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Background: Hypoxemia is common during tracheal intubation in intensive care units. To prevent hypoxemia during intubation, 2 methods of delivering oxygen between induction and laryngoscopy have been proposed: bag-mask ventilation and supplemental oxygen delivered by nasal cannula without ventilation (apneic oxygenation). Whether one of these approaches is more effective for preventing hypoxemia during intubation of critically ill patients is unknown. Methods: We performed a secondary analysis of data from 138 patients enrolled in 2, consecutive randomized trials of airway management in an academic intensive care unit. A total of 61 patients were randomized to receive bag-mask ventilation in a trial comparing bag-mask ventilation to none, and 77 patients were randomized to receive 100% oxygen at 15 L/min by nasal cannula in a trial comparing apneic oxygenation to none. Using multivariable linear regression accounting for age, body mass index, severity of illness, and oxygen saturation at induction, we compared patients assigned to bag-mask ventilation with those assigned to apneic oxygenation regarding lowest oxygen saturations from induction to 2 min after intubation. Results: Patients assigned to bag-mask ventilation and apneic oxygenation were similar at baseline. The median lowest oxygen saturation was 96% (interquartile range [IQR] 89%-100%) in the bag-mask ventilation group and 92% (IQR 84%-99%) in the apneic oxygenation group. After adjustment for prespecified confounders, bag-mask ventilation was associated with a higher lowest oxygen saturation compared to apneic oxygenation (mean difference, 4.2%; 95% confidence interval, 0.7%-7.8%; P = .02). The incidence of severe hypoxemia (oxygen saturation

Background: Oral nimodipine is standard therapy for patients suffering an aneurysmal subarachnoid hemorrhage (aSAH). During a national drug shortage, nimodipine therapy was shortened from a 21-day course to a 14-day course at our institution. Objective: The objective of this study was to compare neurological outcomes among patients who had previously received the standard duration of therapy compared with those who received a shortened duration as a result of the national drug shortage. Methods: This retrospective cohort study evaluated adult patients receiving nimodipine for aSAH from January 2012 to August 2013. Neurological outcome, graded by Modified Rankin Scale (mRS) at hospital discharge, was compared between patients receiving a shortened course and those receiving the standard duration of nimodipine. Results: A total of 199 aSAH patients were included in the analysis. There were 164 patients in the standard-duration and 35 patients in the shortened-duration group. Baseline patient severity of illness, assessed by SAPS II (Simplified Acute Physiology Score), and severity of aSAH, assessed by Fisher grade, and Hunt and Hess grade scores, did not differ between the treatment groups. A shortened duration of nimodipine was not associated with a higher risk of a poor neurological outcome defined by mRS (odds ratio = 1.85; 95% CI = 0.54-6.32; P = 0.32). Mortality rates were similar between the groups. Conclusions: A 14-day course of nimodipine therapy was not associated with worse neurological outcomes in aSAH patients at one institution. More studies are needed prior to recommending a shortened duration of nimodipine therapy in all aSAH patients.

The self-pressurising air-Q® Intubating Laryngeal Airway is a new, commercially available, supraglottic airway device that incorporates a self-regulating periglottic cuff. In this retrospective review, we describe our initial clinical experience using the device in 100 patients. The ease and number of insertion attempts, airway seal pressure, device positioning, intubation success and oropharyngeal morbidity were recorded. The air-Q Intubating Laryngeal Airway was successfully inserted in all 100 patients and functioned adequately as a primary airway in 70 of the 72 patients in which it was used for this purpose. The median (interquartile range [range]) airway seal pressure was 22 (19-29, [10-40]) cmH2O. Intubation via the air-Q Intubating Laryngeal Airway was successful in 28 of 29 (97%) patients. Eleven percent of patients complained of sore throat postoperatively before discharge. In our series, the air-Q Intubating Laryngeal Airway performed adequately as a primary airway during anaesthesia with respect to ease of insertion, adequacy of airway maintenance and as a conduit for intubation in both anticipated and unanticipated difficult airways. Although our initial experience is positive, further investigation with larger numbers of observations are needed as the upper limits of the 95% confidence intervals for device failure (the worst failure rate the clinician could expect) are still high.

The use of the central venous catheter may be complicated by air embolism when central venous pressure is subatmospheric and the catheter is open to the surrounding air. Paradoxical air embolus occurs when the gas bubbles are able to traverse a right to left shunt, gaining access to the systemic arterial circulation causing ischemic symptoms in end organs. In this article, a case of a patient with an unknown patent foramen ovale through which air entered the arterial circulation resulting in obtundation and stroke after inadvertent manipulation of a Hickman catheter is presented. The physiology, clinical manifestations, and management strategies are also discussed.