Volume 35 Issue 5 IHE October 2009
Weekly news updates on www.ihe-online.com
IntensIve care specIal
advanced lar yngoscopy techniques
also in this issue
Functional MrI of the kidneys Improving hospital hygiene
reducing the risk of cIn - page 31
compact colour ultrasound system - page 33
autoclavable spO 2 sensors - page 34
the MagazIne FOr healthcare decIsIOn Makers
www.ihe-online.com & search 45218
– Issue N°5 – Oct. 2009
An effective HIV vaccine at last?
It is now over a quarter of a century since Dr Luc Montagnier first identified the virus that causes AIDS, which at that time was a disease with low prevalence. Since then HIV/ AIDS has spread around the globe; according to the most recent report jointly released by WHO, UNAIDS and UNICEF last year, the number of people living with HIV has risen to 33.2 million, 22.5 million of whom reside in subSaharan Africa. Two and a half million people were newly infected with HIV in 2007. Faced with such daunting facts, is there any cause for optimism? A major achievement in the fight against AIDS is that over three million people in the most severely affected resourcepoor countries are now receiving antiretroviral therapy (ART). This is the result of the increased availability of cheaper drugs for lower income countries, simpler, standardised drug regimens and the growth of decentralised clinics and laboratories, enabling more people to be appropriately tested, diagnosed and treated. Providing facilities in remote areas has especially benefited women and children; ART has successfully prevented vertical transmission and combination ART taken from late pregnancy until six months after birth dramatically reduces breastfeeding mother-to-child transmission. In spite of such substantial progress, however, there has been a very real obstacle to achieving the UNAIDS’ goal of ‘universal access to HIV prevention..... by 2010’, namely a safe and effective vaccine. Twenty-five years ago, after the HIV virus had been isolated, Margaret Heckler, then US Secretary of Health, Education and Welfare, blithely declared that an effective HIV vaccine would be available within two years. Despite concerted efforts as well as sporadic announcements of success, this goal still remains elusive a quarter of a century later. Why have previous vaccines failed, and will the ALVAC/AIDSVAX combination, which is currently being lauded by the mass media on the basis of as yet unpublished data from Phase III trials, really help achieve the UNAIDS’ goal? Most initial efforts towards engineering a vaccine were directed towards the viral envelope glycoprotein, gp120, which it was thought would elicit an antibody response that would prevent infection. Unfortunately the heavily glycosylated viral envelope protein both masks potential protein epitopes, and prevents antibodies binding effectively even if they are generated. In addition the viral envelope proteins vary more than other viruses, both geographically and over time; the HIV virus is highly mutable. Phase II trials with a previous vaccine, (V520) based on an attenuated adenovirus carrying three HIV Subtype B genes, which involved over three thousand paticipants spread over three continents, were abandoned prematurely because the vaccine proved ineffective. Now the Phase III trial with a combination of two earlier vaccines, namely ALVAC, which employs a canarypox virus to carry three HIV genes, and AIDSVAC, based on gp120, has reported a reduced risk of contracting HIV of 31.2% in Thai volunteers. Full data will be presented at the AIDS Vaccine 2009 conference which starts on October 19th. In the meantime we and the mass media should realise that this development may be just a small step for mankind, not the giant leap for which we all hope.
PRIMEDIC™ EXTERNAL DEFIBRILLATOR BECAUSE THE WORLD CAN CHANGE ON A SIMPLE HEARTBEAT
In an emergency every second counts. This means having easy to use and highly reliable equipment. PRIMEDIC™ offers solutions for all applications: from layperson to semi professionals, select from our HeartSave product family, for professional requirements, choose from our DefiMonitor XD generation. PRIMEDIC™ guarantees continuous development to meet future needs. Want to learn more? See www.primedic.de
www.ihe-online.com & search 45187
FRONT COVER PRODUCTS
 reducing the risk of contrast induced nephropathy  Compact, colour ultrasound system  Autoclavable soft sensors for adult and paediatric use
Rue Royale 326 • 1030 Brussels, Belgium Tel. +32-2-240 26 11 • Fax: +32-2-240 26 18 www.ihe-online.com Managing Editors Alan Barclay, Ph.d. email@example.com Frances Bushrod, Ph.d. Editor ruth Knowles, Bsc. Editorial and Advertising Coordinator Anna Hyrkäs Circulation Manager Arthur Léger Publisher Bernard Léger, M.d. Advertising Sales Manager Astrid Wydouw firstname.lastname@example.org Webmaster damien Noël de Burlin
©2009 by PanGlobal Media bvba-sprl. Production & Lay-out by studiopress Communication, Brussels. Circulation Controlled by Business of Performing Audits, shelton, Ct, UsA.
the publisher assumes no responsibility for opinions or statements expressed in advertisements or product news items. the opinions expressed in by-lined articles are those of the author and do not necessarily reflect those of the publisher. No conclusion can be drawn from the use of trade marks in this publication as to whether they are registered or not.
[6 - 7]
  
INTENSIVE CARE SPECIAl
Advanced laryngoscopy techniques Fever in the intensive care unit Paediatric laryngoscopy: history and current developments
Functional MrI of the kidneys
[20 - 22] MAgNETIC RESONANCE IMAgINg
[12 - 21] HOSPITAl HygIENE
  Improving hand hygiene in the hospital setting the challenges of implementing infection control procedures in limited resource hopitals  Hospital hygiene: highlights from the peer-reviewed literature
COMING UP IN NOV. 2009
Imaging & Healthcare It special Urology & renal dialysis ECG
For submission of editorial material, contact Alan Barclay at email@example.com For advertising information, go online to www.ihe-online.com, simply click on ‘Magazine’ and ‘Media Information’ or contact Astrid Wydouw at firstname.lastname@example.org
   [32 - 34]  Editor’s letter News in brief Product news Medica Preview Calendar of upcoming events
Free subscription for healthcare professionals
Healthcare professionals are entitled to receive IHE for the next 12 months completely free of charge. to begin a new subscription or to continue your existing free subscription go to
as part of Ihe’s continuing policy of encouraging reader feedback, we invite our readers to post comments, suggestions or questions on our website. at the foot of each feature article in each issue of Ihe, you will find a specific Ihe web address for comments relating to the article in question.
Comments on this article?
If you have comments, additional data, alternative points of view or simply questions regarding the above article, please feel free to post them at
Click on Free subscription and follow instructions
Onyx® II 9550
Actual size is 1.4 x 2.3 inches
RT Family Ad_ENG.indd 1
www.ihe-online.com & search 45262 9/15/2009 3:22:34 PM
– Issue N°5 – Oct. 2009
Advanced laryngoscopy techniques
Video laryngoscopy (VL) technology plays an important and varied role in airway management. A full understanding of the indications, proper use and limitations of VL is vital for the optimisation of its application in patient care.
screen directly incorporated into the laryngoscope handle; others use a stand-alone monitor. Yet other models, such as the Airtraq , the TruView EVO 2  and the Bonfils Retromolar scope use advanced optics to provide an indirect image of the glottic opening. Another feature that varies by dr t. C. Mort Figure 1. Three Airway Axes between different models is whether the design is channelled or non-channelled. For example, Airtraq and Pentax AWS are channelled models, allowing placement of the endotracheal tube (ETT) into the channel to assist with its guidance through the vocal cords and into the tracheal position. This requires manipulation of the device rather than the ETT itself. Non-channelled models such as GlideScope, McGrath, Trueview and C-Mac rely upon operator manipulation of the ETT or “free-hand” ETT advancement into the airway. Another variant is optical stylet designs based on fibre optics, which provide indirect visFigure 1. Three airway axes. The 3 axes are aligned by flexion of the cervical spine and extension of the head ualisation of the airway. The ETT is mounted on on atlanto-occipital joint to improve the alignment for better viewing. A variety of factors may limit the operator the optical stylet and the ETT-stylet unit is visufrom aligning the 3 axes hence the “line of sight” may be restricted or absent. Drawing courtesy of Anna Mort. The 3 axes are aligned by flexion of the cervical spine and extension of the head on atlanto-occipital joint to ally guided 2. Optical stylet combined with DL for laryngeal exposu Figure into the tracheal position. Typically, improve the alignment for better standard A variety ofof the epiglottis, lateral pharyngeal walls, aryte- the stylet is rigid and relatively fixed in design viewing. method factors may limit the operator from aligning the 3 Direct laryngoscopy (DL), the axes hence the “line of sight” may be restricted or absent. Drawing courtesy of Anna Mort. for placing an endotracheal tube (ETT) into the noids, true and false vocal cords and the entire trachea, has changed little in the past 50 years. The glottic opening into the trachea. Although tratechnique involves following well established, rou- cheal intubation can be successfully carried out tinely practiced manoeuvres to align the oral, pha- with only a restricted view of, for example, the ryngeal and tracheal axis to displace the oral cavity posterior third of the glottic opening, restricted and oropharyngeal tissues (tongue, epiglottis) with views frequently mean an increase in the number a lighted blade to allow visualisation of the vocal of intubation attempts and misplacement of the cords (glottic opening). The “cavity” opened up by ETT into the oesophagus. Optimal viewing is the laryngoscope blade allows the airway structures therefore safest for the patient, although of course to be viewed by looking down past the flattened obtaining a view of the glottic opening does not in surface of the blade [Figure 1]. Thus, the operator’s itself guarantee successful ETT passage. “line of sight” permits accurate and timely placement of the ETT through the vocal cords and into Visualisation of the airway by DL has enabled the the trachea. A variety of factors may however lead grading of airway views so that consistent descripto difficulty in obtaining an unobstructed view tions can be used. There are six generalised grades Operator 2. Operator using a DL the contents Figure using a DL scope to displace scope with the naked eye via the line of sight [Table 1]. representing the commonly seen views of airway of the oropharynx followed by placement of the to displace the Levitan® contents of the oropharynx followed by placement of seeing optical stylet for visualizing and ultimate passing Such restricted or obstructed views may limit the anatomy; they range from grade I (full view), the Levitan seeing optical stylet for visualising and ultiof the ETT with continuous observation. Drawing courtesy successful and timely placement of the ETT and grade IIa (only posterior half of glottis), grade mate passing of the ETT with continuous observation. of Anna Mort. thus jeopardise the patient’s safety from the point IIb (epiglottis, arytenoids visible, cords not visDrawing courtesy of Anna Mort. ible), grade IIIa (epiglottis edge only), grade IIIb of view of oxygenation and ventilation. Experience (EMS trainee or medical student vs. seasoned (floppy, overhanging epiglottis) to grade IV (no anesthesiologist or emergency physician) The technological advance of coupling video- view) [Figure 3]. Presence, character and condition of dentition camera equipment to the basic laryngoscope or Mouth opening (restricted due to trauma, tumour, infection, the intubating stylet has ushered in a new era of Types of video laryngoscopes TMJ disorders, airway management capabilities. Many operators There is now a choice of commercially available Cervical spine mobility use a stylet within the ETT to customise its shape. video laryngoscopes (VL) for use in intubations Head-torso positioning Previously the stylet was static, but it is now more and airway exams. They can be classified in difinteractive and dynamic. Fibre optic capabilities ferent categories. Some models, such as the GliPresence of secretions, blood, vomitus built into the stylet allow visualisation of the air- descope , McGrath , Pentax  and Storz Tumours, mass effect, swelling, oedema, infectious processes way structures as the ETT is advanced through  obtain the image of the glottis by a miniature Blade choice (length, width, style) the glottic opening [Figure 2]. camera placed at the tip of the blade, which transLocation of patient (street or apartment floor vs. operating mits the image electronically to a remote screen. room theatre) Although many of these instruments resemble a A brief review of laryngeal anatomy Congenital/acquired anatomical variations The objective of placing a conventional DL blade standard curved laryngoscope blade, the degree in the hypopharnyx is to open a pathway to expose of angulation differs to allow more “around the Table 1. Factors that may impact ease or difficulty of the periglottic region, thus allowing visualisation corner” visualisation. Some designs have the airway management.
(Levitan, Shikani), but it is also available in a flexible form (Foley model) or with a rigid stylet and an articulated distal tip for improved manoeuvring of the ETT into the airway (RIFL). Since there is no blade to open the airway cavity, the optical stylet models rely on either a hand manoeuvre to provide a jaw thrust-chin lift or the placement of a conventional laryngoscope blade or one provided by the manufacturer. Manufacturers also offer light weight, portable devices that can be easily transported in an airway bag, tackle-box or cart; other devices are pole- or cart-mounted and are more cumbersome to carry. Laryngoscopes also range from less expensive single-use, disposable devices (Airtraq) to more expensive systems that offer reusable blades or disposable blade covers. Manufacturers are continually updating and improving the technology. For example, neonate and paediatric versions are currently available with the TruView EVO, Clarus Medical and GlideScope models. optical stylet using visual guidance. Care must be taken not to damage any structures during the advancement of the ETT — there are multiple case reports documenting soft palate and palatoglossal arch laceration caused by trauma during manipulation, advancement and insertion of the ETT [9,10]. The airway practitioner should then constantly alternate his attention between the monitor/eyepiece, the device and the patient. After the advancement of the ETT into the trachea, which may be verified visually, breathing
– Issue N°5 – Oct. 2009
Figure 4. Laryngeal Grades (Cook-Lentis)
Drawing courtesy of Anna Mort (Cook-Lentis). Drawing courtesy of Anna Mort. Figure 3. Laryngeal grades
noise and end tidal ETCO2 should also confirm that the routine has been correctly carried out . With correct initial instructions and repeated use of the devices in elective situations, successful manipulation can be mastered in a relatively short period of time .
Video laryngoscopy applications
There are many recent papers on the uses of VL, primarily focussing on the improved view of the larynx as compared to conventional laryngoscopes [13,14]. In the first published use of the GlideScope a patient who
Video Laryngoscope Series 5 Designed & manufactured by Aircraft Medical
Video Laryngoscope Series 5 Designed & manufactured by Aircraft Medical
Video Laryngoscope Series 5 Designed & manufactured by Aircraft Medical
Video laryngoscopes are used in many applications, from tracheal intubations [1-6] to the insertion of nasogastric tubes . VL can be used as the primary intubation technique, as a rescue technique for airway evaluations prior to extubation or for ETT exchange . Though each type of VL device requires specific manoeuvres to place it in the airway, several basic tenets should be followed when carrying out a VL-based intubation. Hand and eye coordination is challenged with VL placement and ETT advancement, so that a new skill set must be mastered for each of the stylet, channelled and non-channelled VL devices. In general, while the airway is under direct visualisation, the VL device should be advanced into the oral cavity through to the oral pharynx until the tip is past the posterior part of the tongue. Attention can then be directed to the video screen or optical eyepiece to help in getting the best view of the glottic opening. The ETT is then delivered into the airway either via the device’s channel, by free hand with or without a stylet, or it is advanced into the trachea over the
7:45am, Theatres: Obese patient with limited mouth opening and a history of difficult intubation. 9:30am, Intensive Care Department: Patient on whom multiple intubation attempts have been made with a rigid laryngoscope. 3:27pm, Emergency Department: Semi-sedated patient with collar rushed in, direct visualization not possible.
cut the cable
Wherever your next difficult airway occurs make sure you have the rescue device that’s always ready.
