Resuscitation of the patient with suspected/confirmed COVID-19 when wearing personal protective equipment: A randomized multicenter crossover simulation trial

BACKGROUND

The aim of the study was to evaluate various methods of chest compressions in patients with suspected/confirmed SARS-CoV-2 infection conducted by medical students wearing full personal protective equipment (PPE) for aerosol generating procedures (AGP).

METHODS

This was prospective, randomized, multicenter, single-blinded, crossover simulation trial. Thirty-five medical students after an advanced cardiovascular life support course, which included performing 2-min continuous chest compression scenarios using three methods: (A) manual chest compression (CC), (B) compression with CPRMeter, (C) compression with LifeLine ARM device. During resuscitation they are wearing full personal protective equipment for aerosol generating procedures.

RESULTS

The median chest compression depth using manual CC, CPRMeter and LifeLine ARM varied and amounted to 40 (38-45) vs. 45 (40-50) vs. 51 (50-52) mm, respectively (p = 0.002). The median chest compression rate was 109 (IQR; 102-131) compressions per minute (CPM) for manual CC, 107 (105-127) CPM for CPRMeter, and 102 (101-102) CPM for LifeLine ARM (p = 0.027). The percentage of correct chest recoil was the highest for LifeLine ARM - 100% (95-100), 80% (60-90) in CPRMeter group, and the lowest for manual CC - 29% (26-48).

CONCLUSIONS

According to the results of this simulation trial, automated chest compression devices (ACCD) should be used for chest compression of patients with suspected/confirmed COVID-19. In the absence of ACCD, it seems reasonable to change the cardiopulmonary resuscitation algorithm (in the context of patients with suspected/confirmed COVID-19) by reducing the duration of the cardiopulmonary resuscitation cycle from the current 2-min to 1-min cycles due to a statistically significant reduction in the quality of chest compressions among rescuers wearing PPE AGP.

Comparable long-term results for porcine and pericardial prostheses after isolated aortic valve replacement

OBJECTIVES

Outcome of aortic valve replacement may be influenced by the choice of bioprosthesis. Pericardial heart valves are described to have a favourable haemodynamic profile compared with porcine valves, although the clinical notability of this finding is still controversially debated. Herein, we compared the long-term results of two commonly implanted bioprosthesis at a single centre.

METHODS

All consecutive patients undergoing isolated aortic valve replacement with either a Carpentier-Edwards Magna pericardial prosthesis or a Medtronic Mosaic porcine prosthesis between 2002 and 2008 were analysed regarding preoperative characteristics, short- and long-term survival, valve-related complications and echocardiographic findings.

RESULTS

The Medtronic Mosaic was implanted in 163 patients and the Carpentier-Edwards Magna in 295 patients. The sizes of implanted valves were 22.4 ± 1.5 mm for the Mosaic and 21.8 ± 1.8 mm for the Magna (P = 0.001). The long-term survival rate was 76 and 56% after 5 and 10 years for the Medtronic Mosaic, which was comparable with the Carpentier-Edwards Magna (77 and 57%; P = 0.92). Overall long-term survival was comparable with an age- and sex-matched Austrian general population for both groups. Valve-related adverse events were similar between groups. The postoperative mean transvalvular gradient was significantly increased in the Mosaic group (24 ± 9 mmHg vs 17 ± 7 mmHg; P < 0.001).

CONCLUSIONS

Both types of aortic bioprostheses offer excellent results after isolated aortic valve replacement. Despite relevant differences in gradients, long-term survival was comparable with the expected normal survival for both bioprostheses. Patients with a porcine heart valve had a higher postoperative transvalvular gradient.

Evaluation of airway management associated hands-off time during cardiopulmonary resuscitation: a randomised manikin follow-up study

INTRODUCTION

Airway management is an important component of cardiopulmonary resuscitation (CPR). Recent guidelines recommend keeping any interruptions of chest compressions as short as possible and not lasting more than 10 seconds. Endotracheal intubation seems to be the ideal method for establishing a secure airway by experienced providers, but emergency medical technicians (EMT) often lack training and practice. For the EMTs supraglottic devices might serve as alternatives.

METHODS

40 EMTs were trained in a 1-hour standardised audio-visual lesson to handle six different airway devices including endotracheal intubation, Combitube, EasyTube, I-Gel, Laryngeal Mask Airway and Laryngeal tube. EMTs performances were evaluated immediately after a brief practical demonstration, as well as after 1 and 3 months without any practice in between, in a randomised order. Hands-off time was pair-wise compared between airway devices using a repeated-measures mixed-effects model.

