Turkish journal of anaesthesiology and reanimation, 2018
Some anaesthetists are convinced that a long interval since the last relaxant dose may be suffici... more Some anaesthetists are convinced that a long interval since the last relaxant dose may be sufficient to recover from anaesthesia without a pharmacological reversal. We intended to demonstrate that the dosing pattern of rocuronium could not predict the necessity of reversal. In a cohort analysis, we retrospectively analysed 180 anaesthesia records of adult patients who underwent elective surgical interventions in general anaesthesia and tracheal intubation with rocuronium-induced neuromuscular blockade. The extracted records were divided to 3 post hoc groups of 60 each, according to the reversal method employed at the end of anaesthesia: group N with neostigmine, group S with sugammadex and group Z without pharmacological reversal. All cases were terminated after achieving a train of four ratio of 0.9. Dosing patterns of rocuronium were compared by applying a novel pharmacometric calculation method, residual drug activity coefficient (RDAC), which employs both the administered indivi...
Romanian journal of anaesthesia and intensive care, 2018
Videolaryngoscopes can be fitted either with channeled or non-channeled blades, which may result ... more Videolaryngoscopes can be fitted either with channeled or non-channeled blades, which may result in a different performance and success of tracheal intubation. We investigated the characteristics of the two different blade types of the commercially available KingVision™ videolaryngoscope. A prospective, randomized, single center investigation study in a urological operation unit of a tertiary hospital. Forty adult patients undergoing elective urological surgery in general anaesthesia with tracheal intubation were randomly allocated into group 1 (channeled videolaryngoscopy, n = 20) and group 2 (non-channeled videolaryngoscopy, n = 20). We measured the times from laryngoscope insertion to recognize the glottis and to conclude tracheal intubation. The number of laryngoscopy/intubation attempts and the degree of visual glottis exposure on a visual analog scale from 0 (glottis not visible) to 10 (glottis fully visible) was assessed. The lowest SpO value during airway management was reco...
Fatigue in multiple sclerosis is a very common and cumbersome symptom, but its aetiology is poorl... more Fatigue in multiple sclerosis is a very common and cumbersome symptom, but its aetiology is poorly understood. Proteomics is increasingly implemented in multiple sclerosis research, but has not yet been used to study the neurobiological basis of fatigue in multiple sclerosis. To identify potential cerebrospinal fluid biomarkers of fatigue in multiple sclerosis, we collected cerebrospinal fluid of 20 patients with multiple sclerosis with fatigue (MS+), 20 patients with multiple sclerosis without fatigue (MS-), and 20 control subjects without multiple sclerosis and without fatigue (HC). We used a shotgun proteomics approach and label-free quantitative proteomics to analyse the protein content in cerebrospinal fluid. Selected proteins with differential abundance were further validated by immunoblotting. Out of 591 detected cerebrospinal fluid proteins, the abundance of nine proteins differed between the three groups, and seven additional proteins differed between MS+ and MS- patients. ...
Romanian journal of anaesthesia and intensive care, 2015
To evaluate the patients' baseline condition upon arrival in the PACU as a method of assessme... more To evaluate the patients' baseline condition upon arrival in the PACU as a method of assessment of the quality of anaesthesia, and to establish a model for future comparisons. Prospective observational study. Surgical PACU in an academic tertiary hospital. All patients (n = 11,241) arriving in our hospital's recovery units after elective surgery. In this observational study, clinical data, vital signs and comfort parameters were collected from surgical patients who arrived in the PACU. For each parameter, its frequency distribution or percentage of occurrence was determined. The incidence of anaesthesia associated side effects such as hypoxemia, cold extremities, shivering and/or vomiting was 5%. The incidence of nausea, sore throat, headache and/or pruritus was 9%. Sore throat occurred in 4.8% of intubated patients, in 4% after laryngeal mask insertions and in 3.6% with no usage of any airway device. From all patients 48% had no pain at all (VAS = 0), 31% had low pain score...