Aircraft Medical Limited 10 Saint Andrew Square, Edinburgh EH2 2AF United Kingdom tel: +44 (0) 131 718 6042 fax: +44 (0) 131 718 6100 www.aircraftmedical.com COPYRIGHT 2009 © Aircraft Medical Limited Doc No. AD 001 v1.7
Come and see us at Medica 2009 Hall 16, Stand G04-3
For details of your local distributor visit: www.aircraftmedical.com/distribution/europe
www.ihe-online.com & search 45367
– Issue N°5 – Oct. 2009
followed by an anti-sialagogue allowed the practitioner to adequately evaluate the airway using VL without sedation. All patients were then induced, paralysed, and intubated with a full laryngeal view provided by VL, thus avoiding awake fibre optic bronchoscopy . VL, in the hands of a trained and experienced practitioner, appears to be a straightforward technique that may be significantly faster than fibre optic intubation. VL may also be combined with the flexible bronchoscope and other airway devices to augment management of patients with difficult airways .
Figure 4. McGrath videolaryngoscope. McGrath
Figure 13. McGrath Videolaryngoscope
was a known difficult case for intubation, and who had proved to be a significant management challenge using a variety of other airway devices and techniques, was successfully intubated in 15 seconds . In the first large scale study, in over 700 patients, of VL technology using the GlideScope, the view of the larynx that was achieved with VL was just as good or better than with DL . In a similar case series evaluating the McGrath instrument [Figure 4], 98% of all tracheal intubations were successful thanks to the excellent visualisation provided by the VL technology. A grade I view was obtained in 95% of cases and a grade II view in an additional 4% of cases . Airway practitioners may use VL technology in a variety of clinical settings, but the greatest impact is on the airway management of the patient who is suspected or known to be difficult to intubate. Marrel et al randomised 80 morbidly obese patients undergoing bariatric surgery to either DL or VL approaches. Not only was a better grade view consistently obtained with VL, but in addition, intubation times were shorter . When intubating a morbidly obese patient, many practitioners have altered their airway management policy to ensure immediate access to VL technology at the patient’s bedside . Unstable cervical spine fractures often pose a unique problem for the airway manager in the operating room, the ICU or the emergency department. Three different studies have assessed the intubation view and cervical spine stability (lack of movement) obtained with VL vs. DL with cervical spine immobilisation. The first study found that the use of VL produced better glottic visualisation, but found little difference in spinal column movement between the two methods . The second study noted an improved glottic view with VL at the cost of an increased time-tointubation compared with DL . However in the 3rd study, VL showed limited cervical spine movement without an increased intubation time when compared to DL . These studies support
Primary intubation device Rescue intubation device Assist with ETT exchange Evaluate airway prior to extubation Assessment position of ETT Assist with the placement of: Oro- or nasogastric tube Feeding tube placement TEE probe GI endoscope Assess airway oedema, trauma, infections Visualization of laryngeal function Foreign body location & extraction Placement of oesophageal dilating bougie
Outside the OR
Much emphasis has been placed on the role that VL devices play in the elective operating theatre. However, the technique can also be of potentially huge benefit for urgent and emergent airway interventions in locations outside the operating room (OR), especially in light of the fact that emergency airway management is fraught with difficulty and patient safety concerns. Such interventions may be required in the intensive care unit (ICU), the emergency department, the ward or the cardiac catheterisation suite. Video-augmented periglottic visualisation allows the adaptation of VL for airway procedures well beyond tracheal intubation; there are a variety of ingenious applications and uses [Table 2].
McGrath portable videolaryngoscope with disposable laryngoscope portable videolaryngoscope the disposable laryngoblade. The handle disarticulates fromwithblade so to allow scope in a confined oral opening (hard cervical collar, blade placementblade. The handle disarticulates from the trismus) asto allow placement in a confined oral opening (hard compared to the fixed/rigid construction of other models.
cervical collar, trismus) as compared to the fixed/ rigid construction of other models.
the conviction that VL technology improves the “line of sight” in a patient population with controlled or restricted cervical spine movement. Placement of the VL device is greatly facilitated in many patients by removal of the anterior component (maintaining midline stabilisation) of a rigid cervical collar, since otherwise mouth opening may be restricted. For the patient with a known or suspected difficult airway related to anatomical limitations, infectious processes, mass/tumour effect or trauma, it may be prudent to keep the patient conscious and maintain spontaneous ventilation; this optimises patient safety. The administration of sedative-hypnotics, opioids and/or neuromuscular blocking agents places the onus on the airway manager to support ventilation and oxygenation. Thus an “awake” or “barely aware” patient technique supported by the topical application of local anaesthetics, or placement of nerve blocks supplemented with light sedation and analgaesia, generally avoids the major problems that intubation with anaesthesia may generate. Usually, with flexible fibre optic bronchoscopy placement of the ETT, an awake patient approach is adaptable to a variety of airway devices. VL is a safe alternative to such awake flexible fibre optic intubation. Using the GlideScope, Doyle topicalised the airway with 4% lidocaine supplemented with light midazolam anxiolysis for awake intubation in four patients. Following insertion of the GlideScope and visualisation of the glottis, further lidocaine topicalisation of the airway was accomplished using an atomiser. The styleted endotracheal tube was then advanced under direct visualisation . Two other studies also showed successful awake intubations using the GlideScope and various topicalisation techniques [23,24]. One of these studies used VL to screen the patient with a known or suspected difficult airway in the preoperative holding area to offer the airway team valuable information on the need for an awake fibre optic technique. Topicalisation with local anaesthetic
A word of caution
Despite the current enthusiasm for VL technology, it should be noted that the introduction of any new equipment is frequently accompanied by a “honeymoon” period during which it appears that the technology can do no wrong. Basically the success of VL technology is typically limited by those using it. Patient factors also play a role: the presence of blood, vomitus, secretions, the degree of mouth opening, head-neck-torso configuration and anatomical variations and alterations can all affect success. Equipment maintenance is of primary importance since neglect and mishandling of the equipment may lead to malfunction, suboptimal image recreation and electronic errors. Difficulty in providing ready access to the disposable blade covers thar are required in some VL models may limit their use, especially in locations outside the operating room or regular service area. Despite all these potential limitations and restrictions that could affect VL success, the most important factor is however the practitioner’s experience and judgment in incorporating VL technology into clinical practice. The role of organised instruction on the proper use of VL technology cannot be over-emphasised. Equally, it is important to anticipate the unexpected and to be prepared for the “worst-case scenario” when arriving at the bedside of a critically ill patient in need of airway management. Complete reliance on VL technology is thus ill-advised and shortsighted. VL is an adjunct to airway management techniques, not a replacement for them. Practitioners who ignore
Table 2. In addition to tracheal intubation, video laryngoscopy has been used in many other applications.
Reusable Shikani1 Levitan1 Foley RIFL3 Bonfils4 C-Mac4 TruView EVO5
1. Clarus Medical, Minneapolis, MN USA / 2. Verathon Medical, Bothell, WA USA / 3. Rigid Intubating Fiberoptic Laryngoscope, AI Medical Devices, Williamston, MI USA / 4. Karl Storz, Tuttlingen, Germany / 5 Truphatek International Limited, Netanya, Israel 6. Prodol Meditec, Vizcaya Spain. / 7. Aircraft Medical Limited, Edinburgh, United Kingdom. / 8. Pentax Corporation, Tokyo, Japan
– Issue N°5 – Oct. 2009
Single Use/Disposable Airtraq6
Reusable with DlB McGrath7 GlideScope Cobalt2 GlideScope Ranger2 Airway Scope (AWS)
Table 3. Available airway devices by category.
the fundamentals of airway management and insist on using VL as their main (or only) approach, may meet with negative consequences when the approach fails. A backup plan consisting of other airway management approaches must be available in order to optimise patient safety.
ensured and periodic scheduled charging of portable units should be arranged. In addition, direct access to disposable laryngoscope blades for elective and especially emergency use must be provided and planned for.
The problem of cross-contamination and the need for equipment hygiene routines are increasingly having a huge influence on clinical practice. Depending on how they are treated after being used on patients, video/ optical airway equipment can be classified in three categories, namely (1) reusable devices (cleanable); (2) single patient use devices followed by disposal and (3) video laryngoscope systems with attachable yet disposable laryngoscope blades (DLB) supplied in sterile packaging [Table 3]. Some manufacturers now offer a sleeve or condom-like cover for the reusable devices to reduce contamination. Hygienic reprocessing of reusable devices is essential, since all patients are potentially the source of transmissible infectious diseases.
11. Walls RN. Anesthesiology News Guide to Airway Management. 2009; 2:30-32. 12. Savoldelli GL et al. Euro J of Anaesth. 2009; 26:554-558. 13. Cooper RM. Can J Anaesth 2003; 50:611-3. 14. Van Zundert A et al. Acta Anaesthesiol Belg 2007; 58:129-31. 15. Cooper RM et al. Can J Anaesth 2005; 52:191-98. 16. Shippey B, Ray D, McKeoqn D. Can J Anesth 2007; 54(4):307-313. 17. Marrel J et al. Eur J Anaesthesiol 2007; 24(12):1045-49. 18. Doyle DJ. Anesthesiology News Guide to Airway Management. 2009; 2:33-34. 19. Robitaille A et al. Anesth Analg 2008; 106(3):935-941. 20. Malik MA et al. Br J Anaesth 2008;
101(5):723-730. 21. Turkstra TP, Pelz DM, Jones PM. Anesthesiology 2009; 111(1):97-101. 22. Doyle DJ. Can J Anesth 2004; 51(5):520-521. 23. Villalonga A et al. Rev Esp Anesthesiol Reanim 2008; 55(4):254-256. 24. Xue FS et al. Anaesthesia 2006; 61(10):1014-1015. 25. Jones PM, Harle CC. Can J Anaesth 2006; 53(12):1264-1265.
Thomas C Mort, MD Senior Associate, Anesthesiology Associate Director, Surgical ICU Associate Professor of Anesthesiology & Surgery UCONN Founder, Medical Director, Hartford Hospital Simulation Center, Hartford, CT, USA
VL technology plays an important and varied role in airway management. Understanding the indications, proper use and limitations of VL is paramount for optimising its role in patient care. The wide variety of technologies available today from various manufacturers provides the practitioner with a growing range of devices to accommodate a range of clinical practices. Alhough individual advantages and disadvantages can be found when comparing individual models and designs, it is imperative that there is continuous practice in the elective setting under ideal circumstances. This will allow the use of any or all of the devices available to be mastered, both now and in the future.
T R I star
1. Sun DA et al. Br J Anaesth 2005; 94(3): 381-4. 2. Walker L et al. Br J Anaesth 2009; 103(3): 440-5. 3. Enomoto Y et al. Br J Anaesth 2008; 100(4): 544-8. 4. Kaplan MB et al. J Clin Anesth 2006; 18:357-362. 5. Malin E et al. Acta Anaesth 2009; 53:858-863. 6. Li JB et al. Anaesthesia. 2007;62:940-93 7. Lai HY et al. Br J Anaesth 2006; 97(5):749-750. 8. Mort T. Anesth Analg 2009; 108(4):1228-31. 9. Cooper RM. Can J Anesth. 2007; 54(1):54-57 10. Choo MKF et al. Can J Anesth. 2007;54(4):322-324.
Maintenance of equipment
The introduction of advanced technology into clinical practice requires pre-planning, especially if the equipment is to be shared by a large number of individuals. First and foremost, education on the use, care, limitations and indications of VL technology should be a primary objective. The maintenance and cleaning of the equipment as well as the distribution of VL devices to various operators or locations, must be appropriately coordinated. Otherwise misplacement of equipment will occur with consequent disruption of patient care. Ready access to replacement batteries should be
World Forum for Medicine
www.ihe-online.com & search 45361
– Issue N°5 – Oct. 2009
Fever in the intensive care unit
Fever is among the most common abnormal physical signs observed in patients admitted to intensive care units (ICU). Fever may be attributed to both infectious and non-infectious aetiologies, and its development usually prompts changes in patient management. Although it is a widespread, clinically accepted practice to therapeutically lower temperature in patients with hyperthermic syndromes, marked hyperpyrexia, and selected populations such as those with neurological impairment, whether most critically ill patients with moderate degrees of fever should be treated with anti-pyretic or direct cooling therapies remains controversial. treatment of fever may improve patient comfort and reduce metabolic demand. However, it is a normal adaptive response to infection and its suppression is potentially harmful. Clinical trials that compare fever management strategies in neurologically intact, critically ill patients are needed.
by dr K. B. Laupland
vascular/rheumatic diseases and occult malignancy are relatively uncommon but may also be potential causes of fever .
Occurrence and influence of hyperpyrexia on outcome
The influence of fever on outcome varies among different critically ill cohorts of patients and is also dependent on the cause of fever. We reported a large retrospective cohort study evaluating the epidemiology of fever >38.3°C and high fever >39.5°C among all adults (n=20,466) admitted to ICUs in Calgary, Canada during 2000-2006 . The cumulative incidence (incidence density per 100 ICU-days) of fever was 44% (24.3), and this was 43% (21.8) in medical, 36% (17.5) in cardiac surgical, 65% (38.2) trauma/neurologic and 45% (22.8) in other surgical patients. Male gender, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores <25, as well as younger age were associated with a higher incidence of fever. Prolonged fever and high fever lasting for five or more days in the ICU occurred in 18% and 11% of febrile patients, respectively. After controlling for APACHE II score, Therapeutic Intervention Scoring System score, gender, age and the presence of shock on admission to the ICU, in the logistic regression model the influence of fever on ICU mortality varied significantly according to its timing of onset, its degree and the main admission category.
