Organic synthesis associated with serpentinization and carbonation on early Mars.

Water-rock interactions are relevant to planetary habitability, influencing mineralogical diversity and the production of organic molecules. We examine carbonates and silicates in the martian meteorite Allan Hills 84001 (ALH 84001), using colocated nanoscale analyses, to characterize the nature of water-rock reactions on early Mars. We find complex refractory organic material associated with mineral assemblages that formed by mineral carbonation and serpentinization reactions. The organic molecules are colocated with nanophase magnetite; both formed in situ during water-rock interactions on Mars. Two potentially distinct mechanisms of abiotic organic synthesis operated on early Mars during the late Noachian period (3.9 to 4.1 billion years ago).

Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

[Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study]. / Implementierung anästhesiologischer Qualitätsindikatoren in Deutschland : Eine prospektive, nationale, multizentrische Qualitätssteigerungsstudie German version.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

Low-temperature synthesis of nanoscale ferromagnetic α'-MnB.

The search for tunable, size-dependent properties and unique processability has triggered the development of new synthetic routes for transition metal borides. MnB is a soft to semi-hard ferromagnetic material. This boride is now available by bottom-up, low-temperature solution chemistry. It is obtained as an unexpected metastable α'-variant that crystallises with a stacking-fault dominated CrB-type structure, as shown by transmission electron microscopy and X-ray powder diffraction (space group Cmcm, a = 300.5(8), b = 768.6(2), and c = 295.3(4) pm). The nanostructured powder consists of agglomerates of small particles (mean diameter of 85(41) nm) and transforms into well-known ß-MnB with FeB-type structure at 1523 K. The room temperature ferromagnetic behavior (TC = 545 K) is attributed to the positive exchange-correlation between the manganese atoms, that have many unpaired d electrons.

The First Samples from Almahata Sitta Showing Contacts Between Ureilitic and Chondritic Lithologies: Implications for the Structure and Composition of Asteroid 2008 TC3.

Almahata Sitta (AhS), an anomalous polymict ureilite, is the first meteorite observed to originate from a spectrally classified asteroid (2008 TC3). However, correlating properties of the meteorite with those of the asteroid is not straightforward because the AhS stones are diverse types. Of those studied prior to this work, 70-80% are ureilites (achondrites) and 20-30% are various types of chondrites. Asteroid 2008 TC3 was a heterogeneous breccia that disintegrated in the atmosphere, with its clasts landing on Earth as individual stones and most of its mass lost. We describe AhS 91A and AhS 671, which are the first AhS stones to show contacts between ureilitic and chondritic materials and provide direct information about the structure and composition of asteroid 2008 TC3. AhS 91A and AhS 671 are friable breccias, consisting of a C1 lithology that encloses rounded to angular clasts (<10 µm to 3 mm) of olivine, pyroxenes, plagioclase, graphite, and metal-sulfide, as well as chondrules (~130-600 µm) and chondrule fragments. The C1 material consists of fine-grained phyllosilicates (serpentine and saponite) and amorphous material, magnetite, breunnerite, dolomite, fayalitic olivine (Fo 28-42), an unidentified Ca-rich silicate phase, Fe,Ni sulfides, and minor Ca-phosphate and ilmenite. It has similarities to CI1 but shows evidence of heterogeneous thermal metamorphism. Its bulk oxygen isotope composition (δ18O = 13.53‰, δ17O = 8.93‰) is unlike that of any known chondrite, but similar to compositions of several CC-like clasts in typical polymict ureilites. Its Cr isotope composition is unlike that of any known meteorite. The enclosed clasts and chondrules do not belong to the C1 lithology. The olivine (Fo 75-88), pyroxenes (pigeonite of Wo ~10 and orthopyroxene of Wo ~4.6), plagioclase, graphite, and some metal-sulfide are ureilitic, based on mineral compositions, textures, and oxygen isotope compositions, and represent at least six distinct ureilitic lithologies. The chondrules are probably derived from type 3 OC and/or CC, based on mineral and oxygen isotope compositions. Some of the metal-sulfide clasts are derived from EC. AhS 91A and AhS 671 are plausible representatives of the bulk of the asteroid that was lost. Reflectance spectra of AhS 91A are dark (reflectance ~0.04-0.05) and relatively featureless in VNIR, and have an ~2.7 µm absorption band due to OH- in phyllosilicates. Spectral modeling, using mixtures of laboratory VNIR reflectance spectra of AhS stones to fit the F-type spectrum of the asteroid, suggests that 2008 TC3 consisted mainly of ureilitic and AhS 91A-like materials, with as much as 40-70% of the latter, and <10% of OC, EC and other meteorite types. The bulk density of AhS 91A (2.35 ± 0.05 g/cm3) is lower than bulk densities of other AhS stones, and closer to estimates for the asteroid (~1.7-2.2 g/cm3). Its porosity (36%) is near the low end of estimates for the asteroid (33-50%), suggesting significant macroporosity. The textures of AhS 91A and AhS 671 (finely comminuted clasts of disparate materials intimately mixed) support formation of 2008 TC3 in a regolith environment. AhS 91A and AhS 671 could represent a volume of regolith formed when a CC-like body impacted into already well-gardened ureilitic + impactor-derived debris. AhS 91A bulk samples do not show a solar wind (SW) component, so they represent sub-surface layers. AhS 91A has a lower cosmic ray exposure (CRE) age (~5-9 Ma) than previously studied AhS stones (11-22 Ma). The spread in CRE ages argues for irradiation in a regolith environment. AhS 91A and AhS 671 show that ureilitic asteroids could have detectable ~2.7 µm absorption bands.

