[Automatic load-distributing band CPR (AutoPulse™) in prone position, feasible?] / Mechanische CPR (AutoPulse™) in Bauchlage, machbar?

BACKGROUND: Due to SARS-CoV­2 respiratory failure, prone positioning of patients with respiratory and hemodynamic instability has become a frequent intervention in intensive care units (ICUs), and even in patients undergoing transfer in an ambulance or helicopter. It has become increasingly important how to perform safe and effective CPR in prone position, achieving both an optimal outcome for the patient and optimal protection of staff from infection. MATERIALS AND METHODS: We conducted feasibility tests to assess the effects of CPR with an automatic load-distributing band (AutoPulse™) in prone position and discussed different aspects of mechanical chest compression (mCPR) in prone position. RESULTS: In supine position, AutoPulse™ generated a constant pressure depth of 3cm at a frequency of 84/min. In prone position, AutoPulse™ generated a constant pressure depth of 2.6cm at a frequency of 84/min. CONCLUSION: We found mCPR to be feasible in manikins in both prone and supine positions.

Segmental myocardial wall motion during minimally invasive coronary artery bypass grafting using open and endoscopic surgical techniques.

Current options for minimally invasive surgical treatment of single-vessel coronary artery disease include beating heart procedures without cardiopulmonary bypass (CPB) via mini-thoracotomy (MIDCAB) and totally endoscopic robot-assisted techniques (TECAB) with CPB. Both procedures are associated with potential myocardial stress before revascularization, such as single-lung ventilation (SLV), temporary coronary artery occlusion, cardiac luxation, intrathoracic carbon dioxide insufflation, and extended CPB and operating time. In this echocardiographic study we sought to evaluate the extent of intraoperative segmental wall motion abnormalities (SWMA) during MIDCAB and TECAB surgery and to identify factors affecting SWMA. Forty-six patients with single-vessel coronary artery disease were studied. Sixteen patients were operated using the MIDCAB technique and 30 patients with TECAB. In both groups sequential transesophageal echocardiograms were recorded during the entire procedure. Hemodynamic data and oxygenation variables were acquired simultaneously. In both groups, mild but obvious perioperative SWMA were identified and noted to increase during the course of the operation. These SWMA were more pronounced in the TECAB group. Independent of operating time, these changes disappeared completely after revascularization. No significant hemodynamic compromise was observed. We conclude that MIDCAB and TECAB techniques are associated with significant perioperative SWMA. The appearance of more profound SWMA in the TECAB group compared with the MIDCAB patients might have been the result of intrathoracic CO(2) insufflation, as SLV was used in both groups. No persistent SWMA or post-CPB SWMA were apparent in either group. More extensive intraoperative ventricular SWMA was detected in the TECAB group, suggesting that a more frequent risk for right ventricular dysfunction may exist during TECAB procedures.

Peri-operative complications during percutaneous tracheostomy in obese patients.

The safety of percutaneous tracheostomy in 73 obese patients (body mass index > or = 27.5 kg.m(-2)) in a cohort of 474 adults was studied. Four percutaneous techniques were employed (percutaneous dilational tracheostomy, n = 48; Ciaglia Blue Rhino, n = 157; guide wire dilating forceps, n = 62, translaryngeal tracheostomy, n = 207). The overall complication rate was 43.8% (n = 32) in the obese group compared to 18.2% (n = 73) in the control group (p < 0.001). Seven (9.6%) obese patients suffered life-threatening complications compared to three non-obese patients (0.7%, p < 0.001). Obese patients had a 2.7-fold increased risk for peri-operative complications, and a 4.9-fold increased risk for serious complications. The data suggest that percutaneous tracheostomy in obese patients is associated with a considerably increased risk for peri-operative complications, especially for serious adverse events.

[Transthoracic defibrillation. Physiologic and pathophysiologic principles and their role in the outcome of resuscitation]. / Die transthorakale Defibrillation. Physiologische und pathophysiologische Grundlagen und deren Bedeutung für den Reanimationserfolg.

