Christoph Eich

European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support

Paediatric Intensive Care, Hopital Universitaire des Enfants, 15 av JJ Crocq, Brussels, Belgium Great Ormond Street Hospital for Children, London, UK Zentrum Anaesthesiologie, Rettungsund Intensivmedizin, Universitatsmedizin Gottingen, Robert-Koch-Str. 40, D-37075 Gottingen, Germany Pediatric Intensive Care Department, Hospital General Universitario Gregorio Maranon, Complutense University of Madrid, Madrid, Spain St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK University of Santiago de Compostela FEAS, Pediatric Emergency and Critical Care Division, Pediatric Area Hospital Clinico Universitario de Santiago de Compostela, 5706 Santiago de Compostela, Spain Oslo University Hospital, Kirkeveien, Oslo, Norway Imperial College Healthcare NHS Trust, London, UK

The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians.

BACKGROUND:Rapid establishment of a patent airway in ill or injured patients is a priority for prehospital rescue personnel. Out-of-hospital tracheal intubation can be challenging. Unrecognized esophageal intubation is a clinical disaster. METHODS:We performed an observational, prospective study of consecutive patients requiring transport by air and out-of-hospital tracheal intubation, performed by primary emergency physicians to quantify the number of unrecognized esophageal and endobronchial intubations. Tracheal tube placement was verified on scene by a study physician using a combination of direct visualization, end-tidal carbon dioxide detection, esophageal detection device, and physical examination. RESULTS:During the 5-yr study period 149 consecutive out-of-hospital tracheal intubations were performed by primary emergency physicians and subsequently evaluated by the study physicians. The mean patient age was 57.0 (±22.7) yr and 99 patients (66.4%) were men. The tracheal tube was determined by the study physician to have been placed in the right mainstem bronchus or esophagus in 16 (10.7%) and 10 (6.7%) patients, respectively. All esophageal intubations were detected and corrected by the study physician at the scene, but 7 of these 10 patients died within the first 24 h of treatment. CONCLUSION:The incidence of unrecognized esophageal intubation is frequent and is associated with a high mortality rate. Esophageal intubation can be detected with end-tidal carbon dioxide monitoring and an esophageal detection device. Out-of-hospital care providers should receive continuing training in airway management, and should be provided additional confirmatory adjuncts to aid in the determination of tracheal tube placement.

Excellence in performance and stress reduction during two different full scale simulator training courses: A pilot study☆☆☆

BACKGROUND Simulator training is well established to improve technical and non-technical skills in critical situations. Few data exist about stress experienced during simulator training. This study aims to evaluate performance and stress in intensivists before and after two different simulator-based training approaches. METHODS Thirty-two intensivists took part in one of six 1-day simulator courses. The courses were randomised to either crew resource management (CRM) training, which contains psychological teaching and simulator scenarios, or classic simulator training (MED). Before and after the course each participant took part in a 10-min test scenario. Before (T1) and after (T2) the scenario, and then again 15 min later (T3), saliva samples were taken, and amylase and cortisol were measured. Non-technical skills were evaluated using the Anaesthetists Non-Technical Skills (ANTS) assessment tool. Clinical performance of the participants in the test scenarios was rated using a checklist. RESULTS Twenty-nine participants completed the course (17-CRM, 12-MED). ANTS scores as well as clinical performances were significantly better in the post-intervention scenario, with no differences between the groups. Both cortisol concentration and amylase activity showed a significant increase during the test scenarios. In the post-intervention scenario, the increase in amylase but not cortisol was significantly smaller. There were no differences between the CRM and MED group. CONCLUSIONS High fidelity patient simulation produces significant stress. After a 1-day simulator training, stress response measured by salivary alpha-amylase was reduced. Clinical performance and non-technical skills improved after 1 day of simulator training. Neither stress nor performance differed between the groups.

