Targeted temperature management (TTM) with therapeutic hypothermia (TH) during aortic arch surgery requires valid estimations of core body temperature. The ear canal and epitympanic region might be an easy-to-assess, noninvasive site for the read-out of supra-aortic, cerebral temperature. This observational cohort study comparatively investigated in-ear temperature and different core body temperature (cBT) measurements during TTM/TH for moderate hypothermic circulatory arrest (mHCA) in aortic arch surgery. In total 24 patients (mean age of 56.8 +/- 17.5 years; six females) were measured using infrared-thermography of the epitympanic region (BTtym), thermistor-based measurements at the esophagus (BTeso; gold standard), at the ear canal (BTear), at the nasopharynx (BTnas), in the bladder (BTves), and in the rectum (BTrec). The data analysis comprised absolute agreement (AA), bias, intraclass correlation coefficient (ICC), and limit of agreement (LoA). The results revealed high AAs of BTtym, BTear, BTnas in reference to BTeso (biases 0.3-0.6 degrees C), with also excellent ICCs > 0.9. BTves and BTrec showed lower AAs, higher biases of + 2.5 degrees C to 3.1 degrees C with moderate ICCs during mHCA. In the phases of rapid temperature changes, the biases and LoAs were higher throughout all BT measurements. Herein, BTtym performed best of all measurement sites. The study informs about the BT dynamics at different body sites during the mHCA procedure. It supports the approach of using minimally invasive in-ear techniques to estimate core body temperature in an intrahospital TTM/TH setting of mHCA.

Patienten profitieren vom Einsatz von Rückschlagventilen (RSV), wenn Medikamente mit besonders kurzer Halbwertszeit kontinuierlich (z. B. Katecholamine über das Einwegventil) verabreicht werden, und darüber hinaus bei rascher Bolusgabe (z. B. „rapid sequence induction and intubation“), um eine akzidentielle retrograde Applikation von Medikamenten zu verhindern. Ohne RSV besteht die Gefahr, dass Medikamente nur partiell wirken und eine unzureichende Therapie mit negativen Konsequenzen erfolgt. Damit die Anwendung unter den Aspekten der Patientensicherheit erfolgen kann, ist eine Schulung des Personals ausgesprochen wichtig. Im Gegensatz dazu birgt eine Mehrfachverwendung von Medikamenten oder Einwegmaterial durch den lediglichen Austausch des RSV genauso wie die Missachtung sicherheitstechnischer Informationen vermeidbare Gefahren (z. B. Infektionen, „awareness“) für den Patienten. Wie häufig dies gängige Praxis im deutschsprachigen Raum ist, ist nicht bekannt.

Patients benefit from the use of check valves when drugs with a particularly short half-life (e.g., catecholamines) are continually administered through a one-way valve or when an accidental retrograde bolus application must be prevented, as in the event of a rapid sequence induction and intubation. The lack of a check valve can prevent the administered drug from working in the intended manner resulting in potentially insufficient treatment and negative consequences for the patient. In order to ensure the highest level of patient safety while using check valves appropriate training of medical personnel is essential. In contrast, preventable dangers (e.g., infections, awareness) exist when safety measures are disregarded, including the re-use of medications, syringes or disposable materials in successive patients after having only exchanged the check valves. It is not clear how often this is practiced in German-speaking areas.

Pulmonary hypertension (PH) is a known and life limiting complication of preterm born young adults with bronchopulmonary dysplasia (BPD), ultimately leading to progressive right ventricular (RV) failure. Prognosis remains poor, especially in patients unresponsive to modern vasoactive pharmacotherapy. Therefore, lung transplantation presents the treatment of choice to avert cardiac failure. With limited donor organ availability and long waiting times, the implantation of a paracorporeal lung assist device (PLAD) is a way to bridge the patient as an alternative to veno-arterial ECMO. Herein, we present the case of a prematurely born 23-year-old female, who developed severe PH due to BPD and consequently experienced therapy refractory RV failure. Urgent PLAD implantation was performed and the patient successfully underwent double-lung transplantation after 215 days of PLAD support. No major PLAD-associated complications occurred and full recovery of RV function could be observed after double-lung transplantation.

