C.H.R. Wiese

Lipid emulsion improves recovery from bupivacaine-induced cardiac arrest, but not from ropivacaine- or mepivacaine-induced cardiac arrest.

BACKGROUND: Cardiac toxicity significantly correlates with the lipophilicity of local anesthetics (LAs). Recently, the infusion of lipid emulsions has been shown to be a promising approach to treat LA-induced cardiac arrest. As the postulated mechanism of action, the so-called “lipid sink” effect may depend on the lipophilicity of LAs. In this study, we investigated whether lipid effects differ with regard to the administered LAs. METHODS: In the isolated rat heart, cardiac arrest was induced by administration of equipotent doses of bupivacaine, ropivacaine, and mepivacaine, respectively, followed by cardiac perfusion with or without lipid emulsion (0.25 mL · kg−1 · min−1). Subsequently, the times from the start of perfusion to return of first heart activity and to recovery of heart rate and rate-pressure product (to 90% of baseline values) were assessed. RESULTS: In all groups, lipid infusion had no effects on the time to the return of any cardiac activity. However, recovery times of heart rate and rate-pressure product (to 90% of baseline values) were significantly shorter with the administration of lipids in bupivacaine-induced cardiac toxicity, but not in ropivacaine- or mepivacaine-induced cardiac toxicity. CONCLUSIONS: These data show that the effects of lipid infusion on LA-induced cardiac arrest are strongly dependent on the administered LAs itself. We conclude that lipophilicity of LAs has a marked impact on the efficacy of lipid infusions to treat cardiac arrest induced by these drugs.

Quality of out-of-hospital palliative emergency care depends on the expertise of the emergency medical team—a prospective multi-centre analysis

BackgroundThe number of palliative care patients who live at home and have non-curable life-threatening diseases is increasing. This is largely a result of modern palliative care techniques (e.g. specialised out-of-hospital palliative medical care services), changes in healthcare policy and the availability of home care services. Accordingly, pre-hospital emergency physicians today are more likely to be involved in out-of-hospital emergency treatment of palliative care patients with advanced disease.MethodsIn a prospective multi-centre study, we analysed all palliative emergency care calls during a 24-month period across four emergency services in Germany. Participating pre-hospital emergency physicians were rated according to their expertise in emergency and palliative care as follows—group 1: pre-hospital emergency physicians with high experience in emergency and palliative medical care, group 2: pre-hospital emergency physicians with high experience in emergency medical care but less experience in palliative medical care and group 3: pre-hospital emergency physicians with low experience in palliative and emergency medical care.ResultsDuring the period of interest, the centres received 361 emergency calls requiring a response to palliative care patients (2.8% of all 12,996 emergency calls). Ten percent of all patients were treated by group 1; 42% were treated by group 2 and 47% were treated by group 3. There was a statistically significant difference in the treatment of palliative care patients (e.g. transfer to hospital, symptom control, end-of-life decision) as a result of the level of expertise of the investigated pre-hospital emergency physicians (p< 0.01).ConclusionsIn Germany, out-of-hospital emergency medical treatment of palliative care patients depends on the expertise in palliative medical care of the pre-hospital emergency physicians who respond to the call. In our investigation, best out-of-hospital palliative medical care was given by pre-hospital emergency physicians who had significant expertise in palliative and emergency medical care. Our results suggest that it may be necessary to take the core principles of palliative care into consideration when conducting out-of-hospital emergency medical treatment of palliative care patients.

Emergency calls and need for emergency care in patients looked after by a palliative care team: Retrospective interview study with bereaved relatives.

BackgroundDuring the last stage of life, palliative care patients often experience episodes of respiratory distress, bleeding, pain or seizures. In such situations, caregivers may call emergency medical services leading to unwanted hospital admissions. The study aims to show the influence of our palliative care team to reducing emergency calls by cancer patients or their relatives during the last six month of life.MethodsFifty relatives of deceased patients who had been attended by our palliative care team were randomly selected. Data was obtained retrospectively during a structured interview. In addition to demographic data, the number of emergency calls made during the final six months of the patients life, the reason for the call and the mental compound score (MCS-12) of the caregivers was registered.ResultsForty-six relatives agreed to the interview. Emergency calls were placed for 18 patients (39%) during the final six months of their lives. There were a total of 23 emergency calls. In 16 cases (70%) the patient was admitted to the hospital. Twenty-one (91%) of the calls were made before patients had been enrolled to receive palliative care from the team, and two (9%) were made afterwards. The mean mental compound score of the caregivers at the time of the interview was 41 (range 28–57). There was a lack of correlation between MCS-12 and number of emergency calls.ConclusionEmergency calls were more likely to occur if the patients were not being attended by our palliative care team. Because of the lack of correlation between MCS-12 and the number of emergency calls, the MCS-12 cannot indicate that acutely stressful situations triggered the calls. However, we conclude that special palliative care programs can reduce psychosocial strain in family caregivers. Therefore, the number of emergency calls may be reduced and this fact allows more palliative patients to die at home.

