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Flow-controlled ventilation (FCV) enables precise determination of dynamic compliance due to a continuous flow coupled with direct tracheal pressure measurement. Thus, pressure settings can be adjusted accordingly in an individualised approach.The aim of this study was to compare gas exchange of individualised FCV to pressure-controlled ventilation (PCV) in a porcine model of simulated thoracic surgery requiring one-lung ventilation (OLV).Controlled interventional trial conducted on 16 domestic pigs.Animal operating facility at the Medical University of Innsbruck.Thoracic surgery was simulated with left-sided thoracotomy and subsequent collapse of the lung over a period of three hours. When using FCV, ventilation was performed with compliance-guided pressure settings. When using PCV, end-expiratory pressure was adapted to achieve best compliance with peak pressure adjusted to achieve a tidal volume of 6 ml kg -1 during OLV.Gas exchange was assessed by the Horowitz index (= P aO 2 /FIO 2 ) and CO 2 removal by the P aCO 2 value in relation to required respiratory minute volume.In the FCV group ( n = 8) normocapnia could be maintained throughout the OLV trial despite a significantly lower respiratory minute volume compared to the PCV group ( n = 8) (8.0 vs. 11.6, 95% confidence interval, CI -4.5 to -2.7 l min -1 ; P 0.001), whereas permissive hypercapnia had to be accepted in PCV ( P aCO 2 5.68 vs. 6.89, 95% CI -1.7 to -0.7 kPa; P 0.001). The Horowitz index was comparable in both groups but calculated mechanical power was significantly lower in FCV (7.5 vs. 22.0, 95% CI -17.2 to -11.8 J min -1 ; P 0.001).In this porcine study FCV maintained normocapnia during OLV, whereas permissive hypercapnia had to be accepted in PCV despite a substantially higher minute volume. Reducing exposure of the lungs to mechanical power applied by the ventilator in FCV offers a possible advantage for this mode of ventilation in terms of lung protection.

Background In pressure-controlled ventilation (PCV) a decelerating gas flow pattern occurs during inspiration and expiration. In contrast, flow-controlled ventilation (FCV) guarantees a continuous gas flow throughout the entire ventilation cycle where the inspiration and expiration phases are simply performed by a change of gas flow direction. Aim of this trial was to highlight the effects of different flow patterns on respiratory variables and gas exchange. Methods Anesthetized pigs were ventilated with either FCV or PCV for one hour and thereafter for 30 minutes each in a cross-over comparison. Both ventilation modes were set with a peak pressure of 15 cmH2O, positive end-expiratory pressure of 5 cmH2O, a respiratory rate of 20 /min and a fraction of inspired oxygen at 0.3. All respiratory variables were collected every 15 minutes. Results Tidal volume and respiratory minute volume were significantly lower in FCV (n=5) compared to PCV (n=5) animals (4.6 versus 6.6, MD -2.0 (95% CI -2.6 to -1.4) ml/kg; p2-removal as well as oxygenation was not inferior in FCV compared to PCV. Conclusion Mechanical ventilation with identical ventilator settings resulted in lower tidal volumes and consecutive minute volume in FCV compared to PCV. This finding can be explained physically by the continuous gas flow pattern in FCV which necessitates a lower alveolar pressure amplitude. Interestingly, gas exchange was comparable in both groups, which is suggestive of improved ventilation efficiency at a continuous gas flow pattern.

Atmospheric conditions that are typical for lightning are commonly represented by proxies such as cloud top height, cloud ice flux, CAPE times precipitation, or the lightning potential index. While these proxies generally deliver reasonable results, they often need to be adapted for local conditions in order to perform well. This suggests that there is a need for more complex and holistic proxies. Recent research confirms that the use of machine learning (ML) approaches for describing lightning is promising.In a previous study a deep learning model was trained on single spatiotemporal (30km x 30km x 1h) cells in the summer period of the years 2010--2018 and showed good results for the unseen test year 2019 within Austria. We now improve this model by using multiple neighboring vertical atmospheric columns to also address for horizontal moisture advection. Furthermore data of successive hours is used as input data to enable the model to capture the temporal development of atmospheric conditions such as the build-up and breakdown of convections.In this work we focus on the summer months June to August and use data from parts of Central Europe. This spatial domain is thought to be representative for Continental Europe since it covers mountainous aswell as coastal regions. We take raw ERA5 parameters beyond the tropopause enriched with a small amount of meta data such as the day of the year and the hour of the day for training. The quality of the resulting paramaterized model is then evaluated on Continental Europe to examine the generalization ability.Using parts of Central Europe to train the model, we evaluate its ability to generalize on unseen parts of Continental Europe using EUCLID data. Having a model that generalizes well is a building block for a retrospective analysis back into years where the structured recording of accurate lightning observations in a unified way was not established yet.

