Favour the best in case of emergency cricothyroidotomy-a randomized cross-over trial on manikin focused training and simulation of common devices.

Background: Performing an emergency cricothyroidotomy (EC) is extremely challenging, the devices used should be easy to handle and the selected technique reliable. However, there is still an ongoing debate concerning the most superior technique. Methods: Three different techniques were compared using a standardized, simulated scenario regarding handling, performing, training and decision making: The scalpel-bougie technique (SBT), the surgical anatomical preparation technique (SAPT) and the Seldinger technique (ST). First, anaesthesia residents and trainees, paramedics and medical students (each group n = 50) performed a cricothyroidotomy randomly assigned with each of the three devices on a simulator manikin. The time needed for successful cricothyroidotomy was the primary endpoint. Secondary endpoints included first-attempt success rate, number of attempts and user-satisfaction. The second part of the study investigated the impact of prior hands-on training on both material selection for EC and on time to decision-making in a simulated "cannot intubate cannot ventilate" situation. Results: The simulated scenario revealed that SBT and SAPT were significantly faster than percutaneous EC with ST (p < 0.0001). Success rate was 100% for the first attempt with SBT and SAPT. Significant differences were found with regard to user-satisfaction between individual techniques (p < 0.0001). In terms of user-friendliness, SBT was predominantly assessed as easy (87%). Prior training had a large impact regarding choice of devises (p < 0.05), and time to decision making (p = 0.05; 180 s vs. 233 s). Conclusion: This study supports the use of a surgical technique for EC and also a regular training to create familiarity with the materials and the process itself.The trial was registered before study start on 11.11.2018 at ClinicalTrials.gov (NCT: 2018-13819) with Nicole Didion as the principal investigator.

Changes of pulse wave transit time after haemodynamic manoeuvres in healthy adults: a prospective randomised observational trial (PWTT volunteer study).

Background: Pulse wave transit time (PWTT) shows promise for monitoring intravascular fluid status intraoperatively. Presently, it is unknown how PWTT mirrors haemodynamic variables representing preload, inotropy, or afterload. Methods: PWTT was measured continuously in 24 adult volunteers. Stroke volume was assessed by transthoracic echocardiography. Volunteers underwent four randomly assigned manoeuvres: 'Stand-up' (decrease in preload), passive leg raise (increase in preload), a 'step-test' (adrenergic stimulation), and a 'Valsalva manoeuvre' (increase in intrathoracic pressure). Haemodynamic measurements were performed before and 1 and 5 min after completion of each manoeuvre. Correlations between PWTT and stroke volume were analysed using the Pearson correlation coefficient. Results: 'Stand-up' caused an immediate increase in PWTT (mean change +55.9 ms, P-value <0.0001, 95% confidence interval 46.0-65.7) along with an increase in mean arterial pressure and heart rate and a drop in stroke volume (P-values <0.0001). Passive leg raise caused an immediate drop in PWTT (mean change -15.4 ms, P-value=0.0024, 95% confidence interval -25.2 to -5.5) along with a decrease in mean arterial pressure (P-value=0.0052) and an increase in stroke volume (P-value=0.001). After 1 min, a 'step-test' caused no significant change in PWTT measurements (P-value=0.5716) but an increase in mean arterial pressure and heart rate (P-values <0.0001), without changes in stroke volume (P-value=0.1770). After 5 min, however, PWTT had increased significantly (P-value <0.0001). Measurements after the Valsalva manoeuvre caused heterogeneous results. Conclusion: Noninvasive assessment of PWTT shows promise to register immediate preload changes in healthy adults. The clinical usefulness of PWTT may be hampered by late changes because of reasons different from fluid shifts. Clinical trial registration: German clinical trial register (DRKS, ID: DRKS00031978, https://www.drks.de/DRKS00031978).

Is noninvasive hemoglobin measurement suitable for children undergoing preoperative anesthesia consultation?