As one major link in the chain of survival, early transthoracic (external) cardiac defibrillation is aimed at the termination of ventricular flutter and ventricular fibrillation. Most important to the success of defibrillation is the passage of a defined amount of current through a critical mass of heart muscle. Different transthoracic resistances reduce the effective density of the current within the heart. As for other therapeutic intervention procedures, recommendations for the optimal strength of current to be applied to the fibrillating heart need to be evaluated and defined for therapeutical defibrillation too. Unnecessarily high current density causes damage to the heart and should be prevented. By using biphasic waveforms in contrast to monophasic impulses, the amount of current can be reduced but the same or even higher efficacy is attained. Therefore possible myocardial damage might be clearly reduced. Even with individually altered thoracic impedance effective conversion of cardiac rhythm can be achieved by device-controlled compensation and biphasic waveforms. According to their different mechanisms or origin (electrically induced or spontaneously caused by organic heart disease) the probability of successful conversion of the cardiac rhythm by one single electrical impulse varies. The optimum point in time for defibrillation during resuscitation needs to be redefined. In order to improve comparability, further studies should use standardized definitions for successful defibrillation relating to the resulting cardiac rhythm.

[Analysis of ventricular fibrillation signals for the evaluation of defibrillation success in the treatment of ventricular fibrillation]. / Analyse von Flimmersignalen zur Abschätzung der Defibrillierbarkeit beim Kammerflimmern.

OBJECTIVE: Precise detection of ventricular fibrillation (VF), reliable prediction of defibrillation success and adjustment of the discharge waveform to the patient's transthoracic impedance may contribute to a reduction of electricity-associated myocardial injury caused by unnecessary counter shocks. Specifically, asystole thresholds distinguish between VF and asystole, and thus prevent unnecessary defibrillation attempts. We reviewed various studies and manufacturer characteristics regarding the parameters and algorithms for analyzing arrhythmia ECG signals. METHODS: Asystole threshold values of several defibrillator manufacturers were collected and a literature review was performed including the following parameters: amplitude, frequency, bispectral analysis, amplitude spectrum area, wavelets, nonlinear dynamics, N(alpha)histograms, and combinations of various parameters. RESULTS: The manufacturer dependent asystole thresholds vary substantially. We show ways to optimize an ECG-based analysis for the next technological generation of defibrillators. During advanced cardiac life support (ACLS) the probability of defibrillation success should be estimated. Optimal defibrillation waveform, depending on transthoracic resistance, should be individually determined. In case of prolonged VF with a low ECG amplitude defibrillation should not be attempted unless coronary perfusion has been improved by further measures of ACLS. The combined evaluation of VF amplitude and frequency is effective in predicting defibrillation success. Estimation of further parameters is potentially useful for guiding optimal timing of defibrillation. At present, the implementation of most parameters in out-of-hospital cardiopulmonary resuscitation (CPR) is limited by the lack of technical feasibility of online computing. CONCLUSION: Analysis of VF ECG signals should allow adequate VF detection as well as prediction of defibrillation success. Suitable asystole thresholds for analysis of ECG signals have to be determined, and the adverse effects of CPR associated artefacts on data analysis have to be reduced. Analysis of VF ECG signals is a precondition of individually optimized defibrillation and may contribute substantially to an increased quality of CPR.

[Coronary bypass operation with complete median sternotomy in awake patients with high thoracic peridural anesthesia]. / Koronare Bypassoperation mit kompletter medianer Sternotomie am wachen Patienten in hoher thorakaler Periduralanästhesie.

