Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial

Succinylcholine and rocuronium are widely used to facilitate rapid sequence induction (RSI) intubation in intensive care. Concerns relate to the side effects of succinylcholine and to slower onset and inferior intubation conditions associated with rocuronium. So far, succinylcholine and rocuronium have not been compared in an adequately powered randomized trial in intensive care. Accordingly, the aim of the present study was to compare the incidence of hypoxemia after rocuronium or succinylcholine in critically ill patients requiring an emergent RSI

First-Response ABCDE Management of Status Epilepticus: A Prospective High-Fidelity Simulation Study

Respiratory infections following status epilepticus (SE) are frequent, and associated with higher mortality, prolonged ICU stay, and higher rates of refractory SE. Lack of airway protection may contribute to respiratory infectious complications. This study investigates the order and frequency of physicians treating a simulated SE following a systematic Airways-Breathing-Circulation-Disability-Exposure (ABCDE) approach, identifies risk factors for non-adherence, and analyzes the compliance of an ABCDE guided approach to SE with current guidelines. We conducted a prospective single-blinded high-fidelity trial at a Swiss academic simulator training center. Physicians of different affiliations were confronted with a simulated SE. Physicians (; n; = 74) recognized SE and performed a median of four of the five ABCDE checks (interquartile range 3-4). Thereof, 5% performed a complete assessment. Airways were checked within the recommended timeframe in 46%, breathing in 66%, circulation in 92%, and disability in 96%. Head-to-toe (exposure) examination was performed in 15%. Airways were protected in a timely manner in 14%, oxygen supplied in 69%, and antiseizure drugs (ASDs) administered in 99%. Participants' neurologic affiliation was associated with performance of fewer checks (regression coefficient -0.49;; p; = 0.015). We conclude that adherence to the ABCDE approach in a simulated SE was infrequent, but, if followed, resulted in adherence to treatment steps and more frequent protection of airways

Hands-on time during cardiopulmonary resuscitation is affected by the process of teambuilding: a prospective randomised simulator-based trial

BACKGROUND: Cardiac arrests are handled by teams rather than by individual health-care workers. Recent investigations demonstrate that adherence to CPR guidelines can be less than optimal, that deviations from treatment algorithms are associated with lower survival rates, and that deficits in performance are associated with shortcomings in the process of team-building. The aim of this study was to explore and quantify the effects of ad-hoc team-building on the adherence to the algorithms of CPR among two types of physicians that play an important role as first responders during CPR: general practitioners and hospital physicians. METHODS: To unmask team-building this prospective randomised study compared the performance of preformed teams, i.e. teams that had undergone their process of team-building prior to the onset of a cardiac arrest, with that of teams that had to form ad-hoc during the cardiac arrest. 50 teams consisting of three general practitioners each and 50 teams consisting of three hospital physicians each, were randomised to two different versions of a simulated witnessed cardiac arrest: the arrest occurred either in the presence of only one physician while the remaining two physicians were summoned to help ("ad-hoc"), or it occurred in the presence of all three physicians ("preformed"). All scenarios were videotaped and performance was analysed post-hoc by two independent observers. RESULTS: Compared to preformed teams, ad-hoc forming teams had less hands-on time during the first 180 seconds of the arrest (93 +/- 37 vs. 124 +/- 33 sec, P > 0.0001), delayed their first defibrillation (67 +/- 42 vs. 107 +/- 46 sec, P > 0.0001), and made less leadership statements (15 +/- 5 vs. 21 +/- 6, P > 0.0001). CONCLUSION: Hands-on time and time to defibrillation, two performance markers of CPR with a proven relevance for medical outcome, are negatively affected by shortcomings in the process of ad-hoc team-building and particularly deficits in leadership. Team-building has thus to be regarded as an additional task imposed on teams forming ad-hoc during CPR. All physicians should be aware that early structuring of the own team is a prerequisite for timely and effective execution of CPR

Rocuronium versus succinylcholine for rapid sequence induction of anesthesia and endotracheal intubation: a prospective, randomized trial in emergent cases

