A European consensus statement on the use of four-factor prothrombin complex concentrate for cardiac and non-cardiac surgical patients.

Modern four-factor prothrombin complex concentrate was designed originally for rapid targeted replacement of the coagulation factors II, VII, IX and X. Dosing strategies for the approved indication of vitamin K antagonist-related bleeding vary greatly. They include INR and bodyweight-related protocols as well as fixed dose regimens. Particularly in the massively bleeding trauma and cardiac surgery patient, four-factor prothrombin complex concentrate is used increasingly for haemostatic resuscitation. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology performed a systematic literature review on four-factor prothrombin complex concentrate. The available evidence has been summarised for dosing, efficacy, drug safety and monitoring strategies in different scenarios. Whereas there is evidence for the efficacy of four-factor prothrombin concentrate for a variety of bleeding scenarios, convincing safety data are clearly missing. In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg-1 . This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available. In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg-1 ) should be considered. A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.

Elderly patients with atrial fibrillation in routine clinical practice-peri-procedural management of edoxaban oral anticoagulation therapy is associated with a low risk of bleeding and thromboembolic complications: a subset analysis of the prospective, observational, multinational EMIT-AF study.

BACKGROUND: Annually > 10% of patients with atrial fibrillation on oral anticoagulation undergo invasive procedures. Optimal peri-procedural management of anticoagulation, as judged by major bleeding and thromboembolic events, especially in the elderly, is still debated. METHODS: Procedures from 1442 patients were evaluated. Peri-procedural edoxaban management was guided only by the experience of the attending physician. The primary safety outcome was the rate of major bleeding. Secondary outcomes included the peri-procedural administration of edoxaban, other bleeding events, and the main efficacy outcome, a composite of acute coronary syndrome, non-hemorrhagic stroke, transient ischemic attack, systemic embolic events, deep vein thrombosis, pulmonary embolism, and mortality. RESULTS: Of the 1442 patients, 280 (19%) were < 65, 550 (38%) were 65-74, 514 (36%) 75-84, and 98 (7%) were 85 years old or older. With increasing age, comorbidities and risk scores were higher. Any bleeding complications were uncommon across all ages, ranging from 3.9% in patients < 65 to 4.1% in those 85 years or older; major bleeding rates in any age group were ≤ 0.6%. Interruption rates and duration increased with advancing age. Thromboembolic events were more common in the elderly, with all nine events occurring in those > 65, and seven in patients aged > 75 years. CONCLUSION: Despite increased bleeding risk factors in the elderly, bleeding rates were small and similar across all age groups. However, there was a trend toward more thromboembolic complications with advancing age. Further efforts to identify the optimal management to reduce ischemic complications are needed. TRIAL REGISTRATION: NCT# 02950168, October 31, 2016.

[Postdural puncture headache after neuraxial anesthesia: incidence and risk factors]. / Postpunktioneller Kopfschmerz nach rückenmarknahen Anästhesieverfahren: Inzidenz und Risikofaktoren.

BACKGROUND/OBJECTIVE: Postdural puncture headache (PDPH) is a severe complication after spinal anesthesia. The aim of this study was to investigate the incidence of PDPH in two different operative cohorts and to identify risk factors for its occurrence as well as to analyze its influence on the duration of hospital stay. MATERIAL AND METHODS: In a retrospective study over a period of 3 years (2010-2012), 341 orthopedic surgery (ORT) and 2113 obstetric (OBS) patients were evaluated after spinal anesthesia (SPA). Data were statistically analyzed using (SPSS-23) univariate analyses with the Mann-Whitney U­test, χ2-test and Student's t-test as well as logistic regression analysis. RESULTS: The incidence of PDPH was 5.9% in the ORT cohort and 1.8% in the OBS cohort. Patients with PDPH in the ORT cohort were significantly younger (median 38 years vs. 47 years, p = 0.011), had a lower body weight (median 70.5 kg vs. 77 kg, p = 0.006) and a lower body mass index (median 23.5 vs. 25.2, p = 0.037). Body weight (odds ratio (97.5 % Confidence Intervall [CI]), OR 0.956: 97.5% CI 0.920-0.989, p = 0.014) as well as age (OR 0.963: 97.5% CI 0.932-0.991, p = 0.015) were identified as independent risk factors for PDPH. In OBS patients, PDPH occurred more frequently after spinal epidural anesthesia than after combined spinal epidural anesthesia (8.6% vs. 1.2%, p < 0.001) and the type of neuraxial anesthesia was identified as an independent risk factor for PDPH (OR 0.049; 97.5% CI 0.023-0.106, p < 0.001). In both groups the incidence of PDPH was associated with a longer hospital stay (ORT patients 4 days vs. 2 days, p = 0.001; OBS patients 6 days vs. 4 days, p < 0.0005). CONCLUSION: The incidence of PDPH was different in the two groups with a higher incidence in the ORT but considerably lower than in the literature. Age, constitution and type of neuraxial anesthesia were identified as risk factors of PDPH. Considering the functional imitations (mobilization, neonatal care) and a longer hospital stay, future studies should investigate the impact of an early treatment of PDPH.

