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An elevated intra-abdominal pressure (IAP) above 12 mmHg is a pathological finding in critically ill patients. IAP are classified into different degrees of intra-abdominal hypertension and, in the presence of associated organ failure, as abdominal compartment syndrome. Both disease entities represent an underestimated factor in intensive care patients and are associated with increased mortality and prolonged intensive care and hospital stay. The measurement of intra-abdominal pressure in critically ill patients in intensive care units is not widely established and there is often considerable uncertainty regarding measurement conditions and methods. If risk factors are present, intra-abdominal pressure should be monitored every 4 hours. Bladder pressure measurement is the gold standard for determining intra-abdominal pressure. The measurement is a non-invasive, cost-effective, easy to perform bedside and safe method for the patient.

Background Bystander-initiated resuscitation is essential for surviving out-of-hospital cardiac arrest. Smartphone apps can provide real-time guidance for medical laypersons in these situations. Are these apps a beneficial addition to traditional resuscitation training? Methods In this controlled trial, we assessed the impact of app use on the quality of resuscitation (hands-off time, assessment of the patient’s condition, quality of chest compression, body and arm positioning). Pupils who have previously undergone a standardised resuscitation training, encountered a simulated cardiac arrest either (i) without an app (control group); (ii) with facultative app usage; or (iii) with mandatory app usage. Measurements were compared using generalised linear regression. Results 200 pupils attended this study with 74 pupils in control group, 65 in facultative group and 61 in mandatory group. Participants who had to use the app significantly delayed the check for breathing, call for help, and first compression, leading to longer total hands-off time. Hands-off time during chest compression did not differ significantly. The percentage of correct compression rate and correct compression depth was significantly higher when app use was mandatory. Assessment of the patient’s condition, and body and arm positioning did not differ. Conclusions Smartphone apps offering real-time guidance in resuscitation can improve the quality of chest compression but may also delay the start of resuscitation. Provided that the app gives easy-to-implement, guideline-compliant instructions and that the user is familiar with its operation, we recommend smartphone-guidance as an additional tool to hands-on CPR-training to increase the prevalence and quality of bystander-initiated CPR.

Zusammenfassung Hintergrund Bei medizinischen Akutfällen entscheiden Patienten eigenständig, ob sie den Rettungsdienst bzw. den ärztlichen Bereitschaftsdienst der kassenärztlichen Vereinigung anrufen oder sich in der Notaufnahme vorstellen. Fragestellung Gelingt der Bevölkerung die angemessene Zuordnung verschiedener dringlicher Erkrankungen zu den unterschiedlichen Systemen? Material und Methoden In einer deutschlandweiten, anonymen telefonischen Befragung nach dem Gabler-Häder-Design im Sommer 2018 wurden 708 Personen jeweils 6 verschiedene Szenarien mit medizinischen Akutfällen geschildert. Die Befragten wurden gebeten anzugeben, ob sie kurzfristige medizinische Hilfe für erforderlich hielten. Zusätzlich wurde die subjektive Dringlichkeit der einzelnen Szenarien sowie die Kenntnis der Telefonnummern von Rettungsdienst und ärztlichem Bereitschaftsdienst erhoben. Ergebnisse Die Dringlichkeit der Szenarien wurde häufig fehleingeschätzt: bei Szenarien hoher Dringlichkeit zu 20 %, bei mittlerer Dringlichkeit zu 50 % und bei leichter Dringlichkeit zu 27 %. Zusätzlich misslang einigen Befragten die Ressourcenwahl, wenn sie medizinische Hilfe für erforderlich hielten: 25 % würden bei einem Apoplex bzw. Myokardinfarkt keinen Rettungsdienst rufen. Bei Erkrankungen mittlerer Dringlichkeit würden mehr Befragte eigenständig in die Notaufnahme gehen (38 %), als den ärztlichen Bereitschaftsdienst zu alarmieren (46 %). Diskussion Das Wissen der Bevölkerung über die verschiedenen Ressourcen bei medizinischen Akutfällen und die Fähigkeit, die Dringlichkeit adäquat einzuschätzen, scheint nicht ausreichend zu sein. Die Lösung könnte neben einer Steigerung der Gesundheitskompetenz eine gemeinsame Telefonnummer für Rettungsdienst und ärztlichen Bereitschaftsdienst mit einheitlichem Abfragetool und Ressourcenzuordnung sein.

Die Pravalenz von Vibrio vulnificus hangt entscheidend von der Temperatur und dem Salzgehalt des Meerwassers ab. Am ehesten bedingt durch den Klimawandel sind auch an den deutschen (Ostsee)-Kusten zunehmend Falle von V.-vulnificus-bedingter Sepsis mit letalem Verlauf zu verzeichnen. Aufmerksamkeit generieren fur eine lebensbedrohliche Infektion mit steigender Inzidenz in Deutschland. Dieser Artikel stellt eine Ubersicht der aktuellen Literatur dar, gefolgt von exemplarischen Schilderungen von Fallen mit V.-vulnificus-Sepsis nach Kontakt mit Ostseewasser, die im Sommer 2018 an der Universitatsmedizin Greifswald behandelt wurden. Beim Vorhandensein von Risikofaktoren wie Leber- und Nierenerkrankungen, Immunsuppression oder mannlichem Geschlecht besteht bei Kontakt geschadigter Haut mit kontaminiertem Meereswasser die Gefahr fur eine schwere Sepsis. Haufig zeigt sich schon bei Aufnahme eine ausgepragte Organdysfunktion. In diesen Fallen muss der Verdacht rasch gestellt werden und fruhzeitig mit einer chirurgischen Sanierung und antiinfektiven Therapie (beispielsweise eine Kombination von Tetrazyklinen und Cephalosporinen der 3. Generation) begonnen werden. Die V.-vulnificus-bedingte Sepsis wird vermutlich in den kommenden Jahren zunehmen. Da in einigen Fallen eine zeitliche Latenz zwischen Infektion und Beginn der Sepsis besteht, mussen Arzte auch auserhalb der Kustenregion uber dieses Krankheitsbild informiert sein.

