Publications by authors named "Kai Zacharowski"

317 Publications

The association between intraoperative cell salvage and red blood cell transfusion in cardiac surgery - an observational study in a patient blood management centre.

Anaesthesiol Intensive Ther 2021 Feb 24:1-9. Epub 2021 Feb 24.

Department of Anesthesiology, University Hospital Wuerzburg, Wuerzburg, Germany.

Introduction: Cell salvage (CS) is an integral part of patient blood management (PBM) and aims to reduce allogeneic red blood cell (RBC) transfusion.

Material And Methods: This observational study analysed patients scheduled for elective cardiac surgery requiring cardiopulmonary bypass (CPB) between November 2015 and October 2018. Patients were divided into a CS group (patients receiving CS) and a control group (no CS). Primary endpoints were the number of patients exposed to allogeneic RBC transfusions and the number of RBC units transfused per patient.

Results: A total of 704 patients undergoing cardiac surgery were analysed, of whom 338 underwent surgery with CS (CS group) and 366 were without CS (control group). Intraoperatively, 152 patients (45%) were exposed to allogeneic RBC transfusions in the CS group and 93 patients (25%) in the control group (P < 0.001). Considering the amount of intraoperative blood loss, regression analysis revealed a significant association between blood loss and increased use of RBC units in patients of the control compared to the CS group (1000 mL: 1.0 vs. 0.6 RBC units; 2000 mL: 2.2 vs. 1.1 RBC units; 3000 mL: 3.4 vs. 1.6 RBC units). Thus, CS was significantly associated with a reduced number of allogeneic RBCs by 40% for 1000 mL, 49% for 2000 mL, and 52% for 3000 mL of blood loss compared to patients without CS.

Conclusions: Cell salvage was significantly associated with a reduced number of allogeneic RBC transfusions. It supports the beneficial effect of CS in cardiac surgical patients as an individual measure in a comprehensive PBM program.
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http://dx.doi.org/10.5114/ait.2021.103735DOI Listing
February 2021

[Perthes Syndrome after Roll-Over Trauma].

Anasthesiol Intensivmed Notfallmed Schmerzther 2021 Feb 19;56(2):135-140. Epub 2021 Feb 19.

Roll-over trauma and associated traumatic entrapments frequently result in serious polytraumatisation. In rare cases, severe extrathoracic compressions and a protracted entrapment period can lead to Perthes syndrome, also known as traumatic asphyxia. The Perthes syndrome manifests itself by a triad of craniocervical cyanosis, facial petechiae and subconjunctival haemorrhages, enabling a rapid diagnosis based on these typical clinical features. In addition, a contusion of the heart, lungs or even the liver may occur as well as neurological and other ophthalmological complications. An early identification of this condition, the elevation of the upper body to allow adequate venous drainage in addition to ensuring sufficient oxygenation are essential for optimal therapy. In general, no long-term complications are to be expected for Perthes syndrome. The stasis usually disappears completely within a few months.
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http://dx.doi.org/10.1055/a-1299-0546DOI Listing
February 2021

The visually estimated blood volume in scaled canisters based on a simulation study.

BMC Anesthesiol 2021 Feb 16;21(1):54. Epub 2021 Feb 16.

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.

Background: The most common technique used worldwide to quantify blood loss during an operation is the visual assessment by the attending intervention team. In every operating room you will find scaled suction canisters that collect fluids from the surgical field. This scaling is commonly used by clinicians for visual assessment of intraoperative blood loss. While many studies have been conducted to quantify and improve the inaccuracy of the visual estimation method, research has focused on the estimation of blood volume in surgical drapes. The question whether and how scaling of canisters correlates with actual blood loss and how accurately clinicians estimate blood loss in scaled canisters has not been the focus of research to date.

Methods: A simulation study with four "bleeding" scenarios was conducted using expired whole blood donations. After diluting the blood donations with full electrolyte solution, the sample blood loss volume (SBL) was transferred into suction canisters. The study participants then had to estimate the blood loss in all four scenarios. The difference to the reference blood loss (RBL) per scenario was analyzed.

Results: Fifty-three anesthetists participated in the study. The median estimated blood loss was 500 ml (IQR 300/1150) compared to the RBL median of 281.5 ml (IQR 210.0/1022.0). Overestimations up to 1233 ml were detected. Underestimations were also observed in the range of 138 ml. The visual estimate for canisters correlated moderately with RBL (Spearman's rho: 0.818; p < 0.001). Results from univariate nonparametric confirmation statistics regarding visual estimation of canisters show that the deviation of the visual estimate of blood loss is significant (z = - 10.95, p < 0.001, n = 220). Participants' experience level had no significant influence on VEBL (p = 0.402).

Conclusion: The discrepancies between the visual estimate of canisters and the actual blood loss are enormous despite the given scales. Therefore, we do not recommend estimating the blood loss visually in scaled suction canisters. Colorimetric blood loss estimation could be a more accurate option.
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http://dx.doi.org/10.1186/s12871-021-01265-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885508PMC
February 2021

Direct oral anticoagulants in point-of-care monitoring: an ex-vivo study (NOAPOC).

Minerva Anestesiol 2021 Feb 16. Epub 2021 Feb 16.

Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany.

Background: Anticoagulatory activity of direct oral anticoagulants (DOACs) is not routinely measurable by point-of-care monitoring. Thus, the aim of this study was to evaluate the influence of dabigatran/rivaroxaban on point-of-care testing.

Methods: Samples from 34 participants under DOAC therapy were drawn at two time points. Before ingestion and two-to-three hours afterwards. Thrombelastometric (ROTEM) and aggregometric (Multiplate) measurements were performed. Dabigatran and rivaroxaban plasma levels were determined.

Results: Dabigatran and rivaroxaban plasma levels showed significant correlations with clotting time (CT) in EXTEM (r = 0.765, p < .0001; r = 0.689, p < .0001) and INTEM (r = 0.792, p < .0001; r = 0.595, p < .001). A positive correlation was identified between dabigatran ingestion and maximum-clot-firmness (MCF) (r = 0.354, p < .05) in the EXTEM test, pronounced in the absence of concomitant antiplatelet therapy (r = 0.709, p <.05). EXTEM-MCF positively correlated with the TRAP test in aggregometry (0.662, p < .05), an effect not observed in patients treated with antiplatelet therapy.

