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Background: Video double-lumen tube (VDLT) intubation in lateral position is a potential alternative to intubation in supine position in patients undergoing thoracic surgery. This non-inferiority trial assessed the efficacy and safety of VDLT intubation in lateral position. Methods: Patients (18–70 yr) undergoing right thoracoscopic lung surgery were randomized to either the left lateral position group (group L) or the supine position group (group S). The VDLT was placed under video larygoscopy. The primary endpoint was the intubation time. Secondary endpoints included VDLT displacement rate, intubation failure rate, the satisfaction of surgeon and nurse, and intubation-related adverse events. Results: The analysis covered 80 patients. The total intubation time was 52.0 [20.4]s in group L and 34.3 [13.2]s in group S, with a mean difference of 17.6 s [95% confidence interval (CI): 9.9 s to 25.3 s; P = 0.050], failing to demonstrate non-inferiority with a non-inferiority margin of 10 s. Group L, compared with group S, had significantly lower VDLT displacement rate (P = 0.017) and higher nurse satisfaction (P = 0.026). No intubation failure occurred in any group. Intubation complications (P = 0.802) and surgeon satisfaction (P = 0.415) were comparable between two groups. Conclusions: The lateral VDLT intubation took longer time than in the supine position, and non-inferiority was not achieved. The incidence of displacement as the secondary endpoint was lower in the L group, possibly due to changing body positions beforehand. The indication of lateral VDLT intubation should be based on a balance between the safety of airway management and the lower incidence of displacement. Trial registration: The study was registered at Chictr.org.cn with the number ChiCTR2200064831 on 19/10/2022. [ABSTRACT FROM AUTHOR]

Background: Pregnancy is associated with an increased risk of pulmonary aspiration during general anaesthesia, but the incidence of this complication is not well defined. Methods: We performed a retrospective database review in a tertiary care university hospital to determine the incidence of pulmonary aspiration in pregnant patients undergoing endotracheal intubation, with and without Rapid Sequence Induction (RSI), as well as face-mask ventilation and supraglottic airway devices. We included Patients in the 2nd or 3rd trimester of pregnancy and immediate postpartum undergoing surgical procedures. The primary endpoint was the occurrence of pulmonary aspiration. Results: Data from 2,390 patients undergoing general anaesthesia for cerclage of cervix uteri, manual removal of retained placenta, repair of obstetric laceration, or postpartum bleeding were retrospectively evaluated. A supraglottic airway device or face-mask ventilation was used in 1,425/2,390 (60%) of patients, while 638/2,390 (27%) were intubated. RSI was used in 522/638 (82%) of patients undergoing tracheal intubation, or 522/2,390 (22%) of the entire cohort. In-depth review of the charts, including 54 patients who had been initially classified as "possible pulmonary aspiration" by anaesthetists, revealed that this adverse event did not occur in the cohort. Conclusions: In conclusion, in this obstetric surgery patient population at risk for pulmonary aspiration, supraglottic airway devices were used in approximately 60% of cases. Yet, no aspiration event was detected with either a supraglottic airway or endotracheal intubation. [ABSTRACT FROM AUTHOR]

Background • Severe pneumonia continues to be a prominent cause of hospitalization and global mortality. There is ongoing debate regarding the effectiveness of different oxygen therapy modalities, particularly high-flow nasal cannula (HFNC) oxygen therapy and invasive mechanical ventilation (IMV), in the treatment of severe pneumonia. Objective • This study investigated the risk factors associated with mechanical ventilation in pediatric patients with severe pneumonia. Methods • This retrospective study included a cohort of 240 pediatric patients with severe pneumonia treated at Zhangzhou Hospital, affiliated with Fujian Medical University, from January 2019 to December 2020. Patients were categorized into two groups: the HFNC group and the IMV group. Comparative analysis was performed on general patient information, infection markers, arterial blood gas values, as well as the prevalence of underlying conditions and complications between the two groups. Multivariate logistic regression analysis was employed to identify the risk factors for invasive mechanical ventilation in children with severe pneumonia. Results • Patients in the HFNC group experienced shorter hospitalization durations, and the average age in this group was lower compared to the IMV group (P < .05). Upon admission, respiratory rate and heart rate were higher in the HFNC group compared to the IMV group (P < .05). The IMV group demonstrated higher oxygenation index (OI) and infection markers, while the pH level was lower in the IMV group than in the HFNC group (P < .05). The prevalence of underlying conditions and complications in the IMV group was significantly higher than in the HFNC group (P < .05). Basic conditions such as heart disease, prematurity, heart failure, low OI, toxic encephalopathy, and influenza virus infection were identified as risk factors for IMV. Conclusions • High-flow nasal cannula therapy has shown therapeutic efficacy in pediatric patients with severe pneumonia. However, children with underlying medical conditions may require prompt tracheal intubation and invasive mechanical ventilation. [ABSTRACT FROM AUTHOR]

The article presents the case of a 10-year-old child with a history of X-linked chronic granulomatous disease (CGD) who is experiencing non-productive cough, dysphonia and weight loss for 12 months to discuss chronic granulomatous disease of the upper airway. Also cited are the use of airway endoscopy to confirm friable, edematous mucosa of the supraglottic larynx and the possible causes of CGD like defects in nicotinamide adenine dinucleotide phosphate (NAPH) oxidase subunits.

Purpose: The purpose of this study was to evaluate whether the lung ultrasound (LUS) scores applied to an international cohort of patients presenting to the emergency department (ED) with suspected COVID‐19, and subsequently admitted with proven disease, could prognosticate clinical outcomes. Methods: This was an international, multicentre, prospective, observational cohort study of patients who received LUS and were followed for the composite primary outcome of intubation, intensive care unit (ICU) admission or death. LUS scores were later applied including two 12‐zone protocols ('de Alencar score' and 'CLUE score'), a 12‐zone protocol with lung and pleural findings ('Ji score') and an 11‐zone protocol ('Tung‐Chen score'). The primary analysis comprised logistic regression modelling of the composite primary outcome, with the LUS scores analysed individually as predictor variables. Results: Between April 2020 to April 2022, 129 patients with COVID‐19 had LUS performed according to the protocol and 24 (18.6%) met the composite primary endpoint. No association was seen between the LUS score and the composite primary end point for the de Alencar score [odds ratio (OR) = 1.04; 95% confidence interval (CI): 0.97–1.11; P = 0.29], the CLUE score (OR = 1.03; 95% CI: 0.96–1.10; P = 0.40), the Ji score (OR = 1.02; 95% CI: 0.97–1.07; P = 0.40) or the Tung‐Chen score (OR = 1.02; 95% CI: 0.97–1.08). Discussion: Compared to these earlier studies performed at the start of the pandemic, the negative outcome of our study could reflect the changing scenario of the COVID‐19 pandemic, including patient, disease, and system factors. The analysis suggests that the study may have been underpowered to detect a weaker association between a LUS score and the primary outcome. Conclusion: In an international cohort of adult patients presenting to the ED with suspected COVID‐19 disease who had LUS performed and were subsequently admitted to hospital, LUS severity scores did not prognosticate the need for invasive ventilation, ICU admission or death. [ABSTRACT FROM AUTHOR]

Background:Central airway diseases requiring frequent outpatient visits to a specialized medical center due to tracheal devices. Many of these patients have mobility and cognition restrictions or require specialized transport due to the need for supplemental oxygen. This study describes the implementation and results of a telemedicine program dedicated to patients with central airway diseases based in a Brazilian public health system. Methods:A retrospective study of telemedicine consultation for patients with central airway diseases referred to a public academic hospital between August 1, 2020 and August 1, 2022. The consultations occurred in a telemedicine department using the hospital's proprietary platform. Data retrieved consisted of demographics, disease characteristics, and the treatment modalities of the patients. The analysis included the savings in kilometers not traveled, the carbon footprint based on reducing CO2 emissions, and the cost savings in transportation. Results:A total of 1,153 telemedicine visits conducted in 516 patients (median age of 31.5 years). Two hundred ninety patients (56.2%) had a tracheal device (129 silicone T-Tube, 128 tracheostomy, and 33 endoprosthesis) and 159 patients (30.8%) had difficulties in transportation to the specialized medical center. Patients were served from 147 Brazilian cities from 22 states. The savings in kilometers traveled was 1,224,108.54 km, corresponding to a 250.14 ton reduction in CO2 emissions. The costs savings in transportation for the municipalities was BRL$ 1,272,283.78. Conclusions:Telemedicine consultations for patients with central airway diseases are feasible and safe. Cost savings and the possibility of disseminating specialized care make telemedicine a fundamental tool in current medical practice. [ABSTRACT FROM AUTHOR]

