Cardioprotective effects of vaccination in hospitalized patients with COVID-19.

COVID-19 vaccination has been shown to prevent and reduce the severity of COVID-19 disease. The aim of this study was to explore the cardioprotective effect of COVID-19 vaccination in hospitalized COVID-19 patients. In this retrospective, single-center cohort study, we included hospitalized COVID-19 patients with confirmed vaccination status from July 2021 to February 2022. We assessed outcomes such as acute cardiac events and cardiac biomarker levels through clinical and laboratory data. Our analysis covered 167 patients (69% male, mean age 58 years, 42% being fully vaccinated). After adjustment for confounders, vaccinated hospitalized COVID-19 patients displayed a reduced relative risk for acute cardiac events (RR: 0.33, 95% CI [0.07; 0.75]) and showed diminished troponin T levels (Cohen's d: - 0.52, 95% CI [- 1.01; - 0.14]), compared to their non-vaccinated peers. Type 2 diabetes (OR: 2.99, 95% CI [1.22; 7.35]) and existing cardiac diseases (OR: 4.31, 95% CI [1.83; 10.74]) were identified as significant risk factors for the emergence of acute cardiac events. Our findings suggest that COVID-19 vaccination may confer both direct and indirect cardioprotective effects in hospitalized COVID-19 patients.

Vaccination protects against acute respiratory distress syndrome (ARDS) in hospitalized patients with COVID-19.

This study aimed to analyze the effect of COVID-19 vaccination on the occurrence of ARDS in hospitalized COVID-19 patients. The study population of this retrospective, single-center cohort study consisted of hospitalized COVID-19 patients with known vaccination status and chest computed tomography imaging between July 2021 and February 2022. The impact of vaccination on ARDS in COVID-19 patients was assessed through logistic regression adjusting for demographic differences and confounding factors with statistical differences determined using confidence intervals and effect sizes. A total of 167 patients (69% male, average age 58 years, 95% CI [55; 60], 42% fully vaccinated) were included in the data analysis. Vaccinated COVID-19 patients had a reduced relative risk (RR) of developing ARDS (RR: 0.40, 95% CI [0.21; 0.62]). Consequently, non-vaccinated hospitalized patients had a 2.5-fold higher probability of developing ARDS. This risk reduction persisted after adjusting for several confounding variables (RR: 0.64, 95% CI [0.29; 0.94]) in multivariate analysis. The protective effect of COVID-19 vaccination increased with ARDS severity (RR: 0.61, 95% CI [0.37; 0.92]). Particularly, patients under 60 years old were at risk for ARDS onset and seemed to benefit from COVID-19 vaccination (RR: 0.51, 95% CI [0.20; 0.90]). COVID-19 vaccination showed to reduce the risk of ARDS occurrence in hospitalized COVID-19 patients, with a particularly strong effect in patients under 60 years old and those with more severe ARDS.

Hemostatic disorders associated with extracorporeal membrane oxygenation.

Hemostatic disorders are common during extracorporeal membrane oxygenation (ECMO)-therapy. This includes both bleeding and thrombotic complications. Particularly bleeding is often associated with fatal outcome. The early identification of hemorrhagic diathesis and the diagnosis of the underlying pathology are essential. A distinction into device-, disease-, and drug-related disorders appears reasonable. However, both correct diagnosis and therapy can be challenging and sometimes counterintuitive. Since bleeding seems to be more frequent and dangerous compared to thrombosis, the understanding of coagulation disorders and minimizing anticoagulation has been focused in recent years. Due to progress in membrane coating and configuration of modern ECMO circuits it is even possible to perform ECMO without any anticoagulation in well selected cases. It became apparent that routine laboratory tests are likely to miss severe coagulation disorders during ECMO-therapy. Better understanding can also help to individualize anticoagulation in patients and hence preventing complications. Acquired von Willebrand syndrome, platelet dysfunction, waste coagulopathy as well as silent hemolysis should be taken into account when bleeding or thromboembolic complications appear. Recognizing impaired intrinsic fibrinolysis may favour intensified anticoagulation even in patients exhibiting signs of bleeding. Drug monitoring with standard coagulation tests, viscoelastic tests and anti-Xa-levels as wells as screening for disorders of primary hemostasis should be implemented in clinical routine to guide physicians through complex anticoagulative therapy. The patient's coagulative status should be interpreted taking the underlying disease and current therapy into account in order to enable a personalized approach to hemostasis in patients treated with ECMO.

Pervasive Platelet Secretion Defects in Patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).

