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ABSTRACT: Traumatic hemipelvectomy is a severe, however rare injury associated with high lethality. Up to now, immediate surgical completion of the amputation has been recommended as a lifesaving therapy. We present a case of near complete hemipelvectomy with open fracture of the ileosacral joint, wide open symphysis and severe soft tissue trauma including a decollement around the pelvis. Successful complete replantation was performed by primary internal stabilisation and revascularisation using vascular grafts. In the further hospital course, numerous revisions of the soft tissue injury and reconstructive surgery were needed. Thirty months later, the patient's condition is physically and psychologically stable and he is able to walk using crutches. The key point of successful management was skilled emergency damage control surgery followed by dedicated surgical care to avoid septic complications.
Injury 11/2012; · 1.98 Impact Factor
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ABSTRACT: Percutaneous tracheostomy has become an established procedure in airway management of critically ill patients. It offers advantages over prolonged tracheal intubation. To date, there is no evidence of the optimal timing of the procedure. The Ciaglia Blue Rhino technique is the most common technique and, as any other techniques of percutaneous tracheostomy, is performed under general anaesthesia and with continuous bronchoscopic control. The recently introduced Ciaglia Blue Dolphin technique is based on radial dilatation with a fluid-filled high pressure balloon. Provided that specific contraindications are observed (e.g. difficult tracheal intubation, inability to identify anatomic landmarks, severe coagulopathy etc.), all techniques have low complication rates. The use of ultrasound may further enhance perioperative safety. Finally it must be noted that percutaneous tracheostomy is an elective procedure that requires informed consent from the patient or an attorney of law.
ains · Anästhesiologie · Intensivmedizin 10/2012; 47(10):598-604. · 0.41 Impact Factor
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ABSTRACT: In the case of an emergency, fast and structured patient management is crucial for a patient's outcome. Every physician and graduate medical student should possess basic knowledge of emergency care and the skills to manage common emergencies. This study determines the effect of a simulation-based curriculum in emergency medicine on students' abilities to manage emergency situations.
A controlled, blinded educational trial of 44 final-year medical students was carried out at Frankfurt Medical School; 22 students completed the former curriculum as the control group and 22 the new curriculum as the intervention group. The intervention consists of simulation-based training with theoretical and simulation-based training sessions in realistic encounters based on the Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and adapted Advanced Trauma Life Support (ATLS) training. Further common emergencies were integrated corresponding to the course objectives. All students faced a performance-based assessment in a 10 station Objective Structured Clinical Examination (OSCE) using checklist rating within a maximum of 4 months after completion of the intervention.
The intervention group performed significantly better at all of the 10 OSCE stations in the checklist rating (p<0.0001 to p=0.016).
The simulation-based intervention offers a positively evaluated possibility to enhance students' skills in recognising and handling emergencies. Additional studies are required to measure the long-term retention of the acquired skills, as well as the effect of training in healthcare professionals.
Postgraduate medical journal 06/2012; 88(1040):312-6. · 1.38 Impact Factor
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ABSTRACT: Gastrointestinal complications after cardiac surgery are associated with a high mortality rate. Because of the absence of
early specific clinical signs, diagnosis is often delayed. The present study seeks to determine predictive risk factors for
subsequent gastrointestinal complications after cardiosurgical procedures. Within a 1-year period, a total of 1116 patients
who had undergone open heart surgery with cardiopulmonary bypass were prospectively studied for gastrointestinal complications.
To determine predictive factors, all case histories of the patients were analyzed. Of the 1116 patients, 23 (2.1%) had gastrointestinal
complications during the postoperative period, 10 of whom had to undergo subsequent abdominal surgery. Of these 23 patients,
20 died. Early gastrointestinal complications, which occurred mostly on postoperative days 6 or 7, consisted of bowel ischemia
or hepatic failure. Late complications were gastrointestinal bleeding, pseudomembranous colitis, cholecystitis, and septic
rupture of a spleen. The relative risk for abdominal complications after cardiopulmonary bypass was highly increased in association
with (1) a cardiac index less than 2.0 l/min−1/(m2)−1, (2) postoperative onset of atrial fibrillation, (3) emergency surgery, (4) need for vasopressors, (5) need for intraaortic
balloon counterpulsation, and (6) need for early redo thoracotomy due to surgical complications. All patients with necrotic
bowel disease had elevated serum lactate levels. Furthermore, cardiopulmonary bypass and aortic clamping times were significantly
prolonged in patients who developed gastrointestinal complications. A number of predictive factors contribute to the development
of gastrointestinal complications after cardiopulmonary bypass surgery. Knowledge of these factors may lead to earlier identification
of patients at increased risk and may allow more efficient and earlier interventions to reduce mortality.