Zusammenfassung Zielsetzung In der Notfallversorgung besteht insbesondere in ländlich geprägten Regionen ein Zielkonflikt zwischen hoher Versorgungsqualität und effizientem Mitteleinsatz. Eine mögliche Lösung könnte der Telenotarzt darstellen, der mittels Informations- und Kommunikationstechnologien noch vor Eintreffen des Notarztes oder diesen ersetzend mit der ärztlichen Behandlung beginnen kann.Folgend werden die Kosten eines Telenotarzt-System dargestellt. Die Analyse basiert auf der Einführung eines Telenotarzt-Systems im Landkreis Vorpommern-Greifswald. Methodik Als Datengrundlage dienten die im Rahmen der Einführung des Telenotarzt-Systems im Landkreis Vorpommern-Greifswald angefallenen Kosten. Sämtliche Kosten wurden zu den Positionen Sach- und immaterielle Investitionen sowie jährliche Betriebs- und Personalkosten zusammengefasst. Weiterhin wurden die Investitionskosten anteilig berücksichtigt, so dass eine Jahresbetrachtung möglich war. Abschließend wurden die Kosten zu einer Kostenfunktion summiert. Ergebnisse Bei Zusammenführung aller angefallenen Kosten im Rahmen des Projektes Land|Rettung entstehen jährlich für jeden telenotarztfähigen Rettungswagen Kosten in Höhe von 20 842 €. Unter der Annahme eines betriebenen Telenotarzt-Arbeitsplatzes, belaufen sich die jährlichen Sach-, Personal- und Betriebskosten in dem Kreis insgesamt auf 1 049 466 €. Hierin enthalten sind die Investitions- und Betriebskosten des Telenotarzt-Arbeitsplatzes sowie allgemeine Komponenten des Telenotarzt-Systems (beispielsweise Netzwerk und Personalschulungen). Schlussfolgerung Das Telenotarzt-System, so wie es im Kreis Vorpommern-Greifswald entwickelt wurde, ist grundsätzlich auch für andere ländliche Regionen eine sinnvolle Maßnahme zur Verbesserung der Notfallversorgung. Wie das Beispiel aus Nordostdeutschland zeigt, sind die Kosten jedoch nicht vernachlässigbar. Bei der Übertragung auf andere Regionen können die Kosten abweichen, denn die Größe, der Urbanisierungsgrad sowie die geographische Lage einer Region beeinflussen die Kostenfunktion. Die hier vorgelegte Analyse gibt jedoch einen ersten Ansatz, um diese Kosten abschätzen zu können und damit eine evidenzbasierte Entscheidung über den Einsatz eines Telenotarztes treffen zu können.

Objectives. The easily performed “cough-trick” (CT) reduces pain during venipuncture (VP), although the underlying mechanism remains unclear. The aim was to investigate the pain-reducing effect of CT during VP in comparison with two distraction methods, as well as under the influence of naloxone.Methods. 54 healthy male volunteers participated in 3 investigations. Pain during standardized VP with CT was compared to a “weak” distraction (squeezing a rubber ball; investigation 1;n=20) and to a “strong” distraction (inflating a tourniquet to a given pressure; investigation 2;n=21). In investigation 3 (n=13), pain at a VP without intervention was compared to pain at VP with CT under naloxone; pressure pain thresholds before and after naloxone administration were also measured. Pain was assessed using a 100 mm visual analogue scale. Data were compared within each sample using Student’st-test for paired samples.Results. Pain intensity at VP with CT was lower than under “weak” distraction (mean difference 5 mm; 95% CI: 0.5 to 9.6;P=0.03). Pain levels under CT and “strong” distraction were comparable. There was no difference between pain under CT after naloxone infusion and pain without intervention. Pressure pain threshold decreased (mean difference 1 mm; 95% CI: 0.1 to 1.0 mm;P=0.02) after naloxone administration.Conclusion. Pain-reducing effect of CT during VP is superior to that of simple motor distraction and equivalent to a complex distraction method. This might be due to the activation of segmental pain inhibitory pathways during coughing indicated through the lack of pain reduction due to CT under opioid antagonist blockage.

Zusammenfassung Ziel der Studie In der vergangenen Dekade wurden Initiativen zur Erhöhung der Laienreanimationsrate ergriffen. Ist die Rate in den letzten 10 Jahren gestiegen? Ist dies assoziiert mit Veränderungen der Leitstellenleistung? Methodik Analyse prähospitaler Daten des Deutschen Reanimationsregisters. Einschluss von Fällen aus 19 deutschen Standorten zwischen 2008 und 2017. Ausschluss von Herz-Kreislauf-Stillständen nach Eintreffen des Rettungsdienstes, in Arztpraxen oder Kliniken. Analyse mit Chi-Quadrat-Test und Clopper-Pearson-Konfidenzintervallen. Ergebnisse Analysiert wurden die Daten von 22 555 Patienten. Die Laienreanimationsrate stieg von 23,4% im Jahr 2008 (606 von 2591, 95%-KI: 21,8 – 25,1%) auf 36,9% im Jahr 2017 (1014 von 2749, 95%-KI: 35,1 – 38,7%) (p Schlussfolgerung Die Laienreanimationsrate stieg um mehr als 50% bei vermehrter Telefonreanimation und Laienschulung. Ein kausaler Zusammenhang lässt sich nicht belegen.

Background Witnessing an out-of-hospital cardiac arrest (OHCA) is a traumatic experience. This study analyses bystanders` psychological processing of OHCA. We examined the potential impact of bystanders performing resuscitation and the influence of the relationship between bystander and patient (stranger vs. family/friend of the patient) on the psychological processing. Methods A telephone interview survey with bystanders, who witnessed an OHCA of an adult patient was performed weeks after the event between December 2014 and April 2016. The semi-standardized questionnaire contained a question regarding the paramount emotion at the time of the interview. In a post-hoc analysis statements given in response were rated by independent researchers into the categories “signs of pathological psychological processing”, “physiological psychological processing” and “no signs of psychological distress due to the OHCA”. Results In this analysis 89 telephone interviews were included. In 27 cases (30.3%) signs of pathological psychological processing could be detected. Bystanders performing resuscitation had a higher rate of “no signs of psychological distress after witnessing OHCA” compared to those not resuscitating (54.7% vs. 26.7%, p Conclusions One out of three bystanders of OHCA suffers signs of pathological psychological processing. This was independent of bystander´s age, gender and relationship to the patient. Performing resuscitation seems to help coping with witnessing OHCA.

