[Recommendations of the new S1 guidelines on airway management]. / Empfehlungen zur neuen S1-Leitlinie Atemwegsmanagement.

The German guidelines for airway management aim to optimize the care of patients undergoing anesthesia or intensive care. The preanesthesia evaluation is an important component for detection of anatomical and physiological indications for difficult mask ventilation and intubation. If predictors for a difficult or impossible mask ventilation and/or endotracheal intubation are present the airway should be secured while maintaining spontaneous breathing. In an unexpectedly difficult intubation, attempts to secure the airway should be limited to two with each method used. A video laryngoscope is recommended after an unsuccessful direct laryngoscopy. Therefore, a video laryngoscope should be available at every anesthesiology workspace throughout the hospital. Securing the airway should primarily be performed with a video laryngoscope in critically ill patients and patients at risk of pulmonary aspiration. Experienced personnel should perform or supervise airway management in the intensive care unit.

Evaluation of the C-MAC Miller Video Laryngoscope Sizes 0 and 1 During Tracheal Intubation of Infants Less Than 10 kg.

STUDY OBJECTIVE: Video laryngoscopy has primarily been developed to assist in difficult airways. Using video laryngoscopy in pediatric airway management is an up-and-coming topic. The aim of the presented study was to compare the intubation conditions obtained when using the C-MAC video laryngoscope with Miller blades sizes 0 and 1 for standard direct laryngoscopy and indirect laryngoscopy in children weighing less than 10 kg. DESIGN: This was a prospective study. SETTING: The study was performed in a university hospital. PATIENTS: Following ethical approval, 86 infants weighing less than 10 kg and undergoing surgery under general anesthesia were studied prospectively. INTERVENTION: Indirect and direct laryngoscopy either with C-MAC Miller blade size 0 or size 1. MEASUREMENTS: First, direct laryngoscopy was performed, and the best obtained view was graded without looking at the video monitor. A second investigator blinded to the view obtained under direct laryngoscopy graded the laryngeal view on the video monitor. Time to intubation, intubation conditions, and intubation attempts were recorded. RESULTS: In infants less than 10 kg, intubation conditions were excellent. There were no significant differences between the use of Miller blade 0 or 1 in reference to Cormack-Lehane grade, time to intubation, time to best view, or intubation attempts. Comparing direct and indirect intubation conditions using either Miller blade 0 or 1 revealed that the use of indirect laryngoscopy provided a significantly better view (P < 0.05) of the vocal cords. In 3 infants weighing more than 8 kg, the Miller blade 0 was described as too short and narrow for intubation. CONCLUSIONS: Both devices allowed for an excellent visualization of the vocal cords.

Comparing Four Video Laryngoscopes and One Optical Laryngoscope with a Standard Macintosh Blade in a Simulated Trapped Car Accident Victim.

BACKGROUND: Tracheal intubation still represents the "gold standard" in securing the airway of unconscious patients in the prehospital setting. Especially in cases of restricted access to the patient, video laryngoscopy became more and more relevant. OBJECTIVES: The aim of the study was to evaluate the performance and intubation success of four different video laryngoscopes, one optical laryngoscope, and a Macintosh blade while intubating from two different positions in a mannequin trial with difficult access to the patient. METHODS: A mannequin with a cervical collar was placed on the driver's seat. Intubation was performed with six different laryngoscopes either through the driver's window or from the backseat. Success, C/L score, time to best view (TTBV), time to intubation (TTI), and number of attempts were measured. All participants were asked to rate their favored device. RESULTS: Forty-two physicians participated. 100% of all intubations performed from the backseat were successful. Intubation success through the driver's window was less successful. Only with the Airtraq® optical laryngoscope, 100% success was achieved. Best visualization (window C/L 2a; backseat C/L 2a) and shortest TTBV (window 4.7 s; backseat 4.1 s) were obtained when using the D-Blade video laryngoscope, but this was not associated with a higher success through the driver's window. Fastest TTI was achieved through the window (14.2 s) when using the C-MAC video laryngoscope and from the backseat (7.3 s) when using a Macintosh blade. CONCLUSIONS: Video laryngoscopy revealed better results in visualization but was not associated with a higher success. Success depended on the approach and familiarity with the device. We believe that video laryngoscopy is suitable for securing airways in trapped accident victims. The decision for an optimal device is complicated and should be based upon experience and regular training with the device.

