Endotracheal Intubation Time Research Articles

成人院外心停止患者に対する病院前の高度な気道確保：全国救急蘇生統計コホート研究(Pre–hospital advanced airway management for adults with out–of–hospital cardiac arrest: nationwide cohort study)

要旨【目的】院外心停止患者に対する病院前の高度な気道確保は不良な生存・神経学的アウトカムと関連することが，これまでの多くの観察研究で報告されてきた。成人院外心停止患者に対する病院前の高度な気道確保と生存との関連を明らかにすることを目的として本研究を行った。【対象】2014年1月から2016年12月までの本邦の全国救急蘇生統計（ウツタインデータ）を対象に，連続登録された院外心停止成人症例について，心電図の初回記録をもとに「電気ショック適応（心室細動または無脈性心室頻拍）」および「電気ショック非適応（無脈性電気活動または心静止）」の2つのサブコホートに分類した。時間依存性傾向スコアに基づいて同一時点（分）で心肺蘇生時処置として高度な気道確保を受けた患者と高度な気道確保を受けていない患者とを連続的にマッチングさせた。1か月後または1か月以内の退院時の生存割合を主要アウトカムとした。【結果】適格患者310,620名のうち，電気ショック適応群の患者20,516名中8,459名（41.2%）および電気ショック非適応群の患者290,104名中121,890名（42.0%）が心肺蘇生時に高度な気道確保を受けた。時間依存性傾向スコアによる連続マッチングを行った後，電気ショック適応群の患者16,114名および電気ショック非適応群の患者236,042名を同一時点（分）でそれぞれマッチングさせた。電気ショック適応群では，高度な気道確保を受けた患者と受けなかった患者の間で生存割合に差はみられず，それぞれ8,057名中1,546名（19.2%）および8,057名中1,500名（18.6%）であった（調整リスク比1.00，95%信頼区間0.93–1.07）。電気ショック非適応群では，高度な気道確保を受けた患者は受けなかった患者よりも生存割合が高く，それぞれ118,021名中2,696名（2.3%）および118,021名中2,127名（1.8%）であった（調整リスク比1.27，1.20–1.35）。【結論】成人院外心停止患者における時間依存性傾向スコア連続マッチング解析において，電気ショック適応リズムの患者では高度な気道確保と生存に関連がなかったのに対し，電気ショック非適応リズムの患者では高度な気道確保は生存と関連した。

Assessment of endotracheal intubation procedures following inadvertent esophageal intubation. A randomized crossover manikin trial.

To evaluate the success, degree of difficulty and completion time of endotracheal intubation without removing the endotracheal tube in the event of an oesophageal intubation.. The prospective, randomised crossover study was conducted at Gulhane Training and Research Hospital, Ankara, Turkey, from July 1, 2018, to August 31, 2018, and used a manikin model. Endotracheal intubation was performed using Miller, Macintosh blades and a video laryngoscope. The procedures were randomised into two groups, with group E+ being subjected to it while an endotracheal tube ETT was placed in the oesophagus (E+) simulating the oesophageal intubation, and control group E- getting the standard procedure without the endotracheal tube in the oesophagus. All methods were evaluated for their success, completion time, and degree of difficulty. Data was analysed using SPSS 22. There were 120 manikins, with 60(50%) in each of the two groups. The mean completion time with Miller in E+ group was 19.05±9.65 and for E- it was 17.55±11.95 seconds. With Macintosh, E+ had a mean completion time of 19.85±12.66 seconds and E- had 16.75±8.66. With video laryngoscope, E+ group had a mean completion time of 16.75±8.66 seconds, while E- had it 14.60±8.17. No significant difference was found in the paired group comparisons in terms of the degree of task difficulty (p>0.05). In case of inadvertent oesophageal intubation condition, leaving the tube in the oesophagus and performing subsequent endotracheal intubation attempts was not found to decrease the rate of success regardless of the laryngoscope type.

