Incidence, risk factors and outcome of acute kidney injury in critically ill COVID-19 patients in Tyrol, Austria: a prospective multicenter registry study.

INTRODUCTION: Acute kidney injury is a frequent complication in critically ill patients with and without COVID-19. The aim of this study was to evaluate the incidence of, and risk factors for, acute kidney injury and its effect on clinical outcomes of critically ill COVID-19 patients in Tyrol, Austria. METHODS: This multicenter prospective registry study included adult patients with a SARS-CoV-2 infection confirmed by polymerase chain reaction, who were treated in one of the 12 dedicated intensive care units during the COVID-19 pandemic from February 2020 until May 2022. RESULTS: In total, 1042 patients were included during the study period. The median age of the overall cohort was 66 years. Of the included patients, 267 (26%) developed acute kidney injury during their intensive care unit stay. In total, 12.3% (n = 126) required renal replacement therapy with a median duration of 9 (IQR 3-18) days. In patients with acute kidney injury the rate of invasive mechanical ventilation was significantly higher with 85% (n = 227) compared to 41% (n = 312) in the no acute kidney injury group (p < 0.001). The most important risk factors for acute kidney injury were invasive mechanical ventilation (OR = 4.19, p < 0.001), vasopressor use (OR = 3.17, p < 0.001) and chronic kidney disease (OR = 2.30, p < 0.001) in a multivariable logistic regression analysis. Hospital and intensive care unit mortality were significantly higher in patients with acute kidney injury compared to patients without acute kidney injury (Hospital mortality: 52.1% vs. 17.2%, p < 0.001, ICU-mortality: 47.2% vs. 14.7%, p < 0.001). CONCLUSION: As in non-COVID-19 patients, acute kidney injury is clearly associated with increased mortality in critically ill COVID-19 patients. Among known risk factors, invasive mechanical ventilation has been identified as an independent and strong predictor of acute kidney injury.

[Anesthesia for organ transplant patients]. / Anästhesie bei organtransplantierten Patient:innen.

Organ transplant patients who must undergo nontransplant surgical interventions can be challenging for the anesthesiologists in charge. On the one hand, it is important to carefully monitor the graft function in the perioperative period with respect to the occurrence of a possible rejection reaction. On the other hand, the ongoing immunosuppression may have to be adapted to the perioperative requirements in terms of the active substance and the route of administration, the resulting increased risk of infection and possible side effects (e.g., myelosuppression, nephrotoxicity and impairment of wound healing) must be included in the perioperative treatment concept. Furthermore, possible persistent comorbidities of the underlying disease and physiological peculiarities as a result of the organ transplantation must be taken into account. Support can be obtained from the expertise of the respective transplantation center.

The impact of PECS II blockade in patients undergoing minimally invasive cardiac surgery-a prospective, randomized, controlled, and triple-blinded trial.

BACKGROUND: Classic neuraxial techniques, such as thoracic epidural anesthesia, or alternative approaches like the paravertebral block, are not indicated in cardiac surgery due to increased bleeding risk. To provide satisfactory analgesia without the need for excessive opioid use, novel ultrasound techniques gained popularity and are of growing interest. The pectoralis nerve block II (PECS II) has been shown to provide good postoperative analgesia in modified radical mastectomy and might also be suitable for minimally invasive cardiac surgery. METHODS: In a single center, prospective, triple-blinded, two-group randomized trial, 60 patients undergoing elective, unilateral minimal invasive cardiac surgery will be randomized to receive a PECS II with 30 ml of ropivacaine 0.5% (intervention group) or sodium chloride 0.9% (placebo group). The primary outcome parameter is the overall opioid demand given as intravenous morphine milligram equivalents (MME) during the first 24 h after extubation. Secondary endpoints are the visual analog scale (VAS) 2, 4, 6, 8, 12, and 24 h after extubation, the Overall Benefit of Analgesia Score (OBAS) after 24 h, the interval until extubation, and intensive care unit (ICU) discharge within 24 h, as well as the length of hospital stay (LOS). DISCUSSION: This prospective randomized, controlled, and triple-blinded trial aims to assess if a PECS II with ropivacaine 0.5% helps to decrease the opioid demand in the first 24 h and increases postoperative pain control after minimally invasive cardiac surgery. TRIAL REGISTRATION: www.clinicaltrialsregister.eu ; EudraCT Nr: 2021-005452-11; Lukas Gasteiger MD, November 18, 2021.