Definition and measurement
Normal body temperature is approximately 37.0 o C, although it will naturally vary between different, non-acutely ill, individuals, There is also a normal variability of 0.5 oC that occurs within individuals based on the time of day, with a low in the early morning and a peak in late afternoon/early evening . Because of this variability, and because the magnitude and significance of an elevated temperature will depend on the specific patient populations in question, a wide range of definitions for fever have been used. However, a core body temperature >38.3°C may be generally accepted to represent fever in patients admitted to ICUs . Temperature may be measured using traditional thermometers and a number of other techniques, including thermisters on the pulmonary artery or bladder catheters, eosophageal or rectal probes, and infrared tympanic membrane and temporal artery thermometers. Oral thermometers are rarely practical in the critically ill patient and axillary temperature measurement is not routinely recommended . While the pulmonary artery catheter is considered the ‘gold standard’ measurement technique, in most situations relatively small differences exist among the other commonly used measurement techniques [2, 3]. In any case, where an exact temperature measurement is critical to patient management or when a measurement does not appear clinically reasonable, confirmation using another device is prudent.
differentiate at the bedside and are usually inferred based on clinical diagnosis. The major causes of abnormally elevated temperatures in the critically ill may be broadly classified as the hyperthermia syndromes and infectious and non-infectious fevers. The hyperthermia syndromes include environmental (heat stroke); drug-induced hyperthermia (including neuroleptic malignant syndrome); malignant hyperthermia and serotonin syndrome; and endocrine causes, including thyrotoxicosis, pheochromocytoma and adrenal crisis [4-6]. There is a vast list of bacterial, viral, fungal and protozoal infections that may cause fever in the ICU . Common sources of infection include the lower respiratory tract/pneumonia, the urinary tract, the primary bloodstream, sinusitis, skin/soft tissue and intra-abdominal/gastrointestinal infections [8-13]. The species, focus and antimicrobial resistance profile of infections will depend at least in part on underlying health status, treatments rendered and presumed location of acquisition [8, 14]. Non-infectious causes of fever are common in the ICU [2, 9, 15]. Transfusion reactions and drug hypersensitivity, in particular to antimicrobial agents, are frequent causes. Haematomas at deep body sites, as well as deep vein thrombosis, pulmonary embolus/infarct, myocardial infarction and acute haemorrhage may all cause fever. Intra-abdominal sources include cholecystitis, pancreatitis and organ transplant rejection. Although lung atelectasis per se is controversial as a cause of non-infectious fever, the fibroproliferative phase of acute respiratory distress syndrome and aspiration pneumonitis are established as causes of fever. Collagen
Management of hyperpyrexia in the ICU
There are numerous pharmaceutical and direct cooling methods available to reduce elevated temperature in critically ill patients. While methods of treatment of fever may include direct cooling, most frequently anti-pyretic medications such as acetylsalicylic acid, non-steroidal anti-inflammatory agents and acetaminophen are utilised . Direct cooling methods range in sophistication and include reducing the ambient room temperature and use of fans, application of cool external substances such as mist, ice packs, wet sponges and cooling blankets, and administration of cooled intravenous fluids. A number of newer techniques have evolved and include cooling jackets and intravascular catheter-based heat exchange systems . These techniques have the added advantage of thermostat settings and monitors that facilitate titration to a pre-set temperature goal. It is widely accepted that patients with very high fever, acute neurological impairment, and with hyperthermia syndromes should be treated to reduce elevated temperature [20-23]. At very high levels of elevated temperature such as >40 to
Aetiology of pyrexia
Abnormally elevated body temperatures that occur in association with a normal or an elevated hypothalamic set point are defined as hyperthermia or fever, respectively. However, fever and hyperthermia are often difficult to
www.ihe-online.com & search 45358
– Issue N°5 – Oct. 2009
significantly alter the percent (95% confidence interval) mortality of 37 (31-44%) for ibuprofen versus 40 (34-46%) for placebo. However, it is important to note that although ibuprofen is an anti-pyretic agent, this study was not specifically designed to assess effects of fever control per se. Significant and differential co-intervention with acetaminophen occurred with approximately one third of patients in both of the groups receiving this agent at enrollment. Schulman et al conducted an open, randomised, prospective clinical trial comparing an aggressive fever treatment strategy (acetaminophen 650 mg every six hours for fever >38.5°C and a cooling blanket added if >39.5°C) with a permissive strategy (treatment reserved for fever >40°C only) in patients admitted for at least three days to a trauma surgery ICU . The primary endpoint was development of cultureproven infections. Patients with acute brain injury, malignant hyperthermia, heat stroke, neuroleptic malignant syndrome, hepatic cirrhosis, acute hepatic failure, or a history of stroke, seizure or previous traumatic brain injury, were excluded. The aggressive treatment group had a higher rate of infections as compared to the permissive treatment group (131 vs. 85) and a higher rate of antibiotic use (77% vs 71% of days on therapy). No significant difference between the total number of cultures sent per patient, or length of ventilation or ICU stay was observed. The study had to be prematurely stopped due to safety concerns after interim analysis revealed an excess mortality rate of 7/44 (16%) in the aggressive as compared to 1/38 (3%) in the permissive group (p=0.06). Gozzoli and colleagues conducted a randomised trial comparing external cooling with no treatment in 38 surgical ICU patients with fever >38.5 °C and systemic inflammatory response
41°C, the risk of brain damage and the initiation or worsening of multi-system failure has been shown to increase . It is a widely held view that lowering temperature from such extreme levels is crucial. Fever has an adverse outcome in traumatic brain injury, stroke, anoxic injury and other causes of acute neurological impairment, and treatment of hyperpyrexia is standard therapy [21-23]. While anti-pyretic agents and direct cooling methods are usually used in these patients, the approach given to patients with hyperthermia syndromes differs somewhat. Principles of therapy for hyperthermia syndromes include discontinuation of offending drugs, initiation of direct cooling and administration of antidotes or specific therapies as appropriate. Specific therapies include intravenous dantrolene for patients with malignant hyperthermia and possibly heat stroke , potentially dantrolene and/or bromocriptine for neuroleptic malignant syndrome , and cyproheptadine for serotonin syndrome . Thyrotoxic crisis is usually treated with propylthiouracil or methimazole, glucocorticoids and beta-blockers; pheocromocytoma patients with alpha-blockade using phenoxybenzamine; and adrenal crisis with corticosteroids. Given that hyperthermia syndromes are not associated with an elevated hypothalamic set point, antipyretic agents are not usually effective, may be harmful and are not routinely recommended. Although lowering of body temperature is accepted in the above conditions, there is much controversy as to whether mild to moderate fever such as 38.3-40 to 41°C in other critically ill patients should be treated. Benefits of treating fever include potentially improved patient and caregiver comfort and reduction of metabolic demand/cardiovascular stress [26, 27]. In the setting of severe or refractory shock, treatment of fever results in an improved supplydemand balance that may reduce tissue hypoxic
injury . Lowering temperature may also have benefits in acute liver failure and acute respiratory distress syndrome (ARDS), and myocardial infarction, conditions that frequently complicate patients’ clinical course in the medical ICU [29-32]. On the other hand, fever is an innate adaptive response to infection and several lines of evidence argue against routine treatment in the critically ill. High temperatures inhibit growth of microorganisms, may reduce the expression of virulence factors, increase susceptibility to anti-microbials and enhance host immune responses [33-36]. It is well-established in observational studies that naturally hypothermic septic patients are at higher risk for death than those who have fever [37-39]. In addition, anti-pyretic agents run a not insignificant risk for bleeding, hepatic and renal toxicity, and may contribute to hypotension [40, 41]. Use of active cooling methods may also cause increases in metabolic rate and cause discomfort in non-sedated patients . Fever often instigates investigation and management of new infections and its suppression may delay the early diagnosis and empiric therapy of serious infections for which delays in treatment may be detrimental . There are few randomised clinical trials comparing strategies of fever control in neurologically intact critically ill patients [44-46]. Bernard et al reported on a randomised, double-blind, placebo-controlled trial comparing a total of eight doses of 10 mg per kilogram of intravenous ibuprofen, one every six hours, in 455 patients with fever (>38.3°C or hypothermia less than 35.5°C) and sepsis and at least one organ failure . Significant decreases in temperature, heart rate, oxygen consumption and lactic acidosis were observed in the ibuprofen group as compared with the placebo group. Ibuprofen therapy did not affect the incidence or duration of shock or ARDS and did not
syndrome . Patients with neurotrauma or severe hypoxaemia were excluded. External cooling was achieved using cooling blankets, ice packs, or cloths and was stopped when the patient’s temperature was 37.5°C and was restarted if the temperature increased to >38.5°C. The primary outcome measure was defervescence at 24 hours after intervention and the secondary outcome included patient discomfort as determined by a visual analogue scale. Among the 18 externally cooled patients and the 20 control patients, temperature and discomfort decreased similarly in both groups after 24 hours. No significant differences in recurrence of fever, incidence of infection, antibiotic therapy, intensive care unit and hospital length of stay, or mortality were observed. While this study demonstrated that external cooling did not significantly influence either the duration of fever or patient discomfort, it was not powerful enough to assess major outcomes such as mortality.
– Issue N°5 – Oct. 2009
39. Peres Bota D et al. Intensive Care Med 2004;30(5):811-6. 40. Boyle M, Hundy S, Torda TA. Aust Crit Care 1997;10(4):120-2. 41. Watkins PB et al. Jama 2006;296(1):87-93. 42. Lenhardt R et al. Am J Med 1999;106(5):550-5. 43. Kumar A et al. Crit Care Med 2006;34(6):1589-96. 44. Bernard GR et al. N Engl J Med 1997;336(13):912-8. 45. Schulman CI et al. Surg Infect (Larchmt) 2005;6(4):369-75. 46. Gozzoli V et al. Arch Intern Med 2001;161(1):121-3.
Kevin B. Laupland MD, MSc, FRCPC Departments of Critical Care Medicine and Medicine University of Calgary and Calgary Health Region Calgary, Alberta, Canada. Address correspondence to: Kevin B. Laupland, MD, MSc, FRCPC Room 719, North Tower, Foothills Medical Centre 1403 – 29th Street NW Calgary, Alberta, Canada T2N 2T9 Tel: +1 403 944-5808 e-mail: email@example.com
Summary and conclusion
Fever is common in critically patients, prompts clinical attention and changes in management, and has a variable effect on mortality outcome. While it is accepted that patients with extreme fever, acute neurological impairment and hyperthermia syndromes should be treated aggressively for fever, it is largely unknown whether active treatment with anti-pyretic therapy and/or physical cooling methods affects the outcome of other critically ill ICU patients. Further randomised clinical trials of fever management in neurologically intact, critically ill patients are needed.
1. Mackowiak PA, Wasserman SS, Levine MM. Jama 1992;268(12):1578-80. 2. O’Grady NP et al. Crit Care Med 2008;36(4):1330-49. 3. Leon C et al. J Crit Care 2005;20(1):106-10. 4. Denborough M. Lancet 1998;352(9134):1131-6. 5. Bouchama A, Knochel JP. N Engl J Med 2002;346(25):1978-88. 6. Mason PJ, Morris VA, Balcezak TJ. Medicine (Baltimore) 2000;79(4):201-9. 7. Laupland KB. Crit Care Med 2009;37(7 Suppl):S273-8. 8. Vincent JL. Lancet 2003;361(9374):2068-77. 9. Rizoli SB, Marshall JC. Lancet Infect Dis 2002;2(3):137-44. 10. Bagshaw SM, Laupland KB. Curr Opin Infect Dis 2006;19(1):67-71. 11. Laupland KB et al. Crit Care 2005;9(2):R60-5. 12. Laupland KB et al. Crit Care Med 2004;32(4):992-7. 13. Laupland KB et al. Crit Care Med 2002;30(11):2462-7. 14. Malacarne P et al. Crit Care Med 2008;36(4):1105-13. 15. Shafazand S, Weinacker AB. Chest 2002;122(5):1727-36. 16. Sorensen HT et al. Lancet Oncol 2005;6(11):851-5. 17.Laupland KB et al. Crit Care Med 2008;36(5):1531-5. 18. Hoedemaekers CW et al. Crit Care 2007;11(4):R91. 19. Diringer MN. Crit Care Med 2004;32(2):559-64. 20. Bouchama A, Dehbi M, Chaves-Carballo E. Crit Care 2007;11(3):R54. 21. Diringer MN et al. Crit Care Med 2004;32(7):1489-95. 22. Andrews PJ. Curr Opin Crit Care 2004;10(2):110-5. 23. Zygun DA et al. Can J Neurol Sci 2003;30(4):307-13. 24. Cremer OL, Kalkman CJ. Prog Brain Res 2007;162:153-69. 25. Reulbach U et al. Crit Care 2007;11(1):R4. 26. Vargas R et al. J Clin Pharmacol 1994;34(8):848-53. 27. Pernerstorfer T et al. Clin Pharmacol Ther 1999;66(1):51-7. 28. Manthous CA et al. Am J Respir Crit Care Med 1995;151(1):10-4. 29. Polderman KH. Lancet 2008;371(9628):1955-69. 30. Villar J, Slutsky AS. Resuscitation 1993;26(2):183-92. 31. Dixon SR et al. J Am Coll Cardiol 2002;40(11):1928-34. 32. Stravitz RT et al. Crit Care Med 2007;35(11):2498-508. 33. Graham NM et al. J Infect Dis 1990;162(6):1277-82. 34. Mackowiak PA, Marling-Cason M, Cohen RL. J Infect Dis 1982;145(4):550-3. 35. Ryan M, Levy MM. Crit Care 2003;7(3):221-5. 36. Kluger MJ et al. Infect Dis Clin North Am 1996;10(1):1-20. 37. Arons MM et al. Crit Care Med 1999;27(4):699-707. 38. Clemmer TP et al. Crit Care Med 1992;20(10):1395-401.
NOT JUST ANY STERILISER
From the first pre-vacuum table-top steriliser in 1993, to the third generation Millennium product line, you can count on Mocom for innovation, reliability and performance.
Millennium 17 and 22 liters > Single-piece stainless-steel chamber with, brilliant electro-polishing for longer durability and easy cleaning. > Instant steam generator gives high quality saturated steam and faster cycle times. > High performance fractionated vacuum pump. > Stainless steel wire trays for fast drying. > Robotized door-locking mechanism with triple protection for added safety. Millennium 5,5 liters > Only 18 minutes (drying included) to sterilise and dry wrapped hollow (handpieces) and solid loads! > Only 9 minutes (drying included) to sterilise and dry unwrapped solid instruments in the Emergency cycle!
www.mocom.it • firstname.lastname@example.org
www.ihe-online.com & search 45159
– Issue N°5 – Oct. 2009
Paediatric laryngoscopy: a history and current developments
More than 50 devices intended for paediatric laryngoscopy have been developed or modified from adult instruments since the larynx was first visualised. this article shows how laryngoscopy has evolved to become a smooth and safe procedure in children. by dr Js doherty, dr sr Froom and dr Cd Gildersleve
with Jackson Rees arguing against the notion that intubation was to be avoided in children. Laryngoscopy and intubation in children were now routine. Due to the unique upper airway anatomy of the infant, the straight blade laryngoscope is superior in elevating the tongue, facilitating better visualisation of the larynx than the curved blade laryngoscope. A popular straight blade is the Miller laryngoscope . This provides a narrow C-shaped channel to view the larynx. However, introduction of a tube into or alongside this channel can easily obstruct the view. The use of a curved blade laryngoscope is popular even for small children since the indirect technique for elevation of the epiglottis is most familiar amongst anaesthetists. This helped stimulate the development of the Cardiff paediatric laryngoscope, intended as a universal blade for children, combining elements of both curved and straight blades , thus helping to eliminate the problem of choice of blade for occasional users of paediatric laryngoscopes. The proximal 6 cm of the Cardiff blade is straight, so that no part of the blade can obscure the line of sight, and the miniature halogen bulb is mounted in the web so the light is less likely to be obstructed. The McCoy laryngoscope was developed in the early 1990s to help with difficult intubation in adults. A paediatric version of the McCoy, based on the Seward straight blade, is now available. This allows the epiglottis to be lifted with the blade tip in the vallecula, and may allow a view comparable to that of a straight blade .