PURPOSE:The aim of the study was to evaluate whether the quantification of B-lines via lung ultrasound after lung transplantation is feasible and correlates with the diagnosis of primary graft dysfunction. METHODS:Following lung transplantation, patients underwent daily lung ultrasound on postoperative days 1-3. B-lines were quantified by an ultrasound score based on the number of single and confluent B-lines per intercostal space, using a four-region protocol. The ultrasound score was correlated with the diagnosis of primary graft dysfunction. Furthermore, correlation analyses and receiver operating characteristics analyses taking into account ultrasound score, chest radiographs, and PaO2/FiO2 ratio were performed. RESULTS:A total of 32 patients (91 ultrasound measurements) were included, whereby 10 were diagnosed with primary graft dysfunction. The median B-line score was 5 [IQR: 4, 8]. There was a significant correlation between B-line score and the diagnosis of primary graft dysfunction (r = 0.59, p < 0.001). A significant correlation could also be seen between chest X-rays and primary graft dysfunction (r = 0.34, p = 0.008), but the B-line score showed superiority over chest X-rays with respect to diagnosing primary graft dysfunction in the receiver operating characteristics curves with an area under the curve value of 0.921 versus 0.708. There was a significant negative correlation between B-line score and PaO2/FiO2 ratio (r = -0.41, p < 0.001), but not between chest X-rays and PaO2/FiO2 ratio (r = -0.14, p = 0.279). CONCLUSION:The appearance of B-lines correlated well with primary graft dysfunction and outperformed chest radiographs.

Obwohl ein systemischer Lupus erythematodes (SLE) häufig Frauen im gebärfähigen Alter betrifft und daher Schwangere mit bekanntem SLE keine Seltenheit sind, stellt die Erstmanifestation eines SLE während der Schwangerschaft eine interdisziplinäre Herausforderung dar. Akute Krankheitsschübe während einer Schwangerschaft erfordern eine enge interdisziplinäre Abstimmung, um sowohl das mütterliche als auch das fetale Wohlergehen zu erhalten.

Obwohl ein systemischer Lupus erythematodes (SLE) haufig Frauen im gebarfahigen Alter betrifft und daher Schwangere mit bekanntem SLE keine Seltenheit sind, stellt die Erstmanifestation eines SLE wahrend der Schwangerschaft eine interdisziplinare Herausforderung dar. Akute Krankheitsschube wahrend einer Schwangerschaft erfordern eine enge interdisziplinare Abstimmung, um sowohl das mutterliche als auch das fetale Wohlergehen zu erhalten.

Introduction: Tranexamic acid (TXA) is the standard medication to prevent or treat hyperfibrinolysis. However, prolonged inhibition of lysis (so-called “fibrinolytic shutdown”) correlates with increased mortality. A new viscoelastometric test enables bedside quantification of the antifibrinolytic activity of TXA using tissue plasminogen activator (TPA). Materials and Methods: Twenty-five cardiac surgery patients were included in this prospective observational study. In vivo, the viscoelastometric TPA test was used to determine lysis time (LT) and maximum lysis (ML) over 96 h after TXA bolus. Additionally, plasma concentrations of TXA and plasminogen activator inhibitor 1 (PAI-1) were measured. Moreover, dose effect curves from the blood of healthy volunteers were performed in vitro. Data are presented as median (25–75th percentile). Results: In vivo TXA plasma concentration correlated with LT (r = 0.55; p < 0.0001) and ML (r = 0.62; p < 0.0001) at all time points. Lysis was inhibited up to 96 h (LTTPA-test: baseline: 398 s [229–421 s] vs. at 96 h: 886 s [626–2,175 s]; p = 0.0013). After 24 h, some patients (n = 8) had normalized lysis, but others (n = 17) had strong lysis inhibition (ML <30%; p < 0.001). The high- and low-lysis groups differed regarding kidney function (cystatin C: 1.64 [1.42–2.02] vs. 1.28 [1.01–1.52] mg/L; p = 0.002) in a post hoc analysis. Of note, TXA plasma concentration after 24 h was significantly higher in patients with impaired renal function (9.70 [2.89–13.45] vs.1.41 [1.30–2.34] µg/mL; p < 0.0001). In vitro, TXA concentrations of 10 µg/mL effectively inhibited fibrinolysis in all blood samples. Conclusions: Determination of antifibrinolytic activity using the TPA test is feasible, and individual fibrinolytic capacity, e.g., in critically ill patients, can potentially be measured. This is of interest since TXA-induced lysis inhibition varies depending on kidney function.

Background In recent years, ultrasound (US) has become more incorporated into anesthesia and intensive care medicine. The German Anesthesia Society established a modular curriculum to teach US skills. Until now, the efficacy of this modular curriculum has not been validated. Objective The main objective of this study was to determine whether there is an increase of knowledge and of psychomotor skills for the trainees in this curriculum. Material and methods After ethical committee approval, 41 anesthesia physicians were enrolled. To determine the increase of knowledge and of practical skills theoretical and practical tests performed were evaluated before and after two different US courses. Results Comparing before and after course tests, the participants showed significant improvement in theoretical multiple choice tests ( p = 0.008). Regarding psychomotor skills following course 1, the trainees improved significantly in the time needed to perform the two practical tests ( p = 0.03), but not in the performance of the test. Better needle visualization during simulated US-guided vessel puncture ( p = 0.52) and better identification of the anatomical structures in the axillary region ( p = 0.56) could not be achieved. Conclusion This study shows that although this US course curriculum has positively enhanced the trainees’ theoretical knowledge of US practice, it does not enhance the practical application of that theoretical knowledge. To improve this curriculum, a supervised clinically practical training should follow the course.