Knowledge about extreme values of severe hail plays an important role in engineering and insurance. The estimation of return levels of severe hail events is challenging, as hail is locally rare and documentation about hail events is not available in a unified way. For instance for the state of Austria GeoSphere provides radar based probabilities of hail (POH) and maxima of expected hail size (MEHS) that only span a period from 2010 onward.Based on this sparse data the application of classical extreme value theory, such as Block-Maxima or Peak over Threshold might be invalid. Instead we use a version of the metastatistical extreme value distribution (MEVD), which was shown to work reasonably well in the context of extreme precipitation events, even with a rather small number of available years used for the estimation in comparison to the recurrence time. More precisely we make an assumption about the underlying probability distribution of the daily maximum POH values. The parameters of the distribution are then modeled as smooth functions of the day of the year and the year of observation, thus employing the framework of generalized additive models for location, scale and shape (GAMLSS). Furthermore we add topographic information (longitude, latitude, altitude) to our model, resulting in a full spatiotemporal model across the whole domain of Austria, from which the return values of the POH, respectively MEHS are calculated.This framework allows for the incorporation of an arbitrary number of additional covariables, as long as they are available on the same grid as the desired output. To illustrate this we use the information of daily precipitation extremes to enrich the model with additional atmospheric information.

For the estimation of daily precipitation extremes, the metastatistical extreme value distribution (MEVD) is known to perform superior to classical approaches like the generalized extreme value distribution, especially for small sample lengths. This is due to the fact that the MEVD incorporates all ordinary rainfall events within a block rather than only the extremes, which then emerge from repeated sampling of ordinary events. For daily rainfall extremes, the MEVD combines the Weibull distribution of ordinary daily rainfall events and the number of wet days per year as additional random variable. The MEVD provides yearly distributional parameters, which makes it already capable of analyzing temporal trends in daily precipitation extremes.But still, the MEVD in its current formulation does not take into account the seasonal, i.e. sub-yearly character of ordinary precipitation events. This problem becomes apparent when events originating from fundamentally different precipitation regimes show very similar MEVD parameters.In this contribution we therefore propose to explicitly model both the temporal trend and interannual seasonality of daily rainfall extremes and present an explicitly non-stationary MEVD formulation which is called temporal MEVD or TMEV. The TMEV is then used to derive historical trends of rainfall extremes in Austria. It is shown that the 50-year return level of daily rainfall in Austria has significantly increased over the last 30 years at the majority of Austrian observation sites. Furthermore the temporal change of the extreme value distribution is analyzed with respect to seasonality.

BACKGROUND The effects of adrenaline on cerebral blood vessels during cardiopulmonary resuscitation (CPR) are not well understood. We developed an extracorporeal CPR model that maintains constant low systemic blood flow while allowing adrenaline-associated effects on cerebral vasculature to be assessed at different mean arterial pressure (MAP) levels independently of the effects on systemic blood flow. METHODS After eight minutes of cardiac arrest, low-flow extracorporeal life support (ECLS) (30 ml/kg/min) was started in fourteen pigs. After ten minutes, continuous adrenaline administration was started to achieve MAP values of 40 (n = 7) or 60 mmHg (n = 7). Measurements included intracranial pressure (ICP), cerebral perfusion pressure (CePP), laser-Doppler-derived regional cerebral blood flow (CBF), cerebral regional oxygen saturation (rSO2), brain tissue oxygen tension (PbtO2) and extracellular cerebral metabolites assessed by cerebral microdialysis. RESULTS During ECLS without adrenaline, regional CBF increased by only 5% (25th to 75th percentile: -3 to 14; p = 0.2642) and PbtO2 by 6% (0-15; p = 0.0073) despite a significant increase in MAP to 28 mmHg (25-30; p

The European Committee for Standardization defines zonings and calculation criteria for different European regions to assign snow loads for structural design. In the Alpine region these defaults are quite coarse; countries therefore use their own products, and inconsistencies at national borders are a common problem. A new methodology to derive a snow load map for Austria is presented, which is reproducible and could be used across borders. It is based on (i) modeling snow loads with the specially developed Δsnow model at 897 sophistically quality controlled snow depth series in Austria and neighboring countries and (ii) a generalized additive model where covariates and their combinations are represented by penalized regression splines, fitted to series of yearly snow load maxima derived in the first step. This results in spatially modeled snow load extremes. The new approach outperforms a standard smooth model and is much more accurate than the currently used Austrian snow load map when compared to the RMSE of the 50-year snow load return values through a cross-validation procedure. No zoning is necessary, and the new map's RMSE of station-wise estimated 50-year generalized extreme value (GEV) return levels gradually rises to 2.2 kN m−2 at an elevation of 2000 m. The bias is 0.18 kN m−2 and positive across all elevations. When restricting the range of validity of the new map to 2000 m elevation, negative bias values that significantly underestimate 50-year snow loads at a very small number of stations are the only objective problem that has to be solved before the new map can be proposed as a successor of the current Austrian snow load map.

Despite continuous improvement in minimally invasive surgery (MIS) and growing evidence for its superiority in procedures in various organ systems, a routinely application in patients with acute bowel obstruction (ABO) cannot be seen to date. Besides very general explanations for this attitude, not much is known about the decision process in a particular patient. This retrospective study aims at investigating surgeon- and patient-specific factors for or against MIS in acute bowel obstruction.A retrospective analysis of all patients undergoing either MIS or open surgery (OS) for ABO at a single center between 2009 and 2017 was performed. All available preoperative parameters were included in the analysis and subdivided into patient- (age, gender, BMI, previous abdominal procedures, inflammatory process, ASA score, bowel dilatation) and surgeon-specific (time of patient admission, senior surgeon performed the procedure or taught the case, availability of a surgical resident or junior doctor as assisting surgeon) factors. Statistical analysis was performed to reveal their influence on the surgeon's decision for or against MIS.Of 106 patients requiring surgical intervention, 57 were treated by OS (53.77%) and 49 by MIS (46.23%). Patients with a higher ASA score (ASA III) and a bowel width of ≥ 3.8 cm in preoperative radiologic imaging were more likely to undergo OS (p 0.01). Also, a late admission time to the hospital (x̄ = 14.78 h) was associated with OS (p = 0.01). Concerning previous abdominal surgical interventions, patients with prior appendectomy rather were assigned to MIS (p 0.01) whereas those with prior colectomy to OS (p 0.01).The choice of procedure in patients with bowel obstruction is a highly individualized decision. Whereas scientifically proven parameters, such as high age and BMI, had no influence on the decision process, impaired general health condition (ASA score), high bowel width, previous surgical intervention, and a late admission time influenced the decision process towards open surgery.Retrospectively registered with the German Clinical Trials Register: DRKS00021600.

