German guidelines for airway management 2023.

The German airway management guidelines are intended to serve as an orientation and decision-making aid and thus contribute to the optimal care of patients undergoing anesthesiologic- and intensive medical care. As part of the pre-anesthesiologic evaluation, anatomical and physiological indications for difficult mask ventilation and intubation shall be evaluated. This includes the assessment of mouth opening, dental status, mandibular protrusion, cervical spine mobility and existing pathologies. The airway shall be secured while maintaining spontaneous breathing if there are predictors or anamnestic indications of difficult or impossible mask ventilation and/or endotracheal intubation. Various techniques can be used here. If there is an unexpectedly difficult airway, a video laryngoscope is recommended after unsuccessful direct laryngoscopy, consequently a video laryngoscope must be available at every anesthesiology workplace. The airway shall primarily be secured with a video laryngoscope in critically ill- and patients at risk of aspiration. Securing the airway using translaryngeal and transtracheal techniques is the "ultima ratio" in airway management. The performance or supervision of airway management in the intensive care unit is the responsibility of experienced physicians and nursing staff. Appropriate education and regular training are essential. Clear communication and interaction between team members are mandatory before every airway management procedure. Once the airway has been secured, the correct position of the endotracheal tube must be verified using capnography.

[COVID-19 pandemic: structured expansion of ventilation capacities using home respirators]. / COVID-19-Pandemie: strukturierte Erweiterung von Beatmungskapazitäten mithilfe von Heimrespiratoren.

Due to the current COVID-19 pandemic there is a need for a rapid increase in intensive care and ventilation capacities. Delivery times for additional intensive care respirators are currently not foreseeable. An option to increase ventilation capacities not only for COVID-19, but for all patients requiring mechanical ventilation is to use home respirators. Home respirators are turbine respirators, so they can usually be operated without high-pressure oxygen connections and can therefore also be used in areas outside the classical intensive care medical infrastructure. Due to their limited technical features, home respirators are not suitable for the treatment of severely affected patients but can be used for weaning after respiratory improvement, which means that intensive care respirators are available again more quickly. Respiratory therapists are specially trained nurses or therapists in the field of out of hospital ventilation and can independently use home ventilation respirators, for example for weaning in the intensive care unit. Thus, they relieve intensive care nursing staff in the pandemic. Due to the COVID-19 pandemic medical students from the Oldenburg University are currently being trained in operating home respirators to provide basic support in the hospital if necessary.

[Hot topics in obstetric anesthesia]. / "Hot topics" aus der geburtshilflichen Anästhesie.

In 2019 the annual conference of the scientific working group on obstetric anesthesiology of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) took place in the usual manner. Emergency situations, such as the challenge of a preclinical birth or the recognition and treatment of an amniotic fluid embolism were discussed. In addition, topics on the correct treatment of a female patient with a known addictive disorder were of great interest as well as the discussion on the question when a transfusion should be performed in postpartum anemia and which risks accompany the increasing prevalence of obesity, especially during pregnancy. A further hot topic was the deliberation on the prevalence and differential diagnostic clarification of neurological complications after epidural anesthesia. In connection with the topic of birth, exciting and practice relevant topics for all anesthetists confronted with this field were presented and discussed. The essential aspects are summarized in this article.

Tracheoesophageal fistula following button battery ingestion in an infant : Airway management considerations.

A 13-month-old infant was admitted to hospital approximately 3 weeks after ingestion of a button battery, which was lodged in the esophagus and had caused a tracheoesophageal fistula requiring mechanical ventilation. Since the battery had partially penetrated into the tracheal lumen just above the carina and also was in direct contact with the pulmonary artery, extensive considerations regarding airway and circulatory management were required preoperatively, which are presented and discussed in this case report.

[Update Mallampati : Theoretical and practical knowledge of European anesthetists on basic evaluation of airways]. / Update Mallampati : Theoretische und praktische Kenntnisse europäischer Anästhesisten zur Basisevaluation der Atemwege.

