Fluid excess on intensive care unit after mechanical thrombectomy after acute ischemic stroke is associated with unfavorable neurological and functional outcomes: An observational cohort study.

INTRODUCTION: Endovascular thrombectomy stands as a pivotal component in the standard care for patients experiencing acute ischemic stroke with large vessel occlusion. Subsequent care for patients often extends to a neurological intensive care unit. While fluid management is integral to intensive care, the association between early fluid balance and neurological and functional outcomes post-thrombectomy has not yet been thoroughly investigated. METHODS: In a retrospective analysis of an observational, single-center study spanning from 2015 to 2021 at the University Medical Center Hamburg-Eppendorf, Germany, we enrolled stroke patients who underwent thrombectomy and received subsequent treatment in the ICU. Unfavorable functional and neurological outcome was defined as a mRS > 2 on day 90 after admission (mRS d90) or NIHSS > 5 at discharge, respectively. A multivariate regression model, adjusting for confounders, utilized the average fluid balance in the first 5 days to predict outcomes. Patients were dichotomized by their average fluid balance (>1 L vs <1 L) within the first 5 days, and a multivariate mRS d90 shift analysis was conducted after adjusting for covariates. RESULTS: Between 2015 and 2021, 1252 patients underwent thrombectomy, and 553 patients met the inclusion criteria (299 women [54%]). Unfavorable functional outcome was significantly associated with a higher daily average fluid balance in the first 5 days in the ICU (mRS d90 ⩽ 2: 0.3 ± 0.5 L, mRS d90 > 2: 0.7 ± 0.7 L, p = 0.02). The same association was observed for the NIHSS at discharge (NIHSS ⩽ 5: 0.3 ± 0.5 L; NIHSS > 5: 0.6 ± 0.6 L; p = 0.03). The mRS d90 shift analysis revealed significance for patients with an average fluid balance <1 L for better functional outcomes (adjusted odds ratio [AOR] 2.17; 95% confidence interval [CI] 1.54-3.07; p < 0.01). DISCUSSION: Fluid retention in post-thrombectomy stroke patients in the ICU is associated with poorer functional and neurological outcomes. Consequently, fluid retention emerges as an additional potential predictor for post-intervention stroke outcomes. Our findings provide an initial indication that preventing excessive fluid retention in stroke patients after endovascular thrombectomy could be beneficial for both functional and neurological recovery. Therefore, fluid retention might be an element to consider in optimizing fluid management for stroke patients.

Association Between Dyscapnia, Ventilatory Variables, and Mortality in Patients With Acute Respiratory Distress Syndrome-A Retrospective Cohort Study.

Background: This study aimed to investigate the associations between dyscapnia, ventilatory variables, and mortality. We hypothesized that the association between mechanical power or ventilatory ratio and survival is mediated by dyscapnia. Methods: Patients with moderate or severe acute respiratory distress syndrome (ARDS), who received mechanical ventilation within the first 48 h after admission to the intensive care unit for at least 48 h, were included in this retrospective single-center study. Values of arterial carbon dioxide (PaCO2) were categorized into "hypercapnia" (PaCO2 ≥ 50 mm Hg), "normocapnia" (PaCO2 36-49 mmHg), and "hypocapnia" (PaCO2 ≤ 35 mm Hg). We used path analyses to assess the associations between ventilatory variables (mechanical power and ventilatory ratio) and mortality, where hypocapnia or hypercapnia were included as mediating variables. Results: Between December 2017 and April 2021, 435 patients were included. While there was a significant association between mechanical power and hypercapnia (BEM = 0.24 [95% CI: 0.15; 0.34], P < .01), there was no significant association between mechanical power or hypercapnia and ICU mortality. The association between mechanical power and intensive care unit (ICU) mortality was fully mediated by hypocapnia (BEM = -0.10 [95% CI: -0.19; 0.00], P = .05; BMO = 0.38 [95% CI: 0.13; 0.63], P < .01). Ventilatory ratio was significantly associated with hypercapnia (B = 0.23 [95% CI: 0.14; 0.32], P < .01). There was no significant association between ventilatory ratio, hypercapnia, and mortality. There was a significant effect of ventilatory ratio on mortality, which was fully mediated by hypocapnia (BEM = -0.14 [95% CI: -0.24; -0.05], P < .01; BMO = 0.37 [95% CI: 0.12; 0.62], P < .01). Conclusion: In mechanically ventilated patients with moderate or severe ARDS, the association between mechanical power and mortality was fully mediated by hypocapnia. Likewise, there was a mediating effect of hypocapnia on the association between ventilatory ratio and ICU mortality. Our results indicate that the debate on dyscapnia and outcome after ARDS should consider the impact of ventilatory variables.

