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BackgroundOperation room (OR) planning is a complex process, especially in large hospitals with high rates of unplanned emergency procedures. Postponing elective surgery in order to provide capacity for emergency operations is inevitable at times. Elderly patients, residents of nursing homes, women, patients with low socioeconomic status and ethnic minorities are at risk for undertreatment in other contexts, as suggested by reports in the medical literature. We hypothesized that specific patient groups could be at higher risk for having their elective surgery rescheduled for non-medical reasons.MethodsIn this single center, prospective observational trial, we analysed 2519 patients undergoing elective surgery from October 2018 to May 2019. A 14-item questionnaire was handed out to illicit patient details. Additional characteristics were collected using electronic patient records. Information on the timely performance of the scheduled surgery was obtained using the OR’s patient data management system. 6.45% of all planned procedures analysed were postponed. Association of specific variables with postponement rates were analysed using the Mann–WhitneyUtest and Fisher's exact test/χ2-test.ResultsSignificantly higher rates of postponing elective surgery were found in elderly patients. No significant differences in postponing rates were found for the variables gender, nationality (Germany, EU, non-EU), native language, professional medical background and level of education. Significantly lower rescheduling rates were found in patients with ties to hospital staff and in patients with a private health insurer.ConclusionsElderly patients, retirees and nursing home residents seem to be at higher risk for having their elective surgery rescheduled. However, owing to the study design, causality could not be proven. Our findings raise concern about possible undertreatment of these patient groups and provide data on short-term postponement of elective surgery.Trial registrationDRKS00015836. Retrospectively registered.

Introduction Hemoglobin-based oxygen carriers (HBOC) have been developed as an alternative to blood transfusions . Their nitric-oxide-scavenging properties HBOC also induce vasoconstriction . In acute lung injury , an excess of nitric oxide results in a general vasodilation , reducing oxygenation by impairing the hypoxic pulmonary vasoconstriction . Inhaled nitric oxide (iNO) is used to correct the ventilation perfusion mismatch . We hypothesized that the additional use of HBOC might increase this effect. In a rodent model of ARDS we evaluated the combined effect of HBOC and iNO on vascular tone and gas exchange. Methods ARDS was induced in anaesthetized Wistar rats by saline lavage and aggressive ventilation. Two groups received either hydroxyethylstarch 10% (HES; n = 10) or the HBOC hemoglobin glutamer-200 (HBOC-200; n = 10) via a central venous infusion . Additionally, both groups received iNO. Monitoring of the right ventricular pressure (RVP) and mean arterial pressure (MAP) was performed with microtip transducers. Arterial oxygenation was measured via arterial blood gas analyses. Results Application of HBOC-200 led to a significant increase of MAP and RVP when compared to baseline and to the HES group. This effect was reversed by iNO. The application of HBOC and iNO had no effect on the arterial oxygenation over time. No difference in arterial oxygenation was found between the groups. Conclusion Application of HBOC led to an increase of systemic and pulmonary vascular resistance in this animal model of ARDS. The increase in RVP was reversed by iNO. Pulmonary vasoconstriction by hemoglobin glutamer-200 in combination with iNO did not improve arterial oxygenation in ARDS.

The laryngeal tube suction II (LTS II) is a supraglottic airway device (SAD) with a gastric drainage tube and enhanced seal properties as compared with other SADs. Therefore, its use has been proposed in situations with an elevated risk of aspiration.To compare the safety and efficacy of airway management and controlled mechanical ventilation when using either an LTS II or an endotracheal tube for laparoscopic radical prostatectomy.Randomised, controlled, blinded and single-centre study.Academic tertiary care centre in Leipzig from April 2014 to May 2015.It was planned to include 100 patients but the study was stopped after 50 patients following an interim analysis. These 50 patients were randomised to either the LTS II group or the endotracheal tube group. All male patients aged more than 18 years for elective laparoscopic radical prostatectomy were eligible. Exclusion criteria included a BMI more than 30, American Society of Anesthesiologists class III or greater, a history of gastroesophageal reflux or other factors known to increase the risk of aspiration and a known difficult airway.All patients received general anaesthesia. Airway management was with either a LTS II or an endotracheal tube, according to the randomisation.The primary endpoint was successful insertion of the particular airway device during anaesthesia for laparoscopic radical prostatectomy.In 15 of the 28 patients randomised to LTS II, the device had to be removed and an endotracheal tube inserted, mainly because of an airway leak (n = 10) or swelling of the tongue (n = 3). Ventilation was successful in all patients (n = 22) randomised to endotracheal tube. Quality of ventilation was rated better in the endotracheal tube group.Our data suggest that LTS II should not be the preferred method of airway management in patients undergoing laparoscopic radical prostatectomy.DRKS00008985 (German Clinical Trials Register).

