Surgical bailout during transcatheter aortic valve replacement (TAVR) is rare but highly critical. We evaluated the impact of hospital infrastructure, procedural setting, timing metrics, and haemodynamic stability on patients requiring emergent surgical bailout. A single-centre analysis was conducted on consecutive TAVR cases requiring emergent surgical bailout between 2009 and 2024. Two eras were compared: Era 1 (2009–2016), with procedures performed in a conventional catheterisation laboratory (CCL) requiring transfer to a distant operating room, and Era 2 (2017–2024), using a purpose-built hybrid operating room (HOR) with all disciplines on site. The primary endpoint was in-hospital mortality. Secondary endpoints included time to extracorporeal life support (ECLS) initiation and surgical incision. Of 3039 TAVR procedures, 16 patients (0.53

BACKGROUND:Neuromuscular blocking agents dose-dependently precipitate residual neuromuscular blockade and postoperative respiratory complications. The introduction of sugammadex allowed for reversal of even deep neuromuscular blockade and might have provoked more liberal use of neuromuscular blocking agents. The authors investigated whether the introduction of sugammadex led to higher intraoperative rocuronium doses and whether this impacted postoperative respiratory complications. METHODS:A total of 163,402 adult patient cases who underwent general anesthesia and received exclusively rocuronium at an academic medical center between 2010 and 2024 were included. Interrupted time series analysis adjusted for patient and procedural characteristics was applied to assess changes in cumulative intraoperative rocuronium doses (milligrams per kilogram body weight) after sugammadex introduction in September 2016. Rocuronium-associated risks of postoperative respiratory complications (postextubation desaturation less than 90%, 7-day reintubation or emergency noninvasive ventilation) and effect modification by use of sugammadex and qualitative (twitch count) versus quantitative (train-of-four ratio) neuromuscular monitoring were evaluated. Reported odds ratios represent the dose-response association (per 1 mg/kg rocuronium increase) within the respective subgroup of patient cases. RESULTS:After a stable baseline (-0.01 mg/kg per year between January 2010 and August 2016; 95% CI, -0.05 to 0.03 mg/kg; P = 0.58), rocuronium doses increased by 0.05 mg/kg annually after introduction of sugammadex (95% CI, 0.03 to 0.07 mg/kg; P < 0.001) from (mean ± SD) 0.83 ± 0.49 mg/kg in August 2016 to 1.20 ± 0.65 mg/kg in January 2024. A total of 9,101 of 108,317 patient cases (8.4%) experienced postoperative respiratory complications. Rocuronium was dose-dependently associated with higher postoperative respiratory complication risks, which was most pronounced among patient cases receiving neither sugammadex nor neuromuscular monitoring (adjusted odds ratio [OR adj ], 1.99 per 1 mg/kg; 95% CI, 1.82 to 2.18; P < 0.001). This association was attenuated when sugammadex was administered (n = 42,141; median dose, 200 mg; interquartile range, 200 to 300 mg; OR adj , 1.08 per 1 mg/kg; 95% CI, 1.01 to 1.16; P = 0.023; P for interaction < 0.001) and abolished with quantitative (n = 25,564; OR adj , 10.94 per 1 mg/kg; 95% CI, 0.85 to 1.03; P = 0.19; P for interaction < 0.001) but not qualitative neuromuscular monitoring (n = 49,045; OR adj , 1.10 per 1 mg/kg; 95% CI, 1.02 to 1.18; P = 0.017; P for interaction < 0.001). CONCLUSIONS:Sugammadex introduction was followed by a 45.1% increase in rocuronium doses. While sugammadex attenuated the risk of postoperative respiratory complications, it was completely abolished only with quantitative neuromuscular monitoring.

