Median Intubation Time Research Articles

In Response.

We read with great interest the letter by Priebe1 regarding our review of the use of cricoid pressure (CP).2 While many of the points1 actually reiterate, not dispute, our original conclusions, we again underscore the purpose for our review, stated clearly in our opening paragraph: “[w]e therefore review the available scientific [emphasis added] evidence of the effectiveness and safety of CP…”. We are well aware that clinical care standards vary immensely.2 We also recognize that Germany has largely abandoned CP use in clinical practice3,4 and that the author himself is a strong advocate against CP use.5 Alternatively, other experts strongly defend this procedure.6 One issue that requires clarification is Priebe’s reference to the Sellick Interest in Rapid Sequence Induction (IRIS) randomized trial and the intubation difficulty posed by CP.7 We reanalyzed the original IRIS trial data of Cormack-Lehane scores. We used χ2 test, which yields significant P values in large sample sizes.8 We herein report Cramer’s V of 0.09 as the strength of association measure,9 suggesting a weak association between CP and higher Cormack-Lehane scores. Moreover, operators were asked to release CP in only 14% of CP cases and in 5% of sham group, improving the glottic view in 62% and 33% of cases, respectively.7 The sham group reported improvement in Cormack-Lehane score after sham interruption,7 likely reflecting the assessors’ anticipation of CP use. We suggest that most of the experienced operators could detect CP at laryngoscopy, while the sham itself is likely to be readily guessed (more frequently than by chance) by the operators, making them more likely to report an improved view after its release. In clinically relevant outcomes, the groups did not differ in the number of attempts at intubation or arterial oxygen desaturation, and median intubation times were similar (27 seconds in CP group and 23 seconds in sham group); a 4-second difference is statistically significant7 but not clinically relevant.10 The IRIS trial concluded, “… the interference of the CP with airway control has previously been overestimated.” Moreover, a “…significant increase in the incidence of difficult tracheal intubation…” was not observed, as Priebe1 suggested. From an evidence-based medicine point of view, the IRIS (noninferiority) study7 was severely underpowered. This limitation is acknowledged in the accompanying editorial: “the noninferiority of withholding CP could not be proven because of the overall lower-than-expected incidence of aspiration.”11 Therefore, there is no evidence-based foundation for the selective (and likely erroneous) interpretation, “the study nevertheless documents lack benefit of the application of CP with simultaneous interference with optimal airway management.”1 Alternatively, we would be remiss if we did not also acknowledge study’s tremendous value, as it is the first study granted ethical permission not to use CP during rapid sequence intubation in patients. We continue to recommend that investigators use previous findings effectively in planned research designs, and include generally accepted indicators such as percent of glottic opening score,12,13 upper lip bite test (which has the highest sensitivity for diagnosing difficult laryngoscopy),14 and modified Mallampati test (which has the highest sensitivity for diagnosing difficult tracheal intubation),14 none of which were used in the IRIS study.7 With strong opinions on either side of the argument,1,6 we believe we provided a balanced review of current evidence on CP use, and we are not surprised that our article2 incited controversy. We sincerely hope the debate will galvanize future researchers to provide definitive evidence that can then be translated into guidelines, rather than the consensus opinions that drive current clinical care. Marko Zdravkovic, MDDepartment of Anaesthesiology,Intensive Care and Pain ManagementUniversity Medical Centre MariborMaribor, SloveniaFaculty of MedicineMaribor, Slovenia Mark J. Rice, MDDepartment of AnesthesiologyVanderbilt University Medical CenterNashville, Tennessee Sorin J. Brull, MD, FCARCSI (Hon)Department of Anesthesiology and Perioperative MedicineMayo Clinic College of Medicine and ScienceJacksonville, Florida[email protected]

Comparison of conventional C-MAC video laryngoscope guided intubation by anesthesia trainees with and without Frova endotracheal introducer: A randomized clinical trial.

Background and Aims:Successful intubation with video laryngoscopes necessitates good hand-eye coordination and the use of intubation adjuncts like bougie and stylet. We proposed this study to find whether using Frova introducer with C-MAC video laryngoscope will reduce the intubation time in trainee anesthesiologists.Material and Methods:We enrolled 140 adults without any difficult airway predictors. They were randomly assigned to undergo C-MAC video laryngoscope guided intubation by anesthesia residents using tracheal tube preloaded over Frova introducer (n = 70) or without Frova introducer (n = 70). Primary outcome was the intubation time. Secondary outcomes were the number of redirections of tracheal tube or Frova introducer toward glottis, need for external laryngeal maneuvers (ELMs), first attempt intubation success rate, and ease of intubation.Results:The median actual intubation time (IQR) in Frova and non-Frova group, respectively, were 25.46 (28.11–19.80) and 19.96 (26.59–15.52) s (P = 0.001). The number of redirections of TT or Frova introducer toward glottis, first attempt success rate, and ease of intubation were comparable. The need for ELMs [n (%)] was 15 (21.4) and 26 (37.1) in Frova and non-Frova group, respectively (P = 0.04).Conclusion:Frova introducer guided endotracheal intubation with C-MAC videolaryngoscope in patients with normal airways had a marginally prolonged intubation time with a significant reduction in the need of external laryngeal manoeuvres but with a comparable number of redirections and attempts. Further research is needed to generalize these findings to patients with difficult airways.