Organic synthesis on Mars by electrochemical reduction of CO2.

The sources and nature of organic carbon on Mars have been a subject of intense research. Steele et al. (2012) showed that 10 martian meteorites contain macromolecular carbon phases contained within pyroxene- and olivine-hosted melt inclusions. Here, we show that martian meteorites Tissint, Nakhla, and NWA 1950 have an inventory of organic carbon species associated with fluid-mineral reactions that are remarkably consistent with those detected by the Mars Science Laboratory (MSL) mission. We advance the hypothesis that interactions among spinel-group minerals, sulfides, and a brine enable the electrochemical reduction of aqueous CO2 to organic molecules. Although documented here in martian samples, a similar process likely occurs wherever igneous rocks containing spinel-group minerals and/or sulfides encounter brines.

Evaluation of a wireless activity monitoring system to quantify locomotor activity in horses in experimental settings.

REASONS FOR PERFORMING STUDY: Methods of evaluating locomotor activity can be useful in efforts to quantify behavioural activity in horses objectively. OBJECTIVES: To evaluate whether an accelerometric device would be adequate to quantify locomotor activity and step frequency in horses, and to distinguish between different levels of activity and different gaits. STUDY DESIGN: Observational study in an experimental setting. METHODS: Dual-mode (activity and step count) piezo-electric accelerometric devices were placed at each of 4 locations (head, withers, forelimb and hindlimb) in each of 6 horses performing different controlled activities including grazing, walking at different speeds, trotting and cantering. Both the activity count and step count were recorded and compared by the various activities. Statistical analyses included analysis of variance for repeated measures, receiver operating characteristic curves, Bland-Altman analysis and linear regression. RESULTS: The accelerometric device was able to quantify locomotor activity at each of the 4 locations investigated and to distinguish between gaits and speeds. The activity count recorded by the accelerometer placed on the hindlimb was the most accurate, displaying a clear discrimination between the different levels of activity and a linear correlation to speed. The accelerometer placed on the head was the only one to distinguish specifically grazing behaviour from standing. The accelerometer placed on the withers was unable to differentiate different gaits and activity levels. The step count function measured at the hindlimb was reliable but the count was doubled at the walk. CONCLUSIONS: The dual-mode accelerometric device was sufficiently accurate to quantify and compare locomotor activity in horses moving at different speeds and gaits. Positioning the device on the hindlimb allowed for the most accurate results. The step count function can be useful but must be manually corrected, especially at the walk.

Mastering hysteresis in magnetocaloric materials.

