Managing One-Lung Ventilation in Tracheostomized Patients: A 6-Year Retrospective Analysis.

BACKGROUND: To ensure safe and optimal surgical conditions in thoracic surgery, one-lung ventilation is crucial. Various techniques exist to achieve one-lung ventilation. Tracheotomized patients who require one-lung ventilation represent a unique and rare subgroup that demands specialized knowledge and skills. The very limited literature has discussed alternative methods, no randomized controlled trials have addressed this issue yet. METHODS: We performed a retrospective analysis of patients who underwent one-lung ventilation in the Department of Thoracic Surgery of a German University Hospital between 2016 and 2021. The study assessed patient demographics, airway management techniques, ventilation parameters, and adverse events. RESULTS: In 3,197 anesthesia procedures during the observation period, 152 patients had an existing tracheostomy, of which 56 required one-lung ventilation. Among others in 42 cases, a tracheostomy tube was combined with a bronchial blocker, and in 10 cases, a double-lumen tracheostomy tube was used. There were no severe complications. Intraoperative dislocations that required repositioning of the device occurred in six patients (13.3%) with bronchial blockers and one patient with double-lumen tracheostomy tube (10%). CONCLUSION: The management of one-lung ventilation in tracheotomized patients presents unique challenges. While double-lumen tracheostomy tubes have specific advantages, we recommend considering their use carefully. For most tracheotomized patients, bronchial blockers in conjunction with a tracheostomy tube are used, which offers safety and practicality, irrespective of the tracheostomy's age or type. Further research and randomized controlled trials are warranted to establish best practices for one-lung ventilation in this unique patient population.

An approach to difficult airway in infants: Comparison of GlideScope® Spectrum LoPro, GlideScope® Spectrum Miller and conventional Macintosh and Miller blades in a simulated Pierre Robin sequence performed by 90 anesthesiologists.

BACKGROUND: Airway management can be challenging in neonates and infants. The Pierre Robin sequence (PRS) is a condition characterized by micrognathia, glossoptosis and airway obstruction. The airway management of these patients poses great challenges for anesthesiologists and pediatricians alike. To date, there has been no direct comparison of the hyperangulated GlideScope® Spectrum LoPro (GLP), the straight GlideScope® Spectrum Miller (GSM), a conventional Macintosh (MC) and a conventional Miller blade (ML) in patients with PRS. METHODS: For this purpose, 90 anesthesiologists (43 with limited experience, 47 with extensive experience) performed orotracheal intubation on an Air-Sim® Pierre Robin X manikin using GLP, GSM, MC and ML in randomized order. 'Time-to-vocal-cords', 'time-to-intubate', 'time-to-ventilate', the severity of oral-soft-tissue-trauma and the subjective evaluation of each device were recorded. RESULTS: A significantly faster and better view of the vocal cords and lower oral-soft-tissue-trauma was achieved using the GLP (p<0.001). Though, there were no significant differences in the 'time-to-intubate' or 'time-to-ventilate'. The highest intubation success rate was found with GSM and the lowest with GLP (GSM 100%, ML 97.8%, MC 96.7%, GLP 93.3%). When using the videolaryngoscopes, there were no undetected esophageal intubations but in six cases prolonged attempts of intubation (>120s) with the GLP. In the sub-group with extensive experience, we found significantly shorter intubation times for the GSM and ML. The GLP was the tool of choice for most participants, while the conventional MC received the lowest rating. CONCLUSIONS: Videolaryngoscopy leads to increased safety for the prevention of undetected esophageal intubation in the airway management in a PRS manikin. Hyperangulated blades may ensure a good and fast view of the vocal cords and low oral-soft-tissue-trauma but pose a challenge during the placement of the tube. Specific skills and handling seem to be necessary to ensure a safe tube placement with this sort of blades.

Effects of exercise and cold-water exposure on microvascular muscle perfusion.

