Effect of using smaller blood volume tubes and closed blood collection devices on total blood loss in patients undergoing major cardiac and vascular surgery.

BACKGROUND: Diagnostic laboratory tests are an integral part of managing hospitalized patients. In particular, patients in the intensive care units (ICUs) can experience a concerning amount of blood loss due to diagnostic testing, which can increase the risk developing iatrogenic anemia. Several interventions exist to curtail avoidable blood loss, for example computerized decision support, smaller phlebotomy tubes, and other blood conservation devices. Nevertheless, use of these interventions is not standardized. Therefore, the objective of our study was to quantify the daily phlebotomy volume taken from patients who had undergone major cardiac or vascular surgery. METHODS: We estimated the number of blood analyses and volumes of drawn blood of 400 consecutive patients (≥ 18 yr) undergoing major cardiac or vascular surgery. The amount of blood saved using small-volume tubes and in combination with blood conservation device rather than standard-volume tubes was estimated for serum chemistry (serum), ethylenediaminetetraacetic acid (EDTA) tubes, sodium citrate coagulation (SCC) tubes, and arterial blood gas (ABG) analysis. RESULTS: The mean total blood loss due to phlebotomy drawing using standard-volume tubes during hospitalization was 167.9 mL (95% confidence interval [CI], 158.0 to 177.8), 255.6 mL (95% CI, 226.5 to 284.6), and 695.3 mL (95% CI, 544.1 to 846.4) for patients undergoing cardiac surgery with a hospital length of stay (LOS) of 0-10, 11-20, and ≥ 21 days, respectively. The mean total blood loss due to phlebotomy during hospitalization was 80.5 mL (95% CI, 70.5 to 90.6), 225.0 mL (95% CI, 135.1 to 314.8 mL) and 470.3 mL (95% CI, 333.5 to 607.1) for vascular surgery patients with LOS 0-10, 11-20, and ≥ 21 days, respectively. Patients with at least a two-day stay at the ICU had a mean blood loss of 146.6 mL (95% CI, 134.6 to 158.6 mL) and those with ≥ 11 days incurred a loss of 1,428 mL (95% CI, 1,117.8 to 1,739.2). The use of closed blood collection device and small-volume tubes (serum, EDTA, SCC, and ABG) reduced blood loss by 82.8 mL for patients with an ICU stay of 2 days and up to 824.0 mL for patients with a ICU stay of ≥ 11 days. CONCLUSION: Diagnostic laboratory tests are associated with significant patient blood loss, but are a modifiable risk factor. The use of small-volume tubes and closed blood collection devices decreases the volume of patient blood drawn for analysis and prevents blood waste.