Hysteresis is more than just an interesting oddity that occurs in materials with a first-order transition. It is a real obstacle on the path from existing laboratory-scale prototypes of magnetic refrigerators towards commercialization of this potentially disruptive cooling technology. Indeed, the reversibility of the magnetocaloric effect, being essential for magnetic heat pumps, strongly depends on the width of the thermal hysteresis and, therefore, it is necessary to understand the mechanisms causing hysteresis and to find solutions to minimize losses associated with thermal hysteresis in order to maximize the efficiency of magnetic cooling devices. In this work, we discuss the fundamental aspects that can contribute to thermal hysteresis and the strategies that we are developing to at least partially overcome the hysteresis problem in some selected classes of magnetocaloric materials with large application potential. In doing so, we refer to the most relevant classes of magnetic refrigerants La-Fe-Si-, Heusler- and Fe2P-type compounds.This article is part of the themed issue 'Taking the temperature of phase transitions in cool materials'.

Raman Imaging Spectroscopy of a Putative Microfossil from the ∼3.46 Ga Apex Chert: Insights from Quartz Grain Orientation.

The utility of nondestructive laser Raman for testing the biogenicity of microfossil-like structures in ancient rocks is promising, yet results from deposits like the ∼3.46 Ga Apex chert remain contentious. The essence of the debate is that associated microstructures, which are not purported to be microfossils, also contain reduced carbon that displays Raman D- and G-band peaks similar to those seen in the purported microfossils. This has led to the hypothesis that all features including reported microfossils are due to compression of nonfossil carbon during crystal growth around quartz spherulites or more angular crystals. In this scenario, the precursor to this macromolecular carbon may or may not have been of biogenic origin, while the arcuate and linear features described would be pseudofossils. To test this hypothesis, we have undertaken 2-D micro-Raman imaging of the Eoleptonema apex holotype and associated features using instrumentation with a high spatial and spectral resolution. In addition to this, we utilized the ratio of two Raman active quartz mode intensities (I129/I461) to assess quartz grain orientation and grain-splitting artifacts. These data lead us to conclude that the holotype of Eoleptonema apex is a sheet-shaped pseudofossil that appears to be a carbon infilled intragranular crack; therefore other holotypes should be carefully reexamined for syngenicity.

Development and Implementation of a Novel Sulfur Removal Process from H2S Containing Wastewaters.

A novel process for removing sulfur from wastewater containing dissolved sulfide has been developed and implemented in a membrane bioreactor (MBR) process treating anaerobically pretreated industrial (pulp and paper) wastewater at the Gippsland Water Factory. Controlled oxygen addition to the first bioreactor zone (constituting 27.7% of the total bioreactor volume) to create oxygen-limiting conditions, followed by oxygen-sufficient conditions in the remaining zones of the bioreactor, provide the necessary conditions. Dissolved sulfide is oxidized to elemental sulfur in the first zone, and the accumulated sulfur is retained in the bioreactor mixed liquor suspended solids (MLSS) in the remaining zones. Accumulated sulfur is removed from the process in the waste activated sludge (WAS). Oxidation of dissolved sulfide to elemental sulfur reduces the associated process oxygen requirement by 75% compared to oxidation to sulfate. Microscopic examinations confirm that biological accumulation of elemental sulfur occurs. Process performance was analyzed during a nearly 2-year commissioning and optimization period. Addition of air in proportion to the process influent dissolved sulfide loading proved the most effective process control approach, followed by the maintenance of dissolved oxygen concentrations of 1.0 and 1.5 mg/L in the two downstream bioreactor zones. Sufficient oxygen is added for the stoichiometric conversion of dissolved sulfide to elemental sulfur. Enhanced biological phosphorus removal also occurred under these conditions, thereby simplifying supplemental phosphorus addition. These operating conditions also appear to lead to low and stable capillary suction time values for the MBR mixed liquor.

Molecular weight and molar substitution are more important in HES-induced renal impairment than concentration after hemorrhagic and septic shock.

