Endotracheal Intubation Time Research Articles

Outcome in early vs late intubation among COVID-19 patients with acute respiratory distress syndrome: an updated systematic review and meta-analysis

Timing of endotracheal intubation in COVID-19 patients with acute respiratory distress syndrome (ARDS) remains controversial regarding its risk and benefit in patient outcomes. Our study aims to elucidate early versus late intubation outcomes among COVID-19 patients with ARDS. A protocol of this study is registered at the international prospective register of systematic reviews (PROSPERO) (CRD42021230272). We report our systematic review based on PRISMA and MOOSE guidelines. We searched the Cochrane Library, EBSCOhost, EMBASE, Grey Literature Report, OpenGrey, ProQuest, PubMed, and ScienceDirect from inception until 4 December 2021. Titles and abstracts were reviewed for their relevance. The risk of bias in each study was evaluated using the risk of bias in non-randomised studies-of interventions (ROBINS-I) guideline. Trial sequential analysis is done to elucidate firm evidence. We retrieved 20 observational studies that assessed an intervention (early vs. late intubation). Meta-analysis for in-hospital mortality reduction showed 119 fewer deaths per 1000 patients in early intubation. Early intubation reduces 2.81 days of ICU length of stay (LOS) and 2.12 days of ventilation duration. Benefits for mortality and ICU LOS reduction were based on studies with low to moderate risk of bias while ventilation duration was based on low disease burden setting. According to the contextualized approach, the benefit of mortality reduction showed a trivial effect, while ICU LOS and ventilation duration showed a small effect. GRADE certainty of evidence for mortality reduction in early intubation is moderate. The certainty of evidence for ICU length of stay, ventilation duration, ventilator-free days, and continuous renal replacement therapy are very low. This updated systematic review provided new evidence that early intubation might provide benefits in treating COVID-19 patients with ARDS. The benefits of early intubation appear to have an important but small effect based on contextualized approach for ICU LOS and ventilation duration. In reducing in-hospital mortality, the early intubation effect was present but only trivial based on contextualized approach. TSA showed that more studies are needed to elucidate firmer evidence.

Whether the infracardiac bursa protect right pleura during laparoscopic radical operation of Siewert type II adenocarcinoma of esophagogastric junction?

BackgroundTransthoracic single-port assisted laparoscopic five-step maneuver inferior mediastinal lymphadenectomy for Siewert type II adenocarcinoma of esophagogastric junction (AEG) has superiority in lower mediastinal lymph nodes dissection and digestive tract reconstruction. However, the right pleura was probably ruptured in this surgical technique. The aim of this study was to explore whether the infracardiac bursa (ICB) exposed could protect right pleura.MethodsWe retrospectively collected and evaluated the clinical and pathological data of patients who underwent five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymphadenectomy for Siewert II AEG at Guangdong Provincial Hospital of Chinese Medicine between May 2017 and February 2022.ResultsA total of 49 patients were eligible, including 31 patients in ICB exposed group (group A) and 18 patients in ICB unexposed group (group B). There were no statistically significant differences in baseline characteristics between the two groups. 4 patients (12.9%) had right pleura rupture in group A, while 14 patients (77.8%) in group B, and the difference was statistically significant (p < 0.001). Compared with group B, the extubation time of endotracheal intubation (10.0 (6.0 ~ 12.0) vs. 13.0 (8.0 ~ 15.0) min, p = 0.003) and thoracic drainage tube stay (6.0 (5.0 ~ 7.0) vs. 8.0 (6.0 ~ 10.5) days, p = 0.041) were significantly shorted in the group A. The drainage volume of thorax (351.61 ± 125.00 vs. 418.61 ± 207.86 mL, p = 0.146) was non-significant less and the rate of complications (3.2% vs. 11.1%, p = 0.074) was non-significant lower in group A compared with group B. The postoperative hospital stay (9.0 (8.0,13.0) vs. 9.0 (8.0,12.0) days, p = 0.983) were similar in two groups. No serious adverse event occurred in any patient.ConclusionsThe ICB exposed could protect the right pleura and may promote postoperative recovery, which may be used as an anatomical marker in inferior mediastinal lymphadenectomy.

Co-Infection and Ventilator-Associated Pneumonia in Critically Ill COVID-19 Patients Requiring Mechanical Ventilation: A Retrospective Cohort Study.

