Individualised flow-controlled versus pressure-controlled ventilation in a porcine oleic acid-induced acute respiratory distress syndrome model.

BACKGROUND: A continuous gas flow provided by flow-controlled ventilation (FCV) facilitates accurate dynamic compliance measurement and allows the clinician to individually optimise positive end-expiratory and peak pressure settings accordingly. OBJECTIVE: The aim of this study was to compare the efficiency of gas exchange and impact on haemodynamics between individualised FCV and pressure-controlled ventilation (PCV) in a porcine model of oleic acid-induced acute respiratory distress syndrome (ARDS). DESIGN: Randomised controlled interventional trial conducted on 16 pigs. SETTING: Animal operating facility at the Medical University Innsbruck. INTERVENTIONS: ARDS was induced in lung healthy pigs by intravenous infusion of oleic acid until moderate-to-severe ARDS at a stable Horowitz quotient (PaO 2 FiO 2-1 ) of 80 to 120 over a period of 30 min was obtained. Ventilation was then either performed with individualised FCV ( n  = 8) established by compliance-guided pressure titration or PCV ( n  = 8) with compliance-guided titration of the positive end-expiratory pressure and peak pressure set to achieve a tidal volume of 6 ml kg -1 over a period of 2 h. MAIN OUTCOME MEASURES: Gas exchange parameters were assessed by the PaO 2 FiO 2-1 quotient and CO 2 removal by the PaCO 2 value in relation to required respiratory minute volume. Required catecholamine support for haemodynamic stabilisation was measured. RESULTS: The FCV group showed significantly improved oxygenation [149.2 vs. 110.4, median difference (MD) 38.7 (8.0 to 69.5) PaO 2 FiO 2-1 ; P  = 0.027] and CO 2 removal [PaCO 2 7.25 vs. 9.05, MD -1.8 (-2.87 to -0.72) kPa; P  = 0.006] at a significantly lower respiratory minute volume [8.4 vs. 11.9, MD -3.6 (-5.6 to -1.5) l min -1 ; P  = 0.005] compared with PCV. In addition, in FCV-pigs, haemodynamic stabilisation occurred with a significant reduction of required catecholamine support [norepinephrine 0.26 vs. 0.86, MD -0.61 (-1.12 to -0.09) µg kg -1  min -1 ; P  = 0.037] during 2 ventilation hours. CONCLUSION: In this oleic acid-induced porcine ARDS model, individualised FCV significantly improved gas exchange and haemodynamic stability compared with PCV. TRIAL REGISTRATION: Protocol no.: BMBWF-66.011/0105-V/3b/2019).

[Emergency missions in Tyrol in spring 2020 : Influence of COVID-19-A retrospective observational study focusing on air rescue]. / Notärztliche Einsätze in Tirol im Frühjahr 2020 : Der Einfluss von COVID-19 ­ eine retrospektive Beobachtungsstudie mit Fokus Luftrettung.

BACKGROUND: Tyrol, a province of Austria with about 760,000 inhabitants, was one of the first regions in Europe, along with northern Italy, to be affected by the pandemic spread of the coronavirus in spring 2020. A lockdown with far-reaching restrictions in all areas of life occurred from 16 March 2020. Restrictions were imposed in the areas of gastronomy, trade and free mobility as well as in recreational sports. The ski resorts were closed and due to the strong winter tourism in Tyrol, this meant that about 340,000 people left the region. In the province of Tyrol comprehensive emergency medical care is provided by 13 ground-based emergency medical systems (NEF) in combination with air rescue (16 emergency medical helicopters, some of which are seasonal). Normally, this system provides emergency medical care for approx. 1 million people; however, in spring 2020 during the first lockdown, the number of people to be cared for was approx. 30% less. In order to protect the emergency medical teams as best as possible from infections and thus the system from failures, the Integrated Control Center Tyrol (Landesleitstelle Tirol GmbH) adapted the release order for emergency medical resources. The aim of the study is to describe the influence of the pandemic in spring 2020 on the emergency medical services in Tyrol in comparison to the three preceding years. METHODS: A retrospective survey of all emergency helicopter missions and ground-based emergency physician missions in Tyrol in the period 15 March 2020-15 May 2020, as well as in the same period of the previous years 2017-2019, was conducted. Detailed figures on medical procedures and patient-related data were collected from 6 ÖAMTC helicopter bases. In addition, all ground-based emergency physician missions from all 13 physician systems including appeal mission diagnoses were collected in the same period. RESULTS: The total number of emergency helicopter missions and ground-based emergency physician missions showed a significant decrease during the observational period (67.3% and 39.8%, respectively). In the area of ground-based emergency medical resources, there was a significant increase in respiratory and CNS diseases during the observational period. The range of emergency helicopter missions showed a significant shift from sports and leisure missions to internal medicine and neurological emergencies and the duration of missions was significantly longer. The NACA score was higher with a significant decrease in NACA 3 scores in favor of NACA 4 and 5. The circulatory status of patients during the observational period was significantly more often documented as unstable. Hypertension, impending shock and circulatory arrest occurred more frequently in the trend. Cardiac massage, oxygen administration, circulatory drugs and specific monitoring were used more frequently in 2020. Analgesics were administered less frequently. In air rescue, there was no infection of rescue workers in the field. CONCLUSION: The first pandemic wave in Tyrol and the consecutive lockdown from 16 March 2020 had a massive impact on emergency medical care in Tyrol, both quantitatively and in terms of the spectrum of operations and emergency medical interventions. The decline in patient numbers was highly relevant, especially in air rescue and can be explained in part by the discontinuation of tourism, the general exit restrictions and the restrictive disengagement order. This decline primarily affected patients in the NACA 3 category and the analgesic administration measure. The patients treated had a higher NACA score and the emergency procedures were more extensive during the observational period. The measures to protect the emergency helicopter team from infections were presumably successful as no infections occurred.

