Crystalloid volume versus catecholamines for management of hemorrhagic shock during esophagectomy - assessment of microcirculatory tissue oxygenation of the gastric conduit in a porcine model using hyperspectral imaging - an experimental study.

INTRODUCTION: Oncologic esophagectomy is a two-cavity procedure with considerable morbidity and mortality. Complex anatomy and the proximity to major vessels constitute a risk for massive intraoperative hemorrhage. Currently, there is no conclusive consensus on the ideal anesthesiologic countermeasure in case of such immense blood loss. The objective of this work was to identify the most promising anesthesiologic management in case of intraoperative hemorrhage with regards to tissue perfusion of the gastric conduit during esophagectomy using hyperspectral imaging (HSI). MATERIAL AND METHODS: An established live porcine model (n=32) for esophagectomy was used with gastric conduit formation and simulation of a linear stapled side-to-side esophagogastrostomy. After a standardized procedure of controlled blood loss of about 1 L per pig, the four experimental groups (n=8 each) differed in anesthesiologic intervention i.e. (I) permissive hypotension, (II) catecholamine therapy using noradrenaline, (III) crystalloid volume supplementation and (IV) combined crystalloid volume supplementation with noradrenaline therapy. HSI tissue oxygenation (StO2) of the gastric conduit was evaluated and correlated with systemic perfusion parameters. Measurements were conducted before (T0) and after (T1) laparotomy, after hemorrhage (T2) and 60 minutes (T3) and 120 minutes (T4) after anesthesiologic intervention. RESULTS: StO2 values of the gastric conduit showed significantly different results between the four experimental groups with 63.3% (±7.6%) after permissive hypotension (I), 45.9% (±6.4%) after catecholamine therapy (II), 70.5% (±6.1%) after crystalloid volume supplementation (III) and 69.0% (±3.7%) after combined therapy (IV). StO2 values correlated strongly with systemic lactate values (r=-0.67; CI -0.77 to -0.54), which is an established prognostic factor. CONCLUSION: Crystalloid volume supplementation (III) yields the highest StO2 values and lowest systemic lactate values and therefore appears to be the superior primary treatment strategy after hemorrhage during esophagectomy with regards to microcirculatory tissue oxygenation of the gastric conduit.

[Special emergency situations and hazard control in German hospitals-A survey on the current state]. / Sonderlagen und Gefahrenabwehr in deutschen Krankenhäusern ­ eine Umfrage zum Ist-Zustand.

BACKGROUND AND RESEARCH QUESTION: In case of events such as a cyber attack or a mass casualty incident, ad hoc measures have to be taken in hospitals. As part of the critical infrastructure, hospitals are required by law to prepare, update and exercise alarm and emergency plans for various special situations. The processes and instruments involved for emergency response are defined in the hospital alert and emergency planning. The present study aims to explain with which resources and for which special situations hospitals are prepared. METHODS: A prospective, exploratory, anonymous survey of hospitals in Germany was conducted. Hospitals with both internal medicine and surgery departments were included. Out of 2497 hospitals listed in the German Hospital Directory ( www.deutsches-krankenhaus-verzeichnis.de ), 1049 met the inclusion criteria. After correcting for hospital groups with shared administrations, 850 employees were identified and contacted by e­mail. Quality and risk management managers were asked about resources, risks, and content of their own hospital alert and emergency planning using a standardized questionnaire. The survey was conducted using the online platform EFS Survey (Tivian XI GmbH, Cologne) via www.unipark.de . Access to the survey was via a nonpersonalized hyperlink. Apart from the size and type of hospital surveyed, no data were collected that would allow identification of an individual person. RESULTS: Of the participating hospitals 45% (n = 43) were primary care hospitals, 24% (n = 23) were specialty care hospitals, 10% (n = 9) were nonuniversity maximum care hospitals, and 21% (n = 20) were university maximum care hospitals. In total 95 hospitals participated in the survey, of which 98% (n = 93) reported having a hospital alert and emergency plan. Preparation for individual scenarios varied widely. Of the participating hospitals 45% (n = 43) reported having been the target of cyber attacks with an emphasis on maximum care hospitals (55%, n = 11 of 20). Technical redundancy for computer systems is available in 67% (n = 63) of participating hospitals, while independent means of communication exist in 50% (n = 47) of hospitals. A physician-staffed crisis and disaster management unit existed in 60% (n = 56) of the surveyed hospitals. At least a part time position for planning issues was installed in 12 hospitals. CONCLUSION: Most participating hospitals are aware of the need for a hospital alert and emergency plan and have various scenario-specific plans in place. Especially mass casualty events, fire and hospital evacuation scenarios are uniformly covered among participating hospitals; however, gaps appear to exist not only for chemical, biological or radionuclear situations but also especially in the area of extreme weather events and infrastructure failures. Only about two thirds of all participating hospitals have contingency plans for water supply and/or heating failures. An important limitation of the study is the comparatively low response rate of 12.9% (n = 95 of 850). While primary care hospitals were underrepresented in the study, 32% of Germany's larger hospitals (> 800 beds) participated. In the future, there is a particular need to engage enough medical staff in the area of hospital alert and emergency planning and refunding of these measures by hospitals.

