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Orthostatic hypotension is a cardinal feature of multiple-system atrophy. The upright posture provokes syncopal episodes that prevent patients from standing and walking for more than brief periods. We implanted a system to restore regulation of blood pressure and enable a patient with multiple-system atrophy to stand and walk after having lost these abilities because of orthostatic hypotension. This system involved epidural electrical stimulation delivered over the thoracic spinal cord with accelerometers that detected changes in body position. (Funded by the Defitech Foundation.).

We compared blood pressure (BP) values obtained with a new optical smartphone application (OptiBP™) with BP values obtained using a non-invasive automatic oscillometric brachial cuff (reference method) during the first 2 h of surveillance in a post-anesthesia care unit in patients after non-cardiac surgery. Three simultaneous BP measurements of both methods were recorded every 30 min over a 2-h period. The agreement between measurements was investigated using Bland-Altman and error grid analyses. We also evaluated the performance of the OptiBP™ using ISO81060-2:2018 standards which requires the mean of the differences ± standard deviation (SD) between both methods to be less than 5 mmHg ± 8 mmHg. Of 120 patients enrolled, 101 patients were included in the statistical analysis. The Bland-Altman analysis demonstrated a mean of the differences ± SD between the test and reference methods of + 1 mmHg ± 7 mmHg for mean arterial pressure (MAP), + 2 mmHg ± 11 mmHg for systolic arterial pressure (SAP), and + 1 mmHg ± 8 mmHg for diastolic arterial pressure (DAP). Error grid analysis showed that the proportions of measurement pairs in risk zones A to E were 90.3% (no risk), 9.7% (low risk), 0% (moderate risk), 0% (significant risk), 0% (dangerous risk) for MAP and 89.9%, 9.1%, 1%, 0%, 0% for SAP. We observed a good agreement between BP values obtained by the OptiBP™ system and BP values obtained with the reference method. The OptiBP™ system fulfilled the AAMI validation requirements for MAP and DAP and error grid analysis indicated that the vast majority of measurement pairs (≥ 99%) were in risk zones A and B.Trial Registration ClinicalTrials.gov Identifier: NCT04262323.

Obesity is a clear risk factor for hypertension. Blood pressure (BP) measurement in obese patients may be biased by cuff size and upper arm shape which may affect the accuracy of measurements. This study aimed to assess the accuracy of the OptiBP smartphone application for three different body mass index (BMI) categories (normal, overweight and obese).Participants with a wide range of BP and BMI were recruited at Lausanne University Hospital's hypertension clinic in Switzerland. OptiBP estimated BP by recording an optical signal reflecting light from the participants' fingertips into a smartphone camera. Age, sex and BP distribution were collected to fulfil the AAMI/ESH/ISO universal standards. Both auscultatory BP references and OptiBP BP were measured and compared using the simultaneous opposite arms method, as described in the 81060-2:2018 ISO norm. Subgroup analyses were performed for each BMI category.We analyzed 414 recordings from 95 patients: 34 were overweight and 15 were obese. The OptiBP application had a performance acceptance rate of 82%. The mean and standard deviation (SD) differences between the optical BP estimations and the auscultatory reference rates (criterion 1) were respected in all subgroups: SBP mean value was 2.08 (SD 7.58); 1.32 (6.44); -2.29 (5.62) respectively in obese, overweight and normal weight subgroup. For criterion 2, which investigates the precision errors on an individual level, the threshold for systolic BP in the obese group was slightly above the requirement for this criterion.This study demonstrated that the OptiBP application is easily applicable to overweight and obese participants. Differences between the reference measure and the OptiBP estimation were within ISO limits (criterion 1). In obese participants, the SD of mean error was outside criterion 2 limits. Whether auscultatory measurement, due to arm morphology or the OptiBP is associated with increasing bias in obese still needs to be studied.What is the context? • Hypertension and obesity have a major impact on population health and costs. • Obesity is a chronic disease characterized by abnormal or excessive fat accumulation. • Obesity, in combination with other diseases like hypertension, is a major risk factor for cardiovascular and total death. • In Europe, the obesity rate is 21.5% for men and 24.5% for women. • Hypertension, which continues to increase in the population, is a factor that can be modified when well managed. • Blood pressure measurement by the usual method may be complicated in obese patients due to fat accumulation and the shape of the arm and can lead to measurement errors. In addition, the non-invasive blood pressure measurement can be constraining and uncomfortable.What is new? • Smartphone apps are gradually appearing and allow the measurement of blood pressure without a pressure cuff using photoplethysmography. • OptiBP is a smartphone application that provides an estimate of blood pressure that has been evaluated in the general population. • The objective of this study is to assess whether OptiBP is equally effective in obese and overweight patients.What is the impact? • The use of smartphones to estimate BP in overweight and obese patients may be a solution to the known bias associated with cuff measurement. • The acquisition of more and more data with a larger number of patients will allow the continuous improvement of the application’s algorithm.

