Risk Factors for Postoperative Pulmonary Complications Leading to Increased In-Hospital Mortality in Patients Undergoing Thoracotomy for Primary Lung Cancer Resection: A Multicentre Retrospective Cohort Study of the German Thorax Registry.

Postoperative pulmonary complications (PPCs) represent the most frequent complications after lung surgery, and they increase postoperative mortality. This study investigated the incidence of PPCs, in-hospital mortality rate, and risk factors leading to PPCs in patients undergoing open thoracotomy lung resections (OTLRs) for primary lung cancer. The data from 1426 patients in this multicentre retrospective study were extracted from the German Thorax Registry and presented after univariate and multivariate statistical processing. A total of 472 patients showed at least one PPC. The presence of two PPCs was associated with a significantly increased mortality rate of 7% (p < 0.001) compared to that of patients without or with a single PPC. Three or more PPCs increased the mortality rate to 33% (p < 0.001). Multivariate stepwise logistic regression analysis revealed male gender (OR 1.4), age > 60 years (OR 1.8), and current or previous smoking (OR 1.6), while the pre-operative risk factors were still CRP levels > 3 mg/dl (OR 1.7) and FEV1 < 60% (OR 1.4). Procedural independent risk factors for PPCs were: duration of surgery exceeding 195 min (OR 1.6), the amount of intraoperative blood loss (OR 1.6), partial ligation of the pulmonary artery (OR 1.5), continuing invasive ventilation after surgery (OR 2.9), and infusion of intraoperative crystalloids exceeding 6 mL/kg/h (OR 1.9). The incidence of PPCs was significantly lower in patients with continuous epidural or paravertebral analgesia (OR 0.7). Optimising perioperative management by implementing continuous neuroaxial techniques and optimised fluid therapy may reduce the incidence of PPCs and associated mortality.

Appropriability and basicness of R&D: Identifying and characterising product and process inventions in patent data.

We present a database that classifies all patent applications filed at either the United States Patent and Trademark Office (USPTO) or the European Patent Office (EPO) as being either product patents, process patents or 'mixed patents'. We use the share of claims that refer to either product or process inventions which allows to classify all patent applications along a continuum of pure process patents and pure product patents. We find that process-oriented patents draw more on previous knowledge, are more original and more radical than product patents. Lower breadth of protection is positively associated with pure process patenting, whereas product and mixed variants can be protected more broadly. This characterisation uncovers heterogeneity of patented inventions that allows for a more sophisticated use of patent statistics. It can improve the accuracy of analyses, but also reveal new aspects related to property rights.

Sevoflurane in combination with esketamine is an effective sedation regimen in COVID-19 patients enabling assisted spontaneous breathing even during prone positioning.

BACKGROUND: Effective analgosedation for control of dyspnoea and for toleration of prone positioning (PP) in severe coronavirus disease 2019 (COVID-19) associated acute respiratory distress syndrome (ARDS) is difficult to adjust. This study was designed to evaluate the feasibility and safety of sedation with inhaled sevoflurane in combination with intravenous esketamine during PP in patients with COVID-19-ARDS (CARDS). METHODS: All mechanically ventilated COVID-19 patients admitted to the departmental intensive care unit from March to June 2020 were included in this epidemiological cohort study. Patients were sedated with inhaled sevoflurane in combination with eske-tamine during PP and not or only lightly sedated during the supine position. Assisted spontaneous breathing was applied in both prone and supine position. RESULTS: Adverse events were documented prospectively, and routine ventilation parameters, hemodynamic parameters, Richmond Agitation and Sedation Scale (RASS) and sevoflurane consumption were monitored. Altogether, 146 episodes of PP in 15 patients were observed. No severe sedation-related event was observed during 2610 hours of PP. In 2498 hours (96%) patients were successfully converted to a pressure-supported spontaneous breathing mode. CONCLUSIONS: Inhaled sedation with the AnaConDa-S-System (Sedana Medical AB, Danderyd, Sweden) alone is insufficient as soon as minute volume exceeds 7-8 L min-1, most likely due to technical reasons. Inhaled sedation with sevoflurane in combination with esketamine, however, safely enables prolonged prone positioning in patients with CARDS. Moreover, sedation depth was light enough to enable assisted spontaneous breathing during prone positioning.

