Matthias Hohlrieder

The Laryngeal Mask Airway SupremeTM – a single use laryngeal mask airway with an oesophageal vent. A randomised, cross-over study with the Laryngeal Mask Airway ProSealTM in paralysed, anaesthetised patients

The LMA SupremeTM is a new extraglottic airway device which brings together features of the LMA ProSealTM, FastrachTM and UniqueTM. We test the hypothesis that ease of insertion, oropharyngeal leak pressure, fibreoptic position and ease of gastric tube placement differ between the LMA ProSealTM and the LMA SupremeTM in paralysed anesthetised patients. Ninety‐three females aged 19–71u2003years were studied. Both devices were inserted into each patient in random order. Two attempts were allowed. Digital insertion was used for the first attempt and guided insertion for the second attempt. Oropharyngeal leak pressure and fibreoptic position were determined during cuff inflation from 0 to 40u2003ml in 10u2003ml increments. Gastric tube insertion was attempted if there was no gas leak from the drain tube. First attempt and overall insertion success were similar (LMA ProSealTM, 92% and 100%; LMA SupremeTM 95% and 100%). Guided insertion was always successful following failed digital insertion. Oropharyngeal leak pressure was 4–8u2003ml higher for the LMA ProSealTM over the inflation range (pu2003<u20030.001). Intracuff pressure was 16–35u2003cm higher for the LMA ProSealTM when the cuff volume was 20–40u2003ml (pu2003<u20030.001). There was an increase in oropharyngeal leak pressure with increasing cuff volume from 10 to 30u2003ml for both devices, but no change from 0 to 10u2003ml and 30–40u2003ml. There were no differences in the fibreoptic position of the airway or drain tube. The first attempt and overall insertion success for the gastric tube was similar (LMA ProSealTM 91% and 100%; LMA SupremeTM 92% and 100%). We conclude that ease of insertion, gastric tube placement and fibreoptic position are similar for the LMA ProSealTM and LMA SupremeTM in paralysed, anaesthetised females, but oropharyngeal leak pressure and intracuff pressure are higher for the LMA ProSealTM.

Bacterial contamination of anaesthetists' hands by personal mobile phone and fixed phone use in the operating theatre

Following hand disinfection, 40 anaesthetists working in the operating room (OR) were asked to use their personal in‐hospital mobile phone for a short phone call. After use of the cell phone, bacterial contamination of the physicians hands was found in 38/40 physicians (4/40 with human pathogen bacteria). After repeating the same investigation with fixed phones in the OR anteroom 33/40 physicians showed bacterial contamination (4/40 with human pathogen bacteria). The benefit of using mobile phones in the OR should be weighed against the risk for unperceived contamination. The use of mobile phones may have more serious hygiene consequences, because, unlike fixed phones, mobile phones are often used in the OR close to the patient.

Traumatic intracranial haemorrhage in conscious patients with facial fractures – A review of 1959 cases

OBJECTIVEnFacial fracture patients who are conscious with a Glasgow Coma Scale (GCS) score of 15 in the absence of clinical neurological abnormalities are commonly not expected to have suffered severe intracranial pathology. However, high velocity impact may result in intracranial haemorrhage in different compartments.nnnMETHODSnOver a 7-year period, 1959 facial fracture patients with GCS scores of 15 and the absence of neurological abnormalities were analysed. In 54 patients (2.8%) computed tomography scans revealed the presence of accompanying intracranial haemorrhage (study group). These patients were compared with the 1905 patients without intracranial haemorrhage (control group).nnnRESULTSnUnivariate analysis identified accompanying vomiting/nausea and seizures, cervical spine injuries, cranial vault and basal skull fractures to be significantly associated with intracranial bleeding. In multivariate analysis the risk was increased nearly 25-fold if an episode of vomiting/nausea had occurred. Seizures increased the risk of bleeding more than 15-fold. The mean functional outcome of the study group according to the Glasgow Outcome Scale was 4.7+/-0.7.nnnCONCLUSIONnIntracranial haemorrhage cannot be excluded in patients with facial fractures despite a GCS score of 15 and normal findings following neurological examination. Predictors, such as vomiting/nausea or seizures, skull fractures and closed head injuries, enhance the likelihood of an intracranial haemorrhage and have to be considered.