Impact of COVID-19 on elective, emergency and oncological surgery during the first and the second wave in a tertiary university hospital : Have we learned the lessons?

Background The COVID-19 pandemic caused an important reduction in surgical activities during the first wave. Aim of this retrospective time-trend analysis was to examine whether also during the second wave in fall and winter 2020/2021 surgical interventions decreased. Methods Absolut numbers and types of surgeries in a tertiary university hospital during the second COVID-19 wave in fall/winter 2020/2021 were collected from the surgical planning software and compared with the same time frame over the last 5 years. In a second step, the reduction of surgical interventions during the second wave was compared with the reduction of surgical procedures during the first wave in spring 2020 at the same hospital. Results Despite a higher 7‑day incidence of COVID-19 infection and a higher number of patients needing ICU treatment during the second wave, the reduction of surgical interventions was 3.22% compared to 65.29% during the first wave (p < 0.0001). Elective surgical interventions decreased by 88.63% during the first wave compared to 1.79% during the second wave (p < 0.0001). Emergency and oncological interventions decreased by 35.17% during the first wave compared to 5.15% during the second wave (p : 0.0007) and 47.59% compared to 3.89% (p < 0.0001), respectively. Surgical activity reduction in our institution was less pronounced despite higher occupancy of ICU beds during the second COVID-19 wave in fall/winter 2020/2021. Conclusion Better understanding of the disease, adequate supply of disposables and improved interdisciplinary day by day management of surgical and ICU resources may have contributed to this improvement.

Impact of COVID-19 on elective, emergency and oncological surgery during the first and the second wave in a tertiary university hospital : Have we learned the lessons?

BACKGROUND: The COVID-19 pandemic caused an important reduction in surgical activities during the first wave. Aim of this retrospective time-trend analysis was to examine whether also during the second wave in fall and winter 2020/2021 surgical interventions decreased. METHODS: Absolut numbers and types of surgeries in a tertiary university hospital during the second COVID-19 wave in fall/winter 2020/2021 were collected from the surgical planning software and compared with the same time frame over the last 5 years. In a second step, the reduction of surgical interventions during the second wave was compared with the reduction of surgical procedures during the first wave in spring 2020 at the same hospital. RESULTS: Despite a higher 7­day incidence of COVID-19 infection and a higher number of patients needing ICU treatment during the second wave, the reduction of surgical interventions was 3.22% compared to 65.29% during the first wave (p < 0.0001). Elective surgical interventions decreased by 88.63% during the first wave compared to 1.79% during the second wave (p < 0.0001). Emergency and oncological interventions decreased by 35.17% during the first wave compared to 5.15% during the second wave (p : 0.0007) and 47.59% compared to 3.89% (p < 0.0001), respectively. Surgical activity reduction in our institution was less pronounced despite higher occupancy of ICU beds during the second COVID-19 wave in fall/winter 2020/2021. CONCLUSION: Better understanding of the disease, adequate supply of disposables and improved interdisciplinary day by day management of surgical and ICU resources may have contributed to this improvement.

