Frequency of Intubation for Medicare Beneficiaries With Acute Stroke and Association With Patient Outcomes.

BACKGROUND AND OBJECTIVES: Intubation for acute stroke is common in the United States, with few established guidelines. METHODS: This is a retrospective observational study of acute stroke admissions from 2011 to 2018 among fee-for-service Medicare beneficiaries aged 65-100 years. Patient demographics and chronic conditions as well as hospital characteristics were identified. We identified patient intubation, stroke subtype (ischemic vs intracerebral hemorrhage), and thrombectomy. Factors associated with intubation were identified by a linear probability model with intubation as the outcome and patient characteristics, stroke subtype, and thrombectomy as predictors, adjusting for within-hospital correlation. We compared hospital characteristics between adjusted intubation rate quartiles. We specified a linear probability model with 30-day mortality as the patient-level outcome and hospital intubation rate quartile as the categorical predictor, again adjusting for patient characteristics. We specified an analogous model for quartiles of hospital referral regions. RESULTS: There were 800,467 stroke hospitalizations at 3,581 hospitals. Among 2,588 hospitals with 25 or more stroke hospitalizations, the median intubation rate was 4.8%, while a quarter had intubation rates below 2.4% and 10% had rates above 12.5%. Ischemic strokes had a 21% lower adjusted intubation risk than intracerebral hemorrhages (risk difference [RD] -21.1%, 95% CI -21.3% to -20.9%; p < 0.001), whereas thrombectomy was associated with a 19.2% higher adjusted risk (95% CI RD 18.8%-19.6%; p < 0.001). Women and older patients had lower intubation rates. Large, urban hospitals and academic medical centers were overrepresented in the top quartile of hospital adjusted intubation rates. Even after adjusting for available characteristics, intubated patients had a 44% higher mortality risk than non-intubated patients (p < 0.001). Hospitals in the highest intubation quartile had higher adjusted 30-day mortality (19.3%) than hospitals in the lowest quartile (16.7%), a finding that was similar when restricting to major teaching hospitals (22.3% vs 18.1% in the 4th vs 1st quartiles, respectively). There was no association between market quartile of intubation and patient 30-day mortality. DISCUSSION: Intubation for acute stroke varied by patient and hospital characteristics. Hospitals with higher adjusted rates of intubation had higher patient-level 30-day mortality, but much of the difference may be due to unmeasured patient severity given that no such association was observed for health care markets.

Preoperative airway ultrasound assessment in the sniffing position: a prospective observational study

Abstract Background: Clinical airway screening tests intend to predict difficult airways, but none have a high predictive value. Recent systematic reviews correlate ultrasound with difficult laryngoscopy. This study aimed primarily to correlate ultrasound measurements of anatomical upper airway structures in the sniffing position with difficult direct laryngoscopy. The secondary aim was to observe gender-based differences. Methods: This prospective, cross-sectional, single-center observational study included 209 patients requiring general anesthesia for elective surgery. Preoperatively, we performed six clinical airway assessments and three ultrasound measurements, which were the Distance from Skin to the Hyoid Bone (DSHB), to the Epiglottis (DSE), and to the anterior commissure of the vocal cords (DSAC) in a sniffing position. Benumof's criteria for the "best view at the first attempt" for direct laryngoscopy assessed the difficulty of laryngoscopy. Results: The distance from skin to the epiglottis was the best predictor of direct difficult laryngoscopy (defined as Cormack-Lehane grade > 2b) with a minimum thickness cut-off at 2.70 ± 0.19 cm (sensitivity 91.3%; specificity 96.9%). The skin to the hyoid bone distance cut-off was 1.41 ± 0.30 cm with moderate correlation (sensitivity 80.4%; specificity 60.1%). No correlation was found for the distance to the anterior commissure of the vocal cords. In women compared to men, the skin to the epiglottis distance was more sensitive (92.3% vs. 90.9%) and specific (98.8% vs. 95.2%). Conclusions: DSE in the sniffing position is the most reliable parameter for preoperative airway ultrasound assessment in the Caucasian population, with higher sensitivity and specificity in women, and might be considered as an independent predictor for direct difficult laryngoscopy.

