Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. CONCLUSION: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

Perioperative management of patients with gynecological cancers.

Oncological surgery is the primary treatment for gynecological malignancies and is inseparably linked with anesthesia. The modern approach to interdisciplinary and multidisciplinary perioperative care in gynecologic oncological patients improves the outcome. This paper presents a review of perioperative management of patients with gynecologic oncology related to enhanced recovery after surgery and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. We performed a literature search on MEDLINE, EMBASE, Google Scholar, the Cochrane Central Register of Controlled Trials, and Clinical Trials. The database search focused on selected topics related to perioperative gynecological oncology care. The authors also contributed through individual, independent literature searches.

Anesthesia for gynecological cancer surgery.

Malignant neoplasms are currently a severe medical challenge and the second leading cause of death worldwide. The modern anesthesia applied may improve the patient outcome. This paper presents a review of anesthesia management related to patients with gynaecologic malignancies. It includes the influence of the type of anesthesia on cancer recurrence, application of regional anesthesia in gynaecologic oncologic surgery, and selected aspects of anesthesia for robotic surgery. We performed a literature search on MEDLINE, EMBASE, Google Scholar, the Cochrane Central Register of Controlled Trials, and Clinical Trials. The database search focused on the topics related to anesthesia in gynecological oncology. The authors also contributed through individual, independent literature searches.

Possibilities of using open chest cardiac massage in sudden, non-traumatic cardiac arrest.

Cardiopulmonary resuscitation is one of the most studied procedures in medicine. Over the years, despite numerous scientific studies, changes in guidelines, refining algorithms, expanding the availability of resuscitation equipment and educating the public, it has not been possible to improve the results of treatment of patients after cardiac arrest. Only 10% of them survive until hospital discharge. There is a well-tested medical procedure, wide application of which could improve results of resuscitation. This procedure is open chest cardiac massage (OCCM). OCCM is not a new technique, its use dates back to the nineteenth century, now it is reserved for patients sustaining trauma and those after surgical procedures. A number of experimental and clinical studies have proven its advantage over the currently preferred indirect massage (CCCM) also in the group of non- traumatic patients. Of course, OCCM is an invasive method with a number of possible complications accompanying surgical procedures, and its wide implementation would require a long-term training program, but it seems that it could be an impulse that would significantly improve survival in this group of patients.

Do Epidural Catheter Size and Flow Rate Affect Bolus Injection Pressure in Different Programmed Intermittent Epidural Bolus Regimens? An In Vitro Study.

BACKGROUND: The optimal programmed intermittent epidural bolus regimen for labor analgesia remains unknown. Some studies indicate that better drug spread in the epidural space results from greater injection pressure; however, there is a lack of data regarding the maximum pressure generated by epidural bolus injection using different catheters and flow rates. METHODS: We evaluated the flow and pressure characteristics of 11 commonly used epidural catheters combined with 3 different infusion pumps that deliver epidural infusions according to the programmed intermittent epidural bolus regimen. Pressure changes were measured over time at flow rates of 100, 250, and 400 mL·hour and with a bolus volume of 10 mL. To account for repeated measures, linear mixed models were used. Features were selected with a backward stepwise procedure continued until only statistically significant variables were left in the model. RESULTS: We performed 660 measurements. The mean maximal pressure generated during bolus injection ranged from 86 to 863 mm Hg for different flow rates and catheter designs. The interaction between flow rate and catheter gauge resulted in 1.31, 1.65, and 2.00 mm Hg of pressure increase for 18G, 19G, and 20G catheters, respectively, per 1 mL·hour of increased flow rate (P< .001). Analyses including wire-reinforced catheters revealed a 1.16, 1.76, and 2.36 mm Hg pressure increase for 18G, 19G, and 20G catheters, respectively, per 1 mL·hour of increased flow rate (P< .001). In some cases, it triggered the occlusion pump alarm. CONCLUSIONS: Significant differences were observed in the in vitro maximum pressure value among the various catheter and flow rate combinations with a higher pressure value for wire-reinforced catheters used in the study. The optimal flow rate and epidural catheter combination may allow for delivery of the bolus with high flow rate without triggering the occlusion alarm.

Abnormal lung ultrasound pattern during labor: A prospective cohort pilot study.