PURPOSE: Microvascular blood flow (MBF) and its intramuscular regulation are of importance for physiological responsiveness and adaptation. The quantifiable in-vivo monitoring of MBF after cycling or systemic cold-water exposure may reveal new insights into capillary regulatory mechanisms. This study aimed to assess the role of exercise and cold therapy on MBF by using contrast-enhanced ultrasound (CEUS). METHODS: Twenty healthy athletes were recruited and randomly assigned to an intervention (IG) or a control group (CG). MBF was quantified in superficial (rectus femoris, RF) and deep muscle layers (vastus intermedius, VI). Representative perfusion parameters (peak enhancement (PE) and wash-in area under the curve (WiAUC)) were measured after a standardized measurement protocol for both groups at resting conditions (t0) and after cycling (20 min., 70% Watt max, t1) for both groups, after cold-water immersion exposure for IG (15 min., 12°C) or after precisely 15 minutes of rest for CG (t2) and for both groups after 60 minutes of follow-up (t3). RESULTS: At t1, MBF in VI increased significantly compared to resting conditions in both groups in VI (p= 0.02). After the cold-water exposure (t2), there were no statistically significant changes in perfusion parameters as well as after 60 minutes of follow-up (t3) (p = 0.14). CONCLUSION: Cycling leads to an upregulation of MBF. However, cold exposure does not change the MBF. The implementation of CEUS during different physiological demands may provide deeper insight into intramuscular perfusion regulation and regenerative processes.

Job Satisfaction and Performance Orientation of Paramedics in German Emergency Medical Services-A Nationwide Survey.

(1) Background: Shortage of skilled workers is a relevant global health care problem. To remain competitive with other professions, job satisfaction is a critical issue; however, to date, there are no data available on the German EMS. This study aims to perform a statistical analysis of job satisfaction and performance orientation and to identify risk factors for low job satisfaction of paramedics in the German EMS. (2) Methods: Data were collected from 2590 paramedics through a nationwide cross-sectional survey, using the job satisfaction questionnaire by Neuberger and Allerbeck and the performance orientation questionnaire by Hippler and Krüger. Descriptive and regression statistical analysis were performed. (3) Results: The participants scored significantly lower than the reference sample on job satisfaction, with "organization and management" and "payment" being the lowest rated subscales. Around 9% of employees feared losing their jobs. While work attitude toward performance and success enhancement was high, fear of failure was also common. (4) Conclusions: Job satisfaction of paramedics in the German EMS is below that of the reference sample. Discontent with payment and organizational issues is common. Performance orientation is high, but fear of failure is frequent. Current and future efforts that aim at an attractive working environment should reflect on these findings.

A cross-sectional study on foot loading patterns in elite soccer players of different ages.

BACKGROUND: Alterations in plantar loading patterns are risk factors for stress injuries of the lower limb, particularly of the foot and ankle. Epidemiological studies have revealed a higher incidence of soccer-related stress fractures of the fifth metatarsal (MT V) in younger athletes than in their adult counterparts. OBJECTIVE: The aim of the present study was to assess the plantar pressure distributions of members of four high-level soccer teams of different age groups to identify age-related differences in loading patterns. METHODS: A total of 65 elite soccer players were included in the study. Data were computed with sensor-loaded insoles (pedar® X system, novel Inc., Munich, Germany) while the players ran in soccer shoes. Plantar pressures for nine defined regions on the preferred and nonpreferred foot were analyzed. RESULTS: The participants consisted of 17 elite male soccer professionals from the first national league (mean 23 years, height 184 cm, weight 81 kg), 14 players from the under-21 squad (U21, 20 years, 180 cm, 75 kg), 15 players from the U17 squad (16 years, 176 cm, 69 kg) and 19 players from the U16 squad (15 years, 179 cm, 70 kg). We detected statistically significantly elevated peak pressures on the lateral aspects of the nonpreferred foot compared with the preferred foot in the U16 and U17 players, corresponding to a relative increase by 29% (p= 0.044) in the lateral midfoot, a relative increase by 24% (p= 0.031) in MT heads 4-5 in the U16 players and a difference of 18% (p= 0.049) in the lateral midfoot in the U17 players. In contrast, the U21 and adult professional players displayed symmetric plantar pressure distributions in all foot regions. CONCLUSIONS: In contrast to adult elite soccer players, adolescents demonstrate asymmetric foot loading patterns with increased peak loads in the lateral aspects of the nonpreferred foot. Our results may provide some explanation for MT V stress fractures that occur in elite adolescents.

Effects of Pre- and Post-Exercise Cold-Water Immersion Therapy on Passive Muscle Stiffness.