RESULTS

Overall mean hands-off time was significantly (p<0.01) lower for Laryngeal tube (6.1s; confidence interval 5.2-6.9s), Combitube (7.9s; 95% CI 6.9-9.0s), EasyTube (8.8s; CI 7.3-10.3s), LMA (10.2s; CI 8.6-11.7s), and I-Gel (11.9s; CI 10.2-13.7s) compared to endotracheal intubation (39.4s; CI 34.0-44.9s). Hands-off time was within the recommended limit of 10s for Combitube, EasyTube and Laryngeal tube after 1 month and for all supraglottic devices after 3 months without any training, but far beyond recommended limits in all three evaluations for endotracheal intubation.

CONCLUSION

Using supraglottic airway devices, EMTs achieved a hands-off time within the recommended time limit of 10s, even after three months without any training or practice. Supraglottic airway devices are recommended tools for EMTs with lack of experience in advanced airway management.

Anesthetic considerations for bronchoscopic procedures: a narrative review based on the Cleveland Clinic experience

The advent of advanced diagnostic bronchoscopy has shown an increased demand for anesthesiologists to administer anesthesia in the bronchoscopy suite. Procedures such as navigational bronchoscopy, airway stenting and advanced therapeutic procedures often require the presence of an anesthesiologist to manage these more complex patients and procedures. In this review we describe the various bronchoscopic procedures and anesthetic management and complications of these procedures at our institution The Cleveland Clinic, Cleveland Ohio.

McGrath Video Laryngoscope Versus Macintosh Direct Laryngoscopy for Intubation of Morbidly Obese Patients: A Randomized Trial

BACKGROUND

Two-thirds of the US population is considered obese and about 8% morbidly obese. Obese patients may present a unique challenge to anesthesia clinicians in airway management. Videolaryngoscopes may provide better airway visualization, which theoretically improves intubation success. However, previous work in morbidly obese patients was limited. We therefore tested the primary hypothesis that the use of McGrath video laryngoscope improves visualization of the vocal cords versus Macintosh direct laryngoscopy (Teleflex, Morrisville, NC) in morbidly obese patients.

METHODS

We enrolled 130 surgical patients, aged 18-99 years, with a body mass index ≥40 kg/m and American Society of Anaesthesiologists (ASA) physical status I-III. Patients were randomly allocated 1:1-stratified for patient's body mass index ≥50 kg/m-to McGrath video laryngoscope versus direct laryngoscopy with a Macintosh blade. The study groups were compared on glottis visualization, defined as improved Cormack and Lehane classification, with proportional odds logistic regression model.

RESULTS

McGrath video laryngoscope provided significantly better glottis visualization than Macintosh direct laryngoscopy with an estimated odds ratio of 4.6 (95% confidence interval [CI], 2.2-9.8; P < .01). We did not observe any evidence that number of intubation attempts and failed intubations increased or decreased.

CONCLUSIONS

McGrath video laryngoscope improves glottis visualization versus Macintosh direct laryngoscopy in morbidly obese patients. Large clinical trials are needed to determine whether improved airway visualization with videolaryngoscopy reduces intubation attempts and failures.

Comparison of different methods of postoperative analgesia after thoracotomy-a randomized controlled trial

Background

Continuous thoracic epidural analgesia (TEA) is a preferred method of postoperative analgesia in thoracic surgery. Intravenous patient-controlled analgesia (IVPCA) may be an effective alternative. One of the most commonly used opioids in PCA is morphine. It has high antinociceptive efficacy but is associated with many adverse events. Oxycodone can be an alternative. A small number of scientific reports comparing morphine and oxycodone in PCA for the treatment of acute postoperative pain after thoracotomy was the reason to conduct this study.

Methods

Prospective, randomised, observational study. In total of 99 patients scheduled for elective thoracotomy were randomized into three study groups. TEA group received continuous TEA as a method of postoperative pain management, morphine (MF) group received morphine IVPCA, and morphine (OXY) group oxycodone IVPCA. For 48 hours' hemodynamic parameters, level of pain, sedation and the need for rescue analgesia were monitored. After 48 hours' patients were asked about their satisfaction with pain treatment using Likert scale and assessment of opioid related adverse events via overall benefit of analgesia score (OBAS).

Results

The level of pain in visual analogic score (VAS) and Prince Henry Hospital Pain Score (PHHPS) scales was significantly lower in TEA group with no significant difference between groups MF and OXY. Using morphine in PCA was associated with a significantly higher likelihood of need of rescue analgesia. The level of sedation in Ramsay scale was significantly higher in MF compared to OXY and TEA group. There were no significant differences between groups in OBAS scale. TEA group was characterized by the highest degree of patient satisfaction.