Co-editors' notes

This issue covers numerous and diverse topics related to health professions education and policy development. Contributions are truly global as we are publishing papers of authors from Africa, Argentina, Canada, China, India, Saudi Arabia, Sweden, and the United States. Of interest in this issue is that the scope goes beyond medicine alone, and in the spirit of health professions as a whole brings in disciplines such as dentistry and physiotherapy, as well as focus on the community. In the article, “Is Emotional Intelligence Related to Objective Parameters of Academic Performance in Medical, Dental and Nursing Students: A Systematic Review,” Singh et al. present the results of a systematic review aimed to address the question of the influence of emotional intelligence (EI) on objective parameters of academic performance in undergraduates in three disciplines. Databases were systematically searched for empirical studies which measured the EI of medical, nursing, or dental undergraduate students and compared it with academic performance. Findings of the review showed that EI has a greater role in the academic success of clinical year medical and dental students. In the paper, “Assessing Perceptions of Professionalism in Medical Learners by the Level of Training and Sex,” Spiwak et al. looked at male and female perceptions of 16 vignettes related to such items as lapse in excellence, inappropriate dress, lack of altruism, disrespect, shirking duty, and abuse of power. They found significant differences on many items, with females more likely to rate items as more severe. The authors conclude that more work is needed in the area of professionalism and sex. This is especially important in light of changing conceptions of gender. Rashid et al. – “Doctor, Teacher, Translator: International Medical Students' Experiences of Clinical Teaching on an English-language Undergraduate Medical Course in China”– offer a description of student experiences related to participation in and completion of an English language program. Nonnative English-speaking students indicate that while English proficiency was variable in their clinical teachers, they were able to navigate the challenges of studying clinical medicine from teachers with limited English skills. The students felt that other attributes such as enthusiasm, interactivity, and a desire to teach superseded English proficiency of the clinical teacher. The authors call for future study of clinical teacher perceptions of working with non native English-speaking students and graduate outcomes of students participating in the course. In “Rural Stream: An Effective Alternative to the Longitudinal Integrated Clerkship Model for Small Rural Communities,” Carson et al. provide insight into a regionalized medical program where students spend the first two and one-half years of their undergraduate degree in district hospitals. The authors emphasize the importance of immersion and community engagement. While a challenge, Carson et al. show that effective medical education can occur locally, in small rural communities. There are four Letters to the Editor in this issue. Abu-Zaid (“Where do Medical Students Submit Their Work?”) replies to an Education for Health paper contending that main stream journals should encourage publication of student research work. Kuntz et al. (“Video Review with Sports Performance Software Improves Trainee Endotracheal Intubation Time, Performance, and Confidence”) where the researchers take success from one sector and apply it to another. Gali et al. (“Introducing a Communication Skills Course in an Indian Dental Institution: An Academic Experience”) where the educators share their experience in introducing a communication skills module to preclinical undergraduates. Finally, Paraskevopoulos and Papandreou (“Physiotherapy Clinical Placement during the COVID-19 Pandemic”) propose an alternative method of clinical education delivery through an online platform. Please feel free to submit a Letter to the Editor to Education for Health in response to any topics in this issue that spark your interest or attention.

Prospective observational study of early respiratory management in preterm neonates less than 35\u2009weeks of gestation

BackgroundCurrent guidelines for management of respiratory distress syndrome (RDS) recommend continuous positive airway pressure (CPAP) as the primary mode of respiratory support even in the most premature neonates, reserving endotracheal intubation (ETI) for rescue surfactant or respiratory failure. The incidence and timing of ETI in practice is poorly documented.MethodsIn 27 Level III NICUs in the US (n = 19), Canada (n = 3) and Poland (n = 5), demographics and baseline characteristics, respiratory support modalities including timing of ETI, administration of surfactant and caffeine/other methylxanthines, and neonatal morbidities were prospectively recorded in consecutive preterm neonates following written parental consent. Infants were divided into three groups according to gestational age (GA) at birth, namely 26–28, 29–32 and 33–34 weeks. Statistical comparisons between groups were done using Chi-Square tests.ResultsOf 2093 neonates (US = 1507, 254 Canada, 332 Poland), 378 (18%) were 26–28 weeks gestational age (GA), 835 (40%) were 29–32 weeks, and 880 (42%) were 33–34 weeks. Antenatal steroid use was 81% overall, and approximately 89% in neonates ≤32 weeks. RDS incidence and use of ventilatory or supplemental oxygen support were similar across all sites. CPAP was initiated in 43% of all infants, being highest in the 29–32-week group, with a lower proportion in other GA categories (p < 0.001). The overall rate of ETI was 74% for neonates 26–28 weeks (42% within 15 min of birth, 49% within 60 min, and 57% within 3 h), 33% for 29–32 weeks (13 16 and 21%, respectively), and 16% for 33–34 weeks (5, 6 and 8%, respectively). Overall intubation rates and timing were similar between countries in all GAs. Rates within each country varied widely, however. Across US sites, overall ETI rates in 26–28-week neonates were 30–60%, and ETI within 15 min varied from 0 to 83%. Similar within 15-min variability was seen at Polish sites (22–67%) in this GA, and within all countries for 29–32 and 33–34-week neonates.ConclusionDespite published guidelines for management of RDS, rate and timing of ETI varies widely, apparently unrelated to severity of illness. The impact of this variability on outcome is unknown but provides opportunities for further approaches which can avoid the need for ETI.

