First-pass Success Rate Research Articles

Does preprocedural ultrasound prior to lumbar neuraxial anesthesia or analgesia increase first-pass success in adults with obesity? A systematic review.

Preprocedural ultrasound (PPU) reduces the risk of technical failure in non-obese patients and when technical difficulty is predicted. We conducted this review to determine if PPU improves first-pass needle insertion success for neuraxial anesthesia in patients with obesity. We conducted a systematic review without meta-analysis, due to the small number of included studies. The study protocol was registered (PROSPERO: CRD42022368271). We conducted searches in MEDLINE, Embase, PubMed, and Cochrane Library from January 1, 1980 to October 1, 2022 for peer-reviewed randomized controlled or observational studies comparing PPU versus landmark techniques in patients with body mass index >30 kg/m2. The quality of evidence was assessed using the revised Cochrane risk-of-bias tool for randomized trials and Grading of Recommendations Assessment, Development, and Evaluation approach. There were nine randomized controlled studies, comprising 866 patients having lumbo-sacral neuraxial techniques. Three studies utilized a small handheld ultrasound device called Accuro™ and six utilized non-handheld ultrasound devices. Certainty of evidence was low for improving the first-pass success rate. There was evidence (moderate certainty) that PPU decreased number of passes, increased first insertion attempt success, and reduced number of insertion attempts. There was no evidence that PPU affected identifying time, needling time, or overall procedural time. There was no evidence that PPU influenced procedural failure rate (very low certainty evidence) and insufficient evidence to suggest that artificial intelligence-supported handheld devices were superior to conventional ultrasound devices. In patients with obesity, there is evidence of very-low to moderate certainty that PPU improves markers of insertion success, with no indication of increased adverse effects. PPU should be used to reduce attempts. Further studies adhering to standardized outcome definitions are required for definitive recommendations. The study protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022368271).

Comparison of Drug-Assisted Tracheal Intubation Using Benzodiazepines and Induction Agents for First-Pass Intubation Success in Emergency Airway Management: A Retrospective Cohort Study

Objective: To determine first-pass intubation success between benzodiazepines and induction agents in adult patients who underwent drug-assisted intubation in the emergency department (ED). Materials and Methods: A retrospective chart review observational study collected the data of patients who underwent drug-assisted intubation in the ED of a university teaching hospital between January 1, 2021 and August 31, 2022. Two hundred seven patients were enrolled in the present study. The benzodiazepine and induction agent groups were compared in terms of baseline characteristics, and clinical management. Each benzodiazepine and induction agent were compared in first-pass intubation success, time to intubation success, adverse events, and 24-hour mortality. Results: Of the 207 patients included in the present study, 35 patients used benzodiazepine, and 172 patients used induction agents. The two groups had no differences in baseline characteristics. The first-pass intubation success rate was not significantly different among the medications with 90% in nine diazepam patients, 92% in 23 midazolam patients, 89.8% in 79 etomidate patients, and 94% in 79 propofol patients (p=0.553). Complications associated with intubation included hypotension, desaturation, tachycardia, bradycardia, arrhythmia, cardiac arrest, and pneumonia. No differences in 24-hour survival were observed. Conclusion: The sedative medications used during drug-assisted intubation should be chosen based on patient comorbidities and characteristics, as well as physician preferences and experiences. There were no differences between the benzodiazepine and induction agent groups in terms of first-pass intubation success, adverse events, or 24-hour survival. The use of benzodiazepines in settings with limited resources may be considered.

FreeClimb 88 catheter with Tenzing 8 delivery for contact aspiration mechanical thrombectomy of anterior circulation large vessel occlusions.

