Intubation Time Research Articles

Transaxillary approach enhances postoperative recovery after mitral valve surgery.

Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection, and valve exposure in minimally invasive mitral valve surgery. The aim of this study is to compare the early outcomes of patients operated using a simplified minimally invasive approach through a right transaxillary (TAxA) access with those achieved with conventional full sternotomy (FS) operations. Prospectively collected data of patients who underwent mitral valve surgery between 2017 and 2022 at 2 academic centres were reviewed. Among them, 454 patients were operated through minimally invasive mitral valve surgery TAxA access and 667 patients through FS; associated aortic and coronary arteries surgery (CABG) procedures, infective endocarditis, redo and urgent operations were excluded. A propensity-matched analysis was performed using 17 preoperative variables. Two well-balanced cohorts including a total of 804 patients were analysed. The rate of mitral valve repair was similar in both groups. Operative times were shorter in the FS group; nevertheless, in patients operated with a minimally invasive approach, there was a trend towards decreasing cross-clamp time over the study period (P = 0.07). In the TAxA group, 30-day mortality was 0.25%, and postoperative cerebral stroke rate was 0.7%. TAxA mitral surgery was associated with shorter intubation time (P < 0.001) and intensive care unit stay (P < 0.001). After a median hospital stay of 8 days, 30% of patients who had TAxA surgery were discharged home versus 5% in the FS group (P < 0.001). When compared with FS access, TAxA approach provides at least similar excellent early outcomes in terms of perioperative morbidity and mortality and allows shorter mechanical ventilation time, intensive care unit and postoperative hospital stay with a higher rate of patients able to be discharged home without any further period of cardiopulmonary rehabilitation.

The role of ROX index-based intubation in COVID-19 pneumonia: a cross-sectional comparison and retrospective survival analysis.

Coronavirus disease 2019 (COVID-19) patients with acute respiratory failure who experience delayed initiation of invasive mechanical ventilation have poor outcomes. The lack of objective measures to define the timing of intubation is an area of concern. We investigated the effect of timing of intubation based on respiratory rate-oxygenation (ROX) index on the outcomes of COVID-19 pneumonia. This was a retrospective cross-sectional study performed in a tertiary care teaching hospital in Kerala, India. Patients with COVID-19 pneumonia who were intubated were grouped into early intubation (within 12 hours of ROX index <4.88) or delayed intubation (12 hours or more hours after ROX <4.88). A total of 58 patients was included in the study after exclusions. Among them, 20 patients were intubated early, and 38 patients were intubated 12 hours after ROX index <4.88. The mean age of the study population was 57±14 years, and 55.0% of the patients were male; diabetes mellitus (48.3%) and hypertension (50.0%) were the most common comorbidities. The early intubation group had 88.2% successful extubation, while only 11.8% of the delayed group had successful extubation (P<0.001). Survival was also significantly more frequent in the early intubation group. Early intubation within 12 hours of ROX index <4.88 was associated with improved extubation and survival in patients with COVID-19 pneumonia.

