[Triage protocols for mass casualty incidents : An overview 30 years after START]. / Sichtungskonzepte bei Massenanfällen von Verletzten und Erkrankten : Ein Überblick 30 Jahre nach START.

BACKGROUND: Since the publication of the first mass casualty triage protocol approximately 30 years ago, numerous adaptions and alternatives have been introduced and are currently in use throughout the world. This variety may represent a challenge for the cooperation between emergency medical providers and the interoperability of emergency medical services often required during mass casualty incidents. To enhance cooperation and interoperability a standardization of triage protocols is required. OBJECTIVES: This survey was carried out in order to identify and characterize published triage protocols on national and international levels. Furthermore, evidence for validation of the identified triage algorithms was discussed and recommendations for standardization of triage protocols are given. MATERIAL AND METHODS: In a systematic literature search 59 relevant articles were identified and evaluated with respect to the given objectives. RESULTS: A total of 12 triage concepts were identified and characterized which are categorized according to the basic principle. DISCUSSION: The endpoints of the studies, the chosen observation units and the mode of data collection were discussed with respect to their impact on validation. Furthermore, the impact of the degree and dynamics of system capacity overload, which are pathognomonic for mass casualty incidents, were discussed. CONCLUSION: There is not sufficient evidence to declare one of the triage protocols superior in all aspects to the others and no triage protocol has been implemented on a comprehensive level in Germany. In order to initialize a national or regional convergence process towards an interoperability of emergency medical services, the model uniform core criteria for mass casualty triage approach has been identified as being appropriate.

Incidences and predictors of difficult laryngoscopy in adult patients undergoing general anesthesia : a single-center analysis of 102,305 cases.

BACKGROUND: Hypoxemia caused by difficulties in airway management presents a major cause for perioperative morbidity and mortality. The ability to predict difficult laryngoscopy more accurately would enable anesthesiologists to take specific precautions to reduce airway risks and prevent patient-threatening events. METHODS: Over a 6-year period of time, all anesthesia records with a documented direct laryngoscopic view were retrieved from the electronic data management system and statistically processed. The Cormack-Lehane four-point scale of grading laryngoscopy was used to assess visibility of the vocal cords. RESULTS: Of 102,306 cases, the overall rate of difficult laryngoscopy was 4.9 %. Male gender (6.5 %), Mallampati score III and IV (17.3 %), obesity with a BMI ≥35 kg/m(2) (6.1 %), as well as physical status ASA III or IV (6.2 %), were identified as risk factors for difficult laryngoscopy. Patients undergoing surgery in the departments of oromaxillofacial (8.9 %), ear nose throat surgery (ENT) (7.4 %), and cardiac surgery (7.0 %) showed the highest rates of difficult laryngoscopy. CONCLUSIONS: The results indicate that the risk for difficult airway situations might substantially differ between surgical patient groups. In hospitals with departmental structures and spatially separated operating rooms, the deduction might be increased awareness and particular structural preparation for difficult airway situations in the respective subspecialties.

[Perioperative anaesthesiological management in 167  patients undergoing bariatric surgery]. / Perioperatives anästhesiologisches Management bei 167 Patienten mit bariatrischen Eingriffen.

BACKGROUND: In the long run, surgical treatment proves to the most effective measure for the treatment of both morbid adipositas and concomitant morbidity. Patients undergoing bariatric surgical procedures are a challenge to the anaesthesiologist: Obesity-associated morbidity, the potentially difficult airway and intravenous accesses as well as the demand for effective pain and anti-emetic therapy. Interrestingly, only sparse and conflicting data exist about the perioperative anaesthesiological management of these patients. This study retrospectively reviewed the previous perioperative anaesthesiological management and appraised critically the situation in the follow-ing analysis. A potential for improvement should be identified and included into a new SOP via the PDCA cycle of the quality management system. PATIENTS AND METHODS: Retrospectively, peri-operative charts of all patients undergoing gastric banding or gastric bypass procedures within the last five years at our obesity treatment centre were analysed. Anesthesiological treatment be-fore, during and after the bariatric surgery as well as the pain therapy were documented. Adherence to the standard operating procedures, processing -times and qualification of the anaesthesiologist were further specific benchmarks. RESULTS: Overall, 167  patient charts were available for this survey (n = 103 gastric banding and n = 64 gastric bypass). Most of the patients (64 %) had anaesthesiologically relevant co-morbidites. Significant differences between the bypass and the banding groups were found for the median processing times. The need for postoperative opiods differs significantly as well (9 vs. 12 mg Piritramid). No severe anaesthesiological complications occurred. The overall rate of PONV was impressive with 32 %. Based on a pre-existing SOP, even a large number of different anaesthesiologists of various qualification levels was able to conduct anaethesia in a very homogeneous way. CONCLUSION: Bariatric patients are a high risk patient group. Present-day anaesthesiological practice as well as the profound implementation of a SOP could permit safe anaesthesia and a minimised risk for complications. Due to the high PONV rate, a routine perioperative PONV prophylaxis should be implemented.

