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1.
Br J Anaesth ; 2021 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-34535275

RESUMO

BACKGROUND: Poor medical outcomes often result from series of minor events. The present study assessed events related to airway management to determine whether targeted changes to departmental strategies for airway management can reduce the incidence. METHODS: This prospective before-and-after study was performed with ethics committee approval and written informed consent from patients. Major and minor events related to airway management were prospectively recorded for 9 weeks. After implementation of changes to departmental strategies for airway management, events were again prospectively recorded over 9 weeks. Primary outcome was number of cases with events. Secondary outcomes were various predefined events. RESULTS: At study baseline, 3668 cases and at follow-up 3786 cases were assessed. Cases with events decreased from 566 (15.4%) to 433 (11.4%) (risk ratio [RR]=0.74; 95% confidence interval [CI], 0.66-0.83; P<0.01). As secondary outcomes, the following events decreased: Cormack-Lehane grade 3 or 4 (4.3-2.9%; RR=0.67; 95% CI, 0.52-0.85; P<0.01); difficult bag-mask ventilation (3.8-2.7%; RR=0.69; 95% CI, 0.54-0.89; P<0.01); hypoxaemia (3.8-2.9%; RR=0.75; 95% CI, 0.59-0.96; P=0.03); unplanned use of special equipment (3.2-2.0%; RR=0.62; (95% CI, 0.47-0.83; P<0.01); oesophageal intubation (1.3-0.8%; RR=0.61; 95% CI, 0.39-0.96; P=0.03); bleeding (0.8-0.2%; RR=0.30; 95% CI, 0.14-0.63; P<0.01); insufficient spontaneous breathing (0.3-0.0%; RR=0.09; 95% CI, 0.01-0.68; P<0.01); communication errors (0.1-0.0%; RR=0; 95% CI, 0-NA; P=0.03). CONCLUSIONS: Implementation of changes to departmental strategies for airway management significantly reduced cases with events related to airway management. Analysis of events and implementation of strategies that specifically target identified issues might be key to improving airway management. CLINICAL TRIAL REGISTRATION: NCT02743767.

2.
Scand J Trauma Resusc Emerg Med ; 29(1): 115, 2021 Aug 11.
Artigo em Inglês | MEDLINE | ID: mdl-34380539

RESUMO

BACKGROUND: Incidence of in-hospital cardiac arrest is reported to be 0.8 to 4.6 per 1,000 patient admissions. Patient survival to hospital discharge with favourable functional and neurological status is around 21-30%. The Bern University Hospital is a tertiary medical centre in Switzerland with a cardiac arrest team that is available 24 h per day, 7 days per week. Due to lack of central documentation of cardiac arrest team interventions, the incidence, outcomes and survival rates of cardiac arrests in the hospital are unknown. Our aim was to record all cardiac arrest team interventions over 1 year, and to analyse the outcome and survival rates of adult patients after in-hospital cardiac arrests. METHODS: We conducted a prospective single-centre observational study that recorded all adult in-hospital cardiac arrest team interventions over 1 year, using an Utstein-style case report form. The primary outcome was 30-day survival after in-hospital cardiac arrest. Secondary outcomes were return of spontaneous circulation, neurological status (after return of spontaneous circulation, after 24 h, after 30 days, after 1 and 5 years), according to the Glasgow Outcomes Scale, and functional status at 30 days and 1 year, according to the Short-form-12 Health Survey. RESULTS: The cardiac arrest team had 146 interventions over the study year, which included 60 non-life-threatening alarms (41.1%). The remaining 86 (58.9%) acute life-threatening situations included 68 (79.1%) as patients with cardiac arrest. The mean age of these cardiac arrest patients was 68 ± 13 years, with a male predominance (51/68; 75.0%). Return of spontaneous circulation was recorded in 49 patients (72.1%). Over one-third of the cardiac arrest patients (27/68) were alive after 30 days with favourable neurological outcome. The patients who survived the first year lived also to 5 years after the event with favourable neurological and functional status. CONCLUSIONS: The in-hospital cardiac arrest incidence on a large tertiary Swiss university hospital was 1.56 per 1000 patient admissions. After a cardiac arrest, about a third of the patients survived to 5 years with favourable neurological and functional status. Alarms unrelated to life-threatening situations are common and need to be taken into count within a low-threshold alarming system. TRIAL REGISTRATION: The trial was registered in clinicaltrials.gov (NCT02746640).


Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida , Suíça/epidemiologia , Resultado do Tratamento
3.
Resuscitation ; 165: 77-82, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34107336

RESUMO

AIM OF THE STUDY: The ideal group size for effective teaching of cardiopulmonary resuscitation is currently under debate. The upper limit is reached when instructors are unable to correct participants' errors during skills practice. This simulation study aimed to define this limit during cardiopulmonary resuscitation teaching. METHODS: Medical students acting as simulated Basic Life Support course participants were instructed to make three different pre-defined Basic Life Support quality errors (e.g., chest compression too fast) in 7 min. Basic Life Support instructors were randomized to groups of 3-10 participants. Instructors were asked to observe the Basic Life Support skills and to correct performance errors. Primary outcome was the maximum group size at which the percentage of correctly identified participants' errors drops below 80%. RESULTS: Sixty-four instructors participated, eight for each group size. Their average age was 41 ± 9 years and 33% were female, with a median [25th percentile; 75th percentile] teaching experience of 6 [2;11] years. Instructors had taught 3 [1;5] cardiopulmonary resuscitation courses in the year before the study. A logistic binominal regression model showed that the predicted mean percentage of correctly identified participants' errors dropped below 80% for group sizes larger than six. CONCLUSION: This randomized controlled simulation trial reveals decreased ability of instructors to detect Basic Life Support performance errors with increased group size. The maximum group size enabling Basic Life Support instructors to correct more than 80% of errors is six. We therefore recommend a maximum instructor-to-participant ratio of 1:6 for cardiopulmonary resuscitation courses.


Assuntos
Reanimação Cardiopulmonar , Estudantes de Medicina , Adulto , Simulação por Computador , Avaliação Educacional , Feminino , Humanos , Pessoa de Meia-Idade , Ensino
4.
Scand J Trauma Resusc Emerg Med ; 29(1): 49, 2021 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-33731197

RESUMO

BACKGROUND: Tracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative. METHODS: We conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider's level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy. RESULTS: FPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers' expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified. CONCLUSION: Airway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.


Assuntos
Resgate Aéreo , Intubação Intratraqueal/métodos , Laringoscopia/métodos , Gravação de Videoteipe , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Serviços Médicos de Emergência , Feminino , Humanos , Lactente , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto Jovem
5.
Minerva Anestesiol ; 87(8): 873-879, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33594877

RESUMO

BACKGROUND: The gold standard for management of known or predicted difficult airways is awake tracheal intubation. The newly developed C-MAC Video Stylet promises to combine the advantages of rigid stylets and flexible optical scopes. We therefore evaluated the feasibility of awake orotracheal intubations with this device. METHODS: In this prospective observational study, three anesthesiologists experienced in advanced airway management performed each 12 awake oral intubations with this device on adult patients with known or predicted intubation difficulties. The primary outcome was overall intubation success. Secondary outcomes were total attempts, successful time, first postoperative day sequelae, and subjective intubation difficulty rated on a visual analogue scale (1, very easy; 10, extremely difficult). RESULTS: Thirty-six patients (10 females), aged 64±13 years, with BMI 26±5 kg/m2, were enrolled in the study. ASA status II, III, IV were eight (22%), 23 (64%), and five (14%), respectively. Indications for awake oral intubation were: oropharyngeal tumor 20 (56%), cervical-spine fracture eight (22%), previously known difficult airway four (11%), spinal canal stenosis three (8%), and bilateral peritonsillar abscess one (3%). Overall, 97% were successfully intubated in 45 s (31-88). First-attempt success rate was 80% in 37 s (29-54); 92% of patients would choose the same procedure again. On the first postoperative day, 11 (31%) patients complained of sore throat; five (14%) had minor injuries. Ease of intubation was rated as median VAS 3 (IQR: 1-7). CONCLUSIONS: The new C-MAC Video Stylet has the potential to serve as a suitable device for visualized oral awake intubation in difficult airway situations.


