Success Of Attempts Research Articles

Barriers and Breakthroughs in Targeting the Oxytocin System to Treat Alcohol Use Disorder.

Development of better treatments for alcohol use disorder (AUD) is urgently needed. One promising opportunity for this development is the potential of targeting the oxytocin peptide system. Preclinical studies showed that administration of exogenous oxytocin or, more recently, stimulation of neurons expressing endogenous oxytocin lead to a decreased alcohol consumption across several rodent models. Initial clinical studies also showed that administration of oxytocin decreased craving for alcohol and heavy alcohol drinking. However, several more recent clinical studies were not able to replicate these effects. Thus, although targeting the oxytocin system holds promise for the treatment of AUD, more nuanced approaches toward development and application of these treatments are needed. In this mini-review we discuss potential caveats resulting in differential success of attempts to use oxytocin for modulating alcohol use disorder-related behaviors in clinical studies and evaluate three directions in which targeting the oxytocin system could be improved: (1) increasing potency of exogenously administered oxytocin, (2) developing oxytocin receptor agonists, and (3) stimulating components of the endogenous oxytocin system. Both advances and potential pitfalls of these directions are discussed.

Comparative evaluation of ultrasound guided supraclavicular and infraclavicular subclavian venous catheterizations in adult patients.

Ultrasound-guided subclavian vein cannulation has two approaches: supraclavicular and infraclavicular. The aim of this study was to compare the ease of cannulation by recording the puncture time of the subclavian vein with the two approaches in adult patients. This study was approved by our institutional ethics committee, and a written informed consent was obtained from the patients. This prospective randomized trial recruited patients aged 18 to 80 years with definite indications of subclavian vein cannulation. Real-time in-plane ultrasound-guided technique was used, and the subclavian vein was punctured at the junction of the brachiocephalic and IJV in supraclavicular approach (SC) and in oblique axis below the border of the clavicle in infraclavicular approach (IC). A total of 96 patients were randomly allocated equally into two groups of 48 each, but only 45 patients in each group could be successfully cannulated. Median puncture times were comparable; 15 (9-39) s in SC and 21 (5-80) s in IC group. The first attempt success rate was 82.2% and 62.2%, and the mean total access time was 99.11 ± 34.66 s and 103.44 ± 50.27 s in SC and IC approaches, respectively and were comparable. The attempts of needle puncture were significantly higher in IC approach (1.40 ± 0.54 vs 1.20 ± 0.46 in SC approach; P = 0.04). The complication rates were comparable and less than 5%. Ease of cannulation of the subclavian vein using ultrasound-guided supraclavicular and infraclavicular approach is comparable as no statistically significant difference is noted in the puncture time and first-attempt success rate. The increased number of needle punctures reported in our study with the IC approach did not translate to an increased complication rate.

COMPARATIVE EVALUATION OF LMA CTRACH VERSUS LMA FASTRACH FOR TRACHEAL INTUBATION

Introduction: TM The intubating laryngeal mask airway (ILMA) or LMA Fastrach was invented as a ventilatory device,and TM as a conduit for blind tracheal intubation. However, intubation through LMA Fastrach requires multiple attempts. LMA TM TM CTrach is a modification of LMA Fastrach and allows intubation under direct vision via an integrated fibreoptic bundle and a detachable liquid crystal display viewer.This study was undertaken to compare the first attempt success rate of TM tracheal intubation through the CTrach laryngeal mask and LMA Fastrach . Methods and Materials:This prospective randomized study was conducted on 100 adults,ASA physical status I and II patients of either sex, scheduled to undergo general anaesthesia requiring tracheal intubation for elective surgery.The patients were randomly allocated to two groups of 50 patients each, to be intubated via CTrach (GROUP CT, n=50) or ILMA (GROUP FT,n=50).The first-attempt and overall success rates of tracheal intubation,the times taken and incidence of pharyngo-laryngeal morbidity,were recorded. Results: Tracheal intubation was successful on the first attempt in 96% of patients with the LMA CTrach™ and 84% of patients with the LMA Fastrach™ (p= 0.045). The success rates within three attempts were 100% in both groups (p=0.124).The mean time taken for the complete tracheal intubation process was 109.6 ± 38.679 seconds with the LMA CTrach™ and 118.68 ±22.342 seconds with the LMA Fastrach™ (p= 0.154). Conclusion: To conclude, both airway devices are comparable and efficacious and the overall success of tracheal intubation was 100% in both groups.

