Os primeiros indícios de tentativas de abordagem e manejo da via aérea (VA) datam de cerca de 4000 anos. A intubação traqueal (IT) consiste na introdução de um tubo na luz da traquéia, e é responsável por salvar muitas vidas. O manejo da VA nos serviços de emergência é um dos principais desafios e seguramente um dos momentos mais críticos do cuidado com o paciente grave. As principais complicações e efeitos adversos da IT decorrem da laringoscopia direta e da introdução do tubo traqueal na VA. A sequência rápida de intubação (SRI) é a realização do procedimento de IT através de uma abordagem organizada que envolve a utilização de agentes sedativos, analgésicos e bloqueador neuromuscular. A SRI tem por objetivo diminuir ou limitar os efeitos adversos do procedimento de IT, em especial da laringoscopia direta. A SRI é o método de escolha na maioria dos procedimentos de IT de emergência em pediatria na literatura internacional. Os registros de dados sobre o manejo da VA em serviços de emergência pediátricos no Brasil são raros e não abordam a SRI como técnica de IT. Dessa forma os objetivos do presente estudo foram descrever a experiência do pronto-socorro de um hospital pediátrico de atendimento terciário com o uso da SRI, e detectar possíveis fatores associados ao sucesso da SRI. Para tanto foi realizado estudo prospectivo observacional tipo \"coorte\" de julho de 2005 a dezembro de 2007, onde foram coletados os dados relacionados a todas as ITs realizadas no pronto-socorro do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr-HCFMUSP). Foram incluídos no estudo todos os pacientes que foram submetidos a SRI. Foi considerado IT com sucesso aquela realizada na primeira tentativa. O registro dos dados foi realizado pelo profissional que participou diretamente do procedimento em formulário específico. Durante o período de estudo ocorreram 117 ITs, sendo que 84% delas foram realizadas sob SRI; a idade dos pacientes variou de 29 dias a 17 anos (mediana=4,4anos) e 60% eram do sexo masculino; setenta e nove por cento eram portadores de patologias de base, sendo 21% doenças neurológicas, 18% oncológicas e 8% respiratórias; a insuficiência respiratória aguda foi a causa imediata da IT em 40% dos procedimentos e alteração do nível de consciência e choque em 20% e 18% respectivamente; todas as ITs foram realizadas no pronto-socorro e por um dos médicos da equipe; a taxa de sucesso foi de 39%; o residente de pediatria do segundo ano foi o responsável por 74% das ITs, e com taxa de sucesso de 35%; foi realizada ventilação com pressão positiva em 74% dos procedimentos, sendo menor a sua utilização entre os pacientes que foram intubados com sucesso (21 versus 49 p=0,002). O midazolam foi o sedativo de escolha, utilizado em 80% dos procedimentos, e o rocurônio foi o bloqueador neuromuscular em 100% dos procedimentos; complicações decorrentes da SRI foram descritas em 75 (80%) dos procedimentos, sendo queda da saturação de oxigênio relatada em 47% do total, e significativamente menor nos pacientes que foram intubados com sucesso (p<0.001); dificuldades relativas à IT foram menos relatadas nos procedimentos realizados com sucesso (p<0,001). Em conclusão, pode-se afirmar que a SRI foi o método de escolha nas ITs realizadas no pronto-socorro do ICr-HCFMUSP, que a população que necessitou de manejo da via aérea foi composta em sua grande maioria por pacientes portadores de doenças de base com problemas respiratórios e que, complicações do procedimento de SRI são mais frequentes quando há necessidade de maior número de tentativas de laringoscopia direta. / The first signs of attempts to approach and manage airways date from about 4000 years. The tracheal intubation (TI) consists in to introduce a tube in the trachea lumen and it is responsible for saving many lives. The airway management in the emergency services is one of the most challenges and critical moments of care for the critically ill patient. The major complications and adverse effects of TI stem from the direct laryngoscopy and tracheal tube introduction into the airway. The Rapid Sequence Intubation (RSI) is the actual procedure of TI through an organized approach that involves the use of sedative agents, analgesics and neuromuscular blocker. The objective of SRI is to minimize and limit the main adverse effects of the TI procedure and in special of the direct laryngoscopy. SRI is the method of choice in most of TI procedures in emergency pediatrics in the international literature. The data records on airway management in pediatric emergency services are rare and do not address the SRI as a technique to perform TI. The objectives of this study were to describe the experience of a pediatric tertiary care emergency department with the use of RSI, and identify possible factors associated with the success of RSI. For this, a prospective observational study type \"cohort\" was conducted from July 2005 through December 2007, where all data related to TI performed in the emergency room of the Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr-HCFMUSP) was collected. The study included all patients who underwent to RSI. Intubation was considered successful when it was performed on the first try. Data registration was done by the professional who directly participated in the procedure in a specific form. During the study period 117 tracheal intubations were performed, and 84% of these events were held under RSI; the patients\' ages ranged from 29 days to 17 years (median = 4.4 years) and 60 % were male; seventy-nine percent of patients had underlying diseases, 21% of them were neurological diseases, 18% cancer and 8% respiratory diseases; the acute respiratory failure was the immediate cause of TI in 40% of the procedures and altered level of consciousness and shock in 20% and 18% respectively; all TIs were performed in the emergency room by emergency physician with success rate of 39%; the pediatric resident\'s from the second year was responsible for 74% of the TIs, and with a success rate of 35%; positive pressure ventilation was performed in 74% of procedures, their use was lower among patients who were successfully intubated (21 vs. 49 p = 0.002); Midazolam was chosen as a sedative in 80% of procedures, and rocuronium as a neuromuscular blocking agent in 100% of procedures; Complications from the procedure of TI have been described in 75 (80%) of procedures, where a decrease in oxygen saturation was reported by 47% and significantly lower in patients who were successfully intubated (p <0.001). Difficulties related to TI were reported less in procedures performed with success (p <0.001). In conclusion, it can be stated that RSI was the method of choice in TI performed in the emergency room of ICr-FMUSP, that the patients who required airway management was composed mostly of patients with underlying diseases with respiratory problems and that complications of the RSI procedure are more frequent when there is need for a higher number of direct laryngoscopy attempts.

