Real-Time Ultrasound Guidance as Compared With Landmark Technique for Subclavian Central Venous Cannulation: A Systematic Review and Meta-Analysis With Trial Sequential Analysis.

OBJECTIVES: We conducted a systematic review and meta-analysis to assess the effectiveness of real-time dynamic ultrasound-guided subclavian vein cannulation as compared to landmark technique in adult patients. DATA SOURCES: PubMed and EMBASE until June 1, 2022, with the EMBASE search restricted to the last 5 years. STUDY SELECTION: We included randomized controlled trials (RCTs) comparing the two techniques (real-time ultrasound-guided vs landmark) for subclavian vein cannulation. The primary outcomes were overall success rate and complication rate, whereas secondary outcomes included success at first attempt, number of attempts, and access time. DATA EXTRACTION: Independent extraction by two authors according to prespecified criteria. DATA SYNTHESIS: After screening, six RCTs were included. Two further RCTs using a static ultrasound-guided approach and one prospective study were included in the sensitivity analyses. The results are presented in the form of risk ratio (RR) or mean difference (MD) with 95% CI. Real-time ultrasound guidance increased the overall success rate for subclavian vein cannulation as compared to landmark technique (RR = 1.14; [95% CI 1.06-1.23]; p = 0.0007; I2 = 55%; low certainty) and complication rates (RR = 0.32; [95% CI 0.22-0.47]; p < 0.00001; I2 = 0%; low certainty). Furthermore, ultrasound guidance increased the success rate at first attempt (RR = 1.32; [95% CI 1.14-1.54]; p = 0.0003; I2 = 0%; low certainty), reduced the total number of attempts (MD = -0.45 [95% CI -0.57 to -0.34]; p < 0.00001; I2 = 0%; low certainty), and access time (MD = -10.14 s; [95% CI -17.34 to -2.94]; p = 0.006; I2 = 77%; low certainty). The Trial Sequential Analyses on the investigated outcomes showed that the results were robust. The evidence for all outcomes was considered to be of low certainty. CONCLUSIONS: Real-time ultrasound-guided subclavian vein cannulation is safer and more efficient than a landmark approach. The findings seem robust although the evidence of low certainty.

Emergency Airway Management in Patients with COVID-19: A Prospective International Multicenter Cohort Study.

BACKGROUND: Tracheal intubation for patients with COVID-19 is required for invasive mechanical ventilation. The authors sought to describe practice for emergency intubation, estimate success rates and complications, and determine variation in practice and outcomes between high-income and low- and middle-income countries. The authors hypothesized that successful emergency airway management in patients with COVID-19 is associated with geographical and procedural factors. METHODS: The authors performed a prospective observational cohort study between March 23, 2020, and October 24, 2020, which included 4,476 episodes of emergency tracheal intubation performed by 1,722 clinicians from 607 institutions across 32 countries in patients with suspected or confirmed COVID-19 requiring mechanical ventilation. The authors investigated associations between intubation and operator characteristics, and the primary outcome of first-attempt success. RESULTS: Successful first-attempt tracheal intubation was achieved in 4,017/4,476 (89.7%) episodes, while 23 of 4,476 (0.5%) episodes required four or more attempts. Ten emergency surgical airways were reported-an approximate incidence of 1 in 450 (10 of 4,476). Failed intubation (defined as emergency surgical airway, four or more attempts, or a supraglottic airway as the final device) occurred in approximately 1 of 120 episodes (36 of 4,476). Successful first attempt was more likely during rapid sequence induction versus non-rapid sequence induction (adjusted odds ratio, 1.89 [95% CI, 1.49 to 2.39]; P < 0.001), when operators used powered air-purifying respirators versus nonpowered respirators (adjusted odds ratio, 1.60 [95% CI, 1.16 to 2.20]; P = 0.006), and when performed by operators with more COVID-19 intubations recorded (adjusted odds ratio, 1.03 for each additional previous intubation [95% CI, 1.01 to 1.06]; P = 0.015). Intubations performed in low- or middle-income countries were less likely to be successful at first attempt than in high-income countries (adjusted odds ratio, 0.57 [95% CI, 0.41 to 0.79]; P = 0.001). CONCLUSIONS: The authors report rates of failed tracheal intubation and emergency surgical airway in patients with COVID-19 requiring emergency airway management, and identified factors associated with increased success. Risks of tracheal intubation failure and success should be considered when managing COVID-19.

