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Background: Although there are many reasons for extubation failure, maintaining negative or lower positive fluid balances 24 hours before extubation may be a key measure for successful extubation. Aim: To assess the predictive value of fluid balance before extubation and its outcome in mechanically ventilated cases in the intensive care unit (ICU). Study Design: This retrospective cohort study involved collecting clinical data from patients undergoing mechanical ventilation in Lanzhou general adult ICU from January 2022 to December 2022. Based on extubation outcomes, the patients were divided into a successful extubation group and a failed extubation group. Their fluid balance levels 24 h before extubation were compared with analyse the predictive value of fluid balance on extubation outcomes in patients undergoing mechanical ventilation. Results: In this study, clinical data from 545 patients admitted to a general adult ICU were collected. According to the inclusion and exclusion criteria, 265 (48.6%) patients were included, of which 197 (74.3%) were successfully extubated; extubation was unsuccessful in 68 (25.7%) patients. The total intake and fluid balance levels in patients in the failed extubation group 24 h before extubation were significantly higher than those in the successful extubation group, with a median of 2679.00 (2410.44–3193.50) mL versus 2435.40 (1805.04–2957.00) mL, 831.50 (26.25–1407.94) mL versus 346.00 (−163.00–941.50) mL. Receiver operating characteristic (ROC) curve analysis showed that the optimal cut‐off value for predicting extubation outcomes was 497.5 mL (sensitivity 64.7%, specificity 59.4%) for fluid balance 24 h before extubation. The area under the ROC curve was 0.627 (95% confidence interval [CI] 0.547–0.707). Based on the logistic regression model, cumulative fluid balance >497.5 mL 24 h before extubation could predict its outcomes in mechanically ventilated patients in the ICU (OR = 5.591, 95% CI [2.402–13.015], p <.05). Conclusions: The fluid balance level 24 h before extubation was correlated with the outcome of extubation in mechanically ventilated patients in the ICU. The risk of extubation failure was higher when the fluid balance level was >497.5 mL. Relevance to Clinical Practice: Tracheal intubation is a crucial life support technique for many critically ill patients, and determining the appropriate time for extubation remains a challenge for clinicians. Although there are many reasons for extubation failure, acute pulmonary oedema caused by continuous positive fluid balance and volume overload is one of the main reasons for extubation failure. Therefore, it is very important to study the relationship between fluid balance and extubation outcome to improve the prognosis of patients with invasive mechanical ventilation in ICU. [ABSTRACT FROM AUTHOR]

The article "Video Laryngoscopy in Critically Ill Adults: Nascent, Evolving, or Established?" discusses the use of video laryngoscopy in tracheal intubation procedures for critically ill patients. The study compared video laryngoscopy (VL) with direct laryngoscopy (DL) in critically ill adults and found that VL was associated with a higher rate of first pass success. However, the study also noted limitations in outcome reporting and emphasized the need for further research to fully demonstrate the superiority of VL over DL. The article highlights the importance of considering factors such as operator experience, patient outcomes, and the need for additional data to inform clinical practice in airway management. [Extracted from the article]

OBJECTIVES: Given the uncertainty regarding the optimal approach to laryngoscopy for the intubation of critically ill adult patients, we conducted a systematic review and meta-analysis to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for intubation in emergency department and ICU patients. DATA SOURCES: We searched MEDLINE, PubMed, Embase, Cochrane Library, and unpublished sources, from inception to February 27, 2024. STUDY SELECTION: We included randomized controlled trials (RCTs) of critically ill adult patients randomized to VL compared with DL for endotracheal intubation. DATA EXTRACTION: Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023469945). DATA SYNTHESIS: We included 20 RCTs (n = 4569 patients). Compared with DL, VL probably increases first pass success (FPS) (relative risk [RR], 1.13; 95% CI, 1.06-1.21; moderate certainty) and probably decreases esophageal intubations (RR, 0.47; 95% CI, 0.27-0.82; moderate certainty). VL may result in fewer aspiration events (RR, 0.74; 95% CI, 0.51-1.09; low certainty) and dental injuries (RR, 0.46; 95% CI, 0.19-1.11; low certainty) and may have no effect on mortality (RR, 0.97; 95% CI, 0.88-1.07; low certainty) compared with DL. CONCLUSIONS: In critically ill adult patients undergoing intubation, the use of VL, compared with DL, probably leads to higher rates of FPS and probably decreases esophageal intubations. VL may result in fewer dental injuries as well as aspiration events compared with DL with no effect on mortality. [ABSTRACT FROM AUTHOR]

Summary: Background: The VIDIAC score, a prospectively developed universal classification for videolaryngoscopy, has shown excellent diagnostic performance in adults. However, there is no reliable classification system for videolaryngoscopic tracheal intubation in children. We aimed to develop and validate a multivariable logistic regression model and easy‐to‐use score to classify difficult videolaryngoscopic tracheal intubation in children and to compare it with the Cormack and Lehane classification. A secondary aim was to externally validate the VIDIAC score in children. Methods: We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C‐MAC™ videolaryngoscopes in all children undergoing tracheal intubation for elective surgical procedures. We validated the VIDIAC score externally and assessed its performance. We then identified eligible co‐variables for inclusion in the PeDiAC score, developed a multivariable logistic regression model and compared its performance against the Cormack and Lehane classification. Results: We studied 809 children undergoing 904 episodes of tracheal intubation. The VIDIAC score outperformed the Cormack and Lehane classification when classifying the difficulty of videolaryngoscopic tracheal intubation, with an area under the receiver operating characteristic curve of 0.80 (95%CI 0.73–0.87) vs. 0.69 (95%CI 0.62–0.76), respectively, p = 0.018. Eight eligible tracheal intubation‐related factors, that were selected by 100‐times repeated 10‐fold cross‐validated least absolute shrinkage selector operator regression, were used to develop the PeDiAC model. The PeDiAC model and score showed excellent diagnostic performance and model calibration. The PeDiAC score achieved significantly better diagnostic performance than the Cormack and Lehane classification, with an area under the receiver operating characteristic curve of 0.97 (95%CI 0.96–0.99) vs. 0.69 (95%CI 0.62–0.76), respectively, p < 0.001. Conclusion: We developed and validated a specifically tailored classification for paediatric videolaryngoscopic tracheal intubation with excellent diagnostic performance and calibration that outperformed the Cormack and Lehane classification. [ABSTRACT FROM AUTHOR]

Summary: Introduction: There is uncertainty about the optimal videolaryngoscope for awake tracheal intubation in patients with anticipated difficult airway. The use of channelled and unchannelled videolaryngoscopy has been reported, but there is a lack of evidence on which is the best option. Methods: We conducted a randomised clinical trial to compare the efficacy of the C‐MAC D‐Blade® vs. Airtraq® in adult patients (aged ≥ 18 y) scheduled for elective or emergency surgery under general anaesthesia with anticipated difficult airway who required awake tracheal intubation under local anaesthesia and conscious sedation. The primary endpoint was the first‐attempt tracheal intubation success rate. Secondary outcomes included the overall success rate; number of tracheal intubation attempts; Cormack and Lehane glottic view; level of difficulty (visual analogue score); patient discomfort (visual analogue score); and incidence of complications. Results: Ninety patients (70/90 male (78%); mean (SD) age 65 (12) y) with anticipated difficult airways were randomly allocated to C‐MAC D‐Blade or Airtraq videolaryngoscopy. First‐attempt successful tracheal intubation rate was higher in patients allocated to the C‐MAC D‐Blade group compared with those allocated to the Airtraq group (38/45 (84%) vs. 28/45 (62%), respectively; p = 0.006). The proportion of patients' tracheas that were intubated at the second and third attempt was 4/45 (9%) and 3/45 (7%) in those allocated to the C‐MAC D‐Blade group compared with 14/45 (31%) and 1/45 (2%) in those allocated to the Airtraq group (p = 0.006). There was no significant difference in overall tracheal intubation success rate (C‐MAC D‐Blade group 45/45 (100%) vs. Airtraq group 43/45 (96%), p = 0.494). Discussion: In patients with anticipated difficult airway, first‐attempt awake tracheal intubation success rate was higher with the C‐MAC D‐Blade compared with Airtraq laryngoscopy. No difference was found between the two videolaryngoscopes in overall tracheal intubation success rate. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to assess the impact of positive‐end‐expiratory pressure (PEEP) on the non‐hypoxic apnea time in infants during anesthesia induction with an inspired oxygen fraction of 0.8. Methods: This age stratified randomized controlled trial included patients under 1 year of age. Preoxygenation was performed using an inspired oxygen fraction of 0.8 for 2 min. Inspired oxygen fraction of 0.8 was administered via a face mask with volume‐controlled ventilation at a tidal volume of 6 mL.kg−1, with or without 7 cmH2O of PEEP. Tracheal intubation was performed after 3 min of ventilation; however, it was disconnected from the breathing circuit. Ventilation was resumed once the pulse oximetry readings reached 95%. The primary outcome was the non‐hypoxic apnea time, defined as the time from the cessation of ventilation to achieving a pulse oximeter reading of 95%. The secondary outcome measures included the degree of atelectasis assessed by ultrasonography and the presence of gastric air insufflation. Results: Eighty‐four patients were included in the final analysis. In the positive end‐expiratory pressure group, the atelectasis score decreased (17.0 vs. 31.5, p <.001; mean difference and 95% CI of 11.6, 7.5–15.6), while the non‐hypoxic apnea time increased (80.1 s vs. 70.6 s, p =.005; mean difference and 95% CI of −9.4, −16.0 to −2.9), compared to the zero end‐expiratory pressure group, among infants who are 6 months old or younger, not in those aged older than 6 months. Discussion: The application of positive end‐expiratory pressure reduced the incidence of atelectasis and extended the non‐hypoxic apnea time in infants who are 6 months old or younger. However, it did not affect the incidence of atelectasis nor the non‐hypoxic apnea time in patients aged older than 6 months. [ABSTRACT FROM AUTHOR]

