A Primer for Pediatric Emergency Front-of-the-Neck Access

"Cannot intubate, cannot oxygenate" situations in healthy children are uncommon but are often associated with poor outcomes. Clinical assessment, anticipatory planning, and the use of algorithms can lessen the likelihood of untoward outcomes, but the common final pathway of many algorithms for a difficult pediatric airway involves obtaining emergency tracheal access. The airway practitioner must have the know-how and training needed to invasively secure the airway when confronted with this rare but potentially devastating emergency. We provide practitioners with an overview of pediatric emergency front-of-the-neck access strategies and a structure for their management

Changes in lung volume estimated by electrical impedance tomography during apnea and high-flow nasal oxygenation: A single-center randomized controlled trial.

BACKGROUND Previous studies concerning humidified, heated high-flow nasal oxygen delivered in spontaneously breathing patients postulated an increase in functional residual capacity as one of its physiological effects. It is unclear wheter this is also true for patients under general anesthesia. METHODOLOGY The sincle-center noninferiority trial was registered at ClinicalTrials.gov (NCT NCT03478774). This secondary outcome analysis shows estimated differences in lung volume changes using electrical impedance tomography between different flow rates of 100% oxygen in apneic, anesthetized and paralyzed adults prior to intubation. One hundred and twenty five patients were randomized to five groups with different flow rates of 100% oxygen: i) minimal-flow: 0.25 l.min-1 via endotracheal tube; ii) low-flow: 2 l.min-1 + continuous jaw thrust; iii) medium-flow: 10 l.min-1 + continuous jaw thrust; iv) high-flow: 70l.min-1 + continuous jaw thrust; and v) control: 70 l.min-1 + continuous video-laryngoscopy. After standardized anesthesia induction with non-depolarizing neuromuscular blockade, the 15-minute apnea period and oxygen delivery was started according to the randomized flow rate. Continuous electrical impedance tomography measurements were performed during the 15-minute apnea period. Total change in lung impedance (an estimate of changes in lung volume) over the 15-minute apnea period and times to 25%, 50% and 75% of total impedance change were calculated. RESULTS One hundred and twenty five patients completed the original study. Six patients did not complete the 15-minute apnea period. Due to maloperation, malfunction and artefacts additional 54 measurements had to be excluded, resulting in 65 patients included into this secondary outcome analysis. We found no differences between groups with respect to decrease in lung impedance or curve progression over the observation period. CONCLUSIONS Different flow rates of humidified 100% oxygen during apnea result in comparable decreases in lung volumes. The demonstrated increase in functional residual capacity during spontaneous breathing with high-flow nasal oxygenation could not be replicated during apnea under general anesthesia with neuromuscular blockade

Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE):a prospective European multicentre observational study

Background: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences.Methods: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes.Results: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1e6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2&lt;90% for 60 s) was reported in 40%. No associated risk factors could be identified among comorbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality.Conclusions: The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event. Clinical trial registration: NCT02350348.</p

Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE):a prospective European multicentre observational study

BACKGROUND Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. METHODS We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. RESULTS Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1-6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2<90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. CONCLUSIONS The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event. CLINICAL TRIAL REGISTRATION NCT02350348

Relative importance of geostatistical and transport models in describing heavily tailed breakthrough curves at the Lauswiesen site

We analyze the relative importance of the selection of (1) the geostatistical model depicting the structural heterogeneity of an&nbsp;aquifer, and (2) the basic processes to be included in the conceptual model, to describe the main aspects of&nbsp;solute transport&nbsp;at an experimental site. We focus on the results of a forced-gradient tracer test performed at the &ldquo;Lauswiesen&rdquo; experimental site, near T&uuml;bingen, Germany. In the experiment, NaBr is injected into a well located 52&nbsp;m from a pumping well. Multilevel&nbsp;breakthrough curves&nbsp;(BTCs) are measured in the latter. We conceptualize the aquifer as a three-dimensional, doubly stochastic composite medium, where distributions of geomaterials and attributes, e.g.,&nbsp;hydraulic conductivity&nbsp;(K) and porosity (ϕ), can be uncertain. Several alternative transport processes are considered:&nbsp;advection, advection&ndash;dispersion and/or mass-transfer between mobile and immobile regions. Flow and transport are tackled within a stochastic Monte Carlo framework to describe key features of the experimental BTCs, such as temporal moments, peak time, and pronounced tailing. We find that, regardless the complexity of the conceptual transport model adopted, an adequate description of heterogeneity is crucial for generating alternative equally likely realizations of the system that are consistent with (a) the statistical description of the heterogeneous system, as inferred from the data, and (b) salient features of the depth-averaged breakthrough curve, including preferential paths, slow release of mass particles, and anomalous spreading. While the available geostatistical characterization of heterogeneity can explain most of the integrated behavior of transport (depth-averaged breakthrough curve), not all multilevel BTCs are described with equal success. This suggests that transport models simply based on integrated measurements may not ensure an accurate representation of many of the important features required in three-dimensional transport models

Genetic analysis of post‐epizootic amphibian chytrid strains in Bolivia: Adding a piece to the puzzle

