Temperature loss by ventilation in a calorimetric bench model.

In intensive care medicine heat moisture exchangers are standard tools to warm and humidify ventilation gases in order to prevent temperature loss of patients or airway epithelia damage. Despite being at risk of hypothermia especially after trauma, intubated emergency medicine patients are often ventilated with dry and in winter probably cold ventilation gases. We tried to assess the amount of temperature-loss due to ventilation with cold, dry medical oxygen in comparison to ventilation with warm and humidified oxygen. We ventilated a 50-kg water-dummy representing the calorimetric capacity of a 60-kg patient over a period of 2 hours (tidal volume 6.6 mL/kg = 400 mL; respiratory rate 13/min). Our formal null-hypothesis was that there would be no differences in temperature loss in a 50 kg water-dummy between ventilation with dry oxygen at 10°C vs. ventilation with humidified oxygen at 43°C. After 2 hours the temperature in the water-dummy using cold and dry oxygen was 29.7 ± 0.1°C compared to 30.4 ± 0.1°C using warm and humidified oxygen. This difference in cooling rates between both ventilation attempts of 0.7 ± 0.1°C after 2 hours represents an increased cooling rate of ~0.35°C per hour. Ventilation with cool, dry oxygen using an automated transport ventilator resulted in a 0.35°C faster cooling rate per hour than ventilation with warm humidified oxygen in a bench model simulating calorimetric features of a 60-kg human body.

Safer employment of nitrous oxide in anesthesia machines-a technical simulation.

Several incidents of anesthesia-attributed mortality in the past were caused by misconnection of gas pipelines resulting in ventilation with pure nitrous oxide. A simple safety feature may be to "mark" nitrous oxide with a lower pressure than oxygen and room air within the hospital's gas pipeline system. Then, any misconnection of gas pipelines could be detected by pressure differences with a manometer in the anesthesia machine. To check technical suitability, we tested maximum achievable nitrous oxide flows of an anesthesia machine at different pressures in the nitrous oxide supply line. Using decreased pressures for nitrous oxide compared to oxygen did not result in decreased nitrous oxide flows, as long as pressure in the nitrous oxide supply line was >1500 hPa. A concept of different pressures for nitrous oxide and oxygen could be used to technically differentiate between those two gases, and to avoid potentially fatal misconnections.

A dual-use laryngoscope to facilitate apneic oxygenation.

BACKGROUND: In preoxygenated patients, time until oxygen saturation drops can be extended by insufflating oxygen into their airways, thus oxygenating them apneically. OBJECTIVES: To compare different methods of apneic oxygenation. METHODS: A noncommercial dual-use laryngoscope with an internal lumen in its blade was used to provide oxygen insufflation into a simulated laryngeal space during intubation. In this experimental study, oxygen insufflation via the dual-use laryngoscope was compared with no oxygen insufflation, with nasal oxygen insufflation, and with direct intratracheal oxygen insufflation. In a preoxygenated test lung of a manikin, oxygen percentage decrease was measured over a 20-min observation period for each method of oxygen application. RESULTS: Oxygen percentage in the test lung dropped from 97% to 37 ± 1% in the control group (p < 0.001 compared to all other groups) and to 68 ± 1% in the nasal insufflation group (p < 0.001 compared to all other groups). Oxygen percentage remained over 90% in both the direct intratracheal insufflation group (96 ± 0%) and the laryngoscope blade insufflation group (94 ± 1%) (p < 0.01 between the latter two groups). CONCLUSIONS: Simulating apneic oxygenation in a preoxygenated manikin, deep laryngeal oxygen insufflation via the dual-use laryngoscope kept oxygen percentage in the test lung above 90%, and was more effective than oxygen insufflation via nasal prongs.

Head position angles to open the upper airway differ less with the head positioned on a support.