Is Video Laryngoscopy the Optimal Tool for Successful Intubation in a Neonatal Simulation Setting? A Single-Center Experience.

Background Endotracheal intubation is a skill required for resuscitation. Due to various reasons, intubation opportunities are decreasing for health care providers. Objective To compare the success rate of video laryngoscopy (VL) and direct laryngoscopy (DL) for interprofessional neonatal intubation skills in a simulated setting. Methods This was a prospective nonrandomized simulation crossover trial. Twenty-six participants were divided into three groups based on their frequency of intubation. Group 1 included pediatric residents; group 2 respiratory therapists and transport nurses; and group 3 neonatal nurse practitioners and physicians working in neonatology. We compared intubation success rate, intubation time, and laryngoscope preference. Results Success rates were 100% for both DL and VL in groups 1 and 2, and 88.9% for DL and 100% for VL in group 3. Median intubation times for DL and VL were 22 seconds (interquartile range [IQR] 14.3–22.8 seconds) and 12.5 seconds (IQR 10.3–38.8 seconds) in group 1 ( p = 0.779); 17 seconds (IQR 8–21 seconds) and 12 seconds (IQR 9–16.5 seconds) in group 2 ( p = 0.476); and 11 seconds (IQR 7.5–15.5 seconds) and 15 seconds (IQR 11.5–36 seconds) in group 3 ( p = 0.024). Conclusion We conclude that novice providers tend to perform better with VL, while more experienced providers perform better with DL. In this era of decreased clinical training opportunities, VL may serve as a useful tool to teach residents and other novice health care providers.

Percutaneous tracheostomy for long-term ventilated COVID-19-patients: rationale and first clinical-safe for all-experience.

COVID-19 infection has resulted in thousands of critically ill patients admitted to ICUs and treated with mechanical ventilation. Percutaneous tracheostomy is a well-known technique utilised as a strategy to wean critically ill patients from mechanical ventilation. Worldwide differences exist in terms of methods, operators, and settings, and questions remain regarding timing and indications. If tracheostomy is to be performed in COVID-19 patients, a safe environment is needed for optimal care. We present a guidewire dilating forceps tracheostomy procedure in COVID-19 patients that was optimised including apnoea-moments, protective clothing, checklists, and clear protocols. We performed a retrospective analysis of the outcome after tracheostomy in COVID-19 patients between March 2020 and May 2020. The follow-up of the first 16 patients, median age 62 years, revealed a median intubation time until tracheostomy of 18 days and median cannulation time of 20 days. The overall perioperative complication rate and complication rate while cannulated was 19%, mainly superficial bleeding. None of the healthcare providers involved in performing the procedure developed any symptoms of the disease. This COVID-19-centred strategy based on flexibility, preparation, and cooperation between healthcare providers with different backgrounds facilitated percutaneous tracheostomy in COVID-19 patients without an increase in the overall complication rate or evidence of risk to healthcare providers. Our findings provide initial evidence that tracheostomy can be performed safely as a standard of care for COVID-19 patients requiring prolonged mechanical ventilation as was standard practice in ICU patients prior to the COVID-19 pandemic to promote ventilator weaning and patient recovery.

Efficacy of Novel Ultrathin Single-Balloon Enteroscopy for Crohn's Disease: A Propensity Score-Matched Study.

Background/AimsThe evaluation of small bowel lesions of Crohn’s disease (CD) using balloon-assisted enteroscopy (BAE) is crucial because mucosal healing is associated with a good prognosis. However, BAE procedures are invasive, requiring sedation or analgesia to reduce the patient’s pain. This study evaluated the clinical usefulness of a novel ultrathin single-balloon enteroscopy (SBE) procedure for CD.MethodsThis single-center retrospective study included 102 CD patients who underwent trans-anal SBE between January 2012 and May 2018. Of these patients, 82 underwent enteroscopy using conventional SBE, while 20 underwent ultrathin SBE. Patients were analyzed using propensity score matching, with 20 patients per group. The median duration of the examination, terminal ileum intubation rate, median cecum intubation time, median insertion depth, adverse events, and sedated dose in each group were compared.ResultsBefore propensity score matching, the conventional SBE group had a larger number of surgical history patients than the ultrathin SBE group (p=0.05). After matching, the two groups did not significantly differ clinically. There were no significant differences in the mean duration of the examination, cecum intubation time, or terminal ileal intubation rate between ultrathin SBE and conventional SBE. The mean insertion depth of ultrathin SBE tended to be deeper than that of conventional SBE (p=0.09). The use of ultrathin SBE also reduced the sedative dose during needed for enteroscopy compared with conventional SBE (p=0.005).ConclusionsNovel ultrathin SBE may be less painful for CD patients than conventional SBE.

