Unrestricted drinking before surgery: an iterative quality improvement study.

Average pre-operative fasting times for clear liquids are many times longer than those specified in national and international guidelines. We sought to decrease fasting times by applying a quality management tool aimed at continuous improvement. Through the application of iterative 'plan-do-study-act' cycles, tools to reduce pre-operative liquid fasting times were developed and applied, the effects measured, analysed and interpreted and the conclusions used to inform the next plan-do-study-act cycle. The first step was the introduction of unrestricted drinking until the patient was called to the operating theatre, with training of anaesthetic staff, adaption of local standard procedures and verbal information for patients. This did not result in short liquid fasting times, median (IQR [range]) 12.0 (9.5-14.0 [0.8-23.5]) h. In the second cycle, fasting cards were introduced as a subliminal written training tool for staff, patients and their relatives. This enabled short liquid fasting times to be achieved for outpatients (2.6 (0.8-5.1 [0.3-16]) h) and pre-admission patients (3.4 (1.8-9.4 [0.2-17.2]) h), but not for inpatients (6.5 (2.0-11.7 [0.2-16.2]) h). The third cycle included lectures for ward staff, putting up information posters throughout the hospital, revision of all written materials and provision of screencasts on the homepage for staff and patients. This decreased median liquid fasting time to 2.1 (1.2-3.8 [0.4-18.8]; p < 0.0001) h, with inpatients having the shortest fasting time of 1.4 (1.1-3.8 [0.4-18.8]) h. Repeated quality improvement cycles, adapted to local context, can support sustained reductions in pre-operative liquid fasting times.

[Second generation laryngeal masks : expanded indications]. / Larynxmasken der zweiten Generation : Erweiterte Indikationen.

Since the development of the classic laryngeal mask airway (LMA) in the late 1980s, there has been a continuous increase in the frequency of its use as well as areas of application. While contraindications to its use for elective procedures must be recognized, there are an increasing number of clinical studies on expanded indications for the use of supraglottic airway (SGA) devices, particularly those of the second generation. The present article describes the added features of the second generation LMAs, with special emphasis on the behavior of these devices in position and performance tests. An appraisal is conducted based on the currently available literature on the value of the utility for indications, such as prolonged use, laparoscopic surgery, obesity, prone position and Cesarean section.

[Measurement of carbon dioxide in emergency medicine]. / Kohlenstoffdioxidmessung in der Notfallmedizin.

Expiratory carbon dioxide (CO(2)) monitoring is a valuable tool in the prehospital setting. Recent reports of misplaced endotracheal tubes in the prehospital setting make it important to ensure that tube placement is verified by CO(2) monitoring. The Euronorm 2007:1789 made provision of capnometry mandatory for all medical vehicles. However, the frequency of utilization of CO(2) monitoring after securing the airway and in patients with respiratory insufficiency is low. This article covers the terminology, physiology, technology and clinical applications of CO(2) monitoring. Monitoring of cardiac output and the efficiency of cardiopulmonary resuscitation are described and the article also highlights the importance of CO(2) monitoring in patients with severe head trauma as well as restrictive and obstructive pulmonary disorders.

[Extraglottic airway devices in the intensive care unit]. / Extraglottische Atemwegshilfen auf der Intensivstation.

Extraglottic airway devices (EGA) are not only used in routine anaesthesia practice, they also have a distinct value for in-hospital and out-of-hospital difficult airway management. In the environment of the intensive care unit (ICU) EGA are not used on a regular basis. However, expertise and knowledge regarding EGA coming from the operating theatre or the out-of-hospital setting may also be of value for the ICU setting. This review presents the potential indications for EGA on the ICU for the management of difficult airway situations as well as during percutaneous tracheotomy. Furthermore, the possible advantages of EGA during postoperative recovery from anaesthesia as well as termination of controlled ventilation for intensive care patients are discussed.

[AnaConDa as last resort treatment. Case report of a chronic obstructive pulmonary disease]. / AnaConDa als Ultima-Ratio-Therapie. Fallbericht einer chronisch obstruktiven Lungenerkrankung.

Treatment of patients suffering from decompensated chronic pulmonary disease (COPD) not responding to pharmacological therapy is still a major challenge in intensive care medicine. Administration of volatile anaesthetics may be a therapy of last resort in these cases. We report on a 65-year-old woman suffering from exacerbated COPD, who could not be sufficiently ventilated despite comprehensive pharmacological therapy. In order to administer a volatile anaesthetic in the ICU, we employed the "Anaesthetic Conserving Device" (AnaConDa) consisting of a vaporizer chamber embedded in a charcoal filter system. With this device, every standard intensive care ventilator can be used to deliver volatile anaesthetics in a safe and economic manner. The AnaConDa converts the open breathing system of the intensive care ventilator into a de facto half-closed system. The very low pulmonary compliance of the patient increased dramatically after administration of 0.75 vol% halothane for 48 h (27 vs. 150 ml/mbar). Elimination of CO(2) was improved and weaning from controlled ventilation was achieved. After surgical removal of a pulmonary abscess and a total of 78 days of intensive care therapy, the patient was discharged in good health.

