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ZusammenfassungAnhand einer fiktiven Kasuistik wird die aktuelle Leitlinie „Peripartale Blutungen, Diagnostik und Therapie“ mit einem Schwerpunkt auf die anästhesiologische Sicht zusammengefasst. Die aktualisierte Leitlinie wurde unter Federführung der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe und Beteiligung weiterer Fachgesellschaften und Interessenvertretungen aus Deutschland, Österreich und der Schweiz erarbeitet und bei der AWMF unter der Registriernummer 015/063 publiziert.

The current S2k guidelines on the diagnostics and treatment of peripartum hemorrhage are summarized in this article from the perspective of anesthesiology based on a fictitious case report. The update of the guidelines was written under the auspices of the German Society of Gynecology and Obstetrics with the participation of other professional societies and interest groups from Germany, Austria and Switzerland and published by the AWMF in 2022 under the register number 015/063.Anhand einer fiktiven Kasuistik wird die aktuelle Leitlinie „Peripartale Blutungen, Diagnostik und Therapie“ mit einem Schwerpunkt auf die anästhesiologische Sicht zusammengefasst. Die aktualisierte Leitlinie wurde unter Federführung der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe und Beteiligung weiterer Fachgesellschaften und Interessenvertretungen aus Deutschland, Österreich und der Schweiz erarbeitet und bei der AWMF unter der Registriernummer 015/063 publiziert.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Background Patients with atrial fibrillation (AF) or venous thromboembolism (VTE) receiving long-term direct oral anticoagulant (DOAC) therapy undergo diagnostic or therapeutic procedures at a rate of approximately 10% annually. The prospective Global EMIT-AF/VTE program (Edoxaban Management in Diagnostic and Therapeutic Procedures; NCT02950168, NCT02951039) demonstrated that physician-guided periprocedural management of the DOAC edoxaban in these patients was associated with low bleeding and thromboembolic event rates. It is unclear whether the experience of a previous (index) procedure influences the periprocedural management of subsequent procedures. Purpose To analyze differences in periprocedural edoxaban management in patients on chronic anticoagulation therapy undergoing multiple diagnostic or therapeutic procedures. Methods Baseline characteristics were recorded in patients enrolled in the EMIT-AF/VTE program who underwent multiple procedures. Details of periprocedural edoxaban interruption were collected from patients who underwent two procedures of the same European Heart Rhythm Association (EHRA) bleeding risk level or procedural type. Only data from the index and second procedure of the same category were included in this analysis; procedures conducted less than 7 days apart were excluded. All analyses are exploratory and descriptive in nature. Results Among 227 patients who underwent multiple procedures, the most common types were vascular and gastrointestinal (GI) procedures. Patients had a mean ± standard deviation age of 72.1 ± 9.8 years, a CHA2DS2-VASc score of 3.2 ± 1.6, a HAS-BLED score of 1.9 ± 1.0, and were mostly male (67.0%). Patients who underwent low/minor risk procedures were less likely to undergo edoxaban interruption with their second procedure compared with their index procedure (Figure 1A), and the median interruption duration was shorter for the second procedure (Table 1). A second high risk procedure was associated with a higher rate of both pre- and postprocedural edoxaban interruption compared with a patient’s index procedure, but treatment resumed earlier (Figure 1B). Patients who underwent vascular procedures had a lower rate of pre- and postprocedural interruption and a shorter interruption time with their second procedure (Table 1). Conversely, patients who underwent GI procedures experienced pre- and postprocedural interruption more often for their second procedure. The median interruption duration was longer for GI procedures than for vascular procedures (Table 1). Conclusion Overall, periprocedural edoxaban interruption varied by procedural bleeding risk and type. Edoxaban interruption patterns differed between index and second procedures, indicating that periprocedural edoxaban management may be influenced by the experience of previous procedures.

Hintergrund/Ziel der Arbeit: Der postpunktionelle Kopfschmerz (PKS) ist eine Komplikation nach rückenmarknahen Verfahren (RA) mit erheblichem Krankheitswert. Ziel der Untersuchung war es, die Inzidenz des PKS in 2 großen operativen Kollektiven zu untersuchen, mögliche Risikofaktoren zu identifizieren und den Einfluss auf die Krankenhausverweildauer zu untersuchen. Material und Methoden: In einer retrospektiven Analyse des Zeitraums 2010–2012 wurden 341 unfallchirurgische (UCH) und 2113 geburtsmedizinische (GEB) Patient*innen nach Spinalanästhesie (SPA) analysiert. In der statistischen Auswertung (SPSS-23) kamen univariate Analysen mittels Mann-Whitney-U-, Chi2- und Student’s t‑Test sowie logistische Regressionsanalysen zur Anwendung. Ergebnisse: Die Inzidenz des PKS betrug in der UCH-Gruppe 5,9 % und in der GEB-Gruppe 1,8 %. Patient*innen mit PKS in der UCH wiesen ein jüngeres Patientenalter (38 vs. 47 Jahre, p = 0,011), einen geringeren BMI (23,5 vs. 25,2, p = 0,037) sowie ein niedrigeres Köpergewicht (70,5 kg vs. 77 kg, p = 0,006) als Patient*innen ohne PKS auf. Dabei konnten das Alter mit einer „odds ratio“ (OR 97,5 % Konfidenzintervall [KI]) von 0,963 (97,5% KI 0,932–0,991, p = 0,015) und das Köpergewicht mit einer OR von 0,956 (97,5 % KI 0,920–0,989, p = 0,014) als unabhängige Risikofaktoren für die Entstehung eines PKS identifiziert werden. In der GEB wies die SPA eine höhere Inzidenz des PKS auf als die kombinierte Spinalepiduralanästhesie (CSE) (8,6 % vs. 1,2 %, p < 0,001). Dabei erwies sich das Verfahren mit einer OR von 0,049 (97,5 % KI 0,023–0,106, p < 0,001) als unabhängiger Risikofaktor für die Entstehung eines PKS. In beiden Gruppen war der PKS mit einem verlängerten Krankenhausaufenthalt assoziiert (UCH-Gruppe 4 vs. 2 Tage, p = 0,001; GEB-Gruppe 6 vs. 4 Tage, p < 0.0005). Diskussion: Die Inzidenz des PKS nach SPA/CSE war in unserer Untersuchung in den beschriebenen Patientengruppen unterschiedlich, mit einem deutlich höheren Anteil in der UCH-Gruppe. Alter, Konstitution und Verfahren waren hinweisgebende Risikofaktoren eines PKS. In Anbetracht der funktionellen Einschränkungen (Mobilisation, Versorgung des Neugeborenen) und des verlängerten Krankenhausaufenthalts, sollten zukünftige Studien eine frühe Behandlung des PKS untersuchen., Background/objective: Postdural puncture headache (PDPH) is a severe complication after spinal anesthesia. The aim of this study was to investigate the incidence of PDPH in two different operative cohorts and to identify risk factors for its occurrence as well as to analyze its influence on the duration of hospital stay. Material and methods: In a retrospective study over a period of 3 years (2010–2012), 341 orthopedic surgery (ORT) and 2113 obstetric (OBS) patients were evaluated after spinal anesthesia (SPA). Data were statistically analyzed using (SPSS-23) univariate analyses with the Mann-Whitney U‑test, χ2-test and Student’s t-test as well as logistic regression analysis. Results: The incidence of PDPH was 5.9% in the ORT cohort and 1.8% in the OBS cohort. Patients with PDPH in the ORT cohort were significantly younger (median 38 years vs. 47 years, p = 0.011), had a lower body weight (median 70.5 kg vs. 77 kg, p = 0.006) and a lower body mass index (median 23.5 vs. 25.2, p = 0.037). Body weight (odds ratio (97.5 % Confidence Intervall [CI]), OR 0.956: 97.5% CI 0.920–0.989, p = 0.014) as well as age (OR 0.963: 97.5% CI 0.932–0.991, p = 0.015) were identified as independent risk factors for PDPH. In OBS patients, PDPH occurred more frequently after spinal epidural anesthesia than after combined spinal epidural anesthesia (8.6% vs. 1.2%, p < 0.001) and the type of neuraxial anesthesia was identified as an independent risk factor for PDPH (OR 0.049; 97.5% CI 0.023–0.106, p < 0.001). In both groups the incidence of PDPH was associated with a longer hospital stay (ORT patients 4 days vs. 2 days, p = 0.001; OBS patients 6 days vs. 4 days, p < 0.0005). Conclusion: The incidence of PDPH was different in the two groups with a higher incidence in the ORT but considerably lower than in the literature. Age, constitution and type of neuraxial anesthesia were identified as risk factors of PDPH. Considering the functional imitations (mobilization, neonatal care) and a longer hospital stay, future studies should investigate the impact of an early treatment of PDPH.