Comparison of Different Intubation Methods in Difficult Airways during Simulated Cardiopulmonary Resuscitation with Continuous Chest Compression: A Randomized Cross-Over Manikin Trial

Introduction Airway management is one of key elements of resuscitation. Endotracheal intubation is still considered the gold standard for airway management during resuscitation. Aim The aim of the study was to compare success rates and intubation time of different endotracheal intubation methods during emergency intubation with difficult airways in the conditions of cardiopulmonary resuscitation in a standardized manikin model. Methods The study was designed as a prospective, randomized, cross-over simulation study. It involved 46 paramedics with at least 5 years of experience in Emergency Medical Service. The participants performed endotracheal intubation under difficult airway conditions during continuous chest compression, implemented with the LUCAS3 chest compression system. Three methods of tracheal intubation were applied: (1) standard Macintosh laryngoscope without a bougie stylet; (2) standard laryngoscope and a standard bougie stylet; (3) standard laryngoscope and a new bougie stylet. Results The overall intubation success rate was 100% in the standard bougie and new bougie groups and lower (86.9%) when no bougie stylet was used (P=0.028). The intubation success rate with the 1st attempt equalled 91.3% for the new bougie group, 73.9% for standard bougie, and only 23.9% in the no-bougie group. The median intubation time was shortest in the new bougie group, where it amounted to 29 s (interquartile range [IQR]: 25–38); the time equalled 38s (IQR:31–44.5) in the standard bougie group and 47.5s (IQR:36–58) in the no-bougie group. The ease of use was lowest in the no-bougie group (85, IQR:63–88), average in the standard bougie group (44, IQR:30–51), and highest in the new bougie stylet group (32, IQR:19–41). Conclusion In this manikin-based study, paramedics were able to perform endotracheal intubation with higher efficacy and in a shorter time using the new bougie stylet as compared with the standard bougie stylet.

Pediatric Tracheal Surgery: A 25-Year Review of Slide Tracheoplasty and Tracheal Resection

The purpose of this study was to assess the outcomes of slide tracheoplasty and tracheal resection in pediatric patients and analyze the data for predictors of outcomes. A retrospective review of tracheal surgery from January 1, 1993 to May 1, 2018 was performed. Demographic data, operative details, perioperative data, and clinical outcomes were collected. The study investigators' management strategy has evolved over time, with less rigid bronchoscopy, more reliance on postoperative computed tomographic imaging, and the use of inhaled Ciprodex (combination of ciprofloxacin and dexamethasone) since2007. The study included 41 patients, with a median age of 4.1 months and a median weight of 4.2 kg. There were 6 neonates and 24 infants. Slide tracheoplasty was performed in 27 patients (66%), and resection with end-to-end anastomosis was performed in 14 (34%). Eleven patients (27%) had a pulmonary artery sling. Simultaneous intracardiac repairs requiring cross-clamp and cardioplegia were performed in 9 patients (22%). Lung agenesis (n= 6) or severe hypoplasia (n= 2) was present in 8 patients (20%). Complications included tracheostomy in 5 patients (12%) and in-hospital death in 3 patients (7%). There were no cases of mediastinitis. Inhaled Ciprodex was used to decrease granulation tissue at suture lines. Median intubation time was 7 days, and median length of stay was 25.0 days. There was no difference in outcomes when comparing intracardiac repairs with the remaining patients, lung agenesis or hypoplasia vs the remaining cohort, or neonates vs infants. Slide tracheoplasty and tracheal resection are effective operative strategies for infants and children with tracheal stenosis, including patients with lung agenesis/hypoplasia. Simultaneous repair of intracardiac anomalies and pulmonary artery sling is recommended.