Die supraglottischen Atemwegshilfen (Larynxmaske, Larynxtubus) haben nach wie vor einen klaren Stellenwert im Algorithmus des erwartet und unerwartet schwierigen Atemwegs. Die Datenlage zum prahospitalen bzw. auserklinischen Atemwegsmanagement ist heterogen und teilweise widerspruchlich. Der vorliegende Beitrag diskutiert die Anwendung des Larynxtubus in der praklinischen Notfallmedizin kritisch und zeigt zum einen klare Vorteile, aber auch Nachteile bei seiner Verwendung auf. Die Pro-Gruppe vertritt die Meinung, dass in der Hand des erfahrenen Anwenders der Larynxtubus aktuell und weiterhin eine wertvolle Alternative zur endotrachealen Intubation beim prahospitalen Management des schwierigen Atemwegs ist, auf die derzeit nicht verzichtet werden sollte. Die Kontra-Gruppe weist auf mehrere Studien hin, die eine hohe Komplikationsrate bei Verwendung des Larynxtubus zeigen. Angesichts dessen sei der Einsatz des Larynxtubus bei der Reanimation auserhalb einer strengen Indikationsstellung derzeit kritisch zu werten.

Fur Patienten mit schwerem akuten Lungenversagen (ARDS) konnte ein signifikanter Uberlebensvorteil bei der Durchfuhrung von Bauchlagerungen gezeigt werden. Auch Patienten, die mit einer extrakorporalen Membranoxygenierung (ECMO) behandelt werden, konnten davon profitieren. Die Lagerung ist jedoch mit einem potenziell erhohten Risiko schwerer lagerungsbedingter Komplikationen vergesellschaftet. In dieser Studie sollen die Machbarkeit und die Sicherheit der intermittierenden Bauchlage fur Patienten mit schwerem ARDS unter laufender ECMO-Therapie untersucht werden. Wir untersuchten retrospektiv alle Patienten, die zwischen Januar 2009 und August 2013 auf der Interdisziplinaren Operativen Intensivstation des Universitatsklinikums Leipzig mit venovenoser (vv)ECMO und Bauchlage behandelt wurden. Basisdaten, Krankenhausletalitat und schwere Zwischenfalle wurden erfasst. Als schwere Zwischenfalle wurden Dislokationen oder Obstruktionen von Atemwegszugangen, ECMO-Kanulen und ein Herz-Kreislauf-Stillstand definiert. Ergebnisse werden als Median (1. Quartile; 3. Quartile) angegeben. Es wurden 26 Patienten mit ECMO-Therapie und Bauchlage behandelt. Ursachen des ARDS waren Pneumonien (n = 20), Aspirationen (n = 2) und in 4 Fallen andere seltenere Grunde. Die 26 Patienten wurden 8 (6;11) Tage mit ECMO behandelt. In dieser Zeit fuhrten wir insgesamt 134 Bauchlagerungen durch. Jeder Patient erfuhr im Mittel 5 (3;7) Lagerungsphasen fur jeweils 12 (8;12) h. Wir konnten keine schweren Zwischenfalle feststellen. Die Krankenhausletalitat betrug 42 %, die Letalitat unter ECMO 35 %. Bei Patienten mit ECMO-Therapie bei schwerem ARDS fanden wir bei der Anwendung von Bauchlage keine schwerwiegenden Zwischenfalle.

