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Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Introduction: Pain management for trauma in the extreme environment is vital for both casualty comfort and aiding safe extrication. However, adequate pain management in a resource-limited environment can be challenging and is often limited. We conducted a scoping review of the use of regional anesthesia in the prehospital environment, evaluating which regional anesthetic procedure was performed for various indications, their efficacy, and the type of healthcare provider delivering the anesthetic., Methods: A PRISMA-guided systematic literature review was conducted of Medline, Embase, and Cochrane databases for studies reporting the use of regional anesthesia in the prehospital environment published before June 30, 2022., Results: Thirty studies met the criteria and were included in the review. The most common types of regional anesthesia were fascia-iliaca compartment block ( n  = 317, from 12 studies) and femoral nerve block ( n  = 210, from 8 studies), along with various other blocks for a range of indications. These blocks had good efficacy and a low-risk profile and could be delivered by a wide range of healthcare providers., Conclusions: Regional anesthesia is an effective and non-resource-heavy pain management tool in prehospital environments, which may be applicable to austere settings. It can cover a wide range of injuries and can avoid systemic complications for casualties that may already be challenging to manage in out-of-hospital settings. Additionally, regional anesthesia can be effectively delivered by a wide range of providers. This review provides a holistic summary of pain management using regional anesthesia in the prehospital environment, with a discussion on its potential use in more extreme settings.

Intravenous cannulation is performed on nearly every patient presenting for an anesthetic. Complications of the procedure include infiltration and extravasation, which can have a varied impact on the patient. Here, we present a case of severe intravenous (IV) extravasation, resulting in compartment syndrome of the hand. Rather than treating the compartment syndrome with fasciotomies as is standard, we utilized compression therapy via an Esmarch surgical dressing wrapped distal to proximal on the effected limb, which resulted in marked decrease in swelling and return of perfusion to the hand., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: With the "Artemis"-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency - cardiac arrest., Methods: After the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to "MEDLINE". Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology., Results: We recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved., Discussion: CPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.

By the end of the year 2016, approximately 3 billion people worldwide travelled by commercial air transport. Between 1 out of 14,000 and 1 out of 50,000 passengers will experience acute medical problems/emergencies during a flight (i.e., in-flight medical emergency). Cardiac arrest accounts for 0.3% of all in-flight medical emergencies. So far, no specific guideline exists for the management and treatment of in-flight cardiac arrest (IFCA). A task force with clinical and investigational expertise in aviation, aviation medicine, and emergency medicine was created to develop a consensus based on scientific evidence and compiled a guideline for the management and treatment of in-flight cardiac arrests. Using the GRADE, RAND, and DELPHI methods, a systematic literature search was performed in PubMed. Specific recommendations have been developed for the treatment of IFCA. A total of 29 specific recommendations for the treatment and management of in-flight cardiac arrests were generated. The main recommendations included emergency equipments as well as communication of the emergency. Training of the crew is of utmost importance, and should ideally have a focus on CPR in aircraft. The decision for a diversion should be considered very carefully.

Administration of oxygen is one of the most common interventions in medicine. Previous research showed that differential regulated proteins could be linked to hyperoxia-associated signaling cascades in different tissues. However, it still remains unclear which signaling pathways are activated by hyperoxia. The present study analyses hyperoxia-induced protein alterations in lung, brain, and kidney tissue using a proteomic and bioinformatic approach. Pooled data of 36 Wistar rats exposed to hyperoxia were used. To identify possible hyperoxia biomarkers, and to evaluate the relationship between protein alterations in hyperoxia affected organs and blood, proteomics data from brain, lung, and kidney were analyzed. Functional network analyses (IPA ® , PathwaysStudio ® , and GENEmania ® ) in combination with hierarchical cluster analysis (Perseus ® ) was used to identify relevant pathways and key proteins. Data of 54 2D-gels with more than 2500 significantly regulated spots per gel were collected. Thirty-eight differentially expressed proteins were identified and consecutively analyzed by bioinformatic methods. Most differences between hyperoxia and normoxia (21 proteins up-regulated, 17 proteins down-regulated) were found immediately after hyperoxia (15 protein spots), followed by day 3 (13 spots), and day 7 (10 spots). A highly significant association with inflammation and the inflammatory response was found. Cell proliferation, oxidative stress, apoptosis and cell death as well as cellular functions were revealed to be affected. Three hours of hyperoxia resulted in significant alterations of protein expression in different organs (brain, lung, kidney) up to seven days after exposure. Further studies are required to interpret the relevance of protein alterations in signaling cascades during/after hyperoxia.

