Evaluation of the C-MAC Miller Video Laryngoscope Sizes 0 and 1 During Tracheal Intubation of Infants Less Than 10 kg.

STUDY OBJECTIVE: Video laryngoscopy has primarily been developed to assist in difficult airways. Using video laryngoscopy in pediatric airway management is an up-and-coming topic. The aim of the presented study was to compare the intubation conditions obtained when using the C-MAC video laryngoscope with Miller blades sizes 0 and 1 for standard direct laryngoscopy and indirect laryngoscopy in children weighing less than 10 kg. DESIGN: This was a prospective study. SETTING: The study was performed in a university hospital. PATIENTS: Following ethical approval, 86 infants weighing less than 10 kg and undergoing surgery under general anesthesia were studied prospectively. INTERVENTION: Indirect and direct laryngoscopy either with C-MAC Miller blade size 0 or size 1. MEASUREMENTS: First, direct laryngoscopy was performed, and the best obtained view was graded without looking at the video monitor. A second investigator blinded to the view obtained under direct laryngoscopy graded the laryngeal view on the video monitor. Time to intubation, intubation conditions, and intubation attempts were recorded. RESULTS: In infants less than 10 kg, intubation conditions were excellent. There were no significant differences between the use of Miller blade 0 or 1 in reference to Cormack-Lehane grade, time to intubation, time to best view, or intubation attempts. Comparing direct and indirect intubation conditions using either Miller blade 0 or 1 revealed that the use of indirect laryngoscopy provided a significantly better view (P < 0.05) of the vocal cords. In 3 infants weighing more than 8 kg, the Miller blade 0 was described as too short and narrow for intubation. CONCLUSIONS: Both devices allowed for an excellent visualization of the vocal cords.

Comparing Four Video Laryngoscopes and One Optical Laryngoscope with a Standard Macintosh Blade in a Simulated Trapped Car Accident Victim.

BACKGROUND: Tracheal intubation still represents the "gold standard" in securing the airway of unconscious patients in the prehospital setting. Especially in cases of restricted access to the patient, video laryngoscopy became more and more relevant. OBJECTIVES: The aim of the study was to evaluate the performance and intubation success of four different video laryngoscopes, one optical laryngoscope, and a Macintosh blade while intubating from two different positions in a mannequin trial with difficult access to the patient. METHODS: A mannequin with a cervical collar was placed on the driver's seat. Intubation was performed with six different laryngoscopes either through the driver's window or from the backseat. Success, C/L score, time to best view (TTBV), time to intubation (TTI), and number of attempts were measured. All participants were asked to rate their favored device. RESULTS: Forty-two physicians participated. 100% of all intubations performed from the backseat were successful. Intubation success through the driver's window was less successful. Only with the Airtraq® optical laryngoscope, 100% success was achieved. Best visualization (window C/L 2a; backseat C/L 2a) and shortest TTBV (window 4.7 s; backseat 4.1 s) were obtained when using the D-Blade video laryngoscope, but this was not associated with a higher success through the driver's window. Fastest TTI was achieved through the window (14.2 s) when using the C-MAC video laryngoscope and from the backseat (7.3 s) when using a Macintosh blade. CONCLUSIONS: Video laryngoscopy revealed better results in visualization but was not associated with a higher success. Success depended on the approach and familiarity with the device. We believe that video laryngoscopy is suitable for securing airways in trapped accident victims. The decision for an optimal device is complicated and should be based upon experience and regular training with the device.

Prospective Trial to Compare Direct and Indirect Laryngoscopy Using C-MAC PM® with Macintosh Blade and D-Blade® in a Simulated Difficult Airway.

Objective. Evaluation of C-MAC PM® in combination with a standard Macintosh blade size 3 in direct and indirect laryngoscopy and D-Blade® in indirect laryngoscopy in a simulated difficult airway. Primary outcome was defined as the best view of the glottic structures. Secondary endpoints were subjective evaluation and assessment of the intubation process. Methods. Prospective monocentric, observational study on 48 adult patients without predictors for difficult laryngoscopy/tracheal intubation undergoing orthopedic surgery. Every participant preoperatively received a cervical collar to simulate a difficult airway. Direct and indirect laryngoscopy w/o the BURP maneuver with a standard Macintosh blade and indirect laryngoscopy w/o the BURP maneuver using D-Blade® were performed to evaluate if blade geometry and the BURP maneuver improve the glottic view as measured by the Cormack-Lehane score. Results. Using a C-MAC PM® laryngoscope, D-Blade® yielded improved glottic views compared with the Macintosh blade used with either the direct or indirect technique. Changing from direct laryngoscopy using a Macintosh blade to indirect videolaryngoscopy using C-MAC PM® with D-Blade® improved the Cormack-Lehane score from IIb, III, or IV to I or II in 31 cases. Conclusion. The combination of C-MAC PM® and D-Blade® significantly enhances the view of the glottis compared to direct laryngoscopy with a Macintosh blade in patients with a simulated difficult airway. Trial Registration Number. This trial is registered under number NCT03403946.