PURPOSE: Lung ultrasound (LUS) examination is used to evaluate patients with acute respiratory failure. The physiological LUS pattern during labor in healthy parturients has not been well described. The aim of this study was to evaluate the LUS pattern in a cohort of healthy women during uncomplicated labor. METHODS: We used the 8-point LUS assessment protocol and investigated lung sliding, A-lines, B-lines, interstitial syndrome, lung consolidation, and pleural effusion according to the International Consensus Document with two additional supradiaphragmatic projections. All patients were screened twice; once during the first stage of labor and again within 2 hours after delivery. RESULTS: We included 24 patients in this study from February 2014 to August 2015. A total of 480 LUS records were retained for further analysis. Overall, 16 of 24 patients (67%) had at least one positive region (three or more B-lines) during the peridelivery LUS evaluation. Interstitial syndrome was detected in five patients (21%). There were no differences in A-line (P = 0.38) or B-line (P = 0.68) prevalence between LUS examinations before and after delivery. CONCLUSIONS: Women in uncomplicated labor can present abnormal LUS findings, which may affect the interpretation of LUS results in patients with respiratory deterioration. Further studies should address this topic in larger cohort of patients.

Measurement of the cerebral saturation for assessment of safety of epidural anaesthesia during abdominal surgery.

BACKGROUND: Near Infrared Spectroscopy (NIRS) is considered a reliable assessment method of a balance between cerebral oxygen demand and supply. One of forms of anaesthesia applied during extensive abdominal surgical procedures is the epidural anaesthesia. Its application in addition to the general anaesthesia is a commonly accepted form of anaesthesia in patients undergoing abdominal surgery. The aim of this study was to verify the hypothesis that epidural blocks may have effects on cerebral saturation in patients undergoing abdominal surgery under general anaesthesia. METHODS: Cerebral saturation was monitored intrasurgically. Reduction of cerebral oxymetry by over 25% in relation to the baseline, or cerebral oxymetry value below 50% was considered clinically significant. RESULTS: One hundred and one (101) subsequent and non-randomised patients, age between 35 and 84 years (mean 64 ± 10) qualified for major abdominal surgeries were enrolled. In 14 (13.9%) patients of 101 enrolled a clinically significant reduction of cerebral saturation was observed. In 50 (49.5%) of the enrolled patients, the epidural anaesthesia was applied along the general anaesthesia. A clinically significant reduction of cerebral saturation was observed in 9 of them. No statistically significant association was found between the application of epidural anaesthesia and development of cerebral desaturation. CONCLUSION: The application of epidural anaesthesia caused no clinically significant reduction of cerebral saturation during the general anaesthesia in course of major abdominal surgical procedures.

To assess the level of merit and practicality of an innovative and specialized course with the objective to reduce mortality in trauma patients (European Trauma Course in Poland. Evaluation of implementation).

INTRODUCTION: Trauma is one of the leading causes of death in the European Union. The European Trauma Course (ETC) is a training course that focuses on administering aid to trauma patients in a Hospital's Emergency Department by creating an effective and well-organized trauma team. The purpose of the study is to analyze how the ETC training is evaluated by its participants and whether it is tailored to local needs. MATERIALS AND METHODOLOGY: The study includes eight courses conducted between 2010 and 2015, involving 109 medical professionals. Participants were given questionnaires where they could evaluate the various aspects of the course and comment on each of them, using a four-level scale. Finally, 78 surveys were qualified for the study. RESULTS: The exercises were very highly rated (average 3.79 points), mainly for their interesting scenarios and station preparation. Equally well-evaluated was the short and concise method of instruction. The lowest ranked aspect was the course fee (2.41 points). There were o en negative comments about the use of English during the training (lectures and manuals). DISCUSSION: The opinions of Polish students were similar to those of ETC participants in other European countries. ere are many interesting advantages of workshop scenarios, while the downside is the time constraint. Nevertheless, the ETC has been very successful. High ratings and positive feedback affirm the high demand for such courses in Poland.

Respiratory System Function in Patients after Aortic Valve Replacement through Right Anterior Minithoracotomy.

