Multivariate Analysis of the Failure Risk of First Tracheal Intubation Attempt in a Population of Patients Scheduled for Bariatric Surgery.

BACKGROUND: Airway management during the administration of anesthesia to patients undergoing bariatric surgery is challenging. The goal is to avoid multiple intubation attempts because the risk of complications increases with the number of attempts. The objective of this study was to determine the failed first intubation attempt rate, as well as variables associated with this failure, in patients undergoing bariatric surgery. METHODS: We enrolled patients scheduled for bariatric surgery in this prospective, observational, single-center study. We determined predictive criteria for difficult intubation at the preoperative anesthesia consultation. All patients were evaluated for obstructive sleep apnea by polygraphy. The primary study endpoint was a failed first intubation attempt. RESULTS: We enrolled 519 patients between December 2012 and January 2015. The cohort consisted of 425 women (82%), with a median (interquartile range [IQR]) age of 39 (30-50) years and a body mass index of 42 (39-46) kg/m2. The first intubation attempt failed in 60 patients, with an incidence rate of 11.5% (95% confidence interval [CI], 8.8-14.2%). We included nine variables in the final multivariate model. Two variables were associated with failed first intubation attempt: male sex (odds ratio [OR] [95% CI], 6.9% [2.5-18.7%]) and Mallampati score 3-4 (OR [95% CI], 2.2% [1.0-4.7%]). CONCLUSIONS: In this morbidly obese population, the first intubation attempt failed in 11.5% of patients, and the risk factors for failure were male sex and a high Mallampati score.

Out-of-hospital diagnosis of a ruptured ectopic pregnancy: myometrial embryo implantation, an exceptional diagnosis.

BACKGROUND: Ultrasonography (US) could be used in emergency out-of-hospital settings to diagnose abdominal hemorrhage. OBJECTIVES: To report the diagnosis by US of a suspected case of ruptured ectopic pregnancy despite a supposedly in utero pregnancy. CASE REPORT: A mobile intensive care unit with an emergency physician on board was sent out to a 22-year-old woman suffering from acute abdominal pain. On the previous day, an 11-week pregnancy had been diagnosed and the pelvic US images were reported to be "normal." Physical examination revealed that the patient was in shock. Point-of-care US detected an intraperitoneal effusion and suspected uterine rupture. Emergency laparotomy revealed an 11- or 12-week intra-abdominal pregnancy with uterine rupture due to myometrial implantation of the embryo. CONCLUSION: Ultrasound is a helpful tool in emergency care, particularly in out-of-hospital settings. An earlier "normal" US examination cannot definitively exclude uterine rupture.

Prospective evaluation of peripheral venous access difficulty in emergency care.

OBJECTIVE: Although frequently used and crucial in emergency care, peripheral intravenous access has been poorly documented. We examined whether criteria related to patient characteristics, underlying disease, devices, or environment were associated with difficult peripheral intravenous access. DESIGN AND SETTING: Prehospital prospective observational study. PARTICIPANTS AND MEASUREMENTS: For each peripheral intravenous access attempt a questionnaire was filled in until final success or procedure abandonment. This questionnaire included data on the patient, operator, disease, degree of emergency, cannulation, nature of fluid infused and the use of gloves, environment, and particular medical observations such as recent peripheral intravenous access and chemotherapy. Criteria associated with peripheral intravenous access difficulty were identified comparing successful and unsuccessful attempts. A total of 671 attempts at peripheral intravenous access in 495 patients were studied. RESULTS: The first attempt was successful in 368 cases (74%) and unsuccessful in 127 (26%). Final success was reported in all cases, including the use of central venous access in three cases. No abandonment was reported. Significantly correlated with a successful attempt were: the caliber of the catheter (OR 0.793), cannulation performed by a nurse specialized in emergency care (OR 3.959), lack of particular observations (OR 0.120), and a clean patient (OR 0.505). CONCLUSIONS: Peripheral intravenous access was achieved in 99% of the patients in out-of-hospital settings. Improved success rate was reported when attempts were performed by a nurse specialized in emergency care using a 16- or 18-G catheter in clean patients without a particular medical history.