Comparison of Miller laryngoscope and UEScope videolaryngoscope for endotracheal intubation in four pediatric airway scenarios: a randomized, crossover simulation trial

With different videolaryngoscopes for pediatric patients available, UEScope can be used in all age groups. The aim of this study was to compare the Miller laryngoscope and UEScope in pediatric intubation by paramedics in different scenarios. Overall, 93 paramedics with no experience in pediatric intubation or videolaryngoscopy performed endotracheal intubation in scenarios: (A) normal airway without chest compressions, (B) difficult airway without chest compressions, (C) normal airway with uninterrupted chest compressions, (D) difficult airway with uninterrupted chest compressions. Scenario A. Total intubation success with both laryngoscopes: 100%. First-attempt success: 100% for UEScope, 96.8% for Miller. Median intubation time for UEScope: 13 s [IQR, 12.5–17], statistically significantly lower than for Miller: 14 s [IQR, 12–19.5] (p = 0.044). Scenario B. Total efficacy: 81.7% for Miller, 100% for UEScope (p = 0.012). First-attempt success: 48.4% for Miller, 87.1% for UEScope (p = 0.001). Median intubation time: 27 s [IQR, 21–33] with Miller, 15 s [IQR, 14–21] with UEScope (p = 0.001). Scenario C. Total efficiency: 91.4% with Miller, 100% with UEScope (p = 0.018); first-attempt success: 67.7 vs. 90.3% (p = 0.003), respectively. Intubation time: 21 s [IQR, 18–28] for Miller, 15 s [IQR, 12–19.5] for UEScope. Scenario D. Total efficiency: 65.6% with Miller, 98.9% with UEScope (p < 0.001); first-attempt success: 29.1 vs. 72% (p = 0.001), respectively. Intubation time: 38 s [IQR, 23–46] for Miller, 21 s [IQR, 17–25.5] for UEScope.Conclusion: In pediatric normal airway without chest compressions, UEScope is comparable with Miller. In difficult pediatric airways without chest compressions, UEScope offers better first-attempt success, shorted median intubation time, and improved glottic visualization. With uninterrupted chest compressions in normal or difficult airway, UEScope provides a higher first-attempt success, a shorter median intubation time, and a better glottic visualization than Miller laryngoscope.What is Known:• Endotracheal intubation is the gold standard for adult and children airway management.• More than two direct laryngoscopy attempts in children with difficult airways are associated with a high failure rate and increased incidence of severe complications.What is New:• In difficult pediatric airways with or without chest compressions, UEScope in inexperienced providers in simulated settings provides better first-attempt efficiency, median intubation time, and glottic visualization.

Multimodal Prehabilitation in Patients Listed for Heart Transplantation: A Pilot Study

Purpose To assess the effect of multimodal prehabilitation in patients listed for heart transplantation (HT) Prehabilitation programs that combine physical training, nutritional support and emotional reinforcement have been effective in increasing functional capacity and preventing postoperative complications in selected high risk surgical populations Methods Adult patients listed for HT were included. Exclusion criteria were hospitalized/unstable patients and lack of availability for going to the hospital for 2 times a week. Patients were evaluated before and after completing 8 weeks of prehab program. The intervention consisted on exercise training, nutritional counseling and protein supplementation, respiratory physiotherapy and mindfulness therapy. The exercise training consisted in 2 1-hour sessions/week of personalized monitored and supervised moderate-intensity interval training and endurance strength training at the hospital outpatient gym facility during 8 weeks. After 8 weeks, and until HT, patients followed a mixed maintenance program (1 session/week of supervised training) and were encouraged to keep their physical activity. Results 14 patients were included from July 2017 to October 2018 (12M/2F, Age 53±10yr-old). One patient was transplanted before the program was started. 7 patients completed the 8wks-intensive phase program and were re-assessed and 2 patients are still in the intensive phase. The 4 remaining ones received transplantation before completing the program. 5 patients enrolled in the program were successfully transplanted (median time of intubation=16h (6-19); median hospital stay=15 days (14-17). The median duration of the program was 72 days (range 14-452). One patient asked to opt out from the HT waiting list since symptomatology improved. No cardiac events occurred during the program. Conclusion Multimodal prehabilitation program in patients awaiting HT seems feasible, safe and might increase exercise tolerance, functional capacity and quality of life.

