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 Editor’s Letter 3 – Issue N°5 – Oct. 2009

An effective HIV vaccine at last?

It is now over a quar- was thought would elicit an antibody (V520) based on an attenuated adenovi- reported a reduced risk of contracting
ter of a century since response that would prevent infection. rus carrying three HIV Subtype B genes, HIV of 31.2% in Thai volunteers. Full
Dr Luc Montagnier Unfortunately the heavily glycosylated which involved over three thousand data will be presented at the AIDS Vac-
first identified the viral envelope protein both masks paticipants spread over three continents, cine 2009 conference which starts on
virus that causes potential protein epitopes, and prevents were abandoned prematurely because October 19th. In the meantime we and
AIDS, which at that antibodies binding effectively even if the vaccine proved ineffective. the mass media should realise that this
time was a disease they are generated. In addition the viral Now the Phase III trial with a combi- development may be just a small step for
with low prevalence. Since then HIV/ envelope proteins vary more than other nation of two earlier vaccines, namely mankind, not the giant leap for which we
AIDS has spread around the globe; viruses, both geographically and over ALVAC, which employs a canary- all hope.
according to the most recent report time; the HIV virus is highly mutable. pox virus to carry three HIV genes,
jointly released by WHO, UNAIDS and Phase II trials with a previous vaccine, and AIDSVAC, based on gp120, has
UNICEF last year, the number of people
living with HIV has risen to 33.2 mil-
lion, 22.5 million of whom reside in sub-
Saharan Africa. Two and a half million
people were newly infected with HIV in
2007. Faced with such daunting facts, is
there any cause for optimism?
A major achievement in the fight against
AIDS is that over three million people
in the most severely affected resource-
poor countries are now receiving anti-
retroviral therapy (ART). This is the
result of the increased availability of
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HIV virus had been isolated, Margaret
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Education and Welfare, blithely declared
that an effective HIV vaccine would
be available within two years. Despite
concerted efforts as well as sporadic
announcements of success, this goal still
remains elusive a quarter of a century
later. Why have previous vaccines failed,
and will the ALVAC/AIDSVAX combi-
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FEATURES
[6 - 7] Intensive care special
[6] Advanced laryngoscopy techniques
[10] Fever in the intensive care unit
[14] Paediatric laryngoscopy: history and current developments
[17] RSNA Highlights
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 – Issue N°5 – Oct. 2009 6 Intensive care

Advanced laryngoscopy techniques

Video laryngoscopy (VL) technology plays an important and varied role in airway screen directly incorporated into the laryngo-
management. A full understanding of the indications, proper use and limitations of scope handle; others use a stand-alone monitor.
VL is vital for the optimisation of its application in patient care. Yet other models, such as the Airtraq [5], the Tru-
View EVO 2 [6] and the Bonfils Retromolar scope
use advanced optics to provide an indirect image
by Dr T. C. Mort of the glottic opening. Another feature that varies
Figure 1. Three Airway Axes between different models is whether the design
is channelled or non-channelled. For example,
Airtraq and Pentax AWS are channelled mod-
els, allowing placement of the endotracheal tube
(ETT) into the channel to assist with its guidance
through the vocal cords and into the tracheal
position. This requires manipulation of the device
rather than the ETT itself. Non-channelled mod-
els such as GlideScope, McGrath, Trueview and
C-Mac rely upon operator manipulation of the
ETT or “free-hand” ETT advancement into the
airway. Another variant is optical stylet designs
based on fibre optics, which provide indirect vis-
Figure 1. Three airway axes. The 3 axes are aligned by flexion of the cervical spine and extension of the head
on atlanto-occipital joint to improve the alignment for better viewing. A variety of factors may limit the operator ualisation of the airway. The ETT is mounted on
from aligning the 3 axes hence the “line of sight” may be restricted or absent. Drawing courtesy of Anna Mort. the optical stylet and the ETT-stylet unit is visu-
The 3 axes are aligned by flexion of the cervical spine and extension of the head on atlanto-occipital joint to ally guided Figure 2.into thestylet
Optical tracheal position.
combined with DL Typically,
for laryngeal exposu
improve the alignment for better viewing.
Direct laryngoscopy (DL), the standard method A variety ofoffactors
the may limit
epiglottis, the operator
lateral from
pharyngeal aligning
walls, the 3
aryte- the stylet is rigid and relatively fixed in design
axes hence the “line of sight” may be restricted or absent. Drawing courtesy of Anna Mort.
for placing an endotracheal tube (ETT) into the noids, true and false vocal cords and the entire
trachea, has changed little in the past 50 years. The glottic opening into the trachea. Although tra-
technique involves following well established, rou- cheal intubation can be successfully carried out
tinely practiced manoeuvres to align the oral, pha- with only a restricted view of, for example, the
ryngeal and tracheal axis to displace the oral cavity posterior third of the glottic opening, restricted
and oropharyngeal tissues (tongue, epiglottis) with views frequently mean an increase in the number
a lighted blade to allow visualisation of the vocal of intubation attempts and misplacement of the
cords (glottic opening). The “cavity” opened up by ETT into the oesophagus. Optimal viewing is
the laryngoscope blade allows the airway structures therefore safest for the patient, although of course
to be viewed by looking down past the flattened obtaining a view of the glottic opening does not in
surface of the blade [Figure 1]. Thus, the operator’s itself guarantee successful ETT passage.
“line of sight” permits accurate and timely place-
ment of the ETT through the vocal cords and into Visualisation of the airway by DL has enabled the
the trachea. A variety of factors may however lead grading of airway views so that consistent descrip-
to difficulty in obtaining an unobstructed view tions can be used. There are six generalised grades
with the naked eye via the line of sight [Table 1]. representing the commonly seen views of airway ofFigure
Operator 2. Operator
using a DL scope using a DL the
to displace scope to displace the
contents
contents of the oropharynx followed by placement of
the oropharynx followed by placement of the Levitan®
Such restricted or obstructed views may limit the anatomy; they range from grade I (full view), the seeing optical stylet for visualizing and ultimate passing
Levitan seeing optical stylet forDrawing
visualising and ulti-
of the ETT with continuous observation. courtesy
successful and timely placement of the ETT and grade IIa (only posterior half of glottis), grade mate of Annapassing
Mort. of the ETT with continuous observation.
thus jeopardise the patient’s safety from the point IIb (epiglottis, arytenoids visible, cords not vis- Drawing courtesy of Anna Mort.
of view of oxygenation and ventilation. ible), grade IIIa (epiglottis edge only), grade IIIb
Experience (EMS trainee or medical student vs. seasoned
(floppy, overhanging epiglottis) to grade IV (no anesthesiologist or emergency physician)
The technological advance of coupling video- view) [Figure 3].
Presence, character and condition of dentition
camera equipment to the basic laryngoscope or
the intubating stylet has ushered in a new era of Types of video laryngoscopes Mouth opening (restricted due to trauma, tumour, infection,
TMJ disorders,
airway management capabilities. Many operators There is now a choice of commercially available
use a stylet within the ETT to customise its shape. video laryngoscopes (VL) for use in intubations Cervical spine mobility

Previously the stylet was static, but it is now more and airway exams. They can be classified in dif- Head-torso positioning
interactive and dynamic. Fibre optic capabilities ferent categories. Some models, such as the Gli- Presence of secretions, blood, vomitus
built into the stylet allow visualisation of the air- descope [1], McGrath [2], Pentax [3] and Storz Tumours, mass effect, swelling, oedema, infectious processes
way structures as the ETT is advanced through [4] obtain the image of the glottis by a miniature
Blade choice (length, width, style)
the glottic opening [Figure 2]. camera placed at the tip of the blade, which trans-
mits the image electronically to a remote screen. Location of patient (street or apartment floor vs. operating
room theatre)
A brief review of laryngeal anatomy Although many of these instruments resemble a
The objective of placing a conventional DL blade standard curved laryngoscope blade, the degree Congenital/acquired anatomical variations

in the hypopharnyx is to open a pathway to expose of angulation differs to allow more “around the Table 1. Factors that may impact ease or difficulty of
the periglottic region, thus allowing visualisation corner” visualisation. Some designs have the airway management.

(Levitan, Shikani), but it is also
available in a flexible form (Foley
model) or with a rigid stylet and an
articulated distal tip for improved
manoeuvring of the ETT into the
airway (RIFL). Since there is no
blade to open the airway cavity, the
optical stylet models rely on either
a hand manoeuvre to provide a jaw
thrust-chin lift or the placement of a
conventional laryngoscope blade or
one provided by the manufacturer.
Manufacturers also offer light
weight, portable devices that can be
easily transported in an airway bag,
tackle-box or cart; other devices are
pole- or cart-mounted and are more
cumbersome to carry. Laryngo-
scopes also range from less expen-
sive single-use, disposable devices
(Airtraq) to more expensive systems
that offer reusable blades or dispos-
able blade covers. Manufacturers are
continually updating and improv-
ing the technology. For example,
neonate and paediatric versions are
currently available with the Tru-
View EVO, Clarus Medical and
GlideScope models.
Technique
Video laryngoscopes are used in
many applications, from tracheal
intubations [1-6] to the insertion
of nasogastric tubes [7]. VL can be
used as the primary intubation tech-
nique, as a rescue technique for air-
way evaluations prior to extubation
or for ETT exchange [8]. Though
each type of VL device requires spe-
cific manoeuvres to place it in the
airway, several basic tenets should
be followed when carrying out a
VL-based intubation. Hand and
eye coordination is challenged with
VL placement and ETT advance-
ment, so that a new skill set must
be mastered for each of the stylet,
channelled and non-channelled VL
devices. In general, while the airway
is under direct visualisation, the VL
device should be advanced into the
oral cavity through to the oral phar-
ynx until the tip is past the posterior
part of the tongue.
Attention can then be directed to
the video screen or optical eyepiece
to help in getting the best view of
the glottic opening. The ETT is then
delivered into the airway either via
the device’s channel, by free hand
with or without a stylet, or it is
advanced into the trachea over the
7 – Issue N°5 – Oct. 2009
Figure 4. Laryngeal Grades (Cook-Lentis)
optical stylet using visual guidance.
Care must be taken not to damage
any structures during the advance-
ment of the ETT — there are mul-
tiple case reports documenting soft
palate and palatoglossal arch lacera- Figure
Drawing 3. Laryngeal
courtesy grades
of Anna Mort (Cook-Lentis). Drawing courtesy of Anna Mort.
tion caused by trauma during manip-
ulation, advancement and inser- noise and end tidal ETCO2 should Video laryngoscopy
tion of the ETT [9,10]. The airway also confirm that the routine has applications
practitioner should then constantly been correctly carried out [11]. There are many recent papers on the
alternate his attention between the With correct initial instructions and uses of VL, primarily focussing on
monitor/eyepiece, the device and repeated use of the devices in elec- the improved view of the larynx as
the patient. After the advancement tive situations, successful manipula- compared to conventional laryngo-
of the ETT into the trachea, which tion can be mastered in a relatively scopes [13,14]. In the first published
may be verified visually, breathing short period of time [12]. use of the GlideScope a patient who
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 – Issue N°5 – Oct. 2009
was a known difficult case for intubation, and who
had proved to be a significant management chal-
lenge using a variety of other airway devices and
techniques, was successfully intubated in 15 sec-
onds [13]. In the first large scale study, in over 700
patients, of VL technology using the GlideScope,
the view of the larynx that was achieved with VL
was just as good or better than with DL [15].
In a similar case series evaluating the McGrath
instrument [Figure 4], 98% of all tracheal intuba-
tions were successful thanks to the excellent visu-
alisation provided by the VL technology. A grade
I view was obtained in 95% of cases and a grade II
view in an additional 4% of cases [16].
Airway practitioners may use VL technology
in a variety of clinical settings, but the great-
est impact is on the airway management of the
patient who is suspected or known to be difficult
to intubate. Marrel et al randomised 80 morbidly
obese patients undergoing bariatric surgery to
either DL or VL approaches. Not only was a bet-
ter grade view consistently obtained with VL, but
in addition, intubation times were shorter [17].
When intubating a morbidly obese patient, many
practitioners have altered their airway manage-
ment policy to ensure immediate access to VL
technology at the patient’s bedside [18].
Unstable cervical spine fractures often pose a
unique problem for the airway manager in the
operating room, the ICU or the emergency
department. Three different studies have assessed
the intubation view and cervical spine stability
(lack of movement) obtained with VL vs. DL with
cervical spine immobilisation. The first study
found that the use of VL produced better glottic
visualisation, but found little difference in spinal
column movement between the two methods
[19]. The second study noted an improved glottic
view with VL at the cost of an increased time-to-
intubation compared with DL [20]. However in
the 3rd study, VL showed limited cervical spine
movement without an increased intubation time
when compared to DL [21]. These studies support
Primary intubation device
Rescue intubation device
Assist with ETT exchange
Evaluate airway prior to extubation
Assessment position of ETT
Assist with the placement of: Oro- or nasogastric tube
Feeding tube placement
TEE probe
GI endoscope
Assess airway oedema, trauma, infections
Visualization of laryngeal function
Foreign body location & extraction
Placement of oesophageal dilating bougie
Table 2. In addition to tracheal intubation,
video laryngoscopy has been used in many
other applications.
8 Intensive care
Figure 13. McGrath Videolaryngoscope
Figure 4. McGrath videolaryngoscope. McGrath
McGrath portable videolaryngoscope with disposable laryngoscope
portable videolaryngoscope
disarticulates fromwith disposable
blade. The handle the blade so to allow
scope blade.
placement The handle
in a confined disarticulates
oral opening from
(hard cervical
collar, blade
asto allow placement
compared in aconstruction
to the fixed/rigid confined oral opening
of other models.(hard
cervical collar, trismus) as compared to the fixed/
rigid construction of other models.
the conviction that VL technology improves the
“line of sight” in a patient population with con-
trolled or restricted cervical spine movement.
Placement of the VL device is greatly facilitated in
many patients by removal of the anterior compo-
nent (maintaining midline stabilisation) of a rigid
cervical collar, since otherwise mouth opening
may be restricted.
For the patient with a known or suspected dif-
ficult airway related to anatomical limitations,
infectious processes, mass/tumour effect or
trauma, it may be prudent to keep the patient
conscious and maintain spontaneous ventilation;
this optimises patient safety. The administration
of sedative-hypnotics, opioids and/or neuromus-
cular blocking agents places the onus on the air-
way manager to support ventilation and oxygena-
tion. Thus an “awake” or “barely aware” patient
technique supported by the topical application of
local anaesthetics, or placement of nerve blocks
supplemented with light sedation and analgaesia,
generally avoids the major problems that intuba-
tion with anaesthesia may generate. Usually, with
flexible fibre optic bronchoscopy placement of the
ETT, an awake patient approach is adaptable to a
variety of airway devices. VL is a safe alternative
to such awake flexible fibre optic intubation. Using
the GlideScope, Doyle topicalised the airway with
4% lidocaine supplemented with light midazolam
anxiolysis for awake intubation in four patients.
Following insertion of the GlideScope and visu-
alisation of the glottis, further lidocaine topicali-
sation of the airway was accomplished using an
atomiser. The styleted endotracheal tube was then
advanced under direct visualisation [22]. Two
other studies also showed successful awake intu-
bations using the GlideScope and various topi-
calisation techniques [23,24]. One of these stud-
ies used VL to screen the patient with a known
or suspected difficult airway in the preoperative
holding area to offer the airway team valuable
information on the need for an awake fibre optic
technique. Topicalisation with local anaesthetic
followed by an anti-sialagogue allowed the practi-
tioner to adequately evaluate the airway using VL
without sedation. All patients were then induced,
paralysed, and intubated with a full laryngeal
view provided by VL, thus avoiding awake fibre
optic bronchoscopy [25]. VL, in the hands of a
trained and experienced practitioner, appears to
be a straightforward technique that may be signif-
icantly faster than fibre optic intubation. VL may
also be combined with the flexible bronchoscope
and other airway devices to augment management
of patients with difficult airways [24].
Outside the OR
Much emphasis has been placed on the role that
laryngo-
VL devices play in the elective operating theatre.
the trismus)
However, the technique can also be of potentially
huge benefit for urgent and emergent airway inter-
ventions in locations outside the operating room
(OR), especially in light of the fact that emergency
airway management is fraught with difficulty and
patient safety concerns. Such interventions may
be required in the intensive care unit (ICU), the
emergency department, the ward or the cardiac
catheterisation suite. Video-augmented periglot-
tic visualisation allows the adaptation of VL for
airway procedures well beyond tracheal intuba-
tion; there are a variety of ingenious applications
and uses [Table 2].
A word of caution
Despite the current enthusiasm for VL technology,
it should be noted that the introduction of any new
equipment is frequently accompanied by a “hon-
eymoon” period during which it appears that the
technology can do no wrong. Basically the success
of VL technology is typically limited by those using
it. Patient factors also play a role: the presence of
blood, vomitus, secretions, the degree of mouth
opening, head-neck-torso configuration and ana-
tomical variations and alterations can all affect
success. Equipment maintenance is of primary
importance since neglect and mishandling of the
equipment may lead to malfunction, suboptimal
image recreation and electronic errors. Difficulty
in providing ready access to the disposable blade
covers thar are required in some VL models may
limit their use, especially in locations outside the
operating room or regular service area.
Despite all these potential limitations and restric-
tions that could affect VL success, the most impor-
tant factor is however the practitioner’s experience
and judgment in incorporating VL technology into
clinical practice. The role of organised instruc-
tion on the proper use of VL technology cannot
be over-emphasised. Equally, it is important to
anticipate the unexpected and to be prepared for
the “worst-case scenario” when arriving at the
bedside of a critically ill patient in need of airway
management. Complete reliance on VL technol-
ogy is thus ill-advised and shortsighted. VL is an
adjunct to airway management techniques, not a
replacement for them. Practitioners who ignore