Assuntos
Laringoscópios , Vigília , Adulto , Manuseio das Vias Aéreas , Feminino , Humanos , Intubação Intratraqueal , Laringoscopia , Gravação em Vídeo
6.
Artigo em Inglês | MEDLINE | ID: mdl-33594632

RESUMO

Due to their work activities, emergency physicians are regularly exposed to exceptional mental and physical situations. In order to prevent stress-related illnesses, the triggers of hormonal and subjectively perceived stress must be understood better. On a sample of emergency physicians from two air rescue services (N = 80), the cortisol awakening response (CAR) was determined on flight rescue days, clinic days, and days off. Pearson correlations showed significant connections between the CAR on flight rescue days and individual scales of the Trier Inventory for Chronic Stress (TICS) and the Perceived Stress Scale (PSS). The results indicate that a lower subjective stress level is associated with higher levels of hormonal stress. Stepwise regression analyses showed a significant influence of the number of professional years, subjectively perceived stress, pressure to succeed, and social isolation. The results suggest that the hormonal stress burden of emergency physicians is in a complex relationship with perceived strain.

7.
Scand J Trauma Resusc Emerg Med ; 29(1): 36, 2021 Feb 17.
Artigo em Inglês | MEDLINE | ID: mdl-33596970

RESUMO

BACKGROUND: Pain is one of the major symptoms complained about by patients in the prehospital setting, especially in the case of trauma. When there is mountainous topography, as in Switzerland, there may be a time delay between injury and arrival of professional rescuers, in particular on ski slopes. Administration of a safe opioid by first responders may improve overall treatment. We therefore assessed administration of nasal nalbuphine as an analgesic treatment for trauma patients in Switzerland. METHODS: This observational cohort study examined 267 patients who were treated with nasal nalbuphine by first responders in six ski resorts in Switzerland. All first responders were instructed to begin treatment by assessing the feasibility of using nalbuphine to treat pain in the patient. A treatment algorithm was developed and distributed to assure that nalbuphine was only administered following a strict protocol. Data regarding pain scores and pain reduction after administration of nalbuphine were collected on-site. Refills were handed out to the first responders with the return of each completed questionnaire. RESULTS: Nalbuphine provided effective pain relief, with the median level of pain on the numeric rating scale for pain reduced by 3 units on average, from 8 points (p < 0.001). The multivariate regression model showed that pain reduction was more pronounced in patients with higher initial pain levels. Nalbuphine was more effective in adolsecents than in patients aged 20 to 60 years (p = 0.006). No major side effects were observed. CONCLUSION: Nasal administration of nalbuphine by first responders is a presumably safe and effective noninvasive pain management strategy for acutely injured patients in the prehospital setting. This may be an alternative, especially in the case of severe pain and prolonged time between arrival of the first responders and arrival of EMS/HEMS personnel on scene.


Assuntos
Analgésicos Opioides/administração & dosagem , Serviços Médicos de Emergência , Socorristas , Nalbufina/administração & dosagem , Dor/tratamento farmacológico , Esqui/lesões , Idoso , Estudos de Coortes , Serviços Médicos de Emergência/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Suíça , Ferimentos e Lesões/fisiopatologia
8.
Eur J Anaesthesiol ; 38(3): 302-308, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33470688

RESUMO

BACKGROUND: International guidelines recommend cricothyroidotomy as a life-saving procedure for 'cannot intubate, cannot ventilate' situations. Although commercially available sets facilitate surgical cricothyroidotomy, regular training seems to be the key to success. OBJECTIVES: The goal was to investigate if trained anaesthetists are able to transfer their skill in one surgical cricothyroidotomy technique to another. The primary hypothesis postulated that trained anaesthetists could perform an emergency cricothyroidotomy equally fast and successfully with a pocketknife compared with a surgical cricothyroidotomy set. DESIGN: Crossover noninferiority randomised controlled trial. SETTING: After written informed consent and ethics committee approval, this single-centre study was performed at the University Hospital of Bern, Bern, Switzerland. PARTICIPANTS: Altogether, 61 study participants already familiar with surgical cricothyroidotomy were included. INTERVENTION: The use of a commercially available cricothyroidotomy set was compared with a short-bladed pocketknife and ballpoint pen barrel. A pig-larynx cadaver model including trachea, with pig skin overlaid, was used. Participants underwent additional training sessions in both procedures. MAIN OUTCOME MEASURES: The primary outcome was the time necessary to position the tracheal tube or pen barrel in the trachea. Other outcome parameters were success rate, tracheal and laryngeal injuries and preferred device. RESULTS: Cricothyroidotomy with the pocketknife was performed significantly faster and equally successfully as compared with the cricothyroidotomy sets. Tracheal and laryngeal injuries were similar in both groups. Paratracheal or submucosal placement of the pen barrel occurred in 32%, compared with 29% for the tracheal tube. Sixty-six per cent of participants preferred the cricothyroidotomy set. CONCLUSION: Regularly trained anaesthetists are able to accomplish cricothyroidotomy irrespective of the equipment used. A pocketknife with a ballpoint pen barrel was just as effective as a commercially available surgical set.


