Publications by authors named "Christina Massoth"

25 Publications

  • Page 1 of 1

[Myths and Legends: Electrocardiographic Position Control of Central Venous Catheters - Where Does the P Come from?]

Anasthesiol Intensivmed Notfallmed Schmerzther 2021 Oct 26;56(10):710-712. Epub 2021 Oct 26.

Misplacement of central venous accesses can be associated with deleterious iatrogenic complications. Electrocardiography is often used to guide the placement of central venous catheters and to confirm the correct position of the catheter tip. A characteristically peaked p-wave is traditionally considered to indicate the entrance of the catheter tip into the right atrium. However, recent data show that intraarterial and even extravascular localisation might result in an increased amplitude. The peaked p-wave most likely detects the pericardial reflection rather than a right atrial catheter position, hence real-time ultrasound is to be recommended as a superior technique to confirm a correct catheter position.
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http://dx.doi.org/10.1055/a-1534-1972DOI Listing
October 2021

CT Hypoperfusion-Hypodensity Mismatch to Identify Patients With Acute Ischemic Stroke Within 4.5 Hours of Symptom Onset.

Neurology 2021 Nov 14;97(21):e2088-e2095. Epub 2021 Oct 14.

From the Department of Neuroradiology (P.B.S., A.B., M.P.), Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Department of Radiology (P.B.S., W.H.), University Hospital Muenster; Department of Neuroradiology (A. Kemmling), University Hospital Marburg; Department of Neuroradiology (A. Kemmling, P.S.), University Medical Center Schleswig-Holstein, Luebeck; Institute of Epidemiology and Social Medicine (H.M., A. Karch), University of Muenster; Department of Neurology with Institute of Translational Neurology (L.M., H.W., J.M.), University Hospital Muenster; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University Bochum; Department of Neurology (V.P.), University Hospital Carl Gustav Carus, Dresden; Department of Radiology and Institute of Diagnostic and Interventional Radiology (K.T., S.L.), University Medical Center Rostock; Institute for Stroke and Dementia Research (ISD) (M.D.), University Hospital, LMU Munich, Germany; Medical Image Analysis Center (MIAC AG) and Department of Biomedical Engineering (M.D.), University of Basel, Switzerland; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden; Department of Anesthesiology (C.M.), Intensive Care and Pain Medicine, University Hospital Muenster; Department of Radiology (L.R.), German Cancer Research Center, Heidelberg; Department of Radiology (W.G.K.), University Hospital, LMU Munich; and Department of Neurology (G.R.), Center of Brain, Behaviour and Metabolism, University of Luebeck, Germany.

Background And Objectives: To test the hypothesis that CT hypoperfusion-hypodensity mismatch identifies patients with ischemic stroke within 4.5 hours of symptom onset.

Methods: We therefore performed the Retrospective Multicenter Hypoperfusion-Hypodensity Mismatch for The identification of Patients With Stroke Within 4.5 Hours study of patients with acute ischemic stroke and known time of symptom onset. The predictive values of hypoperfusion-hypodensity mismatch for the identification of patients with symptom onset within 4.5 hours were the main outcome measure.

Results: Of 666 patients, 548 (82.3%) had multimodal CT within 4.5 hours and 118 (17.7%) beyond 4.5 hours. Hypoperfusion-hypodensity mismatch was visible in 516 (94.2%) patients with symptom onset within and in 30 (25.4%) patients beyond 4.5 hours. CT hypoperfusion-hypodensity mismatch identified patients within 4.5 hours of stroke onset with 94.2% (95% confidence interval [CI] 91.9%-95.8%) sensitivity, 74.6% (95% CI 66.0%-81.6%) specificity, 94.5% (95% CI 92.3%-96.1%) positive predictive value, and 73.3% (95% CI 64.8%-80.4%) negative predictive value. Interobserver agreement for hypoperfusion-hypodensity mismatch was substantial (κ = 0.61, 95% CI 0.53-0.69).

Discussion: Patients with acute ischemic stroke with absence of a hypodensity on native CT (NCCT) within the hypoperfused core lesion on perfusion CT (hypoperfusion-hypodensity mismatch) are likely to be within the time window of thrombolysis. Applying this method may guide the decision to use thrombolysis in patients with unknown time of stroke onset.

Trial Registration Information: ClinicalTrials.gov Identifier: NCT04277728.

Classification Of Evidence: This study provides Class III evidence that CT hypoperfusion-hypodensity mismatch identifies patients with stroke within 4.5 hours of onset.
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http://dx.doi.org/10.1212/WNL.0000000000012891DOI Listing
November 2021

Letter commenting on "Ultrasound evaluation of inferior vena cava compression in tilted and supine term parturients".

