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The use of the Airtraq? optical laryngoscope for routine tracheal intubation in high-risk cardio-surgical patients
Gereon Schlte, Ulrike Scheid, Steffen Rex, Mark Coburn, Britta Fiedler, Rolf Rossaint, Norbert Zoremba
BMC Research Notes , 2011, DOI: 10.1186/1756-0500-4-425
Abstract: 123 consecutive ASA III patients undergoing elective coronary artery bypass grafting were routinely intubated with the Airtraq? laryngoscope. Induction of anesthesia was standardized according to our institutional protocol. All tracheal intubations were performed by six anesthetists trained in the use of the Airtraq? prior.Overall success rate was 100% (n = 123). All but five patients trachea could be intubated in the first attempt (95,9%). 5 patients were intubated in a 2nd (n = 4) or 3rd (n = 1) attempt. Mean intubation time was 24.3 s (range 16-128 s). Heart rate, arterial blood pressure and SpO2 were not significantly altered. Minor complications were observed in 6 patients (4,8%), i.e. two lesions of the lips and four minor superficial mucosal bleedings. Intubation duration (p = 0.62) and number of attempts (p = 0.26) were independent from BMI and Mallampati score.Tracheal intubation with the Airtraq? optical laryngoscope was feasible, save and easy to perform in high-risk patients undergoing cardiac surgery. In all patients, a sufficient view on the vocal cords could be obtained, independent from BMI and preoperative Mallampati score.DRKS 00003230Tracheal intubation is still the golden standard of securing the airway under clinical and preclinical conditions. In case of resuscitation, respiratory failure, unconsciousness and loss of a patent airway it is life saving. Since its introduction in 1941, the Macintosh laryngoscope has been the most popular device used for intubation worldwide.However, tracheal intubation using this laryngoscope has been demonstrated to fail in up to 35% of patients with an unpredicted difficult airway [1,2]. Problems in securing the airway are still the main contributors to anesthesia-related morbidity and mortality [3]. Therefore, a wide variety of alternatives to the Macintosh laryngoscope have been introduced into clinical routine, including the Miller-, McCoy-, and Bullard-laryngoscope. Since 1982 Archie Brain's supra glottic la
The intuitive use of laryngeal airway tools by first year medical students
Johannes Bickenbach, Gereon Schlte, Stefan Beckers, Michael Fries, Matthias Derwall, Rolf Rossaint
BMC Emergency Medicine , 2009, DOI: 10.1186/1471-227x-9-18
Abstract: The purpose of the study was to investigate the intuitive use of airway devices by first-year medical students as well as the effect of a simple, but well-directed training programme. Retention of skills was re-evaluated six months thereafter.The insertion of a LMA-Classic and a LMA-Fastrach performed by inexperienced medical students was compared in an airway model. The improvement on their performance after a training programme of overall two hours was examined afterwards.Prior to any instruction, mean time to correct placement was 55.5 ± 29.6 s for the LMA-Classic and 38.1 ± 24.9 s for the LMA-Fastrach. Following training, time to correct placement decreased significantly with 22.9 ± 13.5 s for the LMA-Classic and 22.9 ± 19.0 s for the LMA-Fastrach, respectively (p < 0.05). After six months, the results are comparable prior (55.6 ± 29.9 vs 43.1 ± 34.7 s) and after a further training period (23.5 ± 13.2 vs 26.6 ± 21.6, p < 0.05).Untrained laypersons are able to use different airway devices in a manikin and may therefore provide a secured airway even without having any detailed background knowledge about the tool. Minimal theoretical instruction and practical skill training can improve their performance significantly. However, refreshment of knowledge seems justified after six months.Mortality of "sudden cardiac death" (SCD) in Europe runs up to 375.000 patients per year [1] and is in most cases caused by acute (cardiac failure) coronary syndromes. To prevent secondary hypoxic damage to the brain and other vital organs due to respiratory failure, it is of paramount importance to assess and control the airway.Several devices have been recommended helping to keep the airway open [2]. While still bringing out the "gold-standard" with the tracheal tube, it has already been shown before that the laryngeal mask airway (LMA) and the Combitube are possible alternative tools. In comparison to bag-valve facemask ventilation, they may firstly reduce the risk of gastric regurg
