[Fatal course of COVID-19 despite IL-6 receptor blockade in cytokine storm : Perimyocarditis and coagulopathy after administration of tocilizumab]. / Fataler COVID-19-Verlauf trotz IL­6­Rezeptor-Blockade im Zytokinsturm : Perimyokarditis und Koagulopathie nach Tocilizumabgabe.

A 59-year-old male patient was admitted to hospital diagnosed with moderate pneumonia associated with COVID-19. Upfront treatment with hydroxychloroquine and azithromycin was started. Due to a clinical deterioration (ARDS, circulatory shock) and greatly increased inflammation markers 6 days after admission, a cytokine storm was suspected and off-label treatment with the IL­6 receptor antagonist tocilizumab was initiated. Subsequently there was a dramatic rise of D­dimers indicating pulmonary intravascular coagulopathy and respiratory insufficiency worsened. After a second dose of tocilizumab was administered severe perimyocarditis with cardiac arrhythmia, hemodynamic instability and ST elevation occurred. Shortly afterwards the patient died due to multiorgan failure. From our experience, exacerbation of COVID-19 following treatment with tocilizumab cannot be ruled out. Randomized controlled studies are necessary to further investigate the efficacy, safety and patient selection criteria for tocilizumab treatment in COVID-19.

[Airway management in preclinical emergency anesthesia with respect to specialty and education]. / Notärztliches Atemwegsmanagement in Abhängigkeit von Fachrichtung und Weiterbildung.

BACKGROUND AND OBJECTIVE: Difficult airway management is a key skill in preclinical emergency medicine. A lower rate of subjective difficult airways and an increased success rate of endotracheal intubation have been reported for highly trained emergency physicians. The aim of this study was therefore to analyze the effect for different specialists and the individual state of training in the German emergency medical system. MATERIAL AND METHODS: In a retrospective register analysis of 6024 preclinical anesthesia procedures, the frequencies of airway devices, neuromuscular blocking agents, capnography and difficult airways were analyzed with respect to specialization and status of training. Additionally, low, medium and highly experienced emergency physicians in airway management were summarized by specialization and status of training according to the Dreyfus model of skill acquisition and compared. RESULTS: The incidence of subjective difficult airway situations was 10% for anesthesiological emergency physicians compared to 15-20% for other disciplines. The latter used supraglottic airway devices more often (7-9% vs. 4%) and video laryngoscopes less often (3% vs. 5%) compared to anesthesiological emergency physicians. The discipline-related state of training was inhomogeneous and revealed a reduced rate of supraglottic airway devices for internal specialists with further training (10% vs. 2%). Anesthetists specialized in intensive care medicine used capnography less frequently compared to other anesthetists (79% vs. 72%). With higher levels of experience in airway management, the frequency of endotracheal intubation (86% vs. 94%), neuromuscular blocking agents (59% vs. 73%) and video laryngoscopy (3% vs. 6%) increased and the incidence of subjective difficult airway situations (16% vs. 10%) decreased. CONCLUSION: The level of training in airway management especially for non-anesthetists is inhomogeneous. The recently published German S1 guidelines for prehospital airway management recommend education and training as well as the primary use of the video laryngoscope with Macintosh blade. The implementation could lower the incidence of subjective difficult airways.

[Stocktaking of local anesthetics 2020]. / Bestandsaufnahme der Lokalanästhetika 2020.

