Peripheral perfusion index as a predictor of reintubation in critically ill surgical patients.

PURPOSE: We aimed to evaluate the ability of the peripheral perfusion index (PPI) to predict reintubation of critically ill surgical patients. METHODS: This prospective observational study included mechanically ventilated adults who were extubated after a successful spontaneous breathing trial (SBT). The patients were followed up for the next 48 h for the need for reintubation. The heart rate, systolic blood pressure, respiratory rate, peripheral arterial oxygen saturation (SpO2), and PPI were measured before-, at the end of SBT, 1 and 2 h postextubation. The primary outcome was the ability of PPI 1 h postextubation to predict reintubation using area under the receiver operating characteristic curve (AUC) analysis. Univariate and multivariate analyses were performed to identify predictors for reintubation. RESULTS: Data from 62 patients were analysed. Reintubation occurred in 12/62 (19%) of the patients. Reintubated patients had higher heart rate and respiratory rate; and lower SpO2 and PPI than successfully weaned patients. The AUC (95%confidence interval) for the ability of PPI at 1 h postextubation to predict reintubation was 0.82 (0.71-0.91) with a negative predictive value of 97%, at a cutoff value of ≤ 2.5. Low PPI and high respiratory rate were the independent predictors for reintubation. CONCLUSION: PPI early after extubation is a useful tool for prediction of reintubation. Low PPI is an independent risk factor for reintubation. A PPI > 2.5, one hour after extubation can confirm successful extubation.

Accuracy of oscillometric noninvasive blood pressure at the ankle in the lateral position during general anesthesia.

BACKGROUND: This study aimed to evaluate the accuracy of ankle blood pressure measurements in relation to invasive blood pressure in the lateral position. METHODS: This prospective observational study included adult patients scheduled for elective non-cardiac surgery under general anesthesia in the lateral position. Paired radial artery invasive and ankle noninvasive blood pressure readings were recorded in the lateral position using GE Carescape B650 monitor. The primary outcome was the ability of ankle mean arterial pressure (MAP) to detect hypotension (MAP < 70 mmHg) using area under the receiver operating characteristic curve (AUC) analysis. The secondary outcomes were the ability of ankle systolic blood pressure (SBP) to detect hypertension (SBP > 140 mmHg) as well as bias (invasive measurement - noninvasive measurement), and agreement between the two methods using the Bland-Altman analysis. RESULTS: We analyzed 415 paired readings from 30 patients. The AUC (95% confidence interval [CI]) of ankle MAP for detecting hypotension was 0.88 (0.83-0.93). An ankle MAP of ≤ 86 mmHg had negative and positive predictive values (95% CI) of 99 (97-100)% and 21 (15-29)%, respectively, for detecting hypotension. The AUC (95% CI) of ankle SBP to detect hypertension was 0.83 (0.79-0.86) with negative and positive predictive values (95% CI) of 95 (92-97)% and 36 (26-46)%, respectively, at a cutoff value of > 144 mmHg. The mean bias between the two methods was - 12 ± 17, 3 ± 12, and - 1 ± 11 mmHg for the SBP, diastolic blood pressure, and MAP, respectively. CONCLUSION: In patients under general anesthesia in the lateral position, ankle blood pressure measurements are not interchangeable with the corresponding invasive measurements. However, an ankle MAP > 86 mmHg can exclude hypotension with 99% accuracy, and an ankle SBP < 144 mmHg can exclude hypertension with 95% accuracy.

The use of thermal imaging for evaluation of peripheral tissue perfusion in surgical patients with septic shock.

BACKGROUND: In this study, we aimed to evaluate the ability of central-to-peripheral temperature gradients using thermal imaging to predict in-hospital mortality in surgical patients with septic shock. METHODS: This prospective observational study included adult patients with septic shock admitted to the intensive care unit postoperatively. Serum lactate (in mmol/L), capillary refill time (CRT) (in seconds), toe (peripheral) and canthal (central) temperature by infrared thermography and the corresponding room temperature in (Celsius [°C]) were assessed at the time of admission, 6- and 12 h after admission. The canthal-toe and room-toe temperature gradients were calculated. According to their final outcomes, patients were divided into survivors and non-survivors. The ability of canthal-toe temperature gradient (primary outcome), room-toe temperature gradient, toe temperature, serum lactate and CRT, measured at the prespecified timepoints to predict in-hospital mortality was analyzed using the area under receiver operating characteristic curve (AUC). RESULTS: Fifty-six patients were included and were available for the final analysis and 41/56 (73%) patients died. The canthal-toe and room-toe temperature gradients did not show significant accuracy in predicting mortality at any timepoint. Only the toe temperature measurement at 12 h showed good ability in predicting in-hospital mortality with AUC (95% confidence interval) of 0.72 (0.58-0.84) and a negative predictive value of 70% at toe temperature of ≤ 25.5 °C. Both serum lactate and CRT showed good ability to predict in-hospital mortality at all timepoints with high positive predictive values (> 90%) at cut-off value of > 2.5-4.3 mmol/L for the serum lactate and > 3-4.2 s for the CRT. CONCLUSION: In post-operative emergency surgical patients with septic shock, high serum lactate and CRT can accurately predict in-hospital mortality and were superior to thermal imaging, especially in the positive predictive values. Toe temperature > 25.5 °C, measured using infrared thermal imaging can exclude in-hospital mortality with a negative predictive value of 70%.