The role of fibrinogen and fibrinogen concentrate in cardiac surgery: an international consensus statement from the Haemostasis and Transfusion Scientific Subcommittee of the European Association of Cardiothoracic Anaesthesiology.

To date, data regarding the efficacy and safety of administering fibrinogen concentrate in cardiac surgery are limited. Studies are limited by their low sample size and large heterogeneity with regard to the patient population, by the timing of fibrinogen concentrate administration, and by the definition of transfusion trigger and target levels. Assessment of fibrinogen activity using viscoelastic point-of-care testing shortly before or after weaning from cardiopulmonary bypass in patients and procedures with a high risk of bleeding appears to be a rational strategy. In contrast, the use of Clauss fibrinogen test for determination of plasma fibrinogen level can no longer be recommended without restrictions due to its long turnaround time, high inter-assay variability and interference with high heparin levels and fibrin degradation products. Administration of fibrinogen concentrate for maintaining physiological fibrinogen activity in the case of microvascular post-cardiopulmonary bypass bleeding appears to be indicated. The available evidence does not suggest aiming for supranormal levels, however. Use of cryoprecipitate as an alternative to fibrinogen concentrate might be considered to increase plasma fibrinogen levels. Although conclusive evidence is lacking, fibrinogen concentrate does not seem to increase adverse outcomes (i.e., thromboembolic events). Large prospective multi-centre studies are needed to better define the optimal perioperative monitoring tool, transfusion trigger and target levels for fibrinogen replacement in cardiac surgery.

Impact of brief prewarming on anesthesia-related core-temperature drop, hemodynamics, microperfusion and postoperative ventilation in cytoreductive surgery of ovarian cancer: a randomized trial.

BACKGROUND: General (GA)- and epidural-anesthesia may cause a drop in body-core-temperature (BCTdrop), and hypothermia, which may alter tissue oxygenation (StO2) and microperfusion after cytoreductive surgery for ovarian cancer. Cell metabolism of subcutaneous fat- or skeletal muscle cells, measured in microdialysis, may be affected. We hypothesized that forced-air prewarming during epidural catheter placement and induction of GA maintains normothermia and improves microperfusion. METHODS: After ethics approval 47 women scheduled for cytoreductive surgery were prospectively enrolled. Women in the study group were treated with a prewarming of 43 °C during epidural catheter placement. BCT (Spot on®, 3 M) was measured before (T1), after induction of GA (T2) at 15 min (T3) after start of surgery, and until 2 h after ICU admission (TICU2h). Primary endpoint was BCTdrop between T1 and T2. Microperfusion-, hemodynamic- and clinical outcomes were defined as secondary outcomes. Statistical analysis used the Mann-Whitney-U- and non-parametric-longitudinal tests. RESULTS: BCTdrop was 0.35 °C with prewarming and 0.9 °C without prewarming (p < 0.005) and BCT remained higher over the observation period (ΔT4 = 0.9 °C up to ΔT7 = 0.95 °C, p < 0.001). No significant differences in hemodynamic parameters, transfusion, arterial lactate and dCO2 were measured. In microdialysis the ethanol ratio was temporarily, but not significantly, reduced after prewarming. Lactate, glucose and glycerol after PW tended to be more constant over the entire period. Postoperatively, six women without prewarming, but none after prewarming were mechanical ventilated (p < 0.001). CONCLUSION: Prewarming at 43 °C reduces the BCTdrop and maintains normothermia without impeding the perioperative routine patient flow. Microdialysis indicate better preserved parameters of microperfusion. TRIAL REGISTRATION: ClinicalTrials.gov ; ID: NCT02364219 ; Date of registration: 18-febr-2015.