Um die Effektivität von Wiederbelebungsmaßnahmen und die Behandlungsergebnisse zu optimieren, ist eine kontinuierliche Weiterentwicklung der kardiopulmonalen Reanimation (CPR) notwendig. Dieser Übersichtsartikel diskutiert Erkenntnisse der Reanimationsforschung und die Integration dieser neuen Behandlungsansätze in Algorithmen. Besondere Aufmerksamkeit gilt der „individualisierten“ CPR. Anstelle eines allgemeinen „One-size-fits-all“-Ansatzes wird eine gezielte CPR unter Optimierung diagnostischer und therapeutischer Aspekte betrachtet. Hochqualitative Thoraxkompressionen sind ein Qualitätsmerkmal der CPR und die Kapnographie ein bewährtes Instrument zur Hämodynamikeinschätzung. Der diastolische Blutdruck (DBP) scheint dem endtidalen Kohlenstoffdioxid überlegen zu sein, da er die Koronarperfusion besser widerspiegelt. Hierbei sollten DBP-Zielwerte >25 mmHg angestrebt werden, da sie mit besseren Überlebensraten- und neurologischen Ergebnissen korrelieren. Kontinuierliche Adrenalin- und Volumengaben können den DBP erhöhen und die Rückkehr eines Spontankreislaufs verbessern. Darüber hinaus kann die transösophageale Echokardiographie dazu beitragen, den optimalen Druckpunkt für Thoraxkompressionen zu identifizieren und somit die Effektivität zu steigern. Da die palpatorische Pulskontrolle nicht optimal geeignet ist und die „No-Flow“-Zeit verlängert, kann als bessere Alternative die sonographische Pulskontrolle eingesetzt werden. Falls herkömmliche Reanimationsmaßnahmen erfolglos bleiben, kann die extrakorporale kardiopulmonale Reanimation mittels venoarterieller Membranoxygenierung in Erwägung gezogen werden.

Resuscitation research plays a crucial role in improving survival rates and neurological outcomes following cardiac arrest. This review highlights essential aspects of current resuscitation research and examines the integration of various treatment approaches into existing resuscitation protocols, with a particular focus on individualized resuscitation. The current literature on several key topics in resuscitation is presented. High-quality chest compressions are a central quality feature of cardiopulmonary resuscitation (CPR). Capnography is a proven tool for quantifying hemodynamics during CPR. Diastolic blood pressure (DBP) appears to be a superior parameter compared to end-tidal carbon dioxide, as it reflects coronary perfusion more precisely. Target values for diastolic blood pressure (DBP) should >25 mmHg, as they correlate with improved survival rates and better neurological outcomes. Continuous administration of adrenaline and fluids can increase DBP and improve the chances of return of spontaneous circulation. Additionally, ultrasound, particularly transesophageal echocardiography, can help identify the optimal compression point for chest compressions, thereby increasing CPR effectiveness. Pulse checks are not optimally suited for detecting cardiac arrest or return of spontaneous circulation and prolong the "no-flow" time. A significantly better alternative may be the use of ultrasound for pulse checks. If conventional resuscitation fails, extracorporeal CPR can be considered.

The management of critically ill patients, arriving at the emergency department (ED), requires structured care in critical care facilities, particularly in the resuscitation room. This study examines the significance of initial vital signs and blood gas analysis (BGA)-derived values as clinically useful early indicators of mortality risk in critically ill patients, both during in the resuscitation room care and within the following 30 days, with a focus on evaluating the individual predictive performance of accessible clinical parameters. We pooled data from two consecutive retrospective observational studies in a German university ED to analyze an unselected patient population of non-traumatic critically ill patients. Vital signs, such as heart rate, systolic blood pressure, and BGA values (including pH, bicarbonate, carbon dioxide, glucose, lactate, electrolyte levels) on admission to the ED, were used to estimate the impact on both resuscitation room and 30-day mortality. In 1,536 critically ill patients, pH, lactate and bicarbonate were found to be potential predictors of resuscitation room mortality. In contrast, vital signs showed limited reliability in predicting outcomes. Of all tested variables, pH demonstrated the highest area under the curve (AUC) value among the analyzed markers for resuscitation room mortality (AUC 0.81 [95

BACKGROUND:Inhalational anaesthesia agents contribute to healthcare-related greenhouse gas emissions. We evaluated the carbon footprint of inhalation anaesthesia at a US academic medical centre over time and determined the relative importance of institutional measures (removal of desflurane and limiting fresh gas flow [FGF] and nitrous oxide [N2O] use) to reduce carbon dioxide equivalent emissions (CO2e-emissions). METHODS:From 124 428 patients undergoing inhalational anaesthesia between 2014 and 2022, CO2e-emissions per patient were calculated from minute-by-minute recordings of inspiratory concentrations of sevoflurane, isoflurane, desflurane, and N2O, as well as FGF data. Data were combined with the global warming potential for each gas. Interrupted time series analysis, adjusted for patient and procedural factors, was applied to assess the impact of gradual removal of desflurane from operating rooms in June 2018 and its complete elimination in January 2020. RESULTS:From June 2014 to June 2022, mean CO2e-emissions per patient decreased by 82.8% from an average of 83.1 (median, 23.6 [interquartile range, 10.1-107.8]) kg to 14.3 (median 8.5 [4.2-15.9]) kg. In adjusted analyses, restrictive use of desflurane (-1.53 kg per patient, 95% confidence interval, -1.88 to -1.18; P<0.001) and its subsequent elimination (additional -0.50 kg per patient, -0.80 to -0.19; P=0.002) reduced CO2e-emissions. Before the elimination, desflurane was the main contributor to CO2e-emissions (74% relative contribution). After the elimination, use of N2O (73%) and high FGF (>3.42 L min-1, 4%) emerged as dominant predictors of CO2e-emissions. CONCLUSIONS:Eliminating desflurane led to a substantial reduction in anaesthesia-related CO2e-emissions of ∼900 metric tonnes annually. This study highlights the importance of volatile anaesthetic choice and factors including N2O use and fresh gas flow to minimise the carbon footprint of anaesthesia.