In 1985 Mallampati et al. published a non-invasive score for the evaluation of airways (Mallampati grading scale, MGS), which originally consisted of only three different classes and has been modified several times. At present it is mostly used in the version of Samsoon and Young consisting of four different classes. Class I: soft palate, fauces, uvula, palatopharyngeal arch visible, class II: soft palate, fauces, uvula visible, class III: soft palate, base of the uvula visible and class IV: soft palate not visible. Nevertheless, other versions of MGS still exist, each having different values for sensitivity and specification. The current opinion is therefore that MGS is no longer useful as a stand-alone predictor but in combination with others it is still part of today's most relevant guidelines, such as those of the American Society of Anesthesiologists (ASA), the UK's Difficult Airway Society (DAS), the European Society of Anaesthesiology (ESA) and the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and must therefore be known by anesthetists. Even in times of sophisticated tools for airway management, the procedure remains a high risk, so every anesthetist has to be prepared for and well trained in management of known and unexpected difficult airways. Evaluation of the patient's airway is a part of modern airway management to prevent problems and reduce risk of hypoxia during the procedure. The theoretical knowledge and practical skills of European anesthetists were evaluated at two international congresses, the German Anesthesia Congress (DAC) and Euroanaesthesia 2014. The DAC is an annual meeting of German speaking anesthetists, hosted by the DGAI. The Euroanaesthesia is the annual European pendant hosted by the ESA. Participation was voluntary and only physicians were allowed to take part. Theory was evaluated by a questionnaire containing open and closed questions for MGS that had to be answered by every participant alone. Apart from theory, a practical evaluation was performed. Every participant had to classify the MGS of a human airway model. The model was identical on both congresses. According to the original publication a checklist containing the factors essential for the correct performance was filled out by a supervising experienced anesthetist. During DAC 2014 n = 267 physicians participated in the study, 22 participants were excluded due to inconsistent answers, incomplete questionnaires or missing practical part. A total of 245 data sets were evaluated. During Euroanaesthesia 2014 n = 298 physicians participated in the study, 68 participants were excluded due to inconsistent answers, incomplete questionnaires or missing practical part and 230 data sets were evaluated. At the DAC the mean age (± SD) was 44.5 ± 9.5 years, 157 (64.1%) were male and 88 (35.9%) were female. Working experience was trainee anesthetist in 16.7% and other participants were experienced anesthetists. At the ESA the mean age (± SD) was 42.4 ± 9.5 years, 133 (57.8%) were male and 97 (42.2%) female. Trainee anesthetists were 15.2%, the rest were experienced anesthetists. The DAC participants knew Mallampati classes 1 (65%) and 4 (45%) better than 2 and 3 and there was no relevant differences to the ESA (close to 30% knew the classes 1-4 here). Classification of the airway model was correct in 62% and 67% at DAC and ESA, respectively. Most participants performed the practical evaluation correctly except the sitting position of the model. In agreement with earlier studies, these results show the lack of knowledge in evaluation of airways according to current guidelines of all relevant societies. This is likely to increase preventable risks for patients as unexpected difficult airway management increases the risk for hypoxia and intubation damage.

[Simulator model for ultrasound-guided pericardiocentesis : Construction manual and practical evaluation]. / Simulationsmodell für ultraschallgestützte Perikardiozentese : Bauanleitung und praktische Evaluation.

An important challenge in learning ultrasound-assisted interventions, such as pericardiocentesis, is the navigation of the needle in a three-dimensional space on the basis of a two-dimensional image. In order to learn this in vitro realistic simulators are required. We manufactured a model which allows simulation of pericardiocentesis on the basis of ballistic gelatin (12.6%, 250 Bloom). Furthermore, the pericardiocentesis model was subjectively evaluated by 37 anesthetists in a pre-post design. The models used proved to be technically simple to manufacture, hard wearing and realistic. They are therefore regularly used in our hospitals to learn ultrasound-assisted interventions.

Thyromental distance ("Patil") revisited : Knowledge and performance of a basic airway screening tool among European anesthetists.