Oral midodrine for prophylaxis against post-spinal anesthesia hypotension during hip arthroplasty in elderly population: a randomized controlled trial.

BACKGROUND: We aimed to evaluate the efficacy of midodrine as a prophylaxis against post-spinal hypotension in elderly patients undergoing hip arthroplasty. METHODS: This randomized controlled trial included elderly patients undergoing hip arthroplasty under spinal anesthesia. Ninety minutes before the procedure, patients were randomized to receive either 5-mg midodrine or placebo (metoclopramide). After spinal anesthesia, mean arterial pressure (MAP) and heart rate were monitored every 2 min for 20 min then every 5 min until the end of the procedure. Post-spinal hypotension (MAP < 80% baseline) was treated with 10 mg ephedrine. The primary outcome was intraoperative ephedrine consumption. Secondary outcomes were the incidence of post-spinal hypotension, bradycardia, and hypertension (MAP increased by > 20% of the baseline reading). RESULTS: We analyzed 29 patients in the midodrine group and 27 in the control group. The intraoperative ephedrine consumption was lower in the midodrine group than in the control group (median [quartiles]: 10 [0, 30] mg versus 30 [20, 43] mg, respectively, P-value: 0.002); and the incidence of intraoperative hypotension was lower in the midodrine group than that in the control group. The incidence of hypertension and bradycardia were comparable between the two groups. CONCLUSION: The use of 5 mg oral midodrine decreased the vasopressor requirements and incidence of hypotension after spinal anesthesia for hip surgery in elderly patients. CLINICAL TRIAL REGISTRATION: This study was registered on September 22, 2022 at clinicaltrials.gov registry, NCT05548985, URL: https://classic. CLINICALTRIALS: gov/ct2/show/NCT05548985 .

Intravenous ibuprofen versus ketorolac for perioperative pain control in open abdominal hysterectomy: a randomized controlled trial.

BACKGROUND: We aimed to compare the analgesic effects of intravenous ibuprofen to ketorolac after open abdominal hysterectomy. METHODS: This randomized double-blinded controlled trial included adult women scheduled for elective open abdominal hysterectomy. Participants were randomized to receive either 30 mg ketorolac (n = 50) or 800 mg ibuprofen (n = 50) preoperatively, then every 8 h postoperatively for 24 h. All participants received paracetamol 1 gm/6 h. Rescue analgesic was given if the visual analogue scale (VAS) for pain assessment was > 3. The primary outcome was the mean postoperative dynamic VAS during the first 24 h. Secondary outcomes were static VAS, intraoperative fentanyl consumption, postoperative morphine consumption, time to independent movement, and patient's satisfaction. RESULTS: Forty-six patients in the ibuprofen group and fifty patients in the ketorolac group were analyzed. The 24-h dynamic and static VAS were similar in the two groups. The median (quartiles) dynamic VAS was 1.1 (0.9, 1.9) in the ibuprofen group versus 1.0 (0.7, 1.3) in the ketorolac group, P-value = 0.116; and the median (quartiles) static VAS was 0.9 (0.6, 1.3) in the ibuprofen group versus 0.7 (0.4, 1.1) in the ketorolac group, P-value = 0.113. The intra- and postoperative analgesic requirements were also similar in the two groups. However, patient satisfaction was slightly higher in the ketorolac group than that in the ibuprofen group (median [quartiles]: 6 [5, 7] versus 5 [4, 7], respectively), P-value: 0.009. CONCLUSION: The two drugs, intravenous ibuprofen and ketorolac produced similar analgesic profile in patients undergoing open abdominal hysterectomy receiving multimodal analgesic regimen. NCT05610384, Date of registration: 09/11/2022 CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05610384. https://clinicaltrials.gov/ct2/show/NCT05610384.

