Efficiency of different flows for apneic oxygenation when using high flow nasal oxygen application - a technical simulation.

BACKGROUND: Preoxygenation and application of apneic oxygenation are standard to prevent patients from desaturation e.g. during emergency intubation. The time before desaturation occurs can be prolonged by applying high flow oxygen into the airway. Aim of this study was to scientifically assess the flow that is necessary to avoid nitrogen entering the airway of a manikin model during application of pure oxygen via high flow nasal oxygen. METHODS: We measured oxygen content over a 20-min observation period for each method in a preoxygenated test lung applied to a human manikin, allowing either room air entering the airway in control group, or applying pure oxygen via high flow nasal oxygen at flows of 10, 20, 40, 60 and 80 L/min via nasal cannula in the other groups. Our formal hypothesis was that there would be no difference in oxygen fraction decrease between the groups. RESULTS: Oxygen content in the test lung dropped from 97 ± 1% at baseline in all groups to 43 ± 1% in the control group (p < 0.001 compared to all other groups), to 92 ± 1% in the 10 L/min group, 92 ± 1% in the 20 L/min group, 90 ± 1% in the 40 L/min group, 89 ± 0% in the 60 L/min group and 87 ± 0% in the 80 L/min group. Apart from comparisons 10 l/ min vs. 20 L/min group (p = .715) and 10/L/min vs. 40 L/min group (p = .018), p was < 0.009 for all other comparisons. CONCLUSIONS: Simulating apneic oxygenation in a preoxygenated manikin connected to a test lung over 20 min by applying high flow nasal oxygen resulted in the highest oxygen content at a flow of 10 L/min; higher flows resulted in slightly decreased oxygen percentages in the test lung.

Oxygenation laryngoscope vs. nasal standard and nasal high flow oxygenation in a technical simulation of apnoeic oxygenation.

BACKGROUND: Failed airway management is the major contributor for anaesthesia-related morbidity and mortality. Cannot-intubate-cannot-ventilate scenarios are the most critical emergency in airway management, and belong to the worst imaginable scenarios in an anaesthetist's life. In such situations, apnoeic oxygenation might be useful to avoid hypoxaemia. Anaesthesia guidelines recommend careful preoxygenation and application of high flow oxygen in difficult intubation scenarios to prevent episodes of deoxygenation. In this study, we evaluated the decrease in oxygen concentration in a model when using different strategies of oxygenation: using a special oxygenation laryngoscope, nasal oxygen, nasal high flow oxygen, and control. METHODS: In this experimental study we compared no oxygen application as a control, standard pure oxygen application of 10 l·min- 1 via nasal cannula, high flow 90% oxygen application at 20 l·min- 1 using a special nasal high flow device, and pure oxygen application via our oxygenation laryngoscope at 10 l·min- 1. We preoxygenated a simulation lung to 97% oxygen concentration and connected this to the trachea of a manikin model simulating apnoeic oxygenation. Decrease in oxygen concentration in the simulation lung was measured continuously for 20 min. RESULTS: Oxygen concentration in the simulation lung dropped from 97 ± 1% at baseline to 40 ± 1% in the no oxygen group, to 80 ± 1% in the standard nasal oxygen group, and to 73 ± 2% in the high flow nasal oxygenation group. However, it remained at 96 ± 0% in the oxygenation laryngoscope group (p < 0.001 between all groups). CONCLUSIONS: In this technical simulation, oxygenation via oxygenation laryngoscope was more effective than standard oxygen insufflation via nasal cannula, which was more effective than nasal high flow insufflation of 90% oxygen.

Local anesthetic toxicity: Who is ready for lipid resuscitation? A survey of German Hospitals.