For decades local anesthetics have proven to be safe and effective drugs in the clinical practice, crucially promoting the enormous achievements in regional anesthesia. Meanwhile, it is a well-known fact that local anesthetics are much more than just "simple" sodium channel blockers. They also interact with numerous other ion channels and subcellular structures, enhancing nerve blockade and resulting in systemic "alternative" effects, which can sometimes even be clinically used. By the simultaneous administration of various adjuvants (e.g., opioids, corticosteroids and α2-receptor agonists) attempts are made to prolong the time of action of local anesthetics after a single administration in order to achieve the best possible improvement in postoperative analgesia. In this context, ultralong-acting local anesthetics, such as liposomal bupivacaine, which at least theoretically can provide a sensory nerve block for several days, have been developed and clinically introduced. The coming years will show whether these approaches will develop into genuine alternatives to the personnel and cost-intensive continuous nerve blockades.Local anesthetic-induced systemic toxicity is meanwhile rare but still a potentially life-threatening event, frequently resulting from accidental intravascular injection or extensive systemic resorption. Consequently, slow and fractional application of these agents with intermittent aspiration helps to prevent toxic sequelae. If toxic symptoms occur, however, the intravenous infusion of 20% lipid solutions in addition to basic treatment measures can enhance the success of treatment.

[Preclinical emergency anesthesia : A current state analysis from 2015-2017]. / Notärztliche Durchführung von Narkosen : Eine Istanalyse der Jahre 2015­2017.

BACKGROUND AND OBJECTIVE: Due to multiple factors the performance of preclinical emergency anesthesia is fraught with risks even for experienced emergency physicians. In order to support emergency physicians in monitoring and management of anesthesia, the German practice management guidelines for preclinical emergency anesthesia in adults were published in 2015; however, current data on adherence to the guidelines are not available. MATERIAL AND METHODS: In a retrospective register analysis of preclinical anesthesia from 2015-2017 in Baden-Württemberg, the recorded anesthetic agents, monitoring, airway management and medical disciplines of emergency physicians were analyzed. The anesthetic agents utilized were compared to the emergency scenarios in the guidelines (e.g. cardiac patients, patients with acute respiratory insufficiency or acute neurological disorder and trauma patients). RESULTS: Midazolam and propofol were predominantly used in the 12,605 cases of preclinical emergency anesthesia evaluated. The adherence to the guidelines was 35% for cardiac patients, 51% for patients with acute respiratory insufficiency or 52% for acute neurological disorders and 79% for trauma patients. Securing the airway was carried out in 88.5 % with endotracheal intubation (capnography 79%). Discipline-related differences occurred in airway management for the devices used, capnography, muscle relaxation and the frequency of the subjectively difficult airway. A higher adherence for trauma patients and patients with acute neurological disorders was found for emergency physicians who were anesthesiologists compared to non-anesthesiologists. CONCLUSION: The study of the current state of preclinical emergency anesthesia in Germany showed a deficient implementation of the pharmacological recommendations for action except for trauma patients. Reasons for divergence could arise due to different availability of rescue equipment, training concepts or discipline of emergency physicians. Suitable education and training could improve the quality of prehospital anesthesia in Germany.

[Different levels of experience with anesthetic agents of German emergency physicians : Results of an online survey]. / Notärztliche Erfahrung im Umgang mit Narkosemedikamenten : Ergebnisse einer Umfrage.

BACKGROUND AND OBJECTIVE: In 2015 practice management guidelines on prehospital emergency anesthesia in adults were published in Germany. The aim of the present study was to evaluate whether emergency physicians follow these guidelines in daily practice and to assess their level of experience with the use of anesthetic agents. MATERIAL AND METHODS: In an online survey the way of induction of preclinical anesthesia (including preoxygenation time and applied monitoring techniques) was assessed with the help of virtual scenarios based on the guidelines. Furthermore, the individual level of experience with specific anesthetic agents was estimated by the total number of anesthetic procedures performed with these drugs (0, 1-10, 11-25, 26-50, 51-100, and >100 procedures). RESULT: A total of 155 emergency physicians answered the online survey. Except for cardiac patients and for the preoxygenation time, we found a high accordance between specific algorithms proposed in the guidelines and emergency physicians' clinical practice. Furthermore, the median level of experience with rocuronium and succinylcholine was significantly higher compared to vecuronium. With respect to induction agents the highest level of experience was found for propofol and thiopental, the lowest for the combination of ketamine/propofol and midazolam. Generally, compared to non-anesthetists, emergency physicians had significantly higher levels of experience with the use of these anesthetic agents (except for etomidate and vecuronium). Over 94% used a 4-lead electrocardiogram (ECG), pulse oxymetry, non-invasive blood pressure and quantitative capnography for monitoring. The availability of succinylcholine was 91%, rocuronium 55%, vecuronium 29% and sugammadex 9%. CONCLUSION: The results of this survey demonstrate that clinical practice of emergency physicians is in high accordance with the recommendations named in the guidelines for prehospital emergency anesthesia in adults (except for cardiac patients and time of preoxygenation). With respect to the lower levels of experience of non-anesthetists in the use of anesthetic drugs, specific training concepts may help to further improve the quality of preclinical emergency care.