Early prediction of ventricular peritoneal shunt dependency in aneurysmal subarachnoid haemorrhage patients by recurrent neural network-based machine learning using routine intensive care unit data.

Aneurysmal subarachnoid haemorrhage (aSAH) can lead to complications such as acute hydrocephalic congestion. Treatment of this acute condition often includes establishing an external ventricular drainage (EVD). However, chronic hydrocephalus develops in some patients, who then require placement of a permanent ventriculoperitoneal (VP) shunt. The aim of this study was to employ recurrent neural network (RNN)-based machine learning techniques to identify patients who require VP shunt placement at an early stage. This retrospective single-centre study included all patients who were diagnosed with aSAH and treated in the intensive care unit (ICU) between November 2010 and May 2020 (n = 602). More than 120 parameters were analysed, including routine neurocritical care data, vital signs and blood gas analyses. Various machine learning techniques, including RNNs and gradient boosting machines, were evaluated for their ability to predict VP shunt dependency. VP-shunt dependency could be predicted using an RNN after just one day of ICU stay, with an AUC-ROC of 0.77 (CI: 0.75-0.79). The accuracy of the prediction improved after four days of observation (Day 4: AUC-ROC 0.81, CI: 0.79-0.84). At that point, the accuracy of the prediction was 76% (CI: 75.98-83.09%), with a sensitivity of 85% (CI: 83-88%) and a specificity of 74% (CI: 71-78%). RNN-based machine learning has the potential to predict VP shunt dependency on Day 4 after ictus in aSAH patients using routine data collected in the ICU. The use of machine learning may allow early identification of patients with specific therapeutic needs and accelerate the execution of required procedures.

Acute-on-chronic liver failure alters linezolid pharmacokinetics in critically ill patients with continuous hemodialysis: an observational study.

BACKGROUND: In acute-on-chronic liver failure (ACLF), adequate antibiotic dosing is challenging due to changes of drug distribution and elimination. We studied the pharmacokinetics of linezolid in critically ill patients with ACLF during continuous renal replacement therapy compared to patients without concomitant liver failure (NLF). METHODS: In this prospective cohort study, patients received linezolid 600 mg bid. Linezolid serum samples were analyzed by high-performance liquid chromatography. Population pharmacokinetic modelling was performed followed by Monte-Carlo simulations of 150 mg bid, 300 mg bid, 450 mg bid, 600 mg bid, and 900 mg bid to assess trough concentration target attainment of 2-7 mg/L. RESULTS: Eighteen patients were included in this study with nine suffering from ACLF. Linezolid body clearance was lower in the ACLF group with mean (standard deviation) 1.54 (0.52) L/h versus 6.26 (2.43) L/h for NLF, P < 0.001. A trough concentration of 2-7 mg/L was reached with the standard dose of 600 mg bid in the NLF group in 47%, with 42% being underexposed and 11% overexposed versus 20% in the ACLF group with 77% overexposed and 3% underexposed. The highest probability of target exposure was attained with 600 mg bid in the NLF group and 150 mg bid in the ACLF group with 53%. CONCLUSION: Linezolid body clearance in ACLF was markedly lower than in NLF. Given the overall high variability, therapeutic drug monitoring (TDM) with dose adjustments seems required to optimize target attainment. Until TDM results are available, a dose reduction may be considered in ACLF patients to prevent overexposure.

Glidescope Video Laryngoscopy in Patients with Severely Restricted Mouth Opening-A Pilot Study.