Predicting and managing the difficult airway is a lifesaving and vital basic task for the anesthetist. Current guidelines of all important societies include thyromental distance (TMD, "Patil") as a possible predictor for a difficult airway and includes two important aspects for airway management: the mandibular space and the flexibility of the cervical spine. We evaluated knowledge and execution regarding TMD for predicting a difficult airway on participants at the Euroanaesthesia (ESA) congress and German Anaesthesia Congress (DAC) in 2014. Our evaluation consisted of a theoretical part with questions regarding general knowledge and a practical evaluation with anesthetists performing on a human airway model. Practical evaluations were performed separately from other participants. During the DAC 245 (ESA 230) physicians participated, of which 64% were male (ESA 58%). At the DAC 182 (74.3%) and ESA 82 (35.6%) participants knew about Patil/TMD. Its use as a predictive score for a difficult airway was known by 122 (49.8%; DAC) and 79 (34.4%; ESA) participants. The correct definition for intubation was given by 45 (25.7%) at the DAC and 56 (24.3%) at ESA. Only 40-41% of the participants measured the correct distance for TMD. Only 6.1-6.5% completed both the theoretical and practical parts correctly. As non-invasive TMD includes two different aspects of patient airways and is part of current guidelines, education and training must be extended to assure adequate evaluation in the future.

[Intubating laryngeal tube suction disposable: Initial clinical experiences with a novel device for endotracheal intubation]. / Intubationslarynxtubus Suction Disposable: Erste klinische Erfahrungen mit einem neuen Hilfsmittel zur endotrachealen Intubation.

BACKGROUND: According to the recent guidelines supraglottic airways, such as laryngeal tubes are recommended to ensure oxygenation in patients with unexpected difficult airways. The novel Intubating Laryngeal Tube Suction Disposable (iLTS-D) is a modified laryngeal tube designed for secondary tracheal intubation. This pilot study evaluated the use of the iLTS-D in clinical practice with respect to practicality and efficacy. METHODS: In this study the airways of 30 consecutive adult patients with no evidence of a difficult airway undergoing elective ear, nose and throat (ENT) surgery were managed with the iLTS-D. After induction of anesthesia the iLTS-D was placed in position and checked for correct ventilation. Following muscle relaxation, endotracheal intubation through the iLTS-D was performed under continuous visualization using a flexible bronchoscope. Finally, the iLTS-D was removed leaving the endotracheal tube in place. Data were collected anonymously as part of a quality assurance program. Publication of the data was approved by the institutional review board. RESULTS: Initial iLTS-D placement took a median of 17 s (range 12-90 s) and provided sufficient ventilation in all patients; however, the position of the iLTS-D needed to be adjusted in four patients. Endotracheal intubation through the iLTS-D was achieved in 29 out of 30 patients at the first attempt (n = 23) or after 2 attempts (n = 6) and the median time required for intubation was 32 s (range 18-187 s). In five patients no laryngeal structures could initially be identified by bronchoscopy. Blind endotracheal intubation through the iLTS-D was performed in two cases and in two other patients the endotracheal tube was also blindly advanced but into the esophagus. After removal of the endotracheal tube and repositioning of the iLTS-D, successful tracheal intubation was subsequently achieved under bronchoscopic vision. The procedure was aborted and uneventful conventional intubation using direct laryngoscopy was carried out in one patient. The median time for removal of the iLTS-D after successful intubation was 20 s (range 15-80 s). Minor blood stains on the iLTS-D were observed in three patients. With one exception, all problems and adverse events occurred during the first 10 patients. CONCLUSION: This first clinical study demonstrated that in patients with apparently normal airways and in the hands of users without previous experience, the iLTS-D allowed sufficient ventilation in all patients and had a high success rate for subsequent endotracheal intubation. The results are, however, preliminary until confirmed by further studies, particularly in patients with difficult airways.

[S1 guidelines on airway management]. / S1-Leitlinie Atemwegsmanagement.

Since the publication of the first german guidelines on airway management in 2014, new techniques have been established in the clinical routine and new insights into existing strategies have been published. As a consequence the new guidelines on airway management of the German Society of Anesthesiology and Intensive Care Medicine represent the current state of scientific knowledge and integrate the currently recommended techniques and strategies. The aim of these guidelines is to guarantee an optimal care of patients undergoing anesthesiological procedures and serve as an orientation and decision aid for users.

