[Anesthetist's briefing check. Tool to improve patient safety in the operating room]. / "Briefing-Check" anästhesie. Werkzeug zur verbesserung der patientensicherheit im OP.

Adverse events are not unusual in a more and more complex anesthesiological environment. The main reasons for this are an increasing workload, economic pressure, growing expectations of patients and deficits in planning and communication. However, these incidents mostly do not refer to medical deficits but to flaws in non-technical skills (team organisation, task orientation, decision making and communication). The introduction of the WHO Safe Surgery Checklist depicted that a structural approach can improve the situation. However, it is still questionable if this measure is strong enough and recent publications revealed initial criticisms. Furthermore, remaining security gaps could be found even though the checklist was implemented in the anesthesiological practice of a big teaching hospital. Therefore, an additional checklist was developed to implement an anesthesia briefing in the daily routine. The main objective was to establish a security check before induction similar to the aeronautical pre-flight check. Additionally, this measure should improve coordination of the anesthesiology team. Working through the checklist, doctors and nurses are guided to focus on conjoint patient care prior to induction of anesthesia. In a web-based survey the general attitude of coworkers towards patient safety, as well as the acceptability of the new briefing check was scrutinised at two times: directly before implementation of the checklist and 1 year after. The results (84 % of medical and 97 % of healthcare staff answered the questionnaires) showed improvements with high relevance to parameters associated with awareness concerning safety issues and team coordination. In conclusion, it appears that patient safety can be significantly improved with little time effort of 3-5 min per patient. A prospective trial will be conducted to confirm the impact of this measure on improvements in patient safety.

Austrian clinical practice with anidulafungin in 2008: a multicenter survey.

Anidulafungin had demonstrated favorable efficacy versus fluconazole in a randomized trial on invasive Candida infections. Since patient characteristics in the post-approval use of antifungals likely deviate from clinical trials, we surveyed the use of anidulafungin in clinical routine. We performed a retrospective survey of the post-approval use of anidulafungin in 9 Austrian clinical centers. Anidulafungin was used in 129 critically ill patients with severe comorbidities and multiple risk factors. Indications were suspected invasive fungal infections (IFI) (61%), proven candidemia (19%), and at risk for IFI (prophylaxis, 20%). Candida colonization in conjunction with other risk factors prompted treatment in many patients. predominant pathogens were C. albicans, C. glabrata and C. krusei. Anidulafungin was mostly used for pre-emptive (69%) and first-line treatment (17%) of invasive candidiasis. Treatment response, i.e. complete response/stabilization as determined by investigators (89% in the overall population; 87% for documented candidemia) and survival rates (81% and 75%, respectively) were similar to previous trial data. No breakthrough IFI and few adverse events were reported. Overall, favorable clinical experiences were documented with anidulafungin in the clinical routine setting.

Optimising the unprotected airway with a prototype Jaw-Thrust-Device--a prospective randomised cross-over study.

Despite being a standard procedure during induction of anaesthesia, facemask ventilation can be a major challenge especially for inexperienced anaesthetists. We manufactured a Jaw-Thrust-Device designed to keep the patient's jaws in an optimised position, and thus to maintain the airway in a permanently patent state. Using a cross over design, we compared the influence of using the Esmarch manoeuvre (bimanual jaw-thrust), a nasopharyngeal airway, an oropharyngeal airway, or the Jaw-Thrust-Device on airway physiology in 50 healthy adults with body mass index < 35 kg.m(-2), undergoing standard facemask ventilation for routine induction of anaesthesia. The main study endpoints were expiratory tidal volumes, airway resistances, and gas flow rates. The Jaw-Thrust-Device was more effective in increasing expiratory tidal volumes and peak inspiratory flow than a standard Esmarch manoeuvre, and was more effective than both nasopharyngeal and oropharyngeal airways in decreasing airway resistance.

Effect of decreased inspiratory times on tidal volume. Bench model simulating cardiopulmonary resuscitation.

