[Prehospital management of acute coronary syndrome in patients on long-term direct oral anticoagulant treatment]. / Prähospitale Behandlung des akuten Koronarsyndroms unter DOAK-Dauertherapie.

BACKGROUND: Despite an increasing incidence of patients suffering from acute coronary syndrome (ACS) under simultaneous treatment with direct oral anticoagulants (DOAC), neither sufficient scientific data nor uniform guidelines for the anticoagulation treatment of these patients are currently available. OBJECTIVE: The aim of this study was to determine the current practice of preclinical treatment of ACS in patients under DOAC treatment. MATERIAL AND METHODS: An internet and paper-based survey of emergency physicians, specialists of internal medicine, anesthesiologists, emergency and intensive care physicians was performed concerning the prehospital treatment of ACS in patients under long-term DOAC treatment. RESULTS: Overall, 284 questionnaires were answered. Substantial differences in the current treatment of ACS under long-term DOAC therapy were identified. While 39% of the respondents stated that they administer a combination treatment of heparin and acetylsalicylic acid (ASA), 36% renounced the administration of heparin. If a dose reduction was performed, 71% answered that they reduce the heparin dosage. Also, in cases of ST-segment elevation myocardial infarction 48% of the physicians renounced the administration of heparin. CONCLUSION: In Germany there is currently a heterogeneous practice of emergency treatment of ACS patients under DOAC therapy with respect to the administration of heparin and ASA. Therefore, guidelines of the specialist medical societies should address the prehospital emergency anticoagulation management of ACS in patients under therapy with DOAC, which correspond to the needs of patients and emergency physicians.

Influence of Covid-19 disease on hemostasis dynamics during extracorporeal membrane oxygenation (ECMO)1.

INTRODUCTION: COVID-19 causes a considerable degradation of pulmonary function to the point of an acute respiratory distress syndrome (ARDS). Over the course of the disease the gas exchange capability of the lung can get impaired to such an extent that extracorporeal membrane oxygenation (ECMO) is needed as a life-saving intervention. In patients COVID-19 as well as ECMO may cause severe coagulopathies which manifest themselves in micro and macro thrombosis. Previous studies established D-dimers as a marker for critical thrombosis of the ECMO system while on admission increased D-dimers are associated with a higher mortality in COIVD-19 patients. It is therefore crucial to determine if COVID-19 poses an increased risk of early thrombosis of the vital ECMO system. METHODS: 40 patients who required ECMO support were enrolled in a retrospective analysis and assigned into 2 groups. The COVID group consist of 20 COVID-19 patients who required ECMO support (n = 20), whereas 20 ECMO patients without COVID-19 were assigned to the control group. D-dimers, fibrinogen, antithrombin III (AT III), lactate dehydrogenase (LDH) and platelet count were analysed using locally weighted scatterplot smoothing and MANOVAs. RESULTS: The analysis of both groups shows highly significant differences in the dynamics of hemostasis. The increase in D-dimers that is associated with thrombosis of the ECMO systems occurs in COVID-19 patients around 2 days earlier (p = 2,8115 10-11) while fibrinogen is consumed steadily. In the control group fibrinogen levels increase rapidly after ten days with a plateau phase of around five days (p = 1,407 10-3) . Both groups experience a rapid increase in AT III after start of support by ECMO (p = 5,96 10-15). In the COVID group platelet count decreased from 210 giga/l to 130 giga/l within eight days, while in the same time span in the control group platelets decreased from 180 giga/l to 105 giga/l (p = 1,1 10-15). In both groups a marked increase in LDH beyond 5000 U/l occurs (p = 3,0865 10-15). CONCLUSION: The early increase in D-dimers and decrease in fibrinogen suggests that COVID-19 patients bear an increased risk of early thrombosis of the ECMO system compared to other diseases treated with ECMO. Additionally, the control group shows signs of severe inflammation 10 days after the start of ECMO which were absent in COVID-19 patients.

[Scoring systems in intensive care medicine : principles, models, application and limits]. / Scoring-Systeme in der Intensivmedizin : Grundlagen, Modelle, Anwendung und Grenzen.

Scoring systems are used in all diagnostic areas of medicine. Several parameters are evaluated and rated with points according to their value in order to simplify a complex clinical situation with a score. The application ranges from the classification of disease severity through determining the number of staff for the intensive care unit (ICU) to the evaluation of new therapies under study conditions. Since the introduction of scoring systems in the 1980's a variety of different score models has been developed. The scoring systems that are employed in intensive care and are discussed in this article can be categorized into prognostic scores, expenses scores and disease-specific scores. Since the introduction of compulsory recording of two scoring systems for accounting in the German diagnosis-related groups (DRG) system, these tools have gained more importance for all intensive care physicians. Problems remain in the valid calculation of scores and interpretation of the results.

Hypotension after spinal anesthesia for cesarean section: identification of risk factors using an anesthesia information management system.

