Intubation Outcomes Research Articles

Airway registry and training curriculum improve intubation outcomes in the intensive care unit

Airway registry and training curriculum improve intubation outcomes in the intensive care unit

Evaluation of Functional Outcome of Silicone Intubation on Patency of Lacrimal System in Canalicular Obstruction and Revision Surgeries

Purpose:- The purpose of the present study is to report authors’ experience of functional outcome of Silicone intubation on patency of lacrimal system in canalicular obstruction and revision surgeries.

Manikin Laryngoscopy Motion as a Predictor of Patient Intubation Outcomes: A Prospective Observational Study

The goal of this study was to determine whether motion parameters during laryngoscopy in a manikin differed with experienced operators versus novice trainees and whether motion measurements would predict trainee outcomes when intubating patients. Motion, force, and duration of laryngoscopy on a manikin were compared in two separate experiments between beginning anesthesiology residents (CA1) and anesthesiologists with more than 24 months of anesthesiology training (CA3 or attendings). In one experiment, CA1 residents were also evaluated for the percentage of their laryngoscope path that followed the route used by attending anesthesiologists. The residents were then observed for patient intubation outcomes for 4 weeks after manikin testing. The relationship between manikin test metrics and patient intubation outcomes was analyzed by multilevel modeling. CA1 residents positioned the laryngoscope blade farther right and with less lift than did experienced anesthesiologists. Endpoint position was 0.6 ± 0.3 cm left of midline for residents (n = 10) versus 2.7 ± 0.3 cm for advanced anesthesiologists (n = 8; P = .0003), and 15.6 ± 0.8 versus 17.7 ± 0.2 cm above the table surface, respectively (P = .033). On average, only 74 ± 6% of the CA1 laryngoscopy trajectory coincided with the Attending Route (P < .001 versus 100%). For each percentage point increase in Attending Route match, residents' odds of intubating a patient's trachea improved by a factor of 1.033 (95% confidence interval [CI] 1.007-1.059, P = .040), and their rate of failed laryngoscopy attempts decreased by a factor of 0.982 (0.969-0.996, P = .045). Laryngoscopy motion in manikins may predict which trainees can complete a patient intubation successfully in a few attempts. The assessment could help determine readiness for intubating patients with indirect supervision.

Proactive Use of High-Flow Nasal Cannula With Critically Ill Subjects.

It has been suggested that use of a high-flow nasal cannula (HFNC) could be a first-line therapy for patients with acute hypoxic respiratory failure. The purpose of this study was to determine if protocolized use of HFNC decreases unplanned intubation and adverse outcomes in an ICU population. The study was a prospective evaluation of 2 cohorts who received HFNC per protocol. Control groups were retrospective selections of subjects who received HFNC in the pre-protocol period. Cohort 1 (n = 88) received mechanical ventilation for ≥ 24 h and was extubated directly to HFNC following strict protocol criteria. Cohort 2 (n = 83) were placed on HFNC when oxygen requirements escalated (>4 L/min). Cohort 1 did not differ from its control group in mortality, hospital stay, or ICU days, but there were significant decreases in incidence of Gram-negative pulmonary infection (30% vs 9%, P = .001) and use of bronchodilator therapy (81% vs 61%, P = .008). Failed extubation rates were nearly identical across groups, but time to re-intubation was shorter in the protocol group (24 vs 13 h, P = .19). Cohort 2 did not differ significantly from its control group in intubation rates or mortality, but subjects managed by protocol experienced significant decreases in ICU days (4 vs 3 d, P = .03) and hospital days (12 vs 8 d, P = .007). There was a trend toward fewer hours on HFNC (33 vs 24 h, P = .10) and faster time to intubation when HFNC failed (19 vs 9 h, P = .08). Extubation to HFNC led to a significant decrease in pulmonary infections and bronchodilator therapy in Cohort 1 but did not reduce length of stay or rates of failed extubation. When HFNC was used early and per protocol (Cohort 2), ICU and hospital lengths of stay were reduced and HFNC was initiated more quickly when the need for respiratory support escalated.

Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients \u2013 a systematic review and meta-analysis of randomized controlled trials

BackgroundThere is significant controversy regarding the influence of video laryngoscopy on the intubation outcomes in emergency and critical patients. This systematic review and meta-analysis was designed to determine whether video laryngoscopy could improve the intubation outcomes in emergency and critical patients.MethodsWe searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Scopus databases from database inception until 15 February 2017. Only randomized controlled trials comparing video and direct laryngoscopy for tracheal intubation in emergency department, intensive care unit, and prehospital settings were selected. The primary outcome was the first-attempt success rate. Review Manager 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of evidence for all outcomes.ResultsTwelve studies (2583 patients) were included in the review for data extraction. Pooled analysis did not show an improved first-attempt success rate using video laryngoscopy (relative risk [RR], 0.93; P = 0.28; low-quality evidence). There was significant heterogeneity among studies (I2 = 91%). Subgroup analyses showed that, in the prehospital setting, video laryngoscopy decreased the first-attempt success rate (RR, 0.57; P < 0.01; high-quality evidence) and overall success rate (RR, 0.58; 95% CI, 0.48–0.69; moderate-quality evidence) by experienced operators, whereas in the in-hospital setting, no significant difference between two devices was identified for the first-attempt success rate (RR, 1.06; P = 0.14; moderate-quality evidence), regardless of the experience of the operators or the types of video laryngoscopes used (P > 0.05), although a slightly higher overall success rate was shown (RR, 1.11; P = 0.03; moderate-quality evidence). There were no differences between devices for other outcomes (P > 0.05), except for a lower rate of esophageal intubation (P = 0.01) and a higher rate of Cormack and Lehane grade 1 (P < 0.01) when using video laryngoscopy.ConclusionsOn the basis of the results of this study, we conclude that, compared with direct laryngoscopy, video laryngoscopy does not improve intubation outcomes in emergency and critical patients. Prehospital intubation is even worsened by use of video laryngoscopy when performed by experienced operators.

Clinical profile and neurodevelopmental outcome of new-onset acute symptomatic seizures in children

PurposeTo study clinical profile, neurodevelopmental outcome and its predictors in children with acute symptomatic seizures (ASS). MethodsShort-term neurodevelopmental outcome and predictors of poor outcomes were prospectively assessed in 105 consecutive children with ASS aged 3 months-12 years ResultsMean age was 51.2+42.2months (3–144 months); 67.2% were males. Central nervous system (CNS) infection in 82%, status epilepticus in 15.2%, abnormal neuroimaging in 62.8% and abnormal electroencephalography in 22.3% were noted. At discharge, 27.6% had poor outcome including death (13%); CNS infections were significantly associated with poor outcome compared to ASS of other aetiologies (32.6% vs 5.2%, p=0.02). Low GCS (OR 4.9, 95%CI 1.2–20.7), abnormal electroencephalograph (OR 4.3, 95%CI 1–16.9) and neuroimaging (OR 12.1, 95%CI 1.4–105.2) were independent predictors of poor outcome.After 6 months, 16% children had delayed neurodevelopment and cognition; 6% had seizure recurrences. Abnormal electroencephalograph (p=0.002; OR 6.8, 95%CI 2.0–23.1), abnormal neuroimaging (p=0.015; OR 9.47, 95%CI 1.18–75.8),>1 anti-epileptic (p=0.00; OR 9.9, 95%CI 2.88–33.9), intubation (p=0.004; OR 6.25, 95%CI 1.79–21.7) and poor outcome at discharge (p=0.02; OR 4.44, 95%CI1.38–14.2) predicted abnormal neurodevelopment. ConclusionsCNS infections are the most common cause of ASS in children from developing countries. Abnormal neurodevelopment and seizure recurrences on short-term follow-up are seen in a minority of children.

