Paul Biever

Dual Antiplatelet Therapy (DAPT) versus No Antiplatelet Therapy and Incidence of Major Bleeding in Patients on Venoarterial Extracorporeal Membrane Oxygenation.

Aims Bleeding is a frequent complication in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). An indication for dual antiplatelet therapy due to coronary stent implantation is present in a considerable number of these patients. The objective of this retrospective study was to evaluate if dual antiplatelet therapy (DAPT) significantly increases the high intrinsic bleeding risk in patients on VA-ECMO. Methods and Results A total of 93 patients were treated with VA-ECMO between October 2010 and October 2013. Average time on VA-ECMO was 58.9 ± 1.7 hours. Dual antiplatelet therapy was given to 51.6% of all patients. Any bleeding was recorded in 60.2% of all patients. There was no difference in bleeding incidence in patients on DAPT when compared to those without any antiplatelet therapy including any bleeding (66.7% vs. 57.1%, p = 0.35), BARC3 bleeding (43.8% vs. 33.3%, p = 0.31) or pulmonary bleeding (16.7% vs. 19.0%, p = 0.77). This holds true after adjustment for confounders. Rate of transfusion of red blood cells were similar in patients with or without DAPT (35.4% vs. 28.6%, p = 0.488). Conclusions Bleeding on VA-ECMO is frequent. This registry recorded no statistical difference in bleeding in patients on dual antiplatelet therapy when compared to no antiplatelet therapy. When indicated, DAPT should not be withheld from VA ECMO patients.

Short-term heart and lung support: extracorporeal membrane oxygenation and extracorporeal life support

In the last few years, progress in engineering has helped to develop minimized systems for extracorporeal membrane oxygenation and circulatory support. However, despite progress in engineering, the use of these systems still requires a trained team with special skills to be a beneficial and safe tool in the care of critically ill patients. The described indications and proceedings are based on the daily experience of the Freiburg group using these systems both on site in our own hospital and for transport purposes from primary care hospitals into our center of maximum care. The aim of this review is to share our hands-on experience in urgent/emergent implantations and therefore contribute to the knowledge within the growing community of users in this specialized field of extracorporeal support.

Unprotected Left Main Percutaneous Coronary Intervention in Acute Coronary Syndromes with Extracorporeal Life Support Backup

Background. Left main PCI is superior to coronary bypass surgery in selected patients. Registry data, however, suggest significant early adverse event rates associated with unprotected left main PCI. We aimed to evaluate safety of an extracorporeal life support (ECLS) as backup system during PCI. Methods. We report a registry study of 16 high-risk patients presenting with acute coronary syndromes undergoing unprotected left main PCI with an ECLS backup. Results. Seven patients (43.8%) presented with an acute myocardial infarction while 9 patients (56.3%) had unstable angina. Unprotected left main PCI could be successfully performed in all 16 patients. Mortality or thromboembolic event rates were zero within the index hospital stay. General anesthesia was necessary only in 5 patients (31.3%). Access site bleeding requiring transfusion was encountered in 4 patients (25.0%). Three patients (18.8%) developed access site complications requiring surgical intervention. All patients were ECLS-free after 96 hours. Conclusions. Unprotected left main PCI could be safely and effectively performed after ECLS implantation as backup in acute coronary syndromes in our patient collectively. Vascular access site complications however need to be considered when applying ECLS as backup system.

Isoflurane or propofol sedation in patients with targeted temperature management after cardiopulmonary resuscitation: A single center study

Propose: Targeted temperature management improves outcomes in comatose patients after cardiac arrest. Short lasting sedatives might enable rapid awakening after targeted temperature management and therefore early prognostication and extubation. Aim of the present study was to compare sedation with volatile isoflurane to intravenous propofol. Materials and methods: All patients after cardiopulmonary resuscitation undergoing targeted temperature management treated between 01/2014 and 02/2017 at a single tertiary referral hospital were screened. Exclusion criteria included extracorporeal support or a survival below 48h. Results: Data on 214 patients (median age 66.1years, 62.6% shockable rhythm, survival 69.6%) are reported, 178 patients on propofol and sufentanil and 36 patients on isoflurane and sufentanil. Median time to first spontaneous breathing (9.3h vs. 9.5h, p=.373), median duration on mechanical ventilation in extubated patients (99.4h vs. 105.7h, p=.692) and median ICU stay (11.1d vs. 9.8d, p=.320) were similar in patients on propofol or isoflurane, respectively. Findings were confirmed by propensity score matching. Opioid dose was significantly lower in the isoflurane group (p<.001) while norepinephrine dose was significantly higher (p=.004). Conclusion: Isoflurane sedation is feasible on during targeted temperature management. Time to spontaneous breathing, mechanical ventilation duration or ICU stay was not reduced by isoflurane. HIGHLIGHTSIsoflurane sedation is feasible during targeted temperature management on a medical ICU.Duration of mechanical ventilation was not reduced after implementation of Isoflurane when compared to propofol sedation.Opioid dose was lower in isoflurane patients while norepinephrine dose was higher.

Maternale Bradykardie unter der Geburt

Eine 26-jährige III-Gravida, II-Para in der 38 + 4 SSW mit Wehenbeginn und Blasensprung wählt gegen 10:30 Uhr die Notrufnummer und wird mit dem Rettungswagen in den Kreißsaal eines peripheren Krankenhauses eingeliefert. Auf dem Transport wird ein Elektrokardiogramm (EKG) abgeleitet, auf dem eine mütterliche Bradykardie (34/min) auffällt. Daraufhin erhält die Patientin 1mg Atropin, was zu keiner wesentlichen Änderung der Herzfrequenz führt. Ein im Kreißsaal angelegtes Kardiotokogramm (CTG) ist unauffällig: ohne Hinweise auf kindliche Bradykardien mit unauffälligerBaseline.Bei vorangekommenemGeburtsfortschritt wird die Patientin unter Fenoterol-Tokolyse mit dem Hubschrauber auf die anästhesiologische IntensivtherapiestationdesUniversitätsklinikums Freiburg verlegt. Klinische und laborchemische Befunde