Objectifs: Les complications gastro-intestinales après chirurgie cardiaque sont associéesà un taux de mortalité élevé. Le
diagnostic en est souvent retardé en raison de I’absence de signes cliniques spécifiques, précoces. Cette étude chercheà déterminer
les facteurs de risque prédictifs de complications gastrointestinales après chirurgie cardio-vasculaire. Méthodes: Pendant
une période d’un an, 1116 patients au total ayant eu une intervention chirurgicaleà coeur ouvert avec shunt cardiopulmonaire
ont été étudiés prospectivement dans` la recherche de complications gas tro-intestinales. Afin de déterminer les facteurs
prédictifs, tous les antécédents ont é té analysés. Résultats: 23 (2.1%) des 1116 patients ont eu des complications gastrointestinales
pendant la période postopératoire, dont 10 qui ont nécessité un acte chirurgical abdominal. Parmi ces 23 patients, 20 sont
décédés. Des complications gastro-intestinales précoces sont survenues aux jours postopératoires 6 ou 7, sous forme d’ischémie
intestinale ou d’insuffisance hepatique. Les complications tardives ont été I’hémorragie gastro-intestinale, la colite pseudomembraneuse,
la cholécystite et un cas de rupture septique de la rate. Le risque relatif de faire des complications abdominales après shunt
cardio-pulmonaire était plus important lorsque le patient: (1) avait un indexe cardiaque inférieurà 2,0 l/min−1/ (m2)−1, (2) a prése nté une fibrillation auriculaire postopératoire, (3) a eu besoin d’une intervention en urgence, (4) a eu besoin
de vasopresseurs, (5) a nécessité I’utilisation d’un ballonnetà contrepression, et (6) a eu une re-thoracotomie précoce en
raison des complications. Tous les patients ayant une nécrose intestinale avaient des taux de lactates élevés dans le sérum.
Les temps de shunt cardio-pulmonaire et de clampage aortique ont été prolongés de façon significative chez les patients qui
ont développé des complications gastro-intestinales. Conclusions: II existe un certain nombre de facteurs prédictifs qui peuvent
contribuer au développement des complications gastrointestinales après un shunt cardio-pulmonaire. La connaissance de ces
facteurs pourrait aiderà identifier ces patientsà risque et pourrait permettre une intervention plus efficace et plus précoce,
réduisant ainsi la mortalité.
Objetivo: Las complicaciones gastrointestinales tras cirugía cardiaca conllevan una alta tasa de mortalidad. Debido a la ausencia
de signos clinico precoces, el diagnóstico, con frecuenci à, se retrasa. El presente estudio pretende averiguar los factores
que permitan predecir el riesgo de padecer complicaciones gastrointestinales tras cirugía cardiaca. Métodos: Durante un anõ
se estudiaron prospectivamente las complicaciones gastrointestinales de 1,116 pacientes intervenidos a corazón abierto con
derivación cardio-pulmonar. Se analizaron las historias clínicas de todos los pacientes con objeto de averiguar los factores
predictivos. Resultados: En 23 (2.1%) de los 1,116 pacientes se produjeron complicaciones gastrointestinales en el periodo
postoperatorio, requiriendo 10 de ellos tratamiento quirúrgico. De los 23 pacientes, 20 fallecieron. Las complicaciones gastrointestinales
precoces aparecieron entre el 6, 7 dias del postoperatorio, tratándose de isquemia intestinal o fracaso hepático. Las complicaciones
tardias fueron: hemorragia gastrointestinal, colitis pseudo-membranosa, colecistitis y ruptura séptica del bazo. El riesgo
de desarrollar complicaciones abdominales, tras derivación cardio-pulmonar se incrementa cuando se producen: (1) índice cardiaco
menor a 2.0 l/min−1/ (m2)−1, (2) crisis postoperatorias de fibrilación atrial, (3) cirug ía de urgencia, (4) utilización de vasopresores, (5) empleo
del balón intraaórtico de contrapulsación y (6) retoracotomía precoz por complicaciones quirúrgicas. Todos los pacientes con
afectación necrótica intestinal presentaron niveles altos de la concentración sérica de lactato. Además, en los pacientes
que desarrollaron complicaciones gastrointestinales, tanto el tiempo de derivación cardio-pulmonar como el del clampado de
aorta fueron significativamente más prolongados. Conclusiones: Se describen diversos factores predictivos que contribuyen
al desarrollo de complicaciones gastrointestinales tras cirugía cardiaca con derivación cardio-pulmonar. El conocimiento de
los mismos, permitirá la identificación precoz de los pacientes de mayor riesgo, pudiéndose así realizar intervenciones más
precoces y eficaces que reduzcan la mortalidad.