Lessons Learned from a Study of the Integration of a Point-of-Care Ultrasound Course into the Undergraduate Medical School Curriculum.

BACKGROUND Point-of-care ultrasound (POCUS) diagnosis, performed by a physician at the patient bedside, is routinely used in emergency medicine and critical care. Although training in ultrasonography has become part of the medical school curriculum, POCUS can be challenging for medical students. This study aimed to assess the effectiveness of a one-day POCUS course in a group of final-year medical students by pre-course and post-course assessment of both diagnostic ability and changes in student confidence levels in making a diagnosis. MATERIAL AND METHODS A prospective study recruited 57 final-year medical students who participated in a one-day POCUS course. Improvement in making decisions and levels of confidence were evaluated before and two weeks after the course, using image-based testing and a self- evaluation questionnaire. RESULTS All 57 final-year medical students attended the course and completed the tests and surveys. The pre-training and post-training test scores of medical students improved from 41.78±12% to 58±13%. Student confidence scores in the post-training assessment significantly increased. The post-training confidence scores were significantly increased compared with the pre-training scores regardless of whether or not the questions were answered correctly (p<0.001). The Dunning-Kruger effect, or cognitive bias, might partially explain this phenomenon. CONCLUSIONS One day of POCUS training integrated into anesthesia curriculum for final-year medical students improved performance in the post-training test scores and improved their confidence scores. Further studies are needed to evaluate this effect and to develop adequate tools to assess medical students.

Health care professionals' concerns regarding in-hospital family-witnessed cardiopulmonary resuscitation implementation into clinical practice.

BACKGROUND: In-hospital, family-witnessed cardiopulmonary resuscitation of adults has been found to help patients' family members deal with the short- and long-term emotional consequences of resuscitation. Because of its benefits, many national and international nursing and medical organizations officially recommend this practice. Research, however, shows that family-witnessed resuscitation is not widely implemented in clinical practice, and health care professionals generally do not favour this recommendation. AIM: To describe and provide an initial basis for understanding health care professionals' views and perspectives regarding the implementation of an in-hospital, family-witnessed adult resuscitation practice in two European countries. STUDY DESIGN: An inductive qualitative approach was used in this study. METHODS: Finnish (n = 93) and Polish (n = 75) emergency and intensive care nurses and physicians provided written responses to queries regarding their personal observations, concerns and comments about in-hospital, family-witnessed resuscitation of an adult. Data were analysed using inductive thematic analysis. FINDINGS: The study analysis yielded five themes characterizing health care professionals' main concerns regarding family-witnessed resuscitation: (1) family's horror, (2) disturbed workflow (3) no support for the family, (4) staff preparation and (5) situation-based decision. CONCLUSION: Despite existing evidence revealing the positive influence of family-witnessed resuscitation on patients, relatives and cardiopulmonary resuscitation process, Finnish and Polish health care providers cited a number of personal and organizational barriers against this practice. The results of this study begin to examine reasons why family-witnessed resuscitation has not been widely implemented in practice. In order to successfully apply current evidence-based resuscitation guidelines, provider concerns need to be addressed through educational and organizational changes. RELEVANCE TO CLINICAL PRACTICE: This study identified important implementation barriers for allowing families in critical care settings to be present during resuscitation efforts. These results can be further used in developing and adjusting clinical practice policies, protocols and guidelines related to family-witnessed resuscitation.

Ultrasonographic caval indices do not significantly contribute to predicting fluid responsiveness immediately after coronary artery bypass grafting when compared to passive leg raising.