IMPORTANCE: Cardiopulmonary resuscitation (CPR) is an exceptional physical situation and may lead to significant psychological, spiritual, and social distress in patients and their next of kin. Furthermore, clinicians might experience distress related to a CPR event. Specialist palliative care (sPC) integration could address these aspects but is not part of routine care. OBJECTIVES: This study aimed to explore perspectives on sPC integration during and after CPR. A needs assessment for sPC, possible triggers indicating need, and implementation strategies were addressed. DESIGN, SETTING, AND PARTICIPANTS: A multiprofessional qualitative semistructured focus group study was conducted in a German urban academic teaching hospital. Participants were clinicians (nursing staff, residents, and consultants) working in the emergency department and ICUs (internal medicine and surgical). ANALYSIS: The focus groups were recorded and subsequently transcribed. Data material was analyzed using the content-structuring content analysis according to Kuckartz. RESULTS: Seven focus groups with 18 participants in total were conducted online from July to November 2022. Six main categories (two to five subcategories) were identified: understanding (of palliative care and death), general CPR conditions (e.g., team, debriefing, and strains), prognosis (e.g., preexisting situation, use of extracorporeal support), next of kin (e.g., communication, presence during CPR), treatment plan (patient will and decision-making), and implementation of sPC (e.g., timing, trigger factors). CONCLUSIONS: Perceptions about the need for sPC to support during and after CPR depend on roles, areas of practice, and individual understanding of sPC. Although some participants perceive CPR itself as a trigger for sPC, others define, for example, pre-CPR-existing multimorbidity or complex family dynamics as possible triggers. Suggestions for implementation are multifaceted, especially communication by sPC is emphasized. Specific challenges of extracorporeal CPR need to be explored further. Overall, the focus groups show that the topic is considered relevant, and studies on outcomes are warranted.

Importance The effect of oral midazolam premedication on patient satisfaction in older patients undergoing surgery is unclear, despite its widespread use. Objective To determine the differences in global perioperative satisfaction in patients with preoperative administration of oral midazolam compared with placebo. Design, Setting, and Participants This double-blind, parallel-group, placebo-controlled randomized clinical trial was conducted in 9 German hospitals between October 2017 and May 2019 (last follow-up, June 24, 2019). Eligible patients aged 65 to 80 years who were scheduled for elective inpatient surgery for at least 30 minutes under general anesthesia and with planned extubation were enrolled. Data were analyzed from November 2019 to December 2020. Interventions Patients were randomized to receive oral midazolam, 3.75 mg (n = 309), or placebo (n = 307) 30 to 45 minutes prior to anesthesia induction. Main Outcomes and Measures The primary outcome was global patient satisfaction evaluated using the self-reported Evaluation du Vécu de l’Anesthésie Generale (EVAN-G) questionnaire on the first postoperative day. Key secondary outcomes included sensitivity and subgroup analyses of the primary outcome, perioperative patient vital data, adverse events, serious complications, and cognitive and functional recovery up to 30 days postoperatively. Results Among 616 randomized patients, 607 were included in the primary analysis. Of these, 377 (62.1%) were male, and the mean (SD) age was 71.9 (4.4) years. The mean (SD) global index of patient satisfaction did not differ between the midazolam and placebo groups (69.5 [10.7] vs 69.6 [10.8], respectively; mean difference, −0.2; 95% CI, −1.9 to 1.6; P = .85). Sensitivity (per-protocol population, multiple imputation) and subgroup analyses (anxiety, frailty, sex, and previous surgical experience) did not alter the primary results. Secondary outcomes did not differ, except for a higher proportion of patients with hypertension (systolic blood pressure ≥160 mm Hg) at anesthesia induction in the placebo group. Conclusion and Relevance A single low dose of oral midazolam premedication did not alter the global perioperative patient satisfaction of older patients undergoing surgery or that of patients with anxiety. These results may be affected by the low dose of oral midazolam. Further trials—including a wider population with commonplace low-dose intravenous midazolam and plasma level measurements—are needed. Trial Registration ClinicalTrials.gov Identifier: NCT03052660