BACKGROUND: This study sought to estimate the overall cumulative incidence and odds of Hospital-acquired venous thromboembolism (VTE) among critically ill children with and without exposure to invasive ventilation. In doing so, we also aimed to describe the temporal relationship between invasive ventilation and hospital-acquired VTE development. METHODS: We performed a retrospective cohort study using Virtual Pediatric Systems (VPS) data from 142 North American pediatric ICUs among children < 18 y of age from January 1, 2016-December 31, 2022. After exclusion criteria were applied, cohorts were identified by presence of invasive ventilation exposure. The primary outcome was cumulative incidence of hospital-acquired VTE, defined as limb/neck deep venous thrombosis or pulmonary embolism. Multivariate logistic regression was used to determine whether invasive ventilation was an independent risk factor for hospital-acquired VTE development. RESULTS: Of 691,118 children studied, 86,922 (12.4%) underwent invasive ventilation. The cumulative incidence of hospital-acquired VTE for those who received invasive ventilation was 1.9% and 0.12% for those who did not (P < .001). The median time to hospital-acquired VTE after endotracheal intubation was 6 (interquartile range 3-14) d. In multivariate models, invasive ventilation exposure and duration were each independently associated with development of hospital-acquired VTE (adjusted odds ratio 1.64 [95% CI 1.42-1.86], P < .001; and adjusted odds ratio 1.03 [95% CI 1.02-1.03], P < .001, respectively). CONCLUSIONS: In this multi-center retrospective review from the VPS registry, invasive ventilation exposure and duration were independent risk factors for hospital-acquired VTE among critically ill children. Children undergoing invasive ventilation represent an important target population for risk-stratified thromboprophylaxis trials. [ABSTRACT FROM AUTHOR]

Summary Background Methods Results Conclusions Different sedation regimens have been used to facilitate awake tracheal intubation, but the evidence has not been synthesised robustly, particularly with respect to clinically important outcomes. We conducted a systematic review and network meta‐analysis to determine the sedation techniques most likely to be associated with successful tracheal intubation, a shorter time to successful intubation and a lower risk of arterial oxygen desaturation.We searched for randomised controlled trials of patients undergoing awake tracheal intubation for any indication and reporting: overall tracheal intubation success rate; tracheal intubation time; incidence of arterial oxygen desaturation; and other related outcomes. We performed a frequentist network meta‐analysis for these outcomes if two or more sedation regimens were compared between included trials. We also performed a sensitivity analysis excluding trials with a high risk of bias.In total, 48 studies with 2837 patients comparing 33 different regimens were included. Comparing overall awake tracheal intubation success rates (38 studies, 2139 patients), there was no evidence suggesting that any individual sedation regimen was superior. Comparing times to successful tracheal intubation (1745 patients, 24 studies), any sedation strategy was superior to placebo. When we excluded trials with a high risk of bias, we found no evidence of a difference between any interventions for time to successful tracheal intubation. Thirty‐one studies (1753 patients) suggested that dexmedetomidine and magnesium sulphate were associated with a reduced risk of arterial oxygen desaturation compared with other interventions, but excluding trials with a high risk of bias suggested no relevant differences between interventions. The quality of evidence for each of our outcomes was low.To maximise effective and safe awake tracheal intubation, optimising oxygenation, topical airway anaesthesia and procedural performance may have more impact than any given sedation regimen. [ABSTRACT FROM AUTHOR]

Background: The significance of computed tomography (CT)-based volume measurement of the inferior vena cava (IVC) in the treatment and prognosis of trauma patients is not yet fully understood. The conflicting results that have been reported may be attributable to differences in injury severity and the use of different measurement methods, including IVC index and volumetry. The purpose of this study was to determine the relationship between IVC volume and red blood cell (RBC) transfusion and mortality in intubated trauma patients who were stable enough for initial CT imaging. Methods: A retrospective analysis was conducted on all consecutive trauma patients who underwent emergency tracheal intubation and mechanical ventilation before initial whole-body CT imaging at a level-1 trauma center over a 12-year period (2008–2019). The IVC volume was determined on initial trauma CT and included in multivariable models with demographic and diagnostic data. Associations of overall RBC transfusion, massive transfusion, 24-h mortality, and 30-day mortality were assessed using logistic regression analyses and Cox proportional hazard models. Results: A total of 438 patients (75.3% male) with a median age of 50 years, and a median injury severity score (ISS) of 26 points were included in the analysis. Most of the patients (97.5%) had suffered from blunt trauma mechanisms. Median IVC volume was 36.25 cm3, and RBC transfusion and massive transfusion were performed in 197 and 90 patients, respectively. The 24-h and 30-day mortality rates were 7.3% and 23.3%, respectively. VCI volume was found to be independently associated with the necessity of RBC transfusion and 24-h mortality (OR 0.98, 95% CI 0.96–0.99, p = 0.01 and HR 0.96, 95% CI 0.93–0.99, p = 0.025, respectively), while associations with massive transfusion and 30-day mortality were not statistically significant in multivariable analyses. Conclusion: Initial IVC volume may serve as a predictor of patients at risk for overall RBC transfusion requirements and 24-h mortality, suggesting the possibility of its diagnostic efficacy in short-term outcomes. Further studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Objective: To assess the efficacy and safety of visual rigid laryngoscopy and video laryngoscopy and to provide clinical information for developing a more suitable intubation tool for elderly patients. Methods: In 75 consecutive elderly patients undergoing elective surgery in a single institution, tracheal intubation was randomly performed by 2 experienced anaesthesiologists using visual rigid laryngoscopy (Group I, n = 38) or video laryngoscopy (Group II, n = 37). The primary outcome was intubation time. Secondary outcomes were the first-attempt success rate of tracheal intubation, haemodynamic responses at 1, 3, and 5 min after intubation and the incidence of postoperative airway complications, including immediate complications and postoperative complaints. Results: The intubation times were 35.0 (30.0–41.5) s and 42.5 (38.0–51.3) s in Groups I and II, respectively (P < 0.001). The difference in direct complications between the two groups was statistically significant (P < 0.05). In contrast, there was no significant difference between the two groups regarding the follow-up of the main complaint 30 min and 24 h after tracheal extubation (P > 0.05). There was no difference in the intubation success rate between the 2 groups (P > 0.05). The haemodynamic responses at 1, 3, and 5 min after intubation were not significantly different (P > 0.05). Conclusion: Compared with that of video laryngoscopy, the intubation time of visual rigid laryngoscopy in elderly patients was shorter. At the same time, visual rigid laryngoscopy reduced the incidence of immediate complications. However, during endotracheal intubation, there was no significant difference in haemodynamics between the two groups. Clinical trial registration number: ChiCTR2100054174. [ABSTRACT FROM AUTHOR]

Background: Pulse oximetry is a standart of anesthesia for perioperative monitoring. Due to the principles of Hb oxygen dissociation curve, peripheral oxygen saturation has an approximate sensitivity and specificity of 90% for the detection of hypoxemia. Objectives: The primary outcome of the study was to evaluate ORiⓇ as an early parameter to determine hypoxia in morbidly obese patients. The secondary outcome was to compare the effectiveness of ORiⓇ with SpO2 in non-obese patients. Design: Prospective, observational study. Setting: Department of elective operating room at tertiary hospital. Patients and methods: Observational study included written informed consent from 51 patients with 19 < BMI < 25 kg/m2 and 51 patients with BMI > 40 kg/m2 undergoing an elective surgery requiring tracheal intubation. In addition to standard monitors, an ORi sensor was placed and baseline values were recorded. The patients were preoxygenated until end tidal expiratory oxygen concentration is reached to 90%. After anesthesia induction and tracheal intubation, the breathing circuit was not connected tracheal tube until the SpO2 decreased to 95%. Shapiro-Wilk, Pearson Chi-square, t-test, and Mann Whitney U test were used for the study. Main outcome measures: Times of tolerable apnea, ORiⓇ and SpO2 values at the end of preoxygenation, beginning of intubation, beginning of the ORi alarm, when SpO2 reached 95%, and when ORi reaches a plateau. Sample size: 102 patients. Results: The alert period: time to reach ORiⓇ from 0.24 to a value of 95% SpO2 was observed as 32 s in morbidly obese patients and 94 s in patients with a normal body mass index. The SpO2 alert period was determined as time difference between 97% and 95% SpO2. The data were recorded as 15 s and 36 s, respectively. It was observed that tolerable apnea, ORiⓇ, SpO2 and added alert times were longer in patients with normal BMI compared to morbidly obese patients. Conclusions: As a result, ORiⓇ can provide an early warning to prevent unexpected hypoxia before saturation begins to decrease in morbidly obese patients. Limitations: Inability to perform arterial blood gas sampling in the time periods when we looked at the parameters to determine the relationship between ORiⓇ and PaO2. Clinical trials. gov identifier: NCT05480748 registered 2022-07-29. [ABSTRACT FROM AUTHOR]

