A comparison of the McGrath videolaryngoscope with direct laryngoscopy for rapid sequence intubation in the operating theatre: a multicentre randomised controlled trial.

Aspiration of gastric contents is a recognised complication during all phases of anaesthesia. The risk of this event becomes more likely with repeated attempts at tracheal intubation. There is a lack of clinical data on the effectiveness of videolaryngoscopy relative to direct laryngoscopy rapid sequence intubation in the operating theatre. We hypothesised that the use of a videolaryngoscope during rapid sequence intubation would be associated with a higher first pass tracheal intubation success rate than conventional direct laryngoscopy. In this multicentre randomised controlled trial, 1000 adult patients requiring tracheal intubation for elective, urgent or emergency surgery were allocated randomly to airway management using a McGrath™ MAC videolaryngoscope (Medtronic, Minneapolis, MN, USA) or direct laryngoscopy. Both techniques used a Macintosh blade. First-pass tracheal intubation success was higher in patients allocated to the McGrath group (470/500, 94%) compared with those allocated to the direct laryngoscopy group (358/500, 71.6%), odds ratio (95%CI) 1.31 (1.23-1.39); p < 0.001. This advantage was observed in both trainees and consultants. Cormack and Lehane grade ≥ 3 view occurred less frequently in patients allocated to the McGrath group compared with those allocated to the direct laryngoscopy group (5/500, 1% vs. 94/500, 19%, respectively; p < 0.001). Tracheal intubation with a McGrath videolaryngoscope was associated with a lower rate of adverse events compared with direct laryngoscopy (13/500, 2.6% vs. 61/500, 12.2%, respectively; p < 0.001). These findings suggest that the McGrath videolaryngoscope is superior to a conventional direct laryngoscope for rapid sequence intubation in the operating theatre.

A multicentre randomised controlled trial of the McGrath™ Mac videolaryngoscope versus conventional laryngoscopy.

Before completion of this study, there was insufficient evidence demonstrating the superiority of videolaryngoscopy compared with direct laryngoscopy for elective tracheal intubation. We hypothesised that using videolaryngoscopy for routine tracheal intubation would result in higher first-pass tracheal intubation success compared with direct laryngoscopy. In this multicentre randomised trial, 2092 adult patients without predicted difficult airway requiring tracheal intubation for elective surgery were allocated randomly to either videolaryngoscopy with a Macintosh blade (McGrath™) or direct laryngoscopy. First-pass tracheal intubation success was higher with the McGrath (987/1053, 94%), compared with direct laryngoscopy (848/1039, 82%); absolute risk reduction (95%CI) was 12.1% (10.9-13.6%). This resulted in a relative risk (95%CI) of unsuccessful tracheal intubation at first attempt of 0.34 (0.26-0.45; p < 0.001) for McGrath compared with direct laryngoscopy. Cormack and Lehane grade ≥ 3 was observed more frequently with direct laryngoscopy (84/1039, 8%) compared with McGrath (8/1053, 0.7%; p < 0.001) No significant difference in tracheal intubation-associated adverse events was observed between groups. This study demonstrates that using McGrath videolaryngoscopy compared with direct laryngoscopy improves first-pass tracheal intubation success in patients having elective surgery. Practitioners may consider using this device as first choice for tracheal intubation.

Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

[Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study]. / Implementierung anästhesiologischer Qualitätsindikatoren in Deutschland : Eine prospektive, nationale, multizentrische Qualitätssteigerungsstudie German version.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

[Colonization-outbreak of two clonally different strains of Serratia marcescens in a neonatal intensive care unit]. / Kolonisationsausbruch mit zwei klonal unterschiedlichen Stämmen von Serratia marcescens auf einer neonatologischen Intensivstation.

We describe an outbreak of two clonally different strains of Serratia marcescens in a neonatal intensive care unit. Three colonization cases in the first outbreak phase were related to contact transmission from an index patient during emergency respiratory treatment while eight colonizations in the second phase were caused by contaminated bathing lotion. All transmissions resulted in colonization only and no infections were recorded. Based on our experience and the literature review sufficient staffing levels, basic hygiene and a goal-directed investigation of the environment are the cornerstones of a rapid outbreak termination. The epidemiological search for parallels in cases should be assisted by sophisticated electronic records.