Reusable
Shikani1
Levitan1
Foley 1
GlideScope GVL 2
RIFL3
Bonfils4
C-Mac4
TruView EVO5
1. Clarus Medical, Minneapolis, MN USA / 2. Verathon Medical, Bothell, WA USA / 3. Rigid Intubating Fiberoptic Laryngoscope,
AI Medical Devices, Williamston, MI USA / 4. Karl Storz, Tuttlingen, Germany / 5 Truphatek International Limited, Netanya, Israel
6. Prodol Meditec, Vizcaya Spain. / 7. Aircraft Medical Limited, Edinburgh, United Kingdom. / 8. Pentax Corporation, Tokyo, Japan
Table 3. Available airway devices by category.
the fundamentals of airway manage-
ment and insist on using VL as their
main (or only) approach, may meet
with negative consequences when
the approach fails. A backup plan
consisting of other airway manage-
ment approaches must be available
in order to optimise patient safety.
Sterility
The problem of cross-contamination
and the need for equipment hygiene
routines are increasingly having a
huge influence on clinical practice.
Depending on how they are treated
after being used on patients, video/
optical airway equipment can be
classified in three categories, namely
(1) reusable devices (cleanable); (2)
single patient use devices followed
by disposal and (3) video laryngo-
scope systems with attachable yet
disposable laryngoscope blades
(DLB) supplied in sterile packaging
[Table 3]. Some manufacturers now
offer a sleeve or condom-like cover
for the reusable devices to reduce
contamination. Hygienic reproc-
essing of reusable devices is essen-
tial, since all patients are poten-
tially the source of transmissible
infectious diseases.
Maintenance of equipment
The introduction of advanced
technology into clinical practice
requires pre-planning, especially if
the equipment is to be shared by a
large number of individuals. First
and foremost, education on the use,
care, limitations and indications of
VL technology should be a primary
objective. The maintenance and
cleaning of the equipment as well
as the distribution of VL devices to
various operators or locations, must
be appropriately coordinated. Oth-
erwise misplacement of equipment
will occur with consequent disrup-
tion of patient care. Ready access
to replacement batteries should be
9 – Issue N°5 – Oct. 2009
Single Use/Disposable Reusable with DLB 11. Walls RN. Anesthesiology News 101(5):723-730.
Airtraq6 McGrath7 Guide to Airway Management. 2009; 21. Turkstra TP, Pelz DM, Jones PM.
GlideScope Cobalt2 2:30-32. Anesthesiology 2009; 111(1):97-101.
GlideScope Ranger2
12.Savoldelli GL et al. Euro J of Anaesth. 22. Doyle DJ. Can J Anesth 2004;
Airway Scope (AWS) 8
2009; 26:554-558. 51(5):520-521.
13. Cooper RM. Can J Anaesth 2003; 23. Villalonga A et al. Rev Esp Anesthe-
50:611-3. siol Reanim 2008; 55(4):254-256.
14. Van Zundert A et al. Acta Anaesthe- 24. Xue FS et al. Anaesthesia 2006;
siol Belg 2007; 58:129-31. 61(10):1014-1015.
15. Cooper RM et al. Can J Anaesth 25. Jones PM, Harle CC. Can J Anaesth
2005; 52:191-98. 2006; 53(12):1264-1265.
16. Shippey B, Ray D, McKeoqn D. Can J
Anesth 2007; 54(4):307-313. The author
ensured and periodic scheduled 17. M arrel J et al. Eur J Anaesthesiol Thomas C Mort, MD
charging of portable units should be 2007; 24(12):1045-49. Senior Associate, Anesthesiology
arranged. In addition, direct access 18. Doyle DJ. Anesthesiology News Associate Director, Surgical ICU
to disposable laryngoscope blades Guide to Airway Management. 2009; Associate Professor of Anesthesiology
for elective and especially emer- 2:33-34. & Surgery UCONN Founder,
gency use must be provided and 19. R obitaille A et al. Anesth Analg 2008; Medical Director,
planned for. 106(3):935-941. Hartford Hospital Simulation Center,
20. M alik MA et al. Br J Anaesth 2008; Hartford, CT, USA
Conclusion
VL technology plays an important
and varied role in airway manage-
ment. Understanding the indica-
tions, proper use and limitations of
VL is paramount for optimising its
role in patient care. The wide vari-
ety of technologies available today
T R I star
from various manufacturers pro-
vides the practitioner with a grow-
ing range of devices to accommo-
date a range of clinical practices.
Alhough individual advantages
and disadvantages can be found
when comparing individual mod-
els and designs, it is imperative
that there is continuous practice in
the elective setting under ideal cir-
cumstances. This will allow the use
of any or all of the devices avail-
able to be mastered, both now and
in the future.
References
1. Sun DA et al. Br J Anaesth 2005; 94(3):
381-4.
2. Walker L et al. Br J Anaesth 2009;
103(3): 440-5.
3. E nomoto Y et al. Br J Anaesth 2008;
100(4): 544-8.
4. Kaplan MB et al. J Clin Anesth 2006;
18:357-362.
5. Malin E et al. Acta Anaesth 2009;
53:858-863.
6. Li JB et al. Anaesthesia. 2007;62:940-93 World Forum for Medicine
7. Lai HY et al. Br J Anaesth 2006;
97(5):749-750.
8. Mort T. Anesth Analg 2009;
108(4):1228-31.
9. Cooper RM. Can J Anesth. 2007;
54(1):54-57
10. Choo MKF et al. Can J Anesth.
2007;54(4):322-324.
www.ihe-online.com & search 45361
 – Issue N°5 – Oct. 2009 10 Intensive care

Fever in the intensive care unit

Fever is among the most common abnormal physical signs observed in patients vascular/rheumatic diseases and occult malig-
admitted to intensive care units (ICU). Fever may be attributed to both infectious nancy are relatively uncommon but may also be
and non-infectious aetiologies, and its development usually prompts changes in potential causes of fever [16].
patient management. Although it is a widespread, clinically accepted practice to
Occurrence and influence of
therapeutically lower temperature in patients with hyperthermic syndromes, marked hyperpyrexia on outcome
hyperpyrexia, and selected populations such as those with neurological impair- The influence of fever on outcome varies among
ment, whether most critically ill patients with moderate degrees of fever should be different critically ill cohorts of patients and is
treated with anti-pyretic or direct cooling therapies remains controversial. Treatment also dependent on the cause of fever. We reported
of fever may improve patient comfort and reduce metabolic demand. However, it is a large retrospective cohort study evaluating the
epidemiology of fever >38.3°C and high fever
a normal adaptive response to infection and its suppression is potentially harmful.
>39.5°C among all adults (n=20,466) admitted
Clinical trials that compare fever management strategies in neurologically intact, to ICUs in Calgary, Canada during 2000-2006
critically ill patients are needed. [17]. The cumulative incidence (incidence den-
sity per 100 ICU-days) of fever was 44% (24.3),
by Dr K. B. Laupland and this was 43% (21.8) in medical, 36% (17.5)
in cardiac surgical, 65% (38.2) trauma/neuro-
logic and 45% (22.8) in other surgical patients.
Definition and measurement differentiate at the bedside and are usually Male gender, Acute Physiology and Chronic
Normal body temperature is approximately 37.0 inferred based on clinical diagnosis. The major Health Evaluation II (APACHE II) scores <25, as
o
C, although it will naturally vary between dif- causes of abnormally elevated temperatures in well as younger age were associated with a higher
ferent, non-acutely ill, individuals, There is also the critically ill may be broadly classified as the incidence of fever. Prolonged fever and high fever
a normal variability of 0.5 oC that occurs within hyperthermia syndromes and infectious and lasting for five or more days in the ICU occurred
individuals based on the time of day, with a low non-infectious fevers. in 18% and 11% of febrile patients, respectively.
in the early morning and a peak in late after- After controlling for APACHE II score, Thera-
noon/early evening [1]. Because of this variabil- The hyperthermia syndromes include envi- peutic Intervention Scoring System score, gen-
ity, and because the magnitude and significance ronmental (heat stroke); drug-induced hyper- der, age and the presence of shock on admission
of an elevated temperature will depend on the thermia (including neuroleptic malignant to the ICU, in the logistic regression model the
specific patient populations in question, a wide syndrome); malignant hyperthermia and sero- influence of fever on ICU mortality varied sig-
range of definitions for fever have been used. tonin syndrome; and endocrine causes, includ- nificantly according to its timing of onset, its
However, a core body temperature >38.3°C ing thyrotoxicosis, pheochromocytoma and degree and the main admission category.
may be generally accepted to represent fever in adrenal crisis [4-6].
patients admitted to ICUs [2]. Management of hyperpyrexia
There is a vast list of bacterial, viral, fungal and in the ICU
Temperature may be measured using traditional protozoal infections that may cause fever in the There are numerous pharmaceutical and direct
thermometers and a number of other tech- ICU [7]. Common sources of infection include cooling methods available to reduce elevated
niques, including thermisters on the pulmonary the lower respiratory tract/pneumonia, the uri- temperature in critically ill patients. While meth-
artery or bladder catheters, eosophageal or rec- nary tract, the primary bloodstream, sinusitis, ods of treatment of fever may include direct
tal probes, and infrared tympanic membrane skin/soft tissue and intra-abdominal/gastroin- cooling, most frequently anti-pyretic medica-
and temporal artery thermometers. Oral ther- testinal infections [8-13]. The species, focus tions such as acetylsalicylic acid, non-steroidal
mometers are rarely practical in the critically and antimicrobial resistance profile of infec- anti-inflammatory agents and acetaminophen
ill patient and axillary temperature measure- tions will depend at least in part on underly- are utilised [18]. Direct cooling methods range in
ment is not routinely recommended [2]. While ing health status, treatments rendered and sophistication and include reducing the ambient
the pulmonary artery catheter is considered presumed location of acquisition [8, 14]. room temperature and use of fans, application of
the ‘gold standard’ measurement technique, in cool external substances such as mist, ice packs,
most situations relatively small differences exist Non-infectious causes of fever are common in wet sponges and cooling blankets, and adminis-
among the other commonly used measurement the ICU [2, 9, 15]. Transfusion reactions and tration of cooled intravenous fluids. A number
techniques [2, 3]. In any case, where an exact drug hypersensitivity, in particular to anti- of newer techniques have evolved and include
temperature measurement is critical to patient microbial agents, are frequent causes. Hae- cooling jackets and intravascular catheter-based
management or when a measurement does matomas at deep body sites, as well as deep vein heat exchange systems [19]. These techniques
not appear clinically reasonable, confirmation thrombosis, pulmonary embolus/infarct, myo- have the added advantage of thermostat settings
using another device is prudent. cardial infarction and acute haemorrhage may and monitors that facilitate titration to a pre-set
all cause fever. Intra-abdominal sources include temperature goal.
Aetiology of pyrexia cholecystitis, pancreatitis and organ transplant
Abnormally elevated body temperatures that rejection. Although lung atelectasis per se is It is widely accepted that patients with very high
occur in association with a normal or an ele- controversial as a cause of non-infectious fever, fever, acute neurological impairment, and with
vated hypothalamic set point are defined as the fibroproliferative phase of acute respiratory hyperthermia syndromes should be treated to
hyperthermia or fever, respectively. However, distress syndrome and aspiration pneumoni- reduce elevated temperature [20-23]. At very
fever and hyperthermia are often difficult to tis are established as causes of fever. Collagen high levels of elevated temperature such as >40 to
www.ihe-online.com & search 45358
 – Issue N°5 – Oct. 2009 12
41°C, the risk of brain damage and the initiation
or worsening of multi-system failure has been
shown to increase [24]. It is a widely held view
that lowering temperature from such extreme
levels is crucial. Fever has an adverse outcome
in traumatic brain injury, stroke, anoxic injury
and other causes of acute neurological impair-
ment, and treatment of hyperpyrexia is stand-
ard therapy [21-23]. While anti-pyretic agents
and direct cooling methods are usually used in
these patients, the approach given to patients
with hyperthermia syndromes differs some-
what. Principles of therapy for hyperthermia
syndromes include discontinuation of offend-
ing drugs, initiation of direct cooling and
administration of antidotes or specific thera-
pies as appropriate. Specific therapies include
intravenous dantrolene for patients with malig-
nant hyperthermia and possibly heat stroke [4],
potentially dantrolene and/or bromocriptine
for neuroleptic malignant syndrome [25], and
cyproheptadine for serotonin syndrome [6].
Thyrotoxic crisis is usually treated with pro-
pylthiouracil or methimazole, glucocorticoids
and beta-blockers; pheocromocytoma patients
with alpha-blockade using phenoxybenzamine;
and adrenal crisis with corticosteroids. Given
that hyperthermia syndromes are not associated
with an elevated hypothalamic set point, anti-
pyretic agents are not usually effective, may be
harmful and are not routinely recommended.
Although lowering of body temperature is
accepted in the above conditions, there is much
controversy as to whether mild to moderate
fever such as 38.3-40 to 41°C in other critically
ill patients should be treated. Benefits of treat-
ing fever include potentially improved patient
and caregiver comfort and reduction of meta-
bolic demand/cardiovascular stress [26, 27]. In
the setting of severe or refractory shock, treat-
ment of fever results in an improved supply-
demand balance that may reduce tissue hypoxic
Intensive care
injury [28]. Lowering temperature may also
have benefits in acute liver failure and acute
respiratory distress syndrome (ARDS), and
myocardial infarction, conditions that fre-
quently complicate patients’ clinical course in
the medical ICU [29-32]. On the other hand,
fever is an innate adaptive response to infec-
tion and several lines of evidence argue against
routine treatment in the critically ill. High tem-
peratures inhibit growth of microorganisms,
may reduce the expression of virulence factors,
increase susceptibility to anti-microbials and
enhance host immune responses [33-36]. It is
well-established in observational studies that
naturally hypothermic septic patients are at
higher risk for death than those who have fever
[37-39]. In addition, anti-pyretic agents run a
not insignificant risk for bleeding, hepatic and
renal toxicity, and may contribute to hypoten-
sion [40, 41]. Use of active cooling methods may
also cause increases in metabolic rate and cause
discomfort in non-sedated patients [42]. Fever
often instigates investigation and management
of new infections and its suppression may delay
the early diagnosis and empiric therapy of seri-
ous infections for which delays in treatment
may be detrimental [43].
There are few randomised clinical trials com-
paring strategies of fever control in neuro-
logically intact critically ill patients [44-46].
Bernard et al reported on a randomised, dou-
ble-blind, placebo-controlled trial comparing a
total of eight doses of 10 mg per kilogram of
intravenous ibuprofen, one every six hours, in
455 patients with fever (>38.3°C or hypother-
mia less than 35.5°C) and sepsis and at least
one organ failure [44]. Significant decreases in
temperature, heart rate, oxygen consumption
and lactic acidosis were observed in the ibupro-
fen group as compared with the placebo group.
Ibuprofen therapy did not affect the incidence
or duration of shock or ARDS and did not
significantly alter the percent (95% confidence
interval) mortality of 37 (31-44%) for ibupro-
fen versus 40 (34-46%) for placebo. However,
it is important to note that although ibuprofen
is an anti-pyretic agent, this study was not spe-
cifically designed to assess effects of fever con-
trol per se. Significant and differential co-inter-
vention with acetaminophen occurred with
approximately one third of patients in both of
the groups receiving this agent at enrollment.
Schulman et al conducted an open, randomised,
prospective clinical trial comparing an aggres-
sive fever treatment strategy (acetaminophen
650 mg every six hours for fever >38.5°C and
a cooling blanket added if >39.5°C) with a per-
missive strategy (treatment reserved for fever
>40°C only) in patients admitted for at least
three days to a trauma surgery ICU [45]. The
primary endpoint was development of culture-
proven infections. Patients with acute brain
injury, malignant hyperthermia, heat stroke,
neuroleptic malignant syndrome, hepatic cir-
rhosis, acute hepatic failure, or a history of
stroke, seizure or previous traumatic brain
injury, were excluded. The aggressive treat-
ment group had a higher rate of infections as
compared to the permissive treatment group
(131 vs. 85) and a higher rate of antibiotic use
(77% vs 71% of days on therapy). No signifi-
cant difference between the total number of
cultures sent per patient, or length of ventila-
tion or ICU stay was observed. The study had
to be prematurely stopped due to safety con-
cerns after interim analysis revealed an excess
mortality rate of 7/44 (16%) in the aggressive
as compared to 1/38 (3%) in the permissive
group (p=0.06).
Gozzoli and colleagues conducted a randomised
trial comparing external cooling with no treat-
ment in 38 surgical ICU patients with fever
>38.5 °C and systemic inflammatory response
 13 – Issue N°5 – Oct. 2009

