Publications by authors named "Donat R Spahn"

246 Publications

Iron deficiency in PREVENTT.

Lancet 2021 Feb;397(10275):668-669

Institute of Anesthesiology, University Hospital Zurich, 8091 Zurich, Switzerland. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(21)00226-9DOI Listing
February 2021

Physicians' perceptions regarding acute bleeding management: an international mixed qualitative quantitative study.

BMC Anesthesiol 2021 Feb 10;21(1):43. Epub 2021 Feb 10.

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

Background: Acute bleeding is an omnipresent challenge for all physicians. Uncontrolled hemorrhage is the most common preventable cause of death after trauma worldwide. In different surgical disciplines, hemorrhage represents an independent risk factor for increased postoperative morbimortality, directly affecting patients' outcomes. This study asked anesthesiologists about their personal perceived challenges when treating bleeding patients.

Methods: This investigator-initiated, prospective, international, dual-center, mixed qualitative and quantitative study interrogated anesthesiologists about what they found easy and what difficult in treating acutely bleeding patients. Following the template approach for qualitative research, we identified major and minor topics through free inductive coding and word count. In a second step, we derived ten statements from the participants' answers. Using a field survey, we then asked the participants to rate their level of agreement with the derived statements. We analyzed the answers using one sample Wilcoxon test and the Mann-Whitney test.

Results: We included a total of 84 physicians in the qualitative interrogations and a different group of 42 anesthesiologists in the quantitative part. We identified 11 major topics and 19 associated subtopics. The main topics and the degree of agreement (here as agree or strongly agree) were as follows: "Complexity of the topic" (52.4% agreed to find the topic complex), "Cognitive aids" (92.9% agreed to find them helpful), "Time management" (64.3% agreed to feeling time pressure), "Human factors" (95.2% agreed that human factors are essential), "Resources" (95.2% agreed that resources are essential), "Experience" and "Low frequency of cases" (57.1% agreed to lack practice), "Diagnostic methods" (31.0% agreed that the interpretation of test results is difficult), "Anticoagulation" (85.7% agreed to it being difficult), "Treatment" (81.0% agreed to knowing the first therapeutic steps), and "Nothing".

Conclusions: Anesthesiologists in two large tertiary care facilities in different parts of the world found coagulation management, especially in anticoagulated patients, complex. We identified the delayed diagnostic test results and their interpretation as challenges. Resources, treatment protocols and human factors such as team communication were perceived to facilitate management. Future studies should explore the challenges in smaller hospitals and other parts of the world and test new technologies addressing the identified difficulties.
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http://dx.doi.org/10.1186/s12871-021-01269-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874660PMC
February 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

Functional, Metabolic and Morphologic Results of Ex Vivo Donor Lung Perfusion with a Perfluorocarbon-Based Oxygen Carrier Nanoemulsion in a Large Animal Transplantation Model.

Cells 2020 11 18;9(11). Epub 2020 Nov 18.

Institute of Anesthesiology, University Hospital Zurich-University of Zurich, CH-8091 Zurich, Switzerland.

Background: Ex vivo lung perfusion (EVLP) is a technology that allows the re-evaluation of questionable donor lung before implantation and it has the potential to repair injured donor lungs that are otherwise unsuitable for transplantation. We hypothesized that perfluorocarbon-based oxygen carrier, a novel reconditioning strategy instilled during EVLP would improve graft function.

Methods: We utilized perfluorocarbon-based oxygen carrier (PFCOC) during EVLP to recondition and improve lung graft function in a pig model of EVLP and lung transplantation. Lungs were retrieved and stored for 24 h at 4 °C. EVLP was done for 6 h with or without PFCOC. In the transplantation groups, left lung transplantation was done after EVLP with or without PFCOC. Allograft function was assessed by means of pulmonary gas exchange, lung mechanics and vascular pressures, histology and transmission electron microscopy (TEM).