Augmented Reality Improves Learning Curve of Endovascular Navigation

Intra-Operative Positioning System (IOPS) (Centerline Biomedical, Cleveland, OH) is a 3D electromagnetic (EM) endovascular navigation system approved by the US Food and Drug Administration and developed as an adjunct to fluoroscopy. It provides real-time 3D display of sensorized material on an anatomical map on a flat screen. An investigational prototype based on IOPS incorporates the ability to map implanted stent grafts and visualize the stents and anatomy using augmented reality headset. The aim of this study was to compare the completion of bifurcated stent graft gate cannulation performed by participants of varying experience using fluoroscopy or different variations of IOPS. The task was cannulation of the gate of a bifurcated aortic endograft deployed into a 3D printed abdominal aortic aneurysm model connected to flow pump reproducing physiological conditions, performed in a hybrid operating room (GE Allia IGS 7). Each participant performed the tasks with fluoroscopy, EM guidance with flat screen display (EM-FS), and EM guidance with augmented reality headset (EM-AR) (Fig 1), in randomized order. All participants used the same sensorized guidewire and steerable sensorized 6F catheter for the three runs. Participants were classified in three groups of experience. Primary end points included cannulation time and technical success, defined as the advancement of the catheter over the guidewire within the graft main body. Fifteen minutes was the cutoff time for each trial. There were 26 participants including 13 endovascular naïve trainees (group 1), 12 in training surgeons (group 2) and one advanced level vascular surgeon. In group 1, mean cannulation time was lower using EM-AR versus fluoroscopy (4.3 ± 4.4 vs 7.1 ± 4.9 minutes; P = .04), with no difference between EM-FS and fluoroscopy (6.3 ± 4.5 vs 7.1 ± 4.9 minutes; P = .63). In group 1, technical success was 77% with fluoroscopy and 92% with both EM modalities (P = .59). In group 2, there was a trend toward shorter times with EM-FS or EM-AR as compared to fluoroscopy (mean of 2.5 ± 0.9, 4.4 ± 4.0 and 5.2 ± 4.5 minutes, respectively). In group 2, technical success was 92% with fluoroscopy and 100% with IOPS (P > .99). The advanced level vascular surgeon repeated the cannulation task four times for each endovascular approach, with 100% technical success and no difference in mean time (P = .89) (Fig 2). Augmented reality allows for reducing the gate cannulation time as compared to fluoroscopy in participants with no previous experience in endovascular navigation. This auspicious finding suggests that augmented reality can be beneficial for individuals early in their career and can mitigate the learning curve.Fig 2Mean cannulation times of bifurcated stent graft gate cannulation using electromagnetic (EM) guidance with flat screen display or augmented reality compared to fluoroscopy, performed by operators of varying experience.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Target Vessel Catheterization With Fiber Optic Realshape Using Upper Extremity vs Transfemoral Access for Fenestrated-Branched Endovascular Aortic Aneurysm Repair

The Fiber Optic RealShape (FORS) technology uses pulses of light delivered through specially designed guidewire and catheters that allow the operator to navigate through the vasculature without radiation. Traditionally, and because of length constraints, FORS has been used primarily for transfemoral (TF) access. The purpose of this study is to report the feasibility and benefits of using FORS during fenestrated-branched endovascular aortic aneurysm repair (FBEVAR), including cannulation times of target vessels (TV) and radiation measures comparing upper extremity (UE) (Figure) vs TF access. A single-center retrospective study with prospectively collected data was performed. Patients undergoing FBEVAR with FORS guidance for TV catheterization were included. Custom-made devices, off-the-shelf (TAMBE, tBranch), Zfen, and physician-modified endografts were used. Navigation data was reported per task, including duration, dose area product (DAP), reference air kerma (RAK), and fluoroscopy time (FT) required to accomplish each catheterization. The primary end point included technical success, defined as the navigation accomplishment with no need to switch from FORS to conventional fluoroscopy, and overall radiation exposure. During an 11-month period, 74 patients (70.3% male) underwent FBEVAR with FORS, including 50 custom-made devices, 15 physician-modified endografts, 7 tBranch, 1 TAMBE, and 1 Zfen. Among 370 navigation tasks reported, 350 (94.6%) were performed with FORS, including catheterizations for 225 (64.3%) fenestrations, 61 (17.4%) branches, 50 (14.3%) contralateral gates, and 14 (4%) vessels for preemptive embolization or prestenting. Technical success was 90.3%. Mean time required to deem the catheterization as failure was 8.4 ± 5 minutes. FORS guidewires were used for all procedures. UE access, steerable sheath, and FORS catheters were used in 54.3%, 17.7%, and 13.7%, respectively. The median task duration, RAK, DAP, and FT required for TV cannulation were 5 minutes (interquartile range [IQR], 3-7 minutes), 9.4 mGy (IQR, 4.3-23.7 mGy), 1.0 GyCm2 (IQR, 0.4-2.5 GyCm2), and 1.5 minutes (IQR, 0.8-3.2 minutes), respectively. Among 186 UE TV cannulations and 168 TF TV cannulations, the mean RAK was significantly higher for UE access (25.6 mGy vs 12.5 mGy; P < .00). There were no significant differences in DAP, FT, and TV technical success between UE vs TF access. Overall radiation levels are included in the Table. FBEVAR with FORS technology is feasible using both UE and TF access and facilitates target artery catheterization with acceptable technical success and potentially reduced radiation. Further experience is required to optimize the use of FORS during FBEVARTableFiber-Optic RealShape (FORS) procedural data during fenestrated-branched endovascular aortic aneurysm repair (FBEVAR)VariablesProcedures with FORS technology (n = 74)Cannulation technical success316 (90.3)Procedure duration, minutes313 [246.8-380.8]Total DAP, Gycm2179.5 [116.3-232.5]Total RAK, mGy1327.5 [840.4-1872.3]Fluoroscopy time, minutes71.3 [57.5-92.1]Operator radiation, μSv93 [43-178]Fellow radiation, μSv36.5 [17.3-64.8]Circulator nurse radiation, μSv2 [0-4]Scrub tech radiation, μSv4 [1-9]Anesthesia radiation, μSv5 [2-18]Cannulation time, minutes5 [3-7]Cannulations UE183 (57)Cannulations TF168 (47)Cannulations measuresUETFP valueTotal DAP, Gycm21.0 (0.4-2.10)1.5 (0.5-1.5)NSTotal RAK, mGy8.8 (4.7-20.9)10.5 (4-33.5)<.001Fluoroscopy time, minutes1.6 (0.9-3.2)1.5(0.7-1.5)NSCannulation time, minutes5 (3-7)4 (3-8)NSDAP, Dose area product; N, not significant; RAK, reference air kerma; TF, transfemoral; UE, upper extremity.Values are median [interquartile range] or number (%). Open table in a new tab

