Levosimendan mitigates coagulopathy and organ dysfunction in rats with endotoxemia.

BACKGROUND: In patients with severe sepsis, pro-inflammatory cytokines and subsequent activation of tissue factors trigger a cascade of events that lead to coagulation dysfunction and multiple organ failure. It has been shown that levosimendan has protective effects against tissue injury caused by endotoxin. The purpose of this study was to evaluate the effects of levosimendan on consumptive coagulopathy and organ dysfunction in an endotoxemic animal model induced by lipopolysaccharide (LPS). METHODS: Forty-six male adult Wistar rats were randomly divided into four groups: 1) control group (n = 10), an intravenous infusion of 5% dextrose 1.2 mL/kg for 20 min and 0.03 mL/kg/min for 4 h; 2) the levosimendan-treated control group (n = 12), an intravenous levosimendan infusion (24 µg/kg for 20 min plus 0.6 µg/kg/min for 4 h); 3) the LPS group (n = 12), an intravenous LPS (4 mg/kg) infusion followed by dextrose administration; and 4) the levosimendan-treated LPS group (n = 12), an intravenous LPS infusion followed by levosimendan treatment. Various parameters of hemodynamics, biochemistry, hemostasis and inflammatory response were examined during the experimental period. RESULTS: The administration of levosimendan significantly attenuated (i) consumptive coagulopathy displayed by thromboelastography, (ii) the decreases of platelet count and plasma fibrinogen level, (iii) injury in the lung, liver and kidney, and (iv) the rise in plasma interleukin-6 in rats treated with LPS. CONCLUSION: The treatment of LPS rats with levosimendan was found to reduce organ injury and coagulopathy. These protective effects may be attributed to the anti-inflammatory effects of this drug.

New simulation-based airway management training program for junior physicians: Advanced Airway Life Support.

BACKGROUND: All junior physicians in Taiwan were enrolled into a 3-month post-graduate year 1 (PGY1) course after Severe Acute Respiratory Syndrome (SARS) attack in 2003. AIMS: To develop and evaluate a new airway management training protocol by using an integrated course of lectures, technical workshops and medical simulations. METHODS: In each PGY1 course, the trainees participated in the Advanced Airway Life Support (AALS) program. After 2 h lecture, the trainees were divided into three groups for 4 h technical workshop, including 10 skill stations and medical simulation at the Clinical Skills Resources Center of the hospital at different times. Video-based debriefing and feedback were performed after each simulation. The same scenario was re-simulated after debriefing. Participants' performance was assessed by single global rating and a 5 key actions scoring. RESULTS: A total of 266 junior physicians have been trained with this AALS programs in 2 years. They learned the techniques of airway management, passed the performance checklist of technical workshop, and received higher scores during re-simulation regardless of scoring methods. CONCLUSIONS: The AALS training program can provide methodical and systematic training for junior residents to mature with specialized technical skills and higher-order cognitive skills, behaviors and leadership in airway management.

A modified supraclavicular approach for central venous catheterization by manipulation of ventilation in ventilated patients.

BACKGROUND: Because of overuse and multiple implantations of hemodialysis catheters through internal jugular or subclavian vein (SCV) in patients with chronic hemodialysis, these veins often become stenotic or occlude, therefore necessitating alternative access. We introduce a new technique in ventilated patients for placement of tunneled cuffed chronic hemodialysis catheter: modified supraclavicular approach by cease of ventilation. METHODS: Patients who received implantation of the tunneled cuffed chronic hemodialysis catheters by supraclavicular approach were collected from February 2003 to July 2005. Right subclavian, right innominate or left SCVs were accessed through the supraclavicular approach for catheter insertion. The procedures were performed by certificated anesthesiologists. The following parameters were recorded: co-morbidities, laboratory examinations before the procedure, method for catheterization, duration of procedure, complications related to catheterization and long-term outcome of hemodialysis catheters. RESULTS: Eleven catheters were inserted in nine patients (two patients received twice) by supraclavicular approach during this period. All patients were mechanically ventilated and these catheters (seven at right and four at left) were implanted using the modified supraclavicular approach with lung deflation during venipuncture, advance of guidewire, and insertion of catheter. There were no procedural complications. The average duration of whole procedure was 36.6 minutes (30-45 minutes) and the mean catheter survival days were 62.1 days (13-152 days). The estimated duration was <1 minute of each period of lung deflation. There were no desaturation or pneumothorax during the whole procedure. CONCLUSION: The modified supraclavicular approach with lung deflation for tunneled cuffed chronic hemodialysis catheter in ventilated patients is at least as effective as traditional approach and can be easily performed by surgeons as well as experienced physicians. Based on the results, this simplified technique using lung deflation may be particularly useful to decrease procedural complications.