Epinephrine vs. phenylephrine infusion for prophylaxis against maternal hypotension after spinal anesthesia for cesarean delivery: a randomized controlled trial.

BACKGROUND: The hemodynamic effects of relatively low-dose epinephrine and phenylephrine infusions during cesarean delivery under spinal anesthesia were compared. METHODS: This randomized controlled trial included full-term pregnant women who underwent elective cesarean delivery. After spinal anesthesia, participants received either epinephrine (0.03 mcg/kg/min) or phenylephrine (0.4 mcg/kg/min) infusion that continued until 5 min after delivery. The primary outcome was a composite outcome of the occurrence of any of hypotension, hypertension, bradycardia, and/or tachycardia. Neonatal outcomes, including umbilical artery blood gas and Apgar scores, were assessed. RESULTS: In total, 98 patients in each group were analyzed, and the number of patients with the composite outcome was comparable between the epinephrine and phenylephrine groups (30/98 [31%] vs. 31/98 [32%], respectively; P = 0.877). However, the incidence of hypotension was likely lower in the epinephrine group than in the phenylephrine group (P = 0.066), and the number of hypotensive episodes per patient was lower in the epinephrine group than in the phenylephrine group. On the other hand, the incidence of tachycardia was higher in the epinephrine group than that in the phenylephrine group. The incidence of hypertension was comparable between the two groups and none of the participants developed bradycardia. Neonatal outcomes were comparable between the two groups. CONCLUSIONS: Epinephrine and phenylephrine infusion produced comparable maternal hemodynamics and neonatal outcomes. Epinephrine was associated with a higher incidence of maternal tachycardia and likely lower incidence of maternal hypotension than phenylephrine. IRB number: MD-245-2022. CLINICAL TRIAL REGISTRATION: This study was registered on May 31, 2023 at clinicaltrials.gov registry, NCT05881915, URL: https://classic. CLINICALTRIALS: gov/ct2/show/NCT05881915term=NCT05881915&draw=2&rank=1.

Comparison of different ratios of propofol-ketamine admixture in rapid-sequence induction of anesthesia for emergency laparotomy: a randomized controlled trial.

BACKGROUND: We aimed to compare the hemodynamic effect of two ratios of propofol and ketamine (ketofol), namely 1:1 and 1:3 ratios, in rapid-sequence induction of anesthesia for emergency laparotomy. METHODS: This randomized controlled study included adult patients undergoing emergency laparotomy under general anesthesia. The patients were randomized to receive either ketofol ratio of 1:1 (n = 37) or ketofol ratio of 1:3 (n = 37). Hypotension (mean arterial pressure < 70 mmHg) was managed by 5-mcg norepinephrine. The primary outcome was total norepinephrine requirements during the postinduction period. Secondary outcomes included the incidence of postinduction hypotension, and the intubation condition (excellent, good, or poor). RESULTS: Thirty-seven patients in the ketofol-1:1 and 35 patients in the ketofol 1:3 group were analyzed. The total norepinephrine requirement was less in the ketofol-1:1 group than in the ketofol-1:3 group, P-values: 0.043. The incidence of postinduction hypotension was less in the ketofol-1:1 group (4 [12%]) than in ketofol-1:3 group (12 [35%]), P-value 0.022. All the included patients had excellent intubation condition. CONCLUSION: In patients undergoing emergency laparotomy, the use of ketofol in 1:1 ratio for rapid-sequence induction of anesthesia was associated with less incidence of postinduction hypotension and vasopressor consumption in comparison to the 1:3 ratio with comparable intubation conditions. CLINICAL TRIAL REGISTRATION: NCT05166330. URL: https://clinicaltrials.gov/ct2/show/NCT05166330 .

Evaluation of the accuracy of oscillometric non-invasive blood pressure measurement at the ankle in children during general anesthesia.