Background The aim of the study was to analyze respiratory system function after minimally invasive aortic valve replacement through right anterior minithoracotomy (RAT-AVR). Methods An observational study of 187 patients electively scheduled for RAT-AVR between January 2010 and December 2013. Pulmonary complications were analyzed and spirometry examinations were performed preoperatively, 1 week, 1 month, and 3 months after surgery. Results Hospital mortality was 1.1%. A double-lumen intratracheal tube was used in 88.2% and single-lumen intratracheal tube was used in 11.8% of patients. Pulmonary complications occurred in 10.8% of the patients. Prolonged (>24 hours) mechanical ventilation time was present in five patients (2.7%). The reasons were stroke (n = 1), perioperative myocardial infarction (n = 2), and pneumothorax (n = 2). Right pleural effusion, which occurred in 7.7% (n = 14) of patients, was the most frequent respiratory system complication. One week after surgery, the spirometry parameters decreased in comparison to the preoperative period, then after 3 months statistically significant improvement occurred; however, the spirometry parameters still had not returned to preoperative values. Multivariable median regression analysis shows that the presence of chronic obstructive pulmonary disease and pulmonary complications were associated with lower values of forced expiratory volume in 1 second after surgery. There was no statistically significant difference regarding spirometry values or incidence of pulmonary complications after surgery between patients in whom single-lung or double-lung ventilation was applied. Conclusion Pulmonary functional status measured with spirometry parameters was diminished after RAT-AVR surgery. Single-lung ventilation did not result in a higher rate of respiratory complications after RAT-AVR surgery.

The efficacy of cardiopulmonary resuscitation, in a large city, based on Krakow's Emergency Medical Service.

INTRODUCTION: For many years, one of the biggest challenges of public healthcare system, in the European Union are cardiovascular diseases. PURPOSE: The purpose of this study was to analyze the variables influencing the specific aspects of the chain of survival in a large city. METHODS: Patients included in this study had to fulfill all of the following criteria: (1) patient had to experience an out-of-hospital cardiac arrest (OHCA), (2) emergency medical team had to initiate cardio-pulmonary resuscitation (CPR) at the site of the event. Data were collected from the 1st of January to the 31st of December 2004. RESULT: In a time period from the 1st of January to the 31st of December 2004 emergency medical teams initiated 381 resuscitations. The incidence of OHCA in which CRP was initiated was 50 events / 100 000 habitants. Spontaneous circulation was achieved in 163 patients (42.8%). Thirty-day after the resuscitation 62 patients (16.3%) were alive, and 52 patients (13.6%) were discharged alive from the hospital. CONCLUSIONS: Analysis of collected data shows that return of spontaneous circulation (ROSC) was achieved in 42.8% of patients, 16.3% survived at least 30 days following the event, and 13.6% of patients were discharged alive from the hospital. These results are similar to findings from different studies conducted in Poland.

Perioperative Outcomes of Minimally Invasive Aortic Valve Replacement through Right Anterior Minithoracotomy.

Background The aim of the study was to analyze perioperative outcomes after minimally invasive aortic valve replacement through right anterior minithoracotomy (RAT-AVR). Patient selection criteria, anesthesia protocol, and surgical technique are presented. Methods A retrospective analysis of 194 patients electively scheduled for RAT-AVR was performed between January 2009 and June 2013. For preoperative planning, computed tomography was performed. Results Among studied patients, there were 48.5% females and 51.5% males with a mean age of 69.9 ± 9.2 years. The predicted mortality calculated with EuroSCORE II was 3.2 ± 0.9%, and observed mortality of RAT-AVR patients was 1.5%. Finally, RAT-AVR surgery was performed on 97.9% of patients (n = 190). Reasons for conversions to median sternotomy were bleeding from aortotomy site (n = 4) and from the right ventricle after epicardial pacing wire placement (n = 1), pleural adhesions (n = 2), and ascending aorta hidden under the sternum (n = 2). The second intercostal space was chosen for surgical access in 97.9% of patients.There were 3.6% reoperations for bleeding: aortotomy place (n = 1), epicardial pacing wire placement (n = 3), right lung tear (n = 2), and intercostal vessels (n = 1). The intensive care unit and hospital length of stays were 1.3 ± 1.2 and 5.7 ± 1.4 days, respectively. Strokes were present in 1.5% of patients. The perioperative complications rate diminished with time, occurring in 44.9% of the patients between 2009 and 2010 and in 15.6% of patients in 2013. Conclusions RAT-AVR can be safely performed without increased morbidity and mortality. Reduced complication rates over time reflect a learning curve.