Although the recorded history of nasal and oral intubation goes back as far as 1788, the first oral tracheal intubation was performed in 1878 in an awake adult by the surgeon William Macewan, using his fingers as a guide. Prior to the development of the “autoscope” by Alfred Kirstein, who performed the first direct laryngoscopy in an adult in 1895, the need to view the larynx for intubation was circumvented by the use of tactile or blind oral and nasal techniques.
development of implant testing of polyvinyl chloride tracheal tubes in the 1960s allowed the production of tracheal tubes that were less likely to cause tissue reaction, and consequent sub-glottic stenosis, than the standard red rubber tubes. Furthermore, parallel developments in the management of respiratory failure in premature infants during the 1960s showed that intubation, in part, helped improve survival.
Blade design and development
There followed a proliferation of paediatric blades, each with particular characteristics perhaps suggesting that no ideal design was possible. The Oxford infant blade was described by BryceSmith in 1952, intended to be used in a similar fashion to the Macintosh blade. Other popular paediatric laryngoscopes included the Seward, Srivastava and Robertshaw. The Seward blade was intended to be easy to use for inexperienced practitioners. It has an adult sized light bulb to improve the illumination of the larynx. The Srivastava, described in 1963, combined straight and curved elements in a blade designed primarily for infants. This was easy to use to elevate the epiglottis directly or indirectly. Finally, the Robertshaw allowed binocular vision of the larynx by removal of the lateral wall of the blade.
Procedures on infants
Sir Ivan Magill was the first to apply his adult technique of using a speculum and an assistant to displace the tongue to the left in order to view the vocal cords, to infants needing surgery for cleft lip and palate. He described his adult straight blade laryngoscope in 1926. In 1936, Gillespie invented the Shadwell laryngoscope, a modification of the Chevalier Jackson laryngoscope, described in 1939. This had a tubular blade with a removable slide. Macintosh described his curved adult laryngoscope in 1943. This was designed to lift the epiglottis indirectly by placing the blade tip in the vallecula. The use of the flattened distal portion of this adult blade was preferred for laryngoscopy in small children and infants by many anaesthetists, whereas a paediatric modification produced in 1947 was felt to be too curved, obscuring the view of the larynx. Indeed Macintosh condemned the blade, which was a modification by the manufacturers. In 1946 Miller described a version of his adult laryngoscope for children; this could be inserted either anterior or posterior to the epiglottis, with a blade small enough to allow room for the insertion of a tracheal tube.
The changing face of medicine
By the 1960s anaesthetic practice had changed,
Direct and indirect visualisation
Many paediatric laryngoscope designs are extrapolated from adult practice, indeed more than 50 devices intended for paediatric laryngoscopy have been invented or modified since the larynx was first visualised. Modern laryngoscopic visualisation devices may be classified as either direct or indirect. An example of a direct visualisation device is the Diaz laryngoscope (Pilling Instruments, Fort Washington, Pennsylvania, USA). This tubular laryngoscope has two detachable blades, each with a fibreoptic light source. Intubation is performed through the tubular laryngoscope and the two blades are then removed. It is intended for use when oedema or secretions may make flexible fibre optic intubation difficult.
The impact of neuromuscular drugs
Wider developments between the 1940s and 1960s helped to popularise intubation in children. The introduction of neuromuscular blocking agents, first used in adult practice in 1942, ensured that intubation of children became a smoother and safer procedure. In addition, the
Figure 1. The GlideScope is an indirect visualisation laryngoscope that ustilises a miniature camera to transmit the image.
ICU performance in a portable unit. Built-in turbine and battery options for independent operation. Invasive & Non-invasive ventilation. For adults & pediatrics. The versatility of Versamed iVent 201: the ideal pandemic ventilator. Respiratory Care Re-imagined.
*see environmental specifications
M1186199 08/09 © 2009 All right reserved. GE Healthcare Finland Oy, doing business as GE Healthcare
www.ihe-online.com & search 45365
– Issue N°5 – Oct. 2009
paediatric laryngoscope when manufactured in a disposable version did, in some cases, diminish the obtained view of the vocal cords . While small changes to design will not impact on performance in the majority of children, it is at the extremes of difficulty that these subtle changes will be felt.
Most modern devices are indirect visualisation laryngoscopes. They may be rigid or flexible and use either a fibre optic cable to transmit an image or a miniature camera as in the GlideScope (Saturn Biomedical System Inc., Burnaby, BC, Canada) [Figure 1]. Rigid devices include optical stylets, which can be used in children with difficult airways. For example, the Storz 70-degree nasendoscope (Karl StorzEndoskope, Tuttlingen, Germany) can be used orally to obtain an indirect view of the larynx in children with Pierre-Robin syndrome . Light wands, such as the Trachlight do not visualise the vocal cords, but have been shown to be useful in difficult and standard paediatric intubation . Optical stylets available for paediatric use include the Shikani Seeing Stylet (Clarus Medical LLC, MN, USA), the Fiberlightview Shuttle (Anesthesia Medical Specialties, Sante Fe Springs, CA, USA) and the Video Optical Intubation Stylet (VOIS) (Velpi AG, Schlieren, Switzerland).
Use of video imaging
Video-intuboscopy provides an image from the tip of the tracheal tube during conventional direct laryngoscopy using a video-intubation stylet . An example of this is the Bullard laryngoscope (Circon ACMI, Stamford, CT, USA). The adult Bullard laryngoscope has been used to facilitate tracheal intubation in children over one year of age . Video-laryngoscopy provides a view from the tip of the laryngoscope blade during conventional direct laryngoscopy . This may use fibreoptic image transmission, for example with the Angulated Video-Intubating Laryngoscope (AVIL), or with an embedded small camera head as in the GlideScope. The vertical flange of the blade is flattened in the AVIL, such as in an activated McCoy blade. This facilitates its use in paediatric patients . Video-laryngoscopy has also been performed on children using a Miller 1 paediatric video laryngoscope (Karl Storz, Tuttlingen, Germany) . The GlideScope provides a laryngoscopic view equal to, or better than direct laryngoscopy and may be useful in children, however the time taken to intubation was longer and more attempts were required . Flexible fibre optic laryngoscopes/bronchoscopes are also commonly used in paediatric practice, but this is beyond the scope of this review.
conventional laryngoscopes have an incandescent light bulb that produces a yellow light. Light Emitting Diodes (LEDs) are a “cool” light source in a more appropriate part of the spectrum; they use less energy and last longer than the standard bulb. There are reports of burns caused by incandescent bulbs; this will not be a problem with LEDs . Many modern laryngoscope devices have this superior light source transmitted fibre-optically and laryngoscopes are now being produced with an LED light source. For example the GreenlightII Laryngoscope System (Vital Signs Inc., Totowa, NJ, USA), the ProAct Metal Max 100 Disposable LED Blade (ProAct, Northamptonshire, UK) and the Truphatek Trulite Disposable Laryngoscope (Truphatek Int. Ltd, Netanya, Israel). A comparison of the spectral irradiance of the ProAct Miller 1 Paediatric laryngoscope (containing a standard incandescent bulb) with a custom-made laryngoscope containing an LED  showed that the Miller 1 produced spectral irradiance mainly in the infrared region (>660 nm), while the LED produced most irradiance in the blue/green region of the spectrum (400–550 nm).
This summary article is based on: Pediatric laryngoscopes and intubation aids old and new. Doherty JS, Froom SR and Gildersleve CD. Pediatric Anesthesia 2009; 19 (Suppl.1) 30-37. Copyright ©2009 Wiley-Blackwell Publishing Ltd. An abstract of this review can be found at http://www3.interscience. wiley.com/journal/122467358/abstract
1. McCoy E. Can J Anaesth 2004; 51: 101-105. 2. Jones RM et al. Anaesthesia 2004; 59: 1016-1019. 3. Ravishankar M et al. Br J Anaesth 2002; 88: 728-732. 4. Xue FS et al. Anaesthesia 2008; 63: 520-525. 5. Weiss M. Br J Anaesth 1998; 80: 525-527. 6. Shulman GB, Connelly NR, Gibson C. Can J Anaesth 1997; 44: 969-972. 7. Weiss M, Schwarz U, Gerber ACH. Anesthesiology 1998; 3A: SEE9. 8. Weiss M et al. Br J Anaesth 2001; 87: 453-458. 9. Wald SH, Keyes M, Brown A. Paediatr Anaesth 2008; 18: 790-792. 10. Kim JT et al. Br J Anaesth 2008; 101: 531-534. 11. Malan CA et al. Anaesthesia 2008; 63: 65-70. 12. Scholz A et al. Anaesthesia 2007; 62: 163–168. 13. Koh THHG, Coleman R. Anesthesiology 2000; 92: 277 - 279. 14. Lewis E et al. Paediatr Anaesth 2007; 17: 606-607. 15. Yee KF. Anaesth Intensive Care 2003; 31: 658–662. 16. Goodwin N, Wilkes AR, Hall JE. Anaesthesia 2006; 61: 792-799. 17. Chen YH et al. Infection 2006; 52: 118–123. 18. Sudhir G et al. Anaesthesia 2007; 62: 1056-1060. 19. Bray C. Anaesthesia 2005; 60: 631. 20. International Organization for Standardization (ISO). Anaesthetic and respiratory equipment – Laryngoscopes for tracheal intubation. Draft International Standard ISO/DIS 7376. Geneva: ISO, 2007. 21. Jones RM et al. Anaesthesia 2005; 60: 721-2. A complete list of references is available from the authors.
The advantages and disadvantages of disposable blades
Traditional cleaning and sterilisation of reusable equipment is effective against bacterial contamination but is costly. It may also affect laryngoscope performance . This coupled with concern over prion transmission during laryngoscopy has led to a massive investment in disposable laryngoscopes. Many different manufacturers produce a disposable Miller blade, but these vary widely in blade flexibility, brightness of the light and in the angle and direction of the light emitted . An inexpensive solution is the use of protective sheaths, however this can affect light emission . Disposable blades may be made of metal or plastic. The material used impacts on blade performance, with increased user satisfaction, significantly shorter time taken to view the cords and less force exerted with a metal blade . It is suggested that the disposable metal blade is less likely to cause trauma during use; this may be of particular relevance with vulnerable mucosa in small children. There are no standards for laryngoscope blades with respect to strength, flexibility and light output . However, the International Organisation for Standardization (ISO) has recently published a draft standard that includes requirements for flexibility and light output of laryngoscope blades . The fidelity of reproduction of disposable laryngoscopes has been questioned, for example alterations to the original design of the Cardiff
Doherty JS1, Froom SR2, Gildersleve CD2 1 Specialist Registrar in Anaesthesia, 2 Consultant Anaesthetist Department of Anaesthetics and Intensive Care Medicine University Hospital of Wales, Cardiff Correspondence to: Dr Jane Doherty Department of Anaesthetics and Intensive Care Medicine University Hospital of Wales Heath Park, Cardiff, CF14 4XW, UK e:mail: email@example.com
The importance of illumination
Lighting is crucial and a simple description of the measurement in lux may be insufficient. Factors such as light distribution also need to be considered. A presumption that a brighter light is best is not supported, since most anaesthetists prefer the degree of illumination to be less than 700 lux . Some anaesthetists have expressed a preference for blue/white light . Blue light corresponds to peak haemoglobin absorption (415nm). Most
– Issue N°5 – Oct. 2009
the highlight of the radiology year is the annual meeting of rsNA (held as always in Chicago in November — this year Nov 29th - dec 4th) where the latest clinical developments and scientific advances will be presented. this doesn’t at all mean that the information presented at last year’s meeting is out of date. to prove it we present some highlights of the RSNA 2008 meeting that are still as relevant as ever.
In 14 (36 percent) of the 39 women who underwent biopsy, the newly discovered lesions were cancerous. However, Dr Brem stressed that BSGI is not meant to replace mammography, but to be used as an adjunct to mammography.
MRI shows new types of injuries in young gymnasts
Adolescent gymnasts are developing a wide variety of arm, wrist and hand injuries that are beyond the scope of previously described gymnastic-related trauma, according to a study presented at RSNA 2008. According to the study’s lead author, Jerry Dwek, M.D., an assistant clinical professor of radiology at the University of California, San Diego and a partner of San Diego Imaging at Rady Children’s Hospital and Health Center, the broad constellation of recent injuries was unusual and might point to something new going on in gymnastics training that was affecting young athletes in different ways. Previous studies have reported on numerous injuries to the growing portion of adolescent gymnasts’ bones. However, this study uncovered some injuries to the bones in the wrists and knuckles that have not been previously described. In addition, the researchers noted that these gymnasts had necrosis of the bones of their knuckles. Dr Dwek and coauthor Christine Chung, M.D., used MRI to study overuse injuries seen in the skeletally immature wrists and hands of gymnasts. The researchers studied wrist and hand images of 125 patients, age 12 to 16, including 12 gymnasts with chronic wrist or hand pain. The authors were surprised to observe injuries at every step from the radius to the small bones in the wrist and on to the ends of the finger bones at the knuckles. These types of injuries were likely to develop into early osteoarthritis. Dr Dwek suggested that changing the way that practice routines were performed, the stress on the joints and on delicate growing bones could be limited.