OBJECTIVE: High thoracic epidural anesthesia (TEA) combined with general anesthesia is increasingly being used for coronary artery bypass grafting (CABG) with extracorporeal circulation. Recent developments in beating heart techniques have rendered the use of TEA alone in conscious patients possible and have been reported for single-vessel beating heart CABG via lateral thoracotomy. For multi-vessel revascularization the heart is usually approached via median sternotomy, therefore the use of TEA alone was applied in awake patients with multi-vessel coronary artery disease who underwent CABG via median sternotomy. METHODS: A total of 10 patients scheduled for awake coronary artery bypass grafting (ACAB) received TEA via an epidural catheter placed at T1/2 or T2/3. Total arterial myocardial revascularization was performed after median sternotomy. In addition to standard monitoring, anesthetic sensory and motor block levels were determined using an epidural scoring scale for arm movements (ESSAM). RESULTS: Except for one patient who required intraoperative endotracheal intubation due to a pneumothorax, all patients were awake and maintained spontaneous breathing during the entire procedure. Compared to baseline values, hemodynamic parameters, e.g. arterial blood pressure (SAP, MAP, DAP) and heart rate significantly declined during coronary anastomosis. No significant hypercarbia was observed. The intraoperative pain level was subjectively estimated by the patients as less than 20 out of 100 (median 10.95% confidence interval 4.2-21.6) using a visual analogue scale. All patients rated TEA as "good" or "excellent." Adverse effects associated with TEA were not observed. CONCLUSIONS: We could demonstrate that the use of TEA alone for CABG via median sternotomy was feasible and produced good results. High patient satisfaction in our small and highly selected cohort could be reported. Nevertheless, randomized controlled trials in large cohorts are mandatory to definitively evaluate the role of TEA alone in cardiac surgery.

Echocardiographic findings in minimally invasive coronary artery bypass grafting: The role of intrathoracic CO2 - insufflation and single lung ventilation.

BACKGROUND: Current options for surgical treatment of coronary single vessel disease range from beating heart procedure without cardiopulmonary bypass via a mini thoracotomy (MIDCAB) to totally endoscopic robot-assisted techniques (TECAB) with cardiopulmonary bypass. Both procedures are associated with considerable stress even before revascularization such as single lung ventilation, temporary coronary occlusion, Luxatio cordis, intrathoracic CO2 insufflation and extended bypass and operating time. The aim of the this study was to document the extent of intraoperative segmental wall motion abnormalities (SWMA) by echocardiography, and to identify variables affecting SWMA. MATERIALS AND METHODS: Forty patients with coronary single vessel disease were included in the study. 16 patients were operated with the MIDCAB technique, and 24 patients underwent TECAB. In both groups of patients sequential transesophageal echocardiograms (2D-loops) were recorded and analyzed. Hemodynamic and electrocardiographic data as well as oxygenation parameters were acquired during echo exams. In both groups of patients mild, but significant perioperative SWMA were identified, which increased in the course of the operation. These SWMA were more pronounced in the TECAB as compared to the MIDCAB group. Independent of operating time these changes disappeared completely until the ends of surgery. Significant hemodynamic or elektrocardiographic modifications were not observed. CONCLUSION: The application of minimally invasive techniques for the surgical treatment of coronary single vessel disease is associated with significant perioperative SWMA. The more pronounced SWMA in the TECAB group may be a consequence of intrathoracic CO2-insufflation. Both techniques can be applied without significant myocardial ischemia, provided that appropriate intraoperative monitoring is performed, and intrathoracic CO2 pressure in TECAB patients is limited.

Surgeon's occupational exposure to nitrous oxide and sevoflurane during pediatric surgery.

Health hazards from occupational exposure to trace concentrations of anaesthetic 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.

Mountaineering accidents in the European Alps: have the numbers increased in recent years?

OBJECTIVE: Media reports convey the impression that the incidence of fatal accidents in the European Alps has increased. Because more specific data are lacking, we analyzed available data from the mountain rescue services in Germany, Austria, southern Tirol, Zermatt/Switzerland, and Chamonix/France from 1987 until 1997. METHODS: Information was gathered from the annual reports of the Austrian Mountain Rescue Service, the Swiss Alpine Club Rescue Station in Zermatt, the Mountain Rescue Service of the Southern Tirol Alpine Club, the Mountain Rescue Service of the Bavarian Red Cross, and the Department of Mountain Medicine and Traumatology from the Hospital in Chamonix. RESULTS: Although the total number of rescue missions and injured alpinists increased significantly during the period, the number of fatalities retrieved during such rescue missions showed no significant increase. CONCLUSIONS: Even taking into account the varying definitions of "mountain accident" used in these countries, available data from the analyzed areas of the European Alps do not demonstrate a drastic increase in the number of fatalities. In the future, data concerning mountain accidents in the European Alps should be monitored according to standard definitions and stored by the International Commission for Alpine Rescue.