Background: Data on the incidence of in-flight medical emergencies on-board civil aircraft are uncommon and rarely published. Such data could provide information regarding required medical equipment on-board aircraft and requisite training for cabin crew. The aim of the present study was to gather data on the incidences, nature, and medical equipment for in-flight medical emergencies by way of a survey of physician members of a German aerospace medical society., Materials and Methods: Using unipark.de (QuestBack GmbH, Cologne, Germany), an online survey was developed and used to gather specific information. Members of the German Society for Aviation and Space Medicine (Deutsche Gesellschaft für Luft- und Raumfahrtmedizin e.V.; DGLRM) were invited to participate in the survey during a 4-week period (21 March 2015 to 20 April 2015). Chi-square test was used for statistical analysis ( p <0.05 was considered significant)., Results: Altogether, 121 members of the society responded to the survey (n=335 sent out). Of the 121 respondents, n=54 (44.6%) of the participants (89.9% male and 10.1% female; mean age, 54.1 years; n=121) were involved in at least one in-flight medical emergency. Demographic parameters in this survey were in concordance with the society members' demographics. The mean duration of flights was 5.7 hours and the respondents performed 7.1 airline flights per year (median). Cardiovascular (40.0%) and neurological disorders (17.8%) were the most frequent diagnoses. The medical equipment (78.7%) provided was sufficient. An emergency diversion was undertaken in 10.6% of the cases. Although using a different method of data acquisition, this survey confirms previous data on the nature of emergencies and gives plausible numbers., Conclusion: Our data strongly argue for the establishment of a standardized database for recording the incidence and nature of in-flight medical emergencies. Such a database could inform on required medical equipment and cabin crew training., Competing Interests: Disclosure The authors have no conflicts of interest in this work.

Background . Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated host response to infection. Sepsis is the dominant cause of acute kidney injury (AKI), accounting for nearly 50% of episodes of acute renal failure. Signaling cascades and pathways within the kidney are largely unknown and analysis of these molecular mechanisms may enhance knowledge on pathophysiology and possible therapeutic options. Material and Methods . 26 male Wistar rats were assigned to either a sham group (control, N = 6) or sepsis group ( N = 20; cecal ligature and puncture model, 24 and 48 hours after CLP). Surviving rats ( n = 12) were decapitated at 24 hours (early phase; n = 6) or 48 hours (late phase; n = 6) after CLP and kidneys removed for proteomic analysis. 2D-DIGE and DeCyder 2D software ( t -test, P < 0.01) were used for analysis of significantly regulated protein spots. MALDI-TOF in combination with peptide mass fingerprinting (PMF) as well as Western Blot analysis was used for protein identification. Bioinformatic network analyses (STRING, GeneMania, and PCViz) were used to describe protein-protein interactions. Results . 12 spots were identified with significantly altered proteins ( P < 0.01) in the three analyzed groups. Two spots could not be identified. Four different proteins were found significantly changed among the groups: major urinary protein (MUP5), cytochrome c oxidase subunit B (COX5b), myosin-6 (MYH6), and myosin-7 (MYH7). A significant correlation with the proteins was found for mitochondrial energy production and electron transport. Conclusions . COX5B could be a promising biomarker candidate since a significant association was found during experimental sepsis in the present study. For future research, COX5B should be evaluated as a biomarker in both human urine and serum to identify sepsis., Competing Interests: The authors declare no conflict of interests.