New breast imaging technology targets hard-to-detect cancers at a glance
Breast cancer affects more women than any other non-skin cancer and, according to the American Cancer Society, accounts for more than 40,000 deaths annually in the U.S. Most experts agree that the best way to decrease breast cancer mortality is through early detection using mammography and clinical breast exam. However, some cancers are difficult to detect with mammography and clinical exam, particularly in the earliest stage when treatment is most effective. Breast-specific gamma imaging (BSGI) is effective in the detection of cancers not found on mammograms or by clinical exam, according to a study presented at the 2008 annual meeting of the Radiological Society of North America (RSNA). While mammography findings are characterised by the difference in appearance between normal and suspicious breast tissue, BSGI findings are based on how cancerous cells function. According to lead author of the study, Rachel F. Brem, M.D., professor of radiology and director of the Breast Imaging and Interventional Center at The George Washington University Medical Center in Washington, D.C., the technology can also facilitate the detection of additional lesions of all types of breast cancer in women whose mammograms show only one suspicious lesion. Because cancerous cells have a higher rate of metabolic activity, the radiotracer used in BSGI is taken up by the cells at a higher level than in normal cells. Dr Brem and colleagues reviewed the records of 159 women with at least one suspicious or cancerous lesion found by mammography or physical exam, who had undergone BSGI to determine if additional lesions were present. BSGI results showed an additional suspicious lesion missed by mammography and physical exam in 46 (29 percent) of the women.
a safe and precise method for removal of selfinflicted foreign objects from the body, according to the first report on “self-embedding disorder,” or self-injury and self-inflicted foreign body insertion in adolescents. These findings were presented at RSNA 2008. The study’s principal investigator, William E. Shiels II, D.O., chief of the Department of Radiology at Nationwide Children’s Hospital in Columbus, Ohio said that radiologists were in a unique position to be the first to detect self-embedding disorder, make the appropriate diagnosis and mobilise the healthcare system for early and effective intervention and treatment. Dr Shiels and colleagues studied 19 episodes of self-embedding injury in 10 adolescent girls, age 15 to 18. Using ultrasound and/or fluoroscopic guidance, interventional paediatric radiologists removed 52 embedded foreign objects from nine of the patients. The embedded objects included metal needles, metal staples, metal paperclips, glass, wood, plastic, graphite (pencil lead), crayon and stone. The objects were embedded during injuries to the arms, ankles, feet, hands and neck. One patient had self-embedded 11 objects, including an unfolded metal paperclip more than six inches in length. Ultrasound guidance allowed the researchers to detect the presence and location of wood, crayons and plastic objects, not detectable on x-ray examinations. Removal was performed through small incisions in the skin that left little or no scarring and was successful in all cases, without fragmentation or complications.
jet ventilation the new generation
from intubation to longterm ventilation
Radiologists diagnose and treat self-embedding disorder
Self-injury, or self-harm, refers to a variety of behaviours in which a person intentionally inflicts harm to his or her body without suicidal intent. It is a disturbing trend among U.S. adolescents, particularly girls. Recent studies have reported that 13 to 24 percent of high school students in the U.S. and Canada have practiced deliberate self-injury at least once. More common forms of self-injury include cutting of the skin, burning, bruising, hair pulling, breaking bones or swallowing toxic substances. In cases of self-embedding disorder, objects are used to puncture the skin or are embedded into the wound after cutting. Minimally invasive, image-guided treatment is
> Integrated heating and humidiﬁcation system > Default settings > Optional: Double Jet, EtCO2, Video Camera > 9“ Color Touch Screen > Special parameters for superimposed jet MEdICA ventilation hall 11, stand H11
for more info see editorial
www.ihe-online.com & search 45360
www.ihe-online.com & search 45294
– Issue N°5 – Oct. 2009
MAGNEtIC rEsONANCE IMAGING
Functional MrI of the kidneys
Functional renal Mr imaging is a new and exciting field enabling non-invasive assessment of renal function. diffusion weighted imaging (dWI), Blood Oxygen Level dependent (BOLd) MrI, and magnetic resonance elastography (MrE) are some of the evolving techniques. In this article, we introduce readers to the basic principles of these techniques and their potential applications.
by dr L. Mannelli, dr d. Kim and dr H. Chandarana
Renal function is currently assessed by measuring the serum creatinine level and calculating the glomerular filtration rate (GFR) using one of several formulae . This method is imprecise, does not assess for early reversible renal damage and cannot be used to measure split renal function, i.e. function of each kidney separately . Routine morphologic evaluation with ultrasound, CT and MR, as used in clinical practice, provides only minimal functional information. Nuclear medicine (NM) tests provide functional information but are limited in renal morphologic evaluation due to poor spatial resolution. MR imaging has the potential to offer a comprehensive evaluation of structure and function in renal disease by utilising novel functional imaging techniques like diffusion weighted imaging (DWI), magnetic resonance elastography [MRE] and Blood Oxygen Level Dependent (BOLD) MRI. in capillaries can mimic diffusion at low b values and these perfusion parameters can be extracted if imaging is performed with both low and high b values . Some early studies in renal transplants and in diffuse renal diseases have explored multi-b value imaging . allograft dysfunction without the use of exogenous contrast agent. In patients at high risk for developing nephrogenic systemic fibrosis (NSF), this can be an alternative approach in the assessment of renal function . 3. Renal artery stenosis (RAS) Powers et al. demonstrated that DWI with multiple b values can be used to measure changes in renal blood flow in a canine model of RAS. Thus, the perfusion fraction generated from DWI with multiple b-values, without the use of exogenous gadolinium contrast, has a potential role in evaluating patients with RAS . Yildirim et al. showed that patients with severe RAS had significantly lower ADC values . Hence, ADC values can be used to differentiate patients without RAS, or with mild RAS, from patients with moderate and severe RAS. DWI can potentially provide split renal function without the use of exogenous contrast agent. The technique can be implemented in routine practice without a significant time penalty. The lack of consensus regarding the selection of b values makes it difficult to compare results from different investigators and to generate standardised ADC values in disease and health.
Current and potential applications
1. Chronic renal failure (CRF) Several studies have demonstrated that ADC values of renal cortex and medulla are lower in patients with renal insufficiency when compared to normal healthy kidneys. For example, a study by Bozgeyik et al. demonstrated that an obstructed non-functioning kidney has a lower ADC compared to the contralateral normal functioning kidney . These studies highlight the potential role of renal ADC values in the evaluation of renal dysfunction in native kidneys . 2. Renal allograft In an animal model, the ADC values of renal cortex and medulla were noted to be lower in allografts compared to native kidneys. Thus, DWI could potentially evaluate renal
Diffusion weighted MRI (DWI)
DWI is based on measurement of Brownian motion of water molecules in biological tissues. Apparent diffusion coefficient (ADC) calculation can be used for quantification of the combined effects of capillary perfusion and diffusion. DWI has been routinely used in neurologic imaging . With technical advances, there has been tremendous interest in applying this technique to abdominal imaging. Studies have explored its potential role in liver lesion detection and characterisation, assessment of chronic liver disease and evaluation of renal mass [3, 4]. A handful of studies have also explored the role of DWI in the evaluation of renal function [4 - 6], [Figure 1]. Single shot echo-planar imaging is the sequence most commonly used in clinical practice. In routine practice, diffusion weighted imaging is performed using one low and one or two high b values. The ADC calculation is performed as follows: ADC (mm2 /sec) = (-1/b) ln S1/S0 b = diffusion factor S0 = Signal Intensity (SI) with b=0 S1 = SI after application of diffusion gradient Most studies prefer to exclude imaging at lower b values since signal intensity at lower b values is influenced by the perfusion component. Le Bihan, in his seminal work, has shown that blood flow
Blood oxygen level dependent (BOLD) MRI
BOLD MRI provides an indirect non-invasive measurement of renal oxygenation status. It relies on the different magnetic properties of deoxyhaemoglobin, which is paramagnetic, and oxyhaemoglobin, which is diamagnetic, to acquire images sensitive to local oxygen concentration. With an increase in tissue deoxyhemoglobin concentration, there is accelerated dephasing and a decrease in the T2* relaxation time of the protons in the surrounding tissues. This means that at higher tissue oxygenation there is lower deoxyhemoglobin concentration which results in higher T2* and correspondingly shorter R2*, with R2* = 1/T2* [9, 10], [Figure 2]. A multiple echo gradient-recalled-echo sequence is a rapid sequence that is most commonly used for renal BOLD MRI. Eight to sixteen echoes with different echo times (TE) are acquired with each excitation pulse. Maximum TE should be 50 milliseconds at 1.5 T and 25 milliseconds at 3T based on the T2* of the renal medulla. R2* can be obtained by measuring the slope of the line fit of the natural log of signal intensity vs. TE. An R2* map can be generated by calculating the R2* on a pixel by pixel basis using appropriate software. Regions of interest (ROI) defined on the anatomical template can then be copied and pasted on the R2* maps to estimate the medulla and cortex R2* [9,10].
Figure 1. (A) ADC map obtained at DWI in a 35 year old male with no known renal disease and normal serum creatinine demonstrating corticomedullary differentiation with lower ADC of the medulla with respect to the cortex. In contrast, (B) ADC map in a 84 year old male with chronic renal insufficiency (GFR < 30), demonstrating loss of corticomedullary differentiation.
– Issue N°5 – Oct. 2009
Lighting for intensive care units and recovery rooms
Appropriate lighting is essential in ICUs to provide optimal work conditions for healthcare professionals. However, the seriousness of the patients’ conditions and the anxiety incurred by patients waking up from anaesthesia requires recovery rooms which are more discreetly illuminated. A combination of Dmed halux and Dlite vanera examination lights and reading lights can satisfy these needs of both healthcare professionals and patients so that for example, highly-intense light can be quickly obtained for treating a patient who is in a reduced ambient light. This is ideal for short interventions such as setting up perfusions or giving injections. The compact and simple design of the luminaires allows easy operation. Indirect light avoids too much glare for patients in the recovery phase, and wall-mounted luminaires in warm tones create a feeling of well-being for patients. In addition, the lights are energy-efficient with a low electricity consumption and electronic ballasts; the closed design of the luminaire allows easy cleaning.
Figure 2. T2* map obtained with BOLD imaging (A) in a 35 year old healthy male with no known renal disease demonstrating corticomedullary differentiation with hypoxic (darker) medulla and (B) in a 49 year old male with chronic renal insufficiency (GFR < 30) demonstrating loss of corticomedullary differentiation.
Current and potential applications
1. Renal artery stenosis Animal studies have shown the ability of BOLD MRI to measure changes in renal perfusion . Textor et al used BOLD MRI and a furosemide challenge in patients with reduced GFR and high grade renal artery stenosis to differentiate between kidneys with preserved functional reserve versus nonfunctioning kidneys. Kidneys that were atrophic and nonfunctioning did not demonstrate a change in R2* in response to furosemide, whereas functioning kidneys showed improved oxygenation . The role of this technique in appropriately selecting patients for RAS treatment is under investigation. 2. Renal allograft dysfunction After transplantation, differentiating acute rejection from acute tubular necrosis (ATN) is a clinical challenge question since both conditions present with abnormal serum creatinine and decrease in GFR. Sadowski et al have shown that patients in acute rejection have significantly lower R2* (higher oxygenation) in the medulla with respect to the patients with ATN and normal transplants. Decreased oxygen utilisation and/or increased corticomedullary shunting of the blood are the proposed reasons for this finding. ATN causes an increase in cortical R2* compared to normal transplants and patients with acute rejection, likely due to ischemic insult. BOLD MRI has the potential to replace renal biopsy in the evaluation of acute transplant dysfunction once larger studies confirm these initial promising results . The BOLD MRI technique allows noninvasive measurement of renal hypoxia and can provide information regarding the metabolic status of the kidney.Multiple factors such as oxygen supply and consumption, blood flow, and haemoglobin level influence signal intensity on BOLD MRI. Consequently, direct calibration of R2* vs. pO2 is unreliable. Furthermore, the absolute magnitude of R2* is less reliable than the relative changes observed in response to various physiologic and pharmacologic challenges.
DeRungS LiCht Ag gossau, Switzerland
Medica: Hall 13 A14 www.ihe-online.com & search 45385
Dmed® halux LED 20 P LX
Dmed® halux LED 20 C L1
Medica 2009, Düsseldorf, Hall 13 / Booth A 14
MULTI-FACETTED LIGHT FOR FLEXIBLE APPLICATION
• 50 000 lux/0.5 m
Flexible regulation of luminosity • Dimmable in 5 stages Changeable light colour • 3 colour levels allow better viewing of contrasts State-of-the-art LED technology • Nearly no heat radiation from the light • Considerable energy savings Compact design • Practical and space-saving Easy and clear control panel • Directly on the light head
Figure 3. 32 year old healthy male with no known renal disease imaged with MRE imaging with patient in prone position: gradient echo MRE acquisition magnitude images (a) and three sets of post processed images are displayed: a stiffness colour map (b), the MRE inversion stiffness greyscale images (c), and the wave images (d).
Innovative arm system • Precise and steady arm positioning
Derungs Licht AG (Derungs Medical Lighting) • Hofmattstrasse 12 • 9200 Gossau • Switzerland Telefon +41 71 388 11 66 • Fax +41 71 388 11 77 • firstname.lastname@example.org • www.derungslicht.com
www.ihe-online.com & search 45222
– Issue N°5 – Oct. 2009
MAGNEtIC rEsONANCE IMAGING
weighted echo-planar MR imaging. J Magn Reson Imaging 1999;9:832-837. 5. Bozgeyik Z, Kocakoc E, Sonmezgoz F. Diffusion-weighted MR imaging findings of kidneys in patients with early phase of obstruction. Eur J Radiol 2009;70:138-41. 6. Thoeny HC et al. Functional evaluation of transplanted kidneys with diffusion-weighted and BOLD MR imaging: initial experience. Radiology 2006;241:812-821. 7. Powers TA et al. Renal artery stenosis: in vivo perfusion MR imaging. Radiology 1991;178:543-548. 8. Yildirim E et al. Diffusion-weighted MR imaging of kidneys in renal artery stenosis. Eur J Radiol 2008; 65:148-153. 9. Juillard L et al. Blood oxygen level-dependent measurement of acute intra-renal ischemia. Kidney Int 2004;65:944-950. 10. Sadowski EA et al. Assessment of acute renal transplant rejection with blood oxygen level-dependent MR imaging: initial experience. Radiology 2005;236:911-919 11. Textor SC et al. The use of magnetic resonance to evaluate tissue oxygenation in renal artery stenosis. J Am Soc Nephrol 2008;19:780-788. 12. Shah NS et al. Evaluation of renal parenchymal disease in a rat model with magnetic resonance elastography. Magn Reson Med 2004;52:56-64.
Magnetic Resonance Elastography (MRE)
MRE is a technique that utilises cyclic motionsensitising gradients to image applied propagating acoustic shear waves. Shear waves are applied to organs or tissues by mechanical devices and produce tissue displacement on the order of nanometres to micrometres. Propagation of the waves is dependent on the viscoelastic properties of the imaged tissue. These displacements are directly measured and visualised with MRE. Local frequency estimation inversion algorithm is used to determine the spatial frequency and other parameters of the imaged waves . The mechanical properties of the tissue are then calculated from this information and displayed as a parametric image map. Organs stiffness values in Pascals can be obtained by placing ROIs outlining the organ margins on the axial sections of the gradient echo magnitude images and then copying and pasting the ROIs on the MRE inversion stiffness images , [Figure 3]. Shah et al. in an animal model demonstrated an increment in kidney stiffness after induced renal nephrocalcinosis associated with mild renal insufficiency . The same group has also studied the renal stiffness in healthy volunteers. The role of MRE in the evaluation of renal diseases in native and transplanted kidneys is currently under investigation.