Introduktion: Att skapa fri luftväg i samband med prehospitalt hjärtstopp är en komplicerad åtgärd i en stressande situation. Det finns flera metoder för denna åtgärd och de har olika svårighetsgrad beroende på vilken metod som ambulanssjuksköterskan behöver använda för att nå framgång. Denna åtgärd förväntas ambulanssjuksköterskan klara av trots att miljön är utmanande och tidspressen stor.   Syfte: Att beskriva ambulanssjuksköterskors upplevelser av etablering av fri luftväg i samband med hjärtstopp.   Metod: Kvalitativ intervjustudie som analyseras med latent innehållsanalys. Tolv semistrukturerade intervjuer genomfördes på tre verksamhetsställen i södra Sverige.   Resultat: Ambulanssjuksköterskorna berättade om hur luftvägshantering är en liten men viktig del av allt de ska klara av i sin yrkesroll. Det finns en otrygghet i momentet intubation som beror på bristande utbildning i kombination med hur sällan ambulanssjuksköterskan gör detta i det dagliga arbetet. Studien resulterade i tre huvudkategorier: Otrygghet i yrkesrollen, Prehospitala framgångsfaktorer och Personcentrerad vård genom samarbete med tillhörande tolv subkategorier. Det som bekymrade ambulanssjuksköterskorna mest var luftvägshantering på barn. Det som upplevs vara den största framgångsfaktorn betonades vara de enkla åtgärderna när det gäller luftvägshantering.   Slutsats: För att öka ambulanssjuksköterskans trygghet i luftvägshantering krävs ökade utbildningsinsatser. Arbetsgivaren bör ta ett ökat ansvar för utbildning genom att skapa förutsättningar och uppföljning. Vidare bör de riktlinjer som finns för luftvägshantering ses över. De enklaste metoderna är oftast de bästa prehospitalt. / Introduction: To manage an airway in a prehospital environment is a complex measure in a stressful situation. There are several methods for this measure and they have various level of severity depending on the method the ambulance nurse chooses to apply. This measure is expected to be managed by the ambulance nurse despite rough environment and lack of time.   Purpose: To describe the ambulance nurse’s experiences of airway management in a cardiac arrest situation.   Method:  Twelve semi-structured qualitative interviews was made and analyzed by content analysis. The interviews were made at three different ambulance organizations in the south of Sweden     Result: The ambulance nurses told about how small but essential task airway management is. But it’s still a task they must be able to perform in their work.  There is an insecurity in the moment of intubation which is related to lack of training and how rarely they perform the moment in their daily duties. The study resulted in three main categories: Insecurity in the profession, Prehospital success factors and Person-centered care through teamwork with twelve subcategories. What concerned the ambulance nurses the most was airway management on children. They describe the greatest success factor to be the simplest possible measures when it comes to airway management.   Conclusion: To increase the ambulance nurse’s security in airway management more education efforts is needed. Employers should take a greater responsibility for education by creating conditions and monitoring. Therefore, should the guidelines for airway management be reviewed. The simplest methods in airway management are often the most successful.

