A specialized airway management team for COVID-19 patients: a retrospective study of the experience of two Canadian hospitals in Toronto.

BACKGROUND: In the COVID-19 pandemic, an unprecedented number of individuals required endotracheal intubation. To safely face these challenges, expert intubation teams were formed in some institutions. Here, we report on the experience of emergency rapid intubation teams (ERITs) in two Canadian hospitals. METHODS: We retrospectively collected data on all airway management procedures in confirmed or suspected COVID-19 patients performed by ERITs at two academic hospitals between 3 April and 17 June 2020. The co-primary outcomes were incidence of periprocedural adverse events (hypoxemia, hypotension, and cardiac arrest within 15 min of intubation) and first-attempt intubation success rate. Secondary outcomes included number of intubation attempts, device used to achieve successful airway management, and adherence to personal protective equipment (PPE) protocols. RESULTS: During the study period, 123 patients were assessed for airway management, with 117 patients receiving airway interventions performed by the ERIT. The first-attempt success rate for intubation was 92%, and a videolaryngoscope was the final successful device in 93% of procedures. Hypoxemia (peripheral oxygen saturation [SpO2] < 90%) occurred in 28 patients (24%) and severe hypoxemia (SpO2 < 70%) occurred in ten patients (9%). Hypotension (systolic blood pressure [SBP] < 90 mm Hg) occurred in 37 patients (32%) and severe hypotension (SBP < 65 mm Hg) in 11 patients (9%). Adherence to recommended PPE use among providers was high. CONCLUSION: In this cohort of critically ill patients with respiratory failure requiring time-sensitive airway management, specialized ERIT teams showed high rates of successful airway management with high adherence to PPE use. Hypoxemia and hemodynamic instability were common and should be anticipated within the first 15 min following intubation. STUDY REGISTRATION: www.ClinicalTrials.gov (NCT04689724); registered 30 December 2020.

RéSUMé: CONTEXTE: Pendant la pandémie de COVID-19, un nombre sans précédent de patients ont dû bénéficier d'une intubation endotrachéale. Pour faire face en toute sécurité à ces défis, des équipes d'experts en intubation ont été formées dans certains établissements. Nous rendons compte ici de l'expérience d'équipes d'intubation rapide d'urgence (ou ERIT, pour Emergency Rapid Intubation Team) dans deux hôpitaux canadiens. MéTHODE: Nous avons colligé rétrospectivement les données concernant toutes les interventions de prise en charge des voies aériennes chez les patients COVID-19 confirmés ou suspectés réalisées par les ERIT dans deux hôpitaux universitaires entre le 3 avril et le 17 juin 2020. Les deux critères d'évaluation principaux étaient l'incidence d'événements indésirables péri-procédure (hypoxémie, hypotension et arrêt cardiaque dans les 15 minutes suivant l'intubation) et le taux de réussite de l'intubation à la première tentative. Les critères d'évaluation secondaires comprenaient le nombre de tentatives d'intubation, le dispositif utilisé pour parvenir au succès de la prise en charge des voies aériennes et le respect des protocoles concernant les équipements de protection individuelle (EPI). RéSULTATS: Au cours de la période à l'étude, 123 patients ont été évalués pour une prise en charge des voies aériennes, et 117 patients ont bénéficié d'interventions au niveau des voies aériennes réalisées par l'ERIT. Le taux de réussite de la première tentative d'intubation était de 92 %, et un vidéolaryngoscope a été le dispositif menant à une intubation réussie dans 93 % des interventions. Des épisodes d'hypoxémie (saturation périphérique en oxygène [SpO2] < 90 %) sont survenus chez 28 patients (24 %) et dix patients (9 %) ont souffert d'hypoxémie sévère (SpO2 < 70 %). Des épisodes d'hypotension (tension artérielle systolique [TAS] < 90 mmHg) sont survenus chez 37 patients (32 %) et 11 patients (9 %) ont souffert d'hypotension sévère (TAS < 65 mmHg). Le respect de l'utilisation recommandée des EPI chez les soignants était élevé. CONCLUSION: Dans cette cohorte de patients gravement malades atteints d'insuffisance respiratoire et nécessitant une prise en charge des voies aériennes urgente, les équipes spécialisées de l'ERIT ont montré des taux élevés de succès de prise en charge des voies aériennes, avec une adhésion élevée aux protocoles d'utilisation des EPI. L'hypoxémie et l'instabilité hémodynamique étaient fréquentes et devaient être anticipées dans les 15 premières minutes suivant l'intubation. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov  (NCT04689724); enregistrée le 30 décembre 2020.

Nutritional Considerations when Dealing with an Underweight Adult or Senior Horse.