[Subjective well-being and ability to work after SARS-CoV-2 immunization with the vector vaccine ChAdOx1-S (AstraZeneca COVID-19 vaccine)]. / Subjektives Befinden und Arbeitsfähigkeit nach SARS-CoV-2-Immunisierung mit dem Vektor-Impfstoff ChAdOx1-S (AstraZeneca COVID-19­Vakzin): Ergebnisse einer anonymen Umfrage.

Background: The SARS coronavirus 19 vaccine ChAdOx1­S (Vaxzevria, AstraZeneca) has been licensed since January 2021 by the Paul Ehrlich Institute for Germany. In several campaigns, healthcare workers and medical students were offered this vaccine on a voluntary basis. Aim: The primary endpoint of the study was to assess the rate and duration of the incapacity to work as a result of initial immunization with ChAdOx1­S. Secondary endpoints were type and severity of adverse events and self-perceived tolerability. Material and methods: Anonymized online questionnaire to be completed once by all vaccinated individuals after receiving the first dose of ChAdOx1­S. The severity of side effects was queried using an ordinal numerical rating scale with values ranging from 0 to 10. Other key data points were age, sex, and occupational group. Ability to work in the days following the injection was also assessed by self-reporting. Results: Data from 1988 respondents were analyzed. The mean age was 37.13 years (standard deviation 13.7 years). Of the respondents 69.8% were female, 48.1% belonged to therapeutic and technical professions with patient contact, 38% were students, 10.6% were nursing personnel and 4% were physicians. Only 14.4% of respondents reported having tolerated the vaccination without side effects. The most common side effect was fatigue, followed by pain at the injection site. This was followed in descending frequency by headache, aching limbs, and chills. After vaccination 18% of respondents felt able to return to work immediately, 51% of all respondents had to report themselves unfit for work for at least 1 day after vaccination. Side effects were more prevalent in male and younger respondents. Conclusion: Vaccination with ChAdOx1­S frequently resulted in side effects. These resulted in 37% of respondents reporting sick. Nevertheless, 89.6% of all respondents would choose coronavirus vaccination with ChAdOx1­S again.

Diagnosing capillary leak in critically ill patients: development of an innovative scoring instrument for non-invasive detection.

BACKGROUND: The concomitant occurrence of the symptoms intravascular hypovolemia, peripheral edema and hemodynamic instability is typically named Capillary Leak Syndrome (CLS) and often occurs in surgical critical ill patients. However, neither a unitary definition nor standardized diagnostic criteria exist so far. We aimed to investigate common characteristics of this phenomenon with a subsequent scoring system, determining whether CLS contributes to mortality. METHODS: We conducted this single-center, observational, multidisciplinary, prospective trial in two separately run surgical ICUs of a tertiary academic medical center. 200 surgical patients admitted to the ICU and 30 healthy volunteers were included. Patients were clinically diagnosed as CLS or No-CLS group (each N = 100) according to the grade of edema, intravascular hypovolemia, hemodynamic instability, and positive fluid balance by two independent attending physicians with > 10 years of experience in ICU. We performed daily measurements with non-invasive body impedance electrical analysis, ultrasound and analysis of serum biomarkers to generate objective diagnostic criteria. Receiver operating characteristics were used, while we developed machine learning models to increase diagnostic specifications for our scoring model. RESULTS: The 30-day mortility was increased among CLS patients (12 vs. 1%, P = 0.002), while showing higher SOFA-scores. Extracellular water was increased in patients with CLS with higher echogenicity of subcutaneous tissue [29(24-31) vs. 19(16-21), P < 0.001]. Biomarkers showed characteristic alterations, especially with an increased angiopoietin-2 concentration in CLS [9.9(6.2-17.3) vs. 3.7(2.6-5.6)ng/mL, P < 0.001]. We developed a score using seven parameters (echogenicity, SOFA-score, angiopoietin-2, syndecan-1, ICAM-1, lactate and interleukin-6). A Random Forest prediction model boosted its diagnostic characteristics (AUC 0.963, P < 0.001), while a two-parameter decision tree model showed good specifications (AUC 0.865). CONCLUSIONS: Diagnosis of CLS in critically ill patients is feasible by objective, non-invasive parameters using the CLS-Score. A simplified two-parameter diagnostic approach can enhance clinical utility. CLS contributes to mortality and should, therefore, classified as an independent entity. TRIAL REGISTRATION: German Clinical Trials Registry (DRKS No. 00012713), Date of registration 10/05/2017, www.drks.de.