Turkish journal of anaesthesiology and reanimation, 2017
The prediction of difficult airway is one of the most important challenges before general anaesth... more The prediction of difficult airway is one of the most important challenges before general anaesthesia. This study aimed to assess the clinical usefulness of the FRONT score, a recently developed scoring system to predict and document airway difficulties. This multi-centre, inter-observer, prospective and double-blinded study included 976 patients from two university centres. The pre-operative evaluation of the patients was performed by a pre-operative team of anaesthesiologists (team A) who evaluated and scored the expected difficulty of airway management. An intra-operative team of evaluators (team B) working independently of team A, performed the actual instrumentation of the airway and scored the actual findings. Both teams used the FRONT scoring system and worked independently of each other to ensure blinded assessments. The statistical analysis of the pre- and intra-operative FRONT scores was performed in an off-line blinded manner. Our results show a fair and promising associa...
Successful and sustainable training and learning of the management of difficult and normal airway... more Successful and sustainable training and learning of the management of difficult and normal airway is essential for all clinically active anesthesiologists. We emphasize the importance of a continuously updated learning and training environment based on actual knowledge, best available equipment, standardized procedures, and educational theory. In the past, most of the training were based on 'learning by doing' under the supervision of superiors or experienced colleagues. This has been recognized as insufficient and training has evolved to its recent level by structuring it into technical, methodological, and behavioral components. Additionally, a large part of it has been shifted away from learning on patients to simulated scenarios in designated environments. The contents, structure, components, and succession of components have been refined according to the steadily evolving and available instruments. Increasingly, team interaction and behavioral aspects gained more attent...
Turkish journal of anaesthesiology and reanimation, 2017
World Health Organization and the United States Center for Disease Control have recently recommen... more World Health Organization and the United States Center for Disease Control have recently recommended the use of 0.8 FIO2 in all adult surgical patients undergoing general anaesthesia, to prevent surgical site infections. This recommendation has arisen several discussions: As a matter of fact, there are numerous studies with different results about the effect of FIO2 on surgical site infection. Moreover, the clinical effects of FIO2 are not limited to infection control. We asked some prominent authors about their comments regarding the recent recommendations.
Journal of clinical monitoring and computing, Jan 11, 2017
To assess the impact of short time hypnosis for retro-bulbar anesthesia on ventilation in patient... more To assess the impact of short time hypnosis for retro-bulbar anesthesia on ventilation in patients undergoing ophthalmic surgery of the anterior eye chamber. In all patients, a combined continuous transcutaneous carbon dioxide tension (PtcCO2) and partial oxygen saturation (SpO2) measurement was applied in addition to routine monitoring. To enable unconscious application of retro-bulbar anesthesia, intravenous thiopental was given in one to multiple bolus doses. Transient breathing support included chin lift, Esmarch maneuver and manual hand-bag ventilation via face mask. Main endpoints were apnea time, recovery time according to the Richmond Agitation Sedation Scale, as well as SpO2 and PtcCO2 readings at predefined time points. Fifty-two patients with a mean age of 68 ± 13 years were included. Average thiopental dose was 2.7 ± 0.6 mg/kg. In seven (13.5%) patients repeated doses of thiopental were necessary to a total of 3.3 ± 1.1 mg/kg. Except one patient, no severe, significant o...
Turkish journal of anaesthesiology and reanimation, 2017
There is still a lack of a universally applicable and comprehensive scoring system for documentin... more There is still a lack of a universally applicable and comprehensive scoring system for documenting the invasiveness of surgical procedures. The proposed preliminary 'Universal Surgical Invasiveness Score' (pUSIS) is intended to fill this gap. We used the recently developed pUSIS to obtain values from 8 types of surgery and 80 individual interventions. The results were analysed using descriptive statistical methods. The degree of difficulty on a scale from 0 (very easy) to 10 (extremely difficult) and time expenditures for assessing pUSIS were documented. Individual pUSIS values ranged from 8 in a laparoscopic cholecystectomy case to 36 in a total hip replacement case. The lowest median pUSIS value of 11.5 was found for laparoscopic cholecystectomy and the highest value of 24.5 was found for open thoracic surgery. The correlation between pUSIS values and the duration of surgery resulted in a tight linear regression (R2=0.6419). The lowest mean (±SD) difficulty level to obtain...
