Effect of early vs. delayed extubation on functional outcome among patients with acute ischemic stroke treated with endovascular thrombectomy under general anesthesia: the prospective, randomized controlled EDESTROKE trial study protocol.

BACKGROUND: Recent meta-analyses and randomized studies have shown that among patients with acute ischemic stroke undergoing endovascular thrombectomy, general anesthesia with mechanical ventilation is associated with better functional status compared to local anesthesia and sedation, and they recommend its use. But once the procedure is completed, when is the optimal moment for extubation? Currently, there are no guidelines recommending the optimal moment for extubation. Prolonged mechanical ventilation time could potentially be linked to increased complications such as pneumonia or disturbances in cerebral blood flow due to the vasodilatation produced by most anesthetic drugs. However, premature extubation in a patient who has suffered a stroke could led to complications such as agitation, disorientation, abolished reflexes, sudden fluctuations in blood pressure, alterations in cerebral blood flow, respiratory distress, bronchial aspiration, and the need for reintubation. We therefore designed a randomized study hypothesizing that early compared with delayed extubation is associated with a better functional outcome 3 months after endovascular thrombectomy treatment under general anesthesia for acute ischemic stroke. METHODS: This investigator-initiated, single-center, prospective, parallel, evaluated blinded, superiority, randomized controlled trial will include 178 patients with a proximal occlusion of the anterior circulation treated with successful endovascular thrombectomy (TICI 2b-3) under general anesthesia. Patients will be randomly allocated to receive early (< 6 h) or delayed (6-12 h) extubation after the procedure. The primary outcome measure is functional independence (mRS of 0-2) at 90 days, measured with the modified Rankin Score (mRS), ranging from 0 (no symptoms) to 6 (death). DISCUSSION: This will be the first trial to compare the effect of mechanical ventilation duration (early vs delayed extubation) after satisfactory endovascular thrombectomy for acute ischemic stroke under general anesthesia. TRIAL REGISTRATION: The study protocol was approved April 11, 2023, by the by the Santiago-Lugo Research Ethics Committee (CEI-SL), number 2023/127, and was registered into the clinicaltrials.gov clinical trials registry with No. NCT05847309. Informed consent is required. Participant recruitment begins on April 18, 2023. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.

Videolaryngoscope versus conventional technique for insertion of a transesophageal echocardiography probe in intubated ICU patients (VIDLARECO trial): A randomized clinical trial.

BACKGROUND: Transesophageal echocardiogram probe insertion in intubated critically ill patients can be difficult, leading to complications, such as gastric bleeding or lesions in the oropharyngeal mucosa. We hypothesised that the use of a videolaryngoscope would facilitate the first attempt at insertion of the transesophageal echocardiogram probe and would decrease the incidence of complications compared to the conventional insertion technique. METHODS: In this clinical trial, patients were randomly assigned the insertion of a transesophageal echocardiogram probe using a videolaryngoscope or conventional technique. The primary outcome was the successful transesophageal echocardiogram probe insertion on the first attempt. The secondary outcomes included total success rate, number of insertion attempts, and incidence of pharyngeal complications. RESULTS: A total of 100 intubated critically ill patients were enrolled. The success rate of transesophageal echocardiogram probe insertion on the first attempt was higher in the videolaryngoscope group than in the conventional group (90% vs. 58%; absolute difference, 32%; 95% CI 16%-48%; p < 0.001). The overall success rate was higher in the videolaryngoscope group than in the conventional group (100% vs. 72%; absolute difference, 28%; 95% CI 16%-40%; p < 0.001). The incidence of pharyngeal mucosal injury was smaller in the videolaryngoscope group than in the conventional group (14% vs. 52%; absolute difference, 38%; 95% CI 21%-55%; p < 0.001). CONCLUSIONS: Our study showed that in intubated critically ill patients required transesophageal echocardiogram, the use of videolaryngoscope resulted in higher successful insertion on the first attempt with lower rate of complications when compared with the conventional insertion technique. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04980976.