Diquat poisoning is a fatal condition that is becoming increasingly common. The mortality risk of patients taking lethal doses of diquat is extremely high. It typically leads to rapid dysfunction of multiple organs, including the kidneys, heart, lungs, and brain. Acute kidney injury is usually the first manifestation of this poisoning. However, the optimal treatment strategy for diquat poisoning remains uncertain. Additionally, the mechanism of multiple organ dysfunction syndrome caused by diquat poisoning may resemble the progression of sepsis. In this report, we present 3 cases of diquat poisoning, all of which resulted in death. We emphasize that acute kidney injury is the primary cause of death, and suggest that some strategies used in the treatment of sepsis could be beneficial in managing diquat poisoning-induced acute kidney injury. [ABSTRACT FROM AUTHOR]

Various anaesthetic agents and agents acting on the sympathetic system have been used to attenuate this sympathetic response to direct laryngoscopy and tracheal intubation, such as opioids, calcium channel blockers, local anaesthetics, beta-blockers, magnesium sulphate, dexmedetomidine, esmolol etc. The study involves the patients undergoing laparoscopic surgeries of the age group between 15 to 50 years. Informed written consent was taken from the patients of age 18 to 50 years and for those between 15 to 18 years, assent from the patient and informed written consent from the parents/guardian was obtained. All the patients were assessed preoperatively with history, clinical examination and required investigations. There was significant decrease in MAP observed upto 5 minutes after laryngoscopy and intubation in group E and MAP reached to baseline by 10th minute in group E. When compared to group D, MAP was maintained below the baseline which was seen statistically significant with the P value (<0.001) throughout the study period. [ABSTRACT FROM AUTHOR]

A powerful noxious stimulus like laryngoscopy and tracheal intubation induces hypothalamic activity and results in an increased outflow in the sympathetic tracts. Consequently norepinephrine is released by post ganglionic sympathetic fibers and increased secretion from adrenal medulla. Attempts have been made to assess sympathetic activity directly by measurement of plasma catecholamine concentrations with the use of radio enzymatic assays and high pressure liquid chromatography, by various workers. The study involves the patients undergoing laparoscopic surgeries of the age group between 15 to 50 years. Informed written consent was taken from the patients of age 18 to 50 years and for those between 15 to 18 years, assent from the patient and informed written consent from the parents/guardian was obtained. All the patients were assessed preoperatively with history, clinical examination and required investigations. There was significant increase in the mean HR observed at 5th, 10th and 15th minute after laryngoscopy and intubation in group E and the heart rate reached the basal value by 5th minute in group E. When compared to group D, mean HR was maintained below the baseline which was seen statistically significant with the P value (<0.001) throughout the study period. [ABSTRACT FROM AUTHOR]

Introduction: surgical procedures can lead to severe anxiety and stress in patients scheduled for surgery. Anxiety can cause stimulation leads to cardiovascular changes. Use of certain drugs like GABA mimetic like gabapentin are effective in control of anxiety. This will cause decrease in the level of cathacolamine release from adrenal gland cremafinn cell. Aims and objectives: To assess the level of the anxiety of the patient, to assess the level of the sedation levels of the patients, and to assess the hemodynamic responses produced by the body of the patients. Material and methods: This Prospective - Randomized study was conducted in the Anaesthesia Department in Rama Medical College Hospital and research centre, Kanpur from 25TH AUGUST 2022 TO 25TH MARCH 2024. The study was done on 120 patients who participated in the study. The samples were divided into two groups, 60 in each group, Group C (received clonidine) and Group G (received Gabapentin). Baseline vital signs such blood pressure, pulse rate, respiration rate, and oxygen saturation were recorded and these were recorded again after the intubation. Result: Anxiety score was significantly better in clonidine (group C) as compared with gabapentin (group G). Patient who received Gabapentin have more raise in SPO2 level than clonidine. Oral Gabapentin attenuated increase in heart rate, SPO2 and MAP than oral gabapentin. Conclusion: showed that oral clonidine can be used safely and efficiently to obtund the hemodynamic alterations related with laryngoscopy and endotracheal intubation. It was discovered that clonidine was more successful than gabapentin at reducing hemodynamic reactions to the procedures of intubation and laryngoscopy. [ABSTRACT FROM AUTHOR]

Introduction: Difficult intubation presents a significant challenge for anaesthesiologists, particularly when it is unexpected. Early recognition of a difficult airway through preoperative assessment is crucial to prevent potential complications associated with airway management failure. This study primarily aims to correlate the Mallampati modified score with the laryngoscopic view to enhance the prediction of difficult airways. Materials and Methods: This study included 80 adult patients, aged 18-75 years, of either sex and classified as ASA Class I and II, all requiring endotracheal intubation. Preoperative airway assessment was performed using the Modified Mallampati test, and the results were correlated with laryngoscopic grading based on the Cormack-Lehane classification. Statistical analysis was conducted using the Chi-square test and Kappa statistics. Results: The study found that 10% of the cases predicted to be easy intubations were actually difficult. Conversely, no difficult intubations were predicted as difficult in advance. Additionally, 10% of the cases that were predicted to be difficult intubations turned out to be easy. Conclusion: The Mallampati classification did not exhibit a grade-to-grade correlation with the Cormack-Lehane grading during direct laryngoscopy, indicating limitations in its predictive accuracy for difficult intubation. [ABSTRACT FROM AUTHOR]

Background: and Aim of study: Endotracheal intubation in pediatric patients might be challenging due to anatomical variances. One problem is selecting the appropriate size of endotracheal tube for intubation (1). Choosing the right Endotracheal tube size is crucial, especially for young patients. Using an incorrectly sized ETT can have serious consequences, including death. Various methods are used to estimate correct ETT size based on patient demographics, such as age, weight, and height. Some anesthesiologists use the diameter of the little finger for crude estimation. However, these methods have poor agreement with the actual ETT size appropriate for the patient. This study evaluated the efficacy of ultrasonographic assessment of ETT size to the usual age-based calculation. Material and Method: This cross sectional randomised study was done on 72 patients undergoing elective procedures at the Department of Anaesthesiology, Integral Institute of Medical Sciences, Lucknow, between September 2022 and March 2024, after institutional ethics committee permission. Patients were separated into two groups of 36 each. Group A's ETT size was approximated using Pennington's method. Group B where ETT size was assessed by ultrasonography. The results were evaluated using descriptive statistics and compared between groups. Categorical data were summarized as proportions and percentages (%), whereas discrete data were reported as mean ± SD. Results: Insertion of ETT estimated by ultrasound had greater rate of successful insertion in first attempt, easy insertion and less postoperative complications when compared to ETT size estimated by Penlington's formula. [ABSTRACT FROM AUTHOR]

We present a 60‐year‐old maintenance hemodialysis patient who initially presented with neck swelling, which was diagnosed as a thyroid issue. Following a hemodialysis session, the swelling in the neck progressively enlarged, leading to respiratory distress and eventual cardiac arrest. During a life‐saving tracheotomy, dark red blood was observed, and endotracheal intubation was urgently performed. Subsequent computed tomography examination identified multiple areas of slight high‐density images in the nasopharyngeal cavity, oropharyngeal cavity, and esophagus. As time passed, the patient's hematoma underwent spontaneous absorption, but signs of recovery were absent. We discuss the rarity, etiology, diagnosis, and management of spontaneous neck hematoma in maintenance hemodialysis patients. [ABSTRACT FROM AUTHOR]

Modern medical training consists largely of lecture‐based instruction and in vivo or video modeling of specific skills. Other instructional methods, such as teaching with acoustical guidance (TAGteach), have rarely been evaluated. In this study, we compared teaching with tactile guidance, or tactile TAGteach in which a vibratory stimulus is delivered to indicate a correct response, with video modeling and self‐evaluative video feedback to teach four participants two medical skills: simple interrupted suture and endotracheal intubation. The results showed that both instructional methods improved performance. However, three participants met the mastery criterion in the tactile TAGteach condition first, although this instructional method required more time to train the skills. We discuss the implications of these findings for training skills to medical practitioners. [ABSTRACT FROM AUTHOR]

