Tracheal intubation while wearing personal protective equipment in simulation studies: a systematic review and meta-analysis with trial-sequential analysis

BACKGROUND

Tracheal intubation in patients with coronavirus disease-19 is a high-risk procedure that should be performed with personal protective equipment (PPE). The influence of PPE on operator's performance during tracheal intubation remains unclear.

METHODS

We conducted a systematic review and meta-analysis of simulation studies to evaluate the influence of wearing PPE as compared to standard uniform regarding time-to-intubation (TTI) and success rate. Subgroup analyses were conducted according to device used and operator's experience.

RESULTS

The TTI was prolonged when wearing PPE (eight studies): Standard Mean Difference (SMD) -0.54, 95% Confidence Interval [-0.75, -0.34], p <  0.0001. Subgroup analyses according to device used showed similar findings (direct laryngoscopy, SMD -0.63 [-0.88, -0.38], p < 0.0001; videolaryngoscopy, SMD -0.39 [-0.75, -0.02], p =  0.04). Considering the operator's experience, non-anesthesiologists had prolonged TTI (SMD -0.75 [-0.98, -0.52], p < 0.0001) while the analysis on anesthesiologists did not show significant differences (SMD -0.25 [-0.51, 0.01], p = 0.06). The success rate of tracheal intubation was not influenced by PPE: Risk Ratio (RR) 1.02 [1.00, 1.04]; p = 0.12). Subgroup analyses according to device demonstrated similar results (direct laryngoscopy, RR 1.03 [0.99, 1.07], p = 0.15, videolaryngoscopy, RR 1.01 [0.98, 1.04], p =  0.52). Wearing PPE had a trend towards negative influence on success rate in non-anesthesiologists (RR 1.05 [1.00, 1.10], p = 0.05), but not in anesthesiologists (RR 1.00 [0.98, 1.03], p = 0.84). Trial-sequential analyses for TTI and success rate indicated robustness of both results.

CONCLUSIONS

Under simulated conditions, wearing PPE delays the TTI as compared to dressing standard uniform, with no influence on the success rate. However, certainty of evidence is very low. Performing tracheal intubation with direct laryngoscopy seems influenced to a greater extent as compared to videolaryngoscopy. Similarly, wearing PPE affects more the non-anesthesiologists subgroup as compared to anesthesiologists.

The Easytube for airway management: a systematic review of clinical and simulation studies

STUDY OBJECTIVE

Endotracheal intubation is considered the criterion-standard technique for securing the airway. Supraglottic airway devices (SADs) represent a major advance in airway management and are recommended by the guidelines in difficult situations such as Advanced Life Support and "cannot ventilate-cannot intubate" scenarios. The Easytube (EzT) is an SAD introduced a decade ago but not included yet in the above guidelines.

DESIGN

Systematic review of MEDLINE and EMBASE according to PRISMA guidelines available up to January 12, 2016.

SETTING

We collected experimental and clinical evidence regarding EzT positioning performed by medial students, anesthesiologists, paramedics, or nurses.

PATIENTS

Manikins, cadavers, or patients.

INTERVENTIONS

EzT positioning in both clinical and simulation studies, both under standard and under difficult scenarios.

MEASUREMENTS

Time to insertion and time to ventilation, success rate and operator's assessment of the device, change in ventilatory parameters, and major complications.

MAIN RESULTS

Fifteen manuscripts were found: 6 prospective clinical studies and 9 conducted under experimental conditions (7 with a simulator and 2 on cadavers). The EzT inserted by both inexperienced and experienced personnel in most studies had high success rate, and it showed excellent results also during simulated cardiopulmonary resuscitation and in difficult airway scenarios. The EzT had better ventilatory parameters as compared with the Combitube and showed great airway sealing capacity, comparable to the Combitube and to the laryngeal mask airway and superior to other SADs. EzT allowed the insertion of large nasogastric tubes and has only mild adverse effects like other SADs. No major complications were described.

CONCLUSION

The EzT appears to be a safe and a good alternative to established SADs. It may be considered among SADs by future guidelines on Advanced Life Support and "cannot ventilate-cannot intubate" scenarios.

