Intubation Time Research Articles

Association Between Longer Cecal Intubation Time and Detection and Miss Rate of Colorectal Neoplasms

Background/Aims: A longer cecal intubation time (CIT) occurs during colonoscopy under difficult insertion conditions, which may hinder meticulous mucosal observation. However, whether a longer CIT has detrimental effects on the detection of adenomas remains unclear. We evaluated the effects of CIT on the detection and miss rates of colorectal neoplasms in asymptomatic participants. Methods: Healthy examinees who underwent colonoscopy between March and July 2011, August 2015, and December 2016 were retrospectively enrolled. The primary outcome was the adenoma detection rate (ADR) across CIT quartiles, while the secondary outcomes included the mean number of adenomas, advanced ADR (AADR), clinically significant serrated lesion (CSSP) detection, adenoma miss rate (AMR), miss rate of CSSPs and any colorectal neoplasms, and the mean number of missed colorectal neoplasms in relation to CIT. Results: Overall, 12,402 participants were classified into quartiles according to the CIT. The longer the CIT, the lower the ADR (p < 0.001), AADR (p = 0.004), and mean number of adenomas (p < 0.001). The CSSP detection rate was not associated with CIT. On follow-up colonoscopy, AMR showed marginal increase with longer CIT (p = 0.065). The missed rates of CSSPs (p = 0.002) and colorectal neoplasms (p = 0.001) also increased with longer CIT. In the multivariate analysis, CIT was significantly associated with ADR, AADR, and AMR. Conclusions: Longer CIT was associated with lower ADR and higher AMR. Meticulous inspection is important for high-quality colonoscopy, particularly in patients requiring a longer CIT.

Unsedated or On-Demand Minimally Sedated Water-Aided Outpatient Colonoscopy in Colorectal Cancer Screening and Surveillance: A Step Forward or Backward? Experience from Daily Practice in a Regional (Nonacademic) Hospital.

Background: By using optimal insertion techniques with water infusion and dynamic position changes, pain during colonoscopy is greatly reduced and the procedures can usually be performed without sedation. We investigated whether the excellent results with water-aided colonoscopy reported by experts are reproducible in daily practice in a regional hospital. Methods: During the year 2023, 500 consecutive outpatients 50-75 years old presenting for colorectal cancer screening and surveillance could choose between unsedated or on-demand minimally sedated colonoscopy, moderate sedation with midazolam, or deep sedation with propofol. A total of 57% opted for unsedated colonoscopy, and of those patients, 250 consecutive patients were included. The primary outcome was the feasibility of the procedure. Cecal intubation rate (CIR), pain scores, use of midazolam, and willingness to repeat future procedures in the same way were registered periprocedural. Additional outcomes were cecal intubation time (CIT), detection rate of lesions, polyp resection rate, rate of adequate bowel preparation, and volume of water aspirated during insertion. Results: 250 consecutive sedation-free or on-demand minimally sedated water-based colonoscopies were analyzed. The CIR was 98%. A total of 96.5% completed without sedation and 5% of the procedures were perceived as moderately painful, but none had severe pain. The willingness to repeat was 97%. The mean CIT was 8.2 min. Conclusions: Using water-aided insertion techniques, comfortable sedation-free, or on-demand minimally sedated colonoscopy in daily practice in a regional hospital is feasible in the vast majority of patients presenting for colorectal cancer screening and surveillance, and the willingness to repeat is very high.

The Impact of Systemic Inflammation on Recurrence in Patients with Congenital Nasolacrimal Duct Obstruction.

Background/Objective: Congenital nasolacrimal duct obstruction (CNLDO) is commonly treated by probing, but recurrence remains a clinical issue. This study investigates the potential role of inflammatory biomarkers, such as the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR), in predicting recurrence after probing in children with CNLDO. Methods: This retrospective cohort study included 172 patients who underwent initial probing for unilateral CNLDO. The patients were then categorized into two groups: those who experienced the complete resolution of symptoms after primary probing, and those who required Ritleng tube intubation due to recurrence following primary probing. Blood samples for calculating inflammatory biomarkers in all subjects were collected during general anesthesia preparation prior to initial probing. NLR, MLR, and PLR values were compared between the groups using the independent samples t-test. The predictive performance of the inflammatory biomarkers for recurrence was assessed using Receiver Operating Characteristic (ROC) curve analysis. Results: A total of 110 patients were included in the probing group, while 62 patients were in the recurrence group. The mean age at the time of the initial probing procedure was 15 ± 4.06 months in the probing group and 15.83 ± 4.02 months in the recurrence group. There was no difference in the duration of the probing procedure between the groups. The mean age at the time of Ritleng tube intubation in the recurrence group was 37.80 ± 13.34 months. The recurrence group exhibited significantly higher values in all analyzed inflammatory markers compared to the probing group, including the NLR (1.12 ± 0.56 vs. 0.86 ± 0.39, p = 0.002), MLR (0.16 ± 0.06 vs. 0.14 ± 0.06, p = 0.005), and PLR (95.13 ± 24.34 vs. 82.23 ± 22.77, p < 0.001). ROC curve analysis indicated that these inflammatory biomarkers demonstrated moderate performance in predicting recurrence. Conclusions: Recurrence following probing in children with CNLDO was associated with complete blood cell count-derived inflammatory biomarkers. The preoperative assessment of these biomarkers may aid in the individualization of disease management and inform the development of new therapeutic strategies.