RéSUMé: CONTEXTE: Les tests diagnostiques de laboratoire font partie intégrante de la prise en charge des personnes hospitalisées. Plus spécifiquement, la patientèle des unités de soins intensifs (USI) peut perdre une quantité inquiétante de sang en raison des tests de diagnostic, ce qui peut augmenter le risque d'anémie iatrogène. Plusieurs interventions existent pour réduire les pertes de sang évitables, par exemple une aide à la décision informatisée, des tubes de phlébotomie plus petits et d'autres dispositifs de conservation du sang. Néanmoins, le recours à ces interventions n'est pas normalisé. Par conséquent, l'objectif de notre étude était de quantifier le volume quotidien de phlébotomie prélevée chez des patient·es ayant bénéficié d'une chirurgie cardiaque ou vasculaire majeure. MéTHODE: Nous avons estimé le nombre d'analyses sanguines et les volumes de sang prélevés de 400 personnes consécutives (≥ 18 ans) bénéficiant d'une chirurgie cardiaque ou vasculaire majeure. La quantité de sang économisée à l'aide de tubes de petit volume et en combinaison avec un dispositif de conservation du sang plutôt que des tubes de volume standard a été estimée pour la chimie sérique (sérum), les tubes d'acide éthylène-diamine-tétra-acétique (EDTA), les tubes de coagulation au citrate de sodium (CCS) et l'analyse des gaz du sang artériel (GSA). RéSULTATS: La perte sanguine totale moyenne due au prélèvement de phlébotomie à l'aide de tubes de volume standard pendant l'hospitalisation était de 167,9 mL (intervalle de confiance [IC] à 95 %, 158,0 à 177,8), 255,6 mL (IC 95 %, 226,5 à 284,6) et 695,3 mL (IC 95 %, 544,1 à 846,4) chez les patient·es bénéficiant d'une chirurgie cardiaque avec une durée de séjour à l'hôpital de 0 à 10, 11 à 20, et ≥ 21 jours, respectivement. La perte sanguine totale moyenne due à la phlébotomie pendant l'hospitalisation était de 80,5 mL (IC 95 %, 70,5 à 90,6), 225,0 mL (IC 95 %, 135,1 à 314,8 mL) et 470,3 mL (IC 95 %, 333,5 à 607,1) chez les patient·es ayant bénéficié d'une chirurgie vasculaire avec des durées de séjour de 0-10, 11-20 et ≥ 21 jours, respectivement. Les patient·es ayant séjourné au moins deux jours à l'USI ont eu une perte de sang moyenne de 146,6 mL (IC 95 %, 134,6 à 158,6 mL) et celles et ceux ayant séjourné ≥ 11 jours ont subi une perte de 1428 mL (IC 95 %, 1117,8 à 1739,2). L'utilisation d'un dispositif de prélèvement sanguin fermé et de tubes de petit volume (sérum, EDTA, SCC et gsa) a réduit la perte de sang de 82,8 mL pour les patient·es ayant séjourné à l'USI 2 jours et jusqu'à 824,0 mL pour les patient·es ayant séjourné en USI ≥ 11 jours. CONCLUSION: Les tests de laboratoire diagnostiques sont associés à une perte de sang importante chez les patient·es, mais constituent un facteur de risque modifiable. L'utilisation de tubes de petit volume et de dispositifs fermés de prélèvement sanguin diminue le volume de sang prélevé pour analyse et prévient le gaspillage de sang.

Results from 237 extracorporeal membrane oxygenation runs with drowned patients: a nationwide retrospective study.

BACKGROUND: Drowning is one of the leading causes of death worldwide and presents with a wide range of symptoms, from simple coughing to cardiac or pulmonary failure. In severe cases, extracorporeal membrane oxygenation (ECMO) should be considered as a rescue therapy. Therefore, we sought to analyse ECMO usage, outcomes and predictive factors in drowned patients. METHODS: The Federal Statistical Office of Germany provided the study data. The patients included experienced drowning (ICD T75.1) and ECMO (OPS 8-852.0, 8-852.3) between 2007 and 2020. All age groups were included. Mortality was calculated for the total population and for ECMO patients. A multiple logistic regression model for ECMO patients was applied to account for predefined patient characteristics and complications. RESULTS: Of 12,354 patients who were hospitalised due to drowning, 237 patients (1.9%) received ECMO. Hospital mortality was 14.1% (n = 1741) overall and 74.7% (n = 177) for ECMO patients. In-hospital mortality was positively associated with cardiopulmonary resuscitation (CPR) before admission (odds ratio [OR] 4.49, 1.31-15.39) and in-hospital CPR (OR 6.28, 2.76-14.31). Stroke (OR 0.14, 0.02-0.96) and drug abuse (OR 0.05, 0.01-0.45) were negatively associated with in-hospital mortality. Neither the ECMO mode nor the patient's age and sex had statistically significant effects on survival. CONCLUSION: This study indicates that survival in drowned patients who receive ECMO is lower than previously reported. The proportion of paediatric patients was also smaller than expected. As the effects of different ECMO modes on mortality remain unclear, the need for further study remains great.

Effect of quantitative versus qualitative neuromuscular blockade monitoring on rocuronium consumption in patients undergoing abdominal and gynecological surgery: a retrospective cohort study.