Can J Anaesth 2021 12 22;68(12):1822-1823. Epub 2021 Sep 22.

Department of Anesthesiology and Intensive Care and Pain Medicine, Florence - Nightingale - Hospital Düsseldorf, Düsseldorf, Germany.

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http://dx.doi.org/10.1007/s12630-021-02111-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8563535PMC
December 2021

Diagnosis of Cardiac Surgery-Associated Acute Kidney Injury.

J Clin Med 2021 Aug 19;10(16). Epub 2021 Aug 19.

Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149 Münster, Germany.

Acute kidney injury after cardiac surgery is characterized by specific patterns of damage and recovery that are important to consider for management and outcome. The Kidney Disease: Improving Global Outcomes (KDIGO) classification covers only part of the conceptual framework and is thus insufficient for a comprehensive diagnosis. This review highlights the strengths and limitations of the recent criteria and provides an overview of biomarkers of cardiac surgery-associated acute kidney injury (CSA-AKI). The evolving understanding of CSA-AKI as a time-sensitive condition has increased the demand to enhance the diagnostic criteria and translate biomarkers into clinical practice.
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http://dx.doi.org/10.3390/jcm10163664DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8397056PMC
August 2021

Supine hypotensive syndrome of pregnancy: A review of current knowledge.

Eur J Anaesthesiol 2021 Jul 6. Epub 2021 Jul 6.

From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster (CM), Department of Anaesthesiology and Intensive Care, Klinikum Frankfurt Höchst, Frankfurt am Main (DC), Department of Anaesthesia, Critical Care and Pain Medicine, University Hospitals of Würzburg, Würzburg (PK), and Department of Anesthesiology, Intensive Care and Pain Medicine, Florence - Nightingale - Hospital Düsseldorf, Düsseldorf, Germany (MW).

Since the first description of supine hypotensive syndrome in the 1950s, its potentially detrimental effects on otherwise healthy women during late pregnancy have become a persistent challenge in obstetric practice. Establishing a 15° left lateral tilt during labour and caesarean section is a fundamental principle of obstetric care, universally adopted and upheld by current guidelines and recommendations. Reassessment of the original landmark studies in the light of current physiological and anatomical knowledge questions adherence to this standard in clinical practice. The modern practice of providing vasopressor support during caesarean delivery under neuraxial anaesthesia appears to negate any potential negative effects of a maternal full supine position. Recent MRI studies provide evidence as to the cause of supine hypotension and the physiological effects of different maternal positions at term. This review highlights current data on the acute supine hypotensive syndrome in contrast to traditional knowledge and established practice.
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http://dx.doi.org/10.1097/EJA.0000000000001554DOI Listing
July 2021

Impact of opioid-free anaesthesia on postoperative nausea, vomiting and pain after gynaecological laparoscopy - A randomised controlled trial.

J Clin Anesth 2021 Dec 3;75:110437. Epub 2021 Jul 3.

Department of Anesthesiology, Intensive Care and Pain Medicine, Florence-Nightingale-Hospital, Kreuzbergstraße 79, 40489 Düsseldorf, Germany.

Study Objective: Opioid-free anaesthesia may enhance postoperative recovery by reducing opioid-related side effects such as nausea, hyperalgesia or tolerance. The objective was to investigate the impact of multimodal opioid-free general anaesthesia on postoperative nausea, vomiting, pain and morphine consumption compared to the traditional opioid-based approach.

Design: This study was conducted as a prospective parallel-group randomised controlled trial.

Setting: Perioperative Care.

Patients: 152 adult women undergoing elective inpatient gynaecological laparoscopy.

Interventions: Patients were randomly assigned for opioid-free anaesthesia (Group OF) with dexmedetomidine, esketamine and sevoflurane or to have opioid-based anaesthesia (Group C) with sufentanil and sevoflurane.

Measurements: Primary outcome was the occurrence of nausea within 24 h after surgery. Patients were assessed for the incidence and severity of PONV, postoperative pain and morphine consumption and recovery characteristics.

Main Results: Patients in both groups had comparable clinical and surgical data. 69.7% of patients in the control group and 68.4% of patients in the opioid-free group met the primary endpoint (OR 1.06, 95% Confidence Interval (CI) (0.53; 2.12) p = 0.86). The incidence of clinically important PONV defined by the PONV impact scale was 8.1% (Group C) vs 10.5% (OF); p = 0.57). Antiemetic requirements, pain scores and morphine consumption were equivalent in both groups. Postoperative sedation was significantly increased in group OF (p < 0.001), and the median length of stay at the post-anaesthesia care unit was 69.0 min (46.5-113.0) vs 50.0 (35.3-77.0) minutes in the control group (p < 0.001).

