Publications by authors named "Alexander Kaserer"

29 Publications

  • Page 1 of 1

Coagulation Management after Trauma in the Presence of Direct Oral Anticoagulants.

Anesthesiology 2021 10;135(4):570-572

Division of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.

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http://dx.doi.org/10.1097/ALN.0000000000003928DOI Listing
October 2021

Effect of a factor-based coagulation management on blood product use after major burn injury: A retrospective cohort study.

Burns 2021 Nov 21;47(7):1486-1494. Epub 2021 Aug 21.

Department of Plastic Surgery and Hand Surgery, Burn Center, University and University Hospital Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Cantonal Hospital Aarau, Aarau, Switzerland. Electronic address:

Background: Transfusion of allogenic blood products was shown to be associated with more adverse events and a higher mortality in severely burned patients. This study investigated the impact of a goal-directed and factor-based coagulation algorithm on blood product use and clinical outcomes in severely burned patients.

Methods: This retrospective cohort study included adult patients admitted to the burn center of the University Hospital Zurich with major burn injuries compromising 20-80% of total body surface area. We compared two 3-year periods, one before the introduction of a goal-directed coagulation and transfusion algorithm (period 1: 2009-2011) and one after (period 2: 2016-2018). We applied linear and logistic regression models adjusted for confounders.

Results: We analyzed 36 patients (27.8% female) versus 42 patients (14.3% female) in period 1 and 2, respectively. Comorbidities and burn types were comparable between both collectives. Treatment according to the coagulation algorithm resulted in an overall reduction of 33 units of red blood cells (95% CI -52.8 to -12.9, p = 0.002), 9 units fresh frozen plasma (95% CI -14.7 to -2.6, p = 0.006) and 1.4g fibrinogen (95% CI -2.2 to -0.5, p = 0.001) per patient. We observed less infections (61.8% vs. 41.5%, p = 0.11) and a reduced mortality (38.9% vs. 26.8%, p = 0.33) during the algorithm treated period, although not significant.

Conclusion: Treatment of severely burned patients with a goal-directed coagulation algorithm reduced blood product use and resulted in target-oriented administration of coagulation factors to improve outcomes.
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http://dx.doi.org/10.1016/j.burns.2021.08.015DOI Listing
November 2021

Coronavirus-induced coagulopathy during the course of disease.

PLoS One 2020 17;15(12):e0243409. Epub 2020 Dec 17.

Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland.

Background: A significant proportion of patients with coronavirus disease 19 (COVID-19) suffer from excessive coagulation activation and coagulopathy which is associated with an increased risk of venous and arterial thromboembolism and adverse outcome. Our study investigates coagulation markers and the incidence of thromboembolic events in COVID-19 patients receiving recommended anticoagulation strategies.

Methods: In a retrospective single-center analysis at the University Hospital Zurich, Switzerland, we investigated 31 adult COVID-19 patients between April 6th and May 13th, 2020 and with at least one laboratory assessment of the coagulation markers prothrombin time/Quick, thrombin time, fibrinogen and D-dimers. For antithrombotic prophylaxis low-molecular-weight-heparin or unfractionated heparin was administered and two patients with heparin-induced thrombocytopenia received argatroban.

Results: We analyzed 31 patients (68% male, mean age 60± SD 15 years). 22 (71%) of these required intensive care unit treatment, 5 (16%) were hospitalized in a ward, and 4 (13%) were outpatients. Mean fibrinogen levels were markedly elevated to 6.4± SD 1.8g/l, with a peak in the third week of the disease and no significant decrease over time. D-dimers were elevated to a mean value of 5.1±4.4mg/l with peak levels of 6.8±5.3mg/l in the fourth week of disease, and a subsequent decrease. Platelet count (308±136G/l) and PT/Quick (85±22%) showed no significant changes over time. Sensitivity analyses for patients treated in the ICU showed that D-dimer levels were higher in this group. The results of other sensitivity analyses were comparable. Thromboembolic events were diagnosed in 4 (13%) patients and 5 (16%) patients died during the observation period.

Conclusion: We find coagulation alterations in COVID-19 patients indicating significant hypercoagulability. These alterations are visible despite antithrombotic treatment, and peak around week 3-4 of the disease.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243409PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745968PMC
December 2020

Prevalence and outcome of contrast-induced nephropathy in major trauma patients.

Eur J Trauma Emerg Surg 2020 Sep 19. Epub 2020 Sep 19.

Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Raemistrasse. 100, 8091, Zurich, Switzerland.

Background: Contrast-induced nephropathy (CIN) has been well investigated in patients undergoing coronary angiography, but not in trauma patients. The main aim of this study was to determine the prevalence and to investigate independent risk factors for the development of CIN.

Methods: Between 2008 and 2014, all pre-hospital intubated major trauma patients with documented serum creatinine levels (SCr) undergoing a contrast-enhanced whole-body CT at admission were retrospectively analyzed. CIN was defined as a relative increase in SCr > 25% over the baseline value or an absolute SCr increase of > 44 µmol/l within 72 h. Univariate and multivariable regression analyses were performed to identify significant risk factors. A p value of < 0.01 was considered statistically significant and a p value of 0.01-0.049 suggested evidence.

Results: Of 284 analyzed patients, 41 (14%) met the criteria for CIN. There is suggestive evidence that age and lactate level influenced the development of CIN. Six patients (15%) had hemodialysis in the CIN-group and eight (3.3%) in the group without CIN. Complication and mortality rate was higher in patients with CIN (71% vs. 56% and 32% vs. 23%, respectively). CIN was not an independent risk factor for complications or mortality while controlling for age, gender, injury severity score, and lactate level. The length of stay was not affected by CIN.

Conclusion: CIN occurs frequently in trauma patients, but is not an independent risk factor for complications or mortality. Therefore, contrast enhanced whole-body CT can safely be performed in trauma patients.
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http://dx.doi.org/10.1007/s00068-020-01496-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500990PMC
September 2020

Validation of the Raw National Aeronautics and Space Administration Task Load Index (NASA-TLX) Questionnaire to Assess Perceived Workload in Patient Monitoring Tasks: Pooled Analysis Study Using Mixed Models.

J Med Internet Res 2020 09 7;22(9):e19472. Epub 2020 Sep 7.

Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.

