[Pharmaceutical care for a multimorbid patient mainly suffering from chronic obstructive pulmonary disease]. / Pharmazeutische Betreuung eines multimorbiden Patienten mit Schwerpunkt chronisch obstruktive Lungenerkrankung.

In multimorbid patients the medication for COPD is associated with a high risk for drug-drug interactions, medication errors and adverse drug events. This article describes how the drug therapy of a patient with COPD was optimized using SOAP notes.

Self-reported changes in attitude and behavior after attending a simulation-aided airway management course.

STUDY OBJECTIVE: To evaluate the influence of a simulator-aided course for airway management on participants' daily clinical airway management practice. DESIGN: Survey instrument. SETTING: University hospital. PARTICIPANTS: 88 participants who attended a simulator-aided course for airway management. INTERVENTION: Six mo after 4 consecutive courses with identical structure and content, participants were mailed a standardized questionnaire to answer. MEASUREMENTS AND MAIN RESULTS: Of 88 participants queried, 48 completed the questionnaire. Ninety-two percent had experienced a difficult airway situation in the 6 mo after the course. Fourteen (29%) evaluated predictors for a difficult airway more carefully. Fourteen (29%) established structural changes within their departments. Ten (21%) participants acquired new technical airway devices. The mean estimated impact on the participants' rating for lectures, skill stations, and scenarios on a scale from 1 (very helpful) to 6 (not at all helpful) was 2.8 for lectures, 1.6 for skill stations, and 1.4 for scenarios. CONCLUSIONS: Attendance at a simulator-aided airway management course has a significant impact on self-reported accuracy and confidence in evaluation of airways, use of alternative airway devices, and changes in the practitioner's clinical practice toward difficult airway situations.

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.

Prehospital airway management: a prospective evaluation of anaesthesia trained emergency physicians.

STUDY OBJECTIVE: To determine the characteristics of prehospital tracheal intubation and the incidence of difficult-to-manage airways in out-of-hospital patients managed by emergency medicine physicians with anaesthesia training. METHODS: In a prospective study, conducted over a 4-year period, we evaluated all airway interventions performed by anaesthesia-trained emergency physicians. RESULTS: One thousand, one hundred and six out of 16,559 patients (6.8%) required tracheal intubation. Orotracheal intubation was attempted in 982, laryngoscopic aided nasotracheal intubation in 64 and blind nasotracheal intubation in 90 of the cases. Two techniques were used in 30 patients. Failure rates were 2.4, 8.1 and 25.6%, respectively. A Combitube or LMA was used in 2.0%. In one case of failed Combitube insertion successful needle cricothyrotomy was performed. In patients undergoing direct laryngoscopy, Cormack-Lehane laryngeal grade views I-IV were seen in 52.0, 28.8, 12.6 and 6.6% of cases, respectively. A difficult to manage airway (DMA) was reported in 14.8%, multiple intubation attempts in 4.3% and failed intubation in 2.0% of all cases. Grouping patients based on clinical presentation revealed a significantly higher incidence of DMA in trauma patients (18.6%) and during cardiopulmonary resuscitation (16.7%) than in the remaining patient group (9.8%). Intubation failed significantly more often in trauma (3.9%) than in the remaining patient group (1.1%). CONCLUSION: When compared to studies on laryngoscopy performed in the operating room, this study demonstrated a higher incidence of difficult and failed laryngoscopy, DAM, and high laryngeal grade views when patients were managed in a prehospital setting by anaesthesia trained physicians.

Airway management in infants and children.

Anaesthesiologists, paediatricians, paediatric intensivists and emergency physicians are routinely challenged with airway management in children and infants. There are important differences from adult airway management as a result of specific features of paediatric anatomy and physiology, which are more relevant the younger the child. In addition, a number of inherited and acquired pathological syndromes have significant impact on airway management in this age group. Several new devices--e.g. different types of laryngeal mask airways in various sizes, small fibre-endoscopes--have been introduced into clinical practice with the intention of improving airway management in this age group. Important new studies have gathered evidence about risks and benefits of certain confounding variables for airway problems and specific techniques for solving them. Airway-related morbidity and mortality in children and infants during the perioperative period are still high, and only a thorough risk determination prior to and continuous attention during the procedure can reduce these risks. Appropriate preparation of the available equipment and frequent training in management algorithms for all personnel involved appear to be very important.

Conductive heat exchange with a gel-coated circulating water mattress.

The use of forced-air warming is associated with costs for the disposable blankets. As an alternative method, we studied heat transfer with a reusable gel-coated circulating water mattress placed under the back in eight healthy volunteers. Heat flux was measured with six calibrated heat flux transducers. Additionally, mattress temperature, skin temperature, and core temperature were measured. Water temperature was set to 25 degrees C, 30 degrees C, 35 degrees C, and 41 degrees C. Heat transfer was calculated by multiplying heat flux by contact area. Mattress temperature, skin temperature, and heat flux were used to determine the heat exchange coefficient for conduction. Heat flux and water temperature were related by the following equation: heat flux = 10.3 x water temperature - 374 (r(2) = 0.98). The heat exchange coefficient for conduction was 121 W . m(-2) . degrees C(-1). The maximal heat transfer with the gel-coated circulating water mattress was 18.4 +/- 3.3 W. Because of the small effect on the heat balance of the body, a gel-coated circulating water mattress placed only on the back cannot replace a forced-air warming system.

Efficacy of postoperative rewarming after cardiac surgery.

OBJECTIVE: To compare the efficacy of forced-air warmers and radiant heaters on rewarming after cardiac surgery in a prospective randomized study. METHODS: Fifty male patients who had undergone coronary artery bypass graft surgery were studied. The control group (Gr. C, n=10) was nursed under a standard hospital blanket. Two groups were treated with forced-air warmers: WarmTouch 5700 (Gr. WT, n=10) and Bair Hugger 500 (Gr. BH, n=10). Two other groups were treated by radiant heaters: the Aragona Thermal Ceilings CTC X radiant heater (Gr. TC, n=10) and a self assembled radiant heater of 4 Hydrosun 500 infrared lamps (Gr. HY, n=10). Changes of oesophageal temperature, mean skin temperature, mean body temperature and relative heat balance were calculated from oesophageal temperature, 4 skin temperatures and oxygen consumption (VO(2)). RESULTS: All actively treated groups with exception of the TC group showed significantly faster oesophageal warming than the control group. The mean body temperature increased 1.1 (0.7-1.7) degrees Ch(-1) in Gr. WT, 1.3 (0.7-1.5) degrees Ch(-1) in Gr. BH, 0.8 (0.5-1.4) degrees Ch(-1) in Gr. TC and 0.7 (0.4-1.0) degrees Ch(-1) in Gr. HY compared to Gr. C with 0.4 (0.2-0.7) degrees Ch(-1). The mean VO(2) and the maxima of the VO(2) during the study period did not differ significantly between the groups. CONCLUSION: In the current setting active warming, forced-air warming more than radiant warming, increased speed of rewarming two- to threefold in comparison to insulation with a blanket.