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The present study was conducted under the hypothesis that, in field peas, type of plant material, stage of maturity, ensiling, silage additive, and aerobic stress affect the composition and diversity of epiphytic microbial communities. Epiphytic microbial composition and diversity of pea seeds, partial crop peas, and whole crop peas was analyzed at different stages of late maturity, before and after ensiling, and with or without the use of lactic acid bacteria (LAB) as inoculant. Suitable combinations among pea crop variants, maturity stages, and inoculant use for the production of stable silages with sufficient aerobic stability after opening and during feed-out were identified. Genomic DNA was extracted, and 16S and 18S rRNA gene amplicons were sequenced. To assess the quality of the various silages, nutrient concentration, pH value, concentration of lactic acid, short chain fatty acids, and alcohols, and aerobic stability were determined. Pea seeds were barely colonized by epiphytic microorganisms. In partial and whole crop peas, composition and α-diversity (Shannon index) of bacterial communities did not differ between crop variants but differed among maturity stages. Epiphytic eukaryotes were rarely found on partial and whole crop peas. Bacterial composition and α-diversity were affected by ensiling and subsequent aerobic storage. In partial and whole crop peas, plant maturation caused an increase of the relative abundance of naturally occurring LAB ( Weissella , Pediococcus , and Lactobacillus spp.). As a possible result, natural LAB support stable ensiling conditions even without the use of inoculants beginning with a maturity of 78 on the BBCH scale. This corresponded with a dry matter (DM) concentration of 341 and 363 g/kg in partial and whole crop peas, respectively. Addition of LAB inoculants, however, reduced ammonia, acetic acid, and butanol concentrations, and supported aerobic stability. Earlier stages of plant maturity (BBCH 76 and 77, 300 g DM/kg or less) were more prone to microbial spoilage. Stable pea seed silages can be produced at a maturity between BBCH 78 (427 g DM/kg) and 79 (549 g DM/kg), but they undoubtedly require LAB inoculation or application of other ensiling agents. IMPORTANCE Field peas are important protein suppliers for human and animal nutrition. They can be grown in many areas of the world, which may reduce imports of protein plants and has beneficial economic and ecological effects. Ensiling is a method of preserving feed that can be implemented easily and cost-effectively at the farm. Peas harvested as seeds, partial crop, or whole crop at different maturities enable a wide range of applications. The study characterized epiphytic microbial communities on peas in terms of composition and diversity depending on the maturity of the plants and feed conservation by ensiling as they play an essential role for the production of silages. Even if this study did not consider year, site, or cultivar effects, the results would show which part of the plant is probably well suited for the production of stable and high-quality silages and at which stage of maturity.

We introduce new functionals for the Kohn-Sham correlation energy that are based on the adiabatic-connection fluctuation-dissipation (ACFD) theorem and are named σ-functionals. Like in the well-established direct random phase approximation (dRPA), σ-functionals require as input exclusively eigenvalues σ of the frequency-dependent KS response function. In the new functionals, functions of σ replace the σ-dependent dRPA expression in the coupling-constant and frequency integrations contained in the ACFD theorem. We optimize σ-functionals with the help of reference sets for atomization, reaction, transition state, and non-covalent interaction energies. The optimized functionals are to be used in a post-self-consistent way using orbitals and eigenvalues from conventional Kohn-Sham calculations employing the exchange-correlation functional of Perdew, Burke, and Ernzerhof. The accuracy of the presented approach is much higher than that of dRPA methods and is comparable to that of high-level wave function methods. Reaction and transition state energies from σ-functionals exhibit accuracies close to 1 kcal/mol and thus approach chemical accuracy. For the 10 966 reactions of the W4-11RE reference set, the mean absolute deviation is 1.25 kcal/mol compared to 3.21 kcal/mol in the dRPA case. Non-covalent binding energies are accurate to a few tenths of a kcal/mol. The presented approach is highly efficient, and the post-self-consistent calculation of the total energy requires less computational time than a density-functional calculation with a hybrid functional and thus can be easily carried out routinely. σ-Functionals can be implemented in any existing dRPA code with negligible programming effort.

Analytic energy gradients with respect to nuclear coordinates are derived and implemented for the self-consistent direct random phase approximation (sc-dRPA) method. In contrast to the more common non-self-consistent dRPA methods, the sc-dRPA method does not require a choice for the approach to generate the Kohn-Sham orbitals and eigenvalues serving as input for the dRPA correlation functional. The fact that the sc-dRPA total energy is variational facilitates the calculation of analytic gradients. The analytic gradients are tested against numerical ones and then used to calculate equilibrium geometries and vibrational frequencies for various molecules including weakly bonded dimers and transition metal compounds. The sc-dRPA method can compete in accuracy with Møller-Plesset perturbation theory of second order and with conventional density-functional methods within the generalized gradient approximation or of hybrid type. Indeed, sc-dRPA geometries and vibrational frequencies are most accurate in many cases. Moreover, the sc-dRPA method is robust in the sense that it is applicable to all considered molecules, whereas conventional density-functional methods are not applicable to dispersion bonded dimers, and Møller-Plesset perturbation theory of second order erroneously predicts a number of molecules to be unbound and yields completely wrong vibrational frequencies in some cases. The coupled cluster singles doubles methods yield geometries and vibrational frequencies of a quality that is inferior to that of the other considered methods.