The level of neuromuscular blockade can be assessed by subjective (qualitative) and objective (quantitative) methods. This study aims to compare the dosage of the neuromuscular blocking agents (NMBA) rocuronium and the need for reversion by sugammadex between those methods. A retrospective, observational analysis was conducted. In the tactile qualitative-neuromuscular monitoring-group (tactile NMM) (n = 244), muscle contractions were assessed tactilely. In the quantitative neuromuscular monitoring-group (n = 295), contractions were accessed using an acceleromyograph. Primary endpoints were dosage of rocuronium per minute operation-time (milligram per kilogram bodyweight per minute (mg/kgBW/min)), count of repeated rocuronium administrations and use of sugammadex. Secondary endpoints were: NMM use before repeated NMBA application or extubation, time to extubation, post-operative oxygen demand. A total of n = 539 patients were included. n = 244 patients were examined with tactile NMM and 295 patients by quantitative NMM. Quantitative NMM use resulted in significantly lower rocuronium dosing (tactile NMM: 0.01 (± 0.007) mg/kgBW/min vs. quantitative NMM: 0.008 (± 0.006) mg/kgBW/min (p < 0.001)). In quantitative NMM use fewer repetitions of rocuronium application were necessary (tactile NMM: 83% (n = 202) vs. quantitative NMM: 71% (n = 208) p = 0.007). Overall, 24% (n = 58) in the tactile NMM-group, and 20% (n = 60) in the quantitative NMM-group received sugammadex ((p = 0.3), OR: 1.21 (0.81-1.82)). Significantly fewer patients in the quantitative NMM-group required oxygen-supply postoperative (quantitative NMM: 43% (n = 120)) vs. tactile NMM: 57% (n = 128)) (p = 0.002). The use of quantitative assessment of NMBA results in a lower overall dosage and requires fewer repetitions of rocuronium application. Therefore, quantitative monitoring systems should be used to monitor NMBA intraoperatively to reduce NMBA dosing, while achieving continuous neuromuscular blockade.

[Evaluation of Characteristics and Management of Influenza Patients in Relation to the STIKO Vaccination Recommendation During the 2017/2018 Season]. / Evaluation von Charakteristika und Management von Influenzapatienten in Bezug auf die STIKO Impfempfehlung während der Saison 2017/2018.

BACKGROUND: Every year a large number of patients is suffering from influenza infection with often severe outcome. The influenza season 2017/2018 was characterized by a high number of cases (in Germany>346,000 laboratory-confirmed cases), but also by a high rate of hospitalizations with sometimes severe clinical outcome - also in the group of patients under 60 years. AIM: The aim of the present study was to find out whether patients not fullfilling the STIKO vaccination recommendation in the 2017/18 season were suffering from a worse outcome. MATERIALS AND METHODS: All laboratory-confirmed influenza patients at Frankfurt University Hospital were retrospectively analyzed for disease severity with respect to the primary endpoint. Secondary endpoints were defined as demographic data, length of hospital stay, previous illnesses, intensive care therapy and its duration, drug therapy, and mortality. RESULTS: Fifty-one of 303 patients (16.8%) required intensive care treatments. Of these 51, 46 patients (90.2%) belonged to the group that should have been vaccinated according to the vaccination recommendations according to STIKO, 5 patients (9.8%) did not belong to this group (p=0.434). Of the 51 ICU patients, 16 (31.4%) died. All deceased were from the group with vaccination recommendation (p=0.120). CONCLUSIONS: Based on these data, it appears that severe disease progression occurs in both the group of patients with and without STIKO vaccination recommendation, but deaths occur only in the group of patients with recommendation.

Physician's Subjective Increase in Awareness towards Perioperative Anaemia, Patient's Blood Resource, and Transfusion after the Implementation of Patient Blood Management: A Nationwide Multicentre Survey.