Retromolar intubation with video intubating stylet in difficult airway: A randomized crossover manikin study

ObjectiveDifficult airway situations, such as trismus and neck rigidity, may prohibit standard midline orotracheal intubation. An alternative route of intubation from the retromolar space using a fiberoptic scope or rigid intubation stylet has been reported. There is no study investigating the applicability of retromolar intubation using a video intubating stylet. This study comparatively analyzed difficult airway management using a video intubating stylet in the retromolar and standard midline approaches. MethodsA randomized crossover manikin study was conducted between January 2021 and June 2021 at a tertiary teaching hospital. Thirty-six emergency medicine residents and attending physicians were enrolled, and all participated in an educational course regarding video intubating stylet in standard midline and retromolar approaches. Then, they performed both intubation approaches in a randomized order on a manikin seven times with different airway settings each time. The duration of successful intubation, first attempt success rate, overall success rate, number of attempts, and self-reported difficulty were recorded and compared. ResultsThirty-six emergency physicians were included in the study. Compared with the standard midline approach, the use of the retromolar approach significantly reduced the duration of successful intubation in difficult airway scenarios such as limited mouth opening and neck rigidity with (44.77 [28.58–63.65] vs. 120 [93.86–120] s, p < 0.001) and without tongue edema (31.5 [22.57–57.74] vs. 44.72 [36.23–65.34] s, p = 0.012). Furthermore, the retromolar approach increased the first attempt success rate in scenarios of limited mouth opening and neck rigidity with (91.67% vs. 16.67%, p < 0.001) and without (97.22% vs. 72.22%, p = 0.012) tongue edema. The self-reported difficulty was also significantly lower with the retromolar approach than with the standard approach in the above two scenarios. ConclusionsThe retromolar approach for intubation using a video intubating stylet may be a promising choice for selected patients with a combination of difficult airway features such as limited mouth opening, neck rigidity, and edematous tongue.

Assessment of the GlideScope spectrum single-use video laryngoscope blades and small GlideRite stylet for use in pediatrics: A randomized manikin study

The GlideScope® Spectrum™ single use blades, LoPro S1 and LoPro S2, offer several technical improvements over their predecessors while maintaining the traditional curvature useful in difficult airway scenarios. We performed a single-site, prospective randomized feasibility study with three different pediatric manikin models using these new blades. The primary outcome was first attempt success rate. Secondary outcomes were overall success rate, time to intubation, and Cormack and Lehane glottic view grade. A questionnaire was also administered to each participant following the intubation attempts to gauge their satisfaction with the Spectrum™ blades and proprietary stylet. Fifty total anesthesia providers consisting of attendings (consultants), residents, fellows, certified nurse anesthetists and certified anesthesiologist assistants intubated 3 different manikins, three times each, using both the LoPro S1 and LoPro S2 blades for a total of 18 intubations each. The overall success rate across all blades and manikins was 98% and greater. The median time to intubation for all blade and manikin combinations was less than 13 s. This study demonstrates the GlideScope® Spectrum™ LoPro S1 and LoPro S2 blades are effective video intubation devices, even in a difficult airway pediatric manikin model.

Performance of custom made videolaryngoscope for endotracheal intubation: A systematic review.

IntroductionVideolaryngoscope is regarded as the standard of care for airway management in well-resourced setups however the technology is largely inaccessible and costly in middle and low-income countries. An improvised and cost-effective form of customized videolaryngoscope was proposed and studied for patient care in underprivileged areas however there were no distinct conclusions on its performances.MethodThe study follows PRISMA guidelines for systematic review and the protocol in International Prospective Register for Systematic Reviews. The primary aim was to assess the first attempt success of customized videolaryngoscope for endotracheal intubation. The secondary objective was to evaluate the number of attempts, laryngoscopic view in terms of Cormack Lehane score and Percentage of glottic opening, use of external laryngeal maneuver and stylet and, the airway injuries after the endotracheal intubation.ResultFive studies were analyzed for risk of bias using the National Institute of Health Quality Assessment Tool for cross-sectional studies. Most of the studies had a poor to a fair level of evidence with only one study with a good level of evidence. Certainty of evidence was “very low” for all eligible studies when graded using the Grading of Recommendation, Assessment, Development and Evaluation approach for systematic review.ConclusionsThe certainty of the evidence regarding performance of custom-made videolaryngoscope compared to conventional laryngoscope was very low and the study was performed in small numbers with fair to the poor risk of bias. It was difficult to establish and do further analysis regarding whether the customized form of videolaryngoscope will improve the first attempt success rate for tracheal intubation, reduce the number of attempts, improve the laryngoscopic view, require fewer external aids and reduce the incidences of airway injury with the given low-grade evidence. Some properly conducted randomised clinical trials will be required to further analyze the outcome and make the strong recommendations.