Recently, an institutional Difficult Intubation Drill has been conceived and started at the Unive... more Recently, an institutional Difficult Intubation Drill has been conceived and started at the University Hospital Zürich, which is intended to sustainably improve the handling of difficult airway situations. The drill consists of a weekly course in the airway management SkillsLab of the university to which all staff members of our department are subjected to participate. The hardware of the drill is a standardized difficult intubation cart consisting of 4 airway rescue techniques arranged in successive drawers that represent also the priority and order of use of these 4 devices: 1. SensaScope®, 2. Fastrach®, 3. laryngeal tube, and 4. transtracheal oxygenation and jet ventilation. This actual choice of devices and techniques represent the actual algorithm for the unexpected failed intubation. Repeated assessments of the educational results and clinical outcome of this airway course will possibly contribute to adaptations and modification of the difficult intubation cart and its clinical use.
In order to perform accurate low-flow anaesthesia ventilation, it is desirable to avoid the influ... more In order to perform accurate low-flow anaesthesia ventilation, it is desirable to avoid the influence of fresh gas flow (FGF) and inspiration duration (ID) on the resulting minute volume (MV). The Sulla 808V anaesthesia ventilator (Draeger, Luebeck, Germany) is originally not equipped with a fresh-gas decoupling (FGD) device. Therefore, changes of FGF and ID settings applied during controlled ventilation may lead to alterations of the resulting MV. Recently, a low-cost FGD device (Carbamed, Bern-Liebefeld, Switzerland) has been developed, which can be inserted into the circle system. We investigated the effect of this device on MV in the Sulla 808V anaesthesia apparatus. The performance of a Sulla 808V anaesthesia ventilator was tested with and without a FGD device. During ventilation of a test lung, stepwise changes of tidal volume (400-1000 ml), FGF (0.5-10 l/min), and ID (0.25-0.5) settings were consecutively applied, and the resulting MV was recorded. Correlation and mean prediction error between ventilation parameter settings and MV were calculated. In the presence of a FGD device, the administered MV was not affected by the magnitude of FGF and ID. A mean prediction error (bias) of -3.6 l/min of the resulting MV was observed. Without FGD the bias was only-1.8 l/min, while FGF and ID revealed a pronounced influence on MV. These effects were statistically significant when using FGF exceeding 4 l/min. The tested FGD device can easily be integrated into the circle system of conventional anaesthesia machines such as the Draeger Sulla 808V, and is available at a reasonable cost. It allows constant ventilation parameters to be maintained that remain unaffected by wide FGF and ID variations. With this FGD the performance of the ventilator can be improved considerably, and low-flow anaesthesia can be used more extensively.
Patients' fears of anesthesia mostly focus on a possibly inadequate anesthetic effect, on pos... more Patients' fears of anesthesia mostly focus on a possibly inadequate anesthetic effect, on postoperative wound pain and/or nausea and vomiting (PONV). Concerning the possibility of an inadequate anesthetic effect, patients usually express two different kinds of fears: first, that they might stay conscious during surgery («Awareness») without it being noticed, and second that they might not wake up again after the operation or that they might sustain neurological damages or deficits after the anesthesia. Last but not least patients are afraid they might suffer from substantial pain after waking up from the anesthesia. In this article we take a closer look at these aspects and discuss ways and possibilities of handling them, suggesting useful approaches for the general practitioner when talking these issues through with his patients prior to an operation.
