Treatment of spinal anaesthesia-induced hypotension with cafedrine/theodrenaline versus ephedrine during caesarean section: Results from HYPOTENS, a national, multicentre, prospective, noninterventional study.

BACKGROUND: In Germany, hypotension induced by spinal anaesthesia is commonly treated with a combination of cafedrine hydrochloride (C, 200 mg) and theodrenaline hydrochloride (T, 10 mg) in 2 ml. We compared the effectiveness of C/T with ephedrine. OBJECTIVES: The primary objectives were to assess the speed of onset and the ability to restore blood pressure without an increase in heart rate. Secondary objectives were to evaluate maternal/foetal outcomes and the number of required additional boluses or other additional measures. DESIGN: HYPOTENS was a national, multicentre, prospective, open-label, two-armed, noninterventional study comparing C/T with ephedrine in two prospectively defined cohorts. This study relates to the cohort of patients receiving spinal anaesthesia for caesarean section. SETTING: German hospitals using either C/T or ephedrine in their routine clinical practice. PATIENTS: Women aged at least 18 years receiving spinal anaesthesia for caesarean section. INTERVENTIONS: Bolus administration of C/T or ephedrine at the discretion of the attending anaesthesiologist. MAIN OUTCOME MEASURES: Endpoints within 15 min after initial administration of C/T or ephedrine were area under the curve between the observed SBP and the minimum target SBP; and incidence of newly occurring heart rate of at least 100 beats min-1. RESULTS: Although effective blood pressure stabilisation was achieved with both treatments, this effect was faster and more pronounced with C/T (P < 0.0001). The incidence of tachycardia and changes in heart rate were higher with ephedrine (P < 0.01). Fewer additional boluses (P < 0.01) were required with C/T. Although favourable neonatal outcomes were reported in both groups, base deficit and lactate values were greater with ephedrine (P < 0.01). Physician satisfaction was higher with C/T. CONCLUSIONS: After C/T, tachycardia was not a problem, providing an advantage over ephedrine. Fewer additional boluses were required with C/T, suggesting greater effectiveness. An increased base deficit with ephedrine suggests reduced oxygen supply or increased demands in foetal circulation. TRIALS REGISTRATION: Clinicaltrials.gov: NCT02893241, German Clinical Trials Register: DRKS00010740.

[Infection Prevention in Anesthesiology during the SARS-CoV 2-pandemic]. / Hygiene in der Anästhesie in Zeiten der SARS-CoV-2-Pandemie.

It is necessary to discuss the sometimes competing goals of sufficient critical care capacity, maintenance of regular patient care, protection of medical staff, interruption of infectious chains within the general public and individual aspects of patient care in anesthesia and the operating room in times of the SARS CoV-2 pandemic, given the uncertainty of many data on which decisions need to be based. Basic hygiene remains the cornerstone of infection prevention especially when resources are sparse and SARS-CoV-2 specific additional measures need to be taken according to a risk analysis taking the dynamic of the pandemic as well as local factors into account.

[Case report: extracorporeal life support for treatment of fulminant pulmonary embolism in a young woman during pregnancy]. / Kasuistik: Fulminante Lungenembolie bei Schwangerer in der 19. SSW - Behandlung mittels extrakorporalem Unterstützungssystem (ECLS).

During pregnancy, prothrombotic changes of the coagulation system are associated with an increased risk for thrombotic events such as deep vein thrombosis and/or pulmonary embolism. We report the case of a thirty-one year old woman, who suffered severe pulmonary embolism with cardiogenic shock during pregnancy. Systemic fibrinolysis failed to improve hemodynamic deterioration. Finally, insertion of an extracorporeal life support system with subsequent pulmonary thromboendarterectomysaved the life of the patient.

Anaesthesia protocol evaluation of the videolaryngoscopy with the McGrath MAC and direct laryngoscopy for tracheal intubation in 1000 patients undergoing rapid sequence induction: the randomised multicentre LARA trial study protocol.

INTRODUCTION: Rapid sequence induction of anaesthesia is indicated in patients with an increased risk of pulmonary aspiration. The main objective of the technique is to reduce the critical time period between loss of airway protective reflexes and rapid inflation of the cuff of the endotracheal tube to minimise the chance of aspiration of gastric contents. The COVID-19 pandemic has reinforced the importance of first-pass intubation success to ensure patient and healthcare worker safety. The aim of this study is to compare the first-pass intubation success rate (FPS) using the videolaryngoscopy compared with conventional direct laryngoscopy in surgical patients with a high risk of pulmonary aspiration. METHODS AND ANALYSIS: The LARA trial is a multicentre, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath MAC videolaryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of FPS is 92% in the McGrath group and 82% in the Macintosh group. Each group must include a total of 500 patients to achieve 90% power for detecting a difference at the 5% significance level. Successful intubation with the FPS is the primary endpoint. The secondary endpoints are the time to intubation, the number of intubation attempts, the necessity of airway management alternatives, the visualisation of the glottis using the Cormack and Lehane Score and the Percentage Of Glottic Opening Score and definite adverse events. ETHICS AND DISSEMINATION: The project is approved by the local ethics committee of the Medical Association of the Rhineland Palatine state (registration number: 2020-15502) and medical ethics committee of the University of Freiburg (registration number: 21-1303). The results of this study will be made available in form of manuscripts for publication and presentations at national and international meetings. TRIAL REGISTRATION: NCT04794764.

Neurological emergencies as causes of accidents.