Non-invasive imaging techniques, including DWI and BOLD MRI, have tremendous potential in the clinical evaluation of renal function. The preliminary data using these techniques are promising but larger studies must follow. If these techniques fulfill their promise, a new paradigm will emerge in the comprehensive evaluation of renal function incorporating both anatomic and functional assessments.
We would like to acknowledge Professor David J Lomas and the University Department of Radiology, Cambridge, UK for the MRE images.
1. Coresh J, Auguste P. Reliability of GFR formulas based on serum creatinine, with special reference to the MDRD Study equation. Scand J Clin Lab Invest Suppl 2008;241:30-38. 2. Le Bihan D et al. MR imaging of intravoxel incoherent motions: application to diffusion and perfusion in neurologic disorders. Radiology 1986;161:401-407. 3. Gourtsoyianni S et al. Respiratory gated diffusionweighted imaging of the liver: value of apparent diffusion coefficient measurements in the differentiation between most commonly encountered benign and malignant focal liver lesions. Eur Radiol 2008; 18:486-492. 4. Namimoto T et al. Measurement of the apparent diffusion coefficient in diffuse renal disease by diffusion-
Lorenzo Mannelli MD, Danny Kim MD, Hersh Chandarana MD. Departments of Radiology NYU Langone Medical Center New York, NY, USA.
www.ihe-online.com & search 45314
– Issue N°5 – Oct. 2009
Improving hand hygiene in the hospital setting
Hand hygiene is a term that incorporates the decontamination of the hands by methods including routine hand washing, surgical hand washing and the use of alcohol hand rubs and gels. Although recognised as an essential practice for infection control and patient safety, healthcare workers do not necessarily comply with prescribed hand hygiene protocols. this article presents evidence-based approaches to improving hand hygiene in the hospital setting.
by dr C. day
It has been a challenge to get healthcare workers (HCWs) to consistently comply with hand hygiene practices. This is despite the abundance of scientific evidence to demonstrate that poor HCW hand hygiene puts hospitalised patients at risk. Leaders in healthcare organisations cannot assume that all staff consistently perform proper hand hygiene routines as studies have indicated a wide range compliance with hand hygiene practices. Practitioners including nurses, physicians and other ancillary staff, cite numerous reasons for not complying with hand hygiene protocols. Selfreported reasons for poor hand hygiene include product related issues such as skin irritation or hand dryness, inconvenient placement of sinks, lack of soap and towels, inaccessibility of hand gel or alcohol-based hand rub (AHR), understaffing, lack of time, prioritisation of other patient needs over the time it would take to perform hand hygiene, and practitioner belief that the risk of transmitting infection to a patient is low . An evidence-based guideline was developed and some of its recommendations and strategies were utilised in an academic medical centre as a useful tool to improve hand hygiene of workers, patients, and families. Five areas, each with at least two strategies supported by the literature, were identified in the guideline. The five recommendations included a programme or campaign to draw awareness of HCWs and patients to the importance of hand hygiene; education regarding protocols and techniques; performance feedback; product selection and availability; and organisational commitment and leadership. Understanding the organisation-specific reasons for non-compliance, designing a programme founded on evidence-based interventions, and strong leadership commitment were keys to the success of a programme that resulted in improved performance . An evidence-based approach to improvement can be successfully applied in other organisations. the organisational, nursing unit and departmental levels will lead to identification and implementation of evidence-based recommendations that are the most likely to result in improved performance. The second step of the nursing process is diagnosis. Based on the data gathered in the assessment phase, the team should next analyse the assessment data, and clearly identify the discrete problems and their causes. Determination of whether the problems are related to a HCW knowledge deficit, product or environmental factors, lack of awareness, time constraints, individual accountability, or leadership is important. Key variables to consider before planning an intervention strategy are; a clear definition of the problem, the causative factors, and where and how pervasive the problems are in the organisation. The third step of the nursing process is planning. This step involves taking the problems that were identified in the diagnosis step and identifying the specific evidence-based recommendations and strategies that are most likely to effect an improvement. Some recommendations might be appropriate to implement house-wide (e.g. an institutional hand hygiene campaign); others might be more appropriate at a unit level (e.g. the Intensive Care Unit (ICU) sink availability is not adequate therefore AHR is needed at the bedside, or staff education regarding the policy needs to be reinforced). Becoming a stakeholder (nurse, physician, ancillary, leadership) in the planning process can be an effective way to gain insight into the development of plans and strategies that will work in the organisation but that the staff will also engage in and support.
In order to implement a programme to improve hand hygiene, an effective approach is to first identify a small multi-disciplinary team to champion and lead the initiative. Membership should include staff from nursing and ancillary disciplines, infection control, quality control and medical staff, and administration. A team leader, or co-leaders, from the highest levels of clinical leadership is important in setting the stage and importance of the project. Team education, and a review of the literature and most current guidelines for practice are important. Identification of the team’s objectives, target improvement goal and timelines, along with a framework such as the ‘nursing process’ (assessment, diagnosis, planning, implementation and evaluation) to guide the work are also important. Utilising the nursing process framework, assessment is a first step in order to effectively determine the current state. An assessment of the risks and barriers to hand hygiene should be conducted. Determining whether the policies and procedures regarding hand hygiene are evidence-based and clearly written and the staff’s level of knowledge and understanding of those policies, as well as assessing the availability and placement of hand hygiene products including AHR, are examples of basic information required for an assessment related to hand hygiene. Collection of baseline hospital-acquired infection (HAI) rates and surveillance of HCW hand hygiene practice would provide baseline data and information upon which to help determine appropriate recommendations. Assessment at
The planning step should include the development of detailed written plans specific to each problem identified, including a goal, the guideline recommendation identified to address the problem, the individual(s) who will be accountable for implementation, metrics and a date for completion. The plan should also include a comprehensive communication plan, dates for follow-up evaluation and a budget. Implementation follows the planning phase and should include the communication and implementation of the specific recommendations. Periodic team meetings throughout the process should be conducted in order to ensure that implementation is progressing as planned, or that appropriate course corrections and problem solving are conducted in a timely manner. Barriers to implementation – real or potential - should be anticipated and contingencies identified. The final step is ongoing evaluation of the programme. Building metrics into the organisational and departmental dashboards is important for ongoing monitoring and accountability. Reporting structure, frequency for reporting and accountability expectations should be built into the plan along with feedback, recognition and celebration plans.
– Issue N°5 – Oct. 2009
Numerous organisational issues, including resistance, should be anticipated. Improving hand hygiene may not be perceived as an exciting or even necessary initiative and engagement of staff champions and team members could be difficult. A second challenge may be the time taken to systematically assess and plan the initiative. Many organisations and healthcare leaders are eager to find a “quick fix” rather than taking the time to assess a problem and then strategically implement well-planned interventions. A key strategy for success is to ensure leadership commitment to the initiative. Presentation of the plan to the senior executives, senior leadership and to the governing body of the organisation for endorsement and support is important to success. Periodic progress reports to each of these levels, including barriers, successes and outcomes are important. Management team commitment and involvement would also be key for the achievement of successful outcomes. An additional challenge could be resources, both in labour requirements (e.g. additional expenses related to training and staff participation on an implementation team) and in materials and supplies (e.g. AHR, posters, educational materials, etc). Finally, one of the most difficult challenges might be competing priorities in the institution and the availability of resources to be dedicated to the project.
St an d B0 5
www.ihe-online.com & search 45359
Healthcare organisations and healthcare workers have a responsibility and an obligation to protect patients from harm, including prevention of hospital-acquired infections. The development and application of evidence-based policies and procedures, along with evidence-based approaches to improving hand hygiene in the hospital setting can lower infection rates and thus positively impact on patient care outcomes.
1. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000; 21(6):381-386. 2. Day C. Engaging the Nursing Workforce: An Evidence-Based Tool Kit. Nurs Admin Q 2009: 33(3): 238-244.
Cindy Day, DNP, RN, NEA, BC Stanford Hospital and Clinics Stanford, CA, USA e-mail: email@example.com
www.ihe-online.com & search 45275
Ha ll 9
– Issue N°5 – Oct. 2009
the challenges of implementing infection control procedures in limited resource hospitals
Healthcare-associated infections constitute an important public health problem in developing countries. In many hospitals, infection control procedures are limited by the lack of financial resources, poor infrastructure, overcrowding, inadequate hygiene, deficient laboratory services, poor management, insufficient technology and a shortage of trained staff. the best solutions entail greater governmental commitment and application of infection control procedures consistent with available resources.
by dr Lul raka and dr Gjyle Mulliqi-Osmani
Infectious diseases are a worldwide concern and the second most common cause of death globally. Of the 12 million deaths that occur globally, 95% take place in developing countries, where disease prevention and control policies are either non-existent, poorly adapted or insufficiently funded by governments. Healthcare-associated infections (HCAIs) constitute an important health problem throughout the world and pose a major threat to patient safety. HCAIs impact on the population in many ways. They affect patients directly, causing increased morbidity and mortality; they may lead to disability; and they may reduce quality of life. They also impact on the healthcare system by extending hospitalisation of affected patients and driving up the costs of diagnosis and treatment. HCAIs may be transmitted from healthcare settings into the community, so damaging the reputation of healthcare institutions in the eyes of the public. The majority of HCAIs relate to medical devices, e.g. pneumonia related to mechanical ventilation, urinary tract infections (UTIs) to urinary catheters, surgical site infection (SSI) after trauma or surgery, and bacteraemia derived from intravascular devices. UTIs constitute 30-40% of all nosocomial infections. In intensive care, even in highly resourced units in industrialised countries, ≥25% of patients admitted develop HCAI with a mortality >25%, and in developing countries 66% of patients admitted to the intensive care unit (ICU) develop a HCAI. Ventilator-associated pneumonia (VAP) is a leading cause of death in hospitalised patients in developing countries with rates from 10 to 41.7 per 1000 ventilator-days and a crude mortality ranging from 16% to 94%. Many studies have shown the importance of HCAI among neonates in developing countries, where an average of 4384 children die every day from these infections with rates of infections three to 20-fold higher than those reported in industrialised countries. Between 5% and 10% of human immunodeficiency virus (HIV) infections worldwide are transmitted through transfusion of contaminated blood and blood products. Over 16 billion injections are administered each year in developing and transitional countries and the proportion of injections given by syringes and needles that are re-used without sterilisation ranges from 1.5 to 69.4%. The economic burden of HCAI is substantial everywhere, although it varies from country to country. Jarvis  showed an estimated average cost of (US) $558 to $593 for each UTI, $2,734 for each SSI, $3,061 to $40,000 for each bloodstream infection, and $4,947 for each case of pneumonia. In countries with prospective payment systems based on diagnosis-related groups, hospitals lose from $583 to $4,886 for each nosocomial infection. In developing countries, the great majority of funding is traditionally allocated to hospitals in urban centres, which often have academic affiliations. In some hospitals, adequate supplies to help control infections of normally sterile body sites, mucous membranes and non-intact skin are not available. Overcrowding and understaffing, particularly in the ICU, results in decreased hand hygiene compliance; frequent movement of patients and staff between hospital wards results in an increased risk of transmission of multidrugresistant micro-organisms. Such transmission is often exacerbated by overcrowding, with patients sometimes sharing beds and supplies. There may be a lack of commitment to healthcare by policymakers in the developing world and allocation of funds is often disproportionate to the priorities set by providers. Corruption and nonformal payments are frequent. Information systems are not fully developed. There are limited grants available for research and no legislation mandating accreditation of hospitals or infection control programmes. In-service training for employees is highly variable and often minimal. Transfusion and injections may pose a risk for transmission of HIV and hepatitis. Many other problems abound, for example, sterilisation departments are not centralised and there is lack of quality control in disinfection and sterilisation. Although many hospitals in the developing world may have infection control programmes and committees on paper, in practice they barely exist. Inadequate numbers of trained personnel work in infection control, and they face continual resistance from clinical staff. In addition, inadequate salaries lower healthcare workers’ morale. This litany of problems means that the response by management and staff to common outbreaks of disease in high risk units is mainly reactive rather than proactive. Lack of ongoing surveillance results in delays in detecting outbreaks, with increasing costs and mortality as a result. Resistance to antimicrobial agents is a another important issue in all healthcare facilities. In developing countries inappropriate and uncontrolled use of antibiotics is very common and antimicrobials are frequently available over the counter in pharmacies. The quality and potency of antibiotics are often suspect, with unregulated import, registration and distribution. Between 20% and 50% of a hospital budget is spent on antimicrobials, which are used to treat more than half of all patients. Misuse has been identified as an important factor in the emergence of antimicrobial resistance. In turn, this resistance makes the clinical management of patients more difficult. As a consequence of the weakness and problems outlined above, developing countries face the challenge of high rates of HCAI and frequent
Infection control and hospitals with limited resources
For governments of developing countries, limited resources represent the main challenge to implementing infection control procedures. During the last few decades, infection control activities in developing countries have increased, particularly in South America, South East Europe and countries of the former Soviet Union. Public pressure to improve the quality of hospital care and the increased cost resulting from HCAIs in healthcare systems have played important roles in this development. A high frequency of HCAIs in a healthcare facility is an indicator of the poor quality of healthcare services. HCAIs represent one of the most common complications of healthcare, affecting about two million people admitted to acute hospitals annually. These infections complicate 5-10% of admissions to acute care hospitals in industrialised countries. By contrast, HCAIs occurred in >40% of hospitalisations in developing countries in Asia, Latin America and sub-Saharan Africa.
nosocomial outbreaks. Another consequence of insufficient infection control infrastructure is the spread of multidrug-resistant organisms, such as meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrumbeta-lactamase-producingGramnegative bacilli, multidrug-resistant Mycobacterium tuberculosis and fluconazole-resistant Candida spp.
– Issue N°5 – Oct. 2009
Global initiatives: World Alliance for Patient Safety
Improving the safety of patient care is now a global issue. A growing awareness of HCAI and patient safety prompted the WHO to promote the creation of the World Alliance for Patient Safety to coordinate, spread and accelerate improvements in patient safety.
Challenges and solutions
Most HCAIs can be prevented using readily available and relatively inexpensive strategies. Studies showed that effective infection control programmes can reduce infection rates by as much as 30-70% and are cost-effective. To meet the required level of prevention, multiple strategies must be implemented simultaneously. These so-called ‘bundles’ usually represent a set of three to five practices that, when performed collectively, reliably and continuously have been proven to improve patient outcomes.
