Right Heart Thrombi: Patient Outcomes by Treatment Modality and Predictors of Mortality: A Pooled Analysis.

RATIONALE: Right heart thrombi (RiHT) is characterized by the presence of thrombus within the right atrium or right ventricle (RV). Current literature suggests pulmonary embolism (PE) with RiHT carries a high mortality. Guidelines lack recommendations in managing RiHT. We created a pooled analysis on RiHT and report on our institutional experience in managing RiHT. We aimed to evaluate whether patient characteristics and differing treatment modalities predict mortality. METHODS: We created a pooled analysis of case reports and series of patients with RiHT and PE between January 1956 and 2017. We also reviewed a series of consecutive patients with RiHT identified from our institutional PE registry. Age, shock, RV dysfunction, clot mobility, treatment modality, and hospital outcome had to be reported. RESULTS: We identified 316 patients in our pooled analysis. Patients received the following therapies: no treatment 15 (5%), systemic anticoagulation 73 (23%), systemic thrombolysis 108 (34%), surgical embolectomy 101 (32%), catheter-directed therapy 11 (3%), and systemic thrombolysis with surgery 8 (3%). In-hospital mortality was 18.7%. Univariate analysis showed age and shock reduced odds of survival. Multivariate analysis showed shock reduced odds of survival (odds ratios [OR] 0.36, 95% confidence interval [CI]: 0.19-0.72, P ≤ .01) while age, RV dysfunction, and clot-mobility did not affect mortality. In a reduced multivariate analysis adjusting for shock, treatment modality, and clot location alone, systemic thrombolysis increased odds of survival when compared to systemic anticoagulation (OR 2.72, 95% CI: 1.11-6.64, P = .02). Our institutional series identified 18 patients, where in-hospital mortality was 22.2%, 18 (100%) had RV dysfunction, and 5 (28%) had shock. Patients received the following therapies: systemic anticoagulation 8 (44.4%), systemic thrombolysis 4 (22.2%), surgical embolectomy 4 (22.2%), and catheter-directed thrombolysis 2 (11.1%). CONCLUSION: Presence of shock in RiHT is an independent predictor of mortality. Systemic thrombolysis may offer increased odds of survival when compared to systemic anticoagulation. Our findings should be interpreted with caution as they derive from retrospective reports and subject to publication bias.

Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: a randomized controlled trial.

OBJECTIVES: In the critically ill undergoing urgent endotracheal intubation by direct laryngoscopy, multiple attempts are often required with a higher complication rate due to the urgency, uncontrolled setting, comorbidities, and variability in expertise of operators. We hypothesized that Glidescope video laryngoscopy would be superior to direct laryngoscopy during urgent endotracheal intubation. DESIGN: Single-center prospective randomized controlled trial. SETTING: Beth Israel Medical Center, an 856-bed urban teaching hospital with a 16-bed closed medical ICU. PATIENTS: Of 153 consecutive patients undergoing urgent endotracheal intubation by pulmonary and critical care medicine fellows, 117 met inclusion criteria. INTERVENTIONS: Patients undergoing urgent endotracheal intubation were randomized to Glidescope video laryngoscopy or direct laryngoscopy as the primary intubation device. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was the rate of first-attempt success. Acute Physiology and Chronic Health Evaluation II scores were similar between groups (20.9 ± 8.2 vs 19.9 ± 7.9). First-attempt success was achieved in 74% of the Glidescope video laryngoscopy group compared with 40% in the direct laryngoscopy group (p < 0.001). All unsuccessful direct laryngoscopy patients were successfully intubated with Glidescope video laryngoscopy, 82% on the first attempt. There was no significant difference in rates of complications between direct laryngoscopy and Glidescope video laryngoscopy: esophageal intubations (7% vs 0%; p = 0.05), aspiration events (7% vs 9%; p = 0.69), desaturation (8% vs 4%; p = 0.27), and hypotension (13% vs 11%; p = 0.64). CONCLUSIONS: Glidescope video laryngoscopy improves the first-attempt success rate during urgent endotracheal intubation performed by pulmonary and critical care medicine fellows when compared with direct laryngoscopy.

Survey of video laryngoscopy use by U.S. critical care fellowship training programs.

RATIONALE: Recent studies on video laryngoscopy have demonstrated improvements in both safety and success of endotracheal intubation in the critically ill. OBJECTIVES: We assessed the use of video laryngoscopy among internal medicine fellowship programs training physicians in critical care medicine. METHODS: A 19-question survey was e-mailed to program directors of pulmonary/critical care and internal medicine critical care fellowship training programs. MEASUREMENTS AND MAIN RESULTS: A completed survey was returned by 36% of invited program directors. Sixty-nine percent of respondents reported a change in their approach to intubation training over the prior 3 years, with 56% of changes attributed to the adoption of a video laryngoscope. Other reported changes include new training methods (23%) and adoption of a checklist (10%). A video laryngoscope is available for clinical use in 89% of the responding programs. The video scope is used as the primary device in 16% and is never used in 9%. In the remainder of programs, the video laryngoscope is only used for difficult intubations or after failure of direct laryngoscopy (32%) or the primary device is determined by the preference of the operator (32%). CONCLUSIONS: The majority of internal medicine critical care program directors who recently responded to an e-mail survey reported that they have changed their approach to teaching endotracheal intubation, driven largely by the adoption of video laryngoscopy for upper airway visualization. Nevertheless, despite widespread availability, video laryngoscopy is used uncommonly as the primary visualization device for intubation at the programs represented by the respondents to this survey.

The impact of video laryngoscopy use during urgent endotracheal intubation in the critically ill.

BACKGROUND: The video laryngoscope (VL) has been shown to improve laryngoscopic views and first-attempt success rates in elective operating room and simulated tracheal intubations compared with the direct laryngoscope (DL). However, there are limited data on the effectiveness of the VL compared with the DL in urgent endotracheal intubations (UEIs) in the critically ill. We assessed the effectiveness of using a VL as the primary intubating device during UEI in critically ill patients when performed by less experienced operators. METHODS: We compared success rates of UEIs performed by Pulmonary and Critical Care Medicine (PCCM) fellows in the medical intensive care unit and medical or surgical wards. A cohort of PCCM fellows using GlideScope VL as the primary intubating device was compared with a historical cohort of PCCM fellows using a traditional Macintosh or Miller blade DL. The primary measured outcome was first-attempt intubation success rate. Secondary outcomes included total number of attempts required for successful tracheal intubation, rate of esophageal intubation, need for supervising attending intervention, duration of intubation sequence, and incidence of hypoxemia and hypotension. RESULTS: There were 138 UEIs, with 78 using a VL and 50 using a DL as the primary intubating device. The rate of first-attempt success was superior with the VL as compared with the DL (91% vs 68%, P < 0.01). The rate of intubations requiring ≥3 attempts (4% vs 20%, P < 0.01), unintended esophageal intubations (0% vs 14%, P < 0.01), and the average number of attempts required for successful tracheal intubation (1.2 ± 0.56 vs 1.7 ± 1.1, P < 0.01) all improved significantly with use of the VL compared with the DL. CONCLUSIONS: UEI using a VL as the primary device improved intubation success and decreased complications compared with a DL when PCCM fellows were the primary operators. These data suggest that the VL should be used as the primary device when urgent intubations are performed by less experienced operators.