Modern four-factor prothrombin complex concentrate was designed originally for rapid targeted replacement of the coagulation factors II, VII, IX and X. Dosing strategies for the approved indication of vitamin K antagonist-related bleeding vary greatly. They include INR and bodyweight-related protocols as well as fixed dose regimens. Particularly in the massively bleeding trauma and cardiac surgery patient, four-factor prothrombin complex concentrate is used increasingly for haemostatic resuscitation. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology performed a systematic literature review on four-factor prothrombin complex concentrate. The available evidence has been summarised for dosing, efficacy, drug safety and monitoring strategies in different scenarios. Whereas there is evidence for the efficacy of four-factor prothrombin concentrate for a variety of bleeding scenarios, convincing safety data are clearly missing. In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg-1 . This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available. In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg-1 ) should be considered. A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Background Periprocedural management of patients on direct oral anticoagulants undergoing insertion of permanent pacemaker (PPM) and cardiac monitoring devices is mainly based on pharmacokinetic considerations, clinical experience, and expert opinion. Purpose To describe the characteristics, periprocedural management, and events of edoxaban patients undergoing implantation of PPM/monitoring devices. Methods From the global EMIT-AF/VTE registry, which includes edoxaban patients undergoing any diagnostic or therapeutic procedures, those with PPM/cardiac monitoring device implantation were observed from five days prior to 30 days post procedure. Events documented included the incidence of International Society on Thrombosis and Haemostasis defined Major Bleeding, Clinically Relevant Non-Major Bleeding (CRNMB), acute thromboembolic events (ATE) and perioperative edoxaban interruption times. Results PPM or invasive cardiac monitoring devices were implanted in 136 patients. Conformance with European Heart Rhythm Association Guidance for the interruption of anticoagulation was variable: of the cardiac monitoring patients, 62.5% had interruption of treatment, whereas in PPM procedures 23.4% had no interruption. One case of CRNMB and two cases of minor bleeding were documented. All bleedings seem non procedure-related since they occurred > three days post procedure. There were no ATE. Conclusions Relevant complications for edoxaban treated patients undergoing PPM or invasive cardiac monitoring procedures were rare. This population of patients is apparently well managed in routine practice, but further investigation of risk factors is justified. TablePatient characteristics Parameter All subjectsN = 136 All pacemakerN = 128 Insertion first pacemakerN = 89 Change pacemakerN = 39 Monitoring deviceN = 8 Age, mean (SD)Male, n (%) 75.1 (10.1)85 (62.5) 75.0 (10.3)83 (64.8) 75.7 (9.9)57 (64.0) 73.5 (11.2)26 (66.7) 76.3 (4.3)2 (25.0) BMI, mean (SD) 27.1 (5.5) 27.2 (5.6) 27.2 (6.0) 27.3 (4.5) 25.2 (4.3) AF, n (%)‡ 135 (99.3) 127 (99.2) 89 (100.0) 38 (97.4) 8 (100.0) VTE, n (%)‡ 3 (2.2) 3 (2.3) 1 (1.1) 2 (5.1) 0 CrCL, mean (SD) 63.8 (26.4) 64.1 (26.7) 62.3 (26.2) 68.3 (27.9) 58.9 (21.8) CrCL, ≤50, n (%) 43 (31.6) 41 (32.0) 33 (37.1) 8 (20.5) 2 (25.0) HAS-BLED Score, mean (SD) 2.0 (1.2) 1.9 (1.2) 1.9 (1.0) 2.1 (1.6) 2.6 (0.5) CHA2DS2-VASc Score, mean (SD) 3.7 (1.6) 3.7 (1.6) 3.7 (1.5) 3.8 (1.9) 3.1 (0.6) Edoxaban 30 mg/day, n (%) 49 (36.0) 46 (35.9) 32 (36.0) 14 (35.9) 3 (37.5) Edoxaban 60 mg/day, n (%) 86 (63.2) 81 (63.3) 56 (62.9) 25 (64.1) 5 (62.5) AF, atrial fibrillation; BMI, body mass index; CrCL, creatinine clearance; VTE, venous thromboembolism. ‡Two patients had both AF and VTE.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Background The optimal periprocedural management of direct oral anticoagulants (DOAC), including edoxaban, in patients undergoing catheter-based cardiovascular procedures is unknown, and mainly based on physician opinion and experience. Purpose To assess real-world management of edoxaban in patients undergoing cardiovascular procedures, and to report their clinical events. Methods Global EMIT-AF/VTE is a prospective study of periprocedural management in edoxaban-treated patients undergoing diagnostic and therapeutic procedures. We report the data from patients undergoing cardiovascular procedures. Timing and duration of edoxaban interruption were at the treating physician’s discretion. Outcomes were collected from 5 days before until 30 days post procedure. Primary outcome was the incidence of major bleeding (MB); secondary outcomes included incidence of clinically relevant non-major bleeding (CRNMB) and acute thromboembolic events (ATE). Results Data was collected from 301 and 311 procedures with arterial or venous access, respectively. Baseline characteristics are shown in Table 1. Edoxaban was not interrupted in 36.9% of arterial and 52.7% of venous procedures. Edoxaban was interrupted pre-procedure in 41% of arterial and 32.8% of venous procedures. The median periprocedural interruption was 2 days. The overall incidence of bleeding was very low. Any bleeding was reported in 8 patients undergoing arterial and 10 patients undergoing venous procedures (2.7% and 3.2%). MB or CRNMB occurred in 2 arterial and 3 venous procedures (0.7% and 1.0%) and ATE occurred in 5 arterial and 1 venous procedure (1.7% and 0.3%, Table 1). Conclusions In this study, the periprocedural risks of bleeding and thrombotic events were low. About a third of arterial access procedures and half of venous access procedures were performed without edoxaban interruption. Arterial(n = 301) Venous(n = 311) Baseline characteristics Age, year, mean (SD)Male, n (%)Weight (kg), mean (SD) 71.9 (8.5)211 (70.1%)80.8 (16.7) 64.6 (11.1)215 (69.1%)84.1 (17.4) CrCL (mL/min), mean (SD) CHA2DS2-VASc score, mean (SD)HAS-BLED score, mean (SD) 73.5 (29.8) 3.3 (1.5)2.0 (1.0) 88.9 (35.5) 2.2 (1.5)1.3 (1.0) Edoxaban 60 mg / 30 mg, % 73% / 26% 88% / 26% Coronary heart disease, n (%) Congestive heart failure, n (%) 101 (33.6%) 58 (19.3%) 51 (16.4%) 33 (10.6%) Interruption of edoxaban, n (%) No interruption Pre-procedure only Post-procedure only Pre- and post-procedure 111 (36.9%)125 (41.5%)12 (4.0%)53 (17.6%) 164 (52.7%)102 (32.8%)8 (2.6%)37 (11.9%) Clinical events, n (%) MB or CRNMBACSStroke/Transient ischemic attackCV mortalityAll-cause mortality 2 (0.7%)2 (0.7%)3 (1.0%)1 (0.3%)2 (0.7%) 3 (1.0%) 01 (0.3%)00

