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Purpose: Awake prone positioning has been reported to reduce endotracheal intubation in patients with coronavirus disease 2019 (COVID-19)-related acute hypoxemic respiratory failure (AHRF). However, it is still unclear whether using the awake prone positioning for longer periods can further improve outcomes. Methods: In this randomized, open-label clinical trial conducted at 12 hospitals in China, non-intubated patients with COVID-19-related AHRF were randomly assigned to prolonged awake prone positioning (target > 12 h daily for 7 days) or standard care with a shorter period of awake prone positioning. The primary outcome was endotracheal intubation within 28 days after randomization. The key secondary outcomes included mortality and adverse events. Results: In total, 409 patients were enrolled and randomly assigned to prolonged awake prone positioning (n = 205) or standard care (n = 204). In the first 7 days after randomization, the median duration of prone positioning was 12 h/d (interquartile range [IQR] 12–14 h/d) in the prolonged awake prone positioning group vs. 5 h/d (IQR 2–8 h/d) in the standard care group. In the intention-to-treat analysis, intubation occurred in 35 (17%) patients assigned to prolonged awake prone positioning and in 56 (27%) patients assigned to standard care (relative risk 0.62 [95% confidence interval (CI) 0.42–0.9]). The hazard ratio (HR) for intubation was 0.56 (0.37–0.86), and for mortality was 0.63 (0.42–0.96) for prolonged awake prone positioning versus standard care, within 28 days. The incidence of pre-specified adverse events was low and similar in both groups. Conclusion: Prolonged awake prone positioning of patients with COVID-19-related AHRF reduces the intubation rate without significant harm. These results support prolonged awake prone positioning of patients with COVID-19-related AHRF. [ABSTRACT FROM AUTHOR]

Background: The neuromuscular blocking agent mivacurium can be used during anesthesia to facilitate tracheal intubation. Data on onset time, duration of action, and effect on intubating conditions in patients 80 years and older are however limited. We hypothesized that onset time and duration of action of mivacurium would be longer in elderly patients than in younger adults. Methods: This prospective observational study included 35 elderly (≥80 years) and 35 younger (18–40 years) patients. Induction of anesthesia comprised fentanyl 1–3 μg kg−1 and propofol 1.5–2.5 mg kg−1 and propofol and remifentanil for maintenance. Acceleromyography was used for monitoring neuromuscular blockade. The primary outcome was onset time defined as time from injection of mivacurium 0.2 mg kg−1 to a train‐of‐four (TOF) count of zero. Other outcomes included duration of action (time to TOF ratio ≥0.9), intubating conditions using the Fuchs‐Buder scale and the intubating difficulty scale (IDS), and occurrence of hoarseness and sore throat postoperatively. Results: No difference was found in onset time comparing elderly with younger patients; 219 s (SD 45) versus 203 s (SD 74) (difference: 16 s (95% CI: −45 to 14), p =.30). Duration of action was significantly longer in elderly patients compared with younger patients; 52 min (SD 17) versus 30 min (SD 8) (difference: 22 min [95% CI: 15 to 28], p <.001). No difference was found in the proportion of excellent intubating conditions (Fuchs‐Buder); 31/35 (89%) versus 26/35 (74%) (p =.12) or IDS score (p =.13). A larger proportion of younger patients reported sore throat 24 h postoperatively; 34% versus 0%, p =.0002. No difference was found in hoarseness. Conclusion: No difference in onset time of mivacurium 0.2 mg kg−1 was found comparing elderly and younger patients. However, elderly patients had significantly longer duration of action. No difference was found in intubating conditions. [ABSTRACT FROM AUTHOR]

Purpose: Early empiric antibiotics were prescribed to numerous patients during the Coronavirus disease 2019 (COVID-19) pandemic. However, the potential impact of empiric antibiotic therapy on the clinical outcomes of patients hospitalized with COVID-19 is yet unknown. Methods: In this retrospective cohort study, early antibiotics use cohort was defined as control group, which was compared with no antibiotic use and delayed antibiotic use cohorts for all-cause mortality during hospitalization. The 1:2 propensity score matched patient populations were further developed to adjust confounding factors. Survival curves were compared between different cohorts using a Log rank test to assess the early antibiotic effectiveness. Results: We included a total of 1472 COVID-19 hospitalized patients, of whom 87.4% (1287 patients) received early antibiotic prescriptions. In propensity-score-matched datasets, our analysis comprised 139 patients with non-antibiotic use (with 278 matched controls) and 27 patients with deferred-antibiotic use (with 54 matched controls). Patients with older ages, multiple comorbidities, severe and critical COVID-19 subtypes, higher serum infection indicators, and inflammatory indicators at admission were more likely to receive early antibiotic prescriptions. After adjusting confounding factors likely to influence the prognosis, there is no significant difference in all-cause mortality (HR=1.000(0.246– 4.060), p = 1.000) and ICU admission (HR=0.436(0.093– 2.04), p = 0.293), need for mechanical ventilation (HR=0.723(0.296– 1.763), p = 0.476) and tracheal intubation (HR=1.338(0.221– 8.103), p = 0.751) were observed between early antibiotics use cohort and non-antibiotic use cohort. Conclusion: Early antibiotics were frequently prescribed to patients in more severe disease condition at admission. However, early antibiotic treatment failed to demonstrate better clinical outcomes in hospitalized patients with COVID-19 in the propensity-score-matched cohorts. [ABSTRACT FROM AUTHOR]

Purpose: Prehospital airway management in trauma is a key component of care and is associated with particular risks. Endotracheal intubation (ETI) is the gold standard, while extraglottic airway devices (EGAs) are recommended alternatives. There is limited evidence comparing their effectiveness. In this retrospective analysis from the TraumaRegister DGU®, we compared ETI with EGA in prehospital airway management regarding in-hospital mortality in patients with trauma. Methods: We included cases only from German hospitals with a minimum Abbreviated Injury Scale score ≥ 2 and age ≥ 16 years. All patients without prehospital airway protection were excluded. We performed a multivariate logistic regression to adjust with the outcome measure of hospital mortality. Results: We included n = 10,408 cases of whom 92.5% received ETI and 7.5% EGA. The mean injury severity score was higher in the ETI group (28.8 ± 14.2) than in the EGA group (26.3 ± 14.2), and in-hospital mortality was comparable: ETI 33.0%; EGA 30.7% (27.5 to 33.9). After conducting logistic regression, the odds ratio for mortality in the ETI group was 1.091 (0.87 to 1.37). The standardized mortality ratio was 1.04 (1.01 to 1.07) in the ETI group and 1.1 (1.02 to 1.26) in the EGA group. Conclusions: There was no significant difference in mortality rates between the use of ETI or EGA, or the ratio of expected versus observed mortality when using ETI. [ABSTRACT FROM AUTHOR]

Objectives: Coronary artery calcifications detected by computed tomography (CT) provide prognostic relevance for vascular disorders and coronary heart disease, whereas their prognostic relevance in severely injured trauma patients remains unclear. Material and Methods: All consecutive trauma patients requiring emergency tracheal intubation before initial CT at a level-1 trauma center and admission to the intensive care unit (ICU) over a 12-year period (2008–2019) were reanalyzed. The Weston score, a semiquantitative method to quantify coronary calcifications, was evaluated as a prognostic variable based upon whole-body trauma CT analysis. Results: Four hundred fifty-eight patients (74.6% male) with a median age of 49 years, median injury severity score of 26 points, 24-h mortality rate of 7.6%, and 30-day mortality rate of 22.1% met the inclusion criteria and were analyzed. Coronary artery calcification was present in 214 patients (46.7%). After adjustment for confounding factors, the Weston score was an independent predictor for 24-h mortality (hazard ratio, HR 1.19, 95% confidence interval, CI 1.06–1.32, p =.002) and 30-day mortality (HR 1.09, 95% CI 1.01–1.17, p =.027). In a subanalysis of 357 survivors, the Weston score was significantly associated with ICU length of stay (LOS) (beta weight 0.89, 95% CI 0.3–1.47, p =.003) but not with mechanical ventilation duration (beta weight 0.05, 95% CI -0.2–0.63, p =.304). Conclusion: CT-detected coronary calcification was a significant prognostic factor for 24-h- and 30-day-mortality in severely injured trauma patients requiring tracheal intubation, and influenced ICU LOS in survivors. [ABSTRACT FROM AUTHOR]

This article discusses a 62-year-old woman who has a long term diagnoses of Rheumatoid Arthritis, and had frequent hospitalization for recurrent pneumonia. In the current hospitalization, she suffered from severe pneumonia complicated with respiratory failure, and received endotracheal intubation with mechanical ventilator use. After treatment, she was extubated and high-flow nasal cannula was applied afterwards for avoiding re-intubation. Data was collected from October 19th to November 3rd, 2020, through direct care, observations, physical assessments, conversation and chart reviews, and comprehensive assessments of the physical, psychological, social and spiritual aspects were implemented. Three health problems were identified: ineffective respiratory patterns, impaired skin integrity and anxiety. During the intensive care period, the writer established a healthy nurse-patient relationship, leading the patient to perform lung rehabilitation for improving respiratory pattern. Also, observing and listening to the patient with positive feedback minimized her anxiety. Meanwhile, using cross-team cooperation to draw up caring strategies. Owing to individualized nursing intervention, the patient successfully weaned from the mechanical ventilator. The writer hopes this nursing experience could assist nurses in taking care of these types of patients in the future. [ABSTRACT FROM AUTHOR]