Function of the Respiratory System in Elderly Patients After Aortic Valve Replacement.

OBJECTIVE: To compare the function of the respiratory system after aortic valve replacement through median sternotomy (AVR) or the minimally invasive right anterior minithoracotomy (RAT-AVR) approach among elderly (aged≥75 years) patients. DESIGN: Observational cohort study. SETTINGS: University hospital. PARTICIPANTS: The study included 65 elderly patients scheduled for RAT-AVR and 82 for standard AVR. INTERVENTIONS: Pulmonary function tests (PFT) were performed preoperatively, 1 week, 1 month, and 3 months after surgery. In addition, respiratory complications were analyzed. MEASUREMENTS AND MAIN RESULTS: Respiratory complications occurred in 12.3% of patients in the RAT-AVR group and 18.3% of patients in the AVR group (p = 0.445). Mechanical ventilation time in the intensive care unit was 7.7±3.6 hours for RAT-AVR patients and 9.7±5.4 hours for AVR patients (p = 0.003). Most PFT were worse in the AVR group than in the RAT-AVR group when performed 1 week after surgery. After 1 month, forced expiratory volume in the first second, vital capacity, and total lung capacity differed significantly in favor of the RAT-AVR group (p = 0.002, p<0.001, and p = 0.001, respectively). After 3 months, the PFT parameters still had not returned to preoperative values, but the differences were no longer significant between the RAT-AVR and AVR groups. The multivariable median regression analysis demonstrated that RAT-AVR surgery was a key factor in a patient's higher postoperative PFT parameter values. CONCLUSIONS: RAT-AVR surgery resulted in shorter postoperative mechanical ventilation time and improved the recovery of pulmonary function in elderly patients, but it did not reduce the incidence of pulmonary complications when compared with surgery performed through a median sternotomy.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy. CONCLUSIONS: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Effects of introducing a voluntary virtual patient module to a basic life support with an automated external defibrillator course: a randomised trial.

BACKGROUND: The concept of virtual patients (VPs) encompasses a great variety of predominantly case-based e-learning modules with different complexity and fidelity levels. Methods for effective placement of VPs in the process of medical education are sought. The aim of this study was to determine whether the introduction of a voluntary virtual patients module into a basic life support with an automated external defibrillator (BLS-AED) course improved the knowledge and skills of students taking the course. METHODS: Half of the students were randomly assigned to an experimental group and given voluntary access to a virtual patient module consisting of six cases presenting BLS-AED knowledge and skills. Pre- and post-course knowledge tests and skills assessments were performed, as well as a survey of students' satisfaction with the VP usage. In addition, time spent using the virtual patient system, percentage of screen cards viewed and scores in the formative questions in the VP system throughout the course were traced and recorded. RESULTS: The study was conducted over a six week period and involved 226 first year medical students. The voluntary module was used by 61 (54%) of the 114 entitled study participants. The group that used VPs demonstrated better results in knowledge acquisition and in some key BLS-AED action skills than the group without access, or those students from the experimental group deliberately not using virtual patients. Most of the students rated the combination of VPs and corresponding teaching events positively. CONCLUSIONS: The overall positive reaction of students and encouraging results in knowledge and skills acquisition suggest that the usage of virtual patients in a BLS-AED course on a voluntary basis is feasible and should be further investigated.

[Resuscitation in acute poisonings based on 2005 and 2010 Resuscitation Guideline]. / Postepowanie resuscytacyjne w ostrych zatruciach w oparciu o Wytyczne Resuscytacji z 2005 i 2010 roku.

Acute poisonings in USA are a leading cause of cardiac arrest, especially in youngsters. Primary survey and cardiopulmonary resuscitation for poisoning is based on ABCDE procedure. One of the most common manifestation of acute poisoning is coma. An open airway should be ensured. Endotracheal intubation should be performed by an experienced person. The mouth-to mouth method of artificial respiration can be applied ultimately. In case of cyanide, hydrogen sulfide, organophosphates and corrosives poisonings a special caution is needed and pocket mask or self-inflating bag with a face mask should be rather used. A quick poison identification and a contact with regional poison information centre regarding patient management are crucial. Different procedures include prolonged cardiopulmonary resuscitation.