Background/Objectives: Airway management techniques, including mask ventilation and tracheal intubation, are vital across medical settings. However, these procedures can be challenging, especially when environmental conditions are less than ideal. This study explores how the height of the operating table affects the difficulty of anesthesia techniques involving mask ventilation and tracheal intubation. Methods: Twenty anesthesiologists participated in this study. We assessed the difficulty of procedures such as mask ventilation, Macintosh laryngoscopy, and video laryngoscopy using McGRATH and AWS, on a four-level scale. The operating table's height was adjusted at four points: the operator's umbilicus, the inferior margin of the 12th rib, the xiphoid process, and the nipple. Results: Mask ventilation was easiest at the operating table's height aligned with the inferior margin of the 12th rib. Conversely, direct laryngoscopic exposure was perceived as easier at higher table heights, with nipple height being optimal. The McGRATH laryngoscopy showed consistent difficulty across table heights, whereas the AWS tended to be somewhat more difficult at greater heights. Conclusions: The optimal bed height for video laryngoscopy coincided with that for mask ventilation. Video laryngoscopy offers enhanced flexibility in optimal patient positioning compared to Macintosh laryngoscopy, contributing to its advantages in tracheal intubation procedures. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to conduct a retrospective study to identify inflammatory biomarkers for predicting ventilator‐associated pneumonia in elderly patients. Methods: Our retrospective study included 265 elderly patients (age ≥60 years) undergoing abdominal surgery with tracheal intubation and general anesthesia, with 93 experiencing varying degrees of ventilator‐associated pneumonia during hospitalization, and 172 without. Serum concentrations of serum amyloid A (SAA), toll‐like receptor 4 (TLR4), and soluble myeloid triggering receptor 1 (sTREM‐1) were measured at 24 h post‐operation using enzyme‐linked immunosorbent assay. Comparisons of SAA, TLR4, and sTREM‐1 and other risk factors at 24 h post‐operation between elderly patients with and without ventilator‐associated pneumonia were performed. Results: The study revealed a 35.1% incidence of postoperative ventilator‐associated pneumonia among elderly patients. Upregulations of SAA, TLR4, and sTREM‐1 were observed in patients with ventilator‐associated pneumonia. Chronic obstructive pulmonary disease, smoking, and tracheal intubation were identified as independent risk factors. The joint prediction model was demonstrated with superior predictive accuracy (area under the curve = 0.89) compared to individual biomarkers. Correlations with procalcitonin further supported the predictive potential of SAA, TLR4, and sTREM‐1 in an inflammatory response. Conclusions: SAA, TLR4, and sTREM‐1, particularly when combined, serve as valuable prognostic indicators for postoperative ventilator‐associated pneumonia in elderly patients undergoing abdominal surgery with tracheal intubation and general anesthesia. The joint prediction model offered a promising tool for early risk assessment. [ABSTRACT FROM AUTHOR]

Aims: Establishing a nomogram to estimate the probability of oral mucosal membrane pressure injury of endotracheal tube‐intubated hospitalized patients in intensive care unit. Design: Multicentre prospective cohort study. Methods: Using Lasso regression and COX regression, variable selection was performed on demographic, clinical and laboratory data of 1037 ICU endotracheal tube‐intubated hospitalized patients from West China Hospital, to construct a nomogram. External validation was conducted on 484 ICU endotracheal tube‐intubated patients from People's Hospital of Zhongjiang County. Results: Among 38 potential predictors, five variables emerged as independent predictors, integrated into the nomogram: administration of antibiotics, nutritional therapy duration, agitation, hypotension and albumin levels. Conclusions: We established a nomogram based on the hospital characteristics of ICU endotracheal tube‐intubated patients, aiding in the prediction of the occurrence of oral mucosal membrane pressure injury. Reporting Method: The study followed TRIPOD guidelines. Relevance to Clinical Practice: The nomogram we developed can assist clinical worker in better identifying at‐risk patients and risk factors. It enables the implementation of evidence‐based nursing interventions in care to prevent the development of oral mucosal membrane pressure injury. Trial registration: The study has been registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn) under registration number ChiCTR2200056615. [ABSTRACT FROM AUTHOR]

Purpose: Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA). Methods: An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician–researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Results: The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care. Conclusion: Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties. [ABSTRACT FROM AUTHOR]

Background: The ramped position facilitates mask ventilation and endotracheal intubation in patients with obesity. This study aimed to determine whether the ramped position improves supraglottic airway (SGA) insertion in patients with obesity. Methods: In this prospective, randomized, single-center trial, 48 obese patients undergoing elective surgery were randomized into either ramped or sniffing position groups. The Ambu® AuraGainTM (Ambu A/S), a second-generation SGA, was used. The primary outcome was the time required for the AuraGain insertion. Secondary outcomes included ease and number of insertion attempts, oropharyngeal leak pressure (OLP), and complications. The number needed to treat (NNT) was calculated to ensure ease of insertion. Results: The time required for the AuraGain insertion was significantly shorter in the ramped group than in the sniffing group (13.0 [11.0, 16.0] vs. 24.0 [21.0, 28.0], P < 0.001). The insertion was easier in the ramped group than in the sniffing group (23/24 vs. 13/24, NNT = 2.4 [95% CI, 1.6, 5.0], P = 0.003). The first-attempt success rate was higher in the ramped group than in the sniffing group, although the difference was not statistically significant (22/24 vs. 18/24, P = 0.319). The OLP and postoperative complication rates were not significantly different between the groups. Conclusions: The ramped position reduced the time required for the AuraGain insertion in obese patients while providing comparable airway sealing without increasing adverse events. Therefore, a ramped position may be a more suitable option for SGA insertion in this population. [ABSTRACT FROM AUTHOR]

Objective: In this study, we investigated the safety and practicability of ultra‐fast track anesthesia (UFTA) for endoscopic thoracic sympathectomy (ETS). Methods: A total of 72 patients with palmar hyperhidrosis undergoing ETS were randomly divided into three groups: the UFTA group (group I), the group undergoing single‐lumen tracheal intubation with local infiltration anesthesia technique (group II), and the group undergoing single‐lumen tracheal intubation with routine anesthesia (group III). Mean arterial pressure (MAP) and heart rate (HR) were recorded for all three groups at the following six time points: Before anesthetics administration (T0), the time of intubating or inserting laryngeal mask airway (T1), the time of incising skin (T2), the time of disconnecting of the right sympathetic nerve (T3), the time of disconnecting of the left sympathetic nerve (T4), the time of withdrawing the tracheal tube or laryngeal mask airway (T5), and the time of transferring the patient to a post‐anesthesia care unit (PACU) (T6). The three groups were compared from the following perspectives: surgery duration; anesthesia recovery duration, that is, the duration from discontinuation of anesthesia to extubating the tracheal tube; the dose of propofol and remifentanil per kilogram body mass per unit time interval (the time at the end of the procedure, which lasted from anesthesia induction to incision suturing); and the visual analog scale (VAS) in the resting state in the PACU. Results: Based on pairwise comparisons, the average HR and average MAP values of the three groups differed significantly from T2 to T6 (p < 0.05). As demonstrated by the correlation analysis between remifentanil and propofol with HR and MAP, the doses of the total amount of remifentanil and propofol were lower, and group I used less remifentanil and propofol than group II. No patient in group I experienced throat discomfort following surgery. Patients in groups II and III experienced a range of postoperative discomfort. The VAS scores of groups I and II were significantly lower than those of group III, with group I lower than group II. Conclusion: When utilized in ETS, UFTA can provide effective anesthesia for minor traumas. It is safe, effective, and consistent with the enhanced recovery philosophy of fast‐track surgery departments. [ABSTRACT FROM AUTHOR]

Purpose: This study was performed to evaluate the changes in oxygen supply–demand balance during induction of general anesthesia using an indirect calorimeter capable of measuring oxygen consumption (VO2) and carbon dioxide production (VCO2). Methods: This study included patients scheduled for surgery in whom remimazolam was administered as a general anesthetic. VO2 and VCO2 were measured at different intervals: upon awakening (T1), 15 min after tracheal intubation (T2), and 1 h after T2 (T3). Oxygen delivery (DO2) was calculated simultaneously with these measurements. VO2 was ascertained using an indirect calorimeter and further calculated using vital signs, among other factors. DO2 was derived from cardiac output and arterial blood gas analysis performed with an arterial pressure-based cardiac output measurement system. Results: VO2, VCO2, and DO2 decreased significantly from T1 to T2 and T3 [VO2/body surface area (BSA) (ml/min/m2): T1, 130 (122–146); T2, 107 (83–139); T3, 97 (93–121); p = 0.011], [VCO2/BSA (ml/min/m2): T1, 115 (105–129); T2, 90 (71–107); T3, 81 (69–101); p = 0.011], [DO2/BSA (ml/min/m2): T1, 467 (395–582); T2, 347 (286–392); T3, 382 (238–414); p = 0.0020]. Among the study subjects, a subset exhibited minimal reduction in VCO2. Although the respiratory frequency was titrated on the basis of end-tidal CO2 levels, there was no significant difference between the groups. Conclusion: General anesthetic induction with remimazolam decreased VO2, VCO2, and DO2. [ABSTRACT FROM AUTHOR]