Comparison of three airway conduits for fiberoptic-guided intubation: A randomized controlled trial

ABSTRACTBackground: Many oral airways are used for aiding fiberoptic bronchoscope (FOB)-guided endotracheal intubation. This study was done to evaluate modified William’s airway, modified Guedel’s airway, and LMA MADgic airway as conduits for FOB-guided endotracheal intubation.Methods: Sixty patients presented for elective surgery under general anesthesia were randomly allocated into three groups: Modified Guedel’s airway group (GG), modified Williams airway group (GW), and LMA MADgic airway group (GM). The three study groups were compared with regard to time of insertion of the airway, time of intubation, ease of airway insertion, number of intubation attempts, Laryngeal View Grade (LVG), and the incidence of complications.Results: Gw had shorter time of airway insertion, shorter time of intubation, lower number of intubation attempts, and better laryngeal view compared to GG and GM. The anesthesiologist was more comfortable in Gw compared to the other two groups.The incidence of complications (sore throat, and blood-stained airway) was comparable between the three groups.Conclusion: Modified Williams airway provided shorter time of endotracheal tube intubation, and lower number of intubation attempts in comparison to modified Guedel’s airway and LMA MADgic airway when used as conduit for FOB-guided endotracheal intubation. This randomized controlled study was conducted in Cairo University Hospital. Research Ethics Committee approved the study (N-40–2016).

Clinical practice and evaluation of management of patients based on clinical pathway of emergency respiratory and cardiac arrest

To explore the effect of clinical pathway of emergency respiratory and cardiac arrest on management of patients with sudden respiratory and cardiac arrest. The clinical data of patients with sudden respiratory and cardiac arrest admitted to Huashan North Hospital Affiliated to Fudan University from 1 year before to 1 year (started in July 2017) after the implementation of clinical pathway of emergency respiratory and cardiac arrest were retrospectively analyzed. The patients who managed by clinical pathway of emergency respiratory and cardiac arrest (from July 2017 to June 2018) were served as observational group, and those manually managed by 2015 American Heart Association cardiopulmonary resuscitation and cardiovascular emergency guide update and the procession in the management of emergency key diseases (from July 2016 to June 2017) were set as control group. The gender, age, underlying disease, the initiation time of cardiopulmonary resuscitation (CPR), the first time of defibrillation, the completion time of endotracheal intubation, the time of venous access, the usage time of the first dose of adrenaline, the usage time of vasoactive drugs, the completion rate of high quality CPR, the success rate of return of spontaneous circulation (ROSC) and the table procedure of clinical pathway were compared between the two groups. There was no statistically significant difference in gender, age or underlying disease between the two groups. Compared with the control group, the clinical pathway could effectively guide the decision-making of the emergency medical staffs, significantly reduce the variation in the procession of the resuscitation, the first time of defibrillation, the completion time of the deep vein catheterization, the usage time of norepinephrine and the completion time of the blood specimen delivery were significantly shortened [the first time of defibrillation (minutes): 1.28±0.86 vs. 2.93±1.61, the completion time of deep vein catheter (minutes): 15.13±2.73 vs. 17.25±3.02, the usage time of norepinephrine (minutes): 15.43±2.80 vs. 17.88±1.67, the completion time of blood specimen delivery (minutes): 7.81±1.42 vs. 9.00±1.03, all P < 0.05]. There was no statistically significant difference in the initiation time of CPR, the completion time of tracheal intubation, the time of peripheral venous access, the usage time of the first dose of adrenaline or sodium bicarbonate, or the success rate of ROSC between the two groups. However, the usage time of the first dose of adrenaline and sodium bicarbonate was shortened in the observation group [the usage time of the first dose of adrenaline (minutes): 3.81±1.22 vs. 4.00±1.32, the usage time of the first does of sodium bicarbonate (minutes): 8.94±3.49 vs. 11.19±3.54, both P > 0.05], and the success rate of ROSC was relatively increased as compared with those in the control group [15.04% (17/113) vs. 12.50% (12/96), P > 0.05]. The clinical pathway of emergency respiratory and cardiac arrest could effectively guide the clinical decision-making of the emergency medical staffs, significantly reduce the variation in the procession of the resuscitation, improve the quality of the resuscitation, and ensure medical safety of emergency department.