BACKGROUND: Appropriate fluid management is one of the most important elements of early goal-directed therapy after cardiothoracic surgery. Reliable determination of fluid responsivenss remains the fundamental issue in volume therapy. The purpose of the study was to assess the usefulness of dynamic IVC-derived parameters (collapsibility index, distensibility index) in comparison to passive leg raising, in postoperative fluid management in mechanically ventilated patients with left ventricular ejection fraction ≥ 30 %, immediately after elective coronary artery bypass grafting. METHODS: Prospective observational case series study including 35 patients with LVEF ≥ 30 %, undergoingelective coronary artery bypass grafting was conducted. Transthoracic echocardiography, passive leg raising and intravenous administration of saline were performed in all study subjects. Dynamic parameters derived from ultrasonographic assessment of the IVC diameter (collapsibility index-CI and distensibility index-DI), cardiac output RESULTS: There were 24 (68.57 %) responders in the study population. There were no statistical differences between the groups in relation to: clinical parameters, pre- and postoperative LVEF, fluid balance and CVP. Change in cardiac output after passive leg raising correlated significantly with that after the volume expansion (p=0.000, r=0.822). Dynamic IVC derivatives were slightly higher in fluid responders, however this trend did not reach statistical significance. None of the caval indices correlated with fluid responsiveness. CONCLUSION: Dynamic IVC-derived parameters do not predict fluid responsiveness in mechanically ventilated patients with preserved ejection fraction immediately after elective coronary artery bypass grafting. Passive leg raising is not inferior to volume expansion in differentiating between fluid responders and nonresponders. Immediate fluid challenge after CABG is safe and well tolerated.

Effectiveness and Validity of Sonographic Upper Airway Evaluation to Predict Difficult Laryngoscopy.

OBJECTIVES: Our objective was to evaluate the effectiveness of 9 airway sonographic parameters imaged from the submandibular view as predictors of difficult laryngoscopy. Additionally, we aimed to evaluate the validity of the models of combined sonographic and clinical tests in predicting difficult laryngoscopy. METHODS: This study analyzed a sample of 199 patients who were categorized as having easy (grades 1 and 2) or difficult (grades 3 and 4) laryngoscopy during general anesthesia with endotracheal intubation based on the laryngoscopic criteria of Cormack and Lahane (Anaesthesia 1984; 39:1105-1111). Nine sonographic parameters imaged from the submandibular view, including the hyomental distance in neutral and extended positions, hyomental distance ratio, tongue cross-sectional area, tongue width, tongue volume, tongue thickness-to-oral cavity height ratio, and floor of the mouth muscle cross-sectional area and volume, were analyzed. The validity of the models encompassing combined screening tests was assessed. RESULTS: Twenty-two patients (11.1%) were categorized as having difficult laryngoscopy. Statistically significant differences between patients with difficult and easy laryngoscopy were noted for 5 of 9 parameters. The diagnostic validity profiles showed poor sensitivity (9.1%-42.9%) and positive predictive value (4.5%-66.7%), but good specificity (71.8%-97.7%) and negative predictive value (87.1%-94.5%). The combination of tests improved the diagnostic validity profile (area under the curve, 0.852). CONCLUSIONS: Sonographic predictors may help identify patients with difficult laryngoscopy. Individual measures have unsatisfactory diagnostic profiles. The models based on combined tests have improved diagnostic value.

Validity of a 5-minute focused echocardiography with A-F mnemonic performed by non-echocardiographers in the management of patients with acute chest pain.