Conclusions: Prolongation of CT-EXTEM and CT-INTEM indicates delayed initiation of clot formation. The CT-EXTEM seems to facilitate qualitative monitoring of dabigatran. In contrast, qualitative monitoring of rivaroxaban by CT-EXTEM may be limited as rivaroxaban may affect the measurement at therapeutic plasma levels. It seems that clot formation is faster/firmer in the presence of increased dabigatran plasma levels. This can be attributed to a non-dose-dependent effect via increased fibrin polymerization and second to a dosedependent effect via increased platelet sensitivity to thrombin.
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http://dx.doi.org/10.23736/S0375-9393.21.14788-1DOI Listing
February 2021

Insight into ECMO, mortality and ARDS: a nationwide analysis of 45,647 ECMO runs.

Crit Care 2021 01 28;25(1):38. Epub 2021 Jan 28.

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.

Background: Extracorporeal life support (ECLS) has become an integral part of modern intensive therapy. The choice of support mode depends largely on the indication. Patients with respiratory failure are predominantly treated with a venovenous (VV) approach. We hypothesized that mortality in Germany in ECLS therapy did not differ from previously reported literature METHODS: Inpatient data from Germany from 2007 to 2018 provided by the Federal Statistical Office of Germany were analysed. The international statistical classification of diseases and related health problems codes (ICD) and process keys (OPS) for extracorporeal membrane oxygenation (ECMO) types, acute respiratory distress syndrome (ARDS) and hospital mortality were used.

Results: In total, 45,647 hospitalized patients treated with ECLS were analysed. In Germany, 231 hospitals provided ECLS therapy, with a median of 4 VV-ECMO and 9 VA-ECMO in 2018. Overall hospital mortality remained higher than predicted in comparison to the values reported in the literature. The number of VV-ECMO cases increased by 236% from 825 in 2007 to 2768 in 2018. ARDS was the main indication for VV-ECMO in only 33% of the patients in the past, but that proportion increased to 60% in 2018. VA-ECMO support is of minor importance in the treatment of ARDS in Germany. The age distribution of patients undergoing ECLS has shifted towards an older population. In 2018, the hospital mortality decreased in VV-ECMO patients and VV-ECMO patients with ARDS to 53.9% (n = 1493) and 54.4% (n = 926), respectively.

Conclusions: ARDS is a severe disease with a high mortality rate despite ECLS therapy. Although endpoints and timing of the evaluations differed from those of the CESAR and EOLIA studies and the Extracorporeal Life Support Organization (ELSO) Registry, the reported mortality in these studies was lower than in the present analysis. Further prospective analyses are necessary to evaluate outcomes in ECMO therapy at the centre volume level.
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http://dx.doi.org/10.1186/s13054-021-03463-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7841040PMC
January 2021

Bone cement implantation syndrome in cemented hip hemiarthroplasty-a persistent risk.

Eur J Trauma Emerg Surg 2021 Jan 26. Epub 2021 Jan 26.

Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Frankfurt/Main, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany.

Background: Every year, ~ 210,000 initial implantations of hip endoprostheses are carried out in Germany alone. The "bone cement implantation syndrome" (BCIS) is considered a severe peri- and early-postoperative complication when implanting cemented prostheses. The origin of the BCIS and its impact on the clinical outcome are still uncertain. This study investigates the clinical progression after BCIS cases in patients with cemented hemiarthroplasty. Risk factors for the occurrence of BCIS are evaluated.

Material And Methods: Clinical data of all patients with a proximal femur fracture and which received a cemented hemiarthroplasty within a period of 9.5 years have been collected. BCIS (+) patients and BCIS (-) patients were compared with respect to their demographics and clinical outcome. Risk factors for the development of BCIS were identified.

Results: A total of 208 patients could be included with complete data sets. The mean age was 81.1 ± 10.0 years. Overall, 37% of the patients showed symptoms of BCIS. In comparison to BCIS (-) patients there was a significantly higher rate of cardiovascular complications (27.3% vs. 13.7%, p = 0.016) and a higher in-hospital mortality rate (15.6% vs. 4.6%, p = 0.006) in BCIS (+) patients. Age, absence of a femoral borehole and ASA status were identified as statistically significant risk factors of BCIS.

Conclusion: BCIS is frequently observed and in some cases severe complication. The therapy is exclusively symptomatic; identifying preventional measures might reduce the occurrence of BCIS.
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http://dx.doi.org/10.1007/s00068-020-01587-8DOI Listing
January 2021

Greater Fibrinolysis Resistance but No Greater Platelet Aggregation in Critically Ill COVID-19 Patients.

Anesthesiology 2021 03;134(3):457-467

Background: The hemostatic balance in patients with coronavirus disease 2019 (COVID-19) seems to be shifted toward a hypercoagulable state. The aim of the current study was to assess the associated coagulation alterations by point-of-care-diagnostics, focusing on details of clot formation and lysis in these severely affected patients.

Methods: The authors' prospective monocentric observational study included critically ill patients diagnosed with COVID-19. Demographics and biochemical data were recorded. To assess the comprehensive hemostatic profile of this patient population, aggregometric (Multiplate) and viscoelastometric (CloPro) measures were performed in the intensive care unit of a university hospital at a single occasion. Coagulation analysis and assessment of coagulation factors were performed. Data were compared to healthy controls.