Primary needle-knife fistulotomy versus standard transpapillary technique for cannulation of long-size papilla: a randomized clinical trial

Background: The morphology of the major papilla plays a crucial role in the selection of the cannulation method for the common bile duct (CBD) during endoscopic retrograde cholangiopancreatography (ERCP). Nevertheless, there is limited evidence available that compares the efficacy and safety of cannulation approaches in certain papilla morphologies. This study aims to assess the safety and effectiveness of two cannulation methods, including primary needle-knife fistulotomy (pNKF) and standard transpapillary (STP), in patients with long-size papilla. Methods: A total of 260 patients with intact long-size papilla were enrolled, and were randomly assigned to the pNKF or STP groups (n=130 in each group). The primary endpoint was the rate of post-ERCP pancreatitis (PEP). Biliary cannulation success rates, the duration of cannulation and the overall procedure, and the incidence of adverse events were also compared between the groups. All of the patients were hospitalized for at least 24 hours after the procedure. Results: 125 (96.2%) patients in the pNKF and 114 (87.7%) patients in the STP groups had successful primary biliary cannulation (p=0.01) and were included in the final analysis. PEP occurred in 11 patients in the STP group and 3 patients in the pNKF group (9.6% vs 2.4%, p=0.02; number needed to treat (95% confidence interval) =13.9 (7.5-83.2)). Moreover, compared to the pNKF, STP was associated with more cannulation attempts (3.4 versus 2.5, p&lt;0.001) and longer cannulation time (258 versus 187 seconds, p&lt;0.001). Conclusions: In patients with long-size papilla, pNKF is a safer, easier, and more efficient approach to gain primary biliary access than the STP technique.

Abstract 4138558: The effect of pulsatile vs. non-pulsatile perfusion on hospital stay, ICU stay, and intubation time in patients undergoing cardiopulmonary bypass: A meta-analysis randomized controlled trials.

Background: Pulsatile perfusion is a developing technique that attempts to mimic the natural pulsatile flow of blood during cardiopulmonary bypass (CBP). Purpose: Our meta-analysis was done to evaluate the effects of pulsatile perfusion in CPB compared to non-pulsatile on hospital stay, ICU stay, and intubation time. Methods: Randomized control trials that evaluated the implementation of pulsatile perfusion during CPB were identified by a literature search of the following databases (PubMed, Web of Science, Scopus, Central, and Embase) up to February 2024. Results: Our search yielded 33 trials with 3174 patients, the analysis showed that pulsatile perfusion led to a significant decrease in hospital stay [MD = -1.38, 95% CI (-2.51, -0.25), P = 0.016], ICU stay [MD = -0.47, 95% CI (-0.82, -0.13), P = 0.007], intubation time [MD = -3.73, 95% CI (-5.42, -2.04), P &lt; 0.001]. However, no significant difference between the two regimens was detected in the adult subgroup when we performed sungroup analysis based on the age for hospital stay and ICU stay outcomes [MD = -0.31, 95% CI (-0.95, 0.33), P = 0.334] and [MD = -3.73, 95% CI (-5.42, -2.04), P &lt; 0.001] respectively. Conclusion: Pulsatile perfusion showed positive effects on hospital stay, ICU stay, and intubation time. However, there was no difference between the two methods on hospital and ICU stay in the adult’s subgroup. Also, the outcomes showed significant heterogeneity, which requires more robust RCTs to be conducted to increase the quality and the certainty of evidence.