Tyrol, a province of Austria with about 760,000 inhabitants, was one of the first regions in Europe, along with northern Italy, to be affected by the pandemic spread of the coronavirus in spring 2020. A lockdown with far-reaching restrictions in all areas of life occurred from 16 March 2020. Restrictions were imposed in the areas of gastronomy, trade and free mobility as well as in recreational sports. The ski resorts were closed and due to the strong winter tourism in Tyrol, this meant that about 340,000 people left the region. In the province of Tyrol comprehensive emergency medical care is provided by 13 ground-based emergency medical systems (NEF) in combination with air rescue (16 emergency medical helicopters, some of which are seasonal). Normally, this system provides emergency medical care for approx. 1 million people; however, in spring 2020 during the first lockdown, the number of people to be cared for was approx. 30% less. In order to protect the emergency medical teams as best as possible from infections and thus the system from failures, the Integrated Control Center Tyrol (Landesleitstelle Tirol GmbH) adapted the release order for emergency medical resources. The aim of the study is to describe the influence of the pandemic in spring 2020 on the emergency medical services in Tyrol in comparison to the three preceding years.A retrospective survey of all emergency helicopter missions and ground-based emergency physician missions in Tyrol in the period 15 March 2020-15 May 2020, as well as in the same period of the previous years 2017-2019, was conducted. Detailed figures on medical procedures and patient-related data were collected from 6 ÖAMTC helicopter bases. In addition, all ground-based emergency physician missions from all 13 physician systems including appeal mission diagnoses were collected in the same period.The total number of emergency helicopter missions and ground-based emergency physician missions showed a significant decrease during the observational period (67.3% and 39.8%, respectively). In the area of ground-based emergency medical resources, there was a significant increase in respiratory and CNS diseases during the observational period. The range of emergency helicopter missions showed a significant shift from sports and leisure missions to internal medicine and neurological emergencies and the duration of missions was significantly longer. The NACA score was higher with a significant decrease in NACA 3 scores in favor of NACA 4 and 5. The circulatory status of patients during the observational period was significantly more often documented as unstable. Hypertension, impending shock and circulatory arrest occurred more frequently in the trend. Cardiac massage, oxygen administration, circulatory drugs and specific monitoring were used more frequently in 2020. Analgesics were administered less frequently. In air rescue, there was no infection of rescue workers in the field.The first pandemic wave in Tyrol and the consecutive lockdown from 16 March 2020 had a massive impact on emergency medical care in Tyrol, both quantitatively and in terms of the spectrum of operations and emergency medical interventions. The decline in patient numbers was highly relevant, especially in air rescue and can be explained in part by the discontinuation of tourism, the general exit restrictions and the restrictive disengagement order. This decline primarily affected patients in the NACA 3 category and the analgesic administration measure. The patients treated had a higher NACA score and the emergency procedures were more extensive during the observational period. The measures to protect the emergency helicopter team from infections were presumably successful as no infections occurred.HINTERGRUND: Während der ersten Phase der COVID-19-Pandemie im Frühjahr 2020 erfolgte in Tirol (Österreich) ein Lockdown ab dem 16.03.2020 mit weitreichenden Einschränkungen in allen Lebensbereichen. Ziel der Untersuchung ist die Darstellung des Einflusses der Pandemie im Frühjahr 2020 auf die Notarzteinsätze in Tirol im Vergleich zu den 3 vorangehenden Jahren.Es erfolgte eine retrospektive Erhebung der gesamten Notarzthubschraubereinsätze und bodengebundenen Notarzteinsätze in Tirol im Zeitraum vom 15.03.2020 bis zum 15.05.2020 sowie in den gleichen Zeiträumen der Vorjahre 2017–2019. Detaillierte Zahlen zu medizinischem Vorgehen und patientenbezogene Daten wurden von 6 Hubschrauberstützpunkten des ÖAMTC erfasst. Außerdem wurden die Einsatzdiagnosen der bodengebundenen Notarztmittel erfasst.Die Gesamtzahl der Notarzthubschraubereinsätze und bodengebundenen Notarzteinsätze aller Stützpunkte zeigte im Beobachtungszeitraum einen signifikanten Rückgang. Das Einsatzspektrum der betrachteten Notarzthubschrauber zeigte eine signifikante Verschiebung hin zu internistischen und neurologischen Notfällen; der NACA-Score war höher. Analgetikagabe fand seltener statt. In der Luftrettung kam es zu keiner Ansteckung von Rettungskräften im Einsatzbetrieb.Die erste COVID-19-Pandemie-Welle im Frühjahr 2020 in Tirol zeigte sowohl quantitativ als auch in Bezug auf Einsatzspektrum und notärztliche Maßnahmen deutliche Auswirkungen auf die Notarzteinsätze. Der Rückgang der Patientenzahlen betraf v. a. die Luftrettung. Der Rückgang betraf primär Einsätze im Sport- und Freizeitbereich (NACA 3), allen voran die Maßnahme der Analgetikaverabreichung. Im bodengebundenen Bereich kam es zu einer Umverteilung der Notarzteinsätze auf die RTW bei gleicher Gesamtzahl der Rettungseinsätze.