Contact aspiration mechanical thrombectomy (CAMT) with 0.088-inch catheters may improve first-pass success rates, but delivery of such catheters can be challenging and limit effectiveness. This study examines the initial multicenter experience using the FreeClimb 88 catheter paired with the Tenzing 8 delivery catheter. Retrospective analysis was performed of consecutive patients with large vessel occlusion (LVO) of the internal carotid artery (ICA) or M1 segment of the middle cerebral artery treated with off-label CAMT using the FreeClimb 88 and Tenzing 8 at eight sites participating in the early limited release for these devices. Demographic and procedural variables were collected and analyzed with descriptive statistics and multivariable analysis. Fifty-three consecutive patients were treated. Large vessel occlusion was located in the ICA in 19/53 (35.8%) patients; 34/53 (64.2%) were in the M1 segment. FreeClimb 88 was successfully delivered to the site of occlusion in 50/53 (94.3%) of patients. First-pass TICI 2c or 3 was achieved with FreeClimb 88 delivered by Tenzing 8 in 36 (67.9%) cases. Among cases with successful FreeClimb 88 delivery 9/50 (18.0%) required additional smaller devices to perform thrombectomy of distal occlusions after recanalization of the initial LVO. No complications or symptomatic hemorrhages occurred following thrombectomy. Contact aspiration mechanical thrombectomy performed for ICA or M1 LVOs using FreeClimb 88 delivered with Tenzing 8 was safe, effective, and efficient in this early experience, with first-pass TICI 2c or 3 was achieved in 68% of patients without procedural complications occurring in any cases.

Comparing the effectiveness and safety of videolaryngoscopy and direct laryngoscopy for endotracheal intubation in the paediatric emergency department: a systematic review and meta-analysis.

Endotracheal intubation is an uncommon procedure for children in the emergency department but can be technically difficult and cause significant adverse effects. Videolaryngoscopy (VL) offers improved first-pass success rates over direct laryngoscopy (DL) for both adults and children undergoing elective surgery. This systematic review was designed to evaluate current evidence regarding how the effectiveness and safety of VL compares to DL for intubation of children in emergency departments. Four databases (MEDLINE, Embase, CENTRAL and Web of Science) were searched on 11th May 2023 for studies comparing first-pass success of VL and DL for children undergoing intubation in the emergency department. Studies including adult patients or where intubation occurred outside of the emergency department were excluded. Quality assessment of included studies was carried out using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. Meta-analysis was undertaken for first-pass success and adverse event rate. Ten studies met the inclusion criteria representing 5,586 intubations. All included studies were observational. Significantly greater first-pass success rate was demonstrated with VL compared to DL (OR 1.64, 95% CI [1.21-2.21], p = 0.001). There was no significant difference in risk of adverse events between VL and DL (OR 0.79, 95% CI [0.52-1.20], p = 0.27). The overall risk of bias was moderate to serious for all included studies. VL can offer improved first-pass success rates over DL for children intubated in the emergency department. However, the quality of current evidence is low and further randomised studies are required to clarify which patient groups may benefit most from use of VL. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=415039, Identifier CRD42023415039.

Direct Laryngoscopy Versus Video Laryngoscopy for Intubation in Critically Ill Patients: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Trials.

Given the uncertainty regarding the optimal approach to laryngoscopy for the intubation of critically ill adult patients, we conducted a systematic review and meta-analysis to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for intubation in emergency department and ICU patients. We searched MEDLINE, PubMed, Embase, Cochrane Library, and unpublished sources, from inception to February 27, 2024. We included randomized controlled trials (RCTs) of critically ill adult patients randomized to VL compared with DL for endotracheal intubation. Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023469945). We included 20 RCTs (n = 4569 patients). Compared with DL, VL probably increases first pass success (FPS) (relative risk [RR], 1.13; 95% CI, 1.06-1.21; moderate certainty) and probably decreases esophageal intubations (RR, 0.47; 95% CI, 0.27-0.82; moderate certainty). VL may result in fewer aspiration events (RR, 0.74; 95% CI, 0.51-1.09; low certainty) and dental injuries (RR, 0.46; 95% CI, 0.19-1.11; low certainty) and may have no effect on mortality (RR, 0.97; 95% CI, 0.88-1.07; low certainty) compared with DL. In critically ill adult patients undergoing intubation, the use of VL, compared with DL, probably leads to higher rates of FPS and probably decreases esophageal intubations. VL may result in fewer dental injuries as well as aspiration events compared with DL with no effect on mortality.

