Lower Intubation Rate Research Articles

Versorgungsrealität auf der Basis der Daten des TraumaRegister DGU®

The Trauma Registry of the German Society for Trauma Surgery (TR-DGU) has documented diagnostics, treatment and outcome of severely injured patients since 1993. In 2009 it became the obligatory tool for quality assessment in the regional trauma networks (TraumaNetzwerk DGU). During that time period many things changed, and data from the TR-DGU could be used to monitor these changes. For example, the time from accident until hospital admission, which is about 70 min, has not changed in recent years. Conversely, major trends were observed regarding a reduced amount of preclinical volume and, in conscious patients, a lower intubation rate. In the acute care hospital whole-body CT is used in nearly all hospitals and has contributed to the fact that the mortality rate today is 2-3% lower than a decade ago.

Postoperative Noninvasive Ventilation

Thesemodificationsoftherespiratoryfunctionoccur early after surgery and are more often transient andcould lead to ARF. The clinical result (severity of theARF) is the product of perioperative-related ventilatoryimpairment and severity of the preoperative pulmonarycondition. Maintenance of adequate oxygenation in thepostoperative period is of major importance, especiallywhen pulmonary complications such as ARF occur. Al-though invasive endotracheal mechanical ventilation hasremained the cornerstone of ventilatory strategy for manyyearsforsevereARF,severalstudieshaveshownthatmor-tality associated with pulmonary disease is largely relatedto complications of postoperative reintubation and me-chanicalventilation.Therefore,majorobjectivesforanes-thesiologists are first to prevent the occurrence of postop-erative complications and second to ensure oxygenadministration and carbon dioxide removal while avoid-ing intubation if ARF occurs. Noninvasive ventilation(NIV) does not require an artificial airway (endotrachealtube or tracheotomy), and its use is well established toprevent ARF occurrence (prophylactic treatment) or totreat ARF to avoid reintubation (curative treatment) (fig.1). Studies show that patient-related risk factors, such aschronic obstructive pulmonary disease, age older than 60yr, American Society of Anesthesiologists class of II orhigher, obesity, functional dependence, and congestiveheart failure, increase the risk for postoperative pulmo-nary complications.

The Robotic Colonoscope E-Worm, a New Device to Perform Colonoscopy: Preliminary Report

Colorectal tumor is the second cause of neoplastic mortality in males after lung cancer, and ranks the same in female after breast cancer. Among screening procedures conventional colonoscopy is considered the best available method, however it is invasive, it's associated with procedural risks, usually needs conscious sedation or even deep sedation. The E-Worm is a new medical device for the diagnostic colonoscopy, it is the result of an italian academic research in the field of robotic biomimetics, it moves like a worm using two specific clampers for adhesion with intestinal mucosa. The light sources (LEDS) and the videocamera are inserted in the head of the E-Worm. This allows a live vision on the screen of the workstation like a normal colonoscope. The unique locomotion system with outstanding flexibility, able to follow every type of tree-dimensional shape, gives a new opportunity for a painless colonoscopy procedure. The flexibility together with the low force required to move the probe reduces the risk of any perforation. The Authors present their fist experience in performing colonoscopies using this new colonoscope. From December 2007 to November 2008 we performed 37 colonoscopies with the E-Worm. Patients were prepared with PEG as conventional colonoscopy. Cecal intubation was possible in 15 cases (40%), ileal exploration was performed in 1 patient with crohn's disease (2%). The right colon was reached in other 7 patients (19%). No patients needed sedation. No complications occurred. Pathologies were found in 19 pts (51%). Evaluating the first 20 pts with the last 17 we saw an increase of cecal intubation rate from 35% to 48%. In spite of a lower definition resolution of endoscopic picture, the diagnostic yield was good, comparable to conventional colonoscopy. Our preliminary experience demonstrates that this new colonoscope allows good diagnostic procedures without any need of sedation. In our opinion the low cecal intubation rate could be related to the learning curve.