Conclusions: Opioid-free multimodal general anaesthesia is feasible but did not decrease the incidence of PONV, or reduce pain scores and morphine consumption compared to an opioid-containing anaesthetic regimen.
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http://dx.doi.org/10.1016/j.jclinane.2021.110437DOI Listing
December 2021

[Erratum to: Impact of handover of anesthesia care on adverse postoperative outcomes-The HandiCAP trial].

Anaesthesist 2021 Apr 22. Epub 2021 Apr 22.

Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Geb. A1, 48149, Münster, Deutschland.

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http://dx.doi.org/10.1007/s00101-021-00964-1DOI Listing
April 2021

Comparison of C-C motif chemokine ligand 14 with other biomarkers for adverse kidney events after cardiac surgery.

J Thorac Cardiovasc Surg 2021 Mar 10. Epub 2021 Mar 10.

Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany. Electronic address:

Objective: Outcomes after acute kidney injury are affected by both the severity and the duration of the insult. Patients with persistent acute kidney injury have higher major adverse kidney events, including 90-day mortality, renal replacement therapy, and persistent kidney dysfunction. Methods to identify these patients are urgently needed to improve outcomes. The purpose of this study was to evaluate whether biomarkers, including C-C motif chemokine ligand 14, were able to predict persistent acute kidney injury and major adverse kidney events after cardiac surgery.

Methods: This study was a single-center, prospective, observational study. Patients who developed moderate or severe acute kidney injury (Kidney Disease Improving Global Outcomes 2 or 3) within 72 hours after cardiac surgery were enrolled with a primary end point of persistent severe acute kidney injury (Kidney Disease Improving Global Outcomes 3) lasting 72 hours or more.

Results: A total of 100 patients were available for the primary analysis, and 37 met the primary end point. C-C motif chemokine ligand 14 was the most predictive biomarker for the primary end point with an area under the curve of 0.930 (95% confidence interval, 0.881-0.979). The area under the curve of C-C motif chemokine ligand 14 was significantly higher than the area under the curve for the other biomarkers analyzed. C-C motif chemokine ligand 14 was significantly higher in end point positive patients at enrollment (4.47 ng/mL [2.35-11.5] vs 0.67 ng/mL [0.38-1.07]; P = .001). Sensitivity and specificity were 78% and 95% at a cutoff value of 2.21 ng/mL, respectively. C-C motif chemokine ligand 14 was also highly accurate for predicting renal replacement therapy within 7 days (area under the curve, 0.915; 95% confidence interval, 0.858-0.972; P < .001).

Conclusions: Elevated C-C motif chemokine ligand 14 levels predict persistent acute kidney injury in cardiac surgery patients with moderate or severe acute kidney injury. This new biomarker may help stratify patients destined to receive renal replacement therapy and identify patients who may benefit from novel therapeutic approaches to acute kidney injury.
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http://dx.doi.org/10.1016/j.jtcvs.2021.03.016DOI Listing
March 2021

[Safer anesthesia and duty hour limits: are handovers of personnel allowed?]

Anaesthesist 2021 05 7;70(5):439-448. Epub 2021 Apr 7.

Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Deutschland.

Restrictions of duty hours in medicine are an ambivalent matter with respect to patient safety. Continuity of treatment carries the risk of medical errors from declining performance capability and must be balanced against the risk of communication failure and information loss due to personnel changes. Complete intraoperative changes of anesthetists are frequently carried out in the clinical routine but possibly have the potential to negatively influence the postoperative morbidity and mortality. The relevance of anesthesiological care for the perioperative outcome also seems to vary depending on the specialist discipline involved. While standardized handover protocols seem to be only of limited effectiveness for the improvement of transfer of information, they are nevertheless a reasonable approach for optimization of interprofessional communication and reduction of treatment errors.
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http://dx.doi.org/10.1007/s00101-021-00949-0DOI Listing
May 2021

Acute Kidney Injury in Cardiac Surgery.

Crit Care Clin 2021 Apr 13;37(2):267-278. Epub 2021 Feb 13.

Department of Anesthesiology, Intensive Care, and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, Münster 48149, Germany. Electronic address:

Acute kidney injury (AKI) occurs frequently after cardiac surgery and is associated with high morbidity and mortality. Although the number of cardiac surgical procedures is constantly growing worldwide, incidence of cardiac surgery-associated AKI is still around 40% and has a significant impact on global health care costs. Numerous trials attempted to identify strategies to prevent AKI and attenuate its detrimental consequences. Effective options remained elusive. Current evidence supports a multimodal risk-stratification approach with biomarker-guided management of high-risk patients, perioperative administration of dexmedetomidine, and implementation of a care bundle as recommended by the Kidney Disease: Improving Global Outcomes group.
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http://dx.doi.org/10.1016/j.ccc.2020.11.009DOI Listing
April 2021

[Impact of handover of anesthesia care on adverse postoperative outcomes-The HandiCAP trial].