Bakgrund Endotrakeal intubation används i många olika situationer där det finns ett behov av att skapa en säker luftväg. Den manipulation av luftvägarna som krävs i samband med en intubation kan bland annat orsaka postoperativ halssmärta och heshet, vilket kan ha negativa konsekvenser för patienten. För att försöka undvika komplikationer vid intubering har det utvecklats olika intubationshjälpmedel, där ett av hjälpmedlen är videolaryngoskop, som minskar den kraft som behövs för att skapa en fri insyn i larynx. Syfte Syftet med studien var att jämföra Macintosh direktlaryngoskopi mot McGrath videolaryngoskopi, för att undersöka om någon av metoderna ger minskad förekomst av halssmärta och heshet postoperativt. Metod För att besvara syftet antogs en kvantitativ ansats. Studien utfördes sedan som en förberedande undersökning med en induktiv metod. Datainsamlingen utfördes på en operationsavdelning i Västra Götaland, totalt deltog 24 patienter, varav 12 patienter intuberades med direktlaryngoskopi och 12 patienter intuberades med videolaryngoskopi. Deltagarna fick postoperativt svara på validerade enkätfrågor, och gradera eventuell förekomst av halssmärta och heshet enligt validerade fyrgradiga skalor. Resultat Resultatet visade att det eventuellt kan finnas en viss skillnad gällande postoperativ halssmärta beroende på om man intuberas med Macintosh direktlaryngoskopi eller McGrath videolaryngoskopi. Presenterat i absoluta och relativa mått visar det på att endast 1 deltagare (8%) som videolaryngoskoperades graderade lindrig halssmärta postoperativt, medan det var 3 deltagare (25%) som direktlaryngoskoperades som graderade lindrig halssmärta. Dock var skillnaden inte signifikant (p=0,56). Skillnaderna gällande heshet var större, där 9 deltagare (75%) som videolaryngoskoperades graderade sig helt besvärsfria postoperativt och 3 (25%) graderade en lindrig heshet. Ingen av deltagarna som direktlaryngoskoperades graderade sig som besvärsfri postoperativt, 9 (75%) graderade lindrig heshet och 3 (25%) graderade måttlig heshet. Skillnaden mellan grupperna var signifikant (p=0,001). Slutsats Skillnad verkar föreligga gällande framför allt heshet beroende på vilken intubationsmetod som används. Det kan även finnas en eventuell skillnad gällande halssmärta, dock är denna ej signifikant i pilotstudiens resultat. Studiepopulationen är begränsad i sitt antal, och det finns få studier att jämföra resultatet med. Det finns ett behov av fler och större studier för att finna evidens för den bästa metoden. / Background Endotracheal intubation is used in many different situations where there is a need to create a safe airway. The airway manipulation force that is required when an endotracheal intubation is needed may cause postoperative sore throat and hoarseness. This can adversely affect the patient. To avoid complications of an endotracheal intubation, different intubation aids have been developed, one of which is a videolaryngoscope, which reduces the force needed to create a free laryngeal insight. Aim The purpose of the study was to compare Macintosh direct laryngoscopy to McGrath videolaryngoscopy, to investigate whether either method reduces the incidence of sore throat and hoarseness postoperatively. Method To answer the purpose, a quantitative approach was adopted. The study was then conducted as a preliminary study with an inductive method. The data collection was carried out in an operation theatre in Västra Götaland, Sweden. A total of 24 patients participated, where 12 patients were intubated with direct laryngoscopy and 12 patients with videolaryngoscopy. Postoperatively the participants responded to validated questionnaires, and evaluated any occurrence of sore throat and hoarseness according to validated four-dimensional scales. Result There was a difference in postoperative sore throat depending on intubation with Macintosh direct laryngoscopy or McGrath videolaryngoscopy. Presented in absolute and relative terms, the result show that only 1 participant (8%) that was intubated with videolaryngoscopy graded mild sore throat postoperatively, while there 3 participants (25%) who were intubated with the use of direct laryngoscopy graded mild sore throat. However, the difference was not significant (p=0.56). The differences in hoarseness were greater, where 9 participants (75%) that was intubated with the use of videolaryngoscopy graduated no hoarseness post-operatively and 3 (25%) graded a mild hoarseness. None of the participants who were intubated with the use of direct laryngoscopy graded no hoarseness, 9 (75%) participants graded mild hoarseness and 3 (25%) graded moderate hoarseness. The difference between the groups was significant (p=0.001). Conclusions A difference exists in advance of hoarseness depending on the intubation method that is used. There may also be a difference regarding sore throat, but this result remained non-significant. However, in this pilot study the population was limited in its number, and there are few other studies in this field available for comparison. Therefore, more, and larger studies are needed to find evidence for the best intubation method.

En démontrant sa capacité d’identifier les pneumothorax, de différencier les différentes causes d’insuffisance respiratoire chez les patients dyspnéiques et de confirmer la position d’un tube endotrachéal lors d’une intubation endotrachéale, l’échographie pulmonaire a pris une place prépondérante dans la prise en charge des patients de soins critiques. La majorité des études, notamment celles sur l’intubation endotrachéale, ont évalué la performance de cliniciens possédant une expérience considérable en échographie pulmonaire et souvent dans un cadre idéal permettant des examens d’une durée prolongée. Considérant la disponibilité grandissante de l’échographie ciblée lors des situations de stabilisation et de réanimation des patients de soins critiques, nous voulions évaluer la capacité d’un groupe de clinicien hétérogène en termes de formation échographique à identifier la présence ou l’absence de glissement