Early cognitive function, recovery and well-being after sevoflurane and xenon anaesthesia in the elderly: a double-blinded randomized controlled trial
Jan Cremer, Christian Stoppe, Astrid V Fahlenkamp, Gereon Schlte, Steffen Rex, Rolf Rossaint, Mark Coburn
Medical Gas Research , 2011, DOI: 10.1186/2045-9912-1-9
Abstract: The study was approved by the local ethics committee and written informed consent was obtained from each patient. Patients aged 65-75 years (ASA I-III) scheduled for elective surgery (duration 60-180 min) were enrolled. Investigators performing cognitive testing and patients were blinded towards allocation to either xenon or sevoflurane anaesthesia. Baseline assessment of cognitive function was carried out 12-24 h before the operation. The results were compared to follow-up tests 6-12 and 66-72 h after surgery. Primary outcome parameter was the subtest "Alertness" of the computerized Test of Attentional Performance (TAP). Secondary outcome parameters included further subtests of the TAP, several Paper-Pencil-Tests, emergence times from anaesthesia, modified Aldrete scores and patients' well-being.40 patients were randomized and equally allocated to both groups. No significant differences were found in the TAP or the Paper-Pencil-Tests at 6-12 and 66-72 h after the operation. All emergence times were faster after xenon anaesthesia. The modified Aldrete scores were significantly higher during the first hour in the xenon group. No difference in well-being could be detected between both groups.The results show no difference in the incidence of postoperative cognitive dysfunction (POCD) after xenon or sevoflurane anaesthesia. Emergence from general anaesthesia was faster in the xenon group.Age is a known risk factor for postoperative cognitive dysfunction (POCD) after cardiac and non-cardiac surgery [1-3]. Up to 41% of patients aged 60 years and older are affected by POCD and exposed to an increased risk of death within the first 12 months after major non-cardiac surgery [1].Although a growing number of researchers are concentrating on POCD [4], no significant progress can be seen in the prevention of POCD.The noble gas xenon offers good haemodynamic stability [5-10] and favours rapid recovery from anaesthesia [11,12], both of which have been hypothesized to be beneficia
Does a 4 diagram manual enable laypersons to operate the laryngeal mask supreme?? A pilot study in the manikin
Gereon Schlte, Christian Stoppe, Rolf Rossaint, Laura Gilles, Maike Heuser, Steffen Rex, Mark Coburn, Norbert Zoremba, Annette Rieg
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2012, DOI: 10.1186/1757-7241-20-21
Abstract: An instruction manual of four illustrations with speech bubbles displaying the correct use of the LMAS was designed. Laypersons were handed a bag containing a LMAS, a bag mask valve device (BMV), a syringe prefilled with air and the instruction sheet, and were asked to perform and ventilate the manikin as displayed. Time to ventilation was recorded and degree of success evaluated.A total of 150 laypersons took part. Overall 145 participants (96.7%) inserted the LMAS in the manikin in the right direction. The device was inserted inverted or twisted in 13 (8.7%) attempts. Eight (5.3%) individuals recognized this and corrected the position. Within the first 2 minutes 119 (79.3%) applicants were able to insert the LMAS and provide tidal volumes greater than 150 ml (estimated dead space). Time to insertion and first ventilation was 83.2 ± 29 s. No significant difference related to previous BLS training (P = 0.85), technical education (P = 0.07) or gender could be demonstrated (P = 0.25).In manikin laypersons could insert LMAS in the correct direction after onsite instruction by a simple manual with a high success rate. This indicates some basic procedural understanding and intellectual transfer in principle. Operating errors (n = 91) were frequently not recognized and corrected (n = 77). Improvements in labeling and the quality of instructional photographs may reduce individual error and may optimize understanding.Layperson resuscitation plays an important role in providing lifesaving cardiopulmonary resuscitation (CPR) and bridging the interval to the arrival of healthcare professionals. However, only 50% of laypersons actually administer "first aid" in such situations [1,2]. Reasons given are various and include a lacking sense of personal responsibility when there are many other people "on site", an aversion to strangers' bodily fluids and the percieved risk of infection during "mouth to mouth" ventilation. Individuals may be discouraged from administering CPR by a la