Results: In the EVLP only groups, physiological and biochemical markers during the 6-h perfusion period were comparable. However, perfusate lactate potassium levels were lower and ATP levels were higher in the PFCOC group. Radiologic assessment revealed significantly more lung infiltrates in the controls than in the PFCOC group ( = 0.04). In transplantation groups, perfusate glucose consumption was higher in the control group. Lactate levels were significantly lower in the PFCOC group ( = 0.02). Perfusate flavin mononucleotide (FMN) was significantly higher in the controls ( = 0.008). Post-transplant gas exchange was significantly better during the 4-h reperfusion period in the PFCOC group ( = 0.01). Plasma IL-8 and IL-12 levels were significantly lower in the PFCOC group ( = 0.01, = 0.03, respectively). ATP lung tissue levels at the end of the transplantation were higher and myeloperoxidase (MPO) levels in lung tissue were lower in the PFCOC group compared to the control group. In the PFCOC group, TEM showed better tissue preservation and cellular viability.

Conclusion: PFCOC application is safe during EVLP in lungs preserved 24 h at 4 °C. Although this strategy did not significantly affect the EVLP physiology, metabolic markers of the donor quality such as lactate production, glucose consumption, neutrophil infiltration and preservation of mitochondrial function were better in the PFCOC group. Following transplantation, PFCOC resulted in better graft function and TEM showed better tissue preservation, cellular viability and improved gas transport.
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http://dx.doi.org/10.3390/cells9112501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7698917PMC
November 2020

Physicians' Perceptions of a Situation Awareness-Oriented Visualization Technology for Viscoelastic Blood Coagulation Management (Visual Clot): Mixed Methods Study.

JMIR Serious Games 2020 Dec 4;8(4):e19036. Epub 2020 Dec 4.

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

Background: Viscoelastic tests enable a time-efficient analysis of coagulation properties. An important limitation of viscoelastic tests is the complicated presentation of their results in the form of abstract graphs with a multitude of numbers. We developed Visual Clot to simplify the interpretation of presented clotting information. This visualization technology applies user-centered design principles to create an animated model of a blood clot during the hemostatic cascade. In a previous simulation study, we found Visual Clot to double diagnostic accuracy, reduce time to decision making and perceived workload, and improve care providers' confidence.

Objective: This study aimed to investigate the opinions of physicians on Visual Clot technology. It further aimed to assess its strengths, limitations, and clinical applicability as a support tool for coagulation management.

Methods: This was a researcher-initiated, international, double-center, mixed qualitative-quantitative study that included the anesthesiologists and intensive care physicians who participated in the previous Visual Clot study. After the participants solved six coagulation scenarios using Visual Clot, we questioned them about the perceived pros and cons of this new tool. Employing qualitative research methods, we identified recurring answer patterns, and derived major topics and subthemes through inductive coding. Based on them, we defined six statements. The study participants later rated their agreement to these statements on five-point Likert scales in an online survey, which represented the quantitative part of this study.

Results: A total of 60 physicians participated in the primary Visual Clot study. Among these, 36 gave an interview and 42 completed the online survey. In total, eight different major topics were derived from the interview field note responses. The three most common topics were "positive design features" (29/36, 81%), "facilitates decision making" (17/36, 47%), and "quantification not made" (17/36, 47%). In the online survey, 93% (39/42) agreed to the statement that Visual Clot is intuitive and easy to learn. Moreover, 90% (38/42) of the participants agreed that they would like the standard result and Visual Clot displayed on the screen side by side. Furthermore, 86% (36/42) indicated that Visual Clot allows them to deal with complex coagulation situations more quickly.

Conclusions: A group of anesthesia and intensive care physicians from two university hospitals in central Europe considered Visual Clot technology to be intuitive, easy to learn, and useful for decision making in situations of active bleeding. From the responses of these possible future users, Visual Clot appears to constitute an efficient and well-accepted way to streamline the decision-making process in viscoelastic test-based coagulation management.
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http://dx.doi.org/10.2196/19036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7748952PMC
December 2020

Is patient blood management cost-effective? Comment on Br J Anaesth 2020.

Br J Anaesth 2021 01 26;126(1):e7-e9. Epub 2020 Sep 26.

Medical School, University of Western Australia, Perth, Australia; Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.

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http://dx.doi.org/10.1016/j.bja.2020.09.003DOI Listing
January 2021

Building a patient blood management program in a large-volume tertiary hospital setting: Problems and solutions.

Turk Gogus Kalp Damar Cerrahisi Derg 2020 Jul 28;28(3):560-569. Epub 2020 Jul 28.

Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey.

Successful implementation of a patient blood management program necessitates the collaboration of a strong organization and a multidisciplinary approach. We organized a meeting with broad participation in our center to establish a consensus for implementation of a specific patient blood management program. International and domestic experiences were shared, the importance of coordination and execution of different pillars in patient blood management were discussed, and the problems about the blood transfusion system were also investigated with the proposal for solutions. The data obtained from this meeting are presented to be a guide for similar large-volume tertiary hospitals for integration of a patient blood management protocol.
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http://dx.doi.org/10.5606/tgkdc.dergisi.2020.19701DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493600PMC
July 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

Peri-operative blood transfusion in elective major surgery: incidence, indications and outcome - an observational multicentre study.

Authors:
Dilek Unal Yesim Senayli Reyhan Polat Donat R Spahn Fevzı Toraman Neslıhan Alkis Alanoglu Zekeriyya Aydinli Bahar Bermede Ahmet Onat Bilgin Hulya Buget Mehmet Coskunfirat Nesil Demir Asli Goren Suna Guner Can Meltem Orhan Mukadder Senturk Mert Tezcan Busra Toprak Huseyin Ilksen Yildirim Guclu Cigdem Abitagaoglu Suheyla Abut Yesim Akdaglı Ekici Arzu Akdas Tekin Esra Akdogan Ali Akin Mine Akovali Nukhet Aksoy Semsi Mustafa Alaygut Ergin Arar Makbule Cavidan Arican Sule Arici Ayse Gulbin Arik Emine Arik Esma Arslan Mahmut Ay Necmiye Aykac Zuhal Ayoglu Hilal Basaran Cumhur Baytas Volkan Bedirli Nurdan Bestas Azize Bigat Zekiye Bilgin Mehmet Ugur Boran Omer Faruk Buyukcoban Sibel Cakar Turhan Sanem Cakmak Meltem Cankaya Baris Capar Ayse Cebeci Zubeyir Cetinkaya Ethemoglu Filiz Banu Cicekci Faruk Colak Alkin Colak Yusuf Ziya Dagli Esra Demir Hafize Fisun Derbent Abdurrahim Dumanlı Ozcan Ayca Ekinci Osman Erdogan Kayhan Gulay Erturk Engin Erus Ipek Esen Tekeli Arzu Gamli Mehmet Gulel Basak Gulgun Gamze Gunduz Emel Gunes Isin Guven Aytac Betul Hacibeyoglu Gulcin Has Selmi Nazan Ilgaz Kocyigit Ozgen Ilksen Egilmez Ayse Iyigun Muzeyyen Kara Inci Karakaya Deniz Karasu Derya Karaveli Arzu Kavas Ayse Duygu Kaya Mensure Kaya Suleyman Kazak Bengisun Zuleyha Keskin Gulsen Kilci Oya Kilic Yeliz Kirdemir Pakize Koc Zeynep Koksal Ceren Kozanhan Betul Kucukguclu Semih Kucukosman Gamze Kupeli Ilke Kurtay Aysun Kurtipek Omer Meco Basak Ceyda Nalbant Burak Okyay Rahsan Dilek Omur Dilek Orak Yavuz Ounde Elif Özayar Esra Ozcelik Menekse Ozden Eyup Sabri Ozer Yetkin Ozgok Aysegul Ozhan Mehmet Ozgur Ozlu Onur Sagir Ozlem Saglik Arzu Sagun Aslinur Sahap Mehmet Sahin Cihan Sahiner Yeliz Salman Nevriye Saracoglu Ayten Saracoglu Kemal Tolga Sarizeybek Hilal Selcuk Sert Gokce Sen Betul Sen Ozlem Sener Elif Bengi Sengul Fatma Isil Silay Emin Subası Ferhunde Dilek Tarikci Kilic Ebru Tas Nilay Tekgul Zeki Tuncel Tekgunduz Sibel Tezcan Keles Gonul Topcu Hulya Tunay Abdurrahman Ugun Fatih Un Canan Unal Petek Unver Suheyla Ural Sedef Gulcin Uzumcugil Filiz Yerebakan Akesen Selcan Yesildal Kadir Yildirim Mustafa Yildiz Altun Aysun Yildiz Munise Yilmaz Erisen Hatice Yilmaz Hakan Yilmaz Mehmet Yuzkat Nureddin

Blood Transfus 2020 07;18(4):261-279

Department of Anaesthesiology and Reanimation, Van Yuzuncu Yil University Medical Faculty Dursun Odabası Medical Center, Van, Turkey.

