Use of checklists improves the quality and safety of prehospital emergency care.

OBJECTIVES: High-level emergency medical care requires transfer of evidence-based knowledge into practice. Our study is the first to investigate the feasibility of checklists in improving prehospital emergency care. MATERIALS AND METHODS: Three checklists based on standard operating procedures were introduced: General principles of prehospital care, acute coronary syndrome and acute asthma/acutely exacerbated chronic obstructive pulmonary disease. Subsequent to prehospital care and immediately before transport, information on medical history, diagnostic and therapeutic procedures was obtained. Data of 740 emergency missions were recorded prospectively before (control group) and after implementation of checklists and compared using the χ-test (significance level P<0.05). RESULTS: Documentation on patients' history (pre-existing diseases: 69.1 vs. 74.3%; medication: 55.8 vs. 68.0%; allergies: 6.2 vs. 27.7%) and diagnostic measures (oxygen saturation: 93.2 vs. 98.1%; auscultation: 11.1 vs. 19.9%) as well as basic treatment procedures (application of oxygen: 73.2 vs. 85.3%; intravenous access: 84.6 vs. 92.2%) increased significantly. Subanalysis of acute coronary syndrome cases showed a significant increase of 12-lead ECG use (74.3 vs. 92.4%), administration of oxygen (84.2 vs. 98.6%), ASA (71.7 vs. 81.9%), heparin (71.1 vs. 84.0%), ß blockers (39.5 vs. 57.1%) and morphine (26.8 vs. 44.6%). In the chronic obstructive pulmonary disease subgroup, oxygen supply (78.8 vs. 98.5%) and application of inhalative and intravenous ß2-mimetics (42.4 vs. 66.7% and 12.1 vs. 37.9%) increased significantly. CONCLUSION: Introduction of checklists for prehospital emergency care may help to improve adherence to treatment guidelines. Additional efforts (e.g. team trainings) have to be made to increase quality of care.

Laryngeal tube and intubating laryngeal mask insertion in a manikin by first-responder trainees after a short video-clip demonstration.

INTRODUCTION: This study was performed in the Finnish Defense Forces to assess the potential applicability and value of short video clips as educational material to teach advanced airway management and as the first means of introducing the use of a laryngeal tube (LT) or an intubating laryngeal mask (ILMA) to inexperienced, military, first-responder trainees with no prior hands-on experience. METHODS: The 60 non-commissioned medical officers participating in this study were randomly assigned into one of two groups: the LT- and the ILMA-group. After viewing the video clips, the trainees were required to perform 10 consecutive, successful insertions of the given instrument into a manikin. The number and duration of the attempts required prior to the 10 consecutive successful insertions were measured. RESULTS: The goal of 10 consecutive successful insertions was attained by all 30 subjects in the LT-group, and by 27 of 29 subjects in the ILMA-group with a maximum of 30 attempts. Improvement in the ease and speed of insertion was evident between the first and last consecutive insertions in both groups. CONCLUSIONS: "Satisfactory" to "good" skill levels are achieved with the applied video-clip demonstration method, even in inexperienced first-responder trainees lacking previous hands on experience.

Artificial acrylic finger nails may alter pulse oximetry measurement.

INTRODUCTION: Pulse oximetry is the most common technique to monitor oxygen saturation (SpO(2)) during intensive care therapy. However, intermittent co-oximetry is still the "gold standard" (SaO(2)). Besides acrylic nails, numerous other factors have been reported to interfere with pulse oximetry. Data of measurements with artificial finger nails are not sufficiently published. MATERIALS AND METHODS: A prospective clinical-experimental trial in mechanically ventilated and critically ill patients of an ICU was performed. Patients were randomly assigned to either group S (S: Siemens pulse oximeter) or group P (P: Philips pulse oximeter) prior to the measurements. SpO(2) was determined in each patient three times alternately in standard ((N)SpO(2)) and sideways position at the natural nail ((N90)SpO(2)). For the reference measurements oxygen saturation was measured by means of a haemoximeter (co-oximetry). Thereafter, SpO(2) was obtained at the acrylic finger nail in the same way ((A)SpO(2) and (A90)SpO(2)). Bias was calculated as DeltaS=(N)SpO(2)-SaO(2) and DeltaS=(A)SpO(2)-SaO(2). Accuracy (mean difference) and precision (standard deviation) were used to determine the measurement discrepancy. P<0.05 was considered significant. RESULTS: Accuracy and precision without acrylic nails applied were comparable to SaO(2) in both groups (n.s.). With acrylic nails applied a bias of DeltaS=-1.1+/-3.14% for group S (P=0.00522) and a bias of DeltaS=+0.8+/-3.04% for group P was calculated (n.s.). CONCLUSION: Acrylic finger nails may impair the measurement of oxygen saturation depending on the pulse oximeter used and may cause significant inaccuracy. Hence, removal of artificial acrylic finger nails may be helpful to assure an accurate and precise measurement with pulse oximetry.

