Emergent Surgical Airway Skills: Time to Re-evaluate the Competencies

Introduction: One of the most challenging scenarios an anesthesia provider can face is treating a can\u27t intubate can\u27t ventilate (CICV) patient. The incidence of CICV is estimated to be around one in 10,000 cases. According to the American Society of Anesthesiology Closed Claims Study, adverse respiratory events are the most common type of injury, with difficult intubation and ventilation contributing to the majority of these cases. The objective of this non-interventional quality improvement project was to evaluate the prior training, exposure, and self-reported confidence in handling the CICV scenario among anesthesia providers at Henry Ford Hospital in Detroit, MI. Methods: An online questionnaire was distributed via email to all residents, certified registered nurse anesthetists (CRNAs), and attending anesthesiologists in March 2021. The email contained a link to an online questionnaire via Microsoft Forms (Microsoft Corporation, Redmond, WA). Univariate group comparisons were carried out between the respondents\u27 role (attending, CRNA, or resident), as well as between the number of years that the respondents were in practice (\u3c 5 years, 5-10 years, \u3e 10 years). Results: Out of the total 170 anesthesia providers, 119 participated in the study where 54 (45%) were attendings, 44 (37%) were residents, and 21 (18%) were CRNAs. The majority (75%) did not know the surgical airway kit location, and 87% had not performed the surgical airway procedure before. The vast majority (96.7%) recommended simulation training compared to online training or lecture series, and just over 50% recommended annual training frequency. When looking at the differences in responses based on years of experience as an anesthesia provider, the majority of those with \u3e 10 years in practice knew how to perform the surgical airway technique while respondents with \u3c 5 years did not know how to perform the technique, and 50% of those with five to 10 years experience knew how to perform the surgical airway procedure for a CICV scenario. Conclusion: Although there were many significant differences observed between the various provider roles and years in practice, surprisingly, the responses revealed both a lack of experience and confidence in performing the surgical airway procedure in all provider roles. These findings highlight a need for better emergency airway teaching and training. These findings will be used to guide the design and implementation of improved surgical airway training for residents, CRNAs, and attending anesthesiologists with the goal of better preparedness for handling a CICV scenario

Sequential Organ Failure Assessment (SOFA) Score and Mortality Prediction in Patients With Severe Respiratory Distress Secondary to COVID-19

Background: This study looks at the validity of the sequential organ failure assessment score (SOFA) in detecting mortality in patients with Coronavirus disease of 2019 (COVID-19) pneumonia. Also, it is looking to determine the optimal SOFA score that will discriminate between mortality and survival. Methods: It is a retrospective chart review of the patients admitted to Henry Ford Hospital from March 2020 to December 2020 with COVID-19 pneumonia who developed severe respiratory distress. We collected the following information; patient demographics (age, sex, body mass index), co-morbidities (history of diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, coronary artery disease, or cancer), SOFA scores (the ratio of arterial oxygen tension (PaO(2)) to the fraction of inspired oxygen, Glasgow Coma Scale (GCS) score, mean arterial pressure, serum creatinine level, bilirubin level, and platelet count) as well as inpatient mortality. Results: There were 320 patients; out of these, 111 were intubated. The receiver operating characteristic (ROC) curve for SOFA at the moment of inclusion in the study had an area under the curve of 0.883. The optimal point for discrimination between mortality and survival is SOFA of 5. A SOFA score of less than two is associated with 100% survival, while a score of more than 11 is associated with 100% mortality. Conclusions: SOFA score in COVID-19 patients with severe respiratory distress strongly correlates with the initial SOFA score. It is a valuable tool for predicting mortality in COVID-19 patients

Effect of Intubation Timing on the Outcome of Patients With Severe Respiratory Distress Secondary to COVID-19 Pneumonia.

Background: The optimal timing of intubation for critically ill patients with severe respiratory illness remains controversial among healthcare providers. The coronavirus disease 2019 (COVID-19) pandemic has raised even more questions about when to implement this life-saving therapy. While one group of providers prefers early intubation for patients with respiratory distress because these patients may deteriorate rapidly without it, other providers believe that intubation should be delayed or avoided because of its associated risks including worse outcomes. Research question: Our objective was to assess whether the timing of intubation in patients with severe COVID-19 pneumonia was associated with differences in mortality or other outcomes. Study design and methods: This was a single-center retrospective observational cohort study. We analyzed outcomes of patients who were intubated secondary to COVID-19 pneumonia between March 13, 2020, and December 12, 2020, at Henry Ford Hospital in Detroit, Michigan. Patients were categorized into two groups: early intubated (intubated within 24 hours of the onset of severe respiratory distress) and late intubated (intubated after 24 hours of the onset of severe respiratory distress). Demographics, comorbidities, respiratory rate oxygenation (ROX) index, sequential organ failure assessment (SOFA) score, and treatment received were compared between groups. The primary outcome was mortality. Secondary outcomes were ventilation time, intensive care unit stay, hospital length of stay, and discharge disposition. Post hoc and Kaplan-Meier survival analyses were performed. Results: A total of 110 patients were included: 55 early intubated and 55 late intubated. We did not observe a significant difference in overall mortality between the early intubated (43%) and the late intubated groups (53%) (p = 0.34). There was no statistically significant difference in patients\u27 baseline characteristics including SOFA scores (the early intubation group had a mean score of 7.5 compared to 6.7 in the late intubation group). Based on the ROX index, the early intubation group had significantly more patients with a reduced risk of intubation (45%) than the late group (27%) (p = 0.029). The early intubation group was treated with a high-flow nasal cannula at a significantly lower rate (47%) than the late intubation group (83%) (p \u3c 0.001). Significant differences in patient baseline characteristics, treatment received, and other outcomes were not observed. Post hoc analysis adjusting for SOFA score between 0 and 9 revealed significantly higher mortality in the late intubation group (49%) than in the early intubation group (26%) (p = 0.03). Patients in the 0 to 9 SOFA group who were intubated later had 2.7 times the odds of dying during hospital admission compared to patients who were intubated early (CI, 1.09-6.67). Interpretation: The timing of intubation for patients with severe COVID-19 pneumonia was not significantly associated with overall mortality or other patient outcomes. However, within the subgroup of patients with SOFA scores of 9 or lower at the time of intubation, patients intubated after 24 hours of the onset of respiratory distress had a higher risk of death than those who were intubated within 24 hours of respiratory distress. Thus, patients with COVID-19 pneumonia who are not at a high level of organ dysfunction may benefit from early mechanical ventilation