Pattern of Injury After Rock-Climbing Falls Is Not Determined by Harness Type

Abstract Category 1 Continuing Medical Education credit for physicians is available to Wilderness Medical Society members for this article. Go to http://wms.org/cme/cme.asp?whatarticle=1813 to access the instructions and test questions. Objective.—Experimental data indicate that when using a sit harness alone, any major fall during rock climbing may cause life-threatening thoraco-lumbar hyperextension trauma or “head down position” during suspension. To clarify the actual influence of the type of harness on the pattern and severity of injury, accidents involving a major fall in a climbing harness were analyzed retrospectively. Methods.—Individuals with a height of fall equal to or exceeding 5 m were identified through a search of accident and emergency records for the period from 2000 to 2004. Data concerning the circumstances of the fall and the patterns of injury were obtained from personal interviews, flight and accident reports, as well as hospital medical records. Results.—Of a total of 113 climbers identified, 73 (64.6%) used a sit harness alone, whereas 40 (35.4%) used a body harness. Fractures and dislocations of the extremities, the shoulder, and the pelvic region were the most common injuries, while the most severe injuries occurred in the head and neck region. Although most falls were associated with mild or moderate injuries, 13 (11.5%) climbers sustained severe or critical multisystem trauma. Falls on more difficult routes were associated with less severe injury. The type of harness used did not influence the pattern or severity of injury. In particular, no evidence was found for the existence of a thoraco-lumbar hyperextension trauma. Conclusions.—The type of harness does not influence the pattern or severity of injury, and the forces transferred via the harness do not cause a specific harness-induced pathology. We did not find any evidence that hyperextension trauma of the thoraco-lumbar region is an important mechanism of injury in climbers using a sit harness alone. Rock contact during the fall, and not the force transferred through the harness, is the major cause of significant injury in climbing accidents.

Submission of clinical studies to ethics committees or clinical trials registers: the authors’ point of view

To evaluate the satisfaction of clinical scientists when submitting study drafts to an ethics committee/clinical trials register (CLINICALTRIALS, EUDRACT, ISRCTN) we conducted an online survey of 240 authors publishing in anesthesia/critical care medicine (A) or in major general medical (M) journals from January to December 2007. No statistical difference between groups A and M was seen with regard to the number of studies submitted to ethics committees or registered in various clinical trials registers. On a visual analogue scale (VAS −10 to +10), the subjective evaluation of the effort required to submit a study draft to an ethics committee or enter it in a clinical trials register produced almost only negative grades in both groups. The mean different perceptions ranged from −3.5 to −0.1 in group A and from −4.4 to −0.2 (except for +0.1 and 1.9 in 2 subgroups) in group M. The authors in both groups gave a positive score to the better transparency in scientific research resulting from introduction of the clinical trials registers (+2.4 in group A, +4.8 in group M). The results of our study indicate widespread author dissatisfaction when submitting a clinical trial to ethics committees or clinical trials registers.

Radiological aspects of injuries of avalanche victims

OBJECTIVEnIncreasing numbers of avalanche victims with polytrauma have highlighted their need for radiological injury characterisation, which this study examines.nnnMETHODSnPeople in Tirol injured by avalanche during 1994-2005 and admitted to the Innsbruck Medical University Hospital were included. Data for this retrospective study were obtained from the Austrian avalanche register and local electronic patient files archive.nnnRESULTSnDuring the observation period 94 avalanche victims in Tirol were admitted to our hospital, and a mean of 1.5 radiological methods were used per person at presentation. A mean of three diagnoses per victim were recorded, of which one was eligible for radiological examination only. Most victims (56%) were diagnosed with hypothermia, followed by unspecific contusion (54%), injuries of ligaments, tendons or muscles (26%) and fracture (23%); 21 victims died in hospital.nnnCONCLUSIONSnEmergency radiological examination can discover injuries otherwise not immediately apparent. However, initial use of radiological assessments such as computed tomography for people admitted under cardiopulmonary resuscitation does not always ensure an optimal outcome.