INTRODUCTION: Patient blood management (PBM) is a clinical and multidisciplinary, 3-pillar concept. The aim of this study was to detect the subjective increase in physician's awareness towards perioperative anaemia, patient's blood resource, and transfusion after the implementation of PBM in German hospitals. MATERIAL AND METHODS: A survey among 56 hospitals from the German PBM Network group was conducted from October 27 to December 19, 2020. An electronic questionnaire with 28 questions was sent to the local PBM coordinator for the distribution at the hospital level. For assessment of the physician's subjective increase in awareness, numeric rating scales (0 [no increase] - 10 [maximum increase]) were used. RESULTS: In total, 404 clinicians from 56 hospitals completed the survey. The mean (±standard deviation) time of an existing PBM program was 4.8 (±2.2) years. The physician's subjective increase in awareness towards anaemia (8.2 [±2.0]), patient's blood resource (7.6 [±2.5]), and transfusion (8.1 [±1.9]) was the highest in physicians from hospitals with ≥21 implemented PBM measures. In addition, a subjective increase in awareness towards anaemia (6.6 [±3.3]), patient's blood resource (7.0 [±3.3]), and transfusion (6.6 [±3.4]) was the highest in physicians with daily PBM contact. CONCLUSION: Results suggest that physician's awareness towards perioperative anaemia, patient's blood resource, and transfusion has increased, depending on the hospital's number of implemented PBM measures and physician's PBM contact in everyday clinical practice.

Preoperative anaemia and red blood cell transfusion in patients with aneurysmal subarachnoid and intracerebral haemorrhage - a multicentre subanalysis of the German PBM Network Registry.

PURPOSE: Anaemia is common in patients presenting with aneurysmal subarachnoid (aSAH) and intracerebral haemorrhage (ICH). In surgical patients, anaemia was identified as an idenpendent risk factor for postoperative mortality, prolonged hospital length of stay (LOS) and increased risk of red blood cell (RBC) transfusion. This multicentre cohort observation study describes the incidence and effects of preoperative anaemia in this critical patient collective for a 10-year period. METHODS: This multicentre observational study included adult in-hospital surgical patients diagnosed with aSAH or ICH of 21 German hospitals (discharged from 1 January 2010 to 30 September 2020). Descriptive, univariate and multivariate analyses were performed to investigate the incidence and association of preoperative anaemia with RBC transfusion, in-hospital mortality and postoperative complications in patients with aSAH and ICH. RESULTS: A total of n = 9081 patients were analysed (aSAH n = 5008; ICH n = 4073). Preoperative anaemia was present at 28.3% in aSAH and 40.9% in ICH. RBC transfusion rates were 29.9% in aSAH and 29.3% in ICH. Multivariate analysis revealed that preoperative anaemia is associated with a higher risk for RBC transfusion (OR = 3.25 in aSAH, OR = 4.16 in ICH, p < 0.001), for in-hospital mortality (OR = 1.48 in aSAH, OR = 1.53 in ICH, p < 0.001) and for several postoperative complications. CONCLUSIONS: Preoperative anaemia is associated with increased RBC transfusion rates, in-hospital mortality and postoperative complications in patients with aSAH and ICH. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02147795, https://clinicaltrials.gov/ct2/show/NCT02147795.

Extracorporeal membrane oxygenation in coronavirus disease 2019: A nationwide cohort analysis of 4279 runs from Germany.

BACKGROUND: In the context of the coronavirus disease 2019 (COVID-19) pandemic, many retrospective single-centre or specialised centre reports have shown promising mortality rates with the use of extracorporeal membrane oxygenation (ECMO) therapy. However, the mortality rate of an entire country throughout the COVID-19 pandemic remains unknown. OBJECTIVES: The primary objective is to determine the hospital mortality in COVID-19 patients receiving venovenous ECMO (VV-ECMO) and veno-arterial ECMO (VA-ECMO) therapy. Secondary objectives are the chronological development of mortality during the pandemic, the analysis of comorbidities, age and complications. DESIGN: Cohort study. SETTING: Inpatient data from January 2020 to September 2021 of all hospitals in Germany were analysed. PARTICIPANTS: All COVID-19-positive patients who received ECMO therapy were analysed according to the appropriate international statistical classification of diseases and related health problem codes (ICDs) and process key codes (OPSs). MAIN OUTCOME MEASURES: The primary outcome was the hospital mortality. RESULTS: In total, 4279 COVID-19-positive patients who received ECMO therapy were analysed. Among 404 patients treated with VA-ECMO and 3875 treated with VV-ECMO, the hospital mortality was high: 72% (n = 291) for VA-ECMO and 65.9% (n = 2552) for VV-ECMO. A total of 43.2% (n = 1848) of all patients were older than 60 years with a hospital mortality rate of 72.7% (n = 172) for VA-ECMO and 77.6% (n = 1301) for VV-ECMO. CPR was performed in 44.1% (n = 178) of patients with VA-ECMO and 16.4% (n = 637) of patients with VV-ECMO. The mortality rates widely varied from 48.1 to 84.4% in individual months and worsened from March 2020 (59.2%) to September 2021 (78.4%). CONCLUSION: In Germany, a large proportion of elderly patients with COVID-19 were treated with ECMO, with an unacceptably high hospital mortality. Considering these data, the unconditional use of ECMO therapy in COVID-19 must be carefully considered and advanced age should be considered as a relative contraindication.