Why does a point of care guided transfusion algorithm not improve blood loss and transfusion practice in patients undergoing high-risk cardiac surgery? A prospective randomized controlled pilot study.

BACKGROUND: Adult cardiac surgery is often complicated by elevated blood losses that account for elevated transfusion requirements. Perioperative bleeding and transfusion of blood products are major risk factors for morbidity and mortality. Timely diagnostic and goal-directed therapies aim at the reduction of bleeding and need for allogeneic transfusions. METHODS: Single-centre, prospective, randomized trial assessing blood loss and transfusion requirements of 26 adult patients undergoing elective cardiac surgery at high risk for perioperative bleeding. Primary endpoint was blood loss at 24 h postoperatively. Random assignment to intra- and postoperative haemostatic management following either an algorithm based on conventional coagulation assays (conventional group: platelet count, aPTT, PT, fibrinogen) or based on point-of-care (PoC-group) monitoring, i.e. activated rotational thromboelastometry (ROTEM®) combined with multiple aggregometry (Multiplate®). Differences between groups were analysed using nonparametric tests for independent samples. RESULTS: The study was terminated after interim analysis (n = 26). Chest tube drainage volume was 360 ml (IQR 229-599 ml) in the conventional group, and 380 ml (IQR 310-590 ml) in the PoC-group (p = 0.767) after 24 h. Basic patient characteristics, results of PoC coagulation assays, and transfusion requirements of red blood cells and fresh frozen plasma did not differ between groups. Coagulation results were comparable. Platelets were transfused in the PoC group only. CONCLUSION: Blood loss via chest tube drainage and transfusion amounts were not different comparing PoC- and central lab-driven transfusion algorithms in subjects that underwent high-risk cardiac surgery. Routine PoC coagulation diagnostics do not seem to be beneficial when actual blood loss is low. High risk procedures might not suffice as a sole risk factor for increased blood loss. TRIAL REGISTRATION: NCT01402739 , Date of registration July 26, 2011.

Crystalloid coloading vs. colloid coloading in elective Caesarean section: postspinal hypotension and vasopressor consumption, a prospective, observational clinical trial.

BACKGROUND: Maternal hypotension is a common side effect of spinal anaesthesia for Caesarean section. The combination of colloid coloading and vasopressors was considered our standard for its prevention and treatment. As the safety of hydroxyethyl starch is under debate, we replaced colloid with crystalloid coloading. OBJECTIVE: We hypothesize that the mean blood pressure drop is greater when coloading with crystalloids. DESIGN: Prospective, observational clinical trial. SETTING: Two-centre study conducted in Berlin, Germany. PATIENTS: Parturients scheduled for a Caesarean section were screened for eligibility. INTERVENTION: The study protocol and patient monitoring were based on the standard operating procedure for Caesarean section in both centres. The data from the crystalloid group were prospectively collected between November 2014 and July 2015. MAIN OUTCOME MEASURES: The primary endpoint was the median drop in mean blood pressure after induction of spinal anaesthesia. Secondary endpoints were incidence of hypotension (drop > 20% of baseline systolic pressure /drop < 100 mmHg), vasopressor and additional fluid requirements (mL), incidence of bradycardia (heart rate < 60 beats per minute), blood loss, Apgar score, and umbilical artery pH. In case of hypotension, patients received phenylephrine or cafedrine/theodrenaline according to their heart rate. A p < 0.05 was considered significant. RESULTS: 345 prospectively enrolled patients (n = 193 crystalloid group vs. n = 152 colloid group) were analysed. The median drop in mean blood pressure was greater in the crystalloid group [34 mmHg (25; 42 mmHg) vs. 21 mmHg (13; 29 mmHg), p < 0.001]. Incidences of hypotension [93.3% vs. 83.6%, p: 0.004] and bradycardia [19.7% vs. 9.9%, p: 0.012] were also significantly greater in the crystalloid group. Vasopressor requirements, blood loss and neonatal outcome were not different between the groups. CONCLUSIONS: Crystalloid coloading was associated with a greater drop in mean blood pressure and a higher incidence of hypotension when compared with colloid coloading. Neonatal outcome was, however, unaffected by the type of fluid. TRIAL REGISTRATION: DRKS00006783 ( http://www.drks.de ).