Annually 10% of patients with atrial fibrillation on oral anticoagulation undergo invasive procedures. Optimal peri-procedural management of anticoagulation, as judged by major bleeding and thromboembolic events, especially in the elderly, is still debated.Procedures from 1442 patients were evaluated. Peri-procedural edoxaban management was guided only by the experience of the attending physician. The primary safety outcome was the rate of major bleeding. Secondary outcomes included the peri-procedural administration of edoxaban, other bleeding events, and the main efficacy outcome, a composite of acute coronary syndrome, non-hemorrhagic stroke, transient ischemic attack, systemic embolic events, deep vein thrombosis, pulmonary embolism, and mortality.Of the 1442 patients, 280 (19%) were 65, 550 (38%) were 65-74, 514 (36%) 75-84, and 98 (7%) were 85 years old or older. With increasing age, comorbidities and risk scores were higher. Any bleeding complications were uncommon across all ages, ranging from 3.9% in patients 65 to 4.1% in those 85 years or older; major bleeding rates in any age group were ≤ 0.6%. Interruption rates and duration increased with advancing age. Thromboembolic events were more common in the elderly, with all nine events occurring in those 65, and seven in patients aged 75 years.Despite increased bleeding risk factors in the elderly, bleeding rates were small and similar across all age groups. However, there was a trend toward more thromboembolic complications with advancing age. Further efforts to identify the optimal management to reduce ischemic complications are needed.NCT# 02950168, October 31, 2016.

Postdural puncture headache (PDPH) is a severe complication after spinal anesthesia. The aim of this study was to investigate the incidence of PDPH in two different operative cohorts and to identify risk factors for its occurrence as well as to analyze its influence on the duration of hospital stay.In a retrospective study over a period of 3 years (2010-2012), 341 orthopedic surgery (ORT) and 2113 obstetric (OBS) patients were evaluated after spinal anesthesia (SPA). Data were statistically analyzed using (SPSS-23) univariate analyses with the Mann-Whitney U‑test, χThe incidence of PDPH was 5.9% in the ORT cohort and 1.8% in the OBS cohort. Patients with PDPH in the ORT cohort were significantly younger (median 38 years vs. 47 years, p = 0.011), had a lower body weight (median 70.5 kg vs. 77 kg, p = 0.006) and a lower body mass index (median 23.5 vs. 25.2, p = 0.037). Body weight (odds ratio (97.5 % Confidence Intervall [CI]), OR 0.956: 97.5% CI 0.920-0.989, p = 0.014) as well as age (OR 0.963: 97.5% CI 0.932-0.991, p = 0.015) were identified as independent risk factors for PDPH. In OBS patients, PDPH occurred more frequently after spinal epidural anesthesia than after combined spinal epidural anesthesia (8.6% vs. 1.2%, p 0.001) and the type of neuraxial anesthesia was identified as an independent risk factor for PDPH (OR 0.049; 97.5% CI 0.023-0.106, p 0.001). In both groups the incidence of PDPH was associated with a longer hospital stay (ORT patients 4 days vs. 2 days, p = 0.001; OBS patients 6 days vs. 4 days, p 0.0005).The incidence of PDPH was different in the two groups with a higher incidence in the ORT but considerably lower than in the literature. Age, constitution and type of neuraxial anesthesia were identified as risk factors of PDPH. Considering the functional imitations (mobilization, neonatal care) and a longer hospital stay, future studies should investigate the impact of an early treatment of PDPH.HINTERGRUND/ZIEL DER ARBEIT: Der postpunktionelle Kopfschmerz (PKS) ist eine Komplikation nach rückenmarknahen Verfahren (RA) mit erheblichem Krankheitswert. Ziel der Untersuchung war es, die Inzidenz des PKS in 2 großen operativen Kollektiven zu untersuchen, mögliche Risikofaktoren zu identifizieren und den Einfluss auf die Krankenhausverweildauer zu untersuchen.In einer retrospektiven Analyse des Zeitraums 2010–2012 wurden 341 unfallchirurgische (UCH) und 2113 geburtsmedizinische (GEB) Patient*innen nach Spinalanästhesie (SPA) analysiert. In der statistischen Auswertung (SPSS-23) kamen univariate Analysen mittels Mann-Whitney-U-, ChiDie Inzidenz des PKS betrug in der UCH-Gruppe 5,9 % und in der GEB-Gruppe 1,8 %. Patient*innen mit PKS in der UCH wiesen ein jüngeres Patientenalter (38 vs. 47 Jahre, p = 0,011), einen geringeren BMI (23,5 vs. 25,2, p = 0,037) sowie ein niedrigeres Köpergewicht (70,5 kg vs. 77 kg, p = 0,006) als Patient*innen ohne PKS auf. Dabei konnten das Alter mit einer „odds ratio“ (OR 97,5 % Konfidenzintervall [KI]) von 0,963 (97,5% KI 0,932–0,991, p = 0,015) und das Köpergewicht mit einer OR von 0,956 (97,5 % KI 0,920–0,989, p = 0,014) als unabhängige Risikofaktoren für die Entstehung eines PKS identifiziert werden. In der GEB wies die SPA eine höhere Inzidenz des PKS auf als die kombinierte Spinalepiduralanästhesie (CSE) (8,6 % vs. 1,2 %, p 0,001). Dabei erwies sich das Verfahren mit einer OR von 0,049 (97,5 % KI 0,023–0,106, p 0,001) als unabhängiger Risikofaktor für die Entstehung eines PKS. In beiden Gruppen war der PKS mit einem verlängerten Krankenhausaufenthalt assoziiert (UCH-Gruppe 4 vs. 2 Tage, p = 0,001; GEB-Gruppe 6 vs. 4 Tage, p 0.0005).Die Inzidenz des PKS nach SPA/CSE war in unserer Untersuchung in den beschriebenen Patientengruppen unterschiedlich, mit einem deutlich höheren Anteil in der UCH-Gruppe. Alter, Konstitution und Verfahren waren hinweisgebende Risikofaktoren eines PKS. In Anbetracht der funktionellen Einschränkungen (Mobilisation, Versorgung des Neugeborenen) und des verlängerten Krankenhausaufenthalts, sollten zukünftige Studien eine frühe Behandlung des PKS untersuchen.

Fur eine evidenzbasierte Gerinnungstherapie der peripartalen Hamorrhagie (PPH, Blutverlust >500 ml) mussen strukturelle Voraussetzungen unabhangig von der peripartalen Versorgungsstufe (VS) des Krankenhauses erfullt sein. Ziel dieser Umfrage war eine Bestandsaufnahme der Gerinnungstherapie der PPH unter besonderer Berucksichtigung der VS. In einer Umfrage wurden 533 anasthesiologische Kliniken, die eine geburtsmedizinische Einrichtung versorgen, zu den strukturellen Voraussetzungen und der hamostaseologischen Therapie einer PPH befragt. Aus allen VS konnten 156 Fragebogen (29 %) ausgewertet werden. Peripartale Hamorrhagien kommen in allen VS vor; ihre Inzidenz steigt mit der VS an (VS 1 30 PPH/Jahr). Unabhangig von der VS betragt der Anteil transfusionspflichtiger PPH 80 %, alle VS) und Fibrinogen (>60 % alle VS) ist Therapie der 1. Wahl. Gerinnungsaktives Frischplasma (GFP) ist in 30 % der VS 1/2a 1. Wahl, in den Hausern der VS 2b/3 2. Wahl (>30 %). In 57–69 % (alle VS) erfolgt die Transfusion ab einem Hamoglobin(Hb)-Gehalt von 5–7 g/dl. In der VS 3 geben 15–29 % der Hauser an, ihre Transfusionsentscheidung nicht ausschlieslich vom Hb abhangig zu machen. Die Voraussetzungen fur eine evidenzbasierte Gerinnungstherapie der PPH sind in den meisten Kliniken in Deutschland unabhangig der VS vorhanden. Abweichungen von aktuellen Leitlinienempfehlungen (z. B. Messen des BV, differenzierte Gerinnungsanamnese) betreffen alle VS.