[Thrombotic occlusion of the extracorporeal circulation during hepatic chemosaturation despite targeted anticoagulation : A case report]. / Thrombotischer Verschluss der extrakorporalen Zirkulation während hepatischer Chemosaturation trotz zielgerechter Antikoagulation : Ein Fallbericht.

Percutaneous hepatic chemosaturation is a treatment option for unresectable primary or secondary liver tumors. In this procedure the part of the inferior vena cava (VCI) that collects blood from the hepatic veins is isolated using a double balloon catheter. Like this, systemic distribution of the chemotherapeutic agent melphalan which is administered via the hepatic artery can be prevented. After passage through the liver and drainage from the retrohepatic VCI, the chemosaturated blood passes through two extracorporeal filters. Subsequently, the filtered blood is returned via the jugular vein. The procedure is often accompanied by severe hemodynamic instability, the cause of which is still not completely understood. In addition, coagulation management of extracorporeal circulation is often challenging. The authors report a case in which a thrombus formed in the returning leg of the extracorporeal circulation despite sufficient activated clotting time (ACT). Targeted problem search and resolution were necessary simultaneously to hemodynamic stabilization and interdisciplinary collaboration to successfully perform the intervention and provide the patient with safe treatment.

Toggle-like current-induced Bloch point dynamics of 3D skyrmion strings in a room temperature nanowire.

Research into practical applications of magnetic skyrmions, nanoscale solitons with interesting topological and transport properties, has traditionally focused on two dimensional (2D) thin-film systems. However, the recent observation of novel three dimensional (3D) skyrmion-like structures, such as hopfions, skyrmion strings (SkS), skyrmion bundles, and skyrmion braids, motivates the investigation of new designs, aiming to exploit the third spatial dimension for more compact and higher performance spintronic devices in 3D or curvilinear geometries. A crucial requirement of such device schemes is the control of the 3D magnetic structures via charge or spin currents, which has yet to be experimentally observed. In this work, we utilise real-space imaging to investigate the dynamics of a 3D SkS within a nanowire of Co8Zn9Mn3 at room temperature. Utilising single current pulses, we demonstrate current-induced nucleation of a single SkS, and a toggle-like positional switching of an individual Bloch point at the end of a SkS. The observations highlight the possibility to locally manipulate 3D topological spin textures, opening up a range of design concepts for future 3D spintronic devices.

History-dependent domain and skyrmion formation in 2D van der Waals magnet Fe3GeTe2.

The discovery of two-dimensional magnets has initiated a new field of research, exploring both fundamental low-dimensional magnetism, and prospective spintronic applications. Recently, observations of magnetic skyrmions in the 2D ferromagnet Fe3GeTe2 (FGT) have been reported, introducing further application possibilities. However, controlling the exhibited magnetic state requires systematic knowledge of the history-dependence of the spin textures, which remains largely unexplored in 2D magnets. In this work, we utilise real-space imaging, and complementary simulations, to determine and explain the thickness-dependent magnetic phase diagrams of an exfoliated FGT flake, revealing a complex, history-dependent emergence of the uniformly magnetised, stripe domain and skyrmion states. The results show that the interplay of the dominant dipolar interaction and strongly temperature dependent out-of-plane anisotropy energy terms enables the selective stabilisation of all three states at zero field, and at a single temperature, while the Dzyaloshinksii-Moriya interaction must be present to realise the observed Néel-type domain walls. The findings open perspectives for 2D devices incorporating topological spin textures.

When to operate after SARS-CoV-2 infection? A review on the recent consensus recommendation of the DGC/BDC and the DGAI/BDA.

Since the eruption of the worldwide SARS-CoV-2 pandemic in late 2019/early 2020, multiple elective surgical interventions were postponed. Through pandemic measures, elective operation capacities were reduced in favour of intensive care treatment for critically ill SARS-CoV-2 patients. Although intermittent low-incidence infection rates allowed an increase in elective surgery, surgeons have to include long-term pulmonary and extrapulmonary complications of SARS-CoV-2 infections (especially "Long Covid") in their perioperative management considerations and risk assessment procedures. This review summarizes recent consensus statements and recommendations regarding the timepoint for surgical intervention after SARS-CoV-2 infection released by respective German societies and professional representatives including DGC/BDC (Germany Society of Surgery/Professional Association of German Surgeons e.V.) and DGAI/BDA (Germany Society of Anesthesiology and Intensive Care Medicine/Professional Association of German Anesthesiologists e.V.) within the scope of the recent literature. The current literature reveals that patients with pre- and perioperative SARS-CoV-2 infection have a dramatically deteriorated postoperative outcome. Thereby, perioperative mortality is mainly caused by pulmonary and thromboembolic complications. Notably, perioperative mortality decreases to normal values over time depending on the duration of SARS-CoV-2 infection.

