Intubation Time Research Articles

Hypoalbuminemia is a predictor of mortality in patients with cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation.

Hypoalbuminemia is predictive of mortality in critically ill patients, especially those with cardiac etiologies of illness. The objective of this study was to determine the association of albumin level pre-cannulation for veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) and important clinical hospital outcomes. This was a retrospective, observational cohort study of albumin levels in patients with cardiogenic shock requiring V-A ECMO between December 2015 and August 2021 in a single, high-volume ECMO center. The primary outcome was in-hospital mortality. Of 434 patients assessed, 318 were included. The overall mean pre-ECMO albumin was 3 ± 0.8g/dL and mean albumin at 72 hours post-cannulation was 2.7 ± 0.5g/dL. For patients with pre-ECMO albumin ≤3g/dL vs. >3g/dL, in-hospital mortality was 44.9% vs. 27.5%, respectively (p = .002). In multivariable logistic regression analysis, higher albumin (per 1g/dL increase) at time of V-A ECMO initiation was associated with decreased odds of in-hospital mortality (OR, 0.68; 95% CI, 0.48-0.96; p = .03). Patients with a pre-ECMO albumin ≤3g/dL required significantly more platelet transfusions and had higher incidence of gastrointestinal bleeding during V-A ECMO support (both p < .05). Hypoalbuminemia at time of cannulation is significantly associated with in-hospital mortality and ECMO-related complications including platelet transfusion and gastrointestinal bleeding. Albumin levels at the time of consideration of V-A ECMO may serve as a key prognostic indicator and may assist in effective decision-making regarding this invasive and costly resource.

Video laryngoscopy may improve the intubation outcomes in critically ill patients: a systematic review and meta-analysis of randomised controlled trials

BackgroundThe role of video laryngoscopy in critically ill patients requiring emergency tracheal intubation remains controversial. This systematic review and meta-analysis aimed to evaluate whether video laryngoscopy could improve the clinical...

Bloodless lung transplantation: Comparison between 2 central venoarterial extracorporeal membrane oxygenation anticoagulation strategies and their impact on lung transplant outcomes

ObjectiveTo report differences between 2 anticoagulation protocols during venoarterial extracorporeal membrane oxygenation (VA-ECMO) intraoperative support and their effects on outcomes after lung transplantation. MethodsWe performed a retrospective analysis of patients undergoing double-lung transplantation with intraoperative VA-ECMO from January 1, 2016, to December 30, 2023. Two distinct anticoagulation protocols were in place during this period. One included targeted activated clotting time >180 seconds at all times with protamine reversal after decannulation. The second included 75 units per kilogram of heparin at the time of cannulation with no redosing plus a tranexamic acid infusion after ECMO initiation. ResultsA total of 116 patients (46 low heparin, 70 standard) were included in the analysis. Cannulation strategies and ECMO circuit were equivalent between the groups. The low-dose heparin protocol group had a shorter surgical time (7.28 hours vs 8.53 hours, P < .001) and required significantly less intraoperative packed red blood cells (median 0 vs 4.37 units, P < .001), fresh-frozen plasma (median 0 vs 2 units, P < .001), platelets (median 0 vs 1 units, P < .001), cryoprecipitate (median 0 vs 0 units, P < .001), and total blood products (median 0 vs 9 units, P < .001) compared with the standard group. There were no differences in rates of deep vein thrombosis (P = .13), airway dehiscence (P > .99), pneumonia (P = .38), or acute kidney injury requiring renal-replacement therapy (P = .59). There was no difference in rates of severe grade 3 primary graft dysfunction at 72 hours after transplant (P = .42). ConclusionsOur low-dose heparin VA-ECMO protocol for intraoperative support during lung transplantation led to a significant reduction of blood product use. Although this did not translate to a reduced rates of grade 3 primary graft dysfunction, the low-dose heparin protocol was associated with similar postoperative outcomes.