To provide information about the clinical relevance of blood pressure (BP) measurement differences between a new smartphone application (OptiBP™) and the reference method (automated oscillometric technique) using a noninvasive brachial cuff in patients admitted to the emergency department. We simultaneously recorded three BP measurements using both the reference method and the novel OptiBP™ (test method), except when the inter-arm difference was > 10 mmHg BP. Each OptiBP™ measurement required 1-min and the subsequent reference method values were compared to the values obtained with OptiBP™ using a Bland–Altman analysis and error grid analysis. Among the 110 patients recruited, OptiBP™ BP values could be collected on 61 patients (55%) and were included in the statistical analysis. The mean of differences (95% limits of agreement) between the reference method and the test method were − 0.1(− 22.5 to 22.4 mmHg) for systolic arterial pressure (SAP), − 0.1(− 12.9 to 12.7 mmHg) for diastolic arterial pressure (DAP) and − 0.3(− 18.1 to 17.4 mmHg) for mean arterial pressure (MAP). The proportions of measurements in risk zones A-E were 86.9%, 13.1%, 0%, 0%, and 0% for MAP and 89.3%, 10.7%, 0%, 0%, and 0% for SAP. In this pilot study conducted in stable and awake patients admitted to the emergency department, the absolute agreement between the OptiBP™ and the reference method was moderate. However, when BP measurements were made immediately after an initial calibration, error grid analysis showed that 100% of measurement differences between the OptiBP™ and reference method were categorized as no- or low-risk treatment decisions for all patients. Trial Registration: ClinicalTrials.gov Identifier: NCT04121624.

During anesthesia, noncritical patients are routinely monitored via noninvasive cuff-based blood pressure (BP) monitors. Due to the noncontinuous nature of the monitoring, the BP values of the patient remain unavailable between consecutive cuff measurements, carrying the risk of missing rapid and sudden variations in BP. We evaluated the added value of using a photoplethysmography (PPG)-based continuous BP measurement device in addition to the standard cuff-based monitoring in a cohort of 40 patients in comparison with the current approach, in which only intermittent cuff-based measurements are available. When using a three-minute cuff measurement interval, using the PPG-based BP measurement in addition to the cuff-based monitor reduced the error (mean ± SD) of systolic (SBP) and mean (MBP) BP from 2.6 ± 19.6 mmHg and 1.2 ± 13.2 mmHg to 0.5 ± 11.2 mmHg and 0.0 ± 8.1 mmHg, respectively. Error grid analysis was also used to assess the improvement in patient safety. The additional use of the PPG-based BP measurement reduced the amount of data falling into higher risk categories. For SBP, points falling in the significant-, moderate-, and low-risk categories decreased from 1.1%, 8.7%, and 19.3% to 0.0%, 2.3%, and 9.6%, respectively. Similar results were obtained for MBP. These results suggest that using a PPG-based BP monitor—in addition to the standard cuff-based monitor—can improve patient safety during anesthesia induction, with no additional sensor needed.

Objective The aim of this study was to assess the accuracy of the OptiBP mobile application based on an optical signal recorded by placing the patient's fingertip on a smartphone's camera to estimate blood pressure (BP). Measurements were carried out in a general population according to existing standards of the Association for the Advancement of Medical Instrumentation (AAMI), the European Society of Hypertension (ESH) and the International Organization for Standardization (ISO). Methods Participants were recruited during a scheduled appointment at the hypertension clinic of Lausanne University Hospital in Switzerland. Age, gender and BP distribution were collected to fulfill AAMI/ESH/ISO universal standards. Both auscultatory BP references and OptiBP were measured and compared using the opposite arm simultaneous method as described in the 81060-2:2018 ISO norm. Results A total of 353 paired recordings from 91 subjects were analyzed. For validation criterion 1, the mean ± SD between OptiBP and reference BP recordings was respectively 0.5 ± 7.7 mmHg and 0.4 ± 4.6 mmHg for SBP and DBP. For validation criterion 2, the SD of the averaged BP differences between OptiBP and reference BP per subject was 6.3 mmHg and 3.5 mmHg for SBP and DBP. OptiBP acceptance rate was 85%. Conclusion The smartphone embedded OptiBP cuffless mobile application fulfills the validation requirements of AAMI/ESH/ISO universal standards in a general population for the measurement of SBP and DBP.

Background Fibreoptic intubation is described as the preferred technique for the non-urgent airway control in patients with an unstable cervical spine injury. Indirect laryngoscopes offer promising advantages, but their safety and impact on cervical spine movement is still discussed. Aim We compared the incidence of significant neurophysiologic modifications associated with tracheal intubation performed randomly by an Airtraq® videolaryngoscope contrasted with asleep fibreoptic intubation in 40 patients with a traumatic unstable cervical spine fracture immobilized by a moulded cervical collar and scheduled for elective surgery. Methods Somatosensitive evoked potentials (SSEPs) monitoring was performed at four stages: before airway management (baseline), during facemask ventilation, during intubation and after definitive positioning for surgery. Time, ease of intubation, number of attempts and grade view laryngoscopy were also recorded. Results Significant neurophysiological modifications were detected in one patient in each group during intubation. They were also identified during ventilation in 1/40 patients and 13/40 patients after positioning. Intubation times were significantly shorter when performed by an Airtraq® (median [25th;75th] 45 s [41;54]) than by fiberscope (124 [88;152]), (p Conclusion Tracheal intubation with an Airtraq® appears to be a viable alternative to fibreoptic intubation in patients with a traumatic cervical spine fracture and immobilized by a moulded cervical collar. Time necessary to secure an airway in these patients is significantly shorter with the Airtraq®.

