified. RIPC did not have a significant effect on clinical end-points (death, peri-operative myocardial infarction (MI), renal failure, stroke, mesenteric ischaemia, hospital or critical care length of stay).

CONCLUSION

Pooled data from pilot trials cannot confirm that RIPC has any significant effect on clinically relevant end-points. Heterogeneity in study inclusion and exclusion criteria and in the type of preconditioning stimulus limits the potential for extrapolation at present. An effort must be made to clarify the optimal preconditioning stimulus. Following this, large-scale trials in a range of patient populations are required to ascertain the role of this simple, cost-effective intervention in routine practice.

[Basic algorithm for Point-of-Care based hemotherapy: perioperative treatment of coagulopathic patients]

During perioperative treatment of coagulopathic patients the so-called Point-of-Care (POC) analyses enable more rapidly available and more comprehensive hemostatic analyses compared to routinely performed conventional coagulation testing, such as activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen concentration and platelet count. In this review article a hemotherapy algorithm is presented which is based on viscoelastic and aggregometric POC measurements. The algorithm was designed double sided and consists of a general and a special part. The general part contains boxes and fields for sociodemographic data and gives general recommendations for coagulation management and therapy specifications for particular patient collectives and presents proposals for emergency reversal of anticoagulation therapy. The special part refers to basic physiological conditions for hemostasis and asks for measurement results of clot initiation, clot firmness, clot stability and platelet function analyses. Reference values were defined for each parameter and therapeutic options are presented. In cases of persistent coagulopathy despite algorithm-conform therapy, the algorithm could be run through once again. Finally, the algorithm presents therapeutic options for an ultima ratio therapy approach.

Pre-conditioning with synthetic CpG-oligonucleotides attenuates myocardial ischemia/reperfusion injury via IL-10 up-regulation

The aim of the study was to investigate whether pre-conditioning with CpG-oligodeoxynucleotides (CpG-ODN) may change cardiac ischemia/reperfusion (I/R)-dependent inflammation and modulates infarct size and cardiac performance. WT and TLR9-deficient mice were pre-treated with 1668-, 1612- and H154-thioate or D-Gal as control. Priming with 1668-thioate significantly induced inflammatory mediators in the serum and a concomitant increase of immune cells in the blood and spleen of WT mice. Furthermore, it induced myocardial pattern recognition receptors and pro-inflammatory cytokines peaking 2 h after priming and a continuous increase of IL-10. 16 h after pre-conditioning, myocardial ischemia was induced for 1 h. Infarct size determined after 24 h of I/R was reduced by 75 % due to pre-conditioning with 1668-thioate but not in the other groups. During reperfusion, cytokine expression in 1668-thioate primed mice increased further with IL-10 exceeding the other mediators by far. These changes were observed neither in animals pre-treated with 1612- or H154-thioate nor in TLR9-deficient mice. The 1668-thioate-dependent increase of IL-10 was further supported by results of a micro-array analysis 3 h after begin of reperfusion. Block of IL-10 signaling increased I/R size and prevented influence of priming. In the group pre-treated with 1668-thioate, cardiac function was preserved 24 h, 14 days and 28 days after I/R, whereas animals without pre-conditioning exhibited impaired heart function 24 h and 14 days after I/R. The excessive 1668-thioate-dependent IL-10 up-regulation during pre-conditioning and after I/R seems to be the key factor for reducing infarct size and improving cardiac function. This is in agreement with the finding that IL-10 block prevents cardioprotection by pre-conditioning.

[Routine subclavian revascularisation employing regional anaesthesia]

INTRODUCTION

The increasing incidence of endovascular surgery on the thoracic aorta (TEVAR) is leading to an increased rate of subclavian-carotid transposition (SCT). Intentional overstenting of the left subclavian artery extends the proximal landing zone. If overstenting leads to a subclavian steal syndrome, vertebrobasilar insufficiency or if the risk of spinal ischaemia is present, SCT can safely be carried out with regional anaesthesia by means of a cervical block.

MATERIALS AND METHODS

Since January 2010 regional anaesthesia was employed in 13 consecutive patients receiving an SCT in our clinic. Subclavian revascularisation was performed either as adjunct procedure for TEVAR or in patients with occlusive disease of the aortic arch. The clinical course was prospectively observed.

RESULTS

In 62 % of the cases (n = 8) a transposition of the subclavian artery onto the common carotid artery was carried out. In 38 % of the cases (n = 5) an intraoperative decision was made to construct a carotid-subclavian bypass. In 30 % (n = 4) of the cases a conversion from cervical block to general anaesthesia was necessary. All reconstructions proved to be patent at follow-up.

CONCLUSION

Subclavian-carotid transposition under regional anaesthesia is safe and technically feasible if occlusion of the subclavian artery by thoracic stentgraft or stenosis has occurred. The technique employing regional anaesthesia can, therefore, also be offered to patients with increased risk for complications due to general anaesthesia.

[An online emergency physician survey - demography, education and experience of German emergency physicians]

BACKGROUND AND OBJECTIVE

German emergency patients are treated by (emergency) physicians (EP). The entry level to emergency medicine differs. Manual skills experience (e. g. tracheal intubation) and knowledge of guidelines are minimum requirements. It is currently unclear who works as an EP and what medical experience he or she has.

METHODS

The anonymous survey was online from 10/15/2010 to 11/16/2011 and distribution was supported by leading physicians informing society members. Online networks informed independent physicians.

RESULTS

2091 EP took part, 1991 datasets were evaluated, 100 datasets were excluded. All results are shown as mean ± standard deviation and range (minimum - maximum). Mean age of the EP was 42 ± 8 years (26-71 years), 80 % (n = 1604) were male, 20 % (n = 387) were female. Participants finished medical school in 1997 ± 8 years (1964-2010). Base specialty during rotation was anesthesiology 59 %, internal medicine 32 %, surgery 26 %, trauma surgery/orthopedics 21 %, others 16 %. Consultants were 75 %. Main income source was answered as "hospital physician" by 77 %, "resident doctor" by 15 %, "professional emergency physician" by 7 %. The participants use a widespread chance for CME (Continuing Medical Education).

CONCLUSION

The participants appear experienced in medicine and emergency medicine. They use a widespread chance for CME. Most of the participants work in anaesthesiology.