Recommendations for blood sampling in emergency departments from the European Society for Emergency Medicine (EUSEM), European Society for Emergency Nursing (EuSEN), and European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase. Executive summary.

AIM: Blood Sampling Guidelines have been developed to target European emergency medicine-related professionals involved in the blood sampling process (e.g. physicians, nurses, phlebotomists working in the ED), as well as laboratory physicians and other related professionals. The guidelines population focus on adult patients. The development of these blood sampling guidelines for the ED setting is based on the collaboration of three European scientific societies that have a role to play in the preanalytical phase process: EuSEN, EFLM, and EUSEM. The elaboration of the questions was done using the PICO procedure, literature search and appraisal was based on the GRADE methodology. The final recommendations were reviewed by an international multidisciplinary external review group. RESULTS: The document includes the elaborated recommendations for the selected sixteen questions. Three in pre-sampling, eight regarding sampling, three post-sampling, and two focus on quality assurance. In general, the quality of the evidence is very low, and the strength of the recommendation in all the questions has been rated as weak. The working group in four questions elaborate the recommendations, based mainly on group experience, rating as good practice. CONCLUSIONS: The multidisciplinary working group was considered one of the major contributors to this guideline. The lack of quality information highlights the need for research in this area of the patient care process. The peculiarities of the emergency medical areas need specific considerations to minimise the possibility of errors in the preanalytical phase.

The preanalytical process in the emergency department, a European survey.

OBJECTIVES: Clinical decision-making in emergency medicine is under constant pressure from demand and performance requirements, with blood tests being a fundamental part of this. However, the preanalytical process has received little attention. Therefore, this study aimed to investigate the quality of preanalytical phase processes in European emergency departments (EDs) from the perspectives of the three main providers: clinicians, nurses, and laboratory specialists. METHODS: This online survey, distributed among European EDs and laboratories, was supported by the European Society for Emergency Nursing (EUSEN), European Society for Emergency Medicine (EuSEM), and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM). The size of the centres, the European region, the responder's profession and the country's economic condition were used as co-variables. RESULTS: We included 376 responses from all ED-related professions from 306 European centres. In 66.9% of all ED visits, at least one blood test was performed. Tests were requested mostly by nurses (44.6%) using electronic Order/Entry systems (65.4%). Only a minority (19%) reported not using laboratory quality indicators (QIs). Most responders defined the TAT starting point "when the laboratory receives the sample" (66.1%), defining the goal to be "less than 60 min" (69.9%), but only 42.4% of the centres estimated achieving this goal. CONCLUSIONS: Our survey illustrates the current situation on preanalytical blood sample processing in European EDs from the clinical and laboratory perspectives. The results emphasise the importance of the IT infrastructure and QI usage in this process and highlight some differences between European regions.

Angiotensin II-mediated nondipping during sleep in healthy humans: effects on baroreflex function at subsequent daytime.

Blood pressure dipping at night is mediated by sleep-inherent, active downregulation of sympathetic vascular tone. Concomitantly, activity of the renin-angiotensin system is reduced, which might contribute to the beneficial effect of baroreflex downward resetting on daytime blood pressure homeostasis. To evaluate whether experimental nondipping mediated by angiotensin II during sleep would alter blood pressure and baroreflex function the next day in healthy humans, angiotensin-II or placebo (saline) was infused for a 7-h period at night, preventing blood pressure dipping in 11 sleeping normotensive individuals (5 males, balanced, crossover design). Baroreflex function was assessed about 1 h upon awakening and stop of infusion via microneurographic recordings of muscle sympathetic nerve activity (MSNA), showing that resting MSNA was significantly increased following angiotensin II nondipping compared with placebo (P = 0.029), whereas blood pressure and heart rate remained unchanged. Baroreflex sensitivity in response to vasoactive drug challenge was preserved, and neuroendocrine markers of fluid balance and electrolytes did not differ between conditions. Ambulatory blood pressure during subsequent daytime was not altered. Data were compared with analog experiments previously performed within the same subjects during awake daytime (ANCOVA). We conclude that angiotensin-II mediated nocturnal nondipping did not induce blood pressure elevation at subsequent daytime in healthy humans but was linked to increased vasoconstrictive sympathetic activity. This is in contrast to a prolonged increase in blood pressure in corresponding daytime experiments of the same individuals. Evidently, sleep strongly preserves normotensive blood pressure homeostasis in healthy humans.