The article discusses the importance of preventing maternal cardiac arrest in obstetric anesthesia. The 7th National Audit Project (NAP7) has highlighted the need for improvements in anesthetic care to reduce the incidence of cardiac arrests during pregnancy. The study found that anesthesia management factors were the main cause of maternal cardiac arrests, with regional anesthesia associated with fewer risks compared to general anesthesia. The article also emphasizes the need for better recognition and treatment of obstetric hemorrhage, as well as improvements in airway management and training for obstetric anesthesia. Overall, the findings of NAP7 provide valuable insights for improving the safety of obstetric anesthesia. [Extracted from the article]

Purpose: Surface electromyography (sEMG) has been used to evaluate extrinsic laryngeal muscle activity during swallowing and phonation. In the current study, sEMG amplitudes were measured from the infrahyoid and suprahyoid muscles during phonation through a tube submerged in water. Method: The sEMG amplitude values measured from the extrinsic laryngeal muscles and the electroglottographic contact quotient (CQ) were obtained simultaneously from 62 healthy participants (31 men, 31 women) during phonation through a tube at six different depths (2, 4, 7, 10, 15, and 20 cm) while using two tubes with different diameters (1 and 0.5 cm). Results: With increasing depth, the sEMG amplitude for the suprahyoid muscles increased in men and women. However, sEMG amplitudes for the infrahyoid muscles increased significantly only in men. Tube diameter had a significant effect on the suprahyoid sEMG amplitudes only for men, with higher sEMG amplitudes when phonating with a 1.0-cm tube. CQ values increased with submerged depth for both men and women. Tube diameter affected results such than CQ values were higher for men when using the wider tube and for women with the narrower tube. Conclusions: Vocal fold vibratory patterns changed with the depth of tube submersion in water for both men and women, but the patterns of muscle activation differed between the sexes. This suggests that men and women use different strategies when confronted with increased intraoral pressure during semioccluded vocal tract exercises. In this study, sEMG provided insight into the mechanism for differences between vocally normal individuals and could help detect compensatory muscle activation during tube phonation in water for people with voice disorders [ABSTRACT FROM AUTHOR]

Simple Summary: Rabbit endotracheal intubation is often challenging for anesthetists. Employing an endoscope guided by adjusting the angle of head extension can significantly aid anesthetists in accurately locating and executing rabbit endotracheal intubation, reducing the risk of breathing difficulties during the process. This study explores how specific head extension angles impact endotracheal intubation success rates and time taken. The findings recommend utilizing angles of 110 and 120 degrees for optimal rabbit head extension during endotracheal intubation to enhance success rates and efficiency. Endotracheal intubation in rabbits is always challenging due to the unique anatomical conformation. To improve endotracheal intubation success, this study determined the relationship between head placement angles guided by endoscope-assisted visualization techniques and the endotracheal intubation success rate. Thirty-two rabbit cadavers were used in the study. Six veterinary practitioners who had no experience with rabbit endotracheal intubation were randomly assigned to intubate rabbit cadavers using the guidance of either a rigid endoscope (RE) or flexible endoscope (FE), with the head placement angles with an ascending neck at 90, 100, 110, 120 and 130 degrees. The endotracheal intubation completed in 90 s was determined to be a success. The success rates using RE and FE were 97.2% and 95.9%, respectively. The means and standard error of means (SEM) of endotracheal intubation times guided by RE and FE were 53.7 ± 4.68 and 55.2 ± 4.24 s, respectively. Results from survival time analysis show that the five veterinarians successfully intubated the rabbit within 90 s, regardless of the different types of endoscopes. Angle was the only significant factor that affected the endotracheal intubation success. The head placement angle at 110 and 120 degrees had the highest success rate of endotracheal intubation compared to 90 degrees (p ≤ 0.05). In conclusion, for inexperienced veterinarians, the success of endotracheal intubation in rabbits, guided by endoscope-assisted visualized techniques regardless of rigid endoscope or flexible endoscope guidance, is improved when the head extension is 110 and 120 degrees. [ABSTRACT FROM AUTHOR]

Summary: Complications related to endotracheal intubation are well recognised in both human and veterinary medicine; however, difficult extubation is rare and is typically related to accidental physical fixation, inability to deflate the cuff, anatomical abnormalities or an inappropriate tube. In this case report we describe an unexpected failure to extubate where tracheotomy was required to facilitate the removal of the endotracheal tube in an adult pony. [ABSTRACT FROM AUTHOR]

Introduction: Neonates in intensive care units often require endotracheal intubation and mechanical ventilation. During this intubation procedure, a stylet is frequently used along with an endotracheal tube. Despite the widespread use of a stylet, it is still not known whether its use increases the intubation success rate. This study examined the association between stylet use and the intubation success rate in surgical neonates. Methodology: This single‐center study was conducted between December 2021 and December 2022 in the Neonatal surgical intensive care unit of a tertiary care center in Northern India. Infants were randomized to have the endotracheal intubation procedure performed using either an endotracheal tube alone or with a stylet. The primary outcome of the study was to assess the successful first‐attempt neonatal endotracheal intubation rate with and without using a stylet. Apart from the rate of successful intubation, the duration of the intubation and complications during the intubation procedures as measured by bradycardia, desaturation episodes, and local trauma were also recorded. Both groups were thus compared on above mentioned outcomes. Results: The total number of neonates enrolled were 200, and the overall success rate (81% in the stylet group vs. 73% in the non‐stylet group) was not statistically significant. Intubation time was however less, when stylet was used (16.2 ± 4.3 vs. 17.5 ± 5.0 s, p =.046). When the endotracheal tube size was 3 or less, the success rate was substantially higher in the stylet group (80%) than the non‐stylet group (63%), p =.03. No statistical difference was recorded for bleeding and local trauma, though the esophageal intubation rate was higher when intubation was attempted without the stylet. Conclusion: Endotracheal intubation using a stylet did not significantly improve the success rate of the procedure, however, intubation time significantly varied between groups and in different conditions. The rigidity and curvature provided by the stylet may facilitate the process of intubation when smaller caliber endotracheal tubes are used. [ABSTRACT FROM AUTHOR]

We report the case of a 61-year-old woman who was referred to the Oral Surgery and Implantology Unit of the University Hospitals of Geneva to take care of edentulous sites after the dental avulsions of teeth 11 and 21 following traumatic shock due to endotracheal intubation under general anesthesia. The dental history revealed that the patient had a history of generalized chronic periodontitis that had been treated several years earlier. The treatment consisted, for the first time to our knowledge, of the immediate insertion of implants at sites 11 and 21 with simultaneous bone augmentation in a single surgical procedure and immediate restorations. [ABSTRACT FROM AUTHOR]

Introduction: Thyroid enlargement is considered a risk factor for challenging direct laryngoscopy and intubation. Airway management in patients with thyroid swelling presents unique challenges, requiring thorough preparation for potential difficult airways. Although airway management in the overall population has been thoroughly researched, there is a scarcity of literature specifically addressing airway management in individuals who have thyroid enlargement. Aim: To evaluate the incidence of difficult intubation in patients undergoing thyroid surgery, utilising the Intubation Difficulty Score (IDS). Materials and Methods: This cross-sectional observational study was conducted among 258 patients in the Department of Anaesthesiology, Government TD Medical College, Alappuzha, Kerala, India. Various parameters including Modified Mallampati score, neck circumference, Body Mass Index (BMI), inter-incisor distance, retrognathia, neck extension, thyromental distance, tracheal deviation, and tracheal compression were assessed for all patients with thyroid swelling. The incidence of difficult endotracheal intubation was analysed using the IDS and the time taken for successful intubation was recorded. Data were presented as mean±standard deviation (SD), frequencies, and percentages. The association between variables was analysed using the Chi-square test. Results: Thyroid disorders were more common in females 220 (85.3%) than in males 38 (14.7%). The variables such as BMI, Mallampati score, thyromental distance, inter-incisor distance, and neck mobility were not found to be associated with difficult intubation. However, increased neck circumference (>43 cm) was statistically significant (p-value=0.007) in relation to difficult intubation. According to IDS, 94.2% of patients had easy intubation, while 5.8% experienced difficult intubation. In terms of intubation times, 72.5% of patients were intubated within 10-15 seconds, 24.4% within 16-20 seconds, and 3.1% took longer than 20 seconds. Conclusion: Thyroid surgery itself is not an independent predictive factor for difficult intubation. Among the predictive factors in the study population, a neck circumference greater than 43 cm was found to be associated with difficult endotracheal intubation during thyroid surgery. [ABSTRACT FROM AUTHOR]