Minimizing postoperative pulmonary complications in thoracic surgery patients.

PURPOSE OF REVIEW: Quantification and optimization of perioperative risk factors focusing on anesthesia-related strategies to reduce postoperative pulmonary complications (PPCs) after lung and esophageal surgery. RECENT FINDINGS: There is an increasing amount of multimorbid patients undergoing thoracic surgery due to the demographic development and medical progress in perioperative medicine. Nevertheless, the rate of PPCs after thoracic surgery is still up to 30-50% with a significant influence on patients' outcome. PPCs are ranked first among the leading causes of early mortality after thoracic surgery. Although patients' risk factors are usually barely modifiable, current research focuses on procedural risk factors. From the surgical position, the minimal-invasive approach using video-assisted thoracoscopy and laparoscopy leads to a decreased rate of PPCs. The anesthesiological strategy to reduce the incidence of PPCs after thoracic surgery includes neuroaxial anesthesia, lung-protective ventilation, and goal-directed hemodynamic therapy. SUMMARY: The main anesthesiological strategies to reduce PPCs after thoracic surgery include the use of epidural anesthesia, lung-protective ventilation: PEEP (positive end-expiratory pressure) of 5-8 mbar, tidal volume of 5 ml/kg BW (body weight) and goal-directed hemodynamics: CI (cardiac index) ≥ 2.5 l/min per m2, MAD (Mean arterial pressure) ≥ 70 mmHg, SVV (stroke volume variation) < 10% with a total amount of perioperative crystalloid fluids ≤ 6 ml/kg BW (body weight) per hour.

Dislodgement Forces and Cost Effectiveness of Dressings and Securement for Peripheral Intravenous Catheters: A Randomized Controlled Trial.

OBJECTIVES: Peripheral intravenous catheters (PIVC) are the most frequently used invasive devices in medicine. PIVC failure before treatment completion is a significant concern and occurs in 33-69% of patients. Partial dislodgement and accidental removal are some of the reasons for PIVC failure. The most effective dressing and securement method for preventing accidental removal remains unclear. It was the aim of this study to compare the force required to dislodge a PIVC with four commonly used dressing and securement methods. Additionally, costs were calculated. METHODS: Truncated 18-gauge i.v. cannulas were attached onto the forearm of 209 volunteers using four different dressings and securements (sterile absorbent wound dressing covered by two different types of elastic polyester fleece, bordered and non-bordered polyurethane). The force during continuously stronger pulling until dislodgement was recorded. RESULTS: The highest resistance against dislodgement forces could be observed with a sterile absorbent wound dressing covered by two incised elastic polyester fleece dressings. Commercially-manufactured bordered and non-bordered polyurethan film dressings were 20% to 75% more expensive than sterile absorbent wound dressings covered by elastic polyester fleece dressing. CONCLUSIONS: Elastic polyester fleece secured a PIVC against accidental removal by external force best, compared to commercially-manufactured bordered and non-bordered polyurethane film dressing.

Subcutaneous Enoxaparin Safely Facilitates Bedside Sustained Low-Efficiency Hemodialysis in Hypercoagulopathic Coronavirus Disease 2019 Patients-A Proof-of-Principle Trial.

