High-sensitivity cardiac troponin T in young, healthy adults undergoing non-cardiac surgery.

BACKGROUND: It is unclear if isolated postoperative cardiac-troponin elevation, often referred to as myocardial injury, represents a pathological event, as control studies in otherwise healthy adults are lacking. METHODS: In this single-centre prospective observational cohort study, serial high-sensitivity cardiac troponin T (hscTnT) plasma concentrations were obtained from young, healthy adults undergoing elective orthopaedic surgery at three time points: before operation, 2-6 h, and 18-30 h after surgery. End points were hscTnT increases after surgery: ≥20% (exceeding analytical variability), ≥50% (exceeding short-term biological variability), and ≥85% (exceeding long-term biological variability). The secondary end point was myocardial injury, defined as new postoperative hscTnT elevation >99th % upper reference limit (URL) (women >10 ng litre-1; men >15 ng litre-1). RESULTS: Amongst the study population (n=95), no hscTnT increase ≥20% was detected in 68 patients (73%). A hscTnT increase between 20% and 49% was observed in 17 patients (18%), 50-84% in seven patients (7%), and ≥85% in three patients (3%). Twenty patients (21%) had an absolute ΔhscTnT between 0 and 2 ng litre-1, 12 patients (13%) between 2 and 4 ng litre-1, three patients between 4 and 6 ng litre-1, and one patient (1%) between 6 and 8 ng litre-1. Myocardial injury (new hscTnT elevation >99th%) was diagnosed in one patient (1%). The median hscTnT concentrations did not increase after operation, and were 4 (3.9-5, inter-quartile range) ng litre-1 at baseline, 4 (3.9-5) ng litre-1 at 2-6 h after surgery, and 4 (3.9-5) ng litre-1 on postoperative day 1. CONCLUSIONS: One in four young adult patients without known cardiovascular disease developed a postoperative hscTnT increase, but without exceeding the 99th% URL and without evidence of myocardial ischaemia. These results may have important ramifications for the concept of postoperative myocardial injury, as they suggest that, in some patients, postoperative cardiac-troponin increases may be the result of a normal physiological process in the surgical setting. CLINICAL TRIAL REGISTRATION: NCT 02394288.

Validity and fidelity of the upper airway in two high-fidelity patient simulators.

BACKGROUND: Human patient simulators are frequently used for airway management training and research. However, little is known about their fidelity and validity. The use of these simulators as a benchmark model remains highly questionable. The objective of this study was to evaluate the validity and fidelity of two patient simulators (compared to actual patients) for anaesthesia residents performing three airway management techniques. METHODS: Endotracheal intubation, laryngeal mask airway insertion and mask ventilation were performed by anaesthesia residents on 80 patients undergoing elective surgery. The anaesthesia residents also used these three techniques to secure the airways of two human patient simulators in a randomised crossover study. The durations, difficulties, realism and success rates of the procedures were assessed. RESULTS: Although the performance of endotracheal intubation was comparable in patients and both manikins, no chest rise was visible in 35% (HAL) and 32.5% (SimMan) of the manikins after inserting a laryngeal mask airway. This result was not observed in patients (P<0.001). Furthermore, effective mask ventilation was not possible in 60% of the cases using HAL, compared with 0% of cases using SimMan and 2.5% of patients (P<0.001). CONCLUSION: Patient simulators are not a valid alternative to human patients for conducting scientific evaluations of supraglottic airway management techniques. HAL and SimMan do have adequate validity for endotracheal intubation, but the fidelity and validity are low when a laryngeal mask is used or if mask ventilation is performed. Therefore, previous simulation-based airway device evaluation studies must be interpreted with great caution.

[Thermal injuries in the OEAMTC air rescue service. Epidemiological characteristics of burns/scalds in children and adults]. / Thermische Verletzungen in der ÖAMTC-Luftrettung. Einsatzcharakteristika bei Verbrennungen/Verbrühungen von Kindern und Erwachsenen.

BACKGROUND: Few data exist on the epidemiological characteristics of thermal injuries in prehospital emergency care, especially in the context of air rescue. Therefore, this study aimed to analyze the epidemiology of pediatric and adult thermal injuries in the helicopter emergency medical service (HEMS) run by the Austrian Automobile Motorcycle Touring Club (OEAMTC) air rescue service from an almost nationwide sample. METHODS: All OEAMTC-HEMS rescue missions flown for thermal injuries in 2009 were retrospectively reviewed. Primary (n=88) and secondary missions (n=17) were collated and all primary missions were analyzed in detail. RESULTS: In total 71 out of 16,100 (0.4 %) primary HEMS rescue missions were for patients suffering from burns or scalds (children n=27, adults n=44). The proportion of major burns (burns covering >20 % of the total body surface area) was 40.7 % in children and 54.5 % in adults, 44 (62 %) burn/scald injuries were related to the head/neck, 37 (52.1 %) to the upper limbs and 10 (14.1 %) to the anogenital region. More than half of the victims (63.4%) suffered potentially life-threatening injury. CONCLUSIONS: In HEMS thermal injuries are infrequent but mostly life-threatening. Differences in epidemiological characteristics of pediatric and adult burns/scalds may have important operational, training and public health implications.