BACKGROUND: During cardiopulmonary resuscitation (CPR) with a chest compression rate of 60-100/min the time for secure undisturbed ventilation in the chest decompression phase is only 0.3-0.5 s and it is unclear which tidal volumes could be delivered in such a short time. OBJECTIVES: Attempts were made to assess the tidal volumes that can be insufflated in such a short time window. METHODS: In a bench model tidal volumes were compared in simulated non-intubated and intubated patients employing an adult self-inflating bag-valve with inspiratory times of 0.25, 0.3, and 0.5 s. Respiratory system compliance values were 60 mL/cmH(2)O being representative for respiratory system conditions shortly after onset of cardiac arrest and 20 mL/cmH(2)O being representative for conditions after prolonged cardiac arrest. RESULTS: With a respiratory system compliance of 60 mL/cmH(2)O, tidal volumes (mean+/-SD) in non-intubated versus intubated patients were 144+/-13 mL versus 196+/-23 mL in 0.25 s (p<0.01), 178+/-10 versus 270+/-14 mL in 0.3 s (p<0.01), and 310+/-12 mL versus 466+/-20 mL in 0.5 s (p<0.01). With a respiratory system compliance of 20 mL/cmH(2)O, tidal volumes in non-intubated patient versus intubated patients were 128+/-10 mL versus 186+/-20 mL in 0.25 s (p<0.01), 158+/-17 versus 250+/-14 mL in 0.3 s (p<0.01) and 230+/-21 mL versus 395+/-20 mL in 0.5 s (p<0.01). CONCLUSIONS: Ventilation windows of 0.25, 0.3, and 0.5 s were too short to provide adequate tidal volumes in a simulated non-intubated cardiac arrest patient. In a simulated intubated cardiac arrest patient, ventilation windows of at least 0.5 s were necessary to provide adequate tidal volumes.

[Fatalities due to nitrous oxide. Complications from mistakes in nitrous oxide supply]. / Lachgasbedingte Todesfälle. Komplikationen durch Verwechslungen in der Lachgaszufuhr.

Despite inspiratory oxygen fraction measurement being regulated by law in the European norm EN 740, fatal errors in nitrous oxide delivery still occur more frequently than expected, especially after construction or repair of gas connection tubes. Therefore, if nitrous oxide is to be used further in a hospital, all technical measures and system procedures should be employed to avoid future catastrophes. Among these are measurement of the inspiratory oxygen fraction (F(I)O(2)) and an automatic limitation of nitrous oxide. Also all anaesthetists involved should be informed about repair or construction of central gas supply tubes. Additionally, more awareness of this problem in daily routine is necessary. Furthermore, a system of detecting and analysing errors in anaesthesia has to be improved in each hospital as well as in the anaesthesia community as a whole. Measures for a better "error culture" could include data exchange between different critical incident reporting systems, analysis of closed claims, and integration of medical experts in examination of recent catastrophes.

Fatal errors in nitrous oxide delivery.

Nitrous oxide continues to be used frequently and the possibility of inadvertent fatal hypoxaemia resulting from technical errors with its administration still exists. A Medline analysis revealed only a few case reports over the last 30 years, and a closed claim analysis only reported 'claims involving oxygen supply lines' predating 1990. The aim of this study was to assess the frequency of nitrous oxide-related catastrophes during general anaesthesia in Germany, Austria, and Switzerland. As nitrous oxide-related anaesthesia casualties are rare but generally prosecuted, they almost invariably attract significant media attention. We scanned mass media archives from April 2004 until October 2006 for nitrous oxide-related disasters during general anaesthesia. This approach detected six incidents which were almost certainly nitrous oxide ventilation-related deaths. Searching non-scientific data bases demonstrates that severe incidents involving oxygen supply lines occurred after 1990, and may be much more frequent than previously thought.

Postoperative nausea, vomiting, airway morbidity, and analgesic requirements are lower for the ProSeal laryngeal mask airway than the tracheal tube in females undergoing breast and gynaecological surgery.