Background: One of the most dangerous complications after endotracheal intubation or tracheostomy is tracheal stenosis. Objectives: This study aimed to determine the personal and clinical characteristics of tracheal stenosis following intubation or tracheostomy in intensive care unit patients. Methods: This is a nested case-control study. Thirty-five patients who suffered from tracheal stenosis from March 2016 to March 2021 and had been intubated and tracheostomized in intensive care units (ICU) were selected for the case group. The control group included 105 patients intubated and tracheostomized in ICU during the same period without tracheal stenosis. A demographic and clinical characteristics questionnaire was used to collect data from the patients' medical records. Results: The mean length of intubation (P < 0.001), endotracheal and tracheostomy tube cuff pressure (P < 0.001), chronic obstructive pulmonary disease (COPD) (P = 0.043), intubation history (P = 0.045), and airway management (P < 0.001) showed significant differences between the case and control groups. The logistic regression model revealed that COPD (OR = 8.519, P = 0.037), intubation history (OR = 3.939, P = 0.013), length of intubation (OR = 1.118, P = 0.003), age (OR = 0.960, P = 0.030), and endotracheal and tracheostomy tube cuff pressure (OR = 1.988, P < 0.001) were associated with tracheal stenosis. The time interval between intubation/tracheostomy ranged from approximately 28 to 938 days. Conclusions: Given the impact of certain care practices during hospitalization on the occurrence of tracheal stenosis, such as the mean length of intubation, endotracheal and tracheostomy tube cuff pressure, and airway management, it is recommended that standardized training on these interventions be prioritized for staff in intensive care departments. Additionally, attention must be given to specific patient characteristics, such as age, COPD, and history of intubation. [ABSTRACT FROM AUTHOR]

Emergency medical retrieval services (EMRS) in remote Indigenous islands is rarely investigated. We analyzed the characteristics of patients who underwent EMRS in Lanyu, an offshore island of Taiwan, from January 1, 2014 to December 31, 2021. The need for EMRS for Lanyu Indigenous residents (N=132, 3.83‰) was almost 1.5-fold and 100-fold for non-Indigenous residents (N=16, 2.64‰) and tourists (N=40, 0.04‰), respectively. The resident group had a longer hospitalization (12.0 ± 12.9 vs. 5.9 ± 11.7 days, p=.007). The tourist group had more near-drowning or decompression sickness (44.0% vs. 3.0%, p<.001) and secondary transfers (20.0% vs. 5.4%, p=.003). All the patients (N=12) that required multiple retrievals were Lanyu Indigenous residents. The Lanyu Indigenous residents, compared with the non-Indigenous residents, had fewer admissions to intensive care units (47.7% vs. 80.0%) and more in-hospital mortalities (10.6% vs. 0.0%). Multifaceted approaches should be initiated to improve the health care system in remote Indigenous islands. [ABSTRACT FROM AUTHOR]

Objective: During the first wave of the COVID-19 (SARS CoV-2) pandemic, patients being treated for acute respiratory distress syndrome were proned while intubated with mechanical ventilation. In this study, we aimed to compare the diet outcomes at the time of acute hospital discharge of patients with COVID-19 who were proned while endotracheally intubated (ETT-proned) with those who were intubated with but not proned (ETT-supine). Design: The design used is a single-center, retrospective, descriptive study. Results: Between March 1, 2020, and August 2020, 193 critically ill adult patients with severe COVID-19 requiring endotracheal intubation with mechanical ventilation were referred for a swallowing evaluation at our acute care tertiary hospital; 114 of these patients were ETT-proned. At the time of discharge from the hospital, there was no significant difference in diet level between ETT-proned and ETT-supine patients. Significant factors associated with restricted diet at discharge included older age (p < .001) and non-English-speaking status (p = .05). Conclusions: In this study, diet levels at the time of discharge did not differ significantly between the patient groups by time of discharge. These results should be interpreted with caution in relation to the clinical swallow evaluation, which was curtailed by practice restrictions imposed by pandemic protocols. Future research should objectively assess swallow function in patients who were proned during intubation with mechanical ventilation, utilizing evidence-based swallow screening protocols, standardized assessment of physiology via imaging (videofluoroscopic swallow studies or flexible endoscopic evaluation of swallowing), and long-term follow-up to directly and objectively determine the impact proning has on swallow physiology. [ABSTRACT FROM AUTHOR]

Background: Performing an emergency cricothyroidotomy (EC) is extremely challenging, the devices used should be easy to handle and the selected technique reliable. However, there is still an ongoing debate concerning the most superior technique. Methods: Three different techniques were compared using a standardized, simulated scenario regarding handling, performing, training and decision making: The scalpel-bougie technique (SBT), the surgical anatomical preparation technique (SAPT) and the Seldinger technique (ST). First, anaesthesia residents and trainees, paramedics and medical students (each group n = 50) performed a cricothyroidotomy randomly assigned with each of the three devices on a simulator manikin. The time needed for successful cricothyroidotomy was the primary endpoint. Secondary endpoints included first-attempt success rate, number of attempts and user-satisfaction. The second part of the study investigated the impact of prior hands-on training on both material selection for EC and on time to decision-making in a simulated "cannot intubate cannot ventilate" situation. Results: The simulated scenario revealed that SBT and SAPT were significantly faster than percutaneous EC with ST (p < 0.0001). Success rate was 100% for the first attempt with SBT and SAPT. Significant differences were found with regard to user-satisfaction between individual techniques (p < 0.0001). In terms of user-friendliness, SBT was predominantly assessed as easy (87%). Prior training had a large impact regarding choice of devises (p < 0.05), and time to decision making (p = 0.05; 180 s vs. 233 s). Conclusion: This study supports the use of a surgical technique for EC and also a regular training to create familiarity with the materials and the process itself.The trial was registered before study start on 11.11.2018 at ClinicalTrials.gov (NCT: 2018-13819) with Nicole Didion as the principal investigator. [ABSTRACT FROM AUTHOR]

Background and Objective: Obesity is associated with difficult or failed intubation attempts, making general anesthesia challenging for anesthesiologists to perform. The purpose of this study was to evaluate and compare the efficacy of a McCoy laryngoscope and a C-MAC D-blade video laryngoscope for intubation in obese patients with a body mass index (BMI) ≥ 35 kg/m2. Methods: In total, 104 patients were randomly assigned to be intubated with a McCoy (McCoy group) or C-MAC D-blade video laryngoscope (C-MAC group). The primary outcome was intubation time. The secondary outcomes were vocal cord exposure time, vocal cord passage time, proportion of successful intubation, mask ventilation scale, intubation difficulty scale (IDS), percentage of glottis opening (POGO) score, and hemodynamic variables. Results: Although the intubation time did not significantly differ, the C-MAC group showed shorter vocal cord exposure times and a higher rate of successful vocal cord exposure within 5 s. The IDS value was significantly lower in the C-MAC group than in the McCoy group. The proportion of patients who required an increase in lifting force during laryngoscopy was higher in the McCoy group than in the C-MAC group, which may explain the difference in MAP between the groups. Conclusions: Both the McCoy laryngoscope and the C-MAC D-blade video laryngoscope were useful during the intubation of obese patients. The C-MAC D-blade video laryngoscope might be more useful for obese patients in terms of hemodynamic stability. [ABSTRACT FROM AUTHOR]

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Objective: This study aims to investigate the prognostic significance of inflammatory cytokines and lymphocyte levels in predicting disease progression among patients with COVID-19 infection. Methods: Ninety-two hospitalized COVID-19 patients were retrospectively included as subjects for this study. General clinical information and various indicators, including lymphocyte count, interleukin-2 (IL-2), interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10 (IL-10), tumor necrosis factor (TNF), were collected. All patients received treatment according to the ninth edition of the guidelines for COVID-19. Incidences of endotracheal intubation and mortality within 28 days were observed. Results: 1.In the analysis of intubation impact, multivariate analysis identified age, immunoglobulins, lymphocytes, and IL-6 as independent risk factors. When analyzing the impact on patient mortality, multivariate analysis revealed age, prealbumin, and BNP as independent risk factors. 2. Lymphocyte count and inflammatory factors demonstrated predictive value for endotracheal intubation in COVID-19 patients. The critical lymphocyte count value was 0.91, with a sensitivity of 38.8%, specificity of 92.9%, and AUC of 0.687 (95% CI: 0.580–0.795). The critical IL-6 value was 38.21, with a sensitivity of 81%, specificity of 63.3%, and AUC of 0.771 (95% CI: 0.6670.872). The area under the ROC curve for IL-8, IL-10 and TNF is 0.665, 0.712 and 0.648, respectively. 3.Lymphocyte count and inflammatory factors also exhibited predictive value for death in COVID-19 patients. The critical lymphocyte count value was 0.56, with a sensitivity of 71.2%, specificity of 57.5%, and AUC of 0.641 (95% CI: 0.528–0.754). The critical IL-6 value was 53.05, with a sensitivity of 75%, specificity of 71.2%, and AUC of 0.770 (95% CI: 0.6690.870). The area under the ROC curve for IL-8, IL-10 and TNF is 0.687, 0.683 and 0.636, respectively. Conclusion: Elevated inflammatory factors and decreased lymphocyte levels have prognostic value for predicting endotracheal intubation and mortality in COVID-19 patients, providing valuable insights for clinicians in anticipating disease progression. [ABSTRACT FROM AUTHOR]