Comparison of Clinical Performance of I-gel and Fastrach Laryngeal Mask Airway as an Intubating Device in Adults: A Systematic Review and Meta-Analysis.

The supraglottic airway device (SGD) was introduced as a breakthrough in airway management. The Fastrach emerged as the first commercially available intubating SGD, drawing extensive investigation. I-gel is a more recent device that has gained popularity, can be used as an intubating SGD, and replaced Fastrach in many institutions. However, there is uncertainty regarding the comparison between these devices in terms of efficacy for intubation and ventilation, and safety in an airway rescue situation. PubMed, EMBASE, Scopus, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing I-gel and Fastrach SGD in adult patients undergoing intubation. The primary outcome was the first-pass success rate for tracheal intubation. Secondary outcomes were tracheal intubation time, SGD insertion time and success, and complications. We computed risk ratios (RRs) to assess binary end points and weighted mean differences (WMDs) for continuous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome and its subgroup analysis (P < .05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes (P < .01 was considered statistically significant). This study included a total of 14 RCTs encompassing 1340 patients. The results indicated a significant difference in the first-pass success rate favoring Fastrach (RR, 0.81; 95% CI, 0.67-0.98; P = .03; I² = 91%). In the subgroup analysis, when a flexible scope was utilized through I-gel, providers achieved a better tracheal intubation first-pass success rate (RR, 1.05; 95% CI, 1.01-1.11; P = .03; I² = 0%), compared with the Fastrach. Overall intubation success rates (RR, 0.92; 99% CI, 0.82-1.04; P = .08, I² = 92%) and time (WMD - 1.03 seconds; 99% CI, -4.75 to 2.69; P = .48; I² = 84%) showed no significant difference irrespective of the device used. There was no significant difference regarding device insertion time by the providers (WMD -6.48 seconds; 99% CI, -13.23 to 0.27; P = .01; I2 = 98%). Success rates of the providers' initial SGD insertion and complications such as sore throat (RR, 1.01; 99% CI, 0.65-1.57; P = .95, I² = 33%) and blood presence post-SGD removal (RR, 0.89; 99% CI, 0.42-1.86; P = .68, I² = 0%) showed no significant difference. Based on our findings, a higher first-pass success rate was observed with the use of Fastrach when compared to I-gel. However, the use of I-gel might result in a better intubation success rate with the flexible scope-guided intubation. There are no significant differences in performance in terms of the success rate for intubation overall, time for device insertion, or time to intubation or complications regardless of the device used.

Comparing Air Medical Personnel Intubation Success Rates Using Direct, Channeled Video-Assisted, and Unchanneled Video-Assisted Laryngoscopy

ObjectiveThe aim of this study was to determine the first-pass intubation success rates of air medical providers using direct laryngoscopy, channeled blade video laryngoscopy, and nonchanneled blade video laryngoscopy. MethodsThis was a retrospective cohort study of the Orlando Health Air Care Team (ACT) airway quality registry over a 5-year period. The ACT had 3 approved approaches for endotracheal intubation: direct laryngoscopy, the King Vision (Ambu, Ballerup Denmark) channeled blade laryngoscope, or the C-MAC (Karl-Storz, Tuttlingen Germany) (nonchanneled) laryngoscope. The main outcome was the first-pass success rate. The secondary outcomes included the number of attempts, the overall success rate, and complications. ResultsOf 517 intubations, 312 were performed with direct laryngoscopy, 126 with a channeled video laryngoscope, and 79 with a nonchanneled laryngoscope. The mean number of attempts was 1.26, and the overall success rate was 93%. Use of the nonchanneled video laryngoscope had a higher first-pass success rate than direct or channeled laryngoscopy (92% vs. 76% and 78%, P = .006), required fewer attempts (1.09 [95% confidence interval (CI), 1.01-1.17] vs. 1.29 [95% CI, 1.23-1.35] and 1.28 [95% CI, 1.18-1.38], P < .001), and a higher overall success rate for intubation (99% vs. 90% and 95%, P = .018). ConclusionThe use of a nonchanneled video laryngoscope provided higher first-pass success rates, fewer total attempts, and higher overall success rates.