BACKGROUND: We test the hypothesis that the frequency of postoperative nausea and vomiting is similar for the ProSeal laryngeal mask airway (LMA) and the tracheal tube. METHODS: Two hundred consecutive female patients (ASA I-II, 18-75 yr) undergoing routine breast and gynaecological surgery were divided into two equal-sized groups for airway management with the ProSeal LMA or tracheal tube. RESULTS: Ventilation was better and airway trauma less frequent for the ProSeal LMA. For the ProSeal group, the time spent in the post-anaesthesia care unit was shorter (69 vs 88 min, P < 0.0001); fewer doses of tropisetron were required in the post-anaesthesia care unit (P < or = 0.001) and ward (P = 0.004); morphine requirements were lower in the post-anaesthesia care unit (6.0 vs 8.1 mg, P = 0.005) and ward (6.1 vs 8.9, P = 0.004); nausea was less frequent at all times (overall: 13% vs 53%, P < 0.0001); vomiting was less frequent at 2 h (4% vs 18%, P = 0.003) and 24 h (5% vs 19%, P = 0.004); and sore throat was less frequent at all times (overall: 12% vs 38%, P < 0.0001). CONCLUSIONS: The ProSeal LMA reduced the absolute risk of postoperative nausea and vomiting by 40% (53-13%). In patients without the need for morphine, the ProSeal LMA reduced the absolute risk of postoperative nausea and vomiting by 23% (37-14%). We conclude that the frequency of postoperative nausea, vomiting, airway morbidity, and analgesic requirements is lower for the ProSeal LMA than the tracheal tube in females undergoing breast and gynaecological surgery.

[Anesthesia outside the core operating area]. / Anästhesie ausserhalb des Zentral-OP.

The number of diagnostic and surgical procedures being performed outside the core operating area is growing disproportionately. Due to the higher perioperative risk for such patients, anesthesia should only be provided by a very experienced anesthesiologist, even for supposedly small interventions. At these locations, timely and direct access to the anesthesia machine and/or the patient is often limited and if additional personnel or supplies are required, substantial time delays usually occur and should be allowed for. Standard operating procedures that are optimized to local requirements and providing a specially equipped anesthesia trolley for diagnostic and surgical procedures outside of the core operating area, may decrease the likelihood of complications induced by poorly equipped anesthesia workplaces. For electroconvulsive therapy (ECT), the standard drugs are methohexital in combination with short-acting opioids, such as remifentanil and succinylcholine. Significant variations in arterial blood pressure and heart rate are possible. Anesthesia induction in children with a known difficult airway or difficult intravascular access should initially be performed in a location with optimal infrastructure with subsequent transfer to the diagnostic or surgical suite outside the core operating area. Before entering the magnetic resonance imaging (MRI) suite, personal ferromagnetic items (e.g. pens, credit cards, stethoscopes, keys, telephones, USB sticks) should be removed to prevent injury and data loss; a MRI-compatible anesthesia machine and equipment is compulsory. Patients with cardiac pacemakers, cochlea implants, aneurysm or other clips, metallic-based tattoos or make-up are not normally compatible with MRI. General anesthesia should be preferred over conscious sedation for magnetic resonance imaging and ear protection is necessary for anesthetized patients. Gastroscopy in children should be performed under general anesthesia; and when concluding the procedure, air insufflated into the gastrointestinal tract should be suctioned in all patients. For angiography, maximum monitoring needs to be available to provide hemodynamically unstable patients with adequate anesthesia care; comprehensive radiation protection for patients and staff as well as temperature monitoring for prolonged diagnostic procedures is also necessary. Monitoring oxygen saturation and end-tidal carbon dioxide as well as employing visual and audible alarms is an essential requirement even during conscious sedation. In summary, the number of diagnostic and surgical procedures performed outside the core operating area should be reduced to a minimum and, whenever possible, diagnostic or surgical procedures should be performed within the core operating area.

Head position for opening the upper airway.

Inexperienced rescuers may encounter severe problems in an unconscious patient with opening and maintaining a patent upper airway. Designing a ventilating device that could indicate how to open an upper airway correctly may be beneficial. The heads of 102 volunteers were randomly placed in different head positions by one investigator. A pocket mask was then pressed gently on the volunteer's face followed by measurement of the head position angles. Mean (SD) flexion was - 4 degrees (8 degrees) (95% CI - 5.9 to - 2.9); the mean neutral position was 21 degrees (6 degrees) (95% CI, 19.9 to 22.3); extension was 42 degrees (6 degrees) (95% CI 40.8 to 43.0 degrees) and differed significantly between each position (p < 0.001). The flexion and neutral position angles were significantly greater in men than in women: - 2 (7 degrees) vs. -8 (7 degrees) and 22 (7 degrees) vs 20 (5 degrees); p < 0.001 and p = 0.03, respectively. Maximum extension of the head in both supine men and women was 42 degrees, which could be utilised to optimise assisted ventilation of an unprotected upper airway.