Preoperative anemia in children is a significant clinical concern requiring precise diagnosis. Although traditional blood sample collection is effective, it poses challenges because of children's aversion and technical difficulties. Therefore, this study explores the suitability of noninvasive hemoglobin measurements in children during preoperative anesthesia consultation. Noninvasive hemoglobin measurement (SpHb®; Masimo) in children aged ≤ 17 years was performed during preoperative anesthesia consultation and compared with laboratory hemoglobin (labHb) levels. SpHb was measured in 62 children (median age: 6 years, standard deviation [SD] ± 5.3) without adverse effects but was unsuccessful in one child. The bias, limits of agreement, and root mean square error between SpHb and labHb were 0.3, -2.26- +2.8, and 1.3 g/dl, respectively. LabHb demonstrated a significant regression relationship with R2 of 0.359. LabHb was associated with a negative effect on bias [- 0.443 (CI 95: - 0.591- - 0.153, P < 0.001)], i.e., SpHb tends to underestimate labHb for high labHb values. The retest reliability between two consecutive SpHb measurements was 0.727 (P < 0.001). Double measurement of SpHb, age, weight, sex, heart rate, and perfusion index had no significant effects on accuracy. Using SpHb, a specificity of 96.3% (95% confidence interval [CI 95]: 87.3%-99.5%) and a sensitivity of 57.1% (CI 95: 18.4%-90.1%) were observed. Based on adapted cut-off values for SpHb (age-dependent cut-off values plus 0.8 g/dl), a sensitivity of 100% (CI 95: 64.6%-100%) was achieved for the investigated study collective. SpHb measurement in children is a quick procedure. The accuracy of hemoglobin measurement is insufficient for the diagnosis of anemia. Thus, whether the calculated cut-off SpHb values of this study collective can be considered for anemia screening in pediatric patients undergoing preoperative anesthesia consultation should be confirmed. Trial registration number and date of registration: This prospective study was registered at ClinicalTrials.gov (NCT03586141).

Awake tracheal intubation in routine airway management: A retrospective analysis in a tertiary centre.

INTRODUCTION: While awake tracheal intubation (ATI) is regarded as the gold standard for difficult airway management according to current guidelines, there seems to be a reluctance in its application. This retrospective cohort study, conducted at a German tertiary hospital over a 2-year period, aimed to demonstrate that integrating awake tracheal intubation using flexible bronchoscopy (ATI:FB) into routine airway management makes it a successful and safe approach. MATERIALS AND METHODS: In 2019 and 2020, records from the data acquisition system (DAQ) and archived anesthesia records were screened to evaluate the specifics of ATI:FB procedures, focusing on overall success and safety. Analysis included complications, time required for ATI:FB, and potential influencing factors such as patient characteristics, indication, medical/operative specialty, sedation technique, route and experience of anesthesiologist. Logistic regression assessed the impact of various variables on occurrence of complications and linear regression, with log(time) as the dependent variable, evaluated median time required to perform ATI:FB. RESULTS: ATI:FB constituted 4.3 % (n = 1,911) of all airway management procedures, predominantly observed in dental, oral, and maxillofacial surgery (46.5 %) and otorhinolaryngology (38.4 %). The success rate for ATI:FB was notably high at 99.6 %, with only 5.4 % of cases experiencing complications, including technical issues, agitation, and visibility obstruction due to mucous secretion. Complication risk was influenced by the medical specialty and the experience of the anesthesiologist. A strong effect was observed in otorhinolaryngology (OR = 4.54, 95 % CI [1.64; 14.06]). The median time required for ATI:FB was 16 minutes (IQR: 11 to 23), with factors such as indication (p < 0.0001), experience of anesthesiologist (p < 0.0001), sedation technique (p = 0.0408), priority of the procedure (p = 0.0134), and medical/operative specialty (p < 0.0001) affecting the duration. The median time required for ATI:FB differed significantly based on the experience of the anesthesiologist (p < 0.0001). CONCLUSION: ATI:FB proves successful and safe, with low complications and manageable procedural time. Experience of the anesthesiologist is a modifiable factor enhancing safety, emphasizing the need for ATI:FB integration into routine airway management.

Blood Product Transfusions for Children in the Perioperative Period and for Critically Ill Children.

BACKGROUND: Approximately 1% to 2% of all hospitalized children receive a transfusion of blood products, in Germany as in other countries. High-quality scientific evidence on transfusions in children is scarce. The available evidence is discussed in this review. METHODS: This review is based on publications on blood product transfusions in children that were retrieved by a literature search, including clinical studies, international guideline recommendations, the recommendations of the German cross-sectional guideline, and results of other recent, relevant publications. RESULTS: A restrictive transfusion strategy is recommended for all children, including those who are critically ill. Randomized controlled trials have shown that a restrictive strategy for erythrocyte concentrate transfusion in the intensive care unit is safe for children, including neonates. No robust data are available to enable the definition of a suitable threshold for the intraoperative administration of red blood cell concentrates in children undergoing extracardiac surgery. On the basis of studies from pediatric intensive care units, transfusions for hemodynamically stable children with a hemoglobin concentration of more than 7 g/dL are recommended only in exceptional cases. Therapeutic plasma is not recommended as volume replacement, except in massive transfusion. Platelet concentrate transfusions are indicated in case of active hemorrhage, and only rarely for prophylaxis. CONCLUSION: There is a broad lack of evidence from randomized controlled trials concerning the indications for transfusions in children. A restrictive transfusion strategy, which has been found safe in the intensive-care setting, is favored by the guidelines in the perioperative setting as well. Further studies are needed to evaluate transfusion triggers and indications for all types of blood products, especially therapeutic plasma. Until more evidence is available, physicians should be aware of what the current evidence supports, and blood products should be given restrictively, and not prophylactically.