Background: Patient monitoring is indispensable in any operating room to follow the patient's current health state based on measured physiological parameters. Reducing workload helps to free cognitive resources and thus influences human performance, which ultimately improves the quality of care. Among the many methods available to assess perceived workload, the National Aeronautics and Space Administration Task Load Index (NASA-TLX) provides the most widely accepted tool. However, only few studies have investigated the validity of the NASA-TLX in the health care sector.

Objective: This study aimed to validate a modified version of the raw NASA-TLX in patient monitoring tasks by investigating its correspondence with expected lower and higher workload situations and its robustness against nonworkload-related covariates. This defines criterion validity.

Methods: In this pooled analysis, we evaluated raw NASA-TLX scores collected after performing patient monitoring tasks in four different investigator-initiated, computer-based, prospective, multicenter studies. All of them were conducted in three hospitals with a high standard of care in central Europe. In these already published studies, we compared conventional patient monitoring with two newly developed situation awareness-oriented monitoring technologies called Visual Patient and Visual Clot. The participants were resident and staff anesthesia and intensive care physicians, and nurse anesthetists with completed specialization qualification. We analyzed the raw NASA-TLX scores by fitting mixed linear regression models and univariate models with different covariates.

Results: We assessed a total of 1160 raw NASA-TLX questionnaires after performing specific patient monitoring tasks. Good test performance and higher self-rated diagnostic confidence correlated significantly with lower raw NASA-TLX scores and the subscores (all P<.001). Staff physicians rated significantly lower workload scores than residents (P=.001), whereas nurse anesthetists did not show any difference in the same comparison (P=.83). Standardized distraction resulted in higher rated total raw NASA-TLX scores (P<.001) and subscores. There was no gender difference regarding perceived workload (P=.26). The new visualization technologies Visual Patient and Visual Clot resulted in significantly lower total raw NASA-TLX scores and all subscores, including high self-rated performance, when compared with conventional monitoring (all P<.001).

Conclusions: This study validated a modified raw NASA-TLX questionnaire for patient monitoring tasks. The scores obtained correctly represented the assumed influences of the examined covariates on the perceived workload. We reported high criterion validity. The NASA-TLX questionnaire appears to be a reliable tool for measuring subjective workload. Further research should focus on its applicability in a clinical setting.
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http://dx.doi.org/10.2196/19472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7506540PMC
September 2020

Point-of-Care Diagnostics in Coagulation Management.

Sensors (Basel) 2020 Jul 30;20(15). Epub 2020 Jul 30.

Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland.

This review provides a comprehensive and up-to-date overview of point-of-care (POC) devices most commonly used for coagulation analyses in the acute settings. Fast and reliable assessment of hemostasis is essential for the management of trauma and other bleeding patients. Routine coagulation assays are not designed to visualize the process of clot formation, and their results are obtained only after 30-90 m due to the requirements of sample preparation and the analytical process. POC devices such as viscoelastic coagulation tests, platelet function tests, blood gas analysis and other coagulometers provide new options for the assessment of hemostasis, and are important tools for an individualized, goal-directed, and factor-based substitution therapy. We give a detailed overview of the related tests, their characteristics and clinical implications. This review emphasizes the evident advantages of the speed and predictive power of POC clot measurement in the context of a goal-directed and algorithm-based therapy to improve the patient's outcome. Interpretation of viscoelastic tests is facilitated by a new visualization technology.
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http://dx.doi.org/10.3390/s20154254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7435714PMC
July 2020

Situation Awareness-Oriented Patient Monitoring with Visual Patient Technology: A Qualitative Review of the Primary Research.

Sensors (Basel) 2020 Apr 9;20(7). Epub 2020 Apr 9.

Institute of Anesthesiology, University and University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.

Visual Patient technology is a situation awareness-oriented visualization technology that translates numerical and waveform patient monitoring data into a new user-centered visual language. Vital sign values are converted into colors, shapes, and rhythmic movements-a language humans can easily perceive and interpret-on a patient avatar model in real time. In this review, we summarize the current state of the research on the Visual Patient, including the technology, its history, and its scientific context. We also provide a summary of our primary research and a brief overview of research work on similar user-centered visualizations in medicine. In several computer-based studies under various experimental conditions, Visual Patient transferred more information per unit time, increased perceived diagnostic certainty, and lowered perceived workload. Eye tracking showed the technology worked because of the way it synthesizes and transforms vital sign information into new and logical forms corresponding to the real phenomena. The technology could be particularly useful for improving situation awareness in settings with high cognitive demand or when users must make quick decisions. This comprehensive review of Visual Patient research is the foundation for an evaluation of the technology in clinical applications, starting with a high-fidelity simulation study in early 2020.
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http://dx.doi.org/10.3390/s20072112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180744PMC
April 2020

Not all anemia is solely due to iron deficiency.

J Thorac Dis 2020 Mar;12(3):1130-1132

Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.

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http://dx.doi.org/10.21037/jtd.2019.12.129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138976PMC
March 2020

Comparing Classroom Instruction to Individual Instruction as an Approach to Teach Avatar-Based Patient Monitoring With Visual Patient: Simulation Study.

JMIR Med Educ 2020 Apr 23;6(1):e17922. Epub 2020 Apr 23.

University Hospital Zurich, Zurich, Switzerland.

Background: Visual Patient is an avatar-based alternative to standard patient monitor displays that significantly improves the perception of vital signs. Implementation of this technology in larger organizations would require it to be teachable by brief class instruction to large groups of professionals. Therefore, our study aimed to investigate the efficacy of such a large-scale introduction to Visual Patient.

Objective: In this study, we aimed to compare 2 different educational methods, one-on-one instruction and class instruction, for training anesthesia providers in avatar-based patient monitoring.

Methods: We presented 42 anesthesia providers with 30 minutes of class instruction on Visual Patient (class instruction group). We further selected a historical sample of 16 participants from a previous study who each received individual instruction (individual instruction group). After the instruction, the participants were shown monitors with either conventional displays or Visual Patient displays and were asked to interpret vital signs. In the class instruction group, the participants were shown scenarios for either 3 or 10 seconds, and the numbers of correct perceptions with each technology were compared. Then, the teaching efficacy of the class instruction was compared with that of the individual instruction in the historical sample by 2-way mixed analysis of variance and mixed regression.

