Incidence Of Severe Hypoxemia Research Articles

Comparison of Remimazolam and Propofol for Drug-Induced Sleep Endoscopy: A Randomized Clinical Trial.

To compare the efficacy and safety of remimazolam with those of propofol for drug-induced sleep endoscopy (DISE) in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). A prospective, single-center, randomized clinical trial. Xiangya Hospital of Central South University. Patients with OSAHS receiving DISE were randomly assigned to either the remimazolam or propofol group. The primary outcome was the incidence of hypoxemia (pulse oxygen saturation [SpO2 ] < 90%) during DISE. The secondary outcomes were the incidence of severe hypoxemia (SpO2 < 80%), the minimal value of SpO2 , sedation success rate (completion of DISE according to the medication regimen), and incidence of events of interest (including injection pain, bradycardia, and decreased respiratory rate). Sixty-four patients were included in this study. The incidence of hypoxemia was significantly lower in the remimazolam than in the propofol group (25.00% vs62.50%, respectively; relative risk, 0.40; 95% confidence interval [CI], 0.20-0.74; p < .01). There was no significant difference in the sedation success rate between the remimazolam and propofol groups (96.88% vs81.25%, respectively; relative risk, 1.19; 95% CI, 1.01-1.50; p = .10). The incidence of at least 1 event of interest was lower in the remimazolam than in the propofol group (43.75% vs96.88%, respectively; relative risk, 0.45; 95% CI, 0.29-0.63; p < .01). Remimazolam can present satisfactory sedative efficacy in DISE, with a lower incidence of hypoxemia and a higher safety profile than propofol.

Effect of remimazolam tosilate on the incidence of hypoxemia in elderly patients undergoing gastrointestinal endoscopy: A bi-center, prospective, randomized controlled study.

Background: Remimazolam tosilate is a new ultra-short-acting benzodiazepine sedative medicine. In this study, we evaluated the effect of remimazolam tosilate on the incidence of hypoxemia during sedation in elderly patients undergoing gastrointestinal endoscopy. Methods: Patients in the remimazolam group received an initial dose of 0.1mg/kg and a bolus dose of 2.5mg of remimazolam tosilate, whereas patients in the propofol group received an initial dose of 1.5mg/kg and a bolus dose of 0.5mg/kg of propofol. Patients received ASA standard monitoring (heart-rate, non-invasive blood pressure, and pulse oxygen saturation) during the entire examination process. The primary outcome was the incidence of moderate hypoxemia (defined as 85%≤ SpO2< 90%, >15s) during the gastrointestinal endoscopy. The secondary outcomes included the incidence of mild hypoxemia (defined as SpO2 90%-94%) and severe hypoxemia (defined as SpO2< 85%, >15s), the lowest pulse oxygen saturation, airway maneuvers used to correct hypoxemia, patient's hemodynamic as well as other adverse events. Results: 107 elderly patients (67.6 ± 5.7years old) in the remimazolam group and 109 elderly patients (67.5 ± 4.9years old) in the propofol group were analyzed. The incidence of moderate hypoxemia was 2.8% in the remimazolam group and 17.4% in the propofol group (relative risk [RR] = 0.161; 95% confidence interval [CI], 0.049 to 0.528; p < 0.001). The frequency of mild hypoxemia was less in the remimazolam group, but not statistically significant (9.3% vs. 14.7%; RR = 0.637; 95% CI, 0.303 to 1.339; p = 0.228). There was no significant difference in the incidence of severe hypoxemia between the two groups (4.7% vs. 5.5%; RR = 0.849; 95% CI, 0.267 to 2.698; p = 0.781). The median lowest SpO2 during the examination was 98% (IQR, 96.0%-99.0%) in patients in the remimazolam group, which was significantly higher than in patients in the propofol group (96%, IQR, 92.0%-99.0%, p < 0.001). Patients in the remimazolam group received more drug supplementation during endoscopy than patients in the propofol group (p = 0.014). There was a statistically significant difference in the incidence of hypotension between the two groups (2.8% vs. 12.8%; RR = 0.218; 95% CI, 0.065 to 0.738; p = 0.006). No significant differences were found in the incidence of adverse events such as nausea and vomiting, dizziness, and prolonged sedation. Conclusion: This study explored the safety of remimazolam compared with propofol during gastrointestinal endoscopy in elderly patients. Despite the increased supplemental doses during sedation, remimazolam improved risk of moderate hypoxemia (i.e., 85%≤ SpO2 < 90%) and hypotension in elderly patients.