Early warning for SpO2 decrease by the oxygen reserve index in neonates and small infants.

INTRODUCTION: Continuously assessing the oxygenation levels of patients to detect and prevent hypoxemia can be advantageous for safe anesthesia, especially in neonates and small infants. The oxygen reserve index (ORI) is a new parameter that can assess oxygenation through a relationship with arterial oxygen partial pressure (PaO2 ). The aim of this study was to examine whether the ORI provides a clinically relevant warning time for an impending SpO2 (pulse oximetry hemoglobin saturation) reduction in neonates and small infants. METHODS: ORI and SpO2 were measured continuously in infants aged <2 years during general anesthesia. The warning time and sensitivity of different ORI alarms for detecting impending SpO2 decrease were calculated. Subsequently, the agreement of the ORI and PaO2 with blood gas analyses was assessed. RESULTS: The ORI of 100 small infants and neonates with a median age of 9 months (min-max, 0-21 months) and weight of 8.35 kg (min-max, 2-13 kg) were measured. For the ORI/PaO2 correlation, 54 blood gas analyses were performed. The warning time and sensitivity of the preset ORI alarm during the entire duration of anesthesia were 84 s (25th-75th percentile, 56-102 s) and 55% (95% CI 52%-58%), and those during anesthesia induction were 63 s (40-82 s) and 56% (44%-68%), respectively. The positive predictive value of the preset ORI alarm were 18% (95% CI 17%-20%; entire duration of anesthesia) and 27% (95% CI 21%-35%; during anesthesia induction). The agreement of PaO2 intervals with the ORI intervals was poor, with a kappa of 0.00 (95% CI = [-0.18; 0.18]). The weight (p = .0129) and height (p = .0376) of the infants and neonates were correlated to the correct classification of the PaO2 interval with the ORI interval. CONCLUSIONS: The ORI provided an early warning time for detecting an impending SpO2 decrease in small infants and neonates in the defined interval in this study. However, the sensitivity of ORI to forewarn a SpO2 decrease and the agreement of the ORI with PaO2 intervals in this real-life scenario were too poor to recommend the ORI as a useful early warning indicator for this age group.

[Preoperative fasting in children-Experiences with implementing a liberal fasting policy]. / Präoperative Nüchternheit bei Kindern ­ Erfahrungen bei Einführung eines liberalen Nüchternheitsgebotes.

BACKGROUND: Traditional fasting rules for children prior to elective operations ("6­4­2 rule") often lead to prolonged fasting times with possible adverse events (discomfort, hypoglycemia, metabolic disorders, agitation/delirium). A new liberal fasting policy allowing children to drink clear fluids until being called to the operating room ("6­4­0") was established in our university hospital. This article describes our experiences and retrospectively examines the effects. OBJECTIVE: Evaluation of real fasting times before and up to 6 months after the intervention (success and durability of changing fasting policy). Evaluation of impact on outcome parameters, such as patients' resp. parents' satisfaction as well as perioperative agitation, arterial hypotension after induction and postoperative nausea and vomiting (PONV). MATERIAL AND METHODS: Retrospective evaluation of methods and interventions from 1 month before to 6 months after changing the fasting policy (June-December 2020). Statistical analysis using descriptive statistics, odds ratio and χ2-test. RESULTS: Of 216 analyzed patients 44 were in the pre-change group and 172 in the post-change group. We could significantly reduce clear fluids fasting times over the 6 months after the intervention (median fasting time: from 6.1 h to 4.5 h; p = 0.034) and achieve our aim (fasting time for clear fluids less than or equal to 2h) in 47% of the patients. Fasting times became longer again reaching pre-change intervals in the 4th and 5th month, so reminder measures turned out to be necessary. By reminding the staff we could reduce fasting times again in the 6th month and restore patients' resp. parents' satisfaction. Satisfaction was improved by shorter fasting times (median school grade from 2.8 to 2.2; p = 0.004; odds ratio for better satisfaction 5.24, 2.1-13.2), and preoperative agitation was reduced (agitation modified PAED scale 1-2 in only 34.5% instead of 50%, p = 0.032). In the liberal fasting group, we observed a nonsignificant smaller incidence of hypotension after induction (7% vs. 14%, p = 0.26) while PONV was too rare in both groups for statistical purposes. CONCLUSION: With multiple interventions we could significantly reduce fasting times for clear fluids and improve patients' resp. parents' satisfaction as well as preoperative agitation. These interventions included regular presence in all staff meetings, a handout for both parents and staff, as well as a remark on the anesthesia protocol. Children who were operated on later in the day, benefited most from the new liberal fasting policy as they were allowed to drink until being called to the operating room. Following our experience, we consider simple and safe fasting rules for the whole staff as most important for change management. Nevertheless, we could not reduce the fasting intervals in all cases and had to remind the staff after 5 months to preserve this success. For enduring success, we suggest regular staff updates during the change process instead of one single kick-off information event.