Comparison of Vie Scope® and Macintosh laryngoscopes for intubation during resuscitation by paramedics wearing personal protective equipment.

BackgroundEndotracheal intubation (ETI) is still the gold standard of airway management, but in cases of sudden cardiac arrest in patients with suspected SARS-CoV-2 infection, ETI is associated with risks for both the patient and the medical personnel. We hypothesized that the Vie Scope® is more useful for endotracheal intubation of suspected or confirmed COVID-19 cardiac arrest patients than the conventional laryngoscope with Macintosh blade when operators are wearing personal protective equipment (PPE).MethodsStudy was designed as a prospective, multicenter, randomized clinical trial performed by Emergency Medical Services in Poland. Patients with suspected or confirmed COVID-19 diagnosis who needed cardiopulmonary resuscitation in prehospital setting were included. Patients under 18 years old or with criteria predictive of impossible intubation under direct laryngoscopy, were excluded.Patients were randomly allocated 1:1 to Vie Scope® versus direct laryngoscopy with a Macintosh blade. Study groups were compared on success of intubation attempts, time to intubation, glottis visualization and number of optimization maneuvers.ResultsWe enrolled 90 out-of-hospital cardiac arrest (OHCA) patients, aged 43–92 years. Compared to the VieScope® laryngoscope, use of the Macintosh laryngoscope required longer times for tracheal intubation with an estimated mean difference of −48 s (95%CI confidence interval [CI], −60.23, −35.77; p < 0.001). Moreover VieScope® improved first attempt success rate, 93.3% vs. 51.1% respectively (odds ratio [OR] = 13.39; 95%CI: 3.62, 49.58; p < 0.001).ConclusionsThe use of the Vie Scope® laryngoscope in OHCA patients improved the first attempt success rate, and reduced intubation time compared to Macintosh laryngoscope in paramedics wearing PPE for against aerosol generating procedures.Trial registration: ClinicalTrials registration number NCT04365608

Lumbar Puncture in the prone position for Low Birth Weight Neonates

BackgroundLumbar puncture in the lateral decubitus position will make the neonates uncomfortable and is likely to cause position change and unstable vital signs, and the application of sedative drugs will cause adverse effects. This study explored a novel method for lumbar puncture in the prone position for low weight neonates.MethodsThe neonates were randomly assigned into the standard position group receiving lumbar puncture in the lateral decubitus position; and the improved position group receiving lumbar puncture in the prone position. The success rate of first time attempts and the overall success rate of lumbar puncture, incidence of adverse effects, NIAPAS scores were collected and compared between these two groups. The difference in success rate and adverse effects incidence rate was analysed through Chi-square. Student’s t-test was used for the test of NIAPAS rating.ResultsThe improved position group had a higher success rate of first attempt and overall success rate, significantly lower incidence of adverse effect and lower NIAPAS scores than those of the standard position group (P<0.05).ConclusionThis lumbar puncture in the prone position is safer, more effective, and more comfortable for preterm neonates and those with low birth weight. Thus, this method is worth of further promotion.Trial registrationRegistration number, ChiCTR2100049923; Date of Registration, August 11, 2021; Retrospectively registered.