[Analysis of Treatment Figures in the Munich Emergency Rooms 2013-2014]. / Analyse der Behandlungszahlen in den Münchener Notaufnahmen des Jahres 2013/2014.

Medical care provided at the hospital emergency rooms in Germany has hardly been explored. On the occasion of restructuring the Municipal Hospital, the Munich City Council initiated the "Round Table Emergency Care" in order to determine reference figures for capacity planning. The present study was designed to analyze treatment data from 14 emergency departments which mainly carry the city's hospital emergency service. For inpatient cases, data were used in accordance with §21 Hospital Charges Act, for outpatient cases - as far as available - similar data were used, anonymized and combined with data from prehospital emergency medical services (EMS). In order to describe the domains treatment urgency, diagnostic/therapeutic effort and bed requirements, data were categorized in a 4-stage system. Over 12 months, 524,716 treatment cases were recorded: 34% were admitted to hospital, 80% came without EMS. One in 7 patients who independently went to an emergency room needed a bed in the intensive care or intermediate care unit (ICU/IMC). There were 64 cases per day and per 100,000 inhabitants requiring 7 ICU/IMC and 15 regular ward beds. Most cases (66%) were treated as outpatients and presented to the hospital's emergency department at times when facilities of the ambulatory care system would have been available. Urgency of these cases was usually low (50.9%), but effort was often high, due to diagnostics and surgical procedures. This study offers fundamental knowledge for planning emergency care. A large proportion of the presentations, especially those with injuries and those with diagnosis that require a more differentiated work-up, seem to be medically justified, which is why appropriate capacities have to be planned in. The study also shows that capacity planning on the basis of EMS cases alone is an inappropriate, one-sided approach.

Prolonged blood pressure elevation following continuous infusion of angiotensin II-a baroreflex study in healthy humans.

ANG II interacts with the sympathetic nervous system at central nervous blood pressure-regulating structures, including the baroreflex. It is unknown whether prolonged BP elevation mediated by high ANG II plasma levels could induce a persistent shift of the central nervous baroreflex setpoint, lasting beyond the short ANG II plasmatic half time of a few seconds, thereby consolidating elevated BP and/or increased SNA in healthy humans. In a blinded crossover design, ANG II or placebo (saline) was infused for a 6-h period in 12 resting normotensive students (6 males, 6 females) raising BP to borderline hypertensive levels. Between 60 and 120 min after the infusion period, muscle sympathetic nerve activity (MSNA) was assessed microneurographically and correlated with oscillometric BP measurements and heart rate at supine rest (baseline) and during pharmacologic baroreceptor challenge. Infusion of ANG II increased BP to borderline-hypertensive levels, as intended, whereas heart rate remained unaltered. At baroreflex assessment (i.e., 60-120 min after end of infusion period), systolic BP was significantly higher compared with placebo (Δ8.4 ± 3.1 mmHg; P < 0.05), whereas diastolic values were nearly equal between conditions. Baseline MSNA was neither decreased nor increased, and baroreflex sensitivity to vasoactive drug challenge was not altered. Our results show that elevation of ANG II plasma levels over 6 h was able to increase systolic, but not diastolic, BP far beyond blood-mediated ANG II effects. MSNA or heart rate did not counter-regulate this BP elevation, indicating that ANG II had sustainably reset the central nervous BP threshold of sympathetic baroreflex function to accept elevated BP input signals without counter-regulatory response.

How to diagnose hepatic encephalopathy in the emergency department.