Endotracheal intubation holds significant importance in trauma point care and emergency medicine. However, laryngeal injury and subsequent chronic complications can result from the friction between the mucosa and the tube during intubation. Here we present a lubricant coating based on hyaluronic acid. Inspired by mussels, hyaluronic acid was first conjugated with dopamine to obtain HD, and then a triblock copolymer Pluronic F127 (F127) was complexed with HD to form a micelle layer. Dopamine can assist coating deposition on the tube under weak alkaline conditions, while improving the coating stability. The micelle layer formed by F127 and HD provides excellent water retention and lubrication performance. The friction coefficient of the HD-F127 coating was 56% lower than that of the control, as determined by a friction performance test. Laryngeal injury and subsequent chronic complications can result from the friction between the mucosa and the tube during intubation. Here we present a lubricant coating based on hyaluronic acid. The HD-F127 coatings have great potential in biomedical devices that require lubrication, due to their simple fabrication method and excellent lubrication properties. (Image credit: Wu Chenggang.) [ABSTRACT FROM AUTHOR]

Background: Post-operative sore throat (POST) has an incidence ranging from 21 to 80%. To prevent the development of POST, several pharmacological measures have been tried. Aim of this study was to compare the efficacy of preoperative zinc, magnesium and budesonide gargles in reducing the incidence and severity of POST in patients who underwent endotracheal intubation for elective surgeries. Methods: We conducted a prospective, randomized, double-blind, controlled equivalence trial in 180 patients admitted for elective surgical procedures under general anaesthesia. Patients were randomised into three groups; group Z received 40 mg Zinc, group M received 250 mg Magnesium Sulphate and group B received 200 µg Budesonide in the form of 30 ml tasteless and colourless gargle solutions. Sore throat assessment and haemodynamic recording was done postoperatively at immediate recovery (0 h) and 2, 4, 6, 8, 12 and 24 h post-operatively. POST was graded on a four-point scale (0–3). Results: POST score was comparable at all recorded time points i.e. 0,2,4,6,8,12 and 24 h. Maximum incidence was seen at 8 h in group B (33.3%) and the minimum incidence was at 24 h in group Z (10%) (p > 0.05). It was found that the incidence of POST was more in the surgeries lasting longer than 2 h in all groups. This difference was found to be statistically significant in Groups M and B. The incidence of POST was found to be comparable between laparoscopic and open procedures. Conclusion: Magnesium, zinc and budesonide have an equivocal effect in the prevention of POST at different time points. The incidence of sore throat increases significantly in surgeries lasting more than two hours if magnesium or budesonide have been used as premedicant. Duration of surgery is an independent predictor for POST. Trial registration: CTRI/2021/05/033741 Date-24/05/2021(Clinical Trial Registry of India). [ABSTRACT FROM AUTHOR]

The article discusses the importance of tracheal intubation in critical care and the need to make the procedure safer and more effective. It explores various factors that should be considered during intubation, such as who should perform it, what kind of intubation should be done, when it should occur, where it should happen, and why it is necessary. The article also presents the findings of a study on intubation in Spanish ICUs, highlighting the high-risk nature of the procedure and the associated complications. It emphasizes the need for a high first-pass success rate and the use of video laryngoscopes and neuromuscular blocking agents to improve outcomes. The article concludes by suggesting areas for further research and improvement in intubation practices. [Extracted from the article]

OBJECTIVES: Our aims were to explore current intubation practices in Spanish ICUs to determine the incidence and risk factors of peri-intubation complications (primary outcome measure: major adverse events), the rate and factors associated with first-pass success, and their impact on mortality as well as the changes of the intubation procedure observed in the COVID-19 pandemic. DESIGN: Prospective, observational, and cohort study. SETTING: Forty-three Spanish ICU. PATIENTS: A total of 1837 critically ill adult patients undergoing tracheal intubation. The enrollment period was six months (selected by each center from April 16, 2019, to October 31, 2020). INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: At least one major adverse peri-intubation event occurred in 40.4 % of the patients (973 major adverse events were registered) the most frequent being hemodynamic instability (26.5%) and severe hypoxemia (20.3%). The multivariate analysis identified seven variables independently associated with a major adverse event whereas the use of neuromuscular blocking agents (NMBAs) was associated with reduced odds of major adverse events. Intubation on the first attempt was achieved in 70.8% of the patients. The use of videolaryngoscopy at the first attempt was the only protective factor (odds ratio 0.43; 95% CI, 0.28–0.66; p < 0.001) for first-attempt intubation failure. During the COVID-19 pandemic, the use of videolaryngoscopy and NMBAs increased significantly. The occurrence of a major peri-intubation event was an independent risk factor for 28-day mortality. Cardiovascular collapse also posed a serious threat, constituting an independent predictor of death. CONCLUSIONS: A major adverse event occurred in up to 40% of the adults intubated in the ICU. Peri-intubation hemodynamic instability but not severe hypoxemia was identified as an independent predictor of death. The use of NMBAs was a protective factor for major adverse events, whereas the use of videolaringoscopy increases the first-pass success rate of intubation. Intubation practices changed during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Purpose Orolingual angioedema (OA) secondary to administration of thrombolytic therapy is a rare, but serious, known adverse effect. Despite the lack of robust evidence for their use, C1 esterase inhibitors are recommended by guidelines for the treatment of refractory thrombolytic-associated OA. This report highlights the use of a C1 esterase inhibitor in a patient with tenecteplase-associated OA unresolved by antihistamine and corticosteroid therapy. Summary A 67-year-old white male with a history of hypertension managed with lisinopril presented to the emergency department with acute onset of slurred speech and left-sided hemiparesis. Following workup, an outside hospital's neurology stroke team suspected an acute infarct and determined the patient to be a candidate for tenecteplase. Approximately 1 hour after tenecteplase administration, the patient began complaining of dyspnea and mild oral angioedema. Immediate interventions for OA management included intravenous therapy with dexamethasone 10 mg, diphenhydramine 25 mg, and famotidine 20 mg. After an additional 30 minutes, the patient's OA symptoms continued to progress and a C1 esterase inhibitor (Berinert) was administered. Shortly after administration of the C1 esterase inhibitor, the patient's symptoms continued to worsen, ultimately leading to endotracheal intubation. Following intubation, symptom improvement was noted, and the patient was safely extubated after 30 hours. Conclusion Although rare, OA is a potentially life-threatening complication of tenecteplase therapy and requires prompt pharmacological intervention to optimize patient outcomes. Currently, no single agent or treatment algorithm exists that has shown significant efficacy or safety in the setting of thrombolytic-associated OA. Until data are available for C1 esterase inhibitors in this application, these inhibitors should only be considered if there is continued symptom progression after intravenous administration of corticosteroids and antihistamines. [ABSTRACT FROM AUTHOR]

Objective To investigate the median effective dose (ED50) of esketamine for inhibiting tracheal intubation response during the induction of dexmedetomidine combined with lidocaine under opioid-free anesthesia (OFA). Methods Adult patients aged 18-59 years with body mass index (BMI)<30 kg/m² and ASA grade Ⅰ or Ⅱ were selected for endotracheal intubation general anesthesia. Dixon sequential method was adopted. The initial dose of esketamine was 0.5 mg/kg, and the dose of the next patient was determined according to the tracheal intubation response. The ratio of adjacent doses was 1 ∶ 1.1. The ED50 and 95% confidence interval (CI) of esketamine for inhibiting tracheal intubation response during the induction of dexmedetomidine combined with lidocaine OFA were calculated. Results A total of 29 patients were included for statistical analysis. Tracheal intubation reaction was positive in 15 cases (positive group) and negative in 14 cases (negative group). In the positive group, 3 cases had cough reaction during tracheal intubation. The ED50 of esketamine for inhibiting tracheal intubation response during the induction of dexmedetomidine combined with lidocaine OFA was 0.448 mg/kg, and the corresponding 95%CI was 0.421-0.476 mg/kg. Conclusion In the OFA of esketamine combined with dexmedetomidine and lidocaine, 0.448 mg/kg of esketamine results in 50% of the maximum response intensity for inhibiting tracheal intubation response. [ABSTRACT FROM AUTHOR]

