Use of Rotational Thromboelastometry in Liver Transplantation Is Associated With Reduced Transfusion Requirements

OBJECTIVES

Increased transfusion requirements in liver transplantation have been reported to be associated with worsened outcomes, more frequent reinterventions, and higher expenses. Anesthesiologists might counteract this through improved coagulation management. We evaluated the effects of rotational thromboelastometry on transfusion and coagulation product requirements and on outcome measurements.

MATERIALS AND METHODS

Patients who were 14 years or older and who were undergoing liver transplant at Hannover Medical School between January 2005 and December 2009 were included in this retrospective analysis. Demographic, clinical, and laboratory data, use of rotational thromboelastometry, intraoperative need for blood or coagulation products and antifibrinolytic substances, and clinical course were recorded. Correlations were examined using appropriate statistical tests.

RESULTS

Our study included 413 patients. Use of rotational thromboelastometry was associated with less frequent intraoperative administration of red blood cell concentrates, fresh frozen plasma, platelet concentrates, prothrombin complex concentrates, and antithrombin concentrates (all P < .05). In addition, univariate and multivariate tests showed that rotational thromboelastometry was correlated with decreased need for red blood cell concentrates and fresh frozen plasma (all P < .05). Intraoperative administration rates of antifibrinolytic substances and fibrinogen concentrate were significantly increased in patients who received rotational thromboelastometry monitoring (both P < .05). However, use of rotational thromboelastometry was not associated with massive transfusion rates (> 10 units vs less), clinical outcome, or length of stay in the intensive care unit (all P > .05).

CONCLUSIONS

Use of rotational thromboelastometry during liver transplant may reduce the need for intraoperative transfusion and coagulation products. Relevant effects of rotational thromboelastometry on patient outcomes or lengths of stay in the intensive care unit could not be ascertained. However, readjustment of therapeutic thresholds may improve the clinical impact.

Improved success rates using videolaryngoscopy in unexperienced users: a randomized crossover study in airway manikins

Background

Videolaryngoscopy has been proven to be a safe procedure managing difficult airways in the hands of airway specialists. Information about the success rates in unexperienced users of videolaryngoscopy compared to conventional laryngoscopy is sparse. Therefore, we aimed to evaluate if there might be more success in securing an airway if the unexperienced provider is using a videolaryngoscope in simulated airways in a randomized manikin study. Differences between commonly used videolaryngoscopes were elucidated.

Methods

A standardized hands-on workshop prior to the study was performed. For direct laryngoscopy (DL) we used a Macintosh laryngoscope, whereas for videolaryngoscopy (VL) we used the cMac, the dBlade, and a King Vision videolaryngoscope. Endotracheal intubations in three simulated normal and difficult airways were performed. Main outcome parameters were time to view and time to intubation. Cormack and Lehane (C + L) classification and the percentage of glottic opening (POGO) score were evaluated. After every intubation, the participants were asked to review the airway and the device used.

Results

22 participants (14.8 ± 4.0 intubations per year, mostly trauma surgeons) with limited experience in videolaryngoscopy (mean total number of videolaryngoscopy .4 ± .2) were enrolled. We found improved C + L grades with VL in contrast to DL. We saw similar data with respect to the POGO score, where the participants achieved better visibility of the glottis with VL. The hyperangulated blade geometries of videolaryngoscopes provided a better visibility in difficult airways than the standard geometry of the Macintosh-type blade. The subjective performance of the VL devices was better in more difficult airway scenarios.

Conclusions

After a short introduction and hands-on training, a videolaryngoscope seems to be safe and usable by unexperienced providers. We assume a standard geometry laryngoscope is optimal for a patient with normal anatomy, whereas VL device with a hyperangulated blade is ideal for difficult airway situations with limited mouth opening or restricted neck movement.

Simulator-Based Air Medical Training Program Christoph Life: From Concept to Course

OBJECTIVE

Christoph Life is a simulator-based air medical training program and a new and innovative educational concept. Participants pass different scenarios with a fully equipped and movable helicopter simulator. Main focuses of the program are crew resource management (CRM) elements and team training. Information about expectations end effectiveness of the training is sparse.

METHODS

During a 2-day training, participants learn CRM basics and complete various emergency medical scenarios. For evaluation, we used an anonymous questionnaire either with polar questions or a 6-coded psychometric Likert scale. The Wilcoxon test was used for statistical analysis. The significance level was set at P < .05.

RESULTS

Thirteen teams of emergency physicians and specially trained paramedics underwent Christoph Life. It was evaluated largely positively and considered very helpful for daily work (5.7 ± 0.5) and avoiding mistakes (5.7 ± 0.5). The quality of participants' knowledge about CRM basics (3.5 ± 1.2 vs. 5.4 ± 0.7, P < .001), self-assessment of communication skills (4.2 ± 0.7 vs. 4.8 ± 0.8, P = .02), and active reflection of communication aspects (3.9 ± 0.9 vs. 5.5 ± 0.5, P < .001) could be strikingly increased.