[Ventilation of an unprotected airway: evaluation of a new peak-inspiratory-flow and airway-pressure-limiting bag-valve-mask]. / Beatmung eines ungeschützten Atemwegs: Evaluation eines neuen spitzenfluss- und druckbegrenzenden Beatmungsbeutels.

BACKGROUND: Currently 30 chest compressions and 2 ventilations with an inspiratory time of 1 s are recommended during cardiopulmonary resuscitation with an unprotected airway, thus spending about 15% instead of 40% of resuscitation time on ventilation. Time could be gained for chest compressions when reducing inspiratory time from 2 s to 1 s, however, stomach inflation may increase as well. METHODS: In an established bench model we evaluated the effect of reducing inspiratory time from 2 s to 1 s at different lower oesophageal sphincter pressure (LOSP) levels using a novel peak inspiratory-flow and peak airway-pressure-limiting bag-valve-mask device (Smart-Bag). RESULTS: A reduction of inspiratory time from 2 s to 1 s resulted in significantly lower peak airway pressure with LOSP of 0.49 kPa (5 cm H2O), 0.98 kPa (10 cm H2O) and 1.47 kPa (15 cm H2O) and an increase with 1.96 kPa (20 cm H2O). Lung tidal volume was reduced with 1 s compared to 2 s. When reducing inspiratory time from 2 s to 1 s, stomach inflation occurred only at a LOSP of 0.49 kPa (5 cm H2O). CONCLUSIONS: In this model of a simulated unprotected airway, a reduction of inspiratory time from 2 s to 1 s using the Smart-Bag resulted in comparable inspiratory peak airway pressure and lower, but clinically comparable, lung tidal volume. Stomach inflation occurred only at a LOSP of 0.49 kPa (5 cm H2O), and was higher with an inspiratory time of 2 s vs 1 s.

[Mask ventilation as an exit strategy of endotracheal intubation]. / Maskenbeatmung als Rückzugsstrategie zur endotrachealen Intubation.

The goal of ventilation in an unprotected airway is to optimize oxygenation and carbon dioxide elimination of the patient. This can be achieved with techniques such as mouth-to-mouth ventilation, but preferably with bag-valve-mask ventilation. Securing the airway with an endotracheal tube is the gold standard, but excellent success in emergency airway management depends on initial training, retraining, and actual frequency of a given procedure in the routine. "Patients do not die from failure to intubate; they die from failure to stop trying to intubate or from undiagnosed oesophageal intubation" (Scott 1986). Therefore, adequate face mask ventilation has absolute priority in airway management by an unexperienced rescuer. During ventilation of an unprotected airway, stomach inflation and subsequent severe complications may result. Careful ventilation can be performed with low inspiratory pressure and flow, and subsequently with a low tidal volume at a high inspiratory fraction of oxygen. This could be a strategy to achieve more patient safety.

[Analgesia with remifentanil in spontaneously breathing patients undergoing brief but painful radiological procedures]. / Analgosedierung mit Remifentanil bei spontan atmenden Patienten für Eingriffe in der interventionellen Radiologie.

INTRODUCTION: Percutaneous transhepatic biliary drainage (PTBD) and stenting are very painful procedures in interventional radiology and require potent analgesia; employing remifentanil in spontaneously breathing patients may be one possible strategy. PATIENTS AND METHODS: The study group was composed of 18 men and 2 women with a mean age of 63+/-10 (mean+/-SD) years. Pain intensity was measured with a VAS score before the procedure, after local anesthesia on the rib cage, after stenting and after the radiology procedure. RESULTS: Remifentanil infusion (dosage: 0.12-0.30 microg/kg body weight/min) was infused throughout the entire radiology procedure according to physical status, past medical history, individual pain, and clinical assessment. During insufflation of 10l O(2)/min via a venturi mask, oxygen saturation did not fall below 96% at any time-point during the procedure. In the VAS score, we noted a decrease after starting the remifentanil infusion towards the end of procedure. All patients were able to move into bed without help. Postoperatively, no analgesics and no antiemetics were needed. CONCLUSIONS: Employing a remifentanil infusion for brief interventional radiology procedures in palliative treatment of patients resulted in high patient and radiologist comfort.