Laryngoscopic versus intubating LMA guided tracheal intubation by novice users--a manikin study.

AIM OF THE STUDY: Airway control is a potentially lifesaving procedure but tracheal intubation by direct laryngoscopy is difficult. This pilot study was conducted to determine whether tracheal intubation was more rapid and the success rate higher using an intubating laryngeal mask airway. MATERIAL AND METHODS: The success rates of 119 medical students without prior airway management experience in ventilating and then intubating the trachea of a Laerdal Airway Management Trainer with two different methods were compared. The methods were bag-mask ventilation (BM-V) followed by laryngoscopic intubation (LG-TI), and intubating laryngeal mask ventilation (ILMA-V) followed by ILMA-guided tracheal intubation (ILMA-TI). After an introductory lecture and demonstration, each student was allowed three attempts to intubate using each method in random order. RESULTS: All participants were successful with BM-V and ILMA-V on the first attempt. Laryngoscopic tracheal intubation was achieved by 60 (50.4%), 31 (26.1%) and 12 (10.1%) participants on the first, second and third attempt, respectively, while 16 (13.4%) failed in all three attempts. In the ILMA-TI group, 107 (90.0%), 10 (8.4%) and 2 (1.6%) succeeded on the first, second and third attempt, respectively. None failed. The intergroup difference is highly significant (p<0.001). Male participants were more successful with LG-TI than female (p<0.01), but not with ILMA-TI. CONCLUSION: Laryngoscopic orotracheal intubation is difficult for the untrained, but all participants were successful with ILMA-TI. These data suggest that alternative devices such as the ILMA should be included in the medical school curriculum for airway management.

[The serotonin syndrome. Fatal course of intoxication with citalopram and moclobemide]. / Das Serotoninsyndrom. Tödlicher Verlauf einer Intoxikation mit Citalopram und Moclobemid.

The serotonin syndrome is caused by a drug-induced increase of the intrasynaptic serotonin concentration. Milder forms of the syndrome may be difficult to diagnose because of the variability of symptoms. Severe forms often rapidly turn into a life-threatening situation, therefore the serotonin syndrome may be a challenge for physicians. We describe the pathophysiology and therapeutic options of the serotonin syndrome and report about a 42-year-old female patient who ingested large amounts of moclobemide, a monoamine oxidase inhibitor, and citalopram, a selective serotonin reuptake inhibitor, for attempted suicide. Within a few hours the patient developed a lethal serotonin syndrome although ICU therapy was initiated immediately.

[New perspectives for simulator-based training in paediatric anaesthesia and emergency medicine]. / Neue Perspektiven der simulatorunterstützten Ausbildung in Kinderanästhesie und Kindernotfallmedizin.

Anaesthesia and emergency medical care for infants and toddlers is often associated with high clinical demands and specific challenges. Nevertheless, a significant proportion of interventions is performed by anaesthetists and emergency physicians with no specialised paediatric training and little experience in the management of anaesthetic incidents and emergencies specific to these age groups. Extensive studies have demonstrated a close inverse correlation between the level of specialisation and perioperative morbidity and mortality. However, clinical circumstances and the relatively small number of paediatric cases at many institutions often hinder the establishment of improved training concepts. Recently, high-fidelity infant simulators have become available, which permit authentic exposure to a large spectrum of scenarios in paediatric anaesthesia and emergency medicine. A multimodular concept of training, including such simulator-based techniques, may relieve the widespread shortage in clinical experience, and hence greatly facilitate improvement of quality of care and patient safety.

The aromatase inhibitor, 4-hydroxyandrostenedione, restores immune responses following trauma-hemorrhage in males and decreases mortality from subsequent sepsis.