Results: In total, 27 patients (21 male; mean age, 60 yr) were included. Impedance aggregometry displayed no greater platelet aggregability in COVID-19 in comparison with healthy controls (area under the curve [AUC] in adenosine diphosphate test, 68 ± 37 U vs. 91 ± 29 U [-27 (Hodges-Lehmann 95% CI, -48 to -1); P = 0.043]; AUC in arachidonic acid test, 102 ± 54 U vs. 115 ± 26 U [-21 (Hodges-Lehmann 95% CI, -51 to 21); P = 0.374]; AUC in thrombin receptor activating peptide 6 test, 114 ± 61 U vs. 144 ± 31 U [-31 (Hodges-Lehmann 95% CI, -69 to -7); P = 0.113]). Comparing the thromboelastometric results of COVID-19 patients to healthy controls, the authors observed significant differences in maximum clot firmness in fibrin contribution to maximum clot firmness assay (37 ± 11 mm vs. 15 ± 4 mm [21 (Hodges-Lehmann 95% CI, 17 to 26); P < 0.001]) and lysis time in extrinsic activation and activation of fibrinolysis by tissue plasminogen activator assay (530 ± 327 s vs. 211 ± 80 s [238 (Hodges-Lehmann 95% CI, 160 to 326); P < 0.001]).

Conclusions: Thromboelastometry in COVID-19 patients revealed greater fibrinolysis resistance. The authors did not find a greater platelet aggregability based on impedance aggregometric tests. These findings may contribute to our understanding of the hypercoagulable state of critically ill patients with COVID-19.

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http://dx.doi.org/10.1097/ALN.0000000000003685DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864605PMC
March 2021

COVID-19 Induced Acute Respiratory Distress Syndrome-A Multicenter Observational Study.

Front Med (Lausanne) 2020 18;7:599533. Epub 2020 Dec 18.

Department of Anesthesiology and Critical Care, University Hospital Würzburg, Julius-Maximilians-University Würzburg, Würzburg, Germany.

Proportions of patients dying from the coronavirus disease-19 (COVID-19) vary between different countries. We report the characteristics; clinical course and outcome of patients requiring intensive care due to COVID-19 induced acute respiratory distress syndrome (ARDS). This is a retrospective, observational multicentre study in five German secondary or tertiary care hospitals. All patients consecutively admitted to the intensive care unit (ICU) in any of the participating hospitals between March 12 and May 4, 2020 with a COVID-19 induced ARDS were included. A total of 106 ICU patients were treated for COVID-19 induced ARDS, whereas severe ARDS was present in the majority of cases. Survival of ICU treatment was 65.0%. Median duration of ICU treatment was 11 days; median duration of mechanical ventilation was 9 days. The majority of ICU treated patients (75.5%) did not receive any antiviral or anti-inflammatory therapies. Venovenous (vv) ECMO was utilized in 16.3%. ICU triage with population-level decision making was not necessary at any time. Univariate analysis associated older age, diabetes mellitus or a higher SOFA score on admission with non-survival during ICU stay. A high level of care adhering to standard ARDS treatments lead to a good outcome in critically ill COVID-19 patients.
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http://dx.doi.org/10.3389/fmed.2020.599533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775385PMC
December 2020

Treating patients across European Union borders: An international survey in light of the coronavirus disease-19 pandemic.

Eur J Anaesthesiol 2020 Dec 18;Publish Ahead of Print. Epub 2020 Dec 18.

From the Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, Frankfurt/Main, Germany (EH-A, AF, KZ), Clinic for Anaesthesia and Intensive Therapy, Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia (RJ) and Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (S-DH) A list of the Board of Directors is provided in the Supplementary Appendix.

Background: In light of the coronavirus disease-2019 (COVID-19) pandemic, how resources are managed and the critically ill are allocated must be reviewed. Although ethical recommendations have been published, strategies for dealing with overcapacity of critical care resources have so far not been addressed.

Objectives: Assess expert opinion for allocation preferences regarding the growing imbalance between supply and demand for medical resources.

Design: A 10-item questionnaire was developed and sent to the most prominent members of the European Society of Anaesthesiology and Intensive Care (ESAIC).

Setting: Survey via a web-based platform.

Patients: Respondents were members of the National Anaesthesiologists Societies Committee and Council Members of the ESAIC; 74 of 80 (92.5%), responded to the survey.

Measurements And Main Results: Responses were analysed thematically. The majority of respondents (83.8%), indicated that resources for COVID-19 were available at the time of the survey. Of the representatives of the ESAIC governing bodies, 58.9% favoured an allocation of excess critical care capacity: 69% wished to make them available to supraregional patients, whereas 30.9% preferred to keep the resources available for the local population. Regarding the type of distribution of resources, 35.3% preferred to make critical care available, 32.4% favoured the allocation of medical equipment and 32.4% wished to support both options. The majority (59.5%) supported the implementation of a central European institution to manage such resource allocation.

Conclusion: Experts in critical care support the allocation of resources from centres with overcapacity. The results indicate the need for centrally administered allocation mechanisms that are not based on ethically disputable triage systems. It seems, therefore, that there is wide acceptance and solidarity among the European anaesthesiological community that local medical and human pressure should be relieved during a pandemic by implementing national and international re-allocation strategies among healthcare providers and healthcare systems.
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http://dx.doi.org/10.1097/EJA.0000000000001423DOI Listing
December 2020

The effect of the interruption of agitation, temporary cooling, and pneumatic tube transportation on platelet quality during storage for transfusion.

Transfusion 2020 Dec 17. Epub 2020 Dec 17.

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany.

Background: Conditions during blood product storage and transportation should maintain quality. The aim of this in vitro study was to investigate the effect of interruption of agitation, temporary cooling (TC), and pneumatic tube system transportation (PTST) on the aggregation ability (AA) and mitochondrial function (MF) of platelet concentrates (PC).

Study Design And Methods: A PC was divided equally into four subunits and then allocated to four test groups. The control group (I) was stored as recommended (continuous agitation, 22 ± 2°C) for 4 days. The test groups were stored without agitation (II), stored as recommended, albeit 4°C for 60 minutes on day (d)2 (III) and PTST (IV). Aggregometry was measured using Multiplate (RocheAG; ADPtest, ASPItest, TRAPtest, COLtest) and MF using Oxygraph-2k (Oroboros Instruments). The basal and maximum mitochondrial respiratory rate (MMRR) were determined. AA and MF were measured daily in I and II and AA in III and IV on d2 after TC/PTST. Statistical analysis was performed using tests for matched observations.