Background:New Sepsis-3 criteria are supposed to “facilitate earlier recognition … of patients with sepsis.” To test this, we performed novel and direct comparisons of Sepsis-1 vs. Sepsis-3 criteria with respect to time differences of sepsis onset.Methods:In a cohort of intensive care unit (

Der gravierende Mangel an Spenderorganen hat sich in den vergangenen Jahren nicht gebessert. Die Optimierung der Ablaufe zur fruhzeitigen Identifizierung potenzieller Organspender und ein strukturiertes intensivmedizinische Management ist vordringliche Aufgabe der Intensivmedizin, um die Anzahl und den Erfolg der Transplantationen zu steigern. Die Therapie beginnt lange vor der Diagnostik zur Feststellung des irreversiblen Hirnfunktionsverlusts. Durch strukturierte, hausinterne Organ-Donor-Management-Protokolle wird eine hochqualifizierte intensivmedizinische Versorgung gewahrleistet, die sich direkt auf das Transplantationsergebnis auswirkt. Die Therapie orientiert sich an den etablierten Standards. Im Vordergrund steht dabei vor allem eine differenzierte Katecholamin- und Volumentherapie. Vasopressin ist in Kombination mit Noradrenalin effektiv, um sowohl die Vasoplegie als auch Elektrolytstorungen zu behandeln. Die Steroidgabe ist, trotz der vergleichsweise schwachen Evidenz, zur Stabilisierung der Hamodynamik und der Behandlung der Folgen der neuroendokrinen Dysfunktion geeignet. Insgesamt ist die Studienlage jedoch noch unzureichend, um allgemeingultige Empfehlungen fur die Intensivtherapie zu geben.

Background: Some recipients of ChAdOx1 nCoV-19 COVID-19 Vaccine AstraZeneca develop antibody-mediated vaccine-induced thrombotic thrombocytopenia (VITT), associated with cerebral venous and other unusual thrombosis resembling autoimmune heparin-induced thrombocytopenia. A prothrombotic predisposition is also observed in Covid-19. We explored whether antibodies against the SARS-CoV-2 spike protein induced by Covid-19 cross-react with platelet factor 4 (PF4/CXLC4), the protein targeted in both VITT and autoimmune heparin-induced thrombocytopenia.Methods: Immunogenic epitopes of PF4 and SARS-CoV-2 spike protein were compared via prediction tools and 3D modelling software (IMED, SIM, MacMYPOL). Sera from 222 PCR-confirmed Covid-19 patients from five European centers were tested by PF4/heparin ELISA, heparin-dependent and PF4-dependent platelet activation assays. Immunogenic reactivity of purified anti-PF4 and anti-PF4/heparin antibodies from patients with VITT were tested against recombinant SARS-CoV-2 spike protein. Results: Three motifs within the spike protein sequence share a potential immunogenic epitope with PF4. Nineteen of 222 (8.6%) Covid-19 patient sera tested positive in the IgG-specific PF4/heparin ELISA, none of which showed platelet activation in the heparin-dependent activation assay, including 10 (4.5%) of the 222 Covid-19 patients who developed thromboembolic complications. Purified anti-PF4 and anti-PF4/heparin antibodies from two VITT patients did not show cross-reactivity to recombinant SARS-CoV-2 spike protein. Conclusions: The antibody responses to PF4 in SARS-CoV-2 infection and after vaccination with COVID-19 Vaccine AstraZeneca differ. Antibodies against SARS-CoV-2 spike protein do not cross-react with PF4 or PF4/heparin complexes through molecular mimicry. These findings make it very unlikely that the intended vaccine-induced immune response against SARS-CoV-2 spike protein would itself induce VITT.

Background: Long patient transport times to trauma centers are a well-known problem in sparsely populated regions with a low hospital density. Transfusion of red blood cell concentrates (RBC) and plasma improves outcome of trauma patients with severe bleeding. Helicopter emergency services (HEMS) are frequently employed to provide early advanced medical care and to reduce time to hospital admission. Supplying HEMS with blood products allows prehospital transfusion and may help to prevent exsanguination or prolonged hemorrhagic shock. We have investigated the maintenance of blood product quality under air transport conditions and the logistical steps to introduce a HEMS blood depot into routine practice. Methods: A risk analysis was performed and a validation plan developed. A special, commercially available transport container for blood products was identified. Maintenance of temperature conditions between 2 and 6°C in the box were monitored at ambient temperatures up to 35°C over 48 h. Quality of blood products before and after helicopter air transport were evaluated including (1) for RBCs: hemoglobin, hematocrit, hemolysis rate; (2) for thawed plasma: aPTT, INR, single clotting factor activities. The logistics for blood supply of the regional HEMS were developed by the transfusion service of the Greifswald University Hospital in collaboration with the in-hospital transport team, the HEMS team, and the HEMS operator. Results: The transport container maintained a temperature below 6°C up to 36 h at 35°C ambient temperature. Vibration during helicopter operation did not impair quality of RBC and thawed plasma. To provide blood products for HEMS at least two transport containers and an additional set of cooling tiles is needed as the cooling tiles need a special temperature priming over 20 h. The two boxes were used at alternate days. To reduce wastage, RBCs and thawed plasmas were exchanged every fourth day and reintegrated into the blood bank inventory for further in-hospital use. Conclusions: Supplying HEMS with RBCs and plasma is feasible. Helicopter transport has no negative impact on blood product quality. The logistic challenges require close collaboration between the HEMS team and the blood transfusion service.

Background Over the past decade Smartphone-based activation (SBA) of Community First Responders (CFR) to out-of-hospital cardiac arrests (OHCA) has gained much attention and popularity throughout Europe. Various programmes have been established, and interestingly there are considerable differences in technology, responder spectrum and the degree of integration into the prehospital emergency services. It is unclear whether these dissimilarities affect outcome. This paper reviews the current state in five European countries, reveals similarities and controversies, and presents consensus statements generated in an international conference with the intention to support public decision making on future strategies for SBA of CFR. Methods In a consensus conference a three-step approach was used: (i) presentation of current research from five European countries; (ii) workshops discussing evidence amongst the audience to generate consensus statements; (iii) anonymous real-time voting applying the modified RAND-UCLA Appropriateness method to adopt or reject the statements. The consensus panel aimed to represent all stakeholders involved in this topic. Results While 21 of 25 generated statements gained approval, consensus was only found for 5 of them. One statement was rejected but without consensus. Members of the consensus conference confirmed that CFR save lives. They further acknowledged the crucial role of emergency medical control centres and called for nationwide strategies. Conclusions Members of the consensus conference acknowledged that smartphone-based activation of CFR to OHCA saves lives. The statements generated by the consensus conference may assist the public, healthcare services and governments to utilise these systems to their full potential, and direct the research community towards fields that still need to be addressed.