Effect of nail polish on oxygen saturation determined by pulse oximetry in critically ill patients.

INTRODUCTION: Nail polish of different colours may alter accuracy and precision of pulse oximetry as previous data in healthy volunteers suggest. This trial evaluates the oxygen saturation determined by pulse oximetry and haematoximetry with nail polish of nine different colours applied. MATERIAL AND METHODS: Fifty critically ill and mechanically ventilated patients in an ICU were investigated in a prospective clinical-experimental trial. On nine finger nails polish of different colours was applied in a predetermined consecutive order. Functional oxygen saturation was determined by pulse oximetry (SpO2) on each finger for each colour with the finger sensor probe both in the normal position and at a 90 degrees rotation. Simultaneously oxygen saturation was determined by haematoximetry (SaO2). Accuracy (bias, DeltaS = SaO2-SpO2) and precision (standard deviation, S.D.) of pulse oximetry were analyzed with the t-test. A value of P < 0.05 was considered significant. RESULTS: While black (DeltaS = +1.6+/-3.0%), purple (DeltaS = +1.2+/-2.6%) and dark blue nail polish (DeltaS = +1.1+/-3.5%, each N = 50) had the greatest effect (P < 0.05), all other colours, including colourless nail polish, had a smaller effect (mean bias +0.2 to +0.9%). A rotation of 90 degrees reduced the bias from +2.8 to +1.3% (N = 10, n.s.). CONCLUSION: Nail polish does not alter pulse oximetry readings in mechanically ventilated patients to a clinically relevant extent. The mean error of measurement for all colours was within the manufacturers' specified range of +/-2%. A 90 degrees rotation of the sensor probe does not eliminate errors in measurement. To remove nail polish might be helpful to decrease the error of measurement in some cases.

Oxygen delivery comparison of two constant-flow masks during flight to 6863 m.

OBJECTIVE: Differences in mask design may alter the oxygen flow required to gain similar oxygenation at a particular altitude. The selection of the most efficient mask would be advantageous for general aviation and other applications where oxygen supply is limited. METHODS: We compared a basic mask (BAS) without valves or oxygen reservoir bag to a test mask (TST) with three valves and a reservoir designed to deliver up to 80% oxygen for critically ill patients. Randomly assigned parachutists (n = 31) used the masks during a flight with a gradual climb to 6863 m (22,500 ft). The oxygen flow was individually controlled to produce oxygen saturation (SpO2) of 95-97% as determined by pulse oximetry. Oxygen flow and SpO2 were obtained every 305 m (1000 ft). RESULTS: Baseline age, lung function indices, and SpO2 were comparable for the two groups. Mean in-flight Spo2 values were 95.3 +/- 0.5% for the BAS and 96.2 +/- 1.1 % for the TST, respectively. Above 3965 m (13,000 ft) the TST required significantly less oxygen flow than the BAS to maintain the target SpO2. At 6863 m (22,500 ft), mean oxygen flow was 5.5 +/- 3.5 L x min(-1) for the BAS vs. 3.4 +/- 2.3 L x min(-1) for the TST (p = 0.029). No adverse reactions were reported from either group. CONCLUSION: The TST required significantly less oxygen flow compared with the BAS at high altitudes and may, therefore, reduce total oxygen use, resulting in reduced costs and longer oxygen availability during a flight.

Perioperative risks and their management in patients with sleep-related breathing disorders.

Patients with sleep apnea syndromes pose several challenges to the anaesthetist. These are resulting from comorbidity, but mainly from special requirements for pre-, intra- and postoperative management.Frequently, the diagnosis is not known or not diagnosed adequately, making careful preoperative evaluation of the patient by the anaesthetist imperative to identify patients at risk. Besides cardiovascular complications, problems with airway maintenance must be expected, calling for adequate planning. Several general considerations for anaesthesiologic management should be taken into account. The use of short acting pharmacologic agents is recommended to reduce the risk of postoperative episodes of hypoxia following general anaesthesia.Close cooperation of anaesthesia and the surgical specialties involved is the basis for safe management of patients with sleep related syndromes.

A multicenter study of the Ambu laryngeal mask in nonparalyzed, anesthetized patients.