Critically ill COVID-19 patients suffer from thromboembolic as well as bleeding events. Endothelial dysfunction, spiking of von Willebrand factor (vWF), and excessive cytokine signaling result in coagulopathy associated with substantial activation of plasmatic clotting factors. Thrombocytopenia secondary to extensive platelet activation is a frequent finding, but abnormal platelet dysfunction may also exist in patients with normal platelet counts. In this study, we performed analyses of platelet function and of von Willebrand factor in critically ill COVID-19 patients (n = 13). Platelet aggregometry was performed using ADP, collagen, epinephrin, and ristocetin. VWF and fibrinogen binding of platelets and CD62 and CD63 expression after thrombin stimulation were analyzed via flow cytometry. In addition, VWF antigen (VWF:Ag), collagen binding capacity (VWF:CB), and multimer analysis were performed next to routine coagulation parameters. All patients exhibited reduced platelet aggregation and decreased CD62 and CD63 expression. VWF binding of platelets was reduced in 12/13 patients. VWF:CB/VWF:Ag ratios were pathologically decreased in 2/13 patients and elevated in 2/13 patients. Critically ill COVID-19 patients exhibit platelet secretion defects independent of thrombocytopenia. Platelet exhaustion and VWF dysfunction may result in impaired primary hemostasis and should be considered when treating coagulopathy in these patients.

Predictive markers related to local and systemic inflammation in severe COVID-19-associated ARDS: a prospective single-center analysis.

BACKGROUND: As the COVID-19 pandemic strains healthcare systems worldwide, finding predictive markers of severe courses remains urgent. Most research so far was limited to selective questions hindering general assumptions for short- and long-term outcome. METHODS: In this prospective single-center biomarker study, 47 blood- and 21 bronchoalveolar lavage (BAL) samples were collected from 47 COVID-19 intensive care unit (ICU) patients upon admission. Expression of inflammatory markers toll-like receptor 3 (TLR3), heme oxygenase-1 (HO-1), interleukin (IL)-6, IL-8, leukocyte counts, procalcitonin (PCT) and carboxyhemoglobin (CO-Hb) was compared to clinical course. Clinical assessment comprised acute local organ damage, acute systemic damage, mortality and outcome after 6 months. RESULTS: PCT correlated with acute systemic damage and was the best predictor for quality of life (QoL) after 6 months (r = - 0.4647, p = 0.0338). Systemic TLR3 negatively correlated with impaired lung function (ECMO/ECLS: r = - 0.3810, p = 0.0107) and neurological short- (RASS mean: r = 0.4474, p = 0.0023) and long-term outcome (mRS after 6 m: r = - 0.3184, p = 0.0352). Systemic IL-8 correlated with impaired lung function (ECMO/ECLS: r = 0.3784, p = 0.0161) and neurological involvement (RASS mean: r = - 0.5132, p = 0.0007). IL-6 in BAL correlated better to the clinical course than systemic IL-6. Using three multivariate regression models, we describe prediction models for local and systemic damage as well as QoL. CO-Hb mean and max were associated with higher mortality. CONCLUSIONS: Our predictive models using the combination of Charlson Comorbidity Index, sex, procalcitonin, systemic TLR3 expression and IL-6 and IL-8 in BAL were able to describe a broad range of clinically relevant outcomes in patients with severe COVID-19-associated ARDS. Using these models might proof useful in risk stratification and predicting disease course in the future. Trial registration The trial was registered with the German Clinical Trials Register (Trial-ID DRKS00021522, registered 22/04/2020).

Independent risk factors for an increased incidence of thromboembolism after lung transplantation.

BACKGROUND: Thromboembolism (TE) after lung transplantation (LTX) is associated with increased morbidity and mortality. The aim of this study is to analyze the incidence and outcome of venous and arterial thromboembolic complications and to identify independent risk factors. PATIENTS AND METHODS: We retrospectively analyzed the medical records of 221 patients who underwent LTX at our institution between 2002 and 2021. Statistical analysis was performed using SPSS and GraphPad software. RESULTS: 74 LTX recipients (33%) developed TE. The 30-days incidence and 12-months incidence were 12% and 23%, respectively. Nearly half of the patients (48%) developed pulmonary embolism, 10% ischemic stroke. Arterial hypertension (p = 0.006), a body mass index (BMI) > 30 (p = 0.006) and diabetes mellitus (p = 0.041) were independent predictors for TE. Moreover, a BMI of > 25 at the time of transplantation was associated with an increased risk for TE (43% vs. 32%, p = 0.035). At the time of LTX, 65% of the patients were older than 55 years. An age > 55 years also correlated with the incidence of TE (p = 0.037) and these patients had reduced overall post-transplant survival when the event occurred within the first postoperative year (59% vs. 72%, p = 0.028). CONCLUSIONS: The incidence of TE after LTX is high, especially in lung transplant recipients with a BMI > 25 and an age > 55 years as well as cardiovascular risk factors closely associated with the metabolic syndrome. As these patients comprise a growing recipient fraction, intensified research should focus on the risks and benefits of regular screening or a prolonged TE prophylaxis in these patients. Trial registration number DKRS: 00021501.

