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ZusammenfassungIn Großschadenslagen mit vielen direkt oder indirekt beteiligten Kindern muss nicht nur eine notfallmedizinische Hilfeleistung, sondern auch eine Psychosoziale Notfallversorgung (PSNV) sichergestellt werden. In diesem Zusammenhang werden konkrete Hinweise zu psychosozialen Akuthilfen, zur Einsatztaktik sowie zu Führungs- und Funktionsstrukturen unmittelbar am Ort des Geschehens gegeben. Der Beitrag greift dabei die allgemein bekannten Leitlinien des Konsensusprozesses zur PSNV in Deutschland auf, ergänzt und konkretisiert diese jedoch auch.

Background From the results of a previous study, it remained to be investigated if a perioperative rise of few tested coagulation and inflammation markers is caused by conventional cardiopulmonary bypass (CPB) itself or rather by direct recirculation of pericardial fluids. Methods Forty-eight patients operated on with conventional CPB for myocardial revascularization were randomized either for direct recirculation of pericardial suction fluids or for cell saving (CS). Results Thrombin–antithrombin complexes showed lower values intraoperatively in the CS group (p Conclusion Direct recirculation of pericardial fluids rather than conventional CPB itself causes major intraoperative changes of some coagulation markers. Pericardial blood loss with direct recirculation should be kept to a minimum to avoid unnecessary activation of coagulation. Inflammation markers need further investigations.

Background Cardiopulmonary bypass procedure is associated with an increased risk of renal impairment. To which extent structural damage causes functional decline is unknown. We evaluated perioperative kidney injury and function in patients treated with conventional extracorporeal circulation (CECC), minimized extracorporeal circulation (MECC), and off-pump coronary artery bypass grafting (OPCAB). Methods Blood and urine samples, collected at baseline and up to 72 hours after surgery from patients of the HEPCON trial (DRKS00007580, 120 patients randomized for heparin management and for surgical technique), were analyzed for differences in renal injury and function. Neutrophil gelatinase-associated lipocalin, α glutathione S-transferase, liver fatty acid-binding protein, and kidney injury molecule-1 were measured as urinary protein markers of renal tubular injury. Serum creatinine, blood urea levels, and estimated glomerular filtration rate were determined to monitor renal function. Results Markers of tubular injury differed significantly between surgical technique groups early after surgery, indicating the most detrimental effect in CECC. Hemolysis and hemodilution correlated with these early changes. A late rise did not show intergroup differences. Time courses of renal function parameters, as well as the development of acute kidney injury in 15 patients (13.5%), were irrespective of surgical technique. Heparin management did not influence renal parameters. Conclusion During coronary artery bypass grafting, CECC temporarily induces more tubular injury than MECC or OPCAB. However, late changes of renal function parameters occur irrespective of extracorporeal perfusion mode and even in off-pump surgery.

Objectives: CABG patients suffer from inflammatory response and activation of the coagulation system. Alternatives to conventional heart-lung-machine (ONCAB) have been devised to reduce inflammation and blood contact to artificial surfaces. Are minimized extracorporeal circulation (MECC) or off-pump revascularization (OPCAB) a better choice? Methods: 120 CABG patients were randomized prospectively for surgical technique (ONCAB, MECC, OPCAB). ONCAB used conventional uncoated tubing and cardiotomy suction was recirculated. MECC used coated tubing, and both MECC and OPCAB used a cellsaver. Coagulation and inflammation markers were determined at 7 time points from pre-operatively up to 72 hour post-operatively. Results: Compared with its alternatives, ONCAB showed a transient increase of thrombin-antithrombin-complexes (p

Objectives: To compare routine activated clotting time (ACT) based hemostasis management to individualized heparin management (IHM) in terms of postoperative bleeding, platelet function, and coagulation markers. Methods: 120 CABG patients (≥ 3 distal anastomoses) were enrolled in a prospective trial and were randomized for hemostasis management (ACT versus IHM). With a target ACT of 400 second conventional hemostasis management antagonized heparin with protamine in a ratio of 1:>0.8, whereas in IHM protamine dosages were calculated from residual heparin concentrations. Hemostasis was analyzed immediately post-OP by thrombelastometry, aPTT, INR, and a range of coagulation markers. Results: A total of 112 patients (ACT: 56, IHM: 56) were included. Median heparin dosages were equivalent in both groups, whereas IHM patients received significantly less protamine. INR did not differ significantly, but aPTT values were significantly higher in HM patients. INTEM clotting times were elevated in IHM patients, whereas HEPTEM clotting times did not differ. Most coagulation markers (antithrombin III, d-dimers, fibrinogen, factors II/V/VIII/X, tissue factor pathway inhibitor, platelet counts) did not differ between groups, whereas thrombin-antithrombin complexes (TATs) were higher in ACT patients (29.69 [15.14–42.19] versus 18.50 [12.14–29.22] µg/l, p = 0.005), indicating recovered coagulation capacities. TATs correlated significantly with protamine doses (p = 0.022). Blood losses were slightly but significantly higher in IHM patients within the first 12 hour which balanced at 24 hour and which did not lead to more blood transfusions (40 PRBC in 15 patients versus 44/17, p = 0.926). Conclusions: IHM patients did not benefit from allegedly reduced coagulation factor activation mainly because heparin dosages were unexpectedly identical in both groups. On the contrary, postoperative parameters indicated an incomplete heparin antagonization in IHM patients.

Bei dem 56-jahrigen Patienten ist seit vielen Jahren eine dialysepflichtige Niereninsuffizienz bekannt. Vor 8 Wochen wurde ein Vorhofseptumdefekt (ASD) operativ verschlossen. Echokardiografisch besteht der Verdacht auf einen partiellen Ausriss des Perikard-Patches, das beim ASD-Verschluss verwendet worden ist. Zudem sind die rechten Herzhohlen dilatiert. Um den Shunt zu quantifizieren, haben wir die Sauerstoffsattigung an verschiedenen Stellen des Herzens stufenweise gemessen (Etagen-Oxymetrie). Die Untersuchung ergab zwei pathologische Befunde (▶ Tab. 1 ).