Three near fatal or fatal complications during implantation of tunnelled hemodialysis catheters : Learning from experts.

Tunnelled hemodialysis catheters are well accepted and widely used devices to provide vascular access for dialysis in patients when an arteriovenous shunt is not feasible or dysfunctional. In the literature complications after implantation are well documented but fatal or near-fatal events during implantation are seldom reported. In this article 3 such cases from a single tertiary center over a period of more than 10 years are presented and discussed. The (near) fatal complications occurred despite experienced surgeons and the use of ultrasound and fluoroscopy during implantation. Although the incidence is estimated to be much less than 1% at this centre, implantation of a tunnelled hemodialysis catheter is demanding, a thorough evaluation of vascular structures in advance is mandatory and experiencend professionals with high index of suspicion are essential. Performing the procedure with the patient under conscious sedation has benefits compared to general anesthesia. If the patient indicates atypical pain, the procedure should be stopped immediately and re-evaluated for any cause. If a perforation with relevant vascular damage is suspected, we recommend leaving the dilator/introducer/catheter in place to reduce major hemorrhage until the vascular or cardiothoracic surgeon can fix the problem.

[Increasing Complexity in Performance Delivery - Management Approach for Tertiary Care Centers]. / Komplexitätssteigerung in der Leistungserstellung ­ Managementansätze für ein Zentrumsspital.

Increasing Complexity in Performance Delivery - Management Approach for Tertiary Care Centers Abstract. General social trends such as individualization and female shift increase the complexity for management in both technical and system management in addition to the inherent development in the hospital industry such as subspecialization, ageing societies and multimorbidity. Reduction of complexity is therefore absolutely necessary in order to be able to manage in a patient-friendly way as a maximum care provider. Reducing complexity means resolving therapeutic conflicts. Essential tools for this are digitization, a comprehensive quality paradigm that includes patient experience, patient assessment of treatment outcomes, indication and service quality, and good management. The latter integrates the fragmentation of skills and knowledge of a subspecialized medicine through appropriate system design. This requires the appropriate functional strategies and a comprehensive process management competence that can transform the numerous interfaces into seams.

Effects of hypotension and/or hypocapnia during sevoflurane anesthesia on perfusion and metabolites in the developing brain of piglets-a blinded randomized study.

BACKGROUND: Hypotension (HT) and/or hypocapnia (HC) are frequent complications occurring during pediatric anesthesia and may cause cerebral injury in the developing brain. AIM: The aim of this study is to investigate the effects of HT and/or HC on perfusion and metabolism in the developing brain. METHODS: Twenty-eight piglets were randomly allocated to four groups: control (C), HT, HC, and hypotension and hyocapnia (HTC). Anesthesia was induced and maintained using sevoflurane. Fentanyl was added for instrumentation. Piglets were fully monitored and their lungs were artificially ventilated. Before treatment, conventional magnetic resonance imaging (MRI), dynamic susceptibility-contrast-enhanced T2*-weighted MRI (DSC-MRI), and single voxel proton MR spectroscopy ((1) H MRS) were performed. Hypotension (mean arterial blood pressure: 30 ± 3 mmHg) was induced by blood withdrawal and nitroprusside infusion, and hyperventilation was used to induce HC (PaCO2 : 2.7-3.3 kPa). (1) H MRS and DSC-MRI were repeated immediately once treatment goals were achieved and 120 min later. Radiologists were blinded to the groups. DSCI-MRI and (1) H MRS analyses were performed in the thalamus, occipital and parietal lobe, hippocampus, and watershed areas. RESULTS: In comparison to C, mean time to peak (TTP) increased with HTC in all brain areas as assessed with DSC-MRI (n = 26). Using (1) H MRS, a significant decrease in N-acetyl aspartate, choline, and myoinositol, as well as an increase in glutamine-glutamate complex (Glx) were detected independent of group. Compared to C, changes were more pronounced for Glx (due to an increase in glutamate) and myoinositol with HTC, for N-acetyl aspartate with HT, and for Glx with HC. No lactate signal was present. CONCLUSIONS: The combination of HT and HC during sevoflurane anesthesia resulted in alteration of cerebral perfusion with signs of neuronal dysfunction and early neuronal ischemia. HT and HC alone also resulted in signs of metabolic disturbances despite the absence of detectable cerebral perfusion alterations.