Evaluation of a Pre-Filled Table and a Flowchart-Based Algorithm as Cognitive Aids to Reduce Deviations in Dose Calculation for Intraoperative Red Blood Cell Transfusions in Children-An International Web-Based Simulation.

BACKGROUND: Transfusion of red blood cell concentrate can be life-saving, but requires accurate dose calculations in children. AIMS: We tested the hypothesis that cognitive aids would improve identification of the correct recommended volumes and products, according to the German National Transfusion guidelines, in pediatric transfusion scenarios. METHODS: Four online questionnaire-based scenarios, two with hemodynamically stable and two with hemodynamically unstable children, were sent to German and international pediatric anesthetists for completion. In the two stable scenarios, participants were given pre-filled tables that contained all required information. For the two emergency scenarios, existing algorithms were used and required calculation by the user. The results were classified into three categories of deviations from the recommended values (DRV): DRV120 (<80% or >120%), as the acceptable variation; DRV 300 (<33% or >300%), the deviation of concern for potential harm; and DRV 1000 (<10% or >1000%), the excessive deviation with a high probability of harm. RESULTS: A total of 1.458 pediatric anesthetists accessed this simulation questionnaire, and 402 completed questionnaires were available for analysis. A pre-filled tabular aid, avoiding calculations, led to a reduction in deviation rates in the category of DRV120 by 60% for each and of DRV300 by 17% and 20%, respectively. The use of algorithms as aids for unstable emergencies led to a reduction in the deviation rate only for DRV120 (20% and 15% respectively). In contrast, the deviation rates for DRV300 and DRV1000 rose by 37% and 16%, respectively. Participants used higher transfusion thresholds for the emergency case of a 2-year-old compromised child than for the stable case with a patient of the same age (on average, 8.6 g/dL, 95% CI 8.5-8.8 versus 7.1 g/dL, 95% CI 7.0-7.2, p < 0.001) if not supported by our aids. Participants also used a higher transfusion threshold for unstable children aged 3 months than for stable children of the same age (on average, 8.9 g/dL, 95% CI 8.7-9.0 versus 7.9 g/dL, 95% CI 7.7-8.0, p < 0.001). CONCLUSIONS: The use of cognitive aids with precalculated transfusion volumes for determining transfusion doses in children may lead to improved adherence to published recommendations, and could potentially reduce dosing deviations outside those recommended by the German national transfusion guidelines.

Pain management after robot-assisted minimally invasive esophagectomy.

Background: Adequate pain control after open esophagectomy is associated with reduced complications, earlier recovery and higher patient satisfaction. While further developing surgical procedures like robot-assisted minimally invasive esophagectomy (RAMIE) it is relevant to adapt postoperative pain management. The primary question of this observational survey was whether one of the two standard treatments, thoracic epidural analgesia (TEA) or intravenous patient-controlled analgesia (PCA), is superior for pain control after RAMIE as the optimal pain management for these patients still remains unclear. Use of additional analgesics, changes in forced expiratory volume in 1 s (FEV1), postoperative complications and duration of intensive care and hospital stay were also analyzed. Methods: This prospective observational pilot study analyzed 50 patients undergoing RAMIE (postoperative PCA with piritramide or TEA using bupivacaine; each n = 25). Patient reported pain using the numeric rating scale score and differences in FEV1 using a micro spirometer were measured at postoperative day 1, 3 and 7. Additional data of secondary endpoints were collected from patient charts. Results: Key demographics, comorbidity, clinical and operative variables were equivalently distributed. Patients receiving TEA had lower pain scores and a longer-lasting pain relief. Moreover, TEA was an independent predictive variable for reduced length of hospital stay (HR -3.560 (95% CI: -6.838 to -0.282), p = 0.034). Conclusions: Although RAMIE leads to reduced surgical trauma, a less invasive pain therapy with PCA appears to be inferior compared to TEA in case of sufficient postoperative analgesia and length of hospital stay. According to the results of this observational pilot study analgesia with TEA provided better and longer-lasting pain relief compared to PCA. Further randomized controlled trials should be conducted to evaluate the optimal postoperative analgesic treatment for RAMIE.

