OBJECTIVES: Coronary artery calcifications detected by computed tomography (CT) provide prognostic relevance for vascular disorders and coronary heart disease, whereas their prognostic relevance in severely injured trauma patients remains unclear. MATERIAL AND METHODS: All consecutive trauma patients requiring emergency tracheal intubation before initial CT at a level-1 trauma center and admission to the intensive care unit (ICU) over a 12-year period (2008-2019) were reanalyzed. The Weston score, a semiquantitative method to quantify coronary calcifications, was evaluated as a prognostic variable based upon whole-body trauma CT analysis. RESULTS: Four hundred fifty-eight patients (74.6% male) with a median age of 49 years, median injury severity score of 26 points, 24-h mortality rate of 7.6%, and 30-day mortality rate of 22.1% met the inclusion criteria and were analyzed. Coronary artery calcification was present in 214 patients (46.7%). After adjustment for confounding factors, the Weston score was an independent predictor for 24-h mortality (hazard ratio, HR 1.19, 95% confidence interval, CI 1.06-1.32, p = .002) and 30-day mortality (HR 1.09, 95% CI 1.01-1.17, p = .027). In a subanalysis of 357 survivors, the Weston score was significantly associated with ICU length of stay (LOS) (beta weight 0.89, 95% CI 0.3-1.47, p = .003) but not with mechanical ventilation duration (beta weight 0.05, 95% CI -0.2-0.63, p = .304). CONCLUSION: CT-detected coronary calcification was a significant prognostic factor for 24-h- and 30-day-mortality in severely injured trauma patients requiring tracheal intubation, and influenced ICU LOS in survivors.
BACKGROUND: Providing optimal care for critically ill patients is an extremely important but also highly demanding task, both emotionally and physically. The "ICU Support" team meeting concept aims to support intensive care unit (ICU) teams by promoting interprofessional communication, peer support, and patient safety by providing a structure for daily team meetings. This protocol describes a study to explore the effectiveness of "ICU Support" for patient- and staff-centered outcomes. METHODS: ICU Support will be implemented at nine university hospitals located in Germany, following a two-arm randomized parallel group design with an intervention and a control condition and three data collection periods. In the intervention arm, leading ICU personnel (physicians and nurses) will be trained in ICU Support and implement the ICU Support elements into the daily work routine of their units upon completion of data collection period T0 (baseline). In the control arm, ICU Support will not be implemented until the completion of the data collection period T1 (1 month after study start). Until then, the regular daily schedule of the ICU teams will be maintained. The final data collection period (T2) will take place 4 months after the start of the study. Primary outcomes include the number of intensive care complications per patient during their ICU stay during T1 and the sick-related absence of ICU staff during T1. Secondary outcomes include, among others, the average severity of intensive care complications per patient and employee self-reported data regarding their teamwork and patient safety behaviors. DISCUSSION: The need for healthy and well-trained ICU staff is omnipresent; thus, structured and evidence-based interventions aimed at supporting ICU teams and facilitating patient safety are required. This multicenter study aims to explore the effectiveness of ICU Support for patient- and staff-centered outcomes. The insights derived from this study have the potential to significantly improve ICU patient safety, staff communication, and connectedness and decrease sickness-related expenses and social costs associated with high work demands among ICU staff. TRIAL REGISTRATION: German Clinical Trials Register DRKS00028642 . Registered on 4 April 2022.