Cytokine levels associated with favorable clinical outcome in the CAPSID randomized trial of convalescent plasma in patients with severe COVID-19.

Objectives: To determine the profile of cytokines in patients with severe COVID-19 who were enrolled in a trial of COVID-19 convalescent plasma (CCP). Methods: Patients were randomized to receive standard treatment and 3 CCP units or standard treatment alone (CAPSID trial, ClinicalTrials.gov NCT04433910). The primary outcome was a dichotomous composite outcome (survival and no longer severe COVID-19 on day 21). Time to clinical improvement was a key secondary endpoint. The concentrations of 27 cytokines were measured (baseline, day 7). We analyzed the change and the correlation between serum cytokine levels over time in different subgroups and the prediction of outcome in receiver operating characteristics (ROC) analyses and in multivariate models. Results: The majority of cytokines showed significant changes from baseline to day 7. Some were strongly correlated amongst each other (at baseline the cluster IL-1ß, IL-2, IL-6, IL-8, G-CSF, MIP-1α, the cluster PDGF-BB, RANTES or the cluster IL-4, IL-17, Eotaxin, bFGF, TNF-α). The correlation matrix substantially changed from baseline to day 7. The heatmaps of the absolute values of the correlation matrix indicated an association of CCP treatment and clinical outcome with the cytokine pattern. Low levels of IP-10, IFN-γ, MCP-1 and IL-1ß on day 0 were predictive of treatment success in a ROC analysis. In multivariate models, low levels of IL-1ß, IFN-γ and MCP-1 on day 0 were significantly associated with both treatment success and shorter time to clinical improvement. Low levels of IP-10, IL-1RA, IL-6, MCP-1 and IFN-γ on day 7 and high levels of IL-9, PDGF and RANTES on day 7 were predictive of treatment success in ROC analyses. Low levels of IP-10, MCP-1 and high levels of RANTES, on day 7 were associated with both treatment success and shorter time to clinical improvement in multivariate models. Conclusion: This analysis demonstrates a considerable dynamic of cytokines over time, which is influenced by both treatment and clinical course of COVID-19. Levels of IL-1ß and MCP-1 at baseline and MCP-1, IP-10 and RANTES on day 7 were associated with a favorable outcome across several endpoints. These cytokines should be included in future trials for further evaluation as predictive factors.

Risk Factors for Prolonged Mechanical Ventilation and Delayed Extubation Following Bimaxillary Orthognathic Surgery: A Single-Center Retrospective Cohort Study.

BACKGROUND: Bimaxillary orthognathic surgery bears the risk of severe postoperative airway complications. There are no clear recommendations for immediate postoperative follow-up and monitoring. OBJECTIVE: to identify potential risk factors for prolonged mechanical ventilation and delayed extubation in patients undergoing bimaxillary orthognathic surgery. METHODS: The data of all consecutive patients undergoing bimaxillary surgery between May 2012 and October 2019 were analyzed in a single-center retrospective cohort study. The clinical data were evaluated regarding baseline characteristics and potential factors linked with delayed extubation. RESULTS: A total of 195 patients were included; 54.9% were female, and the median age was 23 years (IQR 5). The median body mass index was 23.1 (IQR 8). Nine patients (4.6%) were of American Society of Anesthesiologists Physical Status Classification System III or higher. The median duration of mechanical ventilation in the intensive care unit was 280 min (IQR, 526 min). Multivariable analysis revealed that premedication with benzodiazepines (odds ratio (OR) 2.60, 95% confidence interval (0.99; 6.81)), the male sex (OR 2.43, 95% confidence interval (1.10; 5.36)), and the duration of surgery (OR 1.54, 95% confidence interval (1.07; 2.23)) were associated with prolonged mechanical ventilation. By contrast, total intravenous anesthesia was associated with shorter ventilation time (OR 0.19, 95% confidence interval (0.09; 0.43)). CONCLUSION: premedication with benzodiazepines, the male sex, and the duration of surgery might be considered to be independent risk factors for delayed extubation in patients undergoing bimaxillary surgery.