Pressure support ventilation versus continuous positive airway pressure ventilation with the ProSeal laryngeal mask airway: a randomized crossover study of anesthetized pediatric patients.

Continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) improve gas exchange in adults, but there are little published data regarding children. We compared the efficacy of PSV with CPAP in anesthetized children managed with the ProSeal laryngeal mask airway. Patients were randomized into two equal-sized crossover groups and data were collected before surgery. In Group 1, patients underwent CPAP, PSV, and CPAP in sequence. In Group 2, patients underwent PSV, CPAP, and PSV in sequence. PSV comprised positive end-expiratory pressure set at 3 cm H(2)O and inspiratory pressure support set at 10 cm H(2)O above positive end-expiratory pressure. CPAP was set at 3 cm H(2)O. Each ventilatory mode was maintained for 5 min. The following data were recorded at each ventilatory mode: ETco(2), Spo(2), expired tidal volume, peak airway pressure, work of breathing patient (WOB), delta esophageal pressure, pressure time product, respiratory drive, inspiratory time fraction, respiratory rate, noninvasive mean arterial blood pressure, and heart rate. In Group 1, measurements for CPAP were similar before and after PSV. In Group 2, measurements for PSV were similar before and after CPAP. When compared with CPAP, PSV had lower ETco(2) (46 +/- 6 versus 52 +/- 7 mm Hg; P < 0.001), slower respiratory rate (24 +/- 6 versus 30 +/- 6 min(-1); P < 0.001), lower WOB (0.54 +/- 0.54 versus 0.95 +/- 0.72 JL(-1); P < 0.05), lower pressure time product (94 +/- 88 versus 150 +/- 90 cm H(2)O s(-1)min(-1); P < 0.001), lower delta esophageal pressure (10.6 +/- 7.4 versus 14.1 +/- 8.9 cm H(2)O; P < 0.05), lower inspiratory time fraction (29% +/- 3% versus 34% +/- 5%; P < 0.001), and higher expired tidal volume (179 +/- 50 versus 129 +/- 44 mL; P < 0.001). There were no differences in Spo(2), respiratory drive, mean arterial blood pressure, and heart rate. We conclude that PSV improves gas exchange and reduces WOB during ProSeal laryngeal mask airway anesthesia compared with CPAP in ASA physical status I children aged 1-7 yr.

[Decreased inspiratory time during ventilation of an unprotected airway. Effect on stomach inflation and lung ventilation in a bench model]. / Verkürzte Inspirationszeit während der Beatmung eines ungeschützten Atemweges. Effekt auf die Magen- und Lungenbeatmung im Simulationsmodell.

BACKGROUND: In an unprotected airway during cardiopulmonary resuscitation, two ventilations with an inspiratory time of 2 s after 15 chest compressions are recommended. Therefore, approximately 30% of the resuscitation attempt is spent on ventilation. Since survival rates did not decrease sharply when minute ventilation levels were relatively low, and uninterrupted chest compressions with a constant rate of approximately 100/min have been shown to be lifesaving, it may be beneficial to decrease the time spent on ventilation and instead, increase the time for chest compressions. METHODS: In an established bench model of a simulated, unprotected airway with increased airway resistance, we evaluated if inspiratory time can be decreased from 2 to 1 s at different lower oesophageal sphincter pressure (LOSP) levels during ventilation with a bag-valve-mask device. RESULTS: An inspiratory time of 2 vs. 1 s resulted in significantly lower peak airway pressure, while lung tidal volume was significantly higher at an inspiratory time of 2 s and a LOSP of 5 cm H(2)O (480+/-20 vs. 380+/-30 ml) and 10 cm H(2)O (630+/-50 vs. 440+/-20 ml) and significantly lower at a LOSP of 15 cm H(2)O (470+/-70 vs. 540+/-20 ml). While neither ventilation strategy produced stomach inflation at 20 cm H(2)O LOSP, 1 vs. 2 s inspiratory time produced significantly higher stomach inflation at 15 cm H(2)O LOSP (8+/-11 vs. 0 ml) and significantly lower stomach inflation at a LOSP of 5 cm H(2)O (359+/-31 vs. 375+/-29 ml) and 10 cm H(2)O (28+/-13 vs. 36+/-12 ml) per breath. CONCLUSION: In this model of a simulated, unprotected airway, a reduction of inspiratory time from 2 to 1 s resulted in a significant increase of peak airway pressure, while lung tidal volumes and stomach inflation volumes were statistically different but clinically comparable.