Background: Fiberoptic-guided intubation is considered as "gold standard" of difficult airway management. Management of the airway in prone position in patients with severe trauma presenting with penetrating waist and hip injury poses a major challenge to the anesthesiologist. Case presentation: A man presented with severe multiple trauma and hemorrhagic shock as a result of an industrial accident with several deformed steel bars penetrating the left lower waist and hip. It was decided to schedule an exploratory laparotomy following extracting the deformed steel bars. Successful administration of awake fiberoptic nasotracheal intubation, performed in a prone position under airway blocks and appropriate sedation, allowed for the procedure. The exploratory laparotomy revealed damage to multiple organs, which were repaired sequentially during a 7-hour surgical operation. The patient's recovery was uneventful, and he was discharged from the hospital one month after the surgery. Conclusions: Awake fiberoptic nasotracheal intubation, along with airway blocks and appropriate sedation, can be a viable option in patients with severe multiple trauma in the prone position. [ABSTRACT FROM AUTHOR]

Introduction Case Presentation Discussion and Conclusions γ‐hydroxybutyrate (GHB) is a GABA‐B agonist that rapidly produces effects that are likened to both alcohol and MDMA/ecstasy. GHB use can lead to neuroadaptation with a characteristic withdrawal syndrome. There is currently a paucity of data on the progression of GHB withdrawal, however, due to the drug's short half‐life it is generally considered to be typically 5–7 days, although some cases can be severe and complicated by life threatening delirium. Here, we present a case of severe GHB withdrawal, which recurred on multiple occasions over 56 days, despite initial clinical stabilisation on each occasion and toxicological evidence of abstinence from GHB between episodes.A male patient in his 30s presented with agitated delirium on a background of severe GHB use disorder with a 15‐year history of daily high dose GHB use. Following 3 hospital admissions over 8 weeks, all requiring intravenous sedation and tracheal intubation, the patient's withdrawal delirium was successfully treated with a slow benzodiazepine and baclofen wean over a period of 6 months. Relapse to GHB use between hospitalisations was excluded toxicologically via blood analysis performed at an institute of forensic pathology.This case highlights that GHB withdrawal can be more prolonged than previously reported in the literature and in some cases may require slow and prolonged tapering of treatment to prevent re‐emergence of delirium. Similar to previous case reports, benzodiazepines and GABA‐B receptor agonists appear to be appropriate drug classes to manage GHB withdrawal. [ABSTRACT FROM AUTHOR]

Background: This systematic review aims to assist clinical decision-making in selecting appropriate preoperative prediction methods for difficult tracheal intubation by identifying and synthesizing literature on these methods in adult patients undergoing all types of surgery. Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines. Comprehensive electronic searches across multiple databases were completed on March 28, 2023. Two researchers independently screened, selected studies, and extracted data. A total of 227 articles representing 526 studies were included and evaluated for bias using the QUADAS-2 tool. Meta-Disc software computed pooled sensitivity (SEN), specificity (SPC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). Heterogeneity was assessed using the Spearman correlation coefficient, Cochran's-Q, and I2 index, with meta-regression exploring sources of heterogeneity. Publication bias was evaluated using Deeks' funnel plot. Results: Out of 2906 articles retrieved, 227 met the inclusion criteria, encompassing a total of 686,089 patients. The review examined 11 methods for predicting difficult tracheal intubation, categorized into physical examination, multivariate scoring system, and imaging test. The modified Mallampati test (MMT) showed a SEN of 0.39 and SPC of 0.86, while the thyromental distance (TMD) had a SEN of 0.38 and SPC of 0.83. The upper lip bite test (ULBT) presented a SEN of 0.52 and SPC of 0.84. Multivariate scoring systems like LEMON and Wilson's risk score demonstrated moderate sensitivity and specificity. Imaging tests, particularly ultrasound-based methods such as the distance from the skin to the epiglottis (US-DSE), exhibited higher sensitivity (0.80) and specificity (0.77). Significant heterogeneity was identified across studies, influenced by factors such as sample size and study design. Conclusion: No single preoperative prediction method shows clear superiority for predicting difficult tracheal intubation. The evidence supports a combined approach using multiple methods tailored to specific patient demographics and clinical contexts. Future research should focus on integrating advanced technologies like artificial intelligence and deep learning to improve predictive models. Standardizing testing procedures and establishing clear cut-off values are essential for enhancing prediction reliability and accuracy. Implementing a multi-modal predictive approach may reduce unanticipated difficult intubations, improving patient safety and outcomes. [ABSTRACT FROM AUTHOR]

Objective The significance of the presence of microorganisms and polymorphonuclear cells in the tracheal aspirates (TAs) of ventilated preterm infants is not well known. Our aim was to correlate information about the presence of polymorphonuclear cells with microbial growth and the cytokine milieu in the TAs of infants who have been intubated for >7 days. Study Design TAs were collected from infants who had been intubated for 7 days or longer. Respiratory cultures were performed, and infants were stratified based on the presence and abundance of polymorphonuclear cells and microbial growth. Cytokines were measured in the TAs of each of the respective groups. Results In the 19 infants whose TAs were collected, the presence of at least moderate WBC with presence of microbial growth was positively associated with the presence of interleukin (IL)-10, IL-1β, IL-8, and tumor necrosis factor (TNF)-α. The presence of at least moderate WBC, with or without microbial growth, was correlated positively with the presence of IL-8 and TNF-α. Conclusion There are higher levels of proinflammatory cytokines (especially, IL-10, IL-1β, and TNF-α) in TAs with higher cell counts and presence of microbial growth. The findings suggest that the presence of microbial growth correlated with inflammatory burden and warrant a larger study to see if treatment of microbial growth can ameliorate the inflammatory burden. Key Points Concomitant evaluation of inflammatory cells, microbial growth, and cytokines in tracheal aspirates. Moderate TA WBC with presence of microbial growth associated with IL-10, IL-1β, IL-8, and TNF-α. Moderate TA WBC, with/without microbial growth, correlated with the presence of IL-8 and TNF-α. Higher levels of IL-10, IL-1β, and TNF-α correlated with higher TA cell counts and microbial growth. [ABSTRACT FROM AUTHOR]

Background: Acute high-altitude illness (AHAI) refers to a series of syndromes including acute mountain sickness (AMS), high-altitude pulmonary edema (HAPE) and high-altitude cerebral edema (HACE). Among these, HACE is a severe and potentially life-threatening condition that can occur when individuals ascend to high altitudes. It is often characterized by ataxia, confusion, and altered mental status. Without appropriate treatment, HACE can rapidly progress to coma, but seizures are infrequent in occurrence. Case presentation: Here, we report a severe HACE patient with coma and status epilepticus. The patient is a 23-year-old male who was visiting Lhasa for the first time. He initially experienced headaches and dizziness on the first day, and then he was found in coma with limb convulsions on the next day. Immediate medical attention was sought, and brain CT and MRI scans showed reversible white matter lesions, especially in the corpus callosum and subcortical white matter. Although the lesions disappeared on T1 and T2 sequences, microbleeds were observed on the SWI sequence. After treatment with tracheal intubation, glucocorticoids and hyperbaric oxygen, the cerebral edema has resolved and the clinical symptoms improved, the patient has no seizures anymore. Conclusions: HACE typically follows AMS and poses a significant risk to life. Clinical manifestations mainly include ataxia, alterations of behavior, and impaired consciousness, with severe cases progressing to coma. Seizures, though rarely observed, may occur. Imaging shows reversible white matter lesions, with microbleeds being a significant and persistent imaging marker over time. Administration of glucocorticoids plays a crucial role in treatment. Despite experiencing seizures, this patient did not experienced any further episodes once his condition improved. [ABSTRACT FROM AUTHOR]

