Swiss Latin Airway Guidelines: a holistic approach for improving airway management.

Airway management is a core competency for many different medical specialties. Despite continuous improvements in equipment, clinical understanding, education and training, airway management complications remain a significant cause of morbidity and mortality worldwide. Several international airway management guidelines already exist, but there has never been a national consensus document for Switzerland. The Fondation Latine des Voies Aériennes (FLAVA) has developed a new set of airway management guidelines based on the latest scientific evidence and the authors' extensive clinical experience. These recommendations are intended to guide and assist clinicians in managing a wide array of airway situations. They are applicable to the daily routine management of anticipated and unanticipated airway difficulties. The new 2022 FLAVA Airway Guidelines (FLAGs) combine cognitive aids for using the latest technical skills and non-technical skills. Specially-designed key mnemonics and ergonomic tools complement these guidelines, including a colour-coded airway cart.

Severe traumatic brain injury in a high-income country: an epidemiological study.

This adult cohort determined the incidence and patients' short-term outcomes of severe traumatic brain injury (sTBI) in Switzerland and age-related differences. A prospective cohort study with a follow-up at 14 days was performed. Patients ≥16 years of age sustaining sTBI and admitted to 1 of 11 trauma centers were included. sTBI was defined by an Abbreviated Injury Scale of the head (HAIS) score >3. The centers participated from 6 months to 3 years. The results are presented as percentages, medians, and interquartile ranges (IQRs). Subgroup analyses were performed for patients ≤65 years (younger) and >65 (elderly). sTBI was observed in 921 patients (median age, 55 years; IQR, 33-71); 683 (74.2%) were male. Females were older (median age, 67 years; IQR, 42-80) than males (52; IQR, 31-67; p<0.00001). The estimated incidence was 10.58 per 100,000 inhabitants per year. Blunt trauma was observed in 879 patients (95.4%) and multiple trauma in 283 (30.7%). Median Glasgow Coma Score (GCS) on the scene was 9 (IQR 4-14; 8 in younger, 12 in elderly) and in emergency departments 5 (IQR, 3-14; 3 in younger, 8 in elderly). Trauma mechanisms included the following: 484 patients with falls (52.6%; younger, 242 patients [50.0%]; elderly, 242 [50.0%]), 291 with road traffic accidents (31.6%; younger, 237 patients [81.4%]; elderly, 54 [18.6%]), and 146 with others (15.8%). Mortality was 30.2% (24.5% in younger, 40.9% in elderly). Median GCS at 14 days was 15 (IQR, 14-15) without differences among subgroups. Estimated incidence of sTBI in Switzerland was low, age was high, and mortality considerable. The elderly had higher initial GCS and a higher death rate, but high GCS at 14 days.

[Alveolar proteinosis: a cause of immunodeficiency]. / Protéinose alvéolaire: une maladie fascinante et un facteur d'immunosuppression peu connu.

Alveolar proteinosis is a rare disease, characterized by accumulation of surfactant in alveoli. Various forms have been identified (congenital, secondary or auto-immune). Treatment is to be reserved for patients that experience moderate to severe symptoms. It requires whole lung lavages, in order to clear the alveoli from the proteinaceous material. Macrophages dysfunction plays a crucial role in the development of the disease and causes immunodeficiency, which in turn can promote opportunistic infections, in patients a priori thought to be immunocompetent.

PRO: osmotherapy for the treatment of acute intracranial hypertension.

Persisting severe brain edema causes intracranial hypertension and is associated with poor patient outcome. The treatment of acute intracranial hypertension is complex and multimodal. The most important options for medical treatment include controlled ventilation and osmotherapy, maintenance of brain and body homeostasis, and sedation. Osmotherapy is recommended in all relevant guidelines. The 2 osmotic agents most frequently used are mannitol and hypertonic saline. Both reduce intracranial pressure and improve cerebral perfusion and cerebral oxygen delivery. However, hypertonic saline seems advantageous over mannitol in many situations. In multitrauma patients, hypertonic saline contributes to hemodynamic stabilization and to the prevention of secondary insults. In addition, hypertonic saline has neurohumoral and immunologic effects, which may be beneficial in cerebral resuscitation.

Complications of different ventilation strategies in endoscopic laryngeal surgery: a 10-year review.