pleural sur de courtes séquences (comparable à la durée probable d’un examen lors de condition de réanimation) d’échographie pulmonaire enregistrées chez des patients intubés. Un total de 280 courtes séquences (entre 4 et 7 secondes) d’échographie pulmonaire démontrant la présence ou l’absence de glissement pleural chez des patients intubés en salle d’opération ont été enregistrées puis présentées de façon aléatoire à deux groupes de cliniciens en médecine d’urgence. Le deuxième groupe avait la possibilité de s’abstenir advenant une incertitude de leur réponse. Nous avons comparé la performance selon le niveau de formation académique et échographique. Le taux moyen d’identification adéquate de la présence ou l’absence du glissement pleural par participant était de 67,5% (IC 95% : 65,7-69,4) dans le premier groupe et 73,1% (IC 95% : 70,7-75,5) dans le second (p<0,001). Le taux médian de réponse adéquate pour chacune des 280 séquences était de 74,0% (EIQ : 48,0-90,0) dans le premier groupe et 83,7% (EIQ : 53,3-96,2) dans le deuxième (p=0,006). Le taux d’identification adéquate de la présence ou absence d’un glissement pleural par les participants des deux groupes était nettement supérieur pour les séquences de l’hémithorax droit par rapport à celles de l’hémithorax gauche (p=0,001). Lorsque des médecins de formation académique et échographique variable utilisent de courtes séquences d’échographie pulmonaire (plus représentatives de l’utilisation réelle en clinique), le taux d’identification adéquate de la présence ou l’absence de glissement pleural est plus élevé lorsque les participants ont la possibilité de s’abstenir en cas de doute quant à leur réponse. Le taux de bonnes réponses est également plus élevé pour les séquences de l’hémithorax droit, probablement dû à la présence sous-jacente du cœur à gauche, la plus petite taille du poumon gauche et l’effet accru du pouls pulmonaire dans l’hémithorax gauche. Considérant ces trouvailles, la prudence est de mise lors de l’utilisation de l’identification du glissement pleural sur de courtes séquences échographique comme méthode de vérification de la position d’un tube endotrachéal lors d’une intubation endotrachéale, et ce, particulièrement pour l’hémithorax gauche. Aussi, une attention particulière devrait être mise sur la reconnaissance du pouls pulmonaire lors de l’enseignement de l’échographie pulmonaire. / The field of targeted lung ultrasound in critical care is in constant expansion. Its many proven use include pneumothorax diagnosis, differentiation of the different causes of acute dyspnoea and endotracheal intubation confirmation. These studies on endotracheal intubation evaluated sonographers with extensive ultrasound training using sometimes lengthy exam. Hence, with the growing presence of bedside lung ultrasound we devised a study to evaluate the capacity of a heterogeneous group of physicians, with different levels of ultrasound training, to correctly identify lung sliding on random short sequences of recorded thoracic ultrasound. 280 short ultrasound sequences (4 to 7 seconds) of present and absent lung sliding of intubated patients recorded in the operating room were randomly presented to 2 groups of physicians. Descriptive data, mean accuracy of each participant, as well as the rate of correct answers for each of the sequences was measured and compared for different subgroups. Participants in the second group where instructed that they could abstain from answering in uncertain cases. Mean accuracy was 67.5% (95%CI: 65.7-69.4) in the first group and 73.1% (95%CI: 70.7-75.5) in the second (p<0.001). When considering each sequence individually, median accuracy was 74.0% (IQR: 48.0-90.0) in the first group and 83.7% (IQR: 53.3-96.2) in the second (p=0.006). The rate of correct answer was higher for right hemithorax sequences (p=0.001). Accuracy in lung sliding identification is better when participants have the possibility to abstain themselves from answering in uncertain cases. It is also improved in the right hemithorax, probably owing to the presence of the heart and the lung pulse artefact in the left hemithorax. Considering our results, caution should be taken when using short ultrasound sequences for identifying lung sliding as a mean of confirming endotracheal intubation, particularly in the left hemithorax. Emphasis should also be put on knowledge and identification of the Lung pulse artefact when teaching chest ultrasound curriculum.

[Truncated abstract] Objective: To investigate the demographics, success rate of application, nature and frequency of complication and the survival outcome of patients receiving advanced airway management in the pre-hospital setting. Design: Prospective observational cohort study. Participants: Patients who were attended to by St. John Ambulance Paramedics in the Perth Metropolitan area and selected regional areas within Western Australia. The patients were unconscious, unresponsive with no gag reflex and where application of an advanced airway would improve ventilation. Methods: Ambulance Paramedics received mannequin training within the classroom environment on the techniques for the application of the Endo-Tracheal Tube and the Laryngeal Mask Airway. The indication for the application of an advanced airway was any patient whose ventilation may be improved by intubation. These patients would be either deeply unconscious and areflexic, long term transport, severely injured (especially head injured) or cardiac arrest patients. Results: ... Paramedic assessment demonstrated that 14 (7.4%) 3 patients had an improvement in outcome. Of the 14 patients, 5 (2.7%) cardiac arrest patients survived to discharge from hospital compared to a 2.1 % survival rate for all cardiac arrest cases attended by the WAAS in 2002. Conclusion: Ambulance Paramedics can successfully apply an advanced airway apparatus in the pre-hospital environment. There was no statistical significance to demonstrate whether the introduction of advanced airway skills was beneficial or detrimental to patient survival outcome.