Considering virus-related and drug-induced immunocompromised status of critically ill COVID-19 patients, we hypothesize that these patients would more frequently develop ventilator-associated pneumonia (VAP) than patients with ARDS from other viral causes. We conducted a retrospective observational study in two intensive care units (ICUs) from France, between 2017 and 2020. We compared bacterial co-infection at ICU admission and throughout the disease course of two retrospective longitudinally sampled groups of critically ill patients, who were admitted to ICU for either H1N1 or SARS-CoV-2 respiratory infection and depicted moderate-to-severe ARDS criteria upon admission. Sixty patients in the H1N1 group and 65 in the COVID-19 group were included in the study. Bacterial co-infection at the endotracheal intubation time was diagnosed in 33% of H1N1 and 16% COVID-19 patients (p = 0.08). The VAP incidence per 100 days of mechanical ventilation was 3.4 (2.2–5.2) in the H1N1 group and 7.2 (5.3–9.6) in the COVID-19 group (p < 0.004). The HR to develop VAP was of 2.33 (1.34–4.04) higher in the COVID-19 group (p = 0.002). Ten percent of H1N1 patients and 30% of the COVID-19 patients had a second episode of VAP (p = 0.013). COVID-19 patients have fewer bacterial co-infections upon admission, but the incidence of secondary infections increased faster in this group compared to H1N1 patients.

An Evaluation of the Intubrite Laryngoscope in Simulated In-Hospital and Out-of-Hospital Settings by Individuals with No Clinical Experience: A Randomized, Cross-Over, Manikin Study.

Introduction: The aim of the study was to compare the Intubrite laryngoscope and the standard Macintosh blade laryngoscope (MCL) used by persons with no clinical experience in simulated hospital and non-hospital conditions on a manikin model. Materials and methods: The study involved 50 students of Medical Rescue. The hospital conditions (intubation height 110 cm—high position) and those occurring at the scene (intubation of a manikin located at floor level-low position) were simulated. The analysis included: duration of intubation, visibility of the laryngeal opening by the Cormack–Lehane scale, the bioelectrical activity of the intubating muscles, comfort and subjective assessment of physical effort by the Borg scale (Borg’s scale of subjective feeling of effort). The statistical analysis was performed with Microsoft Excel and T-student tests for pairs with unequal variables. The statistical importance was set at p < 0.05. Results: The use of an Intubrite laryngoscope significantly reduces the mean endotracheal intubation time compared to the Macintosh laryngoscope in a low position (17.34 s versus 19.04 s, p < 0.05). A higher rate of repeat intubations was observed in a low position for MCL (from 10% to 14%, p < 0.05). The reverse is true for Intubrite laryngoscope intubation (from 8% to 4%, p < 0.05 Please explain what is compared). The Intubrite laryngoscope improved visualization of glottis in the high and the low positions compared to the Macintosh laryngoscope (54% and 50% to 52% and 38%, respectively, p < 0.05). The risk of tooth damage was the same for the Intubrite and the MCL laryngoscopes in a high position (16% and 14%, respectively, p > 0.05), while in the simulated out-of-hospital setting, it was significantly higher for the MCL (22% versus 8%, p < 0.05). The subjective comfort of intubation in both simulated situations was similar according to the Borg scale (p-value, values). The use of the Intubrite laryngoscope was associated with less effort than the MCL in high versus low positions. For MCL, intubation in a high position was associated with lower mean muscle activity than in a low position (+48.24 µV versus +58.25 µV, p-value). For the Intubrite laryngoscope, these values were at similar levels (+52.03 µV and +52.65 µV, p-value). Conclusions: The use of the Intubrite laryngoscope by people with no clinical experience shortens the time of intubation and improves the laryngeal view compared to the standard Macintosh laryngoscope, but it requires similar muscle work in simulated conditions.

Effectiveness of Perioperative Cardiopulmonary Rehabilitation in Patients With Lung Cancer Undergoing Video-Assisted Thoracic Surgery.

ObjectivesPatients with lung cancer pose a high risk of morbidity and mortality after lung resection. Those who receive perioperative cardiopulmonary rehabilitation (PRCR) have better prognosis. Peak oxygen consumption (peak VO2), VO2 at the ventilatory threshold (VO2 at VT), and slope of minute ventilation to carbon dioxide production (VE/VCO2 slope) measured during pre-surgical cardiopulmonary exercise testing (CPET) have prognostic values after lung resection. We aimed to investigate the influence of individualized PRCR on postoperative complications in patients undergoing video-assisted thoracic surgery (VATS) for lung cancer with different pre-surgical risks.MethodsThis was a retrospective study. We recruited 125 patients who underwent VATS for lung cancer between 2017 and 2021. CPET was administered before surgery to evaluate the risk level and PRCR was performed based on the individual risk level defined by peak VO2, VO2 at VT, and VE/VCO2 slope, respectively. The primary outcomes were intensive care unit (ICU) and hospital lengths of stay, endotracheal intubation time (ETT), and chest tube insertion time (CTT). The secondary outcomes were postoperative complications (PPCs), including subcutaneous emphysema, pneumothorax, pleural effusion, atelectasis, infection, and empyema.ResultsThree intergroup comparisons based on the risk level by peak VO2 (3 groups), VO2 at VT (2 groups), and VE/VCO2 slope (3 groups) were done. All of the comparisons showed no significant differences in both the primary and secondary outcomes (p = 0.061–0.910).ConclusionPatients with different risk levels showed comparable prognosis and PPCs after undergoing CPET-guided PRCR. PRCR should be encouraged in patients undergoing VATS for lung cancer.