INTERMACS 3 and 4 Patients Have Excellent Outcomes after Complete Sternal-Sparing HeartMate 3 Implantation

Purpose The purpose of this study was to evaluate early outcomes for INTERMACS Profile 3 and 4 patients implanted with the complete sternal-sparing Heartmate 3 surgical technique. Methods Retrospective analysis of prospectively collected data was performed on 53 consecutive patients implanted with left ventricular assist devices between February and September 2018 at a single institution. Patients were excluded if they were enrolled in a study requiring full sternotomy (3 patients), underwent pump exchange (5 patients), or were implanted with the HeartWare device (4 patients). Early clinical outcomes and survival at 30-days were evaluated for all INTERMACS Profile 3 and 4 patients. Results Of the 41 total patients, 18 (44%) were INTERMACS 3 or 4 at time of implantation and were included in this study. All patients underwent complete sternal-sparing HeartMate3 implantation with no conversions to full sternotomy. Average age was 54.6 ±16.1 years and 67% were male (Table). One patient (6%) returned to the operating room for bleeding. No patients required RVAD support. Median intubation time was 16 [IQR=7-34] hours. Median intensive care unit and hospital length of stay were 3 [IQR=2-4] days and 14 [IQR=12-18] days, respectively. One patient (6%) was readmitted within 30-days for gastrointestinal bleeding. Thirty-day survival was 100% (18/18). Conclusion In our single center experience, complete sternal-sparing HeartMate 3 implantation of INTERMACS 3 and 4 patients is safe with a low complication rate and excellent perioperative outcomes. Multicenter studies are required to further validate this less invasive surgical technique.

Donor-Bound Predictors for Primary Graft Function in Lung Transplantation - Results from a Prospective Multicenter Study

Purpose Acceptance rates of donor lungs differ substantially among transplant centers. This is mainly due to a lack of standardized functional parameters of the donor lungs, which can predict organ function after lung transplantation (LTx). Methods A prospective evaluation of lung donors were performed in three transplant centers between January 2017 and September 2018. Standardized ventilation settings were used to collect respiratory and hemodynamic parameters at the time of retrieval. Duration of mechanical ventilation after lung transplantation was defined as the primary end-point. Results A total of 151 lung donors were included in the study. Median donor age was 46 (12-80), median intubation time was 3 days (1-34), 44 (29.1%) donors had smoking history and 19 (12.6%) had chest trauma. At time of retrieval median P/F ratio was 413 mmHg (79-650), median dynamic compliance 45 ml/mbar (14-121) and median pCO2 40 (19-77). In 10 (6.6%) cases, purulent secretions were found during bronchoscopy. In 6 (3.9%) cases evaluation with EVLP followed organ retrieval. Median recipient age was 55 (18-69). The indications for LTx were: COPD (n=61, 40.4%), CF (n=38, 25.2%) and ILD (n=30, 19.9%). Median length of mechanical ventilation was 32 hours (range: 4 - 964). At 72 hours only 1 (0.7%) PGD grade 3 was recorded. P/F ratio at time of offer, donor intubation time, smoking history, donor age, P/F ratio and peak pressure at time of retrieval did not correlate with recipient length of mechanical ventilation and hospitalization time. On the contrary, dynamic compliance at the time of retrieval correlated inversely with recipient weaning time (rs= - 0.199, p Conclusion In this multicenter analysis of lung donor parameters and their relevance for early post-transplant outcome, we found that dynamic compliance of donor lungs was the only factor associated with recipient weaning and hospitalization time. This parameter may have the potential to improve organ selection and subsequently increase the donor pool.

Less Invasive HeartMate 3 Implantation is Safe and Reproducible with Excellent Outcomes

Purpose The purpose of this study was to analyze early outcomes, safety and reproducibility of the less invasive HeartMate 3 implantation technique. Methods Retrospective review of prospectively collected data was performed on 53 consecutive patients implanted with left ventricular assist devices between February and September 2018 at a single institution. Patients were excluded if they were enrolled in a study requiring full sternotomy (3 patients), were a pump exchange (5 patients) or were implanted with the HeartWare device (4 patients). Safety outcomes included return to the operating room and overall survival. Results A total of 41 patients were included in the study. Thirty-nine patients were implanted with the complete sternal-sparing technique while two had an upper hemi-sternotomy with small left anterior thoracotomy. Average age was 53.6±13.9 years, 76% were male and 41% were INTERMACS Profile 1. Twelve patients (29%) had a right ventricular stoke work index less than 400. Nine patients (22%) were implanted off VA ECMO and 10 patients (24%) had previous cardiac surgery. All patients that qualified for the procedure were implanted using a less invasive technique. No patients required conversion to full sternotomy. Two patients (5%) returned to the operating room for bleeding. Twenty patients (49%) received a perioperative packed red blood cell transfusion within 24 hours of surgery. Median blood loss in the first 24-hours was 1042 mL (IQR=768-1307 mL). 2 patients (5%) requiring RVAD support. Median intubation time was 16 hours (IQR=9-34 hours). Median intensive care unit and hospital length of stay were 4 days (IQR=2-6 days) and 15.5 days (IQR=12-23 days), respectively. Thirty-day survival was 39/41 (95%). Conclusion Less invasive HeartMate 3 implantation in our single center setting is safe and reproducible with excellent outcomes. Multicenter studies are required to further validate this technique.