Assessment of Lacrijet monocanalicular intubation for congenital nasolacrimal duct obstruction.

PURPOSE: To assess the success rate and complications of Lacrijet monocanalicular stent (FCI S.A.S, Paris, France) intubation in children treated for congenital nasolacrimal duct obstruction (CNLDO). METHODS: Retrospective review study which included children with CNLDO that were intubated with Lacrijet monocanalucilar silicone tube.The Lacrijet tube remained in place for 11-15 weeks post operatively and was removed in the clinic with topical anesthesia. Operative time was recorded for each case. All children were evaluated using the following parameters preoperatively and postoperatively: tear meniscus height, Fluorescein dye disappearance test (FDDT), and MUNK score. RESULTS: The study included 20 eyes with mean age of 26.25 ± 11.25 months. 17 eyes (85%) had undergone probing previously. Mean operation time of Lacrijet intubation was 8.5 min (95% CI 7.04-9.95). Mean follow-up period was 204.65 ± 105.27 days. Lacrijet intubation resulted in statistically significant improvements in tear meniscus height (P < .001), FDDT (P < 0.001), and MUNK score (P < 0.001) in all children. Two different sizes of Lacrijet intubations were used. Complete success was obtained in all cases. No complications were observed. CONCLUSIONS: Lacrijet lacrimal intubation has a high rate of success, shortens surgical time and has a low rate of complications in children with CNLDO.

Epidemiology of Surgical Procedures, Anesthesia, and Imaging Studies by Gestational Age during the First Year of Life in Medicaid-Insured Infants.

OBJECTIVES: To evaluate the rate of surgical procedures, anesthetic use, and imaging studies by prematurity status for the first year of life we analyzed data for Texas Medicaid-insured newborns. STUDY DESIGN: We developed a retrospective population-based live birth cohort of newborn infants insured by Texas Medicaid in 2010-2014 with 4 subcohorts: extremely premature, very premature, moderate/late premature, and term. RESULTS: In 1 102 958 infants, surgical procedures per 100 infants were 135.9 for extremely premature, 35.4 for very premature, 15.5 for moderate/late premature, and 6.5 for term. Anesthetic use was 62.0 for extremely premature, 20.8 for very premature, 11.1 for moderate/late premature, and 5.6 for the term subcohort. The most common procedures in the extremely premature were neurosurgery, intubations, and procedures that facilitated caloric intake (gastrostomy tubes and fundoplications). The annual rates for the first year of life for chest radiograph ranged from 15.0 per year for the extremely premature cohort to 0.6 for term infants and for magnetic resonance imaging (MRI) from 0.3 to 0.01. MRI was the most common imaging study with anesthesia support in all maturity levels. MRIs were done in extremely premature without anesthesia in over 90% and in term infants in 57.2%. CONCLUSIONS: Surgical procedures, anesthetic use, and imaging studies in infants are common and more frequent with higher a degree of prematurity while the use of anesthesia is lower in more premature newborns. These findings can provide direction for outcome studies of surgery and anesthesia exposure.

Non-communicable diseases and inequalities increase risk of death among COVID-19 patients in Mexico.

BACKGROUND: The SARS-CoV-2 pandemic compounds Mexico's pre-existing challenges: very high levels of both non-communicable diseases (NCD) and social inequity. METHODS AND FINDINGS: Using data from national reporting of SARS-CoV-2 tested individuals, we estimated odds of hospitalization, intubation, and death based on pre-existing non-communicable diseases and socioeconomic indicators. We found that obesity, diabetes, and hypertension are positively associated with the three outcomes in a synergistic manner. The municipal poverty level is also positively associated with hospitalization and death. CONCLUSIONS: Mexico's response to COVID-19 is complicated by a synergistic double challenge: raging NCDs and extreme social inequity. The response to the current pandemic must take both into account both to be effective and to ensure that the burden of COVID-19 not falls disproportionately on those who are already disadvantaged.

Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network.