A high-quality, low-cost ventilator, dubbed HEV, has been developed by the particle physics community working together with biomedical engineers and physicians around the world. The HEV design is suitable for use both in and out of hospital intensive care units, provides a variety of modes and is capable of supporting spontaneous breathing and supplying oxygen-enriched air. An external air supply can be combined with the unit for use in situations where compressed air is not readily available. HEV supports remote training and post market surveillance via a Web interface and data logging to complement standard touch screen operation, making it suitable for a wide range of geographical deployment. The HEV design places emphasis on the ventilation performance, especially the quality and accuracy of the pressure curves, reactivity of the trigger, measurement of delivered volume and control of oxygen mixing, delivering a global performance which will be applicable to ventilator needs beyond the COVID-19 pandemic. This article describes the conceptual design and presents the prototype units together with a performance evaluation.

This article is a descriptive analysis of the organizational steps undertaken to transform eight OR (operating rooms) of the University Hospital Lausanne CHUV into a dedicated ICU (intensive care unit) during the COVID-19 pandemic. An efficient response of our institution was mandatory to timely increase the number of ICU beds. The transformation of an entire floor of a functioning operating ward was deemed the most appropriate solution to provide rapidly a significant number of beds. The newly created ICU was the first additional ICU to open and admitted its first patient 48 hours after the beginning of the transformation.Cet article résume les étapes organisationnelles entreprises pour transformer huit salles d’opération en une unité de soins intensifs pendant la pandémie de Covid-19. Une réponse efficace de notre institution était obligatoire pour augmenter en temps opportun le nombre de lits en soins intensifs. La transformation d’un étage entier d’un bloc opératoire fonctionnel a été jugée la solution la plus appropriée pour offrir le plus rapidement possible un nombre de lits conséquent. La nouvelle unité de soins intensifs adultes (SIA) a été la première unité de soins intensifs supplémentaire à ouvrir et a admis son premier patient 48 heures après le début des transformations.

L'objectif de notre etude etait de fournir une vue d'ensemble du trauma pediatrique des enfants admis au dechoquage de pediatrie au sein du Centre Hospitalier Universitaire Vaudois et d'ameliorer ainsi la prise en charge des enfants polytraumatises. Nous avons analyse les donnees de tous les enfants de moins de 16 ans souffrant de polytrauma ayant ete admis au dechoquage de pediatrie sur une periode allant de 2011 a 2016. Les admissions au dechoquage de pediatrie faisaient suite a un triage pre-hospitalier. Les donnees ont ete analysees par le biais de statistique descriptive. Les donnees analysees provenaient de notre trauma registre qui a ete debute en janvier 2011. Celui-ci est conforme aux recommandations internationales, permettant ainsi de confronter nos donnees a celles des autres traumas centres Europeens. Les variables recueillies etaient les suivantes: donnees epidemiologiques, signes vitaux, Injury Severity Score (ISS), le mecanisme du trauma, Abbreviated Injury Scale (AIS), Glasgow Coma Scale (GCS), type de transport, mesure therapeutique, resultat d'imagerie, valeurs de laboratoire, intervention immediate, unite de transfert suivant la prise en charge du dechoquage, duree de sejour, mortalite intra-hospitaliere, ainsi que le Trauma and Injury Severity Score (TRISS) des non-survivants. Nous avons inclus 327 enfants, 63% d'entre eux etaient de sexe masculin, l'âge median etait de 8 ans. 97 enfants ont souffert de trauma severe (ISS > 15). Le mecanisme principal des blessures etaient les chutes (45%), les accidents de la voie publique (29%) et les brulures (14%). Les zones corporelles les plus frequemment lesees etaient la tete et les zones externes. Les admissions aux soins intensifs pediatriques s'elevaient a 27%. 22% des enfants ont necessite une intervention chirurgicale immediate (majoritairement des debridements de plaie, des interventions neurochirurgicales et orthopediques). La mortalite globale etait de 5.5% pour un ISS median de 9. La mortalite des traumas severes etait de 17.5% pour un ISS median de 22. La moitie des enfants sont decedes dans les 6h suivant leur admission. Les causes principales de mortalite etaient les chutes de plus de 5 metres et les accidents de la voie publique en tant que pieton. Ce que nous avons observe est que la demographie et les types de blessures decrites dans notre etude sont identiques a ceux des autres traumas centre europeens, mais la mortalite et la severite des blessures est varable. (Royaume-Unis 3.7 %-ISS median 9; Danemark 7.3% - ISS median 9; Allemagne 13.4%-ISS median 25). Le taux eleve de mortalite precoce suggere que les phases initiales de la prise en charge pourraient jouer un role dans la diminution du taux de mortalite (phase pre-hospitaliere, orientation - via le triage - vers un trauma centre pediatrique, soins a l'admission au dechoquage pediatrique). -- Objectives: The purpose of this study was to provide an internationally comparable overview of pediatric trauma of the University Hospital of Lau- sanne to improve the care of children. Methods: We analyzed the data from all injured children (15) occurred in 97 children. The principal mechanisms of injury were falls (45%), traffic accidents (29%), and burns (14%). The most frequently affected areas were the head and external body regions. Intensive care ad- missions amounted to 27%. Twenty percent of patients underwent immedi- ate surgery (wound care, neurosurgery, and orthopedic surgery). The overall mortality rate was 5.5%, with a median ISS of 9. The mortality of severe trauma was 17.5%, with a median ISS of 22. Half of the children died within 6 hours. The main causes of death were falls from greater than 5 m and traffic accidents as pedestrians. Conclusions: The demographics and patterns of injury in the pediatric trauma population are similar to other European pediatric trauma centers, but the mortality and the severity of injuries can vary (United Kingdom, 3.7%, me- dian ISS of 9; Denmark, 7.3%, median ISS of 9; and Germany, 13.4%, median ISS of 25). The elevated early mortality rate suggests that improvements in prehospital care and early resuscitation could decrease mortality.