BACKGROUND: Cold-water immersion (CWI) has become a popular preventive, regenerative and performance-enhancing intervention in various sports. However, its effects on soft tissue, including changes of intramuscular stiffness, are poorly understood. The purpose of this study was to investigate the effect of CWI on muscle stiffness. PATIENTS/MATERIAL AND METHODS: Thirty healthy participants were included and divided into the three following groups (n = 10): 1) post-ESU group: exercise and CWI (post-exercise set-up); 2) control group: exercise without CWI (control condition); 3) pre-ESU group: CWI alone (pre-exercise set-up). Acoustic radiation force impulse (ARFI) elastography was conducted to assess tissue stiffness (shear wave velocity, SWV). Values obtained at resting conditions (baseline, t0) were compared to values post-exercise (t1, for post-ESU group and control group), post-CWI (t2, for post-ESU group and pre-ESU group; rest for control group) and to 60-min follow-up time (t3, for all groups). Data were assessed in superficial and deep muscle tissue (rectus femoris muscle, RF; vastus intermedius muscle, VI). RESULTS: For the post-ESU group (CWI post-exercise), there was no significant difference between the time points of measurements: exercise (t1: RF: 1.63 m/s; VI: 1.54 m/s), CWI (t2: RF: 1.63 m/s; VI: 1.53 m/s) and at 60-min follow-up (t3: RF: 1.72 m/s; VI: 1.61 m/s). In the control group, a significant decrease of SWV was found between baseline conditions at t0 and post-exercise (t1) at VI (VI: 1.37 m/s; p = 0.004; RF: 1.59 m/s; p = 0.084). For t2 and t3, no further significant changes were detected. Regarding the pre-exercise set-up (pre-ESU group), a significant decrease in SWV from baseline to t2 in VI (1.60 m/s to 1.49 m/s; VI: p = 0.027) was found. CONCLUSION: This study shows varying influences of CWI on muscle stiffness. Overall, we did not detect any significant effects of CWI on muscle stiffness post-exercise. Muscle stiffness-related effects of CWI differ in the context of a pre- or post-exercise condition and have to be considered in the implementation of CWI to ensure its potential preventive and regenerative benefits.

Acoustic radiation force impulse tissue characterization of the anterior talofibular ligament: a promising noninvasive approach in ankle imaging.

OBJECTIVES: The anterior talofibular ligament (ATFL) is the most frequently injured ligament during inversion strains of the ankle. The purpose of this study was to evaluate the feasibility of acoustic radiation force impulse (ARFI) elastography and to determine the in vivo mechanical properties of the ATFL in healthy athletes. METHODS: Sixty healthy athletes (32 female, 28 male; 28.9 ± 2.1 years) were recruited from the medical and sports faculty. ARFI values, represented as shear wave velocities (SWVs) as well as conventional ultrasound were obtained for the ATFL in neutral ankle position. A clinical assessment was performed in which the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score and the functional ankle ability measure (FAAM) were collected. Interobserver and intraobserver reliability (repeated sessions and repeated days) were assessed using an intra class correlation coefficient (ICC) and typical error (TE) calculation in absolute (TE) and relative units as coefficient of the variation (CV). RESULTS: SWV values of the ATFL had an average velocity of 1.79 ± 0.20 m/s for all participants, with an average of 1.72 ± 0.36 m/s for females and 1.85 ± 0.31 m/s for males. The interobserver and intraobserver reliability revealed an ICC of 0.902 and 0.933 (TE of 0.67 (CV: 5.2%) and 0.52 (CV: 3.84%)), respectively. FAAM and AOFAS revealed the best possible scores. CONCLUSION: ARFI seems to be a valuable diagnostic modality and represents a promising imaging marker for the assessment and monitoring of ankle ligaments in the context of acute and chronic ankle instabilities; ARFI could also be used to investigate loading or sport dependent adaptions.

Application of Acoustic Radiation Force Impulse Elastography in Imaging of Delayed Onset Muscle Soreness: A Comparative Analysis With 3T MRI.