Prospective Clinical and Fiberoptic Evaluation of the Supreme Laryngeal Mask Airway

Background:In March 2007, a new disposable laryngeal mask airway (LMA) became available. The LMA Supreme™ (The Laryngeal Mask Company Limited, St. Helier, Jersey, Channel Islands) aims to combine the LMA Fastrach™ feature of easy insertion with the gastric access and high oropharyngeal leak pressures of the LMA ProSeal™. Methods:The authors performed an evaluative study with the LMA Supreme™, size 4, on 100 women to measure the ease of insertion, determinate the laryngeal fit by fiberoptic classification, evaluate the oropharyngeal leak pressure, and report adverse events. Results:Insertion of the LMA Supreme™ was possible in 94 patients (94%) during the first attempt, and in 5 patients (5%) during the second attempt. In one small patient, the LMA Supreme™ could not be inserted because of limited pharyngeal space. This patient was excluded from further analysis. Insertion of a gastric tube was possible in all patients at the first attempt. The median time for LMA Supreme™ insertion was 10.0 s (±4.7 s; range, 8–30 s). Laryngeal fit, evaluated by fiberscopic view, was rated as optimal in all patients, both immediately after insertion of the LMA Supreme™ and at the end of surgery. After equalization to room pressure, the mean cuff volume needed to achieve 60 cm H2O cuff pressure was 18.4 ml (±3.8 ml; range, 8–31 ml). The mean oropharyngeal leak pressure at the level of 60 cm H2O cuff pressure was 28.1 cm H2O (±3.8 cm H2O, range, 21–35 cm H2O). Eight patients (8.1%) complained of a mild sore throat. No patient reported dysphagia or dysphonia. Conclusions:Clinical evaluation of the LMA Supreme™ showed easy insertion, optimal laryngeal fit, and low airway morbidity. Oropharyngeal leak pressure results were comparable to earlier data from the LMA ProSeal™.

Novices ventilate and intubate quicker and safer via intubating laryngeal mask than by conventional bag-mask ventilation and laryngoscopy

Background:Because airway management plays a key role in emergency medical care, methods other than laryngoscopic tracheal intubation (LG-TI) are being sought for inadequately experienced personnel. This study compares success rates for ventilation and intubation via the intubating laryngeal mask (ILMA-V/ILMA-TI) with those via bag–mask ventilation and laryngoscopic intubation (BM-V/LG-TI). Methods:In a prospective, randomized, crossover study, 30 final-year medical students, all with no experience in airway management, were requested to manage anesthetized patients who seemed normal on routine airway examination. Each participant was asked to intubate a total of six patients, three with each technique, in a randomly assigned order. A task not completed after two 60-s attempts was recorded as a failure, and the technique was switched. Results:The success rate with ILMA-V was significantly higher (97.8% vs. 85.6%; P < 0.05), and ventilation was established more rapidly with ILMA-V (35.6 ± 8.0 vs. 44.3 ± 10.8 s; P < 0.01). Intubation was successful more often with ILMA-TI (92.2% vs. 40.0%; P < 0.01). The time needed to achieve tracheal intubation was significantly shorter with ILMA-TI (45.7 ± 14.8 vs. 89.1 ± 23.3 s; P < 0.01). After failed LG-TI, ILMA-V was successful in all patients, and ILMA-TI was successful in 28 of 33 patients. Conversely, after failed ILMA-TI, BM-V was possible in all patients, and LG-TI was possible in 1 of 5 patients. Conclusion:Medical students were more successful with ILMA-V/ILMA-TI than with BM-V/LG-TI. ILMA-TI can be successfully used when LG-TI has failed, but not vice versa. These results suggest that training programs should extend the ILMA to conventional airway management techniques for paramedical and medical personnel with little experience in airway management.