STUDY OBJECTIVE: To validate the practicality of focused echocardiography with A-F mnemonic performed by non-specialists in patients with suspected acute coronary syndrome (ACS). DESIGN: This prospective observational study was conducted in the Emergency Room within 12 months period. Study population consisted of consecutive patients with preliminary diagnosis of an ACS. The following data were analyzed: demographics, clinical condition, medical history, ECG, transthoracic echocardiography (TTE) and levels of cardiac necrotic markers. TTE was performed within the first 15 minutes after the admission by the resident on-call. TTE images were interpreted and reported with mnemonic A-F. All studies were recorded and reviewed within 24 hours by the cardiologist. RESULTS: 1312 consecutive patients were enrolled to the study. TTE with A-F mnemonic revealed: RWMAs in 82.87% patients with confirmed ACS, other significant cardiac pathologies were found in 2.21% in ACS and 46.52% in non-ACS groups respectively. On the basis of these findings, 20 (1.92%) ACS and 29 (10.62%) non-ACS group patients underwent target operative treatment. Survey showed that both echocardiographic image acquisition and its interpretation with A-F mnemonic, took less than 5 minutes in 95% of cases. Residents found A-F mnemonic algorithm simple and useful. No differences were found in key findings between TTE performed by resident and the cardiologist. CONCLUSION: Focused echocardiography with A-F mnemonic allows both confirmation of acute myocardial ischemia and detection of the other life-threatening cardiac conditions resulting in proper bedside decision of directed treatment. Mnemonic based TTE enables reliable examination by properly trained residents.

Reliability of focused cardiac ultrasound by novice sonographer in preoperative anaesthetic assessment: an observational study.

BACKGROUND: Use of preoperative echocardiography may help to identify patients with increased cardiac risk, who may benefit from modification of perioperative plan. The objective of our study was to evaluate the reliability of preoperative focused cardiac ultrasound (FoCUS) performed by an anaesthetist with basic ultrasound training and its impact on patient's management. METHODS: The prospective observational study was conducted in 159 adult patients, scheduled for elective operations. Cardiac ultrasound was performed by one anaesthetist with a limited experience of FoCUS. A simple, mnemonic scheme was used for the final reporting of each study. The same scheme was used by a cardiologist who produced an independent report based on digital video loops stored in the machine memory. Anaesthetists in-charge made final perioperative plan. Comparative analysis of anaesthetist and cardiologist performed ultrasound report was made. The incidence of modification of initial perioperative plan resulting from FoCUS report was analyzed. RESULTS: The average time required to complete the examination was 182 s 95% CI [173-190]. Images of quality adequate to answer all questions from the scheme were obtained in 97.5% (155/159) of patients. There was strong agreement between the anaesthetist and the cardiologist in 97.8% (2274/2325) of the examined categories. In two categories (global and regional left ventricle contractility impairment) statistically significant discrepancies between both diagnosticians were confirmed (p McNemar <0.04). When compared with the cardiologist's assessment the agreement of the anesthetist's diagnosis had sensitivity of 0.84, specificity 0.99, positive predictive value 0.78 and negative predictive value 0.99. Kappa statistics showed good agreement between both examining doctors (κ = 0.797). Based on ultrasound findings, the preliminary anaesthetic plan was changed in relation to 20.8% (33/159) of patients. CONCLUSIONS: An anaesthetist with limited training in FoCUS can perform a reliable preoperative examination which alters the perioperative management.

Bedside ultrasonographic measurement of the inferior vena cava fails to predict fluid responsiveness in the first 6 hours after cardiac surgery: a prospective case series observational study.

OBJECTIVE: To assess validity of respiratory variation of inferior vena cava (IVC) diameter to predict fluid responsiveness and guide fluid therapy in mechanically ventilated patients during the first 6 hours after elective cardiac surgery. DESIGN: Prospective observational case series study. SETTING: Single-center hospital. PATIENTS: 50 consecutive patients undergoing elective cardiac surgery. INTERVENTIONS: Transthoracic bedside echocardiography. MEASUREMENTS AND MAIN RESULTS: Parameters derived from ultrasonographic assessment of the IVC diameter (collapsibility index [CI], distensibility index [DI], and IVC/aorta index). In the whole study group, change in fluid balance correlated with change in IVC maximum diameter (p = 0.034, r = 0.176). IVC-CI and IVC-DI correlated with IVC/aorta index. A weak correlation between central venous pressure (CVP) and IVC-derived parameters (IVC-CI and IVC-DI) was noticed. Despite statistical significance (p<0.05), all observed correlations expressed low statistical power (r<0.21). There were no statistically significant differences between fluid responders and nonresponders in relation to clinical parameters, CVP, ultrasound IVC measurement, and IVC-derived indices. CONCLUSION: Dynamic IVC-derived parameters (IVC-CI, IVC-DI, and IVC/aorta index) and CVP are not reliable predictors of fluid responsiveness in the first 6 hours after cardiac surgery. Complexity of physiologic factors modulating cardiac performance in this group may be responsible for the difficulty in finding a plausible monitoring tool for fluid guidance. Bedside ultrasonographic measurement of IVC is unable to predict fluid responsiveness in the first 6 hours after cardiac surgery.