BACKGROUND: Open respiratory secretion suctioning with a catheter causes pain and tracheobronchial mucosal injury in intubated patients. The goal of mechanical insufflation-exsufflation (MI-E) is to move secretions proximally and noninvasively by generating a high peak expiratory air flow. Nebulized hypertonic saline with hyaluronic acid (HS-HA) may facilitate suctioning by hydration. We assessed the safety and tolerance of a single session of airway clearance with MI-E and HS-HA in critically ill intubated patients. METHODS: Adults with a cuffed artificial airway were randomized to (1) open suctioning, (2) open suctioning after HS-HA, (3) MI-E, or (4) MI-E with HS-HA. Adverse events, pain and sedation/agitation scores, and respiratory and hemodynamic variables were collected before, during, and 5-min and 60-min post intervention. RESULTS: One-hundred twenty subjects were enrolled and completed the study. Median (interquartile range [IQR]) Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 22 (16--28); median (IQR) age was 69.0 (57.0--75.7) y, and 90 (75%) were male. Baseline respiratory and hemodynamic variables were comparable. Adverse events occurred in 30 subjects (25%), with no between-group differences. Behavioral pain equivalents and Richmond Agitation-Sedation Scale were higher during suctioning in groups 1 (P < .001) and 2 (P < .001). Independent predictive variables for higher pain and agitation/sedation scores were study groups 1 and 2 and simultaneous analgosedation, respectively. Noradrenaline infusion rates were lower at 60 min in groups 2 and 4. PaO2/FIO2 had decreased at 5 min after open suctioning in group 1 and increased at 60 min in group 3. CONCLUSIONS: We observed no difference in adverse events. MI-E avoids pain and agitation. [ABSTRACT FROM AUTHOR]

After tracheal intubation for a patient in the intensive care unit. it is necessary to check for position appropriateness of the intubated endotracheal tube. Timely identification of dislocation and adjustment can prevent patients from morbidity and mortality. Manual checking ofthe chest X-ray images is time consuming and tedious. An automated way not only speeds the checking but also reduces doctor's work load. In this study, we propose a deep learning model U'+-Net, which yields good performance in semantic segmentation of tracheal and facilitates subsequent localization ofthe carina. In addition, an algorithm is proposed which locates the coordinate of carina from the segmented trachea. Experimental results show that the overall average error distance of detecting the position of carina is 0.29 cm, accuracy of the detection error within 0.5 cm and 1.0 cm are 85% and 99%, respectively, indicating that the proposed method is promising. [ABSTRACT FROM AUTHOR]

The joint definition of pressure ulcers by the European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) states, "Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure alone or in combination with shear." Treating pressure ulcers proves challenging and contributes to increased costs due to prolonged hospitalization stays. In this case study, we address the care of a patient, 18 years of age, hospitalized due to burns, tracheostomized, with a percutaneous endoscopic gastrostomy tube, unconscious, and developed a pressure ulcer. The objective is to provide care for the patient with a stage 3 pressure ulcer on the sacrum by current guidelines. When planning care, a multidimensional assessment was scheduled alongside wound care. Skin assessment and care, appropriate wound dressing selection, nutrition, weight monitoring, hydration, repositioning, and the utilization of support surfaces were carried out as per guidelines. The overall roadmap followed includes: recognizing and staging pressure ulcers, treatment modalities for staged ulcers, monitoring, and basic care principles for pressure ulcers (nutrition, pain management). Following the implemented interventions, the patient's pressure ulcer showed signs of healing. [ABSTRACT FROM AUTHOR]

Socio-demographic inequities in health treatment and outcomes are not new. However, the COVID-19 pandemic presented new opportunities to examine and address biases. This article describes a scoping review of 170 papers published prior to the onset of global vaccinations and treatment (December 2021). We report differentiated COVID-19-related patient outcomes for people with various socio-demographic characteristics, including the need for intubation and ventilation, intensive care unit admission, discharge to hospice care, and mortality. Using the PROGRESS-Plus framework, we determined that the most researched socio-demographic factor was race/ethnicity/culture/language. Members of minoritized racial and ethnic groups tended to have worse COVID-19-related patient outcomes; more research is needed about other categories of social disadvantage, given the scarcity of literature on these factors at the time of the review. It is only by researching and addressing the causes of social disadvantage that we can avoid such injustice in future public health crises. [ABSTRACT FROM AUTHOR]

The relationship among advanced airway management (AAM), ventilation, and oxygenation in patients with out-of-hospital cardiac arrest (OHCA) who achieve prehospital return of spontaneous circulation (ROSC) has not been validated. This study was designed to evaluate ventilation and oxygenation for each AAM technique (supraglottic devices [SGA] or endotracheal intubation [ETI]) using arterial blood gas (ABG) results immediately after hospital arrival. This observational cohort study, using data from the Japanese Association for Acute Medicine OHCA Registry, included patients with OHCA with prehospital and hospital arrival ROSC between July 1, 2014, and December 31, 2019. The primary outcomes were the partial pressure of carbon dioxide in the arterial blood (PaCO2) and partial pressure of oxygen in the arterial blood (PaO2) in the initial ABG at the hospital for each AAM technique (SGA or ETI) performed by paramedics. The secondary outcome was favorable neurological outcome (cerebral performance category [CPC] 1 or 2) for specific PaCO2 levels, which were defined as good ventilation (PaCO2 ≤45 mmHg) and insufficient ventilation (PaCO2 >45 mmHg). This study included 1,527 patients. Regarding AAM, 1,114 and 413 patients were ventilated using SGA and ETI, respectively. The median PaCO2 and PaO2 levels were 74.50 mmHg and 151.35 mmHg in the SGA group, while 66.30 mmHg and 173.50 mmHg in the ETI group. PaCO2 was significantly lower in the ETI group than in the SGA group (12.55 mmHg; 95% CI 15.27 to 8.20, P-value < 0.001), while no significant difference was found in PaO2 by multivariate linear regression analysis. After stabilizing inverse probability of weighting (IPW), the adjusted odds ratio for favorable neurological outcome at 1 month was significant in the good ventilation group compared to the insufficient ventilation cohort (adjusted odds ratio = 2.12, 95%CI: 1.40 to 3.19, P value < 0.001). The study showed that in OHCA patients with prehospital ROSC, the PaCO2 levels in the initial ABG were lower in the group with AAM by ETI than in the SGA group. Furthermore, patients with prehospital ROSC and PaCO2 ≤45 mmHg on arrival had an increased odds of favorable neurological outcome after stabilized IPW adjustment. [ABSTRACT FROM AUTHOR]

This systematic review and meta-analysis aimed to compare the efficacy of dynamic versus standard bougies to achieve tracheal intubation. We searched MEDLINE, Embase, CENTRAL, Web of Science, Scopus and Google Scholar on 10 October 2023. We included clinical trials comparing both devices. The primary outcome was the first-attempt intubation success rate. The secondary outcome was the time required for tracheal intubation. Eighteen studies were included. Dynamic bougies do not increase first-attempt success rate (RR 1.11; p = 0.06) or shorten tracheal intubation time (MD −0.30 sec; p = 0.84) in clinical trials in humans. In difficult airways, first-attempt success intubation rate was greater for dynamic bougies (RR 1.17; p = 0.002); Additionally, they reduced the time required for intubation (MD −4.80 sec; p = 0.001). First-attempt intubation success rate was higher (RR 1.15; p = 0.01) and time to achieve intubation was shorter when using Macintosh blades combined with dynamic bougies (MD −5.38 sec; p < 0.00001). Heterogeneity was high. Dynamic bougies do not increase the overall first-pass success rate or shorten tracheal intubation time. However, dynamic bougies seem to improve first-attempt tracheal intubation rate in patients with difficult airways and in those intubated with a Macintosh blade. Further research is needed for definitive conclusions. CRD42023472122 [ABSTRACT FROM AUTHOR]