syndrome [46]. Patients with neurotrauma or severe hypoxaemia were
excluded. External cooling was achieved using cooling blankets, ice packs,
or cloths and was stopped when the patient’s temperature was 37.5°C
and was restarted if the temperature increased to >38.5°C. The primary
outcome measure was defervescence at 24 hours after intervention and
the secondary outcome included patient discomfort as determined by a
visual analogue scale. Among the 18 externally cooled patients and the
20 control patients, temperature and discomfort decreased similarly in
both groups after 24 hours. No significant differences in recurrence of
fever, incidence of infection, antibiotic therapy, intensive care unit and
hospital length of stay, or mortality were observed. While this study dem-
onstrated that external cooling did not significantly influence either the
duration of fever or patient discomfort, it was not powerful enough to
assess major outcomes such as mortality.
Summary and conclusion
Fever is common in critically patients, prompts clinical attention and
changes in management, and has a variable effect on mortality outcome.
While it is accepted that patients with extreme fever, acute neurological
impairment and hyperthermia syndromes should be treated aggressively for
fever, it is largely unknown whether active treatment with anti-pyretic ther-
apy and/or physical cooling methods affects the outcome of other critically
ill ICU patients. Further randomised clinical trials of fever management in
neurologically intact, critically ill patients are needed.
39. Peres Bota D et al. Intensive Care Med 2004;30(5):811-6.
40. Boyle M, Hundy S, Torda TA. Aust Crit Care 1997;10(4):120-2.
41. Watkins PB et al. Jama 2006;296(1):87-93.
42. Lenhardt R et al. Am J Med 1999;106(5):550-5.
43. Kumar A et al. Crit Care Med 2006;34(6):1589-96.
44. Bernard GR et al. N Engl J Med 1997;336(13):912-8.
45. Schulman CI et al. Surg Infect (Larchmt) 2005;6(4):369-75.
46. Gozzoli V et al. Arch Intern Med 2001;161(1):121-3.
The author
Kevin B. Laupland MD, MSc, FRCPC
Departments of Critical Care Medicine and Medicine
University of Calgary and Calgary Health Region
Calgary, Alberta, Canada.
Address correspondence to:
Kevin B. Laupland, MD, MSc, FRCPC
Room 719, North Tower, Foothills Medical Centre
1403 – 29th Street NW
Calgary, Alberta, Canada T2N 2T9
Tel: +1 403 944-5808
e-mail: kevin.laupland@calgaryhealthregion.ca