Lipid emulsion pretreatment has different effects on mepivacaine and bupivacaine cardiac toxicity in an isolated rat heart model.

BACKGROUND: The use of lipid emulsions to reduce cardiac toxicity of local anaesthetics (LAs) has shown success in experimental studies and some clinical cases, and thus has been implemented in clinical practice. However, lipid treatment is usually given after the occurrence of neurological or cardiovascular symptoms of systemic intoxication. The aim of this study was to determine if pretreatment with lipid emulsion reduces cardiac toxicity produced by bupivacaine or mepivacaine. METHODS: Isolated rat hearts were perfused with or without lipid emulsion (0.25 ml kg(-1) min(-1)) before administration of equipotent doses of bupivacaine (250 µM) or mepivacaine (1000 µM). Haemodynamic parameters and times from start of perfusion LA to a 1 min period of asystole and recovery were determined. RESULTS: Pretreatment with lipid emulsion extended the time until occurrence of asystole and decreased times to recovery in bupivacaine-induced cardiac toxicity but not in mepivacaine-induced cardiac toxicity compared with control. Lipid pretreatment impaired rate-pressure product recovery in mepivacaine-intoxicated hearts. CONCLUSIONS: This study confirms that pretreatment with a lipid emulsion reduces cardiac toxicity of LAs. The efficacy of pretreatment with lipid emulsion was LA-dependent, so pharmacokinetic properties, such as lipophilicity, might influence the effects of lipid emulsion pretreatment.

[Naloxone-induced pulmonary edema. Case report with review of the literature and critical evaluation]. / Naloxoninduziertes Lungenödem. Fallbericht mit Literaturübersicht und kritischer Bewertung.

A case of pulmonary edema after the administration of naloxone for laparoscopic splenectomy is reported. Previous reports of naloxone-induced pulmonary edema are listed and reviewed. The clinical course is compared to other forms of non-cardiogenic pulmonary edema. Uncertainty remains about the underlying pathophysiological process and the true impact of naloxone on the development of pulmonary edema.

[Intensive care unit-acquired weakness in the critically ill : critical illness polyneuropathy and critical illness myopathy]. / Erworbene Muskelschwäche beim kritisch Kranken : Critical-Illness-Polyneuropathie und Critical-Illness-Myopathie.

Intensive care unit-acquired weakness (ICUAW) is a severe complication in critically ill patients which has been increasingly recognized over the last two decades. By definition ICUAW is caused by distinct neuromuscular disorders, namely critical illness polyneuropathy (CIP) and critical illness myopathy (CIM). Both CIP and CIM can affect limb and respiratory muscles and thus complicate weaning from a ventilator, increase the length of stay in the intensive care unit and delay mobilization and physical rehabilitation. It is controversially discussed whether CIP and CIM are distinct entities or whether they just represent different organ manifestations with common pathomechanisms. These basic pathomechanisms, however, are complex and still not completely understood but metabolic, inflammatory and bioenergetic alterations seem to play a crucial role. In this respect several risk factors have recently been revealed: in addition to the administration of glucocorticoids and non-depolarizing muscle relaxants, sepsis and multi-organ failure per se as well as elevated levels of blood glucose and muscular immobilization have been shown to have a profound impact on the occurrence of CIP and CIM. For the diagnosis, careful physical and neurological examinations, electrophysiological testing and in rare cases nerve and muscle biopsies are recommended. Nevertheless, it appears to be difficult to clearly distinguish between CIM and CIP in a clinical setting. At present no specific therapy for these neuromuscular disorders has been established but recent data suggest that in addition to avoidance of risk factors early active mobilization of critically ill patients may be beneficial.