Laryngeal tube suction for airway management during in-hospital emergencies.

OBJECTIVE:: The role of supraglottic airway devices in emergency airway management is highlighted in international airway management guidelines. We evaluated the application of the new generation laryngeal tube suction (LTS-II/LTS-D) in the management of in-hospital unexpected difficult airway and cardiopulmonary resuscitation. METHODS:: During a seven-year period, patients treated with a laryngeal tube who received routine anesthesia and had an unexpected difficult airway (Cormack Lehane Grade 3-4), who underwent cardiopulmonary resuscitation, or who underwent cardiopulmonary resuscitation outside the operating room and had a difficult airway were evaluated. Successful placement of the LTS II/LTS-D, sufficient ventilation, time to placement, number of placement attempts, stomach content, peripheral oxygen saturation/end-tidal carbon dioxide development (SpO2/etCO2) over 5 minutes, subjective overall assessment and complications were recorded. RESULTS:: In total, 106 adult patients were treated using an LTS-II/LTS-D. The main indication for placement was a difficult airway (75%, n=80), followed by cardiopulmonary resuscitation (25%, n=26) or an overlap between both (18%, n=19). In 94% of patients (n=100), users placed the laryngeal tube during the first attempt. In 93% of patients (n=98), the tube was placed within 30 seconds. A significant increase in SpO2 from 97% (0-100) to 99% (5-100) was observed in the whole population and in cardiopulmonary resuscitation patients. The average initial etCO2 of 39.5 mmHg (0-100 mmHg) decreased significantly to an average of 38.4 mmHg (10-62 mmHg) after 5 minutes. A comparison of cardiopulmonary resuscitation patients with non-cardiopulmonary resuscitation patients regarding gastric contents showed no significant difference. CONCLUSIONS:: LTS-D/LTS-II use for in-hospital unexpected difficult airway management provides a secure method for primary airway management until other options such as video laryngoscopy or fiber optic intubation become available.

Laryngeal tube suction for airway management during in-hospital emergencies

OBJECTIVE: The role of supraglottic airway devices in emergency airway management is highlighted in international airway management guidelines. We evaluated the application of the new generation laryngeal tube suction (LTS-II/LTS-D) in the management of in-hospital unexpected difficult airway and cardiopulmonary resuscitation. METHODS: During a seven-year period, patients treated with a laryngeal tube who received routine anesthesia and had an unexpected difficult airway (Cormack Lehane Grade 3-4), who underwent cardiopulmonary resuscitation, or who underwent cardiopulmonary resuscitation outside the operating room and had a difficult airway were evaluated. Successful placement of the LTS II/LTS-D, sufficient ventilation, time to placement, number of placement attempts, stomach content, peripheral oxygen saturation/end-tidal carbon dioxide development (SpO2/etCO2) over 5 minutes, subjective overall assessment and complications were recorded. RESULTS: In total, 106 adult patients were treated using an LTS-II/LTS-D. The main indication for placement was a difficult airway (75%, n=80), followed by cardiopulmonary resuscitation (25%, n=26) or an overlap between both (18%, n=19). In 94% of patients (n=100), users placed the laryngeal tube during the first attempt. In 93% of patients (n=98), the tube was placed within 30 seconds. A significant increase in SpO2 from 97% (0-100) to 99% (5-100) was observed in the whole population and in cardiopulmonary resuscitation patients. The average initial etCO2 of 39.5 mmHg (0-100 mmHg) decreased significantly to an average of 38.4 mmHg (10-62 mmHg) after 5 minutes. A comparison of cardiopulmonary resuscitation patients with non-cardiopulmonary resuscitation patients regarding gastric contents showed no significant difference. CONCLUSIONS: LTS-D/LTS-II use for in-hospital unexpected difficult airway management provides a secure method for primary airway management until other options such as video laryngoscopy or fiber optic intubation become available.