The Clarus Video System (Trachway) and direct laryngoscope for endotracheal intubation with cricoid pressure in simulated rapid sequence induction intubation: a prospective randomized controlled trial

BackgroundDuring an emergency endotracheal intubation, rapid sequence induction intubation (RSII) with cricoid pressure (CP) is frequently implemented to prevent aspiration pneumonia. We evaluated the CVS in endotracheal intubation in RSII with CP, in comparison with a direct laryngoscope (DL).MethodsOne hundred fifty patients were randomly assigned to one of three groups: the CVS as a video stylet (CVS-V) group, the CVS as a lightwand (CVS-L) group and DL group. Primary outcomes were to assess the power of the CVS, compared with DL, regarding the first attempt success rate and intubation time in simulated RSII with CP. Secondary outcomes were to examine hemodynamic stress response and the incidence of complications.ResultsThe first attempt success rates within 30 s and within 60 s were higher in CVS-V and DL group than those in CVS-L group (p = 0.006 and 0.037, respectively). The intergroup difference for intubation success rate within 30 s was nonsignificant and almost all the patients were successfully intubated within 60 s (98% for CVS-L and DL group, 96% for CVS-L group). Kaplan-Meier estimator demonstrated the median intubation time was 10.6 s [95% CI, 7.5 to 13.7] in CVS-V group, 14.6 s [95% CI, 11.1 to 18.0] in CVS-L group and 16.5 s [95% CI, 15.7 to 17.3] in DL group (p = 0.023 by the log-rank test). However, the difference was nonsignificant after Sidak’s adjustment. The intergroup differences for hemodynamic stress response, sore throat and mucosa injury incidence were also nonsignificant.ConclusionsThe CVS-D and DL provide a higher first attempt intubation success rate within 30 and 60 s in intubation with CP; the intubation time for the CVS-V was nonsignificantly shorter than that for the other two intubation methods. Almost all the patients can be successfully intubated with any of the three intubation methods within 60 s.Trial registrationClinicalTrials.gov identifier: NCT03841890, registered on February 15, 2019 (retrospectively registered).

A comparison of the Macintosh laryngoscope, McGrath video laryngoscope, and Pentax Airway Scope in paediatric nasotracheal intubation

We evaluated the performance of the McGrath video laryngoscope and Pentax Airway Scope in comparison with the Macintosh laryngoscope for nasotracheal intubation in paediatric patients. For this, 108 patients were enrolled in an open-label, randomized controlled trial. Patients were randomly allocated to one of three groups based on use of the Macintosh laryngoscope, McGrath video laryngoscope, or Pentax Airway Scope. Time to intubation, the intubation difficulty, and the quality of navigation were compared among groups. The median nasotracheal intubation time [interquartile range] in the Macintosh group (33.5 [28.3–39.8] s) was significantly shorter than those of the McGrath (39.0 [32.0–43.0] s) and Pentax groups (43.0 [35.0–52.0] s). The difficulty of nasotracheal intubation was similar among all groups. When navigating and aligning the tube from the oropharynx into the glottic inlet, the cuff inflation method was required in significantly fewer patients for the Macintosh group (11.1%) than for the McGrath (48.6%) and Pentax (51.4%) groups. Thus, compared to the McGrath video laryngoscope and Pentax Airway Scope, the Macintosh laryngoscope allowed shorter nasotracheal intubation times and better facilitated tracheal navigation, requiring less use of the cuff inflation method to navigate the tracheal tube into the glottic inlet.

RF52 MITRAL VALVE SURGERY IN OBESES: MINIMALLY INVASIVE COULD BE BETTER

Objective: obesity is become an important health problem in the Western world. The feasibility and efficacy of mitral surgery in very obese patients are controversial especially because of high risk of respiratory, infectious and wond complications. Methods: Between 1/2006 and 2/2018, 106 patients with BMI≥30 underwent minimally invasive MV surgery (9.0% of 1175): male were 50%, mean age was 63.4 ± 11.3, mean Euroscore was 6.3 ± 3.5 and Logistic was 11.1 ± 17.0. Comorbidities included: diabetes (26.4%), COPD (19.8%), chronic renal failure (17.0%), peripheral vasculopathy (5.7%), previous AMI (7.5%) and AF (47.2%). The mean EF was 54.9 ± 11.4 and 15.1% had pulmonary hypertension. In 22.6% had undergone previous cardiac surgery, in 4.7% were urgiences. Results: In 39.6% were mitral repair, associated procedures were TV procedures (10.4%) and AF-crioablation (17.0%). Mean cardiopulmonary and cross clamp time were respectively 142.2 ± 53.3 and 96.3 ± 33.5 minutes. The most utilized aortic clamp technique was endoreturn (61.3%). Conversions to sternotomy were 3.8%. Operative mortality was 0%. Reoperation for bleeding occured in 8.5%. Postoperatively, in 5.7% was necessary CVVH, in 3.8% PM implantation and in 2.8% tracheostomy. Only one patient suffered from major neurologic complications. Groin wound infection/linfocele occurred in 5.7% and in 2.8% was necessary a wound revision. Mean, median intubation time, ICU and hospital stay were respectively 45.4 ± 151.1 h (11 h), 3.8 ± 7.4days (1 day) and 12.0 ± 12.5days (8.0 days). The 30-day mortality rate was 5.7%. Conclusions: Minimally invasive approach appears to be safe, feasible and reproducible with low peri-operative morbidity expecially in obeses.