Summary: Background: Tracheal tube introducers are recommended in airway management guidelines and are used increasingly as videolaryngoscopy becomes more widespread. This systematic review aimed to summarise the published literature concerning tracheal tube introducer‐associated airway trauma. Methods: PubMed, EMBASE and CINAHL databases were searched using pre‐determined criteria. Two authors independently assessed search results and performed data extraction and risk of bias assessments. Results: We included 16 randomised controlled trials and five observational studies involving 10,797 patients. There was heterogeneity in patient characteristics, airway manipulation, and airway trauma definition and measurement. One study investigated hyperangulated videolaryngoscopy. The standard stylet was the most commonly reported introducer, followed by bougie and stylets with additional features such as video or lighted tip. Airway trauma resulted in low harm and most frequently involved injuries to the upper airway, followed by laryngeal and tracheobronchial injuries. Eighteen studies were comparative and reported a reduction in airway trauma incidence when an introducer was used, with the exception of the standard stylet. Median (IQR [range]) pooled incidence of airway trauma associated with standard stylets was 13.1% (4.2–31.4 [0.5–79.2])% and with bougies was 5.4% (0.4–49.9 [0.0–68.0])%. The risk of bias of included studies was variable and many randomised trials were found to be at high risk due to non‐robust measurement of the outcome. Conclusions: Stylets might be associated with an increased risk of airway trauma compared with other devices or when no stylet was used, though the quality of evidence is modest. However, other introducers appear to be safe and reduce the risk of airway trauma. [ABSTRACT FROM AUTHOR]

Tracheal tube introducers are commonly used by anaesthetists for airway management, especially in difficult cases. They are recommended in airway management guidelines and should be readily available in operating theatres, intensive care units, and emergency departments. Tracheal tube introducers are particularly useful with videolaryngoscopy, aiding in directing the tracheal tube tip towards the glottis. A systematic review of airway trauma associated with tracheal tube introducers found that the standard stylet was the most common introducer and had a higher incidence of airway injury compared to other introducers. However, the review had limitations in terms of study heterogeneity and risk of bias. The use of tracheal tube introducers should be considered thoughtfully, and further research is needed to compare different introducer devices and assess the frequency and severity of airway trauma. [Extracted from the article]

Summary: Background: Although videolaryngoscopy has been proposed as a default technique for tracheal intubation in children, published evidence on universal videolaryngoscopy implementation programmes is scarce. We aimed to determine if universal, first‐choice videolaryngoscopy reduces the incidence of restricted glottic views and to determine the diagnostic performance of the Cormack and Lehane classification to discriminate between easy and difficult videolaryngoscopic tracheal intubations in children. Methods: We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C‐MAC™ (Karl Storz, Tuttlingen, Germany) videolaryngoscopes in all anaesthetised children undergoing elective tracheal intubation for surgical procedures. The direct and videolaryngoscopic glottic views were classified using a six‐stage grading system. Results: There were 904 tracheal intubations in 809 children over a 16‐month period. First attempt and overall success occurred in 607 (67%) and 903 (> 99%) tracheal intubations, respectively. Difficult videolaryngoscopic tracheal intubation occurred in 47 (5%) and airway‐related adverse events in 42 (5%) tracheal intubations. Direct glottic view during laryngoscopy was restricted in 117 (13%) and the videolaryngoscopic view in 32 (4%) tracheal intubations (p < 0.001). Videolaryngoscopy improved the glottic view in 57/69 (83%) tracheal intubations where the vocal cords were only just visible, and in 44/48 (92%) where the vocal cords were not visible by direct view. The Cormack and Lehane classification discriminated poorly between easy and difficult videolaryngoscopic tracheal intubations with a mean area under the receiver operating characteristic curve of 0.68 (95%CI 0.59–0.78) for the videolaryngoscopic view compared with 0.80 (95%CI 0.73–0.87) for the direct glottic view during laryngoscopy (p = 0.005). Conclusions: Universal, first‐choice videolaryngoscopy reduced substantially the incidence of restricted glottic views. The Cormack and Lehane classification was not a useful tool for grading videolaryngoscopic tracheal intubation in children. [ABSTRACT FROM AUTHOR]

Background and Aims: Antipsychotic drugs are critical in managing psychosis but they also carry risks when misused, leading to toxicity. Case Presentation: A patient overdosed on olanzapine, resulting in anticholinergic toxidrome with symptoms like tachycardia and altered mental status. Immediate recognition and management of antipsychotic toxicity-induced toxidromes in emergency settings are crucial. Treatment strategy includes maintaining airway, breathing and circulation along with decontamination. There is no specific antidote. Conclusion: This case underscores the need for emergency physicians to remain vigilant and proactive in identifying and addressing such toxicity by identification of toxidromes to prevent complications and missed diagnosis in emergency department. [ABSTRACT FROM AUTHOR]

Background: Laryngoscopy is a diagnostic procedure utilized in critical care to examine and visualize the larynx through the diversion of upper airway structures. Its primary functions are airway management and tracheal intubation. The objective of this study was to detect the predictors of laryngeal exposure during microlaryngeal surgery (MLS). Methods: An analytical cross-sectional study was conducted on a consecutive sample of 100 patients presenting laryngeal lesions that were trans-orally microsurgeries to treat various glottic diseases (biopsies revealed 68% benign lesions such as vocal fold polyps, cysts, and nodules, and 32% glottic masses) and prepared for MLS. Results: This study included 100 patients presenting laryngeal lesions from both sexes with the age of 47.0 ± 14.7 years, in multivariate logistic regression analysis, all these parameters were significant predictors for Cormack–Lehane and Italian Grading (P < 0.05). Body mass index (BMI) (OR = 3.449, 95% CI = 2.463–8.187), mandibular protrusion test (OR = 2.981, 95% CI = 1.922–4.044), mento-sternal length (OR = 3.722, 95% CI = 1.980–7.794), and atlanto-occipital joint (AOJ) extension (OR = 1.572, 95% CI = 1.865–4.263). Cormack–Lehane and Italian Grading was significantly associated with BMI, mandibular protrusion test, Mallampati Index, mento-thyroid, mento-sternal length, and AOJ extension, it increased with BMI of > 35, with more protruded mandible (class C), higher Mallampati Index (class III) and shorter mento-sternal distance (≤ 12.5 cm). Conclusions: During microlaryngeal surgery, BMI, mandibular protrusion test, Mallampati Index, mento sternal and AOJ extension were significant predictors of Cormack–Lehane and Italian Grading which makes it easier for laryngeal exposure. [ABSTRACT FROM AUTHOR]

Purpose: To measure the prevalence of speech-language pathologist (SLP) involvement and associated trends for critically ill children in United States (US) paediatric intensive care units (PICU) through secondary analysis of the Prevalence of Acute Rehab for Kids in the PICU (PARK-PICU) study data. Method: A secondary analysis of cross-sectional point prevalence study conducted over 1 day in 82 US PICUs. Data collected included SLP presence, patients' age, length of stay, medical interventions, aetiology, admission data, Glasgow Coma Scale scores, staffing involvement, and family presence. Result: Among 961 patients, 82 were visited by an SLP on the study day for a prevalence of 8.5%. Most visits were for children <3 years old. The odds of SLP involvement were lower for children who were 7–12 years old (vs. age 0–2; adjusted odds ratio [aOR] 0.28; 95% CI 0.1–0.8), were mechanically ventilated via endotracheal tube (vs. room air; aOR 0.02; 95% CI 0.005–0.11), or had mild or severe disability (mild vs. no disability; aOR 0.34; 95% CI 0.16–0.76 and severe vs. no disability; aOR 0.39; 95% CI 0.17–0.90). Concurrent physical and/or occupational therapy involvement was associated with higher odds of SLP involvement (aOR 3.6; 95% CI 2.1–6.4). Conclusion: SLP involvement is infrequent in US PICUs. PICU teams should be educated about the scope of SLP practice, to support communication and oral feeding needs during early recovery from critical illness. [ABSTRACT FROM AUTHOR]