Incidence of postoperative nausea and emetic episodes after xenon anaesthesia compared with propofol-based anaesthesia.

BACKGROUND: Xenon has been proved to be safe and efficacious for general anaesthesia in numerous trials. In addition, experimental studies demonstrate that xenon inhibits the 5-hydroxytryptamine type 3 (5-HT(3)) receptor. As 5-HT(3) receptor antagonists are known to decrease postoperative nausea and vomiting (PONV) to an extent comparable with a propofol-based total i.v. technique, we tested the hypothesis that general anaesthesia with xenon would result in a reduced incidence of PONV similar to that observed with propofol-based anaesthesia. METHODS: After obtaining approval from the local ethics committee and written informed consent, 142 patients were randomized to receive xenon anaesthesia or propofol-based total i.v. anaesthesia (TIVA), both supplemented with remifentanil. The incidence of postoperative nausea and emetic episodes was recorded in the post-anaesthesia care unit and on the ward more than 24 h after anaesthesia. RESULTS: A total of 142 patients were equally distributed between the xenon and TIVA groups. Anaesthesia was maintained with mean (sd) concentrations of either xenon 61 (2)% or propofol 100 (20) microg kg(-1) min(-1). Incidences of nausea and emetic episodes over the whole 24-h period were 66.2% and 35.2% in the xenon group and 26.8% and 16.9% in the TIVA group (P<0.001 and P<0.021). CONCLUSION: Despite knowing the 5-HT(3) antagonistic properties of xenon, its use is associated with a higher incidence of nausea and emetic episodes compared with TIVA with propofol.

[Anesthesia during pregnancy]. / Anästhesie in der Schwangerschaft.

The need for general or regional anesthesia due to nonobstetric surgery occurs in up to 2% of all pregnancies. Safe perioperative care is a challenge to anesthetists. Profound knowledge of physiological and pathophysiological changes during pregnancy and the possible influence of different drugs and anesthesia techniques on mother and fetus is necessary. Although data from randomized controlled trials is missing, safe anesthesia during pregnancy is well documented for nearly every operative procedure. Interdisciplinary cooperation between surgeon, obstetrician, neonatologist, and anesthetist is the key to optimal patient care.

[Diary of a hospital evacuation. Discovery of a 5 hundredweight bomb from World War II]. / Tagebuch einer Krankenhausevakuierung : Fund einer 5-Ztr.-Bombe aus dem Zweiten Weltkrieg.

The discovery of an aircraft bomb from World War II made the complete evacuation of a tertiary care hospital with 629 beds and 17 specialist departments including a neonatal intensive care unit necessary. Some months before an alarm plan had been issued and a fire practice had been carried out which made it obvious to all concerned how important such measures are. Nevertheless, more room for improvement could be learned from the evacuation, in particular the rapid classification of the patients into categories and the fact that 20-30% of the patients needed stretcher-based transport for evacuation.

Emergence and early cognitive function in the elderly after xenon or desflurane anaesthesia: a double-blinded randomized controlled trial.

BACKGROUND: Postoperative cognitive impairment after general anaesthesia, especially in the elderly, is a well-recognized problem. Xenon, known to be an N-methyl-d-aspartate antagonist, may be advantageous. In this study, the early cognitive function in the elderly after general anaesthesia with xenon was compared with that after desflurane. METHODS: After approval by the local ethical committee and after obtaining written informed consent, patients were enrolled in this randomized, double-blinded, controlled study. Thirty-eight patients (65-75 yr old, ASA status I-III) undergoing an elective surgery with a planned duration of 60-180 min were allocated to either the xenon (n = 18) or the desflurane (n = 20) anaesthesia group. The primary outcome was the cognitive Test for Attentional Performance (TAP) with its subtests Alertness, Divided Attention, and Working Memory. After baseline assessment 12-24 h before operation, patients were followed-up 6-12 and 66-72 h after operation. Secondary outcomes were emergence times from anaesthesia and the modified Aldrete score. RESULTS: No difference was found between the groups in the TAP at 6-12 and 66-72 h after operation. In the xenon group, emergence time was significantly faster for the following parameters: time to open eyes (P = 0.001), to react on demand (P = 0.001), to extubation (P = 0.001), and for time and spatial orientation (P = 0.007). The modified Aldrete score was significantly higher after 30, 45 and 60 min in the xenon group. CONCLUSIONS: There was no difference in the postoperative cognitive testing at 6-12 and 66-72 h. Xenon was associated in the elderly with a faster emergence from general anaesthesia than desflurane.