BackgroundWitnessing an out-of-hospital cardiac arrest (OHCA) is a traumatic experience. It is known, that some bystanders struggle with coping of these events. The impact of (part-) performing CPR vs. passive observing OHCA and of being a stranger as bystander vs. family and friends of the patient is still unknown.MethodsBetween December 2014 and April 2016 bystanders, who witnessed an OHCA of an adult patient (>18 years) were interviewed by telephone a few weeks after the event. In a semi-standardized questionnaire the paramount emotion at the time of the interview was asked. The statements given in response to open questions were rated into the categories “signs of pathological psychological processing”, “physiological psychological processing” and “good mental constitution” by independent researchers.ResultsObserving the exclusion criteria 89 telephone interviews could be included in the analyses. In 27 out of 89 cases (30.3%) signs of pathological psychological processing could be detected. Signs of pathological psychological processing were significantly less in bystanders, who received instructions by the dispatcher or autonomously performed CPR. No statistical significant differences in the psychological processing could be shown for gender, age, relationship to the patient, current employment in the health sector, location of cardiac arrest or number of additional bystanders.ConclusionsOne out of three bystanders of OHCA suffers sings of pathological psychological processing. This was independent of age, gender and relationship of the bystander to the patient. Bystanders who performed CPR with or without receiving instructions had a lower risk.

Background German emergency medical services are a 2-tiered system with paramedic-staffed ambulances as the primary response, supported by prehospital emergency doctors for life-threatening conditions. As in all European health care systems, German medical practitioners are in short supply, whereas the demand for timely emergency medical care is constantly growing. In rural areas, this has led to critical delays in the provision of emergency medical care. In particular, in cases of cardiac arrest, time is of the essence because, with each passing minute, the chance of survival with good neurological outcome decreases. Objective The project has 4 main objectives: (1) reduce the therapy-free interval through widespread reinforcement of resuscitation skills and motivating the public to provide help (ie, bystander cardiopulmonary resuscitation), (2) provide faster professional first aid in addition to rescue services through alerting trained first aiders by mobile phone, (3) make more emergency physicians available more quickly through introducing the tele-emergency physician system, and (4) enhance emergency care through improving the cooperation between statutory health insurance on-call medical services (German: Kassenärztlicher Bereitschaftsdienst) and emergency medical services. Methods We will evaluate project implementation in a tripartite prospective and intervention study. First, in medical evaluation, we will assess the influences of various project measures on quality of care using multiple methods. Second, the economic evaluation will mainly focus on the valuation of inputs and outcomes of the different measures while considering various relevant indicators. Third, as part of the work and organizational analysis, we will assess important work- and occupational-related parameters, as well as network and regional indexes. Results We started the project in 2017 and will complete enrollment in 2020. We finished the preanalysis phase in September 2018. Conclusions Overall, implementation of the project will entail realigning emergency medicine in rural areas and enhancing the quality of medical emergency care in the long term. We expect the project to lead to a measurable increase in medical laypersons’ individual motivation to provide resuscitation, to strengthen resuscitation skills, and to result in medical laypersons providing first aid much more frequently. Furthermore, we intend the project to decrease the therapy-free interval in cases of cardiac arrest by dispatching first aiders via mobile phones. Previous projects in urban regions have shown that the tele-emergency physician system can provide a higher availability and quality of emergency call-outs in regular health care. We expect a closer interrelation of emergency practices of statutory health insurance physicians with the rescue service to lead to better coordination of rescue and on-call services. International Registered Report Identifier (IRRID) DERR1-10.2196/14358

ObjectiveAuricular stimulation (AS) is a promising method in the treatment of situational anxiety. Expressive writing (EW) is an established psychological method, which reduces test anxiety and improves exam results. The aim of this crossover trial was to compare AS with EW, and with the no intervention (NI) condition, for treatment of exam anxiety.MethodsHealthy medical students underwent 3 comparable anatomy exams with an interval of one month, either performing EW, receiving AS or NI prior to the exam; the order of interventions was randomized. AS was applied using indwelling fixed needles bilaterally at the areas innervated mostly by the auricular branch of the vagal nerve on the day before the exam. Anxiety level, measured using State-Trait-Anxiety Inventory (STAI) before and after the interventions and immediately before exam, was the primary outcome. Quality of night sleep, blood pressure, heart rate and activity of salivary alpha-amylase (sAA) were analyzed across 3 conditions.ResultsAll 37 included participants completed the study. Anxiety level (STAI) decreased immediately after AS in comparison with baseline (P = 0.02) and remained lower in comparison with that after EW and NI (PConclusionAuricular stimulation, but not expressive writing, reduced exam anxiety and improved quality of sleep in medical students. These changes might be due to reduced activity of the sympathetic nervous system.

Study objective Previous randomized controlled trials (RCTs) suggest that auricular stimulation (AS) is safe and effective in treatment of preoperative anxiety; however, a systematic evaluation is lacking. The aim was to summarize the evidence on efficacy and safety of AS for preoperative anxiety, as well as for other outcomes. Design We conducted a systematic review of RCTs including patients from all available populations. The search was done through MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science and Scopus Database from inception to June 2020. Study selection and data extraction were performed in by 2 independent reviewers with ability to resolve disagreements by a third author. Meta-analyses as well as the risk of bias and evidence quality assessments were performed according to the Cochrane 6.2, 2021 handbook recommendations. Interventions We compared AS with pharmacological and non-pharmacological interventions for different outcomes. Measurements We assessed the repercussion of the evaluated interventions over anxiety scores and their safety, physiological parameters, perioperative medications requirement and intensity of postoperative pain. Main results We have included 15 studies with 1603 patients. AS has presented reduced anxiety scores as compared to the sham control (Standardized Mean Difference (SMD) -0.72, 95% confidence interval (CI) -1.09 to −0.36, p Conclusions AS may be useful in treatment of preoperative anxiety. Due to heterogenous certainty in effect estimates, further research is needed to clarify the actual efficacy of AS for preoperative anxiety.

Temporal summation of pain (TSP) is a promising tool for measuring the pain modulation processes in healthy subjects and patients with chronic pain. We tried to find optimal stimulation parameters in order to elicit a robust reproducible TSP phenomenon. Twenty healthy volunteers (15 women and 5 men) completed four sessions/conditions of pulsating heat pain stimulation, applied to the left forearm with a frequency of 0.33–0.4 sec–1 using a contact heat-evoked potential stimulator. The stimulation temperature (step +0.5°C or +1.0°C up to the pain threshold, pain tolerance), pulse duration (500, 800, or 1000 msec), and number of stimuli (60 or 90) were varied. The participants rated the pain intensity at the first and every 10th heat pulse, using a numeric rating scale (NRS) 0–100. The TSP was calculated as the difference between the lowest rating and the rating of the last stimulus and was compared between conditions. The optimal condition (19 out of 20 participants responded with TSP) showed temperature at pain tolerance, pulse duration of 800 msec, and 90 stimuli. In addition, this condition showed weaker side effects (painful discomfort) than those with less (60) but longer (1000 msec) stimuli presented 1.0 degree above the pain threshold. The protocol with a relatively high stimulus repetition and a moderate pulse duration seems to be the optimal protocol to reproduce TSP. Heat stimulation with longer pulse durations and higher stimulation temperatures was less feasible.

