Prospective Cohort Study

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

/pdf/the-european-guideline-on-management-of-major-bleeding-and-50g3zxrre8.pdf

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

State-Trait Anxiety Inventoryによるペインクリニック外来患者の不安の評価

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

/pdf/consensus-guidelines-for-the-management-of-postoperative-2nf0ld87bn.pdf

Consensus Guidelines for the Management of Postoperative Nausea and Vomiting

Institutional Affiliations Co-chairs Feldman D: Minneapolis Heart Institute, Minneapolis, Minnesota, Georgia Institute of Technology and Morehouse School of Medicine; Pamboukian SV: University of Alabama at Birmingham, Birmingham, Alabama; Teuteberg JJ: University of Pittsburgh, Pittsburgh, Pennsylvania Task force chairs Birks E: University of Louisville, Louisville, Kentucky; Lietz K: Loyola University, Chicago, Maywood, Illinois; Moore SA: Massachusetts General Hospital, Boston, Massachusetts; Morgan JA: Henry Ford Hospital, Detroit, Michigan Contributing writers Arabia F: Mayo Clinic Arizona, Phoenix, Arizona; Bauman ME: University of Alberta, Alberta, Canada; Buchholz HW: University of Alberta, Stollery Children’s Hospital and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Deng M: University of California at Los Angeles, Los Angeles, California; Dickstein ML: Columbia University, New York, New York; El-Banayosy A: Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Elliot T: Inova Fairfax, Falls Church, Virginia; Goldstein DJ: Montefiore Medical Center, New York, New York; Grady KL: Northwestern University, Chicago, Illinois; Jones K: Alfred Hospital, Melbourne, Australia; Hryniewicz K: Minneapolis Heart Institute, Minneapolis, Minnesota; John R: University of Minnesota, Minneapolis, Minnesota; Kaan A: St. Paul’s Hospital, Vancouver, British Columbia, Canada; Kusne S: Mayo Clinic Arizona, Phoenix, Arizona; Loebe M: Methodist Hospital, Houston, Texas; Massicotte P: University of Alberta, Stollery Children’s Hospital, Edmonton, Alberta, Canada; Moazami N: Minneapolis Heart Institute, Minneapolis, Minnesota; Mohacsi P: University Hospital, Bern, Switzerland; Mooney M: Sentara Norfolk, Virginia Beach, Virginia; Nelson T: Mayo Clinic Arizona, Phoenix, Arizona; Pagani F: University of Michigan, Ann Arbor, Michigan; Perry W: Integris Baptist Health Care, Oklahoma City, Oklahoma; Potapov EV: Deutsches Herzzentrum Berlin, Berlin, Germany; Rame JE: University of Pennsylvania, Philadelphia, Pennsylvania; Russell SD: Johns Hopkins, Baltimore, Maryland; Sorensen EN: University of Maryland, Baltimore, Maryland; Sun B: Minneapolis Heart Institute, Minneapolis, Minnesota; Strueber M: Hannover Medical School, Hanover, Germany Independent reviewers Mangi AA: Yale University School of Medicine, New Haven, Connecticut; Petty MG: University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota; Rogers J: Duke University Medical Center, Durham, North Carolina

The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary.

Aerosol delivery of Iloprost is a promising therapeutic approach. The aim of this study was to determine the output of an ultrasonic nebulizer in different ventilation set-ups at the tip of different endotracheal tubes. Method: In set-up A, an ultrasonic nebulizer was connected directly to the endotracheal tube. In set-up B, the nebulizer was incorporated into the inspiratory limb of the ventilator circuit; a bypass arrangement allowed to selectively direct the exspiratory air discharged from the model lung. The test lungs were ventilated through a standard endotracheal tube (ET) and through a double-lumen tube (DLT). The nebulizer was fi lled with 5 ml of a Tc-99m 0.9%-NaCl solution. After nebulization, distribution of radioactivity was detected by gamma scintigraphy. Results: Set-up A, ventilation in volume-controlled mode (VCV) via an ET: Delivered dose (1.61 ± 0.41 ml), nebulization time 10.13 ± 1.71 min. Set-up A, pressure-controlled ventilation (PCV), via a DLT: Delivered dose (1.33 ± 0.88 ml), nebulization time 13.27 ± 2.58 min. Set-up B, VCV mode via an ET: Delivered dose (1.57 ± 0.44 ml), nebulization time (25.9 ± 3.8 min). Set-up B, PCV mode, via a DLT: Delivered dose (1.3 ± 0.17 ml), nebulization time (25.6 ± 4.0 min). Set-up B did not yield a signifi cantly higher output (p 0.05), but the nebulization time was signifi cantly longer (p 0.05) compared with set-up A. Conclusion: Set-ups which involve connecting the nebulizer directly to an ET or a DLT exhibit suffi cient output of aerosol and short nebulization times.

Aerosol delivery by an ultrasonic nebulizer during different mechanical ventilation settings in a lung model--a pilot study.