Legume grains such as field peas and field beans can be produced on a local level, and may be reliable sources of dietary protein and energy apart from common soybean and rapeseed meals. In ruminants, protein, starch, and carbohydrates from peas and field beans are fermented in large part before reaching the small intestine. The objective of this study was to evaluate the effects of a combination of ensiling and hydro-thermic treatment (i.e., toasting at 160 °C for 30 min) of grains of peas and field beans on the concentrations of post-ruminal crude protein (PRCP) and rumen-undegraded protein (RUP). Moreover, 24-h gas production and methane production were measured. For this, an in vitro batch culture system with ruminal fluid from sheep was used. Rumen-undegraded protein was determined using the Streptomyces griseus protease test. Scanning electron micrographs were used to visualize morphological changes of starch granules and their joint matrices in peas and field beans after ensiling, toasting, or a combination of both. Native pea grains contained crude protein (CP) at 199 g/kg DM, PRCP at 155 g/kg DM at a ruminal passage rate of 0.08/h ( K p8), RUP at 33 g/kg DM at K p8, and starch at 530 g/kg DM. Native field beans contained CP at 296 g/kg DM, PRCP at 212 g/kg DM at K p8, RUP at 54 g of/kg DM at K p8, and starch at 450 g/kg DM. The PRCP did not considerably differ among native and treated peas or field beans. Especially in the peas, RUP at K p8 increased after ensiling by 10 g/kg DM (i.e., 30%; P  < 0.05). Toasting increased RUP ( K p8) in ensiled peas by another 28% ( P  < 0.05). Toasting had no effect on PRCP or RUP when the peas or field beans were not ensiled before. Gas and methane production were not affected by any treatment, and scanning electron micrographs did not reveal structural changes on the starches doubtless of any treatment. Protein seemed to be more affected by treatment with ensiled + toasted peas than with ensiled + toasted field beans, but starches and other carbohydrates from both legumes remained unaffected., (© 2020 Chinese Association of Animal Science and Veterinary Medicine. Production and hosting by Elsevier B.V. on behalf of KeAi Communications Co., Ltd.)

Analytic energy gradients with respect to nuclear coordinates for an exact exchange-only (EXX) Kohn-Sham method are presented. In the underlying EXX method, the exact exchange potential is obtained as the electrostatic potential of an exchange charge density, which is determined via the optimized effective potential method. Parts of the presented calculation of analytic EXX energy gradients can be reused for analytic energy gradients in self-consistent Kohn-Sham methods treating correlation via the adiabatic-connection fluctuation-dissipation theorem, e.g., methods relying on the random phase approximation. A version of the analytic EXX energy gradients that uses density-fitting is shown to be highly efficient. The accuracy of the analytic energy gradients is tested by comparison with numerically calculated gradients.

A fully self-consistent hybrid dRPA (direct random phase approximation) method, named sc-H[γ]dRPA, is presented with γ = 1/3. The exchange potential of the new method contains a fraction γ of nonlocal Hartree-Fock-like exchange besides the exact local Kohn-Sham (KS) exchange potential. The sc-H[γ]dRPA method, in contrast to a straightforward self-consistent dRPA method within the KS formalism, does not suffer from convergence problems for systems with small eigenvalue gaps. Moreover, the sc-H[γ]dRPA method yields distinctively more accurate reaction, isomerization, and transition state energies than other dRPA approaches, e.g., the frequently used non-self-consistent dRPA method using orbitals and eigenvalues from a KS calculation with the exchange-correlation potential of Perdew, Burke, and Ernzerhof (PBE). The sc-H[γ]dRPA method outperforms second-order Møller-Plesset perturbation theory and coupled cluster singles doubles methods while exhibiting a more favorable scaling of computational costs with system size. A value of γ = 1/3 is shown to be a good choice also for a dRPA@PBE[γ] method, which is a non-self-consistent dRPA method using orbitals and eigenvalues from the hybrid PBE0 method with an admixture of γ = 1/3 of exact exchange instead of the 25% of the PBE0 functional. The dRPA@PBE[γ] method yields reaction, isomerization, and transition state energies that are as good as the sc-H[γ]dRPA ones but is computationally simpler and more efficient because it does not require the self-consistent construction of the dRPA correlation potential. The direct sc-H[γ]dRPA, on the other hand, in contrast to all standard density-functional methods, yields qualitatively correct correlation potentials.

