[Prioritization of intensive medical treatment places - Concept proposal]. / Priorisierung intensivmedizinischer Behandlungsplätze ­ Konzeptvorschlag.

In the situation of a shortage of ventilation beds, ethically justifiable, transparent and comprehensible decisions must be made. This concept proposes that all patients are first intubated depending on necessity and then assessed by a triage team afterwards. In this situation newly admitted COVID patients compete with newly admitted Non-COVID patients as well as patients already treated in intensive care units for a ventilator. The combination of short-term and long-term prognoses should enable the interprofessional triage team to make comprehensible decisions. The aim of the prioritization concept is to save as many human lives as possible and to relieve the treatment team of the difficult decision on prioritization.

Oxygenation laryngoscope vs. nasal standard and nasal high flow oxygenation in a technical simulation of apnoeic oxygenation.

BACKGROUND: Failed airway management is the major contributor for anaesthesia-related morbidity and mortality. Cannot-intubate-cannot-ventilate scenarios are the most critical emergency in airway management, and belong to the worst imaginable scenarios in an anaesthetist's life. In such situations, apnoeic oxygenation might be useful to avoid hypoxaemia. Anaesthesia guidelines recommend careful preoxygenation and application of high flow oxygen in difficult intubation scenarios to prevent episodes of deoxygenation. In this study, we evaluated the decrease in oxygen concentration in a model when using different strategies of oxygenation: using a special oxygenation laryngoscope, nasal oxygen, nasal high flow oxygen, and control. METHODS: In this experimental study we compared no oxygen application as a control, standard pure oxygen application of 10 l·min- 1 via nasal cannula, high flow 90% oxygen application at 20 l·min- 1 using a special nasal high flow device, and pure oxygen application via our oxygenation laryngoscope at 10 l·min- 1. We preoxygenated a simulation lung to 97% oxygen concentration and connected this to the trachea of a manikin model simulating apnoeic oxygenation. Decrease in oxygen concentration in the simulation lung was measured continuously for 20 min. RESULTS: Oxygen concentration in the simulation lung dropped from 97 ± 1% at baseline to 40 ± 1% in the no oxygen group, to 80 ± 1% in the standard nasal oxygen group, and to 73 ± 2% in the high flow nasal oxygenation group. However, it remained at 96 ± 0% in the oxygenation laryngoscope group (p < 0.001 between all groups). CONCLUSIONS: In this technical simulation, oxygenation via oxygenation laryngoscope was more effective than standard oxygen insufflation via nasal cannula, which was more effective than nasal high flow insufflation of 90% oxygen.

Risk factors for bleeding complications after percutaneous dilatational tracheostomy: a ten-year institutional analysis.

Bleeding complications after percutaneous dilatational tracheostomy (PDT) are infrequent but may have a tremendous impact on a patient's further clinical course. Therefore, it seems necessary to perform risk stratification for patients scheduled for PDT. We retrospectively reviewed the records of 1001 patients (46% male, mean age 68.1 years) undergoing PDT (using the Ciaglia Blue Rhino® technique with direct bronchoscopic guidance) in our cardiothoracic ICU between January 2003 and February 2013. Patients were stratified into two groups: patients suffering acute moderate, severe, or major bleeding (Group A) and patients who had no or only mild bleeding (Group B). In the majority of patients, no or only mild bleeding during PDT occurred (none: 425 [42.5%], mild: 488 [48.8%]). In 84 patients (8.4%), bleeding was classified as moderate. Three patients suffered from severe bleeding; only one major bleed with need for emergency surgery occured. Patients in Group A had a significantly higher Simplified Acute Physiology Score on the day of PDT (P=0.042), higher prevalence of renal replacement therapy on the day of PDT (P=0.026), higher incidence of coagulopathy (P=0.043), lower platelet counts (P=0.037), lower fibrinogen levels (P=0.012), higher proportion of PDTs performed by residents (P=0.034) and higher difficulty grading of PDT (P=0.001). Using logistic regression analyses, difficult PDT, less experienced operator, Simplified Acute Physiology Score>40 and low fibrinogen levels were independent predictors of clinically significant bleeding after PDT. Low fibrinogen levels, as well as difficult PDT, less experienced operator and Simplified Acute Physiology Score>40 are associated with an increased risk for bleeding during PDT.

[Outbreak with Ralstonia pickettii caused by contaminated magnesium vials]. / Ausbruch mit Ralstonia pickettii durch kontaminierte Magnesium-Ampullen.

