The impact of fluid optimisation before induction of anaesthesia on hypotension after induction

Intra-operative hypotension is a known predictor of adverse events and poor outcomes following major surgery. Hypotension often occurs on induction of anaesthesia, typically attributed to hypovolaemia and the haemodynamic effects of anaesthetic agents. We assessed the efficacy of fluid optimisation for reducing the incidence of hypotension on induction of anaesthesia. This prospective trial enrolled 283 patients undergoing radical cystectomy and randomly allocated them to goal-directed fluid therapy (n = 142) or standard fluid therapy (n = 141). Goal-directed fluid therapy patients received fluid optimisation based on stroke volume response to passive leg raise before induction; those with positive passive leg raise received intravenous crystalloid fluid boluses until stroke volume was optimised. Baseline mean arterial pressure was measured on the morning of surgery and on arriving in the operating theatre. This post-hoc analysis defined haemodynamic instability as either a > 30% relative drop in mean arterial pressure compared with baseline or absolute mean arterial pressure < 55 mmHg, within 15 min of induction. Forty-two (30%) goal-directed fluid therapy patients underwent fluid optimisation after finding an intravascular fluid deficit via passive leg raise testing; 106 (75%) goal-directed fluid therapy and 112 (79%) standard fluid therapy patients met criteria for haemodynamic instability. There was no significant difference in the incidence of haemodynamic instability between the goal-directed fluid therapy and standard fluid therapy groups using absolute mean arterial pressure drop below 55 mmHg (p = 0.58) or using pre-surgical testing or pre-surgical mean arterial pressure values as baseline (p = 0.21, p = 0.89, respectively); however, the difference in the incidence of haemodynamic instability was significant using the operating theatre baseline mean arterial pressure (p = 0.004). We conclude that fluid optimisation before induction of general anaesthesia did not significantly impact haemodynamic instability.

Extended induction chemotherapy does not improve the outcome for high-risk neuroblastoma patients: results of the randomized open-label GPOH trial NB2004-HR

BACKGROUND

Long-term survival of high-risk neuroblastoma patients is still below 50% despite intensive multimodal treatment. This trial aimed to address whether the addition of two topotecan-containing chemotherapy courses compared to standard induction therapy improves event-free survival (EFS) of these patients.

PATIENTS AND METHODS

An open-label, multicenter, prospective randomized controlled trial was carried out at 58 hospitals in Germany and Switzerland. Patients aged 1-21 years with stage 4 neuroblastoma and patients aged 6 months to 21 years with MYCN-amplified tumors were eligible. The primary endpoint was EFS. Patients were randomly assigned to standard induction therapy with six chemotherapy courses or to experimental induction chemotherapy starting with two additional courses of topotecan, cyclophosphamide, and etoposide followed by standard induction chemotherapy (eight courses in total). After induction chemotherapy, all patients received high-dose chemotherapy with autologous hematopoietic stem cell rescue and isotretinoin for consolidation. Radiotherapy was applied to patients with active tumors at the end of induction chemotherapy.

RESULTS

Of 536 patients enrolled in the trial, 422 were randomly assigned to the control arm (n = 211) and the experimental arm (n = 211); the median follow-up time was 3.32 years (interquartile range 1.65-5.92). At data lock, the 3-year EFS of experimental and control patients was 34% and 32% [95% confidence Interval (CI) 28% to 40% and 26% to 38%; P = 0.258], respectively. Similarly, the 3-year overall survival of the patients did not differ [54% and 48% (95% CI 46% to 62% and 40% to 56%), respectively; P = 0.558]. The response to induction chemotherapy was not different between the arms. The median number of non-fatal toxicities per patient was higher in the experimental group while the median number of toxicities per chemotherapy course was not different.

CONCLUSION

While the burden for the patients was increased by prolonging the induction chemotherapy and the toxicity, the addition of two topotecan-containing chemotherapy courses did not improve the EFS of high-risk neuroblastoma patients and thus cannot be recommended. CLINICAL TRIALS.

GOV NUMBER

NCT number 03042429.

[Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR) : Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC]

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

CaRdiac Arrest Survival Score (CRASS) - A tool to predict good neurological outcome after out-of-hospital cardiac arrest

AIM

The aim of this study was to develop a score to predict the outcome for patients brought to hospital following out-of-hospital cardiac arrest (OHCA).

METHODS

All patients recorded in the German Resuscitation Registry (GRR) who suffered OHCA 2010-2017, who had ROSC or ongoing CPR at hospital admission were included. The study population was divided into development (2010-2016: 7985) and validation dataset (2017: 1806). Binary logistic regression analysis was used to derive the score. The probability of hospital discharge with good neurological outcome was defined as 1/(1 + e^-X), where X is the weighted sum of independent variables.