World Journal of Surgery 04/2012; 25(9):1140-1144. · 2.36 Impact Factor
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ABSTRACT: Health hazards from occupational exposure to trace concentrations of anesthetic gases cannot be definitively excluded. The
aim of the study was to determine the surgeon’s occupational exposure to nitrous oxide and sevoflurane during pediatric surgical
procedures. Twenty young children (age <10 years) and five teenagers (age > 10 years) underwent elective abdominal surgery
under general inhalational anesthesia. The operating room was equipped with modern air conditioning and waste anesthetic gas
scavenger. Levels of both nitrous oxide and sevoflurane were determined in the breathing zone of the surgeon and the anesthesiologist
during the operative procedures by means of a direct-reading photoacoustic infrared spectrometer. Both the surgeon and the
anesthesiologist were exposed to low concentrations of the inhalational agents used. Exposure to sevoflurane and nitrous oxide
was clearly higher during surgery in young children than during operative procedures in teenagers. Nonetheless, the concentrations
of these agents were well below the threshold limits of 25 ppm for nitrous oxide and 2 ppm for sevoflurane recommended by
the National Institute of Occupational Safety and Health. General anesthesia results in operating room air pollution with
inhalational anesthetics. Under modern air conditioning, personnel’s occupational exposure is low, and inhalational anesthesia
is safe from the standpoint of modern workplace laws and health care regulations. Nonetheless, all efforts must be taken to
maintain occupational exposure at this low level.
Objectives: Des risques en rapport avec l’exposition à des gaz d’anesthésie ne peuvent étre totalement écartés. Le but de
cette étude a été de déterminer le risque qu’encourt le chirurgien avec le protoxyde d’azote et le sevoflurane pendant des
procédés chirurgicaux pédiatriques. Méthodes: 20 enfants (âge≥ 10 ans) et cinq adolescents (âge≥ 10 ans) ont eu une intervention
abdominale élective sous anesthésie générale par inhalation. La salle d’opération était équipée d’un système de ventilation
moderne et d’une cartouche filtrante pour les gaz anesthésiques non utilisés. Les niveaux de protoxyde d’azote et de sevoflurane
ont été déterminés dans l’environnement respiré par les chirurgiens et les anesthésistes pendant les opérations par un spectromètre
infrarouge photo-acoustique de lecture directe. Résultats: Et le chirurgien et l’anesthésiste ont été exposés à des concentrations
basses des agents utilisés. L’exposition au sevoflurane et au protoxyde d’azote était fortement plus élevée lorsqu’il s’agissait
d’enfants plus jeunes par rapport aux adolescents. Néanmoins, les concentrations de ces agents étaient bien plus basses que
les valeurs seuils de 25 ppm pour le protoxyde d’azote et de 2 ppm pour le sevoflurane, recommandées par le National Institute
of Occupational Safety and Health. Conclusions: L’anesthésie générale provoque une certaine pollution de la salle d’opération
par des produits d’anesthésie d’inhalation. Dans les conditions modernes de ventilation, l’exposition aux gaz est trés réduite
et l’anesthésie d’inhalation peut être considérée comme un procédé sur d’un point de vue médico-légal et selon les réglementations
des conditions de travail. Néanmoins, toutes les précautions doivent être prises pour maintenir les niveaux d’exposition à
des niveaux les plus bas possibles.
No puede excluirse con certeza que la exposición, por motivos laborales a pequeñas concentraciones de gases anestésicos, pueda
poner en peligro la salud de los profesionales. El objetivo de este trabajo fue determinar el grado de exposición de los cirujanos
al óxido nitroso y al sevoflurano durante intervenciones quirúrgicas pediátricas. Métodos: 20 niños (menores de 10 años) y
5 adolescentes (mayores de 10 años) sufrieron una intervención quirúrgica abdominal bajo anestesia general por inhalación.
El quirófano estaba equipado con una moderna instalación de aire acondicionado y un sistema eliminador de los gases anestésicos
sobrantes. Utilizando un espectrómetro infrarrojo con lectura directa foto-acústica se determinaron los niveles de óxido nitroso
y de sevoflurano en la zona en la que respiraban, durante la intervención, tanto el cirujano como el anestesista. Resultados:
ambos, anestesista y cirujano, estuvieron expuestos a la inhalación a baja concentración de los agentes anestésicos utilizados.