This study aimed to evaluate the accuracy of oscillometric blood pressure measurement at the ankle in children using invasive blood pressure as reference standard. This prospective observational study included children undergoing noncardiac surgery. Paired radial invasive and ankle non-invasive blood pressure measurements were obtained. Delta blood pressure was calculated as the difference between two consecutive readings. The primary outcome was the mean bias and agreement between the two methods using the Bland-Altman analysis. The ISO standard was fulfilled if the mean bias between the two methods was ≤ 5 ± 8 mmHg. Other outcomes included the trending ability of ankle blood pressure using the four-quadrant plot and the accuracy of ankle measurement to detect hypotension using area under receiver operating characteristic curve (AUC) analysis. We analyzed 683 paired readings from 86 children. The mean bias between the two methods for systolic, diastolic, and mean blood pressure (SBP, DBP, MAP) was - 7.2 ± 10.7, 4.5 ± 12.8, and - 1.8 ± 8.2 mmHg, respectively. The concordance rate of ankle blood pressure was 72%, 71%, and 77% for delta SBP, DBP and MAP, respectively. The AUC (95% confidence interval) for ankle MAP ability to detect hypotension was 0.91 (0.89-0.93) with negative predictive value of 100% at cut-off value ≤ 70 mmHg, We concluded that in pediatric population undergoing noncardiac surgery, ankle blood pressure was not interchangeable with the corresponding invasive readings with the ankle MAP having the least bias compared to SBP and DBP. An ankle MAP > 70 mmHg can exclude hypotension with negative predictive value of 100%.

Parasternal intercostal thickening at hospital admission: a promising indicator for mechanical ventilation risk in subjects with severe COVID-19.

We aimed to evaluate the ability of parasternal intercostal thickening fraction (PIC TF) to predict the need for mechanical ventilation, and survival in subjects with severe Coronavirus disease-2019 (COVID-19). This prospective observational study included adult subjects with severe COVID-19. The following data were collected within 12 h of admission: PIC TF, respiratory rate oxygenation index, [Formula: see text] ratio, chest CT, and acute physiology and chronic health evaluation II score. The ability of PIC TF to predict the need for ventilatory support (primary outcome) and a composite of invasive mechanical ventilation and/or 30-days mortality were performed using the area under the receiver operating characteristic (AUC) analysis. Multivariate analysis was done to identify the independent predictors for the outcomes. Fifty subjects were available for the final evaluation. The AUC (95% confidence interval [CI]) for the right and left PIC TF ability to predict the need for ventilator support was 0.94 (0.83-0.99), 0.94 (0.84-0.99), respectively, with a cut off value of > 8.3% and positive predictive value of 90-100%. The AUC for the right and left PIC TF to predict invasive mechanical ventilation and/or 30 days mortality was 0.95 (0.85-0.99) and 0.90 (0.78-0.97), respectively. In the multivariate analysis, only the PIC TF was found to independently predict invasive mechanical ventilation and/or 30-days mortality. In subjects with severe COVID-19, PIC TF of 8.3% can predict the need to ventilatory support with a positive predictive value of 90-100%. PIC TF is an independent risk factor for the need for invasive mechanical ventilation and/or 30-days mortality.

Evaluation of gastric contents using ultrasound in full-term pregnant women fasted for 8 h: a prospective observational study.

BACKGROUND: We aimed to evaluate the gastric volume and contents after an 8-h fasting period in full-term, non-laboring, pregnant women following a standardized meal. METHODS: In this prospective observational study, we included full-term pregnant women scheduled for elective cesarean delivery. The participants were instructed to fast after a standardized meal (apple juice, bread, and cheese). Participants were scanned in the semi-recumbent and right-lateral positions 8 h after the standardized meal. The primary outcome was the proportion of patients with gastric volume > 1.5 mL kg-1 calculated by two equations. Secondary outcomes included the antral cross-sectional area and gastric volume. Data are expressed as frequency (%, 95% confidence interval [CI]), mean ± standard deviation (95% CI of the mean), or median (quartiles) as appropriate. RESULTS: Forty-one women were available for the final analysis. For the primary outcome, one participant (2.4%, 95% CI of 0.06 to 12.8%) had gastric volume > 1.5 mL kg-1, and none had solids in the antrum. For the secondary outcomes, the mean (95% CI of the mean) of the antral cross-sectional area was 2.11 ± 0.72 (1.88 to 2.34) cm2 and 4.08 ± 1.80 (3.51 to 4.65) cm2 during the semi-recumbent and right-lateral position, respectively. The median (quartiles) gastric volume was 0.53 (0.32, 0.66) mL kg-1 and 0.33 (0.13, 0.52) mL kg-1 as estimated by Perlas et al. and Roukhomovsky et al. equations, respectively. CONCLUSION: After 8-h fasting following a standardized meal, full-term pregnant non-laboring women are less likely to have a high residual gastric volume.

