[Extracorporeal cardiopulmonary resuscitation (eCPR)]

Extracorporeal cardiopulmonary resuscitation (eCPR) is the implementation of extracorporeal membrane oxygenation (ECMO) in selected patients with cardiac arrest and may be considered when conventional CPR efforts fail, as written in the latest international guidelines. eCPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system and it has the risk of several life-threatening complications. However, there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome are lacking. Therefore, optimal timing, patient selection, location and method of implementation vary across centers. As utilization of eCPR has increased in recent years and more centers begin to perform eCPR, considerable uncertainties exist in the prehospital setting as well as in the emergency room. However, structured communication and clearly defined processes are essential especially at the interface between prehospital rescue teams and the eCPR team to achieve the highest possible benefit for cardiac arrest patients using eCPR. This article presents an algorithm for structured, evidence-based logistic considerations, patient selection, and implementation of eCPR as well as early care after establishment of extracorporeal life support (ECLS) which are mainly based on the German national recommendations for eCPR of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC published in 2019 as well as the S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" and local standard operating procedures of the authors.

Risk Factors for Bleeding Complications after Percutaneous Dilatational Tracheostomy: A Ten-year Institutional Analysis

Summary

Bleeding complications after percutaneous dilatational tracheostomy (PDT) are infrequent but may have a tremendous impact on a patient's further clinical course. Therefore, it seems necessary to perform risk stratification for patients scheduled for PDT. We retrospectively reviewed the records of 1001 patients (46% male, mean age 68.1 years) undergoing PDT (using the Ciaglia Blue Rhino® technique with direct bronchoscopic guidance) in our cardiothoracic ICU between January 2003 and February 2013. Patients were stratified into two groups: patients suffering acute moderate, severe, or major bleeding (Group A) and patients who had no or only mild bleeding (Group B). In the majority of patients, no or only mild bleeding during PDT occurred (none: 425 [42.5%], mild: 488 [48.8%]). In 84 patients (8.4%), bleeding was classified as moderate. Three patients suffered from severe bleeding; only one major bleed with need for emergency surgery occured. Patients in Group A had a significantly higher Simplified Acute Physiology Score on the day of PDT ( P=0.042), higher prevalence of renal replacement therapy on the day of PDT ( P=0.026), higher incidence of coagulopathy ( P=0.043), lower platelet counts ( P=0.037), lower fibrinogen levels ( P=0.012), higher proportion of PDTs performed by residents ( P=0.034) and higher difficulty grading of PDT ( P=0.001). Using logistic regression analyses, difficult PDT, less experienced operator, Simplified Acute Physiology Score >40 and low fibrinogen levels were independent predictors of clinically significant bleeding after PDT.

A three-valued photoelectrochemical logic device realising accept anything and consensus operations

A new application of a hybrid material exhibiting the photoelectrochemical photocurrent switching (peps) effect in a three-valued logic device is reported.

Extrakorporale Herz- und Lungenersatzverfahren

Die Verwendung eines extrakorporalen Unterstützungsystems stellt bei kardialem und/oder pulmonalem Versagen eine etablierte Therapieoption dar. Auch wenn die wissenschaftliche Evidenz quantitativ noch nicht ausreichend gesichert ist, gibt es zunehmend Hinweise aus einzelnen Studien [z. B. Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) Trial], dass die „extracorporeal membrane oxygenation“ (ECMO) als pumpenbetriebenes venovenöses Verfahren beim schweren Lungenversagen eine lebensrettende Maßnahme ist. Initial als „rescue option“ beim kardialen Versagen nach Kardiotomie etabliert, erfährt der „extracorporeal life support“ (ECLS) zunehmende Verbreitung als pumpenbetriebenes venoarterielles Herz-Kreislauf-Unterstützungsystem im kardiogenen Schock bei Myokardinfarkt, als „Bridging“-Maßnahme zur Transplantation und im Rahmen einer erweiterten Reanimation. Der „pumpless extracorporeal lung assist“ (pECLA) als pumpenloses arteriovenöses Verfahren ist technisch einfacher zu handhaben, garantiert jedoch nur eine suffiziente Decarboxylierung ohne ausreichende Oxygenierung. Daher wird dieses Verfahren insbesondere im Rahmen eines primär hyperkapnischen Lungenversagens mit respiratorischer Acidose angewendet, um eine lungenprotektive Beatmung zu ermöglichen. Enorme technische Enwticklungen und v. a. die extreme Miniaturisierung der extrakorporalen Unterstützungsysteme dürfen jedoch nicht darüber hinwegtäuschen, dass es sich um eine invasive Therapie mit einer hohen Inzidenz von schwerwiegenden Komplikationen handelt. Vor diesem Hintergrund müssen die weite Verbreitung dieser Technologie kritisch hinterfragt und vielmehr die Konzentrierung auf Zentren mit hoher Expertise gefordert werden.