Background Emergency airway management (AM) is a major key for successful resuscitation of critically ill non-traumatic (CINT) patients. Details of the AM of these patients in German emergency departments (ED) are unknown. This observational study describes epidemiology, airway techniques, success rates and complications of AM in CINT ED patients in the resuscitation room (RR). Methods Data was collected prospectively on adult CINT patients admitted to the RR of a single German university ED September 2014 to August 2015. Patient characteristics, out-of-hospital and in-hospital RR AM, complications and success rates were recorded using a self-developed airway registry form. Results During the study period 34,303 patients were admitted to the ED, out of those 21,074 patients for non-trauma emergencies. Suffering from severe acute life-threatening problems, 532 CINT patients were admitted to the RR. 150 (28.2%) CINT patients had received out-of-hospital AM. In 16 of these cases (10.7%) the inserted airway needed to be changed after RR admission (unrecognized oesophageal intubation: n = 2, laryngeal tube exchange: n = 14). 136 (25.6%) CINT patients without out-of-hospital AM received RR AM immediately after admission. The first-pass and overall success rate in the RR were 71 and 100%, respectively, and multiple intubation attempts were necessary in 29%. A lower Cormack/Lehane (C/L) grade was associated with less intubation attempts (C/L1/2 vs. 3/4: 1.2 ± 0.5 vs. 1.8 ± 1.2, p = 0.0002). Complication rate was 43%. Conclusions OcEAN demonstrates the challenges of AM in CINT patients in a German ED RR. We propose a nation-wide ED airway registry to better track outcomes in the future. Electronic supplementary material The online version of this article (10.1186/s13049-019-0599-1) contains supplementary material, which is available to authorized users.

Viele Einsatze in der praklinischen Notfallrettung erscheinen den Rettern als „Fehleinsatze“ oder falsche Indikationen im Sinne der Landesrettungsgesetze. Solche Einsatze werden oftmals durch soziale Aspekte getriggert, oder diese stehen gar im Vordergrund des Einsatzes. Mitarbeiter der Rettungsdienste werden mit sozialen Problemen konfrontiert und fuhlen sich in der Folge haufig damit allein gelassen. Der vorliegende Beitrag fordert das Verstandnis der Rettungsdienstmitarbeiter fur die Zusammenhange zwischen gesellschaftlichen Problemen und Gesundheit. Fur haufige soziale Notfalle im Rettungsdienst werden Losungsstrategien angeboten. In dieser Arbeit werden Zusammenhange zwischen soziookonomischem Status und Gesundheit bzw. Krankheit aufgezeigt. Typische Einsatzindikationen, bei denen soziale Aspekte eine grose Rolle spielen, werden dargestellt und Losungsstrategien fur das Vorgehen vorgeschlagen. Diskutiert wird der Umgang mit Fallen von Kindesmisshandlung und hauslicher Gewalt. Drei klassische psychiatrische Problematiken mit haufig sozialer Komponente werden erortert: psychomotorische Erregungszustande, Suizide und alkoholassoziierte Einsatze. Hier wird besonders auf Fremdgefahrdung und aggressive Patienten eingegangen. Gerade bei alteren und chronisch-kranken Patienten spielen neben der Behandlung medizinischer Fragen soziale Probleme eine wichtige Rolle. Die Moglichkeiten des Rettungsteams zur Losung sozialer Probleme sind in aller Regel stark begrenzt. Es ist fur den Notarzt jedoch wichtig, die Strukturen und nichtmedizinischen Ansprechpartner in der eigenen Region zu kennen und zielgerichtet an sie zu verweisen. Dazu gehoren Sozialdienste, Jugendamter; Kriseninterventionsteams oder beispielsweise sozialpsychiatrische Dienste.