Die europaischen Leitlinien zum Management der schweren Blutung und Koagulopathie nach Trauma empfehlen seit dem Jahr 2013 die fruhestmogliche Gabe von Tranexamsaure (TXA) zur Inhibierung der Hyperfibrinolyse, die im Zuge der traumaassoziierten Koagulopathie (TIK) bereits bei Klinikaufnahme bestehen kann. Weiter empfehlen die Leitlinienautoren, dass Behandlungsalgorithmen zum Management der schweren Blutung nach Trauma die praklinische Applikation von TXA beinhalten sollten. Daten zur praklinischen Vorhaltung von TXA in Deutschland existieren bislang nicht. Ziel der Arbeit war es, aussagekraftige Daten uber die Vorhaltung von TXA im deutschen Rettungsdienst und zur Behandlung der TIK zu generieren. Es wurde ein dreiteiliger Fragebogen entwickelt. Im Zeitraum vom 01.07.2015 bis 31.08.2015 wurden insgesamt 326 Arztliche Leiter Rettungsdienst (ALRD) in Deutschland per E‑Mail zu einer anonymisierten Onlineumfrage eingeladen. Der Onlinefragebogen wurde von 163 ALRD beantwortet. Hieraus ergab sich eine Rucklaufquote von 50 %. TXA wurde zum Erhebungszeitpunkt in 52,8 % der Rettungsdienstbereiche vorgehalten. In 26 % der Bereiche, die keine TXA vorhielten, ist dies fur die Zukunft geplant. Die Vorhaltungsquote stieg seit 2010 deutlich an. Masgeblich hierfur wurden Leitlinienempfehlungen genannt. SOPs (Standard Operating Procedures) zur praklinischen Anwendung von TXA existierten in 17,4 %. Eine Dosisempfehlung wurde von 76,7 % (n = 66) der ALRD gegeben. Uber 80 % der Dosierungsempfehlungen orientierten sich an den internationalen Empfehlungen. TXA wurde zum Erhebungszeitpunkt mit steigender Tendenz in uber der Halfte der Rettungsdienstbereiche vorgehalten. Eine flachendeckende Vorhaltung ergibt sich hieraus jedoch noch nicht.

SummaryRecent findings require an update of previous recommendations for the perioperative use of Direct Oral AntiCoagulants (DOACs). A break in preoperative treatment of 24-96 hours is recommended based on the pharmacokinetic profiles of DOACs and depends on individual patient characteristics, their renal and possibly liver function, and their surgery-related risk of bleeding. In cases of renal or hepatic insufficiency, whether to extend the preoperative interruption of IIa- and Xa-inhibitors is a clinical decision that must be reached on an individual patient basis. In cases of epidural or spinal anaesthesia, more conservative pausing-intervals are recommended due to the risk of persistent neurologic deficits (e.g., paraplegia) following the development of spinal subdural and epidural haematomas. Elective surgery should be postponed according to these recommendations. Preoperative “bridging” with LMWH (more precisely referred to as “switching”) should be omitted due to a significantly increased risk of bleeding. In addition, the incidence of perioperative thromboembolic risks, such as DVT, PE, and stroke, are no different whether interruption or „switching” is undertaken. Postoperatively, the DOACs can be reinstituted within the first 24 hours. In cases of major surgery or if there is a higher risk of bleeding, resumption of DOACS should only begin after 24-72 hours. In patients with an elevated thromboembolic risk, transient postoperative LMWH administration can be recommended during this period.Interaction of DOACs with other drugs usually occurs during the absorption, transport and elimination of these drugs. Therefore, substance-specific restrictions and recommendations should be observed during these times. In everyday clinical practice, webbased, independent information portals on drug-interactions are very helpful in providing safe and rapid information about potential interactions when DOACs are used in combination with other drugs, especially during perioperative management.Non-adherence to medications is a worldwide problem that has dangerous and costly consequences. Present data suggest that persistence is the primary factor that supports adherence. Despite the adherence data presented in the DOACS approval studies (e.g., persistence in the treatment of acute venous thromboembolism has been reported to be between 94-99%), the first registries and meta-analyses provide sobering results regarding the incidence of persistence and the success rate of interventions designed to improve adherence with DOACs in cases of long-term usage.Nachdruck aus und zu zitieren als: Hämostaseologie 2017; 37: 267–275 https://doi.org/10.5482/HAMO-16-10-1657856

Background: General (GA)- and epidural-anesthesia may cause a drop in body-core-temperature (BCTdrop), and hypothermia, which may alter tissue oxygenation (StO2) and microperfusion after cytoreductive surgery for ovarian cancer. Cell metabolism of subcutaneous fat- or skeletal muscle cells, measured in microdialysis, may be affected. We hypothesized that forced-air prewarming during epidural catheter placement and induction of GA maintains normothermia and improves microperfusion. Methods: After ethics approval 47 women scheduled for cytoreductive surgery were prospectively enrolled. Women in the study group were treated with a prewarming of 43°C during epidural catheter placement. BCT (Spot on®, 3M) was measured before (T1), after induction of GA (T2) at 15 min (T3) after start of surgery, and until 2h after ICU admission (TICU2h). Primary endpoint was BCTdrop between T1 and T2. Microperfusion-, hemodynamic- and clinical outcomes were defined as secondary outcomes. Statistical analysis used the Mann-Whitney-U- and non-parametric-longitudinal tests. Results: BCTdrop was 0.35 °C with prewarming and 0.9 °C without prewarming (p< 0.005) and BCT remained higher over the observation period (ΔT4 = 0.9 °C up to ΔT7 = 0.95 °C, p

Approximately 14-40% of patients in industrialized countries present with preoperative anemia. Depending on the severity, anemia is associates with increased perioperative morbidity and mortality. One of the most important causes of preoperative anemia is iron deficiency which is usually easy to treat. Implemented in the multimodal concept of patient blood management, the diagnostics and treatment of preoperative anemia are important aspects for improvement of perioperative outcome. Adequate and early diagnostics of the cause of anemia before treatment is important because treatment options, e.g. with iron, erythropoetin, folic acid and vitamin B

To date, data regarding the efficacy and safety of administering fibrinogen concentrate in cardiac surgery are limited. Studies are limited by their low sample size and large heterogeneity with regard to the patient population, by the timing of fibrinogen concentrate administration, and by the definition of transfusion trigger and target levels. Assessment of fibrinogen activity using viscoelastic point-of-care testing shortly before or after weaning from cardiopulmonary bypass in patients and procedures with a high risk of bleeding appears to be a rational strategy. In contrast, the use of Clauss fibrinogen test for determination of plasma fibrinogen level can no longer be recommended without restrictions due to its long turnaround time, high inter-assay variability and interference with high heparin levels and fibrin degradation products. Administration of fibrinogen concentrate for maintaining physiological fibrinogen activity in the case of microvascular post-cardiopulmonary bypass bleeding appears to be indicated. The available evidence does not suggest aiming for supranormal levels, however. Use of cryoprecipitate as an alternative to fibrinogen concentrate might be considered to increase plasma fibrinogen levels. Although conclusive evidence is lacking, fibrinogen concentrate does not seem to increase adverse outcomes (i.e., thromboembolic events). Large prospective multi-centre studies are needed to better define the optimal perioperative monitoring tool, transfusion trigger and target levels for fibrinogen replacement in cardiac surgery.