Prospective Trial to Compare Direct and Indirect Laryngoscopy Using C-MAC PM® with Macintosh Blade and D-Blade® in a Simulated Difficult Airway.

Objective. Evaluation of C-MAC PM® in combination with a standard Macintosh blade size 3 in direct and indirect laryngoscopy and D-Blade® in indirect laryngoscopy in a simulated difficult airway. Primary outcome was defined as the best view of the glottic structures. Secondary endpoints were subjective evaluation and assessment of the intubation process. Methods. Prospective monocentric, observational study on 48 adult patients without predictors for difficult laryngoscopy/tracheal intubation undergoing orthopedic surgery. Every participant preoperatively received a cervical collar to simulate a difficult airway. Direct and indirect laryngoscopy w/o the BURP maneuver with a standard Macintosh blade and indirect laryngoscopy w/o the BURP maneuver using D-Blade® were performed to evaluate if blade geometry and the BURP maneuver improve the glottic view as measured by the Cormack-Lehane score. Results. Using a C-MAC PM® laryngoscope, D-Blade® yielded improved glottic views compared with the Macintosh blade used with either the direct or indirect technique. Changing from direct laryngoscopy using a Macintosh blade to indirect videolaryngoscopy using C-MAC PM® with D-Blade® improved the Cormack-Lehane score from IIb, III, or IV to I or II in 31 cases. Conclusion. The combination of C-MAC PM® and D-Blade® significantly enhances the view of the glottis compared to direct laryngoscopy with a Macintosh blade in patients with a simulated difficult airway. Trial Registration Number. This trial is registered under number NCT03403946.

Laryngeal tube suction for airway management during in-hospital emergencies.

OBJECTIVE:: The role of supraglottic airway devices in emergency airway management is highlighted in international airway management guidelines. We evaluated the application of the new generation laryngeal tube suction (LTS-II/LTS-D) in the management of in-hospital unexpected difficult airway and cardiopulmonary resuscitation. METHODS:: During a seven-year period, patients treated with a laryngeal tube who received routine anesthesia and had an unexpected difficult airway (Cormack Lehane Grade 3-4), who underwent cardiopulmonary resuscitation, or who underwent cardiopulmonary resuscitation outside the operating room and had a difficult airway were evaluated. Successful placement of the LTS II/LTS-D, sufficient ventilation, time to placement, number of placement attempts, stomach content, peripheral oxygen saturation/end-tidal carbon dioxide development (SpO2/etCO2) over 5 minutes, subjective overall assessment and complications were recorded. RESULTS:: In total, 106 adult patients were treated using an LTS-II/LTS-D. The main indication for placement was a difficult airway (75%, n=80), followed by cardiopulmonary resuscitation (25%, n=26) or an overlap between both (18%, n=19). In 94% of patients (n=100), users placed the laryngeal tube during the first attempt. In 93% of patients (n=98), the tube was placed within 30 seconds. A significant increase in SpO2 from 97% (0-100) to 99% (5-100) was observed in the whole population and in cardiopulmonary resuscitation patients. The average initial etCO2 of 39.5 mmHg (0-100 mmHg) decreased significantly to an average of 38.4 mmHg (10-62 mmHg) after 5 minutes. A comparison of cardiopulmonary resuscitation patients with non-cardiopulmonary resuscitation patients regarding gastric contents showed no significant difference. CONCLUSIONS:: LTS-D/LTS-II use for in-hospital unexpected difficult airway management provides a secure method for primary airway management until other options such as video laryngoscopy or fiber optic intubation become available.

