Mark Schoberer

Intraoperative amiodarone as prophylaxis against atrial fibrillation after coronary operations.

BACKGROUND New onset of atrial fibrillation is a frequent complication after coronary artery bypass grafting and is a major cause of postoperative morbidity. Preoperative oral treatment with amiodarone hydrochloride has been shown to be efficacious as prophylaxis. The present study investigated whether intraoperative use of intravenous amiodarone has a preventive effect on the incidence of atrial fibrillation after coronary revascularization. METHODS In a prospective study, 150 consecutive patients (mean age, 63 +/- 8 years; 132 men and 18 women) undergoing coronary artery bypass grafting were randomly assigned to one of three groups. Two groups received different doses of intravenous amiodarone (group I, 300-mg bolus and 20 mg x kg(-1) x day(-1) for 3 days; group II, 150-mg bolus and 10 mg x kg(-1) x day(-1) for 3 days) after aortic cross-clamping and one group, placebo (group III). Continuous electrocardiographic online monitoring was performed for 10 days. Arrhythmias were analyzed with respect to type, frequency, duration, and clinical relevance. RESULTS New onset of atrial fibrillation occurred in 24% of patients in group I, 28% in group II, and 34% in group III (p = not significant). Atrial fibrillation with a rapid ventricular response (>120 beats per minute) was significantly more frequent in the control group (group I, 14%; group II, 24%; group III, 32%; p < 0.05, group I versus group III) and appeared significantly earlier (group I, day 4.3 +/- 2.5; group II, day 4.8 +/- 2.9; group III, day 2.6 +/- 1.3; p < 0.05, group III versus groups I and II). Temporary atrial pacing because of bradycardia (<60 beats per minute) was necessary significantly more often in group I (group I, 48%; group II, 40%; group III, 28%; p < 0.05, group I versus group III). Early mortality rate (group I, 4%; group II, 2%; group III, 4%), rate of perioperative complications (group I, 14%; group II, 20%; group III, 14%), and duration of hospital stay (group I, 14.0 days; group II, 14.4 days; group III, 14.7 days) were not different between groups. CONCLUSIONS Intraoperative prophylactic use of amiodarone does not prevent new onset of atrial fibrillation in patients undergoing coronary artery bypass grafting and had no effect on outcome. Therefore, intraoperative prophylactic treatment with amiodarone at the tested doses does not appear to be justified.

NeonatOx: a pumpless extracorporeal lung support for premature neonates.

Gas exchange in premature neonates is regularly impaired by structural and functional immaturity of the lung. Mechanical ventilation, which is vitally important to sustain oxygenation and CO(2) elimination, causes, at the same time, mechanical and inflammatory destruction of lung tissue. To date, extracorporeal oxygenation is not a treatment option, one reason among others being the size of available oxygenators and cannulas. We hypothesized that a substantial improvement in gas exchange can be achieved by maintenance of the fetal cardiopulmonary bypass and interposition of a suitable passively driven (arteriovenous) membrane oxygenator. In close cooperation between engineers and neonatologists, we developed a miniaturized oxygenator and adapted cannulas to be used as a pumpless extracorporeal lung support that is connected to the circulation via cannulation of the umbilical cord vessels. First in vitro and in vivo studies show promising results. We regard this as one step on the way to clinical application of the artificial placenta.

Fifty Years of Work on the Artificial Placenta: Milestones in the History of Extracorporeal Support of the Premature Newborn

The concept of an artificial placenta has been pursued in experimental research since the early 1960s. The principle has yet to be successfully implemented in neonatal care despite the constant evolution in extracorporeal life support technology and advancements in neonatal intensive care in general. For more than three decades, the physical dimensions of the required equipment necessitated pump-driven circuits; however, recent advances in oxygenator technology have allowed exploration of the simpler and physiologically preferable concept of pumpless arteriovenous oxygenation. We expect that further miniaturization of the extracorporeal circuit will allow the implementation of the concept into clinical application as an assist device. To this end, NeonatOx (Fig. 1), a custom-made miniaturized oxygenator with a filling volume of 20 mL, designed by our own group, has been successfully implemented with a preterm lamb model of less than 2000 g body weight as an assist device. We provide an overview of milestones in the history of extracorporeal membrane oxygenation of the preterm newborn juxtaposed against current and future technological advancements. Key limitations, which need to be addressed in order to make mechanical gas exchange a clinical treatment option of prematurity-related lung failure, are also identified.