La exposición tanto al sevoflurano como al óxido nitroso fue significativamente superior durante la cirugía infantil que en
las intervenciones quirúrgicas en adolescentes; sin embargo, ninguna de las concentraciones de los agentes anestésicos estuvieron
por encima del umbral recomendado por el Instituto Nacional de Seguridad Laboral y Salud (25 ppm para el óxido nitroso y 2
ppm para el sevoflurano). Conclusiones: la anestesia general produce una polución del aire del quirófano cuando se utilizan
anestésicos por inhalación. Si existe una moderna instalación de aire acondicionado, la exposición del personal laboral es
muy baja y la anestesia por inhalación es segura, tanto desde el punto de vista de las modernas leyes laborales como de las
regulaciones sobre atención sanitaria; a pesar de ello, no debe ahorrarse ningún esfuerzo para mantener la polución a estos
bajos niveles.
World Journal of Surgery 04/2012; 25(9):1109-1112. · 2.36 Impact Factor
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Canadian Journal of Anaesthesia 04/2012; 55(9):655-657. · 2.35 Impact Factor
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ABSTRACT: To compare hands-off time (HOT) in simulated advanced life support (ALS) following European Resuscitation Council (ERC) 2005 guidelines and ERC 2000 and to provide quantitative data on workflow.
Observations with 18 professional paramedics, performing 39 megacodes (mega-code training; MCT) were videotaped during ALS re-certification. Teams were randomly assigned to train according to ERC 2000 or ERC 2005. HOT, hands-off intervals (HOI) and other variables describing interventions and workflow were analysed.
In group ERC 2000 17±3 HOI appeared with a mean duration of 17.5±10.8 s (mean±SD). Overall HOT was 382±47 s, equivalent to a mean hands-off fraction (HOF) of 0.45±0.05. 15±5 ventilation-free intervals (VFI) were observed, with a mean duration of 21±10 s. In contrast after ERC 2005 variables resulted in 18±3 HOI with a mean duration of 10.0±4.0 s (p<0.001 vs ERC 2000), overall HOT 196±33 s (HOF 0.23±0.04; p<0.001), 24±12 VFI with a duration of 24±7 s (p<0.05). The first HOI lasted for 60.4±33.1 s in ERC 2000 and 17.6±4.3 s in ERC 2005 (p<0.001). In ERC 2000 6.1±2.6 interruptions for two bag/mask ventilations (BMV) lasted for 5.4±0.8 s, whereas in ERC 2005 9.6±3.1 interruptions for two BMV took 6.5±2.2 s (p<0.001). In both groups HOI were used thoroughly for basic life support/ALS-based interventions.
The application of ERC guidelines of 2005 markedly reduced the first HOI and mean duration of HOI at the cost of delayed secure airway management and ECG analysis in this MCT model.
Emergency Medicine Journal 02/2012; 29(2):95-9. · 1.44 Impact Factor
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ABSTRACT: The disposable laryngeal tube suction (LTS-D) is a supraglottic airway device that can be used as an alternative to tracheal tube to provide ventilation. We tested the hypothesis that, with a frontal jaw thrust insertion technique (FIT/JT), the rate of correct placement attempts in patients with a simulated difficult airway by means of a rigid cervical immobilization collar could be significantly increased compared to the standard insertion technique (SIT) recommended by the manufacturer.
70 adult patients undergoing trauma surgery under general anaesthesia had an LTS-D inserted, randomly assigned to the SIT or FIT/JT. In the FIT/JT, the operator was standing in front of the patient's head, and forced chin lift to create sufficient retropharyngeal space was performed. The rate of successful tube placements within 180s and with a maximum of two attempts was the main outcome variable. To distinguish between the effects of the frontal approach and the jaw thrust manoeuvre, a third group was studied after completion of the SIT and FIT/JT groups. The standard insertion technique, but with a jaw thrust manoeuvre (SIT/JT), was employed in another 35 consecutive patients.
Overall placement success was 49% (SIT, 17/35 patients, P<0.001), 91% (SIT/JT, 32/35 patients) and 100% (FIT/JT). The time required for successful insertion was shortest in the FIT/JT group (23±6s), and significantly longer in the SIT/JT (42±29s, P<0.001) and SIT groups (51±29s, P<0.0001).
In anaesthetised patients with a simulated difficult airway created with a rigid cervical collar, the overall LTS-D placement success was significantly higher when a jaw thrust manoeuvre was performed, regardless of the particular technique used to introduce the LTS-D. Therefore, an intense jaw thrust manoeuvre should be performed whenever an LTS-D is being inserted.