Results: Eleven PCs were used. TRAP-6 induced AA was significantly lower in II when compared to I on d4 (P = 0.015*). In III the ASPItest was significantly lower (P = 0.032*). IV showed no significant differences. The basal and MMRR were significantly reduced over 4 days in I and II (for both rates in both groups: P = <0.0001*). No significant differences occurred on d4 (P = 0.495).

Conclusion: Our results indicate that ex vivo AA and MF of PCs are unaffected, even in no-ideal storage and transport circumstances with respect to agitation, temperature, and force.
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http://dx.doi.org/10.1111/trf.16223DOI Listing
December 2020

Nrf2-A Molecular Target for Sepsis Patients in Critical Care.

Biomolecules 2020 12 17;10(12). Epub 2020 Dec 17.

Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany.

The transcription factor NF-E2 p45-related factor 2 (Nrf2) is an established master regulator of the anti-oxidative and detoxifying cellular response. Thus, a role in inflammatory diseases associated with the generation of large amounts of reactive oxygen species (ROS) seems obvious. In line with this, data obtained in cell culture experiments and preclinical settings have shown that Nrf2 is important in regulating target genes that are necessary to ensure cellular redox balance. Additionally, Nrf2 is involved in the induction of phase II drug metabolizing enzymes, which are important both in degrading and converting drugs into active forms, and into putative carcinogens. Therefore, Nrf2 has also been implicated in tumorigenesis. This must be kept in mind when new therapy approaches are planned for the treatment of sepsis. Therefore, this review highlights the function of Nrf2 in sepsis with a special focus on the translation of rodent-based results into sepsis patients in the intensive care unit (ICU).
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http://dx.doi.org/10.3390/biom10121688DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7766194PMC
December 2020

Characterization of neonates born to mothers with SARS-CoV-2 infection: Review and meta-analysis.

Pediatr Neonatol 2021 01 24;62(1):11-20. Epub 2020 Oct 24.

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Germany. Electronic address:

Characterization of neonates born to mothers with SARS-CoV-2 infection has been partially carried out. There has been no systematic review providing a holistic neonatal presentation including possible vertical transmission. A systematic literature search was performed using PubMed, Google Scholar and Web of Science up to June, 6 2020. Studies on neonates born to mothers with SARS-CoV-2 infection were included. A binary random effect model was used for prevalence and 95% confidence interval. 32 studies involving 261 neonates were included in meta-analysis. Most neonates born to infected mothers did not show any clinical abnormalities (80.4%). Clinical features were dyspnea in 11 (42.3%) and fever in 9 newborns (19.1%). Of 261 neonates, 120 neonates were tested for infection, of whom 12 (10.0%) tested positive. Swabs from placenta, cord blood and vaginal secretion were negative. Neonates are mostly non affected by the mother's SARS-CoV-2 infection. The risk of vertical transmission is low.
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http://dx.doi.org/10.1016/j.pedneo.2020.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585378PMC
January 2021

Audit of international intraoperative haemotherapy and blood loss documentation on anaesthetic records.

Minerva Anestesiol 2020 Dec 15. Epub 2020 Dec 15.

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany.

Background: Anaesthetic records facilitate information transmission to the next healthcare professional and should contain all relevant information of perioperative care. While most anaesthesia societies provide guidelines for record content, important topics like haemotherapy and haemostatic therapy are not well represented. We consider the quality of anaesthetic records with regard to the documentation options for haemotherapy and haemostatic therapy. A secondary objective was to examine guidelines for appropriate recommendations.

Methods: Anaesthetic records of international anaesthesiology departments were evaluated for the presence of 20 defined fields associated with haemotherapy, haemostatic and fluid therapy as well as intraoperative diagnostics and monitoring. International guidelines were reviewed for appropriate recommendations.

Results: A total of 98 anaesthetic records from 8 countries and guidelines of six anaesthesia societies were analysed. Data fields for red blood cell transfusion have been found in 29.3% (95% CI 0.20 to 0.38), ABO-testing in 6.1% (95% CI 0.01 to 0.11) and indication for transfusion in 2.0% (CI 0.00 to 0.05) of records. Most records contain fields for blood loss (94.4%; 95% CI 0.91 to 0.99) and diuresis (87.9%; 95% CI 0.81 to 0.94). International guidelines that were analysed do not cover the topic of transfusion, but most give recommendations on basic monitoring, blood loss and fluid management documentation.

Conclusions: The majority of the evaluated anaesthetic records did not contain fields for relevant aspects of perioperative haemotherapy, haemostatic therapy and diagnostics. Guidelines and protocols for anaesthetic documentation should include these topics to ensure information transfer and patient safety.
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http://dx.doi.org/10.23736/S0375-9393.20.14828-4DOI Listing
December 2020

Risk factors and outcomes associated with the carriage of tigecycline- and vancomycin-resistant Enterococcus faecium.

J Infect 2021 Feb 4;82(2):227-234. Epub 2020 Dec 4.

University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; University Center of Competence for Infection Control, State of Hesse, Germany. Electronic address:

Objectives: Vancomycin-resistant E. faecium (VRE) is a common cause of healthcare-associated infections. The emergence of VRE with tigecycline resistance (TVRE) is increasing but its impact on patient outcome is still not well defined. This study aimed to assess risk factors for the acquisition of TVRE and of patient outcomes associated with TVRE carriage/infection.

Methods: At the University Hospital Frankfurt, we conducted a matched pair TVRE-VRE analysis to identify risk factors for TVRE carriage. Bed-to-bed contacts and potential transmission routes were reconstructed. TVRE were whole-genome sequenced to confirm suspected transmission events and to identify tigecycline resistance mechanisms.

Results: 76 TVRE cases were identified between 02/2014-04/2017 and compared to VRE colonized or infected controls. TVRE carriage was associated with exposure to tigecycline, an increased rate of bloodstream infections (BSI) with VRE or Candida spp., and higher mortality. Whole-genome sequencing-based analysis of 24 TVRE provided evidence for transmissions of TVRE, also across different wards.