Current hemoglobin thresholds in pediatric anesthesia - guidelines and studies.

PURPOSE OF REVIEW: The use of restrictive transfusion triggers to avoid unnecessary transfusions is one important pillar of Patient Blood Management (PBM). For the safe application of this principle in pediatric patients, anesthesiologists need evidence-based guidelines for hemoglobin (Hb) transfusions thresholds in this specially vulnerable age-group. RECENT FINDINGS: This review outlines recent prospective and observational studies examining transfusion thresholds in pediatrics. Recommendations to use transfusion triggers in the perioperative or intensive care setting are summarized. SUMMARY: Two high-quality studies confirmed that the use of restrictive transfusion triggers in preterm infants in the intensive care unit (ICU) is reasonable and feasible. Unfortunately, no recent prospective study could be found investigating intraoperative transfusion triggers. Some observational studies showed wide variability in Hb levels before transfusion, a tendency toward restrictive transfusion practices in preterm infants, and liberal transfusion practices in older infants. Although there are comprehensive and useful guidelines for clinical practice in pediatric transfusion, most of them do not cover the intraoperative period in particular because of a lack of high-quality studies. This lack of prospective randomized trials focusing on intraoperative transfusion management remains a major problem for the application of pediatric PBM.

Video Laryngoscopy Using King Vision™ aBlade™ and Direct Laryngoscopy in Paediatric Airway Management: A Randomized Controlled Study about Device Learning by Anaesthesia Residents.

Background: Airway management in children is challenging due to anatomical and physiological differences. This randomized trial investigates whether anaesthesia residents can intubate the paediatric trachea more quickly and with a higher success rate using the King Vision™ Paediatric aBlade™ video laryngoscope (KVL) compared to conventional direct laryngoscopy (DL). Methods: Eleven anaesthesia residents (mean age: 31 years, mean training status 47 months) were each asked to perform intubations with the KVL and DL in paediatric patients. The primary outcome was the first-attempt success rate. Secondary outcomes were the time to best view (TTBV), time to placement of the tracheal tube (TTP), time to ventilation (TTV), and participant-reported ease of use on a Likert scale. Results: 105 intubations with the KVL and 106 DL were performed by the residents. The success rate on the first attempt with the KVL was 81%, and the success rate on the first attempt within a given time limit of 30 s was 45%, which was lower than with DL (93% and 77% with time limit, p < 0.01). The median TTBV [IQR] on the first attempt with KVL was 7 [5−10] s, the median TTP was 28 [19−44] s, and the median TTV was 51 [39−66] s. DL-mediated intubation was significantly faster (TTP: 17 [13−23] s; p < 0.0001 and TTV: 34 [28−44] s; p < 0.001). Application of the KVL was rated as difficult or very difficult by 60% of the residents (DL: 5%). Conclusion: In contrast to promising data on the paediatric training manikin, residents took longer to intubate the airway in children with the KVL and were less successful compared to the DL. Therefore, the KVL should not be recommended for learning paediatric intubation by residents.

Big data: Airway management at a university hospital over 16 years; a retrospective analysis.

PURPOSE: Little is known about the current practice of airway management in Germany and its development over the last decades. The present study was, therefore, designed to answer the following questions. Which airway management procedures have been performed over the last 16 years and how has the frequency of these procedures changed over time? Is there a relationship between patient characteristics or surgical specialisation and the type of airway management performed? METHODS: In the present study, we used our in-house data acquisition and accounting system to retrospectively analyse airway management data for all patients who underwent a surgical or medical procedure with anaesthesiological care at our tertiary care facility over the past 16 years. 340,748 airway management procedures were analysed by type of procedure, medical/surgical specialty, and type of device used. Logistic regression was used to identify trends over time. RESULTS: Oral intubation was the most common technique over 16 years (65.7%), followed by supraglottic airway devices (18.1%), nasal intubation (7.5%), mask ventilation (1.6%), tracheal cannula (1.3%), double lumen tube (0.7%), and jet ventilation (0.6%). On average, the odds ratio of using supraglottic airway devices increased by 17.0% per year (OR per year = 1.072, 95% CI = 1.071-1.088) while oral intubation rates decreased. In 2005, supraglottic airway devices were used in about 10% of all airway management procedures. Until 2020, this proportion steadily increased by 27%. Frequency of oral intubation on the other hand decreased and was about 75% in 2005 and 53% in 2020. Over time, second-generation supraglottic airway devices were used more frequently than first-generation supraglottic airway devices. While second-generation devices made up about 9% of all supraglottic airway devices in 2010, in 2020 they represented a proportion of 82%. The use of fibreoptic intubation increased over time in otorhinolaryngology and dental, oral, and maxillofacial surgery, but showed no significant trends over the entire 16-year period. CONCLUSION: Our data represent the first large-scale evaluation of airway management procedures over a long time. There was a significant upward trend in the use of supraglottic airway devices, with an increase in the use of second-generation masks while a decrease in oral intubations was observed.

