Impact of Inhaled Nitric Oxide (iNO) on the Outcome of COVID-19 Associated ARDS.

Background: Inhaled nitric oxide (iNO) can improve oxygenation in acute respiratory syndrome (ARDS), has anti-inflammatory and antithrombotic effects, and can inhibit coronavirus- replication. The study aim was to investigate the impact of iNO in COVID-19 associated ARDS (CARDS) on oxygenation, the length of mechanical ventilation (MV), the level of inflammatory markers and the rate of thrombotic events during ICU stay. Methods: This was a retrospective, observational, monocentric study analyzing the effect of INO (15 parts per million) vs. non-iNO in adult ventilated CARDS patients on oxygenation, the level of inflammatory markers, and the rate of thrombotic events during ICU stay. Within the iNO group, the impact on gas exchange was assessed by comparing arterial blood gas results obtained at different time points. Results: Overall, 19/56 patients were treated with iNO, with no difference regarding sex, age, body mass index, and SOFA-/APACHE II- score between the iNO and non-iNO groups. iNO improved oxygenation in iNO-responders (7/19) and had no impact on inflammatory markers or the rate of thrombotic events but was associated with an increased MV length. Conclusions: iNO was able to improve oxygenation in CARDS in iNO-responders but did not show an impact on inflammatory markers or the rate of thrombotic events, while it was associated with an increased MV length.

Comparison of blended e-learning and face-to-face-only education for resuscitation training in German schools - A cluster randomized-controlled prospective study.

Background & Objectives: Cardiopulmonary resuscitation (CPR) is the key for surviving cardiac arrest. Recent recommendations propose that CPR can - and should -be taught to schoolchildren. This e-learning-based study analyzes whether face-to-face CPR training can be partly substituted with e-learning by measuring CPR knowledge and self-efficacy in trainees. Methods: In this cluster randomized-controlled prospective, students attending grades 5 to 7 of a German secondary school volunteered to participate and were randomly assigned to one of two groups with different methods for CPR training each: a traditional instructor-led group (control) where students received face-to-face teaching by a BLS instructor (45 min), and an e-learning group (intervention) where schoolchildren were able to accomplish their theoretical CPR training using an e-learning module (15 min). CPR knowledge and self-efficacy were measured and compared before (t0) and after (t1) the training using questionnaires. Face-to-face CPR training (45 min) on manikins proceeded in both groups hereafter. The formal hypothesis was that e-learning would result in better CPR knowledge. Results: Overall, 375 students participated; 33 of which had to be excluded. 342 participants were included in statistical analysis (instructor-led group n = 109; e-learning group n = 233). The study was terminated early due to the Covid19 pandemic, and did not reach the required number of participants. Lacking statistical power, an analysis of the existing datasets failed to show superiority of e-learning vs. conventional training for CPR knowledge (p = 0.306). Both groups improved CPR knowledge (p < 0.001) and self-efficacy (p < 0.001) after CPR training and showed an equal, high level of satisfaction with their perceived training method (face-to-face: 4.1[4.0-4.2] vs. e-learning: 4.0[3.9-4.1]; p = 0.153; maximum 5 points). Conclusions: This study failed to demonstrate superiority for e-learning but was terminated early and hence underpowered. Further research is necessary to prove the efficiency of e-learning tools for CPR.

Anaesthesia Concepts in Patients with Chronic Progressive External Ophthalmoplegia Undergoing Ophthalmic Surgery-A Retrospective Cohort Analysis.