Objective To investigate the effects of intraoperative electroacupuncture analgesia on the stress response to tracheal intubation in patients undergoing general anesthesia for thyroid surgery. Methods A total of 60 patients scheduled for elective combined general anesthesia and thyroid surgery at the Affiliated TCM Hospital of Guangzhou Medical University from June 2022 to June 2023 were randomly assigned to either the control group (Ctr group) or the electroacupuncture group (EA group). Both groups underwent tracheal intubation under general anesthesia. In the EA group, electroacupuncture was applied at bilateral Neiguan (PC6), Quchi (LI11), and Lieque (LU7) acupoints for 15 minutes before tracheal intubation and before extubation, in addition to routine general anesthesia and analgesia. Hemodynamic parameters including systolic blood pressure (SBP), mean arterial pressure (MAP), diastolic blood pressure (DBP), and heart rate (HR) were observed at different time points in both groups (before intubation: T0; 1, 5, 10, 15, and 30 minutes after intubation: T1, T5, T10, T15, T30; 1 minute before extubation: EXBT1; 1 and 5 minutes after extubation: EXAT1, EXAT5). The total amount of opioid analgesics used intraoperatively and any adverse reactions were recorded. Results Significant statistical differences were observed between the EA group and Ctr group in SBP at T1-T15, EXAT1, and EXAT5; MAP at T5-T15 and EXAT1; DBP at T15 and EXAT1; HR at T1, T5, EXAT1, and EXAT5 (P < 0.05). During T1-T15, the SBP, MAP, DBP, and HR in the EA group showed a decreasing trend and were lower compared to the Ctr group. The SBP, MAP, and DBP fluctuations were smaller in the EA group compared to the Ctr group, while the HR fluctuations were larger in the EA group after intubation but smaller after extubation. There was no significant difference in the total amount of opioid analgesics used intraoperatively between the two groups (P > 0.05). The incidence of adverse reactions such as nausea and vomiting differed significantly (P < 0.05), while the incidence of rash and hypertension did not differ significantly between the two groups (P > 0.05). Conclusion Intraoperative electroacupuncture analgesia can effectively attenuate the vascular stress response induced by tracheal intubation and extubation in patients undergoing thyroid surgery and reduce the occurrence of opioid-related adverse reactions. [ABSTRACT FROM AUTHOR]

Background: Widespread vaccinations have significantly decreased the number of tetanus cases in developed countries. Today, most cases of tetanus affect the elderly and those with inadequate immunization in developed countries such as Japan. As vaccinations were believed to be nearly 100% effective in preventing tetanus, tetanus in young, immunized individuals were considered unlikely. However, unexpected tetanus infection has been reported in young adequately immunized individuals. Case: We herein describe a 20-year-old immunized female who visited our emergency department with trismus and painful muscle spasms that started after receiving a puncture wound to her right foot. A physical examination revealed an elevated body temperature (38°C), trismus, muscle spasms in her right leg and neck, and a puncture wound at the sole of her right foot. Following the development of dyspnea after admission to the intensive care unit, the patient was intubated and mechanically ventilated. She fully recovered after six days in intensive care. Conclusion: The present case serves as a stark reminder that tetanus may still occur in young, immunized individuals. Patients with a history of immunization may have a better prognosis than those with no immunizations. [ABSTRACT FROM AUTHOR]

Background. Critically ill patients have increased risk of cardiovascular collapse following endotracheal intubation due to physiological instability. This study aims to validate the Difficult Airway Physiological Score (DAPS) in adults to predict the risk of serious outcomes in the emergency department of a tertiary care private hospital. Methods. This is a cohort study conducted in the emergency department (ED) from 2021 to 2022. Difficult Airway Physiological Score (DAPS) was derived from a sample of 1021 patients through a retrospective study. The variables in the score were age, gender, time of intubation, vitals and vomiting at presentation, pH <7.3, fever, physician's anticipation for patient decline, and agitation. The model performance was assessed prospectively on a separate dataset (n = 326) using train-test split method. Postintubation desaturation, hypotension, cardiac arrest, and mortality postintubation were the serious outcomes. ROC analysis, sensitivity, specificity, PPV, and NPV were used to assess score validity. Results. Our study includes 326 patients, of which 123 (37.7%) were males and 203 (62.2%) were females. The sample was divided into high-risk (DAPS ≥10) group, n = 194 with mean age of 52 (SD = ±18) years, and low-risk (DAPS <10) group, n = 132 with mean age of 47.7 (SD = ±17.4) years. The shock index ≥0.9 was in 128 (66%), while it was <0.9 in low-risk n = 111 (84%), p value <0.001. Similarly, pH <7.3 was seen in 70 (36.1%) in high-risk group compared to 4 (3%) in low-risk group, p value <0.001. Cardiac arrest was observed in 56 (17.2%) patients, of which 45 (23.2%) were in high-risk and 11 (8.3%) in low-risk groups (p < 0.001). Hypotension was the primary outcome in the high-risk group 100 (51.5%) versus 32 (24.2%) in low-risk group (p < 0.001). The DAPS of 10 had an area under the curve of 0.865 (0.71–0.84). The sensitivity of DAPS was 78.5%, specificity 77.9%, and accuracy 78.2%. Conclusion. The score can accurately predict serious outcomes in critically ill adult patients with physiologically difficult airway demonstrating good sensitivity and specificity. [ABSTRACT FROM AUTHOR]

Background: The main cause of anesthesia-related deaths is the failure to manage difficult airways. Difficult laryngoscopic exposure is a major cause of unsuccessful management of difficult airways. Inadequate preoperative airway assessment hinders the clinical management of difficult airways cases, emphasizing the critical need for accurate identification of difficult airways. Currently, no definitive and reliable indicators are available to predict a difficult airway. Our study aims to predict laryngoscope exposure risk factors by combining ultrasonically measured upper airway anatomic parameters with physical examination indicators. Methods: Patients aged 18 to 75 years, classified as American Standards Association (ASA) I-III, and scheduled for elective general anesthesia with endotracheal intubation were included. All patients received the upper airway and ultrasonographic measurements. After anesthesia induction, laryngoscope exposure was analyzed using the Cormack-Lehane grading system, with Grades III and IV as indicative of difficult laryngoscopy. Univariate and multivariate logistic regression analyses were performed to identify reliable indicators for predicting difficult laryngoscopy. Receiver Operating Characteristic (ROC) curve analysis was utilized to assess the predictive performance of each indicator. Results: A total of 1120 patients finished the study, with 710 cases found in Grade I laryngoscopic exposure group, 360 cases in Grade II group, and 50 cases in Grade III group. There was no case observed in Grade IV group, thereby resulting in an incidence of difficult laryngoscopy of 4.46%. Univariate logistic regression analysis revealed that several parameters including age, Body Mass Index (BMI), neck circumference, neck mobility, snoring intensity, as well as ultrasound measurements of the pre-epiglottic space and thyromental distance were identified as significant risk factors for difficult laryngoscopy (P < 0.05). Among these, BMI, and neck circumference exhibited notable predictive value, with Area Under The Curve (AUC) values of 0.746 (95%CI 0.649–0.842) and 0.732 (95%CI 0.638–0.827), respectively. Neck mobility was also identified as an independent risk factor for predicting difficult laryngoscopy (P = 0.009) in multivariate logistic regression analysis, with an AUC of 0.672 (0.562–0.782) in the ROC curve. Conclusions: Our findings revealed a direct correlation between difficult laryngoscopy and age, BMI, neck circumference, neck mobility, snoring intensity, as well as ultrasound measurements of the pre-epiglottic space and thyromental distance. Furthermore, neck mobility was identified as an independent predictive factor. Trial registration: The trial was registered prior to patient enrollment at clinicaltrials.gov (register no. ChiCTR2100053826, Date of registration: November 30, 2021). [ABSTRACT FROM AUTHOR]

Background: Thyroglossal Duct Cyst (TDC) is a common lesion of the midline neck, originating from an incomplete involution of the thyroglossal duct. It is typically observed in pre-scholar patients and surgery is the treatment of choice to prevent infections. Here reported a case of incidental diagnosis in a newborn patient. Case presentation: a 3-week-old male baby was admitted to our hospital for weight loss and projectile vomits after breastfeeding. After a diagnosis of hypertrophic pyloric stenosis, the baby underwent pyloromyotomy. During the endotracheal tube placement, the anesthetist noticed the presence of a midline neck mass. The suspect of TDC was confirmed by an intraoperative ultrasound, so, despite the age of the patient, we proceeded with the excision of the lesion according to Sistrunk's procedure to avoid future complications and anesthesia. Conclusions: even if TDC is a common lesion of pediatric patients, anecdotical neonatal cases were described in the literature, all of them symptomatic. An accurate physical examination and ultrasound are essential diagnostic tools to distinguish TDC from other middle neck lesions, particularly ectopic thyroidal tissue. Sistrunk's procedure is the most effective surgical approach. When diagnosis is made in a newborn, we suggest postponing surgery, unless the baby requires general anesthesia for other surgical procedures, such as in our case. [ABSTRACT FROM AUTHOR]