OBJECTIVES: A large number of people throughout Europe are involved in accidents every year. Neurological emergencies as the underlying cause of accidents are poorly investigated. This retrospective chart review study was performed to evaluate the incidence of such events. METHODS: We retrospectively screened the records of the database of our physician-staffed emergency medical service for a 2-year period of time for patients involved in accidents suspicious of having had a neurological incident leading to the accident. The admission diagnoses of these records were compared with the final diagnosis as taken from the hospital records. Additional demographical (gender, age, time of accident) and medical (Glasgow Coma Scale, Injury Severity Score, National Advisory Committee on Aeronautics-Score) data were evaluated and analyzed. RESULTS: A total of 1545 records associated with accidents were screened, identifying 110 (7.1%) cases eligible for analysis. Fifty-four patients had seizure (49.1%), 7 stroke (6.3%) and 2 suffered from intracerebral hemorrhage (1.8%). The admission diagnosis made by the physician was confirmed in 91.8% of the cases. Accidents with concomitant neurological event happened significantly more frequent between 9 and 12 am. No differences were observed in demographic or medical data for patients with acute neurological event prior to the accident. CONCLUSION: Neurological emergencies, particularly epilepsy, stroke and intracerebral hemorrhage are causes of accidents which have to be considered more often than expected and happen most frequently in the morning. Other demographical and medical data provide no additional information for emergency medical personnel to specifically identify such patients. Nevertheless, emergency physicians seem to be highly skilled in finding the correct diagnosis.

Xenon does not modify mivacurium induced neuromuscular block.

PURPOSE: The interaction between mivacurium and inhaled anesthetics is known, with the exception of xenon. We compared the pharmacodynamics of mivacurium during xenon anesthesia vs total iv anesthesia with propofol. METHODS: This randomized controlled trial was carried out in the Aachen University Hospital. Forty-two adult patients ASA I or II, aged 18 to 60 yr, were randomized to receive either xenon or propofol anesthesia. Anesthesia was induced with propofol and remifentanil in both groups (each n = 21). The xenon group received xenon via face mask until an end-expiratory concentration of 60% was reached for one minute. Meanwhile, the acceleromyograph was calibrated and a train-of-four stimulation of the adductor pollicis muscle was started. After stabilization of the signal for five minutes, a single bolus of 0.16 mg.kg-1 mivacurium was injected. Anesthesia was maintained with xenon and remifentanil or with propofol and remifentanil. RESULTS: There were no significant differences between groups with respect to onset time (xenon 180 +/- 64 vs propofol 195 +/- 77 sec; P = 0.39), duration (xenon 16.18 +/- 4.97 vs propofol 15.68 +/- 6.17 min; P = 0.73), recovery index (xenon 5.63 +/- 2.48 vs propofol 5.73 +/- 2.12 min; P = 0.42) and clinical recovery (xenon 8.75 +/- 2.57 vs propofol 9.28 +/- 2.28 min; P = 0.22). CONCLUSION: We conclude that the neuromuscular blocking effects of mivacurium are similar when given during propofol vs xenon anesthesia.

Xenon does not prolong neuromuscular block of rocuronium.

With the exception of xenon, the interaction between muscle relaxants and inhaled anesthetics is known. We therefore compared the pharmacodynamics of rocuronium during xenon anesthesia versus a total IV anesthesia with propofol. Anesthesia was induced with propofol and remifentanil in both the xenon and propofol groups (each n = 20). The xenon group received xenon via face mask until an end-expiratory concentration of 60% was maintained for 1 min. Meanwhile, the acceleromyograph (TOF-Watch SX(R)) was calibrated and a frequent train-of-four stimulation of the musculus adductor pollicis was started. After stabilization of the signal for 5 min, a single bolus of 0.6 mg/kg rocuronium was injected. Anesthesia was maintained with xenon and remifentanil (xenon group) or with propofol and remifentanil (propofol group). There were no significant differences between the groups concerning the onset time (xenon group 125 +/- 33 and propofol group 144 +/- 43 s), duration (xenon group 33.2 +/- 10.8 and propofol group 32.6 +/- 8.4 min), recovery index (xenon group 9.4 +/- 6.6 and propofol group 8.4 +/- 5.3 min), and clinical recovery (xenon group 18.0 +/- 10.2 and propofol group 17.1 +/- 8.5 min). We conclude that the neuromuscular blocking effects of rocuronium are not different when given during propofol versus xenon anesthesia.

A risk adapted approach reduces the overall institutional incidence of postoperative nausea and vomiting.

PURPOSE: Routine prophylactic antiemetic treatment of surgical patients appears justified only in case of an increased risk of postoperative nausea and vomiting (PONV). The objective of this investigation was to assess the feasibility and efficacy of a dichotomized risk score adapted management of PONV based on ondansetron prophylaxis and treatment with respect to the overall institutional rate of PONV. METHODS: After estimating the individual PONV risk by a simplified score, 162 adult patients scheduled for elective surgery received either 4 mg ondansetron intravenously (two to four risk factors = high-risk) or no prophylaxis (zero to one risk factor = low-risk). For antiemetic treatment ondansetron was given intravenously and orally. Incidence of PONV was recorded during the first 24 hr after recovery. RESULTS: Data from 159 subjects were analyzed with 44 patients classified as low-risk and 115 patients classified as high-risk. Nine low-risk and 58 high-risk patients experienced PONV. The expected institutional PONV incidence of 47% was reduced to 36%. Treatment with ondansetron was necessary in seven low-risk and 37 high-risk patients with a complete response rate of 71% (low-risk) and 43% (high-risk). CONCLUSION: Providing antiemetic prophylaxis with ondansetron to high-risk patients strictly based on a simplified risk score can reduce the overall institutional rate of PONV. However, classifying patients into two groups while using ondansetron as the single antiemetic in the high-risk group appears to be of limited efficacy as the incidence of PONV in high-risk patients is still double that of low-risk patients.