Mechanical power of ventilation and driving pressure: two undervalued parameters for pre extracorporeal membrane oxygenation ventilation and during daily management?

The current ARDS guidelines highly recommend lung protective ventilation which include plateau pressure (Pplat < 30 cm H2O), positive end expiratory pressure (PEEP > 5 cm H2O) and tidal volume (Vt of 6 ml/kg) of predicted body weight. In contrast, the ELSO guidelines suggest the evaluation of an indication of veno-venous extracorporeal membrane oxygenation (ECMO) due to hypoxemic or hypercapnic respiratory failure or as bridge to lung transplantation. Finally, these recommendations remain a wide range of scope of interpretation. However, particularly patients with moderate-severe to severe ARDS might benefit from strict adherence to lung protective ventilation strategies. Subsequently, we discuss whether extended physiological ventilation parameter analysis might be relevant for indication of ECMO support and can be implemented during the daily routine evaluation of ARDS patients. Particularly, this viewpoint focus on driving pressure and mechanical power.

Prevalence of pre-operative anaemia in surgical patients: a retrospective, observational, multicentre study in Germany.

Anaemia is a risk factor for several adverse postoperative outcomes. Detailed data about the prevalence of anaemia are not available over a long time-period in Germany. In this retrospective, observational, multicentre study, patients undergoing surgery in March in 2007, 2012, 2015, 2017 and 2019 were studied. The primary objective was the prevalence of anaemia at hospital admission. The secondary objectives were the association between anaemia and the number of units of red blood cells transfused, length of hospital stay and in-hospital mortality. A total of 23,836 patients were included from eight centres. The prevalence of pre-operative anaemia in patients aged ≥ 18 years decreased slightly from 37% in 2007 to 32.5% in 2019 (p = 0.01) and increased in patients aged ≤ 18 years from 18.8% in 2007 to 26.4% in 2019 (p > 0.001). The total amount of blood administered per 1000 patients decreased from 671.2 units in 2007 to 289.0 units in 2019. Transfusion rates in anaemic patients declined from 33.8% in 2007 to 19.1% in 2019 (p < 0.001) and in non-anaemic patients from 8.4% in 2007 to 3.4% in 2019 (p < 0.001). Overall, the mortality rate remained constant over the years: 2.9% in 2007, 2.1% in 2012, 2.5% in 2015, 1.9% in 2017 and 2.5% in 2019. In the presence of anaemia, mortality was significantly increased compared with patients without anaemia (OR 5.27 (95%CI 4.13-6.77); p < 0.001). Red blood cell transfusion was associated with an increased risk of mortality (OR 14.98 (95%CI 11.83-19.03); p < 0.001). Using multivariable linear regression analysis with fixed effects, we found that pre-operative anaemia (OR 2.08 (95%CI 1.42-3.05); p < 0.001) and red blood cell transfusion (OR 4.29 (95%CI 3.09-5.94); p < 0.001) were predictors of mortality but not length of stay (0.99 (95%CI 0.98-1.00) days; p = 0.12) and analysed years (2007 vs. 2019: OR 1.49 (95%CI 0.86-2.69); p = 0.07). Pre-operative anaemia affects more than 30% of surgical patients in Germany and multidisciplinary action is urgently required to reduce adverse outcomes.

Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: an abridged Cochrane network meta-analysis.

Postoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is currently no comparative ranking of efficacy and safety of these drugs to inform clinical practice. We performed a systematic review with network meta-analyses to compare, and rank in terms of efficacy and safety, single anti-emetic drugs and their combinations, including 5-hydroxytryptamine3 , dopamine-2 and neurokinin-1 receptor antagonists; corticosteroids; antihistamines; and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anaesthesia. We systematically searched for placebo-controlled and head-to-head randomised controlled trials up to November 2017 (updated in April 2020). We assessed how trustworthy the evidence was using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence In Network Meta-Analysis (CINeMA) approaches for vomiting within 24 h postoperatively, serious adverse events, any adverse event and drug class-specific side-effects. We included 585 trials (97,516 participants, 83% women) testing 44 single drugs and 51 drug combinations. The studies' overall risk of bias was assessed as low in only 27% of the studies. In 282 trials, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared with placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single neurokinin-1 receptor antagonists were as effective as other drug combinations. Out of the 10 effective single drugs, certainty of evidence was high for aprepitant, with risk ratio (95%CI) 0.26 (0.18-0.38); ramosetron, 0.44 (0.32-0.59); granisetron, 0.45 (0.38-0.54); dexamethasone, 0.51 (0.44-0.57); and ondansetron, 0.55 (0.51-0.60). It was moderate for fosaprepitant, 0.06 (0.02-0.21) and droperidol, 0.61 (0.54-0.69). Granisetron and amisulpride are likely to have little or no increase in any adverse event compared with placebo, while dimenhydrinate and scopolamine may increase the number of patients with any adverse event compared with placebo. So far, there is no convincing evidence that other single drugs effect the incidence of serious, or any, adverse events when compared with placebo. Among drug class specific side-effects, evidence for single drugs is mostly not convincing. There is convincing evidence regarding the prophylactic effect of at least seven single drugs for postoperative vomiting such that future studies investigating these drugs will probably not change the estimated beneficial effect. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.

[S3 guidelines on "full-term vaginal birth" from an anesthesiological perspective : Worthwhile knowledge for anesthesiologists]. / S3-Leitlinie "Vaginale Geburt am Termin" aus anästhesiologischer Sicht : Wissenswertes für den Anästhesisten.

The publication of the new S3 guidelines on "full-term vaginal birth" and the guidelines on cesarean section, also published in 2020, provide further steps towards the promotion of evidence-based medicine in obstetrics, even if the exact configuration of neonatal monitoring during birth, in particular, is still the subject of current discussions. The multiprofessionality in the medical supervision of a birth is also fundamentally well-represented in the compilation of the S3 guidelines by the participating actors and specialist societies. Important from an anesthesiological perspective is the fact that neuraxial procedures still represent the gold standard in obstetric analgesia. With remifentanil PCA an alternative option is available that enables a reliable analgesia to be accomplished, e.g. when there are contraindications to performing neuraxial methods, if this is appropriate under the prevailing circumstances (1:1 support and appropriate monitoring). During an uncomplicated birth the strict fasting rules are relaxed. Overall, the guidelines underline the importance of self-determination and self-control for the expectant mother and give the highest priority to the safety and well-being of mother and child; however, this presupposes that the expectant mother is sufficiently informed about the value of neuraxial analgesia. For this it appears to be of importance to initiate information proposals, which go beyond the usual information sessions for parents that are often organized exclusively by midwives.

Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

[Ventilation Patients between Acute Care and Long-term Out-of-Hospital Ventilation - Routine Documentation based Analysis of the Care Situation]. / Beatmungspatienten zwischen Akutversorgung und außerstationärer Langzeitbeatmung.

BACKGROUND: The number of invasive and non-invasive long-term out-of-hospital ventilations has been increasing rapidly for years. At the same time, there is poor information on the quality of care of out-of-hospital ventilated patients. The present investigation was conducted as part of the OVER-BEAS study. The aim of this study was to describe the care situation of weaning patients from admission to discharge from the weaning center using existing routine documentation. MATERIAL AND METHODS: In our retrospective analysis, we included all patients admitted in 2018 via the weaning ward of the Thorax Center Münnerstadt. Descriptive analysis of routine data collected as part of quality management was performed. Data sources were the WeanNet database, the discharge letter of the weaning center, and the transfer report of the referring hospital. RESULTS: In the studied weaning center, 50.8 % of the patients (n = 31) could be completely weaned from the respirator and extubated or decannulated (category 3aI). If complete weaning was not successful, 75.0 % (n = 21) required the constant presence of specially trained staff or a specialist nurse in the further course. In this case, further care was mostly provided in inpatient care facilities (e. g., ventilator shared living community). CONCLUSION: Based on routine documentation, the care situation of weaning patients can be presented and compared with known data. In this way, the outcome quality of a weaning center can be made comparable.