[Preclinic in the hospital. In-hospital emergency and rescue service in a large hospital]. / Präklinik in der Klinik. Innerbetrieblicher Notarzt- und Rettungsdienst an einem Grossklinikum.

BACKGROUND AND OBJECTIVE: Many hospitals have a special resuscitation service that is responsible for life-threatening emergencies outside the hospitals intensive care unit, i.e. in the wards and in patient-treatment areas. In contrast, there is generally no emergency service caring for patients, visitors or personnel outside of these areas. In order to provide emergency medical help in the entire hospital area, in 1999 we instituted an additional in-hospital emergency service to cover the larger hospital area. This paper describes the structure of our in-hospital emergency service and our experience in the first 26 months after its establishment. PATIENTS AND METHODS: We analysed the emergency protocols of all 147 episodes, that had occurred within the first 26 months. We classified them according to type of disease and/or injury by using the NACA score (range 1 to 7) to assess the severity of disease and/or injury. RESULTS: 45 episodes took place within one of the 17 hospital buildings. 92 requests for help came from the hospital service and treatment areas including walkways and passages, while 3 came from the immediate vicinity outside of the hospital. A total of 7 requests turned out to be pranks, and 31.3% responses proved to be unnecessary when the team arrived at the scene. Of the total of 125 treated cases, 30 had a NACA score between 4 and 6, denoting life-threatening injury and/or disease. 6 patients were found dead at the scene or died shortly after arrival of the team. 101 of the patients had to be admitted to the hospital's emergency room. CONCLUSION: Since its establishment, knowledge of the existence of our in-hospital emergency service has steadily increased within the hospital community. As a consequence, number of events have likewise steadily increased. We believe that a total of 20.4% life-threatening events underscores the importance of the service in our large and extended hospital area. We also feel that our adherence to the training and personnel requirements demanded of public emergency services is necessary in order to insure the quality and efficacy of the service. This is also important because of current intentions to use our in-hospital service as a back-up and/or reserve for the community's public emergency services.

Abdominal complications after cardiac surgery.

OBJECTIVE: Abdominal complications after cardiac surgery are associated with a high mortality rate. Due to 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. METHODS: Within 12 months, all patients (n = 1,116) who had undergone open heart surgery with cardiopulmonary bypass at our institution were studied for abdominal complications. To determine predictive factors, all case histories of the patients were analysed. RESULTS: Abdominal complications occurred in 23 (2.1%) patients during the postoperative intensive care unit (ICU) stay, ten of whom had to undergo subsequent abdominal surgery. Of these 23 patients, 20 died. Early complications occurred most likely on postoperative days 6 and 7, consisting of bowel ischaemia or hepatic failure. Late complications consisted of gastrointestinal bleeding, pseudomembraneous colitis, cholecystitis and septic rupture of a spleen. The relative risk for abdominal complications after cardiopulmonary bypass was highly increased in association with a cardiac index less than 2.0 l/min-1/(m2)-1 (22.1-fold), postoperative onset of atrial fibrillation (16.6-fold), emergency surgery (10.7-fold), need for vasopressors (10.1-fold), need for intra-aortic balloon counterpulsation (8.6-fold), and the need for re-exploration within the first 24 hours (8.4-fold). All patients with necrotic bowel disease had elevated serum lactate levels. Furthermore, both cardiopulmonary bypass and aortic clamping times were significantly prolonged in patients who developed gastrointestinal complications. CONCLUSIONS: A number of predictive factors has been described to contribute to the development of abdominal complications subsequently after cardiac surgery on cardiopulmonary bypass. Knowledge of these factors may lead to earlier identification of patients at increased risk and may allow for more efficient and earlier interventions.

Bedside percutaneous tracheostomy: clinical comparison of Griggs and Fantoni techniques.

