A comparison of the McGrath videolaryngoscope with direct laryngoscopy for rapid sequence intubation in the operating theatre: a multicentre randomised controlled trial.

Aspiration of gastric contents is a recognised complication during all phases of anaesthesia. The risk of this event becomes more likely with repeated attempts at tracheal intubation. There is a lack of clinical data on the effectiveness of videolaryngoscopy relative to direct laryngoscopy rapid sequence intubation in the operating theatre. We hypothesised that the use of a videolaryngoscope during rapid sequence intubation would be associated with a higher first pass tracheal intubation success rate than conventional direct laryngoscopy. In this multicentre randomised controlled trial, 1000 adult patients requiring tracheal intubation for elective, urgent or emergency surgery were allocated randomly to airway management using a McGrath™ MAC videolaryngoscope (Medtronic, Minneapolis, MN, USA) or direct laryngoscopy. Both techniques used a Macintosh blade. First-pass tracheal intubation success was higher in patients allocated to the McGrath group (470/500, 94%) compared with those allocated to the direct laryngoscopy group (358/500, 71.6%), odds ratio (95%CI) 1.31 (1.23-1.39); p < 0.001. This advantage was observed in both trainees and consultants. Cormack and Lehane grade ≥ 3 view occurred less frequently in patients allocated to the McGrath group compared with those allocated to the direct laryngoscopy group (5/500, 1% vs. 94/500, 19%, respectively; p < 0.001). Tracheal intubation with a McGrath videolaryngoscope was associated with a lower rate of adverse events compared with direct laryngoscopy (13/500, 2.6% vs. 61/500, 12.2%, respectively; p < 0.001). These findings suggest that the McGrath videolaryngoscope is superior to a conventional direct laryngoscope for rapid sequence intubation in the operating theatre.

[Indications for joint replacement : Knee arthroplasty]. / Indikationen zum Gelenkersatz : Knieendoprothese.

Current demographic trends with an increasing number of older patients, have led to a rising number of patients with higher demands on performance. Osteoarthritis in younger patients caused by abnormal forms or accidents also pose new challenges for medical professionals in the orthopedic field. As a rule of thumb, all conservative therapeutic possibilities should be exhausted before starting a surgical intervention. The main aims of surgery are to reduce pain, increase mobility and quality of life. In order to qualify for total knee arthroplasty (TKA) patients must fulfil major and minor criteria; however, after TKA approximately one fifth of patients are not satisfied with the result. In order to reduce this rate, indications should be narrowly set and expectations should be thoroughly discussed with the patient prior to an intervention. The high degree of dissatisfaction must be improved by intensifying efforts in further research.

Intensive care and health outcomes of open abdominal treatment: long-term results of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM).

PURPOSE: The study's purpose is to evaluate the long-term outcome after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) and to identify predictors of quality of life associated with intensive care. METHODS: Fifty-five patients who underwent open abdomen management at our institution from 2006 to 2013 were prospectively enrolled in this study. After a median follow-up period of 3.8 years, 27 patients completed the 36-Item Short Form Survey (SF-36) quality of life questionnaire. As this is a report solely focused on quality of life, direct treatment-related outcome measures like mortality, closure rates, and incisional hernia development of this study cohort have been reported previously. RESULTS: SF-36 physical role (54.6 ± 41.0 (0-100), p < 0.01), physical functioning (68.4 ± 29.5 (0-100), p = 0.01), and physical component summary (41.6 ± 13.0 (19-62), p = 0.01) scores for the patient population were significantly lower than normative scores. Significant correlations were found between physical functioning and total treatment costs (r = -0.66, p = 0.01), total units of packed red blood cells (r = -0.56, p = 0.04), and the complex intensive care scores (r = -0.50, p = 0.02). Simple and multiple regression analyses demonstrated that the complex intensive care score was the only predictor of physical functioning (R 2 = 0.50, ß = -0.70, p = 0.02). CONCLUSIONS: Despite high short-term mortality and morbidity rates for these critically ill patients, open abdomen treatment using VAWCM allows patients to recover to an acceptable long-term quality of life. The complex intensive care score can be used as a surrogate parameter for the global severity of illness and was the only predictor of physical functioning (SF-36).

Primarily conservative treatment for triple (A2-A3-A4) finger flexor tendon pulley disruption.

