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Background: Patient Blood Management (PBM) is a patient-centred, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood whilst promoting patient safety and empowerment. The effectiveness and safety of PBM over a longer period have not yet been investigated., Methods: We performed a prospectively designed, multicentre follow-up study with non-inferiority design. Data were retrospectively extracted case-based from electronic hospital information systems. All in-hospital patients (≥18 yr) undergoing surgery and discharged between January 1, 2010 and December 31, 2019 were included in the analysis. The PBM programme focused on three domains: preoperative optimisation of haemoglobin concentrations, blood-sparing techniques, and guideline adherence/standardisation of allogeneic blood product transfusions. The outcomes were utilisation of blood products, composite endpoint of in-hospital mortality and postoperative complications (myocardial infarction/ischaemic stroke/acute renal failure with renal replacement therapy/sepsis/pneumonia), anaemia rate at admission and discharge, and hospital length of stay., Results: A total of 1 201 817 (pre-PBM: n=441 082 vs PBM: n=760 735) patients from 14 (five university/nine non-university) hospitals were analysed. Implementation of PBM resulted in a substantial reduction of red blood cell utilisation. The mean number of red blood cell units transfused per 1000 patients was 547 in the PBM cohort vs 635 in the pre-PBM cohort (relative reduction of 13.9%). The red blood cell transfusion rate was significantly lower (P<0.001) with odds ratio 0.86 (0.85-0.87). The composite endpoint was 5.8% in the PBM vs 5.6% in the pre-PBM cohort. The non-inferiority aim (safety of PBM) was achieved (P<0.001)., Conclusions: Analysis of >1 million surgical patients showed that the non-inferiority condition (safety of Patient Blood Management) was fulfilled, and PBM was superior with respect to red blood cell transfusion., Clinical Trial Registration: NCT02147795., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: This study tested the influence of continuous medication (more than 4 weeks) with prednisolone on a rocuronium-induced neuromuscular block., Methods: The time course of a rocuronium-induced neuromuscular blockade (0.3 mg/kg) was investigated in 40 patients with chronic inflammatory bowel disease undergoing elective abdominal surgery. The primary end point was the time from the start of injection of rocuronium until recovery of the TOF ratio to 0.9. Twenty patients received continuous medication with prednisolone (group A), and 20 were without glucocorticoid medication (group B). Additionally, another 20 patients without inflammatory bowel disease and without glucocorticoid medication served as control (group C)., Results: The onset time was prolonged in group A [253 (51.2) s] compared with group B [187 (61.3) s]. Twitch height at the onset of the block was higher in group A [16.5 (0-61)%] than that in group B [5.0 (0-33)%]. The duration to 25% twitch height was shorter in group A [12.6 (0-20.7) min] compared with group B [16.7 (0-25.3) min] and group C [16.9 (0-29.3) min]. The recovery to a train-of-four ratio of 0.9 was reduced in group A [25.7 (23-34.3) min] compared with group B [34.7 (32.7-44.2) min] and group C [36.5 (31.7-42.3) min]., Conclusions: Prednisolone treatment in patients with inflammatory bowel disease is associated with a delayed onset and a shorter duration of action of rocuronium. The presence of an inflammatory bowel disease did not influence the neuromuscular block.