Zur Sekundarprophylaxe eines akuten Koronarsyndroms (ACS) wird die duale antithrombozytare Therapie (DAPT) mit Acetylsalicylsaure und einem P2Y12-Adenosindiphosphat-Rezeptorblocker wie Clopidogrel, Prasugrel und Ticagrelor fur eine Dauer von 12 Monaten in den Leitlinien empfohlen. Ein fruhzeitiges Absetzen der DAPT ist mit einem erhohten Risiko fur ischamische Ereignisse verbunden. Die antithrombozytare Therapie ist allerdings auch mit einem erhohten Risiko fur Blutungen assoziiert, welches nicht unter- aber auch nicht uberschatzt werden sollte. Um eine optimale Versorgung der Patienten unter DAPT nach einem ACS zu gewahrleisten, hat eine interdisziplinare Gruppe erfahrener Experten aus den Bereichen Kardiologie, Kardiochirurgie, Gastroenterologie, Anasthesiologie, Intensivmedizin und Hamostaseologie praxisrelevante Informationen und Empfehlungen erarbeitet. Diese schliesen die Bedeutung von Blutungen im Verlauf der Therapie, Masnahmen zur Pravention und die optimale Versorgung von Patienten mit Blutungen ein.

Der Einsatz von Human-Albumin ist im Vergleich zu Kristalloiden und kunstlichen Kolloiden nicht immer vorteilig, wie die Neubewertung der Literatur zeigt, bei der vorrangig prospektiv-randomisierte Studien, systematische Reviews und Leitlinien berucksichtigt wurden. Im Fokus der hier vorliegenden Betrachtungen steht der Volumenersatz mit Human-Albumin beim Trauma- und herzchirurgischen Patienten, bei Intensivpatienten mit und ohne Sepsis, in der perioperativen Phase sowie zur Therapie der Hypalbuminamie des Intensivpatienten.

Background Adult cardiac surgery is often complicated by elevated blood losses that account for elevated transfusion requirements. Perioperative bleeding and transfusion of blood products are major risk factors for morbidity and mortality. Timely diagnostic and goal-directed therapies aim at the reduction of bleeding and need for allogeneic transfusions. Methods Single-centre, prospective, randomized trial assessing blood loss and transfusion requirements of 26 adult patients undergoing elective cardiac surgery at high risk for perioperative bleeding. Primary endpoint was blood loss at 24 h postoperatively. Random assignment to intra- and postoperative haemostatic management following either an algorithm based on conventional coagulation assays (conventional group: platelet count, aPTT, PT, fibrinogen) or based on point-of-care (PoC-group) monitoring, i.e. activated rotational thromboelastometry (ROTEM®) combined with multiple aggregometry (Multiplate®). Differences between groups were analysed using nonparametric tests for independent samples. Results The study was terminated after interim analysis (n = 26). Chest tube drainage volume was 360 ml (IQR 229-599 ml) in the conventional group, and 380 ml (IQR 310-590 ml) in the PoC-group (p = 0.767) after 24 h. Basic patient characteristics, results of PoC coagulation assays, and transfusion requirements of red blood cells and fresh frozen plasma did not differ between groups. Coagulation results were comparable. Platelets were transfused in the PoC group only. Conclusion Blood loss via chest tube drainage and transfusion amounts were not different comparing PoC- and central lab-driven transfusion algorithms in subjects that underwent high-risk cardiac surgery. Routine PoC coagulation diagnostics do not seem to be beneficial when actual blood loss is low. High risk procedures might not suffice as a sole risk factor for increased blood loss. Trial registration NCT01402739, Date of registration July 26, 2011.

Maternal hypotension is a common side effect of spinal anaesthesia for Caesarean section. The combination of colloid coloading and vasopressors was considered our standard for its prevention and treatment. As the safety of hydroxyethyl starch is under debate, we replaced colloid with crystalloid coloading. We hypothesize that the mean blood pressure drop is greater when coloading with crystalloids. Prospective, observational clinical trial. Two-centre study conducted in Berlin, Germany. Parturients scheduled for a Caesarean section were screened for eligibility. The study protocol and patient monitoring were based on the standard operating procedure for Caesarean section in both centres. The data from the crystalloid group were prospectively collected between November 2014 and July 2015. The primary endpoint was the median drop in mean blood pressure after induction of spinal anaesthesia. Secondary endpoints were incidence of hypotension (drop > 20% of baseline systolic pressure /drop

Despite current recommendations on the management of severe peri-operative bleeding, there is no pragmatic guidance for the peri-operative monitoring and management of cardiac surgical patients taking direct oral anticoagulants. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology, of their own volition, performed an independent systematic review of peer-reviewed original research, review articles and case reports and developed the following consensus statement. This has been endorsed by the European Association of Cardiothoracic Anaesthesiology. In our opinion, most patients on direct oral anticoagulant therapy presenting for elective cardiac surgery can be safely managed in the peri-operative period if the following conditions are fulfilled: direct oral anticoagulants have been discontinued two days before cardiac surgery, corresponding to five elimination half-live periods; in patients with renal or hepatic impairment or a high risk of bleeding, a pre-operative plasma level of direct oral anticoagulants has been determined and found to be below 30 ng.ml-1 (currently only valid for dabigatran, rivaroxaban and apixaban). In cases where plasma level monitoring is not possible (e.g. assay was not available), discontinuation for 10 elimination half-live periods (four days) is required. For FXa inhibitors, a standard heparin-calibrated anti-Xa level of < 0.1 IU.ml-1 should be measured, indicating sufficient reduction in the anticoagulant effect. Finally, short-term bridging with heparin is not required in the pre-operative period.

In order to ensure evidence-based haemostatic management of postpartum haemorrhage (PPH, blood loss500 ml) consistent with guidelines appropriate structural conditions must be fulfilled regardless of different levels (1-3) in perinatal care. The aim of the survey was to identify differences in haemostatic management in PPH under consideration of the different levels of perinatal care in Germany.An electronic questionnaire assessing the structural and therapeutic preconditions for haemostatic management was sent to 533 anaesthesiology departments serving obstetric units.A total of 156 (29 %) questionnaires returned from hospitals of all levels were analysed. PPH occur in all and increase with higher level hospitals (level 15 PPH/year vs. 330 PPH/year). The percentage of PPH requiring red blood cell (RBC) transfusion amounts to25 % (all levels). A bleeding history (35 %, all levels), laboratory coagulation tests (29 %, all levels) as well as viscoelastic point-of-care coagulation tests (42 %, mainly level 3) are limited in their availability. Blood loss is usually estimated (99 %, all levels), not measured. Tranexamic acid (80 %, all levels), fibrinogen (60 %, all levels) and fresh frozen plasma (FFP) (30 %, level 2a) are first line therapeutics. In level 2b and 3 FFP is a second line therapeutic. RBC transfusion is indicated at haemoglobin5-7 g/dl (57-69 %, all levels), while 15-29 % in level 3 did not base their decision to transfuse RBC on haemoglobin only.Guideline-consistent haemostatic management of PPH is provided in almost all hospitals independent of the perinatal care level. Deviances from guidelines (measuring blood loss, bleeding history of the patient) affect all levels of perinatal care in Germany.