Long-term results of intensive care patients with post-intubation tracheal stenosis: 7 years follow-up

Background/aimBenign tracheal stenosis (TS) is a potentially life-threatening condition caused by iatrogenic events resulting from endotracheal intubation and tracheostomy. The study aimed to determine the clinical characteristics, management, and long-term outcomes of patients with simple or complex post-intubation tracheal stenosis (PITS) who were admitted to the intensive care unit (ICU).Materials and methodsRetrospective analysis of patients admitted to the ICU between June 2016 and June 2022 and diagnosed with PITS were performed until June 2023.Results76 patients (mean age 54.9 ± 17.3%, 63.2% male, 61.8% complex stenosis) admitted to the ICU were analysed. The diagnosis of PITS was made by fiberoptic bronchoscopy (FOB) in 53.9% and computed tomography (CT) in 46.1%. The most common location of stenosis was the upper trachea area (57.9%, n = 44). The median stenosis length of the TS was 1.9 cm (median 2 cm for complex stenosis, 1 cm for simple stenosis, p < 0.001). Complex stenosis was associated with longer intubation time and multiple intubation history (p = 0.011, p = 0.028). At the same; complex stenosis was associated with prolonged and high stenosis percentage (p < 0.001). While dilatation and cryotherapy were sufficient for treatment in all patients with simple stenosis, the stent was applied to 34% patients with complex stenosis. Recurrence was higher in complex stenosis after bronchoscopic procedure (complex stenosis 95.7%, simple stenosis 17.2%). 19 (25%) patients required surgical operation, and all of these patients had complex stenosis (p < 0.001). Median follow-up was 33 months for simple stenosis and 34 months for complex stenosis. ICU length of stay (LOS) was longer in patients with complex stenosis. There was no statistically significant difference between TS classes in terms of ICU mortality (p = 0.466), 1-year mortality (p = 0.951), and mortality during follow-up (p = 0.608).ConclusionPITS is a challenging situation in ICU patients. In patients with a preliminary diagnosis of PITS, bronchoscopy should be performed without delay, and it should be known that interventional bronchoscopy is not only a diagnostic tool but an effective strategy in treatment management after the diagnosis is finalised. The advantage of interventional bronchoscopy is that it alleviates symptoms that necessitate hospitalisation in the ICU and eliminates the need for ICU of patients.

Central Venous Catheterization in the ICU: A Comparison of Anatomical Landmark and Ultrasound-Guided Techniques

Introduction: Central venous catheterization (CVC) is frequently required in intensive care units (ICUs) for administering medications, fluids, and monitoring central venous pressure. However, CVC insertion can lead to complications such as arterial puncture, hematoma formation, and pneumothorax. Ultrasound guidance has been advocated to reduce these complications, but its effectiveness in the ICU setting remains debated. This study compared the complication rates of anatomical landmark-guided versus ultrasound-guided CVC insertion in ICU patients. Methods: A prospective cohort study was conducted in the ICU of a tertiary care hospital. Patients requiring CVC were divided into two groups: anatomical landmark-guided and ultrasound-guided insertion. The primary outcome was the incidence of complications, including arterial puncture, hematoma, and pneumothorax. Secondary outcomes included cannulation time and the number of cannulation attempts. Results: A total of 39 patients were included in the study. The incidence of complications was significantly lower in the ultrasound-guided group (2 complications) compared to the anatomical landmark group (7 complications) (p=0.017). The most common complication was arterial puncture, occurring in 7 patients in the anatomical landmark group and 2 patients in the ultrasound-guided group. Conclusion: Ultrasound guidance significantly reduces the risk of complications during CVC insertion in the ICU. This technique should be considered the standard of care for CVC insertion in this setting.

A visual laryngoscope combined with a fiberoptic bronchoscope improves intubation outcomes in patients with predicted difficult airways in thoracic surgery

ObjectiveTo study the clinical effectiveness of visual laryngoscopy combined with fiberoptic bronchoscopy-guided double-lumen endotracheal tube intubation in thoracic surgery patients with predicted difficult airways in thoracic surgery airways.MethodsWe randomly divided 162 patients with predicted difficult airways who required double-lumen tracheal intubation for thoracic surgery and randomly divided them into the video laryngoscopy group (Group VL, n = 54),fiberoptic bronchoscopy group (Group F, n = 54), and video laryngoscopy combined with fiberoptic bronchoscopy group (Group FVL, n = 54) according to the randomized number table method. Then, the success rate of the first intubation, the duration of intubation, the duration of positioning, the degree of exposure of the vocal cords (Cormack-Lehane grade), and the adverse reactions during intubation were recorded and analyzed.ResultsThe success rate of first-time intubation was significantly higher in the FVL group than in the F and VL groups (92.6% vs. 87.0% vs. 53.7%, P < 0.001), and the time of intubation in the FVL group was significantly shorter than that in the VL and F groups [(26.22 ± 9.34) s vs. (42.35 ± 11.21) s vs. (46.78 ± 21.96) s, P < 0.001)]. The positioning time in the FVL group was significantly shorter than that in the F and VL groups [(83.76 ± 15.18) s vs. (102.72 ± 21.89) s vs. (145.41 ± 20.12) s, F = 144.896, P < 0.001)].The number of patients with Cormack-Lehane grades I-II was significantly lower in the FVL group and the VL group than in the F group (88.9% vs. 77.8% vs. 59.3%, P < 0.05).The incidence of postoperative sore throat was significantly lower in the FVL group and the F group than in the VL group (22.4% vs. 27.6% vs. 50%, P < 0.001).ConclusionIn difficult airway patients with high airway risk indices who require double-lumen endotracheal intubation, visual laryngoscopy combined with fiberoptic bronchoscopy improved the success rate of first-time intubation and shortened the intubation and positioning time.Trial registrationChinese Clinical Trial Register (identifier: ChiCTR2300076304; Date of registration: September 29, 2023).

