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Pulmonary aspiration during airway management is associated with increased morbidity and mortality. First-pass success during tracheal intubation is a key determinant of patient safety and has been shown to improve with videolaryngoscopy (VL). However, comparative evidence regarding hyperangulated VL and direct laryngoscopy (DL) during massive airway contamination remains limited, particularly within a standardized Suction-Assisted Laryngoscopy and Airway Decontamination (SALAD) workflow. This study aimed to compare DL and hyperangulated VL in a standardized SALAD simulation model. In this 1:1 randomized controlled simulation study, physicians performed tracheal intubation using a standardized regurgitation model. Participants were randomized to hyperangulated VL or DL. The primary endpoint was first-pass success (FPS). Secondary endpoints included time to successful tracheal intubation and time to first successful ventilation. Two hundred physicians from various specialties were enrolled and randomized. FPS was significantly higher in the VL group than in the DL group (94.0% vs. 58.0%; OR 11.34, 95% CI 4.54–28.35; p  < 0.001). Time to successful tracheal intubation was significantly shorter in the VL group (median [IQR]: 34 s [29–40] vs. 41 s [35–48]; p  < 0.001). Likewise, time to first ventilation was significantly reduced (median [IQR]: 40 s [34–44] vs. 45 s [40–53]; p  < 0.001). In multivariable logistic regression analysis, VL remained independently associated with FPS (adjusted OR 13.42, 95% CI 5.18–34.78; p  < 0.001), whereas age, sex, professional experience, specialty, and additional qualifications were not significantly associated with the primary outcome. In this simulation model of massive airway contamination, hyperangulated videolaryngoscopy significantly improved first-pass success and reduced both intubation and ventilation times compared with direct laryngoscopy during SALAD-assisted airway management. Whether these procedural advantages translate into improved patient-centered outcomes requires confirmation in future clinical studies. Trial Registration The registration of the clinical trial was initiated prospectively on July 15, 2024, in the German Clinical Trials Register (DRKS00034683).

Background Pseudocholinesterase, an enzyme produced by the liver and abundantly present in plasma, plays a role in the metabolism of neuromuscular blocking agents such as mivacurium. The administration of mivacurium to patients with pseudocholinesterase deficiency during general anesthesia has been associated with the occurrence of prolonged postoperative paralysis, a rare but potentially severe side effect. Case presentation A 24-month-old girl underwent routine, elective minor surgery. The neuromuscular blocking agent mivacurium was used during general anesthesia. Following the procedure, there was no spontaneous recovery of breathing. The peripheral nerve stimulator used to measure neuromuscular relaxation did not elicit any responses. The patient was subsequently transferred to the pediatric intensive care unit, where she was successfully weaned from the ventilator and extubated four hours later. The following day, the child was deemed fit for discharge from the clinic, exhibiting no residual symptoms. A targeted laboratory analysis conducted subsequent to the event revealed a cholinesterase level of 4176 U/l (normal values 4260–12920 U/l), a cholinesterase dibucaine-number of 12 (normal values > 70) and cholinesterase fluoride-number of 29 (normal values 55–60). Conclusions This is a case report of pseudocholinesterase deficiency in a 24-month-old child undergoing minor surgery. Quantitative neuromuscular monitoring should be used routinely to recognize prolonged muscle relaxation. If the diagnosis of pseudocholinesterase deficiency is confirmed, the patient should be given information about the disorder, the associated risks, inheritance and the need for testing in other family members.

Background Pseudocholinesterase, an enzyme produced by the liver and abundantly present in plasma, plays a role in the metabolism of neuromuscular blocking agents such as mivacurium. The administration of mivacurium to patients with pseudocholinesterase deficiency during general anesthesia has been associated with the occurrence of prolonged postoperative paralysis, a rare but potentially severe side effect. Case presentation A 24-month-old girl underwent routine, elective minor surgery. The neuromuscular blocking agent mivacurium was used during general anesthesia. Following the procedure, there was no spontaneous recovery of breathing. The peripheral nerve stimulator used to measure neuromuscular relaxation did not elicit any responses. The patient was subsequently transferred to the pediatric intensive care unit, where she was successfully weaned from the ventilator and extubated four hours later. The following day, the child was deemed fit for discharge from the clinic, exhibiting no residual symptoms. A targeted laboratory analysis conducted subsequent to the event revealed a cholinesterase level of 4176 U/l (normal values 4260-12920 U/l), a cholinesterase dibucaine-number of 12 (normal values > 70) and cholinesterase fluoride-number of 29 (normal values 55-60). Conclusions This is a case report of pseudocholinesterase deficiency in a 24-month-old child undergoing minor surgery. Quantitative neuromuscular monitoring should be used routinely to recognize prolonged muscle relaxation. If the diagnosis of pseudocholinesterase deficiency is confirmed, the patient should be given information about the disorder, the associated risks, inheritance and the need for testing in other family members. Keywords: Mivacurium, Pseudocholinesterase deficiency, Case report, Prolonged neuromuscular block, Pediatric anesthesia