Background: Double lumen endobronchial tubes (DLTs) are frequently used to employ single lung ventilation strategies during thoracic surgical procedures. Placement of these tubes can be challenging even for experienced clinicians. We hypothesized that airway anatomy, particularly of the glottis and proximal trachea, significantly impacts the ease or difficulty in placement of these tubes. Methods: Images from 24 randomly selected Positron Emission Tomography – Computed Tomography (PET-CT) scans were evaluated for several anatomic aspects of the upper airway, including size and angulation of the glottis and proximal tracheal using calibrated CT measurements and an online digital protractor. The anatomic issues identified were confirmed in cadaveric anatomic models. Results: Proximal tracheal diameter measurements in PET-CT scans demonstrated a mean ± standard deviation of 20.4 ± 2.5 mm in 12 males and 15.5 ± 0.98 mm in 12 females (p < 0.001), and both were large enough to accommodate 39 French and 37 French DLTs in males and females, respectively. Subsequent measurements of the posterior angulation of the proximal trachea revealed a mean angle of 40.8 ± 5.7 degrees with no sex differences. By combining the 24 individual posterior tracheal angles with the 16 angled distal tip measurements DLTs (mean angle 24.9 ± 2.1 degrees), we created a series of 384 patient intubation angle scenarios. This data clearly showed that DLT rotation to a full 180 degrees decreased the mean intubation angle between the DLT and the proximal trachea from a mean of 66.6 ± 5.9 to only 15.8 ± 5.9 degrees. Conclusions: Rotation of DLTs a full 180 instead of the recommended 90 degrees facilitates DLT intubations. [ABSTRACT FROM AUTHOR]

Introduction: The Tokyo Guidelines 2018 (TG2018) is a scoring system used to recommend the clinical management of AC. However, such a scoring system must incorporate a variety of clinical outcomes of acute cholangitis (AC). In an emergency department (ED)-based setting, where efficiency and practicality are highly desired, clinicians may find the application of various parameters challenging. The neutrophil-to-lymphocyte ratio (NLR) and blood urea nitrogen-to-albumin ratio (BAR) are relatively common biomarkers used to assess disease severity. This study evaluated the potential value of TG2018 scores measured in an ED to predict a variety of clinical outcomes. Furthermore, the study also compared TG2018 scores with NLR and BAR scores to demonstrate their usefulness. Methods: This retrospective observational study was performed in an ED. In total, 502 patients with AC visited the ED between January 2016 and December 2021. The primary endpoint was to evaluate whether the TG2018 scoring system measured in the ED was a predictor of intensive care, long-term hospital stays (≥14 days), percutaneous transhepatic biliary drainage (PTBD) during admission care, and endotracheal intubation (ETI). Results: The analysis included 81 patients requiring intensive care, 111 requiring long-term hospital stays (≥14 days), 49 requiring PTBD during hospitalization, and 14 requiring ETI during hospitalization. For the TG2018 score, the adjusted OR (aOR) using (1) as a reference was 23.169 (95% CI: 9.788–54.844) for (3) compared to (1). The AUC of the TG2018 for the need for intensive care was 0.850 (95% CI: 0.815–0.881) with a cutoff of >2. The AUC for long-term hospital stays did not exceed 0.7 for any of the markers. the AUC for PTBD also did not exceed 0.7 for any of the markers. The AUC for ETI was the highest for BAR at 0.870 (95% CI: 0.837–0.899) with a cutoff value of >5.2. Conclusions: The TG2018 score measured in the ED helps predict various clinical outcomes of AC. Other novel markers such as BAR and NLR are also associated, but their explanatory power is weak. [ABSTRACT FROM AUTHOR]

Key Points: Question: What is the effect of initial video laryngoscopy or direct laryngoscopy on number of intubation attempts in patients being intubated for cardiac, thoracic, or vascular surgical procedures? Findings: In this cluster randomized trial including 8429 surgical procedures in 7736 patients, more than 1 intubation attempt was required in 1.7% of patients randomized to receive video laryngoscopy. More than 1 intubation attempt was required in 7.6% of patients randomized to receive direct laryngoscopy. Meaning: In this study of adults having elective or emergent surgical procedures requiring single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy increased initial intubation attempt success and reduced the number of intubation attempts compared with direct laryngoscopy. Importance: Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear. Objective: To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy. Design, Setting, and Participants: Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat. Interventions: Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt. Main Outcomes and Measures: The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries. Results: Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P <.001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P <.001) with an unadjusted absolute risk difference of −3.7% (95% CI, −4.4% to −3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]). Conclusion and Relevance: In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures. Trial Registration: ClinicalTrials.gov Identifier: NCT04701762 This cluster randomized clinical trial assesses the extent to which video laryngoscopy compared with direct laryngoscopy might facilitate intubation in patients undergoing surgical procedures during routine clinical practice. [ABSTRACT FROM AUTHOR]

Background: Adequate preoperative evaluation of the post-intubation hemodynamic instability (PIHI) is crucial for accurate risk assessment and efficient anesthesia management. However, the incorporation of this evaluation within a predictive framework have been insufficiently addressed and executed. This study aims to developed a machine learning approach for preoperatively and precisely predicting the PIHI index values. Methods: In this retrospective study, the valid features were collected from 23,305 adult surgical patients at Peking Union Medical College Hospital between 2012 and 2020. Three hemodynamic response sequences including systolic pressure, diastolic pressure and heart rate, were utilized to design the post-intubation hemodynamic instability (PIHI) index by computing the integrated coefficient of variation (ICV) values. Different types of machine learning models were constructed to predict the ICV values, leveraging preoperative patient information and initiatory drug infusion. The models were trained and cross-validated based on balanced data using the SMOTETomek technique, and their performance was evaluated according to the mean absolute error (MAE), root mean square error (RMSE), mean absolute percentage error (MAPE) and R-squared index (R2). Results: The ICV values were proved to be consistent with the anesthetists' ratings with Spearman correlation coefficient of 0.877 (P < 0.001), affirming its capability to effectively capture the PIHI variations. The extra tree regression model outperformed the other models in predicting the ICV values with the smallest MAE (0.0512, 95% CI: 0.0511–0.0513), RMSE (0.0792, 95% CI: 0.0790–0.0794), and MAPE (0.2086, 95% CI: 0.2077–0.2095) and the largest R2 (0.9047, 95% CI: 0.9043–0.9052). It was found that the features of age and preoperative hemodynamic status were the most important features for accurately predicting the ICV values. Conclusions: Our results demonstrate the potential of the machine learning approach in predicting PIHI index values, thereby preoperatively informing anesthetists the possible anesthetic risk and enabling the implementation of individualized and precise anesthesia interventions. [ABSTRACT FROM AUTHOR]

Background. There is a need for critical care services outside intensive care units (ICUs), especially in emergency departments (EDs). However, there is a paucity of skilled manpower for ED critical care or emergency critical care (ECC) in resource-limited settings. Objective. To evaluate the impact of bedside training on emergency critical care practices of clinical staff. Methods. This was a quasi-experimental study using a pretest - post-test design in a paediatric ED. The intervention was a six-week structured bedside training on bubble continuous positive airway pressure (CPAP) high-flow nasal cannula (HFNC) and mechanical ventilation. Participants' actual ECC practices pre and post training were evaluated, including their perceived proficiency on an uncalibrated 100 mm visual analogue scale (VAS). Descriptive and inferential analyses were done; p<0.05 was considered significant. Results. A total of 35 clinical staff participated in the training, comprising 9 (24.3%) paediatric registrars, 12 (32.5%) senior registrars, 10 (27.0%) nurses, 4 (10.8%) house officers and 2 (5.4%) paediatric consultants. The male: female ratio of the participants was 1:1.6, and their mean (SD) age was 33.24 (6.30 years. Participants' understanding of testing the CPAP circuit, connecting the patient and weaning significantly improved following training (p=0.004). Their capacity to select appropriate HFNC parameters improved (p=0.013). They performed more endotracheal intubations in the post-training period (p=0.001). Their pretest-post-test proficiency in mechanical ventilation increased on VAS (mean scores 45.26+31.99 v. 63.26+22.26; p=0.038). Also, there was a significant increase in their perceived proficiency in paediatric analgesia/sedation (30.83+29.86 v. 49.83+23.90; p=0.029). Conclusion. Short-term bedside critical care training enhanced the self-reported competency of paediatric ED staff. There is a need for on-the-job ECC training and retraining of clinical staff in our setting. [ABSTRACT FROM AUTHOR]