CONCLUSIONS

There is a considerable demand for intensified training on the part of the users. We were able to show that a simulator-based air medical training program is a helpful training tool with an obvious subjective benefit for the participants' nontechnical skills.

Impact of the laryngeal tube as supraglottic airway device on blood flow of the internal carotid artery in patients undergoing general anaesthesia

INTRODUCTION

Laryngeal tubes (LT) are supraglottic airway devices routinely used in emergency airway management. During cardiac arrest in a swine model, the carotid artery blood flow is reduced after insertion of a LT. A compression of the internal carotid (ICA) artery by the inflated cuff was shown. Up to now there is no information if the LT has similar effects in humans with possible negative implications for use of the LT in case of cardiac arrest.

OBJECTIVE

We hypothesized that the use of a LT in humans significantly reduces the blood flow in the ICA compared facemask ventilation. A significant reduction was defined as a 25% reduction from baseline values.

MATERIAL AND METHODS

After induction of general anaesthesia and reaching a haemodynamic steady state (stable heart rate >50/min and mean arterial pressure >60 mmHg), blood flow within the ICA was measured via doppler sonography during pressure-controlled ventilation with facemask-, laryngeal tube- and laryngeal mask.

RESULTS

We found no differences in the carotid blood flow. Neither between the facemask ventilation (right side 419 ± 159 ml min^-1, left side 355 ± 120 ml min^-1) and the laryngeal tube ventilation (right side 400 ± 131 ml min^-1, left side 384 ± 124 ml min^-1. p = 0.86 and p = 0.12), nor the facemask-ventilation and the laryngeal mask ventilation (right ICA 415 ± 150 ml min^-1, left ICA 485 ± 274 ml min^-1, p = 0.49 and 0.26).

CONCLUSIONS

In humans the LT does not impair blood flow of the internal carotid artery during ventilation in general anaesthesia. Further studies are needed to confirm our findings under the conditions of cardiac arrest.

Changes of collective orientation through a medical student's anaesthesia simulation course - simulation-based training study with non-technical skills debriefing versus medical debriefing

BACKGROUND

Non-technical skills (NTS) are known to have a positive impact on quality of medical care. The team performance enhancing behaviour, as an example for NTS, is termed "Collective Orientation" (CO). In this study, we investigated the effect of a simulator-based anaesthesia training upon student's CO in relation to medical and TeamGAINS (guided team self-correction, advocacy-inquiry and systemic-constructivist techniques) debriefing. We hypothesized (a) the scale collective orientation, as demonstrated in other team setting, is applicable to fourth year German medical students, (b) collective orientation increases by a four-hour anaesthesia simulation course, (c) the change in collective orientation can be influenced by type of debriefing.

METHOD

All classes of an anaesthesia module (4th year medical students) were randomized into two groups. Students took part in a four-hour simulation course with team scenarios, supported by a simulated nurse. In group one the trainer focused on a debriefing on medical problems and in group two, a debriefing according to the specifications of the TeamGAINS concept was conducted. The primary outcome was the mean difference between the collective orientation measured (via questionnaires) immediately before (T1) and after (T2) training.

RESULTS

Cronbach's alpha for all scales and measurement points was higher than 0.72. The scale "affiliation" decreases in the group medical debriefing MD = 0.1 (p = 0.008; r = 0.31) and was unchanged in the group TeamGAINS. "Dominance" increases in both groups. The values were MD = 0.19 (p = 0.003; r = 0.25) for medical debriefing and MD = 0.22 (p = 0.01; r = 0.40) for TeamGAINS debriefing.

CONCLUSION

The collective orientation questionnaire can be applied to fourth year medical students. Simulation courses influence the attitude towards teamwork. The influence is negatively to the subscale "affiliation" by a "medical debriefing" and independently regardless of the nature of the debriefing for the subscale "dominance". We recommend a debriefing for medical students using the TeamGAINS approach to clarify the connection between the individual performance and non-technical skills. Anaesthesia simulation courses have the potential being a part of a longitudinal education curriculum for teaching non-technical skills.

Training of airway management for anesthesia teams - Measurement of transfer into daily work routine by questionnaire

THEORY

Problems in airway management are rare in anesthesia but when they occur, they have serious consequences for the patient. For this reason, training is recommended for professionals involved in anesthetic care. Here we investigated, if a newly developed technical/ non-technical hybrid airway training would be relevant for daily practice in a tertiary referral hospital.

HYPOTHESES

We hypothesized that: (a) both parts of the validated questionnaires meet the quality criteria for the application in anesthesia teams, (b) even though the team regularly deals with airway management, airway management training is relevant to all professions and (c) contents of the developed training can be integrated into the behaviour of the teams.