COVID-19 , Humans , SARS-CoV-2 , Intensive Care Units , Critical Care , Patient-Centered Care , Randomized Controlled Trials as Topic , Multicenter Studies as Topic
INTRODUCTION: The management of polytraumatized patients is set in a stressful environment with numerous critical decisions in a brief amount of time. Working along a standardised procedure can improve the outcome for these patients and reduce mortality. To help clinical practitioners, we developed "TraumaFlow", a workflow management system for the primary care of polytrauma patients based on the current treatment guidelines. This study sought to validate the system and investigate its effect on user performance and perceived workload. METHODS: The computer-assisted decision support system was tested in two scenarios in a trauma room of a level 1 trauma centre by 11 final-year medical students and 3 residents. In simulated polytrauma scenarios, the participants functioned as a trauma leader. The first scenario was performed without decision support and the second with support by "TraumaFlow" via tablet. During each scenario, the performance was evaluated in a standardized assessment. After each scenario, the participants answered a questionnaire on workload [NASA Raw Task Load Index (NASA RTLX)]. RESULTS: In total, 14 participants (mean 28 ± 4 years, 43% female) managed 28 scenarios. During the first scenario without computer-assisted support, the participants achieved a mean of 6.6 out of 12 points (SD 1.2, range 5 to 9). With the support of TraumaFlow, the mean performance score was significantly higher with 11.6 out of 12 points (SD 0.5, range 11 to 12, p < 0.001). In the 14 scenarios performed without support, there was no run in which no errors were made. In comparison, ten of the 14 scenarios performed with TraumaFlow ran free of relevant errors. The mean improvement in the performance score was 42%. There was a significant decrease in the mean self-reported mental stress level in scenarios with support of TraumaFlow (55, SD 24) as compared to scenarios without support (72, SD 13, p = 0.041). CONCLUSION: In a simulated environment, computer-assisted decision-making improved the performance of the trauma leader, helped to adhere to clinical guidelines, and reduced stress in a fast-acting environment. In reality, this may improve the treatment outcome for the patient.
Multiple Trauma , Workload , Humans , Female , Male , Multiple Trauma/therapy , Trauma Centers , Primary Health Care , Computers
As a part of a major reform of the medical curriculum in Germany, the national catalogue of learning objectives is being revised with the focus shifting from theory-based learning to teaching practical skills. Therefore, we conducted an online survey to answer the question, which practical skills are essential in anesthesia. Participants were asked to rate the relevance of several skills, that medical students should be able to perform at the time of graduation. A total of 2898 questionnaires could be evaluated. The highest ratings were made for "bringing a patient into lateral recumbent position" and "diagnosing a cardiac arrest". All learning objectives regarding regional anesthesia were rated as irrelevant. Furthermore, learning objectives like "performing a bronchoscopy" or "performing a rapid sequence induction" had low ratings. In the subgroup analysis, physicians with advanced training and those who were working at university hospitals rated most skills with higher relevance compared to others. Our survey provides a good prioritization of practical skills for the development of new curricula and assessment frameworks. The results can also help to establish our discipline as a cross-sectional subject in competency-based medical education, thus further increasing the attractiveness for medical students.
Background: The status of Safety Management is highly relevant to evaluate an organization's ability to deal with unexpected events or errors, especially in times of crisis. However, it remains unclear to what extent Safety Management was developed and sufficiently implemented within the healthcare system during the COVID-19 pandemic. Providing insights of potential for improvement is expected to be directional for ongoing Safety Management efforts, in times of crisis and beyond. Method: A nationwide survey study was conducted among healthcare professionals and auxiliary staff on German Intensive Care Units (ICUs) evaluating their experiences during the first wave of the COVID-19 pandemic. Error Management and Patient Safety Culture (PSC) measures served to operationalize Safety Management. Data were analyzed descriptively and by using quantitative content analysis (QCA). Results: Results for n = 588 participants from 53 hospitals show that there is a gap between errors occurred, reported, documented, and addressed. QCA revealed that low quality of safety culture (27.8%) was the most mentioned reason for errors not being addressed. Overall, ratings of PSC ranged from 26.7 to 57.9% positive response with Staffing being the worst and Teamwork Within Units being the best rated dimension. While assessments showed a similar pattern, medical staff rated PSC on ICUs more positively in comparison to nursing staff. Conclusion: The status-analysis of Safety Management in times of crisis revealed relevant potential for improvement. Human Factor plays a crucial role in the occurrence and the way errors are dealt with on ICUs, but systemic factors should not be underestimated. Further intensified efforts specifically in the fields of staffing and error reporting, documentation and communication are needed to improve Safety Management on ICUs. These findings might also be applicable across nations and sectors beyond the medical field.