BACKGROUND: Chronic progressive external ophthalmoplegia (CPEO) belongs to the group of mitochondrial encephalomyopathies. Anaesthesia for patients with CPEO may be associated with an increased risk due to known drug effects on mitochondrial metabolism. Therefore, the aim of this analysis was to evaluate anaesthesiological concepts in patients with CPEO requiring ophthalmic surgery. METHODS: This is a retrospective, monocentric cohort analysis of eleven patients with CPEO undergoing ophthalmic surgery either with general anaesthesia or local anaesthesia in a German university hospital from January 2012 to February 2022. RESULTS: A total of twelve ophthalmic surgery procedures were performed in eleven adult patients with CPEO. Six patients underwent surgery after receiving local anaesthesia (LA cohort). Five patients underwent six surgical procedures under general anaesthesia (GA cohort). In five cases within the GA cohort, propofol and remifentanil were used for the maintenance of anaesthesia. In one case, balanced anaesthesia with desflurane and remifentanil was used. The median duration of general anaesthesia was 37.5 min (range, 25-65 min). Patients stayed in the recovery room for a median of 48.5 min (range, 35-70 min). All patients were discharged on the first postoperative day. No relevant complications occurred in either the LA or GA cohort. CONCLUSION: Both local and general anaesthesia are feasible concepts for patients with CPEO undergoing ophthalmic surgery. Propofol, at least with a short duration (less than one hour) of use, appears to be a feasible hypnotic drug in CPEO patients.

Evaluation of Intraoperative Right Ventricular Myocardial Work Indices in Left Ventricular Assist Device Implantation: A Case Report.

Right ventricular myocardial work is an echocardiographic technique yielding significant insights into cardiac mechanics, energetics, and efficiency. Combining right ventricular myocardial strain with loading conditions correlates with invasively measured myocardial work and myocardial oxygen consumption. This method has not yet been described intraoperatively by transesophageal echocardiography. We describe this technique during a left ventricular assist device implantation. This case demonstrates that right ventricular myocardial work indices can be monitored intraoperatively and might assist decisions during left ventricular assist device implantation.

Predictive enrichment for the need of renal replacement in sepsis-associated acute kidney injury: combination of furosemide stress test and urinary biomarkers TIMP-2 and IGFBP-7.

BACKGROUND: In sepsis, initial resuscitation with fluids is followed by efforts to achieve a negative fluid balance. However, patients with sepsis-associated acute kidney injury (SA-AKI) often need diuretic or renal replacement therapy (RRT). The dilemma is to predict whether early RRT might be advantageous or diuretics will suffice. Both the Furosemide Stress Test (FST) and measurements of the urinary biomarkers TIMP-2*IGFBP-7, if applied solely, do not provide sufficient guidance. We tested the hypothesis that a combination of two tests, i.e., an upstream FST combined with downstream measurements of urinary TIMP-2*IGFBP-7 concentrations improves the accuracy in predicting RRT necessity. METHODS: In this prospective, multicenter study 100 patients with sepsis (diagnosed < 48h), AKI stage ≥ 2, and an indication for negative fluid balance were included between 02/2020 and 12/2022. All patients received a standardized FST and urinary biomarkers TIMP-2*IGFBP-7 were serially measured immediately before and up to 12 h after the FST. The primary outcome was the RRT requirement within 7 days after inclusion. RESULTS: 32% (n = 32/99) of SA-AKI patients eventually required RRT within 7 days. With the FST, urine TIMP-2*IGFBP-7 decreased within 2 h from 3.26 ng2/mL2/1000 (IQR: 1.38-5.53) to 2.36 ng2/mL2/1000 (IQR: 1.61-4.87) in RRT and 1.68 ng2/mL2/1000 (IQR: 0.56-2.94) to 0.27 ng2/mL2/1000 (IQR: 0.12-0.89) and non-RRT patients, respectively. While TIMP-2*IGFBP-7 concentrations remained low for up to 12 h in non-RRT patients, we noted a rebound in RRT patients after 6 h. TIMP-2*IGFBP-7 before FST (accuracy 0.66; 95%-CI 0.55-0.78) and the FST itself (accuracy 0.74; 95%-CI: 0.64-0.82) yielded moderate test accuracies in predicting RRT requirement. In contrast, a two-step approach, utilizing FST as an upstream screening tool followed by TIMP-2*IGFBP-7 quantification after 2 h improved predictive accuracy (0.83; 95%-CI 0.74-0.90, p = 0.03) compared to the FST alone, resulting in a positive predictive value of 0.86 (95%-CI 0.64-0.97), and a specificity of 0.96 (95%-CI 0.88-0.99). CONCLUSIONS: The combined application of an upstream FST followed by urinary TIMP-2*IGFBP-7 measurements supports highly specific identification of SA-AKI patients requiring RRT. Upcoming interventional trials should elucidate if this high-risk SA-AKI subgroup, identified by our predictive enrichment approach, benefits from an early RRT initiation.