Background: Patients' demographic and epidemiological characteristics, local variations in clinicians' knowledge and experience and types of surgery can influence peri-operative transfusion practices. Sharing data on transfusion practices and recipients may improve patients' care and implementation of Patient Blood Management (PBM).

Materials And Methods: This was a multicentre, prospective, observational, cross-sectional study that included 61 centres. Clinical and transfusion data of patients undergoing major elective surgery were collected; transfusion predictors and patients' outcomes were analysed.

Results: Of 6,121 patients, 1,579 (25.8%) received a peri-operative transfusion. A total of 5,812 blood components were transfused: red blood cells (RBC), fresh-frozen plasma and platelets in 1,425 (23.3%), 762 (12.4%) and 88 (1.4%) cases, respectively). Pre-operative anaemia was identified in 2,019 (33%) patients. Half of the RBC units were used by patients in the age group 45-69 years. Specific procedures with the highest RBC use were coronary artery bypass grafting (16.9% of all units) and hip arthroplasty (14.9%). Low haemoglobin concentration was the most common indication for intra-operative RBC transfusion (57%) and plasma and platelet transfusions were mostly initiated for acute bleeding (61.3% and 61.1%, respectively). The RBC transfusion rate in study centres varied from 2% to 72%. RBC transfusion was inappropriate in 99% (n=150/151) of pre-operative, 23% (n=211/926) of intra-operative and 43% (n=308/716) of post-operative RBC transfusion episodes. Pre-operative haemoglobin, increased blood loss, open surgery and duration of surgery were the main independent predictors of intra-operative RBC transfusion. Low pre-operative haemoglobin concentration was independently associated with post-operative pulmonary complications.

Conclusions: These findings identified areas for improvement in peri-operative transfusion practice and PBM implementation in Turkey.
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http://dx.doi.org/10.2450/2020.0011-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375885PMC
July 2020

Cardiovascular Safety of Clonidine and Dexmedetomidine in Critically Ill Patients after Cardiac Surgery.

Crit Care Res Pract 2020 7;2020:4750615. Epub 2020 May 7.

Institute for Anaesthesiology, University Zurich and University Hospital Zurich, Zürich, Switzerland.

Purpose: The aim of this retrospective study was to assess the haemodynamic adverse effects of clonidine and dexmedetomidine in critically ill patients after cardiac surgery.

Methods: 2769 patients were screened during the 30-month study period. Heart rate (HR), mean arterial pressure (MAP), and norepinephrine requirements were assessed 3-hourly during the first 12 hours of the continuous drug infusion. Results are given as median (interquartile range) or numbers (percentages).

Results: Patients receiving clonidine ( = 193) were younger (66 (57-73) vs 70 (63-77) years, =0.003) and had a lower SAPS II (35 (27-48) vs 41 (31-54), =0.008) compared with patients receiving dexmedetomidine ( = 141). At the start of the drug infusion, HR (90 (75-100) vs 90 (80-105) bpm, =0.028), MAP (70 (65-80) vs 70 (65-75) mmHg, =0.093), and norepinephrine (0.05 (0.00-0.11) vs 0.12 (0.03-0.19) mcg/kg/min, < 0.001) were recorded in patients with clonidine and dexmedetomidine. Bradycardia (HR < 60 bpm) developed in 7.8% with clonidine and 5.7% with dexmedetomidine (=0.51). Between baseline and 12 hours, norepinephrine remained stable in the clonidine group (0.00 (-0.04-0.02) mcg/kg/min) and decreased in the dexmedetomidine group (-0.03 (-0.10-0.02) mcg/kg/min, =0.007).

Conclusions: Dexmedetomidine and the low-cost drug clonidine can both be used safely in selected patients after cardiac surgery.
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http://dx.doi.org/10.1155/2020/4750615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229561PMC
May 2020

Agreement between trainees and supervisors on first-year entrustable professional activities for anaesthesia training.