Assuntos
Cartilagem Cricoide , Laringe , Animais , Cadáver , Cartilagem Cricoide/cirurgia , Laringe/cirurgia , Suínos , Suíça , Traqueia
9.
BMC Anesthesiol ; 20(1): 263, 2020 10 16.
Artigo em Inglês | MEDLINE | ID: mdl-33066735

RESUMO

BACKGROUND: Rigid scopes are successfully used for management of difficult airways, but learning curves have not been established. METHODS: This randomised controlled trial was performed at the University Hospital Bern in Switzerland to establish learning curves for the rigid scopes Bonfils and SensaScope and to assess their performance. Fifteen consultant anaesthetists and 15 anaesthesia registrars performed a total of 740 intubations (10 to 20 intubations with each device per physician) in adult patients without predictors of a difficult airway under general anaesthesia. According to randomisation, physicians intubated the patient's trachea with either the Bonfils or the SensaScope. A maximum of three intubation attempts was allowed. Primary outcome was overall time to successful intubation. Secondary outcome parameters included first attempt success, first attempt success within 60 s, failures and adverse events. RESULTS: A clear learning effect was demonstrated: Over 20 trials, intubations became 2.5-times quicker and first attempt intubation success probability increased by 21-28 percentage points. Fourteen and 20 trials were needed with the Bonfils and the SensaScope, respectively, to reach a 90% first attempt success probability. Intubation times were 23% longer (geometric mean ratio 1.23, 95% confidence interval 1.12-1.36, p < 0.001) and first attempt success was less likely (odds ratio 0.64, 95% confidence interval 0.45-0.92, p = 0.016) with the SensaScope. Consultants showed a tendency for a better first attempt success compared to registrars. Overall, 23 intubations (10 Bonfils, 13 SensaScope) failed. Adverse events were rare and did not differ between devices. CONCLUSIONS: A clear learning effect was demonstrated for both rigid scopes. Fourteen intubations with the Bonfils and 20 intubations with the SensaScope were required to reach a 90% first attempt success probability. Learning of the technique seemed more complex with the SensaScope compared to the Bonfils. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN14429285 . Registered 28 September 2011, retrospectively registered.

10.
Scand J Trauma Resusc Emerg Med ; 28(1): 71, 2020 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-32711548

RESUMO

BACKGROUND: Over the past years, several emergency medical service providers have introduced mechanical chest compression devices (MCDs) in their protocols for cardiopulmonary resuscitation (CPR). Especially in helicopter emergency medical systems (HEMS), which have limitations regarding loading weight and space and typically operate in rural and remote areas, whether MCDs have benefits for patients is still unknown. The aim of this study was to evaluate the use of MCDs in a large Swiss HEMS system. MATERIALS AND METHODS: We conducted a retrospective observational study of all HEMS missions of Swiss Air rescue Rega between January 2014 and June 2016 with the use of an MCD (Autopulse®). Details of MCD use and patient outcome are reported from the medical operation journals and the hospitals' discharge letters. RESULTS: MCDs were used in 626 HEMS missions, and 590 patients (94%) could be included. 478 (81%) were primary missions and 112 (19%) were interhospital transfers. Forty-nine of the patients in primary missions were loaded under ongoing CPR with MCDs. Of the patients loaded after return of spontaneous circulation (ROSC), 20 (7%) experienced a second CA during the flight. In interhospital transfers, 102 (91%) only needed standby use of the MCD. Five (5%) patients were loaded into the helicopter with ongoing CPR. Five (5%) patients went into CA during flight and the MCD had to be activated. A shockable cardiac arrhythmia was the only factor significantly associated with better survival in resuscitation missions using MCD (OR 0.176, 95% confidence interval 0.084 to 0.372, p < 0.001). CONCLUSION: We conclude that equipping HEMS with MCDs may be beneficial, with non-trauma patients potentially benefitting more than trauma patients.