METHOD

In this observational study, 104 professionals took part in a one-day technical/non-technical hybrid airway training programme. Participants received a questionnaire six months after training, based on selected scales of the validated tools; "Training Evaluation Inventory" and "Transfer Climate Questionnaire".

RESULTS

The scales of "perceived usefulness", "task cues" and "positive reinforcement" showed good internal consistency and all were rated higher than 3.9 on a 5-point Likert scale (1=complete rejection; 5=fullest approval). The scale "negative reinforcement and punishment" showed satisfactory internal consistency for physicians (rated 2.75 ± 0.8). By removing an item in each case, the scales "attitude towards training" (rated 4.93 ± 0.2) and "extinction" (rated 3.02 ± 0.8) showed satisfactory internal consistency for nurses and anesthetic technicians. "Social Cues" did not meet qualitative criteria. There was no difference in the assessment by the professional groups.

CONCLUSIONS

The presented training course was perceived as useful by both professional groups equally, which supported the interprofessional concept. The content was positively reinforced in practice six months after training and is relevant for professionals who are regularly confronted with the topic "airway management". Scales which meet qualitative criteria for only one profession and the scale "social cues" should be reconsidered in the context of an interprofessional team.

[Simulation as a Training Method for the Professionalization of Teams]

Simulation as an educational method can be applied to the training of processes, technical and non-technical skills. This article focuses on the role of simulation in crisis resource management and non-technical skills. A realistic work environment requires well-trained staff regarding simulation technology and communication. A training (unit) is divided into three sections. During the briefing the team is introduced to the scenario. Afterwards, the patient is treated by an interdisciplinary team. Communication under the pressure of action, even if one does not agree with the approach of the colleagues, should be practiced. After the scenario a structured debriefing is conducted. The trainer supervises the reflection of the teams' actions. Various methods such as "guided team self-correction", "advocacy-inquiry" and the "TeamGAINS"-approach are available for this decisive phase of the training. A safe environment is guaranteed, video recordings will never leave the training. Active experimentation, concrete experiences and accurate reflection are the key factors of success for the method simulation. Positive effects on critical incidents, resuscitation outcome and improvement of team climate can be observed after simulation training.

Instructors for on-the-job training of advanced paramedics - definition of competencies and development of a quality management tool for a "High Responsibility Organization"

Objective: The psychological demands placed upon the emergency medical services, assures them of their place amongst High Responsibility Organizations. A high pressure to act and an irreversibility of situations are integral features of their workplaces. After the emergency services' job profiles were restructured in Germany, the practical stage of paramedic training is now undertaken in these conditions. That is, they are trained by a supervising instructor whilst caring for critically ill patients. This paper aims to describe the requisite skills for such an instructor, formulate the associated competences as learning objectives, and develop a quality-measuring instrument for the description of training situations. Methods: The compilation of a competence catalogue was done via a two-step process: following a Delphi survey with an expert panel of practical trainers and trainees, a large cohort of parameters were validated in terms of their relevance. Those factors that formed scales together were identified. Results: After validating the results of the Delphi analysis, six scales (composed of 25 items in toto) were defined. They included the areas of "Training during times of action", "Training during periods of calm", "Background and practical relevance", "Character and personality traits", "Pedagogical competencies" and "Organizational behaviour". Conclusion: For the first time, a competency catalogue has been developed for instructors working in the emergency medical services from German-speaking countries. The catalogue focuses upon clinical training during the acute care of critically ill patients. The scales and items can be used for training-the-trainers, and also quality monitoring. Further research needs to focus on the application of the catalogue in clinical practice and evaluate the need for situational customization.

[Complications and success rates of subclavian vein catheterization depending on experience]

BACKGROUND

The infraclavicular puncture of the subclavian vein is a standard procedure for anesthetists. Meanwhile the literature and recommendations are clear and the use of real-time ultrasound guidance is the standard procedure; however, anesthetists will always get into special circumstances were they have to use the landmark technique, so this competence must be preserved. Feared complications of infraclavicular subclavian vein puncture are pneumothorax and arterial puncture. Up to now there is no clear learning curve for the infraclavicular subclavian vein puncture in the landmark technique performed by anesthetists.

OBJECTIVE

The aim of this study was to examine the influence of the puncture experience on the success rate and mechanical complications, such as pneumothorax and arterial puncture in patients who received an infraclavicular subclavian vein puncture with the landmark technique. Three levels of experience were defined for comparison: inexperienced 0-20 punctures, moderately experienced 21-50 and experienced over 50 punctures.

MATERIAL AND METHODS

Post hoc analysis of a previously published noninferiority study to examine the influence of ventilation on the pneumothorax rate in the subclavian vein puncture using the landmark technique. This analysis included 1021 anesthetized patients who were included in the original study between August 2014 and October 2017. Demographic data as well as the number of puncture attempts, puncture success, the overall rate of mechanical complications, pneumothorax rate and arterial puncture rates were calculated.

