Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022.

BACKGROUND: Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN: A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS: These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION: Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION: All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Preoperative anxiety after face-to-face patient assessment versus preanaesthesia telemedicine (PANTEM) in adults: a randomised clinical trial.

Preanaesthesia consultation is performed to assess and optimise patient-specific risk factors before surgery, to inform patients about anaesthesia techniques and to obtain consent. Aside from face-to-face visits, telephone consultation is increasingly being used clinically. Concentration on the content and avoidance of confounding factors could lead to improved patient preparation. We hypothesised that patients receiving a telemedical intervention have less anxiety. Patients scheduled for elective surgery were randomised into two groups according to the consultation performed face-to-face (FTF) or via telephone (TEL). Before consultation (< 48 h) and 1-2 h prior to surgery, both groups had to fill in the State-Trait Anxiety Inventory (STAI). A total of 271 patients were randomised and 130 were analysed. There were no significant intergroup differences in mean state anxiety (STAI-S) before and after the intervention. Patients' positive feedback on telemedical consultation urges future studies on its effect on satisfaction and quality of life.

Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines.

BACKGROUND: Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN: A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS: Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION: Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION: In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.

[Indifferent, Responsible or Overwhelmed? An Online Survey About the Emotional State of Young Adults During the Early Phases of the Covid-19 Lockdown in Germany and Austria]. / Gleichgültig, verantwortungsbewusst oder überfordert? Eine Online-Befragung zum emotionalen Befinden junger Erwachsener in der Frühphase des Corona-bedingten Lockdowns in Deutschland und Österreich.

BACKGROUND: In the COVID 19 pandemia compliance by the population with legally established preventive measures is of utmost importance to contain the spread of the virus. It can be assumed that these prevention measures are associated with specific burdens which are managed differently by the various population groups. OBJECTIVES: The survey assesses not only the general public's acceptance, concerns and burdens with regard to the prevention measures, but also the corresponding applied coping strategies depending on various socio-demographic and personality-specific factors. METHOD: An online survey of N=3006 persons living in Germany and Austria during the early lockdown, by means of a self-constructured questionnaire, assesses concerns about the virus and the prevention measures taken by the governments. In addition, standardized scales were used: Stress Processing Questionnaire (SVF 78), Positive and Negative Affect Schedule (PANAS), Insecurity-Intolerance scale (UI-18) and the State Trait Anxiety Inventory (STAI). RESULTS: Overall, a high level of acceptance of the required prevention measures was found. However, the shown emotional reactions were differing among the various population groups: Individuals between 18 and 29 years showed significantly higher negative emotional reactions compared to all other groups. A cluster analysis of this young population group revealed five groups that differed significantly in all surveyed personality factors and showed group-specific coping profiles. DISCUSSION: Younger people are often described as a particularly vulnerable group in connection with the pandemic. The present study shows, however, that the group of the young adults should not be considered as homogeneous.

The effect of a viscoelastic-guided bleeding algorithm implementation on blood products use in adult liver transplant patients. A propensity score-matched before-after study.

BACKGROUND: Perioperative blood products transfusion is correlated with increased morbidity and mortality in liver transplantation (LTx). The objectives of our study are to assess the effect of a standardized viscoelastic test (VET)-guided bleeding management algorithm implementation on intraoperative bleeding, allogenic blood products and factor concentrates requirements and on early postoperative complications in LTx. METHODS: Retrospective before-after study comparing two matched cohorts of patients undergoing LTx before (control cohort) and after (intervention cohort) the implementation of a VET-based bleeding algorithm in a single center academic hospital. RESULTS: After propensity score matching, we included 94 patients in each cohort. Patients in intervention cohort received significantly less blood products, fresh frozen plasma (FFP), and cryoprecipitate (p < 0.001 for each), while the amount of fibrinogen concentrate used was significantly higher (p < 0.001). Postoperatively, intervention cohort patients had significantly lower postoperative hemoglobin and fibrinogen levels and longer prothrombin time compared to control cohort. There were no significant differences in red blood cells transfusions, intraoperative bleeding, early postoperative complications, and short term survival. CONCLUSIONS: The implementation of a VET-guided bleeding algorithm decreases allogenic blood products requirements, mainly FFP use and allows a more restrictive management of coagulopathy in patients with chronic liver disease undergoing LTx.