BACKGROUND: An inter-incisor gap <3 cm is considered critical for videolaryngoscopy. It is unknown if new generation GlideScope Spectrum™ videolaryngoscopes with low-profile hyperangulated blades might facilitate safe tracheal intubation in these patients. This prospective pilot study aims to evaluate feasibility and safety of GlideScopeTM videolaryngoscopes in severely restricted mouth opening. METHODS: Feasibility study in 30 adults with inter-incisor gaps between 1.0 and 3.0 cm scheduled for ENT or maxillofacial surgery. Individuals at risk for aspiration or rapid desaturation were excluded. RESULTS: The mean mouth opening was 2.2 ± 0.5 cm (range 1.1-3.0 cm). First attempt success rate was 90% and overall success was 100%. A glottis view grade 1 or 2a was achieved in all patients. Nasotracheal intubation was particularly difficult if Magill forceps were required (n = 4). Intubation time differed between orotracheal (n = 9; 33 (25; 39) s) and nasotracheal (n = 21; 55 (38; 94) s); p = 0.049 intubations. The airway operator's subjective ratings on visual analogue scales (0-100) revealed that tube placement was more difficult in individuals with an inter-incisor gap <2.0 cm (n = 10; 35 (29; 54)) versus ≥2.0 cm (n = 20; 20 (10; 30)), p = 0.007, while quality of glottis exposure did not differ. CONCLUSIONS: GlidescopeTM videolaryngoscopy is feasible and safe in patients with severely restricted mouth opening if given limitations are respected.

Comparison of nasotracheal versus orotracheal intubation for sedation, assisted spontaneous breathing, mobilization, and outcome in critically ill patients: an exploratory retrospective analysis.

Nasotracheal intubation (NTI) may be used for long term ventilation in critically ill patients. Although tracheostomy is often favored, NTI may exhibit potential benefits. Compared to orotracheal intubation (OTI), patients receiving NTI may require less sedation and thus be more alert and with less episodes of depression of respiratory drive. We aimed to study the association of NTI versus OTI with sedation, assisted breathing, mobilization, and outcome in an exploratory analysis. Retrospective data on patients intubated in the intensive care unit (ICU) and ventilated for > 48 h were retrieved from electronic records for up to ten days after intubation. Outcome measures were a Richmond Agitation and Sedation Scale (RASS) of 0 or - 1, sedatives, vasopressors, assisted breathing, mobilization on the ICU mobility scale (ICU-MS), and outcome. From January 2018 to December 2020, 988 patients received OTI and 221 NTI. On day 1-3, a RASS of 0 or - 1 was attained in OTI for 4.0 ± 6.1 h/d versus 9.4 ± 8.4 h/d in NTI, p < 0.001. Propofol, sufentanil, and norepinephrine were required less frequently in NTI and doses were lower. The NTI group showed a higher proportion of spontaneous breathing from day 1 to 7 (day 1-6: p < 0.001, day 7: p = 0.002). ICU-MS scores were higher in the NTI group (d1-d9: p < 0.001, d10: p = 0.012). OTI was an independent predictor for mortality (odds ratio 1.602, 95% confidence interval 1.132-2.268, p = 0.008). No difference in the rate of tracheostomy was found. NTI was associated with less sedation, more spontaneous breathing, and a higher degree of mobilization during physiotherapy. OTI was identified as an independent predictor for mortality. Due to these findings a new prospective evaluation of NTI versus OTI should be conducted to study risks and benefits in current critical care medicine.

Vie Scope® versus videolaryngoscopy in expected difficult airways: a randomized controlled trial.

PURPOSE: The management of patients with an anticipated difficult airway remains challenging. We evaluated laryngeal visualization with the recently introduced Vie Scope® as a straight blade laryngoscope consisting of an illuminated tube necessitating bougie-facilitated intubation vs Macintosh videolaryngoscopy. METHODS: We conducted a prospective randomized controlled noninferiority trial. Patients undergoing elective ear, nose, and throat or oral and maxillofacial surgery with an anticipated difficult airway were randomized 1:1 to receive tracheal intubation with the Vie Scope or Macintosh videolaryngoscope (C-MAC®). The primary outcome measure was laryngeal visualization by the percentage of glottis opening (POGO) scale. Secondary outcome measures were the time to successful intubation (TTI) and first-attempt and overall success rates. RESULTS: We included two sets of 29 patients in our analysis. For visualization, the Vie Scope was noninferior to videolaryngoscopy (VL) with mean (standard deviation [SD]) POGO scores of 71 (31)% vs 64 (30)% in the VL group [difference in means, 7 (8)%; 95% confidence interval, -9 to 23; P = 0.38]. Mean (SD) TTI was 125 (129) sec in the Vie Scope and 51 (36) sec in the VL group (difference in means, 75 sec; 95% confidence interval, 25 to 124; P = 0.005). The first-attempt and overall success rates were 22/29 (76%) and 27/29 (93%) in both groups. Two patients per group were switched to a different device. Four accidental esophageal intubations occurred in the Vie Scope group, these were presumably due to bougie misplacement. CONCLUSION: Visualization with the Vie Scope was noninferior to VL in patients with an anticipated difficult airway, but TTI was longer in the Vie Scope group. STUDY REGISTRATION: ClinicalTrials.gov (NCT05044416); registered 5 September 2021.