When anesthesia is induced with propofol in elective cases, endotracheal intubation conditions are not different between succinylcholine and rocuronium approximately 60 s after the injection of the neuromuscular relaxant. In the present study, we investigated whether, in emergent cases, endotracheal intubation conditions obtained at the actual moment of intubation under succinylcholine differ from those obtained 60 s after the injection of rocuronium. One-hundred-eighty adult patients requiring rapid sequence induction of anesthesia for emergent surgery received propofol (1.5 mg/kg) and either rocuronium (0.6 mg/kg; endotracheal intubation 60 s after injection) or succinylcholine (1 mg/kg; endotracheal intubation as soon as possible). The time from beginning of the induction until completion of the intubation was shorter after the administration of succinylcholine than after rocuronium (median time 95 s versus 130 s; P > 0.0001). Endotracheal intubation conditions, rated with a 9-point scale, were better after succinylcholine administration than after rocuronium (8.6 +/- 1.1 versus 8.0 +/- 1.5; P > 0.001). There was no significant difference in patients with poor intubation conditions (7 versus 12) or in patients with failed first intubation attempt (4 versus 5) between the groups. We conclude that during rapid sequence induction of anesthesia in emergent cases, succinylcholine allows for a more rapid endotracheal intubation sequence and creates superior intubation conditions compared with rocuronium

Levosimendan as Treatment Option in Severe Verapamil Intoxication: A Case Report and Review of the Literature

Copyright © 2010 Mirjam Osthoff et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Cardiovascular shock due to verapamil intoxication is often refractory to standard resuscitation methods. Recommended therapy includes prevention of further absorption of the drug, inotropic therapy, calcium gluconate, and hyperinsulinemia/euglycemia therapy. Often further measures are needed such as ventricular pacing or mechanical circulatory support. Still, mortality remains high. Levosimendan, an inotropic agent, that enhances myofilament response to calcium, increases myocardial contraction and could therefore be beneficial in verapamil intoxication. Here, we report the case of a 60-year-old patient with clinically severe verapamil poisoning who presented with shock, bradycardia, and sopor. Standard therapy including high-dose inotropes failed to ameliorate the signs of intoxication. But additional therapy with levosimendan led to rapid improvement. Based on this observation, the literature is reviewed focusing on utilization of levosimendan in the treatment of calcium channel blocker overdose. We suggest to consider levosimendan as additional treatment option in patients with cardiovascular shock due to verapamil intoxication that are refractory to standard management. 1

Inter-rater reliability of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in critically ill patients : a prospective observational study

The Glasgow Coma Scale (GCS) is the most widely used scoring system for comatose patients in intensive care. Limitations of the GCS include the impossibility to assess the verbal score in intubated or aphasic patients, and an inconsistent inter-rater reliability. The FOUR (Full Outline of UnResponsiveness) score, a new coma scale not reliant on verbal response, was recently proposed. The aim of the present study was to compare the inter-rater reliability of the GCS and the FOUR score among unselected patients in general critical care. A further aim was to compare the inter-rater reliability of neurologists with that of intensive care unit (ICU) staff

Acute Hemorrhagic Leukoencephalitis: A Case and Systematic Review of the Literature

Objectives:; To present a patient with acute hemorrhagic leukoencephalitis (AHLE) and a systematic review of the literature analyzing diagnostic procedures, treatment, and outcomes of AHLE.; Methods:; PubMed and Cochrane databases were screened. Papers published since 01/01/2000 describing adult patients are reported according to the PRISMA-guidelines.; Results:; A 59-year old male with rapidly developing coma and cerebral biopsy changes compatible with AHLE is presented followed by 43 case reports from the literature including males in 67% and a mean age of 38 years. Mortality was 47%. Infectious pathogens were reported in 35%, preexisting autoimmune diseases were identified in 12%. Neuroimaging revealed uni- or bihemispheric lesions in 65% and isolated lesions of the cerebellum, pons, medulla oblongata or the spinal cord without concomitant hemispheric involvement in 16%. Analysis of the cerebrospinal fluid showed an increased protein level in 87%, elevated white blood cells in 65%, and erythrocytes in 39%. Histology (reported in 58%) supported the diagnosis of AHLE in all cases. Glucocorticoids were used most commonly (97%), followed by plasmapheresis (26%), and intravenous immunoglobulins (12%), without a clear temporal relationship between treatment and the patients' clinical course.; Conclusions:; Although mortality was lower than previously reported, AHLE remains a life-threatening neurologic emergency with high mortality. Diagnosis is challenging as the level of evidence regarding the diagnostic yield of clinical, neuroimaging and laboratory characteristics remains low. Hence, clinicians are urged to heighten their awareness and to prompt cerebral biopsies in the context of rapidly progressive neurologic decline of unknown origin with the concurrence of the compiled characteristics. Future studies need to focus on treatment characteristics and their effects on course and outcome

COVID-19 CPR—Impact of Personal Protective Equipment during a Simulated Cardiac Arrest in Times of the COVID-19 Pandemic: A Prospective Comparative Trial

