Hemoadsorption in the critically ill-Final results of the International CytoSorb Registry.

The aim of the current paper is to summarize the results of the International CytoSorb Registry. Data were collected on patients of the intensive care unit. The primary endpoint was actual in-hospital mortality compared to the mortality predicted by APACHE II score. The main secondary endpoints were SOFA scores, inflammatory biomarkers and overall evaluation of the general condition. 1434 patients were enrolled. Indications for hemoadsorption were sepsis/septic shock (N = 936); cardiac surgery perioperatively (N = 172); cardiac surgery postoperatively (N = 67) and "other" reasons (N = 259). APACHE-II-predicted mortality was 62.0±24.8%, whereas observed hospital mortality was 50.1%. Overall SOFA scores did not change but cardiovascular and pulmonary SOFA scores decreased by 0.4 [-0.5;-0.3] and -0.2 [-0.3;-0.2] points, respectively. Serum procalcitonin and C-reactive protein levels showed significant reduction: -15.4 [-19.6;-11.17] ng/mL; -17,52 [-70;44] mg/L, respectively. In the septic cohort PCT and IL-6 also showed significant reduction: -18.2 [-23.6;-12.8] ng/mL; -2.6 [-3.0;-2.2] pg/mL, respectively. Evaluation of the overall effect: minimal improvement (22%), much improvement (22%) and very much improvement (10%), no change observed (30%) and deterioration (4%). There was no significant difference in the primary outcome of mortality, but there were improvements in cardiovascular and pulmonary SOFA scores and a reduction in PCT, CRP and IL-6 levels. Trial registration: ClinicalTrials.gov Identifier: NCT02312024 (retrospectively registered).

[Cerebral Emergency - Important Anesthesiological Aspects]. / Der zerebrale Notfall ­ wichtige anästhesiologische Aspekte.

The anesthesiological management of cerebral emergency represents a great challenge for action under pressure and under time pressure and requires smooth interprofessional cooperation. The exact knowledge of the pathophysiological and pharmacological relationships is the basis for rapid identification of therapeutic influences and possible disturbing factors. In the acute situation, paCO2 and MAP are the central determinants for the anesthetist to ensure cerebral perfusion and the resulting cerebral oxygenation. Especially in patients with SHT, a difficult airway must always be expected. Knowledge of the appropriate steps and the necessary equipment must be available. In patients under anticoagulant therapy, written instructions for suspending this therapy are extremely helpful. Interventional thrombectomy is a new emergency situation for the anesthetist. The door-to-needle time has to be kept as short as possible by defined treatment paths and rapid goal-oriented work. Every emergency also creates a stressful reaction in those treating the patient - in a sense, the cerebral emergency "in us". This has a decisive influence on the perception and action of the individual and the entire team.

[Interdisciplinary Simulation of Emergency Caesarean Section to Improve Subjective Competence]. / Subjektiver Kompetenzgewinn zur Durchführung eines Notfallkaiserschnitts mittels interdisziplinärem Simulationstraining.

The emergency caesaran section is a gynecological emergency situation which is potentially life-threatening for mother and child. In the management of these time-critical situations human factors as well as the competence of the crisis resource management team have been shown to be important factors for success. The concept "simulation" has not been validated as a training tool for professional competence of multidisciplinary teams in the delivery suite. The aim of this study was, to assess the competence gain by subjective evaluation of the team members after taking part in an emergency caesarian section training which is integrable into the daily clinic setting. Method 36 members of a multidisciplinary team of a delivery suite took part in a 4-hourly "high-fidelity" simulation training "emergency caesarian section". Scenarios were created around the case setting of eclampsia with bradycardia of the child, uterus rupture, placenta abruption and cord prolapse. Each participant was involved in 2 scenarios as either a spectator or a team member. Using a questionnaire, the course performance and debriefing were evaluated and the subjective professional competence in Crisis Resource Management were recorded. Results In the collective of the trainee (over/equal 5 years), 25% had no experience in any cases of emergency caesarean in practice. On a scale of 1 to 6 (1=very good, 6=fail) the course was given an overall mark of 1.4 and a mark of 1.8 for its relevance to daily work. 6 months after the training, participants rated their competencies in prioritising necessary actions, following treatment plans, communicating among the team members as well as integrating new information as significantly improved. Conclusion The 4-hour simulation training can be easily integrated into everyday clinical practice. The participants marked the course scenarios as realistic and relevant for their clinical practice. The number of years of prior work experience is not significanty related with the experience in rare emergency situations. The interdisciplinary team training is a way to improve individual performance as well as to establish and practise interdisciplinary emergency concepts.

Cerebral Oxygenation Under General Anesthesia Can Be Safely Preserved in Patients in Prone Position: A Prospective Observational Study.

BACKGROUND: The effects of prone position (PP) on cerebral tissue metabolism are not well known. The aim of this investigation was to evaluate regional cerebral oxygen desaturation in patients undergoing lumbar spine surgery in PP during routine anesthesia management. MATERIALS AND METHODS: Between July 2013 and October 2013, 50 consecutive patients undergoing lumbar spine surgery under general anesthesia in PP were enrolled. The anesthetic technique was standardized. Using near-infrared spectroscopy, bilateral regional cerebrovascular oxygen saturation was recorded during the surgery. RESULTS: After 30 and 60 minutes of prone repositioning, significant decreases in bilateral regional cerebral oxygen saturation were observed compared with the values in the supine position (from 76.24% to 73.18% at 30 min and 72.76% at 60 min on the right side and from 77.06% to 73.76% at 30 min and 72.92% at 60 min on the left side; P<0.05). These changes were not clinically important and returned to supine values after 90 minutes of prone positioning. Decreases in cerebral oxygen saturation were accompanied by reductions in heart rate and mean arterial pressure (P<0.05). Older age and higher perioperative risk had a significant effect on the reduction of cerebral oxygen values (P<0.05). CONCLUSIONS: The results of our study show that margin of safety against impaired cerebral oxygenation can be maintained in PP. Preventing bradycardia and arterial hypotension is crucial. Older patients and those at higher perioperative risk need more meticulous attention.

Unanticipated Disturbance in Somatosensory Evoked Potentials in a Patient in Park-Bench Position.

Perioperative neuropathy is a known complication of malpositioning during anaesthesia. Somatosensory evoked potentials are used for detecting such a complication in selected surgeries. Most reports of intraoperative nerve injuries due to malpositioning are limited to injuries to the peripheral nervous system, and there have been no previously reported cases of somatosensory evoked potential monitoring disturbance attributable to position-related cerebral ischemia in the park-bench position. We present the case of a patient with glioblastoma in the park-bench position whose somatosensory evoked potential waveforms disappeared after head and neck repositioning. A prompt diagnosis of this complication and elimination of the underlying cause led to the return of somatosensory evoked potential waveforms, and there was no relevant neurologic deficit at the end of the surgery.