Laypersons can successfully place supraglottic airways with 3 minutes of training. A comparison of four different devices in the manikin
Gereon Schlte, Christian Stoppe, Meral Aktas, Mark Coburn, Steffen Rex, Marlon Schwarz, Rolf Rossaint, Norbert Zoremba
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2011, DOI: 10.1186/1757-7241-19-60
Abstract: Four different supraglottic airway devices: Laryngeal Mask Classic (LMA), Laryngeal Tube (LT), Intubating Laryngeal Mask (FT) and CobraPLA (Cobra) were tested in 141 volunteers recruited in a technical university cafeteria and in a shopping mall. All volunteers received a brief standardized training session. Primary endpoint was the time required to definitive insertion. In a short questionnaire applicants were asked to assess the devices and to answer some general questions about BLS.The longest time to insertion was observed for Cobra (31.9 ± 27.9 s, range: 9-120, p < 0.0001; all means ± standard deviation). There was no significant difference between the insertion times of the other three devices. Fewest insertion attempts were needed for the FT (1.07 ± 0.26), followed by the LMA (1.23 ± 0.52, p > 0.05), the LT (1.36 ± 0.61, p < 0.05) and the Cobra (1.45 ± 0.7, p < 0.0001). Ventilation was achieved on the first attempt significantly more often with the FT (p < 0.001) compared to the other devices. Nearly 90% of the participants were in favor of implementing supraglottic airway devices in first aid algorithms and classes.Laypersons are able to operate supraglottic airway devices in manikin with minimal instruction. Ventilation was achieved with all devices tested after a reasonable time and with a high success rate of > 95%. The use of supraglottic airway devices in first aid and BLS algorithms should be considered.The securing of the airway and ventilation of the lungs is of paramount importance following initial chest compressions during cardiopulmonary resuscitation (CPR). In the preclinical setting, physical contact with the patient (in particular their mouth) presents a strong deterrent to many lay responders. Disgust and fear of infection, associated with contact with bodily fluids are frequently cited as preventing immediate care [1-3]. This may coincide with a fear of incorrect mouth-to-mouth ventilation and potential malpractice consequences.To facilitate
Milrinone Relaxes Pulmonary Veins in Guinea Pigs and Humans
Annette D. Rieg, Said Suleiman, Alberto Perez-Bouza, Till Braunschweig, Jan W. Spillner, Thomas Schr?der, Eva Verjans, Gereon Schlte, Rolf Rossaint, Stefan Uhlig, Christian Martin
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0087685
Abstract: Introduction The phosphodiesterase-III inhibitor milrinone improves ventricular contractility, relaxes pulmonary arteries and reduces right ventricular afterload. Thus, it is used to treat heart failure and pulmonary hypertension (PH). However, its action on pulmonary veins (PVs) is not defined, although particularly PH due to left heart disease primarily affects the pulmonary venous bed. We examined milrinone-induced relaxation in PVs from guinea pigs (GPs) and humans. Material and Methods Precision-cut lung slices (PCLS) were prepared from GPs or from patients undergoing lobectomy. Milrinone-induced relaxation was studied by videomicroscopy in na?ve PVs and in PVs pre-constricted with the ETA-receptor agonist BP0104. Baseline luminal area was defined as 100%. Intracellular cAMP was measured by ELISA and milrinone-induced changes of segmental vascular resistances were studied in the GP isolated perfused lung (IPL). Results In the IPL (GP), milrinone (10 μM) lowered the postcapillary resistance of pre-constricted vessels. In PCLS (GP), milrinone relaxed na?ve and pre-constricted PVs (120%) and this relaxation was attenuated by inhibition of protein kinase G (KT 5823), adenyl cyclase (SQ 22536) and protein kinase A (KT 5720), but not by inhibition of NO-synthesis (L-NAME). In addition, milrinone-induced relaxation was dependent on the activation of KATP-, BKCa2+- and Kv-channels. Human PVs also relaxed to milrinone (121%), however only if pre-constricted. Discussion Milrinone relaxes PVs from GPs and humans. In GPs, milrinone-induced relaxation is based on KATP-, BKCa2+- and Kv-channel-activation and on cAMP/PKA/PKG. The relaxant properties of milrinone on PVs lead to reduced postcapillary resistance and hydrostatic pressures. Hence they alleviate pulmonary edema and suggest beneficial effects of milrinone in PH due to left heart disease.