A Retrospective Multicenter Study of Operating Room Extubation and Extubation Timing following Cardiac Surgery

BackgroundIn an effort to enhance recovery after cardiac surgery, intraoperative extubation has been targeted as possibly beneficial. This multi-center cohort study aimed to assess this by evaluating the outcomes of OR extubation versus extubation within six hours of intensive care unit arrival (early ICU extubation). Furthermore, we assessed time to ICU extubation and mortality and morbidity. MethodsPatients undergoing on-pump cardiac surgery across 79 hospitals between 2011-2020 were included to 1) compare outcomes among OR extubation and early ICU extubation patients, and 2) assess time to overall ICU extubation and outcomes. ResultsThe overall study cohort comprised 163,982 patients, including 95,982 patients [ [ OR extubation : n= 2,529 (2.6%)and early ICU extubation : n= 93,453 (97.4%)] who underwent comparison of OR with early ICU extubation. Following overlap weighting, OR extubation patients had longer OR times (5.6 vs. 5.1 hours, p < 0.0001), and higher rates of reintubation (5.2% vs 2.9%, p=0.003), prolonged ventilation (3% vs 2%, p = 0.021), reoperation for bleeding (1.5% vs 0.7%, p < 0,01), pneumonia (1.9% vs. 1.1% , p < 0.006), and greater in-hospital mortality on multivariable regression (OR 1.34, p < 0.001). OR extubation patients at centers with low OR extubation rates (< 10%, N=60) had higher mortality (odds ratio 1.6, p = 0.001). Beyond 22 hours of postoperative ICU ventilation, the risk of morbidity and mortality increased significantly . ConclusionsFew cardiac surgery patients are extubated in the OR, which is associated with no clinical benefit and with increased morbidity. Cardiac surgery programs should reconsider OR extubation following cardiopulmonary bypass. Additionally, increased intubation time, in particular > 22 hours, is associated with an increase in adverse outcomes.

Characteristics of oral mucosal pressure injuries in children with orotracheal intubation in intensive care units: An observational study.

Tracheal intubation can be used for ventilation to ensure an unobstructed respiratory tract, and it is the most common respiratory support technique used in paediatric intensive care unit (PICU) patients. Orotracheal intubation is usually the preferred method of tracheal intubation. However, it can cause stress-related damage to the oral mucosa. Identifying the factors that cause oral mucosal pressure injury (OMPI) can prevent its occurrence in children with oral endotracheal intubation. To examine the characteristics of OMPI in children who underwent orotracheal intubation in the PICU and to assess their influencing factors. An observational, prospective study. Data were gathered from the PICU of a tertiary hospital in China between January 2023 and October 2023. The patient data were obtained from the 'General Information Questionnaire', 'Paediatric Critical Illness Score', 'STRONGkids Scale' and 'OMPI Staging and Assessment Tools'. Data analysis was subsequently performed using univariate and logistic regression analyses. A total of 187 children who underwent orotracheal intubation were analysed. During the observation period, 44.92% (n = 84) of the children developed OMPI. It comprised 63.10% (n = 53) of stage I injuries, 33.33% (n = 28) of stage II injuries and 3.57% (n = 3) of stage III injuries. The common injury sites were the lower jaw (48.81%), upper jaw (29.76%), tongue (20.24%) and joints (10.71%). The logistic regression analysis results revealed that high critical illness (OR = 0.835, 95% CI: 0.726-0.961), long intubation time (OR = 1.043, 95% CI: 1.021-1.067), prone ventilation (OR = 6.708, 95% CI: 1.421-31.670), hypothermia (OR = 5.831, 95% CI: 1.208-28.149), use of dental pads (OR = 5.520, 95% CI: 1.150-26.487) and low albumin levels (OR = 6.238, 95% CI: 1.285-30.281) were the main contributing factors for OMPI in children with orotracheal intubation (p < .05). The occurrence of OMPI in children who underwent orotracheal intubation in the PICU was notable and was predominantly observed in stages I and II. Consequently, clinical nursing personnel should proactively recognize risk factors and administer timely interventions to mitigate the occurrence of OMPI in such children. The incidence of OMPI in children who underwent orotracheal intubation was relatively high. Nurses and doctors should closely monitor the risk factors for orotracheal intubation in children to prevent the occurrence of OMPI.