The aim of this case series report is to provide a new topical view of styletubation (video intubating stylet technique) in obese patients undergoing bariatric surgeries. In contrast to various conventional direct laryngoscopes (DLs), videolaryngoscopes (VLs) have been applied in such obese populations with potentially difficult airway complications. The safety and effectiveness of VLs have been repeatedly studied, and the superiority of VLs has then been observed in and advocated for routine use. In this article, among our vast use experiences with styletubation (more than 54,998 patients since 2016) for first-line routine tracheal intubation, we present the unique experience to apply the styletubation technique in obese patients undergoing bariatric surgery. Consistent with the experiences applied in other patient populations, we found the styletubation technique itself to be swift (the time to intubate from 5 s to 24 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction). The learning curve is steep, but competency can be enhanced if technical pitfalls can be avoided. We, therefore, propose that the styletubation technique can be feasibly and routinely applied as a first-line airway modality in obese patients undergoing bariatric surgery. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusion Fibrinolysis is a critical aspect of the hemostatic system, with assessment of fibrinolytic potential being critical to predict bleeding and clotting risk. We describe the method for a novel low‐plasma‐volume assay of fibrinolytic capacity utilizing the euglobulin fraction (the “modified mini‐euglobulin clot lysis assay [ECLA]”), its analytic sensitivity to alterations in key fibrinolytic substrates/regulators, and its initial applications in acute and convalescent disease cohorts.The modified mini‐ECLA requires 50 μL of plasma, a maximal read time of 3 h (with most results available within 60 min), and is entirely performed in a 96‐well microplate. Assay measurements were obtained in a variety of commercial control and deficient plasmas representing clinically relevant hypo‐ and hyperfibrinolytic states, and in three distinct adolescent cohorts with acute or convalescent illness: critically ill, following endotracheal intubation; acute COVID‐19‐related illness; and ambulatory, 3 months following a venous thromboembolic event.In 100% and 75% deficient plasmas, hypofibrinolysis for plasminogen‐deficient, fibrinolysis for alpha‐2‐antiplasmin‐deficient, and hyperfibrinolysis for plasminogen activator inhibitor‐1‐deficient plasmas were observed.The modified mini‐ECLA Clot Lysis Time Ratio (“CLTR”) demonstrated moderate‐strength correlations with the Clot Formation and Lysis (CloFAL) assay, is analytically sensitive to altered fibrinolytic states in vitro, and correlates with clinical outcomes in preliminarily‐studied patient populations. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study aimed to compare the effects of Macintosh-type and hyperangulated video laryngoscopy (VL) blades on dental force during endotracheal intubation (ETI) using Glidescope and McGrath VL devices. METHODS: In this randomized, crossover, manikin study conducted at a university emergency medicine (EM) program, 65 EM trainees included interns and residents performed 520 intubations using four different VL blades (GlideScope VL with Macintosh-type Mac T3 and hyperangular Lo Pro T3 blades and McGrath VL Macintosh-type MAC 4 and hyperangular McGrath X3 blades) in normal and difficult airway scenarios. The primary outcome of this study was the dental pressure (Newton) exerted during ETI. The secondary outcomes included c-spine motion (degree), intubation success (%), duration (seconds), successful glottic view (%), and intubator comfort (7-point Likert). RESULTS: Significant differences were observed in dental force (H(3) = 11.7, P = 0.008), c-spine motion (H(3) = 8.34, P = 0.039), duration (H(3) = 16.56, P = 0.001), and comfort (H(3) = 174.96, P < 0.001) across blade types. Glidescope LoPro T3 provided a significant lower dental force (adjusted P = 0.01), less c-spine motion (adjusted P = 0.031), and shorter intubation duration (adj P < 0.01) than the McGrath Mac 4. First attempt success and intubator comfort were significantly better with all Glidescope blades (z score of 3.7 and 4.7) than with McGrath blades (z score of-4.1 and-4.4). CONCLUSION: The Glidescope LoPro T3 blade demonstrated advantages in dental force, c-spine motion, and intubation duration compared with McGrath Mac 4. Overall, the Glidescope blades provided superior comfort and higher first attempt success rates. [ABSTRACT FROM AUTHOR]

Objective: To observe the application of the controlled respiratory persistence monitor designed based on the principle of rhythmic temperature variations in artificial airways among different populations and in various artificial airways, and to discuss the feasibility and efficacy of monitoring controlled respiration persistence, and to provide a new method for the clinical respiratory monitoring. Methods: A total of 60 adult patients scheduled for general anesthesia, and 30 pediatric patients aged from 1 to 3 years old, classified as American Society of Anesthesiologists (ASA)Ⅰ-Ⅱ, were selected. A total of 60 adult patients were randomly divided into adult tracheal intubation (ATI) group and adult laryngeal mask(ALM) group, and there were 30 cases in each group. Additionally, 30 pediatric patients aged from 1 to 3 years old were regarded as pediatric tracheal intubation (CTI) group. After induction of general anesthesia, the patients in CTI and ATI groups were underwent tracheal intubation, while the patients in ALM group were given a laryngeal mask inserted and were connected to the anesthesia machine for mechanical ventilation. Whether or not the device could detect the respiratory rate (RR)of the patients in various groups was observed; the RR detected by the device and the frequency set on the anesthesia machine in various groups were compared. All the patients in three groups were simulated three common clinical scenarios of continuous respiration changes before surgery: disconnection of the breathing circuit, failure to switch from manual to mechanical control on the anesthesia machine, and slow air leakage in the breathing circuit. The ways to report the alert and start time of the atarm by the monitors were compared. Results: The controlled respiratory persistence monitor was able to detect the RR of the patients in three groups, and there was no significantly difference between the RR detected by the device and the frequency set on the anesthesia machine (P>0. 05). In the simulated scenarios of common respiratory persistence changes, all the patients in three groups received an artificial voice alarm signaling “Attention, breathing has stopped. ”, which was acknowledged. There was no significant difference in the start time of alarm of the controlled respiratory persistence monitor between ATI group and ALM group (P>0. 05). Compared with the start time of alarm of the patients in the same group across different scenarios, compared with slow air leakage in the breathing circuit, the start time to alarm for circuit disconnection and failure to switch from manual to mechanical control was shorter (P<0. 05). Conclusion: The clinical application of the controlled respiratory persistence monitor device designed based on the principle of detecting rhythmic temperature variations within artificial airways is feasible and effective in different populations and artificial airways. This device offers a new method for monitoring the respiratory continuity and ensuring the respiratory safety during surgery. [ABSTRACT FROM AUTHOR]

Objective: To analyze the intraoperative hemodynamic management by hypotension prediction index (HPI) in one patient underwent robot-assisted laparoscopic cystectomy, and to provide the reference for anesthesia monitoring and hemodynamic management in the similar major surgery. Methods: The clinical data, intraoperative hemodynamic data, usage and dosage of vasoactive drugs, and clinical outcomes of one patient underwent robot-assisted laparoscopic cystectomy with HPI-guided intraoperative hemodynamic management were retrospectively analyzed, and the relevant literatures were reviewed. Results: The patient, a 72-year-old female, was admitted due to macroscopic hematuria for 5 months accompanied by dysuria for 3 months. The cystoscope results showed a 7 cm×7 cm×5 cm mass on the right side of the bladder trigone and a 4 cm×3 cm×3 cm mass near the bladder neck. The positron emission tomography/computed tomography (PET/CT) results showed thickening of the right posterior bladder wall with high metabolism, and the preliminary diagnosis was bladder malignancy. After preoperative anesthesia evaluation, the robot-assisted laparoscopic cystectomy was planned. After entering the operating room, the routine monitoring was conducted, and the monitor equipped with HPI software was used to guide intraoperative hemodynamic management. After routine anesthesia induction, the tracheal intubation was performed by video laryngoscope. The patient experienced intraoperative hypotension (IOH) for six times, the cumulative time of mean arterial pressure (MAP)<65 mmHg was 13. 7 min, accounting for 4. 40% of the anesthesia duration, and the time-weighted average of MAP< 65 mmHg was 0. 28 mmHg. The time range with HPI≥85 roughly overlapped with and included the period of MAP<65 mmHg. At 146 time points with HPI≥85, the MAP remained greater than 65 mmHg at 68. 5% (100/146) of the points. At 47 time points with MAP<65 mmHg, HPI≥85 occurred at 97. 9% (46/47) of the points. On the first postoperative day, the patient’s hypersensitive cardiac troponin I was <0. 01 μg·L-1, and no perioperative adverse events occurred. The patient was discharged on the eighth day. Conclusion: HPI can promptly and accurately predict the occurrence of IOH in the patients undergoing robot-assisted laparoscopic cystectomy. The use of HPI-based hypotension correction strategies during surgery can maintain the time-weighted average of MAP<65 mmHg at a lower level. [ABSTRACT FROM AUTHOR]

Pierre Robin sequence (PRS) is characterized by facial abnormalities such as micrognathia, glossoptosis, and upper airway obstruction. Up to 90% of these children will present with cleft palate. Cleft palate is considered a common feature of PRS but is not a mandatory diagnostic characteristic. Premature diagnosis of PRS is prudent to plan and decide earlier on modes of airway management in infants with PRS, which, to date, remains a conundrum. We describe the challenges faced in managing an infant with PRS. We perform a narrative review of treatment options available for children with PRS and advocate for the role of early multidisciplinary teams in managing children with PRS. [ABSTRACT FROM AUTHOR]