References
1. Mackowiak PA, Wasserman SS, Levine MM. Jama 1992;268(12):1578-80.
2. O’Grady NP et al. Crit Care Med 2008;36(4):1330-49.
3. Leon C et al. J Crit Care 2005;20(1):106-10. NOT JUST ANY STERILISER
4. Denborough M. Lancet 1998;352(9134):1131-6. From the first pre-vacuum table-top steriliser in 1993,
5. Bouchama A, Knochel JP. N Engl J Med 2002;346(25):1978-88. to the third generation Millennium product line,
6. Mason PJ, Morris VA, Balcezak TJ. Medicine (Baltimore) 2000;79(4):201-9. you can count on Mocom for innovation, reliability
7. Laupland KB. Crit Care Med 2009;37(7 Suppl):S273-8. and performance.
8. Vincent JL. Lancet 2003;361(9374):2068-77.
9. Rizoli SB, Marshall JC. Lancet Infect Dis 2002;2(3):137-44.
10. Bagshaw SM, Laupland KB. Curr Opin Infect Dis 2006;19(1):67-71.
11. Laupland KB et al. Crit Care 2005;9(2):R60-5.
12. Laupland KB et al. Crit Care Med 2004;32(4):992-7.
13. Laupland KB et al. Crit Care Med 2002;30(11):2462-7.
14. Malacarne P et al. Crit Care Med 2008;36(4):1105-13.
15. Shafazand S, Weinacker AB. Chest 2002;122(5):1727-36.
16. Sorensen HT et al. Lancet Oncol 2005;6(11):851-5.
17.Laupland KB et al. Crit Care Med 2008;36(5):1531-5.
18. Hoedemaekers CW et al. Crit Care 2007;11(4):R91.
19. Diringer MN. Crit Care Med 2004;32(2):559-64.
20. Bouchama A, Dehbi M, Chaves-Carballo E. Crit Care 2007;11(3):R54. Millennium 17 and 22 liters
21. Diringer MN et al. Crit Care Med 2004;32(7):1489-95. > Single-piece stainless-steel
chamber with, brilliant
22. Andrews PJ. Curr Opin Crit Care 2004;10(2):110-5. electro-polishing for longer
23. Zygun DA et al. Can J Neurol Sci 2003;30(4):307-13. durability and easy cleaning.
24. Cremer OL, Kalkman CJ. Prog Brain Res 2007;162:153-69. > Instant steam generator gives
25. Reulbach U et al. Crit Care 2007;11(1):R4. high quality saturated steam Millennium 5,5 liters
ONLY
and faster cycle times.
26. Vargas R et al. J Clin Pharmacol 1994;34(8):848-53. 18
minutes
> Only 18 minutes
> High performance fractionated (drying included) to sterilise
27. Pernerstorfer T et al. Clin Pharmacol Ther 1999;66(1):51-7. vacuum pump. and dry wrapped hollow
28. Manthous CA et al. Am J Respir Crit Care Med 1995;151(1):10-4. (handpieces) and solid loads!
> Stainless steel wire trays for fast ONLY
29. Polderman KH. Lancet 2008;371(9628):1955-69. drying. 9
minutes
> Only 9 minutes
(drying included) to sterilise
30. Villar J, Slutsky AS. Resuscitation 1993;26(2):183-92. > Robotized door-locking and dry unwrapped
31. Dixon SR et al. J Am Coll Cardiol 2002;40(11):1928-34. mechanism with triple solid instruments in the
32. Stravitz RT et al. Crit Care Med 2007;35(11):2498-508. protection for added safety. Emergency cycle!
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34. Mackowiak PA, Marling-Cason M, Cohen RL. J Infect Dis 1982;145(4):550-3.
35. Ryan M, Levy MM. Crit Care 2003;7(3):221-5.
36. Kluger MJ et al. Infect Dis Clin North Am 1996;10(1):1-20. Mocom srl
37. Arons MM et al. Crit Care Med 1999;27(4):699-707. www.mocom.it • mocomcom@mocom.it
38. Clemmer TP et al. Crit Care Med 1992;20(10):1395-401.
www.ihe-online.com & search 45159
 – Issue N°5 – Oct. 2009 14
Paediatric laryngoscopy:
a history and current developments
More than 50 devices intended for paediatric laryngoscopy have been developed or modi-
fied from adult instruments since the larynx was first visualised. This article shows how
laryngoscopy has evolved to become a smooth and safe procedure in children.
by Dr JS Doherty, Dr SR Froom and Dr CD Gildersleve
Historical perspective
Although the recorded history of nasal and oral
intubation goes back as far as 1788, the first oral
tracheal intubation was performed in 1878 in an
awake adult by the surgeon William Macewan,
using his fingers as a guide. Prior to the devel-
opment of the “autoscope” by Alfred Kirstein,
who performed the first direct laryngoscopy in
an adult in 1895, the need to view the larynx for
intubation was circumvented by the use of tactile
or blind oral and nasal techniques.
Procedures on infants
Sir Ivan Magill was the first to apply his adult
technique of using a speculum and an assist-
ant to displace the tongue to the left in order to
view the vocal cords, to infants needing surgery
for cleft lip and palate. He described his adult
straight blade laryngoscope in 1926. In 1936,
Gillespie invented the Shadwell laryngoscope,
a modification of the Chevalier Jackson laryn-
goscope, described in 1939. This had a tubular
blade with a removable slide.
Macintosh described his curved adult laryn-
goscope in 1943. This was designed to lift the
epiglottis indirectly by placing the blade tip in
the vallecula. The use of the flattened distal por-
tion of this adult blade was preferred for laryn-
goscopy in small children and infants by many
anaesthetists, whereas a paediatric modifica-
tion produced in 1947 was felt to be too curved,
obscuring the view of the larynx. Indeed Macin-
tosh condemned the blade, which was a modi-
fication by the manufacturers. In 1946 Miller
described a version of his adult laryngoscope
for children; this could be inserted either ante-
rior or posterior to the epiglottis, with a blade
small enough to allow room for the insertion of a
tracheal tube.
The impact of neuromuscular drugs
Wider developments between the 1940s and
1960s helped to popularise intubation in chil-
dren. The introduction of neuromuscular block-
ing agents, first used in adult practice in 1942,
ensured that intubation of children became a
smoother and safer procedure. In addition, the
Intensive care
development of implant testing of polyvinyl
chloride tracheal tubes in the 1960s allowed
the production of tracheal tubes that were less
likely to cause tissue reaction, and consequent
sub-glottic stenosis, than the standard red rub-
ber tubes. Furthermore, parallel developments
in the management of respiratory failure in pre-
mature infants during the 1960s showed that
intubation, in part, helped improve survival.
Blade design and development
There followed a proliferation of paediatric
blades, each with particular characteristics per-
haps suggesting that no ideal design was possible.
The Oxford infant blade was described by Bryce-
Smith in 1952, intended to be used in a similar
fashion to the Macintosh blade. Other popular
paediatric laryngoscopes included the Seward,
Srivastava and Robertshaw.
The Seward blade was intended to be easy to use for
inexperienced practitioners. It has an adult sized
light bulb to improve the illumination of the lar-
ynx. The Srivastava, described in 1963, combined
straight and curved elements in a blade designed
primarily for infants. This was easy to use to ele-
vate the epiglottis directly or indirectly. Finally, the
Robertshaw allowed binocular vision of the larynx
by removal of the lateral wall of the blade.
The changing face of medicine
By the 1960s anaesthetic practice had changed,
Figure 1. The GlideScope is an indirect visualisation
laryngoscope that ustilises a miniature camera to
transmit the image.
with Jackson Rees arguing against the notion
that intubation was to be avoided in children.
Laryngoscopy and intubation in children were
now routine. Due to the unique upper airway
anatomy of the infant, the straight blade laryn-
goscope is superior in elevating the tongue,
facilitating better visualisation of the larynx
than the curved blade laryngoscope. A popular
straight blade is the Miller laryngoscope [1].
This provides a narrow C-shaped channel to
view the larynx. However, introduction of a tube
into or alongside this channel can easily obstruct
the view.
The use of a curved blade laryngoscope is
popular even for small children since the indi-
rect technique for elevation of the epiglottis
is most familiar amongst anaesthetists. This
helped stimulate the development of the Car-
diff paediatric laryngoscope, intended as a uni-
versal blade for children, combining elements
of both curved and straight blades [2], thus
helping to eliminate the problem of choice of
blade for occasional users of paediatric laryn-
goscopes. The proximal 6 cm of the Cardiff
blade is straight, so that no part of the blade
can obscure the line of sight, and the miniature
halogen bulb is mounted in the web so the light
is less likely to be obstructed.
The McCoy laryngoscope was developed in the
early 1990s to help with difficult intubation in
adults. A paediatric version of the McCoy, based
on the Seward straight blade, is now available.
This allows the epiglottis to be lifted with the
blade tip in the vallecula, and may allow a view
comparable to that of a straight blade [1].
Current developments
Direct and indirect visualisation
Many paediatric laryngoscope designs are
extrapolated from adult practice, indeed more
than 50 devices intended for paediatric laryn-
goscopy have been invented or modified since
the larynx was first visualised. Modern laryngo-
scopic visualisation devices may be classified as
either direct or indirect. An example of a direct
visualisation device is the Diaz laryngoscope
(Pilling Instruments, Fort Washington, Penn-
sylvania, USA). This tubular laryngoscope has
two detachable blades, each with a fibreoptic
light source. Intubation is performed through
the tubular laryngoscope and the two blades
are then removed. It is intended for use when
oedema or secretions may make flexible fibre
optic intubation difficult.
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 – Issue N°5 – Oct. 2009 16
Most modern devices are indirect visualisation
laryngoscopes. They may be rigid or flexible and use
either a fibre optic cable to transmit an image or a
miniature camera as in the GlideScope (Saturn Bio-
medical System Inc., Burnaby, BC, Canada) [Figure
1]. Rigid devices include optical stylets, which can
be used in children with difficult airways. For exam-
ple, the Storz 70-degree nasendoscope (Karl Storz-
Endoskope, Tuttlingen, Germany) can be used orally
to obtain an indirect view of the larynx in children
with Pierre-Robin syndrome [3].
Light wands, such as the Trachlight do not visu-
alise the vocal cords, but have been shown to be
useful in difficult and standard paediatric intuba-
tion [4]. Optical stylets available for paediatric use
include the Shikani Seeing Stylet (Clarus Medi-
cal LLC, MN, USA), the Fiberlightview Shuttle
(Anesthesia Medical Specialties, Sante Fe Springs,
CA, USA) and the Video Optical Intubation Stylet
(VOIS) (Velpi AG, Schlieren, Switzerland).
Use of video imaging
Video-intuboscopy provides an image from the
tip of the tracheal tube during conventional direct
laryngoscopy using a video-intubation stylet [5]. An
example of this is the Bullard laryngoscope (Cir-
con ACMI, Stamford, CT, USA). The adult Bullard
laryngoscope has been used to facilitate tracheal
intubation in children over one year of age [6].
Video-laryngoscopy provides a view from the tip
of the laryngoscope blade during conventional
direct laryngoscopy [7]. This may use fibreoptic
image transmission, for example with the Angu-
lated Video-Intubating Laryngoscope (AVIL),
or with an embedded small camera head as in
the GlideScope. The vertical flange of the blade
is flattened in the AVIL, such as in an activated
McCoy blade. This facilitates its use in paediatric
patients [8]. Video-laryngoscopy has also been
performed on children using a Miller 1 paedi-
atric video laryngoscope (Karl Storz, Tuttlingen,
Germany) [9]. The GlideScope provides a laryn-
goscopic view equal to, or better than direct
laryngoscopy and may be useful in children,
however the time taken to intubation was longer
and more attempts were required [10]. Flexible
fibre optic laryngoscopes/bronchoscopes are
also commonly used in paediatric practice, but
this is beyond the scope of this review.
The importance of illumination
Lighting is crucial and a simple description of
the measurement in lux may be insufficient.
Factors such as light distribution also need to
be considered. A presumption that a brighter
light is best is not supported, since most anaes-
thetists prefer the degree of illumination to be
less than 700 lux [11].
Some anaesthetists have expressed a preference
for blue/white light [12]. Blue light corresponds
to peak haemoglobin absorption (415nm). Most
Intensive care
conventional laryngoscopes have an incandes-
cent light bulb that produces a yellow light.
Light Emitting Diodes (LEDs) are a “cool” light
source in a more appropriate part of the spec-
trum; they use less energy and last longer than
the standard bulb. There are reports of burns
caused by incandescent bulbs; this will not be a
problem with LEDs [13]. Many modern laryn-
goscope devices have this superior light source
transmitted fibre-optically and laryngoscopes
are now being produced with an LED light
source. For example the GreenlightII Laryn-
goscope System (Vital Signs Inc., Totowa, NJ,
USA), the ProAct Metal Max 100 Disposable
LED Blade (ProAct, Northamptonshire, UK)
and the Truphatek Trulite Disposable Laryn-
goscope (Truphatek Int. Ltd, Netanya, Israel).
A comparison of the spectral irradiance of the
ProAct Miller 1 Paediatric laryngoscope (con-
taining a standard incandescent bulb) with a
custom-made laryngoscope containing an LED
[14] showed that the Miller 1 produced spectral
irradiance mainly in the infrared region (>660
nm), while the LED produced most irradi-
ance in the blue/green region of the spectrum
(400–550 nm).
The advantages and disadvantages
of disposable blades
Traditional cleaning and sterilisation of re-
usable equipment is effective against bacterial
contamination but is costly. It may also affect
laryngoscope performance [15]. This coupled
with concern over prion transmission during
laryngoscopy has led to a massive investment in
disposable laryngoscopes. Many different manu-
facturers produce a disposable Miller blade, but
these vary widely in blade flexibility, brightness
of the light and in the angle and direction of the
light emitted [16]. An inexpensive solution is the
use of protective sheaths, however this can affect
light emission [17].
Disposable blades may be made of metal or plas-
tic. The material used impacts on blade perform-
ance, with increased user satisfaction, signifi-
cantly shorter time taken to view the cords and
less force exerted with a metal blade [18]. It is
suggested that the disposable metal blade is less
likely to cause trauma during use; this may be of
particular relevance with vulnerable mucosa in
small children.
There are no standards for laryngoscope
blades with respect to strength, flexibility and
light output [19]. However, the International
Organisation for Standardization (ISO) has
recently published a draft standard that includes
requirements for flexibility and light output of
laryngoscope blades [20].
The fidelity of reproduction of disposable laryn-
goscopes has been questioned, for example
alterations to the original design of the Cardiff
paediatric laryngoscope when manufactured in
a disposable version did, in some cases, diminish
the obtained view of the vocal cords [21]. While
small changes to design will not impact on per-
formance in the majority of children, it is at the
extremes of difficulty that these subtle changes
will be felt.
Acknowledgements
This summary article is based on: Pediatric laryngo-
scopes and intubation aids old and new. Doherty JS,
Froom SR and Gildersleve CD. Pediatric Anesthe-
sia 2009; 19 (Suppl.1) 30-37. Copyright ©2009
Wiley-Blackwell Publishing Ltd. An abstract of this
review can be found at http://www3.interscience.
wiley.com/journal/122467358/abstract
References
1. McCoy E. Can J Anaesth 2004; 51: 101-105.
2. Jones RM et al. Anaesthesia 2004; 59: 1016-1019.
3. Ravishankar M et al. Br J Anaesth 2002; 88: 728-732.
4. Xue FS et al. Anaesthesia 2008; 63: 520-525.
5. Weiss M. Br J Anaesth 1998; 80: 525-527.
6. Shulman GB, Connelly NR, Gibson C. Can J Anaesth
1997; 44: 969-972.
7. Weiss M, Schwarz U, Gerber ACH. Anesthesiology
1998; 3A: SEE9.
8. Weiss M et al. Br J Anaesth 2001; 87: 453-458.
9. Wald SH, Keyes M, Brown A. Paediatr Anaesth 2008;
18: 790-792.
10. Kim JT et al. Br J Anaesth 2008; 101: 531-534.
11. Malan CA et al. Anaesthesia 2008; 63: 65-70.
12. Scholz A et al. Anaesthesia 2007; 62: 163–168.
13. Koh THHG, Coleman R. Anesthesiology 2000; 92:
277 - 279.
14. Lewis E et al. Paediatr Anaesth 2007; 17: 606-607.
15. Yee KF. Anaesth Intensive Care 2003; 31: 658–662.
16. Goodwin N, Wilkes AR, Hall JE. Anaesthesia 2006;
61: 792-799.
17. Chen YH et al. Infection 2006; 52: 118–123.
18. Sudhir G et al. Anaesthesia 2007; 62: 1056-1060.
19. Bray C. Anaesthesia 2005; 60: 631.
20. International Organization for Standardization (ISO).
Anaesthetic and respiratory equipment – Laryngo-
scopes for tracheal intubation. Draft International
Standard ISO/DIS 7376. Geneva: ISO, 2007.
21. Jones RM et al. Anaesthesia 2005; 60: 721-2.
A complete list of references is available from the authors.
The authors
Doherty JS1, Froom SR2, Gildersleve CD2
1
Specialist Registrar in Anaesthesia,
2
Consultant Anaesthetist
Department of Anaesthetics and
Intensive Care Medicine
University Hospital of Wales, Cardiff
Correspondence to:
Dr Jane Doherty
Department of Anaesthetics and
Intensive Care Medicine
University Hospital of Wales
Heath Park,
Cardiff, CF14 4XW, UK
e:mail: janes.doherty@virgin.net