Solid Organ Donation and Transplantation Activity in the Eurotransplant Area During the First Year of COVID-19.

BACKGROUND: Transplantation activity during the first wave of the coronavirus disease 2019 (COVID-19) pandemic was severely affected worldwide. This retrospective analysis aimed to assess the impact of COVID-19 on organ donations and transplantations in the Eurotransplant region during the first 12 mo of the pandemic. Specifically, we compared donor and transplantation numbers during both waves to determine whether transplant systems adapted to this new reality. METHODS: All reported organ donations and transplantations from March 1, 2015, to February 28, 2021, were collected from the Eurotransplant International Foundation registry. The observation period from 2020 to 2021 was divided into three 4-mo periods, which were then compared with the corresponding periods of the preceding 5 y. COVID-19 cases for Eurotransplant countries were retrieved from the OurWorldInData.org database. RESULTS: Overall, the number of organ donors decreased by 18.3% (P < 0.0001) and the number of organ transplantations by 12.5% (P > 0.0001) compared with previous years. Pancreas transplantation was the most affected, followed by kidney, liver, heart, and lung transplant. In detail, during period 1, the number of organ donors decreased by 26.2% (P < 0.0001) and the number of organ transplantations by 16.5% (P < 0.0001), in period 2 by 5.5% (P < 0.0091) and 4.9% (P < 0.0001), and in period 3 by 23.1% (P < 0.0001) and 16.4% (P < 0.0001), respectively. CONCLUSIONS: Organ donation and transplantation decreased drastically also during the second wave; however, despite the severity of the second wave, the decline was comparable with that of the first wave.

Impact of COVID-19 Related Lockdown on the Frequency of Acute and Oncological Surgeries-Lessons Learned From an Austrian University Hospital.

Innsbruck Medical University Hospital, Austria, provides the highest level of care for a region of approximately 1.8 million people. During the early COVID-19 outbreak in spring 2020 surgical activity was drastically reduced with the prime goal of preserving hospital capacities, especially intensive care beds. We conducted a retrospective analysis of surgical activities performed at Innsbruck Medical University Hospital during the lockdown period from March 15 to April 14, 2020 and compared these activities to the same period during the previous 5 years. Total surgical activity was reduced by 65.4% compared to the same period during the previous 5 years (p < 0.001); elective surgeries were reduced by 88.7%, acute surgeries by 35.3% and oncological surgeries by 47.8% compared to the previous 5 years (all p < 0.001). This dramatic decrease in acute and oncological surgeries can most likely be ascribed to the fact that many patients avoided health care facilities because of the strict stay-at-home policy and/or the fear of contracting SARS-CoV-2 in the hospital. In view of future waves, the population should be encouraged to seek medical help for acute symptoms and to attend cancer screening programs.

Impaired fibrinolysis in critically ill COVID-19 patients.

BACKGROUND: Critically ill coronavirus disease 2019 (COVID-19) patients present with a hypercoagulable state with high rates of macrovascular and microvascular thrombosis, for which hypofibrinolysis might be an important contributing factor. METHODS: We retrospectively analysed 20 critically ill COVID-19 patients at Innsbruck Medical University Hospital whose coagulation function was tested with ClotPro® and compared with that of 60 healthy individuals at Augsburg University Clinic. ClotPro is a viscoelastic whole blood coagulation testing device. It includes the TPA test, which uses tissue factor (TF)-activated whole blood with added recombinant tissue-derived plasminogen activator (r-tPA) to induce fibrinolysis. For this purpose, the lysis time (LT) is measured as the time from when maximum clot firmness (MCF) is reached until MCF falls by 50%. We compared COVID-19 patients with prolonged LT in the TPA test and those with normal LT. RESULTS: Critically ill COVID-19 patients showed hypercoagulability in ClotPro assays. MCF was higher in the EX test (TF-activated assay), IN test (ellagic acid-activated assay), and FIB test (functional fibrinogen assay) with decreased maximum lysis (ML) in the EX test (hypofibrinolysis) and highly prolonged TPA test LT (decreased fibrinolytic response), as compared with healthy persons. COVID-19 patients with decreased fibrinolytic response showed higher fibrinogen levels, higher thrombocyte count, higher C-reactive protein levels, and decreased ML in the EX test and IN test. CONCLUSION: Critically ill COVID-19 patients have impaired fibrinolysis. This hypofibrinolytic state could be at least partially dependent on a decreased fibrinolytic response.