Effect of high versus low dose of dexamethasone on clinical worsening in patients hospitalised with moderate or severe COVID-19 pneumonia: an open-label, randomised clinical trial.

BACKGROUND: Low-dose dexamethasone demonstrated clinical improvement in patients with coronavirus disease 2019 (COVID-19) needing oxygen therapy; however, evidence on the efficacy of high-dose dexamethasone is limited. METHODS: We performed a randomised, open-label, controlled trial involving hospitalised patients with confirmed COVID-19 pneumonia needing oxygen therapy. Patients were randomly assigned in a 1:1 ratio to receive low-dose dexamethasone (6 mg once daily for 10 days) or high-dose dexamethasone (20 mg once daily for 5 days, followed by 10 mg once daily for an additional 5 days). The primary outcome was clinical worsening within 11 days since randomisation. Secondary outcomes included 28-day mortality, time to recovery and clinical status at day 5, 11, 14 and 28 on an ordinal scale ranging from 1 (discharged) to 7 (death). RESULTS: A total of 200 patients (mean±sd age 64±14 years; 62% male) were enrolled. 32 (31.4%) out of 102 patients enrolled in the low-dose group and 16 (16.3%) out of 98 in the high-dose group showed clinical worsening within 11 days since randomisation (rate ratio 0.427, 95% CI 0.216-0.842; p=0.014). The 28-day mortality was 5.9% in the low-dose group and 6.1% in the high-dose group (p=0.844). There was no significant difference in time to recovery, and in the seven-point ordinal scale at days 5, 11, 14 and 28. CONCLUSIONS: Among hospitalised COVID-19 patients needing oxygen therapy, high dose of dexamethasone reduced clinical worsening within 11 days after randomisation, compared with low dose.

Effectiveness of Prone Positioning in Nonintubated Intensive Care Unit Patients With Moderate to Severe Acute Respiratory Distress Syndrome by Coronavirus Disease 2019.

BACKGROUND: In the treatment for severe acute respiratory distress syndrome (ARDS) from coronavirus disease 2019 (COVID-19), the World Health Organization (WHO) recommends prone positioning (PP) during mechanical ventilation for periods of 12-16 h/d to potentially improve oxygenation and survival. In this prospective observational study, we evaluated the ability of long PP sessions to improve oxygenation in awake intensive care unit (ICU) patients with moderate or severe ARDS due to COVID-19. METHODS: The study was approved by the ethics committee of Galicia (code No. 2020-188), and all patients provided informed consent. In this case series, awake patients with moderate or severe ARDS by COVID-19 admitted to the ICU at University Hospital of Santiago from March 21 to April 5, 2020 were prospectively analyzed. Patients were instructed to remain in PP as long as possible until the patient felt too tired to maintain that position. Light sedation was administered with dexmedetomidine. The following information was collected: number and duration of PP sessions; tissue O2 saturation (StO2) and blood gases before, during, and following a PP session; need of mechanical ventilation; duration of ICU admission; and ICU outcome. Linear mixed-effects models (LMM) were fit to estimate changes from baseline with a random effect for patient. RESULTS: Seven patients with moderate or severe ARDS by COVID-19 were included. All patients received at least 1 PP session. A total of 16 PP sessions were performed in the 7 patients during the period study. The median duration of PP sessions was 10 hours. Dexmedetomidine was used in all PP sessions. Oxygenation increased in all 16 sessions performed in the 7 patients. The ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FIO2) significantly increased during PP (change from baseline 110 with 97.5% confidence interval [CI], 19-202) and, after PP, albeit not significantly (change from baseline 38 with 97.5% CI, -9.2 to 85) compared with previous supine position. Similarly, tissue oxygenation underwent a small improvement during PP (change from baseline 2.6% with 97.5% CI, 0.69-4.6) without significant changes after PP. Two patients required intubation. All patients were discharged from the ICU. CONCLUSIONS: We found that PP improved oxygenation in ICU patients with COVID-19 and moderate or severe ARDS. PP was relatively well tolerated in our patients and may be a simple strategy to improve oxygenation trying to reduce the number of patients in mechanical ventilation and the length of stay in the ICU, especially in COVID-19 pandemic.