The influence of acute pulmonary hypertension on cardiac output measurements: calibrated pulse contour analysis, transpulmonary and pulmonary artery thermodilution against a modified Fick method in an animal model.

BACKGROUND: In critically ill patients with significant pulmonary hypertension (PH), close perioperative cardiovascular monitoring is mandatory, considering the increased morbidity and mortality in this patient group. Although the pulmonary artery catheter is still the standard for the diagnosis of PH, its use to monitor cardiac output (CO) in patients with PH is decreasing as a result of increased morbidity and possible influence of tricuspid regurgitation on the measurements. However, continuous CO measurement methods have never been evaluated under PH regarding their agreement and trending ability. In this study, we evaluated the influence of acute PH and different CO states on transpulmonary thermodilution (TPTD) and calibrated pulse contour analysis (PiCCO; both assessed with PiCCO plus™), intermittent pulmonary artery thermodilution (PATD), and continuous thermodilution (CCO) compared with a modified Fick method (FICK) in an animal model. METHODS: Nine healthy pigs were studied under anesthesia. PH of 25 and 40 mm Hg (by administration of the thromboxane analog U46619), CO decreases, and CO increases were induced to test the different CO measurement techniques over a broad range of hemodynamic situations. Before each step, a new baseline data set was collected. CO values were compared using Bland-Altman analysis; trending abilities were assessed via concordance and polar plot analysis. The influence of pulmonary pressure on CO measurements was analyzed using linear mixed models. RESULTS: A mean bias of -0.26 L/min with prediction intervals of -0.88 to 1.4 L/min was measured between TPTD and FICK. Their concordance rate was 100% (94%-100% confidence interval), and the mean polar angle -3° with radial limits of agreement of ±28° indicated good trending abilities. PATD compared with FICK also showed good trending ability. Comparisons of PiCCO and CCO versus FICK revealed low agreement and poor trending results with concordance rates of 84% (71%-93%) and 88% (74%-95%), mean polar angles from -17° and -19°, and radial limits of agreement of ±45° and 40°. Pulmonary pressures influenced only the difference between FICK and PiCCO, as assessed by linear mixed models. CONCLUSIONS: TPTD compared with FICK was able to track all changes induced during the study period, including those by PH. It yielded better agreement than PATD both compared with FICK. PiCCO and CCO were not mapping all changes correctly, and when used clinically in unstable patients, regular controls with intermittent techniques are required. Acute pharmacologically induced PH did influence the difference between FICK and PiCCO.

The effects of cardiac output and pulmonary arterial hypertension on volumetric capnography derived-variables during normoxia and hypoxia.

The aim of this study was to test the effect of cardiac output (CO) and pulmonary artery hypertension (PHT) on volumetric capnography (VCap) derived-variables. Nine pigs were mechanically ventilated using fixed ventilatory settings. Two steps of PHT were induced by IV infusion of a thromboxane analogue: PHT25 [mean pulmonary arterial pressure (MPAP) of 25 mmHg] and PHT40 (MPAP of 40 mmHg). CO was increased by 50% from baseline (COup) with an infusion of dobutamine≥5 µg kg(-1) min(-1) and decreased by 40% from baseline (COdown) infusing sodium nitroglycerine≥30 µg kg(-1) min(-1) plus esmolol 500 µg kg(-1) min(-1). Another state of PHT and COdown was induced by severe hypoxemia (FiO2 0.07). Invasive hemodynamic data and VCap were recorded and compared before and after each step using a mixed random effects model. Compared to baseline, the normalized slope of phase III (SnIII) increased by 32% in PHT25 and by 22% in PHT40. SnIII decreased non-significantly by 4% with COdown. A combination of PHT and COdown associated with severe hypoxemia increased SnIII by 28% compared to baseline. The elimination of CO2 per breath decreased by 7% in PHT40 and by 12% in COdown but increased only slightly with COup. Dead space variables did not change significantly along the protocol. At constant ventilation and body metabolism, pulmonary artery hypertension and decreases in CO had the biggest effects on the SnIII of the volumetric capnogram and on the elimination of CO2.

