Out-of-hospital cardiac arrest treated with prehospital double sequential external defibrillation during eCPR in refractory VF - a case report.

BACKGROUND: Double sequential external defibrillation (DSED) has demonstrated increased survival with good neurological outcome in a recent randomized controlled trial. DSED has not been studied in patients with extracorporeal cardiopulmonary resuscitation (eCPR). CASE: We present the first case of prehospital eCPR with ongoing refractory ventricular fibrillation (VF), terminated by DSED. After six shocks, return of spontaneous circulation was initially achieved; however, the patient went into recurrent VF. ECPR was performed prehospital, with VF still refractory after three more shocks. DSED successfully terminated VF and showed a further increase in etCO2 and near-infrared spectroscopy cerebral oximetry values. CONCLUSION: DSED can be a sufficient strategy for patients in refractory VF while on eCPR and should be evaluated in further studies.

The impact of "To Err Is Human" on patient safety in anesthesiology. A bibliometric analysis of 20 years of research.

Background: Patient safety gained public notoriety following the 1999 report of the Institute of Medicine: To Err is Human - Building a Safer Health System which summarized a culminated decades' worth of research that had so far been largely ignored. The aim of this study was to analyze the report's impact on patient safety research in anesthesiology. Methods: A bibliometric analysis was performed on all anesthesiologic publications from 2000 to 2019 that referenced To Err Is Human. In bibliometric literature, references are understood to represent an author's conscious decision to express a relationship between his own manuscript and the cited document. Results: The anesthesiologic data base contained 1.036 publications. The journal with the most references to the IOM report is Anesthesia & Analgesia. By analyzing author keywords and patterns of collaboration, changes in the patient safety debate and its core themes in anesthesiology over time could be visualized. The generic notion of "error," while initially a central topic in the scientific discourse, was subsequently replaced by terms representing a more granular, team-oriented, and educational approach. Patient safety research in anesthesia, while profiting from a certain intellectual and conceptual head start, showed a discursive shift toward more managerial, quality-management related topics as observed in the health care system as a whole. Conclusions: Over the last 20 years, the research context expanded from the initial focus set forth by the IOM report, which ultimately led to an underrepresentation of research on critical incident reporting and systemic approaches to safety. Important collaborations with safety researchers from outside of health care dating back to the 1990's were gradually reduced, while previous research within anesthesiology was aligned with a broader, more managerial patient safety agenda.

Emergence of power and complexity in obstetric teamwork.

BACKGROUND: Recently, increasing attention has been paid to team processes in peripartum care settings with the aim to improve fetomaternal outcomes. However, we have yet to understand how the perception of teamwork in peripartum care is shaped in a complex, multi-disciplinary environment. METHODS: The aim of this study was to approach the question using qualitative social-scientific methodology. The theoretical foundation of the study was that obstetric teamwork is the result of a balancing act in which multiple goal conflicts are continuously negotiated and managed right at the boundary of acceptable performance in a complex adaptive system. We explored this theory by gathering lived experiences of successful management of peripartum emergencies. Based on our analysis we generated an understanding of teamwork as a phenomenon emerging from interpersonal relationships, complex relations of power, and the enactment of current quality management practices. RESULTS: Caregivers define teamwork through the quality of their collaboration, defined by respect and appreciation, open communication, role distribution, and shared experiences. However, teamwork also becomes the framework for negotiation of many conflicts that originated elsewhere. Power was the core theme that emerged in the analysis of our participants' narratives, which is in stark contrast to the otherwise promoted egalitarian rhetoric of team training. While our participants generally reverted to explanations based on their professional identities, traditions or cultures, interesting dynamics become visible when work is viewed through the power lens. CONCLUSIONS: Our study paints the convoluted picture of a work environment with all its intricacies, constraints, interpersonal relations and hierarchical struggles that are much more representative of a complex system rather than the easily tractable environment that so many stakeholders would like healthcare practitioners to believe in. The issue of power emerged as a decisive factor in the social dynamics at the workplace, revealing hidden agendas in the teamwork discourse.