In immer mehr Regionen Deutschlands wird ein prahospitales Telemedizinsystem als Erganzung der Regelversorgung eingefuhrt. Ein Telenotarzt kann von einer Zentrale aus mit Rettungsdienstmitarbeitern am Einsatzort in Echtzeit kommunizieren, diagnostisch unterstutzen und therapeutische Masnahmen delegieren. Die technische Machbarkeit und der medizinische Nutzen wurden bereits belegt. Fur den dauerhaften Erfolg eines Telemedizinprojekts ist die Erwartungshaltung der Anwender essenziell. Diese wurde im Projekt Land/Rettung vor der Einfuhrung einer Telenotarztanwendung erhoben. Was erwarten die zukunftigen Anwender (Leitstellendisponenten, arztliches und nichtarztliches Personal im Rettungsdienst und in der Notaufnahme) von der Einfuhrung eines prahospitalen Telemedizinsystems? Im Mai bis August 2017 wurde die Erwartungshaltung der Personen, die mit dem Telenotarzt zusammenarbeiten werden, mittels papierbasiertem Fragebogen erhoben. Es wurden 411 Personen kontaktiert, die Rucklaufquote betrug 51,6 %. Die Mehrheit der Befragten stimmte den Aussagen zu, dass das Telenotarztkonzept zu einer schnelleren Diagnosefindung und einem schnelleren Therapiebeginn fuhre und die Qualitat der Patientenversorgung verbessere. Eine Verbesserung der personlichen beruflichen Leistung sowie Reduktion der Arbeitsbelastung und des Dokumentationsaufwands werden (eher) nicht erwartet. Der Grosteil der Befragten halt das Telenotarztkonzept fur (eher) sinnvoll. Die Mitarbeiter in der Notfallmedizin erwarten eine verbesserte Patientenversorgung durch die Einfuhrung eines Telenotarztes. Personliche Vorteile wie Arbeitserleichterungen werden nicht erwartet. Zusammenfassend wird das Telenotarztkonzept als sinnvoll erachtet.

BACKGROUND Transcutaneous vagus nerve stimulation (TVNS) is a promising treatment for acute and chronic pain. However, experimental studies yielded controversial results. We examined if TVNS reduces the perceived intensity of repetitive painful heat stimulation and temporal summation of pain (TSP) in healthy volunteers in comparison with placebo and sham stimulation, as well as no intervention. METHODS In 4 sessions, 90 heat pulse stimuli at individual pain tolerance temperature were applied to the ventral forearm of 49 healthy volunteers (25 women) using a Contact Heat Evoked Potential Stimulator thermode (Medoc, Ramat Yishai, Israel). Pain intensity was assessed with verbal ratings on a numeric pain scale (0-100) at every tenth heat pulse. After the first session in which pain intensities without intervention were evaluated, participants completed 3 sessions in a single-blinded randomized crossover manner: (1) sham stimulation applied at the earlobes, (2) placebo stimulation (inactive device), or (3) TVNS applied at the cymbas conchae. Primary data were analyzed using analysis of variance for repeated measures and t test for paired samples. RESULTS Pain intensity decreased during all interventions as compared to no intervention (ηp = 0.22, P < .001; mean difference TVNS versus no intervention 9.5; 95% confidence interval [CI], 3.6-15.4; P < .001). Hypoalgesic effect of TVNS was better than that of placebo and sham in men before the onset of TSP (mean differences for TVNS versus placebo 6.2; 95% CI, 0.2-12.1; TVNS versus sham 6.2; 95% CI, 0.2-12.1; P < .05). In women, TSP response under TVNS was decreased if compared to no intervention (median difference, 7.5; 95% CI, 3.5-15.0; P = .003). CONCLUSIONS TVNS, placebo, and sham stimulation exerted comparable effects under experimental heat pain stimulation. Only in male participants, TVNS was superior to sham and placebo conditions in the reduction of heat pain before the onset of TSP.

Sepsis hat eine hohe Mortalitat, die durch einen fruhzeitigen Therapiebeginn reduziert werden kann. Da Patienten mit Sepsis haufig durch den Rettungsdienst in die Notaufnahme gebracht werden, kann hier die Therapie schon gebahnt werden. Ist das Wissen zum Erkennen und Screenen der Sepsis in der Notfallmedizin ausreichend verbreitet? Im Rahmen einer Befragungsstudie wurde im Landkreis Vorpommern-Greifswald das Wissen zur Sepsiserkennung bei arztlichen und nichtarztlichen Mitarbeitern der Rettungswachen, Leitstelle und Notaufnahme ermittelt. Eine Vielzahl des nichtarztlichen Rettungsdienstpersonals und der Leitstellendisponenten hatte noch nie eine Schulung zum Thema Sepsis. Der Sepsis-Score quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) ist wenig bekannt, und der Parameter „alterierter Mentalstatus“ wird kaum mit dem Krankheitsbild Sepsis assoziiert. Damit besteht die Gefahr, Patienten mit Sepsis in der praklinischen und fruhen innerklinischen Versorgung zu ubersehen und so den Therapiebeginn zu verzogern. Eine verbesserte Sepsisausbildung und Erhohung der Aufmerksamkeit in der praklinischen und fruhen innerklinischen Notfallmedizin konnten die Prognose der Sepsis verbessern.

The European Union intends to enable its citizens to interact across borders in relevant areas of society and culture to further integrate neighboring regions. Medicine has not been at the core of recent EU-funded efforts in central Europe, partially due to significant differences in health care administration, delivery, reimbursement, and culture. However, impeding changes in social structure and centralization of specialized care warrant changes in preclinical administration of medical care, which are already transforming practices across developed countries in central Europe. Moreover, demographic and social changes are transforming not only patients but also health care providers, thus leading to an increased need for specialized medical personnel, particularly in regions close to formerly secluding borders. The EU-funded cooperation project presented in this article is located in the Euroregion Pomerania, which consists of northeastern Germany and northwestern Poland. This project emerged because of the need to solve practical emergency medicine–related problems for many years, which brought partners together. Unfortunately, administrative and medical interaction has not become significantly easier with Poland joining the Schengen area in 2007 and, subsequently, initial international contracts regarding, among other things, emergency medicine being negotiated and signed thereafter. Three different interdependent areas of cooperation within the project deal with key aspects of an improved and eventually integrated cooperation. An accepted clarification of administrative and legal foundations – or the lack and thus the need thereof – needs to be defined. Specialized language and simulation-based education and practice sessions employing modern technology throughout will be introduced to the entire region. Finally, the pre-existing and developing acceptance and sustainability aspects of personnel involved in the aforementioned actions and stakeholders on both sides of the border will be evaluated. In essence, the project focuses on a multimodal improvement of professional cooperation of key providers of emergency medicine services in the Euroregion Pomerania. Thereby, it aims to improve infrastructure; interpersonal and professional skills of involved personnel, administrative, and cultural relations; and eventually identification of specialized personnel with their workplace and region to secure and retain important medical workforce in an otherwise remote area on both sides of a formerly secluded border.