Intraoperative Assessment of Noninvasive Left Ventricular Myocardial Work Indices in Patients Undergoing Aortic Valve Replacement.

OBJECTIVE: Evaluation of noninvasive left ventricular (LV) myocardial work (MW) enables insights into cardiac contractility and efficacy beyond conventional echocardiography. However, there is limited intraoperative data on patients undergoing surgical aortic valve replacement (AVR). The aim of this study was to describe the feasibility and the intraoperative course of this technique of ventricular function assessment in these patients and compare it to conventional two (2D)- and three-dimensional (3D) echocardiographic measurements and strain analysis. DESIGN: Prospective observational study. SETTING: Single university hospital. PARTICIPANTS: Twenty-five patients scheduled for isolated AVR with preoperative preserved left and right ventricular function, sinus rhythm, without significant other heart valve disease or pulmonary hypertension, and an uneventful intraoperative course. INTERVENTIONS: Transesophageal echocardiography was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Evaluation was performed in stable hemodynamics, in sinus rhythm or atrial pacing and vasopressor support with norepinephrine ≤ 0.1 µg/kg/min. MEASUREMENTS AND MAIN RESULTS: EchoPAC v206 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D and 3D LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), and LV global work efficiency (GWE). Estimation of myocardial work was feasible in all patients. Although there was no significant difference in the values of 2D and 3D EF, GWI and GCW decreased significantly after AVR (T1 v T2, 1,647 ± 380 mmHg% v 1,021 ± 233 mmHg%, p < 0.001; T1 v T2, 2,095 ± 433 mmHg% v 1,402 ± 242 mmHg%, p < 0.001, respectively), while GWW remained unchanged (T1 v T2, 296 mmHg% [IQR 178-452) v 309 mmHg% [IQR 255-438), p = 0.97). This resulted in a decreased GWE directly after bypass (T1 v T2, 84% ± 6% v 78% ± 5%, p < 0.001), but GWE already improved at the end of surgery (T2 v T3, 78% ± 5% v 81% ± 5%, p = 0.003). There was no significant change in the values of GWI, GCW, or 2D and 3D LVEF before and after sternal closure (T2 v T3). CONCLUSION: LV MW analysis showed a reduction of LV workload after bypass in our group of patients, which was not detected by conventional echocardiographic measures. This evolving technique provides deeper insights into cardiac energetics and efficiency in the perioperative course of aortic valve replacement surgery.

Weaning failure due to isolated residual diaphragmatic paralysis after cervical spinal cord ischemia following aortic surgery- a case report.

BACKGROUND: Bilateral diaphragmatic dysfunction can lead to dyspnea and recurrent respiratory failure. In rare cases, it may result from high cervical spinal cord ischemia (SCI) due to anterior spinal artery syndrome (ASAS). We present a case of a patient experiencing persistent isolated diaphragmatic paralysis after SCI at level C3/C4 following thoracic endovascular aortic repair (TEVAR) for Kommerell's diverticulum. This is, to our knowledge, the first documented instance of a patient fully recovering from tetraplegia due to SCI while still exhibiting ongoing bilateral diaphragmatic paralysis. CASE PRESENTATION: The patient, a 67-year-old male, presented to the Vascular Surgery Department for surgical treatment of symptomatic Kommerell's diverticulum in an aberrant right subclavian artery. After successful surgery in two stages, the patient presented with respiratory insufficiency and flaccid tetraparesis consistent with anterior spinal artery syndrome with maintained sensibility of all extremities. A computerized tomography scan (CT) revealed a high-grade origin stenosis of the left vertebral artery, which was treated by angioplasty and balloon-expandable stenting. Consecutively, the tetraparesis immediately resolved, but weaning remained unsuccessful requiring tracheostomy. Abdominal ultrasound revealed a residual bilateral diaphragmatic paralysis. A repeated magnetic resonance imaging (MRI) 14 days after vertebral artery angioplasty confirmed SCI at level C3/C4. The patient was transferred to a pulmonary clinic with weaning center for further recovery. CONCLUSIONS: This novel case highlights the need to consider diaphragmatic paralysis due to SCI as a cause of respiratory failure in patients following aortic surgery. Diaphragmatic paralysis may remain as an isolated residual in these patients.