Postoperative abdominal sepsis induces selective and persistent changes in CTCF binding within the MHC-II region of human monocytes.

BACKGROUND: Postoperative abdominal infections belong to the most common triggers of sepsis and septic shock in intensive care units worldwide. While monocytes play a central role in mediating the initial host response to infections, sepsis-induced immune dysregulation is characterized by a defective antigen presentation to T-cells via loss of Major Histocompatibility Complex Class II DR (HLA-DR) surface expression. Here, we hypothesized a sepsis-induced differential occupancy of the CCCTC-Binding Factor (CTCF), an architectural protein and superordinate regulator of transcription, inside the Major Histocompatibility Complex Class II (MHC-II) region in patients with postoperative sepsis, contributing to an altered monocytic transcriptional response during critical illness. RESULTS: Compared to a matched surgical control cohort, postoperative sepsis was associated with selective and enduring increase in CTCF binding within the MHC-II. In detail, increased CTCF binding was detected at four sites adjacent to classical HLA class II genes coding for proteins expressed on monocyte surface. Gene expression analysis revealed a sepsis-associated decreased transcription of (i) the classical HLA genes HLA-DRA, HLA-DRB1, HLA-DPA1 and HLA-DPB1 and (ii) the gene of the MHC-II master regulator, CIITA (Class II Major Histocompatibility Complex Transactivator). Increased CTCF binding persisted in all sepsis patients, while transcriptional recovery CIITA was exclusively found in long-term survivors. CONCLUSION: Our experiments demonstrate differential and persisting alterations of CTCF occupancy within the MHC-II, accompanied by selective changes in the expression of spatially related HLA class II genes, indicating an important role of CTCF in modulating the transcriptional response of immunocompromised human monocytes during critical illness.

[Principles of intensive medical care in pregnant patients]. / Prinzipien zur intensivmedizinischen Versorgung der schwangeren Patientin.

As the incidence of diseases during pregnancy or in the puerperium necessitating intensive medical care is very low, intensive care physicians are faced with a multitude of unfamiliar challenges in the treatment of this patient collective. The physiological and pathophysiological alterations during pregnancy induce some specific features with respect to the intensive medical treatment of pregnant or postpartum patients. Therefore, the first article in this CME series summarizes the most important principles and current recommendations on the care of pregnant or postpartum patients who need intensive medical treatment, always under consideration of the well-being of mother and child. The second article describes the diagnostics and treatment of special selected pathologies.

[Special pathologies of pregnant patients in intensive care medicine]. / Spezielle intensivmedizinische Krankheitsbilder der schwangeren Patientin.

As the incidence of diseases during pregnancy that necessitate intensive medical care is very low, intensive care physicians are faced with a multitude of unfamiliar challenges in the treatment of these patients. The physiological and pathophysiological alterations during pregnancy induce some specific features with respect to the intensive medical treatment of pregnant or postpartum patients. After the most important principles and current recommendations on the care of pregnant or postpartum patients who need intensive medical treatment were dealt with in the first article in this CME series, the second article focuses on the diagnostics and treatment of special selected pathologies.

Optimal care for mother and child: Safety in obstetric anaesthesia.

Anaesthetists play a major role in the perioperative treatment of patients, sharing responsibility for quality and safety in anaesthesia, intensive care, emergency and pain medicine. Several aspects lead to the fact that these issues are particularly important in obstetric anaesthesia. As morbidity and mortality are dramatically higher than in a nonpregnant population in this age, there is room for improvement even in regions with a well-developed healthcare system. Adverse events and complications during birth often hit fast, hard and unexpectedly and require immediate patient-centred care. This mostly involves an interdisciplinary and interprofessional approach that includes obstetricians, neonatologists, anaesthetists, intensivists and of course midwives and nurses. In this article, established standards and emerging possibilities to improve patient safety by developing a culture of awareness for safety aspects, education, establishing safety and communication strategies and performing teamwork- and simulation training are discussed. Apart from these issues, self-care of clinicians is vital in the prevention of adverse events, because fatigue and burnout are associated with increased rates of complications.