As a central service provider in medical care, anesthetists manage the growing demand on medical services, thereby increasing specialization and patient morbidity. Various indicators and measurements have been used to match staff capacity, competence, and workload. It remains unclear whether the problems are due to real shortages or "just" to a wrong distribution. Medical services, service development, infrastructure, capacity, and competences of medical staff of 15 departments of anesthesiology at German university hospitals were compared. They reported an increase in medical service and staff capacity. Competences did not grow, fluctuation rates were high, and part-time employment increased. The broad variety of hospitals' infrastructures requires different staff capacity and competence structures. Anesthetists need to take on a key role in redesigning hospital performance and staff management to ensure performance increases, patient safety, and bearable workloads. Optimal distribution of expertise and early counteraction for shortages in staff capacities and competences is needed.

Objectives. Recent advances in the treatment of postoperative pain (POP) have increased the quality of life in surgical patients. The aim of this study was to examine the quality of POP management in patients after CS in comparison with patients after comparable surgical procedures. Methods. This was a prospective observational analysis in patients after CS in comparison with the patients of the same age, who underwent comparable abdominal gynaecological surgeries (GS group) at the university hospital. A standardised questionnaire including pain intensity on the Verbal Rating Scale (VRS-11), incidence of analgesia-related side effects, and incidence of pain interference with the items of quality of life and patients’ satisfaction with the treatment of POP was used. Results. Sixty-four patients after CS reported more pain on movement than the patients after GS (N=63): mean 6.1 versus 3.6 (VRS-11; P<0.001). The patients after CS reported less nausea (8 versus 41%) and vomiting (3 versus 21%; P<0.001) and demonstrated better satisfaction with POP treatment than the patients after GS: 1.4 (0.7) versus 1.7 (0.7) (mean (SD); VRS-5; P=0.02). Conclusion. The disparity between the high level of pain and excellent satisfaction with POP treatment raises the ethical and biomedical considerations of restrictive pharmacological therapy of post-CS pain.

To investigate the impact of a quality improvement initiative for severe sepsis and septic shock focused on the resuscitation bundle on 90-day mortality. Furthermore, effects on compliance rates for antiinfective therapy within the recommended 1-hour interval are evaluated.Prospective observational before-after cohort study.Tertiary university hospital in Germany.All adult medical and surgical ICU patients with severe sepsis and septic shock.Implementation of a quality improvement program over 7.5 years.The primary endpoint was 90-day mortality. Secondary endpoints included ICU and hospital mortality rates and length of stay, time to broad-spectrum antiinfective therapy, and compliance with resuscitation bundle elements.A total of 14,115 patients were screened. The incidence of severe sepsis and septic shock was 9.7%. Ninety-day mortality decreased from 64.2% to 45.0% (p0.001). Hospital length of stay decreased from 44 to 36 days (p0.05). Compliance with resuscitation bundle elements was significantly improved. Antibiotic therapy within the first hour after sepsis onset increased from 48.5% to 74.3% (p0.001). Multivariate analysis revealed blood cultures before antibiotic therapy (hazard ratio, 0.60-0.84; p0.001), adequate calculated antibiotic therapy (hazard ratio, 0.53-0.75; p0.001), 1-2 L crystalloids within the first 6 hours (hazard ratio 0.67-0.97; p = 0.025), and greater than or equal to 6 L during the first 24 hours (hazard ratio, 0.64-0.95; p = 0.012) as predictors for improved survival.The continuous quality improvement initiative focused on the resuscitation bundle was associated with increased compliance and a persistent reduction in 90-day mortality over a 7.5-year period. Based on the observational study design, a causal relationship cannot be proven, and respective limitations need to be considered.

Background Performance of sufficient cardiopulmonary resuscitation (CPR) by medical personnel is critical to improve outcomes during cardiac arrest. It has however been shown that even health care professionals possess a lack of knowledge and skills in CPR performance. The optimal method for teaching CPR remains unclear, and data that compares traditional CPR instructional methods with newer modalities of CPR instruction are needed. We therefore conducted a single blinded, randomised study involving medical students in order to evaluate the short- and long-term effects of a classical CPR education compared with a bilateral approach to CPR training, consisting of problem-based learning (PBL) plus high fidelity simulation. Methods One hundred twelve medical students were randomized during a curricular anaesthesiology course to a control (n = 54) and an intervention (n = 58) group. All participants were blinded to group assignment and partook in a 30-min-lecture on CPR basics. Subsequently, the control group participated in a 90-min tutor-guided CPR hands-on-training. The intervention group took part in a 45-min theoretical PBL module followed by 45 min of high fidelity simulated CPR training. The rate of participants recognizing clinical cardiac arrest followed by sufficiently performed CPR was the primary outcome parameter of this study. CPR performance was evaluated after the intervention. In addition, a follow-up evaluation was conducted after 6 months. Results 51.9% of the intervention group met the criteria of sufficiently performed CPR as compared to only 12.5% in the control group on the day of the intervention (p = 0.007). Hands-off-time as a marker for CPR continuity was significantly less in the intervention group (24.0%) as compared to the control group (28.3%, p = 0.007, Hedges’ g = 1.55). At the six-month follow-up, hands-off-time was still significantly lower in the intervention group (23.7% vs. control group: 31.0%, p = 0.006, Hedges’ g = 1.88) but no significant difference in sufficiently performed CPR was detected (intervention group: 71.4% vs. control group: 54.5%, p = 0.55). Conclusion PBL combined with high fidelity simulation training leads to a measurable short-term increase in initiating sufficient CPR by medical students immediately after training as compared to classical education. At six month post instruction, these differences remained only partially. Electronic supplementary material The online version of this article (10.1186/s12909-019-1626-7) contains supplementary material, which is available to authorized users.

