Resuscitation of Endotheliopathy and Bleeding in Thoracic Aortic Dissections: The VIPER-OCTA Randomized Clinical Pilot Trial.

BACKGROUND: Thoracic aorta dissection is an acute critical condition associated with shock-induced endotheliopathy, coagulopathy, massive bleeding, and significant morbidity and mortality. Our aim was to compare the effect of coagulation support with solvent/detergent-treated pooled plasma (OctaplasLG) versus standard fresh frozen plasma (FFP) on glycocalyx and endothelial injury, bleeding, and transfusion requirements. METHODS: Investigator-initiated, single-center, blinded, randomized clinical pilot trial of adult patients undergoing emergency surgery for thoracic aorta dissection. Patients were randomized to receive OctaplasLG or standard FFP as coagulation factor replacement related to bleeding. The primary outcome was glycocalyx and endothelial injury. Other outcomes included bleeding, transfusions and prohemostatics at 24 hours, organ failure, length of stay in the intensive care unit and in the hospital, safety, and mortality at 30 and 90 days. RESULTS: Fifty-seven patients were included to obtain 44 evaluable on the primary outcome. The OctaplasLG group displayed significantly reduced damage to the endothelial glycocalyx (syndecan-1) and reduced endothelial tight junction injury (sVE-cadherin) compared to standard FFP. In the OctaplasLG group compared to the standard FFP, days on ventilator (1 day [interquartile range, 0-1] vs 2 days [1-3]; P = .013), bleeding during surgery (2150 [1600-3087] vs 2750 [2130-6875]; P = .046), 24-hour total transfusion and platelet transfusion volume (3975 mL [2640-6828 mL] vs 6220 mL [4210-10,245 mL]; P = .040, and 1400 mL [1050-2625 mL] vs 2450 mL [1400-3500 mL]; P = .027), and goal-directed use of prohemostatics (7/23 [30.4%] vs 13/21 [61.9%]; P = .036) were all significantly lower. Among the 57 patients randomized, 30-day mortality was 20.7% (6/29) in the OctaplasLG group and 25% (7/28) in the standard FFP group (P = .760). No safety concern was raised. CONCLUSIONS: In this randomized, clinical pilot trial of patients undergoing emergency surgery for thoracic aorta dissections, we found that OctaplasLG reduced glycocalyx and endothelial injury, reduced bleeding, transfusions, use of prohemostatics, and time on ventilator after surgery compared to standard FFP. An adequately powered multicenter trial is warranted to confirm the clinical importance of the findings.

Airway management in a bronchoscopic simulator based setting: an observational study.

BACKGROUND: Several simulation-based possibilities for training flexible optical intubation have been developed, ranging from non-anatomical phantoms to high-fidelity virtual reality simulators. These teaching devices might also be used to assess the competence of trainees before allowing them to practice on patients. OBJECTIVES: To evaluate the validity of airway simulation as an assessment tool for the acquisition of the preclinical basic skills in flexible optical intubation and to investigate anaesthetists' opinion on airway simulation. DESIGN: Observational study. SETTING: International airway course. PARTICIPANTS: Thirty-six consultants and residents in anaesthesiology. MAIN OUTCOME MEASURES: All participants performed one single procedure on each of the three different simulators. Their video-filmed performances were assessed by two independent, blinded experts and their opinions of simulation were surveyed. RESULTS: The mean score increased 0.33 points after each attempt (P = 0.021). The attitude towards simulation-based training was always more than 4 on a scale from 1 to 5. Only 25% of the procedures were performed to satisfaction with a learning-by-testing effect (P = 0.021). Generalisability coefficient was 0.55, and there was no correlation between the number of clinical procedures performed beforehand and test scores (P = 0.93). CONCLUSION: The increase in mean score is a learning effect indicating that simulator training allows for entry of the learning curve at a higher level. The anaesthetists in our study agreed completely that simulation-based training was useful regardless of the fidelity of the simulator. Local, practical issues such as cost and portability should decide available simulation modalities in each teaching hospital.