Studies have shown that immune responses are depressed in male mice, but not in proestrus females after trauma-hemorrhage (TH), resulting in increased mortality from subsequent sepsis in male mice compared with female mice. These gender-specific alterations in immune function are believed to be due to differences in sex steroid levels. Aromatase is a key enzyme in the sex steroid biosynthesis. Although earlier studies have shown that aromatase inhibitors prevent thymic atrophy in aged male rats, it remains unknown whether the use of 4-hydroxy-androstenedione (4-OHA) after TH in male mice has any salutary effects on the depressed immune responses. Male C3H/HeN mice were sham operated or subjected to trauma (i.e., midline laparotomy) and hemorrhagic shock (30+/-5 mmHg for 90 min) followed by adequate fluid resuscitation. 4-OHA (5 mg/kg) or vehicle was administrated s.c. just before resuscitation. At 2 h after resuscitation, the mice were killed, and spleens were harvested. Splenocyte proliferation, interleukin (IL-2), interferon (IFN-gamma), and IL-10 release and expression of androgen (AR) and estrogen receptors (ER)-alpha and -beta by immunoblot and reverse transcription-polymerase chain reaction (RT-PCR) were assessed. In another group, sepsis was induced by cecal ligation and puncture (CLP) 3 days after resuscitation, and survival was measured over a period of 10 days. A significant decrease in splenocyte proliferation, IL-2, and IFN-gamma release and increased release of IL-10 were observed in vehicle-treated mice. Animals treated with 4-OHA showed increased splenocyte proliferation, IL-2, and IFN-gamma release, and decreased IL-10 release. Immunoblot analysis showed decreased expression of the cytosolic AR, but no significant difference in the cytosolic and nuclear ER-alpha and -beta expression was observed in the vehicle-treated group after TH. In addition, AR and ER-beta mRNA expression was increased, whereas ER-alpha expression decreased in the vehicle-treated group after TH. ER-alpha expression decreased and ER-beta expression increased in the nucleus of 4-OHA treated mice as determined by immunoblot. There was no difference in the cytosolic AR expression in the 4-OHA-treated group after TH. AR and ER-beta mRNA expression was unaffected, whereas ER-alpha expression increased under such conditions. In additional groups, the increased mortality rate after TH and subsequent sepsis was significantly reduced by 4-OHA treatment. Thus, 4-OHA seems to be a novel and useful adjunct for restoring the depressed immune functions in males after TH and for decreasing mortality rates from subsequent sepsis.

[Experimental studies on the course and consequences of infection with Graphidium strigosum (Nematoda, Trichostrongylidae) in Oryctolagus cuniculus (domestic rabbit)]. / Experimentelle Untersuchungen über Verlauf und Auswirkungen des Befalls mit Graphidium strigosum (Nematoda, Trichostrongylidae) bei Oryctolagus cuniculus (Hauskaninchen).

After oral infection of domesticated rabbits with 1,500 Graphidium strigosum-larvae III third-stage larvae were discovered in the stomach during the next 6 d, fourth-stage larvae from the 8th d and mature nematodes from the 34th d onwards. In 26 rabbits infected with 75...2,000 larvae III the prepatent period of Graphidium strigosum-infestation varied from 40 to 60, in most cases from 40 to 50 d. After one oral infection with 500...1,000 Graphidium strigosum-larvae III 3-month old domesticated rabbits showed no clinical symptoms, their performance was impaired but only insignificant and a population of 154 to 765 mature nematodes parasitizing in the stomach caused a gastritis catarrhalis chronica, partly a fibrosing gastritis.

[Experimental studies on the course and the effects of pediculosis in domestic swine]. / Experimentelle Untersuchungen über Verlauf und Auswirkungen des Läusebefalls beim Hausschwein.

Weaned piglets, aged between six and eight weeks, underwent one single experimental infection, using few imaginal stages as well as second and third larval stages of Haematopinus suis. Louse populations of various densities developed on animals of the same litter under the same keeping and feeding conditions. No unambiguous reduction in body weight increase was observed throughout the two months of the experiment. Even pigs with 2,107 or 2,135 adult lice and their larval stages were not affected. Some of the pigs developed allergic dermal inflammations in the course of pediculosis and suffered from considerable aggravation of pruritus which used to be of minor importance before. Excessive rubbing, in response to that itching, led to mechanically caused skin lesions, some of them bleeding.

[Course of the parasite phase of development of Trichostrongylus axei (Cobbold, 1879) Railliet et Henry, 1909, in the domestic rabbit]. / Untersuchungen über den Ablauf der parasitischen Entwicklungsphase von Trichostrongylus axei (Cobbold, 1879), Railliet et Nenry, 1909, im Hauskaninchen

Rabbits of the New Zealand White and Small Chinchilla breeds were each infected at 3-4 months of age with 4-10 thousand invasive trichostrongyle larvae. Prepatent period of the infection was 22-32 days. Third-stage larvae were present up to the 6th day of infection, fourth-stage from the 8th day, fifth-stage from the 14th day and sexually mature trichostrongyles on the 18th day. The period of patency of the infection lasted for over a year, but only small numbers of eggs were passed in faeces, and food intake was not affected. Between 14 and 44% of the third-stage larvae developed into sexually mature nematodes, regardless of infection dose or duration of infection.