Results: In the class instruction group, when participants were presented with the 3-second scenario, there was a statistically significant median increase in the number of perceived vital signs when the participants were shown the Visual Patient compared to when they were shown the conventional display (3 vital signs, P<.001; effect size -0.55). No significant difference was found for the 10-second scenarios. There was a statistically significant interaction between the teaching intervention and display technology in the number of perceived vital signs (P=.04; partial η=.076). The mixed logistic regression model for correct vital sign perception yielded an odds ratio (OR) of 1.88 (95% CI 1.41-2.52; P<.001) for individual instruction compared to class instruction as well as an OR of 3.03 (95% CI 2.50-3.70; P<.001) for the Visual Patient compared to conventional monitoring.

Conclusions: Although individual instruction on Visual Patient is slightly more effective, class instruction is a viable teaching method; thus, large-scale introduction of health care providers to this novel technology is feasible.
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http://dx.doi.org/10.2196/17922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206517PMC
April 2020

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma.

Scand J Trauma Resusc Emerg Med 2019 Dec 30;27(1):117. Epub 2019 Dec 30.

Institute of Anaesthesiology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400, Winterthur, Switzerland.

Background: A factor-based coagulation management following major trauma is recommended as standard of care by the European Trauma Treatment Guidelines. However, concerns about the thromboembolic risk of this approach are still prevalent. Our study therefore aims to assess if such a haemostatic management is associated with an increased risk for thromboembolic events.

Methods: In this retrospective observational study carried out at the University Hospital Zurich we compared two three-year periods before (period 1: 2005-2007) and after (period 2: 2012-2014) implementation of a factor-based coagulation algorithm. We included all adult patients following major trauma primarily admitted to the University Hospital Zurich. Thromboembolic events were defined as a new in-hospital appearance of any peripheral thrombosis, arterial embolism, pulmonary embolism, stroke or myocardial infarction. A logistic regression was performed to investigate the association of thromboembolic events with possible confounders such as age, sex, specific Abbreviated Injury Scale (AIS) subgroups, allogeneic blood products, and the coagulation management.

Results: Out of 1138 patients, 772 met the inclusion criteria: 344 patients in period 1 and 428 patients in period 2. Thromboembolic events were present in 25 patients (7.3%) of period 1 and in 42 patients (9.8%) of period 2 (raw OR 1.39, 95% CI 0.83 to 2.33, p = 0.21). Only AIS extremities (adjusted OR 1.26, 95% CI 1.05 to 1.52, p = 0.015) and exposure to allogeneic blood products (adjusted OR 2.39, 95% CI 1.33 to 4.30, p = 0.004) were independently associated with thromboembolic events in the logistic regression, but the factor-based coagulation management was not (adjusted OR 1.60, 95% CI 0.90-2.86, p = 0.11).

Conclusion: There is no evidence that a goal-directed, factor-based coagulation management is associated with an increased risk for thromboembolic events following major trauma.
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http://dx.doi.org/10.1186/s13049-019-0697-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6937999PMC
December 2019

Impact of allogeneic blood transfusions on clinical outcomes in severely burned patients.

Burns 2020 08 19;46(5):1083-1090. Epub 2019 Dec 19.

Department of Plastic Surgery and Hand Surgery, Burn Center, University and University Hospital Zurich, Zurich, Switzerland. Electronic address:

Background: Allogeneic blood transfusions are common in the treatment of severely burned patients as surgery may lead to major blood loss. However, transfusions are associated with a number of adverse events. Therefore, the purpose of our study was to investigate the impact of allogeneic blood transfusions on clinical outcomes in severely burned patients.

Methods: This retrospective study included all adult patients admitted to the burn center of the University Hospital Zurich between January 2004 and December 2014, with burn injuries greater than 10% of total body surface area and receiving both surgical and intensive care treatment. Primary Endpoints were infectious or thromboembolic complications and mortality and secondary endpoints were length of hospital and ICU stay. Simple and multivariable logistic and linear regression models, adjusted for injury severity and confounders, were applied.

Results: 413 patients met inclusion criteria of which 212 patients (51%) received allogenic blood products. After adjustment for injury severity and confounders, red blood cell transfusion was independently associated with wound infection (OR 13.5, 95% CI 1.7-107, p = 0.014), sepsis (OR 8.3, 4.2-16.3; p < 0.001), pneumonia (OR 4.7, 2.2-10.0; p < 0.001), thrombosis (OR 3.0, 1.2-7.4; p = 0.015), central line infection (OR 34.7, 4.6-260; p = 0.001) and a longer ICU and hospital stay (difference 17.7, CI 12.1-23.4, p < 0.001 and 22.0, 15.8-28.2, p < 0.001, respectively). Fresh frozen plasma transfusion was independently associated with a longer ICU and hospital stay (difference 13.7, 95% CI 5.5-21.8, p = 0.001 and 13.5, 4.6-22.5, p = 0.003, respectively). Platelet transfusion was independently associated with systemic inflammatory response syndrome (OR 4.5, 1.3-15.5; p = 0.018) and mortality (OR 5.8, 2.1-16.0; p = 0.001).

Conclusion: Transfusion of allogeneic blood products is associated with an increased infection rate and thromboembolic morbidity and a longer hospital stay in severely burned patients.
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http://dx.doi.org/10.1016/j.burns.2019.11.005DOI Listing
August 2020

Standard coagulation assays alone are not sufficient to exclude surgically relevant rivaroxaban plasma concentrations.

Perioper Med (Lond) 2019 20;8:15. Epub 2019 Nov 20.

1Institute of Anaesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.

Background: While mainly larger hospitals have introduced routine anti-Xa assays for rivaroxaban (RXA), these are not readily available to smaller hospitals often relying on routine coagulation tests such as prothrombin time (PT) and activated partial thromboplastin time (aPTT).The aim of our study was to investigate the effect of RXA plasma concentration on the standard coagulation tests PT (Quick test and INR) and aPTT in a large group of real-life patients. We further assessed whether normal results of these standard coagulation assays are sufficient to exclude surgically relevant RXA plasma concentration, defined as > 50 mcg/l.

Methods: This retrospective study included all patients between 2012 and 2016 where anti-Xa (calibrated for RXA), PT (Quick test and INR), and/or aPTT were determined from the same sample. PT is expressed as Quick value (% of normal plasma pool). In total, 1027 measurements in 622 patients were eligible for analysis: 752 measurements of 505 patients for Quick/INR and 594 measurements of 417 patients for aPTT.