Br J Anaesth 2020 07 16;125(1):98-103. Epub 2020 May 16.

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

Background: Entrustable professional activities (EPAs) are commonly developed by senior clinicians and education experts. However, if postgraduate training is conceptualised as an educational alliance, the perspective of trainees should be included. This raises the question as to whether the views of trainees and supervisors on entrustability of specific EPAs differ, which we aimed to explore.

Methods: A working group, including all stakeholders, selected and drafted 16 EPAs with the potential for unsupervised practice within the first year of training. For each EPA, first-year trainees, advanced trainees, and supervisors decided whether it should be possible to attain trust for unsupervised practice by the end of the first year of anaesthesiology training (i.e. whether the respective EPA qualified as a 'first-year EPA').

Results: We surveyed 23 first-year trainees, 47 advanced trainees, and 51 supervisors (overall response rate: 68%). All groups fully agreed upon seven EPAs as 'first-year EPAs' and on four EPAs that should not be entrusted within the first year. For all five remaining EPAs, a significantly higher proportion of first-year trainees thought these should be entrusted as first-year EPAs compared with advanced trainees and supervisors. We found no differences between advanced trainees and supervisors.

Conclusions: The views of first-year trainees, advanced trainees, and supervisors showed high agreement. Differing views of young trainees disappeared after the first year. This finding provides a fruitful basis to involve trainees in negotiations of autonomy.
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http://dx.doi.org/10.1016/j.bja.2020.04.009DOI Listing
July 2020

Iron Sucrose: A Wealth of Experience in Treating Iron Deficiency.

Adv Ther 2020 05 15;37(5):1960-2002. Epub 2020 Apr 15.

Department of Gastroenterology, University Hospital Heraklion, Crete, Greece.

Iron deficiency and iron-deficiency anemia are associated with increased morbidity and mortality in a wide range of conditions. In many patient populations, this can be treated effectively with oral iron supplementation; but in patients who are unable to take or who do not respond to oral iron therapy, intravenous iron administration is recommended. Furthermore, in certain conditions, such as end-stage kidney disease, chronic heart failure, and inflammatory bowel disease, intravenous iron administration has become first-line treatment. One of the first available intravenous iron preparations is iron sucrose (Venofer), a nanomedicine that has been used clinically since 1949. Treatment with iron sucrose is particularly beneficial owing to its ability to rapidly increase hemoglobin, ferritin, and transferrin saturation levels, with an acceptable safety profile. Recently, important new data relating to the use of iron sucrose, including the findings from the landmark PIVOTAL trial in patients with end-stage kidney disease, have been reported. Several years ago, a number of iron sucrose similars became available, although there have been concerns about the clinical appropriateness of substituting the original iron sucrose with an iron sucrose similar because of differences in efficacy and safety. This is a result of the complex and unique physicochemical properties of nanomedicines such as iron sucrose, which make copying the molecule difficult and problematic. In this review, we summarize the evidence accumulated during 70 years of clinical experience with iron sucrose in terms of efficacy, safety, and cost-effectiveness.
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http://dx.doi.org/10.1007/s12325-020-01323-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467495PMC
May 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

Essential Role of Patient Blood Management in a Pandemic: A Call for Action.

Anesth Analg 2020 07;131(1):74-85

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

The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.
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http://dx.doi.org/10.1213/ANE.0000000000004844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173035PMC
July 2020

The Mechanisms Responsible for Improved Information Transfer in Avatar-Based Patient Monitoring: Multicenter Comparative Eye-Tracking Study.

J Med Internet Res 2020 03 16;22(3):e15070. Epub 2020 Mar 16.

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

Background: Patient monitoring is central to perioperative and intensive care patient safety. Current state-of-the-art monitors display vital signs as numbers and waveforms. Visual Patient technology creates an easy-to-interpret virtual patient avatar model that displays vital sign information as it would look in a real-life patient (eg, avatar changes skin color from healthy to cyanotic depending on oxygen saturation). In previous studies, anesthesia providers using Visual Patient perceived more vital signs during short glances than with conventional monitoring.

Objective: We aimed to study the deeper mechanisms underlying information perception in conventional and avatar-based monitoring.