[Preoperative Assessment and Improvement of Patient's Medical Conditions]. / Outcome-relevante Anästhesiologie: präoperative Vorbereitung und Optimierung.

Patient safety and reduction of postoperative complications are the top priorities for anaesthesiologists in everyday clinical practice. Therefore, preoperative assessment and optimization of patient specific risk factors are crucial for reduction of postoperative morbidity and mortality. Understanding the patient's medical history and clinical examination represent the two most important aspects of preoperative patient evaluation by the anaesthesiologist. In addition, there are several clinical scores to specify the patient's individual perioperative risk according to the existing comorbidities. These specific assessment tools are easily accessible and have proven effective in everyday clinical practice. Special attention should be paid to preoperative cardiac, respiratory and metabolic conditions. The combination of risk stratification and strategies to improve the patient's preoperative medical status are capable to reduce complications in the postoperative period.

Insight into ECMO, mortality and ARDS: a nationwide analysis of 45,647 ECMO runs.

BACKGROUND: Extracorporeal life support (ECLS) has become an integral part of modern intensive therapy. The choice of support mode depends largely on the indication. Patients with respiratory failure are predominantly treated with a venovenous (VV) approach. We hypothesized that mortality in Germany in ECLS therapy did not differ from previously reported literature METHODS: Inpatient data from Germany from 2007 to 2018 provided by the Federal Statistical Office of Germany were analysed. The international statistical classification of diseases and related health problems codes (ICD) and process keys (OPS) for extracorporeal membrane oxygenation (ECMO) types, acute respiratory distress syndrome (ARDS) and hospital mortality were used. RESULTS: In total, 45,647 hospitalized patients treated with ECLS were analysed. In Germany, 231 hospitals provided ECLS therapy, with a median of 4 VV-ECMO and 9 VA-ECMO in 2018. Overall hospital mortality remained higher than predicted in comparison to the values reported in the literature. The number of VV-ECMO cases increased by 236% from 825 in 2007 to 2768 in 2018. ARDS was the main indication for VV-ECMO in only 33% of the patients in the past, but that proportion increased to 60% in 2018. VA-ECMO support is of minor importance in the treatment of ARDS in Germany. The age distribution of patients undergoing ECLS has shifted towards an older population. In 2018, the hospital mortality decreased in VV-ECMO patients and VV-ECMO patients with ARDS to 53.9% (n = 1493) and 54.4% (n = 926), respectively. CONCLUSIONS: ARDS is a severe disease with a high mortality rate despite ECLS therapy. Although endpoints and timing of the evaluations differed from those of the CESAR and EOLIA studies and the Extracorporeal Life Support Organization (ELSO) Registry, the reported mortality in these studies was lower than in the present analysis. Further prospective analyses are necessary to evaluate outcomes in ECMO therapy at the centre volume level.

Voice alerting as a medical alarm modality for next-generation patient monitoring: a randomised international multicentre trial.