OBJECTIVE: To determine risk factors for developing hypotension after spinal anesthesia for cesarean section to prevent obstetric patients from hypotensive episodes potentially resulting in intrauterine malperfusion and endangering the child. METHODS: The data from 503 women, having received spinal anesthesia for cesarean sections were investigated using online gathered vital signs and specially checked manual entries employing an anesthesia information management system. Blood pressure, heart rate, and oxygen saturation were measured throughout and hypotension was defined as either a drop in mean arterial blood pressure of >20% from baseline value or readings of <90 mmHg systolic arterial blood pressure. Thirty-two variables were studied for association with hypotensive episodes using univariate analysis and logistic regression employing a forward stepwise algorithm to identify independent variables (P < 0.05). RESULTS: Hypotension was found in 284 cases (56.5%). The univariate analysis identified the neonate's weight, mother's age, body mass index, and peak sensory block height associated with hypotension. Body mass index, age and sensory block height were detected as independent factors for hypotension (odds-ratio: 1.61 each). CONCLUSIONS: Knowledge of these risk factors should increase the anesthesiologist's attention to decide for the necessity to employ prophylactic or therapeutic techniques or drugs to prevent the neonate from any risk resulting of hypotension of the mother.

Impact of different sampling strategies on score results of the Nine Equivalents of Nursing Manpower Use Score (NEMS).

OBJECTIVE: Prospective observational study to assess the impact of two different sampling strategies on the score results of the NEMS, used widely to estimate the amount of nursing workload in an ICU. METHODS: NEMS scores of all patients admitted to the surgical ICU over a one-year period were automatically calculated twice a day with a patient data management system for each patient day on ICU using two different sampling strategies (NEMS(individual): 24-hour intervals starting from the time of admission; NEMS(8 a.m.): 24-hour intervals starting at 8 a.m.). RESULTS: NEMS(individual) and NEMS(8 a.m.) were collected on 3236 patient days; 687 patients were involved. Significantly lower scores were found for the NEMS(8 a.m.) (25.0 +/- 8.7) compared to the NEMS(individual) (26.1 +/- 8.9, p < 0.01); the interclass correlation coefficient (ICC) was good but not excellent: 0.78. The inter-rater correlation between the two NEMS scores was high or very high (kappa = 0.6-1.0) for six out of nine variables of the NEMS. CONCLUSIONS: Different sampling strategies produce different score values, especially due to the end of stay. This has to be taken into account when using the NEMS in quality assurance projects and multi-center studies.

Examining the influence of maternal bradycardia on neonatal outcome using automated data collection.

BACKGROUND: Due to the increasing number of caesarean sections, we investigated the influence of maternal bradycardia during general and regional anaesthesia on seven standard paediatric outcome parameters using our online recorded data. METHODS: Data from 1154 women undergoing caesarean section were investigated prospectively. Bradycardia was defined as a heart rate below 60 beats/min. The matched-pairs method was used to evaluate the impact of bradycardia on Apgar scores at 1, 5, and 10 min, umbilical artery pH and base excess, admission to paediatric intensive care unit, and seven-day mortality. Matched references were automatically selected among all patients from the data pool according to anaesthetic technique, sensory block height, urgency, maternal age and body mass index. Stepwise regression models were developed to predict the impact of intra-operative bradycardia on outcome variables with differences between matched pairs assessed using univariate analysis. RESULTS: Bradycardia was found in 146 women (12.7%) for whom a control could be matched in 131 cases (89.7%). Mean 5-minute Apgar score was 9.2+/-1.1 for study patients and 9.3+/-1.1 for controls. pH and base excess were not significantly different between groups. In cases of urgent surgery, neonates had an increased risk of 1.8 (95% CI 1.36-2.44, P<0.01) for an Apgar score

LOINC in prehospital emergency medicine in Germany - experience of the `DIRK´-project.

BACKGROUND: Treatment of patients picked up by emergency services can be improved by data transfer ahead of arrival. Care given to emergency patients can be assessed and improved through data analysis. Both goals require electronic data transfer from the emergency medical services (EMS) to the hospital information system. Therefore a generic semantic standard is needed. OBJECTIVES: Objective of this paper is to test the suitability of the international nomenclature Logical Observation Identifiers Names and Codes (LOINC) to encode the core data-sets for rescue service protocols (MIND 2 and MIND 3). Encoding diagnosis and medication categories using ICD-10 and ATC were also assessed. METHODS: Protocols were broken down into concepts, assigned to categories, translated and manually mapped to LOINC codes. Each protocol was independently encoded by two healthcare professionals and in case of discrepancies a third expert was consulted to reach a consensus. RESULTS: Currently 39% of parameters could be mapped to LOINC. Additional use of other coding systems such as International Statistical Classification of Diseases and Related Health Problems (ICD-10) for diagnoses and Anatomical Therapeutic Chemical Classification System (ATC) for medications increases the rate of 'mappable' parameters to 56%. CONCLUSIONS: Although the coverage is low, mapping has shown that LOINC is suitable to encode concepts of the rescue services. In order to create a generic semantic model to be applied in the field our next step is to request new LOINC codes for the missing concepts.