Patients' self-evaluation after 4-12 weeks following xenon or propofol anaesthesia: a comparison.

BACKGROUND AND OBJECTIVE: The aim of this study was to assess postoperative patients' self-evaluation after xenon anaesthesia compared to total intravenous anaesthesia with propofol. METHODS: 160 patients aged 18-60 yr, ASA I-II undergoing elective surgery took part in this randomised-controlled trial. After approval by the local Ethics Committee and as soon as the patients had given their written informed consent, they were randomly allocated to either the xenon (n = 80) or propofol (n = 80) group. In both groups remifentanil was used as opioid. The postoperative patients' self-evaluation was assessed with a double-blind telephone poll. Early spatial orientation, patients' self-evaluation of anaesthesia, choice of the same anaesthesia for future operations and recall of uncomfortable feelings after anaesthesia were determined. RESULTS: 116 Patients were analysed, 63 in the xenon and 53 in the propofol group. The two study groups were comparable with respect to age, weight, height, gender and ASA classification. The two groups indicated similar values in the early spatial orientation at the onset of recovery and thereafter. Patients' self-evaluation of anaesthesia with main emphasis at high marks and repetition of the same anaesthesia if necessary were similar in both groups. Recalls of uncomfortable feelings were comparable but not for postoperative pain and appetite/thirst which appeared with a significantly higher incidence in the xenon group. CONCLUSIONS: Patients' self-evaluation and memory of early spatial orientation following xenon anaesthesia are comparable to propofol.

Randomized controlled trial of the haemodynamic and recovery effects of xenon or propofol anaesthesia.

BACKGROUND: There is limited clinical experience with xenon in a large number of patients. We present intra- and postoperative haemodynamic and recovery data comparing xenon and total intravenous anaesthesia with propofol. METHODS: A total of 160 patients aged 18-60 years (ASA I and II) undergoing elective surgery took part in this prospective non-blinded randomized controlled trial. After local ethics committee approval and written informed consent, patients were allocated randomly to either the xenon or the propofol group. Anaesthesia was induced with propofol and remifentanil and was maintained with xenon at 60% (minimal alveolar concentration 0.95) or with propofol 0.1-0.12 mg kg(-1) min(-1). Remifentanil was titrated to clinical need in both groups. RESULTS: The two study groups were comparable with respect to age, weight, height, gender and ASA classification. Baseline in heart rate and systolic arterial pressure (SAP) were comparable in both groups. Following induction, SAP initially decreased but returned to baseline values over 15 min in the xenon group and differed significantly from the propofol group. Heart rate decreased significantly only in the xenon group and remained at stable values. Occurrence and duration of hypertension, hypotension and bradycardia showed no significant difference between groups. Patient recovery time in the post-anaesthetic care unit and recovery from anaesthesia was similar in the two groups. CONCLUSIONS: After induction the xenon/opioid regimen maintains systolic blood pressure at baseline levels and a low heart rate. No differences between groups were found in haemodynamic stability during anaesthesia. Recovery from xenon anaesthesia was similar to that observed in the propofol group.

[Clinical importance of hypocaloric parenteral feeding]. / Klinische Bedeutung der hypokalorischen parenteralen Ernährung.

Hypocaloric parenteral nutrition (HPN) is mainly and frequently used in surgical medicine since it allows a reliable and standardized supply of nutrients. Ready-mix solutions which are suitable for peripheral venous nutrition generally contain about 50 g carbohydrates (glucose and/or xylitol), 25 g amino acids and electrolytes per liter. The osmolarity of the solutions averages between 600 and 800 mosmol/l. HPN has two distinct advantages: firstly the minimal effects on carbohydrate metabolism and secondly the good improvement in nitrogen balance. If 2 g/kg and day glucose are administered, even postoperatively, the mean blood sugar levels are only just above the normal range and an amino acid dosage of 1 g/kg and day, compared with liquid substitution alone or the administration of small amounts of carbohydrates, leads to an approximately 60% improvement in postoperative N-balance. Experience gained with HPN in surgical medicine to date permits the following recommendation: 1. HPN should not be used after small and moderate interventions with short nutritional abstinence; it is not necessary to administer nutrients in such cases. 2. HPN may be used after moderate to serious surgical interventions; e.g. after gastrointestinal resections in the case of elective surgery on patients with a normal nutritional status. However, studies have yet to prove the clinical efficacy of HPN, e.g. as evidenced by shorter hospitalization or a reduced perioperative morbidity or mortality, although this reservation equally applies to the routinely administered complete parenteral or enteral nutrition.(ABSTRACT TRUNCATED AT 250 WORDS)