Background The technical feasibility of transumbilical single-incision surgery (SIL) for pancreatic resections has been demonstrated. However, this technique is hampered by the limited degrees of freedom for instrument handling. Dual-incision laparoscopy (DIL) with an additional trocar may simplify dissection and allow drainage. Material and methods Between December 2009 and May 2017, 21 patients were treated with SIL (12/2009 to 01/2014) or DIL (02/2014 to 05/2017) pancreatic resection. All data were collected in a database and retrospectively analysed. Results Demographic parameters of the patients did not differ significantly in the DIL or the SIL group. No conversion to open surgery was required. No intraoperative complication occurred in either group. The surgical difficulty score was significantly higher in the SIL group (4.4 ± 1.56 vs 2.18 ± 1.95; p = .006). Postoperative serum amylase levels were higher (101.9 U/l ± 50.11 vs 48.91 U/l ± 35.20; p = .01) and return to normal levels (6.4 ± 9.66 days vs 2.09 ± 1.98 days; p = .045) was later in the SIL group. Three complications requiring radiological or surgical intervention were witnessed in the SIL group and one complication in the DIL group (p = .42). Conclusion DIL surgery is a safe and feasible alternative to SIL surgery, facilitating key steps of distal pancreatic tail resection.

Background The influence of adrenaline during cardiopulmonary resuscitation (CPR) on the neurological outcome of cardiac arrest survivors is unclear. As little is known about the pathophysiological effects of adrenaline on cerebral oxygen delivery and cerebral metabolism we investigated its effects on parameters of cerebral oxygenation and cerebral metabolism in a pig model of CPR. Methods Fourteen pigs were anesthetized, intubated and instrumented. After 5 min of cardiac arrest CPR was started and continued for 15 min. Animals were randomized to receive bolus injections of either 15 or 30 μg/kg adrenaline every 5 min after commencement of CPR. Results Measurements included mean arterial pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), cerebral regional oxygen saturation (rSO2), brain tissue oxygen tension (PbtO2), arterial and cerebral venous blood gases and cerebral microdialysis parameters, e.g. lactate/pyruvate ratio. Adrenaline induced a significant increase in MAP and CPP in all pigs. However, increases in MAP and CPP were short-lasting and tended to decrease with repetitive bolus administration. There was no statistical difference in any parameter of cerebral oxygenation or metabolism between study groups. Conclusions Both adrenaline doses resulted in short-lasting CPP peaks which did not translate into improved cerebral tissue oxygen tension and metabolism. Further studies are needed to determine whether other dosing regimens targeting a sustained increase in CPP, may lead to improved brain oxygenation and metabolism, thereby improving neurological outcome of cardiac arrest patients.

BACKGROUND Trauma-induced coagulopathy (TIC) substantially contributes to mortality in bleeding trauma patients. OBJECTIVE The aim of the study was to administer fibrinogen concentrate in the prehospital setting to improve blood clot stability in trauma patients bleeding or presumed to bleed. DESIGN A prospective, randomised, placebo-controlled, double-blinded, international clinical trial. SETTING This emergency care trial was conducted in 12 Helicopter Emergency Medical Services (HEMS) and Emergency Doctors' vehicles (NEF or NAW) and four trauma centres in Austria, Germany and Czech Republic between 2011 and 2015. PATIENTS A total of 53 evaluable trauma patients aged at least 18 years with major bleeding and in need of volume therapy were included, of whom 28 received fibrinogen concentrate and 25 received placebo. INTERVENTIONS Patients were allocated to receive either fibrinogen concentrate or placebo prehospital at the scene or during transportation to the study centre. MAIN OUTCOME MEASURES Primary outcome was the assessment of clot stability as reflected by maximum clot firmness in the FIBTEM assay (FIBTEM MCF) before and after administration of the study drug. RESULTS Median FIBTEM MCF decreased in the placebo group between baseline (before administration of study treatment) and admission to the Emergency Department, from a median of 12.5 [IQR 10.5 to 14] mm to 11 [9.5 to 13] mm (P = 0.0226), but increased in the FC Group from 13 [11 to 15] mm to 15 [13.5 to 17] mm (P = 0.0062). The median between-group difference in the change in FIBTEM MCF was 5 [3 to 7] mm (P