Pre-Fontan Assessment Utilizing Combined Cardiac Catheterization and Cardiac MRI: Comparison to the Pre-Fontan Catheterization.

Single ventricle patients eligible for Fontan completion undergo pre-Fontan catheterization for hemodynamic and anatomic assessment prior to surgery. Cardiac magnetic resonance imaging may be used to evaluate pre-Fontan anatomy, physiology, and collateral burden. We describe our center's outcomes in patients undergoing pre-Fontan catheterization combined with cardiac magnetic resonance imaging. A retrospective review of patients undergoing pre-Fontan catheterization from 10/2018 to 04/2022 at Texas Children's Hospital was performed. Patients were divided into 2 groups: combined cardiac magnetic resonance imaging and catheterization (combined group) and those who underwent catheterization only (catheterization only group). There were 37 patients in the combined group and 40 in the catheterization only group. Both groups were similar in age and weight. Patients undergoing combined procedures received less contrast, and experienced less in-lab time, fluoroscopy time and catheterization procedure time. Median radiation exposure was lower in the combined procedure group but was not statistically significant. Intubation and total anesthesia times were higher in the combined procedure group. Patients undergoing a combined procedure were less likely to have collateral occlusion performed than in the catheterization only group. Bypass time, intensive care unit length of stay, and chest tube duration were similar in both groups at the time of Fontan completion. Combined pre-Fontan assessment decreases catheterization procedure and fluoroscopy time associated with cardiac catheterization at the expense of longer anesthetic times, and results in similar Fontan outcomes compared to when cardiac catheterization alone is utilized.

Comparative analysis of anesthesia and clinical efficacy of inhalation anesthesia and intravenous anesthesia in Trigeminal Nerve Balloon Avulsion.

To observe the anesthesia and clinical efficacy of inhalation anesthesia and intravenous anesthesia in patients with trigeminal neuralgia undergoing surgery. This is a retrospective study. Eighty patients with trigeminal neuralgia admitted to the Affiliated Hospital of Beihua University from July 2018 to July 2021 were selected and divided into two groups according to different anesthesia methods: inhalation group and intravenous group, with 40 cases in each group. Patients in the inhalation group were given inhalation anesthesia with sevoflurane, while those in the intravenous group were given intravenous anesthesia. Hemodynamics, intubation and extubation time, postoperative consciousness recovery, adverse reactions and clinical effects of surgery were compared between the two groups during anesthesia. During the induction of anesthesia, after induction and after surgery, the levels of hemodynamic parameters in the two groups increased compared with those before induction of anesthesia, and the increase in the inhalation group was smaller (P<0.05). Patients in the inhalation group had a long time from anesthesia to endotracheal intubation but had a short time from completion of surgery to intubation, which was statistically significant compared with the intravenous group (P<0.05). Compared with the intravenous group, the postoperative consciousness recovery time of the inhalation group was significantly shorter and the incidence of adverse reactions was significantly lower (P<0.05). Inhalation anesthesia with sevoflurane is more effective than intravenous anesthesia in trigeminal neuralgia patients treated with trigeminal nerve balloon avulsion, boasting satisfactory safety, less impact on hemodynamics, and shorter recovery time of consciousness.

