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Background: Most cardiac surgery patients experience postoperative anemia. Delirium and Atrial Fibrillation (AF) are common and independent predictors of morbidity and mortality. Few reports examine their association with postoperative anemia. This study aims to quantify the association between anemia and these outcomes in patients undergoing cardiac surgery. Methods: This post-hoc analysis of the DECADE randomized controlled trial ran at six academic US hospitals. Patients aged 18–85 years with heart rate > 50 bpm undergoing cardiac surgery who had daily hemoglobin measurements in the first 5 Postoperative Days (POD) were included. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM – ICU), preceded by the Richmond Agitation and Sedation Scale, with patients excluded from assessment if sedated. Patients had daily hemoglobin measurements, continuous cardiac monitoring plus twice-daily 12-lead electrocardiograms, up to POD4. AF was diagnosed by clinicians blinded to hemoglobin levels. Results: Five hundred and eighty-five patients were included. Mean postoperative hemoglobin Hazard Ratio (HR): 0.99 (95% CI 0.83, 1.19; p = 0.94) per 1 g.dL−1 hemoglobin decrease. 197 (34%) developed AF, mainly on POD = 2.3. Estimated HR = 1.04 (95% CI 0.93, 1.17; p = 0.51) per 1 g.dL−1 hemoglobin decrease. Conclusions: Most patients undergoing major cardiac surgery were anemic in the postoperative phase. AF and delirium occurred in 34% and 12% of patients, respectively, but neither were significantly correlated with postoperative hemoglobin.

Background: Anemia is common in the preoperative setting and associated with increased postoperative complications and mortality. However, it is unclear if preoperative anemia optimization reduces postoperative complications. We aimed to assess the association between preoperative anemia optimization and a composite endpoint of major cardiovascular, renal, and pulmonary complications and all-cause mortality within 30 days after noncardiac surgery in adult patients. Methods: In this retrospective analysis preoperative anemia was defined as hemoglobin concentration below 12.0 g.dl−1 in women and 13.0 g.dl−1 in men within 6 months before surgery. A propensity score-based generalized estimating equation analysis was used to determine the association between preoperative anemia optimization and the primary outcome. Moreover, mediation analysis was conducted to investigate whether intraoperative red blood cell transfusion or duration of intraoperative hypotension were mediators of the relation between anemia optimization and the primary outcome. Results: Fifty-seven hundred anemia optimized, and 8721 non-optimized patients met study criteria. The proportion of patients having any component of the composite of major complications and all-cause mortality was 21.5% in the anemia-optimized versus 18.0% in the non-optimized, with confounder-adjusted odds ratio estimate of 0.99 (95% CI 0.86‒1.15) for anemia optimization versus non-optimization, p = 0.90. Intraoperative red blood cell transfusion had a minor mediation effect on the relationship between preoperative anemia optimization and the primary outcome, whereas duration of intraoperative hypotension was not found to be a mediator. Conclusion: Preoperative anemia optimization did not appear to be associated with a composite outcome of major in-hospital postoperative cardiovascular, renal, and pulmonary complications and all-cause in-hospital mortality.

Abstract Background Specific immunotherapy for patients with honey bee hypersensitivity is commonly applied. Re-challenge with venom is performed to prove protection in individual cases. Case presenation We report a case of near fatal anaphylaxis with asystole for 24 min in a 35-years-old patient with mastocytosis after honey bee sting challenge, despite 5-years of specific immunotherapy. Successful cardio-pulmonary resuscitation was applied for 32 min. Conclusion This intervention demonstrates, that in anaphylaxis with cardio-vascular arrest, prolonged cardio-pulmonary resuscitation for up to 40 min may be appropriate to overcome the half-life of massively released histamine. Failure of specific immunotherapy was possibly due to sensitization to the allergen Api m10, potentially underrepresented in commercial honey bee venom extracts. Molecular analyses may provide additional clues to the potentially unsuccessful outcome of venom specific immunotherapy, especially in high-risk patients such as mastocytosis.