Conclusions

TEA provided superior anaesthesia compared to PCA in our study group. Use of PCA oxycodone in postoperative pain management after open thoracotomy provides similar nociception control compared to morphine but is associated with less sedation and patients using oxycodone IVPCA require smaller doses of rescue analgesia compared to systemic morphine IVPCA.

Short structured feedback training is equivalent to a mechanical feedback device in two-rescuer BLS: a randomised simulation study

BACKGROUND

Resuscitation guidelines encourage the use of cardiopulmonary resuscitation (CPR) feedback devices implying better outcomes after sudden cardiac arrest. Whether effective continuous feedback could also be given verbally by a second rescuer ("human feedback") has not been investigated yet. We, therefore, compared the effect of human feedback to a CPR feedback device.

METHODS

In an open, prospective, randomised, controlled trial, we compared CPR performance of three groups of medical students in a two-rescuer scenario. Group "sCPR" was taught standard BLS without continuous feedback, serving as control. Group "mfCPR" was taught BLS with mechanical audio-visual feedback (HeartStart MRx with Q-CPR-Technology™). Group "hfCPR" was taught standard BLS with human feedback. Afterwards, 326 medical students performed two-rescuer BLS on a manikin for 8 min. CPR quality parameters, such as "effective compression ratio" (ECR: compressions with correct hand position, depth and complete decompression multiplied by flow-time fraction), and other compression, ventilation and time-related parameters were assessed for all groups.

RESULTS

ECR was comparable between the hfCPR and the mfCPR group (0.33 vs. 0.35, p = 0.435). The hfCPR group needed less time until starting chest compressions (2 vs. 8 s, p < 0.001) and showed fewer incorrect decompressions (26 vs. 33 %, p = 0.044). On the other hand, absolute hands-off time was higher in the hfCPR group (67 vs. 60 s, p = 0.021).

CONCLUSIONS

The quality of CPR with human feedback or by using a mechanical audio-visual feedback device was similar. Further studies should investigate whether extended human feedback training could further increase CPR quality at comparable costs for training.

Evaluation of a newly developed infant chest compression technique: A randomized crossover manikin trial

BACKGROUND

Providing adequate chest compression is essential during infant cardio-pulmonary-resuscitation (CPR) but was reported to be performed poor. The "new 2-thumb technique" (nTTT), which consists in using 2 thumbs directed at the angle of 90° to the chest while closing the fingers of both hands in a fist, was recently introduced. Therefore, the aim of this study was to compare 3 chest compression techniques, namely, the 2-finger-technique (TFT), the 2-thumb-technique (TTHT), and the nTTT in an randomized infant-CPR manikin setting.

METHODS

A total of 73 paramedics with at least 1 year of clinical experience performed 3 CPR settings with a chest compression:ventilation ratio of 15:2, according to current guidelines. Chest compression was performed with 1 out of the 3 chest compression techniques in a randomized sequence. Chest compression rate and depth, chest decompression, and adequate ventilation after chest compression served as outcome parameters.

RESULTS

The chest compression depth was 29 (IQR, 28-29) mm in the TFT group, 42 (40-43) mm in the TTHT group, and 40 (39-40) mm in the nTTT group (TFT vs TTHT, P < 0.001; TFT vs nTTT, P < 0.001; TTHT vs nTTT, P < 0.01). The median compression rate with TFT, TTHT, and nTTT varied and amounted to 136 (IQR, 133-144) min versus 117 (115-121) min versus 111 (109-113) min. There was a statistically significant difference in the compression rate between TFT and TTHT (P < 0.001), TFT and nTTT (P < 0.001), as well as TTHT and nTTT (P < 0.001). Incorrect decompressions after CC were significantly increased in the TTHT group compared with the TFT (P < 0.001) and the nTTT (P < 0.001) group.

CONCLUSIONS

The nTTT provides adequate chest compression depth and rate and was associated with adequate chest decompression and possibility to adequately ventilate the infant manikin. Further clinical studies are necessary to confirm these initial findings.

A comparison of a traditional endotracheal tube versus ETView SL in endotracheal intubation during different emergency conditions: A randomized, crossover cadaver trial

BACKGROUND

Airway management is a crucial skill essential to paramedics and personnel working in Emergency Medical Services and Emergency Departments: Lack of practice, a difficult airway, or a trauma situation may limit the ability of paramedics to perform direct laryngoscopy during cardiopulmonary resuscitation. Videoscope devices are alternatives for airway management in these situations. The ETView VivaSight SL (ETView; ETView Ltd., Misgav, Israel) is a new, single-lumen airway tube with an integrated high-resolution imaging camera. To assess if the ETView VivaSight SL can be a superior alternative to a standard endotracheal tube for intubation in an adult cadaver model, both during and without simulated CPR.