Introduction: Factors associated with mortality among mechanically ventilated COVID-19 patients have been scarcely studied in Latin America. Objective: To identify factors associated with mortality in mechanically ventilated COVID-19 patients. Methods: This prospective study was undertaken in a single center between April and October 2020, recruiting COVID-19 patients managed with mechanical ventilation. We excluded patients who died within the first 24 hours after endotracheal intubation. Clinical characteristics, laboratory results, ventilation interventions, and outcomes were collected and compared between the deceased and surviving groups. The association between these factors and hospital death was examined, and relevant covariates were included in a multivariate logistic regression model. Results: A total of 273 patients were included (72.5% male), the mortality rate was 37% (95% CI 31% - 43%), and the median age was 63 years (IQR 52-72). The most frequent comorbidity was hypertension (45%). Factors associated with mortality were: older age (OR 1.08; 95% CI 1.05- 1.11), male gender (OR 2.79; 95% CI 1.30-6.01), immunosuppression (OR 3.98; 95% CI 1.57-10.06), thrombocytopenia (OR 3.84; CI 95% 1.47-10.01), driving pressure (OR 1.20; 95% CI 1.07-1.34) and the use of dialysis (OR 4.94; 95% CI 2.56-9.51). Chronic hypertension (OR 0.35; 95% CI 0.17-0.71) and fever on admission (OR 0.51; 95% CI 0.27-0.98) were found to have a protective effect. Conclusions: Older age, male sex, immunosuppression, thrombocytopenia, increased driving pressure, use of dialysis, absence of fever, or arterial hypertension were associated with an increased risk of mortality among mechanically ventilated COVID-19 patients. [ABSTRACT FROM AUTHOR]

Introduction: Situational awareness is essential during emergent procedures such as endotracheal intubation. Previous studies suggest that time distortion can occur during intubation. However, only in-hospital intubations performed by physicians have been studied. We aimed to determine whether time distortion affected paramedics performing intubation by examining the perceived vs actual total laryngoscopy time, defined as time elapsed from the laryngoscope blade entering the mouth until the endotracheal tube balloon passes the vocal cords. Methods: For this retrospective study we collected prehospital intubation data from a suburban, fire department-based emergency medical services (EMS) system from January 5, 2021-May 21, 2022. The perceived total laryngoscopy time was queried as a part of the electronic health record. Video laryngoscopy recordings were reviewed by a panel of experts to determine the actual time. Patients >18 years old who underwent intubation by paramedics with video laryngoscopy were included for analysis. The primary outcome was the difference between actual and perceived total laryngoscopy time. Secondary analysis examined the relationship between high time distortion, defined as the highest quartile of the primary outcome, and patient age, paramedic years of experience, perceived presence of difficult anatomy, excess secretions, use of rapid sequence intubation, and multiple intubation attempts. We conducted descriptive analysis followed by logistic regression analysis, chi-square tests, and Fisher exact tests when appropriate. Results: A total of 122 intubations were collected for analysis, and 10 were excluded due to lack of video recording. Final analysis included 112 intubations. Mean actual laryngoscopy time was 50.0 seconds (s) (95% confidence interval [CI] 43.7-56.3). Mean perceived laryngoscopy time was 27.8 s (95% CI 24.7-31.0). The median difference between actual and perceived time was 18 s (interquartile range 6-30). We calculated high time distortion as having a difference greater than 30 s between actual and perceived laryngoscopy time. None of the secondary variables had statistically significant associations with high time distortion. Overall, we show that the paramedic’s perception of total laryngoscopy time is significantly underestimated even when accounting for paramedic experience and perceived airway difficulty. Conclusion: This study suggests that time distortion may lead to an unrecognized prolonged procedure time. Limitations include use of a convenience sample, small sample size, and potential uncollected confounding variables. [ABSTRACT FROM AUTHOR]

Background: Artificial airways are essential in various clinical settings to maintain a patient's airway and provide necessary support for ventilation and oxygenation. These devices are commonly temporary and come in several types, each serving specific purposes. Understanding the indications, types, and proper care of artificial airways is crucial for health care professionals to ensure patients receive optimal care and prevent complications. Objective: This article aims to review the indications for using artificial airways and discuss the most commonly used types, including supraglottic airway devices, endotracheal tubes, tracheostomy tubes, and laryngectomy tubes. It also provides insights into the procedures involved in intubation and percutaneous tracheostomy and offers guidance on patient management, emphasizing assessment, oral care, suctioning, and humidification for patients with these airway devices. Conclusion: This article underscores the significance of understanding artificial airways, not just as a set of skills but as a commitment to patient welfare. Health care professionals who master the knowledge and care of these devices can significantly contribute to their patients' well-being and quality of life. [ABSTRACT FROM AUTHOR]

A meta-analysis published in the journal Anaesthesia compared the use of remifentanil with neuromuscular blocking (NMB) drugs for tracheal intubation in adults. The study found that a remifentanil bolus provided comparable rates of successful tracheal intubation compared to NMB drugs. However, this conflicts with the findings of a recent trial that found remifentanil to be statistically inferior to NMB drugs. While the use of NMB drugs is widely recommended, the study suggests that tracheal intubation with high doses of remifentanil may be a safe alternative in certain situations. Further research is needed to investigate the efficacy of tracheal intubation without NMB drugs and to improve patient safety during the procedure. [Extracted from the article]

Summary: There is increasing interest in the use of short‐acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of remifentanil for tracheal intubation compared with neuromuscular blocking drugs in adult patients. We conducted a systematic search for randomised controlled trials evaluating remifentanil for tracheal intubation. Primary outcomes included tracheal intubation conditions and adverse events. Twenty‐one studies evaluating 1945 participants were included in the analysis. Use of remifentanil (1.5–4.0 μg.kg‐1) showed no evidence of a difference in tracheal intubation success rate compared with neuromuscular blocking drugs (risk ratio (95%CI) 0.97 (0.94–1.01); six studies; 1232 participants; I2 28%; p = 0.16; moderate‐certainty evidence). Compared with neuromuscular blocking drugs, the use of remifentanil (2.0–4.0 μg.kg‐1) makes little to no difference in terms of producing excellent tracheal intubation conditions (risk ratio (95%CI) 1.16 (0.72–1.87); two studies; 121 participants; I2 31%, p = 0.54; moderate‐certainty of evidence). There was no evidence of an effect between remifentanil (2.0–4.0 μg.kg‐1) and neuromuscular blocking drugs for bradycardia (risk ratio (95%CI) 0.44 (0.01–13.90); two studies; 997 participants; I2 81%; p = 0.64) and hypotension (risk ratio (95%CI) 1.05 (0.44–2.49); three studies; 1071 participants; I2 92%; p = 0.92). However, the evidence for these two outcomes was judged to be of very low‐certainty. We conclude that remifentanil may be used as an alternative drug for tracheal intubation in cases where neuromuscular blocking drugs are best avoided, but more studies are required to evaluate the haemodynamic adverse events of remifentanil at different doses. [ABSTRACT FROM AUTHOR]

Background: The pediatric sizes of BlockBuster supraglottic airway (SGA) have been introduced recently. Its efficacy as a conduit for endotracheal intubation in children has not been assessed. Newer devices are often compared with Air‐Q SGA to assess their intubating capability. Aims: The primary objective was to compare the time taken for fiber‐optic‐guided intubation through the BlockBuster and the Air‐Q SGAs. Methods: Sixty children aged 6 months to 12 years with normal airways were randomized into two groups: Air‐Q SGA (Group A) and Blockbuster SGA (Group B). After administration of general anesthesia, an appropriately sized SGA was inserted. The time taken for fiber‐optic‐guided intubation through the SGA, success, ease, and time for SGA insertion and removal were noted. The glottic view was graded by fiber‐optic bronchoscopy. Results: Demographic parameters were comparable. The time to intubate with the BlockBuster 62.40 ± 17.2 s was comparable to the Air‐Q 60.8 ± 18.5 s (mean difference 1.6 s, 95% CI −7.65 to10.85; p =.73). The average time for SGA insertion in BlockBuster and Air‐Q was 14.57 ± 3.2 s and 16.67 ± 5.39 s, respectively (mean difference −2.1, 95% CI −4.39 to 0.19 s; p =.07). The first‐attempt intubation success and overall intubation success rates were comparable in both groups, 96.7% and 100%, respectively. In Group B, 25/3/1/1/0 cases had a glottic view grade of 1/2/3/4/5, respectively. In Group A, 23/3/2/2/0 cases had grade of 1/2/3/4/5 glottic views respectively. The average time to SGA removal was comparable between the BlockBuster (20.17 ± 5.8 s) and the Air‐Q (22.5 ± 12.8 s) groups (mean difference −2.3 s, 95% CI −7.5 to 2.82 s; p =.37). None of the children had any perioperative complications. Conclusion: BlockBuster SGA may be a useful alternative to Air‐Q for SGA‐assisted, fiber‐optic‐guided tracheal intubation in children. [ABSTRACT FROM AUTHOR]