RESULTS

The following variables were found to have a significant positive (+) or negative (-) impact: age 61-70 years (-0·5), 71-80 (-0·9), 81-90 (-1·3) and > = 91 (-2·3); initial PEA (-0·9) and asystole (-1·4); presumable trauma (-1·1); mechanical CPR (-0·3); application of adrenalin > 0 - < 2 mg (-1·1), 2 - <4 mg (-1·6), 4 - < 6 mg (-2·1), 6 - < 8 mg (-2·5) and > = 8 mg (-2·8); pre emergency status without previous disease (+0·5) or minor disease (+0·2); location at nursing home (-0·6), working place/school (+0·7), doctor's office (+0·7) and public place (+0·3); application of amiodarone (+0·4); hospital admission with ongoing CPR (-1·9) or normotension (+0·4); witnessed arrest (+0·6); time from collapse until start CPR 2 - < 10 min (-0·3) and > = 10 min (-0·5); duration of CPR <5 min (+0·6). The AUC in the development dataset was 0·88 (95% CI 0·87-0·89) and in the validation dataset 0·88 (95% CI 0·86-0·90).

CONCLUSION

The CaRdiac Arrest Survival Score (CRASS) represents a tool for calculating the probability of survival with good neurological function for patients brought to hospital following OHCA.

[Current treatment of endocarditis : Innovations and controversies]

Despite many novel diagnostic strategies and advances in treatment, infective endocarditis (IE) remains a severe disease. The epidemiology of IE has shifted and staphylococci have replaced streptococci as the most common cause and nosocomially acquired infections, invasive procedures, indwelling cardiac devices and acquired infections due to intravenous drug abuse are more frequent. The incidence of IE has steadily increased in recent years and the patients affected are older and have more comorbidities. The modern treatment of IE is interdisciplinary. The pharmacotherapy of IE depends on the pathogen and its sensitivity. The presence of a bioprosthetic valve and implantable cardiac devices plays a significant role in selection of antibiotics and duration of treatment. This article provides an update and overview of the current clinical practice in diagnostics and pharmacotherapy of IE in adults with a special focus on partial oral therapy and the role of aminoglycosides.

P6385Association of prehospital acetylsalicylic acid and heparin administration with favourable neurological outcome after out-of-hospital cardiac arrest: a matched-pair analysis

Background/Introduction

To date, no prehospital administered drug has shown to influence favourable neurological outcome in patients with out-of-hospital cardiac arrest (OHCA). Early administration of antiplatelet and anticoagulant medication might affect organ microcirculation and therefore favourable neurological outcome in the setting of OHCA.

Purpose

To evaluate the effect of prehospital acetylsalicylic acid and heparin (AH) administration on favourable neurological outcome and overall survival after OHCA in a large multicentre registry.

Methods

We examined patients with cardiac causes of OHCA that were prospectively included in the German Resuscitation Registry. Patients that were administered AH in the prehospital setting were matched in a 1:4 ratio with patients that were not administered AH. Pairs were matched for age >80 years, public place of collapse, initial ECG rhythm, witnessed by lay people and by emergency medical services (EMS), bystander CPR, usage of vasopressors, ECG signs of ACS or diagnosed ACS, coronary angiography conducted and hypothermia conducted. Analyses in the patients were stratified by treatment arm. Data was collected from 2011 to 2017 and analysed from January 2019 to March 2019. The primary endpoint was favourable neurological outcome at hospital discharge defined as cerebral performance category (CPC) 1 or 2. Secondary endpoints were return of spontaneous circulation (ROSC) as well as survival to hospital discharge. Logistic regression analysis and chi square analysis were used to evaluate the primary and secondary endpoints, respectively.

Results

Within the German Resuscitation Registry, 17,139 patients included between 2011 and 2017 had a presumably cardiac cause of OHCA with completed follow-up data. 205 patients were administered AH in the prehospital setting, whereas 16,934 were not. After matching in a 1:4 ratio, 174 patients in the AH group and 696 in the noAH group were suitable for analysis of the primary and the secondary endpoints. Prehospital AH administration was associated with favourable neurological outcome (OR for CPC 1 or 2 at hospital discharge 1.489 [1.026–2.162], p=0.036). Patients with AH were more likely to have ROSC (73.6% vs. 65.7% in the noAH group, p=0.047). Survival to hospital discharge was not statistically different between groups (32.8% vs. 28.5% in the noAH group).

Consort flow-diagram

Conclusion(s)

In this matched-pair analysis, prehospital administration of AH was associated with an enhanced ROSC rate and with favorable neurological outcome. Randomized controlled trials are needed to confirm these results.

