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BackgroundConventional supine emergence and prone extubation from general endotracheal anesthesia (GEA) are associated with extubation-related adverse events (ERAEs). Given the minimally invasive nature of endoscopic retrograde cholangiopancreatography (ERCP) as well as the improved ventilation/perfusion matching and easier airway opening in the prone position, we aimed to assess the safety of prone emergence and extubation in patients undergoing ERCP under GEA.MethodsTotally, 242 eligible patients were recruited and randomized into the supine extubation group (n = 121; supine group) and the prone extubation group (n = 121; prone group). The primary endpoint was the incidence of ERAEs during emergence, including hemodynamic fluctuations, coughing, stridor, and hypoxemia requiring airway maneuvers. The secondary endpoints included the incidence of monitoring disconnections, extubation time, recovery time, room exit time, and post-procedure sore throat.ResultsThe incidence of ERAEs was significantly lower in the prone group compared with the supine group (8.3% vs 34.7%, OR = 0.17, 95% CI 0.18–0.56; P < 0.001). Moreover, the prone group demonstrated no monitoring disconnections, shorter extubation time and room exit time, faster recovery, and, lower frequency and milder sore throat after the procedure.ConclusionsFor patients undergoing ERCP under GEA, compared with supine, prone emergence, and extubation had remarkably lower rates of EAREs and better recovery, and can maintain continuous monitoring and improve efficiency.

Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections. Reported incidences vary widely from 5 to 40% depending on the setting and diagnostic criteria. VAP is associated with prolonged duration of mechanical ventilation and ICU stay. The estimated attributable mortality of VAP is around 10%, with higher mortality rates in surgical ICU patients and in patients with mid-range severity scores at admission. Microbiological confirmation of infection is strongly encouraged. Which sampling method to use is still a matter of controversy. Emerging microbiological tools will likely modify our routine approach to diagnosing and treating VAP in the next future. Prevention of VAP is based on minimizing the exposure to mechanical ventilation and encouraging early liberation. Bundles that combine multiple prevention strategies may improve outcomes, but large randomized trials are needed to confirm this. Treatment should be limited to 7 days in the vast majority of the cases. Patients should be reassessed daily to confirm ongoing suspicion of disease, antibiotics should be narrowed as soon as antibiotic susceptibility results are available, and clinicians should consider stopping antibiotics if cultures are negative.

Purpose This study aimed to evaluate whether endotracheal tubes (ETTs) with a metal coating reduce the incidence of ventilator-associated pneumonia (VAP) compared to uncoated ETTs. Methods An extensive literature review was conducted to find studies that compared metal-coated ETT with uncoated ETT across four databases: PubMed, Embase, Cochrane Library, and Web of Science. The search parameters were set from the inception of each database until June 2024. The primary outcome measures were the rates of VAP and hospital mortality. Two independent researchers carried out the literature selection, data extraction, and quality evaluation. Data analysis was performed with RevMan 5.4.1. Furthermore, a Deeks funnel plot was used to evaluate potential publication bias in the studies included. Results Following the screening process, five randomized controlled trials (RCTs) encompassing a total of 2157 patients were identified. In terms of the primary outcome, the VAP incidence was found to be lower in the group utilizing metal-coated ETT compared to those with uncoated ETT, demonstrating a statistically significant difference [RR = 0.71, 95% CI (0.54–0.95), P  = 0.02]. No notable difference in mortality rates was observed between the two groups [RR = 1.05, 95% CI (0.86–1.27), P  = 0.65]. Concerning secondary outcomes, two studies were evaluated to compare the mechanical ventilation duration (RR = 0.60, 95% CI (− 0.52, 1.72), P  = 0.29, I 2  = 97%) and intensive care unit (ICU) stay for both patient groups (RR = 0.47, 95% CI (− 1.02, 1.95), P  = 0.54, I 2  = 50%). Due to the marked heterogeneity, a comparison of mechanical ventilation length between the two patient groups was not feasible. However, both studies suggested no significant difference in ventilation duration between patients using metal-coated ETT and those with uncoated ETT. Conclusions Metal-coated ETT show a lower occurrence of VAP compared to the uncoated ETT. Nevertheless, they do not considerably decrease the length of mechanical ventilation, the duration of ICU admission, nor do they reduce hospital mortality rates. Systematic review registration : https://www.crd.york.ac.uk/prospero/ , identifier CRD42024560618.