Factors associated with experiences and attitudes of healthcare professionals towards family-witnessed resuscitation: a cross-sectional study.

AIMS: To examine factors associated with healthcare professionals' experiences and attitudes towards adult family-witnessed resuscitation in the emergency and intensive care units. BACKGROUND: Family-witnessed resuscitation offers the option for patients' families to be present during in-hospital resuscitation. It is important to understand healthcare professionals' views about this practice to determine why, despite its benefits and general recommendation, this practice has not been widely implemented. DESIGN: A descriptive, correlational, cross-sectional survey. METHODS: A total of 390 Finnish and Polish Registered Nurses and physicians from six university hospitals took part in the study. A structured questionnaire that examined nurses' and physicians' experiences and attitudes was used. Data, collected between July-December 2013, were analysed with descriptive statistics, logistic and multiple linear regression analyses. RESULTS: The results indicated that healthcare professionals are not well experienced in family-witnessed resuscitation. The general attitude towards this practice is somewhat negative. Physicians seem more confident about overcoming process-related barriers than nurses. Having previous positive experiences of family-witnessed resuscitation was associated with a more positive attitude towards this practice. Consequently a previous negative experience was associated with more negative attitudes. CONCLUSION: Family-witnessed resuscitation awareness should be increased in daily clinical practice. It is important to find a way to improve experiences and attitudes of healthcare professionals related to this phenomenon. Furthermore, developing local guidelines and multidisciplinary training plans is needed to respond to the needs of patients and their families.

Integrative review: nurses' and physicians' experiences and attitudes towards inpatient-witnessed resuscitation of an adult patient.

AIM: An integrative review of attitudes and experiences of healthcare professionals regarding family-witnessed resuscitation. BACKGROUND: Allowing family members to be present during resuscitation has been a topic of debate in the last years. Increased focus on family centred care led to preparation of official statements concerning this phenomenon. While in some countries witnessed resuscitation is accepted and used, there are many places where it is not respected and remains controversial. DESIGN: Integrative literature review. DATA SOURCES: Databases: CINAHL, PsycINFO and PubMed. REVIEW METHODS: Cooper's five-stage integrative review method has been used. Results were limited to original publications in English, published between 2007-2012, describing nurses' and doctors' experiences and attitudes on inpatient family-witnessed resuscitation of an adult patient. RESULTS: Fifteen articles were included. Healthcare professionals indicated different opinions on family-witnessed resuscitation. Perceptions vary in different cultural settings. There are both positive and negative effects of this practice on the family members and the rescue team. There is a lack of local guidelines. CONCLUSION: Further research with larger sample sizes and different cultural settings would help identify outcomes following the family presence during resuscitation practice. Qualitative research is needed to examine the impact of those outcomes and develop policies and guidelines on cultural variability.

Mortality in patients with septic cardiomyopathy identified by longitudinal strain by speckle tracking echocardiography: An updated systematic review and meta-analysis with trial sequential analysis.