The highlight of the radiology year is
the annual meeting of RSNA (held as
always in Chicago in November — this
year Nov 29th - Dec 4th) where the lat-
est clinical developments and scientific
advances will be presented. This doesn’t
at all mean that the information pre-
sented at last year’s meeting is out of
date. To prove it we present some high-
lights of the RSNA 2008 meeting that
are still as relevant as ever.
New breast imaging technology
targets hard-to-detect cancers
at a glance
Breast cancer affects
more women than any
other non-skin cancer
and, according to the
American Cancer Society,
accounts for more than
40,000 deaths annually
in the U.S. Most experts
agree that the best way
to decrease breast cancer
mortality is through early detection using mam-
mography and clinical breast exam. However, some
cancers are difficult to detect with mammography
and clinical exam, particularly in the earliest stage
when treatment is most effective. Breast-specific
gamma imaging (BSGI) is effective in the detection
of cancers not found on mammograms or by clini-
cal exam, according to a study presented at the 2008
annual meeting of the Radiological Society of North
America (RSNA). While mammography findings
are characterised by the difference in appearance
between normal and suspicious breast tissue, BSGI
findings are based on how cancerous cells func-
tion. According to lead author of the study, Rachel
F. Brem, M.D., professor of radiology and director
of the Breast Imaging and Interventional Center at
The George Washington University Medical Center
in Washington, D.C., the technology can also facili-
tate the detection of additional lesions of all types of
breast cancer in women whose mammograms show
only one suspicious lesion.
Because cancerous cells have a higher rate of meta-
bolic activity, the radiotracer used in BSGI is taken
up by the cells at a higher level than in normal cells.
Dr Brem and colleagues reviewed the records of 159
women with at least one suspicious or cancerous
lesion found by mammography or physical exam,
who had undergone BSGI to determine if additional
lesions were present. BSGI results showed an addi-
tional suspicious lesion missed by mammography
and physical exam in 46 (29 percent) of the women.
RSNA NEWS 17
In 14 (36 percent) of the 39 women who underwent
biopsy, the newly discovered lesions were cancer-
ous. However, Dr Brem stressed that BSGI is not
meant to replace mammography, but to be used as
an adjunct to mammography.
MRI shows new types of injuries
in young gymnasts
Adolescent gymnasts are developing a wide variety
of arm, wrist and hand injuries that are beyond the
scope of previously described gymnastic-related
trauma, according to a study presented at RSNA
2008. According to the study’s lead author, Jerry
Dwek, M.D., an assistant clinical professor of radi-
ology at the University of California, San Diego and
a partner of San Diego Imaging at Rady Children’s
Hospital and Health Center, the broad constella-
tion of recent injuries was unusual and might point
to something new going on in gymnastics train-
ing that was affecting young athletes in different
ways. Previous studies have reported on numerous
injuries to the growing portion of adolescent gym-
nasts’ bones. However, this study uncovered some
injuries to the bones in the wrists and knuckles
that have not been previously described. In addi-
tion, the researchers noted that these gymnasts had
necrosis of the bones of their knuckles.
Dr Dwek and coauthor Christine Chung, M.D.,
used MRI to study overuse injuries seen in the
skeletally immature wrists and hands of gymnasts.
The researchers studied wrist and hand images of
125 patients, age 12 to 16, including 12 gymnasts
with chronic wrist or hand pain. The authors were
surprised to observe injuries at every step from the
radius to the small bones in the wrist and on to
the ends of the finger bones at the knuckles. These
types of injuries were likely to develop into early
osteoarthritis. Dr Dwek suggested that changing
the way that practice routines were performed, the
stress on the joints and on delicate growing bones
could be limited.
Radiologists diagnose and treat
self-embedding disorder
Self-injury, or self-harm,
refers to a variety of
behaviours in which a per-
son intentionally inflicts
harm to his or her body
without suicidal intent.
It is a disturbing trend
among U.S. adolescents,
particularly girls. Recent
studies have reported
that 13 to 24 percent of
high school students in
the U.S. and Canada have practiced deliberate
self-injury at least once. More common forms of
self-injury include cutting of the skin, burning,
bruising, hair pulling, breaking bones or swallow-
ing toxic substances. In cases of self-embedding
disorder, objects are used to puncture the skin or
are embedded into the wound after cutting.
Minimally invasive, image-guided treatment is
– Issue N°5 – Oct. 2009
a safe and precise method for removal of self-
inflicted foreign objects from the body, according
to the first report on “self-embedding disorder,” or
self-injury and self-inflicted foreign body inser-
tion in adolescents. These findings were presented
at RSNA 2008. The study’s principal investigator,
William E. Shiels II, D.O., chief of the Depart-
ment of Radiology at Nationwide Children’s Hos-
pital in Columbus, Ohio said that radiologists
were in a unique position to be the first to detect
self-embedding disorder, make the appropriate
diagnosis and mobilise the healthcare system for
early and effective intervention and treatment.
Dr Shiels and colleagues studied 19 episodes of
self-embedding injury in 10 adolescent girls, age
15 to 18. Using ultrasound and/or fluoroscopic
guidance, interventional paediatric radiologists
removed 52 embedded foreign objects from nine
of the patients. The embedded objects included
metal needles, metal staples, metal paperclips,
glass, wood, plastic, graphite (pencil lead), crayon
and stone. The objects were embedded dur-
ing injuries to the arms, ankles, feet, hands and
neck. One patient had self-embedded 11 objects,
including an unfolded metal paperclip more than
six inches in length. Ultrasound guidance allowed
the researchers to detect the presence and location
of wood, crayons and plastic objects, not detect-
able on x-ray examinations. Removal was per-
formed through small incisions in the skin that
left little or no scarring and was successful in all
cases, without fragmentation or complications.
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 – Issue N°5 – Oct. 2009 20
Functional MRI of the kidneys
Functional renal MR imaging is a new and exciting field enabling non-invasive
assessment of renal function. Diffusion weighted imaging (DWI), Blood Oxygen
Level Dependent (BOLD) MRI, and magnetic resonance elastography (MRE) are
some of the evolving techniques. In this article, we introduce readers to the basic
principles of these techniques and their potential applications.
by Dr L. Mannelli, Dr D. Kim and Dr H. Chandarana
Renal function is currently assessed by measur-
ing the serum creatinine level and calculating
the glomerular filtration rate (GFR) using one of
several formulae [1]. This method is imprecise,
does not assess for early reversible renal damage
and cannot be used to measure split renal func-
tion, i.e. function of each kidney separately [1].
Routine morphologic evaluation with ultrasound,
CT and MR, as used in clinical practice, provides
only minimal functional information. Nuclear
medicine (NM) tests provide functional informa-
tion but are limited in renal morphologic evalua-
tion due to poor spatial resolution. MR imaging
has the potential to offer a comprehensive evalu-
ation of structure and function in renal disease
by utilising novel functional imaging techniques
like diffusion weighted imaging (DWI), mag-
netic resonance elastography [MRE] and Blood
Oxygen Level Dependent (BOLD) MRI.
Diffusion weighted MRI (DWI)
DWI is based on measurement of Brownian
motion of water molecules in biological tissues.
Apparent diffusion coefficient (ADC) calculation
can be used for quantification of the combined
effects of capillary perfusion and diffusion. DWI
has been routinely used in neurologic imaging [2].
With technical advances, there has been tremen-
dous interest in applying this technique to abdom-
inal imaging. Studies have explored its potential
role in liver lesion detection and characterisation,
assessment of chronic liver disease and evaluation
of renal mass [3, 4]. A handful of studies have also
explored the role of DWI in the evaluation of renal
function [4 - 6], [Figure 1].
Single shot echo-planar imaging is the sequence
most commonly used in clinical practice. In routine
practice, diffusion weighted imaging is performed
using one low and one or two high b values. The
ADC calculation is performed as follows:
ADC (mm2 /sec) = (-1/b) ln S1/S0
b = diffusion factor
S0 = Signal Intensity (SI) with b=0
S1 = SI after application of diffusion gradient
Most studies prefer to exclude imaging at lower
b values since signal intensity at lower b values is
influenced by the perfusion component. Le Bihan,
in his seminal work, has shown that blood flow
Magnetic resonance Imaging
in capillaries can mimic diffusion at low b values
and these perfusion parameters can be extracted
if imaging is performed with both low and high b
values [2]. Some early studies in renal transplants
and in diffuse renal diseases have explored multi-b
value imaging [6].
Current and potential applications
1. Chronic renal failure (CRF) Several studies have
demonstrated that ADC values of renal cortex and
medulla are lower in patients with renal insuffi-
ciency when compared to normal healthy kidneys.
For example, a study by Bozgeyik et al. demonstrated
that an obstructed non-functioning kidney has a
lower ADC compared to the contralateral normal
functioning kidney [5]. These studies highlight the
potential role of renal ADC values in the evaluation
of renal dysfunction in native kidneys [4].
2. Renal allograft In an animal model, the ADC
values of renal cortex and medulla were noted
to be lower in allografts compared to native kid-
neys. Thus, DWI could potentially evaluate renal
Figure 1. (A) ADC map obtained at DWI in a
35 year old male with no known renal disease and
normal serum creatinine demonstrating corticomedul-
lary differentiation with lower ADC of the medulla
with respect to the cortex. In contrast, (B) ADC
map in a 84 year old male with chronic renal insuf-
ficiency (GFR < 30), demonstrating loss of
corticomedullary differentiation.
allograft dysfunction without the use of exog-
enous contrast agent. In patients at high risk
for developing nephrogenic systemic fibrosis
(NSF), this can be an alternative approach in the
assessment of renal function [6].
3. Renal artery stenosis (RAS) Powers et al. dem-
onstrated that DWI with multiple b values can be
used to measure changes in renal blood flow in a
canine model of RAS. Thus, the perfusion frac-
tion generated from DWI with multiple b-values,
without the use of exogenous gadolinium contrast,
has a potential role in evaluating patients with RAS
[7]. Yildirim et al. showed that patients with severe
RAS had significantly lower ADC values [8]. Hence,
ADC values can be used to differentiate patients
without RAS, or with mild RAS, from patients with
moderate and severe RAS.
DWI can potentially provide split renal function
without the use of exogenous contrast agent. The
technique can be implemented in routine practice
without a significant time penalty. The lack of con-
sensus regarding the selection of b values makes it
difficult to compare results from different investi-
gators and to generate standardised ADC values in
disease and health.
Blood oxygen level dependent
(BOLD) MRI
BOLD MRI provides an indirect non-invasive meas-
urement of renal oxygenation status. It relies on the
different magnetic properties of deoxyhaemoglobin,
which is paramagnetic, and oxyhaemoglobin, which
is diamagnetic, to acquire images sensitive to local
oxygen concentration. With an increase in tissue
deoxyhemoglobin concentration, there is acceler-
ated dephasing and a decrease in the T2* relaxa-
tion time of the protons in the surrounding tissues.
This means that at higher tissue oxygenation there
is lower deoxyhemoglobin concentration which
results in higher T2* and correspondingly shorter
R2*, with R2* = 1/T2* [9, 10], [Figure 2].
A multiple echo gradient-recalled-echo sequence
is a rapid sequence that is most commonly used
for renal BOLD MRI. Eight to sixteen echoes
with different echo times (TE) are acquired with
each excitation pulse. Maximum TE should be 50
milliseconds at 1.5 T and 25 milliseconds at 3T
based on the T2* of the renal medulla. R2* can be
obtained by measuring the slope of the line fit of
the natural log of signal intensity vs. TE. An R2*
map can be generated by calculating the R2* on
a pixel by pixel basis using appropriate software.
Regions of interest (ROI) defined on the anatom-
ical template can then be copied and pasted on
the R2* maps to estimate the medulla and cortex
R2* [9,10].
 21 – Issue N°5 – Oct. 2009

Lighting for intensive care units and recovery rooms

Figure 2. T2* map obtained with BOLD imaging (A) in a 35 year old healthy
male with no known renal disease demonstrating corticomedullary differentiation
with hypoxic (darker) medulla and (B) in a 49 year old male with chronic renal
insufficiency (GFR < 30) demonstrating loss of corticomedullary differentiation.
Current and potential applications
1. Renal artery stenosis Animal studies have shown the ability of BOLD
MRI to measure changes in renal perfusion [9]. Textor et al used BOLD MRI
and a furosemide challenge in patients with reduced GFR and high grade
renal artery stenosis to differentiate between kidneys with preserved func-
tional reserve versus nonfunctioning kidneys. Kidneys that were atrophic
and nonfunctioning did not demonstrate a change in R2* in response to
furosemide, whereas functioning kidneys showed improved oxygenation
[11]. The role of this technique in appropriately selecting patients for RAS
treatment is under investigation.
Appropriate lighting is essential in ICUs to
provide optimal work conditions for health-
care professionals. However, the seriousness
of the patients’ conditions and the anxiety
incurred by patients waking up from anaes-
thesia requires recovery rooms which are more
discreetly illuminated. A combination of Dmed
halux and Dlite vanera examination lights and
reading lights can satisfy these needs of both
healthcare professionals and patients so that for example, highly-intense light can
be quickly obtained for treating a patient who is in a reduced ambient light. This is
ideal for short interventions such as setting up perfusions or giving injections. The
compact and simple design of the luminaires allows easy operation. Indirect light
avoids too much glare for patients in the recovery phase, and wall-mounted lumi-
naires in warm tones create a feeling of well-being for patients. In addition, the lights
are energy-efficient with a low electricity consumption and electronic ballasts; the
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2. Renal allograft dysfunction After transplantation, differentiating acute

rejection from acute tubular necrosis (ATN) is a clinical challenge question
since both conditions present with abnormal serum creatinine and decrease
in GFR. Sadowski et al have shown that patients in acute rejection have sig-
nificantly lower R2* (higher oxygenation) in the medulla with respect to the
patients with ATN and normal transplants. Decreased oxygen utilisation
and/or increased corticomedullary shunting of the blood are the proposed Dmed® halux LED 20 P LX Dmed® halux LED 20 C L1
reasons for this finding. ATN causes an increase in cortical R2* compared to
normal transplants and patients with acute rejection, likely due to ischemic
insult. BOLD MRI has the potential to replace renal biopsy in the evalua-
tion of acute transplant dysfunction once larger studies confirm these initial
promising results [10].

The BOLD MRI technique allows noninvasive measurement of renal

hypoxia and can provide information regarding the metabolic status of the
kidney.Multiple factors such as oxygen supply and consumption, blood
flow, and haemoglobin level influence signal intensity on BOLD MRI. Con-
sequently, direct calibration of R2* vs. pO2 is unreliable. Furthermore, the
absolute magnitude of R2* is less reliable than the relative changes observed
in response to various physiologic and pharmacologic challenges.

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Figure 3. 32 year old healthy male with no known renal disease imaged with
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 – Issue N°5 – Oct. 2009 22
Magnetic Resonance Elastography
(MRE)
MRE is a technique that utilises cyclic motion-
sensitising gradients to image applied propa-
gating acoustic shear waves. Shear waves are
applied to organs or tissues by mechanical
devices and produce tissue displacement on the
order of nanometres to micrometres. Propaga-
tion of the waves is dependent on the viscoe-
lastic properties of the imaged tissue. These
displacements are directly measured and visu-
alised with MRE. Local frequency estimation
inversion algorithm is used to determine the
spatial frequency and other parameters of the
imaged waves [12]. The mechanical proper-
ties of the tissue are then calculated from this
information and displayed as a parametric
image map. Organs stiffness values in Pascals
can be obtained by placing ROIs outlining the
organ margins on the axial sections of the gra-
dient echo magnitude images and then copy-
ing and pasting the ROIs on the MRE inversion
stiffness images [12], [Figure 3].
Shah et al. in an animal model demonstrated
an increment in kidney stiffness after induced
renal nephrocalcinosis associated with mild
renal insufficiency [12]. The same group has
also studied the renal stiffness in healthy vol-
unteers. The role of MRE in the evaluation
of renal diseases in native and transplanted
kidneys is currently under investigation.
Magnetic resonance Imaging
Conclusion
Non-invasive imaging techniques, including
DWI and BOLD MRI, have tremendous poten-
tial in the clinical evaluation of renal function.
The preliminary data using these techniques are
promising but larger studies must follow. If these
techniques fulfill their promise, a new paradigm
will emerge in the comprehensive evaluation of
renal function incorporating both anatomic and
functional assessments.
Acknowledgments:
We would like to acknowledge Professor David J
Lomas and the University Department of Radiol-
ogy, Cambridge, UK for the MRE images.
References
1. Coresh J, Auguste P. Reliability of GFR formulas based
on serum creatinine, with special reference to the
MDRD Study equation. Scand J Clin Lab Invest Suppl
2008;241:30-38.
2. Le Bihan D et al. MR imaging of intravoxel incoher-
ent motions: application to diffusion and perfusion in
neurologic disorders. Radiology 1986;161:401-407.
3. Gourtsoyianni S et al. Respiratory gated diffusion-
weighted imaging of the liver: value of apparent
diffusion coefficient measurements in the differen-
tiation between most commonly encountered benign
and malignant focal liver lesions. Eur Radiol 2008;
18:486-492.
4. Namimoto T et al. Measurement of the apparent dif-
fusion coefficient in diffuse renal disease by diffusion-
weighted echo-planar MR imaging. J Magn Reson
Imaging 1999;9:832-837.
5. Bozgeyik Z, Kocakoc E, Sonmezgoz F. Diffusion-weighted
MR imaging findings of kidneys in patients with early
phase of obstruction. Eur J Radiol 2009;70:138-41.
6. Thoeny HC et al. Functional evaluation of transplanted
kidneys with diffusion-weighted and BOLD MR imag-
ing: initial experience. Radiology 2006;241:812-821.
7. Powers TA et al. Renal artery stenosis: in vivo perfusion
MR imaging. Radiology 1991;178:543-548.
8. Yildirim E et al. Diffusion-weighted MR imaging of
kidneys in renal artery stenosis. Eur J Radiol 2008;
65:148-153.
9. Juillard L et al. Blood oxygen level-dependent meas-
urement of acute intra-renal ischemia. Kidney Int
2004;65:944-950.
10. Sadowski EA et al. Assessment of acute renal transplant
rejection with blood oxygen level-dependent MR imag-
ing: initial experience. Radiology 2005;236:911-919
11. Textor SC et al. The use of magnetic resonance to evalu-
ate tissue oxygenation in renal artery stenosis. J Am Soc
Nephrol 2008;19:780-788.
12. Shah NS et al. Evaluation of renal parenchymal disease
in a rat model with magnetic resonance elastography.
Magn Reson Med 2004;52:56-64.
The authors
Lorenzo Mannelli MD, Danny Kim MD, Hersh
Chandarana MD.
Departments of Radiology
NYU Langone Medical Center
New York, NY, USA.
www.ihe-online.com & search 45314
 – Issue N°5 – Oct. 2009 24 Intensive care