[Diagnostics and treatment of preoperative anemia]. / Diagnostik und Behandlung der präoperativen Anämie.

Approximately 14-40% of patients in industrialized countries present with preoperative anemia. Depending on the severity, anemia is associates with increased perioperative morbidity and mortality. One of the most important causes of preoperative anemia is iron deficiency which is usually easy to treat. Implemented in the multimodal concept of patient blood management, the diagnostics and treatment of preoperative anemia are important aspects for improvement of perioperative outcome. Adequate and early diagnostics of the cause of anemia before treatment is important because treatment options, e.g. with iron, erythropoetin, folic acid and vitamin B12, may be expensive, may have severe side effects, and in the case of a wrong indication, will not improve anemia. In addition, an adequate regeneration of the erythrocyte volume requires time. This review article presents important aspects of the epidemiology and prognostic implications of preoperative anemia, the physiology and pathophysiology of anemia as well as diagnostic features and the evidence base for preoperative treatment options.

International consensus statement on the peri-operative management of direct oral anticoagulants in cardiac surgery.

Despite current recommendations on the management of severe peri-operative bleeding, there is no pragmatic guidance for the peri-operative monitoring and management of cardiac surgical patients taking direct oral anticoagulants. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology, of their own volition, performed an independent systematic review of peer-reviewed original research, review articles and case reports and developed the following consensus statement. This has been endorsed by the European Association of Cardiothoracic Anaesthesiology. In our opinion, most patients on direct oral anticoagulant therapy presenting for elective cardiac surgery can be safely managed in the peri-operative period if the following conditions are fulfilled: direct oral anticoagulants have been discontinued two days before cardiac surgery, corresponding to five elimination half-live periods; in patients with renal or hepatic impairment or a high risk of bleeding, a pre-operative plasma level of direct oral anticoagulants has been determined and found to be below 30 ng.ml-1 (currently only valid for dabigatran, rivaroxaban and apixaban). In cases where plasma level monitoring is not possible (e.g. assay was not available), discontinuation for 10 elimination half-live periods (four days) is required. For FXa inhibitors, a standard heparin-calibrated anti-Xa level of < 0.1 IU.ml-1 should be measured, indicating sufficient reduction in the anticoagulant effect. Finally, short-term bridging with heparin is not required in the pre-operative period.

[Haemostatic management in postpartum haemorrhage : Nationwide survey in Germany]. / Gerinnungstherapie der peripartalen Hämorrhagie : Deutschlandweite Umfrage.