Laryngeal tube suction for airway management during in-hospital emergencies

OBJECTIVE: The role of supraglottic airway devices in emergency airway management is highlighted in international airway management guidelines. We evaluated the application of the new generation laryngeal tube suction (LTS-II/LTS-D) in the management of in-hospital unexpected difficult airway and cardiopulmonary resuscitation. METHODS: During a seven-year period, patients treated with a laryngeal tube who received routine anesthesia and had an unexpected difficult airway (Cormack Lehane Grade 3-4), who underwent cardiopulmonary resuscitation, or who underwent cardiopulmonary resuscitation outside the operating room and had a difficult airway were evaluated. Successful placement of the LTS II/LTS-D, sufficient ventilation, time to placement, number of placement attempts, stomach content, peripheral oxygen saturation/end-tidal carbon dioxide development (SpO2/etCO2) over 5 minutes, subjective overall assessment and complications were recorded. RESULTS: In total, 106 adult patients were treated using an LTS-II/LTS-D. The main indication for placement was a difficult airway (75%, n=80), followed by cardiopulmonary resuscitation (25%, n=26) or an overlap between both (18%, n=19). In 94% of patients (n=100), users placed the laryngeal tube during the first attempt. In 93% of patients (n=98), the tube was placed within 30 seconds. A significant increase in SpO2 from 97% (0-100) to 99% (5-100) was observed in the whole population and in cardiopulmonary resuscitation patients. The average initial etCO2 of 39.5 mmHg (0-100 mmHg) decreased significantly to an average of 38.4 mmHg (10-62 mmHg) after 5 minutes. A comparison of cardiopulmonary resuscitation patients with non-cardiopulmonary resuscitation patients regarding gastric contents showed no significant difference. CONCLUSIONS: LTS-D/LTS-II use for in-hospital unexpected difficult airway management provides a secure method for primary airway management until other options such as video laryngoscopy or fiber optic intubation become available.

A radiographic comparison of human airway anatomy and airway manikins--Implications for manikin-based testing of artificial airways.

OBJECTIVE: The aim of this prospective, single-center, observational study was to investigate the accuracy of modeling and reproduction of human anatomical dimensions in manikins by comparing radiographic upper airway measurements of 13 different models with humans. METHODS: 13 commonly used airway manikins (male or female anatomy based) and 47 controls (adult humans, 37 male, 10 female) were investigated using a mediosagittal and axial cervical spine CT scan. For anatomical comparison six human upper airway target structures, the following were measured: Oblique diameter of the tongue through the center, horizontal distance between the center point of the tongue and the posterior pharyngeal wall, horizontal distance between the vallecula and the posterior pharyngeal wall, distance of the upper oesophageal orifice length of epiglottis distance at the narrowest part of the trachea. Furthermore, the cross-section of the trachea in axial view and the cross-section of the upper oesophageal orifice in the same section was calculated. All measurements were compared gender specific, if the gender was non-specified with the whole sample. RESULTS: None of the included 13 different airway manikins matched anatomy in human controls (n = 47) in all of the six measurements. The Laerdal Airway Management Trainer, however, replicated human airway anatomy at least satisfactorily. CONCLUSION: This investigation showed that all of the examined manikins did not replicate human anatomy. Manikins should therefore be selected cautiously, depending on the type of airway securing procedure. Their widespread use as a replacement for in vivo trials in the field of airway management needs to be reconsidered.

Impact of peer feedback on the performance of lecturers in emergency medicine: a prospective observational study.

BACKGROUND: Although it is often criticised, the lecture remains a fundamental part of medical training because it is an economical and efficient method for teaching both factual and experimental knowledge. However, if administered incorrectly, it can be boring and useless. Feedback from peers is increasingly recognized as an effective method of encouraging self-reflection and continuing professional development. The aim of this observational study is to analyse the impact of written peer feedback on the performance of lecturers in an emergency medicine lecture series for undergraduate students. METHODS: In this prospective study, 13 lecturers in 15 lectures on emergency medicine for undergraduate medical students were videotaped and analysed by trained peer reviewers using a 21-item assessment instrument. The lecturers received their written feedback prior to the beginning of the next years' lecture series and were assessed in the same way. RESULTS: In this study, we demonstrated a significant improvement in the lecturers' scores in the categories 'content and organisation' and 'visualisation' in response to written feedback. The highest and most significant improvements after written peer feedback were detected in the items 'provides a brief outline', 'provides a conclusion for the talk' and 'clearly states goal of the talk'. CONCLUSION: This study demonstrates the significant impact of a single standardized written peer feedback on a lecturer's performance.

