Reintubation in critically ill patients: Procedural complications and implications for care

Introduction: In critically ill patients, re-intubation is common and may be a high-risk procedure. Anticipating a difficult airway and identifying high-risk patients can allow time for life-saving preparation. Unfortunately, prospective studies have not compared the difficulty or complication rates associated with reintubation in this population. Methods: We performed a secondary analysis of a prospective registry of in-hospital emergency airway management, focusing on patients that underwent multiple out-of-operating room intubations during a single hospitalization. Our main outcomes of interest were technical difficulty of intubation (number of attempts, need for adjuncts to direct laryngoscopy, best Cormack-Lehane grade and training level of final intubator) and the frequency of procedural complications (aspiration, arrhythmia, airway trauma, new hypotension, new hypoxia, esophageal intubation and cardiac arrest). We compared the cohort of reintubated patients to a matched cohort of singly intubated patients and compared each repeatedly intubated patient's first and last intubation. Results: Our registry included 1053 patients, of which 151 patients (14%) were repeatedly intubated (median two per patient). Complications were significantly more common during last intubation compared to first (13% versus 5%, P = 0.02). The most common complications were hypotension (41%) and hypoxia (35%). These occurred despite no difference in any measure of technical difficultly across intubations. Conclusion: In this cohort of reintubated patients, clinically important procedural complications were significantly more common on last intubation compared to first

Energy sector development and carbon abatement challenges in Saudi Arabia, the United Arab Emirates, and Qatar

The issue of climate change is high on the global agenda, and the hydrocarbon-rich countries of the Gulf region are no exception. While the Gulf countries initially resisted the drafting of an international climate agreement for many years, they have now finally realized that decarbonization is not only necessary for their continued existence due to the threat of climate change, but that it would assist in reducing their hydrocarbon demand and meeting their economic diversification goals. This research focuses on how Saudi Arabia, the United Arab Emirates, and Qatar could achieve the decarbonization goals of their Paris Agreement (COP 21) pledges by analyzing the potential impact that various carbon reduction frameworks, such as carbon trading, carbon taxation, and command and control regulations, would have on their economic development. The key questions posed in this paper are whether carbon reduction mechanisms could be a viable way to reduce domestic hydrocarbon demand, and if so, which carbon reduction model would be preferable, and how it should be optimally designed to meet the Paris Agreement commitments? These questions are answered by examining the contours of the energy sectors of the three selected countries, the evolution of their negotiating positions during the various international climate negotiations, and an analysis of the various carbon reduction frameworks and how they might best be designed to optimally decarbonize their macroeconomies. My principal findings are that Saudi Arabia and the UAE would be best placed to implement national carbon markets in their respective jurisdictions, due to their large industrial bases and downstream sectors, as well as their relatively mature economies and growing populations. In Qatar’s case, my research discovered that a command-and-control carbon reduction framework would work optimally because Qatar’s small size, both in population and industrial base, would more efficiently allow direct regulation. This research is an important contribution because as it showed that the Gulf countries may have taken a circuitous route to recognize the importance of combatting climate change, but now they are investing billions of dollars in alternative (nuclear+renewable) projects, implementing robust energy efficiency codes, and announcing, in the case of the UAE and Saudi Arabia, ambitious net-zero goals. As a result, understanding how they may arrive at their Paris Agreement pledges is critical for understanding the potential evolution of the region’s development and the contours of the future global energy market. </p

Clinical detection of abdominal aortic aneurysm in a 74-year-old man in chiropractic practice

OBJECTIVE: The purpose of this article is to present a case of abdominal aortic aneurysm to illustrate its clinical detection through history and physical examination and the importance of this condition to the chiropractic clinical setting. CLINICAL FEATURES: A 74-year-old retired man consulted a doctor of chiropractic for chronic low back pain. The history and physical examination confirmed chronic sacroiliac and a lumbar facet dysfunction. After 5 weeks, the patient stated he had stomach cramps. After this, a more thorough abdominal examination was done. The doctor of chiropractic detected an enlarged pulsatile mass upon abdominal palpation. INTERVENTION AND OUTCOME: The patient was sent to the cardiologist and had successful surgery within weeks. CONCLUSION: An abdominal aortic aneurysm has specific symptoms and associated risk factors. If known risk factors are present, a clinical examination needs to be carried out, even though sensitivity of the clinical examination may be low. It should be a differential diagnosis in every male patient older than 50 years with low back pain. In case of suspicion, the patient should be referred for advanced imaging