Optic nerve ultrasound and cardiopulmonary bypass: A pilot study.

Introduction:Despite advances in surgical, anesthetic, perfusion, and postoperative care, adverse neurological consequences may occur following cardiac surgery and cardiopulmonary bypass (CPB). Consequences of the physiologic effects of CPB may alter the blood–brain barrier, autoregulation, and intracranial pressure (ICP) in the immediate postoperative period.Methods:We evaluated the effects of cardiac surgery and CPB on the central nervous system by measuring the optic nerve sheath diameter (ONSD) by using ultrasound as a surrogate marker of ICP. ONSD was measured after anesthetic induction and endotracheal intubation (time 1), after separation from CPB (time 2), and at the completion of the surgical procedure prior to leaving the OR (time 3).Results:The study cohort included 14 patients, ranging in age from newborn to 6 years. When comparing the Fontan group (n = 5) to the non-Fontan group (n = 9), four elevated ONSD observations were recorded for the Fontan patients during the study period, including one at time 1, one at time 2, and two at time 3. In Fontan versus non-Fontan patients, ONSD was greater at all three time points compared to non-Fontan. The change in the ONSD from time 1 to time 2 was greater (+0.2 mm vs. −0.1 mm), and the mean value at time 2 was significantly higher (4.2 vs. 3.5 mm, P = 0.048).Conclusions:Patients with Fontan physiology may be more prone to higher levels of baseline intracranial pressure due to elevated systemic venous pressure and decreased cardiac output. Alternatively, the chronically high central venous pressures may artificially elevate ONSD without clinical changes in ICP, necessitating the development of separate normative values based on the type of congenital heart disease.

Poor Sensorium at the Time of Intubation Predicts Polymicrobial Ventilator Associated Pneumonia.

BackgroundVentilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit and is associated with a high mortality rate.AimThe study was conducted to estimate the frequency, outcomes, and predictors of polymicrobial VAP.MethodsA prospective observational study was conducted in mechanically ventilated adult patients in the medical intensive care unit in a tertiary care hospital in India from July 2016 to July 2018 with a 30-day follow-up period. The patients were grouped into monomicrobial and polymicrobial VAP. We compared the 30-day outcome parameters such as discharge from hospital, in-hospital stay, death, and complications such as catheter associated urinary tract infection (CAUTI), central line associated blood stream infection (CRBSI), bacteremia and collapse of lung. The predictors of polymicrobial VAP were identified by multiple logistic regression.ResultsOut of 301 patients clinically diagnosed with VAP, 151 patients were excluded, and the remaining 150 developed 186 episodes of VAP during the study period. The incidence of polymicrobial VAP was 62.9%. Out of 150 patients, 51 patients had monomicrobial VAP, and 99 had polymicrobial VAP. On univariate analysis, diabetes mellitus and poor sensorium (Glasgow Coma Scale [GCS] score <8) during endotracheal intubation; 30-day outcome, mean days of mechanical ventilation after VAP diagnosis and days in ICU; and CAUTI were significantly associated with polymicrobial VAP. On multivariable logistic regression, poor sensorium (GCS score <8) at the time of endotracheal intubation was an independent predictor of polymicrobial VAP.ConclusionThe incidence of polymicrobial VAP is high in the medical ICU and is associated with increased duration of mechanical ventilation, hospital stay, and incidence of CAUTI. Poor GCS score was the single independent predictor of polymicrobial VAP.

Variation in Pediatric Anesthesiologist Sedation Practices for Pediatric Gastrointestinal Endoscopy.

Background: Despite a worldwide shift toward anesthesiologist-administered sedation for gastrointestinal endoscopy in children, ideal sedation regimens remain unclear and best practices undefined.Aim: The aim of our study was to document variation in anesthesiologist-administered sedation for pediatric endoscopy. Outcomes of interest included coefficients of variation, procedural efficiency, as well as adverse events.Methods: IRB approval was obtained to review electronic health records of children undergoing routine endoscopy at our medical center during a recent calendar year. Descriptive and multivariate analyses were used to examine predictors of sedation practices.Results: 258 healthy children [2–21 years (median 15, (Q1–Q3 = 10–17)] underwent either upper and/or lower endoscopies with sedation administered by anesthesiologists (n = 21), using different sedation regimens (29) that ranged from a single drug administered to 6 sedatives in combination. Most patients did not undergo endotracheal tube intubation for the procedure (208, 81%), and received propofol (255, 89%) either alone or in combination with other sedatives. A total of 10 (3.8%) adverse events (9 sedation related) were documented to occur. The coefficient of variation (CV) for sedation times was high at 64.2%, with regression analysis suggesting 8% was unexplained by procedure time. Multivariable model suggested that longer procedure time (p < 0.0001), younger age (p < 0.0001), and use of endotracheal tube intubation (p = 0.02) were associated with longer sedation time.Discussion: We found great variation in anesthesiologist administered regimens for pediatric endoscopy at our institution that may be unwarranted, presenting may opportunities for minimizing patient risk, as well as for optimizing procedural efficiency.