Complications associated with the prehospital use of laryngeal tubes--a systematic analysis of risk factors and strategies for prevention.

OBJECTIVE: With the increasing spread of laryngeal tubes (LT) in emergency medicine, complications and side-effects are observed. We sought to identify complications associated with the use of LTs in emergency medicine, and to develop strategies to prevent these incidents. METHODS: In a prospective clinical study, all patients who had their airways managed in the field with a LT and who were admitted through the emergency department of the Frankfurt University Hospital during a 6 year period were evaluated using anonymised data collection sheets. A team of experts was available 24/7 and was requested whenever a patient was admitted with a LT in place. This team evaluated the condition of the patients with respect to prehospital airway management and was responsible for further advanced airway management. All complications were analysed, and strategies for prevention developed. RESULTS: One hundred eighty nine patients were included and analysed. The initial cuff pressure of the LTs was 10 0 cm H2O on the median. Complications consisted of significant tongue swelling (n=73; 38.6%), resulting in life-threatening cannot ventilate, cannot intubate scenarios in two patients (1.0%) and the need for surgical tracheostomy in another patient, massive distension of the stomach (n=20, 10.6%) with ventilation difficulties when LTs without gastric drainage were used; malposition of the LT in the piriform sinus (n=1, 0.5%) and significant bleeding from soft tissue injuries (n=4, 2.1%). CONCLUSIONS: The prehospital use of LTs may result in severe and even life-threatening complications. Likely, such complications could have been prevented by using gastric drainage and cuff pressure adjustment. Both, prehospital health care providers and emergency department staff should develop a greater awareness of such complications to best avoid them in the future.

Laryngeal mask airway versus endotracheal tube for percutaneous dilatational tracheostomy in critically ill adult patients.

BACKGROUND: Percutaneous dilatational tracheostomy (PDT) is one of the most common bedside surgical procedures performed in critically ill adult patients on intensive care units (ICUs) who require long-term ventilation. PDT is generally associated with relevant life-threatening complications (e.g. cuff rupture leading to possible hypoxia or aspiration, puncture of the oesophagus, accidental extubation, mediastinitis, pneumothorax, emphysema). The patient's airway can be secured with an endotracheal tube (ETT) or a laryngeal mask airway (LMA). OBJECTIVES: To assess the safety and effectiveness of ETT versus LMA in critically ill adult patients undergoing PDT on the ICU.This review addresses the following research questions.1. Is an LMA more effective than an ETT in terms of procedure-related or all-cause mortality?2. Is an LMA safer than an ETT in terms of procedure-related life-threatening complications during a PDT procedure?3. Does use of an LMA influence the conditions for performing a tracheostomy (e.g. duration of procedure)? SEARCH METHODS: We searched the Cochrane Database of Systematic Reviews (CDSR); the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 6 (part ofThe Cochrane Library); MEDLINE (from 1984 to 27 June 2013) and EMBASE (from 1984 to 27 June 2013). We searched for reports of ongoing trials in the metaRegister of Controlled Trials (mRCT). We handsearched for relevant studies in conference proceedings of the International Symposium on Intensive Care and Emergency Medicine (ISICEM), the Annual Congress of the European Society of Intensive Care Medicine (ESICM), the Annual Congress of the Society of Critical Care Medicine (SCCM), the American Thoracic Society (ATS) and the Annual Meeting of the American College of Chest Physicians (ACCP). We contacted study authors and experts concerning unpublished data and ongoing trials. We searched for further relevant studies in the reference lists of all included trials and of relevant systematic reviews identified in theCDSR. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared use of endotracheal tubes versus laryngeal mask airways in critically ill adult patients undergoing PDT on the ICU. We imposed no restrictions with regard to language, timing or technique of PDT performed. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the eligibility and methodological quality of each study and carried out data extraction. We resolved disagreements by discussion. Our primary outcomes were all-cause mortality, procedure-related mortality and tally of participants with one or more serious adverse events. When available, we reported on our secondary outcomes, which included duration of the procedure, failure of the procedure requiring conversion to any other procedure, time to extubation after tracheostomy, length of ICU stay after tracheostomy, length of hospital stay after tracheostomy and any other serious adverse events. When possible, we combined homogeneous studies for meta-analysis. We used the risk of bias tool of The Cochrane Collaboration to assess the internal validity of all included studies in six different domains. MAIN RESULTS: We included in this review eight RCTs involving 467 participants. The included trials exclusively assessed critically ill participants (e.g. with head injury, neurological disease, multi-trauma, sepsis, acute respiratory failure (ARF) and/or chronic obstructive pulmonary disease (COPD)). Internal validity was considerably low in studies with a high or unclear risk of bias. The main reason for this was low methodological quality or missing data, even after study authors were contacted. Study size was generally small, with a minimum of 40 and a maximum of 73 participants. Only one study (40 participants) reported on overall mortality, showing no clear evidence of a difference between treatment groups (risk ratio (RR) 1.5, 95% confidence interval (CI) 0.28 to 8.04, Fisher test P value 1.0, low-quality evidence). Four studies (231 participants) reported that no procedure-related deaths occurred with any intervention. Seven studies reported the numbers of participants with adverse events, showing no clear evidence of benefit of either LMA or ETT during PDT (RR 0.73, 95% CI 0.35 to 1.52, P value 0.41, low-quality evidence). The tally of participants in included studies with adverse events ranged from 0% to 33% in the LMA group and from 0% to 50% in the ETT group. However, the duration of the procedure was significantly shorter in the LMA group (mean difference (MD) -1.46 minutes, 95% CI -1.92 to -1.01 minutes, 324 participants, P value ≤ 0.00001, low-quality evidence). No clear evidence of a difference between ETT and LMA groups was found for all other outcomes. Only one study provided follow-up data for late complications related to the intervention, showing no clear evidence of benefit for any treatment group. AUTHORS' CONCLUSIONS: Evidence on the safety of LMA for PDT is too limited to allow conclusions to be drawn on its efficacy or safety compared with ETT. Although the LMA procedure is shorter because of optimal visual conditions, its effect on especially late complications has not been investigated sufficiently. Studies focusing on late complications and relevant patient-related outcomes are necessary for definitive conclusions on safety issues related to this procedure.