Influence of airway management strategy on “no-flow-time” in a standardized single rescuer manikin scenario (a comparison between LTS-D™ and I-gel)

BACKGROUND In 2005 the European Resuscitation Council (ERC) published a revised version of the guidelines for Advanced Life Support (ALS). One of the aims was to reduce the time without chest compression in the first period of cardiac arrest (no-flow-time; NFT). We evaluated in a manikin study the influence on NFT using the single use laryngeal tube with suction option (LTS-D) compared to single use I-gel for emergency airway management. METHODS A randomised prospective study with 200 paramedics who performed standardised simulated cardiac arrest management in a manikin. RESULTS The use of the LTS-D did not significantly reduce NFT compared with the I-gel (104.7s vs. 105.1s; p>0.05). The LTS-D was inserted as fast as the I-gel (10.4s vs. 9.3s; p>0.05). The LTS-D was correctly positioned by 98% of the participants on the first attempt compared to 96% with the I-gel. During the cardiac arrest simulation, establishing and performing first ventilation took an average of 40.5s with the LTS-D compared to 40.9s with the I-gel. CONCLUSION In our manikin study, NFT was comparable using the LTS-D and the I-gel. Therefore, for personnel not experienced in tracheal intubation, the LTS-D and the I-gel seem to be equal alternatives in establishing the airway during cardiac arrest. However, relevant clinical studies are appropriate because any change in guidelines in this area must be based on clinical evidence.

Treatment of palliative care emergencies by prehospital emergency physicians in Germany: an interview based investigation

Palliative care medical emergencies as a consequence of advanced cancer account for approximately 3% of all prehospital emergency cases. Therefore, prehospital emergency physicians (EP) are confronted with ‘end of life decisions’. No educational content exists concerning palliative medicine in emergency medicine curricula. Over the course of 6 months, we interviewed 150 EPs about their experiences in ‘end of life decisions’ using a specific questionnaire. The total response rate was 69% (n = 104). Most of the interviewed EPs (89%, n = 93) had been confronted with palliative care medical emergencies and expressed uncertainties in dealing with these difficult situations, especially in the area of psychosocial care of the patients (50%). The emergency treatment of palliative care patients can become a particular challenge for any EP. A large percentage of interviewed EPs felt uncertain about aspects of social care and in the assessment of decisions at the end of life. Further information and training are necessary to amenable EPs to provide adequate patient-oriented care to palliative care patients and their relatives in emergency situations.

The use of the laryngeal tube disposable by paramedics during out-of-hospital cardiac arrest: a prospectively observational study (2008–2012)

Summary In the previous and the current guidelines of the European Resuscitation Council (ERC), endotracheal intubation (ETI), as an instrument for ventilation during resuscitation, was confirmed as less important for paramedics not trained in this method. For those, during resuscitation, the laryngeal tube is recommended by the ERC as a supraglottic airway device. The present study investigated prospectively the use of the laryngeal tube disposable (LT-D) by paramedics in prehospital emergency cases. Methods During a 42-month period (Sept 2008–Feb 2012), we prospectively registered all prehospital cardiac arrest situations in which the LT-D had been applied by paramedics (from one emergency medical service in Germany). Results During the defined period, 133 attempts, recorded on standardised data sheets, were enrolled into the investigation. Three were excluded from the study because of use during a trauma situation. Therefore, 130 patients were evaluated in this study. For this, the LT-D was used in 98% of all cases during resuscitation, and in about 2% of other emergencies (eg, trauma). With regard to resuscitation, adequate ventilation/oxygenation was described as possible in 83% of all included cases. In 66% of all cases, no problems concerning the insertion of the LT-D were described by the paramedics. No significant problems were reported in 93%. In 7% (n=9 cases), no insertion of the LT-D was possible. Instead of bag-mask-valve ventilation, the LT-D was used as a first-line airway device in about 66%. Between the two defined groups, no statistically significant differences were found (p>0.05). Conclusions As an alternative airway device during resuscitation, recommended by the ERC in 2005 and 2010, the LT-D may enable ventilation rapidly and, as in most of our described cases, effectively. Additionally, by using the LT-D in a case of cardiac arrest, a reduced ‘hands-off time’ and, therefore, a high chest compression rate may be possible. Our investigation showed that the LT-D was often used as an alternative to bag-mask-ventilation and to ETI as well. However, we were able to describe more problems in the use of the LT-D than earlier investigations. Therefore, in future, more studies concerning the use of alternative airway devices in comparison with ETI and/or video-laryngoscopy seem to be necessary.