Comparative effects of lidocaine and esmolol in attenuating the hemodynamic response to laryngoscopy and intubation

Introduction: Transient hemodynamic instability is an inevitable outcome of laryngoscopy and intubation which can have serious effects in patients with COPD, heart disease and hypertension. Hemodynamic stability is one of the main goals of the anesthesiologist. This study was performed to compare the safety and effectiveness of lidocaine and esmolol in comparison to placebo-control group, in modifying the hemodynamic response to laryngoscopy and intubation.Methods: After approval of the study protocol by the institutional review board (IRB), written informed consent was obtained from each patient. It was a randomized placebo-controlled, double-blinded study. 75 patients of American Society of Anesthesiologists physical status I and II, scheduled for general surgery under GA, aged between 20-60 years were randomly allocated into three groups: placebo control group (n=25), lidocaine group (n=25) and esmolol group (n=25). Placebo group received 12 ml normal saline, lidocaine group received 1.5mg/kg lidocaine (total volume 12 ml) and esmolol group received 1.4mg/kg esmolol (total volume 12ml).Results: Following laryngoscopy and intubation, the increase in systolic blood pressure, diastolic blood pressure and heart rate were significantly lower (p &lt; 0.05) in esmolol group compared to the lidocaine and placebo group but there was no statistical significance (p &gt; 0.05) between control and lidocaine group.Conclusion: Esmolol 1.4 mg/kg IV was significantly more effective in controlling the hemodynamic response following laryngoscopy and intubation in comparison to lidocaine 1.5 mg/kg.Journal of Society of Surgeons of NepalVol. 17, No. 2, 2014, Page: 23-30

The Impact of Prehospital Intubation With and Without Sedation on Outcome in Trauma Patients With a GCS of 8 or Less.

Although unconsciousness (Glasgow Coma Scale [GCS] 3 to 8) necessitates intubation according national guidelines, there is a notable lack of evidence to support this approach. This study evaluates the impact on outcome of prehospital intubation with and without sedation in trauma patients with a GCS of ≤8. A retrospective cohort analysis of severely injured trauma patients registered in the TraumaRegister DGU of the German Trauma Society (DGU) from 2002 to 2013 was conducted. Only directly admitted patients alive on admission and with a GCS of ≤8 at the scene were included. The observed outcome was matched with the expected outcome deriving from the Revised Injury Severity Classification, version II (RISC-II). Furthermore, a Standardized Mortality Ratio (SMR) was calculated for various subgroups. Early neurological outcome was classified using the Glasgow Outcome Scale. A total of 21,242 patients fulfilled the study inclusion criteria. A total of 18,975 patients (89.3%) received prehospital intubation. Intubation rates were continuously increasing with decreasing GCS score values. Difference between observed and expected mortality was lower in intubated patients (42.2% [95% confidence interval (CI), 41.5%-42.9%]; RISC-II prognosis 41.4%; SMR 1.020 [95% CI, 1.003-1.037]) compared with nonintubated (30.0% [95% CI, 28.1-31.9%] RISC-II prognosis 26.6% and SMR 1.128 [95% CI, 1.057-1.199]). Patients being sedated before intubation presented significant (P<0.001) lower observed mortality (37.7% [95% CI, 36.7-38.7%], RISC-II prognosis 39.0%, SMR 0.967 [95% CI, 0.951-0.983]) associated with a less poor early neurological outcome compared with those being intubated without sedation. Observed outcome of prehospital intubated patients with a GCS of ≤8 seems less poor than predicted compared with nonintubated patients. Sedation before intubation might potentially decrease mortality and improve early neurological outcome. Further studies are required to clarify this issue.