Die Echokardiographie ist ein zentrales Element in der Diagnostik von Patienten in der Notfall- und Intensivmedizin. Die transösophageale Echokardiographie (TEE) kann im Gegensatz zur transthorakalen Echokardiographie (TTE) unabhängig von Patientenhabitus, Beatmung und Lagerung durchgeführt werden und liefert dadurch eine konstant gute Bildqualität. Relevante Pathologien und reversible Ursachen eines Herz-Kreislauf-Stillstands (z. B. Lungenarterienembolie, Perikardtamponade) können schnell diagnostiziert und damit einer Behandlung zugänglich werden. Zusätzlich bleiben im Rahmen der kardiopulmonalen Reanimation ununterbrochene Thoraxkompressionen während der Diagnostik mittels TEE gewährleistet und es kommt zu keiner diagnostikbedingten Verlängerung der „no-flow-time“ (Unterbrechung der Thoraxkompressionen während der kardiopulmonalen Reanimation). Einige Studien beschreiben auch den Nutzen der TEE zur Termination der Reanimationsmaßnahmen bei ausbleibender mechanischer Herzaktivität. Ein weiteres Anwendungsgebiet der TEE stellt die Implantation und (Re‑)Positionierung der Kanülierung von Kreislaufunterstützungssystemen (z. B. „extracorporeal life support“, ECLS) dar. Zusammengefasst ist die TEE ein sicheres, schnell erlernbares und der TTE in einigen Aspekten überlegenes Verfahren zur Diagnostik von Schockraumpatienten. Die TEE kann bei ausreichender Expertise zu einem diagnostischen Instrument im Rahmen der kardiopulmonalen Reanimation werden. Die Anwendungsgebiete, Vorteile und potenzielle Risiken der TEE im Rahmen der Versorgung kritisch kranker Schockraumpatienten, einschließlich Reanimationssituationen, sollen dargestellt werden.

BACKGROUND:Out-of-hospital cardiac arrest (OHCA) remains a frequent medical emergency with low survival rates even after a return of spontaneous circulation (ROSC). Growing evidence supports formation of dedicated teams in scenarios like cardiogenic shock to improve prognosis. Thus, the European Resuscitation Council (ERC) recommended introduction of Cardiac Arrest Centers (CAC) in their 2015 guidelines. Here, we aimed to elucidate the effects of newly introduced CACs in Germany regarding survival rate and neurological outcome. METHODS:A multicenter retrospective observational cohort study was performed at three university hospitals and outcomes after OHCA were compared before and after CAC accreditation. Primary outcomes were survival until discharge and favorable neurological status (CPC 1 or 2) at discharge. RESULTS:In total 784 patients (368 before and 416 after CAC accreditation) were analyzed. Rates of immediate percutaneous coronary intervention (40 vs. 52%, p = 0.01) and implementation of extracorporeal CPR (8 vs. 13%, p < 0.05) increased after CAC accreditation. Likelihood of favorable neurological status at discharge was higher after CAC accreditation (71 vs. 87%, p < 0.01), whereas overall survival remained similar (35 vs. 35%, p > 0.99). CONCLUSION:CAC accreditation is linked to higher rates of favorable neurological outcome and unchanged overall survival.

Anesthetic gases are potent greenhouse gases, which are currently released into the atmosphere where they remain for many years. Strategies to reduce the carbon footprint in anesthesiology without compromising patient safety are urgently needed. Since 2020 several departments of anesthesiology have installed anesthetic gas capture systems with which anesthetic gases can be collected. This article aims to describe the anesthetic gas capture system CONTRAfluran™ and to give an overview of the first experiences in four departments of anesthesiology working with the new device in the daily clinical routine. The CONTRAfluran™ system presents a new concept in the surgical setting that has the potential to reduce the carbon footprint in anesthesiology; however, in order to accurately estimate CO2 equivalent savings, more information concerning the reprocessing and data on the pharmacokinetics of anesthetic gases are needed. Application of the CONTRAfluran™ system in daily clinical routine is feasible when anesthesiologists are aware of specific issues. In order to minimize the carbon footprint, it remains essential to implement the specific recommendations in the position paper of the German Society of Anaesthesiology and Intensive Care medicine (DGAI) and the Professional Association of German Anaesthesiologists (BDA) on ecological sustainability in anesthesiology and intensive care medicine and to support further research.