Elective tracheostomy is widely considered the preferred airway management of patients on long-term ventilation. In addition to open tracheostomy, a number of percutaneous procedures have been introduced during the last two decades, among them techniques according to Griggs (guidewire dilating forceps, or GWDF) and to Fantoni (translaryngeal tracheostomy, or TLT). The aim of the study was to evaluate these two techniques in terms of perioperative complications, risks, and benefits in critically ill patients. A series of 100 critically ill adult patients on long-term ventilation underwent elective percutaneous tracheostomy, either according to the Griggs (n = 50) or Fantoni (n = 50) technique. Tracheostomy was performed under general anesthesia at the patient's bedside. The mean (+/-SD) operating times were short, 9.2 +/- 3.9 minutes (TLT) and 4.8 +/- 3.7 minutes (GWDF) on average. Perioperative complications were noted in 4% of patients during either TLT or GWDF and included massive bleeding, mediastinal emphysema, posterior tracheal wall injury, and pretracheal placement of the tracheostomy tube. With regard to oxygenation, pre- and postoperative arterial oxygen tension divided by the fraction of inspired oxygen (PaO2/FiO2) ratios did not vary significantly, and no perioperative hypoxia was noted regardless of the technique used. We conclude that both TLT and GWDF represent attractive, safe alternatives to conventional tracheostomy or other percutaneous procedures if carefully performed by experienced physicians and under bronchoscopic control.

Occupational exposure to nitrous oxide and desflurane during ear-nose-throat-surgery.

PURPOSE: To determine occupational exposure of the anesthesiologist and surgeon to nitrous oxide and desflurane during general anesthesia for ear-nose-throat (ENT) surgery in children and adults. METHODS: An observational clinical trial was performed in ten children (C) and ten adults (A). Tracheas were intubated, in adults, with cuffed tubes and in children with uncuffed tubes. The operating room was equipped with modern air conditioning and waste anesthetic gas scavengers. Gas samples were obtained during the operative procedure every 90 sec from the breathing zone of subjects. Time-weighted averages (TWA) over the time of exposure were calculated for nitrous oxide and desflurane. RESULTS: Nitrous oxide TWAs for anesthesiologists were 0.41 +/- 0.23 ppm (A) and 1.20 +/- 0.32 ppm (C, P < 0.0001), and 2.24 +/- 1.93 ppm (A) and 5.30 +/- 0.60 ppm (C, P = 0.0001) for the surgeon who worked close to the patient's airway and thus had higher exposure (P < 0.05 [A], P < 0.0001 [C]). With regard to desflurane, the anesthesiologists' TWAs were 0.02 +/- 0.03 ppm for both adults and children. The surgeon was exposed to 0.21 +/- 0.24 ppm desflurane (A) and 0.30 +/- 0.14 ppm (C, P: n.s.). Although the surgeon's exposure was greater (P < 0.05 [A], P < 0.0001 [C]), the threshold limits of 25 ppm for nitrous oxide and 2 ppm for desflurane recommended by the National Institute of Occupational Safety and Health were not exceeded. CONCLUSIONS: Under modern air conditioning, occupational exposure to inhalational anesthetics is low, and inhalational anesthesia is safe from the standpoint of modern workplace laws and health-care regulations.

Percutaneous tracheostomy: ciaglia blue rhino versus the basic ciaglia technique of percutaneous dilational tracheostomy.