OC42 MINIMALLY INVASIVE MITRAL VALVE SURGERY IN HIGH-RISK PATIENTS: 12-YEAR SINGLE CENTRE EXPERIENCE

Objective: This study analyzed the results of 12-year experience with mini-invasive MV operations in high-risk patients. Methods: From 1/2006 to 2/2018, 153 patients with EuroSCORE ≥ 10 underwent minimally invasive MV surgery (13.0% of 1175): mean EuroSCORE was 12.0 ± 3.1 and Logistic was 30.7 ± 15.8, mean age was 73.6 ± 8.6, male were 32.7%. Comorbidities included: diabetes (23.5%), COPD (24.2%), chronic renal failure (28.1%), peripheral vasculopathy (16.3%), previous AMI (10.5%), neurological deficit (13.7%), active endocarditis (9.2%) and AF (63.4%). The mean EF was 50.7 ± 13.8 and 34.0% had pulmonary hypertension. In 71.2% had undergone previous cardiac surgery, in 11.1% were urgiences. Results: In 24.8% were mitral repair, associated procedures were TV procedures (20.3%) and AF-crioablation (5.3%). Mean cardiopulmonary and cross clamp time were respectively 133.8 ± 54.1 and 83.8 ± 28.5 minutes. The most utilized aortic clamp technique was endoreturn (58.8%). Conversions to sternotomy were 4.6%. Reoperation for bleeding occured in 11.8%. Postoperatively, in 2.6% were reported major neurologic complications, in 14% was necessary CVVH, in 5.2% PM implantation and in 6.5% tracheostomy. Mean, median intubation time, ICU and hospital stay were respectively 135.3 ± 833.9 (12)h, 9.7 ± 36.0 (2)days and 20.1 ± 39.1 (10)days. The 30-day mortality rate was 9.2%. Conclusions: mini-invasive approach allows acceptable morbidity and mortality in high-risk patients.

A method for addressing right upper lobe obstruction with right-sided double-lumen endobronchial tubes during surgery: a randomized controlled trial

BackgroundA right-sided double-lumen tube (R-DLT) tends to obstruct the right upper lobe intraoperatively due to anatomical distortion during surgery. If the R-DLT is poorly matched with the patient’s airway anatomy, it will not be possible to correctly replace the tube with a fiberoptic bronchoscope (FOB). In our study, we aimed to explore an efficient method for difficult repositioning caused by right upper lobe occlusion during surgery: repositioning the R-DLT from the right main bronchus into the left main bronchus. The current study was designed to assess the efficacy and safety of this method.MethodsSixty adult patients scheduled to undergo left-sided thoracic surgery were randomly assigned to two groups. With the patient in the right lateral position during surgery, the R-DLT was pulled back to the trachea while being rotated 90° clockwise; it was then either rotated 90° clockwise for placement into the left main bronchus (Group L) or rotated 90° anticlockwise and returned to the right main bronchus (Group R) using FOB guidance. The primary outcomes included clinical performance, which was measured by intubation time, and the quality of lung collapse. A secondary outcome was safety, which was determined according to bronchial injury and vocal cord injury.ResultsThe median intubation time (IQR [range]) required for placement of a R-DLT into the left main bronchus was shorter than the time required for placement into the right main bronchus (15.0 s [IQR, 12.0 to 20.0 s]) vs 23.5 s [IQR, 14.5 to 65.8 s], P = 0.005). The groups showed comparable overall results for the quality of lung collapse during the total period of one-lung ventilation (P = 1.000). The numbers of patients with bronchial injuries or vocal cord injuries were also comparable between groups (Group R, 11/30 vs. Group L 8/30, P = 0.580 for bronchus injuries; Group R, 15/30 vs. Group L 13/30, P = 0.796 for vocal cord injuries).ConclusionsRepositioning a R-DLT from the right main bronchus into the left main bronchus had good clinical performance without causing additional injury. This may be an efficient method for the difficult repositioning of a R-DLT due to right upper lobe occlusion during surgery.Trial registrationChinese Clinical Trial Registry, ChiCTR-IPR-15006933, registered on 15 August 2015.