Anaesthesist 2021 04 11;70(4):320-323. Epub 2021 Mar 11.

Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Geb. A1, 48149, Münster, Deutschland.

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http://dx.doi.org/10.1007/s00101-021-00940-9DOI Listing
April 2021

Prevention of Cardiac Surgery-Associated Acute Kidney Injury by Implementing the KDIGO Guidelines in High-Risk Patients Identified by Biomarkers: The PrevAKI-Multicenter Randomized Controlled Trial.

Anesth Analg 2021 08;133(2):292-302

From the Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany.

Background: Prospective, single-center trials have shown that the implementation of the Kidney Disease: Improving Global Outcomes (KDIGO) recommendations in high-risk patients significantly reduced the development of acute kidney injury (AKI) after surgery. We sought to evaluate the feasibility of implementing a bundle of supportive measures based on the KDIGO guideline in high-risk patients undergoing cardiac surgery in a multicenter setting in preparation for a large definitive trial.

Methods: In this multicenter, multinational, randomized controlled trial, we examined the adherence to the KDIGO bundle consisting of optimization of volume status and hemodynamics, functional hemodynamic monitoring, avoidance of nephrotoxic drugs, and prevention of hyperglycemia in high-risk patients identified by the urinary biomarkers tissue inhibitor of metalloproteinases-2 [TIMP-2] and insulin growth factor-binding protein 7 [IGFBP7] after cardiac surgery. The primary end point was the adherence to the bundle protocol and was evaluated by the percentage of compliant patients with a 95% confidence interval (CI) according to Clopper-Pearson. Secondary end points included the development and severity of AKI.

Results: In total, 278 patients were included in the final analysis. In the intervention group, 65.4% of patients received the complete bundle as compared to 4.2% in the control group (absolute risk reduction [ARR] 61.2 [95% CI, 52.6-69.9]; P < .001). AKI rates were statistically not different in both groups (46.3% intervention versus 41.5% control group; ARR -4.8% [95% CI, -16.4 to 6.9]; P = .423). However, the occurrence of moderate and severe AKI was significantly lower in the intervention group as compared to the control group (14.0% vs 23.9%; ARR 10.0% [95% CI, 0.9-19.1]; P = .034). There were no significant effects on other specified secondary outcomes.

Conclusions: Implementation of a KDIGO-derived treatment bundle is feasible in a multinational setting. Furthermore, moderate to severe AKI was significantly reduced in the intervention group.
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http://dx.doi.org/10.1213/ANE.0000000000005458DOI Listing
August 2021

Kinetic Changes of Plasma Renin Concentrations Predict Acute Kidney Injury in Cardiac Surgery Patients.

Am J Respir Crit Care Med 2021 05;203(9):1119-1126

Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany.

The renin-angiotensin-aldosterone system is a major pathway in regulating blood pressure, glomerular filtration, and fluid homeostasis. During inflammatory diseases, generation of angiotensin II might be disturbed, leading to increased renin concentrations. Cardiac surgery and the use of cardiopulmonary bypass both induce inflammatory response and cardiovascular instability, which can contribute to acute kidney injury (AKI). To investigate whether renin concentrations are associated with hypotension and AKI. This is a single-center, prospective, observational study among patients undergoing cardiac surgery. The primary endpoint was the occurrence of AKI within 72 hours after cardiac surgery. A total of 197 patients were available for the primary analysis. The median renin serum concentration was 40.2 μU/ml (quartile 1 [Q1]-Q3, 9.3-144.4) at baseline and 51.3 μU/ml (Q1-Q3, 19.1-167.0) 4 hours after cardiac surgery, whereas the difference between postoperation and preoperation concentrations (Δ-renin) was 3.7 μU/ml (Q1-Q3, -22.7 to 50.9). Patients with an elevated Δ-renin developed an AKI significantly more often (43% vs. 12.2%;  < 0.001). High Δ-renin after cardiac surgery was associated with a significantly lower mean arterial pressure, longer time on vasopressors, and longer length of ICU and hospital stay. The area under the curve (AUC) of Δ-renin for the prediction of AKI (AUC, 0.817; 95% confidence interval, 0.747-0.887) was significantly greater compared with the AUC of the postoperative renin concentrations (AUC, 0.702; 95% CI, 0.610-0.793;  = 0.007). Elevated renin concentrations were associated with cardiovascular instability and increased AKI after cardiac surgery. Elevated renin concentrations could be used to identify high-risk patients for cardiovascular instability and AKI who would benefit from timely intervention that could improve their outcomes.
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http://dx.doi.org/10.1164/rccm.202005-2050OCDOI Listing
May 2021

Notsectio: eine Herausforderung in der geburtshilflichen Anästhesie.