Upper Airway Block Using Lidocaine Nebulisation Versus Targeted Nerve Block for Awake Fibre-Optic Intubation in Patients with Head and Neck Burns: A Randomised Controlled Trial

Background: A difficult airway is a scenario in which an adequately trained anesthesiologist faces challenges with mask ventilation, endotracheal intubation, or both. Various anesthetic techniques have been proposed to prepare adequately for awake flexible fiber-optic intubation (AFOI), including nerve blocks for the upper airway, topical anesthesia via a specialized cannula, and lidocaine nebulization (LN). Proper anesthesia of the upper airway is crucial for successful AFOI. Objectives: This study aimed to evaluate the efficacy of airway block (AB) by LN compared to traditional upper AB techniques. Methods: This prospective, randomized, single-blinded study was conducted on 100 patients with head and neck burns scheduled for reconstructive surgery. Participants were randomly assigned to two groups of 50 patients each. In the AB group, AFOI was performed following an AB, while in the LN group, AFOI was performed 30 minutes after LN. The primary outcome measured was the time to successful awake nasal fiber-optic intubation. Secondary outcomes included the number of failed attempts and the revised nonverbal pain scale score. The time to successful awake nasal fiber-optic intubation showed no significant difference between the two groups. Results: Although the AB group had a higher number of failed attempts compared to the LN group, statistical analysis revealed no significant difference. Additionally, there was no significant difference in hemodynamic parameters between the groups. Conclusions: Both AB and LN are effective for awake nasal fiber-optic intubation, with comparable intubation times. However, LN offers a less invasive alternative.

Comparison of Macintosh laryngoscope and King Vision video laryngoscope for endotracheal intubation in adult patients

Background: Development of video laryngoscope has made management of airway easier. 0ur study was aimed to compare the efficacy of Macintosh laryngoscope and King Vision video laryngoscope for endotracheal intubation in adult patients under general anesthesia. Objectives: The primary objective of the study was to compare the glottic view obtained , the need for external manipulation, endotracheal tube insertion time and attempts taken for successful intubation with Macintosh laryngoscope and King Vision video laryngoscope. The secondary objective was to estimate the changes in hemodynamic parameters and to evaluate the occurrence of complications during intubation. Materials and Methods: The study included 136 patients posted for surgery under general anesthesia. Patients were randomly allocated in group C (N=68) and group V (N=68 ).Endotracheal intubation was done in group C by Macintosh and in group V by King Vision video laryngoscope. Laryngoscopy was assessed by Cormack Lehane grading and the need for any manipulation. The intubation time was calculated with each blade. Hemodynamic parameters were recorded and any complication during laryngoscopy and intubation were noted. The observations were analysed statistically by SPSS Program for windows version 28. Results: In group C, 61.8% of patients had Cormack and Lehane score I while in group V 76.5 % of patients had score I . Mean time of successful intubation was 34.90±8.35 sec in group C while in group V it was 32.82± 5.20 second . There was no statistical difference in distribution of patients according to number of attempts of intubation. In group C, 64.7% of patients needed external laryngeal pressure while in group V 97.1 % patients were intubated without external laryngeal pressure. Both the groups were comparable in relation to changes in hemodynamic parameters and any complications associated with laryngoscopy and intubation. Conclusion: We conclude that glottic view is better obtained with King Vision Video laryngoscope whereas optimisation of position and external laryngeal manipulation is often required with Macintosh laryngoscope to get similar glottic view. Introduction of King Vision video laryngoscope into the oral cavity takes time but intubation is easier with it. Hemodynamic variables and complications during the procedure are equally distributed between the two devices.