Impact of catecholamines in cardiac arrest due to acute asphyxia--a study in piglets.

BACKGROUND: Early intravenous epinephrine administration may help to achieve return of spontaneous circulation in cardiac arrest (CA). However, venous access can be challenging in small children. This study investigates the effect of intravenous and intramuscular epinephrine in treatment of asphyxial CA. METHODS: Twenty-eight, 2-5-weeks-old, anesthetized piglets were asphyxiated by ventilation withdrawal. CA was untreated for 8 min, followed by 2 min of basic life support. Following this, epinephrine iv (10 µg·kg(-1) , group IV), epinephrine im (100 µg·kg(-1) , group IM), or normal saline (group NS) were administered. Further doses of epinephrine were given in group IV every 4 min, in group IM after 10 min if required. After twenty-two minutes of CA, iv epinephrine was given to all animals still in CA. Outcome measures were survival and epinephrine plasma concentrations. RESULTS: Ten animals regained spontaneous circulation after 2 min of basic life support. Therefore, no drug treatment was administered (drop out). Resuscitation was effective in 2 pigs of group IM (n = 6), in 6 of group NS (n = 8) and in all of group IV (n = 4). Nonsurvivors had higher epinephrine (P < 0.01) and norepinephrine (P < 0.01) plasma concentrations prior to start of resuscitation. Median increase in epinephrine plasma concentration from T0 to T5 was 138, 134, and 29 nm in group IV, IM, and NS, respectively. CONCLUSIONS: Intravenous and intramuscular administered epinephrine led to similar increase in plasma concentrations during resuscitation of asphyxial CA without hemodynamic or survival benefit. High endogenous epinephrine and norepinephrine plasma concentrations were negative predictors for survival.

Intravenous versus intramuscular epinephrine administration during cardiopulmonary resuscitation - a pilot study in piglets.

BACKGROUND: Early epinephrine administration in cardiac arrest seems to be advantageous to achieve return of spontaneous circulation (ROSC). Because intravenous (i.v.) or intraosseous access is not always immediately available, this study compares efficacy of early intramuscular (i.m.) epinephrine administration with early and delayed i.v. epinephrine injection in an animal cardiac arrest model. METHODS: Piglets anesthetized with sevoflurane were intoxicated by an i.v. ropivacaine infusion until circulatory arrest. After 1 min basic life support (chest compression and ventilation), epinephrine i.v. (10 µg·kg(-1), group IV) or epinephrine i.m. (100 µg·kg(-1), group IM) or normal saline (group NS) was applied. Further doses of epinephrine were given in group IV every 4 min and in group IM after 10 min if required. Twenty-one minutes after circulatory arrest, i.v. epinephrine - as necessary - was given to all animals. Thus, group NS represents late epinephrine administration. Outcomes were survival and time to ROSC. RESULTS: Twenty-four pigs aged 19.5 (median, interquartile range 16-22) days, weighing 5.4 (5.0-5.7) kg were investigated. Total amount of ropivacaine administered was 8.9 (8.1-10.1) mg·kg(-1). Cardiac rhythm before starting CPR was pulseless electric activity and asystole in 15 and 9 pigs, respectively. Eight, seven, and four pigs survived in group IV, IM, and NS. Focusing on surviving animals, time to ROSC was 2, 4 and 19.5 min in group IV, IM, and NS. CONCLUSIONS: Early i.m. epinephrine provided similar survival compared with early i.v. epinephrine and was superior to delayed epinephrine administration in resuscitation of ropivacaine-induced cardiac arrest in piglets.

Effect of rapid fluid resuscitation using crystalloids or colloids on hemostasis in piglets.