Results: A moderate correlation of PT/Quick (Pearson's correlation coefficient - 0.59; < 0.001), INR (Pearson's correlation coefficient 0.5; < 0.001), and aPTT (Pearson's correlation coefficient 0.53; < 0.001) with RXA plasma concentration was observed. However, in 50% of all samples with a normal PT/Quick, in 25% of all samples with a normal INR and in 80% of all samples with a normal aPTT residual RXA plasma concentration was surgically relevant.

Conclusion: Although a moderate correlation of RXA plasma concentration with PT/Quick, INR, and aPTT was observed, standard coagulation assays are not sufficient to exclude surgically relevant RXA plasma concentrations.
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http://dx.doi.org/10.1186/s13741-019-0128-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6864962PMC
November 2019

Clinical practice of pre-hospital analgesia: An observational study of 20,978 missions in Switzerland.

Am J Emerg Med 2020 11 18;38(11):2318-2323. Epub 2019 Nov 18.

Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland. Electronic address:

Background: Pain is a frequent problem faced by emergency medical services (EMS) in pre-hospital settings. This large observational study aims to assess the prevalence of sufficiently provided analgesia and to analyze the efficacy of different analgesics. Moreover, we evaluated if quality of analgesia changed with an emergency physician on scene or depended on paramedics' gender.

Methods: This is a retrospective analysis of all pre-hospital medical charts from adults and adolescents treated by the municipal EMS Schutz & Rettung Zürich over a period of 4 years from 2013 to 2016. Inclusion criteria were age ≥16 years, initial GCS > 13, NACA score ≥I and ≤V, an initial numeric rating scale (NRS) ≥ I and a documented NRS at hospital admission. 20,978 out of 142,484 missions fulfilled the inclusion criteria and therefore underwent further investigation. Descriptive, univariate and multivariate analyses were applied.

Results: Initial NRS on scene was on average 5.2 ± 3.0. Mean NRS reduction after treatment was 2.2 ± 2.5 leading to a NRS at hospital admission of 3.0 ± 1.9. This resulted in sufficient analgesia for 77% of included patients. Among analgesics, the highest odds ratio for sufficient analgesia was observed for ketamine (OR 4.7, 95%CI 2.2-10.4, p < 0.001) followed by fentanyl (OR 1.4, 95%CI 1.1-1.7, p = 0.004). Female paramedics provided better analgesia (OR 1.2, 95%CI 1.1-1.2; p < 0.001). Patient's sex had no influence on analgesia. In patients with a NACA score > 2, the presence of an emergency physician on scene improved the quality of analgesia significantly.

Conclusions: Pre-hospital analgesia is mostly adequate, especially when done with ketamine or fentanyl. Female paramedics provided better analgesia and in selected patients, an emergency physician on scene improved quality of analgesia in critical patients.
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http://dx.doi.org/10.1016/j.ajem.2019.10.033DOI Listing
November 2020

Screening for iron deficiency in surgical patients based on noninvasive zinc protoporphyrin measurements.

Transfusion 2020 01 11;60(1):62-72. Epub 2019 Nov 11.

Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland.

Background: Approximately every third surgical patient is anemic. The most common form, iron deficiency anemia, results from persisting iron-deficient erythropoiesis (IDE). Zinc protoporphyrin (ZnPP) is a promising parameter for diagnosing IDE, hitherto requiring blood drawing and laboratory workup.

Study Design And Methods: Noninvasive ZnPP (ZnPP-NI) measurements are compared to ZnPP reference determination of the ZnPP/heme ratio by high-performance liquid chromatography (ZnPP-HPLC) and the analytical performance in detecting IDE is evaluated against traditional iron status parameters (ferritin, transferrin saturation [TSAT], soluble transferrin receptor-ferritin index [sTfR-F], soluble transferrin receptor [sTfR]), likewise measured in blood. The study was conducted at the University Hospitals of Frankfurt and Zurich.

Results: Limits of agreement between ZnPP-NI and ZnPP-HPLC measurements for 584 cardiac and noncardiac surgical patients equaled 19.7 μmol/mol heme (95% confidence interval, 18.0-21.3; acceptance criteria, 23.2 μmol/mol heme; absolute bias, 0 μmol/mol heme). Analytical performance for detecting IDE (inferred from area under the curve receiver operating characteristics) of parameters measured in blood was: ZnPP-HPLC (0.95), sTfR (0.92), sTfR-F (0.89), TSAT (0.87), and ferritin (0.67). Noninvasively measured ZnPP-NI yielded results of 0.90.

Conclusion: ZnPP-NI appears well suited for an initial IDE screening, informing on the state of erythropoiesis at the point of care without blood drawing and laboratory analysis. Comparison with a multiparameter IDE test revealed that ZnPP-NI values of 40 μmol/mol heme or less allows exclusion of IDE, whereas for 65 μmol/mol heme or greater, IDE is very likely if other causes of increased values are excluded. In these cases (77% of our patients) ZnPP-NI may suffice for a diagnosis, while values in between require analyses of additional iron status parameters.
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http://dx.doi.org/10.1111/trf.15577DOI Listing
January 2020

Impact of rivaroxaban plasma concentration on perioperative red blood cell loss.

Transfusion 2020 01 4;60(1):197-205. Epub 2019 Nov 4.

Division of Hematology, University and University Hospital Zurich, Zurich, Switzerland.

Background: This study investigates the impact of preoperative calculated rivaroxaban (RXA) plasma concentration on perioperative red blood cell (RBC) loss.

Study Design And Methods: In this retrospective single-center study, we identified patients with RXA intake according to a preoperative determination of RXA levels within 96 hours before surgery. RXA plasma concentration at the beginning of surgery was then calculated from the last RXA intake using a single-compartment pharmacokinetic model with four categories of RXA concentration (≤20, 21-50, 51-100, and >100 μg/L). Patients were classified into surgery with high (≥500 mL) or low (<500 mL) expected blood loss. Perioperative bleeding was determined by calculating RBC loss.