Efficacy of inhaled iloprost in the management of pulmonary hypertension after cardiopulmonary bypass in infants undergoing congenital heart surgery. A case series of 31 patients.

INTRODUCTION: Reactive pulmonary hypertension is frequent in children with high pulmonary flow and pressure. Inhaled iloprost and nitric oxide are the only substances approved as selective pulmonary vasodilators, but data about the effectiveness and safety of inhaled iloprost during cardiac surgery in infants and children are limited. METHODS: We retrospectively analysed the effects of inhaled iloprost after cardiopulmonary bypass weaning on the ratio of mean pulmonary artery to mean arterial pressure. The effectiveness of the inhalation set up was tested in an in vitro study. RESULTS: Thirty-one patients received inhaled iloprost during surgery. The clinically used inhalation set up for inhaled iloprost delivered 20% to 30% (500 to 750 ng * kg-1) of the nebulizer dose and caused a decrease in the ratio of mean pulmonary artery to mean arterial pressure from 0.6±0.2 to 0.4±0.1 and 0.4±0.1 (30 and 60 minutes after)p <0.05. In eleven (35%) patients norepinephrine infusion was started. CONCLUSION: Our data suggest that a single dose of inhaled iloprost significantly decreases the ratio of mean pulmonary artery to mean arterial pressure for at least 60 min. Vasopressor support may be indicated to avoid systemic hypotension. The filled dose in the nebulizer should be high enough to compensate for the high depletion rate of the pediatric inhalation system. However, our study allows no final decision about beneficial or detrimental effects of the off label use of inhaled iloprost to reduce pulmonary artery pressure during congenital heart surgery.

[Scoring systems for daily assessment in intensive care medicine. Overview, current possibilities and demands on new developments]. / Intensivmedizinische Scoringsysteme zur täglichen Anwendung. Ubersicht, aktuelle Möglichkeiten und Anforderungen an Neuentwicklungen.

Scoring systems are a fixed element of modern diagnostics and are integrated in the diagnosis-related groups (DRG) billing system as well as quality assurance projects. The ongoing developments require classification according to the terms of use in order to maintain an overview of the numerous systems available. In the area of intensive care medicine scoring systems can be divided into admission scores and progress scores, whereby the scores for daily assessment can be further subdivided into five categories, depending on the target criteria: objective description of the grade of organ dysfunction, progression in intensive care therapy, evaluation of the degree of nursing care, determination of outcome/mortality risk, and grouping of patient collectives for clinical trials. In future developments it will be necessary to generate new strategies to adequately describe the progress of a patient. Not only will mortality be challenged as a target criterion but also the handling of missing data and the simplification of reality by categorization practised so far that can be found in all established scoring systems as far as calculation of predictive values regarding a defined result.

[Registration of material consumption in anesthesia using a data management system]. / Erfassung des Materialverbrauchs in der Anästhesie mit einem Datenmanagementsystem.

BACKGROUND: The aim of this study was to investigate whether an Anesthesia Information Management System (AIMS) can provide reliable data on the consumption of single-use anesthetic material without necessitating an expensive and time-consuming inventory. To this end, the number of selected anesthesia-related materials and the total costs in orthopedic theatres for which the department of anesthesia had been charged in the year 2000 were compared to the data calculated by the AIMS. METHODS: Anesthesia-related material is provided by a computer-based system of storage facilities (KLIMA II) in the Department of Anesthesiology and Intensive Care Medicine at the University Hospital Giessen. All costs arising in orthopedic theatres are exclusively charged to one single account. At the same time, the online-documentation software, NarkoData (IMESO GmbH, Hüttenberg, Germany), collects all data on consumption of anesthetic single-use material. The total amount of peripheral (PVC) and central-venous catheters (CVC), urinary catheters (UC) and endotracheal tubes (ET) used in the year 2000 was ascertained by the AIMS and compared to the respective data accounted by the administration. RESULTS: In the year 2000, the number of patients treated in orthopedic theatres totaled 1,865. By means of the AIMS, a consumption of 783 CVCs, 644 UCs and 949 ETs could be documented. In contrast, hospital administration had billed 880 CVCs, 700 UCs, and 1,050 ETs: discrepancies of 11.0 % for CVCs, 8.0 % for UCs and 9.6 % for ETs. Concerning the two most frequently used CVCs, the AIMS failed to document costs of 3,238 DM. For PVCs (16 gauge and 14 gauge), the official cost was 10.8 % and 46.7 % higher compared to the number documented by the AIMS. Since the number of PVCs totaled 3,400, the AIMS failed to document costs of 1,900 DM. CONCLUSION: Comparison of both methods revealed substantial deficits in documenting cost-relevant materials. There were no detailed data available on the whereabouts of the materials used, i.e. whether tubes and catheters were undocumented, used or discarded. However, the AIMS may provide additional valuable information about possible sources of material wastefulness. This is especially true for infrequently used anesthesia-related materials.