Purpose Progressive loss (sarcopenia) and fatty infiltration of muscle mass (myosteatosis) are well-established risk factors for an adverse clinical outcome in obese patients. Data concerning non-obese sarcopenic patients in oncologic surgery are scarce and heterogeneous. The aim of this study was to determine the impact of sarcopenia and myosteatosis in non-obese patients with cancer of the right colon on clinical outcome. Methods This study comprised 85 patients with a BMI 2, who underwent surgery for right colon cancer in a single center. Skeletal muscle area (SMA), visceral fat area (VFA), and myosteatosis were retrospectively assessed using preoperative abdominal CT images. Univariate und multivariate analysis was performed to evaluate the association between body composition, complications, and oncologic follow-up. Results Traditional risk factors such as visceral fat (p = 0.8653), BMI (p = 0.8033), myosteatosis (p = 0.7705), and sarcopenia (p = 0.3359) failed to show any impact on postoperative complications or early recurrence. In our cohort, the skeletal muscle index (SMI) was the only significant predictor for early cancer recurrence (p = 0.0467). Conclusion SMI is a significant prognostic factor for early cancer recurrence in non-obese colon cancer patients. Our study shows that conventional thresholds for sarcopenia and BMI do not seem to be reliable across various cohorts. Target prehabilitation programs could be useful to improve outcome after colorectal surgery. Trial Registration DRKS00014655, www.apps.who.int/trialsearch

Summary Background The COVID-19 pandemic caused an important reduction in surgical activities during the first wave. Aim of this retrospective time-trend analysis was to examine whether also during the second wave in fall and winter 2020/2021 surgical interventions decreased. Methods Absolut numbers and types of surgeries in a tertiary university hospital during the second COVID-19 wave in fall/winter 2020/2021 were collected from the surgical planning software and compared with the same time frame over the last 5 years. In a second step, the reduction of surgical interventions during the second wave was compared with the reduction of surgical procedures during the first wave in spring 2020 at the same hospital. Results Despite a higher 7‑day incidence of COVID-19 infection and a higher number of patients needing ICU treatment during the second wave, the reduction of surgical interventions was 3.22% compared to 65.29% during the first wave (p p p : 0.0007) and 47.59% compared to 3.89% (p Conclusion Better understanding of the disease, adequate supply of disposables and improved interdisciplinary day by day management of surgical and ICU resources may have contributed to this improvement.

Atmospheric environments favorable for lightning and convection are commonly represented by proxies or parameterizations based on expert knowledge such as CAPE, wind shears, charge separation, or combinations thereof. Recent developments in the field of machine learning, high resolution reanalyses, and accurate lightning observations open possibilities for identifying tailored proxies without prior expert knowledge. To identify vertical profiles favorable for lightning, a deep neural network links ERA5 vertical profiles of cloud physics, mass field variables and wind to lightning location data from the Austrian Lightning Detection & Information System (ALDIS), which has been transformed to a binary target variable labelling the ERA5 cells as lightning and no lightning cells. The ERA5 parameters are taken on model levels beyond the tropopause forming an input layer of approx. 670 features. The data of 2010 - 2018 serve as training/validation. On independent test data, 2019, the deep network outperforms a reference with features based on meteorological expertise. Shapley values highlight the atmospheric processes learned by the network which identifies cloud ice and snow content in the upper and mid-troposphere as relevant features. As these patterns correspond to the separation of charge in thunderstorm cloud, the deep learning model can serve as physically meaningful description of lightning.

Tigecycline is a novel glycylcycline broad-spectrum antibiotic offering good coverage for critically ill patients experiencing complicated infections. A known side effect is a coagulation disorder with distinct hypofibrinogenemia. To date, the information on possible risk factors and outcomes is sparse. Therefore, the aim of this study is to examine the time course of fibrinogen level changes during tigecycline therapy in critically ill patients. Moreover, we sought to identify risk factors for coagulopathy and to report on clinically important outcomes. We retrospectively reviewed all intensive care patients admitted to our General and Surgical Intensive Care Unit receiving tigecycline between 2010 and 2018. A total of 130 patients were stratified into two groups based on the extent of fibrinogen decrease. Patients with a greater fibrinogen decrease received a higher dose, a longer treatment and more dose changes of tigecycline, respectively. In regard to the underlying pathology, these patients showed higher inflammation markers as well as a slightly reduced liver synthesis capacity. We, therefore, conclude that such a fibrinogen decrease may be based upon further impairment of liver synthesis during severe inflammatory states. To decrease the risk of bleeding, cautious monitoring of coagulation in critically ill patients treated with high-dose tigecycline is warranted.

Innsbruck Medical University Hospital, Austria, provides the highest level of care for a region of approximately 1.8 million people. During the early COVID-19 outbreak in spring 2020 surgical activity was drastically reduced with the prime goal of preserving hospital capacities, especially intensive care beds. We conducted a retrospective analysis of surgical activities performed at Innsbruck Medical University Hospital during the lockdown period from March 15 to April 14, 2020 and compared these activities to the same period during the previous 5 years. Total surgical activity was reduced by 65.4% compared to the same period during the previous 5 years (p < 0.001); elective surgeries were reduced by 88.7%, acute surgeries by 35.3% and oncological surgeries by 47.8% compared to the previous 5 years (all p < 0.001). This dramatic decrease in acute and oncological surgeries can most likely be ascribed to the fact that many patients avoided health care facilities because of the strict stay-at-home policy and/or the fear of contracting SARS-CoV-2 in the hospital. In view of future waves, the population should be encouraged to seek medical help for acute symptoms and to attend cancer screening programs.