Turkish journal of anaesthesiology and reanimation, 2018
Some anaesthetists are convinced that a long interval since the last relaxant dose may be suffici... more Some anaesthetists are convinced that a long interval since the last relaxant dose may be sufficient to recover from anaesthesia without a pharmacological reversal. We intended to demonstrate that the dosing pattern of rocuronium could not predict the necessity of reversal. In a cohort analysis, we retrospectively analysed 180 anaesthesia records of adult patients who underwent elective surgical interventions in general anaesthesia and tracheal intubation with rocuronium-induced neuromuscular blockade. The extracted records were divided to 3 post hoc groups of 60 each, according to the reversal method employed at the end of anaesthesia: group N with neostigmine, group S with sugammadex and group Z without pharmacological reversal. All cases were terminated after achieving a train of four ratio of 0.9. Dosing patterns of rocuronium were compared by applying a novel pharmacometric calculation method, residual drug activity coefficient (RDAC), which employs both the administered indivi...
Romanian journal of anaesthesia and intensive care, 2018
Videolaryngoscopes can be fitted either with channeled or non-channeled blades, which may result ... more Videolaryngoscopes can be fitted either with channeled or non-channeled blades, which may result in a different performance and success of tracheal intubation. We investigated the characteristics of the two different blade types of the commercially available KingVision™ videolaryngoscope. A prospective, randomized, single center investigation study in a urological operation unit of a tertiary hospital. Forty adult patients undergoing elective urological surgery in general anaesthesia with tracheal intubation were randomly allocated into group 1 (channeled videolaryngoscopy, n = 20) and group 2 (non-channeled videolaryngoscopy, n = 20). We measured the times from laryngoscope insertion to recognize the glottis and to conclude tracheal intubation. The number of laryngoscopy/intubation attempts and the degree of visual glottis exposure on a visual analog scale from 0 (glottis not visible) to 10 (glottis fully visible) was assessed. The lowest SpO value during airway management was reco...
Fatigue in multiple sclerosis is a very common and cumbersome symptom, but its aetiology is poorl... more Fatigue in multiple sclerosis is a very common and cumbersome symptom, but its aetiology is poorly understood. Proteomics is increasingly implemented in multiple sclerosis research, but has not yet been used to study the neurobiological basis of fatigue in multiple sclerosis. To identify potential cerebrospinal fluid biomarkers of fatigue in multiple sclerosis, we collected cerebrospinal fluid of 20 patients with multiple sclerosis with fatigue (MS+), 20 patients with multiple sclerosis without fatigue (MS-), and 20 control subjects without multiple sclerosis and without fatigue (HC). We used a shotgun proteomics approach and label-free quantitative proteomics to analyse the protein content in cerebrospinal fluid. Selected proteins with differential abundance were further validated by immunoblotting. Out of 591 detected cerebrospinal fluid proteins, the abundance of nine proteins differed between the three groups, and seven additional proteins differed between MS+ and MS- patients. ...
Romanian journal of anaesthesia and intensive care, 2015
To evaluate the patients' baseline condition upon arrival in the PACU as a method of assessme... more To evaluate the patients' baseline condition upon arrival in the PACU as a method of assessment of the quality of anaesthesia, and to establish a model for future comparisons. Prospective observational study. Surgical PACU in an academic tertiary hospital. All patients (n = 11,241) arriving in our hospital's recovery units after elective surgery. In this observational study, clinical data, vital signs and comfort parameters were collected from surgical patients who arrived in the PACU. For each parameter, its frequency distribution or percentage of occurrence was determined. The incidence of anaesthesia associated side effects such as hypoxemia, cold extremities, shivering and/or vomiting was 5%. The incidence of nausea, sore throat, headache and/or pruritus was 9%. Sore throat occurred in 4.8% of intubated patients, in 4% after laryngeal mask insertions and in 3.6% with no usage of any airway device. From all patients 48% had no pain at all (VAS = 0), 31% had low pain score...