Characteristics of out-of-hospital paediatric emergencies attended by ambulance- and helicopter-based emergency physicians

BACKGROUND In Germany, as in many other countries, for the vast majority of cases, critical out-of-hospital (OOH) paediatric emergencies are attended by non-specialised emergency physicians (EPs). As it is assumed that this may lead to deficient service we aimed to gather robust data on the characteristics of OOH paediatric emergencies. METHODS We retrospectively evaluated all OOH paediatric emergencies (0-14 years) within a 9-year period and attended by physician-staffed ground- or helicopter-based emergency medical service (EMS or HEMS) teams from our centre. RESULTS We identified 2271 paediatric emergencies, making up 6.3% of all cases (HEMS 8.5%). NACA scores IV-VII were assigned in 27.3% (HEMS 32.0%). The leading diagnosis groups were age dependent: respiratory disorders (infants 34.5%, toddlers 21.8%, school children 15.0%), convulsions (17.2%, 43.2%, and 16.0%, respectively), and trauma (16.0%, 19.5%, and 44.4%, respectively). Endotracheal intubation was performed in 4.2% (HEMS 7.6%) and intraosseous canulation in 0.7% (HEMS 1.0%) of children. Cardiopulmonary resuscitation (CPR) was commenced in 2.3% (HEMS 3.4%). Thoracocentesis, chest drain insertion and defibrillation were rarities. HEMS physicians attended a particularly high fraction of drowning (80.0%), head injury (73.9%) and SIDS (60.0%) cases, whereas 75.6% of all respiratory emergencies were attended by ground-based EPs. CONCLUSIONS Our data suggest that EPs need to be particularly confident with the care of children suffering respiratory disorders, convulsions, and trauma. The incidence of severe paediatric OOH emergencies requiring advanced interventions is higher in HEMS-attended cases. However, well-developed skills in airway management, CPR, and intraosseous canulation in children are essential for all EPs.

Positive impact of crisis resource management training on no-flow time and team member verbalisations during simulated cardiopulmonary resuscitation: a randomised controlled trial.

OBJECTIVES To evaluate the impact of video-based interactive crisis resource management (CRM) training on no-flow time (NFT) and on proportions of team member verbalisations (TMV) during simulated cardiopulmonary resuscitation (CPR). Further, to investigate the link between team leader verbalisation accuracy and NFT. METHODS The randomised controlled study was embedded in the obligatory advanced life support (ALS) course for final-year medical students. Students (176; 25.35±1.03 years, 63% female) were alphabetically assigned to 44 four-person teams that were then randomly (computer-generated) assigned to either CRM intervention (n=26), receiving interactive video-based CRM-training, or to control intervention (n=18), receiving an additional ALS-training. Primary outcomes were NFT and proportions of TMV, which were subdivided into eight categories: four team leader verbalisations (TLV) with different accuracy levels and four follower verbalisation categories (FV). Measurements were made of all groups administering simulated adult CPR. RESULTS NFT rates were significantly lower in the CRM-training group (31.4±6.1% vs. 36.3±6.6%, p=0.014). Proportions of all TLV categories were higher in the CRM-training group (p<0.001). Differences in FV were only found for one category (unsolicited information) (p=0.012). The highest correlation with NFT was found for high accuracy TLV (direct orders) (p=0.06). CONCLUSIONS The inclusion of CRM training in undergraduate medical education reduces NFT in simulated CPR and improves TLV proportions during simulated CPR. Further research will test how these results translate into clinical performance and patient outcome.

Semi‐elective intraosseous infusion after failed intravenous access in pediatric anesthesia

Background:  Intraosseous (IO) infusion is a well‐established intervention to obtain vascular access in pediatric emergency medicine but is rarely used in routine pediatric anesthesia.

Randomized comparison of the i-gel™, the LMA Supreme™, and the Laryngeal Tube Suction-D using clinical and fibreoptic assessments in elective patients