BACKGROUND Virtual reality (VR) simulation is an effective and safe method of teaching bronchoscopic skills. Few VR bronchoscopy simulators exist; all are expensive. The present study aimed to describe the design, development, and evaluation of a new, affordable, VR bronchoscopy simulator. METHODS Anesthesiologists and engineers collaborated to design and develop the Computer Airway Simulation System (CASS), an iPad-based, high-fidelity, VR bronchoscopy simulator. We describe hardware and software development, as well as the technical and teaching features of the CASS. Twenty-two senior anesthesiologists evaluated various aspects of the simulator (using a 5-point Likert scale) to assess its face validity. RESULTS Anesthesiologists performed a simulated bronchoscopy (mouth to carina) with a median (range) procedural time of 66 seconds (30-96). The simulator's ease of use was rated 4.3 ± 0.8 and the bronchoscope proxy's handling 4.0 ± 0.7. Criticisms included that excessive system reactivity created handling difficulties. Anatomical accuracy, 3-dimensional bronchial segmentation, and mucosal texture were judged to be very realistic. The simulator's usefulness for teaching and its educational value were highly rated (4.9 ± 0.3 and 4.8 ± 0.4, respectively). CONCLUSIONS We describe the design, development, and initial evaluation of the CASS-a new, ultraportable, affordable, VR bronchoscopy simulator. The simulator's face validity was supported by excellent assessments from senior anesthesiologists with regard to anatomical realism, quality of graphics, and handling performance, even though some future refinements are required. All the practitioners agreed on the significant educational potential of the CASS.

The National Advisory Committee for Aeronautics (NACA) score is used by many emergency medical services to assess the severity of prehospital patients. Little is known about its discriminative performance regarding short-term mortality. We retrospectively included adult missions between 2008 and 2014 in a Swiss ground and air-based emergency medical services. We excluded uninjured or dead-on-scene patients. Primary outcome was assessment of the discriminative performance of the NACA score to classify the 48-h vital status of patients. Overall discrimination was quantified using the area under receiver operating characteristic curve (AUC). We also explored the influence of epidemiological characteristics (age and sex), mechanism (trauma or nontrauma) and clinical parameters (respiratory rate, oxygen saturation, heart rate, systolic blood pressure, capillary refill time, and Glasgow Coma Scale) on its discriminative performance. We then assessed the incremental value of these variables in the classification accuracy of a rule based on these variables in addition to the NACA score. We included 11 567 patients out of 11 639 (72 exclusions for missing data). Overall AUC was 0.86. The score was more discriminant for trauma (AUC = 0.95 vs. 0.83), and for younger patients (AUC = 0.91 for 16-59 vs. 0.78 for 84-104 years). Adding age, sex, mechanism, and clinical parameters resulted in a classification rule with higher discriminative performance than NACA score alone (AUC of 0.92 vs. 0.86; P < 0.001). The NACA score is an efficient way to discriminate victims regarding short-term mortality. Its performance can be enhanced by also integrating epidemiological and clinical parameters into an extended classification rule.

To provide information about the clinical relevance of blood pressure (BP) measurement differences between a new smartphone application (OptiBP™) and the reference method (automated oscillometric technique) using a noninvasive brachial cuff in patients admitted to the emergency department. We simultaneously recorded three BP measurements using both the reference method and the novel OptiBP™ (test method), except when the inter-arm difference was 10 mmHg BP. Each OptiBP™ measurement required 1-min and the subsequent reference method values were compared to the values obtained with OptiBP™ using a Bland-Altman analysis and error grid analysis. Among the 110 patients recruited, OptiBP™ BP values could be collected on 61 patients (55%) and were included in the statistical analysis. The mean of differences (95% limits of agreement) between the reference method and the test method were - 0.1(- 22.5 to 22.4 mmHg) for systolic arterial pressure (SAP), - 0.1(- 12.9 to 12.7 mmHg) for diastolic arterial pressure (DAP) and - 0.3(- 18.1 to 17.4 mmHg) for mean arterial pressure (MAP). The proportions of measurements in risk zones A-E were 86.9%, 13.1%, 0%, 0%, and 0% for MAP and 89.3%, 10.7%, 0%, 0%, and 0% for SAP. In this pilot study conducted in stable and awake patients admitted to the emergency department, the absolute agreement between the OptiBP™ and the reference method was moderate. However, when BP measurements were made immediately after an initial calibration, error grid analysis showed that 100% of measurement differences between the OptiBP™ and reference method were categorized as no- or low-risk treatment decisions for all patients.Trial Registration: ClinicalTrials.gov Identifier: NCT04121624.