METHODS

ETView VivaSight SL tube was investigated via an interventional, randomized, crossover, cadaver study. A total of 52 paramedics participated in the intubation of human cadavers in three different scenarios: a normal airway at rest without concomitant chest compression (CC) (scenario A), a normal airway with uninterrupted CC (scenario B) and manual in-line stabilization (scenario C). Time and rate of success for intubation, the glottic view scale, and ease-of-use of ETView vs. sETT intubation were assessed for each emergency scenario.

RESULTS

The median time to intubation using ETView vs. sETT was compared for each of the aforementioned scenarios. For scenario A, time to first ventilation was achieved fastest for ETView, 19.5 [IQR, 16.5-22] sec, when compared to that of sETT at 21.5 [IQR, 20-25] sec (p = .013). In scenario B, the time for intubation using ETView was 21 [IQR, 18.5-24.5] sec (p < .001) and sETT was 27 [IQR, 24.5-31.5] sec. Time to first ventilation for scenario C was 23.5 [IQR, 19-25.5] sec for the ETView and 42.5 [IQR, 35-49.5] sec for sETT.

CONCLUSIONS

In normal airways and situations with continuous chest compressions, the success rate for intubation of cadavers and the time to ventilation were improved with the ETView. The time to glottis view, tube insertion, and cuff block were all found to be shorter with the ETView.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02733536.

Is there any alternative to standard chest compression techniques in infants? A randomized manikin trial of the new "2-thumb-fist" option

BACKGROUND

Pediatric cardiac arrest is a fatal emergent condition that is associated with high mortality, permanent neurological injury, and is a socioeconomic burden at both the individual and national levels. The aim of this study was to test in an infant manikin a new chest compression (CC) technique ("2 thumbs-fist" or nTTT) in comparison with standard 2-finger (TFT) and 2-thumb-encircling hands techniques (TTEHT).

METHODS

This was prospective, randomized, crossover manikin study. Sixty-three nurses who performed a randomized sequence of 2-minute continuous CC with the 3 techniques in random order. Simulated systolic (SBP), diastolic (DBP), mean arterial pressure (MAP), and pulse pressures (PP, SBP-DBP) in mm Hg were measured.

RESULTS

The nTTT resulted in a higher median SBP value (69 [IQR, 63-74] mm Hg) than TTEHT (41.5 [IQR, 39-42] mm Hg), (P < .001) and TFT (26.5 [IQR, 25.5-29] mm Hg), (P <.001). The simulated median value of DBP was 20 (IQR, 19-20) mm Hg with nTTT, 18 (IQR, 17-19) mm Hg with TTEHT and 23.5 (IQR, 22-25.5) mm Hg with TFT. DBP was significantly higher with TFT than with TTEHT (P <.001), as well as with TTEHT than nTTT (P <.001). Median values of simulated MAP were 37 (IQR, 34.5-38) mm Hg with nTTT, 26 (IQR, 25-26) mm Hg with TTEHT and 24.5 (IQR,23.5-26.5) mm Hg with TFT. A statistically significant difference was noticed between nTTT and TFT (P <.001), nTTT and TTEHT (P <.001), and between TTEHT and TFT (P <.001). Sixty-one subjects (96.8%) preferred the nTTT over the 2 standard methods.

CONCLUSIONS

The new nTTT technique achieved higher SBP and MAP compared to the standard CC techniques in our infant manikin model. nTTT appears to be a suitable alternative or complementary to the TFT and TTEHT.

A Novel Method of Newborn Chest Compression: A Randomized Crossover Simulation Study