BACKGROUND AND OBJECTIVES: Impairment of blood coagulation is one of the main side effects of volume replacement, particularly if artificial colloids such as hydroxyethyl starch (HES) and gelatine preparations are used. This animal study aimed to evaluate the effect of a single fast intravenous crystalloid or colloid fluid bolus on blood coagulation as measured by rotation thromboelastometry (ROTEM). METHODS: Thirty-two anesthetized piglets were infused with a rapid 20 ml·kg(-1) fluid bolus of either normal saline (NS), 4% gelatine, 5% albumin or 6% HES 130/0.4 (n = 8 per group) over a period of 2 min. Hemostasis was assessed by ROTEM before and 1 min after fluid administration. Within-group differences were analyzed by Wilcoxon test, and additionally overall Kruskal-Wallis test followed by posthoc Mann-Whitney U-test were applied to detect differences between groups. RESULTS: All fluids caused a significant weakening of clot strength within groups. HES and gelatine showed a significantly stronger impairment of clot growth and maximum clot firmness as compared with albumin and normal saline. Impairment of fibrin polymerization was more pronounced following HES as compared with all other fluids. CONCLUSION: After moderate but very fast volume loading, HES and gelatine impair blood coagulation to a larger extent as compared with albumin or normal saline, while no significant differences were observed between both artificial colloids.

Electrocardiographic and blood pressure alterations caused by intravenous injection of ropivacaine - a study in piglets.

OBJECTIVES: Objective signs to detect inadvertent intravascular injection of local anesthetics are essential in the anesthetized pediatric patient. For early detection of intravenous bupivacaine administration, it was shown that an epinephrine containing test dose reliably provoked T-wave alterations, changes in heart rate (HR) and blood pressure, whereas intravenous injection of plain bupivacaine could not be detected until high doses were applied. This study investigates electrocardiographic and hemodynamic alterations caused by intravenous ropivacaine. METHODS: Twenty-four piglets, anesthetized with sevoflurane, were randomized into two groups: Group R received as test dose plain ropivacaine 0.2% and group RE, ropivacaine 0.2% + epinephrine 5 µg·ml(-1) . Under stable conditions, 0.2 ml kg(-1) of the test solution was intravenously injected. Twenty minutes later, 0.4 ml kg(-1) was applied. A positive effect was defined as HR increase ≥ 10 bpm, increase in mean arterial pressure (MAP) ≥ 15 mmHg, T-wave increase ≥ 25% baseline. In another setting ropivacaine was intravenously infused until cardiac arrest. RESULTS: After injection of 0.2 or 0.4 ml kg(-1) test solution, a positive increase in HR and MAP was found in 0% of group R and in 100% of group RE. An increase in T-wave ≥ 25% was found in 42% of group R and in 100% of group RE. During intoxication, T-elevation was seen in 83%. CONCLUSIONS: An epinephrine containing test dose ropivacaine reliably provoked T-wave elevations and increases in HR and MAP. A small dose plain ropivacaine caused T-elevations in a remarkable percentage, whereas higher, quite toxic doses provoked T-elevations in most of the pigs.

Correlation of activated clotting times and standard laboratory coagulation tests in paediatric non-cardiac surgery.

The activated clotting time (ACT) was invented as a whole blood test to detect coagulopathy, but nowadays is almost exclusively used to guide heparin anticoagulation. Although the ACT provides a fairly reliable and fast bedside test of the coagulation status, only a few studies have focused on its use to monitor pre- or intraoperative coagulation status as an early marker of impaired haemostasis or increased bleeding tendency. The aim of this study was to compare intraoperative i-STAT(®) ACT values with commonly used thresholds of standard coagulation tests for the diagnosis of coagulopathy during paediatric non-cardiac surgery. We performed a prospective, observational study in a University Children's hospital and included 50 paediatric patients who underwent major elective, non-cardiac, surgery. The i-STAT(®) kaolin ACT test was obtained intraoperatively and compared to the commonly used threshold of standard coagulation tests (PT/INR, aPTT, and plasma fibrinogen level). A total of 181 blood samples were taken from 50 pediatric patients. Moderate correlation was found between ACT and aPTT (r = 0.694; p < 0.001), and all other coagulation tests. The median ACT values remained within the normal range throughout the entire surgical phase, while standard coagulation tests were mostly abnormal during surgery. Intraoperative measurement of ACT did not provide comparable thresholds of normal haemostasis as compared to standard coagulation testing.