[Death due to (no) airway. Adverse events by out-of-hospital airway management?]. / Tod durch (k)einen Atemweg. Trauma durch die präklinische Atemwegssicherung?

Securing the airway is a rarely performed procedure in the out-of-hospital setting. In recent years evidence has been accumulated indicating that out-of-hospital airway management is more challenging as compared to elective situations even for experienced health care providers. Furthermore, several authors have questioned the benefit of out-of-hospital tracheal intubation. This review argues the problems regarding out-of-hospital airway management studies and discusses potential solutions which may improve out-of-hospital health care.

Secondary clinical deterioration after successful embolization of a spinal dural arteriovenous fistula: a plea for prophylactic anticoagulation.

We present a case of delayed aggravation of initially-resolved symptoms in a patient after successful embolization of a T5 spinal dural arteriovenous (AV) fistula with N-butyl cyanoacrylate. The symptoms were attributed to venous thrombosis and resolved with systemic anticoagulation after five days of treatment. Although the most adequate treatment for preventing venous thrombosis after spinal dural AV fistula is not known, we describe this patient as a case for more aggressive prophylactic anticoagulation measures in the immediate post-embolization time period.

Minimized extracorporeal circulation in coronary artery bypass surgery is equivalent to standard extracorporeal circulation in patients with reduced left ventricular function.

BACKGROUND: Minimized extracorporeal circulation (MECC) is a promising alternative to standard extracorporeal circulation (ECC) and its use is increasing in routine coronary bypass surgery. We analyzed the clinical outcome of patients with reduced left ventricular function who underwent coronary artery bypass surgery with MECC or with standard ECC. METHODS: From January 2003 to September 2008, 238 patients with a left ventricular function < 30 % underwent bypass surgery with ECC or MECC. The primary end point of our retrospective observational study was 30-day mortality. Secondary endpoints were the transfusion requirements, as well as intensive care and the in-hospital course. RESULTS: Demographic data, comorbidities and left ventricular function were similar in the study groups. MECC patients had a tendency towards a lower 30-day mortality rate, a better postoperative renal function and reduced ventilation times. Extracorporeal circulation time and postoperative high-dose inotropic support were significantly lower in the MECC group, while the stays in the intensive care unit and in hospital were comparable between the two groups. In our study, age in the ECC group, and previous infarction and New York Heart Association grade IV in the MECC group were preoperative risk factors associated with a higher mortality. CONCLUSION: Coronary bypass surgery using MECC is feasible and safe for patients with severely impaired left ventricular function. It is a promising alternative to ECC with a low mortality rate and a more favorable postoperative course.

Early endovascular management of oculomotor nerve palsy associated with posterior communicating artery aneurysms.

Palsy of the third cranial nerve (oculomotor nerve, CNIII) is a well-known clinical presentation of posterior communicating artery (P-com) aneurysm. We report a series of 11 patients with partial or complete third nerve palsy secondary to P-com aneurysm. All were treated with endovascular embolization within seven days of symptom onset. Third nerve palsy symptoms resolved in 7/11 (64%), improved in 2/11 (18%) and did not change in 2/11 (18%) patients.

Inefficacy of simulator-based training on anaesthesiologists' non-technical skills.