First-Pass Intubation Success Associated with Video Laryngoscopy and RSI

Emergency endotracheal intubation is considered by many the cornerstone of emergency medicine procedural knowledge. Increased first-pass intubation success is associated with decreased rates of uncommon serious complications. To examine changes in intubation practice and outcomes, researchers analyzed prospectively collected data for nearly 11,000 emergency intubations (96% capture rate) in the Japanese Emergency Airway …

Abstract WP355: Predictors and Outcome of Intubation for Patients with Primary Intracerebral Hemorrhage

Background: Patients with primary intracerebral hemorrhage (pICH) are at risk of airway compromise and commonly undergo intubation. Poor outcomes have been reported for these patients. Factors predicting intubation prior to admission (PTA), and after admission are unknown. These factors may be helpful in predicting which pICH patients require intubation, and its optimal timing. Methods: Patients with pICH directly admitted or transferred from another facility to our center were included. Patients with SAH, SDH, epidural hemorrhage, underlying lesions, or infarct with hemorrhagic transformation were excluded. Intubation note from medical chart was used to determine the timing of intubation. Demographic and clinical data were recorded. The primary outcome was a discharge mRS (dmRS) of 4-6. Results: A total of 370 patients were included. Patients intubated PTA had a lower average GCS (6 vs. 9; p=0.0003) and a higher average NIHSS (26 vs. 18; p=0.0007) than those intubated after admission. Higher incidences of hematoma expansion (30.9% vs. 16.3%; p=0.0253), tracheostomies performed (17.5% vs. 4.8%; p=0.0004), ICH volumes &gt; 30cc (40% vs. 25.5%; p=0.0352), and pneumonia (35.1% vs. 5.4%; p&lt;0.0001) were seen in patients intubation after admission, when compared to other patients. Patients requiring intubation at any time had statistically non-significant higher incidences of cortical and brainstem hemorrhage (see Table 1), compared to patients not intubated. After adjusting for pneumonia and ICH score, intubation is significantly associated with a dmRS of 4-6 (OR 4.87, 95%CI 1.27-18.7, p=0.0208). Conclusions: Lower GCS and higher NIHSS significantly predict intubation in pICH patients PTA. ICH volumes &gt; 30cc, hematoma expansion and pneumonia significantly predict intubation after admission. Intubation is significantly associated with poor functional outcomes independent of ICH score and pneumonia. Location of ICH does not predict intubation.

Frequency and outcomes of endotracheal intubation in the pediatric emergency department.

Intubation is a core airway skill in Pediatric Emergency Medicine (PEM). The data on pediatric endotracheal intubation in the emergency department, especially in developing countries, is currently very limited. This study was designed to describe the frequency, clinical features and outcomes of pediatric intubation in a large children`s hospital. We performed a retrospective analysis of PEM medical records between January 2014 and December 2015 that involved any attempted intubations of children younger than 18 years. The medical records were reviewed to describe the intubation process, demographics, clinical features and outcomes. A total of 110,000 patients visited our emergency department during the study period. Ninety-one of them (1/1300) were intubated. The median age was 2 years, (F/M: 1) and 25 patients were younger than 12 months. Respiratory failure was the most common indication for intubation (42%), followed by status epilepticus (26%) and sepsis-shock (16%). Mortality was associated with prolonged chest compression (more than 10 minute). A poor outcome was associated with sepsis-shock and cardiac diseases; however, better outcomes were associated with status epilepticus (p < 0.001). The first attempt success (FAS) was achieved in 60/91 (66 %) patients and the FAS rate was also higher in younger patients (p=0.002). The discharge rate of all intubated patients in our study was sixty-four percent. Pediatric residents performed the majority of intubations. A higher FAS rate was associated with younger patients. Favorable outcomes were directly related to duration of cardiopulmonary resuscitation and main diagnosis.