A standard operating procedure for prehospital anaesthesia and its effect on mortality-An observational study.

Prehospital anaesthesia is a complex intervention performed for critically ill patients. To minimise complications, a standard operating procedure (SOP) outlining the process is considered valuable. We investigated the implementation of an SOP for prehospital anaesthesia in helicopter emergency medical services (HEMS). We performed a retrospective observational study of patients receiving prehospital anaesthesia by Finnish HEMS from January 2012 to August 2019. The intervention studied was the implementation of an SOP at two of the five bases during 2015-2016. Patients were stratified according to whether they were anaesthetised before, during or after implementation and the primary outcomes were 1- and 30-day mortality. Secondary outcomes included anaesthesia quality indicators. Confounding factors was assessed via logistic regression. A total of 3902 tracheal intubations were performed without an SOP, 430 during implementation and 1525 after implementation. The SOP had a significant effect on 1-day mortality during implementation with an odds ratio (OR) of 0.56, 95% confidence interval (95% CI) 0.37-0.81 and a further trend towards benefit after implementation (OR 0.84, 95% CI 0.68-1.04), but no difference in 30-day mortality (OR after implementation 1.10, 95% CI 0.92-1.30). Implementation of an SOP improved first-pass success rate from 87.3% to 96.5%, p < 0.001. Implementation of an SOP for prehospital anaesthesia was associated with a trend towards lower 1-day mortality and an improved first-pass success but did not affect 30-day mortality. Despite this, we advocate prehospital systems to consider implementation of a prehospital anaesthesia SOP as immediate performance markers improved significantly.

Multivariate analysis of factors associated with the successful prediction of initial blind placement of a nasointestinal tube in the stomach based on X-ray imaging: a retrospective, single-center study

BackgroundPatients in the intensive care unit (ICU) are highly susceptible to malnutrition, and while enteral nutrition via nasogastric tube is the preferred method, there is a risk of inadvertent reflux and aspiration. Therefore, clinicians have turned to nasointestinal tubes (NET) for enteral nutrition as an alternative option. But the precise localization of NET presents an ongoing challenge. We proposed an innovative approach to provide a valuable reference for clinicians involved in NET placement.MethodData were obtained retrospectively from the medical records of adult patients with a high risk of aspiration or gastric feeding intolerance who had a NET placed in the ICU of Zhejiang Provincial People’s Hospital between October 1, 2017, and October 1, 2023. The collected data were subjected to statistical analysis using SPSS and R software.ResultThere were 494 patients who met the inclusion and exclusion criteria. The first-pass success rate was 81.4% (n = 402). The success of a patient’s initial NET placement was found to be associated with Angle SPC and Distance CP, as determined by univariate analysis (25.6 ± 16.7° vs. 41.9 ± 18.0°, P < 0.001; 40.0 ± 26.2 mm vs. 62.0 ± 31.8 mm, P < 0.001, respectively). By conducting a multivariate regression analysis, we identified a significant association between pyloric types and the success rate of placing NET (OR 29.559, 95%CI 14.084–62.038, P < 0.001).ConclusionAngle SPC, Distance CP, and the type of pylorus are independently associated with successful initial placement of NET. Besides, patients with the outside type of pylorus (OP-type) exhibit a higher rate of initial placement success.

Clinical and radiographic outcomes after mechanical thrombectomy in medium-vessel posterior cerebral artery occlusions: Subgroup analysis from STAR.