Objective: To compare a novel two-thumb chest compression technique with standard techniques during newborn resuscitation performed by novice physicians in terms of median depth of chest compressions, degree of full chest recoil, and effective compression efficacy. Patients and Methods: The total of 74 novice physicians with less than 1-year work experience participated in the study. They performed chest compressions using three techniques: (A) The new two-thumb technique (nTTT). The novel method of chest compressions in an infant consists in using two thumbs directed at the angle of 90° to the chest while closing the fingers of both hands in a fist. (B) TFT. With this method, the rescuer compresses the sternum with the tips of two fingers. (C) TTHT. Two thumbs are placed over the lower third of the sternum, with the fingers encircling the torso and supporting the back. Results: The median depth of chest compressions for nTTT was 3.8 (IQR, 3.7-3.9) cm, for TFT-2.1 (IQR, 1.7-2.5) cm, while for TTHT-3.6 (IQR, 3.5-3.8) cm. There was a significant difference between nTTT and TFT, and TTHT and TFT (p < 0.001) for each time interval during resuscitation. The degree of full chest recoil was 93% (IQR, 91-97) for nTTT, 99% (IQR, 96-100) for TFT, and 90% (IQR, 74-91) for TTHT. There was a statistically significant difference in the degree of complete chest relaxation between nTTT and TFT (p < 0.001), between nTTT and TTHT (p = 0.016), and between TFT and TTHT (p < 0.001). Conclusion: The median chest compression depth for nTTT and TTHT is significantly higher than that for TFT. The degree of full chest recoil was highest for TFT, then for nTTT and TTHT. The effective compression efficiency with nTTT was higher than for TTHT and TFT. Our novel newborn chest compression method in this manikin study provided adequate chest compression depth and degree of full chest recoil, as well as very good effective compression efficiency. Further clinical studies are necessary to confirm these initial results.

Pro-Con Debate: Prehospital Blood Transfusion-Should It Be Adopted for Civilian Trauma?

Exsanguination is the leading cause of death in severely injured patients; nevertheless, prehospital blood transfusion (PHT) remains a controversial topic. Here, we review the pros and cons of PHT, which is now routine in treatment of military trauma patients in the civilian setting. While PHT may improve survival in those who suffer blunt injury or require prolonged transport from the site of injury, PHT for civilian trauma generally is not supported by high-quality evidence. This article was originally presented as a pro-con debate at the 2020 meeting of the European Society of Anesthesiology and Intensive Care.

Practical anesthetic considerations in patients undergoing tracheobronchial surgeries: a clinical review of current literature

Tracheobronchial surgeries require close cooperation and extensive communication between the anesthesia providers and the surgeons. Anesthetic management of tracheal and bronchial pathologies differ basically from regular upper airways management, due access to the patients airway is limited, mostly even practically impossible for the anesthesia providers. As a consequence, the surgeon overtakes responsibility for the airway access from the anesthesia provider in the variety of the cases. Preoperative recognition of a difficult airway, detailed planning and being aware of plan B and plan C are the elementary keys to success. Providers have to be aware, that preoperative airway assessment does not always correlate with the ease of oxygenation and ventilation. Therefore, various methods have been described in the literature and several authors have adopted unique ways to manage the airways in a successful manner. With the advancement of surgical techniques over the years, anesthetic management has also evolved tremendously to match the needs. The commonly encountered conditions requiring surgical interventions include post-intubation stenosis and foreign body aspiration. In this review we will discuss the most common pathologies of tracheobronchial lesions and specific anesthetic management considerations related to them.

Comparison of four different intraosseous access devices during simulated pediatric resuscitation. A randomized crossover manikin trial

The aim of the study was to compare the success rate, procedure time, and user satisfaction of pediatric NIO™ compared to Pediatric BIG®, EZ-IO®, and Jamshidi intraosseous access devices. This was a randomized, crossover manikin trial with 87 paramedics. The correct location of intraosseous access when using NIO, BIG, EZ-IO, and Jamshidi was varied and was respectively 100, 90, 90, and 90%. The time required to obtain intravascular access (time T1) in the case of NIO, BIG, EZ-IO, and Jamshidi was varied and amounted to 9 s [IQR, 8-12] for NIO, 12 s [IQR, 9-16] for BIG, 13.5 s [IQR, 11-17] for the EZ-IO, and 15 s [IQR, 13-19] for Jamshidi. The paramedics evaluated each device on the subjective ease with which they performed the procedures. The intraosseous device, which proved the easiest to use was NIO, which in the case of CPR received a median rating of 1.5 (IQR, 0.5-1.5) points.

CONCLUSION

Our study found that NIO® is superior to BIG®, EZ-IO®, and Jamshidi. NIO® achieved the highest first attempt success rate. NIO® also required the least time to insert and easiest to operate even by novice users. Further study is needed to test our findings in cadavers or human subjects. Based on our findings, NIO® is a promising intraosseous device for use in pediatric resuscitation. What is Known: • Venous access in acutely ill pediatric patients, such as those undergoing cardiopulmonary resuscitation, is needed for prompt administration of drugs and fluids. • Intraosseous access is recommended by American Heart Association and European Resuscitation council if vascular access is not readily obtainable to prevent delay in treatment. What is New: • This simulated pediatric resuscitation compared performance of four commercially available pediatric intraosseous devices in a manikin model. • NIO® outperformed BIG®, EZ-IO®, and Jamshidi in first attempt success rates and time of procedure among novice users.