En démontrant sa capacité d’identifier les pneumothorax, de différencier les différentes causes d’insuffisance respiratoire chez les patients dyspnéiques et de confirmer la position d’un tube endotrachéal lors d’une intubation endotrachéale, l’échographie pulmonaire a pris une place prépondérante dans la prise en charge des patients de soins critiques. La majorité des études, notamment celles sur l’intubation endotrachéale, ont évalué la performance de cliniciens possédant une expérience considérable en échographie pulmonaire et souvent dans un cadre idéal permettant des examens d’une durée prolongée. Considérant la disponibilité grandissante de l’échographie ciblée lors des situations de stabilisation et de réanimation des patients de soins critiques, nous voulions évaluer la capacité d’un groupe de clinicien hétérogène en termes de formation échographique à identifier la présence ou l’absence de glissement pleural sur de courtes séquences (comparable à la durée probable d’un examen lors de condition de réanimation) d’échographie pulmonaire enregistrées chez des patients intubés. Un total de 280 courtes séquences (entre 4 et 7 secondes) d’échographie pulmonaire démontrant la présence ou l’absence de glissement pleural chez des patients intubés en salle d’opération ont été enregistrées puis présentées de façon aléatoire à deux groupes de cliniciens en médecine d’urgence. Le deuxième groupe avait la possibilité de s’abstenir advenant une incertitude de leur réponse. Nous avons comparé la performance selon le niveau de formation académique et échographique. Le taux moyen d’identification adéquate de la présence ou l’absence du glissement pleural par participant était de 67,5% (IC 95% : 65,7-69,4) dans le premier groupe et 73,1% (IC 95% : 70,7-75,5) dans le second (p<0,001). Le taux médian de réponse adéquate pour chacune des 280 séquences était de 74,0% (EIQ : 48,0-90,0) dans le premier groupe et 83,7% (EIQ : 53,3-96,2) dans le deuxième (p=0,006). Le taux d’identification adéquate de la présence ou absence d’un glissement pleural par les participants des deux groupes était nettement supérieur pour les séquences de l’hémithorax droit par rapport à celles de l’hémithorax gauche (p=0,001). Lorsque des médecins de formation académique et échographique variable utilisent de courtes séquences d’échographie pulmonaire (plus représentatives de l’utilisation réelle en clinique), le taux d’identification adéquate de la présence ou l’absence de glissement pleural est plus élevé lorsque les participants ont la possibilité de s’abstenir en cas de doute quant à leur réponse. Le taux de bonnes réponses est également plus élevé pour les séquences de l’hémithorax droit, probablement dû à la présence sous-jacente du cœur à gauche, la plus petite taille du poumon gauche et l’effet accru du pouls pulmonaire dans l’hémithorax gauche. Considérant ces trouvailles, la prudence est de mise lors de l’utilisation de l’identification du glissement pleural sur de courtes séquences échographique comme méthode de vérification de la position d’un tube endotrachéal lors d’une intubation endotrachéale, et ce, particulièrement pour l’hémithorax gauche. Aussi, une attention particulière devrait être mise sur la reconnaissance du pouls pulmonaire lors de l’enseignement de l’échographie pulmonaire. / The field of targeted lung ultrasound in critical care is in constant expansion. Its many proven use include pneumothorax diagnosis, differentiation of the different causes of acute dyspnoea and endotracheal intubation confirmation. These studies on endotracheal intubation evaluated sonographers with extensive ultrasound training using sometimes lengthy exam. Hence, with the growing presence of bedside lung ultrasound we devised a study to evaluate the capacity of a heterogeneous group of physicians, with different levels of ultrasound training, to correctly identify lung sliding on random short sequences of recorded thoracic ultrasound. 280 short ultrasound sequences (4 to 7 seconds) of present and absent lung sliding of intubated patients recorded in the operating room were randomly presented to 2 groups of physicians. Descriptive data, mean accuracy of each participant, as well as the rate of correct answers for each of the sequences was measured and compared for different subgroups. Participants in the second group where instructed that they could abstain from answering in uncertain cases. Mean accuracy was 67.5% (95%CI: 65.7-69.4) in the first group and 73.1% (95%CI: 70.7-75.5) in the second (p<0.001). When considering each sequence individually, median accuracy was 74.0% (IQR: 48.0-90.0) in the first group and 83.7% (IQR: 53.3-96.2) in the second (p=0.006). The rate of correct answer was higher for right hemithorax sequences (p=0.001). Accuracy in lung sliding identification is better when participants have the possibility to abstain themselves from answering in uncertain cases. It is also improved in the right hemithorax, probably owing to the presence of the heart and the lung pulse artefact in the left hemithorax. Considering our results, caution should be taken when using short ultrasound sequences for identifying lung sliding as a mean of confirming endotracheal intubation, particularly in the left hemithorax. Emphasis should also be put on knowledge and identification of the Lung pulse artefact when teaching chest ultrasound curriculum.

Att hantera och etablera en säker luftväg för patienten ingår i anestesisjuksköterskans kompetensbeskrivning. Videolaryngoskop har utvecklats för att enklare ska kunna etablera en säker luftväg via intubation. Korrekt handhavande och användande av videolaryngoskop minskar riskerna för patienten och ökar patientsäkerheten.Syftet med studien var att undersöka anestesisjuksköterskors upplevelse av att intubera med videolaryngoskop. Detta är en kvalitativ studie där datainsamlingen bestod av semistrukturerade intervjuer med nio anestesisjuksköterskor. En kvalitativ innehållsanalys genomfördes vilket resulterade i fyra kategorier: Är en trygghet vid svår intubation och underlättar handledning, Gammal vana och upplevda svårigheter att handha videolaryngoskop, Kan minska skador och vara skonsammare för patienten, och Begränsatantal och avsaknad av rutiner minskar användandet. Denna studie visar att anestesisjuksköterskor upplevde att videolaryngoskop är ett bra hjälpmedel vid intubation men även vid handledning och utbildning. För att stärka patientsäkerheten behöver videolaryngoskop användas mer, vilket kan tydliggöras med uppdaterade rutiner. Författarna till denna studie menar att mer forskning inom området behövs varför anestesisjuksköterskor väljer att inte använda videolaryngoskop. / To manage and establish a patient's airway is included in the competence description for anesthesia nurses. Videolaryngoscope have been developed to make it easier to establish a safe airway by intubation. A proper handling and use of videolaryngoscopes reduces patientrisks and increases patient safety. The aim of this study was to investigate anesthesia nurses experiences of intubating with videolaryngoscope. This is a qualitative study where the data collection consisted of semi-structured interviews with nine anesthesia nurses. A qualitative content analysis was made, which resulted in four categories: Is a security in case of difficultintubation and facilitates guidance, Old habits and perceived difficulties to handle, Can reduce injuries and be gentler for the patient, and Limited number and lack of routines reduces usage. This study shows that anesthesia nurses experienced that videolaryngoscopes are a good helping instrument for intubation but also for tuition and training. To strengthen patient safety, videolaryngoscopes need to be used more often, which can be clarified with updated routines. The authors of this study believe that more research in the field is needed, which is why anesthesia nurses choose not to use videolaryngoscopes.