Whereas mechanical thrombectomy (MT) has become standard-of-care treatment for patients with salvageable brain tissue after acute stroke caused by large-vessel occlusions, the results of MT in patients with medium-vessel occlusions (MEVOs), particularly in the posterior cerebral artery (PCA), are not well known. Using data from the international Stroke Thrombectomy and Aneurysm Registry (STAR), we assessed presenting characteristics and clinical outcomes for patients who underwent MT for primary occlusions in the P2 PCA segment. As a subanalysis, we compared the PCA MeVO outcomes with STAR's anterior circulation MeVO outcomes, namely middle cerebral artery (MCA) M2 and M3 segments. Of the 9812 patients in STAR, 43 underwent MT for isolated PCA MeVOs. The patients' median age was 69 years (interquartile range 61-79), and 48.8% were female. The median NIH Stroke Scale score was 9 (range 6-17). After recanalization, 67.4% of patients achieved successful recanalization (modified treatment in cerebral infarction score [mTICI] ≥ 2b), with a first-pass success rate of 44.2%, and 39.6% achieved a modified Rankin score of 0-2 at 90 days. Nine patients (20.9%) had died by the 90-day follow-up. In comparison with M2 and M3 MeVOs, there were no differences in presenting characteristics among the three groups. Patients with PCA MeVOs were less likely to undergo intra-arterial thrombolysis (4.7% PCA vs. 10.1% M2 vs. 16.2% M3, p = 0.046) or to achieve successful recanalization (mTICI ≥ 2b, 67.4%, 86.7%, 82.3%, respectively, p < 0.001); however, there were no differences in the rates of successful first-pass recanalization (44.2%, 49.8%, 52.3%, respectively, p = 0.65). We describe the STAR experience performing MT in patients with PCA MeVOs. Our analysis supports that successful first-pass recanalization can be achieved in PCA MEVOs at a rate similar to that in MCA MeVOs, although further study and possible innovation may be necessary to improve successful PCA MeVO recanalization rates.

Alfentanil versus fentanyl for emergency department rapid sequence induction with ketamine: A-FAKT, a pilot randomized trial

BackgroundFentanyl is often administered during rapid sequence induction of anesthesia (RSI) in the emergency department (ED) to ameliorate the hypertensive response that may occur. Due to its more rapid onset, the use of alfentanil may be more consistent with both the onset time of the sedative and the commencement of laryngoscopy. As such, we compared the effect of alfentanil and fentanyl on post-induction hemodynamic changes when administered as part of a standardized induction regimen including ketamine and rocuronium in ED RSI. MethodsThis was a double-blind pilot randomized controlled trial of adult patients requiring RSI in the ED of three urban Australian hospitals. Patients were randomized to receive either alfentanil or fentanyl in addition to ketamine and rocuronium for RSI. Non-invasive blood pressure and heart rate were measured immediately before and at two, four, and six minutes after induction. The primary outcome was the occurrence of at least one post-induction systolic blood pressure outside the pre-specified range of 100-160mmHg (with adjustment for patients with baseline hypertension). Secondary outcomes included hypertension, hypotension, hypoxia, first-pass intubation success, 30-day mortality, and the pattern of hemodynamic changes. ResultsA total of 61 patients were included in the final analysis (31 in the alfentanil group and 30 in the fentanyl group). The primary outcome was met in 58% of the alfentanil group and 50% of the fentanyl group (difference 8%, 95% confidence interval: -17% to 33%). The 30-day mortality rate, first-pass success rate, and incidences of hypertension, hypotension, and hypoxia were similar between the groups. There were no significant differences in systolic blood pressure or heart rate between the groups at any of the measured time-points. ConclusionAlfentanil and fentanyl produced comparable post-induction hemodynamic changes when used as adjuncts to ketamine in ED RSI. Future studies could consider comparing different dosages of these opioids.