BACKGROUND: Neonatal-perinatal medicine (NPM) fellowship programs must provide adequate delivery room (DR) experience to ensure that physicians can independently provide neonatal resuscitation to very low birth weight (VLBW) infants. The availability of learning opportunities is unknown. METHODS: The number of VLBW (≤1500 g) and extremely low birth weight (ELBW) (<1000 g) deliveries, uses of continuous positive airway pressure, intubation, chest compressions, and epinephrine over 3 years at accredited civilian NPM fellowship program delivery hospitals were determined from the Vermont Oxford Network from 2012 to 2017. Using Poisson distributions, we estimated the expected probabilities of fellows experiencing a given number of cases over 3 years at each program. RESULTS: Of the 94 NPM fellowships, 86 programs with 115 delivery hospitals and 62 699 VLBW deliveries (28 703 ELBW) were included. During a 3-year fellowship, the mean number of deliveries per fellow ranged from 14 to 214 (median: 60) for VLBWs and 7 to 107 (median: 27) for ELBWs. One-half of fellows were expected to see ≤23 ELBW deliveries and 52 VLBW deliveries, 24 instances of continuous positive airway pressure, 23 intubations, 2 instances of chest compressions, and 1 treatment with epinephrine. CONCLUSIONS: The number of opportunities available to fellows for managing VLBW and ELBW infants in the DR is highly variable among programs. Fellows' exposure to key, high-risk DR procedures such as cardiopulmonary resuscitation is low at all programs. Fellowship programs should track fellow exposure to neonatal resuscitations in the DR and integrate supplemental learning opportunities. Given the low numbers, the number of new and existing NPM programs should be considered.

Caja de protección para intubación aerosol box en el contexto de COVID-19 / Protection box for intubation aerosol box in the context of COVID-19

INTRODUCCIÓN: El COVID-19 es una enfermedad nueva causada por el virus SARS-CoV-2 que ha provocado la actual declarada pandemia. Con respecto a la manera de transmisión del COVID-19, hasta la fecha, la evidencia indica que las principales vías de transmisión son: 1) de persona a persona a través de gotas respiratorias (transmisión directa), y 2) por contacto de superficies contaminadas (transmisión indirecta). La transmisión directa es mediante gotas respiratorias (de 5 a 10 micrómetros de diámetro) que pueden desplazarse desde una persona con síntomas respiratorios (durante la tos o el estornudo) a personas que se encuentran a menos de dos metros de distancia (usando como puerta de entrada la boca, nariz, ojos y posiblemente la inhalación). La transmisión indirecta ocurre cuando una persona entra en contacto con superficies que han sido contaminadas por una persona infectada (OMS 2020; CDC 2020). Adicionalmente, la transmisión podría ocurrir por la vía área mediante núcleos de gotas o aerosoles (menos de 5 micrómetros de diámetro) las cuales pueden permanecer suspendidas en el aire por un período prolongado de tiempo y desplazarse a mas de un metro de distancia. Esta transmisión podría ser posible durante procedimientos generadores de aerosoles (PGA) en ciertas circunstancias y lugares específicos (la OMS1, enlista los siguientes PGA: intubación endotraqueal, broncoscopía, aspiración abierta, administración de un fármaco por nebulización, ventilación manual antes de la intubación, giro del paciente a decúbito

Assessment of Pain Management During Interfacility Air Medical Transport of Intubated Patients.