Research: International Nosocomial Infection Control Consortium
One measure to improve the knowledge base of infection control is through research and development. An important window for research in developing countries arose through the International Nosocomial Infection Control Consortium (INICC). The INICC is the first multinational research network established to control HCAI in hospitals in limitedresource countries. It has developed to a dynamic network of over 100 healthcare centres in 85 cities, from 30 countries of four continents, and is the only source of aggregate standardised international data on HCAI epidemiology in intensive care. Rates of device-associated nosocomial infection have been found to be three to five-fold higher compared to in the developed world.
5. Rosenthal VD et al. Am J Infect control 2008;36:627637. 6. Arabi Y et al. Int J Infect Dis 2008;12:505-512. 7. Zaidi AK et al. Lancet 2005; 365:1175-1188. 8. Jarvis WR. Infect Control Hosp Epidemiol 1996;17:552-557. 9. Okeke IN et al. Lancet Infect Dis 2005; 8:481-493. 10. Harbarth S, Sax H, Gastmeier P. J Hosp Infect 2003;54:258-266.
Lul Raka, M.D. Ph.D & Gjyle Mulliqi-Osmani, M.D. Ph.D. National Institute of Public Health of Kosova & Medical School, Prishtina University, Kosova Correspondence to: Dr Lul Raka Rrethi i spitalit, p.n., 10000 Prishtina, Kosova e-mail: firstname.lastname@example.org Tel: +37744 368 289
An important factor in the prevention of HCAI is commitment. National authorities must understand that without the proper resources, hospitals can be high-risk areas. Therefore, healthcare authorities must establish and support a comprehensive, effective national programme. Many countries already have such programmes. If these are not available, programmes from the developed world should be adopted.
Other prevention/control procedures
Education of healthcare workers, standard precautions and safe and appropriate use of injections are important for prevention and control of HCAI. Important steps in prevention of HCAI are introduction of validated processes for decontamination, cleaning and sterilisation or high level disinfection of soiled instruments and other items; and improving safety in operating rooms and other high risk areas. Due to their contact with patients or infected material from patients, many healthcare workers are at risk of exposure to, and possible transmission of, vaccine-preventable diseases. Immunisation of health care workers is an essential part of prevention and infection control programmes.
Hand hygiene remains the simplest and the primary measure to prevent HCAI and reduce spread of multidrug-resistant organisms. Although hand hygiene is a simple measure, the lack of compliance among healthcare workers is problematic worldwide, averaging <40%. Introduction of alcohol- based hand rub has led to increased hand hygiene compliance among healthcare workers and fewer HCAIs. In some developing countries, implementation of education, process surveillance and performance feedback has considerably enhanced hand hygiene compliance.
www.ihe-online.com & search 45311
HCAIs represent a threat to patient safety and quality healthcare. The sustainability of any activity undertaken will have a great impact on the final outcome. Through focusing on infection control, countries with limited resources can improve the quality of healthcare in the future.
Surveillance is an essential component in HCAI prevention, with the aims of outbreak identification, establishment of endemic baseline rates of infection and the evaluation of control measures. Surveillance data can be used to identify preventable infections in high-risk areas, so that resources are targeted to high-priority areas.
1. Lynch P et al. Infection control in developing countries. In: Jarvis WR, editor. Bennett and Brachman’s Hospital Infections. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 240-255. 2. Ponce-de-Leon-Rosales S, Macias A. In: Wenzel RP, editor. Prevention and control of nosocomial infections. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2003. p. 14-33. 3. Morris K. Lancet 2008;372:1941-1942. 4. Pittet D, Donaldson L. Int J Qual Health Care 2006;18:4-8.
Combating antibiotic resistance
There is good evidence that antibiotic stewardship programmes have been successful in modifying antimicrobial prescribing practices, resulting in reduction of use in most cases. Unfortunately, such programmes are often lacking in developing countries, and antimicrobial resistance problems emphasise the importance of strengthening the clinical microbiology laboratory services.
www.ihe-online.com & search 45309
reflecting the importance of the subject and the interest in it, the number of peer-reviewed papers covering infection control is huge, to such an extent that it is frequently difficult for healthcare professionals to keep up with the literature. As a special service to our readers, IHE presents a selection of literature abstracts, chosen by our editorial board as being particularly worthy of attention. the effect of environmental parameters on the survival of airborne infectious agents.
The successful transmission of infection via the airborne route relies on several factors, including the survival of the airborne pathogen in the environment as it travels between susceptible hosts. This review summarises the various environmental factors (particularly temperature and relative humidity) that may affect the airborne survival of viruses, bacteria and fungi, with the aim of highlighting specific aspects of environmental control that may eventually enhance the aerosol or airborne infection control of infectious disease transmission within hospitals.
Tang JW. J R Soc Interface 2009; Sep 22.
– Issue N°5 – Oct. 2009
prevention and control. Key strategies for prevention and control focus on contact precautions, the management of invasive devices and maintaining a clean, dry environment to prevent the build-up of environmental reservoirs and cross-infection.
Gould D. Nurs Stand. 2009 Aug 5-11; 23(48):42-6.
Five years of implementing a methicillin-resistant Staphylococcus aureus “search and destroy” policy.
The effectiveness of a rigorous search and destroy policy for controlling methicillinresistant Staphylococcus aureus (MRSA) infection or colonisation was evaluated at the largest university medical centre in the Netherlands. Outbreak control was accomplished by the use of active surveillance cultures for persons at risk, by the preemptive isolation of patients at risk, and by the strict isolation of known MRSA carriers and the eradication of MRSA carriage. For unexpected cases of MRSA colonisation or infection, patients placed in strict isolation or contact isolation and healthcare workers (HCWs) were screened. Data were collected from 2000-2004. During the 5-year study period, 51,907 MRSA screening cultures were performed for 21,598 persons at risk (8,403 patients and 13,195 healthcare workers, HCWs). It was determined that 123 (1.5%) of 8,403 patients and 31 (0.2%) of 13,195 HCWs were MRSA carriers. From the results of clinical cultures, it was determined that 54 additional patients were MRSA carriers, resulting in a total of 177 patients carrying MRSA. The average number of nosocomial transmissions was 6.7 per year. The cumulative incidence of MRSA colonisation among this group of patients was 0.10 cases per 100 admissions. Of 156 cases of MRSA colonisation, 44 (28%) were acquired in a healthcare institution outside the Netherlands, and 45 (29%) were acquired in other Dutch hospitals, 22 (47%) of which were acquired in a single hospital. There were 16 cases (10%) that occurred in a nursing home and another 16 cases (10%) that fulfilled the definition of community-acquired MRSA colonisation; there were 4 cases (3%) categorised as “other” and 31 cases (20%) for which the source of MRSA acquisition remained unknown. During the 5-year study period, five episodes of MRSA bacteraemia occurred in which four patients died, an incidence rate of 0.28 cases of infection per 100,000 patient-days per year. Results show that during a rigorous search and destroy policy a low incidence of MRSA was continuously observed and that this policy most likely contributed to a very low nosocomial transmission rate.
Vos MC et al. Infect Control Hosp Epidemiol 2009 Oct;30(10):977-84.
www.ihe-online.com & search 45355
Evolving concepts in Clostridium difficile colitis.
Clostridium difficile infection (CDI) is the most important cause of nosocomial diarrhoea. The emergence of a hypervirulent strain and other factors including antibiotic overuse contribute to the increasing incidence and severity of this potentially lethal infection. CDI has been reported in persons previously considered as low risk, such as peripartum women, children and young healthy persons without exposure to healthcare settings or antibiotics. In patients with inflammatory bowel disease, the risk of C. difficile infection is greater, with higher rates of hospitalisation, bowel surgery and mortality. With increasing incidence and severity of disease, the need for improved diagnostic, treatment and infection control strategies cannot be overstated.
Diggs NG, Surawicz CM. Curr Gastroenterol Rep 2009 Oct;11(5):400-5
www.ihe-online.com & search 45340
Effective strategies for prevention and control of Gram-negative infections.
Infections caused by Gram-negative bacteria such as Pseudomonas, Klebsiella, Proteus and Acinetobacter have been a major problem in healthcare settings for many years. Overlooked in most government targets and unknown to most patients, these infections present considerable challenges for effective infection
HAVE YOU RENEWED YOUR FREE SUBSCRIPTION ? www.ihe-online.com
– Issue N°5 – Oct. 2009
NEWs IN BrIEF
shed new light on the types of vulnerable plaque that are most likely to cause sudden, unexpected adverse cardiac events, and on the ability to identify such plaques through imaging techniques before adverse events occur. This multi-centre trial, which is the first prospective natural history study of atherosclerosis using multimodality imaging to characterise the coronary tree, studied 700 patients with acute coronary syndromes (ACS). It used three-vessel multimodality intracoronary imaging – angiography, intravascular ultrasound (IVUS) and virtual histology – to quantify the clinical event rate due to atherosclerotic progression and to identify those lesions that place patients at risk of unexpected adverse cardiovascular events (sudden death, cardiac arrest, heart attacks and unstable or progressive angina). Among the discoveries of the trial are that most untreated plaques that cause unexpected heart attacks are not mild lesions, as previously thought, but actually large, with a small lumen area. These are characteristics that were invisible with coronary angiogram but easily identifiable by IVUS. Only about half of new cardiac events due to non culprit lesions exemplified the classic notion of vulnerable plaque (rapid lesion progression of non flow limiting lesions), while half were attributable to unrecognised and untreated severe disease with minimal change over time. Perhaps most importantly, for the first time it was demonstrated that characterisation of the underlying plaque composition (with virtual histology) was able to significantly improve the ability to predict future adverse events beyond other more standard imaging techniques.
Identification of highly radiosensitive patients may lead to side effect-free radiotherapy
An international group of scientists has taken the first step on the road to targeting radiotherapy dosage to individual patients by means of their genetic characteristics. Professor Dirk de Ruysscher, from Maastricht University Medical Centre, Maastricht, The Netherlands said that his team’s work might provide the basis for personalised radiotherapy in which, with a simple blood test, it may be possible to select the optimal radiation dose for a particular patient. The team of scientists from The Netherlands, Belgium, Germany and Canada studied a group of patients with hypersensitivity to radiation therapy, drawn from the largest world-wide database available – the European Union-funded GENEtic pathways for the Prediction of the effect of Irradiation (GENEPI) study, which combines biological material with patient data and treatment specifications. The database included information from more than 8000 European patients. A tissue bank including skin fibroblasts, whole blood, lymphocytes, plasma and lymphoblastic cell lines from patients who were known to be hypersensitive to radiation was established from patients in Europe and Canada. When compared with a control group, also drawn from the GENEPI study, the hypersensitive patients showed either severe side effects occurring at very low radiation levels, or severe side effects lasting for more than four weeks after the end of radiotherapy and/or requiring surgery, or severe late side effects occurring or persisting more than 90 days after the end of radiotherapy. Thirtythree such patients, 10 males and 23 females, were identified, of whom 11 (two males and nine females) ultimately proved to be really hypersensitive to radiation, underlining the rarity of this condition. Different types of tumours respond differently to radiotherapy; highly radiosensitive cancer cells such as leukaemias can be killed by quite low radiation doses, whereas melanomas need such a high dose that it would be unsafe to use radiation therapy in such cases. However, the finding that individuals, as well as tumours, react differently will allow doses to be even more carefully targetted in future, taking into account not just the radiosensitivity of the tumour type but also the potential reaction of the particular patient to treatment.
Improved prostate cancer identification using MRI
Rutgers University, USA together with one academic and one industrial collaborating group, namely Penn Medicine, USA and Siemens, have received a $3.4 million research grant to develop tools aimed at improving the identification of prostate cancer using MRI. The five-year grant, with funding in the first two years coming from the American Recovery and Reinvestment Act (ARRA) of 2009, was awarded by the USA National Institutes of Health under an initiative to promote industry and academic partnerships. Recent studies by Rutgers and Penn Medicine researchers show that powerful, high-resolution MRI technology can reveal cancerous tissue in prostate glands and pinpoint where the tissue is concentrated. Radiologists, however, do not always know whether unusual-looking visual features indicate cancerous growth or benign variations. The diagnosis of prostate cancer is currently based on PSA levels in blood, physical examination and biopsy, because current imaging techniques do not distinguish cancerous tissue. MRI has the potential to offer a diagnosis non-invasively and, along with other information, allow the most effective and least debilitating treatment to be carried out. Under the research grant, Penn researchers will make magnetic resonance images of prostate glands in cancer patients and prepare tissue samples from those same glands after they are surgically removed in the course of treatment. Rutgers and Siemens researchers will then develop computerised tools that align MRI views with digitised images of tissue slices. These tools will allow investigators to better identify MRI features that reveal cancerous tissue and develop pattern recognition software that will help radiologists make accurate and timely diagnoses. Siemens will refine research tools into software packages for scientists to use as they conduct additional studies and develop further diagnostic tools and techniques.
Coronary imaging techniques help to identify plaques likely to cause heart attacks
Late-breaking results from the ‘Providing Regional Observations to Study Predictors of Events in the Coronary Tree’ (PROSPECT) clinical trial have
www.ihe-online.com & search 45303
FrONt COVEr PrOdUCt
Reducing the risk of contrast induced nephropathy
Designed to reduce the toxic effects that contrast media can have on the kidneys, the RenalGuard system is based on the theory that creating and maintaining a high urine output is beneficial to patients undergoing imaging procedures in which contrast agents are used. The system is designed to measure fluid output and match its replacement in real-time so that a high urine flow is maintained before, during and after imaging procedures. This allows the body to rapidly eliminate contrast medium, thus reducing its toxic effects. With this matched fluid replacement feature the system thus minimises the risk of over-or underhydration, and allows the patient to achieve high urine output safely through maintainenance of intravascular blood volume by automatic and continuous matching of the amount of infused fluid to the patient’s urine output. This thus helps in reducing the incidence of contrast-induced nephropathy (CIN), a form of acute renal failure that is caused by contrast media.
– Issue N°5 – Oct. 2009
Faster bar code printing
The latest barcode label printers from Citizen Systems Europe are now available with Virtual Communications Port (VCOM) functionality. VCOM eliminates the complex, time consuming and costly programming required to allow computers to communicate effectively with printers using USB drivers. As a result, faster and more reliable label printing technology can be introduced into hospitals without a major investment in programming resources and new hardware.
Citizen SyStemS euRope
Feltham, middlesex, uK
www.ihe-online.com & search 45371 www.ihe-online.com & search 45350
Digital X-Ray system
The DRX - Evolution from Carestream provides a fully automated suite of precision X-ray equipment andaccommodates the world’s first cassette-sized DR detector, the Carestream DRX-1. The speed of wireless DR enables the image to appear on the console in seconds, while the detector size eliminates the need to move patients around a fixed DR Detector — simplifying even the most challenging views. The new versatile digital radiography system uses modular components that can be configured to fit space, procedures, workflow, and budget constraints.
pLC meDiCAL SyStemS
Franklin, mA, uSA
www.ihe-online.com & search 45368
Dedicated ultrasound system for Ob/Gyn
A dedicated ultrasound solution for obstetrics and gynaecology, the Ac u s on X300 ultrasound system from Siemens provides exceptional clinical performance across all modes, including 3D/4D imaging. The new system features “syngo Auto OB” measurements, a unique workflow tool that automates routine biometry measurements of the foetus and eliminates the time-consuming manual process of biometry measurements so that 75 percent fewer keystrokes are needed on the part of the operator. This not only accelerates the workflow, but may also help to reduce repetitive stress injury (RSI) among users.