The "Joint Commission of BDA and DGAI for Graduate Medical Education and Further Education" presents a concept for postgraduate training in anesthesiology. Aiming at a different and demanding generation of young physicians it proposes a new approach to an attractive training in anesthesiology e. g. by simulation as one key concept. It is also intended to meet the guidelines of the German Medical Association of competency based rather than time based or procedure based graduate medical education. A clear structure and the competency based approach shall facilitate a process of professional teaching. The article describes the new concept of graduate medical education by the German Medical Association and the respective aims and objectives of the Scientific Medical Societies in Germany. An existing implementation in a hospital is given as an example of feasibility.

Background Improvement of postoperative pain and other perioperative outcomes remain a significant challenge and a matter of debate among perioperative clinicians. This systematic review aims to evaluate the effects of perioperative i.v. lidocaine infusion on postoperative pain and recovery in patients undergoing various surgical procedures. Methods CENTRAL, MEDLINE, EMBASE, and CINAHL databases and ClinicalTrials.gov, and congress proceedings were searched for randomized controlled trials until May 2014, that compared patients who did or did not receive continuous perioperative i.v. lidocaine infusion. Results Forty-five trials (2802 participants) were included. Meta-analysis suggested that lidocaine reduced postoperative pain (visual analogue scale, 0 to 10 cm) at 1–4 h (MD −0.84, 95% CI −1.10 to −0.59) and at 24 h (MD −0.34, 95% CI −0.57 to −0.11) after surgery, but not at 48 h (MD −0.22, 95% CI −0.47 to 0.03). Subgroup analysis and trial sequential analysis suggested pain reduction for patients undergoing laparoscopic abdominal surgery or open abdominal surgery, but not for patients undergoing other surgeries. There was limited evidence of positive effects of lidocaine on postoperative gastrointestinal recovery, opioid requirements, postoperative nausea and vomiting, and length of hospital stay. There were limited data available on the effect of systemic lidocaine on adverse effects or surgical complications. Quality of evidence was limited as a result of inconsistency (heterogeneity) and indirectness (small studies). Conclusions There is limited evidence suggesting that i.v. lidocaine may be a useful adjuvant during general anaesthesia because of its beneficial impact on several outcomes after surgery.

The provision of emergency doctors in rural regions is challenged by guaranteeing early rescue while limiting the number of emergency doctor positions. The first alternative to achieve these objectives is the increase of the number of emergency medical services. Alterna- tives are helicopter rescue and the so-called „telemedicine emergen- cy doctor”. In particular in regions with low population density and geographical barriers (such as Switzerland) one has to choose an al- ternative which minimises the costs while still warranting that the emergency time is kept. This analysis compares the costs of all three alternatives. It becomes obvious that the telemedicine doctor is a promising innovation which is due to become more relevant for Switzerland.

This study evaluated electric nerve stimulation as a nerve location tool. After eliciting motor response in 43 patients undergoing shoulder surgery, the needle tip's position, distance from the closest nerve, and spread of saline were evaluated using ultrasound imaging. The needle's tip resided 1 to 4 mm from the closest nerve in 21, in direct contact with it in 7, and 6 to 18 mm away in 15 patients. In 21 patients, subsequent saline dissection did not reach the brachial plexus. Thus, the success rate of electric nerve stimulation for correct needle-nerve distance identification was 48.8%, with correct fluid spread reached in only 51.2% of patients.

Background: Preoperative anxiety causes profound psychological and physiological reactions that may lead to a worse postoperative recovery, higher intensity of acute and persistent postsurgical pain and impaired quality of life in the postoperative period. Previous randomized controlled trials (RCTs) suggest that auricular acupuncture (AA) is safe and effective in the treatment of preoperative anxiety; however there is a lack of systematic evidence on this topic. Therefore, this protocol was developed following the PRISMA guidelines to adequately evaluate the existing literature regarding the value of AA for the reduction in anxiety in patients in a preoperative setting, compared to other forms of acupuncture, pharmacological, or no control interventions and measured with questionnaires regarding anxiety and fear. Methods: The following databases will be searched: MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, and Scopus Database. RCTs will be included if an abstract is available in English. Data collection and analysis will be conducted by two reviewers independently. Quality and risk assessment of included studies will be done using the Cochrane 5.1.0 handbook criteria and meta-analysis of effectiveness and symptom scores will be conducted using the statistical software RevMan V.5.3. Conclusions: This systematic review will evaluate the efficacy and safety of AA for preoperative anxiety. Since all data used in this systematic review and meta-analysis have been published, this review does not require ethical approval. The results may be published in a peer-reviewed journal or be presented in relevant conferences. Registration number: PROSPERO ID CRD42020.

Background Elderly people are at particular high risk for postoperative delirium (POD) following spine surgery, which is associated with longer hospital stays, higher costs, risk for delayed complications, long-term care dependency, and cognitive dysfunction (POCD). It is insufficiently understood which mechanisms and risk factors contribute to the development of POD and POCD following these major but plannable surgeries. Objective This study aims to identify modifiable risk factors in spine surgery. A better understanding thereof would help adapt medical management and surgical strategies to individual risk profiles. Methods This is a single-center observational study jointly conducted by the departments of neurosurgery, neurology, and anesthesiology at a tertiary care hospital in Germany. All patients aged 60 years and older presenting to the neurosurgery outpatient clinic or ward for elective spine surgery are screened for eligibility. Exclusion criteria include presence of neurodegenerative or history of psychiatric disease and medication with significant central nervous system activity (eg, antidepressants, antipsychotics, sedatives). Surgical and anesthetic procedures including duration of surgery as primary end point of this study are thoroughly documented. All patients are furthermore evaluated for their preoperative cognitive abilities by a number of tests, including the Consortium to Establish a Registry for Alzheimer's Disease Plus test battery. Physical, mental, and social health and well-being are assessed using the Patient-Reported Outcome Measurement Information System Profile 29 and Hospital Anxiety and Depression Scale. Patients additionally receive preoperative cerebrovascular ultrasound and structural and functional brain imaging. The immediate postoperative period includes screening for POD using the Nursing Delirium Screening Scale and validation through Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria. We furthermore investigate markers of (neuro)inflammation (eg, interleukins, C-reactive protein, tumor necrosis factor alpha). Preoperative examinations are repeated 3 months postoperatively to investigate the presence of POCD and its mechanisms. Statistical analyses will compare delirious and nondelirious patients for predictors of immediate (POD) and delayed (POCD) cognitive dysfunction. Results This is the first study to prospectively evaluate risk factors for POD and POCD in spine surgery. Recruitment is ongoing, and data collection is estimated to be finished with the inclusion of 200 patients by mid-2020. Conclusions The identification of mechanisms, possibly common, underlying POD and POCD would be a major step toward defining effective interventional strategies early in or even before the postoperative period, including the adaptation of surgical strategies to individual risk profiles. Trial Registration ClinicalTrials.gov NCT03486288; https://clinicaltrials.gov/ct2/show/NCT03486288