BACKGROUND: Clinical studies have raised concerns about the safety of 6% hydroxyethylstarch (HES) 130/0.42, but the pathomechanisms of this renal impairment remain unknown. To evaluate the effects of different HES concentrations, molar substitutions and molecular weights in HES-induced renal impairment, we used a porcine two-hit model that combined haemorrhagic and septic shock. METHODS: We conducted a prospective, randomised, double-blinded, controlled study in a university animal laboratory. Thirty anaesthetised and ventilated pigs were randomised to receive volume replacement therapy using 6% HES130/0.42, 6% HES200/0.5, 10% HES130/0.42 or 10% HES200/0.5, all dissolved in 0.9% NaCl rather than 0.9% NaCl alone. First, we bled the animals until they reached half of their baseline mean arterial pressure (MAP) for 45 minutes followed by fluid resuscitation. As a second hit, sepsis was induced using an Escherichia coli-laden clot 6 hours after haemorrhagic shock. Volume resuscitation started with a delay of two hours and a central venous pressure goal of 12 mmHg. RESULTS: At the end of the study, the groups showed no difference in cardiac output or MAP, but the volume balance (mL/kg BW) was significantly higher in the 0.9% NaCl group (346±90; P≤0.05) than in the other groups (6% HES130, 125±26; 6% HES200, 105±15; 10% HES130, 114±17; 10% HES200, 96±23). Creatinine clearance (mL/min) was significantly lower in the 6% HES200 (26±33) and 10% HES200 (15±18) groups compared to the 0.9% NaCl group (104±46; P≤0.05) but not in the HES 130 formulations (6% HES130: 64±51; 10% HES130: 58±38) at the end of the study. CONCLUSION: In this porcine two-hit shock model, treatment with 0.9% NaCl, HES 130/0.42 or HES 200/0.5 led to a similar maintenance of haemodynamic values. Despite this similar maintenance of the haemodynamic values, volume replacement with 6% and 10% HES 200/0.5 led to an accumulation of HES, higher colloid osmotic pressure and significantly reduced renal function after haemorrhagic and septic shock. These facts support the presumption that not the concentration but the degree of substitution and the molecular weight play a decisive role in HES-induced renal impairment.

Argon reduces neurohistopathological damage and preserves functional recovery after cardiac arrest in rats.

BACKGROUND: Xenon has profound neuroprotective effects after neurological injury and is currently undergoing phase 2 clinical trials in cardiac arrest patients. However, xenon is very costly, which might preclude its widespread use. We hypothesized argon, which is more available, might also protect central nervous tissues and allow better functional recovery in a rodent model of global cerebral ischaemia. METHODS: Fourteen male Sprague-Dawley rats were subjected to 7 min of cardiac arrest and 3 min of cardiopulmonary resuscitation (CPR). One hour after successful CPR, animals were randomized to either ventilation with 70% argon in oxygen (n = 7) for 1 h or 70% nitrogen (controls, n=7). A neurological deficit score (NDS) was calculated daily for the following 7 days, then the animals were killed and the brains harvested for histopathological analyses. RESULTS: All animals survived. Control rats had severe neurological dysfunction, while argon-treated animals showed significant improvements in the NDS at all time points. This was paralleled by a significant reduction in the neuronal damage index in the neocortex and the hippocampal CA 3/4 region. CONCLUSIONS: Our study demonstrates that a single 1 h application of 70% argon significantly reduced histopathological damage of the neocortex and hippocampus, associated with a marked improvement in functional neurological recovery.

Micro Raman spectroscopy of carbonaceous material in microfossils and meteorites: improving a method for life detection.