Accuracy of noninvasive blood pressure measured at the ankle during cesarean delivery under spinal anesthesia.

In this study, we evaluated the accuracy of oscillometric noninvasive blood pressure (NIBP) measured at the ankle in detecting low arm NIBP during cesarean delivery under spinal anesthesia. In this prospective observational study, a cohort of full-term mothers undergoing elective cesarean delivery under spinal anesthesia was examined. Simultaneous NIBP measurements were obtained from the arm and the ankle. The primary outcome was the accuracy of the ankle NIBP in detecting arm systolic blood pressure (SBP) < 90 mmHg. Other outcomes included the accuracy of ankle NIBP in detecting SBP < 80% of the baseline value. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate the accuracy of ankle NIBP in detecting low arm NIBP. The Bland-Altman analysis was conducted to evaluate the agreement between values. We analyzed 1729 pairs of readings obtained from 97 mothers. Ankle SBP showed good accuracy in detecting SBP < 90 mmHg, with an AUC (95% confidence interval [CI]) of 0.90 (0.89-0.91) and a negative predictive value (NPV) of 99 (98-99%) at a cutoff value of ≤ 103 mmHg. Furthermore, ankle SBP showed good accuracy in detecting SBP < 80% of the baseline value, with an AUC (95% CI) of 0.84 (0.82-0.89) and an NPV of 95 (93-96%) at a cutoff value of ≤ 76% of the ankle baseline SBP. The mean bias between the two sites of measurement was - 5.4 ± 15.5, - 2.0 ± 11, and 0.5 ± 12.1 mmHg for SBP, diastolic blood pressure, and mean arterial pressure, respectively. In conclusion, ankle NIBP measurement is not interchangeable with arm NIBP measurement. However, ankle NIBP measurement showed good accuracy for ruling out low arm NIBP during a cesarean delivery.Clinical trial rejistration: NCT04199156.

Peripheral perfusion index as a predictor of failed weaning from mechanical ventilation.

We hypothesized that impairment of peripheral perfusion index (PPI) during spontaneous breathing trial (SBT) might be predictive of weaning failure. We included 44 consecutive, adult, patients, who were scheduled for weaning after at least 48 h of invasive mechanical ventilation in this prospective observational study. Weaning failure was defined as failed SBT or reintubation within 48 h of extubation. PPI readings were obtained before initiation of the SBT, and every 5 min till the end of the SBT. PPI ratio was calculated at every time point as: PPI value/ baseline PPI. The primary outcome was the accuracy of PPI ratio at the end of the SBT in detecting failed weaning. Forty-three patients were available for the final analysis. Eighteen patients (42%) were considered failed weaning. PPI ratio was higher in patients with successful weaning compared to patients with failed weaning during the last 15 min of the SBT. PPI ratio at the end of SBT was higher in patients with successful weaning compared to patients with failed weaning. PPI ratio at the end of SBT had good predictive ability for weaning failure {area under receiver operating characteristic curve (95% confidence interval): 0.833(0.688-0.929), cutoff value ≤ 1.41}. The change in PPI during SBT is an independent predictor for re-intubation. PPI could be a useful tool for monitoring the patient response to SBT. Patients with successful weaning showed higher augmentation of PPI during the SBT compared to re-intubated patients. Failure of augmenting the PPI by 41% at the end of SBT could predict re-intubation with negative predictive value of 95%. Clinical trial identifier: NCT03974568. https://clinicaltrials.gov/ct2/show/NCT03974568?term=ahmed+hasanin&draw=3&rank=17.

Tocilizumab in patients with COVID-19: which patient, time, and dose?

Tocilizumab (TCZ) is a recombinant anti-interleukin-6 monoclonal antibody which showed uprising evidence as an anti-inflammatory agent which modulates the cytokine storm in patients with COVID-19. However, proper use of the drug requires selection of the appropriate patient and timing. The two main factors which might improve patient selection are the degree of respiratory failure and systemic inflammation. TCZ can decrease the mortality and progression to invasive mechanical ventilation in patients with severe COVID-19 who are not yet invasively ventilated. However, its use in invasively ventilated patients did not yet gain the same level of evidence especially when administered after > 1 day from mechanical ventilation. Being an anti-inflammatory and immunomodulatory drug, TCZ was mostly used in patients with COVID-19 who have clear signs of cytokine storm. However, the drug still showed positive response in some studies which did not strictly select patients with elevated markers of systemic inflammation. Thus, it is warranted to investigate and/or re-analyze the role of the drug in patients with severe COVID-19 and with no signs of systemic inflammation. TCZ is used in a dose of 8 mg/kg which can be repeated if there was no clinical improvement. However, there are no clear criteria for judgment of the success of the first dose. Being a drug with a major effect on gross outcomes in a serious pandemic with millions of mortalities, TCZ should be meticulously investigated to reach definitive indications and number of doses to avoid drug overuse, shortage, and side effects.

