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Catecholamine crises associated with pheochromocytoma may cause life-threatening cardiovascular conditions. We report the case of a 75-year-old male who developed a hypertensive crisis during induction of general anesthesia for elective resection of a cervical neuroma due to an undiagnosed pheochromocytoma. Hemodynamic instability occurred immediately after the injection of fentanyl, propofol and rocuronium, prior to laryngoscopy and in the absence of any manipulation of the abdomen. In this case report, we present the management of this incident and discuss the underlying pathophysiology triggering a catecholamine crisis. [ABSTRACT FROM AUTHOR]

Background: Acute normovolemic hemodilution (ANH) is performed with the intention to reduce the requirement for allogeneic blood transfusions. After preoperative withdrawal of whole blood, corresponding amounts of crystalloids and/or colloids are infused to maintain normovolemia. The main benefit of ANH is the availability of whole blood containing red blood cells, clotting factors and platelets for reinfusion after removal during the dilution process. Until retransfusion whole blood components are stored at the patient's bedside in the operating theatre.Aim: It was the aim of the present investigation to analyze potential changes in ex vivo induced platelet aggregation in stored blood components.Material and Methods: After obtaining approval 15 patients undergoing complex cardiac surgery were enrolled into this prospective observational study. Acute normovolemic hemodilution (ANH) was routinely performed in this collective based on institutional standards. Besides analyses of pH and plasma concentrations of ionized calcium and hemoglobin, hematological analyses included aggregometric measurements using multiple electrode aggregometry (MEA, Multiplate®, Roche, Grenzach, Germany). Ex vivo platelet aggregation was induced using arachidonic acid (ASPI test), as well as thrombin receptor activating peptide (TRAP test) and adenosine diphosphate (ADP test). Laboratory analyses were performed before beginning ANH (baseline), as well as immediately (T1), 30 min (T2), 60 min (T3), 90 min (T4), 120 min (T5), 150 min (T6) and 180 min (T7) after beginning of storage. The areas under the aggregation curves (AUC) in the MEA were defined as primary (ASPI test) and secondary endpoints (ADP test, TRAP test).Results: As compared to baseline, arachidonic acid induced platelet aggregation was significantly reduced at T1 [77 U (68/94 U) vs. 53 U (25/86 U), p = 0.003] and each consecutive measuring point. As compared to T1 (begin of storage), arachidonic acid induced platelet aggregation was significantly reduced at T4 [26 U (14/54 U); p = 0.002], T5 [30 U (21/36 U); p = 0.007], T6 [25 U (17/40 U); p = 0.004] and T7 [28 U (17/39 U); p < 0.001]. The extent of ex vivo induced platelet aggregation in the TRAP test and ADP test remained unchanged during the study period. The pH as well as the concentrations of ionized calcium and hemoglobin remained unchanged in the blood component during storage.Conclusion: The results of the present study indicate that disturbances of platelet aggregation may occur during storage of whole blood components prepared for the purpose of ANH. Further investigations are needed to analyze whether the observed phenomena are of hemostatic relevance. [ABSTRACT FROM AUTHOR]

During perioperative treatment of coagulopathic patients the so-called Point-of-Care (POC) analyses enable more rapidly available and more comprehensive hemostatic analyses compared to routinely performed conventional coagulation testing, such as activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen concentration and platelet count. In this review article a hemotherapy algorithm is presented which is based on viscoelastic and aggregometric POC measurements. The algorithm was designed double sided and consists of a general and a special part. The general part contains boxes and fields for sociodemographic data and gives general recommendations for coagulation management and therapy specifications for particular patient collectives and presents proposals for emergency reversal of anticoagulation therapy. The special part refers to basic physiological conditions for hemostasis and asks for measurement results of clot initiation, clot firmness, clot stability and platelet function analyses. Reference values were defined for each parameter and therapeutic options are presented. In cases of persistent coagulopathy despite algorithm-conform therapy, the algorithm could be run through once again. Finally, the algorithm presents therapeutic options for an ultima ratio therapy approach. [ABSTRACT FROM AUTHOR]

Background: Securing the airway with supraglottic airway devices, such as a laryngeal tube, is a regular component of most difficult airway management algorithms. It is further recommended that in emergency medicine rescuers less skilled in endotracheal intubation should use supraglottic airways as a first line device. Exchanging the laryngeal tube with an endotracheal tube can be performed with video-assisted laryngoscopy as described below.Material and Methods: A total of 20 adult patients with airways managed using laryngeal tubes due to actual or anticipated difficult intubation underwent endotracheal intubation using the C-MAC videolaryngoscope. After deflating the cuffs of the laryngeal tube, seeking out the glottis was done by following the constructional landmarks of the laryngeal tube, considering concordance with anatomical landmarks of the human airway. In cases of failed video-assisted endotracheal intubation, the laryngeal tube that was still in situ was reinflated to re-establish ventilation of the lungs.Results: In 19 out of the 20 patients the laryngeal tube could be exchanged for an endotracheal tube with the video-assisted technique described. In one patient no laryngeal structures could be identified (Cormack and Lehane grade IV) even with the C-MAC videolaryngoscope and ventilation was continued via the laryngeal tube. No complications related to the video-assisted intubation technique were observed.Conclusions: The C-MAC videolaryngoscope is a mobile system which facilitates endotracheal intubation in patients with a difficult airway and a laryngeal tube in place. It is not only possible but recommended to leave the laryngeal tube in situ as a back-up when videolaryngoscopy fails. [ABSTRACT FROM AUTHOR]