Background and Objectives: Delirium is a common and major complication subsequent to cardiac surgery. Despite scientific efforts, there are no parameters which reliably predict postoperative delirium. In delirium pathology, natriuretic peptides (NPs) interfere with the blood–brain barrier and thus promote delirium. Therefore, we aimed to assess whether NPs may predict postoperative delirium and long-term outcomes. Materials and Methods: To evaluate the predictive value of NPs for delirium we retrospectively analyzed data from a prospective, randomized study for serum levels of atrial natriuretic peptide (ANP) and the precursor of C-type natriuretic peptide (NT-proCNP) in patients undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (off-pump coronary bypass grafting; OPCAB). Delirium was assessed by a validated chart-based method. Long-term outcomes were assessed 10 years after surgery by a telephone interview. Results: The overall incidence of delirium in the total cohort was 48% regardless of the surgical approach (CABG vs. OPCAB). Serum ANP levels >64.6 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 100% (75.3–100) and specificity of 42.9% (17.7–71.1). Serum NT-proCNP levels >1.7 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 92.3% (64.0–99.8) and specificity of 42.9% (17.7–71.1). Both NPs could not predict postoperative survival or long-term cognitive decline. Conclusions: We found a positive correlation between delirium and preoperative plasma levels of ANP and NT-proCNP. A well-powered and prospective study might identify NPs as biomarkers indicating the risk of delirium and postoperative cognitive decline in patients at risk for postoperative delirium.

OBJECTIVESAortic surgery involving hypothermic circulatory arrest (HCA) results in a systemic inflammatory response that may negatively influence outcome. An extracorporeal haemadsorption (HA) device (CytoSorb®) that removes inflammatory triggers may improve haemodynamic and metabolic reactions due to excessive inflammation and, ultimately, outcome.METHODSAs a single-centre experience, the data of 336 patients who had undergone aortic surgery with HCA between 2013 and 2017 were retrospectively analysed. Patients with HA were matched to patients receiving standard therapy without HA (Control) by propensity score matching and compared subsequently.RESULTSDuring aortic surgery with HCA, HA significantly reduced the requirement of norepinephrine (HA: 0.102 µg/kg/min; Control: 0.113; P = 0.043). Severe disturbances of acid-base balance as reflected by a pH lower than 7.19 (HA: 7.1%; Control: 11.6%; P = 0.139), maximum lactate concentrations (HA: 3.75 mmol/l; Control: 4.23 P = 0.078) and the need for tris-hydroxymethylaminomethane buffer (HA: 6.5%; Control: 13.7%; P = 0.045) were less frequent with HA. Compared to standard therapy, HA decreased the need for transfusion of packed red blood cells (1 unit; P = 0.021) and fresh frozen plasma (3 units; P = 0.001), but increased the requirement of prothrombin complex concentrate (800 IE, P = 0.0036). HA did not affect inflammatory laboratory markers on the first postoperative day. Differences in operative mortality (HA: 4.8%; Control: 8.8%) and the length of hospital stay (HA: 13.5 days; Control: 14) were not statistically significant.CONCLUSIONSHA significantly reduces the need for vasopressors, the amount of transfusion and improves acid-base balance in aortic surgery with HCA. Multicentre prospective trials are required to confirm these results.

First, we would like to thank Fessler and Fischler for their interest in our article “Predicting the Necessity for Extracorporeal Circulation During Lung Transplantation: A Feasibility Study.” In their letter to the editor, Fessler and Fischler inquire about the anesthetic management and argue that pulmonary vascular resistance (PVR) might be superior to the mean pulmonary artery pressure (mPAP) in predicting the necessity of extracorporeal circulation because it takes the cardiac output into account.