GlideScope® cobalt video laryngoscope versus direct Miller laryngoscope for lateral position-tracheal intubation in neonates with myelodysplasia: A prospective randomized study.

Background and Objective:Anesthesiologists encounter difficulties during laryngoscopy and tracheal intubation of neonates with myelodysplasia. Tracheal intubation in lateral position in such cases deemed profitable but not easy because of the compromised laryngeal view. We compared GlideScope video laryngoscope (GVL) versus conventional Miller direct laryngoscope (DL) for tracheal intubation in laterally positioned neonates with myelodysplasia.Materials and Methods:Sixty neonates scheduled for elective surgical repair of meningeocele or meningeomyelocele under general anesthesia were allocated randomly for endotracheal intubation using GVL or DL. Percentage of glottis opening (POGO) scores, time to best glottis view (TBGV), endotracheal tube passage time (TPT), intubation time (IT), intubation attempts, and overall success rate of intubation were recorded.Results:TBGV was significantly shorter in GVL group (median = 6.8 s, range = 3.5–28.2 s) in comparison with DL group (median = 8.4 s, range = 4.8–32.7 s) (P = 0.01); however, TPT and IT were comparable. POGO scores were significantly higher with GVL group than DL group (median = 93.8, range = 45–100 and median = 82.4, range 10–100, respectively) (P = 0.001). Overall success of intubation was the same; however, three patients in GVL group required a second attempt for intubation in comparison with five patients in DL group. One patient in DL group required a third attempt.Conclusion:In laterally positioned neonates, GVL is easier than DL with a similar intubation time, comparable time required for tube passage, better views of the glottis, shorter times to obtain the best glottic view, and high success rate as compared with DL. GlideScope seems to be an effective approach for endotracheal intubation of laterally positioned neonates with myelodysplasia.

I-Gel as an intubation conduit: Comparison of three different types of endotracheal tubes.

Background and Aims:I-Gel®, a novel SAD has been introduced as a ventilating device but has widely gained popularity as conduit for intubation. Unlike intubating laryngeal mask airway (ILMA), I-Gel® does not have an endotracheal tube specially designed for it. Hence the aim of this study was to compare the rate of successful intubation via I-Gel® using three different types of endotracheal tubes.Methods:We randomised 75 American Society of Anesthesiologists (ASA) physical status I and II patients, between the age group 18-60 years of either sex undergoing elective surgery under general anaesthesia into three groups on the basis of endotracheal tube (ETT), used for intubation via I-Gel®: Group P (Polyvinyl chloride ETT), Group I (Intubating laryngeal mask airway ETT), Group F (flexometallic ETT). After following the standard induction protocol, appropriate size I Gel® was inserted in all patients. Thereafter group specific ETT was inserted via I-Gel®. We recorded and compared the time taken for successful intubation, the success rate, number of attempts taken, manoeuvres used, and complications among three different types of ETT. Quantitative variables were compared using Kruskal Wallis test and the qualitative variables were compared using Chi-square test.Results:The time taken for successful intubation was least in group P (10.51 ± 3.82 seconds). Group P also had the highest first attempt (68%) and overall rate of successful intubation (88%).Conclusion:PVC ETT had highest first attempt success rate and required minimum time for endotracheal intubation via I-Gel® when compared to ILMA ETT and Flexible ETT.

Comparison of blind intubation via supraglottic airway devices versus standard intubation during different airway emergency scenarios in inexperienced hand