Fibrinogen supplementation is recommended for treatment of severe trauma hemorrhage. However, required dosages and aimed for post-treatment fibrinogen levels remain a matter of discussion. Within the published RETIC study, adult patients suffering trauma-induced coagulopathy were randomly assigned to receive fibrinogen concentrate (FC) as first-line (n = 50) or crossover rescue (n = 20) therapy. Depending on bodyweight, a single dose of 3, 4, 5, or 6 g FC was administered and repeated if necessary (FibA10 &lt, 9 mm). The dose-dependent response (changes in plasma fibrinogen and FibA10) was analyzed. Receiver operating characteristics (ROC) analysis regarding the need for massive transfusion and correlation analyses regarding fibrinogen concentrations and polymerization were performed. Median FC single doses amounted to 62.5 (57 to 66.66) mg.kg−1. One FC single-dose sufficiently corrected fibrinogen and FibA10 (median fibrinogen 213 mg.dL−1, median FibA10 11 mm) only in patients with baseline fibrinogen above 100 mg.dL−1 and FibA10 above 5 mm, repeated dosing was required in patients with lower baseline fibrinogen/FibA10. Fibrinogen increased by 83 or 107 mg.dL−1 and FibA10 by 4 or 4.5 mm after single or double dose of FC, respectively. ROC curve analysis revealed post-treatment fibrinogen levels under 204.5 mg.dL−1 to predict the need for massive transfusion (AUC 0.652, specificity: 0.667, sensitivity: 0.688). Baseline fibrinogen/FibA10 levels should be considered for FC dosing as only sufficiently corrected post-treatment levels limit transfusion requirements.

FXII deficiency results in spontaneous prolongation of activated partial thromboplastin time (aPTT), which is widely used to monitor thromboprophylaxis. Misinterpretation of spontaneously prolonged aPTT may result in omission of thromboembolic treatment or even unnecessary transfusion of blood products. This retrospective analysis was performed to calculate a threshold level of FXII resulting in aPTT prolongation. 79 critically ill patients with spontaneous prolongation of aPTT were included. A correlation analysis and a ROC curve for aPTT prolongation predicted by FXII level were created to find the FXII threshold level. Prolongation of aPTT was associated with disease severity. A significant inverse proportionality between FXII and aPTT was seen. A ROC curve for aPTT prolongation, predicted by FXII level (AUC 0.85; CI 0.76–0.93), revealed a FXII threshold level of 42.5%. Of our patients 50.6% experienced a FXII deficiency, in 80.0% of whom we found aPTT to be prolonged without a significantly higher bleeding rate. The FXII deficiency was more common in patients with higher SAPS3 scores, septic shock, transfusion of red blood cells and platelet concentrates as well as in patients receiving renal replacement therapy. Patients with a FXII deficiency and prolonged aPTT less often received anticoagulatory therapy although they were more severely ill. The rate of thromboembolic events was higher in these patients although the difference was not statistically significant. Of all patients with spontaneous aPTT prolongation 50.6% had a FXII level of 42.5% or less. Those patients received insufficient thromboembolic prophylaxis.

Background: Intraosseous access is a recommended alternative to venous access in emergencies. For its application, knowledge of the correct insertion depth is indispensable. We aimed to determine sex-specific differences on the appropriate insertion depth for intraosseous access in adults at the insertion sites most frequently used, namely the proximal and distal tibia and the proximal humerus. Methods: In this exploratory retrospective study, we measured thickness of soft tissue cover, cortex and cancellous bone along the puncture line on magnetic resonance images or computed tomography scans. Inclusion criteria were both sexes, 18–90 years of age and appropriate image quality. Primary outcome was the appropriate insertion depth to reach the cancellous bone for each sex. This was defined as the corridor between (i) the sum of the soft tissue cover and the cortex and (ii) the sum of (i) plus the diameter of the cancellous bone. Secondary outcomes were the differences in thickness of each layer between sexes. Results: In 179 females and males, the appropriate insertion depth was 32.5–45.5 mm and 20.5–42.0 mm in the proximal tibia, 14.5–30.5 mm and 16.5–34.5 mm in the distal tibia, and 27.5–52.5 mm and 26.0–56.5 mm in the proximal humerus. Although females had a thicker soft tissue cover (+6.8 mm [95% CI 3.7–10.1], p Conclusion: In adults, there are no sex-specific differences in the appropriate insertion depth for intraosseous access in the proximal or distal tibia or in the proximal humerus.

Pleural effusions are a common finding in critically ill patients and small bore chest drains (SBCD) are proven to be efficient for pleural drainage. The data on the potential benefits and risks of drainage remains controversial. We aimed to determine the cut-off volume for complications, to investigate the impact of pleural drainage and drained volume on clinically relevant outcomes. Medical records of all critically ill patients undergoing insertion of SBCD were retrospectively examined. We screened 13,003 chest radiographs and included 396 SBCD cases in the final analysis. SBCD drained on average 900 mL, with less amount in patients with complications (p = 0.003). A drainage volume of 975 mL in 24 h represented the optimal threshold for complications. Pneumothorax was the most frequent complication (4.5%), followed by bleeding (0.8%). Female and lighter-weighted patients experienced a higher risk for any complication. We observed an improvement in the arterial partial pressure of oxygen and respiratory quotient (p &lt, 0.001). We conclude that the small drainage volumes are associated with complications in critically ill patients—the more you drain, the safer the procedure gets. The use of SBCD is a safe and efficient procedure, further investigations regarding the higher rate of complications in female and lighter-weighted patients are desirable.