Summary Introduction Methods Results Conclusions Flexible bronchoscopes have become essential in the operating theatre environment and in critical care. This narrative review compared single‐use and reusable flexible bronchoscopes with a focus on safety, efficacy, cost‐effectiveness and environmental impact.We searched MEDLINE, Embase and PubMed databases for studies related to flexible bronchoscopes for airway management or use in critical care. Human or animal studies of any design assessing single‐use and reusable flexible bronchoscopes were included and qualitatively synthesised. We also searched manufacturer websites for relevant data.We included 52 studies and data from six manufacturer websites. There was mixed evidence for safety, and data on usability also showed significant heterogeneity, with different parameters, manufacturers and models examined. Neither single‐use nor reusable flexible bronchoscopes appeared convincingly superior to the other for safety or usability. Cost analyses showed that the rate of use of flexible bronchoscopes per year, along with several other factors, affects cost‐effectiveness for each institution, though the risk of cross‐contamination is an advantage of single‐use devices. However, sufficient evidence on the rate of bronchoscopy‐induced infection in the operating theatre and critical care environment is lacking. Due to the risk of cross‐contamination, single‐use flexible bronchoscopes must be sterilised or incinerated after use, and completely recyclable single‐use models are not currently available.Further research is required on safety, usability and life cycle assessment in the operating theatre and critical care environment, as well as on the rate of bronchoscopy‐induced infection. Future comparative studies, including new manufacturers and designs, may lend further insights. [ABSTRACT FROM AUTHOR]

Background: To discuss whether decreasing the pressure of endotracheal tube cuff slowly with a constant speed can decrease the incidence of coughing during extubation. Methods: Ninety patients undergoing elective noncardiac surgery under general anesthesia with endotracheal intubation were randomly divided into two groups: group P, the pilot balloon was connected to a syringe and an aneroid manometer through a three-way stopcock, respectively, and the decrease of cuff pressure was controlled at 3 cmH2O/s during deflating before extubation; group C, the pressure in endotracheal tube cuff was decreased suddenly with a syringe extracting the air from the cuff rapidly at once exactly before extubation. The incidence of coughing during extubation period was recorded. Mean arterial pressure (MAP) and heart rate (HR) were recorded before general anesthesia induction (T0), just before cuff deflation (T1), immediately after deflation (T2), at 1 min (T3), 3 min (T4), and 5 min after extubation (T5). The occurrence of adverse reactions was also recorded. Results: The initiation of coughing during extubation period occurs at immediately the time of balloon deflation. Compared with group C, the incidence of coughing was significantly decreased (P = 0.001), MAP and HR were significantly decreased at T2-T4 and T2-T5, respectively (P < 0.05 for all), and the incidence of pharyngolaryngeal discomfort after extubation was significantly reduced (P = 0.021) in group P. Conclusions: Decreasing the pressure of endotracheal tube cuff slowly with a constant speed can significantly reduce the incidence of coughing during extubating period, stabilize hemodynamics, and reduce the incidence of adverse reactions. [ABSTRACT FROM AUTHOR]

Background: Laryngeal injury associated with traumatic or prolonged intubation may lead to voice, swallow, and airway complications. The interplay between inflammation and microbial population shifts induced by intubation may relate to clinical outcomes. The objective of this study was to investigate laryngeal mechanics, tissue inflammatory response, and local microbiome changes with laryngotracheal injury and localized delivery of therapeutics via drug-eluting endotracheal tube. Methods: A simulated traumatic intubation injury was created in Yorkshire crossbreed swine under direct laryngoscopy. Endotracheal tubes electrospun with roxadustat or valacyclovir- loaded polycaprolactone (PCL) fibers were placed in the injured airway for 3, 7, or 14 days (n = 3 per group/time and ETT type). Vocal fold stiffness was then evaluated with normal indentation and laryngeal tissue sections were histologically examined. Immunohistochemistry and inflammatory marker profiling were conducted to evaluate the inflammatory response associated with injury and ETT placement. Additionally, ETT biofilm formation was visualized using scanning electron microscopy and micro-computed tomography, while changes in the airway microbiome were profiled through 16S rRNA sequencing. Results: Laryngeal tissue with roxadustat ETT placement had increasing localized stiffness outcomes over time and histological assessment indicated minimal epithelial ulceration and fibrosis, while inflammation remained severe across all timepoints. In contrast, vocal fold tissue with valacyclovir ETT placement showed no significant changes in stiffness over time; histological analysis presented a reduction in epithelial ulceration and inflammation scores along with increased fibrosis observed at 14 days. Immunohistochemistry revealed a decline in M1 and M2 macrophage markers over time for both ETT types. Among the cytokines, IL-8 levels differed significantly between the roxadustat and valacyclovir ETT groups, while no other cytokines showed statistically significant differences. Additionally, increased biofilm formation was observed in the coated ETTs with notable alterations in microbiota distinctive to each ETT type and across time. Conclusion: The injured and intubated airway resulted in increased laryngeal stiffness. Local inflammation and the type of therapeutic administered impacted the bacterial composition within the upper respiratory microbiome, which in turn mediated local tissue healing and recovery. [ABSTRACT FROM AUTHOR]

In critically ill patients, endotracheal intubation (ETI) is lifesaving but carries a high risk of adverse events, notably hypoxemia. Preoxygenation is performed before introducing the tube to increase the safe apnea time. Oxygenation is monitored by pulse oximeter measurement of peripheral oxygen saturation (SpO2). However, SpO2 is unreliable at the high oxygenation levels produced by preoxygenation and, in the event of desaturation, may not decrease sufficiently early to allow preventive measures. The oxygen reserve index (ORI) is a dimensionless parameter that can also be measured continuously by a fingertip monitor and reflects oxygenation in the moderate hyperoxia range. The ORI ranges from 0 to 1 when arterial oxygen saturation (PaO2) varies between 100 to 200 mmHg, as occurs during preoxygenation. No trial has assessed the potential effects of ORI monitoring to guide preoxygenation for ETI in unstable patients. We designed a multicenter, two-arm, parallel-group, randomized, superiority, open trial in 950 critically ill adults requiring ETI. The intervention consists in monitoring ORI values and using an ORI target for preoxygenation of at least 0.6 for at least 1 minute. In the control group, preoxygenation is guided by SpO2 values recorded by a standard pulse oximeter, according to the standard of care, the goal being to obtain 100% SpO2 during preoxygenation, which lasts at least 3 minutes. The standard-of-care ETI technique is used in both arms. Baseline parameters, rapid-sequence induction medications, ETI devices, and physiological data are recorded. The primary outcome is the lowest SpO2 value from laryngoscopy to 2 minutes after successful ETI. Secondary outcomes include cognitive function on day 28. Assuming a 10% standard deviation for the lowest SpO2 value in the control group, no missing data, and crossover of 5% of patients, with the bilateral alpha risk set at 0.05, including 950 patients will provide 85% power for detecting a 2% between-group absolute difference in the lowest SpO2 value. Should ORI monitoring with a target of ≥0.6 be found to increase the lowest SpO2 value during ETI, then this trial may change current practice regarding preoxygenation for ETI. Trial registration: Registered on ClinicalTrials.gov (NCT05867875) on April 27, 2023. [ABSTRACT FROM AUTHOR]

Background: The perioperative management of patients with chronic cough or cough hypersensitivity syndrome and its sometimes severe effects is currently under-researched and under-reported. Case presentation: A 46-year-old female patient with a history of chronic cough and Cough Hypersensitivity Syndrome. After laparoscopic hiatoplasty and anterior fundoplication under general anesthesia, experienced a pronounced exacerbation of coughing symptoms. Despite prompt and extensive treatment involving antitussives, inhalants, anxiolytics, and sedatives, the symptoms remained uncontrollable. Within a few hours, the patient developed a respiratory alkalosis with severe and life-threatening electrolyte shift (pH 7.705, pCO2 1.72 kPa, K+ 2.1 mmol/l). Lactatemia lasted for more than 12 hours with values up to 6.6 mmol/l. Acute bleeding, pneumothorax, and an acute cardiac event were ruled out. Deep analgosedation and inhalation of high-percentage local anesthetics were necessary to manage the clinical symptoms. Conclusions: This case highlights the challenging nature of chronic cough and hypersensitivity syndrome perioperatively. A tailored anesthesiologic approach, exclusion of other provoking medical problems, and knowledge of possible management and treatment options are key. [ABSTRACT FROM AUTHOR]

Aim Methods Results Conclusion Opioids might be harmful to the developing brain and dosing accuracy is important. We aimed at investigating fentanyl effects on cortical activity in infants using computational re‐analysis of bedside recorded EEG signals.Fifteen infants born at median 26.4 gestational weeks (range 23.3–34.1), with a birth weight 740 grams (530–1420) and postnatal age 7 days (5–11) received fentanyl 0.5 or 2 μg/kg intravenously before a skin‐breaking procedure or tracheal intubation, respectively. Cortical activity was continuously recorded using amplitude‐integrated electroencephalography (aEEG).  Analyses using three computational EEG features representing cortical synchrony and signal power, were conducted five minutes pre‐ and 10 minutes post the drug administration.Visual assessment of trends displayed from the EEG metrics did not indicate systematic changes. However, the magnitude of the changes in the parietal and right hemisphere signals after the dose was significantly correlated (ρ < −0.5, p < 0.05) to the EEG amplitude and frequency power level before drug administration. This effect started after 3–4 min.Fentanyl, even in small doses, may affect cortical activity in the preterm brain. The effect is robustly related to the state of cortical activity prior to drug treatment, which must be taken into account when analysing the effects of sedative drugs. [ABSTRACT FROM AUTHOR]