Perioperative lung ultrasound pattern changes in patients undergoing gynecological procedures - a prospective observational study.

OBJECTIVES: General anesthesia and positive pressure ventilation are associated with perioperative pulmonary complications. Lung ultrasound (LUS) is a method used to evaluate lung parenchyma. The purpose of this study was to evaluate LUS patterns in a cohort of women undergoing gynecological surgery with uncomplicated general anesthesia. MATERIAL AND METHODS: Patients were assessed according to the 8-zone LUS assessment protocol used to detect lung sliding, A-lines, B-lines, interstitial syndrome and lung consolidation. Each patient was screened at specific time intervals: before induction of anesthesia, at induction, 30 and 60 minutes after induction and within two hours after recovery. RESULTS: A total of 99 patients undergoing gynecological surgery with uneventful anesthesia from November 2017 to November 2018 were included in this study. A total of 426 LUS records were retained for further analysis. Overall, no significant changes to patients' A-line appearance were detected, regardless of the time of assessment. There was, however, an increase in the number of B-lines at the screening times of 30 and 60 minutes after induction, as compared to initial assessments (p = 0.011 and p < 0.001 respectively), and an increase in the number of positive regions (≥ 3 B-lines) at 30 and 60 minutes after induction and after recovery, as compared to initial assessment (p < 0.001; p < 0.001 and p = 0.001 respectively). CONCLUSIONS: An uneventful anesthesia may predispose to abnormal LUS findings and should be considered while interpreting of LUS results in cases with perioperative pulmonary complications.

High frequency oscillation, extracorporeal membrane oxygenation and pumpless arteriovenous lung assist in the management of severe ARDS.

BACKGROUND: The protective lung strategy for severe ARDS, has markedly decreased the associated morbidity and mortality. Sometimes, even the best instrumentation and therapeutic strategy may be insufficient, and extracorporeal gas exchange support is necessary. We describe a desperate case of ARDS, in which various modes of ventilation, combined with vigorous extracorporeal support, resulted in a successful outcome. CASE REPORT: A 35-year-old man, a heavy smoker, was admitted to the hospital because of lobar pneumonia. Despite wide spectrum antimicrobial therapy, he developed ARDS and was placed on a ventilator. Standard ventilation was ineffective and veno-venous ECMO was instituted. The extravascular lung water index (EVLWI) was extremely high (over 30 mL kg-1) and signs of a hyperdynamic circulation (CI 6.1 L m-2 min-1) were observed. Modification of the inotropic support and continuous infusion of furosemide resulted in normalisation of the hydration status, and over a week of ECMO therapy, the patient's general condition improved to the stage that he was scheduled to be weaned from extracorporeal treatment. On the 7th day however, he suddenly deteriorated. A lung CT-scan revealed bilateral pneumothoraces and diffuse pulmonary embolism. Three thoracic drains were inserted, but unfortunately, the drainage was complicated by massive bleeding and a subsequent thoracotomy. Two days later, a gastrointestinal haemorrhage occurred. Heparin dosage was reduced, and ECMO was discontinued and replaced with HFOV. This resulted in adequate oxygenation, however because of ineffective CO2 elimination, pumpless arteriovenous extracorporeal lung assist (PECLA) was instituted, allowing conventional ventilation to be resumed after 8 days. The further clinical course was complicated by persistent bilateral pneumothoraces, pleural effusion and Pseudomonas nosocomial infection. The man eventually recovered after 54 days in the ICU, and was transferred to a rehabilitation department. DISCUSSION AND CONCLUSION: ECMO has been recommended for severe ARDS since it avoids overdistension of the lungs and the use of high oxygen concentrations. Early institution of ECMO decreases mortality and morbidity in rapidly progressing ARDS. In the described case, ECMO was probably started too late, after volutrauma has already occurred. A combination of HFOV and PECLA may be recommended in selected cases, in which CO2 retention poses a serious problem.