BACKGROUND: Septic cardiomyopathy is associated with poor outcomes but its definition remains unclear. In a previous meta-analysis, left ventricular (LV) longitudinal strain (LS) showed significant prognostic value in septic patients, but findings were not robust due to a limited number of studies, differences in effect size and no adjustment for confounders. METHODS: We conducted an updated systematic review (PubMed and Scopus up to 14.02.2023) and meta-analysis to investigate the association between LS and survival in septic patients. We included studies reporting global (from three apical views) or regional LS (one or two apical windows). A secondary analysis evaluated the association between LV ejection fraction (EF) and survival using data from the selected studies. RESULTS: We included fourteen studies (1678 patients, survival 69.6%) and demonstrated an association between better performance (more negative LS) and survival with a mean difference (MD) of -1.45%[-2.10, -0.80] (p < 0.0001;I2 = 42%). No subgroup differences were found stratifying studies according to number of views used to calculate LS (p = 0.31;I2 = 16%), severity of sepsis (p = 0.42;I2 = 0%), and sepsis criteria (p = 0.59;I2 = 0%). Trial sequential analysis and sensitivity analyses confirmed the primary findings. Grade of evidence was low. In the included studies, thirteen reported LVEF and we found an association between higher LVEF and survival (MD = 2.44% [0.44,4.45]; p = 0.02;I2 = 42%). CONCLUSIONS: We confirmed that more negative LS values are associated with higher survival in septic patients. The clinical relevance of this difference and whether the use of LS may improve understanding of septic cardiomyopathy and prognostication deserve further investigation. The association found between LVEF and survival is of unlikely clinical meaning. REGISTRATION: PROSPERO number CRD42023432354.

Echocardiography and Ultrasound Committee statement for the accreditation programme in point-of-care ultrasonography in Poland.

Ultrasonography is becoming an essential part of the management of critically ill patients. There has been a sufficient body of evidence to support the incorporation of point-of-care ultrasound (POCUS) in anaesthesia and intensive care medicine training programme. Recently the European Society of Intensive Care Medicine reco-gnized POCUS as an essential skill for European Intensive Care Medicine specialists and updated Competency Based Training in Intensive Care (CoBaTrICe). Following European training standards, the Ultrasound and Echocardiography Committee of the Polish Society of Anaesthesiology and Intensive Therapy issued this Position Statement for recommendations for the accreditation process in POCUS in Poland.

3D Printing in the Fight Against Covid-19.

Purpose: The paper describes the design concept and findings from technological and initial clinical trials conducted to develop a helmet for non-invasive oxygen therapy using positive pressure, known as hCPAP (Helmet Continuous Positive Airway Pressure). Methods: The study utilized PET-G filament, a recommended material for medical applications, along with the FFF 3D printing technique. Additional technological investigations were performed for the production of fitting components. The authors proposed a parameter identification method for 3D printing, which reduced the time and cost of the study while ensuring high mechanical strength and quality of the manufactured elements. Results: The proposed 3D printing technique facilitated the rapid development of an ad hoc hCPAP device, which was utilized in preclinical testing and treatment of Covid-19 patients, and yielded positive results. Based on the promising outcomes of the preliminary tests, further development of the hCPAP device's current version was pursued. Conclusion: The proposed approach offered a crucial benefit by significantly reducing the time and costs involved in developing customized solutions to aid in the fight against the Covid-19 pandemic.

Critical care echocardiography: barriers, competencies and solutions. A survey of over 600 participants.

INTRODUCTION: Critical care echocardiography (CCE) is at the core of point-of-care ultrasound (POCUS), and although a list of the necessary competencies has been created, most European countries do not have established training programmes to allow intensivists to gain such competencies. To address barriers to the implementation of CCE, we conducted an online European survey, and analysed the current barriers to this with the aim of providing novel, modern solutions to them including environmental considerations. MATERIAL AND METHODS: A 23-item survey was distributed via email with support from the European Society of Intensive Care Medicine, national societies, and social media. Questions focused on bedside CCE prevalence, competencies, and barriers to its implementation. An additional questionnaire was sent to recognised experts in the field of CCE. RESULTS: A total of 644 responses were recorded. Most respondents were anaesthesia and intensive care physicians [79% ( n = 468)], and younger, with 56% in their first five years after specialization ( n = 358). Most respondents [92% ( n = 594)] had access to an ultrasound machine with a cardiac probe, and 97% ( n = 623) reported being able to acquire basic CCE windows. The most common barriers identified by respondents to the implementation of CCE in practice were a lack of sufficient experience/skill [64% ( n = 343)], absence of formal qualifications [46% ( n = 246)] and lack of a mentor [45% ( n = 243)]. Twenty-eight experts responded and identified a lack of allocated time for teaching as a main barrier [60% ( n = 17)]. CONCLUSIONS: We found that bedside CCE is perceived as a crucial skill for intensive care medicine, especially by younger physicians; however, there remain several obstacles to training and implementation. The most important impediments reported by respondents were inadequate training, absence of formal qualifications and difficulties in finding a suitable mentor.