Arterial pressure (AP) is a crucial biomarker for cardiovascular disease prevention and management. Photoplethysmography (PPG) could provide a novel, paradigm-shifting approach for continuous, non-obtrusive AP monitoring, comfortably integrated in wearable and mobile devices; yet, it still faces challenges in accuracy and robustness. In this work, we sought to integrate machine learning (ML) techniques into a previously established, clinically-validated classical approach (oBPM®) to develop new accurate AP estimation tools based on PPG, and at the same time improve our understanding of the underlying physiological parameters. In this novel approach, oBPM® was used to pre-process PPG signals and robustly extract physiological features, and ML models were trained on these features to estimate systolic AP (SAP). A feature relevance analysis showed that reference (calibration) information, followed by various morphological parameters of the PPG pulse wave, comprised the most important features for SAP estimation. A performance analysis then revealed that LASSO-regularized linear regression, Gaussian process regression and support vector regression are effective for SAP estimation, particularly when operating on reduced feature sets previously obtained with e.g. LASSO. These approaches yielded substantial reductions in error standard deviation of 9–15% relative to conventional oBPM®. Altogether, these results indicate that ML approaches are well-suited, and promising tools to help overcoming the challenges of ubiquitous AP monitoring.

Introduction L'hypotension arterielle peroperatoire est associee a une augmentation de la morbi-mortalite postoperatoire. Lors d'une intervention chirurgicale, la pression arterielle est principalement mesuree par la methode oscillometrique a l'aide d'une manchette sur le membre superieur. De par l'intermittence des mesures, des changements rapides de pression arterielle peuvent etre manques et par consequent nuire au patient. Les outils de mesures de la pression arterielle en continu de maniere non-invasive existants, sont compliques a mettre en œuvre et restent peu fiables. Dans la presente etude, nous posons l'hypothese que l'analyse d'une courbe d'oxymetre de pouls, a l'aide d'un algorithme dedie, permet de detecter des changements de pression arterielle systolique (PAS) et moyenne (PAM) pendant l'induction d'une anesthesie generale. Methode La performance d'un algorithme d'analyse d'onde d'oxymetrie de pouls (oBPM®) d'estimer la PAS et la PAM et les changements de celles-ci durant l'induction anesthesique chez 40 patients, prevus pour une chirurgie elective, necessitant une anesthesie generale et la mise en place d'un catheter de mesure de pression arterielle invasive a ete evaluee. Des changements rapides de PAS et de PAM de plus de 20 %, mesures par la reference invasive et par l'oBPM® ont ete compares puis representes dans des graphiques a quatre quadrants (four quadrant plot) et en coordonnees polaires (polar plot). La capacite de suivi de la pression arterielle de l'algorithme a ete evaluee pour des changements survenant sur une duree de 30 secondes a cinq minutes. Le second objectif de l'etude etait d'evaluer la compliance de l'algorithme oBPM® aux criteres de l'Association for the Advancement of Medical Instrumentation (AAMI). L'exactitude et la precision de la mesure de PAS et de PAM par l'oBPM®ont ete comparees a la mesure invasive par catheterisme a divers intervalles apres calibration allant de 30 secondes a cinq minutes. Resultats Des changements rapides (survenant sur des periodes de 60 secondes ou moins) de la PAS et la PAM evalues par l'oBPM® sont fortement correles et montrent une excellente concordance avec les changements de la pression arterielle invasive. Le coefficient de correlation de Pearson dans le pire des cas (worst-case Pearson's correlation) est de 0,94 [0,88, 0,97) (intervalle de confiance de 95 %) avec un taux de concordance de 100 % [100 %, 100 %], et un taux de concordance angulaire a 30° de 100 % [100 %, 100 %]. La capacite de suivi de la pression arterielle de l'algorithme a tendance a diminuer progressivement a mesure que la periode pendant laquelle les changements produits s'accroit, atteignant 0,89 [0,85, 0,91) (correlation de Pearson), 97 % [95 %, 100 %] (taux de concordance) et 90 % [85 %, 94 %] (taux de concordance angulaire) dans le pire des cas. En ce qui concerne l'exactitude et la precision, les valeurs PAS derivees de l'OBPM® sont conformes aux criteres AAMI jusqu'a 2 minutes apres calibration, tandis que les valeurs de PAM derivees de l'oBPM® correspondent aux criteres en tout temps. Conclusion L'analyse de la forme de l'onde pouls d'un oxymetre est utilisable pour suivre des changements rapides de PAS et de PAM pendant l'induction d'une anesthesie. Une bonne concordance avec les mesures invasives de reference est observee pour la PAM jusqu'a au moins 5 minutes apres l'etalonnage initial. A l'avenir, cette methode pourrait etre utilisee pour suivre les variations de pression arterielle survenant entre les mesures oscillometriques intermittentes, et pourrait par exemple declencher automatiquement l'inflation des manchettes a pression lorsqu'un changement significatif de la pression arterielle est detecte, contribuant a ameliorer la securite des patients lors d'une anesthesie par une methode simple. -- BACKGROUND: lntraoperative hypotension is associated with postoperative complications and death. 0scillometric brachial cuffs are used to measure arterial pressure (AP) in most surgical patients but may miss acute changes in AP. We hypothesized that pulse oximeter waveform analysis may help to detect changes in systolic AP (SAP) and mean AP (MAP) during anesthesia induction. METHODS: ln 40 patients scheduled for an elective surgery necessitating general anesthe­ sia and invasive AP monitoring, we assessed the performance of a pulse oximeter waveform analysis algorithm (optical blood pressure monitoring [oBPM]) to estimate SAP, MAP, and their changes during the induction of general anesthesia. Acute AP changes (>20%) in SAP and MAP assessed by the reference invasive method and by oBPM were compared using 4-quad­ rant and polar plots. The tracking ability of the algorithm was evaluated on changes occurring over increasingly larger time spans, from 30 seconds up to 5 minutes. The second objective of the study was to assess the ability of the oBPM algorithm to cope with the Association for the Advancement of Medical Instrumentation (AAMI) standards. The accuracy and precision of oBPM in estimating absolute SAP and MAP values compared to the invasive method was evalu­ ated at various instants after algorithm calibration, from 30 seconds to 5 minutes. RESULTS: Rapid changes (occurring over time spans of s:60 seconds) in SAP and MAP assessed by oBPM were strongly correlated and showed excellent concordance with changes in invasive AP (worst-case Pearson correlation of 0.94 [0.88, 0.97] [95% confidence interval], concordance rate of 100% [100%, 100%], and angular concordance rate at ±30° of 100% [100%, 100%]). The trend­ ing ability tended to decrease progressively as the time span over which the changes occurred increased, reaching 0.89 (0.85, 0.91) (Pearson correlation), 97% (95%, 100%) (concordance rate), and 90% (85%, 94%) (angular concordance rate) in the worst case. Regarding accuracy and precision, oBPM