Incidence of Severe Hypoxemia in Anesthetized Horses Undergoing Emergency Exploratory Laparotomy

Prevalence and risk factors of severe hypoxemia in anesthetized horses undergoing emergency exploratory laparotomy are sparsely documented. The aim of this study was to report incidence of severe hypoxemia ( PaO2 < 60 mmHg) in horses undergoing emergency exploratory laparotomy and identify potential risk factors for this complication. A single center retrospective cross sectional designed was used. Clinical data of 714 horses undergoing general anesthesia for emergency explorative laparotomy were reviewed. A backward stepwise elimination procedure was used to determine the final multivariable logistic regression model; all covariables with univariable P-values <.25 were incorporated, with retention of covariables with Wald P-values <.05 at each step, in order to determine which explanatory variables would be included in the final model. The overall incidence of severe hypoxemia in our population was 15.3%. Multivariable logistic regression analysis showed that increasing body weight (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.0–1.01, P = .002), colon torsion (OR 3.0, 95% CI 1.3–6.8, P = .006), increased dead space ventilation (OR 1.06, 95% CI 1.04–1.09, P ≤ .001), shorter time between induction of anesthesia and collection of arterial blood gas samples (OR 0.98, 95% CI 0.98–0.99, P ≤ .001) and intratracheal aerosolized salbutamol (OR 13.5, 95% CI 7.6–24, P ≤ .001) were associated with the outcome. The incidence of hypoxemia found in our study was in line with previous literature. Increasing body weight, colon torsion and shorter time between the time of induction of anesthesia and collection of arterial blood gas samples represented risk factors for hypoxemia.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Bag-Mask Ventilation Versus Apneic Oxygenation During Tracheal Intubation in Critically Ill Adults: A Secondary Analysis of 2 Randomized Trials.

Background: Hypoxemia is common during tracheal intubation in intensive care units. To prevent hypoxemia during intubation, 2 methods of delivering oxygen between induction and laryngoscopy have been proposed: bag-mask ventilation and supplemental oxygen delivered by nasal cannula without ventilation (apneic oxygenation). Whether one of these approaches is more effective for preventing hypoxemia during intubation of critically ill patients is unknown. Methods: We performed a secondary analysis of data from 138 patients enrolled in 2, consecutive randomized trials of airway management in an academic intensive care unit. A total of 61 patients were randomized to receive bag-mask ventilation in a trial comparing bag-mask ventilation to none, and 77 patients were randomized to receive 100% oxygen at 15 L/min by nasal cannula in a trial comparing apneic oxygenation to none. Using multivariable linear regression accounting for age, body mass index, severity of illness, and oxygen saturation at induction, we compared patients assigned to bag-mask ventilation with those assigned to apneic oxygenation regarding lowest oxygen saturations from induction to 2 min after intubation. Results: Patients assigned to bag-mask ventilation and apneic oxygenation were similar at baseline. The median lowest oxygen saturation was 96% (interquartile range [IQR] 89%-100%) in the bag-mask ventilation group and 92% (IQR 84%-99%) in the apneic oxygenation group. After adjustment for prespecified confounders, bag-mask ventilation was associated with a higher lowest oxygen saturation compared to apneic oxygenation (mean difference, 4.2%; 95% confidence interval, 0.7%-7.8%; P = .02). The incidence of severe hypoxemia (oxygen saturation<80%) was 6.6% in the bag-mask ventilation group and 15.6% in the apneic oxygenation group (adjusted odds ratio, 0.33; P = .09). Conclusions: This secondary analysis of patients assigned to bag-mask ventilation and apneic oxygenation during 2 clinical trials suggests that bag-mask ventilation is associated with higher oxygen saturation during intubation compared to apneic oxygenation.

Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation

For critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer ("bougie") increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain. To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt. The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021. Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546). The primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%. Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, -2.6 percentage points [95% CI, -7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, -1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group. Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet. ClinicalTrials.gov Identifier: NCT03928925.

Retrospective Analysis of Peri-Intubation Hypoxemia During the Coronavirus Disease 2019 Epidemic Using a Protocol for Modified Airway Management.

This single-center retrospective study evaluated a protocol for the intubation of patients with confirmed or suspected coronavirus disease 2019 (COVID-19). Twenty-one patients were intubated, 9 of whom were found to have COVID-19. Adherence to the airway management protocol was high. COVID-19 patients had lower peripheral capillary oxygen saturation by pulse oximetry (Spo2) nadirs during intubation (Spo2, 73% [72%-77%] vs 89% [86%-94%], P = .024), and a greater percentage experienced severe hypoxemia defined as Spo2 ≤80% (89% vs 25%, P = .008). The incidence of severe hypoxemia in COVID-19 patients should be considered in the development of guidelines that incorporate high-flow nasal cannula and noninvasive positive pressure ventilation.

Emulating a Novel Clinical Trial Using Existing Observational Data. Predicting Results of the PreVent Study.