Resuscitation 02/2011; 82(2):199-202. · 3.60 Impact Factor
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ABSTRACT: Intraosseous (IO) access represents a reliable alternative to intravenous vascular access and is explicitly recommended in the current guidelines of the European Resuscitation Council when intravenous access is difficult or impossible. We therefore aimed to study the efficacy of the intraosseous needle driver EZ-IO in the prehospital setting.
During a 24-month period, all cases of prehospital IO access using the EZ-IO needle driver within three operational areas of emergency medical services were prospectively recorded by a standardized questionnaire that needed to be filled out by the rescuer immediately after the mission and sent to the primary investigator. We determined the rate of successful insertion of the IO needle, the time required, immediate procedure-related complications, the level of previous experience with IO access, and operator's subjective satisfaction with the device.
77 IO needle insertions were performed in 69 adults and five infants and children by emergency physicians (n = 72 applications) and paramedics (n = 5 applications). Needle placement was successful at the first attempt in all but 2 adults (one patient with unrecognized total knee arthroplasty, one case of needle obstruction after placement). The majority of users (92%) were relative novices with less than five previous IO needle placements. Of 22 responsive patients, 18 reported pain upon fluid administration via the needle. The rescuers' subjective rating regarding handling of the device and ease of needle insertion, as described by means of an analogue scale (0 = entirely unsatisfied, 10 = most satisfied), provided a median score of 10 (range 1-10).
The EZ-IO needle driver was an efficient alternative to establish immediate out-of-hospital vascular access. However, significant pain upon intramedullary infusion was observed in the majority of responsive patients.
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 01/2011; 19:65. · 1.85 Impact Factor
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ABSTRACT: In the case of an emergency, fast and structured patient management is crucial for a patient's outcome. Every physician and graduate medical student should possess basic knowledge of emergency care and the skills to manage common emergencies. This study determines the effect of a simulation-based curriculum in emergency medicine on students' abilities to manage emergency situations.
A controlled, blinded educational trial of 44 final-year medical students was carried out at Frankfurt Medical School; 22 students completed the former curriculum as the control group and 22 the new curriculum as the intervention group. The intervention consists of simulation-based training with theoretical and simulation-based training sessions in realistic encounters based on the Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and adapted Advanced Trauma Life Support (ATLS) training. Further common emergencies were integrated corresponding to the course objectives. All students faced a performance-based assessment in a 10 station Objective Structured Clinical Examination (OSCE) using checklist rating within a maximum of 4 months after completion of the intervention.
The intervention group performed significantly better at all of the 10 OSCE stations in the checklist rating (p<0.0001 to p=0.016).
The simulation-based intervention offers a positively evaluated possibility to enhance students' skills in recognising and handling emergencies. Additional studies are required to measure the long-term retention of the acquired skills, as well as the effect of training in healthcare professionals.
Emergency Medicine Journal 10/2010; 27(10):734-8. · 1.44 Impact Factor
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ABSTRACT: Although the impact of tranexamic acid on platelet function remains controversial, tranexamic acid is part of clinical algorithms for the management of platelet dysfunction. The goal of our prospective, observational study was to examine the effects of tranexamic acid on platelet function in patients treated with dual antiplatelet therapy compared to those who ceased antiplatelet therapy for at least 7 days.
Forty patients scheduled for cardiac surgery were enrolled in this study. Group 1 consisted of 20 patients who ceased antiplatelet therapy with aspirin and clopidogrel at least 7 days before surgery. Group 2 consisted of 20 patients who were treated with aspirin and clopidogrel until the day before surgery. Using the Multiplate device (Dynabyte, Munich, Germany), multiple electrode aggregometry (MEA) was performed following platelet stimulation with thrombin receptor activating peptide-6 (TRAP-6), arachidonic acid or ADP on blood collected 20 min before and after application of 2 g tranexamic acid.
Compared with group 1, platelet aggregation was statistically significantly reduced in ASPItest and ADPtest in group 2, whereas there were no significant differences in the TRAPtest. In group 1, platelet aggregation did not differ significantly before and after tranexamic acid treatment. In contrast, in group 2, we observed a significant increase in arachidonic acid-induced [295 (280/470) arbitrary aggregation units × min [AU*min; median (25th/75th percentile) vs. 214 (83/409) AU*min, P = 0.01] and ADP-induced platelet aggregation [560 AU*min (400/760 AU*min) vs. 470 AU*min (282/550 AU*min), P = 0.013], whereas platelet aggregation following stimulation with TRAP-6 did not change significantly [980 (877/1009) AU*min, median (25th/75th percentile) after tranexamic acid vs. 867 (835/961) AU*min before tranexamic acid, P = 0.464].