Results: We analyzed 308 surgical interventions in 298 patients during the period from January 2012 to July 2018. Among patients undergoing surgery with low expected blood loss, RBC loss varied from 164 mL (standard deviation [SD], 189) to 302 mL (SD, 397) (p = 0.66), and no association of calculated RXA concentration with RBC loss was observed. In patients undergoing surgery with high expected blood loss, we found a significant correlation of calculated RXA concentration with RBC loss (Pearson's correlation coefficient, 0.29; p = 0.002). RBC loss increased with rising RXA concentration from 575 mL (SD, 365) at RXA concentration of 20 μg/L or less up to 1400 mL (SD, 1300) at RXA concentration greater than 100 μg/L. RXA concentration greater than 100 μg/L was associated with a significant increase of in RBC loss of 840 mL (95% confidence interval, 360-1300; p < 0.001). Transfusion of RBC and fresh frozen plasma units tended to increase in patients with RXA concentrations greater than 100 μg/L. The proportion of patients treated with prothrombin complex concentrate and coagulation factor XIII concentrate increased significantly with higher RXA concentrations.

Conclusion: Only in surgery with high expected blood loss, a calculated RXA concentration of greater than 100 μg/L was associated with a significant increase of perioperative RBC loss.
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http://dx.doi.org/10.1111/trf.15560DOI Listing
January 2020

Iron deficiency is associated with higher mortality in patients undergoing cardiac surgery: a prospective study.

Br J Anaesth 2020 01 24;124(1):25-34. Epub 2019 Oct 24.

Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland. Electronic address:

Background: Iron deficiency is frequent in patients undergoing cardiac surgery. The relevance of iron deficiency, however, is ill defined. Therefore, our study aimed to investigate the impact of iron deficiency (ferritin <100 μg L) with or without concomitant anaemia on clinical outcome after cardiac surgery.

Methods: In this prospective observational study, 730 patients undergoing elective cardiac surgery were assigned into four groups according to their iron status and anaemia. Mortality, serious adverse events (SAEs), major cardiac and cerebrovascular events (MACCEs), allogenic blood transfusion requirements, and length of hospital stay were assessed during a 90-day follow-up period. The effect of iron deficiency on these outcomes was first calculated in models adjusting for anaemia only, followed by two multivariate models adjusting for anaemia and either the EuroSCORE II or any possible confounders.

Results: The presence of iron deficiency (ferritin <100 μg L) was associated with an increase in 90-day mortality from 2% to 5% in patients without anaemia, and from 4% to 14% in patients with anaemia. Logistic regression resulted in an odds ratio of 3.5 (95% confidence interval: 1.5-8.4); P=0.004. The effect persisted in both multivariate models. Moreover, iron deficiency was associated with an increased incidence of SAEs, MACCEs, transfusion, and prolonged hospital stay.

Conclusions: Preoperative iron deficiency (ferritin <100 μg L) was independently associated with increased mortality, more SAEs, and prolonged hospital stay after cardiac surgery. These findings underline the importance of preoperative iron deficiency screening in the context of a comprehensive patient blood management programme, and highlight its importance as a research topic in cardiac surgery.

Clinical Trial Registration: NCT02031289.
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http://dx.doi.org/10.1016/j.bja.2019.09.016DOI Listing
January 2020

ECG pre-hospital teletransmission by emergency teams staffed with an emergency physician and paramedics and its impact on transportation and hospital admission.

Medicine (Baltimore) 2019 Aug;98(34):e16636

Lazarski University, Warsaw, Poland.

Electrocardiography (ECG) is essential to detect and diagnose life threatening cardiac conditions and to determine further treatment. Correct interpretation of an ECG can be challenging, especially in the out-of-hospital setting and by less experienced emergency team members.The aim of this study was to compare the rate of ECG transmission from an out-of-hospital emergency scene to an in-hospital cardiologist on call in EMS-B and EMS-S providers and its impact on direct transportation to a cardiac catheterization laboratory and hospital admission.The study was designed as an observational study. Data from 3 separate emergency medical service teams were collected. Two teams are staffed by paramedics only (EMT-B), while another specialized team is staffed with an emergency physician (EMT-S). 5864 out-of-hospital emergencies were performed during a 12-month period and were analyzed for this study.In 124 out of 5864 (2.1%) out-of-hospital emergencies, an ECG transmission from the out-of-hospital scene to an in-hospital cardiologist on call was performed. Rate of transmission was similar between both teams (EMT-B n = 70, 2.2% vs EMT-S n = 54, 2.0%, P = .054). After coordinating with the cardiologist on call, 11 patients (15.7%) of the EMT-B (15.7%) and 24 patients (44.4%) of the EMT-S were directly transported from the scene of emergency to a cardiac catheterization laboratory (P < .001). Overall, 80% of patients treated by EMT-S, compared to 52.5% treated by the EMT-B required subsequent hospital admission (P < .05).Transmission of ECG from the out-of-hospital emergency scene to the in-hospital cardiologist is infrequently performed. The rate of STEMI in transmitted ECG's by emergency teams staffed with an emergency physician was higher compared to emergency teams staffed with paramedics only.
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http://dx.doi.org/10.1097/MD.0000000000016636DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716704PMC
August 2019

Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial.

Lancet 2019 06 26;393(10187):2201-2212. Epub 2019 Apr 26.

Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Berlin, Germany; Department of Cardiothoracic Surgery, Charité - Universitätsmedizin Berlin Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.

Background: Anaemia and iron deficiency are frequent in patients scheduled for cardiac surgery. This study assessed whether immediate preoperative treatment could result in reduced perioperative red blood cell (RBC) transfusions and improved outcome.

Methods: In this single-centre, randomised, double-blind, parallel-group controlled study, patients undergoing elective cardiac surgery with anaemia (n=253; haemoglobin concentration (Hb) <120 g/L in women and Hb <130 g/L in men) or isolated iron deficiency (n=252; ferritin <100 mcg/L, no anaemia) were enrolled. Participants were randomly assigned (1:1) with the use of a computer-generated range minimisation (allocation probability 0·8) to receive either placebo or combination treatment consisting of a slow infusion of 20 mg/kg ferric carboxymaltose, 40 000 U subcutaneous erythropoietin alpha, 1 mg subcutaneous vitamin B12, and 5 mg oral folic acid or placebo on the day before surgery. Primary outcome was the number of RBC transfusions during the first 7 days. This trial is registered with ClinicalTrials.gov, number NCT02031289.