Evaluation of gender differences in postoperative sore throat and hoarseness following the use of Ambu AuraGain laryngeal mask: the randomised controlled LadyLAMA trial study protocol.

INTRODUCTION: Postoperative sore throat (POST) is a comparatively minor but very common side effect of general anaesthesia with a supraglottic airway device. The patient considers these side effects a mirror of the quality of anaesthesia. The aims of this study are to evaluate gender-specific differences in the incidence of POST and to assess whether the effects of known risk factors vary between genders. METHODS AND ANALYSIS: The LadyLAMA trial is a single-centre, patient-blinded, randomised controlled trial. Consecutive patients requiring ophthalmological surgery under general anaesthesia with a second generation Ambu AuraGain laryngeal mask are randomly allocated to either cuff pressure of 45 cmH2O or cuff pressure of 60 cmH2O. We estimate the difference in POST between the genders at 20% and we hypothesised that a reduction of cuff pressure would reduce POST by 10%. A total of 800 patients will be recruited, with each subgroup including 200 patients to achieve 80% power for detecting a difference at the 5% significance level. Primary endpoints are gender differences in the incidence of POST within 24 hours postoperatively, as well as comparison of cuff pressure 45 cmH2O to 60 cmH2O with respect to POST. The main secondary objective is the effect of cuff pressure on POST stratified by gender. Further secondary endpoints are gender-specific differences in POST and hoarseness in postanaesthesia care unit (PACU) at 48 and 72 hours (or until freedom of discomfort). The parameter cuff pressure serves as key-secondary endpoint. ETHICS AND DISSEMINATION: The project is approved by the local ethics committee of the Medical Association of the Rhineland Palatine state (Nr. 2021-15835). The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings. TRIAL REGISTRATION NUMBER: NCT04915534.

Current practice of German anesthesiologists in airway management : Results of a national online survey.

BACKGROUND: There is a worldwide consensus among experts that guidelines and algorithms on airway management contribute to improved patient safety in anesthesia. The present study aimed to determine the current practice of airway management of German anesthesiologists and assess the safety gap, defined as the difference between observed and recommended practice, amongst these practitioners. OBJECTIVE: To determine the effect of implementing the guidelines on airway management practice in Germany amongst anesthesiologists and identify potential safety gaps. METHODS: A survey was conducted in September 2019 by contacting all registered members of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) via email. The participants were asked about their personal and institutional background, adherence to recommendations of the current German S1 guidelines and availability of airway devices. RESULTS: A total of 1862 DGAI members completed the questionnaire (response rate 17%). The main outcome was that anesthesiologists mostly adhered to the guidelines, yet certain recommendations, particularly pertaining to specifics of preoxygenation and training, showed a safety gap. More than 90% of participants had a video laryngoscope and half had performed more than 25 awake intubations using a flexible endoscope; however, only 81% had a video laryngoscope with a hyperangulated blade. An estimated 16% of all intubations were performed with a video laryngoscope, and 1 in 4 participants had performed awake intubation with it. Nearly all participants had cared for patients with suspected difficult airways. Half of the participants had already faced a "cannot intubate, cannot oxygenate" (CICO) situation and one in five had to perform an emergency front of neck access (eFONA) at least once. In this case, almost two thirds used puncture-based techniques and one third scalpel-based techniques. CONCLUSION: Current practice of airway management showed overall adherence to the current German guidelines on airway management, yet certain areas need to be improved.

Esophageal Interventions in Infants Born with Esophageal Atresia: A Comprehensive Analysis of a National Database.

INTRODUCTION: Esophageal atresia (EA) is a rare malformation that often requires a series of procedures, including surgical primary anastomosis, staged repair, and endoscopic procedures. Actual numbers and trends in interventions and variety in treatment strategies remain unclear. MATERIALS AND METHODS: Data from the German federal bureau of statistics containing all EA-related inpatient procedures encoded from 2005 until 2018 were analyzed for children during the first year of life. The sum of esophageal anastomoses and replacements was used to calculate an estimate of incidence of EA. RESULTS: Over 14 years, 12,627,888 inpatient cases were recorded in infants in Germany. The mean incidence of EA was 1 per 4,217 live births. On average, 163.3 (95% confidence interval [CI]: 150.8-176.1) esophageal anastomoses, 11.2 (95% CI: 8.7-13.7) esophageal lengthening procedures, and 6.7 (95% CI: 5.42-8.00) esophageal replacements were recorded annually. Overall, 187.8 (95% CI: 147.1-200.4) endoluminal treatments (ballon dilatation, bougienage, stent placement, or injection) were performed per 100 anastomoses. Over the years, bougienage was increasingly replaced by ballon dilatation as primary treatment. Boys had a significantly higher number of esophageal procedures than girls, but the incidence of endoscopic treatments in relation to anastomoses was the same for both genders. CONCLUSION: The low incidence of EA in relation to a relatively large number of units treating those patients in Germany may pose challenges for maintaining competency and training of all specialists involved. The number of esophagoscopic treatments for esophageal stricture per anastomosis is lower than previously estimated.