Improving hand hygiene in the

hospital setting
Hand hygiene is a term that incorporates the decontamination of the hands by the organisational, nursing unit and departmental
methods including routine hand washing, surgical hand washing and the use of levels will lead to identification and implementation
alcohol hand rubs and gels. Although recognised as an essential practice for of evidence-based recommendations that are the
most likely to result in improved performance.
infection control and patient safety, healthcare workers do not necessarily com-
ply with prescribed hand hygiene protocols. This article presents evidence-based The second step of the nursing process is diag-
approaches to improving hand hygiene in the hospital setting. nosis. Based on the data gathered in the assess-
ment phase, the team should next analyse the
by Dr C. Day assessment data, and clearly identify the dis-
crete problems and their causes. Determination
of whether the problems are related to a HCW
It has been a challenge to get healthcare workers Improvement approach knowledge deficit, product or environmental
(HCWs) to consistently comply with hand hy- In order to implement a programme to im- factors, lack of awareness, time constraints,
giene practices. This is despite the abundance prove hand hygiene, an effective approach is to individual accountability, or leadership is im-
of scientific evidence to demonstrate that poor first identify a small multi-disciplinary team to portant. Key variables to consider before plan-
HCW hand hygiene puts hospitalised patients champion and lead the initiative. Membership ning an intervention strategy are; a clear defini-
at risk. Leaders in healthcare organisations can- should include staff from nursing and ancillary tion of the problem, the causative factors, and
not assume that all staff consistently perform disciplines, infection control, quality control and where and how pervasive the problems are in
proper hand hygiene routines as studies have medical staff, and administration. A team leader, the organisation.
indicated a wide range compliance with hand or co-leaders, from the highest levels of clinical
hygiene practices. leadership is important in setting the stage and The third step of the nursing process is plan-
importance of the project. Team education, and ning. This step involves taking the problems that
Practitioners including nurses, physicians and a review of the literature and most current guide- were identified in the diagnosis step and identi-
other ancillary staff, cite numerous reasons for lines for practice are important. Identification of fying the specific evidence-based recommenda-
not complying with hand hygiene protocols. Self- the team’s objectives, target improvement goal tions and strategies that are most likely to effect
reported reasons for poor hand hygiene include and timelines, along with a framework such as an improvement. Some recommendations might
product related issues such as skin irritation or the ‘nursing process’ (assessment, diagnosis, plan- be appropriate to implement house-wide (e.g.
hand dryness, inconvenient placement of sinks, ning, implementation and evaluation) to guide an institutional hand hygiene campaign); others
lack of soap and towels, inaccessibility of hand gel the work are also important. might be more appropriate at a unit level (e.g. the
or alcohol-based hand rub (AHR), understaffing, Intensive Care Unit (ICU) sink availability is not
lack of time, prioritisation of other patient needs Utilising the nursing process framework, assessment adequate therefore AHR is needed at the bedside,
over the time it would take to perform hand is a first step in order to effectively determine the or staff education regarding the policy needs to
hygiene, and practitioner belief that the risk of current state. An assessment of the risks and barriers be reinforced). Becoming a stakeholder (nurse,
transmitting infection to a patient is low [1]. to hand hygiene should be conducted. Determining physician, ancillary, leadership) in the planning
whether the policies and procedures regarding hand process can be an effective way to gain insight into
An evidence-based guideline was developed hygiene are evidence-based and clearly written and the development of plans and strategies that will
and some of its recommendations and strategies the staff’s level of knowledge and understanding work in the organisation but that the staff will also
were utilised in an academic medical centre as of those policies, as well as assessing the availabil- engage in and support.
a useful tool to improve hand hygiene of work- ity and placement of
ers, patients, and families. Five areas, each with hand hygiene prod-
at least two strategies supported by the literature, ucts including AHR,
were identified in the guideline. The five recom- are examples of basic
mendations included a programme or campaign information required
to draw awareness of HCWs and patients to for an assessment re-
the importance of hand hygiene; education re- lated to hand hygiene.
garding protocols and techniques; performance Collection of baseline
feedback; product selection and availability; and hospital-acquired in-
organisational commitment and leadership. Un- fection (HAI) rates and
derstanding the organisation-specific reasons surveillance of HCW
for non-compliance, designing a programme hand hygiene practice
founded on evidence-based interventions, and would provide base-
strong leadership commitment were keys to the line data and informa-
success of a programme that resulted in improved tion upon which to
performance [2]. An evidence-based approach help determine appro-
to improvement can be successfully applied in priate recommenda-
other organisations. tions. Assessment at
 25 – Issue N°5 – Oct. 2009

The planning step should include the development of detailed written plans
specific to each problem identified, including a goal, the guideline recom-
mendation identified to address the problem, the individual(s) who will be
accountable for implementation, metrics and a date for completion. The
plan should also include a comprehensive communication plan, dates for
follow-up evaluation and a budget.

Implementation follows the planning phase and should include the com-
munication and implementation of the specific recommendations. Periodic
team meetings throughout the process should be conducted in order to
ensure that implementation is progressing as planned, or that appropriate
course corrections and problem solving are conducted in a timely manner.
Barriers to implementation – real or potential - should be anticipated and
contingencies identified.

The final step is ongoing evaluation of the programme. Building metrics into
the organisational and departmental dashboards is important for ongoing
monitoring and accountability. Reporting structure, frequency for report-
ing and accountability expectations should be built into the plan along with
feedback, recognition and celebration plans.
www.ihe-online.com & search 45359
Challenges
Numerous organisational issues, including resistance, should be anticipated.

5
B0
Improving hand hygiene may not be perceived as an exciting or even neces-

d
sary initiative and engagement of staff champions and team members could an
St
9

be difficult. A second challenge may be the time taken to systematically as-

ll
Ha

sess and plan the initiative. Many organisations and healthcare leaders are
eager to find a “quick fix” rather than taking the time to assess a problem and
then strategically implement well-planned interventions.

A key strategy for success is to ensure leadership commitment to the initia-

tive. Presentation of the plan to the senior executives, senior leadership and
to the governing body of the organisation for endorsement and support is
important to success. Periodic progress reports to each of these levels, in-
cluding barriers, successes and outcomes are important. Management team
commitment and involvement would also be key for the achievement of
successful outcomes.

An additional challenge could be resources, both in labour requirements

(e.g. additional expenses related to training and staff participation on an im-
plementation team) and in materials and supplies (e.g. AHR, posters, edu-
cational materials, etc). Finally, one of the most difficult challenges might be
competing priorities in the institution and the availability of resources to be
dedicated to the project.

Conclusion
Healthcare organisations and healthcare workers have a responsibility and
an obligation to protect patients from harm, including prevention of hospi-
tal-acquired infections. The development and application of evidence-based
policies and procedures, along with evidence-based approaches to improv-
ing hand hygiene in the hospital setting can lower infection rates and thus
positively impact on patient care outcomes.

References
1. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control
Hosp Epidemiol 2000; 21(6):381-386.
2. Day C. Engaging the Nursing Workforce: An Evidence-Based Tool Kit. Nurs Admin
Q 2009: 33(3): 238-244.

The author
Cindy Day, DNP, RN, NEA, BC
Stanford Hospital and Clinics
Stanford, CA, USA
e-mail: cday@stanfordmed.org
www.ihe-online.com & search 45275
 – Issue N°5 – Oct. 2009 26 Infection control

The challenges of implementing infection

control procedures in limited resource hospitals
Healthcare-associated infections constitute an important public health problem in help control infections of normally sterile body
developing countries. In many hospitals, infection control procedures are limited by sites, mucous membranes and non-intact skin
the lack of financial resources, poor infrastructure, overcrowding, inadequate hygiene, are not available. Overcrowding and understaff-
ing, particularly in the ICU, results in decreased
deficient laboratory services, poor management, insufficient technology and a short-
hand hygiene compliance; frequent movement of
age of trained staff. The best solutions entail greater governmental commitment and patients and staff between hospital wards results
application of infection control procedures consistent with available resources. in an increased risk of transmission of multidrug-
resistant micro-organisms. Such transmission is
often exacerbated by overcrowding, with patients
by Dr Lul Raka and Dr Gjyle Mulliqi-Osmani sometimes sharing beds and supplies. There may
be a lack of commitment to healthcare by policy-
makers in the developing world and allocation of
Infectious diseases are a worldwide concern and the The majority of HCAIs relate to medical devices, funds is often disproportionate to the priorities set
second most common cause of death globally. Of e.g. pneumonia related to mechanical ventilation, by providers. Corruption and nonformal payments
the 12 million deaths that occur globally, 95% take urinary tract infections (UTIs) to urinary cath- are frequent. Information systems are not fully
place in developing countries, where disease pre- eters, surgical site infection (SSI) after trauma or developed. There are limited grants available for
vention and control policies are either non-existent, surgery, and bacteraemia derived from intravas- research and no legislation mandating accredita-
poorly adapted or insufficiently funded by govern- cular devices. UTIs constitute 30-40% of all noso- tion of hospitals or infection control programmes.
ments. Healthcare-associated infections (HCAIs) comial infections. In intensive care, even in highly In-service training for employees is highly variable
constitute an important health problem throughout resourced units in industrialised countries, ≥25% and often minimal. Transfusion and injections may
the world and pose a major threat to patient safety. of patients admitted develop HCAI with a mortality pose a risk for transmission of HIV and hepatitis.
HCAIs impact on the population in many ways. >25%, and in developing countries 66% of patients Many other problems abound, for example, steri-
They affect patients directly, causing increased mor- admitted to the intensive care unit (ICU) develop a lisation departments are not centralised and there
bidity and mortality; they may lead to disability; and HCAI. Ventilator-associated pneumonia (VAP) is is lack of quality control in disinfection and sterili-
they may reduce quality of life. They also impact a leading cause of death in hospitalised patients in sation. Although many hospitals in the developing
on the healthcare system by extending hospitalisa- developing countries with rates from 10 to 41.7 per world may have infection control programmes and
tion of affected patients and driving up the costs of 1000 ventilator-days and a crude mortality ranging committees on paper, in practice they barely exist.
diagnosis and treatment. HCAIs may be transmit- from 16% to 94%. Many studies have shown the Inadequate numbers of trained personnel work in
ted from healthcare settings into the community, so importance of HCAI among neonates in develop- infection control, and they face continual resist-
damaging the reputation of healthcare institutions ing countries, where an average of 4384 children die ance from clinical staff. In addition, inadequate sal-
in the eyes of the public. every day from these infections with rates of infec- aries lower healthcare workers’ morale. This litany
tions three to 20-fold higher than those reported in of problems means that the response by manage-
Infection control and hospitals with industrialised countries. Between 5% and 10% of ment and staff to common outbreaks of disease in
limited resources human immunodeficiency virus (HIV) infections high risk units is mainly reactive rather than proac-
For governments of developing countries, limited worldwide are transmitted through transfusion tive. Lack of ongoing surveillance results in delays
resources represent the main challenge to imple- of contaminated blood and blood products. Over in detecting outbreaks, with increasing costs and
menting infection control procedures. During 16 billion injections are administered each year in mortality as a result.
the last few decades, infection control activities developing and transitional countries and the pro-
in developing countries have increased, particu- portion of injections given by syringes and needles Resistance to antimicrobial agents is a another
larly in South America, South East Europe and that are re-used without sterilisation ranges from important issue in all healthcare facilities. In devel-
countries of the former Soviet Union. Public 1.5 to 69.4%. oping countries inappropriate and uncontrolled
pressure to improve the quality of hospital care use of antibiotics is very common and antimicro-
and the increased cost resulting from HCAIs in The economic burden of HCAI is substantial eve- bials are frequently available over the counter in
healthcare systems have played important roles rywhere, although it varies from country to coun- pharmacies. The quality and potency of antibiotics
in this development. A high frequency of HCAIs try. Jarvis [8] showed an estimated average cost of are often suspect, with unregulated import, regis-
in a healthcare facility is an indicator of the poor (US) $558 to $593 for each UTI, $2,734 for each tration and distribution. Between 20% and 50% of
quality of healthcare services. SSI, $3,061 to $40,000 for each bloodstream infec- a hospital budget is spent on antimicrobials, which
tion, and $4,947 for each case of pneumonia. In are used to treat more than half of all patients. Mis-
HCAIs represent one of the most common com- countries with prospective payment systems based use has been identified as an important factor in
plications of healthcare, affecting about two mil- on diagnosis-related groups, hospitals lose from the emergence of antimicrobial resistance. In turn,
lion people admitted to acute hospitals annually. $583 to $4,886 for each nosocomial infection. this resistance makes the clinical management of
These infections complicate 5-10% of admissions patients more difficult.
to acute care hospitals in industrialised countries. In developing countries, the great majority of
By contrast, HCAIs occurred in >40% of hospi- funding is traditionally allocated to hospitals in As a consequence of the weakness and prob-
talisations in developing countries in Asia, Latin urban centres, which often have academic affili- lems outlined above, developing countries face
America and sub-Saharan Africa. ations. In some hospitals, adequate supplies to the challenge of high rates of HCAI and frequent