An accurate yet computationally very efficient and formally well justified approach to calculate molecular ionization potentials is presented and tested. The first as well as higher ionization potentials are obtained as the negatives of the Kohn-Sham eigenvalues of the neutral molecule after adjusting the eigenvalues by a recently [ Görling Phys. Rev. B 2015 , 91 , 245120 ] introduced potential adjustor for exchange-correlation potentials. Technically the method is very simple. Besides a Kohn-Sham calculation of the neutral molecule, only a second Kohn-Sham calculation of the cation is required. The eigenvalue spectrum of the neutral molecule is shifted such that the negative of the eigenvalue of the highest occupied molecular orbital equals the energy difference of the total electronic energies of the cation minus the neutral molecule. For the first ionization potential this simply amounts to a ΔSCF calculation. Then, the higher ionization potentials are obtained as the negatives of the correspondingly shifted Kohn-Sham eigenvalues. Importantly, this shift of the Kohn-Sham eigenvalue spectrum is not just ad hoc. In fact, it is formally necessary for the physically correct energetic adjustment of the eigenvalue spectrum as it results from ensemble density-functional theory. An analogous approach for electron affinities is equally well obtained and justified. To illustrate the practical benefits of the approach, we calculate the valence ionization energies of test sets of small- and medium-sized molecules and photoelectron spectra of medium-sized electron acceptor molecules using a typical semilocal (PBE) and two typical global hybrid functionals (B3LYP and PBE0). The potential adjusted B3LYP and PBE0 eigenvalues yield valence ionization potentials that are in very good agreement with experimental values, reaching an accuracy that is as good as the best G 0 W 0 methods, however, at much lower computational costs. The potential adjusted PBE eigenvalues result in somewhat less accurate ionization energies, which, however, are almost as accurate as those obtained from the most commonly used G 0 W 0 variants.

Background: The EasyTube (EzT) is a supraglottic airway device that is used for emergency airway situations. Ventilation during general anesthesia should also be feasible, but literature on the EzT is scarce. We evaluated the EzT in comparison with the endotracheal tube (ETT) in its use during general anesthesia in a comparative study., Methods: A total of 400 patients with American Society of Anesthesiologists (ASA) physical status I to II scheduled for minor surgery in 4 centers were randomized for ventilation via the ETT or EzT., Results: In all patients, the EzT and the ETT could be inserted within 3 attempts. In all EzT patients, the inspiratory and expiratory minute volumes (6.64 ± 0.71 and 6.34 ± 0.69 L/min) were sufficient to reach target oxygenation values, similar to ETT patients (P  =  .59). Mean peak pressure, mean plateau pressure, and mean dynamic compliance did not differ between the groups. Sore throat and blood on the cuff after removal were the most frequent complications in both groups., Conclusion: Ventilation for up to 1 hour during general anesthesia in patients with ASA physical status I to II with the EzT is feasible and safe.

Background: Supraglottic airway devices (SAD) provide an effective way for managing difficult airways. Numerous SADs have been developed in recent years. We compared three SADs utilizing simulated airways. The major aim of this study was to provide evidence for the efficacy of SADs in the management of simulated difficult airway situations., Methods: The study utilized an airway simulation manikin (Laerdal SimMan® 3G) to assess feasibility and time to final placement of three different airway devices (the classic laryngeal mask airway [LMA], the Laryngeal tube [LT], and the EasyTube® [EzT]). Thirty anesthesiologists inserted each of the SADs under standard physiologic airway conditions (STD) as well as pathological airway conditions, including tongue edema (TE) and trismus combined with limited mobility of the cervical spine (TCS), mimicking a patient with cramps., Results: In STD and TE, all participants were able to successfully place the LMA, LT, and EzT correctly. In TCS, one participant failed to place the LMA correctly, whereas six participants failed to place the LT correctly (P=0.031). Under STD and TE conditions, we found a significantly longer time to final placement with the EzT (P=0.001). Under TCS conditions, there was no significant difference between the tested SADs. Under STD conditions, the participants rated the LMA best (P<0.001). Under TE and TCS condition, the EzT was significantly higher rated (P<0.001)., Conclusion: The EzT showed benefits in two difficult airway situations (TE and TCS) in a prospective manikin study amongst anesthesiologists.