Caution Is Warranted When Assessing Diastolic Function Using Transesophageal Echocardiography. Comment on Kyle et al. Consensus Defined Diastolic Dysfunction and Cardiac Postoperative Morbidity Score: A Prospective Observational Study. J. Clin. Med. 2021, 10, 5198

Kyle et al. [...].

Correction to: Practical approach to diastolic dysfunction in light of the new guidelines and clinical applications in the operating room and in the intensive care

In the original article [1], the authors noticed a typographical error in Figure 2. The top left box should have included "E/A <0.8 and E <50 cm/s". Please see below the corrected figure.

The Use of Pulmonary Artery Catheters and Echocardiography in the Cardiac Surgery Setting: A Nationwide Italian Survey

OBJECTIVE

Wide variations exist in the use of pulmonary artery catheters (PACs) and echocardiography in the field of cardiac surgery.

DESIGN

A national survey promoted by the Italian Association of Cardio-Thoracic Anesthesiologists and Intensive Care was conducted.

SETTING

The study occurred in Italian cardiac surgery centers (n = 71).

PARTICIPANTS

Anesthesiologists-intensivists were enrolled.

INTERVENTIONS

Anonymous questionnaires were used to investigate the use of PACs and echocardiography in the operating room (OR) and intensive care unit (ICU).

MEASUREMENTS AND MAIN RESULTS

A total of 257 respondents (32.2% response rate) from 59 centers (83.1% response rate) participated. Use of PACs seems less common in ORs (median insertion in 20% [5-70] of patients), with slightly higher use in ICUs; in about half of cases, it was the continuous cardiac output monitoring system of choice. Almost two-thirds of respondents recently inserted at least one PAC within a few hours of ICU admission, despite its need being largely preoperatively predictable. Protocols regulating PAC insertion were reported by 25.3% and 28% of respondents (OR and ICU, respectively). Transesophageal echocardiography (TEE) was performed intraoperatively in >75% of patients by 86.4% of respondents; only 23.7% stated that intraoperative TEE relied on anesthesiologists. Tissue Doppler and/or 3D imaging were widely available (87.4% and 82%, respectively), but only 37.8% and 24.3% of respondents self-declared skills in these modalities, respectively; 77.1% of respondents had no echocardiography certification, nor were pursuing certification (various reasons); 40.9% had not attended recent echocardiography courses. Lower PAC use was associated with university hospitals (OR: p = 0.014, ICU: p = 0.032) and with lower interventions/year (OR: p = 0.023). Higher independence in performing TEE was reported in university hospitals (OR: p < 0.001; ICU: p = 0.006), centers with higher interventions/year (OR: p = 0.019), and by respondents with less experience in cardiology (ICU: p = 0.046).

CONCLUSION

Variability in the use of PACs and echocardiography was found. Protocols regulating the use of PACs seem infrequent. University centers use PACs less and have greater skills in TEE. Training and certifications in echocardiography should be encouraged.

The influence of policies limiting author self-citations on journals impact factor and self-citation rate in respiratory system

To assess the presence of journal policies discouraging inappropriate author's self-citation (A-SC) in "Respiratory System" journals, we evaluated submission guidelines of "Respiratory System" journals included in Journal-Citation Reports 2020 (Clarivate Analytics^®) for the presence of policies on A-SC and its impact on journals' self-citation (J-SC) rate and impact factor (IF). We found that 14.3% of journals (n=8/56) reported policies on inappropriate A-SC. The median IF was not different in "Respiratory System" journals with (3.6; IQR:2.3) vs without A-SC policies (3.1; IQR:3.0; p=0.41). The J-SC rate was not influenced by the presence of A-SC policies (p=0.83). Fully open-access (n=14) and traditional (n=42) journals had no differences in IF (3.3; IQR:1.5 vs 3.1; IQR:3.4, respectively; p=0.77) and J-SC rate (4.5%; IQR:5.6 vs 6.2%; IQR:8.4, respectively; p=0.38). The majority of "Respiratory System" journals do not have policies discouraging A-SC. The presence of such policies is not associated with changes in IF or J-SC rates.