Effects of body mass index on cecal intubation time in women.

During colonoscopy, cecal intubation time is prolonged with increase in difficulty of the procedure. Cecal intubation time may be affected by age, gender, and body structure. We investigated the relationship between body mass index and cecal intubation time in women. This prospective study included 61 women who underwent colonoscopy in the endoscopy unit of the General Surgery Clinic in Trabzon Kanuni Training and Research Hospital between January 2016 and September 2016. The colonoscopies were performed by a single surgeon. The height and weight of all the participants were measured, and their body mass index values were calculated before the procedure. The timer was activated as soon as entry was made from the anal region with colonoscope and stopped when the cecum was reached. The cecal intubation time was recorded for each subject. The results were evaluated statistically, and p<0.05 was considered to be significant. The mean body mass index was 29.6±6.8 kg/m2. The median cecal intubation time was 4 min. (minimum 2 min; maximum 8 min). A significantly strong positive correlation was found between body mass index and cecal intubation time (r:-0.891, p<0.001). Cecal intubation time was found to be shorter in women whose body mass index values were high. This outcome may help to eliminate the "the colonoscopy will be difficult" preconception, which is common among endoscopists with regard to the colonoscopies for obese female patients.

Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations

BackgroundPre-hospital tracheal intubation success and complication rates vary considerably among provider categories. The purpose of this study was to estimate the success and complication rates of pre-hospital tracheal intubation performed by physician anaesthetist or nurse anaesthetist pre-hospital critical care teams. MethodsData were prospectively collected from critical care teams staffed with a physician anaesthetist or a nurse anaesthetist according to the Utstein template for pre-hospital advanced airway management. The patients served by six ambulance helicopters and six rapid response vehicles in Denmark, Finland, Norway, and Sweden from May 2015 to November 2016 were included. ResultsThe critical care teams attended to 32 007 patients; 2028 (6.3%) required pre-hospital tracheal intubation. The overall success rate of pre-hospital tracheal intubation was 98.7% with a median intubation time of 25 s and an on-scene time of 25 min. The majority (67.0%) of the patients' tracheas were intubated by providers who had performed >2500 tracheal intubations. The success rate of tracheal intubation on the first attempt was 84.5%, and 95.9% of intubations were completed after two attempts. Complications related to pre-hospital tracheal intubation were recorded in 10.9% of the patients. Intubations after rapid sequence induction had a higher success rate compared with intubations without rapid sequence induction (99.4% vs 98.1%; P=0.02). Physicians had a higher tracheal intubation success rate than nurses (99.0% vs 97.6%; P=0.03). ConclusionsWhen performed by experienced physician anaesthetists and nurse anaesthetists, pre-hospital tracheal intubation was completed rapidly with high success rates and a low incidence of complications. Clinical trial numberNCT 02450071.

CAN THE FACE-TO-FACE INTUBATION TECHNIQUE BE USED DURING CARDIOPULMONARY RESUSCITATION? A PROSPECTIVE, RANDOMIZED, CROSSOVER MANIKIN TRIAL

BACKGROUND: Endotracheal intubation in cardiopulmonary resuscitation conditions is the gold standard for the protection of airway patency, allowing for both ventilation with positive pressures and continuous moni­toring of carbon dioxide concentration in the exhaled air, as well as enabling continuous chest compressions. AIM: The aim of the study was to compare the effectiveness of endotracheal intubation performed with the usage of Macintosh laryngoscope in two positions: behind the patient’s head and in the face-to-face position. METHODS: We included 54 students during their final year of medicine in the study. All of participants declared the ability to perform endotracheal intubation based on direct laryngoscopy. Prior to the study, all participants took part in the training in laryngoscopy and cardiopulmonary resuscitation. During the study, the participants performed intubation in the simulated resuscitation environment in two scenarios: Scenario A — intubation from behind the patient;s head, Scenario B — face-to-face intubation. Participants had a maximum of three intubation attempts. The chest compressions were paused during the procedure. RESULTS: The effectiveness of the first intubation attempt in the case of scenario A was 44.4%, while in the case of scenario B — 24.1%. The overall success ratios of intubation for scenarios A and B were 88.9% vs. 53.7%, respectively. The median intubation time during scenario A was 43.5 [IQR; 34–53.5] seconds, and 54.5 [IQR; 38.5–59.5] seconds for scenario B. CONCLUSIONS: In the study, intubation performed by final-year medical students while taking a position behind the head of the victim was of a higher efficiency when compared to the face-to-face position.