RESULTS

The overall rate of mechanical complications (pneumothorax + arterial puncture) was significantly higher in the inexperienced group (0-21) compared to the experienced group (>50, 15% vs. 8.5%, respectively, p = 0.023). This resulted in an odds ratio of 0.52 (confidence interval, CI: 0.32-0.85, p = 0.027). Likewise, the rate of puncture attempts in the group of inexperienced (0-20) with 1.85 ± 1.12 was significantly higher than in the group of experienced (>50, 1.58 ± 0.99, p = 0.004) and resulted in an odds ratio of 0.59 (CI: 0.31-0.96, p = 0.028). Although the puncture attempts of the moderately experienced (21-50) compared to the inexperienced (0-20) was not significant lower, we found an odds ratio of 0.69 (CI: 0.48-0.99, p = 0.042). The rate of successful puncture was 95.1% in the experienced group versus 89.3% in the inexperienced group (p = 0.001), which resulted in an odds ratio of 2.35 (CI: 1.28-4.31, p = 0.018). When viewed individually, no significant differences were found for pneumothorax and arterial puncture.

CONCLUSION

In this post hoc analysis of the puncture of the subclavian vein using the landmark technique, we found a significant reduction of puncture attempts and overall mechanical complications. At least 50 punctures seem to be necessary to achieve the end of the learning curve; however, the landmark technique should only be used under special circumstances, when real-time ultrasound is not available. Anesthetists who want to complete their repertoire and learn the landmark technique should always perform a static ultrasound examination before starting the puncture in order to reduce complications due to anatomical variations or thrombosis.

Expectations, training and evaluation of intensive care staff to an interprofessional simulation course in Germany - Development of a relevant training concept

Objective: Increasingly, intensive care units (ICU) are operated by teams of physicians and nurses with specialist training in anaesthesia and intensive care. The aims of our study were to evaluate any prior experience, expectations and the requisites for interprofessional ICU simulation-based training (SBT), and to evaluate a newly designed training course incorporating these findings. Methods: The study was laid out as a cross-sectional study and is projected in three steps. First, questionnaires were sent out to ICU nurses and physicians from 15 different hospitals in a greater metropolitan area (> million citizens). Based upon this survey a one-day ICU simulator course designed for 12 participants (6 nurses and 6 physicians) was developed, with evaluation data from four subsequent courses being analysed. Results: In the survey 40% of nurses and 57% of the physicians had had prior exposure to SBT. Various course formats were explored with respect to duration, day of the week, and group composition. After completing the course, the majority deemed a full working day in interprofessional setting to be most appropriate (p<0.001). The scenarios were considered relevant and had a positive impact on communication, workflow and coping with stress. Conclusion: Currently SBT is not a mainstream tool used by German ICU teams for further education, and this lack of familiarity must be taken into consideration when preparing SBT courses for them. We developed a nontechnical skills training course for ICU teams which was undertaken in the setting of simulated clinical scenarios (pertinent to their work environment). The participants found the course's content to be relevant for their daily work, rated the course's impact on their workplace practices as being good and advocated for longer training sessions.

[Catheterization of the subclavian vein and the risk of pneumothorax : Mechanical ventilation increases the risk of pneumothorax during infraclavicular landmark-guided subclavian vein puncture: a prospective randomized study]

BACKGROUND

Infraclavicular subclavian vein (SCV) catheterization is a standard procedure in anesthesia and intensive care. There is a lack of evidence on how mechanical ventilation during venipuncture of the SCV influences pneumothorax rates.

OBJECTIVE

Primary hypothesis: non-inferiority of continuing vs. discontinuing mechanical ventilation during infraclavicular puncture of the SCV with respect to the pneumothorax rate.

MATERIAL AND METHODS

This prospective, randomized and single-blinded study was approved by the local ethics committee. A total of 1021 eligible patients who underwent cranial neurosurgery in 2 different university hospitals were assessed between August 2014 and October 2017. Patients were randomly assigned to two groups directly before induction of anesthesia. Intervention groups for venipuncture of the SCV were mechanical ventilation: tidal volume 7 ml/kg ideal body weight, positive end expiratory pressure (PEEP) ideal body weight/10, n = 535, or apnea: manual/spontaneous, APL valve 0 mbar, n = 486. Patients and the physicians who assessed pneumothorax rates were blinded to the intervention group. Venipuncture was carried out by both inexperienced and experienced physicians.

RESULTS

The pneumothorax rate was significantly higher in the mechanical ventilation group (2.2% vs. 0.4%; p = 0.012) with an odds ratio (OR) of 5.63 (95% confidence interval, CI: 1.17-27.2; p = 0.031). A lower body mass index (BMI) was associated with a higher pneumothorax rate, OR 0.89 (95% CI: 0.70-0.96; p = 0.013).