Comparison of the TruView infant EVO2 PCD™ and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways.

OBJECTIVE: Videolaryngoscopy has mainly been developed to facilitate difficult airway intubation. However, there is a lack of studies demonstrating this method's efficacy in pediatric patients. The aim of the present study was to compare the TruView infant EVO2 and the C-MAC videolaryngoscope with conventional direct Macintosh laryngoscopy in children with a bodyweight ≤10 kg in terms of intubation conditions and the time to intubation. METHODS: In total, 65 children with a bodyweight ≤10 kg (0-22 months) who had undergone elective surgery requiring endotracheal intubation were retrospectively analyzed. Our database was screened for intubations with the TruView infant EVO2, the C-MAC videolaryngoscope, and conventional direct Macintosh laryngoscopy. The intubation conditions, the time to intubation, and the oxygen saturation before and after intubation were monitored, and demographic data were recorded. Only children with a bodyweight ≤10 kg were included in the analysis. RESULTS: A total of 23 children were intubated using the C-MAC videolaryngoscope, and 22 children were intubated using the TruView EVO2. Additionally, 20 children were intubated using a standard Macintosh blade. The time required for tracheal intubation was significantly longer using the TruView EVO2 (52 sec vs. 28 sec for C-MAC vs. 26 sec for direct LG). However, no significant difference in oxygen saturation was found after intubation. CONCLUSION: All devices allowed excellent visualization of the vocal cords, but the time to intubation was prolonged when the TruView EVO2 was used. The absence of a decline in oxygen saturation may be due to apneic oxygenation via the TruView scope and may provide a margin of safety. In sum, the use of the TruView by a well-trained anesthetist may be an alternative for difficult airway management in pediatric patients.