[Ventilation Patients between Acute Care and Long-term Out-of-Hospital Ventilation - Routine Documentation based Analysis of the Care Situation]. / Beatmungspatienten zwischen Akutversorgung und außerstationärer Langzeitbeatmung.

BACKGROUND: The number of invasive and non-invasive long-term out-of-hospital ventilations has been increasing rapidly for years. At the same time, there is poor information on the quality of care of out-of-hospital ventilated patients. The present investigation was conducted as part of the OVER-BEAS study. The aim of this study was to describe the care situation of weaning patients from admission to discharge from the weaning center using existing routine documentation. MATERIAL AND METHODS: In our retrospective analysis, we included all patients admitted in 2018 via the weaning ward of the Thorax Center Münnerstadt. Descriptive analysis of routine data collected as part of quality management was performed. Data sources were the WeanNet database, the discharge letter of the weaning center, and the transfer report of the referring hospital. RESULTS: In the studied weaning center, 50.8 % of the patients (n = 31) could be completely weaned from the respirator and extubated or decannulated (category 3aI). If complete weaning was not successful, 75.0 % (n = 21) required the constant presence of specially trained staff or a specialist nurse in the further course. In this case, further care was mostly provided in inpatient care facilities (e. g., ventilator shared living community). CONCLUSION: Based on routine documentation, the care situation of weaning patients can be presented and compared with known data. In this way, the outcome quality of a weaning center can be made comparable.

Surgery in times of COVID-19-recommendations for hospital and patient management.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has escalated rapidly to a global pandemic stretching healthcare systems worldwide to their limits. Surgeons have had to immediately react to this unprecedented clinical challenge by systematically repurposing surgical wards. PURPOSE: To provide a detailed set of guidelines developed in a surgical ward at University Hospital Wuerzburg to safely accommodate the exponentially rising cases of SARS-CoV-2 infected patients without compromising the care of emergency surgery and oncological patients or jeopardizing the well-being of hospital staff. CONCLUSIONS: The dynamic prioritization of SARS-CoV-2 infected and surgical patient groups is key to preserving life while maintaining high surgical standards. Strictly segregating patient groups in emergency rooms, non-intensive care wards and operating areas prevents viral spread while adequately training and carefully selecting hospital staff allow them to confidently and successfully undertake their respective clinical duties.

Improving decision making through presentation of viscoelastic tests as a 3D animated blood clot: the Visual Clot.

Point-of-care viscoelastic coagulation tests are used increasingly and enable physicians to run precise whole blood coagulation diagnostics. However, the somewhat complicated and abstract presentation of results may hinder these advantages. For this reason, we developed the Visual Clot as an alternative mode of presentation for thrombelastometric data. An algorithm takes existing parameters from rotational thromboelastometry and creates a visual representation in the form of an animated blood clot named 'Visual Clot'. In a prospective international dual-centre study, 60 physicians were presented with rotational thromboelastometry results in the standard way or as a Visual Clot. They were then asked to make therapeutic decisions based on pathological findings. Overall proportion of correct therapeutic decisions was median (IQR [range] 100 (83-100 [39-100]) % for Visual Clot vs. 44 (25-50 [0-83]) % for standard rotational thromboelastometry presentation of results, p < 0.001. Mixed regression models yielded a mean OR (95%CI) 22.1 (13.4-36.5), p < 0.001 for correct decisions with the Visual Clot compared with standard rotational thromboelastometry, with an 18.7 (16.4-21.1), p < 0.001 second decrease in decision time. Perceived cognitive work-load was lower, and participants rated their diagnostic confidence to be higher with the Visual Clot, both p < 0.001. Although correct interpretation of standard rotational thromboelastometry results depended on previous rotational thromboelastometry knowledge and experience, Visual Clot interpretation did not. The Visual Clot improved rotational thromboelastometry-based therapeutic decisions, as pathologies can be recognised more rapidly and accurately. These findings underline the significance of an alternative additional visualisation technique that simplifies the interpretation of abstract standard data.