BACKGROUND: The field of pain medicine was established as an obligatory subject area of medical schools in Germany in 2016. No prior study has evaluated the effects of this curricular change on students' competences in the field of pain medicine. OBJECTIVE: The aim of this study was to find out to what extent the introduction of the additional subject "pain medicine" positively influenced the students' acquisition of competences measured via a self-assessment. MATERIAL AND METHODS: A longitudinal and interdisciplinary curriculum for pain medicine was developed according to the current recommendations for curriculum development for medical education. In parallel, a questionnaire was created for the students' self-assessment of their own level of knowledge and the importance of pain medicine teaching content on a 5-stage Likert scale. The surveys were conducted before the implementation of the curriculum (2014), directly after the first cohort finished (2016) and 5 years after the implementation (2019) and compared by Kruskal-Wallis test. RESULTS: The implementation of the curriculum has led to significant improvement in relevant aspects. For example, students now feel better prepared overall for the treatment of pain patients (2.67 in 2014 vs. 3.18 in 2019). Individual sub-aspects such as taking a pain history (3.63 vs. 4.10) or drawing up an analgesia scheme (3.56 vs. 4.14) are now also subjectively better mastered. CONCLUSION: Even though the results are encouraging, there is further potential for improvement in some sub-areas. For example, the students' rating regarding the question about their preparation for treating patients in pain is not yet satisfactory. Therefore, the curriculum should be developed further with a focus on competence orientation. Digital teaching formats can be integrated as well as interprofessional units and simulated patients. Additionally, the examination formats should be further developed towards standardized practical examinations.
Analgesics , Medicine , Humans , Cross-Sectional Studies , Pain , Students
The rate of occult pneumothorax in intubated and mechanically ventilated trauma patients until initial computed tomography (CT) remains undetermined. The primary aims of this study were to analyze initial chest CTs with respect to the thoracic pathology of trauma, the clinical injury severity, and chest tube placement (CTP) before and after CT. In a single-center retrospective analysis of 616 intubated and mechanically ventilated adult patients admitted directly from the scene to the emergency department (ED), 224 underwent CTP (36%). Of these, 142 patients (62%) underwent CTP before CT, of which, 125 (88%) had significant chest injury on CT. Seventeen patients had minor or absent chest injuries, most of which were associated with transient or unrecognized tracheal tube malposition. After CT, CTP was performed in another 82 patients, of which, 56 (68.3%) had relevant pneumothorax and 26 had minor findings on CT. Sixty patients who had already undergone CTP before CT received another CTP after CT, of which, 15 (25%) had relevant pneumothorax and 45 (75%) had functionality issues or malposition requiring replacement. Nine patients showed small pneumothorax on CT, and did not undergo CTP (including four patients with CTP before CT). The physiological variables were unspecific, and the trauma scores were dependent on the CT findings for identifying patients at risk for CTP. In conclusion, the clinical decisions for CTP before CT are associated with relevant false-negative and false-positive cases. Clinical assessment and CT imaging, together, are important indicators for CTP decisions that cannot be achieved by using clinical assessment or CT alone.
PURPOSE: To investigate whether (1 â 3)-ß-d-Glucan (BDG)-guidance shortens time to antifungal therapy and thereby reduces mortality of sepsis patients with high risk of invasive Candida infection (ICI). METHODS: Multicenter, randomized, controlled trial carried out between September 2016 and September 2019 in 18 intensive care units enrolling adult sepsis patients at high risk for ICI. Patients in the control group received targeted antifungal therapy driven by culture results. In addition to targeted therapy, patients in the BDG group received antifungals if at least one of two consecutive BDG samples taken during the first two study days was ≥ 80 pg/mL. Empirical antifungal therapy was discouraged in both groups. The primary endpoint was 28-day-mortality. RESULTS: 339 patients were enrolled. ICI was diagnosed in 48 patients (14.2%) within the first 96 h after enrollment. In the BDG-group, 48.8% (84/172) patients received antifungals during the first 96 h after enrollment and 6% (10/167) patients in the control group. Death until day 28 occurred in 58 of 172 patients (33.7%) in the BDG group and 51 of 167 patients (30.5%) in the control group (relative risk 1.10; 95% confidence interval, 0.80-1.51; p = 0.53). Median time to antifungal therapy was 1.1 [interquartile range (IQR) 1.0-2.2] days in the BDG group and 4.4 (IQR 2.0-9.1, p < 0.01) days in the control group. CONCLUSIONS: Serum BDG guided antifungal treatment did not improve 28-day mortality among sepsis patients with risk factors for but unexpected low rate of IC. This study cannot comment on the potential benefit of BDG-guidance in a more selected at-risk population.