INTRODUCTION: The aim of the study was to assess the effects of positioning the head on a support on "head position angles" to optimally open the upper airway during bag-valve mask ventilation. METHODS: We ventilated the lungs of anesthetized adults with a bag-valve mask and the head positioned with (n = 30) or without a support (n = 30). In both groups, head position angles and ventilation parameters were measured with the head positioned in (1) neutral position, (2) in a position deemed optimal for ventilation by the investigator, and (3) in maximal extension. RESULTS: Between groups ("head with/without a support") and between head positions within each group, head position angles and ventilation parameters differed (P < .0001, respectively). However, head position angles and ventilation parameters between head positions differed less "with a support" (P < .001), and ventilation parameters improved with a support compared with the head-without-a-support group (P < .001). CONCLUSIONS: In the head-with-a-support group, when compared with the head-without-a-support group, head position angles differed less, indicating a decreased potential for failure during bag-valve mask ventilation with the head on a support. Moreover, in the head-with-a-support group, ventilation parameters differed less between head positions, and ventilation improved. These findings suggest a potential benefit of positioning the head on a support during bag-valve mask ventilation.

BMP-2 immobilized on nanocrystalline diamond-coated titanium screws; demonstration of osteoinductive properties in irradiated bone.

BACKGROUND: Irradiation results in impaired bone healing. Thus, osteosynthesis procedures are afflicted with increased failure rates. To improve osseointegration bone morphogenetic protein-2 (BMP-2) immobilized on nanocrystalline diamond (NCD)-coated implant surfaces might be 1 solution. METHODS: By 4 weeks after irradiation of pig's mandible with a dose of 60 Gy a fracture was accomplished. Osteosynthesis was performed either with titanium osteosynthesis screws or NCD-coated screws with immobilized BMP-2. Nonirradiated animals served as control. After 1, 2, 4, and 8 weeks screws were evaluated histologically. Bone biopsies were gained to extract mesenchymal stem or precursor cells (MSCs). RESULTS: MSCs after irradiation demonstrated a behavior comparable to that of unirradiated cells. Consequently, immobilized BMP-2 resulted in an initial increased bone contact ratio (p = .014) but demonstrated no sustainable effect compared with osseointegration in nonirradiated bone (p = .08). CONCLUSION: Immobilized BMP-2 demonstrates an osteoinductive effect in irradiated bone. MSCs as effector cells possess protective mechanisms to overcome the destructive effect of irradiation.

Mobile phone-assisted basic life support augmented with a metronome.

BACKGROUND: Basic life support (BLS) performed by lay rescuers is poor. We developed software for mobile phones augmented with a metronome to improve BLS. STUDY OBJECTIVES: To assess BLS in lay rescuers with or without software assistance. METHODS: Medically untrained volunteers were randomized to run through a cardiac arrest scenario with ("assisted BLS") or without ("non-assisted BLS") the aid of a BLS software program installed on a mobile phone. RESULTS: Sixty-four lay rescuers were enrolled in the "assisted BLS" and 77 in the "non-assisted BLS" group. The "assisted BLS" when compared to the "non-assisted BLS" group, achieved a higher overall score (19.2 ± 7.5 vs. 12.9 ± 5.7 credits; p < 0.001). Moreover, the "assisted BLS" when compared to the "non-assisted" group checked (64% vs. 27%) and protected themselves more often from environmental risks (70% vs. 39%); this group also called more often for help (56% vs. 27%), opened the upper airway (78% vs. 16%), and had more correct chest compressions rates (44% ± 38% vs. 14% ± 28%; all p < 0.001). However, the "assisted BLS" when compared to the "non-assisted BLS" group, was slower in calling the dispatch center (113.6 ± 86.4 vs. 54.1 ± 45.1 s; p < 0.001) and starting chest compressions (165.3 ± 93.3 vs. 87.1 ± 53.2 s; p < 0.001). CONCLUSIONS: "Assisted BLS" augmented by a metronome resulted in a higher overall score and a better chest compression rate when compared to "non-assisted BLS." However, in the "assisted BLS" group, time to call the dispatch center and to start chest compressions was longer. In both groups, lay persons did not ventilate satisfactorily during this cardiac arrest scenario.