Patient blood management during the COVID-19 pandemic: a narrative review.

As COVID-19 disease escalates globally, optimising patient outcome during this catastrophic healthcare crisis is the number one priority. The principles of patient blood management are fundamental strategies to improve patient outcomes and should be given high priority in this crisis situation. The aim of this expert review is to provide clinicians and healthcare authorities with information regarding how to apply established principles of patient blood management during the COVID-19 pandemic. In particular, this review considers the impact of the COVID-19 pandemic on blood supply and specifies important aspects of donor management. We discuss how preventative and control measures implemented during the COVID-19 crisis could affect the prevalence of anaemia, and highlight issues regarding the diagnosis and treatment of anaemia in patients requiring elective or emergency surgery. In addition, we review aspects related to patient blood management of critically ill patients with known or suspected COVID-19, and discuss important alterations of the coagulation system in patients hospitalised due to COVID-19. Finally, we address special considerations pertaining to supply-demand and cost-benefit issues of patient blood management during the COVID-19 pandemic.

[Reticulocyte hemoglobin equivalent as a diagnostic marker for the current iron deficiency : Old wine in new bottles]. / Retikulozyten-Hämoglobin-Äquivalent als diagnostischer Marker der aktuellen Eisendefizienz : Alter Wein in neuen Schläuchen.

The reticulocyte hemoglobin equivalent (RET-He) is presented as a biomarker for the diagnostics and monitoring of iron deficiency. The marker is independent of the acute phase and can be determined within a few minutes by a blood count. Due to the approximately 120-day lifetime of erythrocytes, iron deficiency and changes in the iron status of erythropoiesis can first be recognized at a relatively late stage using classical hematological parameters, such as hemoglobin, mean corpuscular volume, mean cellular hemoglobin content and also with determination of hypochromic erythrocytes (% hypo). The RET-He is a cost-effective parameter for the diagnosis and monitoring of the iron supply for erythropoiesis. Reticulocytes, the precursors of mature erythrocytes, are washed out of the bone marrow into the peripheral blood and normally mature within 2 days to mature erythrocytes. The determination of the reticulocyte number therefore enables a timely statement about erythropoiesis. A measurement of the hemoglobin content of reticulocytes therefore reflects the actual iron metabolism of erythropoiesis and enables assessment of the quality of the cells. Changes in the iron status of erythropoiesis can thus be detected much earlier than by determining only the hemoglobin content of mature erythrocytes, i.e. the mean cellular hemoglobin content. It is recommended that the evaluation of RET-He should be carried out as an inexpensive routine preoperative marker of latent anemia in order to identify patients at risk. In the sense of a perioperative prehabilitation and the enhanced recovery after surgery (ERAS) concept, patients with iron deficiency can be treated proactively at an early stage in order to prevent complications and extended hospital stays.

[Preclinical management of cardiac arrest-extracorporeal cardiopulmonary resuscitation]. / Präklinisches Management bei Herz-Kreislauf-Stillstand ­ extrakorporale kardiopulmonale Reanimation.