Introduktion: Anestesisjuksköterskor arbetar inom flera olika delar av sjukvården. Tack vare deras kunskaper om luftvägar och omhändertagande av kritiskt sjuka patienter så anställs anestesisjuksköterskor inom olika prehospitala verksamheter så som exempelvis resursenheter. Vid plötsliga hjärtstopp är upprättandet av en fri luftväg kritiskt. Detta görs vanligen genom användandet av olika medicintekniska hjälpmedel som larynxmask eller endotrachealtub. De respektive hjälpmedlen har olika styrkor och svagheter som är väl studerade, men upplevelser av att använda dessa metoder finns det lite forskning om. Syfte: Syftet med studien var att studera anestesisjuksköterskans upplevelser av att använda larynxmask och endotrachealtub vid plötsliga hjärtstopp utanför sjukhuset. Metod: En kvalitativ induktiv enkätstudie med öppna semistrukturerade frågor genomfördes för att fånga användarnas upplevelser av skillnader mellan dessa metoder av luftvägshantering. 14 anestesisjuksköterskor med minst två års erfarenhet samt erfarenhet av att arbeta prehospitalt deltog i studien. Deltagarna arbetar i tre regioner vilka har stora skillnader i resurser och arbetsrutiner. Resultat: Larynxmask var mest använt, trots att nästan alla deltagare föredrog att ha patienten intuberad. Orsaken till att laynxmasken användes trots att deltagarna föredrog att patienten skulle ha en endotrachealtub varierade något men hade flera gemensamma faktorer så som tidsåtgång och enkel användning. / Introduction: Nurse anesthesias work in different parts of healthcare. In various prehospital activities and different resource units these specialist nurses are often hired for their knowledge of the airways and critical patients. In case of sudden cardiac arrest, the establishment of a free airway is critical. This is usually done using various medical aids such as a laryngeal mask or endotracheal tube. These have their different strengths and weaknesses that are well studied, but there is little research on experiences of using these methods. Aim: The aim of the study was to study anesthesia nurses' experiences of using a laryngeal mask and endotracheal tube in sudden cardiac arrest outside the hospital. Method: A qualitative inductive survey with open semistructural questions, was done to capture the users’ experiences of the differences between these methods of airway management. This study included 14 nurse anesthetists, with at least 2 years of experience and experience of working in a prehospital setting. Participants from three regions participated, those regions differ in resources and ways of working routines. Result: The laryngeal mask is most commonly used, even though almost all participants prefer to have an intubated patient. The reasons for that varies between the participants but have several common factors such as time of application and ease of use.

Der Einsatz von Ketamin erfolgt in der Humananästhesie, vor allem aufgrund seiner vielfältigen Nebenwirkungen, nur noch nach strenger Indikation. In der Veterinärmedizin ist Ketamin tierartenübergreifend für die Injektionsnarkose weit verbreitet. Um den bekannten Nebenwirkungen vorzubeugen, wird Ketamin mit verschiedenen anderen Anästhetika kombiniert und stellt so ein sicheres Narkoseverfahren bei Tieren dar. Eine besondere Herausforderung ist die Anästhesie bei ophthalmologischen Patienten unter Berücksich-tigung der Kontrolle des Intraokularen Drucks (IOP). In diesem Zusammenhang gibt es in der Literatur widersprüchliche Angaben zur Auswirkung von Ketamin auf den IOP beim Menschen und verschiedenen Tierarten. Auch für die Auswirkungen von Propofol und der endotrachealen Intubation auf den IOP existieren widersprüchliche Aussagen. In der vorliegenden Arbeit wurde untersucht, ob gängige Ketamin-Kombinationsnarkosen bei der augengesunden Katze einen Einfluss auf den IOP haben. Angeregt durch Berichte in der Literatur wurde zudem untersucht, ob die Applikation von Propofol sowie die endotracheale Intubation den IOP bei der Katze beeinflussen. Methodik: Untersucht wurden 48 adulte, augengesunde Katzen, die dem chirurgischen Patientengut der Klinik für Kleintiere der Universität Leipzig entstammten. Es handelt sich um eine prospektive, randomisierte Blindstudie. Die Patienten wurden vier Untersuchungsgruppen zugeordnet. Zur intramuskulären Narkoseeinleitung erhielten Tiere der KX-Gruppe Ketamin (10 mg/kg) und Xylazin (1 mg/kg), der KXAtr-Gruppe Ketamin (10 mg/kg), Xylazin (1 mg/kg) und Atropin (0,025 mg/kg), der KA-Gruppe Ketamin (20 mg/kg) und Acepromazin (0,5 mg/kg) und der KM-Gruppe Ketamin (10 mg/kg) und Medetomidin (50 g/kg). Bei allen Patienten wurde mittels Tono-Pen® XL zu verschiedenen Zeitpunkten der IOP bestimmt: vor Narkoseeinleitung (Ausgangswert), nach Narkoseeinleitung nach 5, Zusammenfassung 86 10, 15 und 20 Minuten und direkt nach der Intubation sowie final nach Beendigung der Narkose während der Aufwachphase. Einige Tiere erhielten zur Vertiefung der Narkose vor der Intubation Propofol. Im Anschluss erfolgte eine ophthalmologische Untersuchung der Patienten, um eine Augenerkrankung auszuschließen. Ergebnisse: Der mittlere Ausgangs-IOP aller Tiere beträgt 15,8 mmHg. Mit p = 0,756 besteht kein signifikanter Unterschied zwischen den Gruppen. Getrennt nach linken (OS) und rechten (OD) Augen ist der mittlere IOP 15,7 und 15,8 mmHg. Dieser Unterschied ist nicht signifikant (p = 0,442). Daher wird für die Auswertung der