nosocomial outbreaks. Another consequence of
insufficient infection control infrastructure is the
spread of multidrug-resistant organisms, such as
meticillin-resistant Staphylococcus aureus (MRSA),
vancomycin-resistant Enterococcus spp. (VRE),
extended-spectrumbeta-lactamase-producingGram-
negative bacilli, multidrug-resistant Mycobacterium
tuberculosis and fluconazole-resistant Candida spp.
Challenges and solutions
Most HCAIs can be prevented using readily avail-
able and relatively inexpensive strategies. Studies
showed that effective infection control programmes
can reduce infection rates by as much as 30-70% and
are cost-effective. To meet the required level of pre-
vention, multiple strategies must be implemented
simultaneously. These so-called ‘bundles’ usually
represent a set of three to five practices that, when
performed collectively, reliably and continuously
have been proven to improve patient outcomes.
Administrative support
An important factor in the prevention of HCAI
is commitment. National authorities must under-
stand that without the proper resources, hospi-
tals can be high-risk areas. Therefore, healthcare
authorities must establish and support a com-
prehensive, effective national programme. Many
countries already have such programmes. If these
are not available, programmes from the developed
world should be adopted.
Hand hygiene
Hand hygiene remains the simplest and the pri-
mary measure to prevent HCAI and reduce spread
of multidrug-resistant organisms. Although hand
hygiene is a simple measure, the lack of compli-
ance among healthcare workers is problematic
worldwide, averaging <40%. Introduction of
alcohol- based hand rub has led to increased hand
hygiene compliance among healthcare workers
and fewer HCAIs. In some developing countries,
implementation of education, process surveil-
lance and performance feedback has considerably
enhanced hand hygiene compliance.
Surveillance
Surveillance is an essential component in HCAI
prevention, with the aims of outbreak identifica-
tion, establishment of endemic baseline rates of
infection and the evaluation of control measures.
Surveillance data can be used to identify prevent-
able infections in high-risk areas, so that resources
are targeted to high-priority areas.
Combating antibiotic resistance
There is good evidence that antibiotic stewardship
programmes have been successful in modifying
antimicrobial prescribing practices, resulting in
reduction of use in most cases. Unfortunately,
such programmes are often lacking in developing
countries, and antimicrobial resistance problems
emphasise the importance of strengthening the
clinical microbiology laboratory services.
27 – Issue N°5 – Oct. 2009
Global initiatives: 5. Rosenthal VD et al. Am J Infect control 2008;36:627-
World Alliance for Patient Safety 637.
Improving the safety of patient care is now a 6. Arabi Y et al. Int J Infect Dis 2008;12:505-512.
global issue. A growing awareness of HCAI and 7. Zaidi AK et al. Lancet 2005; 365:1175-1188.
patient safety prompted the WHO to promote 8. J arvis WR. Infect Control Hosp Epidemiol
the creation of the World Alliance for Patient 1996;17:552-557.
Safety to coordinate, spread and accelerate 9. Okeke IN et al. Lancet Infect Dis 2005; 8:481-493.
improvements in patient safety. 10. Harbarth S, Sax H, Gastmeier P. J Hosp Infect
2003;54:258-266.
Research: International Nosocomial
Infection Control Consortium The authors
One measure to improve the knowledge base of Lul Raka, M.D. Ph.D
infection control is through research and develop- & Gjyle Mulliqi-Osmani, M.D. Ph.D.
ment. An important window for research in develop- National Institute of Public Health of Kosova
ing countries arose through the International Noso- & Medical School, Prishtina University, Kosova
comial Infection Control Consortium (INICC). The Correspondence to:
INICC is the first multinational research network Dr Lul Raka
established to control HCAI in hospitals in limited- Rrethi i spitalit, p.n., 10000
resource countries. It has developed to a dynamic Prishtina, Kosova
network of over 100 healthcare centres in 85 cities, e-mail: lulraka@hotmail.com
from 30 countries of four continents, and is the only Tel: +37744 368 289
source of aggregate standardised international data
on HCAI epidemiology in intensive care. Rates of
device-associated nosocomial infection have been
found to be three to five-fold higher compared to in
the developed world.
Other prevention/control procedures
Education of healthcare workers, standard pre-
cautions and safe and appropriate use of injec-
tions are important for prevention and control
of HCAI. Important steps in prevention of HCAI
are introduction of validated processes for decon-
tamination, cleaning and sterilisation or high
level disinfection of soiled instruments and other
items; and improving safety in operating rooms
and other high risk areas. Due to their contact
with patients or infected material from patients,
many healthcare workers are at risk of exposure
to, and possible transmission of, vaccine-prevent-
able diseases. Immunisation of health care work-
ers is an essential part of prevention and infection
control programmes. www.ihe-online.com & search 45311
Conclusion
HCAIs represent a threat to patient safety and
quality healthcare. The sustainability of any activ-
ity undertaken will have a great impact on the final
outcome. Through focusing on infection control,
countries with limited resources can improve the
quality of healthcare in the future.
References
1. Lynch P et al. Infection control in developing coun-
tries. In: Jarvis WR, editor. Bennett and Brachman’s
Hospital Infections. Philadelphia: Lippincott Wil-
liams & Wilkins; 2007. p. 240-255.
2. Ponce-de-Leon-Rosales S, Macias A. In: Wenzel RP,
editor. Prevention and control of nosocomial infec-
tions. 4th ed. Philadelphia: Lippincott Williams &
Wilkins; 2003. p. 14-33.
3. Morris K. Lancet 2008;372:1941-1942.
4. Pittet D, Donaldson L. Int J Qual Health Care
2006;18:4-8.
www.ihe-online.com & search 45309
 Literature review
Reflecting the importance of the sub-
ject and the interest in it, the number
of peer-reviewed papers covering infec-
tion control is huge, to such an extent
that it is frequently difficult for health-
care professionals to keep up with the
literature. As a special service to our
readers, IHE presents a selection of lit-
erature abstracts, chosen by our edito-
rial board as being particularly worthy
of attention.
The effect of environmental
parameters on the survival of
airborne infectious agents.
The successful transmission of infection via the
airborne route relies on several factors, includ-
ing the survival of the airborne pathogen in
the environment as it travels between suscep-
tible hosts. This review summarises the various
environmental factors (particularly tempera-
ture and relative humidity) that may affect the
airborne survival of viruses, bacteria and fungi,
with the aim of highlighting specific aspects
of environmental control that may eventu-
ally enhance the aerosol or airborne infec-
tion control of infectious disease transmission
within hospitals.
Tang JW. J R Soc Interface 2009; Sep 22.
Evolving concepts in Clostridium
difficile colitis.
Clostridium difficile infection (CDI) is the most
important cause of nosocomial diarrhoea. The
emergence of a hypervirulent strain and other
factors including antibiotic overuse contrib-
ute to the increasing incidence and severity of
this potentially lethal infection. CDI has been
reported in persons previously considered as
low risk, such as peripartum women, children
and young healthy persons without exposure
to healthcare settings or antibiotics. In patients
with inflammatory bowel disease, the risk of C.
difficile infection is greater, with higher rates
of hospitalisation, bowel surgery and mortal-
ity. With increasing incidence and severity
of disease, the need for improved diagnos-
tic, treatment and infection control strategies
cannot be overstated.
Diggs NG, Surawicz CM. Curr Gastroenterol Rep
2009 Oct;11(5):400-5
Effective strategies for prevention and
control of Gram-negative infections.
Infections caused by Gram-negative bacteria
such as Pseudomonas, Klebsiella, Proteus and
Acinetobacter have been a major problem in
healthcare settings for many years. Overlooked
in most government targets and unknown to
most patients, these infections present con-
siderable challenges for effective infection
29 – Issue N°5 – Oct. 2009
prevention and control. Key strategies for pre-
vention and control focus on contact precau-
tions, the management of invasive devices and
maintaining a clean, dry environment to pre-
vent the build-up of environmental reservoirs
and cross-infection.
Gould D. Nurs Stand. 2009 Aug 5-11; 23(48):42-6.
Five years of implementing a
methicillin-resistant Staphylococcus
aureus “search and destroy” policy.
The effectiveness of a rigorous search and
destroy policy for controlling methicillin-
resistant Staphylococcus aureus (MRSA) infec-
tion or colonisation was evaluated at the largest
university medical centre in the Netherlands.
Outbreak control was accomplished by the use
of active surveillance cultures for persons at
risk, by the preemptive isolation of patients at
risk, and by the strict isolation of known MRSA
carriers and the eradication of MRSA carriage. www.ihe-online.com & search 45355
For unexpected cases of MRSA colonisation
or infection, patients placed in strict isolation
or contact isolation and healthcare workers
(HCWs) were screened.
Data were collected from 2000-2004. During
the 5-year study period, 51,907 MRSA screen-
ing cultures were performed for 21,598 per-
sons at risk (8,403 patients and 13,195 health-
care workers, HCWs). It was determined that
123 (1.5%) of 8,403 patients and 31 (0.2%) of
13,195 HCWs were MRSA carriers. From the
results of clinical cultures, it was determined
that 54 additional patients were MRSA carri-
ers, resulting in a total of 177 patients carry-
ing MRSA. The average number of nosocomial
transmissions was 6.7 per year. The cumulative
incidence of MRSA colonisation among this
group of patients was 0.10 cases per 100 admis-
sions. Of 156 cases of MRSA colonisation, 44
(28%) were acquired in a healthcare institution
outside the Netherlands, and 45 (29%) were
acquired in other Dutch hospitals, 22 (47%) of
which were acquired in a single hospital. There
were 16 cases (10%) that occurred in a nursing
home and another 16 cases (10%) that fulfilled
the definition of community-acquired MRSA
colonisation; there were 4 cases (3%) catego-
rised as “other” and 31 cases (20%) for which
the source of MRSA acquisition remained
unknown. During the 5-year study period, five
episodes of MRSA bacteraemia occurred in
which four patients died, an incidence rate of www.ihe-online.com & search 45340
0.28 cases of infection per 100,000 patient-days
per year.
Results show that during a rigorous search and
destroy policy a low incidence of MRSA was
continuously observed and that this policy most
likely contributed to a very low nosocomial HAVE YOU RENEWED YOUR
transmission rate. FREE SUBSCRIPTION ?
Vos MC et al. Infect Control Hosp Epidemiol 2009
www.ihe-online.com
Oct;30(10):977-84.
 – Issue N°5 – Oct. 2009 30 NEWS IN BRIEF
Identification of highly radiosensitive patients may
lead to side effect-free radiotherapy
An international group of scientists has taken
the first step on the road to targeting radiother-
apy dosage to individual patients by means of
their genetic characteristics. Professor Dirk de
Ruysscher, from Maastricht University Medical
Centre, Maastricht, The Netherlands said that
his team’s work might provide the basis for per-
sonalised radiotherapy in which, with a sim-
ple blood test, it may be possible to select the
optimal radiation dose for a particular patient.
The team of scientists from The Netherlands,
Belgium, Germany and Canada studied a
group of patients with hypersensitivity to radiation therapy, drawn from the
largest world-wide database available – the European Union-funded GENEtic
pathways for the Prediction of the effect of Irradiation (GENEPI) study, which
combines biological material with patient data and treatment specifications.
The database included information from more than 8000 European patients.
A tissue bank including skin fibroblasts, whole blood, lymphocytes, plasma
and lymphoblastic cell lines from patients who were known to be hypersensi-
tive to radiation was established from patients in Europe and Canada. When
compared with a control group, also drawn from the GENEPI study, the
hypersensitive patients showed either severe side effects occurring at very low
radiation levels, or severe side effects lasting for more than four weeks after the
end of radiotherapy and/or requiring surgery, or severe late side effects occur-
ring or persisting more than 90 days after the end of radiotherapy. Thirty-
three such patients, 10 males and 23 females, were identified, of whom 11
(two males and nine females) ultimately proved to be really hypersensitive to
radiation, underlining the rarity of this condition.
Different types of tumours respond differently to radiotherapy; highly radio-
sensitive cancer cells such as leukaemias can be killed by quite low radiation
doses, whereas melanomas need such a high dose that it would be unsafe to
use radiation therapy in such cases. However, the finding that individuals, as
well as tumours, react differently will allow doses to be even more carefully tar-
getted in future, taking into account not just the radiosensitivity of the tumour
type but also the potential reaction of the particular patient to treatment.
http://www.ecco-org.eu/
Coronary imaging techniques help to identify plaques
likely to cause heart attacks
Late-breaking results from the ‘Providing Regional Observations to Study
Predictors of Events in the Coronary Tree’ (PROSPECT) clinical trial have
www.ihe-online.com & search 45303
shed new light on the types of
vulnerable plaque that are most
likely to cause sudden, unex-
pected adverse cardiac events,
and on the ability to identify
such plaques through imag-
ing techniques before adverse
events occur.
This multi-centre trial, which
is the first prospective natural history study of atherosclerosis using multi-
modality imaging to characterise the coronary tree, studied 700 patients with
acute coronary syndromes (ACS). It used three-vessel multimodality intra-
coronary imaging – angiography, intravascular ultrasound (IVUS) and virtual
histology – to quantify the clinical event rate due to atherosclerotic progression
and to identify those lesions that place patients at risk of unexpected adverse
cardiovascular events (sudden death, cardiac arrest, heart attacks and unstable
or progressive angina).
Among the discoveries of the trial are that most untreated plaques that cause
unexpected heart attacks are not mild lesions, as previously thought, but actu-
ally large, with a small lumen area. These are characteristics that were invisible
with coronary angiogram but easily identifiable by IVUS. Only about half of
new cardiac events due to non culprit lesions exemplified the classic notion
of vulnerable plaque (rapid lesion progression of non flow limiting lesions),
while half were attributable to unrecognised and untreated severe disease with
minimal change over time. Perhaps most importantly, for the first time it was
demonstrated that characterisation of the underlying plaque composition
(with virtual histology) was able to significantly improve the ability to predict
future adverse events beyond other more standard imaging techniques.
http://www.crf.org/
Improved prostate cancer identification using MRI
Rutgers University, USA together with
one academic and one industrial collab-
orating group, namely Penn Medicine,
USA and Siemens, have received a $3.4
million research grant to develop tools
aimed at improving the identification of
prostate cancer using MRI. The five-year
grant, with funding in the first two years
coming from the American Recovery
and Reinvestment Act (ARRA) of 2009,
was awarded by the USA National Institutes of Health under an initiative to
promote industry and academic partnerships.
Recent studies by Rutgers and Penn Medicine researchers show that power-
ful, high-resolution MRI technology can reveal cancerous tissue in prostate
glands and pinpoint where the tissue is concentrated. Radiologists, how-
ever, do not always know whether unusual-looking visual features indicate
cancerous growth or benign variations.
The diagnosis of prostate cancer is currently based on PSA levels in blood,
physical examination and biopsy, because current imaging techniques do
not distinguish cancerous tissue. MRI has the potential to offer a diagno-
sis non-invasively and, along with other information, allow the most effec-
tive and least debilitating treatment to be carried out. Under the research
grant, Penn researchers will make magnetic resonance images of prostate
glands in cancer patients and prepare tissue samples from those same glands
after they are surgically removed in the course of treatment. Rutgers and
Siemens researchers will then develop computerised tools that align MRI
views with digitised images of tissue slices. These tools will allow investiga-
tors to better identify MRI features that reveal cancerous tissue and develop
pattern recognition software that will help radiologists make accurate and
timely diagnoses. Siemens will refine research tools into software packages
for scientists to use as they conduct additional studies and develop further
diagnostic tools and techniques.
http://www.rutgers.edu/
 PRODUCT NEWS 31 – Issue N°5 – Oct. 2009

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
and gynae- Bi-phasic defibrillator Personal
cology, the Robust, cost-effective Notebook
Ac u s on and designed and
X300 ultra- built to high quality Ultrasound
sound system from Siemens provides exceptional standards, the G-Care
clinical performance across all modes, including XL is a bi-phasic Medica 2009
Hall 09
3D/4D imaging. The new system features “syngo defibrillator system Booth D61
Auto OB” measurements, a unique workflow tool with ECG monitoring
that automates routine biometry measurements and pacing (both NTP and transvenous). The
of the foetus and eliminates the time-consuming system has built-in adult and paediatric paddles
manual process of biometry measurements so that and can be fitted with a thermal recorder; another
75 percent fewer keystrokes are needed on the part optional accessory is pulse oximetry. The bi-
of the operator. This not only accelerates the work- phasic waveform is of equal 180J amplitudes. The
flow, but may also help to reduce repetitive stress system is battery-powered but can operate on
injury (RSI) among users. mains power in case of battery failure.