Trauma-induced coagulopathy, one of the leading causes of trauma-related death, is detected in about one of four trauma patients upon hospital admission. The current European Management of Major Bleeding and Coagulopathy Following Trauma guidelines, published in 2013, recommend that tranexamic acid (TXA) be administered as early as possible to inhibit hyperfibrinolysis (grade of recommendation (GoR 1A)). Furthermore, it is suggested that protocols for the management of patients with bleeding or showing signs of bleeding include the administration of the first dose of TXA at the site of injury or during transportation to hospital (GoR 2C). There is no current data showing to what extent TXA is used in the pre-hospital settings in Germany.This study aimed to collect data about the availability of TXA in the German emergency medical service (EMS). We tried to determine how many EMS stored and used TXA, under which circumstances the substance was used and whether any standard operating procedures (SOPs) were in use. The study also tried to determine what dosage recommendations exist.Between 1 July and 31 August 2015, a total of 326 German emergency medical directors (EMDs) were asked to take part in a survey, which involved answering an online questionnaire.Altogether 163 EMD answered the questionnaire (response rate 50%). The results showed that 52.8% of EMDs stored TXA in their vehicles and 26% planned to do so in the future. The availability of TXA in the EMS has increased since 2010. Most EMDs stated that guidelines were the reason for this. SOPs existed in 17.4%. Dosage recommendations were defined by the EMDs in 76.7%. More than 80% of dosage recommendations followed the European guideline.The survey shows a widespread distribution of TXA in the German EMS, which has significantly increased between 2010 and 2015. However, nationwide distribution has not yet been established. This rise in distribution is interpreted as a reaction to national and European guidelines for the management of severe bleeding and trauma care. A remaining question is to determine which patients should be treated with TXA, as hyperfibrinolysis is not detectable at the site of injury.

For secondary prevention of acute coronary syndrome, guidelines recommend dual antiplatelet therapy with acetylsalicylic acid and a P2Y12 receptor antagonist such as clopidogrel, prasugrel or ticagrelor for a period of 12 months. Premature discontinuation of dual antiplatelet therapy is associated with an increased risk of ischaemic events. However, antiplatelet therapy is also associated with an increased risk of bleeding that should not be under- or overestimated. To ensure an optimal care of patients receiving dual antiplatelet therapy after an acute coronary syndrome, an interdisciplinary group of experienced experts in the fields of cardiology, cardiac surgery, gastroenterology, anaesthesiology, intensive care and haemostaseology gathered bleeding-related information and developed recommendations relevant to daily clinical practice. These include the significance of bleeding events in the course of treatment, measures for bleeding prevention and the adequate care of patients with bleedings.

Hintergrund Mit steigender Zahl implantierter Herzschrittmacher und implantierbarer Kardioverter-Defibrillatoren (ICD) und einer steigenden Inzidenz von onkologischen Erkrankungen nimmt die Wahrscheinlichkeit fur strahlungsbedingte Geratestorungen zu. Die veroffentlichten Leitlinien zum Management von Schrittmacherpatienten stammen aus dem Jahr 1994 und sind seitdem nicht mehr aktualisiert worden. Auf Basis der aktuellen Evidenz und moderner Geratetechnologie mochte die vorliegende Arbeit ein zeitgemases, interdisziplinares Sicherheitsprotokoll zur Minimierung des Patientenrisikos entwickeln.

SummaryRivaroxaban, the first direct factor-Xa inhibitor anticoagulant, has been approved for the prevention of venous thromboembolism in adult patients undergoing elective hip or knee replacement surgery, for stroke prophylaxis in patients with non-valvular atrial fibrillation and for the treatment of deep vein thrombosis. There is no requirement for coagulation monitoring with rivaroxaban in routine clinical practice. However, in certain clinical circumstances such as life-threatening bleeding or an emergency operation the measurement of the thromboplastin time with a sensitive reagent will deliver first information. A quantitative determination of rivaroxaban plasma concentration is possible using an anti-factor Xa assay.In the case of a patient under long-term anticoagulation with rivaroxaban requiring an elective surgery, a discontinuation of rivaroxaban 20 to 30 hours before the operation is sufficient to normalize the associated bleeding risk, as long as the renal and liver function is normal. A longer interval should be taken into consideration, when the patient presents a renal and liver impairment or is of a higher age. In the event of an emergency operation effective rivaroxaban concentrations might be present. Nevertheless, we advise against using a prophylactic dose of factor concentrates. Recommendations: From a clinical perspective, in the event of a minor bleeding we recommend a temporary discontinuation of rivaroxaban, whereas for clinically relevant major or severe bleeding events a mechanical compression or a limited surgical i. e. interventional treatment is required. Supportive measures such as the administration of blood products or tranexamic acid might be beneficial. In addition to haemodynamic supportive measures life threatening bleeding events demand a comprehensive haemostasis management, as well as the application of PCC.

Etwa ein Drittel der Patienten, die sich einer elektiven Huft- oder Kniegelenkendoprothesenoperation unterziehen, weist einen Hamoglobinwert unter 13 g/dl (Manner) bzw. unter 12 g/dl (Frauen) auf, was nach der gultigen WHO-Definition einer Anamie entspricht. Diese ist mit einer erhohten postoperativen Morbiditat- und Mortalitat und mit haufigen Transfusionen verbunden. Transfundierte Patienten haben ebenfalls ein erhohtes Risiko fur Mortalitat und Infektionen und verweilen langer im Krankenhaus. Entsprechend dem Transfusionsgesetz und den Richtlinien der Bundesarztekammer sind Patienten mit einer Transfusionswahrscheinlichkeit von mindestens 10% auf die Moglichkeit autologer Hamotherapieverfahren hinzuweisen. Die Eigenblutspende als ein gangiges autologes Verfahren zur Vermeidung allogener Transfusionen wird in Deutschland in vielen Kliniken angewendet, kann jedoch unter bestimmten Bedingungen eine praoperative Anamie noch verstarken. Deswegen, aber auch weil die Ressource Fremdblut zunehmend knapper wird, besteht die Notwendigkeit neuer Standards in der Diagnostik und Therapie der praoperativen Anamie. In aktuellen internationalen Leitlinien wird empfohlen, den Hamoglobinwert spatestens 28 Tage vor dem Eingriff zu bestimmen und entsprechend der Definition der WHO bei Mannern auf > 13 g/dl und bei Frauen auf > 12 g/dl anzuheben. Als Ursache fur eine Anamie sollten eine chronische Niereninsuffizienz, eine maligne Erkrankung und eine chronische Entzundung abgeklart und ein Mangel an Eisen, Vitamin B12 und/oder Folsaure ausgeglichen werden. Fur Patienten, bei denen keine Mangelerkrankung vorliegt oder eine Substitutionstherapie keine ausreichende Therapie der Anamie erzielt, wird vorgeschlagen, eine Therapie mit erythropoesestimulierenden Substanzen durchzufuhren.

Background Cardiopulmonary bypass (CPB) impairs intestinal barrier function and induces systemic inflammation after cardiac surgery. The objective of this study was to evaluate the effect of profound haemodilution (haematocrit 19–21%) during normothermic CPB on gastrointestinal permeability and cytokine release in comparison with a standard haemodilution (haematocrit 24–26%). Methods This was a prospective, controlled, randomized pilot trial of 60 patients without gastrointestinal disease undergoing normothermic CPB (35.5–36°C) for coronary artery bypass graft surgery. Gastrointestinal permeability was measured by the triple-sugar technique (sucrose, lactulose, and mannitol excretion in urine) before and after CPB. Interleukin (IL)-6, IL-10, and tumour necrosis factor alpha (TNFα) were quantified using enzyme-linked immunosorbent assays. Results Data from 59 patients (19–21% haematocrit, n =28; 24–26% haematocrit, n =31) were analysed. Data on gastrointestinal permeability were available for 47 patients (19–21% haematocrit, n =23; 24–26% haematocrit, n =24), blood samples for cytokine analysis from 59 patients. Mannitol excretion was normal before and after surgery without significant differences between the groups (after operation: 5.4% vs 2.9%, P =0.193). Lactulose and sucrose excretion was within a normal range before surgery and increased afterwards without differences between the groups. IL-6, IL-10, and TNFα were elevated after surgery, but there was no difference between the groups [IL-6 ( P =0.78), IL-10 ( P =0.74), and TNFα ( P =0.67)]. Conclusions Profound haemodilution during normothermic CPB brought about significant changes neither in intestinal permeability nor in cytokine release. It may be concluded that a haematocrit of 19–21% during normothermic CPB does not impair intestinal barrier function and cytokine response in patients without gastrointestinal comorbidity.