S1 guidelines on airway management : Guideline of the German Society of Anesthesiology and Intensive Care Medicine.

Since the publication of the first German guidelines on airway management in 2004 new techniques have been established in the clinical routine and new insights into existing strategies have been published. As a consequence the new guidelines on airway management of the German Society of Anesthesiology and Intensive Care Medicine represent the current state of scientific knowledge and integrate the currently recommended techniques and strategies. The aim of these guidelines is to guarantee an optimal care of patients undergoing anesthesiological procedures and serve as an orientation and decision aid for users.

[Routine subclavian revascularisation employing regional anaesthesia]. / Routinemäßige Subclavia-Revaskularisation in Regionalanästhesie.

INTRODUCTION: The increasing incidence of endovascular surgery on the thoracic aorta (TEVAR) is leading to an increased rate of subclavian-carotid transposition (SCT). Intentional overstenting of the left subclavian artery extends the proximal landing zone. If overstenting leads to a subclavian steal syndrome, vertebrobasilar insufficiency or if the risk of spinal ischaemia is present, SCT can safely be carried out with regional anaesthesia by means of a cervical block. MATERIALS AND METHODS: Since January 2010 regional anaesthesia was employed in 13 consecutive patients receiving an SCT in our clinic. Subclavian revascularisation was performed either as adjunct procedure for TEVAR or in patients with occlusive disease of the aortic arch. The clinical course was prospectively observed. RESULTS: In 62 % of the cases (n = 8) a transposition of the subclavian artery onto the common carotid artery was carried out. In 38 % of the cases (n = 5) an intraoperative decision was made to construct a carotid-subclavian bypass. In 30 % (n = 4) of the cases a conversion from cervical block to general anaesthesia was necessary. All reconstructions proved to be patent at follow-up. CONCLUSION: Subclavian-carotid transposition under regional anaesthesia is safe and technically feasible if occlusion of the subclavian artery by thoracic stentgraft or stenosis has occurred. The technique employing regional anaesthesia can, therefore, also be offered to patients with increased risk for complications due to general anaesthesia.

[Practice guidelines for management of the difficult airway: update by the American Society of Anesthesiologists task force]. / "Practice Guidelines for Management of the Difficult Airway" : Update der American Society of Anesthesiologists Task Force.

In February 2013 the Committee of the American Society of Anesthesiologists (ASA) Task Force published the amended version of the "Practice guidelines for management of the difficult airway" which replace the recommendations from 2003. The amended version re-evaluated the recommendations from 2003 in 2011, evaluated recently published studies and recommendations and included them in the new practice guidelines. In particular, new technical developments, such as the recently established video-assisted intubation procedure were taken into consideration. Despite the many publications in the field of airway management the evidence resulting from the data obtained from recent publications is so low that the new information does not necessitate any amendments to the existing guidelines. In short, the current guidelines basically correspond to the previous version published 10 years ago but are, however, more than twice as extensive. This article summarizes and comments on the cornerstones of the guidelines.

[An online emergency physician survey - demography, education and experience of German emergency physicians]. / Demografie, Ausbildung und Erfahrung der Notärzte in Deutschland: www.notarztfragebogen.de.

BACKGROUND AND OBJECTIVE: German emergency patients are treated by (emergency) physicians (EP). The entry level to emergency medicine differs. Manual skills experience (e. g. tracheal intubation) and knowledge of guidelines are minimum requirements. It is currently unclear who works as an EP and what medical experience he or she has. METHODS: The anonymous survey was online from 10/15/2010 to 11/16/2011 and distribution was supported by leading physicians informing society members. Online networks informed independent physicians. RESULTS: 2091 EP took part, 1991 datasets were evaluated, 100 datasets were excluded. All results are shown as mean ± standard deviation and range (minimum - maximum). Mean age of the EP was 42 ± 8 years (26-71 years), 80 % (n = 1604) were male, 20 % (n = 387) were female. Participants finished medical school in 1997 ± 8 years (1964-2010). Base specialty during rotation was anesthesiology 59 %, internal medicine 32 %, surgery 26 %, trauma surgery/orthopedics 21 %, others 16 %. Consultants were 75 %. Main income source was answered as "hospital physician" by 77 %, "resident doctor" by 15 %, "professional emergency physician" by 7 %. The participants use a widespread chance for CME (Continuing Medical Education). CONCLUSION: The participants appear experienced in medicine and emergency medicine. They use a widespread chance for CME. Most of the participants work in anaesthesiology.