Rochester, ny, uSA
www.ihe-online.com & search 45370 www.ihe-online.com & search 45356
Robust, cost-effective and designed and built to high quality standards, the G-Care XL is a bi-phasic defibrillator system with ECG monitoring and pacing (both NTP and transvenous). The system has built-in adult and paediatric paddles and can be fitted with a thermal recorder; another optional accessory is pulse oximetry. The biphasic waveform is of equal 180J amplitudes. The system is battery-powered but can operate on mains power in case of battery failure.
Medica 2009 Hall 09 Booth D61
www.ihe-online.com & search 45369
SiLiCon LAbS pvt
www.ihe-online.com & search 45382
TELEMED, UAB Dariaus ir Gireno str. 42 Vilnius, LT-02189, Lithuania
phone: (+370-5) 2106272 fax: (+370-5) 2306733 http://www.telemed.lt e-mail: email@example.com
www.ihe-online.com & search 45299
– Issue N°5 – Oct. 2009
A selection of the new products to be presented at MedicA 2009 Nov 18 - 21, dusseldorf
Fully-featured portable ventilator
The IdeVersamed iVent-201 ventilator is a versatile turbine-driven system ideal for pandemic use but packing enough power to handle the needs of the ventilated patient in the intensive care unit. The system does not need a wall-mounted air-supply and is able to provide elevated O2 from either a high-pressure or a low-pressure, low flow source. With a variety of built-in and external battery options, thanks to its compact size and rugged construction the new system can cover ventilation needs during patient transport and in other situations where typical hospital infrastructures are not available. The system offers a wide range of ventilation modes and can display waveforms, loops, respiratory mechanics, SpO2 and patient trends. Able to cover the needs of the acute patient while providing all the monitoring information the clinician needs on simplified displays, the ventilator is quick to set up and suitable for many applications. adaptor based on the use of obstacle finding sensors that give a constant localisation of the head, hands and shoulders of the surgeon.
Medica stand: Hall 9 A52 www.ihe-online.com & search 45374
Reliable and safe infusion/blood warmer
Hypothermia has always been a major concern and can lead to serious side-effects. Infusion of fluids or transfusion at body temperature can help to prevent and treat hypothermia and in general enhances effective intravenous administration. The Animec AM 301 warmer has been designed to provide warmed infusions or transfusion products in pre-, post- or short-term surgery. With a user-adjustable set-point temperature (36°C or 39°C), the system is designed for safety and shows the actual temperature of the outlet fluid on an easy-to-read LED display. There are audible and visible off-temperature alarms, whose proper function can be quickly and easily tested. The system can handle two standard tube sizes (4mm or 5mm) so there is no need for any disposable sets.
Medica stand: Hall 10 A56 / Hall 10 B44 www.ihe-online.com & search 45376
LED-based OR illumination system
Specifically designed for use in the operating room, the new OTSTARLED medical illumination system from ACEM is based on LED technology, thus providing a clean light with no infrared rays or heat and a constant chromatic profile. The striking feature of the new system is the large number of LEDs used (a total of 70) which are positioned in a circle and generate a light spot of high illumination (160000 lux) at a distance of 21 cm to 1 m. The new lights are also equipped with a shadows reduction system and a brightness
Medica stand: Hall 9 C77 SUZUKEN www.ihe-online.com & search 45372
Laser acupuncture application for smoking cessation
The Canadian company MedX has over a decade of experience in designing, manufacturing and distributing ground-breaking laser and light therapy technology. MedX’s laser and light devices have been extensively used in rehabilitation and sports medicine, and more recently in the dental arenas. This expertise has now been incorporated into the MedX Laser Probe devices to effectively treat people that wish to stop smoking without the use of drugs. Developed specifically for smoking cessation and other addiction programmes, the laser probe delivers 200 mW of infrared energy using an 808 nm GaAIAs infrared laser diode and visible red guide light. The ergonomic design ensures simplicity of use and accuracy for auricular and body acupuncture applications. While the use of laser therapy in addiction is not a new concept, it has not been welldocumented and the company wishes to conduct meaningful studies to confirm the efficacy of the laser and established treatment protocols for addiction, which have the potential of leading to more cost-effective ways of treating addiction.
EXPERIENCE THE SUPERIORITY of high-performance de brillator & monitor
RESCUE LIFE THE DEFIBRILLATOR
Medical Equipment Solutions
www.ihe-online.com & search 44950
Visit us Medica 2009 HALL 9 STAND C41
meDX heALth CoRp.
Medica stand: Hall 5 N40 www.ihe-online.com & search 45375
FrONt COVEr PrOdUCt
Multiple applications in one US system
Providing unprecedented performance in a variety of ultrasound applications, the new ProSound Alpha 6 system from Aloka represents the next generation of compact colour ultrasound systems. Fully upgradable and easy to use, the new multipurpose system builds on the proven technology of the high performance ProSound Alpha 10 and Alpha 7 models, but shows a marked difference from other ultrasound systems in that it addresses multiple diagnostic applications in a single unit. The system is supplied with a full suite of application-specific probes and software designed to target all specialist diagnostic areas including imaging, cardiovascular, obstetrics & gynaecology and internal medicine. The high power processor enables a number of different imaging modes that were previously only available in high end systems.
– Issue N°5 – Oct. 2009
approach may indeed induce myocardial angiogenesis, improve myocardial perfusion and reduce systems in patients with endstage CAD. The ESMR treatment itself is carried out using a shockwave generator that is designed to address the unique clinical-anatomical requirements of the chest cavity. A cardiac ultrasound imaging system is used to locate the treatment area and to map the exact position and extent of the ischaemic zone. Shockwaves are then delivered via the anatomical acoustic window to the treatment area under ECG R-wave gating.
Germantown, MD, USA
Medica stand: Hall 10 C11 www.ihe-online.com & search 45377
Semi automatic defibrillator
Automatic external defibrillators (AEDs) must be able to be located instantly and should be able to be carried to the patient quickly and without fumbling. To meet these requirements, Defibtech have designed their Lifeline view defibrillator not only to be as eye-catching as possible but also to be handy to carry and easy to use. The system uses biphasic defibrillation that is extremely effective at defibrillating patients in ventricular fibrillation — the most common form of sudden cardiac arrest — on the first shock.
Medica stand: Hall 10 F58 www.ihe-online.com & search 45373
Guilford CT, USA
Extracorporeal shockwave myocardial revascularisation
ESMR is a new non-invasive therapy approach using extracorporeal shockwaves. Patients with advanced end stage coronary artery disease frequently have recurrent angina and in many such cases the disease becomes too diffuse and extensive to be treated by conventional revascularisation techniques. Surgical and interventional options for these patients have typically been exhausted or result in only partial revascularisation. ESMR offers new hope for these patients and provides an additional therapeutical approach. Recent studies have shown that the application of low-intensity shockwaves may induce the release of angiogenesis-mediating growth factor (VEGF) and proliferating cell antinuclear antigen (PCNA). Additional investigation of low energy shock wave treatment in animals and with a limited number of human patients have shown that the
Medica stand: Hall 16 D32 -1 www.ihe-online.com & search 45378
The new Radical-7 instrument features “gold standard” Masimo SET pulse oximetry, which has been proven in more than 100 independent and objective studies to provide the most accurate and reliable SpO2 readings during motion and low perfusion.
Medica stand: Hall 9 C35 www.ihe-online.com & search 45379
CALENdAr OF EVENts
October 11-14, 2009 ESICM 2009 Vienna, Austria Tel. +32 2 559 03 55 e-mail: Vienna2009@esicm.org www.esicm.org October 20 – 23, 2009 Medical Fair Brno Central Europe 2009 Brno Exhibition Centre, Czech Republic Tel. +420 541 152 818 e-mail: firstname.lastname@example.org www.bvv.cz/medicalfair-gb October 28-31, 2009 62nd CMEF Autumn 2009 Tel. +86 10 6202 8899 ext 3825 e-mail: jin.liu2@ReedSinopharm.com http://en.cmef.com.cn November 17-19, 2009 International Course: DopplerEchocardiography in Intensive Care Medicine Brussels, Belgium Tel. +32 2 555 3631 e-mail: email@example.com www.intensive.org November 18-21, 2009 MEDICA 2009 Düsseldorf, Germany e-mail: firstname.lastname@example.org www.medica.de November 29 – Dec. 4, 2009 RSNA 2009 Chicago, IL, USA http://rsna2009.rsna.org December 10-11, 2009 China International Medical Device Summit 2009 Beijing, China Tel. +86 21 5258 8005 e-mail: info@chinaMDsummit.com http://chinamdsummit.com December 13-16, 2009 Update on Hemodynamic Monitoring Rome, Italy Tel. +32 2 555 3631 e-mail: email@example.com www.intensive.org January 25-28, 2010 Arab Health Dubai, United Arab Emirates Tel. +971 4 3365161 www.arabhealthonline.com February 25-28, 2010 Early Disease Detection and Prevention (EDDP) conference 2010 Munich, Germany Tel. +41 22 5330 948 e-mail: firstname.lastname@example.org www.paragon-conventions.com/ eddp2010/
dates and descriptions of future events have been obtained from usually reliable official industrial sources. IHE cannot be held responsible for errors, changes or cancellations.
On-site medicinal oxygen generator
• turnkey system • economically interesting • complying with ISO 10083 Standard • guaranteed flow and rate of oxygen • output pressure 5 or 12 bar
www.mils.fr email@example.com Hall 17 Stand A 23 B
Your source of on-site oxygen :
For more events see
www.ihe-online.com & search 45357
– Issue N°5 – Oct. 2009
A selection of the new products to be presented at MedicA 2009 Nov 18 - 21, dusseldorf
FrONt COVEr PrOdUCt
Autoclavable soft sensors for adult and paediatric use
The new SoftCapA sensors for adults and infants make it possible for the first time to autoclave SpO2 sensors at 134°C and thereby effectively sterilise them. In this way, the risk of nosocomial infections resulting from pathogenic microorganisms or multiresistant bacteria remaining on the surface of the sensor is significantly reduced. Due to their robust design, the sensors are well suited for use in the ICU and special care units where highly infectious diseases are treated, as well as in the rugged environment of rescue services and emergency care. The sensors are guaranteed for up to 200 autoclaving cycles at 134°C or for two years. The structured design of the sensors gives an ergonomic fit and minimises both motion and ambient light interferences; in addition, in contrast to conventional finger clip sensor technology the new SoftCap A sensors do not adversely affect perfusion. The system’s thermo-balanced light radiation characteristics provide a significantly improved signal-to-noise ratio in cases of low perfusion. Allergic skin reactions are minimised by the bio-compatible and latex-free silicone housing. bluepoint meDiCAL gmbh
Medica Stand: Hall 10 F78 www.ihe-online.com & search 45381
separate high and low frequency gas outlet. Another striking feature is the high performance jet gas conditioning system, which is an integral part of the device and automatically warms and humidifies the entire jet gas that is delivered. The well-established advantages of previous models in Acutronic’s range are maintained, and are even surpassed, thanks to the completely redesigned conditioning unit. It is no longer necessary, as was the case in earlier models, to use cumbersome tubing for distilled water. All that is needed is to connect the infusion system to the luer-lock water inlet and fit a drop counting sensor. This enables continuous jet ventilation for any length of time, from minutes to weeks, without any risk of mucosal damage either because of dry and cold gases or over-hydration from uncontrolled water supply. The many default and customisable settings make the system easy to use in different environments. The large, bright colour display can be oriented in all directions or even installed remote from the mainframe.
maintenance, and is both simple to use and easy to set up, thus giving the clinician complete confidence in its performance. Features include variable flow rates from approximately 0 - 120 litres/ min and oxygen concentrations from 33 to 100%. CPAP can be effective in many different applications, reducing the burden on conventional positive pressure ventilation, resulting in cost savings, fewer intubations and improving the chances of early extubation.
ACutRoniC meDiCAL SyStemS Ag
Wokingham, Berks, UK
Medica stand: Hall 11 A59 www.ihe-online.com & search 45380
Medica stand: Hall 11 H11 www.ihe-online.com & search 45383
Mask for sleep apnoea
Cardiograph to facilitate earlier diagnosis
Philips’ latest product in the field of cardiography is the PageWriter TC50 cardiograph which offers an intuitive 1-2-3 operation and advanced clinical decision support. The new system is designed to help clinicians meet demands and shift the focus to patients. Its ability to handle up to 16 leads provides a more complete view of the heart, and its anatomically designed patient interface module makes attaching lead wires quick and intuitive, contributing to timely triage. As heart disease manifests itself in different patients in different ways, physicians always face the challenge of quickly and accurately diagnosing heart attacks. For this reason, Philips has packed the PageWriter TC50 with a variety of tools to aid clinicians with this task, including those enabled by the innovative DXL 16-lead ECG Algorithm. The DXL Algorithm’s ST Maps provide a graphical representation of ST elevation in patients, a key measure in the diagnosis of ischaemia. STEMI-CA can identify which coronary artery is blocked, aiding the clinician in planning the appropriate intervention.
A new generation, continuous positive airway pressure (CPAP) mask has been introduced to help sleep apnoea patients overcome issues related to wearing a mask at night. With minimal contact on the face and a sleek design, the Swift FX Nasal Pillows mask makes the therapy less intimidating and easy to accept. The mask is soft to wear and stable during sleep so patients can move around and sleep on their side or back, positioning the tube as desired.
San Diego, CA, USA
Medica stand: Hall 11 H24 www.ihe-online.com & search 45382
Flow generator for CPAP
Already equipped with all features that are required for jet ventilation in all imaginable clinical settings, the new MONSOON 3 jet ventilator is available with a large range of optional accessories. The most advanced apparatus of its kind, the new system is equipped with a double jet outlet, which enables the application of superimposed jet ventilation with a Complementing the company’s existing range of products for continuous positive airways pressure (CPAP) therapy, the new InterFlow CPAP flow generator from Intersurgical is a precise, reliable device designed with the end-user in mind. Incorporating integrated patient airway pressure and oxygen monitoring the system requires minimum
eindhoven, The netherlands
Medica stand: Hall 10 A22 www.ihe-online.com & search 45384
starts October 1, 2009
www.ihe-online.com & search 45228