Comparison between in-plane and out-of-plane techniques for ultrasound guided cannulation of the left brachiocephalic vein in pediatric population: A randomised controlled trial

Background and aimsBrachiocephalic vein is a novel site for central venous cannulation in infants. It becomes useful in patients where the internal jugular vein lumen is small (e.g., volume deficient patient), patients with a history of multiple cannulations, and in whom subclavian puncture is contraindicated. MethodsIn this randomized double-blinded study, 100 patients, aged between 0 and 1 year scheduled for elective central venous cannulation were recruited. The patients were allocated into two groups (50 patients in each). Group I patients had ultrasound (US) guided cannulation of the left brachiocephalic vein (BCV) by inserting a needle in-plane to the US probe from lateral to the medial direction, whereas Group II patients underwent cannulation of the BCV via an out-of-plane approach. ResultsThe first-attempt success rate was significantly higher in Group I (74%) than in Group II (36%) (p < 0.001). The total success rate was higher in group I (98%) than in group II (88%) however the difference was statistically insignificant (p > 0.05). The mean BCV cannulation time was significantly shorter in group I (35.46 ± 25.10) than in group II (65.24 ± 40.26) (p < 0.001). The rate of unsuccessful BCV cannulation (12%) and hematoma development (12%) was significantly higher in group II than in group I (2%). ConclusionCompared to the out-of-plane approach of left BCV cannulation, US-guided in-plane cannulation of the left BCV increased the first-attempt success rate, decreased the number of puncture attempts, and decreased the time required for cannulation.

Comparison of the Airtraq and the C-MAC video laryngoscopes during intubation of infants with neural tube defects: A prospective randomized clinical trial

Background and aimDifficult intubation is seen frequently in infants under the age of 1year-especially in babies 1 month old in the pediatric population. This was higher in babies with neural tube defects. Video laryngoscopes are the airway devices that were shown to be effective in difficult airways. However, only a few of them have pediatric and infantile blades. We aimed to compare the channeled Airtraq and Macintosh typed C-MAC in babies less than 1 year of age undergoing elective neurosurgery. MethodsAfter research ethics committee and informed patient consent was obtained 50 infants were enrolled in this prospective randomized study. Patients were divided into two groups; the Airtraq and the C-MAC. Patient demographic characteristics, device insertion time, and intubation times were recorded. ResultsThe values of 1 patient in the Airtraq and 4 patients in the C-MAC group could not be analyzed. The demographic characteristics of the groups were similar. No difference was detected in terms of insertion time, intubation time, and the number of intubation attempts between the groups. ConclusionThe channeled angulated Airtraq and Macintosh typed C-MAC could safely be used in babies less than 1 month and 1 year old.

P46 TRANSAXILLARY MITRAL VALVE SURGERY IS ASSOCIATED WITH EARLY RECOVERY AND SHORTER ICU AND HOSPITAL STAY

Abstract Background and Aim Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection and valve exposure in minimally invasive mitral valve surgery (MIMVS). Aim of this study is to compare the early outcomes of patients operated through a right trans–axillary (TAxA) approach with those achieved in conventional full sternotomy (FS) operations. Methods Prospectively collected data of patients who underwent mitral valve surgery between 2017 and 2022 at two academic centres were reviewed. Among them, 454 patients underwent MIMVS through TAxA access and 667 patients through FS (associated aortic and CABG procedures, infective endocarditis and urgent operations were excluded). A propensity match analysis was performed using seventeen preoperative and intraoperative variables. Results There was no difference in preoperative characteristics in matched populations. The rate of mitral valve repair was similar in both groups. Patients in TAxA group had a higher rate of repair using artificial chordae. Operative times were shorter in FS group but in patients operated in minimally invasive approach there was a trend towards decreasing CPB and cross–clamp time over the study period. Hospital mortality in TAxA group was 0.25%, postoperative cerebral stroke rate was 0.7%. TAxA mitral surgery was associated with shorter intubation time (p&amp;lt;0.001) and ICU stay (p&amp;lt;0.001). After a median hospital stay of 8 days, 30% of patients who had TAxA surgery were discharged home vs. 5% in the FS group (p&amp;lt;0.001). Conclusions TAxA approach is safe and effective. Compared to FS, it allows shorter mechanical ventilation, ICU and postoperative hospital stay with a higher rate of patients able to be discharged home without any further period of cardiopulmonary rehabilitation.