Suctioning via the tube during endotracheal intubation in a model of severe upper airway haemorrhage: is there an advantage vs. suctioning with a separate catheter?

INTRODUCTION: In a model of severe simulated upper airway haemorrhage, we compared two techniques of performing endotracheal intubation: (1) suctioning via the endotracheal tube during laryngoscopy with subsequently advancing the endotracheal tube, and (2) the standard intubation strategy with performing laryngoscopy, and performing suction with subsequently advancing the endotracheal tube. METHODS: Forty-one emergency medical technicians intubated the trachea of a manikin with severe simulated airway haemorrhage using each technique in random order. RESULTS: There was no significant difference in the number of oesophageal intubations between suctioning via the tube and the standard intubation strategy [8/41 (20%) vs. 6/41 (15%); P = 0.688], but suctioning via the endotracheal tube needed significantly more time [median (IQR, CI 95%): 42 (20, 39-60) vs. 33 (15, 35-48)s; P = 0.015]. CONCLUSIONS: Suctioning via the endotracheal tube showed no benefit regarding the number of oesophageal intubations and needed more time when compared to the standard intubation strategy.

Automated emergency ventilation devices in a simulated unprotected airway.

BACKGROUND: Automated ventilation devices are becoming more popular for emergency ventilation, but there is still not much experience concerning the optimal ventilation mode. METHODS: In a bench model representing a non-intubated patient in respiratory and cardiac arrest, we compared a pressure-cycled with a time- and volume-cycled automated ventilation device in their completely automated modes. The main study endpoints were inspiratory time, respiratory rate, stomach inflation, and lung tidal volumes. RESULTS: The pressure-cycled device inspired for 6.7 s in the respiratory arrest setting (respiratory rate 5.6/min), and never reached its closing pressure in the cardiac arrest setting (respiratory rate 1 breath/min). The time- and volume-cycled device inspired in both settings for 1.7 s (respiratory rate 13 breaths/min). In the respiratory arrest setting, mask leakage was 620 ± 20 mL for the pressure-cycled device vs. 290 ± 10 mL for the time- and volume-cycled device (p < 0.0001); lung tidal volume was 1080 ± 50 mL vs. 490 ± 20 mL, respectively (p < 0.0001); and there was no stomach inflation for either device. In the cardiac arrest setting, pressure-cycled device mask leakage was 5460 ± 60 mL vs. 240 ± 20 mL (p < 0.0001) for the time- and volume-cycled device (p < 0.0001); stomach inflation was 13,100 ± 100 mL vs. 90 ± 10 mL, respectively (p < 0.0001); and lung tidal volume 740 ± 60 mL vs. 420 ± 20 mL, respectively (p < 0.0001). CONCLUSION: In a simulated respiratory arrest setting, ventilation with an automated pressure-cycled ventilation device resulted in lower respiratory frequency and larger tidal volumes compared to a time- and volume-cycled device. In a simulated cardiac arrest setting, ventilation with an automated pressure-cycled ventilation device, but not a time- and volume-cycled device, resulted in continuous gastric insufflation.

Head-position angles in children for opening the upper airway.

AIMS: Inexperienced health-care-providers may encounter severe problems to ventilate an unconscious child. Designing a ventilating device that could indicate how to open an upper airway correctly may be beneficial. Neutral position in young children and slight head extension in older children is recommended, although the optimal head angle is not clear. Thus, we compared effects of neutral head position and extension, measuring head-position angles and ventilation parameters. METHODS: Sixty-one children scheduled for tonsillectomy were enrolled, and were ventilated with pressure-controlled ventilation after anaesthesia induction. RESULTS: Children were divided into two groups: 1-5 years old (pre-school children, n=38) and 6-10 years old (school children, n=23). In neutral (mean+/-SD: 1.3+/-6.0) vs. head-extension position (13.2+/-6.0; P<0.001) in pre-school children, tidal volumes (132+/-44,137+/-49 ml), peak-expiratory flow (300+/-90 vs. 310+/-100 mls(-1)) and expiratory airway resistance (20+/-8 vs. 18+/-6c mH(2)O s l(-1)) were comparable (P=NS). In neutral (-0.4+/-5.4) vs. head-extension position (15.7+/-6.4; P<0.001) in school children, expiratory airway resistance (17+/-7 vs. 13+/-5 cmH(2)O s l(-1); P=0.048) differed, while tidal volume (224+/-93 vs. 230+/-92 ml) and peak-expiratory flow (427+/-181 vs. 381+/-144 ml s(-1)) were comparable (P=NS). CONCLUSIONS: Head-extension and neutral head-position angles differed in pre-school and school children. In pre-school children, neutral head position or head extension with an angle of -1 degrees or 13 degrees , and in school children head extension of 16 degrees , may be used to achieve optimal ventilation of an unprotected airway.