The identification of biosignatures in Earth's ancient rock record and detection of extraplanetary life is one of the primary goals in astrobiology. Intrinsic to this goal is the improvement of analytical techniques and protocols used to identify an unambiguous signal of life. Micro Raman spectroscopy is a nondestructive method that allows for in situ identification of a wide range of minerals and compounds. The use of D (∼1350 cm(-1)) and G (∼1580 cm(-1)) band parameters to infer the biogenicity of carbonaceous materials in fossils has become a commonly used analytical tool, but carbonaceous compounds from different sources often share the same spectroscopic characteristics. Microfossil studies do not always take into consideration a nonbiological source for the carbon in their samples and therefore still rely on morphology as the primary mode of identification. Comprehensive studies that consider all carbon sources are typically done on metasediments, coals, or meteorites, and the results are not clearly applicable to microfossil identification. In this study, microfossils from a suite of sedimentary rock samples of various ages were analyzed with micro Raman spectroscopy to investigate the nature and provenance of carbonaceous material. To further constrain D- and G-band carbon characteristics, micro Raman analyses were also performed on well-characterized meteorite samples as abiological controls. The results appear to show a correlation of precursor carbonaceous material with D-band parameters and thermal history with G-band parameters. This systematic study lays the groundwork for improving the use of the G- and D-band trends as useful indicators of the origin of carbon in microfossils. Before unambiguous biosignatures can be established, further work characterizing the carbonaceous material in microfossils of different ages, thermal histories, and host rock compositions is needed.

A reduced organic carbon component in martian basalts.

The source and nature of carbon on Mars have been a subject of intense speculation. We report the results of confocal Raman imaging spectroscopy on 11 martian meteorites, spanning about 4.2 billion years of martian history. Ten of the meteorites contain abiotic macromolecular carbon (MMC) phases detected in association with small oxide grains included within high-temperature minerals. Polycyclic aromatic hydrocarbons were detected along with MMC phases in Dar al Gani 476. The association of organic carbon within magmatic minerals indicates that martian magmas favored precipitation of reduced carbon species during crystallization. The ubiquitous distribution of abiotic organic carbon in martian igneous rocks is important for understanding the martian carbon cycle and has implications for future missions to detect possible past martian life.

Effect of monthly ibandronate on hip structural geometry in men with low bone density.

UNLABELLED: Hip structural analysis (HSA) performed in a subset of participants from the STudy Researching Osteoporosis iN Guys (STRONG) demonstrated that 1 year of ibandronate treatment was associated with a significant improvement in some but not all parameters of hip geometry relative to placebo in men with low bone density. INTRODUCTION: HSA was performed on dual-energy X-ray absorptiometry (DXA) images in a subset of participants from the STRONG to examine the impact of monthly ibandronate on geometric properties of the hip in men with low bone density. METHODS: This prespecified subgroup analysis evaluated men in the intent-to-treat population of STRONG with baseline and 12-month DXA data. Cross-sectional geometric parameters of the femoral shaft (FS), intertrochanter region (IT), and narrow neck (NN) were calculated from femoral DXA scans. All analyses were exploratory. Treatment differences were evaluated using analysis of covariance, which adjusted for baseline parameter value, testosterone level, and treatment. RESULTS: HSA was performed on DXA scans from 89 men (34 placebo; 55 monthly ibandronate). Significant increases in average cortical thickness and cross-sectional area and decreases (i.e., improvements) in the buckling ratio were observed at the FS and IT at 12 months for ibandronate-treated men compared with placebo-treated men. No significant differences were observed between ibandronate and placebo for any NN HSA parameters. CONCLUSIONS: One year of ibandronate treatment was associated with a significant improvement in some but not all parameters of hip geometry relative to placebo in men with low bone density, suggesting that ibandronate may improve resistance to axial compressive forces and bending forces at the hip.

Impact of early vs. late tracheostomy on weaning: a retrospective analysis.

BACKGROUND: Early tracheostomy has been advocated for a number of reasons. Especially in association with weaning from mechanical ventilation, it is known that an early timepoint can help patients being weaned more rapidly from the ventilator. However, timing of tracheostomy is still unknown and evidence is lacking. The effects of early tracheostomy compared with intermediate and late tracheostomy were assessed in critically ill patients. METHODS: Data collected from January 2005 to December 2007 were conducted for retrospective analysis. All patients needing tracheostomy due to extubation failure and/or weaning failure were included (N.=296). Early tracheostomy (ET) was defined as ≤4 days, intermediate tracheostomy (IT) as tracheostomy within 5-9 days, and late tracheostomy (LT) was defined as ≥10 days after endotracheal intubation. After proving normal distribution, significant changes between the three groups were tested by ANOVA followed by post hoc tests for multiple comparisons (Bonferroni's test). RESULTS: Intensive care unit (ICU) mortality was significantly higher in the LT group when being compared with the ET but not when being compared with the IT group (40.7% vs. 24.8% vs. 17.1%). Further, a significantly reduced incidence of VAP and sepsis, a smaller amount of ventilator days and a shorter ICU length of stay could be observed for the ET group. Length of weaning was not significantly different between the groups. CONCLUSION: The length of weaning after tracheostomy is not affected by the timing. It seems beneficial to favour early tracheostomy in order to reduce the time of mechanical ventilation and its associated risks.