Mittelwert aller 6 Datenpunkte pro Tier und Messzeitpunkt zugrunde gelegt. Im Vergleich zum Ausgangswert zeigt die KX-Gruppe keine signifikanten IOP-Änderungen. Die KXAtr-Gruppe und die KM-Gruppe weisen zur Final-Messung einen signifikanten IOP-Abfall um 16 % (p = 0,012) bzw. 17 % (p = 0,021) im Vergleich zum Ausgangswert auf. Die KA-Gruppe zeigt zur 15-Minuten-Messung den stärksten IOP-Abfall mit 21 % Prozent (p = 0,001) gegenüber dem Ausgangswert. Ab der 10-Minuten-Messung bis zur post-Intubations-Messung ist der IOP-Abfall der KA-Gruppe signifikant. Für die Gesamtstichprobe hat die Intubation keinen signifikanten Einfluss auf den IOP (p = 0,063). Die Gabe von Propofol zur Vertiefung der Narkose bei einzelnen Tieren hat ebenfalls keinen signifikanten Einfluss auf den IOP (p = 0,42). Schlussfolgerung: Die verwendeten Ketamin-basierten Narkoseprotokolle bewirken bei der augengesunden Katze keinen signifikanten IOP-Anstieg. Die Gruppen KX, KXAtr und KM gewährleisten für den Zeitraum von 20 Minuten nach Narkoseeinleitung einen relativ stabilen IOP. Trotz des signifikanten IOP-Abfalls in der KA-Gruppe sind sämtliche IOP-Schwankungen aller Gruppen klinisch nicht relevant. Die gemessenen IOP-Werte bewegen sich alle im physiologischen Bereich. Zudem geben die Ergebnisse keinen Hinweis auf eine IOP-Steigerung infolge Propofolgabe und Intubation bei der Katze. / Ketamine is used in human medicine based on strict indications, mainly due to its numerous side effects. In veterinary medicine however Ketamine is commonly used to induce anesthesia intramuscularly throughout all species. To minimize the well known side effects Ketamine is used in combination with several other anesthetics and thus represents a safe anesthetic procedure in animals. Ophthalmological patients are a particular challenge for anesthetists with regard to maintaining the intraocular pressure (IOP). Conflicting data can be found in the literature about the effects of Ketamine on IOP in humans and various animal species. The literature also contains various statements about the effects of Propofol and endotracheal intubation on IOP. In this clinical trial we investigated the effects of commonly used Ketamine-based anesthetic protocols on IOP in cats. Motivated by conflicting statements in the literature the analysis of the effects of Propofol and endotracheal intubation on IOP was included in the study. Methods: This is a prospective, randomized, blinded study. 48 adult cats without ophthalmological abnormalities, recruited from the pool of admitted surgical patients of the Department of Small Animal Medicine of the University of Leipzig were included in the study. The patients were assigned to one of the following four groups and anesthesia was induced intramuscularly. Cats in the KX-group were induced with Ketamine (10 mg/kg) and Xylazine (1 mg/kg). Cats in the KXAtr-group were induced with Ketamine (10 mg/kg), Xylazine (1 mg/kg) and Atropine (0,025 mg/kg). Cats in the KA-group were induced with Ketamine (20 mg/kg) and Acepromazine (0,5 mg/kg). Cats in the KM-group were induced with Ketamine (10 mg/kg) and Medetomidine (50 g/kg). In all patients the IOP was measured three times per eye using the Tono-Pen® XL at particular times: baseline IOP before induction of anesthesia, at 5, 10, 15 and 20 minutes after induction of anesthesia, after intubation and final IOP after completion of surgery. Some cats received a single bolus of Propofol to be able to tolerate endotracheal intubation. After the final IOP-measurement all Zusammenfassung 88 cats were subjected to an ophthalmological examination, including slitlamp biomicroscopy and gonioscopy, in order to exclude patients with ophthalmological pathologies. Results: The mean baseline IOP for all animals is 15,8 mmHg (SD 4,0). There is no significant difference between the four groups (p = 0,756). The mean IOP for the right (OD) and left eyes (OS) of all patients was 15,8 mmHg and 15,7 mmHg, respectively. There is no significant difference between right (OD) and left eyes (OS) (p = 0,442). Therefore all further analyses are based on the mean of all six data points per animal and measuring time. The KX-group shows no significant IOP-change relative to baseline-IOP. The KXAtr and KM-group show a significant decrease in IOP of 16 % and 17 %, respectively, at the final measurement compared with baseline-IOP. The KA-group shows a significant decrease in IOP starting at 10 minutes after induction of anesthesia until the post-intubation measurement. The maximum decrease in IOP in this group is 21 % relative to baseline-IOP 15 minutes after induction of anesthesia. For the total data no significant influence of endotracheal intubation on IOP could be detected (p = 0,063). The application of Propofol in a total of 14 cats has no significant effect on IOP (p = 0,42). Conclusion: The Ketamine-based anesthetic protocols used in this study do not cause a significant increase in IOP in cats without ophthalmological abnormalities. The KX, KXAtr and KM-group ensure a relatively stable IOP for the time period of 20 minutes after induction of anesthesia. Despite the significant IOP-decrease in the KA-group none of the IOP-changes in all groups examined are of clinical relevance. All of the collected IOP-values are within the physiological range for cats. There is no evidence for an increase in IOP caused by endotracheal intubation or the application of Propofol.

