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Background: The direct thrombin inhibitor argatroban is indicated for the treatment of heparin-induced thrombocytopenia II, but it is also used off-label to treat critically ill patients presenting with heparin resistance, severe antithrombin deficiency, or hypercoagulability. Direct drug monitoring is not routinely available, and argatroban dosing is mainly based on global coagulation assays such as activated partial thromboplastin time (PTT) or diluted thrombin time (TT), both of which have limitations in patients with hypercoagulability., Methods: Blood samples were obtained from critically ill patients treated with argatroban. Activated PTT and diluted TT were measured with a STA R Max3 analyzer (STAGO Deutschland GmbH, Germany) using an argatroban-calibrated kit. Ecarin clotting time was measured using a point-of-care viscoelastic test device. Liquid chromatography with tandem mass spectrometry was performed using a reversed-phase column, a solvent gradient, and an API4000 mass spectrometer with electrospray. Correlation was described using Pearson correlation coefficient r and Bayesian multilevel regression to estimate relationships between outcomes and covariates., Results: From June 2021 to March 2022, 205 blood samples from 22 patients were analyzed, allowing for 195 activated PTT-liquid chromatography with tandem mass spectrometry comparisons, 153 ecarin clotting time-liquid chromatography with tandem mass spectrometry comparison, and 105 diluted TT-liquid chromatography with tandem mass spectrometry comparisons. Compared to liquid chromatography with tandem mass spectrometry, performance of argatroban quantification was best for diluted TT (r = 0.91), followed by ecarin clotting time (r = 0.58) and activated PTT (r = 0.48). Regression analysis revealed that patients with sepsis were more prone to argatroban overdosing (coefficient, 4.194; 95% credible interval, 2.220 to 6.792)., Conclusions: Although activated PTT monitoring of argatroban is the most commonly used test, in critically ill patients, diluted TT provides more precise measurements. Alternately, point-of-care viscoelastic ecarin clotting time also provides guidance for argatroban dosing to identify overdosing if available. The data also suggested that patients with sepsis are at greater risk for argatroban overdosing., (Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved.)

Background: Quality indicators are frequently used to assess the performance of health care providers, in particular hospitals. Established approaches to the design of such indicators are subject to distortions due to indirect standardization and high variance of estimators. Indicators for geographical regions are rarely considered., Objectives: To develop and evaluate a methodology of multilevel quality indicators (MQIs) for both health care providers and geographical regions., Research Design: We formally derived MQIs from a statistical multilevel model, which may include characteristics of patients, providers, and regions. We used Monte Carlo simulation to assess the performance of MQIs relative to established approaches based on the standardized mortality/morbidity ratio (SMR) and the risk-standardized mortality rate (RSMR)., Measures: Rank correlation between true provider/region effects and quality indicator estimates; shares of the 10% best and 10% worst providers identified by the quality indicators., Results: The proposed MQIs are (1) standardized hospital outcome rate (SHOR), (2) regional SHOR, and (3) regional standardized patient outcome rate. Monte Carlo simulations indicated that the SHOR provides substantially better estimates of provider performance than the SMR and risk-standardized mortality rate in almost all scenarios. The regional standardized patient outcome rate was slightly more stable than the regional SMR. We also found that modeling of regional characteristics generally improves the adequacy of provider-level estimates., Conclusions: MQIs methodology facilitates adequate and efficient estimation of quality indicators for both health care providers and geographical regions., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The optimal anesthetic management for endovascular therapy (EVT) in patients with posterior circulation stroke remains unclear. Our objective was to investigate the impact of early intubation in patients enrolled in the BASICS trial (Basilar Artery International Cooperation Study)., Methods: BASICS was a multicenter, randomized, controlled trial that compared the efficacy of EVT compared with the best medical care alone in patients with basilar artery occlusion. In this post hoc analysis, early intubation within the first 24 hours of the estimated time of basilar artery occlusion was examined as an additional covariate using regression modeling. We estimated the adjusted relative risks (RRs) for favorable outcomes, defined as modified Rankin Scale scores of 0 to 3 at 90 days. An adjusted common odds ratio was estimated for a shift in the distribution of modified Rankin Scale scores at 90 days., Results: Of 300 patients in BASICS, 289 patients were eligible for analysis (151 in the EVT group and 138 in the best medical care group). compared with medical care alone, EVT was related to a higher risk of early intubation (RR, 1.29 [95% CI, 1.09-1.53]; P <0.01), and early intubation was negatively associated with favorable outcome (RR, 0.61 [95% CI, 0.45-0.84]; P =0.002). Whereas there was no overall treatment effect of EVT on favorable outcome (RR, 1.22 [95% CI, 0.95-1.55]; P =0.121), EVT was associated with favorable outcome (RR, 1.34 [95% CI, 1.05-1.71]; P =0.018) and a shift toward lower modified Rankin Scale scores (adjusted common odds ratio, 1.63 [95% CI, 1.04-2.57]; P =0.033) if adjusted for early intubation., Conclusions: In this post hoc analysis of the neutral BASICS trial, early intubation was linked to unfavorable outcomes, which might mitigate a potential benefit from EVT by indirect effects due to an increased risk of early intubation. This relationship may be considered when assessing the efficacy of EVT in patients with basilar artery occlusion in future trials., Competing Interests: Disclosures Dr van Zwam reports grants from Stryker Corporation; grants from Johnson and Johnson International; and compensation from Philips for data and safety monitoring services. Dr Roos reports stock holdings in Nicolab. Dr Yoo reports stock holdings in Insera; compensation from Johnson & Johnson Medical Devices & Diagnostics Group—Latin America, LLC, for consultant services; grants from Genentech USA, Inc to other; compensation from Vesalio for consultant services; compensation from American Heart Association for other services; compensation from ZOLL Circulation Inc for consultant services; compensation from Penumbra Inc for consultant services; stock options in Nicolab; employment by HCA Healthcare; compensation from Penumbra Inc for consultant services; grants from Penumbra Inc to other; grants from Johnson & Johnson Medical Devices & Diagnostics Group—Latin America, LLC, to other; grants from Stryker to other; compensation from National Institutes of Health for data and safety monitoring services; grants from Medtronic to other; compensation from Nicolab for consultant services; and compensation from Philips for consultant services. Dr Pontes-Neto reports compensation from Medtronic for other services; compensation from Bayer for other services; and compensation from Pfizer for other services. Dr Mazighi reports compensation from Acticor Biotech for consultant services and compensation from Boerhinger-Ingelheim for consultant services. Dr Audebert reports being the current president of the PREhospital Stroke Treatment Organization (PRESTO), compensation from Novo Nordisk for data monitoring committee services, grants from Deutsche Forschungsgemeinschaft, German Federal Ministry of Education and Research, Innovation Funds of the Joint Federal Committee (g-BA) and compensation from Bayer Healthcare, Pfizer for consultant services, grants from Pfizer, grants from BMS, grants from Boehringer Ingelheim and grants from Sanofi. Dr Michel reports grants from University of Lausanne to other; grants from Swiss Heart Foundation to other; and grants from Swiss National Science Foundation to other.