P96 NO PATIENT SELECTION IN TOTALLY ENDOSCOPIC ISOLATED MITRAL VALVE SURGERY: OPERATIVE AND EARLY RESULTS IN DEGENERATIVE MITRAL VALVE REGURGITATION

Abstract Background and aim In high–volume centers MICS can be offered to any patient affected by degenerative mitral valve surgery (MVS). Aim of this study was to evaluate early outcomes in patients undergoing isolated MVS for degenerative mitral regurgitation (MR) using a totally endoscopic technique. Methods From January 2018 to December 2022, 1124 consecutive unselected patients underwent endoscopic MVS at our institution. Among them, 399 patients underwent isolated MVS for degenerative valve pathology. Concomitant surgery and different etiology were excluded. All patients were approached with peripheral cannulation, limited skin incision (peri–areolar/sub–mammary/anterior axillary line) and 5 mm 30° endoscope. Neo–chordae implantation plus annuloplasty ring was the preferred technique for mitral repair. Results Endoscopic MVS was achieved in all patients and no conversion to sternotomy was needed. Median Cross–Clamp and CPB Time were respectively 93 [75 – 11] and 143 minutes [115 – 171]. Overall in hospital mortality was 0.75%. Major Stroke occurred in 1.6%. Replacement for unsuccessful repair occurred in 4 patients (1%). Repeated cross–clamp for residual MR in 13 patients (3,3%). Median intubation time was 5 h [3 – 7], ICU time was 18 h [15 – 21], bleeding requiring revision occurred in 21 patients (5.3%) always through the same access. PM implantation occurred in 3%, vascular complications in 1%. We had 1 case of endocarditis, 1 case of early failure, 1.3% mitral redo. Conclusions In high volume centers isolated endoscopic MVS without preoperative patient selection has proven to be safe with optimal mortality, good fast–track and low incidence of complications.

Comparison of Airtraq™ video-laryngoscope and Macintosh laryngoscope for tracheal intubation in adults—a randomised study

BackgroundAirway management by intubation is considered a major responsibility and vital skill for anaesthesiologists. Direct laryngoscopy and endotracheal intubation under vision continues to be the gold standard for airway management. Though conventional laryngoscopy is done with Macintosh blade, it has its own drawbacks. The Airtraq™ is a tube/guide channelled video-laryngoscope and can be used in patients with normal as well as difficult airway. On literature review, studies comparing intubation time with Airtraq™ and Macintosh laryngoscopes have shown heterogeneous results. Therefore, the present study was designed to compare the Airtraq™ video-laryngoscope and Macintosh laryngoscope for tracheal intubation in adults.ResultsThe median time to intubation was significantly longer in group A [45 (27–77) s] than in group M [24 (21–26) s] (p < 0.001). In both groups, 96% patients had POGO score 75–100% and CL grade I. Intubation was noted to be easy in 88% cases in group A and 92% in group M (p > 0.05). Three cases in group A required a second attempt for successful intubation, whereas in group M, all cases were intubated in the first attempt (p > 0.05). Hemodynamic parameters and complications were comparable among the groups (p > 0.05).ConclusionsAirtraq™ video-laryngoscope took longer time for intubation than Macintosh laryngoscope. However, both the devices were similar in terms of glottic view, ease of intubation, number of intubation attempts, incidence of failed intubation, hemodynamic changes, and complications. The overall performance of Airtraq™ video-laryngoscope was similar to Macintosh laryngoscope in patients having normal airways.

Efficacy of a Newly Developed Guidewire for Selective Biliary Cannulation: A Multicenter Randomized Controlled Trial.