[Treatment of hemorrhagic shock. New therapy options]. / Die Behandlung des hämorrhagischen Schocks. Neue Therapieoptionen.

The future of shock treatment depends on the importance of scientific results, and the willingness of physicians to optimize, and to reconsider established treatment protocols. There are four major potentially promising approaches to advanced trauma life support. First, control of hemorrhage by administration of local hemostatic agents, and a better, target-controlled management of the coagulation system. Second, improving intravascular volume by recruiting blood from the venous vasculature by preventing mistakes during mechanical ventilation, and by employing alternative spontaneous (i.e. use of the inspiratory threshold valve) or artificial ventilation strategies. In addition, artificial oxygen carriers may improve intravascular volume and oxygen delivery. Third, pharmacologic support of physiologic, endogenous mechanisms involved in the compensation phase of shock, and blockade of pathomechanisms that are known to cause irreversible vasoplegia (arginine vasopressin and K(ATP) channel blockers for hemodynamic stabilization). Fourth, employing potentially protective strategies such as mild or moderate hypothermia. Finally, the ultimate vision of trauma resuscitation is the concept of "suspended animation" as a form of delayed resuscitation after protection of vital organ systems.

Aspiration and the laryngeal mask airway: three cases and a review of the literature.

The primary limitation of the laryngeal mask airway (LMA) is that it does not reliably protect the lungs from regurgitated stomach content. We describe three cases of aspiration associated with the LMA, including the first brain injury, the first death, and the first associated with the intubating LMA, and review the 20 specific case reports of aspiration associated with the LMA that we were able to find described in the literature.

Positive pressure versus pressure support ventilation at different levels of PEEP using the ProSeal laryngeal mask airway.

We compared positive pressure ventilation with pressure support ventilation at different levels of positive end expiratory pressure (PEEP) using the ProSeal laryngeal mask airway (PLMA). Forty-two anaesthetized adults (ASA 1-2, aged 19 to 63 years) underwent positive pressure ventilation and then pressure support ventilation each with PEEP set at 0, 5 and 10 cmH2O in random order. Pressure support ventilation was with the inspired tidal volume (VTInsp) set at 7 ml/kg and the respiratory rate adjusted to maintain the end-tidal CO2 (ETCO2) at 40 mmHg. Pressure support ventilation was with pressure support set at 5 cmH2O above PEEP and initiated when inspiration produced a 2 cmH2O reduction in airway pressure. Tidal volumes were similar during positive pressure and pressure support ventilation with PEEP, but were higher for the former without PEEP Respiratory rate and peak inspiratory flow rate were higher during pressure support than positive pressure ventilation (all P < 0.001). Peak airway pressure (Ppaw), mean airway pressure (Mpaw), peak expiratory flow rate, and expired airway resistance were lower during pressure support than positive pressure ventilation (all P < 0.001). With PEEP set at 10 cmH2O, ETCO2 was lower for pressure support than positive pressure ventilation. During positive pressure ventilation, there was an increase in Ppaw, Mpaw and dynamic compliance (Cdyn) with increasing levels of PEEP (all P < 0.01). During pressure support ventilation, there was an increase in inspired and expired tidal volume, Ppaw, peak inspiratory and expiratory flow rates and Cdyn, and a reduction in ETCO2, work of breathing, and expired airway resistance with increasing levels of PEEP (all P < 0.01). There were no differences in SpO2, non-invasive mean arterial pressure, heart rate or leak fraction. We conclude that pressure support ventilation provides equally effective gas exchange as positive pressure ventilation during PLMA anaesthesia with or without PEEP at the tested settings. During pressure support, PEEP increases ventilation and reduces work on breathing without increasing leak fraction.