Background:Securing the airway and enabling adequate oxygenation and ventilation is essential during cardiopulmonary resuscitation (CPR). The aim of the study was to evaluate the success rate of blind intubation via the I-Gel and the Air-Q compared with direct laryngoscopy guided endotracheal intubation by inexperienced physician and to measure time to successful intubation.Methods:The study was designed as a randomized, cross-over simulation study. A total of 134 physicians, from specialties other than Anesthesia or Emergency Medicine, who considered themselves skilled in endotracheal intubation but who have never used any kind of supraglottic airway device performed blind intubation via the I-Gel and Air-Q and direct laryngoscopy guided endotracheal intubation in 3 randomized scenarios: normal airway without chest compression during intubation attempt; normal airway with continuous chest compression during intubation attempt; difficult airway with continuous chest compression.Results:Scenario A: Success rate with initial intubation attempt was 72% for endotracheal intubation, 75% in Air-Q, and 81% in I-Gel. Time to endotracheal intubation and ease of intubation was comparable with all 3 airway devices used. Scenario B: Success rate with the initial intubation attempt was 42% for endotracheal intubation, compared with 75% in Air-Q and 80% in I-Gel. Time for endotracheal intubation was significantly prolonged in endotracheal intubation (42 seconds, 35–49), compared with Air-Q (21 seconds, 18–32) and I-Gel (19 seconds, 17–27). Scenario C: The success rate with the initial intubation attempt was 23% in endotracheal intubation, compared with 65% in Air-Q and 74% in I-Gel. Time to intubation was comparable with both supraglottic airway devices (20 vs 22 seconds) but was significantly shorter compared with endotracheal intubation (50 seconds, P < .001).Conclusions:Less to moderately experienced providers are able to perform endotracheal intubation in easy airways but fail during ongoing chest compressions and simulated difficult airway. Consequently, less to moderately experienced providers should refrain from endotracheal intubation during ongoing chest compressions during CPR and in expected difficult airways. Supraglottic airway devices are reliable alternatives and blind intubation through these devices is a valuable airway management strategy.

Hypotension after induction of general anesthesia: occurrence, risk factors, and therapy. A prospective multicentre observational study.

Hypotension after induction of general anesthesia (GAIH) is common in anesthesiology practice and can impact outcomes. In this prospective multicenter, cross-sectional, observational study, the hypotension was defined as a decrease in mean arterial pressure of > 30% compared to the first measurement in the operation theatre before general anesthesia (GA) induction. Blood pressure was measured immediately at the time of endotracheal intubation (TETI), at five (T5) and 10 (T10) minutes after. All subjects aged > 18years undergoing elective non-cardiac surgery under GA were included. The goals were description of GAIH occurrence, the association of GAIH with selected comorbidities, chronic medications, and anesthetics with GAIH, and the type and efficacy of interventions used to correct hypotension. Data from 661 subjects, whose GA was induced with propofol and sufentanil, were analyzed. In 36.5% of subjects, GAIH was observed at ≥ 1 of the assessed time points. GAIH was present in 2.9% subjects at all time points. The probability of GAIH is raising with age, degree of hypertension at time of arrival to theatre and presence of diabetes. The type of volatile anesthetic was not associated with the occurrence of GAIH. The overall efficiency of interventions to correct hypotension was 94.4%. Bolus fluids were the most often used intervention and was 96.4% effective. GAIH rate depends on age, degree of blood pressure decompensation prior the surgery, and presence of diabetes mellitus type II.

O papel do videolaringoscópio em programas de treinamento de intubação endotraqueal

BackgroundMacintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education. MethodsEndotracheal intubation was performed on a human manikin owing a standard respiratory tract by Macintosh laryngoscopes and C-MAC® videolaryngoscope (Karl Storz, Tuttligen, Germany). Eighty paramedic students were randomly allocated to four groups. At the first week of the study 10 endotracheal intubation trials were performed where, Group‐MM and Group‐MV used Macintosh laryngoscopes; Group‐VV and Group‐VM used videolaryngoscopes. Four weeks later all groups performed another 10 endotracheal intubation trial where Macintosh laryngoscopes was used in Group‐MM and Group‐VM and videolaryngoscopes used in Group‐VV and Group‐MV. ResultsSuccess rates increased in the last 10 endotracheal intubation attempt in groups MM, VV and MV (p=0.011; p=0.021, p=0.290 respectively) whereas a decrease was observed in group‐VM (p=0.008). ConclusionsThe success rate of endotracheal intubation decreases in paramedic students who used VL during endotracheal intubation education and had to use Macintosh laryngoscopes later. Therefore we believe that solely videolaryngoscopes is not enough in endotracheal intubation training programs.

The role of videolaryngoscope in endotracheal intubation training programs

BackgroundMacintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education. MethodsEndotracheal intubation was performed on a human manikin owing a standard respiratory tract by Macintosh laryngoscopes and C-MAC® videolaryngoscope (Karl Storz, Tuttligen, Germany). Eighty paramedic students were randomly allocated to four groups. At the first week of the study 10 endotracheal intubation trials were performed where, Group-MM and Group-MV used Macintosh laryngoscopes; Group-VV and Group-VM used videolaryngoscopes. Four weeks later all groups performed another 10 endotracheal intubation trial where Macintosh laryngoscopes was used in Group-MM and Group-VM and videolaryngoscopes used in Group-VV and Group-MV. ResultsSuccess rates increased in the last 10 endotracheal intubation attempt in groups MM, VV and MV (p=0.011; p=0.021, p=0.290 respectively) whereas a decrease was observed in group-VM (p=0.008). ConclusionsThe success rate of endotracheal intubation decreases in paramedic students who used VL during endotracheal intubation education and had to use Macintosh laryngoscopes later. Therefore we believe that solely videolaryngoscopes is not enough in endotracheal intubation training programs.