Background: The primary objective of anesthesiologists during the induction of anaesthesia is to mitigate the operative stress response resulting from endotracheal intubation. In this prospective, randomized controlled trial, our aim was to assess the feasibility and efficacy of employing Index of Consciousness (IoC, IoC1 and IoC2) monitoring in predicting and mitigating circulatory stress induced by endotracheal intubation for laparoscopic cholecystectomy patients under general anesthesia (GA). Methods: We enrolled one hundred and twenty patients scheduled for laparoscopic cholecystectomy under GA and randomly allocated them to two groups: IoC monitoring guidance (Group T, n = 60) and bispectral index (BIS) monitoring guidance (Group C, n = 60). The primary endpoints included the heart rate (HR) and mean arterial pressure (MAP) of the patients, as well as the rate of change (ROC) at specific time points during the endotracheal intubation period. Secondary outcomes encompassed the systemic vascular resistance index (SVRI), cardiac output index (CI), stroke volume index (SVI), ROC at specific time points, the incidence of adverse events (AEs), and the induction dosage of remifentanil and propofol during the endotracheal intubation period in both groups. Results: The mean (SD) HR at 1 min after intubation under IoC monitoring guidance was significantly lower than that under BIS monitoring guidance (76 (16) beats/min vs. 82 (16) beats/min, P = 0.049, respectively). Similarly, the mean (SD) MAP at 1 min after intubation under IoC monitoring guidance was lower than that under BIS monitoring guidance (90 (20) mmHg vs. 98 (19) mmHg, P = 0.031, respectively). At each time point from 1 to 5 min after intubation, the number of cases with HR ROC of less than 10% in Group T was significantly higher than in Group C (P < 0.05). Furthermore, between 1 and 3 min and at 5 min post-intubation, the number of cases with HR ROC between 20 to 30% or 40% in Group T was significantly lower than that in Group C (P < 0.05). At 1 min post-intubation, the number of cases with MAP ROC of less than 10% in Group T was significantly higher than that in Group C (P < 0.05), and the number of cases with MAP ROC between 10 to 20% in Group T was significantly lower than that in Group C (P < 0.01). Patients in Group T exhibited superior hemodynamic stability during the peri-endotracheal intubation period compared to those in Group C. There were no significant differences in the frequencies of AEs between the two groups (P > 0.05). Conclusion: This promising monitoring technique has the potential to predict the circulatory stress response, thereby reducing the incidence of adverse reactions during the peri-endotracheal intubation period. This technology holds promise for optimizing anesthesia management. Trail registration: Chinese Clinical Trail Registry Identifier: ChiCTR2300070237 (20/04/2022). [ABSTRACT FROM AUTHOR]

Background: Ball thrombus is rare and life-threatening. The correct diagnosis and timely management are key to improving patient prognosis. Here, we present a case report and literature review of ball thrombus. Case presentation: A 75-year-old woman presented to our outpatient clinic because of palpitations and chest distress for 8 months. She was diagnosed mitral stenosis, and transthoracic echocardiography (TTE) showed a round mass attached to the left atrial (LA) wall. Before anesthesia induction, TTE found that the mass has dropped from the LA wall, and was spinning in the LA causing intermittent obstruction of the valve. Anesthesia induction was then carried out under TTE monitoring, and transesophageal echocardiograph found another mass in the LA appendage after intubation. She underwent LA mass removal and mitral valve replacement, and was discharged uneventfully. Histopathology confirmed the diagnosis of thrombus. Our literature review identified 19 cases of ball thrombus between 2015 and 2024. The average age was 54.8 (range 3–88) years. Heart failure was present as the initial symptom in 11 cases, and most patients had mitral valve disease or concomitant with atrial fibrillation. 12 cases received surgery, and 7 received medical treatment only. 2 deaths occurred, one due to the obstruction of left ventricular inflow tract and the other due to the worsening of heart failure. Conclusion: Ball thrombus is rare in clinical settings. Urgent thrombectomy should be performed as soon as possible, and echocardiography can be used for real-time monitoring during surgery. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course Background: Submental intubation, a technique often considered a good alternative for managing the airway in challenging maxillofacial surgical scenarios, plays a pivotal role in providing accessibility to the surgical site and ensuring airway safety, particularly in cases involving facial fractures. This innovative approach not only grants surgeons adequate access to the operative field but also mitigates potential complications associated with traditional intubation methods, making it a valuable tool in dealing with complex facial trauma cases. Case Report: A 37-year-old man arrived at the Emergency Department (ED) with a severe facial injury caused from a traumatic incident involving a falling concrete wall, resulting in severe facial injuries that included multiple lacerations and abrasions on his face and body. The patient presented with multiple facial and body lacerations and abrasions, necessitating prompt medical intervention. The ED team swiftly treated the facial lacerations, controlled the bleeding, stabilized the patient, and proceeded to secure the airway through orotracheal intubation. Following stabilization, the patient was transferred to the operation theater (OT) for further management of his extensive pan-facial fractures under general anesthesia, utilizing the submental intubation technique for airway management. Conclusions: Despite its limited use, submental intubation is a good option for some maxillofacial surgeries, offering a less intrusive approach to airway management and presenting an alternative pathway to the conventional endotracheal intubation technique. Its ability to streamline procedures, enhance patient outcomes, and reduce complications underscores the importance of considering submental intubation as a valuable tool in dealing with complex maxillofacial cases. [ABSTRACT FROM AUTHOR]

Background: Prehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective. Methods: This was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0. Results: Out of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11). Conclusions: Prehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety. Trial registration: The study was registered in the German Register for Clinical Studies (number DRKS00028068). [ABSTRACT FROM AUTHOR]

Introduction Between 2011 and 2014, The Combat Casualty Training Consortium research study sought to evaluate all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among U.S. combat fatalities. This study identified a major training gap in critical airway management. To address this gap, the Advanced Joint Airway Management System (AJAMS) was designed and assessed for physical fidelity and educational utility in a population of paramedic instructors. Materials and Methods Paramedic instructors served as participants in this prospective observational pilot study (n  = 12). Participants interacted with three airway management trainers: The AJAMS trainer, the Laerdal Airway Management Trainer, and the TruCorp AirSim Advance Bronchi X Trainer. Participants then completed an evaluation of the trainer using a purpose-built data collection instrument that queried the trainer's realism and educational utility. Within-group differences were analyzed via a 1-way repeated measures ANOVA, with a Bonferroni post hoc analysis. Rank data were analyzed via non-parametric Freidman's test, and Wilcoxon signed-rank test post hoc analysis, corrected using the Bonferroni correction. Results The AJAMS trainer conveys significantly more physical fidelity (visual: P  < .001, ηp2 = 0.977; tactile: P  < .001, ηp2 = 0.983; and behavioral: P  = .001, ηp2 = 0.971) and overall educational utility (χ2(2) = 15.273, P  < .001) than the two commercially available skill trainers. Conclusions These data suggest that physical fidelity is an important attribute in the design of simulators for health care, as perceived by expert instructors. These data illustrate that the AJAMS-integrated simulator demonstrates unparalleled physical fidelity, relative to commercially available airway management skill trainers. [ABSTRACT FROM AUTHOR]

Introduction Between 2011 and 2014, the Combat Casualty Training Consortium research study sought to evaluate all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among American combat fatalities. This study identified a major training gap in critical airway management. Because of the high rate of morbidity and mortality associated with poor or incorrect airway management, an effort to address this training gap was necessary. Materials and Methods This experiment compared the training using the Advanced Joint Airway Management System, a novel high-fidelity airway simulator, relative to one of the most utilized simulators for endotracheal intubation (ETI) via a parallel group randomized control trial design. Before training, participants (n  = 19) attempted an ETI on a cadaver using direct laryngoscopy. Performance during the attempt was recorded and scored by trained blinded raters. Participants were then randomly allocated to either novel or conventional training. Post-training, participants completed a second ETI under the same parameters. Analysis was completed via 2 × 2 mixed analysis of variance for (1) ETI Score, (2) Errors, (3) Critical Failures, and (4) Duration, across both the pre- and post-training tests and between the two groups. Results A priori power analysis required a total sample size of 84 participants in this experimental design. Consequently, this study is under-powered to reach statistical significance. Scores for all trainees did improve with training, yet analyses did not reveal a difference in overall ETI score between the novel and conventional training group, at baseline or at the post-training test (P  = .249). Conclusion The Advanced Joint Airway Management System simulator presents a training effect that is comparable to the conventional training model. However, given this study's small sample size, these results must be considered preliminary and further research is merited to draw firm conclusions about its impact on trainee performance. Future studies engaging larger cohorts of trainees and exploring the other capabilities of the Advanced Joint Airway Management System (cricothyroidotomy, needle chess decompression) are needed to further examine the educational potential of this novel airway management training system. [ABSTRACT FROM AUTHOR]