CONCLUSION

In this study landmark-guided infraclavicular SCV catheterization was associated with a significantly higher rate of pneumothorax when venipuncture was performed during mechanical ventilation and not in apnea. If a short phase of apnea is justifiable in the patient, mechanical ventilation should be discontinued during the venipuncture procedure.

Preoperative Recipient Parameters Allow Early Estimation of Postoperative Outcome and Intraoperative Transfusion Requirements in Liver Transplantation

CONTEXT

Liver transplantation is a complex intervention, and early anticipation of personnel and logistic requirements is of great importance. Early identification of high-risk patients could prove useful. We therefore evaluated prognostic values of recipient parameters commonly available in the early preoperative stage regarding postoperative 30- and 90-day outcomes and intraoperative transfusion requirements in liver transplantation.

DESIGN, SETTING, AND PARTICIPANTS

All adult patients undergoing first liver transplantation at Hannover Medical School between January 2005 and December 2010 were included in this retrospective study. Demographic, clinical, and laboratory data as well as clinical courses were recorded. Prognostic values regarding 30- and 90-day outcomes were evaluated by uni- and multivariate statistical tests. Identified risk parameters were used to calculate risk scores.

RESULTS

There were 426 patients (40.4% female) included with a mean age of 48.6 (11.9) years. Absolute 30-day mortality rate was 9.9%, and absolute 90-day mortality rate was 13.4%. Preoperative leukocyte count >5200/μL, platelet count <91 000/μL, and creatinine values ≥77 μmol/L were relevant risk factors for both observation periods ( P < .05, respectively). A score based on these factors significantly differentiated between groups of varying postoperative outcomes and intraoperative transfusion requirements ( P < .05, respectively).

CONCLUSION

A score based on preoperative creatinine, leukocyte, and platelet values allowed early estimation of postoperative 30- and 90-day outcomes and intraoperative transfusion requirements in liver transplantation. Results might help to improve timely logistic and personal strategies.

Supportive Hepatocyte Transplantation after Partial Hepatectomy Enhances Liver Regeneration in a Preclinical Pig Model

BACKGROUND

Hepatocyte transplantation (HTx) is regarded as a potential treatment modality for various liver diseases including acute liver failure. We developed a preclinical pig model to evaluate if HTx could safely support recovery from liver function impairment after partial hepatectomy.

METHODS

Pigs underwent partial hepatectomy with reduction of the liver volume by 50% to induce a transient but significant impairment of liver function. Thereafter, 2 protocols for HTx were evaluated and compared to a control group receiving liver resection only (group 1, n = 5). Portal pressure-controlled HTx was performed either immediately after surgery (group 2, n = 6) or 3 days postoperatively (group 3, n = 5). In all cases, liver regeneration was monitored by conventional laboratory tests and the novel noninvasive maximum liver function capacity (LiMAx) test with a follow-up of 4 weeks.

RESULTS

Partial hepatectomy significantly impaired liver function according to conventional liver function tests as well as LiMAx in all groups. A mean of 4.10 ± 1.1 × 108 and 3.82 ± 0.7 × 108 hepatocytes were transplanted in groups 2 and 3, respectively. All animals remained stable with respect to vital parameters during and after HTx. The animals in group 2 showed enhanced liver regeneration as observed by mean postoperative LiMAx values (621.5 vs. 331.3 μg/kg/h on postoperative day 7; p < 0.001) whereas HTx in group 3 led to a significant increase in mean liver-specific coagulation factor VII (112.2 vs. 54.0% on postoperative day 7; p = 0.003) compared to controls (group 1), respectively. In both experimental groups, thrombotic material was observed in the portal veins and pulmonary arteries on histology, despite the absence of clinical symptoms.

CONCLUSION

HTx can be performed safely and effectively immediately after a partial (50%) hepatectomy as well as 3 days postoperatively, with comparable results regarding the enhancement of liver function and regeneration.

[Evaluation and assessment of the health care process in patients with carbon monoxide poisoning in Germany]

BACKGROUND

Carbon monoxide poisoning (COP) is the most common cause for poisoning by inhalation in Germany. In the past 8 years, a marked increase in the number of COP-related deaths has been registered nationwide. A national German guideline is missing.

METHODS

The national and international literature was screened systematically. Existing international guidelines and expert recommendations for the diagnosis and treatment of COP were compared and evaluated. Furthermore, quality of health care was analyzed by a prospective preclinical dataset of emergency rescue services and retrospective analysis of routine data from 2014 to 2016 in Germany.

RESULTS

There is not a single evidence-based guideline worldwide. We determined 8 key performance indicators based on the five recommendations available for treatment of COP. These indices were subdivided into prehospital terms, hospital facilities, and diagnostic and therapeutic measures performed; they act as indicators for quality of care. In particular, the key figure "start oxygen" revealed that up to 41 % of the patients had not been treated with inhaled oxygen. In summary, data capture showed considerable incompleteness that is mainly due to missing time stamps.