INTRODUCTION: Blood ammonia-measurements are often performed in the emergency departments to diagnose or rule out hepatic encephalopathy (HE). However, the utility and correct interpretation of ammonia levels is a matter of discussion. At this end the present prospective study evaluated whether blood ammonia levels coincide with HE which was also established by the West Haven criteria and the critical flicker frequency, respectively. MATERIAL AND METHODS: In 59 patients with known cirrhosis ammonia-levels were determined and patient were additionally categorized by the West-Haven criteria and were also evaluated psychophysiologically using the critical flicker frequency, CFF for the presence of HE. RESULTS: When false positive and false negative results were collapsed the determination of blood ammonia levels alone resulted in 40.7% in a misdiagnoses of HE compared to the West-Haven criteria (24/59 when using West-Haven criteria, 95% confidence interval [CI], 28.1% to 54.3%) and 49.2% when compared with the results of the CFF (29/59, when using CFF, 95% CI, 35.9% to 62.5%). DISCUSSION: Ammonia blood levels do not reliably detect HE and the determination of blood ammonia can not be regarded a useful screening test for HE. Its use as sole indicator for a HE in the Emergency Department may frequently result in frequent misinterpretations.

Ghrelin modulates baroreflex-regulation of sympathetic vasomotor tone in healthy humans.

Ghrelin, a neuropeptide originally known for its growth hormone-releasing and orexigenic properties, exerts important pleiotropic effects on the cardiovascular system. Growing evidence suggests that these effects are mediated by the sympathetic nervous system. The present study aimed at elucidating the acute effect of ghrelin on sympathetic outflow to the muscle vascular bed (muscle sympathetic nerve activity, MSNA) and on baroreflex-mediated arterial blood pressure (BP) regulation in healthy humans. In a randomized double-blind cross-over design, 12 lean young men were treated with a single dose of either ghrelin 2 µg/kg iv or placebo (isotonic saline). MSNA, heart rate (HR), and BP were recorded continuously from 30 min before until 90 min after substance administration. Sensitivity of arterial baroreflex was repeatedly tested by injection of vasoactive substances based on the modified Oxford protocol. Early, i.e., during the initial 30 min after ghrelin injection, BP significantly decreased together with a transient increase of MSNA and HR. In the course of the experiment (>30 min), BP approached placebo level, while MSNA and HR were significantly lower compared with placebo. The sensitivity of vascular arterial baroreflex significantly increased at 30-60 min after intravenous ghrelin compared with placebo, while HR response to vasoactive drugs was unaltered. Our findings suggest two distinct phases of ghrelin action: In the immediate phase, BP is decreased presumably due to its vasodilating effects, which trigger baroreflex-mediated counter-regulation with increases of HR and MSNA. In the delayed phase, central nervous sympathetic activity is suppressed, accompanied by an increase of baroreflex sensitivity.

Critical Care Providers' Moral Distress: Frequency, Burden, and Potential Resources.

BACKGROUND: Critical Care Providers (CCPs) experience situations that challenge their ethics and professional standards and may entail moral distress (MD). AIM: To analyze MD perceived by CCPs in intensive care units (ICUs) or emergency departments (EDs) and further clarify whether CCPs who rely on spiritual resources differ in their perception of MD from those who do not utilize these resources. METHODS: A cross-sectional anonymous survey was administered using a modified version of the German language version of the Moral Distress Scale (MDS) with 2 × 12 items to assess the frequency and the respective perceived burden of specific situations by applying a 5-point Likert scale. Explorative factor analysis was performed and the sub-constructs of the respective items regarding MD frequency and burden were identified. Job burden and professional satisfaction were measured using visual analogue scales (VAS) and a four-point Likert scale, respectively. The 15-item SpREUK questionnaire was applied to measure spiritual attitudes and behaviours and to differentiate between religious and spiritual persons. Data from 385 German-speaking CCPs were included (55% physicians, 45% nurses). RESULTS: Conflict situations are similar for physicians and nurses although they are perceived as more burdensome by nurses. Among physicians, the MDS factor Looking away/Resignation scores highest for assistant physician residents, whereas distress caused by looking away is more often perceived by specialist physicians without a managerial position. Work satisfaction is inversely associated with MD and emotional exhaustion is positively associated with it. Participants' spirituality is marginally associated with MD. The best predictors of both MD frequency and burden are emotional exhaustion with further influences of work satisfaction, being a nurse, and being a non-believer on the frequency of MD perception. Being a nurse, participants' experience in ICU/ED, and being of the male gender are further predictors of MD burden. CONCLUSIONS: MD is experienced differently by different groups of CCPs depending on their place in the hierarchy of responsibility. As MD perception is best predicted by emotional exhaustion, these situations should be avoided. Although some CCPs may rely on spiritual resources, all need individual and team support to cope with MD.