Comparison of Tracheal Intubation Conditions in Operating Room and Intensive Care Unit: A Prospective, Observational Study.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Tracheal intubation is a common intervention in the operating room and in the intensive care unit. The authors hypothesized that tracheal intubation using direct laryngoscopy would be associated with worse intubation conditions and more complications in the intensive care unit compared with the operating room. METHODS: The authors prospectively evaluated during 33 months patients who were tracheally intubated with direct laryngoscopy in the operating room, and subsequently in the intensive care unit (within a 1-month time frame). The primary outcome was to compare the difference in glottic visualization using the modified Cormack-Lehane grade between intubations performed on the same patient in an intensive care unit and previously in an operating room. Secondary outcomes were to compare first-time success rate, technical difficulty (number of attempts, operator-reported difficulty, need for adjuncts), and the incidence of complications. RESULTS: A total of 208 patients met inclusion criteria. Tracheal intubations in the intensive care unit were associated with worse glottic visualization (Cormack-Lehane grade I/IIa/IIb/III/IV: 116/24/47/19/2) compared with the operating room (Cormack-Lehane grade I/IIa/IIb/III/IV: 159/21/16/12/0; P < 0.001). First-time intubation success rate was lower in the intensive care unit (185/208; 89%) compared with the operating room (201/208; 97%; P = 0.002). Tracheal intubations in the intensive care unit had an increased incidence of moderate and difficult intubation (33/208 [16%] vs. 18/208 [9%]; P < 0.001), and need for adjuncts to direct laryngoscopy (40/208 [19%] vs. 21/208 [10%]; P = 0.002), compared with the operating room. Complications were more common during tracheal intubations in the intensive care unit (76/208; 37%) compared with the operating room (13/208; 6%; P < 0.001). CONCLUSIONS: Compared with the operating room, tracheal intubations in the intensive care unit were associated with worse intubation conditions and an increase of complications.

[Hemodynamic effects of levosimendan compared with dobutamine in patients with low cardiac output after cardiac surgery]. / Comparación de los efectos hemodinámicos del levosimendán con la dobutamina en pacientes con bajo gasto después de cirugía cardiaca.

INTRODUCTION AND OBJECTIVES: Levosimendan is an inotropic agent that is effective in the treatment of heart failure. However, experience with levosimendan in patients with reduced cardiac output following cardiopulmonary bypass is limited. The objective of this study was to compare the short-term hemodynamic effects of levosimendan with those of dobutamine in managing low cardiac output after cardiac surgery. METHODS: Forty-one patients who had low cardiac output after cardiopulmonary bypass were randomly assigned to dobutamine (n=20), 24-hour infusion of 7.5 microg/kg per min, or levosimendan (n=21), at a loading dose of 12 microg/kg followed by 24-hour infusion of 0.2 microg/kg per min. The following parameters were determined during a 48-hour observation period: arterial, central venous, pulmonary arterial and pulmonary capillary wedge pressure, cardiac index, heart rate, stroke volume, and systemic and pulmonary vascular resistance. RESULTS: Although both dobutamine and levosimendan improved the cardiac index, the increase was significantly greater with levosimendan (2.4 [0.2] l/min per m2 vs 2.9 [0.3] l/min per m2, respectively, at 24 h; P<.05). Moreover, levosimendan significantly reduced systemic and pulmonary vascular resistance, and significantly decreased systemic arterial, pulmonary arterial, pulmonary capillary wedge, and central venous pressure. CONCLUSIONS: Both dobutamine and levosimendan are effective in managing postoperative low cardiac output. However, levosimendan induces non-specific systemic, venous and pulmonary vasodilation which can result in hypotension as a adverse event. In these patients, it is advisable to omit or reduce the loading dose.