A regular hydration status and compensated vascular filling are targets of perioperative fluid and volume management and, in parallel, represent precautions for sufficient stroke volume and cardiac output to maintain tissue oxygenation. The physiological and pathophysiological effects of fluid and volume replacement mainly depend on the pharmacological properties of the solutions used, the magnitude of the applied volume as well as the timing of volume replacement during surgery. In the perioperative setting surgical stress induces physiological and hormonal adaptations of the body, which in conjunction with an increased permeability of the vascular endothelial layer influence fluid and volume management. The target of haemodynamic monitoring in the operation room is to collect data on haemodynamics and global oxygen transport, which enable the anaesthetist to estimate the volume status of the vascular system. Particularly in high risk patients this may improve fluid and volume therapy with respect to maintaining cardiac output. A goal-directed volume management aiming at preventing hypovolaemia may improve the outcome after surgery. The objective of this article is to review the monitoring devices that are currently used to assess haemodynamics and filling status in the perioperative setting. Methods and principles for measuring haemodynamic variables, the measured and calculated parameters as well as clinical benefits and shortcomings of each device are described. Furthermore, the results for monitoring devices from clinical studies of goal-directed fluid and volume therapy which have been published will be discussed.

Surgery elicits a series of metabolic stress reactions. Stress hormones and inflammatory mediators (i. e. cytokines) cause catabolism of glycogen, lipids and proteins. Glucose, free fatty acids, and amino acids are released for the tasks of healing and immune response. Thus, substrates are diverted from normal purposes such as physical activity. However, the patient requires anabolic metabolism to reach optimal recovery. Many stress-reducing measures have proven to minimize catabolism and support anabolism, and have led to faster and better rehabilitation, even after major surgical trauma. The so-called „Enhanced Recovery After Surgery” (ERAS) concepts focus on better preoperative preparation, anaesthesia, analgesia, and early mobilisation as well as improved supplies of nutritional substrates. This includes generally reduced preoperative fasting, preoperative carbohydrate loading, no interruption of oral nutritional intake after surgery, if possible, and a perioperative consumption of oral nutritional supplements. Studies have shown that such nutritional practices contribute to perioperative stabilisation of the organism by reducing postoperative insulin resistance, minimising protein catabolism, decreasing oxidative stress, and improving various organ functions. Further consequences are improved perioperative condition, attenuated depletion of muscle mass, reduction of postoperative complications, and reduced intensive care unit and hospital stays.

Summary Background Gastroduodenal and small intestinal permeability are increased in patients with Crohn's disease (CD) and intensive care patients. The relevance of colonic permeability has not yet been adequately investigated. The aim of this study was to investigate the clinical value of sucralose excretion as indicator for colonic permeability in these patient groups. Design After oral administration of four sugars and subsequent analysis of urinary excretion, gastroduodenal and intestinal permeability were calculated from saccharose excretion and lactulose/mannitol (L/M) ratio over 5 h, and sucralose excretion from 5 to 26 h in 100 healthy controls, 29 CD and 35 patients after coronary surgery (CABG). Results In controls, sucralose excretion was highly variable (0·67 ± 0·92%) and not related to small intestinal permeability. In CD and CABG, L/M ratio was increased (0·054 ± 0·060; 0·323 ± 0·253 vs. 0·018 ± 0·001 in controls). Sucralose excretion was increased in 77% of CABG but only in 7% of CD. There was an association between gastroduodenal and intestinal permeability in CD and CABG (r = 0·72, and r = 0·51), but sucralose excretion was not related to either one of these two parameters. Other than a weak association between sucralose and length of stay in intensive care in CABG patients (P = 0·099), sucralose excretion was not related to clinical outcome. Conclusions The proposed cut-off for normal sucralose excretion is 2·11%, but its high variability and lack of association to gastrointestinal permeability or clinical outcome leave it open, if it can provide information beyond established permeability tests.

SummaryOral anticoagulation with a vitamin K-antagonist requires special consideration when surgery or interventional procedures are planned. This is mainly due to the half life of vitamin K-antagonists and to the need for safe and effective anticoagulation prior to and during surgery as well as in the postoperative period. So far, the continuous infusion of unfractionated heparin (UFH) has been the medication of choice to ,,bridge“ patients to surgery.The use of low molecular weight heparins (LMWH) has been prospectively investigated in this setting and represents a safe alternative. The advantages of LMWH are the better dose-response relationship and reduced need for monitoring. This facilitates the bridging procedure to be started out of hospital, which may reduce hospital stay and associated costs. Furthermore, the so-called bridging of patients with oral anticoagulation prior to and during surgery reduces bleeding complications and maintains a safe anticoagulation for patients at risk.

In cardiac surgery, perioperative haemodynamic management is often guided by cardiac output (CO) measurements. The Vigileo™ monitor offers uncalibrated CO measurement by arterial waveform analysis (COwave). This validation study compared CO measurements derived from radial artery waveform analysis with those derived from the ascending aorta. CO measurements from the radial artery versus the ascending aorta showed a significant correlation before and after cardiopulmonary bypass (CPB). However, Bland–Altman analysis showed a mean bias of 0.1 l/min and 0.1 l/min, and limits of agreement (LOA) of +2.2 l/min and −1.9 l/min prior to CPB, and +2.5 l/min and −2.7 l/min after weaning from CPB. A comparison of these CO measurements showed a low mean bias, but wide LOA before and after CPB. Therefore measurements using uncalibrated COwave have to be interpreted with caution in a clinical situation.

Within recent years patient safety has become increasingly important. Within US hospitals more than 98.000 deaths have been reported annually due to medical errors, more than 80 % due to preventable mistakes. To improve patient safety it is therefore important to develop training tools, which center on the complexity of preventable mistakes, analyze underlying factors and eventually train to deal with them. Since the Berlin Simulation training was founded in 1997 it focused on the internationally accepted "global approach" based on three phases of briefing, simulation and debriefing. It concentrates on the reasons of preventable mistakes and their interaction. Problem solving strategies and the application of NTS ( planing, management, teamwork and communication) and TS (sound scientific knowledge and abilities) are practiced under the supervision of experienced trainers. The goal is to provide insight into the cascades of error and terminate them, to ultimately increase patient safety and provider satisfaction.

Apixaban (Eliquis®) is a direct and competitive inhibitor of factor FXa that is approved for thrombosis prophylaxis after hip and knee replacement surgery, in non-valvular atrial fibrillation and venous thromboembolic events therapy [1]. In cases of severe hemorrhages there is no approved specific antidote available to reverse the effect of apixaban yet. Previous animal and in vitro studies [2, 3] with supratherapeutic concentrations of apixaban (200ng ml-1) have shown that activated prothrombin complex concentrate (aPCC) and recombinant factor VIIa (rFVIIa) have a greater effect in reversing the effect of apixaban than prothrombin complex concentrate (PCC). The effect of these non-specific hemostatic agents for reversal of apixaban concentrations measured in patients after prophylactic doses (maximum observed plasma concentration 62 ng ml-1 [4]) remains unclear.

Unmittelbar nach Notsectio erlitt eine 37-jahrige Patientin eine atone Uterusnachblutung, die eine erweiterte operative Therapie (Clipping der Aa. uterinae bds.) in Kombination mit einer uterotonen und hamostaseologischen Therapie inkl. Massentransfusion und rFVIIa-Gabe erforderte. Nach einem blutungsfreien Intervall von 17 Tagen kam es erneut zu einer schweren Hamorrhagie, die erst durch eine angiografische Embolisation der anterioren Bundel der A. iliaca interna bds. in Kombination mit einer erneuten medikamentosen uterotonen und hamostaseologischen Therapie beherrscht wurde. Die Risikofaktoren und Ursachen einer rezidivierenden postpartalen Blutung werden diskutiert und die aktuellen Therapieempfehlungen im Rahmen eines interdisziplinaren Therapiealgorithmus fur die peripartale Blutung in unserer Klinik vorgestellt.