Over-inflation of an endotracheal tube (ETT) cuff may lead to tracheal mucosal irritation, tracheal wall ischemia or necrosis, whereas under-inflation increases the risk of pulmonary aspiration as well as leaking anesthetic gas and polluting the environment. The objectives of this two-phase study were to (1) identify the incidence of improper ETT cuff inflation (both over- and under-inflation) using the minimum occlusive volume (MOV) technique coupled with a regular injectable syringe in the anesthetized dogs, and (2) evaluate the performance of two commercially available inflation syringe devices (Tru-Cuff and AG Cuffill®) with the regular injectable syringe in inflating the ETT cuff to a recommended safe cuff pressure range (20-30 cmH O). Dogs undergoing general anesthesia at Purdue Veterinary Medicine Teaching Hospital were included. The ETT cuff pressure was assessed with an aneroid manometer after the syringe inflation. The results of the first objective showed that a total of 80 dogs enrolled and that 50 of these 80 dogs required ETT cuff inflation. Among the 50 dogs, only 14% had proper ETT cuff inflation; 76% of the ETT cuffs were over-inflated and 10% were under-inflated. Ninety dogs were enrolled for the second objective study and they were randomly and equally assigned to the three syringe device treatment groups. The results showed that 80% of the ETT cuffs were over-inflated in the regular injectable syringe treatment group, whereas only 6.7% and 3.3% ETT cuffs were over-inflated in the Tru-Cuff and AG Cuffill® syringe treatment groups, respectively. The AG Cuffill® syringe treatment group had a significantly ( < 0.05) higher percentage of properly inflated ETT cuffs (86.7%) compared to the other two groups (regular injectable syringe [3.3%]; Tru-Cuff syringe [50%]. We concluded that there was a high incidence of improper ETT cuff inflation when using MOV technique coupled with a regular injectable syringe. The use of an AG Cuffill® syringe significantly reduced improper ETT cuff inflation.

Effective securing of the endotracheal tube (ETT) after inserting is essential to prevent unplanned extubation (UE). This study compared six ETT securing techniques and a no-device control in resisting to simulated UE, assessing performance across different traction speeds (slow and fast) and planes (frontal and sagittal). A mechanically ventilated mannequin was used. Extubation, defined as a sudden loss of airway pressure, was induced using a tensile testing machine. The required force to cause extubation (forceextubation) was recorded. For each combination of securing technique, traction speed and traction plane, five measurements of forceextubation were collected. Techniques included three cord-based, two elastic adhesive tape-based, one commercial device (AnchorFast™, Hollister), and a control with no securing method. In the sagittal plane, AnchorFast™ required significantly higher forceextubation (median 75 N [IQR: 52–86]) compared to adhesive tape methods (short: 28 N [19–34], p < 0.001; long: 34 N [24–45], p = 0.026). Cord-based techniques performed similarly to the AnchorFast™. The control setup (i.e., without any securing device) and the elastic adhesive tape showed comparable forceextubation levels which were also significantly lower than that of a single cord with a knot. In the frontal plane, forceextubation was higher than in the sagittal plane (115 N [89;148] and 44 N [26;57], respectively, p < 0.001), and no significant differences were observed between techniques. ETT securing techniques using elastic adhesive tape were less effective at preventing simulated UE than either the AnchorFast™ device or a single cord with a knot. •Elastic adhesive tape did not significantly resist simulated UE better than no device.•AnchorFast™ and single cord with a knot secured ETTs better than adhesive tape.•Simulated UE occurred with less force with the use with elastic adhesive tape.

Objective: Dexmedetomidine has been studied for attenuation of laryngoscopy and intubation response with varied results, however the depth of anaesthesia and plasma catecholamine levels have not been measured. Considering the lacunae, this study was planned with three doses of dexmedetomidine: 0.5, 0.75 and 1 μg kg-1 under bi-spectral index monitoring and plasma catecholamine assessment. Methods: One hundred sixty-eight consenting adult patients of either sex were divided into 3 groups (56 each) to receive I/V dexmedetomidine 0.5, 0.75 or 1 μg kg-1 prior to induction. A baseline sample of catecholamines was taken and study drug was infused over 10 minutes. Thereafter, standard anaesthesia induction followed and haemodynamic parameters were noted at designated time intervals. Another sample of catecholamines was drawn at 3 minutes after intubation. The primary outcome was to compare the change in heart rate and systolic blood pressure. Secondary outcomes included: change in catecholamine levels, sedation scores, propofol dose and adverse events. Results: All doses of dexmedetomidine successfully obtunded the haemodynamic response; however, no significant difference was seen on inter-group comparison (P >0.05). A significant fall in nor-adrenaline values compared with baseline was noted in all groups, without any significant difference among groups for both catecholamines. Sedation scores reduced from baseline in all groups without any difference on inter- group comparison. Statistically significant reduction in propofol requirement and higher incidence of bradycardia with 1 µg kg-1 (P=0.014) were observed. Conclusion: 0.5 μg kg-1 of dexmedetomidine can be used for pressor response attenuation as the incidence of bradycardia was higher with 1 μg kg-1 and 0.75 μg kg-1 had no added advantage.