RéSUMé: OBJECTIF: La prise en charge des patients dont les voies aériennes sont anticipées comme étant difficiles demeure un défi. Nous avons évalué la visualisation laryngée obtenue avec le nouveau Vie Scope®, un laryngoscope à lame droite constitué d'un tube éclairé nécessitant une intubation facilitée par bougie, par rapport à celle obtenue avec un vidéolaryngoscope Macintosh. MéTHODE: Nous avons réalisé une étude randomisée contrôlée prospective de non-infériorité. Les patient·es bénéficiant d'une chirurgie non urgente des oreilles, du nez et de la gorge ou une chirurgie buccale et maxillo-faciale présentant des voies aériennes anticipées comme difficiles ont été randomisé·es à un ratio 1:1 à recevoir une intubation trachéale avec un laryngoscope Vie Scope ou un vidéolaryngoscope Macintosh (C-MAC®). Le critère d'évaluation principal était la visualisation laryngée selon l'échelle de pourcentage d'ouverture de la glotte (POGO). Les critères d'évaluation secondaires étaient le délai avant une intubation réussie et les taux de réussite de la première tentative et globaux. RéSULTATS: Nous avons inclus deux groupes de 29 patient·es dans notre analyse. En matière de visualisation, le Vie Scope n'était pas inférieur à la vidéolaryngoscopie (VL), avec des scores POGO moyens (écart type [ET]) de 71 (31) % vs 64 (30) % dans le groupe VL [différence dans les moyennes, 7 (8) %; intervalle de confiance à 95 %, ­9 à 23; P = 0,38]. Le délai moyen (ET) avant une intubation réussie était de 125 (129) sec avec le Vie Scope et de 51 (36) secondes dans le groupe VL (différence dans les moyennes, 75 sec; intervalle de confiance à 95 %, 25 à 124; P = 0,005). Les taux de réussite de la première tentative et de réussite globale étaient de 22/29 (76 %) et 27/29 (93 %) dans les deux groupes. Un dispositif différent a dû être utilisé chez deux patient·es par groupe. Quatre intubations œsophagiennes accidentelles sont survenues dans le groupe Vie Scope; celles-ci étaient probablement dues à un mauvais placement de la bougie. CONCLUSION: La visualisation obtenue avec le Vie Scope n'était pas inférieure à la vidéolaryngoscopie chez les patient·es dont les voies aériennes étaient anticipées comme difficiles, mais le délai avant une intubation réussie était plus long dans le groupe Vie Scope. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT05044416); registered 5 September 2021.

Incidence of hypoxic hepatitis in patients with cardiogenic shock and association with mortality.

AIMS: Shock of any cause leads to end-organ damage due to ischaemia, especially in perfusion-sensitive organs such as the liver. In septic shock, hypoxic hepatitis (S-HH) is defined as the 20-fold increase of the upper normal limit of aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) and is associated with a mortality of up to 60%. However, as pathophysiology, dynamics, and treatment differ between septic and cardiogenic shock (CS), the S-HH definition may not be suitable for CS. Therefore, we aim to evaluate if the S-HH definition is applicable in CS patients. METHODS AND RESULTS: This analysis was based on a registry of all-comer CS patients treated between 2009 and 2019 at a tertiary care centre with exclusion of minors and patients without all necessary ASAT and ALAT values. N = 698. During in-hospital follow-up, 386 (55.3%) patients died. The S-HH was not significantly associated with in-hospital mortality in CS patients. To define HH among patients with CS (C-HH), optimal cut-off values were found to be ≥1.34-fold increase for ASAT and ≥1.51-fold increase for ALAT in serial measurements. The incidence of C-HH was 254/698 patients (36%) and C-HH showed a strong association with in-hospital mortality (odds ratio 2.36, 95% confidence interval: 1.61, 3.49). CONCLUSION: The C-HH is a frequent and relevant comorbidity in patients with CS, although its definition varies from the established definition of HH in patients with septic shock. As C-HH contributed to excess mortality risk, these findings emphasize the need for further investigation of therapies reducing the occurrence of C-HH and also improving the associated outcome.