Novel airway device Vie Scope in several pediatric airway scenario: A randomized simulation pilot trial

CONTEXT

Endotracheal intubation of pediatric patients is challenging, especially in the pre-hospital emergency setting and if performed by less experienced providers. Securing an airway should be achieved with a single intubation attempt, as each intubation attempt contributes to morbidity and mortality. A new airway device, the VieScope, was recently introduced into clinical market, but efficacy to reduced intubation attempts remains unclear thus far.

OBJECTIVE

We aimed to compare endotracheal intubation by paramedics using the Vie Scope in different pediatric airway simulation conditions.

METHODS

We conducted a randomized, cross-over simulation study. Following a theoretical and practical training session, paramedics performed endotracheal intubation in 3 different pediatric emergency scenarios: normal airway; tongue edema; cardiopulmonary resuscitation using the VieScope. Overall intubation success rate was the primary outcome. Secondary outcomes included number of intubation attempts, time to intubation, Cormack-Lehane grade, POGO score, and ease of use (using 1-100 scale).

RESULTS

Fifty-five paramedics with at least 2 years of clinical experience and without any previous experience with the VieScope participated in this study. The overall intubation success rate was 100% in all 3 scenarios. The median intubation time was 27 (24-34) versus 27 (25-37) versus 29 (25-40) s for scenarios A, B, and C, respectively. In scenario A, all paramedics performed successful intubation with 1 single intubation attempt, whereas 2% of the paramedics had to perform 2 intubation attempts in scenario B and 9% in scenario C.

CONCLUSIONS

Results of this simulation study indicate preliminary evidence, that the VieScope enables adequate endotracheal intubation in the pediatric setting. Further clinical studies are needed to confirm these results.

Comparison of the new flexible tip bougie catheter and standard bougie stylet for tracheal intubation by anesthesiologists in different difficult airway scenarios: a randomized crossover trial

Background

Incidence of difficult endotracheal intubation ranges between 3 and 10%. Bougies have been recommended as an airway adjunct for difficult intubation, but reported success rates are variable. A new generation flexible tip bougie appears promising but was not investigated so far. We therefore compared the new flexible tip with a standard bougie in simulated normal and difficult airway scenarios, and used by experienced anesthesiologists.

Methods

We conducted a observational, randomized, cross-over simulation study. Following standardized training, experienced anesthesiologists performed endotracheal intubation using a Macintosh blade and one of the bougies in six different airway scenarios in a randomized sequence: normal airway, tongue edema, pharyngeal obstruction, manual cervical inline stabilization, cervical collar stabilization, cervical collar stabilization and pharyngeal obstruction. Overall success rate with a maximum of 3 intubation attempts was the primary endpoint. Secondary endpoints included number of intubation attempts, time to intubation and dental compression.

Results

Thirty-two anesthesiologist participated in this study between January 2019 and May 2019. Overall success rate was similar for the flexible tip bougie and the standard bougie. The flexible tip bougie tended to need less intubation attempts in more difficult airway scenarios. Time to intubation was less if using the flexible tip bougie compared to the standard bougie. Reduced severity of dental compression was noted for the flexible tip bougie in difficult airway scenarios except cervical collar stabilization.

Conclusion

In this simulation study of normal and difficult airways scenarios, overall success rate was similar for the flexible tip and standard bougie. Especially in more difficult airway scenarios, less intubation attempts, and less optimization maneuvers were needed if using the flexible tip bougie.

Trial registration

clinicaltrials.gov Identifier: NCT03733158. 7th November 2018.

Comparison of the ETView Single Lumen and Macintosh laryngoscopes for endotracheal intubation in an airway manikin with immobilized cervical spine by novice paramedics: A randomized crossover manikin trial

CONTEXT

Management of the airway of a trauma victim is considered challenging. Various approaches have been described to achieve airway control in this setup; many of them include video-assited viewing of the larynx during intubation. ETView Single Lumen (SL) is a novice single-use endotracheal tube equiped with a video camera and a light source at its distal tip. Its use was previously described in seeral clinical and training setups.

OBJECTIVE

The aim was to evaluate the efficacy of the VivaSight SL compared with classic direct laryngoscopy performed with a Macintosh blade in a manikin-simulated trauma setup presenting various degrees of airway challenge when performed by inexperienced physicians.

DESIGN, SETTING, PARTICIPANTS

This was prospective, randomized, crossover, manikin trial. After short training on the ETView system, 67 novice paramedics attempted to perform oral intubation using both standard direct laryngoscopy (MAC group) and the VivaSight SL endotracheal tube (ETView group) in a randomized order on manikins in 3 increasingly more difficult scenarios (simple intubation, cervical spine manual stabilization, and with cervical collar in place).

