Improved recall of handover information in a simulated emergency - A randomised controlled trial

Background

Handovers during medical emergencies are challenging due to time-critical, dynamic and oftentimes unorderly and distracting situations. We evaluated the effect of distraction-reduced clinical surroundings during handover on (1) the recall of handover information, (2) the recall of information from the surroundings and (3) self-reported workload in a simulated in-hospital cardiac arrest scenario.

Methods

In a parallel group design, emergency team leaders were randomly assigned to receive a structured handover of a cardio-pulmonary resuscitation (CPR) either inside the room ("inside group") right next to the ongoing CPR or in front of the room ("outside group") with no audio-visual distractions from the ongoing CPR. Based on the concept of situation awareness, the primary outcome was a handover score for the content of the handover (0-19 points) derived from the pieces of information given during handover. Furthermore, we assessed team leaders' perception of their surroundings during the scenario (0-5 points) and they rated their subjective workload using the NASA Task Load Index.

Results

The outside group (n = 30) showed significant better recall of handover information than the inside group (n = 30; mean difference = 1.86, 95% CI = 0.67 to 3.06, p = 0.003). The perception of the surroundings (n = 60; mean difference = -0.27, 95% CI = -0.85 to 0.32, p = 0.365) and the NASA Task Load Index (n = 58; mean difference = 1.1; p = 0.112) did not differ between the groups.

Conclusions

Concerning in-hospital emergencies, a structured handover in a distraction reduced environment can improve information uptake of the team leader.

Genome-wide association study of myocardial infarction, atrial fibrillation, acute stroke, acute kidney injury and delirium after cardiac surgery - a sub-analysis of the RIPHeart-Study

Background

The aim of our study was the identification of genetic variants associated with postoperative complications after cardiac surgery.

Methods

We conducted a prospective, double-blind, multicenter, randomized trial (RIPHeart). We performed a genome-wide association study (GWAS) in 1170 patients of both genders (871 males, 299 females) from the RIPHeart-Study cohort. Patients undergoing non-emergent cardiac surgery were included. Primary endpoint comprises a binary composite complication rate covering atrial fibrillation, delirium, non-fatal myocardial infarction, acute renal failure and/or any new stroke until hospital discharge with a maximum of fourteen days after surgery.

Results

A total of 547,644 genotyped markers were available for analysis. Following quality control and adjustment for clinical covariate, one SNP reached genome-wide significance (PHLPP2, rs78064607, p = 3.77 × 10^− 8) and 139 (adjusted for all other outcomes) SNPs showed promising association with p < 1 × 10^− 5 from the GWAS.

Conclusions

We identified several potential loci, in particular PHLPP2, BBS9, RyR2, DUSP4 and HSPA8, associated with new-onset of atrial fibrillation, delirium, myocardial infarction, acute kidney injury and stroke after cardiac surgery.

Trial registration

The study was registered with ClinicalTrials.gov NCT01067703, prospectively registered on 11 Feb 2010.

Electronic supplementary material

The online version of this article (10.1186/s12872-019-1002-x) contains supplementary material, which is available to authorized users.

RIPHeart (Remote Ischemic Preconditioning for Heart Surgery) Study: Myocardial Dysfunction, Postoperative Neurocognitive Dysfunction, and 1 Year Follow-Up

BACKGROUND

Remote ischemic preconditioning (RIPC) has been suggested to protect against certain forms of organ injury after cardiac surgery. Previously, we reported the main results of RIPHeart (Remote Ischemic Preconditioning for Heart Surgery) Study, a multicenter trial randomizing 1403 cardiac surgery patients receiving either RIPC or sham-RIPC.

METHODS AND RESULTS

In this follow-up paper, we present 1-year follow-up of the composite primary end point and its individual components (all-cause mortality, myocardial infarction, stroke and acute renal failure), in a sub-group of patients, intraoperative myocardial dysfunction assessed by transesophageal echocardiography and the incidence of postoperative neurocognitive dysfunction 5 to 7 days and 3 months after surgery. RIPC neither showed any beneficial effect on the 1-year composite primary end point (RIPC versus sham-RIPC 16.4% versus 16.9%) and its individual components (all-cause mortality [3.4% versus 2.5%], myocardial infarction [7.0% versus 9.4%], stroke [2.2% versus 3.1%], acute renal failure [7.0% versus 5.7%]) nor improved intraoperative myocardial dysfunction or incidence of postoperative neurocognitive dysfunction 5 to 7 days (67 [47.5%] versus 71 [53.8%] patients) and 3 months after surgery (17 [27.9%] versus 18 [27.7%] patients), respectively.