OBJECTIVES: Renal replacement therapy in coronavirus disease 2019 patients is complicated by increased activation of the coagulation system. This may worsen the quality of hemodialysis and contribute to a shortage of dialysis machines as well as plastic disposables during the pandemic. This study describes a simple and safe protocol of anticoagulation with low-molecular-weight heparin in combination with bedside sustained low-efficiency hemodialysis in coronavirus disease 2019 patients. DESIGN: Monocentric observational cross-over trial investigating sustained low-efficiency hemodialysis with unfractionated heparin following sustained low-efficiency hemodialysis with low-molecular-weight heparin. SETTING: Coronavirus disease 2019-ICU in a German Tertiary Care University Hospital. PATIENTS: Three consecutive severe coronavirus disease 2019 patients receiving nine sustained low-efficiency hemodialysis therapies with unfractionated heparin followed by 18 sustained low-efficiency hemodialysis therapies with low-molecular-weight heparin. INTERVENTIONS: Switch from IV unfractionated heparin to subcutaneous low-molecular-weight heparin enoxaparin in therapeutic doses for patients receiving bedside sustained low-efficiency hemodialysis. MEASUREMENTS AND MAIN RESULTS: Nine renal replacement therapy sessions in patients anticoagulated with high doses of unfractionated heparin had to be discontinuated prematurely because of clotting of tubes or membrane and poor quality of hemodialysis. In the same patients, the switch to anticoagulation with therapeutic doses of the low-molecular-weight heparin enoxaparin allowed undisturbed bedside sustained low-efficiency hemodialysis for at least 12 hours. Quality of hemodialysis was excellent, no bleeding event was observed. CONCLUSIONS: Systemic anticoagulation with subcutaneous enoxaparin provides an effective and safe renal replacement procedure in critically ill patients with coronavirus disease 2019 and hypercoagulability. The protocol reduces the risk of filter clotting, blood loss, and poor dialysis quality and may also prevent systemic thromboembolism.

Erratum to preoperative treatment of anemia-could an ultra-short-term multimodal approach be beneficial for patients undergoing lung surgery?

[This corrects the article DOI: 10.21037/jtd.2019.08.95.].

Early Postoperative Use of Diuretics After Kidney Transplantation Showed Increase in Delayed Graft Function.

PURPOSE: In acute renal injury, diuretics are widely considered to be harmful. Nevertheless, they are used frequently after kidney transplantation. We hypothesized that diuretics administered in the early postoperative treatment after kidney transplantation increase the incidence of delayed graft function (DGF). METHODS: In this monocentric, retrospective cohort analysis, we screened the closed files of all consecutive patients who underwent kidney transplantation from 2011 to 2017. The outcome variable was DGF, defined as at least 1 hemodialysis within 7 days postoperatively. To stratify for baseline characteristics such as waiting time or cold ischemic period, we employed a propensity score-matched analysis. Further statistical processing included basic descriptive statistics, Mann-Whitney U test, and binary logistic regression analysis. RESULTS: The unmatched cohort included 445 patients and showed a significantly increased rate of DGF for patients who received either furosemide or mannitol or a combination of both (5% vs 25%; P < .001). Mannitol (odds ratio [OR]: 4.094) and furosemide (OR: 2.915) showed a significant correlation with DGF in the multivariate regression analysis. Propensity score-based matching resulted in a matched cohort of 214 patients with balanced baseline risk variables. In this matched cohort, the rate of DGF was significantly increased in patients who received diuretics in the early postoperative treatment (7% vs 16%; P = .031). CONCLUSION: Our results show that postoperatively administered diuretics are associated with an increased rate of DGF even in a cohort with balanced preoperative risk variables. This study supports recently published reviews, which call diuretics in the transplantation process into question.

Medical science faces the post-truth era: a plea for the grassroot values of science.

PURPOSE OF REVIEW: Science and its public perception are compromised by scientific fraud and predatory journals, and also by the general erosion of the meaning of truth in the so-called post-truth era. These developments have significant influence on scientific medicine and their impact on the public discourse. The purpose of this article is to show how fake science, and also the uncritical dissemination of compromised results in public and social media, threatens scientific medicine. RECENT FINDINGS: As social media rises to the preferred source of information of ever larger parts of the modern societies, the dissemination of falsified scientific results within the communities is almost unstoppable. With growing numbers of predatory journals and repetitive cases of fake science, the risk of publication of false results increases. Due to the underlying mechanisms of the post-truth era and social media, these compromised results find their way to the public discourse and continue to be disseminated even when they were, beyond all doubt, proven to be a lie. In medical sciences, dissemination of falsified results directly threats health and life of patients. SUMMARY: In the post-truth era, publication of false results in predatory journals and by fraudulent authors become even more dangerous for the health and life of patients, as their dissemination via new social media is nearly unstoppable and in the public perception truth is losing its meaning. The scientific community has implemented specific counter-measures to minimize the chances of false results being published. However, it is even more important that every participant in the scientific process assumes the responsibility according to his or her role. An orientation towards the values that have constituted and formed science is helpful in fulfilling this responsibility.