International multiphase mixed methods study protocol to develop a patient-reported outcome instrument for children and adolescents with lower limb deformities

INTRODUCTION: Our recent systematic review has indicated the lack of a patient-reported outcome (PRO) instrument to measure health-related quality of life (HRQOL) of children and adolescents with lower limb deformities. We are developing a PRO instrument which will be applicable internationally across various countries. This manuscript describes our approach to the development of a new PRO instrument for measuring HRQOL for children and adolescents with lower limb deformities. METHODS AND ANALYSIS: Three phases in the development of this PRO instrument are as described: (1) This phase involves the development of a conceptual framework of HRQOL and item pool that is used to inform a set of preliminary scales. We have developed a preliminary conceptual framework of HRQOL based on our systematic review. Qualitative interviews are being conducted at five sites in Canada, Ethiopia, India and the USA. An item pool will be generated from this qualitative phase. The preliminary items and scales will be sent out to children at the five participating centres. Cognitive debriefing interviews will gather detailed feedback on the items from the children. Expert opinion will be sought from clinicians from the participating centres. (2) During this phase, an international field-test study will be conducted to refine the scales and examine their psychometric properties. (3) During this phase, tests of reliability, validity and responsiveness will be conducted. Phase 1 will also involve translations and cultural adaptations. At the end of this study, we expect to produce an internationally applicable PRO instrument which is scientifically sound and clinically relevant to the lower limb deformity population. ETHICS AND DISSEMINATION: This study is approved by Research Ethics Boards for each of the participating sites.Results of this study will be published in peer-reviewed journals and presented at national and international conferences. An integrated knowledge translation approach is applied to engage patients, families and clinicians from the start of the study

Cytological diagnosis of pulmonary nocardiosis in an immunocompromised patient

We report a case of pulmonary nocardiosis in an immunosuppressed patient having vasculitis who presented with fever, cough and chest pain. A suspicion of nocardiosis was made on auramine O staining of material procured by CT guided fine needle aspiration cytology right lung. Modified Ziehl-Neelsen staining was useful in confirming the diagnosis. The patient showed remarkable recovery after treatment with co-trimoxazole. Quick identification of this uncommon pathogen in the cytological material using special stains helped in timely diagnosis and successful treatment of the patient

Effect of fenfluramine on the electrical activity of the hypothalamic feeding centers

Electrodes were stereotaxically implanted in the lateral hypothalamic feeding center and medial satiety center as well as in other hypothalamic and cerebral regions in male rhesus monkeys. Electrical activity of these regions was recorded electroencephalographically, before and following iv injections of Fenfluramine given daily for 7-10 days in doses of 1.5 mg/kg and 3 mg/kg body-weight respectively. In addition changes in the eating behavior, daily food intake, body weight and general behavior were observed. In another set of animals arteriovenous glucose differences (to provide indices of glucose utilization in the body) in response to Fenfluramine injections were estimated. Fenfluramine in doses of 1.5 mg/kg gradually resulted in slow wave activity in the feeding center, which became more pronounced after subsequent injections thus demonstrating a cumulative effect. This coincided with anorexic behavior and decrease in food intake. The activity of the satiety center changed to low voltage fast response, specially in starving animals. Arteriovenous glucose estimations suggest that the effects of Fenfluramine may be due to the increased level of glucose utilization in the body. Injections in doses of 3 mg/kg however produced a generalized drowsy response

Influence of gonadal hormones and genital afferents on EEG activity of the hypothalamus in adult male rhesus monkeys

Electrodes were stereotaxically implanted in hypothalamic and cerebral cortical regions of 15 adult male gonadally intact rhesus monkeys. The electrical activity of these regions was recorded electroencephalographically before and after genital stimulation. Observations were also taken after stimulation on skin, abdomen and nipples and repeated daily for 4 to 6 days, before and after intravenous injections of testosterone propionate (0.4 mg/kg). The experiment was repeated on the same animal after gonadectomy. The influence of gential afferents appears to produce focal inhibition of electroencephalographic (EEG) activity in ventromedial nucleus (VMN) in monkeys with intact gonads. Exogenous administration of testosterone propionate produces EEG facilitation in VMN with simultaneous inhibition of the anterior hypothalamic area. With continued increase in amounts of circulating hormone, the EEG activity in the posterior hypothalamic area is also inhibited by the incoming genital afferent information. Gonadectomy brings about EEG slowing with genital stimulation in ventromedial nucleus before hormone injection but this was less marked than that observed in EEG records of intact preparation