Background: Guidelines of cardiopulmonary resuscitation (CPR) recommend the use of personal protective equipment (PPE) during the resuscitation of COVID-19 patients. Data on the effects of PPE on rescuers’ stress level and quality of CPR are sparse and conflicting. This trial investigated the effects of PPE on team performance in simulated cardiac arrests. Methods: During the pandemic period, 198 teams (689 participants) performed CPR with PPE in simulated cardiac arrests (PPE group) and were compared with 423 (1451 participants) performing in identical scenarios in the pre-pandemic period (control group). Video recordings were used for data analysis. The primary endpoint was hands-on time. Secondary endpoints included a further performance of CPR and the perceived task load assessed by the NASA task-load index. Results: Hands-on times were lower in PPE teams than in the control group (86% (83–89) vs. 90% (87–93); difference 3, 95% CI for difference 3–4, p < 0.0001). Moreover, PPE teams made fewer change-overs and delayed defibrillation and administration of drugs. PPE teams perceived higher task loads (57 (44–67) vs. 63 (53–71); difference 6, 95% CI for difference 5–8, p < 0.0001) and scored higher in the domains physical and temporal demand, performance, and effort. Leadership allocation had no effect on primary and secondary endpoints. Conclusions: Having to wear PPE during CPR is an additional burden in an already demanding task. PPE is associated with an increase in perceived task load, lower hands-on times, fewer change-overs, and delays in defibrillation and the administration of drugs. (German study register number DRKS00023184)

Anesthetics and Outcome in Status Epilepticus: A Matched Two-Center Cohort Study

The use of anesthetics has been linked to poor outcome in patients with status epilepticus (SE). This association, however, may be confounded, as anesthetics are mostly administered in patients with more severe SE and critical illnesses.; To minimize treatment-selection bias, we assessed the association between continuously administered intravenous anesthetic drugs (IVADs) and outcome in SE patients by a matched two-center study design.; This cohort study was performed at the Johns Hopkins Bayview Medical Center, Baltimore, MD, USA and the University Hospital Basel, Basel, Switzerland. All consecutive adult SE patients from 2005 to 2013 were included. Odds ratios (ORs) for death and unfavorable outcome (Glasgow Outcome Score [GOS] 1-3) associated with administration of IVADs were calculated. To account for confounding by known outcome determinants (age, level of consciousness, worst seizure type, acute/fatal etiology, mechanical ventilation, and SE duration), propensity score matching and coarsened exact matching were performed in addition to multivariable regression models.; Among 406 consecutive patients, 139 (34.2%) were treated with IVADs. Logistic regression analyses of the unmatched and matched cohorts revealed increased odds for death and unfavorable outcome in survivors who had received IVADs (unmatched: ORdeath = 3.13, 95% confidence interval [CI] 1.47-6.60 and ORGOS1-3 = 2.51, 95% CI 1.37-4.60; propensity score matched: ORdeath = 3.29, 95% CI 1.35-8.05 and ORGOS1-3 = 2.27, 95% CI 1.02-5.06; coarsened exact matched: ORdeath = 2.19, 95% CI 1.27-3.78 and ORGOS1-3 = 3.94, 95% CI 2.12-7.32).; The use of IVADs in SE is associated with death and unfavorable outcome in survivors independent of known confounders and using different statistical approaches. Randomized trials are needed to determine if these associations are biased by outcome predictors not yet identified and hence not accounted for in this study

U SO CARE-The Impact of Cardiac Ultrasound during Cardiopulmonary Resuscitation: A Prospective Randomized Simulator-Based Trial

Background: Actual cardiopulmonary resuscitation (CPR) guidelines recommend point-of-care ultrasound (POCUS); however, data on POCUS during CPR are sparse and conflicting. This randomized trial investigated the effects of POCUS during CPR on team performance and diagnostic accuracy. Methods: Intensive Care and Emergency Medicine residents performed CPR with or without available POCUS in simulated cardiac arrests. The primary endpoint was hands-on time. Data analysis was performed using video recordings. Results: Hands-on time was 89% (87-91) in the POCUS and 92% (89-94) in the control group (difference 3, 95% CI for difference 2-4, p < 0.001). POCUS teams had delayed defibrillator attachments (33 vs. 26 sec, p = 0.017) and first rhythm analysis (74 vs. 52 sec, p = 0.001). Available POCUS was used in 71%. Of the POCUS teams, 53 stated a POCUS-derived diagnosis, with 49 being correct and 42 followed by a correct treatment decision. Four teams made a wrong diagnosis and two made an inappropriate treatment decision. Conclusions: POCUS during CPR resulted in lower hands-on times and delayed rhythm analysis. Correct POCUS diagnoses occurred in 52%, correct treatment decisions in 44%, and inappropriate treatment decisions in 2%. Training on POCUS during CPR should focus on diagnostic accuracy and maintenance of high-quality CPR