Hirudotherapy (medicinal leeches) for treatment of upper airway obstruction in a dog

To describe upper airway obstruction (UAO) in a dog treated with medicinal leeches (hirudotherapy) as an ancillary therapy to hasten recovery. A 10-month-old neutered female Mastiff presented for acute respiratory distress. On admission, the dog was tachycardic, cyanotic, and orthopneic; stridor was audible. A 10-cm soft tissue swelling in the right ventral cervical region and bruising around the rostral mandible were noted. At the time of endotracheal intubation, the trachea was deviated to the right as a consequence of severe soft tissue swelling that was contiguous with the sublingual hematoma and cervical region, causing loss of visualization of the arytenoids. A computed tomography with contrast scan of the head, neck, and thorax was performed, showing severe soft tissue swelling of the tongue, obliteration of the common pharyngeal/laryngeal regions from suspected hemorrhage, and rightward displacement of pharynx, larynx, and proximal trachea. Marked diffuse bronchial/bronchiolar thickening associated with bronchiolectasis and diffuse opacification of the pulmonary parenchyma with regions of consolidation were noted. The dog was minimally hypercoagulable on thromboelastography. The imaging results together with results of bronchoalveolar lavage cytology supported a comorbidity of eosinophilic bronchopneumopathy. Intubation was maintained with infusions of propofol and fentanyl, with minimal changes in oropharyngeal swelling within the first 18hours of treatment. Medicinal leeches were then applied to the sublingual and cervical regions. There was continued slow bleeding from the sites of leech detachment, and the dog was able to be extubated at 44hours, followed by hospital discharge. Leeches are utilized in human medicine for treatment of UAO. Although UAO from hemorrhage has been described in dogs, this is the first report of medicinal leeches (Hirudo verbana) as complementary treatment for sublingual hematoma that contributed to UAO.

The ROX index as a predictor of standard oxygen therapy outcomes in thoracic trauma

BackgroundThoracic trauma is commonplace and accounts for 50–70% of the injuries found in severe trauma. Little information is available in the literature as to timing of endotracheal intubation. The main objective of this study was to assess the accuracy of the ROX index in predicting successful standard oxygen (SO) therapy outcomes, and in pre-empting intubation.MethodsPatient selection included all thoracic trauma patients treated with standard oxygen who were admitted to a Level I trauma center between January 1, 2013 and April 30, 2020. Successful standard SO outcomes were defined as non-requirement of invasive mechanical ventilation within the 7 first days after thoracic trauma.ResultsOne hundred seventy one patients were studied, 49 of whom required endotracheal intubation for acute respiratory distress (28.6%). A ROX index score ≤ 12.85 yielded an area under the ROC curve of 0.88 with a 95% CI [0.80–0.94], 81.63sensitivity, 95%CI [0.69–0.91] and 88.52 specificity, 95%CI [0.82–0.94] involving a Youden index of 0.70. Patients with a median ROX index greater than 12.85 within the initial 24 h were less likely to require mechanical ventilation within the initial 7 days of thoracic trauma.ConclusionWe have shown that a ROX index greater than 12.85 at 24 h was linked to successful standard oxygen therapy outcomes in critical thoracic trauma patients. It is our belief that an early low ROX index in the initial phase of trauma should heighten vigilance on the part of the attending intensivist, who has a duty to optimize management.

Application of different kinds of endotracheal intubation in the combined thoracoscopic and laparoscopic esophagectomy