Impact of discontinuing contact precautions and enforcement of basic hygiene measures on nosocomial vancomycin-resistant Enterococcus faecium transmission.

OBJECTIVES: Vancomycin-resistant Enterococcus faecium (VREfm) has emerged as a pathogen of major concern for public health. Although definitive evidence is lacking, contact precautions have been a crucial element in infection prevention and control (IPC) strategies designed to limit nosocomial VRE transmission. This study investigated the effect of discontinuing contact precautions while enforcing basic hygiene measures, including hand hygiene, environmental cleaning and antiseptic body washing, for patients with VRE in intensive care units (ICUs) on the prevention of nosocomial VRE transmission causing bacteraemia. METHODS: Contact precautions were discontinued in January 2018. In total, 96 VREfm isolates from 61 patients with VREfm bacteraemia and/or colonization hospitalized in eight ICUs in a tertiary care hospital in 2016 and 2019 in were characterized by whole-genome sequencing. VRE transmission was investigated using patient movement data and admission screening for reliable identification of nosocomial acquisition. RESULTS: Discontinuation of contact precautions did not increase VREfm transmission events (eight in 2016 vs one in 2019). While the rate of endogenous VREfm was similar in both years (38% vs 31%), the number of non-colonized patients prior to VREfm bacteraemia was 16 (16/29, 55%) in 2019, which was significantly higher than in 2016 (8/32, 25%). The mean incidence density for VREfm bacteraemia was similar for both years (0.26 vs 0.31 per 1000 patient-days in 2016 and 2019, respectively). CONCLUSION: Discontinuation of contact precautions while enforcing basic hygiene measures did not lead to an increase in nosocomial bloodstream infection rates due to VREfm transmission in a hyperendemic ICU setting.

Bedside hyperspectral imaging indicates a microcirculatory sepsis pattern - an observational study.

INTRODUCTION: Microcirculatory alterations are key mechanisms in sepsis pathophysiology leading to tissue hypoxia, edema formation, and organ dysfunction. Hyperspectral imaging (HSI) is an emerging imaging technology that uses tissue-light interactions to evaluate biochemical tissue characteristics including tissue oxygenation, hemoglobin content and water content. Currently, clinical data for HSI technologies in critical ill patients are still limited. METHODS AND ANALYSIS: TIVITA® Tissue System was used to measure Tissue oxygenation (StO2), Tissue Hemoglobin Index (THI), Near Infrared Perfusion Index (NPI) and Tissue Water Index (TWI) in 25 healthy volunteers and 25 septic patients. HSI measurement sites were the palm, the fingertip, and a suprapatellar knee area. Septic patients were evaluated on admission to the ICU (E), 6 h afterwards (E+6) and three times a day (t3-t9) within a total observation period of 72 h. Primary outcome was the correlation of HSI results with daily SOFA-scores. RESULTS: Serial HSI at the three measurement sites in healthy volunteers showed a low mean variance expressing high retest reliability. HSI at E demonstrated significantly lower StO2 and NPI as well as higher TWI at the palm and fingertip in septic patients compared to healthy volunteers. StO2 and TWI showed corresponding results at the suprapatellar knee area. In septic patients, palm and fingertip THI identified survivors (E-t4) and revealed predictivity for 28-day mortality (E). Fingertip StO2 and THI correlated to SOFA-score on day 2. TWI was consistently increased in relation to the TWI range of healthy controls during the observation time. Palm TWI correlated positively with SOFA scores on day 3. DISCUSSION: HSI results in septic patients point to a distinctive microcirculatory pattern indicative of reduced skin oxygenation and perfusion quality combined with increased blood pooling and tissue water content. THI might possess risk-stratification properties and TWI could allow tissue edema evaluation in critically ill patients. CONCLUSION: HSI technologies could open new perspectives in microcirculatory monitoring by visualizing oxygenation and perfusion quality combined with tissue water content in critically ill patients - a prerequisite for future tissue perfusion guided therapy concepts in intensive care medicine.

[Summary and comments on the WSES guidelines on open abdomen in trauma and non-trauma patients]. / Zusammenfassung und Kommentar zur WSES-Leitlinie Abdomen apertum bei Trauma- und Nichttraumapatienten.

The first edition of the World Society of Emergency Surgeons (WSES) guidelines on the indications and treatment of open abdomen in trauma as well as in non-trauma patients was published at the end of 2018. Publications from 1980 to 2017 were included in the evaluation. Based on the GRADE system each publication was checked for its evidence and evaluated in a Delphi process. In this article the aspects of the guidelines are presented and commented on.