Intraoperative Position System guided with Augmented Reality Improves the Learning Curve of Endovascular Navigation in Endovascular Naïve Operators

ObjectiveThis study aimed to compare the completion of gate cannulation task performed by participants of varying experience using fluoroscopy, the Intra-Operative Positioning System (IOPS) – an FDA-cleared endovascular navigation system that has been developed to reduce dependence on fluoroscopy – or an investigational augmented reality electromagnetic navigation technology based on IOPS. MethodsThe task consisted in the cannulation of the gate of a GORE Excluder AAA endoprosthesis bifurcated aortic stent graft (W.L. GORE & Associates, Flagstaff, AZ USA) deployed into a 3D printed abdominal aortic aneurysm (AAA) model connected to a 7000 MDX flow pump (Sarns Inc/3M, Ann Arbor, MI USA) reproducing physiological conditions. The procedure was performed in a hybrid operating room (GE Allia IGS 7). Each participant performed the cannulation task with fluoroscopy, standard IOPS guidance with flat screen display (IOPS-FS), and the investigational IOPS with augmented reality headset (IOPS-AR), in a randomly assigned order. All participants used the same sensorized guidewire and steerable 6Fr catheter during their three cannulation tasks. A total of 26 participants were classified in three groups of experience: Group 1 (endovascular naïve; n = 13), Group 2 (surgeon in training; n = 12) and Group 3 (one expert surgeon). Primary endpoints included cannulation time and technical success, which was defined as the advancement of the catheter over the guidewire within the main body of the aortic stent graft within a maximum 15 minutes cutoff time for each trial. ResultsIn group 1, the mean cannulation time was shorter using IOPS-AR versus fluoroscopy (4.3 ±4.4 min vs 7.1±4.9 min; P=.04), but not statistically different when comparing IOPS-FS and fluoroscopy (6.3±4.5 min vs 7.1±4.9 min; P=.63). In group 1, technical success was 77% with fluoroscopy and 92% with both IOPS-FS and IOPS-AR (P=.59). In group 2, although there was no significant difference between cannulation time amongst the three different endovascular approaches, there was a trend towards shorter cannulation times with IOPS-FS or IOPS-AR as compared to fluoroscopy (mean time of 2.5±0.9, 4.4±4.0 and 5.2±4.5 min, respectively). In group 2, technical success was 92% with fluoroscopy and 100% with both IOPS-FS and IOPS-AR (P>.99). The expert vascular surgeon repeated the cannulation task four times for each endovascular approach, with 100% technical success and no difference in mean cannulation time between the imaging modalities (P=.89). ConclusionsAugmented reality allows for reducing the gate cannulation time as compared to fluoroscopy in participants with no previous exposure to any endovascular procedure. This suggests that augmented reality can be beneficial for individuals early in their career and can mitigate the learning curve. As individuals become experts, their ability to adapt to different endovascular modalities increases, eliminating the learning curve altogether.

Effect of an artificial intelligence-assisted recognition system on colonoscopy quality

Objective: To explore the value of the artificial intelligence (AI)-assisted recognition system in the detection quality of colonoscopy. Methods: From January 2023, the data on 700 patients who underwent colonoscopy in the Digestive Endoscopy Center of the First Affiliated Hospital of Zhejiang Chinese Medical University were collected prospectively. Based on a computerized number method, patients were divided into the AI assistance group and control group. The detection rate of adenomas (ADR) and polyps, number and size of adenomas, Boston bowel preparation scale (BBPS), intubation time, withdrawal time, and cecal intubation rate were compared between groups. Normally distributed data were analyzed with the t-test for independent samples. Non-normally distributed data were analyzed with the Rank sum test. Categorical data were analyzed with the Chi-square test. Results: In total, 691 patients were included in the analysis. According to the intention to treat (ITT) analysis and per-protocol (PP) analysis, the withdrawal time of the AI group was higher than that of the control group (ITT:436 (305, 620) vs 368 (265, 510) s, Z=-4.24, P<0.001;PP:439 (306, 618) vs 364 (262, 500) s,t=-4.50, P<0.001); however, there were no significant differences in the ADR (ITT:123(35.5%) vs 111(32.2%), χ2=0.88, P=0.349;PP:108(34.2%) vs 99(31.1%), χ2=0.67, P=0.414), the number of adenomas (ITT:0(0, 1) vs 0(0, 1),Z=-1.08, P=0.282;PP:0(0, 1) vs 0(0, 1),Z=-0.87, P=0.387), the polyp detection rate (ITT:85(24.6%) vs 85(24.6%),χ2=0.001, P=0.983;PP:79(25.0%) vs 77(24.2%),χ2=0.05, P=0.818), BBPS (ITT:6.5±0.9 vs 6.5±0.7,t=-0.59, P=0.555;PP:6.7±0.6 vs 6.6±0.6,t=-1.83, P=0.068), and cecal intubation rate (ITT:346(100.0%) vs 343(99.4%), χ2=0.50, P=0.478) between these two groups. After excluding inadequate bowel preparation and failed cecal intubation cases, the AI-assisted system was found to significantly improve the detection rate of small adenomas (≤5 mm) (PP:27.8%(88/316)vs 21.1%(67/318), χ2=3.94, P=0.047). Conclusions: The application of an AI-assisted system in colonoscopy can increase the withdrawal time and improve the detection rate of small adenomas.