[Case Report: Zinc phosphide poisoning after ingestion of a rodentizide in suicidal intention]. / Kasuistik - Suizidale Einnahme von Wühlmausköder (Zinkphosphid).

Zinc phosphide normally serves as a rodenticide but is occasionally ingested for suicide, potentially causing multiorgan failure. Phosphine gas is commonly in use for fumigation of grain silos and shipping containers.We describe a suicide attempt of a 54 year old female, the clinical symptoms, the treatment, the chemical and biochemical background and we give information on the potential occurrence of zinc phosphide and phosphine gas.

A radiographic comparison of human airway anatomy and airway manikins--Implications for manikin-based testing of artificial airways.

OBJECTIVE: The aim of this prospective, single-center, observational study was to investigate the accuracy of modeling and reproduction of human anatomical dimensions in manikins by comparing radiographic upper airway measurements of 13 different models with humans. METHODS: 13 commonly used airway manikins (male or female anatomy based) and 47 controls (adult humans, 37 male, 10 female) were investigated using a mediosagittal and axial cervical spine CT scan. For anatomical comparison six human upper airway target structures, the following were measured: Oblique diameter of the tongue through the center, horizontal distance between the center point of the tongue and the posterior pharyngeal wall, horizontal distance between the vallecula and the posterior pharyngeal wall, distance of the upper oesophageal orifice length of epiglottis distance at the narrowest part of the trachea. Furthermore, the cross-section of the trachea in axial view and the cross-section of the upper oesophageal orifice in the same section was calculated. All measurements were compared gender specific, if the gender was non-specified with the whole sample. RESULTS: None of the included 13 different airway manikins matched anatomy in human controls (n = 47) in all of the six measurements. The Laerdal Airway Management Trainer, however, replicated human airway anatomy at least satisfactorily. CONCLUSION: This investigation showed that all of the examined manikins did not replicate human anatomy. Manikins should therefore be selected cautiously, depending on the type of airway securing procedure. Their widespread use as a replacement for in vivo trials in the field of airway management needs to be reconsidered.

Benefit of piezoosteotomy in cranioplasties for craniosynostosis correction versus conventional saw-and-chisel osteotomy: a pilot study.

OBJECTIVE: Pilot study evaluation of the benefit of piezoosteotomy in cranioplasty of craniosynostoses, based on clinical data. DESIGN: Retrospective case-control study. SETTING: Universitarian institution. PATIENTS: Craniosynostosis patients (n = 19) operated upon conventionally with a craniotome and microsaw versus 19 patients operated upon with a piezoosteotomy and a craniotome. INTERVENTION: Piezoosteotomy of the supraorbital "bandeau" and osteotomies on part of the parietal and occipital regions versus conventional saw-and-chisel osteotomy. MAIN OUTCOME MEASURES: Perioperative age, weight, laboratory parameters, transfusion and infusion requirements, operation time, and blood loss. RESULTS: The intraoperative erythrocyte concentrate transfusion and noncolloidal infusions were comparable (P = .15; P = .56). The fresh frozen plasma transfusion was significantly higher (P = .03); possibly, the anesthesiologist's reaction was secondary to the higher irrigation-fluid accumulation in the aspiration bag during piezoosteotomy. The postoperative erythrocyte concentrate transfusion rate was significantly lower (P = .01) as a result of local hemostasis in piezoosteotomy. The fresh frozen plasma transfusion and noncolloidal infusion volumes were nonsignificantly lower (P = .27; P = .85). Operation time was slightly shorter with a smaller standard deviation (P = .09), due to a lower rate of dural lacerations and consecutive repair; patients in the study group were on the intensive care unit half a day less (P = .73) than those in the control group. C-reactive protein was significantly lower preoperatively (P = .00) and on the operation day (P = .01) and nonsignificant postoperatively (P = .81); hematocrit was postoperatively higher (P = .23). Thrombocytes were preoperatively lower and postoperatively higher, both nonsignificant (P = .29; P = .52). CONCLUSIONS: Piezoosteotomy appears to be less traumatic than conventional saw-and-chisel osteotomy by the evaluated parameters. The main study limitation is its nonrandomized retrospective design; results should be confirmed by a randomized controlled trial.