Objective: The European Resuscitation Council recommends that only rescuers experienced and well-trained in airway management should perform endotracheal intubation. Less trained rescuers should use alternative airway devices instead. Therefore, a concept to train almost 1,100 emergency physicians (EP) and emergency medical technicians (EMT) in prehospital airway management using the disposable laryngeal tube suction (LTS-D) is presented.Methods: In five operational areas of emergency medicine services in Germany and Switzerland all EPs and EMTs were trained in the use of the LTS-D by means of a standardized curriculum in the years 2006 and 2007. The main focus of the training was on different insertion techniques and LTS-D use in children and infants. Subsequently, all prehospital LTS-D applications from 2008 to 2010'were prospectively recorded.Results: None of the 762 participating EMTs and less than 20% of the EPs had previous clinical experience with the LTS-D. After the theoretical (practical) part of the training, the participants self-assessed their personal familiarity in using the LTS-D with a median value of 8 (8) and a range of 2-10 (range 1-10) of 10 points (1: worst, 10: best). Within the 3-year follow-up period the LTS-D was used in 303 prehospital cases of which 296 were successfully managed with the device. During the first year the LTS-D was used as primary airway in more than half of the cases, i.e. without previous attempts of endotracheal intubation. In the following years such cases decreased to 40% without reaching statistical significance. However, the mean number of intubation attempts which failed before the LTS-D was used as a rescue device decreased significantly during the study period (2008: 2.2 ± 0.3; 2009: 1.6 ± 0.4; 2010: 1.7 ± 0.3).Conclusion: A standardized training concept enabled almost 1,100 rescuers to be trained in the use of an alternative airway device and to successfully implement the LTS-D into the prehospital airway management algorithm. Because the LTS-D recently became an accepted alternative to endotracheal intubation in difficult airway scenarios, the number of intubation attempts before considering an alternative airway device is steadily decreasing. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to assess ex-vivo function of pathogen-inactivated versus conventional platelet concentrates (PC) in the perioperative setting. Material and methods: A total of 30 patients who underwent cardiac surgery and who postoperatively depended on the transfusion of two platelet concentrates were enrolled into this study. Of the patients 15 received conventional buffy coat PC (conv. PC) and 15 received pathogen-inactivated PC (PI-PC). Age, volume and platelet content of each PC were recorded. Before (T0) and 30 min after PC transfusion (T1), blood samples were taken and platelet function analyses (MEA) and conventional laboratory coagulation analyses were performed. The transfusion-associated increment of platelet concentration (increment) and the corrected count increment (CCI) were assessed at timepoint T1. Results: There were no significant group differences between the groups in MEA analyses or conventional laboratory at T0 or T1. The platelet content per PC was significantly higher in the PI-PC group [3.3 (3.1/3.5)× 10 platelets per PI-PC versus 3 (2.9/3)× 10 platelets per conv. PC, p<0.001]. Platelet increment (42±27×10/l versus 69.4±29×10/l, p=0.013) was significantly lower in the PI-PC group. Conclusion: Whereas ex-vivo analyses of platelet function did not show any group differences at T1, a significantly lower increment was seen in the pilot study after transfusion of PI-PC as compared to conventional PC. [ABSTRACT FROM AUTHOR]

Background: The goal of the present study was to evaluate the publication rate of abstracts presented during the German Anesthesia Congress (Deutscher Anästhesiecongress, DAC) and the meeting of the European Society of Anesthesiologists (ESA) in the years 2000 and 2005 in Medline listed journals (http://www.ncbi.nlm.nih.gov/pubmed). In addition, the respective impact factors of the journals in which the articles were published were evaluated (http://www.isiknowledge.com).Methods: All abstracts of free papers and posters presented at the DAC and ESA from the years 2000 and 2005 were included into the study. The presence of authors and the topics of abstracts in the literature were analyzed by a Medline based inquiry over a time period of 5 years. The search was based on the last name and initials of authors and when these could not be identified in Medline the search was extended by keywords of relevant topics of the abstract. Umlauts "ä/ö/ü" were replaced by "ae/oe/ue" and "ß" was replaced by "ss". Only original papers were included in this analysis. Once an original paper was found the impact factor of the journal in that year was identified.Results: A total of 465 abstracts from the DAC 2000, 378 abstracts from the DAC 2005, 644 abstracts from the ESA 2000 and 720 abstracts from the ESA 2005 were included. Of the abstracts from the DAC 2000, 183 (39%) were published in Medline listed journals, 179 (47%) from DAC 2005, 218 (34%) from ESA 2000 and 233 (32%) from ESA 2005. The ESA abstracts were published in English more often than the DAC abstracts (ESA 2000: 95%; ESA 2005: 95%; DAC 2000: 78%; DAC 2005: 86%). While the publication rate after the ESA remained nearly unchanged between 2000 and 2005, the publication rate after the DAC increased by about 7%. The average impact factors of the publications were 1.777 (DAC 2000), 2.836 (DAC 2005), 1.825 (ESA 2000) and 2.36 (ESA 2005). Independent of the congress (DAC or ESA) where the abstract was presented, most articles were published in the journal Anesthesia & Analgesia.Conclusion: In the year 2005 more abstracts of the DAC were published in Medline listed papers than in 2000. When comparing the number of abstracts published in Medline listed journals, more abstracts of the DAC were published compared to abstracts of the ESA. The increase in papers written in English after abstract presentation on the DAC is mostly due to the wider readership which can be reached with manuscripts in the English language. Besides a larger readership, English journals often also have a higher ranked impact factor. This analysis does not claim to be a complete registration of all published abstracts due to the limitation on Medline listed journals and publications in other journals were not rated. Medline was selected because of the widespread and international use of this database. [ABSTRACT FROM AUTHOR]