Preoperative administration of esomeprazole has no influence on frequency of refluxes

STUDY OBJECTIVEnTo examine the effect of esomeprazole in a fixed time setting on gastric content volume, gastric acidity, gastric barrier pressure, and reflux propensity.nnnDESIGNnRandomized, controlled, double-blind trial.nnnSUBJECTSn21 healthy, ASA I physical status volunteers.nnnINTERVENTIONnEsomeprazole was given 12 hours and one hour before investigation. Before the study, a multichannel intraluminal impedance catheter, pH monitoring data logger (PHmetry) catheter, and an intragastric-esophageal manometry catheter were placed nasally after topical anesthesia.nnnMEASUREMENTSnGastric acidity and gastric content volume were determined by PHmetry after aspiration of gastric contents over a nasogastric tube. Gastroesophageal reflux and intragastric-esophageal barrier pressure were investigated by multichannel intraluminal impedance measurement, PHmetry, and intragastric-esophageal manometry.nnnMAIN RESULTSnThe pH of gastric contents was significantly (P < 0.001) higher after esomeprazole (mean [25th-75th percentile], 4.2 [3.9-4.8] vs 2.0 [1.9-2.7]), and gastric content volume was significantly (P < 0.001) lower (5.0 mL [3.0-12.0] vs 15 mL [10.0-25.0]) in comparison to placebo. No significant difference between esomeprazole and placebo was found with respect to number of refluxes per person, duration of reflux, or barrier pressure.nnnCONCLUSIONnEsomeprazole in a fixed time setting can markedly increase the pH of gastric contents and decrease gastric content volume, but has no influence on the frequency, duration of refluxes, or gastroesophageal barrier pressure.

Accidental intracerebroventricular injection of anaesthetic drugs during induction of general anaesthesia

A 51‐year‐old patient scheduled for surgery under general anaesthesia was accidentally given remifentanil 150u2003μg and propofol 1% 10u2003ml through an intracerebroventricular totally implantable access port placed in the right infraclavicular region, which was mistakenly thought to be an intravenous line. Severe pain in the head and neck caused the mistake to be discovered rapidly, and 20u2003ml of a mixture of cerebrospinal fluid and the anaesthetic drugs were aspirated from the implantable access port. The patient suffered no apparent adverse neurological sequelae.

Bipolar anastomosis technique with removable instruments: an easy, fast, and reliable technique for vascular anastomosis.

The interrupted suture technique is most commonly used for microsurgical vascular anastomosis. For several reasons (e.g., exposure of suture material to blood, time needed), many attempts have been made to find other solutions. This article describes a new means of performing a microsurgical vascular anastomosis. The aim of this study was to show the feasibility and possible advantages of this new technique. The basic components at work here are a modified cuff and electrically generated heat used to unite the vessel walls. In this way, both endothelial layers are adapted without manipulating the inside of the vessel or leaving behind foreign matter. Various energy/coagulation time settings were used to perform arterial anastomoses (n = 42) in an isogeneic abdominal aorta interposition model in the rat. The quality of anastomosis was evaluated at days 1, 10, 21, and 120. Immediately after the welding process all anastomoses (n = 42) were patent. No stenosis was found at any observation time. Anastomosis time ranged from 3 to 18 minutes (average, 11 minutes). This new technique permits a vascular anastomosis to be performed easily and reliably with a high patency rate. With this technique, the authors are convinced that a skilled surgeon can create a high-quality anastomosis in a fraction of the time needed to sew an anastomosis.