Precision and accuracy of a new device (CNAPTM) for continuous non-invasive arterial pressure monitoring: assessment during general anaesthesia.

BACKGROUND: Continuous non-invasive arterial pressure measured with CNAP (CNAP) has been shown to be superior to intermittent oscillometric measurements during procedural sedation and spinal anaesthesia. We assessed the performance of CNAP during general anaesthesia by analysis of agreement with invasive measurements of arterial pressure (AP). METHODS: Eighty-eight patients undergoing elective abdominal surgery, cardio-, or neurosurgery were included in the study. Systolic, diastolic, and mean AP measured by an intra-arterial catheter in the radial artery (IAP) were compared with those obtained by CNAP from the same arm. Data were analysed to determine the precision (i.e. measurement error) and accuracy (i.e. systematic error) of beat-to-beat CNAP values with respect to IAP. Also, we compared the frequency of fast changes in AP (FCAP) and hypotension (IOH) by both methods. RESULTS: CNAP precision of 4.5, 3.1, and 3.2 mm Hg (systolic, diastolic, and mean AP, respectively) was not significantly different from IAP precision, and CNAP accuracy was +6.7, -5.6, and -1.6 mm Hg. The frequency of AP pairs having a difference within the calculated limits of agreement was 81%, 64%, and 76% for systolic, diastolic, and mean AP, respectively. The calculated limits of agreement were +/-17.6, +/-11.4, and +/-12.0 mm, Hg, respectively. CNAP and IAP detected simultaneously to 82.1% FCAP and to 84.6% IOH. CONCLUSIONS: CNAP provides real-time estimates of arterial pressure comparable with those generated by an invasive intra-arterial catheter system during general anaesthesia.

Mechanical properties of hyaline and repair cartilage studied by nanoindentation.

Articular cartilage is a highly organized tissue that is well adapted to the functional demands in joints but difficult to replicate via tissue engineering or regeneration. Its viscoelastic properties allow cartilage to adapt to both slow and rapid mechanical loading. Several cartilage repair strategies that aim to restore tissue and protect it from further degeneration have been introduced. The key to their success is the quality of the newly formed tissue. In this study, periosteal cells loaded on a scaffold were used to repair large partial-thickness cartilage defects in the knee joint of miniature pigs. The repair cartilage was analyzed 26 weeks after surgery and compared both morphologically and mechanically with healthy hyaline cartilage. Contact stiffness, reduced modulus and hardness as key mechanical properties were examined in vitro by nanoindentation in phosphate-buffered saline at room temperature. In addition, the influence of tissue fixation with paraformaldehyde on the biomechanical properties was investigated. Although the repair process resulted in the formation of a stable fibrocartilaginous tissue, its contact stiffness was lower than that of hyaline cartilage by a factor of 10. Fixation with paraformaldehyde significantly increased the stiffness of cartilaginous tissue by one order of magnitude, and therefore, should not be used when studying biomechanical properties of cartilage. Our study suggests a sensitive method for measuring the contact stiffness of articular cartilage and demonstrates the importance of mechanical analysis for proper evaluation of the success of cartilage repair strategies.

Feasibility of an endoscopic approach to the submandibular neck region--experimental and clinical results.

We have investigated the feasibility of an exclusively endoscopic approach to the submandibular region in four pigs, four cadavers and two women. We inflated the subplatysmal space with carbon dioxide at low pressure. The submandibular gland and the jugulodigastric region were easy to identify once the correct anatomical space had been dissected and inflated. Four endoscopic resections of the submandibular gland were done successfully.

Neurochemical profile of glioneuronal lesions from patients with pharmacoresistant focal epilepsies.