Examination of Primary Bougie Use in Air Medical Intubations

<h3>Introduction</h3> Use of a bougie during emergency rapid sequence intubation (RSI) appears to increase first attempt success but may increase time to a definitive airway. This analysis was performed to explore primary use of a bougie during air medical RSI. <h3>Methods</h3> For this analysis, patients undergoing RSI by air medical crews were identified from a large air medical database. First attempt success (FAS), and first attempt success without desaturation (FASWD) were used as outcome measures. Patients in whom a bougie was used during the initial intubation attempt were compared to patients undergoing intubation without the bougie. Propensity scores for bougie use were calculated and multiple logistic regression used to calculate odds ratios for both outcome measures. <h3>Results</h3> A total of 11,836 air medical RSI patients were identified. Patients in whom a bougie was used on the first attempt had more difficult airway predictors. Logistic regression analysis with propensity adjusted odds ratios revealed no associations between use of a bougie on first attempt and FAS (adjusted OR 0.92, 95% CI 0.80-1.05, p=0.212). However, FASWD rates were statistically significantly lower with use of a bougie on first attempt after adjusting for age, gender, trauma, and presence of difficult airway criteria (adjusted OR 0.85, 95% CI 0.75-0.96, p=0.009). <h3>Conclusion</h3> Primary use of the bougie during intubation resulted in similar rates of first pass success when compared to non-bougie group. Primary bougie use may be associated with a higher rate of desaturation during first attempt intubation. Limitations include the potential for selection bias not addressed by the statistical models. Further examination to explore the effects of bougie use related to desaturation is recommended.

Pediatric Rapid Sequence Intubation Success with a Novel Training Program

<h3>Introduction</h3> Pediatric rapid sequence intubation (RSI) is a critical skill. PICU and ED physicians report first attempt success (FAS) rates of 62-78% and first attempt success without desaturation (FASWD) rates of 58%. Here we report air medical pediatric RSI success rates using a novel training program [HeART]. <h3>Methods</h3> All pediatric RSI patients over a five-year period (2015-2019) from a large air medical company were included. FAS and FASWD were calculated for all patients and for specific age cohorts [0-2 years, 3-8 years, 9-17 years]. Meta-analysis was performed to compare to reported physician success rates. <h3>Results</h3> A total of 1,116 pediatric RSI patients were included [0-2: n=247, 3-8: n=250, 9-17: n=619]. Intubation success rates were similar across age groups. Both FAS and FASWD rates were significantly higher than reported for PICU and ED physicians (FAS = 91% vs 61%, p<0.001; FASWD = 63% vs 58%, p=0.034). <h3>Conclusion</h3> We observed high FAS and FASWD rates for air medical pediatric RSI using a novel airway curriculum. Although RSI success rates were higher than reported for PICU and ED physicians, the comparisons may reflect undetected differences in various airway difficulty factors.

A Comparison of Tracheal Intubation with Ambu® AuraGainTM, Fastrach® and BlockBuster® Laryngeal Mask Airway: A Randomised Clinical Trial

Introduction: Airway management has been a key to quality, efficacy and safety of anaesthesia. The Ambu® AuraGain™ is an anatomically curved Supraglottic Airway Device (SAD), which has gastric access port and is used for both ventilation and endotracheal intubation. Fastrach® Intubating Laryngeal Mask Airway (FT-LMA) serves as a conduit for intubation and ventilation for difficult airway situation. It has an epiglottic elevating bar designed to lift the epiglottis as endotracheal tube passes. BlockBuster® LMA is latest generation LMA used for ventilation and intubation. It has a short airway tube which has &gt; 95° angulation to match the oropharyngeal curve and thus makes the insertion easy and less traumatic. Aim: To compare first attempt success rate of tracheal intubation using Ambu® AuraGain™, Fastrach® and BlockBuster® LMA in adult patients. Materials and Methods: The present randomised clinical trial was conducted in the Department of Anaesthesiology, Ravindra Nath Tagore Medical College, Udaipur, Rajasthan, India from February 2021 to February 2022. The study comprised of 135 ASA physical status I and II patients of both sex, aged 18-60 years who were admitted and scheduled for elective surgery requiring general anaesthesia and tracheal intubation. The patients were randomly assigned into three groups (45 in each) - group A (Ambu® AuraGain™ group), group F (Fastrach® group), and group B (BlockBuster® group). Tracheal intubation was performed using appropriate size endotracheal tube after LMA placement. The outcome measures were first attempt successful intubation, time taken for intubation, glottis visualisation, and incidence of complications (blood stained LMA, nausea/vomiting). Results: The mean age of the group A, group B and group F were 35.8±15.0, 32.71±12.59, and 38.7.0±14 respectively which was statistically not significant. Group B had a significantly greater success rate of first attempt intubation (93.3%) in comparison with group F (64.4%), and group A (22.2%). LMA insertion score of 1 was found in 53.3% patients in group B, 42.2% patients in group F and 15.5% patients in group A. A Brimacombe score of 4 was found in 46.6% patients in group B as compared to 13.3% patients in group F and (33.3%) patients in group A, (p-value=0.020). Blood stained LMA was found in 1 patient in group B, 9 in group F and 7 in group A (p-value=0.030). Conclusion: BlockBuster® LMA is a better conduit for tracheal intubation than Fastrach® LMA and Ambu® AuraGain™ in adult patients with no anticipated airway difficulties.