Anasthesiol Intensivmed Notfallmed Schmerzther 2020 Nov 26;55(11-12):662-673. Epub 2020 Nov 26.

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http://dx.doi.org/10.1055/a-1070-6810DOI Listing
November 2020

Hypotension after spinal anesthesia for cesarean section: how to approach the iatrogenic sympathectomy.

Curr Opin Anaesthesiol 2020 Jun;33(3):291-298

Department of Anesthesiology, Intensive Care and Pain Medicine, Florence - Nightingale - Hospital Düsseldorf, Düsseldorf, Germany.

Purpose Of Review: Hypotension during cesarean section remains a frequent complication of spinal anesthesia and is associated with adverse maternal and fetal events.

Recent Findings: Despite ongoing research, no single measure for sufficient treatment of spinal-induced hypotension was identified so far. Current literature discusses the efficacy of low-dose spinal anesthesia, timing and solutions for adequate fluid therapy and various vasopressor regimens. Present guidelines favor the use of phenylephrine over ephedrine because of decreased umbilical cord pH values, while norepinephrine is discussed as a probable superior alternative with regard to maternal bradycardia, although supporting data is limited. Alternative pharmacological approaches, such as 5HT3-receptor antagonists and physical methods may be taken into consideration to further improve hemodynamic stability.

Summary: Current evidence favors a combined approach of low-dose spinal anesthesia, adequate fluid therapy and vasopressor support to address maternal spinal-induced hypotension. As none of the available vasopressors is associated with relevantly impaired maternal and fetal outcomes, none of them should be abandoned from obstetric practice. Rapid crystalloid co-loading is of equivalent efficacy as compared with colloids and should be preferred because of a more favorable risk profile.
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http://dx.doi.org/10.1097/ACO.0000000000000848DOI Listing
June 2020

Biomarker-guided implementation of the KDIGO guidelines to reduce the occurrence of acute kidney injury in patients after cardiac surgery (PrevAKI-multicentre): protocol for a multicentre, observational study followed by randomised controlled feasibility trial.

BMJ Open 2020 04 6;10(4):e034201. Epub 2020 Apr 6.

Anesthesiology, Intensive Care and Pain Medicine, Universitatsklinikum Munster, Munster, Nordrhein-Westfalen, Germany

Introduction: Acute kidney injury (AKI) is a frequent complication after cardiac surgery with adverse short-term and long-term outcomes. Although prevention of AKI (PrevAKI) is strongly recommended, the optimal strategy is uncertain. The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommended a bundle of supportive measures in high-risk patients. In a single-centre trial, we recently demonstrated that the strict implementation of the KDIGO bundle significantly reduced the occurrence of AKI after cardiac surgery. In this feasibility study, we aim to evaluate whether the study protocol can be implemented in a multicentre setting in preparation for a large multicentre trial.

Methods And Analysis: We plan to conduct a prospective, observational survey followed by a randomised controlled, multicentre, multinational clinical trial including 280 patients undergoing cardiac surgery with cardiopulmonary bypass. The purpose of the observational survey is to explore the adherence to the KDIGO recommendations in routine clinical practice. The second phase is a randomised controlled trial. The objective is to investigate whether the trial protocol is implementable in a large multicentre, multinational setting. The primary endpoint of the interventional part is the compliance rate with the protocol. Secondary endpoints include the occurrence of any AKI and moderate/severe AKI as defined by the KDIGO criteria within 72 hours after surgery, renal recovery at day 90, use of renal replacement therapy (RRT) and mortality at days 30, 60 and 90, the combined endpoint major adverse kidney events consisting of persistent renal dysfunction, RRT and mortality at day 90 and safety outcomes.

Ethics And Dissemination: The PrevAKI multicentre study has been approved by the leading Research Ethics Committee of the University of Münster and the respective Research Ethics Committee at each participating site. The results will be used to design a large, definitive trial.

Trial Registration Number: NCT03244514.
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http://dx.doi.org/10.1136/bmjopen-2019-034201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245412PMC
April 2020

[Update: Renal Replacement Therapy].

Anasthesiol Intensivmed Notfallmed Schmerzther 2020 Mar 19;55(3):178-189. Epub 2020 Mar 19.