Can a flowchart improve the quality of bystander cardiopulmonary resuscitation?

BACKGROUND: Since the introduction of basic life support in the 1950s, on-going efforts have been made to improve the quality of bystander cardiopulmonary resuscitation (CPR). Even though bystander-CPR can increase the chance of survival almost fourfold, the rates of bystander initiated CPR have remained low and rarely exceed 20%. Lack of confidence and fear of committing mistakes are reasons why helpers refrain from initiating CPR. The authors tested the hypothesis that quality and confidence of bystander-CPR can be increased by supplying lay helpers with a basic life support flowchart when commencing CPR, in a simulated resuscitation model. MATERIALS AND METHODS: After giving written informed consent, 83 medically untrained laypersons were randomised to perform basic life support for 300s with or without a supportive flowchart. The primary outcome parameter was hands-off time (HOT). Furthermore, the participants' confidence in their actions on a 10-point Likert-like scale and time-to-chest compressions were assessed. RESULTS: Overall HOT was 147±30 s (flowchart) vs. 169±55 s (non-flowchart), p=0.024. Time to chest compressions was significantly longer in the flowchart group (60±24 s vs. 23±18 s, p<0.0001). Participants in the flowchart group were significantly more confident when performing BLS than the non-flowchart counterparts (7±2 vs. 5±2, p=0.0009). CONCLUSIONS: A chart provided at the beginning of resuscitation attempts improves quality of CPR significantly by decreasing HOT and increasing the participants' confidence when performing CPR. As reducing HOT is associated with improved outcome and positively impacting the helpers' confidence is one of the main obstacles to initiate CPR for lay helpers, charts could be utilised as simple measure to improve outcome in cardiopulmonary arrest.

Impact of the European Paediatric Life Support course on knowledge of resuscitation guidelines among Austrian emergency care providers.

BACKGROUND: Even though anaesthetists do not resuscitate children on a daily basis, they need to perform paediatric life support regularly due to their different duties. As the knowledge of international guidelines varies widely, highly standardized European Paediatric Life Support (EPLS) courses have been introduced to improve standards of care. This national survey among Austrian anaesthetists and EPLS course participants evaluated the impact of this course at the end of the guideline period 2005-2010. METHODS: After approval by the institutional review board an online survey about paediatric resuscitation guidelines was sent to EPLS course participants of the guideline period 2005 (EPLS group) and members of the Austrian Society of Anaesthesia, Resuscitation and Intensive Care (ÖGARI) two weeks before publication of the resuscitations guidelines 2010. Respondents without an EPLS course were assigned to the non-EPLS group. RESULTS: Of 333 respondents 247 finished the survey. One hundred eighty five persons were assigned to EPLS group and 62 to the non-EPLS group. Members of the EPLS group performed significantly better than the non-EPLS group (76 ± 19% correct answers EPLS group vs. 63 ± 18% correct answers non-EPLS group, p<0.0001). Furthermore, the EPLS group performed better than anesthetists with regular resuscitation training and or resuscitation experience but without an EPLS course. CONCLUSION: The attendance of an EPLS course within the guideline period 2005 significantly increased the theoretical knowledge of paediatric resuscitation guidelines.

The epidemiology of amputation injuries in the Austrian helicopter emergency medical service: a retrospective, nationwide cohort study.

PURPOSE: Data on the epidemiological characteristics of traumatic amputations in prehospital emergency care, especially in the context of air rescue, are scarce. Therefore, we aimed to describe the epidemiology of total and subtotal amputation injuries encountered by the OEAMTC helicopter emergency medical service (HEMS) in Austria, based on an almost nationwide sample. METHODS: We retrospectively reviewed all HEMS rescue missions flown for amputation injuries in 2009. Only primary missions were analyzed. RESULTS: In total, 149 out of 16,100 (0.9 %) primary HEMS rescue missions were for patients suffering from amputation injuries. Among these, HEMS physicians diagnosed 63.3 % (n = 94) total and 36.9 % (n = 55) subtotal amputations, with both groups showing a predominance of male victims (male:female ratios were 8:1 and 6:1, respectively).The highest rate occurred among adults between 45 and 64 years of age (35.6 %, n = 53). The most common causes were working with a circular saw (28.9 %, n = 43) and processing wood (16.8 %, n = 25). The majority of the cases included digital amputation injuries (77.2 %, n = 115) that were mainly related to the index finger (36.2 %, n = 54). One hundred forty patients (94.0 %) showed a total GCS of more than 12. Amputations were most prevalent in rural areas (84.6 %, n = 126) and between Thursday and Saturday (55.0 %, n = 82). The replantation rate after primary air transport was low (28 %). CONCLUSIONS: In the HEMS, amputation injuries are infrequent and mostly not life-threatening. However, HEMS crews need to maintain their focus on providing sufficient and fast primary care while facilitating rapid transport to a specialized hospital. The knowledge of the epidemiological characteristics of amputation injuries encountered in the HEMS gained in this study may be useful for educational and operational purposes.

Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients.

BACKGROUND: Although the integral role of ED thoracotomy for open cardiac massage has been extensively reviewed in adult literature, this "heroic maneuver" remains very controversial and greatly debated in children. METHODS AND RESULTS: A retrospective cohort review of emergency thoracotomies in children, performed at a European Level I trauma center between 1992 and 2008 was undertaken. Clinical manifestation, injury mechanism and surgical treatment were described, with special regard to prognostic factors and outcome. A total of eleven thoracotomies were performed, ten for blunt injuries (91%), and one for perforating injury (9%), with a mean age of 7.8 years, range 2.6-15.4 years, comprising eight boys and three girls. The mean Injury Severity Score of the children with blunt force trauma was 46, ranging from 25 to 66 compared with 20 of the penetrating trauma victim. Ten of eleven patients (91%) who underwent ED thoracotomy died. Nine of them were in cardiac arrest on arrival. One patient who had a penetrating knife injury and had stable vital sign on arrival survived. CONCLUSIONS: Similar to previous studies, out data confirmed ED thoracotomy for children in cardiac arrest from blunt trauma had universally fatal outcome. The mechanism of injury and signs of life at arrival were predictive key factors that influence the outcome of ED thoracotomy.

[Paediatric simulation today and tomorrow. Perspectives and concepts]. / Kindersimulation heute und morgen. Perspektiven und Konzepte.

The confrontation with critically ill newborns, infants and small children is rare and poses a particular challenge for the medical team. Confident technical and non-technical skills are essential for successful emergency treatment. Paediatric simulators facilitate a didactic infrastructure, linking textbook theory with experience-based practice. To summarize the current status of paediatric simulation in Germany, Austria and Switzerland an online survey of all associated centres was conducted. Paediatric simulation is currently available at 24 centres, which have 39 paediatric simulators available, including 8 for newborns, 26 for infants and 5 for children. A certain congruence of standards is detectable among these centres and most instructors have completed a specialized instructor training. Of the instructors 26% are specialized nursing personnel and 67% are physicians of which most are paediatricians and anaesthesiologists. Many centres (38%) operate solely by means of the enthusiastic dedication of the employees who organize various activities during their free time. Nearly all centres (92%) place particular emphasis on non-technical skills which include the interpersonal aspects of crisis resource management. Video-supported debriefing is considered to be the basis for effective training. Within the scope of the recently established PaedSim project the curricula of paediatric simulation courses should be more structured and internationally standardized, thereby increasing both efficacy and sustainability of these training programs.

The effects of aminophylline on bispectral index during inhalational and total intravenous anaesthesia.

Aminophylline is usually used during anaesthesia to treat bronchospasm but recent findings suggest that it can also be used to shorten recovery time after general anaesthesia. However, it is unclear whether aminophylline shows similar properties during a steady-state phase of deep surgical anaesthesia. We therefore wanted to test the hypothesis that the administration of aminophylline leads to an increase in bispectral index as a surrogate parameter suggesting a lighter plane of anaesthesia. The study was designed as a double-blind, randomised, controlled trial with two main groups (aminophylline and placebo) and two subgroups (sevoflurane and propofol). We studied 60 patients. The injection of aminophylline 3 mg x kg(-1) was associated with significant increases in bispectral index up to 10 min after its injection, while heart rate and blood pressure did not change. It appears that aminophylline has the ability to partially antagonise the sedative effects of general anaesthetics.

Anaesthesia for brachytherapy--51/2 yr of experience in 1622 procedures.

BACKGROUND: Brachytherapy presents the anaesthetist with unique problems. Information on anaesthesia for brachytherapy, however, is limited. The aim of this paper is to report on our experience involving a large number of brachytherapy procedures. METHODS: A retrospective analysis of records of 1622 anaesthetic procedures in 952 patients is presented. Records were analysed in respect of patient data, tumour localization, brachytherapy treatment and the type and duration of anaesthetic procedures. RESULTS: More than one-third of patients were at high risk (ASA III or IV) and 40% were more than 60 yr. Repetitive treatments were performed on half of the patients. Breast cancer was the most common indication. The average duration of anaesthesia for pelvic brachytherapy was more than 3 h, with a high degree of variability. Regional anaesthesia was used in 30% of all cases and was the predominant technique for pelvic brachytherapy. Spinal catheter techniques represented a high proportion of those receiving regional anaesthesia. Complications resulting from regional and general anaesthesia were minor and no serious incidents occurred. CONCLUSIONS: Based on a large number of procedures, this study gives an example of anaesthetic management in brachytherapy. A substantial minority of patients would be considered high risk for surgical intervention. Regional anaesthesia was the principal technique used when dealing with tumours of the lower body.