UNLABELLED: Percutaneous dilational tracheostomy (PDT), according to Ciaglia's technique described in 1985, has become the most popular technique for percutaneous tracheostomy and is demonstrably as safe as surgical tracheostomy. In 1999, an extensively modified technique of PDT was introduced, the Ciaglia Blue Rhino (CBR; Cook Critical Care, Bloomington, IL), that consists of one-step dilation by means of a curved dilator with hydrophilic coating. To compare CBR with the basic technique of PDT, we performed a prospective, randomized trial in 50 critically ill adults. Twenty-five of these patients had PDT, and 25 had CBR. Average operating times were <3 min for CBR (range: 50-360 s) and <7 min for PDT (range: 4-20 min; P<0.0001). Tracheostomy was successfully completed in all patients. When CBR was performed, 11 minor, nonlife-threatening complications were noted: nine fractures of tracheal cartilage and two short periods of intraoperative oxygen desaturation. During PDT, seven complications occurred, of which three were potentially life-threatening: two injuries to the posterior tracheal wall, one pneumothorax, two tracheal cartilage fractures (P< 0.05 vs CBR), one case of bleeding, and one short episode of intraoperative oxygen desaturation. Regardless of whether PDT or CBR was performed, oxygenation was not significantly affected, and there was no infection of the tracheostoma. Based on our data, we conclude that new CBR is more practicable than PDT. No life-threatening complications occurred during CBR. IMPLICATIONS: To assess practicability and safety of the Ciaglia Blue Rhino (Cook Critical Care, Bloomington, IL)-an extensively modified technique of percutaneous dilatational tracheostomy-50 critically ill adults on long-term ventilation underwent either new Ciaglia Blue Rhino or percutaneous dilatational tracheostomy in a prospective, randomized clinical trial.

Pharmacodynamics and tolerability of acetyl starch as a new plasma volume expander in patients undergoing elective surgery.

OBJECTIVE: Acetyl starch (ACS) is a new synthetic colloid solution for plasma volume expansion and is now undergoing phase II clinical trials. We compared the pharmacodynamics and tolerability of ACS with those ofhydroxyethyl starch (HES) in 32 patients (American Society of Anesthesiologists physical status I and II) undergoing elective surgery. SUBJECTS, MATERIAL AND METHODS: In this prospective, randomized, double-blind trial patients received either 15 ml/kg ACS 6% (average molecular weight (Mw) 200,000/molar substitution (MS) 0.5) or HES 6% (Mw 200,000/MS 0.5) i.v. up to a maximum dose of 1000 ml. Hemodynamic parameters, rheologic parameters, volume effect, acid-base status as well as effects on hemostasis were studied. RESULTS: After infusion of ACS and HES there was a similar increase in central venous pressure and mean arterial pressure in both groups. Acid-base status was not significantly altered after the end of the colloid infusions. After ACS infusion, plasma acetate concentration increased from 0.13+/-0.16 mg/dl to 2.87+/-1.13 mg/dl, however, after 24 h there was no significant difference in plasma acetate concentration compared to HES. The volume effect ranged from 104-116%(ACS) and from 88-118% (HES) of the colloid dose administered. These differences were not statistically significant. Partial thromboplastin time (aPTT) was only slightly increased after ACS infusion (from 38.6+/-5.7 sec to 41.4+/-5.1 sec), but was significantly increased after HES infusion (from 38.7+/-5.7 sec to 46.1+/-7.0 sec). CONCLUSION: ACS and HES are equally effective plasma volume expanders; ACS might be a new, alternative colloid solution with fewer coagulation side-effects than HES.

[Special anesthesiologic features in minimally invasive heart surgery]. / Anästhesiologische Besonderheiten bei minimalinvasiver Herzchirurgie.

When heart-lung machines made extracorporeal circulation possible in the fifties, cardiac surgeons gained virtually unrestricted access to the resting, motionless heart. Valve repair and reconstruction, in particular, made great progress as a result of extracorporeal circulation. While the distinct advantages of extracorporeal circulation for cardiosurgery remain undisputed, awareness of the significant perioperative risks of extracorporeal circulation for the patient has been increasing in recent years. This has lead to an interest in alternative cardiosurgical techniques avoiding extracorporeal circulation. Inspired by minimally-invasive procedures in abdominal surgery, cardiosurgical instruments as well as surgical techniques of access to the heart and large thoracic vessels were systematically modified leading to today's minimally-invasive cardiosurgical procedures such as off-pump coronary artery bypass grafting on the beating heart. Similarly, in the field of cardiac valve repair, new cannulation techniques for instituting extracorporeal circulation make median sternotomy unnecessary. The developments described above have lead to the recent introduction of robot-assisted techniques with or without extracorporeal circulation, which are expected to make possible in the near future the performance of the whole range of cardiosurgical procedures with minimal surgical trauma. The introduction of the new techniques has changed the intraoperative responsibilities of the anesthesiologist. The present article will therefore describe both the new surgical techniques as well as the new tasks required of the anesthesiologist, in particular with regard to cannulation and monitoring. Since a number of terms in minimally-invasive cardiosurgery are not precisely defined, a clear description of the various surgical techniques is also provided.