The European Committee for Standardization provides coarse rules for the estimation of snow load maps for structural design. European countries can apply their own methodologies, resulting in inconsistencies for the 50-year return level of snow load at national borders. Commonly used approaches base on more or less sophisticated interpolation of snow depths with a subsequent assignment of snow density, or spatial extreme value interpolation of snow load measurements. We propose a novel methodology for Austria, where snow load observations are not available. It is based on (1) modeling yearly snow load maxima with the specially developed ∆SNOW model, and (2) a generalized additive model, where explaining covariates and their combinations are represented by penalized regression splines, fitted to such derived snow load series. Results show an RMSE of 0.7 kN/m2, and a BIAS of -0.2 kN/m2 over all altitudes, thereby outperforming a smooth spatial extreme value model and the actual Austrian standard, when compared to locally estimated, “quasi-observed “ 50-year snow load maxima at 870 stations in and tightly around Austria.The new approach requires no zoning and provides a reproducible and transparent approach. Due to the relatively ease of use and snow depth measurements as single prerequisite, the method is applicable in other countries as well. Negative BIASes, that significantly underestimate 50-year snow loads at a small number of stations, are the only objective problem that has to be solved before the new map can be proposed as a successor of the actual Austrian snow load map.

BackgroundFlow-controlled ventilation is a novel ventilation method which allows to individualize ventilation according to dynamic lung mechanic limits based on direct tracheal pressure measurement at a stable constant gas flow during inspiration and expiration. The aim of this porcine study was to compare individualized flow-controlled ventilation (FCV) and current guideline-conform pressure-controlled ventilation (PCV) in long-term ventilation.MethodsAnesthetized pigs were ventilated with either FCV or PCV over a period of 10 h with a fixed FiO2of 0.3. FCV settings were individualized by compliance-guided positive end-expiratory pressure (PEEP) and peak pressure (Ppeak) titration. Flow was adjusted to maintain normocapnia and the inspiration to expiration ratio (I:E ratio) was set at 1:1. PCV was performed with a PEEP of 5 cm H2O andPpeakwas set to achieve a tidal volume (VT) of 7 ml/kg. The respiratory rate was adjusted to maintain normocapnia and the I:E ratio was set at 1:1.5. Repeated measurements during observation period were assessed by linear mixed-effects model.ResultsIn FCV (n = 6), respiratory minute volume was significantly reduced (6.0 vs 12.7, MD − 6.8 (− 8.2 to − 5.4) l/min;p n = 6). Oxygenation was improved in the FCV group (paO2119.8 vs 96.6, MD 23.2 (9.0 to 37.5) Torr; 15.97 vs 12.87, MD 3.10 (1.19 to 5.00) kPa;p = 0.010) and CO2removal was more efficient (paCO240.1 vs 44.9, MD − 4.7 (− 7.4 to − 2.0) Torr; 5.35 vs 5.98, MD − 0.63 (− 0.99 to − 0.27) kPa;p = 0.006).Ppeakand driving pressure were comparable in both groups, whereas PEEP was significantly lower in FCV (p = 0.002). Computed tomography revealed a significant reduction in non-aerated lung tissue in individualized FCV (p = 0.026) and no significant difference in overdistended lung tissue, although a significantly higherVTwas applied (8.2 vs 7.6, MD 0.7 (0.2 to 1.2) ml/kg;p = 0.025).ConclusionOur long-term ventilation study demonstrates the applicability of a compliance-guided individualization of FCV settings, which resulted in significantly improved gas exchange and lung tissue aeration without signs of overinflation as compared to best clinical practice PCV.

Although platelets play a central role in haemostasis, the dynamics of platelet counts during haemostatic resuscitation, the response to platelet transfusion, and effects on clinical outcome are poorly described for trauma patients. As a sub-study of the already published randomized controlled RETIC Study &ldquo, Reversal of Trauma-induced Coagulopathy using First-line Coagulation Factor Concentrates or Fresh-Frozen Plasma&rdquo, trial, we here analysed whether the type of first-line haemostatic resuscitation influences the frequency of platelet transfusion and determined the effects of platelet transfusion in coagulopathic patients with major trauma. Patients randomly received first-line plasma (FFP) or coagulation factor concentrates (CFC), mainly fibrinogen concentrate. In both groups, platelets were transfused to maintain platelet counts between 50 and 100 &times, 109 /L. Transfusion rates were significantly higher in the FFP (n = 44) vs. CFC (n = 50) group (FFP 47.7% vs. CFC 26%), p = 0.0335. Logistic regression analysis adjusted for the stratification variables injury severity score (ISS) and brain injury confirmed that first-line FFP therapy increases the odds for platelet transfusion (odds ratio (OR) 5.79 (1.89 to 20.62), p = 0.0036) and this effect was larger than a 16-point increase in ISS (OR 4.33 (2.17 to 9.74), p =0.0001). In conclusion, early fibrinogen supplementation exerted a platelet-saving effect while platelet transfusions did not substantially improve platelet count and might contribute to poor clinical outcome.