Renal replacement therapy (RRT) remains the cornerstone of treatment for severe acute kidney injury. However, despite its spreading use along with rising incidences of acute kidney injury, evidence of most recommendations is limited so far. Early initiation of RRT seems to reduce mortality but is associated with higher incidence of adverse events. Continuous RRT is advantageous in terms of hemodynamic control and decreased incidence of chronic dialysis dependency but without affecting mortality. Regional citrate anticoagulation should be preferred with regard to longer filter circuit life span. Intensified RRT with a prescribed dose ≥ 35 mL/kg/h has no benefit with regard to mortality but is associated with higher occurrence of complications. Urine output has the best prognostic value for cessation of RRT. Biomarkers of renal impairment and recovery are needed for better guidance of therapy.
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http://dx.doi.org/10.1055/a-0853-3928DOI Listing
March 2020

Risk Stratification for Targeted AKI Prevention After Surgery: Biomarkers and Bundled Interventions.

Semin Nephrol 2019 09;39(5):454-461

Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany. Electronic address:

Perioperative acute kidney injury (AKI) is a surgery-associated complication with increasing incidence, not only because of enhanced awareness for the diagnosis, but also as a result of the aging society with a growing number of severe comorbidities undergoing major surgical procedures. The dilemma of AKI as a global health burden lies in the discrepancy between its importance as a significant risk factor for morbidity and mortality, and the unavailability of specific therapies to modify these adverse outcomes. Thus, it is all the more important to focus management on AKI prevention, and when AKI occurs to focus on early recognition and immediate adaption of individualized care. AKI is the result of an inter-relationship between patient susceptibility and determinants of perioperative exposures. Screening for constellations of risk factors along with measurement of novel biomarkers allows for early identification of patients who are susceptible to AKI and to initiate early targeted care. Targeted care involves implementation of a bundle of interventions adapted from a consensus management guideline, and is a strategy with growing evidence of a beneficial effect on patients' short- and long-term outcomes.
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http://dx.doi.org/10.1016/j.semnephrol.2019.06.005DOI Listing
September 2019

Nasolaryngeal Distances in the Adult Population and an Evaluation of Commercially Available Nasotracheal Tubes.

Anesth Analg 2020 04;130(4):1018-1025

From the Departments of Anesthesiology and Intensive Care.

Background: Preformed nasal endotracheal tubes (NETs) come with a predefined insertion depth due to their curved design. While size indication refers to internal diameter, there is a considerable variability in the corresponding lengths and proportions of same-sized tubes of different manufacturers which is probably based on the lack of data of nasolaryngeal distances (NLDs) in the adult population. Choosing the best-fitting NET is therefore difficult and carries the risk of endobronchial intubation or, on the contrary, cuff inflation at the vocal cord level. The aim of this study was to develop a prediction model for NLD and a selection guide to choose the appropriate NET based on a radiographic description of NLD in comparison to the measurements of available NETs of several manufacturers.

Methods: After institutional ethics board review, 388 computed tomography (CT) scan images of head, neck, and upper thorax in a heterogeneous adult cohort were included. Mean distances from the nares to the lower border of the thyroid cartilage were measured. NETs from different manufacturers were measured and compared to the NLD derived from the radiographic analysis. The patients' sex, body height, and weight were considered as possible covariates in quantile regression models for predicting the NLD.

Results: Data from 200 patients were analyzed. NLD was associated with sex, body height, and weight. A simple quantile regression model using the body height as the only covariate sufficed to achieve accurate predictions of NLD. Validation on independent test data showed that 92.8% of the NLD predictions were closer than ±20 mm to the observed NLD values. Measurements of equal-sized NETs varied considerably in outer diameter, proportion, the nasopharyngeal part, and guide marks. Length differences of the bend-to-cuff distance, containing the anatomically NLD, ranged between 218 and 270 mm at same sizes.

Conclusions: A reliable prediction of NLD can be obtained simply by body height, using the formula (Equation is included in full-text article.). As manufacturers' tube lengths vary substantially, additional information about the bend-to-cuff distance as corresponding tube section would allow for more accurate tube selection.
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http://dx.doi.org/10.1213/ANE.0000000000004241DOI Listing
April 2020

Epidural test dose in obstetric patients: should we still use it?

Curr Opin Anaesthesiol 2019 Jun;32(3):263-267

Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany.

Purpose Of Review: As the application of a test dose after epidural catheter insertion in obstetrics has recurrently been associated with serious adverse events affecting both maternal and foetal outcomes, the question whether to test or not remains a controversial issue.

Recent Findings: Present guidelines do not provide clear recommendations in this regard and several recent surveys indicate a heterogeneity in clinical routine.