Objective: To observe the application of three different kinds of endotracheal intubation in the combined thoracoscopic and laparoscopic esophagectomy. Methods: one hundred and eighty patients undergoing combined thoracoscopic and laparoscopic esophagectomy under general anesthesia from the Affiliated Cancer Hospital of Zhengzhou University from February to September 2019 were randomly divided into three groups which include: double-lumen endotracheal intubation group (group S,n=60),single-lumen endotracheal intubation group (group D,n=60) and Coopdech occlusion of bronchial catheter combined with a single-lumen endotracheal intubation group (group C,n=60). The arterial blood samples were collected immediately after endotracheal intubation (T0), 30 min after artificial pneumothorax (single lung ventilation) (T1), 30 min after artificial pneumothorax (double lung ventilation) (T2), and 30 min after extubation (T3) to detect arterial blood gas. Patients' heart rate (HR), blood oxygen partial pressure (PaO2), blood carbon dioxide partial pressure (PaCO2) and airway pressure(Paw) were recorded at T0-T3.Completion time of endotracheal intubation, carbon dioxide intrathoracic inflation pressure, degree of lung collapse and incidence of postoperative 3-day pneumonia in three groups were recorded. The bronchoalveolar lavage fluid (BALF) of patients at T0, T2 and the end of the operation (T4) were collected to detect the levels of tumor necrosis factor-α(TNF-α), interleukin-6 (IL-6) and interleukin-8 (IL-8) in BALF by enzyme-linked immunosorbent assay (ELISA). Results: A total of 14 patients were excluded during the operation, of which 9 cases lasted longer than 6 hours, 3 cases had arrhythmia during the operation and 2 cases lasted less than 1 hour. Finally, 56 cases in group S, 54 cases in group D and 56 cases in group C completed the experiment. The satisfaction rates of lung collapse in group S, group D and group C were 85.7% (48/56), 100.0% (54/54), 89.2% (50/56), respectively, with no statistically significant difference (χ²=1.308, P>0.05). The intrathoracic inflation pressure of carbon dioxide in group D was (10.2±2.2) mmHg (1 mmHg=0.133 kPa), which was higher than (5.1±3.4) mmHg in group S and (5.6±3.1) mmHg in group C, the difference was statistically significant (F=-9.303, P<0.05). The incidence of postoperative 3-day pneumonia in group D was 14.8%, which was lower than 39.3% in group S and 17.8% in group C, the difference was statistically significant (χ²=8.300, P<0.05). At T4, the value of TNF-α in group D was (122.4±4.4) ng/L, which was lower than that in group S and group C, (257.9±6.3) and (185.8±5.6) ng/L, with statistically significant difference (F=69.020, P<0.05). At T4, the value of IL-6 in group D was (175.4±4.9) ng/L, which was lower than that of patients in group S and group C, (289.6±6.8) and (226.2±4.4) ng/L, with statistically significant difference (F=59.750, P<0.05). At T4, the value of IL-8 in group D was (303.1±7.2) ng/L, which was lower than in group S and group C, (595.4±22.1) and (436.8±10.9) ng/L, with statistically significant difference (F=55.359, P<0.05). Conclusion: All the three endotracheal intubations can produce satisfactory ventilation effect in the combined thoracoscopic and laparoscopic esophagectomy, however, single-lumen endotracheal intubation has less effect on lung injury.

Early endotracheal intubation improves neurological outcome following witnessed out-of-hospital cardiac arrest in Japan: a population-based observational study.

AimIt is unclear whether endotracheal intubation in the prehospital setting improves outcomes following out‐of‐hospital cardiac arrest. The purpose of this study was to evaluate the association between endotracheal intubation time (time from patient contact to endotracheal intubation) and favorable neurological outcomes on out‐of‐hospital cardiac arrest.MethodsWe extracted patients who underwent endotracheal intubation on the scene from a nationwide out‐of‐hospital cardiac arrest database registered between 2014 and 2017 in Japan. We included 14,969 witnessed and intubated adult out‐of‐hospital cardiac arrest cases. Patients were divided into Shockable (n = 1,102) and Non‐shockable (n = 13,867) cohorts. We first drew the logistic curve due to predicting the association between endotracheal intubation time and favorable neurological outcome defined as Cerebral Performance Category (CPC) 1 or 2. Secondary, multivariable logistic regressions were used to estimate the association between the endotracheal intubation time (1‐min unit increase), CPC 1 or 2.ResultsThe logistic curve for CPC 1 or 2 showed similar shapes and indicated a decreasing outcome over time. From the results of multivariable logistic regression, in the Shockable cohort, endotracheal intubation time delay was correlated with decreasing favorable outcomes: CPC 1 or 2 (adjusted odds ratio, 0.89; 95% confidence interval, 0.82–0.87). Results were the same for the Non‐shockable cohort: CPC 1 or 2 (adjusted odds ratio, 0.94; 95% confidence interval, 0.89–0.99).ConclusionEarly endotracheal intubation was correlated with favorable neurological outcome. Training for intubation skills and improving protocols are needed for carrying out early endotracheal intubation.

A Comparative Study in Airway Novices Using King Vision Videolaryngoscope and Conventional Macintosh Direct Laryngoscope for Endotracheal Intubation.