BACKGROUND: In order to ensure evidence-based haemostatic management of postpartum haemorrhage (PPH, blood loss >500 ml) consistent with guidelines appropriate structural conditions must be fulfilled regardless of different levels (1-3) in perinatal care. The aim of the survey was to identify differences in haemostatic management in PPH under consideration of the different levels of perinatal care in Germany. MATERIALS AND METHODS: An electronic questionnaire assessing the structural and therapeutic preconditions for haemostatic management was sent to 533 anaesthesiology departments serving obstetric units. RESULTS: A total of 156 (29 %) questionnaires returned from hospitals of all levels were analysed. PPH occur in all and increase with higher level hospitals (level 1 <5 PPH/year vs. 3 >30 PPH/year). The percentage of PPH requiring red blood cell (RBC) transfusion amounts to <25 % (all levels). A bleeding history (35 %, all levels), laboratory coagulation tests (29 %, all levels) as well as viscoelastic point-of-care coagulation tests (42 %, mainly level 3) are limited in their availability. Blood loss is usually estimated (99 %, all levels), not measured. Tranexamic acid (>80 %, all levels), fibrinogen (>60 %, all levels) and fresh frozen plasma (FFP) (30 %, level 2a) are first line therapeutics. In level 2b and 3 FFP is a second line therapeutic. RBC transfusion is indicated at haemoglobin <5-7 g/dl (57-69 %, all levels), while 15-29 % in level 3 did not base their decision to transfuse RBC on haemoglobin only. CONCLUSIONS: Guideline-consistent haemostatic management of PPH is provided in almost all hospitals independent of the perinatal care level. Deviances from guidelines (measuring blood loss, bleeding history of the patient) affect all levels of perinatal care in Germany.

[Tranexamic acid in the German emergency medical service : A national survey]. / Vorhaltung von Tranexamsäure im deutschen Rettungsdienst : Eine nationale Umfrage.

BACKGROUND: Trauma-induced coagulopathy, one of the leading causes of trauma-related death, is detected in about one of four trauma patients upon hospital admission. The current European Management of Major Bleeding and Coagulopathy Following Trauma guidelines, published in 2013, recommend that tranexamic acid (TXA) be administered as early as possible to inhibit hyperfibrinolysis (grade of recommendation (GoR 1A)). Furthermore, it is suggested that protocols for the management of patients with bleeding or showing signs of bleeding include the administration of the first dose of TXA at the site of injury or during transportation to hospital (GoR 2C). There is no current data showing to what extent TXA is used in the pre-hospital settings in Germany. OBJECTIVES: This study aimed to collect data about the availability of TXA in the German emergency medical service (EMS). We tried to determine how many EMS stored and used TXA, under which circumstances the substance was used and whether any standard operating procedures (SOPs) were in use. The study also tried to determine what dosage recommendations exist. MATERIALS AND METHODS: Between 1 July and 31 August 2015, a total of 326 German emergency medical directors (EMDs) were asked to take part in a survey, which involved answering an online questionnaire. RESULTS: Altogether 163 EMD answered the questionnaire (response rate 50%). The results showed that 52.8% of EMDs stored TXA in their vehicles and 26% planned to do so in the future. The availability of TXA in the EMS has increased since 2010. Most EMDs stated that guidelines were the reason for this. SOPs existed in 17.4%. Dosage recommendations were defined by the EMDs in 76.7%. More than 80% of dosage recommendations followed the European guideline. CONCLUSION: The survey shows a widespread distribution of TXA in the German EMS, which has significantly increased between 2010 and 2015. However, nationwide distribution has not yet been established. This rise in distribution is interpreted as a reaction to national and European guidelines for the management of severe bleeding and trauma care. A remaining question is to determine which patients should be treated with TXA, as hyperfibrinolysis is not detectable at the site of injury.

[Radiation therapy in patients with cardiac pacemakers or implantable cardioverter defibrillators. Interdisciplinary safety recommendations]. / Strahlentherapie bei Patienten mit Herzschrittmachern oder implantierbaren Kardioverter-Defibrillatoren. Interdisziplinäre Sicherheitsempfehlungen.

BACKGROUND: With increasing numbers of implanted pacemakers and implantable cardioverter defibrillators (ICD) and a rising incidence of malignant tumors, there is a growing probability of radiation-mediated device dysfunction. The only guidelines for the management of patients with cardiac pacemakers in the case of radiation therapy were published in 1994 and have not been updated since then. Based on the current evidence and modern device technology, the present paper aims to develop contemporary and interdisciplinary safety recommendations for the minimization of patient risk. METHODS AND RESULTS: A systematic literature research was carried out including the most relevant medical electronic databases. The search yielded 147 articles published between 1994 and 2012 of which 45 met the selection criteria and of these studies 34 presented primary data (9 in vitro and 25 in vivo studies). The impact of ionizing radiation varied significantly between implanted devices and ranged from no functional changes to complete loss of function. Important device dysfunctions included changes in sensing capability, altered pacing pulses or rate, changed or disabled tachyarrhythmia ICD therapies, early battery depletion and loss of telemetry. Modern pacemakers and ICDs are more sensitive to radiation than older models. Potentially life-threatening complications were observed after exposure of the pulse generator to comparatively low radiation doses (0.11 Gy). CONCLUSIONS: Practical recommendations for patient management and safety are presented that can be readily adopted by any institution carrying out radiation therapy.