Findings: Between Jan 9, 2014, and July 19, 2017, 1006 patients were enrolled; 505 with anaemia or isolated iron deficiency and 501 in the registry. The combination treatment significantly reduced RBC transfusions from a median of one unit in the placebo group (IQR 0-3) to zero units in the treatment group (0-2, during the first 7 days (odds ratio 0·70 [95% CI 0·50-0·98] for each threshold of number of RBC transfusions, p=0·036) and until postoperative day 90 (p=0·018). Despite fewer RBC units transfused, patients in the treatment group had a higher haemoglobin concentration, higher reticulocyte count, and a higher reticulocyte haemoglobin content during the first 7 days (p≤0·001). Combined allogeneic transfusions were less in the treatment group (0 [IQR 0-2]) versus the placebo group (1 [0-3]) during the first 7 days (p=0·038) and until postoperative day 90 (p=0·019). 73 (30%) serious adverse events were reported in the treatment group group versus 79 (33%) in the placebo group.

Interpretation: An ultra-short-term combination treatment with intravenous iron, subcutaneous erythropoietin alpha, vitamin B12, and oral folic acid reduced RBC and total allogeneic blood product transfusions in patients with preoperative anaemia or isolated iron deficiency undergoing elective cardiac surgery.

Funding: Vifor Pharma and Swiss Foundation for Anaesthesia Research.
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http://dx.doi.org/10.1016/S0140-6736(18)32555-8DOI Listing
June 2019

Comparison of the UEScope videolaryngoscope with the Macintosh laryngoscope during simulated cardiopulmonary resuscitation: A randomized, cross-over, multi-center manikin study.

Medicine (Baltimore) 2018 Sep;97(36):e12085

Lazarski University Department of Emergency Medicine, Medical University of Warsaw, Warsaw, Poland Department of Surgery, Hunter Holmes McGuire VA Medical Center, Richmond, VA Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw, Poland Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland Department of Anesthesiology and Intensive Care Grodno State Medical University, Grodno, Belarus Department of Emergency Medicine and Disaster, Medical University Bialystok, Bialystok, Poland Departments of Outcomes Research and General Anesthesia, Cleveland Clinic, Cleveland, OH.

Background: Endotracheal intubation (ETI) can be challenging, especially in life-threatening situations such as cardiopulmonary resuscitation (CPR). Videolaryngoscopes aim to ease ETI, but effort is still widely discussed. This study intended to investigate 2 different airway devices regarding the success rate of ETI during ongoing chest compressions.

Methods: This randomized, cross-over, multi-center manikin trial included 85 experienced paramedics actively working in the emergency medicine service. After a standardized training session, all paramedics underwent 3 airway scenarios using both, direct laryngoscopy using a Macintosh blade and videolaryngoscope (the UEScope): normal airway without chest compressions, normal airway with uninterrupted chest compressions, and difficult airway with uninterrupted chest compressions. The primary outcome was successful ETI, defined as successful placement of the endotracheal tube within the manikin's trachea. Secondary outcomes were number of intubation attempts, time to successful ETI, time to best glottis view, best percent of glottic opening, best glottic view score (Cormack and Lehane), occurrence of dental trauma, ease of use, and willing to reuse in real-life situations.

Results: The UEScope provided a better glottis visualization, and higher first pass intubation success rate compared to direct laryngoscopy in all 3 scenarios. The overall intubation success was higher, and the intubation time was shorter with the UEScope in scenario B and scenario C, but was comparable in scenario A. Dental compression occurred less often using the UEScope and paramedics rated intubation using the UEScope easier compared to direct laryngoscopy in all 3 airway scenarios.

Conclusion: In simulated CPR scenarios, intubation with the UEScope resulted in a better glottis visualization, a higher intubation success, and a shorter intubation time compared to Macintosh laryngoscope (MAC). Moreover, in situations where the airway is difficult for ETI especially by the paramedic, the UEScope would be a better choice than the MAC. Further studies are needed to confirm these results in real-life patients.
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http://dx.doi.org/10.1097/MD.0000000000012085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6133438PMC
September 2018

Is There an Influence of Surgeon's Experience on the Clinical Course in Patients With a Proximal Femoral Fracture?

J Surg Educ 2018 Nov 24;75(6):1566-1574. Epub 2018 Apr 24.

Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

Objectives: Teaching of surgical procedures is of paramount importance. However, it can affect patients outcome. The aim of this study was to evaluate if teaching of hip fracture surgery is an independent predictor for negative in-hospital outcome.

Design And Setting: Retrospectively, we analyzed all hip fracture patients between 2008 and 2013 recorded in a national quality measurement database (AQC). Inclusion criteria were proximal femoral fracture (ICD-10 diagnostic codes S72.00-S72.11), surgical care of those fracture and a documented teaching status of the intervention. Variables were sought in bivariate and multivariate analyses. Teaching status was entered in multiple regression analysis models for in-hospital death, complications and length of stay while controlling for confounders.

Participants: In the 6-year study period, a total of 4397 patients at a mean age of 80 years met the inclusion criteria. Totally, 48% (n = 2107) of the procedures were conducted as teaching interventions. The rest of our examined cases (n = 2290) were conducted as nonteaching procedures.

Results: There was no association between teaching and mortality, but complications (odds ratio = 1.3; 95% CI: 1.04-1.5; p = 0.018) and prolonged hospitalization (standardized beta = 0.045, p = 0.002) were more likely to occur in the teaching group while controlling for confounders.

Conclusions: There appears to be no effect of the educational status on the in-hospital death in patients with a proximal femoral fracture. However, teaching was an independent predictor of complications and longer length of stay. Although the differences were significant, the clinical outcome was comparable in both groups, thus justifying the benefits of resident teaching.
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http://dx.doi.org/10.1016/j.jsurg.2018.04.010DOI Listing
November 2018

Risk Factors for Higher-than-Expected Residual Rivaroxaban Plasma Concentrations in Real-Life Patients.

Thromb Haemost 2018 05 3;118(5):808-817. Epub 2018 Apr 3.

Division of Haematology, University and University Hospital Zurich, Zurich, Switzerland.