Endotracheal intubation using a spiral endotracheal tube effectively reduces total tube handling time in children aged one month to six years using a McGrathTM video laryngoscope: a prospective randomized trial.

Airway management in children is challenging because of the smaller size, different proportions of anatomical structures compared to adults, and a higher risk of hypoxemia. Efforts to improve the efficiency of pediatric intubation can be made by manually twisting a spiral endotracheal tube (ETT) using a flexible stylet to manipulate its shape and angle. This controlled trial randomized fifty children aged one month to six years who underwent elective surgery under general anesthesia into two groups (spiral ETT [sETT] and no-stylet ETT/standard ETT). The sETT was formed by twisting the ETT using a handmade tool. The primary objective was to determine the effectiveness of the sETT compared to the standard ETT in reducing intubation time. Secondary objectives were ETT placement accuracy, first-attempt intubation success rate, and adverse effects. The mean total tube handling time in the sETT group was significantly shorter compared to the no-stylet ETT group (sETT 16.8 ± 3.6 vs. standard ETT 18.8 ± 3.7 seconds; P = 0.049). sETT placement had a significantly greater central placement accuracy (odds ratio, 4.846; 95% confidence interval, 1.287-18.255; P = 0.015). However, first-attempt successful intubation rate (sETT 80% vs. standard ETT 64%, P = 0.208) and total intubation time (sETT: 46.5 ± 5.2 vs. standard ETT 48.4 ± 4.9 seconds; P = 0.205) were not significantly different. No adverse effects were observed for either ETT type. Spiral ETT effectively reduces total tube handling time and improves ETT placement accuracy in children using video laryngoscopy.

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational monocentric prospective study

Abstract Background Although temporary mechanical circulatory support (MCS) devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process and decision although there are no standardized protocols for the trial nor accordance on the parameters to apply. Purpose We sought to evaluate the overall accuracy of echocardiographic indices in predicting successful weaning from VA ECMO in patients with CS. Specifically, we tested total isovolumic time (tIVT), an index of ventricular performance, and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Monocentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Weaning trials were performed daily, starting 48 hours after VA-ECMO institution, when patients were hemodynamically stable: mean arterial pressure &amp;gt;65 mmHg, no or minimum adrenergic support (vasoactive inotropic score &amp;lt;10), heart rate &amp;lt;110 bpm, lactate &amp;lt;2 mmol/L, and no signs of respiratory distress. Weaning trials were performed with a stepwise decrease of VA-ECMO blood flow until reaching 1 or 1.5 L/min under adequate anticoagulation. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (table): stroke volume &amp;gt;13.9 mL (p 0.002), tIVT &amp;gt;23.6 min/sec (p 0.053), LV VTI &amp;gt;6.6 cm (p&amp;lt;0.001), MAPSE &amp;gt;6.15 mm (p 0.001), TAPSE &amp;gt;11 mm (p 0.023), RV S’ &amp;gt;10 cm/s (p 0.012). LVEF did not reach the statistical significance. Figure shows Kaplan-Meier analysis on echocardiographic indices collected at time of cannulation (panel A) and during the last weaning trial (panel B). Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Considering the known limitations of LVEF (heart rate, loading and left ventricular dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation of patients in the acute setting.TableFigure

Sedation for awake tracheal intubation: A systematic review and network meta-analysis.