The results of this study indicate that tranexamic acid potentially corrects defects in arachidonic acid-induced and ADP-induced platelet aggregation imposed by dual antiplatelet therapy. However, platelet aggregation in response to arachidonic acid or ADP in the blood of patients who have not received aspirin and clopidogrel is unaffected by tranexamic acid. These results support the use of tranexamic acid to partially reverse platelet aggregation dysfunction due to antiplatelet therapy.
European Journal of Anaesthesiology 10/2010; 28(1):57-62. · 2.23 Impact Factor
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ABSTRACT: To establish a training course for Prehospital Focused Abdominal Sonography for Trauma (P-FAST) and to evaluate the accuracy of the participants after the course and at the trauma scene.
A training programme was developed to provide medical staff with the skills needed to perform P-FAST. In order to evaluate the accuracy of P-FAST performed by the students, nine participants (five emergency doctors and four paramedics) were followed during their course and in practice after the course. An assessment was made of 200 ultrasound procedures performed during the course in healthy volunteers and in patients with peritoneal dialysis or ascites. Regular P-FAST performed on-scene by the participants commenced immediately following the course. The results for the nine participants (C-group, course group) were compared with those members of medical staff with more than 3 years of experience in FAST (P-group, professional group). A group of physicians untrained in P-FAST served as a control (I-group, indifferent group). P-FAST findings were further verified by subsequent FAST and CT scans in the emergency department.
After the training programme the C-group performed 39 P-FAST procedures without any false negative or false positive findings (100% accuracy). In the P-group, 112 procedures were performed with one false positive case. In the I-group there were 2 false negative cases among the 46 procedures performed.
Following completion of a 1-day P-FAST course, participants were able to perform ultrasound procedures at the scene of an accident with a high level of accuracy.
Emergency Medicine Journal 05/2010; 27(5):345-9. · 1.44 Impact Factor
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ABSTRACT: Initiated by a clinical case of critical endotracheal tube (ETT) obstruction, we aimed to determine factors that potentially contribute to the development of endotracheal tube obstruction by its inflated cuff. Prehospital climate and storage conditions were simulated.
Five different disposable ETTs (6.0, 7.0, and 8.0 mm inner diameter) were exposed to ambient outside temperature for 13 months. In addition, every second of these tubes was mechanically stressed by clamping its cuffed end between the covers of a metal emergency case for 10 min. Then, all tubes were heated up to normal body temperature, placed within the cock of a syringe, followed by stepwise inflation of their cuffs to pressures of 3 kPa and > or =12 kPa, respectively. The inner lumen of the ETT was checked with the naked eye for any obstruction caused by the external cuff pressure.
Neither in tubes that were exposed to ambient temperature (range: -12 degrees C to +44 degrees C) nor in those that were also clamped, visible obstruction by inflated cuffs was detected at any of the two cuff pressure levels.
We could not demonstrate a critical obstruction of an ETT by its inflated cuff, neither when the cuff was over-inflated to a pressure of 12 kPa or higher, nor in ETTs that had been exposed to unfavorable storage conditions and significant mechanical stress.
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 04/2010; 18:18. · 1.85 Impact Factor
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ABSTRACT: Endotracheal intubation (ETI) is considered to be the gold standard of prehospital airway management. However, ETI requires substantial technical skills and ongoing experience. Because failed prehospital ETI is common and associated with a higher mortality, reliable airway devices are needed to be used by rescuers less experienced in ETI. We prospectively evaluated the feasibility of laryngeal tubes used by paramedics and emergency physicians for out-of-hospital airway management.
During a 24-month period, all cases of prehospital use of the laryngeal tube disposable (LT-D) and laryngeal tube suction disposable (LTS-D) within five operational areas of emergency medical services were recorded by a standardised questionnaire. We determined indications for laryngeal tube use, placement success, number of placement attempts, placement time and personal level of experience.
Of 157 prehospital intubation attempts with the LT-D/LTS-D, 152 (96.8%) were successfully performed by paramedics (n=70) or emergency physicians (n=87). The device was used as initial airway (n=87) or rescue device after failed ETI (n=70). The placement time was < or =45s (n=120), 46-90s (n=20) and >90s (n=7). In five cases the time needed was not specified. The number of placement attempts was one (n=123), two (n=25), three (n=2) and more than three (n=2). The majority of users (61.1%) were relative novices with no more than five previous laryngeal tube placements.