German Cardiac Arrest Registry (G-CAR)-results of the pilot phase.

BACKGROUND: In Europe, more than 300,000 persons per year experience out-of-hospital cardiac arrest (OHCA). Despite medical progress, only few patients survive with good neurological outcome. For many issues, evidence from randomized trials is scarce. OHCA often occurs for cardiac causes. Therefore, we established the national, prospective, multicentre German Cardiac Arrest Registry (G-CAR). Herein, we describe the first results of the pilot phase. RESULTS: Over a period of 16 months, 15 centres included 559 consecutive OHCA patients aged ≥ 18 years. The median age of the patients was 66 years (interquartile range 57;75). Layperson resuscitation was performed in 60.5% of all OHCA cases which were not observed by emergency medical services. The initial rhythm was shockable in 46.4%, and 29.1% of patients had ongoing CPR on hospital admission. Main presumed causes of OHCA were acute coronary syndromes (ACS) and/or cardiogenic shock in 54.8%, with ST-elevation myocardial infarction being the most common aetiology (34.6%). In total, 62.9% of the patients underwent coronary angiography; percutaneous coronary intervention (PCI) was performed in 61.4%. Targeted temperature management was performed in 44.5%. Overall in-hospital mortality was 70.5%, with anoxic brain damage being the main presumed cause of death (38.8%). Extracorporeal cardiopulmonary resuscitation (eCPR) was performed in 11.0%. In these patients, the in-hospital mortality rate was 85.2%. CONCLUSIONS: G-CAR is a multicentre German registry for adult OHCA patients with a focus on cardiac and interventional treatment aspects. The results of the 16-month pilot phase are shown herein. In parallel with further analyses, scaling up of G-CAR to a national level is envisaged. Trial registration ClinicalTrials.gov identifier: NCT05142124.

Postoperative Pain Following Eye Enucleation: A Prospective Observational Study.

Background and Objectives: Enucleation of an eye is the most invasive procedure in ophthalmologic surgery. It can be the result of various diseases (malignant/chronic/trauma/infection) and is nevertheless relatively rare, but leads to the loss of a strongly innervated neuronal organ. This study systematically evaluates postoperative pain levels following enucleation of the eye globe. Materials and Methods: This prospective single-center study enrolled twenty-four patients undergoing enucleation of the eye globe. Perioperatively all patients completed (preoperative day, day of surgery, 1st, 2nd, and 3rd day following surgery) standardized questionnaires concerning their pain experience and treatment-related side-effects (internal protocol, QUIPS, painDETECT®). Patients received usual pain therapy in an unstandardized individual manner. Results: Preoperatively, mean average pain intensity of all included patients was 3.29 ± 2.46 (range, 0-8), 3.29 ± 3.24 (range, 0-8) on the day of surgery, 4.67 ± 1.90 (range, 2-10) on day 1, 3.25 ± 1.39 (range, 1-6) on day 2, and 2.71 ± 1.30 (range, 1-6) on day 3 after surgery. Mean maximum pain intensity was 4.71 ± 3.28 (range, 0-10) preoperatively, 4.04 ± 3.78 (range, 0-10) on the day of surgery, 5.75 ± 2.01 (range, 2-10) on day 1, 4.25 ± 1.89 (range, 2-10) on day 2, and 3.88 ± 1.54 (range, 2-8) on day 3 after surgery. Nineteen patients (79.2%) stated that they would have preferred more pain therapy. Conclusions: Patients undergoing eye enucleation report pain sensations in need of intervention in this university hospital. Thus, effective standardized pain treatment concepts are now a high priority to be established in an interdisciplinary manner containing standardized regimens and continuous regional procedures. Awareness of this problem in the medical team should be sharpened through targeted training and information.