CONCLUSIONS

Similar to our main study, RIPC had no effect on intraoperative myocardial dysfunction, neurocognitive function and long-term outcome in cardiac surgery patients undergoing propofol anesthesia.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01067703.

A Multicenter Trial of Remote Ischemic Preconditioning for Heart Surgery

BACKGROUND

Remote ischemic preconditioning (RIPC) is reported to reduce biomarkers of ischemic and reperfusion injury in patients undergoing cardiac surgery, but uncertainty about clinical outcomes remains.

METHODS

We conducted a prospective, double-blind, multicenter, randomized, controlled trial involving adults who were scheduled for elective cardiac surgery requiring cardiopulmonary bypass under total anesthesia with intravenous propofol. The trial compared upper-limb RIPC with a sham intervention. The primary end point was a composite of death, myocardial infarction, stroke, or acute renal failure up to the time of hospital discharge. Secondary end points included the occurrence of any individual component of the primary end point by day 90.

RESULTS

A total of 1403 patients underwent randomization. The full analysis set comprised 1385 patients (692 in the RIPC group and 693 in the sham-RIPC group). There was no significant between-group difference in the rate of the composite primary end point (99 patients [14.3%] in the RIPC group and 101 [14.6%] in the sham-RIPC group, P=0.89) or of any of the individual components: death (9 patients [1.3%] and 4 [0.6%], respectively; P=0.21), myocardial infarction (47 [6.8%] and 63 [9.1%], P=0.12), stroke (14 [2.0%] and 15 [2.2%], P=0.79), and acute renal failure (42 [6.1%] and 35 [5.1%], P=0.45). The results were similar in the per-protocol analysis. No treatment effect was found in any subgroup analysis. No significant differences between the RIPC group and the sham-RIPC group were seen in the level of troponin release, the duration of mechanical ventilation, the length of stay in the intensive care unit or the hospital, new onset of atrial fibrillation, and the incidence of postoperative delirium. No RIPC-related adverse events were observed.

CONCLUSIONS

Upper-limb RIPC performed while patients were under propofol-induced anesthesia did not show a relevant benefit among patients undergoing elective cardiac surgery. (Funded by the German Research Foundation; RIPHeart ClinicalTrials.gov number, NCT01067703.).

The Role of Cyclooxygenase-1 and -2 in Sevoflurane-Induced Postconditioning Against Myocardial Infarction

Cyclooxygenase (COX)-2 mediates ischemic pre- and postconditioning as well as anesthetic-induced preconditioning. However, the role of COX-1 and -2 in anesthetic-induced postconditioning has not been investigated. We evaluated the role of COX-1 and -2 in sevoflurane-induced postconditioning in vivo. Pentobarbital-anaesthetized male C57BL/6 mice were subjected to 45 minutes of coronary artery occlusion and 3 hours of reperfusion. Animals received either no intervention, the vehicle dimethyl sulfoxide (DMSO, 10 µL/g intraperitoneally), acetylsalicylic acid (ASA, 5 µg/g intraperitoneally), the selective COX-1 inhibitor SC-560 (10 µg/g intraperitoneally), or the selective COX-2 inhibitor NS-398 (5 µg/g intraperitoneally). 1.0 MAC (minimum alveolar concentration) sevoflurane was administered for 18 minutes during early reperfusion either alone or in combination with ASA, SC-560, and NS-398. Infarct size was determined with triphenyltetrazolium chloride. Statistical analysis was performed using 1-way and 2-way analyses of variance with post hoc Duncan testing. The infarct size in the control group was 44% ± 9%. DMSO (42% ± 7%), ASA (36% ± 6%), and NS-398 (44% ± 18%) had no effect on infarct size. Sevoflurane (17% ± 4%; P < .05) and SC-560 (26% ± 10%; P < .05) significantly reduced the infarct size compared with control condition. Sevoflurane-induced postconditioning was not abolished by ASA (16% ± 5%) and SC-560 (22% ± 4%). NS-398 abolished sevoflurane-induced postconditioning (33% ± 14%). It was concluded that sevoflurane induces postconditioning in mice. Inhibition of COX-1 elicits a myocardial infarct size reduction and does not abolish sevoflurane-induced postconditioning. Blockade of COX-2 abolishes sevoflurane-induced postconditioning. These results indicate that sevoflurane-induced postconditioning is mediated by COX-2.