Prospective Randomized Study of Ultrasound Guided In-Plane Versus Out-Of-Plane Radial Artery Cannulation in Adult Cardiac Surgery Patients

Background: With the more frequent use of ultrasound in medical practice, radial artery cannulation using ultrasound has proven to be better than the traditional landmark technique. Ultrasound-guided techniques reduce the risk of cannulation failure and complications like hematoma, arterial spasm, etc. Ultrasound is helpful in obesity, pediatric age group, and hemodynamically unstable patients with a feeble pulse. This study performed a comparison between in-plane and out-of-plane ultrasound-guided techniques for cannulation of the radial artery.Methodology: This study was prospective randomized and interventional. The study involved adult patients scheduled to undergo cardiac surgery requiring arterial cannulation. Institutional ethics committee approval and consent was taken from the patients. A total of 128 patients were randomized into the in-plane and the out-of-plane ultrasound groups. In the operation room, radial artery cannulation was done under local anesthesia using a hockey stick ultrasound probe. The objective of the study was to compare the incidence of first-pass success rate, the number of attempts, number of redirections, cannulation completion time and incidence of complications in two groups.Results: The demographic data was found to be comparable. The in-plane group had a higher incidence of first attempt success as compared to the out-of-plane group with a P value of 0.021. There was no statistically significant difference in other clinical outcomes.Conclusion: The in-plane technique had a higher first-attempt success rate. Hence it should be considered for use in routine practice to improve patient care.

The Impact of Location and Asset Type on the Success of Advanced Airway Management in a Critical Care Transport Environment

ObjectiveAdvanced airway management (AAM) is a critical component of prehospital critical care. Airway management in flight can be more challenging because of spatial, ergonomic, and environmental factors. This study examines the frequency of in-flight intubation (IFI), first-pass success (FPS) rates, and definitive airway sans hypoxia/hypotension on first attempt (DASH-1A) across different locations of airway management. MethodsWe conducted a retrospective database analysis of all patients transported between January 2016 and July 2021 who received AAM from a single air medical service. Patient records were reviewed for location of intubation, patient characteristics, and FPS and DASH-1A rates. The primary outcome was the frequency of IFI. The secondary outcomes included FPS and DASH-1A rates by location and type of transport asset. ResultsDuring the study period, 473 patients required AAM. Three percent (15/473) of patients were intubated in an in-flight setting, 28% (130/473) were intubated on scene, and 70% (328/473) were intubated in a health care facility. The primary reason for IFI was unanticipated cardiac arrest or clinical deterioration. The overall FPS rate was 69% (328/473), and the DASH-1A rate was 49% (194/399). Based on the location of AAM, the FPS and DASH-1A rates were the lowest for on-scene intubations (56% [74/130] and 27% [20/74], respectively). Most of the on-scene AAM took place with rotor wing flight crews. ConclusionAirway management occurs infrequently in an in-flight setting and is necessary because of patient deterioration or cardiac arrest. Based on our results, we identified opportunities for targeted AAM quality improvement and clinical governance.

A Randomized Study Comparing Ultrasound-Guided Internal Jugular Vein Cannulation Using Two Techniques: Short-Axis Out-of-Plane With Dynamic Needle Tip Positioning Versus Long-Axis In-Plane.

Introduction Internal jugular vein (IJV) cannulation is a routine procedure in operating rooms, critical care units, and perioperative settings. Ultrasound guidance has notably increased the success rates of IJV cannulation. A modified ultrasound technique known as the short-axis out-of-plane method with dynamic needle tip positioning (DNTP) allows for continuous visualization of the needle tip throughout the procedure. This study aims to compare the first-pass success rate of IJV cannulation using the DNTP and long-axis in-plane (LAIP) approaches. Methods One hundred patients between 18 and 70 years undergoing elective surgery requiring IJV cannulation were recruited.Patients were assigned randomly to the DNTP group (n = 50) or the LAIP group (n = 50). We recorded the first-pass success rate, time to achieve successful cannulation, number of skin punctures, overall success rate within five minutes, and potential complications such as pneumothorax and hematoma. Results The first pass success rate was higher in the DNTP group (48/50, 96%) as compared to the LAIP group (38/50, 76%, relative risk, 1.67; 95% confidence interval, 0.039-0.707; p = 0.008). The cannulation time was shorter in DNTP (116.98 ± 22.90 seconds) versus the LAIP group (213.04 ± 52.08 seconds; p < 0.001). No complications like pneumothorax or hematoma were noted in both groups. Conclusion We conclude that the ultrasound-guided DNTP technique for IJV cannulation, as compared with the LAIP technique, may significantly improve the first attempt cannulation, number of attempts, and cannulation time.