Summary: Physiological alterations during pregnancy and labour restrict the use and also the validity of traditional test agents. Epinephrine is not appropriate to detect a vascular insertion in labour and the application of a local anaesthetic test dose may lead to dose-dependent fatal consequences should the catheter be intrathecal, due to an increased sensitivity in parturients. Given the current practice of opioid-amended-low-concentration epidurals, the waiving of a test dose results at worst in a failed epidural, a stark contrast to the potentially severe to fatal complications of a 'traditional' test dose. Hence, an originally preventive measure providing potentially more harm than the consequences of the situation aimed to prevent, should not be recommended. A simple fractionated administration of the initial analgesic dose seems reasonable though.
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http://dx.doi.org/10.1097/ACO.0000000000000721DOI Listing
June 2019

High-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students.

BMC Med Educ 2019 Jan 21;19(1):29. Epub 2019 Jan 21.

Department of Anesthesiology and Intensive Care, University Hospital Münster, Albert-Schweitzer-Campus 1 (A1), 48149, Münster, Germany.

Background: Simulation has become integral to the training of both undergraduate medical students and medical professionals. Due to the increasing degree of realism and range of features, the latest mannequins are referred to as high-fidelity simulators. Whether increased realism leads to a general improvement in trainees' outcomes is currently controversial and there are few data on the effects of these simulators on participants' personal confidence and self-assessment.

Methods: One-hundred-and-thirty-five fourth-year medical students were randomly allocated to participate in either a high- or a low-fidelity simulated Advanced Life Support training session. Theoretical knowledge and self-assessment pre- and post-tests were completed. Students' performance in simulated scenarios was recorded and rated by experts.

Results: Participants in both groups showed a significant improvement in theoretical knowledge in the post-test as compared to the pre-test, without significant intergroup differences. Performance, as assessed by video analysis, was comparable between groups, but, unexpectedly, the low-fidelity group had significantly better results in several sub-items. Irrespective of the findings, participants of the high-fidelity group considered themselves to be advantaged, solely based on their group allocation, compared with those in the low-fidelity group, at both pre- and post-self-assessments. Self-rated confidence regarding their individual performance was also significantly overrated.

Conclusion: The use of high-fidelity simulation led to equal or even worse performance and growth in knowledge as compared to low-fidelity simulation, while also inducing undesirable effects such as overconfidence. Hence, in this study, it was not beneficial compared to low-fidelity, but rather proved to be an adverse learning tool.
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http://dx.doi.org/10.1186/s12909-019-1464-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341720PMC
January 2019

Dietary salt promotes ischemic brain injury and is associated with parenchymal migrasome formation.

PLoS One 2018 27;13(12):e0209871. Epub 2018 Dec 27.

Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany.

Sodium chloride promotes vascular fibrosis, arterial hypertension, pro-inflammatory immune cell polarization and endothelial dysfunction, all of which might influence outcomes following stroke. But despite enormous translational relevance, the functional importance of sodium chloride in the pathophysiology of acute ischemic stroke is still unclear. In the current study, we show that high-salt diet leads to significantly worse functional outcomes, increased infarct volumes, and a loss of astrocytes and cortical neurons in acute ischemic stroke. While analyzing the underlying pathologic processes, we identified the migrasome as a novel, sodium chloride-driven pathomechanism in acute ischemic stroke. The migrasome was previously described in vitro as a migrating organelle, which incorporates and dispatches cytosol of surrounding cells and plays a role in intercellular signaling, whereas a pathophysiological meaning has not been elaborated. We here confirm previously reported characteristics of the migrasome in vivo. Immunohistochemistry, electron microscopy and proteomic analyses further demonstrate that the migrasome incorporates and dispatches cytosol of surrounding neurons following stroke. The clinical relevance of these findings is emphasized by neuropathological examinations, which detected migrasome formation in infarcted brain parenchyma of human stroke patients. In summary, we demonstrate that high-salt diet aggravates stroke outcomes, and we characterize the migrasome as a novel mechanism in acute stroke pathophysiology.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0209871PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6307724PMC
May 2019

Availability of cookies during an academic course session affects evaluation of teaching.

Med Educ 2018 10 29;52(10):1064-1072. Epub 2018 Jun 29.

Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Münster, Germany.

Objectives: Results from end-of-course student evaluations of teaching (SETs) are taken seriously by faculties and form part of a decision base for the recruitment of academic staff, the distribution of funds and changes to curricula. However, there is some doubt as to whether these evaluation instruments accurately measure the quality of course content, teaching and knowledge transfer. We investigated whether the provision of chocolate cookies as a content-unrelated intervention influences SET results.