Anaesthetic protocol for paediatric glaucoma examinations: the prospective EyeBIS Study protocol.

INTRODUCTION: Neonates and young infants with diagnosed or highly suspected glaucoma require an examination under anaesthesia to achieve accurate intraocular pressure (IOP) measurements, since crying or squinting of the eyes may increase IOP and lead to falsely high values. IOP considerably depends on perioperative variables such as haemodynamic factors, anaesthetics, depth of anaesthesia and airway management. The aim of this paper is to report the design and baseline characteristics of EyeBIS, which is a study to develop a standardised anaesthetic protocol for the measurement of IOP under anaesthesia in childhood glaucoma, by investigating the link between the magnitude of IOP and depth of anaesthesia. METHODS AND ANALYSIS: This is a single-centre, prospective cohort study in 100 children with diagnosed or highly suspected glaucoma all undergoing ophthalmological examination under general anaesthesia. 20 children, who undergo general anaesthesia for other reasons, are included as controls. The primary outcome measure is the establishment of a standardised anaesthetic protocol for IOP measurement in childhood glaucoma by assessing the relationship between IOP and depth of anaesthesia (calculated as an electroencephalography variable, the bispectral index), with special emphasis on airway management and haemodynamic parameters. The dependence of IOP under anaesthesia on airway management and haemodynamic parameters will be described, using a mixed linear model. Restricting the model to patients with healthy eyes will allow to determine a 95% reference region, in which 95% of the measurement values of patients with healthy eyes can be expected. ETHICS AND DISSEMINATION: The study has been approved by the local ethics committee of the Medical Association of Rhineland-Palatine (Ethik-Kommisssion der Landesaerztekammer Rheinland-Pfalz), Germany (approval number: 2019-14207). This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at national and international scientific meetings and data sharing with other investigators. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03972852).

Anaesthesia protocol evaluation of the videolaryngoscopy with the McGrath MAC and direct laryngoscopy for tracheal intubation in 1000 patients undergoing rapid sequence induction: the randomised multicentre LARA trial study protocol.

INTRODUCTION: Rapid sequence induction of anaesthesia is indicated in patients with an increased risk of pulmonary aspiration. The main objective of the technique is to reduce the critical time period between loss of airway protective reflexes and rapid inflation of the cuff of the endotracheal tube to minimise the chance of aspiration of gastric contents. The COVID-19 pandemic has reinforced the importance of first-pass intubation success to ensure patient and healthcare worker safety. The aim of this study is to compare the first-pass intubation success rate (FPS) using the videolaryngoscopy compared with conventional direct laryngoscopy in surgical patients with a high risk of pulmonary aspiration. METHODS AND ANALYSIS: The LARA trial is a multicentre, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath MAC videolaryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of FPS is 92% in the McGrath group and 82% in the Macintosh group. Each group must include a total of 500 patients to achieve 90% power for detecting a difference at the 5% significance level. Successful intubation with the FPS is the primary endpoint. The secondary endpoints are the time to intubation, the number of intubation attempts, the necessity of airway management alternatives, the visualisation of the glottis using the Cormack and Lehane Score and the Percentage Of Glottic Opening Score and definite adverse events. ETHICS AND DISSEMINATION: The project is approved by the local ethics committee of the Medical Association of the Rhineland Palatine state (registration number: 2020-15502) and medical ethics committee of the University of Freiburg (registration number: 21-1303). The results of this study will be made available in form of manuscripts for publication and presentations at national and international meetings. TRIAL REGISTRATION: NCT04794764.

Intraoperative transfusion practice in burned children in a university hospital over four years: a retrospective analysis.