Objective: A correct prehospital diagnosis of emergency patients is crucial as it determines initial treatment, admitting specialty, and subsequent treatment. We evaluated the diagnostic accuracy of emergency physicians., Methods: All patients seen by six emergency physicians staffing the local emergency ambulance and rescue helicopter services during an 8-month period were studied. The ambulance and helicopter physicians had 3 and 4 years, respectively, training in anesthesia and intensive care medicine. The admission diagnoses were compared with the discharge diagnoses for agreement. Time of day of the emergency call, patients' age, and sex, living conditions, and presenting symptoms were evaluated as contributing factors., Results: Three hundred and fifty-five ambulance and 241 helicopter deployment protocols were analyzed. The overall degree of agreement between initial and discharge diagnoses was 90.1% with no difference attributable to years of experience. The lowest agreement rate was seen in neurological disorders (81.5%), with a postictal state after an unobserved seizure often being diagnosed as a cerebrovascular accident. Inability to obtain a complete medical history (e.g. elderly patients, patients in nursing homes, neurological impairment) was associated with a lower agreement rate between initial and discharge diagnoses (P<0.05)., Conclusion: Medical history, physical examination, ECG, and blood glucose enabled a correct diagnosis in most cases, but some were impossible to resolve without further technical and laboratory investigations. Only a few were definitively incorrect. A detailed medical history is essential. Neurological disorders can present with misleading symptoms and when the diagnosis is not clear it is better to assume the worst case.

Introduction: Bag-valve-mask ventilation is recommended as the initial airway management option for paramedics during cardiopulmonary resuscitation, although this technique requires considerable skill and is associated with the risk of stomach insufflation, regurgitation, and aspiration. The present two-phase study investigated the efficacy and safety of the laryngeal tube (LT-D) used by paramedics as the sole technique for ventilation in out-of-hospital cardiac arrest., Methods: Paramedics staffing the emergency services' ambulances were selected for the study and trained in the use of the LT-D (phase I). They were then requested to use the device in patients requiring out-of-hospital cardiopulmonary resuscitation without prior bag-valve-mask ventilation. Patients were evaluated with regard to successful placement and effective ventilation using the airway. On arrival at the scene, the emergency physician replaced the LT-D with an endotracheal tube and assessed the incidence of regurgitation and injuries to the airways (phase II)., Results: Forty patients were enrolled into this study. One was excluded from analysis because of protocol violation. Insertion of the LT-D was successful and ventilation was effective in 33 patients (85%). Ventilation was not possible in six patients (15%) because of cuff rupture (n = 3) or massive regurgitation and aspiration before LT-D insertion (n = 3). No patient regurgitated after tube placement. No airway injuries were observed. The participants rated ventilation using the LT-D as effective., Conclusion: The LT-D is feasible and effective for airway management and ventilation when used by paramedics in out-of-hospital cardiopulmonary resuscitation and can be recommended as the sole technique in such situations.

Background: Rapid establishment of a patent airway in ill or injured patients is a priority for prehospital rescue personnel. Out-of-hospital tracheal intubation can be challenging. Unrecognized esophageal intubation is a clinical disaster., Methods: We performed an observational, prospective study of consecutive patients requiring transport by air and out-of-hospital tracheal intubation, performed by primary emergency physicians to quantify the number of unrecognized esophageal and endobronchial intubations. Tracheal tube placement was verified on scene by a study physician using a combination of direct visualization, end-tidal carbon dioxide detection, esophageal detection device, and physical examination., Results: During the 5-yr study period 149 consecutive out-of-hospital tracheal intubations were performed by primary emergency physicians and subsequently evaluated by the study physicians. The mean patient age was 57.0 (+/-22.7) yr and 99 patients (66.4%) were men. The tracheal tube was determined by the study physician to have been placed in the right mainstem bronchus or esophagus in 16 (10.7%) and 10 (6.7%) patients, respectively. All esophageal intubations were detected and corrected by the study physician at the scene, but 7 of these 10 patients died within the first 24 h of treatment., Conclusion: The incidence of unrecognized esophageal intubation is frequent and is associated with a high mortality rate. Esophageal intubation can be detected with end-tidal carbon dioxide monitoring and an esophageal detection device. Out-of-hospital care providers should receive continuing training in airway management, and should be provided additional confirmatory adjuncts to aid in the determination of tracheal tube placement.