Light-emitting Diode Vein Finding Device in Facilitating Peripheral Intravenous Cannulation in Children: A Randomised Clinical Study

Introduction: Peripheral venous cannulation in the paediatric age group is always a challenging task. The transillumination technique improves the visualization of veins. The Light Emitting Diode (LED) vein finder device is based on the side transillumination principle. Aim: To evaluate the role of transilluminating LED vein finder device (Optramed Vein-Lite), for peripheral intravenous cannulation in children with respect to ease of cannulation, time taken and number of attempts. Materials and Methods: This randomised clinical study was conducted in Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, from January 2018 to January 2020. Total 130 patients, age &lt;3 years, of either sex, and scheduled for surgery under general anaesthesia were included in the study. They were randomised into two groups. Group I (n=65) where venous cannulation was done using a transilluminating LED vein finder device, and group II (n=65) where venous cannulation was done after visualising and palpating the vein manually (conventional technique). Both the groups were compared with respect to the Difficult intravenous access (DIVA) score, number of attempts, ease of intravenous cannulation (cannulation on first or second attempt as ‘easy’, more than two attempts as ‘difficult’ cannulation) and time required for intravenous cannulation. The qualitative variables were expressed as frequencies/percentages and compared using the Chi-square test. A p-value &lt;0.05 was considered statistically significant. Results: The mean age of the population in group I was 17±13 months, and in group II was 15±23 months (p-value=0.5427). There was a significant variation with respect to the number of attempts; the first attempt success was 90.7% in group I vs 63% in group II (p-value= 0.0014). In group I, cannulation was easy in 95% of patients while in group II only 76.9% of patients had easy cannulation (p-value=0.0018). Time taken for intravenous cannulation in group I was 19.385±6.2015 sec and in group II was 22.886±11.6716 sec (p-value=0.0346). Conclusion: Transillumination is a useful technique to improve the success rate of peripheral venous cannulation in infants and children.

Effect of Real-Time Carbon Dioxide Sensing Stylet Assisted Endotracheal Intubation: A Pilot Study Using the Porcine Model

Introduction: Safe and prompt endotracheal intubation is crucial to prevent morbidity and mortality in patients requiring airway management. The aim of this pilot study was to test the effect of real-time carbon dioxide (CO2) sensing stylet assisted intubation compared with conventional intubation in porcine experiment. Methods: Thirty-four swine were assigned to either the intervention or control group in a 1:1 ratio. Real-time CO2 sensing stylet was manually manufactured and used for assisting intubation in the intervention group. Conventional intubation using direct laryngoscopy was performed in the control group. The primary outcome was total procedure time and the secondary outcome was first attempt success rate. Cumulative hazard curves were obtained by analyzing the total procedure time to successful intubation for each swine, and the log-rank test was used to compare between the two groups. Results: Compared to the control group, a trend of shorter total procedure time was observed in the intervention group (mean ± standard deviation, 59.8 ± 34.6 s vs. 92.2 ± 68.2 s; p-value = 0.09). The cumulative hazard plot showed a consistent trend of shorter total procedure time in the intervention group compared to the control group (p-value = 0.16). The first attempt success rate showed a higher trend (70.6% vs. 52.9%; p-value = 0.29) in the intervention group. Conclusion: The real-time CO2 sensing stylet assisted endotracheal intubation has potential to reduce the time to successful intubation and improve first attempt success rate.