OBJECTIVE: The management of pain is an important component of care in the prehospital and transport setting. However, recent evidence suggests that pain control is infrequently achieved in these settings. The objective of the current study was to determine the proportion and frequency of opioid analgesia provided to intubated patients during interfacility transport by an air medical transport system. METHODS: This was a health records review examining electronic records of intubated patients transported by Ornge from July 2015 to November 2015. Cases were identified using Ornge database, and intubated patients were selected based on the inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was whether analgesia was provided. Secondary outcomes included the frequency of administration and dose adequacy of an opioid analgesia; the analgesic used; adverse events; and the impact of age, sex, past medical history of chronic pain, or reason for transfer on pain management. RESULTS: Of the 500 potential patient transports, 448 met our inclusion criteria. Among the 448 patients, 295 (65.8%) were men, 327 (73.0%) received analgesia, and 211 (64.3%) received more than 1 dose during transport (median frequency of 2 doses, interquartile range = 1 to 3). The average transport time was 135 minutes, and repeated dosing (> 1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.9%), and the most common dose was 50 µg (51.8%). Adverse events occurred in 8 patients (2.5%), most commonly new hypotension (mean arterial pressure < 65 mm Hg, n = 5). There was no significant difference in the administration of analgesia based on the patient's age or sex (68.0% of female patients and 75.6% of male patients received analgesia). Interestingly, only 30.8% of patients repatriated to their originating hospital received analgesia compared with 72.3% of patients undergoing their initial transfer to a higher level of care. CONCLUSION: Seventy-three percent of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex, past medical history of chronic pain, or reason for transfer other than repatriation to the originating hospital.

Daily systemic energy expenditure in the acute phase of aneurysmal subarachnoid hemorrhage.

Background: Patients with subarachnoid hemorrhage often have impaired consciousness and cannot regulate nutritional intakes themselves. Previous studies have demonstrated elevated energy expenditure in the acute phase, but it is not known whether the energy demand is constant during the first week after onset of the disease. In this study, we performed daily measurements of energy expenditure with indirect calorimetry during the first 7 days after aneurysmal subarachnoid hemorrhage in mechanically ventilated patients.Methods: Metabolic measurements were performed daily with indirect calorimetry in 26 patients with aneurysmal subarachnoid hemorrhage. All patients were intubated and mechanically ventilated. The measured value was compared to the predicted values from the Harris-Benedict equation and the Penn State University 1998 equation. Urinary nitrogen excretion was measured daily.Results: There was a significant increase in energy expenditure during days 2-3 compared to days 5-6. The Harris-Benedict equation underestimated metabolic demand. The Penn State 1998 equation was closer to the measured values, but still underestimated caloric need. Urinary nitrogen excretion increased throughout the first week from initially low values.Conclusions: There is a dynamic course in energy expenditure in patients with aneurysmal subarachnoid hemorrhage, with increasing metabolic demand during the first week of the disease. Indirect calorimetry could be used more often to help provide an adequate amount of energy.

Clinical Decision Making in the ICU: Dysphagia Screening, Assessment, and Treatment.

Clinicians often perceive the intensive care unit as among the most intimidating environments in patient care. With the proper training, acquisition of skill, and approach to clinical care, feelings of intimidation may be overcome with the great rewards this level of care has to offer. This review-spanning the ages of birth to senescence and covering oral/nasal endotracheal intubation and tracheostomy-presents a clinically relevant, directly applicable review of screening, assessment, and treatment of dysphagia in the patients who are critically ill for clinical speech-language pathologists and identifies gaps in the clinical peer-reviewed literature for researchers.

Monocanalicular Stents in Eyelid Lacerations: A Report by the American Academy of Ophthalmology.

PURPOSE: To determine the efficacy and complication rates of monocanalicular stents in the setting of canalicular lacerations. METHODS: A literature search was performed in May 2018 in the PubMed database to identify all English-language reports of monocanalicular stenting to address canalicular lacerations. Studies that did not include at least 10 patients with at least 3 months of follow-up evaluation after surgery were excluded. Ninety-nine articles were identified, and 15 of these met criteria for data abstraction and were included in this assessment. The panel methodologist (V.K.A.) evaluated the quality of evidence and assigned a level-of-evidence rating to each of these studies. RESULTS: All 15 studies were rated as level III evidence. Anatomic and functional success rates after surgery ranged from 68% to 100% and 79% to 100%, respectively. Stents were generally well tolerated, although extrusion rates varied from 0% to 29%. CONCLUSIONS: Only level III evidence was available, and studies were not powered to detect differences between groups for rare complications or failure. Monocanalicular stents seem to be efficacious and well tolerated in the management of canalicular lacerations. Potential complications include extrusion (most commonly), tube displacement, granuloma, ectropion, slit punctum, fistula, and infection. Further comparative studies would help to identify the optimal time for device removal and to directly compare monocanalicular with bicanalicular stents.