[TEAM®-G (Trauma Evaluation and Management Germany). Serves as a basis for an interdisciplinary training in the emergency room]. / TEAM®-G ("Trauma Evaluation and Management Germany"). Grundlage für ein interdisziplinäres und interprofessionelles Schockraumtraining.

BACKGROUND: The implementation of ATLS® in the daily routine of trauma management in the emergency department is a challenge. This goal cannot be reached by educating ATLS® to a few team members only. In order to enforce the implementation of ATLS® in a level I trauma centre, a generic in-house training was introduced in 2009 with inter-professional integration of all specialists of the trauma team. MATERIALS AND METHODS: The TEAM® course (trauma evaluation and management concept of the American College of Surgeons) was the theoretical basis of the training. This educational program was developed for medical students and multidisciplinary team members. Prior training, a questionnaire for self-assessment was completed by n=84 team members to assess their knowledge about ATLS® principles. The hands-on training time was 90 min. N=10 members of the trauma team worked out three scenarios of multiple injured patients. These were provided as near-reality manikin simulations by a specialist trainer. After the training participants re-evaluated and analysed improvement by the training. Duration of trauma management and the number of missed injuries were analysed one year prior and one year after the training and served as a marker of the process and outcome quality of trauma care. RESULTS: Prior the training, 57% of trainees specified their knowledge related to the ATLS® can be improved. Their expectations were generally satisfied by the training. The mean time of trauma management in the ED could not be reduced one year after the training (36±16 min) compared to one year prior the training (39±18 min), however, the detection of missed injuries (5.6% vs. 3.2%, p<0.05) was significantly diminished after the training. CONCLUSION: Apart form education of ATLS® providers the inauguration of an interdisciplinary and interprofessionel team training may enhance implementation of ATLS- algorithms into daily routine.

[Reintubation using the C-MAC videolaryngoscope. Implementation in patients with difficult airways initially managed with in situ laryngeal tubes]. / Umintubation mithilfe des C-MAC-Videolaryngoskops. Durchführung bei Patienten mit schwierigem Atemweg und einliegendem Larynxtubus.

BACKGROUND: Securing the airway with supraglottic airway devices, such as a laryngeal tube, is a regular component of most difficult airway management algorithms. It is further recommended that in emergency medicine rescuers less skilled in endotracheal intubation should use supraglottic airways as a first line device. Exchanging the laryngeal tube with an endotracheal tube can be performed with video-assisted laryngoscopy as described below. MATERIAL AND METHODS: A total of 20 adult patients with airways managed using laryngeal tubes due to actual or anticipated difficult intubation underwent endotracheal intubation using the C-MAC videolaryngoscope. After deflating the cuffs of the laryngeal tube, seeking out the glottis was done by following the constructional landmarks of the laryngeal tube, considering concordance with anatomical landmarks of the human airway. In cases of failed video-assisted endotracheal intubation, the laryngeal tube that was still in situ was reinflated to re-establish ventilation of the lungs. RESULTS: In 19 out of the 20 patients the laryngeal tube could be exchanged for an endotracheal tube with the video-assisted technique described. In one patient no laryngeal structures could be identified (Cormack and Lehane grade IV) even with the C-MAC videolaryngoscope and ventilation was continued via the laryngeal tube. No complications related to the video-assisted intubation technique were observed. CONCLUSIONS: The C-MAC videolaryngoscope is a mobile system which facilitates endotracheal intubation in patients with a difficult airway and a laryngeal tube in place. It is not only possible but recommended to leave the laryngeal tube in situ as a back-up when videolaryngoscopy fails.