Translaryngeal tracheostomy in highly unstable patients.

Percutaneous tracheostomy is a widely accepted and commonly performed technique for attaining long-term airway access in critically ill patients. However, severe respiratory failure and coagulopathy are relative contraindications for these procedures. We describe two patients with severe respiratory failure and inhibitor-complicated haemophilia A who underwent elective percutaneous tracheostomy performed translaryngeally, using the new Fantoni technique. Apart from two minor bleeding episodes in the haemophilic patient which were controlled promptly, no other complications occurred. If certain precautions are observed carefully, we believe that translaryngeal tracheostomy is a procedure which is superior to other percutaneous techniques and safe even in patients with severe respiratory failure and coagulopathy.

Early percutaneous tracheostomy after median sternotomy.

OBJECTIVE: Tracheostomy offers significant advantages over endotracheal intubation in patients requiring long-term assisted ventilation. However, in patients who have undergone median sternotomy, it is believed that the danger of microbial contamination and consecutive infection of the sternal wound with microbes from the tracheostomy is high when conventional tracheostomy is performed. In contrast, percutaneous techniques are less likely to result in tracheostomy infection and thus bacterial contamination of neighboring structures. Nonetheless, to date there has been no prospective study confirming or disproving this assumption. Our study evaluated outcome after percutaneous tracheostomy in patients with a median sternotomy. METHODS: A total of 144 cardiac surgical patients had elective percutaneous tracheostomy at the bedside until postoperative day 14, with 4 different techniques. Systematic microbiologic monitoring of the sternal and tracheal wounds was used. RESULTS: In 13 patients sternal wound infection was suspected, but was confirmed in only 4 (2.8%) patients who actually showed microbial contamination of the sternum. In 2 of these patients, the identified microbes were not identical to those cultured from the trachea. The other 2 patients had sternal and tracheal cultures positive for methicillin-resistant Staphylococcus aureus. Cross-contamination of the sternotomy with microbes from the patient's airways was therefore ruled out. No patient had clinical signs of tracheostomy infection. Likewise, there were no cases of mediastinitis. CONCLUSIONS: On the basis of our data, we conclude that cross-contamination of the sternal wound with microbes from the trachea is not a problem. Elective percutaneous tracheostomy is safe, even if performed during the first 14 days after median sternotomy.

Translaryngeal tracheostomy: two modified techniques versus the basic technique--early experience in 75 critically ill adults.

OBJECTIVES: Elective tracheostomy is an established procedure in the management of ICU patients on long-term ventilation. In addition, percutaneous tracheostomy techniques are increasingly being used. In 1997, Fantoni's translaryngeal technique (TLT), another minimally invasive procedure, was introduced. While clinical studies of TLT showed that the technique is safe and can be performed rapidly, technical difficulties which sometimes led to prolonged operating times were also noted. Our study compared the basic TLT technique to a modified TLT approach and to TLT performed with the manufacturer's new, improved "Straight Cannula" set. Twenty-five patients were enrolled in each group, and the advantages and disadvantages of the respective techniques were evaluated. SETTING: Surgical ICU of a university hospital. PATIENTS: Seventy-five adult, surgical intensive care patients. MEASUREMENTS AND RESULTS: Average operating times with the modified TLT techniques were significantly shorter, 4 and 5 min respectively, as compared to 11 min for the basic TLT technique. Initially, use of the new, improved TLT set resulted in a complete passage of the tracheal cannula in two patients; uneventful Griggs's tracheostomy was performed instead. Regardless of the technique used, no other perioperative complications were noted and the perioperative gas exchange remained unaffected by the tracheostomy procedure. CONCLUSIONS: The modified TLT procedures are safer and more readily performed than the basic technique. Difficulty in the retrograde passage of the guide wire was seen only occasionally with the modified techniques. Based on our data we conclude that the modified techniques are superior to the basic technique and represent significant progress in TLT.