BACKGROUND: Acoustic alarms in medical devices are vital for patient safety. State-of-the-art patient monitoring alarms are indistinguishable and contribute to alarm fatigue. There are two promising new sound modalities for vital sign alarms. Auditory icons convey alarms as brief metaphorical sounds, and voice alerts transmit information using a clear-spoken language. We compared how reliably healthcare professionals identified alarms using these two modalities. METHODS: This investigator-initiated computer-based multicentre simulation study included 28 anaesthesia providers who were asked to identify vital sign alarms in randomised order, once with voice alerts and once with auditory icons. We further assessed time to decision, diagnostic confidence, and perceived helpfulness. We analysed the results using mixed models, adjusted for possible confounders. RESULTS: We assessed 14 alarms for each modality, resulting in 392 comparisons across all participants. Compared with auditory icons, healthcare providers had 58 times higher odds of correctly identifying alarms using voice alerts (odds ratio 58.0; 95% confidence interval [CI]: 25.1-133.6; P<0.001), made their decisions about 14 s faster (coefficient -13.9; 95% CI: -15.8 to -12.1 s; P<0.001), perceived higher diagnostic confidence (100% [392 of 392] vs 43% [169 of 392; P<0.001]), and rated voice alerts as more helpful (odds ratio 138.2; 95% CI: 64.9-294.1; P<0.001). The participants were able to identify significantly higher proportions of alarms with voice alerts (98.5%; P<0.001) and auditory icons (54.1%; P<0.001) compared with state-of-the-art alarms (17.9%). CONCLUSIONS: Voice alerts were superior to auditory icons, and both were superior to current state-of-the-art auditory alarms. These findings demonstrate the potential that voice alerts hold for patient monitoring.

The visually estimated blood volume in scaled canisters based on a simulation study.

BACKGROUND: The most common technique used worldwide to quantify blood loss during an operation is the visual assessment by the attending intervention team. In every operating room you will find scaled suction canisters that collect fluids from the surgical field. This scaling is commonly used by clinicians for visual assessment of intraoperative blood loss. While many studies have been conducted to quantify and improve the inaccuracy of the visual estimation method, research has focused on the estimation of blood volume in surgical drapes. The question whether and how scaling of canisters correlates with actual blood loss and how accurately clinicians estimate blood loss in scaled canisters has not been the focus of research to date. METHODS: A simulation study with four "bleeding" scenarios was conducted using expired whole blood donations. After diluting the blood donations with full electrolyte solution, the sample blood loss volume (SBL) was transferred into suction canisters. The study participants then had to estimate the blood loss in all four scenarios. The difference to the reference blood loss (RBL) per scenario was analyzed. RESULTS: Fifty-three anesthetists participated in the study. The median estimated blood loss was 500 ml (IQR 300/1150) compared to the RBL median of 281.5 ml (IQR 210.0/1022.0). Overestimations up to 1233 ml were detected. Underestimations were also observed in the range of 138 ml. The visual estimate for canisters correlated moderately with RBL (Spearman's rho: 0.818; p < 0.001). Results from univariate nonparametric confirmation statistics regarding visual estimation of canisters show that the deviation of the visual estimate of blood loss is significant (z = - 10.95, p < 0.001, n = 220). Participants' experience level had no significant influence on VEBL (p = 0.402). CONCLUSION: The discrepancies between the visual estimate of canisters and the actual blood loss are enormous despite the given scales. Therefore, we do not recommend estimating the blood loss visually in scaled suction canisters. Colorimetric blood loss estimation could be a more accurate option.

Effects of an Animated Blood Clot Technology (Visual Clot) on the Decision-Making of Users Inexperienced in Viscoelastic Testing: Multicenter Trial.

BACKGROUND: Viscoelastic test-guided coagulation management has become increasingly important in assessing hemostasis. We developed Visual Clot, an animated, 3D blood clot that illustrates raw rotational thromboelastometry (ROTEM) parameters in a user-centered and situation awareness-oriented method. OBJECTIVE: This study aimed to evaluate the applicability of Visual Clot by examining its effects on users that are novices in viscoelastic-guided resuscitation. METHODS: We conducted an investigator-initiated, international, multicenter study between September 16, 2020, and October 6, 2020, in 5 tertiary care hospitals in central Europe. We randomly recruited medical students and inexperienced resident physicians without significant prior exposure to viscoelastic testing. The 7 participants per center managed 9 different ROTEM outputs twice, once as standard ROTEM tracings and once as the corresponding Visual Clot. We randomly presented the 18 viscoelastic cases and asked the participants for their therapeutic decisions. We assessed the performance, diagnostic confidence, and perceived workload in managing the tasks using mixed statistical models and adjusted for possible confounding factors. RESULTS: Analyzing a total of 630 results, we found that the participants solved more cases correctly (odds ratio [OR] 33.66, 95% CI 21.13-53.64; P<.001), exhibited more diagnostic confidence (OR 206.2, 95% CI 93.5-454.75; P<.001), and perceived less workload (coefficient -41.63; 95% CI -43.91 to -39.36; P<.001) using Visual Clot compared to using standard ROTEM tracings. CONCLUSIONS: This study emphasizes the practical benefit of presenting viscoelastic test results in a user-centered way. Visual Clot may allow inexperienced users to be involved in the decision-making process to treat bleeding-associated coagulopathy. The increased diagnostic confidence, diagnostic certainty, reduced workload, and positive user feedback associated with this visualization may promote the further adoption of viscoelastic methods in diverse health care settings.