BACKGROUND: The modalities of tracheostomy for critically ill patients are still controversially discussed. Although the use of percutaneous dilatational tracheostomy (PDT) is generally accepted to be a safe procedure, it is still not considered to be suitable for patients requiring a permanent tracheostomy. METHODS: This was an observational cohort study investigating long-term outcome parameters of PDT. All patients having received a PDT at the interdisciplinary ICU at the University of Leipzig between October 2008 and August 2009 that survived to discharge were asked for consent to participate (n = 103). Baseline data, admitting diagnosis, reasons for tracheostomy, and timing for tracheostomy were recorded. Subjects and medical providers were asked for neurological outcome, adverse events, and personal discomfort related to the tracheostomy. The study period was 2 y from the time of tracheostomy. RESULTS: Seventy-one subjects were finally included in the survey. Data of 8 subjects (11%) were incomplete. Reasons for tracheostomy were the need for long-term ventilation (42%), weaning (31%), and neurological deficits (27%). No severe adverse events were registered. Sixty-five percent of all subjects could finally be decannulated. Two subjects remained with their initial tracheostomy, and in 5 subjects (7%) tracheostomy was modified to a surgical tracheostomy. Thirty-seven percent of subjects died during the 2 y. Twenty-five of the surviving subjects (35%) had only minor or moderate neurological and psychological deficits. Complaints were mostly connected to swallowing and breathing. CONCLUSIONS: Decannulations after PDT are easily done. Complications after PDT requiring a transformation to a surgical tracheostomy are rare. Elective surgical conversions are not necessary.

Recommendations concerning the management of hemoglobin levels and hematocrit in patients on extracorporeal membrane oxygenation (ECMO) still advise maintenance of a normal hematocrit. In contrast, current transfusion guidelines for critically ill patients support restrictive transfusion practice. We report on a series of patients receiving venovenous ECMO (vvECMO) for acute respiratory distress syndrome (ARDS) treated according to the restrictive transfusion regimen recommended for critically ill patients. We retrospectively analyzed 18 patients receiving vvECMO due to severe ARDS. Hemoglobin concentrations were kept between 7 and 9 g/dL with a transfusion trigger at 7 g/dL or when physiological transfusion triggers were apparent. We assessed baseline data, hospital mortality, time on ECMO, hemoglobin levels, hematocrit, quantities of packed red blood cells received, and lactate concentrations and compared survivors and nonsurvivors. The overall mortality of all patients on vvECMO was 38.9%. Mean hemoglobin concentration over all patients and ECMO days was 8.30 ± 0.51 g/dL, and hematocrit was 0.25 ± 0.01, with no difference between survivors and nonsurvivors. Mean numbers of given PRBCs showed a trend towards higher quantities in the group of nonsurvivors, but the difference was not significant (1.97 ± 1.47 vs. 0.96 ± 0.76 units; P = 0.07). Mean lactate clearance from the first to the third day was 45.4 ± 28.3%, with no significant difference between survivors and nonsurvivors (P = 0.19). In our cohort of patients treated with ECMO due to severe ARDS, the application of a restrictive transfusion protocol did not result in an increased mortality. Safety and feasibility of the application of a restrictive transfusion protocol in patients on ECMO must further be evaluated in randomized controlled trials.

The in-hospital spread of automated external defibrillators (AEDs) is aimed to allow for a shock-delivery within three minutes. However, it has to be questioned if the implementation of AED alone really contributes to a ‘heart-safe hospital’. We performed a cohort study of 1008 in-hospital emergency calls in a university tertiary care hospital, analysing cardiopulmonary resuscitation (CPR) cases with and without AED use. In total, 484 patients (48%) had cardiac arrest and received CPR. Response time of the emergency team was 4.3 ± 4.0 minutes. Only 8% percent of the CPR cases had a shockable rhythm. In three of 43 placements a shock was delivered by the AED. There were no differences in survival between patients with CPR only and CPR with AED use. Our data do not support the use of an AED for in-hospital CPR if a professional response team is rapidly available.