[Analysis of the anesthesiologist's vigilance with an eye-tracking device. A pilot study for evaluation of the method under the conditions of a modern operating theatre]. / Analyse der Aufmerksamkeitsverteilung des Anästhesisten mit Hilfe der Blickbewegungsmessung. Pilotstudie zur Methodenevaluation unter den Bedingungen eines modernen Operationsbetriebes.

INTRODUCTION: With the inclusion of new monitoring devices over the last two decades, the distribution of the anesthesiologists vigilance has changed which might influence the ergonomic profile of an optimal anesthesia workstation. The aim of this pilot study was the evaluation of an eyetracking device to analyze the vigilance distribution of an anesthesiologist during routine cases in an operating theatre of the 21st century. MATERIAL AND METHODS: Five anesthesiologist with different levels of training were followed during different types of surgery using a video camera-based eye-tracking system. The films were analyzed by an independent observer and rated according to defined regions of interest (ROI). Then typical scan-paths were identified and quantitatively analyzed. RESULTS: The eye-tracking studies proved to be technically of high quality but were time-consuming. Only few disturbances to the operating room (OR) personnel were recorded according to their subjective impressions but bias of behaviour due to the measurement procedure itself cannot be completely excluded. The vigilance of the anesthesiologist towards different factors was dependent on the level of professional training, the type of anesthesia and the type of surgery. Certain factors such as documentation (10-15%) or external disturbances (approximately 20%) proved to be relatively constant. Typical scan-paths could also be identified. CONCLUSION: Eye-tracking studies proved to be a suitable way to analyze the distribution of vigilance of anesthesiologists in a modern operating theatre. For further studies examining the influence of detailed modifications of the OR environment, a standardized study design with the same level of education, the same anesthesia technique and the same surgical procedure needs to be chosen.

[Hyperpyrexia and rhabdomyolysis after ecstasy (MDMA) intoxication]. / Ausgeprägte Hyperthermie und Rhabdomyolyse nach Ecstasy (MDMA)-Intoxikation.

Abuse of 3,4-methylenedioxymethamphetamine (MDMA,Ecstasy) is still growing over the last years and reports of severe or even fatal complications, such as arrhythmias, hyperpyrexia, rhabdomyolysis, disseminated intravascular coagulopathy (DIC), acute renal or liver failure or brain oedema are also increasing. We report the case of a 21-year-old male who took a suicidal overdose of MDMA and subsequently developed severe hyperpyrexia (>43 degrees C/109.4 degrees F), rhabdomyolysis with an initial myoglobin level of 88,000 microg/l, disseminated intravascular coagulation (DIC) and beginning renal and liver failure. Infusing dantrolene 140 mg (2.5 mg/kg body weight) i.v. and using supportive cooling was effective in treating hyperpyrexia. To support renal function and diuresis we increased the intravenous fluid supply up to 5 l per day which led to a raised elimination of myoglobin, urea nitrogen and creatinine within 1 week. Hemodialysis was not necessary. DIC was treated according to laboratory parameters by supply of antithrombin (AT) III, fresh frozen plasma, prothrombin complex concentrates (PPSB) and continuous aprotinin 100,000 IE/h.

[Epiglottic abscess as a rare reason for airway obstruction in adults]. / Epiglottisabszess als seltene Ursache einer Atemwegsverlegung beim Erwachsenen.

Acute epiglottitis in adults is a potentially life-threatening disease of increasing incidence. Although pharyngitis is the most common cause of sore throat in the adult, acute epiglottitis must be considered in the differential diagnosis when there is unrelenting throat pain and minimal objective signs of pharyngitis. We report the case of a 45-year old man with acute epiglottitis and occlusion of the upper airways due to an epiglottic abscess. A brief discussion of the diagnosis and treatment of adult epiglottitis is presented. Patients with acute painful dysphagia should be considered to have epiglottitis until the diagnosis is proven. Early diagnosis and aggressive airway management can be life saving.

