Hand-held minimised extracorporeal membrane oxygenation: a new bridge to recovery in patients with out-of-centre cardiogenic shock.

OBJECTIVE: Cardiogenic shock is associated with mortality rates up to 70%, even if patients are treated with intensive care support or thrombolytic therapy. Early coronary revascularisation can be life-saving but it is oftentimes not available at the hospital to which the patient was initially taken. Up to now, transferring patients in a state of severe cardiogenic shock and/or cardiopulmonary resuscitation is mostly decided to be impossible. We report on the use of two newly developed minimised systems for hand-held-extracorporeal membrane oxygenation (ECMO) (ELS-System™ and CARDIOHELP™, both from MAQUET Cardiopulmonary AG, Germany), which we have used for rapid extracorporeal life support and interhospital transfer on Mini-ECMO. We characterise the emergency use, safety instructions and bridging function of these novel Mini-ECMO devices. METHODS: Between June 2007 and August 2010, we administered percutaneous Mini-ECMO support to 21 adult cardiogenic shock patients. The main components of each Mini-ECMO system are a centrifugal pump and a membrane oxygenator. The systems can act independently from wall connection points, and are they are small enough to be attached nearby a patient's side during transport. RESULTS: On ECMO, gas exchange improved significantly, vasopressor support could be significantly marked down and signs of shock disappeared in all patients. Emergency medical service was carried out in re-established blood-flow and oxygen delivery. The patients were bridged to coronary artery bypass grafting (CABG) (n = 6), ventricular assist device (n = 1) or pulmonary embolectomy (n=1) or specialised intensive care (n=13). Thirteen patients (62%) had completely recovered. CONCLUSIONS: The use of hand-held Mini-ECMO systems enables for the first time the rapid onset of extracorporeal life support independent from the patient's current location. However, success is extremely time- and team dependent. Highly skilled interdisciplinary patient management is essential to let minimised-ECMO become a new and highly effective bridge to recovery in out-of-centre cardiogenic shock patients.

Infection prevention during anaesthesia ventilation by the use of breathing system filters (BSF): Joint recommendation by German Society of Hospital Hygiene (DGKH) and German Society for Anaesthesiology and Intensive Care (DGAI).

An interdisciplinary working group from the German Society of Hospital Hygiene (DGKH) and the German Society for Anaesthesiology and Intensive Care (DGAI) worked out the following recommendations for infection prevention during anaesthesia by using breathing system filters (BSF). The BSF shall be changed after each patient. The filter retention efficiency for airborne particles is recommended to be >99% (II). The retention performance of BSF for liquids is recommended to be at pressures of at least 60 hPa (=60 mbar) or 20 hPa above the selected maximum ventilation pressure in the anaesthetic system. The anaesthesia breathing system may be used for a period of up to 7 days provided that the functional requirements of the system remain unchanged and the manufacturer states this in the instructions for use.THE BREATHING SYSTEM AND THE MANUAL VENTILATION BAG ARE CHANGED IMMEDIATELY AFTER THE RESPECTIVE ANAESTHESIA IF THE FOLLOWING SITUATION HAS OCCURRED OR IT IS SUSPECTED TO HAVE OCCURRED: Notifiable infectious disease involving the risk of transmission via the breathing system and the manual bag, e.g. tuberculosis, acute viral hepatitis, measles, influenza virus, infection and/or colonisation with a multi-resistant pathogen or upper or lower respiratory tract infections. In case of visible contamination e.g. by blood or in case of defect, it is required that the BSF and also the anaesthesia breathing system is changed and the breathing gas conducting parts of the anaesthesia ventilator are hygienically reprocessed.Observing of the appropriate hand disinfection is very important. All surfaces of the anaesthesia equipment exposed to hand contact must be disinfected after each case.

The prognostic value of NSE and S100B from serum and cerebrospinal fluid in patients with spontaneous subarachnoid hemorrhage.

Neuron-specific enolase (NSE) and S100B protein have been shown to be increased in cerebrospinal fluid (CSF) and serum of patients suffering from subarachnoid hemorrhage. This study was designed to evaluate the accuracy of NSE and S100B from CSF and serum for the prognosis of outcome and the detection of cerebral infarction, vasospasm and intracranial hypertension. In 55 patients with spontaneous subarachnoid hemorrhage and requiring external ventricular drainage the concentrations of NSE and S100B were determined daily from the serum and the CSF from admission until day 8. At ICU discharge patients' outcome was assessed by the Glasgow outcome scale and occurrence of cerebral infarction, vasospasm and intracranial hypertension were registered. Mean and peak values of each parameter for each patient were calculated. For accuracy assessment receiver operating characteristics were used. Bad outcome (Glasgow outcome scale 1 to 3) was found in 33 patients. Cerebral infarction, vasospasm, and intracranial hypertension were found in 31 (56%), 34 (62%), and 36 (65%) patients. Mean and peak values of NSE CSF (P<0.001), S100B CSF (P<0.001), and S100B serum (P<0.001) but not of NSE serum provided the ability to distinguish between patients with good and bad outcome. The accuracy of NSE CSF and S100B CSF did not differ significantly from that of S100B serum. NSE CSF (P<0.001), S100B CSF (P<0.001), and S100B serum (P<0.001) allowed the detection of cerebral infarction and intracranial hypertension. Cerebral vasospasm was detected by none of the parameters. In conclusion, NSE CSF, S100B CSF, and S100B serum provide similar prognostic values for outcome, intracranial hypertension and cerebral infarction. Significantly lower accuracy was found for NSE serum.

[Implementation of a web based software for documentation and control of quality of an acute pain service]. / Die webbasierte Software im Akutschmerzdienst - Implementierung, Dokumentation und Qualitätskontrolle.

Providing an acute pain service means accumulation of a large amount of data. The alleviation of data collection, improvement of data quality and data analysis plays a pivotal role. The electronic medical record (EMR) is gaining more and more importance in this context and is continuously spreading in clinical practice. Up to now only a few commercial softwares are available that specifically fit to the needs of an acute pain service. Here we report the development and implementation of such a program (Schmerzvisite, Medlinq, Hamburg, Germany) in the acute pain service of a University Hospital.

[Emergency care management of patients with cancer at the final stage of disease--seven cases]. / Notärztliche Betreuung von Tumorpatienten--Sieben Fälle aus der finalen Krankheitsphase.

The care of patients with cancer disease in the final stage amounts to 2.5% of all emergency-medical applications. This corresponded to the number of pediatric emergency cases. For this every emergency physician can be involved in the care of those patients. Emergency physicians may allow adapted treatment in the will or supposed will of the patient always. Therefore it is necessary to know special legal bearings of the case. We analysed seven emergency cases with patients in the final stage of their cancer disease retrospectively. For this we present seven different emergency cases with different regulatory framework for each emergency physician. The cases have shown seven possible care concepts of patients in the final stage of a cancer disease. All patients could be categorised as palliative ones. Nevertheless, the emergency physicians were alarmed by the patients' relatives because of needing professional help at the moment. The differences of the cases appeared in the regulatory framework. The seven cases have shown that different legal meanings could be important in emergency therapy of palliative patients.