Introduction: Difficult tracheal intubation is associated with serious morbidity and mortality and cannot be always predicted based on preoperative airway assessment using conventional clinical predictors. Ultrasonographic airway assessment could be a useful adjunct, but at present, there are no well-defined sonographic criteria that can predict the possibility of encountering a difficult airway. Aims: To.assess the usefulness.of USG in predicting difficult laryngoscopy. Materials and methods:. It is a descriptive observational study done conducted in a total of 80 patients were enrolled for. the study and informed. consent was obtained from all the patients. ASA grade I / II, Age 18-60.years of either sex, Patients.undergoing elective. surgery under.general anaesthesia. Results: The incidence of difficult intubation was 23%. We found that Skin to Epiglottis Distance at level of Thyrohyoid membrane on USG (USG-SET) > 1.67 cm had a sensitivity of 78.9% and specificity of 90.2% in predicting a CL Grade of 3 or 4, which was higher than that of physical parameters like MMPC, Wilson's score, Neck circumference or BMI. Conclusions: USG can be used to predict difficult airway preoperatively by measuring soft tissue thickness at neck and Skin to epiglottis distance at the level of Thyrohyoid membrane on USG is a potential predictor of difficult intubation. [ABSTRACT FROM AUTHOR]

This study compares Retrograde Light-Guided Laryngoscopic (RLGL) intubation with Conventional Direct Laryngoscopic (DL) intubation in emergency operating theatres. Given the challenges and varying success rates among novices performing tracheal intubations via DL, alternative methods that are cost-effective and simpler to execute are continually sought. RLGL, utilizing retrograde transtracheal light transmission, offers a promising approach by simplifying the identification of the glottis. This randomized, open-label, parallel-arm superiority trial involved 205 patients and aimed to evaluate the effectiveness and practicality of RLGL against DL, focusing on glottic exposure, intubation success rates, and the learning curve for novice intubators. Results suggested that RLGL could significantly improve success rates and reduce the time for both glottic exposure and tracheal intubation, demonstrating its potential as a valuable tool for novice intubators. [ABSTRACT FROM AUTHOR]

Background:Airway management is of prime importance to the anaesthesiologist. For securing airway, tracheal intubation using direct laryngoscopy remains the method of choice in majority of the cases. No anaesthetic drug is safe unless diligent efforts are made to secure and maintain an intact airway. Objective: this study was undertaken to compare the various airway assessment predictors (ULBT, HLM, Thyromental Distance (TMD) and Sternomental Distance (SMD),) for difficult endotracheal intubation. Methods: Prospective observational study was conducted among 400 patients undergoing elective surgery under general anaesthesia in hospitals attached to Bangalore Medical college and research institute for a period of two years. Results: In the study majority of subjects were in the age group 31 to 40 years (35.75%), Majority of subjects were males and had ASA grade 1. Based on Cormack Lehane scoring, 59% had Score 1, 23% had Score 2, 16% had Score 3 and 2% had Score 4. 72 subjects with difficult grade in CL, 37.5% were graded difficult in TMD, 75% were graded difficult in SMD, 2.8% were graded difficult in ULBT, 5.6% were graded difficult in HLM, 4.2% were graded difficult in HNM and 90.3% were graded difficult in RHTMD. Conclusions: Thyromental Distance (TMD) and Sternomental Distance (SMD) had highest Specificity, Positive Predictive value (PPV) compared to the other tests. [ABSTRACT FROM AUTHOR]

Background: In this study, we wanted to compare the haemodynamic responses to endotracheal intubation using Intubating Laryngeal mask airway (ILMA Fastrach TM) and direct laryngoscopy in adult patients with normal airway. Methods: This was a hospitalbased study conducted among 60 ASA grade I and II patients undergoing elective lumbar spine surgeries under general anaesthesia. They were grouped into two groups, group I - Laryngoscopy group and group II - ILMA Fastrach TM (group II). Circulatory response to intubation was recorded in both groups by invasive arterial Blood Pressure(BP) monitoring device placed before induction of anaesthesia. The values were recorded at pre induction, at induction, every minute post induction for 3minutes and at ILMA / laryngoscopy, every 10 second post intubation for 2 minutes followed by every minute for next 3 minutes. The maximum values and maximum increase in BP and HR were recorded in both groups. Results:Intubation through I LMA-Fastrach™ was associated with significantly lower cardiovascular responses compared to direct laryngoscopy and intubation. There was a significant increase in blood pressure and heart rate from baseline in both the groups. The maximum increase was above or equal to preinduction values with laryngoscopy and intubation. The maximum values in I LMA (Fastrach™) group were never beyond preinduction values with respect to changes in blood pressure. The maximum increase in blood pressure and heart rate from respective base line values were similar between the two groups. This occurred in spite of longer time required for intubation in I LMA(Fastrach™) group in comparison with laryngoscopy group. Conclusion:The intubation done through ILMA(Fastrach™) was associated with lesser haemodynamic response associated with intubation in adult normotensive patients with normal airway. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine is a highly selective, a2 adrenoreceptor agonist drug, which has sedative, analgesic and anxiolytic property without any respiratory depressive action. Dexmedetomidine causes post synaptic activation of a2 adrenoreceptors in the CNS resulting in hypotension and bradycardia through sympatholysis. Preoperative administration of dexmedetomidine can successfully attenuate the laryngoscopic stress response via intravenous, intramuscular or intranasal routes. Material and Methods: 80 adult patients of either sex between the age group of 18 to 60 years of ASA-I and ASA-II undergoing elective major surgeries were divided randomly into two groups of 40 patients each. Group - D(IV) received intravenous dexmedetomidine (0.50µg/kg) diluted in 50 ml syringe with normal saline through an infusion pump over 40 min before induction. Group - D(IN) received intranasal dexmedetomidine (1 µg/kg) in undiluted form which was prepared from parenteral preparation (100µg/ml). Intranasal drug dripped into both nostrils in equal volume using a 1 ml syringe in supine head down position about 40 min before induction. Result: The mean baseline heart rate in group D(IV) was (82.73 ± 5.95) per minute and it decreased to (80.33 ± 5.93) per min at 10 minutes time interval but was statistically insignificant. The p-value became statistically significant at 30minute (0.024) and 40-minute (0.011) time interval in pre induction period. During laryngoscopy and intubation time interval Mean heart rate was (87.18 ±5.54) beats/minute in group D(IV) and (90.95±6.02) beats/minute in group D(IN) and the p-value in intergroup comparison came out to be 0.004 which was statistically significant. Conclusion: Dexmedetomidine drug when given in group D(IN) through intranasal route at a dose of 1 µg/kg body weight forty minutes before induction of anesthesia produced similar haemodynamic changes as when given through intravenous route as infusion in group D(IV) at a dose of 0.5 µg/kg body weight in patients undergoing major surgeries under general anaesthesia. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of adverse events associated with immediate tracheal intubation in children (1-18 years) from Pediatric Intensive Care Unit of Tertiary Care Hospital of Karachi, Pakistan. Study Design: Observational study. Setting: PICU of the Aga Khan University Hospital Karachi. Period: September 2020 to August 2021. Methods: A total of 183 intubations occurred during the study period. Data was extracted using the pre-designed peri-intubation proforma, data recorded on the checklist by the observer (Staff) who was fully trained by the Physician, later on compared by the researcher using the video recorded laryngoscopy used during the intubation procedure. Results: There were 183 intubations occurred during study period. Maximum intubations were in age group of 1-5 years (27.3%) and among total intubations, there were 11(6%) intubation related complications occurred. 6 (3.3%) cases have hypoxia, 3 (1.6%) bradycardia and 2 (1.1%) others (hypotension and esophageal intubation). Majority of the complications were observed during morning hours with statistically significant association. 63.60% TI related cases survived whereas 36.40% of them expired, 54.5% stayed in PICU for 0-10 days. Conclusion: Tracheal intubation related adverse events were 6% and majority of them lead to hypoxia. Physiological and mechanical complications with the procedure do occur inspite of our best efforts. Recognizing the complications associated with tracheal intubation can help physicians better care for patients requiring intubation. [ABSTRACT FROM AUTHOR]

Tracheal intubation is the gold standard for airway management in emergency medicine, but more difficult to apply for inexperienced individuals than laryngeal mask airway (LMA). The aim of our study was to investigate if inexperienced individuals are able to secure the airway with the help of LMA after a short introduction. A second aim was to evaluate Thiel-fixed specimens against unfixed ones. In a body donor model, LMA application was evaluated between medical students without previous airway experience and anesthesiologists by comparing the sealing of the larynx using a water column applied to the esophagus. LMAs were successfully applied in 46 out of 55 (83.6%) attempts by medical students and in 30 out of 39 (76.9%) attempts by anesthesiologists. Among medical students, 14.1% of all LMA applications were primarily leaky, compared with 18.8% in anesthesiologists. Esophageal sealing was better in Thiel-fixed specimens (leakage 10.9%) compared with unfixed specimens (leakage 22.9%). Our data showed no significant difference between anesthesiologists and medical students in terms of sealing of LMA. Therefore, we conclude that medical students without previous airway experience can quickly learn to apply LMA sufficiently and thus, achieve aspiration protection similar to anesthesiologists. Medical students without previous airway experience can successfully insert LMAs after a short introduction. Thiel-fixed specimens are suitable for studies as well as for training in LMA application. [ABSTRACT FROM AUTHOR]