Turkish journal of anaesthesiology and reanimation, 2017
The prediction of difficult airway is one of the most important challenges before general anaesth... more The prediction of difficult airway is one of the most important challenges before general anaesthesia. This study aimed to assess the clinical usefulness of the FRONT score, a recently developed scoring system to predict and document airway difficulties. This multi-centre, inter-observer, prospective and double-blinded study included 976 patients from two university centres. The pre-operative evaluation of the patients was performed by a pre-operative team of anaesthesiologists (team A) who evaluated and scored the expected difficulty of airway management. An intra-operative team of evaluators (team B) working independently of team A, performed the actual instrumentation of the airway and scored the actual findings. Both teams used the FRONT scoring system and worked independently of each other to ensure blinded assessments. The statistical analysis of the pre- and intra-operative FRONT scores was performed in an off-line blinded manner. Our results show a fair and promising associa...
Successful and sustainable training and learning of the management of difficult and normal airway... more Successful and sustainable training and learning of the management of difficult and normal airway is essential for all clinically active anesthesiologists. We emphasize the importance of a continuously updated learning and training environment based on actual knowledge, best available equipment, standardized procedures, and educational theory. In the past, most of the training were based on 'learning by doing' under the supervision of superiors or experienced colleagues. This has been recognized as insufficient and training has evolved to its recent level by structuring it into technical, methodological, and behavioral components. Additionally, a large part of it has been shifted away from learning on patients to simulated scenarios in designated environments. The contents, structure, components, and succession of components have been refined according to the steadily evolving and available instruments. Increasingly, team interaction and behavioral aspects gained more attent...
Turkish journal of anaesthesiology and reanimation, 2017
World Health Organization and the United States Center for Disease Control have recently recommen... more World Health Organization and the United States Center for Disease Control have recently recommended the use of 0.8 FIO2 in all adult surgical patients undergoing general anaesthesia, to prevent surgical site infections. This recommendation has arisen several discussions: As a matter of fact, there are numerous studies with different results about the effect of FIO2 on surgical site infection. Moreover, the clinical effects of FIO2 are not limited to infection control. We asked some prominent authors about their comments regarding the recent recommendations.
Journal of clinical monitoring and computing, Jan 11, 2017
To assess the impact of short time hypnosis for retro-bulbar anesthesia on ventilation in patient... more To assess the impact of short time hypnosis for retro-bulbar anesthesia on ventilation in patients undergoing ophthalmic surgery of the anterior eye chamber. In all patients, a combined continuous transcutaneous carbon dioxide tension (PtcCO2) and partial oxygen saturation (SpO2) measurement was applied in addition to routine monitoring. To enable unconscious application of retro-bulbar anesthesia, intravenous thiopental was given in one to multiple bolus doses. Transient breathing support included chin lift, Esmarch maneuver and manual hand-bag ventilation via face mask. Main endpoints were apnea time, recovery time according to the Richmond Agitation Sedation Scale, as well as SpO2 and PtcCO2 readings at predefined time points. Fifty-two patients with a mean age of 68 ± 13 years were included. Average thiopental dose was 2.7 ± 0.6 mg/kg. In seven (13.5%) patients repeated doses of thiopental were necessary to a total of 3.3 ± 1.1 mg/kg. Except one patient, no severe, significant o...
Turkish journal of anaesthesiology and reanimation, 2017
There is still a lack of a universally applicable and comprehensive scoring system for documentin... more There is still a lack of a universally applicable and comprehensive scoring system for documenting the invasiveness of surgical procedures. The proposed preliminary 'Universal Surgical Invasiveness Score' (pUSIS) is intended to fill this gap. We used the recently developed pUSIS to obtain values from 8 types of surgery and 80 individual interventions. The results were analysed using descriptive statistical methods. The degree of difficulty on a scale from 0 (very easy) to 10 (extremely difficult) and time expenditures for assessing pUSIS were documented. Individual pUSIS values ranged from 8 in a laparoscopic cholecystectomy case to 36 in a total hip replacement case. The lowest median pUSIS value of 11.5 was found for laparoscopic cholecystectomy and the highest value of 24.5 was found for open thoracic surgery. The correlation between pUSIS values and the duration of surgery resulted in a tight linear regression (R2=0.6419). The lowest mean (±SD) difficulty level to obtain...