Comparison of Mallampati scores and hemodynamic responses between elderly and younger patients: Prospective cohort study

Summary Background This study aimed to evaluate the effect of aging on the Mallampati score, intubation time, and hemodynamic response for endotracheal intubation during induction of anesthesia. Methods One hundred and twenty patients were enrolled and allocated according to age to either group N (35–49 years, n = 60) or group E (65–74 years, n = 60). Patients were administered 3 MAC (minimum alveolar concentration) of sevoflurane for 5 min to induce anesthesia. Systolic blood pressure (SBP), mean arterial pressure (MAP), diastolic blood pressure (DBP), pulse pressure (PP), and heart rate (HR) were recorded before (baseline), immediately after (T0), and at 1-min intervals during the first 4 min after endotracheal intubation (T1–T4). The Mallampati score and intubation time were also recorded. Results There were significant differences between groups with regard to overall changes in SBP, MAP, DBP, and HR. The change in SBP and MAP was higher in group E than in group N at T0 and T1. HR was significantly lower in group E than in group N at T0, T1, and T2. The Mallampati score and intubation time were significantly higher in group E than in group N. After controlling for the Mallampati score, there were no significant differences between the groups; however, HR was significantly lower in group E than in group N. Conclusion After intubation, the changes in SBP, MAP and DBP, Mallampati score, and intubation time were higher, and changes in HR were lower in elderly patients. The changes in SBP, MAP and DBP in elderly patients are associated with the changes in Mallampati score.

Efficacy and Safety of Using High-Flow Nasal Oxygenation in Patients Undergoing Rapid Sequence Intubation.

To assess the efficacy and safety of high-flow nasal oxygen (HFNO) therapy in patients undergoing rapid sequence intubation (RSI) for emergency abdominal surgery. HFNO of 60 L.min-1 at an inspiratory oxygen fraction of 1 was delivered 4 min before laryngoscopy and maintained until the patient was intubated, and correct intubation was verified by the appearance of the end-tidal CO2 (EtCO2) waveform. Transcutaneous oxygenation (SpO2), heart rate and non-invasive mean arterial pressure were monitored at baseline (T0), after 4 min on HFNO (T1) and at the time of laryngoscopy (T2) and endotracheal intubation (ETI) (T3). An SpO2 of <3% from baseline was recorded at any sampled time. The value of EtCO2 at T3 was registered after two mechanical breaths. The apnoea time was defined as the time from the end of propofol injection to ETI. RSI was performed with propofol, fentanyl and rocuronium. Forty-five patients were enrolled. SpO2 levels showed a statistically significant increase at T1, T2 and T3 compared with those at T0 (p<0.05); median SpO2% (interquartile range) was 97% (range, 96%-99%) at T0, 99% (range, 99%-100%) at T1, 99% (range, 99%-100%) at T2 and 99% (range, 99%-100%) at T3. Minimal SpO2 was 96%; no patient showed an SpO2 of <3% from baseline; mean EtCO2 at the time of ETI was 36±4 mmHg. Maximum apnoea time was 12 min. HFNO is an effective and safe technique for pre-oxygenation in patients undergoing rapid sequence induction of general anaesthesia for emergency surgery.

Bispectral Index in Poisoning Cases with Multi-drug Ingestion: A Predictable Role for Early Endotracheal Intubation.