Alcohol withdrawal syndrome (AWS) is defined as the cessation or reduction in heavy and prolonged alcohol use within several hours to a few days of cessation. The recommended first-line therapy for AWS ranging from mild to severe or complicated remains benzodiazepines; in cases where benzodiazepines are not adequate in controlling persistent autonomic hyperactivity or anxiety, dexmedetomidine could be utilized. The possible advantage of dexmedetomidine compared to benzodiazepines is that it does not cause respiratory depression, thus reducing the risk of intubation and hospitalization in the ICUs, with the potential reduction in healthcare costs. The purpose of this systematic review and meta-analysis (PROSPERO CRD42018084370) is to evaluate the effectiveness and safety of dexmedetomidine as adjunctive therapy to the standard of care for the treatment of AWS. We retrieved literature from PubMed, EMBASE, and CENTRAL until 10 January 2024. Eligible studies were both randomized trials and nonrandomised studies with a control group, published in the English language and peer-reviewed journals. The primary outcome was tracheal intubation; secondary outcomes were (i) bradycardia and (ii) hypotension. A total of 3585 papers were retrieved: 2635 from EMBASE, 930 from Medline, and 20 from CENTRAL. After eliminating duplicates, 2960 papers were screened by title and abstract; 75 out of the 2960 papers were read in full text. The qualitative synthesis included nine of all manuscripts read in full text. The quantitative synthesis included eight studies for the primary outcome (tracheal intubation), seven for the secondary outcome bradycardia, and six for the secondary outcome hypotension. The meta-analysis showed that Dexmedetomidine, as adjunctive therapy, is not more effective than standard therapy in reducing the risk of tracheal intubation in AWS [RR: 0.57, 95% CI: 0.25–1.3, p = 0.15]. It also appears to be less safe than sedative therapy as it significantly increases the risk of bradycardia [RR: 2.68, 95% CI: 1.79–4.16, p = 0.0016]. Hypotension was not significantly different in patients who received dexmedetomidine [RR: 1.5, 95% CI: 0.69–3.49, p = 0.21]. [ABSTRACT FROM AUTHOR]

Tracheal stenosis is a common complication of endotracheal intubation or tracheostomy, resulting in significant morbidity and mortality. Bronchoscope interventions have been proposed as a safe alternative for the management of post‐intubation post‐intubation tracheal stenosis (PITS). Data for patients diagnosed with PITS across two hospitals, between 2021 and 2022, encompassing demographic, clinical, and procedural details were gathered from electronic medical records, and analysed. Primary outcomes centred on assessing the incidence and severity of PITS through bronchoscope examination and radiological imaging, and the efficacy of bronchoscope interventions, including stenting and the application of mitomycin C. Twelve patients were managed for PITS. Majority of patients were females (9/12) with mean age of 46.41 years. Presenting signs and symptoms were dyspnea, rhonchi and failed extubation, the mean duration of intubation/ tracheostomy is 16.41 days (range: 3–40 days). Most common comorbidity was type 2 diabetes, (5 patients, 41.6%). The lesions mean length was 3.09 cm and Cotton‐Meyer Grade II and III. Prompt evaluation is crucial, in these patients. The Cotton‐Meyer grade is pivotal in treatment decisions, with intubating times correlating with the severity of stenotic disease. Our case series demonstrates the increasing utility of bronchoscopy in managing these cases. [ABSTRACT FROM AUTHOR]

Background: Highflow nasal cannula oxygen (HFNO) is known to be used for noninvasive oxygenation in intensive care patients but it has rarely been used in airway management for elective surgery of the upper aerodigestive tract. Objectives: HFNO offers opportunities of a tubeless oxygenation system which is easy to handle and not limited only on surgery of the endolarynx. Methods: We evaluated this method for oxygenation during brief interventional procedures of the larynx and pharynx in 92 adult patients for safety and intraoperative complications. The need of secondary endotracheal intubation and limiting comorbidities as pulmonal and cardiac diseases were documented. Results: HFNO showed a good safety profile concerning saturation and hypercapnia. Oxygen desaturation below 90% occurred only in 5 patients, mask ventilation led to quick recovery except in one patient who was secondary intubated. A significant influence of the body mass index on the minimal O2 saturation was shown (p < 0,001) so that a possible limitation of the method exists here. Comorbidities were grouped into the ASA classification. There was a significant difference between ASA I/II and ASA III patients in terms of minimum O2saturation. Conclusion: We conclude that HFNO may hold great promise for changing ventilator technique in general anesthesia, particularly in short elective laryngeal and pharyngeal surgery. Safety and feasibility were proven in this study. [ABSTRACT FROM AUTHOR]

Background and Aims: Laryngoscopy and endotracheal intubation are critical aspects of general anesthesia, often provoking significant stress responses that impact circulatory parameters. This study aims to compare the hemodynamic stress responses and intubation conditions between the Macintosh and McCoy blades in patients with ASA grades I and II undergoing various surgical procedures under general anesthesia. Methods: A total of 100 patients were randomly assigned into two groups: Group A (Macintosh blade) and Group B (McCoy blade), each consisting of 50 patients. Hemodynamic parameters, including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP), were recorded at Pre-Induction, At the Start of Laryngoscopy, Immediately After Intubation, 1 Minute After Intubation, 3 Minutes After Intubation, 5 Minutes After Intubation, 10 Minutes After Intubation. Intubation ease was evaluated by recording the duration of laryngoscopy, Cormack and Lehane Grades, Modified Mallampati scores, and the necessity for optimal external laryngeal manipulation (OELM) or stylet use. Results: The Macintosh group exhibited significantly higher HR, SBP, DBP, and MAP immediately after intubation compared to the McCoy group (p < 0.001). The McCoy blade was associated with better attenuation of the hemodynamic response and facilitated improved laryngeal view under Cormack and Lehane grading, particularly beneficial in patients with higher Mallampati grades. Conclusion: The McCoy blade offers superior hemodynamic stability and enhanced visualization during intubation compared to the Macintosh blade, making it potentially more advantageous for patients with challenging airways, although further research in Mallampati grades III and IV is warranted. [ABSTRACT FROM AUTHOR]

Background: Propofol auto co-induction or the Priming Principle has also been proposed to lower Propofol requirements. The purpose of this study was to see if using the ‘Priming Principle’ for the propofol induction, 2 minutes before actual induction would attenuate the pulse rate to laryngoscopy and intubation, as opposed to the reflex tachycardia due to increased sympathetic activity. Material and Methods: Present study was Comparative, randomized, prospective, observational study, conducted patients belonging to age groups 18- 35 years, to either gender, belonging to ASA physical status 1 and 2, scheduled for elective surgical procedures requiring general anaesthesia with endotracheal intubation. Patients were randomly allocated into two groups of 25 each and were subjected to the Group A (priming of propofol with 25% of the calculated dose) & Group B (No priming of propofol). Results: In the group that was administered with primed dose of propofol it was noted that the administered dose was much less compared to the originally calculated dose. The dose of propofol that was administered in the primed group was much less compared to the control group with a statistical difference having a P value of 0.00. The pulse rate at 1 minute post laryngoscopy and intubation in the case group was lower than that of the control group with the p value of 0.010. The SBP was higher in cases when compared to controls with statistical significance. The p values at laryngoscopy, post laryngoscopy and intubation at 1-,3- and 5 minutes are 0.000, 0.000, 0.000 and 0.001 respectively. Conclusion: Priming of propofol with 25% of the calculated dose two minutes before the induction is effective in attenuating the pulse rate at 1 minute post intubation. The group with priming required doses lesser than the calculated dose with better hemodynamic stability. [ABSTRACT FROM AUTHOR]

Background: Endotracheal intubation and carbon dioxide pneumoperitoneum in patients undergoing laparoscopic cholecystectomy changes hemodynamic parameters. The impact of magnesium sulfate on hemodynamic responses during laparoscopic cholecystectomy remains controversial Objectives: To evaluate the efficacy of administration of magnesium sulphate to attenuate hemodynamic responses during laparoscopic cholecystectomy Methods: This was a randomized control study conducted in the department of Anaesthesia. Forty patients undergoing laparoscopic cholecystectomy were assigned into two groups. One group received magnesium sulfate (50mg/kg) and second group received normal saline (0.9%). Systolic and diastolic blood pressures, heart rate and mean arterial pressure were measured before the induction, at the end of infusion and after the induction in both the groups. Results: There is no statistically significant differences between magnesium sulphate and normal saline groups in terms of age, gender, weight, ASA grade and duration of surgery (p>0.05). Common adverse effects like bradycardia, and hypotension were observed. The mean values of systolic blood pressure, diastolic blood pressure, heart rate and mean arterial pressure were significantly less (P< 0.05) in magnesium sulphate group as compared to normal saline group. Conclusion: Magnesium sulphate effectively attenuates hemodynamic responses during intubation and pneumoperitoneum during laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]