Airway Management Skills in Emergency Services

Introduction: Endotracheal intubation in critically ill and injured patients is a high- risk procedure in an Emergency Room (ER). The risk of complications increases with repeated or prolonged attempts, making first attempt success primary goal for airway management in these patients. The primary objectives were to compare first pass success during intubation among various specialties with different level of airway management training and education. Methods: This was a quantitative, observational, cross-sectional study conducted at Tribhuvan University Teaching Hospital for one year. The intubators completed an intubation data collecting form post intubation. After a failed first attempt, alternative methods such as using experienced intubators for subsequent intubation attempts were performed. Results: In the emergency room, 265 attempts of endotracheal intubation were made on total 224 patients. Most common causes for intubation were stroke (49 [21.8 %]), sepsis (39 [17.20 %]), COPD (28 [12.20 %]), and head traumas (24 [10.90 %]). During endotracheal intubation, 185 (82.58%) patients had a successful first-attempt success, and 39 (17.41 %) patients required ≥2 attempts. First pass success was least among medical officers (13/20 (65%)), compared to other senior specialties (p=0.01). Conclusion: With more training and education on the airway, first-pass success during endotracheal intubation increased. All front-line workers should consider it an ethical commitment to stay updated through lifelong learning, an obligation that should be made easier by governing bodies enforcing a thorough airway management training programs.

Success and failure of attempts to improve the accuracy of Raviart–Thomas mixed finite elements in curved domains

Several important problems in Mechanics can be efficiently solved using Raviart–Thomas mixed finite element methods. Whenever the domain of interest has a curved boundary the methods of this family for N-simplexes are the natural choice. But in this case the question arises on the best way to prescribe normal flux conditions across the boundary, if any. It is generally acknowledged that the normal component of the flux variable should preferably not take up corresponding prescribed values at nodes shifted to the boundary of the approximating polytope in the underlying normal direction. This is because an accuracy downgrade is to be expected, as shown in Bertrand and Starke (2016). In that work an order-preserving technique was studied, based on a parametric version of these elements with curved simplexes. In this work an alternative with straight-edged triangles for two-dimensional problems is examined. The key feature of this approach is a Petrov–Galerkin formulation, in which the test-flux space is a little different from the shape-flux space. Based on previous author’s experience with this technique, as applied to Lagrange finite elements, it would lead to an overall accuracy improvement here as well. The experimentation reported hereafter provides examples and counterexamples confirming or not such an expectation, depending on the unknown field of the mixed problem at hand.

Exploring the mechanics of fish escape attempts through mesh

Predictive selectivity modelling is used to study fishing gear selectivity. These models rely on fish morphology parameters and fall-through experiments. Here, we developed a model of the mechanical interaction between a fish and a netting mesh during an escape attempt. In this model, the fish is described with three parameters: the first parameter measures its mechanical ability to penetrate a mesh and the others are body stiffness coefficients accounting for fish body deformation under mesh twine pressure. These parameters were identified from the results of a bench test simulating a fall-through experiment through a single 60-mm Polyethylene (PE) mesh. A rigid circular cone, a rigid elliptical cone and a small number of horse mackerel and haddock, offering a limited length range, were tested. Results were generalised and compared with those obtained on a piece of netting. Within the model's assumptions, it is possible to predict the success of an escape attempt if one knows the three fish parameters and the mesh load in normal and transverse directions. The study showed that escape potential is greater through an actual deformable mesh than through a non-deformable mesh. The potential size of this difference depends on the mesh load and orientation.

Comparison of Standard Technique, Ultrasonography, and Near-Infrared Light in Difficult Peripheral Vascular Access: A Randomized Controlled Trial