PurposeEtomidate and ketamine are hemodynamically stable induction agents often used to sedate critically ill patients during emergency endotracheal intubation. In 2015, quality improvement data from our hospital suggested a survival benefit at Day 7 from avoidance of etomidate in critically ill patients during emergency intubation. In this clinical trial, we hypothesized that randomization to ketamine instead of etomidate would be associated with Day 7 survival after emergency endotracheal intubation.MethodsA prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at one high-volume medical center in the United States. 801 critically ill patients requiring emergency intubation were randomly assigned 1:1 by computer-generated, pre-randomized sealed envelopes to receive etomidate (0.2–0.3 mg/kg, n = 400) or ketamine (1–2 mg/kg, n = 401) for sedation prior to intubation. The pre-specified primary endpoint of the trial was Day 7 survival. Secondary endpoints included Day 28 survival.ResultsOf the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%, difference − 7.8, 95% confidence interval − 13, − 2.4, p = 0.005). Day 28 survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%, difference − 2.7, 95% confidence interval − 9.3, 3.9, p = 0.294).ConclusionWhile the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.

Abstract The day of extubation is a critical time during an intensive care unit (ICU) stay. Extubation is usually decided after a weaning readiness test involving spontaneous breathing on a T-piece or low levels of ventilatory assist. Extubation failure occurs in 10 to 20% of patients and is associated with extremely poor outcomes, including high mortality rates of 25 to 50%. There is some evidence that extubation failure can directly worsen patient outcomes independently of underlying illness severity. Understanding the pathophysiology of weaning tests is essential given their central role in extubation decisions, yet few studies have investigated this point. Because extubation failure is relatively uncommon, randomized controlled trials on weaning are underpowered to address this issue. Moreover, most studies evaluated patients at low risk for extubation failure, whose reintubation rates were about 10 to 15%, whereas several studies identified high-risk patients with extubation failure rates exceeding 25 or 30%. Strategies for identifying patients at high risk for extubation failure are essential to improve the management of weaning and extubation. Two preventive measures may prove beneficial, although their exact role needs confirmation: one is noninvasive ventilation after extubation in high-risk or hypercapnic patients, and the other is steroid administration several hours before extubation. These measures might help to prevent postextubation respiratory distress in selected patient subgroups.

Objective: To compare I–Gel versus endotracheal tube effects on hemodynamic stability and intraocular pressure in patients undergoing elective ophthalmological surgeries. Study Design: Quasi-experimental study. Place and Duration of Study: Armed Forces Institute of Ophthalmology, Rawalpindi Pakistan, from Nov 2019 to Oct 2020. Methodology: A total of 108 patients undergoing elective ophthalmological surgeries under general anesthesia from both genders, age range between 18-45 years, American Society of Anesthesiologists status I or II were included. General anesthesia given following standard procedures and monitoring. Heart rate, Systolic & Diastolic blood pressure monitored and intraocular pressure measured in each eye with Reichert ton open at baseline, upon insertion of airway device and 5 minutes after insertion. Results: Total 108 patients enrolled in the study with a mean age of 37.74 ± 6.0 years and age-range of 18-45. Heart rate at Insertion in I-Gel group was 78.14 ± 3.41 beats per minute whereas in intubated group was 97.20 ± 2.84 beats per minute, mean systolic blood pressure at insertion in group A and B was 115.28 ± 5.3 and 130.44 ± 2.81mm of Hg respectively. Intraocular pressure at insertion right eye in group A and B was 12.04 ± 0.48 and 17.98 ± 0.42 mm of Hg respectively. Intraocular pressure at insertion left eye in group A was 12.12 ± 0.45 whereas in group B was 17.95 ± 0.38mm of Hg (p-value=0.001). Conclusion: I–Gel provides better hemodynamic profile and intraocular pressure stability when compared with endotracheal tube.