Various guidewires are used for biliary cannulation, and each one has its own characteristics affecting its effectiveness. This study aimed to measure the basic properties and evaluate the effectiveness of a newly developed 0.025-inch guidewire for selective biliary cannulation. A total of 190 patients at five referral hospitals were randomly allocated to undergo selective biliary cannulation using the newly developed guidewire (NGW group, n = 95) or a conventional guidewire (CGW group, n = 95). The primary outcome was the selective biliary cannulation rate in naïve papillae. The secondary outcome was to measure the NGW basic properties, compare them with those of the CGW, and analyze the importance of basic property differences. There were no significant differences between the groups in the baseline characteristics. The primary outcome (75.8% vs. 84.2%, p = 0.102) and adverse event rate (6.3% vs. 4.2%, p = 0.374) were similar in both groups. However, compared with the CGW group, the NGW group showed a higher number of ampulla contacts (2.58 vs. 2.02, p = 0.011) and longer cannulation time (216.5 vs. 135.1 s, p = 0.016). Furthermore, the NGW group had higher maximum friction (34.6 ± 1.34 vs. 30.2 ± 4.09), lower stiffness, and better elastic resiliency. In the multivariate analysis, a curved-tip GW (OR = 0.26, 95% CI 0.11-0.62, p = 0.002) and normal papillary shape (OR = 0.39, 95% CI 0.17-0.86, p = 0.021) were contributing factors for successful selective biliary cannulation. The NGW group had high friction and low stiffness, characteristics affecting biliary cannulation. Clinically, the NGW group had similar success and adverse event rates as the CGW, but they showed a higher number of ampulla contacts and longer cannulation time.

Efficacy of a newly developed guidewire for selective biliary access

A clinical efficacy study of 0.025-inch guidewires (GWs) according to mechanical property analysis has not been reported yet. This study was designed to evaluate the clinical efficacy of a newly developed 0.025-inch GW for biliary access according to the basic mechanical property. Commercially available 0.025-inch GWs were in vitro tested based on parameters of mechanical property. Patients with naïve papilla requiring diagnostic or therapeutic ERCP were randomly assigned to an experimental 0.025-inch newly developed GW or a control 0.025-inch GW group. Technical success rate of wire-guided cannulation (WGC), difficult biliary cannulation (DBC), and adverse event rates were measured in this multicenter randomized trial. The technical success rate of primary WGC was 79.1% (151 of 191) in the experimental group and 70.8% (131 of 185) in the control group (95% two-sided confidence interval: 8.25%; p < 0.001; for a noninferiority margin of 15%). The technical success rate including cross-over to each other was also non-inferior. However, the chi-square test showed a statistical difference (81.7% vs. 68.1%; p = 0.002). Median biliary cannulation time was shorter in the experimental group (53 s vs. 77 s; p = 0.047). The rate of DBC was more frequent in the control group (34.6% vs. 50.3% p = 0.002). Multivariate analysis revealed that control group was one of contributing factors for DBC. Overall rate of post-ERCP pancreatitis was not different (4.7% vs. 8.6%; p = 0.125). WGC using a newly developed GW with superior physical performance GW in a bench test showed similar clinical efficacy and the rate of DBC was significantly lower in experimental GW.

Universal prophylactic rectal nonsteroidal anti-inflammatory drugs with a policy of selective pancreatic duct stenting significantly reduce post-endoscopic retrograde cholangiopancreatography pancreatitis.

Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective for the prevention of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis (PEP) in high-risk patients, the benefit in average-risk patients is unclear. We aimed at assessing the benefit of prophylactic rectal NSAIDs in unselected consecutive patients to prevent PEP. All patients undergoing index ERCP procedures from January 2018 until March 2020 were included. All patients received prophylactic rectal diclofenac. A prophylactic pancreatic duct (PD) stent was placed if there was repeated PD cannulation, at the discretion of the endoscopist. The frequency of PEP was compared with historical controls. Of 769 patients who underwent ERCP, 34 (4.4%) developed PEP (mild in 29 [85.3%], moderate in four [11.8%] and severe in one [2.9%]). Female gender, precut sphincterotomy, inadvertent PD cannulation and procedural time of > 30minutes predicted PEP in univariate analysis. Inadvertent PD cannulation (OR 4.6, 95% CI: 1.8-11.7; p < 0.001) and procedural time of > 30minutes (OR 8.5, 95% CI: 3.7-10.1; p < 0.001) were independent risk factors on multivariate analysis. When compared with historical controls, the odds of PEP with prophylactic use of rectal NSAIDs and selective PD stenting was 0.54 (CI: 0.31-0.93, p = 0.027). The number needed to treat (NNT) was 22 to prevent one PEP with prophylactic rectal NSAIDs. Routine use of prophylactic rectal NSAIDs effectively prevents the occurrence of PEP in unselected consecutive patients in a real-world scenario.