Background: Anesthesia is required for endoscopic removal of esophageal foreign bodies (EFBs) in children. Historically, endotracheal intubation has been the de facto gold standard for airway management in these cases. However, as more elective endoscopic procedures are now performed under propofol sedation with natural airway, there has been a move toward using similar Monitored Anesthesia Care (MAC) for select patients who require endoscopic removal of an EFB. Methods: In this single‐center retrospective cohort study, we compared endoscopic EFB removal with either MAC or endotracheal intubation. Descriptive statistics summarized factors stratified by initial choice of airway technique, including intra‐ and postanesthesia complications and the frequency of mid‐procedure conversion to endotracheal intubation in those initially managed with MAC. To demonstrate the magnitude of associations between these factors and the anesthesiologist's choice of airway technique, univariable Firth logistic and quantile regressions were used to estimate odds ratios (95% CI) and beta coefficients (95% CI). Results: From the initial search, 326 patients were identified. Among them, 23% (n = 75) were planned for intubation and 77% (n = 251) were planned for MAC. Three patients (0.9%) who were initially planned for MAC required conversion to endotracheal intubation after induction. Two (0.6%) of these children were admitted to the hospital after the procedure and treated for ongoing airway reactivity. No patient experienced reflux of gastric contents to the mouth or dislodgement of the foreign body to the airway, and no patient required administration of vasoactive medications or cardiopulmonary resuscitation. Patients had higher odds that the anesthesiologist chose to utilize MAC if the foreign body was a coin (OR, 3.3; CI, 1.9–5.7, p <.001) or if their fasting time was >6 h. Median total operating time was 15 min greater in intubated patients (11 vs. 26 min, p <.001). Conclusions: This study demonstrates that MAC may be considered for select pediatric patients undergoing endoscopic removal of EFB, especially those who have ingested coins, who do not have reactive airways, who have fasted for >6 h, and in whom the endoscopic procedure is expected to be short and uncomplicated. Prospective multi‐site studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

This article examines the connection between early endotracheal intubation (ETI) and patient outcomes in emergency department cardiac arrest (EDCA) cases. The study found that early ETI did not have a significant effect on the rate of return of spontaneous circulation (ROSC) after EDCA, but it was linked to better 24-hour survival. However, the study has limitations, such as its retrospective nature and absence of a control group. The authors recommend further research to gain more conclusive findings and stress the importance of delivering high-quality CPR and using clinical judgment in airway management. [Extracted from the article]

Purpose The benefits of pharmacists' involvement in medical emergencies are well established, but optimal methods of training pharmacists for emergency response are unknown. The primary objective of this report is to describe the design and evaluation of a pharmacy resident medical emergency response training (PR-MERT) program for preparing trainees to respond to hospital medical emergencies, including cardiac arrest and rapid sequence intubation (RSI). Summary The PR-MERT program was a year-long longitudinal experience designed to prepare postgraduate year 1 pharmacy residents for medical emergency response. During the first month, the residents completed an orientation session that encompassed several lectures, certification by the American Heart Association in basic life support and advanced cardiovascular life support, standardized simulation scenarios, and mock medical emergencies. The trainees continued to utilize these skills and clinical knowledge through a longitudinal didactic lecture series, resident case conferences, and practice-based application by responding to real-life medical emergencies. Residents were assessed and coached throughout the program by clinical pharmacy preceptors and a "code coach" with extensive medical emergency response experience. After the year-long training, residents completed an anonymous survey assessing self-confidence and the structure of the program. The results showed improved confidence in medication selection and dosing, as well as anticipating the needs of the team and speaking up in cardiac arrest and RSI situations. Residents were satisfied with the training offered and structure of the program. Conclusion The development of a PR-MERT program at an academic medical center was successful in achieving longitudinal learning objectives and improving residents' confidence in responding to medical emergencies. The implementation of a similar medical emergency training curriculum in inpatient pharmacy residency programs may be beneficial. [ABSTRACT FROM AUTHOR]

Background: Tracheal intubation sometimes causes postoperative sore throat (POST) due to laryngeal damage. However, clinical observations suggest that the environment of the oral cavity may also affect POST. Objective: The purpose of this study was to investigate whether salivary pH in the oral cavity affects POST. Methods: After obtaining ethical approval, informed consent was obtained from all patients. Patients who underwent surgery in the supine position were enrolled as the control group. Patients who underwent laparoscopic surgery in the head‐down position were enrolled as the intervention group. Immediately before both groups of patients were anaesthetised, expelled saliva was collected, and salivary pH was measured. Immediately postoperatively, the same measurement was carried out before the patient regained consciousness. The primary outcome was the change in salivary pH. The secondary outcome was POST. In our study, POST was defined as pharyngeal and swallowing pain in the glossopharyngeal and superior laryngeal nerves. The normal distribution of pH was tested using the Shapiro–Wilk test followed by analysis using repeated‐measurements and one‐way analysis of variance. Statistical significance was set at p <.05. Results: A total of 62 patients were enrolled, of whom two were excluded based on the exclusion criteria. Salivary pH in the intervention group was significantly lower than that in the control group. Five patients had POST in the intervention group, whereas none had POST in the control group had POST. Conclusion: Acidotic‐shifted saliva is considered one of the causes of POST. [ABSTRACT FROM AUTHOR]

Background: Myoclonus is a common issue in etomidate anesthesia induction, and various drugs have been used to reduce its incidence, highlighting the ongoing search for better alternatives in anesthesiology. Aims and Objectives: The study analyzed the impact of dexmedetomidine (DEX) and midazolam pre-treatment on etomidate-induced myoclonus incidence, stress response at laryngoscopy, and intubation during etomidate induction. Materials and Methods: A prospective randomized controlled intervention study (superiority trial) was done involving 42 patients of age 20–60 years, randomly allocated in two equal groups (Group D: Inj. DEX was given as infusion (0.5 µg/kg) in 10 mL 0.9% normal saline over 10 min and 5 min before induction. Group M: Inj. Midazolam was given 0.02 mg/kg, prepared in 10 mL 0.9% normal saline, to be infused over 10 min and 5 min before induction). Myoclonus was graded after intravenous administration of etomidate (0.3 mg/kg) and hemodynamic response to laryngoscopy and intubation were observed at various time intervals. Statistical analysis was done using SPSS version 27.0. Independent t-test/ Mann–Whitney test (for non-parametric data) and Chi-square test/Fisher’s exact test were used to compare variables. A P<0.05 was considered statistically significant. Results: The study found that DEX effectively suppressed stress response due to intubation compared to midazolam, with mean myoclonus gradation (Mean±SD) in Group-D and Group-M being 0.6190±0.7400 and 1.6667±0.8563, respectively, indicating a significant distribution with group. Conclusion: DEX was found to be more effective than midazolam in preventing etomidate-induced myoclonus and attenuating stress response compared to midazolam. [ABSTRACT FROM AUTHOR]

Background: Confirmation of the position of the endotracheal tube (ETT) is an essential step for verification of intubation. Failure to diagnose esophageal intubation may lead to fatal consequences. Capnography is the gold standard for confirmation of ETT position, but it is practically impossible to be performed in all situations. Ultrasonography (USG) or “visual stethoscope” can be used as an effective alternative for all intubators in all situations. Aims and Objectives: The study was conducted to evaluate the ultrasonography (USG) technique with respect to its efficacy to detect the proper endotracheal position of ETT compared to end-tidal capnography among patients undergoing general anesthesia; to compare the time taken by the USG technique with that of capnography for detection of proper placement of ETT; to assess the feasibility of USG to detect accidental esophageal intubation. Materials and Methods: This prospective comparative cross-sectional observational study was conducted on 68 patients. Both capnography and upper airway USG were performed immediately after intubation to confirm the ETT placement. Sensitivity, specificity, and positive and negative predictive values of upper airway USG were determined against capnography as the reference method. The time required to determine ETT placement by the two methods was found out and compared. Agreement between the methods was assessed with kappa statistics. Results: USG detected all three cases of esophageal intubation but could not detect two patients with correct tracheal intubation. Upper airway USG had a sensitivity of 96.92% (95% confidence interval [CI]: 93.54–100%), specificity of 100%, positive predictive value of 100%, and negative predictive value of 60% (95% CI: 50.4–69.6%). The Kappa value was found to be 0.735, indicating a good agreement between upper airway USG and capnography for confirmation of ETT placement. Time taken for confirmation of ETT by capnography was 21.68±2.63 s versus 11.44±1.38 s for upper airway USG (P<0.001). USG demonstrated bilateral lung sliding in 60 (88.2%) patients, unilateral lung sliding in 3 (4.4%) patients, and lung sliding was absent in 5 (7.4%) patients. Conclusion: Realtime upper airway USG is an alternative method of confirmation of ETT that is not only sensitive and accurate but is faster than the current gold standard method, capnography. [ABSTRACT FROM AUTHOR]

Background: The use of cuffed endotracheal tubes (ETTs) has become the standard of care in pediatric practice. The rationale for the use of a cuffed ETT is to minimize pressure around the cricoid while providing an effective airway seal. However, safe care requires that the cuff lie distal to the cricoid ring following endotracheal intubation. The current study demonstrates the capability of computed tomography (CT) imaging in identifying the position of the cuff of the ETT in intubated patients. Methods: The study included patients ranging in age from 1 month to 10 years who underwent neck and chest CT imaging that required general anesthesia and endotracheal intubation. The location of the ETT and of the cuff within the airway was determined from axial CT images at three levels (proximal, middle, and distal). Anatomical orientations were tabulated, and percent chances of each orientation were determined for the ETT and the cuff. Results: The study cohort included 42 patients ranging in age from 1 to 114 months. An ETT with a polyvinylchloride cuff was used in 24 patients, and an ETT with a polyurethane cuff was used in 18 patients. The ETT was located near the posterior wall of the trachea in approximately 24-38% of patients, being most likely to be centrally located at the proximal end and at its mid-portion. The middle part of the cuff was most likely to be positioned in the mid-portion of the trachea but tended to skew anteriorly at both the proximal and distal ends. Conclusion: This is the first study using CT imaging to identify the uniformity of cuff inflation within the trachea in children. With commonly used cuffed ETTs, cuff inflation and the final position of ETT cuff within the tracheal lumen were not uniform. Future investigations are needed to determine the reasons for this asymmetry and its clinical implications. [ABSTRACT FROM AUTHOR]

