Laryngeal Injury and Upper Airway Symptoms After Endotracheal Intubation During Surgery: A Systematic Review and Meta-analysis.

Laryngeal injury from intubation can substantially impact airway, voice, and swallowing, thus necessitating multidisciplinary interventions. The goals of this systematic review were (1) to review the types of laryngeal injuries and their patient-reported symptoms and clinical signs resulting from endotracheal intubation in patients intubated for surgeries and (2) to better understand the overall the frequency at which these injuries occur. We conducted a search of 4 online bibliographic databases (ie, PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature [CINAHL], and The Cochrane Library) and ProQuest and Open Access Thesis Dissertations (OPTD) from database inception to September 2019 without restrictions for language. Studies that completed postextubation laryngeal examinations with visualization in adult patients who were endotracheally intubated for surgeries were included. We excluded (1) retrospective studies, (2) case studies, (3) preexisting laryngeal injury/disease, (4) patients with histories of or surgical interventions that risk injury to the recurrent laryngeal nerve, (5) conference abstracts, and (6) patient populations with nonfocal, neurological impairments that may impact voice and swallowing function, thus making it difficult to identify isolated postextubation laryngeal injury. Independent, double-data extraction, and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Collaboration's criteria. Twenty-one articles (1 cross-sectional, 3 cohort, 5 case series, 12 randomized controlled trials) representing 21 surgical studies containing 6140 patients met eligibility criteria. The mean patient age across studies reporting age was 49 (95% confidence interval [CI], 45-53) years with a mean intubation duration of 132 (95% CI, 106-159) minutes. Studies reported no injuries in 80% (95% CI, 69-88) of patients. All 21 studies presented on type of injury. Edema was the most frequently reported mild injury, with a prevalence of 9%-84%. Vocal fold hematomas were the most frequently reported moderate injury, with a prevalence of 4% (95% CI, 2-10). Severe injuries that include subluxation of the arytenoids and vocal fold paralysis are rare (<1%) outcomes. The most prevalent patient complaints postextubation were dysphagia (43%), pain (38%), coughing (32%), a sore throat (27%), and hoarseness (27%). Overall, laryngeal injury from short-duration surgical intubation is common and is most often mild. No uniform guidelines for laryngeal assessment postextubation from surgery are available and hoarseness is neither a good indicator of laryngeal injury or dysphagia. Protocolized screening for dysphonia and dysphagia postextubation may lead to improved identification of injury and, therefore, improved patient outcomes and reduced health care utilization.

Hydrogel Culture Surface Stiffness Modulates Mesenchymal Stromal Cell Secretome and Alters Senescence.

Current cell culture surfaces used for the expansion and production of mesenchymal stromal cells (MSCs) are not optimized for the production of highly secretory and nonsenescent cells. In this study, we used poly (ethylene glycol) hydrogel substrates with tunable mechanical and biochemical properties to screen the effect of culture surfaces on pro-regenerative secretome by multiplex enzyme-linked immunosorbent assay, proliferation by PicoGreen DNA analysis, and senescence by senescence-associated ß-galactosidase activity. We demonstrate that MSCs cultured on 30 kPa hydrogels, regardless of biochemical functionalization, broadly enhanced the secretion of immunomodulatory and regenerative factors versus stiffer 100 kPa or tissue culture plastic surfaces, but did not support robust proliferation. In contrast, culture on 100 kPa hydrogel surfaces promoted proliferation at a similar level and did not substantially alter the amount of secreted factors as compared with tissue culture plastic. Culture on integrin-engaging, cadherin-engaging, and hyaluronic acid-containing 30 kPa substrates enhanced MSC-conditioned media (CM) angiogenic activity in a human umbilical vein endothelial cell tube formation assay and human THP-1 monocyte chemoattraction in a transwell assay. However, 30 kPa substrate culture did not impact the myogenic activity of MSC CM in a C2C12 myoblast tube formation assay. Culture on selected 100 kPa surfaces enhanced CM angiogenic activity and monocyte chemotaxis, but not myogenic activity. Serial culture on 100 kPa RGD hydrogel surfaces significantly reduced senescence in MSCs versus tissue culture plastic, while maintaining the capacity of the cells to enhance their secretome in response to 30 kPa surfaces. Thus, hydrogel substrates that exhibit stiffness orders of magnitude lower than standard tissue culture plastic can serve as novel surfaces for the production of MSCs with an improved therapeutic secretory capacity and reduced senescence. Impact statement The success of mesenchymal stromal cell (MSC)-based therapies is dependent on the manufacture of a large number of cells with high therapeutic potency. Among the culture surfaces tested in this study, we demonstrate that substrate stiffness rather than biochemical functionalization predominantly guides changes in MSC proliferation and secretory capacity. We have identified substrate parameters to support MSC proliferation, enhance secretion of paracrine factors, and to reduce replicative senescence. By maximizing secretory capacity and reducing senescence through the choice of hydrogel culture materials, these findings have great potential to improve the large-scale production of therapeutic MSCs.

Effectiveness of the combat application tourniquet for arterial occlusion in young children.