Association Between Outdoor Air Pollution Levels and Inpatient Outcomes in Pediatric Pneumonia Hospitalizations, 2007 to 2008.

OBJECTIVE: Pneumonia is a leading cause of pediatric admissions. Although air pollutants are associated with poor outcomes, few national studies have examined associations between pollutant levels and inpatient pediatric pneumonia outcomes. We examined the relationship between ozone (O3) and fine particulate matter with a diameter ≤2.5 µm (PM2.5) and outcomes related to disease severity. METHODS: In this cross-sectional study, we obtained discharge data from the 2007 to 2008 Nationwide Inpatient Sample and pollution data from the Air Quality System. Patients ≤18years with a principal diagnosis of pneumonia were included. Discharge data were linked to O3 and PM2.5 levels (predictors) from the patient's ZIP Code (not publicly available) from day of admission. Outcomes were mortality, intubation, length of stay (LOS), and total costs. We calculated weighted national estimates and performed multivariable analyses adjusting for sociodemographic and hospital factors. RESULTS: There were a total of 57,972 (278,871 weighted) subjects. Median PM2.5 level was 9.5 (interquartile range [IQR] 6.8-13.4) µg/m3. Median O3 level was 35.6 (IQR 28.2-45.2) parts per billion. Mortality was 0.1%; 0.75% of patients were intubated. Median LOS was 2 (IQR 2-4) days. Median costs were $3089 (IQR $2023-$5177). Greater levels of PM2.5 and O3 were associated with mortality, longer LOS, and greater costs. Greater O3 levels were associated with increased odds of intubation. CONCLUSIONS: Greater levels of O3 and PM2.5 were associated with more severe presentations of pneumonia. Future work should examine these relationships in more recent years and over a longer time period.

Comparative Study of Recessive Spherical Headed Silicone Intubation and Endonasal Dacryocystorhinostomy under Nasal Endoscopy for Nasolacrimal Duct Obstruction.

Between July 2014 and November 2015, we compared the curative effects and cost-effectiveness of two kinds of nasal endoscopic surgery for nasolacrimal duct obstruction (NLDO) in a single-centre, two-armed clinical trial with a 1-year follow-up. We included two groups: a recessive spherical headed silicone intubation (RSHSI) group and an endonasal dacryocystorhinostomy (En-DCR) group; both received nasal endoscopy. Patients were recruited from the Otorhinolaryngology and Ophthalmology departments. The main outcome measures were epiphora improvement (classified as cure, effective, or invalid), cost-effectiveness, visual analogue scale (VAS) intraoperative pain score, bleeding volume, operating time, hospitalisation time, total cost, and VAS postoperative epiphora score. No significant group difference was identified in postoperative epiphora VAS scores (P > 0.050) or success rate (P = 0.406). However, average VAS intraoperative pain score, operating time, bleeding volume, hospitalisation time and total cost in the RSHSI group were clearly lower to those in the En-DCR group (P = 0.000). In conclusion, RSHSI under nasal endoscopy can provide similar treatment outcomes to En-DCR. RSHSI has advantages including minimal invasiveness, reduced risk, shorter duration of surgery and hospitalisation, reduced intraoperative discomfort, and lower financial burden, which is more acceptable to patients. Thus, RSHSI may be the preferred option for NLDO.