Introduction: In recent years, new angle-stable plate implants with polyaxial screw direction were developed with the aim of an improved treatment of displaced 3- and 4-part fractures of the proximal humerus. There are only a few studies available about polyaxial implants in the treatment of 3- and 4-part proximal humerus fractures. Therefore, the aim of this study was to evaluate clinical results and complications of open reduction and internal fixation of displaced 3- and 4-part fractures using a polyaxial plate., Patients and Methods: Within 51 months, 105 patients with a displaced 3- or 4-part fracture of the proximal humerus were treated with a polyaxial locking plate. The complications were evaluated and the Constant & Murley score was assessed and correlated with patient satisfaction ("very satisfied" to "not satisfied"). Additionally, the results were compared with those of monoaxial plates from the literature. Furthermore, the operative experience of the surgeons at the time of surgery was correlated with the objective results of the patients., Results: 65 patients (average age: 71.3 ± 11.4 years; average follow-up: 19,6 ± 9,8 month [10-44 month]) with a displaced 3- or 4-part fracture were re-examined retrospectively (female: n = 54; male: n = 11). Overall, there were 27 3-part fractures and 38 4-part fractures. The Constant and Murley Score was on average 62.1 ± 16.5 points and the complication rate was 26 %. The most frequent complication was screw perforation through the humeral head. Patient satisfaction with clinical outcome was high within the whole study group. 40 % of the patients were "very satisfied" with their shoulder function, 29 % were "satisfied" ("fair": 12 %, "not satisfied": 19 %). Additionally, the operative experience of the surgeons influenced the final clinical result., Conclusion: In comparison to the literature we could not delineate better clinical outcomes or lower complication rates with polyaxial implants compared to monoaxial plates in 3- and 4-part fractures. Nevertheless, the majority of patients were satisfied with the clinical result in the context of age-related shoulder function. In addition, a close correlation could be detected between the degree of satisfaction and the objectively measured shoulder function. A high level of operative experience is required to avoid typical complications and to achieve a good clinical result., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Immobilization of the shoulder in 60 ° external rotation and 30 ° abduction after primary anterior shoulder dislocation has been shown to allow anatomical reduction and potential healing of the capsule-labrum complex. The purpose of the present study was to evaluate commercially available shoulder braces concerning functionality and comfort as well as for potential problems., Methods: In this study ten healthy subjects (6 female, 4 male and average age 23 years) tested four braces: 1. Omo Immobil (Ottobock), 2. Quadrat (DJO Global), 3. MP Airplane Axilla (Horst Rattenhuber GmbH) and 4. ARC XR (Bledsoe Brace Systems) with respect to functionality and comfort. Each subject completed simulated activities of daily living (ADLs) and a the end of each ADL the subject evaluated comfort, difficulty of the activities and potential pain on a points scale. The position or the change of the position were controlled by digital photographs. Additionally it was checked whether the subjects could actively change the position of the brace contrary to the desired position., Results: Braces 3 and 4 were rated significantly more comfortable (p < 0.05). Even the difficulty of the activities was rated lower and in particular putting on and taking off the braces was assessed to be significantly easier in comparison to braces 1 and 2. In addition, differences of potential pain were statistically significant and pain was experienced only with braces 1 and 2. The measuring of the position showed no significant differences (p > 0.05). For braces 1 and 2 the active change of the position by subjects was significantly higher and the arm could be rotated more against the favored position (p < 0.05). Between braces 3 and 4, there were no statistical differences during the whole evaluation., Conclusions: Ortheses where the main joint is positioned in and not in front of the axilla or which can ensure a jointless stabilization of the shoulder or which allow an improved position by an additional sling on the opposite shoulder, are most qualified for immobilization of the shoulder in an external rotation/abduction position with respect to functionality and comfort.

Objective: To compare the direct and indirect (video monitor) views of the glottic opening using a new Macintosh blade that is modified to provide a video image of airway structures during laryngoscopy., Design: Prospective multicenter trial., Setting: 11 university-affiliated hospitals., Patients: 867 adults undergoing elective surgery requiring general anesthesia and tracheal intubation., Interventions: Patients received general anesthesia and were paralyzed. Direct laryngoscopy was supervised by one of the investigators at each institution. The best possible view was obtained with a Macintosh video laryngoscope during direct vision using standard techniques such as external laryngeal manipulation and backward, upward, and rightward pressure, if necessary. The laryngoscopist then looked at the video monitor and performed any necessary maneuvers to obtain the best view on the video monitor. Thus, 2 assessments were made during the same laryngoscopy (direct naked-eye view vs video monitor view). Tracheal intubation was then performed using the monitor view. Glottic views were rated according to the Cormack-Lehane scoring system, as modified by Yentis and Lee. A questionnaire was completed for each patient., Measurements and Main Results: Data from 865 patients were suitable for analysis. Visualization was considered easy (Cormack-Lehane score<3) in 737 patients and difficult (Cormack-Lehane score=3 or 4) in 21 for both direct and video-assisted views. In 7 patients, the view was considered easy during direct visualization yet difficult on the video monitor view. On the other hand, the view was considered difficult in 100 patients during direct visualization yet easy on the video monitor view (P<0.001)., Conclusions: Video-assisted laryngoscopy provides an improved view of the larynx, as compared with direct visualization. This technique may be useful for cases of difficult intubation and reintubation as well as for teaching laryngoscopy and intubation.