A 33-years-old male patient presented with cardiac arrhythmias, acute shock and multiple organ dysfunction after the surgical removal of a massive epidermoid posterior to the brainstem. The patient initially presented with paraesthesia along the right C6 dermatome due to a big tumour at the brain stem. Surgical removal was performed without adverse events and he was transferred to our intensive care unit (ICU) immediately after the operation. Though initially showing a stable postsurgical course he developed cardiac arrhythmias and a state of acute distributive shock with consecutive multi organ failure. Extensive diagnostic measures could not identify a specific cause for this rapid deterioration. However, under carefully monitored symptomatic therapy the patient improved quickly, was extubated 72 h after admission and discharged from the ICU 6 days later. The follow-up did not show any persisting neurological deficits and no evidence of a residual tumour in the MRI-study.

Perioperative immunonutrition is aiming at modulating altered immunological and metabolic functions in the context of major surgery. It is defined as the supplementation of constitutionally essential substrates such as glutamine, arginine, omega-3-fatty acids or nucleotides. The application of such formula is recommended for patients undergoing major abdominal-surgical procedures and tumour surgery in the head neck area. The substitution should be given 5-7 days before and after the intervention.

The treatment of acute lung injury is one of the most challenging tasks in intensive care medicine. Conventional therapeutic options cover lung protective mechanical ventilation with low tidal volumes and adequate PEEP, restrictive fluid management, prone positioning, and early recruitment maneuvers. These options should be used in parallel and should be accompanied by a suitable anti-infective therapy. In cases of refractory hypoxemia, inhaled nitric oxide offers in most patients a successful rescue option. In specialized centers the application of ECMO remains as a final ultima ratio.

In major trauma patients, multiple organ failure (MOF) is considered a leading cause of death. Acute lung injury is deemed a "pacemaker" of MOF. The purpose of this study was to determine if incidence of organ failure and mortality in multiple trauma patients can be reduced by implementation of lung-protective strategies.All critically ill multiple trauma patients admitted to the ICU of a major trauma center in Berlin, Germany from January 1999 to December 2002 were analyzed retrospectively. Patients were ventilated pressure controlled with low tidal volumes and adequate PEEP.n=287 patients were included. The most frequent injuries were traumatic brain injury (TBI-68%), chest trauma (68%), and lung contusions (55%). Injury severity score (ISS) was 32+/-19 (mean+/-standard deviation), polytraumaschluessel (PTS) 34+/-19, and APACHE II 14+/-7. During their ICU-stay 16 patients died, 9 (56%) from TBI. Single-organ-failure occurred in n=69 patients (24%, mortality 5%), two-organ-failure in n=22 (8%, mortality 14%), and MOF in n=9 (3%, mortality 13%); one patient died from MOF 14 days after trauma. The number of days on mechanical ventilation increased depending on the number of organs failed (R=0.618, p0.001). Seven patients (2%) fulfilled ARDS criteria for longer than 24h despite optimized ventilatory settings, one died of irreversible shock. Patients with MOF had a significantly increased ICU-LOS (35+/-15 days) compared to patients without organ failure (11+/-11 days; p0.001).The low incidence of MOF in our series of trauma patients suggests that MOF may be prevented in some patients by implementation of lung-protective strategies. The improved outcome was associated with an increased ICU-LOS.

To determine whether glycemic control is less feasible when hydrocortisone is given as a bolus compared with continuous application in septic shock patients. Observational prospective pilot study. Fourteen-bed surgical university hospital ICU. Sixteen consecutive patients with septic shock receiving a continuous infusion of 200 mg hydrocortisone/day and an infusion regime of insulin keeping blood glucose below 150 mg/dl. Blood glucose and insulin infusion were adjusted to steady state before intervention. At baseline, the continuous hydrocortisone infusion was replaced with a single bolus of 50 mg hydrocortisone. During a subsequent 6-h period, blood glucose was monitored hourly and insulin infusion was kept constant. Afterwards, hydrocortisone application and adjustment of blood glucose was resumed according to standard treatment. Mean blood glucose in steady state at baseline immediately prior to intervention was 128 mg/dl (range 114–141 mg/dl; 95% confidence interval). After bolus injection of hydrocortisone, blood glucose increased significantly within 6 h with peak levels of 154 mg/dl (range 132–178 mg/dl; p