Characteristics and anesthetic management of patients presenting for cleft surgery

Background: Anesthetic management during surgery for cleft repair can be challenging due to abnormal airway anatomy and preoperative medical conditions. We sought to determine the characteristics, type, and incidence of associated medical problems, airway and other intraoperative complications in patients who presented to our facility for cleft lip and palate repair. Methodology: Fifty-six consecutive patients aged 16 years and below who had surgical repair of cleft lip or palate under general anesthesia during the study period were involved in this prospective, observational study. Routine preoperative review and anesthetic management were not altered. Preoperative medical and airway problems, associated congenital anomalies, intubation outcomes, intraoperative anesthetic complications, and postoperative airway problems were recorded by a blinded observer. Results: Forty-eight (72.7%) and 18 (27.3%) of the 56 patients had cleft lip and palate repair, respectively. Baseline packed cell volume was not significantly different. The incidence of upper respiratory tract infections (URTIs) and anemia were 33% and 0%, respectively, in the cleft palate repair group compared to 18.8% and 16.7% in the cleft lip repair group. Difficult laryngoscopy was found in 4.2% and 11.1% of patients that presented for cleft lip and palate repairs, respectively, and the overall incidence of desaturation was 7.5%. The mean blood loss was more in the cleft palate group compared to that of the cleft lip repair group (33.33 ± 37.73 versus 7.92 ± 6.51, P = 0.001). Conclusions: Cleft lip repair was most common in our review, and URTI was the predominant comorbidity in both groups. The risk of a wide range of perioperative airway complications necessitates the presence of skilled manpower during general anesthesia for cleft lip and palate surgery.

Timing of Intubation and Clinical Outcomes in Adults With Acute Respiratory Distress Syndrome

OBJECTIVE The prevalence, clinical characteristics, and outcomes of critically ill, nonintubated patients with evidence of the acute respiratory distress syndrome remain inadequately characterized. DESIGN Secondary analysis of a prospective observational cohort study. SETTING Vanderbilt University Medical Center. PATIENTS Among adult patients enrolled in a large, multi-ICU prospective cohort study between the years of 2006 and 2011, we studied intubated and nonintubated patients with acute respiratory distress syndrome as defined by acute hypoxemia (PaO2/FIO2 ≤ 300 or SpO2/FIO2 ≤ 315) and bilateral radiographic opacities not explained by cardiac failure. We excluded patients not committed to full respiratory support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 457 patients with acute respiratory distress syndrome, 106 (23%) were not intubated at the time of meeting all other acute respiratory distress syndrome criteria. Nonintubated patients had lower morbidity and severity of illness than intubated patients; however, mortality at 60 days was the same (36%) in both groups (p = 0.91). Of the 106 nonintubated patients, 36 (34%) required intubation within the subsequent 3 days of follow-up; this late-intubation subgroup had significantly higher 60-day mortality (56%) when compared with the both early intubation group (36%, P<0.03) and patients never requiring intubation (26%; p = 0.002). Increased mortality in the late intubation group persisted at 2-year follow-up. Adjustment for baseline clinical and demographic differences did not change the results. CONCLUSIONS A substantial proportion of critically ill adults with acute respiratory distress syndrome were not intubated in their initial days of intensive care, and many were never intubated. Late intubation was associated with increased mortality. Criteria defining the acute respiratory distress syndrome prior to need for positive pressure ventilation are required so that these patients can be enrolled in clinical studies and to facilitate early recognition and treatment of acute respiratory distress syndrome.

Unplanned, Postoperative Intubation in Pediatric Surgical Patients

To date, the independent predictors and outcomes of unplanned postoperative intubation (UPI) in pediatric patients after noncardiac surgery are yet to be characterized. The authors aimed to identify the incidence and predictors of this event and evaluated the effect of this event on postoperative mortality. Data of 87,920 patients from the American College of Surgeons National Surgical Quality Improvement Program Pediatric database were analyzed and assigned to derivation (n = 58,614; 66.7%) or validation (n = 29,306; 33.3%) cohorts. The derivation cohort was analyzed for the incidence and independent predictors of early UPI. The final multivariable logistic regression model was validated using the validation cohort. Early UPI occurred with an incidence of 0.2% in both cohorts. Among the 540 patients who experienced a UPI, 178 (33.0%) were intubated within the first 72 h after surgery. The final logistic regression model indicated operation time, severe cardiac risk factors, American Society of Anesthesiologists physical status classification more than or equal to 2, tumor involving the central nervous system, developmental delay/impaired cognitive function, past or current malignancy, and neonate status as independent predictors of early UPI. Having an early UPI was associated with an increased risk of unadjusted, all-cause 30-day mortality, demonstrating an odds ratio of 11.4 (95% CI, 5.8 to 22.4). Pediatric patients who experienced an early UPI after noncardiac surgery had an increased likelihood of unadjusted 30-day mortality by more than 11-fold. Identification of high-risk patients can allow for targeted intervention and potential prevention of such outcomes.

Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults.

To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults. A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows. Medical ICU in a tertiary, academic medical center. Critically ill patients 18 years old or older. Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation. Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator's previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82-5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy. In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.

Just-in-Time Video Laryngoscopy Versus Direct Laryngoscopy for Neonatal Intubation.

As neonatal endotracheal intubation (ETI) is a low-frequency, high-consequence event, it is essential that providers have access to resources to aid in ETI. We sought to determine the impact of video laryngoscopy (VL) with just-in-time training on intubation outcomes over direct laryngoscopy (DL) when performed by neonatal nurses. We conducted a prospective, randomized, crossover study with neonatal nurses employed at a level 2 neonatal intensive care unit (NICU). Nurses performed both DL and VL on a neonatal mannequin using a CMAC (Karl Storz Corp, Tuttlingen, Germany) either with the assistance of the screen (VL) or without (DL). Before performing the intubation, providers were given a just-in-time, brief education presentation and allowed to practice with the device. Each ETI attempt was reviewed to obtain the percentage of glottic opening (POGO) score, time to intubation (TTI, time from insertion of the blade into the mouth until the first breath was delivered), and time from blade insertion until the best POGO score. We enrolled 19 participants, with a median (interquartile range) of 20 (9-26) years of experience and having a median of 2 (1-3) intubations within the past year. None had used VL in the NICU previously. Median TTI did not differ between DL and VL: 19.9 (15.3-41.5) vs 20.3 (17.9-24.4) (P = 1). POGO scores and the number of attempts also did not differ between DL and VL. In our simulated setting, just-in-time VL training provided similar intubation outcomes compared with DL in ETI performed by neonatal nurses. Just-in-time VL education may be an alternative to traditional DL for neonatal intubations.

Should We Intubate the Patient First? Outcomes of Prophylactic Endotracheal Intubation for Upper Gastrointestinal Bleeding

Should We Intubate the Patient First? Outcomes of Prophylactic Endotracheal Intubation for Upper Gastrointestinal Bleeding

385 Plasma Syndecan-1 Levels Identify a Cohort of Patients With Severe Sepsis at a High Risk of Intubation Following Large Volume Intravenous Fluid Resuscitation

Sepsis damages the endothelium and extracellular matrix (ECM), contributing to fluid extravasation, acute organ injury, and death. Biomarker-based risk stratification holds promise in identifying those patients who may benefit from restrictive fluid resuscitation strategies. We sought to determine if plasma syndecan–1 levels can predict a cohort at particularly high risk of respiratory failure following intravenous fluid (IVF) administration. Syndecan-1 levels were measured in plasma samples at the time of enrollment. The primary outcome was the difference in syndecan-1 levels in patients intubated versus those not requiring intubation, while secondary outcomes were differences in syndecan-1 based on in-hospital mortality and development of acute kidney injury. A cutoff for high versus low syndecan-1 levels was developed using an ROC curve, and logistic regression was performed to evaluate the risk of intubation associated with administration of IV fluids. Syndecan-1 levels were measured in 175 patients. Fifty two patients (22%) met the primary outcome of intubation, 34 (21%) died, and 100 (57%) developed kidney injury. Levels of syndecan-1 were non-significantly higher in patients who were intubated, and significantly higher in non-survivors and those with kidney injury. High syndecan-1 levels were defined as >240 ng/mL. Median IVF volume administered was 4.0 L (IQR 2.0, 5.3) and was not significantly different between high and low syndecan-1 groups. IVF volume was not associated with risk of intubation in patients with a low syndecan-1 level (p = 0.99), but demonstrated a significant linear relationship with the risk of intubation in patients with high syndecan-1 levels (p < 0.05). These data are represented in Figure 1 as Lowess smoothing plots. Syndecan-1 levels are significantly elevated in ED sepsis non-survivors and non-significantly higher among those requiring intubation. Patients with high syndecan-1 levels may represent a cohort at particular risk for intubation following large volume fluid administration. Further studies to validate these findings in a prospective cohort are indicated.