Impact of COVID-19 on Sedation Requirements during Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome.

COVID-19-associated ARDS (C-ARDS) is mentioned to express higher analgosedation needs, in comparison to ARDS of other etiologies. The objective of this monocentric retrospective cohort study was to compare the analgosedation needs between C-ARDS and non-COVID-19 ARDS (non-C-ARDS) on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Data were collected from the electronic medical records of all adult patients treated with C-ARDS in our Department of Intensive Care Medicine between March 2020 and April 2022. The control group included patients treated with non-C-ARDS between the years 2009 and 2020. A sedation sum score was created in order to describe the overall analgosedation needs. A total of 115 (31.5%) patients with C-ARDS and 250 (68.5%) with non-C-ARDS requiring VV-ECMO therapy were included in the study. The sedation sum score was significantly higher in the C-ARDS group (p < 0.001). COVID-19 was significantly associated with analgosedation in the univariable analysis. By contrast, the multivariable model did not show a significant association between COVID-19 and the sum score. The year of VV-ECMO support, BMI, SAPS II and prone positioning were significantly associated with sedation needs. The potential impact of COVID-19 remains unclear, and further studies are warranted in order to evaluate specific disease characteristics linked with analgesia and sedation.

Cerebrospinal fluid penetration of fosfomycin in patients with ventriculitis: an observational study.

BACKGROUND: For treatment of ventriculitis, vancomycin and meropenem are frequently used as empiric treatment but cerebrospinal fluid (CSF) penetration is highly variable and may result in subtherapeutic concentrations. Fosfomycin has been suggested for combination antibiotic therapy, but data are sparse, so far. Therefore, we studied CSF penetration of fosfomycin in ventriculitis. METHODS: Adult patients receiving a continuous infusion of fosfomycin (1 g/h) for the treatment of ventriculitis were included. Routine therapeutic drug monitoring (TDM) of fosfomycin in serum and CSF was performed with subsequent dose adaptions. Demographic and routine laboratory data including serum and CSF concentrations for fosfomycin were collected. Antibiotic CSF penetration ratio as well as basic pharmacokinetic parameters were investigated. RESULTS: Seventeen patients with 43 CSF/serum pairs were included. Median fosfomycin serum concentration was 200 [159-289] mg/L and the CSF concentration 99 [66-144] mg/L. Considering only the first measurements in each patient before a possible dose adaption, serum and CSF concentrations were 209 [163-438] mg/L and 104 [65-269] mg/L. Median CSF penetration was 46 [36-59]% resulting in 98% of CSF levels above the susceptibility breakpoint of 32 mg/L. CONCLUSION: Penetration of fosfomycin into the CSF is high, reliably leading to appropriate concentrations for the treatment of gram positive and negative bacteria. Moreover, continuous administration of fosfomycin appears to be a reasonable approach for antibiotic combination therapy in patients suffering from ventriculitis. Further studies are needed to evaluate the impact on outcome parameters.

Terson Syndrome in Patients with Aneurysmal Subarachnoid Hemorrhage: A 10-Year Single-Center Experience.

BACKGROUND: Terson syndrome (TS), an intraocular hemorrhage associated with aneurysmal subarachnoid hemorrhage (aSAH), occurs in up to 46% of all patients with subarachnoid hemorrhage. Despite its high incidence, TS is underrepresented in the literature, and patients with aSAH are sometimes not systematically evaluated for the presence of TS in clinical practice. This work aims to raise awareness of TS, reevaluate previous scientific findings, describe risk factors associated with the occurrence of TS, and present our local diagnostic and treatment concept. METHODS: All patients with aSAH treated at our institution between October 2010 and May 2020 were included in this retrospective study. The frequency of ophthalmological screening by indirect funduscopy, as well as the results, was investigated. In addition, the collection and statistical analysis of epidemiological and clinical data was performed using χ2, Kruskal-Wallis, and analysis of variance testing; multivariate regression; and receiver operating characteristic analysis. The significance level was set at p < 0.05. RESULTS: A total of 617 patients were treated for aSAH in our institution. Of these, 367 patients (59.5%) were ophthalmologically examined for the presence of TS. The rate of TS in the examined patients was 21.3% (n = 78). Patients with TS had significantly higher Fisher and World Federation of Neurosurgical Societies (WFNS) scores (p < 0.0001). Regression analyses showed WFNS grade (p = 0.003) and the occurrence of seizures (p = 0.002) as independent predictors of TS, as did receiver operating characteristic analyses, which had a significant area under the curve of 0.66 for the combination of WFNS grade and seizures. For 12 (15.4%) patients, the TS had to be surgically treated by pars plana vitrectomy in a total of 14 eyes, which resulted in significant improvement of visual function in all patients: mean preoperative best-corrected visual acuity was 0.03 (± 0.08) versus 0.76 (± 0.21) postoperatively (p < 0.001). CONCLUSIONS: TS is a common complication in patients with aSAH, affecting approximately one in five patients. A higher WFNS grade and the occurrence of seizures are associated with TS; therefore, screening for TS should be performed in these patients.