Comparison of two Norepinephrine rescue bolus for Management of Post-spinal Hypotension during Cesarean Delivery: a randomized controlled trial.

BACKGROUND: Data on the best norepinephrine bolus dose for management of hypotension are limited. The aim of this study was to compare the efficacy and safety of two norepinephrine bolus doses in the rescue management of maternal hypotension during cesarean delivery. METHODS: This randomized, controlled trial included mothers scheduled for cesarean delivery with spinal anesthesia with a prophylactic norepinephrine infusion. Following spinal anaesthesia administration, a participant was considered hypotensive if systolic blood pressure was ≤80% compared to the baseline reading. Participants were allocated to receive either 6 mcg or 10 mcg norepinephrine bolus for the management of hypotensive episodes. The hemodynamic response after administration of norepinephrine bolus was recorded. The episode was considered successfully managed if systolic blood pressure returned to within 80% from the baseline reading within 2 min after norepinephrine bolus administration, and did not drop again within 6 min after the norepinephrine bolus. The primary outcome was the incidence of successful management of the first hypotensive episode. Other outcomes included systolic blood pressure, heart rate, incidence of maternal bradycardia, and reactive hypertension. RESULTS: One hundred and ten mothers developed hypotensive episodes and received norepinephrine boluses for management. The number of successfully managed first hypotensive episodes was 50/57 (88%) in the 6 mcg-treated episodes and 45/53 (85%) in the 10 mcg-treated episodes (p = 0.78). Systolic blood pressure was comparable after administration of either bolus dose. Heart rate was lower after administration of 10 mcg bolus compared to 6 mcg bolus, without significant bradycardia requiring atropine administration. The incidence of reactive hypertension was comparable between both groups. CONCLUSION: In mothers undergoing elective cesarean delivery under prophylactic norepinephrine infusion at 0.05 mcg/kg/min, there was no advantage to the use of 10 mcg norepinephrine bolus over 6 mcg norepinephrine bolus for the rescue management of first hypotensive episode. Neither of the 2 bolus doses reached a 100% success rate. The incidences of bradycardia and reactive hypertension were comparable between both norepinephrine doses. TRIAL REGISTRATION: At clinicaltrial.gov registry system on January 4, 2019 Clinical trial identifier: NCT03792906.

Modified-ramped position: a new position for intubation of obese females: a randomized controlled pilot study.

BACKGROUND: Endotracheal intubation requires optimum position of the head and neck. In obese females, the usual ramped position might not provide adequate intubating conditions. We hypothesized that a new position, termed modified-ramped position, during induction of anesthesia would facilitate endotracheal intubation through bringing the breasts away from the laryngoscope and would also improve the laryngeal visualization. METHODS: Sixty obese female patients scheduled for general anesthesia were randomly assigned into either ramped or modified-ramped position during induction of anesthesia. In the ramped position (n = 30), the patient head and shoulders were elevated to achieve alignment of the sternal notch and the external auditory meatus; while in the modified-ramped position (n = 30), the patient shoulders were elevated using a special pillow, and the head was extended to the most possible range. Our primary outcome was the incidence of failed laryngoscopic insertion in the oral cavity (the need for patient repositioning). Other outcomes included time till vocal cord visualization, time till successful endotracheal intubation, difficulty of the mask ventilation, and Cormack-Lehane grade for laryngeal view. RESULTS: Fourteen patients (47%) in ramped group required repositioning to facilitate introduction of the laryngoscope in the oral cavity in comparison to one patient (3%) in the modified-ramped position (p < 0.001). Modified-ramped position showed lower incidence of difficult mask ventilation, shorter time for glottic visualization, and shorter time for endotracheal tube insertion compared to the ramped position. The Cormack-Lehane grade was better in the modified-ramped position. CONCLUSION: Modified-ramped position provided better intubating conditions, improved the laryngeal view, and eliminated the need for repositioning of obese female patients during insertion of the laryngoscope compared to ramped position. CLINICAL TRIAL REGISTRATION: Identifier: NCT03640442. Date: August 2018.