Assessment of endotracheal tube cuff pressure: results obtained by the technique of digital palpation and anesthesiologist experience / Avaliação da pressão do balonete das sondas de intubação traqueal: resultados obtidos pela técnica da palpação digital e experiência do anestesiologista

INTRODUÇÃO: Uma das funções do balonete do tubo endotraqueal é selar a via aérea, ou seja, ocupar o espaço entre o tubo e a parede da traqueia, impedindo a ocorrência de broncoaspiração e permitindo o funcionamento dos ventiladores. Considera-se adequada a pressão do balonete entre 25 a 30 cmH2O. OBJETIVO: Avaliar o método da palpação digital como técnica para determinar a insuflação adequada do balonete dos tubos traqueais de pacientes submetidos à anestesia geral. MÉTODOS: Foi conduzido um estudo prospectivo no Centro Cirúrgico do Hospital de Clínicas da Universidade Federal do Triângulo Mineiro. Após a intubação orotraqueal, o balonete foi insuflado com ar ambiente e o volume injetado determinado pela sensibilidade tátil. A insuflação foi realizada pelo residente em anestesiologia ou pelo Staff. Em qualquer momento da cirurgia foi anotada a pressão do balonete através do cufômetro. (AU)

Introduction: One of the functions of the endotracheal tube cuff is to seal the airway, that is, to occlude the space between the tube and the tracheal wall, thus preventing pulmonary aspiration and ensuring ventilator function. Cuff pressure must be maintained within the recommended range of 25-30 cmH2O. Objective: To evaluate digital palpation as a method to determine the appropriate inflation of endotracheal tube cuff of patients undergoing general anesthesia. Methods: A prospective study was performed at the Surgical Center of Hospital de Clínicas da Universidade Federal do Triângulo Mineiro, in Uberaba, Brazil. After orotracheal intubation, the cuff was inflated with air and the injected volume was determined by tactile sensitivity. Inflation was performed by an anesthesiology resident or by anesthesiology staff, and the cuff pressure was measured by a cuff manometer at any time during the surgery. Results: 15.65% of the cases had adequate insufflation pressure, 21.2% had inadequate pressure, and 63.15% had high pressure. Statistical analysis showed that the R1 group had a mean cuff pressure of 61.7 cmH2O; R2 had 62.7; R3 had 55.4; and the Staff group had 55.6. Measurement of the degree of accuracy was appropriate in 27.3% of R1 cases, in 25.5% of R2 cases, in 7.2% of R3 cases, and in 8.9% of Staff cases. Conclusion: 84.34% were not in accordance with the appropriate limits, so digital palpation and professional experience were shown to be inappropriate methods for estimating the inflated pressure. Therefore, it is recommended that cuff pressure be measured by a specific device, the cuff manometer. (AU)

Evaluation of perfusion index as a tool for pain assessment in critically ill patients.

Pain is a common and undertreated problem in critically ill patients. Pain assessment in critically ill patients is challenging and relies on complex scoring systems. The aim of this work was to find out the possible role of the perfusion index (PI) measured by a pulse oximeter (Masimo Radical 7; Masimo Corp., Irvine, CA, USA) in pain assessment in critically ill patients. A prospective observational study was carried out on 87 sedated non-intubated patients in a surgical intensive care unit. In addition to routine monitoring, a Masimo pulse oximeter probe was used for PI measurement. The sedation level of the patients was assessed by using the Richmond Agitation-Sedation Scale (RASS). The pain intensity was determined by applying the behavioral pain scale for non-intubated (BPS-NI) patients. The PI, arterial blood pressure, heart rate, RASS, and BPS-NI values before and after the application of a standard painful stimulus (changing the patient position) were reported. Correlation between the PI and other variables was carried out at the two measurements. Correlation between changes in the PI (delta PI) and in the hemodynamic variables, RASS, and BPS-NI was also done. Changing the patient position resulted in a significant increase in SBP (128 ± 20 vs 120.4 ± 20.6, P = 0.009), DBP (71.3 ± 11.2 vs 68.7 ± 11.3, P = 0.021), heart rate (99.5 ± 19 vs 92.7 ± 18.2, P = 0.013), and BPS-NI (7[6-8] vs 3[3-3], P < 0.001) values and a significant decrease in the PI (1[0.5-1.9] vs 2.2[0.97-3.6], P < 0.001) value compared to the baseline readings. There was no correlation between the values of the PI and the ABP, BPS-NI, and RASS at the two measurements. A good correlation was found between the delta PI and delta BPS-NI (r = -0.616, P < 0.001). A weak correlation was observed between the PI and heart rate after the patient positioning (r = -0.249, P < 0.02). In surgical critically ill non-intubated patients, the application of a painful stimulus was associated with decreased PI. There was a good correlation between the change in the PI and the change in BPS-NI values after the application of painful stimulus.

