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Abstract Secondary transports of patients from one hospital to another are indicated for medical reasons or to address local constraints in capacity. In particular, interhospital transports of critically ill infectious patients present a logistical challenge and can be key in the effective management of pandemic situations. The state of Saxony in Germany has two characteristics that allow for an extensive evaluation of secondary transports in the pandemic year 2020/2021. First, all secondary transports are centrally coordinated by a single institution. Second, Saxony had the highest SARS-CoV-2 infection rates and the highest COVID-19 associated mortality in Germany. This study evaluates secondary interhospital transports from March 2019 to February 2021 in Saxony with a detailed analysis of transport behaviour during the pandemic phase March 2020 to February 2021. Our analysis includes secondary transports of SARS-CoV-2 patients and compares them to secondary transports of non-infectious patients. In addition, our data show differences in demographics, SARS-CoV-2- incidences, ICU occupancy of COVID-19 patients, and COVID-19 associated mortality in all three regional health clusters in Saxony. In total, 12,282 secondary transports were analysed between March 1st, 2020 and February 28th, 2021, of which 632 were associated with SARS-CoV-2 (5.1%) The total number of secondary transports changed slightly during the study period March 2020 to February 2021. Transport capacities for non-infectious patients were reduced due to in-hospital and out-of-hospital measures and could be used for transport of SARS-CoV-2 patients. Infectious transfers lasted longer despite shorter distance, occurred more frequently on weekends and transported patients were older. Primary transport vehicles were emergency ambulances, transport ambulances and intensive care transport vehicles. Data analysis based on hospital structures showed that secondary transports in correlation to weekly case numbers depend on the hospital type. Maximum care hospitals and specialized hospitals show a maximum of infectious transports approximately 4 weeks after the highest incidences. In contrast, standard care hospitals transfer their patients at the time of highest SARS-CoV-2 case numbers. Two incidence peaks were accompanied by two peaks of increased secondary transport. Our findings show that interhospital transfers of SARS-CoV-2 and non-SARS-CoV-2 patients differ and that different hospital care levels initiated secondary transports at different times during the pandemic.

Background Extracorporeal Membrane Oxygenation (ECMO) use is increasing despite limited evidence. The aim of this study was to demonstrate heterogeneity of ECMO use and its association with hospital size and annual frequency in Germany. Methods This is a database analysis of all ECMO cases in Germany from 2010 to 2016 using the German Diagnosis Related Groups (DRG) coding system for ECMO. Results During the study period, 510 hospitals performed 29,929 ECMO runs (12,572 vvECMO, 11,504 vaECMO, 1993 pECLA) with an increase over time. Mortality ranged between 58% and 66% for vaECMO cases and 66% and 53% for vvECMO cases. 304 (61%) hospitals performed only one ECMO per year. 78%% of all ECMO runs were performed in centres with more than 20 cases per year and more than half of all ECMO runs were performed in hospitals with >1.000 beds. Mortality for vv and vaECMO was highest in very small hospitals (< 200 beds; 70%; 74%) and very large hospitals (>1000 beds; 60%; 62%). Conclusions Use of ECMO is still increasing and a substantial proportion of hospitals performs very few ECMO runs. Small hospitals had a significantly higher mortality, but dependence on hospital size and ECMO mortality was irregular.

[This corrects the article DOI: 10.1371/journal.pone.0254817.].

BackgroundPercutaneous hepatic melphalan perfusion (PHMP) for the selective treatment of hepatic metastases is known to be associated with procedural hypotension and coagulation disorders. Studies on anesthetic management, perioperative course, complications, and postoperative recovery in the intensive care unit (ICU) have not been published.MethodsIn a retrospective observational study, we analyzed consecutive patients who were admitted for PHMP over a 6-year period (2016-2021). Analyses included demographic, treatment, and outcome data with regard to short-term complications until ICU discharge.ResultsFifty-three PHMP procedures of 16 patients were analyzed. In all of the cases, procedure-related hypotension required the median (range) highest noradrenaline infusion rate of 0.5 (0.17-2.1) μg kg min-1 and fluid resuscitation volume of 5 (3-14) liters. Eighty-four PHMP-related complications were observed in 33 cases (62%), of which 9 cases (27%) involved grade III and IV complications. Complications included airway constriction (requiring difficult airway management), vascular catheterization issues (which resulted in the premature termination of PHMP, as well as to the postponement of PHMP and to the performance of endovascular bleeding control after PHMP), and renal failure that required hemodialysis. Discharge from the ICU was possible after one day in most cases (n = 45; 85%); however, in 12 cases (23%), prolonged mechanical ventilation was required. There were no procedure-related fatalities.ConclusionsPHMP is frequently associated with challenging cardiovascular conditions and complications that require profound anesthetic skills. For safety reasons, PHMP should only be performed in specialized centers that provide high-level hospital infrastructures and interdisciplinary expertise.