Emotional distress in the early stages of the COVID-19 related lockdowns depending on the severity of the pandemic and emergency measures: a comparative online-survey in Germany, Austria and Italy.

BACKGROUND: The first wave of the COVID-19-pandemic hit different countries with varying degrees of severity, so that differences in the type and level of emergency measures were also necessary. It can be assumed that the psychological burden was higher in countries subjected to a more severe course of the pandemic (Italy) than in countries subjected to a less severe one (Germany, Austria). OBJECTIVE: To investigate and contrast the wellbeing of the population in Italy, Austria, and Germany in the early phase of the first lockdown. METHOD: Online survey on N = 4289 individuals. The questionnaire comprised a self-administered section, exploring the dimensions: perceived severity of COVID-19, perceived risk of disease, concerns related to COVID-19, emergency measure acceptance and emotional distress due to emergency measures; and standardized scales to record emotional state and coping: Stress-Coping-Style Questionnaire, Positive and Negative Affect Schedule, State-Trait-Anxiety-Inventory. RESULTS: The three countries displayed significant differences in all investigated dimensions (p < .001). Italian participants assessed the COVID-19 virus as much more dangerous (p < .001), but despite the prevalence of the virus, the subjective risk of disease was perceived to be lower in Italy (p < .001). This could be a positive effect of the restrictive curfews set by the government in Italy. The emergency measures were generally perceived to be very effective in all three countries, but due to the duration and the severity of the measures, the fear and stress-reaction were the strongest among Italian participants (p < .001). CONCLUSION: The stricter measures in Italy prevented an application of many positive stress processing strategies, which, in turn, fostered the perpetuation of stresses and fear.

[Preoperative risk clarification and anesthesia disclosure by telephone conversation]. / Präoperative Risikoabklärung und Anästhesieaufklärung mittels Telefonvisite.

BACKGROUND: Preoperative risk stratification, patient optimization and anesthesia disclosure are mostly carried out in the preanesthesia outpatient department in a direct conversation between physician and patient. The aim of this article is a description of the preanesthesia telephone contact as an alternative disclosure and clarification option for the clinical practice. METHODS: After clarification of data protection and medicolegal aspects, experiences with providing information via telephone in a single center were gathered. RESULTS: Initially, before spinal operations pain patients with unreasonably long access routes to the preanesthesia outpatient department received clarification and disclosure via the telephone. Due to the effectiveness and the lack of medical and processual complications, after 1 year the offer of a telephone conversation was extended to all patients. In the meantime, 47% of preanesthesia conversations are now carried out by telephone. Factors relevant for success are the consent of the patient to a telephone conversation, a multimedia patient education before the telephone conversation, competence of the anesthetist in communication, documentation and a clearly defined description of the process including changeover to the direct conversation. CONCLUSION: The preanesthesia telephone conversation is suitable as an alternative to the preanesthesia conversation in the outpatient department. High patient satisfaction results from the patient-oriented process, avoidance of transportation routes and the participative communication.

European Section/Board of Anaesthesiology/European Society of Anaesthesiology consensus statement on competency-based education and training in anaesthesiology.