The purpose of this article is to review the main airway devices available to the emergency physician in a prehospital setting. Since the risk of difficult intubation is increased under pre-hospital conditions; the emergency physician should be aware of alternatives to direct tracheal intubation such as supraglottic devices, video laryngoscopes and cricothyroidotomy. These different techniques and devices must be integrated into a strategy for the management of the upper airway. We propose a prehospital airways algorithm adapted from the Latin Airway Foundation (FLAVA).L’objectif de cet article est de passer en revue les principaux dispositifs de gestion des voies aériennes à disposition du médecin d’urgence. Le risque d’intubation difficile étant majoré dans les conditions d’intervention préhospitalière, le médecin d’urgence doit connaître les alternatives à l’intubation trachéale par laryngoscopie directe telles que les dispositifs supraglottiques, les vidéolaryngoscopes et la cricothyroïdotomie. Ces différentes techniques et dispositifs doivent être intégrés dans une stratégie de gestion des voies aériennes supérieures. Nous proposons un algorithme adapté pour le préhospitalier inspiré de celui de la Fondation latine des voies aériennes (FLAVA).

Mobile health diagnostics have been shown to be effective and scalable for chronic disease detection and management. By maximizing the smartphones’ optics and computational power, they could allow assessment of physiological information from the morphology of pulse waves and thus estimate cuffless blood pressure (BP). We trained the parameters of an existing pulse wave analysis algorithm (oBPM), previously validated in anaesthesia on pulse oximeter signals, by collecting optical signals from 51 patients fingertips via a smartphone while simultaneously acquiring BP measurements through an arterial catheter. We then compared smartphone-based measurements obtained on 50 participants in an ambulatory setting via the OptiBP app against simultaneously acquired auscultatory systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean blood pressure (MBP) measurements. Patients were normotensive (70.0% for SBP versus 61.4% for DBP), hypertensive (17.1% vs. 13.6%) or hypotensive (12.9% vs. 25.0%). The difference in BP (mean ± standard deviation) between both methods were within the ISO 81,060–2:2018 standard for SBP (− 0.7 ± 7.7 mmHg), DBP (− 0.4 ± 4.5 mmHg) and MBP (− 0.6 ± 5.2 mmHg). These results demonstrate that BP can be measured with accuracy at the finger using the OptiBP smartphone app. This may become an important tool to detect hypertension in various settings, for example in low-income countries, where the availability of smartphones is high but access to health care is low.