Background: Corticosteroids interact with neuromuscular blocking agents. However, experimental data are contradictory: enhancement and attenuation of the neuromuscular block has been observed. This study tested the influence of long-term medication with prednisolone on atracurium-induced neuromuscular block., Methods: Sixty patients with chronic inflammatory bowel disease undergoing elective abdominal surgery were investigated. Thirty patients received a long-term medication with prednisolone (Group A) and 30 were without corticoid medication (Group B). Additionally, another 30 patients without inflammatory bowel disease and without corticoid medication served as control (Group C). The following parameters of an atracurium-induced neuromuscular block (0.25 mg kg(-1)) were measured: onset time, maximum block, recovery to 25% first twitch height, recovery index (time from 25% until 75% recovery of first twitch), duration to recovery to a train-of-four (TOF) rate of 0.7 and 0.9., Results: The groups did not differ with regard to onset time, maximum block, and recovery index. The duration to 25% twitch height was significantly lower in Group A [18.1 (0-30.7) min] compared with Group B [23.5 (0-36.7) min; P<0.05]. Duration to a TOF rate of 0.7 and 0.9, respectively, were significantly reduced in Group A [36.1 (7.9) and 40.9 (9.0 min)] compared with Group B [47.9 (7.6) and 53.4 (9.2) min; P<0.001]., Conclusions: Long-term medication with prednisolone resulted in a shorter duration of an atracurium-induced neuromuscular block in patients with Crohn's disease or ulcerative colitis. The presence of the inflammatory bowel disease did not influence the time course of the neuromuscular block.

Background: Hypertonic-hyperoncotic solutions may be an effective treatment for systemic inflammatory response syndrome (SIRS). With regard to the immunomodulatory effects of these drugs, previous studies demonstrated controversial results. Therefore, the present study investigated the influence of different hyperoncotic and hypertonic-hyperoncotic solutions on polymorphonuclear neutrophil leukocyte (PMNL) count, elastase and superoxide-anion production in patients undergoing elective coronary artery bypass grafting (CABG) with cardiopulmonary bypass., Methods: Fifty patients scheduled for elective CABG with cardiopulmonary bypass were randomly assigned to five groups: (i) NaCl 0.9%, 750 ml/m(2) body surface area (BSA); (ii) hydroxyethylic starch 10%, 250 ml/m(2) BSA and NaCl 0.9%, 400 ml/m(2) BSA; (iii) dextran 10%, 250 ml/m(2) BSA and NaCl 0.9%, 300 ml/m(2) BSA; (iv) hypertonic sodium chloride 7.2%/hyperoncotic hydroxyethylic starch 10%, 150 ml/m(2) BSA; and (v) hypertonic sodium chloride 7.2%/hyperoncotic dextran 10%, 150 ml/m(2) BSA. Blood samples were drawn from arterial, central venous and coronary artery sinus catheters peri-operatively. PMNL count, superoxide-anion production and elastase were recorded., Results: PMNL counts and elastase activity increased in all groups after reperfusion. Superoxide-anion production showed only minor changes. Between groups, no significant differences were demonstrated., Conclusions: Infusion of clinically relevant doses of hypertonic-hyperoncotic solution did not affect PMNL count, elastase- or superoxide-anion production during elective CABG with cardiopulmonary bypass.

This study was designed to assess the pCO(2) accuracy of portable mainstream (Tidal Wave, Novametrix; Propaq 106, Protocol) and sidestream capnometers (Capnocheck 8200, BCI; Capnocount mini, Weinmann; NPB-75, Nellcor Puritan Bennett; SC-210, Pryon) with respect to international standards and preclinical emergency conditions. Measurements were performed under temperature conditions of +22 degrees C and -20 degrees C using dry gas mixtures with different CO(2) concentrations (STPD) and in patients ventilated with pure oxygen (BTPS). Accuracy presented to be between +1% (Capnocheck) and +12% (Propaq) (STPD) and between -0.4% (Capnocheck) and +11% (Tidal Wave) (BTPS). The measurements were affected by low ambient temperature only in the NPB-75 (+15%). Our results indicate that portable quantitative capnometers are able to fulfill accuracy requirements as requested by international standards but can be affected by changing ambient temperatures.