The Use of Topical Nitroglycerin to Facilitate Radial Arterial Catheter Insertion in Children: A Randomized Controlled Trial.

OBJECTIVES: To determine whether the use of topical nitroglycerin patch increases radial artery diameter and facilitate cannulation in children. DESIGN: Randomized controlled trial. SETTING: Cairo University Hospital. PARTICIPANTS: Children aged 2 to 8 years old scheduled for cardiac surgery. INTERVENTION: In the nitroglycerin group (n = 20), a gauze-covered, half-sized nitroglycerin patch (5 mg) was applied at the site of radial pulsation 1 hour before induction of anesthesia. In the control group (n = 20), a gauze pad was applied to the bare skin at the site of radial pulsation with no intervention. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the diameter of the radial artery in both limbs using ultrasonography. Other outcomes included the degree of arterial palpability, number of arterial punctures, and incidence of successful first puncture cannulation. The radial artery diameter increased after 30 minutes and 60 minutes compared with the baseline value in the nitroglycerin group in both limbs, whereas no change was reported in the radial artery diameter in the control group. The nitroglycerin group showed a greater incidence of successful first cannulation trial, a fewer number of trials, and a shorter cannulation time compared with the control group. There were no significant hypotensive episodes in any patient. CONCLUSION: Local application of a half-sized, 5 mg nitroglycerin patch for 60 minutes in children increased the radial artery diameter bilaterally, increased the rate of first trial success, and decreased the time needed for arterial cannulation without significant hypotensive episodes.

Evaluation of noninvasive hemoglobin monitoring in children with congenital heart diseases.

BACKGROUND: Noninvasive measurement of blood hemoglobin could save time and decrease the risk of anemia and infection. The accuracy of CO-oximetry-derived noninvasive hemoglobin (Sp-Hb) had been evaluated in pediatric population; however, its accuracy in children with congenital heart disease has not been studied till date. We evaluated the accuracy of Sp-Hb in relation to laboratory-measured hemoglobin (Lab-Hb) in children with congenital heart disease. METHODS: This prospective observational study included children with congenital heart disease undergoing procedural intervention. Sp-Hb measurements were obtained using Radical-7 Masimo pulse CO-oximeter and were compared against simultaneous Lab-Hb measurements obtained from the arterial line. Children were divided in cyanotic and acyanotic, and separate analysis was performed for each group. The values of both measurements were analyzed using Spearman's correlation coefficient and Bland-Altman analysis. Correlation was performed between Sp-Hb and Lab-Hb bias and each of arterial oxygen saturation and perfusion index. RESULTS: One-hundred and eleven pairs of readings were obtained from 65 children. The median (quartiles) age and weight of the children were 1 (1.2-4) years and 11 (8-17) kg, respectively. There was moderate correlation between Lab-Hb and Sp-Hb with a correlation coefficient (95% confidence interval [CI]) of 0.75 (0.63-0.83) in acyanotic children and 0.62 (0.37-0.79) in cyanotic children. The mean bias (95% limits of agreements) was -0.4 g/dL (-2.4 to 1.6 g/dL) and 1 g/dL (-2.7 to 4.6 g/dL) in acyanotic and cyanotic children, respectively. The mean bias between Sp-Hb and Lab-Hb showed a weak negative correlation with oxygen saturation (r [95% CI]): (-0.36 [-0.51--0.18]), and a weak positive correlation with the perfusion index (r [95% CI]): (0.19 [0.01-0.37]). CONCLUSION: The large bias and the wide limits of agreement between Sp-Hb and Lab-Hb denote that Masimo-derived Sp-Hb is not accurate in children with congenital heart disease especially in the cyanotic group; the error in Sp-Hb increases when oxygen saturation decreases.

The ability of perfusion index to detect segmental ulnar nerve sparing after supraclavicular nerve block.