Background To date, the decision to set up therapeutic extra-corporeal life support (ECLS) in hypothermia-related cardiac arrest is based on the potassium value only. However, no information is available about how the analysis should be performed. Our goal was to compare intra-individual variation in serum potassium values depending on the sampling site and analytical technique in hypothermia-related cardiac arrests. Methods Adult patients with suspected hypothermia-related refractory cardiac arrest, admitted to three hospitals with ECLS facilities were included. Blood samples were obtained from the femoral vein, a peripheral vein and the femoral artery. Serum potassium was analysed using blood gas (BGA) and clinical laboratory analysis (CL). Results Of the 15 consecutive patients included, 12 met the principal criteria, and 5 (33%) survived. The difference in average potassium values between sites or analytical method used was ≤1 mmol/L. The agreement between potassium values according to the three different sampling sites was poor. The ranges of the differences in potassium using BGA measurement were − 1.6 to + 1.7 mmol/L; − 1.18 to + 2.7 mmol/L and − 0.87 to + 2 mmol/L when comparing respectively central venous and peripheral venous, central venous and arterial, and peripheral venous and arterial potassium. Conclusions We found important and clinically relevant variability in potassium values between sampling sites. Clinical decisions should not rely on one biological indicator. However, according to our results, the site of lowest potassium, and therefore the preferred site for a single potassium sampling is central venous blood. The use of multivariable prediction tools may help to mitigate the risks inherent in the limits of potassium measurement. Trial registration ClinicalTrials.gov Identifier: NCT03096561.

The airway management of a patient with severe tracheal stenosis depends on its severity, length, location, and type of surgery. Its management is complex and requires the collaboration of an experienced team of anaesthetist and ear, nose, and throat surgeon. We report an innovative combination of Ventrain™ and S-Guide™ for airway management of a planned endoscopic dilation of a severe subglottic stenosis in an adult patient. This new alternative may offer advantages over existing airway management techniques in similar cases.

Resume But Les guides et mandrins sont des dispositifs regulierement utilises pour la gestion des voies aeriennes difficiles dans differents scenarios. Leur utilisation en premiere intention est proposee par un grand nombre d’algorithmes. Leur forme et techniques d’utilisation evoluent regulierement. Notre but est de fournir au clinicien une mise a jour concernant les caracteristiques, indications, techniques d’utilisation et les dangers des differents guides et mandrins utilises comme aides a l’intubation. Methode Nous avons effectue une recherche systematique de la litterature jusqu’en mai 2015, sans restrictions de langue. Les deux auteurs ont retire, de facon independante, toutes les etudes, rapports de cas et series avec les mots cles « bougie », « gum elastic bougie », « stylet », « airway management », « tracheal tube introducer », « intubation aid », « extubation catheter », « bougie elastique », « mandrin », « stylet d’intubation », « management des voies aeriennes », « introducteur », « aide a l’intubation » et « mandrin d’extubation ». Resultats Nous avons trouve principalement des etudes observationnelles et retrospectives avec au total un petit nombre de sujets. Ces donnees ont ete synthetisees dans une revue narrative. Conclusion A ce jour, de nombreux guides et mandrins existent pour assister a la gestion de la voie aerienne difficile. Chacun d’entre eux possede des indications differentes, avec une specificite variable. Les medecins anesthesistes, reanimateurs et urgentistes se doivent d’avoir une connaissance et comprehension maximale de ces differents dispositifs afin d’utiliser le bon instrument au bon moment et de maniere adaptee a la situation. Ainsi une prise en charge optimale de la voie aerienne difficile pourra etre atteinte.

Routine monitoring of blood pressure during general anaesthesia relies on intermittent measurements with a non-invasive brachial cuff every five minutes. This manuscript provides first experimental evidence that a physiology-based pulse wave analysis algorithm applied to optical data (as provided by a standard fingertip pulse oximeter) is capable of accurately estimating blood pressure changes in-between cuff readings. Combined with the routine use of oscillometric cuffs, the presented novel approach is a candidate technology to increase patient safety by providing beat-to-beat hemodynamic measurements without the need of invasive monitoring procedures.

Tracheal tube introducers and stylets are highly successful devices for the management of various airway scenarios. Their first-line use is advocated in many difficult airway algorithms. Although they have been used for decades, the shape and design of introducers and stylets as well as their patterns of use are constantly evolving. Our purpose is to provide the clinician with an update on these different devices. We performed a systematic literature search from 2005 until May 2015, without language restrictions. The two authors independently retrieved all studies with the keywords "bougie", "gum elastic bougie", "stylet", "airway management", "tracheal tube introducer" and "extubation catheter". Our search did yield mostly observational and retrospective studies with small case numbers. The data was synthesized into a narrative review to provide the clinician with an update on the characteristics, indications and techniques of use as well as the dangers of different intubation aids. Today, numerous tracheal tube introducers and stylets exist with different indications, ranging from general to specific situations. Anesthetists should be familiar with the different devices, their characteristics and indications in order to use the right device at the right time in the right way.

The effectiveness of transoral microsurgery for early-stage glottic cancer relies on the possibility to obtain adequate exposure of the lesion. The purpose of this study was to design a new surgical technique allowing efficient endoscopic removal of these tumors in patients with unsatisfactory transoral exposure. A minimal invasive access to the glottis, made through the thyrohyoid membrane and the preepiglottic space, was used for endoscopic resection of an early-stage glottic tumor in a patient with a medical history of previous radiotherapy and unsatisfactory endoscopic exposure of the lesion. This approach provided excellent exposure of the glottis and allowed endoscopic resection with adequate surgical margins. The surgical procedure and the postoperative period were uneventful. Functional outcomes were back to baseline after 1 month. This technique represents an attractive solution for patients presenting with early-stage glottic tumors that cannot be exposed transorally and have contraindications to alternative therapeutic procedures. © 2016 Wiley Periodicals, Inc. Head Neck 38:1286-1289, 2016.