Effect of timing of intubation on clinical outcomes of patients with septic shock: a retrospective cohort study.

Evidence-based data regarding the timing of the application of invasive mechanical ventilation among adults with septic shock is insufficient. The guidelines fail to provide clear advice about the optimal time to initiate this support. Consequently, we aimed to investigate whether early intubation could improve survival rates in septic shock patients. We conducted a retrospective analysis of the MIMIC-IV database to evaluate the effectiveness of early intubation on mortality in a cohort of septic shock patients. Adults diagnosed with septic shock, according to the Sepsis-3 definition, were included. They were categorized into an early intubation group (first 8h after vasopressor initiation) and a non-early intubation group (unexposed). A propensity score matching (PSM) analysis was used to balance the baseline characteristics between the two groups. The primary outcomes were 30-day and 90-day all-cause mortality rates. In addition, we employed the restricted cubic spline to analyze the potential non-linear relationship between the timing of intubation and 30-day or 90-day all-cause mortality. A total of 6864 adult patients, of whom 2048 were intubated in the first 8h, were evaluated in the final cohort. Following a 1:1 PSM procedure, 2786 patients were successfully paired. At 30days, 288 of 1393 patients (20.7%) in the early intubation group and 381 of 1393 patients (27.4%) in the non-early intubation group had died (hazard ratio [HR] 0.717; 95% confidence interval [CI] 0.616-0.836; p < 0.001). Similarly, the results also showed that early intubation was associated with a lower 90day all-cause mortality rate (HR 0.761; 95% CI 0.663-0.874; p < 0.001). Furthermore, ICU and hospital lengths of stay were significantly different between the groups (3.6 [1.9, 7.1] vs. 2.3 [1.3, 4.3]; p < 0.001 and 8.9 [5.4, 15.1] vs. 7.2 [4.5, 12.0]; p < 0.001). In the subgroup analysis, we further confirmed the robustness of our findings. Additionally, we found that the timing of intubation is inversely U-shaped correlated to the 30day all-cause mortality rate. Among adult patients with septic shock, the early initiation of invasive mechanical ventilation could improve clinical outcomes. The timing of intubation demonstrated an inverse U-shaped association with the 30day all-cause mortality rate, with the peak risk of death occurring at 50.5h after septic shock.

Characterization of Conventional Endovascular Devices in Treatment of Abdominal Aortic Aneurysms

Abstract Abdominal aortic aneurysms (AAA) are often repaired through an endovascular approach known as endovascular aneurysm repair (EVAR). The success and duration of these challenging procedures are primarily attributable to the accuracy and reliability of navigating corresponding interventional devices. This study investigates the performance of conventional nonsteerable and steerable catheters in EVAR procedures, focusing on two primary metrics: reachable workspace and gate cannulation success. We developed two abdominal aortic aneurysm (AAA) phantoms using patient CT images for our experiments. Under X-ray fluoroscopy guidance, the reachable workspace was quantified, and gate cannulation success rates, cannulation time, and fluoroscopy times were recorded for both nonsteerable and steerable catheters and were compared. We were unable to observe statistically significant differences between the two catheter types in overall cannulation success rates or fluoroscopy time. However, in challenging anatomical scenarios (particularly a more challenging gate location), the steerable catheter showed statistically significant advantages in success rates and cannulation times. While there were no statistical differences in reachable workspace between nonsteerable and steerable catheters when considering the whole aneurysm, segmented analysis showed that the steerable catheter performed better in the central region, and nonsteerable catheters performed better in the peripheral region. This study provides a systematic method for quantifying the performance of endovascular devices. The findings suggest that while steerable catheters may offer advantages in complex anatomical conditions, nonsteerable catheters are preferable in peripheral areas of the aneurysm. These insights can inform catheter selection in EVAR, potentially influencing device design and clinical practice.