Objective: Using hyperoncotic colloids as volume replacement to provide haemodynamic stability appears to be a suitable approach to diminish fluid overload and subsequent interstitial edema during cardiac surgery. The aim of the present study was to investigate for the first time the haemodynamic effects following preoperative haemodilution with different hypertonic hyperoncotic colloid solutions in patients undergoing coronary artery bypass grafting., Methods: A total of 43 patients with normal left ventricular ejection fraction, undergoing elective coronary artery bypass grafting received preoperatively after induction of anaesthesia according to randomisation the following solutions: 1: 750 ml/m(2) (body surface area) NaCl 0.9% ( n=10, control group, NACL), 2: 250 ml/m(2) 10% HES 200/0.5 plus 400 ml/m(2) NaCl 0.9% ( n=9, HES), 3: 250 ml/m(2) 10% dextran 40 plus 300 ml/m(2) NaCl 0.9% ( n=8, DEX), 4: 150 ml/m(2) hypertonic NaCl (7.2%) 10% HES 200/0.5 (n=8, HYPER-HES), 5: 150 ml/m(2) hypertonic NaCl (7.2%) 10% dextran 60 ( n=8, HYPER-DEX). Haemodynamic measurements were performed immediately before and 15 min after haemodilution and up to 60 min after termination of extracorporeal circulation in 10 min intervals. Fluid balances were calculated separately, during the time period of surgery, postoperatively up to 24 h after termination of surgery, and during the course of extracorporeal circulation., Results: After haemodilution with colloid solutions, a marked increase was observed in all patients and with HYPER-HES and HYPER-DEX a statistically significant increase in cardiac index (CI: +38%, +54%), stroke volume index (SVI: +42%, +40%), and oxygen availability (DO2: +34%; +41%), respectively, was observed during the pre-bypass period. At the same time right and left ventricular filling pressures increased slightly in all patients but these changes did not differ among the treatment groups. Heart rate and mean arterial pressure remained almost unchanged in all groups. The amount of crystalloid solutions required by the patients during surgery was markedly decreased with HES and DEX and significantly decreased with HYPER-HES and HYPER-DEX (1,013+/-341 ml/m(2), 1,096+/-234 ml/m(2)) compared to the control group NACL (1629+/-426 ml/m(2)). Serum sodium concentrations increased with HYPER-HES and HYPER-DEX to maximal values of 150+/-3 mmol/l and 149+/-4 mmol/l, respectively (baseline 141+/-3 mmol/l, 141+/-1 mmol/l), Conclusions: Compared to isotonic saline solution, preoperative volume replacement with hyperoncotic colloids improves haemodynamic conditions during the pre-bypass period in patients with normal left ventricular function undergoing coronary artery bypass grafting. Additionally intraoperative crystalloid solution requirements are reduced. The volume saving effects are increased with administration of hyperoncotic colloids in a preparation with hypertonic saline solution, whereas the choice of the colloid, either hydroxyethyl starch or dextran seems to be of minor importance.

Objective: Procalcitonin (PCT) is currently recommended as a suitable parameter to detect and to evaluate the course of bacterial, fungal or parasitic infections. However, recent studies provide evidence that surgical trauma and humoral mediators of inflammation, respectively,may induce PCT synthesis, thereby reducing the validity and reliability of PCT as an "infection-monitoring" parameter. The aim of the present study was to assess and to compare PCT and CRP (C-reactive protein) plasma concentrations in patients presenting without infection following different types of surgery in the absence or presence of a systemic inflammatory response syndrome (SIRS)., Methods: PCT and CRP plasma concentrations were assessed daily on postoperative days 1-5 and maximal values were determined in 94 patients. The patients were allocated to four groups of different types of surgery as follows: A: minor, primarily aseptic surgery, B: major abdominal surgery, C: major vascular surgery and D: thoracic surgery including esophagectomy. All categories were divided into two subgroups representing patients with and without SIRS, respectively. RESULTS. PCT plasma concentrations increased moderately compared to normal values in 21% of patients after minor and aseptic surgery (A), in 27% and 41% after major vascular (C) and thoracic (D) surgery, respectively, and in 65% of patients after major abdominal (B) surgery. The difference between PCT concentrations in patients undergoing major abdominal surgery and the patients after minor, aseptic surgery was significant ( p<0,05: A vs. B). Comparing the patients presenting with or without systemic inflammatory response (SIRS), no significant differences in PCT concentrations between groups could be observed. In the majority of patients PCT values rose to peak levels on the first and second postoperative days, followed by a rapid decline based on the plasma half-life of PCT. In contrast, postoperative CRP plasma concentrations were markedly elevated above normal values in all investigated patients during the whole observation period. Between-categories statistical analysis revealed significant differences comparing patients undergoing minor and aseptic surgery with patients after major vascular, and thoracic surgery, respectively ( p<0,05,A vs.C, D). CRP concentrations were significantly increased in patients with systemic inflammatory response compared to patients with normal postoperative course in surgical categories B, C, and D, respectively ( p<0,05)., Conclusions: Postoperative PCT plasma concentrations in patients presenting without signs of infection are largely influenced by the type of surgical procedure. During the first and second postoperative day PCT concentrations are more frequently elevated in patients after major abdominal, major vascular and thoracic surgery compared to patients undergoing minor, aseptic operations. Thus an "infection monitoring" considering PCT value analysis during the postoperative course may transiently be impeded after major and particularly after intestinal surgery during the first 2 days postoperatively, whereas it appears not to be substantially affected by the presence or absence of systemic inflammatory response.

