Anesthesiology

Point-of-Care diagnostics of coagulation in the management of bleeding and transfusion in trauma patients Purpose of review Trauma-associated bleeding and coagulopathy require timely identification, prevention, and effective treatment. The present review summarizes the recent literature around point-of-care (POC) coagulation tests, their usefulness in the management of trauma-induced coagulopathy (TIC), their impact on trauma patient outcomes, and the requirement of quality assurance. Recent findings Best practice algorithms to manage TIC have been compiled in the 2019 European Guideline on the management of major bleeding and coagulopathy after trauma. Evidence supports the use of goal-directed approaches to manage TIC. POC coagulation tests can accelerate and tailor individualized therapies. Recent findings emphasize: the time sparing of POC tests in prehospital settings and the validity of POC measurements in extreme environments; the potential scalability of POC-guided TIC algorithms in burn injuries and the pediatric population; the need for careful considerations of strategies to monitor and reverse the effects of direct oral anticoagulants in major trauma. Summary In contrast to an abundance of reviews and practical approaches to POC coagulation management in trauma patients, there is a scarcity of research in the field and large-scale clinical trials are urgently needed. The paneuropean multicenter trial Implementing Treatment Algorithms for the Correction of Trauma Induced Coagulopathy (iTACTIC) will inform on the potential of viscoelastic tests to augment transfusion protocols for better patient outcomes. Correspondence to Prof. Dr. med. Roland C.E. Francis, Charité – Universitätsmedizin Berlin, Klinik für Anästhesiologie m.S. operative Intensivmedizin, Augustenburger Platz 1, 13353 Berlin, Germany. Tel: +49 30 450 551002; fax: +49 30 450 551900; e-mail: Roland.francis@charite.de Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

ICU management based on big data Purpose of review The availability of large datasets and computational power has prompted a revolution in Intensive Care. Data represent a great opportunity for clinical practice, benchmarking, and research. Machine learning algorithms can help predict events in a way the human brain can simply not process. This possibility comes with benefits and risks for the clinician, as finding associations does not mean proving causality. Recent findings Current applications of Data Science still focus on data documentation and visualization, and on basic rules to identify critical lab values. Recently, algorithms have been put in place for prediction of outcomes such as length of stay, mortality, and development of complications. These results have begun being implemented for more efficient allocation of resources and in benchmarking processes, to allow identification of successful practices and margins for improvement. In parallel, machine learning models are increasingly being applied in research to expand medical knowledge. Summary Data have always been part of the work of intensivists, but the current availability has not been completely exploited. The intensive care community has to embrace and guide the data science revolution in order to decline it in favor of patients’ care. Correspondence to Stefano Falini, c/o Istituto Clinico Humanitas, Via Alessandro Manzoni 56, 20089 Rozzano, Italy. Tel: +39 335 812 6498; e-mail: stefano.falini@humanitas.it Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Red cell use in trauma Purpose of review Red cell transfusions are commonly used in management of hemorrhage in trauma patients. The appropriate indications and criteria for transfusion are still debated. Here, we summarize the recent findings on the use of red cell transfusion in trauma setting. Recent findings Recent evidence continues to support the long-established link between allogeneic transfusion and worse clinical outcomes, reinstating the importance of more judicious use of allogeneic blood and careful consideration of benefits versus risks when making transfusion decisions. Studies support restrictive transfusion strategies (often based on hemoglobin thresholds of 7–8 g/dl) in most patient populations, although some argue more caution in specific populations (e.g. patients with traumatic brain injury) and more studies are needed to determine if these patients benefit from less restrictive transfusion strategies. It should be remembered that anemia remains an independent risk factor for worse outcomes and red cell transfusion does not constitute a lasting treatment. Anemia should be properly assessed and managed based on the cause and using hematinic medications as indicated. Summary Although the debate on hemoglobin thresholds for transfusion continues, clinicians should not overlook proper management of the underlying issue (anemia). Correspondence to Aryeh Shander, MD, Englewood, Hospital and Medical Center, 350 Engle Street, Englewood, NJ 07631, USA. Tel: +1-201-894-3238; fax: +1-201-894-0585; e-mail: aryeh.shander@EHMCHEALTH.org Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Medical science faces the post-truth era: a plea for the grassroot values of science Purpose of review Science and its public perception are compromised by scientific fraud and predatory journals, and also by the general erosion of the meaning of truth in the so-called post-truth era. These developments have significant influence on scientific medicine and their impact on the public discourse. The purpose of this article is to show how fake science, and also the uncritical dissemination of compromised results in public and social media, threatens scientific medicine. Recent findings As social media rises to the preferred source of information of ever larger parts of the modern societies, the dissemination of falsified scientific results within the communities is almost unstoppable. With growing numbers of predatory journals and repetitive cases of fake science, the risk of publication of false results increases. Due to the