Do laypersons need App-linked real-time feedback devices for effective resuscitation? - Results of a prospective, randomised simulation trial.

Background: App-linked real-time feedback-devices for cardiopulmonary resuscitation (CPR) aim to improve laypersons' resuscitation quality. Resuscitation guidelines recommend these technologies in training settings. This is the first study comparing resuscitation quality of all App-linked feedback-devices currently on market. Methods: A prospective randomised simulation study was performed. After standardised instructions, participants performed 2-minutes compression-only CPR on a manikin without feedback (baseline). Afterwards, participants performed 4 × 2 min CPR with four different feedback devices in randomised order (CorPatch® Trainer, CPRBAND AIO Training, SimCPR®ProTrainer, Relay Response™) (intervention). CPR metrics (chest compression depth (CD), chest compression rate (CR), percentage of correct CD/CR (%), correct hand position, correct chest recoil, and technical preparation-time) were assessed. Devices data were compared to the baseline group using Wilcoxon testing with IBM SPSS (primary outcome). Differences between devices were analysed with ANOVA testing (secondary outcome). Normally distributed data were described as mean ± standard deviation (SD) and non-normally distributed data as Median [Interquartile range (IQR). CPR self-confidence was measured by means of questionnaire before and after feedback devices' use. Comparison was performed by students t-test. Results: Forty participants were involved. SimCPR®ProTrainer was the only device, which resulted in guideline-compliant chest compressions (Mean ± SD:5.37 ± 0.76) with improved chest compression depth (p < 0.001), and percentage of correct chest compression depth (p < 0.001) compared to unassisted CPR (baseline). CorPatch® Trainer as the only device with audio-visual recoil instructions resulted in improved chest recoil (Mean ± SD:72.25 ± 24.89) compared to baseline (Mean ± SD:49.00 ± 42.20; p < 0.01), while the other three devices resulted in significantly lower chest recoil rates (CPRBAND AIO Training: 37.03 ± 39.90; p < 0.01, SimCPR®ProTrainer: Mean ± SD:39.88 ± 36.50; p = 0.03, Relay Response™: Mean ± SD:36.88 ± 37.73; p = 0.02). CPR quality when using the different feedback devices differ in chest compression depth (p = 0.02), chest compression rate (p < 0.001), percentage of correct chest compression depth/rate (p = 0.03/p = 0.04), and technical preparation-time (p < 0.001). Feedback-devices' use increased participant's CPR self-confidence (p < 0.001). Conclusion: Although, CPR feedback devices show improved CPR performance in layperson in some metrics, none of the tested CPR feedback devices supported layperson in overall adequate CPR performance. More and better technical functionality is necessary, to fully utilise the potential of CPR feedback devices and to prevent a worsening of CPR performance when layperson use this technology.

Laryngeal Mask Airway Versus Endotracheal Intubation during Lacrimal Duct Stenosis Surgery in Children-A Retrospective Analysis.

Background: The use of laryngeal masks in the surgical treatment of infantile lacrimal duct stenosis is controversial due to the potential risk of aspiration. Aims: This study investigates airway procedures in children aged <6 years for surgery of lacrimal duct stenosis in a tertiary care university hospital. Methods: After institutional approval, airway procedures, duration of anesthesiological measures, and airway-related complications were retrospectively analyzed. Patients were divided into two groups according to the airway procedures used (endotracheal tube [ET] vs. laryngeal mask [LMA] airway). Associations were calculated using the Chi-square test or Mann-Whitney U-test. Results: Clinical data of 84 patients (ET n = 36 [42.9%] vs. LMA n = 48 [57.1%]) were analyzed. There were no significant differences in surgical treatment, age distribution, and pre-existing conditions between the groups. None of the patients showed evidence of tracheal aspiration or changes in measured oxygen saturation. LMA airway shortened time for anesthesia induction (p = 0.006) and time for recovery/emergence period (p = 0.03). In contrast, the time to discharge from the recovery room was significantly prolonged using LMA (p = 0.001). A total of 7 adverse events were recorded. Five of these were directly or indirectly related to ET (laryngo-/bronchospasm; muscle relaxant residual). Conclusions: LMA airway for infantile lacrimal duct stenosis seems to be a safe procedure and should be used in appropriate pediatric patients due to its lower invasiveness, low complication rate, and time savings.