Anaesthesia in prehospital emergencies and in the emergency room.

AIMS: To review anaesthesia in prehospital emergencies and in the emergency room, and to discuss guidelines for anaesthesia indication; pre-oxygenation; anaesthesia induction and drugs; airway management; anaesthesia maintenance and monitoring; side effects and training. METHODS: A literature search in the PubMed database was performed and 87 articles were included in this non-systematic review. CONCLUSIONS: For pre-oxygenation, high-flow oxygen should be delivered with a tight-fitting face-mask provided with a reservoir. In haemodynamically unstable patients, ketamine may be the induction agent of choice. The rocuronium antagonist sugammadex may have the potential to make rocuronium a first-line neuromuscular blocking agent in emergency induction. An experienced health-care provider may consider prehospital anaesthesia induction. A moderately experienced health-care provider should optimise oxygenation, fasten hospital transfer and only try to intubate a patient in extremis. If intubation fails twice, ventilation should be resumed with an alternative supra-glottic airway or a bag-valve-mask device. A lesser experienced health-care provider should completely refrain from intubation, optimise oxygenation, fasten hospital transfer and only in extremis ventilate with an alternative supra-glottic airway or a bag-valve-mask device. With an expected difficult airway, the patient should be intubated awake. With an unexpected difficult airway, bag-valve-mask ventilation should be resumed and an alternative supra-glottic airway device inserted. Senior help should be called early. In a "can-not-ventilate, can-not-intubate" situation an alternative airway should be tried and if unsuccessful because of severe upper airway pathology, a surgical airway should be performed. Ventilation should be monitored continuously with capnography. Clinical training is important to increase airway management skills.

The mouth-to-bag resuscitator during standard anaesthesia induction in apnoeic patients.

AIM: Ventilation of a non-intubated emergency patient by inexperienced rescuers with a standard bag-valve device may result in high inspiratory flow rates and subsequently high airway pressures with stomach inflation. Therefore, a self-inflating bag has been developed that requires lay rescuers to blow up a single-use balloon inside an adult bag-valve device, which, in turn, displaces air within the bag towards the patient. This concept has been compared to standard adult bag-valve devices earlier in bench models but not in patients. METHODS: An anaesthetist who was blinded to all monitor tracings ventilated the lungs of 40 apnoeic patients during routine anaesthesia induction either with a standard bag-valve device or with the mouth-to-bag resuscitator in a random order. Study endpoints were peak inspiratory flow rates, peak airway pressure, tidal volumes and inspiratory time. RESULTS: Peak inspiratory flow was 40+/-10lmin(-1) for the standard bag-valve device versus 33+/-13lmin(-1) for the mouth-to-bag resuscitator (P<0.0001); peak airway pressure was 17+/-5cmH(2)O versus 14+/-5cmH(2)O (P<0.0001); inspiratory tidal volume was 477+/-133ml versus 644+/-248ml (P<0.001) and inspiratory time was 1.1+/-0.3s versus 1.9+/-0.6s (P<0.0001). CONCLUSION: Employing the mouth-to-bag resuscitator during simulated ventilation of a non-intubated patient in respiratory arrest significantly decreased peak inspiratory flow and peak airway pressure and increased inspiratory tidal volume and inspiratory times compared to a standard bag-valve device.