Assuntos
Resgate Aéreo , Reanimação Cardiopulmonar/instrumentação , Equipamentos e Provisões , Serviços Médicos de Emergência , Equipamentos e Provisões/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/terapia , Estudos Retrospectivos , Suíça
11.
Scand J Trauma Resusc Emerg Med ; 28(1): 61, 2020 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-32600438

RESUMO

BACKGROUND: The human external cargo (HEC) operations conducted by Helicopter Emergency Medical Services (HEMS) rarely take place at night, making it difficult for crew members to attain and maintain the level of expertise needed to perform winch operations in the dark. As EASA requirements for training cannot currently be met, we evaluated whether simulation training could be an option. METHODS: This paper reports on a training concept using indoor simulation for the training of nighttime HEC operations. Participants' experience and perceptions were evaluated with a survey and the procedural and economic advantages of the simulation approach were compared with those of the usual outdoor HEC training. RESULTS: Most participants had limited exposure to real-life nighttime HEC missions before undergoing the simulation-based training. The frequency of training cycles in simulation was much higher compared to conventional training (60 cycles indoors vs. 20 outdoors for HEMS-TC, 20 cycles indoors vs. 4 outdoors for MCM). Trainees perceived that their technical and non-technical skills (NTS) improved with the training. The estimated costs of standard outdoor-based nighttime HEC training (138€ per cycle) are at least 6.5 times higher than the costs of indoor simulated training (approximately 21€ per cycle). With a change to simulation, carbon dioxide emissions could potentially be reduced by more than 35 tons. CONCLUSIONS: Indoor simulation training of night HEC operations has advantages with regard to cost-effectiveness, environmental friendliness, and self-reported improvements in skills and knowledge. Its use is feasible and could improve crew and patient safety and fulfill regulatory demands for training intensity.


Assuntos
Resgate Aéreo , Aeronaves , Serviços Médicos de Emergência , Treinamento por Simulação , Análise Custo-Benefício , Currículo , Meio Ambiente , Alemanha , Humanos , Competência Profissional , Estudos Prospectivos , Treinamento por Simulação/economia , Suíça
12.
Scand J Trauma Resusc Emerg Med ; 28(1): 40, 2020 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-32410706

RESUMO

BACKGROUND: The current COVID-19 pandemic highlights the challenges air ambulance services are facing when transporting highly infectious patients for several hours in enclosed spaces. This overview provides an example of a standard operating procedure (SOP) for infection prevention measures in HEMS missions during the COVID-19 pandemic. Furthermore, we describe different methods used by several organizations in Europe and the experience of the Swiss air rescue organization Rega in transporting these patients. Possible benefits of the use of small patient isolation units (PIU) are discussed, including the fact that accompanying medical personnel do not need to wear personal protective equipment (PPE) during the transport but can still maintain full access to the patient. Rega has developed and patented its own PIU. This device allows spontaneously breathing or mechanically ventilated patients to be transported in pressurized jet cabins, small helicopters and ambulance vehicles, without the need to change between transport units. This PIU is unique, as it remains air-tight even when there is a sudden loss of cabin pressure. CONCLUSION: A wide variety of means are being used for the aeromedical transport of infectious patients. These involve isolating either the patient or the medical crew. One benefit of PIUs is that the means of transport can be easily changed without contaminating the surroundings and while still allowing access to the patient.


Assuntos
Resgate Aéreo/organização & administração , Resgate Aéreo/normas , Aeronaves/normas , Infecções por Coronavirus/prevenção & controle , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Transporte de Pacientes/métodos , Transporte de Pacientes/normas , Betacoronavirus , COVID-19 , Infecções por Coronavirus/epidemiologia , Europa (Continente) , Pessoal de Saúde , Humanos , Controle de Infecções/métodos , Controle de Infecções/normas , Pneumonia Viral/epidemiologia , SARS-CoV-2 , Suíça
13.
Eur J Anaesthesiol ; 37(10): 842-846, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-31860603