Background: Since astronauts are selected carefully, are usually young, and are intensively observed before and during training, relevant medical problems are rare. Nevertheless, there is a certain risk for a cardiac arrest in space requiring cardiopulmonary resuscitation (CPR). Up to now, there are 5 known techniques to perform CPR in microgravity. The aim of the present study was to analyze different techniques for CPR during microgravity about quality of CPR., Material and Methods: To identify relevant publications on CPR quality in microgravity, a systematic analysis with defined searching criteria was performed in the PubMed database (http://www.pubmed.com). For analysis, the keywords ("reanimation" or "CPR" or "resuscitation") and ("space" or "microgravity" or "weightlessness") and the specific names of the techniques ("Standard-technique" or "Straddling-manoeuvre" or "Reverse-bear-hug-technique" or "Evetts-Russomano-technique" or "Hand-stand-technique") were used. To compare quality and effectiveness of different techniques, we used the compression product (CP), a mathematical estimation for cardiac output., Results: Using the predefined keywords for literature search, 4 different publications were identified (parabolic flight or under simulated conditions on earth) dealing with CPR efforts in microgravity and giving specific numbers. No study was performed under real-space conditions. Regarding compression depth, the handstand (HS) technique as well as the reverse bear hug (RBH) technique met parameters of the guidelines for CPR in 1G environments best (HS ratio, 0.91 ± 0.07; RBH ratio, 0.82 ± 0.13). Concerning compression rate, 4 of 5 techniques reached the required compression rate (ratio: HS, 1.08 ± 0.11; Evetts-Russomano [ER], 1.01 ± 0.06; standard side straddle, 1.00 ± 0.03; and straddling maneuver, 1.03 ± 0.12). The RBH method did not meet the required criteria (0.89 ± 0.09). The HS method showed the highest cardiac output (69.3% above the required CP), followed by the ER technique (33.0% above the required CP)., Conclusions: Concerning CPR quality, the HS seems to be most effective to treat a cardiac arrest. In some environmental conditions where this technique cannot be used, the ER technique is a good alternative because CPR quality is only slightly lower., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: In renal tissue as well as in other organs, supranormal oxygen pressure may lead to deleterious consequences on a cellular level. Additionally, hyperoxia-induced effect in cells and related free radicals may potentially contribute to renal failure. The aim of this study was to analyze time-dependent alterations of rat kidney protein expression after short-term normobaric hyperoxia using proteomics and bioinformatic approaches., Material and Methods: N = 36 Wistar rats were randomized into six different groups: three groups with normobaric hyperoxia (exposure to 100% oxygen for 3 h) and three groups with normobaric normoxia (NN; room air). After hyperoxia exposure, kidneys were removed immediately, after 3 days and after 7 days. Kidney lysates were analyzed by two-dimensional gel electrophoresis followed by peptide mass fingerprinting using tandem mass spectrometry. Statistical analysis was performed with DeCyder 2D software (p < 0.01). Biological functions of differential regulated proteins were studied using functional network analysis (Ingenuity Pathways Analysis and PathwayStudio)., Results: Expression of 14 proteins was significantly altered (p < 0.01): eight proteins (MEP1A&#95;RAT, RSSA&#95;RAT, F16P1&#95;RAT, STML2&#95;RAT, BPNT1&#95;RAT, LGMN&#95;RAT, ATPA&#95;RAT, and VDAC1&#95;RAT) were downregulated and six proteins (MTUS1&#95;RAT, F16P1&#95;RAT, ACTG&#95;RAT, ACTB&#95;RAT, 2ABA&#95;RAT, and RAB1A&#95;RAT) were upregulated. Bioinformatic analyses revealed an association of regulated proteins with inflammation., Conclusions: Significant alterations in renal protein expression could be demonstrated for up to 7 days even after short-term hyperoxia. The identified proteins indicate an association with inflammation signaling cascades. MEP1A and VDAC1 could be promising candidates to identify hyperoxic injury in kidney cells.

Background: In this study, we evaluated the influence of propofol versus desflurane anesthesia in overweight patients on postoperative lung function and pulse oximetry values., Methods: We prospectively studied 134 patients with body mass indices of 25 to 35 kg/m(2) undergoing minor peripheral surgery lasting 40 to 120 minutes. Patients were randomly assigned to receive propofol (total IV anesthesia) or desflurane anesthesia via a tracheal tube targeting bispectral index values of 40 to 60. Premedication, adjuvant drug usage, and ventilation were standardized. We measured oxyhemoglobin saturation and lung function preoperatively (baseline), and at 10 minutes, 0.5 hour, 2 hours, and 24 hours after tracheal extubation. All values were measured with the patient supine, in a 30° head-up position. Changes from preoperative baseline values were first analyzed for the impact of body mass index and type of anesthesia using univariate methods, followed by linear regression and multivariate analysis of variance., Results: Within the first 2 hours after surgery, the propofol group displayed lower oxyhemoglobin saturation (at 2 hours, mean ± SD, 93.8% ± 2.0% vs 94.6% ± 2.1%; P < 0.007) and lung function (forced vital capacity, forced expiratory volume exhaled in 1 second [FEV(1)], peak expiratory flow, midexpiratory flow [MEF], forced inspiratory vital capacity, and peak inspiratory flow; between 11% and 20% larger reduction from baseline in the propofol group, all P < 0.001) compared with the desflurane group. Even 24 hours after surgery, FEV(1), peak expiratory flow, MEF, forced inspiratory vital capacity, and peak inspiratory flow were reduced more in the propofol group (all P < 0.01). At 2 hours after extubation, increasing obesity was associated with decreasing FEV(1) and MEF in patients anesthetized with propofol but not desflurane (P < 0.01)., Conclusion: We conclude that, for superficial surgical procedures of up to 120 minutes, maintenance of anesthesia with propofol impairs early postoperative lung function and pulse oximetry values more than with desflurane. Furthermore, increasing obesity decreases pulmonary function at 2 hours after propofol anesthesia but not after desflurane anesthesia.