Conclusions: Tigecycline exposure is the main risk factor for TVRE carriage. VRE/TVRE- and Candida-BSI are associated with worse clinical outcome. Hospital transmission of TVRE may occur despite strict contact precautions, whereas both antimicrobial stewardship and infection control interventions are of high importance to prevent emergence and spread of TVRE.
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http://dx.doi.org/10.1016/j.jinf.2020.12.003DOI Listing
February 2021

Implementation of an anaemia walk-in clinic: Feasibility and preliminary data from the Orthopedic University Hospital.

Transfus Med 2020 Dec 25;30(6):467-474. Epub 2020 Nov 25.

Department of Special Orthopedics, Orthopedic University Hospital Friedrichsheim gGmbH, Frankfurt, Germany.

Background: Approximately one in three patients suffers from preoperative anaemia. Even though haemoglobin is measured before surgery, anaemia management is not implemented in every hospital.

Objective: Here, we demonstrate the implementation of an anaemia walk-in clinic at an Orthopedic University Hospital. To improve the diagnosis of iron deficiency (ID), we examined whether reticulocyte haemoglobin (Ret-He) could be a useful additional parameter.

Material And Methods: In August 2019, an anaemia walk-in clinic was established. Between September and December 2019, major orthopaedic surgical patients were screened for preoperative anaemia. The primary endpoint was the incidence of preoperative anaemia. Secondary endpoints included Ret-He level, red blood cell (RBC) transfusion rate, in-hospital length of stay and anaemia at hospital discharge.

Results: A total of 104 patients were screened for anaemia. Preoperative anaemia rate was 20.6%. Intravenous iron was supplemented in 23 patients. Transfusion of RBC units per patient (1.7 ± 1.2 vs. 0.2 ± 0.9; p = 0.004) and hospital length of stay (13.1 ± 4.8 days vs. 10.6 ± 5.1 days; p = 0.068) was increased in anaemic patients compared to non-anaemic patients. Ret-He values were significantly lower in patients with ID anaemia (33.3 pg [28.6-40.2 pg]) compared to patients with ID (35.3 pg [28.9-38.6 pg]; p = 0.015) or patients without anaemia (35.4 pg [30.2-39.4 pg]; p = 0.001).

Conclusion: Preoperative anaemia is common in orthopaedic patients. Our results proved the feasibility of an anaemia walk-in clinic to manage preoperative anaemia. Furthermore, our analysis supports the use of Ret-He as an additional parameter for the diagnosis of ID in surgical patients.
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http://dx.doi.org/10.1111/tme.12740DOI Listing
December 2020

Changes in Transfusion Practice in Children and Adolescents over Time.

Transfus Med Hemother 2020 Oct 16;47(5):379-384. Epub 2020 Sep 16.

Department of Anaesthesia and Critical Care, University Hospitals of Würzburg, University of Würzburg, Würzburg, Germany.

Introduction: In recent years, resource-saving handling of allogeneic blood products and a reduction of transfusion rates in adults has been observed. However, comparable published national data for transfusion practices in pediatric patients are currently not available. In this study, the transfusion rates for children and adolescents were analyzed based on data from the Federal Statistical Office of Germany during the past 2 decades.

Methods: Data were queried via the database of the Federal Statistical Office (Destasis). The period covered was from 2005 to 2018, and those in the sample group were children and adolescents aged 0-17 years receiving inpatient care. Operation and procedure codes (OPS) for transfusions, procedures, or interventions with increased transfusion risk were queried and evaluated in detail.

Results: In Germany, 0.9% of the children and adolescents treated in hospital received a transfusion in 2018. A reduction in transfusion rates from 1.02% (2005) to 0.9% (2018) was observed for the total collective of children and adolescents receiving inpatient care. Increases in transfusion rates were recorded for 1- to 4- (1.41-1.45%) and 5- to 10-year-olds (1.24-1.33%). Children under 1 year of age were most frequently transfused (in 2018, 40.2% of the children were cared for in hospital). Transfusion-associated procedures such as chemotherapy or machine ventilation and respiratory support for newborns and infants are on the rise.

Conclusion: Transfusion rates are declining in children and adolescents, but the reasons for increases in transfusion rates in other groups are unclear. Prospective studies to evaluate transfusion rates and triggers in children are urgently needed.
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http://dx.doi.org/10.1159/000511231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588733PMC
October 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

Airway management in a prehospital setting during the SARS-CoV-2 pandemic.

Anaesthesiol Intensive Ther 2020 ;52(4):341-343

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany.

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http://dx.doi.org/10.5114/ait.2020.100536DOI Listing
November 2020

Volatile Isoflurane in Critically Ill Coronavirus Disease 2019 Patients-A Case Series and Systematic Review.

Crit Care Explor 2020 Oct 21;2(10):e0256. Epub 2020 Oct 21.

All authors: Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany.

Objectives: The ongoing coronavirus pandemic is challenging, especially in severely affected patients who require intubation and sedation. Although the potential benefits of sedation with volatile anesthetics in coronavirus disease 2019 patients are currently being discussed, the use of isoflurane in patients with coronavirus disease 2019-induced acute respiratory distress syndrome has not yet been reported.

Design: We performed a retrospective analysis of critically ill patients with hypoxemic respiratory failure requiring mechanical ventilation.

Setting: The study was conducted with patients admitted between April 4 and May 15, 2020 to our ICU.

Patients: We included five patients who were previously diagnosed with severe acute respiratory syndrome coronavirus 2 infection.

Intervention: Even with high doses of several IV sedatives, the targeted level of sedation could not be achieved. Therefore, the sedation regimen was switched to inhalational isoflurane. Clinical data were recorded using a patient data management system. We recorded demographical data, laboratory results, ventilation variables, sedative dosages, sedation level, prone positioning, duration of volatile sedation and outcomes.