Sir, A 34-year-old Caucasian woman (gravida 3, primiparous), with previously unknown heterozygous factor V Leiden mutation (FVL), had a fulminate pulmonary thromboembolism (PTE) in her 10th week of gestation. The acute therapy required treatment with norepinephrine and dobutamine as well as assisted ventilation. Arterial blood pressure and oxygen saturation decreased to levels below 50 mmHg for systolic blood pressure and a value below -50% for oxygen saturation for at least 10 min. After successful initial therapy with systolic blood pressure above 100 mmHg and O2 saturation of 98% the diagnosis of PTE was confirmed by computer tomography that revealed thrombi in all major branches of the pulmonary arteries. Doppler derived estimation of systolic pulmonary pressure, however, was not performed at that time (it is standard care for such patients today). Thereafter, thrombolytic treatment with recombinant tissue plasminogen activator (rTPA: initial dose 30 mg/30 min followed by 60 mg/90 min) was initiated. In addition, intravenous heparin was started with 20,000 U/24 h. After thrombolytic therapy, a subsequent CT scan was done and showed dramatic amelioration with little remaining thrombotic material in the pulmonary arteries. Three days after initiation of heparin treatment, thrombocytopenia developed due to heparin induced antibodies (HIT), as confirmed by standard ELISA (Roche Diagnostics, Germany). Heparin was therefore replaced by danaparoid. In order to achieve a therapeutic factor Xa activity the initial danaparoid dose of 3 = 750 U was increased to a final dose of 2000 U subcutaneously twice daily. We had no evidence of minor or major bleeding. Ultrasound examination of placental perfusion and fetal development were unremarkable.

Delivery of a healthy child 30 weeks after resuscitation for thromboembolism and treatment with danaparoid: 5-year follow up.

Abstract Massive diffuse bleeding is still a problem in cardiovascular surgery. The first line treatment is platelet concentrate transfusion, although there is still insufficient information regarding efficacy, quantity, and timing. The objective of this prospective cohort study was to find out whether the amount of 4 apheresis platelet concentrates could reduce intraoperative bleeding and improve viscoelasticity and aggregometry. 10 patients were enrolled intraoperatively because of life-threatening diffuse bleeding after cardiopulmonary bypass and received 4 apheresis platelet concentrates back-to-back. The units were given every 5 minutes. After every unit, thromboelastometry, performed by ROTEM®, and aggregometry, performed by Multiplate®, were done together with Hematocrit, Hemoglobin, and Platelet Count. Hematocrit and Hemoglobin showed a statistically significant decrease of 14%, whereas Platelet Count showed a statistically significant increase of 205%. MCE-EXTEM increased statistically significant: 46%. There was no statistically significant increase in both ADP and COL results. Even a series of 4 platelet concentrates did not comprehensively improve both essential components of an adequate hemostasis: viscoelasticity and aggregation. Just the transfusion of platelet concentrates alone did not build a sufficient strategy improving hemostasis and reducing bleeding. A positive effect of surgical packing on stopping the bleeding could be seen.

Efficacy of platelet transfusion in cardiac surgery

This study was undertaken to compare the influence of balanced anesthesia utilizing sevoflurane and fentanyl with total intravenous anesthesia (TIVA) utilizing propofol and fentanyl on endocrine stress response in CABG patients. 40 patients scheduled for CABG were prospectively and randomly assigned to two groups. Group A (n=20) received balanced anesthesia with sevoflurane, fentanyl and pancuronium whereas group B (n=20) received TIVA with propofol, fentanyl and pancuronium. EEG and AEP were used to ensure a comparable depth of anesthesia. During 7 time points (T1 baseline, T2 intubation, T3 sternotomy, T4 aortic cannulation, T5 30 min on pump, T6 separation from CPB, T7 end of surgery), hemodynamic parameters and plasma levels of epinephrine, norepinephrine, ADH, ACTH and cortisol were determined. CK-MB, troponin T were measured postoperatively. Outcome was followed for 24 months. Biometric data were comparable between the groups. Plasma levels of epinephrine were significantly lower in group B than in group A at T4 (106 vs 63 pg/ml) and T5 (308 vs 67 pg/ml). Group mean value of ADH was lower in group B (p=0.02). Plasma levels of cortisol in group B were significantly lower at T5 (197 vs 140 ng/ml) and T7 (173 vs 120 ng/ml), when compared to group A. A positive correlation between ADH levels and the postoperative length of hospital stay was found. No significant differences occurred with respect to myocardial markers and hemodynamic data. At comparable depth of anesthesia, the endogenous stress response during TIVA with propofol was less pronounced than during balanced anesthesia with sevoflurane.

Niels Rahe-Meyer

Papers

Aerosol delivery by an ultrasonic nebulizer during different mechanical ventilation settings in a lung model--a pilot study.

Delivery of a healthy child 30 weeks after resuscitation for thromboembolism and treatment with danaparoid: 5-year follow up.

Efficacy of platelet transfusion in cardiac surgery

Endocrine stress response and myocardial outcome under balanced anesthesia with sevoflurane or TIVA with propofol in patients undergoing CABG

Effectiveness and Safety of Internal Rectilinear Biphasic Versus Monophasic Defibrillation in Patients Undergoing Cardiac Surgery