CONCLUSION

In order to achieve a consistent treatment of patients with COP which meets the standard of recommended care, there is an urgent need for a consented national guideline. Another objective is to establish a nationwide prospective registry evaluating the treatment of carbon monoxide poisoning.

Change of collective orientation through an interprofessional training with medical students and student nurses depending on presence and professional group

BACKGROUND

Teamwork is an important success factors for patient treatment. The willingness of a healthcare provider to work in a team can be descripted with the construct of "Collective Orientation" (CO). The level of CO can be trained and is related to team performance. In this study, we investigated the effect of a simulator-based interprofessional training on the subject of patient fall in a hospital setting upon participations CO. To evaluate whether the course could be integrated into a longitudinal education concept, the participants were medical students and student nurses. Since effects of simulations can be influenced by the perceived reality, the results were measured as a function of Presence.

METHOD

In this observation study, 62 medical students and student nurses took part in six one-day interprofessional simulation trainings with the topic patient fall. The primary outcome was the mean difference between the CO measured immediately before (T1) and after the training (T2). The Presence of the participants was measured by questionnaire immediately after the course (T2).

RESULTS

Cronbach´s alpha for all scales and measurement points was higher than 0.69. CO increases over all professional groups from M = 3.42 (SD = 0.39) to M = 3.68 (SD = 0.54) significantly (p < .00; r = .5). Only the subscale "Dominance" in the professional group of the student nurses did not increase significantly. There was no correlation between Presence and the change in CO.

CONCLUSION

The questionnaires of CO and Presence can be applied to medical students and student nurses. The simulation course with the topic patient fall influences the CO and can be integrated in a longitudinal curriculum of teamwork training. The subscale "Dominance" of student nurses did not change. Preparatory learning units may increase the effects. The perceived reality of the scenario is not a main success factor.

Mannitol and the Combination of Mannitol and Gelatin Impair Whole Blood Coagulation and the Platelet Function In Vitro

Objective

Mannitol 20% and succinylated gelatin 4% are routinely used in neurosurgical procedures. The aim of this in vitro study was to explore the influence of both agents on blood coagulation and platelet function.

Methods

Blood from 21 healthy volunteers was obtained and then diluted so as to form five groups: (1) 7% dilution with mannitol; (2) 10% dilution with gelatin; (3) 17% dilution with isotonic balanced electrolyte solution; (4) 17% dilution with mannitol+gelatin; and (5) undiluted blood. The extrinsic thrombelastometry (EXTEM) and fibrin thrombelastometry (FIBTEM) tests were examined by rotational thrombelastometry via ROTEM®, and thrombocyte aggregometry with the aspirin inhibiting- (ASPI), adenosine diphosphate- (ADP), and thrombin-activating protein (TRAP) tests performed by Multiplate.

Results

In the EXTEM test clot formation time, the alpha angle, and maximum clot firmness were significantly reduced by mannitol and the combination of mannitol with gelatin. The platelet function tested in the ADP test was also significantly reduced with this combination.

Conclusion

In this in vitro study, clinically relevant dilutions of mannitol and gelatin showed a significant inhibition of whole blood coagulation and the platelet function, which could be detrimental in neurosurgical settings.

Influence of alcohol consumption on blood coagulation in rotational thromboelastometry (ROTEM): an in-vivo study

Background

Twenty-five to 85% of trauma patients are under the influence of alcohol in addition to experiencing injury-related coagulation impairment. Viscoelastic point-of-care tests (thrombelastography [TEG], rotational thromboelastometry [ROTEM]) are popular tools for rapid hemostasis assessment and therapeutic decision-making in this and other settings. While alcohol affects these tests in-vitro, their specific effects in-vivo are unclear. Therefore, we evaluated the effects of alcohol ingestion on ROTEM parameters.

Methods

Twenty volunteers provided informed consent to drinking red wine, whisk(e)y, or vodka to a target blood alcohol concentration of 1‰ within one hour, calculated with the Widmark formula. Blood samples were collected before drinking, at a breath alcohol concentration of 0.5‰, and at 1.0‰, but no later than one hour. After each blood collection, ExTEM and FibTEM tests were performed directly "at the bedside."

Results

All participants had a blood alcohol concentration (BAC) of 0.00‰ at the beginning. The mean BACs at the second and third collection were 0.48 and 0.76‰, respectively. There were no significant differences in the ExTEM parameters. FibTEM measurements showed a significant difference at the A10 value (13.0 vs. 14.0 mm, P = 0.014) and a trend at the maximum amplitude (maximum clot firmness 13.7 vs. 16.2 mm, P = 0.075). We saw no significant differences in fibrinolysis parameters and no hyperfibrinolysis in our ROTEM measurements.

Conclusions

Ethanol ingestion can impair early fibrin polymerization. These results might be of special relevance in trauma and support routine application of ROTEM/TEG in such cases.