„No-flow-time“-Reduzierung durch Einsatz des Larynxtubus

OBJECTIVE In 2005 the European Resuscitation Council (ERC) published the new guidelines for Advanced Life Support (ALS). One of the aims was to reduce the no flow time (NFT), without chest compression in the first period of cardiac arrest. Furthermore the guidelines recommend that endotracheal intubation should only be carried out by personnel experienced in this procedure. METHODS An attempt was made to evaluate whether the use of the laryngeal tube suction (LTS-D) for emergency airway management could contribute to reduce NFT compared to bag-mask ventilation (BMV). In a randomised prospective study 50 participants were asked to perform standardised simulated cardiac arrest management on a full-scale simulator following a one-day cardiac arrest training. Each participant was randomised into the LTS-D and the BMV group for airway management. At the end of each scenario an evaluation of the use of each ventilation procedure by the participants was made by means of a questionnaire. RESULTS During the manikin scenario (430 s for LTS-D and 420 s for BMV) there was a significant difference in the overall NFT comparing the use of the LTS-D vs. BMV (105.8 s, range 94-124 s vs. 150.7 s, range 124-179 s; p<0.01). This corresponded during the whole scenario to a proportion of 24.6% (LTS-D) or 35.9% (BMV). Using the LTS-D all participants were able to ventilate the manikin successfully (tidal volume 500-600 ml). In a subjective evaluation of the different airway management procedures by the participants more than 90% expressed a positive opinion about the LTS-D with respect to ease of insertion and safety of ventilation. CONCLUSION The use of the LTS-D on a manikin by emergency physicians after standardised cardiac arrest training significantly reduces the NFT in comparison to BMV. Therefore the LTS-D seems to be a good alternative to BMV during a simulated cardiac arrest scenario.

Paramedics experiences and expectations concerning advance directives: A prospective, questionnaire-based, bi-centre study:

Background: Advance directives and palliative crisis cards are means by which palliative care patients can exert their autonomy in end-of-life decisions. Aim: To examine paramedics’ attitudes towards advance directives and end-of-life care. Design: Questionnaire-based investigation using a self-administered survey instrument. Setting/participants: Paramedics of two cities (Hamburg and Goettingen, Germany) were included. Participants were questioned as to (1) their attitudes about advance directives, (2) their clinical experiences in connection with end-of-life situations (e.g. resuscitation), (3) their suggestions in regard to advance directives, ‘Do not attempt resuscitation’ orders and palliative crisis cards. Results: Questionnaires were returned by 728 paramedics (response rate: 81%). The majority of paramedics (71%) had dealt with advance directives and end-of-life decisions in emergency situations. Most participants (84%) found that cardiopulmonary resuscitation in end-of-life patients is not useful and 75% stated that they would withhold cardiopulmonary resuscitation in the case of legal possibility. Participants also mentioned that more extensive discussion of legal aspects concerning advance directives should be included in paramedic training curricula. They suggested that palliative crisis cards should be integrated into end-of-life care. Conclusions: Decision making in prehospital end-of-life care is a challenge for all paramedics. The present investigation demonstrates that a dialogue bridging emergency medical and palliative care issues is necessary. The paramedics indicated that improved guidelines on end-of-life decisions and the termination of cardiopulmonary resuscitation in palliative care patients may be essential. Participants do not feel adequately trained in end-of-life care and the content of advance directives. Other recent studies have also demonstrated that there is a need for training curricula in end-of-life care for paramedics.

Post-mortal bereavement of family caregivers in Germany: a prospective interview-based investigation