We designed this multicenter trial to evaluate the performance and safety of the Ambu laryngeal mask, a new disposable supraglottic airway device, in patients scheduled for elective surgery. One-hundred-eighteen nonparalyzed, anesthetized patients (ASA physical status I-II, age, 18-65 yr, body mass index, 18-30 kg/m(-2)) receiving total IV anesthesia were included in this study. After device insertion, fiberoptic position and oropharyngeal leak pressure were determined at an intracuff pressure of 60 cm H2O. Ease of ventilation was determined by controlling ventilation at 6 mL/kg tidal volume. Any complications were noted and recorded. Device placement was successful in all patients on the first or second attempt (92.4% or 7.6%, respectively) with an insertion time (removal of face mask until first tidal volume) of 44.9 +/- 37.91 s. Adequate ventilation was achieved in all patients and the vocal cords could be visualized by fiberoptic endoscopy in 91.5% of patients. Oropharyngeal leak pressures were 24.1 +/- 5.44 cm H2O. Blood was detected on the device in 8.5% of patients. Complications and patient complaints were minor and quickly resolved. The Ambu laryngeal mask is easy and quick to insert and provides a safe and efficient seal during positive pressure ventilation in nonparalyzed patients scheduled for elective surgery.

Airway management with the Laryngeal Tube Suction II in a patient with cervical spine injury.

Supraglottic airway devices may offer alternative strategies for securing the airway in patients with cervical spine injuries. A case of airway management with the LTS II, a modified version of the laryngeal tube suction, in a patient with a paramedian atlas fracture scheduled for decompression of a haematoma on the forehead is described. Device insertion was successful in the first attempt and a gastric tube was inserted without problems. Ventilation was uneventful, no complaints were stated after surgery.

Ventilation with the laryngeal tube in pediatric patients undergoing elective ambulatory surgery.

BACKGROUND: The laryngeal tube is a new supraglottic alternative for securing the airway. Few data on the use of this airway device in pediatric patients are so far available. Experiences of the study are reported. METHODS: Use of the laryngeal tube for ventilation during intermittent positive-pressure ventilation was studied in an open, noncomparative observational study in 80 pediatric patients (age: 2-12 years) undergoing elective ambulatory surgery. Insertion success, time to achieve a patent airway, and occurrence of adverse events were documented. RESULTS: Mean (sd) patient age was 5.8 (2.3) years. The laryngeal tube was placed at the first attempt in 90% of patients, a second attempt was necessary in 6%. Ventilation was not possible after two attempts in three patients. Mean (sd) tidal volume was 10.1 (2.0) ml.kg(-1) with a mean (sd) peak airway pressure of 15.6 (2.1) cmH(2)O. Chin lift was applied to improve ventilation in 15 patients (18.8%). Laryngospasm occurred in one patient, but ventilation was possible after adapting depth of anesthesia. Mean (sd) time for airway maintenance was 11.2 (3.7) s. No gastric insufflation of air occurred, no traces of blood could be detected after removal of the device. One patient complained of mild problems (swallowing, VAS 1). Mean (sd) anesthesia time was 44 (9) min. CONCLUSIONS: In the age group studied, the laryngeal tube provides a rapid, patent airway in the majority of patients with a low complication rate.

Detection of a systolic pressure threshold for reliable readings in pulse oximetry.

OBJECTIVE: To determine the error of measurement in pulse oximetry with a decreased arterial perfusion and to identify a systolic pressure threshold for (1) initial detection and (2) a reliable reading of oxygen saturation. DESIGN: An experimental clinical prospective study. The study was approved by the local ethics committee. SETTING: Eighteen bed intensive care unit at a University hospital. PATIENTS AND PARTICIPANTS: Twenty-five adult mechanically ventilated and critically ill patients in the ICU during a 3-month period. INTERVENTIONS: A blood pressure cuff at the upper arm (same side as an arterial catheter already in place) was inflated to decrease the arterial pulsatile flow. The cuff was deflated stepwise and the resulting oxygen saturation was measured simultaneously. The error of measurement [delta S = SpO2 (baseline)-SpO2 (indicated)] was calculated for each 5 mmHg of blood pressure (BP). MEASUREMENTS AND RESULTS: Twenty-five patients (9 female, 16 male, 48 +/- 15.9 years old) with a mean SpO2 of 98.3 +/- 1.5% and a BP of 129 +/- 18.4 mmHg participated. The mean systolic BP to obtain initial readings with pulse oximetry was 45.8 +/- 17.7 (range, 25-101) mmHg (35% of the baseline pressure) resulting in lower readings of pulse oximetry (mean -11.5 +/- 13.6%, range -45 to +4%). With a systolic BP > 80 mmHg the mean bias was within the manufacturers limits of +/-2%. CONCLUSIONS: Pulse oximetry is reliable with a systolic blood pressure > 80 mmHg. The lower the BP, the lower the pulse oximetry readings leading to a bias of up to -45%.