PURPOSE: Toxic reactions to local anesthetics are rare but potentially lethal. In fact, animal studies and case reports demonstrate that the administration of lipid emulsions after initializing cardiopulmonary resuscitation is a promising treatment option. The aim of this study was to determine how many hospitals in Germany are prepared to treat toxic reactions to local anesthetics with lipid infusion and to identify how often and what type of toxic reactions occur and if treatment was successful. Further, we aimed to elucidate if current guidelines lead to more immediate availability of lipid emulsions in direct proximity to the room where regional anesthesia is performed. METHODS: A standardized survey was sent to 1,305 German hospitals. The main question was whether lipid emulsions are readily available and if published guidelines contributed to this availability. Additionally, we asked whether local anesthetic toxicity had already successfully been treated by lipid emulsions and what type of symptoms were treated. RESULTS: We received replies from n = 509 (39%) hospitals. In 338 (66%) of the responding hospitals, lipid emulsions are readily available. Hospitals with standard operating procedures (SOPs) implemented according to published guidelines have lipids significantly more often immediately available than hospitals with just SOPs (chi-square test of independence, p-value < 0.01). Of all responding hospitals 287 (56%) have implemented a SOP for the treatment of toxic reactions to local anesthetics and 196 (39%) of the hospitals introduced the SOP because of the guidelines. In 28 (6%) of the hospitals, local anesthetic toxicity had already caused cardiac arrest with subsequent cardiopulmonary resuscitation in at least one patient. In 132 (26%) hospitals, local anesthetic toxicity had already been treated by infusing lipid emulsions. Of these hospitals 128 (96%) state this therapeutic approach was successful. Treatment with lipid emulsions was performed frequently after prodromal symptoms 83 (63%) were witnessed. CONCLUSIONS: The majority of surveyed German hospitals are prepared to treat toxic reactions to local anesthetics and published guidelines contributed to this preparedness. The infusion of lipid emulsions is a promising measure to deal with toxic reactions to local anesthetics. Since toxic reactions to local anesthetics are potentially lethal, it seems desirable that lipid emulsions are generally available in routine clinical practice. Currently, the treatment of toxic reactions to local anesthetics is mostly performed in situations (e.g. treatment of prodromal symptoms) that are not recommended by current guidelines. Further research is necessary to better define the future use of lipid emulsions in routine clinical practice.

[Specific aspects of anesthesiological management of laser surgery in otorhinolaryngology]. / Besonderheiten des anästhesiologischen Managements bei laserchirurgischen Eingriffen in der Hals-Nasen-Ohren-Heilkunde.

Transoral laser surgery has become a standard procedure in the treatment of benign and malignant neoplasms of the upper aerodigestive tract. As the laser cuts and coagulates simultaneously, intraoperative bleeding is reduced, thus improving visualization of the operative field. However, the specific risks for patients and personnel that are associated with this technique necessitate strict compliance with safety regulations and precautions. The safe anesthesiological and surgical management of such procedures requires explicit knowledge of the risks inherent to laser use, as well as close communication between surgeon and anesthesiologist throughout all operative and perioperative procedures. Although potentially fatal complications are rare, surgeon and anesthesiologist need to be aware of the dangers at all times and have exact knowledge of emergency measures. The use of suitable laser-resistant endotracheal tubes, total intravenous anesthesia and an optimized breathing gas mixture can contribute to minimize the occurrence of complications in otorhinolaryngology laser surgery.

[Specific aspects of anesthesiological management of laser surgery in otorhinolaryngology]. / Besonderheiten des anästhesiologischen Managements bei laserchirurgischen Eingriffen in der Hals-Nasen-Ohren-Heilkunde.

Transoral laser surgery has become a standard procedure in the treatment of benign and malignant neoplasms of the upper aerodigestive tract. As the laser cuts and coagulates simultaneously, intraoperative bleeding is reduced, thus improving visualization of the operative field. However, the specific risks for patients and personnel that are associated with this technique necessitate strict compliance with safety regulations and precautions. The safe anesthesiological and surgical management of such procedures requires explicit knowledge of the risks inherent to laser use, as well as close communication between surgeon and anesthesiologist throughout all operative and perioperative procedures. Although potentially fatal complications are rare, surgeon and anesthesiologist need to be aware of the dangers at all times and have exact knowledge of emergency measures. The use of suitable laser-resistant endotracheal tubes, total intravenous anesthesia and an optimized breathing gas mixture can contribute to minimize the occurrence of complications in otorhinolaryngology laser surgery.

Reporting standard for describing first responder systems, smartphone alerting systems, and AED networks.