BACKGROUND: Tourniquet use for extremity hemorrhage has become a mainstay in adult trauma care in last 15 years. The efforts of the Stop the Bleed campaign have increased the distribution and use of tourniquets in civilian settings in response to mass shootings and as part of disaster preparedness. Little research or published experience exists regarding the use of tourniquets in the pediatric population. This study sought to determine the minimum patient age on which the combat application tourniquet (CAT) is able to control extremity hemorrhage. METHODS: A convenience sample of pediatric patients, ages 1 year to 8 years, scheduled for elective orthopedic surgery at an academic hospital, were eligible for enrollment. Subject age, weight, height, blood pressure, and arm and leg circumferences were obtained. Once under general anesthesia, the pulse of an upper and a lower limb were obtained by Doppler, a CAT was then placed at the most proximal practical location of the limb until the corresponding pulse was either no longer obtainable by Doppler or until the tourniquet was as tight as its design allows. The tourniquet was removed after 30 seconds of arterial occlusion. RESULTS: Thirteen children, ages 2 years to 7 years were enrolled. Weights ranged from 12.8 kg to 23.9 kg, with a mean of 16.7 kg. Leg circumferences were 24.5 cm to 34.5 cm, with a mean of 27.9 cm and arm circumferences were 13 cm to 24 cm, with a mean of 16.3 cm. Subject heights were 87 cm to 122 cm, with a mean of 103.4 cm. Twenty-four total extremities were tested, 11 arms and 13 legs. Arterial occlusion was obtained on 100% of limbs tested (95% confidence interval, 85.8-100%). CONCLUSION: This study is similar to previous adult tourniquet efficacy studies in design, size and outcomes. It is the first to show successful arterial occlusion on preschool-aged children with a commercial tourniquet in a controlled setting. The results suggest that the CAT can be used in school-aged children with severe extremity hemorrhage with a high likelihood of success. LEVEL OF EVIDENCE: Therapeutic, level II.

From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings.

Throughout history, battlefield medicine has led to advancements in civilian trauma care. In the most recent conflicts of Operation Enduring Freedom in Afghanistan/Operation Iraqi Freedom, one of the most important advances is increasing use of point-of-injury hemorrhage control with tourniquets. Tourniquets are gradually gaining acceptance in the civilian medical world-in both the prehospital setting and trauma centers. An analysis of Emergency Medical Services (EMS) data shows an increase of prehospital tourniquet utilization from 0 to nearly 4,000 between 2008 and 2016. Additionally, bystander educational campaigns such as the Stop the Bleed program is expanding, now with over 125,000 trained on tourniquet placement. Because the medical community and the population at large has broader acceptance and training on the use of tourniquets, there is greater potential for saving lives from preventable hemorrhagic deaths.

The impact of interruptions on the duration of nursing interventions: a direct observation study in an academic emergency department.

BACKGROUND: Interruptions to nursing workload may contribute to procedural failures and clinical errors impacting quality/safety of care, but the impact of interruptions on the duration of these activities has not been closely scrutinised. This study analyses the effect of interruptions to care provided by nurses and clinical technicians on the length of clinical procedures and interventions (excluding the length of the interruption). METHODS: An observational time study of the effect of interruptions on common nursing interventions in the emergency department (ED) of a large academic medical centre was conducted. This study used direct observations of nurses and clinical technicians while delivering care to patients. RESULTS: The average time spent on an uninterrupted intervention was 296.47 s (median:185.15, SD:319.05), while interrupted interventions took 682.02 s (median:589.63, SD:504.59). Controlling for intervention type and other potential confounding factors using multiple linear regression found that interrupted interventions were 121.36 s (95% CI 79.57 to 163.15) longer, a 19 percentage point increase (95% CI 11.31 to 26.89), than an intervention without (excluding the length of the interruption). Family/patient interruptions effected duration the most while staff interruptions affected the intervention time the least. DISCUSSION: Our findings are consistent with outcomes of studies in non-healthcare domains, but are contrary to a study of ED physicians, suggesting differential responses to interruptions by physicians and nurses. Future studies on interruptions in healthcare should thus be discipline specific. Though the effect of interruptions on intervention length is only about 2 min, in an ED setting, this can increase patient risks and costs. To better focus efforts to reduce interruptions future research should focus on further separation of interruption type (eg, urgent vs routine or unnecessary).

A Multiyear Analysis of the Clinical Encounters of the ATF Tactical Medical Program.

BACKGROUND: The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medical Program provides tactical medical support for ATF's tactical Special Response Teams (SRTs) and investigative National Response Teams (NRTs) through the deployment of specially trained ATF Agent-Medics. All patient care activities are centrally coordinated through ATF Headquarters. METHODS: A retrospective analysis of de-identified patient care reports (PCRs) from the ATF Tactical Medical Program from 2009 to 2012 was performed. Clinical and operational data were extracted from PCRs and were entered into a database by the research team. Descriptive and summative analyses were performed to assess patient type, law enforcement incident type, chief complaint, and interventions performed. RESULTS: Analysis was performed on the 254 charts. Nearly half (114; 44.9%) of patients encountered during the study period were law enforcement officers. High-risk warrant service was associated with one third (85; 33.5%) of the ATF medics' clinical encounters. The most common chief complaints of patients encountered were musculoskeletal pain/injury (57; 22.4%) and wounds/lacerations (57; 22.4%), followed by heat illness (17; 6.7%). The most common intervention was wound care (61; 26.9%), followed by control of bleeding with direct pressure (43; 18.9%). The most common medications administered were ibuprofen (28; 25.2%), topical antibiotic (12; 10.8%), and acetaminophen (12;10.8%). CONCLUSION: This multiyear analysis represents an important contribution to the growing body of scientific literature surrounding tactical medicine. The results of this analysis demonstrate a continued need for expanded scope of practice training, as well as enhanced treatment protocols for tactical medics.