Gangliogliomas, dysembryoplastic neuroepithelial tumors (DNT) and glioneuronal malformations are frequently encountered in patients with pharmacoresistant focal epilepsies. In order to characterize the neurochemical profile of these neoplastic and malformative glioneuronal lesions, we have examined the presence of the alpha 1 subunit of the GABAA receptor, the N-methyl-D-aspartate receptor subunit 1 (NR1), glutamate decarboxylase, tyrosine hydroxylase, somatostatin, parvalbumin, and calretinin in 60 gangliogliomas, 11 DNT, 10 tuberous sclerosis-like lesions and 17 non-tuberous sclerosis-like glioneuronal malformations. All DNT and tuberous sclerosis-like lesions, 59 gangliogliomas (98%), and 13 non-tuberous sclerosis-like hamartias (76%) were positive for at least one of the markers. Despite a great variation between and within the different entities, the neurochemical profile was generally reminiscent of normal neocortex: glutamate decarboxylase, GABAA receptor and NR1 which are common in neocortical neurons were present in the great majority of the lesions and often showed high labeling indices. There were three tuberous sclerosis-like lesions (30%) that contained both NR1 and glutamate decarboxylase immunoreactive giant cells in addition to well-differentiated ganglion cells. This supports the idea that at least some of these giant cells are of neuronal origin. The oligodendroglia-like cells of DNT and glioneuronal hamartias did not show immunoreactivity for any of the markers. The very high incidence of ganglioglial lesions in patients with chronic focal epilepsies and the presence of neurotransmitter-producing enzymes, neurotransmitter receptors, neuropeptides, and calcium-binding proteins in many of these lesions suggests that they may play an active role in the pathogenesis of epileptic seizures.

[Anesthesiological time requirements and reasons for delayed processes in MRI examinations of children undergoing sedation or general anesthesia]. / Magnetresonanztomografie bei Kindern in Sedierung--anästhesiologisches Prozedere, Zeitbedarf und Determinanten verzögerter Prozessabläufe.

PURPOSE: MRI examinations in children under sedation or general anesthesia are a multidisciplinary challenge for pediatric, radiology and anesthesiology departments. This article presents findings about patient population, anesthesiology procedures and process times in pediatric MRI procedures under sedation or general anesthesia. The analysis is focused on the potential to optimize process times. MATERIALS AND METHODS: Retrospectively over a 5-year period, data from diagnostic radiology procedures in children requiring sedation or general anesthesia were retrieved from anesthesia records and analyzed statistically. RESULTS: The median anesthesia time in patients without an airway device was 6 min. In patients with a laryngeal mask (19 min) and in patients receiving endotracheal intubation (20 min), the anesthesia time was significantly longer (p < 0.001). The need for airway management in the age groups was 67 % for neonates, 25 % for infants, 8 % for toddlers and 7 % for school children. Improved clinical pathways could potentially save additional time up to 69 hours in our period of investigation. CONCLUSION: In relation to older children, toddlers, infants and neonates had the longest process times in diagnostic radiology procedures, caused by the need to secure the airway. Improved pre-MRI processes have an enormous potential to generate additional examination time.

Static and dynamic periosteal elevation: a pilot study in a pig model.

The osteoinductive potential of periosteum and bone can be stimulated by elevating the periosteum in a distraction-like modus, but also by an ad-hoc elevation. This was tested and proved in an experiment in 9 Goettingen mini-pigs with elevation heights of 5, 10 and 15mm. Specially designed and perforated titanium meshes were implanted subperiosteally to compare the dynamic elevation procedure with static shielding. The cumulative results for bone formation underneath the mesh were 66% in dynamic and 67% in non-dynamic elevation. The cumulative results for mineralization of the bone regenerates in comparison with the underlying basal bone of the skull showed independently from the technique applied no difference bigger than 5%. No major difference in bone formation could be observed in this pilot study. The main advantages of dynamic periosteal elevation and static shielding are minimal invasion and morbidity. Periosteal elevation could be applied in cranio-maxillofacial surgery, in preimplantological augmentation and in reconstructive surgery of the skull; applications in other specialties may be possible.

Effects of osteoinduction on bone regeneration in distraction: results of a pilot study.