Introduction: Rivaroxaban (RXA) is a direct oral factor Xa (Xa) antagonist with a short half-life and a fast onset and offset of effect. Before elective surgery, discontinuation is recommended with an interval of at least > 24 hours. In clinical practice, this is, however, not always sufficient to achieve a residual RXA plasma concentration deemed appropriate for surgery, defined as ≤ 50 mcg/L. Our study aimed at identifying factors associated with a higher-than-expected residual RXA plasma concentration in a large group of real-life patients.

Materials And Methods: This retrospective single-centre study included all patients taking RXA between 2012 and 2016 where RXA plasma concentration was determined by pharmacodynamic anti-Xa assay (518 measurements in 368 patients). Medical records were reviewed. Residual RXA plasma concentrations were then compared with expected values according to a pharmacokinetic model.

Results: Residual RXA plasma concentration was significantly higher-than-expected in patients with atrial fibrillation, impaired kidney function (glomerular filtration rate [GFR] < 60 mL/min), CYP3A4-, CYP2J2- and PGP-inhibitory co-medication including amiodarone. Impaired kidney function (odds ratio [OR], 2.22, 95% confidence interval [CI], 1.30-3.78,  = 0.003) and concomitant amiodarone intake (OR, 1.97, 95% CI, 1.04-3.72,  = 0.036) were significantly associated with RXA plasma concentrations > 50 mcg/L at 24 to 48 hours after the last RXA intake.

Conclusion: In our group of real-life patients, impaired kidney function (GFR < 60 mL/min) and co-medication with amiodarone were independently associated with higher-than-expected residual RXA plasma concentrations. In these patients, standard intervals of RXA discontinuation may not always be sufficient before elective surgery and routine pre-operative determination of the residual RXA concentration could be advisable.
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http://dx.doi.org/10.1055/s-0038-1639585DOI Listing
May 2018

Comparison of two different coagulation algorithms on the use of allogenic blood products and coagulation factors in severely injured trauma patients: a retrospective, multicentre, observational study.

Scand J Trauma Resusc Emerg Med 2018 Jan 8;26(1). Epub 2018 Jan 8.

Institute of Anaesthesiology, University and University Hospital Zürich, Raemistrasse 100, 8091, Zürich, Switzerland.

Background: At the University Hospital Zurich (USZ) and the Cantonal Hospital of Lucerne (LUKS) an individualized goal-directed coagulation and transfusion algorithm was introduced and implemented before 2012 (Coagulation algorithm of the USZ: USZ-Alg; of the LUKS: LUKS-Alg). Main differences between both algorithms are: 1) A target haematocrit-range of 0.21-0.24 (USZ-Alg) vs. a lower haematocrit limit only (LUKS-Alg). 2) Blind coagulation-package in selected cases (LUKS-Alg only). 3) Factor XIII substitution is considered earlier according to the USZ-Alg. The Aim of this study was to analyse the impact of two different coagulation algorithms on the administration of allogeneic blood products, coagulation factors, the frequency of point of care measurements and haemoglobin level during resuscitation in trauma patients.

Methods: This retrospective, multicentre, observational study included all adult trauma patients with an injury severity score (ISS) ≥ 16 primarily admitted to the USZ or the LUKS in the period of 2012 to 2014. Referred patients and patients with missing/incomplete records of the initial treatment at the emergency department (ED) were excluded. Two propensity score matched groups were created using a non-parsimonious logistic regression to account for potential differences in patient and trauma epidemiology.

Results: A total of 632 patients meeting the inclusion criteria were admitted to the two hospitals: 428 to the USZ and 204 to the LUKS. Two Propensity score matched groups (n = 172 per group) were created. Treatment with USZ-Alg compared with LUKS-Alg resulted in a lower number of patients receiving RBC transfusion (11.6% vs. 29.7%, OR 3.2, 95% CI 1.8-5.7, p < 0.001) and lower amount of RBC transfusion (0.5 SD 1.9 vs. 1.5 SD 3.9, p < 0.001). The different treatment algorithms resulted in lower mean haemoglobin levels in the USZ during resuscitation (8.0 SD 1.7 vs. 9.4 SD 1.8 g/dl, p < 0.001) and at admission to the ICU (8.3 SD 1.2 vs. 10.6 SD 1.9 g/dl, p < 0.001. Blood gas analyses to monitor treatment and haematocrit were made more frequently in the USZ (1.4 SD 0.8 vs. 1.0 SD 0.7 measurements per hour, p = 0.004).

Conclusion: A goal-directed coagulation algorithm including a target haematocrit-range including frequent and repeated haematocrit measurement may lead to less transfusion of RBC compared to only a lower haematocrit limit, when treating severely traumatized patients.
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http://dx.doi.org/10.1186/s13049-017-0463-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5759800PMC
January 2018

Patient Blood Management: Der Standard heute.

Ther Umsch 2017;74(7):369-376

1 Institut für Anästhesiologie, Universität und Universitätsspital Zürich, Zürich.

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http://dx.doi.org/10.1024/0040-5930/a000928DOI Listing
March 2018

Factors Influencing Quality of Pain Management in a Physician Staffed Helicopter Emergency Medical Service.

Anesth Analg 2017 07;125(1):200-209

From the *Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland; †Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland; and ‡Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.

Background: Pain is frequently encountered in the prehospital setting and needs to be treated quickly and sufficiently. However, incidences of insufficient analgesia after prehospital treatment by emergency medical services are reported to be as high as 43%. The purpose of this analysis was to identify modifiable factors in a specific emergency patient cohort that influence the pain suffered by patients when admitted to the hospital.

Methods: For that purpose, this retrospective observational study included all patients with significant pain treated by a Swiss physician-staffed helicopter emergency service between April and October 2011 with the following characteristics to limit selection bias: Age > 15 years, numerical rating scale (NRS) for pain documented at the scene and at hospital admission, NRS > 3 at the scene, initial Glasgow coma scale > 12, and National Advisory Committee for Aeronautics score < VI. Univariate and multivariable logistic regression analyses were performed to evaluate patient and mission characteristics of helicopter emergency service associated with insufficient pain management.