"Attention Everyone, Time Out!": Safety Attitudes and Checklist Practices in Anesthesiology in Germany. A Cross-Sectional Study.

BACKGROUND: The use of perioperative checklists has generated a growing body of evidence pointing toward reduction of mortality and morbidity, improved compliance with guidelines, reduction of adverse events, and improvements in human factor-related areas. Usual quality management metrics generally fall short in assessing compliance with their perioperative application. Our study assessed application attitudes and compliance with safety measures centered around the World Health Organization (WHO) "Safe Surgery Saves Lives" campaign as perceived by anesthesia professionals in Germany. METHODS: Three hundred sixteen physicians and nurses participated in our cross-sectional survey, and 304 completed all 35 questions. RESULTS: Only 59.5% of participants had knowledge of the theoretical framework behind the WHO campaign. During the "sign-in," patient ID and surgical site were checked in 99.6% and 95.1% as recommended by the WHO. Allergies were addressed by 89.2%, expected difficult airway by 65.7%, and the availability of blood products by 70.5%. A total of 84.9% of participants advocated for the time-out to include all persons present in the operating room, which was the case in 57.0%. A total of 40.8% stated that the time-out was only performed between anesthetist and surgeon; in 17.0% of cases, the patient was simultaneously draped and/or surgically scrubbed. No significant differences between hospital types were observed. CONCLUSIONS: Our study paints a heterogeneous picture of the implementation, usage, and safety attitudes concerning the Safe Surgery Checklist as promoted by the WHO. The lack of standardized execution and team-mindedness can be taken as further evidence for the importance of interdisciplinary training focusing on human factors, communication, and collaboration rather than the mere implementation by decree.

Cardiopulmonary resuscitation (CPR) during spaceflight - a guideline for CPR in microgravity from the German Society of Aerospace Medicine (DGLRM) and the European Society of Aerospace Medicine Space Medicine Group (ESAM-SMG).

BACKGROUND: With the "Artemis"-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency - cardiac arrest. METHODS: After the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to "MEDLINE". Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology. RESULTS: We recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved. DISCUSSION: CPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.

Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects.

: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.

Impact of a semi-structured briefing on the management of adverse events in anesthesiology: a randomized pilot study.

BACKGROUND: Human factors research has identified mental models as a key component for the effective sharing and organization of knowledge. The challenge lies in the development and application of tools that help team members to arrive at a shared understanding of a situation. The aim of this study was to assess the influence of a semi-structured briefing on the management of a simulated airway emergency. METHODS: 37 interprofessional teams were asked to perform a simulated rapid-sequence induction in the simulator. Teams were presented with a "cannot ventilate, cannot oxygenate" scenario that ultimately required a cricothyroidotomy. Study group (SG) teams were asked to perform a briefing prior to induction, while controls (CG) were asked to perform their usual routine. RESULTS: We observed no difference in the mean time until cricothyroidotomy (SG 8:31 CG 8:16, p = 0.36). There was a significant difference in groups' choice of alternative means of oxygenation: While SG teams primarily chose supraglottic airway devices, controls initially reverted to mask ventilation (p = 0.005). SG teams spent significantly less time with this alternative airway device and were quicker to advance in the airway algorithm. CONCLUSIONS: Our study addresses effects on team coordination through a shared mental model as effected by a briefing prior to anesthesia induction. We found measurable improvements in airway management during those stages of the difficult airway algorithm explicitly discussed in the briefing. For those, time spent was shorter and participants were quicker to advance in the airway algorithm.

Airway management in microgravity: A systematic review.