Background and Objectives:Tracheal intubation using laryngoscopy is a fundamental skill, for an anesthesiologist. However, teaching this skill is difficult since Macintosh direct laryngoscope (DL) allows only one individual to view the larynx during the procedure. Hence, this study aimed to determine whether King Vision® videolaryngoscope (KVL) provides any advantage over direct laryngoscopy in teaching this skill to airway novices.Materials and Methods:In this prospective randomized crossover study, Ethical Committee clearance was obtained from the institutional review board (MSRMC/EC/2017) and the study was registered with Clinical Trial Registry. After informed consent, 53 medical students were allotted to perform laryngoscopy and endotracheal intubation on a manikin by using either KVL or Macintosh DL. The participants first performed laryngoscopy with either KVL or Macintosh DL following a brief instruction and then crossed over to the second arm of the study to perform laryngoscopy using the other scope. The primary outcome measure was the time for successful endotracheal intubation. The secondary outcome measures were incidence of esophageal intubation (EI), excess application of pressure on maxillary teeth excess maxillary pressure, and success rate.Results:Mean time for endotracheal intubation was significantly faster using KVL than in DL (44.64 vs. 87.72 s; P < 0.001). No significant difference was found in the incidence of esophageal intubation 15.1% in KVL group versus 24.5% in DL group (P = 0.223). In the KVL group, 81.1% did not apply pressure on maxillary teeth versus 26.4% in the DL group (P < 0.001). The success rate of intubation was 100% in the KVL group versus 86.8% in the DL group (P = 0.006).Conclusion:The KVL is a more effective tool to teach endotracheal intubation in comparison to Macintosh laryngoscope in airway novice medical students. Clinical trial registry India registration number: CTRI/2017/11/010491.

Analysis on clinical characteristics of patients undergoing CPR in department of emergency and factors influencing the success of resuscitation

To analyze the clinical data and characteristics of patients undergoing cardiopulmonary resuscitation (CPR) in the emergency department and the factors affecting the success of resuscitation, so as to allocate medical resources in emergency department, improve the CPR process and increase the success rate of CPR. 538 patients with cardiac arrest who were registered by Utstein in the emergency department of the Third Central Hospital of Tianjin from December 2009 to December 2019 were selected as study subjects. The clinical data and characteristics were analyzed. According to whether the resuscitation was successful, the patients were divided into successful group and failed group, and the factors influencing success of resuscitation were analyzed. A total of 538 patients were enrolled in this study, with an average age of (65.53±15.56) years old. The number of patients aged 71-80 years old was the largest (145 cases, 27.0%), followed by those aged 61-70 years old (105 cases, 19.5%) and 51-60 years old (99 cases, 18.4%). The main causes of cardiac arrest were acute myocardial infarction in 203 cases (37.7%), unknown causes in 77 cases (14.3%) and other cardiac causes in 61 cases (11.3%). The initial types of heart rhythm were no pulse electrical activity (215 cases, 40.0%) and cardiac arrest (179 cases, 33.3%). In this study, 195 patients were resuscitated successfully, and the success rate of recovery was 36.2%. Compared with the successful group, the time of onset to resuscitation (minutes: 14.94±1.03 vs. 9.02±1.05), start time of epinephrine application (minutes: 8.50±0.02 vs. 4.21±0.16), time of onset to endotracheal intubation success (minutes: 9.56±1.87 vs. 5.86±0.84) and total duration of CPR (minutes: 48.75±1.73 vs. 35.39±2.51) in the failed group were significantly prolonged (all P < 0.05), and the cumulative epinephrine dosage was significantly increased (mg: 8.48±4.81 vs. 6.31±4.86, P < 0.05). There were significant differences in the location of onset and main causes of cardiac arrest between the two groups (both P < 0.05), but there were no significant differences in gender, age, initial heart rate type and the proportion of defibrillation (all P > 0.05). Binary Logistic analysis showed that the time from onset to resuscitation [odds ratio (OR) = 1.763, 95% confidence interval (95%CI) was 1.713-1.804, P = 0.000], cumulative dosage of epinephrine (OR = 1.759, 95%CI was 1.708-1.765, P = 0.000), time of onset to endotracheal intubation success (OR = 1.023, 95%CI was 0.988-1.047, P = 0.008) and start time of epinephrine use (OR = 1.819, 95%CI was 1.785-1.946, P = 0.002) were risk factors for successful resuscitation (all P < 0.05). Cardiogenic disease is the main cause of cardiac arrest, and the time from onset to resuscitation, cumulative dosage of epinephrine, success time of endotracheal intubation and time of epinephrine application are independent factors influencing the success of resuscitation in department of emergency.