Background: Fluid resuscitation after severe burns remains a challenging task particularly in the preclinical and early clinical phases. To facilitate volume substitution after burn trauma several formulae have been published and evaluated, nevertheless, the optimal formula has not yet been identified., Methods: A systematic PubMed search was performed to identify published formulae for fluid resuscitation after severe burns. The search terms "burn", "thermal", "treatment", "therapy" or "resuscitation", "fluid", "formula" and "adult", "pediatric" or "paediatric" were used in various combinations. Analysis was limited to the period from 01.01.1950 to 30.06.2010 and database entries in PubMed (http://www.pubmed.com). Additionally, references cited in the papers were analyzed and relevant publications were also included. Publications and formulae were assessed and classified by two independent investigators., Results: Within the specified time frame eight publications (five original contributions and three book chapters) were identified of which three formulae recommended colloid solutions, four recommended electrolyte solutions and one suggested hypertonic solutions within the first 24 h for fluid resuscitation. Only one formula specifically dealt with fluid resuscitation in infants., Conclusion: The identified formulae led to sometimes strikingly diverse calculations of resuscitation fluid volumes. Therefore their use should be monitored closely and clinical values included. Urine output is a well established individual parameter. Use of colloid and hypertonic solutions leads to a reduced total fluid volume but is still controversially discussed.

Background and Objective: Obesity aggravates the negative effects of general anaesthesia and surgery on the respiratory system, resulting in decreased functional residual capacity and expiratory reserve volume, and increased atelectasis and ventilation/perfusion (Va/Q) mismatch. High-inspired oxygen concentrations also promote atelectasis. This study compares the effects of perioperative inspired low-oxygen and high-oxygen concentrations on postoperative lung function and pulse oximetry values in moderately obese patients (BMI 25-35)., Methods: We prospectively studied 142 overweight patients, BMI 25-35, undergoing minor peripheral surgery; they were randomly allocated to receive either low-inspired or high-inspired oxygen concentrations during general anaesthesia. Premedication, general anaesthesia and respiratory patterns were standardized. Arterial oxygen saturation (pulse oximetry) was measured on air breathing. Inspiratory and expiratory lung functions were measured preoperatively (baseline) and at 10 min, 0.5, 2 and 24 h after extubation with the patient supine, in a 30 degrees head-up position. The two groups were compared using repeated-measure analysis of variance and t-test analysis., Results: The low-inspired oxygen group had significantly better arterial saturation during the first 24 h (P < 0.01). Mid-expiratory flow 25 values indicating small airway collapse were significantly better in the low-oxygen group at all measurements (P < 0.05)., Conclusion: We conclude that postoperative lung function and arterial saturation is better preserved by a low-oxygen strategy, although it is not clear whether this has clinical relevance for the prevention of postoperative pulmonary complications.

Background: Obesity is a well-established risk factor for perioperative pulmonary complications. Anaesthetic drugs and the effect of obesity on respiratory mechanics are responsible for these pathophysiological changes, but tracheal intubation with muscle relaxation may also contribute. This study evaluates the influence of airway management, i.e. intubation vs. laryngeal mask airway (LMA), on postoperative lung volumes and arterial oxygen saturation in the early postoperative period., Methods: We prospectively studied 134 moderately obese patients (BMI 30) undergoing minor peripheral surgery. They were randomly assigned to orotracheal intubation or LMA during general anaesthesia with mechanical ventilation. Premedication, general anaesthesia and respiratory settings were standardized. While breathing air, we measured arterial oxygen saturation by pulse oximetry. Inspiratory and expiratory lung function was measured preoperatively (baseline) and at 10 min, 0.5, 2 and 24 h after extubation, with the patient supine, in a 30 degrees head-up position. The two groups were compared using repeated-measure analysis of variance (ANOVA) and t-test analysis. Statistical significance was considered to be P<0.05., Results: Postoperative pulmonary mechanical function was significantly reduced in both groups compared with preoperative values. However, within the first 24 h, lung function tests and oxygen saturation were significantly better in the LMA group (P<0.001; ANOVA)., Conclusions: In moderately obese patients undergoing minor surgery, use of the LMA may be preferable to orotracheal intubation with respect to postoperative saturation and lung function.