The LT-D/LTS-D represents a reliable tool for prehospital airway management in the hands of both paramedics and emergency physicians. It can be used as an initial tool to secure the airway until ETI is prepared, as a definitive airway by rescuers less experienced with ETI or as a rescue device when ETI has failed.
Resuscitation 12/2009; 81(3):323-6. · 3.60 Impact Factor
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ABSTRACT: In case of an emergency, a fast and structured patient management is crucial for patient's outcome. The competencies needed should be acquired and assessed during medical education. The objective structured clinical examination (OSCE) is a valid and reliable assessment format to evaluate practical skills. However, traditional OSCE stations examine isolated skills or components of a clinical algorithm and thereby lack a valid representation of clinical reality. We developed emergency case OSCE stations (ECOS), where students have to manage complete emergency situations from initial assessment to medical treatment and consideration of further procedures. Our aim was to increase the authenticity and validity in the assessment of students' capability to cope with emergency patients. 45 students participated in a 10-station OSCE with 6 ECOS and 4 traditional OSCE stations. They were assessed using a case-specific checklist. An inter-station and post-OSCE-questionnaire was completed by each student to evaluate both ECOS and traditional OSCE. In this study, we were able to demonstrate that ECOS are feasible as time-limited OSCE stations. There was a high acceptance on both students and examiners side. They rated ECOS to be more realistic in comparison to the traditional OSCE scenarios. The reliability estimated via Crohnbach's alpha for the 6 ECOS is high (0.793). ECOS offer a feasible alternative to the traditional OSCE stations with adequate reliability to assess students' capabilities to cope with an acute emergency in a realistic encounter.
Advances in Health Sciences Education 08/2009; 15(1):81-95. · 2.09 Impact Factor
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ABSTRACT: Thoracic paravertebral block for postoperative pain control has been introduced more than a century ago. It is currently gaining increasing popularity. This simple and safe technique can be used for postoperative analgesia, as well as sole anesthetic technique. When compared to epidural analgesia for postthoracotomy pain control, thoracic paravertebral analgesia provides comparable analgesic efficacy, but less side-effects. Regarding concomitant use of anticoagulants and antiplatelet drugs, paravertebral blockade is considered a central nerve block.
ains · Anästhesiologie · Intensivmedizin 08/2009; 44(7-8):530-42. · 0.41 Impact Factor
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ABSTRACT: Difficult paediatric airways, both expected and unexpected, present major challenges to every anaesthesiologist, paediatrician and emergency physician. However, the integration of supraglottic airway devices, such as the laryngeal mask (LM), into the algorithm of difficult airways has improved the handling of difficult airway situations in patients. A recent device for establishing a supraglottic airway is the laryngeal tube, introduced in 1999. We report on the successful use of the laryngeal tube suction II (LTS II) in securing the airway when endotracheal intubation or alternative mask ventilation has failed.
The use of the LTS II in 10 cases of difficult airway management in neonates and infants <6 months was reviewed.
Use of the LTS II was associated with a high level of success (100%), often rescuing the airway when other techniques had failed. All insertions were successful on first attempt using a modified insertion technique. Placement was classified as "easy" by all users.
The potential advantage of the LTS II is the suction port which allows gastric tube placement and subsequent egression of gastric contents. In emergency situations when direct laryngoscopy fails, or is too time-consuming because of anatomical abnormalities, we recommend the LTS II tube as the first-line device to secure the airway. As with all supraglottic airways, familiarity and clinical experience with the respective device and its insertion technique is essential for safe and successful use, especially in emergencies.
Resuscitation 05/2009; 80(7):805-10. · 3.60 Impact Factor
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ABSTRACT: The present prospective study was designed to evaluate hemodynamic changes associated with head-down positioning and prolonged pneumoperitoneum during totally endoscopic robot-assisted radical prostatectomy.
Ten American Society of Anesthesiologists (ASA) physical status I-III patients undergoing totally endoscopic robot-assisted radical prostatectomy were enrolled in the study. Invasive hemodynamic parameters were measured by transpulmonary arterial thermodilution using the PiCCO system with a femoral artery catheter. Cardiac index (CI), heart rate (HR), mean arterial pressure (MAP), systemic vascular resistance index (SVRI), intrathoracic blood volume (ITBV), and central venous pressure (CVP) were recorded with the patient in the supine position, after head-down tilt, intraoperatively after 30 min, 1 h, 2 h, 3 h, and 4 h of pneumoperitoneum at an insufflation pressure of 12 mmHg, after deflation still with head-down positioning, and finally, with the patient in the supine position.