BACKGROUND: Analysis of critical incidents in anaesthesia practice emphasizes the important role of non-technical skills (NTS) in improving patient safety. Therefore, debriefing with regard to NTS has been added to medical management (MM) simulator training to improve acute crisis competencies of anaesthesiologists. The purpose of this study was to compare the NTS and MM performance of two groups of anaesthesiologists in a simulated anaesthesia crisis after undergoing different types of training. METHODS: Forty-two anaesthesiologists were randomly assigned to two different training groups, with each group participating in two simulation training sessions. One group's (NTS+MMG) training included extensive debriefing of NTS (resource management, planning, leadership and communication) and MM, while the other group (MMG) received a simpler debriefing that focused solely on MM. The quality and quantity of NTS and quality of MM performance were rated by reviewing the videotapes of the scenarios. RESULTS: NTS+MMG did not prove superior to MMG with regard to behavioural and MM markers. The quality of NTS performances correlated significantly (P<0.01) with the quantity of NTS demonstration, and also correlated significantly with the MM actions (P<0.01) in both groups. CONCLUSION: A single session of training including debriefing of NTS and MM did not improve the NTS performances of anaesthesiologists when compared with anaesthesiologists who only received MM training. This might indicate that a more frequent or individual training is needed to improve participants' NTS performance.

Novel microcatheters for selective intra-arterial injection of fluid in the rat brain.

BACKGROUND AND PURPOSE: The internal carotid artery (ICA) in the rat has a single extracranial branch, which supplies the muscles of mastication. The rat ICA also has multiple intracranial branches including (from proximal to distal): multiple small perforating arteries which supply the hypothalamus and the anterior choroidal artery which supplies the choroid plexus and part of the basal ganglia. At the ICA terminus, the vessel bifurcates into the anterior and middle cerebral arteries. The purpose of this study was to demonstrate selective injection of ICA branches in the rat. MATERIALS AND METHODS: Microcatheters (mucath1 and mucath2) were fabricated by plugging the tip of 169-mum outer diameter polyimide tubing and perforating the sidewalls. A 450-mum polydimethyl-siloxane cylinder was affixed to the distal tip of mucath2 but not mucath1. We evaluated the territory of mucath1 injection ex vivo using magnetization-prepared rapid acquisition of gradient echo MR imaging of brain specimens injected at necropsy. Territories of mucath1 and mucath2 injection were evaluated in vivo with dynamic susceptibility-weighted contrast-enhanced MR imaging. The territory of mucath2 also was evaluated in vivo with fused static microPET/T1 MR images performed after [(18)F] fluorodeoxyglucose ((18)FDG) injection. We evaluated additional catheterized and injected animals at 48 hours using physical examination, T2 MR images, and postmortem brain histologic specimens. RESULTS: Gadolinium-diethylene-triamine pentaacetic acid (Gd-DTPA) and (18)FDG injected through mucath1 selectively opacified the ipsilateral cerebral hemisphere, with no contralateral opacification. Gd-DTPA injected through mucath2 selectively opacified the territories of the hypothalamic perforating arteries, and anterior choroidal artery. There was no iatrogenic complication 48 hours after 20- to 25-minute injections performed with mucath1 or mucath2. CONCLUSIONS: We have developed 2 microcatheters which can be placed in the ICA for selective injection of its branches. One microcatheter selectively injects the ipsilateral cerebral hemisphere. The other selectively injects only the hypothalamus and lateral thalamus.

Balloon-assisted technique for trapped microcatheter retrieval following onyx embolization. A case report.

SUMMARY: During embolization of a large frontal arteriovenous malformation (AVM), Onyx-18 (eV3) was injected into an M3 branch of the middle cerebral artery via a Marathon microcatheter (eV3). After 40 minutes of embolization, the microcatheter could not be retracted due to fixation within the Onyx cast despite prolonged, robust attempts. A balloon microcatheter (Hyperform(TM), eV3) was advanced distally and inflated to provide distal counter tension, allowing microcatheter retrieval with minimal traction on the vasculature.

Simulation as an additional tool for investigating the performance of standard operating procedures in anaesthesia.