Background: We compared the ease of viewing the glottis under direct vision during conventional laryngoscopy with the quality of indirectly viewing on a monitor during laryngoscopy with a Macintosh videolaryngoscope in a multicenter study., Patients and Methods: After ethical approval and written informed consent of 300 patients with no anticipated difficult airway, conventional laryngoscopy with a Macintosh videolaryngoscopy blade was performed and the quality of the view of the glottis was assessed and documented according to the Cormack and Lehane scoring system as modified by Yentis and Lee. Subsequently, the indirect viewing conditions on the monitor were documented without changing the position of the blade. Differences between both distributions were analyzed using the Bland-Altman Test., Results: Videolaryngoscopy improved the laryngoscopy score by 1 grade in 72 cases, by 2 grades in 17 cases and by 3 grades in 2 cases. A relevant improvement (from grades III/IV to II) was found in 28 patients. Viewing conditions worsened in 3 cases by 1 grade, in 4 cases by 2 grades and in 3 cases by 3 grades. A statistical analysis of the data gave a bias of 0.31 and an SD bias of 0.77.The 95% confidence interval of the distribution ranged from -1.12 to 1.81., Conclusion: Videolaryngoscopy can lead to better viewing conditions but in rare cases it may result in worse viewing conditions.

Combat lifesavers and Army medics are regular combat soldiers who possess skills that enable them to provide lifesaving assistance to combat casualties. Although their training is not equal to that of paramedics, combat lifesavers and Army medics are trained to assess casualties for airway obstruction, as well as the presence or absence of spontaneous ventilation. They are also familiar with the same basic airway maneuvers that are required for blind insertion of the esophageal-tracheal double-lumen airway (ETDLA). Use of the ETDLA in combination with an esophageal detector device and a colorimetric carbon dioxide detector would require skill similar to that which they already possess in performing many mission-essential and combat lifesaver tasks. Because the U.S. Army has introduced the ETDLA for use, it is important that providers at all echelons understand the dynamics of the ETDLA. Inclusion of the ETDLA, esophageal detector device, and colorimetric carbon dioxide detector in combination with the bag-valve ventilation device could provide a viable alternative to mouth-to-mouth rescue breathing with the oral airway, as currently used by combat lifesavers on the battlefield. Improved airway management, in conjunction with other lifesaving measures, could potentially improve survival rates for combat casualties and assist in stabilizing them for evacuation to higher echelons of combat medical care.

Background: The value of the laryngeal tube S (LTS) for emergency airway management was evaluated in comparison to endotracheal intubation (ETI)., Methods: Physicians were asked to perform simulated airway management in an airway mannequin. The physicians were allocated into three groups according to their experience in intubation (1: <50, 2: >50, 3: >500 intubations). The success rate using LTS and ETI, the time needed for securing the airway, and the rating of both techniques by the participants were recorded., Results: A correct position was achieved with the LTS in 99.39% of attempts (n=325), and with the endotracheal tube in 92.35% (n=302). Using the LTS it took an average time of 10.85 s to achieve the first successful ventilation, as compared to 17.75 s in ETI (p<0.0001). Participants from group 1 needed longer to achieve ETI in the 2nd (18.4 s vs. 16.4 s, p<0.0001) and 3rd attempts (16.9 s vs. 15.8 s, p<0.0001) compared to those from group 3., Conclusions: The LTS represents a fast and reliable method to secure the airway and to achieve ventilation in the mannequin model described. The success rate, the time until successful ventilation and the rating by the participants indicates that the LTS is an important alternative to ETI. The LTS offers special benefits for the less experienced users.

Nasotracheal intubation is frequently used for airway management during maxillofacial surgery. Complications such as haemorrhage occur more frequently with this route of intubation than with the orotracheal route. This case report describes a male patient aged 51 yr who developed severe epistaxis after the tube had passed the nares. As an additional complication laryngoscopy and endotracheal intubation failed because of difficult airway (Cormack-Lehane grade 4). Attempts using an intubating laryngeal mask airway and a Bonfils intubating fibrescope did not succeed. The airway was finally managed by cricothyroidotomy. A modified sequence of nasotracheal intubation is proposed to avoid similar life-threatening complications.