Editor—An excess of human-generated carbon dioxide emissions has caused climate change since the Industrial Revolution. Methane, nitrous oxide, and halogenated hydrocarbons continue to contribute to the warming of the atmosphere. To quantify these effects, the global warming capacity of each of these agents can be referenced to carbon dioxide and expressed as CO2e footprint. Anaesthesiologists have recognised their ecological responsibility and have discussed how to decrease the CO2e footprint of anaesthetic gases. Active carbon absorbers can be utilised for exhaust ports of anaesthesia machines to decrease inhaled anaesthetic emissions. However, as patients have not fully eliminated inhaled anaesthetics at the time of tracheal extubation, the fraction of recaptured anaesthetic is unknown. To address this question, we quantified the fraction of recaptured inhaled anaesthetic in relation to the amount vaporised in patients undergoing inhaled anaesthesia. The study protocol was approved by the Ethical Committee of the Medical Faculty of the Heinrich Heine University (Study ID 2021–1381, 24 February, 2021). The anaesthetic gas scavenging hose was disconnected from the anaesthesia machine (Primus, Dräger Lübeck, Germany) and the gas capture system (CONTRAfluran; ZEOZYS, Luckenwalde, Germany) was connected to the machine's exhaust. A detector (SENSOfluran; ZEOZYS) that allowed identification of inhaled anaesthetic was connected to the gas capture system to indicate saturation of the activated charcoal canister and need for replacement. Anaesthetic management was at the discretion of the attending anaesthesiologist and according to institutional standards. Tracheal intubation was performed in all patients, with cuff pressure set at 30 cm H2O. Anaesthesia was maintained with desflurane (2.4–6.0 vol% end-tidal concentration to achieve a minimum alveolar concentration [MAC] of 0.7–1.0) and remifentanil i. v. Patients were mechanically ventilated with a tidal volume of 6–8 ml kg−1 ideal body weight with ventilatory frequency adapted to normocapnia (4.6–6 kPa end-tidal carbon dioxide). The weight of the vaporiser and the charcoal canister were assessed before and after each anaesthetic with a precision scale (Kern KB 10K0.05N; Kern&Sohn GmbH, Balingen-Frommern, Germany; maximum weight=10 000 g; d=0.05 g). The amount of vaporised desflurane was determined through the change in vaporiser weight in grams. A new charcoal canister was used for each patient. After tracheal extubation, canisters were sealed and transferred to the factory for desorption. Because the desorption procedure requires a minimum amount of activated charcoal, the charcoal of 80 canisters was desorbed together and measured across all canisters. The weight of the canisters was constant (<1 g change) during storage. The primary outcome was the fraction of recaptured desflurane, expressed as percentage of its vaporised amount. In secondary analyses, we investigated the association between the fraction of recaptured desflurane and patient- and anaesthesia-related factors using multivariable negative binomial regression analysis. Analyses were adjusted for the three different operating rooms. Non-normally distributed variables were entered as quantiles or clinically relevant categories into the regression model. Results are reported as adjusted incidence rate ratios (IRRs) with corresponding 95% confidence intervals. The absolute change in percent recaptured desflurane was calculated for statistically significant IRR using the margins command of Stata (Version 16.1; StataCorp LLC, College Station, TX, USA). Other data are expressed as absolute values, mean (standard deviation), or median [inter-quartile range]. We considered a P-value <0.05 statistically significant. We included 80 consecutive anaesthetics. Table 1 depicts patient and anaesthesia characteristics.Table 1Patient characteristics and distribution of variables for the overall cohort, and patients with a low and high percentage of recaptured desflurane (based on the median in the cohort). Data are expressed as frequency (prevalence in %) or median (inter-quartile range [25th–75th percentile]).Total (n=80)Recaptured desflurane ≤52.3% (n=40)Recaptured desflurane >52.3% (n=40)P-valueBMI (kg m−2)26.4 (24.6–28.7)26.4 (24.4–28.5)26.2 (24.6–29.1)0.54Duration of desflurane administration (min)238.0 (105.0–349.0)340.0 (240.0–381.5)112.5 (73.5–231.5)<0.001Circuit leak at incision (L min−1)0.0 (0.0–0.1)0.0 (0.0–0.0)0.0 (0.0–0.2)0.025Minute ventilation (L min−1)6.5 (5.5–7.5)6.7 (5.8–8.1)6.2 (4.9–7.0)0.010Ventilatory frequency (breaths per