RESUMO

BACKGROUND: Since the WHO release of the Safe Surgery Saves Lives Program in 2008, peri-operative checklists minimise errors and improve patient safety worldwide. Anaesthesia professionals are often reluctant to use these checklists in front of patients because they fear causing patients' discomfort before anaesthesia and surgery. OBJECTIVE: To assess and compare the subjective level of patient discomfort caused by the use of pre-induction checklists with the patient discomfort estimated by anaesthesia providers. DESIGN: Prospective observational study. SETTING: The current single-centre trial included 110 anaesthesia providers and 125 nonpremedicated ear, nose and throat or maxillofacial surgery patients in Switzerland from June to August 2016. Inclusion criterion: signed general research consent. EXCLUSION CRITERIA: received premedication, less than 18 years old, day-care patients, dementia or other mental illnesses. INTERVENTIONS: Anaesthesia healthcare providers and patients before surgery and on the first postoperative day were asked to rate three statements: MAIN OUTCOME MEASURES: All statements were rated on a 100-mm visual analogue scale, where 0 meant no agreement and 100 meant total agreement. RESULTS: Patients overwhelmingly agreed that anaesthesia providers should use checklists in front of them. Anaesthesia providers rated the patient discomfort much higher than actually perceived by patients. Both, patients and anaesthesia providers rated the possibility of reducing the risk of errors high. CONCLUSION: Patients experience far less discomfort observing the use of pre-induction checklists than anaesthesia providers expect. Patients value the potential safety benefit significantly higher than anaesthesia providers. These results further support the implementation of peri-operative checklists in the operating room environment. TRIAL REGISTRATION: The current observational study had no intervention, therefore, was not registered.


Assuntos
Anestesia , Anestesiologia , Adolescente , Lista de Checagem , Humanos , Estudos Prospectivos , Suíça
14.
Br J Anaesth ; 125(1): e61-e68, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31812268

RESUMO

BACKGROUND: Cannot intubate-cannot ventilate situations in healthy children are uncommon but are often associated with poor outcome. Several airway management algorithms suggest emergency tracheal access. Little agreement exists on how to perform emergency front of the neck access (eFONA) in children <8 yr. We studied the learning curves of clinicians performing simulated paediatric eFONA. METHODS: After watching an instructional video, 50 physicians, from five medical specialties, performed 10 emergency tracheotomies on rabbit cadavers. We analysed their learning curves relative to performance time and concurring injuries. RESULTS: With an overall success rate of 94%, performance time decreased from 107 s (standard deviation [sd], 45) to 55 s (sd 17) over 10 attempts. The learning curve was steep between the first and the fourth attempts with an 11% decrease in performance time (95% confidence interval [CI], 9-13%; P<0.001) per attempt and then flattened to a 4% (95% CI, 3-5%; P<0.001) decrease per attempt between the fourth and the tenth attempt. Age, years of clinical experience, and sex showed a significant effect on the learning curve, whereas medical specialty and adult eFONA experience did not. The 58% (95% CI, 44-72%) probability for severe injury during the first attempt decreased to 14% (95% CI, 8-20%) at the second attempt. Men were more likely to cause minor injuries than women (P<0.001). CONCLUSIONS: Irrespective of medical specialty, paediatric clinicians acquired the eFONA technique within four attempts and were on average able to establish an airway in <1 min when performing emergency tracheotomy on a paediatric airway simulator. CLINICAL TRIAL REGISTRATION: NCT03576352.


Assuntos
Competência Clínica/estatística & dados numéricos , Traqueotomia/educação , Adulto , Manuseio das Vias Aéreas , Animais , Emergências , Feminino , Humanos , Masculino , Modelos Animais , Coelhos , Fatores Sexuais
16.
BMJ Open ; 9(7): e025442, 2019 07 11.
Artigo em Inglês | MEDLINE | ID: mdl-31300494

RESUMO

INTRODUCTION: Apnoeic oxygenation using nasal high-flow oxygen delivery systems with heated and humidified oxygen has recently gained popularity in the anaesthesia community. It has been shown to allow a prolonged apnoea time of up to 65 min as CO2 increase was far slower compared with previously reported data from CO2 increase during apnoea. A ventilatory exchange due to the high nasal oxygen flow was proposed explaining that phenomenon. However, recent studies in children did not show any difference in CO2 clearance comparing high-flow with low-flow oxygen. To investigate this ventilatory exchange in adults, we plan this study comparing different oxygen flow rates and the increase of CO2 during apnoea. We hypothesise that CO2 clearance is non-inferior when applying low oxygen flow rates. METHODS AND ANALYSIS: In this single-centre, single-blinded, randomised controlled trial, we randomly assign 100 patients planned for elective surgery to either control (oxygen 70 L/min, airway opened by laryngoscopy) or one of three intervention groups: oxygen 70, or 10, or 2 L/min, all with jaw thrust to secure airway patency. After anaesthesia induction and neuromuscular blockage, either one of the interventions or the control will be applied according to randomisation. Throughout the apnoea period, we will measure the increase of transcutaneous pCO2 (tcpCO2) until any one of the following criteria is met: time=15 min, SpO2 <92%, tcpCO2 >10.67 kPa, art. pH <7.1, K+ >6.0 mmol/L. Primary outcome is the mean tcpCO2 increase in kPa/min. ETHICS AND DISSEMINATION: After Cantonal Ethic Committee of Bern approval (ID 2018-00293, 22.03.2018), all study participants will provide written informed consent. Patients vulnerable towards hypoxia or hypercarbia are excluded. Study results will be published in a peer-reviewed journal and presented at national and international conferences. TRIAL REGISTRATION NUMBER: This study was registered on www.clinicaltrials.gov (NCT03478774,Pre-results) and the Swiss Trial Registry KOFAM (SNCTP000002861).