phone: (+370-5) 2106272

Siemens Silicon labs Pvt TELEMED, UAB
Dariaus ir Gireno str. 42 fax: (+370-5) 2306733
Erlangen, Germany Chennai, India Vilnius, LT-02189, http://www.telemed.lt
Lithuania e-mail: info@telemed.lt
www.ihe-online.com & search 45369 www.ihe-online.com & search 45382
www.ihe-online.com & search 45299
 – Issue N°5 – Oct. 2009
32 Medica Preview:
A selection of the new products to be presented at MEDICA 2009 Nov 18 - 21, Dusseldorf
Fully-featured portable ventilator
The IdeVersamed iVent-201 ventilator is
a versatile turbine-driven system ideal for
pandemic use but packing enough power
to handle the needs of the ventilated patient
in the intensive care unit. The system does
not need a wall-mounted air-supply and
is able to provide elevated O2 from either
a high-pressure or a low-pressure, low
flow source. With a variety of built-in and
external battery options, thanks to its com-
pact size and rugged construction the new
system can cover ventilation needs during
patient transport and in other situations where typical hospital infrastruc-
tures are not available. The system offers a wide range of ventilation modes
and can display waveforms, loops, respiratory mechanics, SpO2 and patient
trends. Able to cover the needs of the acute patient while providing all the
monitoring information the clinician needs on simplified displays, the
ventilator is quick to set up and suitable for many applications.
GE Healthcare
Helsinki, Finland
Medica stand: Hall 10 A56 / Hall 10 B44
www.ihe-online.com & search 45376
LED-based OR illumination system
Specifically designed for use in
the operating room, the new OT-
STARLED medical illumination
system from ACEM is based on
LED technology, thus provid-
ing a clean light with no infra-
red rays or heat and a constant
chromatic profile. The striking
feature of the new system is the
large number of LEDs used (a
total of 70) which are positioned in a circle and generate a light spot of
high illumination (160000 lux) at a distance of 21 cm to 1 m. The new
lights are also equipped with a shadows reduction system and a brightness
EXPERIENCE THE SUPERIORITY
of high-performance defibrillator & monitor
RESCUE LIFE
THE DEFIBRILLATOR
Visit us
Medical Equipment Solutions Medica 2009
HALL 9
www.progettimedical.com STAND C41
www.ihe-online.com & search 44950
adaptor based on the use of obstacle finding sensors that give a constant
localisation of the head, hands and shoulders of the surgeon.
ACEM
Bologna, Italy
Medica stand: Hall 9 A52
www.ihe-online.com & search 45374
Reliable and safe infusion/blood warmer
Hypothermia has always been a major concern
and can lead to serious side-effects. Infusion of
fluids or transfusion at body temperature can help
to prevent and treat hypothermia and in general
enhances effective intravenous administration.
The Animec AM 301 warmer has been designed
to provide warmed infusions or transfusion prod-
ucts in pre-, post- or short-term surgery. With a
user-adjustable set-point temperature (36°C or
39°C), the system is designed for safety and shows
the actual temperature of the outlet fluid on an
easy-to-read LED display. There are audible and
visible off-temperature alarms, whose proper
function can be quickly and easily tested. The sys-
tem can handle two standard tube sizes (4mm or
5mm) so there is no need for any disposable sets.
Elltec
Nagoya, Japan
Medica stand: Hall 9 C77 SUZUKEN
www.ihe-online.com & search 45372
Laser acupuncture application for smoking cessation
The Canadian company MedX
has over a decade of experi-
ence in designing, manu-
facturing and distributing
ground-breaking laser and
light therapy technology.
MedX’s laser and light devices
have been extensively used in
rehabilitation and sports medi-
cine, and more recently in the
dental arenas. This expertise has now been incorporated into the MedX
Laser Probe devices to effectively treat people that wish to stop smoking
without the use of drugs. Developed specifically for smoking cessation
and other addiction programmes, the laser probe delivers 200 mW of
infrared energy using an 808 nm GaAIAs infrared laser diode and vis-
ible red guide light. The ergonomic design ensures simplicity of use and
accuracy for auricular and body acupuncture applications. While the use
of laser therapy in addiction is not a new concept, it has not been well-
documented and the company wishes to conduct meaningful studies to
confirm the efficacy of the laser and established treatment protocols for
addiction, which have the potential of leading to more cost-effective
ways of treating addiction.
MedX Health Corp.
Toronto, Canada
Medica stand: Hall 5 N40
www.ihe-online.com & search 45375
 PRODUCT NEWS 33 – Issue N°5 – Oct. 2009

approach may indeed induce myocardial angiogenesis, improve myocardial

FRONT COVER PRODUCT perfusion and reduce systems in patients with endstage CAD. The ESMR treat-
ment itself is carried out using a shockwave generator that is designed to address
Multiple applications in one US system the unique clinical-anatomical requirements of the chest cavity. A cardiac ultra-
Providing unprecedented performance in a vari- sound imaging system is used to locate the treatment area and to map the exact
ety of ultrasound applications, the new ProSound position and extent of the ischaemic zone. Shockwaves are then delivered via the
Alpha 6 system from Aloka represents the next anatomical acoustic window to the treatment area under ECG R-wave gating.
generation of compact colour ultrasound systems.
Fully upgradable and easy to use, the new multi- Medispec
purpose system builds on the proven technology Germantown, MD, USA
of the high performance ProSound Alpha 10 and Medica stand: Hall 10 C11
Alpha 7 models, but shows a marked difference www.ihe-online.com & search 45377
from other ultrasound systems in that it addresses
multiple diagnostic applications in a single unit.
The system is supplied with a full suite of applica- Semi automatic defibrillator
tion-specific probes and software designed to tar- Automatic external defibrillators (AEDs) must
get all specialist diagnostic areas including imag- be able to be located instantly and should be able
ing, cardiovascular, obstetrics & gynaecology and to be carried to the patient quickly and with-
internal medicine. The high power processor ena- out fumbling. To meet these requirements,
bles a number of different imaging modes that were Defibtech have designed their Lifeline view defi-
previously only available in high end systems. brillator not only to be as eye-catching as possible
but also to be handy to carry and easy to use. The system uses biphasic defibrilla-
ALOKA tion that is extremely effective at defibrillating patients in ventricular fibrillation
Tokyo, Japan — the most common form of sudden cardiac arrest — on the first shock.
Medica stand: Hall 10 F58
www.ihe-online.com & search 45373 Defibtech
Guilford CT, USA
Medica stand: Hall 16 D32 -1
Extracorporeal shockwave myocardial revascularisation www.ihe-online.com & search 45378
ESMR is a new non-invasive therapy approach
using extracorporeal shockwaves. Patients
with advanced end stage coronary artery Pulse oximeter
disease frequently have recurrent angina and The new Radical-7 instrument features
in many such cases the disease becomes too “gold standard” Masimo SET pulse oxi-
diffuse and extensive to be treated by conven- metry, which has been proven in more
tional revascularisation techniques. Surgical than 100 independent and objective
and interventional options for these patients have typically been exhausted or studies to provide the most accurate and
result in only partial revascularisation. ESMR offers new hope for these patients reliable SpO2 readings during motion and low perfusion.
and provides an additional therapeutical approach. Recent studies have shown
that the application of low-intensity shockwaves may induce the release of ang- Masimo
iogenesis-mediating growth factor (VEGF) and proliferating cell antinuclear Neuchatel, Switzerland
antigen (PCNA). Additional investigation of low energy shock wave treatment Medica stand: Hall 9 C35
in animals and with a limited number of human patients have shown that the www.ihe-online.com & search 45379

Calendar of events
October 11-14, 2009 Tel. +32 2 555 3631 Rome, Italy
PRO2XY
ESICM 2009 e-mail: sympicu@ulb.ac.be Tel. +32 2 555 3631
Vienna, Austria www.intensive.org e-mail: sympicu@ulb.ac.be On-site
Tel. +32 2 559 03 55 www.intensive.org
e-mail: Vienna2009@esicm.org November 18-21, 2009 medicinal
www.esicm.org MEDICA 2009 January 25-28, 2010
Düsseldorf, Germany Arab Health oxygen
October 20 – 23, 2009 e-mail: info@medica.de Dubai, United Arab Emirates
Medical Fair Brno Central Europe www.medica.de Tel. +971 4 3365161 generator
2009 www.arabhealthonline.com
Brno Exhibition Centre, Czech Republic November 29 – Dec. 4, 2009 Your source of on-site oxygen :
Tel. +420 541 152 818 RSNA 2009 February 25-28, 2010
e-mail: medicalfair@bvv.cz Chicago, IL, USA Early Disease Detection and Pre-
• turnkey system
www.bvv.cz/medicalfair-gb http://rsna2009.rsna.org vention (EDDP) conference 2010 • economically interesting
Munich, Germany
October 28-31, 2009 December 10-11, 2009 Tel. +41 22 5330 948 • complying with
62nd CMEF Autumn 2009 China International Medical e-mail: eddp2010@paragon- ISO 10083 Standard
Tel. +86 10 6202 8899 ext 3825 Device Summit 2009 conventions.com
• guaranteed flow
e-mail: jin.liu2@ReedSinopharm.com Beijing, China www.paragon-conventions.com/
http://en.cmef.com.cn Tel. +86 21 5258 8005 eddp2010/ and rate of oxygen
e-mail: info@chinaMDsummit.com • output pressure 5 or 12 bar
For more events see
November 17-19, 2009 http://chinamdsummit.com
www.ihe-online.com/events/
International Course: Doppler-
Echocardiography in Intensive December 13-16, 2009
Dates and descriptions of future events have
www.mils.fr Hall 17
been obtained from usually reliable official
Care Medicine Update on Hemodynamic industrial sources. IHE cannot be held respon- sales@mils.fr Stand A 23 B
Brussels, Belgium Monitoring sible for errors, changes or cancellations.

www.ihe-online.com & search 45357

 – Issue N°5 – Oct. 2009
34
A selection of the new products to be presented at MEDICA 2009 Nov 18 - 21, Dusseldorf
FRONT COVER PRODUCT
Autoclavable soft sensors for
adult and paediatric use
The new SoftCapA sensors for adults and
infants make it possible for the first time to
autoclave SpO2 sensors at 134°C and thereby
effectively sterilise them. In this way, the
risk of nosocomial infections resulting
from pathogenic microorganisms or multi-
resistant bacteria remaining on the surface
of the sensor is significantly reduced. Due
to their robust design, the sensors are well
suited for use in the ICU and special care
units where highly infectious diseases are
treated, as well as in the rugged environ-
ment of rescue services and emergency
care. The sensors are guaranteed for up to
200 autoclaving cycles at 134°C or for two
years. The structured design of the sensors
gives an ergonomic fit and minimises both
motion and ambient light interferences; in
addition, in contrast to conventional finger
clip sensor technology the new SoftCap A
sensors do not adversely affect perfusion.
The system’s thermo-balanced light radia-
tion characteristics provide a significantly
improved signal-to-noise ratio in cases
of low perfusion. Allergic skin reactions
are minimised by the bio-compatible and
latex-free silicone housing.
bluepoint MEDICAL GmbH
Selmsdorf, Germany
Medica Stand: Hall 10 F78
www.ihe-online.com & search 45381
Jet ventilator
Already equipped with all features that are required
for jet ventilation in all imaginable clinical settings,
the new MONSOON 3 jet ventilator is available
with a large range of optional accessories. The most
advanced apparatus of its kind, the new system is
equipped with a double jet outlet, which enables the
application of superimposed jet ventilation with a
Medica Preview:
separate high and low frequency gas outlet. Another
striking feature is the high performance jet gas con-
ditioning system, which is an integral part of the
device and automatically warms and humidifies the
entire jet gas that is delivered. The well-established
advantages of previous models in Acutronic’s range
are maintained, and are even surpassed, thanks to
the completely redesigned conditioning unit. It is no
longer necessary, as was the case in earlier models,
to use cumbersome tubing for distilled water. All
that is needed is to connect the infusion system to
the luer-lock water inlet and fit a drop counting sen-
sor. This enables continuous jet ventilation for any
length of time, from minutes to weeks, without any
risk of mucosal damage either because of dry and
cold gases or over-hydration from uncontrolled
water supply. The many default and customisable
settings make the system easy to use in different
environments. The large, bright colour display can
be oriented in all directions or even installed remote
from the mainframe.
ACUTRONIC Medical Systems AG
Hirzel, Switzerland.
Medica stand: Hall 11 H11
www.ihe-online.com & search 45383
Mask for sleep apnoea
A new generation, continuous positive airway
pressure (CPAP) mask has been introduced to
help sleep apnoea patients overcome issues related
to wearing a mask at night. With minimal contact
on the face and a sleek design, the Swift FX Nasal
Pillows mask makes the therapy less intimidating
and easy to accept. The mask is soft to wear and
stable during sleep so patients can move around
and sleep on their side or back, positioning the
tube as desired.
ResMed Corp
San Diego, CA, USA
Medica stand: Hall 11 H24
www.ihe-online.com & search 45382
Flow generator for CPAP
Complementing the company’s existing range of
products for continuous positive airways pressure
(CPAP) therapy, the new InterFlow CPAP flow
generator from Intersurgical is a precise, reliable
device designed with the end-user in mind. Incor-
porating integrated patient airway pressure and
oxygen monitoring the system requires minimum
maintenance, and is both simple to use and easy
to set up, thus giving the clinician complete con-
fidence in its performance. Features include vari-
able flow rates from approximately 0 - 120 litres/
min and oxygen concentrations from 33 to 100%.
CPAP can be effective in many different applica-
tions, reducing the burden on conventional posi-
tive pressure ventilation, resulting in cost savings,
fewer intubations and improving the chances of
early extubation.
Intersurgical
Wokingham, Berks, UK
Medica stand: Hall 11 A59
www.ihe-online.com & search 45380
Cardiograph to facilitate
earlier diagnosis
Philips’ latest product in
the field of cardiography
is the PageWriter TC50
cardiograph which offers
an intuitive 1-2-3 opera-
tion and advanced clini-
cal decision support. The
new system is designed
to help clinicians meet
demands and shift the
focus to patients. Its abil-
ity to handle up to 16
leads provides a more
complete view of the heart, and its anatomically
designed patient interface module makes attach-
ing lead wires quick and intuitive, contributing
to timely triage. As heart disease manifests itself
in different patients in different ways, physicians
always face the challenge of quickly and accurately
diagnosing heart attacks. For this reason, Philips
has packed the PageWriter TC50 with a variety
of tools to aid clinicians with this task, including
those enabled by the innovative DXL 16-lead ECG
Algorithm. The DXL Algorithm’s ST Maps pro-
vide a graphical representation of ST elevation in
patients, a key measure in the diagnosis of ischae-
mia. STEMI-CA can identify which coronary
artery is blocked, aiding the clinician in planning
the appropriate intervention.
Philips
Eindhoven, The Netherlands
Medica stand: Hall 10 A22
www.ihe-online.com & search 45384
Online RegistRatiOn
starts October 1, 2009
www.ihe-online.com & search 45228