Rationale: "Target trial emulation" has been proposed as an observational method to answer comparative effectiveness questions, but it has rarely been attempted concurrently with a randomized clinical trial (RCT).Objectives: We tested the hypothesis that blinded analysts applying target trial emulation to existing observational data could predict the results of an RCT.Methods: PreVent (Preventing Hypoxemia with Manual Ventilation during Endotracheal Intubation) was a multicenter RCT examining the effects of positive-pressure ventilation during tracheal intubation on oxygen saturation and severe hypoxemia. Analysts unaware of PreVent's results used patient-level data from three previous trials evaluating airway management interventions to emulate PreVent's eligibility criteria, randomization procedure, and statistical analysis. After PreVent's release, results of this blinded observational analysis were compared with those of the RCT. Difference-in-differences estimates for comparison of treatment effects between the observational analysis and the PreVent trial are reported on the absolute scale.Results: Using observational data, we were able to emulate PreVent's randomization procedure to produce balanced groups for comparison. The lowest oxygen saturation during intubation was higher in the positive-pressure ventilation group than the no positive-pressure ventilation group in the observational analysis (n = 360; mean difference = 1.8%; 95% confidence interval [CI] = -1.0 to 4.6) and in the PreVent trial (n = 401; mean difference = 3.9%; 95% CI = 1.4 to 6.4), though the observational analysis could not exclude no difference. Difference-in-differences estimates comparing treatment effects showed reasonable agreement for lowest oxygen saturation between the observational analysis and the PreVent trial (mean difference = -2.1%; 95% CI = -5.9 to 1.7). Positive-pressure ventilation resulted in lower rates of severe hypoxemia in both the observational analysis (risk ratio = 0.60; 95% CI = 0.38 to 0.93) and in the PreVent trial (risk ratio = 0.48; 95% CI = 0.30 to 0.77). The absolute reduction in the incidence of severe hypoxemia with positive-pressure ventilation was similar in the observational analysis (9.4%) and the PreVent trial (12.0%), though the difference between these estimates had wide CIs (mean difference = 2.5%; 95% CI = -8.0 to 13.6%).Conclusions: Applying target trial emulation methods to existing observational data for the evaluation of a novel intervention produced results similar to those of a randomized trial. These findings support the use of target trial emulation for comparative effectiveness research.

Apneic Oxygenation May Not Prevent Severe Hypoxemia During Rapid Sequence Intubation: A Retrospective Helicopter Emergency Medical Service Study

ObjectiveThis study sought to determine the effectiveness of apneic oxygenation in preventing hypoxemia during prehospital rapid sequence intubation (RSI). MethodsWe performed a case-cohort study using a pre-existing database looking at intubation management by a single helicopter emergency medical service between July 2013 and June 2015. Apneic oxygenation using high-flow nasal cannula (15 L/min) was introduced to the standard RSI protocol in July 2014. Severe hypoxemia was defined as an incidence of oxygen saturation less than 90%. We compared patients who received apneic oxygenation during RSI with patients who did not using the Fisher exact test. ResultsNinety-three patients were identified from the database; 29 (31.2%) received apneic oxygenation. Nineteen patients had an incidence of severe hypoxemia during RSI (20.43%; 95% confidence interval, 12.77%-30.05%). There was no statistically significant difference between the rate of severe hypoxemia between patients in the apneic oxygenation group versus the control group (17.2% vs. 21.9%, P = .78). ConclusionIn this study, patients who received apneic oxygenation did not show a statistically significant difference in severe hypoxemia during RSI.

Role of intubating laryngeal mask airway for endotracheal intubation in the intensive care unit: an observational trial

Purpose Avoidance of further worsening of hypoxemia is a prime objective during intubation of patients with acute respiratory failure. The aim of this study was to compare conventional laryngoscopy with intubating laryngeal mask airway (ILMA) with the aid of flexible fiberoptic bronchoscopes (FOBs) for intubation of class III/IV Coramck-Leahne patients in the intensive care unit. Materials and methods After failure of an initial attempt at intubation using conventional direct laryngoscopy, 112 Cormack-Lehane class III/IV patients were subjected to repeated attempts of intubation using either a Macintosh-type laryngoscope (ML, n = 59) or an ILMA with FOB ( n = 53). After failure of two further trials using either technique, intubation would be attempted using the GlideScope video laryngoscope. The primary outcome was the incidence of severe hypoxemia (defined as arterial saturation <80%). Secondary outcomes were intubating time, number of attempts, and incidence of other complications. Results Twenty-five patients (42.2%) in the ML group suffered from severe hypoxemia, compared with eight (15.1%) patients in ILMA group ( P = 0.002). The median (interquartile range) intubating time was 39 s (32.3-87.8 s) in the ML group versus 102 s (73.8-123 s) in the ILMA group ( P P = 0.003). Both groups were comparable as regards the incidence of other intubation-related complications and postintubation course in the intensive care unit ( P > 0.05). Conclusion In Cormack-Lehane class III/IV patients who failed to be intubated in the first attempt, retrying intubation using the ILMA with the aid of a flexible FOB was associated with a lower incidence of severe hypoxemia.