Critical illness polyneuropathy/myopathy (CIP/CIM) is frequently described in critically ill patients who survive severe sepsis. Clinically relevant paresis is major symptom of CIP/CIM. We aimed at determining risk factors and diagnostic value of electrophysiologic testing for CIP/CIM in patients with acute respiratory distress syndrome (ARDS).Single-center, retrospective analysis, using charts.University medical center.Fifty consecutive ARDS patients in our intensive care unit.Patient characteristics and clinical course were analyzed. All patients received early electrophysiologic testing. CIP/CIM was diagnosed by the presence of clinical relevant paresis.Clinically relevant paresis was confirmed in 27 ARDS patients (60%), whereas in 18 patients no paresis was determined (controls); five patients died before clinical assessment of paresis was feasible. Patients with paresis were older, had more days on mechanical ventilation, and had increased intensive care unit length of stay compared with controls. Patients who developed paresis had elevated daily peak blood glucose levels during 28 days of intensive care unit treatment: 166 (134, 200) mg/dL in CIP/CIM patients vs. 144 (132, 161) mg/dL in controls (median, quartiles). Twenty-five of 27 patients with paresis revealed reduced motor unit potentials, fibrillation potentials, or positive sharp waves on early electrophysiologic testing indicating CIP/CIM, whereas 16 of 18 control patients did not.In ARDS patients, paresis is a frequent complication causing prolonged mechanical ventilation and intensive care unit length of stay. An association between hyperglycemia and CIP/CIM has been found. However, since this is a retrospective survey, a causal relation is not clearly supported. In this study, the use of early electrophysiologic testing in ARDS patients was a valuable diagnostic tool for detecting CIP/CIM.

Summary Background: In this study we compare the postoperative pain relief for inguinal herniotomy in children provided by instillation of bupivacaine into the wound with that provided by a caudal block. Methods: Fifty-eight children aged 0–5 years having elective unilateral hernia repair were studied in this prospective, randomized, single-blind study. Anaesthesia was induced and maintained with oxygen, nitrous oxide, sevoflurane and propofol. Patients were randomly assigned to receive caudal analgesia with 1.0 ml·kg−1 body weight (BW) bupivacaine 0.25% or wound instillation with 0.2 ml·kg−1 BW bupivacaine 0.5% at the end of surgery. Pain was assessed over 24 h using a modified 10-point objective pain scale. During the first postoperative hour in the postanaesthesia care unit (PACU), intravenous (i.v.) piritramide (0.05 mg·kg−1) was administered to any child scoring 5 or more points on the pain scale. On the ward, rectal acetaminophen was administered by a staff nurse when considered necessary. Results: Thirty children in the caudal group and 28 children in the wound instillation group were studied. There were no statistically significant differences between the groups regarding need for i.v. opioids, discharge time from the PACU and administration of acetaminophen. No statistically significant differences in postoperative pain score were observed in 16 of a total of 17 postoperative observations. No complications and no adverse effects were observed. Conclusion: Instillation of bupivacaine into a wound provides postoperative pain relief following hernia repair, which is as effective as that provided by a postoperative caudal block.