BackgroundFactor XIII (FXIII) deficiency increases bleeding risk and delays wound healing, yet its recognition, diagnosis, and treatment remain challenging in the complex clinical routine.ObjectiveTo determine real-world diagnosis and management strategies of acquired FXIII deficiency.MethodsAdult patients undergoing FXIII activity testing (diagnostic phase) and FXIII supplementation (treatment phase) for acquired FXIII deficiency were consecutively enrolled in this retrospective data collection. Treatment outcomes were analyzed in patients with postsurgical bleeding and wound healing disorders (WHD).ResultsA total of 255 patients were included in the diagnostic cohort, of whom 84% were diagnosed with clinically relevant FXIII deficiency and 77% received FXIII supplementation. Median FXIII activity in patients with a clinically relevant deficiency was 42.5%, compared to 74.0% in those without. Most patients with FXIII activity levels below 60% were considered to have a clinically relevant deficiency. The treatment cohort comprised 96 postsurgical bleeding cases and 78 WHD cases. Median FXIII activity levels were similarly reduced in both cohorts (44.0% vs 48.0%). Conventional coagulation tests remained mainly within reference ranges for most patients, highlighting the diagnostic gap. Persistent infection was the leading comorbidity, affecting 33% of patients in both cohorts.ConclusionIn this real-world setting, FXIII supplementation was most frequently initiated at FXIII activity levels below 60%-70%. These findings suggest using this range as a clinical reference point for therapeutic intervention, while bearing in mind the exploratory nature of the data. Routine FXIII testing should be considered in patients with unexplained bleeding or impaired wound healing, particularly perioperatively, after major trauma, or with persistent infections.

Acute kidney injury (AKI) secondary to sepsis results in poor outcomes and conventional kidney function indicators lack diagnostic value. Soluble urokinase plasminogen activator receptor (suPAR) is an innate immune–derived molecule implicated in inflammatory organ damage. We characterized the diagnostic ability of longitudinal serum suPAR levels to discriminate severity and course of sepsis-induced AKI (SI-AKI) in 200 critically ill patients meeting Sepsis-3 criteria. The pathophysiologic relevance of varying suPAR levels in SI-AKI was explored in a polymicrobial sepsis model in WT, (s)uPAR-knockout, and transgenic suPAR-overexpressing mice. At all time points studied, suPAR provided a robust classification of SI-AKI disease severity, with improved prediction of renal replacement therapy (RRT) and mortality compared with established kidney biomarkers. Patients with suPAR levels of greater than 12.7 ng/mL were at highest risk for RRT or death, with an adjusted odds ratio of 7.48 (95% CI, 3.00–18.63). suPAR deficiency protected mice against SI-AKI. suPAR-overexpressing mice exhibited greater kidney damage and poorer survival through inflamed kidneys, accompanied by local upregulation of potent chemoattractants and pronounced kidney T cell infiltration. Hence, suPAR allows for an innate immune–derived and kidney function–independent staging of SI-AKI and offers improved longitudinal risk stratification. suPAR promotes T cell–based kidney inflammation, while suPAR deficiency improves SI-AKI.

Factor XIII (FXIII) is a protein involved in blood clot stabilisation which also plays an important role in processes including trauma, wound healing, tissue repair, pregnancy, and even bone metabolism. Following surgery, low FXIII levels have been observed in patients with peri-operative blood loss and FXIII administration in those patients was associated with reduced blood transfusions. Furthermore, in patients with low FXIII levels, FXIII supplementation reduced the incidence of post-operative complications including disturbed wound healing. Increasing awareness of potentially low FXIII levels in specific patient populations could help identify patients with acquired FXIII deficiency; although opinions and protocols vary, a cut-off for FXIII activity of ~ 60–70% may be appropriate to diagnose acquired FXIII deficiency and guide supplementation. This narrative review discusses altered FXIII levels in trauma, surgery and wound healing, diagnostic approaches to detect FXIII deficiency and clinical guidance for the treatment of acquired FXIII deficiency.