Major cardiac surgery with recombinant FIX Fc fusion protein replacement in hemophilia B: a case report.

The introduction of extended factor IX (FIX) products has significantly facilitated the treatment of hemophilia B patients. However, optimal perioperative management remains a topic of hot debate, particularly in surgeries with high bleeding risk. For the first time, we report here a patient with mild hemophilia B and degenerative aneurysms of aortic root and ascending aorta undergoing elective Bentall's operation with full cardiopulmonary bypass, who was successfully managed with eftrenonacog alfa (Alprolix®), a recombinant FIX Fc fusion protein (rFIXFc). rFIXFc could safely be monitored using the Pathromtin SL aPTT-reagent. No significant bleeding was noted intraoperatively despite systemic heparinization as well as postoperatively. Higher doses of rFIXFc were inevitable to reach target FIX levels intraoperatively, whereas in the post-surgery setting stable FIX concentrations were maintained with only few rFIXFc injections facilitating fast wound healing and remobilization of the patient.

Changes in characteristics and outcomes of critically ill COVID-19 patients in Tyrol (Austria) over 1 year.

BACKGROUND: Widely varying mortality rates of critically ill Coronavirus disease 19 (COVID-19) patients in the world highlighted the need for local surveillance of baseline characteristics, treatment strategies and outcome. We compared two periods of the COVID-19 pandemic to identify important differences in characteristics and therapeutic measures and their influence on the outcome of critically ill COVID-19 patients. METHODS: This multicenter prospective register study included all patients with a SARS-CoV­2 infection confirmed by polymerase chain reaction, who were treated in 1 of the 12 intensive care units (ICU) from 8 hospitals in Tyrol, Austria during 2 defined periods (1 February 2020 until 17 July: first wave and 18 July 2020 until 22 February 2021: second wave) of the COVID-19 pandemic. RESULTS: Overall, 508 patients were analyzed. The majority (n = 401) presented during the second wave, where the median age was significantly higher (64 years, IQR 54-74 years vs. 72 years, IQR 62-78 years, p < 0.001). Invasive mechanical ventilation was less frequent during the second period (50.5% vs 67.3%, p = 0.003), as was the use of vasopressors (50.3% vs. 69.2%, p = 0.001) and renal replacement therapy (12.0% vs. 19.6%, p = 0.061), which resulted in shorter ICU length of stay (10 days, IQR 5-18 days vs. 18 days, IQR 5-31 days, p < 0.001). Nonetheless, ICU mortality did not change (28.9% vs. 21.5%, p = 0.159) and hospital mortality even increased (22.4% vs. 33.4%, p = 0.039) in the second period. Age, frailty and the number of comorbidities were significant predictors of hospital mortality in a multivariate logistic regression analysis of the overall cohort. CONCLUSION: Advanced treatment strategies and learning effects over time resulted in reduced rates of mechanical ventilation and vasopressor use in the second wave associated with shorter ICU length of stay. Despite these improvements, age appears to be a dominant factor for hospital mortality in critically ill COVID-19 patients.

EMT-led laryngeal tube vs. face-mask ventilation during cardiopulmonary resuscitation - a multicenter prospective randomized trial.