Design of a novel antisymmetric coil array for parallel transmit cardiac MRI in pigs at 7 T

The design, simulation, assembly and testing of a novel dedicated antisymmetric transmit/receive (Tx/Rx) coil array to demonstrate the feasibility of cardiac magnetic resonance imaging (cMRI) in pigs at 7 T was described. The novel antisymmetric array is composed of eight elements based on mirrored and reversed loop orientations to generate varying B₁⁺ field harmonics for RF shimming. The central four loop elements formed together a pair of antisymmetric L-shaped channels to allow good decoupling between all neighboring elements of the entire array. The antisymmetric array was compared to a standard symmetric rectilinear loop array with an identical housing dimension. Both arrays were driven in the parallel transmit (pTx) mode forming an 8-channel transmit and 16-channel receive (8Tx/16Rx) coil array, where the same posterior array was combined with both anterior arrays. The hardware and imaging performance of the dedicated cardiac arrays were validated and compared by means of electromagnetic (EM) simulations, bench-top measurements, phantom, and ex-vivo MRI experiments with 46 kg female pig. Combined signal-to-noise ratio (SNR), geometry factor (g-factor), noise correlation maps, and high resolution ex-vivo cardiac images were acquired with an in-plane resolution of 0.3 mm × 0.3 mm using both arrays. The novel antisymmetric array enhanced the SNR within the heart by about two times and demonstrated good decoupling and improved control of the B₁⁺ field distributions for RF shimming compared to the standard coil array. Parallel imaging with acceleration factor (R) up to 4 was possible using the novel antisymmetric coil array while maintaining the mean g-factor within the heart region of 1.13.

Improving network approaches to the study of complex social-ecological interdependencies

Achieving effective, sustainable environmental governance requires a better understanding of the causes and consequences of the complex patterns of interdependencies connecting people and ecosystems within and across scales. Network approaches for conceptualizing and analyzing these interdependencies offer one promising solution. Here, we present two advances we argue are needed to further this area of research: (i) a typology of causal assumptions explicating the causal aims of any given network-centric study of social-ecological interdependencies; (ii) unifying research design considerations that facilitate conceptualizing exactly what is interdependent, through what types of relationships, and in relation to what kinds of environmental problems. The latter builds on the appreciation that many environmental problems draw from a set of core challenges that re-occur across contexts. We demonstrate how these advances combine into a comparative heuristic that facilitates leveraging case-specific findings of social-ecological interdependencies to generalizable, yet context-sensitive, theories based on explicit assumptions of causal relationships.

Microcatheter-assisted stenting of the tortuous vertical ductus arteriosus via femoral access in a duct-dependent pulmonary circulation

BACKGROUND

Stenting of the patent ductus arteriosus (PDA) has been accepted as alternative option to surgical shunting to enable additional pulmonary blood flow or for palliation of patients with a truly duct-dependent pulmonary circulation. The procedure can be challenging given the variable and often tortuous anatomy of the PDA and various technical approaches are reported.

OBJECTIVE

To report an alternative technique to treat tortuous ducts with microcatheter assistance and by transfemoral approach.

METHODS

We applied this technique of PDA stenting in 5 consecutive patients (4/5 age < 1 week, weight 2,7-3,2 kg; 1/5 re-do PDA stenting at 6,5 month and 5,9 kg). A soft coronary guidewire was advanced by microcatheter assistance into the branch pulmonary arteries and thereafter replaced by an extrastiff guidewire to enable the placement of long coronary stents.

RESULTS

Successful PDA stenting with this stepwise approach and with femoral access only could be achieved in all patients (n = 5/5). A single stent was used in 2 patients (one with re-do stenting and previous stents). 3/5 patients had 2 stents implanted by telescopic technique. Stent sizes used were 4,5 × 15 mm (n = 2) and 4,5 × 18 mm (n = 6). No guide wire or stent dislodgement appeared through all procedures with microcatheter assistance.

CONCLUSIONS

This technique enables PDA stenting via transfemoral approach in complex and tortuous ducts and thereby offers an attractive addition to the interventional management of truly duct-dependent pulmonary circulation.

Secure quantum remote state preparation of squeezed microwave states

Quantum communication protocols based on nonclassical correlations can be more efficient than known classical methods and offer intrinsic security over direct state transfer. In particular, remote state preparation aims at the creation of a desired and known quantum state at a remote location using classical communication and quantum entanglement. We present an experimental realization of deterministic continuous-variable remote state preparation in the microwave regime over a distance of 35 cm. By employing propagating two-mode squeezed microwave states and feedforward, we achieve the remote preparation of squeezed states with up to 1.6 dB of squeezing below the vacuum level. Finally, security of remote state preparation is investigated by using the concept of the one-time pad and measuring the von Neumann entropies. We find nearly identical values for the entropy of the remotely prepared state and the respective conditional entropy given the classically communicated information and, thus, demonstrate close-to-perfect security.

Continuous-variable remote state preparation in the microwave domain would allow to leverage the superconducting technology for quantum networks applications. Here, the authors show how to deterministically prepare squeezed Gaussian states across 35 cm using previously shared entanglement.