CONTEXT: Delayed onset muscle soreness is one of the most common reasons for impaired muscle performance in sports and is associated with reduced muscle strength and frequently observed both in professional and recreational athletes. OBJECTIVE: To emphasize the diagnostic value of acoustic radiation force impulse (ARFI) in imaging of delayed onset muscle soreness by comparing findings with high-resolution 3T magnetic resonance imaging T2-weighted sequences. DESIGN: Case series. SETTING: Laboratory environment. PARTICIPANTS: Fifteen healthy students (7 females and 8 males; mean [SD]: age 24 [4] y, height 178 [10] cm, body weight 67 [12] kg). MAIN OUTCOME MEASURES: ARFI values, represented as shear wave velocities of the gastrocnemius muscle and soleus muscle, as well as conventional ultrasound, high-resolution 3T magnetic resonance imaging, creatine kinase activity, extension range of the ankle joint, calf circumference, and muscle soreness were assessed before (baseline) and 60 hours after (postintervention) a standardized eccentric exercise. RESULTS: ARFI shear wave velocity values of the gastrocnemius muscle revealed a statistically significant decrease of 19.1% between baseline (2.2 [0.26] m/s) and postintervention (1.78 [0.24] m/s); P = .01. At follow-up, the magnetic resonance imaging investigations showed intramuscular edema for the gastrocnemius muscle in all participants corresponding to a significant raise in T2 signal intensity (P = .001) and in T2-time values (P = .004). CONCLUSIONS: ARFI elastography seems to be an additional sensitive diagnostic modality in the diagnostic workup of delayed onset muscle soreness. Intramuscular shear wave velocities could represent an additional imaging marker for the assessment and monitoring of ultrastructural muscle injuries and therefore be helpful for individual training composition in elite sports.

How do leg press exercises comply with limited weight bearing?

OBJECTIVES: To investigate foot loadings in different leg press settings with respect to a possible graduation of weight bearing (WB). DESIGN: Case series. SETTINGS: Assessing plantar force values by means of dynamic pedobarography taken place in orthopaedic departments' rehab center. PARTICIPANTS: 15 healthy students (9 men and 6 women, age 23 ± 2, weight 75 ± 6 kg) were recruited as participants from the medical faculty. MAIN OUTCOME MEASURES: Peak force values from normal gait (referred to as 100%) and single and double leg presses (SLP, DLP) with resistances of 10 kg, 20 kg and 40 kg, obtained with pedobarographic insoles. RESULTS: Performing DLP produced foot loadings (N) of 37 ± 15 with 10 kg, 91 ± 29 with 20 kg and 203 ± 27 with 40 kg, equal to 5%, 12% and 26% of full WB. SLP result in force values of 195 ± 32 with 10 kg, 308 ± 34 with 20 kg and 516 ± 45 with 40 kg, corresponding to 25%, 40% and 67% baseline. CONCLUSIONS: Leg press exercises can be performed in accordance with a given limitation of foot loading. Above mentioned conditions allow a graduation from 5% to 67% of full WB.

A multimodal approach to ankle instability: Interrelations between subjective and objective assessments of ankle status in athletes.

The aim of this retrospective cohort study is to investigate the association between different subjective and objective assessments of ankle function in a population of athletes with or without functional ankle instability (FAI). 29 athletes with a history of ankle spraining were divided into two groups according to their ankle status: 16 with FAI (initial ankle sprain with residual functional instability) (age 24.6 ± 3.1 years), and 13 COPERS (initial ankle sprain without residual instability) (age 25.3 ± 4.4 years). The assessment of each individual's ankle function was based on three approaches: The "functional-ankle-ability-measure" (FAAM) assessing subjective ankle functionality, measures of sensorimotor control as objective functional measurements and MRI-based T2-mapping as a quantitative marker of compositional joint status. Pearson's product-moment-correlation coefficient, student's t-test and analysis-of-variance were used for statistical analysis. Significant group differences existed for subjective ankle function (FAAM, p = 0.04) and MRI-data mainly in the medial compartment of the ankle joint (p ≤ 0.05). We found unique associations between T2-mapping results and sensorimotor scores in the COPER (r = -0.756-0.849), and "FAI"-group (r = 0.630-0.657). The location and magnitude differed between groups. No correlations existed between these measures and the FAAM. This exploratory study provides preliminary evidence for potential interrelations between various diagnostic measures of ankle function and structure in individuals with and without FAI. We found associations between MRI-results and selected measures of sensorimotor control, indicating a potential link between loss of ankle function and early joint degeneration. Despite these interrelations, each of the different assessment options appears to contain unique information on ankle functionality important in a clinical assessment.