Within the last few years, increasing evidence of relative adrenal insufficiency in septic shock evoked a reassessment of hydrocortisone therapy. To evaluate the effects of hydrocortisone on the balance between proinflammatory and antiinflammation, 40 patients with septic shock were randomized in a double-blind crossover study to receive either the first 100 mg of hydrocortisone as a loading dose and 10 mg per hour until Day 3 (n = 20) or placebo (n = 20), followed by the opposite medication until Day 6. Hydrocortisone infusion induced an increase of mean arterial pressure, systemic vascular resistance, and a decline of heart rate, cardiac index, and norepinephrine requirement. A reduction of plasma nitrite/nitrate indicated inhibition of nitric oxide formation and correlated with a reduction of vasopressor support. The inflammatory response (interleukin-6 and interleukin-8), endothelial (soluble E-selectin) and neutrophil activation (expression of CD11b, CD64), and antiinflammatory response (soluble tumor necrosis factor receptors I and II and interleukin-10) were attenuated. In peripheral blood monocytes, human leukocyte antigen-DR expression was only slightly depressed, whereas in vitro phagocytosis and the monocyte-activating cytokine interleukin-12 increased. Hydrocortisone withdrawal induced hemodynamic and immunologic rebound effects. In conclusion, hydrocortisone therapy restored hemodynamic stability and differentially modulated the immunologic response to stress in a way of antiinflammation rather than immunosuppression.

A case of a premature infant with tracheal atresia together with an exceptional combination of congenital abnormalities that partially corresponds to the TACRD and VACTERL associations is presented. Tracheal atresia was not detectable in the prenatal ultrasound due to lacking of the typical diaphragmatic and pulmonary findings because of the esophago-tracheal fistula, and therefore the resuscitation team was not prepared for this severe airway complication. After prolonged resuscitation efforts were terminated and the newborn expired after birth. Even without typical warning signs physicians have to be aware of tracheal atresia and airway obstruction if VACTERL or TACRD associations are diagnosed.

Importance Adjunctive hydrocortisone therapy is suggested by the Surviving Sepsis Campaign in refractory septic shock only. The efficacy of hydrocortisone in patients with severe sepsis without shock remains controversial. Objective To determine whether hydrocortisone therapy in patients with severe sepsis prevents the development of septic shock. Design, Setting, and Participants Double-blind, randomized clinical trial conducted from January 13, 2009, to August 27, 2013, with a follow-up of 180 days until February 23, 2014. The trial was performed in 34 intermediate or intensive care units of university and community hospitals in Germany, and it included 380 adult patients with severe sepsis who were not in septic shock. Interventions Patients were randomly allocated 1:1 either to receive a continuous infusion of 200 mg of hydrocortisone for 5 days followed by dose tapering until day 11 (n = 190) or to receive placebo (n = 190). Main Outcomes and Measures The primary outcome was development of septic shock within 14 days. Secondary outcomes were time until septic shock, mortality in the intensive care unit or hospital, survival up to 180 days, and assessment of secondary infections, weaning failure, muscle weakness, and hyperglycemia (blood glucose level >150 mg/dL [to convert to millimoles per liter, multiply by 0.0555]). Results The intention-to-treat population consisted of 353 patients (64.9% male; mean [SD] age, 65.0 [14.4] years). Septic shock occurred in 36 of 170 patients (21.2%) in the hydrocortisone group and 39 of 170 patients (22.9%) in the placebo group (difference, −1.8%; 95% CI, −10.7% to 7.2%; P = .70). No significant differences were observed between the hydrocortisone and placebo groups for time until septic shock; mortality in the intensive care unit or in the hospital; or mortality at 28 days (15 of 171 patients [8.8%] vs 14 of 170 patients [8.2%], respectively; difference, 0.5%; 95% CI, −5.6% to 6.7%; P = .86), 90 days (34 of 171 patients [19.9%] vs 28 of 168 patients [16.7%]; difference, 3.2%; 95% CI, −5.1% to 11.4%; P = .44), and 180 days (45 of 168 patients [26.8%] vs 37 of 167 patients [22.2%], respectively; difference, 4.6%; 95% CI, −4.6% to 13.7%; P = .32). In the hydrocortisone vs placebo groups, 21.5% vs 16.9% had secondary infections, 8.6% vs 8.5% had weaning failure, 30.7% vs 23.8% had muscle weakness, and 90.9% vs 81.5% had hyperglycemia. Conclusions and Relevance Among adults with severe sepsis not in septic shock, use of hydrocortisone compared with placebo did not reduce the risk of septic shock within 14 days. These findings do not support the use of hydrocortisone in these patients. Trial Registration clinicaltrials.gov Identifier:NCT00670254