The "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care--International Consensus on Science" recommend a tidal ventilation volume of 10 ml/kg body-weight without the use of supplemental oxygen during two-rescuer adult cardiopulmonary resuscitation (CPR). This relates to a ventilation volume of about 6.4 l/min. Additionally, the first aid provider ventilating the victim will breathe for him/herself during the external chest compression period adding another 3.2 l/min of ventilation. Finally, a deep breath is recommended before each ventilation to increase the end-expiratory oxygen concentration of the air exhaled. To investigate the effects of these recommendations, 20 healthy volunteers were asked to perform two-rescuer CPR in a lung model connected to a BLS-manikin. End-tidal carbon dioxide, oxygen saturation, and heart rate were recorded continuously. Capillary blood gas samples were collected and non-invasive blood pressure was recorded prior to the start of external chest compressions and immediately after the end of each measurement period. Furthermore, hyperventilation related symptoms reported by the volunteers were also recorded. The data reveal a significant decrease in capillary and end-tidal carbon dioxide pressure in the volunteers (P < 0.001). Additionally, in 75% of test persons multiple hyperventilation associated symptoms occurred. Ventilation during two-rescuer CPR performed according to the Guidelines 2000 may cause injury to the health of first aid providers. To minimize hyperventilation, both rescuers should exchange their positions at intervals of 3-5 min. These data challenge the recommendation to take a deep breath prior to each ventilation.

A solution to managing intubation difficulties during anaesthesia induction is described in this article. After two attempts at laryngoscopy had failed, endotracheal intubation was achieved by the combined use of a laryngoscope and the Bonfils rigid fiberscope. The successful technique involved two anaesthesiologists, one who displaced the patient's tongue to the left ventral part of the mouth with a laryngoscope and cleared the airway by suctioning, and one who accomplished the intubation using the Bonfils rigid fiberscope by following the blade of the laryngoscope to the larynx. After securing a good view of the vocal cords, the tube was successfully inserted into the trachea. The entire procedure of intubation was accomplished within 20 s.

Background: Oxygenation and ventilation as well as prevention of aspiration are of vital importance for emergency patients. Prehospital airway management is not comparable to clinical anaesthesia. However, prehospital data of the occurrence of potential life-threatening complications and less severe adverse events of airway management procedures by emergency physicians are not yet available., Methods: All airway management procedures predominantly performed by emergency physicians over a period of 36 months were recorded prospectively., Results: Data of 598 consecutive patients were collected, in all patients prehospital airway management could be accomplished successfully. Of the patients 98.5% were successfully intubated endotracheally with a maximum of 3 attempts, 84.6% of patients were intubated at the first attempt, and in 9 patients other techniques such as the Combitube were required. In more than 80% of procedures, no complications or adverse events were recorded and potentially life-threatening complications occurred in 9% of patients only., Conclusions: Prehospital airway management by emergency physicians experienced in anaesthesia is associated with low complication and high success rates.

At the scene of an accident, the most severely injured patients need trauma care urgently. Bystanders are often present before the emergency medical service arrives and may be able to limit trauma-related damage by providing trauma care at the scene. The aim of this prospective study conducted in Mainz, Germany, and Vienna, Austria, was to compare the frequency and quality of bystander trauma care in moderately versus severely injured patients. Five specific measures (making the scene readily visible for oncoming traffic, extrication and positioning of the trauma patient, control of haemorrhage, and hypothermia protection) were assessed in a questionnaire and evaluated statistically. Bystanders were present at the scene in 58.7% of all accidents. Making the scene readily visible for oncoming traffic, patient extrication and patient positioning were initiated significantly more often than haemorrhage control and hypothermia protection. Extrication, patient positioning and hypothermia protection were initiated significantly more often in moderately (NACA I-II) compared to severely (NACA III-VII) injured patients. In severely injured patients, bystanders attempted measures less frequently and the measures performed were more often incorrect compared to those in moderately injured patients. Our findings show that severely injured patients received less and less appropriate bystander trauma care than moderately injured patients. In an effort to correct this serious problem and to improve trauma care on-scene, we advocate offering lay persons more extensive training in bystander trauma care.

The 'Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - International Consensus on Science' recommend an artificial ventilation volume of 10 ml/kg bodyweight (equivalent to a tidal volume of 700-1000 ml) without the use of supplemental oxygen in adults with respiratory arrest. For first aid providers using the mouth-to-mouth or mouth-to-nose-ventilation technique, respectively, a ventilation volume of approximately 9.6 l/min results. Additionally, a deep breath is recommended before each ventilation to increase the end-expiratory oxygen concentration of the air exhaled by the first aid provider. To investigate the effects of these recommendations in healthy volunteers, test persons were asked to ventilate an artificial lung model for a period of up to 10 min. The tidal volume was set at 800 ml at a breathing rate of 12/min. End-tidal carbon dioxide, oxygen saturation (measured by pulse oximetry), and heart rate were measured continuously. Capillary blood gas samples were collected and non-invasive blood pressure readings were recorded prior to the start of ventilation and immediately after the end of the measuring period. The data reveal a statistically significant and clinically relevant decrease in end-tidal carbon dioxide pressure (P<0.001, median decrease 14 mmHg), and the occurrence of hyperventilation-associated symptoms such as paraesthesia, dizziness, and carpopedal spasms in more than 75% of the participants. Clinically and statistically significant hyperventilation results in first aid providers performing artificial ventilation according to the guidelines. This artificial ventilation is associated with a significant decrease in capillary and end-tidal carbon dioxide pressure as well as with multiple symptoms of an acute hyperventilation syndrome. Ventilation performed according to these guidelines may cause injury to the health of the first aid provider. Rescuers ventilating the victim should be replaced at regular intervals and the recommendation to take a deep breath before each ventilation should not be upheld in order to minimise the risk of hyperventilation.