[Peripartum hemorrhage, diagnostics and treatment : Update of the S2k guidelines AWMF 015/063 from August 2022]. / Peripartale Blutungen, Diagnostik und Therapie : Update der S2k-Leitlinie AWMF 015/063 vom August 2022.

The current S2k guidelines on the diagnostics and treatment of peripartum hemorrhage are summarized in this article from the perspective of anesthesiology based on a fictitious case report. The update of the guidelines was written under the auspices of the German Society of Gynecology and Obstetrics with the participation of other professional societies and interest groups from Germany, Austria and Switzerland and published by the AWMF in 2022 under the register number 015/063.

[Preoperative anemia in orthopedic surgery: clinical impact, diagnostics and treatment]. / Präoperative Anämie in der Orthopädie: Klinische Relevanz, Diagnostik und Therapie.

In a national audit of elective orthopedic surgery conducted in the US, 30% of patients were found to have hemoglobin (Hgb) levels < 13 g/dl at preadmission testing. Preoperative anemia has been associated with increased mortality and morbidity after surgery, increased allogeneic blood transfusion therapy and increased rates of postoperative infection leading to a longer length of hospital stay. Because of the risks associated with allogeneic blood transfusions according to German law patients have to be offered the option of autologous transfusion if the risk associated with allogeneic blood transfusion is > 10%. However, one of these measures, the autologous blood donation, can exaggerate anemia and can increase the overall transfusion rates (allogeneic and autologous). As autologous procedures (autologous blood donation and cell salvage) are not always appropriate for anemic patients together with an expected shortage of blood and because preoperative anemia is associated with perioperative risks of blood transfusion, a standardized approach for the detection, evaluation and management of anemia in this setting was identified as an unmet medical need. A panel of multidisciplinary physicians was convened by the Society for Blood Management to develop a clinical care pathway for anemia management in elective surgery patients for whom blood transfusion is an option. In these guidelines elective surgery patients should have Hgb level determination at the latest 28 days before the scheduled surgical procedure. The patient target Hgb before elective surgery should be within the normal range (normal female ≥ 120 g/l, normal male ≥ 130 g/l). Laboratory testing should take place to further determine nutritional deficiencies, chronic renal insufficiency and/or chronic inflammatory diseases. Nutritional deficiencies should be treated and erythropoiesis-stimulating agent (ESA) therapy should be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected.

[Perioperative anesthesia management of extended partial liver resection. Pathophysiology of hepatic diseases and functional signs of hepatic failure]. / Perioperatives anästhesiologisches Management bei ausgedehnten Leberteilresektionen. Pathophysiologie der Lebererkrankungen und funktionelle Zeichen des Leberversagens.

The importance of partial liver resection as a therapeutic option to cure hepatic tumors has increased over the last decades. This has been influenced on the one hand by advances in surgical and anesthetic management resulting in a reduced mortality after surgery and on the other hand by an increased incidence of hepatocellular carcinoma. Nowadays, partial resection of the liver is performed safely and as a routine operation in specialized centers. This article describes the pathophysiological changes secondary to liver failure and assesses the perioperative management of patients undergoing partial or extended liver resection. It looks in detail at the preoperative assessment, the intraoperative anesthetic management including fluid management and techniques to reduce blood loss as well as postoperative analgesia and intensive care therapy.

Central area for induction of anesthesia and job satisfaction.