BACKGROUND: In medicine, the use of standard operating procedures (SOPs) is often evaluated using questionnaires (QUES). However, QUES can have limitations with regard to method, thus leading to errors. Simulation (SIM) offers another opportunity for evaluation. We hypothesized that medical errors in the evaluation of SOPs using QUES could be detected by SIM, and that SIM is better qualified to demonstrate applied medicine. METHODS: We investigated the use of SOPs in anaesthesia, rapid sequence induction (RSI), by means of a QUES (n=42) or SIM (n=42) among 84 anaesthesiologists. Seven measures for preventing aspiration during induction of anaesthesia were examined and evaluated according to a predetermined points system. RESULTS: The average number of times that precautionary measures to prevent aspiration were mentioned in the QUES [4.8 (0.9)] or performed during SIM [5.0 (1.1)] did not differ between the two groups. Pre-oxygenation was the most frequently described or performed measure (95% vs 93%). However, other measures, such as avoidance of positive pressure ventilation (45% vs 85%), differed significantly between the two groups. CONCLUSIONS: QUES and SIM are powerful instruments for evaluating the implementation of SOPs such as RSI. SIM demonstrates automated behaviours and thus more clearly represents behaviours used in clinical practice than is possible to demonstrate using QUES. Using a combination of these two instruments, method errors resulting from the individual instruments can be reduced.

Spinal cord ischemia after endovascular repair of the descending thoracic aorta in a sheep model.

OBJECTIVES: Spinal cord ischemia remains a devastating complication after thoracic aortic surgery. The aim of this study was to investigate the pathophysiology of spinal cord ischemia after thoracic aortic endografting and the role of intercostal artery blood supply for the spinal cord in a standardized animal model. METHODS: Female merino sheep were randomized to either I, open thoracotomy with cross-clamping of the descending aorta for 50 min (n=7), II, endograft implantation (TAG, WL Gore & Ass.), (n=6) or III open thoracotomy with clipping of all intercostal arteries (n=5) . CT-angiography was used to assess completion of surgical protocol and assess the fate of intercostal arteries. Tarloy score was used for daily neurological examination for up to 7 days post-operatively. Histological cross sections of the lumbar, thoracic and cervical spinal cords were scored for ischemic damage after stained with Hematoxylin-Eosin, Klüver-Barrrera and antibodies. Exact Kruskall-Wallis-Test was used for statistical assessment (p<0.05). RESULTS: Incidence of paraplegia was 100% in group I and 0% in group II (p=0.0004). When compared to the endovascular group, there was a higher rate of histological changes associated with spinal cord ischemia in the animals of the control group (p=0.0096). Group III animals showed no permanent neurological deficit and only 20% infarction rate (p=0.0318 compared to group I). CONCLUSIONS: In sheep, incidence of histological and clinical ischemic injury of the spinal cord following endografting was very low. Complete thoracic aortic stent-grafting was feasible without permanent neurologic deficit. Following endovascular coverage or clipping of their origins, there is retrograde filling of the intercostal arteries which remain patent.

[Myotoxicity of local anaesthetics: experimental myth or clinical truth?]. / Myotoxizität von Lokalanästhetika : Experimenteller Mythos oder klinische Wahrheit?

Intramuscular injections of local anaesthetic agents regularly result in reversible muscle damage, with a dose-dependent extent of the lesions. All local anaesthetic agents that have been examined are myotoxic, whereby procaine produces the least and bupivacaine the most severe muscle injury. The histological pattern and the time course of skeletal muscle injury appear relatively uniform: hypercontracted myofibrils become evident directly after injection, followed by lytic degeneration of striated muscle sarcoplasmic reticulum myocyte edema and necrosis. Intriguingly, in most cases myoblasts, basal laminae and connective tissue elements remain intact which subsequently ensures complete muscular regeneration. Subcellular pathomechanisms of local anaesthetic myotoxicity are still not understood in detail. Increased intracellular Ca(2+) levels are suggested to be the most important element in myocyte injury, since denervation, inhibition of sarcolemmal Na(+) channels and direct toxic effects on myofibrils have been excluded as sites of action. Although experimental myotoxic effects are impressively intense and reproducible, only few case reports of myotoxic complications in patients after local anaesthetic administration have been published. In particular, the occurrence of clinically relevant myopathy and myonecrosis has been described after continuous peripheral blockades, infiltration of wound margins, trigger point injections, peribulbar and retrobulbar blocks.