Objectives: Infections are major causes of morbidity and mortality in the early postoperative period after liver transplant. We observed a high rate of enterococcal infections at our center. Therefore, we added an intraoperative single shot of vancomycin to the standard regimen of meropenem given over 5 days. The aim of this study was to determine the prevalence of both Enterococcus faecium and Enterococcus faecalis infections during the first 28 days after surgery depending on the type of antibiotic prophylaxis and their implications on mortality and morbidity. Materials and Methods: Our retrospective cohort analysis included 179 patients: 93 patients received meropenem only and 86 patients were treated with meropenem plus vancomycin. Results: During the first 28 days after transplant, microbiological tests showed that 51 patients (28.5%) were positive for Enterococcus faecium and 25 patients (14.0%) were positive for Enterococcus faecalis. Enterococcus faecium infections appeared significantly more often in patients without vancomycin (P = .013). In the second week after transplant, there was a significant reduction in Enterococcus faecium infections in the meropenem plus vancomycin group (P = .015). Enterococcus faecalis infections occurred more often in the patients receiving meropenem alone, but results were not statistically significant (P = .194). There was a trend toward more frequent renal replacement therapy in the meropenem plus vancomycin group. We found no differences between the groups regarding survival after 1 and 2 years, length of hospital stay, or duration in the intensive care unit. Overall 1-year survival was 78.8% (141/179 patients). Conclusions: Although postoperative Enterococcus species infections can be reduced after liver transplant by adding vancomycin to the intraoperative antibiotic regimen, it does not improve the long-term outcomes.

•It is unclear if intravenous or volatile anesthetic agents cause more anesthesia-related problems in pediatric inpatients.•In total, nine RCTs comprising 762 children were analyzed.•Propofol during strabismus surgery significantly increased the relative risk of oculocardiac reflex (2 RCTs, 257 children).•PONV was less frequent after general anesthesia with intravenous than with volatile anesthetic agents (5 RCTs, 563 children).

ZusammenfassungDer Einsatz von Ultraschalltechnologie in der Anästhesiologie hat in den letzten Jahren erheblich zugenommen und beschränkt sich nicht mehr nur auf die perioperative ultraschallgesteuerte Anlage von Nervenblockaden oder zentralen Venenkathetern, sondern umfasst mittlerweile auch die prä- und innerklinische Notfallversorgung sowie die postoperative Nachbetreuung auf der Intensivstation. Die Sonografie wird dabei bettseitig im Sinne eines Point-of-Care-Verfahrens vor allem für die Beurteilung von Herz, Lunge und Abdomen eingesetzt. Charakteristischerweise kommt Ultraschall hier als diagnostisches und therapeutisches Werkzeug fokussiert – das heißt, mit einer klar definierten qualitativen Fragestellung, die idealerweise mit ja oder nein zu beantworten ist – zum Einsatz. Für Befunde, die einer weiteren Abklärung oder komplexeren Intervention bedürfen, kann der jeweilige Spezialist (z. B. Kardiologe, Radiologe, Gastroenterologe) hinzugezogen werden. Da die Bedeutung der Sonografie im Bereich der Anästhesiologie und Intensivmedizin für Assistenten in Weiterbildung und Fachärzte voraussichtlich auch in Zukunft weiter zunehmen wird, ist die fundierte Ausbildung in der Ultraschallanwendung für das Fachgebiet von zentraler Bedeutung.

Background. Lung ultrasound (LUS) is a point-of-care technique which can quickly identify or rule out pathological findings. To date, it is unclear if knowledge about the use of LUS is readily available. Objectives. We aimed to identify how much knowledge about the use of LUS is present, if there is a need for teaching in LUS, as well as the preferred teaching method in LUS. Materials and methods. A total of 54 participants from two university departments of anesthesiology were randomized into the groups Online, Classroom, and Control. The Online group was taught by videos, the Classroom group by a traditional lecture with hands-on training, and the Control group was not taught at all. We conducted a pre- and posttest as well as a retention test 4 weeks after the end of the study bymeans of a survey (comparison with Mann-Whitney U test or t-test, respectively, with p < 0.05 considered to be significant). Results. LUS is used "rarely" or "never", and mainly if there is a suspicion for pleural effusion (41.3%). There is a need for LUS (Online: 21.7%; Classroom: 60.9%; Control: 62.5%, p < 0.05). Hybrid teaching consisting of classroom-based and online-based teaching is preferred by the users (Online: 52.2%; Classroom: 56.5%; Control: 62.5%). At the end of the study, 32.6% of the participants of the intervention groups had used LUS in the diagnosis of a pneumothorax. Of the participants, 93.5% planned to use LUS more often in the future. Conclusions. LUS is rarely used. There is a considerable need for teaching of LUS. Internet- based teaching and traditional lectures are considered equal. Both teaching methods improve the knowledge about LUS and lead to increased use of LUS in daily practice. The participants prefer hybrid teaching incorporating both teaching methods.

Durch Lungenultraschall (LUS) können pathologische Befunde schnell und bettseitig nachgewiesen bzw. ausgeschlossen werden. Unklar ist, wie verbreitet Kenntnisse über LUS sind.