Intermittent normobaric hypoxia (IH) is increasingly used to pre - acclimatize for a sojourn to high altitude. There is a number of hypoxia - protocols observing the hypoxic ventilatory response (HVR), but little is known about the carry - over quality of the Lake Louise Score (LLS). We thus studied a week - long, one hour per day poikilocapnic hypoxia protocol on whether acclimatization could be carried over for one week. Rationale for this was that it usually takes one week to get from Europe, Britain or the USA to the base camp of a major mountain. Forty-nine healthy volunteers of both sexes were exposed to daily bouts of 1 hour at an inspiratory fraction of oxygen (FiO2) of 0.11 or 0.21 (control) for 7 consecutive days. Seven days after cessation of IH or sham exposures participants were again subjected to hypoxia (FiO2 = 0.11) for 6 hours and measurements of isocapnic HVR and blood gases out of the arterialized earlobe were taken and LLS was assessed. In those with IH exposures LLS was reduced which was not the case in those with sham exposure (87% vs. 50%). Changes in HVR or the arterial hemoglobin saturation were not observed. Gender neither affected LLS nor HVR nor blood gases or carry -over quality. We found that our week - long, hypoxia protocol grants a reduction in LLS that can be carried over the time span of one week. In this way, antedated acclimatization may improve safety and comfort on the mountain.

Background Scores can assess the severity and course of disease and predict outcome in an objective manner. This information is needed for proper risk assessment and stratification. Furthermore, scoring systems support optimal patient care, resource management and are gaining in importance in terms of artificial intelligence. Objective This study evaluated and compared the prognostic ability of various common pediatric scoring systems (PRISM, PRISM III, PRISM IV, PIM, PIM2, PIM3, PELOD, PELOD 2) in order to determine which is the most applicable score for pediatric sepsis patients in terms of timing of disease survey and insensitivity to missing data. Methods We retrospectively examined data from 398 patients under 18 years of age, who were diagnosed with sepsis. Scores were assessed at ICU admission and re-evaluated on the day of peak C-reactive protein. The scores were compared for their ability to predict mortality in this specific patient population and for their impairment due to missing data. Results PIM (AUC 0.76 (0.68–0.76)), PIM2 (AUC 0.78 (0.72–0.78)) and PIM3 (AUC 0.76 (0.68–0.76)) scores together with PRSIM III (AUC 0.75 (0.68–0.75)) and PELOD 2 (AUC 0.75 (0.66–0.75)) are the most suitable scores for determining patient prognosis at ICU admission. Once sepsis is pronounced, PELOD 2 (AUC 0.84 (0.77–0.91)) and PRISM IV (AUC 0.8 (0.72–0.88)) become significantly better in their performance and count among the best prognostic scores for use at this time together with PRISM III (AUC 0.81 (0.73–0.89)). PELOD 2 is good for monitoring and, like the PIM scores, is also largely insensitive to missing values. Conclusion Overall, PIM scores show comparatively good performance, are stable as far as timing of the disease survey is concerned, and they are also relatively stable in terms of missing parameters. PELOD 2 is best suitable for monitoring clinical course.

Tigecycline offers broad anti-bacterial coverage for critically ill patients with complicated infections. A described but less researched side effect is coagulopathy. The aim of this study was to test whether tigecycline interferes with fibrinogen polymerization by peripheral interactions. To study the effect of unmetabolized tigecycline, plasma of healthy volunteers were spiked with increasing concentrations of tigecycline. In a second experimental leg, immortalized human liver cells (HepG2) were treated with the same concentrations to test an inhibitory effect of hepatic tigecycline metabolites. Using standard coagulation tests, only the activated thromboplastin time in humane plasma was prolonged with increasing concentrations of tigecycline. Visualization of the fibrin network using confocal live microscopy demonstrated a qualitative difference in tigecycline treated experiments. Thrombelastometry and standard coagulation tests did not indicate an impairment of coagulation. Although the discrepancy between functional and immunologic fibrinogen levels increased in cell culture assays with tigecycline concentration, fibrinogen levels in spiked plasma samples did not show significant differences determined by functional versus immunologic methods. In our in vitro study, we excluded a direct effect of tigecycline in increasing concentrations on blood coagulation in healthy adults. Furthermore, we demonstrated a rapid loss of mitochondrial activity in hepatic cells with supra-therapeutic tigecycline dosages.

Objective Craniosynostosis surgery in small children is very often associated with a high blood loss. Tranexamic acid (TXA) reduces blood loss during this procedure, although the potential underlying coagulopathy in these children is not known in detail. Objective was to determine the nature of any coagulopathy found during and after craniosynostosis surgery and to characterize the effect of TXA on fibrin clot formation, clot strength, and fibrinolysis. Materials and Methods Thirty children received either TXA (bolus dose of 10 mg/kg followed by 8 hours continuous infusion of 3 mg/kg/h) or placebo. Dynamic whole blood clot formation assessed by thromboelastometry, platelet count, dynamic thrombin generation/thrombin-antithrombin, clot lysis assay, and fibrinogen/factor XIII (FXIII) levels were measured. Additionally, clot structure was investigated by real-time live confocal microscopy and topical data analysis. Results Increased ability of thrombin generation was observed together with a tendency toward shortened activated partial thromboplastin time and clotting time. Postoperative maximum clot firmness was higher among children receiving TXA. FXIII decreased significantly during surgery in both groups.Resistance toward tissue plasminogen activator-induced fibrinolysis was higher in children that received TXA, as evidenced by topical data analysis and by a significant longer lysis time. Fibrinogen levels were higher in the TXA group at 24 hours. Conclusion A significant coagulopathy mainly characterized by changes in clot stability and not parameters of thrombin generation was reported. Tranexamic acid improved clot strength and reduced fibrinolysis, thereby avoiding reduction in fibrinogen levels.