INTRODUCTION: In the near future, space programs will shift their focus toward long-duration interplanetary missions, in particular to the Moon and Mars. These exploration missions will be associated with an increased risk of acute medical problems, which will need to be handled by an autonomous crew operating in extreme isolation. An important skill in emergencies is represented by airway management. Many airway devices are available and it is unclear which one would be the most suitable in the context of a space mission. The aim of this systematic review was to analyze the existing literature on airway management in the special situation of weightlessness during space missions. MATERIAL AND METHODS: We performed a standardized review of published literature on airway management in spaceflight and analogue environments using the database PubMed. RESULTS: We identified a total of 3111 publications of which 3039 were initially excluded after evaluation. The screening identified three randomized comparative manikin studies, two of them in parabolic flights, one in a submerged setup. Under free-floating conditions, the insertion success rate of supraglottic airway devices (SGA) was excellent (91%-97%). The administration of artificial ventilation could be successfully achieved in weightlessness with SGA. The success rate of conventional laryngoscopy under free-floating conditions fluctuated between 15% and 86%. CONCLUSION: It appears possible to safely manage the airway in weightlessness, provided that certain conditions are ensured, such as restraining the patient and operator for conventional orotracheal intubation. If airway protection is required with endotracheal intubation, both the operator and the patient should be restrained.

Applying the human factors analysis and classification system to critical incident reports in anaesthesiology.

BACKGROUND: The Human Factors Analysis and Classification System (HFACS) was developed as a practical taxonomy to investigate and analyse the human contribution to accidents and incidents. Based on Reason's "Swiss Cheese Model", it considers individual, environmental, leadership and organizational contributing factors in four hierarchical levels. The aim of this study was to assess the applicability of a modified HFACS taxonomy to incident reports from a large, anonymous critical incident database with the goal of gaining valuable insight into underlying, more systemic conditions and recurring schemes that might add important information for future incident avoidance. METHODS: We analysed 50 reports from an anonymous, anaesthesiologic, single-centre Critical Incident Reporting System using a modified HFACS-CIRS taxonomy. The 19 HFACS categories were further subdivided into a total of 117 nanocodes representing specific behaviours or preconditions for incident development. RESULTS: On an individual level, the most frequent contributions were decision errors, attributed to inadequate risk assessment or critical-thinking failure. Communication and Coordination, mostly due to inadequate or ineffective communication, was contributory in two-thirds of reports. Half of the reports showed contributory complex interactions in a sociotechnical environment. Ratability scores were noticeably lower for categories evaluating leadership and organizational influences, necessitating careful interpretation. CONCLUSIONS: We applied the HFACS taxonomy to the analysis of CIRS reports in anaesthesiology. This constitutes a structured approach that, especially when applied to a large data set, might help guide future mitigation and intervention strategies to reduce critical incidents and improve patient safety. Improved, more structured reporting templates could further optimize systematic analysis.

In-flight cardiac arrest and in-flight cardiopulmonary resuscitation during commercial air travel: consensus statement and supplementary treatment guideline from the German Society of Aerospace Medicine (DGLRM).

By the end of the year 2016, approximately 3 billion people worldwide travelled by commercial air transport. Between 1 out of 14,000 and 1 out of 50,000 passengers will experience acute medical problems/emergencies during a flight (i.e., in-flight medical emergency). Cardiac arrest accounts for 0.3% of all in-flight medical emergencies. So far, no specific guideline exists for the management and treatment of in-flight cardiac arrest (IFCA). A task force with clinical and investigational expertise in aviation, aviation medicine, and emergency medicine was created to develop a consensus based on scientific evidence and compiled a guideline for the management and treatment of in-flight cardiac arrests. Using the GRADE, RAND, and DELPHI methods, a systematic literature search was performed in PubMed. Specific recommendations have been developed for the treatment of IFCA. A total of 29 specific recommendations for the treatment and management of in-flight cardiac arrests were generated. The main recommendations included emergency equipments as well as communication of the emergency. Training of the crew is of utmost importance, and should ideally have a focus on CPR in aircraft. The decision for a diversion should be considered very carefully.

Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology.

: The purpose of this update of the European Society of Anaesthesiology (ESA) guidelines on the pre-operative evaluation of the adult undergoing noncardiac surgery is to present recommendations based on the available relevant clinical evidence. Well performed randomised studies on the topic are limited and therefore many recommendations rely to a large extent on expert opinion and may need to be adapted specifically to the healthcare systems of individual countries. This article aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthesiologists all over Europe to integrate - wherever possible - this knowledge into daily patient care. The Guidelines Committee of the ESA formed a task force comprising members of the previous task force, members of ESA scientific subcommittees and an open call for volunteers was made to all individual active members of the ESA and national societies. Electronic databases were searched from July 2010 (end of the literature search of the previous ESA guidelines on pre-operative evaluation) to May 2016 without language restrictions. A total of 34 066 abtracts were screened from which 2536 were included for further analysis. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members, individual or national (thus including most European national anaesthesia societies). Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

In-flight medical emergencies during airline operations: a survey of physicians on the incidence, nature, and available medical equipment.

BACKGROUND: Data on the incidence of in-flight medical emergencies on-board civil aircraft are uncommon and rarely published. Such data could provide information regarding required medical equipment on-board aircraft and requisite training for cabin crew. The aim of the present study was to gather data on the incidences, nature, and medical equipment for in-flight medical emergencies by way of a survey of physician members of a German aerospace medical society. MATERIALS AND METHODS: Using unipark.de (QuestBack GmbH, Cologne, Germany), an online survey was developed and used to gather specific information. Members of the German Society for Aviation and Space Medicine (Deutsche Gesellschaft für Luft- und Raumfahrtmedizin e.V.; DGLRM) were invited to participate in the survey during a 4-week period (21 March 2015 to 20 April 2015). Chi-square test was used for statistical analysis (p<0.05 was considered significant). RESULTS: Altogether, 121 members of the society responded to the survey (n=335 sent out). Of the 121 respondents, n=54 (44.6%) of the participants (89.9% male and 10.1% female; mean age, 54.1 years; n=121) were involved in at least one in-flight medical emergency. Demographic parameters in this survey were in concordance with the society members' demographics. The mean duration of flights was 5.7 hours and the respondents performed 7.1 airline flights per year (median). Cardiovascular (40.0%) and neurological disorders (17.8%) were the most frequent diagnoses. The medical equipment (78.7%) provided was sufficient. An emergency diversion was undertaken in 10.6% of the cases. Although using a different method of data acquisition, this survey confirms previous data on the nature of emergencies and gives plausible numbers. CONCLUSION: Our data strongly argue for the establishment of a standardized database for recording the incidence and nature of in-flight medical emergencies. Such a database could inform on required medical equipment and cabin crew training.

Cognitive responses to hypobaric hypoxia: implications for aviation training.

The aim of this narrative review is to provide an overview on cognitive responses to hypobaric hypoxia and to show relevant implications for aviation training. A principal element of hypoxia-awareness training is the intentional evocation of hypoxia symptoms during specific training sessions within a safe and controlled environment. Repetitive training should enable pilots to learn and recognize their personal hypoxia symptoms. A time span of 3-6 years is generally considered suitable to refresh knowledge of the more subtle and early symptoms especially. Currently, there are two different technical approaches available to induce hypoxia during training: hypobaric chamber training and reduced-oxygen breathing devices. Hypoxia training for aircrew is extremely important and effective, and the hypoxia symptoms should be emphasized clearly to aircrews. The use of tight-fitting masks, leak checks, and equipment checks should be taught to all aircrew and reinforced regularly. It is noteworthy that there are major differences in the required quality and quantity of hypoxia training for both military and civilian pilots.