The goal of this analysis is to describe seasonal disaster patterns in Central Europe in order to raise awareness and improve hospital disaster planning and resilience, particularly during peak events. Hospitals are essential pillars of a country’s critical infrastructure, vital for sustaining healthcare services and supporting public well-being—a key issue of national security. Disaster planning for hospitals is crucial to ensure their functionality under special circumstances. But the impact of climate change and seasonal variations in the utilization of hospital services are raising challenges. Therefore, the knowledge of perennial disaster patterns could help strengthen the resilience of hospitals. We conducted a cross-sectional analysis of the Emergency Events Database EM-DAT for disasters in Central Europe (Germany, France, Denmark, The Netherlands, Belgium, Luxembourg, Switzerland, Austria, Czech Republic, and Poland) between January 2000 and December 2023. Time distribution of disasters, patterns and longitudinal trends, were analyzed to discuss impact on disaster preparedness in hospitals. Out of 474 events, 83% were associated with a natural hazard and only 80 events (17%) were of technological cause. While technological disasters were spread equally over the whole year, the vast majority of disasters related to natural hazards (n = 394), i.e. storms (n = 178, 45%), floods (n = 101, 26%), and extreme temperatures (n = 93, 24%) peaked during summer and winter months. Fewer disasters were registered during autumn and especially spring seasons. More than 50% of the technological disasters were categorized in the transport accident subgroup. Technological disasters were spread equally over the whole year. Looking at the three most common disaster types, extreme temperatures, floods, and storms are clearly dominating and cause over 90% of the disasters due to natural hazards in central Europe. Overall, the number of events per year fluctuates without a clear trend, only the technological events appear to become less frequent with 70% (n = 56) of the registered disasters occurring in the first half of the study period (2000–2011). An overlap of hospital admissions due to seasonal effects and catastrophic events, mainly triggered by disasters of natural cause in vulnerable periods may lead to a partial collapse of the health care system. To close knowledge gaps, future comprehensive data collection is vital for informed decision-making. Awareness and preparedness are key: an \"all-hazards\" approach to manage diverse, potentially simultaneous seasonal threats is often the most versatile strategy for hospital emergency planning.

Background Sepsis-associated acute kidney injury (SA-AKI) is a prevalent and severe complication in critically ill patients. However, diagnostic and therapeutic advancements have been hindered by the biological heterogeneity underlying the disease. Both transcriptomic endotyping and biomarker profiling have been proposed individually to identify molecular subtypes of sepsis and may enhance risk stratification. This study aimed to evaluate the utility of combining transcriptomic endotyping with protein-based biomarkers for improving risk stratification in SA-AKI. Methods This secondary analysis of the PredARRT-Sep-Trial included 167 critically ill patients who met Sepsis-3 criteria. Patients were stratified into three transcriptomic endotypes—inflammopathic (IE), adaptive (AE), and coagulopathic (CE)—using a validated whole-blood gene expression classifier. Eight protein-based biomarkers encompassing kidney function, vascular integrity, and immune response were measured. Predictive performance for the primary endpoint kidney replacement therapy or death was assessed using receiver operating characteristic curve analysis and logistic regression models. Results Stratification into transcriptomic endotypes assigned 33% of patients to IE, 42% to AE, and 24% to CE. Patients classified as IE exhibited the highest disease severity and were most likely to meet the primary endpoint (30%), compared to AE and CE (17% and 10%, respectively). Kidney function biomarkers showed stepwise increases with AKI severity across all endotypes, whereas non-functional biomarkers (neutrophil gelatinase-associated lipocalin [NGAL], soluble urokinase plasminogen activator receptor [suPAR], and bioactive adrenomedullin [bio-ADM]) exhibited endotype-specific differences independent of AKI severity. NGAL and suPAR levels were disproportionately elevated in the IE group, suggesting a dominant role of innate immune dysregulation in this endotype. In contrast, bio-ADM, a marker of endothelial dysfunction, was the strongest risk-predictor of outcomes in CE. The combination of transcriptomic endotyping with protein-based biomarkers enhanced predictive accuracy for the primary endpoint and 7-day mortality, with the highest area under the receiver operating characteristic curve of 0.80 (95% CI 0.72–0.88) for endotyping + bio-ADM and 0.85 (95% CI 0.78–0.93) for endotyping and suPAR, respectively. Combinations of endotyping with functional and non-functional biomarkers particularly improved mortality-related risk stratification. Conclusions Combining transcriptomic endotyping with protein-based biomarker profiling enhances risk-stratification in SA-AKI, offering a promising strategy for personalized treatment and trial enrichment in the future. Further research should validate these findings and explore therapeutic applications.