Ventilation strategies in the obstructed airway in a bench model simulating a nonintubated respiratory arrest patient.

BACKGROUND: The Smart Bag MO(R) is an adult flow-limited bag-valve device designed to reduce the risk of stomach inflation in an unprotected airway. Its properties in severe airway obstruction are as yet unknown. METHODS: In a bench model, we evaluated respiratory mechanics and delivered tidal volumes although ventilating at airway resistances of 4, 10, and 20 cm H(2)O . L(-1) . s(-1) once with a flow-limited bag-valve device and once with a standard bag-valve device to simulate a respiratory arrest patient with an unprotected airway. RESULTS: Inspiratory times were always longer with the flow-limited bag-valve device than with the standard bag-valve device. Lung tidal volume in the simulated unobstructed airway was 750 +/- 70 mL using the flow-limited bag-valve device versus 780 +/- 30 mL using the standard bag-valve device (n.s.); in the simulated medium obstructed airway it was 800 +/- 70 versus 850 +/- 20 mL (n.s.), and in the simulated severely obstructed airway it was 210 +/- 20 versus 170 +/- 10 mL (P < 0.01). Peak airway pressure in the simulated unobstructed airway was 15 +/- 2 cm H(2)O using the flow-limited bag-valve device versus 22 +/- 4 cm H(2)O using the standard bag-valve device (P < 0.01); in the simulated medium obstructed airway it was 22 +/- 1 versus 39 +/- 7 cm H(2)O (P < 0.01), and in the simulated severely obstructed airway it was 26 +/- 1 versus 61 +/- 3 cm H(2)O (P < 0.01). Stomach inflation in the simulated unobstructed airway was 0 mL/min using both bag-valve devices; in the simulated medium obstructed airway it was 0 mL/min for the flow-limited bag-valve device versus 200 +/- 20 mL/min for the standard bag-valve device (P < 0.01), and in the simulated severely obstructed airway it was 0 versus 1240 +/- 50 mL/min (P < 0.01). CONCLUSION: In a simulated severely obstructed unprotected airway, the use of a flow-limited bag-valve device resulted in longer inspiratory times, higher tidal volumes, lower inspiratory pressures, and no stomach inflation compared with a standard bag-valve device.

A suction laryngoscope facilitates intubation for physicians with occasional emergency medical service experience--a manikin study with severe simulated airway haemorrhage.

INTRODUCTION: We developed a suction laryngoscope, which enables simultaneous suction and laryngoscopy in cases of airway haemorrhage and evaluated its potential benefits in physicians with varying emergency medical service experience. METHODS: Eighteen physicians with regular and 24 physicians with occasional emergency medical service experience intubated the trachea of a manikin with severe simulated airway haemorrhage using the suction laryngoscope and the Macintosh laryngoscope in random order. RESULTS: In physicians with regular emergency medical service experience, there was neither a difference in time needed for intubation [median (IQR, CI 95%)]: 34 (18, 30-46) vs. 34 (22, 30-52) s; P=0.52, nor in the number of oesophageal intubations [0/18 (0%) vs. 3/18 (16.7%); P=NS] when using the suction vs. the Macintosh laryngoscope. In physicians with occasional emergency medical service experience, there was no difference in time needed for intubation [median (IQR, CI 95%)]: 42 (25, 41-57) vs. 45 (33, 41-65) s; P=0.56, but the number of oesophageal intubations was significantly lower when using the suction laryngoscope [4/24 (16.7%) vs. 12/24 (50.0%); P=0.04]. CONCLUSIONS: In a model of severe simulated airway haemorrhage, employing a suction laryngoscope significantly decreased the likelihood of oesophageal intubations in physicians with occasional emergency medical service experience.

Effects of stomach inflation on haemodynamic and pulmonary function during spontaneous circulation in pigs.