min−1)12.0 (12.0–14.0)13.0 (12.0–15.0)12.0 (10.5–14.0)0.012Fresh gas flow (L min−1)0.8 (0.5–0.8)0.7 (0.5–0.8)0.8 (0.7–0.9)0.095End-tidal concentration of desflurane (%)4.6 (4.2–5.0)4.8 (4.3–5.3)4.5 (4.1–4.8)0.051Minimum alveolar concentration of desflurane0.8 (0.8–0.9)0.9 (0.8–0.9)0.8 (0.7–0.9)0.002End-tidal concentration of desflurane at extubation (%)0.8 (0.6–1.0)0.9 (0.8–1.1)0.8 (0.6–0.9)0.010Operating room<0.001113 (16%)1 (3%)12 (30%)228 (35%)1 (3%)27 (68%)339 (49%)38 (95%)1 (3%) Open table in a new tab A total of 6902 g of desflurane was administered for general anaesthesia across the 80 patients. During anaesthesia, desflurane and water absorption increased the weight of the 80 charcoal canisters by 2509 g. Charcoal desorption yielded 1727 g of desflurane, indicating that 25% of the administered desflurane was recaptured and could potentially be processed for reuse, with 70% of the overall weight gain of the canisters attributable to recaptured desflurane. Assuming that the relative weight gain of each canister attributable to desflurane was the same, secondary analyses were performed to identify factors associated with the fraction of recaptured desflurane. Data on covariates were available for all included patients. After confounder adjustment, a higher MAC of desflurane during anaesthesia and at the time of tracheal extubation and longer duration of desflurane administration were associated with a lower percentage of recaptured desflurane (Supplementary Table S1). Variability in circuit leak at incision, minute ventilation, and average fresh gas flow were too low to identify an association. Multiple mechanisms could explain the low recapture rate of 25% of desflurane in our study. First, uptake of inhaled anaesthetics is determined by anaesthetic solubility in blood, inspired concentration, and duration of administration. In a multicompartment pharmacokinetic model, equilibration of partial pressures between blood and tissue further depends on the blood flow to each compartment.1Yasuda N. Lockhart S.H. Eger 2nd, E.I. et al.Kinetics of desflurane, isoflurane, and halothane in humans.Anesthesiology. 1991; 74: 489-498Crossref PubMed Scopus (220) Google Scholar In a simulated model, desflurane at 1 MAC for 180 min resulted in uptake of 22 g of desflurane.2Lockwood G. Theoretical context-sensitive elimination times for inhalational anaesthetics.Br J Anaesth. 2010; 104: 648-655Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar After discontinuation, the end-tidal concentration decreased by >80% within 5 min. In contrast, the pulmonary arterial concentration decreased by <20% at the same time.3Lu C.C. Tsai C.S. Hu O. et al.Pharmacokinetics of desflurane elimination from respiratory gas and blood during the 20 minutes after cardiac surgery.J Form Med Assoc. 2013; 112: 185-192Crossref PubMed Scopus (10) Google Scholar This indicates that despite low end-tidal concentrations of desflurane at the time of tracheal extubation, a larger fraction of administered anaesthetic remains to be eliminated over hours. This effect is further magnified by longer durations of anaesthesia. In our study, average duration of desflurane administration was 4 h. We hypothesise that a significant residual amount of desflurane after extubation was not captured. This is supported by our secondary analyses indicating a lower fraction of recaptured desflurane with longer durations of anaesthesia. In summary, application of charcoal filters allows recapture of a fraction of inhaled anaesthetic for potential future reuse, that also reduces deleterious environmental impact,4McGain F. Muret J. Lawson C. Sherman J.D. Environmental sustainability in anaesthesia and critical care.Br J Anaesth. 2020; 125: 680-692Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar which is particularly important for desflurane.5Shelton C.L. Sutton R. White S.M. Desflurane in modern anaesthetic practice: walking on thin ice(caps)?.Br J Anaesth. 2020; 125: 852-856Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar The fraction of recaptured anaesthetic can be increased with shorter durations of anaesthesia and utilisation of lower inhaled concentrations. It is likely that recovery of more soluble inhaled anaesthetics (e.g. sevoflurane) would be even lower under similar conditions,6Bailey J.M. Context-sensitive half-times and other decrement times of inhaled anesthetics.Anesth Analg. 