Background: Laparoscopic surgical approaches enhance recovery, reduce postoperative pain, and shorten hospital length-of-stay. Nevertheless, increased intra-abdominal pressure is associated with decreased renal blood flow, renal hypoxia and acute kidney injury. When combined with Trendelenburg positioning, renal function may further deteriorate. We tested the primary hypothesis that the combination of laparoscopic surgical approach and Trendelenburg position is associated with larger reductions in estimated Glomerular Filtration Rate (eGFR) within the initial 48 postoperative hours compared to open surgery without Trendelenburg positioning. Secondarily, we tested, if laparoscopic procedures are associated with greater incidence of postoperative acute kidney injury. Methods: Adults who had laparoscopic colorectal surgery in Trendelenburg position at the Cleveland Clinic Main Campus from 2009 to 2016 were propensity-matched to patients who had comparable open procedures. Patients with pre-existing renal impairment were excluded. Results: Among 7,357 eligible patients, 1,846 laparoscopic cases with Trendelenburg were matched to 1,846 open cases. No association was found between laparoscopic approach and postoperative eGFR. A significant protective effect of the laparoscopic procedure on the odds of having AKI was found. Patients who had laparoscopic surgeries were an estimated 0.70 (95% CI 0.55, 0.90, pHolm-adj = 0.006) times as likely to have AKI as open surgical patients. Conclusion: Despite compelling potential mechanisms, laparoscopic approach with Trendelenburg position in adult colorectal surgeries did not worsen postoperative eGFR, and actually reduced postoperative acute kidney injury. Given the other advantages of laparoscopic surgery, the approach should not be avoided for concerns about renal injury.

Abstract Background Incidence of difficult endotracheal intubation ranges between 3 and 10%. Bougies have been recommended as an airway adjunct for difficult intubation, but reported success rates are variable. A new generation flexible tip bougie appears promising but was not investigated so far. We therefore compared the new flexible tip with a standard bougie in simulated normal and difficult airway scenarios, and used by experienced anesthesiologists. Methods We conducted a observational, randomized, cross-over simulation study. Following standardized training, experienced anesthesiologists performed endotracheal intubation using a Macintosh blade and one of the bougies in six different airway scenarios in a randomized sequence: normal airway, tongue edema, pharyngeal obstruction, manual cervical inline stabilization, cervical collar stabilization, cervical collar stabilization and pharyngeal obstruction. Overall success rate with a maximum of 3 intubation attempts was the primary endpoint. Secondary endpoints included number of intubation attempts, time to intubation and dental compression. Results Thirty-two anesthesiologist participated in this study between January 2019 and May 2019. Overall success rate was similar for the flexible tip bougie and the standard bougie. The flexible tip bougie tended to need less intubation attempts in more difficult airway scenarios. Time to intubation was less if using the flexible tip bougie compared to the standard bougie. Reduced severity of dental compression was noted for the flexible tip bougie in difficult airway scenarios except cervical collar stabilization. Conclusion In this simulation study of normal and difficult airways scenarios, overall success rate was similar for the flexible tip and standard bougie. Especially in more difficult airway scenarios, less intubation attempts, and less optimization maneuvers were needed if using the flexible tip bougie. Trial registration clinicaltrials.gov Identifier: NCT03733158 . 7th November 2018.