The evolutionary history and dispersal pattern of Batrachochytrium dendrobatidis (Bd), an emergent fungal pathogen responsible for the decline and extinctions of many species of amphibians worldwide, is still not well understood. In South America, the tropical Andes are known as an important site for amphibian diversification, but also for being a place where hosts are at greater risk of chytridiomycosis. In an attempt to understand the history and the geographic pattern of Bd‐associated amphibian declines in Bolivia, we isolated Bd from hosts at two locations that differ in their chronology of Bd prevalence and host survival outcome, the cloud forests of the Amazonian slopes of the Andes and Lake Titicaca in the altiplano. We genotyped Bd from both locations and sequenced the genome from the cloud forest isolate and then compared them to reference sequences of other Bd strains across the world. We found that the Bolivian chytrid isolates were nearly genotypically identical and that they belong to the global panzootic lineage (Bd‐GPL). The Bolivian Bd strain grouped with other tropical New World strains but was closest to those from the Brazilian Atlantic Forest. Our results extend the presence of Bd‐GPL to the central Andes in South America and report this hypervirulent strain at Lago Titicaca, where Bd has been detected since 1863, without evidence of amphibian declines. These findings suggest a more complex evolutionary history for this pathogen in Bolivia and may point to the existence of an old lineage of Bd that has since been extirpated following the arrival of the panzootic Bd‐GPL or that the timing of Bd‐GPL emergence is earlier than generally acknowledged.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/162756/2/tbed13568_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/162756/1/tbed13568.pd

Communication Patterns During Routine Patient Care in a Pediatric Intensive Care Unit: The Behavioral Impact of In Situ Simulation.

OBJECTIVE Effective communication minimizes medical errors and leads to improved team performance while treating critically ill patients. Closed-loop communication is routinely applied in high-risk industries but remains underutilized in healthcare. Simulation serves as an educational tool to introduce, practice, and appreciate the efficacy of closed-loop communication. METHODS This observational before-and-after study investigates behavioral changes in communication among nurses brought on by simulation team training in a pediatric intensive care unit (PICU). The communication patterns of PICU nurses, who had no prior simulation experience, were observed during routine bedside care before and after undergoing in situ simulation.One month before and 1 and 3 months after simulation (intervention), 2 trained raters recorded nurse communications relative to callouts, uttered by the sender, and callbacks, reciprocated by the recipient. The impact of simulation on communication patterns was analyzed quantitatively. RESULTS Among the 15 PICU nurses included in this study, significant changes in communication behavior were observed during patient care after communication-focused in situ simulation. The PICU nurses were significantly less likely to let a callout go unanswered during clinical routine. The effect prevailed both 1 month (P = 0.039) and 3 months (P = 0.033) after the educational exposure. CONCLUSIONS This observational before-and-after study describes the prevalence and pattern of communication among PICU nurses during routine patient care and documents PICU nurses transferring simulation-acquired communication skills into their clinical environment after a single afternoon of in situ simulation. This successful transfer of simulation-acquired skills has the potential to improve patient safety and outcome

Atelectasis in obese patients undergoing laparoscopic bariatric surgery are not increased upon discharge from Post Anesthesia Care Unit.

BACKGROUND Obese patients frequently develop pulmonary atelectasis upon general anesthesia. The risk is increased during laparoscopic surgery. This prospective, observational single-center study evaluated atelectasis dynamics using Electric Impedance Tomography (EIT) in patients undergoing laparoscopic bariatric surgery. METHODS We included adult patients with ASA physical status I-IV and a BMI of ≥40. Exclusion criteria were known severe pulmonary hypertension, home oxygen therapy, heart failure, and recent pulmonary infections. The primary outcome was the proportion of poorly ventilated lung regions (low tidal variation areas) and the global inhomogeneity (GI) index assessed by EIT before discharge from the Post Anesthesia Care Unit compared to these same measures prior to initiation of anesthesia. RESULTS The median (IQR) proportion of low tidal variation areas at the different analysis points were T1 10.8% [3.6-15.1%] and T5 10.3% [2.6-18.9%], and the mean difference was -0.7% (95% CI: -5.8% -4.5%), i.e., lower than the predefined non-inferiority margin of 5% (p = 0.022). There were no changes at the four additional time points compared to T1 or postoperative pulmonary complications during the 14 days following the procedure. CONCLUSION We found that obese patients undergoing laparoscopic bariatric surgery do not leave the Post Anesthesia Care Unit with increased low tidal variation areas compared to the preoperative period

Factors influencing on-scene time in a physician-staffed helicopter emergency medical service (HEMS): a retrospective observational study.

BACKGROUND For helicopter emergency service systems (HEMS), the prehospital time consists of response time, on-scene time and transport time. Little is known about the factors that influence on-scene time or about differences between adult and paediatric missions in a physician-staffed HEMS. METHODS We analysed the HEMS electronic database of Swiss Air-Rescue from 01-01-2011 to 31-12-2021 (N = 110,331). We included primary missions and excluded missions with National Advisory Committee for Aeronautics score (NACA) score 0 or 7, resulting in 68,333 missions for analysis. The primary endpoint 'on-scene time' was defined as first physical contact with the patient until take-off to the hospital. A multivariable linear regression model was computed to examine the association of diagnosis, type and number of interventions and monitoring, and patient's characteristics with the primary endpoint. RESULTS The prehospital time and on-scene time of the missions studied were, respectively, 50.6 [IQR: 41.0-62.0] minutes and 21.0 [IQR: 15.0-28.6] minutes. Helicopter hoist operations, resuscitation, airway management, critical interventions, remote location, night-time, and paediatric patients were associated with longer on-scene times. CONCLUSIONS Compared to adult patients, the adjusted on-scene time for paediatric patients was longer. Besides the strong impact of a helicopter hoist operation on on-scene time, the dominant factors contributing to on-scene time are the type and number of interventions and monitoring: improving individual interventions or performing them in parallel may offer great potential for reducing on-scene time. However, multiple clinical interventions and monitoring interact and are not single interventions. Compared to the impact of interventions, non-modifiable factors, such as NACA score, type of diagnosis and age, make only a minor contribution to overall on-scene time