Triple finger flexor tendon pulley injuries (A2-A3-A4) are generally reconstructed due to the considerable extent of bowstringing and resulting loss of range of motion (ROM). We present a series of 11 patients (12 cases) with triple pulley lesions. Six cases were diagnosed acutely (<2 weeks after injury), one subacutely (4 weeks), 3 late (>2 months) and 2 incidentally (asymptomatic). All patients but one were climbers. All acute and subacute patients were initially treated with two-pulley protection splint at the centre of the middle and proximal phalanx, proximal interphalangeal (PIP) joint extension splints for 2 months and had occupational therapy to prevent extension deficit. At 6 months' follow-up, the 6 patients with acutely and the 1 subacutely diagnosed injuries were back climbing at the same level. Almost no pain or restriction in daily activities remained; they had full flexion but a slight extension deficit (0-25°). Two of the three patients who were seen and diagnosed late had secondary pulley reconstruction because of persistent pain and increased extension deficit in the PIP joint. Both patients gained almost full range of motion without remaining pain. The third patient was asymptomatic with an extension deficit of 30°. Our case series suggests that early conservative treatment in acute and subacute triple pulley ruptures holds promise to decrease bowstringing, regain full flexion and return to pre-injury climbing level. Delayed diagnosis with delayed treatment is associated with less favorable results. Secondary pulley reconstruction of these chronic injuries yields good results even when performed months after the injury occurred.

[Effect of different training methods on the use of the i-gel laryngeal mask by lay persons on a manikin]. / Auswirkung verschiedener Ausbildungsmethoden auf die Anwendung der i-gel®-Larynxmaske durch Laien am Phantom.

BACKGROUND: Several studies have described the successful application of extraglottic airways by lay people to a phantom. OBJECTIVES: This study examined the influence of the training method on the success of the application. METHODS: A total of 150 visitors of a shopping mall were asked to place an i­gel laryngeal mask (Intersurgical GmbH, Sankt Augustin, Germany) on a manikin. The short instruction was randomized and performed either as a practical demonstration or through the self-study of an illustrated manual. RESULTS: Application success in the first attempt was 95.8 % for the practical demonstration group and 78.5 % for the written instruction group (p = 0.001). Placement times were also significantly different (median 11.5 s vs. 22.5 s, p < 0.001). CONCLUSIONS: Learning success can be achieved with both training methods. Initially, a hands-on training should be carried out with a practical demonstration.

Artificial ventilation for basic life support leads to hyperventilation in first aid providers.

The 'Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - International Consensus on Science' recommend an artificial ventilation volume of 10 ml/kg bodyweight (equivalent to a tidal volume of 700-1000 ml) without the use of supplemental oxygen in adults with respiratory arrest. For first aid providers using the mouth-to-mouth or mouth-to-nose-ventilation technique, respectively, a ventilation volume of approximately 9.6 l/min results. Additionally, a deep breath is recommended before each ventilation to increase the end-expiratory oxygen concentration of the air exhaled by the first aid provider. To investigate the effects of these recommendations in healthy volunteers, test persons were asked to ventilate an artificial lung model for a period of up to 10 min. The tidal volume was set at 800 ml at a breathing rate of 12/min. End-tidal carbon dioxide, oxygen saturation (measured by pulse oximetry), and heart rate were measured continuously. Capillary blood gas samples were collected and non-invasive blood pressure readings were recorded prior to the start of ventilation and immediately after the end of the measuring period. The data reveal a statistically significant and clinically relevant decrease in end-tidal carbon dioxide pressure (P<0.001, median decrease 14 mmHg), and the occurrence of hyperventilation-associated symptoms such as paraesthesia, dizziness, and carpopedal spasms in more than 75% of the participants. Clinically and statistically significant hyperventilation results in first aid providers performing artificial ventilation according to the guidelines. This artificial ventilation is associated with a significant decrease in capillary and end-tidal carbon dioxide pressure as well as with multiple symptoms of an acute hyperventilation syndrome. Ventilation performed according to these guidelines may cause injury to the health of the first aid provider. Rescuers ventilating the victim should be replaced at regular intervals and the recommendation to take a deep breath before each ventilation should not be upheld in order to minimise the risk of hyperventilation.