Comparison of the TruView infant EVO2 PCD™ and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways.

OBJECTIVE: Videolaryngoscopy has mainly been developed to facilitate difficult airway intubation. However, there is a lack of studies demonstrating this method's efficacy in pediatric patients. The aim of the present study was to compare the TruView infant EVO2 and the C-MAC videolaryngoscope with conventional direct Macintosh laryngoscopy in children with a bodyweight ≤10 kg in terms of intubation conditions and the time to intubation. METHODS: In total, 65 children with a bodyweight ≤10 kg (0-22 months) who had undergone elective surgery requiring endotracheal intubation were retrospectively analyzed. Our database was screened for intubations with the TruView infant EVO2, the C-MAC videolaryngoscope, and conventional direct Macintosh laryngoscopy. The intubation conditions, the time to intubation, and the oxygen saturation before and after intubation were monitored, and demographic data were recorded. Only children with a bodyweight ≤10 kg were included in the analysis. RESULTS: A total of 23 children were intubated using the C-MAC videolaryngoscope, and 22 children were intubated using the TruView EVO2. Additionally, 20 children were intubated using a standard Macintosh blade. The time required for tracheal intubation was significantly longer using the TruView EVO2 (52 sec vs. 28 sec for C-MAC vs. 26 sec for direct LG). However, no significant difference in oxygen saturation was found after intubation. CONCLUSION: All devices allowed excellent visualization of the vocal cords, but the time to intubation was prolonged when the TruView EVO2 was used. The absence of a decline in oxygen saturation may be due to apneic oxygenation via the TruView scope and may provide a margin of safety. In sum, the use of the TruView by a well-trained anesthetist may be an alternative for difficult airway management in pediatric patients.

Comparison of the TruView infant EVO2 PCD and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways

OBJECTIVE: Videolaryngoscopy has mainly been developed to facilitate difficult airway intubation. However, there is a lack of studies demonstrating this method's efficacy in pediatric patients. The aim of the present study was to compare the TruView infant EVO2 and the C-MAC videolaryngoscope with conventional direct Macintosh laryngoscopy in children with a bodyweight ≤10 kg in terms of intubation conditions and the time to intubation. METHODS: In total, 65 children with a bodyweight ≤10 kg (0-22 months) who had undergone elective surgery requiring endotracheal intubation were retrospectively analyzed. Our database was screened for intubations with the TruView infant EVO2, the C-MAC videolaryngoscope, and conventional direct Macintosh laryngoscopy. The intubation conditions, the time to intubation, and the oxygen saturation before and after intubation were monitored, and demographic data were recorded. Only children with a bodyweight ≤10 kg were included in the analysis. RESULTS: A total of 23 children were intubated using the C-MAC videolaryngoscope, and 22 children were intubated using the TruView EVO2. Additionally, 20 children were intubated using a standard Macintosh blade. The time required for tracheal intubation was significantly longer using the TruView EVO2 (52 sec vs. 28 sec for C-MAC vs. 26 sec for direct LG). However, no significant difference in oxygen saturation was found after intubation. CONCLUSION: All devices allowed excellent visualization of the vocal cords, but the time to intubation was prolonged when the TruView EVO2 was used. The absence of a decline in oxygen saturation may be due to apneic oxygenation via the TruView scope and may provide a margin of safety. In sum, the use of the TruView by a well-trained anesthetist may be an alternative for difficult airway management in pediatric patients. .

A novel method for the direct determination of heparin concentration during cardiopulmonary bypass surgery.

BACKGROUND: Heparin is the standard drug for anticoagulation treatment and is used in many cardiac surgical interventions to prevent blood clotting. The anticoagulation status is controlled by various clotting tests. However, these tests depend on parameters like temperature, hemodilution etc. and are thus not applicable for a direct monitoring of the heparin concentration. The aim of this prospective study was to test a novel light scattering assay (LiSA) for the direct determination of heparin concentration during cardiopulmonary bypass (CPB) surgery and to compare the heparin concentrations with routinely determined activated clotting time (ACT). METHODS: The patient group consisted of 50 patients undergoing coronary bypass surgery with CPB. The coagulation status was monitored by the measurement of ACT, which was performed approximately every 30 min during surgery. Parallel to each ACT measurement, the heparin concentration was measured by LiSA. RESULTS: For 70% of the patients, ACT and heparin concentration measured by LiSA correlated reasonably over the entire time course of the intervention. For 30% of the patients, an insufficient correlation or even no correlation at all was observed. CONCLUSIONS: This study showed that LiSA enables the determination of intra-operative heparin levels. The lack of correlation between ACT and heparin concentration in a substantial group of patients shows that monitoring of heparin concentration is important. A more precise blood coagulation management, in particular, a precise administration of heparin and protamine, should be based on a combination of the measurement of heparin concentration and of ACT, but not on ACT alone.

Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients.

INTRODUCTION: The current investigation aimed to study the efficacy of hemostatic therapy guided either by conventional coagulation analyses or point-of-care (POC) testing in coagulopathic cardiac surgery patients. METHODS: Patients undergoing complex cardiac surgery were assessed for eligibility. Those patients in whom diffuse bleeding was diagnosed after heparin reversal or increased blood loss during the first 24 postoperative hours were enrolled and randomized to the conventional or POC group. Thromboelastometry and whole blood impedance aggregometry have been performed in the POC group. The primary outcome variable was the number of transfused units of packed erythrocytes during the first 24 h after inclusion. Secondary outcome variables included postoperative blood loss, use and costs of hemostatic therapy, and clinical outcome parameters. Sample size analysis revealed a sample size of at least 100 patients per group. RESULTS: There were 152 patients who were screened for eligibility and 100 patients were enrolled in the study. After randomization of 50 patients to each group, a planned interim analysis revealed a significant difference in erythrocyte transfusion rate in the conventional compared with the POC group [5 (4;9) versus 3 (2;6) units [median (25 and 75 percentile)], P<0.001]. The study was terminated early. The secondary outcome parameters of fresh frozen plasma and platelet transfusion rates, postoperative mechanical ventilation time, length of intensive care unit stay, composite adverse events rate, costs of hemostatic therapy, and 6-month mortality were lower in the POC group. CONCLUSIONS: Hemostatic therapy based on POC testing reduced patient exposure to allogenic blood products and provided significant benefits with respect to clinical outcomes.

Emergency airway management in trauma patients using laryngeal tube suction.

BACKGROUND: Endotracheal intubation (ETI) is considered to be the "gold standard" of prehospital airway management of trauma patients. 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 who are less experienced in ETI. OBJECTIVE: To prospectively evaluate the feasibility of the use of laryngeal tubes by paramedics and emergency physicians for out-of-hospital airway management in trauma patients. METHODS: During a 40-month period, data for all cases of prehospital use of the laryngeal tube suction disposable (LTS-D) within a large metropolitan area were recorded by a standardized questionnaire. We determined indications for laryngeal tube use, placement success, number of placement attempts, placement time, and personal level of experience. All patients admitted to our institution also underwent in-hospital follow-up. RESULTS: Fifty-six of 57 prehospital intubations attempts with the LTS-D were successfully performed by paramedics (n = 19) or emergency physicians (n = 37) within one (n = 50) or two (n = 6) placement attempts. The device was used as initial airway (n = 27) or rescue device after failed ETI (n = 30). The placement time was ≤ 45 seconds (n = 42), 46-90 seconds (n = 13), and >90 seconds (n = 1). The majority of users (n = 44) were relative novices with no more than 10 previous laryngeal tube placements on actual patients. Of 33 patients eligible for follow-up, one underwent urgent LTS-D removal and subsequent ETI upon hospital admission, six underwent ETI after primary survey, and 26 underwent both primary and secondary survey or even damage-control surgery with the LTS-D. CONCLUSION: The LTS-D represents a promising alternative to ETI 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 in ETI, or as a rescue device when ETI has failed.

Tranexamic acid partially improves platelet function in patients treated with dual antiplatelet therapy.

BACKGROUND: 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. METHODS: 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. RESULTS: 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]. CONCLUSION: 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.

Normovolemic modified ultrafiltration is associated with better preserved platelet function and less postoperative blood loss in patients undergoing complex cardiac surgery: a randomized and controlled study.