Measurements & Main Results: Mean age (four men, one women) was 53.0 (± 12.7) years. The mean duration of isoflurane sedation was 103.2 (± 66.2) hours. Our data demonstrate a substantial improvement in the oxygenation ratio when using isoflurane sedation. Deep sedation as assessed by the Richmond Agitation and Sedation Scale was rapidly and closely controlled in all patients, and the subsequent discontinuation of IV sedation was possible within the first 30 minutes. No adverse events were detected.

Conclusions: Our findings demonstrate the feasibility of isoflurane sedation in five patients suffering from severe coronavirus disease 2019 infection. Volatile isoflurane was able to achieve the required deep sedation and reduced the need for IV sedation.
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http://dx.doi.org/10.1097/CCE.0000000000000256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587445PMC
October 2020

Analysis of Humoral Immune Responses in Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

J Infect Dis 2021 01;223(1):56-61

Paul-Ehrlich-Institut, Department of Virology, Langen, Germany.

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has caused a pandemic with tens of millions of cases and hundreds of thousands of deaths. The infection causes coronavirus disease 2019 (COVID-19), a disease of the respiratory system of divergent severity. In the current study, humoral immune responses were characterized in a cohort of 143 patients with COVID-19 from the University Hospital Frankfurt am Main, Germany.

Methods: SARS-CoV-2-specific-antibodies were detected by enzyme-linked immunosorbent assay (ELISA). SARS-CoV-2 and human coronavirus NL63 neutralization activity was analyzed with pseudotyped lentiviral vectors.

Results: The severity of COVID-19 increased with age, and male patients encountered more serious symptoms than female patients. Disease severity was correlated with the amount of SARS-CoV-2-specific immunoglobulin (Ig) G and IgA and the neutralization activity of the antibodies. The amount of SARS-CoV-2-specific IgG antibodies decreased with time after polymerase chain reaction conformation of the infection, and antibodies directed against the nucleoprotein waned faster than spike protein-directed antibodies. In contrast, for the common flu coronavirus NL63, COVID-19 disease severity seemed to be correlated with low NL63-neutralizing activities, suggesting the possibility of cross-reactive protection.

Conclusion: The results describe the humoral immune responses against SARS-CoV-2 and might aid the identification of correlates of protection needed for vaccine development.
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http://dx.doi.org/10.1093/infdis/jiaa680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665662PMC
January 2021

Factors influencing the bias between blood gas analysis versus central laboratory hemoglobin testing. A secondary analysis of a randomized controlled trial.

PLoS One 2020 30;15(10):e0240721. Epub 2020 Oct 30.

Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany.

Background: Anemia is the most important complication during major surgery and transfusion of red blood cells is the mainstay to compensate for life threating blood loss. Therefore, accurate measurement of hemoglobin (Hb) concentration should be provided in real-time. Blood Gas Analysis (BGA) provides rapid point-of-care assessment using smaller sampling tubes compared to central laboratory (CL) services.

Objective: This study aimed to investigate the accuracy of BGA hemoglobin testing as compared to CL services.

Methods: Data of the ongoing LIBERAL-Trial (Liberal transfusion strategy to prevent mortality and anemia-associated ischemic events in elderly non-cardiac surgical patients, LIBERAL) was used to assess the bias for Hb level measured by BGA devices (ABL800 Flex analyzer®, GEM series® and RapidPoint 500®) and CL as the reference method. For that, we analyzed pairs of Hb level measured by CL and BGA within two hours. Furthermore, the impact of various confounding factors including age, gender, BMI, smoker status, transfusion of RBC, intraoperative hemodilution, and co-medication was elucidated. In order to ensure adequate statistical analysis, only data of participating centers providing more than 200 Hb pairs were used.

Results: In total, three centers including 963 patients with 1,814 pairs of Hb measurements were analyzed. Mean bias was comparable between ABL800 Flex analyzer® and GEM series®: - 0.38 ± 0.15 g/dl whereas RapidPoint 500® showed a smaller bias (-0.09 g/dl) but greater median absolute deviation (± 0.45 g/dl). In order to avoid interference with different standard deviations caused by the different analytic devices, we focused on two centers using the same BGA technique (309 patients and 1,570 Hb pairs). A Bland-Altman analysis and LOWESS curve showed that bias decreased with smaller Hb values in absolute numbers but increased relatively. The smoker status showed the greatest reduction in bias (0.1 g/dl, p<0.001) whereas BMI (0.07 g/dl, p = 0.0178), RBC transfusion (0.06 g/dl, p<0.001), statins (0.04 g/dl, p<0.05) and beta blocker (0.03 g/dl, p = 0.02) showed a slight effect on bias. Intraoperative substitution of volume and other co-medications did not influence the bias significantly.

Conclusion: Many interventions like substitution of fluids, coagulating factors or RBC units rely on the accuracy of laboratory measurement devices. Although BGA Hb testing showed a consistently stable difference to CL, our data confirm that BGA devices are associated with different bias. Therefore, we suggest that hospitals assess their individual bias before implementing BGA as valid and stable supplement to CL. However, based on the finding that bias decreased with smaller Hb values, which in turn are used for transfusion decision, we expect no unnecessary or delayed RBC transfusion, and no major impact on the LIBERAL trial performance.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240721PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598475PMC
December 2020

Safety considerations for the use of Point-Of-Care diagnostics during SARS-CoV-2 pandemic.

J Clin Lab Anal 2021 Jan 22;35(1):e23631. Epub 2020 Oct 22.

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

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http://dx.doi.org/10.1002/jcla.23631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645901PMC
January 2021

Do we visually estimate intra-operative blood loss better with white or green sponges and is the deviation from the real blood loss clinically acceptable? Results from a simulated scenario study.

PLoS One 2020 21;15(10):e0240808. Epub 2020 Oct 21.

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany.

Background: The intraoperative blood loss is estimated daily in the operating room and is mainly done by visual techniques. Due to local standards, the surgical sponge colours can vary (e.g. white in US, green in Germany). The influence of sponge colour on accuracy of estimation has not been in the focus of research yet.