Comparison of common perioperative blood loss estimation techniques: a systematic review and meta-analysis.

Estimating intraoperative blood loss is one of the daily challenges for clinicians. Despite the knowledge of the inaccuracy of visual estimation by anaesthetists and surgeons, this is still the mainstay to estimate surgical blood loss. This review aims at highlighting the strengths and weaknesses of currently used measurement methods. A systematic review of studies on estimation of blood loss was carried out. Studies were included investigating the accuracy of techniques for quantifying blood loss in vivo and in vitro. We excluded nonhuman trials and studies using only monitoring parameters to estimate blood loss. A meta-analysis was performed to evaluate systematic measurement errors of the different methods. Only studies that were compared with a validated reference e.g. Haemoglobin extraction assay were included. 90 studies met the inclusion criteria for systematic review and were analyzed. Six studies were included in the meta-analysis, as only these were conducted with a validated reference. The mixed effect meta-analysis showed the highest correlation to the reference for colorimetric methods (0.93 95% CI 0.91-0.96), followed by gravimetric (0.77 95% CI 0.61-0.93) and finally visual methods (0.61 95% CI 0.40-0.82). The bias for estimated blood loss (ml) was lowest for colorimetric methods (57.59 95% CI 23.88-91.3) compared to the reference, followed by gravimetric (326.36 95% CI 201.65-450.86) and visual methods (456.51 95% CI 395.19-517.83). Of the many studies included, only a few were compared with a validated reference. The majority of the studies chose known imprecise procedures as the method of comparison. Colorimetric methods offer the highest degree of accuracy in blood loss estimation. Systems that use colorimetric techniques have a significant advantage in the real-time assessment of blood loss.

The multisystem inflammatory syndrome in children and its association to SARS-CoV-2.

PURPOSE OF REVIEW: Multisystem inflammatory syndrome in children (MIS-C)/pediatric inflammatory multisystem syndrome (PIMS) is a new and serious disease that occurs in temporal association with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We describe the clinical presentation, diagnosis, and treatment recommendations. RECENT FINDING: To date, no randomized prospective studies have been published; recommendations are based on some observational studies, case reports, and expert opinions. The article provides an overview of the most important publications, presents the current results of the German Registry for PIMS and expert recommendations for treatment. SUMMARY: MIS-C PIMS is a new syndrome that is associated with a variety of virus infections, and also with SARS-CoV-2. The main characteristics are fever, multiple organ dysfunction due to a hyper-inflammatory state. In particular, cardiac dysfunction and severe shock. A high proportion of patients require intensive medical care, but the absolute number of children with SARS-CoV-2 MIS-C is low. Medical therapy is based on pathophysiologic considerations and is not evidence-based. Immunoglobulins, steroids and biologics are used and lead to effective treatment. Therefore, the mortality rate is very low. Patients usually recover within days, sequelae are reported only in a minority of cases.

Current concepts in the evaluation and management of preoperative anemia.