Different sedation regimens have been used to facilitate awake tracheal intubation, but the evidence has not been synthesised robustly, particularly with respect to clinically important outcomes. We conducted a systematic review and network meta-analysis to determine the sedation techniques most likely to be associated with successful tracheal intubation, a shorter time to successful intubation and a lower risk of arterial oxygen desaturation. We searched for randomised controlled trials of patients undergoing awake tracheal intubation for any indication and reporting: overall tracheal intubation success rate; tracheal intubation time; incidence of arterial oxygen desaturation; and other related outcomes. We performed a frequentist network meta-analysis for these outcomes if two or more sedation regimens were compared between included trials. We also performed a sensitivity analysis excluding trials with a high risk of bias. In total, 48 studies with 2837 patients comparing 33 different regimens were included. Comparing overall awake tracheal intubation success rates (38 studies, 2139 patients), there was no evidence suggesting that any individual sedation regimen was superior. Comparing times to successful tracheal intubation (1745 patients, 24 studies), any sedation strategy was superior to placebo. When we excluded trials with a high risk of bias, we found no evidence of a difference between any interventions for time to successful tracheal intubation. Thirty-one studies (1753 patients) suggested that dexmedetomidine and magnesium sulphate were associated with a reduced risk of arterial oxygen desaturation compared with other interventions, but excluding trials with a high risk of bias suggested no relevant differences between interventions. The quality of evidence for each of our outcomes was low. To maximise effective and safe awake tracheal intubation, optimising oxygenation, topical airway anaesthesia and procedural performance may have more impact than any given sedation regimen.

Comparison between Split Dose and Single Dose Bowel Laxatives for Preparation of Colonoscopy in Patients with Bangladeshi Diets: A Randomized Clinical Trial

Introduction: Colonoscopy is an important diagnostic tool for colonic disease and its efficacy and safety have been correlated with adequate bowel preparation. This study compared the efficacy and tolerability of single-dose and split-dose sodium picosulfate lavage as a colon cleansing agent for colonoscopy preparation. Methods: This randomized clinical trial was conducted at the Department of Gastroenterology in Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh from June 2021 to May 2022.A total of 110 patients were selected by randomized sampling technique who underwent elective colonoscopy and were divided into split-dose (n=57) and single-dose (n=53) laxative groups. Bowel preparation was assessed by the Ottawa Bowel Preparation Scale (OBPS) and data were analyzed by SPSS 24.0. Result: The mean age of the patients was 47.4±17.7(SD) years in split-dose and 47.6±15.9 (SD) years in single-dose group. Both groups were statistically similar in terms of socio-demographic profile, medical history, clinical manifestation, and indication of colonoscopy (p&gt;0.05). The mean of total OBPS score (4.39±2.0 vs 5.56±2.2, p=0.004) and caecal intubation time (6.60±3 vs 7.74±2.5, p=0.035) was lower significantly in split-dose than the single-dose group. However, colonoscopy findings, adverse events, and patient compliance were similar between groups (p&gt;0.05). Conclusion: Split-dose is superior to single-dose bowel laxatives for colonoscopy preparation in terms of better mucosal cleanliness and lower caecal intubation time. However, further randomized controlled trial is recommended. J Bangladesh Coll Phys Surg 2024; 42: 329-335

Visual rigid laryngoscopy versus video laryngoscopy for endotracheal intubation in elderly patients: A randomized controlled trial.

To assess the efficacy and safety of visual rigid laryngoscopy and video laryngoscopy and to provide clinical information for developing a more suitable intubation tool for elderly patients. In 75 consecutive elderly patients undergoing elective surgery in a single institution, tracheal intubation was randomly performed by 2 experienced anaesthesiologists using visual rigid laryngoscopy (Group I, n = 38) or video laryngoscopy (Group II, n = 37). The primary outcome was intubation time. Secondary outcomes were the first-attempt success rate of tracheal intubation, haemodynamic responses at 1, 3, and 5 min after intubation and the incidence of postoperative airway complications, including immediate complications and postoperative complaints. The intubation times were 35.0 (30.0-41.5) s and 42.5 (38.0-51.3) s in Groups I and II, respectively (P < 0.001). The difference in direct complications between the two groups was statistically significant (P < 0.05). In contrast, there was no significant difference between the two groups regarding the follow-up of the main complaint 30 min and 24 h after tracheal extubation (P > 0.05). There was no difference in the intubation success rate between the 2 groups (P > 0.05). The haemodynamic responses at 1, 3, and 5 min after intubation were not significantly different (P > 0.05). Compared with that of video laryngoscopy, the intubation time of visual rigid laryngoscopy in elderly patients was shorter. At the same time, visual rigid laryngoscopy reduced the incidence of immediate complications. However, during endotracheal intubation, there was no significant difference in haemodynamics between the two groups. ChiCTR2100054174.