Impact of Simulator-Based Crisis Resource Management Training on Collective Orientation in Anaesthesia: Pre-Post Survey Study With Interprofessional Anaesthesia Teams

THEORY

Individuals have different qualities, levels of willingness, and degrees of engagement for working in teams. This behaviour is termed 'Collective Orientation' (CO). Collective orientation can be trained and has a positive influence on team processes. Here, we investigated the effect of a simulator-based, Crisis Resource Management team training upon the participants' CO.

HYPOTHESES

We hypothesized (1) the scales of CO and Presence for lab-based microworld research (PLBMR) are applicable to the German anaesthesia teams, (2) the CO can be influenced by means of simulation training, (3) the training effect is dependent on sex and/or profession, and (4) the change of CO depends on the perceived presence of the participants in the scenario.

METHOD

In a pre-post study, 66 nurses and doctors from various anaesthetic departments took part in a 1-day training course to improve non-technical skills. The primary outcome was the mean difference between the CO measured (via questionnaires) immediately before (T1) and after (T2) training. The change was then tested for dependence upon other variables, such as sex, professional group, and immersion into the simulation scenarios.

RESULTS

Collective orientation improved significantly after training (mean difference: 0.2; P < .001; dz = 0.53). Considering the subscales, affiliation increased significantly (P < .001; dz = 0.59), whereas dominance remained unchanged. Furthermore, no correlation was found regarding sex, professional group, or immersion into the simulation scenarios.

CONCLUSIONS

Our study demonstrated that simulation-based training improves the participants' COs, primarily by increasing affiliation. Subjective scenario reality did not significantly influence this. Nonetheless, it remains unclear as to what factors categorically resulted in this benefit. The shared experience in the course by all team members might trigger the effects. However, further studies are needed to identify the modifiable factors that can improve teamwork attitudes.

[Care of Patients During Emergency Caesarian Section - Evaluation of Quality Characteristics from the Patients Point of View]

BACKGROUND

An emergency caesarian section can be a terrifying experience for expectant mothers. Fear for her own life as well as her unborn child's is a traumatic event that can result in the development of post-traumatic stress disorder (PTSD). The aim of this survey was to define scales and items that describe the quality of care of parturients in cases of emergency caesarian section.

METHODS

A pool of items was developed via a 2-step online Delphi survey administered to women who had undergone an emergency caesarian section. The resulting parameters were evaluated for relevance and validity in a larger patient collective. Lastly, we identified factors that could be grouped into relevant scales.

RESULTS

After validating the results of the Delphi survey, 5 scales with 18 items were identified. They encompassed the following dimensions: "team external effect," "mother's level of information," "subjective evaluation," "personal integrity," and "after-care." These items could explain 58.2% of total variance and provide a stable factorial solution (KMO 0.76).

CONCLUSION

To our knowledge, this is the first time a German criteria checklist has been developed to evaluate the care of expectant mothers undergoing an emergency caesarian section. This checklist can be used in addition to medical outcomes to measure quality of care. Further studies are needed to evaluate practical implementation and its impact on patient care.

Albumin combined with Mannitol impairs whole blood coagulation and platelet function in vitro

BACKGROUND

The indication of hydroxyethyl starch is currently under critical discussion and albumin 5% (ALB) has an increasing use in the operating theatre. Therefore, ALB is routinely used in neurosurgical procedures and often combined with mannitol 20% (MAN). Purpose of this in vitro study was to determine the influence of the combination of MAN and ALB on blood coagulation and platelet function.

METHODS

22 healthy volunteers were included into this study and 21 analysed. Blood was obtained and diluted into five groups: (1) 7% dilution with MAN, (2) 10% dilution with ALB (3) 17% dilution with isotonic balanced electrolyte solution, (4) 17% dilution with MAN + ALB and (5) undiluted blood as control group (CON). Rotational thrombelastometry via ROTEM® (EXTEM, FIBTEM-Test) and thrombocyte aggregometry via Multiplate® (ASPI, ADP and TRAP-test) were used to detect differences within the intervention groups and compared to the control group.

RESULTS

The maximum clot firmness in the FIBTEM test decreased under the normal range with the combination of MAN+ALB: 8mm (5.5-11) compared to CON: 15mm (12.5-20), p<0.05. Platelet function (ADP-test) showed significant decreases for ALB: 51 AUC (40-84) and MAN+ALB: 54 AUC (41-68) compared to CON: 92 AUC (75-101), p<0.05. Except in clotting time all other EXTEM tests of MAN+ALB subgroup showed significant impairment on blood coagulation compared to the control group.

CONCLUSIONS

In this in vitro study clinically relevant dilutions of MAN+ALB showed a significant inhibition of blood coagulation and platelet function. Further in vivo studies are necessary to confirm these results.