[Preclinical emergency anesthesia : A current state analysis from 2015-2017]

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.

Effects of elevated CO2 concentration on leaves and berries of black elder (Sambucus nigra) using UHPLC-ESI-QTOF-MS/MS and gas exchange measurements

The effect of elevated CO₂ concentration on leaves of black elder (Sambucus nigra) was investigated based on leaf gas exchange, chlorophyll content as well as on the analysis of the underlying metabolite profile of the fruits. The measurements were carried out once a month over a period of time of 4 months. The CO₂ uptake rate, the transpiration rate and stomatal conductance were significantly higher in plants under ambient CO₂, in comparison to plants grown under elevated CO₂ concentrations. On the other hand, at the initial phase of the experiments, the photosynthesis rate was higher in CO₂ loaded plants compared to plants grown under normal conditions. Remarkably, after about one month a habituation effect could be observed leading to a decrease of the photosynthetic efficiency approaching again the normal level. To understand the observed effects on a molecular level, non-targeted fingerprinting analysis was performed on the ripe elder berries using LC-qToF-ESI-MS(/MS). Differences in the composition of various phenols, triglycerides and PC (36:5) as well as a stigmasterole-derivate could be detected. In contrast, central metabolic pathways such as photosynthesis, the tricarboxylic acid cycle as well as the biosynthesis of essential amino acids obviously are not considerably affected.

Der natürliche Verlauf der Choroideremie

Seit ihrer Erstbeschreibung im Jahr 1872 herrscht um den natürlichen Verlauf der Choroideremie eine rege und in Teilen bis heute andauernde akademische Debatte. Aufgrund der Seltenheit der Erkrankung verlief diese traditionell weitgehend am Rande des klinisch geprägten Interessenhorizonts. Nun jedoch hat die Entwicklung grundlegend neuer, potenziell verlaufsmodifizierender Therapieansätze die Frage nach dem natürlichen Verlauf der Chorioideremie ins Zentrum der Aufmerksamkeit eines größeren Fachpublikums gerückt. Dieser Übersichtsartikel subsumiert den aktuellen Stand der Fachliteratur zum natürlichen Verlauf dieser seltenen Erkrankung und illustriert dessen Eigenheiten anhand eines übersichtlichen 2-Phasen-Modells. Neben einer ausführlichen Besprechung klinisch gängiger Modalitäten liegt der Fokus des Manuskripts auf der Ausarbeitung forschungsrelevanter Fragestellungen wie der intraindividuellen Symmetrie sowie der Etablierung neuer Endpunkte. Darüber hinaus werden die Limitationen bisheriger Studien diskutiert und Empfehlungen für zukünftige Beobachtungsstudien entwickelt.

Breastfeeding and vitamin D supplementation reduce the risk of Kawasaki disease in a German population-based case-control study

Background

In Kawasaki disease (KD), a vasculitis of unknown etiology, the most serious complication is the development of coronary artery aneurysm (CAA). To date, the exact pathomechanism of KD is unknown. Both environmental and genetic factors seem to be associated with the development of the disease.

Methods

Data on KD patients recruited from the population-based German Pediatric Surveillance Study during 2012–2014 were used to evaluate the impact of various factors from the perinatal and infancy period on the development of KD. The study design was a matched case-control study with respect to age, sex and place of residence (n = 308 KD cases, n = 326 controls). All KD patients were individually re-evaluated; all fulfilled the international diagnostic KD criteria. A standardized questionnaire was used to review breastfeeding practices, vitamin D supplementation and birth characteristics. Logistic regression analyses were performed to obtain odds ratios (OR) for various risk factors among the case-control pairs. Simple measures of association were used to assess the impact of these factors on the clinical course.

Results

There was no difference in lengths of gestation, birth weight or parturition between KD patients and controls, but independently from each other vitamin D supplementation and breastfeeding were negatively associated with KD, even when adjusted for age, place of residence and sex. The duration of vitamin D was significantly shorter among children with KD than among children without KD (p = 0.039, OR = 0.964, 95% CI: 0.931–0.998), as was the duration of breastfeeding (p = 0.013, OR = 0.471, 95% CI: 0.260–0.853). Comparing KD patients with and without breastfeeding and/or vitamin D supplementation, there were no differences regarding developing CAA, being refractory to intravenous immunoglobulin treatment, age at onset of the disease and levels of inflammatory laboratory values.

Conclusion

Our findings indicate breastfeeding and vitamin D supplementation to have protective effects in association with KD in our study population; however, these seem not to influence the natural course of the disease. Although the overall effects were relatively small, they nevertheless underline the overall benefit of both interventions.

Trial registration

Clinical Trial Registration: German clinical trial registration, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00010071. Date of registration was 26. February 2016. The trial was registered retrospectively.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1438-2) contains supplementary material, which is available to authorized users.