Standardized reporting of data is crucial for out-of-hospital cardiac arrest (OHCA) research. While the implementation of first responder systems dispatching volunteers to OHCA is encouraged, there is currently no uniform reporting standard for describing these systems. A steering committee established a literature search to identify experts in smartphone alerting systems. These international experts were invited to a conference held in Hinterzarten, Germany, with 40 researchers from 13 countries in attendance. Prior to the conference, participants submitted proposals for parameters to be included in the reporting standard. The conference comprised five workshops covering different aspects of smartphone alerting systems. Proposed parameters were discussed, clarified, and consensus was achieved using the Nominal Group Technique. Participants voted in a modified Delphi approach on including each category as a core or supplementary element in the reporting standard. Results were presented, and a writing group developed definitions for all categories and items, which were sent to participants for revision and final voting using LimeSurvey web-based software. The resulting reporting standard consists of 68 core items and 21 supplementary items grouped into five topics (first responder system, first responder network, technology/algorithm/strategies, reporting data, and automated external defibrillators (AED)). This proposed reporting standard generated by an expert opinion group fills the gap in describing first responder systems. Its adoption in future research will facilitate comparison of systems and research outcomes, enhancing the transfer of scientific findings to clinical practice.

[Lightning strikes and lightning injuries in prehospital emergency medicine. Relevance, results, and practical implications]. / Blitzschlag und Blitzunfälle in der präklinischen Notfallmedizin. Relevanz, Folgen und praktische Implikationen.

Up to 32.2% of patients in a burn center suffer from electrical injuries. Of these patients, 2-4% present with lightning injuries. In Germany, approximately 50 people per year are injured by a lightning strike and 3-7 fatally. Typically, people involved in outdoor activities are endangered and affected. A lightning strike usually produces significantly higher energy doses as compared to those in common electrical injuries. Therefore, injury patterns vary significantly. Especially in high voltage injuries and lightning injuries, internal injuries are of special importance. Mortality ranges between 10 and 30% after a lightning strike. Emergency medical treatment is similar to common electrical injuries. Patients with lightning injuries should be transported to a regional or supraregional trauma center. In 15% of all cases multiple people may be injured. Therefore, it is of outstanding importance to create emergency plans and evacuation plans in good time for mass gatherings endangered by possible lightning.

[Preclinical treatment of severe burn trauma due to an electric arc on an overhead railway cable]. / Präklinische Versorgung einer lichtbogenbedingten schweren Verbrennung an einer Bahnoberleitung.

Severe burns due to electrical accidents occur rarely in Germany but represent a challenge for emergency physicians and their team. Apart from extensive burns cardiac arrhythmia, neurological damage caused by electric current and osseous injury corresponding to the trauma mechanism are also common. It is important to perform a survey of the pattern of injuries and treat acute life-threatening conditions immediately in the field. Furthermore, specific conditions related to burns must be considered, e.g. fluid resuscitation, thermal management and analgesia. In addition, a correct strategy for further medical care in an appropriate hospital is essential. Exemplified by this case guidelines for the treatment of severe burns and typical pitfalls are presented.

Emergency extracorporeal membrane oxygenation to treat massive aspiration during anaesthesia induction. A case report.

Since first described in 1946 by Mendelson, aspiration of gastric content resulting in severe pulmonary complications is a known hazard of general anaesthesia. We report on a case of massive aspiration of gastric content during induction of general anaesthesia, resulting in severe prolonged hypoxaemia with cardiac arrest, followed by rapid onset of an acute respiratory distress syndrome (ARDS) associated with severe global respiratory insufficiency and severe hypoxia. ARDS was successfully treated using emergency extracorporeal membrane oxygenation within 3 h after the incident.

[Comparison of ready-to-use devices for emergency cricothyrotomy : randomized and controlled feasibility study on a mannequin]. / Vergleich von Fertigsets zur Koniotomie : Randomisierte und kontrollierte Anwendungsstudie am Halsphantom.