Comparison of Tracheal Intubation Using the Air-Q ILA and LMA Blockbuster Among Adults Undergoing Elective Surgery: A Randomized Controlled Trial.

Air-Q intubating laryngeal airway (ILA) is associated with a 58-77% success rate in blind intubation. The newer laryngeal mask airway (LMA) blockbuster is specially designed to facilitate easier endotracheal intubation and may have a higher success rate. The current study aimed to compare the success rate of endotracheal intubation using the Air-Q ILA and LMA blockbuster. After ethics committee approval and informed written consent, 140 adult patients with normal airways who were scheduled for elective surgery under general anaesthesia requiring endotracheal intubation were recruited for this randomized controlled trial. Blind endotracheal intubation was performed using the Air-Q ILA in group A and the LMA blockbuster in group B with special maneuvers and/or tubes in the second attempt. Fibreoptic bronchoscope (FOB) guidance was used in the third attempt if required. The primary outcome was the success rate of intubation without FOB assistance. The number of attempts for supraglottic airway (SGA) insertion, the time taken for SGA insertion, and the overall intubation time was also noted. The success rate of intubation without FOB guidance was significantly higher in group B than in group A [91.4% vs 55.7%; relative risk (RR) 1.68; (95% confidence interval (CI) 1.34, 2.11); p<0.0001]. The number of attempts for SGA insertion was similar in groups A and group B [87% vs 90%; RR 1.03; (95% CI-0.92, 1.16); p=0.60]. The times for successful SGA insertion and endotracheal intubation were also similar between the groups. The LMA blockbuster offers a significantly higher success rate for endotracheal intubation without FOB guidance than the Air-Q ILA in adult patients with normal airways. However, an increased success rate was achieved with the use of a specially designed flexible endotracheal tube and maneuvers.

Study of the intensive care unit activity scale in the early rehabilitation of patients after direct cardiac surgery.

Direct cardiac surgery often necessitates intensive post-operative care, and the intensive care unit (ICU) activity scale represents a crucial metric in assessing and guiding early rehabilitation efforts to enhance patient recovery. To clarify the clinical application value of the ICU activity scale in the early recovery of patients after cardiac surgery. One hundred and twenty patients who underwent cardiac surgery between September 2020 and October 2021 were selected and divided into two groups using the random number table method. The observation group was rated using the ICU activity scale and the corresponding graded rehabilitation interventions were conducted based on the ICU activity scale. The control group was assessed in accordance with the routine rehabilitation activities, and the postoperative rehabilitation indexes of the patients in both groups were compared (time of tracheal intubation, time of ICU admission, occurrence of complications, and activity scores before ICU transfer). The two groups were compared according to postoperative rehabilitation indicators (time of tracheal intubation, length of ICU stay, and occurrence of complications) and activity scores before ICU transfer. In the observation group, tracheal intubation time lasted for 18.30 ± 3.28 h and ICU admission time was 4.04 ± 0.83 d, which were significantly shorter than the control group (t-values: 2.97 and 2.038, respectively, P < 0.05). The observation group also had a significantly lower number of complications and adverse events compared to the control group (P < 0.05). Before ICU transfer, the observation group (6.7%) had few complications and adverse events than the control group (30.0 %), and this difference was statistically significant (P < 0.05). Additionally, the activity score was significantly higher in the observation (26.89 ± 0.97) compared to the control groups (22.63 ± 1.12 points) (t-value; -17.83, P < 0.05). Implementation of early goal-directed activities in patients who underwent cardiac surgery using the ICU activity scale can promote the recovery of cardiac function.