Background: Previous studies have shown that video laryngoscopy enhances laryngeal view in patients with apparently normal and difficult airways. The utility of the novel, portable, battery-powered C-MAC video laryngoscope is as yet unproven. It was hypothesized that in routine patients undergoing ENT surgery, the rate of glottic views considered unsatisfactory, i.e. Cormack and Lehane grades IIb, III, and IV, could be significantly reduced with the C-MAC video laryngoscope compared to direct laryngoscopy.Methods: Following ethical approval and sample size estimates 108 consecutive patients undergoing ENT surgery under general anesthesia were studied. First, direct laryngoscopy was performed with the naked eye. The best view obtained was graded by the first anesthesiologist without looking at the video monitor. A second anesthesiologist blinded to the laryngeal view obtained under direct laryngoscopy graded the laryngeal view on the video monitor. Endotracheal intubation using Ring-Adair-Elwyn (RAE) tracheal tubes was then attempted under video-aided visualization. The tubes were not reinforced with a stylet. The C-MAC video laryngoscopy system (Karl Storz, Tuttlingen, Germany) is a novel device that can be used with Macintosh laryngoscope blades in different sizes. A camera and light source are located recessed from the tip of the blade. The camera unit sits in a handle attached to the laryngoscope blade and is connected by a wire to a TFT video monitor. It allows for both direct and indirect laryngoscopy and the low profile of the original British Macintosh blades may prove advantageous in patients with limited mouth opening.Results: A total of 108 patients were enrolled in the study but for various reasons only 94 completed the study (post hoc power 97%). In 89 patients a size 3 Macintosh laryngoscope was used while a size 4 blade was used in the remaining 5 patients. With direct laryngoscopy the glottic view was considered unsatisfactory in 40 patients (42%), but this was the case in only 15 patients (16%) when video laryngoscopy was used (p<0.0001). Endotracheal tube placement was successful in all but one patient where the Bonfils intubation fiberscope needed to be employed. No complications related to the C-MAC system were observed.Conclusions: Compared to direct laryngoscopy with a Macintosh laryngoscope blade in unselected patients undergoing ENT surgery and thus patients more susceptible to an unexpected difficult airway than a general patient population, the mobile C-MAC video laryngoscope significantly enhanced laryngeal view. Using RAE tracheal tubes seems to compensate the unfavorable deviation of optical and anatomical axes when indirect laryngoscopy is performed with the C-MAC system. [ABSTRACT FROM AUTHOR]

Increased intra-operative and postoperative blood loss might be caused by acquired platelet function disorders. In particular because conventional coagulation analyses and platelet count fail to detect impaired platelet function, implementation of bedside-tests for platelet function in the peri-operative period is desirable according to the results of retrospective studies. Following adequate adjustment of basic conditions of haemostasis (e.g. temperature, pH, Ca2+-concentration, haematocrit) a pharmacological approach with desmopressin (1-desamino-8-d-arginine vasopressin; DDAVP) or tranexamic acid potentially represents a low cost alternative to platelet transfusions with minor side effects. [ABSTRACT FROM AUTHOR]

Besides severe cerebral trauma, abdominal bleeding is the most frequent cause of death after multiple trauma. Abdominal bleeding is difficult to diagnose because initially at the scene a multiply injured patient with a stable circulation is often encountered. Ultrasound diagnostics have played a central role in the diagnostics of emergency patients for many years. This technique is used both in the emergency room and in the intensive care unit, in the operation center and to an increasing extent in emergency diagnostics during the pre-hospital setting. The following article deals with the ultrasound investigation of injured patients, the indications and examination technique are described, as well as the specific characteristics of using ultrasound at the scene. Finally, device-specific characteristics and the state of development in Germany are presented. [ABSTRACT FROM AUTHOR]