Diagnosis and treatment of the acute porphyrias: an interdisciplinary challenge.

The porphyrias comprise a group of fascinating disorders resulting from predominantly inherited as well as acquired deficiencies of one of the eight enzymes along the pathway of heme biosynthesis. On the basis of clinical aspects, the different types of porphyrias can be classified in acute and non-acute forms. However, an exact classification is often difficult since the porphyrias might reveal unspecific clinical symptoms and/or overlapping biochemical features. In particular, this is true for the acute porphyrias which can present with life-threatening acute neurovisceral attacks that require immediate medical intervention. Due to the multiple facets of these disorders, the diagnosis and treatment of the acute porphyrias should always imply a close interdisciplinary collaboration to serve patients and their families most effectively.

[A patient with nodal tachycardia after general anesthesia during medication with a selective serotonin reuptake inhibitor]. / Patientin mit Knotentachykardie nach Narkoseausleitung bei vorbestehender Medikation mit einem selektiven Serotonin-Wiederaufnamehemmer.

We report on a 62 year old female patient treated with paroxetine, a selective serotonin reuptake inhibitor, because of an anxiety neurosis undergoing a vaginal hysterectomy in general anesthesia. Apart from a dietary treated diabetes mellitus there were no other diseases. There were no complications during the operation. At the end of the anesthesia an A-V nodal tachycardia appeared which spontaneously changed to a sinus rhythm ten hours after the end of the operation. No clinical or laboratory findings indicated a cardiac ischemia and an additional Holter ECG-Recording showed no further cardiac arrhythmias. No other complications occurred afterwards and the patient was discharged after two weeks. This case report demonstrates clearly that despite a reduced rate of cardiovascular complications compared to other types of antidepressants selective serotonin reuptake inhibitors can lead to perioperative cardiac arrhythmias.

[Cuff pressure monitoring and regulation in adults]. / Cuffdruckmessung und Regelung im Erwachsenenalter.

OBJECTIVES: In adults the use of cuffed endotracheal tubes is the standard technique. Nitrous oxide increases the cuff pressure secondary to diffusion through the cuff membrane. The aim of the study was to verify a newly designed cuff pressure regulating device and comparison of postoperative complications. METHODS: In a prospective, randomized, open trial the cuff pressure and the incidence of postoperative complications (e.g., hoarseness, coughing and pain while swallowing) were measured using the newly designed automatic pressure monitoring and regulating device Cuff Pressure Control (Tracoe) and a conventional handheld manometer. A total of 40 patients were assigned to the automatic group with a goal of 25.5 cmH(2)O and 40 patients to the conventional group where the pressures were kept between 20 cmH(2)0 and 40 cmH(2)0 with intermittent measurements and manual pressure release. RESULTS: The automatic device reliably maintained the pressure at the chosen constant level within +/-2 cmH(2)O. In the control group increases in cuff pressure to 40 cmH(2)O were common. The incidence of postoperative complications in both groups was not significantly different. CONCLUSIONS: In conclusion our data demonstrate that the automatic cuff pressure and regulation device was useful and reliable in an adult population of intubated patients in the studied pressure range.

Prostate-specific antigen immunoreactivity in spinal fluid.

OBJECTIVES: Prostate-specific antigen (PSA) is no longer believed to be tissue specific for prostate epithelial cells as it has been documented in various human tissues. The physiological role of PSA in this context is currently unknown. Furthermore the distribution of PSA throughout the human body remains to be established. We therefore investigated PSA immunoreactivity in human spinal fluid (SF). METHODS: The PSA concentration was measured in the SF and sera of 34 men and 6 women. The SF was obtained prior to spinal anesthesia and was kept frozen at -20 degrees C until analysis. RESULTS: PSA was detected in the SF of male patients. Median SF PSA was 0.03 ng/ml in the 34 men, whereas SF PSA was below the detection limit in the 6 women. In men we could establish a positive correlation between SF PSA and serum PSA with a correlation coefficient of r = 0.85 (p < 0.001). CONCLUSION: These results confirm recent literature reports indicating that PSA is detectable in various human tissues and fluids.