Material And Methods: A blood loss simulation study containing four "bleeding" scenarios each per sponge colour were created by using expired whole blood donation samples. The blood donations were applied to white and green surgical sponges after dilution with full electrolyte solution. Study participants had to estimate the absorbed blood loss in sponges in all scenarios. The difference to the reference blood loss was analysed. Multivariate linear regression analysis was performed to investigate other influence factors such as staff experience and sponge colour.

Results: A total of 53 anaesthesists participated in the study. Visual estimation correlated moderately with reference blood loss in white (Spearman's rho: 0.521; p = 3.748*10-16) and green sponges (Spearman's rho: 0.452; p = 4.683*10-12). The median visually estimated blood loss was higher in white sponges (250ml IRQ 150-412.5ml) than in green sponges (150ml IQR 100-300ml), compared to reference blood loss (103ml IQR 86-162.8). For both colour types of sponges, major under- and overestimation was observed. The multivariate statistics demonstrates that fabric colours have a significant influence on estimation (p = 3.04*10-10), as well as clinician's qualification level (p = 2.20*10-10, p = 1.54*10-08) and amount of RBL to be estimated (p < 2*10-16).

Conclusion: The deviation of correct blood loss estimation was smaller with white surgical sponges compared to green sponges. In general, deviations were so severe for both types of sponges, that it appears to be advisable to refrain from visually estimating blood loss whenever possible and instead to use other techniques such as e.g. colorimetric estimation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240808PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577479PMC
December 2020

The Emerging Therapeutic Potential of Nitro Fatty Acids and Other Michael Acceptor-Containing Drugs for the Treatment of Inflammation and Cancer.

Front Pharmacol 2020 3;11:1297. Epub 2020 Sep 3.

Department of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen, Germany.

Nitro fatty acids (NFAs) are endogenously generated lipid mediators deriving from reactions of unsaturated electrophilic fatty acids with reactive nitrogen species. Furthermore, Mediterranean diets can be a source of NFA. These highly electrophilic fatty acids can undergo Michael addition reaction with cysteine residues, leading to post-translational modifications (PTM) of selected regulatory proteins. Such modifications are capable of changing target protein function during cell signaling or in biosynthetic pathways. NFA target proteins include the peroxisome proliferator-activated receptor (PPAR-), the pro-inflammatory and tumorigenic nuclear factor-κB (NF-κB) signaling pathway, the pro-inflammatory 5-lipoxygenases (5-LO) biosynthesis pathway as well as soluble epoxide hydrolase (sEH), which is essentially involved in the regulation of vascular tone. In several animal models of inflammation and cancer, the therapeutic efficacy of well-tolerated NFA has been demonstrated. This has already led to clinical phase II studies investigating possible therapeutic effects of NFA in subjects with pulmonary arterial hypertension. Albeit Michael acceptors feature a broad spectrum of bioactivity, they have for a rather long time been avoided as drug candidates owing to their presumed unselective reactivity and toxicity. However, targeted covalent modification of regulatory proteins by Michael acceptors became recognized as a promising approach to drug discovery with the recent FDA approvals of the cancer therapeutics, afatanib (2013), ibrutinib (2013), and osimertinib (2015). Furthermore, the Michael acceptor, neratinib, a dual inhibitor of the human epidermal growth factor receptor 2 and epidermal growth factor receptor, was recently approved by the FDA (2017) and by the EMA (2018) for the treatment of breast cancer. Finally, a number of further Michael acceptor drug candidates are currently under clinical investigation for pharmacotherapy of inflammation and cancer. In this review, we focus on the pharmacology of NFA and other Michael acceptor drugs, summarizing their potential as an emerging class of future antiphlogistics and adjuvant in tumor therapeutics.
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http://dx.doi.org/10.3389/fphar.2020.01297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495092PMC
September 2020

Fibrin-derived peptide Bβ15-42 (FX06) as salvage treatment in critically ill patients with COVID-19-associated acute respiratory distress syndrome.

Crit Care 2020 09 24;24(1):574. Epub 2020 Sep 24.

Department of Anaesthesiology and Critical Care, University Hospital Wuerzburg, Julius-Maximilians-University, Wuerzburg, Germany.

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http://dx.doi.org/10.1186/s13054-020-03293-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7512215PMC
September 2020

The () Promoter Polymorphisms (rs3063368, rs755622) Predict Acute Kidney Injury and Death after Cardiac Surgery.

J Clin Med 2020 Sep 11;9(9). Epub 2020 Sep 11.

Department of Intensive Care Medicine, University Hospital Aachen, Rheinisch Westphälische Technische Hochschule Aachen, 52074 Aachen, Germany.

Background: Macrophage Migration Inhibitory Factor (MIF) is highly elevated after cardiac surgery and impacts the postoperative inflammation. The aim of this study was to analyze whether the polymorphisms CATT (rs5844572/rs3063368,"-794") and G>C single-nucleotide polymorphism (rs755622,-173) in the gene promoter are related to postoperative outcome.

Methods: In 1116 patients undergoing cardiac surgery, the gene polymorphisms were analyzed and serum MIF was measured by ELISA in 100 patients.

Results: Patients with at least one extended repeat allele (CATT) had a significantly higher risk of acute kidney injury (AKI) compared to others (23% vs. 13%; OR 2.01 (1.40-2.88), = 0.0001). Carriers of CATT were also at higher risk of death (1.8% vs. 0.4%; OR 5.12 (0.99-33.14), = 0.026). The GC genotype was associated with AKI (20% vs. GG/CC:13%, OR 1.71 (1.20-2.43), = 0.003). Multivariate analyses identified CATT predictive for AKI (OR 2.13 (1.46-3.09), < 0.001) and death (OR 5.58 (1.29-24.04), = 0.021). CATT was associated with higher serum MIF before surgery (79.2 vs. 50.4 ng/mL, = 0.008).

Conclusion: The CATT allele associates with a higher risk of AKI and death after cardiac surgery, which might be related to chronically elevated serum MIF. Polymorphisms in the gene may constitute a predisposition for postoperative complications and the assessment may improve risk stratification and therapeutic guidance.
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http://dx.doi.org/10.3390/jcm9092936DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7565645PMC
September 2020

Aerosol Exposure During Surgical Tracheotomy in SARS-CoV-2 Positive Patients.