BACKGROUND: Laryngeal tube (LT) application by rescue personnel as an alternate airway during the early stages of out-of-hospital cardiac arrest (OHCA) is still subject of debate. We evaluated ease of handling and efficacy of ventilation administered by emergency medical technicians (EMTs) using LT and bag-valve-mask (BVM) during cardiopulmonary resuscitation of patients with OHCA. METHODS: An open prospective randomized multicenter study was conducted at six emergency medical services centers over 18 months. Patients in OHCA initially resuscitated by EMTs were enrolled. Ease of handling (LT insertion, tight seal) and efficacy of ventilation (chest rises visibly, no air leak) with LT and BVM were subjectively assessed by EMTs during pre-study training and by the attending emergency physician on the scene. Outcome and frequency of complications were compared. RESULTS: Of 97 eligible patients, 78 were enrolled. During pre-study training EMTs rated efficacy of ventilation with LT higher than with BVM (66.7% vs. 36.2%, p = 0.022), but efficacy of on-site ventilation did not differ between the two groups (71.4% vs. 58.5%, p = 0.686). Frequency of complications (11.4% vs. 19.5%, p = 0.961) did not differ between the two groups. CONCLUSIONS: EMTs preferred LT ventilation to BVM ventilation during pre-study training, but on-site there was no difference with regard to efficacy, ventilation safety, or outcome. The results indicate that LT ventilation by EMTs during OHCA is not superior to BVM and cannot substitute for BVM training. We assume that the main benefit of the LT is the provision of an alternative airway when BVM ventilation fails. Training in BVM ventilation remains paramount in EMT apprenticeship and cannot be substituted by LT ventilation. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01718795).

Manual versus Mechanical Chest Compressions on Surfaces of Varying Softness with or without Backboards: A Randomized, Crossover Manikin Study.

BACKGROUND: Chest compression quality is decisive for overall outcome after cardiac arrest. Chest compression depth may decrease when cardiopulmonary resuscitation (CPR) is performed on a mattress, and the use of a backboard does not necessarily improve compression depth. Mechanical chest compression devices may overcome this problem. OBJECTIVES: We sought to investigate the effectiveness of manual chest compressions both with and without a backboard compared to mechanical CPR performed on surfaces of different softness. METHODS: Twenty-four advanced life support (ALS)-certified rescuers were enrolled. LUCAS2 (Physio-Control, Redmond, WA) delivers 52 ± 2 mm deep chest compressions and active decompressions back to the neutral position (frequency 102 min(-1); duty cycle, 50%). This simulated CPR scenario was performed on a Resusci-Anne manikin (Laerdal, Stavanger, Norway) that was lying on 3 different surfaces: 1) a concrete floor, 2) a firm standard mattress, and 3) a pressure-relieving mattress. Data were recorded by the Laerdal Skill Reporting System. RESULTS: Manual chest compression with or without a backboard were performed correctly less often than mechanical chest compressions (floor: 33% [interquartile range {IQR}, 27-48%] vs. 90% [IQR, 86-94%], p < 0.001; standard mattress: 32% [IQR, 20-45%] vs. 27% [IQR, 14-46%] vs. 91% [IQR, 51-94%], p < 0.001; and pressure-relieving mattress 29% [IQR, 17-49%] vs. 30% [IQR, 17-52%] vs. 91% [IQR, 87-95%], p < 0.001). The mean compression depth on both mattresses was deeper with mechanical chest compressions (floor: 53 mm [range, 47-57 mm] vs. 56 mm [range, 54-57 mm], p = 0.003; standard mattress: 50 mm [range, 44-55 mm] vs. 51 mm [range, 47-55 mm] vs. 55 mm [range, 54-58 mm], p < 0.001; and pressure-relieving mattress: 49 mm [range, 44-55 mm] vs. 50 mm [range, 44-53 mm] vs. 55 mm [range, 55-56 mm], p < 0.001). In this ∼6-min scenario, the mean hands-off time was ∼15 to 20 s shorter in the manual CPR scenarios. CONCLUSIONS: In this experimental study, only ∼30% of manual chest compressions were performed correctly compared to ∼90% of mechanical chest compressions, regardless of the underlying surface. Backboard use did not influence the mean compression depth during manual CPR. Chest compressions were deeper with mechanical CPR. The mean hands-off time was shorter with manual CPR.

Exploring patient satisfaction with foodservice through focus groups and meal rounds.

The purpose of this study was to investigate adult patients' perceptions of hospital foodservice through focus groups with patients postdischarge and with nurses. The focus group themes included an emphasis on health, quality, freshness, and appropriateness; variety, selection, and choice; inability to provide feedback; menu errors; accessibility to food on the units; service; tray layout; and waste. The themes emerging from the focus groups were further explored through meal round interviews with patients (n=116) to determine areas for improvement. Patients thought food served in the hospital should be a model for a healthy diet. Ongoing education and communication with patients and nurses is important in improving satisfaction with foodservice.