Background Supraglottic airway devices are increasingly used in anaesthesia and emergency medicine. This study was designed to investigate the oesophageal seal of the novel supralaryngeal airway device, I-Gel™ (I-Gel), in comparison with two of the laryngeal mask airways, Classic™ (cLMA) and ProSeal™ (pLMA), in a model of elevated oesophageal pressure. Methods The three supralaryngeal airway devices were inserted into eight unfixed cadaver models with exposed oesophagi that had been connected to a water column producing both a slow and a fast oesophageal pressure increase. The pressure applied until the loss of oesophageal seal during a slow and fast pressure increase was measured. Results During the slow increase of pressure, the pLMA withstood an oesophageal pressure up to a median of 58 cm H 2 O, while the cLMA was able to block the oesophagus up to a median of 37 cm H 2 O, and I-Gel already lost its seal at 13 cm H 2 O. One minute after maximum pressure had been applied, the pLMA withstood an oesophageal pressure of 59 cm H 2 O, the cLMA of 46 cm H 2 O, and I-Gel airway of 21 cm H 2 O. A fast release of oesophageal fluid was accomplished through the oesophageal lumen of both the pLMA and I-Gel. Conclusions Both the pLMA and cLMA provided a better seal of the oesophagus than the novel I-Gel airway. The pLMA and I-Gel drain off gastrointestinal fluid fast through the oesophageal lumen. Thus, tracheal aspiration may be prevented with their use. Further study is necessary.

After a road traffic accident a pregnant patient at 34 weeks of gestation developed ARDS following blunt chest trauma, for which she required mechanical ventilation. Twenty-four hours after the accident, ongoing severe hypoxaemia with atelectasis mainly in the dorsal parts of the lung led to the decision to manage the patient in the prone position. Prone positioning over 8h resulted in a persistent improvement of oxygenation, which allowed extubation the following day. At term, however, our patient was admitted with dyspnoea, chest pain, haemodynamic instability and fetal bradycardia, for which she required emergency caesarean section followed by thoracotomy for haemothorax, from which she eventually made a full recovery. We have demonstrated that prone positioning can be used safely and effectively in a pregnant patient. It might be superior to other therapeutic options for improvement of oxygenation in pregnant patients. Careful positioning avoiding any external abdominal pressure and continuous fetal monitoring are mandatory.

BACKGROUND:Supraglottic airway devices are increasingly important in clinical anesthesia and prehospital emergency medicine, but there are only few data to assess the risk for aspiration. We designed this study to compare the seal of seven supraglottic airway devices in a cadaver model of elevated esophageal pressure. METHODS:The classic laryngeal mask airway, laryngeal mask airway ProSeal™, intubating laryngeal mask airway Fastrach™, laryngeal tube™, laryngeal tube LTS II™, Combitube™, and Easytube™ were inserted into unfixed human cadavers with an exposed esophagus that had been connected to a water column of 130 cm height. Slow and fast increases of esophageal pressure were performed and the water pressure at which leakage appeared was registered. RESULTS:The Combitube, Easytube, and intubating laryngeal mask Fastrach withstood the water pressure up to more than 120 cm H 2 O. The laryngeal mask airway ProSeal, laryngeal tube, and laryngeal tube LTS II were able to block the esophagus until 72‐82 cm H 2 O. The classic laryngeal mask airway showed leakage at 48 cm H 2 O, but only minor leakage was found in the trachea. Devices with an additional esophageal drain tube drained fluid sufficiently without pulmonary aspiration. CONCLUSIONS:Concerning the risk of aspiration, the use of devices with an additional esophageal drainage lumen might be superior for use in patients with an increased risk of aspiration. The Combitube, Easytube, and intubating laryngeal mask Fastrach showed the best capacity to withstand an increase of esophageal pressure. (Anesth Analg 2008;106:445‐8)