Remote ischaemic preconditioning for heart surgery. The study design for a multi-center randomized double-blinded controlled clinical trial--the RIPHeart-Study

AIMS

Transient ischaemia of non-vital tissue has been shown to enhance the tolerance of remote organs to cope with a subsequent prolonged ischaemic event in a number of clinical conditions, a phenomenon known as remote ischaemic preconditioning (RIPC). However, there remains uncertainty about the efficacy of RIPC in patients undergoing cardiac surgery. The purpose of this report is to describe the design and methods used in the "Remote Ischaemic Preconditioning for Heart Surgery (RIPHeart)-Study".

METHODS

We are conducting a prospective, randomized, double-blind, multicentre, controlled trial including 2070 adult cardiac surgical patients. All types of surgery in which cardiopulmonary bypass is used will be included. Patients will be randomized either to the RIPC group receiving four 5 min cycles of transient upper limb ischaemia/reperfusion or to the control group receiving four cycles of blood pressure cuff inflation/deflation at a dummy arm. The primary endpoint is a composite outcome (all-cause mortality, non-fatal myocardial infarction, any new stroke, and/or acute renal failure) until hospital discharge.

CONCLUSION

The RIPHeart-Study is a multicentre trial to determine whether RIPC may improve clinical outcome in cardiac surgical patients.

Early treatment with arteriovenous extracorporeal lung assist and high-frequency oscillatory ventilation in a case of severe acute respiratory distress syndrome

BACKGROUND

Lung protective ventilation can reduce mortality in acute respiratory distress syndrome (ARDS). However, many patients with severe ARDS remain hypoxemic and more aggressive ventilation is necessary to maintain sufficient gas exchange. Pumpless arteriovenous extracorporeal lung assist (av-ECLA) has been shown to remove up to 95% of the systemic CO(2) production, thereby allowing ventilator settings and modes prioritizing oxygenation and lung protection. High-frequency oscillatory ventilation (HFOV) is an alternative form of ventilation that may improve oxygenation while limiting the risk of further lung injury by using extremely small tidal volumes (VT).

METHODS

We discuss the management of a patient suffering from severe ARDS as a result of severe bilateral lung contusions and pulmonary aspiration.

RESULTS

Severe ARDS developed within 4 h after intensive care unit admission. Conventional mechanical ventilation (CV) with high-airway pressures and low VT failed to improve gas exchange. Av-ECLA was initiated to achieve a less aggressive ventilation strategy. VT was reduced to 2-3 ml/kg, but oxygenation did not improve and airway pressures remained high. HFOV (8-10 Hz) was started using a recruitment strategy and oxygenation improved within 2 h. After 5 days, the patient was switched back to CV uneventfully and av-ECLA was removed after 8 days.

CONCLUSION

The combination of two innovative treatment modalities resulted in rapid stabilization and improvement of gas exchange during severe ARDS refractory to conventional lung protective ventilation. During av-ECLA, extremely high oscillatory frequencies were used minimizing the risk of baro- and volutrauma.

The effectiveness and patient comfort of the novel streamlined pharynx airway liner (SLIPA) compared with the conventional laryngeal mask airway in ophthalmic surgery

BACKGROUND

The novel, disposable streamlined pharynx airway liner (SLIPA) has recently been introduced into clinical practice. It has no inflatable cuff, because the shape of the SLIPA closely resembles the anatomy of the pharynx.

METHODS

We compared the SLIPA with the conventional laryngeal mask airway (LMA) regarding handling, safety, sealing of the pharynx, and patient comfort in 124 adult patients (ASA I-III) undergoing ophthalmic surgery under general anesthesia.

RESULTS

Insertion of the SLIPA was straightforward in 88%, slightly difficult in 10%, and obviously difficult in 0% of cases. The SLIPA could not be inserted in 2% of patients. In the LMA group, insertion was straightforward in 90%, slightly difficult in 8%, obviously difficult in 2%, and a failure in 0% of patients. Maximum seal pressure was 24 +/- 6 mm H2O with the SLIPA and 24 +/- 4 mm H2O with the LMA. Gastric air insufflation was noticed in 19% of patients in the SLIPA group and 3% in the LMA group (P < 0.05). No regurgitation of gastric contents was observed. Removal of the airway was uneventful in all cases. Blood traces were noted on the surface of the device in 20% in the SLIPA versus 11% (n.s.) in the LMA group. Complaints of a sore throat were recorded in 2% vs. 14% in the SLIPA and the LMA group, respectively.

CONCLUSION

The SLIPA is a useful alternative to the conventional LMA in patients undergoing minor surgery. However, it is associated with a higher incidence of gastric air insufflation, which may increase the risk of aspiration.