AIM: Stomach inflation during mask ventilation is frequent, but the effects on haemodynamic and pulmonary function are unclear. We evaluated the effects of stomach inflation on haemodynamic and pulmonary function during spontaneous circulation in a porcine model. METHODS: Randomised prospective animal study. After randomisation, in 23 domestic pigs the stomach was inflated every 90s with 0L (control; n=8), 0.5L (n=7) or 1L (n=8) ambient air. RESULTS: After 22.5min, i.e. 8.5L in the 0.5L and 17L in the 1L stomach inflation group, stomach inflation increased central venous pressure (median) (control: 10mmHg vs. 1L: 23mmHg, P<0.05) and mean pulmonary artery pressure (control: 24mmHg vs. 1L: 45mmHg, P<0.05). As a result stroke volume index decreased (control: 135mL/kg vs. 0.5L: 90mL/kg, P<0.05; vs. 1L: 72mL/kg, P<0.05). Stomach inflation also decreased static pulmonary compliance (control: 24mL/cmH(2)O vs. 0.5L: 8mL/cmH(2)O, P<0.05; vs. 1L: 3mL/cmH(2)O, P<0.05), which increased peak airway pressure (control: 28cmH(2)O vs. 0.5L: 69cmH(2)O, P<0.05; vs. 1L: 73cmH(2)O, P<0.05). Additionally, arterial oxygen partial pressure (control: 305mmHg vs. 0.5L: 140mmHg, P<0.05; vs. 1L: 21mmHg, P<0.05) and systemic oxygen delivery (control: 53mLO(2)/min vs. 1L: 19mLO(2)/min, P<0.05) decreased. Stomach inflation increased mortality (control: 0/8 vs. 1L: 5/8, P<0.05). CONCLUSIONS: Stomach inflation with 1L when compared to 0.5L increments resulted in faster haemodynamic and pulmonary failure and increased mortality. Stomach inflation may cause a hyper-acute abdominal compartment syndrome.

Effects of a suction laryngoscope in a model with simulated severe airway hemorrhage.

In severe airway hemorrhage, simultaneous suction and laryngoscopy may render intubation difficult. We built a suction laryngoscope that consists of an adjustable stainless steel-guide tube fixed at the lingual surface of a standard Macintosh laryngoscope blade. Via this steel-guide tube, a large suction catheter can be inserted and positioned exactly to suction pharyngeal blood or vomitus, rendering simultaneous suctioning and laryngoscopy possible. In contrast to previous suction laryngoscopes, our suction catheter has a large lumen, which enables fast suctioning and exact placement by adjusting the steel-guide tube. To assess whether our suction laryngoscope could provide better intubation conditions in comparison to a standard Macintosh laryngoscope in a bleeding airway scenario, 44 medical students intubated a manikin with severe simulated airway hemorrhage using our suction laryngoscope and a standard Macintosh laryngoscope in random order. There was no significant difference in time needed for intubation when using the suction versus the Macintosh laryngoscope (mean +/- SD: 43 +/- 13 vs 52 +/- 31 s; P = 0.07), but the number of esophageal intubations was significantly lower when using the suction laryngoscope [6 of 44 (13.6%) vs 19 of 44 (43.2%); P = 0.004]. In conclusion, when compared with a standard Macintosh laryngoscope, using a suction laryngoscope did not result in more rapid intubation, but significantly decreased the likelihood of esophageal intubations.

Minimizing stomach inflation versus optimizing chest compressions.

In a bench model, we evaluated a bag-valve device (Smart Bag MO) with limited maximum inspiratory gas flow developed to reduce the risk of stomach inflation in an unprotected airway. During simulated cardiopulmonary resuscitation with uninterrupted chest compressions, ventilation with the "disabled" Smart Bag MO or an adult self-inflating bag-valve device provided only adequate tidal volumes if inspiratory time was 0.5 s. Ventilation with the "enabled" Smart Bag MO, even in ventilation windows of 0.5 s, provided inadequate tidal volumes during simulated cardiopulmonary resuscitation and would result in hypoventilation in a patient.