BACKGROUND: The chances of surviving out-of-hospital cardiac arrest (OHCA) are still very low. Despite intensive efforts the outcome has remained relatively poor over many years. In specific situations, new technologies, such as extracorporeal cardiopulmonary resuscitation (eCPR) could significantly improve survival with a good neurological outcome. OBJECTIVE: Does the immediate restoration of circulation and reoxygenation via eCPR influence the survival rate after OHCA? Is eCPR the new link in the chain of survival? MATERIAL AND METHODS: Discussion of current study results and guideline recommendations. RESULTS: The overall survival rates after OHCA have remained at 10-30% over many years. Despite low case numbers more recent retrospective studies showed that an improved outcome can be achieved with eCPR. In selected patient collectives survival with a favorable neurological outcome is possible in 38% of the cases. CONCLUSION: Survival after cardiac arrest and the subsequent quality of life dependent on many different factors. The time factor, i.e. the avoidance of a no-flow phase and reduction of the low-flow phase is of fundamental importance. The immediate restoration of the circulation and oxygen supply by eCPR can significantly improve survival; however, large randomized, controlled trials are currently not available.

[Anesthesia and intensive care ventilators: differences and usability in COVID-19 patients]. / Anästhesie- und Intensivbeatmungsgeräte: Unterschiede und Nutzbarkeit bei COVID-19-Patienten.

The current coronavirus disease 2019 (Covid-19) pandemia is a highly dynamic situation characterized by therapeutic and logistic uncertainties. Depending on the effectiveness of social distancing, a shortage of intensive care respirators must be expected. Concomitantly, many physicians and nursing staff are unaware of the capabilities of alternative types of ventilators, hence being unsure if they can be used in intensive care patients. Intensive care respirators were specifically developed for the use in patients with pathological lung mechanics. Nevertheless, modern anesthesia machines offer similar technical capabilities including a number of different modes. However, conceptual differences must be accounted for, requiring close monitoring and the presence of trained personnel. Modern transport ventilators are mainly for bridging purposes as they can only be used with 100% oxygen in contaminated surroundings. Unconventional methods, such as "ventilator-splitting", which have recently received increasing attention on social media, cannot be recommended. This review intends to provide an overview of the conceptual and technical differences of different types of mechanical ventilators.

[Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study]. / Implementierung anästhesiologischer Qualitätsindikatoren in Deutschland : Eine prospektive, nationale, multizentrische Qualitätssteigerungsstudie German version.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

[Various scenarios for billing and remuneration of preoperative management of iron deficiency anemia in the German healthcare system]. / Verschiedene Szenarien zu Abrechnung und Kostenerstattung eines präoperativen Managements der Eisenmangelanämie im deutschen Gesundheitssystem.

More than 30% of all patients undergoing surgery suffer from preoperative anemia. Iron deficiency anemia is the most common type of anemia. The diagnostics and treatment of iron deficiency anemia can be carried out before patients undergo surgery as an alternative to blood transfusion and is an interdisciplinary task. This article gives an overview of various billing modalities and payment arrangements for management of preoperative anemia in the German healthcare system.

An international consensus statement on the management of postoperative anaemia after major surgical procedures.

Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.

International consensus statement on the peri-operative management of anaemia and iron deficiency.

Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.

Patient Blood Management in Europe: surveys on top indications for red blood cell use and Patient Blood Management organization and activities in seven European university hospitals.

BACKGROUND AND OBJECTIVES: Patient Blood Management (PBM) in Europe is a working group of the European Blood Alliance with the initial objective to identify the starting position of the participating hospitals regarding PBM for benchmarking purposes, and to derive good practices in PBM from the experience and expertise in the participating teams with the further aim of implementing and strengthening these practices in the participating hospitals. METHODS: We conducted two surveys in seven university hospitals in Europe: Survey on top indications for red blood cell use regarding usage of red blood cells during 1 week and Survey on PBM organization and activities. RESULTS: A total of 3320 units of red blood cells were transfused in 1 week at the seven hospitals. Overall, 61% of red cell units were transfused to medical patients and 36% to surgical patients, although there was much variation between hospitals. The organization and activities of PBM in the seven hospitals were variable, but there was a common focus on optimizing the treatment of bleeding patients, monitoring the use of blood components and treatment of preoperative anaemia. CONCLUSION: Although the seven hospitals provide a similar range of clinical services, there was variation in transfusion rates between them. Further, there was variable implementation of PBM activities and monitoring of transfusion practice. These findings provide a baseline to develop joint action plans to further implement and strengthen PBM across a number of hospitals in Europe.