Pilotprojekt "Patientensicherheit" in der medizinischen Lehre [Pilot project "Patient-Safety" in Medical Education]
Rosentreter, Michael,Gro?, Dominik,Sch?fer, Gereon
GMS Zeitschrift für Medizinische Ausbildung , 2011, DOI: 10.3205/zma000724
Abstract: [english] Since the summer term 2009 the study project Patientensicherheit – Der klinische Umgang mit Patienten- und Eingriffsverwechslungen sowie Medikationsfehlern“ (Patient Safety – the clinical handling of patients – and mistaking of procedures as well as medication errors) is offered within the Modellstudiengang Medizin. Seminars on patient safety in Germany so far mainly address trained doctors and health economists. In contrast, this study project on patient safety should at an early stage contribute to a “culture of discussing and preventing mistakes” – an aspect that is little established in clinical medicine, but also in medical training. For this purpose, a broad variety of courses was developed, which – relying on problem-oriented learning – enables the students to analyse so-called adverse events (AE) and develop adequate prevention measures on the basis of the insights gained by this analysis. Therefore, theoretical lessons are complemented by discussing prototypical clinical cases. These discussions are moderated by experienced clinicians. After completing the seminar, students showed a significant increase (comparison of means) in the self-assessed qualifications Wissen zu Patientensicherheit“ (Knowledge of Patient Safety) and Wahrnehmung von Risikosituationen“ (Appreciation of Risk Situations). All in all, the students rated their training success with a grade of 1.5 (good). [german] Seit dem Sommersemester 2009 wird im Rahmen des Modellstudiengangs Medizin der RWTH Aachen das Lehrprojekt Patientensicherheit – Der klinische Umgang mit Patienten- und Eingriffsverwechslungen sowie Medikationsfehlern“ angeboten Seminare zur Patientensicherheit in Deutschland zielen bislang vor allem auf ausgebildete rzte und Gesundheits konomen ab. Demgegenüber soll das Lehrprojekt Patientensicherheit einen frühzeitigen Beitrag zu einer Kultur der Fehlerdiskussion und -vermeidung“ leisten – ein Aspekt, der bisher in der klinischen Medizin, aber auch in der medizinischen Ausbildung wenig etabliert ist. Dazu wurde ein thematisch breit angelegtes Lehrangebot erarbeitet, das die Studierenden auf der Grundlage des problemorientierten Lernens bef higt, sog. Unerwünschte Ereignisse (UE) zu analysieren und – auf der Basis der so gewonnenen Erkenntnisse – geeignete Pr ventionsma nahmen zu entwickeln. Theoretische Lerneinheiten werden erg nzt durch Besprechungen prototypischer klinischer F lle, die von erfahrenen Klinikern moderiert werden. Bei den selbsteingesch tzten Kompetenzen Wissen zu Patientensicherheit“ und Wahrnehmung von Risikosituationen“ wiesen d
Stable etale realization and etale cobordism
Gereon Quick
Mathematics , 2006,
Abstract: We show that there is a stable homotopy theory of profinite spaces and use it for two main applications. On the one hand we construct an \'etale topological realization of the stable motivic homotopy theory of smooth schemes over a base field of arbitrary characteristic in analogy to the complex realization functor for fields of characteristic zero. On the other hand we get a natural setting for \'etale cohomology theories. In particular, we define and discuss an \'etale topological cobordism theory for schemes. It is equipped with an Atiyah-Hirzebruch spectral sequence starting from \'etale cohomology. Finally, we construct maps from algebraic to \'etale cobordism and discuss algebraic cobordism with finite coefficients over an algebraically closed field after inverting a Bott element.
Continuous group actions on profinite spaces
Gereon Quick
Mathematics , 2009,
Abstract: For a profinite group, we construct a model structure on profinite spaces and profinite spectra with a continuous action. This yields descent spectral sequences for the homotopy groups of homotopy fixed point space and for stable homotopy groups of homotopy orbit spaces. Our main example is the Galois action on profinite \'etale topological types of varieties over a field. One motivation is to understand Grothendieck's section conjecture in terms of homotopy fixed points.
Existence of rational points as a homotopy limit problem
Gereon Quick
Mathematics , 2013,
Abstract: We show that the existence of rational points on smooth varieties over a field can be detected using homotopy fixed points of etale topological types under the Galois action. As our main example we show that the surjectivity statement in Grothendieck's Section Conjecture would follow from the surjectivity of the map from fixed points to continuous homotopy fixed points on the level of connected components. Along the way we define a new model for the continuous etale homotopy fixed point space of a smooth variety over a field under the Galois action.
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