Candidiasis, Invasive , Sepsis , beta-Glucans , Adult , Antifungal Agents/therapeutic use , Candidiasis, Invasive/drug therapy , Glucans/therapeutic use , Humans , Sensitivity and Specificity , Sepsis/complications , Sepsis/drug therapy
BACKGROUND: The transfer of classic concepts of competency-based medical education into clinical practice has been proven to be difficult in the past, being described as partially fragmented, misleading and inadequate. At the beginning of training, novice doctors commonly feel overwhelmed, overloaded and exposed to extreme time pressure. The discrepancy between expected and actual clinical competence of doctors at the start of their speciality training jeopardizes patient safety. The framework of Entrustable Professional Activities (EPAs) is a promising instrument to effectively integrate competency-based training into clinical practice and may help to close this gap and consequently to improve patient safety. METHODS: For anaesthesiology, we developed 5 EPAs for final-year medical students. The EPAs comprised the following seven categories: 1. Title, 2. Specifications, 3. Limitations, 4. Competency domains, 5. Knowledge, abilities and skills, professional attitudes, 6. Assessment and 7. Entrustment. Based on a modified, online-based Delphi study, we further developed and refined these EPAs. Education experts were recruited from the alumni network of the Master of Medical Education (MME) degree course from the University of Heidelberg, Germany. RESULTS: 28 data sets were evaluated in three Delphi rounds. 82% of study participants had previous experience with EPAs. Qualitative and quantitative data formed the basis during the iterative process and resulted in complete descriptions of 5 EPAs for final-year medical students in anaesthesiology. CONCLUSIONS: Our study including the associated description of 5 EPAs represent a further step and starting point for EPA-based curricula in medical training in Germany linking undergraduate training, to residency training and continuous medical education.
Anesthesiology , Internship and Residency , Students, Medical , Competency-Based Education/methods , Consensus , Humans
BACKGROUND: The SARS-CoV2 pandemic has been a major challenge for graduate education. Teaching had to be digitalized within a very short time. This also affected the areas of anesthesiology, intensive care, emergency, pain and palliative care at the Department of Anesthesiology and Intensive Care Medicine at the University of Leipzig. OBJECTIVE: The aim of this questionnaire-based survey was to find out which courses can be digitalized from the students' point of view and which forms of teaching are associated with obstacles. In addition, we examined which technical infrastructure supports digitalization best. MATERIAL AND METHODS: In the course of digitalization the lecture series in the areas of palliative care and pain medicine had to be revised but also digital alternatives for seminars, simulation courses and bedside teaching had to be created. Video podcasts, digital learning material, educational films and video conferences were used for the digital implementation of the courses. Depending on the course, different digital methods were combined. In addition, a discussion forum for the exchange between faculty and students was established. An online evaluation was then carried out to assess the content. RESULTS: A total of 82 4th and 5th year medical students took part in the survey. More than 60% of students rated the learning effect of digital courses as "high" or "very high". Video podcasts of the lectures (45.1%) and digital bedside teaching (34.1%) were rated as the most effective ways of imparting knowledge. In particular, 92.7% of the surveyed students believed that the lectures could be replaced digitally on a permanent basis. For bedside teaching (3.7%) and emergency simulation course (1.2%) this is far less the case. In the majority of cases (56.1%), students needed 30-90â¯min daily for the preparation and post-processing of the contents. Just under 90% gave the digital courses offered by the hospital an overall grade of 1 or 2 (on a scale from 1â¯= best to 6â¯= worst). CONCLUSION: The SARS-CoV2 pandemic posed major challenges for graduate teaching. At the same time, however, it also helped to overcome often long-standing hurdles to the digitalization of teaching. In the course of the digital semester, different teaching formats could be digitalized to varying degrees: Lectures can be digitally reproduced particularly well from the students' perspective, whereas the digitalization of bedside teaching has not been possible in most cases.