Assuntos
Manuseio das Vias Aéreas/métodos , Anestesia Geral , Apneia , Oxigenoterapia/métodos , Administração Intranasal , Dióxido de Carbono/metabolismo , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
17.
Eur J Drug Metab Pharmacokinet ; 44(5): 691-711, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31114948

RESUMO

BACKGROUND AND OBJECTIVES: Lack of information on the pharmacokinetics of the active moiety of Cannabis or the metabolites of delta-9-tetrahydrocannabinol (THC) does not seem to be discouraging medical or recreational use. Cytochrome P450 (CYP) 2C9, the primary enzyme responsible for THC metabolism, has two single nucleotide polymorphisms-Arg144Cys (*2) and Ile359Leu (*3). In the Caucasian population, allelic frequency is between 0.08 and 0.14 for CYP2C9*2 and between 0.04 and 0.16 for CYP2C9*3. In vitro data suggest that metabolic capacity for the variants CYP2C9*2 and CYP2C9*3 is about one-third compared to wild-type CYP2C9. Previous work has suggested exposure to the terminal metabolite is genetically determined. We therefore sought to characterize the pharmacokinetics of THC and its major metabolites 11-hydroxy-delta-9-tetrahydrocannabinol (THC-OH) and 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH) in healthy volunteers with known CYP2C9 status by non-compartmental analysis (NCA), compartmental modeling (CM) and minimal physiologically based pharmacokinetic (mPBPK) modeling. METHODS: Blood samples drawn for THC, THC-OH and THC-COOH after a single intravenous (IV) bolus of 0.1 mg/kg (0.32 µM/kg) THC were analyzed using a validated LC-MS/MS method. NCA generated initial estimates and CM and the mPBPK model were then fit to plasma concentration data using non-linear mixed-effects modeling. Blood samples from orally dosed (10, 25 and 50 mg) THC brownies were added to validate the model. RESULTS: THC can be described as a high hepatic extraction ratio drug with blood flow-dependent metabolism not restricted by protein binding. THC hepatic clearance is dependent on the CYP2C9 genetic variant in the population. High extraction drugs display route-dependent metabolism. When administered via the IV or inhalation routes, induction or inhibition of CYP2C9 should be non-contributory as the elimination of THC is dependent only on liver blood flow. THC-OH is also a high extraction ratio drug, but its hepatic clearance is significantly impacted by the hepatic diffusional barrier that impedes its access to hepatic CYP2C9. THC-COOH is glucuronidated and renally cleared; subjects homozygous for CYP2C9*3 have reduced exposure to this metabolite as a result of the polymorphism reducing THC production, the hepatic diffusional barrier impeding egress from the hepatocyte, and increased renal clearance. CONCLUSION: It has recently been reported that the terminal metabolite THC-COOH is active, implying the exposure difference in individuals homozygous for CYP2C9*3 may become therapeutically relevant. Defining the metabolism of THC in humans is important, as it is increasingly being used as a drug to treat various diseases and its recreational use is also rising. We have used NCA, CM, and mPBPK modeling of THC and its metabolites to partially disentangle the complexity of cannabis disposition in humans.


Assuntos
Dronabinol/administração & dosagem , Dronabinol/farmacocinética , Administração Intravenosa , Administração Oral , Adulto , Citocromo P-450 CYP2C9 , Dronabinol/análogos & derivados , Feminino , Frequência do Gene/genética , Voluntários Saudáveis , Hepatócitos/metabolismo , Humanos , Fígado/metabolismo , Masculino , Adulto Jovem
18.
BMC Anesthesiol ; 19(1): 52, 2019 04 11.
Artigo em Inglês | MEDLINE | ID: mdl-30971211