Management of severe acute pain in emergency settings: ketamine reduces morphine consumption.

OBJECTIVE: The aim of the study was to compare in emergency settings 2 analgesic regimens, morphine with ketamine (K group) or morphine with placebo (P group), for severe acute pain in trauma patients. METHODS: This was a prospective, multicenter, randomized, double-blind, clinical trial. Seventy-three trauma patients with a severe acute pain defined as a visual analog scale (VAS) score of at least 60/100 were enrolled. Patients in the K group received 0.2 mg x kg(-1) of intravenous ketamine over 10 minutes, and patients in the P group received isotonic sodium chloride solution. In both groups, patients were given an initial intravenous morphine injection of 0.1 mg x kg(-1), followed by 3 mg every 5 minutes. Efficient analgesia was defined as a VAS score not exceeding 30/100. The primary end points were morphine consumption and VAS at 30 minutes (T30). RESULTS: At T30, morphine consumption was significantly lower in the K group vs the P group, with 0.149 mg x kg(-1) (0.132-0.165) and 0.202 mg x kg(-1) (0.181-0.223), respectively (P < .001). The VAS score at T30 did not differ significantly between the 2 groups, with 34.1 (25.6-42.6) in the K group and 39.5 (32.4-46.6) in the P group (P = not significant). CONCLUSION: Ketamine was able to provide a morphine-sparing effect.

A multicenter survey of visiting policies in French intensive care units.

OBJECTIVE: To determine the visiting policies of French intensive care units. DESIGN AND SETTING: Descriptive study in intensive care units. METHODS: A questionnaire on their official visiting policies was sent to 200 French ICUs. RESULTS: Ninety-five ICUs completed the questionnaire (47.5%). Ninety-two (97%) ICUs reported restricted visiting-hour policies, allowing visits at only one or several preassigned times. Mean total daily visiting time was 168 min (range 30-370). The number of visitors was restricted in 90 ICUs (95%). The type of visitors (immediate relatives only) was restricted in 57 (60%). Visiting was forbidden for children in 10 (11%), and 41 (44%) fixed an age limit for visiting. A gowning procedure was imposed on visitors in 78 (82%). Eighteen (19%) ICUs had no waiting room available, 35 (37%) used a special room for providing families with information in addition to the waiting room, 61 (64%) provided an information leaflet. A structured first meeting was organized in 68 (71%). A last structured family meeting at the ICU discharge was provided in 6 (6%). CONCLUSIONS: Responding ICUs provide homogeneously restrictive visiting policies concerning visiting hours, number and type of visitors. However, family reception cannot be reduced to some quantitative factors and depends on multiple other parameters such as the organization of family meetings and the use of an information leaflet. These results should be an interesting starting point to observe any change in mentalities and practices in the future.

Basic cardiac life support providers checking the carotid pulse: performance, degree of conviction, and influencing factors.

UNLABELLED: The American Heart Association recently abolished the carotid pulse check during cardiopulmonary resuscitation for lay rescuers, but not for health care providers. OBJECTIVES: The aim of the study was to evaluate health care providers' performance, degree of conviction, and influencing factors in checking the carotid pulse. METHODS: Sixty-four health care providers were asked to check the carotid pulse for 10 or 30 seconds on a computerized mannequin simulating three levels of pulse strength (normal, weak, and absent). Health care providers were asked whether they felt a pulse and how certain were they that they felt a pulse. Performance was evaluated, as well as degree of conviction about the answer, using a visual analog scale. Data were compared by using a general linear model procedure. RESULTS: In the pulseless situations, the answers were correct in 58% and 50% when checking the pulse for 10 and 30 seconds, respectively. In the situation with a weak pulse, the answer was correct in 83% when checking the pulse for 10 seconds. In situations with a normal pulse, the answers were correct in 92%, 84%, and 84%, respectively, when checking the pulse for 10 (twice) and 30 seconds. The exactitude of the answer was correlated with the pulse strength (p < 0.05). The degree of conviction about the answer was correlated with the exactitude of the answer (p < 0.01) and the pulse strength (p < 0.0001). CONCLUSIONS: These results question the routine use of the carotid pulse check during cardiopulmonary resuscitation, including for health care providers.