Anesthesiology , COVID-19 , Palliative Medicine , Students, Medical , Critical Care , Curriculum , Humans , Pain , SARS-CoV-2 , Surveys and Questionnaires , Teaching
BACKGROUND: Emergency tracheal intubation during major trauma resuscitation may be associated with unrecognised endobronchial intubation. The risk factors and outcomes associated with this issue have not previously been fully defined. METHODS: We retrospectively analysed adult patients admitted directly from the scene to the ED of a single level 1 trauma centre, who received either prehospital or ED tracheal intubation prior to initial whole-body CT from January 2008 to December 2019. Our objectives were to describe tube-to-carina distances (TCDs) via CT and to assess the risk factors and outcomes (mortality, length of intensive care unit stay and mechanical ventilation) of patients with endobronchial intubation (TCD <0 cm) using a multivariable model. RESULTS: We included 616 patients and discovered 26 (4.2%) cases of endobronchial intubation identified on CT. Factors associated with an increased risk of endobronchial intubations were short body height (OR per 1 cm increase 0.89; 95% CI 0.84 to 0.94; p≤0.001), a high body mass index (OR 1.14; 95% CI 1.04 to 1.25; p=0.005) and ED intubation (OR 3.62; 95% CI 1.39 to 8.90; p=0.006). Eight of 26 cases underwent tube thoracostomy, four of whom had no evidence of underlying chest injury on CT. There was no statistically significant difference in mortality or length of stay although the absolute number of endobronchial intubations was small. CONCLUSIONS: Short body height and high body mass index were associated with endobronchial intubation. Before considering tube thoracostomy in intubated major trauma patients suspected of pneumothorax, the possibility of unrecognised endobronchial intubation should be considered.
Emergency Medical Services , Adult , Humans , Intubation, Intratracheal/adverse effects , Retrospective Studies , Risk Factors , Trachea
BACKGROUND: General anesthesia may cause atelectasis and deterioration in oxygenation in obese patients. The authors hypothesized that individualized positive end-expiratory pressure (PEEP) improves intraoperative oxygenation and ventilation distribution compared to fixed PEEP. METHODS: This secondary analysis included all obese patients recruited at University Hospital of Leipzig from the multicenter Protective Intraoperative Ventilation with Higher versus Lower Levels of Positive End-Expiratory Pressure in Obese Patients (PROBESE) trial (n = 42) and likewise all obese patients from a local single-center trial (n = 54). Inclusion criteria for both trials were elective laparoscopic abdominal surgery, body mass index greater than or equal to 35 kg/m2, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score greater than or equal to 26. Patients were randomized to PEEP of 4 cm H2O (n = 19) or a recruitment maneuver followed by PEEP of 12 cm H2O (n = 21) in the PROBESE study. In the single-center study, they were randomized to PEEP of 5 cm H2O (n = 25) or a recruitment maneuver followed by individualized PEEP (n = 25) determined by electrical impedance tomography. Primary endpoint was Pao2/inspiratory oxygen fraction before extubation and secondary endpoints included intraoperative tidal volume distribution to dependent lung and driving pressure. RESULTS: Ninety patients were evaluated in three groups after combining the two lower PEEP groups. Median individualized PEEP was 18 (interquartile range, 16 to 22; range, 10 to 26) cm H2O. Pao2/inspiratory oxygen fraction before extubation was 515 (individual PEEP), 370 (fixed PEEP of 12 cm H2O), and 305 (fixed PEEP of 4 to 5 cm H2O) mmHg (difference to individualized PEEP, 145; 95% CI, 91 to 200; P < 0.001 for fixed PEEP of 12 cm H2O and 210; 95% CI, 164 to 257; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Intraoperative tidal volume in the dependent lung areas was 43.9% (individualized PEEP), 25.9% (fixed PEEP of 12 cm H2O) and 26.8% (fixed PEEP of 4 to 5 cm H2O) (difference to individualized PEEP: 18.0%; 95% CI, 8.0 to 20.7; P < 0.001 for fixed PEEP of 12 cm H2O and 17.1%; 95% CI, 10.0 to 20.6; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Mean intraoperative driving pressure was 9.8 cm H2O (individualized PEEP), 14.4 cm H2O (fixed PEEP of 12 cm H2O), and 18.8 cm H2O (fixed PEEP of 4 to 5 cm H2O), P < 0.001. CONCLUSIONS: This secondary analysis of obese patients undergoing laparoscopic surgery found better oxygenation, lower driving pressures, and redistribution of ventilation toward dependent lung areas measured by electrical impedance tomography using individualized PEEP. The impact on patient outcome remains unclear.