Methods: In this prospective, multicenter study with a within-subject design, we showed 32 anesthesia providers four 3- and 10-second monitoring scenarios alternatingly as either routine conventional or avatar-based in random sequence. All participants observed the same scenarios with both technologies and reported the vital sign status after each scenario. Using eye-tracking, we evaluated which vital signs the participants had visually fixated (ie, could have potentially read and perceived) during a scenario. We compared the frequencies and durations of participants' visual fixations of vital signs between the two technologies.

Results: Participants visually fixated more vital signs per scenario in avatar-based monitoring (median 10, IQR 9-11 versus median 6, IQR 4-8, P<.001; median of differences=3, 95% CI 3-4). In multivariable linear regression, monitoring technology (conventional versus avatar-based monitoring, difference=-3.3, P<.001) was an independent predictor of the number of visually fixated vital signs. The difference was less prominent in the longer (10-second) scenarios (difference=-1.5, P=.04). Study center, profession, gender, and scenario order did not influence the differences between methods. In all four scenarios, the participants visually fixated 9 of 11 vital signs statistically significantly longer using the avatar (all P<.001). Four critical vital signs (pulse rate, blood pressure, oxygen saturation, and respiratory rate) were visible almost the entire time of a scenario with the avatar; these were only visible for fractions of the observations with conventional monitoring. Visual fixation of a certain vital sign was associated with the correct perception of that vital sign in both technologies (avatar: phi coefficient=0.358; conventional monitoring: phi coefficient=0.515, both P<.001).

Conclusions: This eye-tracking study uncovered that the way the avatar-based technology integrates the vital sign information into a virtual patient model enabled parallel perception of multiple vital signs and was responsible for the improved information transfer. For example, a single look at the avatar's body can provide information about: pulse rate (pulsation frequency), blood pressure (pulsation intensity), oxygen saturation (skin color), neuromuscular relaxation (extremities limp or stiff), and body temperature (heatwaves or ice crystals). This study adds a new and higher level of empirical evidence about why avatar-based monitoring improves vital sign perception compared with conventional monitoring.
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http://dx.doi.org/10.2196/15070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7105929PMC
March 2020

Hypoxia sensing by hepatic stellate cells leads to VEGF-dependent angiogenesis and may contribute to accelerated liver regeneration.

Sci Rep 2020 03 9;10(1):4392. Epub 2020 Mar 9.

Institute of Physiology, University of Zurich, Zurich, Switzerland.

Portal vein ligation (PVL) induces liver growth prior to resection. Associating liver partition and portal vein ligation (PVL plus transection=ALPPS) or the addition of the prolyl-hydroxylase inhibitor dimethyloxalylglycine (DMOG) to PVL both accelerate growth via stabilization of HIF-α subunits. This study aims at clarifying the crosstalk of hepatocytes (HC), hepatic stellate cells (HSC) and liver sinusoidal endothelial cells (LSEC) in accelerated liver growth. In vivo, liver volume, HC proliferation, vascular density and HSC activation were assessed in PVL, ALPPS, PVL+DMOG and DMOG alone. Proliferation of HC, HSC and LSEC was determined under DMOG in vitro. Conditioned media experiments of DMOG-exposed cells were performed. ALPPS and PVL+DMOG accelerated liver growth and HC proliferation in comparison to PVL. DMOG alone did not induce HC proliferation, but led to increased vascular density, which was also observed in ALPPS and PVL+DMOG. Activated HSC were detected in ALPPS, PVL+DMOG and DMOG, again not in PVL. In vitro, DMOG had no proliferative effect on HC, but conditioned supernatant of DMOG-treated HSC induced VEGF-dependent proliferation of LSEC. Transcriptome analysis confirmed activation of proangiogenic factors in hypoxic HSC. Hypoxia signaling in HSC induces VEGF-dependent angiogenesis. HSC play a crucial role in the cellular crosstalk of rapid liver regeneration.
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http://dx.doi.org/10.1038/s41598-020-60709-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7062856PMC
March 2020

Patient Blood Management: Effectiveness and Future Potential.

Anesthesiology 2020 07;133(1):212-222

From the Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland (D.R.S.) the Department of Surgical Specialties, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain (M.M.) the Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom (A.A.K.) the Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina (J.H.L.) the Department of Anesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Germany (K.Z.).