Effects of selective slow-wave sleep deprivation on nocturnal blood pressure dipping and daytime blood pressure regulation.

Nocturnal blood pressure (BP) decline or "dipping" is an active, central, nervously governed process, which is important for BP regulation during daytime. It is, however, not known whether the sleep process itself or, more specifically, slow-wave sleep (SWS) is important for normal dipping. Therefore, in the present study, healthy subjects (6 females, 5 males) were selectively deprived of SWS by EEG-guided acoustic arousals. BP and heart rate (HR) were monitored during experimental nights and the following day. Additionally, nocturnal catecholamine excretion was determined, and morning baroreflex function was assessed by microneurographic measurements of muscle sympathetic nerve activity (MSNA) and heart rate variability (HRV). Data were compared with a crossover condition of undisturbed sleep. SWS was successfully deprived leading to significantly attenuated mean arterial BP dipping during the first half (P < 0.05), but not during the rapid-eye-movement-dominated second half of total sleep; however, dipping still evolved even in the absence of SWS. No differences were found for nighttime catecholamine excretion. Moreover, daytime resting and ambulatory BP and HR were not altered, and morning MSNA and HRV did not differ significantly, indicating that baroreflex-mediated sympathoneural BP regulation was not affected by the preceding SWS deprivation. We conclude that in healthy humans the magnitude of nocturnal BP dipping is significantly affected by sleep depth. Deprivation of SWS during one night does not modulate the morning threshold and sensitivity of the vascular and cardiac baroreflex and does not alter ambulatory BP during daytime.

[Presence and future of emergency medicine in Germany]. / Professionalisierung der klinischen Notfallmedizin - Gegenwart und Zukunft.

Health care policy has changed duties and responsibilities of hospitals in Germany. The transition zone of in- and outpatient care has been recognized as a critical gateway for the success of hospitals, subsequently leading to the appreciation of the value of professionalized emergency departments. Currently, hospital-based emergency medicine in Germany is organized in a very heterogeneous manner. Due to the key function of emergency departments for the medical and economic success of hospitals, professional expertise in clinical emergency medicine has to be strengthened: We discuss possible models of hospital-based emergency care and present first data that professionalisation of hospital-based emergency medicine in Germany improves treatment quality and outcome of patients presenting with chest-pain or community-acquired pneumonia to the emergency department. Furthermore, those strategies are accompanied with the improvement of economic characteristics. Summing up, professionalisation of hospital-based emergency medicine in Germany is urgently needed and may improve medical and economic success of hospital-based patient care.

Attributes of analgesics for emergency pain relief: results of the Consensus on Management of Pain Caused by Trauma Delphi initiative.

OBJECTIVES: Management of pain is suboptimal in many prehospital and emergency department settings, and European guidelines are lacking. We carried out the Consensus On Management of PAin Caused by Trauma (COMPACT) Delphi initiative to gain insights into the factors physicians consider important when selecting analgesics for trauma pain. PATIENTS AND METHODS: A pan-European panel of experts in emergency medicine or pain (N = 31) was recruited to participate in the COMPACT Delphi initiative. In round 1, panelists supplied free-text responses to an open question about the attributes of analgesics for emergency pain relief favored by physicians. Common themes were consolidated into factors. In round 2, factors rated important by more than 75% of the panel were taken forward into round 3. In round 3, the point at which the consensus was achieved was defined a priori as at least 75% of panelists agreeing or strongly agreeing that a factor was important. RESULTS: Twenty-nine experts participated, representing 12 European countries and with a mean (SD) of 20 (8.6) years of clinical experience. Most worked in an emergency department (79.3%). The consensus was achieved for 10 factors that were important to consider when selecting analgesics for trauma pain relief. The highest level of consensus was achieved for 'efficacy' (100%), followed by 'safety and tolerability' (96.6%), and 'ease of use' (93.1%). CONCLUSION: These findings may facilitate the development of evidence-based guidelines supporting the provision of pain management in prehospital, emergency department, and critical care settings.