Pulmonary Atelectasis , Respiration, Artificial , Humans , Obesity , Positive-Pressure Respiration , Tidal Volume
Purpose: Communication skills are an essential instrument for building a sustainable patient-doctor-relationship for future doctors. They are learnable and teachable. The learning should be facilitated with the help of a longitudinal curriculum, which is planned at Leipzig University. Project: At the Medical Faculty of Leipzig University, the Longitudinal Communication Curriculum is established since 2016/17. Up to now, the curriculum consists of four parts in which students repeatedly practise their communication skills in curricular and extracurricular courses. Several formats help to teach an integrated learning of communication and physical examination skills. Assessment of communication skills is also performed. Curricular implementation is accompanied by concomitant evaluation. Results: Three parts of the curriculum already have taken place. Students report an increase in communication skills. Students rate the units as instructive and helpful. The assessment of communication skills occurs in two clinical practical examinations (OSCEs). Together with summative assessment a formative feedback was implemented. Students judge this practice as highly positive. Discussion: The curriculum is part of undergraduate medical education in Leipzig. It would be beneficial to add another simulated patient encounter, as well as interprofessional units. Student questionnaires will be evaluated and results will help to develop the curriculum. Conclusion: Consolidation of the curriculum accompanied by evaluation and adaption of content can help to assure the quality of the curriculum. Additional professions and study units shall be integrated in the Longitudinal Communication Curriculum in the future.
Communication , Curriculum , Education, Medical , Clinical Competence , Education, Medical/methods , Education, Medical/standards , Faculty, Medical , Germany , Humans , Students, Medical , Universities
Introduction: Due to the expanding role of ultrasound as a diagnostic tool in modern medicine, medical schools rapidly include ultrasound training in their curriculum. The objective of this study was to compare simulator-based training along with classical teaching, using human models, to impart focused transthoracic echocardiography examination. Subject and Methods: A total of 22 medical students, with no former transthoracic echocardiography training, undertook a 90-min e-learning module, dealing with focused echocardiography and important echocardiographic pathologies. Subsequently, they had to complete a multiple-choice-questioner, followed by a 120-min practical training session either on the Heartworks™, (Cardiff, UK) and the CAE Vimedix®, (Québec, Canada) simulator (n = 10) or on a live human model (n = 12). Finally, both groups had to complete a post-test consisting of ten video-based multiple-choice-questions and a time-based, focused echocardiography examination on another human model. Two blinded expert observers scored each acquired loop which recorded 2 s of each standard view. Statistical analysis was performed with SPPS 24 (SPSS™ 24, IBM, USA) using the Mann-Whitney-Test to compare both groups. Results: Analysis of measurable outcome skills showed no significant difference between transthoracic echocardiography training on human models and high-fidelity simulators for undergraduate medical students. Conclusions: Both teaching methods are effective and lead to the intended level of knowledge and skills.
Clinical Competence/statistics & numerical data , Echocardiography/methods , Simulation Training/methods , Students, Medical/statistics & numerical data , Ultrasonics/education , Humans
BACKGROUND: Robot-assisted laparoscopic radical prostatectomy requires general anaesthesia, extreme Trendelenburg positioning and capnoperitoneum. Together these promote impaired pulmonary gas exchange caused by atelectasis and may contribute to postoperative pulmonary complications. In morbidly obese patients, a recruitment manoeuvre (RM) followed by individualised PEEP improves intraoperative oxygenation and end-expiratory lung volume (EELV). We hypothesised that individualised PEEP with initial RM similarly improves intraoperative oxygenation and EELV in non-obese individuals undergoing robot-assisted prostatectomy. METHODS: Forty males (age, 49-76 yr; BMI <30 kg m-2) undergoing prostatectomy received volume-controlled ventilation (tidal volume 8 ml kg-1 predicted body weight). Participants were randomised to either (1) RM followed by individualised PEEP (RM/PEEPIND) optimised using electrical impedance tomography or (2) no RM with 5 cm H2O PEEP. The primary outcome was the ratio of arterial oxygen partial pressure to fractional inspired oxygen (Pao2/Fio2) before the last RM before extubation. Secondary outcomes included regional ventilation distribution and EELV which were measured before, during, and after anaesthesia. The cardiovascular effects of RM/PEEPIND were also assessed. RESULTS: In 20 males randomised to RM/PEEPIND, the median PEEPIND was 14 cm H2O [inter-quartile range, 8-20]. The Pao2/Fio2 was 10.0 kPa higher with RM/PEEPIND before extubation (95% confidence interval [CI], 2.6-17.3 kPa; P=0.001). RM/PEEPIND increased end-expiratory lung volume by 1.49 L (95% CI, 1.09-1.89 L; P<0.001). RM/PEEPIND also improved the regional ventilation of dependent lung regions. Vasopressor and fluid therapy was similar between groups, although 13 patients randomised to RM/PEEPIND required pharmacological therapy for bradycardia. CONCLUSION: In non-obese males, an individualised ventilation strategy improved intraoperative oxygenation, which was associated with higher end-expiratory lung volumes during robot-assisted laparoscopic prostatectomy. CLINICAL TRIAL REGISTRATION: DRKS00004199 (German clinical trials registry).