RESUMO

BACKGROUND: The dislocation rate of oral versus nasal airway exchange catheters (AEC) in the postoperative care unit (PACU) are unknown. Our aim was to establish dislocation rates and to assess the usefulness of waveform capnography to detect dislocation. METHODS: In this non-randomized, prospective observational trial at the University Hospital Bern, Switzerland, we included 200 patients admitted to PACU after extubation via AEC, having provided written informed consent. The study was approved by the local ethical committee. AEC position was assessed by nasal fiberoptic endoscopy at beginning of PACU stay and before removal of the AEC. Capnography was continuously recorded via the AEC. Additional measurements included retching and coughing of the patient, and re-intubation, if necessary. RESULTS: Data from 182 patients could be evaluated regarding dislocation. Overall dislocation rate was not different between oral and nasal catheters (7.2% vs. 2.7%, p = 0.16). Retching was more often noted in oral catheters (26% vs. 8%, p < 0.01). Waveform capnography was unreliable in predicting dislocation (negative predictive value 17%). Re-intubation was successful in all five of the nine re-intubations where an AEC was still in situ. In four patients, the AEC was already removed when re-intubation became necessary, and re-intubation failed once, with a front of neck access as a rescue maneuver. CONCLUSIONS: We found no difference in dislocation rate between nasal and oral position of an airway exchange catheter. However, nasal catheters seemed to be tolerated better. In the future, catheters like the staged extubation catheter may further increase tolerance. TRIAL REGISTRATION: The study was registered in a clinical study registry ( ISRCTN 96726807 ) on 10/06/2010.


Assuntos
Capnografia/instrumentação , Capnografia/tendências , Cateteres/tendências , Falha de Equipamento , Boca , Cavidade Nasal , Adulto , Idoso , Extubação/instrumentação , Extubação/tendências , Feminino , Humanos , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/tendências , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Suíça/epidemiologia
19.
Scand J Trauma Resusc Emerg Med ; 26(1): 54, 2018 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-29973290

RESUMO

BACKGROUND: Avalanche rescues mostly rely on helicopter emergency medical services (HEMS) and include technical rescue and complex medical situations under difficult conditions. The adequacy of avalanche victim management has been shown to be unexpectedly low, suggesting the need for quality improvement. We analyse the technical rescue and medical competency requirements of HEMS crewmembers for avalanche rescue missions, as well as their clinical exposure. The study aims to identify areas that should be the focus of future quality improvement efforts. METHODS: This 15-year retrospective study of avalanche rescue by the Swiss HEMS Rega includes all missions where at least one patient had been caught by an avalanche, found within 24 h of the alarm being raised, and transported. RESULTS: Our analyses included 422 missions (596 patients). Crews were frequently confronted with technical rescue aspects, including winching (29%) and patient location and extrication (48%), as well as multiple casualty accidents (32%). Forty-seven percent of the patients suffered potential or overt vital threat; 29% were in cardiac arrest. The on-site medical management of the victims required a large array of basic and advanced medical skills. Clinical exposure was low, as 56% of the physicians were involved in only one avalanche rescue mission over the study period. CONCLUSIONS: Our data provide a solid baseline measure and valuable starting point for improving our understanding of the challenges encountered during avalanche rescue missions. We further suggest QI interventions, that might be immediately useful for HEMS operating under similar settings. A coordinated approach using a consensus process to determine quality indicators and a minimal dataset for the specific setting of avalanche rescue would be the logical next step.


Assuntos
Resgate Aéreo/organização & administração , Avalanches , Serviços Médicos de Emergência/organização & administração , Melhoria de Qualidade , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Suíça
20.
Int J Pediatr Otorhinolaryngol ; 108: 151-154, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29605345

RESUMO

OBJECTIVE: Reporting our institutional experience with high-flow nasal oxygen therapy (HFNOT), a recently-introduced technique, for endoscopic airway approaches. METHODS: Prospective collection of data of children (<16 years) undergoing endoscopic between January 2016 and August 2017 at a tertiary referral university hospital. RESULTS: HFNOT was used in 6 children who underwent 14 procedures for different forms and causes of upper airway obstruction of various origins. No intraoperative complications; related to oxygenation were observed, and the surgical procedures could be carried out as; initially planned. CONCLUSIONS: We found that HFNOT is an effective and safe technique with a variety of potential applications in the field of endoscopic pediatric airway surgery.


Assuntos
Obstrução das Vias Respiratórias/cirurgia , Endoscopia/métodos , Oxigenoterapia/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Nariz , Oxigênio , Estudos Prospectivos
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