Rate and frequency of distraction as well as stimulatory effects transmitted by growth factors and local gene therapy have a decisive influence on bone regeneration. In a pilot study we tested the effect of four different morphogenetic and mitotic proteins and a genetically transferred vector system on bone healing in continuous osteodistraction in a large animal experiment on 24 Goettingen mini-pigs. For this purpose bone morphogenetic protein (BMP-2), BMP-7, TGF-beta, IGF-1 and a liposome vector were instilled into the distraction gap. The animals were killed after 1-4 weeks of consolidation. Histological and radiological evaluations showed maximum bone formation after the application of BMP-2/7, whereas the application of TGF-beta, IGF-1 and the liposomal vector had only a limited effect on bone regeneration. The quantitative analysis demonstrated an average amount of bone in the distraction gap of 50% and 61% after instillation of BMP-2 and 7, respectively. The BMP-2 expression, however, was maximal after induction with the non-viral vector. Only after BMP-2/7 application could physical, radiographic and histological evidence of bone union be detected. In bone distraction with a short observation period the application of morphogenetic proteins seems to enhance bone regeneration significantly. Before application in humans further studies are necessary to measure the dose-effect relationship, the mode of application and the efficacy of different inductive proteins. The combination of osteodistraction with osteoinduction, however, could shorten treatment times dramatically.

Minimally invasive neck surgery. Surgical feasibility and physiological effects of carbon dioxide insufflation in a unilateral subplatysmal approach.

Endoscopically assisted, minimally invasive techniques to regions without a natural cavity require insufflation with carbon dioxide (CO2). In the neck region this may impair hemodynamics, blood gas homoeostasis, cerebral blood circulation and increase the intracranial pressure. An exclusively endoscopic unilateral subplatysmal approach to the submandibular region was investigated in nine mini-pigs randomized to three groups. On both neck sides, within a 14 day interval, the subplatysmal space was inflated with CO2 at 10 mmHg, 20 mmHg (1.33/2.66 x 10 (3)Pa) or 20 mmHg (2.66 x 10 (3)Pa) combined with mechanical suspension. Data for hemodynamic and blood gas parameters, gas volumes, and intracranial pressure were obtained preoperatively, 30 min after onset and 10 min postopeatively. In a pocket created by insufflation of 20 mmHg (2.66 x 10 (3)Pa), exposition and resection of the submandibular gland were accomplished easily. The elevation procedure had technical disadvantages. The mean operation time was 48.9 min. Unilateral subplatysmal carbon dioxide insufflation of the submandibular neck region up to 20 mmHg (2.66 x 10 (3)Pa) did not affect physiological parameters. As an exclusive endoscopical approach for unilateral surgery of the submandibular region, the use of inflation pressures of up to 20 mmHg (2.66 x 10 (3)Pa) might be considered.

[Equipment of a land-based emergency medical service in Bavaria: a questionnaire]. / Ausstattung bodengebundener Notarztrettungsmittel in Bayern: Eine Umfrage.

BACKGROUND: Currently valid DIN regulations concerning the emergency equipment in physician-staffed rescue vehicles are not well defined for every single item. This leads to variations in the equipment in different ambulances. The aim of this study was to demonstrate the differences with some exemplary equipment purchases. METHODS: All 218 physician-staffed rescue vehicles in Bavaria received a questionnaire asking for current emergency medical equipment and planned items. RESULTS: A reply was received from 177 of the 218 bases (81%). The main results were that 88% of all bases had a 12-lead ECG, a portable emergency ventilator was available at 93% of all bases, 77% had alternative airway management devices (set for emergency coniotomy 71%, laryngeal mask 26%), expiratory CO(2 )measuring was available at 32% and 31 bases (18%) had fibrinolytic drugs in the emergency vehicles. CONCLUSIONS: There are vast differences among the emergency physician-staffed ambulances concerning the equipment which means that medical treatment according to current recommendations is not always possible at all bases.

[Patients with ornithine transcarbamylase deficiency. Anaesthesiological and intensive care management]. / Der Patient mit Ornithintranscarbamylasemangel. Anästhesiologisches und intensivmedizinisches Management.

Ornithine transcarbamylase deficiency (OTCD) is the most common inborn urea cycle disorder. Patients with OTCD are at risk of acute metabolic decompensation with hyperammonemia and subsequent encephalopathy, coma and death. Symptoms may be triggered by infections, drugs and stress, evoked by trauma, pain, fear, surgery and anaesthesia or by episodes of protein catabolism, i.e. fasting-induced, post partum or during gastrointestinal bleeding. Several specific considerations must be made for anaesthetic and intensive care management in patients with this disease in order to avoid metabolic decompensation. We report the intensive care management of the first manifestation of late-onset OTCD in a 16-year-old girl and a course of inconspicuous general anaesthesia with midazolam, s-ketamine, fentanyl and isoflurane in a 22-year-old girl with known OTCD.