Effect of cooled tracheal tubes on time to intubate and first pass intubation success in novice intubators: A randomized crossover manikin study

Polyvinyl chloride (PVC) tracheal tubes (TTs) may change in stiffness with changing temperatures. Cooling an TT may increase its rigidity and may assist in maintaining its slope at the tip. In this study, we aim to investigate the effects of a cooled TT on intubation time and first pass success. In a randomized cross-over design, senior medical students without prior intubation experience performed intubation with a direct laryngoscope on a manikin. During the first group's intubations, cooled TTs were used first and then room temperature TTs, while the second group performed it vice versa. The primary outcome was the time to intubation. As secondary outcomes, first pass success, esophageal intubation, and dental click were measured. The study included 21 participants. Cooled TT intubations (61.9%) had significantly higher first-pass success rates than room temperature TT intubations (33.3%) (p = 0.031). When room temperature TT was used for intubations, the mean time to intubation was 14.33 (95% CI 5.59–23.08) seconds longer than when cooled TT was used (p = 0.003). In terms of esophageal intubation and dental click rates, there was no statistically significant difference between the groups (p = 0.754, p = 0.99, respectively). In this manikin study, we observed that novice intubators performed intubation with improved time to intubate and higher first pass success using cooled TT.

The effect of the use of a stylet and/or McGrath videolaryngoscope on intubation time in obese patients: A randomized clinical trial

BackgroundObese people have low oxygen reserves because of low functional capacity. For this reason, the time for airway manipulation before intubation is reduced and airway management may be difficult in obese population. AimThe purpose of the present study was to investigate whether videolaryngoscope or stylet or both, shorten the intubation time in obese patients. MethodsA total of 120 obese patients scheduled for surgery under general anesthesia were included in the study, 30 in each group; Group DL utilizing a standardized Macintosh blade, Group DLS: DL utilizing a standardized Macintosh blade + Stylet, Group VL: McGrath VL (Series 5), Group VLS: McGrath VL (Series 5) + Stylet. Intubation time was investigated as the primary outcome. ResultsIntubation times were found to be significantly different between the study groups (P < 0.001). According to the Post-Hoc Test results, the intubation time of Group DL was significantly lower than the intubation time of Group VL and Group VLS (P < 0.001, P = 0.014, respectively). Group DLS intubation time was significantly lower than those of Group VL and Group VLS (P < 0.001, P < 0.001, respectively). Intubation times were similar between the other groups (P > 0.05). ConclusionsThe intubation times of obese patients were shorter with direct laryngoscopy, with or without a stylet when compared to those with a McGrath videolaryngoscope, with or without a stylet. Among the same type of laryngoscopy groups, the use of stylet did not change the intubation time. The rate of first-pass intubation was lower with the stylet-free McGrath videolaryngoscope when compared to direct laryngoscopy and direct laryngoscopy plus stylet groups.

Depth of anesthesia, temperature, and postoperative delirium in children and adolescents undergoing cardiac surgery

BackgroundAfter pediatric cardiosurgical interventions, postoperative delirium can occur, which can be associated with undesirable consequences during and after the hospital stay. It is therefore important to avoid any factors causing delirium as far as possible. Electroencephalogram (EEG) monitoring can be used during anesthesia to individually adjust dosages of hypnotically acting drugs. It is necessary to gain knowledge about the relationship between intraoperative EEG and postoperative delirium in children.MethodsIn a dataset comprising 89 children (53 male, 36 female; median age: 0.99 (interquartile range: 0.51, 4.89) years) undergoing cardiac surgery involving use of a heart–lung machine, relationships between depth of anesthesia as measured by EEG (EEG index: Narcotrend Index (NI)), sevoflurane dosage, and body temperature were analyzed. A Cornell Assessment of Pediatric Delirium (CAP-D) score ≥ 9 indicated delirium.ResultsThe EEG could be used in patients of all age groups for patient monitoring during anesthesia. In the context of induced hypothermia, EEG monitoring supported individually adjusted sevoflurane dosing. The NI was significantly correlated with the body temperature; decreasing temperature was accompanied by a decreasing NI.A CAP-D score ≥ 9 was documented in 61 patients (68.5%); 28 patients (31.5%) had a CAP-D < 9. Delirious patients with an intubation time ≤ 24 h showed a moderate negative correlation between minimum NI (NImin) and CAP-D (rho = -0.41, 95% CI: -0.70 – -0.01, p = 0.046), i.e., CAP-D decreased with increasing NImin. In the analysis of all patients’ data, NImin and CAP-D showed a weak negative correlation (rho = -0.21, 95% CI: -0.40 – 0.01, p = 0.064). On average, the youngest patients had the highest CAP-D scores (p = 0.002). Patients with burst suppression / suppression EEG had a longer median intubation time in the intensive care unit than patients without such EEG (p = 0.023).There was no relationship between minimum temperature and CAP-D score.ConclusionsThe EEG can be used to individually adjust sevoflurane dosing during hypothermia. Of the patients extubated within 24 h and classified as delirious, patients with deeper levels of anesthesia had more severe delirium symptoms than patients with lighter levels of anesthesia.