OUTCOME MEASURE

Overall success rate, time to intubation, number of intubation attempts, laryngeal view grade, dental compression, and overall participant satisfaction were monitored.

RESULTS

Duration of intubation and number of attempts were significantly superior in the ETView group in the latter 2 more challenging scenarios. All other parameters showed superiority to the ETView group in all 3 scenarios.

CONCLUSION

The VivaSight SL system performed better in a complex scenario of airway management of a trauma victim in need for cervical spine stabilization performed by novice caregivers compared to standard direct laryngoscopy and should be considered in this clinical setup.

U, Ruetzler K. The TrueCPR device in the process of teaching cardiopulmonary resuscitation: A randomized simulation trial

BACKGROUND

International resuscitation guidelines emphasize the importance of high quality chest compressions, including correct chest compression depth and rate and complete chest recoil. The aim of the study was to assess the role of the TrueCPR device in the process of teaching cardiopulmonary resuscitation in nursing students.

METHODS

A prospective randomized experimental study was performed among 94 first year students of nursing. On the next day, the participants were divided into 2 groups-the control group practiced chest compressions without the use of any device for half an hour, and the experimental group practiced with the use of TrueCPR. Further measurement of chest compressions was performed after a month.

RESULTS

The chest compression rate achieved the value of 113 versus 126 (P < .001), adequate chest compression rate (%) was 86 versus 68 (P < .001), full chest release (%) 92 versus 69 (P = .001), and correct hand placement (%) 99 versus 99 (P, not significant) in TrueCPR and standard BLS groups, respectively. As for the assessment of the confidence of chest compression quality, 1 month after the training, the evaluation in the experimental group was statistically significantly higher (91 vs 71; P < .001) than in the control group.

CONCLUSIONS

Cardiopulmonary resuscitation training with the use of the TrueCPR device is associated with better resuscitation skills 1 month after the training. The participants using TrueCPR during the training achieved a better chest compression rate and depth with in international recommendations and better full chest release percentage and self-assessed confidence of chest compression quality comparing with standard cardiopulmonary resuscitation training.

An optimal chest compression technique using personal protective equipment during resuscitation in the COVID-19 pandemic: a randomized crossover simulation study

BACKGROUND

Cardiopulmonary resuscitation with the use of personal protective equipment (PPE) for aerosol generating procedures (AGP) in patients with suspected or confirmed coronavirus disease 2019 (COVID‑19) remains challenging.

AIMS

The aim of this study was to compare 3 chest compression (CC) methods used by paramedics wearing PPE.

METHODS

The single‑blinded, multicenter, randomized, crossover simulation study involved 67 paramedics wearing PPE AGP. They performed 2‑minute continuous CCs in an adult with suspected or confirmed COVID‑19 in 3 scenarios: 1) manual CCs; 2) CCs with the TrueCPR feedback device; 3) CCs with the LUCAS 3 mechanical CC device.

RESULTS

The depth of CC was more frequently correct when using LUCAS 3 compared with TrueCPR and manual CC (median [IQR] 51 [50-55] mm vs 47 [43-52] mm vs 43 [38-46] mm; P = 0.005). This was also true for the CC rate (median [IQR]102 [100-102] compressions per minute [CPM] vs 105 [98-1114] CPM vs 116 [112-129] CPM; P = 0.027) and chest recoil (median [IQR]100% [98%-100%] vs 83% [60%-92%] vs 39% [25%-50%]; P = 0.001). A detailed analysis of 2‑minute resuscitation with manual CCs showed a decrease in compression depth and full chest recoil after 1 minute of CCs.

CONCLUSION

We demonstrated that during simulated resuscitation with the use of PPE AGP in patients with suspected or confirmed COVID‑19, CC with LUCAS 3 compared with manual CCs as well as the TrueCPR essentially increased the CC quality. In the case of manual CCs by paramedics dressed in PPE AGP, it is advisable to change the person performing resuscitation every minute.

Effect of various durations of smoking cessation on postoperative outcomes: A retrospective cohort analysis

BACKGROUND

Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes. However, it remains unclear for how long smoking cessation is necessary, and even whether a brief preoperative period of abstinence is helpful and well tolerated.

OBJECTIVE

We evaluated associations between various periods of preoperative smoking cessation and major morbidity and death.

DESIGN

Retrospective cohort analysis.

SETTING

Adults who had noncardiac surgery at the Cleveland Clinic Main Campus between May 2007 and December 2013.