Bleeding During Veno-Venous ECMO: Prevention and Treatment.

Veno-venous extracorporeal membrane oxygenation (vvECMO) has become a routine treatment for severe lung failure in specialized centers. Spontaneous bleeding complications, however, are observed in 30-60% of patients during vvECMO treatment. Bleeding increases mortality by factors 2-3. Anticoagulation in combination with several acquired bleeding disorders caused by the mechanical pump and the foreign layer of the extracorporeal system contribute to the risk of bleeding. In this review, the mechanisms of the underlying pathologies and the route from diagnosis to treatment are described.

Integration of sustained low-efficiency dialysis into extracorporeal membrane oxygenation circuit in critically ill COVID-19 patients: A feasibility study.

BACKGROUND: Severe COVID-19 can necessitate multiple organ support including veno-venous extracorporeal membrane oxygenation (vvECMO) and renal replacement therapy. The therapy can be complicated by venous thromboembolism due to COVID-19-related hypercoagulability, thus restricting vascular access beyond the vvECMO cannula. Although continuous renal replacement therapy can be performed via a vvECMO circuit, studies addressing sustained low-efficiency dialysis (SLED) integration into vvECMO circuits are scarce. Here we address the lack of evidence by evaluating feasibility of SLED integration into vvECMO circuits. METHODS: Retrospective cohort study on nine critically ill COVID-19 patients, treated with integrated ECMO-SLED on a single intensive care unit at a tertiary healthcare facility between December 2020 and November 2021. The SLED circuits were established between the accessory arterial oxygenator outlets of a double-oxygenator vvECMO setup. Data on filter survival, quality of dialysis, and volume management were collected and compared with an internal control group receiving single SLED. RESULTS: This study demonstrates general feasibility of SLED integration into existing vvECMO circuits. Filter lifespans of ECMO-SLED compared with single SLED are significantly prolonged (median 18.3 h vs. 10.3 h, p < 0.01). ECMO-SLED treatment is furthermore able to sufficiently normalize creatinine, blood urea nitrogen, and serum sodium, and allows for adequate ultrafiltration rates. CONCLUSIONS: We can show that ECMO-SLED is practical, safe, results in adequate dialysis quality and enables sufficient electrolyte and volume management. Our data indicate that SLED devices can serve as potential alternative to continuous-veno-venous-hemodialysis for integration in vvECMO circuits.

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

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

Aspirin, heparin and ischemia time in microvascular free flap surgery - their influence and an optimal anticoagulation protocol.

BACKGROUND: Microvascular surgery has become a standardized technique for reconstruction of large tissue defects in Head and Neck Reconstructive Surgery. However, the main dreaded complications are thrombosis of blood vessels or major bleeding after surgery. Several different anticoagulation protocols have been established in the last decades to overcome these problems with varying degrees of success. METHODS: Over a period of six years, a standardized anticoagulation protocol including acetylsalicylic acid (ASA) and unfractionated heparin (UFH) for direct intraoperative and postoperative administration was established, optimized and compared to a previously used non-standardized protocol. A total of 178 flap surgeries were included in the development and optimization process of the protocol. RESULTS: ASA significantly increased the risk of complications when used for longer than 72 h (OR = 2.52; p = 0.002; 95% CI 1.39-4.59). Administration of UFH reduced flap loss (bolus: OR 0.68; p = 0.47; 95% CI 0.24-1.93; continuous UFH administration: OR = 0.61; p = 0.33; 95% CI 0.22-1.66), however doses greater than 500 IU/ h of UFH as continuous infusion increased the risk of complications. Reduction in ischemia time had no effect on the occurrence of complications. CONCLUSION: Anticoagulation regimes in microvascular surgery can influence the postoperative complication rate. The optimal protocol should consist of a combination of ASA and UFH for the intraoperative and direct postoperative phase. Prolonged administration of ASA as well as doses >500 IU/ h of UFH are to be avoided due to the increased complication rate.

Acquired von Willebrand Syndrome and Desmopressin Resistance During Venovenous Extracorporeal Membrane Oxygenation in Patients With COVID-19: A Prospective Observational Study.