BACKGROUND: Patient blood management programs should be applied to the pediatric population, but little is known about the current transfusion practice of pediatric burn injury patients. This retrospective study was performed to evaluate the practice of red blood cell (RBC) transfusion in children with burn injury, their predictive factors, and adherence to the German transfusion guideline. METHODS: We reviewed the RBC transfusion practice of all children younger than 8 years with burn injury who were operated during a four-year period in a German university medical center. We analyzed the data associated with transfusion and guideline conformity of transfusion triggers for RBCs from the beginning to the end of hospital stay using logistic regression. RESULTS: During the four-year period, 138 children (median age 21 months, minimum-maximum 9-101 months) with burn injury needed surgery, 31 children were transfused with RBCs. During their hospital stay, the median hemoglobin concentrations (Hb) of transfused and non-transfused children were 8 g/dL (6.3-11.3 g/dL) and 10.7 (7-13.8 g/dL), respectively. Total body surface area burned (TBSA) (OR = 1.17 per % TBSA, 95% CI = [1.05; 1.30], p = 0.0056), length of surgery (OR = 1.016 per minute, 95% CI = [1.003; 1.028], p = 0.0150), and Hb (OR = 0.48 per 1 g/dl in Hb, 95% CI = [0.24; 0.95], p = 0.0343) were associated with transfusion while other factors (age, gender, ASA, and catecholamines) did not show notable association. Length of stay was mainly influenced by TSBA (+ 1.38 days per %, p <  0.0001), age (+ 0.21 days per month, p = 0.0206), and administering of catecholamines (+ 14.3 days, p = 0.0118), but not by RBC transfusion. The decision to transfuse was in 23% too restrictive and in 74% too liberal according to the German guidelines. CONCLUSIONS: Amount of TBSA, length of surgery, and Hb influenced the RBC transfusion rate in burned children. However, age and length of stay were not affected by transfusion of RBCs. In clinical practice of burned children, physicians follow a more liberal transfusion strategy than the proposed in guidelines.

[Comparison of the Accuracy of the Measurement of Fetal Hemoglobin by Blood Gas Analysis and by Laboratory Gold Standard: a Prospective Diagnostic Study]. / Prospektiver Vergleich der Genauigkeit der Messung des fetalen Hämoglobins mittels Blutgasanalyse mit dem Goldstandard bei früh- und reifgeborenen Neugeborenen.

BACKGROUND: In neonatologic clinical practice and research the percentage of fetal hemoglobin (HbF) of total hemoglobin can be of interest. Blood gas analyzers offer the measurement of HbF. However, it is not known if results are accurate enough to apply in clinical decision-making or scientific questions. In this prospective diagnostic study, we examined the accuracy of HbF measurement by a blood gas analyzer. METHODS: On a neonatal intensive care and neonatal ward, the percentage of HbF was measured using both the laboratory gold standard (HbFlab, reference method) and the blood gas analyzer (HbFgas) (ABL 800 Flex, Radiometer). Agreement of HbFlab and HbFgas was assessed by the Bland-Altman method including bias and limits of agreement and by calculation of the root mean square error (RMSE). RESULTS: Thirty-five measurements in 23 term and preterm infants with a median body weight of 2190 g (min-max 967-3800 g) and a median postmenstrual age of 36+1 weeks (min-max 29+6-43+2) were performed. The Bland-Altman diagram for the measurement of HbF(gas) versus HbF(lab) shows an overestimation of HbF by the blood gas analyzer (bias 9.3%, limits of agreement 1 to 17.6%). RMSE was 10.2%; 45.7% of HbFgas measurements were >10% out of range from HbFlab. There was no influence of age, body temperature or oxygen saturation on the bias (p=0,132; p=0,194; p=0,970), but bias increased with increasing HbFlab (Pearson correlation r=0,426; p=0,011). CONCLUSION: The measurement of HbF in term and preterm infants by a blood gas analyzer lacked sufficient agreement with that of the reference method to recommend this application for clinical decision-making or scientific purposes.

Pediatric non-red cell blood product transfusion practices: what's the evidence to guide transfusion of the 'yellow' blood products?

PURPOSE OF REVIEW: Research studies pertaining to the management of pediatric non-red cell blood product transfusion is limited. Clinical practices vary within disciplines and regions. Anesthesiologists need evidence-based guidelines to make appropriate and safe decisions regarding transfusion of the 'yellow' blood products for pediatric patients. RECENT FINDINGS: This review outlines clinical indications for transfusion of fresh frozen plasma, cryoprecipitate, platelets, and fibrinogen concentrate in pediatrics. Recent studies of non-red blood cell transfusions in critical, but stable situations are highlighted. Recommendations to guide transfusion of the 'yellow' blood products in operative and non-operative settings are summarized. Special attention is drawn to guidelines in massive hemorrhage and trauma situations. SUMMARY: Evidence-based guidelines and expert consensus recommendations exist to guide the transfusion of pediatric non-red blood products and should be followed when transfusing the 'yellow' blood components. As high-quality studies in neonates, infants and children are limited, future research should broaden our knowledge in this direction with the goal to use restrictive strategies to improve patient outcomes.