PATIENTS

A total of 37 511 patients whose smoking history was identified from a preoperative Health Quest questionnaire. Of these patients, 26 269 (70%) were former smokers and 11 242 (30%) were current smokers. Of the current smokers, 9482 (84%) were propensity matched with 9482 former smokers (36%). We excluded patients with American Society of Anesthesiologists' physical status exceeding four, patients who did not have general anaesthesia, and patients with missing outcomes and/or covariables. When multiple procedures were performed within the study period, only the first operation for each patient was included in the analysis.

MAIN OUTCOME MEASURES

The relationship between smoking cessation and in-hospital morbidity/mortality.

RESULTS

The incidence of the primary composite of in-hospital morbidity/mortality was 6.9% (656/9482) for all former smokers; the incidence was 7.8% (152/1951) for patients who stopped smoking less than 1 year before surgery, 6.3% (118/1977) for 1 to 5 years, 7.2% (115/1596) for 5 to 10 years and 6.9% (271/3457) for more than 10 years.

CONCLUSION

Smoking cessation was associated with reduced in-hospital morbidity and mortality which was independent of cessation interval.

Preoperative Vitamin D Concentration and Cardiac, Renal, and Infectious Morbidity after Noncardiac Surgery

BACKGROUND

Low 25-hydroxyvitamin D is associated with cardiovascular, renal, and infectious risks. Postsurgical patients are susceptible to similar complications, but whether vitamin D deficiency contributes to postoperative complications remains unclear. We tested whether low preoperative vitamin D is associated with cardiovascular events within 30 days after noncardiac surgery.

METHODS

We evaluated a subset of patients enrolled in the biobank substudy of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) study, who were at least 45 yr with at least an overnight hospitalization. Blood was collected preoperatively, and 25-hydroxyvitamin D was measured in stored samples. The primary outcome was the composite of cardiovascular events (death, myocardial injury, nonfatal cardiac arrest, stroke, congestive heart failure) within 30 postoperative days. Secondary outcomes were kidney injury and infectious complications.

RESULTS

A total of 3,851 participants were eligible for analysis. Preoperative 25-hydroxyvitamin D concentration was 70 ± 30 nmol/l, and 62% of patients were vitamin D deficient. Overall, 26 (0.7%) patients died, 41 (1.1%) had congestive heart failure or nonfatal cardiac arrest, 540 (14%) had myocardial injury, and 15 (0.4%) had strokes. Preoperative vitamin D concentration was not associated with the primary outcome (average relative effect odds ratio [95% CI]: 0.93 [0.85, 1.01] per 10 nmol/l increase in preoperative vitamin D, P = 0.095). However, it was associated with postoperative infection (average relative effect odds ratio [95% CI]: 0.94 [0.90, 0.98] per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.005) and kidney function (estimated mean change in postoperative estimated glomerular filtration rate [95% CI]: 0.29 [0.11, 0.48] ml min 1.73 m per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.004).

CONCLUSIONS

Preoperative vitamin D was not associated with a composite of postoperative 30-day cardiac outcomes. However, there was a significant association between vitamin D deficiency and a composite of infectious complications and decreased kidney function. While renal effects were not clinically meaningful, the effect of vitamin D supplementation on infectious complications requires further study.

Evaluation of performance of two different chest tubes with either a sharp or a blunt tip for thoracostomy in 100 human cadavers

BACKGROUND

Emergent placement of a chest tube is a potentially life-saving procedure, but rate of misplacement and organ injury is up to 30%. In principle, chest tube insertion can be performed by using Trocar or Non-trocar techniques. If using trocar technique, two different chest tubes (equipped with sharp or blunt tip) are currently commercially available. This study was performed to detect any difference with respect to time until tube insertion, to success and to misplacement rate.

METHODS

Twenty emergency physicians performed five tube thoracostomies using both blunt and sharp tipped tube kits in 100 fresh human cadavers (100 thoracostomies with each kit). Time until tube insertion served as primary outcome. Complications and success rate were examined by pathological dissection and served as further outcomes parameters.

RESULTS

Difference in mean time until tube insertion (63 s vs. 59 s) was statistically not significant. In both groups, time for insertion decreased from the 1st to the 5th attempt and showed dependency on the cadaver's BMI and on the individual physician. Success rate differed between both groups (92% using blunt vs. 86% using sharp tipped kits) and injuries and misplacements occurred significantly more frequently using chest tubes with sharp tips (p = 0.04).

CONCLUSION

Data suggest that chest drain insertion with trocars is associated with a 6-14% operator-related complication rate. No difference in average time could be found. However, misplacements and organ injuries occurred more frequently using sharp tips. Consequently, if using a trocar technique, the use of blunt tipped kits is recommended.