1997; 85: 681-686Crossref PubMed Google Scholar which should be investigated in future studies. According to information released by the manufacturer, ZEOZYS, technical and regulatory actions required for processing of recaptured desflurane have been established so that desflurane can be offered for reuse in the near future without reduction in pharmaceutical quality. The price for captured and recycled desflurane compared with new desflurane has not been announced. To better quantify the sustainable effects of the anaesthesia gas capture system, future studies could consider a standardised life cycle analysis for desflurane and sevoflurane. As the atmospheric CO2e footprint of desflurane is 15 times higher compared with sevoflurane, we can expect the greatest environmental effects by using anaesthesia gas capture systems for desflurane. Implementation of inhaled anaesthesia gas capture systems can be a relevant measure to reduce the CO2e footprint while maintaining the current portfolio of anaesthetic drugs. The authors thank John J. Bellamente for language and grammar editing. PK has served as a consultant for Air Liquide, Baxter, Orion, and Tevar ratiopharm. MSS has received grants for investigator-initiated trials not related to this study from Merck & Co. MSS and PK are associate editors for BMC Anesthesiology. The funders had no role in the study design and conduct, the collection, management, analyses, and interpretation of the data, the preparation, review, or approval of the manuscript, or the decision to submit the manuscript for publication. JH, TB, AG, MH, TMT, and MSS have no conflicts of interest. The gas capture technology (CONTRAfluran, Sensofluran) was provided by Christian Ewers (ZEOZYS, Luckenwalde, Germany). The following is the Supplementary data to this article: Download .docx (.03 MB) Help with docx files Multimedia component 1 When will we call time on desflurane? Comment on Br J Anaesth 2022; 129: e79–e81British Journal of AnaesthesiaVol. 129Issue 4PreviewEditor—Recently, Hinterberg and colleagues1 reported the results of an analysis of the efficiency of desflurane recapture by a commercially available system during 80 consecutive anaesthetics lasting on average 4 h. The rationale for their study is obvious. The global warming effects of desflurane are well known, so when desflurane is used, attempts to prevent it from reaching the atmosphere are sensible. Full-Text PDF Proper use of CONTRAfluran™ for optimal desorption and reuse of volatile anaesthetics. Comment on Br J Anaesth 2022; 129: e79–81British Journal of AnaesthesiaVol. 131Issue 3PreviewEditor—We read with interest the correspondence ‘Efficiency of inhaled anaesthetic recapture in clinical practice’.1 We broadly agree with the general conclusion that the fraction of recovery of desflurane is, at first glance, rather disappointing and reveals both the opportunities and limitations of the technology to mitigate its ecologic effects. CONTRAfluran™ (ZeoSys, Luckenwalde, Germany) gas capture technology has two main purposes: prevention of release of volatile anaesthetics into the atmosphere and recovery of valuable volatile anaesthetics for reuse. Full-Text PDF Efficiency of inhaled anaesthetic recapture in clinical practice. Comment on Br J Anaesth 2022; 129: e79–81British Journal of AnaesthesiaVol. 130Issue 6PreviewEditor—We were delighted to read the paper by Hinterberg and colleagues1 investigating the efficacy of the Baxter–ZeoSys gas capture system (CONTRAfluran; ZEOZYS, Luckenwalde, Germany). However, we were surprised by their 25% recapture rate using desflurane. At the time of their publication, we had carried out a similar pilot study using SageTech Medical's Volatile Capture Device (VCD; SageTech Medical, Paignton, UK), but finding a markedly different volatile recapture rate. Like theirs, the aim of our study was to quantify the efficacy of SageTech's VCD and the amount of volatile anaesthetic that could potentially remain in the patient as they leave the operating theatre. Full-Text PDF Efficiency of inhaled anaesthetic recapture in clinical practice. Comment on Br J Anaesth 2022; 129: e79–81British Journal of AnaesthesiaVol. 129Issue 5PreviewEditor—We read with enthusiasm the correspondence by Hinterberg and colleagues,1 who described a study of the clinical performance of volatile capture technology based on activated charcoal (CONTRAfluran; ZEOZYS, Luckenwalde, Germany) in capturing desflurane. We were, however, disappointed to learn that only ∼25% of the administered desflurane was captured. Full-Text PDF