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http://dx.doi.org/10.1097/ALN.0000000000003198DOI Listing
July 2020

Avatar-based versus conventional vital sign display in a central monitor for monitoring multiple patients: a multicenter computer-based laboratory study.

BMC Med Inform Decis Mak 2020 02 10;20(1):26. Epub 2020 Feb 10.

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

Background: Maintaining adequate situation awareness is crucial for patient safety. Previous studies found that the use of avatar-based monitoring (Visual Patient Technology) improved the perception of vital signs compared to conventional monitoring showing numerical and waveform data; and was further associated with a reduction of perceived workload. In this study, we aimed to evaluate the effectiveness of Visual Patient Technology on perceptive performance and perceived workload when monitoring multiple patients at the same time, such as in central station monitors in intensive care units or operating rooms.

Methods: A prospective, within-subject, computer-based laboratory study was performed in two tertiary care hospitals in Switzerland in 2018. Thirty-eight physician and nurse anesthetists volunteered for the study. The participants were shown four different central monitor scenarios in sequence, where each scenario displayed two critical and four healthy patients simultaneously for 10 or 30 s. After each scenario, participants had to recall the vital signs of the critical patients. Perceived workload was assessed with the National Aeronautics and Space Administration Task-Load-Index (NASA TLX) questionnaire.

Results: In the 10-s scenarios, the median number of remembered vital signs significantly improved from 7 to 11 using avatar-based versus conventional monitoring with a mean of differences of 4 vital signs, 95% confidence interval (CI) 2 to 6, p < 0.001. At the same time, the median NASA TLX scores were significantly lower for avatar-based monitoring (67 vs. 77) with a mean of differences of 6 points, 95% CI 0.5 to 11, p = 0.034. In the 30-s scenarios, vital sign perception and workload did not differ significantly.

Conclusions: In central monitor multiple patient monitoring, we found a significant improvement of vital sign perception and reduction of perceived workload using Visual Patient Technology, compared to conventional monitoring. The technology enabled improved assessment of patient status and may, thereby, help to increase situation awareness and enhance patient safety.
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http://dx.doi.org/10.1186/s12911-020-1032-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011453PMC
February 2020

Red cell use in trauma.

Curr Opin Anaesthesiol 2020 Apr;33(2):220-226

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

Purpose Of Review: Red cell transfusions are commonly used in management of hemorrhage in trauma patients. The appropriate indications and criteria for transfusion are still debated. Here, we summarize the recent findings on the use of red cell transfusion in trauma setting.

Recent Findings: Recent evidence continues to support the long-established link between allogeneic transfusion and worse clinical outcomes, reinstating the importance of more judicious use of allogeneic blood and careful consideration of benefits versus risks when making transfusion decisions. Studies support restrictive transfusion strategies (often based on hemoglobin thresholds of 7-8 g/dl) in most patient populations, although some argue more caution in specific populations (e.g. patients with traumatic brain injury) and more studies are needed to determine if these patients benefit from less restrictive transfusion strategies. It should be remembered that anemia remains an independent risk factor for worse outcomes and red cell transfusion does not constitute a lasting treatment. Anemia should be properly assessed and managed based on the cause and using hematinic medications as indicated.

Summary: Although the debate on hemoglobin thresholds for transfusion continues, clinicians should not overlook proper management of the underlying issue (anemia).
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http://dx.doi.org/10.1097/ACO.0000000000000837DOI Listing
April 2020

Predictors of blood loss in lung transplant surgery-a single center retrospective cohort analysis.

J Thorac Dis 2019 Nov;11(11):4755-4761

Department of Anesthesiology, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland.

Background: This retrospective study aims to identify clinical predictors of intraoperative blood loss during lung transplantation. While for other surgical specialties predictors of blood loss have been identified such as previous likewise located surgery, poor preoperative health status of patients, blood coagulation status, and use of extra corporeal circulation, predictors of blood loss during lung transplantation are not yet established.

Methods: A total of 326 lung transplants were performed between January 2000 and February 2014 at a tertiary hospital. The primary aim was to associate blood loss with the following potential predictors: pulmonary arterial hypertension, pre- or intraoperative extracorporeal life support (ECLS), previous thoracic surgery, previous lung transplant, and Charlson Comorbidity Index (CCI). Postoperative complications and 30-day mortality were secondary endpoints of the study.