An active simulator for neonatal intubation: Design, development and assessment.

This study describes the technical realization and the pre-clinical validation of a instrumented neonatal intubation skill trainer able to provide objective feedback for the improvement of clinical competences required for such a delicate procedure. The Laerdal® Neonatal Intubation Trainer was modified by applying pressure sensors on areas that are mainly subject to stress and potential injuries. Punctual Force Sensing Resistors (FSRs) were characterized and fixed on the external side of the airway structure on the dental arches and epiglottis. A custom silicone tongue was designed and developed to integrate a matrix textile sensor for mapping the pressure applied on its whole surface. The assessment of the developed tool was performed by nine clinical experts who were asked to practice three intubation procedures apiece. Median and maximum forces, over threshold events (i.e. 2N for gingival arch sensors and 7N for epiglottis and tongue sensors respectively) and execution time were measured for each trainee. Data analysis from training sessions revealed that the epiglottis is the point mainly stressed during an intubation procedure (maximum value: 16.69N, median value: 3.11N), while the analysis carried out on the pressure distribution on the instrumented tongue provided information on both force values and distribution, according to clinicians' performance. The debriefing phase was used to enhance the clinicians' awareness of applied force and gestures performed, confirming that the present study is an adequate starting point for achieving and optimizing neonatal intubation skills for both residents and expert clinicians.

Reporting of Malposition of Lines and Tubes on Portable Radiographs Using Alert Notification of Critical Results.

Line malposition may result in significant iatrogenic complications. Awareness of the most common types of line malposition and the frequency of significant line-related complications is an important reminder to the radiologist to look carefully at all lines, especially the devices that are most commonly subject to malposition. Alert Notification of Critical Results (ANCR) are computer-generated pages or e-mails created by the radiologist to inform referring clinicians of significant radiologic findings. The alert is logged on the computer and all data are saved for future review. The primary purpose of the ANCR is to ensure that radiologists and clinicians have an effective and well-documented method of communication regarding significant imaging findings. A secondary purpose of ANCR data is the ability to review clinical practice. We have used the ANCR data to identify the frequency and types of line malpositions in the intensive care unit.

Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients.

PURPOSE: To develop and validate a scale using variables easily obtained at the bedside for prediction of failure of noninvasive ventilation (NIV) in hypoxemic patients. METHODS: The test cohort comprised 449 patients with hypoxemia who were receiving NIV. This cohort was used to develop a scale that considers heart rate, acidosis, consciousness, oxygenation, and respiratory rate (referred to as the HACOR scale) to predict NIV failure, defined as need for intubation after NIV intervention. The highest possible score was 25 points. To validate the scale, a separate group of 358 hypoxemic patients were enrolled in the validation cohort. RESULTS: The failure rate of NIV was 47.8 and 39.4% in the test and validation cohorts, respectively. In the test cohort, patients with NIV failure had higher HACOR scores at initiation and after 1, 12, 24, and 48 h of NIV than those with successful NIV. At 1 h of NIV the area under the receiver operating characteristic curve was 0.88, showing good predictive power for NIV failure. Using 5 points as the cutoff value, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for NIV failure were 72.6, 90.2, 87.2, 78.1, and 81.8%, respectively. These results were confirmed in the validation cohort. Moreover, the diagnostic accuracy for NIV failure exceeded 80% in subgroups classified by diagnosis, age, or disease severity and also at 1, 12, 24, and 48 h of NIV. Among patients with NIV failure with a HACOR score of >5 at 1 h of NIV, hospital mortality was lower in those who received intubation at ≤12 h of NIV than in those intubated later [58/88 (66%) vs. 138/175 (79%); p = 0.03). CONCLUSIONS: The HACOR scale variables are easily obtained at the bedside. The scale appears to be an effective way of predicting NIV failure in hypoxemic patients. Early intubation in high-risk patients may reduce hospital mortality.