Background: The National Spinal Cord Injury Registry of Iran (NSCIR-IR) and the National Trauma Registry of Iran (NTRI) were established to meet the data needs for research and assessing trauma status in Iran. These registries have a group of patients shared by both registries, and it is expected that some identical data will be collected about them. A general question arises whether the spinal cord injury registry can receive part of the common data from the trauma registry and not collect them independently. Methods: We examined variables captured in both registries based on structure and concept, identified the overlapping period during which both systems recorded data in the same centers and extracted relevant data from both registries. Further, we evaluated the data for any discrepancies in amount or nature and pinpointed the underlying reasons for any inconsistencies. Results: Out of all the variables in the NSCIR-IR database, 18.6% of variables were similar to the NTRI in terms of concept and structure. Although four hospitals participated in both registries, only two (Sina and Beheshti Hospitals) had common cases. Patient names, prehospital intubation, ambulance arrival time, ICU length of stay, and admission time were consistent across both registries with no differences. Other common data variables had significant discrepancies. Conclusion: This study highlights the potential for health information exchange (HIE) between NSCIR-IR and NTRI and serves as a starting point for stakeholders and policymakers to understand the differences between the two registries and work toward the successful adoption of HIE. [ABSTRACT FROM AUTHOR]

BACKGROUND: High acuity trauma and patients in cardiopulmonary arrest are not frequently seen in all pediatric Level I trauma centers. Yet, nurses are required to manage these patients in fast-paced, high-pressure environments. OBJECTIVE: This project aims to develop and evaluate an education program for high-risk, low-volume equipment and skills in the pediatric emergency department setting. METHODS: This is a pre- and post-quality improvement study conducted in a Northeastern United States pediatric Level I trauma center. Emergency department nurses were invited to view videos detailing high-risk, low-volume equipment use. For the convenience of access, Quick Response (QR) codes linked to the videos were placed on each piece of equipment reviewed. General self-efficacy and levels of self-efficacy in using the equipment were assessed before the intervention and again after 4 weeks from January to February 2023. RESULTS: A total of 43 pediatric emergency nurses participated in the education. The mean aggregate general self-efficacy score was 32.93. Mean scores in all areas (Level 1 rapid infuser, fluid warmer, blood administration, and securing an endotracheal tube) improved after the intervention. CONCLUSIONS: Easily accessible, brief refresher videos linked to QR codes in the pediatric emergency department can help empower nurses who need to use high-risk, low-volume equipment. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has had an unprecedented impact on population health and hospital operations. Over 7 million patients have been hospitalized for COVID-19 thus far in the United States alone. Mortality rates for hospitalized patients during the first wave of the pandemic were > 30%, but as we enter the fifth year of the pandemic hospitalizations have fallen and mortality rates for hospitalized patients with COVID-19 have plummeted to 5% or less. These gains reflect lessons learned about how to optimize respiratory support for different kinds of patients, targeted use of therapeutics for patients with different manifestations of COVID-19 including immunosuppressants and antivirals as appropriate, and high levels of population immunity acquired through vaccines and natural infections. At the same time, the pandemic has helped highlight some long-standing sources of harm for hospitalized patients including hospital-acquired pneumonia, ventilator-associated events (VAEs), and hospital-acquired respiratory viral infections. We are, thankfully, on the leeside of the pandemic at present; but the large increases in ventilator-associated pneumonia (VAP), VAEs, bacterial superinfections, and nosocomial respiratory viral infections associated with the pandemic beg the question of how best to prevent these complications moving forward. This paper reviews the burden of hospitalization for COVID-19, the intersection between COVID-19 and both VAP and VAEs, the frequency and impact of hospital-acquired respiratory viral infections, new recommendations on how best to prevent VAP and VAEs, and current insights into effective strategies to prevent nosocomial spread of respiratory viruses. [ABSTRACT FROM AUTHOR]

BACKGROUND: Re-intubation is necessary in 2% to 30% of cases of patients receiving a planned extubation. This procedure is associated with prolonged mechanical ventilation, a greater need for tracheostomy, a higher incidence of ventilator-associated pneumonia, and higher mortality. The aim of this study was to evaluate the effect of re-intubation within 48 h on mortality after planned extubation by using a randomized controlled trial database. METHODS: Secondary analysis of a multi-center randomized trial, which evaluated the effect of reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial, followed by extubation. The study included adult subjects who received invasive mechanical ventilation for > 12 h. The subjects were divided into an extubation failure group and an extubation success group. The outcome was in-hospital mortality. Two multivariate logistic regression models were constructed to identify independent factors associated with mortality. RESULTS: Among the 336 subjects studied, extubation failed in 52 (15.4%) and they were re-intubated within 48 h. Most re-intubations occurred between 12 and 24 h after planned extubation (median [interquartile range] 16 [6-36] h). Mortality of the extubation failure group was higher both in the ICU (32.6% vs 6.6%; odds ratio [OR] 6.77, 95% CI 3.22-14.24; P < .001) and in-hospital (42.3% vs 14.0%; OR 4.47, 95% CI 2.34-8.51; P < .001) versus the extubation success group. Multivariate logistic regression analyses showed that re-intubation within 48 h was independently associated with both ICU mortality (OR 6.10, 95% CI 2.84-13.07; P < .001) and in-hospital mortality (OR 3.36, 95% CI 1.67-6.73; P = .001). In-hospital mortality was also associated with rescue noninvasive ventilation after extubation (OR 2.44, 95% CI 1.25-4.75; P = .009). CONCLUSIONS: Re-intubation within 48 h after planned extubation was associated with mortality in subjects who were critically ill. [ABSTRACT FROM AUTHOR]

Subglottic stenosis is a condition causing narrowing of the trachea, which can occur rarely secondary to trauma, infection, tumors, inflammatory, and iatrogenic causes. In our case, the child developed subglottic stenosis postcardiac surgery after being mechanically ventilated in the postoperative period. The causes for subglottic stenosis may be some trauma in the presence of coagulation abnormalities in cyanotic heart diseases such as TOF, the ischemia to the subglottic tissue by reduced perfusion during cardiopulmonary bypass, and/or the trauma caused by crying and fighting of the child while being with the endotracheal tube. Anesthetic management of the surgery is challenging for the anesthesiologist due to the shared airway by the surgeon and the anesthesiologist. The inability to effectively ventilate the patient after induction of general anesthesia will result in catastrophic complications. Subglottic stenosis requires careful planning and execution along with proper communication between the team. [ABSTRACT FROM AUTHOR]

Background: The main clinical manifestations of patients with Pierre Robin sequence (PRS) include micrognathia, the glossoptosis and dyspnoea. The difficulty of tracheal intubation (TI) in such patients is increased. Objective: The purpose of the study was to evaluate the reliability and efficacy of the PRS simulator. Methods: A PRS simulator was developed by using 3-dimensional (3D) printing technology under computer-aided design. A total of 12 anaesthesiologists each trained 5 times for TI on the PRS Training Simulator-1 and recorded the simulation time. After the training, they were randomly divided into three groups with a total of 12 nontrained anaesthesiologists, and the simulation was completed on PRS Simulator-2, 3 and 4. The simulation time was recorded, and the performance was evaluated by three chief anaesthesiologists. Then, all 24 anaesthesiologists completed the questionnaire. Results: A PRS simulator developed by 3D printing was used to simulate the important aspects of TI. The average number of years worked was 6.3 ± 3.1 years, and 66.7% were female. The time for the 12 anaesthesiologists to complete the training gradually decreased (p < 0.01). Compared with the trained anaesthesiologists, the simulation time of TI in the nontrained anaesthesiologists was much longer (all p < 0.01). In addition, the simulation performance of the trained anaesthesiologists was relatively better (all p < 0.01). Conclusion: The reliability and efficacy of the PRS simulator is herein preliminarily validated, and it has potential to become a teaching and training tool for anaesthesiologists. [ABSTRACT FROM AUTHOR]

Background & Aims: Endotracheal intubation is essential for safe general anesthesia practice but it is associated with stress response due to sympathetic stimulation resulting in hypertension and tachycardia. So, to attenuate this stress response during laryngoscopy and endotracheal intubation, the efficacy of intravenous dexmedetomidine and esmolol were compared in this study. Materials And Methods: The study was carried on total 210 ASA grade I or II patients of aged 18-60 years who were scheduled for elective laparoscopy surgery under general anesthesia. All the patients were randomly divided into the three groups of 70 each. In control group (group C)-intravenous (IV) 0.9% saline plain, dexmedetomidine group (group D)- 1 μg/kg dexmedetomidine and esmolol group (group E)- 1.5 mg/kg esmolol diluted with 0.9% saline in volume of 20 ml IV were infused over 10 minutes and after that induction of anaesthesia was done. Hemodynamic parameters were recorded atbaseline, before intubation, during intubation, and then every 1 minute upto 10 minutes. Results: In group D, increase in heart rate and blood pressure after intubation at any time intervals was not statistically significant, whereas in group E, there was a statistically significant increase in blood pressure after intubation at 1, 2, and 3 minutes only and in heart rate up to 5 minutes. Conclusion- Dexmedetomidine is better alternative to esmolol for attenuating the stress response to laryngoscopy and intubation during general anaesthesia. [ABSTRACT FROM AUTHOR]