Laryngoscope plastic blades in scheduled general anesthesia patients: a comparative randomized study.

STUDY OBJECTIVE: To compare two brands of disposable plastic laryngoscope blades, Vital View plastic blades and Heine XP plastic blades, with the reusable Heine Classic+ Macintosh metal blades. DESIGN: Prospective randomized, controlled, single-blinded study. SETTING: Operating room of a university-affiliated hospital. PATIENTS: 519 patients without criteria for predicted difficult intubation, undergoing scheduled surgery during general anesthesia. INTERVENTIONS: Patients were randomized to three groups according to laryngoscope blade brand. MEASUREMENTS: Difficult tracheal intubation was evaluated by the Intubation Difficulty Scale (IDS) (IDS > 5 = procedure involving moderate to major difficulty). MAIN RESULTS: The percentage of intubations with an IDS > 5 was 3.1% in Group M (metal blade group), 5.1% in Group V (Vital View plastic blade group), and 10.0% in Group H (Heine plastic blade group). A significant difference was noted between Groups M and H (P = 0.02) but not between Groups M and V. CONCLUSIONS: Intubation may be more challenging when using Heine XP plastic blades but no significant difference exists between Vital-View plastic blades and Heine Classic+ metal blades.

Impact of the use of an automated chest-compression device on airway management during out-of-hospital cardiopulmonary resuscitation: the PLAINT study.

INTRODUCTION: Automated chest-compression devices (ACCDs) have recently been proposed in the management of out-of-hospital cardiac arrest (cardiopulmonary resuscitation, CPR). During CPR, it is still unknown whether the ACCD or intubation is to be first implemented. Knowing the impact of an ACCD on intubation conditions could strongly contribute to determine the best sequence. Therefore, we undertook an experimental study on intubation conditions on a mannequin with or without the use of an ACCD. METHODS: Emergency physicians and nurses experienced in the field of cardiac-arrest management (including orotracheal intubation) were randomly assigned to three scenarios to intubate a mannequin: patient lying on the floor without an ACCD (group 1), patient lying on the floor with the ACCD switched off (group 2) or switched on (group 3). The primary end point was intubation time. Estimated intubation difficulty evaluated on a visual analogue scale (VAS), ranging from 0 (easy) to 100 (impossible), number of attempts, Cormack grade and dental traumatisms associated with the intubation procedure were secondary end points. RESULTS: A total of 44 operators performed the intubation. Times to intubation were 14 (11-22), 15 (10-21) and 18 (15-27)s for groups 1, 2 and 3, respectively. The VAS difficulties were 12 (5-25), 15 (10-25) and 15 (5-21), respectively. Intubation conditions did not differ between the 'without an ACCD group' and the 'switched-off ACCD group'. In the 'switched-on ACCD group', time to intubation was significantly increased in comparison with groups 1 and 2 with a median difference of 4 (1-10) and 3 (0-7)s, respectively. The VAS difficulty was also significantly increased in the 'switched-on ACCD group'. Other secondary end-point criteria did not differ between the three groups. CONCLUSION: Due to the major role of compression during CPR, we suggest that the ACCD should not be systematically switched off for routine intubation.

Use of an automated device for external chest compressions by first-aid workers unfamiliar with the device: a step toward public access?