underlying mechanisms of the post-truth era and social media, these compromised results find their way to the public discourse and continue to be disseminated even when they were, beyond all doubt, proven to be a lie. In medical sciences, dissemination of falsified results directly threats health and life of patients. Summary In the post-truth era, publication of false results in predatory journals and by fraudulent authors become even more dangerous for the health and life of patients, as their dissemination via new social media is nearly unstoppable and in the public perception truth is losing its meaning. The scientific community has implemented specific counter-measures to minimize the chances of false results being published. However, it is even more important that every participant in the scientific process assumes the responsibility according to his or her role. An orientation towards the values that have constituted and formed science is helpful in fulfilling this responsibility. Correspondence to Sebastian Heinrich, MD, Department of Anesthesiology and Critical Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany. Tel: +49 761 270 23060; fax: +49 761 270 23960; e-mail: sebastian.heinrich@uniklinik-freiburg.de Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Bioethics: cancelling patient operations Purpose of review This review aims to surmise a bioethical approach to the phenomenon of cancelling patient operations. There is increasing public and political interest in the matter with a rise in the frequency of cancellations. Cancellations are emotional for patients and are difficult clinical decisions. Recent findings Reasons for cancellation involve patient factors and resource allocation applying to elective and emergency surgery. The four pillars of bioethics are easily applied, (autonomy, beneficence, nonmaleficence and justice), although their failings are becoming more prominent with the rise of more encompassing virtue ethics. These include dignity, solidarity, phronesis and trust. Importantly patient dignity should be preserved, this complimenting solidarity and trust in specialist knowledge more than autonomy does. Beauchamp and Childress have provided a descriptive framework describing futility, which may aid communication and mental clarity when deliberating if it is the right choice to cancel. With regards to resource factors, ideally managerial staff should be involved in these decisions leaving the physician to be the patient's clinical advocate. Summary Although cancellations are undesirable, they are inevitable and form part of the duties of a doctor. When they do occur, care must remain patient-centred, asking how we can improve this situation. Correspondence to Louise Denholm, Registrar in Intensive Care, Royal Alexandra Hospital, Paisley PA29PN. Tel: +01413146125; e-mail: ldenholm@nhs.net Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Decision aids in anesthesia: do they help? Purpose of review Patient decision aids are educational tools used to assist patients and clinicians in healthcare decisions. As healthcare moves toward patient-centered care, these tools can provide support to anesthesiologists by facilitating shared decision-making. Recent findings Recent research has shown that patient decision aids are beneficial in the clinical setting for patients and physicians. Studies have shown that patients feel better informed, have better knowledge, and have less anxiety, depression, and decisional conflict after using patient decision aids. In addition, a structured approach for the development of patient decision aids in the field of anesthesia has been established. Summary Patient decision aids can support patient-centered care delivery and shared decision-making, especially in the field of anesthesia. Current research involves implementing the use of patient decision aids in the discussion for monitored anesthesia care. Further development of quality metrics is needed to improve the decision aids and maximize decision quality. Correspondence to Richard D. Urman, MD, MBA, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street CWN L1, Boston, MA 02115, USA. Tel: +1 617 732 8486; fax: +1 617 277 2192; e-mail: rurman@bwh.harvard.edu Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Doctor and healthcare workers strike: are they ethical or morally justifiable: another view Purpose of review This review analyzed legal and ethical issues surrounding recent doctor and healthcare worker (HCW) strikes and considered whether HCW strikes are legally and morally justifiable, underlying causes, and impact of such strikes on healthcare service delivery. Recent findings Recent reports show that doctor and HCW strikes are an ongoing phenomenon globally, occurring in both developed and developing countries. The main reasons for HCW strikes are failed employer–employee negotiations regarding fair wages and working conditions, policy issues, infrastructural deficiencies in poorer countries, and concerns by HCWs regarding personal security in the workplace. The main impact of HCW strikes is disruption of healthcare service delivery, such as canceled outpatients’ appointments, hospital admissions, and elective surgeries. There was no clear evidence of increased patients’ mortality during strikes, except in isolated cases, where emergency services were also withdrawn during strikes. Summary Doctors and HCWs strikes are lawful deadlock-breaking mechanisms when collective bargaining negotiations have reached an impasse. Doctors’ strikes appear to create an ethical conflict with the Hippocratic tradition and obligation to place patients’ best interests as the primary moral consideration in medical practice. However, the rise of consumerism in healthcare, and loss of power by doctors, many of whom now work as employees, subject to regulations imposed by different stakeholders, including governments, health-maintenance organizations, and healthcare insurers, has impacted on modern medical practice. Therefore, doctors, like other employees may occasionally resort to strikes to