Comparison of the TruView infant EVO2 PCD and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways

OBJECTIVE: Videolaryngoscopy has mainly been developed to facilitate difficult airway intubation. However, there is a lack of studies demonstrating this method's efficacy in pediatric patients. The aim of the present study was to compare the TruView infant EVO2 and the C-MAC videolaryngoscope with conventional direct Macintosh laryngoscopy in children with a bodyweight ≤10 kg in terms of intubation conditions and the time to intubation. METHODS: In total, 65 children with a bodyweight ≤10 kg (0-22 months) who had undergone elective surgery requiring endotracheal intubation were retrospectively analyzed. Our database was screened for intubations with the TruView infant EVO2, the C-MAC videolaryngoscope, and conventional direct Macintosh laryngoscopy. The intubation conditions, the time to intubation, and the oxygen saturation before and after intubation were monitored, and demographic data were recorded. Only children with a bodyweight ≤10 kg were included in the analysis. RESULTS: A total of 23 children were intubated using the C-MAC videolaryngoscope, and 22 children were intubated using the TruView EVO2. Additionally, 20 children were intubated using a standard Macintosh blade. The time required for tracheal intubation was significantly longer using the TruView EVO2 (52 sec vs. 28 sec for C-MAC vs. 26 sec for direct LG). However, no significant difference in oxygen saturation was found after intubation. CONCLUSION: All devices allowed excellent visualization of the vocal cords, but the time to intubation was prolonged when the TruView EVO2 was used. The absence of a decline in oxygen saturation may be due to apneic oxygenation via the TruView scope and may provide a margin of safety. In sum, the use of the TruView by a well-trained anesthetist may be an alternative for difficult airway management in pediatric patients. .

[The Helsinki Declaration for Patient Safety in Anaesthesiology--preoperative assessment and preparation]. / Deklaration von Helsinki zur Patientensicherheit in der Anästhesiologie - Teil 6: Präoperative Evaluation und Vorbereitung.

The Helsinki Declaration offers guidelines for the warranty and improvement of patient safety in Anaesthesiology. The assessment of elective patients and their preoperative optimization plays a key role herein. Individual risk factors and preexisting pathologies have to be identified in order to initiate specific pre- and aftercare and an appropriate monitoring. The measures need to be evidence-based, goal-oriented and efficient. Our recommendations aim at elective adult patients planned for non-cardiac and non-lung-resecting surgery and stress the importance of gathering information from patients, performing physical examinations and arranging further diagnostic customized upon these findings only in contrast to routine testing. They shall spark the formulation or improvement of center-based, interdisciplinary standards of procedure in order to fulfill our great responsibility for the perioperative care of our patients.

First successful complete replantation of a traumatic hemipelvectomy: follow-up after 30 months.

Traumatic hemipelvectomy is a severe, however rare injury associated with high lethality. Up to now, immediate surgical completion of the amputation has been recommended as a lifesaving therapy. We present a case of near complete hemipelvectomy with open fracture of the ileosacral joint, wide open symphysis and severe soft tissue trauma including a decollement around the pelvis. Successful complete replantation was performed by primary internal stabilisation and revascularisation using vascular grafts. In the further hospital course, numerous revisions of the soft tissue injury and reconstructive surgery were needed. Thirty months later, the patient's condition is physically and psychologically stable and he is able to walk using crutches. The key point of successful management was skilled emergency damage control surgery followed by dedicated surgical care to avoid septic complications.

Efficacy and safety of local versus general anesthesia in stereotactic biopsies: a matched-pairs cohort study.

BACKGROUND: Frame-based stereotactic biopsies remain the gold standard for the diagnosis of intracerebral lesions. A major advantage is the ability to perform these procedures under local anesthesia (LA). However, there is no consensus on whether or when to use LA or general anesthesia (GA). It has been postulated that the use of LA may reduce the risk of complications. This study aims to objectify the efficacy and safety of stereotactic biopsies under LA versus GA by analyzing a prospective registry for stereotactic biopsies. METHODS: A prospective registry for stereotactic procedures was analyzed for the activities performed between May 2009 and August 2011. Inclusion criteria were patients undergoing a stereotactic biopsy. Patients with functional stereotactic procedures, cyst or abscess evacuation, and children were excluded. Of the remaining 274 patients, 204 could be randomly matched considering sex, age, American Society of Anesthesiologists (ASA) classification, and type of hospitalization. The primary endpoint was the diagnostic yield. Secondary endpoints were safety and procedural time intervals. RESULTS: Ninety-six percent of diagnosis was achieved in the LA group and 94% within the GA group. There was no significant difference in the overall complication rate. However, the rate of pulmonary complications was higher in the GA group (P=0.059). The rate of bleeding was significantly higher in the LA group (P=0.003) intraoperatively. However, no significant difference was found clinically or on routine postoperative computed tomography scan reports. There was a significant reduction in the time spent in the operating room within the LA group (P<0.001). CONCLUSIONS: The type of anesthesia may not interfere with the diagnostic yield in stereotactic biopsies. Patients operated under LA are less likely to suffer pulmonary complications. Furthermore, LA could spare hospital resources in this setting.

