Fulfilling the requirements of point-of-care testing (POCT) training regarding proper execution of measurements and compliance with internal and external quality control specifications is a great challenge. Our aim was to compare the values of the highly critical parameter hemoglobin (Hb) determined with POCT devices and central laboratory analyzer in the highly vulnerable setting of an emergency department in a supra maximal care hospital to assess the quality of POCT performance. In 2548 patients, Hb measurements using POCT devices (POCT-Hb) were compared with Hb measurements performed at the central laboratory (Hb-ZL). Additionally, sub collectives (WHO anemia classification, patients with Hb <8 g/dl and suprageriatric patients (age >85y.) were analyzed. Overall, the correlation between POCT-Hb and Hb-ZL was highly significant (r = 0.96, p<0.001). Mean difference was -0.44g/dl. POCT-Hb values tended to be higher than Hb-ZL values (t(2547) = 36.1, p<0.001). Standard deviation of the differences was 0.62 g/dl. Only in 26 patients (1%), absolute differences >2.5g/dl occurred. McNemar´s test revealed significant differences regarding anemia diagnosis according to WHO definition for male, female and total patients (♂ p<0.001; ♀ p<0.001, total p<0.001). Hb-ZL resulted significantly more often in anemia diagnosis. In samples with Hb<8g/dl, McNemar´s test yielded no significant difference (p = 0.169). In suprageriatric patients, McNemar´s test revealed significant differences regarding anemia diagnosis according to WHO definition in male, female and total patients (♂ p<0.01; ♀ p = 0.002, total p<0.001). The difference between Hb-ZL and POCT-Hb with Hb<8g/dl was not statistically significant (<8g/dl, p = 1.000). Overall, we found a highly significant correlation between the analyzed hemoglobin concentration measurement methods, i.e. POCT devices and at the central laboratory. The results confirm the successful implementation of the presented POCT concept. Nevertheless some limitations could be identified in anemic patients stressing the importance of carefully examining clinically implausible results.

Background: Providing anesthesia for pediatric patients undergoing congenital cardiac surgery is complex and requires profound knowledge and clinical experience. Prospective studies on best anesthetic management are missing, partially due to different standards. The aim of the present study was to survey the current standard practice in anesthetic management in pediatric cardiac surgical centers in Germany. Methods: All 78 cardiac surgical centers in Germany were reviewed for a congenital cardiac surgery program. Centers with an active program for congenital cardiac surgery were interviewed to participate in the present online questionnaire to assess their current anesthetic practice. Results: Twenty-seven German centers running an active program for congenital heart surgery were identified, covering more than 3,000 pediatric cardiac surgeries annually. Of these centers, 96.3% (26/27) participated in our survey. Standard induction agents were etomidate in 26.9% (7/26), propofol in 19.2% (5/26), a combination of benzodiazepines and ketamine in 19.2% (5/26), and barbiturates in 11.5% (3/26). General anesthesia was preferentially maintained using volatile agents, 61.5% (16/26), with sevoflurane being the most common volatile agent within this group, 81.2% (13/16). Intraoperative first-choice/first-line inotropic drug was epinephrine, 53.8% (14/26), followed by milrinone, 23.1% (6/26), and dobutamine 15.4% (4/26). Fast-track programs performing on-table extubation depending on the type of surgical procedure were established at 61.5% (16/26) of the centers. Conclusion: This study highlights the diversity of clinical standards in pediatric cardiac anesthesia for congenital cardiac surgery in Germany.