[Anatomic and radiologic studies of of ovarian arteries in women of various ages]

The main source of ovarian arterial blood supply is so called an ovarian arcade. It is an arterial system made of the uterine and ovarian artery junction. Depend on the source of information, there are different descriptions of ovarian arcade vessels, as well as there are different anatomical nomenclature. Anatomical material was taken from 63 women aged 15 to 85. Arterial vessels were appropriately prepared, filled with contrast medium and X-ray examined. An ovarian and uterine vessels junction into the ovarian arcade was observed in the all examined material. In order to be include into the arcade, an appropriate vessel diameter had to be stated at the level of uterine and tubal end. In multiparas in comparison with nulliparas, an average diameter was bigger about 17%. Number of vessels, the arcade gives to ovarian hilus is also of variable quantity. There are markedly less vessels in postmenopausal women.

[Variability of the course of the uterine artery and its branches within the broad ligament and vascularization of uterine walls depending on a woman's age in light of anatomical, radiologic and microangiographic studies]

The aim of the study was to perform uterus measurements in order to demonstrate variability of size, shape and proportions of each part of uterus. Topography, shape and dimensions of the uterine artery and its organic branches were also analyzed. The main part of the study was to analyze the arterial system in the walls of the human uterus. The study has been performed in order to find correlation between anatomic variety and age, and obstetric history of the investigated females. Internal genital organs taken at autopsy from 105 female cadavers (only unchanged pathologically) aged from 3 to 85, underwent evaluation (Table 1). Material consisted of 8 non menstruating girls, 30 nulliparas (20 premenopausal and 10 postmenopausal) and 67 multiparas (32 and 35, respectively). During postmortem examination topography of the origin sites of the uterine artery originating from the internal iliac artery, its diameters and its position towards ureter have been estimated. External measurements of the uterus have been performed. After excision of the uterus, uterine arteries have been injected with radiologic contrast medium. Radiography of the uterus has been taken using roentgenographic apparatus for structural research, and then arrangement of the uterine arteries in myometrium and their organic branches have been assessed. Uteri have been sectioned horizontally, and finally enlarged radiographs of each layer have been taken to estimate the arrangement of vessels at different levels of the myometrium. Fractionation itself made accurate measurements of the walls of the uterus possible at different levels. It has been stated that shape and size of the uterus changed considerably during the whole individual's life. Changes occurred not only within time, but they were connected with motherhood as well. Variability of the external dimensions of the uterus was always closely connected with variability of the uterus wall's thickness at different levels. Angiographic studies revealed that uterine arteries were present in every case, on both sides, regardless of the age and obstetric history. Topographic investigations proved that the vessels always crossed the ureter superficially on both sides. Considering each of the three segments of the uterine artery, it was stated that the length of the descending part of the vessel varied only within age, while the transverse and ascending parts were elongated within age and also after pregnancies. The number of the uterine artery branches running towards the body and cervix of the uterus was significantly variable and depended not only on age, but on pregnancies as well. Radiographic analysis revealed that connections between uterine vessels on both sides of the same uterus were not constant. Their absence was associated with the presence of the hypovascular, or even avascular zone in the medial part of the fundus and body of the uterus. This situation was evident at any age, regardless of the obstetric history. Artery of the fundus uteri, which had been previously described in many studies, was a rarely existing vessel. In the investigated material no azygos uterine artery has been found. Microangiographic studies (Fig. 1-4) revealed that angioarchitectonics of blood vessels in consecutive layers of the wall of the human uterus at different levels was variable to a great degree. It has been stated that situation depended not only on age, but also on past pregnancies.

[Vascularization of the posterior wall of the urinary bladder in women after past cesarean section in light of microangiographic studies]

Arterial vascularization of membranes in the urinary bladder wall has been studied in 14 women of reproductive age, who were bearing children. Four of them had exclusively spontaneous deliveries. Ten delivered at least once by cesarean section. The studies consisted in filling the uterine, ovarian and vesical arteries with Microtrast preparation. After the filling of vessels and fixation of the preparation in 10% formalin solution, specimens, 4-5 mm thick, were taken from the bladder wall at the junction with uterus, and comparatively specimens from the free parts of the uterus body. The serial specimens were used to obtain photographs by means of X-ray apparatus with microfocal tube, being implemented for structural studies. On the basis of the above-mentioned investigations we disclosed that the course of the blood vessels in membranes of the urinary bladder wall undergoes changes after routine dissection during the cesarean section. There is a disappearance of regular arrangement of the vascular network, particularly in mucous membrane. New vessels of larger calibre with an irregular course are seen to appear throughout the entire width. Such changes were not detected at sites distal to the field of operation. Specimens stemming from the urinary bladders of women, who delivered spontaneously, failed to reveal such changes.

[Lateral geniculate bodies in humans--analysis of development]

Macroscopial and microscopial analysis of development of the lateral geniculate bodies was performed in 32 human brains of persons of various age. Their presence was revealed in all the cases. Observation of the histopahtological specimen showed---in contradistinction to the results of experimental animal investigations found in the world's literature--a lack of influence of the light stimulus on the stratification of structure of the lateral geniculate body in humans.