Electric Impedance , Positive-Pressure Respiration/methods , Prostatectomy/methods , Robotic Surgical Procedures/methods , Aged , Humans , Male , Middle Aged , Prospective Studies
Obesity in pediatric surgical patients is a challenge for the anesthesiologist. Despite potentially beneficial properties, propofol might also induce hypotension. This study examined whether a dose adjustment in overweight children could avoid hypotension and if there would be differences regarding hormonal regulation in children under anesthesia. Fifty-nine children undergoing surgery under general anesthesia were enrolled in this prospective observational trial. Participants were allocated into two groups according to their BMI. The induction of anesthesia was conducted using propofol ("overweight": 2 mg/kgBW, "regular": 3.2 mg/kgBW). The maintenance of anesthesia was conducted as total intravenous anesthesia. Hormone levels of renin, angiotensin II, aldosterone, copeptin, norepinephrine and epinephrine were assessed at different timepoints. Blood pressure dropped after the administration of propofol in both groups, with a nadir 2 min after administration-but without a significant difference in the strength of reduction between the two groups. As a reaction, an increase in the plasma levels of renin, angiotensin and aldosterone was observed, while levels of epinephrine, norepinephrine and copeptin dropped. By adjusting the propofol dosage in overweight children, the rate of preincision hypotension could be reduced to the level of normal-weight patients with a non-modified propofol dose. The hormonal counter regulation was comparable in both groups. The release of catecholamines and copeptin as an indicator of arginine vasopressin seemed to be inhibited by propofol.
INTRODUCTION: Posttraumatic pneumothorax (PTX) is often overseen in anteroposterior chest X-ray. Chest sonography and Electrical Impedance Tomography (EIT) can both be used at the bedside and may provide complementary information. We evaluated the performance of EIT for diagnosing posttraumatic PTX in a pig model. METHODS: This study used images from an existing database of images acquired from 17 mechanically ventilated pigs, which had sustained standardized blunt chest trauma and had undergone repeated thoracic CT and EIT. 100 corresponding EIT/CT datasets were randomly chosen from the database and anonymized. Two independent and blinded observers analyzed the EIT data for presence and location of PTX. Analysis of the corresponding CTs by a radiologist served as reference. RESULTS: 87/100 cases had at least one PTX detected by CT. Fourty-two cases showed a PTX > 20% of the sternovertebral diameter (PTXtrans20), whereas 52/100 PTX showed a PTX>3 cm in the craniocaudal diameter (PTXcc3), with 20 cases showing both a PTXtranscc and a PTXcc3. We found a very low agreement between both EIT observers considering the classification overall PTX/noPTX (κ = 0.09, p = 0.183). For PTXtrans20, sensitivity was 59% for observer 1 and 17% for observer 2, with a specificity of 48% and 50%, respectively. For PTXcc3, observer 1 showed a sensitivity of 60% with a specificity of 51% while the sensitivity of observer 2 was 17%, with a specificity of 89%. By programming a semi-automatized detection algorithm, we significantly improved the detection rate of PTXcc3, with a sensitivity of 73% and a specificity of 70%. However, detection of PTXtranscc was not improved. CONCLUSION: In our analysis, visual interpretation of EIT without specific image processing or comparison with baseline data did not allow clinically useful diagnosis of posttraumatic PTX. Multimodal imaging approaches, technical improvements and image postprocessing algorithms might improve the performance of EIT for diagnosing PTX in the future.