Impact of Cold Ischemia Time on the Function of Liver Grafts Preserved With Custodiol

ObjectiveThis study aimed to evaluate how cold ischemia time (CIT) interferes with liver graft function in the first 7 days after surgery for Custodiol (HTK) preserved organs. MethodsThis retrospective observational study analyzed the medical records of 38 transplantation patients at Hospital Leforte Liberdade, São Paulo, in 2018. The study population was divided into 2 groups (group A, CIT < 8 hours; group B, CIT > 8 hours). Postoperative parameters—such as international normalized ratio, total bilirubin, aspartate aminotransferase/alanine aminotransferase, alkaline phosphatase, gamma glutamyl transferase (GGT), lactate dehydrogenase, lactate, creatinine, red blood cell transfusion, need for hemodialysis, use of vasoactive drugs, endotracheal intubation time, length of stay in the intensive care unit (ICU), and length of hospital stay—were compared. ResultsGroup A (CIT < 8 hours) presented less need for red blood cell transfusions (odds ratio 0.29; confidence interval 0.06-0.98; P = .04), had a shorter hospital stay (P = .024), and had lower levels of total bilirubin (P = .05) and GGT (P = .05) in the first 7 postoperative days. The other variables showed no statistically significant difference. ConclusionIn livers preserved with Custodiol, CIT > 8 hours generated higher levels of total bilirubin and GGT in the postoperative period, in addition to higher hospital costs; greater need for red blood cell transfusions; and longer hospitalization, including longer stays in the ICU.

Proteomic profiling identifies key differences between inter-stage infants with single ventricle heart disease and healthy controls

Despite significant morbidity among infants with single ventricle heart disease (SVHD), clinical monitoring is limited by poor understanding of the underlying pathobiology. Proteomics can identify novel biomarkers and important pathways in complex disease. No prior study has evaluated whether the proteome of SVHD infants differs from healthy controls, how it shifts after stage 2 palliation, or whether differences can predict post-operative outcomes. We present a prospective cohort study of cardiovascular proteomic phenotyping in infants with SVHD undergoing stage 2 palliation. Twenty-nine pre-stage-2 SVHD infants and 25 healthy controls were enrolled. Outcomes included postoperative hypoxemia and endotracheal intubation time. Serum samples were drawn pre-operatively (systemic and pulmonary vein) and at 24 hours postoperation. Targeted cardiovascular proteomic analysis included 184 proteins. Partial least squares discriminant analysis distinguished cases from controls (Accuracy = 0.98, R2 = 0.93, Q2 = 0.81) with decreased inflammatory mediators and increased modulators of vascular tone. Partial least squares discriminant analysis also distinguished cases pre-operation vs. post-operation (Accuracy=0.98, R2=0.99, Q2 = 0.92) with postoperative increase in both inflammatory and vascular tone mediators. Pre-operation pulmonary vein tissue inhibitor of metalloproteinase-1 (1.8x-fold, p=1.6 × 10-4) and nidogen-1 (1.5x-fold, p=1.7 × 10-4) were higher in subjects with longer endotracheal intubation time. Postoperation matrix metalloproteinase 7 levels were higher in subjects with greater postoperative hypoxemia (1.5x-fold, P= 1.97 × 10-5). Proteomic analysis identifies significant changes among SVHD infants pre- and post-stage 2, and healthy controls. Tissue inhibitor of metalloproteinase-1, nidogen-1, and matrix metalloproteinase 7 levels are higher in SVHD cases with greater morbidity suggesting an important role for regulation of extracellular matrix production. Proteomic profiling may identify high-risk SVHD infants.

Assessment of endotracheal intubation procedures following inadvertent esophageal intubation. A randomized crossover manikin trial

Abstract&#x0D; Objective: To evaluate the success, degree of difficulty and completion time of endotracheal intubation without removing the endotracheal tube in the event of an oesophageal intubation.&#x0D; Methods: The prospective, randomised crossover study was conducted at Gulhane Training and Research Hospital, Ankara, Turkey, from July 1, 2018, to August 31, 2018, and used a manikin model. Endotracheal intubation was performed using Miller, Macintosh blades and a video laryngoscope. The procedures were randomised into two groups, with group E+ being subjected to it while an endotracheal tube ETT was placed in the oesophagus (E+) simulating the oesophageal intubation, and control group E- getting the standard procedure without the endotracheal tube in the oesophagus. All methods were evaluated for their success, completion time, and degree of difficulty. Data was analysed using SPSS 22.&#x0D; Results: There were 120 manikins, with 60(50%) in each of the two groups. The mean completion time with Miller in E+ group was 19.05±9.65 and for E- it was 17.55±11.95 seconds. With Macintosh, E+ had a mean completion time of 19.85±12.66 seconds and E- had 16.75±8.66. With video laryngoscope, E+ group had a mean completion time of 16.75±8.66 seconds, while E- had it 14.60±8.17. No significant difference was found in the paired group comparisons in terms of the degree of task difficulty (p&gt;0.05).&#x0D; Conclusion: In case of inadvertent oesophageal intubation condition, leaving the tube in the oesophagus and performing subsequent endotracheal intubation attempts was not found to decrease the rate of success regardless of the laryngoscope type.&#x0D; Continuous… &#x0D;

Effects of Using an Endotracheal Tube Introducer for Intubation During Mechanical Chest Compressions of a Manikin: Randomized, Prospective, Crossover Study.