Outcome and mortality risk factors in long-term treated ICU patients: a retrospective analysis.

BACKGROUND: Little is known about the prognosis and outcome of critically ill patients with a prolonged length of stay (LOS). The aim of this study was to examine mortality and its risk factors in patients requiring intensive care therapy for more than 30 days. METHODS: A retrospective, single-center analysis of data collected in a surgical intensive care unit (ICU) of a university hospital in Germany from 2005 to 2007 was conducted. All demographic data and clinical variables were collected. A univariate analysis followed by multivariate regression was performed to detect the relevant risk factors for short and long-term mortality. RESULTS: Altogether, 10 737 patients were admitted to the ICU; 136 patients fulfilled the criteria for long-term treatment, 75% (N=102) of whom were discharged from ICU. The one-year survival rate was 61.8% (N=60). The most significant risk factors were pulmonary compromise with prolonged mechanical ventilation and infectious disorders leading to sepsis. However, sepsis was not a predictor of outcome. Weaning failure was present in 67.6% (N=92) at day 30 but was reduced to 37.5% of the cases (N=51) over the total course of the stay. Acute and long-term prognoses were determined by a successful weaning. CONCLUSION: Although the long-term treatment of critically ill patients requires significant effort, the outcome for this particular cohort was reasonably favorable. Prolonged mechanical ventilation and weaning are the factors that influence mortality independently of sepsis. Because reasonable improvements can be shown even after a prolonged LOS, further attention should be paid to weaning processes.

Performance of cardiac output measurement derived from arterial pressure waveform analysis in patients requiring high-dose vasopressor therapy.

BACKGROUND: Arterial pressure waveform analysis of cardiac output (APCO) without external calibration (FloTrac/Vigileo™) is critically dependent upon computation of vascular tone that has necessitated several refinements of the underlying software algorithms. We hypothesized that changes in vascular tone induced by high-dose vasopressor therapy affect the accuracy of APCO measurements independently of the FloTrac software version. METHODS: In this prospective observational study, we assessed the validity of uncalibrated APCO measurements compared with transpulmonary thermodilution cardiac output (TPCO) measurements in 24 patients undergoing vasopressor therapy for the treatment of cerebral vasospasm after subarachnoid haemorrhage. RESULTS: Patients received vasoactive support with [mean (sd)] 0.53 (0.46) µg kg(-1) min(-1) norepinephrine resulting in mean arterial pressure of 104 (14) mm Hg and mean systemic vascular resistance of 943 (248) dyn s(-1) cm(-5). Cardiac output (CO) data pairs (158) were obtained simultaneously by APCO and TPCO measurements. TPCO ranged from 5.2 to 14.3 litre min(-1), and APCO from 4.1 to 13.7 litre min(-1). Bias and limits of agreement were 0.9 and 2.5 litre min(-1), resulting in an overall percentage error of 29.6% for 68 data pairs analysed with the second-generation FloTrac(®) software and 27.9% for 90 data pairs analysed with the third-generation software. Precision of the reference technique was 2.6%, while APCO measurements yielded a precision of 29.5% and 27.9% for the second- and the third-generation software, respectively. For both software versions, bias (TPCO-APCO) correlated inversely with systemic vascular resistance. CONCLUSIONS: In neurosurgical patients requiring high-dose vasopressor support, precision of uncalibrated CO measurements depended on systemic vascular resistance. Introduction of the third software algorithm did not improve the insufficient precision (>20%) for APCO measurements observed with the second software version.

[Comments on the 2010 guidelines on cardiopulmonary resuscitation of the European Resuscitation Council]. / Kommentar zu den Leitlinien 2010 zur kardiopulmonalen Reanimation des European Resuscitation Council.