BACKGROUND: According to various algorithms of airway management, emergency cricothyrotomy (coniotomy) represents the ultimate step for managing the difficult airway. As most physicians have limited experience with this technique several ready-to-use devices have emerged on the market with the aim of simplifying the procedure. However, they differ in details, such as configuration or the order of particular steps. Therefore, the intention of this randomized and controlled feasibility study was to test various sets and compare them to the classical surgical approach. METHODS: After obtaining informed consent German anesthesiologists who were also board-certified emergency physicians were asked to perform the cricothyrotomy procedure in a cervical mannequin (Frova Crico-Trainer, VBM Medizintechnik) in a randomized order using a scalpel, peripheral intravenous cannula and the commercial devices TracheoQuick, Airfree, Portex-Crico-Kit, Quicktrach I and Quicktrach II. Handling and duration of the procedures were analyzed utilizing the Wilcoxon signed-rank test. A p-value < 0.05 was considered significant. RESULTS: A total of 20 anesthesiologists (11 residents and 9 specialists) with a mean age of 34 years were included in this study and all had the additional qualification of emergency physician, which enabled them to work in prehospital emergency medicine in Germany. Participants had been working in this field for an average of 29.9 months (range 6-84 months) performing a mean of 1.9 24 h shifts per month (range 1-6 shifts/month). Of the participants only 2 (10%) had performed a coniotomy in reality before. In this study surgical coniotomy required a median time of 35.4 s (range 30.0-61.8 s). No significant differences were seen when the cuffed devices Quicktrach II (median: 29.9 s, range 25.0-50.5 s) and Portex-Crico-Kit (median: 46.7 s, range 37.0-67.3 s) were used. A significantly faster airway was established using the non-cuffed devices TracheoQuick (median: 20.2 s, range 11.4-44.7 s), Airfree (median: 22.8 s, range 14.3-33.2 s), Quicktrach I (median: 21.1 s, range 14.5-32.4 s) and the peripheral intravenous cannula (median: 19.2 s, range 10.8-27.8 s). Incorrect tube placements were not observed. CONCLUSION: This study allowed the comparison of surgical coniotomy to several ready-to-use devices in a standardized setting utilizing a reusable plastic mannequin. The interpretation for real emergency conditions is limited as individual anatomy, traumatic alterations of the neck or complications, such as bleeding or damage of important structures were not part of the study objectives. However, all participating emergency physicians successfully used the coniotomy sets provided at the first attempt. No device required significantly more time than the surgical approach. The procedures using cuffed devices lasted longer in comparison to procedures using uncuffed ones; however, this difference would only play a minor role in reality as effective ventilation with minute volumes greater than 7 l/min will only be achieved by a cuffed cannula with a minimum internal diameter of 4 mm. Devices with no cuff or with tube diameters smaller than 4 mm will only allow oxygenation of the patient, which in turn requires an inspiratory oxygen concentration of 100% and a relatively high ventilation frequency.

Current evidence on where to end a fusion within the thoracolumbar junction most preferably - A systematic literature review.

Proximal junctional kyphosis (PJK) is one main complication in the surgical treatment of adult spinal deformities. Ending within the thoracolumbar junction (TLJ) should but cannot always be avoided to reduce the risk for PJK. With this systematic review we sought to define the most preferable vertebra within the TLJ to minimize the risk for PJK and establish recommendations based on our findings. We conducted a systematic literature review by scanning the MEDLINE database in accordance with the PRISMA criteria. All articles addressing primary long-distance dorsal thoracolumbar fusion of at least three segments to treat adult spinal deformities were included. 1385 articles were identified and three were included to this review. The first study showed significantly higher rates of PJK in patients where the construct was extended to T7 or higher when compared to an ending at T11 to L1. The second article stated that an expansion to the TLJ resulted in significantly less surgical revisions due to PJK reduction. On the other hand, the third article found that a fusion of the whole thoracic spine reduces the PJK incidence postoperatively. Even though the most favorable vertebra within the TLJ to avoid PJK best could not yet be determined, our study identifies several principles that represent the current state of evidence for surgical treatment of adult scoliosis. Proper preoperative decision making based on thorough analysis and interpretation of the patient's sagittal alignment parameters can improve the individual outcome critically.

[Estimation of substitution volume after burn trauma. Systematic review of published formulae]. / Abschätzung des Substitutionsvolumens nach Verbrennungstrauma. Systematische Übersichtsarbeit über publizierte Formeln.