Miniaturization: the clue to clinical application of the artificial placenta.

The artificial placenta as a fascinating treatment alternative for neonatal lung failure has been the subject of clinical research for over 50 years. Pumpless systems have been in use since 1986. However, inappropriate dimensioning of commercially available oxygenators has wasted some of the theoretical advantages of this concept. Disproportional shunt fractions can cause congestive heart failure. Blood priming of large oxygenators and circuits dilutes fetal hemoglobin (as the superior oxygen carrier), is potentially infectious, and causes inflammatory reactions. Flow demands of large extracorporeal circuits require cannula sizes that are not appropriate for use in preterm infants. NeonatOx, a tailored low-volume oxygenator for this purpose, has proven the feasibility of this principle before. We now report the advances in biological performance of a refined version of this specialized oxygenator.

Incidence and Severity of Prescribing Errors in Parenteral Nutrition for Pediatric Inpatients at a Neonatal and Pediatric Intensive Care Unit

Objectives Pediatric inpatients are particularly vulnerable to medication errors (MEs), especially in highly individualized preparations like parenteral nutrition (PN). Aside from prescribing via a computerized physician order entry system (CPOE), we evaluated the effect of cross-checking by a clinical pharmacist to prevent harm from PN order errors in a neonatal and pediatric intensive care unit (NICU/PICU). Methods The incidence of prescribing errors in PN in a tertiary level NICU/PICU was surveyed prospectively between March 2012 and July 2013 (n = 3,012 orders). A pharmacist cross-checked all PN orders prior to preparation. Errors were assigned to seven different error-type categories. Three independent experts from different academic tertiary level NICUs judged the severity of each error according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index (categories A–I). Results The error rate was 3.9% for all 3,012 orders (118 prescribing errors in 111 orders). 77 (6.0%, 1,277 orders) errors occurred in the category concentration range, all concerning a relative overdose of calcium gluconate for peripheral infusion. The majority of all events (60%) were assigned to categories C and D (without major harmful consequences) while 28% could not be assigned due to missing majority decision. Potential harmful consequences requiring interventions (category E) could have occurred in 12% of assessments. Conclusion Next to systematic application of clinical guidelines and prescribing via CPOE, order review by a clinical pharmacist is still required to effectively reduce MEs and thus to prevent minor and major adverse drug events with the aim to enhance medication safety.

Thermomanagement in Neonatology and Paediatrics: Clinical Problems and Challenges.

Maintenance of an adequate body temperature is an essential part in neonatology and paediatrics. Delivery room, transports, daily routine care, diseases like sepsis, operations etc. retrieve the danger of hypothermia in these patients. Consequences of an inadequate heat loss especially for preterm and term infants are: metabolic acidosis, increasing oxygen consumption, hypoglycaemia, the risk of brain damage and a higher mortality. Prevention through external heat supply, routine care in the “thermoneutral-zone” and continuous temperature monitoring are necessary to prevent the risks of a drop of body temperature. Further development of existing methods and application of other, e.g. non-invasive, techniques are needed to simplify, improve and reduce the physical stress of these patients.