Objective: The evaluation of services by patients is an integral part of continuous quality improvement in anaesthesia. Patient satisfaction is affected by various objective and subjective variables. Individual experiences, impressions and needs represent an important part of overall patient satisfaction., Methods: Data of 519 patients were collected in a standardised anonymous questionnaire independent of the post-anaesthetic visit., Results: Anaesthesia staff appeared to be friendly to 97 % of patients asked, 95 % of patients wanted to be treated by the same staff in case of another anaesthesia, nearly 87 % felt relaxed and satisfied after anaesthesia. Up to 26 % of patients felt tense after pre-anaesthetic visit and 38 % before anaesthesia, 35 % felt that waiting before operation was endless and 20 % complained about loss of humaneness because of technical equipment and monitoring. Significant differences could be found between specific groups of patients: Older and male patients were in all more satisfied compared to younger and female patients, patients after regional anaesthesia were more satisfied compared to ones after general anaesthesia., Conclusion: The inquiry of subjective patient impressions can be performed in anaesthesia departments without much effort. The results help to identify and avoid psycho-vegetative stressing situations and to improve patient satisfaction with anaesthesia.

Objective: The present study was conducted to evaluate the quality of paramedic care and the feasibility and cost-effectiveness of sending a well-trained paramedic team to the sight of a medical emergency to initiate active medical treatment prior to the arrival of the mobile intensive care unit (MICU)., Methods: We examined 200 cases of medical treatment initiated by paramedics before arrival of the MICU team at the site of the medical emergency. Using a questionnaire, all emergency procedures performed by the paramedic team on scene were recorded and defined as "required", "carried out", and "accurately performed". The documented emergency procedures were divided into three categories: basic procedures (e. g. positioning, CRP, oxygen administration), additional procedures (e. g. placement of iv-lines, application of intravenous medication), and routine emergency diagnostic measures (e. g. monitoring of cardiopulmonary status). Further documented were the time of onset of emergency physician treatment, and the definitive transport vehicle used. To evaluate the time required for the measures performed, three different groups were identified according to the time gap between the arrival of the paramedic and the emergency physician teams (< 3 min, 3 - 5 min and > 5 min)., Results: In the 200 emergencies included in the study, 76 - 95 % of the required procedures were accurately performed prior to the arrival of the MICU team, at a success rate ranging from 87 to 100 %., Conclusions: In this study, a large number of emergency procedures could be performed by the paramedic team within a short period of time (in some cases < 3 min), and adequate effectiveness. Based on our results, the activation of paramedic-staffed first-tier ambulances with shorter response times is recommended in addition to the MICU system.

We report on a very rare case of pre-hospital total spinal anaesthesia. In addition to initial management, other possible complications of paravertebral injections are discussed. The identification of symptoms and an immediately initiated life-saving therapy can avoid the necessity of introducing extensive diagnostic and therapeutic procedures. Patients who are adequately treated usually return to their former state of health. Specific medical training of physicians using paravertebral infiltration techniques is mandatory to treat side-effects appropriately. Immediate personal and instrumental measures must be taken for granted to prevent an adverse outcome.

Franz Kuhn (1866-1929), a German surgeon, made a significant practical and scientific contribution towards the development of modern anaesthesia and emergency medicine. He developed modern, scientifically based concepts in close correlation to practical inventions for every day use. All of his studies and developments were patient orientated and led to remarkable improvements in patient safety. Kuhn was a major protagonist of endotracheal intubation, perfected his flexo-metallic endotracheal tubes, worked on different techniques of intubating the trachea, applied positive pressure to the lungs during thoracic surgery and developed anaesthesia machines. In the early 20th century, he wrote several papers on this topic including a remarkable monograph, dealing with the techniques, indications in anaesthesia and emergency medicine and his experiences of endotracheal intubation. Due to a dispute with Sauerbruch on the methods of avoiding a pneumothorax during thoracic surgery and the development of local and regional anaesthesia techniques, the value of his work and his revolutionary ideas were not appreciated until 40 years later.