ZusammenfassungHINTERGRUND: Unterstützende Aspekte ambulanter Palliativdienste umfassen medizinische, psychologische und spirituelle Bedürfnisse von Patienten und ihren betreuenden Angehörigen. Die Zielsetzung der vorliegenden Arbeit ist die Untersuchung der postmortalen Trauerverarbeitung betreuender Angehöriger. METHODIK: In der Studie wurde der Einfluss eines ambulanten Palliativdienstes auf die postmortale Trauerverarbeitung von 50 betreuenden Angehörigen verstorbener Patienten untersucht. Die Interviews wurden mithilfe eines für die Untersuchung erstellten Fragebogens in Bezug auf die validierten Kriterien von Prigerson, Horowitz sowie der Definition nach ICD-10 zur Trauerverarbeitung erstellt. Eingeschlossen wurden alle Personen im Alter von über 18 Jahren, die den Patienten während seiner Krankheit überwiegend betreuten. ERGEBNISSE: Es konnten insgesamt 46 betreuende Angehörige entsprechend der definierten Kriterien in die Untersuchung eingeschlossen werden. Gemäß den Kriterien von Prigerson, Horowitz sowie nach ICD-10 wurde bei bis zu 30% der Untersuchten eine komplizierte Trauerverarbeitung festgestellt. Bezüglich der drei Kriterien konnte kein statistisch signifikanter Unterschied festgestellt werden (P > 0,05). Ebenfalls konnte unter Berücksichtigung des Alters, des Geschlechts der Angehörigen, der Art der Tumorerkrankung, der Dauer der Erkrankung oder der Qualitätsempfindung der Betreuung durch den ambulanten Palliativdienst kein statistisch signifikanter Unterschied der Trauerverarbeitung bzw. des Risikos für eine pathologische Trauerreaktion ermittelt werden (P > 0,05). Insgesamt waren 97% der Angehörigen mit der Betreuung durch den Palliativdienst zufrieden. SCHLUSSFOLGERUNG: Die Ergebnisse unserer Untersuchung lassen vermuten, dass die Unterstützung betreuender Angehöriger das Risiko einer pathologischen Trauerreaktion vermindern kann. Eine sorgsame Exploration möglicher Faktoren, die auf eine pathologische Trauerreaktion deuten, ist in der Betreuung von besonderer Bedeutung. Unterstützende spezialisierte ambulante palliativmedizinische Hilfsangebote sind zu empfehlen, um zahlreiche Probleme zu reduzieren und die Trauerreaktion positiv zu beeinflussen. Deshalb scheint es notwendig, Hilfe sowohl vor als auch nach dem Tod eines Patienten anzubieten, um die Trauerverarbeitung positiv beeinflussen zu können.SummaryBACKGROUND: Care aspects of outpatient palliative-care teams involve the medical, psychological, and spiritual needs of patients and their caregivers. The objective of our study was to examine the post-mortal bereavement of family caregivers. METHODS: The investigation was based on interviews with 50 family caregivers of 50 palliative-care patients assessed by a palliative-care team. Each caregiver was interviewed using interview sheets (mixed method designs) in accordance with three groups of validated criteria for complicated grief: Prigerson, Horowitz, and ICD-10. RESULTS: Forty-six family caregivers of terminally ill patients participated in the study. Complicated grief existed in up to 30% of the caregivers, based on the three sets of criteria. There was no significant difference (P > 0.05) among the three groups and no significant differences were found (P > 0.05) in relation to age, sex, psychosocial distress, primary cancer disease, and duration of illness or quality of care. Overall, 97% of the care-giving relatives were satisfied with the help given by the palliative-care team. CONCLUSION: The results of the study suggest that care from a specialized palliative-care team providing psychological and social support may reduce the risk of complicated grief. Careful exploration of possible risk factors for complicated grief is important for optimal care. Our study shows that healthcare providers play an important role in helping family caregivers to manage the multiple burdens and the grieving reaction. Family-focused grief therapy may prevent complicated grieving reactions.

The eNOS 786C/T polymorphism in cardiac surgical patients with cardiopulmonary bypass is associated with renal dysfunction

OBJECTIVE Renal dysfunction is one of the most serious complications following cardiac surgery with cardiopulmonary bypass. The causes of renal dysfunction following cardiac surgery are poorly understood. We hypothesised that T-786C endothelial NO synthase (eNOS) polymorphism may lead to an increase in the occurrence of postoperative renal dysfunction following cardiac surgery with cardiopulmonary bypass. METHODS A total of 497 patients undergoing cardiac surgery with cardiopulmonary bypass were included in the study. The T-786C eNOS polymorphism was detected by a polymerase chain reaction. The patients were grouped on the basis of whether they were homozygous or heterozygous for the C allele (TC+CC; n=289) or only homozygous for the T allele (TT; n=208). RESULTS No significance was demonstrated in the preoperative risk factors, with the exclusion of smoking habits (p=0.04) for the C-allele carrier. The administration of anti-lipid agents (p=0.01) and anti-arrhythmics (p=0.01) was significantly lower in the TC/CC group. The TC+CC genotype group had a significantly greater decrease in creatine clearance (p=0.024), the lowest creatine clearance (p=0.004) and more C-allele carriers received acute renal replacement therapy (p=0.04). The usage of norepinephrine (p=0.02) and dobutamine (p=0.02) was significantly higher in C-allele carriers. In the TC+CC genotype group, cross-clamp time (p=0.02) and administration of red cell transfusion (p=0.04) achieved statistically significant difference. The overall in-hospital mortality rate was 8.2% for all patients and was not significant between genotypes. CONCLUSIONS The present findings support the hypothesis that the T-786C eNOS polymorphism may play a role in the development of renal dysfunction and increase the occurrence of renal replacement therapy following cardiac surgery with cardiopulmonary bypass. This polymorphism may be useful in stratifying the risk for the development of postoperative renal dysfunction.