: The change from time-based to competency-based medical education has been driven by society's requirement for greater accountability of medical practitioners and those who train them. The European Society of Anaesthesiology and European Section/Board of Anaesthesiology (Anaesthesiology Section of the European Union Medical Specialists) endorse the general principles of competency-based medical education and training (CBMET) outlined by the international competency-based medical education collaborators. A CBMET curriculum is built on unambiguously defined learning objectives, each of which offers a measurable outcome, amenable to assessment using valid and reliable tools. The European training requirements laid out by the European Board of Anaesthesiology define four 'Generic Competences', namely expert clinician, professional leader, academic scholar and inspired humanitarian. A CBMET programme should clearly document core competencies, defined end-points, proficiency standards, practical descriptions of teaching and assessment practices and an assessment plan. The assessment plan should balance the need to provide regular, multidimensional formative feedback to the trainee with the need to inform high stakes decisions. A trainee who has not achieved a proficiency standard should be provided with an individualised training plan to address specific competencies or deficits. Programme formats will inevitably differ given the constraints of scale and resource that apply in different settings. The resources necessary to develop and maintain a CBMET programme in anaesthesiology include human capital, access to clinical learning opportunities, information technology and physical infrastructure dedicated to training and education. Simulation facilities and faculty development require specific attention. Reflective practice is an important programme element that supports wellbeing, resilience and achievement of professional goals. CBMET programmes should enable establishment of a culture of lifelong learning for the anaesthesiology community.

[Anesthesiological perspectives on perioperative management in continuous subcutaneous insulin infusion (CSII): stop or continue?] / Anästhesiologische Perspektive zum perioperativen Management bei kontinuierlicher subkutaner Insulininfusion (CSII): Stoppen oder fortführen?

OBJECTIVE: Perioperative handling of insulin pumps (CSII) is inconsistent. The aims of this study were a literature search addressing this clinical question, analysis of data found and a proposal for perioperative management recommendations for clinical practice. METHODS: A systematic search was conducted in PubMed and Clinical Research Network. RESULTS AND DISCUSSION: A total of 11 publications on CSII in perioperative medicine were identified. According to the evidence CSII guarantees perioperative glycemic stability under certain clinical situations. The use of CSII could be continued in patients undergoing elective non-cardiac minor surgery with fasting for up to one meal only. International guidelines on surgery in diabetes do not address the use of perioperative CSII. There is no nationwide register data for CSII, the use of which could be around 18%. Based on the search results, a hospital internal protocol for perioperative management with CSII and patient information material were designed. CONCLUSION: Growing evidence for improved patient outcome with perioperative CSII usage warrants interdisciplinary transfer of knowledge and experiences on intensified insulin therapy and patient empowerment.

New Hemostatic Agents: Perioperative Anesthetic Considerations.

AIM: Pharmacologic agents with procoagulant effects and antidotes against antithrombotic drugs play an important role in the prevention and management of perioperative coagulopathic bleeding. The aim of this narrative review is knowledge transfer from new and renewed hemostatic agents to anesthesiologists and other physicians involved in perioperative medicine. METHODS: The literature search was performed on PubMed and the Summaries of Product Characteristics of 6 pharmacologic agents of interest: fibrinogen concentrate, vonicog alfa, susoctocog alfa, idarucizumab, andexanet alfa, and argatroban. RESULTS AND DISCUSSION: This review highlights renewed interest in fibrinogen concentrate, an old prohemostatic drug, in correcting hypofibrinogenemia which is a leading pathomechanism of perioperative bleeding. This review describes clinically relevant aspects for brand new recombinant prohemostatic drugs for their use in critical clinical situations: vonicog alfa for the prevention and correction of bleeding in von Willebrand syndrome, and susoctocog alfa in acquired hemophilia A. Clinical experience and increasing evidence broadened the field of applications of the old antithrombotic drug argatroban to heparin resistance. New antidotes against new antithrombotic agents revolutionized the safety of chronic antithrombotic therapy in the emergency situations of acute and trauma surgery. Information on dosing and handling of new hemostatic drugs is summarized. CONCLUSION: New and potent hemostatic agents exist for perioperative use and may enrich the armamentarium of anesthesiologists. Implementation into clinical practice requires their availability and user knowledge. Sustainability of these new drugs depends on post-licensing research, cost-effectiveness, and clinical experience.