OBJECTIVE: The purpose of the investigation was to study the impact of normovolemic modified ultrafiltration (N-MUF) on hemostasis and perioperative blood loss. METHODS: Fifty patients scheduled for elective complex cardiac surgery were enrolled in this prospective, randomized, and controlled study. Patients were randomized into a control group (n = 25) or an N-MUF group (n = 25). N-MUF was performed using a BC140plus Filter (Maquet Cardiopulmonary AG, Hirrlingen, Germany) in the N-MUF group. Blood samples were taken before (T1) and 30 minutes after (T2) N-MUF in the N-MUF group and at corresponding time points in the control group. Platelet function analyses (TRAPtest, ASPItest, ADPtest) using multiple electrode aggregometry (Multiplate, Dynabyte, Munich, Germany), thrombelastometry (ROTEM, Pentapharm GmbH, Munich, Germany), and conventional laboratory coagulation analyses were performed at each time point. Intraoperative and postoperative transfusion requirements, hemostatic therapy, and blood loss were recorded. RESULTS: There were no significant group differences in demographic or surgical data. At T1, platelet aggregation revealed no significant group differences in the TRAPtest, ASPItest, or ADPtest. Platelet aggregation at T2 was significantly higher in the N-MUF group compared with the control group in the TRAPtest (65 [50/87] U vs 44 [28/51]; P < .001), the ASPItest (52 [36/69] U vs 22 [8/47] U; P = .001), or the ADPtest (39 [28/51] U vs 28 [19/39] U; P = .009). The postoperative chest tube blood loss was significantly lower in the N-MUF at 24 hours (890 [500/1100] mL vs 1075 [800/1413] mL in the N-MUF group vs the control group; P = .039) and 48 hours (900 [550/1350] mL vs 1400 [900/1750] mL; P = .026) postoperatively. Conventional laboratory coagulation analyses and thrombelastometric parameters did not differ within the groups at T1 or T2. CONCLUSIONS: N-MUF improved general platelet aggregation and reduced postoperative blood loss in a significant manner. However, performing N-MUF did not result in less postoperative transfusion requirements.

Disposable laryngeal tube suction: standard insertion technique versus two modified insertion techniques for patients with a simulated difficult airway.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

[Thoracic paravertebral block]. / Thorakale Paravertebralblockade.

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.

Impact of general versus local anesthesia on early postoperative cognitive dysfunction following carotid endarterectomy: GALA Study Subgroup Analysis.

BACKGROUND: The aim of this study was to compare the influence of either general (GA) or local (LA) anesthesia on the postoperative neurocognitive outcome in patients undergoing carotid endarterectomy (CEA) in a randomized study. Therefore, we performed a subgroup analysis of the multicenter GALA study. METHODS: A total of 40 patients were enrolled and randomized to receive either LA (n = 17) or GA (n = 23) anesthesia. The indication for intraoperative shunting was based on the intraoperative cognitive performance in the LA group and on the clinical experience of the surgeon in the GA group. Outcome measurements included patient performance on a neuropsychological Trail Making Test, evaluation of patients mood using the self-report inventory BSKE, and serum levels of the neurobiochemical marker S100beta. The data were analyzed for each variable using a t-test and were presented as the mean (SD). Differences in shunt frequency were analyzed performing a chi-squared test. Group differences in the Trail Making Test, BSKE evaluation, and S100beta concentrations were derived from the analyses of covariances with repeated measurements using preoperative values as covariates. RESULTS: Compared to baseline, the S100beta concentrations increased significantly in the GA group [0.086 (0.038) vs. 0.061 (0.024) microg/l; p < 0.001] before unclamping of the carotid artery, whereas there were no changes in the LA group [0.068 (0.024) microg/l, p = 0.09 vs. 0.061 (0.021) microg/l, p = 0.09). Furthermore, we detected significant group differences after surgical intervention (GA 0.087 (0.031) microg/l; LA 0.06 (0.021) microg/l; p = 0.006). The postoperative neurocognitive performance in the Trail Making Test decreased significantly in the GA group, whereas there were no significant changes in the LA group. The self-report inventory BSKE evaluation revealed no significant group differences. CONCLUSIONS: We concluded that performing local anesthesia in patients undergoing CEA positively influenced early postoperative neurocognitive outcomes. Significant group differences in postoperative S100beta concentrations confirmed the beneficial effect of local anesthesia.

Laryngeal tube suction II for difficult airway management in neonates and small infants.

OBJECTIVE: 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. METHODS: The use of the LTS II in 10 cases of difficult airway management in neonates and infants <6 months was reviewed. RESULTS: 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. CONCLUSIONS: 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.