BACKGROUND: Spontaneous ventilation, mechanical controlled ventilation, apneic intermittent ventilation, and jet ventilation are commonly used during interventional suspension microlaryngoscopy. The aim of this study was to investigate specific complications of each technique, with special emphasis on transtracheal and transglottal jet ventilation. METHODS: The authors performed a retrospective single-institution analysis of a case series of 1,093 microlaryngoscopies performed in 661 patients between January 1994 and January 2004. Data were collected from two separate prospective databases. Feasibility and complications encountered with each technique of ventilation were analyzed as main outcome measures. RESULTS: During 1,093 suspension microlaryngoscopies, ventilation was supplied by mechanical controlled ventilation via small endotracheal tubes (n = 200), intermittent apneic ventilation (n = 159), transtracheal jet ventilation (n = 265), or transglottal jet ventilation (n = 469). Twenty-nine minor and 4 major complications occurred. Seventy-five percent of the patients with major events had an American Society of Anesthesiologists physical status classification of III. Five laryngospasms were observed with apneic intermittent ventilation. All other 24 complications (including 7 barotrauma) occurred during jet ventilation. Transtracheal jet ventilation was associated with a significantly higher complication rate than transglottal jet ventilation (P < 0.0001; odds ratio, 4.3 [95% confidence interval, 1.9-10.0]). All severe complications were related to barotraumas resulting from airway outflow obstruction during jet ventilation, most often laryngospasms. CONCLUSIONS: The use of a transtracheal cannula was the major independent risk factor for complications during jet ventilation for interventional microlaryngoscopy. The anesthetist's vigilance in clinically detecting and preventing outflow airway obstruction remains the best prevention of barotrauma during subglottic jet ventilation.

[Autologous blood pre-donation and perioperative use of erythropoietin]. / Prédonation autologue et place de l'érythropoïétine en phase périopératoire.

The general concept of blood saving covers a number of technical and pharmacological actions which all aim to maintain the erythrocyte mass of the patient, and of which blood transfusion is only one. Severe anemia (Hb <60-80 g/l) increases postoperative mortality and morbidity. However, its correction by blood transfusion tends to worsen the prognosis. It is therefore imperative to conserve the patient's blood by any means possible. Detecting anemia is of primary importance. Whenever possible, its cause should be identified and treated. Depending on the detected anemia, as well as the blood loss expected during surgery, the patient should receive EPO (anemia with foreseeable moderate blood loss), or autologous pre-donation associated with EPO (anemia with foreseeable large blood loss).

[Hemorrhage and transfusion: the case of Jehovah's witnesses]. / Hémorragie et transfusion: le cas des Témoins de Jéhovah.

For Jehovah Witness patients the additional responsibilities of surgeon, anesthetist and intensivist represent a particular challenge. A "therapeutic" contract needs to be established at the very outset specifying the commitment and undertaking of each party. The management of these patients requires that all the medical team demonstrate expertise in minimizing the risk of blood loss and in ensuring adequate oxygen transport to the tissues in the event of acute anaemia. The patient's autonomy must be respected at all times, including the availability of colleagues who agree with patients' demand. Above all, the entire medical team must respect the personal values of the patient despite any contradiction with their own values. This means that judgements based on values must be avoided in order to allow for the freedom of thought.

[Antiplatelet drugs and intraoperative hemorrhage]. / Antiplaquettaires et hemorragie peropératoire.

Antiplatelet drugs and intraoperative haemorrhage Current literature demonstrates that there is less risk involved in maintaining anti-aggregant therapy (which might imply to transfuse more the patients), than in stopping it, which then increases dangerously the risk of coronary thrombosis. Aspirin, as a secondary preventive drug, should not be interrupted. Clopidogrel is essential for protection against thrombosis in areas where the endothelium is not intact. Unless there is a high hemorrhagic risk in closed cavities (intracranial surgery), clopidogrel should not be interrupted. Furthermore, any surgical intervention increasing the coagulability of the platelets, it seems particularly dangerous to stop such medication perioperatively.

[Comparison of three protocols in the control of cardiovascular response to suspended laryngoscopy in ENT surgery]. / Comparaison de trois protocoles dans le contrôle de la réponse cardiovasculaire à laryngoscopie suspendue dans la chirurgie ORL.

The objective was to compare the effect of three pharmacological agents on the hemodynamic response to suspended laryngoscopy in micro ENT Surgery. Double blind randomised prospective study having included: groupe A (n = 16) having benefited before laryngoscopy of 150 mcg/kg esmolol, groupe B (n = 16) 15 mcg/kg of nicardipine, groupe C (n = 15) 1 mg/kg of lidocaine and groupe D (n = 16), placebo group. All groups were comparable for demographic and anesthetic data. A significant reduction of the heart rate and pressure rate product were noted in esmolol group during the endoscopic act and maintained until arousal. Whereas there was no difference in the blood pressure during the procedure whatever the pharmacological agent for prevention of cardiovascular complications for patients to risk in micro ENT surgery.