Electric Impedance , Pneumothorax/diagnosis , Thoracic Injuries/pathology , Tomography, X-Ray Computed/methods , Algorithms , Animals , Pneumothorax/etiology , Pneumothorax/veterinary , Respiration, Artificial , Swine , Thoracic Injuries/complications , Thoracic Injuries/veterinary , Ultrasonography , Wounds, Nonpenetrating/complications , Wounds, Nonpenetrating/pathology , Wounds, Nonpenetrating/veterinary
BACKGROUND: Iatrogenic tracheal ruptures are rare but life-threatening airway complications that often require surgical repair. Data on perioperative vital functions and anesthetic regimes are scarce. The goal of this study was to explore comorbidity, perioperative management, complications and outcomes of patients undergoing thoracotomy for surgical repair. METHODS: We retrospectively evaluated adult patients who required right thoracotomy for emergency surgical repair of iatrogenic posterior tracheal ruptures and were admitted to a university hospital over a 15-year period (2004-2018). The analyses included demographic, diagnostic, management and outcome data on preinjury morbidity and perioperative complications. RESULTS: Thirty-five patients who met the inclusion criteria were analyzed. All but two patients (96%) presented with critical underlying diseases and/or emergency tracheal intubations. The median time (interquartile range) from diagnosis to surgery was 0.3 (0.2-1.0) days. The durations of anesthesia, surgery and one-lung ventilation (OLV) were 172 (128-261) min, 100 (68-162) min, and 52 (40-99) min, respectively. The primary airway management approach to OLV was successful in only 12 patients (34%). Major complications during surgery were observed in 10 patients (29%). Four patients (11%) required cardiopulmonary resuscitation, one of whom received extracorporeal membrane oxygenation, and another one of these patients died during surgery. Major complications were associated with significantly higher all-cause 30-day mortality (p = 0.002) and adjusted mortality (p = 0.001) compared to patients with minor or no complications. CONCLUSIONS: Surgical repair of iatrogenic tracheal ruptures requires advanced perioperative care in a specialized center due to high morbidity and potential complications. Airway management should include early anticipation of alternative OLV approaches to provide acceptable conditions for surgery.
Airway Management/methods , Thoracotomy/methods , Trachea/surgery , Adult , Aged , Aged, 80 and over , Cardiopulmonary Resuscitation/statistics & numerical data , Emergencies , Extracorporeal Membrane Oxygenation , Female , Humans , Iatrogenic Disease , Intubation, Intratracheal , Male , Middle Aged , One-Lung Ventilation/statistics & numerical data , Perioperative Care/methods , Retrospective Studies , Rupture/surgery , Trachea/injuries
Endotracheal intubation is still the gold standard in airway management. For medical students and young professionals, it is often difficult to train personal skills. We tested a high-fidelity simulator with an additional quantitative feedback integration to elucidate if competence acquisition for airway management is increased by using this feedback method. In the prospective trial, all participants (n = 299; 4th-year medical students) were randomized into two groups-One had been trained on the simulator with additional quantitative feedback (n = 149) and one without (n = 150). Three simulator measurements were considered as quality criteria-The pressure on the upper front row of teeth, the correct pressure point of the laryngoscope spatula and the correct depth for the fixation of the tube. There were a total of three measurement time points-One after initial training (with additional capture of cognitive load), one during the exam, and a final during the follow-up, approximately 20 weeks after the initial training. Regarding the three quality criteria, there was only one significant difference, with an advantage for the control group with respect to the correct pressure point of the laryngoscope spatula at the time of the follow-up (p = 0.011). After the training session, the cognitive load was significantly higher in the intervention group (p = 0.008) and increased in both groups over time. The additional quantitative feedback of the airway management trainer brings no measurable advantage in training for endotracheal intubation. Due to the increased cognitive load during the training, simple airway management task training may be more efficient for the primary acquisition of essential procedural steps.