"Team time-out" and surgical safety-experiences in 12,390 neurosurgical patients.

OBJECT: Quality and safety are basic concerns in any medical practice. Especially in daily surgical practice, with increasing turnover and shortened procedure times, attention to these topics needs to be assured. Starting in 2007, the authors used a perioperative checklist in all elective procedures and extended the checklist in January 2011 according to the so-called team time-out principles, with additional assessment of patient identity and the planned surgical procedure performed immediately before skin incision, including the emergency cases. METHODS: The advanced perioperative checklist includes parts for patient identification, preoperative assessments, team time-out, postoperative treatment, and imaging controls. All parts are signed by the responsible physician except for the team time-out, which is performed and signed by the theater nurse on behalf of the surgeon immediately before skin incision. RESULTS: Between January 2007 and December 2010, 1 wrong-sided bur hole in an emergency case and 1 wrong-sided lumbar approach in an elective case (of 8795 surgical procedures) occurred in the authors' department. Using the advanced perioperative checklist including the team time-out principles, no error occurred in 3595 surgical procedures (January 2011-June 2012). In the authors' department all team members appreciate the chance to focus on the patient, the surgical procedure, and expected difficulties. The number of incomplete checklists and of patients not being transferred into the operating room was lowered significantly (p = 0.002) after implementing the advanced perioperative checklist. CONCLUSIONS: In the authors' daily experience, the advanced perioperative checklist developed according to the team time-out principles improves preoperative workup and the focus of the entire team. The focus is drawn to the procedure, expected difficulties of the surgery, and special needs in the treatment of the particular patient. Especially in emergency situations, the team time-out synchronizes the involved team members and helps to improve patient safety.

[Percutaneous tracheostomy in intensive care medicine - Update 2012]. / Punktionstracheotomie in der Intensivmedizin - Update 2012.

Percutaneous tracheostomy has become an established procedure in airway management of critically ill patients. It offers advantages over prolonged tracheal intubation. To date, there is no evidence of the optimal timing of the procedure. The Ciaglia Blue Rhino technique is the most common technique and, as any other techniques of percutaneous tracheostomy, is performed under general anaesthesia and with continuous bronchoscopic control. The recently introduced Ciaglia Blue Dolphin technique is based on radial dilatation with a fluid-filled high pressure balloon. Provided that specific contraindications are observed (e.g. difficult tracheal intubation, inability to identify anatomic landmarks, severe coagulopathy etc.), all techniques have low complication rates. The use of ultrasound may further enhance perioperative safety. Finally it must be noted that percutaneous tracheostomy is an elective procedure that requires informed consent from the patient or an attorney of law.

[Anaesthesia in endoscopic and percutaneous procedures in cardio-thoracic and cardiovascular interventions, part 2 - endoscopic thoracic interventions and endovascular percutaneous aortic aneurysm repair (EVAR)]. / Anästhesie bei Eingriffen an Herz, Thorax und den großen Gefäßen, Teil 2 - Endoskopische Thoraxeingriffe und endovaskuläre Aortenstentanlage.

Despite the ongoing further development of high definition imaging techniques (CT, MRI), mediastinoscopy and thoracoscopy remain essential instruments e.g. for extracting mediastinal lymph nodes allowing further histological diagnostics, or increasingly complex thoracoscopic procedures. Furthermore, in the course of the development of endoscopic thoracic and percutaneous interventions, the therapy of thoracic aortic aneurysms is increasingly the domain of endovascular procedures. In the second part of this review the anaesthesiological procedure and specialties concerning endoscopic thoracic interventions and percutaneous aortic aneurysm repair (EVAR) will be described.