Long-term alcoholic patients have a fivefold higher risk of post-operative bleeding complications compared with non-alcoholic individuals. Serotonin increases and cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP) decrease platelet aggregation. We examined the platelet-rich plasma levels of these substances and agonist-induced platelet aggregation in long-term alcoholic patients before and after surgery. Thirty-three consecutive patients (13 long-term alcoholics and 20 non-alcoholics) scheduled for tumour resections of the upper digestive tract were included in the study. The levels of cAMP were significantly decreased before and after surgery in long-term alcoholic patients, but there were no significant differences in cGMP and serotonin levels in alcoholic compared with non-alcoholic patients. In contrast to previous studies, no significantly altered aggregation responses in long-term alcoholics were found. A possible explanation is decreased inhibition through diminished cAMP levels; cGMP and serotonin do not seem to influence peri-operative haemostasis.

OBJECTIVE To evaluate the association between the intraoperative and postoperative application of different quantities of fluids and the incidence of postoperative complications after "fast-track"-colonic surgery. METHODS We performed a retrospective analysis of 136 patients undergoing elective "fast-track" colonic surgery (sigma resection and right hemicolectomy). Data collection in regard of fluid administration during surgery and in the post anaesthesia care unit (PACU) was based on anaesthesia charts and a prospectively generated surgery database. Classification into three volume groups (up to 3500 ml = group 1, 3500 - 5500 ml = group 2, more than 5500 ml = group 3). Basic patient characteristics, pre-existing conditions, type and duration of surgery and anastomoses were documented. We analysed the incidence of postoperative complications such as wound infections, anastomotic leak, bleeding, bowel obstruction, cardiovascular failure, hypertension, pulmonary failure, pneumonia, renal failure, urinary tract infection, neurological and psychiatric complications in the different volume groups. RESULTS 115 patients were infused with up to 3500 mLs of fluids, 19 patients received more than 3500 mLs, two patients were infused with 6000 ml and 7500 mLs, respectively. This was in median 36 ml/kg in the restrictive and 53 ml/kg in the higher volume groups (group 2 and 3 together), respectively. The duration of surgery and anaesthesia was significantly different between both fluid groups (p = 0,023). In a logistic regression model only intraoperative blood loss was independently associated with the volume of infused fluid (OR 0,393, 95 % CI 1.028 - 2.306, p < 0.01). The rate of postoperative complications was not different between groups (p = 0,228). CONCLUSION The incidence of postoperative complications was not different between patients who were infused 36 ml/kg or 53 ml/kg of fluids during surgery and post anaesthesia care unit stay.

SummaryCardiac surgery carries the risk of significant blood loss requiring the transfusion of blood products. In addition to such blood loss, international studies have shown that severe bleeding necessitating re-operation occurs in 3–5% of patients. Morbidity and mortality are significantly increased, so effective and safe haemostatic measures will decisively improve outcome of patients.Recombinant activated factor VII (rFVIIa) has been approved for the treatment of patients with inhibitor haemophilia, as well as with Glanzmann’s thrombasthenia and factor VII deficiency. Many publications have appeared in the last few years which report the successful and reliable use of rFVIIa for the treatment of refractory bleeding after cardiac surgery. This review presents the pathophysiological changes in the coagulation system which occur when a heart-lung machine is used and which have been blamed for an increased risk of bleeding in patients who have undergone cardiac surgery. Published experience with rFVIIa in paediatric and adult cardiac surgery is presented and discussed critically with regard to the efficacy and safety of its use.

ZusammenfassungHerzchirurgische Operationen sind mit dem Risiko verbunden, einen relevanten Blutverlust zu erleiden und eine Transfusion von Blutprodukten zu erhalten. Neben dem Blutverlust treten internationalen Studien zufolge schwere Blutungen, die eine Reoperation zur Blutstillung erfordern, bei 3-5% der Patienten auf. Die Morbidität und Mortalität ist signifikant erhöht, so dass eine effektive und sichere hämostatische Therapie die Prognose entscheidend verbessern kann.Rekombinanter aktivierter Faktor VII ist für die Therapie von Patienten mit Hemmkörper-Hämophilie sowie Thrombasthenie Glanzmann und Faktor-VII-Mangel zugelassen. In den vergangenen Jahren häufen sich die Publikationen, die über eine erfolgreiche und sichere Stillung von Blutungen nach herzchirurgischen Operationen berichten, die einer konventionellen Therapie gegenüber refraktär waren. Dieses Review stellt die pathophysiologischen Veränderungen des Gerinnungssystems, die der Anschluss an die Herz- Lungen-Maschine induziert und die für die Erklärung des erhöhten Blutungsrisikos herzchirurgischer Patienten herangezogen werden, dar. Die publizierten Erfahrungen mit rFVIIa in der Kinder- und Erwachsenen-Herzchirurgie werden dargestellt und hinsichtlich der Effektivität und Sicherheit kritisch diskutiert.

OBJECTIVE Platelet aggregation inhibitors, such as aspirin and clopidogrel, are associated with increased bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass. We investigated the impact of time between the last intake of aspirin and clopidogrel before CABG surgery and drainage loss, transfusion requirements and rate of reoperation. PATIENTS AND METHODS The records of patients who had coronary artery bypass graft surgery (CABG) were reviewed for intake of aspirin and clopidogrel within 7 days prior to surgery. Drainage loss, transfusion requirements and rate of reoperation for bleeding within 5 days after the operation, were recorded. RESULTS Out of 261 analysed patients, 225 patients (86.2 %) had no anti-platelet medication and 36 patients (13.8 %) were on aspirin and clopidogrel. Aspirin and clopidogrel, taken all until 2 days prior to operation, were associated with a significantly higher postoperative blood loss (1840 mL [1230 - 3710] vs. 280 mL [185 - 765], p = 0.005 for one day and 850 mL [345 - 1725] vs. 277 mL [165 - 778], p = 0.026, for 2 days prior to surgery). The trend showed that patients in the study group received more platelet concentrates (PC: 5.3 % vs. 13.9 %, p = 0.067). The rate of reoperation for bleeding was not different ( p = 0.25). CONCLUSION Aspirin and clopidogrel up to 2 days prior to CABG were associated with a significantly higher postoperative drainage loss.

Die gemas dem Transfusionsgesetz (1998) entwickelten und eingesetzten Masnahmen zur Qualitatssicherung Hamotherapie an der Charite Campus Mitte werden dargestellt und diskutiert. In einer 3-Jahres-Analyse (2001–2003) werden die Rucklaufquote der Transfusionsbegleitscheine (Qualitat der Anwendungsdokumentation) und der Blutprodukteverfall mit den im Jahr 2001 ermittelten Basiswerten verglichen. Anhand der Auswertung der Selbstinspektionsbogen der transfundierenden Kliniken werden die Verbesserungspotenziale von 2001–2003 verglichen. Die Rucklaufquote der Transfusionsbegleitscheine von 90% (2001) erhohte sich auf 98,3% (2002) und blieb 2003 konstant. Der Verfall von Blutprodukten wurde von 5,1% (2001) auf 1,7% (2003) gesenkt; hierdurch reduzierten sich die Kosten von 140.000 EUR auf 50.000 EUR. Anhaltend hoher Verbesserungsbedarf bestand bei der jahrlich vorgeschriebenen Fortbildung der arztlichen Mitarbeiter uber das Qualitatsmanagement bzw. -handbuch. Die Selbstinspektion der transfundierenden Kliniken offenbart noch Verbesserungspotenziale, obwohl die Anwendungsdokumentation der durchgefuhrten Transfusionen verbessert und der Verfall von Blutprodukten sowie die dadurch verursachten Kosten erheblich reduziert wurden.