Airway management methods during out-of-hospital cardiac arrest remain controversial. This study aimed to compare the impact of using an endotracheal tube introducer with a Macintosh laryngoscope on the first-pass success rates of final-year medical students on a manikin during continuous chest compressions with a mechanical compression device. Fifty-two final-year students of the faculty of medicine performed endotracheal intubations on a manikin using the Macintosh laryngoscope with and without the endotracheal tube introducer during chest compressions. First-pass success rates, the times of endotracheal intubations, the second endotracheal intubation attempt success rates, and the difficulty level of each method according to the participants' perceptions were measured. First-pass success rates did not differ using an endotracheal tube introducer as an adjunct to a Macintosh laryngoscope. Second endotracheal intubation attempt success rates also did not differ by endotracheal tube introducer use. The usage of an endotracheal tube introducer required significantly longer endotracheal intubation time than using only a Macintosh laryngoscope. The perception of difficulty was significantly lower with endotracheal tube introducer use. The use of an endotracheal tube introducer as an adjunct to a Macintosh laryngoscope is not associated with higher first-pass success rates during mechanical chest compressions in adult simulations performed by final-year medical students. © 2020 Elsevier Inc.

The Combination of Tocilizumab and Methylprednisolone Along With Initial Lung Recruitment Strategy in Coronavirus Disease 2019 Patients Requiring Mechanical Ventilation: A Series of 21 Consecutive Cases.

Objective:To describe the outcomes with use of a combination of tocilizumab and methylprednisolone administered around the time of endotracheal intubation in patients with confirmed coronavirus disease 2019-associated hypoxemic respiratory failure requiring mechanical ventilation.Data Sources:Retrospective chart review.Study Selection/Data Extraction:Twenty-one consecutive patients with confirmed coronavirus disease 2019-associated hypoxemic respiratory failure requiring mechanical ventilation. Initial ventilator parameters were positive end-expiratory pressure 14 cm H2o and target plateau pressure 29 cm H2o to maximize lung recruitment. Methylprednisolone (125 mg every 6hr for 24 hr with tapering to 60 mg every 12 hr) was administered shortly after patients were intubated (median 11 hr after intubation).Data Synthesis:No patient in the cohort died while hospitalized (mortality, 0%; 95% CI, 0%–18%) and 18 patients have been discharged from the acute care setting. Twenty of 21 patients (95%) have been liberated from mechanical ventilation after a median duration of 8 days (range, 4–30 d). Following 48 hours of methylprednisolone, the A-a o2 gradient decreased from 455 ± 103 to 228 ± 109 mm Hg (difference 227 ± 108 mm Hg; p < 0.01).Conclusions:Our positive experience with tocilizumab in combination with methylprednisolone started early after endotracheal intubation may be one avenue for reducing the morbidity and mortality seen with severe coronavirus disease 2019 and merits further exploration in clinical studies.

Timing of Endotracheal Intubation in Patients with Fulminant Enterovirus 71 Infection.

Background and objective: Enterovirus 71 (EV 71) infections may result in the rapid progression of cardiopulmonary failure. Early endotracheal intubation is considered to be of primary importance. However, the appropriate timing for this is still not known. The aim of this study is to investigate the timing of intubation of children with fulminant EV71 infection. Material and Methods: From March 1998 to May 2012, patients with severe EV71 infection who were admitted to the pediatric intensive care unit of the National Cheng Kung University Hospital were enrolled in this study. Medical records were retrospectively reviewed. The patients were classified into three groups in accordance with the outcome of intubation. We used rhombencephalitis grading to describe the neurological presentation of these patients. The study was approved by the institutional review board. Results: There were a total of 105 patients enrolled. Of these, 77 patients were in Grade I, and only three of them needed intubation, who were, however, soon extubated within 24 h. There were 10 patients in Grade II; nine of them needed intubation. In total, 18 patients belonged to Grade III, and all of them need to be intubated. We then compared the outcome of intubation of grades II and III. There was only one patient out of the nine patients in grade II who experienced failed extubation due to the progression of the disease. Among grade III patients, only four patients were successfully extubated. We also listed clinical parameters to determine which one could be a sign that indicated intubation. Comparing the favorable outcomes, cranial nerve involvement was a good indicator for the timing of intubation. Conclusions: This study showed that early intubation in Grade II provides favorable outcomes and improves morbidity and mortality. We also found that if cranial nerve involvement was present, then early intubation is indicated.