Results: Median estimated blood loss during lung transplant was 1,500 mL (IQR, 1,000-2,875 mL). Pre- and intraoperative ECLS (P=0.02, P<0.001) independently increased blood loss by 59% and 107%, respectively. The higher blood loss during re-transplant marginally missed the significance level (P=0.05). Pulmonary arterial hypertension, previous thoracic surgery and high CCI were not associated with increased blood loss. As secondary outcomes, postoperative complications were more common in patients with a higher blood loss (P=0.04) but was not associated with higher 30-day mortality (P=0.18).

Conclusions: Pre- and intraoperative ECLS were significant risk factors for higher blood loss during lung transplantation. Higher blood loss was associated with higher incidence of postoperative complications but not with a higher 30-day mortality.
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http://dx.doi.org/10.21037/jtd.2019.10.61DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6940236PMC
November 2019

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

Effects of a standardized distraction on caregivers' perceptive performance with avatar-based and conventional patient monitoring: a multicenter comparative study.

J Clin Monit Comput 2020 Dec 25;34(6):1369-1378. Epub 2019 Nov 25.

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

Patient monitoring requires constant attention and may be particularly vulnerable to distractions, which frequently occur during perioperative work. In this study, we compared anesthesia providers' perceptive performance and perceived workload under distraction for conventional and avatar-based monitoring, a situation awareness-based technology that displays patient status as an animated patient model. In this prospective, multicenter study with a within-subject design, 38 participants evaluated scenarios of 3- and 10-s durations using conventional and avatar-based monitoring, under standardized distraction in the form of a simple calculation task. We quantified perceptual performance as the number of vital signs correctly remembered out of the total of 11 vital signs shown. We quantified perceived workload using the National Aeronautics and Space Administration Task Load Index score. Anesthesia providers remembered more vital signs under distraction using the avatar monitoring technology in the 3-s scenario: 6 (interquartile range [IQR] 5-7) vs. 3 (IQR 2-4), p < 0.001, mean of differences (MoD): 3 (95% confidence interval [95% CI] 1 to 4), and in the 10-s monitoring task: 6 (IQR 5-8) vs. 4 (IQR 2-7), p = 0.028, MoD: 1 (95% CI 0.2 to 3). Participants rated perceived workload lower under distraction with the avatar in the 3-s scenario: 65 (IQR 40-79) vs. 75 (IQR 51-88), p = 0.007, MoD: 9 (95% CI 3 to 15), and in the 10-s scenario: 68 (IQR 50-80) vs. 75 (IQR 65-86), p = 0.019, MoD: 10 (95% CI 2 to 18). Avatar-based monitoring improved anesthesia providers' perceptive performance under distraction and reduced perceived workload. This technology could help to improve caregivers' situation awareness, especially in high-workload situations.
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http://dx.doi.org/10.1007/s10877-019-00429-2DOI Listing
December 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

NOACs in Anesthesiology.

Transfus Med Hemother 2019 Aug 29;46(4):282-293. Epub 2019 Jan 29.

Center for Laboratory Medicine; Hemostasis and Hemophilia Center, St. Gallen, Switzerland.

Background: Due to increasing use of new oral anticoagulants (NOACs), clinicians are faced more and more frequently with clinical issues related to these drugs.

Objective: The objective of this publication is to make practical suggestions for the perioperative management of NOACs as well as for their handling in overdoses and bleedings.

Recommendations: In elective surgery and creatinine clearance ≥ 50 ml/min, a NOAC should be discontinued 24-36 h before the intervention, and even earlier in case of reduced kidney function. In emergency interventions that cannot be delayed, the management is dependent on the NOAC plasma levels. With levels ≤ 30 ng/ml, surgery can be performed. With levels >30 ng/ml, reversal agents should be considered. In low bleeding risk surgery, NOACs can be re-started 24 h after the intervention, which is prolonged to 48-72 h after surgery with high bleeding risk. In case of NOAC overdose and minor bleedings, temporary discontinuation and supportive care are usually sufficient to control the situation. In severe or life-threatening bleedings, nonspecific and specific reversal agents should be considered.
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http://dx.doi.org/10.1159/000491400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739714PMC
August 2019

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