extract concessions from employers. Mortality is rarely increased during HCW strikes, especially where emergency healthcare services are provided. Correspondence to Sylvester C. Chima, MD, LLM, LLD, Programme of Bio and Research Ethics and Medical Law, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa. Tel.: +27 312604604;. fax: +27 312603914; e-mail: chima@ukzn.ac.za Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Multidrug-resistant bacteria in ICU: fact or myth Purpose of review Antimicrobial resistance (AMR) is increasing in ICUs around the world, but the prevalence is variable. We will review recent literature and try to answer the question whether this is a myth or a new reality, as well as discuss challenges and potential solutions. Recent findings AMR is diverse, and currently Gram-negative multidrug-resistant organisms (MDROs) are the main challenge in ICUs worldwide. Geographical variation in prevalence of MDROs is substantial, and local epidemiology should be considered to assess the current threat of AMR. ICU patients are at a high risk of infection with MDRO because often multiple risk factors are present. Solutions should focus on reducing the risk of cross-transmission in the ICU through strict infection prevention and control practices and reducing exposure to antimicrobials as the major contributor to the development of AMR. Summary AMR is a reality in most ICUs around the world, but the extent of the problem is clearly highly variable. Infection prevention and control as well as appropriate antimicrobial use are the cornerstones to turn the tide. Correspondence to Jan J. De Waele, MD, Ph.D., Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium. Tel: +32 93 32 62 19; fax: +32 93 32 49 95; E-mail: Jan.DeWaele@UGent.be Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Organ donation: from diagnosis to transplant Purpose of review Organ transplantation has largely expanded over the last decades and despite several improvements have been made in the complex process occurring between the identification of organ donors and organ transplant, there is still a chronic inability to meet the needs of patients. Consequently, the optimization of the transplant process through its different steps is crucial, and the role of the intensivists is fundamental as it requires clinical, managerial and communication skills to avoid the loss of potential donors. The purpose of this review is to provide an update on the transplant process from the early identification of the donor, to donor management. The two main pathways of organ donation will be discussed: donation after death by neurologic criteria and the donation after cardiac death (DCD). Recent findings Recent evidence demonstrates that appropriate intensive care management is fundamental to increase organ availability for transplantation. The expansion of pool donation requires a strong legal framework supporting ethical and organizational considerations in each country, together with the implementation of physicians’ technical expertise and communication skills for family involvement and satisfaction. New evidence is available regarding organ donor's management and pathway. The importance of checklists is gaining particular interest according to recent literature. Recent clinical trials including the use of naloxone, simvastatin and goal directed hemodynamic therapies were not able to demonstrate a clear benefit in improving quality and number of transplanted organs. Ethical concerns about DCD are recently being raised, and these will be discussed focusing on the differences of outcome between controlled and uncontrolled procedure. Summary The major change in the process of organ donation has been to implement parallel DCD and donation after brain death pathways. However, more research is needed for improving quality and number of transplanted organs. Correspondence to Giuseppe Citerio, School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy. Tel: +0 39 2334316; fax: +0 39 2334340; e-mail: giuseppe.citerio@unimib.it;ORCID:0000-0002-5374-3161 Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Is there an indication to utilize intravenous iron in acute trauma patients? Why, how, and when Purpose of review Traumatic injury has been described as a growing pandemic which has significant implications for global health. In the trauma setting, anemia is a common occurrence and is frequently inadequately addressed. It is associated with significant morbidity and incurs great cost – both to the patient and to the health system. The cause is multifactorial, and the pathophysiology is incompletely understood. Appropriate care of the trauma patient is a multidisciplinary responsibility and a focused approach to anemia is vital. The recommendation for restrictive transfusion strategies and the potential benefit of intravenous iron (IVI) in the perioperative setting, make the intervention an attractive proposition in the anemic trauma patient. Recent findings In an era where the importance of patient blood management is recognized, there is significant attention being given to both the implications and the appropriate management of anemia, in various settings. Advances have been made in the understanding of the mechanisms underlying the anemia associated with traumatic injury and the efficacy of current interventions is being explored. This increased understanding of the pathophysiology behind the condition has also facilitated the postulation of potential therapeutic targets for the future. Summary Suboptimally managed anemia impacts on clinical outcome and contributes to the burden of costs associated with trauma. The cause of the anemia associated with trauma is multifactorial and should be addressed at several levels. The role of IVI in this setting is yet to be clearly defined. Correspondence to Bernd Froessler, Department of Anesthesia, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5112, Australia. Tel: +61 8 81829806; e-mail: bernd.froessler@sa.gov.au Copyright © 2020 YEAR Wolters Kluwer Health, Inc. All rights reserved.