Do lower cuff pressures reduce damage to the tracheal mucosa? A scanning electron microscopy study in neonatal pigs.

BACKGROUND: Modern high volume-low pressure (HVLP) endotracheal tubes (ETT) cuffs can seal the trachea using baseline cuff pressures (CP) lower than peak inspiratory airway pressures (PIP). The aim of the study was to determine whether this technique reduces the damage to the tracheal mucosa compared to constant CP of 20 cmH(2)O. METHODS: Eighteen piglets were intubated with an ID 4.0 mm HVLP cuffed ETT (Microcuff PET) and artificially ventilated with 20 cmH(2)O PIP and 5 cmH(2)O PEEP. Animals were randomly allocated to two groups of CP: group A (just seal; n = 9) and group B (20 cmH(2)O; n = 9), controlled constantly with a manometer during the following 4-h study period under sevoflurane anesthesia. After euthanasia, cuff position was marked in situ. Damage in the cuff region was evaluated with scanning electron microscopy (SEM) examination by grading of mucosal damage and by estimating percentage of intact mucosal area both by a blinded observer. RESULTS: Maximal CP to seal the trachea in group A ranged from 12 to 18 cmH(2)O (median: 14 cmH(2)O). Using a mixed effects model approach, the estimated mean effect of group B vs group A was an increase of 17.9% (SE 8.1%) higher proportion of pictures with an area of at least 5% intact mucosa (P = 0.042). CONCLUSION: Minimal sealing pressures with cyclic pressure changes from CP did not result in decreased damage to the tracheal mucosa compared to constant CP of 20 cmH(2)O in this short-term animal trial.

Effect of Lanz pressure regulating valve on self-sealing mechanism and air leakage across the tracheal tube cuffs in a benchtop model.

BACKGROUND: The aim of the present study was to investigate the effect of the Lanz system on air sealing by self-inflation in high volume-low pressure (HVLP) tube cuffs. METHODS: In vitro tracheal air sealing was studied in HVLP tracheal tube cuffs (internal diameter [ID] 8.0 mm) made from polyurethane ([PU] Seal Guard tracheal tube, Covidien, Athlone, Ireland) and from polyvinylchloride ([PVC] HiLo tracheal tube, Covidien) with and without Lanz pressure regulating valve. Tube cuffs were placed in a vertical 22 mm ID artificial trachea and inflated to 5, 10, 15, 20, 25, or 30 cm H2O cuff pressures. Pressure control ventilation with peak inspiratory pressures (PIPs) of 20 or 25 cm H2O was applied and air leakage was assessed spirometrically as the ratio of expiratory to inspiratory tidal volumes. Nonparametric Mann-Whitney test was applied to compare the air leakage with and without Lanz system for both cuff types at each cuff pressure and PIP (P < .05). RESULTS: The PVC tube cuffs with Lanz system resulted in significant air leakage at both 20 and 25 cm H2O PIP as compared to those without the Lanz system, especially at cuff pressures lower than the preset PIP (P < .05). Although PU tube cuffs with Lanz system showed reduced air sealing when compared with cuffs without Lanz, the difference was not statistically significant. CONCLUSION: Cuff pressure compensation with the Lanz system during cyclic respiratory pressure changes interferes with the self-sealing mechanism in HVLP tube cuffs at cuff pressures lower than PIP level. This results in larger air leak across tube cuffs particularly in tube cuffs made from PVC.

Reproducibility of thrombelastometry (ROTEM®): point-of-care versus hospital laboratory performance.