Epidural analgesia and avoidance of blood transfusion are associated with reduced mortality in patients with postoperative pulmonary complications following thoracotomic esophagectomy: a retrospective cohort study of 335 patients.

BACKGROUND: Postoperative pulmonary complications (PPCs) represent the most frequent complications after esophagectomy. The aim of this study was to identify modifiable risk factors for PPCs and 90-days mortality related to PPCs after esophagectomy in esophageal cancer patients. METHODS: This is a single center retrospective cohort study of 335 patients suffering from esophageal cancer who underwent esophagectomy between 1996 and 2014 at a university hospital center. Statistical processing was conducted using univariate and multivariate stepwise logistic regression analysis of patient-specific and procedural risk factors for PPCs and mortality. RESULTS: The incidence of PPCs was 52% (175/335) and the 90-days mortality rate of patients with PPCs was 8% (26/335) in this study cohort. The univariate and multivariate analysis revealed the following independent risk factors for PPCs and its associated mortality. ASA score ≥ 3 was the only independent patient-specific risk factor for the incidence of PPCs and 90-days mortality of patients with an odds ratio for PPCs being 1.7 (1.1-2.6 95% CI) and an odds ratio of 2.6 (1.1-6.2 95% CI) for 90-days mortality. The multivariate approach depicted two independent procedural risk factors including transfusion of packed red blood cells (PRBCs) odds ratio of 1.9 (1.2-3 95% CI) for PPCs and an odds ratio of 5.0 (2.0-12.6 95% CI) for 90-days mortality; absence of thoracic epidural anesthesia (TEA) revealed the highest odds ratio 2.0 (1.01-3.8 95% CI) for PPCs and an odds ratio of 3.9 (1.6-9.7 95% CI) for 90-days mortality. CONCLUSION: In esophageal cancer patients undergoing esophagectomy via thoracotomy, epidural analgesia and the avoidance of intraoperative blood transfusion are significantly associated with a reduced 90-days mortality related to PPCs.

Modifiable Risk Factors for Delayed Graft Function After Deceased Donor Kidney Transplantation.

PURPOSE: Delayed graft function is a major complication after kidney transplantation affecting patients' long-term outcome. The aim of this study was to identify modifiable risk factors for delayed graft function after deceased donor kidney transplantation. METHODS: This is a single-center retrospective cohort study of a university transplantation center. Univariate and multivariate step-wise logistic regression analysis of patient-specific and procedural risk factors were conducted. RESULTS: We analyzed 380 deceased donor kidney transplantation patients between October 30, 2008 and December 30, 2017. The incidence of delayed graft function was 15% (58/380). Among the patient-specific risk factors recipient diabetes (2.8 [1.4-5.9] odds ratio [OR] [95% confidence interval [CI]]), American Society of Anesthesiologist score of 4 (2.7 [1.2-6.5] OR [95% CI]), cold ischemic time >13 hours (2.8 [1.5-5.3] OR [95% CI]) and donor age >55 years (1.9 [1.01-3.6] OR [95% CI]) revealed significance. The significant intraoperative, procedural risk factors included the use of colloids (3.9 [1.4-11.3] OR [95% CI]), albumin (3.0 [1.2-7.5] OR [95% CI]), crystalloids >3000 mL (3.1 [1.2-7.5] OR [95% CI]) and mean arterial pressure <80 mm Hg at the time of reperfusion (2.4 [1.2-4.8] OR [95% CI]). CONCLUSION: Patients undergoing deceased donor kidney transplantation with a mean arterial pressure >80 mm Hg at the time of transplant reperfusion without requiring excessive fluid therapy in terms of colloids, albumin or crystalloids >3000 mL are less likely to develop delayed graft function.

Risk factors for post-operative pulmonary complications in lung cancer patients after video-assisted thoracoscopic lung resection: Results of the German Thorax Registry.