OBJECTIVE: The objective was to establish the feasibility of using an automated external chest compression (ECC) device among first-aid workers unfamiliar with the device. METHODS: Eighty first-aid workers unfamiliar with the Autopulse ECC device were randomized into three groups. Group 1 was given two explanatory illustrations on device use. Group 2 was given four explanatory illustrations. Group 3 was shown a 5-minute video on the placement and use of the device and allowed to handle the device for 5 minutes. The time taken to place and start the device on a mannequin was recorded. RESULTS: There was no significant difference among the three groups with regard to age, sex ratio, experience, and time elapsed since their last training session. No mistakes in device placement were made by any of the groups. All 80 participants started ECC in less than 160 seconds. There was no significant difference between Groups 1 and 2 in time taken to place or start the device (medians and 25-75 percentiles = 72 [54-112] vs. 86 [46-130] seconds and 154 [103-183] vs. 156 [120-197] seconds, respectively). However, Group 3 first-aid workers obtained significantly better results (19 [16-26] seconds to place and 48 [40-65] seconds to start; p<0.0001). CONCLUSIONS: An automated ECC device can be rapidly placed and used by first-aid workers unfamiliar with the device. In the light of these results, use of the device by the general public can be envisaged.

Intravenous fluid temperature management by infrared thermometer.

BACKGROUND: The management of intravenous (IV) fluid temperature is a daily challenge in critical care, anesthesiology, and emergency medicine. Infusion of IV fluids at the right temperature partly influences clinical outcomes of critically ill patients. Nowadays, intravenous fluid temperature is poorly managed, as no suitable device is routinely available. Infrared (IR) thermometers have been recently developed for industrial, personal, or medical purposes. The aim of this study was to evaluate the accuracy of an IR thermometer in measuring temperature of warmed and cooled infusion fluids in fluid bags. METHODS: This study compared temperatures simultaneously recorded by an infrared thermometer and a temperature sensor. Temperatures of warmed (41 degrees C) and cooled (4 degrees C) infusion fluids in fluid bags were recorded by 2 independent operators every minute until IV bags' temperature reached ambient temperature. RESULTS: The relation curve was established with 576 measures. Temperature measures performed with an IR thermometer were perfectly linear and perfectly correlated with the reference method (R(2) = 0.995, P < 10(-5)). CONCLUSION: Infrared thermometers are efficient to measure IV fluid bag temperature in the range of temperatures used in clinical practice. As these devices are easy to use and inexpensive, they could be largely used in critical care, anesthesiology, or emergency medicine.

Usefulness of hand-held ultrasound devices in out-of-hospital diagnosis performed by emergency physicians.

OBJECTIVE: To evaluate the usefulness of ultrasonographic examinations as a diagnostic tool for emergency physicians in out-of-hospital settings. METHODS: Prospective study performed in a French teaching hospital. Eight emergency physicians given ultrasound training for out-of-hospital diagnosis of pleural, peritoneal, or pericardial effusion; deep venous thrombosis; and arterial flow interruption. After clinical examination, a probability of diagnosis ("clinical score") was assigned on visual analog scale from 0 (absent lesion) to 10 (present lesion). Clinical score between 3 and 7 was considered as clinically doubtful. After ultrasound examination, a second probability ("ultrasound score") was similarly determined. Potential usefulness of ultrasound examination was evaluated by calculating the absolute difference between clinical and ultrasound scores. Patients were followed up to determine final diagnosis: present or absent lesion. "Ultrasound usefulness score" (USS) was determined attributing a positive (when ultrasonography increased diagnostic accuracy) or a negative (when ultrasonography decreased diagnostic accuracy) value to the absolute difference between clinical and ultrasound scores. RESULTS: One hundred sixty-nine patients were included and 302 ultrasound examinations performed. Median duration of examination was 6 minutes (5-10 minutes). The suspected lesion was found in 45 cases (17%). Mean USS was +2 (0-4). Ultrasonographic examination improved diagnostic accuracy (ie, positive USS) in 181 (67%) cases, decreased it (ie, negative USS) in 22 (8%) cases, and was not contributive (ie, USS was 0) in 67 (25%) cases. When initial diagnosis was uncertain (n = 115), diagnostic performance reached +4 (3-5) and ultrasonographic examination improved diagnostic accuracy in 103 (90%) cases. CONCLUSION: Out-of-hospital ultrasonography increased diagnostic accuracy in out-of-hospital settings.