Introduction Real or simulated cycling tests under the influence of alcohol might be biased by laboratory settings. Accident analyses consider incidents with injuries only. Herein, criminal offenses consisting of drunk cycling are evaluated in detail to fill this gap. Material and methods All police-recorded cases of cycling under the influence of alcohol that took place in Düsseldorf, Germany, from 2009 to 2018 were identified. A total of 388 respective prosecutor’s files were available for analyses. Results Mean blood alcohol concentrations were approximately 2 g/kg in both men and women. Men were overrepresented (6:1). Almost 60% of the cases were recorded between Friday and Sunday (the “weekend”). The average blood alcohol concentration (BAC) at night (01:00–05:59) was 0.39 g/kg lower than that during the day (06:00–17:59). Drinking after cycling allegations appear almost irrelevant among (German) cyclists. On average, the legal outcomes show 33 daily rates (median: 30). Additionally, the presented data raise doubts about whether the utilized medical tests or the ways in which they are carried out reliably discriminate between different grades of intoxication. Negative tests did not exclude high BACs, nor did positive tests correlate well with BACs. Discussion/Conclusion In practice, CUI is seen with BACs above 1.60 g/kg in most cases. BACs below 1.60 g/kg either seem to be a minor problem or they have been incompletely addressed thus far. In summary, to be prosecuted, drunk cyclists have to ride their bikes in either a highly insecure or rude manner or they must cause an accident.

COVID-19 patients who may require invasive therapeutic procedures such as extracorporeal membrane oxygenation (ECMO) have high symptom burden and in-hospital mortality. In addition, awake patients on ECMO are new in the intensive care unit (ICU) setting. Inpatient specialist palliative care (sPC) provides support such as symptom control on a physical, psychosocial and spiritual level. The field of sPC in COVID-19 patients is still new and important to investigate. We aim to analyze sPC of COVID-19 patients in the ICU with regard to patient characteristics and symptoms from a palliative care perspective. We conducted a retrospective analysis (03/2020–04/2021) and identified 51 ICU patients receiving sPC. The statistical analysis included descriptive statistics and comparisons of symptoms. The first sPC contact of patients (mean age 69.5 years, 62.7% male) was around 14 days after COVID-19 confirmation, and 43% were treated with ECMO therapy. The baseline symptom burden was high with a focus on weakness (100%), tiredness (98%), dyspnea (96%) and family burden (92%). The symptom intensity significantly decreased during the time period of sPC and COVID-19 treatment (t(99) = 3.119, p = 0.003, d = 0.437). These results help intensivists and sPC clinicians to identify symptoms and the need for sPC in COVID-19 patients. However, studies with prospective and controlled designs need to follow.

Background: Previous studies indicated an association between impaired cerebral perfusion and post-procedural neurological disorders. We investigated whether intra-procedural hypoxaemia or hypocapnia are associated with delirium after surgery. Methods: Inpatients & GE;60 yr of age undergoing anaesthesia for surgical or interventional procedures between 2009 and 2020 at an academic healthcare network in the USA (Massachusetts) were included in this hospital registry study. The primary exposure was intra-procedural hypoxaemia, defined as peripheral oxygen saturation <90% for >2 cohering min. The co-primary exposure was hypocapnia during general anaesthesia, defined as end-tidal carbon dioxide pressure <25 mm Hg for >5 cohering min. The primary outcome was delirium within 7 days after surgery. Results: Of 71 717 included patients, 1702 (2.4%) developed postoperative delirium, and hypoxaemia was detected in 2532 (3.5%). Of 42 894 patients undergoing general anaesthesia, 532 (1.2%) experienced hypocapnia. The occurrence of either hypoxaemia (adjusted odds ratio [ORadj]=1.71; 95% confidence interval [CI], 1.40-2.07; P<0.001) or hypocapnia (ORadj=1.77; 95% CI, 1.30-2.41; P<0.001) was associated with a higher risk of delirium within 7 days. Both associations were dependent on the magnitude, and increased with event duration (ORadj=1.03; 95% CI, 1.02-1.04; P<0.001 and ORadj=1.01; 95% CI, 1.00-1.01; P=0.005, for each minute increase in the longest continuous episode, respectively). There was no association between occurrence of hypercapnia and postoperative delirium (ORadj=1.24; 95% CI, 0.90-1.71; P=0.181). Conclusions: Intra-procedural hypoxaemia and hypocapnia were dose-dependently associated with a higher risk of postoperative delirium. These findings support maintaining normal gas exchange to avoid postoperative neurological disorders.