Background Supplementation of vitamin C in septic patients remains controversial despite eight large clinical trials published only in 2020. We aimed to evaluate the evidence on potential effects of vitamin C treatment on mortality in adult septic patients. Methods Data search included PubMed, Web of Science, and the Cochrane Library. A meta-analysis of eligible peer-reviewed studies was performed in accordance with the PRISMA statement. Only studies with valid classifications of sepsis and intravenous vitamin C treatment (alone or combined with hydrocortisone/thiamine) were included. Results A total of 17 studies including 3133 patients fulfilled the predefined criteria and were analyzed. Pooled analysis indicated no mortality reduction in patients treated with vitamin C when compared to reference (risk difference − 0.05 [95% CI − 0.11 to − 0.01]; p = 0.08; p for Cochran Q = 0.002; I2 = 56%). Notably, subgroup analyses revealed an improved survival, if vitamin C treatment was applied for 3–4 days (risk difference, − 0.10 [95% CI − 0.19 to − 0.02]; p = 0.02) when compared to patients treated for 1–2 or > 5 days. Also, timing of the pooled mortality assessment indicated a reduction concerning short-term mortality (< 30 days; risk difference, − 0.08 [95% CI − 0.15 to − 0.01]; p = 0.02; p for Cochran Q = 0.02; I2 = 63%). Presence of statistical heterogeneity was noted with no sign of significant publication bias. Conclusion Although vitamin C administration did not reduce pooled mortality, patients may profit if vitamin C is administered over 3 to 4 days. Consequently, further research is needed to identify patient subgroups that might benefit from intravenous supplementation of vitamin C.

BACKGROUND: Recently, a very low incidence of 3 per 10,000 and a mortality of 30% were reported for pediatric perioperative cardiac arrest (POCA). However, high-risk patients, namely children already anesthetized on the intensive care unit (ICU), were excluded. This study investigates the incidence and mortality of POCA in children in whom anesthesia was induced in the ICU or in the operating room using real-world data. In addition, different classifications of POCA were compared with respect to outcome relevance. METHODS: This is a retrospective observational study conducted at a German level 1 perinatal center and tertiary care hospital between 2008 and 2018. Children ≤15 years who underwent an anesthetic procedure and suffered from POCA (defined as any condition requiring chest compressions and/or defibrillation) from the beginning of care provided by an anesthesiologist to 60 minutes after anesthesia or sedation were included. Primary end points were incidence and mortality of POCA in children with anesthesia induced in the ICU versus in the operating room. Secondary end points included incidences and outcomes with respect to the pathophysiological cause (respiratory versus circulatory associated). RESULTS: There were 18 POCA during 22,650 anesthetic procedures (incidence 7.9 per 10,000; 95% confidence interval [CI], 4.7-12.5). Thirty-day mortality was 3.5 per 10,000 (95% CI, 1.5-6.9). Incidence and mortality were higher in children in whom anesthesia was induced in the ICU versus in the operating room (incidence: 131.6; 95% CI, 57 to 257.6 versus 4.5; 95% CI, 2.2-8.3; P < .001; and mortality: 82.2; 95% CI, 26.7-190.8 versus 1.4; 95% CI, 0.3-3.9; P < .001). Mortality in circulatory-induced POCA (n = 8; 44%) was 100%, in respiratory-induced POCA (n = 9; 50%) 0% (P < .001). CONCLUSIONS: Children with anesthesia induction in the ICU represent a high-risk population for POCA and POCA-associated mortality. POCA classification should be based on the individual cause (respiratory versus circulatory) rather than on the perioperative phase or the responsible specialty.

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BACKGROUND Treatment of reversible causes of cardiac arrest often requires intrahospital transportation during ongoing resuscitation. But high-quality chest compression with minimal interruption is the most essential prerequisite for an optimal outcome after cardiac resuscitation. OBJECTIVE We aimed to evaluate chest compression quality according to the provider position during intrahospital transportation. DESIGN Manikin observational study. SETTING German Tertiary Care Hospital. PARTICIPANTS A total of 20 paramedics (eight female, 12 male); average professional experience 4.8 ± 3.1 years since their initial enrolment for training. INTERVENTION(S) Participants performed chest compressions during simulated intrahospital transportation in four groups: provider kneeling beside manikin on the floor (control group), walking next to the bed (group 1), kneeling on the bed beside the manikin (group 2), kneeling astride the manikin on the bed (group 3). MAIN OUTCOME MEASURES Quality metrics as European Resuscitation Council Guidelines 2015. Subsequently, the participants were asked to assess their own subjective feelings of safety, comfort and strain, and to recommend one position. RESULTS The quality of chest compression in the control group and groups 2 and 3 did not differ significantly. Group 1 performed significantly worse in terms of the correct hand placement on the chest (P = 0.044 vs. control group) and compression depth (P = 0.004 vs. control group, P = 0.035 vs. group 2, P = 0.006 vs. group 3). Transport speed was faster in groups 2 and 3 vs. group 1 (P < 0.05 vs. group 1, P < 0.05 vs. group 2). The majority of participants rated position 1 as unsafe (90%), unpleasant (100%) and exhausting (100%). They predominantly favoured position 3 (70%). CONCLUSION Performing guideline-compliant chest compressions during intra-hospital transportation is feasible with an appropriate provider position. Our results suggest, kneeling beside or astride the patient on the bed enables high-quality chest compressions, faster transport and is perceived by the providers as more pleasant. ‘Walking next to the bed’ while performing chest compressions should be avoided.

Background Diaphragmatic lesions as a result of blunt or penetrating trauma are challenging to detect in the initial trauma setting. This is especially true when diaphragmatic trauma is part of a polytrauma. Complications of undetected diaphragmatic defects with incarcerating bowel are rare, but as in our patient can be serious. Case presentation A 57-year-old female presented to the Emergency Room of our Hospital in a critical condition with 3 days of increasing abdominal pain. The initial clinical examination showed peritonism with tinkling peristaltic bowel sounds of mechanical obstruction. A thoraco-abdominal CT scan demonstrated colon prolapsed through the left diaphragmatic center with a large sero-pneumothorax under tension. As the patient was hemodynamically increasingly unstable with developing septic shock, an emergency laparotomy was performed. After retraction of the left colon, which had herniated through a defect of the tendinous center of the left diaphragm and was perforated due to transmural ischemia, large amounts of feces and gas discharged from the left thorax. A left hemicolectomy resulting in a Hartmann-type procedure was performed. A fully established pleural empyema required meticulous debridement and lavage conducted via the 7–10 cm in diameter phrenic opening followed by a diaphragmatic defect reconstruction. Due to pneumonia and recurring pleural empyema redo-debridement of the left pleural space via thoracotomy were required. The patient was discharged on day 56. A thorough history of possible trauma revealed a bicycle-fall trauma 7 months prior to this hospitalization with a surgically stabilized fracture of the left femur and conservatively treated fractures of ribs 3–9 on the left side. Conclusion This is the first report on a primarily established empyema at the time of first surgical intervention for feco-pneumothorax secondary to delayed diagnosed diaphragmatic rupture following abdomino-thoracic blunt trauma with colic perforation into the pleural space, requiring repetitive surgical debridement in order to control local and systemic sepsis. Thorough investigation should always be undertaken in cases of blunt abdominal and thoracic trauma to exclude diaphragmatic injury in order to avoid post-traumatic complications.