Instructor-based real-time multimedia medical simulation to update concepts of difficult airway management for experienced airway practitioners.

BACKGROUND: We integrated lecture, real-time multimedia display and medical simulation into a new renewal airway management training protocol for experienced nurse anesthetists. METHODS: Trainees of the Taiwan Association of Nurse Anesthetists from northern Taiwan and junior residents from our department were enrolled into the training program. A 4-hour renewal curriculum in the management of airway emergencies was developed, which consisted of a 2-hour general lecture (including 4 divided sections) and a 2-hour instructor-based real-time multimedia medical simulation of 4 specific techniques. After detailed explanation of each specific instrument at the beginning of each simulation, the instructors demonstrated accurate and successful management of 4 airway crises from clinical experience by using a standardized human patient simulator situated on the stage of the conference room. Meanwhile, real-time display of instructors' performance, responsive physical parameters and images from specific instruments were conducted by video camera and video processor, and projected on a 3-frame screen. Brief summary and feedback were performed after each simulation. Trainees completed a questionnaire 6 months after they participated in the training program. RESULTS: Two hundred and forty-two nurse anesthetists and 13 young residents were trained with this protocol. The questionnaire revealed that the renewal training program was useful. Participants updated their knowledge of difficult airway management, gained more confidence, improved performance, and provided effective assistance in handling airway crises. CONCLUSION: Renewing practice guidelines and teaching airway management skills, especially for difficult airway crises and protection of personnel, continues to be an important issue. Instructor-based real-time multimedia simulation is a fast, useful and systematic renewal educational method for many participants with extensive experience of airway management to update their knowledge about difficult airway management, and acquire improved decision-making and communication capabilities, skills of specific airway management.

Experience of anesthesiologists with percutaneous nonangiographic venous access.

STUDY OBJECTIVE: To compare percutaneous nonangiographic insertion of a venous access device with a standard surgical cutdown insertion technique. DESIGN: Prospective, controlled, randomized study. SETTING: Operating room and anesthesia induction room of a university hospital. PATIENTS: 100 consecutive oncology patients scheduled for intravenous chemotherapy. INTERVENTIONS: Patients were randomized to two groups: (1) The percutaneous group received implantation through the internal jugular vein by experienced anesthesiologists, whereas (2) the surgical group received venous cutdown insertion through the cephalic or subclavian vein by surgeons (n = 50 for each group). MEASUREMENTS: Duration of procedure, long-term device function, complications such as hematoma formation, infection, hemothorax, pneumothorax, and patients' satisfaction with the placement procedure at two months of follow-up were all measured and recorded. MAIN RESULTS: The percutaneous technique was found to have several advantages, including reduced time for insertion and greater patient satisfaction with procedure. The percutaneously implanted devices also had fewer insertion-associated complications. CONCLUSION: The simplified, percutaneous, nonangiographic technique is as effective as the traditional venous cutdown technique and can be safely done by surgeons as well as by experienced physicians who are not surgeons.

Successful management of severe upper airway obstruction during emergence of anesthesia in consequence of fracture of deflated laryngeal mask airway due to biting--a case report.

Biting the laryngeal mask airway during general anesthesia in the absence of a bite block as a forestallment is a common but usually uncomplicated event. We report a young healthy adult female patient who underwent removal of fixation implant in the right elbow under general anesthesia, during the emergence of which she bit and severed the airway tube of the laryngeal mask airway (LMA) after cuff deflation and developed upper airway obstruction in consequence of air blockade by the displaced deflated LMA cuff remaining inside the mouth. Removal of residual part of the LMA in the mouth was successful with propofol re-anesthetization without molestation of 02 saturation. We discuss the management of this critical airway condition resulting from fracture of deflated LMA in the closed mouth.

Intravenous propofol precipitates the hypotension induced by inadvertent epidural thiopental injection.

Administration of improper drugs into epidural space is occasionally present in anesthetic practice. In most instances it would not contribute to significant neurological complications. There had not been severe hypotension reported in the literature in consequence of inadvertent epidural thiopental administration. Here we describe our experience in a case of inadvertent epidural administration of thiopental coinciding with induction of anesthesia with propofol, as a consequence of which profound hypotension was induced, necessitating aggressive inotropic and vasopressive agents to maintain blood pressure. Rapid vascular uptake of thiopental in the epidural space and synergistic action of propofol jointly contributed to the development of the hypotension. Attempts to forestall neurological sequela after the inadvertence seem unnecessary unless apparent symptoms or signs of neurological injury have come upon.