Difficult airway management represents a challenge. Guidelines recommend choosing the airway technique based on physicians' skills, equipment, available devices and context. A man with acute respiratory failure needed an emergent intubation. He was obese with Mallampati score 4, Cormack-Lehane grading 4, macroglossia, reducedmouth opening, stocky and wide neck, and deviated laryngotracheal axis due to expanding neck hematoma. After endotracheal intubation failure, the anesthetist placed a second-generation laryngeal mask airway and started ventilation. In the next step, definite airway was provided by an endotracheal tube placed through the mask under flexible fiberscope vision. Supraglottic airway devices are recommended in cases of unanticipated difficult intubation after endotracheal intubation failure. They are used to ensure satisfactory oxygenation and occasionally to guide the endotracheal tube. Fiberscope is useful to ensure vision of larynx and trachea in these scenarios. This is a unique case of emergency and difficult airway management using this combined approach. [ABSTRACT FROM AUTHOR]

Rationale: Endotracheal intubation is the third most common bedside procedure in U.S. hospitals. In over 40% of intubations, preventable complications attributable to human factors occur. A better understanding of team dynamics during intubation may improve patient safety. Objectives: To explore team dynamics and safety-related actions during emergent endotracheal intubations in the emergency department and intensive care unit and to engage members of the care team in reflection for process improvement through a novel video-based team debriefing technique. Methods: Video-reflexive ethnography involves in situ video recording and reflexive discussions with practitioners to scrutinize behaviors and to identify opportunities for improvement. In this study, real-time intubations were recorded in the emergency department and intensive care unit at Mayo Clinic Rochester, and facilitated video-reflexive sessions were conducted with the multidisciplinary procedural teams. Themes about team dynamics and safety-related action were identified inductively from transcriptions of recorded sessions. Results: Between December 2022 and January 2023, eight video-reflexive sessions were conducted with a total of 78 participants. Multidisciplinary members included nurses (n = 23), respiratory therapists (n = 16), pharmacists (n = 7), advanced practitioners (n = 5), and physicians (n = 26). In video-reflexive discussions, major safety gaps were identified and several solutions were proposed related to the use of a multidisciplinary intubation checklist, standardized communication and team positioning, developing a culture of safety, and routinely debriefing after the procedure. Conclusions: The findings of this study may inform the development of a team supervision model for emergent endotracheal intubations. This approach could integrate key components such as a multidisciplinary intubation checklist, standardized communication and team positioning, a culture of safety, and debriefing as part of the procedure itself. [ABSTRACT FROM AUTHOR]

Background and Purpose: Patients who have been intubated ≥48 hours are at risk of dysphagia. Evaluation of swallowing before starting oral feeding after extubation is necessary to prevent aspiration and the problems caused by aspiration. The Postextubation Dysphagia Screening tool is a validated and reliable tool used to evaluate extubation-induced dysphagia. This study was conducted to evaluate the validity and reliability of the Postextubation Dysphagia Screening Tool for the Turkish population. Methods: The study had a methodological design and was carried out with 50 patients followed in the intensive care unit of a public hospital. The study was carried out in four stages: (1) language validity, (2) content validity, (3) establishing interrater reliability by agreement with two observers (intensive care nurse and intensivist), and (4) establishing sensitivity and specificity with the intensive care nurse and intensivist. Results: The overall content validity index was 0.91, indicating content validity. Interrater reliability was established (Cohen's g = 0.93). The prevalence of postextubation dysphagia was 42%, and the sensitivity of the Postextubation Dysphagia Screening Tool was 82% and the specificity was 64%. Implications for Practice: The Turkish version of the Postextubation Dysphagia Screening Tool exhibited good evidence of validity and reliability and was determined important as it can help nurses evaluate postextubation dysphagia in intensive care patients. The use of this tool by a nurse reduces the risk of unsafe oral intake among patients after prolonged intubation. This tool allows accurate assessment of dysphagia and initiation of early and safe oral feeding in critical care patients. [ABSTRACT FROM AUTHOR]

Background: Music therapy has been used as a complementary intervention to provide synergistic analgesia for various procedures. Objective: To evaluate the effects of natural sound therapy on pain intensity and agitation scores in intubated adult Chinese patients who received endotracheal suctioning in a critical care unit. Methods: A prospective, real-world, randomized, double-blind, controlled study was conducted from July 2021 through February 2022 among intubated surgical intensive care unit patients in a Chinese hospital. Patients were randomly assigned to a control group receiving conventional treatment or an intervention group receiving natural sound therapy plus conventional treatment (50 patients in each group). Patients' pain intensity and agitation levels were analyzed before, during, immediately after, 5 minutes after, and 15 minutes after completion of endotracheal suctioning. Pain intensity was assessed with the Critical-Care Pain Observation Tool (CPOT); agitation was assessed with the Richmond Agitation-Sedation Scale (RASS). Results: According to CPOT scores, patients in the intervention group had significant relief of pain intensity during, immediately after, and 5 minutes after endotracheal suctioning compared with patients in the control group (all P <.001). The RASS scores showed that agitation levels were significant lower in the intervention group than in the control group during (P =.002) and immediately after (P <.001) endotracheal suctioning. Conclusions: In this real-world study, natural sound therapy was part of a holistic bundle of interventions used to reduce pain and agitation in surgical intensive care unit patients during endotracheal suctioning. [ABSTRACT FROM AUTHOR]

Background: Use of noninvasive ventilation in patients with acute respiratory distress syndrome (ARDS) is debated. The COVID-19 pandemic posed challenges due to high patient volumes and worldwide resource strain. Objectives: To determine associations between use of noninvasive ventilation in adult patients with moderate to severe ARDS due to SARS-CoV-2 pneumonia, progression to intubation, and hospital mortality. Methods: This retrospective cohort study included patients in an institutional COVID-19 registry. Adult patients were included if they were admitted for COVID-19 between March 1, 2020, and March 31, 2022, and developed moderate to severe ARDS. Primary outcomes were progression to intubation and hospital mortality in patients who received noninvasive ventilation or mechanical ventilation. A secondary outcome was successful treatment with noninvasive ventilation without intubation. Results: Of 823 patients who met inclusion criteria, 454 (55.2%) did not receive noninvasive ventilation and 369 (44.8%) received noninvasive ventilation. Patients receiving noninvasive ventilation were more likely to require mechanical ventilation than were patients not receiving noninvasive ventilation. Among patients requiring endotracheal intubation, those receiving noninvasive ventilation had a higher likelihood of mortality. Patients receiving noninvasive ventilation had lower severity-adjusted odds of survival to discharge without intubation than did patients not receiving noninvasive ventilation. Conclusion: Patients with moderate to severe ARDS due to SARS-CoV-2 pneumonia treated with noninvasive ventilation had increased likelihood of progression to endotracheal intubation and hospital mortality. [ABSTRACT FROM AUTHOR]

Purpose: Awake extubation and deep extubation are commonly used anesthesia techniques. In this study, the safety of propofol-assisted deep extubation in the dental treatment of children was assessed. Materials and methods: Children with severe caries who received dental treatment under general anesthesia and deep extubation between January 2017 and June 2023 were included in this study. Data were collected on the following variables: details and time of anesthesia, perioperative vital signs, and incidence of postoperative complications. The incidence of laryngeal spasm (LS) was considered to be the primary observation indicator. Results: The perioperative data obtained from 195 children undergoing dental treatment was reviewed. The median age was 4.2 years (range: 2.3 to 9.6 years), and the average duration of anesthesia was 2.56 h (range 1 to 4.5 h). During intubation with a videoscope, purulent mucus was found in the pharyngeal cavity of seven children (3.6%); LS occurred in five of them (2.6%), and one child developed a fever (T = 37.8 °C) after discharge. Five children (2.6%) experienced emergence agitation (EA) in the recovery room. Also, 13 children (6.7%) experienced epistaxis; 10 had a mild experience and three had a moderate experience. No cases of airway obstruction (AO) and hypoxemia were recorded. The time to open eyes (TOE) was 16.3 ± 7.2 min. The incidence rate of complications was 23/195 (11.8%). Emergency tracheal reintubation was not required. Patients with mild upper respiratory tract infections showed a significantly higher incidence of complications (P < 0.001). Conclusions: Propofol-assisted deep extubation is a suitable technique that can be used for pediatric patients who exhibited non-cooperation in the outpatient setting. Epistaxis represents the most frequently encountered complication. Preoperative upper respiratory tract infection significantly increases the risk of complications. The occurrence of EA was notably lower than reported in other studies. [ABSTRACT FROM AUTHOR]