Mechanical thrombectomy with Embolus Retriever with Interlinked Cages device for medium vessel occlusions: First pass results and safety profile.

Reperfusion of medium vessel occlusions is correlated with good outcomes. However, optimal techniques and medical devices are still unclear. In this study, we sought to evaluate the safety and efficacy of mechanical thrombectomy with Embolus Retriever with Interlinked Cages (ERIC™) retrieval device in patients with acute ischemic stroke due to distal medium vessel occlusions. A retrospective review of the prospectively collected mechanical thrombectomy database revealed 50 patients who had fulfilled the inclusion criteria. The data collected includes clinical patient characteristics, procedural measures, timestamps at each stage, and patient outcomes. Intravenous thrombolytics application, pre- and post-intervention imaging findings, device-related adverse events and any type of intracranial hemorrhage were recorded. There were 25 men (50%) and 25 women (50%) with a median of 67 years (interquartile range (IQR) 41-84). Median presenting NIHSS was 14 (IQR, 3-23). First pass rates were: eTICI3 in 16 cases (32%), eTICI-2c in eight cases (16%), eTICI-2B67 in nine cases (10%), eTICI2B50 in three cases (6%) and mTICI 0-2A in 18 cases (36%). Final recanalization rate of mTICI 2b-3 was 90% and 2c-3 was 70%. In conclusion, the ERIC thrombectomy device offers a high rate of first-pass success along with a favorable safety profile. Larger series and multi-center studies are needed for further investigation.

Video Laryngoscopy vs. Direct Laryngoscopy in Adult Patients with Difficult Airways Who Require Emergency Intubation

This review compares the efficacy of video laryngoscopy (VL) with that of direct laryngoscopy (DL) in adult patients with difficult airways who require emergency intubation. Intubation and laryngoscopy are critical in emergency settings, and VL has emerged as an alternative to DL, particularly in difficult airway cases and when performed by non-experienced practitioners. VL demonstrates advantages such as a wider field of view, enhanced glottic visibility, and higher first-pass success rates, particularly in difficult airway scenarios. However, it also presents limitations, including potential view obstruction and technical complexity. While the evidence points to the advantages of VL, particularly in achieving higher first-pass success rates and minimizing adverse events in adult patients with difficult airways, the inconclusive findings from randomized trials emphasize the importance of future research in refining practices and improving patient outcomes.

Identification of epicardial connections can improve the success rate of first-pass right pulmonary vein isolation

BackgroundEpicardial connections between the right pulmonary vein (PV) and the right atrium have been reported. ObjectiveWe evaluated the usefulness of our new PV isolation (PVI) strategy with identification of these epicardial connections. MethodsOverall, 235 patients with atrial fibrillation were included. High-density mapping of the left atrium was performed to identify the earliest activation sites (EASs) before PVI in all patients. With our new strategy, if we identified EASs around the right PV carina, we ablated these sites in addition to performing usual first-pass circumferential PVI. The patients were divided into two groups according to the ablation strategy. One hundred fifteen patients underwent first-pass PVI without information on EASs (non-analyzed group), and 78 patients underwent ablation at EASs around the right PV carina in addition to PVI (analyzed group). After first-pass ablation around the PV antrum, re-mapping was performed. ResultsHigh-density mapping before PVI showed that the prevalence of EASs around the right PV carina was 10.9% in all patients (9.6% in the non-analyzed group and 12.8% in the analyzed group; p = 0.74. The first-pass right PVI success rate was higher in the analyzed group than in the non-analyzed group (93.6% vs. 82.6%; p = 0.04). The radiofrequency application time for PVI was significantly shorter in the analyzed group than in the non-analyzed group (45.6 ± 1.0 min vs. 51.2 ± 0.9 min; p < 0.05). ConclusionIdentification of epicardial connections before ablation could improve the success rate of first-pass right PVI.