The role of prehospital advanced airway management on outcomes for out-of-hospital cardiac arrest patients: a meta-analysis

ObjectiveThe objective of this meta-analysis was to compare the benefits of prehospital advanced airway management (AAM) and basic airway management (BAM) for out-of-hospital cardiac arrest (OHCA) patients. MethodsTwo investigators performed a systematic review of PubMed, EMBASE, and the Cochrane Database to identify all peer-reviewed articles relevant to this meta-analysis. We included all articles describing emergency medical system–treated nontraumatic OHCAs; specifically, all articles that described intervention of the prehospital AAM type were considered. The primary outcome was survival to discharge, whereas the secondary outcome was neurologic recovery after an OHCA event. For subgroup analysis, we compared the clinical outcome of endotracheal intubation (ETI), a specific type of AAM, vs BAM. ResultsWe reviewed 1452 studies, 10 of which satisfied all the inclusion criteria and involved 17 380 patients subjected to AAM and 67 525 subjected to BAM. Based on the full random effects model, patients who received AAM had lower odds of survival (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.29-0.90) compared with BAM. Subgroup analysis for ETI vs BAM showed no significant association with respect to survival (OR, 0.44; 95% CI, 0.16-1.23). There were no significant differences in the odds of neurologic recovery between AAM and BAM (OR, 0.64; 95% CI, 0.03-1.37). ConclusionsOur results reveal decreased survival odds for OHCA patients treated with AAM by emergency medical service personnel compared with BAM. However, the role of prehospital AAM, especially ETI, on achieving neurologic recovery remains unclear.

Treatment of Acute Purulent Dacryocystitis by Early Bicanalicular Silicone Intubation: Safety, Efficacy, and Outcomes

ABSTRACTPurpose: To evaluate the safety, efficacy, and outcomes of early bicanalicular silicone intubation in the treatment of acute purulent dacryocystitis. Methods: This prospective interventional case series focused on acute purulent dacryocystitis from February 2010 to March 2014. Of the 21 cases, 16 cases were treated at the Fujian Provincial Hospital, and five cases were treated at the Lianjiang Hospital. Bicanalicular silicone intubation was inserted in the original lacrimal duct within 10 days after abscess decompression by pus aspiration method and systemic antibiotic application. Data collection included demographic profiles, perioperative and postoperative complications, and revision surgery. Resolution of signs and symptoms of acute purulent dacryocystitis, as well as successful anatomical patency assessed by irrigation, was evaluated. Follow-up times were more than 12 months, and ranged from 14 to 63 months.Results: All patients showed remarkable improvement of pain and swelling within 48 hours. Resolution of the erythema and edema was observed within one week after bicanalicular silicone intubation combined with topical antibiotic lavage. No intraoperative and postoperative complications were observed. After initial bicanalicular silicone intubation, anatomical success was observed in 66.7% (14/21) of the patients. Of the remaining seven patients who presented with severe reflux in irrigation, two patients chose re-intubation and five patients underwent standard external dacryocystorhinostomy. All patients had anatomical success at last follow-up. Conclusion: Early bicanalicular silicone intubation appears to be a safe, effective, and simple procedure, which offers a reasonable option in the treatment of acute purulent dacryocystitis, especially for those developing and underdeveloped areas.