Thrombelastometry (ROTEM®) has gained wide acceptance in detecting and tailoring acquired hemostatic changes in adults and children. We investigated in this observational trial whether the reproducibility of this point-of-care testing was influenced by performance at the bedside or in the hospital laboratory. In addition, difference in time of performance between both measurements was compared. Perioperative blood samples obtained during major pediatric surgery were run in duplicate on two different ROTEM® devices located in the OR and in the hospital laboratory. The Bland-Altman test was used to compare differences of both measurements. ROTEM® measurements of 90 blood samples obtained from 24 children showed no overall clinically meaningful differences, whether they were performed bedside or in the hospital laboratory. Minor differences were found for the InTEM clot formation time (CFT) showing a mean bias of 10.79 seconds. Time saving was 11 minutes (8-16 minutes) if ROTEM® measurements were performed bedside (p < 0.001). In conclusion, there were minimal effects on ROTEM® measurements irrespective of whether they were performed in the hospital laboratory or at the bedside by a single trained staff member, while the latter saved valuable time.

Management of Dilutional Coagulopathy during Pediatric Major Surgery.

Perioperative dilutional coagulopathy is a major coagulation disorder during adult and pediatric surgery. Although the main underlying mechanisms are comparable, data of the development and management of dilutional coagulopathy in children are scarce. Observational data showed that intraoperative coagulation disorders mainly based on complex disturbances of clot firmness including acquired fibrinogen as well as factor XIII deficiencies, while clotting time and platelet counts remained fairly stable. A fast and reliable monitoring of the entire coagulation process (e.g. thrombelastometry) might be of extreme value for detection and guidance of effective coagulation management. Although the transfusion of fresh frozen plasma was recommended in several guidelines, the use of coagulation factors might offer an alternative and potentially superior approach in managing perioperative coagulation disorders. Further studies are urgently needed to determine the efficacy of modern coagulation management.

Perioperative course of FXIII in children undergoing major surgery.

BACKGROUND: Acquired deficiency of FXIII because of perioperative hemodilution has been described several times in adults; however, data in children are scarce. We performed a prospective observational trial to evaluate the intraoperative course of FXIII in children undergoing elective major surgery. METHODS: Blood samples were repeatedly taken from 46 children aged 0.3-16 years undergoing major surgery. Concentrations of FXIII and fibrinogen, thrombelastometry by ROTEM®, and cell count were assessed intraoperatively. RESULTS: A significant decrease in FXIII concentration (median 60%; IQR 49-69%) was already noted at beginning of surgical procedures, while most ROTEM® traces remain unchanged. FXIII levels further deteriorated intraoperatively to minimal levels of 33% (15-61%). Lowest intraoperative clot strength (ExTEM) was 44 mm (34-50 mm), and fibrinogen plasma levels decreased to minimal levels of 130 mg·dl(-1) (95-160 mg·dl(-1) ). In 43 of 46 children, transfusion therapy was necessary. Despite of transfusion of fresh frozen plasma (cumulative total dose 22 ml·kg(-1) [11-32 ml·kg(-1) ]) in 21 of 46 children, FXIII level remains low in all children till the end of surgery at levels of 39% (20-46%). CONCLUSIONS: Coagulation factor XIII decreased early during major surgery owing to hemodilution. Overall intraoperative FXIII levels remain low despite of transfusion of fresh frozen plasma.

Evaluation of two devices for point-of-care testing of haemoglobin in neonatal pigs.

In veterinary medicine, point-of-care testing (POCT) techniques have become popular, since they provide immediate results and only small amounts of blood are needed. However, their accuracy is controversial. Pigs are often used for research purposes and accurate measurement of haemoglobin (Hb) is important during invasive procedures. The aim of this study was to evaluate two different Hb POCT devices in neonatal pigs. A prospective study with 57 pigs of 3-6 weeks of age, weighing 4.1-6.2 kg (median 5.1 kg) was performed. Fifty-seven blood samples were analysed for Hb using a conductivity-based and a photometrical POCT device and compared with a photometrical reference method. Statistical analysis was performed with Bland-Altman analysis, Spearman correlation and Passing-Bablok regression analysis. Hb values ranged from 32 to 108 g/L (median 80 g/L) using the reference method. The bias of the photometrical method (HemoCue(®)) to the reference method was -1 g/L, with limits of agreement (LOA) of -7 to 6 g/L. The conductivity-based method (i-STAT(®)) had a bias of -15 g/L with LOA from -24 to -6 g/L. There was a significant association between protein values and the bias of i-STAT versus CellDyn (r(2) = 0.27, P < 0.05) but not with the bias of HemoCue versus CellDyn (r(2) = 0.001, P = 0.79). The lower the protein values were, the lower the Hb values were measured by the i-STAT. The conductivity-based measurement of Hb constantly underestimated Hb values, whereas the photometrical method demonstrated a better accuracy and is therefore more reliable for on-site measurement of Hb in pigs.