Objective: To review and analyze the airway and anesthesia management methods for patients who underwent endoscopic closure of tracheoesophageal fistula (TEF) and to summarize the experience of intraoperative airway management. Method: We searched the anesthesia information system of the First Affiliated Hospital of Nanjing Medical University for anesthesia cases of TEF from July 2020 to July 2023 and obtained a total of 34 anesthesia records for endoscopic TEF occlusion. The intraoperative airway management methods and vital signs were recorded, and the patients' disease course and follow-up records were analyzed and summarized. Results: The airway management strategies used for TEF occlusion patients included nasal catheter oxygen (NCO, n = 5), high-flow nasal cannula oxygen therapy (HFNC, n = 4) and tracheal intubation (TI, n = 25). The patients who underwent tracheal intubation with an inner diameter of 5.5 mm had stable hemodynamics and oxygenation status during surgery, while intravenous anesthesia without intubation could not effectively inhibit the stress response caused by occluder implantation, which could easily cause hemodynamic fluctuations, hypoxemia, and carbon dioxide accumulation. Compared with those in the TI group, the NCO group and the HFNC group had significantly longer surgical times, and the satisfaction score of the endoscopists was significantly lower. In addition, two patients in the NCO group experienced postoperative hypoxemia. Conclusion: During the anesthesia process for TEF occlusions, a tracheal catheter with an inner diameter of 5.5 mm can provide a safe and effective airway management method. [ABSTRACT FROM AUTHOR]

In this segment of the emergency palliative care case series, we present a patient who arrives at a small community emergency department with acute intracranial hemorrhage, aspiration, and respiratory failure. Usual care includes aggressive airway management with intubation and mechanical ventilation, and a recommendation from stroke neurologists and neurosurgeons at the tertiary care center to transfer the patient. The patient's wife has some understanding that the prognosis is likely to be poor, and asks that the patient not be transferred if he is unlikely to return to independent function. A general neurologist is consulted to provide a prognostic opinion, and goals-of-care discussions are facilitated by a palliative care consultant. After expedited evaluation, the neurologist provides a prognostic assessment, while the palliative care clinician explores potential next steps with the patient's wife, based upon his known goals and values, ultimately leading to high-value goal-concordant end-of-life care for the patient and his family. [ABSTRACT FROM AUTHOR]

Background and objective: Inadequate postintubation sedation (PIS) can lead to unplanned extubations, conscious paralysis, and overall unsafe care of patients. From 2018 to 2020, we realized at our hospital that -25% of children received sedation in an adequate time frame in the pediatric emergency department, with 2 unplanned dislodgements of the endotracheal tube. Our objective was to reduce time to initiating PIS from a mean of 39 minutes to less than 15 minutes in our pediatric emergency department by September 2021. Methods: A multidisciplinary team was formed in March 2020 to develop a key driver diagram and a protocol to standardize PIS. Baseline data were obtained from December 2017 through March 2020. The primary measure was time from intubation to administration of first sedation medication. Plan-do-study-act cycles informed interventions for protocol development, awareness, education, order set development, and PIS checklist. The secondary measure was unplanned extubations and the balancing measure was PIS-related hypotension requiring pressors. An X-bar and S chart were used to analyze data. Results: Protocol implementation was associated with decrease in mean time to PIS from 39 minutes to 21 minutes. Following educational interventions, order set implementation, and the addition of PIS plan to the intubation checklist, there was a decrease in mean time to PIS to 13 minutes, which was sustained for 9 months without any observed episodes of PIS-related hypotension or unplanned extubations. Conclusions: Quality improvement methodology led to a sustained reduction in time to initiation of PIS in a pediatric emergency department. [ABSTRACT FROM AUTHOR]

Background and objectives: Neonatal endotracheal tube (ETT) size recommendations are based on limited evidence. We sought to determine data-driven weight-based ETT sizes for infants undergoing tracheal intubation and to compare these with Neonatal Resuscitation Program (NRP) recommendations. Methods: Retrospective multicenter cohort study from an international airway registry. We evaluated ETT size changes (downsizing to a smaller ETT during the procedure or upsizing to a larger ETT within 7 days) and risk of procedural adverse outcomes associated with first-attempt ETT size selection when stratifying the cohort into 200 g subgroups. Results: Of 7293 intubations assessed, the initial ETT was downsized in 5.0% of encounters and upsized within 7 days in 1.5%. ETT downsizing was most common when NRP-recommended sizes were attempted in the following weight subgroups: 1000 to 1199 g with a 3.0 mm (12.6%) and 2000 to 2199 g with a 3.5 mm (17.1%). For infants in these 2 weight subgroups, selection of ETTs 0.5 mm smaller than NRP recommendations was independently associated with lower odds of adverse outcomes compared with NRP-recommended sizes. Among infants weighing 1000 to 1199 g: any tracheal intubation associated event, 20.8% with 2.5 mm versus 21.9% with 3.0 mm (adjusted OR [aOR] 0.62, 95% confidence interval [CI] 0.41-0.94); severe oxygen desaturation, 35.2% with 2.5 mm vs 52.9% with 3.0 mm (aOR 0.53, 95% CI 0.38-0.75). Among infants weighing 2000 to 2199 g: severe oxygen desaturation, 41% with 3.0 mm versus 56% with 3.5mm (aOR 0.55, 95% CI 0.34-0.89). Conclusions: For infants weighing 1000 to 1199 g and 2000 to 2199 g, the recommended ETT size was frequently downsized during the procedure, whereas 0.5 mm smaller ETT sizes were associated with fewer adverse events and were rarely upsized. [ABSTRACT FROM AUTHOR]

Background: Obese patients often pose endotracheal intubation (ETI) and/or ventilation difficulties, when compared to non-obese patients. Reducing the duration of intubation helps to prevent the associated respiratory and hemodynamic complications. We evaluated the effect of lubricating the undersurface of the Glidescope® blade at the intubation time as well as other associated drawbacks while intubating obese patients. Methodology: A total of 54 adult patients undergoing elective bariatric surgery requiring general anesthesia and oral ETI were included in this study. Out of these 27 patients were included in Group L, in which the underside of the GlideScope® blade used for intubation was lubricated by soluble lidocaine jelly, taking care not to touch the camera or the source of light. The rest of the patients (n = 27) were included in Group C (control group). In the control group, the patients were handled with the same technique but using a standard non-lubricated blade. Intubation time, staring from blade introduction in the mouth to tube entrance into the glottis was registered. Results: There was a statistically significant difference in intubation outcomes between the Group L and the Group C. The mean intubation times were 15.15 ± 4.24 sec vs. 23.98 ± 5.94 sec (P = 0.0001) for the Group L and C respectively. Conclusion: Lubricating the blade can be an independent factor that can reduce the time of tracheal intubation, such as smoothening the insertion of the blade during tracheal intubation and preventing the tongue from being curled up. The maneuver can also reduce bleeding during the tracheal intubation due to dry tongue. [ABSTRACT FROM AUTHOR]

Summary: While videolaryngoscopy has resulted in better overall success rates of tracheal intubation, airway assessment is still an important prerequisite for safe airway management. This study aimed to create an artificial intelligence model to identify difficult videolaryngoscopy using a neural network. Baseline characteristics, medical history, bedside examination and seven facial images were included as predictor variables. ResNet‐18 was introduced to recognise images and extract features. Different machine learning algorithms were utilised to develop predictive models. A videolaryngoscopy view of Cormack‐Lehane grade of 1 or 2 was classified as 'non‐difficult', while grade 3 or 4 was classified as 'difficult'. A total of 5849 patients were included, of whom 5335 had non‐difficult and 514 had difficult videolaryngoscopy. The facial model (only including facial images) using the Light Gradient Boosting Machine algorithm showed the highest area under the curve (95%CI) of 0.779 (0.733–0.825) with a sensitivity (95%CI) of 0.757 (0.650–0.845) and specificity (95%CI) of 0.721 (0.626–0.794) in the test set. Compared with bedside examination and multivariate scores (El‐Ganzouri and Wilson), the facial model had significantly higher predictive performance (p < 0.001). Artificial intelligence‐based facial analysis is a feasible technique for predicting difficulty during videolaryngoscopy, and the model developed using neural networks has higher predictive performance than traditional methods. [ABSTRACT FROM AUTHOR]