European Society For Emergency Medicine position paper on emergency medical systems' response to COVID-19.

The 2019 novel coronavirus acute respiratory epidemic is creating a stressed situation in all the health systems of the affected countries. Emergency medical systems and specifically the emergency departments as the front line of the health systems are suffering from overload and severe working conditions, the risk of contagion and transmission of the health professionals adds a substantial burden to their daily work. Under the perspective of European Society For Emergency Medicine, the recommendations provided by the health authorities are reviewed focus on the emergency department's activity.

[Noninvasive ventilation]. / Nichtinvasive Beatmung.

Every dyspnea is a medical emergency which affords urgent treatment. In cases of an acute exacerbation of a chronic obstructive lung disease an early trial with noninvasive ventilation is recommended to avoid further deterioration which might result in intubation and invasive ventilation. In this disease invasive ventilation induces a considerably higher mortality than noninvasive ventilation. Such clear effects on mortality can not be observed in dyspnoea due to pulmonary edema in cardiac failure. However, symptoms of this disease are faster resolved by the application of positive airway pressure either through the use of chronic positive airway pressure (CPAP) or positive endexpiratory pressure (PEEP) together with pressure support using noninvasive ventilation. Thus, noninvasive ventilation has an important place in the emergency treatment in many cases of dyspnea.

European Society of Emergency Medicine position paper on the 1-hour sepsis bundle of the Surviving Sepsis Campaign: expression of concern.

In 2018 the Surviving Sepsis Campaign issued new guidance with a revised version of their sepsis bundle. Instead of the 2016 3-hour sepsis bundle, the Surviving Sepsis Campaign now recommends that blood cultures, lactate measurement, broad-spectrum antibiotic therapy and 30 ml/kg crystalloid fluid administration should be initiated within 1 hour after triage. The European Society of Emergency Medicine wishes to express its concerns regarding the low level of evidence that underlies this guidance, and the potential implications from an emergency physician point of view.

Sleep-stage-specific regulation of plasma catecholamine concentration.

The catecholaminergic system is critically involved in the regulation of sleep, wake and arousal states. In the central nervous system, sleep is characterized by low levels of norepinephrine compared to wakefulness, reaching minimum levels during rapid eye movement (REM) sleep. It is not yet clear whether blood catecholamine concentrations (as a measure of sympathetic activity in the body periphery) show a similar sleep stage-dependent decline or depend mainly on a circadian rhythm. Here, we show that during sleep in humans, plasma concentrations of norepinephrine (NE) and epinephrine (E) exhibit a progressive decline associated with the stage of sleep, irrespective of the circadian time of sleep. In a within-subject design, healthy men (n=12) slept for 7h either during daytime or nighttime. Sleep was framed by 3-h periods of wakefulness during which subjects rested in a supine position. We sampled blood at a fast rate (1/10 min) and monitored blood pressure and heart rate continuously. Plasma catecholamine concentrations distinctly declined in a linear fashion as sleep deepened, reaching a minimum during REM sleep both during daytime and nighttime sleep. Diverging from this pattern, cardiovascular parameters indicated lowest blood pressure and heart rate during slow wave sleep (SWS), whereas during REM sleep activity increased almost to waking levels. Because the changes observed here in human blood catecholamine levels closely mimic the changes in brain catecholamine activity, as well-documented in animals, we suggest that the organism's overall catecholamine activity during sleep is well represented by measures of plasma catecholamine concentrations.