ADULTS: Administer chest compressions (minimum 100/min, minimum 5 cm depth) at a ratio of 30:2 with ventilation (tidal volume 500-600 ml, inspiration time 1 s, F(I)O2 if possible 1.0). Avoid any interruptions in chest compressions. After every single defibrillation attempt (initially biphasic 120-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min independent of the ECG rhythm. Tracheal intubation is the optimal method for securing the airway during resuscitation but should be performed only by experienced airway management providers. Laryngoscopy is performed during ongoing chest compressions; interruption of chest compressions for a maximum of 10 s to pass the tube through the vocal cords. Supraglottic airway devices are alternatives to tracheal intubation. Drug administration routes for adults and children: first choice i.v., second choice intraosseous (i.o.). Vasopressors: 1 mg epinephrine every 3-5 min i.v. After the third unsuccessful defibrillation amiodarone (300 mg i.v.), repetition (150 mg) possible. Sodium bicarbonate (50 ml 8.4%) only for excessive hyperkaliemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider aminophylline (5 mg/kgBW). Thrombolysis during spontaneous circulation only for myocardial infarction or massive pulmonary embolism; during on-going cardiopulmonary resuscitation (CPR) only when indications of massive pulmonary embolism. Active compression-decompression (ACD-CPR) and inspiratory threshold valve (ITV-CPR) are not superior to good standard CPR. CHILDREN: Most effective improvement of outcome by prevention of full cardiorespiratory arrest. Basic life support: initially five rescue breaths, followed by chest compressions (100-120/min depth about one third of chest diameter), compression-ventilation ratio 15:2. Foreign body airway obstruction with insufficient cough: alternate back blows and chest compressions (infants), or abdominal compressions (children >1 year). Treatment of potentially reversible causes: ("4 Hs and 4 Ts") hypoxia and hypovolaemia, hypokalaemia and hyperkalaemia, hypothermia, and tension pneumothorax, tamponade, toxic/therapeutic disturbances, thrombosis (coronary/pulmonary). Advanced life support: adrenaline (epinephrine) 10 µg/kgBW i.v. or i.o. every 3-5 min. Defibrillation (4 J/kgBW; monophasic or biphasic) followed by 2 min CPR, then ECG and pulse check. NEWBORNS: Initially inflate the lungs with bag-valve mask ventilation (p(AW) 20-40 cmH2O). If heart rate remains <60/min, start chest compressions (120 chest compressions/min) and ventilation with a ratio 3:1. Maintain normothermia in preterm babies by covering them with foodgrade plastic wrap or similar. POSTRESUSCITATION PHASE: Early protocol-based intensive care stabilization; initiate mild hypothermia early regardless of initial cardiac rhythm [32-34°C for 12-24 h (adults) or 24 h (children); slow rewarming (<0.5°C/h)]. Consider percutaneous coronary intervention (PCI) in patients with presumed cardiac ischemia. Prediction of CPR outcome is not possible at the scene, determine neurological outcome <72 h after cardiac arrest with somatosensory evoked potentials, biochemical tests and neurological examination. ACUTE CORONARY SYNDROME: Even if only a weak suspicion of an acute coronary syndrome is present, record a prehospital 12-lead ECG. In parallel to pain therapy, administer aspirin (160-325 mg p.o. or i.v.) and clopidogrel (75-600 mg depending on strategy); in ST-elevation myocardial infarction (STEMI) and planned PCI also prasugrel (60 mg p.o.). Antithrombins, such as heparin (60 IU/kgBW, max. 4000 IU), enoxaparin, bivalirudin or fondaparinux depending on the diagnosis (STEMI or non-STEMI-ACS) and the planned therapeutic strategy. In STEMI define reperfusion strategy depending on duration of symptoms until PCI, age and location of infarction. TRAUMA: In severe hemorrhagic shock, definitive control of bleeding is the most important goal. For successful CPR of trauma patients a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation and excessive ventilation pressure may impair outcome in patients with severe hemorrhagic shock. TRAINING: Any CPR training is better than nothing; simplification of contents and processes is the main aim.