Prospective evaluation of extended reality for neonatal intubation education

Purpose360° immersive videos may be useful in procedure-based healthcare settings. We hypothesized that extended reality (XR) neonatal intubation education is a feasible alternative to live demonstration in skill and knowledge transfer.MethodsThis was a prospective single center evaluation of an educational XR intubation video using Premature Anne™ (Laerdal Medical, Stavanger, Norway) comparing to a live demonstration. Participants were randomly allocated to either live demonstration or XR group. Each group received 20 min of teaching from the pediatric respiratory care education specialist, either in person or in video format. Intubation success, knowledge and skill acquisition were measured using a questionnaire and checklist.ResultsWe had a total of 23 participants, XR (n = 11) and live demonstration (n = 12). The groups were heterogeneous in experience level.The XR group was successful at intubating 73% of the time (n = 8), which was not significantly different to the live demonstration group 58% (n = 7) (p = 0.667). For patients who achieved intubation, there was no difference between groups in the mean time to successful intubation; 98 s (SD 73) for the XR group and 65 s (SD 22) for the live demonstration group (p = 0.685).When comparing scores between groups there were no statistically significant differences regarding knowledge scores (p = 0.514), skill scores (p = 0.826) and total scores (p = 0.926).ConclusionThese preliminary findings indicated no significant differences between the XR and live demonstration groups in terms of intubation success, knowledge acquisition, skill performance, total scores or time to successful intubation.

Improving airway management in pediatric emergency intubation: A narrative review with a focus on bougie guidance in settings with limited resources

AbstractBackgroundEffective airway management in pediatric emergency settings, especially in resource‐limited environments, presents unique challenges that necessitate innovative solutions.ObjectivesThis review investigates the role of bougie‐guided pediatric intubation as a crucial technique in addressing these challenges.MethodsA comprehensive search of peer‐reviewed literature was conducted using reputable databases such as PubMed, Scopus, Google Scholar, and Web of Science. Suitable keywords and Medical Subject Headings terms were employed. Data extraction focused on study design, patient demographics, intervention protocols, primary outcomes, and safety profiles. A qualitative synthesis was performed to provide a comprehensive narrative review.ResultsPediatric bougies, known for their cost‐effectiveness and adaptability, emerge as promising tools for successful and efficient pediatric intubation. Comparative studies indicate that bougie use results in superior first‐pass success rates and reduced intubation times. Case studies highlight the bougie's versatility in managing difficult pediatric airways.ConclusionsThe bougie's cost‐effectiveness positions it as a practical solution to disparities in treatment levels. Successful pediatric intubation in resource‐limited settings requires improved accessibility, standardized proficiency, and infrastructure readiness. Integrating the bougie into pediatric airway management guidelines represents a proactive approach to these challenges.

Cervical spine motion during videolaryngoscopic intubation using a Macintosh-style blade with and without the anterior piece of a cervical collar: a randomized controlled trial.

Applying a cervical collar during videolaryngoscopic intubation can increase the lifting force required to achieve adequate glottic view, potentially increasing cervical spine motion. We aimed to compared cervical spine motion during videolaryngoscopic intubation between applying only the posterior piece (posterior-only group) and applying both the anterior and posterior pieces (anterior-posterior group) in patients wearing a cervical collar. We conducted a dingle-centre, parallel-group, randomized controlled trial in 102 patients (each group, N = 51). We used a videolaryngoscope (AceScope™, Ace Medical, Seoul, Republic of Korea) with a Macintosh-style blade (AceBlade™, Ace Medical, Seoul, Republic of Korea) for videolaryngoscopic intubation. In each group (posterior-only vs anterior-posterior), we measured cervical spine motion during intubation, defined as change in cervical spine angle (calculated as cervical spine angle at intubation minus that before intubation) at three cervical spine segments on lateral cervical spine radiographs. The differences in mean cervical spine motion during intubation between the posterior-only and anterior-posterior groups were 1.2° (98.3% confidence interval [CI], -0.7 to 3.0), 1.0° (98.3% CI, -0.6 to 2.6), and -0.3° (98.3% CI, -2.2 to 1.7) at the occiput-C1, C1-C2, and C2-C5 segments, respectively. Mean (standard deviation) cervical spine angles at the occiput-C1, C1-C2, and C2-C5 segments in the posterior-only vs anterior-posterior groups were 10.8° (4.2) vs 9.6° (3.3) (P = 0.13), 5.6° (3.0) vs 4.7° (3.5) (P = 0.14), and 1.2° (3.7) vs 1.5° (4.3) (P = 0.74), respectively. Intubation times were shorter in the posterior-only group (median [interquartile range], 23 [19-28] sec vs 33 [20-47] sec; P = 0.003). In patients wearing a cervical collar, the differences in mean cervical spine motions during intubation between applying only the posterior piece and applying both the anterior and posterior pieces were approximately 1°. Intubation times were significantly shorter without the anterior piece of a cervical collar. These findings can be referred to when removal of the anterior piece of a cervical collar is considered to address difficult videolaryngoscopic intubation conditions. CRIS.nih.go.kr ( KCT0008151 ); first submitted 17 January 2023.