A central area for induction of anesthesia (CAIA) is supposed to optimize processes of preoperative patient preparation for anesthesia. The purpose of this study was to assess whether the separation of the anesthesia process into anesthesia induction and anesthesia maintenance is associated with residents' job satisfaction. The central area for induction of anesthesia model (CAIA model) was prospectively compared to the conventional model of anesthesia being induced, maintained and ended by the same anesthetist. Quality of senior staff supervision for each day as well as workday satisfaction was additionally graded by a Likert-scale. More than 80% of residents considered their workday as satisfying or very satisfying, regardless of the model applied. Furthermore, work day satisfaction was significantly associated with the quality of supervision provided by the teaching staff. It was concluded that time and attention provided by the teaching staff rather than the anesthesia organisational model were the major determinants of workday satisfaction.

Clinical relevance of measuring colonic permeability.

BACKGROUND: Gastroduodenal and small intestinal permeability are increased in patients with Crohn's disease (CD) and intensive care patients. The relevance of colonic permeability has not yet been adequately investigated. The aim of this study was to investigate the clinical value of sucralose excretion as indicator for colonic permeability in these patient groups. DESIGN: After oral administration of four sugars and subsequent analysis of urinary excretion, gastroduodenal and intestinal permeability were calculated from saccharose excretion and lactulose/mannitol (L/M) ratio over 5 h, and sucralose excretion from 5 to 26 h in 100 healthy controls, 29 CD and 35 patients after coronary surgery (CABG). RESULTS: In controls, sucralose excretion was highly variable (0.67+/-0.92%) and not related to small intestinal permeability. In CD and CABG, L/M ratio was increased (0.054+/-0.060; 0.323+/-0.253 vs. 0.018+/-0.001 in controls). Sucralose excretion was increased in 77% of CABG but only in 7% of CD. There was an association between gastroduodenal and intestinal permeability in CD and CABG (r=0.72, and r=0.51), but sucralose excretion was not related to either one of these two parameters. Other than a weak association between sucralose and length of stay in intensive care in CABG patients (P=0.099), sucralose excretion was not related to clinical outcome. CONCLUSIONS: The proposed cut-off for normal sucralose excretion is 2.11%, but its high variability and lack of association to gastrointestinal permeability or clinical outcome leave it open, if it can provide information beyond established permeability tests.

Profound haemodilution during normothermic cardiopulmonary bypass influences neither gastrointestinal permeability nor cytokine release in coronary artery bypass graft surgery.

BACKGROUND: Cardiopulmonary bypass (CPB) impairs intestinal barrier function and induces systemic inflammation after cardiac surgery. The objective of this study was to evaluate the effect of profound haemodilution (haematocrit 19-21%) during normothermic CPB on gastrointestinal permeability and cytokine release in comparison with a standard haemodilution (haematocrit 24-26%). METHODS: This was a prospective, controlled, randomized pilot trial of 60 patients without gastrointestinal disease undergoing normothermic CPB (35.5-36 degrees C) for coronary artery bypass graft surgery. Gastrointestinal permeability was measured by the triple-sugar technique (sucrose, lactulose, and mannitol excretion in urine) before and after CPB. Interleukin (IL)-6, IL-10, and tumour necrosis factor alpha (TNFalpha) were quantified using enzyme-linked immunosorbent assays. RESULTS: Data from 59 patients (19-21% haematocrit, n=28; 24-26% haematocrit, n=31) were analysed. Data on gastrointestinal permeability were available for 47 patients (19-21% haematocrit, n=23; 24-26% haematocrit, n=24), blood samples for cytokine analysis from 59 patients. Mannitol excretion was normal before and after surgery without significant differences between the groups (after operation: 5.4% vs 2.9%, P=0.193). Lactulose and sucrose excretion was within a normal range before surgery and increased afterwards without differences between the groups. IL-6, IL-10, and TNFalpha were elevated after surgery, but there was no difference between the groups [IL-6 (P=0.78), IL-10 (P=0.74), and TNFalpha (P=0.67)]. CONCLUSIONS: Profound haemodilution during normothermic CPB brought about significant changes neither in intestinal permeability nor in cytokine release. It may be concluded that a haematocrit of 19-21% during normothermic CPB does not impair intestinal barrier function and cytokine response in patients without gastrointestinal comorbidity.