Bakgrund: Dagligen drabbas mer än 25 personer av hjärtstopp utanför sjukhus där ungefär 500 av dessa räddas årligen. Luftvägshanteringen är en av de viktigaste faktorerna under hjärt-och lungräddning och en obehandlad hypoxi i samband med hjärtstopp ökar risken för att patienten kan erhålla neurologiska skador. Enligt Erikssons omvårdnadsteori kan olika former av lidande upplevas, men när kroppen, själen och anden är i balans uppnås hälsa. För att hantera luftvägen kan ambulanspersonal använda sig utav mask-och blåsa eller larynxmask. Endotrakeal intubation är även ett alternativ, men kräver särskild kompetens i Sverige vilken främst specialistsjuksköterska inom anestesisjukvård innehar. Studier visar på en låg procentuell framgång för antal lyckade försök gällande utövandet av endotrakeal intubation prehospitalt och att larynxmask numera används i stället av ambulanspersonalenför att den kan appliceras snabbt och enkelt. Syfte: Syftet var att belysa om förekommande luftvägshjälpmedel vid hjärtstopp utanför sjukhus kan påverka patientens utfall vid återkomst av spontan cirkulation. Metod: Litteraturöversikt med systematisk ansats. Cinahl plus och PubMed har använts som databassökning. Totalt 15 artiklar av kvantitativ metod inkluderades. Artiklarna har därefter analyserats genom integrerad analys. Resultat: De signifikanta huvudfynden som framkom med var att luftvägshantering med mask-och blåsa påvisade en hög prevalens för gynnsamt neurologiskt utfall och överlevnad medan endotrakeal intubation påvisade en högre prevalens för återgång av spontan cirkulation. Slutsats: Utifrån resultatet visade sig användning av mask-och blåsa ge mest utdelning för att uppnå ett gynnsamt neurologiskt utfall och ökad chans till överlevnad för patienten. Däremot framkom det att användning av endotrakealtub vid prehospitalt hjärtstopp medförde störst chans till återkomst av spontan cirkulation. Av de tre förekommande luftvägshjälpmedlen att använda sig av vid prehospitalt hjärtstopp kan det förekomma skillnader i utfallet för patienten. Det förekommer däremot inte tillräckligt med stora skillnader och resultatet bördärmed tolkas med försiktighet då det anses behövas fler studier inom området. / Background: Every day more than 25 people suffer from out-of hospital cardiac arrest, of which approximately 500 rescued annually. Airway management is one of the most important factors in cardiopulmonary resuscitation and an untreated hypoxia in conjunction with cardiac arrest increases the patient’s risk of receiving neurological damage. According to Eriksson's nursing theory, various forms of suffering can be experienced, and a state of health can only be achieved when the body, soul and spirit are in balance. To manage the airway, the ambulance clinician can use a bag-valve mask or laryngeal mask. Endotracheal intubation is also an alternative, but in Sweden, it requires specific competence that mainly specialist nurses in anesthesia care possess. Studies shows a low success rate regarding the practice of performing a prehospital endotracheal intubation and that laryngeal mask nowadays more used instead by ambulance staff because it’s applied quickly and easily. Aim: The purpose was to shed light on whether the available respiratory aids in out-of-hospital cardiac arrest can affect the patient outcomes on the return of spontaneous circulation. Method: Literature overview with systematic approach. Cinahl plus and PubMed has been used as database search. A total of 15 articles of quantitative method were included. The articles were analyzed through integrated analysis. Results: The significant main findings that emerged were that airway management with bag-valve mask correlated with a high prevalence for favorable neurological outcome and survival while endotracheal intubation showed a higher prevalence for return of spontaneous circulation. Conclusion: Based on the results, the use of bag-valve mask found to be the best option to achieve a favorable neurological outcome and increased chance of survival for the patient. However, the use of endotracheal tube in out-ofhospital cardiac arrest for increasing the chance of the patient regaining return of spontaneous circulation. Out of the three available airway aids to use in out-of-hospital cardiac arrest, there may be differences in the outcome for the patient. However, there are not enough significant differences, and the result therefore should be interpreted with caution as it is considered that more studies in the subject required.