Comparison of C-MACTM Videolaryngoscope with Macintosh Laryngoscope in Anticipated Difficult Airway

Background: Failure to intubate is one of the dreaded outcomes of airway management. Videolaryngoscopes have the potential to increase intubation success by overcoming the shortcomings of direct laryngoscopy. This study aimed to compare the first-attempt intubation success rate of the C-MACTM videolaryngoscope and Macintosh laryngoscope in patients with anticipated difficult airways. Methods: Eighty adult patients with multiple predictors of difficult airway scheduled for surgery under general anaesthesia were randomised either into Group C (first using the C-MACTM videolaryngoscope) or Group D (first using the Macintosh laryngoscope). Laryngoscopy was done sequentially with both laryngoscopes in a patient based on the randomisation. The primary outcome was the first-attempt intubation success rate. Intubation time, Cormack–Lehane view, use of airway adjuncts and the need for external laryngeal manipulations constituted the secondary outcomes. Results: The first-attempt intubation success rate was 100% in both groups with the P value 1.0 and the intubation time was 26 s in Group C and 24.4 s in Group D with P = 0.17. The C-MACTM videolaryngoscope provided better grades of laryngoscopic view than direct laryngoscopy (P = 0.02). Tracheal tube introducer-assisted intubation (P = 0.01) and requirement of laryngeal manipulation to aid intubation (P = 0.01) were higher with the Macintosh laryngoscope. Conclusion: The Macintosh laryngoscope was comparable to the C-MACTM videolaryngoscope in terms of intubation success, intubation time and complications. However, an increased requirement for external laryngeal manipulation, lifting force and the use of an introducer for intubation were noted in the Macintosh group.

An observational study on the timing of intubation and outcome in COVID-19 ARDS patients who were treated with high flow nasal oxygen prior to invasive mechanical ventilation: A time series analysis (InOutHFNO trial).

Prolonged high flow nasal oxygen (HFNO) application might delay intubation and increase mortality in acute hypoxemic respiratory failure (AHRF) patients. Intubation in coronavirus disease 2019 (COVID-19) AHRF (CAHRF) patients 24 to 48 hours after HFNO initiation has been associated with increased mortality in previous studies. This cut-off period is variable in previous studies. A time series analysis could reflect more robust data on outcome in relation to HFNO duration before intubation in CAHRF. A retrospective study was conducted at 30-bedded ICU of a tertiary care teaching hospital from July 2020 to August 2021. The study cohort comprised 116 patients who required HFNO and were subsequently intubated following HFNO failure. A time series analysis of patient outcomes on each day of HFNO application prior to invasive mechanical ventilation (IMV) was done. ICU and hospital mortality was 67.2%. Beyond day 4 of HFNO application, there was a trend towards increased risk-adjusted ICU and hospital mortality for each day delay in intubation of CAHRF patients on HFNO [OR 2.718; 95% CI 0.957-7.721; P 0.061]. This trend was maintained till day 8 of HFNO application, after which there was 100% mortality. Taking day four as a cut-off in the timeline of HFNO application, we have observed an absolute mortality benefit of 15% with early intubation despite a higher APACHE-IV score than the late intubation group. IMV beyond the 4th day of HFNO initiation in CAHRF patients increases mortality.

Tickle Me ECMO…Differences and Outcomes Unearthed for Kids Requiring Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Syndrome Coronavirus 2-Associated Disease.

Tickle Me ECMO…Differences and Outcomes Unearthed for Kids Requiring Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Syndrome Coronavirus 2-Associated Disease.