Usefulness and safety of new ultrasmall-diameter colonoscope for cases with difficult insertion: a retrospective study

Colonoscopies are widely available, but there are cases where insertion can be difficult, even for experienced endoscopists. EC-760XP/L, a new ultrasmall-diameter long scope, may be useful in such cases. This single-center retrospective study included 39 cases where colonoscope insertion was difficult even when previously conducted by an experienced endoscopist. The primary outcome was the cecal intubation time using EC-760XP/L compared to the time used in a previous examination with a standard scope. The secondary outcomes were the cecum intubation rate, intestinal cleanliness level, adenoma detection rate, polyp detection rate, sedative use rate, occurrence of adverse events, and pain experience. A comparison of cecal intubation times between EC-760XP/L and the standard scope showed that insertion times were significantly lower with EC-760XP/L (9.5 min) compared to the standard scope (19 min) (p < 0.01). The standard scope achieved cecal intubation in 30 cases (76.9%), whereas EC-760XP/L reached the cecum in all cases (p < 0.01). Pain was observed in 3 cases (8.3%) with the EC-760XP/L, which was significantly lower than the 22 cases (56.4%) with the standard scope (p < 0.01). In conclusion, EC-760XP/L proved to be useful in cases where colonoscope insertion was difficult.

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.

Peripheral warming for prevention of hypothermia in small dogs during soft tissue surgery: A randomized controlled trial

ObjectiveTo evaluate the effects of wrapping the extremities of small dogs with table leg covers to prevent hypothermia during anesthesia. Study designRandomized parallel-group study. AnimalsA total of 60 adult dogs with a body mass <15 kg anesthetized for soft tissue surgery. MethodsDogs were randomly assigned to one of two groups. The control group received routine intraoperative thermal support, while the limb-wrapping group had their peripheral limbs covered with table leg covers up to the mid-metacarpal/metatarsal region, in addition to routine thermal support. Rectal temperature during anesthesia was recorded and compared between the two groups. Data analyses were performed using Student’s t-test for rectal temperature, Fisher’s exact test for hypothermia incidence and analysis of covariance for the effect of limb-wrapping while taking other factors into account. ResultsThirty dogs were included per group. Rectal temperature did not differ between the groups at the time of intubation, but it was significantly higher in the limb-wrapping group (36.7 ± 1.0 °C) than in the control group (35.9 ± 0.8 °C) at the end of surgery (p = 0.003). The mean difference was 0.81 °C (95% confidence interval of mean difference 0.33–1.29 °C). The incidence of hypothermia (<37.0 °C) was significantly lower in the limb-wrapping group than in the control group (19/30 versus 28/30 dogs, respectively; p = 0.010). ConclusionsFor dogs with body masses <15 kg, limb-wrapping with table leg covers slowed the reduction in intraoperative rectal temperature. Limb-wrapping is inexpensive and easy to perform, making it a practical method for minimizing hypothermia during anesthesia in small dogs undergoing soft tissue surgery. Clinical relevancePeripheral warming with table leg covers has the potential to reduce hypothermia during soft tissue surgery in small dogs.

A Comparison of Conventional Rotating Method and Non-Rotating Method for Double-Lumen Tube Insertion Using a Customized Rigid J-Shaped Stylet for One-Lung Ventilation: A Randomized Controlled Trial.

Background: The conventional double-lumen tube (DLT) insertion method requires a rotatory maneuver that was developed using direct laryngoscopy and may not be optimal for video laryngoscopy. This study compared a new non-rotatory maneuver with the conventional method for DLT insertion using video laryngoscopy. Methods: Patients scheduled for thoracic surgery requiring one-lung ventilation were randomly assigned to either the rotating (R) or non-rotating (NR) method groups. All patients were intubated using a customized rigid J-shaped stylet, a video laryngoscope, and a left-sided silicone DLT. The conventional rotatory maneuver was performed in the R group. In the NR group, the stylet was inserted with its tip oriented anteriorly (12 o'clock direction) while maintaining the bronchial lumen towards the left (9 o'clock direction). After reaching the glottic opening, the tube was inserted using a non-rotatory maneuver, maintaining the initial orientation. The primary endpoint was the intubation time. Secondary endpoints included first-trial success rate, sore throat, hoarseness, and airway injury. Results: Ninety patients (forty-five in each group) were included. The intubation time was significantly shorter in the NR group compared to the R group (22.0 [17.0, 30.0] s vs. 28.0 [22.0, 34.0] s, respectively), with a median difference of 6 s (95% confidence interval [CI], 3-11 s; p = 0.017). The NR group had a higher first-attempt success rate and a lower incidence of sore throats. Conclusions: The non-rotatory technique with video laryngoscopy significantly reduced intubation time and improved first-attempt success rate, offering a viable and potentially superior alternative to the conventional rotatory technique.