We investigated the analgesic effect and the neurological recovery time after administration of remifentanil in mechanically ventilated patients in an intensive care unit. Twenty patients, after trauma or major surgery with no intracranial pathology, were randomized to receive either remifentanil/propofol (n=10) or sufentanil/propofol (n=10). A sedation score and a simplified pain score were used to assess adequate sedation and analgesia. Medication was temporarily stopped after 24 h. Immediately before and 10 and 30 min after, the degree of sedation and pain score were evaluated. Adequate analgesia and sedation was achieved with remifentanil 10.6 microg kg(-1) h(-1) and propofol 2.1 mg kg(-1) h(-1), or sufentanil 0.5 microg kg(-1) h(-1) and propofol 1.3 mg kg(-1) h(-1). The difference in propofol dose between groups was significant. Ten minutes after terminating the medication, the degree of sedation decreased significantly after remifentanil and all patients could follow simple commands. During the following 20 min, all patients with remifentanil emerged from sedation and complained of considerable pain. By contrast, in the sufentanil group, only six (7) responded to commands after 10 (30) min and their pain score remained essentially unchanged during the 30-min observation period. We conclude that, in contrast to sufentanil, remifentanil facilitates rapid emergence from analgesia and sedation, allowing a clinical neurological examination within 10-30 min in mechanically ventilated patients with no intracranial pathology.

Objective: In this phase 2 study gammahydroxybutyric acid-ethanolamide (GHB-ethanolamide) was compared with midazolam for sedation of patients in the intensive care unit (ICU). GHB-ethanolamide is a new derivative of gammahydroxybutyric acid, a drug commonly used for sedation in intensive care patients., Methods: A total of 29 non-intubated, spontaneously breathing patients following major surgery, were randomly assigned to 2 groups: group A (n = 14) received 150 mg/kg GHB-ethanolamide i.v. followed by 150 mg/kg/h. Group B (n = 15) received 0.025 mg/kg midazolam i.v. followed by 0.025 mg/kg/h. The degree of sedation was assessed over a 3-5 h period both clinically by the Ramsay Score and by the spectral frequency index (SFx), derived by continuous computerized EEG recording (CATEEM)., Results: EEG: the SFx showed a significantly deeper sedation compared to baseline values, 10, 60 and 120 min after start of sedation in the GHB-ethanolamide group. By contrast, no difference could be observed compared to baseline values in the midazolam group. A comparison between both groups showed a deeper sedation in the GHB group 60 and 120 min after start of sedation. The Ramsay Score increased from baseline values of 2.0 (2.0/2.0) to 3.0 (2.0/3.0) during sedation (Median (25th/75th percentile) and no significant differences could be observed between groups. In the Midazolam group the sedation of two patients had to be terminated because of side effects (Ramsay Score 6 and paradoxical, agitated reaction)., Conclusions: GHB-ethanolamide produces adequate sedation for extubated and spontaneously breathing ICU patients. The drug might be safer than midazolam with regards to side effects such as respiratory depression.