Aim of the Study: The aim was to compare cardiopulmonary resuscitation (CPR) quality of an automated external defibrillator (AED) with and without additional video instruction during basic life support (BLS) by laypersons.Methods: First-year medical students were randomized either to an AED with audio only or audio with additional video instructions during CPR. Each student performed 4 min of single-rescuer chest compression only BLS on a manikin (Ambu Man C, Ballerup, Denmark) using the AED. The primary outcome was the effective compression ratio during this scenario. This combined parameter was used to evaluate the quality of chest compressions by multiplying compressions with correct depth, correct hand position, and complete decompression by flow time. Secondary outcomes were percentages of incomplete decompression and hand position, mean compression rate, time-related parameters, and subjective assessments.Results: Effective compression ratio did not differ between study groups in the overall sample (p = 0.337) or in students with (p = 0.953) or without AED experience (p = 0.278). Additional video instruction led to a higher percentage of incorrect decompressions (p = 0.014). No significant differences could be detected in time-related resuscitation parameters. An additional video was subjectively rated as more supporting (p = 0.001).Conclusions: Audio–video instructions did not significantly improve resuscitation quality in these laypersons despite that it was felt more supportive. An additional video to the verbal AED prompts might lead to cognitive overload. Therefore, future studies might target the influence of the video content and the potential benefits of video instructions in specific populations.

Abstract Background The seroprevalence of Toxoplasma gondii ranges widely in different areas of the world and different populations. Although toxoplasmosis is typically benign and asymptomatic, it induces major complications in immunocompromised individuals and during pregnancy. Prevention of maternal primary infection constitutes the major tool for avoiding congenital T. gondii infections and toxoplasmosis complications. The preventive measures depend on the women’s knowledge about toxoplasmosis. The aim of the study was to assess the knowledge on toxoplasmosis among pregnant women in Poland. Methods The study was conducted between October 2016 and January 2017 in 3 Polish cities. During a visit in a hospital outpatient clinic, pregnant women aged > 16 years fulfilled a previously validated questionnaire. The questions concerned personal data (age, parity, educational level, place of residence), toxoplasmosis knowledge (etiology, routes of transmission, symptoms, sequelae), and sources consulted to collect information. Results Overall, 465 pregnant women participated in the survey; 439 (94.4%) were aware of toxoplasmosis. Toxoplasmosis was perceived as a zoonotic disease by 77.4%, as a parasitic disease by 41.7%, as a disease transmitted through poor hand hygiene by 8.6%, as a childhood illness by 4%, and as a congenital disease by 0.4%. Regarding the transmission route, 84.5% of women pointed at a domestic cat, 46.7% at eating raw or undercooked meat. The total of 84.3% did not know toxoplasmosis symptoms, and 12.0% stated that they did not present the symptoms. In multivariate analysis, younger age (OR, 2.74; 95% CI, 1.67–4.49; p

Abstract Background Electrical impedance tomography (EIT) is a tool to monitor regional ventilation distribution in patient’s lungs under general anesthesia. The objective of this study was to assess the regional ventilation distribution using different driving pressures (DP) during high frequency jet ventilation (HFJV). Methods Prospective, observational, cross-over study. Patients undergoing rigid bronchoscopy were ventilated HFJV with DP 1.5 and 2.5 atm. Hemodynamic and ventilation parameters, as well as ventilation in different regions of the lungs in percentage of total ventilation, assessed by EIT, were recorded. Results Thirty-six patients scheduled for elective rigid bronchoscopy. The final analysis included thirty patients. There was no significant difference in systolic, diastolic and mean arterial blood pressure, heart rate, and peripheral saturation between the two groups. Peak inspiratory pressure, mean inspiratory pressure, tidal volume, and minute volume significantly increased in the second, compared to the first intervention group. Furthermore, there were no statistically significant differences between each time profiles in all ROI regions in EIT. Conclusions In our study intraoperative EIT was an effective method of functional monitoring of the lungs during HFJV for rigid bronchoscopy procedure. Lower driving pressure was as effective in providing sufficient ventilation distribution through the lungs as the higher driving pressure but characterized by lower airway pressure. Trial registration The study was registered on ClinicalTrials.gov under no. NCT02997072.