Objective To provide an update to French guidelines about “Difficult intubation and extubation in adult anaesthesia 2006”. Design A consensus committee of 13 experts was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Few recommendations were ungraded. Methods The panel focused on 6 questions: 1) Why must oxygen desaturation be avoided during intubation and what preoxygenation and oxygenation techniques should be used to prevent it? 2) Should videolaryngoscopes be used instead of standard laryngoscopy with or without a long stylet to achieve a better success rate of intubation after the first attempt during anticipated difficult intubation off fiberoptic intubation? 3) Should TCI or target controlled inhalation anaesthesia (TCIA) be used instead of bolus sedation for airway control in the event of suspected or proven difficulty in a patient spontaneously breathing? 4) What mode of anaesthesia should be performed in patients with difficult intubation criteria and potentially difficult mask ventilation? 5) In surgical patients, what criteria predict difficulties encountered during postoperative tracheal extubation? 6) Should decision trees and algorithms be employed to direct decision-making for the management of difficult intubation, whether foreseen or not? (based on the information from the preceding five issues). Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE® methodology. Results The SFAR Guideline panel provided 13 statements on difficult intubation and extubation in adult anaesthesia. After two rounds of discussion and various amendments, a strong agreement was reached for 99% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), 8 have a low level of evidence (Grade 2±). No recommendation was provided for one question. Conclusions Substantial agreement exists among experts regarding many strong recommendations for the best care of patients with difficult intubation and extubation in adult anaesthesia.

OBJECTIVE Since the introduction of modern surgical techniques and monitoring tools for the treatment of severe traumatic brain injury (TBI) in Switzerland, standardized nationwide operative procedures are still lacking. This study aimed to assess surgical management and monitoring strategies in patients admitted throughout Switzerland with severe TBI. METHODS Demographic, clinical, and radiologic data from a prospective national cohort study on severe brain-injured patients (Patient-relevant Endpoints after Brain Injury from Traumatic Accidents [PEBITA]) were collected during a 3-year period. This study evaluated patients admitted to 7 of the 11 trauma centers included in PEBITA. We retrospectively analyzed surgery-related computed tomography (CT) findings prior to and after treatment, intracranial pressure (ICP) monitoring, size and technical features of craniotomy, as well as surgical complications. ResULTS: This study included 353 of the 921 patients enrolled in PEBITA who underwent surgical treatment for severe TBI. At admission, acute subdural hematoma was the most frequent focal lesion diagnosed (n = 154 [44%]), followed by epidural hematoma (n = 96 [27%]) and intracerebral hematoma (n = 84 [24%]). A total of 198 patients (61%) presented with midline shift. Clinical deterioration in terms of Glasgow Coma Scale scores or intractable ICP values as an indication for surgical evacuation or decompression were documented in 20% and 6%, respectively. A total of 97 (27.5%) only received a catheter/probe for ICP monitoring. Surgical procedures to treat a focal lesion or decompress the cerebrum were performed in 256 patients (72.5%). Of the 290 surgical procedures (excluding ICP probe implantation), craniotomy (137 [47.2%]) or decompressive craniectomy (133 [45.9%]) were performed most frequently. The mean size of craniectomy in terms of maximal linear width on the CT axial slice was 8.4 ± 2.9 cm. Intraoperative ICP monitoring was reported in 61% of the interventions. Significant intraoperative brain swelling was documented in 50.6% of the procedures. Surgery-related complications occurred in 89 cases (32%). CONCLUSION This study highlights the lack of standardized and systematic documentation of technical aspects of surgical treatment of patients presenting with severe TBI in Switzerland. Technical strategies such as size of craniectomy and the use of perioperative ICP measurement were not documented in a standardized manner. A prospective systematic surgical documentation system might contribute to future formulation of recommendations for the surgical treatment of patients presenting with severe TBI in Switzerland.

Secondary injuries are associated with bad outcomes in the case of severe traumatic brain injury (sTBI). Patients with a Glasgow Coma Scale (GCS) &lt, 9 should undergo pre-hospital intubation (PHI). There is controversy about whether PHI is beneficial. The aim of this study was to estimate the effect of PHI in patients after sTBI. A multicenter, prospective cohort study was performed in Switzerland, including 832 adults with sTBI. Outcomes were death and impaired consciousness at 14 days. Associations between risk factors and outcomes were assessed with univariate and multivariate Cox models for survival, and univariate and multivariate regression models for impaired consciousness. Potential risk factors were age, GCS on scene, pupil reaction, Injury Severity Score (ISS), PHI, oxygen administration, and type of admission to trauma center. Age, GCS on scene &lt, 9, abnormal pupil reaction and ISS &ge, 25 were associated with mortality. GCS &lt, 9 and ISS &ge, 25 were correlated with impaired consciousness. PHI was overall not associated with short-term mortality and consciousness. However, there was a significative interaction with PHI and major trauma. PHI improves outcome from patients with sTBI and an ISS &ge, 25.