INTRODUCTION:Posttraumatic pneumothorax (PTX) is often overseen in anteroposterior chest X-ray. Chest sonography and Electrical Impedance Tomography (EIT) can both be used at the bedside and may provide complementary information. We evaluated the performance of EIT for diagnosing posttraumatic PTX in a pig model. METHODS:This study used images from an existing database of images acquired from 17 mechanically ventilated pigs, which had sustained standardized blunt chest trauma and had undergone repeated thoracic CT and EIT. 100 corresponding EIT/CT datasets were randomly chosen from the database and anonymized. Two independent and blinded observers analyzed the EIT data for presence and location of PTX. Analysis of the corresponding CTs by a radiologist served as reference. RESULTS:87/100 cases had at least one PTX detected by CT. Fourty-two cases showed a PTX > 20% of the sternovertebral diameter (PTXtrans20), whereas 52/100 PTX showed a PTX>3 cm in the craniocaudal diameter (PTXcc3), with 20 cases showing both a PTXtranscc and a PTXcc3. We found a very low agreement between both EIT observers considering the classification overall PTX/noPTX (κ = 0.09, p = 0.183). For PTXtrans20, sensitivity was 59% for observer 1 and 17% for observer 2, with a specificity of 48% and 50%, respectively. For PTXcc3, observer 1 showed a sensitivity of 60% with a specificity of 51% while the sensitivity of observer 2 was 17%, with a specificity of 89%. By programming a semi-automatized detection algorithm, we significantly improved the detection rate of PTXcc3, with a sensitivity of 73% and a specificity of 70%. However, detection of PTXtranscc was not improved. CONCLUSION:In our analysis, visual interpretation of EIT without specific image processing or comparison with baseline data did not allow clinically useful diagnosis of posttraumatic PTX. Multimodal imaging approaches, technical improvements and image postprocessing algorithms might improve the performance of EIT for diagnosing PTX in the future.

BACKGROUND:Management of cardiac surgery patients is a very standardized procedure in respective local institutions. Yet only very limited evidence exists concerning optimal indication, safety and efficacy of hemodynamic monitoring catecholamine and fluid therapy. METHODS:Between April and May 2013, all 81 German anaesthesia departments involved in cardiac surgery care were asked to participate in a questionnaire addressing the institutional specific current practice in hemodynamic monitoring, catecholamine and volume therapy. RESULTS:51 (63%) questionnaires were completed and returned. All participating centers used basic hemodynamic monitoring (i.e. invasive arterial blood pressure and central venous pressure), supplemented by transesophageal echocardiography. Pulmonary arterial catheter and calibrated trend monitoring devices were also routinely available. In contrast, non-calibrated trend monitoring and esophageal doppler ultrasound devices were not commonly in use. Cerebral oximetry is increasingly emerging, but lacks clear indications. The majority of patients undergoing cardiac surgery, especially in university hospitals, required catecholamines during perioperative care, In case of low cardiac output syndrome, dobutamine (32%), epinephrine (30%) or phosphodiesterase inhibitors (8%) were first choice. In case of hypotension following vasoplegia, norepinephrine (96%) represented the most common catecholamine. 88% of the participating centers reported regular use of colloid fluids, with hydroxyethyl starches (HES) being first choice (64%). CONCLUSIONS:Choice of hemodynamic monitoring is homogenous throughout German centers treating cardiac surgery patients. Norepinephrine is the first line catecholamine in cases of decrease in peripheral vascular resistance. However, catecholamine choice for low cardiac output syndrome varies considerably. HES was the primary colloid used for fluid resuscitation. After conduct of this survey, HES use was restricted by European regulatory authorities in critically ill patients and should only be considered as second-line fluid in surgical patients without renal impairment or severe coagulopathy. Large clinical studies addressing catecholamine and fluid therapy in cardiac surgery patients are lacking.