Successful placement of a peripheral intravenous catheter (PIVC) on the first attempt is an important outcome for difficult vascular access (DVA) patients. This study compared standard technique, ultrasonography (USG), and near-infrared light (NIR) in terms of success in the first attempt in patients with DVA. This was a prospective, randomized controlled study. The study was conducted in a tertiary care hospital. Emergency department patients who describe DVA history, have no visible or palpable veins, and were assessed by the nurse to have a difficult PIVC were included to study. The PIVC procedure was performed on patients by standard, USG, or NIR device techniques. For all approaches, the success of the first attempt was the primary aim. Total procedure time, the total number of attempts, and the need for rescue intervention were secondary aims. This study evaluated 270 patients. The first attempt success rates for USG, standard, and NIR methods were 78.9%, 62.2%, and 58.9%, respectively. The rate of first attempt success was higher in patients who underwent USG (USG versus standard, P = .014; USG versus NIR, P = .004; standard versus NIR, P = .648). The total median (IQR) procedure time for USG, standard, and NIR methods was 107 (69-228), 72 (47-134), and 82 (61-163) seconds, respectively. The total procedure time was longer in patients undergoing USG (standard versus USG, P <.001; NIR versus USG, P = .035; standard versus NIR, P = .055). The total median (IQR) number of attempts of USG, standard, and NIR methods were 1 (1-1), 1 (1-2), and 1 (1-2), respectively. A difference was found among the groups regarding the total number of attempts (USG versus NIR, P = .015; USG versus standard P = .108; standard versus NIR, P = .307). No difference was found among groups in terms of the need for rescue methods. It was found that USG increases the success of the first attempt compared with the standard method and NIR in patients with DVA.

Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department

BackgroundChallenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric...

The Use of Video Laryngoscopy Did Not Lead to Greater First-Pass or Overall Success Rates Compared to Direct Laryngoscopy in Pediatric Intubation in a Helicopter Emergency Medical Service

ObjectiveWe hypothesized that video laryngoscopy (VL) would significantly increase the first attempt and final success rates over direct laryngoscopy (DL) in helicopter emergency medical services. MethodsThis was a study of an emergency medical service in the Midwestern United States. Pediatric patients (age < 18 years) transported between January 1, 2010, and July 31, 2016, with an attempted intubation were identified. Demographics (age group and sex), first-pass success (FPS), and total attempts by intubation type were abstracted and compared with a historical control. ResultsFifty-five pediatric patient runs were abstracted (DL: n = 28, VL: n = 27). There were no significant differences between the DL and VL groups based on sex (DL: 54% male, VL: 70% male; P = .200) or age group (P = .239). Analyses of FPS between DL and VL showed no difference (DL: 82.1% success vs. VL: 70.4% success; P = .304). There was no difference for final success rate between DL and VL (DL: 85.7%, VL: 96.3%; P = .172). A significantly larger number of difficult airways were reported in the VL group (37.0%) compared with DL (7.1%, P = .007). ConclusionVL did not improve FPS over DL nor did it improve the final endotracheal intubation success rate over DL. The VL group had more airways reported as being difficult by the flight crew than the DL group.

Emergency cricothyrotomy in morbid obesity: comparing the bougie-guided and traditional techniques in a live animal model

Cricothyrotomy is a rare, time sensitive procedure that is more challenging to perform when anatomical landmarks are not easily palpated before the initial incision. There is a paucity of literature describing the optimal technique for cricothyrotomy in patients with impalpable airway structures, such as in morbid obesity. In this study, we used a live sheep model of morbid obesity to compare the effectiveness of two common cricothyrotomy techniques. We randomly assigned emergency medicine residents to perform one of two cricothyrotomy techniques on a live anesthetized sheep. To simulate the anterior soft tissue neck thickness of an adult with morbid obesity we injected 120mL of a mixture of autologous blood and saline into the anterior neck of the sheep. The traditional technique (as described in the New England Journal Video titled "Cricothyroidotomy") used a Shiley tracheostomy tube and no bougie, and the bougie-guided technique used a bougie and a standard endotracheal tube. The primary outcome was the total procedure time; the secondary outcome was first attempt success. 23 residents were included, 11 assigned to the bougie-guided technique and 12 to the traditional technique. After injection of blood and saline, the median depth from skin to cricothyroid membrane was 3.0cm (IQR 2.5-3.4cm). The median time for the bougie technique was 118s (IQR 77-200s) compared to 183s (IQR 134-270s) for the traditional technique (median difference 62s, 95% CI 10-144s). Success on the first attempt occurred in 7/11 (64%) in the bougie group and 6/12 (50%) in the traditional technique group. In this study, which simulated morbid obesity on a living animal model complete with active hemorrhage and time pressure caused by extubation before the procedure, the bougie-guided technique was faster than the traditional technique using a tracheostomy tube without a bougie.