Timing of intubation and clinical outcomes in critically ill COVID-19 patients with respiratory failure

Timing of intubation and clinical outcomes in critically ill COVID-19 patients with respiratory failure

Magnesium as an Adjuvant to Rocuronium to Improve Intubation Conditions and Shorten the Intubation Time: A Randomized Controlled Study.

The purpose of the study is to compare the effects of rocuronium priming with the combined technique of magnesium pretreatment and rocuronium priming and to investigate whether this pretreatment could further accelerate the onset of neuromuscular blockade during intubation. A double-blinded randomized controlled trial (RCT) clinical study was done on patients at a tertiary care center for six months after obtaining approval from the institutional ethical committee. A total of 150 patients were randomly allocated as Group MP (infusion of 50 mg/kg of MgSo4 over 10 min was given 10 mins prior to premedication and dose of rocuronium 0.06 mg/kg given three minutes), Group P (priming dose of rocuronium 0.06 mg/kg given three minutes before the intubating dose), and Group C (control group with the same volume of 0.9% saline and rocuronium bolus of 0.6 mg/kg on intubation). Parameters such as demographic and hemodynamical data, American Society of Anesthesiologists (ASA) score, Mallampati scoring, neuromuscular monitoring, intubation grading, and number of successful/failed attempts were recorded. Our results showed that Group MP had a rapid onset of action of rocuronium with 58.90 +/- 4.77 seconds and a longer duration of action of rocuronium with 54.92 +/- 10.39 minutes, which are statistically significant compared to Group P (onset of action of ROC 106.70 +/- 4.24 seconds and duration of action rocuronium 45.88 +/- 6.22 minutes) and Group C (onset of action of ROC 154.56 +/- 11.39 seconds and duration of ROC 40.56 +/- 3.96 minutes). The maximum number of patients in Group MP (33 patients) showed good intubation conditions compared to Group P (23 patients) and Group C (16 patients), which was statistically significant. We conclude that magnesium sulfate pretreatment in combination with rocuronium priming (Group MP) considerably accelerates the onset of rocuronium action, increases the duration of action of rocuronium, and enhances the intubation procedure without any adverse effect of rocuronium and magnesium sulfate.

Incidence of post-extubation dysphagia among critical care patients undergoing orotracheal intubation: a systematic review and meta-analysis

BackgroundPost-extubation dysphagia (PED) emerges as a frequent complication following endotracheal intubation within the intensive care unit (ICU). PED has been strongly linked to adverse outcomes, including aspiration, pneumonia, malnutrition, heightened mortality rates, and prolonged hospitalization, resulting in escalated healthcare expenditures. Nevertheless, the reported incidence of PED varies substantially across the existing body of literature. Therefore, the principal objective of this review was to provide a comprehensive estimate of PED incidence in ICU patients undergoing orotracheal intubation.MethodsWe searched Embase, PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science, Technology Journal Database (VIP), and SinoMed databases from inception to August 2023. Two reviewers independently screened studies and extracted data. Subsequently, a random-effects model was employed for meta-statistical analysis utilizing the “meta prop” command within Stata SE version 15.0 to ascertain the incidence of PED. In addition, we performed subgroup analyses and meta-regression to elucidate potential sources of heterogeneity among the included studies.ResultsOf 4144 studies, 30 studies were included in this review. The overall pooled incidence of PED was 36% (95% confidence interval [CI] 29–44%). Subgroup analyses unveiled that the pooled incidence of PED, stratified by assessment time (≤ 3 h, 4–6 h, ≤ 24 h, and ≤ 48 h), was as follows: 31.0% (95% CI 8.0–59.0%), 28% (95% CI 22.0–35.0%), 41% (95% CI 33.0–49.0%), and 49.0% (95% CI 34.0–63.0%), respectively. When sample size was 100 < N ≤ 300, the PED incidence was more close to the overall PED incidence. Meta-regression analysis highlighted that sample size, assessment time and mean intubation time constituted the source of heterogeneity among the included studies.ConclusionThe incidence of PED was high among ICU patients who underwent orotracheal intubation. ICU professionals should raise awareness about PED. In the meantime, it is important to develop guidelines or consensus on the most appropriate PED assessment time and assessment tools to accurately assess the incidence of PED.Graphical abstract