OBJECTIVE: Post-operative pulmonary complications (PPCs) represent the most frequent complications after lung surgery. The aim of this study was to identify the modifiable risk factors for PPCs after video-assisted thoracoscopic surgery (VATS) in lung cancer patients. METHODS: Data of this retrospective study were extracted from the German Thorax Registry, an interdisciplinary and multicenter database of the German Society of Anesthesiology and Intensive care medicine and the German Society of Thoracic Surgery. Univariate and multivariate stepwise logistic regression analysis of patient-specific and procedural risk factors for PPCs were conducted. RESULTS: We analyzed 376 patients with lung cancer who underwent VATS bilobectomy (n = 2), lobectomy (n = 258) or segmentectomy (n = 116) in 2016 and 2017. One-hundred fourteen patients (114/376; 30%) developed PPCs. Two patients died within 30 days after surgery. In the univariate analysis, patients of the PPC group showed significantly more often a body mass index (BMI) ≤ 19 kg/m2 ; a pre-operative forced expiratory volume in 1 second (FEV1 ) ≤ 60%; a pre-operative arterial oxygen partial pressure (pa O2 ) ≤ 60 mm Hg; a higher rate of prolonged duration of surgery (≥2 hours [h]) and a higher frequency of intraoperative blood loss ≥500 mL. The multivariate stepwise logistic regression analysis revealed 4 independent risk factors: FEV1 ≤ 60% (1.9[1.1-3.4] OR [95% CI], P = 0.029); pa O2 ≤ 60 mm Hg (4.6[1.7-12.8] OR [95% CI], P = 0.003; duration of surgery ≥2 hours (2.7[1.5-4.7] OR [95% CI], P = 0.001) and intraoperative crystalloids ≥6 mL/kg/h (2.9[1.2-7.5] OR [95% CI], P = 0.023). CONCLUSION: Intraoperative amount of crystalloid fluids should be kept below 6 mL/kg/h and duration of surgery should be below 2 hours to avoid an increased risk for PPCs.

Lower rate of delayed graft function is observed when epidural analgesia for living donor nephrectomy is administered.

BACKGROUND: The beneficial effects of epidural analgesia (EDA) in terms of pain control and postoperative convalescence are widely known and led to a frequent use for patients who underwent living donor kidney nephrectomy. The objective of this study was to determine whether general anesthesia (GA) plus EDA compared to GA only, administered for living donor nephrectomy has effects on postoperative graft function in recipients. METHODS: In this monocentric, retrospective cohort analysis we analyzed the closed files of all consecutive donor- recipient pairs who underwent living donor kidney transplantations from 2008 to 2017. The outcome variable was delayed graft function (DGF), defined as at least one hemodialysis within seven days postoperatively, once hyperacute rejection, vascular or urinary tract complications were ruled out. Statistical analyses of continuous variables were calculated using the two-tail Student's t test and Fisher exact test for categorical variables with a significance level of p < 0.05, respectively. RESULTS: The study enclosed 291 consecutive living donor kidney transplantations. 99 kidney donors received epidural analgesia whereas 192 had no epidural analgesia. The groups showed balanced pretransplantational characteristics and comparable donors´ and recipients' risk factors. 9 out of all 291 recipients needed renal replacement therapy (RRT) during the first 7 days due to delayed graft function; none of these donors received EDA. The observed rate of DGF in recipients whose kidney donors received epidural analgesia was significantly lower (0% vs. 4.6%; p = 0.031). CONCLUSIONS: In our cohort we observed a significantly lower rate of DGF when epidural analgesia for donor nephrectomy was administered. Due to restrictions of the study design this observation needs further confirmation by prospective studies.

Does volatile sedation with sevoflurane allow spontaneous breathing during prolonged prone positioning in intubated ARDS patients? A retrospective observational feasibility trial.

BACKGROUND: Lung-protective ventilation and prolonged prone positioning (PP) are presented as essential in treating acute respiratory distress syndrome (ARDS). The optimal respirator mode, however, remains controversial. Pressure-supported spontaneous breathing (PS) during ARDS provides several advantages, but is difficult to achieve during PP because of respiratory depression as a side effect of sedative drugs. This study was designed to evaluate the feasibility and safety of PS during PP in ARDS patients sedated with inhaled sevoflurane. RESULTS: Overall, we have observed 4339 h of prone positioning in 62 patients who had a median of four prone episodes during treatment. Within 3948 h (91%), patients were successfully brought into a pressure-supported spontaneous breathing mode. The median duration of each prone episode was 17 h (IQR 3). Median duration of pressure-supported spontaneous breathing per episode was 16 h (IQR 5). Just one self-extubation occurred during 276 episodes of PP. CONCLUSIONS AND IMPLICATIONS: Pressure-supported spontaneous breathing during prolonged prone positioning in intubated ARDS patients with or without ECMO can be achieved during volatile sedation with sevoflurane. This finding may provide a basis upon which to question the latest dogma in ARDS treatment. Our concept must be further investigated and compared to controlled ventilation with regard to driving pressure, lung-protective parameters, muscle weakness and mortality before it can be routinely applied.