BACKGROUND: Fluid resuscitation after severe burns remains a challenging task particularly in the preclinical and early clinical phases. To facilitate volume substitution after burn trauma several formulae have been published and evaluated, nevertheless, the optimal formula has not yet been identified. METHODS: A systematic PubMed search was performed to identify published formulae for fluid resuscitation after severe burns. The search terms "burn", "thermal", "treatment", "therapy" or "resuscitation", "fluid", "formula" and "adult", "pediatric" or "paediatric" were used in various combinations. Analysis was limited to the period from 01.01.1950 to 30.06.2010 and database entries in PubMed (http://www.pubmed.com). Additionally, references cited in the papers were analyzed and relevant publications were also included. Publications and formulae were assessed and classified by two independent investigators. RESULTS: Within the specified time frame eight publications (five original contributions and three book chapters) were identified of which three formulae recommended colloid solutions, four recommended electrolyte solutions and one suggested hypertonic solutions within the first 24 h for fluid resuscitation. Only one formula specifically dealt with fluid resuscitation in infants. CONCLUSION: The identified formulae led to sometimes strikingly diverse calculations of resuscitation fluid volumes. Therefore their use should be monitored closely and clinical values included. Urine output is a well established individual parameter. Use of colloid and hypertonic solutions leads to a reduced total fluid volume but is still controversially discussed.

Preoperative stress and anxiety in day-care patients and inpatients undergoing fast-track surgery.

BACKGROUND: To investigate preoperative levels of stress and anxiety in day-care patients and inpatients undergoing surgical interventions. METHODS: Before induction of anaesthesia, the degree of stress and anxiety was assessed in 135 patients using stress and anxiety questionnaires, bio-feedback, physiological measures, and serum levels for stress variables. Questionnaire responses and physiological measures such as arterial pressure, heart rate, skin conductance, cortisol, and catecholamine levels were compared for day-care patients and inpatients. RESULTS: Significant preoperative anxiety was reported by 34 (45.3%) inpatients and 23 (38.3%) day-care patients. Personal responses in stress and anxiety questionnaires and mean values of arterial pressure and heart rate did not differ significantly in day-care patients when compared with inpatients. Correlation between deviations in plasma cortisol concentrations from normal diurnal distribution and anxiety scores and stress scores was also similar, and the relative increase in preoperative stress variables and measures observed in day-care patients and inpatients was also comparable. Bio-feedback measurements revealed significantly higher preoperative skin conductance (P<0.001) in day-care patients than in inpatients, indicating increased vegetative stress responses. CONCLUSIONS: Preoperative anxiety and stress are common in surgical patients. Questionnaires and bio-feedback measurements may help to assess the degree of patients' burdens. Surgeons should be aware of the personal anxiety of patients and consider patient preferences when deciding who should undergo fast-track surgery in day-care.

[Resuscitation 2015-the new guidelines]. / Reanimation 2015 - das sind die neuen Leitlinien.

Sudden cardiac arrest is amongst the major causes of death in industrialized countries. The patient's prognosis however is still very serious. Because diagnosis and therapy in medicine constantly undergo further development, guidelines on cardiopulmonary resuscitation are updated und published frequently, to ensure that every patient receives the best state of the art medical therapy and consequently has the best chances to survive. On October 15, 2015, the new guidelines on cardiopulmonary resuscitation were published. This article gives a short summary of the most important changes.

[Thrombolysis during cardio-pulmonary resuscitation]. / Thrombolyse während der kardiopulmonalen Reanimation.

Sudden cardiac death is a leading cause of death in Europe. In the vast majority, myocardial infarction or pulmonary embolism is the underlying cause. Lethality is still high, especially if the arrest occurs out of hospital. For these two severe conditions, thrombolysis has proven to be an established therapy. Coronary perfusion is restored or the occlusion in the pulmonary arteries is removed, restoring normal circulation and normalising right-ventricular afterload. Nevertheless, thrombolysis was contraindicated during cardio-pulmonary resuscitation (CPR) for many years due to the fear of severe bleeding complications. Case reports and series using thrombolysis as successful ultima ratio therapy during prolonged CPR were soon followed by retrospective and interventional studies. These trials showed significantly improved survival for patients after thrombolysis during CPR. Nevertheless, none of these trials was randomised. Other trials showed that bleeding complications do not occur more frequently after thrombolysis during CPR. Experimental investigations demonstrated that thrombolysis during CPR improves cerebral microcirculation. The results of the randomised, multicenter trial TROICA show that tenecteplase alone, does not significantly improve survival. Further studies on thrombolysis during CPR with additional administration of heparin and acetylsalicylic acid must follow to ascertain the role of thrombolysis during CPR. Although thrombolysis during CPR is not a standard therapy, it should not be withheld from patients in whom pulmonary embolism is the suspected cause of cardiac arrest, as well as in selected other patients on the physician's individual decision according to recent guidelines.