PURPOSE OF REVIEW: In the past years, patient blood management (PBM) has evolved to improve patient's care and safety. Anemia is one of the most common medical diseases in the world and is an independent risk factor for morbidity and mortality. Iron deficiency is the main cause for anemia and constitutes a potentially preventable condition with a great impact on surgical outcome. However, preoperative anemia management is not yet established in most hospitals. Changing workflows and re-thinking is challenging. Numerous published studies confirmed the positive effect of preoperative anemia diagnosis and treatment recently. RECENT FINDINGS: Iron supplementation in iron-deficient anemic (IDA) patients reduce the need for allogenic blood transfusion thereby improving perioperative outcome. SUMMARY: Since the introduction of PBM programs, important movements towards early detection and therapy of preoperative anemia have been observed. However, preoperative anemia management is not implemented on a large scale as many healthcare professionals are not aware of the most recent findings in the field. Preoperative anemia management, particularly iron supplementation in IDA patients, has proven to be highly effective and has a tremendous effect on patient safety and outcome.

Implementation of an anaemia walk-in clinic: Feasibility and preliminary data from the Orthopedic University Hospital.

BACKGROUND: Approximately one in three patients suffers from preoperative anaemia. Even though haemoglobin is measured before surgery, anaemia management is not implemented in every hospital. OBJECTIVE: Here, we demonstrate the implementation of an anaemia walk-in clinic at an Orthopedic University Hospital. To improve the diagnosis of iron deficiency (ID), we examined whether reticulocyte haemoglobin (Ret-He) could be a useful additional parameter. MATERIAL AND METHODS: In August 2019, an anaemia walk-in clinic was established. Between September and December 2019, major orthopaedic surgical patients were screened for preoperative anaemia. The primary endpoint was the incidence of preoperative anaemia. Secondary endpoints included Ret-He level, red blood cell (RBC) transfusion rate, in-hospital length of stay and anaemia at hospital discharge. RESULTS: A total of 104 patients were screened for anaemia. Preoperative anaemia rate was 20.6%. Intravenous iron was supplemented in 23 patients. Transfusion of RBC units per patient (1.7 ± 1.2 vs. 0.2 ± 0.9; p = 0.004) and hospital length of stay (13.1 ± 4.8 days vs. 10.6 ± 5.1 days; p = 0.068) was increased in anaemic patients compared to non-anaemic patients. Ret-He values were significantly lower in patients with ID anaemia (33.3 pg [28.6-40.2 pg]) compared to patients with ID (35.3 pg [28.9-38.6 pg]; p = 0.015) or patients without anaemia (35.4 pg [30.2-39.4 pg]; p = 0.001). CONCLUSION: Preoperative anaemia is common in orthopaedic patients. Our results proved the feasibility of an anaemia walk-in clinic to manage preoperative anaemia. Furthermore, our analysis supports the use of Ret-He as an additional parameter for the diagnosis of ID in surgical patients.

Changes in Transfusion Practice in Children and Adolescents over Time.

INTRODUCTION: In recent years, resource-saving handling of allogeneic blood products and a reduction of transfusion rates in adults has been observed. However, comparable published national data for transfusion practices in pediatric patients are currently not available. In this study, the transfusion rates for children and adolescents were analyzed based on data from the Federal Statistical Office of Germany during the past 2 decades. METHODS: Data were queried via the database of the Federal Statistical Office (Destasis). The period covered was from 2005 to 2018, and those in the sample group were children and adolescents aged 0-17 years receiving inpatient care. Operation and procedure codes (OPS) for transfusions, procedures, or interventions with increased transfusion risk were queried and evaluated in detail. RESULTS: In Germany, 0.9% of the children and adolescents treated in hospital received a transfusion in 2018. A reduction in transfusion rates from 1.02% (2005) to 0.9% (2018) was observed for the total collective of children and adolescents receiving inpatient care. Increases in transfusion rates were recorded for 1- to 4- (1.41-1.45%) and 5- to 10-year-olds (1.24-1.33%). Children under 1 year of age were most frequently transfused (in 2018, 40.2% of the children were cared for in hospital). Transfusion-associated procedures such as chemotherapy or machine ventilation and respiratory support for newborns and infants are on the rise. CONCLUSION: Transfusion rates are declining in children and adolescents, but the reasons for increases in transfusion rates in other groups are unclear. Prospective studies to evaluate transfusion rates and triggers in children are urgently needed.