Unterstützte Handerkennung in Thermographiebildern zur Validierung der hygienischen Händedesinfektion

Bei der Verbreitung und Ubertragung von Infektionen im Krankenhaus sind die Hande ein zentraler Infektionsweg. Die korrekt ausgefuhrte hygienische Handedesinfektion ist deshalb entscheidend, um nosokomiale Infektionen zu verhindern. Unser Prototyp, aus voran gegangenen Arbeiten, bewertet die Handedesinfektion mit Hilfe von Infrarotthermographie. Ziel ist dem medizinischen Personal im Krankenhausalltag unmittelbare Ruckmeldung uber die Qualitat ihrer Handedesinfektion zu geben. Dazu ist es essentiell die Hande imWarmebild zu detektieren, was bei ahnlicher Umgebungs- und Handoberflachentemperatur nicht moglich ist. Hier stellen wir eine Erweiterung unseres Systems vor, welche die benotigte Handdetektion in einem Farbbild robust ermoglicht und transformieren die Ergebnisse anschliesend ins Warmebild.

Adult "termination-of-resuscitation" (TOR)-criteria may not be suitable for children - a retrospective analysis.

BackgroundOnly a small number of patients survive out-of-hospital-cardiac-arrest (OHCA). The duration of CPR varies considerably and transportation of patients under CPR is often unsuccessful. Termination-of-resuscitation (TOR)-criteria aim to preclude futile resuscitation efforts.Our goal was to find out to which extent existing TOR-criteria can be transferred to paediatric OHCA-patients with special regard to their prognostic value.MethodsWe performed a retrospective analysis of an eleven-year single centre patient cohort. 43 paediatric patients admitted to our institution after emergency-medical-system (EMS)-confirmed OHCA from 2003 to 2013 were included. Morrison’s BLS- and ALS-TOR-rules as well as the Trauma-TOR-criteria by the American Association of EMS Physicians were evaluated for application in children, by calculating sensitivity, specificity, negative and positive predictive value for death-, as well as survival-prediction in our cohort.Results26 patients achieved ROSC and 14 were discharged alive (n = 7 PCPC 1/2, n = 7 PCPC 5). Sensitivity for BLS-TOR-criteria predicting death was 48.3%, specificity 92.9%, the PPV 93.3% and the NPV 46.4%. ALS-TOR-criteria for death had a sensitivity of 10.3%, specificity of 100%, a PPV of 100% and an NPV of 35%.ConclusionRetrospective application of the BLS-TOR-rule in our patient cohort identified the resuscitation of one later survivor as futile. ALS-TOR-criteria did not give false predictions of death. The proportion of CPRs that could have been abandoned is 48.2% for the BLS-TOR and only 10.3% for the ALS-TOR-rule. Both rules therefore appear not to be transferable to a paediatric population.

PS-047 Medicines safety: the incidence and severity of prescribing errors in parenteral nutrition in paediatric inpatients

Background Parenteral nutrition (PN) is important for providing sufficient food for neonates, especially premature infants. Individually prescribed PN addresses specific patient requirements.1 Due to the diversity and complexity of PN prescribing, medicines errors may occur.2 Purpose To identify the incidence, type and severity of prescribing errors in PN in a paediatric intensive care unit (PICU). In this context the role of a clinical pharmacist should be checked as a member of an interdisciplinary team. Material and methods The occurrence of prescribing errors in PN in a PICU in a university hospital was analysed retrospectively between March 2012 and July 2013. First the errors were categorised in seven pre-defined categories. Afterwards the potential severity of each individual error was assessed independently by three medical experts from three different Level III neonatal units, not involved in any treatment regimen and blinded for patient outcome, based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorising Medicines Errors.3 Results 118 prescribing errors were identified from 2,889 PN orders. Each error had been discussed and eliminated before preparing the PN, so no errors reached the patient. The majority of errors constituted the category ‘concentration range’; 65%. Nearly 11% of the errors occurred in the categories ‘dose’ and ‘indication’. Error rates of 5% and lower were due to ‘choice of drug’, ‘compatibility’, ‘patient data’ and ‘osmolarity’. (By using the NCC MERP Index, the three experts classified the errors into several categories.) Conclusion These results underline that clinical pharmacists can prevent minor as well as major adverse drug events. Physicians as well as clinical pharmacists have to be aware of these risks and have to implement strategies to enhance medicines safety in PN treatment. Reference 1,2,3 Literature available from the author No conflict of interest.