BACKGROUND:High-quality chest compressions are imperative for Cardio-Pulmonary-Resuscitation (CPR). International CPR guidelines advocate, that chest compressions should not be interrupted for ventilation once a patient's trachea is intubated or a supraglottic-airway-device positioned. Supraglottic-airway-devices offer limited protection against pulmonary aspiration. Simultaneous chest compressions and positive pressure ventilation both increase intrathoracic pressure and potentially enhances the risk of pulmonary aspiration. The hypothesis was, that regurgitation and pulmonary aspiration is more common during continuous versus interrupted chest compressions in human cadavers ventilated with a laryngeal tube airway. METHODS:Twenty suitable cadavers were included, and were positioned supine, the stomach was emptied, 500 ml of methylene-blue-solution instilled and laryngeal tube inserted. Cadavers were randomly assigned to: 1) continuous chest compressions; or, 2) interrupted chest compressions for ventilation breaths. After 14 minutes of the initial designated CPR strategy, pulmonary aspiration was assessed with a flexible bronchoscope. The methylene-blue-solution was replaced by 500 ml barium-sulfate radiopaque suspension. 14 minutes of CPR with the second designated ventilation strategy was performed. Pulmonary aspiration was then assessed with a conventional chest X-ray. RESULTS:Two cadavers were excluded for technical reasons, leaving 18 cadavers for statistical analysis. Pulmonary aspiration was observed in 9 (50%) cadavers with continuous chest compressions, and 7 (39%) with interrupted chest compressions (P = 0.75). CONCLUSION:Our pilot study indicate, that incidence of pulmonary aspiration is generally high in patients undergoing CPR when a laryngeal tube is used for ventilation. Our study was not powered to identify potentially important differences in regurgitation or aspiration between ongoing vs. interrupted chest compression. Our results nonetheless suggest that interrupted chest compressions might better protect against pulmonary aspiration when a laryngeal tube is used for ventilation.

Objective: To compare a novel two-thumb chest compression technique with standard techniques during newborn resuscitation performed by novice physicians in terms of median depth of chest compressions, degree of full chest recoil, and effective compression efficacy.Patients and Methods: The total of 74 novice physicians with less than 1-year work experience participated in the study. They performed chest compressions using three techniques: (A) The new two-thumb technique (nTTT). The novel method of chest compressions in an infant consists in using two thumbs directed at the angle of 90° to the chest while closing the fingers of both hands in a fist. (B) TFT. With this method, the rescuer compresses the sternum with the tips of two fingers. (C) TTHT. Two thumbs are placed over the lower third of the sternum, with the fingers encircling the torso and supporting the back.Results: The median depth of chest compressions for nTTT was 3.8 (IQR, 3.7–3.9) cm, for TFT−2.1 (IQR, 1.7–2.5) cm, while for TTHT−3.6 (IQR, 3.5–3.8) cm. There was a significant difference between nTTT and TFT, and TTHT and TFT (p < 0.001) for each time interval during resuscitation. The degree of full chest recoil was 93% (IQR, 91–97) for nTTT, 99% (IQR, 96–100) for TFT, and 90% (IQR, 74–91) for TTHT. There was a statistically significant difference in the degree of complete chest relaxation between nTTT and TFT (p < 0.001), between nTTT and TTHT (p = 0.016), and between TFT and TTHT (p < 0.001).Conclusion: The median chest compression depth for nTTT and TTHT is significantly higher than that for TFT. The degree of full chest recoil was highest for TFT, then for nTTT and TTHT. The effective compression efficiency with nTTT was higher than for TTHT and TFT. Our novel newborn chest compression method in this manikin study provided adequate chest compression depth and degree of full chest recoil, as well as very good effective compression efficiency. Further clinical studies are necessary to confirm these initial results.