Results: A total of 778 patients were included in the analysis. Insufficient pain management (NRS > 3 at hospital admission) was identified in 298 patients (38%). Factors associated with insufficient pain management were higher National Advisory Committee for Aeronautics scores, high NRS at the scene, nontrauma patients, no analgesic administration, and treatment by a female physician. In 16% (128 patients), despite ongoing pain, no analgesics were administered. Factors associated with this untreated persisting pain were short time at the scene (below 10 minutes), secondary missions of helicopter emergency service, moderate pain at the scene, and nontrauma patients. Sufficient management of severe pain is significantly better if ketamine is combined with an opioid (65%), compared to a ketamine or opioid monotherapy (46%, P = .007).

Conclusions: In the studied specific Swiss cohort, nontrauma patients, patients on secondary missions, patients treated only for a short time at the scene before transport, patients who receive no analgesic, and treatment by a female physician may be risk factors for insufficient pain management. Patients suffering pain at the scene (NRS > 3) should receive an analgesic whenever possible. Patients with severe pain at the scene (NRS ≥ 8) may benefit from the combination of ketamine with an opioid. The finding about sex differences concerning analgesic administration is intriguing and possibly worthy of further study.
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http://dx.doi.org/10.1213/ANE.0000000000002016DOI Listing
July 2017

Prevalence and in-hospital outcome of aspiration in out-of-hospital intubated trauma patients.

Eur J Emerg Med 2018 10;25(5):362-367

Department of Surgery, Division of Trauma Surgery, University Hospital Zurich.

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http://dx.doi.org/10.1097/MEJ.0000000000000465DOI Listing
October 2018

Point-of-Care Coagulation Monitoring in Trauma Patients.

Semin Thromb Hemost 2017 Jun 15;43(4):367-374. Epub 2017 Mar 15.

Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland.

Trauma remains one of the major causes of death and disability all over the world. Uncontrolled blood loss and trauma-induced coagulopathy represent preventable causes of trauma-related morbidity and mortality. Treatment may consist of allogeneic blood product transfusion at a fixed ratio or in an individualized goal-directed way based on point-of-care (POC) and routine laboratory measurements. Viscoelastic POC measurement of the developing clot in whole blood and POC platelet function testing allow rapid and tailored coagulation and transfusion treatment based on goal-directed, factor concentrate-based algorithms. The first studies have been published showing that this concept reduces the need for allogeneic blood transfusion and improves outcome. This review highlights the concept of goal-directed POC coagulation management in trauma patients, introduces a selection of POC devices, and presents algorithms which allow a reduction in allogeneic blood product transfusion and an improvement of trauma patient outcome.
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http://dx.doi.org/10.1055/s-0037-1598062DOI Listing
June 2017

Failure rate of prehospital chest decompression after severe thoracic trauma.

Am J Emerg Med 2017 Mar 30;35(3):469-474. Epub 2016 Nov 30.

Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland. Electronic address:

Introduction: Chest decompression can be performed by different techniques, like needle thoracocentesis (NT), lateral thoracostomy (LT), or tube thoracostomy (TT). The aim of this study was to report the incidence of prehospital chest decompression and to analyse the effectiveness of these techniques.

Material And Methods: In this retrospective case series study, all medical records of adult trauma patients undergoing prehospital chest decompression and admitted to the resuscitation area of a level-1 trauma center between 2009 and 2015 were reviewed and analysed. Only descriptive statistics were applied.

Results: In a 6-year period 24 of 2261 (1.1%) trauma patients had prehospital chest decompression. Seventeen patients had NT, six patients TT, one patient NT as well as TT, and no patients had LT. Prehospital successful release of a tension pneumothorax was reported by the paramedics in 83% (5/6) with TT, whereas NT was effective in 18% only (3/17). In five CT scans all thoracocentesis needles were either removed or extrapleural, one patient had a tension pneumothorax, and two patients had no pneumothorax. No NT or TT related complications were reported during hospitalization.

Conclusion: Prehospital NT or TT is infrequently attempted in trauma patients. Especially NT is associated with a high failure rate of more than 80%, potentially due to an inadequate ratio between chest wall thickness and catheter length as previously published as well as a possible different pathophysiological cause of respiratory distress. Therefore, TT may be considered already in the prehospital setting to retain sufficient pleural decompression upon admission.
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http://dx.doi.org/10.1016/j.ajem.2016.11.057DOI Listing
March 2017

Sex and Age Aspects in Patients Suffering From Out-Of-Hospital Cardiac Arrest: A Retrospective Analysis of 760 Consecutive Patients.

Medicine (Baltimore) 2016 May;95(18):e3561

From the Institute of Anesthesiology, University and University Hospital Zurich (TP, NT, AK, MB, SS, DRS, KR); Schutz und Rettung, Ambulance Service, Zurich, Switzerland (SMM); Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics, University of Zurich, Switzerland (BS); and Department of Outcomes Research and General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH (KR).

Cardiopulmonary resuscitation (CPR) is indicated in patients suffering from out-of-hospital cardiac arrest. Several studies suggest a sex- and age-based bias in the treatment of these patients. This particular bias may have a significant impact on the patient's outcome. However, the reasons for these findings are still unclear and discussed controversially. Therefore, the aim of this study was to retrospectively analyze treatment and out-of-hospital survival rates for potential sex- and age-based differences in patients requiring out-of-hospital CPR provided by an emergency physician in the city of Zurich, Switzerland.A total of 3961 consecutive patients (2003-2009) were included in this retrospective analysis to determine the frequency of out-of-hospital CPR and prehospital survival rate, and to identify potential sex- and age-based differences regarding survival and treatment of the patients.Seven hundred fifty-seven patients required CPR during the study period. Seventeen patients had to be excluded because of incomplete or inconclusive documentation, resulting in 743 patients (511 males, 229 females) undergoing further statistical analysis. Female patients were significantly older, compared with male patients (68 ± 18 [mean ± SD] vs 64 ± 18 years, P = .012). Men were resuscitated slightly more often than women (86.4% vs 82.1%). Overall out-of-hospital mortality rate was found to be 81.2% (492/632 patients) with no differences between sexes (82.1% for males vs 79% for females, odds ratio 1.039, 95% confidence interval 0.961-1.123). No sex differences were detected in out-of-hospital treatment, as assessed by the different medications administered, initial prehospital Glasgow Coma Scale, and prehospital suspected leading diagnosis.The data of our study demonstrate that there was no sex-based bias in treating patients requiring CPR in the prehospital setting in our physician-led emergency ambulance service.
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http://dx.doi.org/10.1097/MD.0000000000003561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863792PMC
May 2016
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