Methods: We performed a randomised controlled trial in the setting of a curricular emergency medicine course. Participants were 118 third-year medical students. Participants were randomly allocated into 20 groups, 10 of which had free access to 500 g of chocolate cookies during an emergency medicine course session (cookie group) and 10 of which did not (control group). All groups were taught by the same teachers. Educational content and course material were the same for both groups. After the course, all students were asked to complete a 38-question evaluation form.

Results: A total of 112 students completed the evaluation form. The cookie group evaluated teachers significantly better than the control group (113.4 ± 4.9 versus 109.2 ± 7.3; p = 0.001, effect size 0.68). Course material was considered better (10.1 ± 2.3 versus 8.4 ± 2.8; p = 0.001, effect size 0.66) and summation scores evaluating the course overall were significantly higher (224.5 ± 12.5 versus 217.2 ± 16.1; p = 0.008, effect size 0.51) in the cookie group.

Conclusions: The provision of chocolate cookies had a significant effect on course evaluation. These findings question the validity of SETs and their use in making widespread decisions within a faculty.
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http://dx.doi.org/10.1111/medu.13627DOI Listing
October 2018

Feasibility of Cervical Epidural Anesthesia for Breast Cancer Surgery.

Anesthesiol Res Pract 2017 18;2017:7024924. Epub 2017 Jul 18.

Department of Anesthesiology and Intensive Care, St. Franziskus Hospital, Muenster, Germany.

Background: Effects of perioperative cervical level neuraxial blocks on the dissemination of cancer metastases have become a matter of substantial interest. However, experience with these catheters has been limited and data on feasibility and efficacy is sparse.

Methods: Data from 39 patients scheduled to undergo breast cancer surgery while awake with a cervical epidural alone was retrospectively analyzed.

Results: In 26 patients (66,7%, 95% CI 51,7-81,7) the cervical epidural catheter was sufficient for surgery. In one patient (2.6%, 95% CI 0-7.6) identification of the epidural space was not possible. Four patients (10.3%, 95% CI 0,7-19,9) had an insufficient sensory block. Seven patients (17.9%, 95% CI 5,7-30,1) had a partially insufficient sensory block. Rates of failed epidural blocks were not significantly different between different insertion levels. 21 patients (80.8%, 95% CI 65,4-96,1) developed hypotension and required an intravenous vasopressor. One patient developed nausea. In one patient the dura was accidentally punctured. No neurological damage was observed. No other major complications were observed.

Discussion: Epidural punctures in the cervical region are feasible but do bear potential for major complications. Anesthesiologists should familiarize themselves with high epidural block techniques.
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http://dx.doi.org/10.1155/2017/7024924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540389PMC
July 2017

Not Only Sleepwalking But NREM Parasomnia Irrespective of the Type Is Associated with HLA DQB1*05:01.

J Clin Sleep Med 2016 Apr 15;12(4):565-70. Epub 2016 Apr 15.

Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.

Study Objectives: Despite the high prevalence and clinical relevance of NREM parasomnias, data on supportive genetic markers are scarce, and mainly refer to sleepwalking only.

Methods: We retrospectively analyzed clinical, polysomnographic, and HLA findings of 74 adults (37 men) with NREM parasomnia gathered from four neurological sleep centers. Parasomniac events were classified according to ICSD-2 criteria. HLA DQB1 genotyping was compared to regional-matched reference allele-frequencies.

Results: Fifty-six patients had more than 2 different parasomnia type: 11 sleepwalking, 4 sleep terrors, 3 confusional arousals only. Parasomniac events were documented during video-polysomnography (V-PSG) in 70% (49/70) of subjects (71.4% confusional arousals, 8.2% sleep terrors, 4.1% sleepwalking, 16.3% ≥ 2 NREM parasomnia types). Violent behavior during V-PSG occurred in 8.5% (6/71). NREM parasomnia onset was reported after the age of 30 years in 6.8% (5/74). The HLA DQB1*05:01 allele was present in 41% (29/71) compared to 24.2% in the regional-matched reference allele group (p < 0.05). This haplotype prevalence did not differ within the NREM parasomnia type. Epworth Sleepiness Score was 10 or higher in 28.6%.

Conclusions: This is a large polysomnography-based case series of patients with NREM parasomnia. In patients with suspected sleepwalking or sleep terrors, polysomnography is highly useful in detecting arousals from NREM sleep as a marker of NREM parasomnia. We confirmed previous findings by demonstrating a high prevalence of the HLA DQB1*05:01 genotype for different types of NREM parasomnias. Our findings therefore support a common genetic background, and corroborate the importance of video-polysomnography in the work-up of parasomnia.
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http://dx.doi.org/10.5664/jcsm.5692DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795284PMC
April 2016
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