Objective:Bispectral index (BIS) is one of the several methods used to monitor the depth of anesthesia. Poisoning with ingestion of different drugs is one of the most common poisonings that have different clinical signs from drowsiness to coma. This study was performed to compare the BIS index number in poisoned patients with multi drugs ingestion with or without the need for endotracheal intubation.Methods:This cross-sectional study was performed on poisoned patients with ingestion of different drugs referring to Clinical Toxicology Department of Noor University Hospital, Isfahan, Iran. The clinical signs and symptoms and the vital signs at the admission time were measured, and the required therapies were given. The endotracheal intubation was done for patients who had the indication of intubation. BIS was monitored and compared for all patients with or without a need for intubation on the admission time and time of endotracheal intubation. Obtained data were analyzed by SPSS software.Findings:At the admission time, the mean (standard error [SE]) BIS index value for poisoned patients who needed endotracheal intubation was 66.47 ± 2.57 in comparison with 85.21 ± 1.47 for patients who did not need intubation (P < 0.001). The results of receiver operating characteristic curve (mean ± SE) showed the discrimination was excellent for BIS (0.899 ± 0.04; 95% confidence interval: 0.81–0.98) (P < 0.0001). BIS <79.5 had the sensitivity 88% and specificity 87% for endotracheal intubation.Conclusion:BIS is an appropriate index for prediction of the need to intubation in poisoned patients with ingestion of different drugs.

Differences in Return of Spontaneous Circulation in Early vs Late Endotracheal Intubation among Patients in Hospital Cardiac Arrest.

Common airway management strategies during cardiopulmonary resuscitation are bag- mask-valve ventilation followed by endotracheal intubation. Timing of endotracheal intubation is controversial. This study was designed to compare the effect of early vs late endotracheal intubation in terms of return of spontaneous circulation. This is an observational retrospective study done at tertiary center for the period of two years. The study population was inpatient, adult and pediatric with witnessed cardiac arrest in whom airway management was initially done with bag-valve-mask ventilation followed by endotracheal intubation. Timing of intubations were grouped into early and late with cut off time of five minutes and the groups were compared in terms of return of spontaneous circulation. There were total of 193 patients included in the study. Early intubation was done in 114 patients (59.06%) and late intubation was done in 79 patients (40.94%). Mean time for early intubation was 3.11 minutes. Mean time for late intubation was 7.89 minutes. Seventy three patients (37.8%) attained sustained ROSC. Thirty five patients (30.7%) achieved ROSC in early intubation group while 38 patients (48.1%) attained sustained ROSC in late intubation group(p = 0.016). Early intubation during cardiopulmonary resuscitation was associated with lower rate of return of spontaneous circulation.

The effect of predictable aid support in tracheal intubation with severe acute organophosphorus pesticide poisoning patients

Objective To explore the effect of predictable aid support in tracheal intubation with severe acute organophosphorus pesticide poisoning(SAOPP)patients. Methods A total of 109 patients were randomly divided into treatment group(n=55) and control group(n=54). All the patients were treated with the gastric lavage and catharsis, and accepted atropine, pralidoxime chloride and ventilatory support as prescribed.More predictability ambulance measures were applied to the treatment group such as: reinforcement tracheal intubation, endotracheal intubation tube off alarm device and joint of thermostatic wetting with oxygen driving atomization.The therapy efficacy were compared between the two groups. Results There was no statistically significant difference between the two groups of patients before treatment, such as respiration, heart rate and blood oxygen saturation(P>0.05). The observation group was compared with the control group of 72 hours after treatment, and the difference was statistically significant(P<0.01). The mechanical ventilation time, endotracheal intubation time, monitoring time and length of hospital stay of the observation group were(25.63±3.24) hours, (32.17±3.50) hours, (5.65±1.63) days and (8.52±2.13) days respectively, while the control group were (37.82±3.75) hours, (43.64±3.83) hours, (9.78±1.85) days and(13.79±2.17) days.The differences between the two groups were statistically significant(P<0.01). The incidence of UE and complications of the observation group was significantly lower than those in the control group, while the success rate of rescue was significantly higher than that in the control group, and the difference was statistically significant(P<0.05). Conclusions Foresight rescue support plan in endotracheal intubation can increase the success rate, enhance the efficacy, reduce complications and improve prognosis of SAOPP patients. Key words: Organophosphorus pesticide poisoning; Tracheal intubation; Medical support; Prognosis

Related factors of nosocomial infection in severe thoracic trauma patients after operation