BackgroundIn case of a cardiac arrest, start of cardiopulmonary resuscitation by a bystander before the arrival of the emergency personnel increases the probability of survival. However, the steps of high-quality resuscitation are not known by every bystander or might be forgotten in this complex and time-critical situation. Mobile phone apps offering real-time step-by-step instructions might be a valuable source of information. ObjectiveThe aim of this study was to examine mobile phone apps offering real-time instructions in German or English in case of a cardiac arrest, to evaluate their adherence to current resuscitation guidelines, and to test their usability. MethodsOur 3-step approach combines a systematic review of currently available apps guiding a medical layperson through a resuscitation situation, an adherence testing to medical guidelines, and a usability evaluation of the determined apps. The systematic review followed an adapted preferred reporting items for systematic reviews and meta-analyses flow diagram, the guideline adherence was tested by applying a conformity checklist, and the usability was evaluated by a group of mobile phone frequent users and emergency physicians with the system usability scale (SUS) tool. ResultsThe structured search in Google Play Store and Apple App Store resulted in 3890 hits. After removing redundant ones, 2640 hits were checked for fulfilling the inclusion criteria. As a result, 34 apps meeting all inclusion criteria were identified. These included apps were analyzed to determine medical accuracy as defined by the European Resuscitation Council’s guidelines. Only 5 out of 34 apps (15%, 5/34) fulfilled all criteria chosen to determine guideline adherence. All other apps provided no or wrong information on at least one relevant topic. The usability of 3 apps was evaluated by 10 mobile phone frequent users and 9 emergency physicians. Of these 3 apps, solely the app “HELP Notfall” (median=87.5) was ranked with an SUS score above the published average of 68. This app was rated significantly superior to “HAMBURG SCHOCKT” (median=55; asymptotic Wilcoxon test: z=−3.63, P

Objective: The detection of auricular acupuncture (AA) points by measuring electrical skin resistance (ESR) is often used in diagnostics and therapy; however, systematic investigations of ESR in AA points are rare. The aim of this study was to examine the frequency of detection of AA points with reduced ESR in patients scheduled for unilateral hip arthroplasty.

Introduction To determine whether on-site incubation of blood cultures at the intensive care unit (ICU) improves not only the time to incubation but also time to positivity, time to knowledge of positivity and time to results (identification and antibiotic susceptibility testing). Methods This observational single-centre study in ICU patients with severe sepsis and septic shock investigated the impact of blood culture incubation immediately on-site at the ICU (ICU group) by comparison with traditional processing in a remote laboratory (LAB group) on different time intervals of blood culture diagnostics from obtaining blood to clinician notification of final result. The effect of on-site incubation was evaluated in Kaplan-Meier estimates for the time to positivity, time to knowledge of positivity and time to microbiological results and a linear mixed model was built. Results A total of 3,549 blood culture sets from 657 ICU patients were analysed: 2,381 in the LAB group and 1,168 in the ICU group. Overall, 660 (18.6%) blood culture sets were positive and 2,889 (81.4%) sets remained negative. On-site incubation was associated with reduced time to knowledge of positivity (46.9 h [CI 43.4–50.8 h] vs. 28.0 h [CI 23.6–32.2 h], p < 0.001) and reduced time to result (61.4 h [CI 58.4–64.8 h] vs. 42.1 h [CI 39.1–47.5 h], p < 0.001). In blood cultures processed instantaneously at the ICU compared to incubation in the remote laboratory within 4 h, the time to microbiological result was significantly reduced by 8.5 h (p < 0.001). Pre-existing anti-infective therapy had no significant impact on diagnostic time intervals. Conclusions Instantaneous incubation of blood cultures in the ICU compared to incubation in a remote laboratory significantly improves time to knowledge to positivity and time to result. These effects are even more pronounced during off-hours of the microbiological laboratory. The results underline the importance of 24/7 diagnostics to provide round-the-clock processing of blood culture samples in patients with sepsis and septic shock and an immediate to communication of the results to the clinicians.

BACKGROUND: The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non‐opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. OBJECTIVES: To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. SELECTION CRITERIA: We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. DATA COLLECTION AND ANALYSIS: We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS: We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after). The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies. IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) −0.50, 95% confidence interval (CI) −0.72 to −0.28; 29 studies, 1656 participants; very low‐quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD −0.14, 95% CI −0.25 to −0.04; 33 studies, 1847 participants; moderate‐quality evidence), and at late time points (48 hours) (SMD −0.11, 95% CI −0.25 to 0.04; 24 studies, 1404 participants; moderate‐quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures. We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) −7.92 hours, 95% CI −12.71 to −3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD −4.52 mg morphine equivalents , 95% CI −6.25 to −2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes. The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low‐quality evidence). IV Lidocaine compared to TEA The effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI −0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI −1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD −1.66, 95% CI −10.88 to 7.56; 2 studies, 102 participants); all very low‐quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low‐quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low‐quality evidence). AUTHORS' CONCLUSIONS: We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review.

Sepsis guidelines recommend obtaining blood cultures before starting anti-infective therapy in patients with sepsis. However, little is known of how antibiotic treatment before sampling affects bacterial growth. The aim of this study was to compare the results of blood cultures drawn before and during antibiotic therapy.Prospective clinical cohort study of septic patients. Adult intensive care unit patients with two or three blood culture sets at the beginning of sepsis between 2010 and 2017 were included. Patients with blood culture samples obtained before antibiotic therapy were compared with patients with samples taken during antibiotic therapy. Blood culture positivity, defined as presence of a microbiological pathogen, was compared between the groups. Logistic regression was performed to adjust the impact of different factors with respect to blood culture positivity.In total, 559 patients with 1364 blood culture sets at the beginning of sepsis were analysed. Blood culture positivity was 50.6% (78/154) among patients with sepsis who did not receive antibiotics and only 27.7% (112/405) in those who were already receiving antibiotics (p0.001). Logistic regression revealed antibiotic therapy as an independent factor for less pathogen identification (odds ratio 0.4; 95% CI 0.3-0.6). Gram-positive pathogens (28.3% (111/392) versus 11.9% (116/972); p0.001) and also Gram-negative pathogens (16.3% (64/392) versus 9.3% (90/972); p0.001) were more frequent in blood culture sets drawn before antibiotic therapy compared with sets obtained during antibiotic therapy.Obtaining blood cultures during antibiotic therapy is associated with a significant loss of pathogen detection. This strongly emphasizes the current recommendation to obtain blood cultures before antibiotic administration in patients with sepsis.