Bed-up-head-elevated Position versus Supine Sniffing Position in Patients Undergoing Rapid Sequence Intubation Using Direct Laryngoscopy in the Emergency Department - A Randomized Controlled Trial.

The objective of this study is to compare bed-up-head-elevated (BUHE) position with supine sniffing position (SSP) in patients undergoing rapid sequence intubation (RSI) using direct laryngoscopy in the emergency department (ED). This single-center randomized controlled superiority trial was carried out from September 2021 to December 2022 in an academic emergency medicine department. The patients undergoing RSI in ED were grouped into two arms, namely BUHE position and SSP. The primary outcome was the time taken for endotracheal intubation. The secondary outcomes were the first-pass success rates and postintubation complications. A total of 136 patients were enrolled in the study. Time for intubation in the BUHE group was no different from SSP (32.09 s [interquartile range (IQR): 23.30-42.68] vs. 33.40 [IQR: 27.53-45.90], P = 0.17). There was a modest reduction in intubation time when performed by trained experts (22.5 s [IQR: 17.7-25.3] versus 30.3 s [IQR: 21.3-33.2], P = 0.04). The first-attempt success rate in the BUHE position was also similar to the SSP position ([91.18% vs. 90.91%] P = 0.958). Postintubation complications were lesser in BUHE compared to the SSP group ([7.4% vs. 19.7%] P = 0.04). In our study, BUHE position did not improve time to intubation and first-pass success rate in ED patients compared to SSP. A modest decrease in intubation time was noted while experts used the BUHE position. The postintubation complications were slightly lesser in the BUHE group.

Transitions in Video Laryngoscope Technology to Improve First-Pass Success.

Prehospital intubation is a high-risk, relatively low frequency procedure. Provider experience plays a key role in first-pass success rates, especially in the setting of a difficult airway. While strong foundational knowledge is necessary to equip providers with an adequate understanding of intubation procedures and the skill set needed to manage a difficult airway, effective equipment may provide an extra boost in first-pass success for novice airway providers. First-pass success is correlated with decreased adverse events and should be maximized in the prehospital setting. After evaluating overall first-pass success of 66% to 83% from 2016 to 2020, AHN LifeFlight enacted changes in education, training, and video laryngoscopy equipment to successfully increase first-pass success to over 90%.

A prospective, pragmatic non-inferiority study of emergency intubation success with the single-use i-view versus standard reusable video laryngoscope.

Video laryngoscope (VL) technology improves first-pass success. The novel i-view VL device is inexpensive and disposable. We sought to determine the first-pass intubation success with the i-view VL device versus the standard reusable VL systems in routine use at each site. We performed a prospective, pragmatic study at two major emergency departments (EDs) when VL was used. We rotated i-view versus reusable VL as the preferred device of the month based on an a priori schedule. An investigator-initiated interim analysis was performed. Our primary outcome was a first-pass success with a non-inferiority margin of 10% based on the per-protocol analysis. There were 93 intubations using the reusable VL devices and 81 intubations using the i-view. Our study was stopped early due to futility in reaching our predetermined non-inferiority margin. Operator and patient characteristics were similar between the two groups. The first-pass success rate for the i-view group was 69.1% compared to 84.3% for the reusable VL group. A non-inferiority analysis indicated that the difference (-15.1%) and corresponding 90% confidence limits (-25.3% to -5.0%) did not fall within the predetermined 10% non-inferiority margin. The i-view device failed to meet our predetermined non-inferiority margin when compared to the reusable VL systems with the study stopping early due to futility. Significant crossover occurred at the discretion of the intubating operator during the i-view month.