HISTORY: In February 2013, 5 patients in an intensive care unit (ICU) were found to have positive blood cultures with Ralstonia pickettii within one week. Because all patients got intravenous therapy, improper work of a staff member was suspected. Some days later, a 6th patient was found with a positive blood culture of Ralstonia pickettii in another department of the hospital. INVESTIGATIONS: Hygienic investigations showed no evidence of failures in preparation of intravenous therapy. All patients were on different intravenous drugs, but every patient had received glucose 5 % and magnesium. We examined samples of glucose and magnesia as well as samples from environment. RESULTS AND COURSE: Glucose and magnesium samples were examined by membrane filter method. Ralstonia pitteckii was detected in some Magnesium vials. We concluded, that contamination of Magnesium vials might have been the reason for blood stream infection of patients. Pharmacists and authorities were informed and all vials were collected and replaced by vials from another company. Later a nationwide recall of Magnesium vials was performed by the producing company. No further Ralstonia pickettii was found in blood cultures in our hospital. CONCLUSION: Unusual pathogens in blood cultures should lead to reflection of rarer causes such as contamination of medicines.

Early thromboelastometric variables reliably predict maximum clot firmness in patients undergoing cardiac surgery: a step towards earlier decision making.

BACKGROUND: While much effort has been spent on guiding coagulation and transfusion therapy in patients undergoing cardiopulmonary bypass (CPB) surgery, the use of conventional laboratory-based coagulation tests is hampered by long turnaround times and interference with heparin and protamine. To allow faster assessment of maximum clot firmness (MCF) by point-of-care thromboelastometry (ROTEM®, TEM International GmbH, Munich, Germany), we tested whether clotting time (CT), clot formation time (CFT), or early values of clot firmness (CF) predict MCF. METHODS: Results of 437 ROTEM® assays (EXTEM®, INTEM®, FIBTEM®, and HEPTEM®) from 84 patients undergoing CPB surgery were analyzed. Measurements were performed prior to and after heparin administration, as well as after protamine administration and CT, CFT, and CF after 5, 10, and 15 min (A5, A10, and A15) after initial clotting (CT) were related to MCF. STATISTICS: Regression and Bland-Altman analyses and receiver-operating characteristics (ROCs). RESULTS: CFT (r = 0.87-0.95), A5 (r = 0.84-0.98; P < 0.0001), A10 (r = 0.86-0.98; P < 0.0001), and A15 (r = 0.86-0.98; P < 0.0001) demonstrated high correlation coefficients with MCF, whereas CT correlated weakly (r = 0.07-0.41). As expected, correlation coefficients increased with the time allowed to assess a specific variable. ROC analyses demonstrated excellent accuracy for CFT, A5, A10, and A15 [area under the curve (AUC): 0.9476-0.9931] to predict a subnormal MCF, whereas CT demonstrated poor accuracy (AUC: 0.5796-0.6774). CONCLUSION: Taking into account specific bias, early values of CF (A5-A15) reliably predict maximum CF under all conditions and, therefore, allow for marked time savings in the interpretation of ROTEM® measurements. This may guide earlier and more specific treatment of CPB-related coagulation disorders.

[Extracorporeal heart and lung replacement procedures]. / Extrakorporale Herz- und Lungenersatzverfahren: "Extracorporeal membrane oxygenation", "extracorporeal life support" und "pumpless extracorporeal lung assist".

The use of extracorporeal support systems in cardiac and/or pulmonary failure is an established treatment option. Although scientific evidence is limited there is an increasing amount of data from individual studies, e.g. Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial 2010, suggesting that extracorporeal membrane oxygenation (ECMO) as a veno-venous pump-driven system is a life-saving procedure in severe respiratory failure. Initially established as a rescue option for postcardiotomy cardiac failure extracorporeal life support (ECLS) as a pump-driven veno-arterial cardiovascular support system is increasingly being used in cardiogenic shock after myocardial infarction, as bridging to transplantation or as part of extended cardiopulmonary resuscitation. The pumpless extracorporeal lung assist (pECLA) as an arterio-venous pumpless system is technically easier to handle but only ensures sufficient decarboxylation and not oxygenation. Therefore, this method is mainly applied in primarily hypercapnic respiratory failure to allow lung protective ventilation. Enormous technical improvements, e.g. extreme miniaturization of the extracorporeal assist devices must not obscure the fact that this therapeutic option represents an invasive procedure frequently associated with major complications. With this in mind a widespread use of this technology cannot be recommended and the use of extracorporeal systems should be restricted to centers with high levels of expertise and experience.