Resuscitation strategies from bupivacaine-induced cardiac arrest.

OBJECTIVES: Local anesthetic (LA) intoxication with cardiovascular arrest is a potential fatal complication of regional anesthesia. Lipid resuscitation has been recommended for the treatment of LA-induced cardiac arrest. Aim of the study was to compare four different rescue regimens using epinephrine and/or lipid emulsion and vasopressin to treat cardiac arrest caused by bupivacaine intoxication. METHODS: Twenty-eight piglets were randomized into four groups (4 × 7), anesthetized with sevoflurane, intubated, and ventilated. Bupivacaine was infused with a syringe driver via central venous catheter at a rate of 1 mg·kg(-1)·min(-1) until circulatory arrest. Bupivacaine infusion and sevoflurane were then stopped, chest compression was started, and the pigs were ventilated with 100% oxygen. After 1 min, epinephrine 10 µg·kg(-1) (group 1), Intralipid(®) 20% 4 ml·kg(-1) (group 2), epinephrine 10 µg·kg(-1) + Intralipid(®) 4 ml·kg(-1) (group 3) or 2 IU vasopressin + Intralipid(®) 4 ml·kg(-1) (group 4) were administered. Secondary epinephrine doses were given after 5 min if required. RESULTS: Survival was 71%, 29%, 86%, and 57% in groups 1, 2, 3, and 4. Return of spontaneous circulation was regained only by initial administration of epinephrine alone or in combination with Intralipid(®). Piglets receiving the combination therapy survived without further epinephrine support. In contrast, in groups 2 and 4, return of spontaneous circulation was only achieved after secondary epinephrine rescue. CONCLUSIONS: In cardiac arrest caused by bupivacaine intoxication, first-line rescue with epinephrine and epinephrine + Intralipid(®) was more effective with regard to survival than Intralipid(®) alone and vasopressin + Intralipid(®) in this pig model.

Intrarater and interrater variability of point of care coagulation testing using the ROTEM delta.

This study aimed to assess intrarater and interrater variability of coagulation point-of-care testing (POCT) using ROTEM delta operated by trained staff. Arterial blood samples were taken from 43 anesthetized piglets aged up to 6 weeks and weighing 4-6 kg. The following clotting measurements were recorded: clotting time, clot formation time (CFT), maximum clot firmness (MCF) and alpha angle using ROTEM delta assays ExTEM, InTEM, FibTEM and ApTEM. Intrarater variability was assessed when a single operator performed the same assay simultaneously in all four channels of the ROTEM device. Interrater variability was assessed by two different operators simultaneously performing the same assay. Variance components of the data were analyzed using linear mixed modeling. Three hundred and forty-three tests from 86 samples were loaded and analyzed. The intraclass correlation coefficient (ICC) was more than 0.7 for clotting measurements except for CFT and alpha in InTEM. For intrarater and interrater assessment, different relative variability for the ROTEM measurements were found with consistently higher variability for clotting time and CFT and lower variability of MCF and alpha angle. Interrater variability was not statistically significant as supported using Akaike's information criterion. Piglet coagulation testing using ROTEM delta showed a high ICC. Variability was significantly lower in MCF and angle alpha compared with clotting time and CFT. No further variability was added by a second user. Based on these data, ROTEM delta appears to be suitable as POCT.