Background In Germany, emergency medical teams are staffed with physicians but evidence regarding their prehospital diagnostic accuracy remains poor. Objective To evaluate the out-of-hospital diagnostic accuracy of physician-staffed emergency medical teams (PEMTs). Methods A retrospective observational cohort study involving the Emergency Medical Service Bonn, Germany, from January to December 2004 and 2014 respectively. A total of 8346 patients underwent medical treatment by PEMTs, of which 1960 adult patients (inclusion criteria: ≥18 years of age, hospital diagnosis available) were included for further analysis. Reasons for non-inclusion: death on scene, outpatient, interhospital transfer, mental illness, false alarm, no hospital medical history available. The overall diagnostic accuracy (correct or false) of PEMTs was measured after matching the prehospital diagnosis with the corresponding diagnosis of the hospital. Secondary outcome measures were incidence of common PEMT diagnoses (acute coronary syndrome (ACS), dyspnea, stroke/intracerebral bleeding), recognition rate of a given disease by PEMTs, and prehospital diagnostic accuracy in elderly patients. Results PEMT calls increased 2-fold over a decade (2004: n = 3151 vs. 2014: n = 5195). Overall diagnostic accuracy of PEMTs increased from 87.5% in 2004 to 92.6% in the year 2014. The incidence of common PEMT diagnoses such as ACS, dyspnea or stroke/intracerebral bleeding increased 2-fold from 2004 to 2014. The recognition rate of a given disease by the PEMT varied between 2004 and 2014: an increase was observed when a stroke/intracerebral bleeding was diagnosed (2004: 67% vs. 2014: 83%; p = 0.054), a decreased rate of recognition occurred when a syncope/collapse was diagnosed (2004: 81% vs. 2014: 56%; p = 0.007) and a sepsis appears to be a rare event for EMS personnel (2004: 0% vs. 2014: 23%). Linear regression analysis revealed that the prehospital diagnostic accuracy decreases in the elderly patient. Conclusions The overall prehospital diagnostic accuracy of PEMTs improved between the year 2004 and 2014 respectively. Our findings suggest that the incidence of common diseases (ACS, dyspnea stroke/intracerebral bleeding, sepsis) increased over a 10-year period. Diagnostic accuracy of different diseases varied but generally decreased in the elderly patient. Regular training of EMS personnel and public campaigns should be implemented to improve the diagnostic accuracy in the future. Electronic supplementary material The online version of this article (10.1186/s13049-019-0617-3) contains supplementary material, which is available to authorized users.

BackgroundHeparin-induced thrombocytopenia (HIT) causes thromboembolic complications which threaten life and limb. Heparin is administered to virtually every critically ill patient as a protective measure against thromboembolism. Argatroban is a promising alternative anticoagulant agent. However, a safe dose which still provides effective thromboembolic prophylaxis without major bleeding still needs to be identified.MethodsCritically ill patients (n = 42) diagnosed with HIT at a tertiary medical center intensive care unit from 2005 to 2010 were included in this retrospective analysis. Patient records were perused for preexisting history of HIT, heparin dosage before HIT, argatroban dosage, number of transfusions required, thromboembolic complications and length of ICU stay (ICU LOS). Patients were allocated to Simplified Acute Physiology Scores above and below 30 (SAPS >30, SAPS <30), respectively. For calculations, patients (n = 19) without previous history of HIT were compared to patients (n = 23) with a history of HIT before initiation of argatroban.ResultsThe mean initial argatroban dosage was below 0.4 mcg/kg/min regardless of SAPS score. Maintenance dosage had to be increased in patients with SAPS <30 to 0.54 ± 0.248 mcg/kg/min (p >0.05) to achieve effective anticoagulation. No thromboembolic complications were encountered. Argatroban had to be discontinued temporarily in 16 patients for a total of 57 times due to diagnostic or surgical procedures, supratherapeutic aPTT and bleeding without increasing the number of transfusions. A history of HIT was associated with a shorter ICU LOS and significantly reduced transfusion need when compared to patients with no history of HIT. Cost calculation favour argatroban due to increased transfusion needs during heparin administration and increase ICU LOS.ConclusionArgatroban can be used at doses < 0.4 mcg/kg/min without an increase in transfusion requirements and at a reduced overall treatment cost compared to heparin.

It remains unclear how introduction of high-sensitivity troponin T testing, as opposed to conventional troponin testing, has affected the diagnosis of acute myocardial infarction (AMI) and resource utilization in unselected hospitalized patients. In this retrospective analysis, we include all consecutive cases from our center during two corresponding time frames (10/2016–04/2017 and 10/2017–04/2018) for which different troponin tests were performed: conventional troponin I (cTnI) and high-sensitivity troponin T (hs-TnT) assays. Testing was performed in 18,025 cases. The incidence of troponin levels above the 99th percentile was significantly higher in cases tested using hs-TnT. This was not associated with increased utilization of echocardiography, coronary angiography, or percutaneous coronary intervention. Although there were no changes in local standard operating procedures, study site personnel, or national coding guidelines, the number of coded AMI significantly decreased after introduction of hs-TnT. In this single-center retrospective study comprising 18,025 mixed medical and surgical cases with troponin testing, the introduction of hs-TnT was not associated with changes in resource utilization among the general cohort, but instead, led to a decrease in the international classification of diseases (ICD)-10 coded diagnosis of AMI.