Supraclavicular nerve block (SCB) is a commonly used regional block for upper extremity surgery. The most common form of failure of SCB is ulnar segmental sparing. We aimed to evaluate the accuracy of perfusion index (PI) in early detection of segmental sparing of the ulnar component of SCB. A prospective observational study included adult patients scheduled for surgery under ultrasound-guided SCB. PI was simultaneously measured at the index finger and little finger. PI was recorded every minute for the first 10 min after SCB. PI ratio was calculated at every measurement point as PI/baseline PI. The area under the receiver operating characteristic (AUROC) curve was calculated for the ability of PI ratio to detect segmental ulnar sparing with comparison of little finger readings to the index finger readings. Forty-nine patients were available for the final analysis. Nine patients (18%) had segmental ulnar sparing. PI ratio at the little finger showed excellent predictive ability for ulnar sparing starting from the fifth minute (AUROC 0.92 [0.8-0.98], cutoff value ≤ 1.71) and reached the highest value at the seventh minute (AUROC 0.96 [0.86-1], cutoff value ≤ 1.35), whereas PI ratio at the index finger showed poor predictive ability. When using the PI for evaluation of successful SCB, segmental ulnar sparing could be accurately detected when the PI was measured at the little finger and not at the index finger. An increase of 71% in PI at the little finger 5 min after SCB could accurately rule out ulnar sparing.Clinical trial identifier NCT03880201. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT03880201?term=NCT03880201&draw=2&rank=1 .

Evaluation of fluid responsiveness during COVID-19 pandemic: what are the remaining choices?

Non-protocolized fluid administration in critically ill patients, especially those with acute respiratory distress syndrome (ARDS), is associated with poor outcomes. Therefore, fluid administration in patients with Coronavirus disease (COVID-19) should be properly guided. Choice of an index to guide fluid management during a pandemic with mass patient admissions carries an additional challenge due to the relatively limited resources. An ideal test for assessment of fluid responsiveness during this pandemic should be accurate in ARDS patients, economic, easy to interpret by junior staff, valid in patients in the prone position and performed with minimal contact with the patient to avoid spread of infection. Patients with COVID-19 ARDS are divided into two phenotypes (L phenotype and H phenotype) according to their lung compliance. Selection of the proper index for fluid responsiveness varies according to the patient phenotype. Heart-lung interaction methods can be used only in patients with L phenotype ARDS. Real-time measures, such a pulse pressure variation, are more appropriate for use during this pandemic compared to ultrasound-derived measures, because contamination of the ultrasound machine can spread infection. Preload challenge tests are suitable for use in all COVID-19 patients. Passive leg raising test is relatively better than mini-fluid challenge test, because it can be repeated without overloading the patient with fluids. Trendelenburg maneuver is a suitable alternative to the passive leg raising test in patients with prone position. If a cardiac output monitor was not available, the response to the passive leg raising test could be traced by measurement of the pulse pressure or the perfusion index. Preload modifying maneuvers, such as tidal volume challenge, can also be used in COVID-19 patients, especially if the patient was in the gray zone of other dynamic tests. However, the preload modifying maneuvers were not extensively evaluated outside the operating room. Selection of the proper test would vary according to the level of healthcare in the country and the load of admissions which might be overwhelming. Evaluation of the volume status should be comprehensive; therefore, the presence of signs of volume overload such as lower limb edema, lung edema, and severe hypoxemia should be considered beside the usual indices for fluid responsiveness.

Accuracy of thyromental height test for predicting difficult intubation in elderly.

BACKGROUND: Studies of the accuracy of different airway tests are lacking in elderly. We evaluated and compared the accuracy of thyromental height in predicting difficult intubation in relation to the other traditional airway tests in elderly. METHODS: We included 120 patients aged ≥ 65 years scheduled for general anesthesia with tracheal intubation. Thyromental height, modified Mallampati test, thyromental distance and sternomental distance were evaluated. Cormack-Lehane grade > 2 was considered difficult laryngoscopy. Difficult tracheal intubation was considered if successful intubation required more than 2 attempts. The accuracy of different tests in predicting difficult intubation and difficult laryngoscopy were evaluated through area under receiver operating characteristic (AUROC) curves. Univariate and multivariate analyses were conducted to identify risk factors for difficult intubation and difficult laryngoscopy. RESULTS: Our cohort had a mean age of 71(7) years. We encountered difficult laryngoscopy in 15/120 (12%) patients, difficult intubation in 20/120 (17%) patients, and failed laryngoscopy requiring alternative methods for securing the airway in 3/120 (3%) patients. For predicting difficult intubation, thyromental height and modified Mallampati test showed the highest accuracy AUROC (95% confidence interval): 0.9 (0.83-0.95), cut-off value ≤ 5.9 cm, and AUROC (95% confidence interval): 0.89 (0.82-0.94), cut-off value > 2, respectively. Low thyromental height and high modified Mallampati test were the only independent risk factors for difficult laryngoscopy and difficult intubation. CONCLUSION: In elderly scheduled for elective procedure, both thyromental height and modified Mallampati tests showed good accuracy in predicting difficult intubation and difficult laryngoscopy, whilst thyromental distance and sternomental distance were poor predictors.