[Cardioprotection in cardiac surgical patients : Everything good comes from the heart]. / Kardioprotektion beim herzchirurgischen Patienten : Alles Gute kommt von Herzen.

BACKGROUND: Despite substantial success in the anesthetic and surgical management of cardiac surgery, patients frequently show postoperative complications and organ dysfunctions. This is highly relevant for mid- to long-term outcomes. OBJECTIVES: To evaluate cardioprotective strategies that may offer effective protection in vulnerable cardiac surgery patients. METHODS: To demonstrate recent cardioprotective approaches for cardiac surgery patients, aiming to modulate the body's own protective mechanisms in cardiac surgery patients. RESULTS: Both cardioplegia and hypothermia belong to the well-established protective strategies during myocardial ischemia. Volatile anesthetics have been repeatedly shown to improve the left ventricular function and reduce the extent of myocardial injury compared to a control group with intravenous anesthesia. Furthermore, patients receiving volatile anesthetics showed a significantly shortened stay in the ICU and in hospital after cardiac surgery. In contrast, numerous other protective strategies failed translation into the clinical practice. Despite the published reduction of troponin release after remote ischemic preconditioning, two recent large-scale randomized multicenter trials were unable to demonstrate a clinical benefit. CONCLUSIONS: Beside the use of cardioplegia and hypothermia, the use of volatile anesthetics is well-established during cardiac surgery because of its conditioning and protective properties. Regardless of the promising results derived from experimental studies and small clinical trials, the majority of other approaches failed to translate their findings into the clinic. Therefore, systematic experimental studies are needed to identify potential confounding factors that may affect the protective effects.

[Cost analysis of patient blood management]. / Kostenanalyse eines Patient-Blood-Management-Konzepts.

BACKGROUND: Patient blood management (PBM) is a multidisciplinary approach focusing on the diagnosis and treatment of preoperative anaemia, the minimisation of blood loss, and the optimisation of the patient-specific anaemia reserve to improve clinical outcomes. Economic aspects of PBM have not yet been sufficiently analysed. OBJECTIVES: The aim of this study is to analyse the costs associated with the clinical principles of PBM and the project costs associated with the implementation of a PBM program from an institutional perspective. MATERIALS AND METHODS: Patient-related costs of materials and services were analysed at the University Hospital Frankfurt for 2013. Personnel costs of all major processes were quantified based on the time required to perform each step. Furthermore, general project costs of the implementation phase were determined. RESULTS: Direct costs of transfusing a single unit of red blood cells can be calculated to a minimum of €147.43. PBM-associated costs varied depending on individual patient requirements. The following costs per patient were calculated: diagnosis of preoperative anaemia €48.69-123.88; treatment of preoperative anaemia (including iron-deficiency anaemia and megaloblastic anaemia) €12.61-127.99; minimising perioperative blood loss (including point-of-care diagnostics, coagulation management and cell salvage) €3.39-1,901.81; and costs associated with the optimisation of the tolerance to anaemia (including patient monitoring and volume therapy) €28.62. General project costs associated with the implementation of PBM were €24,998.24. CONCLUSIONS: PBM combines various alternatives to the transfusion of red blood cells and improves clinical outcome. Costs of PBM vary from institution to institution and depend on the extent to which different aspects of PBM have been implemented. The quantification of costs associated with PBM is essential in order to assess the economic impact of PBM, and thereby, to efficiently re-allocate health care resources. Costs were determined at a single university hospital. Thus, further analyses of both the costs of transfusion and the costs of PBM-principles will be necessary to evaluate the cost-effectiveness of PBM.