INTRODUCTION:Maintaining normothermia during anesthesia is imperative to provide quality patient care and to prevent adverse outcomes. Prolonged laparoscopic procedures have been identified as a potential risk factor for hypothermia, due to continuous insufflation of cold and dry carbon dioxide. Perioperative hypothermia is associated with increased hospital cost and many complications including; impaired drug metabolism, impaired immune function, cardiac morbidity, shivering, coagulopathy. METHODS:In this experimental study, four pigs underwent four interventions each, resulting in 16 total trials. Using standardized general anesthesia in a randomized Latin-square sequence the four interventions include: 1. Control group without an administered pneumoperitoneum, 2. Administered standard pneumoperitoneum using 21°C insufflated gas and under-body forced-air warming, 3. Administered pneumoperitoneum with insufflation of warmed/humidified carbon dioxide, 4. Administered pneumoperitoneum with insufflation of warmed/humidified carbon dioxide and under-body forced-air warming. The primary outcome was distal esophageal temperature change 4 hours after trocar insertion. RESULTS:Four hours after trocar insertion, pigs in the control group lost 2.1 ± 0.4°C; pigs with warmed and humidified insufflation lost 1.8 ± 0.4°C; pigs with forced-air warming group lost 1.3 ± 0.9°C; and pigs exposed to a combination of warmed and humidified insufflation with forced-air warming increased by 0.3 ± 0.2°C. CONCLUSION:This experimental animal study provides evidence that a combination of warmed and humidified insufflation of carbon dioxide (CO2) in conjunction with forced-air warming is an effective strategy in the prevention of perioperative hypothermia. Further clinical trials investigating humans are therefore indicated.

BACKGROUND:Predicting difficult intubation is of high clinical interest. METHODS:237 patients aged ≥18 years were included in the study. Preoperative airway evaluation included: Mallampati test, thyromental distance, sternomental distance and thyromental height test. During direct laryngoscopy Cormack & Lehane classification was graded. We calculated the ROC AUC, sensitivity and specificity for thyromental height test as a primary end point of our study. RESULTS:Only thyromental height test and Cormack-Lehane scale proved significant on occurrence of difficult intubation. The optimal sensitivity and specificity values of thyromental height test were met with a cut off value of 50 mm. With 1 mm increase in thyromental height test, risk of difficult intubation decreased by 7%. CONCLUSION:Thyromental height test is a simple, easy to perform and non-invasive test to predict difficult intubation in patients scheduled for elective double lumen tube intubation during thoracic surgical procedures. With 1 mm above 50 mm increase in thyromental height test the risk of difficult intubation decreased by 7%. TRIAL REGISTRATION:Clinicaltrials.gov Identifier: NCT02988336.

INTRODUCTION:Sufficient ventilation and oxygenation through proper airway management is essential in patients undergoing cardio-pulmonary resuscitation (CPR). Although widely discussed, securing the airway using an endotracheal tube is considered the standard of care. Endotracheal intubation may be challenging and causes prolonged interruption of chest compressions. Videolaryngoscopes have been introduced to better visualize the vocal cords and accelerate intubation, which makes endotracheal intubation much safer and may contribute to intubation success. Therefore, we aimed to compare hands-off time and intubation success of direct laryngoscopy with videolaryngoscopy (C-MAC, Karl Storz, Tuttlingen, Germany) in a randomized, cross-over manikin study. METHODS:Twenty-six anesthesia residents and twelve anesthesia consultants of the University Hospital Zurich were recruited through a voluntary enrolment. All participants performed endotracheal intubation using direct laryngoscopy and C-MAC in a random order during ongoing chest compressions. Participants were strictly advised to stop chest compression only if necessary. RESULTS:The median hands-off time was 1.9 seconds in direct laryngoscopy, compared to 3 seconds in the C-MAC group. In direct laryngoscopy 39 intubation attempts were recorded, resulting in an overall first intubation attempt success rate of 97%, compared to 38 intubation attempts and 100% overall first intubation attempt success rate in the C-MAC group. CONCLUSION:As a conclusion, the results of our manikin-study demonstrate that video laryngoscopes might not be beneficial compared to conventional, direct laryngoscopy in easily accessible airways under CPR conditions and in experienced hands. The benefits of video laryngoscopes are of course more distinct in overcoming difficult airways, as it converts a potential "blind intubation" into an intubation under visual control.