Background Postoperative complications are of great relevance in daily clinical practice, and the gut microbiome might play an important role by preventing pathogens from crossing the intestinal barrier. The two aims of this prospective clinical pilot study were: (1) to examine changes in the gut microbiome following pancreatic surgery, and (2) to correlate these changes with the postoperative course of the patient. Results In total, 116 stool samples of 32 patients undergoing pancreatic surgery were analysed by 16S-rRNA gene next-generation sequencing . One sample per patient was collected preoperatively in order to determine the baseline gut microbiome without exposure to surgical stress and/or antibiotic use. At least two further samples were obtained within the first 10 days following the surgical procedure to observe longitudinal changes in the gut microbiome. Whenever complications occurred, further samples were examined. Based on the structure of the gut microbiome, the samples could be allocated into three different microbial communities (A, B and C). Community B showed an increase in Akkermansia , Enterobacteriaceae and Bacteroidales as well as a decrease in Lachnospiraceae , Prevotella and Bacteroides . Patients showing a microbial composition resembling community B at least once during the observation period were found to have a significantly higher risk for developing postoperative complications (B vs. A, odds ratio = 4.96, p  < 0.01**; B vs. C, odds ratio = 2.89, p  = 0.019*). Conclusions The structure of the gut microbiome is associated with the development of postoperative complications.

In severe trauma, it is estimated that approximately 2% of patients will sustain a spinal cord injury. The optimal method for advanced airway management that will minimize any associated cervical spine movement remains a topic of debate. Therefore, the aim of this study is to compare the effects of different tracheal intubation techniques in unstable injuries of the cervical spine. Tracheal intubation using conventional laryngoscopy (CL), video laryngoscopy (VL) or flexible bronchoscopic intubation (FO) was performed in six fresh human cadavers. Compression of the dural sac as well as angulation, distraction and intubation time were assessed by myelography in the presence of isolated atlanto-occipital dislocation (AOD) and of combined atlanto-occipital dislocation with atlanto-axial instability (AAI). In case of an isolated AOD, FO intubation resulted in significantly less compression of the dural sac at both levels compared to CL (− 0.46 mm vs. − 1.31 mm; p  < 0.001, r = .66) for C0/C1 and (− 0.09 mm vs. − 0.19 mm; p  =  < 0.05, r = .36) for C1/C2 and VL (− 0.46 mm vs. − 0.64 mm; p  =  < 0.05, r = .42 for C0/C1 and (− 0.09 mm vs. − 0.22 mm; p  =  < 0.01, r = .52) for C1/C2. Atlanto-axial Angulation in simultaneous AOD and AAI, the differences between CL and VL were significantly in favor of VL (4.1° vs. 3.2°; p  =  < 0.05, r = .39), and using FO resulted in less angulation than CL (2.5° vs. 4.1°; p  =  < 0.001, r = .60) and VL (2.5° vs. 3.2°; p  =  < 0.05). FO required longer in the case of combined AOD and AAI (FO 16.6 s vs. CL 9.8 s; p  =  < 0.001, r = .56), (FO 16.6 s vs. VL 9.7 s; p  =  < 0.001, r = .56). The study demonstrated that tracheal intubation using VL caused significant less compression of the dural sac than the CL. FO showed the lowest compression at all measuring points, but took almost twice as long. For elective or stable patients, where time to airway management is not a relevant factor, FO appears to be the safest method. However, FO is not available everywhere, and in urgent emergency situations, the longer duration may not be acceptable. In such cases, video laryngoscopy can represent a compromise between duration and patient safety, and most physicians have more clinical experience with VL than with FO.