Placing the patient in the Trendelenburg (head-down) position caused a significant increase in CVP (from 9.9 +/- 3.4 to 15.1 +/- 2.3 mmHg), whereas all other hemodynamic parameters remained nearly unaffected. The induction of pneumoperitoneum resulted in a significant increase in MAP (from 74.9 +/- 12.9 to 95.4 +/- 11.9 mmHg). No other parameter was affected. Even at 4 h of pneumoperitoneum only mild hemodynamic changes were observed. After release of the pneumoperitoneum with the patient still in the head-down position, HR (49.0 +/- 4 versus 63.9 +/- 12.4 min(-1)) and after placing the patient in the supine position, CI (2.4 +/- 0.2 versus 3.3 +/- 0.7 l min(-1 )m(-2)) increased significantly, whereas CVP returned to baseline values.
Patients undergoing totally endoscopic radical prostatectomy with 4 h of pneumoperitoneum in the Trendelenburg position experienced no significant hemodynamic depression during posture and pneumoperitoneum.
World Journal of Surgery 08/2008; 32(7):1400-5. · 2.36 Impact Factor
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ABSTRACT: The Bonfils intubation fibrescope (BIF), a rigid, straight and reusable fibreoptic device, is being used increasingly to facilitate endotracheal intubation after direct laryngoscopy has failed. We tested the hypothesis that, with the BIF compared to direct laryngoscopy, the rate of failed endotracheal intubation could be reduced in patients with a difficult airway, simulated by means of a rigid cervical immobilization collar.
Seventy-six adults undergoing elective gynecological surgery under general anesthesia were randomly assigned to have endotracheal intubation, facilitated with either a standard size 3 Macintosh laryngoscope blade, or the BIF. A rigid cervical immobilization collar was used to simulate a difficult airway, by reducing mouth opening and limiting neck extension. If endotracheal intubation could not be achieved within two attempts, the cervical collar was removed, and direct laryngoscopy was performed thereafter, using a Macintosh blade in all subjects. The success rate of endotracheal tube placement was the primary outcome variable.
Patient characteristics were similar in the two groups. After neck immobilization, the inter-incisor distance was reduced to 2.6 +/- 0.7 cm (Macintosh) and 2.6 +/- 0.8 cm (BIF). Tube placement was successful in 15/38 (39.5%) patients with a Macintosh blade, and in 31/38 patients with the BIF (81.6%; P = 0.0003). Time required for tube placement was 53 +/- 22 sec (Macintosh) and 64 +/- 24 sec (BIF; P = 0.15).
The Bonfils intubation fibrescope is a more effective intubating device for patients with immobilized cervical spine and significantly limited inter-incisor distance, when compared to direct laryngoscopy.
Canadian Journal of Anaesthesia 05/2008; 55(4):232-7. · 2.35 Impact Factor
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ABSTRACT: Laryngeal tubes are supraglottic airway devices that can be used in alternative to a tracheal tube to provide ventilation during cardiopulmonary resuscitation. The product line has recently been expanded by the disposable laryngeal tube suction (LTS-D). We tested the hypothesis that, with a modified insertion technique (MIT), the rate of correct placement attempts within 45 s could be significantly increased compared to the standard insertion technique (SIT) recommended by the manufacturer.
Fifty-four adult patients undergoing trauma surgery under general anaesthesia had an LTS-D inserted by first-time users, randomly assigned to the SIT or a MIT. A brief manikin-based demonstration of the device and the assigned technique was given before insertion. In the MIT the tip of the LTS-D was rotated by 180 degrees prior to insertion. Forced chin lift to create sufficient retropharyngeal space was performed with the other hand. Introduced to one-third of its length, the LTS-D was again rotated by 180 degrees and pushed down the pharynx. The rate of successful tube placements within 45 s was the main outcome variable.
Insertion took 73+/-41 s (SIT) and 40+/-8s (MIT, P<0.01). Insertion within 45 s was possible in n=7/27 patients (26%, SIT) and in n=20/27 patients (74%, MIT, P<0.01). In one patient of the MIT group, placement failed. Non-anaesthesia personnel, such as nurses and emergency medical technicians (n=27), performed comparably to board-certified anaesthesiologists or those in training (n=27).
Applying a MIT significantly reduced the time for successful insertion of an LTS-D by first-time users. Insertion within 45 s was significantly more frequent with this technique. Further studies need to be conducted to determine if the LTS-D can be recommended as a first-line airway during cardiopulmonary resuscitation.
Resuscitation 03/2008; 76(3):364-8. · 3.60 Impact Factor