The technique of light-guided intubation is based on the principle that a source of light brought into the trachea results in clearly visible and defined transcutaneous illumination, while no illumination can be observed with the light source in the oesophagus (Fig. 1-7). The Trachlight is a reintroduced instrument for this alternative intubation technique. The essential developments are: a length-adjustable stylet with a removable internal metal wire, a brighter light source, a stable handle with tight fixation of the endotracheal tube, and a time-dependent warning device to avoid extended intubations. One hundred twenty patients (Mallampati I. ASA I-III) were included in the study (conventional intubation [group KL, n = 60]. Trachlight intubation [group TT, n = 60]. The goals of the investigation were to examine the handling, application, problems, limitations, and possible indications of the method. The recorded parameters were: number of intubation attempts: course and duration of intubation; complications; and difficulties. In 40 patients (20 in each group) the indication for invasive blood pressure measurement was given due to the surgical procedure, and circulatory parameters were recorded at defined moments during the intubation course. In group KL 55 patients were intubated in the attempt, 4 on the second, and 1 on the third (mean duration 23.6 +/- 10.4 s, range 12-60 s). Complications were: unilateral intubation (3 patients), bradycardia (2), asystole (1) and soft-tissue injury (1). Of the 60 patients in group TT. 54 were intubated successfully, the mean time needed being 29.9 +/- 14.8 s (range: 6-61 s). The remaining 6 were then intubated by the conventional method. Positive results in group TT included: easy handling and application, no injury to soft tissues or teeth, and invariably correct placement of the tube. Problems included: sufficient transillumination was achieved only after (entire) dimming of the room, insufficient control over the distal end of the tube due to an unfixed metal wire, unintentional switching off of the light while with-drawing the metal wire, difficulties in withdrawing the metal wire (too strong fixation), as well as disturbing effects of the warning device (blinking of the light 30 s after switching on). Reasons for the 6 intubation failures were introduction of the instrument into the oesophagus despite a supposed correct position, impossibility of correct placement in a patient with an extremely large goiter, and insufficiently clear transillumination in 3 extremely obese patients. The cardiovascular parameters showed no changes during laryngeal manipulation; a clear rise in heart rate and blood pressure was recorded, however, when the tube was inserted into the trachea. The cardiovascular parameters during conventional intubations were similar. The light-guided intubation technique can be regarded as a further alternative for airway management, due to the described improvement of the instrument. The indication for the technique is given in patients in whom no difficulty with intubation is expected, to avoid soft tissue damage and traumatising temporomandibular joint movements. Preclinical use may be limited due to environmental brightness. In patients with expected difficult airway management, fiberoptic intubation will remain the method of choice.

Laryngoscopy causes temporary postoperative dysfunction of the temporomandibular joint (TMJ): during iatrogenic TMJ manipulation in anaesthetised patients, the TMJs have lost the protection afforded by the tone of the surrounding muscles. Thus far, the exact type and extent of TMJ movements have not been known. The purpose of this study was to develop a method to visualise and assess TMJ movements during intubation by means of electronic axiography, a diagnostic monitor of TMJ movements used in dentistry: registration of the hinge axis (HA) as an equivalent of the condylar paths on extra-oral sagittaly mounted, parallel plates. The HA is individually defined in each patient by the pure, rotating TMJ movement during initial mouth opening (no farward gliding of the condyles, incisor distance up to 10 mm). The parallel plates are placed in the TMJ region in the skull-mounted plate bow: both registration tips ("drawing" the HA tracings on the electronic plates) are connected to the mandible by a face bow, paraocclusally fixed to the teeth. The face bow is individually shaped for each patient to allow mask ventilation and free movement of the laryngoscope during intubation. HA tracings are registered and calculated for both sides independently every 24 ms with the SAM/Klett system and presented on sagittal and frontal projections. In the operating theatre, the active mouth-opening traces (MOT) are registered first and the passive endotracheal intubation traces (EIT) after induction of anaesthesia (same head position). With informed consent and approval by the ethics committee of the Landesärztekammer Rheinland Pfalz. 40 male patients (ASA I. Mallampati I, limb surgery) were randomly allocated to four groups (n = 10 each). OS: Oral intubation, suxamethonium (1.5 mg/ kg); OV: Oral intubation, vecuronium (0.1 mg/kg); NS: Nasal intubation, suxamethonium (1.5 mg/kg); and NV: Nasal intubation, vecuronium (0.1 mg/kg). Intubation was performed 100 s after injection of the relaxant. Pre- and postoperatively (every 24 h over 3 days, in case of positive findings longer) recorded were: active movements of the mandible (maximal mouth opening/ max. laterotrusion); dysfunction of the TMJ; and pain sensation in the TMJ (Helkimo rating). MOTs and EITs were recorded and analysed with the system described and typical EIT patterns were identified: bland, clinically uneventful intubations (n = 7), massive distraction and laterotrusion of the EIT compared to the MOT (n = 24), and blocked or limited TMJ movements resulting in intubation problems (n = 1). With the method presented, TMJ movements could be visualised during endotracheal intubation for the first time. It can be used to assess techniques, routes, and instruments for intubation as well as to evaluate potential traumatising movements during endotracheal intubation.