Interleukin-18 and High-Mobility-Group-Protein B1 are Early and Sensitive Indicators for Cell Damage During Normothermic Machine Perfusion after Prolonged Cold Ischemic Storage of Porcine Liver Grafts

In the era of organ machine perfusion, experimental models to optimize reconditioning of (marginal) liver grafts are needed. Although the relevance of cytokine signatures in liver transplantation has been analyzed previously, the significance of molecular monitoring during normothermic machine perfusion (NMP) remains elusive. Therefore, we developed a porcine model of cold ischemic liver graft injury after prolonged static cold storage (SCS) and subsequent NMP: Livers obtained from ten minipigs underwent NMP for 6 h directly after procurement (control group) or after 20 h of SCS. Grafts after prolonged SCS showed significantly elevated AST, ALT, GLDH and GGT perfusate concentrations, and reduced lactate clearance. Bile analyses revealed reduced bile production, reduced bicarbonate and elevated glucose concentrations after prolonged SCS. Cytokine analyses of graft perfusate simultaneously demonstrated an increase of pro-inflammatory cytokines such as Interleukin-1α, Interleukin-2, and particularly Interleukin-18. The latter was the only significantly elevated cytokine compared to controls, peaking as early as 2 h after reperfusion (11,012 ng/ml vs. 1,493 ng/ml; p = 0.029). Also, concentrations of High-Mobility-Group-Protein B1 were significantly elevated after 2 h of reperfusion (706.00 ng/ml vs. 148.20 ng/ml; p < 0.001) and showed positive correlations with AST (r² = 0.846) and GLDH (r² = 0.918) levels. Molecular analyses during reconditioning of liver grafts provide insights into the degree of inflammation and cell damage and could thereby facilitate future interventions during NMP reducing acute and chronic graft injury.

Further development of crew resource management training : Needs assessment by means of teamwork-context analysis in anesthesia and intensive care teams

BACKGROUND

Teams in anesthesia and intensive care work as high responsibility teams (HRT). Success in this environment partly depends on the use of nontechnical skills which can be learned through simulation-based training. A teamwork context analysis could help to identify training requirements for crew resource management training.

MATERIAL AND METHODS

We used a multicentric observational cross-sectional study design utilizing survey methodology to evaluate the teamwork context of different work environments, using the 62-item TAKAI inventory. We surveyed anesthesia and intensive care staff from nine hospitals in Germany which provide varying levels of care.

RESULTS

In total, 128 people (44.5% male, 53.9% female) from 9 German hospitals participated in the study. The topics "interconnectedness: departments", "interconnectedness: information flow", "dynamics", "polytely", "velocity of the team's movement", "velocity of system changes", "hierarchy" and "hierarchy: leadership", "shared task mental model", "shared team mental model" and all aspects of the scale "adaptive behaviors" were identified as focal aspects to be implemented into Crew-Resource-Management (CRM) training for the evaluated work environments.

CONCLUSION

The TAKAI scales meet quality criteria (Cronbach's alpha > 0.6) and are appropriate for use in the analysis of the teamwork environment. The results indicate many similarities between the work contexts surveyed but also slight differences. TAKAI can be an additional method to design an appropriate simulation training program for HRT in anesthesia and intensive care medicine as there does not seem to be a one-size-fits-all simulation concept. For a special focus on the needs of a work context, the easy to perform TAKAI analysis in the needs analysis step is worthwhile.

Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia

BACKGROUND

In our institution, a modified WHO surgical safety checklist was implemented more than ten years ago. In retrospect, we noticed that pediatric anesthesia was underrepresented in our surgical safety checklist modification. Therefore, we added a standardized team briefing (pedSOAP-M) immediately before induction of anesthesia and hypothesized that the use of this checklist was effective to detect relevant errors with potentially harmful consequences.

AIMS

The primary aim was to assess the incidence and characteristics of the detected errors, and the secondary aim was to identify factors influencing error detection.

METHODS

This prospective observational study was performed between November 2020 and October 2021 in five operation rooms at the Children's Hospital of Hannover Medical School, Germany. The subcategories of the pedSOAP-M checklist were suction, oxygen, airway, pharmaceuticals, and monitoring. Demographic and procedure-related data and the briefing results were documented anonymously and undated, using a standardized case report form.

RESULTS

We enrolled 1030 and analyzed 1025 patients (aged 0-18 years). Relevant errors were detected in 111 (10.8%) cases (suction 2.5%, oxygen 3.0%, airway 0.2%, pharmaceuticals 2.4%, monitoring 3.0%). In the pharmaceuticals subcategory, the most common error was entering a wrong patient weight into the perfusor syringe pumps. Experienced anesthetists detected significantly more errors than less experienced ones.

CONCLUSION

The briefing tool pedSOAP-M was effective in detecting relevant errors with potentially harmful consequences. The presence of an experienced anesthetist was associated with a higher efficacy of the briefing. Particular attention should be given to entering patient weight into the anesthesia workstation and the perfusor syringe pumps.