Weight loss occurs when the supply of energy is insufficient to meet the energy needs of an individual. The energy supply may be reduced by inadequate provision of feed, inadequate consumption, reduced digestion and absorption, or disruption in metabolic processing. Increased energy expenditure occurs with exercise and during cold temperatures, pregnancy, and lactation. Underlying clinical disease, particularly chronic inflammation, neoplasia, and protein-losing conditions, can cause weight loss or exacerbate existing weight loss. A methodical approach to weight-loss investigation and treatment is necessary, because of the often multifactorial nature of this condition.

The experience of auditory implant recipients undergoing magnetic resonance imaging: Factors associated with pain.

OBJECTIVE: Many patients with cochlear implants (CI) and auditory brainstem implants (ABI) require magnetic resonance imaging (MRI) following implantation. This study explores the patient experience of MRI, identifying factors associated with pain, and the effect of interventions designed to enhance comfort and safety. METHODS: A prospective observational case series from a tertiary referral unit. Tight head bandaging ± local anaesthetic injection (devices with non-MRI-compatible magnets) or observation alone (implants with MRI-compatible magnets) were employed for 1.5 T MRI of consecutive adult patients with CI or ABI without magnet removal. Pain was recorded via visual analogue scale (1 = no pain, 5 = extreme pain) at three time points; (1) baseline, (2) head bandage applied (3) during scanning. Patient age, device type, body area imaged and total scan time were recorded as variables, alongside adverse events. RESULTS: Data were collected for 227 MRI scans (34 patients with ABI, 32 with CI). In patients managed with bandaging, pain score after bandaging but prior to scanning (median 2.2) did not differ from pain during scanning (2.1), but both were significantly higher than baseline (1.4, both P ≤ 0.001). Scanning areas other than the head/cervical spine was associated with higher pain scores (P = 0.036). Pain during MRI differed between different manufacturers implants (P ≤ 0.001). Adverse events occurred in 8/227 scans (3.5%), none occurring with devices containing an MRI-compatible magnet. CONCLUSION: MRI scanning with auditory implant magnets in situ is safe and well tolerated by patients.

Nutrition of the aged horse.

This article reviews current thoughts on nutrition of the older horse in health and disease. Common causes of weight loss and poor body condition in old horses include dental or oral cavity abnormalities, pituitary pars intermedia dysfunction, and reduced feed intake attributable to competition from herd mates or pain associated with osteoarthritis. Feed intake and body condition may improve after institution of management changes. Thin but otherwise healthy old horses can benefit from a diet that provides 12% to 16% crude protein and includes highly digestible feedstuffs. In horses with severe irreversible dental problems, long-stem fiber (hay) should be replaced by soaked hay cubes, short chopped hay, or heavily soaked sugar beet pulp. Evidence of chronic endocrine, hepatic, or renal disease dictates dietary modifications.

Diagnosis of sporadic neurofibromatosis type 2 in the paediatric population.

OBJECTIVE: Onset of symptoms in severe sporadic neurofibromatosis type 2 (NF2) is typically within childhood; however, there is poor awareness of presenting features in young children, potentially resulting in delayed diagnosis and poorer outcome. We have reviewed presentation of sporadic paediatric NF2 to raise awareness of early features, highlighting those requiring further investigation. DESIGN: Patients diagnosed with NF2 at age ≤16 and seen between 2012 and 2015 were notified via the British Paediatric Neurology Surveillance Unit or identified through the English NF2 service. RESULTS: Epidemiological data estimate that 1 in 110 611 births are affected with childhood-onset NF2. Notes of 32 patients with sporadic NF2 were reviewed. Of those presenting under the age of 5, 89% (17/19) had ocular, 74% (14/19) dermatological and 58% (11/19) neurological signs; in 84% (16/19) features were multisystemic. Sixty-six per cent (21/32) had ≥1 atypical feature, including cerebellar hypoplasia in three cases (9%) and focal cortical dysplasia in five out of seven seizure-related presentations. Five cases presented with a sometimes transient or intermittent cranial nerve mononeuropathy. The mean delay to diagnosis was 3.16 years; in eight cases (25%) this exceeded 6 years. Most significant delay occurred in mononeuropathy, ophthalmological and/or seizure presentations, with a mean delay of 3, 4.5 and 6 years, respectively. Eighty-four per cent (27/32) of cases needed intervention in childhood. CONCLUSIONS: All non-vestibular schwannoma NF2 presentations in childhood had significant diagnostic delay. We emphasise the importance of detailed assessment of skin and eyes in unusual presentations and propose an aide to prompt timely referral to specialist services.