The ed-sed multicenter study of outcomes associated with sedation depth for mechanically ventilated patients

Background: A previous investigation of mechanically ventilated patients demonstrated that deep sedation in the ED was common (64%), and associated with increased mortality, longer ventilation duration, and longer lengths of stay. As this was a single center study, it is unknown if the results are generalizable. The objective of this study was to test the hypothesis that deep sedation in the ED is associated with worse clinical outcomes in mechanically ventilated patients. Methods: This was a multicenter, prospective cohort study which enrolled 271 mechanically ventilated ED patients at fifteen academic medical centers during a one-month time frame. Deep sedation was defined as a Richmond Agitation-Sedation Scale of-3 to-5 or Sedation Agitation Scale of 2 or 1. Outcomes of interest included ventilator-free days, lengths of stay, mortality, and acute brain dysfunction (delirium and coma). The primary analysis examined ventilator-free days as a function of ED sedation depth. A multivariable linear regression model was constructed to adjust for potentially confounding variables using backward elimination. Results: ED deep sedation was observed in 143 patients (52.8%), and was associated with a higher incidence of deep sedation in the ICU on day one (53.1% vs. 21.1%, p= 0.003), when compared to light sedation. Mean (SD) ventilator-free days were 17.7 (11.1) in the ED deep sedation group compared to 19.4 (10.1) in the light sedation group (mean difference 1.7; 95% CI-0.90 to 4.22, p= 0.20). Similar results according to ED sedation depth existed for ICU-free days (mean difference 1.5; 95% CI-0.88 to 4.20, p= 0.27) and hospital-free days (mean difference 2.2; 95% CI-0.01 to 4.42, p= 0.051). Mortality was 21.7% in the deep sedation group and 16.4% in the light sedation group (between-group difference 5.3%; OR 1.41; 0.76-2.61, p= 0.27). The incidence of acute brain dysfunction was 65.7% in the deep sedation group and 53.1% in the light sedation group (between-group difference 12.6%; OR 1.69; 1.04-2.76, p= 0.04). Conclusion: Early deep sedation in the ED is common in mechanically ventilated patients, carries over into the ICU, and may be associated with worse outcomes. Sedation practices in the ED and associated clinical outcomes are in need of further investigation

Effect of a fluid bolus on cardiovascular collapse during tracheal intubation: A randomized clinical trial

Background: Emergency tracheal intubation of critically ill adults is frequently complicated by hypotension, cardiac arrest, or death. Whether administration of an intravenous fluid bolus reduces the risk of peri-intubation cardiovascular collapse is unknown. Methods: We conducted a multicenter, two-armed, parallel-group, unblinded randomized controlled trial at nine US sites to evaluate the effectiveness of administering a 500 ml fluid bolus during rapid sequence intubation of critically-ill adults for preventing cardiovascular collapse. By opening opaque envelopes after the decision to intubate and before induction, we randomized patients to receive either a 500 ml fluid bolus started before induction (experimental group), or no fluid bolus (control group). The primary outcome was cardiovascular collapse, defined as the composite of: new systolic blood pressure \u3c65 mmHg; new or increased vasopressor receipt between induction and two minutes after intubation; cardiac arrest within one hour of intubation; or death within one hour of intubation. Results: The data and safety monitoring board stopped the trial for futility at the first planned interim analysis, which occurred after 337 patients had been enrolled. The primary outcome of cardiovascular collapse occurred in 33 of 168 patients (19.6%) in the fluid bolus group compared with 31 of 169 patients (18.3%) in the no fluid bolus group (absolute between-group difference, 1.3% [95% CI,-7.1% to 9.7%]). Individual components of the cardiovascular collapse composite outcome were not significantly different between groups. Bag-mask ventilation between induction and laryngoscopy modified the effect of fluid bolus administration on the rate of cardiovascular collapse (P value for interaction = .01). Fluid bolus administration appeared to decrease the rate of cardiovascular collapse among patients receiving bag-mask ventilation and increase the rate of cardiovascular collapse among patients not receiving bag-mask ventilation Conclusion: Administration of an intravenous fluid bolus during emergency tracheal intubation of critically ill adults did not decrease the overall rate of cardiovascular collapse compared to no fluid bolus. The effect of fluid bolus administration on cardiovascular collapse may depend on the receipt of bag-mask ventilation during intubation. (clintrials.gov: NCT03026777