Comprehensive evaluation of manikin-based airway training with second generation supraglottic airway devices.

BACKGROUND: Supraglottic airway devices (SADs) are an essential second line tool during difficult airway management after failed tracheal intubation. Particularly for such challenging situations the handling of an SAD requires sufficient training. We hypothesized that the feasibility of manikin-based airway management with second generation SADs depends on the type of manikin. METHODS: Two airway manikins (TruCorp AirSim® and Laerdal Resusci Anne® Airway Trainer™) were evaluated by 80 experienced anesthesia providers using 5 different second generation SADs (LMA® Supreme™ [LMA], Ambu® AuraGain™, i-gel®, KOO™-SGA and LTS-D™). The primary outcome of the study was feasibility of ventilation measured by assessment of the manikins' lung distention. As secondary outcome measures, oropharyngeal leakage pressure (OLP), ease of gastric tube insertion the insertion time, position and subjective assessments were evaluated. RESULTS: Ventilation was feasible with all combinations of SAD and manikin. By contrast, an OLP exceeding 10 cm H2O could be reached with most of the SADs in the TruCorp but with the LTS-D only in the Laerdal manikin. Gastric tube insertion was successful in above 90% in the Laerdal vs 87% in the TruCorp manikin (P<0.009). Insertion times differed significantly between manikins. The SAD positions were better in the Laerdal manikin for LMA, Ambu, i-gel and LTS-D. Participant's assessments were superior in the Laerdal manikin for LMA, Ambu, i-gel and KOO-SGA. CONCLUSIONS: Ventilation is possible with all combinations. However, manikins are variable in their ability to adequately represent additional functions of second generation SADs. In order to achieve the best performance during training, the airway manikin should be chosen depending on the SAD in question.

Perioperative cytokine profile during lung surgery predicts patients at risk for postoperative complications-A prospective, clinical study.

BACKGROUND: Postoperative complications after lung surgery are frequent, having a detrimental effect on patients' further course. Complications may lead to an increased length of hospital stay and cause additional costs. Several risk factors have been identified but it is still difficult to predict contemporary which patients are at risk. We hypothesized that patients who show an increased inflammatory response at the time of wound closure and 24 hours after surgery are at risk of postoperative complications within 30 days after surgery. METHODS: Postoperative complications (pulmonary, cardiac, neurological and renal) of 96 patients scheduled for lung surgery at the Medical Center-University of Freiburg were analyzed in this prospective, clinical study. Blood samples for cytokine analysis (Interleukin (IL)-6, IL-8, IL-10, Tumor necrosis factor [TNF]-α, IL-1ß and IL12p70) were taken before surgery, at wound closure and 24 hours after surgery. Cytokine levels of patients with and without postoperative complications were analyzed by Receiver operating characteristic (ROC) curve analysis. To adjust the results according to existing covariates a multivariate logistic regression analysis was conducted. RESULTS: The complication and non-complication group differed significantly according to nicotine dependency, Angiotensin-receptor-II blocker medication, rate of thoracotomy and preoperative lung function. The intraoperative hemodynamic parameters and therapy did not differ between the groups. Twenty-nine patients (30%) developed postoperative complications within 30 days after surgery. Plasma concentrations of IL-6, IL-10 and IL-8 at the time of wound closure and 24 hours after surgery were higher in the complication group. Multivariate regression analysis on postoperative complications revealed an Odds ratio of 56 for patients with IL-6 and IL-8 levels above the 3rd quartile measured on the first postoperative day. CONCLUSIONS: Perioperative detection of increased plasma concentrations of inflammatory cytokines in lung surgery may be used in addition to other clinical predictors to identify patients at risk for postoperative complications. TRIAL REGISTRATION: German Clinical Trials Register 00006961.