Objective To investigate the related factors of nosocomial infection after severe thoracic trauma so as to provide basis and interventions for lowering nosocomial infection rate. Methods A retrospective case series study was conducted in 148 cases of severe thoracic trauma surgically treated from January 2014 to January 2016. There were 98 males and 50 females with an average age of 34.7 years. The abbreviated injury scale (AIS) was ≥ 3 points. The incidence of nosocomial infection was statistically analyzed. The possible factors related to nosocomial infection were analyzed, including age, gender, previous basic diseases, coma, blood transplantation, surgical procedure, operation time, tracheal intubation time, postoperative tracheotomy, and postoperative ICU hospitalization. Results Nosocomial infection occurred in 18 cases, with infection rate of 12.2%. There were 11 cases of pulmonary infection, four urinary tract infection, two incision infection, and one thoracic cavity infection. There were four cases (22%) of Gram-positive bacteria as pathogen, both of which were Staphylococcus aureus. A total of 12 cases (67%) were Gram-negative bacteria, among which four were infected with Klebsiella pneumonia, three with Acinetobacter baumannii, three with Pseudomonas aeruginosa, and two with Escherichia coli. Two cases were infected by fungi. The incidence of infection was correlated with the patients' age (≥60 years), previous basic disease, coma, operation methods, operation time (≥3 hours), endotracheal intubation time (≥24 hours), tracheotomy after surgery, and postoperative hospitalization duration in the ICU (P<0.05), rather than gender and blood transplantation. Conclusions The most common pathogen of nosocomial infection in severe thoracic trauma patients is Gram-negative bacteria. The older age, previous basic diseases, coma, thoracotomy, long operation time, long tracheal intubation time, tracheotomy and long ICU hospital stay are the risk factors for nosocomial infection. More attention should be paid to these risk factors in order to minimize the occurrence of postoperative hospital infection, and to reduce the harm to patients. Key words: Thoracic injuries; Surgical procedures, operative; Cross infection; Risk factors

Association between timing of intubation and outcome in critically ill patients: A secondary analysis of the ICON audit

PurposeThe optimal timing of endotracheal intubation in critically ill patients requiring invasive mechanical ventilation remains undefined. Material and methodsIn a secondary analysis of the large, prospective ICON database, we used a piecewise proportional hazards model to compare outcomes in patients who underwent intubation early (within two days after intensive care unit [ICU] admission) or later. ResultsAfter excluding 5340 patients already intubated on admission or with therapeutic limitation, 4729 patients were analyzed, of whom 4074 never underwent intubation. Of the remaining 655 patients, 449 underwent intubation early and 206 later. Despite similar severity scores on ICU admission, unadjusted ICU (27.6 vs. 18.2%) and hospital (33.3 vs. 23.4%) mortality rates were higher in patients intubated later than in those intubated earlier, as were ICU (9 [5–16] vs. 4 [2–9] days) and hospital (24 [9–35] vs. 13 [7–24] days) lengths-of-stay (all p<0.001). After adjustment, the hazard for ICU and hospital death was significantly greater >10days after ICU admission for patients intubated late. ConclusionsIn this large cohort of critically ill patients requiring intubation, intubation >2days after admission was associated with increased mortality later in the hospital course.

Nasogastric tube placement with video-guided laryngoscope: A manikin simulator study

BackgroundThis study aimed to investigate video-guided laryngoscopy for nasogastric tube placement. MethodsThis was an observational comparative study performed in a hospital. The participants included volunteers from the medical staff (physicians and nurses) experienced with nasogastric intubation, and non-medical staff (medical students, pharmacists and emergent medical technicians) with knowledge of nasogastric intubation but lacking procedural experience. Medical and non-medical hospital staff performed manual, laryngoscope-assisted and video-guided laryngoscope nasogastric intubation both in the presence and in the absence of an endotracheal tube, using a manikin. Nasogastric intubation times were compared between groups and methods. ResultsUsing the video-guided laryngoscope resulted in a significantly shorter intubation time compared to the other 2 methods, both with and without an endotracheal tube, for the medical and non-medical staff alike (all p < 0.05). For the medical staff, mean nasogastric intubation time was significantly shorter using video-guided laryngoscope without endotracheal intubation, direct laryngoscope with endotracheal intubation and video-guided laryngoscope with endotracheal intubation compared to manual intubation without endotracheal intubation (0.49, 0.63 and 0.72 vs. 5.63, respectively, p ≤ 0.008). For non-medical staff, nasogastric intubation time was significantly shorter using video-guided laryngoscope without endotracheal intubation, direct laryngoscope with endotracheal intubation and video-guided laryngoscope with endotracheal intubation compared to manual intubation without endotracheal intubation (1.67, 1.58 and 0.95 vs. 6.9, respectively, p ≤ 0.002). And mean nasogastric intubation time for video-guided laryngoscope endotracheal intubation was significantly shorter for medical staff than for non-medical staff (0.49 vs. 1.67 min, respectively, p = 0.041). ConclusionVideo-guided laryngoscope reduces nasogastric intubation time compared to manual and direct laryngoscope intubation, which promotes a consistent technique when performed by experienced medical and previously untrained non-medical staff.