Shock 2020 Sep 9. Epub 2020 Sep 9.

Department of Oto-Rhino-Laryngology, University Hospital Frankfurt, Goethe University, Germany.

Introduction: Since December 2019, the novel coronavirus SARS-CoV-2 has been spreading worldwide. Since the main route of infection with SARS-CoV-2 is probably via contact with virus-containing droplets of the exhaled air, any method of securing the airway is of extremely high risk for the health care professionals involved. We evaluated the aerosol exposure to the interventional team during a tracheotomy in a semi-quantitative fashion. In addition, we present novel protective measures.

Materials And Methods: To visualize the air movements occurring during a tracheotomy, we used a breathing simulator filled with artificial fog. Normal breathing and coughing were simulated under surgery. The speed of aerosol propagation and particle density in the direct visual field of the surgeon were evaluated.

Results: Laminar air flow (LAF) in the OR reduced significantly the aerosol exposure during tracheostomy. Only 4.8 ± 3.4% of the aerosol was in contact with the surgeon. Without LAF, however, the aerosol density in the inspiratory area of the surgeon is ten times higher (47.9 ± 10.8%, p < 0.01). Coughing through the opened trachea exposed the surgeon within 400ms with 76.0 ± 8.0% of the aerosol - independent of the function of the LAF. Only when a blocked tube was inserted into the airway, no aerosol leakage could be detected.

Discussion: Coughing and expiration during a surgical tracheotomy expose the surgical team considerably to airway aerosols. This is potentially associated with an increased risk for employees being infected by airborne transmitted pathogens. Laminar airflow in an operating room leads to a significant reduction in the aerosol exposure of the surgeon and is therefore preferable to a bedside tracheotomy in terms of infection prevention. Ideal protection of medical staff is achieved when the procedure is performed under endotracheal intubation and muscle relaxation.
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http://dx.doi.org/10.1097/SHK.0000000000001655DOI Listing
September 2020

Comparison of common perioperative blood loss estimation techniques: a systematic review and meta-analysis.

J Clin Monit Comput 2020 Aug 19. Epub 2020 Aug 19.

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.

Estimating intraoperative blood loss is one of the daily challenges for clinicians. Despite the knowledge of the inaccuracy of visual estimation by anaesthetists and surgeons, this is still the mainstay to estimate surgical blood loss. This review aims at highlighting the strengths and weaknesses of currently used measurement methods. A systematic review of studies on estimation of blood loss was carried out. Studies were included investigating the accuracy of techniques for quantifying blood loss in vivo and in vitro. We excluded nonhuman trials and studies using only monitoring parameters to estimate blood loss. A meta-analysis was performed to evaluate systematic measurement errors of the different methods. Only studies that were compared with a validated reference e.g. Haemoglobin extraction assay were included. 90 studies met the inclusion criteria for systematic review and were analyzed. Six studies were included in the meta-analysis, as only these were conducted with a validated reference. The mixed effect meta-analysis showed the highest correlation to the reference for colorimetric methods (0.93 95% CI 0.91-0.96), followed by gravimetric (0.77 95% CI 0.61-0.93) and finally visual methods (0.61 95% CI 0.40-0.82). The bias for estimated blood loss (ml) was lowest for colorimetric methods (57.59 95% CI 23.88-91.3) compared to the reference, followed by gravimetric (326.36 95% CI 201.65-450.86) and visual methods (456.51 95% CI 395.19-517.83). Of the many studies included, only a few were compared with a validated reference. The majority of the studies chose known imprecise procedures as the method of comparison. Colorimetric methods offer the highest degree of accuracy in blood loss estimation. Systems that use colorimetric techniques have a significant advantage in the real-time assessment of blood loss.
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http://dx.doi.org/10.1007/s10877-020-00579-8DOI Listing
August 2020

Visualized effect of the Frankfurt COVid aErosol pRotEction Dome - COVERED.

Indian J Anaesth 2020 May 23;64(Suppl 2):S156-S158. Epub 2020 May 23.

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany.

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http://dx.doi.org/10.4103/ija.IJA_569_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293375PMC
May 2020

Total Intravenous Anesthesia in Joubert Syndrome Patient for Otorhinolaryngology Surgery: A Case Report and Mini Review of the Literature.

Am J Case Rep 2020 Aug 7;21:e923018. Epub 2020 Aug 7.

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany.

BACKGROUND Joubert syndrome is a rare autosomal recessive disorder first described in 1969, with an estimated prevalence of 1 in 100 000. Joubert syndrome is characterized by partial or complete agenesis of the cerebellar vermis - the structure that connects both parts of the cerebellum. This results in the main clinical symptoms, such as muscular hypotonia, ataxia, mental retardation, abnormal eye movements, and a central apnea breathing pattern. Joubert syndrome can combine neurological signs with variable multi-organ involvement, mainly of the retina, kidneys, liver, and musculoskeletal system. CASE REPORT A 13-year-old boy presenting with recurrent otitis media, fever, respiratory infections, and tonsillar hyperplasia needed surgery. At the otorhinolaryngology outpatient clinic, the indication for surgical paracentesis, adenoidectomy, and tonsillectomy under general anesthesia (first in his life) was set. We performed a total intravenous anesthesia (TIVA) using propofol (described as safe) and remifentanil (organ-independent metabolism) without any side-effects. For postoperative pain therapy we used metamizole instead of paracetamol in order to avoid liver injury. CONCLUSIONS Due to the possible facial dysmorphism we recommend a critical evaluation of the airway to assess a potential difficult airway preoperatively. Our case underlines that TIVA, with the medications used in this case, is safe. We refrained from premedication in order not to trigger central apnea. For safety reasons, all preparatory procedures were carried out in the recovery room under monitor surveillance and with audio-visual distraction for the patient in order to reduce the stress level. For postoperative pain therapy, we recommend the use of metamizole.
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http://dx.doi.org/10.12659/AJCR.923018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440750PMC
August 2020