OBJECTIVES: Although COVID-19 is associated with high von Willebrand factor (vWF) parameters promoting thrombosis, venovenous extracorporeal membrane oxygenation (vvECMO) is associated with the development of acquired von Willebrand syndrome (AVWS) promoting bleeding. This study was designed to assess both the incidence and severity of AVWS in COVID-19 patients undergoing vvECMO, and the benefit of comprehensive vWF analyses. DESIGN: Prospective observational study. SETTING: ICU at a tertiary-care center. PATIENTS: Twenty-seven consecutive COVID-19 patients with acute respiratory distress syndrome (ARDS) requiring vvECMO. MEASUREMENTS AND MAIN RESULTS: Comprehensive vWF analyses (including sodium dodecyl-sulfate polyacrylamide gel electrophoresis) were performed before, during, and after vvECMO. In a subgroup of 12 patients with AVWS, effectiveness of treatment with desmopressin was assessed. The patients' mean age was 53 years (range, 23-73), 70% were male, and all had various comorbidities. Following markedly elevated vwf antigen (vWF: Ag; mean, 546% ( sd , 282]), vWF collagen binding capacity (mean, 469% [ sd , 271]), vWF activity (vWF:A; mean, 383% [ sd , 132]), and factor VIII activity (mean, 302% [ sd , 106]), and only borderline decreases in high-molecular-weight (HMW) vWF multimers before vvECMO, all of these variables decreased and HMW vWF multimers became undetectable within hours following initiation of vvECMO. All variables fully recovered within 3-38 hours after discontinuation of vvECMO. During vvECMO, decreases in the vWF:A/vWF:Ag ratio correlated with absent HMW vWF multimers. Desmopressin did not affect vWF parameters. CONCLUSIONS: In patients with COVID-19-associated ARDS, AVWS developed soon after initiation of vvECMO. The vWF:A/vWF:Ag ratio was a suitable screening test for AVWS. As desmopressin was ineffective, bleeding during vvECMO-associated AVWS should preferably be treated with concentrates containing vWF.

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

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

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

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

Influence of surgical stabilization of clavicle fractures in multiply-injured patients with thoracic trauma.

Thoracic trauma has decisive influence on the outcome of multiply-injured patients and is often associated with clavicle fractures. The affected patients are prone to lung dysfunction and multiple organ failure. A multi-center, retrospective analysis of patient records documented in the TraumaRegister DGU was performed to assess the influence of surgical stabilization of clavicle fractures in patients with thoracic trauma. A total of 3,209 patients were included in the analysis. In 1362 patients (42%) the clavicle fracture was treated operatively after 7.1 ± 5.3 days. Surgically treated patients had a significant reduction in lung failure (p = 0.013, OR = 0.74), multiple organ failure (p = 0.001, OR = 0.64), intubation time (p = 0.004; -1.81 days) and length of hospital stay (p = 0.014; -1.51 days) compared to non-operative treatment. Moreover, surgical fixation of the clavicle within five days following hospital admission significantly reduced the rates of lung failure (p = 0.01, OR = 0.62), multiple organ failure (p = 0.01, OR = 0.59) and length of hospital stay (p = 0.01; -2.1 days). Based on our results, multiply-injured patients with thoracic trauma and concomitant clavicle fracture may benefit significantly from surgical stabilization of a clavicle fracture, especially when surgery is performed within the first five days after hospital admission.

The Role of von Willebrand Factor in Microvascular Surgery in Severely Injured Patients.

Microvascular anastomosis has become a standard surgical technique for reconstruction because of increasing possibilities, indications, and clinical success regarding the survival of the flaps. However, the main dreaded complications exist in thrombosis. Leaving surgical complications aside, systemic problems like disorder of the coagulation-fibrinolysis system are a significant cause of graft loss usually being unrecognized. Reports exist describing a hypercoagulable state with clotting activation and inhibition of fibrinolysis after trauma and delayed surgery considering the secondary homeostasis. In this clinical case, a patient had a large soft tissue defect at the temporal side of the head after severe trauma. After some days of primary stabilization, reconstruction using a free microvascular latissimus dorsi flap was performed. Multiple revisions of the arterial and venous branches had to be performed intraoperatively due to insufficient flap perfusion. After 24 hours, definitive flap loss occurred due to multiple thrombosis in the arterial and venous branches. Postoperative comprehensive coagulation analysis revealed a distinct activation of primary hemostasis with massively increased von Willebrand factor parameters and factor VIII activity as well as acetylsalicylic acid resistance contributing to thrombotic occlusion. In severely injured patients, comprehensive preoperative determination of the coagulation status (especially those of the primary hemostasis) is indispensable before performing free flap reconstruction surgeries to reduce the risk of microvascular flap loss.