Cerebral Diseases in Liver Transplant Recipients: Systematic Review of Clinical Evidence.

This systematic review presents clinical evidence on early and long-term cerebral diseases in liver transplant recipients. The literature search led to the retrieval of 12 relevant studies. Early postoperative cerebral complications include intracranial hemorrhage associated with a coexisting coagulopathy, perioperative hypertension, and higher MELD scores and is more frequent in critically ill recipients; central pontine and extrapontine myelinolysis are associated with notable perioperative changes in the plasma Na+ concentration and massive transfusion. Long-term follow-up cerebral complications include focal brain lesions, cerebrovascular diseases, and posterior reversible encephalopathy; there is no proven relationship between the toxicity immunosuppressive drugs and cerebral complications. This SR confirms a very low incidence of opportunistic cerebral infections.

[The skin incisions (blow holes) for treatment of massive subcutaneous emphysema]. / Blow holes ­ metoda leczenia masywnej odmy podskórnej .

BACKGROUND: Subcutaneous emphysema (SE) is rarely life-threatening, although it may create significant discomfort to patients. It may impede eye opening, movement of the limbs and sometimes causes stridor and respiratory distress. We describe two cases of SE, in which small incisions in the skin helped to relieve symptoms. CASE REPORTS: Case 1. A 64-year-old male was admitted to ITU, having been intubated after blunt chest trauma during a traffic accident. Initial presentation included respiratory failure, massive SE of the face, neck and chest, and fractured ribs with bilateral pneumothorax and bilateral lung contusion. Ventilation with BiPAP with 15 cm H2O PEEP was commenced and a right chest drain was inserted. This resulted in rapid improvement of gas exchange, but SE became progressively larger. On the second day, several 2 cm skin incisions were made bilaterally in the subclavicular regions; immediately a loud hiss of escaping air was heard and the patient's condition improved rapidly. He was extubated after seven days and made a full recovery. Case 2. A 42-yr-old male was admitted to ITU three days after a street fight because of rapidly progressing SE, extending to the head, neck, chest, abdomen and legs. He was suffering from pneumomediastinum, pneumopericardium, and broken ribs, hyoid bone and Th10 spinous process. An emergency tracheostomy was performed and blow holes were made in both subclavicular regions. This resulted in rapid improvement and he was discharged home after two weeks in hospital. DISCUSSION AND CONCLUSION: Several methods of treatment for severe SE have been described, including pleural drainage, subcutaneous insertion of pig-tail drains, iv cannulas or large bore drains. The method described, albeit not always successful, is simple and can be applied in every setting.

HPLC-MS-based design of experiments approach on cocoa roasting.

Modern statistical methods, such as the design of experiments and response surface methodology, are widely used to describe changes in multiparameter processes during the processing of food in both science and technology contexts. However, these approaches are described to a lesser degree in the case of cocoa roasting than other foods and processes. Our study aimed to use the design of experiments to establish a model of cocoa roasting for relevant flavor-related constituents. We have used HPLC-MS techniques to link standard process parameters with chemical compounds changing in concentration during cocoa roasting. Influence of time, temperature, the addition of water, acid, and base, on relative concentrations of procyanidin monomers, dimers, and trimers, an Amadori compound, and a peptide, was shown. High-quality models for each compound were established and validated, displaying good prediction accuracy. Such an approach could be used to optimize processing conditions for cocoa roasting in order to influence the concentration of certain chemical compounds, and in turn, improving the flavor of chocolate products.