Recently, an institutional Difficult Intubation Drill has been conceived and started at the Unive... more Recently, an institutional Difficult Intubation Drill has been conceived and started at the University Hospital Zürich, which is intended to sustainably improve the handling of difficult airway situations. The drill consists of a weekly course in the airway management SkillsLab of the university to which all staff members of our department are subjected to participate. The hardware of the drill is a standardized difficult intubation cart consisting of 4 airway rescue techniques arranged in successive drawers that represent also the priority and order of use of these 4 devices: 1. SensaScope®, 2. Fastrach®, 3. laryngeal tube, and 4. transtracheal oxygenation and jet ventilation. This actual choice of devices and techniques represent the actual algorithm for the unexpected failed intubation. Repeated assessments of the educational results and clinical outcome of this airway course will possibly contribute to adaptations and modification of the difficult intubation cart and its clinical use.
In order to perform accurate low-flow anaesthesia ventilation, it is desirable to avoid the influ... more In order to perform accurate low-flow anaesthesia ventilation, it is desirable to avoid the influence of fresh gas flow (FGF) and inspiration duration (ID) on the resulting minute volume (MV). The Sulla 808V anaesthesia ventilator (Draeger, Luebeck, Germany) is originally not equipped with a fresh-gas decoupling (FGD) device. Therefore, changes of FGF and ID settings applied during controlled ventilation may lead to alterations of the resulting MV. Recently, a low-cost FGD device (Carbamed, Bern-Liebefeld, Switzerland) has been developed, which can be inserted into the circle system. We investigated the effect of this device on MV in the Sulla 808V anaesthesia apparatus. The performance of a Sulla 808V anaesthesia ventilator was tested with and without a FGD device. During ventilation of a test lung, stepwise changes of tidal volume (400-1000 ml), FGF (0.5-10 l/min), and ID (0.25-0.5) settings were consecutively applied, and the resulting MV was recorded. Correlation and mean prediction error between ventilation parameter settings and MV were calculated. In the presence of a FGD device, the administered MV was not affected by the magnitude of FGF and ID. A mean prediction error (bias) of -3.6 l/min of the resulting MV was observed. Without FGD the bias was only-1.8 l/min, while FGF and ID revealed a pronounced influence on MV. These effects were statistically significant when using FGF exceeding 4 l/min. The tested FGD device can easily be integrated into the circle system of conventional anaesthesia machines such as the Draeger Sulla 808V, and is available at a reasonable cost. It allows constant ventilation parameters to be maintained that remain unaffected by wide FGF and ID variations. With this FGD the performance of the ventilator can be improved considerably, and low-flow anaesthesia can be used more extensively.
Patients' fears of anesthesia mostly focus on a possibly inadequate anesthetic effect, on pos... more Patients' fears of anesthesia mostly focus on a possibly inadequate anesthetic effect, on postoperative wound pain and/or nausea and vomiting (PONV). Concerning the possibility of an inadequate anesthetic effect, patients usually express two different kinds of fears: first, that they might stay conscious during surgery («Awareness») without it being noticed, and second that they might not wake up again after the operation or that they might sustain neurological damages or deficits after the anesthesia. Last but not least patients are afraid they might suffer from substantial pain after waking up from the anesthesia. In this article we take a closer look at these aspects and discuss ways and possibilities of handling them, suggesting useful approaches for the general practitioner when talking these issues through with his patients prior to an operation.
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Papers by Peter Biro