Comparison of AirAngel® vs. Storz® videolaryngoscope and Macintosh® laryngoscope for endotracheal intubation training: prospective randomized crossover study

BackgroundFor both normal and difficult airway management, VL is thought to be more effective. However, VL seems far from being offered as a standard option in both healthcare delivery and educational activities in low-income countries, considering its high costs. Therefore, three-dimensional(3D)printed VLs may be considered an alternative to conventional VLs in low-income countries and other places with limited resources. Our objective was to compare the efficacy of AirAngel 3D-printed VL (3D-PVL) with those of commercially available Storz® VL (SVL) and conventional Macintosh® laryngoscope (MCL) in normal and difficult airway scenarios in the hands of inexperienced users.MethodsThis is a prospective randomized crossover manikin study that included 126 senior medical students with no experience in intubation. The effectiveness of all three laryngoscopy devices in the hands of inexperienced users was evaluated in terms of intubation time, glottic visualization, ease of use, endotracheal tube placement, and intubation success rate. Between 2020 and 2022, 126 last year medical students participated in the study.ResultsMCL resulted in significantly longer intubation times than 3D-PVL and SVL in the difficult airway scenario, with no significant difference between 3DPVL and SVL (Wilcoxon test, p < 0.016; Bonferroni correction MCL: 28.54 s; SVL: 26.68 s; 3DPVL: 26.64 s). Both SVL and 3D-PVL resulted in significantly better Cormack − Lehane grades in both normal and difficult airway scenarios, and thus provided better glottic viewing than MCL, with no significant difference between 3D-PVL and SVL (Wilcoxon test, p < 0.016; Bonferroni correction, MCL: 1.73; SVL: 1.29; 3DPVL: 1.25). The SVL was the easiest device to use for normal airway scenarios (1: very easy, 5: very difficult), while the MCL was the most difficult (MCL: 2.64; 3DPVL: 1.98; SVL: 1.49). Conversely, no significant difference was found between 3DPVL and other devices in terms of ease of use in difficult airway scenarios and in terms of accurate placement of the endotracheal tube and successful intubation attempts.Conclusion3D-PVL is a good educational and possible clinical alternative to conventional VL, particularly in places with limited resources, due to its low cost.

Flow-mediated dilation facilitates radial artery cannulation in patients undergoing intravenous general anesthesia: A prospective randomized controlled trial.

Flow-mediated dilation (FMD) is commonly used as a diagnostic tool to assess endothelial function, and compared with other methods for stimulating radial artery dilation, FMD offers several advantages such as non-invasiveness, ease of execution, minimal equipment requirements, and negligible risk. The study aimed to investigate the effect of FMD in facilitating radial arterial cannulation in the context of intravenous general anesthesia. Eighty patients undergoing intravenous general anesthesia and requiring radial artery cannulation were randomized 1:1 to the FMD group and control group. Patients in the FMD group received an upper arm occlusion for 5 min after anesthesia induction, and the cuff was placed without inflation for the equivalent duration in the control group. The primary outcome was first-attempt success rate. Secondary outcomes were the diameter and percentage of dilation of radial artery, overall success rate, total number of attempts, cannulation time, and occurrence of procedure-related complications. Intravenous anesthetic agents significantly dilated the radial artery (p < 0.05), which was further increased by FMD. An increase in both the first-attempt and overall success rate of radial artery cannulation was demonstrated with the use of FMD (67.5% vs 42.5%, p < 0.05). The total number of attempts needed to cannulate the radial artery was reduced in the FMD group as compared with the control group (p < 0.05), but no differences in cannulation time and procedure-related complications were found between the two groups (p > 0.05). FMD induced by a 5-min upper arm occlusion may facilitate radial artery cannulation in patients undergoing intravenous general anesthesia.