Comparing Simulation Training of Bronchoscopy-Guided Percutaneous Dilatational Tracheostomy Using Conventional Versus 3D Printed Simulators (TRAC-Sim Study).

Background: Individual implementation rate of bronchoscopy-guided percutaneous dilatational tracheostomy (PDT) varies among intensivists. Simulation training (ST) can increase the safety of medical procedures by reducing stress levels of the performing team. The aim of this study was to evaluate the benefit of ST in PDT regarding procedural time, quality of performance, and percepted feelings of safety of the proceduralist and to compare conventional simulators (CSIM) with simulators generated from 3D printers (3DSIM). Methods: We conducted a prospective, single-center, randomized, blinded cross-over study comparing the benefit of CSIM versus 3DSIM for ST of PDT. Participants underwent a standardized theoretical training and were randomized to ST with CSIM (group A) or 3DSIM (group B). After ST, participants' performance was assessed by two blinded examiners on a porcine trachea regarding time required for successful completion of PDT and correct performance (assessed by a performance score). Percepted feelings of safety were assessed before and after ST. This was followed by a second training and second assessment of the same aspects with crossed groups. Results: 44 participants were included: 24 initially trained with CSIM (group A) and 20 with 3DSIM (group B). Correctness of the PDT performance increased significantly in group B (p < .01) and not significantly in group A (p = .14). Mean procedural time required for performing a PDT after their second ST compared to the first assessment (p < .01) was lower with no difference between group A and group B and irrespective of the participants' previous experience regarding PDT, age, and sex. Moreover, percepted feelings of safety increased after the first ST in both groups (p < .001). Conclusions: ST can improve procedural skills, procedural time, and percepted feelings of safety of the proceduralist in simulated PDT.

The Value of Next-Generation Sequencing in Diagnosis and Therapy of Critically Ill Patients with Suspected Bloodstream Infections: A Retrospective Cohort Study.

Bloodstream infection (BSI), a frequent cause of severe sepsis, is a life-threatening complication in critically ill patients and still associated with a high mortality rate. Rapid pathogen identification from blood is crucial for an early diagnosis and the treatment of patients with suspected BSI. For this purpose, novel diagnostic tools on the base of genetic analysis have emerged for clinical application. The aim of this study was to assess the diagnostic value of additional next-generation sequencing (NGS) pathogen test for patients with suspected BSI in a surgical ICU and its potential impact on antimicrobial therapy. In this retrospective single-centre study, clinical data and results from blood culture (BC) and NGS pathogen diagnostics were analysed for ICU patients with suspected BSI. Consecutive changes in antimicrobial therapy and diagnostic procedures were evaluated. Results: 41 cases with simultaneous NGS and BC sampling were assessed. NGS showed a statistically non-significant higher positivity rate than BC (NGS: 58.5% (24/41 samples) vs. BC: 21.9% (9/41); p = 0.056). NGS detected eight different potentially relevant bacterial species, one fungus and six different viruses, whereas BC detected four different bacterial species and one fungus. NGS results affected antimicrobial treatment in 7.3% of cases. Conclusions: NGS-based diagnostics have the potential to offer a higher positivity rate than conventional culture-based methods in patients with suspected BSI. Regarding the high cost, their impact on anti-infective therapy is currently limited. Larger randomized prospective clinical multicentre studies are required to assess the clinical benefit of this novel diagnostic technology.