VivaSight Single-Lumen Tube Combined With Hyperangulated Videolaryngoscopy to Rescue Failed Tracheal Intubation in a Patient With Goldenhar Syndrome: A Case Report.

This report describes a patient with Goldenhar syndrome undergoing anesthesia for whom Macintosh videolaryngoscopy failed, as the epiglottis was adhered to the posterior pharynx and could not be lifted with a tracheal introducer (Cormack-Lehane grade 3B). Hyperangulated videolaryngoscopy revealed only the arytenoids (Cormack-Lehane grade 2B), even after direct lifting of the epiglottis, and endotracheal tube advancement failed due to unclear tissue resistance. Hyperangulated videolaryngoscopy was combined with a tube-mounted camera (VivaSight single lumen tube). The combination of both camera perspectives was successfully used to allow placement of the endotracheal tube underneath the epiglottis and through the vocal cords.

Hyperoxia is Dose-Dependently Associated with an Increase of Unfavorable Outcomes in Ventilated Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study.

BACKGROUND: Adequate oxygenation in patients with aneurysmal subarachnoid hemorrhage (SAH) is imperative. However, hyperoxia increases formation of reactive oxygen species and may be associated with a dose-dependent toxicity. We postulated a threshold for arterial partial pressure of oxygen (paO2) above which toxicity effects precipitate and sought to study the effects on 30-day mortality, favorable outcome at discharge and at 3 months, and delayed cerebral ischemia. METHODS: In this retrospective single-center cohort study, patients with SAH and mechanical ventilation > 72 h were included. Oxygen integrals were calculated above the following thresholds: 80, 100, 120, and 150 mm Hg and time-weighted mean paO2. All calculations were done from admission to end of day 1, day 3, and day 14. We conducted multivariable logistic regression analyses adjusted for age, sex, duration of ventilation, and Hunt and Hess grade. Time-weighted mean paO2 was categorized by quartiles. Favorable outcome was defined as Glasgow Outcome Scale scores of 4 and 5. RESULTS: From November 2010 to February 2021, 282 of 549 patients fulfilled the inclusion criteria. Odds ratios for 30-day mortality increased dose dependently and were as follows: 1.07 (95% confidence interval [CI] 1.03-1.11; p = 0.001) for each 1 mm Hg per day above 80 mm Hg; 1.16 (95% CI 1.07-1.27), above 100 mm Hg; 1.36 (95% CI 1.15-1.61), above 120 mm Hg; and 1.59 (95% CI 1.22-2.08), above 150 mm Hg (all p < 0.001) at day 14. For favorable outcome at 3 months, odds ratios were 0.96 (95% CI 0.92-0.99) for each 1 mm Hg per day above 80 mm Hg; 0.90 (95% CI 0.84-0.98), above 100 mm Hg; 0.83 (95% CI 0.72-0.97), above 120 mm Hg; and 0.77 (95% CI 0.61-0.97), above 150 mm Hg (all p < 0.05). For time-weighted mean paO2, lowest 30-day mortality and highest favorable outcome at 3 months were found in the second quartile (78-85 mm Hg). Thirty-day mortality increased above 93 mm Hg (fourth quartile), with an odds ratio of 3.4 (95% CI 1.4-8.4, p = 0.007). Odds ratios for favorable outcome at 3 months were 0.28 (95% CI 0.12-0.69), 0.27 (95% CI 0.11-0.67), and 0.24 (95% CI 0.10-0.59) for the first, third, and fourth quartiles, respectively (all p < 0.01). No significant association was found at day 1 and day 3, for favorable outcome at discharge, or for delayed cerebral ischemia. CONCLUSIONS: Integrals above the defined paO2 thresholds were dose-dependently associated with an increase in mortality in ventilated patients with SAH. When we considered time-weighted mean paO2, unfavorable outcomes and 30-day mortality were more frequent both below and above a certain range. Unfavorable outcomes increased in paO2 ranges usually defined as normoxia. This emphasizes the necessity to further characterize oxygenation thresholds in ventilated patients with SAH in prospective clinical studies.