Feasibility of veno-arterial extracorporeal life support in awake patients with cardiogenic shock.

This study sought to demonstrate outcomes of veno-arterial extracorporeal life support (VA-ECLS) in non-intubated ("awake") patients with cardiogenic shock, as very few studies have investigated safety and feasibility in this population. This was a retrospective review of 394 consecutive VA-ECLS patients at our institution from 2017 to 2021. We excluded patients cannulated for indications definitively associated with intubation. Patients were stratified by intubation status at time of cannulation and baseline differences were balanced by inverse probability of treatment weighting. The primary outcome was in-hospital mortality while secondary outcomes included adverse events during ECLS and destination at discharge. Out of 135 patients in the final cohort, 79 were intubated and 56 were awake at time of cannulation. All awake patients underwent percutaneous femoral cannulation with technical success of 100% without intubation. Indications for VA-ECLS in awake patients included acute decompensated heart failure (64.3%), pulmonary hypertension or massive pulmonary embolism (12.5%), myocarditis (8.9%), and acute myocardial infarction (5.4%). After adjustment, awake and intubated patients had similar ECLS duration (7 vs 6 days, p = 0.19), in-hospital mortality (39.6% vs 51.7%, p = 0.28), and rates of various adverse events. Intubation status was not a significant risk factor for 90-day mortality (HR [95% CI]: 1.26 [0.64, 2.45], p = 0.51) in multivariable analysis. Heart transplantation (15.1% vs 4.9%) and ventricular assist device (17.4% vs 2.2%) were more common destinations at discharge in awake patients than intubated patients (p = 0.02). Awake VA-ECLS is safe and feasible with comparable outcomes as intubated counterparts in select cardiogenic shock patients.

Timely administration of sodium citrate for cesarean delivery under general anesthesia: A retrospective analysis

Study objectiveThe ASA practice guidelines for obstetric anesthesia recommend timely administration of nonparticulate antacids before cesarean delivery to minimize risks with aspiration. The median duration of action for sodium citrate is 30 min. This study aimed to determine the timeliness of sodium citrate administration by evaluating the time between sodium citrate administration and intubation, and whether time differences exist between planned versus unplanned general anesthetics (GAs) for cesarean delivery. DesignThis was an IRB approved single center retrospective analysis of electronic medical records for all patients undergoing general anesthesia for cesarean delivery in the year 2017. Patients81 medical records of patients undergoing cesarean delivery with general anesthesia. MeasurementsThe time of sodium citrate administration, time of intubation, indication for GA, and aspiration events were extracted. Planned general anesthetics were defined as anesthetics that were carried out in the primary modality intended by the provider. The primary study outcome was the time interval between sodium citrate administration and intubation. Data were stratified by whether the general anesthetic was planned or unplanned. Main resultsOf 3014 cesarean deliveries, 81 patients underwent GA (2.7%). Sixty-seven patients received sodium citrate before intubation (83%). The median time from sodium citrate administration to intubation for planned GAs was 8 min (interquartile range, [IQR]: 5–19 min), whereas the median time for unplanned GAs was 37.5 min (IQR: 15–62 min) (P < 0.0001). There were no aspiration events. ConclusionsThe interval between sodium citrate administration and intubation exceeds the median duration of action (30 min) in unplanned general anesthetics. Timing of sodium citrate administration for unplanned GAs may occur outside the window of drug efficacy. Consideration should be given to administering sodium citrate prior to intubation, as opposed to prior to OR transfer, with the goal of avoiding a prolonged interval between administration and intubation.