BackgroundThe i-gel™, LMA-Supreme (LMA-S) and Laryngeal Tube Suction-D (LTS-D) are single-use supraglottic airway devices with an inbuilt drainage channel. We compared them with regard to their position in situ as well as to clinical performance data during elective surgery.MethodsProspective, randomized, comparative study of three groups of 40 elective surgical patients each. Speed of insertion and success rates, leak pressures (LP) at different cuff pressures, dynamic airway compliance, and signs of postoperative airway morbidity were recorded. Fibreoptic evaluation was used to determine the devices’ position in situ.ResultsLeak pressures were similar (i-gel™ 25.9, LMA-S 27.1, LTS-D 24.0 cmH2O; the latter two at 60 cmH2O cuff pressure) as were insertion times (i-gel™ 10, LMA-S 11, LTS-D 14 sec). LP of the LMA-S was higher than that of the LTS-D at lower cuff pressures (p <0.05). Insertion success rates differed significantly: i-gel™ 95%, LMA-S 95%, LTS-D 70% (p <0.05). The fibreoptically assessed position was more frequently suboptimal with the LTS-D but this was not associated with impaired ventilation. Dynamic airway compliance was highest with the i-gel™ and lowest with the LTS-D (p <0.05). Airway morbidity was more pronounced with the LTS-D (p <0.01).ConclusionAll devices were suitable for ventilating the patients’ lungs during elective surgery.Trial registrationGerman Clinical Trial Register DRKS00000760

Neue Perspektiven der simulatorunterstützten Ausbildung in Kinderanästhesie und Kindernotfallmedizin

Anaesthesia and emergency medical care for infants and toddlers is often associated with high clinical demands and specific challenges. Nevertheless, a significant proportion of interventions is performed by anaesthetists and emergency physicians with no specialised paediatric training and little experience in the management of anaesthetic incidents and emergencies specific to these age groups. Extensive studies have demonstrated a close inverse correlation between the level of specialisation and perioperative morbidity and mortality. However, clinical circumstances and the relatively small number of paediatric cases at many institutions often hinder the establishment of improved training concepts. Recently, high-fidelity infant simulators have become available, which permit authentic exposure to a large spectrum of scenarios in paediatric anaesthesia and emergency medicine. A multimodular concept of training, including such simulator-based techniques, may relieve the widespread shortage in clinical experience, and hence greatly facilitate improvement of quality of care and patient safety.ZusammenfassungDie anästhesiologische und notfallmedizinische Versorgung von Säuglingen und Kleinkindern ist mit hohen klinischen Anforderungen verbunden. Dabei erfolgt ein Großteil der Maßnahmen durch pädiatrisch nichtspezialisierte Anästhesisten und Notärzte, die häufig wenig Routine im Umgang mit kinderanästhesiologischen Zwischenfällen und pädiatrischen Notfällen besitzen. Die Korrelation zwischen höherem Spezialisierungsgrad einerseits und verminderter perioperativer Morbidität und Mortalität andererseits ist durch umfangreiche Untersuchungen gut belegt. Die Etablierung verbesserter Ausbildungskonzepte scheitert jedoch häufig an den klinischen Strukturen und an den relativ geringen pädiatrischen Fallzahlen der meisten Einrichtungen. Seit kurzem nun stehen leistungsfähige Säuglingssimulatoren zur Verfügung, die ein sehr realitätsnahes Training eines großen Spektrums aus Kinderanästhesie und Kindernotfallmedizin ermöglichen. Ein multimodales Ausbildungskonzept, unter Einbeziehung simulatorunterstützter Techniken, könnte die weit verbreiteten Erfahrungsdefizite lindern und damit Behandlungsqualität und Patientensicherheit nachhaltig verbessern.AbstractAnaesthesia and emergency medical care for infants and toddlers is often associated with high clinical demands and specific challenges. Nevertheless, a significant proportion of interventions is performed by anaesthetists and emergency physicians with no specialised paediatric training and little experience in the management of anaesthetic incidents and emergencies specific to these age groups. Extensive studies have demonstrated a close inverse correlation between the level of specialisation and perioperative morbidity and mortality. However, clinical circumstances and the relatively small number of paediatric cases at many institutions often hinder the establishment of improved training concepts. Recently, high-fidelity infant simulators have become available, which permit authentic exposure to a large spectrum of scenarios in paediatric anaesthesia and emergency medicine. A multimodular concept of training, including such simulator-based techniques, may relieve the widespread shortage in clinical expierience, and hence greatly facilitate improvement of quality of care and patient safety.