A response to ‘Incidence and outcome of critical illness amongst hospitalised patients with haematological malignance: a prospective observational study of ward and intensive care unit based care’

I read with interest the study by Gordon and colleagues [1] on the outcome of critical illness in patients with haematological malignancy. Having worked in a large haemato-oncology centre before joining the anaesthetic ranks I was glad to see this study. I strongly agree with authors and their comments on provision of intermediate or high dependency care on the haematology ward and the importance of critical care outreach. The authors note the low hospital mortality in their study population. This may be a reflection of their low intubation rate or time-lead bias, as they were likely to pick up their critically ill patients more readily, but it may also reflect the authors' increasing experience in managing this difficult group of patients. It has been demonstrated, in a similar group of patients, that with increasing experience, ITU mortality falls [2]. It would be interesting to know the admission and mortality rates of haematology patients over past few years for the intensive care unit involved in the study. The volume of cases that the authors clearly have to deal with is significant enough to allow for the learning process to occur, thus improving patient outcomes. Finally, again stressing the importance of outreach teams, I'd be keen to know the timing of the referral to ITU and whether the outreach team assistance was offered straight away if decision was made not to admit the patient to ITU. Among patients with critical illness how many were diagnosed ‘out-of-hours’ and what proportion of those went on to receive care on ITU? Was mortality in any way related to the time of diagnosis of critical illness? These issues are relevant, especially in hospitals where experience with such patients is limited. Often critically ill haematology patients are deemed not salvageable, especially when discussed over the phone with the ITU gatekeepers, by staff with less experience.

Changes in Resuscitation Practice at Birth

The investigators, in the course of an ongoing monitoring program, prospectively collected information on neonatal resuscitation covering 17,885 infants born in a 4-year period in 1993 through 1997. In early 1995, T-piece circuits and facemasks were introduced in the maternity unit, and all medical and midwifery staff received practical training in their use. After 6 months, the previously used 500-mL self-inflating bags and masks were removed. Mean maternal age increased by approximately 6 months during the period under study. Forceps deliveries and cesarean sections (elective and emergency) declined significantly, whereas ventouse extractions and vaginal deliveries through meconium increased. Although medical staff electively attended progressively fewer deliveries during the 4-year study period, the number of infants seen after delivery by a pediatrician did not change significantly. Rates of early neonatal encephalopathy and meconium aspiration syndrome did not change significantly, but neonatal convulsions became markedly less frequent. The intubation rate fell significantly throughout the study period. The crude rate of endotracheal intubation fell 51%, and that of ventilatory resuscitation by any method decreased from 11% to 8.9%. The proportion of infants who received ventilatory support at birth but were not intubated rose from 76% to 86%. Intubation rates declined for infants of 30 weeks gestation and above. Rates of mask ventilation and intubation were 3.7% and 0.6%, respectively, for infants born by normal vaginal delivery. In contrast, 8.3% of infants born by elective cesarean section and 19.1% of those born by emergency section received mask ventilation. There was no independent association between the advent of T-piece ventilation and a lower intubation rate. No consistent change in 5-minute Apgar scores was evident during the period under review. Intubation rates fell substantially in this population with no decline in neonatal status. T-piece ventilation appears to be an effective and safe alternative to bag-valve-mask ventilation for resuscitating newborn infants. Education in the use of noninvasive airway support could help account for declining rates of intubation.

Factors that predict incomplete colonoscopy

PURPOSE AND METHODS: Certain factors in a patient's history, such as prior abdominal surgery or complicated diverticular disease, have been reported to hinder cecal intubation during colonoscopy. Over a 16-month period, 1,047 consecutive colonoscopies were prospectively evaluated to determine whether these factors were indeed clinically relevant. RESULTS: Of the 90 patients (9 percent) who had incomplete intubation of the colon, there were significantly more women (66 percent) than men (34 percent) (P<0.001). Women with a history of abdominal hysterectomy had a significantly lower cecal intubation rate (P< 0.01). A history of diverticulitis did not alter the cecal intubation rate. In patients with incomplete colonic intubation, the most proximal extent of intubation was the sigmoid colon in women (31 percent) and the right colon in men (68 percent). Sixty-seven percent of patients with incomplete intubation of the colon had a prior colonoscopy completed to the cecum (67 percent women, 67 percent men), whereas 50 percent had a follow-up colonoscopy completed to the cecum (56 percent women, 40 percent men). CONCLUSIONS: Women, especially those with a history of abdominal hysterectomy, had a significantly lower cecal intubation rate usually because of an impassable sigmoid colon. Prior inability to complete colonoscopy to the cecum does not necessarily forecast future failure.