Percutaneous dilatational tracheostomy with single use bronchoscopes versus reusable bronchoscopes - a prospective randomized trial (TraSUB).

BACKGROUND: Apart from conventional reusable bronchoscopes, single-use bronchoscopes (SUB) were recently introduced. Data suggest that SUB might prevent from the risk of cross contamination (i.e. multiresistant pathogens, SARS CoV-2) and save costs. We aimed to investigate visualization, ventilation, handling characteristics, changes in patients' gas exchange, and costs associated with both types of bronchoscopes during percutaneous dilatational tracheostomy (PDT). METHODS: In this prospective, randomized, noninferiority study, 46 patients undergoing PDT were randomized 1:1 to PDT with SUB (Ambu aScope) or reusable bronchoscopes (CONV, Olympus BF-P60). Visualization of tracheal structures rated on 4-point Likert scales was the primary end-point. Furthermore, quality of ventilation, device handling characteristics, changes in the patients' gas exchange, pH values, and costs were assessed. RESULTS: Noninferiority for visualization (the primary endpoint) was demonstrated for the SUB group. Mean visualization scores (lower values better) were 4.1 (95% confidence intervals: 3.9;4.3) for SUB vs. 4.1 (4.0;4.2) for CONV. Noninferiority of ventilation (estimated by minute volume and SpO2) during the procedure could be shown as well. Mean score was 2.6 (2.0;3.1) for SUB vs. 2.4 (2.1;2.7) for CONV (lower values better). No significant differences regarding handling (SUB: 1.2 (1.0;1.4), CONV: 1.3 (1.1;1.6)), blood gas analyses and respiratory variables were found. Cost analysis in our institution revealed 93 € per conventional bronchoscopy versus 232.50 € with SUB, not considering an estimate for possible infection due to cross-contamination with the reusable device. CONCLUSION: In our study, visualization and overall performance of the SUB during PDT were noninferior to reusable bronchoscopes. Therefore, PDT with SUB is feasible and should be considered if favored by individual institution's cost analysis. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03952247 . Submitted for registration on 28/04/2019 and first posted on 16/05/2019.

Elective Tracheal Intubation With the VieScope-A Prospective Randomized Non-inferiority Pilot Study (VieScOP-Trial).

Background: Tracheal intubation is commonly performed after direct laryngoscopy using Macintosh laryngoscopes (MacL), but visualization of the larynx may be inadequate. The VieScope (VSC) as a new type of laryngoscope consisting of a straight, shielded, illuminated tube used to perform intubation via a bougie was investigated in this prospective randomized trial in patients without expected difficult airways. Methods: With ethics approval, 2 × 29 patients for elective surgery were randomized 1:1 to intubation with VSC or MacL. Endpoints were first attempt success rates (FAS), Percentage of Glottis Opening Scale (POGO), time to intubation (TTI), and difficulty ratings on visual analog scales (0-100, lower values better). Data are given as mean ± standard deviation. Results: The FAS was 83 ± 38% for VSC and 86 ± 34% for MacL (P = 0.723). For VSC, POGO was 86 ± 17% and for MacL 68 ± 30% (P = 0.007). TTI for VSC was 93 ± 67s vs. 38 ± 17 for MacL (P < 0.001). Difficulty of intubation was rated 23 ± 22 for VSC vs. 18 ± 22 for MacL (P = 0.422), viewing conditions 12 ± 15 vs. 24 ± 25 (P = 0.031), and difficulty of tube placement was rated 27 ± 30 vs. 7 ± 8 (P = 0.001). Conclusion: No difference in FAS was detected between VSC and MacL. Visualization of the larynx was superior using the VSC, while TTI was prolonged and tube placement via bougie was more challenging. The VSC could be an alternative to MacL in patients with difficult laryngoscopy, but this should be investigated further in patients with expected difficult airways.